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Copyright of Portuguese Journal of Mental Health Nursing / Revista Portuguesa de Enfermagem de Saúde Mental is the property of Portuguese Society of Mental Health Nursing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background/Aims: The Indonesian family planning programme promotes contraceptive use to control population density. Counselling is widely used to improve contraceptive use. The aim of this study was to explore women's use of contraceptives before and after counselling. Methods: This cross-sectional study collected data from 10 790 women across 10 districts/cities in East Java. The data obtained were analysed using descriptive statistical analysis and paired t-tests. Results: After counselling, use of contraceptives increased significantly (P<0.001), from 75.8% using contraceptives before counselling to 99.98% using them after counselling. Use of the contraceptive pill notably increased from 16.7% to 40.9%. Conclusions: Short-term contraceptives were most popular with women in this population. Counselling can contribute to increased use of long-term contraceptive methods. [ABSTRACT FROM AUTHOR]

Background: Most pregnant women in low and lower-middle-income countries do not receive all components of antenatal care (ANC), including counselling on obstetric danger signs. Facility-level ANC guidelines and provider in-service training are major factors influencing ANC counselling. In Ethiopia, little is known about the extent to which guidelines and provider in-service training can increase the quality of ANC counselling. Methods: We examined the effect of national ANC guidelines and ANC provider in-service training on obstetric danger sign counselling for pregnant women receiving ANC using the 2014 Ethiopian service provision assessment plus (ESPA +) survey data. We created two analysis samples by applying a propensity score matching method. The first sample consisted of women who received ANC at health facilities with guidelines matched with those who received ANC at health facilities without guidelines. The second sample consisted of women who received ANC from the providers who had undertaken in-service training in the last 24 months matched with women who received ANC from untrained providers. The outcome variable was the number of obstetric danger signs described during ANC counselling, ranging from zero to eight. The covariates included women's socio-demographic characteristics, obstetric history, health facility characteristics, and ANC provider characteristics. Results: We found that counselling women about obstetric danger signs during their ANC session varied according to the availability of ANC guidelines (61% to 70%) and provider training (62% to 68%). After matching the study participants by the measured covariates, the availability of ANC guidelines at the facility level significantly increased the average number of obstetric danger signs women received during counselling by 24% (95% CI: 12–35%). Similarly, providing refresher training for ANC providers increased the average number of obstetric danger signs described during counselling by 37% (95% CI: 26–48%). Conclusion: The findings suggest that the quality of ANC counselling in Ethiopia needs strengthening by ensuring that ANC guidelines are available at every health facility and that the providers receive regular ANC related in-service training. Plain language summary: Maternal death from preventable pregnancy-related complications remains a global health challenge. In 2017, there were 295,000 maternal deaths worldwide, and about two-thirds of these deaths were from Sub-Saharan Africa. Ethiopia is a Sub-Saharan African country with 401 maternal deaths per 100,000 live births in 2017, and this rate is higher than the target indicated in sustainable development goals. Most maternal deaths are due to obstetric complications and could have been averted through early detection and treatment. Providing antenatal care counselling about obstetric danger signs enhances women's awareness of obstetric complications and encourages women to seek treatment from a skilled care provider. However, most women from low-income settings, including Ethiopia, do not receive counselling about obstetric danger signs. Facility-level antenatal care guidelines and provider in-service training improve antenatal care counselling. In Ethiopia, little is known to what extent antenatal care guidelines and provider training increase counselling on obstetric danger signs. The present study used the 2014 Ethiopian service provision assessment data and estimated the effect of antenatal care guidelines and provider training on counselling about obstetric danger signs. The analysis involved a propensity score matching method and included 1725 pregnant women. The study found that antenatal care guidelines at health facilities and antenatal care provider in-service training significantly increase counselling on obstetric danger signs by 24% and 37%, respectively. The finding suggests improving the quality of antenatal care counselling in Ethiopia needs antenatal care guidelines at each antenatal care clinic and refresher training for the providers. [ABSTRACT FROM AUTHOR]

