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Background: Timely intrapartum referral between facilities is pivotal in reducing maternal/neonatal mortality and morbidity but is distressing to women, resource-intensive and likely to cause delays in care provision. We explored the complexities around referrals to gain understanding of the characteristics, experiences and outcomes of those being transferred.Methods: We used a mixed-method parallel convergent design, in Tanzania and Zambia. Quantitative data were collected from a consecutive, retrospective case-note review (target, n = 2000); intrapartum transfers and stillbirths were the outcomes of interest. A grounded theory approach was adopted for the qualitative element; data were collected from semi-structured interviews (n = 85) with women, partners and health providers. Observations (n = 33) of transfer were also conducted. Quantitative data were analysed descriptively, followed by binary logistic regression models, with multiple imputation for missing data. Qualitative data were analysed using Strauss's constant comparative approach.Results: Intrapartum transfer rates were 11% (111/998; 2 unknown) in Tanzania and 37% (373/996; 1 unknown) in Zambia. Main reasons for transfer were prolonged/obstructed labour and pre-eclampsia/eclampsia. Women most likely to be transferred were from Zambia (as opposed to Tanzania), HIV positive, attended antenatal clinic < 4 times and living > 30 min away from the referral hospital. Differences were observed between countries. Of those transferred, delays in care were common and an increase in poor outcomes was observed. Qualitative findings identified three categories: social threats to successful transfer, barriers to timely intrapartum care and reparative interventions which were linked to a core category: journey of vulnerability.Conclusion: Although intrapartum transfers are inevitable, modifiable factors exist with the potential to improve the experience and outcomes for women. Effective transfers rely on adequate resources, effective transport infrastructures, social support and appropriate decision-making. However, women's (and families) vulnerability can be reduced by empathic communication, timely assessment and a positive birth outcome; this can improve women's resilience and influence positive decision-making, for the index and future pregnancy. [ABSTRACT FROM AUTHOR]

This study assessed a) the impact of playing the Dignity board game on participants' understanding of respectful maternal and newborn care and b) participants' perceptions of how the game influenced their subsequent practice in Malawi and Zambia. Nurse-midwives' poor understanding of respectful maternal and newborn care can lead to substandard practice; thus, effective education is pivotal. Used in several disciplines, game-based learning can facilitate skills acquisition and retention of knowledge. a quasi-experimental study, using mixed-methods of data collection. Data were collected between January and November 2020. Nurse-midwives (N = 122) and students (N = 115) were recruited from public hospitals and nursing schools. Completion of paper-based questionnaires, before and after game-playing, assessed knowledge of respectful care principles and perceptions around behaviours and practice. Face-to-face interviews (n = 18) explored perceived impact of engaging with the game in clinical practice. Paired and unpaired t-test were used to compare scores. Qualitative data were analysed and reported thematically. The study was completed by 215 (90.7 %) participants. Post-test scores improved significantly for both groups combined; from 25.91 (SD 3.73) pre-test to 28.07 (SD 3.46) post-test (paired t = 8.67, 95 % confidence interval 1.67–2.65), indicating an increased knowledge of respectful care principles. Nurse-midwives performed better than students, both before and after. In Malawi, the COVID pandemic prevented a third of nurse-midwives' from completing post-game questionnaires. Qualitative findings indicate the game functioned as a refresher course and helped nurse-midwives to translate principles of respectful care into practice. It was also useful for self-reflection. The Dignity board game has the potential to enhance understanding and practice of respectful maternal and newborn care principles in low-resource settings. Integration into nursing and midwifery curricula and in-service training for students and healthcare workers should be considered. [ABSTRACT FROM AUTHOR]

