Recently-delivered Women Research Articles

Inequality in iron and folic acid consumption and dietary diversity in pregnant women following exposure to maternal nutrition interventions in three low- and middle-income countries.

Research is available on improved coverage and practices from several large-scale maternal nutrition programmes, but not much is known on change in inequalities. This study analyses wealth and education inequality using Erreygers and Concentration indices for four indicators: adequate iron and folic acid (IFA) consumption, women's dietary diversity, and counselling on IFA and dietary diversity. A pre-test-post-test, control group design. Maternal nutrition intervention programmes conducted in Bangladesh, Burkina Faso and Ethiopia during 2015-2022. Recently delivered women (RDW) and pregnant women (PW). Statistically significant reductions in education inequality were observed for adequate IFA consumption, counselling on IFA and dietary diversity in intervention areas of Bangladesh and for adequate IFA consumption in intervention areas of Burkina Faso.A significant decrease in wealth inequality was observed for adequate IFA consumption in the intervention areas of Bangladesh, whereas a significant increase was observed in the non-intervention areas for counselling on IFA in Ethiopia and for dietary diversity in Burkina Faso. The results can be attributed to the extensive delivery system at community level in Bangladesh and being predominantly facility-based in Burkina Faso and Ethiopia. COVID-19 disruptions (in Burkina Faso and Ethiopia) and indicator choice also had a role in the results.The main takeaways for nutrition programmes are as follows: (a) assessing inequality issues through formative studies during designing, (b) monitoring inequality indicators during implementation, (c) diligently addressing inequality through targeted interventions, setting aside resources and motivating frontline workers to reduce disparities and (d) making inequality analysis a routine part of impact evaluations.

Factors affecting practices of recently delivered women on maternal and neonatal health care in selected rural areas of Bangladesh

Bangladesh has made laudable progress in maternal and child health (MCH). Maternal and child mortalities have reduced substantially accompanied by stellar rise in immunization and contraceptive prevalence rate (CPR). However, such success is distributed unevenly throughout and the country is among one of the top ten countries with highest number of neonatal and under-five children mortalities. Rural Bangladesh is home to more than half of the country’s total population. Yet, disparity in access to healthcare services and information are overt in these areas. Utilization of maternal health services (MHS) is low whereas maternal and child mortalities are high in the rural areas. Thus, this cluster randomized cross sectional study was conducted with the aim to observe the practices that rural women followed in regards to maternal and child health and factors that affected these practices. Primary data was collected from 550 respondents using a structured questionnaire within the time period September—October 2019. All our participants were recently delivered women (RDW), defined in our study as women of reproductive age (15–49 years) who had delivered a child recently, i.e. 12 months prior (September 2018 – August 2019) the data collection. We conducted logistic regression and multivariate analysis to analyze data. Results from this study depict that while 96.3% of RDW opted for ANC visits and 99.1% fed colostrum to their newborn, fewer have had institutional deliveries and the number of RDW who had PNC was only 64.7%. Education was found to be the most prominent factor that affected practices employed by RDW. The more educated a respondent was, the greater the chance was of her engaging in appropriate maternal and child health practices. The RDW preferred and visited private facilities the most to obtain healthcare services with private medical doctors being one of the prime sources of healthcare information for the respondents. On the contrary, monthly expenditure exerted no statistically significant impact on the aforementioned practices. Thus, results of our study imply that interventions enhancing education and health knowledge of women and engaging private sector be designed for improving maternal and neonatal health care in rural areas of Bangladesh.

Case Studies on Maternal & Newborn Care among Recently Delivered Women of Scheduled Caste Community through the Role of ASHA in Banda District of Uttar Pradesh, India

Case Studies on Maternal & Newborn Care among Recently Delivered Women of Scheduled Caste Community through the Role of ASHA in Banda District of Uttar Pradesh, India

Case Studies on Maternal & Newborn Care among Recently Delivered Women of Scheduled Caste Community through the Role of ASHA in Saharanpur District of Uttar Pradesh, India

Case Studies on Maternal & Newborn Care among Recently Delivered Women of Scheduled Caste Community through the Role of ASHA in Saharanpur District of Uttar Pradesh, India

