Ascertaining the level of fertility preference implementation in Nigeria

Abstract Using the 1990 and 2003 Nigeria Demographic and Health Survey (NDHS) data, the study examines the levels of, trend and differentials in fertility preference implementation in Nigeria and how this has contributed to observed fertility changes in the country. Results show that the extent to which women implement their fertility preference is high and increased by about 4% over the period. Its contribution to observed fertility decline of 0.5 births was however small (6%). The index also increased over the period by the various characteristics of women examined except among respondents with tertiary level of education and women from the South West. Percentage change is high among women from rural areas, the North-East and women with no formal education. The pattern among different categories of couples shows that preference implementation is higher among cohabiting, monogamously married and concordant couples. The paper concludes with program and research recommendations.Keywords: Fertility; preference; implementation; index; NigeriaResume Utilisant les données de L’Enquête Démographique et de Santé du Nigeria pour les années 1990 et 2003, l'étude examine les niveaux, tendances et différences dans la mise en oeuvre des préférences de fécondité au Nigeria et comment cela a contribué aux changements observés dans la fécondité. Les résultats montrent que le degré auquel les femmes adhèrent à leurs préférences de fécondité est élevé et a augmenté d'environs 4 % sur cette période. La contribution de celui-ci à la baisse en fécondité de 0.5 naissances était cependant petite (6 %). L'index a également augmenté pendant cette période par les diverses caractéristiques des femmes examinées, sauf parmi les répondants de niveau universitaire et les femmes du Sud-ouest. Le changement en pourcentage est élevé chez les femmes en milieu rural, au Nord-est et les femmes illettrées. La constante parmi les différentes catégories de couples montre que l’adhérence à ces préférences est plus élevée chez les couples qui cohabitent, mariés monogames et les couples concordants. Le document se conclut par des recommandations de programme et recherche

Fertility Transition in Nigeria: Exploring the Role of Desired Number of Children

Reports have suggested the onset of fertility transition in Nigeria and speculations are rife about the factors driving the observed fertility changes. This study investigates if and how 'desired number of children' influences the observed fertility change in the country, utilizing information collected from twenty-four focus group discussion (FGD) sessions conducted across the country. The results show that people are revising the number of children they are having downward, but the desired number of children remains high. Religion and culture are key drivers of current desired number of children but changing socio-economic factors greatly limit the actual number of children people have. The desired number of children does not play noticeable role in the observed fertility transition in Nigeria, posing significant challenges for policies and programmes that aim to lower desired number of children for sustainable fertility level in the country

Exploring the need for preconception care: the pregnancy experiences of women with pre-existing medical conditions in Ibadan, Nigeria

