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Background: Improving maternal healthcare services is crucial to achieving the Sustainable Development Goal (SDG-3), which aims to reduce maternal mortality and morbidity. There is a consensus among different researchers that proper utilization of maternal healthcare services can improve the reproductive health of women, and this can be achieved by providing Antenatal Care (ANC) during pregnancy, Health Facility Delivery (HFD), and Postnatal Care (PNC) to all pregnant women. The main aim of this study was to investigate the utilization and factors associated with maternal and child healthcare services among women of reproductive age in the pastoralist communities in Kenya. Methods: A cross-sectional survey was conducted among 180 pastoralist women who gave birth in the past two years across ten mobile villages in Marsabit County between 2nd January and 29th February 2019. Three key outcomes were analyzed, whether they attended ANC 4+ visits, delivered at HF, and received PNC. Pearson χ2 test and multivariate logistic regression analysis were conducted by IBM SPSS27.0 following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The significance level was set at p < 0.05. Results: Of the 180 eligible pastoralist women (mean age 27.44 ± 5.13 years), 92.2% were illiterate, 93.9% were married, 33.3% were in polygamy, and 14.4% had mobile phones. The median commuting distance was 15.00 (10–74) km, 41.7% attended ANC 4+, 33.3% HFD, and 42.8% PNC. Those women residing close (≤ 15 km) to a health facility had a threefold higher ANC 4+ (OR 3.10, 95% CI 1.47–6.53), 2.8-fold higher HFD (OR 2.80, 95% CI 1.34–5.84), and 2.5-fold higher PNC (OR 2.49, 95% CI 1.19–5.22) probability. The likelihood was 30-fold higher for ANC 4+ (OR 29.88, 95% CI 6.68–133.62), 2.5-fold higher for HFD (OR 2.56, 95% CI 0.99–6.63), and 60-fold higher for PNC (OR 60.46, 95% CI 10.43–350.55) in women with mobile phones. A monogamous marriage meant a fivefold higher ANC 4+ (OR 5.17, 95% CI 1.88–14.23), 1.6-fold higher HFD (OR 1.67, 95% CI 0.77–3.62), and a sevenfold higher PNC (OR 7.05, 95% CI 2.35–21.19) likelihood. Hosmer Lemeshow test indicated a good-fitting model for ANC 4+, HFD, and PNC (p = 0.790, p = 0.441, p = 0.937, respectively). Conclusion: In conclusion, the utilization of three essential maternal health services is low. Geographic proximity, monogamous marriage, and possession of mobile phones were significant predictors. Therefore, it is recommended that stakeholders take the initiative to bring this service closer to the pastoralist community by providing mobile health outreach and health education. Plain Language Summary: Attending maternal healthcare clinics is essential to reduce maternal deaths and infections. This can be achieved by receiving antenatal care, delivering at health facilities, and checkups after delivery. We investigated the utilization and factors associated with maternal and child healthcare services among pastoralist women of reproductive age who have given birth in the past two years. Of one hundred and eighty women who participated, most of them were illiterate; the majority were married, of which almost a quarter were in polygamous marriages. This population's uptake of antenatal care, delivery in health facilities, and checkups after delivery is low. This means, that walking distance to the health facility was more than 15 km, almost half of women attended antenatal care and received checkups after delivery but only thirty-three percent delivered at a health facility. Geographic proximity, monogamy, and possession of mobile phones for communication were significant in determining the usage of maternal health care. Living close to a health facility means almost three times more antenatal care, two times more health facility delivery, and checkups after delivery. Women with mobile phones showed twenty-seven more times chances to attend antenatal care, more than four times chances to deliver in a health facility and sixty times more chances of having checkups after delivery. Monogamous marriage showed five times higher odds to attend ANC 4+ visits, and seven times having checkups after delivery. Therefore, it is recommended that stakeholders take the initiative to bring this service closer to the pastoralist community. [ABSTRACT FROM AUTHOR]

Background: Unintended pregnancies can adversely affect maternal health, preventable through timely postpartum contraception. During the COVID-19 pandemic, family planning services were constrained by policies that curtailed outpatient visits. We investigated the prevalence of postpartum contraceptive initiation at King Chulalongkorn Memorial Hospital (KCMH) during January to June 2020, comparing with the same period in 2019, and identified factors associated with such initiation. Methods: We reviewed the medical records of 4506 postpartum women who delivered at KCMH during the study period. Logistic regression was conducted to test the association between early COVID-19 phase deliveries and post-partum long acting reversible contraception (LARC) initiation including copper intrauterine devices, levonorgestrel intrauterine systems, contraceptive implants, and progestogen-only injectable contraceptives. Results: A total of 3765 women (83.6%), of whom 1821 delivered during the pandemic and 1944 during the historical cohort period, were included in this study. The proportion of women who initiated non-permanent modern contraceptives at six weeks postpartum was comparable between the COVID-19 (73.4%) and historical cohort (75.3%) (p = 0.27) periods. The proportion of women who initiated LARC at six weeks postpartumwas comparable between the historical cohort period (22.5%) and the COVID-19 (19.7%) (p = 0.05) period. Accessing a six-week postpartum check-up was independently associated with LARC initiation, of which the adjusted odds ratio (OR) (95% confidence interval) was 3.01 (2.26 to 4.02). Conclusions: Our findings demonstrated that accessing postpartum care significantly associate with the use of LARC. The data suggest the strong influence of postpartum check-ups in facilitating the adoption of effective contraception, emphasizing the need for accessible postpartum care to sustain maternal health during health crises. Plain language summary: In this study, we looked at how often new mothers used birth control methods after giving birth during the COVID-19 pandemic in Thailand. We also wanted to find the factors that influenced their decision to use birth control. We reviewed the medical records of 4,506 women who had recently given birth at King Chulalongkorn Memorial Hospital. Out of these, 3,765 women were included in the study. Some gave birth during the pandemic, and others gave birth before the pandemic. We found that a similar number of women started using birth control about six weeks after giving birth, whether it was during the pandemic or before it. However, slightly fewer women chose very effective methods of birth control during the pandemic compared to before it. One important factor we found was that women who went for a check-up six weeks after giving birth were more likely to use highly effective birth control. This means that getting regular check-ups after childbirth can help women make better choices about birth control. In summary, our study showed that receiving postpartum care is closely linked to using LARC. This underlines how important it is for new mothers to have their check-ups after giving birth, to help them start using effective birth control if they choose. [ABSTRACT FROM AUTHOR]

Background: The "Adequate Childbirth Program" (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation. Method: This study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software. Results: The three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals. Conclusions: After the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it's harmful. Plain English summary: Brazil has high Cesarean Section (CS) rates, with rates far from the ideal recommended by the World Health Organization and a model of care that does not favor women's autonomy and empowerment. In 2015, a quality improvement project, called "Projeto Parto Adequado" (PPA), was implemented in Brazilian private hospitals to reduce unnecessary cesarean section, in addition to encouraging the process of natural and safe childbirth. One of the components of this project was to reorganize the model of care in hospitals to prepare professionals for humanized and safe care. The data were collected in 8 hospitals with interviews with 49 professionals, approximately two years after the beginning of the project in the hospitals. There were changes in the hospital routine and in the care of women after the project. The professionals incorporated practices such as skin-to-skin contact and breastfeeding; diet during labor; non-invasive care technologies, especially to relieve pain during labor; birth plan; pregnancy courses with guided tours in hospitals (for pregnant women and family); and analgesia for vaginal labor. There was adaptation of existing practices in hospitals to reduce CS that had no clinical indication; better monitoring of labor, favoring vaginal delivery. And finally, the professionals rejected the practice that presses the uterine fundus, for not having shown efficacy in recent studies. We can conclude that the hospitals that participated in this study have made an effort to change their obstetric model. However, specific aspects of each hospital, the organization of the health system in Brazil, and the incentive of the local administration influenced the implementation of these changes by professionals in practice. [ABSTRACT FROM AUTHOR]

Background: Most forcibly displaced persons are hosted in low- and middle-income countries (LMIC). There is a growing urbanization of forcibly displaced persons, whereby most refugees and nearly half of internally displaced persons live in urban areas. This scoping review assesses the sexual and reproductive health (SRH) needs, outcomes, and priorities among forcibly displaced persons living in urban LMIC. Methods: Following The Joanna Briggs Institute scoping review methodology we searched eight databases for literature published between 1998 and 2023 on SRH needs among urban refugees in LMIC. SHR was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception; fertility care; safe abortion care). Searches included peer-reviewed and grey literature studies across quantitative, qualitative, or mixed-methods designs. Findings: The review included 92 studies spanning 100 countries: 55 peer-reviewed publications and 37 grey literature reports. Most peer-reviewed articles (n = 38) discussed sexual health domains including: GBV (n = 23); HIV/STI (n = 19); and CSE (n = 12). Over one-third (n = 20) discussed reproductive health, including: antenatal, intrapartum and postnatal care (n = 13); contraception (n = 13); fertility (n = 1); and safe abortion (n = 1). Eight included both reproductive and sexual health. Most grey literature (n = 29) examined GBV vulnerabilities. Themes across studies revealed social-ecological barriers to realizing optimal SRH and accessing SRH services, including factors spanning structural (e.g., livelihood loss), health institution (e.g., lack of health insurance), community (e.g., reduced social support), interpersonal (e.g., gender inequitable relationships), and intrapersonal (e.g., low literacy) levels. Conclusions: This review identified displacement processes, resource insecurities, and multiple forms of stigma as factors contributing to poor SRH outcomes, as well as producing SRH access barriers for forcibly displaced individuals in urban LMIC. Findings have implications for mobilizing innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing) to address these gaps. Regions such as Africa, Latin America, and the Caribbean are underrepresented in research in this review. Our findings can guide SRH providers, policymakers, and researchers to develop programming to address the diverse SRH needs of urban forcibly displaced persons in LMIC. Plain English summary: Most forcibly displaced individuals live in low- and middle-income countries (LMICs), with a significant number residing in urban areas. This scoping review examines the sexual and reproductive health (SRH) outcomes of forcibly displaced individuals in urban LMICs. We searched eight databases for relevant literature published between 1998 and 2023. Inclusion criteria encompassed peer-reviewed articles and grey literature. SRH was defined to include various dimensions of sexual health (comprehensive sexuality education; sexual and gender-based violence; HIV/ STI prevention; sexual function, and psychosexual counseling) and reproductive health (antenatal, intrapartum, and postnatal care; contraception; fertility care; and safe abortion care). We included 90 documents (53 peer-reviewed articles, 37 grey literature reports) spanning 100 countries. Most peer-reviewed articles addressed sexual health and approximately one-third centered reproductive health. The grey literature primarily explored sexual and gender-based violence vulnerabilities. Identified SRH barriers encompassed challenges across structural (livelihood loss), health institution (lack of insurance), community (reduced social support), interpersonal (gender inequities), and individual (low literacy) levels. Findings underscore gaps in addressing SRH needs among urban refugees in LMICs specifically regarding sexual function, fertility care, and safe abortion, as well as regional knowledge gaps regarding urban refugees in Africa, Latin America, and the Caribbean. Self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, abortion self-management) hold significant promise to address SRH barriers experienced by urban refugees and warrant further exploration with this population. Urgent research efforts are necessary to bridge these knowledge gaps and develop tailored interventions aimed at supporting urban refugees in LMICs. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic disrupted maternal and newborn health services in Bangladesh, exacerbating the large gaps in service utilization that existed prior to the pandemic. As part of its response, Bangladesh initiated remote antenatal and postnatal care telemedicine services led by midwives in 36 sub-district hospitals across five of Bangladesh's 64 districts. Gender-based violence screening and referral were integrated into the service to address a reported rise in violence following the country's pandemic lockdown. Methods: Mixed-methods implementation research was used to develop an intrinsic case study describing the design and implementation of the telemedicine program. Qualitative analysis comprised document review, key informant interviews, and focus group discussions. Quantitative analysis employed an interrupted time series analysis with segmented multi-variate regression to compare maternity care service use trends before and after implementation. Poisson regression analysis was used to examine the trend in number of gender-based violence remote screenings, sessions held, and cases identified. Results: A statistically significant change in trend for onsite antenatal and postpartum care as well as women seeking care at the hospital as a result of postpartum hemorrhage arising in the community was observed following the introduction of telemedicine. Facility births and cases of eclampsia appropriately identified and managed also had significant increases. In addition, over 6917 women were screened for GBV, 223 received counseling and 34 referrals were made, showing a statistically significant increase in frequency over time following the implementation of the telemedicine program. Challenges included that not all midwives adopted GBV screening, some women were reluctant to discuss GBV, there was an unanticipated need to introduce a patient visit scheduling system in all intervention hospitals, and many women were not reachable by phone due to lack of access or network coverage. Conclusions: Maternal health and gender-based violence telemedicine led by midwives was an effective, low-cost intervention in Bangladesh for addressing pandemic and pre-pandemic gaps in service use. Other low and middle-income countries planning to implement remote maternal health interventions via midwives should consider whether a patient visit scheduling system needs to be introduced, as well as limitations around mobile phone access and connectivity. Future research should include care quality oversight and improvement, and a more well-informed strategy for facilitating effective GBV screening. Plain language summary: To support the continuation of sexual and reproductive health services following pandemic lockdowns, Bangladesh introduced a midwife-led telemedicine program. Through the program, midwives who were already employed within the health system delivered remote antenatal and postnatal care, including gender-based violence screening and referral. The program operated in 36 sub-district hospitals across five of Bangladesh's 64 districts. Intrinsic implementation research was used to develop a case study describing the design and implementation of the telemedicine program. Qualitative and quantitative methods comprised document review, key informant interviews, focus group discussions, and service use trends. Analysis of the data identified a statistically significant trend increase for most maternity care services. Although they did increase significantly over time, referrals for GBV were less than expected, which may have been related to some midwives not screening for GBV, and/or that many women were reluctant to discuss GBV. In addition, there was an unanticipated need to introduce a patient visit scheduling system in all intervention hospitals, and many women were not reachable by phone due to lack of access or network coverage. In spite of this, 6197 women were screened for GBV. Of those, 223 received counseling and 34 received referrals. Overall, telemedicine led by midwives was an effective, low-cost intervention for maternal health, and a step toward stronger GBV response in Bangladesh. Other low and middle-income countries planning to implement remote maternal health interventions via midwives should consider what is needed to facilitate comfort for both providers and women as related to GBV screening, as well as practical issues regarding introducing scheduling systems and limitations of mobile phone access and connectivity. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effect of Internet based intervention model on breastfeeding knowledge, attitude, self-confidence and breastfeeding rate. Methods: An electronic literature search of PubMed, Embase, Web of Science, Cochrane Library, CINAHL, CNKI, Wanfang, CBM and VIP database was performed using combinations of the keywords "Breastfeeding," "Breastfeeding, Exclusive," "Internet," "Online," and "Website". The retrieval period was from their inception to March 31, 2023. Quality appraisal was performed using the Cochrane 5.1 for randomized controlled trials (RCTs). RevMan5.3 was used for data analysis. Results: Thirty-two studies were included in the review, with a total of 9514 samples. The results of Meta-analysis showed that, compared with routine nursing, the intervention model based on the Internet can effectively improve breastfeeding knowledge and attitude of pregnant women, improve breastfeeding self-confidence (P < 0.05), and improve the rate of exclusive breastfeeding in the short term (within 6 weeks) and the long-term postpartum (3–6 months) had a positive effect on the rate of exclusive breastfeeding (P < 0.05). Conclusions: The Internet breastfeeding intervention model may be an effective intervention to improve the effect of exclusive breastfeeding. In the future, more high-quality, large-sample randomized controlled trials can be carried out to further explore the effect of the Internet intervention model on breastfeeding. [ABSTRACT FROM AUTHOR]

