Maternal Health Issues Research Articles

Use of ADDIED Model to Develop Self Learning Material on Behavior Change Communication (BCC) related to Reproductive and Child Health Care and Assess its Effectiveness on Knowledge of Auxiliary Nurse and Midwives (ANMs) Regarding BCC for Antenatal Care

Introduction: As per WHO Every year an estimated 2,87,000 women die worldwide from complicationsrelated to pregnancy. Behavior Change Communication (BCC) is one of the most cost effective ways oftargeting the issues of maternal health . There is a need to sensitize the in service ANMs regarding thebenefits of adopting a systematic BCC intervention.Objective: 1: To develop self learning material on BCC for RCH care2: To assess effectiveness of Self learning material (SLM)on knowledge of ANMs regarding BCC forAntenatal careMethod: Study was based on ADDIE Model to develop instructional material. Researcher developedSLM with learning objective to describe the process of Behaviour Change Communication and relatedrole of ANMs, to acquire knowledge about relevant information about selected ANC issues, plan andconduct BCC sessions for the selected ANC issues. Structured questionnaire was developed by theresearcher consisting items on knowledge of BCC and information related to antenatal period for earlyregistration, Importance of TT immunization, Diet and Rest, Identification and treatment of Anemia,Hi-Risk Pregnancy, Importance of Institutional Delivery , Identification and treatment of RTI/STI. Onegroup pretest post-test time series design was used to assess the retention of knowledge among 94 studysample after reading the SLM up to three months.Result: Majority of In-service ANMs (ISAs) 67 (71.3%) were from the age group of 40 years andabove and had not attended any course /In service education programme on BCC. Finding shows thatSLM was significantly effective to enhance the pre-test mean knowledge score from 32.78 to 78 .61and 70.16 (p<.001).
 Conclusion: SLM was effective to improve the knowledge of In-service ANMs on BCC and relevant information related essentialhealth care practices during antenatal period

Associations of Enteric Protein Loss, Vaccine Response, Micronutrient Deficiency, and Maternal Depressive Symptoms with Deviance in Childhood Linear Growth: Results from a Multicountry Birth Cohort Study.

ABSTRACT.We identified the determinants of positive (children who had a birth weight < 2.5 kg and/or maternal height < 145 cm but were nonstunted at 24 months of age) and negative (children who had a birth weight ≥ 2.5 kg and maternal height ≥ 145 cm but were stunted at 24 months of age) deviance in childhood linear growth. We found that socioeconomic status (β = 1.54, P < 0.01), serum retinol (β = 0.05, P < 0.01), hemoglobin (β = 0.36, P < 0.01), length-for-age Z-score (LAZ) at birth (β = 0.47, P < 0.01), and tetanus vaccine titer (β = 0.182, P < 0.05) were positively and maternal depressive symptom (β = –0.05, P < 0.01), serum ferritin (β = –0.03, P < 0.01), male sex (β = –1.08, P < 0.01), and α1-antitrypsin (β = –0.81, P < 0.01) were negatively associated with positive deviance. Further, diarrhea episodes (β = 0.02, P < 0.01), male sex (β = 0.72, P < 0.01), and α1-antitrypsin (β = 0.67, P < 0.01) were positively and hemoglobin (β= –0.28, P < 0.01), soluble transferrin receptor level (β = –0.15, P < 0.01), and LAZ score at birth (β = –0.90, P < 0.01) were negatively associated with negative deviance. To summarize, enteric protein loss, micronutrient deficiency, vaccine responses and maternal depressive symptoms were associated with linear growth deviance in early childhood. In such a background, public health approaches aimed at reducing the risk of intestinal inflammation and altered gut permeability could prove fruitful in ensuring desired linear growth in children. In addition, maternal mental health issue should also be considered, especially for promoting better nutritional status in children in the context of linear growth deviance.

