PLOS Global Public Health

Background: Unintended adolescent pregnancies remain a public health challenge in Zambia, where LARC use is low despite their effectiveness. Barriers such as stigma, misconceptions, and limited access persist. Previous studies conducted in Lusaka district did not explore the challenges faced by adolescents in trying to access and use LARCs. Understanding these challenges is crucial for developing targeted interventions to promote safe and effective contraception practices. This study examined factors influencing adolescent knowledge, willingness, and uptake of LARCs in public health facilities in Lusaka. Methods: A cross-sectional study was conducted between November 2024 and March 2025 among adolescent girls aged 15-19 years in five first-level hospitals in Lusaka, Zambia, using structured questionnaires to obtain quantitative data1. LARC use was measured as a binary outcome, with multiple regression identifying associated factors. Results: There were 400 participants in total, of whom 48% (181/376) had ever used a LARC. In the adjusted model, age was significantly associated with LARC use (AOR = 1.27, 95% CI: 1.11-1.77; p < 0.001). Adolescents who were willing to delay pregnancy had markedly higher odds of using LARCs (AOR = 7.46, 95% CI: 1.42-39.06; p = 0.017). Knowledge of LARCs remained a strong independent predictor, more than doubling the likelihood of uptake (AOR = 2.69, 95% CI: 1.12-6.46; p = 0.027). Having children was also significantly associated with higher LARC use (AOR = 2.62, 95% CI: 1.11-6.23; p = 0.029), while participants with unknown HIV status had lower odds of LARC use (AOR = 0.31, 95% CI: 0.10-0.97; p = 0.044). In addition, adolescents residing in Chipata had substantially higher odds of LARC uptake compared to those in Kanyama (AOR = 317.93, 95% CI: 35.01-2887.2; p < 0.001). Conclusions: The findings indicate that age, knowledge of LARCs, reproductive experience (having children), and willingness to delay pregnancy were significantly associated with higher odds of LARC uptake, and almost half of the participants had already used a LARC method. Although higher education showed an upward trend, it was not statistically significant in the adjusted model. Limited awareness and variability in service delivery across clinics highlight the need for strengthened counseling and reliable access to LARCs. As this study focused only on adolescents already attending Family Planning Clinics, further research is needed to assess LARC availability, accessibility, and quality of counseling across different settings in Zambia.

Despite established national immunization programmes for children and livestock, pastoral communities in Kenya remain chronically underserved, with low vaccination coverage attributed mainly due to seasonal mobility, vast terrain, and limited health infrastructure. Even less understood is whether these assumptions hold across all pastoral contexts, and how livelihood practices such as hiring herders during drought seasons may intersect with vaccine access. This study examined factors associated with child and livestock vaccination among Maasai communities in Kajiado Central Subcounty, Kenya, using a One Health lens. We employed a mixed-methods design across three wards (Dalalekutuk, Ildamat, and Purko). Quantitative data were collected through semi-structured household surveys (n=180), with bivariate analysis examining the associations between the vaccine hesitant group and the vaccine accepting group in children and livestock. Qualitative data were gathered through two gendered focus group discussions (FGDs, n=31) and seven key informant interviews (KIIs). Inductive thematic analysis was interpreted through the COM-B framework, and findings were integrated using convergent triangulation. Child immunization coverage averaged 90% (range 87-98%), which is higher than typically reported for pastoral populations. In contrast, livestock vaccination coverage averaged 53% (range 5-87%) despite comparable willingness to vaccinate in both children (97%) and livestock (93%). Vaccine hesitancy co-occurred across children and livestock within the same households (OR 36.7, 95% CI 5.9 - 227.5). Eighty-eight percent of households hired herders to migrate with livestock during the cool-dry season (June-September), suggesting a shift toward sedentarization. Qualitatively, supply chain failures including vaccine production monopoly, counterfeit vaccines, stockouts, and understaffing were identified as key contributors to low livestock vaccination coverage. Closing the livestock vaccination gap requires supply-chain reforms such as breaking the KEVEVAPI monopoly, strengthening the VMD regulatory framework, and securing transport budgets to avoid stockouts. The relationship between hiring herders and vaccine access warrants further investigation as a potential structural enabler towards strengthening pastoral health programming.

Community Health Promoters (CHPs) connect households with formal health services. In maternal nutrition, they provide counselling, follow-up and referrals. However, pregnant women experiencing poverty, food insecurity, and socio-cultural issues in resource-constrained settings may be unable to act on nutritional advice. While social protection could alleviate such socioeconomic issues, maternal nutrition and social safety nets operate in institutional silos, creating gaps that systematically exclude vulnerable mothers from essential relief. This qualitative study examines how CHPs navigate these gaps across three underserved Kenyan settings. We analysed semi-structured interviews of 12 purposively selected CHPs from a broader study of 75 stakeholders, using the Braun and Clarke thematic analysis framework. CHPs described recurrent gaps between household needs and resources available through formal maternal health, nutrition, and social protection systems. CHPs stepped in; extending follow-up care, brokering information, negotiating access, and spending personal resources with inadequate formal mechanisms. They experienced emotional and relational pressure from community mistrust, cultural limitations, administrative gatekeeping, digital-system failures, heavy workloads, and performance targets tied to unreliable pay. These insights reveal that CHPs act as invisible safety nets for fragmented services, taking on burdens that official programs overlook. We describe this as workforce cost absorption. Recognising this hidden contribution is important for workforce planning and for designing integrated maternal nutrition and social protection programs.

