Medical Education Commons^™

Understanding The Mental Health Impact And Needs Of Public Healthcare Professionals During Covid-19 In Pakistan : A Qualitative Study, Waqas Hameed, Anam Shahil Feroz, Bilal Iqbal Avan, Bushra Khan, Zafar Fatmi, Noreen Afzal, Hussain Jafri, Mansoor Ali Wassan, Sameen Siddiqi

Community Health Sciences

Objectives: A dearth of qualitative studies constrains in-depth understanding of health service providers' perspectives and experiences regarding the impact of COVID-19 on their mental health. This study explored the mental health impact and needs of of public sector healthcare workers during COVID-19 who working in secondary-level and tertiary-level healthcare settings of Pakistan.
Design: An exploratory qualitative study.
Setting: Twenty-five secondary-level and eight tertiary-level public hospitals of Sindh and Punjab provinces of Pakistan.
Participants: In-depth interviews were conducted with 16 health service providers and 40 administrative personnel. Study data were analysed on NVivo V.11 using the conventional content analysis technique.
Results: …

Impact Of A Multifaceted Intervention On Physicians' Knowledge, Attitudes And Practices In Relation To Pharmaceutical Incentivisation: Protocol For A Randomised Control Trial, Muhammad Naveed Noor, Mishal Khan, Afifah Rahman-Shepherd, Amna Rehana Siddiqui, Sabeen Sharif Khan, Iqbal Azam, Sadia Shakoor, Rumina Hasan

Department of Pathology and Laboratory Medicine

Introduction: In settings where the private sector constitutes a larger part of the health system, profit-gathering can take primacy over patients' well-being. In their interactions with pharmaceutical companies, private general practitioners (GPs) can experience the conflict of interest (COI), a situation whereby the impartiality of GPs' professional decision making may be influenced by secondary interests such as financial gains from prescribing specific pharmaceutical brands.
Methods and analysis: This study is a randomised controlled trial to assess the impact of a multifaceted intervention on GPs' medical practice. The study sample consists of 419 registered GPs who own/work in private clinics and …

Reflection Of Mentors And Mentees At Initiation Of Faculty Mentorship Program At Aga Khan University: A Perspective, Rehana Rehman, Fauzia Khan, Naila Kayani, Tazeen Saeed Ali

Department of Biological & Biomedical Sciences

Objectives: To explore perception of mentors and mentees about 'Mentorship Program at Aga Khan University Medical College (AKU-MC) from a structured feedback form.
Methods: A retrospective study was conducted for evaluation of mentorship program at AKU-MC during the period from Jan 2019 to March, 2021. Responses on validated "Pre-intervention Probe Forms", from forty-seven mentors and fourteen mentees inducted in the program were reviewed. Confidentiality and anonymity of data were deliberated. All replies to each question were entered in a separate worksheet to determine the frequency and percentage of answers. Responses conveying same message, but worded differently were then grouped.
Results: …

Medical Students In Karachi And Covid-19: Myths And Facts, Omer Bin Khalid Jamil, Muhammad Muhib, Muhammad Anas Abbal, Amna Muhammed Ahmed, Hafsa Hayat Khan, Nabeela Yar Khan

Department of Surgery Docs

Objectives: COVID-19 pandemic brought mortalities, morbidities, fear, and financial despair among people around the world. As it advanced, misinformation and myths about it caught wildfire, contributing to misbelief among the already shocked population. Medical students are the building blocks of the medical community and can provide a pivotal role in combating COVID-19 misinformation by delivering correct knowledge and awareness to the non-medical population of the country. Hence, it is important to assess their knowledge and perception of COVID-19 myths. Therefore, this study evaluates medical student's knowledge regarding myths and misinformation related to COVID-19 infection and its vaccine. The study also …

Facilitators And Barriers Of Reflective Learning In Postgraduate Medical Education: A Narrative Review, Catherine Gathu

Family Medicine, East Africa

Background: Reflection in postgraduate medical education has been found to aid in the development of professional skills, improve clinical expertise, and problem solving with the aim of advancing lifelong learning skills and self-awareness, leading to good medical practice among postgraduate residents. Despite the evidenced benefits, reflection remains underused as a tool for teaching and learning, and few trainee physicians regularly engage in the process. Factors that affect the uptake of reflective learning in residency training have not yet been adequately explored.

