Facility Delivery Rates Research Articles

Maternal morbidity in postpartum severe preeclampsia by obstetric delivery volume

BackgroundPre-eclampsia is a leading cause of maternal morbidity and mortality in the United States. Emerging data suggests that postpartum pre-eclampsia may be associated with a higher incidence of maternal morbidity compared to hypertensive disorders of pregnancy (HDP) diagnosed antenatally. Understanding postpartum maternal risk across facilities with a spectrum of obstetric services is critical with the rising rates of pre-eclampsia in all healthcare settings. ObjectiveWe investigated the relationship between facility delivery volume and rates of nontransfusion severe maternal morbidity (SMM) among patients readmitted postpartum for pre-eclampsia with severe features. Study DesignThis is a retrospective cohort study using the Nationwide Readmissions Database (2015–2019) of postpartum patients readmitted for pre-eclampsia with severe features. Our primary outcome was nontransfusion SMM during readmission, defined per U.S. Centers for Disease Control and Prevention criteria. We also evaluated SMM, cardiac SMM, and individual morbidities. The exposure variable was the number of annual deliveries at the readmitting facility. Restricted cubic splines with 4 knots were used to assess the functional form of the relationship between obstetric delivery volume and nontransfusion SMM; a linear relationship was identified as optimal. Logistic regression was used to estimate adjusted odds ratios (aOR) which controlled for maternal age, nontransfusion SMM at delivery, expanded obstetric comorbidity index, and HDP during delivery. ResultsThe cohort included 29,472 patients readmitted with postpartum pre-eclampsia with severe features. The primary payer was 55% private and 42% governmental. Median age was 31.4 years. Most patients did not have prior HDP (65%) or chronic hypertension (86%) diagnosis antenatally. The median interval from delivery hospitalization to readmission was 3.9 days (25th percentile–75th percentile: 2.2–6.5). Nontransfusion SMM occurred in 7% of patients readmitted to facilities with >2000 deliveries compared to 9% with 1 to 2000 deliveries, and 52% without any delivery hospitalizations. The most common SMM was pulmonary edema and heart failure, observed in 4% of readmissions. We observed that for every increase in 1000 deliveries, the odds of a nontransfusion SMM at readmission decreased by 3.5% (aOR: 0.965; 95% confidence interval: 0.94, 0.99). ConclusionNontransfusion SMM for postpartum readmissions with pre-eclampsia with severe features was inversely associated with readmitting hospital delivery volume. This information may guide risk-reducing initiatives for identifying strategies to optimize postpartum care at facilities with lower or no delivery volume.

Maternal health service utilization in the Jimma Zone, Ethiopia: results from a baseline study for mobile phone messaging interventions

BackgroundOver the last 20 years, global healthcare has placed a major focus on improving the survival rates of mothers and children, recognizing the potential to prevent a significant number of deaths resulting from pregnancy and childbirth. Nevertheless, there remains an ongoing obstacle to the insufficient utilization of critical obstetric services to achieve optimal health outcomes for pregnant women. This study aimed to assess the magnitude and determinants of maternal healthcare use in the Jimma Zone, Ethiopia.MethodsData were obtained from a household survey as part of the baseline assessment of a cluster randomized controlled trial. The study participants comprised 588 women in early pregnancy, specifically those with a gestational age of less than 20 weeks. Logistic regression analysis was employed to identify factors associated with the use of maternal health services. Adjusted odds ratios (AORs) were used to assess the strength of the associations, with significance level set at a p-value ≤ 0.05.ResultsThe overall prevalence of maternal health service utilization was 87.9% (CI: 85.1, 90.4) for antenatal care, 74.7% (CI: 73.2, 79.9) for health facility delivery, and 60.4% (CI: 56.4, 64.3) for postnatal care. Multivariable logistic analysis revealed that maternal health service use was significantly influenced by access to health facilities (AOR: 6.6; 95% CI: 2.39, 18.16), financial hardship (AOR: 3; 95% CI: 1.97, 4.61), perceived respectful care (AOR: 2.3; 95% CI: 1.07, 5.11), perceived privacy of service provisions (AOR: 2.4; 95% CI: 1.47, 4.06), and attitudes toward maternal service use (AOR: 2.2; 95% CI: 1.48, 3.24).ConclusionsThe study revealed slightly higher rates of antenatal care, facility delivery, and postpartum care utilization. However, there was a low proportion of early antenatal care initiation, and high rates of antenatal care dropout. Mobile phone-based messaging intervention may enhance maternal health service use by addressing factors such as lack of access, economic challenges, disrespectful care, no privacy of procedures, and unfavorable attitudes.

