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The aim of this study was to describe perceptions of maternal referrals in a rural district in Tanzania. Focus group discussions (FGDs) with health workers and community members, stratified by age and gender, were conducted. The FGDs revealed that husbands and relatives are the decision makers in maternal referrals, whereas the women had limited influence, especially on emergency referrals. The process in deciding to seek referral care is envisaged within community perception of seriousness of the condition, difficulty to access and cost involved in transport, living expenses at the hospital, and perceived quality of care at facility level. The hospitals were seen as providing acceptable quality of care, whereas, the health centres had lower quality than expected. To improve maternal referral compliance and reduce perinatal and maternal morbidity and mortality, community views of existing referral guidelines, poverty reduction, women's empowerment and male involvement in maternal care are necessary. [ABSTRACT FROM AUTHOR]

Background: Postpartum depression (PPD) affects approximately 17% of the women worldwide with nearly half of all cases going undetected. More research on maternal mental health, particularly among healthcare professionals and pregnant mothers, could help identify PPD risks and reduce its prevalence., Objective: Given that awareness of PPD is a crucial preventive factor, we studied PPD awareness among midwives and pregnant women in Arkhangelsk, Arctic Russia., Methods: A qualitative study was conducted using in-depth semi-structured interviews. Midwives and pregnant women were recruited from the women's clinic of the Arkhangelsk municipal polyclinic. Seven midwives and 12 pregnant mothers were interviewed., Results: Midwives described limited time for psychological counselling of pregnant women; they reported that their primary focus was on the physiological well-being of women. Pregnant women have expressed a desire for their families to share responsibilities. The participants considered PPD as a mix of psychological and physiological symptoms, and they also highlighted a discrepancy between the expectations of pregnant women and the reality of motherhood. The present study underscored the limited understanding of PPD identification., Conclusions: The findings suggest that there is a need for increased awareness among midwives and pregnant women regarding PPD. Prevention programs targeting PPD with a specific emphasis on enhancing maternal mental health knowledge are warranted.

Background: All Nepalese citizens have the right to high-quality healthcare services free of charge. To achieve this, healthcare services for the rural population in Nepal need to be improved in terms of personnel, medicines, and medical equipment., Objectives: To explore challenges and possible improvements healthcare personnel experience when travelling to rural parts of Nepal to provide healthcare., Method: Data was collected from various health professionals using focus group discussions at Dhulikhel Hospital in Nepal. The data were transcribed and analysed using Systematic text condensation., Results: Twenty-two professional healthcare personnel participated in five group discussions. Four categories emerged from the collected material: Finding ORC services being underutilised, Wanting to fulfil tasks and do a good job, Facing inadequate resources, and Seeing the need for improved organisation and cooperation. There was consensus that rural clinics are important to maintaining health for the rural population of Nepal. However, there was frustration that the rural population was not benefitting from all available healthcare services due to underutilisation., Conclusion: Rural healthcare clinics are not utilised appropriately, according to healthcare workers at the rural outreach clinics. Potential ways of overcoming the perceived challenges of underutilising available healthcare services include financial and human resources. The rural population´s health awareness needs to be increased, and the work environment for rural healthcare workers needs to be improved. These issues need to be prioritised by the government and policymakers.

Background: Approximately 15 million children are born each year prematurely, representing more than 10 percent of all childbirths worldwide. Prematurity is an acute event and the leading cause of death among newborns and children under five. Sixty percent of these premature deaths occur in Sub-Saharan Africa and Southeast Asia., Objective: The current study aimed to explore and understand women's experiences and perceptions regarding giving birth prematurely at the National Hospital of Muhimbili in Dar es Salaam, Tanzania., Method: A qualitative method, using Interpretive Phenomenological Analysis approach was chosen to understand and describe the women's experiences. A semi-structured guide was used during the interviews. All interviews were audio-recorded and transcribed verbatim., Findings: Eight in-depth interviews were conducted. The analysis revealed three superordinate themes: (a) Emotional turmoil: unmet expectations shattering maternal identity, emotional distress, and loss of hope; (b) Adapting to preterm birth and challenges: the unexpected situation, lack of proper care, strenuous breastfeeding routines, and socioeconomic challenges; (c) Significance of proper care and emotional support: good maternal care, mother-to-mother and family support., Conclusion: This study provided a deeper understanding of women's experiences and perceptions of premature childbirth. The current study indicated the importance of caregivers' awareness of the women's emotional distress, their need to adapt to a sudden unexpected situation, and the necessity of emotional support., (© 2024 Habtu TA et al.)

Background: Pneumonia is a severe infection and one of the most common causes of mortality among children under five years of age, when not appropriately managed. Infection of the lungs by bacteria, viruses, or fungi and consequent inflammation may lead to cough and difficult breathing. Some of the key predisposing factors are malnutrition and air pollution. WHO reports that Africa has the highest burden of global child mortality, and 16% of all deaths in pneumonia, were children under five years of age in 2016., Objectives: This study aimed to explore how health providers perceive pneumonia as a cause of under-five mortality in Nigeria., Methods: A qualitative study design with in-depth interviews and focus group discussions was used to explore and understand nurses and pediatricians' views regarding the pneumonia situation, vaccinations, and preventive suggestions to reduce under five pneumonia deaths in Nigeria., Results: Two themes and four categories emerged: participant's anxiety over the situation, their views on impediments, current policies and strategies, and suggestions on addressing severe pneumonia., Conclusions: The results from this study highlight contextual issues playing major roles in pneumonia mortality among children in Nigeria, which will need approaches on several levels to address them., (© 2023 Okafor C et al.)