Case Studies on Maternal & Newborn Care among Recently Delivered Women of Scheduled Caste Community through the Role of ASHA in Gonda District of Uttar Pradesh, India

When ASHAs were introduced in NRHM in 2005, their primary aim was to visit homes of newborns as the first program in UP operated through the ASHAs was the Comprehensive Child Survival Program in 2008. Since then, tracking of all deliveries and all the newborns are an integral part of the work of ASHAs in all the primary health care programs operated by the NHM in UP. Evaluation studies on the performance of ASHAs was done since 2011 as by then ASHAs had actually worked in the field for a minimum period of 5 years. It is to be noted that National Rural Health Mission was rolled out in April 2005 but it took about one to two years for the states to hire ASHAs and put things in place right from the state to the village level. In this article, a comprehensive feedback is elicited from the mothers of Scheduled Caste (SC) community from the last visit of ASHAs to their homes to visits during pregnancy & newborn care in Gonda district of UP. The current study explores some of the crucial variables through five case studies on the performance of ASHAs through their message delivery & visits during natal, newborn care of mothers of Scheduled Caste (SC) community. The article also includes the feedback of the SC community mothers on the work & approach of ASHAs. That’s how the perception of the Recently Delivered Women of SC community in the state of UP is included in this article. The mothers of SC community responded about the performance based upon their experience in visits & messaging by ASHAs on Janani Surakhya Yojana (JSY), New Born Care (NBC) & Routine Immunization (RI) as these were the frontline programs for the states. The responses of these mothers or Recently Delivered Women (RDW) (as named for the current study) had a 3 to 6 months old child during the time of survey. They were selected as respondents as they were from SC community & were in a position to recollect the health care events of their children. The relevance of the study assumes significance as .....

Mother's care-seeking behavior for neonatal danger signs from qualified providers in rural Bangladesh: A generalized structural equation modeling and mediation analysis.

Neonatal deaths contribute to nearly half (47%) of under-five mortality globally and 67% in Bangladesh. Despite high neonatal mortality, care-seeking from qualified providers for newborn danger signs remains low. Identification of direct and indirect factors and their pathways affecting care-seeking will help to design a well-targeted intervention. This study assessed the direct, indirect, and total effect of the predictive factors on neonatal care-seeking in Bangladesh. This was a cross-sectional baseline household survey conducted in 14 districts of Bangladesh in 2019 with 17,251 recently delivered women (RDW) with a live birth outcome in the preceding 15 months. We used a two-stage stratified cluster sampling process to select the samples from 14 districts. We investigated the inter-relationship of maternal background characteristics, maternal health utilizations, child/neonate factors, health service delivery-related factors and newborn danger sign knowledge with newborn care-seeking practices and estimated the direct, indirect, and total effects using Generalized Structural Equation Modeling (GSEM) and mediation analysis. p-value = 0.05 was considered statistically significant. The result of the mediation analysis was reported in Log Odds (LOD). The positive LOD (LOD > 0) implies a positive association. Half of the mothers (50.8%) reported a neonatal illness and among them, only 36.5% mothers of sick neonates sought care from qualified providers. Our mediation analysis showed that maternal health utilization factors, i.e., 4 + antenatal care visits (ANC) from a qualified provider (LOD: 0.63, 95% CI: 0.49, 0.78), facility delivery (LOD: 0.74, 95% CI: 0.30, 1.17) and postnatal care (PNC) from a qualified provider (LOD: 0.50, 95% CI: 0.21, 0.78) showed the highest total effect over other factors domains, and therefore, were the most important modifiable predictors for qualified neonatal care-seeking. Other important factors that directly and/or indirectly increased the chance of newborn care-seeking from qualified providers were household wealth (LOD: 0.86, 95% CI: 0.70, 1.02), maternal education (LOD: 0.48, 95% CI: 0.32, 0.63), distance to nearest health facility (LOD: 0.20, 95% CI: 0.10, 0.30), community health worker's (CHWs) home visits during ANC (LOD: 0.24, 95% CI: 0.13, 0.36), neonatal danger sign counseling after delivery (LOD: 0.20, 95% CI: 0.06, 0.34) and women's knowledge of neonatal danger signs (LOD: 0.37, 95% CI: 0.09, 0.64). The inter-relationship and highest summative effect of ANC, facility delivery, and PNC on newborn care-seeking suggested the maternal care continuum altogether from ANC to facility delivery and PNC to improve care-seeking for the sick newborn. Additionally, referral training for unqualified providers, targeted intervention for poorer households, increasing CHWs home visits and neonatal danger sign counseling at the facility and community should also be considered.

