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This study assesses the impact of a voucher project that targeted vulnerable and poor pregnant women in Uganda. Highly subsidised vouchers gave access to a package of safe delivery services consisting of four antenatal visits, safe delivery, one postnatal visit, the treatment and management of selected pregnancy-related medical conditions and complications, and emergency transport. Vouchers were sold during the project's operational period from 2016 to 2019. This study covers 8 out of 25 project-benefiting districts in Uganda and a total of 1,881 pregnancies, including both beneficiary and non-beneficiary mothers. Using a matching design, the results show a positive effect on the survival of new-born babies. The difference in the survival rate between the control group and the treatment group is 5.4% points, indicating that the voucher project reduced infant mortality by more than 65 per cent. [ABSTRACT FROM AUTHOR]

Unstructured, verbal, obstetrical anesthesia handovers have led to omission of critical information, which can harm patients or delay care. The SAFE Handover Tool is a standardized mnemonic: Sick patients, At-risk patients, Follow-ups, and Epidurals. Use of the tool during handover significantly increases the percentage of relevant parturients that are discussed and improves provider communication. This study implemented the SAFE Handover Tool for Certified Registered Nurse Anesthetists (CRNAs) in a Level III (Subspecialty) Maternal Care unit. A mixed methodology was used to operationalize handover quality. Descriptive, statistical, and content analyses showed significant improvements between PRE- and POST-implementation assessments of handover quality after using the SAFE Handover Tool. The SAFE Handover Tool improved the quality of CRNA communication and enabled situational awareness. A modified SAFE Handover Tool was subsequently integrated into the obstetrical anesthesia electronic charting system. The SAFE Handover Tool is a novel, low-cost, sustainable method to improve CRNA handovers and patient safety. [ABSTRACT FROM AUTHOR]

Despite a relatively permissive abortion law, women in the Netherlands encounter difficulties in accessing abortion care. Little is known about their experiences. This study explores women's experiences with (online) abortion services and relevant health professionals' experiences delivering care, with the goal of identifying key barriers encountered by abortion-seekers in the Netherlands. An exploratory qualitative research design with a constructivist approach and an abbreviated grounded theory method was used. Interviews with 20 women who had had an abortion and 14 health professionals who provide abortion care, and 200 emails of women seeking abortion care through the non-governmental organisation Women on Web, were coded inductively and deductively (using the Candidacy Framework) thereby generating themes. Abortion-seekers faced barriers including: (i) burden of taboo, (ii) vulnerability (emotional, financial, and social), (iii) health professional evaluation and (iv) disempowerment and distress. The overarching theme was women's lack of autonomy in access to abortion care. The key barriers to abortion access in the Netherlands are the institutionalisation of taboo in abortion law and care, complex candidacy regulations, lack of permeability for certain marginalised groups, and women's inability to speak openly about abortion. To increase the permeability of abortion care, and thereby women's autonomy, legislators and policy-makers must trust women to make their own reproductive decisions and avoid actions that stigmatise abortion and hinder access to care, while actively developing systemic support for vulnerable groups. [ABSTRACT FROM AUTHOR]

We provide a situational update on COVID-19 in Ghana, the seventh African country reporting the most cases. Some modifications occurring within the health system to curtail the outbreak and its potential impact on the delivery of antenatal care services are also highlighted. With the discovery of the Delta variant in Ghana, the current attention is to prevent a third wave of infection, and also control and manage existing cases. Efforts to procure vaccines, vaccinate special populations and sensitize the public on the implications of vaccine hesitancy are ongoing. Amidst these activities, we suggest some innovations and countermeasures to safeguard primary healthcare services and potentially reinvest efforts towards achieving the sustainable development goal three within the context of maternal healthcare, citing examples specific to developing countries. [ABSTRACT FROM AUTHOR]

