Journal of Global Health

BackgroundHigh-quality healthcare for pregnant women and newborns, particularly postnatal care (PNC) and small and/or sick newborn care (SSNC), is essential to reducing maternal and newborn morbidity and mortality in low- and middle-income countries (LMICs). Poor quality of care is a major contributor to preventable morbidity and mortality, emphasizing the need for improvements in health service delivery, which requires measuring and monitoring quality of care (QoC). Although indicators measuring QoC have been identified, there is a current gap in the availability of composite indicators that can summarize the complex, multidimensional nature of QoC. This study systematically developed three composite QoC indices for maternal PNC, newborn PNC, and SSNC feasible to measure using existing data in LMICs. MethodsA four-step process was used to define the indices: (1) Intervention selection: Key interventions were identified by reviewing global clinical guidelines and QoC frameworks; (2) Guideline review and item identification: Discrete items recommended for delivery of each of the selected interventions were extracted from intervention-specific guidelines; (3) Data mapping: These items were mapped to health facility survey data to assess their alignment with standardized tools; and (4) Final index development: A quality readiness index (QRI) was developed for each service area based on QoC frameworks, available data, and clinical guidelines. ResultsThe maternal PNC-QRI includes 12 interventions and contains 24 items. The newborn PNC-QRI includes 3 interventions and contains 16 items. The SSNC-QRI includes 8 interventions and contains 48 items. Data gaps for maternal PNC, newborn PNC, and SSNC led to the exclusion of some evidence-based interventions and limited item inclusion. No data on provision/experience of care were available for PNC or SSNC, thus the indices reflect only facility readiness. ConclusionsThe three QRIs developed provide composite measures for PNC and SSNC readiness and can be adapted at country level and operationalized using health facility assessment survey data, facilitating their use by decision-makers for planning and resource allocation. Revision of existing health facility assessments to address gaps in readiness and provision/experience of care measurement for PNC and SSNC would bolster efforts to monitor and improve QoC for mothers and newborns.

Dropout from essential maternal health services across pregnancy, childbirth, and the postnatal period remains a major barrier to improving maternal and neonatal outcomes in Bangladesh. This study examined stage-specific dropout patterns along the maternal continuum of care and identified factors associated with discontinuation. We analysed nationally representative data from the Bangladesh Demographic and Health Survey 2022 for 5,162 women with a recent live birth. Dropout from antenatal care, skilled birth attendance, and postnatal care was examined using multivariable logistic regression to estimate adjusted odds ratios and 95% confidence intervals, with comparisons to BDHS 2017-18 and assessment of regional variation. Only 44% of women received four or more antenatal care visits. Of these, 33% delivered with a skilled birth attendant, and among those receiving both antenatal care and skilled delivery, only 15% received postnatal care within 48 hours. Overall, 57% dropped out before completing adequate antenatal care, with additional dropouts between antenatal care and delivery (10%) and between delivery and postnatal care (18%). Compared with 2017-18, overall dropout from the maternal continuum of care more than doubled in 2022 (5.0% to 11.7%), driven by increased antenatal care dropout, while skilled birth attendance dropout declined and postnatal care dropout increased slightly. Higher maternal education, household wealth, media exposure, and womens decision-making power were consistently associated with lower odds of dropout, whereas higher birth order increased dropout risk. Substantial regional variation was observed, with the highest overall dropout in Sylhet and the lowest in Khulna. High dropout from the maternal continuum of care in Bangladesh occurs predominantly at the antenatal care stage and is shaped by socioeconomic status, birth order, womens access to information, and regional disparities. Strengthening early antenatal engagement and womens decision-making autonomy is critical to improving continuity of maternal care and reducing preventable maternal and neonatal risks.

BackgroundNeonatal mortality in Afghanistan is among the highest worldwide, driven by rural-urban disparities, low maternal education, and poor healthcare access. Antenatal care (ANC) remains severely underutilized, with fewer than one in five women meeting minimum visits despite its link to neonatal survival, highlighting the need to assess its impact in conflict-affected settings. ObjectivesDetermine whether the number of antenatal care visits during pregnancy is associated with neonatal mortality in Afghanistan and investigate whether 4 ANC visits could be a sufficient minimum requirement to prevent neonatal mortality in conflict settings such as Afghanistan. MethodsAnalytic, population-based, cross-sectional study. Using data from the 2015 DHS for Afghanistan, logistic regression was performed to assess the association between fewer than 4 ANC visits and neonatal mortality. ResultsThe overall prevalence of neonatal mortality was 1.85% (CI:1.56-2.20). The odds of neonatal mortality for children whose mothers attended ANC less than 4 times were 1.8 times higher in comparison to those whose mothers attended ANC 4 times or more. After adjusting for the age of the mother, sex, ANC provider, place of residence (urban/rural), wealth index, education of mother, and education of father, the odds of neonatal mortality were 1.1 (95% CI 0.72-1.71) with not enough evidence against the null hypothesis (p-value 0.637). While the mothers education, place of residence, wealth index, ANC provider, and fathers education confounded the relationship, sex showed an interactive effect on the main relationship. ConclusionsANC visits less than 4 times were 1.8 times more likely to result in neonatal mortality than ANC visits 4 or more times. This study confirmed the importance of setting 4 visits as a minimal threshold for improved pregnancy outcomes, even where access to health care could be challenging, such as in Afghanistan.