Background Violence against women and girls is frequent, a third of all women is estimated to experience violence in their lifetime and mostly by an intimate partner. Women in Southeast Asia are most affected, and previous studies in Nepal found that one in five women had experiences of domestic violence, including being afraid of someone in the family. Objective To investigate women's attitudes to domestic violence and their emotional distress, in a specific group of pregnant women. Method Validated questions from the WHO multi-country study on women's health and experiences of domestic violence, and questions from the Hopkins Symptom Checklist (HSCL-5), measuring depression and anxiety, were used. Women could answer anonymously by hearing questions in a headset and touching a tablet screen, for 'yes' or 'no'. Result In total 1011 pregnant women participated in the research and 240 women admitted being exposed to domestic violence (23.7%). These women had a more accepting attitude to violence compared to non-violence exposed women. They agreed more that the husband had good reasons to hit his wife, if she does not complete the household work to his satisfaction, she disobeys or refuses to have sex with him. Violence exposed women also reported more emotional distress and subsequently reduced wellbeing. They admitted worrying too much, feelings of hopelessness, feeling blue, fearful, or nervous. Conclusion The present study found that the pregnant Nepali women having an accepting attitude to violence suffer from emotional distress.

Background: Medical device development is an area facing multiple challenges, resulting in a high number of products not reaching the clinical setting. Neonatal hyperbilirubinemia, manifesting as neonatal jaundice (NNJ), is an important cause of newborn morbidity and mortality. It is important to identify infants with neonatal hyperbilirubinemia at an early stage, but currently there is a lack of tools that are both accurate and affordable., Objective: This study aimed to develop a novel system to assess the presence of NNJ. The device should provide accurate results, be approved as a medical device, be easy to use, and be produced at a price that is affordable even in low-resource settings., Methods: We used an iterative approach to develop a smartphone-based system to detect the presence of NNJ. We performed technical development, followed by clinical and usability testing in parallel, after which we initiated the regulatory processes for certification. We updated the system in each iteration, and the final version underwent a clinical validation study on healthy term newborns aged 1 to 15 days before all documentation was submitted for conformity assessment to obtain Conformité Européenne (CE) certification. We developed a system that incorporates a smartphone app, a color calibration card, and a server., Results: Three iterations of the smartphone-based system were developed; the final version was approved as a medical device after complying with Medical Device Regulation guidelines. A total of 201 infants were included in the validation study. Bilirubin values using the system highly correlated with total serum or plasma bilirubin levels (r=0.84). The system had a high sensitivity (94%) to detect severe jaundice, defined as total serum or plasma bilirubin >250 µmol/L, and maintained a high specificity (71%)., Conclusions: Our smartphone-based system has a high potential as a tool for identifying NNJ. An iterative approach to product development, conducted by working on different tasks in parallel, resulted in a functional and successful product. By adhering to the requirements for regulatory approval from the beginning of the project, we were able to develop a market-ready mobile health solution., (©Anders Aune, Gunnar Vartdal, Gabriela Jimenez Diaz, Lobke Marijn Gierman, Håkon Bergseng, Elisabeth Darj. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org), 28.02.2023.)

Background: Abortion-related complications are among the common causes of maternal mortality in Malawi. Misoprostol is recommended for the treatment of first-trimester incomplete abortions but is seldom used for post-abortion care in Malawi., Methods: A descriptive cross-sectional study that used mixed methods was conducted in three hospitals in central Malawi. A survey was done on 400 women and in-depth interviews with 24 women receiving misoprostol for incomplete abortion. Convenience and purposive sampling methods were used and data were analysed using STATA 16.0 for quantitative part and thematic analysis for qualitative part., Results: From the qualitative data, three themes emerged around the following areas: experienced effects, support offered, and women's perceptions. Most women liked misoprostol and reported that the treatment was helpful and effective in expelling retained products of conception. Quantitative data revealed that the majority of participants, 376 (94%) were satisfied with the support received, and 361 (90.3%) believed that misoprostol was better than surgical treatment. The majority of the women 364 (91%) reported they would recommend misoprostol to friends., Conclusions: The use of misoprostol for incomplete abortion in Malawi is acceptable and regarded as helpful and satisfactory among women., (© 2023. The Author(s).)

