Ghanaian women's experience of intimate partner violence (IPV) during group antenatal care: a brief report from a cluster randomised controlled trial.

Intimate partner violence (IPV) impacts women of reproductive age globally and can lead to significant negative consequences during pregnancy. This study describes an exploratory aim of a cluster randomised controlled trial designed to assess the outcomes of Group Antenatal Care (ANC) in Ghana. The purpose was to understand the effect of a healthy relationship Group ANC module on experiences of IPV and safety planning as well as to explore the relationship between self-efficacy on the experiences of IPV and safety planning. Data were collected at baseline and at 11-14 months postpartum (post). Survey measures captured reported experiences of violence, self-efficacy, and safety. The chi-square test was used to compare baseline and post scores, and a logistic regression was performed to ascertain the effects of self-efficacy on the experiences of IPV in both groups. The sample included 1,751 participants, of whom 27.9% reported IPV at baseline. Between baseline and postpartum, there was a small increase in reported emotional (6.2% vs. 4.6%) and sexual (5.4% vs. 3.2%) violence in the intervention group compared to the control group. Logistic regression demonstrated that an increasing self-efficacy score was associated with an increased likelihood of experiencing IPV. There were no changes in safety knowledge. This study found higher rates of reported sexual and emotional violence post-intervention among the intervention group. Group ANC may be just one part of a portfolio of interventions needed to address IPV at all socio-ecological levels.Paper ContextMain findings: There was no reduction in experiences of intimate partner violence or increases in safety planning among Ghanaian pregnant women participating in a Group Antenatal Care session focused on healthy relationships and safety planning.Added knowledge: Group Antenatal Care has been identified as an effective modality for providing antenatal care and facilitating conversations about sensitive topics such as intimate partner violence and safety. However, this study highlights the importance of developing multifaceted approaches to decrease the risk of intimate partner violence among women, especially during the critical times of pregnancy and postpartum.Global health impact for policy and action: Effective global health action and policy must extend beyond educational efforts, incorporating multifaceted strategies that include healthcare provider training, robust community engagement, and legislation aimed at preventing intimate partner violence, with a special focus on safeguarding the well-being of women during pregnancy and the postpartum period.

Pranks, Obscene Chatters, and Ambiguous Content: Exploring the Identification and Navigation of Inappropriate Messages to a Web-Based Sexual Assault Hotline.

Sexual assault crisis hotlines provide crucial support for survivors. Though some hotline users engage in inappropriate conduct (e.g. prank or obscene calls), few studies explore these interactions. To address the lack of literature exploring inappropriate hotline interactions, we conducted a secondary data analysis of chat transcripts (n = 233) shared with the research team as part of the formative evaluation of a university-based sexual assault program's web-based crisis hotline. From those transcripts, we analyzed potentially inappropriate interactions (n = 38), most of which (n = 28) hotline responders flagged as inappropriate in post-chat log forms. We used codebook thematic analysis to explore how hotline responders identified and navigated these interactions. Our analysis generated three themes describing the processes through which responders seemed to identify potentially inappropriate chats - detecting implausibly graphic and abusive content, identifying patterns of presumably inauthentic chat topics, and interpreting ambiguous content. Hotline responders seemed to navigate ambiguous and less egregious boundary violations by gently redirecting conversations, and addressed clearer violations by setting firm, direct boundaries. Chatters responded to boundary setting by desisting and disconnecting or attempting to reengage responders. Findings highlight ambiguities and challenges web-based sexual assault hotline responders face and suggest a need for additional responder support, training, and debriefing options.

University Sexual and Gender-Based Violence Policies in Sub-Saharan Africa: Exploring Best Practices.

