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Lisa M Calhoun,1– 3 Amelia Maytan-Joneydi,1 Abdoul Moumouni Nouhou,4 Lenka Benova,3 Thérèse Delvaux,3 Thomas van den Akker,2,5 Balki Ibrahim Agali,4 Ilene S Speizer1,6 1Carolina Population Center, the University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; 2Athena Institute, Vrije Universiteit, Amsterdam, Netherlands; 3Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; 4GRADE Africa, Niamey, Niger; 5Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Netherlands; 6Department of Maternal and Child Health, Gillings School of Global Public Health, the University of North Carolina at Chapel Hill, Chapel Hill, NC, USACorrespondence: Lisa M Calhoun, Carolina Population Center, the University of North Carolina at Chapel Hill, 123 West Franklin Street, Suite 210, Chapel Hill, NC, 27516, USA, Email lisa_calhoun@unc.eduBackground: 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.Keywords: client satisfaction, family planning, contraception, Niger

Introduction: Digital data systems have the potential to improve data quality and provide individual-level information to understand gaps in the quality of care. This study explored experiences and perceptions of a perinatal eRegistry in two hospitals in Mtwara region, Tanzania. Drawing from realist evaluation and systems thinking, we go beyond a descriptive account of stakeholders' experiences and provide insight into key structural drivers and underlying social paradigms., Methods: We carried out 6 weeks of focused ethnographic observations at the labour wards of the two hospitals and 29 semi-structured qualitative interviews with labour ward staff, as well as with administrative and managerial stakeholders at hospital, district and regional levels. Multi-stage reflexive thematic data analysis was carried out., Results: We provide an in-depth account of the day-to-day functioning of the eRegistry in the two hospitals, including both aspects of positive change and key challenges with its integration into routine documentation duties. Experiences with and perceptions of the eRegistry were inextricably linked to broader systemic constraints relating to staffing, workload and infrastructure. A key underlying theme shaping the way people engaged with the eRegistry was the notion of data ownership: the presence or absence of a feeling of being responsible, involved and in control of data., Conclusion: Some of the key systemic challenges in recording accurate, timely information about women and their babies are not solved by digital tools. Our findings also underline that when healthcare workers feel that data are not primarily for them, they document only for reporting purposes. The eRegistry increased a sense of data ownership among the nurse-midwives directly involved with data entry, but the potential for promoting and supporting data use feedback loops for improvement in care provision remained largely untapped. Our findings highlight the importance of local relevance and ownership in digitisation of routine health information systems., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Growing evidence suggests that extreme heat events affect both pregnant women and their infants, but few studies are available from sub-Saharan Africa. Using data from 138,015 singleton births in 16 hospitals in Benin, Malawi, Tanzania and Uganda, we investigated the association between extreme heat and early perinatal deaths, including antepartum and intrapartum stillbirths, and deaths within 24 h after birth using a time-stratified case-crossover design. We observed an association between an increase from the 75th to the 99th percentile in mean temperature 1 week (lag 0-6 d) before childbirth and perinatal mortality (odds ratio (OR) = 1.34 (95% confidence interval (CI) 1.01-1.78)). The estimates for stillbirths were similarly positive, but CIs included unity: OR = 1.29 (95% CI 0.95-1.77) for all stillbirths, OR = 1.18 (95% CI 0.71-1.95) for antepartum stillbirths and OR = 1.64 (95% CI 0.74-3.63) for intrapartum stillbirths. The cumulative exposure-response curve suggested that the steepest slopes for heat for intrapartum stillbirths and associations were stronger during the hottest seasons. We conclude that short-term heat exposure may increase mortality risks, particularly for intrapartum stillbirths, raising the importance of improved intrapartum care., Competing Interests: Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Objective: To assess stillbirth mortality by Robson ten-group classification and the usefulness of this approach for understanding trends., Design: Cross-sectional study., Setting: Prospectively collected perinatal e-registry data from 16 hospitals in Benin, Malawi, Tanzania and Uganda., Population: All women aged 13-49 years who gave birth to a live or stillborn baby weighting >1000 g between July 2021 and December 2022., Methods: We compared stillbirth risk by Robson ten-group classification, and across countries, and calculated proportional contributions to mortality., Main Outcome Measures: Stillbirth mortality, defined as antepartum and intrapartum stillbirths., Results: We included 80 663 babies born to 78 085 women; 3107 were stillborn. Stillbirth mortality by country were: 