PLOS Global Public Health

Antenatal care (ANC) plays a crucial role in preventing and detecting pregnancy risks, facilitating prompt treatment, and disseminating essential information to expectant mothers. This role is particularly vital in developing countries, where a 4.65% rise in maternal mortality rate was observed in 2022, with 800 maternal and 7,700 perinatal deaths reported. The study aims to analyse the predictors and geospatial trends of the number of visits and timing of antenatal care in Zambia from 1992 to 2018, utilizing a generalised linear mixed model approach. The analysis utilized the Zambia Demographic Health Survey (ZDHS) database. The relationship between dependent and independent variables was examined using the Rao-Scott Chi-square test. Predictors of inadequate utilisation of ANC were identified through the multilevel generalised linear model. Spatial effects were modeled using Quantum Geographic Information System (QGIS) version 3.34.1 to develop univariate choropleth maps. A total of 45, 140 (31, 482 women had less than 8 ANC visits and 2, 004 had 8 or more ANC visits) women with a prior childbirth were included in the study. The findings in the study revealed that among women aged 15 to 19 years in 1992, 1996 and 2013/14, the rates of inadequate antenatal care utilization (less than eight ANC visits) was 90.87%, 90.99%, and 99.63%, respectively. Lack of formal education was associated with inadequate ANC from 1992 to 2018, with percentages ranging from 91.12% to 99.64%. They were notable geospatial variations in the distribution of ANC underutilization across provinces with Luapula, Muchinga, Northwestern, Northern and Eastern recording higher proportions. Furthermore, the study showed that age (25 to 29 and 30 to 34) was associated with increased risk of inadequacy ANC utilization (AOR, 2.94; 95% CI, 1.20 - 7.19 and AOR, 2.65; 95% CI, 1.05 - 6.65 respectively). Higher education and wealth index correlated with reduced odds of inadequate ANC utilization. In conclusion, this study highlights worrisome trends in ANC utilization in Zambia, with a significant rise in inadequacy, especially in adhering to the WHOs recommended eight ANC visits. Over the period from 1996 to 2018, there was a discernible decline in the prevalence of delayed initiation of ANC. The findings underscore a notable disparity between current ANC practices and established guidelines. Additionally, various factors predicting suboptimal ANC attendance have been identified. These insights call for targeted interventions to address the identified challenges and improve the overall quality and accessibility of ANC services in Zambia.

Many adolescents face barriers to accessing reproductive health care even though quality reproductive health care is a fundamental human right. This qualitative analysis describes quality reproductive health requests among adolescent high school girls in Kenya. We conducted a secondary analysis of qualitative data from a sub-sample of adolescent girls in Kenya who participated in the What Women Want global campaign. The campaign utilized one open-ended survey question. We also analyzed interview data from key informants involved in the survey. We used pre-existing codes and current literature to design the coding framework and thematic analysis to describe emerging themes. Atlas. ti 8 was used to organize and analyze codes. Over 4,500 high school girls, ages 12 and 19 years, were included in the analysis, with 61.6% from all-girls boarding schools and 13.8% from mixed-day schools. Data from nine key informants complemented findings from the survey. Emerging themes included: 1) The need for improved menstrual health and hygiene: Sanitary towels and cleaner toilets; 2) Prevention of adolescent pregnancy: Access to contraception; 3) Respect and dignity: Participants want privacy and confidentiality; and 4) The need to address social determinants of health: Economic stability and a safe physical environment. This study indicated that adolescent high school girls have varied requests for reproductive health care and services. While menstrual health and hygiene are key issues, reproductive needs are beyond just sanitary products. The results suggest a need for targeted reproductive health interventions using a multi-sectoral approach.

Sexually transmitted infections (STIs) remain a major global public health concern, with a disproportionate burden in low- and middle-income countries affected by conflict and displacement. In Nigeria, STI prevention and treatment sit within a crowded sexual and reproductive health (SRH) policy landscape shaped by vertically financed HIV programmes, expanding self-care agendas and one of the largest internally displaced populations in Africa. This qualitative study examines how structural, institutional and sociocultural forces shape STI service delivery for IDPs and how they reproduce or challenge sexual and reproductive health and rights. We conducted in-depth interviews with federal and state policymakers, United Nations representatives and national and international non-governmental actors involved in SRH and humanitarian programming in Nigeria. Using an interpretive, structurally informed approach, we explored participants accounts of funding architectures, governance priorities, humanitarian protocols, provider practices and gendered norms. Nigeria was considered "policy-rich but implementation-poor", with HIV-centred vertical financing creating a hierarchy of infections that renders non-HIV STIs comparatively invisible, unsubsidised and often effectively privatised in displacement settings. Chronic commodity shortages, workforce depletion in conflict-affected areas, weak surveillance systems and reliance on informal providers were seen as routine features of STI care in IDP camps. Sociocultural dynamics, including toilet infection narratives, gendered gatekeeping of womens healthcare and STI-related stigma, shaped how IDPs interpreted symptoms, when they sought care and which providers they used. At programme and government levels, self-care and task-shifting policies, although framed as expanding choice and autonomy, were implemented through fragile supply chains, limited regulation of informal providers and uneven access to digital platforms. The findings indicate that improving STI care for IDPs in Nigeria will require rebalancing HIV-dominated financing, securing affordable STI commodities, strengthening supervision and data systems and referral pathways so that self-care and humanitarian responses translate into accessible, reliable services.

