Disrespect and abuse of women during childbirth in Nigeria: A systematic review.

BACKGROUND: Promoting respectful care at childbirth is important to improve quality of care and encourage women to utilize skilled delivery services. However, there has been a relative lack of public health research on this topic in Nigeria. A systematic review was conducted to synthesize current evidence on disrespect and abuse of women during childbirth in Nigeria in order to understand its nature and extent, contributing factors and consequences, and propose solutions. METHODS: Five electronic databases were searched for relevant published studies, and five data sources for additional grey literature. A qualitative synthesis was conducted using the Bowser and Hill landscape analytical framework on disrespect and abuse of women during childbirth. RESULTS: Fourteen studies were included in this review. Of these studies, eleven were cross sectional studies, one was a qualitative study and two used a mixed method approach. The type of abuse most frequently reported was non-dignified care in form of negative, poor and unfriendly provider attitude and the least frequent were physical abuse and detention in facilities. These behaviors were influenced by low socioeconomic status, lack of education and empowerment of women, poor provider training and supervision, weak health systems, lack of accountability and legal redress mechanisms. Overall, disrespectful and abusive behavior undermined the utilization of health facilities for delivery and created psychological distance between women and health providers. CONCLUSION: This systematic review documented a broad range of disrespectful and abusive behavior experienced by women during childbirth in Nigeria, their contributing factors and consequences. The nature of the factors influencing disrespectful and abusive behavior suggests that educating women on their rights, strengthening health systems to respond to specific needs of women at childbirth, improving providers training to encompass interpersonal aspects of care, and implementing and enforcing policies on respectful maternity care are important. This review has also shown that more robust research is needed to explore disrespect and abuse of women during childbirth in Nigeria and propose compelling interventions

Stakeholder views on the incorporation of traditional birth attendants into the formal health systems of low-and middle-income countries: a qualitative analysis of the HIFA2015 and CHILD2015 email discussion forums.

BACKGROUND: Health workforce shortages are key obstacles to the achievement of the health-related Millennium Development Goals. Task shifting is seen as a way to improve access to pregnancy and childbirth care. However, the role of traditional birth attendants (TBAs) within task shifting initiatives remains contested. The objective of this study was to explore stakeholder views and justifications regarding the incorporation of TBAs into formal health systems. METHODS: Data were drawn from messages submitted to the HIFA2015 and CHILD2015 email discussion forums. The forums focus on the healthcare information needs of frontline health workers and citizens in low - and middle-income countries, and how these needs can be met, and also include discussion of diverse aspects of health systems. Messages about TBAs submitted between 2007-2011 were analysed thematically. RESULTS: We identified 658 messages about TBAs from a total of 193 participants. Most participants supported the incorporation of trained TBAs into primary care systems to some degree, although their justifications for doing so varied. Participant viewpoints were influenced by the degree to which TBA involvement was seen as a long-term or short-term solution and by the tasks undertaken by TBAs. CONCLUSIONS: Many forum members indicated that they were supportive of trained TBAs being involved in the provision of pregnancy care. Members noted that TBAs were already frequently used by women and that alternative options were lacking. However, a substantial minority regarded doing so as a threat to the quality and equity of healthcare. The extent of TBA involvement needs to be context-specific and should be based on evidence on effectiveness as well as evidence on need, acceptability and feasibility

Zambia Signal Functions study 2016 dataset

This dataset contains information related to health facilities’ infrastructure, staffing, equipment, supplies, and capacity to perform various clinical functions related to reproductive and maternal health service provision. The study was conducted in Central Province, Zambia and its primary aim was to assess facilities’ capacity to provide termination of pregnancy services

Women's knowledge and attitudes surrounding abortion in Zambia: a cross-sectional survey across three provinces.

OBJECTIVES: In Zambia, despite a relatively liberal legal framework, there remains a substantial burden of unsafe abortion. Many women do not use skilled providers in a well-equipped setting, even where these are available. The aim of this study was to describe women's knowledge of the law relating to abortion and attitudes towards abortion in Zambia. SETTING: Community-based survey in Central, Copperbelt and Lusaka provinces. PARTICIPANTS: 1484 women of reproductive age (15-44 years). PRIMARY AND SECONDARY OUTCOME MEASURES: Correct knowledge of the legal grounds for abortion, attitudes towards abortion services and the previous abortions of friends, family or other confidants. Descriptive statistics and multivariable logistic regression were used to analyse how knowledge and attitudes varied according to sociodemographic characteristics. RESULTS: Overall, just 16% (95% CI 11% to 21%) of women of reproductive age correctly identified the grounds for which abortion is legal. Only 40% (95% CI 32% to 45% of women of reproductive age knew that abortion was legally permitted in the extreme situation where the pregnancy threatens the life of the mother. Even in urban areas of Lusaka province, only 55% (95% CI 41% to 67%) of women knew that an abortion could legally take place to save the mother's life. Attitudes remain conservative. Women with correct knowledge of abortion law in Zambia tended to have more liberal attitudes towards abortion and access to safe abortion services. Neither correct knowledge of the law nor attitudes towards abortion were associated with knowing someone who previously had an induced abortion. CONCLUSIONS: Poor knowledge and conservative attitudes are important obstacles to accessing safe abortion services. Changing knowledge and attitudes can be challenging for policymakers and public health practitioners alike. Zambia could draw on its previous experience in dealing with its large HIV epidemic to learn cross-cutting lessons in effective mass communication on what is a difficult and sensitive issue

