Maternal Health Interventions Research Articles

Intervening factors in health care professionals’ attitudes and behaviours towards comprehensive abortion care in the workplace: a comparative case study of Tanzania and Ethiopia

Purpose Health care professionals’ attitudes and behaviours play a fundamental role in the provision of timely comprehensive abortion care as a maternal health intervention and save hundreds of thousands of women’s lives, annually. This study explores underlying factors influencing Tanzanian and Ethiopian health care professionals’ attitudes and behaviours towards comprehensive abortion care between 2015 and 2020. Materials and methods The study inductively explored Ethiopian and Tanzanian health care professionals’ behaviours using a comparative case study design and a textual analytical approach. Published and unpublished literature, documents and newspapers were used as data sources. The two cases were selected because of their different approaches towards the governance of abortion care, one gradually legalising while the other persistently restricting. Results Results demonstrated that there are both subjective (beliefs, attitudes, images, pre-dispositions) and objective (institutional incapacity) factors that impact the actions of health care professionals in the work environment. Conclusions The study concluded that the intervention of subjective factors results from the institutional failure to effectively bridge the divide between governance and accessibility of safe abortion care.

Are the Poor Catching Up with the Rich in Utilising Reproductive, Maternal, New Born and Child Health Services: An Application of Delivery Channels Framework in Indian Context

The article is aimed to assess trends in wealth-related inequalities in coverage of reproductive, maternal, neonatal and child health (RMNCH) interventions using delivery channels framework in Indian context, at national level as well as at state level—Tamil Nadu (TN) and Chhattisgarh (CG)—a better off and poorer state, respectively. We used National Family Health Survey—3rd (2005–2006) and 4th (2015–2016) to study the trends and differentials of inequalities in the RMNCH coverage. We have used two summary indices—absolute inequalities using the slope index of inequality (SII) and relative inequalities using the concentration index (CIX). Culturally driven interventions had pro-poor inequalities in TN, CG and in India, but the coverage has improved significantly for the women from wealthier households recently. Environmental interventions were highly inequal in distribution, particularly for the ‘use of clean fuels’. Inequalities in the coverage of health facilities-based interventions has reduced in TN, CG and overall India, but more so in TN. The inequalities in coverage of community-based interventions have reduced over the period of ten years in TN, CG as well as at national level. Adopting RMNCH delivery channel framework could be useful for assessing and monitoring the progress of public health programmes. Policy makers can gain insights from the success of coverage of various interventions and determine specific implementation strategies to reduce inequalities in the coverage and its effectiveness.

Scoping review of maternal and newborn health interventions and programmes in Nigeria

ObjectiveTo systematically scope and map research regarding interventions, programmes or strategies to improve maternal and newborn health (MNH) in Nigeria.DesignScoping review.Data sources and eligibility criteriaSystematic searches were conducted from 1...

Using theory of change in child health service interventions: a scoping review protocol.

Background: The objective of this scoping review is to map the evidence of how child health service interventions use their theory of change. A theory of change is a hypothesis of how and why an intervention is intended to bring about change. It can be used as a program design, implementation, and evaluation tool. This scoping review will provide an overview of the evidence base for, and identify the way in which, theories of change in child health service interventions are defined, rationalised, developed, presented, and refined. Methods: The inclusion criteria for this scoping review is any child health service intervention globally, that describes their theory of change or theory of change development process. Relevant exclusions include: logic models or logic frameworks that do not meet this review's definition of theory of change, systematic reviews, behavioural change interventions that target patient's behaviour, school-based interventions, and maternal health interventions not related to child health outcomes. This scoping review will follow the Joanna Briggs Institute Reviewer's manual. Relevant publications will be first searched on selected electronic databases and grey literature. A search strategy will be developed. The search will be limited to articles written in the English language. Results of the search will be curated using Endnote and duplicates removed. Results will be imported to Rayyan. The inclusion criteria will be applied during the process of title and abstract screening, by two independent reviewers and disagreements resolved by a third independent reviewer. Full-texts will have the inclusion criteria applied via the same reviewer process. Data relevant to the research sub-questions will be extracted, analysed, charted and discussed. Ethics and dissemination: Ethical approval is not required for this review as we will make use of already published data. We aim to publish the findings of our review in a peer-reviewed journal.

