Facilitating factors for this community-level scale up in 35 districts included strong government support, local champions, and a national policy on preventing postpartum hemorrhage (PPH). Challenges included a lack of a systematic scale-up strategy, limited communication of the PPH policy, a shift from a universal distribution policy to application of eligibility criteria, difficulties engaging remote traditional birth attendants, and implementation of a parallel M&E system. Facilitating factors for this community-level scale up in 35 districts included strong government support, local champions, and a national policy on preventing postpartum hemorrhage (PPH). Challenges included a lack of a systematic scale-up strategy, limited communication of the PPH policy, a shift from a universal distribution policy to application of eligibility criteria, difficulties engaging remote traditional birth attendants, and implementation of a parallel M&E system. Mozambique has a high maternal mortality ratio, and postpartum hemorrhage (PPH) is a leading cause of maternal deaths. In 2015, the Mozambican Ministry of Health (MOH) commenced a program to distribute misoprostol at the community level in selected districts as a strategy to reduce PPH. This case study uses the ExpandNet/World Health Organization (WHO) scale-up framework to examine the planning, management, and outcomes of the early expansion phase of the scale-up of misoprostol for the prevention of PPH in 2 provinces in Mozambique.Qualitative semistructured interviews were conducted between February and October 2017 in 5 participating districts in 2 provinces. Participants included program stakeholders, health staff, community health workers (CHWs), and traditional birth attendants (TBAs). Interviews were analyzed using the ExpandNet/WHO framework alongside national policy and planning documents and notes from a 2017 national Ministry of Health maternal, newborn, and child health workshop. Outcomes were estimated using misoprostol coverage and access in 2017 for both provinces.The study revealed a number of barriers and facilitators to scale-up. Facilitators included a supportive political and legal environment; a clear, credible, and relevant innovation; early expansion into some Ministry of Health systems and a strong network of CHWs and TBAs. Barriers included a reduction in reach due to a shift from universal distribution to application of eligibility criteria; fear of misdirecting misoprostol for abortion or labor induction; limited communication and understanding of the national PPH prevention strategy; inadequate monitoring and evaluation; challenges with logistics systems; and the inability to engage remote TBAs. Lower coverage was found in Inhambane province than Nampula province, possibly due to NGO support and political champions.This study identified the need for a formal review of the misoprostol program to identify adaptations and to develop a systematic scale-up strategy to guide national scale-up. In Mozambique, TBAs are female and generally illiterate. They do not receive a salary, and they work with very few resources. For example, they do not receive clean birthing kits. The majority of Mozambican TBAs do not have formal training or certification in child birth practices or obstetric emergencies.The TBAs involved in the misoprostol program are affiliated with the participating health facilities. They receive a 3-day training on how to safely administer misoprostol to women after they give birth, distribute chlorhexidine, and recognize danger signs for referral and safe birth practices. The training emphasizes the role of TBAs in referring or accompanying women to the health facility to give birth. When a TBA is aware of an impending birth in the community, she requests a dose of misoprostol from the CHW in her catchment area. The TBA is responsible for safeguarding that dose until she attends the birth and administers it directly to the woman after she gives birth. TBAs and CHWs do not distribute misoprostol to pregnant women.Agentes Polivelantes Elementares (APEs) in Portuguese. The vast majority (85%) of APEs are men, mainly due to the prerequisite of primary school education and the need to undertake a 4- to 5-month training, often outside their community. The APE program is now actively working to improve gender equality by recruiting more women.CHWs in Mozambique are referred to as Integrated community case management of malaria, pneumonia, and diarrhea is a key component of the work that CHWs undertake. The CHWs receive a small medical kit and have the authority to provide medicines, including antimalarials, amoxicillin, and zinc.Strategy for the Prevention of Postpartum Hemorrhage at the Community Level . The first objective of the strategy was the implementation of the misoprostol program, which included advance distribution of misoprostol to women during pregnancy and direct administration by TBAs to women who give birth in the community to reduce maternal mortality associated with PPH.In 2015, the MOH launched the national ,Nine Steps for Developing a Scaling-Up Strategy,–There is an urgent need for information about the process of scale-up of MNCH interventions that highlights the operational realities countries experience.This article uses the ExpandNet/WHO framework to retrospectively analyze the early phases of scale-up of the community distribution of misoprostol to prevent postpartum hemorrhage in Mozambique. The aim of this article is to present a case study that will inform MNCH stakeholders about the barriers and facilitators in the early expansion of the misoprostol program and offer recommendations to stakeholders, both within Mozambique and internationally, of the key components to bring programs to scale.We used a mixed-methods approach to assess the implementation of the early expansion phase of scaling up misoprostol in 2 provinces in Mozambique. The objectives of this study were to: (1) identify facilitators and barriers to the early expansion of the misoprostol program for the prevention of PPH at the community level, and (2) examine coverage and use of misoprostol in the 2 provinces.The qualitative component of the study applied a phenomenological approach to understand the experiences of those involved in Mozambique's misoprostol program. Phenomenology is an interpretive approach based on the lived experiences of people who participated in the phenomenon.Agentes Polivalentes Elementares in Mozambique) and TBAs. In addition, focus group discussions were conducted separately with CHWs and TBAs. The ExpandNet/WHO framework and the document entitled 20 Questions for Developing a Scale-up Case StudyOne-to-one, semistructured qualitative interviews were conducted with (1) MNCH national, provincial, and district stakeholders with experience working on the misoprostol program; (2) health staff ; and (3) CHWs , the Mozambican National Bioethics Committee, and the MOH. All participants provided informed consent and none requested to be withdrawn from the study.In total, we included in the analysis qualitative interviews with 15 stakeholders, 19 health staff, 15 CHWs and coordinators, and 15 TBAs; 6 focus group discussions; and a review of national policy and planning documents.In the ExpandNet/WHO framework, the innovation refers to “the health service interventions or other new