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

Objectives Despite a remarkable decline, childhood morbidity and mortality in Ethiopia remain high and inequitable. Thus, we estimated the effective coverage of curative child health services in Ethiopia.Design We conducted a cross-sectional analysis of data from the 2016 Ethiopia Demographic and Health Survey (DHS) and the 2014 Ethiopia Service Provision Assessment Plus (SPA+) survey.Setting Nationally representative household and facility surveys.Participants and outcomes We included a sample of 2096 children under 5 years old (from DHS) who had symptoms of one or more common childhood illnesses (diarrhoea, fever and acute respiratory infection) and estimated the percentage of sick children who were taken to a health facility (crude coverage). To construct a quality index of child health services, we used the SPA+ survey, which was conducted in 1076 health facilities and included observations of care for 1980 sick children and surveys of 1908 mothers/caregivers and 5328 health providers. We applied the Donabedian quality of care framework to identify 58 quality parameters (structure, 31; process, 16; and outcome, 11) and used the weighted additive method to estimate the overall quality of care index. Finally, we multiplied the crude coverage by the quality of care index to estimate the effective coverage of curative child health services, nationally and by region.Results Among the 2096 sick children, only 38.4% (95% CI: 36.5 to 40.4) of them were taken to a health facility. The overall quality of care was 54.4%, weighted from structure (30.0%), process (9.2%) and outcome (15.2%). The effective coverage of curative child health services was estimated at 20.9% (95%CI: 19.9 to 22.0) nationally, ranging from 16.9% in Somali to 34.6% in Dire Dawa regions.Conclusions System-wide interventions are required to address both demand-side and supply-side bottlenecks in the provision of child health services if child health-related targets are to be achieved in Ethiopia.

Introduction Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care—typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity.Methods Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators.Results This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%–29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda.Discussion Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.

# Background The World Health Organization promotes antenatal care (ANC) as a package of health interventions women receive during pregnancy. This study examined the association between the number of ANC visits and the number of ANC components received in Burundi. # Methods This cross-sectional study used data from the most recent Burundi Demographic and Health Survey (DHS) 2016/2017. The Burundi DHS is a household survey using a stratified two-stage sampling design. We included all women aged 15-49 years who had a live birth in the two years preceding the survey, and ANC for the pregnancy leading to the most recent live birth in this period was analysed. We analysed women’s self-report of receipt of eight routine ANC components. We used chi-square and ANOVA tests to examine the distribution of the number of ANC visits and the number of components received among ANC users, and linear regression to investigate the crude and adjusted association between the number of ANC visits and number of ANC components received. # Results Nearly all women (99.4%, 95% confidence interval, CI=99.2-99.6) reported receiving some ANC; half (51.7%, 95% CI=49.8-53.6) reported receiving 4+ visits. The mean number of visits among ANC users was 4.44, and this was only marginally higher (4.63) among women who received 4+ ANC visits. Among ANC users, blood sample taken was the most commonly reported ANC component (88.3%); urine sample taken was the least received component (28.3%). Women’s report of blood pressure having been measured and iron tablets or syrup taken were not significantly associated with number of ANC visits (P>0.05); the probability of receiving the other six components increased with higher number of ANC visits. The number of ANC visits was significantly associated with an increasing number of components received in both bivariate (regression coefficient= 0.23; 95% CI=0.18–0.28; P

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

Anomaly detection is essential to spot cyber-attacks within networks. Unsupervised anomaly detection methods are becoming more popular due to difficult and expensive process of labeling network data as well as their superior ability to detect unknown attacks when compared with supervised or signature-based solutions. In this paper, we introduce an LSTM-based Autoencoder anomaly detection model trained in a fully unsupervised environment, with optimizations for minimal memory usage. Secondly, we compare the Autoencoder model with an Isolation Forest model by analysing their results. Our Autoencoder attempts to capture the profile of the data by dimensionality reduction and the use of LSTM layers enables it to leverage the data from previous requests. Reconstruction error is calculated to decide about the anomality. We train the models on a dataset of requests towards a webserver in an unsupervised fashion. Before training, significant feature engineering is done to process multiple categorical attributes. The training process of introduced Autoencoder is optimized for minimum memory usage. We evaluated the results based on our analysis of the data as well as their statistical features. A manual analysis revealed differing focuses between numerical and categorical attributes. The Isolation Forest disregards most categorical attributes and emphasizes numerical values. Autoencoder on the other hand detects missing features more effectively but largely disregards numerical attributes. As such, Autoencoder might have a higher probability of detecting a zero-day attack when compared to Isolation Forest.

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

The demographic, ecological and socioeconomic changes associated with urbanisation are linked to changes in disease incidence, health service provision and mortality. These effects are heterogeneous between and within urban areas, yet without a clear definition of what constitutes an ‘urban’ area, their measurement and comparison are constrained. The definitions used vary between countries and over time hindering analyses of the relationship between urbanisation and health outcomes, evaluation of policy actions and results in uncertainties in estimated differences. While a binary urban-rural designation fails to capture the complexities of the urban-rural continuum, satellite data augmented with models of population density and built-up areas offer an opportunity to develop an objective, comparable and continuous measure which captures urbanisation gradient at high spatial resolution. We examine the urban gradient within the context of population health. We compare the categorisation of urban and rural areas (defined by national statistical offices) used in household surveys in sub-Saharan Africa (SSA) to an urban-rural gradient derived from augmented satellite data within a geospatial framework. Using nine Demographic and Health Surveys (DHS) conducted between 2005 and 2019 in six SSA countries, we then assess the extent of misalignment between urbanicity based on DHS categorisation compared with a satellite-derived measure, while discussing the implications on the coverage of key maternal health indicators. The proposed indicator provides a useful supplement to country-specific urbanicity definitions and reveals new health dynamics along the rural-urban gradient. Satellite-derived urbanicity measures will need frequent updates to align with years when household surveys are conducted.

Objectives The COVID-19 pandemic affected provision and use of maternal health services. This study describes changes in obstetric complications, referrals, stillbirths and maternal deaths during the first year of the pandemic and elucidates pathways to these changes.Design Prospective observational mixed-methods study, combining monthly routine data (March 2019–February 2021) and qualitative data from prospective semi-structured interviews. Data were analysed separately, triangulated during synthesis and presented along three country-specific pandemic periods: first wave, slow period and second wave.Setting Six referral maternities in four sub-Saharan African countries: Guinea, Nigeria, Tanzania and Uganda.Participants 22 skilled health personnel (SHP) working in the maternity wards of various cadres and seniority levels.Results Percentages of obstetric complications were constant in four of the six hospitals. The percentage of obstetric referrals received was stable in Guinea and increased at various times in other hospitals. SHP reported unpredictability in the number of referrals due to changing referral networks. All six hospitals registered a slight increase in stillbirths during the study period, the highest increase (by 30%–40%) was observed in Uganda. Four hospitals registered increases in facility maternal mortality ratio; the highest increase was in Guinea (by 158%), which had a relatively mild COVID-19 epidemic. These increases were not due to mortality among women with COVID-19. The main pathways leading to these trends were delayed care utilisation and disruptions in accessing care, including sub-optimal referral linkages and health service closures.Conclusions Maternal and perinatal survival was negatively affected in referral hospitals in sub-Saharan Africa during COVID-19. Routine data systems in referral hospitals must be fully used as they hold potential in informing adaptations of maternal care services. If combined with information on women’s and care providers’ needs, this can contribute to ensuring continuation of essential care provision during emergency.