Pre-existing medical conditions predisposing to poor maternal and child health outcomes are amenable to preconception care(PCC). Despite an increasing pool of women of reproductive age with pre-existing medical conditions, PCC services are notprovided routinely in Nigeria. This study explores the pregnancy experiences of women with pre-existing medical conditions tomake a case for PCC services. Nine women having pre-existing medical conditions were purposively selected for in-depthinterviews at two referral hospitals for maternal and child health services in Ibadan North LGA, Oyo State, Nigeria. Thematicanalysis was done using MAXQDA 2018. There were seven pregnant and two non-pregnant participants having eitherhypertension, diabetes mellitus, sickle cell disorder, chronic hepatitis, HIV, or secondary infertility. None of the participants wereaware of PCC and although they all desired their current pregnancy, there was no active preparation: they neither notified theirhealth care providers about their desire for pregnancy nor had their medications adjusted or changed till after pregnancy. All exceptone of the participants believed they could have benefitted from PCC if they had been aware before pregnancy. The regular contactwith the health system afforded by their pre-existing medical conditions is an opportunity for participants to have been adequatelyprepared for pregnancy through counselling, adjustment or change in treatment to prevent complications. This opportunity wasmissed among the study participants. Health care providers need to be proactive and ask women of reproductive age about theirpregnancy desires during routine clinic visits in order to make adequate preparation. Keywords: Pregnancy desire; preparation for pregnancy; opinion about preconception care; benefit of preconception care   Les conditions médicales préexistantes prédisposant à de mauvais résultats pour la santé maternelle et infantile se prêtent aux soinsavant la conception (PCC). Malgré un nombre croissant de femmes en âge de procréer avec des conditions médicales préexistantes,les services de PCC ne sont pas fournis systématiquement au Nigéria. Cette étude explore les expériences de grossesse des femmesayant des conditions médicales préexistantes pour plaider en faveur des services de PCC. Neuf femmes ayant des conditionsmédicales préexistantes ont été sélectionnées à dessein pour des entretiens approfondis dans deux hôpitaux de référence pour lesservices de santé maternelle et infantile à Ibadan North LGA, État d'Oyo, Nigéria. L'analyse thématique a été réalisée à l'aide deMAXQDA 2018. Il y avait sept femmes enceintes et deux non enceintes souffrant d'hypertension, de diabète sucré, dedrépanocytose, d'hépatite chronique, de VIH ou d'infertilité secondaire. Aucune des participantes n'était au courant de la PCC etbien qu'elles souhaitaient toutes leur grossesse actuelle, il n'y avait pas de préparation active: elles n'ont pas informé leursfournisseurs de soins de santé de leur désir de grossesse et leurs médicaments n'ont été ajustés ou modifiés qu'après la grossesse.Toutes sauf une des participantes pensaient qu'elles auraient pu bénéficier du PCC si elles en avaient été informées avant lagrossesse. Le contact régulier avec le système de santé, grâce à leurs conditions médicales préexistantes, est l'occasion pour lesparticipantes d'avoir été correctement préparées à la grossesse grâce à des conseils, à des ajustements ou à un changement detraitement pour éviter les complications. Cette opportunité a été manquée parmi les participants à l'étude. Les prestataires de soinsde santé doivent être proactifs et interroger les femmes en âge de procréer sur leurs désirs de grossesse lors des visites de routine àla clinique afin de se préparer adéquatement. Mots-clés: Désir de grossesse; préparation à la grossesse; opinion sur les soins avant la conception; bénéfice des soins préconception &nbsp

Analysis of fertility dynamics in Nigeria: exploration into fertility preference implementation

