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the depth of midwives' contribution in Afghanistan - from increased maternal health care service utilisation to changing community's perceptions of women's education and professional independence - is overwhelmingly positive. Lessons learned can serve as a model to other low resource, post-conflict settings that are striving to increase the workforce of skilled providers.

Approximately 15% of expected births worldwide will result in life-threatening complications during pregnancy, delivery, or the postpartum period. Providers skilled in emergency obstetric and newborn care (EmONC) services are essential, particularly in countries with a high burden of maternal and newborn mortality. Jhpiego and its consortia partners have implemented three global programs to build provider capacity to provide comprehensive EmONC services to women and newborns in these resource-poor settings. Providers have been educated to deliver high-impact maternal and newborn health interventions, such as prevention and treatment of postpartum hemorrhage and pre-eclampsia/eclampsia and management of birth asphyxia, within the broader context of quality health services. This article describes Jhpiego's programming efforts within the framework of the basic and expanded signal functions that serve as indicators of high-quality basic and emergency care services. Lessons learned include the importance of health facility strengthening, competency-based provider education, global leadership, and strong government ownership and coordination as essential precursors to scale-up of high impact evidence-based maternal and newborn interventions in low-resource settings.

BackgroundThis paper responds to the global call to action for respectful maternity care (RMC) by examining whether and how gender inequalities and unequal power dynamics in the health system undermine quality of care or obstruct women’s capacities to exercise their rights as both users and providers of maternity care.MethodsWe conducted a mapping review of peer-reviewed and gray literature to examine whether gender inequality is a determinant of mistreatment during childbirth. A search for peer-reviewed articles published between January 1995 and September 2017 in PubMed, Embase, SCOPUS, and Web of Science databases, supplemented by an appeal to experts in the field, yielded 127 unique articles. We reviewed these articles using a gender analysis framework that categorizes gender inequalities into four key domains: access to assets, beliefs and perceptions, practices and participation, and institutions, laws, and policies. A total of 37 articles referred to gender inequalities in the four domains and were included in the analysis.ResultsThe mapping indicates that there have been important advances in documenting mistreatment at the health facility, but less attention has been paid to addressing the associated structural gender inequalities. The limited evidence available shows that pregnant and laboring women lack information and financial assets, voice, and agency to exercise their rights to RMC. Women who defy traditional feminine stereotypes of chastity and serenity often experience mistreatment by providers as a result. At the same time, mistreatment of women inside and outside of the health facility is normalized and accepted, including by women themselves. As for health care providers, gender discrimination is manifested through degrading working conditions, lack of respect for their abilities, violence and harassment,, lack of mobility in the community, lack of voice within their work setting, and limited training opportunities and professionalization. All of these inequalities erode their ability to deliver high quality care.ConclusionWhile the evidence base is limited, the literature clearly shows that gender inequality—for both clients and providers—contributes to mistreatment and abuse in maternity care. Researchers, advocates, and practitioners need to further investigate and build upon lessons from the broader gender equality, violence prevention, and rights-based health movements to expand the agenda on mistreatment in childbirth and develop effective interventions.Electronic supplementary materialThe online version of this article (10.1186/s12978-018-0584-6) contains supplementary material, which is available to authorized users.

BackgroundResuscitation with bag and mask is a high-impact intervention that can reduce neonatal deaths in resource-poor countries. This study assessed the capacity to perform newborn resuscitation at facilities offering comprehensive emergency obstetric and newborn care (EmONC) in Afghanistan, as well as individual and facility characteristics associated with providers’ knowledge and clinical skills.MethodsAssessors interviewed 82 doctors and 142 midwives at 78 facilities on their knowledge of newborn resuscitation and observed them perform the procedure on an anatomical model. Supplies, equipment, and infrastructure were assessed at each facility. Descriptive statistics and simple and multivariate regression analyses were performed using STATA 11.2 and SAS 9.1.3.ResultsOver 90% of facilities had essential equipment for newborn resuscitation, including a mucus extractor, bag, and mask. More than 80% of providers had been trained on newborn resuscitation, but midwives were more likely than doctors to receive such training as part of pre-service education (59% and 35%, respectively, p < 0.001). No significant differences were found between doctors and midwives on knowledge, clinical skills, or confidence in performing newborn resuscitation. Doctors and midwives scored 71% and 66%, respectively, on knowledge questions and 66% and 71% on the skills assessment; 75% of doctors and 83% of midwives felt very confident in their ability to perform newborn resuscitation. Training was associated with greater knowledge (p < 0.001) and clinical skills (p < 0.05) in a multivariable model that adjusted for facility type, provider type, and years of experience offering EmONC services.ConclusionsLack of equipment and training do not pose major barriers to newborn resuscitation in Afghanistan, but providers’ knowledge and skills need strengthening in some areas. Midwives proved to be as capable as doctors of performing newborn resuscitation, which validates the major investment made in midwifery education. Competency-based pre-service and in-service training, complemented by supportive supervision, is an effective way to build providers’ capacity to perform newborn resuscitation. This kind of training could also help skilled birth attendants based in the community, at private clinics, or at primary care facilities save the lives of newborns.