Quality Maternal Health Research Articles

Unraveling the Multifactorial Determinants of Miscarriage: Insights from SEM Analysis of Maternal Characteristics, Lifestyle Factors, and Antenatal Care

Background: This paper establishes that miscarriage is still a major determinant of maternal health, with the implication that factors such as maternal age, lifestyle factors, socioeconomic status and antenatal care visits affect the condition. This knowledge of factors involved can help in designing ways of ensuring they do not lead to miscarriages. Objective: The purpose of this work was to examine the relationship between a range of maternal lifestyle behaviors, education, visits to the antenatal care facility, and miscarriage rates by using structural equation modelling (SEM). Methods: Assuming a female population of 2000, data was generated on Maternal Age, education, Smoking, alcohol, exercise, Antenatal Care visits and an outcome variable representing miscarriage. SEM was employed to test the hypothesized relationships of these variables with Latent Lifestyle Risks captured under the observed behavior (smoking, alcohol use, exercise). To check the model fit, the following fit measure was used; Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA) and Standardized Root Mean Square Residual (SRMR). Results: Consequently, the assumption of good model fit in the current SEM was obtained with CFI = 0.984, TLI = 0.971, RMSEA = 0.033, and SRMR = 0.021. Hence in this study maternal age was significantly related to miscarriage risk (Estimate = 0.028, p < 0.001), while higher level of education was inversely inclined to miscarriage (Estimate = -0.042, p < 0.001). Latent Lifestyle Risks were identified to have a positive relationship with miscarriages (Estimate = 0.200, p < 0.001 while antenatal care visits have a negative association with miscarriage risks (Estimate = -0.022, p < 0.001). Conclusions: Descriptive findings also reveal that maternal age, specific lifestyle patterns, educational attainment and utilization of antenatal care services are potential determinants of miscarriage. We found that offering changes to lifestyle behaviors and increasing the accessibility of antenatal care could lower miscarriage risk, and hence there can be great potential in public health approaches which address such factors to enhance the quality of maternal health.

Telehealth to Address Preventable Maternal Deaths: A Call to Action.

Over 80% of maternal deaths are preventable. Telehealth approaches can help address disparities by increasing access to quality maternal health care. In this position statement, we advocate for the utility of telehealth to address maternal mortality disparities, focusing specifically on the postpartum period, where most maternal deaths occur. Specifically, we describe how telehealth visits, mobile health applications, and wearable devices for remote patient monitoring can be used to promote the uptake of postpartum care and adherence to evidence-based treatment for the most common causes of maternal death (i.e., cardiovascular conditions and mental health-related conditions). We discuss challenges that must be overcome to ensure the broad and equitable reach of telehealth and identify specific action steps to address this pressing public health issue.

Association between maternal and child health care and neonatal death in Angola: a secondary analysis of Angola Demographic Health Survey 2015–16

BackgroundNeonatal mortality has decreased in Angola; however, it remains high. Quality maternal and child health (MCH) care is key to improving neonatal survival. In Angola, however, the association between neonatal mortality and MCH care has not yet been investigated. Therefore, this study aimed to identify the association between neonatal mortality and MCH services in Angola.MethodsWe used the Angola Demographic Health Survey 2015–16, which is the latest nationally representative dataset of Angola. The associations between early/late neonatal death and MCH care utilization were identified by a multivariable logistic regression analysis, adjusted by the sex of the child, type of residence, wealth index, caesarian section, size of the child at birth and delivery assisted by skilled birth attendant. The individual sample weight, sample strata for sampling errors/design, and cluster number were incorporated in a descriptive and logistic regression analysis to account for the unequal probability sampling in different strata.ResultsThe early and late neonatal mortality rates were 22 and 2 per 1000 live births, respectively. We found that having none, one, two or three tetanus injections before the last pregnancy compared to five or more injections, and no postnatal health check for children before discharge were associated with the occurrence of late neonatal death. During the first 2 days after childbirth, no observation of breastfeeding, no counseling on breastfeeding, no counseling on newborn danger signs, no measurement of child body temperature, and no examination of the cord as well as not checking child health before discharge were associated with early neonatal death.ConclusionsDoses of maternal tetanus vaccination and postnatal child health check before discharge were modifiable factors associated to late neonatal death. Further studies to improve MCH care coverage are needed.

Perceived quality of maternal care and its barriers based on women's perspective in hospitals of Northwest Ethiopia: a qualitative study.