IntroductionResearch on episiotomy practices in Vietnam is limited. This study aimed to describe episiotomy use and identify factors associated with its practice among vaginal births in Central Vietnam, following the implementation of restrictive episiotomy guidelines. MethodsWe used data from a hospital-based, retrospective study conducted at Danang Hospital for Women and Children from April 2015 to March 2016. The study included all singleton, full-term vaginal births. Multivariable logistic regression was used to estimate the odds of episiotomy by selected neonatal or maternal factors. ResultsAmong 3,471 eligible singleton births, 2,770 mothers (79.8%) underwent an episiotomy. The episiotomy rate was significantly higher in first-time births (97.7%) compared to second or subsequent births (61.5%), p<0.001. Multivariable analyses showed that first-time births, higher birth weight, younger maternal age, a less physical active occupation, and a history of miscarriage were significantly associated with higher odds of episiotomy. For example, the odds of episiotomy in first-time births was 24.21 (95% CI: 17.13-34.22) times higher than in second or subsequent births, and the odds for mothers with a history of miscarriage was 1.34 (95%CI: 1.03-1.73) compared to those without. Stratified analysis showed that these associations persisted in multiparous women but were not observed in primiparous women. ConclusionThis study highlights a very high episiotomy rate among primiparous women in Central Vietnam, one year after the implementation of restrictive episiotomy guidelines, despite of other maternal or neonatal factors associated with episiotomy in multiparous women. Comprehensive research and targeted interventions are needed to reduce episiotomy rates, particularly among first-time mothers in Vietnam.

BackgroundCesarean section (CS) rates have risen dramatically worldwide, with a majority of the countries exceeding the World Health Organizations (WHO) preferred rate of 10-15%. However, disparities exist, with evidence suggesting that socioeconomic disadvantage and geographic location play significant roles. Despite this, comprehensive estimates, especially in Bangladesh, remain scarce. This study aims to determine trends, district-level variations, and socioeconomic disparities in CS rates in Bangladesh. MethodsData from six rounds of Bangladesh Demographic and Health Surveys were analyzed. The considered outcome variables were the occurrence of CS delivery in relation to the mode of delivery and delivery place. Neonatal mortality was also assessed as another outcome variable. Explanatory variables included districts, wealth quintiles, and socio-demographic characteristics. Descriptive statistics were used to provide an over-the-year trend and variation in CS delivery in Bangladesh. Multilevel mixed-effects binary logistic regressions were used to explore predictors of CS delivery and the association between CS and neonatal mortality. ResultsBetween 1999/2000 and 2017/18, hospital births in Bangladesh increased by 42%, primarily driven by a substantial rise in CS delivery, from 30% to 66%. Private healthcare facilities played a significant role, contributing 80% of the countrys total CS delivery in 2017/18, a substantial increase from 45.5% in 1999/2000. In contrast, CS delivery rates in government healthcare facilities decreased from 49.7% to 15.5% during the same period. Deficient use of CS was reported by women in border and hilly districts, as well as those in the poorest wealth quintile. A clear link between a CS delivery and neonatal mortality was not found. ConclusionThe uneven distribution of CS delivery across districts and socioeconomic groups underscores the need for a more nuanced approach to childbirth. While government efforts to curb unnecessary use of CS have fallen short, this study suggests a one-size-fits-all strategy could worsen disparities. Instead, the focus should shift from mere accessibility to ensuring justified and appropriate utilization, with public healthcare facilities playing a key role in offering safe alternatives.

