Impact of COVID-19 pandemic on food availability and affordability: an interrupted time series analysis in Ghana.

BACKGROUND: In Africa, approx. 675 million people were at risk of food insecurity. COVID-19 pandemic is likely to have exacerbated this situation, by damaging populations' access to and affordability of foods. This study is aimed at estimating the impacts of the COVID-19 pandemic on availability and prices of essential food commodities at 20 large markets in Ghana. METHODS: Data on food availability and food retail prices collected through weekly market-level data during the period from July 2017 to September 2020 were used in this study. We performed interrupted time-series analyses and estimated the percentage increases between the observed and predicted food prices by food group and by region to assess the impact of COVID-19 pandemic on food prices. RESULTS: As a result, the impact of COVID-19 on food availability was limited. However, the results of interrupted time-series analyses indicate a significant increase in overall mean food prices in Greater Accra, Eastern and Upper East regions. It was also found that mean price of starchy roots, tubers and plantains significantly increased across regions. DISCUSSION: The impact of COVID-19 pandemic on food availability and prices was significant but varied by food type and regions in Ghana. Continuous monitoring and responses are critical to maintain food availability and affordability.

Understanding challenges related to menstrual hygiene management: Knowledge and practices among the adolescent girls in urban slums of Jaipur, India.

Objective: This study aimed to determine the factors associated with knowledge and practices related to menstrual hygiene management among adolescent girls in urban slums in Jaipur, India. Material and Methods: A cross-sectional study among 417 adolescent girls was conducted. Descriptive statistics, Chi-square, and bivariate and multivariate logistic regression methods were used to analyze the data and determine the associated factors. Findings: Only 48.7% of girls had a correct understanding of menstruation. In addition, 55.1% of the menstruating girls had faced health problems related to mensuration in the last 6 months; however, only 47.6% visited a health facility for treatment. Educational status of the girl (AOR = 1.89, 95% CI = 0.88-4.06), mother's education (AOR = 2.19, 95% CI = 1.30-3.67) and income (AOR = 1.89, 95% CI = 0.67-3.95), father's income (AOR = 1.42, 95% CI = 0.76-2.95), and counseling by field health workers (AOR = 2.08, 95% CI = 1.23-3.51) were found to be associated with knowledge about menstruation. Girl's education (AOR = 1.49, 95% CI = 0.74-2.95), mother's education (AOR = 1.46, 95% CI = 0.7-2.84) and income (AOR = 1.314, 95% CI = 0.44-2.02), father's education (AOR = 1.64, 95% CI = 0.55-3.08) and income (AOR = 2.0, 95% CI = 0.86-3.28), and counseling by field health workers (AOR = 1.48, 95% CI = 0.76-2.64) were found to be associated with the type of absorbents used. Conclusion: The findings from the study show that the awareness about mensuration and utilization of health services among adolescent girls is low. There is a need to create an enabling environment for girls to access knowledge and health services related to menstruation by creating awareness at the community level, strengthening outreach by field health workers, and ensuring privacy in healthcare facilities.

How using light touch immersion research revealed important insights into the lack of progress in malaria elimination in Eastern Indonesia.