The magnitude and severity of abortion-related morbidity in settings with limited access to abortion services:a systematic review and meta-regression

Introduction: Defining and accurately measuring abortion-related morbidity is important for understanding the spectrum of risk associated with unsafe abortion and for assessing the impact of changes in abortion-related policy and practices. This systematic review aims to estimate the magnitude and severity of complications associated with abortion in areas where access to abortion is limited, with a particular focus on potentially life-threatening complications. Methods: A previous systematic review covering the literature up to 2010 was updated with studies identified through a systematic search of Medline, Embase, Popline and two WHO regional databases until July 2016. Studies from settings where access to abortion is limited were included if they quantified the percentage of abortion-related hospital admissions that had any of the following complications: mortality, a near-miss event, haemorrhage, sepsis, injury and anaemia. We calculated summary measures of the percentage of abortion-related hospital admissions with each complication by conducting meta-analysis and explored whether these have changed over time. Results: Based on data collected between 1988 and 2014 from 70 studies from 28 countries, we estimate that at least 9% of abortion-related hospital admissions have a near-miss event and approximately 1.5% ends in a death. Haemorrhage was the most common complication reported; the pooled percentage of abortion-related hospital admissions with severe haemorrhage was 23%, with around 9% having near-miss haemorrhage reported. There was strong evidence for between-study heterogeneity across most outcomes. Conclusions: In spite of the challenges on how near miss morbidity has been defined and measured in the included studies, our results suggest that a substantial percentage of abortion-related hospital admissions have potentially life-threatening complications. Estimates that are more reliable will only be obtained with increased use of standard definitions such as the WHO near-miss criteria and/or better reporting of clinical criteria applied in studies

Why not? Understanding the spatial clustering of private facility-based delivery and financial reasons for homebirths in Nigeria.

BACKGROUND: In Nigeria, the provision of public and private healthcare vary geographically, contributing to variations in one's healthcare surroundings across space. Facility-based delivery (FBD) is also spatially heterogeneous. Levels of FBD and private FBD are significantly lower for women in certain south-eastern and northern regions. The potential influence of childbirth services frequented by the community on individual's barriers to healthcare utilization is under-studied, possibly due to the lack of suitable data. Using individual-level data, we present a novel analytical approach to examine the relationship between women's reasons for homebirth and community-level, health-seeking surroundings. We aim to assess the extent to which cost or finance acts as a barrier for FBD across geographic areas with varying levels of private FBD in Nigeria. METHOD: The most recent live births of 20,467 women were georeferenced to 889 locations in the 2013 Nigeria Demographic and Health Survey. Using these locations as the analytical unit, spatial clusters of high/low private FBD were detected with Kulldorff statistics in the SatScan software package. We then obtained the predicted percentages of women who self-reported financial reasons for homebirth from an adjusted generalized linear model for these clusters. RESULTS: Overall private FBD was 13.6% (95%CI = 11.9,15.5). We found ten clusters of low private FBD (average level: 0.8, 95%CI = 0.8,0.8) and seven clusters of high private FBD (average level: 37.9, 95%CI = 37.6,38.2). Clusters of low private FBD were primarily located in the north, and the Bayelsa and Cross River States. Financial barrier was associated with high private FBD at the cluster level - 10% increase in private FBD was associated with + 1.94% (95%CI = 1.69,2.18) in nonusers citing cost as a reason for homebirth. CONCLUSIONS: In communities where private FBD is common, women who stay home for childbirth might have mild increased difficulties in gaining effective access to public care, or face an overriding preference to use private services, among other potential factors. The analytical approach presented in this study enables further research of the differentials in individuals' reasons for service non-uptake across varying contexts of healthcare surroundings. This will help better devise context-specific strategies to improve health service utilization in resource-scarce settings

A new approach to assess the capability of health facilities to provide clinical care for sexual violence against women: a pilot study.

Several tools have been developed to collect information on health facility preparedness to provide sexual violence response services; however, little guidance exists on how this information can be used to better understand which functions a facility can perform. Our study therefore aims to propose a set of signal functions that provide a framework for monitoring the availability of clinical sexual violence services. To illustrate the potential insights that can be gained from using our proposed signal functions, we used the framework to analyse data from a health facility census conducted in Central Province, Zambia. We collected the geographic coordinates of health facilities and police stations to assess women's proximity to multi-sectoral sexual violence response services. We defined three key domains of clinical sexual violence response services, based on the timing of the visit to the health facility in relation to the most recent sexual assault: (1) core services, (2) immediate care, and (3) delayed and follow-up care. Combining information from all three domains, we estimate that just 3% of facilities were able to provide a comprehensive response to sexual violence, and only 16% could provide time-sensitive immediate care services such as HIV post-exposure prophylaxis and emergency contraception. Services were concentrated in hospitals, with few health centres and no health posts fulfilling the signal functions for any of the three domains. Only 23% of women lived within 15 km of comprehensive clinical sexual violence health services, and 38% lived within 15 km of immediate care. These findings point to a need to develop clear strategies for decentralizing sexual violence services to maximize coverage and ensure equity in access. Overall, our findings suggest that our proposed signal functions could be a simple and valuable approach for assessing the availability of clinical sexual violence response services, identifying areas for improvement and tracking improvements over time

Who Meets the Contraceptive Needs of Young Women in Sub-Saharan Africa?

