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Background: Data dashboards have become more widely used for the public communication of health-related data, including in maternal health., Objective: We aimed to evaluate the content and features of existing publicly available maternal health dashboards in the United States., Methods: Through systematic searches, we identified 80 publicly available, interactive dashboards presenting US maternal health data. We abstracted and descriptively analyzed the technical features and content of identified dashboards across four areas: (1) scope and origins, (2) technical capabilities, (3) data sources and indicators, and (4) disaggregation capabilities. Where present, we abstracted and qualitatively analyzed dashboard text describing the purpose and intended audience., Results: Most reviewed dashboards reported state-level data (58/80, 72%) and were hosted on a state health department website (48/80, 60%). Most dashboards reported data from only 1 (33/80, 41%) or 2 (23/80, 29%) data sources. Key indicators, such as the maternal mortality rate (10/80, 12%) and severe maternal morbidity rate (12/80, 15%), were absent from most dashboards. Included dashboards used a range of data visualizations, and most allowed some disaggregation by time (65/80, 81%), geography (65/80, 81%), and race or ethnicity (55/80, 69%). Among dashboards that identified their audience (30/80, 38%), legislators or policy makers and public health agencies or organizations were the most common audiences., Conclusions: While maternal health dashboards have proliferated, their designs and features are not standard. This assessment of maternal health dashboards in the United States found substantial variation among dashboards, including inconsistent data sources, health indicators, and disaggregation capabilities. Opportunities to strengthen dashboards include integrating a greater number of data sources, increasing disaggregation capabilities, and considering end-user needs in dashboard design., (©Jennifer A Callaghan-Koru, Paige Newman Chargois, Tanvangi Tiwari, Clare C Brown, William Greenfield, Güneş Koru. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 17.09.2024.)

Background: Various data quality issues have prevented healthcare administration data from being fully utilized when dealing with problems ranging from COVID-19 contact tracing to controlling healthcare costs., Objectives: (i) Describe the currently adopted approaches and practices for understanding and improving the quality of healthcare administration data. (ii) Explore the challenges and opportunities to achieve continuous quality improvement for such data., Materials and Methods: We used a qualitative approach to obtain rich contextual data through semi-structured interviews conducted at a state health agency regarding Medicaid claims and reimbursement data. We interviewed all data stewards knowledgeable about the data quality issues experienced at the agency. The qualitative data were analyzed using the Framework method., Results: Sixteen themes emerged from our analysis, collected under 4 categories: (i) Defect characteristics: Data defects showed variability, frequently remained obscure, and led to negative outcomes. Detecting and resolving them was often difficult, and the work required often exceeded the organizational boundaries. (ii) Current process and people issues: The agency adopted primarily ad-hoc, manual approaches to resolving data quality problems leading to work frustration. (iii) Challenges: Communication and lack of knowledge about legacy software systems and the data maintained in them constituted challenges, followed by different standards used by various organizations and vendors, and data verification difficulties. (iv) Opportunities: Training, tool support, and standardization of data definitions emerged as immediate opportunities to improve data quality., Conclusions: Our results can be useful to similar agencies on their journey toward becoming learning health organizations leveraging data assets effectively and efficiently., Competing Interests: Dr Koru owns Maryland Health Information Technology LLC and Maryland Data Science and Engineering LLC. Dr Zhang has no competing interests to declare., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Early recognition of the warning signs of pregnancy-related complications and provision of timely, quality care could prevent many maternal deaths. We piloted a maternal warning signs education intervention with five Maryland-based maternal, infant, and early childhood home visiting programs serving populations disproportionately affected by adverse maternal outcomes. The intervention included a 1.5-hr online training for home visitors, monthly collaborative calls with program managers, and a client education toolkit with a 3-min video, illustrated handout of 15 urgent maternal warning signs, magnet with the same, and discussion guide for home visitor-client interactions. A mixed-methods formative evaluation assessed the acceptability, feasibility, and utilization of different components of the intervention. Home visiting program staff reported that the materials were highly acceptable and easily understood by diverse client populations. They valued the illustrations, simple language, and translation of materials in multiple languages. Program managers found implementation a relatively simple process, feasible for in-person and remote visits. Despite positive reception, not all components of the toolkit were used consistently. Program managers and staff also identified the need for more guidance and tools to help clients communicate with health care providers and advocate for their health care needs. Feedback from pilot sites was used to adapt the training and tools, including adding content on patient self-advocacy. Home visiting programs have a unique ability to engage families during pregnancy and the postpartum period. This pilot offers lessons learned on strategies and tools that home visiting programs can use to improve early recognition and care-seeking for urgent maternal warning signs.