AIMS: Addressing sexual and gender-based violence (SGBV) in educational settings across the globe, particularly in institutions of higher education, requires strong institutional framework and policy guidelines. Most research about university SGBV policies has focused on high-income countries with little or no recourse to universities in low- and middle-income countries. This policy analysis aims to analyze existing policies related to SGBV from select sub-Saharan African universities to provide guidance on best practices toward addressing SGBV at universities in Africa. METHODS: Seven university policies and six national policies from six countries across sub-Saharan Africa (Ghana, Liberia, Nigeria, Rwanda, South Africa, and Zimbabwe) were reviewed using a standardized data extraction form. The policy analysis identified eight key elements of policies related to SGBV for sub-Saharan African universities, which were verified using a nominal group technique with five international experts in the field. RESULTS: Overall, policies varied significantly in accessibility, terminology, definitions, format, and inclusivity across the sites. Some of the policies were not readily accessible, and there was limited evidence provided in some of the policy documents. CONCLUSIONS: Policies for universities in sub-Saharan Africa should (a) be evidence based, (b) be readily available in multiple formats, (c) define key terms broadly with gendered signifiers, (d) be succinct and concise, (e) incorporate broad definitions for all university stakeholders, (f) identify who created the policy and when, (g) address prevention, and (h) address response. Evidence-based policies addressing SGBV prevention, response, and justice are sorely needed at universities across the globe.

Measuring Sexual and Gender-Based Violence at the University of Cape Coast: Developing and Deploying a Campus Climate Survey.

AIMS: Sexual and gender-based violence (SGBV) is a global public health crisis, impacting university youth around the world. The purpose of this study was twofold: (a) determine the best methodology for conducting a campus climate survey at the University of Cape Coast (UCC) in Ghana and (b) gather data on SGBV knowledge, attitudes, and behaviors from a representative sample of students. METHODS: This descriptive study included three phases: (a) develop a campus climate survey unique to UCC, (b) develop a sampling methodology, and (c) deploy the first ever campus climate survey at UCC. RESULTS: A 71-item survey was developed and then administered via a student portal to 2,000 students. Of those students, 1,381 (69.1%) responded. Although most students (63.2%) know the university has a sexual harassment policy, fewer have seen it (25.9%) or read it (22.3%). Students held generally positive views of how the university would respond to reports of sexual harassment, although 50.2% of participants believed the reporter would be labeled a troublemaker. More participants reported seeking and giving verbal than nonverbal consent, and more men than women reported both seeking and giving verbal consent. More men than women reported they "always" sought verbal consent (61.2% vs. 47.7%, p = 0.001). Most students ( n = 316, 56.5%) sought verbal consent all of the time, and an additional 99 (17.7%) sought it most of the time. CONCLUSIONS: Accurate data about students' knowledge, attitudes, and experiences with SGBV policy, prevention, and response are needed globally to better inform locally appropriate practices. POTENTIAL IMPACT OF CAMPUS INTIMATE PARTNER VIOLENCE AND SEXUAL ASSAULT ON FORENSIC NURSING: Forensic nursing is currently localized in high-income countries. University students' knowledge, attitudes, and experiences with SGBV can support the expansion of forensic nursing research and practice to low- and middle-income countries.

Creating a tool to understand university students' experiences regarding inappropriate, disrespectful, and coercive (IDC) healthcare interactions.

Objective: The purpose of this study was to develop a survey tool to capture inappropriate, disrespectful, and coercive (IDC) interactions with healthcare providers among a diverse sample of university students. Participants: Participants were university students at one large Midwestern public university. Methods: An exploratory qualitative approach was used to create a survey tool to capture IDC interactions. Results: In Phase I, 9 focus group discussions (FGDs) and 3 individual interviews were conducted with a total of 38 participants. In Phase II, 18 participants completed cognitive interviews. Themes across all FGDs included: (1) communication; (2) respect for identity; (3) institutional practices; (4) power imbalances; and (5) lack of patient education and empowerment. Queer participants discussed unique considerations of how queer identity influences one's IDC healthcare experiences. Conclusions: This study resulted in the development of a 64-70 item tool, the IDC Survey, to measure the prevalence and characteristics of IDC healthcare interactions.

Innovate 4 Change: An interdisciplinary nursing student-led hackathon.

