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Diagnostics, including laboratory tests, medical and nuclear imaging, and molecular testing, are essential in the diagnosis and management of cancer to optimize clinical outcomes. With the continuous rise in cancer mortality and morbidity in the Association of Southeast Asian Nations (ASEAN), there exists a critical need to evaluate the accessibility of cancer diagnostics in the region so as to direct multifaceted interventions that will address regional inequities and inadequacies in cancer care. This paper identifies existing gaps in service delivery, health workforce, health information systems, leadership and governance, and financing and how these contribute to disparities in access to cancer diagnostics in ASEAN member countries. Intersectoral health policies that will strengthen coordinated laboratory services, upscale infrastructure development, encourage health workforce production, and enable proper appropriation of funding are necessary to effectively reduce the regional cancer burden., Competing Interests: BAM received research grants from the 10.13039/100000892Prostate Cancer Foundation, the 10.13039/100001960American Society for Radiation Oncology, the United States 10.13039/100000005Department of Defense, and the 10.13039/100018896Sylvester Comprehensive Cancer Center. ECD is funded in part through the Cancer Center Support Grant from the National Cancer Institute (P30 CA008748). All other authors declare no conflicts of interest., (© 2023 The Authors.)

Purpose: To evaluate the performance of a deep learning (DL) algorithm for retinopathy of prematurity (ROP) screening in Nepal and Mongolia., Design: Retrospective analysis of prospectively collected clinical data., Participants: Clinical information and fundus images were obtained from infants in 2 ROP screening programs in Nepal and Mongolia., Methods: Fundus images were obtained using the Forus 3nethra neo (Forus Health) in Nepal and the RetCam Portable (Natus Medical, Inc.) in Mongolia. The overall severity of ROP was determined from the medical record using the International Classification of ROP (ICROP). The presence of plus disease was determined independently in each image using a reference standard diagnosis. The Imaging and Informatics for ROP (i-ROP) DL algorithm was trained on images from the RetCam to classify plus disease and to assign a vascular severity score (VSS) from 1 through 9., Main Outcome Measures: Area under the receiver operating characteristic curve and area under the precision-recall curve for the presence of plus disease or type 1 ROP and association between VSS and ICROP disease category., Results: The prevalence of type 1 ROP was found to be higher in Mongolia (14.0%) than in Nepal (2.2%; P  < 0.001) in these data sets. In Mongolia (RetCam images), the area under the receiver operating characteristic curve for examination-level plus disease detection was 0.968, and the area under the precision-recall curve was 0.823. In Nepal (Forus images), these values were 0.999 and 0.993, respectively. The ROP VSS was associated with ICROP classification in both datasets ( P < 0.001). At the population level, the median VSS was found to be higher in Mongolia (2.7; interquartile range [IQR], 1.3-5.4]) as compared with Nepal (1.9; IQR, 1.2-3.4; P < 0.001)., Conclusions: These data provide preliminary evidence of the effectiveness of the i-ROP DL algorithm for ROP screening in neonatal populations in Nepal and Mongolia using multiple camera systems and are useful for consideration in future clinical implementation of artificial intelligence-based ROP screening in low- and middle-income countries., (© 2022 by the American Academy of Ophthalmology.)

Background: The benefits of a neurosurgical skill laboratory (NSL) are unquestionable. Despite the increasing number of sub-Saharan African neurosurgeons, few cadaveric laboratories are available for neurosurgical education. The first of its kind in West Africa, a NSL opened in 2019 in Abidjan, Cote d'Ivoire to promote neurosurgeons' education and technical skills. We have described our experience in creating and running this facility., Methods: NSL is a private academic center in Abidjan, Cote d'Ivoire. It includes 2 rooms dedicated to cadaveric hands-on training and microscopic neurosurgery and multipurpose rooms, which contain 7 table-mounted microscopes and 3 endoscopes. The designed layout replicates an operating room. The curriculum was designed to meet the needs for training for complex brain and spine surgeries., Results: The training covers skull base (conventional and extended) approaches, microsuturing, and anterolateral and posterior approaches for spine surgeries. The training was open to residents and consultants. The faculty members included anatomists, neurosurgeons, otolaryngologists, and orthopedists. Additionally, the NSL welcomes fellows from foreign countries. Fellows from 4 countries have been trained, and 14 educational activities have been organized., Conclusions: In the present report, we have provided insight into a sub-Saharan African neurosurgical laboratory striving toward an affordable and self-sustainable center. The short-term goal of the NSL is to be a center for developing technical skills for African neurosurgeons for better patient outcomes., (© 2022 The Author(s).)