Maternal mortality in Afghanistan: Challenges, efforts, and recommendations

Maternal mortality is a major concern in Afghanistan. Even though the mortality rate is decreasing, Afghanistan still ranks below most countries in terms of maternal mortality. Challenges such as political instability, the COVID-19 pandemic, and unskilled staff are proving to be a burden on the healthcare system of Afghanistan, which has become an obstacle for the aim of further reducing the rate. Along with the struggling healthcare system, illiteracy and ignorance are further exacerbating the maternal health issues. In order to address these challenges, the Taliban must work alongside international organizations on improving the basic healthcare facilities, build more maternity clinics, provide better training for the medical staff, and educate citizens.

How Gender Influenced the Experience of Using a mHealth Intervention in Rural Mozambique: Secondary Qualitative Analysis of Community Health Worker Survey Data

BackgroundThe mixed-gender community health worker (CHW) program in Mozambique is a window into the different experiences that male and female CHWs may face in their work. The objective of this study is to investigate how gender influenced the experiences of community health workers using the PIERS on the Move (POM) mHealth app in Mozambique.MethodsThis is a secondary analysis by gender of health care workers involved in the Mozambique Community Level Intervention for Pre-eclampsia (CLIP) cluster randomized trial (NCT01911494). A structured survey with 10 open-ended questions was used to elicit CHW experiences using the POM app. Data collection took place in 2017 after completion of the CLIP trial. This analysis examined emergent themes to consider how experiences may have been shaped by health worker gender.ResultsOf the 43 CHWs who used the POM app, there were 31 (72%) women and 12 (28%) men. Gender differences emerged in descriptions of how using POM increased their value and respect by pregnant women and community members. Fifty-eight percent of female CHWs (18/31) said that POM positively influenced their status in the community in comparison to 33% of their male counterparts (4/12). While the small sample sizes, particularly of male CHWs who used POM, preclude conclusions, these findings were supported by qualitative results. Female CHWs tended to elaborate more about community perceptions of their increased value and status as health care providers than male CHWs.ConclusionCHWs work within existing gender norms. While gender norms are perceived to support the comfort of women to speak to another woman about their maternal and child health issues, gender norms also work against female CHWs as their professionalism may be questioned more than for their male counterparts. CHW's narratives suggested that the mHealth intervention was valued beyond the technology itself because it also added symbolic clinical value and demonstrated a tangible investment in their professional capacities, which may have been especially appreciated by the female CHWs.

From the Womb into the World: Protecting the Fetal Brain from Maternal Stress During Pregnancy

No other period in a child's life matches the speed of brain development than the first nine months in the womb. Rapid growth goes hand in hand with enormous potential, but also with great vulnerability. This policy-focused review focuses on maternal mental health as a key factor for fetal brain development. Already during pregnancy, the fetal brain wires differently when exposed to maternal stress, and children prenatally exposed to stress have a higher risk of developing neurodevelopmental disorders. Maternal prenatal stress is preventable, treatable, and tractable by policy. Research-based, policy recommends: (1) screening for maternal mental health issues throughout pregnancy, (2) encourage talking about prenatal mental health, (3) evidence-based interventions for pregnant women with mental health issues, (4) avoiding stress-inducing communication towards pregnant women, and (5) stimulating positive postnatal parenting. Investing in healthy pregnancies will improve fetal brain growth, and, ultimately lead to a healthier next generation.

Global health and its role

Global health and its role

A study to assess the perceived barriers in utilization of partograph

Background: Though maternal mortality can visualize the decreasing trends in India, but still we need to work hard for attaining sustainable development goals. As per the WHO, partograph must be used to monitor labor of all intra-natal mothers, but its implementation is limited due to various barriers experienced by health workers. The aim of the study was to assess the barriers which are experienced by the health care providers in actual utilization of the existing partograph.Methods:Qualitative research approach was adopted to understand the views related to the partograph. Interview techniques was adopted to collect data. Various focus group discussions were conducted from November 2018 to March 2019 to gather data related to barriers experienced by the partograph users in the hospital setting. The participants were from the health centres and educational institutions of Mohali and Patiala districts of Punjab.Results: Certain factors were highlighted in the discussion which needs to be addressed if we want that partograph should be used to its maximum potential. It brought to light various themes and factors which lead to underutilization of the existing partograph. The results highlighted the factors related to the partograph utilization, factors related to health centre, factors related to components of the partograph and enhancement of utilization of the partograph.Conclusions:It can be concluded that in developing countries like India, where we are still struggling with the maternal and child health issues, attention should be drawn to the actual problems faced by the health care providers so that maternal and perinatal outcomes can be improved.

