Improving the quality of life for premature infants through the continuity of care approach: A literature review

Background: The agenda for strengthening the global health architecture is to improve quality of life for premature infants. Premature births increase the morbidity and mortality of newborns, necessitating innovation in primary health care. Objectives: This study was conducted to examine innovation programs with a continuity of care approach in primary health care for premature infants in an effort to strengthen the global health architecture. Methods: A literature review method was used to analyze articles obtained using databases such as Science Direct and Google Scholar. The researcher used the key words “continuity of care” and “premature infants”. The inclusion criteria were full-text journal articles published from January 2020-December 2022 in English-language journals. Results: This study obtained ten articles that correspond to the continuity of care approach for premature infants. The articles included four qualitative studies, three quantitative studies, one mixed-method study, one literature review, and one systematic review. There are three themes related to the continuity of care for premature infants, including (1) Primary healthcare with information continuity, relationships continuity, and management continuity; (2) Continuity of care in the antenatal, natal, and postnatal periods; (3) The continuity of care on premature infant approach improves the outcome of premature infant care, the ability of parents, and health service quality. Conclusions: A continuity of care approach can increase the achievement of adequacy, equity, efficiency, and effectiveness in primary health care for premature infants. Joint synergy between the community, health services, and health policymakers is essential in efforts to strengthen the quality of life for premature infants

Music therapy following preterm birth : Results from a pragmatic trial evaluating the effects of parental singing on bonding and parent mental health