Background: According to World Health Organization (WHO), the postnatal care provision aims to provide care and treatment with the highest quality and the least intervention to obtain the best health and well-being for the family. The present study aims to adapt international guidelines for the clinical recommendations for the postpartum period and implement and determine its effectiveness. Methods/design: This study will be done in two phases. In the first phase, international clinical guidelines for mother and newborn postnatal care will be adapted. The second phase is a randomized controlled trial in which the adapted guideline recommendations will be implemented, and maternal and neonatal outcomes will be measured. The ADAPTE method for adaptation of clinical guidelines, is usedg in the first phase. A systematic review was conducted in the databases and clinical guidelines related to postpartum care were extracted according to the inclusion criteria. The quality of clinical guidelines was evaluated using the AGREE-II tool. The WHO clinical guideline obtained the highest evaluation score and was chosen as the main guideline, and the NICE clinical guideline, with a second higher evaluation score, was also used to fill some gaps in the WHO guideline. Based on the pre-determined questions, recommendations will be sent to the relevant experts and stakeholders for their evaluation. After the external evaluation and the finalization of the recommendations, the postpartum clinical guideline will be compiled and used in the second phase of the study. In the second phase, 272 women in the immediate postnatal stage of the maternity and postpartum ward of Taleghani and AL-Zahra Hospitals in Tabriz will be assigned into the intervention (receiving care based on adapted guidline recommendations) and control (receiving routine hospital care) groups uing individual stratified block randomization. At 6 weeks after birth, we will complete the Edinburgh postnatal depression scale, postpartum specific anxiety scale and Barkin index of maternal functioning (to assess the primary outcomes), as well as a maternal health problems checklist, infant care behavior, and violence assessment questionnaires (to asses the seconadary outcomes). Further, the maternal health problems checklist and the Edinburgh postnatal depression scale will be completed in the second week after birth. The data will be analyzed using an independent t-test and ANCOVA. Discussion: It is expected that the implementation of evidence-based clinical guidelines improves maternal and neonatal outcomes and experience of the postpartum period. The positive experience can also help to achieve Iran's population policies and the need to increase childbearing in the country. Trial registration: Iranian Registry of Clinical Trials (IRCT): IRCT20120718010324N76; Date of registration: 27/1/2023. URL: https://en.irct.ir/user/trial/66874/view; Date of first registration: 27/3/2023. Plain language summary: The postpartum period, starting immediately after childbirth up to the first six weeks (42 days), is a significant and critical period in the lives of mothers and newborns, spouses, caregivers, and families. Maternal and newborn deaths and complications are high during the postpartum period. Postpartum care with high quality could reduce maternal and newborn deaths and complications, and makes the mother have a positive childbirth experience and a favourable attitude toward her next birth. World Health Organization (WHO) recommend providing medical care and treatment with the highest quality and the least intervention to obtain the best health and well-being conditions for the family. The present study aims to localize and use the international recommendations for the postpartum period in Iran. This study will be done in two phases. In the first phase, the international recommendations for mother and newborn care and postnatal well-being will be adapted according to our country's resources and conditions. In the second phase, the recommendations of adapted guideline will be implemented on 272 mothers and newborn in two groups in the maternity and postpartum ward of Taleghani and AL-zahra Hospitals in Tabriz, and we compare the result of using these recommendations and routine care on mothers' and newborns' well-being. In clinical guideline recommendations group, we will educate mothers, fathers and families and will share with them adapted recommendations, up to 6 weeks after birth and we will support them via the network. During the postpartum period we will assess mental and physical health problems of the mothers; counsel about breastfeeding, baby care, family planning, nutrition, activity, pain killer, bonding and emotional attachment, and prevention of postpartum depression; and any questions will be answered. [ABSTRACT FROM AUTHOR]

BackgroundThe Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women's experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements.MethodsWe completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation.ResultsBefore implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout.DiscussionThese results are consistent with other published reports of women's perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women's experiences of care.ConclusionGroup antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model.Trial registrationThis trial is registered at clinicaltrials.gov as NCT03154177 .

Plain Language summary Utilisation of essential maternity and newborn health (MNH) interventions during pregnancy, childbirth, and the postnatal period can improve the health of mothers and newborns. There are increasing access trends for routine MNH visits in Nepal, such as at least four (4+) antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits. Little is known, however, about the utilisation of recommended MNH interventions, or who is benefitting or being left behind in relation to better quality MNH services. This study examined different types of health service coverage cascades across routine MNH services and associated determinants using Nepal Demographic and Health Survey 2016 data. A total of 1978 women aged 15–49 years who had live-births 2 years preceding the survey were included in the analysis. Despite improved access to routine visits during the pregnancy-postnatal period, some women had not received all recommended interventions, and had low-quality-adjusted coverage of MNH services. Women with advantaged ethnicities or financial assets received optimal quality MNH services, while Maithili-speaking women or those with high birth order received poor quality ANC services. Women from Karnali province or women who preferred to be seen by a female healthcare provider experienced poor quality PNC service. Demographic and health survey data can be used to assess the population-level coverage of quality health services. Policy and program efforts require better quality MNH services that employ female health providers.

Background: The Baby-Friendly Hospital Initiative's Step 4 recommends: "support mothers to start breastfeeding as soon as possible after birth", thus contributing to the reduction of neonatal mortality. The objective of this study is to estimate the prevalence of breastfeeding in the first hour of life in private maternity hospitals participating in the "Adequate Childbirth Project", a quality-of-care improvement project, and to analyze determinants of this outcome. Methods: Secondary analysis of data collected by the cross-sectional evaluative "Healthy Birth Study", conducted in 2017 in 12 maternity hospitals participating in the Adequate Childbirth Project, where 4800 mothers were interviewed, and hospital records were observed. Conditions that prevented breastfeeding at birth, such as maternal HIV-infection and newborns' severe malformations, were excluded. Multiple logistic regression was performed according to a hierarchical theoretical model. Results: The prevalence of breastfeeding in the first hour of life was 58% (CI 95% 56.6–59.5%). Lower maternal education (aOR 0.643; CI 95% 0.528–0.782), lower economic status (aOR 0.687; CI 95% 0.504–0.935), cesarean section delivery (ORa 0.649; CI 95% 0.529–0.797), preterm birth (aOR 0.660; CI 95% 0.460–0.948) and non-rooming-in at birth (aOR 0.669; CI 95% 0.559–0.800) were negatively associated with the outcome. Receiving information during prenatal care about the importance of breastfeeding at birth (aOR 2.585; CI 95% 2.102–3.179), being target of the quality-of-care improvement project (aOR 1.273; CI 95% 1.065–1.522), skin-to-skin contact at birth (aOR 2.127; CI 95% 1.791–2.525) and female newborn (aOR 1.194; CI 95% 1.008–1.415) were factors positively associated with the outcome. Conclusions: The private maternities participating in the Healthy Birth Study showed a good prevalence of breastfeeding in the first hour of life, according to WHO parameters. Prenatal guidance on breastfeeding at birth, being target of the quality-of-care improvement project and skin-to-skin contact at birth contributed to breastfeeding in the first hour of life. [ABSTRACT FROM AUTHOR]

Plain Language Summary Out of more than one billion persons with disabilities in the world, 80% of them live in developing countries. Persons with disabilities commonly face discrimination and health disparities, particularly experiencing major barriers in accessing sexual and reproductive health (SRH) services. Education is a key factor that often leads to social and economic empowerment, which positively contributes towards individuals’ SRH service utilization. In this paper, we examined the relationship between education and SRH service utilization for persons with disabilities in Bangladesh. We surveyed persons with disabilities across all of Bangladesh on their utilization of SRH services and conducted mini-ethnographic case studies with selected participants to more deeply understand their SRH issues and SRH service utilization. Our survey findings show that education significantly increases persons with disabilities’ SRH service utilization of antenatal care, delivery care, postnatal care, and family planning in Bangladesh. Interestingly, for persons with disabilities, primary education may only be able to increase family planning use while secondary or post-secondary education may be required to increase antenatal care, delivery care, and postnatal care use. Our qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of higher education prioritized obtaining formal SRH services from qualified health care providers, even when financially constrained, while lower educated participants tended to be misinformed and distrustful of formal SRH services. We recommend helping persons with disabilities attain higher formal education levels and including comprehensive sexuality education (CSE) in their schools, as it likely will reduce SRH health disparities for this vulnerable group.