BACKGROUND: Health care challenges are increasingly complex. Nursing student involvement in hackathons can help create a sustainable culture of innovation and leadership within nursing. PURPOSE: To host and evaluate the inaugural Innovate 4 Change Hackathon. METHODS: Nursing student-led interdisciplinary teams worked together for 5 weeks to solve pressing health care problems, ultimately pitching ideas for prizes. FINDINGS: Seven teams with 33 students represented multiple disciplines. For nearly 70% of participants, hackathons were a new experience. Nursing students were on every team, representing 50% of the participants. DISCUSSION: Nurse-led hackathons help students gain experience in innovative problem-solving and elevate confidence. They provide a structured format to learn about nursing innovation, design thinking, and business models while also challenging students to address problems related to health equity, clinical care, health care delivery, and policy.

Non-adherence to WHO's recommended 8-contact model: geospatial analysis of the 2017 Maternal Health Survey.

INTRODUCTION: Evidence shows that most women in Ghana do not meet the minimum 8-contact model for antenatal care as recommended by WHO with only 31.2%-41.9% of them meeting the recommendation. To the best of our knowledge, no study in Ghana has examined women's noncompliance with the WHO's recommended 8-contact model for antenatal care using geospatial analysis, as this study sets out to do. METHODS: We sourced data from the recent version of the Ghana Maternal Health Survey which was executed in 2017. A sample of 10,077 women with complete data participated in this study. The link between the explanatory variables and the outcome variable was investigated using binary and multivariate logistic regression models and Spatial analyses such as spatial autocorrelation (Moran's I), hotspot, cluster and outlier analysis, and geographically weighted regression were conducted using ArcMap version 10.7. RESULTS: Districts found in the north-eastern and south-western parts of the country were more likely to experience noncompliance with ANC. Women staying within the middle belt without health insurance were more likely (17-29%) to be noncompliant with ANC. Women with low community socioeconomic status were found to be more likely (17-34%) to be noncompliant with ANC in the eastern parts of Ghana. CONCLUSION: The study has shown that in order to achieve targets one and three of Sustainable Development Goal 3, the government of Ghana, the Ministry of Health, together with the Ghana Health Service may have to intensify health education in the identified areas to highlight the importance of adherence to the WHO recommendations on ANC 8-contact model.

Patient satisfaction with Sexual Assault Nurse Examiner services and post-assault resource utilization at a university health center and emergency department.

Objective: Describe a model for incorporating campus-based Sexual Assault Nurse Examiner (SANE) services. Describe differences in patient satisfaction and utilization of follow-up resources between patients seeking SANE services at a university health center (UHC) compared to an emergency department (ED). Participants: Patients seeking SANE services at the UHC or ED of a large Midwestern university from January 2016-April 2018. Fifty-eight participants completed a satisfaction survey, including 28 students. Twenty-eight participants completed a follow-up survey, including 15 students. Methods: A Qualtrics survey assessed: 1) satisfaction following the SANE exam and 2) use of follow-up services 4-6 weeks later. Descriptive analyses, exact logistic regressions, and OLS regressions were calculated. Results: There were no differences in satisfaction, services received, or follow-up services accessed between patients at the UHC and ED, including between students. Conclusions: Campus-based SANE services meet the expectations of survivors and do not differ significantly from services at the ED.

Danger and sexuality: exploring negotiations in romantic and sexual relationships among university students in Ghana.

Gender inequalities and social mores normalise gender-based violence in many settings. The goal of this study was to gain a more in-depth understanding of romantic and sexual relationships, consent, and gender-based violence among university students in Ghana. We used focus group discussions to explore individual factors influencing romantic and sexual relationships among students enrolled at a university in the Central Region of the country to inform the development and tailoring of future interventions. During a series of four focus group discussions comprising students recruited via convenience and snowball sampling, participants were asked to reflect on the nature of their romantic and sexual relationships. Demographic data and experiences of gender-based violence were also collected. The focus groups discussions were recorded and transcribed verbatim and analysed thematically. Five themes were developed from the data: (1) traditional gender roles; (2) self-control; (3) relationship-based consent; (4) cheating; and (5) non-verbal communication. This study suggests negative health and social ramifications of violence will continue until there is a resolution of conflicting social norms that result in different expectations about how men and women can address their sexual needs. Future programming and interventions for gender-based violence prevention should reflect on their impact across all ecological levels.

