Maternal And Newborn Health Care Research Articles

Implementing maternal and newborn health quality of care standards in healthcare facilities to improve the adoption of respectful maternity care in Bangladesh, Ghana and Tanzania: a controlled before and after study

IntroductionMany women worldwide cannot access respectful maternity care (RMC). We assessed the effect of implementing maternal and newborn health (MNH) quality of care standards on RMC measures.MethodsWe used a facility-based...

Procrastination of Global Progress in Tackling Maternal and Newborn Deaths: Need to Act Differently for Different Outcomes

Maternal and newborn mortality is great public health issue that need strong global attention. Although most of them are preventable, an estimate of 4.5 million, including 0.29 million maternal deaths, 1.9 million stillbirths, and 2.3 million newborn deaths, occurs every year. This is equivalent to the death of 800 women and 6700 newborns every day or the death of one pregnant woman or newborn every seven seconds. The regions with the highest death rates include SubSaharan Africa and Central and Southern Asia. Despite many available interventions, if offered to all expectant mothers and newborns, would greatly reduce maternal and newborn mortality burden, the world is off track to meet the global targets for maternal deaths, infant deaths and stillbirths, and this should not be acceptable. Even though there has been considerable progress in maternal and newborn health (MNH) care that led to 45% reduction in maternal mortality since 1990, from 2015, the world's efforts to reduce maternal and infant deaths have significantly reduced and even reversing in some countries, according to the recent report. This halt has been caused by the COVID-19 pandemic, climate change, increased poverty, and humanitarian crises that increased the burden on the already underwhelmed MNH care. Increasing financial investment and political commitment, enhancing health service delivery, improving community engagement, and strengthening data and information system are mostly required to eventually minimize maternal and neonatal deaths. We must act differently if we need different outcomes.

Multidomain and multilevel strategies to improve equity in maternal and newborn health services in Nepal: perspectives of health managers and policymakers

BackgroundNepal has committed to achieving universal coverage of quality maternal and newborn health (MNH) services by 2030. Achieving this, however, requires urgently addressing the widening inequity gradient in MNH care utilisation. This qualitative study examined the multidomain systemic and organisational challenges, operating in multi-level health systems, that influence equitable access to MNH services in Nepal.MethodsTwenty-eight in-depth interviews were conducted with health policymakers and program managers to understand supply-side perspectives of drivers of inequity in MNH services. Braun and Clarke’s thematic approach was employed in analysing the data. Themes were generated and explained using a multidomain (structural, intermediary, and health system) and multi-level (micro, meso and macro) analytical framework.ResultsParticipants identified underlying factors that intersect at the micro, meso and macro levels of the health system to create inequity in MNH services. Key challenges identified at the macro (federal) level included corruption and poor accountability, weak digital governance and institutionalisation of policies, politicisation of the health workforce, poor regulation of private MNH services, weak health management, and lack of integration of health in all policies. At the meso (provincial) level, identified factors included weak decentralisation, inadequate evidence-based planning, lack of contextualizing health services for the population, and non-health sector policies. Challenges at the micro (local) level were poor quality health care, inadequate empowerment in household decision making and lack of community participation. Structural drivers operated mostly at macro-level political factors; intermediary challenges were within the non-health sector but influenced supply and demand sides of health systems.ConclusionsMultidomain systemic and organisational challenges, operating in multi-level health systems, influence the provision of equitable health services in Nepal. Policy reforms and institutional arrangements that align with the country’s federalised health system are needed to narrow the gap. Such reform efforts should include policy and strategic reforms at the federal level, contextualisation of macro-policies at the provincial level, and context-specific health service delivery at the local level. Macro-level policies should be guided by political commitment and strong accountability, including a policy framework for regulating private health services. The decentralisation of power, resources, and institutions at the provincial level is essential for technical support to the local health systems. Integrating health in all policies and implementation is critical in addressing contextual social determinants of health.

‘The false reporter will get a praise and the one who reported truth will be discouraged’: a qualitative study on intentional data falsification by frontline maternal and newborn healthcare workers in two regions in Ethiopia

IntroductionHealth Management Information Systems (HMIS) are vital to ensure accountability and for making decisions including for tracking the Sustainable Development Goals. The Ethiopia Health Sector Transformation Plan II includes preventing...