Objectives: The study was conducted to determine effectiveness of a training intervention in increasing use of misoprostol in management of incomplete abortions., Design: A quasi-experimental study with training intervention on use of misoprostol in treatment of incomplete abortion., Setting: Five secondary-level public hospitals in Malawi, one in urban and four in semiurban settings. Three intervention and two control sites., Participants: Records of women treated for first-trimester incomplete abortion from March to May 2020 (baseline) and April to June 2021 (endline). Clinical data were collected from 865 records, 421 before and 444 after the intervention in all study sites., Intervention: Three-hour theoretical training sessions for 81 healthcare workers were conducted in July 2020 at the three intervention sites., Primary and Secondary Outcome Measures: Proportion of women with incomplete abortion treated with misoprostol before and after the intervention. The proportion of women treated with sharp curettage at the study sites., Results: At the intervention sites, there was a significant increase in use of misoprostol from 22.8% (95% CI 17.9% to 28.0%) to 35.9% (95% CI 30.5% to 41.6%) and significant reduction in use of sharp curettage from 48.1% (95% CI 41.9% to 54.3%) to 39.4% (95% CI 35.3% to 42.6%) p<0.01 at baseline and endline, respectively. The use of misoprostol was significantly higher at the intervention sites with OR of 5.02 (95% CI 1.7 to 14.7) p<0.05 compared with control sites at the endline in multivariable models, and there was a difference in the difference of 14.4% ((95% CI 10.4% to 18.2%) p<0.001) between the intervention and control sites after the intervention., Conclusions: A training intervention effectively increased the use of misoprostol in the treatment of incomplete abortions. Increasing misoprostol use will make treatment of incomplete abortion cheaper, easier and more easily accessible. Making quality postabortion care accessible to more women may reduce maternal morbidity and mortality. Further training interventions are recommended., 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: In Malawi, abortion is only legal to save a pregnant woman's life. Treatment for complications after unsafe abortions has a massive impact on the already impoverished health care system. Even though manual vacuum aspiration (MVA) and misoprostol are the recommended treatment options for incomplete abortion in the first trimester, surgical management using sharp curettage is still one of the primary treatment methods in Malawi. Misoprostol and MVA are safer and cheaper, whilst sharp curettage has more risk of complications such as perforation and bleeding and requires general anesthesia and a clinician. Currently, efforts are being made to increase the use of misoprostol in the treatment of incomplete abortions in Malawi. To achieve successful implementation of misoprostol, health care providers' perceptions on this matter are crucial., Methods: A qualitative approach was used to explore health care providers' perceptions of misoprostol for the treatment of incomplete abortion using semi-structured in-depth interviews. Ten health care providers were interviewed at one urban public hospital. Each interview lasted 45 min on average. Health care providers of different cadres were interviewed in March and April 2021, nine months after taking part in a training intervention on the use of misoprostol. Interviews were recorded, transcribed verbatim and analyzed using 'Systematic Text Condensation'., Results: The health care providers reported many advantages with the increased use of misoprostol, such as reduced workload, less hospitalization, fewer infections, and task-shifting. Availability of the drug and benefits for the patients were also highlighted as important. However, some challenges were revealed, such as deciding who was eligible for the drug and treatment failure. For these reasons, some health care providers still choose surgical treatment as their primary method., Conclusion: Findings in this study support the recommendation of increased use of misoprostol as a treatment for incomplete abortion in Malawi, as the health care providers interviewed see many advantages with the drug. To scale up its use, proper training and supervision are essential. A sustainable and predictable supply is needed to change clinical practice. Unsafe abortion is a major contributor to maternal mortality worldwide. Unsafe abortion is the termination of an unintended pregnancy by a person without the required skills or equipment, which might lead to serious complications. In Malawi, post-abortion complications are common, and the maternal mortality ratio is among the highest in the world. Retained products of conception, referred to as an incomplete abortion, are common after spontaneous miscarriages and unsafe induced abortions. There are several ways to treat incomplete abortion, and the drug misoprostol has been successful in the treatment of incomplete abortion in other low-income countries. This study explored perceptions among health care providers using misoprostol to treat incomplete abortions and whether the drug can be fully embraced by Malawian health care professionals. Health personnel at a Malawian hospital were interviewed individually regarding the use of the drug for treating incomplete abortions. This study revealed that health care providers interviewed are satisfied with the increased use of misoprostol. They highlighted several benefits, such as reduced workload and that it enabled task-shifting so that various hospital cadres could now treat patients with incomplete abortions. The health care workers also observed benefits for women treated with the drug compared to other treatments. The challenges mentioned were finding out who was eligible for the drug and drug failure. This study supports scaling up the use of misoprostol in the treatment of incomplete abortions in Malawi; the Ministry of Health and policymakers should support future interventions to increase its use., (© 2022. The Author(s).)

The aim of the study was to investigate previous PhD students' views on the Norwegian Research School of Global Health and its activities. Of the research schools for PhD students, few focus on global health and even fewer have evaluated the students' perspectives of the schools. In this study, a questionnaire including quantitative and qualitative questions were sent to alumni PhD students. Demographic status was investigated, along with the alumni's views on activities offered at the research school, suggestions for improvement, views on his or her social life as a student and as a member of the school. A total of 60 alumni were contacted by email and invited to participate in an anonymous online survey. The response rate was 65%; 90% were in employment and a few were seeking employment. All research school activities were evaluated as useful. Content analysis of qualitative questions generated three categories of the alumni's reflections on their involvement in the research school: valued activities, challenges, and future. The alumni expressed a wish for continued contact with the school. The findings indicated that a research school for PhD students with similar interests should be continued; although modifications should be considered, based on the specific challenges revealed in the evaluation.