The role of Savings and Internal Lending Communities (SILCs) in improving community-level household wealth, financial preparedness for birth, and utilization of reproductive health services in rural Zambia: a secondary analysis.

BACKGROUND: Savings and Internal Lending Communities (SILCs) are a type of informal microfinance mechanism widely adapted in Zambia. The benefits of SILCs paired with other interventions have been studied in many countries. However, limited studies have examined SILCs in the context of maternal health. This study examined the association between having access to SILCs and: 1) household wealth, 2) financial preparedness for birth, and 3) utilization of various reproductive health services (RHSs). METHODS: Secondary analysis was conducted on baseline and endline household survey data collected as part of a Maternity Waiting Home (MWH) intervention trial in 20 rural communities across seven districts of Zambia. Data from 4711 women who gave birth in the previous year (baseline: 2381 endline: 2330) were analyzed. The data were stratified into three community groups (CGs): CG1) communities with neither MWH nor SILC, CG2) communities with only MWH, and CG3) communities with both MWH and SILC. To capture the community level changes with the exposure to SILCs, different women were randomly selected from each of the communities for baseline and endline data, rather than same women being surveyed two times. Interaction effect of CG and timepoint on the outcome variables - household wealth, saving for birth, antenatal care visits, postnatal care visits, MWH utilization, health facility based delivery, and skilled provider assisted delivery - were examined. RESULTS: Interaction effect of CGs and timepoint were significantly associated only with MWH utilization, health facility delivery, and skilled provider delivery. Compared to women from CG3, women from CG1 had lower odds of utilizing MWHs and delivering at health facility at endline. Additionally, women from CG1 and women from CG2 had lower odds of delivering with a skilled provider compared to women from CG3. CONCLUSION: Access to SILCs was associated with increased MWH use and health facility delivery when MWHs were available. Furthermore, access to SILCs was associated with increased skilled provider delivery regardless of the availability of MWH. Future studies should explore the roles of SILCs in improving the continuity of reproductive health services. TRIAL REGISTRATION: NCT02620436.

Barriers and facilitators to facility-based delivery in rural Zambia: a qualitative study of women's perceptions after implementation of an improved maternity waiting homes intervention.

OBJECTIVES: Women in sub-Saharan Africa face well-documented barriers to facility-based deliveries. An improved maternity waiting homes (MWH) model was implemented in rural Zambia to bring pregnant women closer to facilities for delivery. We qualitatively assessed whether MWHs changed perceived barriers to facility delivery among remote-living women. DESIGN: We administered in-depth interviews (IDIs) to a randomly selected subsample of women in intervention (n=78) and control (n=80) groups who participated in the primary quasi-experimental evaluation of an improved MWH model. The IDIs explored perceptions and preferences of delivery location. We conducted content analysis to understand perceived barriers and facilitators to facility delivery. SETTING AND PARTICIPANTS: Participants lived in villages 10+ km from the health facility and had delivered a baby in the previous 12 months. INTERVENTION: The improved MWH model was implemented at 20 rural health facilities. RESULTS: Over 96% of participants in the intervention arm and 90% in the control arm delivered their last baby at a health facility. Key barriers to facility delivery were distance and transportation, and costs associated with delivery. Facilitators included no user fees, penalties for home delivery, desire for safe delivery and availability of MWHs. Most themes were similar between study arms. Both discussed the role MWHs have in improving access to facility-based delivery. Intervention arm participants expressed that the improved MWH model encourages use and helps overcome the distance barrier. Control arm participants either expressed a desire for an improved MWH model or did not consider it in their decision making. CONCLUSIONS: Even in areas with high facility-based delivery rates in rural Zambia, barriers to access persist. MWHs may be useful to address the distance challenge, but no single intervention is likely to address all barriers experienced by rural, low-resourced populations. MWHs should be considered in a broader systems approach to improving access in remote areas. TRIAL REGISTRATION NUMBER: NCT02620436.