BackgroundStillbirth remains a critical public health challenge in low-resource settings and is a significant cause of perinatal mortality, where gaps in antenatal care, healthcare access, and socioeconomic disparities exacerbate risks. Understanding maternal post-discharge outcomes and identifying modifiable predictors for stillbirths is essential to improve care pathways. MethodsThis prospective cohort study analyzed maternal and perinatal health data from 7131 women who delivered 7359 newborns at the Mbarara and Jinja Regional Referral Hospitals between April, 2022 and September, 2023. A stillbirth was defined as the death of a foetus >28 weeks of gestation. Univariate logistic regression models were used to determine risk factors. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported. ResultsAmong 7129 women who survived and were discharged post-delivery, 261 (3.7%) experienced a stillbirth. Six-week post-discharge readmission of women of stillborn infants was 8.5% as compared to 3% among those who were discharged with a live newborn. The strongest risk factor for a stillbirth was previous child death (OR: 7.11, 95% CI: 5.5-9.17, p <0.001), followed by transport delays >1 hour (OR: 2.71, 95% CI: 1.95-3.75) and pregnancy-related illnesses (OR: 1.70, 95% CI: 1.30-2.25). Each additional year of maternal age increased odds by 2% (OR: 1.02, 95% CI: 1.00-1.04). Protective factors included adequate antenatal care (4-8 visits) (OR: 0.51, 95% CI: 0.40-0.66) and partner support (OR: 0.72, 95% CI: 0.56-0.95). ConclusionMaternal morbidity following stillbirths is high. Furthermore, several demographic, health, and socioeconomic strongly influenced the risk of stillbirths. Many stillbirths may be prevented following early identification of these risk factors through interventions to ensure expectant mothers receive adequate support during their pregnancy.

BackgroundExploring the impact of national health expenditure and its allocation on neonate and child mortality can help policy makers implement strategies aimed at achieving target 3.2 of Sustainable Development Goals (SDGs). The aim of the current study is to explore the impact of selected indicators of national health accounts on neonate and under-5 mortality across 188 countries from 2000 to 2019. Methods and findingsThis study has an ecological design. Data on health expenditure was obtained from the Global Health Expenditure Database (GHED) for 188 countries from 2000 to 2019. The Global Burden of Disease study (GBD) 2019 data on neonatal and under 5 mortality rates at national levels from 2000 to 2019 were obtained from the website of the Global Health Data Exchange (GHDx) supported by the Institute for Health Metrics and Evaluation. The income groups were stratified based on the World Bank classification. We employed a mixed-effects regression model to investigate the association of different health account indicators with changes in neonatal and under-5 mortality rates over time across countries. We used the Multiple Change Points model to determine the turning points in the association of health expenditure per capita with mortality across countries in 2019. And finally, we estimated the observed-to-expected ratio of mortality based on the segmented regression model for all 188 countries in 2019. Increase in the current health expenditure in International dollar Purchasing Power Parity (Int$ PPP) per capita was associated with lower mortality among both neonates and children in all strata of countries. Reductions were very minimal among high-income countries and were generally more prominent in low-income countries and decreased along with increase in income. Reductions were more noteworthy for under-5 mortality rates. The percentage of domestic general government health expenditure and the percentage of compulsory financing arrangements out of current health expenditure were inversely associated with mortality, while the association of percentage of domestic private health expenditure and out-of-pocket expenditure out of current health expenditure with mortality was positive. Results showed that the reduction in neonatal mortality associated with each ten-dollar increase in current health expenditure per capita is significantly more prominent for per capita expenditures less that the cut-point of 480 Int$ PPP per capita. The respective figure for under-5 mortality was 386 Int$ PPP per capita. Ultimately, a total of 110 countries had observed versus expected ratio less than one for neonatal mortality and 118 countries for child mortality. ConclusionsIncrease in health expenditure is significantly associated with decrease in neonate and under-5 mortality especially among low and low-middle income countries. However, the association fades among countries in which health expenditure per capita is higher than the threshold. In all countries, improvement in neonate and under-5 mortality requires modifying the health system infrastructure to move towards universal health coverage. However, the COVID-19 pandemic may have influenced the health spending at national levels.