While studies have indicated the onset of fertility transition in Nigeria as in most Sub- Saharan countries, no systematic attempt has been made to identify the factors responsible for this trend. Existing explanation tends to draw from the demographic transition theory without exploring the value of other key variables. One of these variables is the degree of preference implementation. This study explores the role of fertility preference implementation on the onset of fertility transition in Nigeria. The study estimated the extent to which couples have been able to implement their fertility preferences with a view to better understand the factors that are responsible for the fertility changes in the country. This study was based on the socio-economic and microeconomic frameworks of fertility namely: the Bongaarts et al (1984) version and its Stover’s reformulation (1998) of the proximate determinants of fertility and the Bongaarts (1993) supply-demand framework for the analysis of the determinants of fertility, respectively. The proximate determinant of fertility frameworks holds that all demographic, socioeconomic, cultural, institutional, psychological, health and environmental factors (background variables) operate through the proximate or intermediate variables to affect fertility. The Bongaarts (1993) supply-demand framework posits that fertility (F) as measured by total fertility rate is an outcome of the interaction of supply of births (natural fertility), demand for births (wanted fertility) and degree of fertility preference implementation (an index, which measures the extent to which people have been able to implement their fertility preferences). The degree of preference implementation is in turn dependent on cost of fertility regulation and that of unwanted childbearing. The husbands’ family planning attitude and desired number of children were incorporated into the latter framework to recognize and bring out the crucial roles of the males in eventual fertility outcomes. The 1990, 1999 and 2003 Nigeria Demographic and Health Survey (NDHS) data sets for men, women and couples were used. The methodology of the three NDHS is not too different from each other. They are nationally representative cross-sectional survey of women between the ages of 15 and 49 in 1990, 1999 and 2003 and men between 15 and 64 in 1999 and 15-59 in the 2003 survey. Twenty-four focus group discussions were also conducted among the sexes across the country to gain better insight and understanding into the issues examined. Focus group research is based on facilitating an organized discussion with a group of individuals selected because they were believed to be representative of some class. The discussion is used to bring out insights and understandings in ways, which cannot be captured by questionnaire. The focus group discussions (FGD) are also national in scope. Participants were drawn from the Northern, South Eastern and South Western regions of the country. The study population consisted of 8,781; 8,199 and 7,620 women aged 15-49 interviewed during the 1990, 1999 and 2003 NDHS, respectively. In addition, 2,584 men aged 15-64 and 2,346 men aged 15-59 interviewed during the 1999 and 2003 NDHS, respectively were used. One thousand, one hundred and sixty-eight (1,168) couples’ records derived from the 2003 NDHS and 1,280 (constructed) couples’ records for 1999 were also used. A total of eighty-nine (89) men and eighty-five (85) women participated in the twenty-four (24) focus group discussion sessions. To achieve the research objectives, a wide range of analysis was carried out in the study. In the estimation of all means and medians, the Kaplan Meier survival analysis is used. Some other estimations were done using specific formulations developed for the purpose. Thirty-six binary logistic regression models were also fitted to bring out spousal influences on each other’s attitude to family planning and desired number of children. Lastly, the focus group discussion sessions were analysed by themes to give better understanding into the issues examined. Five hypotheses were tested in the study. There was a general decline in the age specific fertility rates (ASFR) between 1990 and 2003 in all the age groups. This is reflected in the total fertility rate (TFR) for the country as a whole, which declined from 6.32 in 1990 to 5.82 in 2003. The national average masks large variations in the fertility levels between subgroups in the country. The women in the North generally have higher number of children than their Southern counterparts. This is particularly marked in the early childbearing years. Fertility levels are also higher among rural residents compared to those in the urban area. Substantial differences equally exist in the fertility levels of women by their level of education with fertility being negatively associated with level of education. A comparison of the past and current fertility also confirms that fertility has been on the decline in the country. Age at first and last births have been declining and the differentials between the two show that the number of years spent in childbearing is decreasing. Non-marital birth was also found to be increasing over time but at a level below six percent and with no identifiable educational or regional pattern. Teenage motherhood is equally declining both nationally and regionally and is relatively high among teenagers from the rural area and those with less than secondary level of education. The proportion of women that progress from one parity to another decreases as parity increases and no socially imposed optimum number of children is observed (although there is a political four-child policy in existence) among the Nigerian women. Apart from age of mother at the birth of child, which has a positive association with median length of birth interval and the surviving status of preceding child (which is understandably shorter if the preceding child is dead), length of birth interval by other characteristics shows no significant variation across sub groups. Age at first marriage remained between 16 and 17 over the years. This is lower for respondents from the rural, the North and for those with less than secondary level of education. For age at first sexual intercourse, it increased over time in the age groups. Respondents from the North and rural area however initiated sexual intercourse earlier and age at first sexual intercourse increases with level of education. Among the proximate determinant indices, the index of postpartum insusceptibility has the greatest inhibiting effect, followed by that of marriage/sexually active, contraception and then sterility. In the Bongaarts model, the indices reduced total fecundity by 12.46 births in the total sample of married women in 1990; 8.90 births in 1999 and 9.45 births in 2003 while the indices jointly reduced potential fertility by 17.69 births in the total sample of sexually active women in 1990; 16.06 births in 1999 and 16.50 births in 2003 in the Stover’s reformulation. The number of children desired marginally increased over time. This could have been affected by the high proportion of non-response especially in the 1990 survey. The desired number of children is positively related to age and number of surviving children while it is negatively related to education. Number of children desired is found to be lower among urban residents and respondents from the Southern part of the country and highest among currently married women. The focus group discussion sessions also show that people have been revising the number of children they are having downward due to ‘supposed’ economic hardship in the country and the need to give quality education, training and care to the children. However, their desire remain high. The extent, to which fertility preference is achieved, is generally high and increasing over the years in the total sample of married women with some variations in the sub groups. It is higher in the urban compared to the rural; increases with level of education, lowest in the North East and highest in the South West. Surprisingly, the extent to which concordant couples achieve their fertility preferences was lower than that of discordant couples. The fitted logistic models showed no evidence of the husbands having an upper hand in the number of children desired by the wives or on their attitude to family planning and vice versa. While the husbands play greater role in fertility decision-making in households, who has the upper hand between the husbands and the wives in actual fertility outcome was not conclusive in this study. Knowledge about family planning methods and their availability is high. The costs of fertility regulation in terms of its social, economic and in particular health components as well as obstacles to the use of fertility regulation methods were highlighted. The psychological, health, social and more frequently the economic costs of unwanted childbearing were also brought out. The responses to questions on pregnancy wantedness was also validated in this study as people generally acknowledged the circumstance of the birth of additional child(ren) as accidental. Two of the five hypotheses proposed were confirmed. One, the hypothesis that ‘the degree of fertility preference implementation is higher in the south than in the North, higher among urban residents compared to the rural residents and increases as the level of education increases’ is supported by the results of the study. Two, that ‘the degree of fertility preference implementation is increasing and playing an increasing (a more positive) role in fertility changes in Nigeria’ is also supported. The study could not confirm that ‘the indices of marriage/sexual activity, postpartum insusceptibility and contraception (in that order) have the most inhibiting effect on fertility in Nigeria.’ The other two hypotheses could not be proven conclusively either. These were that ‘degree of fertility preference implementation is higher among couples with similar desired number of children than among discordant couples’ and ‘the Husbands have more influence on their wives’ family planning attitude and desired number of children than the wives have over their husbands’. These findings have programme and policy implications. For instance, although the reduction in the number of years spent in child bearing is welcome as a result of decline in the number of older women in active childbearing, the increasing entrance of women under the age of eighteen years is worrisome. This could impact negatively on school enrolment and retention as well as on the health of the women since it is recognised that women under the age of eighteen years is one of the four groups of women with higher risk of morbidity and mortality during pregnancy and childbirth. Despite the pertinent findings of this study, a number of study limitations can be identified. This include not identifying people who have achieved their desired fertility and those who have not and conducting in-depth interview with them to gain greater insight into their fertility decision-making, desire and behaviour. This aspect requires further detailed investigation. A number of programme, policy and research recommendations are made based on the findings of this study