Part 4: Value-informed nursing practice depends on nursing innovation.

With the adoption of value-based payments which tie reimbursement to patient outcomes and costs, days when nursing is viewed primarily as a cost to hospitals will soon be over. Already the backbone of high-quality care delivery and patient outcomes, nurses are becoming key drivers of health care organizations' financial outcomes, too. The first three articles published in this 6-part series on value-informed nursing practice-practice that considers both the outcomes and the cost of producing the outcomes-described what value-informed nursing practice means, its economic, policy, and ethical impetuses, and how value-informed nursing practice helps improve environmental sustainability of health systems. Here, in Part 4, we focus on the importance of nursing innovation in implementing value-informed nursing practice. We begin by discussing how innovation is connected to value and then examine the false dichotomy, perceived by many, between innovation and evidence-based care. Following this, we examine how health care organizations and systems can support nursing innovation, before concluding with recommendations for nursing educators.

Trauma History as a Significant Predictor of Posttraumatic Growth Beyond Mental Health Symptoms in Women-Identifying Survivors of Undergraduate Non-Consensual Sexual Experiences.

There is little data on what influences posttraumatic growth for women who experienced non-consensual sexual contact (NCSC) as an undergraduate college student. The purpose of this study is to garner a better understanding of posttraumatic growth among women-identifying survivors of undergraduate NCSC by addressing the following aims: 1) evaluate the mediating role of NCSC-related shame on the relationship between perceived peer rape myth acceptance and posttraumatic growth (n = 174); and 2) evaluate the shared and independent variance contributions of mental health symptoms and trauma history clusters on posttraumatic growth (n = 151).NCSC-related shame did not mediate the relationship between perceived peer rape myth acceptance and posttraumatic growth. Mental health symptoms and trauma history significantly contributed to 35.27% of posttraumatic growth variance, with the trauma history cluster significantly influencing posttraumatic growth scores beyond mental health symptoms. Based on these findings, it is important that clinicians assess for a history of trauma and the impact of that trauma in addition to mental health symptoms when trying to understand posttraumatic growth after campus sexual violence.

A precise quantification of how prior experience informs current behavior.

Human behavior does not exist in a bubble-it is influenced by countless forces, including each individual's current goals, preexisting cognitive biases, and prior experience. The current project leveraged a massive behavioral data set to provide a data-driven quantification of the relationship between prior experience and current behavior. Data from two different behavioral tasks (a categorization task and a visual search task) demonstrated that prior history had a precise, systematic, and meaningful influence on subsequent performance. Specifically, the greater the evidence for (or against) all aspects of the current trial, the more (or less) efficient behavior was on that trial. The robust influence of prior experience was present for even distracting and likely unattended information. The ubiquity and consistency of the effect for features both related and unrelated to stimulus presence suggests a domain-general mechanism that increases the efficiency of behavior in contexts that match prior experience. These findings are theoretically important for understanding behavioral adaptation, experimentally powerful for directly addressing effects of previous trials when designing and analyzing research projects, and potentially useful for optimizing behavior in various applied contexts. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Understanding Stalking Among University Students in Ghana: A Mixed-Methods Study.