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

Background Perinatal palliative care is a relatively new component of paediatric palliative care which supports families who are expecting the birth of a child with a life-limiting condition. This study seeks to understand the characteristics of the infants and families referred for perinatal palliative care and the context for referrals in terms of diagnoses, referral characteristics, interventions, and outcomes. Methods A retrospective chart review of infants with prenatally diagnosed life-limiting conditions that were referred for perinatal palliative care. Results Eighty-five referrals were made for perinatal palliative care during the 10-year period, of which, 84 chose to continue with the service. Average gestational age at diagnosis was 23 weeks, and the mean time between diagnosis and referral to palliative care was 7 weeks. Stillbirths were common, occurring in 29% cases. Of livebirths, 59% of the infants survived for 2 days, and 80% died within 30 days. The most commonly referred conditions were trisomy 13 or 18 (24%), severe central nervous system malformations (20%), and severe congenital cardiac disease (16%). Referrals were most often made by neonatologists (39%), and maternal–fetal medicine specialists (36%). Discussion Our study confirms previously observed characteristics of diagnosis, referrals, and outcomes, while providing the most detailed account of lifespans for particular diagnoses to date. Our findings validate the need for perinatal palliative care, as 99% of those referred continued with the service. Future research should adopt a prospective approach to identify critical factors affecting decision making of families and physicians in the wake of a life-limiting diagnosis. [ABSTRACT FROM AUTHOR]

Background: Equitable access to services that promote health and wellbeing is an important component of social justice. A community-engaged participatory qualitative study was conducted in Flint, Michigan, USA, to understand the needs of special populations (young women, perinatal women and new mothers, older women, women with disabilities, and LGBTQIA women) and elicit their ideas about solutions. Methods: In-depth interviews (n = 100) were conducted. Participants were either women living in the Flint area, human service providers in the area, or both. A team of community and academic coders analyzed the data using an a priori framework. Results: Participants identified needs of different groups of women and suggested ways to address them. Access to healthy food, reducing healthcare costs, and improving transportation, job opportunities and affordable quality housing were crosscutting themes across all groups of women. Mentoring support was said to protect vulnerable young women from the risk of human trafficking. Older women were said to gain a sense of purpose, build their social support and reduce their loneliness by engaging in mentoring younger women. Women with disabilities were reported to benefit from infrastructure accessibility and authentic inclusion in all areas of life. Providing help that considers their dignity, pride and self-worth were suggested. LGBTQIA women were reported to have housing needs due to discrimination; mostly turned down as renters and can be rejected from faith-based homeless shelters. LGBTQIA women would also benefit from increased sensitivity among healthcare providers. For all groups of women, streamlining access to social services and other resources, building social support networks and increasing awareness about existing resources were recommended. Conclusion: Efforts directed towards improving women's health and wellbeing should include perspectives and suggestions of diverse groups of women from the community. Acting on suggestions that emanate from the community's lived experiences may reduce inequalities in health and wellbeing. [ABSTRACT FROM AUTHOR]

Background: Despite substantial progress on maternal and child mortality, neither the Millennium Development Goal 4 nor 5 targets could be met. The global maternal mortality ratio declined by 44% between 1990 and 2015, short of the targeted 75% fall. Objectives: The objective of the study is to evaluate the maternal health services being provided to the high-risk mothers (HRMs) of Bhavnagar district. Methodology: It was a cross-sectional study conducted among the HRMs of Bhavnagar district during the period from March 2017 to August 2018. A total of 90 HRMs were selected and interviewed. Results: All the HRMs were measured for blood pressure and weight; tested for hemoglobin, blood group, and HIV; and examined for pedal edema. None of the HRMs were tested for sickle cell anemia. In the best performing primary health centers (PHCs), all the HRMs were tested for venereal disease research laboratory and hepatitis B surface antigen as against 79.5% of the HRMs from the worst-performing PHCs. About 47.7% of the HRMs from the worst-performing PHCs and 13.3% of the HRMs from the best-performing PHCs made <4 antenatal care (ANC) visits. Conclusions: For most of the ANC services, reason for nonreceipt of the service as given by the HRMs was "service not offered." [ABSTRACT FROM AUTHOR]