Objective: The purpose of this review is to demonstrate the factors that influence the adoption of reflective …

Heterotopic Gestation In Polycystic Ovary Disease: Termination Of Tubal Pregnancy And Intrauterine Pregnancy Progressing To Term, Munawar Kaguta, Ahmed Jusabani, Ntiyakuze Gregory, Shweta Jaiswal, Zainab Fidaali, Pilly Ally, Davis Rubagumya, Miriam Mgonja, Farhat Seif

Faculty of Health Sciences, East Africa

Heterotopic pregnancy is rare. We report a 27-year-old lady with polycystic ovarian disease. She presented at our health facility with acute abdomen. Her evaluation revealed heterotopic pregnancy. High index of suspicion for heterotopic pregnancy in any woman with early pregnancy presenting with acute abdomen is crucial. Therefore, correct and early diagnosis allows appropriate management while it preserves the intrauterine pregnancy as in the index case.

Scaling Up Context-Tailored Clinical Guidelines And Training To Improve Childbirth Care In Urban, Low-Resource Maternity Units In Tanzania: A Protocol For A Stepped-Wedged Cluster Randomized Trial With Embedded Qualitative And Economic Analyses (The Partoma Scale-Up Study), Nanna Maaløe, Natasha Housseine, Jane Brandt Sørensen, Josephine Obel, Brenda Sequeira Dmello, Monica Lauridsen Kujabi, Haika Osaki, Thomas Wiswa John, Rashid Saleh Khamis, Zainab Suleiman Said Muniro, Daniel Joseph Nkungu, Britt Pinkowski Tersbøl, Flemming Konradsen, Sangeeta Mookherji, Columba Mbekenga, Tarek Meguid, Jos Van Roosmalen, Ib Christian Bygbjerg, Thomas Van Den Akker, Andreas Kryger Jensen, Morten Skovdal, Hussein Kidanto, Dan Wolf Meyrowitsch

Faculty of Health Sciences, East Africa

While facility births are increasing in many low-resource settings, quality of care often does not follow suit; maternal and perinatal mortality and morbidity remain unacceptably high. Therefore, realistic, context-tailored clinical support is crucially needed to assist birth attendants in resource-constrained realities to provide best possible evidence-based and respectful care. Our pilot study in Zanzibar suggested that co-created clinical practice guidelines (CPGs) and low-dose, high-frequency training (PartoMa intervention) were associated with improved childbirth care and survival. We now aim to modify, implement, and evaluate this multi-faceted intervention in five high-volume, urban maternity units in Dar es Salaam, Tanzania (approximately 60,000 births …

Healthcare Simulation: A Key To The Future Of Medical Education - A Review, Omair Ayaz, Faisal Wasim Ismail

Medical College Documents

Aim: Simulation originates from its application in the military and aviation. It is implemented at various levels of healthcare education and certification today. However, its use remains unevenly distributed across the globe due to misconception regarding its cost and complexity and to lack of evidence for its consistency and validity. Implementation may also be hindered by an array of factors unique to the locale and its norms. Resource-poor settings may benefit from diverting external funds for short-term simulation projects towards collaboration with local experts and local material sourcing to reduce the overall cost and achieve long-term benefits. The recent shift …

Tuberculous Meningitis Presenting With Stroke In An Immunocompetent Adolescent: A Case Report, Rukhsar S. Osman, Rahim Damji, Zainab Y. Fidaali, Nahida Walli, Mariam Noorani

Faculty of Health Sciences, East Africa

Background:

Tuberculous meningitis (TBM) is a severe infection of the central nervous system that has high mortality. The disease predominantly affects young children and those who are immuncompromised. Strokes have been reported in about one-third of children with tuberculous meningitis and are associated with poor clinical outcomes.

Case report:

A previously healthy 14-year-old girl living in Dar es Salam, Tanzania presented with one month history of weight loss associated with weakness, loss of appetite, apathy; without respiratory symptoms. Anti-TB therapy was started, based on radiological findings of the chest which showed multiple patchy centrilobular nodules with linear branching pattern bilaterally, …

A Case Report Of Minimally Invasive Percutaneous Ultrasound Guided Tuberculous Iliopsoas Abscess Drainage In An Immunocompromised Patient, Allyzain Ismail, Neelam Ismail, Authar Ali, Shabbir Adamjee, Ahmed Jusabani, Zainab Fidaali

Faculty of Health Sciences, East Africa

Introduction and importance

Iliopsoas abscess is a collection of pus that presents with nonspecific features with often delays in diagnosis however cause significant morbidity and mortality with Mycobacterium tuberculosis to be considered as causative agent in at risk individuals in tuberculous endemic regions. Management involves drainage and initiation of adequate antibiotics with radiological guided percutaneous approach considered the appropriate initial approach.