The Sustainable Development Goals (SDGs) in health focus on achieving equity to reduce maternal mortality disparities among subpopulations globally. The goal is to lower the maternal mortality ratio (MMR) to below 70 per 100,000 live births by 2030 for countries with an MMR below 420 in 2010. For those exceeding 420, the target is to keep the MMR below 140 by 2030. This target could not be achieved unless quality maternal health care service is implemented in all health care settings. This study aimed to assess the quality of maternal care and perceived barriers based on women's perspectives among women who receive delivery services in hospitals of South Gondar Zone, Northwest, Ethiopia. A phenomenological method was implemented to explore women's perspectives on quality maternal care and its perceived barriers. An in-depth interview (IDI) was used to collect data using a semi-structured in-depth interview guide. The study was conducted from January 1-30, 2021. All in-depth interview notes were translated into meaningful notes. Then notes were organized by coding texts into meaningful elements using open code version 4.03 software. The majority (14 in 20) tried to interpret quality care in terms of respect during procedures, providing family support, and timely care. Some (6 in 20) tried to associate quality care with the competency of care providers, the cleanliness of the procedure, and privacy during care. With regards to perceived barriers to quality care, the majority (15 in 20) of the IDI participants agreed that a high caseload, limited drugs, and administrative problems were barriers to providing quality maternal care. Participants articulate a multifaceted understanding of quality maternal care that encompasses emotional support, accessibility, cleanliness, timely interventions, and respectful treatment. They also identify significant barriers that stem from facility limitations, provider attitudes and knowledge, and administrative inefficiencies. Addressing these barriers is essential for enhancing the quality of maternal health services.

Sleep Disturbances Among Pregnant Women Attending a Maternity Teaching Hospital in Erbil, Iraq.

Background and aim Sleep disturbances during pregnancy are a common occurrence and can significantly impact both maternal and fetal health. Therefore, this study aimed to assess the severity of sleep disturbances among pregnant women attending the Erbil Maternity Teaching Hospital in Erbil, Iraq. Method This cross-sectional study was conducted from July 15, 2023, to August 15, 2024, at the Erbil Maternity Teaching Hospital in Erbilusing convenience sampling. Data were gathered using a self-structured questionnaire that included demographic information and a 20-item sleep disturbance assessment. Statistical analysis was performed using Stata version 12 (StataCorp LLC, College Station, TX), and parametric tests such as the t-test, ANOVA, and multiple linear regression were used to examine the relationships between sleep disturbances and demographic variables. A p-value of less than 0.001 was considered statistically significant. Results A total of 300 participants were enrolled in the study. The mean sleep disturbance score was 47.58 ± 9.83, indicating that most participants experienced mild sleep disturbances. Sleep disturbances did not significantly differ by age, education level, occupation, or residency. However, economic status was significantly associated with sleep disturbance levels, with lower-income participants experiencing more severe disturbances (p = 0.02). Conclusions The study found that most pregnant women experienced mild sleep disturbances, with lower economic status being a significant predictor of more severe sleep issues. Healthcare providers and policymakers are recommended to develop targeted interventions that address the unique needs of pregnant women, particularly those from lower-income groups, to improve sleep quality and overall maternal health outcomes.

Supporting Timor-Leste midwives and nurses through an educational program: An evaluative study

Little is currently known about the impacts of participation in a five-week Australian maternal and newborn health training program for Timorese midwives and nurses. BackgroundThe maternal mortality rate in Timor-Leste is estimated to be around 204 per 100,000 live births, and there is a correlation between safe and quality maternal and newborn health services. Hence, there is a need to develop the nation’s maternity workforce. Whilst numerous training programs have been geared towards improving the knowledge and skills of Timorese midwives and nurses, to date, no published study has evaluated their impact on participants. AimTo describe satisfaction of an Australian maternal and newborn health training program for Timorese midwives and nurses and its impact based upon the participants survey and qualitative evaluations. MethodsAn evaluative study was conducted using a survey to explore the impacts of a five-week Australian residential training program on 12 Timorese midwives and one nurse. FindingsThe survey data demonstrated an increase in the participants knowledge and skills required to provide enhanced maternal and newborn care; post-training, most participants demonstrated increased knowledge of obstetric emergencies. The participants showed the most pronounced increase in Advanced Clinical Skills in the subjects of fetal assessment, neonatal resuscitation and obstetric emergencies.The qualitative data identified two main themes and six subthemes related to professionalism, communication, and connections. ConclusionAn Australian residential training program, provided in collaboration with local Rotary clubs can enhance the development of maternal and newborn healthcare skills for midwives and nurses from Timor-Leste.

