The World Health Organization (WHO) recommends that a pregnant woman get an ultrasound scan (USS) as part of routine antenatal care. The Scale-up and normalization of ultrasound scanning still lag in low- and middle-income countries (LMIC), including Malawi. This study assessed barriers, facilitators, and strategies for scaling up and enhancing the normalization of ultrasound scanning during pregnancy in Malawi. Method We conducted one qualitative participatory workshop in each of Malawi’s administrative regional cities, including one workshop in the southern region on 17–18 May 2022, one in the Central region on 20–21 May 2022, and one in the Northen region on 23–24 May 2022. Forty USS trained and untrained midwives, one maternal and neonatal Zonal manager from the Ministry of Health (MoH), two District Nursing Officers (DNO), three district safe motherhood coordinators, and two Tutors from Nursing and Midwifery training institutions participated in the workshops to explore barriers, facilitators, and strategies and develop a training manual for scaling up ultrasound scanning in routine antenatal care (ANC) in Malawi. In addition, a validation workshop was conducted centrally in the central region, on September 22–23, 2022, with four representatives from the Ministry of Health, one from regulatory bodies, three from training institutions, one sonographer, and 10 district and Principal Nursing Officers (PNO) and midwives to validate the manual, which was developed with input from workshop participants. Data was audio recorded throughout the discussion, coded, and thematically analysed using NVivo 12 software. Results The barriers to normalization of USS in routine care include limited capacity and resources, such as a lack of USS-trained staff, infrastructure, including electricity interruptions, and misconceptions. The facilitators to normalization include political will to offer USS, availability of resources including trained midwives, restructuring of service provision, task sharing, revisions of staff allocations, and service integration. The strategies include preservice and on-the-job training, support and supervision, increased availability of resources, improved facility infrastructure, and community sensitization. Conclusion Scaling up of ultrasound is possible in Malawi. Staff training, community sensitization, and adequate human and material resources, including a standardised training manual, should be considered when planning USS scale-up and normalization into routine ANC.

The partograph and WHO safe childbirth checklist (SCC), which include on-admission, before-birth, after-birth and discharge components, are quality improvement (QI) tools in intrapartum care that have long been recommended for use. However, poor-quality intrapartum care remains a significant barrier to improving maternal and newborn health outcomes in countries like Ethiopia, largely due to total non-use or poor adherence to these QI tools. eHealth-based interventions present promising strategies to enhance healthcare quality. Therefore, we conducted implementation research to examine the effect of ADHERE (Antenatal care, chilDbirtH carE and postnatal ca.RE), an innovative eHealth system with a clinical decision support element, on adherence to QI tools during intrapartum care in health facilities in Ethiopia. A quasi-experimental study was conducted in 3 hospitals and 6 health centers (5 intervention and 4 control) in Ethiopia, guided by the Implementation Research Logic Model. Data were collected from labor and delivery charts by trained data collectors. A total of 2,190 charts (1,076 baseline [538 per arm] and 1,114 end-line [554 control and 560 intervention arms] charts) were included in the analysis. Difference-in-difference (DiD) analysis was used to estimate the effect of the intervention. The partograph adherence score and SCC completion rates were compared between the two arms. Statistically significant differences were determined using a p-value < 0.05 cutoff. Baseline mean partograph scores in the control and intervention arms were 4.11 and 4.23, respectively. Baseline SCC adherence rates at admission, before-birth, after-birth, and discharge were 25.8%, 24.9%, 24.9%, and 24.3% in the control arm, respectively, and 49.6%, 47.8%, 45.9%, and 45.5% in the intervention arm, respectively. The ADHERE intervention increased partograph adherence score by 4.27 units (DiD = 4.27, 95%CI [1.80, 5.09]). The ADHERE intervention increased SCC adherence by 9.3%-points (DiD = 0.093, 95%CI [0.036, 0.151]) at admission, 22.3%-points (DiD = 0.223, 95%CI [0.121, 0.325]) before-birth, and 15.2%-points (DiD = 0.152, 95%CI [0.072, 0.231]) after-birth. Conversely, the ADHERE intervention did not significantly change SCC adherence at discharge (DiD = -0.025, 95%CI [-0.071, 0.021]). The lack of significant improvement may be due to providers less attention to discharge evaluation because of work overload. The ADHERE intervention significantly improved adherence to partograph and SCC at admission, before-birth, and immediately after-birth during intrapartum care. However, it did not significantly improve adherence to the discharge checklist. Therefore, ADHERE-assisted implementation of QI tools can potentially prevent adverse birth outcomes related to low-quality intrapartum care and could be considered for scale up across health facilities in Ethiopia. Poor-quality childbirth care remains a significant barrier to improving health outcomes in countries like Ethiopia. eHealth interventions present promising strategies to enhance healthcare quality. We conducted implementation research to see the effect of a clinical decision support intervention on childbirth care in health facilities in Ethiopia. The study was conducted in three hospitals and six health centers: five received the new intervention and four continued with the usual care. We followed a step-by-step guide during project implementation. The data were gathered from 2,190 patient charts. We compared how childbirth care practices changed between the two groups over the two time periods (before- and after-intervention). We followed scientific procedure to declare that the differences were real. The intervention increased the correct use of partograph by 4.27 units as compared to without intervention. The intervention increased essential childbirth practices at admission by 9.3% points, practices during labor by 22.3% points, and practices immediately after birth by 15.2% points. Conversely, the intervention did not change essential childbirth practices at discharge from the facility. The intervention clearly helped health workers use the partograph correctly and follow key childbirth care steps when the woman arrived, during labor, and right after birth. Therefore, eHealth-assisted provision of key childbirth care can potentially prevent bad birth outcomes related to low-quality childbirth care and could be considered for scale-up across health facilities in Ethiopia.