Bakgrunn Prematur fødsel er et stort globalt helseproblem som rammer både foreldre og barn. Som regel er prematur fødsel en uventet hendelse som medfører mye stress og bekymring for foreldre. Usikkerhet, og frykt for barnets liv og helse kan prege hverdagen på nyfødtintensivavdelingen. Prematurfødte barn er i risiko for en rekke langsiktige helseutfordringer, men også foreldre rapporterer belastninger og symptomer på psykisk uhelse, som angst og depresjon, etter prematur fødsel. En sentral antakelse i dette forskningsprosjektet er at prematur fødsel kan ha en negativ innvirkning på utviklingen av kontakten og kvaliteten av båndet mellom forelder og barn, på engelsk kalt bonding. Tidligere forskning har funnet positive effekter av musikkterapi (MT) på premature nyfødte sin hjertefrekvens, respirasjonsfrekvens, stressnivå og spising, samt på angst hos mødre. Det er imidlertid behov for mer forskning i form av større studier som undersøker både korttids- og langtidseffekter av musikkterapi etter prematur fødsel på barn, foreldre, og på felles utfallsmål som bonding. Dette doktorgradsprosjektet ble gjennomført som en del av “LongSTEP” (Longitudinal Study of music Therapy’s Effectiveness for Premature infants and their caregivers), en multinasjonal, pragmatisk, randomisert kontrollert studie (RCT). Hovedmålet med LongSTEP er å undersøke langtidseffekten av musikkterapi under innleggelse på nyfødtintensiv avdeling, og/eller som oppfølging etter utskrivelse, på båndet mellom mor og barn. I tillegg undersøkes både korttids- og langtidseffekter av musikkterapi på foreldrenes psykiske helse og barnets utvikling. Mål Doktorgradsprosjektet består av tre delstudier der alle data ble innsamlet gjennom LongSTEP. De tre delstudiene hadde følgende mål: 1) å utdype det teoretiske rammeverket for musikkterapi-intervensjonen og beskrive de essensielle elementene i intervensjonsprotokollen, 2) å rapportere korttidseffektene av musikkterapi under innleggelse på nyfødtintensiv på båndet mellom mor og barn, og på foreldrenes psykiske helse, og 3) å evaluere treatment fidelity - om musikkterapien ble gjennomført i tråd med LongSTEPs intervensjonsprotokoll i begge intervensjonsfaser av studien (under innleggelse og ved oppfølging etter utskrivelse). Metode og prosedyrer LongSTEP ble designet som en 2×2 faktoriell, multinasjonal, pragmatisk RCT. Dette doktorgradsprosjektet rapporterer korttidseffektene fra studien målt ved utskrivelse fra nyfødtintensivavdelingen. Deltakere i studien var premature barn født før svangerskapsuke 35 og foreldrene deres. De ble rekruttert fra åtte nyfødtintensivavdelinger fordelt på fem land: Argentina, Colombia, Israel, Norge og Polen. Deltakerne ble randomisert til enten kontrollgruppen som mottok standardbehandling gjennom innleggelsen, eller til intervensjonsgruppen som fikk musikkterapi i tillegg. Musikkterapien besto av tre sesjoner per uke, der foreldrene måtte delta i minst to av dem. Musikkterapi-intervensjonen som ble evaluert i studien bygger på prinsipper fra ressursorientert musikkterapi og utviklingstilpasset- og familiesentrert omsorg. Musikalsk interaksjon ble individuelt tilpasset barnas utvikling og behov i øyeblikket. Foreldres stemme ble vektlagt som en unik ressurs for å styrke båndet mellom foreldre og barn, og var det viktigste musikalske elementet i sesjonene. Musikkterapeutens rolle var å støtte opp om den musikalske interaksjonen mellom foreldre og barn. For å gi rom til foreldrenes stemme og tilrettelegge for at de skulle bli hørt, brukte musikkterapeuten andre instrumenter sparsommelig (Artikkel I). Hovedutfall i studien var endringer i mor-barn-båndet målt med Postpartum Bonding Questionnaire (PBQ). Sekundærutfall var depresjon hos mor og angst hos begge foreldre målt med henholdsvis Edinburgh Postpartum Depression Scale og Generalized Anxiety Disorder-7. Effekten av musikkterapi ble målt ved å teste gruppeforskjeller med en lineær sammensatt modell, (ANCOVA), justert for behandlingssted på grunn av stratifisert randomisering (Artikkel II). Fidelity-målinger ble gjort med Likert-skalabaserte spørreskjemaer utviklet spesifikt for studien. Spørreskjemaenes interne konsistens ble evaluert med Cronbach’s alpha, og interrater-reliabilitet med intraclass korrelasjonskoeffisient og Gwet’s AC. Fidelity-skåringer ble analysert med deskriptive metoder (Artikkel III). Resultater I perioden mellom august 2018 og april 2020 ble 213 familier rekruttert til studien. Av disse ble 108 randomisert til standardbehandling og 105 til musikkterapi. En svært høy andel av deltakerne gjennomførte de planlagte sesjonene og ble værende i studien. Musikkterapien ble evaluert som sikker og gjennomførbar. Fidelity-analysen viste at musikkterapien ble gjennomført og mottatt som planlagt ved alle studiens behandlingssteder. Dette indikerer høy anvendelighet av tilnærmingen i ulike kulturelle kontekster og nyfødtintensivavdelinger med høy foreldre-tilstedeværelse. Vi fant imidlertid ingen signifikante forskjeller mellom gruppene på verken primæreller sekundærutfall målt ved utskrivelse. Den estimerte gruppeeffekten (95% CI) for PBQ var –0.61 (–1.82 to 0.59). På baseline-målingen skåret kun 4% (9/209) av mødrene over terskelen for indikasjon på et problematisk mor-barn-bånd. I begge grupper skåret mødrene under terskelen for indikasjon på depresjon ved baseline. Mødre i begge grupper, og fedre i intervensjonsgruppen hadde indikasjoner på mild angst ved baseline. Konklusjoner Selv om musikkterapien i studien var godt mottatt av deltakerne og vurdert som sikker og gjennomførbar, kunne vi ikke påvise noen signifikant forbedring av morbarn- båndet som et resultat av intervensjonen. Mangelen på effekt kan muligens forklares av den svært lave forekomsten av problemer med mor-barn-båndet i utgangspunktet. Funnene våre utfordrer antagelsen om at mange foreldre strever med båndet til barnet og har utfordringer med psykisk helse etter prematur fødsel. I fremtidige studier av ressursorienterte musikkterapitilnærminger ved prematur fødsel