Complications after abortion are a major cause of maternal death. Incomplete abortions are common and require treatment with surgical or medical uterine evacuation. Even though misoprostol is a cheaper and safer option, it is rarely used in Malawi. To improve services, an intervention was performed to increase the use of misoprostol in post-abortion care. This study explored healthcare providers' perceptions and experiences with misoprostol in the Malawian setting and their role in achieving effective implementation of the drug. A descriptive phenomenological study was conducted in three hospitals in central Malawi. Focus group discussions were conducted with healthcare workers in centres where the training intervention was offered. Participants were purposefully sampled, and thematic analysis was done. Most of the healthcare workers were positive about the use of misoprostol, knew how to use it and were confident in doing so. The staff preferred misoprostol to surgical treatment because it was perceived safe, effective, easy to use, cost-effective, had few complications, decreased hospital congestion, reduced workload, and saved time. Additionally, misoprostol was administered by nurses/midwives, and not just physicians, thus enhancing task-shifting. The results showed acceptability of misoprostol in post-abortion care among healthcare workers in central Malawi, and further implementation of the drug is recommended.

Malawi is a low-income country with a high maternal mortality rate. This study aimed to investigate the use of contraception and factors associated with unmet need of family planning among fertile women in selected health facilities in southern Malawi. A cross-sectional study design was employed using a validated questionnaire to investigate the unmet need. A total of 419 pregnant women, who attended antenatal clinics at a central hospital and two district hospitals, voluntarily participated in the study. Logistic regression analysis was used to identify possible factors associated with unmet needs. Amongst the participants, 15.1% reported unmet need, 27.0% had never used a contraceptive method, and 27.2% had an unwanted pregnancy. Being married, 20-24 years of age, living in a rural area, and high parity were protective factors against having unmet need regarding family planning. Malawi, a country with a young population and a high fertility rate, has a high level of unmet family planning need. Barriers and facilitators need to be identified and addressed at different levels by the health care system, society, and the government of Malawi.

Background: There is significant evidence of the prevalence and factors associated with domestic violence in high and low-income country settings. However, men's views on domestic violence are still understudied and have never been reported in Nepali society., Objective: The aim of the study was to explore Nepali men's perceptions regarding domestic violence in their communities., Method: The authors undertook a qualitative study using focus group discussions., Results: Sixty-six married men, considered they were responsible for upholding family discipline and physically demonstrating their masculinity, and they suggested that violence was a mean for achieving this. Men's frustration when unable to fulfil their family's expectations or material needs, and cultural attitudes that precluded interference in other families' lives, were perceived as factors contributing to domestic violence. The men held the opinion that women also perpetrated domestic violence. Some men were reluctant to accept domestic violence as a norm in Nepali families and were aware of recent changes in societal expectations regarding gender roles., Conclusion: Overall, the Nepali men who participated in the study held different and sometimes opposing views on domestic violence, ranging from violence justified as a necessity for family discipline, uneasy acceptance that violence was commonplace in families, to definite opposition to the use of domestic violence. The study's findings provide information for identifying points of intervention for violence-prevention efforts and strategies to alter the social and cultural norms that lead to acceptance of domestic violence.

Aim: Neonatal jaundice is an important cause of morbidity and mortality, and identifying the condition remains a challenge. This study evaluated a novel method of estimating bilirubin levels from colour-calibrated smartphone images., Methods: A cross-sectional prospective study was undertaken at two hospitals in Norway from February 2017 to March 2019, with standardised illumination at one hospital and non-standardised illumination at the other hospital. Healthy term-born infants with a normal birthweight were recruited up to 15 days of age. The main outcome measures were bilirubin estimates from digital images, plus total bilirubin in serum (TSB) and transcutaneous bilirubin (TcB)., Results: Bilirubin estimates were performed for 302 newborn infants, and 76 had severe jaundice. The correlation between the smartphone estimates and TSB was measured by Pearson's r and was .84 for the whole sample. The correlation between the image estimates and TcB was 0.81. There were no significant differences between the hospitals. Sensitivity was 100%, and specificity was 69% for identifying severe jaundice of more than 250 µmol/L., Conclusion: A smartphone-based tool that estimated bilirubin levels from digital images identified severe jaundice with high sensitivity and could provide a screening tool for neonatal jaundice., (© 2020 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Global microarray gene expression analyses previously demonstrated differences in female and male embryos during neurodevelopment. In particular, before sexual maturation of the gonads, the differences seem to concentrate on the expression of genes encoded on the X- and Y-chromosomes. To investigate genome-wide differences in expression during this early developmental window, we combined high-resolution RNA sequencing with qPCR to analyze brain samples from human embryos during the first trimester of development. Our analysis was tailored for maximum sensitivity to discover Y-chromosome gene expression, but at the same time, it was underpowered to detect X-inactivation escapees. Using this approach, we found that 5 out of 13 expressed gametolog pairs showed unbalanced gene dosage, and as a consequence, a male-biased expression. In addition, we found six novel non-annotated long non-coding RNAs on the Y-chromosome with conserved expression patterns in newborn chimpanzee. The tissue specific and time-restricted expression of these long non-coding RNAs strongly suggests important functions during central nervous system development in human males., (Copyright © 2019 Johansson, Pottmeier, Suciu, Ahmad, Zaghlool, Halvardson, Darj, Feuk, Peuckert and Jazin.)