Plain language summary Postnatal care is a care that a delivered women and her newborn baby receive after delivery and up to 42 days of childbirth, regardless of place of delivery. This period is considered critical in minimizing morbidity and mortality of both the mother and the baby. In Ethiopia, the coverage of postnatal care utilization remained low. Recent studies showed only 33.8% of mothers received postnatal care, this becomes very low for mothers who delivered at home, of which only 8.2% of them received the care. On top of other factors that hinder maternal health care utilization, in Ethiopia there are widely accepted and persistent cultural ceremonies after childbirth that encourages a women to stay in door. This study introduced a new intervention called Checklist-based box system intervention, which aimed to improve postnatal care utilization through demand creation and dropout tracing mechanisms. The intervention was carried out by health professionals in health centers and community health workers (health extension workers) who visited mothers in their homes. Despite some practical challenges, its implementation demonstrated an improvement over clusters that did not receive the intervention. This intervention is recommended to be implemented on a larger scale. Simultaneously, practical level challenges need to be addressed in order for the intervention’s effect to be seen in its best form.

Background: Antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits are vital to improve the health of mothers and newborns. Despite improved access to these routine maternal and newborn health (MNH) services in Nepal, little is known about the cascade of health service coverage, particularly contact coverage, intervention-specific coverage, and quality-adjusted coverage of MNH services. This study examined the cascade of MNH services coverage, as well as social determinants associated with uptake of quality MNH services in Nepal. Methods: We conducted a secondary analysis of data derived from the Nepal Demographic and Health Survey (NDHS) 2016, taking 1978 women aged 15–49 years who had a live birth in the 2 years preceding the survey. Three outcome variables were (i) four or more (4+) ANC visits, (ii) institutional delivery, and (iii) first PNC visit for mothers and newborns within 48 h of childbirth. We applied a cascade of health services coverage, including contact coverage, intervention-specific and quality-adjusted coverage, using a list of specific intervention components for each outcome variable. Several social determinants of health were included as independent variables to identify determinants of uptake of quality MNH services. We generated a quality score for each outcome variable and dichotomised the scores into two categories of "poor" and "optimal" quality, considering > 0.8 as a cut-off point. Binomial logistic regression was conducted and odds ratios (OR) were reported with 95% confidence intervals (CIs) at the significance level of p < 0.05 (two-tailed). Results: Contact coverage was higher than intervention-specific coverage and quality-adjusted coverage across all MNH services. Women with advantaged ethnicities or who had access to bank accounts had higher odds of receiving optimal quality MNH services, while women who speak the Maithili language and who had high birth order (≥ 4) had lower odds of receiving optimal quality ANC services. Women who received better quality ANC services had higher odds of receiving optimal quality institutional delivery. Women received poor quality PNC services if they were from remote provinces, had higher birth order and perceived problems when not having access to female providers. Conclusions: Women experiencing ethnic and social disadvantages, and from remote provinces received poor quality MNH services. The quality-adjusted coverage can be estimated using household survey data, such as demographic and health surveys, especially in countries with limited routine data. Policies and programs should focus on increasing quality of MNH services and targeting disadvantaged populations and those living in remote areas. Ensuring access to female health providers and improving the quality of earlier maternity visits could improve the quality of health care during the pregnancy-delivery-postnatal period. Plain Language summary: Utilisation of essential maternity and newborn health (MNH) interventions during pregnancy, childbirth, and the postnatal period can improve the health of mothers and newborns. There are increasing access trends for routine MNH visits in Nepal, such as at least four (4+) antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits. Little is known, however, about the utilisation of recommended MNH interventions, or who is benefitting or being left behind in relation to better quality MNH services. This study examined different types of health service coverage cascades across routine MNH services and associated determinants using Nepal Demographic and Health Survey 2016 data. A total of 1978 women aged 15–49 years who had live-births 2 years preceding the survey were included in the analysis. Despite improved access to routine visits during the pregnancy-postnatal period, some women had not received all recommended interventions, and had low-quality-adjusted coverage of MNH services. Women with advantaged ethnicities or financial assets received optimal quality MNH services, while Maithili-speaking women or those with high birth order received poor quality ANC services. Women from Karnali province or women who preferred to be seen by a female healthcare provider experienced poor quality PNC service. Demographic and health survey data can be used to assess the population-level coverage of quality health services. Policy and program efforts require better quality MNH services that employ female health providers. [ABSTRACT FROM AUTHOR]

Background: Promoting exclusive breastfeeding (EBF) is a major child survival strategy in developing countries like Ethiopia. Studies in EBF are found in a fragmented and inconclusive way in Ethiopia. Therefore, the aim of this study was to examine evidences on the effect of post natal care counseling and maternal employment status on exclusive breastfeeding practice of women in Ethiopia. Methods: A systematic literature search was conducted from PubMed (contains MEDLINE), CINAHL (EBSCO), Global Health, Food Science and Technology Abstracts (FSTA) (EBSCO) and Grey literature sources such as Google and Google scholar. All primary studies on the effects of employment status and/or post-natal care utilization on EBF practices of women in Ethiopia were included. Data analyses were performed using STATA software. Forest plot, I2 test and the Cochrane Q statistics were used to detect heterogeneity among studies. Heterogeneity was considered significant when the I2 value was ≥ 50%, with p-value < 0.05. Publication bias was checked by looking the asymmetry of funnel and confirmed by Egger's regression test at a 5% significant level. The pooled odds ratio (POR) with 95% confidence interval (CI) was used to report the measures of associations. Result: A total of 622 studies were identified in the initial search of which 42 articles were included this systematic review and meta-analysis. A meta-analysis of 24 studies indicated that maternal employment status was significantly associated (POR = 0.51, 95% CI 0.16, 0.86) EBF practice in that employed mother were less likely to practice to practice EBF. Post-natal care service utilization significantly increases (POR = 1.76, 95% CI 1.32, 2.34) the EBF practice in Ethiopia and it was computed using 25 eligible articles. Besides, the pooled estimates of EBF practice was found to be 62.58% (95% CI 56.98, 68.19, I2 = 96.4%, p < 0.001). Conclusion: This review found that post-natal care service utilization and maternal employment status has a significant effect on EBF practice. The findings from this review may be used to inform for better supportive and promotive strategies for EBF practice in Ethiopia. Plain Language summary: Promotion of EBF in developing countries including Ethiopia is very crucial strategy to improve the survival of children. Despite this, several factors prohibit women from practicing EBF of which post-natal care service utilization and employment status are the main determinants. The previous studies in Ethiopia are inconsistent and inconclusive to policy makers. Thus, this systematic review and meta-analysis underpinned the effects post-natal care service and maternal employment status on the EBF practice of women in Ethiopia. The findings of this study will be vital to forward recommendations on the duration of maternal leave and design promotion strategies of post-natal care, the most unaddressed maternal health care service in Ethiopia. The original studies were retrieved systematically from reputable databases and grey literature sources. The data were extracted using standardized data extraction sheet. Analyses were performed using STATA software. Fixed and random effect models were utilized to compute pooled estimates. Heterogeneities were computed and the sources of heterogeneities were explained. In the current study, the pooled prevalence of EBF was 62.6%. Likewise, post-natal care service utilization and employment status were found to have significant association with the EBF practice. Unemployed women had a better EBF practice as compared to the employed ones. This could be due to the fact that most employed women in Ethiopia are governmental employees where the maximum duration of maternal leave is four months after birth. This is before the due date of commencement of complementary feeding. Post-natal care should also be promoted to improve the EBF practice. [ABSTRACT FROM AUTHOR]

Across sub-Saharan Africa where access to adequate maternal healthcare is fraught with myriad challenges, especially for hard-to-reach populations, digital health technologies offer opportunities to improve maternal health outcomes. Digital health can circumvent inefficiencies in the traditional healthcare system and address challenges such as limited access to in-person medical consultations, and poor access to skilled birth attendants and health promotion activities. These benefits notwithstanding, digital health can be exclusionary. Too often, digital maternal health programs are not designed with a focus on equity in distribution nor are they designed from a gender equity standpoint. In this paper, we illustrate exclusionary practices of digital health programs through an extensive literature review of digital maternal health programs across sub-Saharan Africa. Taking an intersectional approach, we discuss how women are most vulnerable and excluded at the intersection of gender, literacy, and disability. Tackling exclusionary practices in digital health is crucial to ensure that no woman or girl is left behind. [ABSTRACT FROM AUTHOR]

Background: Persons with disabilities comprise more than one billion people in the world, yet they are one of the most discriminated groups and face significant health disparities. Particularly in developing countries, which contain 80% of the entire population with disabilities, these individuals experience major barriers in accessing sexual and reproductive health (SRH) services. Education is an important factor that greatly affects individuals' SRH service utilization. Hence, we sought to investigate the relationship between education and SRH service utilization for persons with disabilities in Bangladesh. Methods: Using an explanatory sequential mixed-methods design, a total of 5000 persons with disabilities were surveyed for the quantitative component and 15 mini-ethnographic case studies were conducted with persons with disabilities for the qualitative component. Chi-squared tests and logistic regression analyses were performed on the survey data, while the qualitative interviews were coded and their SRH themes synthesized accordingly. Results: Our quantitative findings show that education statistically significantly increases persons with disabilities' SRH service utilization of antenatal care, delivery care, postnatal care, and family planning (P < 0.05). Interestingly, for persons with disabilities, primary education shows increased adjusted odds of family planning use but is likely not enough to increase antenatal care, delivery care, or postnatal care use; secondary or post-secondary education may be required to improve utilization of these latter services. Qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of lower educational attainment held misinformation and distrust in SRH services and experienced mistreatment by SRH healthcare providers, discouraging them from seeking future SRH services. Conclusions: We report that higher formal education level is associated with greater SRH service use for persons with disabilities in Bangladesh. Formally educating persons with disabilities expands their SRH knowledge and familiarity with SRH services, as well as leads to more economic opportunities so they can afford SRH services. Increasing formal education levels for persons with disabilities, paired with integrating comprehensive sexuality education (CSE) in their schools, will likely help close the gap in SRH health disparities for this vulnerable population. Plain Language Summary: Out of more than one billion persons with disabilities in the world, 80% of them live in developing countries. Persons with disabilities commonly face discrimination and health disparities, particularly experiencing major barriers in accessing sexual and reproductive health (SRH) services. Education is a key factor that often leads to social and economic empowerment, which positively contributes towards individuals' SRH service utilization. In this paper, we examined the relationship between education and SRH service utilization for persons with disabilities in Bangladesh. We surveyed persons with disabilities across all of Bangladesh on their utilization of SRH services and conducted mini-ethnographic case studies with selected participants to more deeply understand their SRH issues and SRH service utilization. Our survey findings show that education significantly increases persons with disabilities' SRH service utilization of antenatal care, delivery care, postnatal care, and family planning in Bangladesh. Interestingly, for persons with disabilities, primary education may only be able to increase family planning use while secondary or post-secondary education may be required to increase antenatal care, delivery care, and postnatal care use. Our qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of higher education prioritized obtaining formal SRH services from qualified health care providers, even when financially constrained, while lower educated participants tended to be misinformed and distrustful of formal SRH services. We recommend helping persons with disabilities attain higher formal education levels and including comprehensive sexuality education (CSE) in their schools, as it likely will reduce SRH health disparities for this vulnerable group. [ABSTRACT FROM AUTHOR]