Continuum of maternal health care services among peri-urban women- a community-based cross-sectional study in North India

Background: Low level of utilization of continuum of maternal health services (CMHS) is a major factor responsible for high maternal mortality and morbidity. This study was conducted to assess status of utilization, determinants and satisfaction of /about CMHS in peri-urban women of north India.Methods: A community based, cross-sectional study of 310 recently delivered women (RDWs) was conducted. Data were collected using a structured interviewer administered questionnaire and analysed using SPSS 26.0.Results: 158 (51%), 228 (73.5%) and 92 (29.7%) of RDWs had full utilization of antenatal care (ANC), intra natal care (INC) and post-natal care (PNC) respectively. Birth order, education of husband, complications in previous pregnancies, type of family, first ANC visit and place of ANC were significant (p<0.05) predictor of full utilization of ANC. Education of RDW and husband, complications in previous pregnancies were significant (p<0.05) predictor of full utilization of INC. Age, birth order and education of husband were significant predictors (p<0.05) of full utilization of PNC. Full utilization of overall CMHS was only 60 (19.4%). >70% RDWs expressed satisfaction with the quality of CMHS while 28.5% were not satisfied.Conclusions: Utilization of all the three aspects of CMHS still lagging behind with regards to required goals with full utilization of PNC, as limiting factor. Comprehensive approach to increase utilization of CMHS is need of hour, to address the issue of drop out with special emphasis on PNC.

Bottleneck analysis of maternal and newborn health services in hard-to-reach areas of Bangladesh using 'TANAHASHI' framework': An explanatory mixed-method study.

Maternal and Newborn Health (MNH) is of paramount importance in the realm of attaining sustainable development goals that also focuses on universal health coverage (UHC). The study aimed at identifying and exploring the bottlenecks in MNH services in Hard-to-reach (HtR) areas of Bangladesh using the Tanahashi framework exploring the possible remedial approaches. The study was conducted in four different types of HtR areas (hilly, coastal, lowlands, and river islands) by utilizing a sequential explanatory mixed-method design. Overall, we collected information from 20 health facilities and 2,989 households by interviewing 2,768 recently delivered women (RDW) with a structured questionnaire and qualitative interviews (n = 55) of facility managers, local stakeholders, RDWs, and health care providers (HCP). The quantitative data were analyzed principally for descriptive statistics and the qualitative data was analyzed by utilizing the thematic approach. Antenatal care, under-5 care, and family planning services were available in almost all the facilities. However, Normal vaginal deliveries were performed in 55.6% of the union-level facilities. Only 40% of sub-district level facilities had provision for C-sections. Blood transfusion services were available in only 20.1% of facilities, whereas laboratory services were obtainable in 51.7% of facilities. Overall, the bottlenecks were identified in cases of availability of drugs, human resources, transportation, lack of knowledge regarding different essential services and health components, out of pocket expenditure etc. There have been several remedial approaches suggested from both the demand and supply side that included incentives for care providers for staying in these areas, a coordinated transport/referral system, and health education campaigns. More research works are warranted in HtR areas, especially to test the proposed interventions. Meanwhile, the government should take the necessary steps to overcome the bottlenecks identified.

Prevalence and factors associated with skin-to-skin contact (SSC) practice: findings from a population-based cross-sectional survey in 10 selected districts of Bangladesh