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

Objectives This study aims to characterise the physical and psychological well-being of maternal and newborn healthcare workers (MNHCWs) during the COVID-19 pandemic.Design Observational repeated cross-sectional study.Setting An online questionnaire was distributed to MNHCWs around the globe in three separate rounds from March 2020 to March 2021.Participants Total samples of N=1357 (round 1) and N=420 (round 3) primarily consisted of doctors, midwives and nurses in maternal and newborn specialties. Samples represented all WHO regions, with 33% (round 1) and 42% (round 3) from low- or middle-income countries (LMICs).Primary and secondary outcome measures Responses from rounds 1 (March–June 2020) and 3 (December 2020–March 2021) were analysed to measure self-reported levels of relative stress and workplace protection from COVID-19, while associated factors were determined through multivariable ordinal logistic regression.Results In round 1, 90% of MNHCWs reported increased stress levels and 45% reported insufficient personal protective equipment (PPE) access. Nurses and physicians were less likely to report increased stress than midwives at the pandemic onset. Factors associated with increased stress included being female, being from an LMIC and insufficient PPE. In round 3, 75% reported similar or increased stress while 10% reported insufficient PPE. In both rounds, over 50% of MNHCWs felt relatively or completely unprotected from COVID-19 in the workplace. Those from LMICs were more likely to report feeling unprotected, while receiving organisational information that valued safety was associated with better feelings of protection in the workplace.Conclusions Among our international sample of MNHCWs, we observed high rates of self-reported stress increase at the start of the pandemic with persistence or increase up to a year later. High rates of feeling unprotected persisted even as PPE became more available. These results may inform interventions needed to support and protect MNHCWs during this and future pandemics.

Objectives The continuum of maternal care along antenatal (ANC), intrapartum and postnatal care (PNC) is fundamental for protecting women’s and newborns’ health. The COVID-19 pandemic interrupted the provision and use of these essential services globally. This study examines maternal healthcare utilisation along the continuum during the COVID-19 pandemic in the Democratic Republic of the Congo (DRC).Design This is a cross-sectional study using data collected on a survey of 599 households in Lubumbashi, DRC, using stratified random sampling.Participants We included 604 women (15–49 years) who were pregnant between March 2020 and May 2021.Outcome measures A structured interview involved questions on sociodemographic characteristics, attitudes regarding COVID-19 and maternal service use and cost. Complete continuum of care was defined as receiving ANC 4+ consultations, skilled birth attendance and at least one PNC check for both mother and newborn. Data were analysed in SPSS using descriptive statistics and multivariable logistic regression.Results One-third (36%) of women who gave birth during the COVID-19 pandemic completed the continuum of maternal healthcare. Factors significantly associated with completing the continuum included higher education (aOR=2.6; p

Background Caesarean section (CS) rates in women experiencing stillbirth have not been studied with nationally representative data. Two Ghana Maternal Health Surveys (GMHS) have captured pregnancy and mode of birth data for all women including those with stillbirths. We compared CS rates between women with live births and stillbirths, and identified socio-economic and pregnancy-related factors associated with CS in stillbirths.Methods A population-based cross-sectional study was conducted in a pooled sample of 17 138 women who had given birth within 5 years preceding the 2007 and 2017 GMHS. CS rates were compared between women with stillbirths and very early neonatal deaths (SBVENDs) and women with live births who survived the first day. Bivariate and multivariable logistic regressions explored variables associated with CS. Effect modification of household’s wealth and maternal educational level by birth outcome was assessed using multivariable logistic regression with interaction terms.Results CS rate in women with SBVEND was 19.3% compared with 9.6% in women with live births who survived the first day (rate ratio 2.2; 95% CI 1.6 to 2.9). In multivariable analysis, attaining middle school compared with no formal education (adjusted OR, aOR 2.8; 95% CI 1.1 to 7.1), having had five or more births compared with nulliparity (aOR 3.7; 95% CI 1.3 to 10.7) and reporting prolonged or obstructed labour (aOR 3.3; 95% CI 1.3 to 8.3) were associated with CS in women with SBVEND. Higher household wealth and educational levels were associated with an increased risk of CS in both study groups, with no statistically significant difference in effect.Conclusion Disaggregating CS rates by birth outcome revealed a high rate among women with SBVEND, twice the overall rate compared with live births. Exclusion of these ‘hidden’ CSs from rate calculations may lead to underestimation of (inter)national CS rates and potentially conceals CS overuse or misuse.

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

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

# Background Modern contraceptives are effective interventions for preventing unwanted pregnancies, but their use remain low among adolescent girls in sub-Saharan Africa. First, we aimed to assess the trends of modern contraceptive use among adolescent girls aged 15-19 years in Sierra Leone in the period 2008-2019. Second, we explored how individual and contextual determinants of their use changed during this period. # Methods We used a combined sample of 8,774 adolescent girls aged 15-19 years from the 2008, 2013, and 2019 Sierra Leone Demographic and Health Surveys (SLDHS), respectively, to estimate the modern contraceptive prevalence rate (MCPR) and unmet need for family planning. We described the method mix and sources of contraceptives among modern method users. We then conducted a multivariable logistic regression to examine the determinants of modern contraceptive use among sexually active adolescent girls, separately for 2008 and 2019. # Results MCPR increased from 5.9% (95% CI=4.5-7.8) in 2008 to 21.0% (95% CI=19.2-22.9) in 2019. Most of the increase had occurred by 2013. Norplant (48.8%) and injectables (39%) were the common methods in 2019. Unmet need for family planning declined from 15.4% (95% CI=13.2-17.9) in 2008 to 11.3% (95% CI=9.9-12.7) in 2019, while the prevalence of modern contraceptive use among sexually active adolescent girls increased from 13.1% (95% CI=10-17.0) in 2008 to 43.5% (95% CI=40.2-46.9) in 2019. In both the 2008 and 2019 surveys, the adjusted odds of using modern contraceptives among sexually active adolescent girls were higher among those with more than one sexual partner in the past 12 months, and with secondary or tertiary education. In 2019, the adjusted odds of using a modern contraceptive were also lower among adolescent girls who were married or living with a partner, had more than one child, and lived in the Western province. # Conclusions The increase in contraceptive use among adolescent girls in Sierra Leone had stalled since 2013. Interventions, including increasing awareness and accessibility to modern contraceptives, are urgently needed, particularly for adolescents without formal education. Comprehensive and affordable community and school-based interventions, including adolescent-friendly services, would be helpful.

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

Plain language summary In Kenya, about 15% of women age 15–19 have already had a birth and approximately one third of these women did not want to have a child at that time. Yet about 45% of sexually active women ages 15–24 report that they currently use family planning (FP). Among young people, friends and peers are an important influence on behaviors. This study focused on a representative sample from Kenya of female and male youth (ages 15–24) who ever had sex. Men and women were asked questions about use of FP, if they think their peers use FP and about characteristics such as age and education. The results showed that young women and men who believed their peers use FP were more likely to use FP themselves. Also, young men and women who believed that peers use FP were more likely to use condoms than not use any FP and more likely to use condoms than to use another modern method of FP. Young women who thought their peers use were more likely to use another modern method (not including condoms) than to be a nonuser of FP. Programs targeting young people should include information on a range of FP methods and aim to include groups of peers and encourage open discussion.

