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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., (© 2022 The Authors Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Background: The huge proportion of child marriage contributes to high rates of pregnancies among adolescent girls in Bangladesh. Despite substantial progress in reducing maternal mortality in the last two decades, the rate of adolescent pregnancy remains high. The use of skilled maternal health services is still low in Bangladesh. Several quantitative studies described the use of skilled maternal health services among adolescent girls. So far, very little qualitative evidence exists about attitudes and practices related to maternal health. To fill this gap, we aimed at exploring maternal health care-seeking behavior of adolescent girls and their experiences related to pregnancy and delivery in Bangladesh., Methods and Findings: A prospective qualitative study was conducted among thirty married adolescent girls from three Upazilas (sub-districts) of Rangpur district. They were interviewed in two subsequent phases (2014 and 2015). To triangulate and validate the data collected from these married adolescent girls, key informant interviews (KIIs) and focus group discussions (FGDs) were conducted with different stakeholders. Data analysis was guided by the Social-Ecological Model (SEM) including four levels of factors (individual, interpersonal and family, community and social, and organizational and health systems level) which influenced the maternal health care-seeking behavior of adolescent girls. While adolescent girls showed little decision making-autonomy, interpersonal and family level factors played an important role in their use of skilled maternal health services. In addition, community and social factors and as well as organizational and health systems factors shaped adolescent girls' maternal health care-seeking behavior., Conclusions: In order to improve the maternal health of adolescent girls, all four levels of factors of SEM should be taken into account while developing health interventions targeting adolescent girls., Competing Interests: The authors have declared that no competing interests exist.

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]

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]

Background: Contraceptive vaginal rings could play a role in expanding the contraceptive method mix and in preparing communities for the introduction of HIV prevention and multipurpose rings. Methods: We conducted an open label single-centre randomised clinical trial of intermittent versus continuous use of NuvaRing® in Kigali, Rwanda, in 2013–2014. We randomised 120 HIV-negative women 1:1 to intermittent use (three rings with a ring-free week in between rings) or continuous use (four rings without ring-free weeks). Women underwent an interview, counselling, and a speculum examination, and were tested for pregnancy, bacterial vaginosis (BV) by Nugent scoring, yeasts and trichomonads on wet mount, and sexually transmitted infections. Findings: Only one woman withdrew early. Deliberate ring removals were rare, but spontaneous ring expulsions occurred during 14% of ring use periods. There were no incident pregnancies, serious adverse events, serious social harms, or early discontinuations for safety reasons. Systemic side effects were uncommon, and local side effects were not significantly differently distributed between groups except for lower abdominal pain (P = 0.013). The incidence of vaginal yeasts during ring use was high: 22% of intermittent users and 27% of continuous users had incident vaginal yeasts at one or multiple ring removal visits (P = 0.666), and symptomatic vaginal yeast cases were more common in the continuous than intermittent users (P = 0.031). In contrast, mean Nugent scores improved over time in both groups. Conclusions: Intermittent and continuous NuvaRing® use were safe in Rwandan women and improved Nugent scores over time. However, attention should be paid to ring expulsions and to a potential increased risk of vaginal candidiasis. [ABSTRACT FROM AUTHOR]

Background: Bangladesh has the highest rate of adolescent pregnancy in South Asia. Child marriage is one of the leading causes of pregnancies among adolescent girls. Although the country’s contraceptive prevalence rate is quite satisfactory, only 52% of married adolescent girls use contraceptive methods. This qualitative study is aimed at exploring the factors that influence adolescent girls’ decision-making process in relation to contraceptive methods use and childbearing. Methods and Results: We collected qualitative data from study participants living in Rangpur district, Bangladesh. We conducted 35 in-depth interviews with married adolescent girls, 4 key informant interviews, and one focus group discussion with community health workers. Adolescent girls showed very low decision-making autonomy towards contraceptive methods use and childbearing. Decisions were mainly made by either their husbands or mothers-in-law. When husbands were unemployed and financially dependent on their parents, then the mothers-in-law played most important role for contraceptive use and childbearing decisions. Lack of reproductive health knowledge, lack of negotiation and communication ability with husbands and family members, and mistrust towards contraceptive methods also appeared as influential factors against using contraception resulting in early childbearing among married adolescent girls. Conclusions: Husbands and mothers-in-law of newly married adolescent girls need to be actively involved in health interventions so that they make more informed decisions regarding contraceptive use to delay pregnancies until 20 years of age. Misunderstanding and distrust regarding contraceptives can be diminished by engaging the wider societal actors in health intervention including neighbours, and other family members. [ABSTRACT FROM AUTHOR]