Background: Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA., Methods: This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures., Results: Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research., Conclusions: Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area., (© 2023. The Author(s).)

Background: Maternal mortality rate reviews have identified the need for improved patient education regarding the warning signs of maternal complications to reduce preventable deaths. Maternal and child home visiting programs have the potential to deliver this education in communities., Aims: This study sought to evaluate the baseline provision of warning signs education among home visiting programs in Maryland and to assess the acceptability of and preferences for warning signs education materials among program staff., Materials and Methods: This sequential exploratory, mixed-methods study included qualitative interviews and focus group discussions followed by a web-based survey of all home visiting programs providing early postpartum visits in Maryland., Results: Twenty-five home visiting program staff took part in qualitative data collection, and survey responses were submitted by a manager from 40 of 58 eligible home visiting programs (69% response rate). All survey respondents agreed that home visiting programs should provide warning signs education and more than 80% of programs provided some warning signs education during pregnancy and the postpartum period. Printed pamphlets were provided by 68% of programs for pregnancy complications and 43% for postpartum complications. Only 33% of respondents were satisfied with their existing warnings signs education materials; 98% were interested in new illustrated pamphlets and 88% were interested in education videos. Qualitative participants considered pamphlets with simple designs, limited text, and visuals, as the most accessible for home visiting clients., Conclusions: There are opportunities to strengthen and expand warning signs education in Maryland through home visiting programs using new printed and video education materials., Competing Interests: No competing financial interests exist., (© Jennifer A. Callaghan-Koru et al., 2022; Published by Mary Ann Liebert, Inc.)

Objective: To assess the extent to which hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) to reduce primary cesarean deliveries adopted policy and practice changes and the association of this adoption with state-level cesarean delivery rates., Methods: This prospective evaluation of the MDPQC includes 31 (97%) of the birthing hospitals in the state, which all voluntarily participated in the 30-month collaborative from June 2016 to December 2018. Hospital teams agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. Each hospital's implementation of practices in the bundle was measured through surveys of team leaders at 12 months and 30 months. Half-yearly cesarean delivery rates were calculated from aggregate birth certificate data for each hospital, and differences in rates between the 6 months before the collaborative (baseline) and the 6 months afterward (endline) were tested for statistical significance., Results: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle., Conclusion: The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest. Dr. Ann Burke received funding from her employer, Trinity Health, to complete a pilot usability study of quantification of blood loss using the Gauss Surgical Triton OR Unit., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