BackgroundSkin-to-skin contact (SSC) practice improves newborn survival and child development through preventing hypothermia in newborns, improving early initiation of breastfeeding practice, and strengthening mother-child bonding. Despite having numerous benefits, it is one of the least practiced interventions in low and middle-income countries (1 to 74%). In Bangladesh, the prevalence of SSC was 26% in 2014. In this study, we aimed to estimate the prevalence of SSC in the study districts and identify factors that facilitate or inhibit SSC practice so that context-specific recommendations can be made to advance the use of this intervention.MethodsWe used baseline household survey data of USAID’s MaMoni MNCSP project conducted in 10 districts of Bangladesh in 2019. Our analysis included 13,695 recently delivered women (RDW) with a live birth outcome. Our primary outcome was the mother’s reported practice of SSC. We examined various antepartum, intrapartum, newborn, and sociodemographic factors associated with SSC using a multivariable generalized linear model. Our findings were reported using adjusted Prevalence Risk Ratios (aPRRs) and 95% Confidence Intervals (CIs).ResultsOverall, 28% of RDW reported practicing SSC across the 10 surveyed districts. Our multivariable analysis showed that public facility delivery (aPRR 2.01; 95%CI: 1.80, 2.26), private facility delivery (aPRR 1.23; 95%CI: 1.06, 1.42) and ≥ 4 antenatal care (ANC) visits at least one from a medically trained provider (MTP) (aPRR 1.17; 95%CI: 1.03, 1.26) had a significant positive association with SSC practice. Caesarean section (aPRR 0.64; 95%CI: 0.56, 0.73) had a significant negative association with SSC practice compared to vaginal births. We also found a significant positive association of SSC practice with mothers’ who perceived the birth size of their baby to be small, mothers with a higher education level (≥10 years), and mothers from households in the highest wealth quintile.ConclusionsThe prevalence of SSC is very low in the surveyed districts of Bangladesh. Considering the factors associated with SSC, relevant stakeholders need to increase their efforts on improving ANC and facility delivery coverages as well as improving SSC practice in the facilities especially after caesarean deliveries. Countries with a high burden of home deliveries, also need to emphasize community-based interventions and increasing coverage of skilled birth attendance for improving this life-saving intervention.

Impact of local terminology on the design of a community-based diagnostic and management algorithm for postpartum sepsis: findings of formative research.

BackgroundPostpartum sepsis is one of the leading causes of maternal mortality and morbidity in developing countries. This formative research elicits local terms used for postpartum illnesses and symptoms of postpartum sepsis with the aim of improving postpartum diagnosis and management in Pakistan.MethodsWe conducted 34 in-depth interviews with recently delivered women (RDW), traditional birth attendants (TBAs), healthcare providers and family members of RDW from rural Sindh to explore local Sindhi terms used to describe postpartum sepsis and related symptoms. During interviews, all participants were asked to orally free list common symptoms of postpartum illnesses; those who were aware of the concept were asked to free list possible symptoms of postpartum sepsis. The responses were recorded by the interviewer. Free listing data were analyzed for frequency and salience.ResultsMost participants, including TBAs, were not familiar with the concept of postpartum sepsis as a distinct disease or of a local term denoting the concept. Almost all could identify and report symptoms related to postpartum sepsis in the local language. Only physicians were able to recognize the term postpartum sepsis and related symptoms. Multiple local terms were used for a particular symptom; still others were used to denote gradations of severity. ‘Bukhar’ (fever) was the most commonly named symptom although it was often considered a normal part of puerperium. Many postpartum illnesses were related to the highly non-specific local term ‘kamzori’ (weakness).ConclusionsBetter awareness about local terminology used in rural areas related to postpartum sepsis could improve communication, care-seeking patterns, diagnosis and management.

Sickness of neonates of recently delivered women and their referral in Uttar Pradesh, India

Background: The current study done in 2017 explores some of the crucial variables of the type of problems of the newborns as reported by their mothers. The mothers also responded about the type of personnel who referred their newborns. The responses of these mothers or recently delivered women (RDW) (as named for the current study) had a 3 to 6 months old child during the time of survey. They were selected as respondents as they were in a position to recollect the events of their children during their newborn period.Methods: A total of four districts of Uttar Pradesh were selected purposively for the study and the data collection was conducted among the RDWs in the villages of the respective districts with the help of a pre-tested structured interview schedule with both close-ended and open-ended questions. These in-depth interviews were conducted amongst the RDWs and a total 500 respondents participated in the study.Results: The results reflected that more than 97% RDWs reported fever as the problem of their newborn in Banda, Gonda and Barabanki districts except Saharanpur where 82% RDWs reported fever in their newborns. Another major problem of newborn across the 4 districts was ‘unable to take feeds. The results as per the response of the RDWs in all the four districts demonstrated that ASHA was the personnel who referred the maximum number of their newborns.Conclusions: To conclude, fever was the leading cause of health problem as identified by the RDWs and mostly ASHAs referred the majority of the newborns.