A mixed-method study exploring experiences, perceptions, and acceptability of using a safe delivery mHealth application in two district hospitals in Rwanda

Background: Innovative use of mobile health (mHealth) technology in timely management of childbirth complications is a promising strategy, but its evidence base is limited. The Safe Delivery mHealth Application (SDA) is one of the recent mhealth applications (loaded in smartphones) which is a clinical decision support and training tool for basic emergency obstetric and newborn care (BEmONC). This paper describes, the health providers’ experiences, perceptions, and acceptability of using the SDA, as well as the perceptions of key stakeholders.Methods: A mixed-methods approach was utilized. Quantitative methods consisted of a self-reported acceptability survey, administered to 54 nurses and midwives, including questions on their usage and perceptions of the SDA. Descriptive statistics were employed to analyze the survey data. Qualitative methods included two focus group discussions with 24 nurses and midwives, and six key informant interviews with stakeholders (maternity matrons, responsible for maternal and child health, and district hospital managers). Thematic analysis was performed and selected quotations used to illustrate themes. The study took place in two district hospitals in Rwanda.Results: Quantitative results found that 31 (57.4%) participants used the SDA four to six times per week. Many participants felt more confident (53.7%) and better at their job (40.7%) since having the SDA. Likert scale survey responses (1–5, 1 = Strongly Disagree, 5 = Strongly Agree) indicated general agreement that SDA is easy to use (Mean = 4.46), is an effective decision support tool (4.63), and training tool (4.65). Qualitative results included themes on perceived usefulness; professional growth acquired through the use of the SDA; SDA, an empowering, intuitive, and user-friendly technology; desired SDA features and functions; benefits of SDA as perceived by key informants, and future use of the SDA.Conclusions: The nurses and midwives perceive the SDA as having improved their ability to manage childbirth complications. Key stakeholders also perceive the SDA as a useful tool with a reasonable cost and recommend its implementation in routine practices. This study deepens the understanding of the potential benefits of mHealth such as the SDA in low-income settings, like Rwanda. It also provides more evidence on the impact of mHealth in assuring quality BEmONC

An epidemiological perspective of unintended pregnancy amoung South African youth