Out-of-school adolescents (OSY) in urban slums face layered vulnerabilities and are often excluded from mainstream reproductive health services. The Youth-Powered Ecosystem to Advance Urban Adolescent Health (YPE4AH) project in Nigeria implemented a multi-sectoral, safe-space-centered model to improve access to family planning (FP) for this group. The project, implemented across Lagos and Kano States from 2021 to 2024, utilized a hub-and-spoke model, combining youth-designed safe spaces (Youth Hubs) with a network of adolescent-friendly health providers. All participants received a foundational life-skills curriculum (SKILLZ), a financial literacy training (SKILLZ Club), and supplemental livelihood and leadership tracks, driven by peer-learning and mentoring. The design utilized a mixed-method approach comprising review of service statistics, longitudinal survey from program participants, and regression analysis to assess trends in uptake of FP services. Quantitative data were drawn from service statistics, longitudinal survey data, and regression analysis of FP uptake. Over 66,000 adolescents completed the SKILLZ curriculum, with a 90% transition into SKILLZ Club. Adolescent preference for non-traditional health spaces was validated, with hubs acting as entry points to broader health services. More than 75,000 adolescents accessed FP services through hub-based and referral pathways, contributing 16,303 couple years of protection (CYPs) and averting an estimated 7,324 unintended pregnancies and 39 maternal deaths. FP uptake increased steadily over time, with a diverse method mix and regional variation in preferences. Integration was achieved through collaboration with public systems, not by co-locating services in primary healthcare centers, but by embedding free FP commodities and referral systems within adolescent-friendly environments. For OSY (especially those in urban slums), safe spaces grounded in youth participation and community trust can serve as critical platforms for FP access. When designed as entry points (not endpoints), and supported by intentional integration with government supply systems, such models offer an alternative pathway to adolescent-responsive health delivery. The YPE4AH experience challenges traditional models of integration and provides a replicable blueprint for reaching marginalized adolescents at scale.

Globally, the risk of acquiring Tuberculosis (TB) among Diabetes mellitus (DM) patients is three (3) times higher than in the general population. Patients with DM not only have a high risk of getting TB disease but also have poor treatment outcomes Despite the National TB guideline recommending TB screening among DM patients, adherence remains low. This study aims to assess the implementation fidelity (IF) and factors affecting TB screening for DM patients among providers offering DM services in public health facilities in Ubungo district. We conducted a descriptive cross-sectional study from April 4th to May 25th, 2025, in 20 public facilities (3 hospitals, 5 health centers, 12 dispensaries) in Ubungo district using quantitative methods among 94 health providers offering DM services. Data were collected through a questionnaire and analyzed for fidelity levels (low or high) using descriptive statistics. Then, regression models using STATA version 16 identified factors affecting the fidelity of TB screening for DM patients among the healthcare providers offering DM services. The overall fidelity score was 83.0% with (n=78) out of 94 providers achieving high fidelity, with only 17.0 % (n=16) of the total providers having lower fidelity levels. Teamwork (aPR 2.28, 95% CI 1.11-7.12; p-value =0.031), self-efficacy (aPR 2.29, 95% CI 1.04-5.02; p-value =0.024), and facility-level the provider was working, especially hospital level (aPR 3.60, 95% CI 1.52-8.50; p-value =0.004) were significantly associated with IF of TB screening for DM patients among healthcare providers. Key factors influencing TB screening for DM patients among healthcare providers were effective teamwork, self-efficacy, and the level of the facility where the healthcare was working, such as hospitals. Therefore, strengthening teamwork and provider self-efficacy through training, is critical in universalizing high-fidelity practice and accelerating TB screening for DM patients among healthcare providers offering DM services in Ubungo district.