Geographical variation and predictors of zero utilization for a standard maternal continuum of care among women in Ethiopia: a spatial and geographically weighted regression analysis

BackgroundMaintaining and effectively utilizing maternal continuum of care could save an estimated 860,000 additional mothers and newborn lives each year. In Ethiopia, the number of maternal and neonatal deaths occurred during pregnancy, childbirth, and the postpartum period was very high. It is indisputable that area-based heterogeneity of zero utilization for a standard maternal continuum of care is critical to improve maternal and child health interventions. However, none of the previous studies explored the spatial distribution of zero utilization for maternal continuum of care. Hence, this study was aimed to explore geographical variation and predictors of zero utilization for a standard maternal continuum of care among women in Ethiopia.MethodsA total of 4178 women who gave birth five years preceding the 2016 Ethiopian demographic and health survey were included. ArcGIS version 10.7, SaT Scan version 9.6, and GWR version 4.0 Software was used to handle mapping, hotspot, ordinary least square, Bernoulli model analysis, and to model spatial relationships. Finally, a statistical decision was made at a p-value< 0.05 and at 95% confidence interval.Main findingsThe proportion of mothers who had zero utilization of a standard maternal continuum of care was 48.8% (95% CI: 47.3–50.4). Hot spot (high risk) regions for zero utilization of maternal continuum of care was detected in Afder, Warder, Korahe and Gode Zones of Somali region and West Arsi Zone of Oromia region. Respondents who had poor wealth index, uneducated mothers, and mothers who declared distance as a big problem could increase zero utilization of maternal continuum of care by 0.24, 0.27, and 0.1 times.ConclusionFive women out of ten could not utilize any components of a standard maternal continuum of care. Hot spot (high risk) areas was detected in Afder, Warder, Korahe and Gode Zones of Somali region and West Arsi Zone of Oromia region. Poor wealth index, uneducated mothers, and mothers who declare distance as a big problem were factors significantly associated with zero utilization of maternal continuum of care. Thus, geographical based intervention could be held to curve the high prevalence of zero utilization of maternal continuum of care.

Factors associated with maternal tetanus vaccination in Myanmar: An analysis of demographic and health survey data

BackgroundTetanus toxoid vaccination is a life-saving maternal and child health intervention. Understanding gaps in maternal vaccination coverage is key to informing progress towards universal health coverage. We assessed the vaccination coverage in Myanmar and investigated factors associated with being unvaccinated. MethodIn this cross-sectional analysis of 2015–16 Demographic and Health Survey data including women aged 15–49 years with at least one childbirth in the last five years. The outcome maternal tetanus vaccination during her last pregnancy, defined as protected against neonatal tetanus based on the Myanmar National Guidelines for Antenatal Care. We also examined mothers who missed a second dose of tetanus toxoid containing vaccine (TTCV) by states and regions. We used logistic regression models to assess factors associated with being unvaccinated. ResultsOverall maternal tetanus vaccination coverage was 72%. At subnational level, the percent unvaccinated was highest in Shan State (42%), followed by Magway Region (33%), Kayin State (33%), and Sagaing Region (32%). The percentage of mothers who missed a second dose of TTCV was high predominantly in regions, rather than states. We found that the percentage of unvaccinated mothers was higher among younger mothers, and mothers with lower educational attainment. No antenatal care (ANC) or receiving ANC in non-public healthcare facilities were strongly associated with being unvaccinated. Differences in percent unvaccinated by maternal age were largely mediated through their healthcare access, particularly ANC services. InterpretationWe identified regional, structural, and individual differences in maternal tetanus vaccination coverage. Factors influencing mothers who missed a second dose of TTCV warrant further investigation. Achieving universal coverage of maternal tetanus vaccination will largely depend on the ability to provide accessible antenatal care to most women who do not currently receive it.

Determinants of practice of birth preparedness and complication readiness among pregnant women in Sodo Zuria District, Southern Ethiopia: Content analysis using Poisson's regression.