Strengthening Weak Healthcare Systems for Maternal and Neonatal Care in Low and Middle Income Countries: The Missing Link

Introduction: Preventable maternal and newborn mortalities still occur in local communities in Kenya since access to maternal and newborn healthcare services remains a big challenge. Barriers to access in resource-constrained settings have not been examined adequately in literature. The World Health Organization (WHO) has 6 building blocks for strengthening healthcare systems that informed this study. This paper examines how user-side and institutional factors influence access and use of Maternal and Newborn Healthcare (MNH) Services in Matayos sub-County-Busia County. Methods: A mixed method approach, with an ethnographic inquiry and a descriptive cross-sectional design, was adopted to assess access to MNH services in Matayos-Busia County, Western Kenya. Postpartum women who had delivered within the previous 12 months and health care providers in the study area were recruited as respondents. A total of 348 postpartum women were selected through stratified systematic random sampling for the survey. Purposive sampling was used to select postpartum women, conventional and traditional health care providers for 16 in-depth interviews and 7 focus group discussions. Data were analyzed using descriptive and inferential statistics. Qualitative data analysis was done thematically. Results: Institutional delivery was low at 68% and family planning at 75% although demand for services was high at 99%. User-side barriers to access included shared beliefs and practices in the community; high direct transport costs from home; and high costs for missing drugs and other supplies in hospitals. Middle (5th-7th) order deliveries occurred at home with traditional birth attendants. The choice of place of delivery in households was influenced by spouses to respondents and communities of residence where respondents lived or were married. All 6 WHO health system building blocks were weak in Matayos sub-County and needed system-wide strengthening involving all pillars. The user-community voice alone was insufficient and the 7th pillar for user-community engagement was absent. The underlying factors were weak governance and underfunding for healthcare. Conclusion: The six WHO building blocks were inadequate due to weak governance and inadequate funding. User-community engagement, the 7th Pillar, was absent in these resource-limited settings. We recommend user-community empowerment, engagement and participation, adoption of a system thinking approach and adequate funding.

Impact of Recurrent Floods on the Utilization of Maternal and Newborn Healthcare in Bangladesh.

Floods are one of the most common types of disasters in Bangladesh and lead to direct and indirect impacts on health. The aim of the study was to assess the impact of floods on Maternal and Newborn Healthcare (MNH) utilization in Bangladesh between the years 2011 and 2014. We used variables from the Bangladesh Demographic and Health Survey 2014 data and georeferenced data of floods between 2011 and 2014 from the Emergency Events Database. Multivariate logistic regression was used to determine whether the flood-affected exposures were significant in predicting differences in MNH utilization. The odds for the received antenatal care by skilled providers, institutional deliveries, deliveries by c-section, and postnatal care of the babies were significantly lower (Unadjusted OR = 0.81, 0.88, 0.83, and 0.82 respectively; P < 0.05) in the flood-affected area than the non-affected area. Additionally, the odds of postnatal checkup of women was statistically significant (P < 0.001) and less likely to be received in flood-affected area (OR = 0.76). The odds of all indicators were significantly lower (OR < 1) for the women living in the twice and four times flooded areas compared to the once flooded areas. The study shows that floods can have a negative impact on MNH utilization. In addition, repeated floods have a worse impact on MNH utilization than incidental floods. Extra effort should be put on ensuring access to MNH of women in flood-affected areas.

What do women want? An analysis of preferences of women, involvement of men, and decision-making in maternal and newborn health care in rural Bangladesh

