Innovative dashboard for optimising emergency obstetric care geographical accessibility in Nigeria: Qualitative study with technocrats

Objective: To explore perspectives of public sector technocrats on the role of and considerations needed for implementing an innovative dashboard that leverages geographic information systems (GIS) in supporting optimisation of emergency obstetric care (EmOC) geographical accessibility in Nigeria. Methods: Twenty-three semi-structured interviews were conducted in person or virtually with six policymakers and 17 senior civil servants in Nigeria. Braun and Clarke's six-step approach to thematic analysis, which involved data familiarisation, initial code generation, searching for themes, reviewing themes, defining themes, and producing the report, was applied. Results: Despite recognising the ideal of data-driven needs assessment, in reality, factors such as political pressure, persistent community advocacy, and donor funding drive decisions on siting EmOC facilities. Irregular short-term political cycles and exigencies in health systems prevent new facilities from being established or motivate a focus on facility quality over quantity. There was a strong appetite for using GIS-enabled dashboards to support planning, with enthusiasm for such technology more apparent where innovation was already part of government's philosophy. A digital dashboard that is dynamic, reflective of reality, inclusive of public and private providers, incorporates facility characteristics, and can test accessibility scenarios, was deemed particularly valuable. Its value proposition extended beyond EmOC and provider type. However, its success as a policy tool will depend on the veracity and currency of the data informing it. Conclusions: Technocrats welcome dynamic GIS-enabled dashboards as it offers a significant step-change compared to the current practice for EmOC service planning. Value-for-money of such innovations must be considered if implemented. Public Interest Summary: Planning and siting of emergency services used by pregnant women (EmOC) in many low-resource countries are mostly haphazard. However, there is increasing recognition that technology can refine this process. In this study, we explored perspectives of public sector technocrats in Nigeria on the role of and considerations needed for implementing an innovative digital dashboard that leverages geographic information systems in optimising EmOC geographical accessibility. We found that current planning is mainly driven by political pressure, community advocacy, and donor funding. However, there is a strong appetite in government for using GIS-enabled dashboards to inform service planning, with enthusiasm for such technology appearing to be more grounded in states where innovation was already part of the government's philosophy. Yet, concerns about data accuracy were expressed. Broadly, dashboards that are dynamic, reflective of reality, inclusive of public and private providers, incorporate facility characteristics, and can test access scenarios, were deemed particularly valuable

Cost of maternal health services in low- and middle-income countries: protocol for a systematic review

Introduction There is substantial evidence that maternal health services across the continuum of care are effective in reducing morbidities and mortalities associated with pregnancy and childbirth. There is also consensus regarding the need to invest in the delivery of these services towards the global goal of achieving Universal Health Coverage in low/middle-income countries (LMICs). However, there is limited evidence on the costs of providing these services. This protocol describes the methods and analytical framework to be used in conducting a systematic review of costs of providing maternal health services in LMICs. Methods African Journal Online, CINAHL Plus, EconLit, Embase, Global Health Archive, Popline, PubMed and Scopus as well as grey literature databases will be searched for relevant articles which report primary cost data for maternal health service in LMICs published from January 2000 to June 2019. This search will be conducted without implementing any language restrictions. Two reviewers will independently search, screen and select articles that meet the inclusion criteria, with disagreements resolved by discussions with a third reviewer. Quality assessment of included articles will be conducted based on cost-focused criteria included in globally recommended checklists for economic evaluations. For comparability, where feasible, cost will be converted to international dollar equivalents using purchasing power parity conversion factors. Costs associated with providing each maternal health services will be systematically compared, using a subgroup analysis. Sensitivity analysis will also be conducted. Where heterogeneity is observed, a narrative synthesis will be used. Population contextual and intervention design characteristics that help achieve cost savings and improve efficiency of maternal health service provision in LMICs will be identified. Ethics and dissemination Ethical approval is not required for this review. The plan for dissemination is to publish review findings in a peer-reviewed journal and present findings at high-level conferences that engage the most pertinent stakeholders. PROSPERO registration number CRD4201811412

Mechanisms behind gender transformative approaches targeting adolescent pregnancy in low- and middle-income countries: a realist synthesis protocol

