Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women’s access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa. Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings. The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff. A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness. PROSPERO CRD42017074102

Antenatal care uptake is among the key indicators for monitoring the progress of maternal outcomes. Early initiation of antenatal care facilitates the timely management and treatment of pregnancy complications to reduce maternal deaths. In Ethiopia, antenatal care utilization is generally low, and delayed initiation of care is very common. We aimed to systematically identify and synthesize available evidence on delayed initiation of antenatal care and the associated factors in Ethiopia. Studies published in English from 1 January 2002 to 30 April 2017 were systematically searched from PubMed, Medline, EMBASE, CINAHL and other relevant sources. Two authors independently reviewed the identified studies against the eligibility criteria. The included studies were critically appraised using the Joanna Briggs-MAStARI instrument for observational studies. Meta-analysis was conducted in RevMan v5.3 for Windows using a Mantel–Haenszel random effects model. The presence of statistical heterogeneity was checked using the Cochran Q test, and its level was quantified using the I2 statistics. Pooled estimate of the proportion of the outcome variable was calculated. Pooled Odd Ratios with 95% CI were calculated to measure the effect sizes. The pooled magnitude of delayed antenatal care in Ethiopia was 64% (95% CI: 57%, 70%). Maternal age (OR = 0.70; 95% CI: 0.53, 0.93), place of residence (OR = 0.29, 95% CI: 0.16, 0.50), maternal education (OR = 0.49; 95% CI: 0.38, 0.63), husband’s education (OR = 0.44; 95% CI: 0.23, 0.85), maternal occupation (OR = 0.75; 95% CI: 0.61, 0.93), monthly income (OR = 2.06; 95% CI: 1.23, 3.45), pregnancy intention (OR = 0.49; 95% CI: 0.40, 0.60), parity (OR = 0.46; 95% CI: 0.36, 0.58), knowledge of antenatal care (OR = 0.40; 95% CI: 0.32, 0.51), women’s autonomy (OR = 0.38; 95% CI: 0.15, 0.94), partner involvement (OR = 0.24; 95% CI: 0.07, 0.75), pregnancy complications (OR = 0.23; 95% CI: 0.06, 0.95), and means of identifying pregnancy (OR = 0.50; 95% CI: 0.36, 0.69) were significantly associated with delayed antenatal care. Improving female education and women’s empowerment through economic reforms, strengthening family planning programs to reduce unintended pregnancy and promoting partner involvement in pregnancy care could reduce the very high magnitude of delayed antenatal care in Ethiopia. CRD42017064585 .

Gender-based violence is a public health issue. The prevalence of gender-based violence is high in Sub-Saharan Africa. Therefore, this study aims to produce an overall summary estimate on the prevalence of gender-based violence according to different types and its risk factors among female youths in educational institutions of Sub-Saharan Africa. Studies published in English between 2000 and 2017 were identified by searching electronic databases such as MEDLINE, CINAHL, EMBASE, PsychINFO, and other relevant data bases. Three reviewers independently extracted the data and assessed the quality of studies using the Loney guidelines. The pooled prevalence of gender-based violence and type of GBV was computed using STATA software version 14, and between studies heterogeneity was tested using Cochran’s Q test and I2 statistics. Meta-regression analyses were done to identify factors associated with GBV estimates. A total of 1377 articles were produced from different databases, and a final 24 articles were included in the review. The overall prevalence of gender-based violence ranged from 42.3% in Nigeria to 67.7% in Ethiopia. The lifetime prevalence of sexual violence ranged from 4.3 to 76.4%, physical violence ranged from 7.4 to 66.1%, and emotional violence prevalence ranged from 26.1 to 50.8%. The overall pooled prevalence of lifetime GBV (n = 7 studies) was 52.83% [95% CI 39.54–65.90%, I2 = 99.1, P < 0.00]. The pooled estimate of sexual violence (n = 23), 26.22% [95% CI 19.48–33.57%, I2 = 99.39, P < 0.00], physical violence (n = 9), 18.86% [95% CI 10.96–28.3%, I2 = 98.98, P < 0.00], and emotional violence (n = 5), 27.06% [95% CI19.57–35.28%], I2 = 97.1, P < 0.00]. The review showed that gender-based violence was significantly associated with place of residence, witnessing parental violence, substance abuse, marital status, and educational status. The overall prevalence of overall gender-based violence, sexual, physical, and emotional violence was high in Sub-Saharan Africa. The lowest prevalence of GBV was observed in Nigeria, and it was highest in Ethiopia. However, the results should be interpreted with caution because of high between studies heterogeneity. Evidence from the review part revealed GBV was significantly associated with place of residence, witnessing parental violence, substance abuse, marital status, and educational status. The Sub-Saharan African countries should develop a comprehensive educational institution-based prevention strategy and effective interventions to mitigate gender-based violence and to specifically achieve the SDG5. PROSPERO CRD4201073260