BackgroundTo improve the utilization of maternal and newborn health (MNH) care and to improve the quality of care, the World Health Organization (WHO) has strongly recommended men’s involvement in pregnancy, childbirth, and after birth. In this article, we examine women’s preferences for men’s involvement in MNH care in rural Bangladesh and how this compares to husbands’ reported involvement by women.MethodsA cross-sectional household survey of 1367 women was administered in 2018 in the district of Brahmanbaria. Outcomes of interest included supporting self-care during pregnancy, participation in birth planning, presence during antenatal care, childbirth, and postnatal care, and participation in newborn care. Binary and multiple logistic regressions were done to understand the associations between the outcomes of interest and background characteristics.ResultsAlthough women preferred a high level of involvement of their husbands in MNH care, husbands’ reported involvement varied across different categories of involvement. However, women’s preferences were closely associated with husbands’ reported involvement. Around three-quarters of the women reported having been the primary decision makers or reported that they made the decisions jointly with their husbands. The likelihood of women reporting their husbands were actively involved in MNH care was 2.89 times higher when the women preferred their husbands to be involved in 3–4 aspects of MNH care. The likelihood increased to 3.65 times when the women preferred their husbands to be involved in 5–6 aspects. Similarly, the likelihood of husbands’ reported active involvement was 1.43 times higher when they jointly participated in 1–2 categories of decision-making. The likelihood increased to 2.02 times when they jointly participated in all three categories.ConclusionThe findings of our study suggest that women in rural Bangladesh do indeed desire to have their husbands involved in their care during pregnancy, birth and following birth. Moreover, their preferences were closely associated with husbands’ reported involvement in MNH care; that is to say, when women wanted their husbands to be involved, they were more likely to do so. Programmes and initiatives should acknowledge this, recognizing the many ways in which men are already involved and further allow women’s preferences to be realized by creating an enabling environment at home and in health facilities for husbands to participate in MNH care.

Quality of maternal and newborn healthcare services in two public hospitals of Bangladesh: identifying gaps and provisions for improvement

BackgroundHealthcare service delivery systems need to ensure standard quality of care (QoC) for achieving expected health outcomes. Although Bangladesh has a good healthcare service delivery system, there are major concerns about the quality of maternal and newborn health (MNH) care services, which is imperative for achievements in health. The study aimed to measure the QoC for different MNH services in two selected public health facilities of Bangladesh. This study also documented the specific areas of each care which needs intervention.MethodsThe study was conducted in two district-level public health facilities—a district hospital (DH) and a mother and child welfare centre (MCWC). A total of 228 cases of MNH services were observed by using contextualized checklist ‘Standards-based Management and Recognition (S-BMR)’ for 8 selected MNH care services. For scoring, performed activities were calculated as percentages of the total recommended activities and categorized as high (> 80%), moderate (50 to 80%), and low (< 50%).ResultsOverall QoC scores were moderate for each DH (54.8%), and MCWC (56.1%). In DH, the QoC score was high for blood transfusion (80.3%); moderate for maternal complications management (77.0%), caesarean section (CS) (65.6%), infection prevention (64.3%), sick newborn care (54.1%), and normal vaginal delivery (NVD) (52.6%); and low for antenatal care (ANC) (25.6%) and postnatal care (PNC) (19.0%). In MCWC, the QoC scores were high for infection prevention (83.0%); moderate for CS (76.5%) and NVD (59.8%); and low for ANC (36.9%) and PNC (24.5%).ConclusionsIn the study facilities, the QoC for MNH services is found to be unsatisfactory, particularly for ANC and PNC. Urgent initiative needs to be taken by introducing contextualized quality monitoring tools at health facilities, along with training of the care providers and introducing a quality monitoring system.

Improving the quality of maternal and newborn health outcomes through a clinical mentorship program in the Democratic Republic of the Congo: study protocol

BackgroundThe Democratic Republic of the Congo (DRC) boasts one of the highest rates of institutional deliveries in sub-Saharan Africa (80%), with eight out of every ten births also assisted by a skilled provider. However, the maternal and neonatal mortality are still among the highest in the world, which demonstrates the poor in-facility quality of maternal and newborn care. The objective of this ongoing project is to design, implement, and evaluate a clinical mentorship program in 72 health facilities in two rural provinces of Kwango and Kwilu, DRC.MethodsThis is an ongoing quasi-experimental study. In the 72 facilities, 48 facilities were assigned to the group where the clinical mentorship program is being implemented (intervention group), and 24 facilities were assigned to the group where the clinical mentorship program is not being implemented (control group). The groups were selected and assigned based on administrative criteria, taking into account the number of deliveries in each facility, the coverage of health zones, accessibility, and ease of implementation of a clinical mentorship program. The main activities are organizing and training a national team of mentors (including senior midwives, obstetricians, and pediatricians) in clinical mentoring, deploying them to mentor all health providers (mentees) performing maternal and newborn health (MNH) services, and providing in-service training in routine and Emergency Obstetrical and Newborn Care (EmONC) to the mentees in health facilities over an 18-month period. Baseline and endline assessments are carried out to evaluate the effectiveness of the clinical mentorship program on the quality of MNH care and the effective coverage of key interventions to reduce maternal and neonatal mortality. Findings will be disseminated nationwide and internationally, as scientific evidence is scarce. A national strategy, guidelines, and tools for clinical mentorship in MNH will be developed for replication in other provinces, thus benefitting the entire country.DiscussionThis is the largest project on clinical mentorship aimed to improving the quality of MNH care in Africa. This program is expected to generate one of the first pieces of scientific evidence on the effectiveness of a clinical mentorship program in MNH on a scientifically designed and sustainable model.