Introduction: Adolescent pregnancy is defined as pregnancy at the age of 19 or below. Pregnancy and childbirth complications are the most significant cause of death among 15–19-year-old girls. Several studies have indicated that inequitable gender norms can increase the vulnerability of adolescent girls, including violence exposure, early marriage, and adolescent pregnancy. To address these disparities, gender transformative approaches aim to challenge and transform restrictive gender norms, roles, and relations through targeted interventions, promoting progressive changes. This realist review aims to synthesise existing evidence from a broad range of data sources to understand how, why, for whom, and in what contexts gender transformative approaches succeed in reducing adolescent pregnancy in low- and middle-income countries. Method and analysis: We employ a five-step realist synthesis approach: (1) clarify the scope of review and assessment of published literature, (2) development of initial programme theories, (3) systematic search for evidence, (4) development of refined programme theories, and (5) expert feedback and dissemination of results. This protocol presents the results of the first three steps and provides details of the next steps. We extracted data from 18 studies and outlined eight initial programme theories on how gender transformative approaches targeting adolescent pregnancy work in the first three steps. These steps were guided by experts in the field of sexual and reproductive health, implementation science, and realist methodology. As a next step, we will systematically search evidence from electronic databases and grey literature to identify additional studies eligible to refine the initial programme theories. Finally, we will propose refined programme theories that explain how gender transformative approaches work, why, for whom, and under which circumstances. Ethics and dissemination: Ethics approval is not required because the included studies are published articles and other policy and intervention reports. Key results will be shared with the broader audience via academic papers in open-access journals, conferences, and policy recommendations. The protocol for this realist review is registered in PROSPERO (CRD42023398293)

Targeting strategies of mHealth interventions for maternal health in low and middle-income countries: a systematic review protocol

INTRODUCTION: Recently, there has been a steady increase in mobile health (mHealth) interventions aimed at improving maternal health of women in low-income and middle-income countries. While there is evidence indicating that these interventions contribute to improvements in maternal health outcomes, other studies indicate inconclusive results. This uncertainty has raised additional questions, one of which pertains to the role of targeting strategies in implementing mHealth interventions and the focus on pregnant women and health workers as target groups. This review aims to assess who is targeted in different mHealth interventions and the importance of targeting strategies in maternal mHealth interventions. METHODS AND ANALYSIS: We will search for peer-reviewed, English-language literature published between 1999 and July 2017 in PubMed, Web of Knowledge (Science Direct, EMBASE) and Cochrane Central Registers of Controlled Trials. The study scope is defined by the Population, Intervention, Comparison and Outcomes framework: P, community members with maternal or reproductive needs; I, electronic health or mHealth programmes geared at improving maternal or reproductive health; C, other non-electronic health or mHealth-based interventions; O, maternal health measures including family planning, antenatal care attendance, health facility delivery and postnatal care attendance. ETHICS AND DISSEMINATION: This study is a review of already published or publicly available data and needs no ethical approval. Review results will be published in a peer-reviewed journal and presented at international conferences. PROSPERO REGISTRATION NUMBER: CRD42017072280

Cost of maternal health services in low and middle-income countries: protocol for a systematic review

INTRODUCTION: There is substantial evidence that maternal health services across the continuum of care are effective in reducing morbidities and mortalities associated with pregnancy and childbirth. There is also consensus regarding the need to invest in the delivery of these services towards the global goal of achieving Universal Health Coverage in low/middle-income countries (LMICs). However, there is limited evidence on the costs of providing these services. This protocol describes the methods and analytical framework to be used in conducting a systematic review of costs of providing maternal health services in LMICs. METHODS: African Journal Online, CINAHL Plus, EconLit, Embase, Global Health Archive, Popline, PubMed and Scopus as well as grey literature databases will be searched for relevant articles which report primary cost data for maternal health service in LMICs published from January 2000 to June 2019. This search will be conducted without implementing any language restrictions. Two reviewers will independently search, screen and select articles that meet the inclusion criteria, with disagreements resolved by discussions with a third reviewer. Quality assessment of included articles will be conducted based on cost-focused criteria included in globally recommended checklists for economic evaluations. For comparability, where feasible, cost will be converted to international dollar equivalents using purchasing power parity conversion factors. Costs associated with providing each maternal health services will be systematically compared, using a subgroup analysis. Sensitivity analysis will also be conducted. Where heterogeneity is observed, a narrative synthesis will be used. Population contextual and intervention design characteristics that help achieve cost savings and improve efficiency of maternal health service provision in LMICs will be identified. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. The plan for dissemination is to publish review findings in a peer-reviewed journal and present findings at high-level conferences that engage the most pertinent stakeholders. PROSPERO REGISTRATION NUMBER: CRD42018114124

Factors associated with adolescent pregnancy in Maharashtra,India: a mixed-methods study

