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Nancy A Scott,1 Elizabeth G Henry,1 Jeanette L Kaiser,1 Kaluba Mataka,2 Peter C Rockers,1 Rachel M Fong,1 Thandiwe Ngoma,3 Davidson H Hamer,1,4 Michelle L Munro-Kramer,5 Jody R Lori6 1Department of Global Health, Boston University School of Public Health, Boston, MA, USA; 2Akros Zambia, Lusaka, Zambia; 3Right to Care Zambia, Lusaka, Zambia; 4Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, MA, USA; 5Department of Health Behavior & Biological Sciences, University of Michigan School of Nursing, Ann Arbor, MI, USA; 6Department of Health Behavior & Biological Sciences, University of Michigan, School of Nursing, Ann Arbor, MI USA Purpose: Access to skilled care and facilities with capacity to provide emergency obstetric and newborn care is critical to reducing maternal mortality. In rural areas of Zambia, 42% of women deliver at home, suggesting persistent challenges for women in seeking, reaching, and receiving quality maternity care. This study assessed the determinants of home delivery among remote women in rural Zambia.Methods: A household survey was administered to a random selection of recently delivered women living 10 km or more from their catchment area health facility in 40 sites. A subset of respondents completed an in-depth interview. Multiple regression and content analysis were used to analyze the data.Results: The final sample included 2,381 women, of which 240 also completed an interview. Households were a median of 12.8 km (interquartile range 10.9, 16.2) from their catchment area health facility. Although 1% of respondents intended to deliver at home, 15.3% of respondents actually delivered at home and 3.2% delivered en route to a facility. Respondents cited shorter than expected labor, limited availability and high costs of transport, distance, and costs of required supplies as reasons for not delivering at a health facility. After adjusting for confounders, women with a first pregnancy (adjusted OR [aOR]: 0.1, 95% CI: 0.1, 0.2) and who stayed at a maternity waiting home (MWH) while awaiting delivery were associated with reduced odds of home delivery (aOR 0.1, 95% CI: 0.1, 0.2). Being over 35 (aOR 1.3, 95% CI: 0.9, 1.9), never married (aOR 2.1, 95% CI: 1.2, 3.7), not completing the recommended four or more antenatal visits (aOR 2.0, 95% CI: 1.5, 2.5), and not living in districts exposed to a large-scale maternal health program (aOR 3.2, 95% CI: 2.3, 4.5) were significant predictors of home delivery. After adjusting for confounders, living nearer to the facility (9.5–10 km) was not associated with reduced odds of home delivery, though the CIs suggest a trend toward significance (aOR 0.7, 95% CI: 0.4, 1.1).Conclusion: Findings highlight persistent challenges facing women living in remote areas when it comes to realizing their intentions regarding delivery location. Interventions to reduce home deliveries should potentially target not only those residing farthest away, but multigravida women, those who attend fewer antenatal visits, and those who do not utilize MWHs. Keywords: distance, maternal health, pregnancy, delivery location, maternity waiting home, mixed-methods

Aims: Addressing sexual and gender-based violence (SGBV) in educational settings across the globe, particularly in institutions of higher education, requires strong institutional framework and policy guidelines. Most research about university SGBV policies has focused on high-income countries with little or no recourse to universities in low- and middle-income countries. This policy analysis aims to analyze existing policies related to SGBV from select sub-Saharan African universities to provide guidance on best practices toward addressing SGBV at universities in Africa., Methods: Seven university policies and six national policies from six countries across sub-Saharan Africa (Ghana, Liberia, Nigeria, Rwanda, South Africa, and Zimbabwe) were reviewed using a standardized data extraction form. The policy analysis identified eight key elements of policies related to SGBV for sub-Saharan African universities, which were verified using a nominal group technique with five international experts in the field., Results: Overall, policies varied significantly in accessibility, terminology, definitions, format, and inclusivity across the sites. Some of the policies were not readily accessible, and there was limited evidence provided in some of the policy documents., Conclusions: Policies for universities in sub-Saharan Africa should (a) be evidence based, (b) be readily available in multiple formats, (c) define key terms broadly with gendered signifiers, (d) be succinct and concise, (e) incorporate broad definitions for all university stakeholders, (f) identify who created the policy and when, (g) address prevention, and (h) address response. Evidence-based policies addressing SGBV prevention, response, and justice are sorely needed at universities across the globe., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 International Association of Forensic Nurses.)