Background An increasing number of migrants have fled armed conflict, persecution and deteriorating living conditions, many of whom have also endured risky migration journeys to reach Europe. Despite this, little is known about the perinatal health of migrant women who are particularly vulnerable, such as refugees, asylum-seekers, and undocumented migrants, and their access to perinatal care in the host country. Methods Using the Swedish Pregnancy Register, we analyzed indicators of perinatal health and health care usage in 31 897 migrant women from the top five refugee countries of origin between 2014 and 2017. We also compared them to native-born Swedish women. Results Compared to Swedish-born women, migrant women from Syria, Iraq, Somali, Eritrea and Afghanistan had higher risks of poor self-rated health, gestational diabetes, stillbirth and infants with low birthweight. Within the migrant population, asylum-seekers and undocumented migrants had a higher risk of poor maternal self-rated health than refugee women with residency, with an adjusted risk ratio (RR) of 1.84 and 95% confidence interval (95% CI) of 1.72–1.97. They also had a higher risk of preterm birth (RR 1.47, 95% CI 1.21–1.79), inadequate antenatal care (RR 2.56, 95% CI 2.27–2.89) and missed postpartum care visits (RR 1.15, 95% CI 1.10–1.22). Conclusion Refugee, asylum-seeking and undocumented migrant women were vulnerable during pregnancy and childbirth. Living without residence permits negatively affected self-rated health, pregnancy and birth outcomes in asylum-seekers and undocumented migrants. Pregnant migrant women's special needs should be addressed by those involved in the asylum reception process and by health care providers. [ABSTRACT FROM AUTHOR]

Background: To present the differences in prenatal, labor and neonatal outcomes for Syrian refugees and Turkish citizens. Methods: Between January 2013 and December 2016, all patients in our hospital were screened retrospectively. Totally, 17 000 pregnant women included in the study were divided into three groups: group 1: 4802 pregnant in Syrian refugees group; group 2: 6752 pregnant in the low-income Turkish citizens (LI groups); and group 3: 5446 women in high-income Turkish citizens (HI groups). The groups were compared for demographic parameters, prenatal, labor and postnatal results. Results: Age, gestational week, birth weights, antenatal follow-up, antenatal iron supplementation and prenatal hemoglobin (Hb) values were significantly lower in the Syrian refugee group (P < 0.001). Only moderate preterm delivery and moderate low birth weight were higher in the refugee group (P = 0.023 and P = 0.001). Stillbirth rates were similar in all three groups (P = 0.203), but all other neonatal complications were higher in the Turkish citizens group. Conclusion: In comparison to non-refugee control patients, adverse perinatal outcomes were not observed in pregnant refugees. The refugee health policies of the Republic of Turkey seem to be working. However, further larger multicenter studies may provide more convincing data about obstetric outcomes and health results in the Syrian refugee population. [ABSTRACT FROM AUTHOR]

Background: Food-assisted maternal and child health and nutrition (FA-MCHN) programs are widely used to address undernutrition, but little is known about their effectiveness in improving child linear growth.Objective: We assessed the impact of Burundi's Tubaramure FA-MCHN program on linear growth. The program targeted women and their children during the first 1000 d and included 1) food rations, 2) strengthening of health services and promotion of their use, and 3) behavior change communication (BCC). A second objective was to assess the differential effect when varying the timing and duration of receiving food rations.Methods: We used a 4-arm, cluster-randomized controlled study to assess program impact with the use of cluster fixed-effects double-difference models with repeated cross-sectional data (baseline and follow-up 4 y later with ∼3550 children in each round). Treatment arms received food rations (corn-soy blend and micronutrient-fortified vegetable oil) for the first 1000 d (T24), from pregnancy through the child reaching 18 mo (T18), or from birth through the child reaching 24 mo ["no food during pregnancy" (TNFP)]. All treatment arms received BCC for the first 1000 d. The control arm received no food rations or BCC.Results: Stunting (height-for-age z score <2 SDs) increased markedly from baseline to follow-up, but Tubaramure had a significant (P < 0.05) beneficial effect in the T24 [7.4 percentage points (pp); P < 0.05], T18 (5.7 pp; P < 0.05), and TNFP (4.6; P = 0.09) arms; the differences in effect across arms were not significant (P > 0.01). Secondary analyses showed that the effect was limited to children whose mother and head of household had some primary education and who lived in households with above-median assets.Conclusions: FA-MCHN programs are an effective development tool to improve child linear growth and can protect children from political and economic shocks in vulnerable countries such as Burundi. A better understanding of how to improve the nutritional status of children in the worst-off households is needed. This trial was registered at www.clinicaltrials.gov as NCT01072279. [ABSTRACT FROM AUTHOR]