Tipping the Scales: Population Estimates and Risk Factors for Severe Thinness, Thinness, Overweight and Obesity Among Pregnant Women and Mothers in India

Abstract Objectives Thinness and overweight/obesity are prevalent among women of reproductive age in India but there is limited evidence on the burden and predictors of this during pregnancy and post-partum. We estimated prevalence and risk factors for thinness and overweight among pregnant and recently delivered women (RDW). Methods We used India's National Family Health Survey (2015–2016), including 16,153 pregnant women <20 weeks of gestation and 19,430 RDW of 2–6-month-old infants. All women were classified as severe thin (ST), thin (TH), overweight (OV) or obese (OB) (body mass index, BMI <16, <18.5, ≥23 and ≥25 kg/m2, respectively), using cutoffs for Asian populations. Logistic regression was used to examine associated factors (including socio-demography, hygiene and sanitation, antenatal health services and diet) with those outcomes. Results Barely 40% of women were of normal BMI. ST, TH, OV/OB and OB were seen in 2%, 20%, 25% and 13% respectively among pregnant women, and for RDW, they were 2%, 21%, 24% and 13%. Factors associated with a lower odds of ST and TH among pregnant women and RDW included higher wealth quintile (adjusted odds ratios, AORs ranging from 0.58–0.63 for highest quintile), higher education (AORs: 0.64–0.81), age group ≥25 y (AORs: 0.58–0.83), and improved toilet facility (AOR 0.81). Multiparous pregnant women had higher odds of TH compared to primiparas (AORs: 1.24–1.31). Factors associated with OV and OB among pregnant women and RDW were belonging in higher socio-economic group (AORs: 1.34–1.53), higher wealth quintile (AORs: 1.56–8.49), age group ≥25 y (AORs: 2.73–5.09), urban residence (AOR 1.16–1.36), and having higher education (AORs: 1.44–1.60). Among RDW, receiving supplementary food and health and nutrition education increased odds of TH (AORs: 1.15) and reduced odds of OV and OB (AORs: 0.83–0.87), but this is likely attributable to selection bias in program use. Conclusions TN and OV/OB affect 1 in 5 pregnant women and 1 in 4 RDW in India. Socio-economic factors, sanitation, parity, education and age influence TN and OV/OB. Better diet and physical activity estimates are needed to understand OV and OB in this population. Given the high burden of both forms of malnutrition, a policy focus on healthy weight gain is essential. Funding Sources UNICEF; Bill & Melinda Gates Foundation (via POSHAN).

What Worked for Improving Balanced Maternal Dietary Intake in Rural Bangladesh? Implications for New Programs

Abstract Objectives To assess the strategies that worked to motivate the women and families to adhere to a nutrition behavior change intervention trial that aimed to promote balanced diet in pregnancy in rural Bangladesh. Methods We designed this process evaluation as part of a cluster randomized controlled trial. We conducted in-depth interviews with pregnant women, recently-delivered women, and husbands; focus groups with mothers and mothers-in-law; and key-informant interviews with Shasthya Kormis (community health workers) who provided the balanced plate nutrition intervention. Results The novel finding in the study was that the balanced plate nutrition education helped women through practical demonstration to learn about a balanced meal considering appropriate portion sizes and diversity of foods. We also found that pregnant women needed active involvement of community health workers in mobilizing social support to create an enabling environment essential to bring changes in dietary behavior with self-motivation. Practical demonstration, opportunity to participate and convenience of making of the plate with the food available in own or neighbors’ kitchen were the most commonly mentioned reasons of acceptance of the intervention to the women and families. We identified six key areas within the intervention strategy that played crucial role in achieving desired adherence. These include: practical demonstration of portion sizes engaging the end-users; addressing local food perceptions; demystifying animal-source foods; engaging husbands and mothers-in-law; leveraging women's social networks; and harnessing community health workers’ social role. Conclusions Programs to improve maternal nutritious food consumption should focus on promoting diet through practical demonstration of portion sizes through active engagement of the women and family instead of replicating the conventional information-based counseling. Funding Sources The University of Sydney Faculty of Medicine and Health.