BACKGROUND: By 2022, the Government of Indonesia had successfully eliminated malaria in 389 out of 514 districts but continues to face a challenge in Eastern Indonesia where 95% of the total 2021 malaria cases were reported from Papua, West Papua and Nusa Tenggara Timur provinces. There is an increased recognition that malaria elimination will require a better understanding of the human behavioural factors hindering malaria prevention and treatment, informed by local context and local practice. METHODS: This research used a light-touch immersion research approach. Field researchers lived in communities over several days to gather data through informal conversations, group-based discussions using visual tools, participant observation and direct experience. The study was conducted in four high malaria endemic areas in Papua, West Papua, and Sumba Islands in Nusa Tenggara Timur. RESULTS: The research highlights how people's perception of malaria has changed since the introduction of effective treatment which, in turn, has contributed to a casual attitude towards early testing and adherence to malaria treatment. It also confirms that people rarely accept there is a link between mosquitoes and malaria based on their experience but nevertheless take precautions against the annoyance of mosquitoes. There is widespread recognition that babies and small children, elderly and incomers are more likely to be seriously affected by malaria and separately, more troubled by mosquitoes than indigenous adult populations. This is primarily explained by acclimatization and strong immune systems among the latter. CONCLUSIONS: Using immersion research enabled behaviour research within a naturalistic setting, which in turn enabled experiential-led analysis of findings and revealed previously unrecognized insights into attitudes towards malaria in Eastern Indonesia. The research provides explanations of people's lack of motivation to consistently use bed nets, seek early diagnosis or complete courses of treatment. The felt concern for the wellbeing of vulnerable populations highlighted during light touch immersion provides an entry point for future social behaviour change communication interventions. Rather than trying to explain transmission to people who deny this connection, the research concludes that it may be better to focus separately on the two problems of malaria and mosquitoes (especially for vulnerable groups) thereby resonating with local people's own experience and felt concerns.

Strengthening polio vaccine demand in Ghana: Understanding the factors influencing uptake of the vaccine and the effectiveness of different message frames.

BACKGROUND: Ghana has experienced recent polio outbreaks. Behavioral insights can be used to understand behavior and create demand for the polio vaccine. METHODS: This cross-sectional study is based on an interactive mobile phone survey that explored factors influencing the uptake of the polio vaccine among Ghanaian mothers with children younger than five years old. The survey also explores the mothers' intention to vaccinate their children in the future as well as an experiment with short polio vaccine voice message nudges to identify the most effective message frames in encouraging vaccination. The study sample was drawn from volunteers from a mobile service platform. Linear probability model regressions with Ordinary Least Squares (OLS) estimates were used to analyze the data. RESULTS: In total, data from 708 caregivers was assessed. Out of the sample, 35% (n = 250) had not vaccinated their children against polio, around 8% (n = 53) of respondents stated they did not plan to do so, while 28% expressed intent to do so during the next polio vaccination campaign. Higher vaccination of children against polio, i.e. better uptake of the polio vaccine, appeared to be associated with children's caregivers knowing that polio causes paralysis (with a coefficient of 0.13 (95% CI: 0.02, 0.24), i.e. 13% more likely than not to have their child vaccinated). Higher vaccine uptake also appeared to be associated with the perception that the polio vaccine is safe (with a coefficient of 0.11 (95% CI: 0.01, 0.22), i.e. 11% more likely than not to have their child vaccinated). Another factor in increasing vaccine uptake is whether caregivers receive support from healthcare workers with a coefficient of 0.11 (95% CI: 0.02, 0.20), i.e. 11% more likely than not to have their child vaccinated. Crucially, difficulty accessing the polio vaccine appeared to be associate with a negative change in vaccine uptake (with a coefficient of -0.16 (95% CI: -0.23, -0.08), i.e. 16% less likely to have their child vaccinated). Satisfaction with the information provided by vaccinators was also associated with better vaccine uptake (with a coefficient of 0.12 (95% CI: 0.05, 0.20) i.e. 12% more likely than not to have their child vaccinated); and having seen or heard something negative about the polio vaccine with a coefficient of 0.10 (95% CI: 0.03, 0.17), i.e. 10% more likely than not to have their child vaccinated. The social norms message frame was statistically significant with a coefficient of 0.06 (95% CI: -0.004, 012). CONCLUSION: The findings from this study suggest that most women with children under the age of 5 appear to have vaccinated their children against polio. Many more caregivers express an intention to vaccinate their children, never having done so before. The behavior and the intention to vaccinate are both driven by a number of factors that must be addressed to create demand for the polio vaccine. Targeted message frames appeared to be statistically significant drivers of vaccine uptake. However, more research is required to understand how they impact vaccine behavior and future intention for vaccination.