Background: Utilizing maternity waiting homes (MWHs) is a strategy to improve access to skilled obstetric care in rural Zambia. However, out-of-pocket (OOP) expenses remain a barrier for many women. We assessed delivery-related expenditure for women who used MWHs and those who did not who delivered at a rural health facility., Methods: During the endline of an impact evaluation for an MWH intervention, household surveys (n = 826) were conducted with women who delivered a baby in the previous 13 months at a rural health facility and lived >10 km from a health facility in seven districts of rural Zambia. We captured the amount women reported spending on delivery. We compared OOP spending between women who used MWHs and those who did not. Amounts were converted from Zambian kwacha (ZMW) to US dollar (USD)., Results: After controlling for confounders, there was no significant difference in delivery-related expenditure between women who used MWHs (US$40.01) and those who did not (US$36.66) ( P =.06). Both groups reported baby clothes as the largest expenditure. MWH users reported spending slightly more on accommodation compared to those did not use MWHs, but this difference represents only a fraction of total costs associated with delivery., Conclusion: Findings suggest that for women coming from far away, utilizing MWHs while awaiting delivery is not costlier overall than for women who deliver at a health facility but do not utilize a MWH., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Objectives: Women in sub-Saharan Africa face well-documented barriers to facility-based deliveries. An improved maternity waiting homes (MWH) model was implemented in rural Zambia to bring pregnant women closer to facilities for delivery. We qualitatively assessed whether MWHs changed perceived barriers to facility delivery among remote-living women., Design: We administered in-depth interviews (IDIs) to a randomly selected subsample of women in intervention (n=78) and control (n=80) groups who participated in the primary quasi-experimental evaluation of an improved MWH model. The IDIs explored perceptions and preferences of delivery location. We conducted content analysis to understand perceived barriers and facilitators to facility delivery., Setting and Participants: Participants lived in villages 10+ km from the health facility and had delivered a baby in the previous 12 months., Intervention: The improved MWH model was implemented at 20 rural health facilities., Results: Over 96% of participants in the intervention arm and 90% in the control arm delivered their last baby at a health facility. Key barriers to facility delivery were distance and transportation, and costs associated with delivery. Facilitators included no user fees, penalties for home delivery, desire for safe delivery and availability of MWHs. Most themes were similar between study arms. Both discussed the role MWHs have in improving access to facility-based delivery. Intervention arm participants expressed that the improved MWH model encourages use and helps overcome the distance barrier. Control arm participants either expressed a desire for an improved MWH model or did not consider it in their decision making., Conclusions: Even in areas with high facility-based delivery rates in rural Zambia, barriers to access persist. MWHs may be useful to address the distance challenge, but no single intervention is likely to address all barriers experienced by rural, low-resourced populations. MWHs should be considered in a broader systems approach to improving access in remote areas., Trial Registration Number: NCT02620436., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Community mobilization (CM) is recommended as a best practice intervention for low resource settings to reduce maternal mortality. Measurement of process outcomes are lacking and little is known about how CM impacts individuals or how community members perceive its function. Given the complex and recursive nature of CM interventions, research that describes the CM process at multiple levels is needed. This study examines change in CM domains at baseline and endline in rural Zambia., Methods: This secondary analysis uses data from a large maternity waiting homes intervention in rural Zambia that employed CM over 3 years as part of a package of interventions. A 19-item CM survey was collected from three groups (women with babies < 1, health workers, community members; n = 1202) with focus groups (n = 76) at two timepoints from ten intervention and ten comparison sites. Factor analysis refined factors used to assess temporal change through multivariable regression. Independent covariates included time (baseline vs endline), intervention vs comparison site, group (women with babies, healthworkers, community members), and demographic variables. Interaction effects were checked for time and group for each factor., Results: Final analyses included 1202 individuals from two districts in Zambia. Factor analysis maintained domains of governance, collective efficacy, self-efficacy, and power in relationships. CM domains of self-efficacy, power in relationships, and governance showed significant change over time in multivariable models. All increases in the self-efficacy factor were isolated within intervention communities (b = 0.34, p < 0.001) at endline. Between groups comparison showed the women with babies groups consistently had lower factor scores than the healthworkers or community member groups., Conclusions: Community mobilization interventions increase participation in communities to address health as a human right as called for in the 1978 Alma Ata Declaration. Grounded in empowerment, CM addresses socially prescribed power imbalances and health equity through a capacity building approach. These data reflect CM interventions function and have impact in different ways for different groups within the same community. Engaging directly with marginalized groups, using the community action cycle, and simultaneous quality improvement at the facility level may increase benefit for all groups, yet requires further testing in rural Zambia., (© 2021. The Author(s).)