Influence of Sociodemographic Factors and Obstetric History on Choice of Place of Delivery: A Retrospective Study Among Post-Natal Women in Ghana.

Even though Ghana has recorded an appreciable level of facility delivery compared to other countries in sub-Saharan Africa, the country still has a lot of regional and community variations in facility delivery where professional maternal health care is guaranteed. This study assessed the main factors associated with facility delivery in the Sagnarigu Municipal Assembly of the Northern Region of Ghana. Using a simple random sampling method, a retrospective community-based cross-sectional study was conducted from July 12, 2021 to October 17, 2021, among 306 postnatal women within 15 to 49 years who had delivered within the last six months. We conducted descriptive analyses, and the Pearson chi-square test of association between the sociodemographic factors and obstetrics history with the outcome variable, choice of place of birth. Lastly, significant variables in the chi-square test were entered into adjusted multivariate logistics regression to determine their association with the place of delivery. Data analysis was performed using the Statistical Package for Social Sciences version-25, with statistical significance set at a p-value of 0.05. The study reported a facility delivery rate of 82%, which is slightly higher than the national target (80%). We observed that age group [AOR 2.34 (1.07-5.14)], marital status [AOR 0.31 (0.12-0.81)], ethnicity [AOR 3.78 (1.18-12.13)], and couple's occupation [AOR 24.74 (2.51-243.91)] were the significant sociodemographic factors influencing facility delivery. The number of antenatal care (ANC) attendance [AOR 8.73 (3.41 - 22.2)] and previous pregnancy complications [AOR 2.4 (1.11 - 5.7)] were the significant obstetrics factors influencing facility delivery. We found that specific sociodemographic and obstetric factors significantly influence the choice of place of delivery in the study area. To address this, the study recommends targeted interventions that focus on providing support and resources for women from different age groups, marital statuses, ethnicities, and occupational backgrounds to access facility delivery services. Additionally, improving ANC attendance and effectively managing pregnancy complications were highlighted as important measures to encourage facility-based deliveries.

Does maternal health voucher scheme have association with distance inequality in maternal and newborn care utilization? Evidence from rural Bangladesh.

Bangladesh has made substantial progress in maternal health. However, persistent inequities in service use undermine the achievements at the national level. In 2007, the government introduced a Maternal Health Voucher Scheme (MHVS) to reduce barriers to service utilization. The current study explores the impact of MHVS on reducing distance inequality in utilization across the maternal and newborn continuum of care (MNCoC). A cross-sectional survey was conducted from October'2017 to April'2018 in four selected MHVS sub-districts of Chattogram and Sylhet Divisions of Bangladesh. 2,400 women with at-least one child aged below two years were randomly selected. Both bivariate and multivariate analyses were carried out to explore the absolute and relative influence of the voucher scheme and chi-square test was used for hypothesis testing. Nineteen percent of the women were MHVS beneficiaries and 23% of them lived within 5 km of the health facility. Among the beneficiaries no significant differences were observed in the utilization of at-least 4 antenatal visits, skilled-assistance at delivery, postnatal care, and MNCoC between those living closer to the health facility and those living far away. However, a higher facility delivery rate was observed among beneficiary women living closer. By contrast, for non-beneficiaries, a significant difference was found in service use between women living closer to health facilities compared to those living further away. The study found the use of MNCoC to be similar for all MHVS beneficiaries irrespective of their distance to health facilities whereas non-beneficiary women living further away had lower utilization rates. MHVS could have potentially reduced distance-related inequality for its beneficiaries. However, despite the provision of transport incentives under MHVS the reduction in inequality in facility delivery was limited. We propose a revision of the transportation incentive adjusting for distance, geographical remoteness, road condition, and transport cost to enhance the impact of MHVS.