BackgroundHealth inequalities in low- and middle-income countries (LMICs) often reflect compounding social disadvantages. Intersectionality theory emphasizes that multiple axes of disadvantage can interact to shape health experiences in ways not captured by single-factor analyses (Crenshaw, 1989, 1991). Understanding how poverty and low education combine to affect maternal and reproductive health is essential for advancing universal health coverage and "leaving no one behind" under the Sustainable Development Goals (United Nations, 2015; World Health Organization, 2023). This study examined intersectional socioeconomic inequalities in maternal and reproductive health outcomes among Cambodian women. MethodsWe conducted a secondary analysis of women aged 15-49 years interviewed in the Cambodia Demographic and Health Survey (CDHS) 2021-22, a nationally representative household survey implemented by the National Institute of Statistics (NIS) in collaboration with the Ministry of Health, with technical assistance from ICF (National Institute of Statistics et al., 2022). Women were classified into six intersectional socioeconomic status (SES) groups by cross-classifying household wealth (poor/middle/rich) and education (no/primary vs. secondary+). Outcomes included antenatal care (ANC) [&ge;]4 visits, facility delivery, skilled birth attendance, modern contraception use, unmet need for family planning, and teenage childbearing. Multivariable logistic regression estimated adjusted odds ratios (aORs) with 95% confidence intervals (CIs), accounting for the complex survey design (National Institute of Statistics et al., 2022). ResultsAmong 6,968 women with recent births, 82% attended [&ge;]4 ANC visits and 96% delivered in facilities, but only 20% had skilled birth attendance. Compared with women with both high wealth and secondary+ education (reference), women with poor wealth and no/primary education had substantially lower odds of [&ge;]4 ANC visits (aOR = 0.33, 95% CI [0.23, 0.48]), facility delivery (aOR = 0.29, 95% CI [0.13, 0.63]), and skilled birth attendance (aOR = 0.20, 95% CI [0.14, 0.27]). For reproductive health, poor/low-education women had higher odds of modern contraception use (aOR = 1.24, 95% CI [1.06, 1.43]) and no difference in unmet need (aOR = 0.99, 95% CI [0.85, 1.16]). Teenage childbearing showed strong educational gradients (35% in poor/low-education vs. 16% in rich/high-education). ConclusionsIntersectional socioeconomic disadvantage creates compounding barriers to quality maternal healthcare in Cambodia. Despite near-universal facility delivery, skilled attendance--defined in global monitoring as births attended by trained health personnel such as doctors, nurses, or midwives--remains highly unequal and concentrated among advantaged groups (United Nations Statistics Division, 2023). Policies should prioritize equitable quality of delivery care, target multiply disadvantaged women, strengthen rural health workforce distribution, and invest in girls secondary education as a long-term maternal health strategy (National Institute of Statistics et al., 2015; World Health Organization, 2023).

BackgroundDespite significant progress in reducing maternal and neonatal mortality, home delivery remains a substantial public health challenge in Bangladesh and many other low- and middle-income countries. While the proportion of home deliveries has markedly decreased in the past decade, pronounced disparities persist across geographic, socioeconomic, and demographic groups. A nuanced understanding of the prevalence and determinants of maternal home delivery is key to designing targeted interventions. This study examines national and subnational variations in maternal home delivery and associated factors in Bangladesh. MethodsWe analyzed data from the Multiple Indicator Cluster Surveys (2012-13 and 2019) and the Bangladesh Demographic and Health Survey (2022), covering 20,770 ever-married women aged 15-49 who gave birth in the preceding two years. District-level prevalence, descriptive statistics, and multivariable logistic regression were used to assess trends and determinants. ResultsHome delivery prevalence declined from 68% in 2012-13 to 35% in 2022. Disparities remain: divisions such as Barisal (48.9%), Chattogram, Sylhet, and Mymensingh showed higher rates, while Dhaka and Khulna had the lowest. At the subnational level, remote areas like Bandarban, Rangamati, and Bhola exhibited higher prevalence. The logistic regression analysis identified several significant predictors, such as women with no formal education, limited ANC visits ([&le;]3), rural residence, lower wealth status, multiparity ([&ge;]3 children), and lack of media exposure were more likely to deliver at home. ConclusionsDespite marked improvement, persistent geographic and socioeconomic inequities highlight the need for targeted interventions. Strengthening healthcare infrastructure in underserved regions, promoting maternal health awareness, scaling up ANC utilization, and reducing financial barriers through subsidies and incentive programs can help further decrease home deliveries. Future research should explore cultural and religious factors to inform context-specific policies for equitable facility-based childbirth.

BackgroundAround half of births in Bangladesh occur at home without skilled birth personnel. This study aims to identify the geographical hot spots and cold spots of home delivery in Bangladesh and associated factors. MethodsWe analyzed data from the 2017/2018 Bangladesh Demographic and Health Survey and the 2017 Bangladesh Health Facility Survey. The outcome variable was home delivery without skilled personnel supervision (yes, no). Explanatory variables included individual, household, community, and healthcare facility factors. Morans I was used to determine hot spots and cold spots of home delivery. Geographically weighted regression models were used to identify cluster-specific predictors of home delivery. ResultsThe prevalence of non-supervised and unskilled supervised home delivery was 53.18%. Hot spots of non-supervised and unskilled supervised home delivery were primarily in Dhaka, Khulna, Rajshahi, and Rangpur divisions. Cold spots of home delivery were mainly in Mymensingh and Sylhet divisions. Predictors of higher home births in hot spot areas included womens illiteracy, lack of formal job engagement, higher number of children ever born, partners agriculture occupation, higher community-level illiteracy, and greater distance to the nearest healthcare facility from womens homes. ConclusionsUnskilled supervised home delivery is prevalent in Bangladesh, and the distance between womens homes and healthcare facilities plays a significant role. Awareness-building programs should emphasize the importance of skilled and supervised hospital deliveries, particularly among the poor and disadvantaged groups.