BackgroundThe consequences of unsafe abortions weigh heavily on individuals, families, society, and health care systems. Developing countries continue to experience a high prevalence of mistimed and unintended pregnancies resulting in induced abortions that are largely unsafe. Globally, 25 million unsafe abortions take place every year [1]. In Africa, 3 out of 4 abortions are categorized as unsafe [2]. In Kenya, it is estimated that 464,690 induced abortions occur annually- 2 out of 3 of these are unsafe[3]. With the high prevalence of mistimed and unwanted pregnancies in Sub-Saharan Africa and Kenya in particular, unsafe abortions will be on the rise unless deliberate measures and policies are put in place to guarantee safe abortion procedures[4]. MethodIpas Africa Alliance embarked on the Medical Abortion Self-Use (MASU) project aimed at reducing morbidity and mortality tied to unintended pregnancies among women in the Counties of Vihiga, Kisumu, Busia, Siaya, and Trans Nzoia. To inform on the progress and the potential for scale-up of the project, Ipas commissioned a process evaluation. This evaluation adopted both qualitative and quantitative methods. This involved in-depth interviews (IDIs), Focus Group Discussions (FGDs), and face-face-interviews through a semi-structured questionnaire. ResultsFrom the analysis, those seeking medical abortion were mainly youths under 25 years of age. There was low awareness of safe abortion practices and the gestation period within which safe medical abortion (MA) can be safely done. Nearly half (47%) of the women and girls reported being coerced to take post-abortion contraceptives they never wanted. Further, MA costs were not only found to be expensive but also varied greatly across the Counties. Some MA users experienced medical complications attributed to the failure of pharmacists responsible to provide the correct dose and correct route of administration. On the other hand, youth champions were found to be few and not able to fully cover their areas and only have basic knowledge of MA self-use services. ConclusionThe IPAS MASU project intervention, in the five counties of Western Kenya namely Busia, Siaya, Vihiga, Kisumu, and Trans Nzoia, has increased access to safe Medical Abortion self-use, enhanced availability of MA drugs in pharmacies, the improved service delivery of MA services through regular training of pharmacists. Further, the project has enhanced awareness about MA services among young girls and women through trained Youth Champions and pharmacists, and the MASU project has significantly reduced cases of unsafe abortions and by extension deaths and medical complications associated with them. To realize more gains, the project needs to be scaled up within the five counties and beyond, specifically to target the rural areas where cases of unsafe abortion are still thought to be rampant.

COVID-19 pandemic remains a major global public health challenge also in Low- and Middle-Income Countries (LMIC), due to fragile health systems, limited resources and personnel, low testing and counseling capacity, community perceptions, among others. In Kisumu County of Western Kenya, a unique Public Private Partnership (PPP) was rolled-out to increase testing and capacity building by linking private facilities to the ongoing public sector efforts in combating COVID-19. It became increasingly clear that centralized PCR testing for COVID-19 was too labor-intensive, expensive, prone to machine breakdowns and stock-outs of essential reagents, resulting in long turn-around times and sometimes even adaptations of patient selection criteria. A clear need was identified for rapid point-of-care COVID-19 testing (AgRDT). After successful field evaluation, RDT for COVID-19 was offered through the PPP. This paper aimed to understand the health workers perspective on the feasibility and acceptability of the introduction of the AgRDT in Kisumu County. In-Depth Interviews were conducted with selected health workers (n=23) from the participating facilities and analyzed using Nvivo 11 The health workers accepted the use of AgRDT as it enabled the strengthening of the existing health system, increased testing capacity and provided capacity building opportunities. Challenges included poor management of results discrepant with PCR gold standard. The health workers applauded the introduction of AgRDT with the Kisumu County Department of Health as a more realistic and user-friendly approach, leading to fast turn-around times and increased personal safety experience.

The incidence of child marriage (CM) and intimate partner violence (IPV) are high in Uganda. The study sought to assess the association between child marriage and IPV across two waves of the Ugandan Demographic and Health Survey (UDHS). The evidence is important to inform policy implementation strategies aimed at curbing child marriages and IPV. We analyzed data from UDHS 2011 and 2016. The analysis was restricted to women who have ever cohabited. Simple and multiple logistic regression models were used to assess the association between child marriage and IPV. Following the 2011 and 2016 UDHS findings, child marriage was 54.7% in 2011 and 47.4% in 2016. Child marriage among the current adolescents increased from 9.4% in 2011 to 14.2% in 2016. According to UDHS 2011, 40.0% and 39.0% experienced physical and sexual violence respectively. In 2011 and 2016, 23.1% and 17.4% experienced both physical and sexual violence. There are higher odds of physical violence among child marriages compared to adult marriages in 2011 and 2016 (AOR = 1.44; 95% CI: 1.12-1.84 in 2011 and AOR = 1.26; 95% CI: 1.12-1.42). A wealthy or educated woman has lower odds (AOR = 0.61; 95% CI: 0.41-0.91 and AOR = 0.41; 95% CI: 0.25-0.66) to experience both physical violence and sexual violence than a poor or uneducated one. Alcohol is the most common cause of IPV. A woman married to an husband who consumes alcohol has higher odds of experiencing physical, sexual or both physical and sexual violence as compared to someone whose husband did not consume alcohol (AOR = 2.23; 95% CI:1.61-3.09 in 2011 and AOR = 2.42; 95% CI: 2.15-2.73 in 2016) Intimate Partner Violence is associated with child marriage, level of education, wealth quintile, residence, and partners alcohol consumption. Much emphasis needs to be directed to cultural, as well as social economic factors but more specifically on the contribution of women emancipation/empowerment to prevent IPV.