HOME VISITS DURING THE FIRST MONTH OF DELIVERY FOR RECENTLY DELIVERED WOMEN IN UTTAR PRADESH, INDIA

HOME VISITS DURING THE FIRST MONTH OF DELIVERY FOR RECENTLY DELIVERED WOMEN IN UTTAR PRADESH, INDIA

What is the state of awareness of Janani Suraksha Yojna in Aligarh: a comparison between Rural and Urban Areas

Background: Maternal mortality and morbidity continues to remain high in India, despite the existence of successive national programs for improving maternal and child health since the 1980s. In 2005, the Government of India launched the National Rural Health Mission to provide accessible, affordable and quality health care to the rural population, especially the vulnerable populations. Reduction in MMR to 100/100,000 is one of its goals and the Janani Suraksha Yojana is the key strategy to achieve this reduction. But the awareness of scheme is low in women from rural areas and urban slums, especially in low performing states. Aims: To study the comparative awareness of JSY and the socio-demographic factors influencing it, among the recently delivered women (RDWs). Methodology: A community based cross-sectional study was carried out in the ten rural areas and urban slums coming under the practice areas of JNMC, AMU, Aligarh for a period of one year. The prevalence of institutional delivery in Uttar Pradesh as found in a study by UNFPA 2008 (50.2%) was used for calculation of sample size. The yielded sample size 300 was selected proportionately from these areas. The study subjects were interviewed by a pre-designed and pre-tested questionnaire. Statistical analysis used: MS excel, chi square and logistic regression. Results: Awareness regarding the existence of a monetary scheme related to institutional delivery was more in rural areas i.e 75%. Regarding components of JSY maximum people (78%) were aware about the cash component. Religion, caste, parity, socio-economic status and place of residence showed a significant statistical association with the level of awareness of JSY. Conclusions: There is an urgent need to strengthen IEC campaigns and monitoring strategies for JSY as well as regularize the monetary flow for the health workers

Natal and neonatal care practices of recently-delivered woman in rural areas of Lucknow district

Background: The health of women and children are eternally linked and when the health of women and child improves, life improves by every measure. Deaths associated with child birth were so common that societies developed cultural coping strategies or traditional practices. The objective of the study is to assess natal and neonatal care practices in rural areas of Lucknow district.Methods: The present study was carried out in the rural areas of Lucknow district. Study unit was recently delivered women (RDW), who gave birth to live newborn in last 1 year in rural areas of Lucknow for a period of 12 months. It was community based cross sectional study. A total of 368 RDW were interviewed. Multi stage random sampling technique was used to select RDW.Results: Majority cited all the reasons for preferring institutional delivery (58.2%) followed by those citing it cheaper or better services (17.4%) each and incentive (7.4%) respectively. Weight of baby was 2.5 to 3.5 kg in maximum cases (88%) followed by <2.5 kg (10.3%) respectively. Majority did not have any complication at birth (87%). Exclusive breast feeding was reported by majority (81%).Conclusions: Community needs to be appraised regarding performance and important positive achievement of MCH services in relation to health status of mother and neonate in their respective areas through community participation and will make the community more respective towards availing of accredited social health activist (ASHA) services. Proper provisioning of auxiliary nurse midwiferys, ASHAs and lady health workers would facilitate improvements in rural areas.

The power of peers: an effectiveness evaluation of a cluster-controlled trial of group antenatal care in rural Nepal