Effectiveness of the Gratuité user fee exemption policy on utilization and outcomes of maternal, newborn and child health services in conflict-affected districts of Burkina Faso from 2013 to 2018: a pre-post analysis

BackgroundEvidence on effectiveness of user fee exemption policies targeting maternal, newborn, and child health (MNCH) services is limited for conflict-affected settings. In Burkina Faso, a country that has had its fair share of conflicts, user fee exemption policies have been piloted since 2008 and implemented along with a national government-led user fee reduction policy (‘SONU’: Soins Obstétricaux et Néonataux d'Urgence). In 2016, the government transitioned the entire country to a user fee exemption policy known as Gratuité. Our study objective was to assess the effect of the policy on the utilization and outcomes of MNCH services in conflict-affected districts of Burkina Faso.MethodsWe conducted a quasi-experimental study comparing four conflict-affected districts which had the user fee exemption pilot along with SONU before transitioning to Gratuité (comparator) with four other districts with similar characteristics, which had only SONU before transitioning (intervention). A difference-in-difference approach was initiated using data from 42 months before and 30 months after implementation. Specifically, we compared utilization rates for MNCH services, including antenatal care (ANC), facility delivery, postnatal care (PNC) and consultation for malaria. We reported the coefficient, including a 95% confidence interval (CI), p value, and the parallel trends test.ResultsGratuité led to significant increases in rates of 6th day PNC visits for women (Coeff 0.15; 95% CI 0.01–0.29), new consultations in children < 1 year (Coeff 1.80; 95% CI 1.13–2.47, p < 0.001), new consultations in children 1–4 years (Coeff 0.81; 95% CI 0.50–1.13, p = 0.001), and uncomplicated malaria cases treated in children < 5 years (Coeff 0.59; 95% CI 0.44–0.73, p < 0.001). Other service utilization indicators investigated, including ANC1 and ANC5+ rates, did not show any statistically significant positive upward trend. Also, the rates of facility delivery, 6th hour and 6th week postnatal visits were found to have increased more in intervention areas compared to control areas, but these were not statistically significant.ConclusionsOur study shows that, even in conflict-affected areas, the Gratuité policy significantly influences MNCH service utilization. There is a strong case for continued funding of the user fee exemption policy to ensure that gains are not reversed, especially if the conflict ceases to abate.

Factors associated with maternal decision against hospital delivery despite ANC attendance in Kakamega central sub county

Despite a large proportion of woman attending ANC during pregnancy, a significant percentage still avoid delivering at the health facility. This increases the risk of adverse pregnancies outcomes and deaths. Knowledge of factors associated with the decision against health facility delivery is limited. The main objective was to describe health facility factors associated with maternal decision against despite ANC attendance in Kakamega Central Sub-County. A community based cross sectional study was undertaken focused on a structured interview method in collecting quantitative data. Sample of 332 mothers who attended ANC but did not deliver in a health facility were drawn from a study population. A multistage random sampling method was applied in the selection of a primary data. Factors that made mothers to decide against health facility delivery despite ANC attendance included costs of transport and lunch, lack of supplies and commodities and lack of sufficient preparatory service for delivery emerges as more crucial determinant for decision against health facility. Chi-square tests were used describe single variables and to assess associations between variables. The statistical significance level was set at p&lt;0.05. Income source of the women were also associated with the perception on all staff always being available at the facility. We found significant associations between costs, and other costs. Availability of different levels of health facility will not alone solve the problem of low health facility delivery rates. These facilities need to be equally empowered with supplies, staffs who can give quality comprehensive service. Furthermore the women need to be economically empowered to be able to meet other costs like transport and lunch. Focus on increasing financing for maternity service by the government and intersectoral approach for maternal health is crucial in Kakamega Central Sub County. The county government should provide ambulance services for pregnant women, decentralization of delivery services in all health facilities and provide with staffs, supplies and commodities for equity of usage of delivery services, improved road network. Need for constructive and collaborative approach to promote maternal health and need to multi-sectoral approach to overcoming the barriers to health facility deliveries.