Women with disabilities' use of maternal care services in sub-Saharan Africa.

Quality maternal health care is central to the Sustainable Development Goals efforts to reduce maternal mortality, yet there remain limited quantitative data on maternal care inequities for women with disabilities in sub-Saharan Africa. This study aims to understand the differences in maternal care providers for women with and without disabilities. We used Multiple Indicator Cluster Surveys from 13 sub-Saharan African countries conducted between 2017-2020. We used logistic and multinomial logistic regression to examine the relationship between disability (Washington Group definition) and antenatal care attendance and the type of care provider for antenatal care, skilled birth attendance, and postnatal and postpartum checks. All analyses were adjusted for age, wealth, country, and location. The sample included 10 021 women, including 306 (3.1%) women with disabilities. There were small absolute and no relative differences in antenatal care attendance, qualified antenatal care provider, postnatal, and postpartum checks, for disabled and women without disabilities. Women with disabilities had some evidence of higher odds of having a doctor at their birth compared to women without disabilities (aOR = 1.52, 95% CI: 0.99-2.33). This study shows small absolute and no relative differences between women with and without disabilities for antenatal access and provider types for maternal care, though these findings are limited by a small sample and no data on care quality, acceptability, or outcomes. More research on care quality and outcomes is needed. This study is the first quantitative, multi-country study in sub-Saharan Africa to examine maternal care seeking patterns, demonstrating important data on maternal health indicators for women with disabilities.

Timeliness and quality of peripartum care provision during a health system strengthening initiative in rural Guinea-Bissau: a qualitative situation analysis

Guinea-Bissau has among the world’s highest maternal and perinatal mortality rates. To improve access to quality maternal and child health (MCH) services and thereby reduce mortality, a national health system strengthening initiative has been implemented. However, despite improved coverage of MCH services, perinatal mortality remained high. Using a systems-thinking lens, we conducted a situation analysis to explore factors shaping timeliness and quality of facility-based care during labour, childbirth, and the immediate postpartum period in rural Guinea-Bissau. We implemented in-depth interviews with eight peripartum care providers and participant observations at two health facilities (192 h) in 2021-22, and analysed interview transcripts and field notes using thematic network analysis. While providers considered health facilities as the only reasonable place of birth and promoted facility birth uptake, timeliness and quality of care were severely compromised by geographical, material and human-resource constraints. Providers especially experienced a lack of human resources and materials (e.g., essential medicines, consumables, appropriate equipment), and explained material constraints by discontinued donor supplies. In response, providers applied several adaptation strategies including prescribing materials for private purchase, omitting tests, and delegating tasks to birth companions. Consequences included financial barriers to care, compromised patient and occupational safety, delays, and diffusion of health worker responsibilities. Further, providers explained that in response to persisting access barriers, women conditioned care seeking on their perceived risk of developing birthing complications. Our findings highlight the need for continuous monitoring of factors constraining timeliness and quality of essential MCH services during the implementation of health system strengthening initiatives.

Unmet Need for Family Planning Among Women Attending Primary Healthcare in Alahsa, Saudi Arabia.

Enhancing maternal health quality is a concern among researchers globally. According to the World Health Organization (WHO), one factor in women's health and empowerment is the rate of use of various contraceptive techniques. The WHO defines unmet contraceptive need as the discrepancy between a woman's desire to delay or cease childbearing and lack of contraception use to achieve this goal. Our study was designed to measure the unmet need for family planning and contraceptive use among married Saudi women attending primary healthcare centers in Alahsa, Saudi Arabia. A cross-sectional study was carried out using multistage cluster stratified sampling. The study included all married Saudi women aged 18-49 attending primary health centers. A structured questionnaire from the United States Agency for International Development Demographic and Health Surveys Methodology was used. Data analysis was performed using the statistical software IBM SPSS version 29(IBM Corp., Armonk, NY). In all, 430 individuals were included.The participants' ages ranged from 19 to 49 years (33.4 ± 7 years). Among them, 50 (11.6%) were pregnant. Among those who were not pregnant, 268 (62.3%) were using a method of contraception. Based on the definitions adopted in this study, 90 (20.9%) had unmet needs for family planning, and 340 (79.1%) had their needs met. The total demand for family planning was estimated to be 83.2%. The percentage of demand for family planning satisfied by a modern contraceptive method was 46.9%. Although Alahsa has a lower unmet need rate (20%) than other cities in Saudi Arabia, it remains notably higher than the average rate in Northern African and Western Asian countries, which is 10.9%. A number of factors, including nulliparity and having more than two children, were associated with unmet contraceptive needs. The majority of women who did not use contraceptives had concerns about the side effects and inconvenience of use.