Objectives: Despite being preventable, cervical cancer remains the most common cancer among women in Nepal, a country where there is no nationwide screening programme. Hence, the objective was to investigate and better understand Nepali women's perceptions on barriers to participation in cervical cancer screening and what might facilitate their participation., Methods: A qualitative study design with focus group discussions was employed and women were purposively invited. The interviews were tape-recorded, transcribed verbatim, and analysed using manifest content analysis., Findings: Women had misconceptions about the screening and low levels of knowledge. Sociocultural barriers, service providers' behaviour, geographical challenges, and limited finances were all perceived as obstacles to attending screening centres. Facilitating factors, such as participation in awareness programmes and support from family and women's groups, may convince women to attend screening clinics., Conclusions: The findings contribute information on Nepalese women's perceptions of cervical cancer screening. They may serve to support the Government of Nepal's promotion of cervical cancer screening and treatment as a right for all Nepali women, whenever necessary., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Domestic violence is one of the most common forms of violence against women. Domestic violence during pregnancy is associated with adverse perinatal and maternal outcomes. We aimed to assess whether domestic violence was associated with mode of delivery, low birthweight and preterm birth in two sites in Nepal., Methods: In this prospective cohort study we consecutively recruited 2004 pregnant women during antenatal care at two hospitals between June 2015 and September 2016. The Abuse Assessment Screen (modified) was used to assess fear and violence. Having ever experienced either fear or violence was defined as any domestic violence. Obstetric outcomes were obtained from hospital records for 1381 (69%) women, selecting singleton pregnancies only. Mode of delivery was assessed as birth by cesarean section or not. A birthweight of less than 2500 g was defined as low birthweight and preterm birth as birth before completion of 37 weeks gestation. Descriptive and multiple logistic regression analyses were performed to assess associations., Results: Twenty percent of the women reported any domestic violence. Among all 1381 women, 37.6% gave birth by cesarean section. Of those women who delivered by cesarean section, 84.7% had an emergency cesarean section. Less than 10% of the babies were born prematurely and 13.5% were born with low birthweight. We found no significant association between exposure to any domestic violence during pregnancy and risk of a low birthweight baby or birth by cesarean section. However, having experienced both violence and fear was significantly associated with giving birth to a preterm infant [aOR 2.33 (95% CI;1.10-4.73)]., Conclusions: Domestic violence is common in Nepal. This is a potential risk factor for severe morbidity and mortality in newborns. We found that the risk of having a preterm baby was higher for pregnant women who experienced both fear and violence. This should be recognized by the health sector. In this study, no significant differences were found in the rate of cesarean section nor low birthweight for women who had experienced any domestic violence compared to those who did not.

Background: Malawi has one of the highest maternal mortality rates in the world, with unsafe abortion as a major contributor. Curettage is most frequently used as the surgical method for treating incomplete abortions, even though it is costly for an impoverished health system and the less expensive and safe manual vacuum aspiration (MVA) method is recommended., Methods: The aim of this 2016-17 study is to explore health worker's perception of doing MVA 1 year after an educational intervention. Focus group discussions were recorded, transcribed verbatim, and analyzed using content analysis for interpreting the findings. A knowledge, attitude and practice survey was administered to health professionals to obtain background information before the MVA training program was introduced., Results: Prior to the training sessions, the participants demonstrated knowledge on abortion practices and had positive attitudes about participating in the service, but preferred curettage over MVA. The training was well received, and participants felt more confident in doing MVA after the intervention. However, focus group discussions revealed obstacles to perform MVA such as broken equipment and lack of support. Additionally, the training could have been more comprehensive. Still, the participants appreciated task-sharing and team work., Conclusion: Training sessions are considered useful in increasing the use of MVA. This study provides important insight on how to proceed in improving post-abortion care in a country where complications of unsafe abortion are common and the health system is low on resources.

Background: Midwives are the main providers of routine antenatal care services including the routine ultrasound examination in Norway. The ultrasound examination can be perceived by expectant parents not only as a medical examination but also as a social event facilitating attachment to their fetus. This study explores Norwegian midwives' experiences and views on the role of ultrasound in clinical management of pregnancy., Methods: A qualitative study design was applied. Twenty-four midwives who all performed obstetric ultrasound examinations were recruited for focus group discussions and individual interviews. Data collection took place in 2015 in five hospitals in two different regions of Norway. Data were analyzed using qualitative content analysis., Results: Midwives described obstetric ultrasound examinations as very valuable although doing ultrasounds placed high demands on their operational and counselling skills. Increasing requests for ultrasound from pregnant women were mentioned. Advancements in ultrasound diagnosis were considered to have put the fetus in the position of a patient, and that pregnant women declining ultrasound could be viewed as irresponsible by some health professionals. Ethical concerns were raised regarding the possibility of pregnancy termination when fetal anomalies were detected. Fears were also expressed that prenatal diagnoses including those following ultrasound, might create a society where only 'perfect' children are valued. However, participants stressed that their intention in performing ultrasound was to optimize pregnancy outcome and thereby assist expectant couples and their unborn children., Conclusions: Midwives in Norwegian maternity care services describe obstetric ultrasound as very valuable, playing a central role in pregnancy management by optimizing pregnancy outcomes. Although high demands are placed on operators' technical skills and counseling, midwives described performing obstetric ultrasound as very satisfying work. However, midwives believed that expectant parents' approach to the ultrasound examination, both its medical value and the precious images obtained of the fetus, could put extra strain on the midwives performing ultrasounds. The potential of ultrasound to detect fetal anomalies and the possibility that this may lead to termination of pregnancy, seemed to create some ambivalent feelings in midwives towards its use.