Improving maternal and child health outcomes through a community involvement strategy in Kabula location, Bungoma County, Kenya.

Maternal, fetal and neonatal mortality are higher in low-income compared to high-income countries due to weak health systems including poor access and utilization of health services. Despite enormous recent improvements in maternal, neonatal and under five children health indicators, more rapid progress is needed to meet the targets including the Sustainable Development Goal 3(SDG). In Kenya these indicators are still high and comprehensive systems are needed to attain these goals. To facilitate innovative partnerships in health care provision and to assess trends in access, utilization and quality of Maternal and Child Health care through the health systems approach using community owned initiatives including use of community owned resourse persons (CORPs), establishment of Community Based Organisations (CBOs) and Income Generating Activities(IGAs). This was implemented in Kabula location, Bungoma County, Kenya between January 2016 and April 2019. Pregnant women, newborns and under-five children living in Kabula location identified by Community Owned Resource Persons (CORPs). A prospective study to show trends in maternal, neonatal and infant outcomes through the implementation of community owned initiatives. General, under five and antenatal clinic attendance increased four fold in 2016,2017 and 2018. There was a 76% full immunization coverage with 97% BCG and 84% Polio coverage respectively among children studied. There was an 87% facility delivery rate among the pregnant women enrolled in the study. Trends in Maternal and under-five health indicators in Kabula showed improvements over the study period following the implementation of the community owned initiatives and community participation. The community owned initiatives as implemented in this study is useful in primary care and universal health coverage programs in health care delivery systems in LMICs.

Effective Methods for Mitigating Maternal Mortality in Developing Countries

Ninety-nine percent of maternal mortality occurs in developing countries; this is a global crisis, yet efforts to improve mortality rates in the short term have been largely uncoordinated and dispersed (Latt et al., 2019). Two promising options to reduce maternal mortality are improving access to contraception and distributing misoprostol, but to maximize investment potential the better method must be identified. This study examined the idea that increasing contraceptive access is the better short-term method to reduce maternal mortality in developing countries. The analysis centered on three studies on the effects of misoprostol and a single scoping projection on the effect of contraceptive distribution. The first study found that in transitioning from no misoprostol coverage to high misoprostol coverage, there could be a 25.49% reduction in maternal mortality. By contrast, a second study found that distributing misoprostol increased risk of maternal mortality because of increased hyperpyrexia, or elevated body temperature (Prata et al., 2014; Hofymeyr et al., 2013). A third study reported that misoprostol is unlikely to be misused and does not affect facility delivery rates (Tiruneh et al., 2019). By satisfying unmet need for contraception, there could be a 29% reduction globally in maternal mortality (Ahmed et al., 2012). Because there are limited studies available, it is difficult to draw a conclusion over which method is most effective. Based on current data, contraception distribution appears to be slightly more effective, but further research into both methods is necessary to guide resource distribution.

Impact of the COVID-19 pandemic on utilisation of facility-based essential maternal and child health services from March to August 2020 compared with pre-pandemic March–August 2019: a mixed-methods study in North Shewa Zone, Ethiopia

IntroductionHealth systems are often weakened by public health emergencies that make it harder to access health services. We aimed to assess maternal, newborn and child health (MNCH) service utilisation during...

Identifying Programmatic Factors that Increase Likelihood of Health Facility Delivery: Results from a Community Health Worker Program in Zanzibar.