Developing a Maternal Health Worker Training Program in Rural Mississippi [ID 2683576

INTRODUCTION: Mississippi faces the highest infant mortality rate and maternal mortality rate in the United States, with rates for Black women four times higher than for White women. Using community maternal health workers (MHWs) to support patients during pregnancy and postpartum has proven beneficial in other locations and could be transformative in rural Mississippi. We aimed to identify key patient needs to create a MHW training program in the rural Mississippi Delta, as a component of a broader maternal health quality improvement project. METHODS: We conducted quality improvement interviews with 18 obstetric patients (10 prenatal, 8 postpartum) at Delta Health Center, a federally qualified health center in Mound Bayou, Mississippi. We queried patients about strengths and gaps in their prenatal care and their opinions on MHWs. We also queried the obstetrics and gynecology and pediatrics teams at Delta Health Center to identify key pregnancy, postpartum, and infant care and development topics needed for MHW training. RESULTS: 17/18 (94%) of the patients interviewed were in support of the MHW program. The following themes emerged in patient interviews: desire for psychologic support, connection to community resources, and help managing high-risk pregnancy conditions. We designed a 2-week training for MHWs that covers: MHW Responsibilities, Pregnancy Care, Childbirth, Postpartum Care, and Newborn Care and Infant Development. Based on patient feedback, the training prioritizes content related to psychological support and high-risk pregnancy care. CONCLUSION: Patients expect MHWs to be valuable assets for their care. Maternal health workers have the potential to support pregnant women in rural health care settings, ultimately enhancing maternal–fetal health outcomes.

The Effects of Central Government Financial Allocation on the Provision of Quality Maternal Health Care in Kampala City

The relationship between devolution and service delivery has been a matter of inquiry for the past three decades. This paper aimed to examine the impact of Central Government financial allocation on the quality of delivery of maternal healthcare services in Kampala City, Uganda. To achieve this, a case study design incorporating both qualitative and quantitative methods was employed. Data collection involved the use of questionnaires and interviews conducted among healthcare professionals, KCCA (Kampala Capital City Authority) staff, and mothers receiving maternal healthcare at selected public health centers. The gathered data underwent both qualitative and quantitative analyses using measures of central tendency such as mean, standard deviation, correlation, and regression analysis. The results of regression analysis indicated that Central Government financial allocation had a significant influence on the provision of quality maternal healthcare. In light of these findings, it is recommended that steps be taken to enhance Central Government financial allocation. Additionally, the administration of KCCA should consider implementing anti-corruption measures as part of their best practices. Furthermore, healthcare center leadership and KCCA leadership should prioritize effective planning, good governance, and transparency in their financial expenditure and operations.

Midwife-led birthing centres in Bangladesh, Pakistan and Uganda: an economic evaluation of case study sites

IntroductionAchieving the Sustainable Development Goals to reduce maternal and neonatal mortality rates will require the expansion and strengthening of quality maternal health services. Midwife-led birth centres (MLBCs) are an alternative...

Determinants of pregnant women’s satisfaction with interactions with health providers at antenatal consultation in primary health care in Southern Mozambique in 2021: a cross-sectional study