Background : The indiscriminate use of antimicrobial medicines has contributed to the development of microorganisms' resistance to antibiotics. Antimicrobial resistance (AMR) is a major global health problem and is most acute in countries that have a weak health care and regulatory system and a high burden of infectious diseases, such as Bangladesh. Due to shortages of physicians available to diagnose and prescribe appropriate antibiotics, people with ailments in Bangladesh are forced to contact various types of health care services, including retail pharmacies, that lack supervision by qualified medical personnel. It is unknown how pharmacists perceive the AMR situation and the related challenges they face. Objective : The aim of the study was to understand retail pharmacist's perceptions regarding AMR. Method : A qualitative study design was used, and in-depth interviews were held with retail pharmacists in Dhaka. Results : The participants demonstrated a variety of concerns regarding AMR. They considered that self-medication, old prescriptions, lack of regulations and supervision, and readily available antibiotics were the main factors that contributed to the misuse of antimicrobial medicines and the development of AMR. Conclusions : To control the further spread of AMR in Bangladesh, there is a need to work at several levels of the health system simultaneously. Initiatives could include establishment of the 'Model Pharmacy' programme nationwide, increasing and widening the focus on AMR in pharmacists' education, ensuring the implementation of government guidelines on AMR, increasing public awareness of the consequences of antimicrobial use, and surveillance and monitoring of regulations and progress. A multipronged strategy is necessary not only for better AMR control but also for investment in a system that is well equipped to provide equitable care in the face of both existing and new health challenges.

Background: Sexual harassment occurs within the nursing profession globally, challenging the health and safety of nurses and the quality and efficiency of health systems. In Sri Lanka, no studies have explored this issue in the health sector; however, female employees face sexual harassment in other workplace settings., Objective: To explore female nurses' perceptions of workplace sexual harassment in a large state hospital in Sri Lanka., Methods: This is a qualitative study conducted in an urban, mainly Buddhist and Singhalese context. We invited all female senior and ward nurses working in the hospital to participate in the study. We conducted individual in-depth interviews with four senior nurses and focus group discussions with 29 nurses in three groups., Results: The nurses described a variety of perceived forms of sexual harassment in the hospital. They discussed patient-perpetrated incidents as the most threatening and the clearest to identify compared with incidents involving doctors and other co-workers. There was significant ambiguity regarding sexual consent and coercion in relationships between female nurses and male doctors, which were described as holding potential for exploitation or harassment. The nurses reported that typical reactions to sexual harassment were passive. Alternatively, they described encountering inaction or victim blaming when they attempted to formally report incidents. They perceived that workplace sexual harassment has contributed to negative societal attitudes about the nursing profession and discussed various informal strategies, such as working in teams, to protect themselves from sexual harassment in the hospital., Conclusions: Sexual harassment was a perceived workplace concern for nurses in this hospital. To develop effective local prevention and intervention responses, further research is required to determine the magnitude of the problem and explore differences in responses to and consequences of sexual harassment based on perpetrator type and intent, and personal vulnerabilities of the victims, among other factors.

Aims: The primary aim of this study was to assess the prevalence of domestic violence (DV) and its associated factors among pregnant women in Nepal. The secondary aims were to investigate disclosure of DV by women to health-care personnel and to assess whether health-care personnel had asked women about their experience of DV., Methods: This cross-sectional study included 2004 pregnant women between 12 and 28 weeks of gestation attending routine antenatal care at two hospitals in Nepal from August 2014 to November 2015. In this study, DV was defined as fear of a family member and/or an experience of physical, emotional or sexual violence. Associated risk factors were analysed using logistic regression analyses., Results: Twenty-one per cent of the women had experienced DV; 12.5% experienced fear only, 3.6% violence only and 4.9% experienced both violence and fear. Less than 2% per cent reported physical violence during pregnancy. This study found that just 17.7% had ever been asked by health-care personnel about DV, and of the women who had reported DV, only 9.5% had disclosed their experience to health-care personnel. Women of young age and low socio-economic status were more likely to have experienced DV. Women who reported having their own income and the autonomy to use it were at significantly lower risk of DV compared to women with no income., Conclusions: A substantial proportion of women reported having experienced DV. Victims had rarely disclosed their experience of DV to health-care personnel. This study underlines the importance of integrating systematic assessment of DV in antenatal care.