Community health worker (CHW) interventions have been utilized to address barriers that prevent pregnant women from delivering in health facilities in low- and middle-income countries (LMICs). The objective of this research was to assess the programmatic factors that increase the likelihood of health facility delivery within a large digital health-supported CHW program in Zanzibar, Tanzania. This study included 36,693 women who were enrolled in the Safer Deliveries program with a live birth between January 1, 2017 and July 31, 2019. We assessed whether long-term enrollment, recency of CHW pregnancy visit prior to delivery, and number of routine home pregnancy visits were associated with an increased likelihood of health facility delivery compared to home delivery. We used Chi-squared tests to assess bivariate relationships and performed logistic regression analyses to assess the association between each programmatic variable and health facility delivery, adjusting for relevant confounders. We found that long-term enrollment was significantly associated with increased likelihood of health facility delivery, with the strongest relationship among women with a previous home delivery (OR = 1.4, 95%CI [1.0,1.7]). Among first-time mothers, two or more pregnancy visits by a CHW was positively associated with health facility delivery (OR = 1.8, 95%CI [1.2, 2.7]). Recent pregnancy visit by a CHW was positively associated with health facility delivery, but was not significant at the α = 0.05 level. In this program, we found evidence that at least two routinehome pregnancyvisits, longer length of enrollment in the program, and recency of home visit to the delivery date were strategies to increase health facility delivery rates among enrolled mothers. Maternal and child health programs should undertake similar evaluations to improve program delivery.

Can programmatic inputs improve adolescent mothers\u2019 access to maternal care in rural Bangladesh? Nine years of evidence from a cohort study

BackgroundAdolescent mothers (Girls aged 15–19) constitute 8% of annual global births, but account for 10% of annual maternal deaths. WHO recommended 4–8 Antenatal Care (ANC) visits, in addition to quality care and facility-based deliveries, are well-documented interventions to reduce maternal and child morbidity and mortality. Determinants of maternal and child health care in Bangladesh have received considerable attention, but less attention has been focused on adolescent mothers. This study explores the factors associated with 4 or more (4 +) ANC visits and facility-based delivery among adolescent mothers in one rural area of Bangladesh.MethodsThis study uses Health and Demographic Surveillance System (HDSS) data. We conducted a comparative study on trends in 4 + ANC visits and facility-based deliveries among adolescent mothers (10–19 years) residing in an intervention area (icddr,b service area, ISA) against a comparison area (government service areas, GSA) of HDSS between 2007 and 2015. Totally, 4,996 adolescent mothers were included in the final analysis. Binary logistic regression was used to document the statistical difference on outcome indicators in the two study areas.ResultsTrends in 4 + ANC visits and facility-based deliveries were higher in the ISA relative to the GSA. The adjusted odds of an adolescent mother accessing 4 + ANC visits in the GSA, relative to ISA, were 0.57 (95% CI 0.49–0.66, p value < 0.05); the adjusted odds of an adolescent mother accessing facility-based delivery in the ISA, relative to GSA, were 6.63 (95% CI: 5.85–7.52, p value < 0.05). Increasing numbers of ANC visits were associated with increases in facility-based births in both the ISA and GSA.ConclusionThis study documented that both 4 + ANC visits and facility delivery rates among adolescent mothers are much higher in the ISA than GSA. Increasing 4 + ANC visits and facility deliveries over the years, particularly in the ISA, coincide with programmatic efforts to improve the quality and availability of maternal and newborn health services. Learning from existing interventions in ISA and applying them to other areas will strengthen Bangladesh’s efforts to improve maternal and newborn health outcomes and achieve the Sustainable Development Goal 3 (SDG 3).

Impact of ultrasound scanning on pregnant Women's compliance with attendance at antenatal care visits and supervised delivery at primary healthcare centres in northern Nigeria: Initial experiences