anbefaler vi å velge utfallsmål som er bedre i stand til å fange opp det som er hovedhensikten, nemlig å styrke ressurser. Det kan være for eksempel foreldres mestringstro, empowerment og livskvalitet.Background Preterm birth is recognized as a major global health problem with potential adverse consequences for both infants and parents. The unexpected event of preterm birth is stressful, and often leaves parents with fears and worries for their baby’s survival and health. Long-term sequalae of prematurity involve a range of health problems for infants, and some parents report mental health challenges, such as anxiety and depression, following preterm birth. A key assumption in the present research is that preterm birth may have a negative impact on parent-infant bonding. Previous research has confirmed positive effects of music therapy (MT) on premature infants’ heart rate, respiratory rate, stress levels and feeding volume, as well as maternal anxiety. However, more large-scale, rigorous investigations of short- and long-term infant and parent outcomes, as well as mutual parent-infant outcomes like bonding, are necessary. This PhD-project was realized as a part of the multinational, pragmatic, randomized controlled trial (RCT) “LongSTEP” (Longitudinal Study of music Therapy’s Effectiveness for Premature infants and their caregivers). The overall aim of LongSTEP was to determine whether MT, delivered during a neonatal intensive care unit (NICU) stay, and/or during follow-up post-discharge, is superior to standard care in improving long-term mother-infant bonding, parent mental health and infant development. Aims The present thesis consists of three substudies for which all data were collected within LongSTEP. The aims for the substudies were: 1) to further develop and refine the theoretical framework and essential elements of the MT protocol; 2) to measure and report the short-term effects of the RCT on mother-infant bonding and parent mental health; and 3) to evaluate treatment fidelity of the MT intervention in both the NICU and post-discharge phases of the LongSTEP trial. Methods and procedures The LongSTEP trial was designed as a 2×2 factorial, multinational, pragmatic RCT. In this thesis, the short-term effects of the MT-intervention were analyzed at the timepoint of discharge from NICU. Participants were premature infants born before week 35 of gestation and their parents recruited from eight NICUs in five countries: Argentina, Colombia, Israel, Norway, and Poland. Participants were randomized to either the control group receiving standard care throughout NICU hospitalization or the intervention group receiving MT in addition to standard care. MT during NICU consisted of three weekly sessions throughout hospitalization. Parents were required to participate in at least two of three weekly sessions. The MT approach was built on principles from resource-oriented MT, and developmental- and family-centered care. Musical interaction was tailored according to, and informed by, infant neurodevelopment and behavioral needs. Parents’ voices were emphasized as a unique resource to build and strengthen the parent-infant bond. Hence, parental voice was promoted as the main musical source in our intervention. The role of the music therapist was a collaborative and supportive one, intentionally leaving space for parents’ voices to be heard by minimal use of accompanying instruments (Article I). The primary outcome, mother-infant bonding, was measured with the Postpartum Bonding Questionnaire (PBQ). Secondary outcomes, maternal depression, and parent anxiety were measured with the Edinburgh Postpartum Depression Scale and Generalized Anxiety Disorder-7, respectively. Effects were examined by testing group differences at discharge by linear mixed effects models (ANCOVA), adjusted for site due to stratified randomization (Article II). Treatment fidelity was measured with Likert-scale-based questionnaires designed specifically for the study. The internal consistency of the questionnaires was evaluated with Cronbach’s alpha. Interrater reliability was measured with an intraclass correlation coefficient and Gwet’s AC. Fidelity scores were analyzed with descriptive methods (Article III). Results A total of 213 families were recruited between August 2018 and April 2020. 108 of them were randomized to standard care, 105 to MT. Treatment uptake and retainment in the study was very high, and the MT approach was feasible and safe. Treatment fidelity analyses showed that MT was delivered and received as intended across the included sites. This indicates high applicability of the approach across cultural contexts where parents’ presence in NICU is high. However, we found no significant differences between groups, neither on the primary outcome, mother-infant bonding, nor the secondary outcomes, maternal depression, and parent anxiety, as measured at discharge from NICU. The estimated group effect (95% CI) for the PBQ was –0.61 (–1.82 to 0.59). At baseline, only 4% (9/209) of the mothers scored above the threshold for impaired bonding. For maternal depression, both groups scored below the clinical cutoff at baseline. Mothers in both groups, and fathers in the MT group, showed mild anxiety at baseline. Conclusions While the MT intervention with emphasis on parental singing was found feasible and well-accepted by the participants across the sites, results from the RCT showed no significant improvements of mother-infant bonding in the MT group. These results may be attributed to an already good mother-infant bonding in most enrolled participants at the outset. Our findings challenge the assumptions of problematic bonding and poor parent-mental health following preterm birth. We propose that future studies on the effect of resource-oriented MT approaches in NICU-settings with high parental presence and participation choose outcomes that are less pathology-oriented, such as parent self-efficacy, empowerment, and quality of life.Doktorgradsavhandlin