Background: In many settings, health care service provision has been modified to managing COVID-19 cases, and this has been affecting the provision of maternal and child health services. The aim of this study was to assess trends in selected maternal and child health services performance in the context of COVID-19 pandemic. Methods: A cross-sectional data review was conducted in Addis Ababa, Ethiopia from April to May 2021. Routine health management information system database was reviewed from Addis Ababa Health Bureau for the period from July 2019 to March 2021 across all quarters. Proportion and mean with standard deviation were computed. T-test was used to assess statistically significant differences in services mean performance. Results: Postnatal care visit, new contraceptives accepters, safe abortion care and number of under-5 years old children treated for pneumonia significantly decreased by 9.3% (p-value 0.04), 20.3% (p-value 0.004), 23.7% (p-value 0.01) and 77.2% (p-value < 0.001), respectively during the first 8 months of the COVID-19 pandemic compared to the previous 8 months' average performance. The trends in Antenatal care first visit, new contraceptive accepters, pentavalent-3 vaccination and under-five children treated for pneumonia began to decline in January to March 2020, a quarter when the COVID-19 pandemic began; with accelerated declines in April to June 2020 following national lockdown. The trends for the stated services began to increase during July–September 2020, the last quarter of national lockdown. Contraceptive accepters and pentavalent-1 vaccination continued to decline and showed no recovery until January–March 2021 when this study was completed. Conclusions: Most of the maternal and child health services performance declined following the onset of COVID-19 pandemic and national lockdown, and most of the services began recovering during July–September 2020, the last quarter of national lockdown. However, new and repeat contraceptive accepters and pentavalent-1 recipients continue to decline and show no recovery during end of the study period. Implementing COVID-19 prevention measures and assuring the community about the safety of service delivery is imperative to ensure continuity of the maternal and child health services. Regular monitoring and evaluation of services performance is required to identify slowly recovering services and respond to potentially volatile changes during the COVID-19 pandemic. Plain English summary: The coronavirus disease 2019 (COVID-19) is the worst global health crisis of a century. In many settings, health care service provision has been modified to focus on managing COVID-19 cases, and this has been affecting the provision of health services including maternal and child health services. The aim of this study was to assess the trends in maternal and child health services performance in the era of COVID-19 pandemic in Addis Ababa, Ethiopia. The results of the studies showed post-delivery care, new family planning attendees, safe abortion care and number of under-5 years old children treated for pneumonia decreased during the first 8 months of the COVID-19 pandemic compared to the previous 8 months' average performance. The trends in antenatal care (care during pregnancy), new family planning attendees, pentavalent-3 vaccination and under-five children treated for pneumonia began to decline between January-March 2020, a quarter when the COVID-19 pandemic began; with accelerated declines in April to June 2020 following national lockdown. The trends for the stated services began to increase during July–September 2020, the last quarter of national lockdown. Family planning attendees and pentavalent-1 vaccination continued to decline and showed no recovery until January–March 2021when this study was completed. Implementing COVID-19 prevention measures and assuring the community about the safety of service delivery is imperative to ensure continuity of the maternal and child health services. Regular monitoring and evaluation of services performance is required to identify slowly recovering services and respond to potentially volatile changes during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Prior to COVID-19, postnatal resettled refugee women in Canada reported barriers to healthcare and low levels of social support, contributing to maternal health morbidities. The COVID-19 pandemic appears to be further exacerbating health inequities for marginalized populations. The experiences of resettled refugee women are not fully known. Aim: To understand Syrian refugee women's experiences accessing postnatal healthcare services and supports during the COVID-19 pandemic. Methods: Semi-structured, virtual interviews were conducted with eight resettled Syrian refugee women living in Nova Scotia (Canada) who were postnatal between March and August 2020. Data analysis was informed by constructivist grounded theory. Findings: Three themes emerged: "the impacts of COVID-19 on postnatal healthcare;" "loss of informal support;" and "grief and anxiety." Women experienced difficult healthcare interactions, including socially and physically isolated deliveries, challenges accessing in-person interpreters, and cancelled or unavailable in-home services (e.g., public health nurse and doula visits). Increased childcare responsibilities and limited informal supports due to pandemic restrictions left women feeling overwhelmed and exhausted. Stay-at-home orders resulted in some women reporting feelings of isolation and loss, as they were unable to share in person postnatal moments with friends and family, ultimately impacting their mental wellness. Conclusions: COVID-19 and associated public health restrictions had significant impacts on postnatal Syrian refugee women. Data presented in this study demonstrated the ways in which the pandemic environment and related restrictions amplified pre-existing barriers to care and postnatal health inequalities for resettled refugee women—particularly a lack of postnatal informal supports and systemic barriers to care. [ABSTRACT FROM AUTHOR]

Background: Monitoring clients' experiences with contraceptive care is vital to inform quality improvement efforts and ensure fulfillment of individuals' human rights. The Quality of Contraceptive Counseling (QCC) Scale is a previously validated scale that comprehensively measures individuals' experiences receiving counseling in three subscales: Information Exchange, Interpersonal Relationship, and Disrespect and Abuse. We sought to better understand the correlation of client, provider, and visit factors with client-reported quality of contraceptive counseling in the public sector in two Mexican states using the QCC Scale. Methods: This cross-sectional survey study used the QCC Scale total score and subscale scores as outcome variables. Explanatory variables included clients' age, LGBTTTIQ status, relationship status, number of children, education, and occupation; providers' gender and type of provider; and the reason for visit. Linear and logistic regression models assessed bivariate associations. Multivariable, multilevel mixed-effects models with clinic as a random effect were fit. All models used complete cases (n = 470). Results: In the multilevel mixed-effects analyses, patients aged 35+ years reported worse Information Exchange (coefficient − 0.29, p = 0.01). Clients receiving care post-partum reported worse Information Exchange (coefficient − 0.25, p = 0.02) and worse total scores (coefficient − 0.15, p = 0.04) compared to clients seeking contraceptive information or methods. Clients who had 1+ children reported better Information Exchange (coefficient 0.21, p = 0.01) than those with no children. Though Disrespect and Abuse subscale scores were overall high (indicating high quality of care), we found a significant association between age and report of such negative experiences: clients in increasing age categories had increasingly higher adjusted odds of reporting no disrespect and abuse (aORs compared to the youngest group were 2.50 for those aged 19–24 years, p = 0.04; 4.53 for those 25–34 years, p = 0.01; and 6.11 for those 35+ years, p = 0.01.) Conclusions: Our findings align with previous results that younger clients have lower adjusted odds of reporting high-quality services in Mexico. There is a need for continued work supporting youth-friendly services in Mexico, and efforts should aim to ensure zero tolerance for disrespectful or coercive provider behaviors, such as pressuring or scolding clients. Improvements are also needed to ensure quality in counseling for post-partum clients, those aged 35+ years, and those without children. Plain English summary: Monitoring clients' experiences with contraceptive care is vital to help improve service delivery and make sure individuals' human rights are fulfilled. The Quality of Contraceptive Counseling (QCC) Scale is a survey which measures individuals' experiences receiving counseling about contraceptives. It is grounded in principles of person-centeredness and human rights and asks directly about negative experiences. This paper describes an analysis of data collected using the QCC Scale, exploring statistical associations between the QCC Scale scores and the client, provider, and visit characteristics. The study also analyses scores from the three QCC subscales (Information Exchange, Interpersonal Relationship, and Disrespect and Abuse). The results of the analyses revealed that, though it was not commonly reported, younger clients had higher odds of reporting Disrespect and Abuse. Clients aged 35+ years reported worse Information Exchange, clients receiving care post-partum reported both worse Information Exchange and worse total scores, and clients who had 1+ children reported better Information Exchange. These findings align with previous results that younger clients have lower odds of reporting high-quality services in Mexico. There is a need for continued work supporting youth-friendly services in Mexico, and efforts should aim to reduce disrespectful or coercive provider behaviors, such as pressuring or scolding clients. Improvements are also needed to ensure quality in counseling for post-partum clients, those aged 35+ years, and those without children. [ABSTRACT FROM AUTHOR]

Abstract Background The Post Natal Club (PNC) model assures comprehensive care, including HIV and Maternal and Child Health care, for postpartum women living with HIV and their infants during an 18-month postnatal period. The PNC model was launched in 2016 in Town Two Clinic, a primary health care facility in Khayelitsha, South Africa. This qualitative research study aims to understand how participation in PNCs affected knowledge transmission, peer support, behaviour change and satisfaction with the care provided. Methods We conducted ten in-depth interviews; three focus group discussions and participant observation with PNC members, health-care workers and key informants selected through purposive sampling. Seventeen PNC members between 21 and 38 years old, three key informants and seven staff working in PNC participated in the research. All participants were female, except for one of the three key informants who was male. Data was collected until saturation. The data analysis was performed in an inductive way and involved an iterative process, using Nvivo11 software. Results PNC members acquired knowledge on HIV, ART, adherence, infant feeding, healthy eating habits, follow up tests and treatment for exposed infants. Participants believed that PNC created strong relationships among members and offered an environment conducive to sharing experience and advice. Most interviewees stated that participating in PNC facilitated disclosure of their HIV status, enhanced support network and provided role models. PNC members said that they adapted their behaviour based on advice received in PNCs related to infant feeding, ART adherence, monitoring of symptoms and stimulation of early childhood development. The main benefits were believed to be comprehensive care for mother-infant pairs, time-saving and the peer dynamic. The main challenge from the perspective of key informants was the sustainability of dedicating human resources to PNC. Conclusion The PNC model was believed to improve knowledge acquisition, behaviour change and peer support. Participants, staff and the majority of key informants expressed a high level of satisfaction with the PNC model. Sustainability and finding adequate human resources for PNCs remained challenging. Strategies to improve sustainability may include handing over some PNC tasks to members to increase their sense of ownership.

Abstract Background Maternal death remains a public health burden in the developing countries including Nigeria and the major causes are pregnancy related. Lack of male involvement in pregnancy related care is one of the contributing factors. Previous studies on male involvement focused on family planning services and were majorly targeted at women. This study, therefore, was carried out to assess the knowledge, perception and involvement of male partners in pregnancy related care among married men in Ibadan, Nigeria. Methods A cross sectional study was conducted using a four-stage sampling technique to select 367 married men in an urban community in Ibadan. A semi-structured, interviewer-administered questionnaire was used to obtain information on the knowledge, perception and involvement of respondents regarding pregnancy related care. Responses to questions on knowledge of pregnancy related care were converted to a 33-point scale. Scores greater than or equal to the mean knowledge score (26.2) were categorized as good knowledge of pregnancy related care. Similarly, responses to involvement in pregnancy related care questions were converted to a 24-point scale with scores greater than or equal to the mean (15.1) classified as good involvement in pregnancy related care. Data were analyzed using descriptive statistics and association between qualitative variables was established using Chi-square test at p