Introduction: Women with miscarriage experience several negative emotional feelings such as grief, isolation, coping, and despair. However, less is known about how the type of treatment and diagnosis of miscarriage influence the emotional experience., Material and Methods: The present study was a randomized prospective longitudinal cohort study, in which women with spontaneous miscarriage (n = 35), and women with missed miscarriage (n = 67), were included to answer three validated questionnaires: Revised Impact of Miscarriage Scale, Perinatal Grief Scale, and Montgomery and Åsberg Depression Rating Scale, concerning experience of miscarriage, psychological well-being, and mental health 1 week and 4 months after finalized treatment., Results: There was no difference between the 2 diagnosis groups in feelings as measured by Revised Impact of Miscarriage Scale, Montgomery and Åsberg Depression Rating Scale, and Perinatal Grief Scale 1 week after the miscarriage. However, the psychological well-being improved significantly 4 months after the miscarriage. Separated by treatment, women treated with misoprostol alone had more depressive symptoms than women treated with misoprostol and subsequent vacuum aspiration., Conclusions: It can be concluded that diagnosis of miscarriage had limited influence on the experiences of miscarriage, but shorter duration of treatment with misoprostol and subsequent vacuum aspiration resulted in fewer depressive symptoms., (© 2018 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction: The maternal mortality ratio is decreasing globally, although it remains high in Malawi. Unsafe abortion is a major cause and treatment of complications after abortion is a big burden on the health system. Even though manual vacuum aspiration (MVA) is the recommended surgical treatment of incomplete abortions in the first trimester, many hospitals in Malawi continue to use sharp curettage. It is known to have more complications and is more expensive in the long run. The purpose of this study was to determine the effectiveness of a structured MVA training programme in the treatment of incomplete abortions in Malawi., Methods: A quasi-experimental before-and-after study design was employed in an MVA training programme for health personnel at three hospitals in Southern Malawi. A total of 53 health personnel at the Queen Elizabeth Central Hospital and the district hospitals of Chikwawa and Chiradzulu (intervention hospitals) were trained in the use of MVA. Kamuzu Central Hospital in Lilongwe and the Thyolo District Hospital served as control institutions. Medical files for all women treated for an incomplete abortion at the study hospitals were reviewed before and after the intervention. Information on demographic and obstetric data and the type of treatment was collected., Results: There was a significant increase in the use of MVA from 7.8% (95% CI 5.8 to 10.3) to 29.1% (95% CI 25.9 to 32.5) 1 year after the intervention. In comparison, we found a mere 3% increase in the control hospitals., Conclusions: By providing a refresher training programme to health personnel who treat women with incomplete abortions, it was possible to increase the use of MVA as recommended in the Malawi national guidelines., Competing Interests: Competing interests: None declared.

Objective: Although miscarriage is common and affects up to 20% of pregnant women, little is known about these couples' short term and long term experiences after miscarriage. The aim of the present study was to study emotional experience, grief and depressive symptoms in women and men, one week and four months after miscarriage., Research Design /setting: Women, (n = 103), and their male partner (n = 78), were recruited at the gynecological clinic after miscarriage. Control women were recruited from the general population. Three validated questionnaires concerning psychological wellbeing and mental health, RIMS, PGS and MADRS-S were answered by the participants one week and four months after the miscarriage., Findings: It was shown that for women, the emotional experiences of miscarriage, grief and depressive symptoms were more pronounced than for their male partners. Grief and depressive symptoms were reduced with time, which was not the case for the emotional experiences of miscarriage. Previous children was favorable for emotional experience while previous miscarriage or infertility treatment made the emotional experience worse., Conclusion: Grief and depressive symptoms is reduced over time while emotional experiences such as isolation, loss of baby and a devastating event persist for longer time than four months. Lack of previous children, previous miscarriage and infertility diagnosis could increase negative emotional experiences after miscarriage, this was especially pronounced for grief reaction. The questionnaires could be used both clinically and in research to understand the emotional experiences after miscarriage., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: This study aimed to evaluate if domestic violence affected women's ability to prepare for childbirth. Birth preparedness and complication readiness (BP/CR) includes saving money, arranging transportation, identifying a skilled birth attendant, a health facility, and a blood donor before childbirth. During data collection, Nepal experienced two earthquakes and therefore it was possible to examine associations between domestic violence, women's BP/CR and effects of the earthquakes., Methods: Women who were between 12 and 28 weeks of gestation participated in a descriptive cross-sectional study at a hospital antenatal clinic in Nepal, where they completed a structured questionnaire on sociodemographic characteristics, obstetric history, experiences of domestic violence, and BP/CR. The 5-item Abuse Assessment Screen was used to assess prevalence of domestic violence, and a questionnaire on safe motherhood obtained from Jhpiego was used to assess BP/CR status. The participants self-completed the questionnaire on a tablet computer. Those who reported at least three out of five BP/CR activities were considered prepared for childbirth., Results: A total of 1011 women participated in the study: 433 pre-earthquakes and 578 post-earthquakes. With respect to BP/CR, 78% had identified a health facility for childbirth and 65% had saved money prior to childbirth. Less than 50% had identified a birth attendant to assist with the delivery, transportation to a health facility, or arranged for a potential blood donor. Prior to the earthquakes, 38% were unprepared; by contrast, almost 62% were not prepared after the earthquakes. A significant association was found between exposure to violence and not being prepared for childbirth (AOR = 2.3, 95% CI: 1.4-3.9). The women with increased odds of not being prepared for childbirth were illiterate (AOR = 9.9, 95% CI:5.7-17), young (AOR = 3.4, 95% CI:1.6-7.2), from the most oppressed social classes (AOR = 3.0, 95% CI:1.2-7.6), were married to illiterate husbands (AOR = 2.5, 95% CI:1.2-5.2), had attended fewer than four antenatal visits (AOR = 2.0, 95% CI: 1.4-2.6), had low incomes (AOR = 1.7, 95% CI:1.1-2.9) or lived in rural settings (AOR = 1.5, 95% confidence interval CI:1.2-2.1)., Conclusion: The paper identifies vulnerable women who require extra care from the health system, and draws attention to the need for interventions to reduce the harmful effects of domestic violence on women's preparations for childbirth., Competing Interests: The authors have declared that no competing interests exist.