Effects of the COVID-19 pandemic on essential health and nutrition service utilisations in Ghana: interrupted time-series analyses from 2016 to 2020.

OBJECTIVES: This study aimed to assess the national-level and subnational-level effects of the COVID-19 pandemic on essential health and nutrition service utilisation in Ghana. DESIGN: Interrupted time-series. SETTING AND PARTICIPANTS: This study used facility-level data of 7950 governmental and non-governmental health facilities in Ghana between January 2016 and November 2020. OUTCOME MEASURES: As the essential health and nutrition services, we selected antenatal care (ANC); institutional births, postnatal care (PNC); first and third pentavalent vaccination; measles vaccination; vitamin A supplementations (VAS); and general outpatient care. We performed segmented mixed effects linear models for each service with consideration for data clustering, seasonality and autocorrelation. Losses of patient visits for essential health and nutrition services due to the COVID-19 pandemic were estimated as outcome measures. RESULTS: In April 2020, as an immediate effect of the COVID-19 pandemic, the number of patients for all the services decreased except first pentavalent vaccine. While some services (ie, institutional birth, PNC, third pentavalent and measles vaccination) recovered by November 2020, ANC, VAS and outpatient services had not recovered to prepandemic levels. The total number of lost outpatient visits in Ghana was estimated to be 3 480 292 (95% CI: -3 510 820 to -3 449 676), followed by VAS (-180 419, 95% CI: -182 658 to -177 956) and ANC (-87 481, 95% CI: -93 644 to -81 063). The Greater Accra region was the most affected region by COVID-19, where four out of eight essential services were significantly disrupted. CONCLUSION: COVID-19 pandemic disrupted the majority of essential healthcare services in Ghana, three of which had not recovered to prepandemic levels by November 2020. Millions of outpatient visits and essential ANC visits were lost. Furthermore, the immediate and long-term impacts of the COVID-19 pandemic on service utilisation varied by service type and region.

Situational Analysis on the Impact of Perinatal Deaths Among Bereaved Families in Ghana.

Background: Annually, about 5.9 million perinatal deaths occur worldwide, leaving millions bereaved due to stillbirths or early neonatal deaths. The highest burden of stillbirths (97%) and newborn deaths (98%) occurs in lower- and middle-income countries, with the majority occurring in Sub-Saharan African countries. Method: This cross-sectional qualitative study was conducted to identify existing policies and protocols to support bereaved families, explore the needs of bereaved families, and to also assess the impact of perinatal death on families in Ghana. All in-depth interviews were audio-recorded, transcribed verbatim and analyzed thematically. The results were presented in narratives and supported with illustrative quotes from respondents. Results: In all, 42 in-depth interviews were conducted with 10 (23.8%) from the Northern belt (Upper East), 11 (26.2%) from the middle belt (Ashanti) and 21 (50.0%) from the Southern belt (Greater Accra). The study revealed that practicing health professionals and other stakeholders within the health service delivery chain were not aware of protocols, written guidelines or written documents to initiate counseling at the facility in the event of a mother losing a child. Most of the respondents did not know what to do in the event that a mother loses a baby during delivery or immediately after. Respondents were in favor of having a policy or guidelines which will help them to counsel families who go through perinatal bereavement. Respondents were of the view that it is important for families who experience perinatal grief to be supported. Conclusion: All staff who meet the pregnant mother during her pre-and-post-delivery stages should be trained on the use of guidelines or policies. There is the need to have a policy, train and equip health staff to ensure that families experiencing perinatal grief are provided with effective counseling. Ghana Health Service should consider training and recruiting professional counselors who will support the health staff in dealing with perinatal grief.

Understanding Factors Influencing Polio Vaccine Uptake in Ghana-Developing Meaningful Community Mobilization and Engagement Strategies in Collaboration with Religious Leaders.