7.3% (Benin), 1.9% (Malawi), 1.6% (Tanzania) and 4.9% (Uganda). The largest contributor to stillbirths was Robson group 10 (preterm birth, 28.2%) followed by Robson group 3 (multipara with cephalic term singleton in spontaneous labour, 25.0%). The risk of dying was highest in births complicated by malpresentations, such as nullipara breech (11.0%), multipara breech (16.7%) and transverse/oblique lie (17.9%)., Conclusions: Our findings indicate that group 10 (preterm birth) and group 3 (multipara with cephalic term singleton in spontaneous labour) each contribute to a quarter of stillbirth mortality. High mortality risk was observed in births complicated by malpresentation, such as transverse lie or breech. The high mortality share of group 3 is unexpected, demanding case-by-case investigation. The high mortality rate observed for Robson groups 6-10 hints for a need to intensify actions to improve labour management, and the categorisation may support the regular review of labour progress., (© 2024 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Background: Abortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR)., Methods: We mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals' PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively., Results: Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of abortion-near-miss happening ≥ 24h after presentation was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time., Conclusion: Our comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance., (© 2024. The Author(s).)

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., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Admassu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Despite a remarkable decline, childhood morbidity and mortality in Ethiopia remain high and inequitable. Thus, we estimated the effective coverage of curative child health services in Ethiopia., Design: We conducted a cross-sectional analysis of data from the 2016 Ethiopia Demographic and Health Survey (DHS) and the 2014 Ethiopia Service Provision Assessment Plus (SPA+) survey., Setting: Nationally representative household and facility surveys., Participants and Outcomes: We included a sample of 2096 children under 5 years old (from DHS) who had symptoms of one or more common childhood illnesses (diarrhoea, fever and acute respiratory infection) and estimated the percentage of sick children who were taken to a health facility (crude coverage). To construct a quality index of child health services, we used the SPA+ survey, which was conducted in 1076 health facilities and included observations of care for 1980 sick children and surveys of 1908 mothers/caregivers and 5328 health providers. We applied the Donabedian quality of care framework to identify 58 quality parameters (structure, 31; process, 16; and outcome, 11) and used the weighted additive method to estimate the overall quality of care index. Finally, we multiplied the crude coverage by the quality of care index to estimate the effective coverage of curative child health services, nationally and by region., Results: Among the 2096 sick children, only 38.4% (95% CI: 36.5 to 40.4) of them were taken to a health facility. The overall quality of care was 54.4%, weighted from structure (30.0%), process (9.2%) and outcome (15.2%). The effective coverage of curative child health services was estimated at 20.9% (95%CI: 19.9 to 22.0) nationally, ranging from 16.9% in Somali to 34.6% in Dire Dawa regions., Conclusions: System-wide interventions are required to address both demand-side and supply-side bottlenecks in the provision of child health services if child health-related targets are to be achieved in Ethiopia., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In this study, we present a novel machine learning framework for web server anomaly detection that uniquely combines the Isolation Forest algorithm with expert evaluation, focusing on individual user activities within NGINX server logs. Our approach addresses the limitations of traditional methods by effectively isolating and analyzing subtle anomalies in vast datasets. Initially, the Isolation Forest algorithm was applied to extensive NGINX server logs, successfully identifying outlier user behaviors that conventional methods often overlook. We then employed DBSCAN for detailed clustering of these anomalies, categorizing them based on user request times and types. A key innovation of our methodology is the incorporation of post-clustering expert analysis. Cybersecurity professionals evaluated the identified clusters, adding a crucial layer of qualitative assessment. This enabled the accurate distinction between benign and potentially harmful activities, leading to targeted responses such as access restrictions or web server configuration adjustments. Our approach demonstrates a significant advancement in network security, offering a more refined understanding of user behavior. By integrating algorithmic precision with expert insights, we provide a comprehensive and nuanced strategy for enhancing cybersecurity measures. This study not only advances anomaly detection techniques but also emphasizes the critical need for a multifaceted approach in protecting web server infrastructures.

