Sally Griffin

Introduction Experts agree that male involvement (MI) in maternal health (MH) is a multifaceted concept, but a universal definition is lacking, hampering comparison of findings and interpretation of the literature. This systematic review aims to examine the conceptualization of MI in MH globally and critically review commonly used indicators. Methods PubMed, Embase, Scopus, Web of Science and CINAHL databases were searched for quantitative literature (between the years 2000 and 2020) containing indicators or variables representing MI in MH, which was defined as the involvement, participation, engagement or support of men in all activities related to maternal health. Results After full text review, 282 studies were included in the review. Most studies were conducted in Africa (43%), followed by North America (23%), Asia (15%) and Europe (12%). Descriptive analysis and text mining analysis showed MI in MH has been conceptualised by focusing on two main aspects: psychosocial support and instrumental support for maternal health care utilisation. Differences in measurement and topics were noted according to continent with Africa focusing on HIV prevention, North America and Europe on psychosocial health and stress, and Asia on nutrition. One third of studies used one single indicator for assessing MI in MH and no common pattern of indicators could be identified. Antenatal care attendance was the most used indicator (40%) followed by financial support (17%), presence during childbirth (17%) and HIV testing (14%). Majority of studies did not collect data from men directly. Discussion Researchers often focus on a single aspect of MI in MH, resulting in the usage of a narrow and simplified set of indicators. Aspects such as communication between the couple, shared decision making, participation in household tasks and the subjective feeling of being supported have received little attention. We believe a more multidimensional approach can broaden the potential of MI programs. Further research, involving experts and pilot testing, is recommended to develop consensus regarding a more robust and comprehensive set of valid and feasible indicators for assessing MI in MH.

Background: Midwifery care plays a vital role in the reduction of preventable maternal and newborn mortality and morbidity. There is a growing concern about the quality of care during facility based childbirth and the occurrence of disrespect and abuse (D&A) worldwide. While several studies have reported a high prevalence of D&A, evidence about the drivers of D&A is scarce. This study aims to explore midwives’ professional identity and perspectives on the occurrence of D&A in urban Mozambique. Methods: A qualitative study took place in the central hospital of Maputo, Mozambique. Nine focus group discussions with midwives were conducted, interviewing 54 midwives. RQDA software was used for analysing the data by open coding and thematic analysis from a grounded theory perspective. Results: Midwives felt proud of their profession but felt they were disrespected by the institution and wider society because of their inferior status compared to doctors. Furthermore, they felt blamed for poor health outcomes. The occurrence of D&A seemed more likely in emergency situations but midwives tended to blame this on women being “uncooperative”. The involvement of birth companions was a protective factor against D&A together with supervision. Conclusion: In order to improve quality of care and reduce the occurrence of D&A midwives will need to be treated with more respect within the health system. Furthermore, they should be trained in handling obstetric emergency situations with respect and dignity for the patient. Systematic and constructive supervision might be another promising strategy for preventing D&A.

Background: The role of the male partner and wider family in maternal health, especially in case of emergencies, has been receiving increasing attention over the last decade. Qualitative research has highlighted that women depend on others to access high quality maternity care. Currently little is known about these factors in relation to maternal health in Mozambique. Methods: A cross sectional household survey was conducted with men and women in southern Mozambique about decision making, financial support and knowledge of danger signs. A multivariable logistic model was used to identify factors associated with knowledge of danger signs and Cohen’s kappa for agreement among couples. Results: A total of 775 men and women from Marracuene and Manhica districts were interviewed. Maternal health care decisions were frequently made jointly by the couple (32–49%) and financial support was mainly provided by the man (46–80%). Parental and parent-in-law involvement in decision making and financial support was minimal (0–3%). The average number of danger signs respondents knew was 2.05 and no significant difference (p = 0.294) was found between men and women. Communication with the partner was a significant predictor for higher knowledge of danger signs for both men (p = 0.01) and women (p = 0.03). There was very low agreement within couples regarding decision making (p = 0.04), financial support (p = 0.01) and presence at antenatal care consultations (p = 0.001). Results suggest women and men have a high willingness for more male participation in antenatal care, although their understanding of what constitutes this participation is not clear. Conclusion: The study findings highlight the important role men play in decision making and financial support for maternal health care issues. Strengthening male involvement in antenatal care services, by investing in counselling and receiving couples, could help accelerate gains in maternal health in Mozambique. Maternal health care studies should collect more data from men directly as men and women often report different views and behavior regarding maternal health care issues and male involvement.