Abstract Background Insufficient reductions in maternal and neonatal deaths and stillbirths in the past decade are a deterrence to achieving the Sustainable Development Goal 3. The majority of deaths occur during the intrapartum and immediate postnatal period. Overcoming the knowledge-do-gap to ensure implementation of known evidence-based interventions during this period has the potential to avert at least 2.5 million deaths in mothers and their offspring annually. This paper describes a study protocol for implementing and evaluating a multi-faceted health care system intervention to strengthen the implementation of evidence-based interventions and responsive care during this crucial period. Methods This is a cluster randomised stepped-wedge trial with a nested realist process evaluation across 16 hospitals in Benin, Malawi, Tanzania and Uganda. The ALERT intervention will include four main components: i) end-user participation through narratives of women, families and midwifery providers to ensure co-design of the intervention; ii) competency-based training; iii) quality improvement supported by data from a clinical perinatal e-registry and iv) empowerment and leadership mentoring of maternity unit leaders complemented by district based bi-annual coordination and accountability meetings. The trial’s primary outcome is in-facility perinatal (stillbirths and early neonatal) mortality, in which we expect a 25% reduction. A perinatal e-registry will be implemented to monitor the trial. Our nested realist process evaluation will help to understand what works, for whom, and under which conditions. We will apply a gender lens to explore constraints to the provision of evidence-based care by health workers providing maternity services. An economic evaluation will assess the scalability and cost-effectiveness of ALERT intervention. Discussion There is evidence that each of the ALERT intervention components improves health providers’ practices and has modest to moderate effects. We aim to test if the innovative packaging, including addressing specific health systems constraints in these settings, will have a synergistic effect and produce more considerable perinatal mortality reductions. Trial registration Pan African Clinical Trial Registry ( www.pactr.org ): PACTR202006793783148. Registered on 17th June 2020.

Abstract Background The highest risk of maternal and perinatal deaths occurs during and shortly after childbirth and is preventable if functional referral systems enable women to reach appropriate health services when obstetric complications occur. Rising numbers of deliveries in health facilities, including in high mortality settings like Nigeria, require formalised coordination across the health system to ensure that women and newborns get to the right level of care, at the right time. This study describes and critically assesses the extent to which referral and its components can be captured using three different data sources from Nigeria, examining issues of data quality, validity, and usefulness for improving and monitoring obstetric care systems. Methods The study included three data sources on referral for childbirth care in Nigeria: a nationally representative household survey, patient records from multiple facilities in a state, and patient records from the apex referral facility in a city. We conducted descriptive analyses of the extent to which referral status and components were captured across the three sources. We also iteratively developed a visual conceptual framework to guide our critical comparative analysis. Results We found large differences in the proportion of women referred, and this reflected the different denominators and timings of the referral in each data source. Between 16 and 34% of referrals in the three sources originated in government hospitals, and lateral referrals (origin and destination facility of the same level) were observed in all three data sources. We found large gaps in the coverage of key components of referral as well as data gaps where this information was not routinely captured in facility-based sources. Conclusions Our analyses illustrated different perspectives from the national- to facility-level in the capture of the extent and components of obstetric referral. By triangulating across multiple data sources, we revealed the strengths and gaps within each approach in building a more complete picture of obstetric referral. We see our visual framework as assisting further research efforts to ensure all referral pathways are captured in order to better monitor and improve referral systems for women and newborns.

Abstract Introduction Job aids such as observation charts are commonly used to record inpatient nursing observations. For sick newborns, it is important to provide critical information, intervene, and tailor treatment to improve health outcomes, as countries work towards reducing neonatal mortality. However, inpatient vital sign readings are often poorly documented and little attention has been paid to the process of chart design as a method of improving care quality. Poorly designed charts do not meet user needs leading to increased mental effort, duplication, suboptimal documentation and fragmentation. We provide a detailed account of a process of designing a monitoring chart. Methods We used a Human-Centred Design (HCD) approach to co-design a newborn monitoring chart between March and May 2019 in three workshops attended by 16–21 participants each (nurses and doctors) drawn from 14 hospitals in Kenya. We used personas, user story mapping during the workshops and observed chart completion to identify challenges with current charts and design requirements. Two new charts were piloted in four hospitals between June 2019 and February 2020 and revised in a cyclical manner. Results Challenges were identified regarding the chart design and supply, and how staff used existing charts. Challenges to use included limited staffing, a knowledge deficit among junior staff, poor interprofessional communication, and lack of appropriate and working equipment. We identified a strong preference from participants for one chart to capture vital signs, assessment of the baby, and feed and fluid prescription and monitoring; data that were previously captured on several charts. Discussion Adopting a Human-Centred Design approach, we designed a new comprehensive newborn monitoring chart that is unlike observation charts in the literature that only focus on vital signs. While the new chart does not address all needs, we believe that once implemented, it can help build a clearer picture of the care given to newborns. Conclusion The chart was co-designed and piloted with the user and context in mind resulting in a unique monitoring chart that can be adopted in similar settings.

Objectives To assess HIV testing uptake and its determinants among adolescents and young adults.Design Cross-sectional design involving analysis of 2016 Demographic and Health Survey data.Setting Nationally representative survey of Burundi.Participants A total of 7218 young women and 2860 young men were included.Primary and secondary outcome We estimated the proportion of adolescent (15–19 years) and young adult (20–24 years) women and men who had tested for HIV and received results in the 12 months preceding the survey. Multivariable logistic models for determining predictors of HIV testing uptake were fitted among respondents aged 15–24 regardless of sexual activity in the 12 months before the survey and separately among a subset that reporting having had sex in the 12 months preceding the survey.Results An estimated 27.1% (95% CI 25.8% to 28.4%) women and 16.6% (95% CI 15.1% to 18.1%) men had tested for HIV and received results in the 12 months preceding the survey. The proportion was more than twice as high among those aged 20–24 years compared with 15–19 years, among both sexes. In multivariable analysis, older age (20–24 years) was associated with HIV testing (adjusted OR (aOR): 1.62, 95% CI 1.38 to 1.91) among women; (aOR: 1.78, 95% CI 1.32 to 2.40) among men. Higher educational level (aOR: 1.40, 95% CI 1.11 to 1.76) was significantly associated with HIV testing uptake among women. Male circumcision status, condom use, number of sex partners, history of STIs were not associated with HIV testing among the subset that reported having had sex in the 12 months preceding the survey.Conclusion Despite the interventions implemented to reach the 90-90-90 UNAIDS goals, HIV testing among youth in Burundi was low. Youth-friendly health centres should be part of strategies to stimulate young people to increase uptake of HIV preventive services in Burundi.