IntroductionThe world health organisation (WHO) recommends at least one ultrasound scan amidst eight antenatal care visits, however, most pregnant women in low and middle-income countries do not achieve this. This study aims to assess the impact of limited obstetrics ultrasound (LOUS) within primary healthcare centres in northern Nigeria. MethodsA cross sectional study was conducted across selected primary healthcare centres in Bauchi and Kano States (northern Nigeria). The study protocol was approved by the Ministry of Health in each State. Within each State a total of nine primary healthcare centres were randomly selected. Information on all complete antenatal care (ANC) records of women who used the primary healthcare facility for 12 months prior to introduction of ultrasound (January 2016 to December 2016) and 12 months after (January 2018 to December 2018) were collected. Study data were analysed using descriptive (mean, standard deviations) and inferential statistics. Independent sample t-test were used to find out if there was a statistical difference between the pre and post-intervention data on women compliance to ANC visits, facility based delivery, maternal and child mortality. Data were analysed using the Statistical Package for Social Sciences and significance was set at p ≤ 0.05. ResultsThere was a significant increase in the number of ANC visits and supervised facility delivery after introduction of ultrasound services (LOUS) in the primary healthcare centres. The number of ANC visits in Kano State was 2637.6 ± 972.0 before and 3793.0 ± 517.5 after the introduction of ultrasound services. The number of ANC visits in Bauchi State was 1866.6 ± 488.3 before and 2854.0 ± 631.3 after the introduction of ultrasound services. The number of supervised facility deliveries in Kano state was 520.1 ± 128.7 before and 1021.1 ± 217.0 after the introduction of LOUS. The number of supervised facility deliveries for Bauchi state was 553.1 ± 309.9 before and 1056.3 ± 295.4 after introduction of LOUS. A total of 2486 (11.0%) women were referred for further imaging due to equivocal ultrasound findings. A total of 2185 (9.7%) pregnant women were referred for appropriate care due to multiple gestations. ConclusionThis study found that LOUS, in resource scarce settings, has the potential of improving ANC visits, facility delivery rates and reduce maternal and child mortality. It also leads to change in patient management plans resulting in referrals for appropriate care. Implication for practiceTechnological interventions using ultrasound have the potential to motivate pregnant women to attend ANC, give birth in a healthcare facility and thus reduce maternal and child morbidity and mortality. This is in line with the global drive to reduce maternal and child death by 2030 to less than 70 maternal deaths in 100,000 live births and neonatal mortality reduction to 12 in 1000 live births and under 5 mortality reduction to 25 in 1000 live births.

Associations between community health workers’ home visits and education-based inequalities in institutional delivery and perinatal mortality in rural Uttar Pradesh, India: a cross-sectional study

IntroductionIndia’s National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to visit and counsel women before and after birth. Little is known about the extent...

Increasing facility delivery through maternity waiting homes for women living far from a health facility in rural Zambia: a quasi-experimental study.

ObjectiveTo report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility.DesignQuasi‐experimental design with partial randomisation at the cluster level.SettingSeven rural districts in Zambia.PopulationWomen delivering at 40 health facilities between June 2016 and August 2018.MethodsTwenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference‐in‐differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes.Main outcome measuresDifferences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher‐level health facility between intervention and comparison group.ResultsWe detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6–7.6, P = 0.03), adolescent women (<18 years) living >10 km away (DID 18.1%, 95% CI 6.3–29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4–16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7–28, P < 0.001).ConclusionThe core MWH model was successful in increasing rates of facility delivery for women living >10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit.Tweetable abstractA core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia.

Improving health facility delivery rates in Zanzibar, Tanzania through a large-scale digital community health volunteer programme: a process evaluation.

The utilization of community health worker (CHW) programmes to improve maternal and neonatal health outcomes has become widely applied in low- and middle-income countries. While current research has focused on discerning the effect of these interventions, documenting the process of implementing, scaling and sustaining these programmes has been largely ignored. Here, we focused on the implementation of the Safer Deliveries CHW programme in Zanzibar, a programme designed to address high rates of maternal and neonatal mortality by increasing rates of health facility delivery and postnatal care visits. The programme was implemented and brought to scale in 10 of 11 districts in Zanzibar over the course of 3 years by D-tree International and the Zanzibar Ministry of Health. As the programme utilized a mobile app to support CHWs during their visits, a rich data resource comprised of 133481 pregnancy and postpartum home visits from 41653 women and 436 CHWs was collected, enabling the evaluation of numerous measures related to intervention fidelity and health outcomes. Utilizing the framework of Steckler et al., we completed a formal process evaluation of the primary intervention, CHW home visits to women during their pregnancy and postpartum period. Our in-depth analysis and discussion will serve as a model for process evaluations of similar CHW programmes and will hopefully encourage future implementers to report analogous measures of programme performance.