Abstract Background Evaluating antenatal care (ANC) quality is critical to reducing maternal and neonatal mortality. In Zambia, despite high basic ANC attendance, comprehensive national evidence on the clinical content and quality of services remains limited. This study assessed the coverage of WHO-recommended ANC interventions and identified factors associated with care quality using the latest national data. Methods A cross-sectional analysis was conducted using data from the 2024 Zambia Demographic and Health Survey. The final analytic sample comprised 4,829 women aged 15-49 with a live birth in the preceding 5 years. A composite index of 15 selected, equally weighted WHO-recommended components evaluated clinical assessment, counseling/screening, preventive interventions, and utilization. Survey-weighted Poisson regression estimated adjusted incidence rate ratios (aIRRs) for the count of ANC components received. Results The mean ANC quality score was 12.5 out of 15 (95% CI: 12.4-12.6), and 78.5% (95% CI: 77.0-80.0) of women achieved adequate ANC ([&ge;] 12/15 components). While individual clinical and counseling coverage generally exceeded 90%, only 47.2% (95% CI: 45.3-49.0) of women initiated care during the first trimester, and just 4.8% (95% CI: 4.1-5.6) achieved [&ge;] 8 ANC contacts. Maternal education was the strongest and most stable predictor of quality across all models. Compared to no education, higher education was associated with an 8.0% higher expected quality score (aIRR = 1.080, 95% CI: 1.051-1.110). Lower ANC quality was significantly associated with unwanted pregnancies (aIRR = 0.970, 95% CI: 0.956-0.993) and with residence in Western (aIRR = 0.923, 95% CI: 0.897-0.951) and North Western (aIRR = 0.966, 95% CI: 0.937-0.996) provinces. Absence of distance barriers and residence in Eastern, Luapula, and Copperbelt provinces were associated with higher quality scores. Conclusion While average ANC component coverage in Zambia is high, critical gaps persist in early initiation and total contact frequency. Care adequacy is strongly influenced by maternal education, relationship status, pregnancy intention, and regional inequities. These findings underscore the need for interventions targeted at uneducated women, preventing unintended pregnancies, and underserved regions such as Western and North Western Provinces. Keywords: Antenatal care quality, ANC content, Zambia, maternal education.

Abstract Background The COVID-19 pandemic disrupted Ghanas health, economic, and social systems, prompting the government to launch a mass vaccination programme in March 2021, targeting 20 million people by the end of 2022, to reduce transmission and mitigate socio-economic strain. This study explored stakeholders perspectives on the politics of the COVID-19 vaccination programme, highlighting implementation challenges, political dynamics, and lessons for future pandemics. Methods A qualitative, exploratory, descriptive study was conducted between June and September 2021. Fourteen stakeholders from the Ministry of Health, the Ghana Health Service, academia, political leaders, and professional associations were purposively selected and engaged in key informant interviews. Data were analysed using Braun and Clarke's thematic analysis approach, guided by the Health Policy Triangle and Campos and Reichs policy implementation framework. Results Three main themes were generated. First, governance and institutional capacity shaped implementation through issues of procurement transparency, communication gaps, donor dependence, and operational constraints in data systems and logistics. Second, the political economy of vaccine procurement and distribution was influenced by leadership politics, bureaucratic dynamics, fiscal constraints, donor priorities, and interest-group influence. Third, stakeholders highlighted lessons for future pandemic preparedness, including strengthening transparent governance, improving public communication, building local vaccine research and manufacturing capacity, enhancing intersectoral coordination, and establishing robust monitoring and evaluation systems. Conclusion The rollout of COVID-19 vaccines in Ghana was shaped not only by technical and logistical considerations but also by complex political and governance dynamics. The study highlights how governance structures, political incentives, and interactions among key stakeholders influence policy implementation in resource-constrained settings. Ghanas experience underscores the importance of transparent governance, effective multistakeholder coordination, sustainable financing mechanisms, and strategic investment in regional vaccine research and manufacturing as critical pillars of pandemic preparedness. Strengthening these institutional and governance dimensions is essential not only for sustaining immunisation programmes but also for building resilient health systems capable of responding effectively to future global health emergencies.