Reducing the adolescent birth rate is paramount in achieving the health-related Sustainable Development Goals, given that pregnancy and childbirth are the leading cause of mortality among young women aged 15–19. This study aimed to explore predictors of adolescent pregnancy among girls aged 13–18 years in Maharashtra, India, during the COVID-19 pandemic. Using a mixed-methods approach, primary data were gathered from two regions in Maharashtra between February and April 2022. Quantitative data from face-to-face interviews with 3049 adolescent girls assessed various household, social, and behavioural factors, as well as the socioeconomic and health impacts of COVID-19. Qualitative data from seven in-depth interviews were analysed thematically. The findings reveal that girls from low socioeconomic backgrounds face a higher likelihood of adolescent pregnancy. Multivariable analysis identified several factors associated with increased risk, including older age, being married, having more sexual partners, and experiencing COVID-19-related economic vulnerability. On the other hand, rural residence, secondary and higher secondary education of the participants, and higher maternal education were associated with a decreased likelihood of adolescent pregnancy. In the sub-sample of 565 partnered girls, partner's emotional abuse also correlated with higher rates of adolescent pregnancy. Thematic analysis of qualitative data identified four potential pathways leading to adolescent pregnancy: economic hardships and early marriage; personal safety, social norms, and early marriage; social expectations; and lack of knowledge on contraceptives. The findings underscore the significance of social position and behavioural factors and the impact of external shocks like the COVID-19 pandemic in predicting adolescent pregnancy in Maharashtra, India

Viability of diagnostic decision support for antenatal care in rural settings: findings from the Bliss4Midwives Intervention in Northern Ghana

Background: Antenatal screening is useful for early identification and management of high-risk pregnancies. In low-resource settings, provision of the full complement of tests is limited and diagnostic referrals incure additional costs for pregnant women. We assessed the viability of Bliss4Midwives (B4M) - a point-of-care diagnostic decision support device for decentralized screening of pre-eclampsia, gestational diabetes and anaemia during antenatal care (ANC). Methods: The device was piloted in seven health facilities across two districts in Northern Ghana over a ten-month period. Health workers were expected to screen women at each ANC visit till delivery. All screening records from the device were automatically archived digitally and later downloaded. After removing duplicates or invalid entries, descriptive quantitative analysis was carried out with IBM SPSS Statistics (version 23). B4M usage behavior, diagnostic and referral outcome were analyzed. Results: Health workers conducted 1323 partial or full antenatal screening on 940 women, resulting in decision support for 835 (88.8%) B4M beneficiaries. Diagnostic referral was eliminated for 708 (84.7%) beneficiaries, with 335 (40.1%) of these from facilities without on-site diagnostic alternatives. Of visits with complete data, 92/559 (16.4%) women were screened in their first trimester, 28/940 (2.9%) had 4+ B4M visits and 107/835 (12.8%) women were recommended for urgent referral to a higher-level facility on the first visit. Follow-up screenings flagged an additional 17 women for urgent referral with 10 cases of repeated alerts in five women. Wide variations between high (9 months use) and low adopting (1.5 months use) facilities were observed, with some similarities in usage trend. Conclusions: B4M helped decentralize ANC screening and decrease unnecessary referrals. Project outcomes were influenced by implementation strategy, technical features and behavioural dispositions of users and beneficiaries

Cost of utilising maternal health Services in low and middle-income countries: a systematic review

Background: Cost is a major barrier to maternal health service utilisation for many women in low- and middle-income countries (LMICs). However, comparable evidence of the available cost data in these countries is limited. We conducted a systematic review and comparative analysis of costs of utilising maternal health services in these settings. Methods: We searched peer-reviewed and grey literature databases for articles reporting cost of utilising maternal health services in LMICs published post-2000. All retrieved records were screened and articles meeting the inclusion criteria selected. Quality assessment was performed using the relevant cost-specific criteria of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. To guarantee comparability, disaggregated costs data were inflated to 2019 US dollar equivalents. Total adjusted costs and cost drivers associated with utilising each service were systematically compared. Where heterogeneity in methods or non-disaggregated costs was observed, narrative synthesis was used to summarise findings. Results: Thirty-six studies met our inclusion criteria. Many of the studies costed multiple services. However, the most frequently costed services were utilisation of normal vaginal delivery (22 studies), caesarean delivery (13), and antenatal care (ANC) (10). The least costed services were post-natal care (PNC) and post-abortion care (PAC) (5 each). Studies used varied methods for data collection and analysis and their quality ranged from low to high with most assessed as average or high. Generally, across all included studies, cost of utilisation progressively increased from ANC and PNC to delivery and PAC, and from public to private providers. Medicines and diagnostics were main cost drivers for ANC and PNC while cost drivers were variable for delivery. Women experienced financial burden of utilising maternal health services and also had to pay some unofficial costs to access care, even where formal exemptions existed. Conclusion: Consensus regarding approach for costing maternal health services will help to improve their relevance for supporting policy-making towards achieving universal health coverage. If indeed the post-2015 mission of the global community is to “leave no one behind,” then we need to ensure that women and their families are not facing unnecessary and unaffordable costs that could potentially tip them into poverty