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

Plain English Summary In the last 30 years, the proportion of adolescents (10–19 years) in Uganda having a first live birth before age 18 years has declined. However, among these, the proportion who proceed to have another live birth before age 20 years (=repeat adolescent birth) has not declined. We therefore set out to find out what motivated or were the circumstance under which these adolescent girls had repeat adolescent birth. We answered this question by interviewing people in Eastern Uganda: 1) women age 20–25 years who had first birth before age 18 years; those with and without history of repeat adolescent birth, 2) the parents with girls who had first birth before 18 years, 3) partners to women with repeat adolescent birth, and 4) community leaders. We found that the financial challenges that had escalated following the first birth was responsible for the events or decisions that culminated into a repeat adolescent birth. In an attempt to find a solution to the financial challenges, the adolescent girls end up in unwanted unions with men and ultimately lost their power to decide on whether or not to get pregnant again. Many wanted to have this repeat birth later but were robbed of the opportunity to do so. The study findings suggest that beyond helping adolescent girls prevent the first birth, they need to be supported with economic empowerment activities, improved contraception services, and re-integration in school.

Résumé Contexte La plupart des décès maternels surviennent pendant les périodes intrapartum et péripartum en Afrique subsaharienne, ce qui souligne l'importance de l’accès à temps aux services de santé de qualité pour l'accouchement et les soins post-partum. L'augmentation des accouchements institutionnels et l’offre de soins post-partum ont fait l'objet de nombreuses interventions dans le monde entier, y compris en Afrique subsaharienne. L'objectif de cette étude est de synthétiser les caractéristiques et l'efficacité des interventions visant à accroître les accouchements institutionnels ou l’offre de soins post-partum en Afrique subsaharienne. Méthodes Nous avons recherché des revues systématiques, des revues de portée, des études qualitatives et des études quantitatives utilisant des types expérimentaux, quasi expérimentaux ou d'observation, qui rapportaient sur des interventions visant à accroître les accouchements institutionnels et l’offre de soins post-partum en Afrique subsaharienne. Ces études ont été publiées en anglais ou en français. La recherche a porté sur six bases de données de littérature scientifique (Pubmed, CAIRN, la Banque de Données en Santé Publique, la Cochrane Library). Nous avons également utilisé Google Scholar et le suivi des boules de neige ou des citations. Résultats Les stratégies identifiées dans la littérature comme accroissant les accouchements intentionnels dans le contexte de l'Afrique subsaharienne comprennent la sensibilisation des communautés, la réduction des dépenses de santé (transport ou frais d'utilisation), des programmes d'incitation non monétaires (kits pour bébés), ou une combinaison de ces éléments avec l'amélioration de la qualité des soins (respect de la vie privée du patient, temps d'attente, formation du prestataire), et ou le suivi des femmes enceintes pour qu'elles utilisent l'établissement de santé pour l'accouchement. Les stratégies qui ont été trouvées pour accroitre l’offre des soins post-partum comprennent l'amélioration de la qualité des soins, l'identification au niveau communautaire et la référence des problèmes post-partum et le programme de bons de transport. Conclusions Pour accélérer les réalisations en matière d'accouchement institutionnel et d’offre de soins post-partum en Afrique subsaharienne, nous recommandons des stratégies qui peuvent être mises en œuvre de manière durable ou produire des changements durables. La manière de motiver durablement les acteurs communautaires dans les interventions sanitaires peut être particulièrement importante à cet égard. En outre, nous recommandons que davantage d'études d'intervention soient mises en œuvre en Afrique de l'Ouest et du Centre, et qu'elles soient davantage axées sur les soins post-partum.

Abstract Background In Guinea, high fertility among adolescents and young women in urban areas remains a public health concern. This study describes trends in contraceptive use, unmet need, and factors associated with the use of modern family planning (FP) methods among urban adolescents and young women in Guinea. Methods We used four Guinea Demographic and Health Surveys (DHS) conducted in 1999, 2005, 2012, and 2018. Among urban adolescents and young women (15–24 years), we examined trends over time in three key indicators: 1. Modern Contraceptive use, 2. Unmet need for FP and 3. Modern contraceptive use among those in need of FP (demand satisfied). We used multivariable logistic regression to examine association between socio-demographic factors and modern FP use on the most recent DHS dataset (2018). Results We found statistically significant changes over the time period examined with an increase in modern contraceptive use (8.4% in 1999, 12.8% in 2018, p

Introduction Despite a strong evidence base for developing interventions to reduce child mortality and morbidity related to pregnancy and delivery, major knowledge–implementation gaps remain. The Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project aims to overcome these gaps through strengthening the capacity of multidisciplinary teams that provide maternity care. The intervention includes competency-based midwife training, community engagement for study design, mentoring and quality improvement cycles. The realist process evaluation of ALERT aims at identifying and testing the causal pathway through which the intervention achieves its impact.Methods and analysis This realist process evaluation complements the effectiveness evaluation and the economic evaluation of the ALERT intervention. Following the realist evaluation cycle, we will first elicit the initial programme theory on the basis of the ALERT theory of change, a review of the evidence on adoption and diffusion of innovations and the perspectives of the stakeholders. Second, we will use a multiple embedded case study design to empirically test the initial programme theory in two hospitals in each of the four intervention countries. Qualitative and quantitative data will be collected, using in-depth interviews with hospital staff and mothers, observations, patient exit interviews and (hospital) document reviews. Analysis will be guided by the Intervention-Actors-Context-Mechanism-Outcome configuration heuristic. We will use thematic coding to analyse the qualitative data. The quantitative data will be analysed descriptively and integrated in the analysis using a retroductive approach. Each case study will end with a refined programme theory (in-case analysis). Third, we will carry out a cross-case comparison within and between the four countries. Comparison between study countries should enable identifying relevant context factors that influence effectiveness and implementation, leading to a mid-range theory that may inform the scaling up the intervention.Ethics and dissemination In developing this protocol, we paid specific attention to cultural sensitivity, the do no harm principle, confidentiality and non-attribution. We received ethical approval from the local and national institutional review boards in Tanzania, Uganda, Malawi, Benin, Sweden and Belgium. Written or verbal consent of respondents will be secured after explaining the purpose, potential benefits and potential harms of the study using an information sheet. The results will be disseminated through workshops with the hospital staff and national policymakers, and scientific publications and conferences.Trial registration number PACTR202006793783148.

Abstract Background Since the introduction of highly active antiretroviral therapy (HAART), acquired immune deficiency syndrome (AIDS) related mortality has markedly declined. As HAART is becoming increasingly available, the infection with human immunodeficiency virus (HIV+) in sub-Saharan Africa (SSA) is becoming a chronic condition. While pregnancy in HIV+ women in SSA has always been considered a challenging event for the mother and the fetus, for pregnant HIV+ women also diagnosed with epilepsy (WWE), there are additional risks as HIV increases the odds of developing seizures due to the vulnerability of the central nervous system to other infections, immune dysfunction, and overall metabolic disturbances. In light of a growing proportion of HIV+ WWE on HAART and an increasing number of pregnant women accessing mother-to-child transmission of HIV programs through provision of HAART in SSA, there is a need to develop contextualized and evidenced-based clinical strategies for the management of epilepsy in this population. In this study, we conduct a literature scoping review to identify issues that warrant consideration for clinical management. Result Twenty-three articles were retained after screening, which covered six overarching clinical aspects: status epilepticus (SE), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), dyslipidemia, congenital malformation (CM), chronic kidney disease (CKD), and neurological development. No studies for our population of interest were identified, highlighting the need for a cautionary approach to be employed when extrapolating findings. Conclusion High risks of CM and drug interactions with first-line antiepileptic drugs (AEDs) warrant measures to increase the accessibility and choices of safer second-line AEDs. To ensure evidence-based management of epilepsy within this population, the potential high prevalence of SE, CKD, dyslipidemia, and SJS/TEN and the cumulative effect of drug-drug interactions should be considered. Further understanding of the intersections between pregnancy and drug-drug interactions in SSA is needed to ensure evidenced-based management of epilepsy in pregnant HIV+ WWE. To prevent SE, the barriers for AED treatment adherence in pregnant HIV+ women should be explored. Our review underscores the need to conduct cohort studies of HIV+ WWE in reproductive age over time and across pregnancies to capture the cumulative effect of HAART and AED to inform clinical management.