BackgroundAdolescence is a formative period in which self-concept and sexual identity are developed. Unintended teenage pregnancies represent a sensitive and stigmatized issue, often associated with major psychosocial challenges. The aim of this study is to explore the lived experiences of women with unintended teenage pregnancies in Germany, with a particular focus on adverse childhood experiences (ACE) and Teen Dating Violence (TDV).MethodsThe analysis is based on five biographical narrative interviews conducted within the ELSA project (November 2020–April 2024), which aimed to investigate how unintended pregnancies are managed and to identify needs for counseling and care. Using the documentary method, we reconstructed the meaning of communicative and conjunctive knowledge in adolescents’ narratives and compared these orientations across four comparative dimensions: childhood biography, handling of the unintended pregnancy, construction of intimate relationships, and construction of minority.ResultsTwo contrasting orientation types were reconstructed across the dimensions, shaped by how adolescents processed external framings. Type 1 (subordinated, resigned orientation) was characterized by communicative deficit narratives and conjunctive patterns of resignation, dependency, and restricted agency. Type 2 (reflexive, pro-active orientation) demonstrated communicative acknowledgment of burdens but conjunctive practices of resilience, negotiation, and self-assertion. Unintended pregnancies were frequently constructed as existential crises, in which personal needs and emotions were suppressed. Minority status intensifies these challenges, while ACE -related patterns of behavior were reproduced in the context of pregnancy and intimate relationships.ConclusionsThe study provides valuable insights into the complex realities and decision-making processes of female adolescents with unintended pregnancies. The findings highlight the need for specific support services that strengthen girls’ empowerment and agency in order to promote sexual and reproductive health and rights. Outdated role models that ascribe contraceptive responsibility solely to women should be replaced by gender-equitable sexual education. In addition, legal regulations and counseling services should be better aligned with the often precarious family and partnership situations of young pregnant women.

This paper offers a critical review of reproductive injustices informed by secondary analysis of Black Queer birthing individuals’ narratives in the United States, focusing on how intersecting systems of oppression, particularly anti-Black racism, anti-queerness, and medical inequity, impact their access to and quality of reproductive health services, including assisted reproductive technology (ART), pregnancy, birthing, abortion, and postpartum care. Drawing on in-depth interviews with ten self-identified Black Queer birthing individuals from a prior published study (Qual Health Res 34:1039–52, 2024), we conducted secondary thematic analysis re-examining their narratives through the framework of obstetric racism, alongside extant health literature on medical racism, obstetric violence, and justice-oriented care to identify systemic barriers and areas where justice is routinely denied. Findings revealed systemic barriers across access, support, and aftermath, with interview excerpts highlighting experiences of insurance discrimination, lack of bodily autonomy, and post-abortion mental health neglect. Participants often felt unheard, misgendered, or dismissed in clinical settings. Additionally, high ART costs, limited Black sperm donors, and inadequate mental health care exacerbated reproductive inequities. In contrast, community-based care models, such as those led by doulas and midwives, were mentioned by participants as affirming and empowering alternatives. Black Queer birthing individuals experience compounding systemic harms across the reproductive healthcare continuum. Addressing these injustices requires intersectional, justice-oriented healthcare reforms and stronger integration of community-based care models to ensure dignity, autonomy, and equity for all birthing people.