Northern Ghana faces a significant shortage of family planning (FP) services, leading to high rates of unplanned pregnancies and unsafe abortions that contribute to regional maternal mortality. Through the Academic Model Providing Access to Healthcare (AMPATH) Ghana, a partnership between Tamale Teaching Hospital (TTH), the University for Development Studies School of Medicine (UDS-SoM), and New York University Grossman School of Medicine (NYUGSOM), key stakeholders began strengthening regional FP services using the Exploration-Preparation-Implementation-Sustainment (EPIS) framework. We present how an adapted landscape assessment was used during the Exploration and Preparation phase to guide intervention development at TTH, the regions sole tertiary referral FP clinic. We adapted the Supply-Enabling Environment-Demand (SEEDTM) Assessment Guide for Family Planning Programming. The original survey, which included both open-ended and closed-ended questions, was edited and contextualized by stakeholders at TTH, UDS, and NYUGSOM, pilot tested (n=8), and distributed to clinicians at the FP unit (n=24). Responses were analyzed and grouped by key themes. Areas for improvement included staff training, especially youth-friendly delivery, service integration with a focus on cervical cancer screening and abortion care, and barriers to access for underserved groups including youth, adolescents, and single men. Stakeholder review of survey results highlighted three priorities: in-service trainings, integration of cervical cancer screening, and youth-centered counseling training. The landscape assessment provided clear direction for strengthening FP services at TTH and set the foundation for AMPATH Ghanas next steps. The priorities identified offer a focused roadmap for improving training, service integration, and access. As the team advances into the Implementation and Sustainment phases of the EPIS framework, these findings will guide coordinated action and demonstrate the value of implementation science in building effective and equitable interventions within global health partnerships.

Violence against women and girls (VAWG) is a serious human rights violation that has intensified in Yemen due to war, displacement, and pandemics. The cultural stigma surrounding discussions of VAWG, particularly sexual violence, compounded by a lack of resources for affected individuals, poses significant challenges for research and program implementation. This study involved qualitative interviews with 20 community midwives from the National Yemeni Midwifery Association across four governorates to explore the causes, forms, and consequences of VAWG and identify potential resources for survivors. A Yemeni physician trained in ethical VAWG research conducted the interviews, which were analysed thematically by two researchers. The findings indicated that physical partner violence was widely recognised as a crime; however, women and girls facing sexual violence often faced severe social ramifications, including ostracism or violence aimed at preserving family honour, leading to underreporting. Midwives identified patriarchal culture and the ongoing economic crisis as key contributors to VAWG. Health-related consequences for survivors included physical injuries such as vaginal tears and obstetric fistula. Additionally, midwives reported that survivors encountered humiliation within the healthcare system. Most women and girls did not seek help; however, when they did, they turned to their families or local leaders for support. To effectively understand, prevent, and address VAWG in Yemen, strategies should prioritise the safety and needs of women and align with cultural values. Insights from community midwives can guide the development of VAWG-focused community-led initiatives.

In Northern Uganda, communities continue to face significant health challenges driven by a legacy of conflict, poverty, and structural health system challenges. Community health workers (CHW) play a critical role in rural districts like Pader, where access to formal care remains limited. This study explores CHWs perspectives on community health needs, barriers to care, and priorities for strengthening CHW-led service delivery. Six focus group discussions (7-9 participants each) were conducted with 46 CHWs from across Pader District using a semi-structured topic guide. The guide explored eight key domains: general health, health maintenance, modern versus traditional medicine, nutrition, maternal and infant health, environmental factors, malaria practices, and feedback for the CHW program. CHWs identified malaria, maternal and child health complications, and a rising burden of non-communicable diseases as key community concerns. Major barriers to care included long distances to health facilities, drug stockouts, and inadequate transportation. Although communities had strong awareness of disease symptoms and prevention strategies, financial hardship and service limitations undermined preventive practices and timely care-seeking behavior. CHWs emphasized their growing role as trusted frontline providers but highlighted the need for tools, transportation, ongoing training, supportive supervision, and formal recognition to fulfill their responsibilities effectively. CHWs in Pader District navigate complex structural and resource constraints while serving as trusted liaisons between communities and the formal health system. Their insights point to actionable strategies, such as improved supply chains, transportation, training, and inclusion in program planning, that are vital for building equitable and effective community health systems in post-conflict settings.

