William Stones

Objective This study aimed to apply a validated multidomain respectful maternity care index to assess women’s reported childbirth care experiences across four hospitals in Malawi, and to examine how reported less respectful maternity care varied by maternal education. Design Cross-sectional survey nested within the ALERT implementation research programme. Data were analysed using descriptive statistics and logistic regression, with sensitivity analyses using continuous outcome, modified Poisson and narrower abuse-focused outcome models. Setting The study was conducted in four high-volume secondary-level maternity units in Malawi’s Central Region, including three public facilities and one faith-based facility. Participants 1004 postpartum women who gave birth in participating hospitals to infants weighing at least 1000 g or at a gestational age of at least 28 weeks. Data were collected between December 2021 and March 2024 across five survey rounds. Primary outcome measures The primary outcome was reported less respectful maternity care, measured using a validated composite score covering absence of abuse, privacy and confidentiality, dignity and respect, communication and supportive care, social support and the hospital environment. Scores were expressed as a percentage of best possible care and dichotomised at the 25th percentile (≤84.5/100). Individual respectful care indicators, including verbal abuse, privacy violations and non-consented care, were also assessed, alongside variations in reported care experiences across maternal educational levels. Results Overall, 16% of women were classified as reporting less respectful maternity care based on the composite score. Verbal abuse was the most frequently reported form of mistreatment, while non-consented care, neglect and privacy violations were less common; physical abuse and bribery were rare. Women with secondary or higher education had higher odds of reporting less respectful maternity care than women with primary or no education (adjusted OR 1.48, 95% CI 1.02 to 2.15; p=0.04) defined as being in the lowest quartile of respectful maternity care scores. Sensitivity analyses using the continuous respectful maternity care score and modified Poisson regression yielded similar evidence of an association with education, whereas no association was observed for the narrower abuse-focused outcome. Conclusion Less respectful maternity care remains a concern in Malawi. Women with secondary or higher education had higher odds of reporting poorer respectful maternity care. This association may reflect differences in expectations, recognition, reporting or true experiences of care, which could not be distinguished in this study. Research should examine education-related reporting differences, while reforms strengthen communication, accountability and maternity infrastructure.

Background Anemia affects 40% of pregnant women globally, leading to maternal mortality, premature birth, low birth weight, and poor baby development. Iron deficiency causes over 40% of anemia cases in Africa. Oral iron supplementation is insufficient for Low-and-Middle-Income-Countries (LMICs) to meet current WHO targets. We hypothesized that a single intravenous dose of Ferric Carboxymaltose (FCM) may be more effective than oral iron treatment for anemia recovery, particularly in these settings where women present late for antenatal care. Methods This is a two-arm parallel open-label individual-randomized controlled trial in third trimester, in malaria Rapid Diagnostic Test-negative pregnant women with moderate or severe anemia - capillary hemoglobin <10 g/dL – who are randomized to receive either parenteral iron – with FCM – or standard-of-care oral iron for the remainder of pregnancy. This is the sister trial to the second-trimester REVAMP trial, funded by the Bill and Melinda Gates Foundation (trial registration ACTRN12618001268235, Gates Grant number INV-010612). In REVAMP-TT, recruitment and treatment are performed within primary health centers. The trial will recruit 590 women across Zomba district, Malawi. The primary outcome is the proportion of anemic women - venous hemoglobin <11 g/dL - at 36 weeks’ gestation or delivery (whichever occurs first). Other pre-specified key secondary clinical and safety outcomes include maternal iron-status and hypophosphatemia, neonate birth weight, infant growth and infant iron and hematological parameters. Discussion This study will determine whether FCM, delivered within primary health centers, is effective, safe and feasible for treating moderate to severe anemia in third-trimester pregnant Malawian women. This intervention could have long-term benefits for maternal and child health, resulting in improved survival and child development.