The purpose of this study is to explore experiences of stalking behaviors among midwifery students at one Ghanaian university, as well as their association with mental health disorders. Specifically, this study had the following three aims: (a) to identify the frequency of stalking experiences in this population; (b) to explore mental health symptoms, such as depression and anxiety, within this population; and (c) to better understand intervention opportunities related to stalking, including bystander intervention and use of available resources. The study utilized an exploratory mixed-methods design with surveys (n = 118) and focus group discussions (n = 2 with 16 participants) with midwifery students recruited from a centrally located Ghanaian university campus in July of 2018 using convenience sampling. Results indicate a large percentage (80.3%) of participants have experienced stalking behavior(s) within the last six months. Multiple regression analyses demonstrate a statistically significant relationship between any stalking behaviors and depressive symptomatology as well as between unwanted monitoring/following and anxiety. This was reinforced by focus group discussions in which participants discussed the themes of: (a) types of stalking, with a heavy emphasis on using technology for unwanted following/monitoring; (b) positive versus negative perceptions of stalking intentions, where some types of monitoring and following could be seen as forms of flattery or interest; and (c) barriers to seeking help that focused on stigma, cultural barriers, systemic barriers, and personal barriers. Future research should delve more deeply into barriers to existing resources to identify ways to increase accessibility for stalking survivors in connection with mental health services. This study also highlights the need for additional research to more clearly understand stalking in Ghana so that interventions can begin to address mental health services, healthy relationships, communication, and consent.

The Dynamics of Interpersonal Relationships: Understanding Power and Control Tactics Among College Students.

Intimate partner violence (IPV) is a significant public health problem among college students and many students have difficulty identifying unhealthy and abusive behaviors. The aims of this mixed methods study are to: (a) create an inclusive tool that illustrates the power and control experiences of a diverse group of young adult college students, (b) ensure a broad scope of tactics are illustrated (related to technology and different types of relationships), and (c) measure the experience of these tactics, including how IPV knowledge, attitudes, and self-efficacy are influenced by a more inclusive tool. In Phase I, semi-structured interviews were conducted with students (n = 33) and staff (n = 10) at campus sexual assault centers at the three University of Michigan (UM) campuses to explore power and control tactics utilized by perpetrators on college campuses. Content analysis revealed 13 categories of tactics in college relationships. A draft tool was created and assessed for accuracy using cognitive interviews with students (n = 20) from all three campuses in Phase II. Cognitive interviews resulted in the following changes to the final tool: (a) new presentation of the Socioecological Model, (b) identification of substance use as a facilitator for multiple forms of violence, and (c) edits to tactic descriptions. In Phase III, 250 students at UM-Ann Arbor participated in a quasi-experimental evaluation in which 133 interacted with the tool and 117 received access to usual care (campus sexual misconduct policy). Both groups answered survey questions about IPV knowledge, attitudes, self-efficacy, and experiences at baseline, and after one month and five months. Among all college participants in Phase III, 33.5% had experienced lifetime IPV and 25.2% had experienced IPV in the past year. There were no significant differences among IPV knowledge, attitudes, or self-efficacy by group. The Dynamics of Interpersonal Coercion Among College Students tool was created by incorporating current tactics utilized among a diverse college population.

Out-of-Pocket Expenditures for Delivery for Maternity Waiting Home Users and Non-users in Rural Zambia.

BACKGROUND: Utilizing maternity waiting homes (MWHs) is a strategy to improve access to skilled obstetric care in rural Zambia. However, out-of-pocket (OOP) expenses remain a barrier for many women. We assessed delivery-related expenditure for women who used MWHs and those who did not who delivered at a rural health facility. METHODS: During the endline of an impact evaluation for an MWH intervention, household surveys (n = 826) were conducted with women who delivered a baby in the previous 13 months at a rural health facility and lived >10 km from a health facility in seven districts of rural Zambia. We captured the amount women reported spending on delivery. We compared OOP spending between women who used MWHs and those who did not. Amounts were converted from Zambian kwacha (ZMW) to US dollar (USD). RESULTS: After controlling for confounders, there was no significant difference in delivery-related expenditure between women who used MWHs (US$40.01) and those who did not (US$36.66) (P=.06). Both groups reported baby clothes as the largest expenditure. MWH users reported spending slightly more on accommodation compared to those did not use MWHs, but this difference represents only a fraction of total costs associated with delivery. CONCLUSION: Findings suggest that for women coming from far away, utilizing MWHs while awaiting delivery is not costlier overall than for women who deliver at a health facility but do not utilize a MWH.