Abstract Background In efforts to reduce neonatal mortality, the World Health Organization (WHO) has included breastfeeding among its recommended packages of interventions. Early initiation of breastfeeding and avoidance of prelacteal feeding are key contributors to optimal feeding practices. This study aims to assess the prevalence and associated factors of early breastfeeding practices in Sudan. Methods This study utilises the cross-sectional nationally-representative Sudan Multiple Indicator Cluster Survey (MICS) conducted in 2014. The sample includes women who had a live birth in the two years before the survey and their self-report on early breastfeeding practices, namely early initiation and prelacteal feeding. Percentages of these early breastfeeding practices indicators were estimated accounting for the complex survey design. Multivariable logistic regression analyses were used to examine the factors associated with these outcomes. Results Of 5622 mothers, 69% initiated breastfeeding within one hour of birth, 72% avoided prelacteal feeding in the first three days after birth, and 51% met the criteria for both (i.e. practised optimal early feeding practice). Optimal early feeding varied across regions of Sudan. Birth by caesarean section (Adjusted Odds Ratio [AOR] 0.34; 95% CI 0.25, 0.47) and at a health facility (AOR 0.75; 95% CI 0.60, 0.94) were negatively associated with optimal early feeding practice. Mothers with secondary education (AOR 1.62; 95% CI 1.30, 2.02), those who desired their pregnancy at the time (AOR 1.31; 95% CI 1.08, 1.60), those who were assisted by a skilled birth attendant at birth (AOR 1.48; 95% CI 1.19, 1.83), and those who gave birth to female infants (AOR 1.16; 95% CI 1.02, 1.33) had higher odds of use optimal early feeding practice. Similarly, the odds of optimal early feeding increased with parity and maternal age. Conclusions Only half of Sudanese mothers practised optimal early feeding practice, with important differences between regions in the country. Early feeding practices in Sudan are associated with various maternal, child and community level factors. The findings suggest the need to develop breastfeeding promotion programs with consideration of regional variations and healthcare system interventions.

Abstract Introduction Uganda has high adolescent pregnancy. The details of adolescent childbirth and urban/rural patterns are scarce. We investigated the levels, time trends and determinants of adolescent childbirth in Uganda separately for urban and rural women. Methods We estimated the percentage of women 20–24 years at each of the six Uganda Demographic and Health Surveys (1988/89, 1995, 2000/01, 2006, 2011 and 2016) who reported a live childbirth before age 20 years (“adolescent childbirth”), and examined change over time using t-test. A modified multivariable Poisson regression was used to examine determinants of having adolescent childbirth on the 2016 survey. Results Among these women, 67.5, 66.4, 70.1, 62.3, 57.3 and 54.1% reported an adolescent childbirth in 1988/89, 1995, 2000/01, 2006, 2011 and 2016 surveys, respectively. Between 1988/89 to 2000/01, there was no evidence of change (+ 2.6% point (pp), p = 0.170), unlike between the 2000/01 and 2016 surveys when a significant decline occurred (− 16.0 pp., p

Abstract Background The Sustainable Development Goals (SDGs) include specific targets for family planning (SDG 3.7) and birth attendance (SDG 3.1.2), and require analyses disaggregated by age and other dimensions of inequality (SDG 17.18). We aimed to describe coverage with demand for family planning satisfied with modern methods (DFPSm) and institutional delivery in low- and middle-income countries across the reproductive age spectrum. We attempted to identify a typology of patterns of coverage by age and compare their distribution according to geographic regions, World Bank income groups and intervention coverage levels. Methods We used Demographic and Health Survey and Multiple Indicator Cluster Surveys. For DFPSm, we considered the woman’s age at the time of the survey, whereas for institutional delivery we considered the woman’s age at birth of the child. Both age variables were categorized into seven groups of 5 year-intervals, 15–19 up to 45–49. Five distinct patterns were identified: (a) increasing coverage with age; (b) similar coverage in all age groups; (c) U-shaped; (d) inverse U-shaped; and (e) declining coverage with age. The frequency of the five patterns was examined according to UNICEF regions, World Bank income groups, and coverage at national level of the given indicator. Results We analyzed 91 countries. For DFPSm, the most frequent age patterns were inverse U-shaped (53%, 47 countries) and increasing coverage with age (41%, 36 countries). Inverse-U shaped patterns for DFPSm was the commonest pattern among lower-middle income countries, while low- and upper middle-income countries showed a more balanced distribution between increasing with age and U-shaped patterns. In the first and second tertiles of national coverage of DFPSm, inverse U-shaped was observed in more than half of countries. For institutional delivery, declining coverage with age was the prevailing pattern (44%, 39 countries), followed by similar coverage across age groups (39%, 35 countries). Most (79%) upper-middle income countries showed no variation by age group while most low-income countries showed declining coverage with age (71%). Conclusion Large inequalities in DFPSm and institutional delivery were identified by age, varying from one intervention to the other. Policy and programmatic approaches must be tailored to national patterns, and in most cases older women and adolescents will require special attention due to lower coverage and because they are at higher risk for maternal mortality and other poor obstetrical outcomes.

Abstract Background In 2004, The Kenyan government removed user fees in public dispensaries and health centers and replaced them with registration charges of 10 and 20 Kenyan shillings (2004 $US 0.13 and $0.25), respectively. This was termed the 10/20 policy. We examined the effect of this policy on the coverage, timing, source, and content of antenatal care (ANC), and the equity in these outcomes. Methods Data from the 2003, 2008/9 and 2014 Kenya Demographic and Health Surveys were pooled to investigate women’s ANC care-seeking. We conducted an interrupted time series analysis to assess the impact of the 10/20 policy on the levels of and trends in coverage for 4+ ANC contacts among all women; early ANC initiation and use of public facility-based care among 1+ ANC users; and use of public primary care facilities and receipt of good content, or quality, of ANC among users of public facilities. All analyses were conducted at the population level and separately for women with higher and lower household wealth. Results The policy had positive effects on use of 4+ ANC among both better-off and worse-off women. Among users of 1+ ANC, the 10/20 policy had positive effects on early ANC initiation at the population-level and among better-off women, but not among the worse-off. The policy was associated with reduced use of public facility-based ANC among better-off women. Among worse-off users of public facility-based ANC, the 10/20 policy was associated with reduced use of primary care facilities and increased content of ANC. Conclusions This study highlights mixed findings on the impact of the 10/20 policy on ANC service-seeking and content of care. Given the reduced use of public facilities among the better-off and of primary care facilities among the worse-off, this research also brings into question the mechanisms through which the policy achieved any benefits and whether reducing user fees is sufficient for equitably increasing healthcare access.