BackgroundAlthough Bangladesh has made significant improvements in maternal, neonatal, and child health, the disparity between rich and poor remains a matter for concern. ObjectiveThe study aimed to increase coverage of women in seeking skilled maternal healthcare services while minimizing inequity gap among different socioeconomic groups. Methodsicddr, b implemented an integrated maternal and neonatal health (MNH) intervention between 2009 and 2012, in Shahjadpur sub-district of Shirajganj district, Bangladesh. The study was pre- and post-test in design for evaluation including baseline and endline surveys. The baseline and endline surveys were conducted among 3158 and 3540 recently delivered mothers respectively. Asset index derived from household assets using principal component analysis was categorized into five ordinal categories, i.e. Poor, Less poor, Middle, Upper middle, Rich. Inequity in maternal healthcare utilization was calculated for the baseline and endline periods using rich- to-poor ratio and the concentration index. ResultMean age of mothers were 23.5 and 24.3 years in baseline and endline, respectively. Reduction in rich-poor ratio was quite large in utilization of skilled 4+ antenatal care (ANC) (2.4:1 to 1.1:1), childbirth (1.7:1 to 1.0:1), and postnatal care (PNC) (2.5:1 to 1.0:1) from trained providers between these two surveys. The concentration indices (CI) in endline for skilled 4+ ANC (CI: 0.220 and 0.013), delivery (CI: 0.161 and -0.021), and PNC (CI: 0.197 and -0.004) were found to be lower than the indices in baseline period respectively. ConclusionThe MNH intervention was successful in reducing inequity in receiving skilled 4+ ANC, delivery, and PNC in rural Bangladesh. Improvements in maternal healthcare utilizations by poor mothers would be influenced by the properly designed and integrated demand- and supply-side MNH interventions package.

IntroductionThe World Health Organization recommends a minimum of eight antenatal care (ANC) contacts, with the first visit occurring before the 12th week of gestation, as a strategy to enhance the preparedness of women for institutional delivery and improve perinatal outcomes. The present study aims to assess the prevalence of delayed ANC attendance among pregnant women in rural Burkina Faso and identify associated risk factors. MethodsThis is a secondary analysis of clinical data collected from a randomised-controlled trial (clinicaltrials.gov ref: NCT03199547); conducted between 2018 and 2021 in rural Burkina Faso. We estimated gestational age (GA) at the first ANC visit based on recall information on the last menstrual period provided by study participants or, when such information was unavailable, symphysis-fundal height measurements taken by ANC nurses. We used descriptive methods followed by unadjusted and adjusted logistic regression, informed by an original conceptual framework, to determine the prevalence and risk factors associated with delayed first ANC visit, defined as occurring after the 12th week of gestation. A significance threshold was set at 0.05. ResultsOut of the 5250 women enrolled in the study, 2480 (47.2%) had data available from their first ANC visit, and 90.6% (2248/2480) of those women had gestational age estimates. Most women (n=2037/2248, 90.6%) attended their first ANC after the 14th week of gestation. The main factors associated with this delay were multiparity [&ge;] 4 pregnancies (OR=2.26, 95%CI [1.48 - 3.4], p < 0.001) and first ANC visit attended during the dry season (OR=1.79, 95%CI [1.34 - 2.39], p < 0.001). ConclusionOur study highlights that most pregnant women in rural Burkina Faso attended their first ANC visit later than the WHO recommended timeline, increasing their risk of poor delivery outcome. Although we identified some factors that increased this risk of late ANC attendance, awareness raising interventions are required for the whole population as starting late seems to be the norm.

Health systems in low- and middle-income countries (LMICs) like Bangladesh face persistent challenges in delivering timely and equitable care, often exacerbated by poor planning and inefficient resource allocation. Forecasting service utilisation using routine health data can support more responsive and data-driven health system planning, yet such approaches remain underutilised in Bangladesh. By analysing service utilization trends and projecting future service volume at national and regional level, we aim to improve region-specific health planning and promote more efficient and equitable health service provision. We analyzed monthly routine health service data reported into the District Health Information Software 2 (DHIS2) platform between January 2021 and March 2025 in Bangladesh. We examined key indicators across maternal, newborn, child, and hospital-based services. Bayesian log-linear Poisson regression models, adjusted for seasonality and autocorrelation, were applied to forecast service utilisation for the final nine months of 2025 and all of 2026. Relative changes in 2025 and 2026 were calculated using 2024 as the reference year.The analysis revealed rising trends across most service areas relative to 2024 levels. Compared to levels in 2024, normal deliveries are projected to increase by 6% in 2025 and 10% in 2026, while caesarean sections are expected to rise by 4% and 12%, respectively. Low birth weight (LBW) deliveries are forecasted to increase by 10% in 2025 and 25% in 2026, with the largest relative growth in Rajshahi and Dhaka. Coverage of Kangaroo Mother Care (KMC) is projected to rise substantially--by 20% in 2025 and 74% in 2026. Pneumonia treatment is expected to increase by 31% by 2026, particularly in Dhaka. Outpatient visits are forecasted to grow by 32% by 2026. Notable regional disparities persist, with Dhaka and Chattogram showing the highest service utilisation, while Barisal and Sylhet consistently report the lowest levels. Bangladeshs health system must prepare for increasing service utilisation across all service categories. Forecasting using DHIS2 data supports for proactive planning and equitable resource allocation. Strategic investments in infrastructure, workforce, and data-driven planning are essential for building a resilient health system.

