Maternal Health Interventions Research Articles

Erosion of the Capital City Advantage in Child Survival and Reproductive, Maternal, Newborn, and Child Health Intervention Coverage in Sub-Saharan Africa.

The place of residence is a major determinant of RMNCH outcomes, with rural areas often lagging in sub-Saharan Africa. This long-held pattern may be changing given differential progress across areas and increasing urbanization. We assessed inequalities in child mortality and RMNCH coverage across capital cities and other urban and rural areas. We analyzed mortality data from 163 DHS and MICS in 39 countries with the most recent survey conducted between 1990 and 2020 and RMNCH coverage data from 39 countries. We assessed inequality trends in neonatal and under-five mortality and in RMNCH coverage using multilevel linear regression models. Under-five mortality rates and RMNCH service coverage inequalities by place of residence have reduced substantially in sub-Saharan Africa, with rural areas experiencing faster progress than other areas. The absolute gap in child mortality between rural areas and capital cities and that between rural and other urban areas reduced respectively from 41 and 26 deaths per 1000 live births in 2000 to 23 and 15 by 2015. Capital cities are losing their primacy in child survival and RMNCH coverage over other urban areas and rural areas, especially in Eastern Africa where under-five mortality gap between capital cities and rural areas closed almost completely by 2015. While child mortality and RMNCH coverage inequalities are closing rapidly by place of residence, slower trends in capital cities and urban areas suggest gradual erosion of capital city and urban health advantage. Monitoring child mortality and RMNCH coverage trends in urban areas, especially among the urban poor, and addressing factors of within urban inequalities are urgently needed.

Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India

IntroductionIndia’s progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health,...

The Equity Impact of Universal Home Visits to Pregnant Women and Their Spouses in Bauchi State, Nigeria: Secondary Analysis From a Cluster Randomised Controlled Trial.

Socio-economically disadvantaged women have poor maternal health outcomes. Maternal health interventions often fail to reach those who need them most and may exacerbate inequalities. In Bauchi State, Nigeria, a recent cluster randomised controlled trial (CRCT) showed an impressive impact on maternal health outcomes of universal home visits to pregnant women and their spouses. The home visitors shared evidence about local risk factors actionable by households themselves and the program included specific efforts to ensure all households in the intervention areas received visits. To examine equity of the intervention implementation and its pro-equity impact. The overall study was a CRCT in a stepped wedge design, examining outcomes among 15,912 pregnant women. We examined coverage of the home visits (three or more visits) and their impact on maternal health outcomes according to equity factors at community, household, and individual levels. Disadvantaged pregnant women (living in rural communities, from the poorest households, and without education) were as likely as those less disadvantaged to receive three or more visits. Improvements in maternal knowledge of danger signs and spousal communication, and reductions in heavy work, pregnancy complications, and post-natal sepsis were significantly greater among disadvantaged women according to the same equity factors. The universal home visits had equitable coverage, reaching all pregnant women, including those who do not access facility-based services, and had an important pro-equity impact on maternal health.

Health education to promote knowledge about sickle cell disease and newborn screening in pregnant women: a community-based pilot study using the healthy beginning initiative

BackgroundPregnancy presents a critical period for any maternal and child health intervention that may impact the health of the newborn. With low antenatal care attendance by pregnant women in health facilities in Nigeria, community-based programs could enable increased reach for health education about sickle cell disease (SCD) and newborn screening (NBS) among pregnant women. This pilot study aimed to assess the effect of education on the knowledge about SCD and NBS among pregnant women using the Healthy Beginning Initiative, a community-based framework.MethodsA pre-post study design was used to evaluate knowledge of SCD and NBS in a convenience sample of 89 consenting pregnant women from three communities. Participants were given surveys prior to and following completion of a health education session. McNemar’s test was used to compare the proportion of participants with correct responses. The level of significance was taken as p < 0.05.ResultsCompared to pre-test values, post-test values showed that participants understood that SCD is hereditary (93.3% vs. 69.7%), both parents must have at least one gene for someone to have SCD (98.9% vs. 77.5) and blood test is the right way to know if one has SCD (98.8% vs. 78.7%). Also, a large proportion of participants (post-test ~ 89.9%; compared to pre-test ~ 23.6%) understood that the chance of conceiving a child with SCD was 25% for a couple with the sickle cell trait (SCT). Knowledge of the possibility of diagnosing SCD shortly after birth was highly increased in the post test phase of the study when compared to the pre-test phase (93.3% vs. 43.9%, respectively). Concerning the overall knowledge scores, those with high level of knowledge significantly increase from 12.6% pretest to 87.4% posttest (p = 0.015).ConclusionThe health education intervention was associated with significant improvement on almost all measures of SCD knowledge. Focused health education for pregnant women using community structures can improve knowledge of SCD and NBS.