There is a well-recognized need for empirical study of processes and factors that influence scale up of evidence-based interventions in low-income countries to address the 'know-do' gap. We undertook a qualitative case study of the scale up of chlorhexidine cleansing of the umbilical cord (CHX) in Bangladesh to identify and compare facilitators and barriers for the institutionalization and expansion stages of scale up. Data collection and analysis for this case study were informed by the Consolidated Framework for Implementation Research (CFIR) and the WHO/ExpandNet model of scale up. At the national level, we interviewed 20 stakeholders involved in CHX policy or implementation. At the district level, we conducted interviews with 31 facility-based healthcare providers in five districts and focus group discussions (FGDs) with eight community-based providers and eight programme managers. At the community level, we conducted 7 FGDs with 53 mothers who had a baby within the past year. Expanded interview notes were thematically coded and analysed following an adapted Framework approach. National stakeholders identified external policy and incentives, and the engagement of stakeholders in policy development through the National Technical Working Committee for Newborn Health, as key facilitators for policy and health systems changes. Stakeholders, providers and families perceived the intervention to be simple, safe and effective, and more consistent with family preferences than the prior policy of dry cord care. The major barriers that delayed or decreased the public health impact of the scale up of CHX in Bangladesh's public health system related to commodity production, procurement and distribution. Bangladesh's experience scaling up CHX suggests that scale up should involve early needs assessments and planning for institutionalizing new drugs and commodities into the supply chain. While the five CFIR domains were useful for categorizing barriers and facilitators, additional constructs are needed for common health systems barriers in low-income settings., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: World Health Organization revised the global guidelines for management of possible serious bacterial infection (PSBI) in young infants to recommend the use of simplified antibiotic therapy in settings where access to hospital care is not possible. The Bangladesh Ministry of Health and Family Welfare (MoHFW), Government of Bangladesh (GOB) adopted these guidelines, allowing treatment at first-level facilities. During the first year of implementation, the Projahnmo Study Group and USAID/MaMoni Health Systems Strengthening (HSS) Project supported the MoHFW to operationalize the new guidelines and conducted an implementation research study in selected districts to assess challenges and identify solutions to facilitate scale-up across the country., Implementation Support: Projahnmo and MaMoni HSS teams supported implementation in three areas: building capacity, strengthening service delivery, and mobilizing communities. Capacity building focused on training paramedics to conduct outpatient management of PSBI cases and developing monitoring and supervision systems. The teams also filled gaps in government supply of essential drugs, equipment, and logistics. Community mobilization strategies to promote care-seeking and referrals to facilities varied across districts; in one district community, health workers made home visits while in another district, the promotion was carried out through community volunteers, village doctors, and through existing community structures., Methods: We followed a plan-do-study-act (PDSA) cycle to identify and address implementation challenges. Three cycles-1 every 4 months-were conducted. We collected data utilizing quantitative and qualitative methods in both the community and facilities. The total sample size for this study was 13,590., Discussion: This article provides implementation research design details for program managers intending to implement new guidelines on management of young infant infections. Results of this research will be reported in the forthcoming papers. Preliminary findings indicate that the management of PSBI cases at the UH&FWCs is feasible. However, MoHFW, GOB needs to address the implementation challenges before scale-up of this policy to the national level.

Objective: To describe the status of implementation of the Alliance for Innovation in Maternal Health's primary cesarean birth patient safety bundle in Maryland after 1 year (2016-2017), and assess whether hospital characteristics and implementation strategies employed are associated with bundle implementation., Methods: The Alliance for Innovation in Maternal Health's bundle to decrease primary cesarean births includes 26 evidence-based practices that hospitals can adopt based on specific needs. One year after the start of a statewide implementation collaborative at 31 of 32 birthing hospitals in Maryland, we sent a computer-based survey to hospital collaborative leaders to assess progress. Respondents reported on hospital characteristics, adoption of bundle practices, and use of 15 selected implementation strategies. We conducted descriptive and bivariate analyses of their responses., Results: Among 26 hospitals with complete reporting, 23 fully implemented at least one bundle practice (range 1-7) during the collaborative's first year. Of 26 bundle practices, on average, hospitals had fully implemented a third (mean 8.6; SD 5.5; range 0-17) before the collaborative, and 3 new practices (SD 2.4; range 0-8) during the collaborative. Hospitals' use of six implementation strategies, all highly dependent on strong clinician involvement, was significantly associated with their fully implementing more practices during the collaborative's first year., Conclusion: Our assessment has promising results, with a majority of hospitals having implemented new cesarean birth bundle practices during the collaborative's first year. However, there are lessons from the wide variability in the number and type of practices adopted. Clinicians should be aware of this variability and become more involved in the implementation of cesarean birth bundle practices. We identified six strategies associated with full implementation of more bundle practices for which clinicians' support and commitment to practice changes are critical. Clinicians' understanding of available and effective implementation strategies can better assist with the implementation of this and other Alliance for Innovation in Maternal Health patient safety bundles.

Background: Ethiopia has one of the lowest rates of facility delivery and is promoting birth preparedness among pregnant women through its community health services to increase the rate of institutional delivery and reduce maternal mortality. Observational studies of birth preparedness in Ethiopia have thus far only reported the marginal effect of birth preparedness when controlling for other factors, such as parity and education., Objectives: In this cross-sectional study, we use propensity score modeling to estimate the average population-level effect of birth preparedness on the likelihood of delivering at a facility., Methods: We conducted secondary analysis of household survey data collected from 215 women with a recent live birth within the catchment areas of 10 semi-urban health centers. A mother was considered well prepared for birth if she reported completing four of the following six actions: identified a skilled provider, identified an institution, saved money, identified transport, prepared clean delivery materials, and prepared food. We performed unadjusted and multivariate logistic regression analyses, with and without propensity score weighting, to assess the relationship between birth preparedness and institutional delivery., Findings: One hundred respondents (47%) delivered in an institution, and over two-thirds (151, 71%) were considered well prepared for birth. Institutional delivery was more common among women who were considered well prepared (57%) versus those who were considered not well prepared (19%). In the model with propensity score weighting, women who were well prepared for birth had 3.83 times higher odds of delivering at a facility (95% CI: 1.41-10.40, p-value = 0.010)., Conclusions: This study contributes to existing evidence supporting the inclusion of antenatal birth preparedness counseling as a part of an antenatal care package for promoting institutional delivery. Important gaps remain in operationalizing the definition of birth preparedness and understanding the pathway from exposure to outcome., Competing Interests: The authors have no competing interests to declare., (© 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.)