Background: There are an estimated 55 million internally displaced persons (IDPs) globally. IDPs commonly have worse health outcomes than host populations and other forcibly displaced populations such as refugees. Official development assistance (ODA) is a major source of the global financial response for health in low- and middle-income countries (LMICs), including for populations affected by armed conflict and forced displacement. Analysis of ODA supports efforts to improve donor accountability, transparency and the equitable use of ODA. The aim of this study is to examine international donor support and responsiveness to IDP health needs through analysis of ODA disbursements to LMICs between 2010 and 2019., Methods: ODA disbursement data to LMICs from 2010 to 2019 were extracted from the Creditor Reporting System (CRS) database and analysed with Stata software using a combination of: (i) text searching for IDP and refugee related terms; and (ii) relevant health and humanitarian CRS purpose codes. Descriptive analysis was used to examine patterns of ODA disbursement, and nonlinear least squared regression analysis was used to examine responsiveness of ODA disbursement to recipient country IDP population size and health system capacity and health characteristics., Findings: The study highlighted declining per IDP capita health ODA from USD 5.34 in 2010 to USD 3.72 in 2019 (with annual average decline of -38% from the 2010 baseline). In contrast, health ODA for refugees in LMICs increased from USD 18.55 in 2010 to USD 23.31 in 2019 (with an annual average increase of +14%). Certain health topics for IDPs received very low ODA, with only 0.44% of IDP health ODA disbursed for non-communicable diseases (including mental health). There was also weak evidence of IDP health ODA being related to recipient country IDP population size, and health system capacity and health characteristics. The paper highlights the need for increased investment by donors in IDP health ODA and to ensure that it is responsive to their health needs., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Background: Subjective social status (SSS, perception of social position relative to a frame of reference) has been associated with physical, mental and socio-emotional wellbeing. However, these associations may be susceptible to unmeasured confounding by life course objective socio-economic position (SEP; such as wealth, education and employment) and life satisfaction., Purpose: To estimate the association of position on ladders of perceived community respect and perceived economic status with weight, distress and wellbeing, independent of objective SEP in cohorts from three low and middle-income countries., Methods: We used data from birth cohorts in Guatemala (n = 1258), Philippines (n = 1323) and South Africa (n = 1393). We estimated the association of perceived community respect and perceived economic status with body mass index (kg/m 2 ), the World Health Organization's Self-Reported Questionnaire-20 (SRQ-20) for psychological distress, and Lyubomirsky's Subjective Happiness Scale. We estimated these associations using robust linear regression models adjusting for indicators of life course objective SEP, early life characteristics, adult covariates, and life satisfaction., Results: Participants in South Africa (age 27-28y) rated themselves higher on average for both the respect (7 vs 5 in Guatemala and 6 in Philippines) and economic (5 vs 3 in Guatemala and 4 in Philippines) ladder measures. Position on neither community respect nor economic ladders were associated with BMI or psychological distress. Higher position on community respect (Guatemala: 0.03, 95%CI: 0.01, 0.04; Philippines: 0.03, 95% CI: 0.02, 0.05; South Africa: 0.07, 95%CI: 0.04, 0.09) and economic (Guatemala: 0.02, 95%CI: 0, 0.04; Philippines: 0.04, 95%CI: 0.02, 0.07; South Africa: 0.07, 95%CI: 0.04, 0.10) ladders were associated with greater happiness., Conclusions: Subjective social status showed small but consistent associations with happiness in birth cohorts independent of life-course SEP., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