This qualitative study explores how religious leaders in Ghana view polio and polio vaccine-related knowledge and perceptions of the community members. It also examines the personal characteristics of those who are most likely to accept or reject the vaccine. On the basis of the findings, this study provides a set of evidence-based recommendations to support religious leaders' efforts to create polio vaccine demand in their communities. The study is based on focus group discussions conducted with religious leaders from various geographic locations across Ghana. The discussions were transcribed verbatim and analyzed thematically. Twenty religious leaders, including Christian, Muslim, and leaders of traditional African religions, participated in the study. The findings show that both religious leaders and community members lack knowledge and have multiple culturally and religiously influenced explanations for polio. In addition, the findings reveal that vaccine safety and efficacy are linked to emotional narratives, and receiving the polio vaccine is not a social norm in all communities. Educated mothers in urban settings were identified as those most receptive to the polio vaccine. To create polio vaccine demand, religious leaders need to combat misinformation and the negative perceptions about the vaccine. Recommendations include conveying high-quality information to community members, developing tactics to address culturally and religiously sensitive matters, using emotionally inspired personal accounts to enhance positive attitudes toward polio vaccines and act as catalysts for positive social norms towards the polio vaccine. Educated mothers from urban areas can be engaged as champions in vaccine demand creation.

Institutionalising maternal and newborn quality-of-care standards in Bangladesh, Ghana and Tanzania: a quasi-experimental study.

INTRODUCTION: Facility interventions to improve quality of care around childbirth are known but need to be packaged, tested and institutionalised within health systems to impact on maternal and newborn outcomes. METHODS: We conducted cross-sectional assessments at baseline (2016) and after 18 months of provider-led implementation of UNICEF/WHO's Every Mother Every Newborn Quality Improvement (EMEN-QI) standards (preceding the WHO Standards for improving quality of maternal and newborn care in health facilities). 19 hospitals and health centres (2.8M catchment population) in Bangladesh, Ghana and Tanzania were involved and 24 from adjoining districts served for 'comparison'. We interviewed 43 facility managers and 818 providers, observed 1516 client-provider interactions, reviewed 12 020 records and exit-interviewed 1826 newly delivered women. We computed a 39-criteria institutionalisation score combining clinical, patient rights and cross-cutting domains from EMEN-QI and used routine/District Health Information System V.2 data to assess the impact on perinatal and maternal mortality. RESULTS: EMEN-QI standards institutionalisation score increased from 61% to 80% during EMEN-QI implementation, exceeding 75% target. All mortality indicators showed a downward trajectory though not all reached statistical significance. Newborn case-fatality rate fell significantly by 25% in Bangladesh (RR=0·75 (95% CI=0·59 to 0·96), p=0·017) and 85% in Tanzania (RR=0.15 (95% CI=0.08 to 0.29), p<0.001), but not in Ghana. Similarly, stillbirth (RR=0.64 (95% CI=0.45 to 0.92), p<0.01) and perinatal mortality in Tanzania reduced significantly (RR=0.59 (95% CI=0.40 to 0.87), p=0.007). Institutional maternal mortality ratios generally reduced but were only significant in Ghana: 362/100 000 to 207/100 000 livebirths (RR=0.57 (95% CI=0.33 to 0.99), p=0.046). Routine mortality data from comparison facilities were limited and scarce. Systematic death audits and clinical mentorship drove these achievements but challenges still remain around human resource management and equipment maintenance systems. CONCLUSION: Institutionalisation of the UNICEF/WHO EMEN-QI standards as a package is feasible within existing health systems and may reduce mortality around childbirth. Critical gaps around sustainability must be fundamental considerations for scale-up.

Nurses' and auxiliary nurse midwives' adherence to essential birth practices with peer coaching in Uttar Pradesh, India: a secondary analysis of the BetterBirth trial.