Magnitude and determinants of unmet need for family planning among reproductive age women in East Africa: multilevel analysis of recent demographic and health survey data

IntroductionUnmet need for family planning is the main obstacle to achieve healthy timing and desired number of children. Decreasing the unmet need for FP respects and protects human right and help to decrease the influence on biodiversity. Unmet need for family planning is the contributor and devastating issue of maternal health. Therefore, meeting the unmet need of contraceptive averts the maternal death and poverty. Therefore, determining the magnitude and its determinants is very important to intervene and design appropriate program umbrella.ObjectiveTo determine the magnitude and its determinants of unmet need for family planning among reproductive age women in East Africa.MethodThis study was analyzed secondary data from Demographic and Health Surveys (DHS) of which contained detailed family planning for all interviewed women aged 15 to 49 years. The data were weighted using sampling weight before any statistical analysis to account the sampling design. STATA version 15 was used for extracting, editing, recoding, and multilevel analysis. Median odds ratio (MOR), proportional change in Variance (PCV), Intraclass correlation coefficient (ICC), and Akaike Information Criteria (AIC) was analyzed. Four model was build and the best model was selected based on the smallest Akaike Information Criteria (AIC). Both bivariable and multivariable multilevel analysis was done. Variable with p-value< 0.25 were selected for multivariable multilevel logistic regression analysis. Variables with p-value ≤5% declared as statistical significant with outcome variable.ResultsThe magnitude of unmet need for family planning was 24.66% (95%CI: 24.1–25.2). The identified determinants of unmet need for family planning was 30–39 years (AOR = 0.7; 95% CI 0.54–0.91), age of 40–49 (AOR = 0.76; 95% CI 0.58–0.99), rural residence (AOR = 1.17; 95% CI 1.02–1.34), female household head (AOR = 0.66; 95% CI 0.61–0.73), women having 4–6 child (AOR = 1.76; 95% CI 1.55–1.99), women having 7–9 child (AOR = 2.77; 95% CI 2.34–3.28) women having ≥10 child (AOR = 3.51; 95% CI 2.58–4.78), women who give their first birth 19-25 years (AOR = 1.1; 95% CI 1.0–1.26), 26–34 years (AOR = 1.4; 95% CI 1.19–1.83) ≥35 years (AOR = 2.1; 95% CI 1.1–4.27) and no fertility desire (AOR = 1.52; 95% CI 1.36–1.67) were the determinants of unmet need for family planning in east Africa.ConclusionUnmet need in east Africa is high as compare to other previous study. Maternal age, residence, sex of household head, number of children, age at first birth and fertility desire were the determinants identified in this study. Therefore, health interventions that reduce unmet need which enhance family planning service delivery among rural, male-headed household, women having more than three children and women who had no fertility desire needed in advance. Policies and programs of unmet need should be tailored the rural, young and no fertility desire women as well as male headed households.