Health care-seeking behavior for childhood illnesses in western Kenya: Qualitative findings from the Child Health and Mortality Prevention Surveillance (CHAMPS) Study

Background Child mortality in Kenya is 41 per 1,000 live births, despite extensive investment in maternal, newborn, and child health interventions. Caregivers’ health-seeking for childhood illness is an important determinant of child survival, and delayed healthcare is associated with high child mortality. We explore determinants of health-seeking decisions for childhood illnesses among caregivers in western Kenya. Methods We conducted a qualitative study of 88 community members between April 2017 and February 2018 using purposive sampling in an informal urban settlement in Kisumu County, and in rural Siaya County. Key informant interviews, semi-structured interviews and focus group discussions were performed. We adopted the Partners for Applied Social Sciences model focusing on factors that influence the decision-making process to seek healthcare for sick infants and children. The discussions were audio-recorded and transcribed. Data management was completed on Nvivo® software. Iterative analysis process was utilized and themes were identified and collated. Results Our findings reveal four thematic areas: Illness interpretation, the role of social relationship on illness recognition and response, medical pluralism and healthcare access. Participants reported some illnesses are caused by supernatural powers and some by biological factors, and that the illness etiology would determine the health-seeking pathway. It was common to seek consensus from respected community members on the diagnosis and therefore presumed cause and necessary treatment for a child’s illness. Medical pluralism was commonly practiced and caregivers would alternate between biomedicine and traditional medicine. Accessibility of healthcare may determine the health seeking pathway. Caregivers unable to afford biomedical care may choose traditional medicine as a cheaper alternative. Conclusion Health seeking behavior was driven by illness interpretation, financial cost associated with healthcare and advice from extended family and community. These findings enrich the perspectives of health education programs to develop health messages that address factors that hinder prompt health care seeking.

Quality of antenatal care in 13 sub-Saharan African countries in the SDG era: evidence from Demographic and Health Surveys

BackgroundMaternal and neonatal mortality remains high in sub-Saharan Africa (SSA) with women having 1 in 36 lifetime risk. The WHO launched the new comprehensive recommendations/guidelines on antenatal care (ANC) in 2016, which stresses the essence of quality antenatal care. Consequently, the objective of this cross-sectional study is to investigate the quality of ANC in 13 SSA countries.MethodsThis is a cross-sectional study that is premised on pre-existing secondary data, spanning 2015 to 2021. Data for the study was obtained from the Measure DHS Programme and included a total of 79,725 women aged 15–49 were included. The outcome variable was quality ANC and it was derived as a composite variable from four main ANC services: blood pressure taken, urine taken, receipt of iron supplementation and blood sample taken. Thirteen independent variables were included and broadly categorised into individual and community-level characteristics. Descriptive statistics were used to present the proportion of women who had quality ANC across the respective countries. A two-level multilevel regression analysis was conducted to ascertain the direction of association between quality ANC and the independent variables.ResultsThe overall average of women who had quality ANC was 53.8% [CI = 51.2,57.5] spanning from 82.3% [CI = 80.6,85.3] in Cameroon to 11% [CI = 10.0, 11.4] in Burundi. Women with secondary/higher education had higher odds of obtaining quality ANC compared with those without formal education [aOR = 1.23, Credible Interval [Crl] = 1.10,1.37]. Poorest women were more likely to have quality ANC relative to the richest women [aOR = 1.21, Crl = 1.14,1.27]. Married women were more likely to receive quality ANC relative to those cohabiting [aOR = 2.04, Crl = 1.94,3.05]. Women who had four or more ANC visits had higher odds of quality ANC [aOR = 2.21, Crl = 2.04,2.38]. Variation existed in receipt of quality ANC at the community-level [σ2 = 0.29, Crl = 0.24,0.33]. The findings also indicated that a 36.2% variation in quality ANC is attributable to community-level factors.ConclusionTo achieve significant improvement in the coverage of quality ANC, the focus of maternal health interventions ought to prioritise uneducated women, those cohabiting, and those who are unable to have at least four ANCs. Further, ample recognition should be accorded to the existing and potential facilitators and barriers to quality ANC across and within countries.