Children with developmental disabilities remain among the most underserved globally, with significant delays in early identification and access to care. In Kenya, limited capacity in the frontline workforce further disrupts the timely recognition and management of DDs. This study evaluated the impact of a multi-cadre capacity-strengthening training intervention on the knowledge and practice of healthcare workers (HCWs) and community support workers (CSWs) (including community health promoters, teachers, and caregivers of children with disabilities) to improve early identification, assessment, care, and referral of children with DDs in Kenya. We conducted a sequential mixed-methods study and collected data between 2023 and 2025. Quantitative measures included sociodemographic surveys for all participants (CSWs and HCWs) and pre- and post-knowledge assessments using a 15-item Mental Health Gap Action Programme Intervention Guide (mhGAP-IG)- based questionnaire administered only to HCWs participating in the training. Qualitative data were obtained through focus group discussions with CSWs (n=5, 58 participants) and HCWs (n=5, 48 participants) to explore training experiences, perceived skill gains, and implementation experiences. Quantitative analysis used descriptive statistics and Wilcoxon signed-rank tests, while qualitative data were analysed thematically. A total of 321 frontline providers were trained. Ninety-seven HCWs from 25 public health facilities received DDs training based on the WHO mhGAP-IG module, while 224 CSWs received a DD-focused co-designed training on community-based early identification and referral. Among HCWs with pre-post assessments (n=70), knowledge scores improved significantly (mean change: +0.86, p < 0.001), and the proportion scoring [&ge;]12 increased from 51% to 75%. Qualitative findings post-implementation indicated strengthened capacity in developmental milestone assessment, identification of DDs, and improved referral across the community, facility and other related sectors. Both cadres reported improved confidence in addressing myths and misconceptions related to DDs, coordinated teamwork, and improved caregiver engagement during assessment, and referrals driven by improved provider confidence and more supportive communication following the training. Increased workload, limited time for assessments, and limited resources were reported as challenges. This evaluation of a multi-cadre training model demonstrated improved knowledge, skills, and confidence among CSWs and HCWs, improving early identification, care, and referral practices for children with DDs. Sustaining these gains will require ongoing supervision, integration into routine workflows, strengthened referral systems, and continued investment in frontline workforce development within primary care settings.

Maternal and newborn health (MNH) outcomes in Somalia remain among the worst globally, driven in large part by limited access to facility-based care, particularly in rural and underserved communities; approximately one in five births take place in a health facility. To address major MNH service delivery gap in rural Somalia, the International Rescue Committee implemented a community-based maternal and newborn care (CBMNC) program, delivering a package of evidence-based interventions across selected villages. An implementation research study was conducted to generate transferable learning to inform the scale-up of comparable community-based MNH programs in similar low-resource and humanitarian settings. The study triangulated and synthesized data from existing primary research data (e.g. population-based surveys before and after program implementation, qualitative program acceptability study, cost-efficiency analyses), program monitoring data, and program documentation. The data were organized using Proctor et al.s Implementation Research Outcomes Framework, exploring the outcomes of acceptability, appropriateness, feasibility, fidelity, adoption, implementation cost, penetration, and sustainability. The synthesis consisted of meta-summaries across sub-domains under each outcome area. The program delivered through 34 community health workers (CHW) served 1,165 women across a 24-month period. The program demonstrated strong acceptability among participants, who reported trust in CHWs, respect for cultural and religious norms, and tangible improvements in their pregnancy health knowledge. CHWs similarly expressed intrinsic motivation and a sense of fulfillment in their roles, despite notable challenges around workload, geographic barriers, and financial burdens. The model showed reasonable epidemiological and sociocultural fit, though some recommended health behaviors conflicted with entrenched traditional practices, such as avoiding colostrum or giving sugar water to newborns. Equity gaps were identified, particularly the underrepresentation of women with disabilities. Feasibility was constrained by household dispersal, seasonal mobility, complex task management, and an initially irregular visit schedule, which CHWs ultimately simplified to a monthly system. CHW competency improved markedly over time, with average assessment scores reaching 94% by the program's end. Coverage was broad, with 88% of women who delivered during the program period enrolled. Sustainability considerations remained underdeveloped, representing a key area for future programming. The CBMNC model demonstrated potential to expand access to MNH services in rural settings, with CHWs earning broad trust and acceptance among women and communities, and the intervention widely regarded as a good epidemiological, sociocultural, and contextual fit. Nevertheless, the findings make clear that achieving successful and sustainable scale-up will require more than replicating the care package itself. Practical challenges, including CHW workload, referral pathways, health literacy, and equitable reach to marginalized groups, must be deliberately addressed. Ultimately, expansion efforts must invest as much in strengthening the underlying systems that enable effective delivery as in the content of care provided.