Background: The period after childbirth poses a substantial risk both to the mother and the newborn. Yet, this period received less attention as compared to the cares provided during pregnancy and childbirth. Hence, this study aimed to assess the effectiveness of checklist-based box system intervention on improving three postnatal care visit utilization. Methods: A double blind, parallel group, two-arm cluster randomized controlled trial design was used to assess effectiveness of checklist-based box system intervention on improving third postnatal care visit. Pregnant mothers below 16 weeks of gestation were recruited from 15 intervention and 15 control clusters, which were randomized using simple randomization. Data from baseline and end line surveys were collected using open data kit and analyzed using STATA version 15.0. The status of three postnatal care visit between intervention and control groups over time was assessed using difference in difference estimator. The predictors of the outcome variable were then analysed using mixed effects multilevel logistic regression model. Result: Of 1200 mothers considered from each of the baseline and end line studies, this study included data from 1162 and 1062 mothers at baseline and end line surveys, respectively. As it is shown from the difference-in-difference estimation (14.8%, 95%CI 5.4–24.2%, p = 0.002) and the final model (AOR 4.45, 95%CI 2.31–8.54), checklist-based box system intervention was effective on improving third postnatal care visit. In addition, institutional delivery (AOR 1.62, 95%CI 1.15–2.28) and knowledge on danger signs during postnatal period (AOR 5.20, 95%CI 3.71–7.29) were found to be significant predictors of the outcome variable. In the contrary, mothers who got influenced by older generations of individuals were (AOR 0.32, 95%CI 0.18–0.59) less likely to attend three postnatal care visit. Conclusions: The implementation of checklist-based box system intervention was found to be effective in improving utilization of the recommended three postnatal care visits. The contribution of the trial on improving third postnatal care visit can be enhanced by minimizing practical level challenges, as well as expanding health messages to reach unreached mothers and significant others who can influence the mother's decision. Trial registration: ClinicalTrials.gov, NCT03891030, Retrospectively registered on 26 March, 2019, https://clinicaltrials.gov/ct2/show/NCT03891030. Plain language summary: Postnatal care is a care that a delivered women and her newborn baby receive after delivery and up to 42 days of childbirth, regardless of place of delivery. This period is considered critical in minimizing morbidity and mortality of both the mother and the baby. In Ethiopia, the coverage of postnatal care utilization remained low. Recent studies showed only 33.8% of mothers received postnatal care, this becomes very low for mothers who delivered at home, of which only 8.2% of them received the care. On top of other factors that hinder maternal health care utilization, in Ethiopia there are widely accepted and persistent cultural ceremonies after childbirth that encourages a women to stay in door. This study introduced a new intervention called Checklist-based box system intervention, which aimed to improve postnatal care utilization through demand creation and dropout tracing mechanisms. The intervention was carried out by health professionals in health centers and community health workers (health extension workers) who visited mothers in their homes. Despite some practical challenges, its implementation demonstrated an improvement over clusters that did not receive the intervention. This intervention is recommended to be implemented on a larger scale. Simultaneously, practical level challenges need to be addressed in order for the intervention's effect to be seen in its best form. [ABSTRACT FROM AUTHOR]

Introduction: The ministry of health (MOH) of Ethiopia recommends 4 or more focused antenatal care (ANC) visits at health centre (HC) or at a higher level of health facility (HF). In Ethiopia, few studies investigated time dimension of maternal health continuum of care but lack data regarding place dimension and its effect on continuum of care. The aim of this study is to estimate effect of place of ANC-1 visit and adherence to MOH's recommendations of MOH for ANC visits on continuum of care rural in Ethiopia. Methods: We used data collected from 1431 eligible women included in the National Health Extension Program (HEP) assessment survey that covered 6324 households from 62 woredas in nine regions. The main outcome variable is continuum of care (CoC), which is the uptake of all recommended ANC visits, institutional delivery and postnatal care services. Following descriptive analysis, Propensity Score Matching was used to estimate the effect of place of ANC-1 visit on completion of CoC. Zero inflated Poisson regression was used to model the effect of adherence to MOH recommendation of ANC visits on intensity of maternal health continuum of care. Result: Only 13.9% of eligible women completed the continuum of care, and place of first antenatal care (ANC) visit was not significantly associated with the completion of continuum of care (β = 0.04, 95% CI = -0.02, 0.09). Adherence of ANC visit to the MOH recommendation (at least 4 ANC visits at higher HFs than health posts (HPs)) increased the likelihood of higher intensity of continuum of care (aIRR = 1.29, 95% CI: 1.26, 1.33). Moreover, the intensity of continuum of care was positively associated with being in agrarian areas (aIRR = 1.17, 95% CI: 1.06, 1.29), exposed to HEP (IRR = 1.22, 95% CI: 1.16, 1.28), being informed about danger signs (aIRR = 1.14, 95% CI: 1.11, 1.18) and delivery of second youngest child at HF (IRR = 1.16, 95% CI: 1.13, 1.20). Increasing age of women was negatively associated with use of services (IRR = 0.90, 95% CI: 0.87, 0.94). Conclusion: Completion of maternal health continuum of care is very low in Ethiopia, however most of the women use at least one of the services. Completion of continuum of care was not affected by place of first ANC visit. Adherence to MOH recommendation of ANC visit increased the intensity of continuum of care. Intensity of continuum of care was positively associated with residing in agrarian areas, HEP exposure, danger sign told, delivery of second youngest child at health facility. To boost the uptake of all maternal health services, it is crucial to work on quality of health facilities, upgrading the infrastructures of HPs and promoting adherence to MOH recommendations of ANC visit. Plain language summary: Maternal health continuum of care is an integrated service delivery of antenatal care, facility delivery and postnatal care on appropriate time and place. Continuum of care averts more maternal mortality than individual service provision. In Ethiopia a small percent of women complete continuum of care. Previous studies in Ethiopia explored the effect of time on CoC, however the effect of place of service delivery on subsequent continuum of care were not addressed. This study, therefore, assessed the effect of place of service delivery on completion of subsequent continuum of care using data from 1431 fixed cohort of women during the National HEP assessment survey. The proportion of women who took all essential maternal health services was very low. Whether first antenatal care is at health post or at health centre did not have a significant effect on the completion of maternal health continuum of care. Adherence to the existing recommendations of Ministry of Health for antenatal care visit increases the uptake of maternal health continuum of care. Better completion of maternal health services was observed in agrarian than pastoralist areas, among those who have exposure to health extension program, who have information about danger signs, and who deliver their previous child at health facility. We can conclude that good implementation of the health extension program, and improving service quality at health facilities increase the uptakes of maternal health service. Moreover, promoting adherence of women to the ministry of health ANC recommendations increase uptakes. [ABSTRACT FROM AUTHOR]

Background: The use of reproductive health (RH) services is important to promote RH. However, little is known about RH services in rural areas, especially in low- and middle-income countries. China is the most populous country in the world, and 40.4% of its population is rural. Our study determined the utilization of and factors associated with RH services in rural China. Methods: A cross-sectional study of 978 20- to 39-year-old women was performed in four villages of four cities in Hunan Province. A researcher-created structured questionnaire was used to collect the data. The data were entered into EpiData v3.0 and analysed using SPSS v18.0. Statistical significance was defined as a two-sided P-value of less than 0.05. Descriptive statistics were used to examine the socio-demographic factors and the use of RH services by the sample population. Chi-square tests were used to assess associations between categorical variables. Logistic regression analyses were performed to examine factors that correlated with the use of RH services. Results: The top three services used were antenatal examinations (90.2%), postpartum visits (73.0%) and free folic acid supplements (71.6%). Age, monthly household income, employment, spousal education level, and artificial abortion history were associated with RH service utilization (P < 0.05). The most desired RH service was cervical/breast cancer prevention services (58.9%). The most preferred method participants used to obtain information on RH services was the internet. Conclusions: The utilization rate for RH services in rural China needs improvement. Future efforts should target high-risk populations of women by providing them with RH-related information and cultivating positive attitudes towards RH services. Plain language summary: Reproductive health (RH) services are recognized worldwide as a cost-effective strategy to promote RH. However, little is known about RH services in rural areas, especially in low- and middle-income countries. China is the most populous country in the world, and 40.4% of its population is rural. Due to the implementation of China's universal two-child policy, women between 20 and 39 years old are likely to experience more RH problems related to childbirth. Our study investigated the utilization of and factors associated with RH services in rural China. The top three services used among the 978 participants were antenatal examinations (90.2%), postpartum visits (73.0%) and free folic acid supplements (71.6%). Age, monthly household income, employment, spousal education level, and artificial abortion history were associated with RH service utilization. The participants most desired services pertained to the prevention of cervical/breast cancer, and the most preferred methods used to obtain information related to RH services was the internet. In conclusion, the utilization of RH services requires improvement, and future efforts should target high-risk populations of women by providing them with RH-related information and cultivating positive attitudes towards RH services. [ABSTRACT FROM AUTHOR]

Background: Gestational diabetes (GDM) is a global problem affecting millions of pregnant women, including in mainland China. These women are at high risk of Type II diabetes (T2DM). Cost-effective and clinically effective interventions are needed. We aimed to explore Chinese women's perspectives, concerns and motivations towards participation in early postpartum interventions and/or research to prevent the development of T2DM after a GDM-affected pregnancy. Methods: We conducted a qualitative study in two hospitals in Chengdu, Southwest China. Face-to-face semi-structured interviews were conducted with 20 women with recent experience of GDM: 16 postpartum women and 4 pregnant women. Women were asked about their attitudes towards postpartum screening for type 2 diabetes, lifestyle interventions, mHealth delivered interventions and pharmacologic interventions (specifically metformin). An inductive approach to analysis was used. Interviews were recorded, transcribed, and coded using NVivo 12 Pro. Results: Most women held positive attitudes towards participating in T2DM screening, and were willing to participate in postpartum interventions to prevent T2DM through lifestyle change or mHealth interventions. Women were less likely to agree to pharmacological intervention, unless they had family members with diabetes or needed medication themselves during pregnancy. We identified seven domains influencing women's attitudes towards future interventions: (1) experiences with the health system during pregnancy; (2) living in an enabling environment; (3) the experience of T2DM in family members; (4) knowledge of diabetes and perception of risk; (5) concerns about personal and baby health; (6) feelings and emotions, and (7) lifestyle constraints. Those with more severe GDM, an enabling environment and health knowledge, and with experience of T2DM in family members expressed more favourable views of postpartum interventions and research participation to prevent T2DM after GDM. Those who perceived themselves as having mild GDM and those with time/lifestyle constraints were less likely to participate. Conclusions: Women with experiences of GDM in Chengdu are generally willing to participate in early postpartum interventions and/or research to reduce their risk of T2DM, with a preference for non-drug, mHealth based interventions, integrating lifestyle change strategies, blood glucose monitoring, postpartum recovery and mental health. Plain language summary: Gestational diabetes mellitus (GDM) is a common pregnancy complication affecting up to 1 in 6 pregnant women worldwide. Whilst the condition usually resolves soon after delivery, women are at high risk of developing type 2 diabetes mellitus (T2DM). In this study, we asked women living in Chengdu, a city in western China, about what they knew about their risk of diabetes and how they felt about participating in interventions after birth to prevent T2DM. After listening to the views of 20 women, we concluded that in this setting most women are happy to attend T2DM screening programs after birth, and would be willing to consider participating in interventions and research after birth to prevent T2DM. The interventions most preferred were those that aimed at lifestyle changes, and many women said would like to receive this information through their smartphone, for example through an app or social media channel. Women were reluctant to take medications to prevent T2DM. The main factors that influenced how women felt towards interventions to prevent T2DM were: (1) their experiences with the health system during pregnancy; (2) whether the home environment was supportive to make changes to diet and lifestyle; (3) any experiences of T2DM in family members; (4) their knowledge of diabetes and perception of risk; (5) concerns about personal and baby health; (6) feelings and emotions in the postnatal period, and (7) lifestyle constraints making it difficult to make dietary changes. [ABSTRACT FROM AUTHOR]

Abstract Introduction Above half of mothers in Ethiopia give birth at home. Home based care within the first week after birth as a complementary strategy to facility-based postnatal care service is critical to increase the survival of both mothers and newborns. However, evidence on utilization of postnatal care and location of service among mothers who delivered at home in Ethiopia is insufficiently documented. Therefore, this study assessed the magnitude and determinants for place of postnatal care service utilization among mothers who delivered at home in Ethiopia. Methods We used the 2016 Ethiopian Demographic and Health Survey, and extracted data from 4491 mothers who delivered at home during 5 years preceding the survey. A multinomial logistic regression model was applied to examine the determinants of both facility and home -based postnatal care service utilization. Likelihood ratio test was used to see the model fitness and p-value of

Abstract Background The Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women’s experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements. Methods We completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation. Results Before implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout. Discussion These results are consistent with other published reports of women’s perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women’s experiences of care. Conclusion Group antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model. Trial registration This trial is registered at clinicaltrials.gov as NCT03154177.

