Critical insights from conducting a social return on investment study in maternal and newborn health

Compared with traditional approaches such as cost-effectiveness, cost–utility, and cost–benefit analyses, the social return on investment methodology has the unique capacity to account for the broader social value and value for money of interventions while capturing perspectives of multiple stakeholders and relating this to the cost of implementing the intervention in a singular ratio. This case study describes the comprehensive assessment of and assesses the social impact and value for money of an emergency obstetric care training intervention for health care providers implemented in Kenya. Critical insights are shared into the practicalities of using the methodology within the maternal and newborn health area. Insights will be relevant to any other researcher who is keen to apply the methodology in any area of health

The potential utility of an augmented data collection approach in understanding the journey to care of pregnant women for maternal and perinatal death surveillance and response

Background: The Maternal and Perinatal Death Surveillance and Response (MPDSR) proposed by the World Health Organization recognises the importance for health systems to understand the reasons underpinning the death of a pregnant woman or her newborn as an essential first step in preventing future similar deaths. Data for the surveillance component of the MPDSR process are typically collected from health facility sources and post-mortem interviews with affected families, though it may be traumatising to them. This brief report aimed to assess the potential utility of an augmented data collection method for mapping journeys of maternal and perinatal deaths, which does not require sourcing additional information from grieving family members. Methods: A descriptive analysis of maternal and perinatal deaths that occurred across 24 public hospitals in Lagos State, Nigeria, between 1 st November 2018 and 30 th October 2019 was conducted. Data on their demographic, obstetric history and complication at presentation, travel to the hospital, and mode of birth were extracted from their hospital records. The extracted travel data was exported to Google Maps, where driving distance and travel time to the hospital for the period of the day of travel were also extracted. Results: Of the 182 maternal deaths, most presented during the week (80.8%), travelled 5-10 km (30.6%) and 10-29 minutes (46.9%), and travelled to the nearest hospital to their places of residence (70.9%). Of the 442 pregnant women who had perinatal deaths, most presented during the week (78.5%), travelled 90.0%) and the period of the day they travelled (approximately 30.0%). Conclusion: An augmented data collection approach that includes accurate and complete travel data and closer-to-reality estimates of travel time and distance can be beneficial for MPDSR purposes

The potential utility of an augmented data collection approach in understanding the journey to care of pregnant women for maternal and perinatal death surveillance and response

Background: The Maternal and Perinatal Death Surveillance and Response (MPDSR) proposed by the World Health Organization recognises the importance for health systems to understand the reasons underpinning the death of a pregnant woman or her newborn as an essential first step in preventing future similar deaths. Data for the surveillance component of the MPDSR process are typically collected from health facility sources and post-mortem interviews with affected families, though it may be traumatising to them. This brief report aimed to assess the potential utility of an augmented data collection method for mapping journeys of maternal and perinatal deaths, which does not require sourcing additional information from grieving family members. Methods: A descriptive analysis of maternal and perinatal deaths that occurred across all 24 public hospitals in Lagos State, Nigeria, between 1st November 2018 and 30th October 2019 was conducted. Data on their demographic, obstetric history and complication at presentation, travel to the hospital, and mode of birth were extracted from their hospital records. The extracted travel data was exported to Google Maps, where driving distance and travel time to the hospital for the period of the day of travel were also extracted. Results: Of the 182 maternal deaths, most presented during the week (80.8%), travelled 5-10 km (30.6%) and 10-29 minutes (46.9%), and travelled to the nearest hospital to their places of residence (70.9%). Of the 442 pregnant women who had perinatal deaths, most presented during the week (78.5%), travelled 90.0%) and the period of the day they travelled (approximately 30.0%). Conclusion: An augmented data collection approach that includes accurate and complete travel data and closer-to-reality estimates of travel time and distance can be beneficial for MPDSR purposes

I guess we have to treat them, but...: health care provider perspectives on management of women presenting with unsafe abortion in Botswana