In Benin maternal mortality remains high at 397 deaths per 100,000 live births, despite 80% of births being attended by skilled birth attendants in health facilities. To identify childbirth practices that potentially contribute to this trend, an ethnographic study was conducted on the use of biomedical and alternative health services along the continuum of maternal care in Allada, Benin. Data collection techniques included in-depth interviews ( N  = 83), informal interviews ( N  = 86), observations ( N  = 32) and group discussions ( N  = 3). Informants included biomedical, spiritual and alternative care providers and community members with a variety of socioeconomic and religious profiles. In Southern Benin alternative and spiritual care, inspired by the Vodoun, Christian or Muslim religions, is commonly used in addition to biomedical care. As childbirth is perceived as a "risky journey to the unknown", these care modalities aim to protect the mother and child from malevolent spirits, facilitate the birth and limit postpartum complications using herbal decoctions and spiritual rites and rituals. These practices are based on mystical interpretations of childbirth that result in the need for additional care during facility-based childbirth. Because such complementary care is not foreseen in health facilities, facility-based childbirth is initiated only at an advanced stage of labour or at the onset of a perceived immediate life-threatening complication for the mother or baby. Programmes and policies to reduce maternal mortality in Benin must seek synergies with alternative providers and practices and consider the complementary and integrated use of alternative and spiritual care practices that are not harmful.

Objectives: This study aims to characterise the physical and psychological well-being of maternal and newborn healthcare workers (MNHCWs) during the COVID-19 pandemic., Design: Observational repeated cross-sectional study., Setting: An online questionnaire was distributed to MNHCWs around the globe in three separate rounds from March 2020 to March 2021., Participants: Total samples of N=1357 (round 1) and N=420 (round 3) primarily consisted of doctors, midwives and nurses in maternal and newborn specialties. Samples represented all WHO regions, with 33% (round 1) and 42% (round 3) from low- or middle-income countries (LMICs)., Primary and Secondary Outcome Measures: Responses from rounds 1 (March-June 2020) and 3 (December 2020-March 2021) were analysed to measure self-reported levels of relative stress and workplace protection from COVID-19, while associated factors were determined through multivariable ordinal logistic regression., Results: In round 1, 90% of MNHCWs reported increased stress levels and 45% reported insufficient personal protective equipment (PPE) access. Nurses and physicians were less likely to report increased stress than midwives at the pandemic onset. Factors associated with increased stress included being female, being from an LMIC and insufficient PPE. In round 3, 75% reported similar or increased stress while 10% reported insufficient PPE. In both rounds, over 50% of MNHCWs felt relatively or completely unprotected from COVID-19 in the workplace. Those from LMICs were more likely to report feeling unprotected, while receiving organisational information that valued safety was associated with better feelings of protection in the workplace., Conclusions: Among our international sample of MNHCWs, we observed high rates of self-reported stress increase at the start of the pandemic with persistence or increase up to a year later. High rates of feeling unprotected persisted even as PPE became more available. These results may inform interventions needed to support and protect MNHCWs during this and future pandemics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The continuum of maternal care along antenatal (ANC), intrapartum and postnatal care (PNC) is fundamental for protecting women's and newborns' health. The COVID-19 pandemic interrupted the provision and use of these essential services globally. This study examines maternal healthcare utilisation along the continuum during the COVID-19 pandemic in the Democratic Republic of the Congo (DRC)., Design: This is a cross-sectional study using data collected on a survey of 599 households in Lubumbashi, DRC, using stratified random sampling., Participants: We included 604 women (15-49 years) who were pregnant between March 2020 and May 2021., Outcome Measures: A structured interview involved questions on sociodemographic characteristics, attitudes regarding COVID-19 and maternal service use and cost. Complete continuum of care was defined as receiving ANC 4+ consultations, skilled birth attendance and at least one PNC check for both mother and newborn. Data were analysed in SPSS using descriptive statistics and multivariable logistic regression., Results: One-third (36%) of women who gave birth during the COVID-19 pandemic completed the continuum of maternal healthcare. Factors significantly associated with completing the continuum included higher education (aOR=2.6; p<0.001) and positive attitude towards the COVID-19 vaccination (aOR=1.9; p=0.04). Reasons for not seeking maternal care included lack of money and avoiding COVID-19 vaccination., Conclusion: During the COVID-19 pandemic, maternal healthcare seeking behaviours were shaped by vaccine hesitancy and care unaffordability in Lubumbashi. Addressing the high cost of maternal healthcare and vaccine hesitancy appear essential to improve access to maternal healthcare., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Caesarean section (CS) rates in women experiencing stillbirth have not been studied with nationally representative data. Two Ghana Maternal Health Surveys (GMHS) have captured pregnancy and mode of birth data for all women including those with stillbirths. We compared CS rates between women with live births and stillbirths, and identified socio-economic and pregnancy-related factors associated with CS in stillbirths., Methods: A population-based cross-sectional study was conducted in a pooled sample of 17 138 women who had given birth within 5 years preceding the 2007 and 2017 GMHS. CS rates were compared between women with stillbirths and very early neonatal deaths (SBVENDs) and women with live births who survived the first day. Bivariate and multivariable logistic regressions explored variables associated with CS. Effect modification of household's wealth and maternal educational level by birth outcome was assessed using multivariable logistic regression with interaction terms., Results: CS rate in women with SBVEND was 19.3% compared with 9.6% in women with live births who survived the first day (rate ratio 2.2; 95% CI 1.6 to 2.9). In multivariable analysis, attaining middle school compared with no formal education (adjusted OR, aOR 2.8; 95% CI 1.1 to 7.1), having had five or more births compared with nulliparity (aOR 3.7; 95% CI 1.3 to 10.7) and reporting prolonged or obstructed labour (aOR 3.3; 95% CI 1.3 to 8.3) were associated with CS in women with SBVEND. Higher household wealth and educational levels were associated with an increased risk of CS in both study groups, with no statistically significant difference in effect., Conclusion: Disaggregating CS rates by birth outcome revealed a high rate among women with SBVEND, twice the overall rate compared with live births. Exclusion of these 'hidden' CSs from rate calculations may lead to underestimation of (inter)national CS rates and potentially conceals CS overuse or misuse., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR)., Methods: We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records' reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity., Results: We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%)., Conclusion: Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings., (© 2023. The Author(s).)

Background: Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA., Methods: We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning., Results: About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had  20,000 women having

Introduction: Maternal mortality remains very high in Sub-Saharan African countries and the risk is higher among adolescent girls. Maternal mortality occurs in these settings mainly around the time of childbirth and the first 24 hours after birth. Therefore, skilled attendance in an enabling environment is essential to reduce the occurrence of adverse outcomes for both women and their children. This study aims to analyze the determinants of facility childbirth among adolescents and young women in Guinea., Methods: We used the Guinea Demographic and Health Survey (DHS) conducted in 2018. All females who were adolescents (15-19) or young women (20-24 years) at the time of their most recent live birth in the five years before the survey were included. We examined the use of health facilities for childbirth and its determinants selected through the Andersen health-seeking model using descriptive analysis and multilevel multivariable logistic regression. All descriptive and analytical estimated were produced by adjusting for the survey sampling using the svy option, including adjustment for clustering, stratification and unequal probability of selection and non-response (individual sample weights). The subpopulation option was also used to account for the variance of estimations., Results: Overall, 58% of adolescents and 57% of young women gave birth in a health facility. Young women were more likely to have used private sector facilities compared to adolescents (p<0.001). Factors significantly associated with a facility birth in multivariable regression included: secondary or higher educational level (aOR = 1.86; 95%CI:1.24-2.78) compared to no formal education; receipt of 1-3 antenatal visits (aOR = 9.33; 95%CI: 5.07-17.16) and 4+ visits (aOR = 16.67; 95%CI: 8.82-31.48) compared to none; living in urban (aOR = 2.50; 95%CI: 1.57-3,98) compared to rural areas. Women from poorest households had lower odds of facility-based childbirth. There was substantial variation in the likelihood of birth in a health facility by region, with highest