PURPOSE: Despite efforts to expand contraceptive access for young people, few studies have considered where young women (age 15-24) in low- and middle-income countries obtain modern contraceptives and how the capacity and content of care of sources used compares with older users. METHODS: We examined the first source of respondents' current modern contraceptive method using the most recent Demographic and Health Survey since 2000 for 33 sub-Saharan African countries. We classified providers according to sector (public/private) and capacity to provide a range of short- and long-term methods (limited/comprehensive). We also compared the content of care obtained from different providers. RESULTS: Although the public and private sectors were both important sources of family planning (FP), young women (15-24) used more short-term methods obtained from limited-capacity, private providers, compared with older women. The use of long-term methods among young women was low, but among those users, more than 85% reported a public sector source. Older women (25+) were significantly more likely to utilize a comprehensive provider in either sector compared with younger women. Although FP users of all ages reported poor content of care across all providers, young women had even lower content of care. CONCLUSIONS: The results suggest that method and provider choice are strongly linked, and recent efforts to increase access to long-term methods among young women may be restricted by where they seek care. Interventions to increase adolescents' access to a range of FP methods and quality counseling should target providers frequently used by young people, including limited-capacity providers in the private sector

Developing a forward-looking agenda and methodologies for research of self-use of medical abortion

Research has not kept abreast of women’s self-use of medical abortion, leaving many gaps in the scientific literature regarding the ideal conditions for safe and effective use. Therefore, our main objectives were to assess the research gaps highlighted during the conference, identify specific challenges to conducting research on medical abortion self-use, and to share promising research methodologies to advance this research. Although there are overlaps with the recommended and wellresearched practice of women’s self-management of the abortion process at home after receiving medical abortion medicines, screening and information from a clinician [1], our intent was focused on the emerging practice of self-use

Provision of postpartum care to women giving birth in health facilities in sub-Saharan Africa: A cross-sectional study using Demographic and Health Survey data from 33 countries.

BACKGROUND: Postpartum care has the potential to avert a substantial proportion of maternal and perinatal mortality and morbidity. There is a crucial gap in understanding the quality of postpartum care for women giving birth in health facilities in low- and middle-income settings. This is particularly the case in sub-Saharan Africa (SSA), where the levels of maternal and neonatal mortality are highest globally despite rapid increases in facility-based childbirth. This study estimated the percentage of women receiving a postpartum health check following childbirth in a health facility in SSA and examined the determinants of receiving such check. METHODS AND FINDINGS: We used the most recent Demographic and Health Survey (DHS) conducted in 33 SSA countries between 2000-2016. We estimated the percentage of women receiving a postpartum check by a health professional while in the childbirth facility and the associated 95% confidence interval (CI) for each country. We analyzed determinants of receiving such checks using logistic regression of the pooled data. The analysis sample included 137,218 women whose most recent live birth in the 5- year period before the survey took place in a health facility. Of this pooled sample, 65.7% of women were under 30 years of age, 85.9% were currently married, and 57% resided in rural areas. Across countries, the median percentage of women who reported receiving a check was 71.7%, ranging from 26.6% in Eswatini (Swaziland) to 94.4% in Burkina Faso. The most fully adjusted model showed that factors from all four conceptual categories (obstetric/neonatal risk factors, care environment, and women's sociodemographic and child-related characteristics) were significant determinants of receiving a check. Women with a cesarean section had a significantly higher adjusted odds ratio (aOR) of 1.88 (95% CI 1.72-2.05, p < 0.001) of receiving a check. Women giving birth in lower-level public facilities had lower odds of receiving a check (aOR 0.94, 95% CI 0.90-0.98, p = 0.002) compared to those in public hospitals, as did women attended by a nurse/midwife (compared to doctor/nonphysician clinician) (aOR 0.74, 95% CI 0.69-0.78, p < 0.001). This study was limited by the accuracy of the respondent's recall of the provider, timing, and receipt of postpartum checks. The outcome of interest was measured using three slightly different question sets across the 33 included countries. CONCLUSIONS: The suboptimal levels of postpartum checks in health facilities in many of the included SSA countries partially reflect the lack of importance given to postpartum care in the global discourse on essential interventions and quality improvement in maternal health. Addressing disparities in access to both facility-based childbirth and good-quality postpartum care in SSA is critical to addressing stalling declines in maternal mortality and morbidity