BackgroundAdolescent sexual and reproductive health and rights (SRHR) remains a critical public health issue in low- and middle-income countries, with adverse health, educational, and economic consequences. Uganda faces significant challenges with high rates of unintended pregnancies among adolescents. This study investigated the factors associated with unintended pregnancies among unmarried adolescents in Eastern Uganda and explored the potential of using mobile money vendors to provide SRHR services. MethodsA cross-sectional study was conducted among 1267 unmarried girls/boys, aged 15-19 years, in the Busoga region. Data were collected through face-to-face interviews, using a structured questionnaire. Sociodemographic characteristics, sexual behaviors, contraceptive knowledge, and environmental factors were analyzed. Multivariate logistic regression analysis identified factors associated with unintended pregnancies. ResultsOf the adolescents who had sexual intercourse (n=876), 22.5% (n=197) experienced unintended pregnancies. Fundamental factors associated with lower prevalence of pregnancy included being a current student (adjusted odds ratio [AOR]: 0.36, 95% confidence interval [CI]: 0.24-0.54), living with parents (AOR: 0.48, 95% CI: 0.33-0.69), and teacher engagement (AOR: 0.56, 95% CI: 0.37-0.84). Factors associated with higher prevalence of pregnancy included knowledge regarding contraceptive use (AOR: 2.28, 95% CI: 1.16-4.49), parental communication (AOR: 1.91, 95% CI: 1.32-2.75), parental contraception support (AOR: 1.64, 95% CI: 1.03-2.59), and mobile phone possession (AOR: 2.31, 95% CI: 1.09-4.90). Public health facilities and community-based distributors, including mobile money vendors, were considered comfortable channels for obtaining contraceptives for adolescents who had experienced pregnancy. ConclusionsUnintended pregnancies among unmarried adolescents in Eastern Uganda were influenced by educational, parental, and environmental factors. Enhancing SRHR education from earlier ages, parental involvement, and leveraging community resources such as mobile money vendors could improve adolescent SRHR outcomes. Innovative approaches outside conventional health and education sectors are necessary for sustainable and effective adolescent SRHR programs. Trial registrationThis study was registered at Japans University Hospital Medical Information Network (UMIN000053332) on 12 January 2024. Plain English summaryAdolescent sexual and reproductive health and rights (SRHR) is a pressing public health issue globally. Uganda has a high rate of unintended pregnancies among adolescents. This study investigated the factors associated with unintended pregnancies among unmarried adolescents in Eastern Uganda and explored the potential of using mobile money vendors to provide SRHR services. This cross-sectional study was conducted using a structured questionnaire at 60 vendors. It included 1267 unmarried girls/boys aged 15-19 years. Of 876 adolescents who ever had sexual intercourse, 22.5% experienced unintended pregnancies. Factors associated with a lower prevalence of pregnancy were: a current student (adjusted odds ratio [AOR] = 0.36), living with parents (AOR = 0.48), and teacher engagement (AOR = 0.56). Contrarily, factors associated with a higher prevalence of pregnancy were: knowledge regarding contraceptive use (AOR = 2.28), parental communication (AOR = 1.91), parental contraception support (AOR =1.64), and mobile phone possession (AOR = 2.30), which may imply that teenagers who had experienced pregnancy tend to become more serious about contraception and engagement of parents and teachers enhanced. In addition, community-based SRHR service distributors, including mobile money vendors, were considered comfortable channels. In conclusion, unintended pregnancies among unmarried adolescents in Eastern Uganda were influenced by educational, parental, and environmental factors. Enhancing SRHR education before starting sexually active and parental and school involvement may reduce unintended pregnancies among unmarried adolescents in Eastern Uganda. In addition, leveraging accessible community-based distributors, such as mobile money vendors, may be a potential channel for delivering SRHR information and contraceptives.

Neonatal mortality is the death of a live-born infant within the first 28 completed days of life. Neonatal mortality remains a major public health concern in most African countries, with the Sub-Saharan region being the highest contributor at 27 deaths per 1000 live births, accounting for 43% of the total number of deaths. Zambia still fares poorly in terms of neonatal mortality, ranking 162 out of 195 countries globally. The study aimed to investigate the spatial patterns and predictors of neonatal mortality in rural Zambia. This study utilized the national-level data from the Zambia Demographic and Health Survey (ZDHS) program, utilizing the survey dataset from 2018. Statistical analyses were conducted using the Rao - Scott Chi-square test to assess associations between dependent and independent variables. Additionally, a multilevel mixed effect logistic regression model was used to examine predictors of neonatal mortality. Geospatial patterns of neonatal mortality across Zambias ten provinces were investigated using Quantum Geographical Information System (QGIS) version 3.34.1 to generate a univariate choropleth map. Data analysis was performed using Stata version 14.2. The study findings indicate a higher mortality rate among HIV-infected mothers aged 45 to 49 (100%) compared to 95.21% among non-HIV-infected mothers. Neonatal mortality was notably elevated among neonates born to mothers with no education (40.78%) and those with HIV infection (54.56%). Employment status also influenced mortality rates, with employed non-HIV-infected mothers showing 36.35% mortality compared to 49.39% among unemployed HIV-infected mothers. Higher birth weights, particularly 4000 grams or higher, were associated with increased mortality for both HIV-infected (81.15%) and non-infected (21.00%) mothers. Multilevel logistic regression identified predictors of mortality, including maternal age (40 to 44 years), neonates sex (female), and maternal HIV status. Geospatial analysis revealed Eastern and North-Western provinces as hotspots for neonatal mortality among HIV-infected mothers, while Muchinga was a hotspot for non-HIV-infected mothers. This study examined neonatal mortality among HIV-infected and non-infected mothers in rural Zambia, uncovering predictors such as maternal age, neonate sex, birthweight, maternal HIV status, and community desired number of children. Regional variations in mortality underscore the necessity for targeted interventions. Strengthening healthcare infrastructure, community outreach, healthcare worker training, maternal education, and addressing regional differences are crucial for improving maternal and child health and meeting Sustainable Development Goals targets.