Maternal mortality due to unsafe abortion and its complications stands among the three leading causes of maternal death in Botswana. Health care providers (HCPs) including doctors and nurses are at the frontline of providing care to women who have had an unsafe abortion. This qualitative study explored the knowledge, attitudes and perceptions of HCPs towards unsafe abortion in Botswana. We purposively sampled 18 HCPs and used a semi-structured topic guide to engage them in in-depth interviews, which were audio-recorded. These interviews were transcribed and analysed to identify emerging themes. We found that HCPs were knowledgeable about unsafe abortion, local inducers, and its management. However, their religious and moral biases as well as concern for the safety of women biased their view on the subject-matter and of the women themselves. These biases also affected their willingness to provide care, including provision of analgesics. Notwithstanding these biases and the reported lack of clarity on their legal role in managing unsafe abortion, many HCPs recognised their duty-of-care to patients. The continued strengthening of post-abortion services should be implemented in conjunction with engagements with providers to clarify their values and the roles they would be willing to play in abortion and post-abortion care services

Factors influencing utilisation of maternal health services by adolescent mothers in Low-and middle-income countries: a systematic review

Background Adolescent mothers aged 15–19 years are known to have greater risks of maternal morbidity and mortality compared with women aged 20–24 years, mostly due to their unique biological, sociological and economic status. Nowhere Is the burden of disease greater than in low-and middle-income countries (LMICs). Understanding factors that influence adolescent utilisation of essential maternal health services (MHS) would be critical in improving their outcomes. Methods We systematically reviewed the literature for articles published until December 2015 to understand how adolescent MHS utilisation has been assessed in LMICs and factors affecting service utilisation by adolescent mothers. Following data extraction, we reported on the geographical distribution and characteristics of the included studies and used thematic summaries to summarise our key findings across three key themes: factors affecting MHS utilisation considered by researcher(s), factors assessed as statistically significant, and other findings on MHS utilisation. Results Our findings show that there has been minimal research in this study area. 14 studies, adjudged as medium to high quality met our inclusion criteria. Studies have been published in many LMICs, with the first published in 2006. Thirteen studies used secondary data for assessment, data which was more than 5 years old at time of analysis. Ten studies included only married adolescent mothers. While factors such as wealth quintile, media exposure and rural/urban residence were commonly adjudged as significant, education of the adolescent mother and her partner were the commonest significant factors that influenced MHS utilisation. Use of antenatal care also predicted use of skilled birth attendance and use of both predicted use of postnatal care. However, there may be some context-specific factors that need to be considered. Conclusions Our findings strengthen the need to lay emphasis on improving girl child education and removing financial barriers to their access to MHS. Opportunities that have adolescents engaging with health providers also need to be seized. These will be critical in improving adolescent MHS utilisation. However, policy and programmatic choices need to be based on recent, relevant and robust datasets. Innovative approaches that leverage new media to generate context-specific dis-aggregated data may provide a way forward

The potential utility of an augmented data collection approach in understanding the journey to care of pregnant women for maternal and perinatal death surveillance and response.

Background: The Maternal and Perinatal Death Surveillance and Response (MPDSR) proposed by the World Health Organization recognises the importance for health systems to understand the reasons underpinning the death of a pregnant woman or her newborn as an essential first step in preventing future similar deaths. Data for the surveillance component of the MPDSR process are typically collected from health facility sources and post-mortem interviews with affected families, though it may be traumatising to them. This brief report aimed to assess the potential utility of an augmented data collection method for mapping journeys of maternal and perinatal deaths, which does not require sourcing additional information from grieving family members. Methods: A descriptive analysis of maternal and perinatal deaths that occurred across 24 public hospitals in Lagos State, Nigeria, between 1 st November 2018 and 30 th October 2019 was conducted. Data on their demographic, obstetric history and complication at presentation, travel to the hospital, and mode of birth were extracted from their hospital records. The extracted travel data was exported to Google Maps, where driving distance and travel time to the hospital for the period of the day of travel were also extracted. Results: Of the 182 maternal deaths, most presented during the week (80.8%), travelled 5-10 km (30.6%) and 10-29 minutes (46.9%), and travelled to the nearest hospital to their places of residence (70.9%). Of the 442 pregnant women who had perinatal deaths, most presented during the week (78.5%), travelled 90.0%) and the period of the day they travelled (approximately 30.0%). Conclusion: An augmented data collection approach that includes accurate and complete travel data and closer-to-reality estimates of travel time and distance can be beneficial for MPDSR purposes

Social Return on Investment (SROI): an innovative approach to Sustainable Development Goals for sexual and reproductive health programming in sub-Saharan Africa