Maternal Near-Miss (MNM) is a woman who nearly dies but survives complications during pregnancy, childbirth, or 42 days following termination of pregnancy. MNM has emerged as a proxy indicator for the quality of maternal health services. For every maternal death, there are 20-30 MNM cases. However, there is a dearth of comprehensive evidence on MNM according to the WHO's MNM approach, as well as inconsistencies in risk factors from primary studies. Hence, we conducted a systematic review and meta-analysis on the maternal near-miss incidence ratio, causes, and risk factors in East Africa. The review was conducted according to PRISMA 2020 checklist guidelines. Studies were identified from MEDLINE, Scopus, CNIAHL, PsycINFO, ProQuest, Web of Science, Emcare, and Google Scholar. Random-effect meta-analyses were conducted to produce pooled estimates. Further, an influential leave-one-out sensitivity analyses were conducted to investigate the impact of each study on the pooled estimates. Thirty-nine primary studies on the MNM incidence ratio and/or causes and/or factors associated with MNM were included. The pooled MNM incidence ratio was 37.12 per 1,000 live births (95% CI: 20.22-54.03), ranging from 12 per 1,000 live births in Kenya to 53 per 1,000 live births in Ethiopia. The pooled proportion of direct causes of MNM were as follows: obstetric haemorrhage 29.9% (95%CI: 25.7%-34%), hypertensive disorder of pregnancy 27.8% (95%CI: 22.3%-33.3%), uterine rupture 13.8% (95%CI: 7.9%-19.6%), sepsis 9.9% (95%CI: 7.1-12.8%), abortion complications 8.1% (95%CI: 5.9%-10.3%), and ectopic pregnancy 7.3% (95%%CI: 3.1-11.5%). Several factors were significantly associated with MNM. Low-income women had higher odds of MNM (AOR 2.95, 95% CI: 1.28-4.61), while employed women had lower odds (AOR 0.53, 95% CI: 0.21-0.81). Parity ≥ 5 (AOR 1.65, 95% I: 1.14-2.16), history of abortion (AOR 1.63, 95%CI: 1.04-2.22), history of pregnancy complications (AOR 4.09, 95%CI: 1.43-6.78), history of cesarean section (CS) (AOR = 5.04, 95%CI: 3.17-6.90), lack of antenatal care (AOR 2.91, 95%CI: 2.02-3.78), lack of birth preparedness and complication readiness (AOR 4.18, 95%CI: 2.64-5.72), and long distance to health facility (AOR 3.06, 95%CI:1.09-5.03) were positively associated with MNM. Conversely, women admitted by provider referral had lower odds of MNM (AOR 0.31, 95% CI: 0.07-0.55). The MNM incidence ratio in East Africa was high. Obstetric haemorrhage, hypertensive disorder of pregnancy, and uterine rupture were the three leading obstetric causes of MNM. Income, employment status, parity, ANC, history of CS, and distance to health facilities were found to be associated with MNM. Policymakers and healthcare workers need to consider these identified risk factors in interventions aimed at improving maternal health.

ObjectiveIndividuals choosing permanent female contraception (PFC) face barriers including age and parity. Prior literature has focused on regret, but rarely on understanding patient perspectives. Social media is increasingly used to obtain medical information; hence this study seeks to use popular platforms to evaluate motivations, barriers, and facilitators to obtaining PFC.MethodsThis study collected Twitter and Reddit posts from October 2020 to April 2023 and July 2017 to April 2023, respectively. Data was analyzed using Bidirectional Encoder Representations from Transformers (BERT), followed by manual deductive coding of relevant topic clusters to characterize user-generated PFC discussions. We collected 409,641 posts including 321,267 tweets and 88,374 Reddit posts and performed content analysis using a deductive coding schema using the socio-ecological model approach to determine which posts to include in the final analysis. Sentiment analysis was conducted to detect emotions and themes most correlated with post engagement.ResultsWe identified 2,356 posts, including 2,076 tweets (88.12%) and 280 subreddit posts (11.88%) from Reddit relevant to PFC discourse. Major themes included clinician (n = 246; 10.44%), patient (n = 1,388; 58.91%), interpersonal (n = 254; 10.78%), institutional (n = 311; 13.20%), and policy-level perspectives (n = 157; 6.66%) and derived 22 subthemes. The top subthemes included patients’ seeking/sharing PFC advice (20.80%), discussion of successful completion or commitment/intent to undergo PFC (27.04%), interactions with healthcare providers and beliefs surrounding PFC regret (10.77%), the cost associated with PFC (7.05%), and the Dobbs V. Jackson ruling (6.66%). Additionally, there was a significant increase in posts on PFC following the Dobbs decision. Sentiment analysis shows that posts containing emotional words (both positive and negative) and words related to themes such as home, friends, and family were more likely to receive engagement on Reddit while sentiments related to health, optimism, and communication were correlated with tweet engagement.ConclusionAs reproductive healthcare continues to face restrictions, online communities provide insight into the motivations and decision-making behaviors of people seeking PFC. Findings can help clinicians better understand patient perspectives, and improve our ability to provide person-centered contraception care for patients desiring PFC.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12978-025-02239-z.