BACKGROUND: The BetterBirth trial tested the effect of a peer coaching program around the WHO Safe Childbirth Checklist for birth attendants in primary-level facilities in Uttar Pradesh, India on a composite measure of perinatal and maternal mortality and maternal morbidity. This study aimed to examine the adherence to essential birth practices between two different cadres of birth attendants-nurses and auxiliary nurse midwives (ANMs)-during and after a peer coaching intervention for the WHO Safe Childbirth Checklist. METHODS: This is a secondary analysis of birth attendant characteristics, coaching visits, and behavior uptake during the BetterBirth trial through birth attendant surveys, coach observations, and independent observations. Descriptive statistics were calculated overall, and by staffing cadre (staff nurses and ANMs) for demographic characteristics. Logistic regression using the Pearson overdispersion correction (to account for clustering by site) was used to assess differences between staff nurses and ANMs in the intervention group during regular coaching (2-month time point) and 4 months after the coaching program ended (12-month time point). RESULTS: Of the 570 birth attendants who responded to the survey in intervention and control arms, 474 were staff nurses (83.2%) and 96 were ANMs (16.8%). In the intervention arm, more staff nurses (240/260, 92.3%) received coaching at all pause points compared to ANMs (40/53, 75.5%). At baseline, adherence to practices was similar between ANMs and staff nurses (~ 30%). Overall percent adherence to essential birth practices among ANMs and nurses was highest at 2 months after intervention initiation, when frequent coaching visits occurred (68.1% and 64.1%, respectively, p = 0.76). Practice adherence tapered to 49.2% among ANMs and 56.1% among staff nurses at 12 months, which was 4 months after coaching had ended (p = 0.68). CONCLUSIONS: Overall, ANMs and nurses responded similarly to the coaching intervention with the greatest increase in percent adherence to essential birth practices after 2 months of coaching and subsequent decrease in adherence 4 months after coaching ended. While coaching is an effective strategy to support some aspects of birth attendant competency, the structure, content, and frequency of coaching may need to be customized according to the birth attendant training and competency. TRIAL REGISTRATION: ClinicalTrials.gov: NCT2148952; Universal Trial Number: U1111-1131-5647.

'Know-Can' gap: gap between knowledge and skills related to childhood diarrhoea and pneumonia among frontline workers in rural Uttar Pradesh, India.

OBJECTIVES: In India, frontline workers (FLWs) - public accredited social health activists (ASHAs) and private rural medical providers (RMPs) - are important for early detection and treatment of childhood diarrhoea and pneumonia. This cross-sectional study aims to measure knowledge and skills, and the gap between the two ('know-can' gap), regarding assessment of childhood diarrhoea with dehydration and pneumonia among FLWs, and to explore factors associated with them. METHODS: We surveyed 473 ASHAs and 447 RMPs in six districts of Uttar Pradesh. We assessed knowledge and skills using face-to-face interviews and video vignettes, respectively, about key signs of both conditions. The 'know-can' gap corresponds to absent skills among FLWs with correct knowledge. We used logistic regression to identify the correlates of knowledge and skills. RESULTS: FLWs' correct knowledge ranged from 23% to 48% for dehydration signs and 27% to 37% for pneumonia signs. Their skills ranged from 3% to 42% for dehydration and 3% to 18% for pneumonia. There was a significant 'know-can' gap in all the signs, except 'sunken eyes'. Training and supervisory support was associated with better knowledge and skills for diarrhoea with dehydration, but only better knowledge for pneumonia. CONCLUSIONS: FLWs are crucial to the Indian health system, and high-quality FLW services are necessary for continued progress against under-five deaths. The gap between FLWs' knowledge and skills warrants immediate attention. In particular, our results suggest that knowledge-focused trainings are insufficient for FLWs to convert knowledge into appropriate assessment skills.