Infant/Early Childhood Mental Health and Collaborative Partnerships: Beyond the NICU

The NICU experience impacts all family dynamics not just during the intensive care unit stay but in the months and years afterwards. For each family, the first experiences with their baby, whether in the home or the intensive care unit, can set the trajectory for the long-term parent–child relationship and the parent's perspective of their parent roles. These difficult experiences have the potential to be addressed through infant and early childhood mental health (I/ECMH) methods. In this article we review the need for a wide range of social and emotional supports that present in intensive care and continue as families and infants transition to home and community. The potential for addressing these ongoing issues by a variety of providers within many different settings using Infant and Early Childhood Mental Health (I/ECMH) approaches is discussed and examples of successful programs are provided. Finally, we make recommendations for infusing I/ECMH across programs that serve intensive care unit graduates and their families, from the hospital to the home, with primary care providers and other community support programs

Factors Associated with High Risk Infant Follow-Up Attendance

Prematurity is a significant public health problem and preterm infants face well described risks of adverse neurodevelopmental outcomes. Bronfenbrenner’s bioecological theory of development describes interactions between biological and environmental factors and explains how these interactions can impact development. Systematic follow-up of preterm, high-risk infants is recommended for early identification of problems and provision of interventions and support services. Most research on follow-up attendance has involved small, single sites. A retrospective analysis of population based data available in the California Children’s Services High Risk Infant Follow-up Quality of Care Initiative (HRIF-QCI) data system was performed to examine factors associated with attendance at the second recommended visit. Applying the bioecological theory of development to the high-risk infant population reveals the numerous biologic, family, social, cultural, and political factors that influence development. This theory supports the provision of early intervention services to this population. Only 74% of those infants seen for the first visit attended the second recommended visit. Infants with birth weights equal to or less than 750 grams were almost twice as likely to attend the visit compared with those with birth weights greater than 1,250 grams. Private insurance, two parents as caregivers, completion of the first visit during the recommended interval and enrollment in early intervention during the first visit were all associated with higher attendance rates. Public insurance, a single parent as caregiver, or maternal race of Black or Asian were all associated with decreased attendance. Infants with maternal race of Black were 45% less likely to attend the second visit, and the factor with the strongest association with lack of visit two attendance. Rural residence was associated with decreased HRIF attendance (they were 30% less likely to attend) and there were marked differences between the rural and non-rural population, with rural caregivers being younger, less educated, and with lower rates of employment. There were marked differences in attendance rates between different HRIF programs, with risk-adjusted rates ranging from 34.4% to 89.9%. These findings offer new knowledge into factors associated with HRIF clinic attendance and suggest future research opportunities to improve clinical practice with this population

Improving quality of care and outcome at very preterm birth: the Preterm Birth research programme, including the Cord pilot RCT