odds in N'Zérékoré and lowest in Labé., Conclusion: The percentage of births in health facilities among adolescents and young women in Guinea was 58%. This remains suboptimal regarding the challenges associated maternal mortality and morbidity issues in Guinea. Socio-economic characteristics, region of residence and antenatal care use were the main determinants of its use. Efforts to improve maternal health among this group should target care discontinuation between antenatal care and childbirth (primarily by removing financial barriers) and increasing the demand for facility-based childbirth services in communities, while paying attention to the quality and respectful nature of healthcare services provided there., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Grovogui et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: To assess HIV testing uptake and its determinants among adolescents and young adults., Design: Cross-sectional design involving analysis of 2016 Demographic and Health Survey data., Setting: Nationally representative survey of Burundi., Participants: A total of 7218 young women and 2860 young men were included., Primary and Secondary Outcome: We estimated the proportion of adolescent (15-19 years) and young adult (20-24 years) women and men who had tested for HIV and received results in the 12 months preceding the survey. Multivariable logistic models for determining predictors of HIV testing uptake were fitted among respondents aged 15-24 regardless of sexual activity in the 12 months before the survey and separately among a subset that reporting having had sex in the 12 months preceding the survey., Results: An estimated 27.1% (95% CI 25.8% to 28.4%) women and 16.6% (95% CI 15.1% to 18.1%) men had tested for HIV and received results in the 12 months preceding the survey. The proportion was more than twice as high among those aged 20 - 24 years compared with 15 - 19 years, among both sexes. In multivariable analysis, older age (20 - 24 years) was associated with HIV testing (adjusted OR (aOR): 1.62, 95% CI 1.38 to 1.91) among women; (aOR: 1.78, 95% CI 1.32 to 2.40) among men. Higher educational level (aOR: 1.40, 95% CI 1.11 to 1.76) was significantly associated with HIV testing uptake among women. Male circumcision status, condom use, number of sex partners, history of STIs were not associated with HIV testing among the subset that reported having had sex in the 12 months preceding the survey., Conclusion: Despite the interventions implemented to reach the 90-90-90 UNAIDS goals, HIV testing among youth in Burundi was low. Youth-friendly health centres should be part of strategies to stimulate young people to increase uptake of HIV preventive services in Burundi., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Many young women experience important key life transitions during adolescence and early adulthood, such as initiation of sexual activity, first use of contraceptives, marriage, and childbirth. For young women to be able to plan and manage their lives, it is critical to understand how these life events intersect and shape their contraceptive decision-making. This study aims to explore young women's contraceptive method use trajectories, including the factors that influence contraceptive decision-making throughout adolescence and youth., Methodology: In 2019, the Full Access, Full Choice project (FAFC), implemented by the University of North Carolina at Chapel Hill and the African Institute for Development Policy, conducted 30 in-depth interviews with young women aged 18-24 years in three counties in Kenya (Nairobi, Mombasa and Migori). Eligible respondents had used two or more modern contraceptive methods. Interview guides utilized a modified life history approach to capture details about respondents' contraceptive use and life experiences from the time they first used contraception until the time of interview., Results: We identified five separate contraceptive use trajectories based on the occurrence and timing of marriage, childbirth, and contraceptive method choice as well as various influences on contraceptive decision-making. The majority of respondents began their contraceptive journey by using male condoms or emergency contraception, but subsequent contraceptive decisions were varied across trajectories and influenced by different factors. For many women, the initiation of a non-coitally dependent method occurred after the birth of a child; for some, this was the first method used. Once women transitioned to using a non-coitally dependent method such as injectables or implants, many cycled through different methods to find one that had fewer side effects or provided the desired duration of protection., Discussion: This study highlights the nuanced needs of young women throughout their adolescent and youth years in Kenya. This suggests that programs and policies need to encompass young women's diversity of experiences and motivations to best serve them., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Calhoun, Mandal, Onyango, Waga, McGuire, Zulu, van den Akker, Benova, Delvaux and Speizer.)