Case presentation

50-year-old immunosuppressed presenting with left iliopsoas abscess who underwent ultrasound guided drainage and placement of pigtail catheter successfully without the need for open surgical drainage. Our experience of interventional radiology for diagnosis of causative agent and treatment …

In A Digitally Connected World Through Likes, Hashtags And Followers - Advancing Surgical Research Through A Social Media: A Narrative Review, Sabah Uddin Saqib, Qamar` Riaz, Russell Seth Martins, Amna Riaz, Hasnain Zafar

Department for Educational Development

In this era of modern information technology, the world is now digitally connected through various platforms on social media, which has changed the way medical professionals work, communicate and learn. The use of social media in surgery is expanding, and it is now becoming an essential tool for surgical training, research and networking. Articles, journal clubs and surgical conferences are within reach of everyone regardless of geographical location worldwide. Electronic publications have now resoundingly replaced printed editions of journals. Collaborative research through social media platforms helps collect diverse data, enhancing the research's global generalisability. The current narrative review was planned …

Otorhinolaryngology Consultations In A Multidisciplinary Hospital - Their Effects On Residents Training On Floor, Ambreen Abdullah Unar, Muhammad Hammad Deewani, Mohammad Sohail Awan, Syeda Amrah Hashmi, Abdul Basit Shah Vardag, Ainulakbar Mughal

Section of Otolaryngology, Head & Neck Surgery

Objective: To determine all types and severity of Otolaryngology consultation requests at our tertiary care center and spectral records of problems related to otorhinolaryngology come across initially by residents which will help in re-shaping residency programmes and enhance patient related care.
Methodology: All otorhinolaryngology consultation received over a three-month period were recorded prospectively. Information collected for each encounter included the time, date, reason for consult at primary service and admission with final ENT diagnosis, any surgical or non-surgical intervention, and basic patient demographics.
Results: A total of 127 consults for inpatients were reviewed from April 2020 to June 2020. Out …

Conceptual Framework For A Cardiac Surgery Simulation Laboratory And Competency-Based Curriculum In Pakistan - A Short Innovation Report, Ali Aahil Noorali, Asma A H. Merchant, Sardar Shahmir Babar Chauhan, Mustafa Ali Khan, Anam Noor Ehsan, Mohammad Bin Pervez, Muhammad Tariq, Saulat Fatimi

Medical College Documents

Simulation is a commonly utilized technique in healthcare education as it provides trainees a realistic, but safe, environment to learn a variety of skills. Trainees belonging to fields known for high stakes with low margins for error, such as cardiac surgery, can greatly benefit from simulation-based education. We propose the establishment of the first multi-tier high fidelity cardiac surgery simulation lab with a structured curriculum that will eventually provide multidisciplinary training to promising cardiac surgeons across Pakistan. The simulation lab may also be used for research, grant acquisition and patent development. Our setup will include the following levels of simulation: …

Path To Publication: A Peer Mentorship Model For Student-Lead Surgical Research, Usama Waqar, Hareem Rauf, Muskaan Abdul Qadir, Hina Inam

Medical College Documents

Early and sustained involvement in research is imperative for medical students to ensure better career prospects in addition to provision of high-quality, evidence-based care to patients. However, involvement of students in surgical research still remains limited, owing to inadequate research training. The current paper was planned to describe the structure of the "Path to Publication" series, incorporating peer mentorship with capacity-building research workshops for medical students. A total of 25 students were grouped into 8 surgical subspecialty groups to conduct research, supervised by experienced student research and faculty mentors. In addition, a series of research workshops were organized in synchronization …

Perioperative Registries In Resource-Limited Settings: The Way Forward For Pakistan, Usama Waqar, Shaheer Ahmed, Ayesha Nasir Hameed, Namrah Aziz, Hina Inam