Objective: To report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility., Design: Quasi-experimental design with partial randomisation at the cluster level., Setting: Seven rural districts in Zambia., Population: Women delivering at 40 health facilities between June 2016 and August 2018., Methods: Twenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes., Main Outcome Measures: Differences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher-level health facility between intervention and comparison group., Results: We detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6-7.6, P = 0.03), adolescent women (<18 years) living >10 km away (DID 18.1%, 95% CI 6.3-29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4-16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7-28, P < 0.001)., Conclusion: The core MWH model was successful in increasing rates of facility delivery for women living >10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit., Tweetable Abstract: A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia., (© 2021 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Introduction: Skilled care is indicated as a measure to prevent the deaths of pregnant women across sub-Saharan Africa. Despite this, many women continue to give birth at home. There has been little attention as to how the experience of intimate partner violence (IPV) or autonomous decision-making about place of birth influences home births in rural Zambia. This study explores how markers of sociocultural gender inequities (prevalence of IPV and autonomous decision-making) correlate with home birth in rural Zambia., Methods: This secondary analysis uses quantitative data from a baseline household survey with women who had given birth within the past 13 months in rural Zambia. Control variables shown to be significant in the literature were included in the model, and binary logistic regression was used to assess the influence of IPV and autonomous decision-making on home birth., Results: This sample included 2381 women from rural Zambia, of whom 384 reported a home birth within the past 13 months. Women who were autonomously making the decision about where to give birth were more likely to have a home birth (adjusted odds ratio [AOR], 1.729; SE, 0.210; 95% CI, 1.362-2.194; P < .001). Self-report of experiencing physical IPV in the past 2 weeks was not significant in predicting home birth (AOR, 0.783; SE, 0.181; 95% CI, 0.496-1.234; P = .293). Women who self-identified as Tumbuka or other, were able to afford school fees, had completed secondary education or higher, were married, and had 4 or more antenatal care visits were significantly less likely to report a home birth., Discussion: This quantitative analysis did not corroborate findings from other research that implicates IPV as a predictor of home birth. Additionally, autonomous decision-making was not associated with a decrease in home births. Future work should incorporate qualitative or mixed methods strategies to comprehensively explore household- and facility-level interventions to promote facility birth., (© 2021 by the American College of Nurse-Midwives.)

The purpose of this study was to describe the day-to-day healing processes of women who experienced undergraduate sexual violence. We engaged 19 women in a photo-elicitation experience with follow-up individual interviews to identify themes of both healing and darker moments in survivors' everyday lives. Healing was found to function on a continuum influenced by darker moments (i.e., moments that elicited fear, anxiety, loneliness, guilt, anger, and worthlessness) and healing moments (i.e., rebuilding moments of self-care, self-love, connection, hope, peace, and freedom). Responses to darker moments included feeling overwhelmed, disconnected, and intentional vulnerability. Healing moments were influenced by self-reflection, authentic interactions, and resource utilization. The photographs taken in this study shed light on the impact of sexual violence in women's daily lives long after these traumatic and unjust experiences. This knowledge can be used to foster a sense of universality in survivors who are currently struggling and growing after their experiences as well as give service providers greater insight into what survivors' day-to-day needs may be., (© 2019 Wiley Periodicals, Inc.)

Background: Human trafficking is a human rights violation occurring around the world. Despite the profound social, health, and economic consequences of this crime, there is a lack of research about the prevalence and needs of human trafficking victims. The purpose of this study is to describe the healthcare, social service, and legal needs of human trafficking victims seeking services at the University of Michigan Human Trafficking Clinic., Methods: A secondary analysis of the University of Michigan Human Trafficking Clinic closed case files from 2009-2016 was performed. Data were extracted from the legal files to create a database and data analyses were completed using descriptive frequencies, logistic, and linear regression., Results: Data were extracted from 65 closed cases made up of 49 female victims(75.4%) and 16 male victims (24.6%) between the ages of 13 and 68 years old (M=30.15). Victims had experienced labor (56.9%) and sex (47.7%) trafficking. Logistic regression modeling indicated that trafficking experiences significantly influenced posttrafficking mental healthcare, social service, and legal needs., Conclusions: Victims of human trafficking have extensive needs; however, there are many barriers to seeking and receiving comprehensive services. In order to serve this vulnerable population, collaboration between disciplines must occur., Competing Interests: Disclosure Statement None of the authors report any conflicts of interest.

Objectives: This study aimed to describe the attitudes toward abortion of Ghanaian University students and to determine factors which are associated with supporting a woman's right to an abortion., Methods: This cross-sectional survey was administered to residential students at the University of Cape Coast. Participants were posed a series of 26 statements to determine to what extent they were supportive of abortion as a woman's right. An exploratory factor analysis was used to create a scale with the pertinent factors that relate to abortion attitudes and a multivariable linear regression model explored the relationships among significant variables noted during exploratory factor analysis., Results: 1038 students completed the survey and these students had a generally negative view of abortion. Two factors emerged: (1) the Abortion as a Right scale consisted of five questions (α = .755) and (2) the Moral Objection to Abortion scale consisted of three questions (α = .740). In linear regression, being older (β = 1.9), sexually experienced (β = 1.2), having a boyfriend/girlfriend (β = 1.4), and knowing someone who has terminated a pregnancy (β = 1.1) were significantly associated with a more liberal view of a right to an abortion., Discussion: This work supports the idea that students who have personal exposure to an abortion experience hold more liberal views on abortion than those who have not had a similar exposure., (Copyright © 2016 Elsevier B.V. All rights reserved.)