Adverse birth outcome among women who gave birth at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia

BackgroundIn Ethiopia, various maternal and child health interventions, including comprehensive and basic obstetric cares were conducted to curb high neonatal and infant morbidity and mortality. As such, adverse birth outcome has been a public health concern in the country. Thus, this study aimed to assess the burden and associated factors with adverse birth outcomes among women who gave birth at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.MethodsA health facility-based cross-sectional study was employed from 30 March to 01 May 2021 at the University of Gondar Comprehensive Specialized Hospital. A total of 455 women were interviewed using a structured questionnaire. A binary logistic regression model was fitted Adjusted Odds Ratio (AOR) with 95%CI and p-value < 0.05 were used to declare factors significantly associated with adverse birth outcomes.ResultsIn this study, 28% of women had adverse birth outcomes (8.4% stillbirths, 22.9% preterm births, and 10.11% low birth weights). Women aged 20–34) (AOR: 0.32, 95%CI: 0.14, 0.76), rural dwellers (AOR: 2.7, 95%CI: 1.06, 6.32), lack of ANC visits (AOR: 4.10, 95%CI: 1.55, 10.85), APH (AOR: 3.0, 95%CI: 1.27, 7.10) and fever (AOR: 7.80, 95%CI: 3.57, 17.02) were associated to stillbirths. Multiple pregnancy (AOR:7.30, 95%CI:1.75, 20.47), rural dwellers (AOR:4.60, 95%CI:1.36, 15.52), preterm births (AOR: 8.60, 95% CI: 3.88, 19.23), previous perinatal death (AOR:2.90, 95%CI:1.35, 6.24), fever (AOR:2.7,95%CI:1.17 ,6.23) and premature rupture of membrane (AOR:2.60, 95% CI:1.02, 6.57) were affecting low birth weights. In addition, previous antepartum hemorrhage (AOR: 2.40, 95%CI: 1.37, 4.10) and fever (AOR: 3.8, 95%CI: 2.13, 6.89) were also factors contributing to preterm births.ConclusionAdverse birth outcomes continue to pose a significant public health concern. Such high rates of adverse birth outcomes, such as preterm birth, low birth weight, and birth defects, can have serious and long-lasting effects on the health and well-being of both infants and their families, and the community at large. As such, public health efforts are crucial in addressing and mitigating the risk factors associated with adverse birth outcomes. This may involve implementing interventions and policies to improve maternal health, access to prenatal care and nutritional support, and reducing exposure to environmental risks.

Uncovering the causes and socio-demographic constructs of stillbirths and neonatal deaths in an urban slum of Karachi.

Neonatal deaths and stillbirths are significant public health concerns in Pakistan, with an estimated stillbirth rate of 43 per 1,000 births and a neonatal mortality rate of 46 deaths per 1,000 live births. Limited access to obstetric care, poor health seeking behaviors and lack of quality healthcare are the leading root causes for stillbirths and neonatal deaths. Rehri Goth, a coastal slum in Karachi, faces even greater challenges due to extreme poverty, and inadequate infrastructure. This study aims to investigate the causes and pathways leading to stillbirths and neonatal deaths in Rehri Goth to develop effective maternal and child health interventions. A mixed-method cohort study was nested with the implementation of large maternal, neonatal and child health program, captured all stillbirths and neonatal death during the period of May 2014 till June 2018. The Verbal and Social Autopsy (VASA) tool (WHO 2016) was used to collect primary data from all death events to determine the causes as well as the pathways. Interviews were conducted both retrospectively and prospectively with mothers and caregivers. Two trained physicians reviewed the VASA form and the medical records (if available) and coded the cause of death blinded to each other. Descriptive analysis was used to categorize stillbirth and neonatal mortality data into high- and low-mortality clusters, followed by chi-square tests to explore associations between categories, and concluded with a qualitative analysis. Out of 421 events captured, complete VASA interviews were conducted for 317 cases. The leading causes of antepartum stillbirths were pregnancy-induced hypertension (22.4%) and maternal infections (13.4%), while obstructed labor was the primary cause of intrapartum stillbirths (38.3%). Neonatal deaths were primarily caused by perinatal asphyxia (36.1%) and preterm birth complications (27.8%). The qualitative analysis on a subset of 40 death events showed that health system (62.5%) and community factors (37.5%) contributing to adverse outcomes, such as delayed referrals, poor triage systems, suboptimal quality of care, and delayed care-seeking behaviors. The study provides an opportunity to understand the causes of stillbirths and neonatal deaths in one of the impoverished slums of Karachi. The data segregation by clusters as well as triangulation with qualitative analysis highlight the needs of evidence-based strategies for maternal and child health interventions in disadvantaged communities.