Objective: Uterine rupture is a well-known but unusual complication in vaginal deliveries with a Cesarean section in the history. The risk of uterine rupture is at least two-fold when labor is induced. In Sweden, women are allowed to deliver vaginally after one previous Cesarean section, regardless if labor starts spontaneously or is induced. The aim of the study is to compare the proportion of uterine ruptures between the three methods (balloon catheter, Minprostin® and Cytotec®) for induction of labor in women with an unfavorable cervix and one previous Cesarean section., Material and Methods: Retrospective cohort study of all women with one previous Cesarean section and induction of labor with an unfavorable cervix at the four largest clinics in Stockholm during 2012-2015. Inclusion criteria: Women with a previous Cesarean section and induction of labor with a viable fetus, cephalic presentation, singleton, at ≥34 w, (n = 910)., Results: 3.0% (27/910) of the women with induction of labor had a uterine rupture, 91% of them had no previous vaginal delivery. The proportion of uterine ruptures was 2.0% (6/295) with orally administrated Cytotec®, 2.1% (7/335) with balloon catheter and 5.0% (14/ 281) when Minprostin® was used., Conclusions: No difference in the proportion of uterine ruptures was shown when orally administrated Cytotec® and balloon catheter were compared (p = 0.64). Orally administrated Cytotec® and balloon catheter give a high success rate of vaginal deliveries (almost 70%) despite an unfavorable cervix., Competing Interests: The authors declared that no competing interests exist.

Introduction: The primary aim of this study was to investigate midwives' and obstetricians' views on how many ultrasound examinations should be part of standard care during pregnancy in Norway., Material and Methods: This study is a part of a larger study, the CROss-Country Ultrasound Study (CROCUS), an international investigation of midwives' and obstetricians' experiences of and views on the use of ultrasound. We distributed 400 questionnaires to respondents in all five health regions in Norway: 40 to municipal midwives, 180 to midwives working in hospitals and 180 to obstetricians. The questionnaire included specific questions about the appropriate number of examinations during pregnancy, examinations without medical indication, non-medical ultrasound, commercialisation and safety., Results: The response rate was 45%. Of the respondents, 58% reported satisfaction with the offer of one scheduled ultrasound examination during pregnancy, as recommended in the Norwegian guidelines. Health care professionals who used ultrasound themselves were significantly more likely to want to offer more ultrasound examinations: 52% of the ultrasound users wanted to offer two or more ultrasound examinations vs. 16% of the non-users (p < .01). The majority of obstetricians (80%) reported that pregnant women expect to undergo ultrasound examination, even in the absence of medical indication., Conclusion: The majority of Norwegian health care professionals participating in this study supported the national recommendation on ultrasound in pregnancy. Ultrasound users wanted to offer more ultrasound examinations during pregnancy, whereas non-users were generally content with the recommendation. The majority of respondents thought that commercialisation was not a problem at their institution, and reported that ultrasound is often performed without a medical indication. The ultrasound users thought that ultrasound is safe., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To explore obstetricians' experiences and views of the use of obstetric ultrasound in clinical management of pregnancy., Methods: A qualitative interview study was undertaken in 2015 with obstetricians (N = 20) in Norway as part of the CROss Country Ultrasound Study (CROCUS)., Results: Three categories developed during analyses. 'Differing opinions about ultrasound and prenatal diagnosis policies' revealed divergent views in relation to Norwegian policies for ultrasound screening and prenatal diagnosis. Down syndrome screening was portrayed as a delicate and frequently debated issue, with increasing ethical challenges due to developments in prenatal diagnosis. 'Ultrasound's influence on the view of the fetus' illuminated how ultrasound influenced obstetricians' views of the fetus as a 'patient' and a 'person'. They also saw ultrasound as strongly influencing expectant parents' views of the fetus, and described how ultrasound was sometimes used as a means of comforting women when complications occurred. 'The complexity of information and counselling' revealed how obstetricians balanced the medical and social aspects of the ultrasound examination, and the difficulties of 'delivering bad news' and counselling in situations of uncertain findings., Conclusion: This study highlights obstetricians' experiences and views of ultrasound and prenatal diagnosis in Norwegian maternity care and the challenges associated with the provision of these services, including counselling dilemmas and perceived differences in expectations between caregivers and expectant parents. There was notable diversity among these obstetricians in relation to their support of, and adherence to Norwegian regulations about the use of ultrasound, which indicates that the care pregnant women receive may vary accordingly., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

This article was migrated. The article was marked as recommended. In all societies, violence is a social problem and violation of human rights. Changing attitudes and behaviors, which accept violence at individual and societal levels are key components in prevention strategies. The aim of this study was to produce educational material on Gender Based Violence (GBV). A participatory study design including educators and university students was used to create four teaching modules. The teaching was evaluated by descriptive surveys before and after the training and focus group discussions followed the training session. The questionnaire covered attitudes to gender, violence and laws. One hundred eleven teachers and 25 students representing different faculties and universities participated in separate workshops in three Sri Lankan universities. The students lacked knowledge of the meaning of GBV, consequences and existing laws. Women held more gender-equitable attitudes. Both women and men favoured equal participation of work and decision in the households. Male undergraduates showed less accepting attitudes toward rape or blaming women for rape Three categories emerged after the FGDs; Make training module compulsory and teacher led; Mind your own business; What can be done. The newly prepared and context specific material was well-received by educators and students and they provided valuable inputs, which improved the educational modules., (Copyright: © 2018 Axemo P et al.)