Background: Evidence suggests that many women experience mistreatment during childbirth in health facilities across the world, but the magnitude of the problem is unknown. The occurrence of disrespect and abuse (D&A) in maternity care services affects the overall quality of care and may undermine women’s trust in the health system. Studies about the occurrence of disrespect and abuse in Mozambican health facilities are scarce. The aim of this study was to explore the experience of women giving birth in hospital in different settings in Maputo City and Province, Mozambique. Methods: A cross sectional descriptive survey was conducted between April and June 2018 in the Central Hospital of Maputo (HCM) and district hospitals of Manhiça and Marracuene, Maputo Province, Mozambique. Five hundred seventy-two exit interviews were conducted with women leaving the hospital after delivery. The questionnaire consisted of the following components: socio-demographic characteristics, the occurrence of disrespect and abuse, male involvement during labor and childbirth and intrapartum family planning counselling and provision. Results: Prevalence of disrespect and abuse ranged from 24% in the central hospital to 80% in the district hospitals. The main types of D&A reported were lack of confidentiality/privacy, being left alone, being shouted at/scolded, and being given a treatment without permission. While very few women’s partners attended the births, the majority of women (73-80%) were in favor of involving their partner as a birth companion. Intrapartum counseling of family planning was very low (9-17%). Conclusion: The occurrence of disrespect and abuse was much higher in the district hospitals compared to the central hospital, emphasizing the high need for interventions outside Maputo City. Allowing male partners as birth companions should be explored further, as women seem in favor of involving their partners. Investing in intrapartum counselling for family planning is currently a missed opportunity for improving the uptake of contraception in the country.

In Mozambique, both the government and partners have undertaken efforts over the last decade to improve FP (family planning) services, especially through training health care providers and promoting the uptake of LARCs (Long Acting Reversible Contraceptives). Despite this, uptake of FP methods has not increased significantly. This study aims to examine women’s knowledge on LARCs, including their main sources of information, and the quality of care of FP services in rural areas. We conducted a repeated cross-sectional study, interviewing 417 women leaving FP consultations in 15 health facilities in Maputo Province, Mozambique. The main quality outputs measured were: 1)discussed, preferred and received contraceptive methods, 2)information received on usage and side-effects, 3)client-provider interaction, 4)being informed about the need for a follow-up visit 5)health examinations conducted and travel time to the facility. In addition, knowledge on LARCs was measured among the clients as well as sources of information regarding FP methods. Taking into account the design effect of the study, Chi-square statistics were used to detect differences between groups and linear regression analyses to identify associations between sources of information and higher knowledge. We found that IUDs (intrauterine devices) and implants were discussed in 23 and 33% of the consultations respectively, but only administered in a very few cases(< 1%). Half of the women were counselled on side-effects of contraceptives; this did not differ between first time clients and follow-up clients. Almost all women(98%) were satisfied with the received service and 83% of the women found the waiting time acceptable. Health examinations were performed on 18% of the women. Overall, women’s knowledge about LARCs was poor and misconceptions are still common. Women who had received FP information through outreach activities had better knowledge than those counselled at a facility. Our study highlights that only a minority of the women received information regarding LARCs during the consultation and that usage is almost non-existent. Counseling about all types of contraceptives during the consultation is sub-optimal, resulting in poorly informed clients. Multifaceted long-term interventions, focusing on both users and providers, are needed to improve uptake of contraceptives (including LARCs) in rural areas.

Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a ‘diagonal’ intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance. Applying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions’ feasibility, acceptability by providers, managers and policy makers, and potential sustainability. The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.

Good progress is being made towards universal access to contraceptives, however stock-outs still jeopardize progress. A seldom considered but important building block in optimizing supply management is the degree to which health workers feel motivated and responsible for monitoring supply. We explored how and to what extent motivation can be improved, and the impact this can have on avoiding stock-outs. Fifteen health facilities in Maputo Province, Mozambique, were divided into 3 groups (2 intervention groups and 1 control), and 10 monthly audits were implemented in each of these 15 facilities to collect data through examination of stock cards and stock-counts of 6 contraceptives. Based on these audits, the 2 intervention groups received a monthly evaluation report reflecting the quality of their supply management. One of these 2 groups was also awarded material incentives conditional on their performance. A Wilcoxon-Mann Whitney test was used to detect differences between the groups in the average number of stocked-out centres, while changes over time were verified through applying a Friedman test. Additionally, staff motivation was measured through interviewing health care providers of all centres at baseline, and after 5 and 10 months. To detect differences between the groups and changes over time, a Kruskal Wallis and a Wilcoxon signed-rank test were applied, respectively. Motivation reported by providers (n = 55, n = 40 and n = 39 at baseline, 1st and 2nd follow-up respectively) was high in all groups, during all rounds, and did not change over time. Facilities in the intervention groups had better supply management results (including less stock-outs) during the entire intervention period compared with those in the control group, but the difference was only significant for the group receiving both material incentives and a monthly evaluation. However, our data also suggest that supply management also improved in control facilities, receiving only a monthly audit. During this study, more stock-outs occurred for family planning methods with lower demand, but the number of stock-outs per family planning method in the intervention groups was only significantly lower, compared with the control group, for female condoms. While a rise in motivation was not measurable, stock management was enhanced possibly as a result of the monthly audits. This activity was primarily for data collection, but was described as motivating and supportive, indicating the importance of feedback on health workers’ accomplishments. More research is needed to quantify the additional impact of the interventions (distribution of evaluation reports and material incentives) on staff motivation and supply management. Special attention should be paid to supply management of less frequently used contraceptive methods.