SummaryBackgroundWomen across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries.MethodsWe prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment.Findings2016 labour observations and 2672 surveys were done. 838 (41·6%) of 2016 observed women and 945 (35·4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75·1%] of 253; survey: 295 [56·1%] of 526) or caesarean section (observation: 35 [13·4%] of 261; survey: 52 [10·8%] of 483), despite receiving these procedures. 133 (5·0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15–19 years) and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio [OR] 3·6, 95% CI 1·6–8·0) and younger women with some education (OR 1·6, 1·1–2·3) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity.InterpretationMore than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context.FundingUnited States Agency for International Development and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO.

Background Women across the world are mistreated during childbirth. We aimed to develop and implement evidenceinformed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries. MethodsWe prospectively recruited women aged at least 15 years in twelve health facilities (three per country) in Ghana, Guinea, Myanmar, and Nigeria between Sept 19, 2016, and Jan 18, 2018. Continuous observations of labour and childbirth were done from admission up to 2 h post partum. Surveys were administered by interviewers in the community to women up to 8 weeks post partum. Labour observations were not done in Myanmar. Data were collected on sociodemographics, obstetric history, and experiences of mistreatment. Findings 2016 labour observations and 2672 surveys were done. 838 (41•6%) of 2016 observed women and 945 (35•4%) of 2672 surveyed women experienced physical or verbal abuse, or stigma or discrimination. Physical and verbal abuse peaked 30 min before birth until 15 min after birth (observation). Many women did not consent for episiotomy (observation: 190 [75•1%] of 253; survey: 295 [56•1%] of 526) or caesarean section (observation: 35 [13•4%] of 261; survey: 52 [10•8%] of 483), despite receiving these procedures. 133 (5•0%) of 2672 women or their babies were detained in the facility because they were unable to pay the bill (survey). Younger age (15-19 years)and lack of education were the primary determinants of mistreatment (survey). For example, younger women with no education (odds ratio [OR] 3•6, 95% CI 1•6-8•0) and younger women with some education (OR 1•6, 1•1-2•3) were more likely to experience verbal abuse, compared with older women (≥30 years), adjusting for marital status and parity.Interpretation More than a third of women experienced mistreatment and were particularly vulnerable around the time of birth. Women who were younger and less educated were most at risk, suggesting inequalities in how women are treated during childbirth. Understanding drivers and structural dimensions of mistreatment, including gender and social inequalities, is essential to ensure that interventions adequately account for the broader context.

Background Guinea has a high prevalence of female genital mutilation (FGM) (95%) and it is a major concern affecting the health and the welfare of women and girls. Population-based surveys suggest that health care providers are implicated in carrying out the practice (medicalization). To understand the attitudes of health care providers related to FGM and its medicalization as well as the potential role of the health sector in addressing this practice, a study was conducted in Guinea to inform the development of an intervention for the health sector to prevent and respond to this harmful practice. Methodology Formative research was conducted using a mixed-methods approach, including qualitative in-depth interviews with health care providers and other key informants as well as questionnaires with 150 health care providers. Data collection was carried out in the provinces of Faranah and Labé and in the capital, Conakry. Results The majority of health care providers participating in this study were opposed to FGM and its medicalization. Survey data showed that 94% believed that it was a serious problem; 89% felt that it violated the rights of girls and women and 81% supported criminalization. However, within the health sector, there is no enforcement or accountability to the national law banning the practice. Despite opposition to the practice, many (38%) felt that FGM limited promiscuity and 7% believed that it was a good practice. Conclusion Health care providers could have an important role in communicating with patients and passing on prevention messages that can contribute to the abandonment of the practice. Understanding their beliefs is a key step in developing these approaches.