Integrating nutrition interventions into antenatal care (ANC) requires adapting global recommendations to fit existing health systems and local contexts, but the evidence is limited on the process of tailoring nutrition interventions for health programmes. We developed and integrated maternal nutrition interventions into ANC programmes in Bangladesh, Burkina Faso, Ethiopia and India by conducting studies and assessments, developing new tools and processes and field testing integrated programme models. This paper elucidates how we used information and data to contextualize a package of globally recommended maternal nutrition interventions (micronutrient supplementation, weight gain monitoring, dietary counselling and counselling on breastfeeding) and describes four country‐specific health service delivery models. We developed a Theory of Change to illustrate common barriers and strategies for strengthening nutrition interventions during ANC. We used multiple information sources including situational assessments, formative research, piloting and pretesting results, supply assessments, stakeholder meetings, household and service provider surveys and monitoring data to design models of maternal nutrition interventions. We developed detailed protocols for implementing maternal nutrition interventions; reinforced staff capacity, nutrition counselling, monitoring systems and community engagement processes; and addressed micronutrient supplement supply bottlenecks. Community‐level activities were essential for complementing facility‐based services. Routine monitoring data, rapid assessments and information from intensified supervision were important during the early stages of implementation to improve the feasibility and scalability of models. The lessons from addressing maternal nutrition in ANC may serve as a guide for tackling missed opportunities for nutrition within health services in other contexts. Key messages: Integrating evidence‐based nutrition interventions into ANC to reach PW at scale is urgently needed for improving maternal and newborn health and nutrition.The Theory of Change and steps for strengthening nutrition interventions based on four‐country experiences provide practical guidance on addressing missed opportunities for nutrition in ANC.Strategic use of data can contextualize global maternal nutrition guidelines, protocols, capacity building and supervision approaches, and improve micronutrient supply chains and record‐keeping as part of health services strengthening.Engaging family and community members to support PW and improving the knowledge and self‐confidence of PW are important elements of all country programme models. [ABSTRACT FROM AUTHOR]

Background: Decision‐making for infants born at 23–25 weeks involves counselling parents about survival and major disability risks. Accurate information is needed for parents to make informed decisions about their baby's care. Aims: To determine if perinatal clinicians had accurate perceptions of outcomes of infants born at 23–25 weeks' gestation, and if accuracy had changed over a decade. Materials and Methods: A web‐based survey was sent to midwives, nurses, neonatologists, and obstetricians working in tertiary and non‐tertiary hospitals, and the neonatal retrieval service in the state of Victoria in 2020. A similar survey had been completed in 2010. Clinicians' estimates of survival and major neurodevelopmental disability rates were compared with true rates for actively managed infants overall, and by infant birthplace and gestational age, and professional workplace and discipline. Accuracy of outcomes was compared between eras. Results: Overall, 165 surveys were received. Participants underestimated survival (absolute mean difference [%] −14.4%; [95% confidence interval (CI) −16.6 to −12.3]; P < 0.001) and overestimated major disability (absolute mean difference 32.7%; [95% CI 29.7 to 35.8]; P < 0.001) rates overall, and at each week of gestation, and were worse for outborn compared with inborn infants. Perceptions of clinicians in tertiary centres were similar to those of non‐tertiary clinicians. Nurses/midwives were more pessimistic, and paediatricians were more optimistic. Clinicians' perceptions of outcome were less accurate in 2020 than in 2010. Conclusions: Most perinatal clinicians underestimate survival and overestimate major disability of infants born at 23–25 weeks' gestation, which may translate into overly pessimistic counselling of parents. [ABSTRACT FROM AUTHOR]