Averting Maternal Death and Disability in an Urban Network of Care in Dar es Salaam, Tanzania: A Descriptive Case Study

ABSTRACT The non-governmental organization Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) developed a multi-facility maternal and neonatal Network of Care (NOC) among 22 government hospitals and catchment facilities operating across Dar es Salaam. While facility delivery rates were above 90% in the Dar es Salaam region, the quality of services was substandard, leading to an excess of preventable maternal and neonatal morbidity and mortality. In partnership with the Dar es Salaam regional health authorities CCBRT developed a plan to improve the quality of service delivery at childbirth by through a system strengthening approach, capacitating lower-level facilities to provide routine care during pregnancy and uncomplicated deliveries, as well as improving care at secondary level referral hospitals and developing an inter-connected strengthened referral system. The Regional–CCBRT partnership implemented interventions across the continuum of care that included clinical training in basic and comprehensive emergency obstetric care, investments in infrastructure, and a rigorous maternal and perinatal death audit and follow-up program. Routine data generated were reflected upon at quarterly quality improvement meetings to follow up on problems identified. The government has initiated the replication of the model. This descriptive case study uses the four domains of the Networks of Care framework to document the wide-ranging efforts made to build and maintain the CCBRT Network of Care in order to solve for specific challenges in maternal and neonatal health service delivery in the urban context of the Dar es Salaam region.

Trends in maternal and child health outcomes in a health systems intervention: a case of Obekai dispensary in western Kenya

Background Maternal, fetal and neonatal mortality are higher in low-income compared to high-income countries primarily due to weak health systems that impede access and utilization of health services. Despite significant improvements in maternal, neonatal and under five children indicators, in some low-income countries, including Kenya these indicators remain relatively high prompting the search for innovative interventions to catalyze the progress towards attaining the Sustainable Development Goal (SDG) 3 target by 2030. We describe the results of a study that assessed the impact of an innovative health systems approach on maternal, neonatal and under-five children outcomes. Methods This was a four year pre-post prospective study to describe trends in the outcomes through the implementation of the Enhanced Health Care (EHC) using the Find Link Treat and Retain (FLTR) strategy. This was implemented in the catchment population of a ‘level 2’ facility, Obekai dispensary in Busia County, Kenya between January 2016 and January 2019. The study population was pregnant women, newborns and under-five children identified and referred to the facility over the study period. Women were identified in the community by community health workers early in pregnancy and followed up in Obekai dispensary until delivery. The newborns were followed up for the whole period the mother baby dyads were in the study. The EHC was implemented on these pairs during the duration of study upto 2-3 years. An interrupted time series model for a single group was used to assess the effect of the intervention on the outcome. Results Attendance in the outpatient, under five and antenatal clinic increased by 76%, 37% and 54% respectively from 2015 to 2018. There was a 90% fully immunization coverage with 97% and 94% BCG and Polio coverage respectively among children studied. There was a 91% facility delivery rate among the pregnant women enrolled in the study. After introduction of FLTR the immunization uptake increased significantly per quarter at a rate of 29.2 (95% confidence interval, CI=20.1-38.3). There was an increase in facility delivery, antenatal (ANC) attendance and decrease in neonatal death after introduction on FLTR. Conclusions Maternal and under-five health indicators in Obekai improved over the study period following the implementation of the EHC package.

Reducing the distance to walk: establishing a remote maternity facility in Runga, Hoima District, Uganda

Despite a substantial reduction in global maternal mortality, rates in low-income countries remain unacceptably high. Multiple contributing factors exist, grouped into three delays: health-seeking behaviour; accessibility of care; quality of care. In the Hoima District, rates of health facility delivery and skilled birth attendance remain low and maternal mortality exceeds the national average. Establishing the Midwives At Maternity Azur Clinic (February 2017) has addressed these issues at a local level. Health education and antenatal care are provided at the clinic, encouraging women to seek timely, appropriate intrapartum care. Access from surrounding villages is facilitated by a waiting home and weekly transport for antenatal care, alongside transport to a health facility with a staffed operating theatre, when required. It is run by a resident midwife, with regular training updates, and is stocked with the necessary resources for quality healthcare. Since its advent, village leaders report all-cause burials have reduced from one a day to one a week.