Background: Most maternal deaths occur during the intrapartum and peripartum periods in sub-Saharan Africa, emphasizing the importance of timely access to quality health service for childbirth and postpartum care. Increasing facility births and provision of postpartum care has been the focus of numerous interventions globally, including in sub-Saharan Africa. The objective of this scoping review is to synthetize the characteristics and effectiveness of interventions to increase facility births or provision of postpartum care in sub-Saharan Africa. Methods: We searched for systematic reviews, scoping reviews, qualitative studies and quantitative studies using experimental, quasi experimental, or observational designs, which reported on interventions for increasing facility birth or provision of postpartum care in sub-Saharan Africa. These studies were published in English or French. The search comprised six scientific literature databases (Pubmed, CAIRN, la Banque de Données en Santé Publique, the Cochrane Library). We also used Google Scholar and snowball or citation tracking. Results: Strategies identified in the literature as increasing facility births in the sub-Saharan African context include community awareness raising, health expenses reduction (transportation or user fee), non-monetary incentive programs (baby kits), or a combination of these with improvement of care quality (patient's privacy, waiting time, training of provider), and or follow-up of pregnant women to use health facility for birth. Strategies that were found to increase provision of postpartum care include improvement of care quality, community-level identification and referrals of postpartum problems and transport voucher program. Conclusions: To accelerate achievements in facility birth and provision of postpartum care in sub-Saharan Africa, we recommend strategies that can be implemented sustainably or produce sustainable change. How to sustainably motivate community actors in health interventions may be particularly important in this respect. Furthermore, we recommend that more intervention studies are implemented in West and Central Africa, and focused more on postpartum. Plain English summary: In in sub-Saharan Africa, many women die when giving or few days after birth. This happens because they do not have access to good health services in a timely manner during labor and after giving birth. Worldwide, many interventions have been implemented to Increase the number of women giving birth in a health facility or receiving care from health professional after giving birth. The objective of this study is to synthetize the characteristics and effectiveness of interventions that have been implemented in sub-Saharan Africa, aiming to increase the number of women giving birth in a health facility or receiving care from health professional after birth. To proceed with this synthesis, we did a review of studies that have reported on such interventions in sub-Saharan Africa. These studies were published in English or French. The interventions identified to increase the number of women giving birth in a health facility include community awareness raising, reduction of health expenses (transportation or user fee), non-monetary incentive programs (baby kits), or a combination of these with improvement of care quality (patient's privacy, waiting time, training of provider), and or follow-up of pregnant women to use health facility for birth. Interventions implemented to increase the number women receiving care from a health professional after birth include improvement of care quality, transport voucher program and community-level identification and referrals to the health center of mothers' health problems. In sub-Saharan Africa, to accelerate increase in the number of women giving birth in a health facility and receiving care from a health professional after, we recommend interventions that can be implemented sustainably or produce sustainable change. How to sustainably motivate community actors in health interventions may be particularly important in this respect. Furthermore, we recommend the conduct in West and Central Africa, of more studies targeting interventions to increase the number of women giving birth in a health facility and or receiving care from a health professional after birth. [ABSTRACT FROM AUTHOR]

Background: There are high expectations that mobile health (mHealth) strategies will increase uptake of health care services, especially in resource strained settings. Our study aimed to evaluate effects of an mHealth intervention on uptake of maternal health services. Methods: This was an intervention cohort study conducted at six public antenatal and postnatal care clinics in inner-city Johannesburg, South Africa. The intervention consisted of twice-weekly informative and pregnancy stage-based maternal health information text messages sent to women during pregnancy until their child was one year of age. The intervention arm of 87 mother-infant pairs was compared to a control arm of 90 pairs. Univariate and multivariate analyses were used to compare the probability of the outcome between the two groups. Results: Intervention participants had higher odds of attending all government-recommended antenatal and postnatal visits, all recommended first year vaccinations (OR: 3.2, 95% CI 1.63–6.31) and had higher odds of attending at least the recommended four antenatal visits (OR: 3.21, 95% CI 1.73–5.98). Conclusion: We show an improvement in achieving complete maternal-infant continuum of care, providing evidence of a positive impact of informative maternal mHealth messages sent to pregnant women and new mothers. Trial registration ISRCTN, ISRCTN41772986. Registered 13 February 2019—Retrospectively registered, https://www.isrctn.com/ISRCTN41772986 [ABSTRACT FROM AUTHOR]

Background: The Post Natal Club (PNC) model assures comprehensive care, including HIV and Maternal and Child Health care, for postpartum women living with HIV and their infants during an 18-month postnatal period. The PNC model was launched in 2016 in Town Two Clinic, a primary health care facility in Khayelitsha, South Africa. This qualitative research study aims to understand how participation in PNCs affected knowledge transmission, peer support, behaviour change and satisfaction with the care provided. Methods: We conducted ten in-depth interviews; three focus group discussions and participant observation with PNC members, health-care workers and key informants selected through purposive sampling. Seventeen PNC members between 21 and 38 years old, three key informants and seven staff working in PNC participated in the research. All participants were female, except for one of the three key informants who was male. Data was collected until saturation. The data analysis was performed in an inductive way and involved an iterative process, using Nvivo11 software. Results: PNC members acquired knowledge on HIV, ART, adherence, infant feeding, healthy eating habits, follow up tests and treatment for exposed infants. Participants believed that PNC created strong relationships among members and offered an environment conducive to sharing experience and advice. Most interviewees stated that participating in PNC facilitated disclosure of their HIV status, enhanced support network and provided role models. PNC members said that they adapted their behaviour based on advice received in PNCs related to infant feeding, ART adherence, monitoring of symptoms and stimulation of early childhood development. The main benefits were believed to be comprehensive care for mother-infant pairs, time-saving and the peer dynamic. The main challenge from the perspective of key informants was the sustainability of dedicating human resources to PNC. Conclusion: The PNC model was believed to improve knowledge acquisition, behaviour change and peer support. Participants, staff and the majority of key informants expressed a high level of satisfaction with the PNC model. Sustainability and finding adequate human resources for PNCs remained challenging. Strategies to improve sustainability may include handing over some PNC tasks to members to increase their sense of ownership. [ABSTRACT FROM AUTHOR]

Background: Measurement of quality of health care has been largely overlooked and continues to be a major health system bottleneck in monitoring performance and quality to evaluate progress against defined targets for better decision making. Hence, metrics of maternity care are needed to advance from health service contact alone to content of care. We assessed the accuracy of indicators that describe the quality of basic care for childbirth functions both at the individual level as well as at the population level in Northern Ethiopia. Methods: A validation study was conducted by comparing women's self-reported coverage of maternal and newborn health interventions during intra-partum and immediate postpartum care received in primary level care facilities of Northern Ethiopia against a gold standard of direct observation by a trained third party (n = 478). Sensitivity, specificity and individual-level reporting accuracy via the area under the receiver operating curve (AUC) and inflation factor (IF) to estimate population-level accuracy for each indicator was applied for validity analysis. Findings: 455(97.5%) of women completed the survey describing health interventions. Thirty-two (43.2%) of the 93-basic quality child birth care indicators that were assessed could be accurately measure at the facility and population level (AUC > 0.60 and 0.75 < IF< 1.25). Few of the valid indicators were: whether women and their companion were greeted respectfully, whether an HIV test was offered, and whether severe bleeding (hemorrhage) was experienced by the woman. An additional 21(28.4%) indicators accurately measure at the facility or individual level, but the indicators under or over estimate at population level. Thirteen other indicators could accurately measure at population level. Eight (8.6%) indicators didn't meet either of the validity criteria. Conclusion: Women were able to accurately report on several indicators of quality for basic child birth care. For those few indicators that required a technical understanding tended to have higher don't know response from the women. Therefore, valid indicators should be included as a potential measurement of quality for the childbirth care process to ensure that essential interventions are delivered. [ABSTRACT FROM AUTHOR]

Background: Pregnancy and parenthood are known to be high-risk times for mental health. However, less is known about the mental health of pregnant adolescents or adolescent parents. Despite the substantial literature on the risks associated with adolescent pregnancy, there is limited evidence on best practices for preventing poor mental health in this vulnerable group. This systematic review therefore aimed to identify whether psychosocial interventions can effectively promote positive mental health and prevent mental health conditions in pregnant and parenting adolescents. Methods: We used the standardized systematic review methodology based on the process outlined in the World Health Organization's Handbook for Guidelines Development. This review focused on randomized controlled trials of preventive psychosocial interventions to promote the mental health of pregnant and parenting adolescents, as compared to treatment as usual. We searched PubMed/Medline, PsycINFO, ERIC, EMBASE and ASSIA databases, as well as reference lists of relevant articles, grey literature, and consultation with experts in the field. GRADE was used to assess the quality of evidence. Results: We included 17 eligible studies (n = 3245 participants). Interventions had small to moderate, beneficial effects on positive mental health (SMD = 0.35, very low quality evidence), and moderate beneficial effects on school attendance (SMD = 0.64, high quality evidence). There was limited evidence for the effectiveness of psychosocial interventions on mental health disorders including depression and anxiety, substance use, risky sexual and reproductive health behaviors, adherence to antenatal and postnatal care, and parenting skills. There were no available data for outcomes on self-harm and suicide; aggressive, disruptive, and oppositional behaviors; or exposure to intimate partner violence. Only two studies included adolescent fathers. No studies were based in low- or middle-income countries. Conclusion: Despite the encouraging findings in terms of effects on positive mental health and school attendance outcomes, there is a critical evidence gap related to the effectiveness of psychosocial interventions for improving mental health, preventing disorders, self-harm, and other risk behaviors among pregnant and parenting adolescents. There is an urgent need to adapt and design new psychosocial interventions that can be pilot-tested and scaled with pregnant adolescents and adolescent parents and their extended networks, particularly in low-income settings. [ABSTRACT FROM AUTHOR]

Background: Postnatal depression (PND) is the second most common cause of disability and the most common complication after childbirth. Understanding the potential mechanisms by which the stress process can lead to PND is an important step for planning preventive interventions for PND. This study employed a stress process model to explore the possible pathways leading to PND in Gondar Town, Ethiopia. Methods: A community-based cohort study was conducted in 916 pregnant women, who were assessed for depression in their second or third trimester of pregnancy and re-assessed two to eight weeks after birth. Women with an Edinburgh Postnatal Depression Scale (EPDS) ≥6 were considered to be depressed. Modified Poisson regression was used to identify the independent predictors of PND. A Generalized Structural Equation Modeling (GSEM) was then used to explore the direct and indirect effects of stressors and their mediators on PND. Results: The prevalence and incidence proportion of PND were 9.27% (95%CI: 7.45, 11.36) and 7.77% (95%CI: 6.04, 9.79), respectively and 2.1% of the women demonstrated symptoms of depression within the study period. PND was independently predicted by having limited postnatal care services, Antenatal Depression (AND) and a Common Mental Disorders (CMD) before pregnancy, (IRR = 1.8; 95%CI: 1.0, 3.2), 1.6(95%CI: 1.4, 1.7), and 2.4 (95%CI: 1.4, 4.3) respectively). In SEM, AND (standardized total effect = 0.36) and a CMD before pregnancy (standardized total effect = 0.11) had both a direct and an indirect positive effect on PND scores. Low birth weight (standardized β = 0.32) and self-reported labor complications (standardized β = 0.09) had direct effects only on PND scores. Conclusion: The observed incidence and prevalence of PND in Ethiopia were lower than in previous studies. A CMD before pregnancy and low birth weight (LBW) increased PND scores, and these effects were in part mediated via antenatal depression and labor complications. Early detection and treatment of depression before or during pregnancy could either directly or indirectly reduce the risk of labor complications and PND. Interventions that reduce LBW or improve the uptake of postnatal care might reduce PND incidence. [ABSTRACT FROM AUTHOR]