Objectives:Every pregnancy can face risk. One of the World Health Organization recommendations for health promotion interventions for maternal and newborn health was to increase birth preparedness and complication readiness. The main objective of this recommendation was to increase the use of skilled care at birth and to increase the timely use of facility care for obstetric and newborn complications. However, to the best of our knowledge, there is a dearth of documented evidence on the magnitude of birth preparedness and complication readiness and factors associated with it in our study area. Thus, the aim of this study was to identify factors affecting the practice of birth preparedness and complication readiness.Methods:A community-based cross-sectional study was carried out from 15 February to 15 March 2020. A total of 698 pregnant women were randomly selected and interviewed using a pretested semi-structured questionnaire. A multivariate generalized linear regression with Poisson link was carried out to see the effect of each independent variable on the dependent variable.Result:Of the sampled 710 participants, 698 participated, which made a response rate of 98.3%. The mean score of practice of birth preparedness and complication readiness was 3.3 (standard deviation = 1.8). Mothers who used pre-pregnancy contraception methods (adjusted odds ratio = 1.22 (95% confidence interval = 1.09, 1.37)), used bare feet as a mode of transportation (adjusted odds ratio = 1.11 (95% confidence interval = 1.01, 1.21)), used more antenatal care content (adjusted odds ratio = 1.09 (95% confidence interval = 1.06, 1.13)), and whose husbands were educated at the primary level of education (adjusted odds ratio = 1.19 (95% confidence interval = 1.03, 1.37)) were predictors in multivariable general.Conclusion:The mean score and overall practice of birth preparedness and complication readiness were low. This study revealed a low level of birth preparedness and complication readiness. In order to improve access to lifesaving care for women and neonates, there is a pressing need for implementation of existing strategies to increase practice of birth preparedness and complication readiness.

Payment Subsidy and Equity in Access to Health Care: The Case of the Democratic Republic of Congo

Since the 2000s, the Democratic Republic of Congo has adopted national policies to phase out direct payment at the point of service to make health care more accessible. The objective of this study is to measure inequalities in access and financing of a subsidised health system. The measurement of inequalities in access and financing was applied to data from the Improved Monitoring for Action (N = 475 households in the Tshilenge health zone, East Kasai province, Democratic Republic of Congo), which is part of the evaluation of the performance of the health system through high-impact interventions for maternal, newborn and child health. The concentration curve and index (CI) method was used to assess the degree of inequality in the distribution of health care consumption and expenditures. A negative CI indicates a disproportionate concentration of subsidies among the poor, while a positive CI indicates that the subsidy is favourable to the rich; a CI of zero indicates perfect equity. In addition, the Kakwani Progressivity Index (KPI) was used to assess the progressivity of direct household spending on care. A positive value of the KPI indicates the progressivity of the system and a negative value its degressivity. The indices of concentration of use are respectively 0.034 for self-medication and -0.050 for use of a health facility, and the indices of standardised use are 0.00 in both cases. Comparison of the standardised and non-standardised concentration of use curves shows that standardisation reduces the differences between quintiles: there is horizontal equity of use after indirect standardisation. All Lorenz curves are below the standard of the living curve (the KPIs are significantly negative). Health expenditure is therefore all-regressive. The measurement of the degree of equity showed that there is imperfect equity in the use of care and that the system of financing care is inequitable and regressive. Direct household spending increases inequities in access. The contribution is greater for the lowest income groups. The low budget of the health sector prohibits universality and free access to services by producing a recourse to self-medication and renunciation of care.

A study on prevalence of anemia among antenatal females registered at rural health training centre, Budhi in district Kathua

Background: Anemia has been recognized as the most common form of nutritional deficiency worldwide, particularly in developing countries like India. Anemia is a public health problem in both developed and developing countries. It affects 1.62 billion people globally, which corresponds to 24.8% of the world population. Though anemia is easily treatable and preventable disease, it continues to be significantly associated with pregnancy. The aims of the study were to determine the magnitude of anemia in pregnant women according to severity and to find out association of anemia with different variables.Methods: The present study was a retrospective type of study which was conducted over a period of 2 years. A total of 109 antenatal females were registered over the period of 2 years.Results: The most common age group seen was 26-30 years (45%), majority of females were Hindu (95.4%) and belonged to lower socio-economic status (52.3%). The obstetrics history of the antenatal females’ shows, majority of them registered themselves in their 1st trimester (73.4%) and around 22.1% of the females had birth interval between 2-3 years, followed by 1-2 years. Majority of them had moderate anemia (82%), followed by mild anemia (10%). Only 1% of females had severe anemia while rest had no anemia (7%).Conclusions: This study revealed a high prevalence of anemia in antenatal females, irrespective of religion, socio-economic status, etc. anemia is found to be endemic in this region, due to various unfavorable socio-demographic factors. Strengthening of the existing adolescent and maternal health interventions focusing towards anemia screening and prevention among reproductive age group.