Medical College Documents

Capable of improving surgical quality, perioperative registries can allow performance benchmarking, reliable reporting and the development of risk-prediction models. Well established in high-income countries, perioperative registries remain limited in lower- and middle-income countries due to several challenges. First, ensuring comprehensive data entry forums to power the registries is difficult because of limited electronic medical records requiring sustained efforts to develop and integrate these into practice. Second, lack of adequate expertise and resources to develop and maintain registry software necessitates the involvement of software developers and information technology personnel. Third, case ascertainment and item completion are challenging secondary to poor-quality medical …

Delivery Room St Segment Analysis To Predict Short Term Outcomes In Near-Term And Term Newborns, Jørgen Linde, Anne Lee Solevåg, Joar Eilevstjønn, Ladislaus Blacy, Hussein Kidanto, Hege Ersdal, Claus Klingenberg

Faculty of Health Sciences, East Africa

Background:

ST-segment changes to the fetal electrocardiogram (ECG) may indicate fetal acidosis. No large-scale characterization of ECG morphology immediately after birth has been performed, but ECG is used for heart rate (HR) assessment. We aimed to investigate ECG morphology immediately after birth in asphyxiated infants, using one-lead dry-electrode ECG developed for HR measurement.

Methods:

Observational study in Tanzania, between 2013–2018. Near-term and term infants that received bag-mask ventilation (BMV), and healthy controls, were monitored with one-lead dry-electrode ECG with a non-diagnostic bandwidth. ECGs were classified as normal, with ST-elevations or other ST-segment abnormalities including a biphasic ST-segment. We analyzed ECG …

Role Of Micrornas In Non-Functioning Pituitary Adenoma, Mehak Ismail Rajani, Yumna Mirza, Rohan Advani, Syed Muhammad Adnan Ali, Ather Enam

Centre for Innovation in Medical Education

Non-functioning pituitary adenomas account for 30% of anterior pituitary tumours. Based on their inability to secrete hormones, these are often diagnosed incidentally or due to pressure symptoms. Understanding the pathogenesis of these adenomas can provide insight into factors leading to its progression and serving as biomarkers for early recognition. A literature search was performed in the current narrative review for articles published in PubMed for the last 10 years till January 2020 on micro-ribonucleic acid involved in the pathogenesis of non-functioning pituitary adenomas. Of the 478 articles found, 21(4.4%) were filtered. In total, 106 micro-ribonucleic acids were identified, 25(23.5%) of …

Evaluation Of Venous Thromboembolism (Vte) Risk Assessment And Thrombo-Prophylaxis Practices In Hospitalized Medical And Surgical Patients At Aga Khan Hospital Dar Es Salaam: Single-Centre Retrospective Study, Allyzain Ismail, Nikhil Jadawji, Philip Adebayo, Ahmed Jusabani, Kamran Hamid, Ali Akbar Zehri, Willy Kiviri, Authar Ali

General Surgery, East Africa

Introduction: venous thromboembolism is a complication among admitted medical and surgical patients. International guidelines recommend patients are assessed upon admission and appropriate thromboprophylaxis should be initiated. However, studies have shown that thromboprophylaxis for patients at risk of venous thromboembolism is underutilized.

Methods: this was a retrospective study conducted on hospitalized medical and surgical patients at Aga Khan Hospital Dar es salaam from January to June 2019. Patient’s medical records were reviewed and data was collected for analysis of venous thromboembolism assessment and compliance with Caprini risk assessment model. The data was entered into statistical package for the social …

Effectiveness Of Simulation-Based Clinical Skills Training For Medical Students In Respiratory Medicine: A Pilot Study, Russell S. Martins, Saniya Sabzwari, Meesha Iqbal

Medical College Documents

Objective: To assess the effectiveness of high-fidelity simulation-based medical education (HF-SBME) in teaching and learning respiratory clinical examination in medical students.
Study design: Quasi-experimental pilot study.
Place and duration of study: The Aga Khan University, Karachi, from November 2018 to January 2020. Methodology: This study was conducted amongst third year medical students at the University. Students were assigned to intervention (IG) or control groups (CG). The IG underwent training for the respiratory clinical examination on a high-fidelity simulator mannequin, while the CG received the conventional practice session on standardised patients. Students were assessed on their respiratory clinical examination skills in …