Background: Maternal and newborn healthcare providers are essential professional groups vulnerable to physical and psychological risks associated with the COVID-19 pandemic. This study uses machine learning algorithms to create a predictive tool for maternal and newborn healthcare providers' perception of being safe in the workplace globally during the pandemic., Methods: We used data collected between 24 March and 5 July 2020 through a global online survey of maternal and newborn healthcare providers. The questionnaire was available in 12 languages. To predict healthcare providers' perception of safety in the workplace, we used features collected in the questionnaire, in addition to publicly available national economic and COVID-19-related factors. We built, trained and tested five machine learning models: Support Vector Machine (SVM), Random Forest (RF), XGBoost, CatBoost and Artificial Neural Network (ANN) for classification and regression. We extracted from RF models the relative contribution of features in output prediction., Results: Models included data from 941 maternal and newborn healthcare providers from 89 countries. ML models performed well in classification and regression tasks, whereby RF had 82% cross-validated accuracy for classification, and CatBoost with 0.46 cross-validated root mean square error for regression. In both classification and regression, the most important features contributing to output prediction were classified as three themes: (1) information accessibility, clarity and quality; (2) availability of support and means of protection; and (3) COVID-19 epidemiology., Conclusion: This study identified salient features contributing to maternal and newborn healthcare providers perception of safety in the workplace. The developed tool can be used by health systems globally to allow real-time learning from data collected during a health system shock. By responding in real-time to the needs of healthcare providers, health systems could prevent potential negative consequences on the quality of care offered to women and newborns., (© 2022. The Author(s).)

The COVID-19 pandemic continues to have substantial impacts on health systems globally. This study describes experiences during the COVID-19 pandemic, and physical, psychological and economic impacts among maternal and newborn healthcare providers. We conducted a global online cross-sectional survey of maternal and newborn healthcare providers. Data collected between July and December 2020 included demographic characteristics, work-related experiences, and physical, psychological, and economic impacts of COVID-19. Descriptive statistics of quantitative data and content analysis of qualitative data were conducted. Findings were disaggregated by country income-level. We analysed responses from 1,191 maternal and newborn healthcare providers from 77 countries: middle-income 66%, high-income 27%, and low-income 7%. Most common cadres were nurses (31%), midwives/nurse-midwives (25%), and obstetricians/gynaecologists (21%). Quantitative and qualitative findings showed that 28% of respondents reported decreased workplace staffing levels following changes in staff-rotation (53%) and staff self-isolating after exposure to SARS-CoV-2 (35%); this led to spending less time with patients, possibly compromising care quality. Reported insufficient access to personal protective equipment (PPE) ranged from 12% for gloves to 32% for N-95 masks. Nonetheless, wearing PPE was tiresome, time-consuming, and presented potential communication barriers with patients. 58% of respondents reported higher stress levels, mainly related to lack of access to information or to rapidly changing guidelines. Respondents noted a negative financial impact-a decrease in income (70% among respondents from low-income countries) concurrently with increased personal expenditures (medical supplies, transportation, and PPE). Negative physical, psychological and economic impacts of COVID-19 on maternal and newborn healthcare providers were ongoing throughout 2020, especially in low-income countries. This can have severe consequences for provision and quality of essential care. There is need to increase focus on the implementation of interventions aiming to support healthcare providers, particularly those in low- and middle-income countries to protect essential health services from disruption., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Kolié et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To assess the implementation of the Maternal and Perinatal Death Surveillance and Response (MPDSR) strategy institutionalized in Benin in 2013 to address the alarmingly high maternal and neonatal death rates., Methods: A retrospective, mixed-methods study was performed. We used all maternal and neonatal death notifications and reviews from 2016 to 2018, reviewed the reports of 63 MPDSR working groups, and held two online group discussions. Descriptive quantitative analysis was performed, and content analysis was applied to qualitative data., Results: Deaths were under-notified, with estimated notification rates at 46%-48% for maternal and 16%-21% for neonatal deaths over the 3 years. Review completion rates were low, corresponding to 50%-56% of maternal and 8%-17% of neonatal deaths. Causes of undernotification included very low notification of community-based and private health facility deaths, and fear of blame. Low review completion rates were due to heavy workload, staffing shortages, fear of blame, and weak leadership. Moreover, reviews were of poor quality and the response was weak., Conclusion: Maternal and Perinatal Death Surveillance and Response is operational in Benin. However, this assessment highlights the need to strengthen the notification strategy, continuously build MPDSR committee members' capacities, engage decision-makers for an effective response, and create a better blame-free, accountable, and learning culture., (© 2021 International Federation of Gynecology and Obstetrics.)