Mothers' Experiences of Husband’s Involvement in Maternal Fetal Attachment: A Qualitative Study

Background: The involvement of husbands during pregnancy within the Iranian culture is one of the challenging topics. In this context, efforts to encourage male involvement in the maternal health issues can strengthen family bonds and consequently improve the relationships between men and women in societies. Objectives: This qualitative study aimed to elucidate the involvement of husbands in maternal-fetal attachment (MFA). Methods: Using a qualitative approach and conventional content analysis, 11 pregnant women referring to the health care centers in Sari, Iran were interviewed from March 2020 to February 2021. The participants met the maximum diversity criteria in terms of age, level of education, occupation, and socioeconomic status. Deep and unstructured interviews were utilized to obtain the research data. All the interviews were then transcribed verbatim and analyzed using the qualitative content analysis method developed by Graneheim and Lundman in MAXQDA Software. Results: A total of 350 codes emerged from the data. We identified a main theme entitled ‘husband support’, which included four categories and 11 sub-categories. The main categories were: (1) empathic response, (2) emotional support, (3) continued support, and (4) attention to fetus. Conclusions: Interventions to enhance husband support could increase MFA. Planning to promote male participation in pregnancy process is essential to promote maternal and child health.

Coverage of maternal health issues during the Covid 19 pandemic: A study of Uttarakhand in India

The COVID-19 pandemic impacted maternal health and health care services. Studies have argued that disruptions in public health result in damage leading to implications for vulnerable populations. Besides that, during the lockdown period, maternal health services dropped down at a significant rate leading to maternal mortality and morbidity in Uttarakhand. Government restricted the movement of the population by halting non-essential services, reducing public transport, and barriers to health care access. The hospital beds were overburdened with infected patients. There were differences observed in the maternal health care provided to the patients in the rural areas in comparison to urban counterparts. The digitalization era made it possible for the urban masses to avail of online consultation, whereas in the rural areas, the condition worsened due to a lack of technology, access, and connectivity. The print Media reflected maternal health issues due to restrictions in movement in different regions in Uttarakhand, namely, Haldwani, Berinag, Bajpur, Kashipur, and Sitarganj. The local communities had to face the challenges and bear loss due to preventable maternal deaths. This paper is an attempt to analyze the maternal health cases presented in local newspapers during the pandemic. The qualitative case studies from the local newspapers, Amar Ujala & The Hindustan, circulated in the regions of Uttarakhand, are mentioned in the study. The arguments in the study are presented based on content analysis from the period March 2020-April 2021.

What Women Really Think About Breastfeeding and Breast Pumping: A Qualitative Analysis of Women Who Deliver at a Baby-Friendly Hospital.

Introduction: The Baby-Friendly Hospital Initiative has had a positive impact on breastfeeding initiation; however, posthospital exclusive breastfeeding (EBF) rates remain low. We aimed to analyze thoughts and attitudes toward breastfeeding at the postpartum visit among women who deliver at a Baby-Friendly hospital. Methods: Women ≥14 years who delivered a live-born infant at our center were eligible. Participants completed an infant feeding questionnaire at the postpartum visit recording patient and delivery characteristics, antepartum care and infant feeding details, reasons for breastfeeding discontinuation or formula initiation, workplace environment, and cultural beliefs about breastfeeding. Thematic coding via line-by-line analysis of the free responses was performed using NVivo12 by QSR international. Results: Of 263 participants, 110 responded to the open-ended question. Of these, 53 and 46 were negative-toned and positive-toned, respectively. Negative breastfeeding responses related to the mother addressed the need for more support, low milk supply, pressure to breastfeed and feelings of guilt if unsuccessful, maternal health issues, painful breastfeeding, and high time requirements. Negative breastfeeding responses about the baby included concerns about infant health, latching issues, and disinterest. Positive responses focused on the support system, maternal weight loss, health benefits for baby, and mom-baby bonding. Some women (27) commented specifically on pumping. Negative comments noted that pumping led to less milk production, was time consuming, and was too much work. Positive comments about pumping noted that it is a convenient alternative to breastfeeding. Conclusion: Efforts to improve posthospital EBF rates in accordance with national guidelines must acknowledge the complex experience of breastfeeding mothers.

Socio-culturally adapted educational videos increase maternal and newborn health knowledge in pregnant women and female community health volunteers in Nepal's Khotang district.