SummaryBackgroundThe Ministry of Health of Mozambique (MISAU) and the World Health Organization (WHO) recommend enhancing pregnant women’s satisfaction with health care services in order to advance maternal and child health. This study aims to assess the levels and determinants of pregnant women’s satisfaction regarding their interactions with antenatal care (ANC) providers, the services of which were provided at the primary health care level in southern Mozambique.MethodologyWe conducted an observational, quantitative, and cross-sectional study from November 4 to December 10, 2021. A structured questionnaire was administered to pregnant women who attended ANC during that period. The characteristics of the participants were illustrated using descriptive statistics; to analyse pregnant women’s satisfaction determinants, we estimated crude and adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) using logistic regression models. All analyses were performed in SPSS version 24 using a 5% significance level.ResultsWe selected 951 pregnant women with a mean age of 25 years old; 14% attained a secondary educational level, 36% were married or living in a marital relationship, and 85.9% reported being satisfied with their current ANC. Factors that reduced the odds of being satisfied were the following: an “insufficient” ANC duration (AOR = 0.173; 95% CI: 0.079, 0.381); inadequate ANC waiting area (AOR = 0.479; 95% CI: 0.265, 0.863); women’s perception about the existing norm of nonattendance in case of late arrival to the ANC (AOR = 0.528; 95% CI 0.292, 0.954); the perception of the existing norm that women are obliged to give birth in same health facility where ANC occurred (AOR = 0.481; 95% CI: 0.273, 0.846); and the perception that delivered ANC is not important for foetal health (AOR = 0.030; 95% CI:0.014, 0.066).ConclusionsMost of the pregnant women mentioned being satisfied with the ANC they received. The perception of short consultation duration, inadequate waiting spaces, strict linkage rules to specific health facilities and ANC norms, the perception that the received ANC is not relevant for foetal well-being are determinants of not being satisfied with ANC, and these determinants can be addressed by reorganizing ANC and, indeed, are modifiable by the improved paced implementation of the MISAU strategies for quality maternal and child health care.

Mapping the Role of Digital Health Interventions to Enhance Effective Coverage of Antenatal Care: A Scoping Review.

Antenatal care (ANC) is a core component of maternal health services. However, only half of the pregnant women in LMICs obtain WHO recommended minimum of four antenatal contacts. In addition, ANC 4+ is a commonly used indicator in monitoring ANC utilization. However, contact coverage alone provides no indications of service quality. In recent years, digital health interventions bring opportunities to provide quality maternal health care. Yet, there are few reviews on how digital health interventions contribute to improving effective coverage of antenatal care. A rigorous review that examines the role of digital health interventions in improving effective coverage of antenatal care is needed to examine how digital health solutions were rapidly deployed to support quality antenatal care service delivery. This review aimed to map evidence on the role of digital health solutions on quality of antenatal care service to enhance effective ANC coverage. A scoping review approach was used and four Databases (PubMed, Cochrane Library, Scopus and Embase) as well as search engines like Advanced Google Search and Google Scholar were searched from September 1 to 8, 2022. Thematic content analysis was used to present the findings. A total of 1701 articles were searched. A total of 27 full-text studies were included in the final analysis. The most reported use of digital health was for client education and behavior change communication. Most studies showed that digital health interventions have proven effective in improving antenatal care. However, most of the studies did not address to assess the quality of ANC services. In this review, we found out that digital health solutions targeted at pregnant women can improve antenatal care services. There is body of evidence showing the effectiveness of digital health interventions on a range of maternal health outcomes. Few pieces of literature exist on the use of digital health interventions on the quality of antenatal care services. There is a need for more trial and program evaluation studies that examine the role of digital health interventions on the quality of ANC.

System barriers to the provision of quality maternal health care in two regional teaching and referral hospitals in Kenya: a qualitative study

ObjectiveSub-Saharan Africa accounts for 66% of global maternal deaths. In Kenya, 362 maternal deaths occur in every 100 000 live births. Most of these deaths occur as a result of suboptimal quality care of mothers during labor, delivery, or within 24 h of delivery. This study explored barriers that nurse-midwives encounter in trying to provide high-quality obstetric care during these periods. MethodsA qualitative research design utilizing focus group discussion as part of a mixed method study was used to find out the participants’ experiences. Data were collected between February and March 2022 in the maternity units of two regional teaching and referral hospitals in Kenya. Eligible participants were nurse-midwives in charge of the maternity unit. The discussion was conducted in English, tape-recorded, and transcribed verbatim. Data were analyzed thematically, following Braun and Clarke 6-step framework. Nvivo version 7.0 computer software was used to facilitate this process. ResultsTwo focused group discussions each involving seven participants were conducted. The participants agreed that maternal mortality due to postpartum hemorrhage and pregnancy-induced hypertension is a major health concern. Further, maternal care in the two hospitals was substandard. Themes that emerged as barriers were: inadequate supplies; inadequate obstetric knowledge and skills; shortage of nurse-midwives, and inadequate support supervision. The underlying factors include inadequate funding by the county government and high staff turnover. ConclusionThis study showed that nurse-midwives are working under very difficult circumstances which are hindering the provision of quality maternal care. This is mainly due to system failures and inadequate nurse-midwife numbers. Targeted strategies need to be urgently implemented to mitigate these challenges to improve the quality of maternal health care.