Intimate partner violence exposes women to a wide range of health problems that can either directly or indirectly lead to maternal death. Although in a number of studies intimate partner violence has been associated with inadequate utilization of antenatal care and skilled delivery care, in other studies no association has been found. Therefore, we aimed to comprehensively review the evidence, and quantify the strength and direction of the association between intimate partner violence and utilizing adequate antenatal and skilled delivery care services. We systematically searched studies from MEDLINE, Embase, Psych INFO, CINAHL, and Maternity and Infant Care. Two independent reviewers screened the articles for eligibility. Quality and risk of bias in the articles were evaluated by using the Newcastle-Ottawa scale for observational studies. Pooled odds ratios and 95% confidence intervals were computed to estimate the association of intimate partner violence and antenatal care, and skilled delivery care. Random-effects models were used to allow for the significant heterogeneity that might possibly be found between studies. The degree of heterogeneity was expressed by using the I2 statistic. The meta-analyses have shown that women who experienced intimate partner violence had 25% decreased odds (AOR = 0.75, 95%CI = 0.61, 0.92) of using adequate antenatal care than those who did not experience IPV. Similarly, women who experienced IPV had 20% decreased odds (AOR = 0.8, 95%CI = 0.69, 0.92) of using skilled delivery care compared to those who did not experience IPV. The meta-analyses indicated that experiencing intimate partner violence is associated with a lower likelihood of receiving adequate antenatal care and skilled delivery care. Both community-based and facility-based interventions that target the reduction of partner violence, and strictly implementing proven health facility-based counselling interventions, could aid in improving utilization of maternal health care services.

While it is common practice for health surveys to include an open-ended question asking for additional comments, the responses to these questions are often not analysed or used by researchers as data. The current project employed an automated semantic program to assess the useability and thematic content of the responses to an open-ended free response item included in the Australian Longitudinal Study on Women’s Health (ALSWH) surveys. The study examined the comments of three cohorts of women, born between 1973–78, 1946–51, and 1921–26, from Survey 1 (in 1996) and Survey 5 (in 2007–2009). Findings revealed important differences in the health status of responders compared to non-responders. Across all three cohorts, and at both time points, women who commented tended to have poorer physical health (except for women aged 82–87) and social functioning, experienced more life events, were less likely to be partnered, and (except for women aged 18–23 years) more likely to have higher levels of education, than women who did not comment. Results for mental health were mixed. The analysis revealed differences between cohorts as well as changes over time. The most common themes to emerge for the 1973–78 cohort were health, time, pregnant and work, for the 1946–51 cohort, the most common themes were health, life, time and work, while for the 1921–26 cohort, the most common themes were husband, health and family. The concepts and frequency of concepts changed from the first to the fifth survey. For women in the 1973–78 cohort, pregnant emerged as a prevalent theme, while eating disappeared. Among women in the 1946–51 cohort, cancer, operation and medication emerged as prevalent themes, while for women in the 1921–26 cohort, the concept children disappeared, while family emerged. This analysis suggests that free-text comments are a valuable data source, suitable for content, thematic and narrative analysis, particularly when collected over time.

While grief, emotional distress and other mental health conditions have been associated with pregnancy loss, less is known about the mental health impact of these events during subsequent pregnancies and births. This paper examined the impact of any type of pregnancy loss on mental health in a subsequent pregnancy and postpartum. Data were obtained from a sub-sample (N = 584) of the 1973-78 cohort of the Australian Longitudinal Study on Women's Health, a prospective cohort study that has been collecting data since 1996. Pregnancy loss was defined as miscarriage, termination due to medical reasons, ectopic pregnancy and stillbirth. Mental health outcomes included depression, anxiety, stress or distress, sadness or low mood, excessive worry, lack of enjoyment, and feelings of guilt. Demographic factors and mental health history were controlled for in the analysis. Women with a previous pregnancy loss were more likely to experience sadness or low mood (AOR = 1.75, 95% CI: 1.11 to 2.76, p = 0.0162), and excessive worry (AOR = 2.01, 95% CI: 1.24 to 3.24, p = 0.0043) during a subsequent pregnancy, but not during the postpartum phase following a subsequent birth. These results indicate that while women who have experienced a pregnancy loss are a more vulnerable population during a subsequent pregnancy, these deficits are not evident in the postpartum.