Reverse innovation, defined as the flow of ideas from low- to high-income settings, is gaining traction in healthcare. With an increasing focus on value, investing in low-cost but effective and innovative solutions can be of mutual benefit to both high- and low-income countries. Reverse innovation has a role in addressing maternal health challenges in high-income countries by harnessing these innovative solutions for vulnerable populations especially in rural and remote regions. In this paper, we present three examples of 'reverse innovation' for maternal health: a low-cost, easy-to-use blood pressure device (CRADLE), a diagnostic algorithm (mini PIERS) and accompanying mobile app (PIERS on the Move), and a novel method for mapping maternal outcomes (MOM). [ABSTRACT FROM AUTHOR]

Background: In Gujarat, India, a state led public private partnership scheme to promote facility birth named Chiranjeevi Yojana (CY) was implemented in 2005. Institutional birth is provided free of cost at accredited private health facilities to women from socially disadvantaged groups (eligible women). CY has contributed in increasing facility birth and providing substantially subsidized (but not totally free) birth care; however, the retention of mothers in this scheme in subsequent child birth is unknown. Therefore, we conducted a study aimed to determine the effect of previous utilization of the scheme and previous out of pocket expenditure on subsequent child birth among multiparous eligible women in Gujarat.Methods: This was a retrospective cohort study of multiparous eligible women (after excluding abortions and births at public facility). A structured questionnaire was administered by trained research assistant to those with recent delivery between Jan and Jul 2013. Outcome of interest was CY utilization in subsequent child birth (Jan-Jul 2013). Explanatory variables included socio-demographic characteristics (including category of eligibility), pregnancy related characteristics in previous child birth, before Jan 2013, (including CY utilization, out of pocket expenditure) and type of child birth in subsequent birth. A poisson regression model was used to assess the association of factors with CY utilization in subsequent child birth.Results: Of 997 multiparous eligible women, 289 (29%) utilized and 708 (71%) did not utilize CY in their previous child birth. Of those who utilized CY (n = 289), 182 (63%) subsequently utilized CY and 33 (11%) gave birth at home; whereas those who did not utilize CY (n = 708) had four times higher risk (40% vs. 11%) of subsequent child birth at home. In multivariable models, previous utilization of the scheme was significantly associated with subsequent utilization (adjusted Relative Risk (aRR): 2.7; 95% CI: 2.2-3.3), however previous out of pocket expenditure was not found to be associated with retention in the CY scheme.Conclusion: Women with previous CY utilization were largely retained; therefore, steps to increase uptake of CY are expected to increase retention of mothers within CY in their subsequent child birth. To understand the reasons for subsequent child birth at home despite previous CY utilization and previous zero/minimal out of pocket expenditure, future research in the form of systematic qualitative enquiry is recommended. [ABSTRACT FROM AUTHOR]

Background: Maternity care in South Asia is available in both public and private sectors. Using data from demographic surveillance sites in Bangladesh, Nepal and rural and urban India, we aimed to compare institutional delivery rates and public-private share.Methods: We used records of maternity care collected in socio-economically disadvantaged communities between 2005 and 2011. Institutional delivery was summarized by four potential determinants: household asset index, maternal schooling, maternal age, and parity. We developed logistic regression models for private sector institutional delivery with these as independent covariates.Results: The data described 52 750 deliveries. Institutional delivery proportion varied and there were differences in public-private split. In Bangladesh and urban India, the proportion of deliveries in the private sector increased with wealth, maternal education, and age. The opposite was observed in rural India and Nepal.Conclusions: The proportion of institutional delivery increased with economic status and education. The choice of sector is more complex and provision and perceived quality of public sector services is likely to play a role. Choices for safe maternity are influenced by accessibility, quantity and perceived quality of care. Along with data linkage between private and public sectors, increased regulation should be part of the development of the pluralistic healthcare systems that characterize south Asia. [ABSTRACT FROM AUTHOR]

Background: "Chiranjeevi Yojana (CY)", a state-led large-scale demand-side financing scheme (DSF) under public-private partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005. The scheme aims to provide free institutional childbirth services in accredited private health facilities to women from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility with the intention of service being free to the user. This community-based study estimates CY uptake among eligible women and explores factors associated with non-utilization of the CY program.Methods: This was a community-based cross sectional survey of eligible women who gave birth between January and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by trained research assistant to collect information on socio-demographic details, pregnancy details, details of childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the factors associated with non-utilization of the CY program.Results: Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6, 95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY program overall paid more than women who delivered in the free public facilities.Conclusion: Uptake of the CY among eligible women was low after almost a decade of implementation. Community level awareness programs are needed to increase participation among eligible women. OOP expense was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy which needs to be studied. There is also a need to ensure financial protection of women who have C-section. [ABSTRACT FROM AUTHOR]