Background: Having a medication available in the home is a prerequisite to medication adherence. Our objectives with this study are to assess asthma medication readiness among low-income urban minority preschool-aged children, and the association between beliefs about medications and medication readiness., Methods: During a baseline assessment, a research assistant visited the home to administer a caregiver survey and observe 5 criteria in the medication readiness index: the physical presence and expiration status of medications, the counter status of metered-dose inhalers, and caregiver knowledge of medication type and dosing instructions., Results: Of 288 enrolled children (mean age 4.2 years [SD: 0.7], 92% African American, 60% boys), 277 (96%) of their caregivers reported a rescue medication, but only 79% had it in the home, and only 60% met all 5 of the medication readiness criteria. Among the 161 children prescribed a controller medication, only 79% had it in the home, and only 49% met all 5 readiness criteria. Fewer worries and concerns about medications were associated with higher odds of meeting all 5 readiness criteria for controller medications., Conclusions: Inadequate availability of asthma medications in the home is a barrier to adherence among low-income urban preschoolers. Assessment of medication readiness should be incorporated into clinical care because this is an underrecognized barrier to adherence, and interventions are needed to improve medication management and knowledge to increase adherence., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Aim: To assess the effects of a facility and community newborn intervention package on coverage of early skin-to-skin contact (SSC) and exclusive breastfeeding - the therapeutic components of kangaroo mother care., Methods: A multilevel community and facility intervention in Ethiopia trained health workers in 10 health centres and the surrounding communities to promote early SSC and exclusive breastfeeding for all babies born at home or in the facility. Changes in SSC and exclusive breastfeeding were assessed by comparing baseline and endline household surveys., Results: Overall practice of SSC at any time following delivery increased significantly from 13.1 to 44.1% of mothers. Coverage of immediate SSC also increased significantly from 8.4 to 24.1%. Breastfeeding within the first hour increased from 51.4 to 67.9% and exclusive breastfeeding within the first three days increased from 86 to 95.8%. At endline, SSC was significantly higher among facility births than home births and community health workers had limited contact with mothers., Conclusion: While targeted behaviours improved overall, the programme did not achieve adequate increases in SSC and exclusive breastfeeding among home deliveries to expect a reduction in mortality for low birthweight babies. Newborn care programs in Ethiopia should continue to encourage facility delivery while strengthening coverage of community programmes., (©2016 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Antenatal care (ANC) remains an important contact point on the continuum of care for mothers and children in low- and middle-income countries. In Tanzania, the proportion of pregnant women completing at least four ANC visits (ANC-4) dropped from 70% to 43% between 1999 and 2010. To identify potential causes of the decline in the number of ANC visits, we conducted qualitative research at 18 health centres in Morogoro Region, exploring providers' communication about ANC visits and clients' and providers' perceptions of changes in ANC services and barriers to completing four visits. We also observed counselling messages delivered during 203 ANC consultations. Our results indicate that provider communication about ANC visit recommendations is inadequate, and confusion exists among clients about when and how often they should attend. Participants highlighted how the scale up of Prevention of Mother-to-Child Transmission, with routine human immunodeficiency virus testing for women and their male partners, presents additional barriers for some women. Changes to the timing and content of ANC services following the adoption of the Focused ANC model was described by participants as changing women's perceptions and decisions in how they utilize ANC services. In particular, condensed delivery of technical interventions fostered a sense among clients that multiple visits are unnecessary. Other barriers that may contribute to declining ANC-4 include changing norms about family planning and birth spacing, out-of-pocket costs for clients and informal practices adopted by health facilities and providers such as turning women away who attend early in pregnancy or are not accompanied by male partners. Further research is needed to determine the role and extent that these barriers may be contributing to declining ANC-4. Issues of poor communication, supply inadequacies and informal practices, deserve immediate attention from the health system., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims and Objectives: This study aims to provide insight into key factors from a clinician's perspective that influence uninterrupted early skin-to-skin contact after vaginal and caesarean delivery of healthy full-term infants., Background: Early skin-to-skin contact of healthy full-term infants ideally begins immediately after birth and continues for the first hour or the first breastfeed as recommended by the Baby Friendly Hospital Initiative. However, adoption of early skin-to-skin contact is low in many settings and the barriers that hinder its universal use are not well understood., Design: An exploratory qualitative research design using semi-structured interviews., Methods: Eleven clinicians were interviewed, including five registered nurses and one medical doctor from the obstetrics and gynaecology unit as well as four registered nurses and one medical doctor from the neonatal intensive care unit. Core topics that were discussed included perceptions on early skin-to-skin contact and facilitating factors and barriers to early skin-to-skin contact after vaginal and caesarean delivery. Interview sessions were recorded, transcribed and analysed using a thematic analysis approach. A coding framework was developed from which subthemes emerged. The overall themes were adopted from Lee et al.'s thematic framework to categorise factors into institutional, familial-level and implementation factors., Findings: Critical institutional factors included inadequate staffing and education of clinicians on early skin-to-skin contact. On a familial level, parental education and motivation were identified as important factors. Barriers to implementation included the absence of a clinical algorithm and unclear definitions for eligible mothers and infants., Conclusions: Various facilitating factors and barriers to early skin-to-skin contact of healthy full-term infants born via vaginal and caesarean delivery were identified., Relevance to Clinical Practice: Addressing these factors can help to provide a better understanding of clinician perspectives on early skin-to-skin contact and help guide its implementation as standard of care for healthy full-term infants., (© 2016 John Wiley & Sons Ltd.)