e-income countries from a provider's perspective: a systematic review

INTRODUCTION: Maternal health services are effective in reducing the morbidity and mortality associated with pregnancy and childbirth. We conducted a systematic review on costs of maternal health services in low-income and middle-income countries from the provider's perspective. METHODS: We searched multiple peer-reviewed databases (including African Journal Online, CINAHL Plus, EconLit, Popline, PubMed, Scopus and Web of Science) and grey literature for relevant articles published from year 2000. Articles meeting our inclusion criteria were selected with quality assessment done using relevant cost-focused criteria of the Consolidated Health Economic Evaluation Reporting Standards checklist. For comparability, disaggregated costs data were inflated to 2019 US$equivalents. Costs and cost drivers were systematically compared. Where heterogeneity was observed, narrative synthesis was used to summarise findings. RESULTS: Twenty-two studies were included, with most studies costing vaginal and/or caesarean delivery (11 studies), antenatal care (ANC) (9) and postabortion care (PAC) (8). Postnatal care (PNC) has been least costed (2). Studies used different methods for data collection and analysis. Quality of peer-reviewed studies was assessed average to high while all grey literature studies were assessed as low quality. Following inflation, estimated provision cost per service varied (ANC (US$7.24-US$31.42); vaginal delivery (US$14.32-US$278.22); caesarean delivery (US$72.11-US$378.940; PAC (US$97.09-US$1299.21); family planning (FP) (US$0.82-US$5.27); PNC (US$5.04)). These ranges could be explained by intercountry variations, variations in provider type (public/private), facility type (primary/secondary) and care complexity (simple/complicated). Personnel cost was mostly reported as the major driver for provision of ANC, skilled birth attendance and FP. Economies of scale in service provision were reported. CONCLUSION: There is a cost savings case for task-shifting and encouraging women to use lower level facilities for uncomplicated services. Going forward, consensus regarding cost component definitions and methodologies for costing maternal health services will significantly help to improve the usefulness of cost analyses in supporting policymaking towards achieving Universal Health Coverage

Reaching health facilities in situations of emergency: qualitative study capturing experiences of pregnant women in Africa’s largest megacity

Background: The consequences of delays in travel of pregnant women to reach facilities in emergency situations are well documented in literature. However, their decision-making and actual experiences of travel to health facilities when requiring emergency obstetric care (EmOC) remains a ‘black box’ of many unknowns to the health system, more so in megacities of low- and middle-income countries which are fraught with wide inequalities. Methods: This in-depth study on travel of pregnant women in Africa’s largest megacity, Lagos, is based on interviews conducted between September 2019 and January 2020 with 47 women and 11 of their relatives who presented at comprehensive EmOC facilities in situations of emergency, requiring some EmOC services. Following familiarisation, coding, and searching for patterns, the data was analysed for emerging themes. Results: Despite recognising danger signs, pregnant women are often faced with conundrums on “when”, “where” and “how” to reach EmOC facilities. While the decision-making process is a shared activity amongst all women, the available choices vary depending on socio-economic status. Women preferred to travel to facilities deemed to have “nicer” health workers, even if these were farther from home. Reported travel time was between 5-240 minutes in daytime and 5-40 minutes at night. Many women reported facing remarkably similar travel experiences, with varied challenges faced in the daytime (traffic congestion) compared to night-time (security concerns and scarcity of public transportation). This was irrespective of their age, socio-economic background, or obstetric history. However, the extent to which this experience impacted on their ability to reach facilities depended on their agency and support systems. Travel experience was better if they had a personal vehicle for travel at night, support of relatives or direct/indirect connections with senior health workers at comprehensive EmOC facilities. Referral barriers between facilities further prolonged delays and increased cost of travel for many women. Conclusion: If the goal, to leave no one behind, remains a priority, in addition to other health systems strengthening interventions, referral systems need to be improved. Advocacy on policies to encourage women to utilise nearby functional facilities when in situations of emergency and private sector partnerships should be explored