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The initial program theory (IPT) is a core element of realist evaluation. An IPT presents a hypothesis about how, for whom, why, and in what contexts an intervention is effective. Despite their importance within realist studies, methodological guidance on how to develop an IPT is relatively scarce. We describe the methodological process of eliciting an IPT of facility-based maternal death reviews (FbMDRs), a multicomponent intervention to improve the quality of maternal care. We used a four-step approach to elicit the IPT through a combination of literature review, document review, and in-depth interviews with key stakeholders while drawing on the experience of the research team. The literature and document reviews enabled us to identify facilitators and barriers influencing the functioning of FbMDRs. We used the causal pathway approach to deconstruct the maternal death review procedure and we elicited a causal explanation for each component on the basis of the results of the document review, the literature review and key respondent interviews. We organised stakeholder consultations that provided insights of key actors and validated its real-world relevance. We discuss the challenges encountered during its development and the lessons learned. The challenges include the fact that maternal death reviews are multicomponent interventions, for which a 'simple' programme theory cannot be defined, the positionality of the research team, and the visual representation of a programme theory with multiple components. [ABSTRACT FROM AUTHOR]

Background: Violence against women and girls (VAWG) is a significant global public health problem and a violation of human rights experienced by one in three women worldwide. This study explores community perceptions of and responses to VAWG and challenges in accessing support services among female violence survivors in Arbaminch City. Methods: We adopted a phenomenological explorative qualitative study design. A total of 62 participants including female violence survivors, religious leaders, service providers, police, women, and men in participated in interviews, focus group discussions, and observations in August 2022. Participants were selected purposively, and the findings were analyzed thematically. We applied data source and respondent triangulation to increase the findings' trustworthiness. Results: Community perceptions of VAWG, specifically of intimate partner violence (IPV) and non-partner sexual violence (NPSV), varied depending on gender, age, and social position. IPV and NPSV were normalized through tolerance and denial by young and married men, while resistance to all forms of violence was common among women. Survivors of violence responded to the act of violence by leaving their homes, separating from their husbands, or taking harsh actions against their husbands, such as murder. Support for VAWG survivors was available through health care, free legal services, and a temporary shelter. Yet factors ranging from individual to societal levels, such as fear, lack of knowledge, lack of family and community support, and social and legal injustice, were barriers to accessing existing services. Nonetheless, violence survivors desired to speak about their experiences and seek psychosocial support. Conclusions: Our qualitative evidence gathered here can inform tailored VAWG prevention and response services such as interventions to shift social norms and the perception towards VAWG among different population group through raising awareness in schools, health care settings, faith-based venues, and using social media. [ABSTRACT FROM AUTHOR]

Health facility assessments (HFAs) assessing facilities' readiness to provide services are well-established. However, HFA questionnaires are typically quantitative and lack depth to understand systems in which health facilities operate-crucial to designing context-oriented interventions. We report lessons from a multiple embedded case study exploring the experiences of HFA data collectors in implementing a novel HFA tool developed using systems thinking approach. We assessed 16 hospitals in four countries (Benin, Malawi, Tanzania and Uganda) as part of a quality improvement implementation research. Our tool was organized in 17 sections and included dimensions of hospital governance, leadership and financing; maternity care standards and procedures; ongoing quality improvement practices; interactions with communities and mapping of the areas related to maternal care. Data for this study were collected using in-depth interviews with senior experts who conducted the HFA in the countries 1-3 months after completion of the HFAs. Data were analysed using the inductive thematic analysis approach. Our HFA faced challenges in logistics (accessing key hospital-based respondents, high turnover of managerial staff and difficulty accessing information considered sensitive in the context) and methodology (response bias, lack of data quality and data entry into an electronic platform). Data elements of governance, leadership and financing were the most affected. Opportunities and strategies adopted aimed at enhancing data collection (building on prior partnerships and understanding local and institutional bureaucracies) and enhancing data richness (identifying respondents with institutional memory, learning from experience and conducting observations at various times). Moreover, HFA data collectors conducted abstraction of records and interviews in a flexible and adaptive way to enhance data quality. Lessons and new skills learned from our HFA could be used as inputs to respond to the growing need of integrating the systems thinking approach in HFA to improve the contextual understanding of operations and structure. [ABSTRACT FROM AUTHOR]