Does mHealth voice messaging work for improving knowledge and practice of maternal and newborn healthcare?

BackgroundAponjon (meaning “near and dear ones”), a mobile phone-based mHealth service, customized voice messages for expectant (6–42 weeks pregnancy) and new mothers (1–52 weeks after delivery) for promotion of recommended healthcare practices. The Aponjon system sent two voice messages per week to subscribers, tailored to the timing during pregnancy or post-partum. The current study is an external evaluation of the effect of Aponjon use on knowledge and behaviors related to maternal and newborn health (MNH) care.MethodsWe implemented an observational study of Aponjon users with propensity score matched non-users in Bangladesh. Subscribers with at least 3 months exposure to Aponjon and non-users were interviewed retrospectively on knowledge and practices surrounding MNH. The sample included women with infants ≤6 months (243 users; 369 non-user) for maternal health knowledge and practice indicators and women with infants > 6 to 12 months old (332 users; 454 non-user) for neonatal health knowledge and practice indicators. Data were analyzed using principal component analysis and categorized as ‘high’ and ‘low’ at the median of principal component scores. Interactions between duration of use of Aponjon services and self-reported patterns of receiving and listening to messages were examined to assess the effect on knowledge and practices for MNH.ResultsWomen reporting at least 6 months of using Aponjon were approximately 3 times as likely as the non-users to score high on both maternal healthcare knowledge questions and related practices. Similarly women with at least 6 months of Aponjon exposure were 1.5 times as likely as the non-users to score high on knowledge questions on newborn health. Reporting a good-pattern of Aponjon use (i.e. receiving a minimum of 3 messages per month and listening to all of them) had an even stronger association with knowledge and practices related to MNH care. However, a shorter exposure to Aponjon service (i.e. 3–5 months), despite having a good-pattern of use, did not have an effect on the related outcomes.ConclusionsThe use of Aponjon services for at least 6 months, with a good-pattern of receiving and listening to the messages, was associated with improved knowledge and practices related to MNH care.

The roles of community health workers who provide maternal and newborn health services: case studies from Africa and Asia

IntroductionA variety of community health workers (CHWs) provide maternal and newborn health (MNH) services in low-income and middle-income settings. However, there is a need for a better understanding of the...

Temporal trends in spatial inequalities of maternal and newborn health services among four east African countries, 1999\u20132015

BackgroundSub-Saharan Africa continues to account for the highest regional maternal mortality ratio (MMR) in the world, at just under 550 maternal deaths per 100,000 live births in 2015, compared to a global rate of 216 deaths. Spatial inequalities in access to life-saving maternal and newborn health (MNH) services persist within sub-Saharan Africa, however, with varied improvement over the past two decades. While previous research within the East African Community (EAC) region has examined utilisation of MNH care as an emergent property of geographic accessibility, no research has examined how these spatial inequalities have evolved over time at similar spatial scales.MethodsHere, we analysed temporal trends of spatial inequalities in utilisation of antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) among four East African countries. Specifically, we used Bayesian spatial statistics to generate district-level estimates of these services for several time points using Demographic and Health Surveys data in Kenya, Tanzania, Rwanda, and Uganda. We examined temporal trends of both absolute and relative indices over time, including the absolute difference between estimates, as well as change in performance ratios of the best-to-worst performing districts per country.ResultsAcross all countries, we found the greatest spatial equality in ANC, while SBA and PNC tended to have greater spatial variability. In particular, Rwanda represented the only country to consistently increase coverage and reduce spatial inequalities across all services. Conversely, Tanzania had noticeable reductions in ANC coverage throughout most of the country, with some areas experiencing as much as a 55% reduction. Encouragingly, however, we found that performance gaps between districts have generally decreased or remained stably low across all countries, suggesting countries are making improvements to reduce spatial inequalities in these services.ConclusionsWe found that while the region is generally making progress in reducing spatial gaps across districts, improvement in PNC coverage has stagnated, and should be monitored closely over the coming decades. This study is the first to report temporal trends in district-level estimates in MNH services across the EAC region, and these findings establish an important baseline of evidence for the Sustainable Development Goal era.