Maternal antenatal mental health and its associations with perinatal outcomes and the use of healthcare services in children from the NINFEA birth cohort study.

To investigate the associations between maternal mental health disorders before and during pregnancy and perinatal outcomes and child healthcare utilization between 6 and 18months of age. Among the 6814 mother-child pairs from the Italian Internet-based NINFEA birth cohort, maternal depression, anxiety, and sleep disorders diagnosed by a physician before and during pregnancy were assessed through self-reported questionnaires completed during pregnancy and 6months after delivery. Perinatal outcomes (preterm birth, birth weight, small for gestational age, congenital anomalies, and neonatal intensive care unit (NICU)) and children's healthcare utilization (emergency department (ED) visits, hospitalizations, and outpatient visits) were reported by mothers at 6 and 18months postpartum. We used regression models adjusted for maternal age, education, parity, country of birth, region of delivery, and household income. Maternal mental health disorders were not associated with perinatal outcomes, except for depression, which increased the risk of offspring admission to NICU, and anxiety disorders during pregnancy, which were associated with preterm birth and lower birth weight. Children born to mothers with depression/anxiety disorders before pregnancy, compared to children of mothers without these disorders, had an increased odds of a visit to ED for any reason (odds ratio (ORadj) = 1.26, 95% confidence interval (CI): 1.02-1.54), of an ED visit resulting in hospitalization (ORadj = 1.75, 95%CI: 1.27-2.42), and of planned hospital admissions (ORadj = 1.55, 95%CI: 1.01-2.40). These associations with healthcare utilization were similar for mental disorders also during pregnancy. The association pattern of maternal sleep disorders with perinatal outcomes and child healthcare utilization resembled that of maternal depression and/or anxiety disorders with these outcomes. Conclusion: Antenatal maternal mental health is a potential risk factor for child-health outcomes and healthcare use. Early maternal mental health interventions may help to promote child health and reduce healthcare costs. What is Known: • Poor maternal mental health affects pregnancy outcomes and child health, and children of mothers with mental health conditions tend to have increased healtcare utilization. • Parents with poor mental health often face challenges in caring for their children and have less parenting self-efficacy, which could potentially lead to frequent medical consultations for minor health issues. What is New: • Maternal pre-pregnancy mental disorders were not associated with preterm birth, low birth weight, SGA, and congenital anomalies, except for depression, which increased the risk of offspring admission to NICU. Anxiety disorders during pregnancywere associated with lower birth weight and an increased odds of preterm birth. • Maternal depression and/or anxiety and sleep disorders, both before and during pregnancy, were associated with an increase in children's healthcare utilization between 6 and 18months of life.

Maternal and child oral health barriers and solutions: Case studies from South Africa, Brazil, and Indonesia.