BackgroundReducing the maternal mortality ratio to less than 70 per 100,000 live births globally is one of the Sustainable Development Goals. Approximately 830 women die from pregnancy- or childbirth-related complications every day. Almost 99% of these deaths occur in developing countries. Increasing antenatal care quality and completion, and institutional delivery are key strategies to reduce maternal mortality, however there are many implementation challenges in rural and resource-limited settings. In Nepal, 43% of deliveries do not take place in an institution and 31% of women have insufficient antenatal care. Context-specific and evidence-based strategies are needed to improve antenatal care completion and institutional birth. We present an assessment of effectiveness outcomes for an adaptation of a group antenatal care model delivered by community health workers and midwives in close collaboration with government staff in rural Nepal.MethodsThe study was conducted in Achham, Nepal, via a public private partnership between the Nepali non-profit, Nyaya Health Nepal, and the Ministry of Health and Population, with financial and technical assistance from the American non-profit, Possible. We implemented group antenatal care as a prospective non-randomized, cluster-controlled, type I hybrid effectiveness-implementation study in six village clusters. The implementation approach allowed for iterative improvement in design by making changes to improve the quality of the intervention. We evaluated effectiveness through a difference in difference analysis of institutional birth rates between groups prior to implementation of the intervention and 1 year after implementation. Additionally, we assessed the change in knowledge of key danger signs and the acceptability of the group model compared with individual visits in a nested cohort of women receiving home visit care and home visit care plus group antenatal care. Using a directed content and thematic approach, we analyzed qualitative interviews to identify major themes related to implementation.ResultsAt baseline, there were 457 recently-delivered women in the six village clusters receiving home visit care and 214 in the seven village clusters receiving home visit care plus group antenatal care. At endline, there were 336 and 201, respectively. The difference in difference analysis did not show a significant change in institutional birth rates nor antenatal care visit completion rates between the groups. There was, however, a significant increase in both institutional birth and antenatal care completion in each group from baseline to endline. We enrolled a nested cohort of 52 participants receiving home visit care and 62 participants receiving home visit care plus group antenatal care. There was high acceptability of the group antenatal care intervention and home visit care, with no significant differences between groups. A significantly higher percentage of women who participated in group antenatal care found their visits to be ‘very enjoyable’ (83.9% vs 59.6%, p = 0.0056). In the nested cohort, knowledge of key danger signs during pregnancy significantly improved from baseline to endline in the intervention clusters only (2 to 31%, p < 0.001), while knowledge of key danger signs related to labor and childbirth, the postpartum period, and the newborn did not in either intervention or control groups. Qualitative analysis revealed that women found that the groups provided an opportunity for learning and discussion, and the groups were a source of social support and empowerment. They also reported an improvement in services available at their village clinic. Providers noted the importance of the community health workers in identifying pregnant women in the community and linking them to the village clinics. Challenges in birth planning were brought up by both participants and providers.ConclusionWhile there was no significant change in institutional birth and antenatal care completion at the population level between groups, there was an increase of these outcomes in both groups. This may be secondary to the primary importance of community health worker involvement in both of these groups. Knowledge of key pregnancy danger signs was significantly improved in the home visit plus group antenatal care cohort compared with the home visit care only group. This initial study of Nyaya Health Nepal’s adapted group care model demonstrates the potential for impacting women’s antenatal care experience and should be studied over a longer period as an intervention embedded within a community health worker program.Trial registrationClinicalTrials.gov Identifier: NCT02330887, registered 01/05/2015, retroactively registered.

Socio-economic inequalities in ANC attendance among mothers who gave birth in the past 12 months in Debre Brehan town and surrounding rural areas, North East Ethiopia: a community-based survey

BackgroundIn Ethiopia, socio-economic inequalities in the utilization of antenatal care (ANC) have long been an obstacle to the country’s effort in achieving universal coverage of the service. The study aimed to investigate socio-economic inequalities in the use of ANC services among recently-delivered women in Debre Brehan and surrounding areas, North East Ethiopia.MethodsA community-based survey was carried out in Debre Brehan and surrounding areas in North East Ethiopia. Two-stage cluster sampling technique was followed to recruit study participants. Data was collected using interviewer-administered structured questionnaire from a sample of 412 mothers who gave birth in the 12 months prior to the study. The socio-economic inequalities were assessed by calculating a relative concentration index. Decomposition analysis was done to explain measured inequalities. Analysis was carried out in RStudio statistical environment using the ‘decomp’ package.ResultsThe first ANC attendance has slight pro-poor concentration, with a relative concentration index of-0.128, and 95%CI -0.175, − 0.082.Socio-Economic Status (SES) of a household, educational level and occupation of a woman and her husband were the most important contributors to the measured inequality in ANC attendance. We found no SES-based inequality in the attendance of four or more ANC visits between the poor and rich.ConclusionsAttendance of the first ANC visit appeared to be slightly concentrated among women in the lower end of SES. The utilization of at least four ANC visits was found to be similar among the poor and rich. Population-based interventions that target all socio-economic groups are recommended to accelerate universal coverage of these process indicators.