Bangladesh and many other low- and middle-income countries experience a high number of maternal and neonatal deaths; antenatal care (ANC) and hospital delivery are crucial to reducing these deaths. In this cross-sectional study, we investigated the relationship of socioeconomic status with at least 4 ANC visits and hospital delivery in Bangladesh. We also tested whether antenatal care mediated the association of socioeconomic variables and facility delivery. We used data from the Bangladesh Demographic and Health Survey 2022. After descriptive analysis, generalized structural equation modeling was used to investigate the associations. A total of 4,950 women were included in the analysis (mean age: 25.7 years, 73.2% rural). The proportion of women with at least 4 ANC visits and hospital delivery was 39.8% and 64.4%, respectively. In adjusted analyses, all socioeconomic variables had significant associations with at least 4 ANC visits and hospital delivery. For instance, compared to women with the poorest wealth quintile, those with poorer (adjusted odds ratio (AOR): 1.26, 95% confidence interval (CI):1.02-1.55), middle (AOR: 1.43, 95% CI: 1.16-1.77), richer (AOR: 1.98, 95% CI: 1.59-2.45), and richest (AOR: 3.12, 95% CI: 2.45-3.99) wealth quintiles higher odds of at least 4 ANC visits. Similarly, for hospital delivery, compared to women with the poorest wealth quintile, those with poorer (AOR: 1.44, 95% CI: 1.19-1.75), middle (AOR: 1.82, 95% CI: 1.48-2.24), richer (AOR: 2.48, 95% CI: 1.98-3.10), and richest (AOR: 3.90, 95% CI: 2.94-5.18) wealth quintiles higher odds. Women with at least 4 ANC visits, had more than two times higher odds of hospital delivery (AOR: 2.56, 95% CI: 2.20-2.97). When we looked into the mediation, at least 4 ANC visits mediated 60.5%, 34.6%, and 41.1% of the relationships of womens education, husbands education, and household wealth with hospital delivery, respectively. Considering the lower utilization of at least 4 ANC visits and its mediating impact on the relationship between socioeconomic status and facility delivery, more community-based programs are required to increase awareness about at least 4 ANC visits and hospital births.

Background Caesarean section (CS) rates in Bangladesh have increased rapidly in recent decades. This increase raises concerns about unnecessary procedures and their potential impacts on maternal health. Womens knowledge and positive attitudes toward CS influence delivery preferences and decisions, yet these aspects remain underexplored in Bangladesh. Objectives To assess knowledge and positive attitudes toward CS and to identify factors associated with knowledge and positive attitudes among married women in Bangladesh. Methods The study utilized a cross-sectional sample of married women of reproductive age. A structured questionnaire was used in face-to-face interviews to collect data covering socio-demographic information, obstetric experiences, knowledge, and positive attitudes toward CS. Descriptive statistics, independent sample t-tests, and multiple linear regression analysis were performed to identify factors. Results This study showed that knowledge was lower among rural than urban women; lower among women with a previous CS than those without, and higher among women from husband-headed households. Additionally, respondents without an income source had higher knowledge than those with an income. Regarding attitudes, higher monthly family income was associated with more positive attitudes, while larger family size was associated with lower positive attitudes. Women in husband-headed households had more positive attitudes than those in other-headed households, and women with previous CS had lower positive attitudes. Importantly, higher knowledge scores were strongly associated with more positive attitudes toward CS. Conclusion Strengthening antenatal care, including health, educational, and counselling services, particularly for rural women, larger families, husband-headed households, and women with prior CS, could improve knowledge and promote informed, positive attitudes toward appropriate CS use. Policies and programs should prioritize rural outreach, improve provider-patient communication (especially after a CS), and ensure high-quality counselling, informed consent, and male-inclusive antenatal sessions to support the appropriate use of CS.