Ambivalence and moral dilemmas in women's lived experiences of obesity and pregnancy: Qualitative insights for maternal lifestyle interventions.

Maternal obesity is a global health concern that is associated with significant effects on both short- and long-term health of both mother and child. However, maternal lifestyle interventions tend to focus solely on diet and physical activity in ways that disembody and disengage the social context in which women live their lives. The aim of this study was to explore the lived experiences of maternal obesity and delve into how experiences of the body and motherhood affect women's motivation for participating in a postpartum lifestyle intervention. A qualitative study using in-depth semi-structured interviews based on participant-generated photographs was used to allow the women to openly express their lived experiences of maternal obesity. The study emanated from a gynaecological department of a major Danish hospital, and five pregnant or postpartum women living with obesity participated. Interviews were audio recorded, transcribed and analysed using an Interpretive Phenomenological Approach. The analysis identified an overall theme of ambivalence and four subthemes among the participating women. The themes reflected contrasting feelings where the obese body was simultaneously an arena for aesthetic failure, functional success and moral dilemmas. Experiences of weight stigma and moral accusations in healthcare settings further increased the women's sense of ambivalence and challenged their strong desire to lose weight. This study highlights an ambivalent and vulnerable situation of maternal obesity which makes moral sensitivity towards weight and body concerns crucial to consider in future maternal health interventions. Our data suggest that an emphasis on functionality and capability rather than aesthetics and measured ideals would be useful in providing care and support in postpartum lifestyle interventions for women living with obesity.

Universal coverage of the first antenatal care visit but poor continuity of care across the maternal and newborn health continuum among Nepalese women: analysis of levels and correlates

BackgroundRoutine maternity care visits (MCVs) such as antenatal care (ANC), institutional delivery, and postnatal care (PNC) visits are crucial to utilisation of maternal and newborn health (MNH) interventions during pregnancy-postnatal period. In Nepal, however, not all women complete these routine MCVs. Therefore, this study examined the levels and correlates of (dis)continuity of MCVs across the antenatal-postnatal period.MethodsWe conducted further analysis of the 2016 Nepal Demographic and Health Survey. A total of 1,978 women aged 15–49 years, who had live birth two years preceding the survey, were included in the analysis. The outcome variable was (dis)continuity of routine MCVs (at least four ANC visits, institutional delivery, and PNC visit) across the pathway of antennal through to postnatal period. Independent variables included several social determinants of health under structural, intermediary, and health system domains. Multinomial logistic regression was conducted to identify the correlates of routine MCVs. Relative risk ratios (RR) were reported with 95% confidence intervals at a significance level of p<0.05.ResultsApproximately 41% of women completed all routine MCVs with a high proportion of discontinuation around childbirth. Women of disadvantaged ethnicities, from low wealth status, who were illiterate had higher RR of discontinuation of MCVs (compared to completion of all MCVs). Similarly, women who speak Bhojpuri, from remote provinces (Karnali and Sudurpaschim), who had a high birth order (≥4), who were involved in the agricultural sector, and who had unwanted last birth had a higher RR of discontinuation of MCVs. Women discontinued routine MCVs if they had poor awareness of health mother-groups and perceived the problem of not having female providers.ConclusionsRoutine monitoring using composite coverage indicators is required to track the levels of (dis)continuity of routine MCVs at the maternity care continuum. Strategies such as raising awareness on the importance of maternity care, care provision from female health workers could potentially improve the completion of MCVs. In addition, policy and programmes for continuity of maternity care are needed to focus on women with socioeconomic and ethnic disadvantages and from remote provinces.

Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention

IntroductionDespite ongoing maternal health interventions, maternal deaths in Tanzania remain high. One of the main causes of maternal mortality includes postoperative infections. Surgical site infection (SSI) rates are higher in...