• Sphere chlorination targets may not ensure household water safety in refugee camps. • This is most concerning in camps in hot settings where WASH conditions are poor. • We investigated post-distribution chlorine decay in multiple refugee camps globally. • We applied a nonlinear optimization to the novel post-distribution decay challenge. • We demonstrate that site-specific FRC targets can improve household water safety. The current Sphere guideline for water chlorination in humanitarian emergencies fails to reliably ensure household water safety in refugee camps. We investigated post-distribution chlorine decay and household water safety in refugee camps in South Sudan, Jordan, and Rwanda between 2013-2015 with the goal of demonstrating an approach for generating site-specific and evidence-based chlorination targets that better ensure household water safety than the status quo Sphere guideline. In each of four field studies we conducted, we observed how water quality changed between distribution and point of consumption. We implemented a nonlinear optimization approach for the novel technical challenge of modelling post-distribution chlorine decay in order to generate estimates on what free residual chlorine (FRC) levels must be at water distribution points, in order to provide adequate FRC protection up to the point of consumption in households many hours later at each site. The site-specific FRC targets developed through this modelling approach improved the proportion of households having sufficient chlorine residual (i.e., ≥0.2 mg/L FRC) at the point of consumption in three out of four field studies (South Sudan 2013, Jordan 2014, and Rwanda 2015). These sites tended to be hotter (i.e., average mid-afternoon air temperatures >30°C) and/or had poorer water, sanitation, and hygiene (WASH) conditions, contributing to considerable chlorine decay between distribution and consumption. Our modelling approach did not work as well where chlorine decay was small in absolute terms (Jordan 2015). In such settings, which were cooler (20 to 30°C) and had better WASH conditions, we found that the upper range of the current Sphere chlorination guideline (i.e., 0.5 mg/L FRC) provided sufficient residual chlorine for ensuring household water safety up to 24 hours post-distribution. Site-specific and evidence-based chlorination targets generated from post-distribution chlorine decay modelling could help improve household water safety and public health outcomes in refugee camp settings where the current Sphere chlorination guideline does not provide adequate residual protection. Water quality monitoring in refugee/IDP camps should shift focus from distribution points to household points of consumption in order to monitor if the intended public health goal of safe water at the point of consumption is being achieved. Image, graphical abstract [ABSTRACT FROM AUTHOR]

Objective: We study how life course objective socioeconomic position (SEP) predicts subjective social status (SSS) and the extent to which SSS mediates the association of objective SEP with nutritional status and mental health outcomes., Methods: We use data from participants of the INCAP Longitudinal Study 1969-2018 (n = 1258) from Guatemala. We use the MacArthur ladder for two measures of SSS - perceived community respect and perceived economic status. We estimate the association of SSS with health outcomes after adjusting for early life characteristics and life course objective SEP (wealth, schooling, employment) using linear regression. We use path analysis to study the extent of mediation by SSS on the health outcomes of body mass index (BMI; kg/m 2 ), psychological distress (using the WHO Self-Reported Questionnaire; SRQ-20) and happiness, using the Subjective Happiness Scale (SHS)., Results: Median participant rating was 5 [IQR: 3-8] for the perceived community respect and 3 [IQR: 1-5] for the perceived economic status, with no differences by sex. Objective SEP in early life and adulthood were predictive of both measures of SSS in middle adulthood as well as health outcomes (BMI, SRQ-20 and SHS). Perceived community respect (z-scores; 1 z = 3.1 units) was positively associated with happiness (0.13, 95 % CI: 0.07, 0.19). Perceived economic status (z-scores; 1 z = 2.3 units) was inversely associated with psychological distress (-0.28, 95 % CI: -0.47, -0.09). Neither measure of SSS was associated with BMI. Neither perceived community respect nor perceived economic status attenuated associations of objective SEP with health outcomes on inclusion as a mediator., Conclusions: Subjective social status was independently associated with happiness and psychological distress in middle adulthood after adjusting for objective SEP. Moreover, association of objective SEP with health was not mediated by SSS, suggesting potentially independent pathways., Competing Interests: None., (© 2021 The Authors. Published by Elsevier Ltd.)

