Trends in health facility deliveries and caesarean sections by wealth quintile in Morocco between 1987 and 2012.

OBJECTIVES: To examine trends in the utilisation of facility-based delivery care and caesareans in Morocco between 1987 and 2012, particularly among the poor, and to assess whether uptake increased at the time of introduction of policies or programmes aimed at improving access to intrapartum care. METHODS: Using data from nationally representative household surveys and routine statistics, our analysis focused on whether women delivered within a facility, and whether the delivery was by caesarean; analyses were stratified by relative wealth quintile and public/private sector where possible. A segmented Poisson regression model was used to assess whether trends changed at key events. RESULTS: Uptake of facility-based deliveries and caesareans in Morocco has risen considerably over the past two decades, particularly among the poor. The rate of increase in facility deliveries was much faster in the poorest quintile (annual increase RR: 1.09; 95% CI: 1.07-1.11) than the richest quintile (annual increase RR: 1.01; 95% CI: 1.02-1.02). A similar pattern was observed for caesareans (annual increase among poorest RR: 1.13; 95% CI: 1.07-1.19 vs. annual increase among richest RR: 1.08; 95% CI: 1.06-1.10). We found no significant acceleration in trend coinciding with any of the events investigated. CONCLUSIONS: Morocco's success in improving uptake of facility deliveries and caesareans is likely to be the result of the synergistic effects of comprehensive demand and supply-side strategies, including a major investment in human resources and free delivery care. Equity still needs to be improved; however, the overall trend is positive

Incidence of abortion-related near-miss complications in Zambia: cross-sectional study in Central, Copperbelt and Lusaka Provinces.

OBJECTIVES: To describe the magnitude and severity of abortion-related complications in health facilities and calculate the incidence of abortion-related near-miss complications at the population level in three provinces in Zambia, a country where abortion is legal but stigmatized. STUDY DESIGN: We conducted a cross-sectional study in 35 district, provincial and tertiary hospitals over 5 months. All women hospitalized for abortion-related complications were eligible for inclusion. Cases of abortion-related near-miss, moderate and low morbidity were identified using adapted World Health Organization (WHO) near-miss and the prospective morbidity methodology criteria. Incidence was calculated by annualizing the number of near-misses and dividing by the population of women of reproductive age. We calculated the abortion-related near-miss rate, abortion-related near-miss ratio and the hospital mortality index. RESULTS: Participating hospitals recorded 26,723 births during the study. Of admissions for post-abortion care, 2406 (42%) were eligible for inclusion. Near-misses constituted 16% of admitted complications and there were 14 abortion-related maternal deaths. The hospital mortality index was 3%; the abortion-related near-miss rate for the three provinces was 72 per 100,000 women, and the near-miss ratio was 450 per 100,000 live births. CONCLUSIONS: Abortion-related near-miss and mortality are challenges for the Zambian health system. Adapted to reflect health systems capabilities, the WHO near-miss criteria can be applied to routine hospital records to obtain useful data in low-income settings. Reducing avoidable maternal mortality and morbidity due to abortion requires efforts to de-stigmatize access to abortion provision, and expanded access to modern contraception. IMPLICATIONS: The abortion-related near-miss rate is high in Zambia compared with other restrictive contexts. Our results suggest that near-miss is a promising indicator of unsafe abortion; can be measured using routine hospital data, conveniently defined using the WHO criteria; and can be incorporated into the frequently utilized prospective morbidity methodology

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

Consequences of maternal morbidity on health-related functioning: a systematic scoping review.

OBJECTIVES: To assess the scope of the published literature on the consequences of maternal morbidity on health-related functioning at the global level and identify key substantive findings as well as research and methodological gaps. METHODS: We searched for articles published between 2005 and 2014 using Medline, Embase, Popline, CINAHL Plus and three regional bibliographic databases in January 2015. DESIGN: Systematic scoping review PRIMARY OUTCOME: Health-related functioning RESULTS: After screening 17 706 studies, 136 articles were identified for inclusion. While a substantial number of papers have documented mostly negative effects of morbidity on health-related functioning and well-being, the body of evidence is not spread evenly across conditions, domains or geographical regions. Over 60% of the studies focus on indirect conditions such as depression, diabetes and incontinence. Health-related functioning is often assessed by instruments designed for the general population including the 36-item Short Form or disease-specific tools. The functioning domains most frequently documented are physical and mental; studies that examined physical, mental, social, economic and specifically focused on marital, maternal and sexual functioning are rare. Only 16 studies were conducted in Africa. CONCLUSIONS: Many assessments have not been comprehensive and have paid little attention to important functioning domains for pregnant and postpartum women. The development of a comprehensive instrument specific to maternal health would greatly advance our understanding of burden of ill health associated with maternal morbidity and help set priorities. The lack of attention to consequences on functioning associated with the main direct obstetric complications is of particular concern. REVIEW REGISTRATION: CRD42015017774

Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort in the UK

Background: In the UK, women are recommended to engage with maternity services and establish a plan of care prior to the 12th completed week of pregnancy. The aim of this study was to identify predictors for late initiation of antenatal care within an ethnically diverse cohort in East London. Methods: Cross-sectional analysis of routinely collected electronic patient record data from Newham University Hospital NHS Trust (NUHT). All women who attended their antenatal booking appointment within NUHT between 1st January 2008 and 24th January 2011 were included in this study. The main outcome measure was late antenatal booking, defined as attendance at the antenatal booking appointment after 12 weeks (+6 days) gestation. Data were analysed using multivariable logistic regression with robust standard errors. Results: Late initiation of antenatal care was independently associated with non-British (White) ethnicity, inability to speak English, and non-UK maternal birthplace in the multivariable model. However, among those women who both spoke English and were born in the UK, the only ethnic group at increased risk of late booking were women who identified as African/Caribbean (aOR: 1.40: 95% CI: 1.11, 1.76) relative to British (White). Other predictors identified include maternal age younger than 20 years (aOR: 1.32; 95% CI: 1.13-1.54), high parity (aOR: 2.09; 95% CI: 1.77-2.46) and living in temporary accommodation (aOR: 1.71; 95% CI: 1.35-2.16). Conclusions: Socio-cultural factors in addition to poor English ability or assimilation may play an important role in determining early initiation of antenatal care. Future research should focus on effective interventions to encourage and enable these minority groups to engage with the maternity services

Maternal mortality in the covid-19 pandemic: findings from a rapid systematic review

BACKGROUND: The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in maternal mortality provide a lens to gauge impact and inform mitigation strategies. OBJECTIVE: To report the findings of a rapid systematic review of studies on levels of maternal mortality before and during the COVID-19 pandemic. METHODS: We systematically searched for studies on the 1st March 2021 in MEDLINE and Embase, with additional studies identified through MedRxiv and searches of key websites. We included studies that reported levels of mortality in pregnant and postpartum women in time-periods pre- and during the COVID-19 pandemic. The maternal mortality ratio was calculated for each study as well as the excess mortality. RESULTS: The search yielded 3411 references, of which five studies were included in the review alongside two studies identified from grey literature searches. Five studies used data from national health information systems or death registries (Mexico, Peru, Uganda, South Africa, and Kenya), and two studies from India were record reviews from health facilities. There were increased levels of maternal mortality documented in all studies; however, there was only statistical evidence for a difference in maternal mortality in the COVID-19 era for four of these. Excess maternal mortality ranged from 8.5% in Kenya to 61.5% in Uganda. CONCLUSIONS: Measuring maternal mortality in pandemics presents many challenges, but also essential opportunities to understand and ameliorate adverse impact both for women and their newborns. Our systematic review shows a dearth of studies giving reliable information on levels of maternal mortality, and we call for increased and more systematic reporting of this largely preventable outcome. The findings help to highlight four measurement-related issues which are priorities for continuing research and development

Maternal mortality in the covid-19 pandemic: findings from a rapid systematic review

BACKGROUND: The COVID-19 pandemic is having significant direct and associated effects on many health outcomes, including maternal mortality. As a useful marker of healthcare system functionality, trends in maternal mortality provide a lens to gauge impact and inform mitigation strategies. OBJECTIVE: To report the findings of a rapid systematic review of studies on levels of maternal mortality before and during the COVID-19 pandemic. METHODS: We systematically searched for studies on the 1st March 2021 in MEDLINE and Embase, with additional studies identified through MedRxiv and searches of key websites. We included studies that reported levels of mortality in pregnant and postpartum women in time-periods pre- and during the COVID-19 pandemic. The maternal mortality ratio was calculated for each study as well as the excess mortality. RESULTS: The search yielded 3411 references, of which five studies were included in the review alongside two studies identified from grey literature searches. Five studies used data from national health information systems or death registries (Mexico, Peru, Uganda, South Africa, and Kenya), and two studies from India were record reviews from health facilities. There were increased levels of maternal mortality documented in all studies; however, there was only statistical evidence for a difference in maternal mortality in the COVID-19 era for four of these. Excess maternal mortality ranged from 8.5% in Kenya to 61.5% in Uganda. CONCLUSIONS: Measuring maternal mortality in pandemics presents many challenges, but also essential opportunities to understand and ameliorate adverse impact both for women and their newborns. Our systematic review shows a dearth of studies giving reliable information on levels of maternal mortality, and we call for increased and more systematic reporting of this largely preventable outcome. The findings help to highlight four measurement-related issues which are priorities for continuing research and development

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

Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort

Abstract Background: In the UK, women are recommended to engage with maternity services and establish a plan of care prior to the 12th completed week of pregnancy. The aim of this study was to identify predictors for late initiation of antenatal care within an ethnically diverse cohort in East London