A reduction in maternal mortality remains critical, particularly in sub-Saharan Africa, were significant disparities in access to healthcare affect outcomes. In Angola, almost half of women give birth outside the health system, highlighting the need to increase access to maternity services and information related to womens sexual and reproductive health and rights (SRHR). The study comprehensively examines young Angolan womens health literacy in SRHR and its role for institutional delivery. The data were derived from a cross-sectional survey involving 1139 women aged 18-24 years who had given birth, recruited from the provinces of Luanda, Huambo and Lunda Sul. The results included a univariate description of the participants socio-demographics and SRHR characteristics, and the barriers and facilitators to institutional delivery they identified. In addition, logistic regression models assessed associations between the participants health literacy levels and the odds for institutional delivery. Findings revealed that more than half of the women delivered in healthcare institutions. These women were comparably economically advantaged, often literate and resided in urban areas. Major barriers identified included lack of transportation and financial resources; facilitators also included companionship and trust in respectful treatment. Regardless of the delivery setting, many women lacked information on fundamental SRHR topics. There were significant associations between health literacy and the site of delivery in all areas considered, except in Lunda Sul. Women who had acquired SRHR information from healthcare professionals, had access to several sources of SRHR information and were acquainted with multiple SRHR topics exhibited higher odds of having had an institutional delivery. The study underscores the need to bolster young womens access to essential SRHR information and knowledge. However, addressing socio-economic barriers and healthcare limitations concurrently is essential. Multisectoral approaches are vital to ensure widespread access to quality maternity services, thereby ensuring women can safely give birth in quality healthcare settings.

IntroductionMidwives are often the first point of contact for pregnant women; yet their roles, training, and referral practices regarding obstetric ultrasound vary widely. This study aimed to explore midwives perspectives and experiences with obstetric ultrasound across key clinical and operational domains to assess the feasibility of conducting future multicentre maternal-foetal health research and surveillance. MethodsA descriptive cross-sectional study was conducted among 473 practicing midwives across diverse healthcare settings in Ghana. A self-administered structured questionnaire was used to collect data on midwives perspectives and experiences regarding obstetric ultrasound across multiple dimensions. Data analysis was performed using Microsoft Excel. ResultsMost midwives were female, aged 26-35 years, held diploma qualifications, and practiced within district hospitals. Key ultrasound measures prioritised by midwives in the 1st trimester include gestational age, foetal viability, estimated date of delivery (EDD), number of fetuses, and the presence of an intrauterine gestational sac. Comparatively, midwives emphasize foetal anomaly detection, amniotic fluid (liquor) volume, placental location, foetal viability, and gestational age during second trimester ultrasound screening, while in the 3rd trimester screening, they prioritise foetal presentation, amniotic fluid volume, estimated foetal weight, placental location, and foetal viability. Findings suggest infrequent ultrasound reports indicating foetal anomalies. We observed a moderate perceived ability among midwives to understand foetal anomalies on obstetric ultrasound reports. Only 57.5% indicated they refer patients between one and three times for obstetric ultrasound before delivery. From the findings, it was observed that there is a predominance of sonographers undertaking obstetric ultrasound scans. Midwives may have moderate competence in interpreting obstetric ultrasound reports. An overwhelmingly positive response indicated that obstetric ultrasound improved their work performance, and a high proportion expressed interest in learning how to undertake obstetric ultrasound. ConclusionOur findings highlight the need to standardize midwifery practices and strengthen obstetric ultrasound literacy through targeted capacity-building initiatives, not only to improve clinical decision-making but also to establish a robust foundation for scalable maternal-foetal research in low-resource settings. Additionally, our study demonstrates the potential feasibility of engaging midwives as key stakeholders in multicentre maternal-foetal research initiatives.