Community-based maternal and newborn care interventions have been shown to improve neonatal survival and other key health indicators. It is important to evaluate whether the improvement in health indicators is accompanied by a parallel increase in the equitable distribution of the intervention activities, and the uptake of healthy newborn care practices. We present an analysis of equity improvements after the implementation of a Community Based Newborn Care Package (CB-NCP) in the Bardiya district of Nepal. The package was implemented alongside other programs that were already in place within the district. We present changes in concentration indices (CIndices) as measures of changes in equity, as well as percentage changes in coverage, between baseline and endline. The CIndices were derived from wealth scores that were based on household assets, and they were compared usingt-tests. We observed statistically significant improvements in equity for facility delivery [CIndex: -0.15 (-0.24, -0.06)], knowledge of at least three newborn danger signs [-0.026(-0.06, -0.003)], breastfeeding within 1 h [-0.05(-0.11, -0.0001)], at least one antenatal visit with a skilled provider [-0.25(-0.04, -0.01)], at least four antenatal visits from any provider [-0.15(-0.19, -0.10)] and birth preparedness [-0.09(-0.12, -0.06)]. The largest increases in practices were observed for facility delivery (50%), immediate drying (34%) and delayed bathing (29%). These results and those of similar studies are evidence that community-based interventions delivered by female community health volunteers can be instrumental in improving equity in levels of facility delivery and other newborn care behaviours. We recommend that equity be evaluated in other similar settings within Nepal in order to determine if similar results are observed., (© The Author 2015. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: Family planning has been shown to be an effective intervention for promoting maternal, newborn and child health. Despite family planning's multiple benefits, women's experiences of - or concerns related to - side effects present a formidable barrier to the sustained use of contraceptives, particularly in the postpartum period. This paper presents perspectives of postpartum, rural, Tanzanian women, their partners, public opinion leaders and community and health facility providers related to side effects associated with contraceptive use., Methods: Qualitative interviews were conducted with postpartum women (n = 34), their partners (n = 23), community leaders (n = 12) and health providers based in both facilities (n = 12) and communities (n = 19) across Morogoro Region, Tanzania. Following data collection, digitally recorded data were transcribed, translated and coded using thematic analysis., Results: Respondents described family planning positively due to the health and economic benefits associated with limiting and spacing births. However, side effects were consistently cited as a reason that women and their partners choose to forgo family planning altogether, discontinue methods, switch methods or use methods in an intermittent (and ineffective) manner. Respondents detailed side effects including excessive menstrual bleeding, missed menses, weight gain and fatigue. Women, their partners and community leaders also described concerns that contraceptives could induce sterility in women, or harm breastfeeding children via contamination of breast milk. Use of family planning during the postpartum period was viewed as particularly detrimental to a newborn's health in the first months of life., Conclusions: To meet Tanzania's national target of increasing contraceptive use from 34 to 60 % by 2015, appropriate counseling and dialogue on contraceptive side effects that speaks to pressing concerns outlined by women, their partners, communities and service providers are needed.