Abstract Background Egypt has achieved important reductions in maternal and neonatal mortality and experienced increases in the proportion of births attended by skilled professionals. However, substandard care has been highlighted as one of the avoidable causes behind persisting maternal deaths. This paper describes changes over time in the use of childbirth care in Egypt, focusing on location and sector of provision (public versus private) and the content of immediate postpartum care. Methods We used five Demographic and Health Surveys conducted in Egypt between 1995 and 2014 to explore national and regional trends in childbirth care. To assess content of care in 2014, we calculated the caesarean section rate and the percentage of women delivering in a facility who reported receiving four components of immediate postpartum care for themselves and their newborn. Results Between 1995 and 2014, the percentage of women delivering in health facilities increased from 35 to 87% and women delivering with a skilled birth attendant from 49 to 92%. The percentage of women delivering in a private facility nearly quadrupled from 16 to 63%. In 2010–2014, fewer than 2% of women delivering in public or private facilities received all four immediate postpartum care components measured. Conclusions Egypt achieved large increases in the percentage of women delivering in facilities and with skilled birth attendants. However, most women and newborns did not receive essential elements of high quality immediate postpartum care. The large shift to private facilities may highlight failures of public providers to meet women’s expectations. Additionally, the content (quality) of childbirth care needs to improve in both sectors. Immediate action is required to understand and address the drivers of poor quality, including insufficient resources, perverse incentives, poor compliance and enforcement of existing standards, and providers’ behaviours moving between private and public sectors. Otherwise, Egypt risks undermining the benefits of high coverage because of substandard quality childbirth care.

Abstract Background In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries. Methods We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors. Results The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play. Conclusions Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.

IntroductionMaternal mortality remains very high in Sub-Saharan African countries and the risk is higher among adolescent girls. Maternal mortality occurs in these settings mainly around the time of childbirth and the first 24 hours after birth. Therefore, skilled attendance in an enabling environment is essential to reduce the occurrence of adverse outcomes for both women and their children. This study aims to analyze the determinants of facility childbirth among adolescents and young women in Guinea.MethodsWe used the Guinea Demographic and Health Survey (DHS) conducted in 2018. All females who were adolescents (15-19) or young women (20-24 years) at the time of their most recent live birth in the five years before the survey were included. We examined the use of health facilities for childbirth and its determinants selected through the Andersen health-seeking model using descriptive analysis and multilevel multivariable logistic regression. All descriptive and analytical estimated were produced by adjusting for the survey sampling using the svy option, including adjustment for clustering, stratification and unequal probability of selection and non-response (individual sample weights). The subpopulation option was also used to account for the variance of estimations.ResultsOverall, 58% of adolescents and 57% of young women gave birth in a health facility. Young women were more likely to have used private sector facilities compared to adolescents (pConclusionThe percentage of births in health facilities among adolescents and young women in Guinea was 58%. This remains suboptimal regarding the challenges associated maternal mortality and morbidity issues in Guinea. Socio-economic characteristics, region of residence and antenatal care use were the main determinants of its use. Efforts to improve maternal health among this group should target care discontinuation between antenatal care and childbirth (primarily by removing financial barriers) and increasing the demand for facility-based childbirth services in communities, while paying attention to the quality and respectful nature of healthcare services provided there.

The COVID-19 pandemic continues to have substantial impacts on health systems globally. This study describes experiences during the COVID-19 pandemic, and physical, psychological and economic impacts among maternal and newborn healthcare providers. We conducted a global online cross-sectional survey of maternal and newborn healthcare providers. Data collected between July and December 2020 included demographic characteristics, work-related experiences, and physical, psychological, and economic impacts of COVID-19. Descriptive statistics of quantitative data and content analysis of qualitative data were conducted. Findings were disaggregated by country income-level. We analysed responses from 1,191 maternal and newborn healthcare providers from 77 countries: middle-income 66%, high-income 27%, and low-income 7%. Most common cadres were nurses (31%), midwives/nurse-midwives (25%), and obstetricians/gynaecologists (21%). Quantitative and qualitative findings showed that 28% of respondents reported decreased workplace staffing levels following changes in staff-rotation (53%) and staff self-isolating after exposure to SARS-CoV-2 (35%); this led to spending less time with patients, possibly compromising care quality. Reported insufficient access to personal protective equipment (PPE) ranged from 12% for gloves to 32% for N-95 masks. Nonetheless, wearing PPE was tiresome, time-consuming, and presented potential communication barriers with patients. 58% of respondents reported higher stress levels, mainly related to lack of access to information or to rapidly changing guidelines. Respondents noted a negative financial impact-a decrease in income (70% among respondents from low-income countries) concurrently with increased personal expenditures (medical supplies, transportation, and PPE). Negative physical, psychological and economic impacts of COVID-19 on maternal and newborn healthcare providers were ongoing throughout 2020, especially in low-income countries. This can have severe consequences for provision and quality of essential care. There is need to increase focus on the implementation of interventions aiming to support healthcare providers, particularly those in low- and middle-income countries to protect essential health services from disruption.

Documenting inpatient care is largely paper-based and it facilitates team communication and future care planning. However, studies show that nursing documentation remains suboptimal especially for newborns, necessitating introduction of standardised paper-based charts. We report on a process of implementing a comprehensive newborn monitoring chart and the perceptions of health workers in a network of hospitals in Kenya. The chart was launched virtually in July 2020 followed by learning meetings with nurses and the research team. This is a qualitative study involving document review, individual in-depth interviews with nurses and paediatricians and a focus group discussion with data clerks. The chart was co-designed by the research team and hospital staff then implemented using a trainer of trainers' model where the nurses-in-charge were trained on how to use the chart and they in turn trained their staff. Training at the hospital was delivered by the nurse-in-charge and/or paediatrician through a combined training with all staff or one-on-one training. The chart was well received with health workers reporting reduced writing, consolidated information, and improved communication as benefits. Implementation was facilitated by individual and team factors, complementary projects, and the removal of old charts. However, challenges arose related to the staff and work environment, inadequate supply of charts, alternative places to document, and inadequate equipment. The participants suggested that future implementation should be accompanied by mentorship or close follow-up, peer experience sharing, training at the hospital and in pre-service institutions and wider stakeholder engagement. Findings show that there are opportunities to improve the implementation process by clarifying roles relating to the filing system, improving the chart supply process, staff induction and specifying a newborn patient file. The chart did not meet the need for supporting documentation of long stay patients presenting an opportunity to explore digital solutions that might provide more flexibility and features.