Background: Communication and interaction with healthcare workers at the time of stillbirth remain in parents' long-term memories and impact on emotional and psychological well-being. Cultural attitudes and norms influence how stillbirth is acknowledged and discussed in society. There is limited evidence on how women from sub-Saharan Africa became aware of the death of their babies. This research explored how women perceived the approach adopted by healthcare workers when the news of their stillbirth was disclosed to them., Methods: Grounded theory study. Women (n = 33) who had birthed a stillborn baby in the preceding 12 months were purposively sampled and participated in in-depth interviews (9 in Zambia, 16 in Tanzania and 8 in Malawi). Informed consent was gained from all participants. Data were analysed via a coding process using constant comparative analysis., Findings: Women sacrificed individualized and personal grieving strategies to conform and behave according to what was expected within their community. An overarching theme of cultural conformity overrides personal grief incorporated four sub-themes: perceiving something was wrong, the unexpected outcome, experience contrasting emotions, bonding with the baby., Discussion and Conclusions: Most participants embarked on a negative 'emotion work' to adapt and suppress emotions and grief due to cultural expectations. Inability to voice the trauma of losing a baby may lead to perinatal mental health issues and needs addressing. Maternity healthcare workers should encourage women to express their feelings and grief. Appropriate training in perinatal bereavement care including good communication, appropriate attitudes and provision of meaningful information to grieving women is recommended., Competing Interests: Conflict of Interest None declared., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Effective antenatal care is fundamental to the promotion of positive maternal and new-born outcomes. International guidance recommends an initial visit in the first trimester of pregnancy, with a minimum of four antenatal visits in total: the optimum schedule being eight antenatal contacts. In low- and middle-income countries, many women do not access antenatal care until later in pregnancy and few have the recommended number of contacts., Aim: To gain understanding of women's antenatal experiences in Tanzania and Zambia, and the factors that influence antenatal engagement., Methods: The study was underpinned by Strauss's grounded theory methodology. Interviews were conducted with 48 women, 16 partners, 21 health care providers and 11 stakeholders, and analysed using constant comparison., Findings: The core category was 'The tipping point of antenatal engagement', supported by four categories: awareness of health benefits, experiential motivators, influential support, and environmental challenges. Although participants recognised the importance of antenatal care to health outcomes, individual motivations and external influences determined attendance or non-attendance. The 'tipping point' for antenatal engagement occurred when women believed that any negative impact could be offset by tangible gain. For some women non-attendance was a conscious decision, for others it was an unchallenged cultural norm., Conclusion: A complex interplay of factors determines antenatal engagement. Short-term modifiable factors to encourage attendance include the development of strategies for increasing respectful care; use of positive women's narratives, and active community engagement. Further research is required to develop innovative, cost-effective care models that improve health literacy and meet women's needs., (Crown Copyright © 2021. Published by Elsevier B.V. All rights reserved.)

Background: Quality of maternal and newborn care is integral to positive clinical, social and psychological outcomes. Respectful care is an important component of this but is suboptimum in many low-income settings. A renewed energy among health professionals and academics is driving an international agenda to eradicate disrespectful health facility care around the globe. However, few studies have explored respectful care from different vantage points., Methods: We used Strauss and Corbin's grounded theory methodology to explore intrapartum experiences in Tanzania and Zambia. In-depth interviews were conducted with 98 participants (48 women, 18 partners, 21 health-providers and 11 key stakeholders), resulting in data saturation. Analysis involved constant comparison, comprising three stages of coding: open, axial and selective. The process involved application of memos, reflexivity and positionality., Results: Findings demonstrated that direct and indirect social discrimination led to inequity of care. Health-providers were believed to display manipulative behaviours to orchestrate situations for their own or the woman's benefit, and were often caring against the odds , in challenging environments. Emergent categories were related to the core category: respectful care, an added extra , which reflects the notion that women did not always expect or receive respectful care, and tolerated poor experiences to obtain services believed to benefit them or their babies. Respectful care was not seen as a component of good quality care, but a luxury that only some receive., Conclusion: Both quality of care and respectful care were valued but were not viewed as mutually inclusive. Good quality treatment (transactional care) was often juxtaposed with disrespectful care; with relational care having a lower status among women and healthcare providers. To readdress the balance, respectful care should be a predominant theme in training programmes, policies and audits. Women's and health-provider voices are pivotal to the development of such interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)