Background: Wealth mobility, as both relative (positional) and absolute (material) wealth acquisition, may counteract negative consequences of early life adversities on adult health., Methods: We use longitudinal data (1967-2018) from the INCAP birth cohort, Guatemala (n = 1386). Using wealth as a measure of socio-economic position, we assess the association of life course relative mobility using latent class analysis and absolute material gains using conditional wealth measures. We estimate associations of wealth mobility with indicators of human capital, specifically height, weight status (BMI in kg/m 2 ), psychological distress (WHO SRQ-20 score) and fluid intelligence (Ravens Progressive Matrices score; RPM) in middle adulthood., Results: We identified four latent classes of relative mobility - Stable Low (n = 498), Stable High (n = 223), Downwardly Mobile (n = 201) and Upwardly Mobile (n = 464). Attained schooling (years) was positively associated with membership in Upwardly Mobile (odds ratio; 1.50, 95%CI: 1.31, 1.71) vs Stable Low, and inversely with membership in Downwardly Mobile (0.65, 95%CI: 0.54, 0.79) vs Stable High. Being Upwardly Mobile (vs Stable Low) was positively associated with height (1.88 cm, 95%CI: 1.04, 2.72), relative weight (1.32 kg/m 2 , 95%CI: 0.57, 2.07), lower psychological distress (-0.82 units, 95%CI: 1.34, -0.29) and fluid intelligence (0.94 units, 95%CI: 0.28, 1.59). Being Downwardly Mobile (vs Stable High) was associated with lower fluid intelligence (-2.69 units, 95%CI: 3.69, -1.68), and higher psychological distress (1.15 units, 95%CI: 0.34, 1.95). Absolute wealth gains (z-scores) from early to middle adulthood were positively associated with relative weight (0.62 kg/m 2 , 95%CI: 0.28, 0.96), lower psychological distress (-0.37 units, 95%CI: 0.60, -0.14) and fluid intelligence (0.50 units, 95%CI: 0.21, 0.79)., Conclusions: Higher attained schooling provided a pathway for upward relative mobility and higher absolute wealth gains as well as protection against downward relative mobility. Upward mobility was associated with lower psychological distress and higher fluid intelligence but also higher weight status., Competing Interests: None., (© 2021 The Authors.)

Background: International guideline-recommended on-demand treatments for hereditary angioedema (HAE) include: C1-esterase inhibitor (plasma-derived or recombinant), or bradykinin-receptor antagonists. In most low- and middle-income countries (LMIC) these products are not registered or are unaffordable. Solvent-detergent, fresh or freeze-dried plasma therapy is thus the only available on-demand treatment in these settings; but published data on efficacy and safety are limited. This study evaluated the efficacy and safety of on-demand plasma treatment of acute HAE in two LMICs., Methods: A retrospective folder or patient registry review of acute swelling episodes necessitating emergency room attendance amongst known HAE patients was conducted at treatment centers in South Africa and Iran. Data collected included the site of angioedema, timing and amount of fresh frozen plasma (FFP) administered, time-to-resolution, hospital length of stay and adverse events., Results: There were 176 acute swelling episodes amongst 43 HAE patients; 98 were treated with FFP. The face, upper airway, and abdomen were involved in 15.3% (15/98), 53.1% (52/98) and 29.6% (29/98) of episodes treated with FFP respectively. Median (interquartile range ([IQR]) of FFP administered was 400 (280-560) mLs. In all episodes except two, FFP led to resolution, with median (IQR) hours to resolution 4 (2-12). Five transfusion reactions occurred, with one case of anaphylaxis and no deaths; giving an adverse reaction rate of 5%. Differences between South Africa and Iran included: (1) proportion of HAE type II(2) median (IQR) hours to FFP administration and hospitalization, (3) number of intubations after FFP infusion. Healthcare cost for FFP treatment was USD369- 791 in South Africa and USD275-550 in Iran, largely influenced by hospital length of stay., Conclusions: Plasma (fresh-frozen) remains the only available effective on-demand treatment for acute HAE in many countries. FFP is effective and safe, but time-to-resolution is slower and adverse events are more frequent than published data on targeted therapies. Overall healthcare cost of FFP approaches that of targeted therapies - now available through global access programs - when hospitalization is prolonged., (© 2019 The Author(s).)