BackgroundMen and women with undiagnosed tuberculosis (TB) in high burden countries may have differential factors influencing their healthcare seeking behaviors and access to TB services, which can result in delayed diagnoses and increase TB-related morbidity and mortality. MethodsA convergent, parallel, mixed-methods study design was used to explore and evaluate TB care engagement among adults ([≥]18 years) with newly diagnosed, microbiologically-confirmed TB attending three public health facilities in Lusaka, Zambia. Quantitative structured surveys characterized the TB care pathway (time to initial care-seeking, diagnosis, and treatment initiation) and collected information on factors influencing care engagement. Multinomial multivariable logistic regression was used to determine predicted probabilities of TB health-seeking behaviors and determinants of care engagement. Qualitative in-depth interviews (IDIs; n=20) were conducted and analyzed using a hybrid approach to identify barriers and facilitators to TB care engagement by gender. ResultsOverall, 400 TB patients completed a structured survey, of which 275 (68.8%) and 125 (31.3%) were men and women, respectively. Men were more likely to be unmarried (39.3% and 27.2%), have a higher median daily income (50 and 30 Zambian Kwacha [ZMW]), alcohol use disorder (70.9% [AUDIT-C score [≥]4] and 31.2% [AUDIT-C score [≥]3]), and a history of smoking (63.3% and 8.8%), while women were more likely to be religious (96.8% and 70.8%) and HIV-positive (70.4% and 36.0%). After adjusting for potential confounders, the adjusted probability of delayed health-seeking [≥]4 weeks after symptom onset did not differ significantly by gender (44.0% and 36.2%, p=0.14). While the top reasons for delayed healthcare-seeking were largely similar by gender, men were more likely to report initially perceiving their symptoms as not being serious (94.8% and 78.7%; p=0.032), while women were more likely to report not knowing the symptoms of TB before their diagnosis (89.5% and 74.4%; p=0.007) and having a prior bad healthcare experience (26.4% and 9.9%; p=0.036). Notably, women had a higher probability of receiving TB diagnosis [≥]2 weeks after initial healthcare seeking (56.5% and 41.0%, p=0.007). While men and women reported similar acceptability of health-information sources, they emphasized different trusted messengers. Also, men had a higher adjusted probability of stating that no one influenced their health-related decision making (37.9% and 28.3%, p=0.001). IDIs largely corroborated the quantitative findings while offering more context and in-depth understanding of the factors that affected initial health seeking decisions, diagnoses, and treatment experiences across each step of mens and womens TB care pathways. To improve TB detection, men recommended TB testing sites at convenient community locations, while women endorsed an incentivized, peer-based, case-finding approach. Sensitization and TB testing strategies at bars and churches were highlighted as promising approaches to reach men and women, respectively. ConclusionsMen and women with TB differ with respect to TB risk factors, TB care engagement experiences and determinants, and broader health influences. These differences suggest that gender-tailored TB health promotion and case-finding strategies may be needed to improve TB diagnosis and care engagement in high burden settings.

Cardiovascular disease (CVD) is the leading cause of death in Myanmar, but care models are lacking to deliver evidence-based treatments to reduce CVD risks in areas of armed conflict. Village health workers (VHWs) play a key role in bridging communities and clinics, but their role in CVD prevention and management in conflict-affected settings has not been clearly defined. This study aimed to identify the functions of VHWs that could improve access and quality of CVD care in conflict-affected areas of Karen State, Myanmar. We conducted 33 key informant interviews with patients, VHWs, clinic staff, ethnic health organization leaders, donors, and non-government organization health experts. A qualitative content analysis was carried out to explore barriers, facilitators, and potential leverage points for improving CVD care in conflict-affected settings. Participants reported that many people were unaware of CVD and its risks, and there were persistent gaps in CVD screening, medication adherence, and referral systems. Transportation costs and hazards, medicine shortages, and security risks made it difficult for patients to visit clinics or achieve continuity of care. Respondents believed VHWs could play an important role in improving CVD care by providing health education sessions, screening for high blood pressure and diabetes, delivering medications and supporting adherence, and facilitating referrals. Results showed expanding VHW roles could make CVD care more accessible, particularly where travel to clinics was unsafe or unaffordable. This study underscores the urgent need to develop and test community-based strategies to mitigate the growing burden of CVD in conflict-affected Eastern Myanmar. VHWs have the potential to address CVD care gaps. Targeted training and regular supervision of VHWs, coupled with structured systems for referral and follow-up, could enhance continuity of care, adherence to treatment, and community resilience to acute conflict events.