Background: Bangladesh has made substantial progress in maternal health. However, persistent inequities in service use undermine the achievements at the national level. In 2007, the government introduced a Maternal Health Voucher Scheme (MHVS) to reduce barriers to service utilization. The current study explores the impact of MHVS on reducing distance inequality in utilization across the maternal and newborn continuum of care (MNCoC). Methods: A cross-sectional survey was conducted from October’2017 to April’2018 in four selected MHVS sub-districts of Chattogram and Sylhet Divisions of Bangladesh. 2,400 women with at-least one child aged below two years were randomly selected. Both bivariate and multivariate analyses were carried out to explore the absolute and relative influence of the voucher scheme and chi-square test was used for hypothesis testing. Results: Nineteen percent of the women were MHVS beneficiaries and 23% of them lived within 5 km of the health facility. Among the beneficiaries no significant differences were observed in the utilization of at-least 4 antenatal visits, skilled-assistance at delivery, postnatal care, and MNCoC between those living closer to the health facility and those living far away. However, a higher facility delivery rate was observed among beneficiary women living closer. By contrast, for non-beneficiaries, a significant difference was found in service use between women living closer to health facilities compared to those living further away. Conclusion: The study found the use of MNCoC to be similar for all MHVS beneficiaries irrespective of their distance to health facilities whereas non-beneficiary women living further away had lower utilization rates. MHVS could have potentially reduced distance-related inequality for its beneficiaries. However, despite the provision of transport incentives under MHVS the reduction in inequality in facility delivery was limited. We propose a revision of the transportation incentive adjusting for distance, geographical remoteness, road condition, and transport cost to enhance the impact of MHVS.

Background: Anemia affects 40% of pregnant women globally, leading to maternal mortality, premature birth, low birth weight, and poor baby development. Iron deficiency causes over 40% of anemia cases in Africa. Oral iron supplementation is insufficient for Low-and-Middle-Income-Countries (LMICs) to meet current WHO targets. We hypothesized that a single intravenous dose of Ferric Carboxymaltose (FCM) may be more effective than oral iron treatment for anemia recovery, particularly in these settings where women present late for antenatal care. Methods: This is a two-arm parallel open-label individual-randomized controlled trial in third trimester, in malaria Rapid Diagnostic Test-negative pregnant women with moderate or severe anemia - capillary hemoglobin <10 g/dL – who are randomized to receive either parenteral iron – with FCM – or standard-of-care oral iron for the remainder of pregnancy. This is the sister trial to the second-trimester REVAMP trial, funded by the Bill and Melinda Gates Foundation (trial registration ACTRN12618001268235, Gates Grant number INV-010612). In REVAMP-TT, recruitment and treatment are performed within primary health centers. The trial will recruit 590 women across Zomba district, Malawi. The primary outcome is the proportion of anemic women - venous hemoglobin <11 g/dL - at 36 weeks’ gestation or delivery (whichever occurs first). Other pre-specified key secondary clinical and safety outcomes include maternal iron-status and hypophosphatemia, neonate birth weight, infant growth and infant iron and hematological parameters. Discussion: This study will determine whether FCM, delivered within primary health centers, is effective, safe and feasible for treating moderate to severe anemia in third-trimester pregnant Malawian women. This intervention could have long-term benefits for maternal and child health, resulting in improved survival and child development.

Background: Interpersonal violence has physical, emotional, educational, social, and economic implications. Although there is interest in empowering young people to challenge harmful norms, there is scant research on how individual agency, and, specifically, the “power to” resist or bring about an outcome relates to peer violence perpetration and victimization in early adolescence. This manuscript explores the relationship between individual agency and peer violence perpetration and victimization among very young adolescents (VYAs) living in two urban poor settings in sub-Saharan Africa (Kinshasa, Democratic Republic of Congo (DRC) and Blantyre, Malawi).Methods and findings: The study draws on two cross-sectional surveys including 2,540 adolescents 10 to 14 years from Kinshasa in 2017 (girls = 49.8% and boys = 50.2%) and 1,213 from Blantyre in 2020 (girls = 50.7% and boys = 49.3%). The sample was school based in Malawi but included in-school and out-of-school participants in Kinshasa due to higher levels of early school dropout. Peer violence in the last 6 months (dependent variable) was defined as a four categorical variable: (1) no victimization or perpetration; (2) victimization only; (3) perpetration only; and (4) both victimization and perpetration. Agency was operationalized using 3 scales: freedom of movement, voice, and decision-making, which were further divided into tertiles. Univariate analysis and multivariable multinomial logistic regressions were conducted to evaluate the relationships between each agency indicator and peer violence. The multivariable regression adjusted for individual, family, peer, and community level covariates. All analyses were stratified by gender and site.In both sites, adolescents had greater voice and decision-making power than freedom of movement, and boys had greater freedom of movement than girls. Boys in both settings were more likely to report peer violence in the last six months than girls (40% to 50% versus 32% to 40%,p< 0.001), mostly due to higher rates of a perpetration–victimization overlap (18% to 23% versus 10% to 15%,p< 0.001). Adolescents reporting the greatest freedom of movement (Tertile 3) (with the exception of girls in Kinshasa) had a greater relative risk ratio (RRR) of reporting a perpetrator–victim overlap (boys Kinshasa: RRR = 1.9 (1.2 to 2.8,p= 0.003); boys Blantyre: RRR = 3.8 (1.7 to 8.3,p= 0.001); and girls Blantyre: RRR = 2.4 (1.1 to 5.1,p= 0.03)). Adolescents with the highest decision-making power in Kinshasa also had greater RRR of reporting a perpetrator–victim overlap (boys: RRR = 3.0 (1.8 to 4.8,p< 0.001). Additionally, girls and boys in Kinshasa with intermediate decision-making power (tertile 2 versus 1) had a lower RRR of being victimized (Girls: RRR = 1.7 (1.02 to 2.7,p= 0.04); Boys: RRR = 0.6 (0.4 to 0.9,p= 0.01)). Higher voice among boys in Kinshasa (Tertile 2: RRR = 1.9 (1.2 to 2.9,p= 0.003) and Tertile 3: 1.8 (1.2 to 2.8,p= 0.009)) and girls in Blantyre (Tertile 2: 2.0 (1.01 to 3.9,p= 0.048)) was associated with a perpetrator–victim overlap, and girls with more voice in Blantyre had a greater RRR of being victimized (Tertile 2: RRR = 1.9 (1.1 to 3.1,p= 0.02)). Generally, associations were stronger for boys than girls, and associations often differed when victimization and perpetration occurred in isolation of each other. A main limitation of this study is that the cross-sectional nature of the data does not allow a causal interpretation of the findings, which need further longitudinal exploration to establish temporality.Conclusions: In this study, we observed that peer violence is a gendered experience that is related to young people’s agency. This stresses the importance of addressing interpersonal violence in empowerment programs and of including boys who experience the greatest perpetration–victimization overlap.