The delivery of nutrition‐related interventions and counselling during antenatal care is critical for a healthy pregnancy for both mother and child. However, the accuracy of maternal reports of many of these services during household surveys has not yet been examined. Our objectives were to assess the validity of the maternal reports of 10 antenatal nutrition interventions, including counselling, and examine associates between maternal characteristics and accuracy. Maternal report of services received collected during a post‐partum survey was compared to the gold standard, the direct observation of all women's antenatal care visits. Individual‐level validity was assessed by calculating indicator sensitivity, specificity and area under the operating curve (AUC). The inflation factor (IF) measured population‐level bias. For five indicators, the high true coverage limited our ability to assess the validity of the maternal reports. There were no indicators that had both high individual‐level validity (AUC > 0.70) and low population bias (0.75 < IF < 1.25). Indicators with greater true coverage estimates had higher sensitivity and lower specificity estimates compared to those indicators with lower true coverage. There were no maternal characteristics associated with the accuracy of the report. Maternal report of antenatal nutrition‐related interventions and counselling during household surveys was found to have variable validity across indicators. Additional research in settings with varying coverage levels should be considered to best inform antenatal care coverage measurement in household surveys. Key Messages: The coverage of nutrition‐related interventions and counselling was high (>89%) for the majority of indicators.Maternal reports resulted in higher coverage estimates than what was observed for all but one indicator.No indicator assessed had high individual level validity (AUC > 0.70) and low population bias (0.75 < IF < 1.25).The greater the indicator's true coverage estimate, the greater the sensitivity and lower the specificity values. [ABSTRACT FROM AUTHOR]

Background: A study was done to explore the attitudes of relevant health care professionals (HCP) towards the provision of intensive care for periviable and extremely premature babies.Methods/design: Applying a constructivist grounded theory methodology, HCP were interviewed about their attitudes towards the provision of resuscitation and intensive care for extremely premature babies. These babies are at increased risk of death and neurodisability when compared to babies of older gestations. Participants included HCP of varying disciplines at a large tertiary centre, a regional centre and a remote centre. Staff with a wide range of experience were interviewed.Results: Six categories of i) who decides, ii) culture and context of families, iii) the life ahead, iv) to treat a bit or not at all, v) following guidelines and vi) information sharing, emerged. Role specific implicit bias was found as a theoretical construct, which depended on the period for which care was provided relative to the delivery of the baby. This implicit bias is an underlying cause for the negativity seen towards extreme prematurity and is presented in this paper. HCP caring for women prior to delivery have a bias towards healthy term babies that involves overestimation of the risks of extreme prematurity, while neonatal staff were biased towards suffering in the neonatal period and paediatricians recognise positivity of outcomes regardless of neurological status of the child. The implicit bias found may explain negativity towards intensive care of periviable neonates.Conclusion: Understanding the presence and origins of role specific implicit bias may enable HCP to work together to improve care for parents preparing for the delivery of extremely premature babies. [ABSTRACT FROM AUTHOR]

Key content: Perinatal management of pregnant women delivering at the threshold of viability has medical and ethical considerations. It should be preceded by the best advice from a multidisciplinary neonatal and obstetric team to fully inform parents and achieve a consensus on the optimal care for the mother and neonate. Obstetric interventions can affect maternal and neonatal outcomes after birth at the threshold of viability. These include administration of steroids, magnesium sulphate and tocolysis, fetal monitoring in labour and mode of delivery. Obstetric complications such as malpresentation are common and can affect delivery choices at extreme preterm gestational ages. This requires obstetricians to plan carefully with parents before labour starts. Learning objectives: To understand how obstetric decisions and interventions can affect maternal and neonatal outcomes when women are at risk of delivery at extreme premature gestational ages. To enable trainee obstetricians to better counsel women and their partners about possible complications before and during labour at extreme preterm gestations. Ethical issues: Should we monitor the fetal heart during labour, deliver by caesarean section and resuscitate a baby born at extreme prematurity when short‐term and long‐term neonatal outcomes are likely to be poor? [ABSTRACT FROM AUTHOR]