Bangladesh has one of the world's highest rates of low birth weight along with prevalent traditional care practices that leave newborns highly vulnerable to hypothermia, infection, and early death. We conducted formative research to explore existing newborn care practices in rural Bangladesh with an emphasis on thermal protection, and to identify potential facilitators, barriers, and recommendations for the community level delivery of kangaroo mother care (CKMC). Forty in-depth interviews and 14 focus group discussions were conducted between September and December 2012. Participants included pregnant women and mothers, husbands, maternal and paternal grandmothers, traditional birth attendants, village doctors, traditional healers, pharmacy men, religious leaders, community leaders, and formal healthcare providers. Audio recordings were transcribed and translated into English, and the textual data were analyzed using the Framework Approach. We find that harmful newborn care practices, such as delayed wrapping and early initiation of bathing, are changing as more biomedical advice from formal healthcare providers is reaching the community through word-of-mouth and television campaigns. While the goal of CKMC was relatively easily understood and accepted by many of the participants, logistical and to a lesser extent ideological barriers exist that may keep the practice from being adopted easily. Women feel a sense of inevitable responsibility for household duties despite the desire to provide the best care for their new babies. Our findings showed that participants appreciated CKMC as an appropriate treatment method for ill babies, but were less accepting of it as a protective method of caring for seemingly healthy newborns during the first few days of life. Participants highlighted the necessity of receiving help from family members and witnessing other women performing CKMC with positive outcomes if they are to adopt the behavior themselves. Focusing intervention messages on building a supportive environment for CKMC practice will be critical for the intervention's success., (Copyright © 2014. Published by Elsevier Ltd.)

In Tanzania, the coverage of four or more antenatal care (ANC 4) visits among pregnant women has declined over time. We conducted an exploratory analysis to identify factors associated with utilization of ANC 4 and ANC 4 decline among pregnant women over time. We used data from 8035 women who delivered within two years preceding Tanzania Demographic and Health Surveys conducted in 1999, 2004/05 and 2010. Multivariate logistic regression models were used to examine the association between all potential factors and utilization of ANC 4; and decline in ANC 4 over time. Factors positively associated with ANC 4 utilization were higher quality of services, testing and counseling for HIV during ANC, receiving two or more doses of SP (Sulphadoxine Pyrimethamine)/Fansidar for preventing malaria during ANC and higher educational status of the woman. Negatively associated factors were residing in a zone other than Eastern zone, never married woman, reported long distance to health facility, first ANC visit after four months of pregnancy and woman's desire to avoid pregnancy. The factors significantly associated with decline in utilization of ANC 4 were: geographic zone and age of the woman at delivery. Strategies to increase ANC 4 utilization should focus on improvement in quality of care, geographic accessibility, early ANC initiation, and services that allow women to avoid pregnancy. The interconnected nature of the Tanzanian Health System is reflected in ANC 4 decline over time where introduction of new programs might have had unintended effects on existing programs. An in-depth assessment of the recent policy change towards Focused Antenatal Care and its implementation across different geographic zones, including its effect on the perception and understanding among women and performance and counseling by health providers can help explain the decline in ANC 4.