Objectives:While Nepal has made significant improvements in maternal and newborn health overall, the lack of maternal and newborn health–related knowledge in the more rural parts of the country has led to significant disparities in terms of both maternal and newborn health service utilization and maternal and newborn health outcomes. This study aimed to assess whether viewing culturally adapted maternal and newborn health educational films had a positive impact on (1) the maternal and newborn health knowledge levels among pregnant women and (2) the postpartum hemorrhage–related knowledge levels among Female Community Health Volunteers in rural Nepal.Methods:Four locations were selected for their remoteness and comparatively high number of pregnancies. A convenience sample of 101 pregnant women and 39 Female Community Health Volunteers were enrolled in the study. A pre- and post-test design was employed to assess this intervention. Paired t-tests were used to analyze the change in number of correct responses by knowledge domain for multi-film participants, producing a numeric “mean knowledge score,” and McNemar’s tests were used to calculate the change and significance among select questions grouped into distinct themes, domains, and points of “maternal and newborn health–related knowledge” based on the priorities outlined in Nepal’s maternal and newborn health 2030 goals.Results:There was a significant improvement in knowledge scores on maternal and newborn health issues after watching the educational films for both types of participants. The mean knowledge score for pregnant women improved from 10 to 15 (P < 0.001) for the Understanding Antenatal Care (ANC) film, 3 to 10 (P < 0.001) for the Warning Sign in Pregnancy film, and 6 to 14 (P < 0.001) for the Newborn Care film. For the Female Community Health Volunteers, knowledge also significantly improved (P < 0.05) in all except one category after watching the postpartum hemorrhage film. The percent that correctly answered when to administer misoprostol (80%−95%) was the only variable in which knowledge improvement was not significant (P < 0.057).Conclusion:Using culturally adapted educational films is an effective intervention to improve short-term maternal and newborn health–related knowledge among rural populations with low educational levels. The authors recommend additional larger-scale trials of this type of intervention in Nepal and other low- and middle-income countries to determine the impact on long-term maternal and newborn health knowledge and behaviors among rural populations.

Use of ADDIED Model to Develop Self Learning Material on Behavior Change Communication (BCC) related to Reproductive and Child Health Care and Assess its Effectiveness on Knowledge of Auxiliary Nurse and Midwives (ANMs) Regarding BCC for Antenatal Care

Introduction: As per WHO Every year an estimated 2,87,000 women die worldwide from complicationsrelated to pregnancy. Behavior Change Communication (BCC) is one of the most cost effective ways oftargeting the issues of maternal health . There is a need to sensitize the in service ANMs regarding thebenefits of adopting a systematic BCC intervention.Objective: 1: To develop self learning material on BCC for RCH care2: To assess effectiveness of Self learning material (SLM)on knowledge of ANMs regarding BCC forAntenatal careMethod: Study was based on ADDIE Model to develop instructional material. Researcher developedSLM with learning objective to describe the process of Behaviour Change Communication and relatedrole of ANMs, to acquire knowledge about relevant information about selected ANC issues, plan andconduct BCC sessions for the selected ANC issues. Structured questionnaire was developed by theresearcher consisting items on knowledge of BCC and information related to antenatal period for earlyregistration, Importance of TT immunization, Diet and Rest, Identification and treatment of Anemia,Hi-Risk Pregnancy, Importance of Institutional Delivery , Identification and treatment of RTI/STI. Onegroup pretest post-test time series design was used to assess the retention of knowledge among 94 studysample after reading the SLM up to three months.Result: Majority of In-service ANMs (ISAs) 67 (71.3%) were from the age group of 40 years andabove and had not attended any course /In service education programme on BCC. Finding shows thatSLM was significantly effective to enhance the pre-test mean knowledge score from 32.78 to 78 .61and 70.16 (p&lt;.001). Conclusion: SLM was effective to improve the knowledge of In-service ANMs on BCC and relevant information related essentialhealth care practices during antenatal period

Analysis of Pesticides Residues in Breast Milk of primiparous and multiparous women in Gilgit