Effective Aid for Hitting the Bull's Eye Comment on "It's About the Idea Hitting the Bull's Eye": How Aid Effectiveness Can Catalyse the Scale-up of Health Innovations".

This article studies how six key aid effectiveness principles for "Hitting the bull’s eye" can bring about the scale up of maternal and newborn health (MNH) interventions. These key principles are based on accepted international agreements such as the Paris Declaration on Aid Effectiveness. The results indicate that the six principles should be a guide for recipient countries to take ownership of the development process and work with donors to plan effective coordination structures. Countries that take ownership will be able to work with donors and implementers to not only test new interventions that address pressing challenges to deliver quality MNH care but also include the successful knowledge transfer and handover of these interventions, the effective integration of the new intervention as part of the country’s health system and a costed scale-up plan. The article could have been strengthened with clear and actionable recommendations for the three countries to improve their ownership of donor-funded assistance, but it showed that there is need to change how aid is delivered and that embracing and applying these principles will help countries take ownership of MNH programs and lead the dialog and effective scale up with those involved. The authors should be commended on taking the lead in the field of aid effectiveness, and encouraged to conduct quantitative and further qualitative measurements of the application of their findings in the three counties included in the study.

Determinants of Low Maternal and Newborn Health Service Utilization in Haiti: A Community-Based Cross-Sectional Study

Background: Haiti suffers from among the world’s poorest maternal and newborn health (MNH) indicators and utilization of skilled MNH care remains alarmingly low. In 2013, Enfants du Monde (EdM) and Doctors of the World Switzerland initiated a project aiming to empower women and communities to improve MNH and increase demand for skilled care. During 2013 participatory community assessment (PCA) was conducted, followed by a cross-sectional baseline study in 2014 to better understand the situation and lay the groundwork for implementation of interventions. Methods: A cross-sectional design was adopted for the study, using a mixedmethods approach. The quantitative component consisted of a randomized survey of 320 women who had given birth during the previous year living in the intervention area. Qualitative methods included focus groups discussions with women (n=8) and male partners (n=2) and semi-structured interviews (n=10) with health workers. Results: The baseline study revealed a number of factors which contribute to low use of MNH services in Haiti, with lower utilization in rural compared to urban areas. Notably, while use of antenatal care (ANC) remains relatively high, with 83% of women receiving ANC 1, only 34% of women give birth in the presence of a skilled birth attendant. Awareness of maternal health needs remains low, with few respondents able to cite three danger signs during pregnancy (63%), birth (41%) and after birth (39%). FGDs with men revealed low knowledge, as well. Geographic and financial barriers remain important obstacles. In addition, women express low satisfaction regarding health services and interactions with providers. Discussion: These results of the study demonstrate that a number of factors come into play impacting on women’s decision to seek care, reach health facilities and obtain skilled MNH care once at health facilities. While geographic and financial barriers remain important, other obstacles are also critical, including the social status of women, preference of care from matrones—traditional birth attendants (TBA) practicing widely in Haiti, and low perceptions of the quality of care and treatment by health care professionals. Conclusion: These studies revealed a number of factors which contribute to preventing women and newborns from accessing MNH services. Effectively improving MNH in Haiti requires action at both the community- and health services-level to address the multitude of factors contributing to low utilization of services.