Improving Maternal And Child Health In Pakistan: A Programme Evaluation Using A Difference In Difference Analysis, Muhammad Ashar Malik, Lara Riedige Rohm, Pieter Van Baal, Eddy Van Doorslaer Van Doorslaer

Community Health Sciences

Introduction: Pakistan is a country with high maternal and infant mortality. Several large foreign funded projects were targeted at improving maternal, neonatal and child health. The Norway-Pakistan Partnership Initiative (NPPI) was one of these projects. This study aims to evaluate whether NPPI was successful in improving access and use of skilled maternal healthcare.
Methods: We used data from three rounds (2009-2010, 2011-2012 and 2013-2014) of the Pakistan Social and Living Standards Measurement Survey (PSLM). A difference-in-difference regression framework was used to estimate the effectiveness of NPPI and its different programme components with respect to maternal healthcare seeking behaviour of pregnant …

Low-Cost Peer-Taught Virtual Research Workshops For Medical Students In Pakistan: A Creative, Scalable, And Sustainable Solution For Student Research, Ronika Devi Ukrani, Ayesha Niaz Shaikh, Russell S. Martins, Syeda Sadia Fatima, Hamna Amir Naseem, Mishall Ahmed Baig

Medical College Documents

Background: Pakistan has not been a major contributor to medical research, mainly because of the lack of learning opportunities to medical students. With the increase in online learning systems during COVID-19, research related skills can be taught to medical students via low-cost peer taught virtual research workshops.
Aim of the study: To assess the effectiveness of a comprehensive low-cost peer-taught virtual research workshops amongst medical students in Pakistan.
Methods: This quasi-experimental study assessed the effectiveness of five virtual research workshops (RWs) in improving core research skills. RWs for medical students from across Pakistan were conducted over Zoom by medical students …

Plagiarism In Non-Anglophone Countries: A Cross-Sectional Survey Of Researchers And Journal Editors, Latika Gupta, Javeria Tariq, Marlen Yessirkepov, Olena Zimba, Durga Prasanna Misra, Vikas Agarwal, Armen Yuri Gasparyan

Medical College Documents

Background: Plagiarism is one of the most common violation of publication ethics, and it still remains an area with several misconceptions and uncertainties.
Methods: This online cross-sectional survey was conducted to analyze plagiarism perceptions among researchers and journal editors, particularly from non-Anglophone countries.
Results: Among 211 respondents (mean age 40 years; M:F, 0.85:1), 26 were scholarly journal editors and 70 were reviewers with a large representation from India (50, 24%), Turkey (28, 13%), Kazakhstan (25, 12%) and Ukraine (24, 11%). Rigid and outdated pre- and post-graduate education was considered as the origin of plagiarism by 63% of respondents. Paraphragiarism was …

Self-Reported Knowledge, Attitudes, Practices And Barriers In Use Of Evidence-Based Medicine Among Resident Physicians In Kenya: A Mixed Methods Study, Megha Unadkat, Caroline K. Mbuba, Anthony Ngugi, Dorothy Kamya

Paediatrics and Child Health, East Africa

Background: Evidence based medicine (EBM) helps clinicians to integrate latest research evidence into their daily clinical practice. There is a need for all healthcare professions to adopt it in order to provide safe and most costefective care. Postgraduate doctors are at the frontline of healthcare delivery and all medical institutions should strive to produce practitioners of EBM. Studies have shown that physicians are still struggling to adapt to this paradigm shift in the practice of medicine but very few studies have been done in Sub Saharan Africa. This study explored the self-reported knowledge, attitudes, practices and barriers of evidence-based …

Cardiovascular Fellow-In-Training Feedback On Virtual And Simulator-Based Learning Experience During Covid-19 Pandemic In A Low To Middle Income Country - A Cross-Sectional Study, Pirbhat Shams, Intisar Ahmed, Hunaina Shahab, Zehra Kadani, Aisal Khan, Marvi Shams, Yawer Saeed, Syedah Saira Bokhari, Aamir Hameed Khan

Section of Cardiology

Background: COVID-19 pandemic has introduced us to a greater need of virtual learning platforms and has resulted in less clinical exposure for fellows-in-training. Virtual and simulator-based learning is not widely available in LMIC. It is imperative to analyze feedback of CV fellow-in-training regarding this mode of learning before large scale implementation.
Methodology: This was an observational study conducted between July-August 2020. A multicentered survey was conducted. Survey questionnaire was disseminated to FIT (fellow-in-training) via Google Forms. The questionnaire contained a total of 24 questions about virtual and simulator-based learning during the pandemic.
Results: A total of 68 FIT responded to …

Flipped Laboratory Sessions Using Video Vignette And Active Learning: A Hybrid Approach For Online Teaching, Sabah Farhat, Rehana Rehman, Syeda Sadia Fatima

Department of Biological & Biomedical Sciences

No abstract provided.