OBJECTIFS: En Inde, les travailleurs de première ligne (TPL) - activistes de la santé sociale accrédités par le public (ASSAP) et prestataires médicaux ruraux privés (PMRP) - sont importants pour la détection et le traitement précoces de la diarrhée et de la pneumonie infantiles. Cette étude transversale vise à mesurer les connaissances et les compétences, et l'écart entre les deux (écart ''savoir-pouvoir''), en ce qui concerne l'évaluation de la diarrhée infantile avec déshydratation et la pneumonie chez les TPL et à explorer les facteurs qui leur sont associés. MÉTHODES: Nous avons mené une enquête sur 473 ASSAP et 447 PMRP dans six districts de l'Uttar Pradesh. Nous avons évalué les connaissances et les compétences à l'aide d'entretiens de face à face et de vignettes vidéo, respectivement, sur les signes clés des deux conditions. L'écart «savoir-pouvoir¼ correspond à des compétences absentes parmi les TPL ayant des connaissances correctes. Nous avons utilisé la régression logistique pour identifier les corrélats des connaissances et des compétences. RÉSULTATS: Les connaissances correctes des TPL variaient de 23% à 48% pour les signes de déshydratation, 27% à 37% pour les signes de pneumonie. Leurs compétences variaient de 3% à 42% pour la déshydratation et de 3% à 18% pour la pneumonie. Il y avait un écart important dans le «savoir-pouvoir¼ pour tous les signes, à l'exception des «yeux enfoncés¼. La formation et le soutien à la supervision étaient associés à de meilleures connaissances et compétences pour la diarrhée avec déshydratation, mais seulement à de meilleures connaissances pour la pneumonie. CONCLUSIONS: Les TPL sont cruciaux pour le système de santé indien, et des services de TPL de haute qualité sont nécessaires pour continuer à lutter contre les décès d'enfants de moins de cinq ans. L'écart entre les connaissances et les compétences des TPL mérite une attention immédiate. En particulier, nos résultats suggèrent que les formations axées sur les connaissances sont insuffisantes pour que les TPL convertissent les connaissances en compétences d'évaluation appropriées.

Categorizing and assessing comprehensive drivers of provider behavior for optimizing quality of health care.

Inadequate quality of care in healthcare facilities is one of the primary causes of patient mortality in low- and middle-income countries, and understanding the behavior of healthcare providers is key to addressing it. Much of the existing research concentrates on improving resource-focused issues, such as staffing or training, but these interventions do not fully close the gaps in quality of care. By contrast, there is a lack of knowledge regarding the full contextual and internal drivers-such as social norms, beliefs, and emotions-that influence the clinical behaviors of healthcare providers. We aimed to provide two conceptual frameworks to identify such drivers, and investigate them in a facility setting where inadequate quality of care is pronounced. Using immersion interviews and a novel decision-making game incorporating concepts from behavioral science, we systematically and qualitatively identified an extensive set of contextual and internal behavioral drivers in staff nurses working in reproductive, maternal, newborn, and child health (RMNCH) in government public health facilities in Uttar Pradesh, India. We found that the nurses operate in an environment of stress, blame, and lack of control, which appears to influence their perception of their role as often significantly different from the RMNCH program's perspective. That context influences their perceptions of risk for themselves and for their patients, as well as self-efficacy beliefs, which could lead to avoidance of responsibility, or incorrect care. A limitation of the study is its use of only qualitative methods, which provide depth, rather than prevalence estimates of findings. This exploratory study identified previously under-researched contextual and internal drivers influencing the care-related behavior of staff nurses in public facilities in Uttar Pradesh. We recommend four types of interventions to close the gap between actual and target behaviors: structural improvements, systemic changes, community-level shifts, and interventions within healthcare facilities.

Discordance in self-report and observation data on mistreatment of women by providers during childbirth in Uttar Pradesh, India.