In less-resourced settings, adverse pregnancy outcome rates are unacceptably high. To effect improvement, we need accurate epidemiological data about rates of death and morbidity, as well as social determinants of health and processes of care, and from each country (or region) to contextualise strategies. The PRECISE database is a unique core infrastructure of a generic, unified data collection platform. It is built on previous work in data harmonisation, outcome and data field standardisation, open-access software (District Health Information System 2 and the Baobab Laboratory Information Management System), and clinical research networks. The database contains globally-recommended indicators included in Health Management Information System recording and reporting forms. It comprises key outcomes (maternal and perinatal death), life-saving interventions (Human Immunodeficiency Virus testing, blood pressure measurement, iron therapy, uterotonic use after delivery, postpartum maternal assessment within 48 h of birth, and newborn resuscitation, immediate skin-to-skin contact, and immediate drying), and an additional 17 core administrative variables for the mother and babies. In addition, the database has a suite of additional modules for 'deep phenotyping' based on established tools. These include social determinants of health (including socioeconomic status, nutrition and the environment), maternal co-morbidities, mental health, violence against women and health systems. The database has the potential to enable future high-quality epidemiological research integrated with clinical care and discovery bioscience. [ABSTRACT FROM AUTHOR]

Background: Postpartum intrauterine device (PPIUD) use remains very low in Nepal despite high levels of unmet need for postpartum family planning and the national government's efforts to promote its use. This study investigates reasons for continuing or discontinuing PPIUD use among Nepali women. Methods: We conducted in-depth interviews (IDIs) with 13 women who had discontinued PPIUD use and 12 women who were continuing to use the method 9 months or longer following the insertion. All interviews were audio recorded, transcribed, translated into English, and analyzed using a thematic approach. Results: Women discontinued PPIUD for several reasons: 1) side effects such as excessive bleeding during menstruation, nausea, back and abdominal pain; 2) poor quality of counselling and, relatedly, mismatched expectations in terms of device use; and 3) lack of family support from husbands and in-laws. In contrast, women who were continuing to use the method at the time of the study stated that they had not experienced side-effects, had received appropriate information during counselling sessions, and had the backing of their family members in terms of using PPIUD. Conclusion: Experiencing side-effects or complications following PPIUD insertion and poor quality of family planning counselling were the two main reasons for discontinuation. Family members appeared to play a major role in influencing a woman's decision to continue or discontinue PPIUD suggesting that counseling may need to be expanded to them as well. Improving quality of counselling by providing complete and balanced information of family planning methods as well as ensuring sufficient time for counselling and extending PPIUD service availability at lower level clinics/health posts will potentially increase the uptake and continued use of postpartum family planning, including PPIUD, in Nepal. [ABSTRACT FROM AUTHOR]

Background: Obstetric fistula is still common in low- and middle-income countries (LMIC) despite the on-going shift to increased facility deliveries in the same settings. The social behavioural circumstances in which fistula, as well as its consequences, still occur are poorly documented, particularly from the perspective of the experiences of women with obstetric fistula. This study sought to describe women's experiences of antenatal, partum and post-partum care in southern Mozambique, and to pinpoint those experiences that are unique to women with fistula in order to understand the care-seeking and care provision circumstances which could have been modified to avoid or mitigate the onset or consequences of fistula. Methods: This study took place in Maputo and Gaza provinces, southern Mozambique, in 2016–2017. Qualitative data were collected through in-depth interviews conducted with 14 women with positive diagnoses of fistula and an equal number of women without fistula. All interviews were audio-recorded and transcribed verbatim prior to thematic analysis using NVivo11. Results: Study participants had all attended antenatal care (ANC) visits and had prepared for a facility birth. Prolonged or obstructed labour, multiple referrals, and delays in receiving secondary and tertiary health care were common among the discourses of women with fistula. The term "fistula" was rarely known among participants, but the condition (referred to as "loss of water" or "illness of spillage") was recognised after being prompted on its signs and symptoms. Women with fistula were invariably aware of the links between fistula and poor birth assistance, in contrast with those without fistula, who blamed the condition on women's physiological and behavioural characteristics. Conclusion: Although women do seek antenatal and peri-partum care in health facilities, deficiencies and delays in birth assistance, referral and life-saving interventions were commonly reported by women with fistula. Furthermore, weaknesses in quality of care, not only in relation to prevention, but also the resolution of the damage, were evident. Quality improvement of birth care is necessary, both at primary and referral level. There is a need to increase awareness and develop guidelines for prevention, early detection and management of obstetric fistula, including early postpartum treatment, availability of fistula repair for complex cases, and rehabilitation, coupled with the promotion of community consciousness of the problem. [ABSTRACT FROM AUTHOR]

Background: Maternal death remains a public health burden in the developing countries including Nigeria and the major causes are pregnancy related. Lack of male involvement in pregnancy related care is one of the contributing factors. Previous studies on male involvement focused on family planning services and were majorly targeted at women. This study, therefore, was carried out to assess the knowledge, perception and involvement of male partners in pregnancy related care among married men in Ibadan, Nigeria. Methods: A cross sectional study was conducted using a four-stage sampling technique to select 367 married men in an urban community in Ibadan. A semi-structured, interviewer-administered questionnaire was used to obtain information on the knowledge, perception and involvement of respondents regarding pregnancy related care. Responses to questions on knowledge of pregnancy related care were converted to a 33-point scale. Scores greater than or equal to the mean knowledge score (26.2) were categorized as good knowledge of pregnancy related care. Similarly, responses to involvement in pregnancy related care questions were converted to a 24-point scale with scores greater than or equal to the mean (15.1) classified as good involvement in pregnancy related care. Data were analyzed using descriptive statistics and association between qualitative variables was established using Chi-square test at p < 0.05. Results: Sixty-three percent had good knowledge of pregnancy related care. Majority believed that they had roles to play in their partners' care during pregnancy (89.9%), labor and delivery (92.9%), and in newborn care (97.5%). Overall, 56.9% had good involvement in pregnancy related care. About 20% followed their partners to antenatal care (19.6%) and postnatal (19.9%) clinics. A significantly higher proportion of respondents with good knowledge accompanied their partners for antenatal care (p = 0.008) and postnatal care clinic (p = 0.014); participated in birth preparedness (p < 0.001) and assisted with newborn care (p < 0.001). Job demands, social stigma and long waiting time at the health facilities were reasons highlighted for non-involvement in pregnancy related care. Conclusions: The study revealed gaps in knowledge and involvement in pregnancy related care. There is a need for reproductive health policy review to strongly emphasize the need for involvement of male partners in reproductive health issues including pregnancy related care. [ABSTRACT FROM AUTHOR]

Introduction: Above half of mothers in Ethiopia give birth at home. Home based care within the first week after birth as a complementary strategy to facility-based postnatal care service is critical to increase the survival of both mothers and newborns. However, evidence on utilization of postnatal care and location of service among mothers who delivered at home in Ethiopia is insufficiently documented. Therefore, this study assessed the magnitude and determinants for place of postnatal care service utilization among mothers who delivered at home in Ethiopia. Methods: We used the 2016 Ethiopian Demographic and Health Survey, and extracted data from 4491 mothers who delivered at home during 5 years preceding the survey. A multinomial logistic regression model was applied to examine the determinants of both facility and home -based postnatal care service utilization. Likelihood ratio test was used to see the model fitness and p-value of < 0.05 was used to determine statistical significance at 95% confidence interval. Results: From the total 4491 mothers who delivered at home, only 130(2.9%) and 236(5.3%) of them utilized postnatal service at home and at a health facility respectively. Being from an urban region (AOR = 0.378, 95%CI: 0.193–0.740), ever using the calendar method to delay pregnancy (AOR = 0.528, 95%CI: 0.337–0.826), receiving four and above antenatal care visits (AOR = 0.245, 95%CI: 0.145–0.413) and having a bank account (AOR = 0.479, 95%CI: 0.243–0.943) were the factors associated with utilizing home- based postnatal care. Similarly being a follower of the orthodox religion (AOR = 1.698, 95%CI: 1.137–2.536), being in the rich wealth index (AOR = 0.608, 95%CI: 0.424–0.873), ever using the calendar method to delay pregnancy (AOR = 0.694, 95%CI: 0.499–0.966), wantedness of the pregnancy (AOR = 0.264, 95%CI: 0.352–0.953), receiving four and above antenatal care visits (AOR = 0.264, 95%CI: 0.184–0.380) and listening to radio at least once a week (AOR = 0.652, 95%CI: 0.432–0.984) were the determinants of facility-based postnatal care utilization. Conclusion: The coverage of postnatal care service utilization among mothers who delivered at home was very low. Living in urban region, following the Orthodox religion, having higher wealth index, having a bank account, ever using calendar method to delay pregnancy, wantedness of the pregnancy, receiving four and above antenatal care visit and listening to radio at least weakly were associated with postnatal care service utilization. Therefore, targeted measures to improve socio-economic status, strengthen the continuum of care, and increase health literacy communication are critically important to increase postnatal care service utilization among women who deliver at home in Ethiopia. [ABSTRACT FROM AUTHOR]

Background: Approximately 2.7 million neonatal deaths occur annually, with highest rates of neonatal mortality in countries that have recently experienced conflict. Constant instability in South Sudan further strains a weakened health system and poses public health challenges during the neonatal period. We aimed to describe the state of newborn facility-level care in displaced person camps across Juba, Malakal, and Maban. Methods: We conducted clinical observations of the labor and delivery period, exit interviews with recently delivered mothers, health facility assessments, and direct observations of midwife time-use. Study participants were mother-newborn pairs who sought services and birth attendants who provided delivery services between April and June 2016 in five health facilities. Results: Facilities were found to be lacking the recommended medical supplies for essential newborn care. Two of the five facilities had skilled midwives working during all operating hours, with 6.2% of their time spent on postnatal care. Selected components of thermal care (62.5%), infection prevention (74.8%), and feeding support (63.6%) were commonly practiced, but postnatal monitoring (27.7%) was less consistently observed. Differences were found when comparing the primary care level to the hospital (thermal: relative risk [RR] 0.48 [95% CI] 0.40-0.58; infection: RR 1.28 [1.11-1.47]; feeding: RR 0.49 [0.40-0.58]; postnatal: RR 3.17 [2.01-5.00]). In the primary care level, relative to newborns delivered by traditional birth attendants, those delivered by skilled attendants were more likely to receive postnatal monitoring (RR 1.59 [1.09-2. 32]), but other practices were not statistically different. Mothers' knowledge of danger signs was poor, with fever as the highest reported (44.8%) followed by not feeding well (41.0%), difficulty breathing (28.9%), reduced activity (27.7%), feeling cold (18.0%) and convulsions (11.2%). Conclusions: Addressing health service delivery in contexts affected by conflict is vital to reducing the global newborn mortality rate and reaching the Sustainable Development Goals. Gaps in intrapartum and postnatal care, particularly skilled care at birth, suggest a critical need to build the capacity of the existing health workforce while increasing access to skilled deliveries. [ABSTRACT FROM AUTHOR]

Background: Regular utilization of maternal health care services reduces maternal morbidity and mortality. This study assessed the maternal health care seeking behavior and associated factors of reproductive age women in rural villages of Haramaya district, East Ethiopia. Methods: Community based cross sectional study supplemented with qualitative data was conducted in Haramaya district from November 15 to Decemeber 30, 2015. A total of 561 women in reproductive age group and who gave birth in the last 2 years were randomly included. Bivariate and multivariate logistic regressions model was used to identify the associated factors. Odds ratios with 95% CI were used to measure the strength of association. Result: Maternal health care service seeking of women was found as; antenatal care 74.3% (95% CI; 72.5, 76.14), attending institutional delivery 28.7% (95% CI; 26.8, 30.6) and postnatal care 22.6% (95% CI; 20.84, 24.36). Knowledge of pregnancy complications, Educational status, and religion of women were found to be significantly associated with antenatal health care, delivery and postnatal health care service seeking behaviours triangulated with individual, institutional and socio-cultural qualitative data. Conclusion: The maternal health care service seeking behavior of women in the study area was low. Educational status of the women, birth order and knowledge about pregnancy complications were the major factors associated with maternal health care service seeking behavior Focused health education with kind and supportive health care provider counseling will improve the maternal health care seeking behaviors of women. [ABSTRACT FROM AUTHOR]