Impact of COVID-19 on maternal and perinatal outcomes in Harare, Zimbabwe: a comparative maternal audit

Background The COVID-19 pandemic lockdown resulted in the disruption of health services in Zimbabwe. The objectives of this study were two-fold. First, the study sought to determine the impact of the lockdown on maternal and perinatal outcomes at two tertiary hospitals in Harare, Zimbabwe, using a maternal audit. Second, the study sought to estimate the potential effect of COVID-19 related decreases in coverage of maternal and newborn health interventions on maternal, and neonatal mortality in Zimbabwe using the Lives Saved Tool (LiST). Methods A retrospective review of labour ward delivery registers, postnatal records and patients’ maternity booklets was conducted. Data on total hospital deliveries, mode of delivery, and maternal and neonatal outcomes for March-August 2020 were abstracted and compared to data from March-August 2019. Logistic regression was performed to assess the association between maternal and perinatal outcomes and year as a proxy for the COVID-19 pandemic impact. Based on changes in coverage of interventions, LiST was used to estimate the impact of COVID-19 related disruptions on maternal and neonatal mortality at the national level. Results A total of 19,835 hospital deliveries that occurred at Sally Mugabe and Mbuya Nehanda Maternity Hospitals (11,346 for 2019 and 8,489 for 2020) were reviewed. Compared to 2019, there was a significant increased likelihood of breech deliveries (odds ratio, OR=1.2; 95% confidenxce interval, CI=1.1-1.5), uterine ruptures (OR=2.3; 95% CI=1.1-5.1), stillbirths (OR=1.8; 95% CI=1.5-2.2) and neonatal deaths (OR=1.4; 95% CI=1.03-1.86) in 2020. However, there was a decrease in the odds of caesarean deliveries (OR=0.7; 95% CI=0.7-0.8). From the LiST analysis, if similar disruptions to maternity services were observed across the country for a 12 month period, there would be an excess of 343 maternal deaths, 2,658 neonatal deaths and 450 stillbirths nationally. Conclusions These findings indicate a reduction in the utilisation of maternal health services and an increased risk of adverse maternal and neonatal outcomes during the nationwide lockdown. The provision of maternal and neonatal health services amid the pandemic remains crucial to reducing the negative indirect impacts of the pandemic.

The impact of a maternal mental health intervention on intimate partner violence in Northern Ghana and the mediating roles of social support and couple communication: secondary analysis of a cluster randomized controlled trial

BackgroundsDiverse intervention efforts are implemented to address intimate partner violence (IPV) against women. Via a syndemics theory lens and emerging empirical evidence, mental health interventions demonstrate promise to partially ameliorate IPV. However, the mechanisms of change underlying many IPV interventions are not well understood. These gaps impede our efforts to strengthen or integrate effective components into the current mental health resources, especially in low- and middle-income countries (LMICs). This study aims to examine the impact of a maternal mental health intervention called Integrated Mothers and Babies Course & Early Childhood Development (iMBC/ECD) on IPV and whether social support and/or couple communication mediates the intervention effects among women in rural, Northern Ghana.MethodsThe current study is a secondary data analysis of a cluster randomized controlled trial. IPV was measured at baseline and 8 months post-intervention (~ 19 months post-baseline). At baseline, 84.8% of the women enrolled in the study (n = 374) reported some type of IPV in the past 12 months. Logistic regression models and multiple mediation analyses were used to address the study aims.ResultsiMBC/ECD did not reduce IPV in the intervention group compared to the control group. Social support and couple communication did not mediate the intervention effects on IPV as indicated by the indirect effects of the multiple mediation models. However, increase in social support reduced women’s odds of experiencing emotional violence by 7%, odds ratio (OR) = 0.93, p = 0.007; b = − 0.07, 95% confidence interval (CI) = (− 0.13, − 0.02), and improvement in couple communication demonstrated promise in reducing women’s odds of experiencing controlling behaviors by 7%, OR = 0.93, p = 0.07; b = − 0.07, CI = (− 0.14, 0.005), though the improvements were not due to the intervention.ConclusionThis maternal mental health intervention did not reduce IPV; however, the findings extend our knowledge about the impact of such interventions on IPV and the potential mechanisms of change via social support and couple communication. Future research evaluating the impact of mental health interventions on IPV and mechanisms of change is essential for the development of effective interventions. Future programs addressing IPV in LMICs should consider risk factors beyond relationship level (e.g. poverty and gender inequity).Trial registrationClinicalTrials.gov # NCT03665246, Registered on August 20th, 2018.

Maternal and child factors associated with early initiation of breastfeeding in Chad: evidence from nationally representative cross-sectional data.