Routine postnatal care (PNC) allows monitoring, early detection and management of complications, and counselling to ensure immediate and long-term wellbeing of mothers and newborns; yet effective coverage is sub-optimal globally. The COVID-19 pandemic disrupted availability and quality of maternal and newborn care despite established guidelines promoting continuity of essential services. We conducted a cross-sectional global online survey of 424 maternal and newborn healthcare providers from 61 countries, to explore PNC provision, availability, content and quality following the early phase of the COVID-19 pandemic. The questionnaire (11 languages), included four multiple-choice and four open-text questions on changes to PNC during the pandemic. Quantitative and qualitative responses received between July and December 2020 were analysed separately and integrated during reporting. Tightened rules for visiting postpartum women were reported in health facilities, ranging from shorter visiting hours to banning supportive companions and visitors. A quarter (26%) of respondents reported that mothers suspected/confirmed with COVID-19 were routinely separated from their newborns. Early initiation of breastfeeding was delayed due to waiting for maternal SARS-CoV-2 test results. Reduced provision of breastfeeding support was reported by 40% of respondents in high-income countries and 7% in low-income countries. Almost 60% reported that women were discharged earlier than usual and 27% perceived a reduction in attendance to outpatient PNC. Telemedicine and home visits were mostly reported in high-income countries to ensure safe care provision. Beyond the early phase of the COVID-19 pandemic, severe disruptions to content and quality of PNC continued to exist, whereas disruptions in availability and use were less commonly reported. Depriving women of support, reducing availability of PNC services, and mother-newborn separation could lead to negative long-term outcomes for women, newborns and families, and deny their rights to respectful care. Protecting these essential services is imperative to promoting quality woman-centred PNC during and beyond the pandemic.

Introduction: Acceptability of and satisfaction with contraceptive methods are paramount for uptake and continuation. In the current context of multipurpose prevention of pregnancy and sexually transmitted diseases/HIV development, it is critical to have a better understanding of acceptability of and satisfaction with the contraceptive vaginal ring (CVR) including sexual satisfaction. The objective of this study was to review the evidence about acceptability of CVRs and general and sexual satisfaction of users.Methods: We searched PubMed, CINAHL, and Web of Science (until December 31, 2020) and selected original studies documenting actual use of hormonal CVR and explicitly addressing any of the 3 outcomes.Results: Of a total of 1,129 records screened, 46 studies were included. Most studies (n = 43, 93%) were prospective, conducted in high-income settings (n = 35), and reported on NuvaRing® use (n = 31). Overall, 27 (59%) studies included a comparison group, 38 (82%) studies used exclusively quantitative questionnaires, with qualitative only (n = 4, 9%), or mixed methods (n = 4, 9%) studies being less common. Ease of CVR insertion/removal/reinsertion was high in all the settings and improved with time of use, with qualitative studies supporting these findings. When mentioned, ring-related events were associated with discontinuation, and results on continuation of use were mixed. Among NuvaRing® studies, general satisfaction (being satisfied or very satisfied) was between 80 and 90% and tended to mirror continuation. Sexual satisfaction was less commonly reported and results were mixed. Overall, limited information was provided on actual CVR experiences of women (and men) and cultural norms that may affect sexuality and CVR use.Conclusion: Positive aspects of acceptability of and satisfaction with CVRs were reported, but ring-related events and factors, which may affect long-term CVR use, deserve further study. More information is needed on actual experiences of women using CVRs, relationship aspects, male partner opinions, and contextual norms to better understand the acceptability of and satisfaction with CVRs.

Introduction Access to emergency obstetric care can lead to a 45%–75% reduction in stillbirths. However, before a pregnant woman can access this care, she needs to travel to a health facility. Our objective in this study was to assess the influence of distance and travel time to the actual hospital of care on stillbirth.Methods We conducted a retrospective cross-sectional study of pregnant women who presented with obstetric emergencies over a year across all 24 public hospitals in Lagos, Nigeria. Reviewing clinical records, we extracted sociodemographic, travel and obstetric data. Extracted travel data were exported to Google Maps, where typical distance and travel time for period-of-day they travelled were extracted. Multivariable logistic regression was conducted to determine the relative influence of distance and travel time on stillbirth.Results Of 3278 births, there were 408 stillbirths (12.5%). Women with livebirths travelled a median distance of 7.3 km (IQR 3.3–18.0) and over a median time of 24 min (IQR 12–51). Those with stillbirths travelled a median distance of 8.5 km (IQR 4.4–19.7) and over a median time of 30 min (IQR 16–60). Following adjustments, though no significant association with distance was found, odds of stillbirth were significantly higher for travel of 10–29 min (OR 2.25, 95% CI 1.40 to 3.63), 30–59 min (OR 2.30, 95% CI 1.22 to 4.34) and 60–119 min (OR 2.35, 95% CI 1.05 to 5.25). The adjusted OR of stillbirth was significantly lower following booking (OR 0.37, 95% CI 0.28 to 0.49), obstetric complications with mother (obstructed labour (OR 0.11, 95% CI 0.07 to 0.17) and haemorrhage (OR 0.30, 95%CI 0.20 to 0.46)). Odds were significantly higher with multiple gestations (OR 2.40, 95% CI 1.57 to 3.69) and referral (OR 1.55, 95% CI 1.13 to 2.12).Conclusion Travel time to a hospital was strongly associated with stillbirth. In addition to birth preparedness, efforts to get quality care quicker to women or women quicker to quality care will be critical for efforts to reduce stillbirths in a principally urban low-income and middle-income setting.

Objectives The prevalence of diabetes has reportedly increased among adolescents in low-income and middle-income countries of the Middle East and may be linked to social, demographic and economic contextual factors. This study aimed: (1) to estimate the prevalence of self-reported diagnosis of diabetes in the adolescent population of the United Arab Emirates (UAE); (2) to assess differences in the prevalence based on gender and (3) to identify other characteristics of those with diabetes including parental marital status, smoking/illegal drug use, quality of life and nationality.Design A secondary data analysis was performed on data from the National Study of Population Health in the UAE, conducted between 2007 and 2009.Setting Large cross-sectional population-based survey study.Participants Survey was administered to a stratified random sample of 151 public and private schools from the UAE, across 7 emirates. 6365 school-attending adolescents (12–22 years; mean=16 years) participated.Outcomes Multivariable logistic regression analysis was used to examine the relationships between diabetes diagnosis and characteristics of participants after adjusting for confounding from other predictors.Results The overall prevalence of self-reported diabetes was 0.9% (95% CI 0.7% to 1.2%) and was higher in males 1.5% (95% CI 1.0% to 2.1%) than females 0.5% (95% CI 0.3% to 0.8%), (p

Abstract Background Egypt has seen substantial decreases in maternal mortality and reached near universal coverage for antenatal care (ANC). The objective of this paper is to describe the changes over time (1991–2014) in the use of ANC in Egypt, focusing on sector of provision (public versus private), and the content and equity of this care, to inform future policies for improving maternal and newborn health. Methods We used Demographic and Health surveys (DHS) conducted in Egypt in 1995, 2000, 2005, 2008 and 2014 to explore national and regional trends in ANC. To assess content of care, we calculated the percentage of ANC users who reported receiving seven ANC components measured in DHS in 2014. Results During the period under consideration, the percentage of women in need of ANC who received facility-based ANC increased from 42 to 90%, the majority of which was private-sector ANC. The mean number of ANC visits among ANC users increased over time from 7.5 (95% confidence interval [CI] = 7.1–7.9) in 1991–1995 to 9.7 (95%CI 9.6–9.9) in 2010–2014. In 2010–2014, 44% of women using public ANC reported eight or more visits compared to 71% in private ANC. In the same period, 24% of ANC users received all seven care components. This percentage ranged from 10% of women reporting fewer than four ANC visits to 29% of women reporting eight or more. The poorest ANC users received all seven measured components of care less often than the wealthiest (20% versus 28%, p-value