Introduction: Pregnancy and childbirth are transformative life experiences that can create or exacerbate significant emotional, physical, social, and relational challenges. Midwives help women to feel confident and knowledgeable, to cope with anxiety and fear, and to prepare for considerable shifts of identity, responsibility, and family life. Research shows that counselling has the potential to positively impact women's birth experiences and outcomes; however, less is known about how midwives understand and experience their role in counselling women. Methods: In the current study, nine practicing midwives in British Columbia, Canada, participated in a semi-structured interview. Interview transcripts were coded for themes. Results: Five themes emerged from the qualitative analysis of the interview responses, including: counselling as "part of the job", the importance of "meeting people where they are at", feeling that "sometimes we're out of our depths", "learning by doing", and the importance of "taking care of the midwife." Discussion: Findings from this study suggest that counselling is a prevalent part of midwifery care in British Columbia. Future studies should focus on exploring the impact of midwives' accessibility to their clients when specialized counselling services are not available, collaborative ways for midwives to participate with mental health professionals in the broader community, and tailoring professional development for midwives in both health and mental health counselling. [ABSTRACT FROM AUTHOR]

Background: Since 2010, intensive care can be offered in the Netherlands at 24+0 weeks gestation (with parental consent) but the Dutch guideline lacks recommendations on organization, content and preferred decision-making of the counselling. Our aim is to explore preferred prenatal counselling at the limits of viability by Dutch perinatal professionals and compare this to current care.Methods: Online nationwide survey as part of the PreCo study (2013) amongst obstetricians and neonatologists in all Dutch level III perinatal care centers (n = 205).The survey regarded prenatal counselling at the limits of viability and focused on the domains of organization, content and decision-making in both current and preferred practice.Results: One hundred twenty-two surveys were returned out of 205 eligible professionals (response rate 60%). Organization-wise: more than 80% of all professionals preferred (but currently missed) having protocols for several aspects of counselling, joint counselling by both neonatologist and obstetrician, and the use of supportive materials. Most professionals preferred using national or local data (70%) on outcome statistics for the counselling content, in contrast to the international statistics currently used (74%). Current decisions on initiation care were mostly made together (in 99% parents and doctor). This shared decision model was preferred by 95% of the professionals.Conclusions: Dutch perinatal professionals would prefer more protocolized counselling, joint counselling, supportive material and local outcome statistics. Further studies on both barriers to perform adequate counselling, as well as on Dutch outcome statistics and parents' opinions are needed in order to develop a national framework.Trial Registration: Clinicaltrials.gov, NCT02782650 , retrospectively registered May 2016. [ABSTRACT FROM AUTHOR]

Opinions abound regarding how to best approach anticipated extremely preterm birth. No unified approach presently exists in Canada. In the process of updating the Canadian Paediatric Society statement on 'Counselling and management for anticipated extremely preterm birth', there was recognition of the need for a novel methodology in its development and a primary focus on enhancing the involvement of parents in the generation of a care plan for their infant. The development process involved a national consultation with health care providers and parents from across the country, with much of the feedback provided through the use of validated guideline appraisal tools. Future Canadian Paediatric Society statements may benefit from applying components of this new development process during their creation. Dedication to shared decision making and best practices in communication highlighted the importance of parental involvement in the decision-making process, particularly given the cultural and social diversity in Canada. [ABSTRACT FROM AUTHOR]