Student Number : 0411802R - MSc (Med) research report - Faculty of Health SciencesUnintended pregnancy among the youth is a serious public health problem for it exposes the young women and the foetuses to higher risk of morbidity and mortality. Although recognised as a major public health problem, studies on it have been limited and localised in South Africa. Using the 1998 South African Demographic and Health Survey (SADHS) data set, this study examines the distribution of and factors associated with unintended pregnancy among South African youth. The 1998 SADHS was a nationally representative cross-sectional survey with a probability sample of twelve thousand (12 000) women between the ages of 15 and 49. The survey used a structured questionnaire to collect information on fertility issues in general from the respondents. Analysis was based on 1 395 observations which was arrived at after sub setting observations of women aged 15-24 that had pregnancy at the time of and/or three years preceding the survey. Logistic regression model was employed to estimate the effects of identified predictors on unintended pregnancy. The results show a high level of unintended pregnancy with only 29% of the pregnancies wanted. The level of unintended pregnancy varies by region and some socio-economic variables. Respondents from KwaZulu Natal had the highest percentage (81%) of unintended pregnancy while North West had the lowest at 56%. It was also found that the higher the educational level of the respondents, the higher the incidence of unwanted pregnancy. Among the respondents using modern method of contraception, 74% reported having unintended pregnancy while the probability of unintended pregnancy was found to decrease with increase in age at first intercourse. Overall, about 69% of respondents who reported unintended pregnancy had last sexual relation with their regular partners, 21% with marital partners and 10% with casual partners. Using stepwise logistic regression, five critical predictors of unintended pregnancy among South African youth were identified. These are: age group, region, marital status, education and relationship to the last sexual partner. The findings of this study have implications for reproductive health policies and programs in designing appropriate national programs for reducing the incidence of unintended pregnancy among South African youth. The need for further research into this area using triangulated methodology is recommended

Context specific realities and experiences of nurses and midwives in basic emergency obstetric and newborn care services in two district hospitals in Rwanda:a qualitative study

Background: In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into experiences of these healthcare workers in managing obstetric emergencies are critical for improving the quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. Rwanda has made remarkable progress in obstetric care. However, challenges remain in the provision of high-quality basic emergency obstetric and newborn care (BEmONC). This study is a qualitative part of a broader research project about implementation of an mLearning and mHealth decision support tool in BEmONC services in Rwanda.Methods: In this exploratory qualitative aspect of the research, four focus group discussions (FGDs) with 26 nurses and midwives from two district hospitals in Rwanda were conducted. Each FGD was made up of two parts. The first part focused on the participants’ reflections on the research results (from the previous study), while the second part explored their experiences of delivering obstetric care services. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis.Results: The analysis revealed three main themes: (1) reflections to the baseline research results, (2) self-reflection on the current practices, and (3) contextual factors influencing the delivery of BEmONC services. Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants’ narratives of lived experiences of providing BEmONC services are also presented.Conclusion: The insights of nurses and midwives regarding the management of birth-related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on PPH management and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health, particularly in low and middle-income countries

The effect of an mLearning application on nurses’ and midwives’ knowledge and skills for the management of postpartum hemorrhage and neonatal resuscitation:pre–post intervention study

Background: Globally, mobile learning (mLearning) tools have attracted considerable attention as a means of continuous training for healthcare workers. Rwanda like other low-resource settings with scarce in-service training opportunities requires innovative approaches that adapt technology to context to improve healthcare workers’ knowledge and skills. One such innovation is the safe delivery application (SDA), a smartphone mLearning application for Basic Emergency Obstetric and Neonatal Care (BEmONC) content. This study assessed the effect of the SDA intervention on nurses’ and midwives’ knowledge and skills for the management of postpartum hemorrhage (PPH) and neonatal resuscitation (NR).Methods: The study used a pre–post test design to compare knowledge and skills of nurses and midwives in the management of PPH and NR at two measurement points: immediately prior to SDA intervention and after 6 months of SDA intervention. The intervention took place in two district hospitals in Rwanda and included 54 participants. A paired-sample t-test was used to measure the pre–post intervention, mean knowledge and skills scores differences. Confidence intervals (CIs) and effect size were calculated. A t-test and a one-way Anova were used to test for potential confounders.Results: The analysis included 54 participants. Knowledge scores and skills scores on PPH management and NR increased significantly from baseline to endline measurements. The mean difference for PPH knowledge is 17.1 out of 100; 95% CI 14.69 to 19.49 and 2.6% for PPH skills; 95% CI 1.01 to 4.25. The mean difference for NR knowledge is 19.1 out of 100; 95% CI 16.31 to 21.76 and 5.5% for NR skills; 95% CI 3.66 to 7.41. Increases were unaffected by participants’ attendance to in-service training 6 months prior and during SDA intervention and previous smartphone use. However, pre- and post-intervention skills scores were significantly different by years of experience in obstetric care.Conclusion: The SDA intervention improved the knowledge and skills of nurses and midwives on the management of PPH and NR as long as 6 months after SDA introduction. The results are highly relevant in low-income countries like Rwanda, where quality of delivery care is challenged by a lack of in-service continuous training for healthcare providers