Milk contains all the essential nutrients like fats, proteins, and minerals. The utilization of contaminated food can induce a proportion of pesticides in the body. The main purpose of the study was to determine the pesticide residues and current status of breast milk in primiparous and multiparous mothers. In a current study, a total of 50 samples were collected from different areas of District Gilgit and Astore. The pesticides cypermethrin, deltamethrin, and chlorpyrifos were analyzed using gas chromatography. The presence of cypermethrin in 10 samples was in a range 0.00 – 0.012 mg/kg, while the detection of Deltamethrin in 07 with variation from 0.000.12mg/kg. Whereas chlorpyrifos was found in 05 samples with the ranges of 0.00-0.0062 mg/kg. Residue level was quite higher in urban areas than rural areas. The multiparous women had prominent residues level than primiparas and the concentration of Deltamethrin was higher than other pesticides. All the pesticides residues levels in the breast milk of primiparous and multiparous mothers were within the permissible limits of WHO. Yet the women of these areas are not vulnerable but prolong exposure may pose a serious threat to neonatal and maternal health and other relevant reproductive issues. To manage the risk of milk contamination in the future, the demand for public awareness campaigns and the adoption of alternative clean approaches to control pests and other disease-spreading vectors in the best interests of public health seems reasonable.

Viral Infections During Pregnancy: The Big Challenge Threatening Maternal and Fetal Health.

Viral infections during pregnancy are associated with adverse pregnancy outcomes, including maternal and fetal mortality, pregnancy loss, premature labor, and congenital anomalies. Mammalian gestation encounters an immunological paradox wherein the placenta balances the tolerance of an allogeneic fetus with protection against pathogens. Viruses cannot easily transmit from mother to fetus due to physical and immunological barriers at the maternal-fetal interface posing a restricted threat to the fetus and newborns. Despite this, the unknown strategies utilized by certain viruses could weaken the placental barrier to trigger severe maternal and fetal health issues especially through vertical transmission, which was not fully understood until now. In this review, we summarize diverse aspects of the major viral infections relevant to pregnancy, including the characteristics of pathogenesis, related maternal-fetal complications, and the underlying molecular and cellular mechanisms of vertical transmission. We highlight the fundamental signatures of complex placental defense mechanisms, which will prepare us to fight the next emerging and re-emerging infectious disease in the pregnancy population.

Maternal health and Indigenous traditional midwives in southern Mexico: contextualisation of a scoping review.

ObjectivesCollate published evidence of factors that affect maternal health in Indigenous communities and contextualise the findings with stakeholder perspectives in the Mexican State of Guerrero.DesignScoping review and stakeholder fuzzy cognitive mapping.Inclusion and exclusionThe scoping review included empirical studies (quantitative, qualitative or mixed methods) that addressed maternal health issues among Indigenous communities in the Americas and reported on the role or influence of traditional midwives before June 2020. The contextualisation drew on two previous studies of traditional midwife and researcher perspectives in southern Mexico.ResultsThe initial search identified 4461 references. Of 87 selected studies, 63 came from Guatemala and Mexico. Three small randomised trials involved traditional midwives. One addressed the practice of traditional midwifery. With diverse approaches to cultural differences, the studies used contrasting definitions of traditional midwives. A fuzzy cognitive map graphically summarised the influences identified in the scoping review. When we compared the literature’s map with those from 29 traditional midwives in Guerrero and eight international researchers, the three sources coincided in the importance of self-care practices, rituals and traditional midwifery. The primary concern reflected in the scoping review was access to Western healthcare, followed by maternal health outcomes. For traditional midwives, the availability of hospital or health centre in the community was less relevant and had negative effects on other protective influences, while researchers conditioned its importance to its levels of cultural safety. Traditional midwives highlighted the role of violence against women, male involvement and traditional diseases.ConclusionsThe literature and stakeholder maps showed maternal health resulting from complex interacting factors in which promotion of cultural practices was compatible with a protective effect on Indigenous maternal health. Future research challenges include traditional concepts of diseases and the impact on maternal health of gender norms, self-care practices and authentic traditional midwifery.