Objective: To analyse the effect of community-based counselling on feeding patterns during the first 12 weeks after birth, and to study whether the effect differs by maternal HIV status, educational level or household wealth.Design: Cluster-randomized trial with fifteen clusters in each arm to evaluate an integrated package providing two pregnancy and five postnatal home visits delivered by community health workers. Infant feeding data were collected using 24 h recall of nineteen food and fluid items.Setting: A township near Durban, South Africa.Subjects: Pregnant women (1894 intervention and 2243 control) aged 17 years or more.Results: Twelve weeks after birth, 1629 (intervention) and 1865 (control) mother-infant pairs were available for analysis. Socio-economic conditions differed slightly across intervention groups, which were considered in the analyses. There was no effect on early initiation of breast-feeding. At 12 weeks of age the intervention doubled exclusive breast-feeding (OR=2·29; 95 % CI 1·80, 2·92), increased exclusive formula-feeding (OR=1·70; 95 % CI 1·28, 2·27), increased predominant breast-feeding (OR=1·71; 95 % CI 1·34, 2·19), decreased mixed formula-feeding (OR=0·68; 95 % CI 0·55, 0·83) and decreased mixed breast-feeding (OR=0·54; 95 % CI 0·44, 0·67). The effect on exclusive breast-feeding at 12 weeks was stronger among HIV-negative mothers than HIV-positive mothers (P=0·01), while the effect on mixed formula-feeding was significant only among HIV-positive mothers (P=0·03). The effect on exclusive feeding was not different by household wealth or maternal education levels.Conclusions: A perinatal intervention package delivered by community health workers was effective in increasing exclusive breast-feeding, exclusive formula-feeding and decreasing mixed feeding. [ABSTRACT FROM AUTHOR]

BACKGROUND Supportive care is regularly offered to women with recurrent miscarriages (RMs). Their preferences for supportive care in their next pregnancy have been identified by qualitative research. The aim of this study was to quantify these supportive care preferences and identify women's characteristics that are associated with a higher or lower need for supportive care in women with RM. METHODS A questionnaire study was conducted in women with RMs (≥2 miscarriages) in three hospitals in the Netherlands. All women who received diagnostic work-up for RMs from January 2010 to December 2010 were sent a questionnaire. The questionnaire quantified supportive care options identified by a previous qualitative study. We next analysed associations between women's characteristics (age, ethnicity, education level, parity, pregnancy during questionnaire and time passed since last miscarriage) and their feelings about supportive care options to elucidate any differences between groups. RESULTS Two hundred and sixty-six women were asked to participate in the study. In total, 174 women responded (response rate 65%) and 171 questionnaires were analysed. Women with RM preferred the following supportive care options for their next pregnancy: a plan with one doctor who shows understanding, takes them seriously, has knowledge of their obstetric history, listens to them, gives information about RM, shows empathy, informs on progress and enquires about emotional needs. Also, an ultrasound examination during symptoms, directly after a positive pregnancy test and every 2 weeks. Finally, if a miscarriage occurred, most women would prefer to talk to a medical or psychological professional afterwards. The majority of women expressed a low preference for admission to a hospital ward at the same gestational age as previous miscarriages and for bereavement therapy. The median preference, on a scale from 1 to 10, for supportive care was 8.0. Ethnicity, parity and pregnancy at the time of the survey were associated with different preferences, but female age, education level and time passed since the last miscarriage were not. CONCLUSIONS Women with RM preferred a plan for the first trimester that involved one doctor, ultrasounds and the exercise of soft skills, like showing understanding, listening skills, awareness of obstetrical history and respect towards the patient and their miscarriage, by the health care professionals. In the event of a miscarriage, women prefer aftercare. Women from ethnic minorities and women who were not pregnant during the questionnaire investigation were the two patient groups who preferred the most supportive care options. Tailor-made supportive care can now be offered to women with RM. [ABSTRACT FROM AUTHOR]