BACKGROUND:Being born very premature (i.e. before 32 weeks’ gestation) has an impact on survival and quality of life. Improving care at birth may improve outcomes and parents’ experiences. OBJECTIVES:To improve the quality of care and outcomes following very preterm birth. DESIGN:We used mixed methods, including a James Lind Alliance prioritisation, a systematic review, a framework synthesis, a comparative review, qualitative studies, development of a questionnaire tool and a medical device (a neonatal resuscitation trolley), a survey of practice, a randomised trial and a protocol for a prospective meta-analysis using individual participant data. SETTING:For the prioritisation, this included people affected by preterm birth and health-care practitioners in the UK relevant to preterm birth. The qualitative work on preterm birth and the development of the questionnaire involved parents of infants born at three maternity hospitals in southern England. The medical device was developed at Liverpool Women’s Hospital. The survey of practice involved UK neonatal units. The randomised trial was conducted at eight UK tertiary maternity hospitals. PARTICIPANTS:For prioritisation, 26 organisations and 386 individuals; for the interviews and questionnaire tool, 32 mothers and seven fathers who had a baby born before 32 weeks’ gestation for interviews evaluating the trolley, 30 people who had experienced it being used at the birth of their baby (19 mothers, 10 partners and 1 grandmother) and 20 clinicians who were present when it was being used; for the trial, 261 women expected to have a live birth before 32 weeks’ gestation, and their 276 babies. INTERVENTIONS:Providing neonatal care at very preterm birth beside the mother, and with the umbilical cord intact; timing of cord clamping at very preterm birth. MAIN OUTCOME MEASURES:Research priorities for preterm birth; feasibility and acceptability of the trolley; feasibility of a randomised trial, death and intraventricular haemorrhage. REVIEW METHODS:Systematic review of Cochrane reviews (umbrella review); framework synthesis of ethics aspects of consent, with conceptual framework to inform selection criteria for empirical and analytical studies. The comparative review included studies using a questionnaire to assess satisfaction with care during childbirth, and provided psychometric information. RESULTS:Our prioritisation identified 104 research topics for preterm birth, with the top 30 ranked. An ethnographic analysis of decision-making during this process suggested ways that it might be improved. Qualitative interviews with parents about their experiences of very preterm birth identified two differences with term births: the importance of the staff appearing calm and of staff taking control. Following a comparative review, this led to the development of a questionnaire to assess parents’ views of care during very preterm birth. A systematic overview summarised evidence for delivery room neonatal care and revealed significant evidence gaps. The framework synthesis explored ethics issues in consent for trials involving sick or preterm infants, concluding that no existing process is ideal and identifying three important gaps. This led to the development of a two-stage consent pathway (oral assent followed by written consent), subsequently evaluated in our randomised trial. Our survey of practice for care at the time of birth showed variation in approaches to cord clamping, and that no hospitals were providing neonatal care with the cord intact. We showed that neonatal care could be provided beside the mother using either the mobile neonatal resuscitation trolley we developed or existing equipment. Qualitative interviews suggested that neonatal care beside the mother is valued by parents and acceptable to clinicians. Our pilot randomised trial compared cord clamping after 2 minutes and initial neonatal care, if needed, with the cord intact, with clamping within 20 seconds and initial neonatal care after clamping. This study demonstrated feasibility of a large UK randomised trial. Of 135 infants allocated to cord clamping ≥ 2 minutes, 7 (5.2%) died and, of 135 allocated to cord clamping ≤ 20 seconds, 15 (11.1%) died (risk difference –5.9%, 95% confidence interval –12.4% to 0.6%). Of live births, 43 out of 134 (32%) allocated to cord clamping ≥ 2 minutes had intraventricular haemorrhage compared with 47 out of 132 (36%) allocated to cord clamping ≤ 20 seconds (risk difference –3.5%, 95% CI –14.9% to 7.8%). LIMITATIONS:Small sample for the qualitative interviews about preterm birth, single-centre evaluation of neonatal care beside the mother, and a pilot trial. CONCLUSIONS:Our programme of research has improved understanding of parent experiences of very preterm birth, and informed clinical guidelines and the research agenda. Our two-stage consent pathway is recommended for intrapartum clinical research trials. Our pilot trial will contribute to the individual participant data meta-analysis, results of which will guide design of future trials. FUTURE WORK:Research in preterm birth should take account of the top priorities. Further evaluation of neonatal care beside the mother is merited, and future trial of alternative policies for management of cord clamping should take account of the meta-analysis. STUDY REGISTRATION:This study is registered as PROSPERO CRD42012003038 and CRD42013004405. In addition, Current Controlled Trials ISRCTN21456601. FUNDING:This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 8. See the NIHR Journals Library website for further project information

Discharge Readiness for Families with a Premature Infant Living in Appalachia

With increased advances in technology, the overall survival rates in the Neonatal Intensive Care Unit (NICU) for premature infants at lower gestational ages, has also increased. Although premature infants survive at lower gestational ages, they are often discharged to home with unresolved medical issues. While the birth of a new baby for parents is a joyous occasion, they often have difficulty coping and transitioning into a parental role. Premature infants also have ongoing complications such as difficulty with feeding, developmental delays in growth, and long-term eye and respiratory complications. As a result of chronic health sequelae, premature infants require extensive utilization of hospital and community health resources. In addition, hospitals must coordinate between community resources, while preparing parents for specialized discharge teaching. Furthermore, individuals living in rural and underserved areas face unique challenges and barriers to access healthcare resources. An interpretive phenomenology study was conducted to bring insight and develop an understanding into how families perceive discharge readiness, accessing health care resources, and ability to cope at home after discharge from a Level III NICU located in Appalachia. Ten parents total were enrolled in the study and consisted of three couples, three married mothers, and two single mothers. Interviews were conducted over a period of six months and transcript analysis revealed development of major and minor themes. The studies overarching theme was Adapting to a New Family Roles, Finding Normalcy, which described parents experience of being prepared for discharge and their transition to home. Three major themes related to discharge readiness from detailed analysis included; 1) Riding out the storm, 2) Righting the ship, and 3) Safe port, finding solid ground. Subthemes that supported development of the major these were 1a) having the carpet pulled out from under me, 1b) things I lost, 1c) feel like an outsider, 1d) sink or swim, 2a) quest for knowledge, 2b) caring for me, care for my baby, 2c) customized learning, 3a) getting to know baby, 3b) becoming the expert, 3c) ongoing emotions, and 3d) adjusted parental role. Practice and research implications for discharge readiness include providing customized support for parents as they adjust to a new normal for their family, identify necessary resources, and become self-reliant once home