Tuberculosis (TB) services often fail to adequately address the needs of adolescents and young adults in many high-TB-burden settings. Despite evidence on the barriers this age group faces across the TB care pathway, young people are rarely involved in designing solutions to improve care that better meets their needs. This study focused on the perspectives of adolescents and young adults who had completed TB treatment in Nairobi, Kenya, engaging them as partners to examine their treatment experiences and co-create ways to improve youth?responsive TB services. This participatory qualitative study was conducted among young people aged 15-24 years (n=37) who had completed treatment for drug-susceptible TB from six health facilities in Nairobi County. Other study participants included County TB stakeholders, healthcare workers, facility managers and community representatives (n=214). Data were collected in December 2024 through four participatory workshops organised by age and gender to facilitate open discussion of shared lived experiences. Participants in each workshop used visual methods to describe their journey with TB, identified common challenges through group discussions, and proposed solutions to improve TB services for the young people. The findings from the workshops with the young people were subsequently discussed in stakeholder feedback sessions involving healthcare workers, facility managers, community representatives, and county TB actors. Data were analysed thematically across both workshops and feedback sessions. Results were structured around four interrelated themes. First, young people reported experiencing prolonged illness before diagnosis, with symptoms often normalised or attributed to other conditions, leading to disruption of school, work, and social life. Second, participants experienced lengthy and uncertain pathways to TB diagnosis, characterised by repeated healthcare visits and treatment for alternative conditions before TB was recognised. Receiving a TB diagnosis represented a pivotal turning point, evoking both fear and concerns about stigma as well as relief at finally understanding the cause of their illness and accessing treatment. Third, support from family and friends helped young people navigate the challenges of illness, diagnosis, treatment, and repeated health-system encounters. Fourth, participants and stakeholders identified practical service adaptations to strengthen youth-responsiveness, including respectful communication, enhanced counselling, peer support, greater privacy within TB service outlets, and flexible medicine collection such as after 5 pm. Adolescents and young adults with TB navigate multiple social and health systems barriers before reaching diagnosis, initiating treatment, and completing it. Involving young people directly in identifying gaps and priorities in TB care generated feasible opportunities for strengthening youth-responsive services within existing health systems. Further research is needed to evaluate the effectiveness and acceptability of the models proposed by study participants.

Intimate Partner Violence (IPV) has been shown to affect womens access to sexual and reproductive health services, including modern contraceptives. However, there is conflicting data in the literature on how the experience of IPV among women affects modern contraceptive use, with some studies showing decreased rates of modern contraceptive use, while others have shown increased rates of modern contraceptive use among these women. This study therefore, aimed at studying the association between the experience of IPV and modern contraceptive use among women presenting for abortion care in Lusaka District, Zambia. A cross-sectional study was conducted from 1 November to 31 December 2024 at four hospitals in Lusaka District. Women seeking abortion care were enrolled via convenience sampling, and data were obtained using a pre-tested interviewer-administered questionnaire. The outcome variable was modern contraceptive use in the preceding six months; exposures included IPV within the prior six months, as well as socio-demographic and reproductive characteristics. Analyses comprised descriptive statistics, chi-square test and multiple logistic regression. A total of 372 women participated in the study and data was analysed for 367 women, with a median age of 25 years (IQR 22-30). IPV was reported by 231 participants (62.9%), most commonly emotional violence (44.7%). Modern contraceptive use within the preceding six months was reported by 150 women (40.9%). The odds of modern contraceptive use was lower amon women with IPV exposure compared with those who were not exposed (aOR 0.3; 95% CI 0.17-0.52), but higher among women seeking abortion care services from Chawama First Level Hospital compared to those seeking services from the Women and Newborn University Teaching Hospital ((aOR 4.4; 95% CI 1.68 - 11.65) and among women aged above 24 years compared to adolescent girls and young women (AGYW) aged 14-24 years (aOR 14; 95% CI, 6.40 - 30.60). More than half of the women accessing abortion care services in Lusaka district experienced intimate partner violence, and less than half had used modern contraceptives within six months before they participated in the study. Thus, policies and programmes aimed at increasing modern contraceptive use among women should pay particular attention at addressing IPV and the reproductive health needs of AGYW and women residing in peri-urban areas.

Domestic gender-based violence (DGBV) remains a major public health concern that undermines womens sexual and reproductive health (SRH). This study assessed the influence of DGBV on SRH-seeking behavior among women of reproductive age in the Lusaaze Zone, Kampala District, Uganda. A quantitative cross-sectional descriptive-correlational design was employed among 383 women aged 15 to 49 years selected through systematic random sampling. The data were analyzed using descriptive statistics, chi-square tests and modified Poisson regression. The prevalence of DGBV was high, with 61.6% of women reporting public humiliation, 60.0% reporting physical violence, 59.0% reporting forced sexual intercourse, and 45.1% reporting economic exclusion. Women exposed to DGBV were nearly twice as likely to report partner prevention of HIV service access (66.8% vs. 35.2%; p < 0.001). Household financial control emerged as the strongest predictor of DGBV exposure, with women whose partner-controlled household income was approximately 2.4 times more likely to experience violence. The primary indicator for SRH-seeking behavior was STI treatment-seeking status, which was not independently associated with DGBV after adjustment (aPR=0.99, 95% CI=0.65 to 1.49). The study concludes that DGBV is highly prevalent and driven largely by unequal household power relations. Strengthening community DGBV prevention programs, womens economic empowerment, and the integration of DGBV response services within SRH programs are recommended.