BACKGROUND Supportive care is currently the only ‘therapy’ that can be offered to women with unexplained recurrent miscarriage (RM). What these women themselves prefer as supportive care in their next pregnancy has never been substantiated. Therefore the aim of this study was to explore what women with unexplained RM prefer as supportive care during their next pregnancy. METHODS We performed explorative, semi-structured, in-depth interviews. The interviews were performed with 15 women with unexplained RM who were actively seeking conception. All interviews were conducted by telephone. The interviews were fully transcribed and two researchers independently identified text segments from the transcribed interviews and categorized them in the appropriate domain. RESULTS Women identified 20 different supportive care options; 16 of these options were preferred for their next pregnancy. Examples of the preferred supportive care were early and frequently repeated ultrasounds, βHCG monitoring, practical advice concerning life style and diet, emotional support in the form of counselling, a clear policy for the upcoming 12 weeks and medication. The four supportive care options that were not preferred by the women were admittance to a hospital ward at the same gestational age as previous miscarriages, Complementary Alternative Medicine, ultrasound every other day and receiving supportive care from their general practitioner. CONCLUSIONS Our study identified several relevant preferences for supportive care in women with unexplained RM. Many of these can be offered by the gynaecologist and will help in guaranteeing high-quality patient-centred care. [ABSTRACT FROM AUTHOR]

During the recent New South Wales and Australian Capital Territory consensus workshop on Perinatal Care at the limits of viability, recommendations were made in the areas of education, counselling and management. Critically, there was a consensus that between 23 weeks and zero days and 25 weeks and six days of gestation, it was reasonable to offer the option of non-initiation of resuscitation and intensive care. Within this, obligation to treat increases as the gestation advances. Implications of the statement for obstetricians are discussed in this article. [ABSTRACT FROM AUTHOR]

Objectives: Many women in Western countries fail to breastfeed long enough. The aim of this study was to examine the attitudes and knowledge of Israeli family physicians (FPs), gynaecologists and paediatricians towards breastfeeding. Design and participants: A questionnaire examined Physicians' attitudes towards breastfeeding and their role in encouraging it, their sources of information and adequacy of knowledge. Results: Four hundred and seventy-eight physicians responded to the survey: 123 FPs, 134 gynaecologists and 221 paediatricians. Ninety to —hundred per cent of physicians agreed that breastfeeding is the best feeding method for infants and agree that physicians should encourage it. Less than 20% of physicians discuss breastfeeding with pregnant women, and less than 30% discuss it with women 3 months or more postnatally. On average, physicians correctly answered 3.5 ± 1.7 out of seven questions examining knowledge. Physicians state their main sources of information as their own experience and reading. One hundred and ninety physicians specified how they encourage breastfeeding – of those, 75.3% speak only of the advantages of breastfeeding. Conclusion: Physicians have a positive disposition towards breastfeeding but their knowledge is somewhat low. It seems awareness is lacking to the importance of continuous support and practical guidance beginning before birth and continuing until 3 months or more postnatal. [ABSTRACT FROM AUTHOR]

Abstract: Psychological and social interventions are used singly or as adjuncts to drug treatment. Health visitor counselling, and individual psychotherapy are effective, can be given in a group setting and adapted to treat women with other disorders and pregnant women. Multidisciplinary services should relate to maternity care professionals, the voluntary sector and meet the needs of mothers and fathers. [Copyright &y& Elsevier]

A multidisciplinary workshop with parent/consumer involvement was held to determine a consensus in the difficult arena of perinatal care of women and babies at the borderlines of viability. Interactive forums produced consensus statements following an extensive consultation process. A grey zone between 230 and 256 weeks of gestation was identified and agreed upon. In this grey zone, while there was an increasing obligation to treat, it was acceptable not to initiate intensive care following appropriate counselling with parents. Important areas identified before birth, were continuing communication between the perinatal team and parents, a review of choice with continued counselling, decision support and empathy. The process must be transparent, open and honest, using the most relevant up to date outcome data in a collaborative framework. [ABSTRACT FROM AUTHOR]