BackgroundEarly initiation of breastfeeding (EIB) is an inexpensive practice but has a substantial potential to reduce neonatal morbidity. Therefore, this study investigated the maternal and child-related factors associated with EIB and makes recommendations that could help improve the practice in Chad.MethodsWe used data from the children's recode file of the 2014–2015 Chad Demographic and Health Survey. A total of 3991 women ages 15–49 y who had last-born children in the 2 y preceding the survey were included in our study. The outcome variable for the study was EIB. Both descriptive (frequencies and percentages) and inferential (binary logistic regression) analyses were carried out. All results of the binary logistic analyses are presented as adjusted odds ratios (aORs) with 95% confidence intervals (CIs).ResultsWe found the prevalence of EIB in Chad to be 23.8%. In terms of maternal factors, the likelihood of EIB was high among non-working women (aOR 1.37 [95% CI 1.18 to 1.59]), the richest wealth quintile women (aOR 1.37 [95% CI 1.04 to 1.79]) and non-media-exposed women (aOR 1.58 [95% CI 1.24 to 2.02]) compared with working women, the poorest wealth quintile women and media-exposed women, respectively. EIB was lower among children whose mothers had one to three antenatal care visits (ANC; aOR 0.73 [95% CI 0.61 to 0.87]) and four or more ANC visits (aOR 0.80 [95% CI 0.66 to 0.97]) compared with those who had no ANC visits. With the child factors, EIB was higher among mothers of children who were smaller than average size at birth compared with those of larger than average birth size (aOR 1.47 [95% CI 1.24 to 1.74]). Mothers of children of fifth-order or more births compared with those of first-order births (aOR 1.51 [95% CI 1.07 to 2.12]) and those who were delivered through vaginal birth compared with those delivered through caesarean section (aOR 4.71 [95% CI 1.36 to 16.24]) were more likely to practice EIB.ConclusionsMaternal and child-related factors play roles in EIB in Chad. Hence, it is important to consider these factors in maternal and neonatal health interventions. Such initiatives, including training of outreach health workers, health education, counselling sessions and awareness-raising activities on breastfeeding geared towards EIB should be undertaken. These should take into consideration the employment status, wealth quintile, exposure to mass media, size of the baby at birth, ANC visits, parity and delivery method.

1354Delivery channels and socioeconomic inequalities in coverage of RMNCH interventions: analysis across 36 LMICs

Abstract Background Socioeconomic inequalities in the coverage of reproductive, maternal, neonatal, and child health (RMNCH) interventions have been frequently described in global reports, but little is known about how inequalities vary across indicators in low- and middle-income countries (LMICs). Methods In this cross-sectional study, we identified publicly available national surveys from LMICs. We identified the most recent survey from the period 2010–19 for 36 countries containing data for our preselected set of 18 RMNCH interventions. Twenty-one countries also had information on two common malaria interventions. We classified interventions into four groups according to their predominant delivery channels: health facility-based, community-based, environmental, and culturally driven. We estimated absolute inequalities using the slope index of inequality (SII) and relative inequalities using the concentration index (CIX). Results We observed higher coverage levels among wealthier households than poorer households for most interventions in most countries, except for two breastfeeding indicators showing higher coverage for poor households than wealthy households. Environmental interventions were the most unequal, particularly use of clean fuels. Primarily health facility-based interventions—e.g. institutional childbirth—also usually had pro-rich patterns. By comparison, primarily community-based interventions, including those against malaria, were more equitably distributed. Conclusions Community-based interventions are usually more equitably distributed than health facility-based or environmental interventions. Policymakers need to learn from community delivery channels to promote more equitable access to all RMNCH interventions. Key messages The delivery channels framework is useful for designing equitable health policies and programmes, which must adapt the successes of community-based interventions to all RMNCH interventions.

The CHAMNHA project: defining heat impacts on maternal and neonatal health and testing adaptive interventions in Burkina Faso and Kenya