Experiences of mothers and health workers with MomCare and SafeCare bundles in Kenya and Tanzania: A qualitative evaluation.

Between 2019 and 2022, the digital dividend project (DDP), a technology-based intervention that combined care (MomCare) and quality improvement (SafeCare) bundles to empower mothers to access quality care during pregnancy, labor, and delivery, and postnatally, was implemented in Kenya and Tanzania aiming to improve maternal and newborn health outcomes. We describe the experiences of the mothers in accessing and utilizing health services under the bundles, and the experiences of the health workers in providing the services. Between November and December 2022, we conducted a qualitative evaluation across health facilities in Kenya and Tanzania. We held Interviews with mothers (pregnant and postpartum women who had benefited from the care bundles) and health workers (physicians, nurses, and midwives who provided the care bundles, including health facility In-Charges) at the antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) service delivery points. We performed content analysis. Findings are reported using themes and quotes from the participants. We included 127 mothers (Kenya = 76, Tanzania = 51) and 119 health workers. Findings revealed that among mothers, the care bundles eased access to health services, ensured easy access and optimal ANC use, provision of respectful care, removed financial constraints, and led to the receipt of sufficient health education. Health workers reported that the care bundles offered them a new opportunity to provide quality maternal and newborn care and to adhere to the standard of care besides experiencing a positive and fulfilling practice. Health systems improvements included prompt emergency response and continual care, infrastructural developments, medical supplies and logistics, staffing, and increased documentation. Overall, the care bundles led to the strengthening of the healthcare system (staffing, service delivery, financing, supplies/logistics, and information management) in order to deliver quality maternal and child health services. The bundles should be replicated in settings with similar maternal and child health challenges.

Effects of COVID-19 pandemic on provision and use of maternal health services in Allada, southern Benin: a local health system perspective.

To assess the effects of the COVID-19 pandemic on the provision and use of maternal health services in southern Benin from a local health system perspective. We conducted a qualitative study from April to December 2021 in a health district in southern Benin. We interviewed health workers involved in antenatal, delivery, postnatal and family planning care provision, alternative and spiritual care providers, administrative staff of the district hospital, community health workers, adolescents and women who had given birth in the past six weeks in public health centers were interviewed. The World Health Organization health systems building blocks framework was used to guide the thematic analysis from a local health system perspective. The COVID-19 pandemic changed the lines of command and the institutional arrangements in the local health systems leadership; it put the interpersonal relationships in the health care provision team under stress and reduced the overall revenues of the district hospital. The motivation of allopathic health workers was undermined. Communities underutilized maternal health services in the COVID-19 period. Plausible causes included negative patient perceptions of COVID-19 measures taken at the public health facility level as well as well as fear of being forcibly vaccinated against COVID-19 in the health facilities. In times of health crises, appropriate local health system governance that integrates providers' concerns into effective guidelines is critical to reach and maintain a sufficient level of work motivation to ensure quality maternal health services.

Effect of mentorship and a mHealth application in updating provider skills and knowledge in maternal and newborn care in two informal settlements of Nairobi

BackgroundChildren and women in urban informal settlements have fewer choices to access quality maternal and newborn health care. Many facilities serving these communities are under-resourced and staffed by fewer providers with limited access to skills updates. We sought to increase provider capacity by equipping them with skills to provide general and emergency obstetric and newborn care in 24 facilities serving two informal settlements in Nairobi. We present evidence of the combined effect of mentorship using facility-based mentors who demonstrate skills, support skills drills training, and provide practical feedback to mentees and a self-guided online learning platform with easily accessible EmONC information on providers’ smart phones.MethodsWe used mixed methods research with before and after cross-sectional provider surveys conducted at baseline and end line. During end line, 18 in-depth interviews were conducted with mentors and mentees who were exposed, and providers not exposed to the intervention to explore effectiveness and experience of the intervention on quality maternal health services.ResultsResults illustrated marked improvement from ability to identify antepartum hemorrhage (APH), postpartum hemorrhage (PPH), manage retained placenta, ability to identify and manage obstructed labour, Pre-Eclampsia and Eclampsia (PE/E), puerperal sepsis, and actions taken to manage conditions when they present. Overall, out of 95 elements examined there were statistically significant improvements of both individual scores and overall scores from 29/95 at baseline (30.5%) to 44.3/95 (46.6%) during end line representing a 16- percentage point increase (p > 0.001). These improvements were evident in public health facilities representing a 17.3% point increase (from 30.9% at baseline to 48.2% at end line, p > 0.001). Similarly, providers working in private facilities exhibited a 15.8% point increase in knowledge from 29.7% at baseline to 45.5% at end line (p = 0.0001).ConclusionThis study adds to the literature on building capacity of providers delivering Maternal and Newborn Health (MNH) services to women in informal settlements. The complex challenges of delivering MNH services in informal urban settings where communities have limited access require a comprehensive approach including ensuring access to supplies and basic equipment. Nevertheless, the combined effects of the self-guided online platform and mentorship reinforces EmONC knowledge and skills. This combined approach is more likely to improve provider competency, and skills as well as improving maternal and newborn health outcomes.