Background: Midwives are a central cadre in the health system, particularly in conflict-affected settings where they are sometimes the primary or even only skilled providers available. Yet, despite their critical role, there is limited qualitative evidence capturing their lived experiences and how these shape workforce entry, retention, and overall well-being. Methods: Drawing on a phenomenological research methodology, this qualitative study was embedded within a larger prospective longitudinal cohort of midwifery students and graduates in Somalia and Nigeria. We conducted focus group discussions with graduate midwives (n=48 in Nigeria; n=63 in Somalia) to explore their experiences transitioning into the workforce and their realities working in health systems impacted by conflict and violent insecurity. Data were analysed using inductive thematic analysis. Results: Five themes emerged from the data: (1) job search and workforce entry, which was described as fraught with challenges and shaped by a set of formal systems in Nigeria but informal networks and structural barriers in Somalia (2) working conditions that were marked by resource scarcity, infrastructural challenges, and heavy and unreasonable workloads, (3) safety, security and coping strategies that differed across the two contexts but reflected persistent exposure to violence and a reliance on ad hoc and personal coping in lieu of systematic protection, (4) community perceptions of midwives, shaped and constrained by social and gender norms and (5) mental health and emotional wellbeing, highlighting stress, burnout and moral injury experienced by this cadre. Conclusion: Our findings highlight the profound challenges faced by midwives working in conflict-affected settings, and they shine a light on the urgent need to support and invest in this critical and predominantly female health workforce.

Background: Annually, 2.3 million newborns die, largely from preventable causes. Neonatal hypothermia is an important contributor to morbidity and mortality, particularly in low-resource settings. This study quantified the burden of hypothermia at and after admission in four NEST360-supported countries and examined associations between outside air temperature, ward temperature, and neonatal hypothermia. Methods: We conducted a retrospective analysis of newborn admissions (January 2021 to June 2025) across 66 neonatal units in Kenya, Malawi, Nigeria, and Tanzania. Hypothermia was defined using WHO thresholds (mild: 36.0-36.4{degrees}C, moderate: 32.0-35.9{degrees}C, severe: <32.0{degrees}C). Newborn admission and lowest after admission body temperatures were extracted from routine clinical records. Ward temperatures were captured using the Hadli Monitoring System, and environmental temperatures were obtained from Open-Meteo. Multivariate ordinal logistic regression assessed associations between air temperature, ward temperature, and hypothermia at admission and during admission. Results: Among 418,458 newborn admissions with recorded admission temperatures, 47.3% (n=220,684) were hypothermic at admission (country range: 22.8%-61.9%), while 63.5% (n=48,746) experienced hypothermia during hospital stay (country range: 18.5%-74.4%), based on 76,855 admissions (July 2024-June 2025) with temperature data. Based on admission and subsequent temperature, 28.5% had no documented hypothermia, 8.6% improved to non-hypothermic status, 29.4% developed hypothermia after admission, and 33.5% experienced hypothermia at admission and during hospital stay. Across 59 neonatal units, minimum ward temperatures >26{degrees}C were maintained on 92.6% of 365 days. At admission, ward temperatures of 30-33{degrees}C were associated with 9% lower odds of a lower thermal category versus 26-28{degrees}C (p<0.01). After admission, ward temperatures of 28-30{degrees}C reduced odds by 18% (p<0.05). Warmer outside temperatures (>24{degrees}C day, >21{degrees}C night) were protective, corresponding to 19% and 68% lower odds of a lower thermal category after admission, respectively, compared with 19-24{degrees}C and 15-21{degrees}C reference groups. Newborns had 3.6-fold higher odds of hypothermia at night than during the day. Each 1{degrees}C increase in post-admission temperature reduced odds of death by 6%. Conclusion: Neonatal hypothermia remains highly prevalent despite most units maintaining ward temperatures above WHO minimum standards (26{degrees}C). Strengthening all components of the warm chain, particularly at night and during colder seasons, is essential to reduce hypothermia and improve survival.

Postpartum haemorrhage (PPH) remains the leading direct cause of maternal mortality globally, with a disproportionate burden in low- and middle-income countries. Although prophylactic uterotonics are effective, their impact is often constrained by health system limitations, including unreliable cold-chain storage affecting oxytocin quality. Heat-stable carbetocin (HSC) offers a thermally stable alternative; however, evidence on its large-scale integration into routine public health systems remains limited. We conducted a district-wide implementation evaluation of an HSC-based Active Management of the Third Stage of Labour (AMTSL) strengthening model across 32 public-sector delivery facilities in Dewas district, Madhya Pradesh, India. Implemented through a phased public-private partnership, the model integrated HSC into routine labour room practice alongside provider capacity building, strengthened documentation, and supportive supervision. A retrospective observational design was used to analyse routinely collected facility-level data from August 2022 to December 2024. Key outcomes included prophylactic uterotonic coverage, timeliness of administration, PPH incidence, and management practices. A total of 48,487 institutional deliveries were recorded during the study period. Documented prophylactic uterotonic coverage was nearly universal (99.9%), with administration within one minute of birth achieved in 99.4% of deliveries. Among deliveries with documented prophylactic uterotonic use, 41,658 (85.9%) received HSC and 6,812 (14.1%) received oxytocin. Overall, 275 PPH cases (0.57%) were documented. Among women receiving HSC prophylaxis, 200 (0.48%) developed PPH, compared with 75 (1.10%) among those receiving oxytocin. These findings are descriptive because prophylactic uterotonic allocation reflected routine programme implementation rather than random assignment. Uterine atony was the leading documented cause of PPH (176/275; 64.0%). Management included tranexamic acid in 239 (86.9%) cases, intravenous fluids in 273 (99.3%), blood transfusion in 36 (13.1%), and referral to a higher-level facility in 84 (30.5%) cases. HSC uptake was significantly higher in First Referral Units than non-FRU facilities (89.3% vs. 81.4%; p<0.001), as was administration within one minute among HSC recipients (100% vs. 98.7%; p<0.001). District-wide implementation of an HSC-based AMTSL strengthening model achieved high coverage and timely administration of prophylactic uterotonics across public-sector facilities operating at different levels of obstetric capacity. The findings provide real-world implementation evidence supporting the feasibility of integrating HSC into routine government maternity services using existing health-system infrastructure, supervision, and reporting mechanisms. Such embedded implementation approaches may offer a pragmatic pathway for strengthening PPH prevention in settings where reliable maintenance of the oxytocin cold chain remains challenging.