BACKGROUND: The study aims to assess the discordance between self-reported and observed measures of mistreatment of women during childbirth in public health facilities in Uttar Pradesh, India, as well as correlates of these measures and their discordance. METHODS: Cross sectional data were collected through direct observation of deliveries and follow-up interviews with women (n = 875) delivering in 81 public health facilities in Uttar Pradesh. Participants were surveyed on demographics, mistreatment during childbirth, and maternal and newborn complications. Provider characteristics (training, age) were obtained through interviews with providers, and observation data were obtained from checklists completed by trained nurse investigators to document quality of care at delivery. Mistreatment was assessed via self-report and observed measures which included 17 and 6 items respectively. Cohen's kappas assessed concordance between the 6 items common in the self-report and observed measures. Regression models assessed associations between characteristics of women and providers for each outcome. RESULTS: Most participants (77.3%) self-reported mistreatment in at least 1 of the 17-item measure. For the 6 items included in both self-report and observations, 9.1% of women self-reported mistreatment, whereas observers reported 22.4% of women being mistreated. Cohen's kappas indicated mostly fair to moderate concordance. Regression analyses found that multiparous birth (AOR = 1.50, 95% CI = 1.06-2.13), post-partum maternal complications (AOR = 2.0, 95% CI = 1.34-3.06); new-born complications (AOR = 2.6, 95% CI = 1. 96-4.03) and not having an Skilled Birth Attendant (SBA) trained provider (AOR = 1.47, 95% CI = 1.05-2.04) were associated with increased risk for mistreatment as measured by self-report. In contrast, only provider characteristics like older provider (AOR = 1.03, 95% CI = 1.02-1.05) and provider not trained in SBA (AOR = 1.44, 95% CI = 1.02-2.02) were associated with mistreatment as measured through observations. Younger age at marriage (AOR = 0.86, 95% CI = 0.78-0.95) and provider characteristics (older provider AOR = 1.05, 95% CI = 1.01-1.09; provider not trained in SBA AOR = 0.96, 95% CI = 0.92-0.99) were associated with discordance (based on mistreatment reported by observer but not by women). CONCLUSION: Provider mistreatment during childbirth is prevalent in Uttar Pradesh and may be under-reported by women, particularly when they are younger or when providers are older or less trained. The findings warrant programmatic action as well as more research to better understand the context and drivers of both behavior and reporting. TRIAL REGISTRATION: CTRI/2015/09/006219. Registered 28 September 2015.

Associations Between Mistreatment by a Provider during Childbirth and Maternal Health Complications in Uttar Pradesh, India.

Objectives This study assesses associations between mistreatment by a provider during childbirth and maternal complications in Uttar Pradesh, India. Methods Cross-sectional survey data were collected from women (N = 2639) who had delivered at 68 public health facilities in Uttar Pradesh, participating in a quality of care study. Participants were recruited from April to July 2015 and surveyed on demographics, mistreatment during childbirth (measure developed for this study, Cronbach's alpha = 0.70), and maternal health complications. Regression models assessed associations between mistreatment during childbirth and maternal complications, at delivery and postpartum, adjusting for demographics and pregnancy complications. Results Participants were aged 17-48 years, and 30.3% were scheduled caste/scheduled tribe. One in five (20.9%) reported mistreatment by their provider during childbirth, including discrimination and abuse; complications during delivery (e.g., obstructed labor) and postpartum (e.g., excessive bleeding) were reported by 45.8 and 41.5% of women, respectively. Health providers at delivery included staff nurses (81.8%), midwives (14.0%), and physicians (2.2%); Chi square analyses indicate that women were significantly more likely to report mistreatment when their provider was a nurse rather than a physician or midwife. Women reporting mistreatment by a provider during childbirth had higher odds of complications at delivery (AOR = 1.32; 95% CI 1.05-1.67) and postpartum (AOR = 2.12; 95% CI 1.67-2.68). Conclusions for Practice Mistreatment of women by their provider during childbirth is a pervasive health and human rights violation, and is associated with increased risk for maternal health complications in Uttar Pradesh. Efforts to improve quality of maternal care should include greater training and monitoring of providers to ensure respectful treatment of patients.