Documenting inpatient care is largely paper-based and it facilitates team communication and future care planning. However, studies show that nursing documentation remains suboptimal especially for newborns, necessitating introduction of standardised paper-based charts. We report on a process of implementing a comprehensive newborn monitoring chart and the perceptions of health workers in a network of hospitals in Kenya. The chart was launched virtually in July 2020 followed by learning meetings with nurses and the research team. This is a qualitative study involving document review, individual in-depth interviews with nurses and paediatricians and a focus group discussion with data clerks. The chart was co-designed by the research team and hospital staff then implemented using a trainer of trainers' model where the nurses-in-charge were trained on how to use the chart and they in turn trained their staff. Training at the hospital was delivered by the nurse-in-charge and/or paediatrician through a combined training with all staff or one-on-one training. The chart was well received with health workers reporting reduced writing, consolidated information, and improved communication as benefits. Implementation was facilitated by individual and team factors, complementary projects, and the removal of old charts. However, challenges arose related to the staff and work environment, inadequate supply of charts, alternative places to document, and inadequate equipment. The participants suggested that future implementation should be accompanied by mentorship or close follow-up, peer experience sharing, training at the hospital and in pre-service institutions and wider stakeholder engagement. Findings show that there are opportunities to improve the implementation process by clarifying roles relating to the filing system, improving the chart supply process, staff induction and specifying a newborn patient file. The chart did not meet the need for supporting documentation of long stay patients presenting an opportunity to explore digital solutions that might provide more flexibility and features., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Muinga et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Significant adjustments to maternity care in response to the COVID-19 pandemic and the direct impacts of COVID-19 can compromise the quality of maternal and newborn care., Aim: To explore how the COVID-19 pandemic negatively affected frontline health workers' ability to provide respectful maternity care globally., Methods: We conducted a global online survey of health workers to assess the provision of maternal and newborn healthcare during the COVID-19 pandemic. We collected qualitative data between July and December 2020 among a subset of respondents and conducted a qualitative content analysis to explore open-ended responses., Findings: Health workers (n = 1127) from 71 countries participated; and 120 participants from 33 countries provided qualitative data. The COVID-19 pandemic negatively affected the provision of respectful maternity care in multiple ways. Six central themes were identified: less family involvement, reduced emotional and physical support for women, compromised standards of care, increased exposure to medically unjustified caesarean section, and staff overwhelmed by rapidly changing guidelines and enhanced infection prevention measures. Further, respectful care provided to women and newborns with suspected or confirmed COVID-19 infection was severely affected due to health workers' fear of getting infected and measures taken to minimise COVID-19 transmission., Discussion: Multidimensional and contextually-adapted actions are urgently needed to mitigate the impacts of the COVID-19 pandemic on the provision and continued promotion of respectful maternity care globally in the long-term., Conclusions: The measures taken during the COVID-19 pandemic had the capacity to disrupt the provision of respectful maternity care and therefore the quality of maternity care., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Routine postnatal care (PNC) allows monitoring, early detection and management of complications, and counselling to ensure immediate and long-term wellbeing of mothers and newborns; yet effective coverage is sub-optimal globally. The COVID-19 pandemic disrupted availability and quality of maternal and newborn care despite established guidelines promoting continuity of essential services. We conducted a cross-sectional global online survey of 424 maternal and newborn healthcare providers from 61 countries, to explore PNC provision, availability, content and quality following the early phase of the COVID-19 pandemic. The questionnaire (11 languages), included four multiple-choice and four open-text questions on changes to PNC during the pandemic. Quantitative and qualitative responses received between July and December 2020 were analysed separately and integrated during reporting. Tightened rules for visiting postpartum women were reported in health facilities, ranging from shorter visiting hours to banning supportive companions and visitors. A quarter (26%) of respondents reported that mothers suspected/confirmed with COVID-19 were routinely separated from their newborns. Early initiation of breastfeeding was delayed due to waiting for maternal SARS-CoV-2 test results. Reduced provision of breastfeeding support was reported by 40% of respondents in high-income countries and 7% in low-income countries. Almost 60% reported that women were discharged earlier than usual and 27% perceived a reduction in attendance to outpatient PNC. Telemedicine and home visits were mostly reported in high-income countries to ensure safe care provision. Beyond the early phase of the