The World Federation of Public Health Associations (WFPHA) has introduced a maternal oral health framework and launched its Global Maternal and Child Oral Health Initiative, advocating for maternal and child health as a strategic entry point for oral health to be integrated into primary healthcare systems. This article delves into maternal oral health initiatives in South Africa, Brazil, and Indonesia, exploring challenges and proposing context-specific solutions aligned with the WFPHA maternal oral health framework and its Global Maternal and Child Oral Health Initiative. The apartheid legacy in South Africa has led to the gross health inequalities, including oral health disparities characterized by maldistribution of dental facilities and dental professionals in the public sector. The proposed objectives focus on effective leadership, human resource capacity building, and integration of maternal and child oral health policy into existing health policies. Brazil faces challenges in reaching pregnant women, especially pregnant teens, due to workforce shortages. Brazil's Oral Health National Program mandates all pregnant women undergo at least one dental appointment, but a shortage of oral health teams persists and impedes timely access to dental care during pregnancy. Dental students' outreach to vulnerable pregnant teens can enhance the future oral health workforce's sensitivity to maternal oral health matters. In Indonesia, the Antenatal Care Innovative (iANC) Project has introduced a co-training model for midwives and oral health professionals addressing oral health needs of mothers and their spouses and fostering a comprehensive understanding of the interplay between oral health and maternal well-being. These country cases demonstrate the importance of tailored policies, health promotion, and care delivery interventions in maternal oral health. All cases highlight the importance of workforce training and distribution, fostering cross-disciplinary collaboration and future oral health workforce who can promote health beyond treatment delivery.

Feasibility and Acceptability of Smartphone Interventions for Maternal and Child Health in Slum Settings in Kampala, Uganda

The use of mobile phones for health interventions has become increasingly popular in low-income settings, particularly in sub-Saharan Africa. This study aimed to investigate the acceptability of a smartphone intervention to provide maternal and child health messages for women living in slum settings in Uganda. The study utilized a mixed-methods design, comprising a survey and interviews. A total of 200 women participated in the survey, and 23 women participated in the interview sessions. The results indicated a high level of acceptability of the smartphone intervention, with the majority of women expressing their willingness to receive maternal and child health messages via their mobile phones. The women reported that the messages were informative, relevant, and useful for their daily lives. They also appreciated the privacy and convenience of receiving messages on their phones. However, some women expressed concern about the cost of receiving the messages and the need for support to access and use the technology. The study findings suggest that mobile phone interventions for maternal and child health promotion are acceptable to women living in slum settings in Uganda. The findings also highlight the need for equitable access to mobile phones and support for technology use in these settings.

COMPLICATIONS ASSOCIATED WITH INTERNAL ILIAC LIGATION IN THE CONTEXT OF SEVERE POST-PERIPARTUM HYSTERECTOMY BLEEDING

Severe post-peripartum hysterectomy bleeding poses a critical threat to maternal health, necessitating swift and effective interventions to ensure favorable outcomes. The main objective of the study is to find the potential complications associated with internal iliac ligation in the context of severe post-peripartum hysterectomy bleeding. This prospective observational study was conducted in the gynecology and obstetrics department of Lady Reading Hospital Peshawar from June 2022 til the required sample size is obtained. The study included women who had significant and profuse post-peripartum hysterectomy bleeding. All women with post-peripartum hysterectomy hemorrhage were identified, focusing specifically on cases where internal iliac ligation was employed as an intervention. The demographic information, including patient age, parity, medical history, and obstetric details, was collected on predesigned proforma. Data was collected from 196 patients. The mean age of the patients was 31.5±4.2 years. About 97% of patients were multiparas, and all patients presented with postpartum hemorrhage (100%). The mode of delivery was vaginal in 89% of cases. It is concluded that internal iliac ligation, while effective in controlling severe post-peripartum hysterectomy hemorrhage, presents a nuanced landscape marked by a low incidence of vascular (1.5%) and ureteric (0.5%) injuries. Consequently, we believe that procedure is worth try in the face of catastrophic uncontrolled haemorrhage, especially in low-income countries.