Introduction Anaemia in pregnancy remains a critical global health problem, affecting 46% of pregnant women in Africa and 49% in Asia. Oral iron therapy requires extended adherence to achieve correction of anaemia and replenishment of iron stores. Ferric carboxymaltose (FCM) is a recently established intravenous iron formulation associated with substantial advantages in safety, speed of delivery and total dose deliverable in a single infusion. We aim to determine whether FCM given once during the second trimester of pregnancy compared with standard oral iron distributed through routine antenatal services is effective and safe for treatment of moderate to severe maternal anaemia in sub-Saharan Africa. Methods and analysis The randomized controlled trial of the effect of intravenous iron on anaemia in Malawian pregnant women (REVAMP) is a two-arm confirmatory individually randomised trial set in Blantyre and Zomba districts in Malawi. The trial will randomise 862 women in the second trimester of pregnancy with a capillary haemoglobin concentration below 100.0 g/L. The study comprises two arms: (a) intravenous FCM (20 mg/kg up to 1000 mg) given once at randomisation, and (b) standard of care oral iron (65 mg elemental iron two times per day) for 90 days (or the duration of pregnancy, whichever is shorter) provided according to local healthcare practices. Both arms receive sulfadoxine-pyrimethamine as intermittent preventive treatment in pregnancy. The primary outcome is the prevalence of anaemia (Hb Ethics and dissemination Ethical approval was granted by the Research Ethics Committee (COMREC P.02/18/2357) in Malawi and the Human Research Ethics Committee (WEHI: 18/02), Melbourne, Australia. The protocol is registered with the Australian and New Zealand Clinical Trials Registry. The results will be shared with the local community that enabled the research, and also to the international fora. Trial registration number ACTRN12618001268235; Pre-results.

Engagement in dating relationships plays an important role in the health trajectories of young people, particularly during the early adolescent period between ages 10–14. Yet little is known about such relationships among youth in low resource contexts. This study sought to contribute to the literature on this topic by exploring reasons why school-going young people aged 12–14 years engage in dating relationships in Blantyre, Malawi. A thematic analysis was used to code and analyse in-depth interview data from 23 young people and 19 caregivers. Against the backdrop of growing sexual desires and feelings of attraction, participants stressed harassment from boys and coercion from older men, peer pressure, social status attainment, financial deprivation and encouragement during initiation ceremonies as reasons for engaging in dating relationships. Girls were found to be subject to multiple power dynamics—including gender power relations, as well as power dynamics within same-gender peer groups—that influenced their sex and relationship involvement. These findings carry implications for the design and timing of sexual and reproductive health youth programmes in Sub-Saharan Africa and emphasise the need for multi-level interventions to address the multiple influences in young people’s dating lives.