The effects of maternity waiting homes on the health workforce and maternal health service delivery in rural Zambia: a qualitative analysis

BackgroundMaternity waiting homes (MWHs) are a potential strategy to address low facility delivery rates resulting from access-associated barriers in resource-limited settings. Within a cluster-randomized controlled trial testing a community-generated MWH model in rural Zambia, we qualitatively assessed how MWHs affect the health workforce and maternal health service delivery at their associated rural health centers.MethodsFour rounds of in-depth interviews with district health staff (n = 21) and health center staff (n = 73) were conducted at intervention and control sites over 24 months. We conducted a content analysis using a mixed inductive-deductive approach. Data were interpreted through the lens of the World Health Organzation Health Systems Framework.ResultsNearly all respondents expressed challenges with understaffing and overwork and reported that increasing numbers of facility-based deliveries driven by MWHs contributed substantively to their workload. Women waiting at MWHs allow staff to monitor a woman’s final stage of pregnancy and labor onset, detect complications earlier, and either more confidently manage those complications at the health center or refer to higher level care. District, intervention, and control site respondents passionately discussed this benefit over all time points, describing it as outweighing challenges of additional work associated with MWHs. Intervention site staff repeatedly discussed the benefit of MWHs in providing a space for postpartum women to wait after the first few hours of clinical observation through the first 48 h after delivery. Additionally, intervention site staff perceived the ability to observe women for longer before and after delivery allowed them to better anticipate and plan their own work, adjust their workloads and mindset accordingly, and provide better and more timely care. When understaffing and overwork were frequently discussed, this satisfaction in providing better care was a meaningful departure.ConclusionsMWHs may benefit staff at rural health centers and the health system more broadly, allowing for the provision of more timely and comprehensive obstetric care. We recommend future studies consider how MWHs impact the workforce, operations, and service delivery at their associated health facilities. Considering the limited numbers of skilled birth attendants available in rural Zambia, it is important to strategically select locations for new MWHs.Trial registrationClinicaltrials.gov, NCT02620436. Registered December 3, 2015, https://clinicaltrials.gov/ct2/show/NCT02620436

Effect of community-based distribution of misoprostol on facility delivery: a scoping review

IntroductionCommunity distribution of misoprostol to pregnant women in advance of labor is one of the compelling strategies for preventing postpartum hemorrhage. Concerns have been reported that misoprostol distribution could reduce facility delivery or lead to misuse of the medication. This scoping review was conducted to synthesize the evidence on the effect of community-based misoprostol distribution on rates of facility delivery, and to assess the frequency of mothers taking distributed misoprostol before delivery, and any harmful outcomes of such misuse.MethodsWe included peer-reviewed articles on misoprostol implementation from PubMed, Cochrane Review Library, Popline, and Google Scholars. Narrative synthesis was used to analyze and interpret the findings, in which quantitative and qualitative syntheses are integrated.ResultsThree qualitative studies, seven observational studies, and four experimental or quasi-experimental studies were included in this study. All before-after household surveys reported increased delivery coverage after the intervention: ranging from 4 to 46 percentage points at the end of the intervention when compared to the baseline. The pooled analysis of experimental and quasi-experimental studies involving 7564 women from four studies revealed that there was no significant difference in rates of facility delivery among the misoprostol and control groups [OR 1.011; 95% CI: 0.906–1.129]. A qualitative study among health professionals also indicated that community distribution of misoprostol for the prevention of postpartum hemorrhage is acceptable to community members and stakeholders and it is a feasible interim solution until access to facility birth increases.In the community-based distribution of misoprostol programs, self-administration of misoprostol by pregnant women before delivery was reported in less than 2% of women, among seven studies involving 11,108 mothers. Evidence also shows that most women who used misoprostol pills, used them as instructed. No adverse outcomes from misuse in either of the studies reviewed.ConclusionsThe claim that community-based distribution of misoprostol would divert women who would have otherwise had institutional deliveries to have home deliveries and promote misuse of the medication are not supported with evidence. Therefore, community-based distribution of misoprostol can be an appropriate strategy for reducing maternal deaths which occur due to postpartum hemorrhages, especially in resource-limited settings.