BackgroundConflicting evidence exists on the impact of the COVID-19 pandemic restrictions on preterm birth (PTB) and stillbirth rates. We aimed to evaluate changes in PTB and stillbirth rates before and during the pandemic period and assess the potential effect modification of socioeconomic status (SES). MethodsUsing the linked administrative health databases from Manitoba, Canada, we conducted a quasi-experimental study among all pregnant women, comparing 3.5 years pre-pandemic (1 October 2016 to 29 February 2020) to the first year of the pandemic (1 March 2020 to 31 March 2021). We used interrupted time series analysis using autoregressive integrated moving average models to assess the quarterly rates of PTB (<37 weeks) and stillbirths. We calculated the predicted trends based on pre-pandemic period data. Finally, we evaluated the lower and higher SES (average annual household income) using subgroup analysis and interaction models. ResultsWe examined 70,931 pregnancies in Manitoba during the study period. Following the implementation of COVID-19 restrictions in March 2020, there were no statistically significant changes in the rates of both PTB (p=0.094) and stillbirths (p=0.958). However, over the pandemic, the PTB rate significantly decreased as a rebound effect by 0.63% per quarter(p=0.005); whereas the stillbirth rate did not change significantly (p=0.878) compared to pre-pandemic period. During the first quarter of 2021, the absolute differences in the observed and expected PTB and stillbirth percentages were 2.05% and 0.04%, respectively. We observed a statistically significant effect modification by SES for PTB rates (p=0.047). ConclusionWhile the onset of COVID-19 pandemic restrictions was not associated with significant effects on PTB and stillbirth rates, we observed a statistically significant rebound effect on PTB rates. The impact of COVID-19 on preterm birth was dependent on SES, with higher influence on families with lower SES. Further studies are needed to detect future trend changes during pandemic waves after 2021 and assess potential underlying mechanisms.

BackgroundAntenatal care (ANC) is crucial for ensuring the health of pregnant women and their newborns. Although ANC coverage has improved globally, ANC quality remains suboptimal in some settings. Evidence on the association between ANC quality and perinatal outcomes in low-resource countries is still limited. Hence, this study assessed ANC quality and its relationship with fetal loss and low birth weight (LBW) newborns. Methods and findingsWe used data from the eCohort study that collected longitudinal data on ANC utilization and quality until the end of pregnancy across eight sites in Ethiopia, Kenya, South Africa, and India. Women were enrolled from public government-owned facilities only in India and South Africa and from both public and private facilities in Ethiopia and Kenya. Primary outcomes included fetal loss ([&ge;]13 weeks of gestation) and LBW. Good quality ANC was defined as receiving six essential care components during the first ANC visit: blood pressure measurement, blood and urine tests, ultrasound, iron and folic acid supplementation, and counseling on pregnancy danger signs. We conducted mixed-effect logistic regressions to assess the association between good quality ANC and perinatal outcomes, with a sensitivity analysis where good quality ANC excluded ultrasound scans. Among 3,597 pregnant women followed until the end of pregnancy, only 5.8% received all six essential care components during their first ANC visit (ranging from 1.4% in India to 14.0% in Ethiopia) and 30.7% received five care components (excluding ultrasounds) ranging from 5.7% in India to 52.5% in Kenya. Fetal loss prevalence was 3.7% in Ethiopia, 3.8% in Kenya, 4.0% in South Africa, and 6.0% in India. India and South Africa had higher rates of LBW newborns (among neonates who were alive at the time of the survey): 16.3% and 13.1%, respectively, compared to 8.6% in Ethiopia and 8.5% in Kenya. Multiple pregnancies were rarely detected at the first ANC visit. Good quality ANC was associated with a 22% to 58% lower risk of fetal loss (RR 0.78, 95% CI 0.61 - 0.95 to RR 0.42, 95% CI 0.10 - 0.73). No statistically significant associations were observed between good quality ANC and LBW. ConclusionsThis study identified important gaps in ANC quality and found that receiving essential ANC services was associated with a lower risk of fetal loss. With increasing global ANC coverage, future research should continue assessing quality, and programs should prioritize quality improvement, ensuring the delivery of good clinical practice and proven evidence-based interventions in pregnancy. AUTHOR SUMMARYO_ST_ABSWhy was this study done?C_ST_ABSO_LIANC utilization has significantly increased in low-resource settings; however, the quality of care received remains insufficient. C_LIO_LIMost prior research investigating the associations between ANC and perinatal outcomes has focused on ANC utilization or the number of visits. C_LIO_LIWhile the global dialogue has gradually shifted to ANC quality rather than merely ANC utilization, limited evidence has explored the association between ANC quality and critical perinatal outcomes, including fetal loss and LBW newborns. C_LI What did the researchers do and find?O_LIWe used data from a longitudinal study that collected information on the utilization and quality of ANC throughout pregnancy and assessed the care received and its relationship with fetal and neonatal outcomes. C_LIO_LIOur study found that ANC quality was overall poor. Only 6% of pregnant women received all six care components (blood pressure measurement, blood and urine tests, ultrasound examination, iron and folic acid given or prescribed, and counseling on pregnancy danger signs) at their first ANC visits and only 31% received five care components (excluding ultrasounds). C_LIO_LIGood quality ANC was significantly associated with a lower risk of fetal loss (including late miscarriage and stillbirth), while no significant association was found between the receipt of good quality ANC and LBW newborns. C_LI What do these findings mean?O_LIPoor-quality antenatal care is not only inefficient but can also be harmful. This issue is particularly concerning as increasing numbers of women in low-resource settings seek ANC services. C_LIO_LIEfforts at the national level should ensure the delivery of good clinical practice and essential care components for high quality ANC to improve perinatal outcomes. C_LI