Student Research Mentorship Programme: A Novel Solution For Promoting Research In Medical School, Inaara Akbar, Russell S. Martins, Syeda Sadia Fatima

Medical College Documents

No abstract provided.

Sonogames: Sounds Of The Right Kind Introducing Gamification Into Radiology Training, Maria Fatima Ali, Naila Nadeem, Farah Khalid, Naveed Muhammad Anwar, Ghulam Nabie, Charles Docherty

Centre for Innovation in Medical Education

Background: Radiology as compared to other fields of medicine has lagged, in incorporating modern training modalities such as gamification and simulation into its teaching curriculum.
Objective: This study aims to evaluate effectiveness of simulation-based teaching in collaboration with gamification. Bandura's conception of self-efficacy was used to provide qualitative assessment of participants' learning process through training event. Modified competitive game-based teaching methodology was utilized in an experimental study conducted for radiology residents. Workshop was divided into two sessions, first being three interactive didactic lectures followed by three competitive rounds. All participants were required to fill pre and post-self-efficacy questionnaire along with …

Comparative Trends In Ischemic Heart Disease Admissions, Presentation And Outcomes Due To The Covid-19 Pandemic: First Insights From A Tertiary Medical Center In Pakistan, Ali Aahil Noorali, Humza Thobani, Shiraz Hashmi, Sara Iqbal, Asma A H. Merchant, Mian Arsam Haroon, Sardar Shahmir Babar Chauhan, Saad Mallick, Nida Zahid, Yasir Khan, Osman Faheem, Saulat Fatimi

Department of Medicine

Introduction: COVID-19 has manifested a striking disarray in healthcare access and provision, particularly amongst patients presenting with life-threatening ischemic heart disease (IHD). The paucity of data from low-middle income countries has limited our understanding of the consequential burden in the developing world. We aim to compare volumes, presentations, management strategies, and outcomes of IHD amongst patients presenting in the same calendar months before and during the COVID-19 pandemic.
Methods: We conducted a retrospective cross-sectional analysis at the Aga Khan University Hospital, one of the premier tertiary care centres in Pakistan. Data were collected on all adult patients (>18 years) …

Postoperative Subcutaneous Emphysema Following Percutaneous Nephrolithotomy: A Rare Complication, Hussam Uddin Soomro, Isaac Mawalla, Shabbir Adamjee, Nadeem Kassam, Authar Ali

Faculty of Health Sciences, East Africa

Percutaneous Nephrolithotomy (PCNL) is a common urological procedure performed for complicated upper urinary tract stones. The advantages of PCNL include lower morbidity and mortality rates and quicker recovery compared to traditional open surgery. A number of complications have been reported which can be life threatening. Here we present a case of 71 years old lady, who developed subcutaneous emphysema following PCNL.

Maternal Health Care Professionals’ Experiences And Views On The Use Of Obstetric Ultrasound In Rwanda: A Cross-Sectional Study, Ingrid Mogren, Joseph Ntaganira, Jean Paul Semasaka Sengoma, Sophia Holmlund, Rhonda Small, Lan Pham Thi, Hussein Lesio Kidanto, Matilda Ngarina, Cecilia Bergström, Kristina Edvardsson

Faculty of Health Sciences, East Africa

Background This study, undertaken in Rwanda, aimed to investigate health professionals’ experiences and views on the following topics: current clinical guidelines for ultrasound from second trimester at the clinic, regional and national levels, and adherence to clinical guidelines; medically indicated ultrasound examinations; non-medical use of ultrasound including ultrasounds on maternal request; commercialisation of ultrasound; the value of ultrasound in relation to other clinical examinations in pregnancy; and ultrasound and medicalisation of pregnancy.

Methods A cross-sectional design was adopted. Health professionals providing antenatal care and delivery services to pregnant women in 108 health facilities were invited to complete a survey, which …