Despite efforts, sub-Saharan Africa did not achieve many key Sexual and Reproductive Health (SRH) targets under the Millennium Development Goals. In the post 2015 era, the Sustainable Development Goals (SDGs) will frame decisions on donor priorities and resource allocations. Successfully addressing SRH challenges in sub-Saharan Africa have been blunted due to fragmentation of SRH interventions in planning and implementation, lack of coherence between policies and program implementation, resulting in poor program performance and lack of accountability. We suggest the Social Return on Investment (SROI) framework offers a strategic approach for sub-Saharan Africa in support of the implementation, monitoring and evaluation of SRH programs given its capacity to capture social and economic impacts, stakeholder participation, and sensitivity towards key human rights concerns relevant to SRH. SROI disrupts a ―business as usual‖ approach for one that is systematic, participatory, and supportive of economic and human rights needs for success in the SDG era.Keywords: Sustainable Development Goals; Social Return on Investment; SROI; Sexual and Reproductive Health; sub-Saharan Africa; Human Right

Beyond the science: advancing the “art and craft” of implementation in the training and practice of global health

Interesting debates are ongoing on how to develop practical implementation science competencies that can bridge the “know-do” gap in global health. We advance these debates by arguing that apprenticeship and mentorship models drawn from “art and craft” used in industry is the missing piece of the puzzle that will bridge the persisting gap between academics and real-world practitioners. We propose examples of such models and how they can be applied to improve existing capacity building programs, as well as implementation in practice

Utilisation of Maternal Health Services by Adolescent Mothers in Kenya: Analysis of the Demographic Health Survey 2008 - 2009

Background Many Kenyan adolescents die following pregnancy and childbirth complications. Maternal health services (MHS) utilisation is key to averting such poor outcomes. Our objectives were to understand the characteristics of adolescent mothers in Kenya, describe their MHS utilisation pattern and explore factors that influence this pattern. Methods We collected demographic and MHS utilisation data of all 301 adolescent mothers aged 15–19 years included in the Kenya Demographic Health Survey 2008/2009. Descriptive statistics were used to characterise them and their MHS utilisation patterns. Bivariate and multivariate analyses were used to test associations between selected predictor variables and MHS utilisation. Findings 86%, 48% and 86% of adolescent mothers used ante-natal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) respectively. Adolescent mothers from the richest quintile were nine (CI=2.00-81.24,p=0.001) and seven (CI=3.22-16.22,p<0.001) times more likely to use ANC and SBA respectively compared to those from the poorest. Those with primary education were four (CI=1.68-9.64,p<0.001) and two (CI=0.97-4.81,p=0.043) times more likely to receive ANC and SBA respectively compared to uneducated mothers, with similar significant findings amongst their partners. Urban adolescent mothers were six (CI=1.89-32.45,p=0.001) and four (CI=2.00-6.20,p<0.001) times more likely to use ANC and SBA respectively compared to their rural counterparts. Odds of Maasai adolescent mothers using ANC was 90% (CI=0.02-0.93,p=0.010) lower than Kalenjin mothers. Conclusions Adolescent MHS utilisation in Kenya is an inequality issue. In addressing this, focus should be placed on the poorest, least educated, rural dwelling adolescent mothers living in the most disadvantaged communities

There is no ideal place, but it is best to deliver in a hospital: expectations and experiences of health facility-based childbirth in Imo state, Nigeria

Introduction: annually, about 67,000 of the 196,000 maternal deaths in sub-Saharan Africa occur in Nigeria, second only to India. Though health facility childbirths have been linked with improved health outcomes, evidence suggests that experiences of care influence future use. This study explored the expectations and experiences of health facility childbirths for mothers in Imo State, Nigeria. Methods: this qualitative study utilised in-depth interviews with 22 purposively sampled mothers who delivered in different types (private and public) and levels (primary, secondary, tertiary) of health facilities in Imo State. Interviews were digitally recorded, transcribed verbatim and analysed following Braun and Clarke´s six-stage thematic analysis. Results: four key themes emerged from the analysis. Generally, women saw value in facility-based delivery. However, they had varying expectations for seeking care with different care providers. For those who sought care from public hospitals, the availability of “experts” was a key driver. While those who used private facilities went there because of their perceived empathy and dignity. However, while experiences of disrespect, abuse and health worker expectation for them to cooperate were reported in both public and private facilities, long waiting times, unconducive environments, and lack of privacy were experienced in public facilities. Conclusion: every woman deserves a positive experience of childbirth. To achieve this, mothers´ perceptions of different providers need to be heard. Going forward, strategies ensuring that both public and private sector providers can guarantee holistic care for every woman will be key to realising the maternal mortality target of the Sustainable Development Goal 3