Background Infection with human papillomavirus (HPV), the primary cause of cervical cancer, disproportionately affects women in low- and middle-income countries (LMICs). While school-based vaccination of adolescent girls against HPV is highly effective, this strategy systematically excludes out-of-school (OOS) girls. Using the RE-AIM framework, we explored strategies to reach OOS girls with HPV vaccination across six African and Asian LMICs. Methods We conducted semi-structured key informant interviews with 32 vaccination program stakeholders from Cambodia, Cameroon, Kenya, Malawi, Mozambique, and Uganda between May and September 2024. Interviews explored countries implementation successes, challenges, and strategies to reach OOS girls with HPV vaccination and sustainability considerations. Data were analyzed using a hybrid team-based thematic analysis approach guided by the RE-AIM framework. Results Community outreach-based strategies, typically integrated into routine immunization outreach, were identified as the most effective approach to reach OOS girls with HPV vaccination. Targeted strategies, such as locating outreach clinics in community venues frequented by OOS girls (e.g., churches, markets) enhanced implementation. Perceived effectiveness of these strategies varied across participants, and formal assessment of effectiveness was constrained by the absence of disaggregated vaccination coverage data by school enrollment status. Some subpopulations of OOS girls (i.e., girls in nomadic or migrant communities, urban OOS girls) were not readily reached through standard outreach approaches, prompting implementation of adapted and tailored strategies for these subpopulations. Costs associated with conducting outreach in harder-to-reach areas were major barriers to reaching OOS girls, presenting challenges to the sustainability and cost-effectiveness of these approaches. Conclusions Routine community outreach platforms were widely perceived as most effective for reaching OOS girls. Strengthening disaggregated monitoring systems, adapting outreach for harder-to-reach subpopulations of OOS girls, and financing delivery models for tailored outreach strategies will be critical to improving equitable HPV vaccine coverage among OOS girls.

Background: Early identification of gestational diabetes mellitus (GDM) is critical to improving maternal and neonatal outcomes, particularly in resource-constrained settings where universal oral glucose tolerance testing (OGTT) is burdensome. We assessed whether early-pregnancy HbA1c alone or combined with common risk factors can predict GDM and reduce the burden of OGTT requirements in a peri-urban cohort in Karachi, Pakistan. Methods: We conducted a secondary analysis of the Pregnancy Risk Infant Surveillance and Measurement Alliance (PRISMA) Pakistan cohort. Women enrolled before 20 weeks' gestation with available early-pregnancy HbA1c and a 2-hour 75g OGTT at 24 to 28 weeks were included. We externally validated GDM prediction models originally developed in the STRiDE-India cohort. Model performance was evaluated using receiver operating characteristic (ROC) curves and area under the curve (AUC). We assessed four models: HbA1c alone (Model 1a); age, BMI, and family history of diabetes mellitus (FH DM) (Model 1b); HbA1c combined with age, BMI, and FH DM (Model 2); and an extended model, i.e., Model 2 combined with socioeconomic status, gestational age, parity, systolic and diastolic blood pressure (Model 3). A dual-threshold approach was applied to assess rule-in and rule-out performance. Results: Among 2,489 women, GDM incidence was 7.5% (n=186). Models with a broader set of predictors demonstrated higher AUC values, with Model 2 achieving an AUC of 0.61 (95% CI: 0.57, 0.66). Including additional factors (Model 3) did not further improve predictive ability (AUC: 0.62; 95% CI: 0.58, 0.66). In addition, at predefined thresholds, Model 2 achieved sensitivity of 73.7% (rule-out) and specificity of 83.5% (rule-in), with the potential to reduce OGTT requirements (58.5%). Conclusions: Early-pregnancy risk stratification using HbA1c combined with simple clinical predictors offers a pragmatic approach to streamline GDM screening among high-risk pregnant women. A dual-threshold strategy using Model 2 could reduce reliance on universal OGTT while prioritizing high-risk women for confirmatory testing.