Interprofessional Collaboration in a New Model of Transitional Care for Families with Preterm Infants – The Health Care Professional's Perspective

Background: Families with preterm infants find life after hospital discharge challenging and need tailored support to thrive. The “Transition to Home (TtH)”-model offers structured, individual support for families with preterm infants before and after hospital discharge. TtH improves parental mental health and competence, promotes child development and fosters interprofessional collaboration (IPC). Aim: Evaluate the TtH-models’ structure and implementation process and its associated interprofessional collaboration from the healthcare professional’s (HCP) perspective. Methods: This qualitative explorative study thematically analyzed four focus group inter- views (n=28 HCP) and an open-ended questionnaire with general pediatricians (n=8). Results: The main themes of the thematic analysis were the benefits of the TtH-model, tailored parental support, the challenges of changing interprofessional collaboration, facil- itators and barriers to successfully implementing the model, and feasibility and health economic limits. HCP acknowledge that continuous family-centered care led by an advanced practice nurse (APN) supports, strengthens, and relieves families with preterm infants in the transition from hospital to home. Families in complex situations benefit most. The TtH- model incorporates key aspects of integrated care like shared decision-making, considering family preferences, and defining the APN as the family’s main contact. HCP want network collaboration but found communication, cooperation, and reorganization challenging in the new IPC process. IPC challenges and involving many HCP in family care can create parental oversupply, negatively affect treatment outcomes, and raise health care costs. Conclusion: These challenges need to be addressed to ensure sustainable implementation of the model. The roles and tasks of HCP should be clearly distinguished from each other, and HCP must have time to learn this new form of IPC. Learning requires time, effective communication strategies, and leadership support. Political action is also required to imple- ment new models of care, including regulating advanced practice roles and developing new financing models

Costs and health consequences of chlamydia management strategies among pregnant women in sub-Saharan Africa

Objectives: Chlamydia is the most common bacterial sexually transmitted infection worldwide and a major cause of morbidity – particularly among women and neonates. We compared costs and health consequences of using point-of-care (POC) tests with current syndromic management among antenatal care attendees in sub-Saharan Africa. We also compared erythromycin with azithromycin treatment and universal with age-based chlamydia management. Methods: A decision analytic model was developed to compare diagnostic and treatment strategies, using Botswana as a case. Model input was based upon 1) a study of pregnant women in Botswana, 2) literature reviews and 3) expert opinion. We expressed the study outcome in terms of costs (US$), cases cured, magnitude of overtreatment and successful partner treatment. Results: Azithromycin was less costly and more effective than was erythromycin. Compared to syndromic management, testing all attendees on their first visit with a 75$38 per additional case cured. This cost was lower in high-prevalence populations or if testing was restricted to teenagers. The specific POC tests provided the advantage of substantial reductions in overtreatment with antibiotics and improved partner management. Conclusions: Using POC tests to diagnose chlamydia during antenatal care in sub-Saharan Africa entails greater health benefits than syndromic management does – and at acceptable costs – especially when restricted to younger women. Changes in diagnostic strategy and treatment regimens may improve people’s health and even reduce health care budgets.Chlamydia trachomatis (MeSH); Cost-effectiveness analysis (non-MeSH); Cost Analysis (MeSH); Developing countries (MeSH); Africa (MeSH); Sub-Saharan Africa (MeSH) Maternal health (non-MeSH); Maternal Health Services (MeSH); Women’s Health (MeSH); Point-of-care tests (non-MeSH); Diagnostic tests (non-MeSH); Diagnosis (MeSH); Syndromic approach (non-MeSH); STI management (non-MeSH)