Equality in Maternal and Newborn Health: Modelling Geographic Disparities in Utilisation of Care in Five East African Countries.

BackgroundGeographic accessibility to health facilities represents a fundamental barrier to utilisation of maternal and newborn health (MNH) services, driving historically hidden spatial pockets of localized inequalities. Here, we examine utilisation of MNH care as an emergent property of accessibility, highlighting high-resolution spatial heterogeneity and sub-national inequalities in receiving care before, during, and after delivery throughout five East African countries.MethodsWe calculated a geographic inaccessibility score to the nearest health facility at 300 x 300 m using a dataset of 9,314 facilities throughout Burundi, Kenya, Rwanda, Tanzania and Uganda. Using Demographic and Health Surveys data, we utilised hierarchical mixed effects logistic regression to examine the odds of: 1) skilled birth attendance, 2) receiving 4+ antenatal care visits at time of delivery, and 3) receiving a postnatal health check-up within 48 hours of delivery. We applied model results onto the accessibility surface to visualise the probabilities of obtaining MNH care at both high-resolution and sub-national levels after adjusting for live births in 2015.ResultsAcross all outcomes, decreasing wealth and education levels were associated with lower odds of obtaining MNH care. Increasing geographic inaccessibility scores were associated with the strongest effect in lowering odds of obtaining care observed across outcomes, with the widest disparities observed among skilled birth attendance. Specifically, for each increase in the inaccessibility score to the nearest health facility, the odds of having skilled birth attendance at delivery was reduced by over 75% (0.24; CI: 0.19–0.3), while the odds of receiving antenatal care decreased by nearly 25% (0.74; CI: 0.61–0.89) and 40% for obtaining postnatal care (0.58; CI: 0.45–0.75).ConclusionsOverall, these results suggest decreasing accessibility to the nearest health facility significantly deterred utilisation of all maternal health care services. These results demonstrate how spatial approaches can inform policy efforts and promote evidence-based decision-making, and are particularly pertinent as the world shifts into the Sustainable Goals Development era, where sub-national applications will become increasingly useful in identifying and reducing persistent inequalities.

The Effect of Integrating Family Planning with a Maternal and Newborn Health Program on Postpartum Contraceptive Use and Optimal Birth Spacing in Rural Bangladesh.

Meeting postpartum contraceptive need remains a major challenge in developing countries, where the majority of women deliver at home. Using a quasi-experimental trial design, we examine the effect of integrating family planning (FP) with a community-based maternal and newborn health (MNH) program on improving postpartum contraceptive use and reducing short birth intervals <24 months. In this two-arm trial, community health workers (CHWs) provided integrated FP counseling and services during home visits along with their outreach MNH activities in the intervention arm, but provided only MNH services in the control arm. The contraceptive prevalence rate (CPR) in the intervention arm was 15 percent higher than in the control arm at 12 months, and the difference in CPRs remained statistically significant throughout the 24 months of observation. The short birth interval of less than 24 months was significantly lower in the intervention arm. The study demonstrates that it is feasible and effective to integrate FP services into a community-based MNH care program for improving postpartum contraceptive use and lengthening birth intervals.

Newborn health initiatives in NGO sector

In India many non-profit, voluntary, non-government organizations (NGOs) are working amongst marginalized, poor population in remote villages and crowded urban slums, and have demonstrated the possibility of sustained and considerable reduction of neonatal mortality and morbidity by shifting the focus to integrated Maternal and Newborn Healthcare (MNH) rather than a diluted approach of Maternal and Child Health care (MCH). Initiatives by these NGOs include advocacy for newborn care, capacity building of local traditional birth attendants for safe delivery and childbirth, effective package of home-based newborn care and promotion of primary newborn care as Essential Newborn Care (ENBC). In addition these organizations have created fresh human resources for newborn care in the form of Village Health Workers (VHW) or volunteers and similar link workers or change agents and demonstrated their potential. Other initiatives have been developing database through verbal autopsy or other suitable reporting system, production and distribution of Disposable Delivery Kits (DDK) and training and health education material, developing initiatives for the care of newborns in urban slums, providing level II services for newborn care, innovations of simple tools and equipment, promotion of proper breast feeding and lactation management, emergency transport system and others.