Do Women in Nepal Like Playing a Mobile Game? MANTRA: A Mobile Gamified App for Improving Healthcare Seeking Behavior in Rural Nepal.

In Low and Middle Income Countries (LMIC), one of the causes of maternal and child mortality is a lack of medical knowledge and consequently the inability to seek timely healthcare. Mobile health (mHealth) technology is gradually becoming a universal intervention platform across the globe due to ubiquity of mobile phones and network coverage. MANTRA is a novel mHealth intervention developed to tackle maternal and child health issues through a serious mobile game app in rural Nepal, which demonstrated a statistically significant knowledge improvement in rural women. This paper explores the perceptions and usability of the MANTRA app amongst rural women and Female Community Health Volunteers (FCHVs) in Nepal. Despite the challenges of a target user group with limited educational levels and low smartphone experience, all participants viewed the MANTRA app with approval and enthusiasm. They were willing to engage further with the mHealth intervention and to share their experience and knowledge with fellow community members. Participants also showed an increase in awareness of danger signs enabling them to make better informed health decisions in the future. FCHVs viewed the app as a validation tool providing and support for greater impact of their efforts in rural Nepal. Growing mobile ownership, network coverage and availability of smartphones along with acceptance of the prototype MANTRA app in rural communities suggest encouraging prospects for mHealth interventions to be incorporated in the national health infrastructure in Nepal and other LMICs.

Cesarean section: More than a maternal health issue.

A cesarean section (CS) can be a lifesaving intervention when medically indicated, but it may also lead to adverse short- and long-term health effects for women and children.

HEALTH CARE PROVIDERS’ VIEWS CONCERNING KNOWLEDGE AND PRACTICES OF TRADITIONAL BIRTH ATTENDANTS IN TAJIKISTAN: A QUALITATIVE STUDY

Introduction: This study seeks to explore health care providers’ perspectives of the traditional birth attendants’ knowledge and practices. Methods: This qualitative study was conducted in 2018 with 16 health care professionals working at various levels of maternal health care system in two purposefully selected research settings, Khorog town and Dushanbe, which have different social, economic and ethnic backgrounds. Semi-structured face-to-face interviews were conducted to gather the data. Duration of interviews ranged from 30-60 min. NVivo software for qualitative research was used to analyse the results. Results: This study has shown that health care workers have extremely negative views of the knowledge and practices of traditional birth attendants. They highlight the lack of adequate knowledge of traditional birth attendants on biomedical aspects of birth, poor skills in infections control and lack of use of clean delivery practices. They also claim that the traditional birth attendants’ practices also lead to different complications while they are woefully unprepared to recognize obstetric complications during birth. Conclusion: The study recommends providing a skilled birth attendant in every area. It also recommends avoiding a homogeneous approach to address maternal health issues in diverse countries of the Global South and reviewing maternal health care policies and programs to provide the most marginalized groups of women with skilled birth services to improve their maternal health and further decrease maternal mortality in Tajikistan.

Overcoming the challenges of community-engaged emergency referrals in a rural district of Pakistan

A functional referral system for addressing maternal and child health issues requires coordinated efforts by health system stakeholders and community. Using Rural Health Program (RHP) Thatta as platform provided by an academic institution, district health system stakeholders and community of Mirpur Sakro taluka of Thatta were engaged to strengthen the emergency referral system for maternal and child health emergencies through active community engagement. Through combined consultation, referral system plan for maternal and child health emergencies was developed. Community volunteers from each village liaised for transportation, referring patients to health facilities and maintaining referral documentation. An ambulance service under contract with health department and private transporters were taken on-board to facilitate patients’ transportation. Community’s experiences of referral system were assessed through qualitative in-depth interviews. Patients’ experiences of referral system improved but faced structural challenges including out of pocket transport expenses, direct self-referrals, Continuous...