Background: Death is a social and cultural phenomenon whose meaning shapes how and whether losses are mourned, disclosed, and reported. These dynamics have direct implications for maternal and perinatal death surveillance and response (MPDSR), yet remain understudied, particularly in humanitarian contexts. Methods: This phenomenological qualitative study was conducted in two conflict-affected health zones in Eastern Democratic Republic of Congo. In-depth interviews (n=50) were conducted with bereaved family members of maternal or perinatal deaths, community leaders, and health providers to understand the socio-cultural practices surrounding death and the factors influencing MPDSR. Interviews were transcribed in French and analyzed using inductive thematic content analysis. Results: Four themes characterized the socio-cultural practices surrounding maternal and perinatal deaths: burial practices, mourning and bereavement traditions, rationale for these practices, and the impact of insecurity on customs. Burial and mourning practices differed markedly by type of death, with stillbirths and neonatal deaths accorded significantly less social recognition than maternal deaths. Deaths were commonly attributed to witchcraft or spiritual causality, or blame directed at mothers, husbands, and health providers. Active conflict further disrupted customary practices and eroded community trust. Collectively, these dynamics inhibit disclosure and reporting of deaths, undermining MPDSR case identification. Conclusion: Effective MPDSR in conflict-affected settings requires culturally responsive adaptation, community involvement in case identification, and trust in health sector actors. By documenting specific actors involved in burials, variations in burial and mourning practices, and how conflict changes socio-cultural practices, findings offer actionable entry points for strengthening MPDSR in conflict-affect health zones in Eastern DRC.

Background: Prematurity is the leading cause of child deaths worldwide, with the highest neonatal mortality in sub Saharan Africa. Respiratory distress syndrome (RDS) is the leading mortality pathway in preterm neonates, but continuous positive airway pressure (CPAP) has high impact. This analysis reports CPAP coverage and quality of care for preterm neonates admitted to 66 neonatal units in Kenya, Malawi, Nigeria and Tanzania. Methods: Analyses used individually linked neonatal inpatient data and cross-sectional health systems data. All admitted neonates were eligible for inclusion (January 2021 through December 2024). Service readiness for CPAP delivery and mean CPAP coverage were described for CPAP eligible newborns (weighing <1500g and symptomatic newborns >1500g). Quality of care cascades were constructed to illustrate key indicators. Survival among CPAP eligible neonates was analysed using regression models, stratified by clinical severity scores. Results: 375,255 newborn admissions were analysed in 66 neonatal units. Functional CPAP availability varied with median 16% of days (IQR: 4 to 47%) classified as high demand (>1.5 eligible newborns per CPAP). Of 64,761 CPAP eligible neonates, 22,006 (34%, 95% CI 33 to 34%) received CPAP. All countries showed improvement in CPAP coverage, with Tanzanian hospitals recording 63% increase in mean coverage (p-value=0.001) over time. Quality of care cascades showed treatment was initiated <24 hours after birth and continued for >1 day for 42% (95% CI 41 to 43%) of eligible neonates receiving CPAP. Only 10% of neonates <1500g started CPAP within the first hour of life. Among newborns on CPAP, 55% also received KMC (from 48% in Tanzania to 88% in Nigeria). Among newborns with high clinical severity, those treated with CPAP had a higher probability of survival (32%, 95% CI 29 to 36%) than those who were not (23%, 95% CI 21 to 26%). Odds of survival were higher for CPAP eligible newborns whose mothers received antenatal corticosteroids (aOR 1.07, p=0.001). Lower aOR of survival was associated with hypoglycaemia (aOR 0.71, p<0.001), respiratory distress (aOR 0.91, p<0.001), and outborn newborns (aOR 0.72, p<0.001). Conclusion: CPAP coverage and quality are critical for premature neonates. Clinical cascades highlight quality gaps, particularly in timely prophylactic CPAP initiation and appropriate duration. Improving comprehensive care quality for newborns on CPAP, including provision of co-interventions and maternal antenatal corticosteroids, can improve survival for preterm neonates.

Background Patient-reported satisfaction is a core tracer of health-system responsiveness in Universal Health Coverage (UHC) monitoring, yet its determinants in rural Sierra Leone are poorly characterised. We quantified overall and domain-specific satisfaction and identified modifiable predictors across three rural border districts. Methods We conducted a cross-sectional, population-based household survey in October 2024 in Kailahun, Kambia and Pujehun districts, using a two-stage cluster design (chiefdoms sampled with probability proportional to size; households sampled at random). A validated 29-item instrument measured overall satisfaction and eight patient-experience domains on five-point Likert scales. The primary outcome was the five-level single-item overall satisfaction rating. We fitted a multivariable proportional-odds ordinal logistic regression, with 95% confidence intervals (CIs) obtained by a cluster bootstrap resampling the 20 chiefdom clusters. Robustness was assessed with binary and composite-outcome sensitivity models. Results Of 750 respondents, 679 (90.5%) had used a formal health facility in the previous 12 months and formed the analytic sample (510 [75.1%] female; mean age 28.2 years [SD 13.8]). The instrument showed high internal consistency (Cronbach = 0.87 for the five core domains). Overall, 375/679 (55.2%) were satisfied or very satisfied, ranging from 185/244 (75.8%) in Kambia to 110/224 (49.1%) in Kailahun and 80/211 (37.9%) in Pujehun ({chi}{superscript 2} = 70.8; p<0.001). In the adjusted model, staff attitude was the strongest predictor of higher satisfaction (adjusted odds ratio [AOR] 2.74, 95% CI 2.03-3.70; p<0.001 per one-point increase), followed by waiting-time satisfaction (AOR 1.89, 1.39-2.46) and medicine availability (AOR 1.43, 1.16-2.10). Travel-time category, facility type and sex were not independently associated. Large district disparities persisted after adjustment: relative to Kambia, the AOR for higher satisfaction was 0.27 (0.15-0.50) in Kailahun and 0.33 (0.20-0.66) in Pujehun. Adjusted probabilities of high satisfaction were 0.72, 0.48 and 0.43, respectively. Conclusions Respectful provider behaviour, shorter waits and reliable medicine supply, all amenable to district-level management, were the dominant and actionable drivers of patient satisfaction, whereas geographic distance was not. Persistent between-district gaps call for tailored quality-improvement in Kailahun and Pujehun. Institutionalising routine patient-experience measurement would strengthen accountability for people-centred care and support equitable progress towards UHC.