This study compares the effect of group and individual pre-test counselling on uptake of HIV voluntary counselling and testing (VCT) by African pregnant women and knowledge about HIV/AIDS in 2 antenatal clinics of Bobo-Dioulasso, Burkina Faso. Pre-test counselling was offered to 3958 pregnant women, 927 by group counselling and 3031 by individual counselling. Acceptance of the test improved with individual counselling, which was already high with group counselling (93.3% versus 89.4%). The return rate for results was independent of the pre-test counselling technique. At post-test session, knowledge about HIV/AIDS was better after group than individual counselling, except for reporting the existence of an asymptomatic stage of HIV infection. At a public health level, group pre-test counselling can be easily integrated into existing sessions of antenatal care counselling, routinely performed by the current clinic staff. Our findings may help programme managers in the field of maternal and child health to choose optimal options of pre-test counselling adapted to local circumstances in resource-poor settings. [ABSTRACT FROM AUTHOR]

The nutritional status of women before pregnancy, during pregnancy, and after delivery has far reaching consequences for maternal health and child survival, growth, and development. In South Asia, the high prevalence of short stature, thinness, and anaemia among women of reproductive age underlie the high prevalence of child undernutrition in the region, whereas overweight and obesity are rising concerns. A systematic review of evidence (2000–2017) was conducted to identify barriers and programme approaches to improving the coverage of maternal nutrition interventions in the region. The search strategy used 13 electronic bibliographic databases and 14 websites of development and technical agencies and identified 2,247 citations. Nine studies conducted in Bangladesh (n = 2), India (n = 5), Nepal (n = 1), and Pakistan (n = 1) were selected for the review, and outcomes included the receipt and consumption of iron and folic acid and calcium supplements and the receipt of information on dietary intake during pregnancy. The studies indicate that a range of barriers acting at the individual (maternal), household, and health service delivery levels affects intervention coverage during pregnancy. Programme approaches that were effective in improving intervention coverage addressed barriers at multiple levels and had several common features: use of formative research and client assessments to inform the design of programme approaches and actions; community‐based delivery platforms to increase access to services; engagement of family members, as well as pregnant women, in influencing behavioural change; actions to improve the capacity, supervision, monitoring, and motivation of front‐line service providers to provide information and counselling; and access to free supplements. [ABSTRACT FROM AUTHOR]

Background: The postpartum period represents a critical window where many maternal and child deaths occur. We assess the quality of postpartum care (PPC) as well as efforts to improve service delivery through additional training and supervision in Health Centers (HCs) in Morogoro Region, Tanzania.Methods: Program implementers purposively selected nine program HCs for assessment with another nine HCs in the region remaining as comparison sites in a non-randomized program evaluation. PPC quality was assessed by examining structural inputs; provider and client profiles; processes (PNC counselling) and outcomes (patient knowledge) through direct observations of equipment, supplies and infrastructure (n = 18) and PPC counselling (n = 45); client exit interviews (n = 41); a provider survey (n = 62); and in-depth provider interviews (n = 10).Results: While physical infrastructure, equipment and supplies were comparable across study sites (with water and electricity limitations), program areas had better availability of drugs and commodities. Overall, provider availability was also similar across study sites, with 63% of HCs following staffing norms, 17% of Reproductive and Child Health (RCH) providers absent and 14% of those providing PPC being unqualified to do so. In the program area, a median of 4 of 10 RCH providers received training. Despite training and supervisory inputs to program area HCs, provider and client knowledge of PPC was low and the content of PPC counseling provided limited to 3 of 80 PPC messages in over half the consultations observed. Among women attending PPC, 29 (71%) had delivered in a health facility and sought care a median of 13 days after delivery. Barriers to PPC care seeking included perceptions that PPC was of limited benefit to women and was primarily about child health, geographic distance, gaps in the continuity of care, and harsh facility treatment.Conclusions: Program training and supervision activities had a modest effect on the quality of PPC. To achieve broader transformation in PPC quality, client perceptions about the value of PPC need to be changed; the content of recommended PPC messages reviewed along with the location for PPC services; gaps in the availability of human resources addressed; and increased provider-client contact encouraged. [ABSTRACT FROM AUTHOR]