Background: To expand access to safe deliveries, some developing countries have initiated demand-side financing schemes promoting institutional delivery. In the context of conditional cash incentive scheme and free maternity care in public health facilities in India, studies have highlighted high out of pocket expenditure (OOPE) of Indian families for delivery and maternity care. In this context the study assesses the components of OOPE that women incurred while accessing maternity care in public health facilities in Uttar Pradesh, India. It also assesses the determinants of OOPE and the level of maternal satisfaction while accessing care from these facilities. Method: It is a cross-sectional analysis of 558 recently delivered women who have delivered at four public health facilities in Uttar Pradesh, India. All OOPE related information was collected through interviews using structured pre-tested questionnaires. Frequencies, Mann-Whitney test and categorical regression were used for data reduction. Results: The analysis showed that the median OOPE was INR 700 (US$ 11.48) which varied between INR 680 (US$ 11.15) for normal delivery and INR 970 (US$ 15.9) for complicated cases. Tips for getting services (consisting of gifts and tips for services) with a median value of INR 320 (US$ 5.25) contributed to the major share in OOPE. Women from households with income more than INR 4000 (US$ 65.57) per month, general castes, primi-gravida, complicated delivery and those not accompanied by community health workers incurred higher OOPE. The significant predictors for high OOPE were caste (General Vs. OBC, SC/ST), type of delivery (Complicated Vs. Normal), and presence of ASHA (No Vs. Yes). OOPE while accessing care for delivery was one among the least satisfactory items and 76 % women expressed their dissatisfaction. Conclusion: Even though services at the public health facilities in India are supposed to be provided free of cost, it is actually not free, and the women in this study paid almost half of their mandated cash incentives to obtain delivery care. [ABSTRACT FROM AUTHOR]

Background: Despite recent achievements in health targets, Ethiopia still faces challenges in health service delivery. Between 2012 and 2015, a non-governmental organisation (NGO), Doctors with Africa CUAMM, implemented a multifaceted project aimed at improving access to maternal and child health services in three districts in Ethiopia. This paper evaluates the performance of this project, based on four maternal health indicators. Methods: A before-and-after study utilising data collected through cross-sectional surveys involving 999 women was conducted. The date of delivery was used to stratify the intervention period as follows: pre-intervention, early intervention, and late intervention. Changes during the intervention in the coverage of four antenatal care (ANC) visits, receipt of three basic components of ANC, skilled birth attendant (SBA) at delivery, and postnatal care (PNC) in seven days were assessed using logistic regression, adjusting for socio-demographic factors. Results: There was an increase in the coverage of receipt of all three ANC components and SBA at delivery between the pre-intervention period and the late intervention period. The percent of health centre deliveries increased from 7.3 % in the pre-intervention period to 35.6 % in the late intervention period. The odds of receiving all three components of ANC were twice higher in the late intervention period than in the pre-intervention period (OR 2.09; 95 % CI 1.12-3.89). The odds of SBA at delivery were five times higher in the late intervention period than in the pre-intervention period (OR 5.04; 95 % CI 2.53-10.06). There was no significant change in the coverage of four ANC visits and PNC after accounting for sociodemographic factors. Conclusions: This NGO implemented maternal health project in three districts in Ethiopia was associated with increased likelihood that a pregnant woman would receive three basic components of ANC and be assisted by a SBA at delivery. Increase in skilled birth attendance was driven by increased utilisation of health centres. More efforts are needed to bolster the coverage of ANC and PNC. [ABSTRACT FROM AUTHOR]

Background: The majority of women in sub-Saharan Africa now deliver in a facility, however, little is known about the quality of services for maternal and newborn basic and emergency care, nor how this is associated with patient's perception of their experiences. Methods: Using data from the Service Provision Assessment (SPA) survey from Kenya 2010 and Namibia 2009, we explore whether facilities have the necessary signal functions for providing emergency and basic maternal (EmOC) and newborn care (EmNC), and antenatal care (ANC) using descriptives and multivariate regression. We explore differences by type of facility (hospital, center or other) and by private and public facilities. Finally, we see if patient satisfaction (taken from exit surveys at antenatal care) is associated with the quality of services (specific services provided). Results: We find that most facilities do not have all of the signal functions, with 46 and 27 % in Kenya and 18 and 5 % in Namibia of facilities have high/basic scores in routine and emergency obstetric care, respectively. We found that hospitals preform better than centers in general and few differences emerged between public and private facilities. Patient perceptions were not consistently associated with services provided; however, patients had fewer complaints in private compared to public facilities in Kenya (-0.46 fewer complaints in private) and smaller facilities compared to larger in Namibia (-0.26 fewer complaints in smaller facilities). Service quality itself (measured in scores), however, was only significantly better in Kenya for EmOC and EmNC. Conclusions: This analysis sheds light on the inadequate levels of care for saving maternal and newborn lives in most facilities in two countries of Africa. It also highlights the disconnect between patients' perceptions and clinical quality of services. More effort is needed to ensure that high quality supply of services is present to meet growing demand as an increasing number of women deliver in facilities. [ABSTRACT FROM AUTHOR]

Background: While it is estimated that for every maternal death, 20-30 women suffer morbidity, these estimates are not based on standardized methods and measures. Lack of an agreed-upon definition, identification criteria, standardized assessment tools, and indicators has limited valid, routine, and comparable measurements of maternal morbidity. The World Health Organization (WHO) convened the Maternal Morbidity Working Group (MMWG) to develop standardized methods to improve estimates of maternal morbidity. To date, the MMWG has developed a definition and provided input into the development of a set of measurement tools. This protocol outlines the pilot test for measuring maternal morbidity in antenatal and postnatal clinical populations using these new tools. Methods: In each setting, the tools will be piloted on approximately 250 women receiving antenatal care (ANC) (at least 28 weeks pregnant) and 250 women receiving postpartum care (PPC) (at least 6 weeks postpartum). The tools will be administered by trained health care workers. Each tool has three modules as follows: 1. personal history -- socio-economic information, and risk-factors (such as violence and substance abuse) 2. patient symptoms -- WHO Disability Assessment Schedule (WHODAS) 12-item, and mental health questionnaires, General Anxiety Disorder, 7-item (GAD-7) and Personal Health Questionnaire, 9-item (PHQ-9) 3. physical examination -- signs, laboratory tests and results. Discussion: This pilot (planned for Jamaica, Kenya and Malawi) will allow for comparing the types of morbidities women experience between and across settings, and determine the feasibility, acceptability and utility of using a modified, streamlined tool for routine measurement and summary estimates of morbidity to inform resource allocation and service provision. As part of the post-2015 Sustainable Development Goals (SDGs) estimating and measuring maternal morbidity will be essential to ensure appropriate resources are allocated to address its impact and improve well-being. [ABSTRACT FROM AUTHOR]

Background: In countries, such as Mozambique, where maternal mortality remains high, the greatest contribution of mortality comes from the poor and vulnerable communities, who frequently reside in remote and rural areas with limited access to health care services. This study aimed to understand women's health care seeking practices during pregnancy, taking into account the underlying social, cultural and structural barriers to accessing timely appropriate care in Maputo and Gaza Provinces, southern Mozambique. Methods: This ethnographic study collected data through in-depth interviews and focus group discussions with women of reproductive age, including pregnant women, as well as household-level decision makers (partners, mothers and mothers-in-law), traditional healers, matrons, and primary health care providers. Data was analysed thematically using NVivo 10. Results: Antenatal care was sought at the heath facility for the purpose of opening the antenatal record. Women without antenatal cards feared mistreatment during labour. Antenatal care was also sought to resolve discomforts, such as headaches, flu-like symptoms, body pain and backache. However, partners and husbands considered lower abdominal pain as the only symptom requiring care and discouraged women from revealing their pregnancy early in gestation. Health care providers for pregnant women often included those at the health facility, matrons, elders, traditional birth attendants, and community health workers. Although seeking care from traditional healers was discouraged during the antenatal period, they did provide services during pregnancy and after delivery. Besides household-level decision-makers, matrons, community health workers, and neighbours were key actors in the referral of pregnant women. The decision-making process may be delayed and particularly complex if an emergency occurs in their absence. Limited access to transport and money makes the decision-making process to seek care at the health facility even more complex. Conclusions: Women do seek antenatal care at health facilities, despite the presence of other health care providers in the community. There are important factors that prevent timely care-seeking for obstetric emergencies and delivery. Unfamiliarity with warning signs, especially among partners, discouragement from revealing pregnancy early in gestation, complex and untimely decision-making processes, fear of mistreatment by health-care providers, lack of transport and financial constraints were the most commonly cited barriers. Women of reproductive age would benefit from community saving schemes for transport and medication, which in turn would improve their birth preparedness and emergency readiness; in addition, pregnancy follow-up should include key family members, and community-based health care providers should encourage prompt referrals to health facilities, when appropriate. [ABSTRACT FROM AUTHOR]

Background: Karnataka State continues to have the highest rates of maternal mortality in south India at 144/100,000 live births, but lower than the national estimates of 190-220/100,000 live births. Various barriers exist to timely and appropriate utilization of services during pregnancy, childbirth and postpartum. This study aimed to describe the patterns and determinants of routine and emergency maternal health care utilization in rural Karnataka State, India. Methods: This study was conducted in Karnataka in 2012-2013. Purposive sampling was used to convene twenty three focus groups and twelve individual interviews with community and health system representatives: Auxiliary Nurse Midwives and Staff Nurses, Accredited Social Health Activists, community leaders, male decision-makers, female decision-makers, women of reproductive age, medical officers, private health care providers, senior health administrators, District health officers, and obstetricians. Local researchers familiar with the setting and language conducted all focus groups and interviews, these researchers were not known to community participants. All discussions were audio recorded, transcribed, and translated to English for analysis. A thematic analysis approach was taken utilizing an a priori thematic framework as well as inductive identification of themes. Results: Most women in the focus groups reported regular antenatal care attendance, for an average of four visits, and more often for high-risk pregnancies. Antenatal care was typically delivered at the periphery by non-specialised providers. Participants reported that sought was care women experienced danger signs of complications. Postpartum care was reportedly rare, and mainly sought for the purpose of neonatal care. Factors that influenced women's care-seeking included their limited autonomy, poor access to and funding for transport for non-emergent conditions, perceived poor quality of health care facilities, and the costs of care. Conclusions: Rural south Indian communities reported regular use of health care services during pregnancy and for delivery. Uptake of maternity care services was attributed to new government programmes and increased availability of maternity services; nevertheless, some women delayed disclosure of pregnancy and first antenatal visit. Community-based initiatives should be enhanced to encourage early disclosure of pregnancies and to provide the community information regarding the importance of facility-based care. Health facility infrastructure in rural Karnataka should also be enhanced to ensure a consistent power supply and improved cleanliness on the wards. [ABSTRACT FROM AUTHOR]

Background: Integration of sexual and reproductive health (SRH), HIV/AIDS and maternal health (MH) services is a critical strategy to confront the HIV/AIDS epidemic, high maternal mortality and the unmet need for contraception. In 2011 the AIDS Information Centre (AIC) in partnership with the Ministry of Health implemented SRH, HIV/AIDS and MH integration services in the districts of Katakwi and Mubende in Uganda. This paper documents challenges encountered in providing these integrated services in the two districts. Methods: This was a cross-sectional qualitative study conducted in Mubende and Katakwi districts in Uganda. Data were collected using 10 focus group discussions with 89 women attending ANC and postnatal care and 21 key informant interviews with district managers and health workers who were involved in the integrated service delivery. Content thematic approach was used for data analysis. Results: The study findings indicate that various challenges were encountered in integrating HIV, ANC and PNC services. Major challenges included inadequate staff, gaps in knowledge of service providers especially with regard to provision of long-term family planning, limited space, shortage of critical supplies such as HIV test kits, drugs and gloves. Conclusion: These findings indicate that the delivery of integrated HIV, SRH and MH services is hampered greatly by health system challenges and depict the need for additional staffing in health facilities, capacity building of health workers and health managers as well as ensuring sufficient supplies to health facilities for smooth implementation of integrated SRH, HIV and MH services. [ABSTRACT FROM AUTHOR]