Background: Ethiopia is one of the ten countries with the highest number of neonatal deaths globally, and only 1 in 10 women deliver with a skilled attendant. Promotion of essential newborn care practices is one strategy for improving newborn health outcomes that can be delivered in communities as well as facilities. This article describes newborn care practices reported by recently-delivered women (RDWs) in four regions of Ethiopia., Methods: We conducted a household survey with two-stage cluster sampling to assess newborn care practices among women who delivered a live baby in the period 1 to 7 months prior to data collection., Results: The majority of women made one antenatal care (ANC) visit to a health facility, although less than half made four or more visits and women were most likely to deliver their babies at home. About one-fifth of RDWs in this survey had contact with Health Extension Workers (HEWS) during ANC, but nurse/midwives were the most common providers, and few women had postnatal contact with any health provider. Common beneficial newborn care practices included exclusive breastfeeding (87.6%), wrapping the baby before delivery of the placenta (82.3%), and dry cord care (65.2%). Practices contrary to WHO recommendations that were reported in this population of recent mothers include bathing during the first 24 hours of life (74.7%), application of butter and other substances to the cord (19.9%), and discarding of colostrum milk (44.5%). The results suggest that there are not large differences for most essential newborn care indicators between facility and home deliveries, with the exception of delayed bathing and skin-to-skin care., Conclusions: Improving newborn care and newborn health outcomes in Ethiopia will likely require a multifaceted approach. Given low facility delivery rates, community-based promotion of preventive newborn care practices, which has been effective in other settings, is an important strategy. For this strategy to be successful, the coverage of counseling delivered by HEWs and other community volunteers should be increased.

Background: Inequities in both health status and coverage of health services are considered important barriers to achieving Millennium Development Goal 4. Community-based health promotion is a strategy that is believed to reduce inequities in rural low-income settings. This paper examines the contributions of community-based programming to improving the equity of newborn health in three districts in Malawi., Methods: This study is a before-and-after evaluation of Malawi's Community-Based Maternal and Newborn Care (CBMNC) program, a package of facility and community-based interventions to improve newborn health. Health Surveillance Assistants (HSAs) within the catchment area of 14 health facilities were trained to make pregnancy and postnatal home visits to promote healthy behaviors and assess women and newborns for danger signs requiring referral to a facility. "Core groups" of community volunteers were also trained to raise awareness about recommended newborn care practices. Baseline and endline household surveys measured the coverage of the intervention and targeted health behaviors for this before-and-after evaluation. Wealth indices were constructed using household asset data and concentration indices were compared between baseline and endline for each indicator., Results: The HSAs trained in the intervention reached 36.7% of women with a pregnancy home visit and 10.9% of women with a postnatal home visit within three days of delivery. Coverage of the intervention was slightly inequitable, with richer households more likely to receive one or two pregnancy home visits (concentration indices (CI) of 0.0786 and 0.0960), but not significantly more likely to receive a postnatal visit or know of a core group. Despite modest coverage levels for the intervention, health equity improved significantly over the study period for several indicators. Greater improvements in inequities were observed for knowledge indicators than for coverage of routine health services. At endline, a greater proportion of women from the poorest quintile knew three or more danger signs for pregnancy, delivery, and postpartum mothers than did women from the least poor quintile (change in CI: -0.1704, -0.2464, and -0.4166, respectively; p < 0.05). Equity also significantly improved for coverage of some health behaviors, including delivery at a health facility (change in CI: -0.0591), breastfeeding within the first hour (-0.0379), and delayed bathing (-0.0405)., Conclusions: Although these results indicate promising improvements for newborn health in Malawi, the extent to which the CBMNC program contributed to these improvements in coverage and equity are not known. The strategies through which community-based programs are implemented likely play an important role in their ability to improve equity, and further research and program monitoring are needed to ensure that the poorest households are reached by community-based health programs.

Objective: To assess the quality of care provided by Health Surveillance Assistants (HSAs)-a cadre of community-based health workers-as part of a national scale-up of community case management of childhood illness (CCM) in Malawi., Methods: Trained research teams visited a random sample of HSAs (n = 131) trained in CCM and provided with initial essential drug stocks in six districts, and observed the provision of sick child care. Trained clinicians conducted 'gold-standard' reassessments of the child. Members of the survey team also interviewed caregivers and HSAs and inspected drug stocks and patient registers., Findings: HSAs provided correct treatment with antimalarials to 79% of the 241 children presenting with uncomplicated fever, with oral rehydration salts to 69% of the 93 children presenting with uncomplicated diarrhoea and with antibiotics to 52% of 58 children presenting with suspected pneumonia (cough with fast breathing). About one in five children (18%) presented with danger signs. HSAs correctly assessed 37% of children for four danger signs by conducting a physical exam, and correctly referred 55% of children with danger signs., Conclusion: Malawi's CCM programme is a promising strategy for increasing coverage of sick child treatment, although there is much room for improvement, especially in the correct assessment and treatment of suspected pneumonia and the identification and referral of sick children with danger signs. However, HSAs provided sick child care at levels of quality similar to those provided in first-level health facilities in Malawi, and quality should improve if the Ministry of Health and partners act on the results of this assessment.