Objective: The safety and effectiveness of task-sharing (TS) in neurosurgery, delegating clinical roles to non-neurosurgeons, is not well understood. This study evaluated an ongoing TS model in the Philippines, where neurosurgical workforce deficits are compounded with a large neurotrauma burden., Methods: Medical records from emergency neurosurgical admissions to 2 hospitals were reviewed (January 2015-June 2018): Bicol Medical Center (BMC), a government hospital in which emergency neurosurgery is chiefly performed by general surgery residents (TS providers), and Mother Seton Hospital, an adjacent private hospital where neurosurgery consultants are the primary surgeons. Univariable and multivariable linear and logistic regression compared provider-associated outcomes., Results: Of 214 emergency neurosurgery operations, TS providers performed 95 and neurosurgeons, 119. TS patients were more often male (88.4% vs. 73.1%; P  = 0.007), younger (mean age, 27.6 vs. 50.5 years; P < 0.001), and had experienced road traffic accidents (69.1% vs. 31.4%; P < 0.001). There were no significant differences between Glasgow Coma Scale (GCS) scores on admission. Provider type was not associated with mortality (neurosurgeons, 20.2%; TS, 17.9%; P  = 0.68), reoperation, or pneumonia. No significant differences were observed for GCS improvement between admission and discharge or in-hospital GCS improvement, including or excluding inpatient deaths. TS patients had shorter lengths of stay (17.3 days vs. 24.4 days; coefficient, -6.67; 95% confidence interval, -13.01 to -0.34; P  < 0.05) and were more likely to undergo tracheostomy (odds ratio, 3.1; 95% confidence interval, 1.30-7.40; P  = 0.01)., Conclusions: This study, one of the first to examine outcomes of neurosurgical TS, shows that a strategic TS model for emergency neurosurgery produces comparable outcomes to the local neurosurgeons., Competing Interests: This work was supported by the Centre for Global Health at King's College London, the Department of Neurosurgery at Brigham and Women's Hospital, and the Scholars in Medicine Office, Department of Global Health at Harvard Medical School., (© 2019 The Authors.)

Background: Because nearly 23,000 more neurosurgeons are needed globally to address 5 million essential neurosurgical cases that go untreated each year, there is an increasing interest in task-shifting and task-sharing (TS/S), delegating neurosurgical tasks to nonspecialists, particularly in low- and middle-income countries (LMICs). This global survey aimed to provide a cross-sectional understanding of the prevalence and structure of current neurosurgical TS/S practices in LMICs., Methods: The survey was distributed to a convenience sample of individuals providing neurosurgical care in LMICs with a Web-based survey link via electronic mailing lists of continental societies and various neurosurgical groups, conference announcements, e-mailing lists, and social media platforms. Country-level data were analyzed by descriptive statistics., Results: The survey yielded 127 responses from 47 LMICs; 20 countries (42.6%) reported ongoing TS/S. Most TS/S procedures involved emergency interventions, the top 3 being burr holes, craniotomy for hematoma evacuation, and external ventricular drain. Most (65.0%) believed that their Ministry of Health does not endorse TS/S (24.0% unsure), and only 11% believed that TS/S training was structured. There were few opportunities for TS/S providers to continue medical education (11.6%) or maintenance of certification (9.4%, or receive remuneration (4.2%)., Conclusions: TS/S is ongoing in many LMICs without substantial structure or oversight, which is concerning for patient safety. These data invite future clinical outcomes studies to assess effectiveness and discussions on policy recommendations such as standardized curricula, certification protocols, specialist oversight, and referral networks to increase the level of TS/S care and to continue to increase the specialist workforce., Competing Interests: A.G.K. is supported by the National Institute for Health Research (NIHR) Global Health Research Group on Neurotrauma. The Group was commissioned by the NIHR using Official Development Assistance funding (project 16/137/105). The views expressed in this article are those of the authors and are not necessarily those of the United Kingdom National Health Service, NIHR, or the United Kingdom Department of Health., (© 2019 The Authors.)