Leadership and governance are key components of health systems, nevertheless research into leadership and governance of mental healthcare at the community level is probably the least well researched and understood part of these systems. As part of assessing the integration of mental health in Primary Health Care in Ghana, the leadership and governance organisation and structures to ensure oversight and coordination were examined. A concurrent mixed-methods design involving both quantitative and qualitative research methods approach was adopted. The quantitative data were collected through a questionnaire, which was either self-administered or interviewer administered, on 1010 respondents with 830 completed (response rate 82%). Key informant interviews and focus group discussions were used to collect the qualitative data. Thematic content analysis with the use of NVivo 12 was applied for the qualitative field data and Stata SE16 was used for quantitative data. Data triangulation strategy was used to report the qualitative and quantitative results. The study showed that leadership and governance of mental health at the PHC level were lowly developed due to the modest level of awareness of the Mental Health Law, inadequate functioning of mental health units and coordination, low level of private sector participation in mental health care services, and low levels of provision of monitoring, supervision, and evaluation. This affected the integration of mental health at the PHC level, which was also gauged as low. The study concludes that despite the presence of legislation and policy aiming to achieve decentralised and integrated mental health services at the PHC level, mental health care is still a low-level priority within the health care system in Ghana and tends to operate within a silo. The study recommends that more practical and concerted leadership of mental health at the regional and district levels is required to drive decentralisation and integration at these levels.

BackgroundAnemia remains a major global health crisis, affecting over 500 million women of reproductive age, with high burdens in resource-limited regions like Sub-Saharan Africa. Despite ongoing interventions such as iron supplementation programs, 49% of women of reproductive age in Zambia are anemic. Thus, the purpose of this study was to establish the national and subnational prevalence of anemia and identify its determinants among women of reproductive age in Zambia. MethodsData were drawn from the 2018 Zambia Demographic and Health Survey (ZDHS), a nationally representative survey employing a stratified two-stage cluster sampling design across 545 enumeration areas. A multilevel mixed-effects logistic regression model was used to identify individual-and community-level factors associated with anemia among women aged 15-49 years (n = 13,055). Four hierarchical models were constructed (null, individual-level, community-level, and full) to assess fixed and random effects, with model selection guided by AIC and BIC criteria. Spatial analysis was conducted using QGIS, incorporating displaced GPS coordinates in accordance with DHS protocols. All analyses applied sampling weights and assessed multicollinearity (VIFs < 5). ResultsThe national prevalence of anemia among women of reproductive age was 31% (95% CI: 29- 33%), with the highest rates observed in Western (38%) and Lusaka (36%) provinces, and the lowest in Central Province (24%). In adjusted analyses, pregnancy (AOR = 1.76; 95% CI: 1.52- 2.03), HIV positivity (AOR = 2.21; 1.97-2.49), and breastfeeding (AOR = 1.15; 1.02-1.30) were significantly associated with increased odds of anemia. Conversely, being married (AOR = 0.78; 0.68-0.90) and age 25-29 years (AOR = 0.84; 0.71-0.97) were protective. Spatial mapping identified Western Province as a high-burden hotspot. Community-level variance was notable (ICC = 6%, MOR = 1.52), with 5% residual clustering persisting after adjusting for both individual and contextual factors, suggesting the influence of unmeasured ecological determinants. ConclusionAnemia remains a significant public health issue among Zambian women of reproductive age, shaped by both individual- and community-level factors. These findings highlight the need for integrated, targeted interventions focusing on high-risk groups in high-prevalence areas. Strengthening clinical services and implementing community-based strategies to address healthcare access and environmental determinants are essential to reducing the burden of anemia in Zambia.

BackgroundIn 2014, Uganda launched the National Male Involvement Strategy in Maternal and Child Health. In 2020, the District Health Management Information System report for Lamwo district, where Palabek Refugee Settlement is located, indicated a 10% male involvement in antenatal care (ANC). We investigated determinants of male involvement in ANC in Palabek Refugee Settlement to inform programs on improvement of male involvement in ANC in a refugee setting. MethodologyWe conducted a community-based cross-sectional analytical study among a proportionate sample of mothers in Palabek Refugee Settlement from October-December 2021. Using a standardized questionnaire, we collected information on demographics and the constructs of the socio-ecological model where consent was given. We summarized data in tables and figures. We used Pearson chi-square test to determine significance of independent variables at bivariate level. A multivariable logistic regression model was run for all variables found significant at bivariate analysis to determine association between the different independent variables and male involvement in ANC. ResultsWe interviewed 423 mothers. The mean age of their male partners was 31 years, SD 7. Eighty-one percent (343/423) of male partners had formal education, with 13% (55/423) having a source of income and 61% (257/423) having access to ANC information during their pregnancy. The level of male involvement in ANC in Palabek Refugee Settlement was 39% (164/423). Male involvement in ANC was positively associated with access to information on ANC (AOR 3.0; 95%Cl: 1.7-5.4) and frequent couple discussion on ANC (AOR 10.1; 95%Cl: 5.6-18.0). However, it was negatively associated with distance [&ge;]3km to the health facility (AOR 0.6 ;95%Cl: 0.4-1.0). ConclusionsApproximately one in three male partners in Palabek Refugee Settlement were involved in ANC. Male partners who had access to information during ANC and those who had frequent discussions were more likely to get involved in ANC. Men who lived [&ge;]3 kilometers from the health facility were less likely to be involved in ANC. We recommend intensified awareness creation on importance of male involvement in ANC and implementation of integrated community outreaches to reduce distance to the health facility.