BackgroundMost maternal and neonatal deaths occur in low- and middle-income countries and are largely preventable with quality care. In Indonesia, 98% of pregnant people receive antenatal care and birth commonly occurs in community settings or hospitals. Outside of high-income countries, few studies identify where women with pregnancy-related risk factors give birth. Accurate identification of pregnancy risk factors and referral to an appropriate birth setting is considered an essential element of quality antenatal care, though its efficacy in Indonesia is unknown. MethodsThis study aimed to identify suitable indicators of pregnancy risk factors for Indonesia and examine population-level patterns in pregnancy-related risk, care and appropriateness of birth setting. Risk factors in pregnancy based on internationally relevant referral guidelines were identified from literature search and mapped to available indicators. Using self-reported data from three waves of the Indonesian Demographic Health Survey (2007, 2012, 2017), a representative survey of women aged 15-49 years, we examined receipt of maternity care, prevalence of pregnancy risk factors and time trends in birth setting, overall and by presence of risk factors. ResultsIn the weighted sample (n=43,846), one quarter of women reported pregnancy risk factors. From 2002-2017, numbers of births in hospitals have doubled and births at home have halved. However, the proportions of women with pregnancy risk in each setting remains largely unchanged. DiscussionThese findings identify opportunities for shifting care in Indonesia to ensure women are receiving the appropriate level of care at birth.

BackgroundAntenatal corticosteroids (ACS) utilization is disproportionately limited in low- and middle-income countries where most global preterm newborns who could benefit from this intervention are born. Understanding the factors affecting ACS use is crucial for improving its uptake. This study aimed to investigate facility-level factors associated with ACS use in low-resource countries. MethodsWe used data from ten Service Provision Assessment surveys across nine countries. We restricted the sample to facilities that provided delivery services. Our primary outcome was recent ACS use, defined as having administered ACS within the past three months before the survey. We conducted mixed-effect log binomial regressions, with country as a fixed effect and sub-national regions as random intercepts, to explore the association between recent ACS use and facility characteristics, injectable corticosteroids and ultrasound availability, facility structural readiness, and past performance of nine Comprehensive Emergency Obstetric and Newborn Care (CEmONC) signal functions. ResultsThis study included 6183 facilities from nine countries. Across eight countries with nationally representative data, only 22.7% (median, range 4.0% to 27.4%) of facilities that provided delivery services had used ACS recently. Urban facilities had a 21% higher likelihood of recent ACS use (95% CI 6%-38%) than rural facilities. Corticosteroid availability was associated with a 14% higher likelihood of recent ACS use (95% CI 1%-29%). Facilities in the highest readiness tertile were more likely to have recent ACS use than those in the lowest (RR 1.91, 95% CI 1.58-2.30). Each CEmONC signal function, except for assisted vaginal deliveries, was significantly associated with recent ACS use, with neonatal resuscitation having the largest effect (RR 2.62, 95% CI 1.93-3.55). ConclusionFacilities that had performed CEmONC services were more likely to administer ACS, highlighting the importance of provider knowledge, skills, and competence in managing obstetric and newborn emergencies for effective ACS provision.

Despite the recent decline, neonatal mortality rates (NMR) remain high in India. Family members are often responsible for the postpartum care of newborns and mothers. Yet, low health literacy and varied beliefs can lead to poor neonatal health outcomes. Postpartum education for family caregivers can improve the adoption of evidence-based newborn care and health outcomes. The Care Companion Program (CCP) is a hospital-based, pre-discharge health training session where nurses teach key healthy behaviors and help mothers and family members learn skills and practice in the hospital. Here, we assessed the impact of CCP on NMR. We conducted a quasi-experimental study to assess the effect of the CCP sessions on mortality outcomes among families seeking care in 28 public tertiary facilities, across 4 Indian states. Neonatal mortality outcomes were reported post-discharge, collected via phone surveys at four weeks of age of baby, between October 2018 to February 2020. Risk ratios (RR), adjusting for hospital-level clustering, were calculated by comparing mortality rates before and after CCP implementation. A total of 46,428 families participated in the pre-intervention group and 87,305 in the post-intervention group; 76% of families participated in the phone survey. The crude NMR was 33.64 deaths per 1000 live births (RR=0.82, 95% CI: 0.76, 0.87). After accounting for hospital-clustering, the NMR was 41.3 (adjusted RR=0.81, 95% CI: 0.71, 0.93). There may be a substantial benefit to family-centered education in the early postnatal period to reduce neonatal mortality.