Background Despite efforts to reduce the burden of female genital mutilation (FGM) in Guinea, the practice remains prevalent, and health care providers are increasingly being implicated in its medicalization. This formative study was conducted to understand the factors that facilitate or impede the health sector in providing FGM prevention and care services to inform the development of health sector-based interventions. Methods Between April and May 2018, a mixed methods formative study was carried out using a rapid assessment methodology in three regions of Guinea—Faranah, Labe and Conakry. A structured questionnaire was completed by one hundred and fifty health care providers of different cadres and 37 semi-structured interviews were conducted with health care providers, women seeking services at public health clinics and key stakeholders, including health systems managers, heads of professional associations and schools of nursing, midwifery, and medicine as well as representatives of the Ministry of Health. Eleven focus group discussions were conducted with female and male community members. Results This study revealed health systems factors, attitudinal factors held by health care providers, and other factors, that may not only promote FGM medicalization but also impede a comprehensive health sector response. Our findings confirm that there is currently no standardized pre-service training on how to assess, document and manage complications of FGM nor are there interventions to promote the prevention of the practice within the health sector. This research also demonstrates the deeply held beliefs of health care providers and community members that perpetuate this practice, and which need to be addressed as part of a health sector approach to FGM prevention. Conclusion As integral members of FGM practicing communities, health care providers understand community beliefs and norms, making them potential change agents. The health sector can support them by incorporating FGM content into their clinical training, ensuring accountability to legal and policy standards, and promoting FGM abandonment as part of a multi-sectoral approach. The findings from this formative research have informed the development of a health sector intervention that is being field tested as part of a multi-country implementation research study in Guinea, Kenya, and Somalia.

Background Chronic renal failure can lead to dialysis and/or a kidney transplant in the final stage. The number of patients under dialysis has increased considerably in the world and particularly in sub-Saharan Africa. Dialysis is a very expensive care. This is the reason why this study on the costs of dialysis management was initiated in Burkina Faso. The objective of the study is to determine the direct medical and non-medical costs of managing chronic renal failure among dialysis patients in Ouagadougou in 2020. Methods An analytical cross-sectional study was conducted. Data were collected in the hemodialysis department of three public university hospitals in Ouagadougou, Burkina Faso. All dialysis patients with chronic renal failure were included in the study. Linear regression was used to investigate the determinants of the direct medical and non-medical cost of hemodialysis. Results A total of 290 patients participated in this study, including children, adults, and the elderly with extremes of 12 and 82 years. Almost half of the patients (47.5%) had no income. The average monthly total direct cost across all patients was 75842 CFA or US$134.41.The average direct medical cost was 51315 CFA or US$90.94 and the average direct non-medical cost was 24 527 CFA or US$43.47. Most of the patients (45.2%) funded their hemodialysis by their own source. The multivariate analysis showed that the presence of an accompanying person during treatment, residing in a rural area, ambulatory care, use of personal cars, and treatment at the dialysis center of Yalgado Teaching Hospital were associated with higher direct costs. Conclusion The average cost of dialysis services borne by the patient and his family is very high in Burkina Faso, since it is 2.1 times higher than the country's minimum interprofessional wage (34664 CFA or US$61.4). It appears that the precariousness of the means of subsistence increases strongly with the onset of chronic renal failure requiring dialysis. Thus, to alleviate the expenses borne by dialysis patients, it would be important to extend the government subsidy scheme to the cost of drugs and to promote health insurance to ensure equitable care for these patients.

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Introduction: Maternal mortality remains a major public health problem in the world. Complications during pregnancy and childbirth are the main causes of maternal mortality in low-income countries. It is estimated that 15% of deaths are related to these complications. Studies have shown that women have little or no acquaintance on sign danger and complications during pregnancy and childbirth. Limited literature exists on women's knowledge and attitudes about pregnancy and childbirth's complications as well as the barriers for their management, therefore necessity to carry out this study. Objective: To explore women's knowledge and attitudes in the community about complications during pregnancy and childbirth. Method: A qualitative study was conducted in three prefectures of Guinea. Eighteen focus groups were conducted with women of reproductive age living in urban and rural areas. Results: Complications during pregnancy and childbirth are common among pregnant women in Guinea. Many women have knowledge about various sorts of complications related to pregnancy and childbirth. These complications were mostly vaginal bleeding, abortions and maternal mortality. The use of a health facility in case of complications during pregnancy and childbirth was reported as a major attitude in this study. Accompanying the woman to the health facility was another attitude identified. Lack of financial means, the distance from the health facilities and the lack of means of transport were listed as barriers to the management of complications during pregnancy and childbirth. Conclusion: This study showed that women's knowledge and attitudes about obstetric complications are insufficient. To that effect, women counselling during prenatal consultations on the risks of complications and How to cite this paper:

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