Background: National community-based health worker (CBHW) programs often face challenges in ensuring that these remote workers are adequately trained, equipped and supervised. As governments increasingly deploy CBHWs to improve access to primary health care, there is an urgent need to assess how well health systems are supporting CBHWs to provide high quality care., Methods: This paper presents the results of a mixed-methods assessment of selected health systems supports (supervision, drug supply, and job aids) for a national community case management (CCM) program for childhood illness in Malawi during the first year of implementation. We collected data on the types and levels of drug supply and supervision through a cross-sectional survey of a random sample of Health Surveillance Assistants (HSAs) providing CCM services in six districts. We then conducted in-depth interviews and focus group discussions with program managers and HSAs, respectively, to gain an understanding of the barriers and facilitating factors for delivering health systems supports for CCM., Results: Although the CCM training and job aid were well received by stakeholders, HSAs who participated in the first CCM training sessions often waited up to 4 months before receiving their initial supply of drugs and first supervision visits. One year after training began, 69% of HSAs had all essential CCM drugs in stock and only 38% of HSAs reported a CCM supervision visit in the 3 months prior to the survey. Results of the qualitative assessment indicated that drug supply was constrained by travel distance and stock outs at health facilities, and that the initial supervision system relied on clinicians who were able to spend only limited time away from clinical duties. Proactive district managers trained and enrolled HSAs' routine supervisors to provide CCM supervision., Conclusions: Malawi's CCM program is promising, but health systems supports must be improved to ensure consistent coverage and quality. Mixed-methods implementation research provided the Ministry of Health with actionable feedback that it is using to adapt program policies and improve performance.

Community case management (CCM) is a promising task-shifting strategy for expanding treatment of childhood illness that is increasingly adopted by low-income countries. Its success depends in part on how the strategy is perceived by those responsible for its implementation. This study uses qualitative methods to explore health workers' and managers' perceptions about CCM provided by health surveillance assistants (HSAs) during the program's first year in Malawi. Managers and HSAs agreed that CCM contributed beneficially by expanding access to the underserved and reducing caseloads at health facilities. Managers differed among themselves in their endorsements of CCM, most offered constrained endorsement, and a few had stronger justifications for CCM. In addition, HSAs uniformly wanted continued expansion of their clinical role, while managers preferred to view CCM as a limited mandate. The HSAs also reported motivating factors and frustrations related to system constraints and community pressures related to CCM. The impact of CCM on motivation and workload of HSAs is noted and deserves further attention.

Direct observation (DO) with re-examination (RE) by a skilled clinician is a rigorous method for assessing health worker performance, but is not always feasible. We assessed the performance of 131 community health workers in Malawi in community case management of sick children with cough and fast breathing, fever, and diarrhea. We compared estimates of correct treatment measured through DO with RE (n = 382 cases) to DO only (n = 382 cases), register review (n = 1,219 cases), and case scenarios (n = 917 cases). Estimates of correct treatment of uncomplicated fever and diarrhea measured through DO only, register review, and case scenarios were within 9 percentage points of DO with RE estimates, while estimates for uncomplicated cough and fast breathing, and severe illness were substantially higher than DO with RE (12-51 percentage points above the estimate). Those planning for community health worker assessments in community case management can use these results to make an informed choice of methods on the basis of their objectives and the local context.

The Government of Malawi (GoM) initiated activities to deliver treatment of common childhood illnesses (suspected pneumonia, fever/suspected malaria, and diarrhea) in the community in 2008. The service providers are Health Surveillance Assistants (HSAs), and they are posted nationwide to serve communities at a ratio of 1 to 1,000 population. The GoM targeted the establishment of 3,452 village health clinics (VHCs) in hard-to-reach areas by 2011. By September of 2011, 3,296 HSAs had received training in integrated case management of childhood illness, and 2,709 VHCs were functional. An assessment has shown that HSAs are able to treat sick children with quality similar to the quality provided in fixed facilities. Monitoring data also suggest that communities are using the sick child services. We summarize factors that have facilitated the scale up of integrated community case management of children in Malawi and address challenges, such as ensuring a steady supply of medicines and supportive supervision.