Will You Like to Return to This Facility for Your Next Delivery? Measuring Respectful Maternity Care Delivered within Health Facilities in Bangladesh, Ghana and Tanzania

Background: In 2015, a WHO statement called for global actions to prevent and eliminate disrespect and abuse during facility-based childbirth. UNICEF and health ministries in Bangladesh, Ghana and Tanzania tested the feasibility of implementing WHO's eight standards for improving quality of health facility care for mothers and newborns. This manuscript presents findings from measuring respectful maternity care (RMC) in facilities at baseline. Methods: Uniform methods and tools were used for data collection in the three countries: Assessment involved interviews with 43 managers, 325 providers, 849 recently-delivered women exiting post-discharge and 641 client-provider observations in the 43 facilities across the three countries. Trained clinicians and social scientists/anthropologists spent 2 weeks in facilities between May-July 2016. Data were analysed in Stata 14·1 and NVIVO 12. Responses to open-ended questions were coded into themes and triangulated with close-ended questions to facilitate their contextual interpretations. Findings: Facilities in Ghana (81%) were the most likely to have policies and processes for identifying client abuses compared to Tanzania (73%) and Bangladesh(50). Between 30%-60% of providers had no training in providing RMC but up to 80% could not cite two measures to prevent abuses and 80%-90% did not know how facilities respond to abuses, though 96%-100% claim they provide RMC. Women's account on the experience of RMC were not always consistent; up to 97% were happy with care received but up to 36% were sometimes concerned that providers were not doing enough for them and up to 7% were abused. Majority will recommend these facilities to relatives/friends, but based on their experiences, they would not return to these same facilities for future care. In Bangladesh, 97.4% expressed satisfaction with care received but only 43% will return to the same facilities for the next delivery (p<0·001). These were similar in Ghana and Tanzania. Interpretation: Measuring care satisfaction with questions that merely ask whether women or providers were satisfied with care received or provided are unreliable. A better index of satisfaction with care may be the significant proportion of women who reported that, based on the maternity care experienced, they will not return to the same facilities for birth in the future. This needs exploration in other settings. Funding: The study was funded by the Bill and Melinda Gates Foundation through UNICEF headquarters, New York. Declaration of Interests: All the authors declare no conflict of or competing interests. Ethics Approval Statement: The study protocol was approved by institutional ethics review boards (IRBs) in all three countries: ICDDR,B in Bangladesh, Ghana Health Service (GHS) in Ghana and NIMR in Tanzania. Clearance was sought from the facility managers for the study in the respective facilities.

Janani Shishu Suraksha Karyakram services utilization among rural mothers: community perspective from southern areas of West Bengal

Background: Janani Shishu Suraksha Karyakram (JSSK) was launched to increase accessibility of healthcare services for expectant mothers and children. The present study was conducted to understand the utilization pattern of JSSK services among recently-delivered women of southern West Bengal.Methods: A community based cross-sectional study was conducted in the rural areas of South 24-Parganas district of West Bengal. By multistage sampling 340 mothers were selected. Data regarding child-bearing experiences, different services related to maternal health and the utilization of JSSK services were collected through interview.Results: The mean age of the mothers was 23.58 years (±4.36 years). Majority of the respondents had education up to primary level with majority having two living children or less. During ante-natal period 74.6% of the respondents in delta regions did not undergo any diagnostic tests. In Kolkata-nearing non-delta regions, majority of the respondents (92.8%) utilized exclusively government hospital for diagnostic tests. In delta regions most of the deliveries (78.8%) happened at home. After delivery in government/accredited facility, majority of women did not get the free drop-back facility. While 18.4% of the respondents from delta region utilized free diagnostic services, 16.9% utilized the free delivery services. A marginally higher utilization of free transportation among the respondents of non-delta region was observed for transport back to home.Conclusions: Delta blocks need to be given special attention especially regarding institutional delivery. Along with promotion of the services generation of awareness, acceptance and also implementation of methods to reach out to people should be focused more.