Understanding Health Facility Needs for Human Trafficking Response in Michigan.

OBJECTIVES: Human trafficking is a public health issue that has substantial health consequences. However, research on the preparedness of health facilities to serve people who have experienced or are experiencing human trafficking is limited. We examined health facility preparedness related to human trafficking in Michigan. METHODS: We used a cross-sectional design to explore health facility preparedness related to human trafficking in Michigan. We sampled 10 prosperity regions according to health facility type (Federally Qualified Health Centers, health departments, and hospitals). An email invitation was sent to identified health facility personnel (eg, administrators, physicians, nurses) from May to June 2019 with a link to a 26-item survey with items about current policies, protocols, and areas for improvement related to human trafficking. RESULTS: Forty-two Federally Qualified Health Centers, health departments, and hospitals responded to the survey. Most health facilities had screening policies and response protocols related to child maltreatment (screening: 32/41 [78.0%]; response: 38/40 [95.0%]) and intimate partner violence (screening: 33/41 [80.5%]; response: 37/40 [92.5%]). However, fewer facilities had a screening policy (16/41 [39.0%]) and response protocol (25/40 [62.5%]) for human trafficking; more of these facilities focused on sex trafficking than on labor trafficking. The top needs related to human trafficking were (1) individual-level health care provider training, (2) health facility-level screening policies and response protocols, (3) community-level resources, and (4) societal-level awareness, funding allocation, and data. CONCLUSIONS: Facility-level resources are needed to ensure that health care providers have adequate training and support to address human trafficking in the health care system.

If we build it, will they come? Results of a quasi-experimental study assessing the impact of maternity waiting homes on facility-based childbirth and maternity care in Zambia.

INTRODUCTION: Maternity waiting homes (MWHs) aim to increase access to maternity and emergency obstetric care by allowing women to stay near a health centre before delivery. An improved MWH model was developed with community input and included infrastructure, policies and linkages to health centres. We hypothesised this MWH model would increase health facility delivery among remote-living women in Zambia. METHODS: We conducted a quasi-experimental study at 40 rural health centres (RHC) that offer basic emergency obstetric care and had no recent stockouts of oxytocin or magnesium sulfate, located within 2 hours of a referral hospital. Intervention clusters (n=20) received an improved MWH model. Control clusters (n=20) implemented standard of care. Clusters were assigned to study arm using a matched-pair randomisation procedure (n=20) or non-randomly with matching criteria (n=20). We interviewed repeated cross-sectional random samples of women in villages 10+ kilometres from their RHC. The primary outcome was facility delivery; secondary outcomes included postnatal care utilisation, counselling, services received and expenditures. Intention-to-treat analysis was conducted. Generalised estimating equations were used to estimate ORs. RESULTS: We interviewed 2381 women at baseline (March 2016) and 2330 at endline (October 2018). The improved MWH model was associated with increased odds of facility delivery (OR 1.60 (95% CI: 1.13 to 2.27); p<0.001) and MWH utilisation (OR 2.44 (1.62 to 3.67); p<0.001). The intervention was also associated with increased odds of postnatal attendance (OR 1.55 (1.10 to 2.19); p<0.001); counselling for family planning (OR 1.48 (1.15 to 1.91); p=0.002), breast feeding (OR 1.51 (1.20 to 1.90); p<0.001), and kangaroo care (OR 1.44 (1.15, 1.79); p=0.001); and caesarean section (OR 1.71 (1.16 to 2.54); p=0.007). No differences were observed in household expenditures for delivery. CONCLUSION: MWHs near well-equipped RHCs increased access to facility delivery, encouraged use of facilities with emergency care capacity, and improved exposure to counselling. MWHs can be useful in the effort to increase delivery at advanced facilities in areas where substantial numbers of women live remotely. TRIAL REGISTRATION NUMBER: NCT02620436.