Background: Client satisfaction is recognized as an important construct for evaluating health service provision, yet the field of family planning (FP) lacks a standard approach to its measurement. Further, little is known about satisfaction with FP services in Niger, the site of this study. This study aims to understand what features of FP visits were satisfactory or dissatisfactory from a woman's perspective and reflect on the conceptualization and measurement of satisfaction with FP services. Methods: Between February and March 2020, 2720 FP clients (ages 15– 49) were interviewed across 45 public health centers in Dosso region, Niger using a structured survey tool. The focus of this paper is on a random sub-sample of 100 clients who were additionally asked four open-ended questions regarding what they liked and disliked about their FP visit. Responses were audio-recorded, translated into French, transcribed, translated into English, coded, and analyzed thematically. Results: FP clients described nine key visit attributes related to their satisfaction with the visit: treatment by the provider, content of the counseling, wait time, FP commodity availability, privacy, cleanliness/infrastructure, visit processes and procedures, cost, and opening hours. The reason for FP visit (start, continue, or change method) was an important driver of the dimensions which contributed to satisfaction. Pre-formed expectations about the visit played a critical role in shaping satisfaction, particularly if the client's pre-visit expectations (or negative expectations) were met or not and if she obtained what she came for. Conclusion: This study makes a significant contribution by identifying visit attributes that are important to FP clients in Dosso region, Niger, and highlights that satisfaction with FP services is shaped by more than just what occurs on the day of service. We propose a conceptual framework to understand satisfaction with FP services that can be used for future FP programming in Niger. [ABSTRACT FROM AUTHOR]

Objective: Continuum of care (CoC) in maternal health is built on evidence suggesting that the integration of effective interventions across pregnancy, childbirth, and the postnatal period leads to better perinatal health outcomes. We explored gaps along the CoC in maternal health in Benin. Methods: A mixed‐methods study triangulating results from a qualitative study in southern Benin with a quantitative analysis of Benin Demographic and Health Survey (BDHS) data on the use of services along the CoC was conducted. Results: Benin Demographic and Health Survey analysis showed that although 89% of women reported at least one antenatal care (ANC) visit, only half initiated ANC in the first trimester and completed 4 or more visits. 85% reported facility‐based childbirth and 69% a postnatal check within 48 h after childbirth. Our qualitative study confirms early initiation of ANC and the transition from facility‐based childbirth to postnatal care are important gaps along the CoC and reveals late arrival at health facility for childbirth as an additional gap. These gaps interact with spiritual and alternative care practices that aim to safeguard pregnancy and prevent complications. Structural factors related to poverty and disrespectful care in health facilities compounded to limit the utilisation of formal healthcare. Conclusions: The combined use of BDHS and qualitative data contributed to highlighting critical gaps along the maternal CoC. A lack of integration of spiritual or alternative aspects of care into biomedical services, as well as structural factors, impeded access to healthcare in Benin. [ABSTRACT FROM AUTHOR]

Objective: To examine women's progression through the antenatal, birth, and post‐partum maternal care in Guinea in 2018. Methods: Using the Guinea Demographic and Health Survey of 2018, we analysed data on most recent live births in the 24 months preceding the survey among women aged 15–49 and the determinants (health system, quality of care, reproductive and sociodemographic factors) of women's progression through three steps of the continuum of care, using multivariable logistic regression. Results: In the sample of 3,018 women, 87% reported at least one ANC visit (ANC1) with a health professional and 36% reported ANC4+, at least one of which was with a health professional. In the study, 26% of women reported ANC4+ plus birth in a health facility, and 20% reported ANC4+, birth in a health facility, plus post‐partum check‐up. Predictors of woman's progression from ANC1 to ANC4+ visits included living in the administrative regions of Kindia (AOR: 1.96, 95% CI: 1.23–3.14) and Nzérékoré (AOR: 0.50, 95% CI: 0.32–0.79) vs. Kankan, being aged 15 to 17 (AOR: 0.55, 95% CI: 0.35–0.86) vs. aged 25 to 34, having primary or more education (AOR: 1.37, 95% CI: 1.09–1.72), and being from a middle (AOR: 1.52, 95% CI: 1.18–1.96) or wealthier (AOR: 2.38, 95% CI: 1.67–3.39) household vs. a poor household. Living in the administrative regions of Nzérékoré (AOR: 6.27, 95% CI: 1.57–25.05) vs. Kankan, in a middle (AOR: 1.64, 95% CI: 1.05–2.57) or wealthier (AOR: 3.23, 95% CI: 1.98–5.29) household vs. a poor household, nulliparity (AOR: 1.75, 95% CI: 1.03–2.97) vs. 2–4 previous births, the distance to health facility perceived as not being a problem (AOR: 1.75, 95% CI: 1.23–2.50), and higher ANC content score (AOR: 1.29, 95% CI: 1.10–1.52) remained independently associated with progression from ANC4+ to birth in a health facility. Predictors of progression from birth in the health facility to post‐partum check‐up included residing in the administrative regions of Labé (AOR: 0.22, 95% CI: 0.09–0.51) or Faranah (AOR: 0.43, 95% CI: 0.19–0.96) vs. Kankan, higher ANC content score (AOR: 1.76, 95% CI: 1.36–2.28), skin‐to‐skin contact after birth (AOR: 3.00, 95% CI: 1.70–5.31), and being attended at birth by a health professional (AOR: 17.52, 95% CI: 4.68–65.54). Conclusions: Removing financial barriers and improving quality of care appear to be important to increase the percentage of women receiving the full maternal continuum of care. [ABSTRACT FROM AUTHOR]