The Effect of Self Leadership on Breastfeeding with Intention Mediation

Purpose: This study aims to investigate the influence of maternal self-leadership on breastfeeding practices, with a particular focus on examining the mediating role of intention. Recognizing the crucial role of maternal self-leadership in fostering successful exclusive breastfeeding, the research seeks to understand how maternal self-leadership impacts breastfeeding behavior, and whether intention serves as a mediator in this relationship. Methods: The research involves 118 breastfeeding mothers with infants aged 6-12 months as the study subjects. The independent variable under scrutiny is self-leadership, while breastfeeding serves as the dependent variable, with intention acting as the mediating variable. Structural equation modeling (SEM) is employed as the data analysis method to explore the relationships between these variables and assess the mediation effects. Results and Discussion: The findings reveal that maternal self-leadership exerts a positive and significant influence on both intention and breastfeeding practices. However, contrary to expectations, intention does not demonstrate a significant effect on breastfeeding behavior. Furthermore, the mediation analysis indicates that the relationship between self-leadership and breastfeeding is partially mediated by intention. This suggests that while intention plays a role in translating maternal self-leadership into breastfeeding practices, other factors may also contribute to this relationship, indicating potential avenues for further exploration. Implications of the Research: The research outcomes hold important implications for maternal and child health interventions aimed at promoting exclusive breastfeeding. By highlighting the significance of maternal self-leadership in influencing breastfeeding practices, the study underscores the importance of empowering mothers with self-leadership skills to enhance breastfeeding initiation and continuation. Additionally, the findings suggest that interventions targeting intention formation may not be sufficient on their own to promote breastfeeding behavior, emphasizing the need for multifaceted approaches that address various determinants of breastfeeding practices. Originality/Value: This study contributes to the existing literature by examining the interplay between maternal self-leadership, intention, and breastfeeding practices within the context of breastfeeding promotion. By employing structural equation modeling to assess mediation effects, the research provides a nuanced understanding of the mechanisms underlying the relationship between maternal self-leadership and breastfeeding behavior. The findings offer valuable insights for policymakers, healthcare practitioners, and breastfeeding support programs seeking to develop more effective strategies to support and encourage exclusive breastfeeding among mothers.

Effectiveness of Postnatal Maternal or Caregiver Interventions on Outcomes among Infants under Six Months with Growth Faltering: A Systematic Review.

The care of infants at risk of poor growth and development is a global priority. To inform new WHO guidelines update on prevention and management of growth faltering among infants under six months, we examined the effectiveness of postnatal maternal or caregiver interventions on outcomes among infants between 0 and 6 months. We searched nine electronic databases from January 2000 to August 2021, included interventional studies, evaluated the quality of evidence for seven outcome domains (anthropometric recovery, child development, anthropometric outcomes, mortality, readmission, relapse, and non-response) and followed the GRADE approach for certainty of evidence. We identified thirteen studies with preterm and/or low birth weight infants assessing effects of breastfeeding counselling or education (n = 8), maternal nutrition supplementation (n = 2), mental health (n = 1), relaxation therapy (n = 1), and cash transfer (n = 1) interventions. The evidence from these studies had serious indirectness and high risk of bias. Evidence suggests breastfeeding counselling or education compared to standard care may increase infant weight at one month, weight at two months and length at one month; however, the evidence is very uncertain (very low quality). Maternal nutrition supplementation compared to standard care may not increase infant weight at 36 weeks postmenstrual age and may not reduce infant mortality by 36 weeks post-menstrual age (low quality). Evidence on the effectiveness of postnatal maternal or caregiver interventions on outcomes among infants under six months with growth faltering is limited and of 'low' to 'very low' quality. This emphasizes the urgent need for future research. The protocol was registered with PROSPERO (CRD42022309001).

The infant health effects of doulas: Leveraging big data and machine learning to inform cost-effective targeting.

Doula services represent an underutilized maternal and child health intervention with the potential to improve outcomes through the provision of physical, emotional, and informational support. However, there is limited evidence of the infant health effects of doulas despite well-established connections between maternal and infant health. Moreover, because the availability of doulas is limited and often not covered by insurers, existing evidence leaves unclear if or how doula services should be allocated to achieve the greatest improvements in outcomes. We use unique data and machine learning to develop accurate predictive models of infant health and doula service participation. We then combine these predictive models within the double machine learning method to estimate the effects of doula services. We show that while doula services reduce risk on average, the benefits of doula services increase as the risk of negative infant health outcomes increases. We compare these benefits to the costs of doula services under alternative allocation schemes and show that leveraging the risk predictions dramatically increases the cost effectiveness of doula services. Our results show the potential of big data and novel analytic methods to provide cost-effective support to those at greatest risk of poor outcomes.