BackgroundOverlapping and intersecting structural violence facing im/migrant sex workers has contributed to significant sexual health inequities, such as reduced odds of recent HIV testing, Sexually transmitted and blood borne illness treatment, and client condom refusal. Limited research has been conducted among im/migrant sex workers around access to contraception, particularly using an intersectional lens. The purpose of this paper is to examine the association between im/migration status and difficulty accessing non-barrier contraception among a prospective, community-based cohort of sex workers in Metro Vancouver, Canada, as well as whether this association is modified by racialization.MethodsSemi-annual questionnaire data were drawn from AESHA (An Evaluation of Sex Workers Health Access), an open, community-based longitudinal cohort of women sex workers in Vancouver, Canada (January 2010 – August 2022). We assessed the association between im/migration status and difficulty accessing non-barrier contraceptives (last 6 months), using racialization (Asian, Black, Latinx, or other racialized identity) as an effect modifier. We developed a multivariable confounder model using modified Poisson regression with generalized estimating equations using sandwich robust standard error.ResultsEight hundred and three participants were included, contributing a total of 5,133 observations over 12.8 years. The median number of visits per participant was four (range: 1–24). 32.6% of participants were im/migrants to Canada and 34.5% were Asian, Black, Latinx, or another racialized identity. In adjusted multivariable analysis exploring racialized identity as an effect modifier, participants who were both im/migrants and racialized faced the highest risk of experiencing difficulties accessing non-barrier contraceptives, when compared to non-im/migrant and non-racialized sex workers (Risk Ratio: 1.50; 95% CI: 0.99, 2.28).ConclusionsOne-quarter of all participants reported experiencing difficulty accessing non-barrier contraceptives at least once during the study period. Im/migrant women sex workers who are Asian, Black, Latinx, or another racialized identity faced a greater risk of experiencing difficulties accessing non-barrier contraceptives compared to non-racialized, non-im/migrant sex workers. These findings indicate a critical need towards investment in culturally safe, linguistically congruent, and sex work-friendly sexual health services to increase contraceptive access and reduce the potential for sexual health inequities.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12978-025-02214-8.

Globally, less safe or least safe abortion among adolescents remains a public health concern. In Ghana, complications from less safe and least safe abortions result in approximately 43,000 facility-based post-abortion care cases annually, contributing significantly to the overall burden of maternal morbidity and mortality. Healthcare workers play a critical role in delivering comprehensive abortion care (CAC) services to address the challenges of less safe and least safe abortion. At the same, there is scanty literature in Ghana on the experiences of these healthcare workers. This study explored the experiences of healthcare workers in providing CAC to adolescents in the New Juaben Municipality in Eastern Region, Ghana. A phenomenological qualitative study was conducted. Data were collected from November 2022 to January 2023 among 12 healthcare providers. Prior to data collection, ethical approval was obtained from the Ghana Health Service (GHS) Ethics Review Committee (GHS-ERC: 039/11/22). Participants who had provided CAC services for at least 6 months were purposively sampled. In-depth interviews were conducted and audio-recorded with permission from participants. The interviews were transcribed verbatim and inductive thematic analysis was done using ATLAS. ti. Results were presented using quotes. Three main themes emerged, namely desire to minimize harm, attitudes and beliefs toward CAC provision for adolescents, and stigma and psychosocial impacts of providing CAC services. First, providers offered CAC to adolescents to reduce maternal morbidity and mortality, viewing their work as life-saving and a way to prevent less safe and least safe abortions and promote contraceptive use. Second, providers’ attitudes and beliefs were shaped by professional duty, personal discomfort, religious and moral dilemmas, and empathy for adolescents’ vulnerability. Third, stigma and psychosocial impacts influenced their experiences. Many faced judgments from colleagues and society, leading to emotional distress and, in some cases, psychological trauma. The experiences of healthcare providers in delivering CAC to adolescents in the New Juaben Municipality reflect a complex interplay of professional responsibilities/ obligations, national health policy requirements, personal and religious beliefs, and societal stigma. Addressing these challenges requires coordinated and targeted interventions. These include institutionalizing values clarification and attitude transformation (VCAT) training, integrating cultural competence into provider education, and ensuring legal and ethical accountability that emphasizes patient safety over personal beliefs. Structured mentorship and peer support programs are also essential to reduce emotional burden and sustain provider motivation. Expanding task sharing to include other trained cadres can enhance service continuity and retention. Finally, strengthening public education on safe abortion care is critical to destigmatizing CAC and fostering an environment where providers can deliver adolescent-centered care effectively.