Transactional sex and HIV infection among commercial farm workers in South Africa

Background: High prevalence of HIV infection has been reported among commercial farm workers in South Africa, but studies of the role of transactional sex in this epidemic is limited. Objective: This study seeks to examine the association between transactional sex and HIV infection among commercial farm workers in South Africa. Methods: This is a cross-sectional secondary data analysis of the Integrated Biological and Behavioural Surveillance Survey by the International Organization of Migration among farm workers in Mpumalanga and Limpopo Provinces, South Africa in 2010. The study included 2,758 sexually active farm workers. The outcome variable was HIV infection while the main explanatory variable was engagement in transactional sex. Other explanatory variables were sex, age, marital status, number of sex partners, food security, recent history of sexually transmitted infection, condom use at last sex with non-regular partner, history of sexual violence and migration status. Bivariate and multivariable logistic regression analyses were done to obtain unadjusted and adjusted odds ratios of the association between transactional sex and HIV infection. Results: Engagement in transactional sex was common (19%) but not significantly associated with HIV infection (OR 1.1; CI 0.57-2.44). Female sex (1.93; 1.60-2.32), age 25 to 44 years, recent STI (OR 1.37; CI 1.18-1.58) and sexual violence (OR 1.39; CI 1.19-1.63) were significant risk factors for HIV infection. Conclusion: Risky sexual behaviours were common among the farmworker population. HIV prevention interventions should include behavioural change communication and improved access to healthcare for STI and HIV treatment

Context specific realities and experiences of nurses and midwives in basic emergency obstetric and newborn care services in two district hospitals in Rwanda:a qualitative study

Background: In low and middle-income countries, nurses and midwives are the frontline healthcare workers in obstetric care. Insights into experiences of these healthcare workers in managing obstetric emergencies are critical for improving the quality of care. This article presents such insights, from the nurses and midwives working in Rwandan district hospitals, who reflected on their experiences of managing the most common birth-related complications; postpartum hemorrhage (PPH) and newborn asphyxia. Rwanda has made remarkable progress in obstetric care. However, challenges remain in the provision of high-quality basic emergency obstetric and newborn care (BEmONC). This study is a qualitative part of a broader research project about implementation of an mLearning and mHealth decision support tool in BEmONC services in Rwanda.Methods: In this exploratory qualitative aspect of the research, four focus group discussions (FGDs) with 26 nurses and midwives from two district hospitals in Rwanda were conducted. Each FGD was made up of two parts. The first part focused on the participants’ reflections on the research results (from the previous study), while the second part explored their experiences of delivering obstetric care services. The research results included: survey results reflecting their knowledge and skills of PPH management and of neonatal resuscitation (NR); and findings from a six-month record review of PPH management and NR outcomes, from the district hospitals under study. Data were analyzed using hybrid thematic analysis.Results: The analysis revealed three main themes: (1) reflections to the baseline research results, (2) self-reflection on the current practices, and (3) contextual factors influencing the delivery of BEmONC services. Nurses and midwives felt that the presented findings were a true reflection of the reality and offered diverse explanations for the results. The participants’ narratives of lived experiences of providing BEmONC services are also presented.Conclusion: The insights of nurses and midwives regarding the management of birth-related complications revealed multi-faceted factors that influence the quality of their obstetric care. Even though the study was focused on PPH management and NR, the resulting recommendations to improve quality of care could benefit the broader field of maternal and child health, particularly in low and middle-income countries