Are populations of postpartum women differentially served by community health worker programs: an observational cohort study from Zanzibar, Tanzania

BackgroundAlthough community health worker (CHW) programs focus on improving access to healthcare, some individuals may not receive the intended quality or quantity of an intervention. The objective of this research was to examine if certain populations of pregnant women differentially experience the implementation of a community health worker-led maternal health intervention in Zanzibar.MethodsWe included pregnant women enrolled in the Safer Deliveries (Uzazi Salama) program, which operated in 10 of 11 districts in Zanzibar, Tanzania between January 1, 2017, and June 19, 2019 (N = 33,914). The outcomes of interest were receipt of the entire postpartum intervention (three CHW visits) and time to first postpartum CHW visit (days). Visits by CHWs were done at the women’s home, however, a telehealth option existed for women who were unable to be reached in-person. We conducted statistical tests to investigate the bivariate associations between our outcomes and each demographic and health characteristic. We used multivariate logistic regression to estimate the relationships between covariates and the outcomes and multivariate linear regression to estimate the association between covariates and the average time until first postpartum visit.ResultsHigher parity (OR = 0.85; P = 0.014; 95%CI: 0.75–0.97), unknown or unreported HIV status (OR = 0.64; p < 0.001; 95%CI: 0.53–0.78), and receipt of phone consultations (OR = 0.77; p < 0.001; 95%CI: 0.69–0.87) were associated with a lower odds of receiving all postpartum visits. Similarly, women with an unknown or unreported HIV status (estimated mean difference of 1.81 days; p < 0.001; 95%CI: 1.03–2.59) and those who received a phone consultation (estimated mean difference of 0.83 days; p < 0.001; 95%CI: 0.43–1.23), on average, experienced delays to first visit. In addition, current delivery at a referral hospital was associated with lower odds of receiving a postpartum visit and longer time to first visit compared to delivery at home, cottage hospital, PHCU + , or district hospital. Women from all other districts received their first visit earlier than women from Kaskazini B. There were no differences in the odds of receiving the entire postpartum intervention by sociodemographic variables, including age, education, and poverty assessment indicators.ConclusionThe results indicate no differences in intervention contact across wealth and education levels, suggesting that the program is effectively reaching women regardless of SES. However, women with other characteristics (e.g., higher parity, unknown or unreported HIV status) had lower odds of receiving the complete intervention. Overall, this work generates knowledge on existing disparities in intervention coverage and enables future programs to develop approaches to achieve equity in health care utilization and outcomes.

Bridging the gap: Implementation science, knowledge translation, and innovation for advancing maternal health sustainable development goals

Background: Maternal health remains a critical global concern, with sustainable development goal 3 aiming to reduce the maternal mortality ratio and ensure universal access to reproductive healthcare by 2030. According to a 2023 report, a woman dies from preventable causes related to pregnancy and childbirth every 2 minutes, and almost 70% of maternal deaths occur in sub-Saharan Africa. The reduction of maternal mortality and promotion of maternal health and well-being are complex tasks. Objective: To understand how a synergistic approach integrating complex interventions’ research, implementation science principles, knowledge translation, and innovative solutions can be leveraged to achieve sustainable improvements in maternal health outcomes in different contexts. Methods: This study employed sequential and iterative critical interpretive synthesis (CIS), integrative literature (ILR) review with multiscale analysis of extant literature on maternal health starting with the landmark Lancet series on “Maternal Survival” 2006 (5 papers); 2016 “Maternal Health” series (6 papers); the 2023 Series – “Maternal health in Perinatal period and Beyond” (4 papers); and health sector strategic plans. Results: Despite knowledge that healthcare is a complex adaptive system (CAS), whereas interventions for maternal health are considered complex interventions, the predominant implementation approaches assume a linear cause-effect approach, leading to the observed stagnation in maternal health. Conclusion: The effectiveness of complex interventions and their success in reaching relevant populations is critically influenced by their implementation in each context. A linear understanding of evidence translation, from ‘bench to bedside’, is naïve. This is because those who deliver, manage, and receive healthcare, negotiate multiple forms and sources of evidence, which complement and compete within a complex system of institutional logics.

Lived experiences of women during induction of labour at a tertiary hospital in Ghana: A qualitative study.