Peripartum care provision in a resource-constrained setting – a qualitative study from Guinea-Bissau

Abstract Background Guinea-Bissau has among the world's highest maternal-perinatal mortality. Here, the European Union financed a national health system strengthening initiative to improve access to quality peripartum care from 2013-21. Thereafter, the initiative was supported by the World Bank. We conducted a situational analysis to explore factors shaping the provision of timely and quality peripartum care amid this transition in rural Guinea-Bissau. Methods We conducted in-depth interviews with eight peripartum care providers in four rural regions, and participant observations (192 hours) at the regional hospital and a health center in one region in 2021-22. Interviews and observation notes were analyzed using thematic network analysis aided by theories of social practice and the WHO framework for quality maternal and newborn health care. Results Peripartum services were provided under severely resource-constrained conditions. Care providers especially experienced a lack of materials (e.g., essential drugs, consumables, appropriate equipment), space and staffing, and commonly voiced feeling overburdened. Material constraints were explained by discontinued donor supplies. To navigate this context, providers used several tactics, including: delegating monitoring and support tasks to birth companions; prescriptions of materials for purchase; omitting tests; and using materials thrifty, e.g., by shifting tasks requiring gloves to the staff member wearing them or rationing disinfectants. These tactics had several consequences: diffusion of health worker responsibilities; financial barriers to care; delays; unsanitary conditions; and compromised occupational and patient safety. Conclusions With provision of quality peripartum care being highly dependent on external support amid scarce domestic resources, support disruptions led to severely compromised care. This highlights the need to strengthen donor-coordination warranting continuity and quality of essential health services. Key messages • Disruptions in donor support led to severely compromised peripartum care in rural Guinea-Bissau. • This underscores the need for strengthened donor-coordination warranting continuity of service quality.

Strengthening quality in sexual, reproductive, maternal, and newborn health systems in low- and middle-income countries through midwives and facility mentoring: an integrative review

BackgroundThere is an urgent global call for health systems to strengthen access to quality sexual, reproductive, maternal, newborn and adolescent health, particularly for the most vulnerable. Professional midwives with enabling environments are identified as an important solution. However, a multitude of barriers prevent midwives from fully realizing their potential. Effective interventions to address known barriers and enable midwives and quality sexual, reproductive, maternal, newborn and adolescent health are less well known. This review intends to evaluate the literature on (1) introducing midwives in low- and middle-income countries, and (2) on mentoring as a facilitator to enable midwives and those in midwifery roles to improve sexual, reproductive, maternal, newborn and adolescent health service quality within health systems.MethodsAn integrative systematic literature review was conducted, guided by the Population, Intervention, Comparison, Outcome framework. Articles were reviewed for quality and relevance using the Gough weight-of-evidence framework and themes were identified. A master table categorized articles by Gough score, methodology, country of focus, topic areas, themes, classification of midwives, and mentorship model. The World Health Organization health systems building block framework was applied for data extraction and analysis.ResultsFifty-three articles were included: 13 were rated as high, 36 as medium, and four as low according to the Gough criteria. Studies that focused on midwives primarily highlighted human resources, governance, and service delivery while those focused on mentoring were more likely to highlight quality services, lifesaving commodities, and health information systems. Midwives whose pre-service education met global standards were found to have more efficacy. The most effective mentoring packages were comprehensive, integrated into existing systems, and involved managers.ConclusionsEffectively changing sexual, reproductive, maternal, newborn and adolescent health systems is complex. Globally standard midwives and a comprehensive mentoring package show effectiveness in improving service quality and utilization.Trial registrationThe protocol is registered in PROSPERO (CRD42022367657).