Bangladesh continues to report one of the highest adolescent fertility rates in South Asia, yet most prior national analyses have not fully accounted for the complex survey design of the Demographic and Health Surveys or assessed the robustness of findings to missing data. Using the most recent nationally representative data, this study examined factors associated with adolescent fertility among ever-married adolescent women aged 15-19 years in Bangladesh. We analysed data from the 2022 Bangladesh Demographic and Health Survey. Adolescent fertility was defined as being currently pregnant or having had at least one live birth. Of 2,449 eligible ever-married women aged 15-19 years, 1,601 with complete information on all model variables were included in the primary complete-case analysis. Survey-weighted logistic regression incorporating sampling weights, clustering, and stratification was used to estimate adjusted odds ratios (AORs) with 95% confidence intervals (CIs). Multiple imputation by chained equations among all 2,449 respondents was conducted as a sensitivity analysis. Analyses were performed in R version 4.5.1, and a two-sided p < 0.05 was considered significant. Adolescent fertility was strongly associated with age at first cohabitation. Compared with women who first cohabited before age 15 years, the odds were significantly lower among those cohabiting at 15-17 years (AOR = 0.41, 95% CI: 0.31-0.55) and 18-19 years (AOR = 0.15, 95% CI: 0.10-0.22; both p < 0.001). Women whose husbands had higher education had lower odds of adolescent fertility than those whose husbands had no formal education (AOR = 0.46, 95% CI: 0.27-0.77, p = 0.004), whereas a spousal age gap of 11 years or more was associated with higher odds (AOR = 1.63, 95% CI: 1.20-2.20, p = 0.002). Higher household wealth showed a borderline protective association (rich vs poor: AOR = 0.75, 95% CI: 0.56-1.01, p = 0.057). Respondent educational attainment and current working status were not independently associated with adolescent fertility after adjustment. Estimates from the multiply imputed datasets were broadly consistent with the complete-case findings. Adolescent fertility in Bangladesh is shaped by socioeconomic and relational factors, with age at first cohabitation the strongest determinant, alongside partner's education and spousal age gap. Multisectoral strategies that delay early marriage, strengthen child marriage legislation, engage male partners in reproductive health, and address socioeconomic and power inequalities are needed to reduce adolescent fertility and advance progress toward Sustainable Development Goal target 3.7

Despite Malawi's progress toward the UNAIDS 95-95-95 targets, facility-level rights-based challenges in HIV services persist, including stigma, discrimination and limited community participation. Community-led monitoring (CLM) has been promoted as an accountability mechanism, yet independent, facility-level evidence from urban settings remains scarce. This convergent parallel mixed-methods study assessed CLM at Ndirande and Limbe health facilities in Blantyre using a client survey (n=250), key informant interviews (n=12), and focus group discussions (three groups, 15 participants), totalling 277 participants. Chi-square tests (with Cramer's V) and binary logistic regression were used for the quantitative data; qualitative data were thematically analysed and triangulated. Analysis was guided by the rights-based approach to health and Arnstein's ladder of citizen participation. Awareness of CLM was moderate (56.0%) but participation was lower (40.2%), with involvement rated 2.78 out of 5, indicating consultative engagement. Awareness of CLM was the strongest and only robust predictor of participation (adjusted odds ratio {approx} 5.0, 95% confidence interval 2.4-10.6, p<0.001); a bivariate gender association did not survive adjustment. Notably, 41% of participants engaged in monitoring without recognising the term "CLM." CLM strengthened community-provider communication (68.5%) more than responsiveness (36.2%). Accountability mechanisms existed but functioned informally and were inconsistently documented. The two facilities did not differ significantly on any of nine indicators (all p>0.12). Barriers were structural: funding, transport, staff attitudes, fear of reprisal, and cultural norms. Urban CLM is a real but under-institutionalised accountability practice. The decisive lever is closing the awareness-action gap and formalising existing, unrecognised community monitoring through low-cost documentation, scheduled feedback, and independent, confidential complaint mechanisms. Findings are analytically transferable and offered as hypotheses for national piloting rather than as statistically generalisable conclusions.