BACKGROUND AND AIM: Heat exposure increasingly threatens the health of pregnant women, foetuses and neonates, especially in low-resource settings. The CHAMNHA project documents the size and nature of these threats, pathways to impacts, and intervention effectiveness in Africa. METHODS: We assess heat impacts in pregnancy using systematic reviews and statistical modelling of existing data from birth registries and cohorts. These findings, together with multi-component qualitative enquiries will inform co-design and then testing of facility- and community-level interventions. RESULTS:More than 100 studies on heat exposure in pregnancy were located, demonstrating clear patterns of heat impacts, though methodological and statistical heterogeneity are considerable. Gaps in existing evidence are being addressed in time-series analyses of pregnancy outcomes and breastfeeding patterns in Burkina Faso and South Africa. While in Sweden, birth outcomes in a countrywide population-level database from 2014-2020 are being correlated with 1x1km2 grid exposure data. In qualitative research in urban Ouagadougou and rural sites in Burkina Faso and Kenya, pregnant women, male partners and other key informants have described multiple effects of heat on daily activities, and the health and wellbeing of pregnant women and neonates. In Burkina Faso women recounted a range of heat-related symptoms in themselves and their foetus, and obstacles that extreme heat poses to health facility access and care quality. For women in Kenya, heat exposure and water shortages are inextricably linked, and interventions addressing either hazard in isolation may have limited efficacy. Participatory workshops will advance data interpretation and intervention co-design. Interventions at facility-level in Burkina Faso and with community health workers in Kenya will be implemented and evaluated over nine months. CONCLUSIONS:The project heighten attention of policy makers and funders to the vulnerabilities of pregnant women to heat exposure and climate change, and the need for commensurate responses at multiple levels. KEYWORDS: Temperature, Female, Maternal health, neonates, time-series analysis

Care Around Birth Approach: A Training, Mentoring, and Quality Improvement Model to Optimize Intrapartum and Immediate Postpartum Quality of Care in India.

With the highest risk of maternal and newborn mortality occurring during the period around birth, quality of care during the intrapartum and immediate postpartum periods is critical for maternal and neonatal survival. The United States Agency for International Development's Scaling Up Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions project, also known as the Vriddhi project, collaborated with the national and 6 state governments to design and implement the Care Around Birth approach in 141 high caseload facilities across 26 high-priority districts of India from January 2016 to December 2017. The approach aimed to synergize evidence-based technical interventions with quality improvement (QI) processes, respectful maternity care, and health system strengthening efforts. The approach was designed using experiential training, mentoring, and a QI model. A baseline assessment measured the care ecosystem, staff competencies, and labor room practices. At endline, the approach was externally evaluated. Availability of logistics, recording and reporting formats, and display of protocols improved across the intervention facilities. At endline (October-December 2017), delivery and newborn trays were available in 98% of facilities compared to 66% and 55% during baseline (October-December 2015), respectively. Competency scores (> 80%) for essential newborn care and newborn resuscitation improved from 7% to 70% and from 5% to 82% among health care providers, respectively. The use of partograph in monitoring labor improved from 29% at the baseline to 61%; administration of oxytocin within 1 minute of delivery from 35% to 93%; newborns successfully resuscitated from 71% to 96%; and postnatal monitoring of mothers from 52% to 94%. The approach successfully demonstrated an operational design to improve the provision and experience of care during the intrapartum and immediate postpartum periods, thereby augmenting efforts aimed at ending preventable child and maternal deaths.

Effectiveness of a short-structured training programme on knowledge of healthcare providers and programme managers involved in maternal and child health programmes in Odisha, India: a quality improvement study

ObjectiveTo evaluate the effectiveness of training programme on knowledge related to new interventions proposed under India Newborn Action Plan (INAP) and Integrated Action Plan against Pneumonia and Diarrhoea (IAPPD).DesignQuality improvement...

Success Factors for Community Health Workers in Implementing an Integrated Group-Based Child Development Intervention in Rural Bangladesh.

Community Health Workers (CHWs) can effectively implement maternal and child health interventions, but there is paucity of evidence on how to integrate child stimulation into these interventions, and their delivery at scale. In rural Bangladesh, CHWs implemented an intervention integrating psychosocial stimulation, nutrition, maternal mental health, water, sanitation, hygiene (WASH) and lead exposure prevention. In each of 16 intervention villages, one CHW worked with 20 households. CHWs bi-weekly held group meetings or alternated group meetings and home visits with pregnant women and lactating mothers. We assessed the intervention through five focus groups, four interviews and one group discussion with CHWs and their supervisors to explore success factors of implementation. CHWs’ training, one-on-one supervision and introduction by staff to their own community, and adoption of tablet computers as job aids, enabled successful session delivery to convey behavioral recommendations. CHWs reported difficulties delivering session due to the complexity of behavioral recommendations and struggled with age-specific intervention material. Young children’s attendance in group sessions generated distractions that undermined content delivery. We identified ways to minimize the difficulties to strengthen intervention-delivery during implementation, and scale-up. Iterative revisions of similarly integrated interventions based on qualitative evaluation findings could be delivered feasibly by CHWs and allow for implementation at scale.