Many risk factors associated with adverse pregnancy outcomes can be identified and modified preconceptionally. Despite a broad consensus that preconception care should be provided to all couples of reproductive age, it has not been integrated in routine healthcare. There are several barriers to its implementation, and even in the most resourceful countries, it is only provided to some select high-risk groups, rather than being an organized healthcare service provision to all. Recently, China seems to be leading the way by implementing preconception care nationwide in all rural areas. Its National Free Preconception Health Examination Project is a unique model of comprehensive preconception care. Advantages of this ambitious project are now becoming evident and benefiting the most vulnerable sections of Chinese society. This commentary provides an overview of National Free Preconception Health Examination Project and highlights the concepts that could be further developed and adapted into a model of preconception care. [ABSTRACT FROM AUTHOR]

Background: Previous studies demonstrate that people's satisfaction with healthcare influences their further use of that healthcare system. Satisfied patients are more likely to take part in the decision making process and to complete treatment. One of the important determinants of satisfaction is the fulfillment of expectations. This study aims to analyse both expectations and satisfaction with antenatal care among pregnant women, with a particular focus on vulnerable groups.Methods: A quantitative descriptive study was conducted in 155 women seeking antenatal care at the University Hospital of Ghent (Belgium), of whom 139 completed the questionnaire. The statistical program SPSS-21 was used for data analysis.Results: Women had high expectations relating to continuity of care and women-centered care, while expectations regarding availability of other services and complete care were low. We observed significantly lower expectations among women without higher education, with low income, younger than 26 years and women who reported intimate partner violence. General satisfaction with antenatal care was high. Women were satisfied with their relationship with the healthcare worker, however ; they evaluated the information received during the consultation and the organizational aspects of antenatal care as less satisfactory.Conclusions: In order to improve satisfaction with antenatal care, organizational aspects of antenatal care (e.g. reducing waiting times and increasing accessibility) need to be improved. In addition, women would appreciate a better provision of information during consultation. More research is needed for an in-depth understanding of the determinants of satisfaction and the relationship with low socio economic status (SES). [ABSTRACT FROM AUTHOR]

Background: Discussions of maternity care in developing countries tend to emphasise service uptake and overlook choice of provider. Understanding how families choose among health providers is essential to addressing inequitable access to care. Our objectives were to quantify the determinants and choice of maternity care provider in Mumbai's informal urban settlements, and to explore the reasons underlying their choices.Methods: The study was conducted in informal urban communities in eastern Mumbai. We developed regression models using data from a census of married women aged 15-49 to test for associations between maternal characteristics and uptake of care and choice of provider. We then conducted seven focus group discussions and 16 in-depth interviews with purposively selected participants, and used grounded theory methods to examine the reasons for their choices.Results: Three thousand eight hundred forty-eight women who had given birth in the preceding 2 years were interviewed in the census. The odds of institutional prenatal and delivery care increased with education, economic status, and duration of residence in Mumbai, and decreased with parity. Tertiary public hospitals were the commonest site of care, but there was a preference for private hospitals with increasing socio-economic status. Women were more likely to use tertiary public hospitals for delivery if they had fewer children and were Hindu. The odds of delivery in the private sector increased with maternal education, wealth, age, recent arrival in Mumbai, and Muslim faith. Four processes were identified in choosing a health care provider: exploring the options, defining a sphere of access, negotiating autonomy, and protective reasoning. Women seeking a positive health experience and outcome adopted strategies to select the best or most suitable, accessible provider.Conclusions: In Mumbai's informal settlements, institutional maternity care is the norm, except among recent migrants. Poor perceptions of primary public health facilities often cause residents to bypass them in favour of tertiary hospitals or private sector facilities. Families follow a complex selection process, mediated by their ability to mobilise economic and social resources, and a concern for positive experiences of health care and outcomes. Health managers must ensure quality services, a functioning regulatory mechanism, and monitoring of provider behaviour. [ABSTRACT FROM AUTHOR]