Introduction Progress in reducing maternal and neonatal mortality, particularly in sub-Saharan Africa, is insufficient to achieve the Sustainable Developmental Goals by 2030. The first 24 hours following childbirth (immediate postnatal period), where the majority of morbidity and mortality occurs, is critical for mothers and babies. In Uganda,

Introduction The COVID-19 pandemic has led to a rapid implementation of telemedicine for the provision of maternal and newborn healthcare. The objective of this study was to document the experiences with providing telemedicine for maternal and newborn healthcare during the pandemic among healthcare professionals globally.Methods The second round of a global online survey of maternal and newborn health professionals was conducted, disseminated in 11 languages. Data were collected between 5 July and 10 September 2020. The questionnaire included questions regarding background, preparedness and response to COVID-19, and experiences with providing telemedicine. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregated by country income level.Results Responses from 1060 maternal and newborn health professionals were analysed. Telemedicine was used by 58% of health professionals and two-fifths of them reported not receiving guidelines on the provision of telemedicine. Key telemedicine practices included online birth preparedness classes, antenatal and postnatal care by video/phone, a COVID-19 helpline and online psychosocial counselling. Challenges reported lack of infrastructure and technological literacy, limited monitoring, financial and language barriers, lack of non-verbal feedback and bonding, and distrust from patients. Telemedicine was considered as an important alternative to in-person consultations. However, health providers emphasised the lower quality of care and risk of increasing the already existing inequalities in access to healthcare.Conclusions Telemedicine has been applied globally to address disruptions of care provision during the COVID-19 pandemic. However, some crucial aspects of maternal and newborn healthcare seem difficult to deliver by telemedicine. More research regarding the effectiveness, efficacy and quality of telemedicine for maternal healthcare in different contexts is needed before considering long-term adaptations in provision of care away from face-to-face interactions. Clear guidelines for care provision and approaches to minimising socioeconomic and technological inequalities in access to care are urgently needed.

Objectives To describe the long-term socioeconomic and reproductive health outcomes of women in Uganda by adolescent birth history.Design Cross-sectional study.Setting Uganda.Participants Women aged 40–49 years at the 2016 Uganda Demographic and Health Survey.Outcome measures We compared socioeconomic and reproductive outcomes among those with first birth

Background Travel time to comprehensive emergency obstetric care (CEmOC) facilities in low-resource settings is commonly estimated using modelling approaches. Our objective was to derive and compare estimates of travel time to reach CEmOC in an African megacity using models and web-based platforms against actual replication of travel.Methods We extracted data from patient files of all 732 pregnant women who presented in emergency in the four publicly owned tertiary CEmOC facilities in Lagos, Nigeria, between August 2018 and August 2019. For a systematically selected subsample of 385, we estimated travel time from their homes to the facility using the cost-friction surface approach, Open Source Routing Machine (OSRM) and Google Maps, and compared them to travel time by two independent drivers replicating women’s journeys. We estimated the percentage of women who reached the facilities within 60 and 120 min.Results The median travel time for 385 women from the cost-friction surface approach, OSRM and Google Maps was 5, 11 and 40 min, respectively. The median actual drive time was 50–52 min. The mean errors were >45 min for the cost-friction surface approach and OSRM, and 14 min for Google Maps. The smallest differences between replicated and estimated travel times were seen for night-time journeys at weekends; largest errors were found for night-time journeys at weekdays and journeys above 120 min. Modelled estimates indicated that all participants were within 60 min of the destination CEmOC facility, yet journey replication showed that only 57% were, and 92% were within 120 min.Conclusions Existing modelling methods underestimate actual travel time in low-resource megacities. Significant gaps in geographical access to life-saving health services like CEmOC must be urgently addressed, including in urban areas. Leveraging tools that generate ‘closer-to-reality’ estimates will be vital for service planning if universal health coverage targets are to be realised by 2030.

Background Telemedicine enables new forms of medical consultation and is expanding worldwide. Patients in sub-Saharan Africa could potentially benefit substantially from telemedicine. Objective To improve primary healthcare services, especially referrals to the district hospital, for the population in three health centres in the rural district Kingandu in the Democratic Republic of the Congo (DRC) by introducing Smart Glasses, and leveraging them for telemedicine. Methods The project involved the design and introduction of an intervention combining community engagement with technological innovation (Smart Glasses, communication equipment, moto-ambulances, and new diagnostic tests), and with staff training. Utilisation of the intervention, use of the health centres, and referrals to the hospital were monitored through the routine health information system and project-specific registers. Key stakeholders were interviewed and the project costs were analysed. Results The use cases for the intervention were defined in consultation with the stakeholders. Smart Glasses were used in 10% of consultations in the health centres mostly for advice during curative consultations. The total number of consultations increased significantly in the intervention health centres. The number of referrals to the hospital remained stable, but an increased proportion effectively arrived in the hospital. The Smart Glasses and moto-ambulance greatly facilitated emergency referrals, often requiring a potentially life-saving intervention in the hospital. All stakeholders involved highly valued the intervention. Conclusion Telemedicine can contribute to improving primary healthcare services in a remote rural area, as part of a more comprehensive intervention and with intensive participation of all stakeholders. It can increase acceptability and use of the existing services; improve diagnosis, treatment, and referral of patients; and can also facilitate on-the-job training and supportive supervision.

Introduction Fertility levels among adolescents remain high in many settings. The objective of this paper was to review the available literature about postpartum and lactational amenorrhoea among adolescents in low-income and middle-income countries (LMICs).Methods We searched Medline, Embase, Global Health and CINAHL Plus databases using terms capturing adolescence and lactational or postpartum amenorrhoea. Inclusion criteria included publication date since 1990, data from LMICs, and topic related to lactational amenorrhoea as a postpartum family planning method or as an effect of (exclusive) breast feeding among adolescents. Thematic analysis and narrative synthesis were applied to summarise and interpret the findings.Results We screened 982 titles and abstracts, reviewed 75 full-text articles and included nine. Eight studies assessed data from a single country (three from India, two from Bangladesh, two from Turkey, one from Nigeria). One study using Demographic and Health Survey data included 37 different LMICs. The five studies measuring duration of postpartum or lactational amenorrhoea reported a wide range of durations across the contexts examined. Four studies (from Bangladesh, Nigeria and Turkey) examined outcomes related to the use of lactational amenorrhoea as a family planning method among adolescents. We did not find any studies assessing adolescents’ knowledge of lactational amenorrhoea as a postpartum family planning method. Likewise, little is known about the effectiveness of lactational amenorrhoea method among adolescents using sufficiently large samples and follow-up time.Conclusion The available evidence on lactational amenorrhoea among adolescents in LMICs is scarce. Given the potential contribution of lactational amenorrhoea to prevention of short interpregnancy intervals among adolescents and young women, there is a need for a better understanding of the duration of lactational amenorrhoea, and the knowledge and effective use of lactational amenorrhoea method for family planning among adolescents in a wider range of LMIC settings.