Induction of labour (IOL) has become a major and vital maternal health intervention to facilitate childbirth and minimize the rising caesarean section rates globally. However, there is limited information to facilitate appropriate client counselling, birth preparedness and informed decision making although the procedure has inherent tendency for adverse maternal/perinatal outcomes. Given the need for optimal client education and shared decision making in maternal health, this study explored women's knowledge and their lived experiences of IOL. This qualitative study used in-depth interviews, conducted at the largest teaching hospital in Ghana. Purposive sampling was used to recruit the study participants. Data analysis was performed based on thematic content using inductive framework synthesis. We included 17 women who had undergone IOL, delivered and discharged. Most participants(52.9%) were ≥30 years old, married(88.2%), and 41.1% had no previous childbirth experience. The main indications of IOL were postdate(47%), pre-eclampsia(29%) and gestational diabetes mellitus(11.8%). Data synthesis resulted in three broad themes: women's knowledge on IOL, women's experiences of care and women's difficult experiences including coping mechanisms. We determined mixed responses concerning the themes explored: adequate versus inadequate knowledge; positive versus negative experiences of care and satisfaction. Nearly all women mentioned vaginal examination as their most difficult experience due to severe pain, extreme discomfort, and being psychologically traumatic. The main coping strategy the women developed to navigate the traumatic vaginal examination was by "psyching" themselves. Our study indicates women encounter significant negative and positive experiences during IOL and childbirth in Ghana with vaginal examination cited as the most painful experience. Appropriate antenatal counselling, women empowerment and pre-labour education on childbirth processes and expectations are recommended to enhance birth preparedness and complication awareness. Health system improvement and regular refreshers courses for health workers are urgently required to promote positive women's experiences of care during labour induction and childbirth.

A composite index; socioeconomic deprivation and coverage of reproductive and maternal health interventions.

To examine inequalities in the coverage of reproductive and maternal health interventions in low- and middle-income countries and territories using a composite index of socioeconomic deprivation status. We obtained data on education and living standards from national household surveys conducted between 2015 and 2019 to calculate socioeconomic deprivation status. We assessed the coverage of reproductive and maternal health interventions, using three indicators: (i)demand for family planning satisfied with modern methods; (ii)women who received antenatal care in at least four visits; and (iii)the presence of a skilled attendant at delivery. Absolute and relative inequalities were evaluated both directly and using the slope index of inequality and the concentration index. In the 73 countries and territories with available data, the median proportions of deprivation were 41% in the low-income category, 11% in the lower-middle-income category and less than 1% in the upper-middle-income category. The coverage analysis, conducted for 48 countries with sufficient data, showed consistently lower median coverage among deprived households across all health indicators. The coverage of skilled attendant at delivery showed the largest inequalities, where coverage among the socioeconomically deprived was substantially lower in almost all countries. Antenatal care visits and demand for family planning satisfied with modern methods also showed significant disparities, favouring the less deprived population. The findings highlight persistent disparities in the coverage of reproductive and maternal health interventions, requiring efforts to reduce those disparities and improve coverage, particularly for skilled attendant at delivery.

High Child Mortality and Interventions Coverage in the City of Dar es Salaam, Tanzania: Are the Poorest Paying an Urban Penalty?

The 'urban penalty' in health refers to the loss of a presumed survival advantage due to adverse consequences of urban life. This study investigated the levels and trends in neonatal, post-neonatal and under-5 mortality rate and key determinants of child survival using data from Tanzania Demographic and Health Surveys (TDHS) (2004/05, 2010 and 2015/16), AIDS Indicator Survey (AIS), Malaria Indicator survey (MIS) and health facility data in Tanzania mainland. We compared Dar es Salaam results with other urban and rural areas in Tanzania mainland, and between the poorest and richest wealth tertiles within Dar es Salaam. Under-5 mortality declined by 41% between TDHS 2004/05 and 2015/2016 from 132 to 78 deaths per 1000 live births, with a greater decline in rural areas compared to Dar es Salaam and other urban areas. Neonatal mortality rate was consistently higher in Dar es Salaam during the same period, with the widest gap (> 50%) between Dar es Salaam and rural areas in TDHS 2015/2016. Coverage of maternal, new-born and child health interventions as well as living conditionswere generally better in Dar es Salaam than elsewhere. Within the city, neonatal mortality was 63 and 44 per 1000 live births in the poorest 33% and richest 33%, respectively. The poorest had higher rates of stunting, more overcrowding, inadequate sanitation and lower coverage of institutional deliveries and C-section rate, compared to richest tertile. Children in Dar es Salaam do not have improved survival chances compared to rural children, despite better living conditions and higher coverage of essential health interventions. This urban penalty is higher among children of the poorest households which could only partly be explained by the available indicators of coverage of services and living conditions. Further research is urgently needed to understand the reasons for the urban penalty, including quality of care, health behaviours and environmental conditions.