Background: Neurosurgical task shifting and task sharing (TS/S), delegating clinical care to non-neurosurgeons, is ongoing in many hospital systems in which neurosurgeons are scarce. Although TS/S can increase access to treatment, it remains highly controversial. This survey investigated perceptions of neurosurgical TS/S to elucidate whether it is a permissible temporary solution to the global workforce deficit., Methods: The survey was distributed to a convenience sample of individuals providing neurosurgical care. A digital survey link was distributed through electronic mailing lists of continental neurosurgical societies and various collectives, conference announcements, and social media platforms (July 2018-January 2019). Data were analyzed by descriptive statistics and univariate regression of Likert Scale scores., Results: Survey respondents represented 105 of 194 World Health Organization member countries (54.1%; 391 respondents, 162 from high-income countries and 229 from low- and middle-income countries [LMICs]). The most agreed on statement was that task sharing is preferred to task shifting. There was broad consensus that both task shifting and task sharing should require competency-based evaluation, standardized training endorsed by governing organizations, and maintenance of certification. When perspectives were stratified by income class, LMICs were significantly more likely to agree that task shifting is professionally disruptive to traditional training, task sharing should be a priority where human resources are scarce, and to call for additional TS/S regulation, such as certification and formal consultation with a neurosurgeon (in person or electronic/telemedicine)., Conclusions: Both LMIC and high-income countries agreed that task sharing should be prioritized over task shifting and that additional recommendations and regulations could enhance care. These data invite future discussions on policy and training programs., Competing Interests: A.G.K. is supported by the National Institute for Health Research (NIHR) Global Health Research Group on Neurotrauma. The Group was commissioned by the NIHR using Official Development Assistance funding (project 16/137/105). The views expressed in this manuscript are those of the authors and are not necessarily those of the UK National Health Service, NIHR, or the UK Department of Health., (© 2019 The Authors.)

We examined the spatial distribution of antibiotic-resistant coliform bacteria amongst livestock from three distinct cultural groups, where group-level differences in practices (e.g., antibiotic use) may influence the magnitude of antibiotic resistance, while livestock interactions (e.g., mixing herds, shared markets) between these locations may reduce heterogeneity in the distribution of antibiotic resistant bacteria. Data was collected as part of a larger study of antibiotic-resistance in northern Tanzania. Simple regression and generalized linear regression were used to assess livestock management and care practices in relation to the prevalence of multidrug-resistant (MDR) coliform bacteria. Simple and multivariable logistic regression were then used to identify how different management practices affected the odds of households being found within MDR "hotspots." Households that had a higher median neighbourhood value within a 3000 m radius showed a significant positive correlation with livestock MDR prevalence (β = 4.33, 95% CI: 2.41-6.32). Households were more likely to be found within hotspots if they had taken measures to avoid disease (Adjusted Odds Ratio (AOR) 1.53, CI: 1.08-2.18), and if they reported traveling less than a day to reach the market (AOR 2.66, CI: 1.18-6.01). Hotspot membership was less likely when a greater number of livestock were kept at home (AOR 0.81, CI: 0.69-0.95), if livestock were vaccinated (AOR 0.32, CI: 0.21-0.51), or if distance to nearest village was greater (AOR 0.46, CI: 0.36-0.59). The probability of MDR increases when herds are mixed, consistent with evidence for passive transmission of resistant bacteria between animals. Reduced MDR with vaccination is consistent with many studies showing reduced antibiotic use with less disease burden. The neighbourhood effect has implications for design of intervention studies.

Background: Many women experience mistreatment during childbirth in health facilities across the world. However, limited evidence exists on how social norms and attitudes of both women and providers influence mistreatment during childbirth. Contextually-specific evidence is needed to understand how normative factors affect how women are treated. This paper explores the acceptability of four scenarios of mistreatment during childbirth., Methods: Two facilities were identified in Abuja, Nigeria. Qualitative methods (in-depth interviews (IDIs) and focus group discussions (FGDs)) were used with a purposive sample of women, midwives, doctors and administrators. Participants were presented with four scenarios of mistreatment during childbirth: slapping, verbal abuse, refusing to help the woman and physical restraint. Thematic analysis was used to synthesize findings, which were interpreted within the study context and an existing typology of mistreatment during childbirth., Results: Eighty-four IDIs and 4 FGDs are included in this analysis. Participants reported witnessing and experiencing mistreatment during childbirth, including slapping, physical restraint to a delivery bed, shouting, intimidation, and threats of physical abuse or poor health outcomes. Some women and providers considered each of the four scenarios as mistreatment. Others viewed these scenarios as appropriate and acceptable measures to gain compliance from the woman and ensure a good outcome for the baby. Women and providers blamed a woman's "disobedience" and "uncooperativeness" during labor for her experience of mistreatment., Conclusions: Blaming women for mistreatment parallels the intimate partner violence literature, demonstrating how traditional practices and low status of women potentiate gender inequality. These findings can be used to facilitate dialogue in Nigeria by engaging stakeholders to discuss how to challenge these norms and hold providers accountable for their actions. Until women and their families are able to freely condemn poor quality care in facilities and providers are held accountable for their actions, there will be little incentive to foster change.