COVID-19 pandemic, severe disruptions to content and quality of PNC continued to exist, whereas disruptions in availability and use were less commonly reported. Depriving women of support, reducing availability of PNC services, and mother-newborn separation could lead to negative long-term outcomes for women, newborns and families, and deny their rights to respectful care. Protecting these essential services is imperative to promoting quality woman-centred PNC during and beyond the pandemic., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Semaan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Despite a strong evidence base for developing interventions to reduce child mortality and morbidity related to pregnancy and delivery, major knowledge-implementation gaps remain. The Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project aims to overcome these gaps through strengthening the capacity of multidisciplinary teams that provide maternity care. The intervention includes competency-based midwife training, community engagement for study design, mentoring and quality improvement cycles. The realist process evaluation of ALERT aims at identifying and testing the causal pathway through which the intervention achieves its impact., Methods and Analysis: This realist process evaluation complements the effectiveness evaluation and the economic evaluation of the ALERT intervention. Following the realist evaluation cycle, we will first elicit the initial programme theory on the basis of the ALERT theory of change, a review of the evidence on adoption and diffusion of innovations and the perspectives of the stakeholders. Second, we will use a multiple embedded case study design to empirically test the initial programme theory in two hospitals in each of the four intervention countries. Qualitative and quantitative data will be collected, using in-depth interviews with hospital staff and mothers, observations, patient exit interviews and (hospital) document reviews. Analysis will be guided by the Intervention-Actors-Context-Mechanism-Outcome configuration heuristic. We will use thematic coding to analyse the qualitative data. The quantitative data will be analysed descriptively and integrated in the analysis using a retroductive approach. Each case study will end with a refined programme theory (in-case analysis). Third, we will carry out a cross-case comparison within and between the four countries. Comparison between study countries should enable identifying relevant context factors that influence effectiveness and implementation, leading to a mid-range theory that may inform the scaling up the intervention., Ethics and Dissemination: In developing this protocol, we paid specific attention to cultural sensitivity, the do no harm principle, confidentiality and non-attribution. We received ethical approval from the local and national institutional review boards in Tanzania, Uganda, Malawi, Benin, Sweden and Belgium. Written or verbal consent of respondents will be secured after explaining the purpose, potential benefits and potential harms of the study using an information sheet. The results will be disseminated through workshops with the hospital staff and national policymakers, and scientific publications and conferences., Trial Registration Number: PACTR202006793783148., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Lactational mastitis is an extremely painful and distressing inflammation of the breast, which can seriously disrupt breastfeeding. Most of the evidence on the frequency of this condition and its risk factors is from high-income countries. Thus, there is a crucial need for more information on lactational mastitis and its associated factors in Sub-Saharan Africa (SSA)., Methods: We used data from representative, community-based cross-sectional household surveys conducted in 2020 with 3,315 women from four countries (Ethiopia, Kenya, Malawi, and Tanzania) who reported ever-breastfeeding their last child born in the two years before the survey. Our measure of lactational mastitis was self-reported and defined using a combination of breast symptoms (breast redness and swelling) and flu-like symptoms (fever and chills) experienced during the breastfeeding period. We first estimated country-specific and pooled prevalence of self-reported lactational mastitis and examined mastitis-related breastfeeding discontinuation. Additionally, we examined factors associated with reporting mastitis in the pooled sample using bivariate and multivariable logistic regression accounting for clustering at the country level and post-stratification weights., Results: The prevalence of self-reported lactational mastitis ranged from 3.1% in Ethiopia to 12.0% in Kenya. Close to 17.0% of women who experienced mastitis stopped breastfeeding because of mastitis. The adjusted odds of self-reported lactational mastitis were approximately two-fold higher among women who completed at least some primary school compared to women who had no formal education. Study participants who delivered by caesarean section had 1.46 times higher odds of reporting lactational mastitis than women with a vaginal birth. Despite wide confidence intervals, our models also indicate that young women (15 - 24 years) and women who practiced prelacteal feeding had higher odds of experiencing lactational mastitis than older women (25 + years) and women who did not give prelacteal feed to their newborns., Conclusions: The prevalence of lactational mastitis in four countries of SSA might be somewhat lower than estimates reported from other settings. Further studies should explore the risk and protective factors for lactational mastitis in SSA contexts and address its negative consequences on breastfeeding., (© 2022. The Author(s).)