practices that are being scaled up.”BOX 2A pregnant woman must:Be registered for antenatal care Have reached 28 weeks gestationShe must additionally meet at least 1 of these criteria:Have a history of giving birth at home/outside of the health facilityLive more than 8 km from a health facilityBe a grand multipara (more than 5 previous births)Have a current or past history of multiple pregnanciesHave a history of postpartum hemorrhageWomen received misoprostol either directly during an antenatal care visit or through TBAs who administered it to women after they gave birth at home.A woman who meets the eligibility criteria at her antenatal care visit receives information from the nurse regarding how and when to take misoprostol and a dose (3 pills in a blister pack) to safeguard until her labor. Distribution at the community level occurs between the TBA and the pregnant woman directly after the birth of the baby and before the placenta has been delivered. A CHW provides the TBA with the misoprostol. CHWs, who are salaried employees and have access to a bicycle, are the link between the health facility and TBAs. Upon request, the CHWs usually receive 3 doses (9 pills) of misoprostol, which they then distribute to the TBA(s) in their coverage area monthly .Some challenges arose with the flow of distribution. In many cases, CHWs lived further from the facility than the selected TBAs. CHWs provided TBAs with the supply of misoprostol, but the CHWs themselves were not trained or permitted to distribute it to pregnant women. In some cases, CHWs lived too far from the TBAs, and they both suggested that the TBAs collect the misoprostol directly from the health facility during monthly TBA meetings. A health staff member from Inhambane province identified this as a major challenge, saying:… the only constraint that we have had with the TBAs … is the fact that we do not give misol to them directly.CHWs provided TBAs with the supply of misoprostol, but the CHWs themselves were not trained or permitted to distribute it to pregnant women.This may have limited distribution of misoprostol and reach to remote areas.During the initial pilot phase, the MOH shifted from a universal distribution strategy, as outlined in the National PPH Strategy, to application of eligibility criteria . This shThis shift impacted the amount of misoprostol required for the program; only 8% of the forecasted stock for universal distribution was needed. The criterion of distance from a facility was explicit ; however, interpretations of “far from the facility” varied widely among health staff. Some nurses and midwives felt that if a woman lived 10 or 15 km away they would not need misoprostol, as they “should be able to reach the facility” prior to or while in labor. Others defined “far” as 20–30 km from the health facility and thought that only then should women receive the medication. Some MNCH stakeholders and health staff based in the field applauded the additional controls, stating that misoprostol was ‘flooding’ the communities, which increased the risk for potentially using misoprostol for abortion. They also believed that too many doses were returned to the health facility, which produced issues for recordkeeping and disposal. Others criticized the criteria for limiting the number of women who received uterotonic coverage:So if we want to prevent PPH it has to be covered universally, it cannot be how it is being done. … this strategy has to be reviewed as soon as possible, it must be universal distribution of misoprostol. A number of stakeholders and health staff in the MOH national MNCH workshop in October 2017 proposed removing the restrictions to improve coverage.The environment consists of political, sociocultural, and economic factors that impact scale-up and can present opportunities or challenges to expansion.The country's financial situation was an important environmental factor. In 2016, the Mozambican economy experienced a significant disruption with the revelation of US$1.4 billion in undisclosed debt. The International Monetary Fund halted credit to the country and many international donors, including bilateral governments, withdrew funding. Economic instability was cited as a key issue that could impact scalability of the misoprostol program. Fiscal spending became limited across all government institutions. Many health staff described low motivation with the lack of essential consumables, including gloves for births and vaginal examinations.National Health Sector Strategy 2014–2019.Financial constraints were tempered by strong government support for the program. The MOH prioritized the prevention of maternal mortality in the Changes to the abortion law in Mozambique may have positively influenced the political and legal settings in which misoprostol for PPH was introduced. The MOH branded misoprostol for the prevention of PPH as ‘misol’ to differentiate it between misoprostol used for induction of labor or abortion.The MOH branded misoprostol for postpartum hemorrhage prevention as ‘misol’ to differentiate it from misoprostol used for induction of labor or abortion.Some central and provincial stakeholders were very supportive of the changes to the legislation and the impact that they would have on improving maternal health. For example, a stakeholder from Maputo explained:I think that PPH and safe abortion are very distinct matters. … And when we think that as a country we are limiting the access to misol because we don't want to give access to providers, to women, in case they can misuse this misol … I think we are just limiting access to life.However, other stakeholders feared that misoprostol could be misdirected for abortion or labor induction and wanted stricter controls:We need to control the misoprostol because other people can use it for other purposes like abortions, and they also know about this use for misoprostol and so we think the district should distribute it to ensure the best control. The environment also includes the capacity of the health system to deliver care and services that impact the success of the planned scale-up.Varying support for working alongside TBAs also impacted planning for the scale-up of misoprostol. Historically, involvement of TBAs within the formal health sector has been limited in Mozambique.Some TBAs charge people and promote these births to be held on her account so she can gain something. Others in favor of TBA participation argued that the health system did not have the capacity to provide a skilled birth attendant for every woman due to a lack of sufficient transport and human resources:That woman who lives 25–30 km from the health unit, she will go to prenatal consultation until the sixth, seventh month of pregnancy and then she will not go, and where will she have the baby? She'll go to the [traditional] midwife. In my opinion, it is not to say that the traditional midwife should not help women to give birth, my opinion is to enable the traditional midwife to make a clean birth. These political, sociocultural, and economic factors were all essential components that influenced the planning and management of the misoprostol program.The user organization in the ExpandNet/WHO framework is defined as the institution(s) and/or organization(s) that are expected to adopt and implement the innovation at scale.Misoprostol is distributed using the routine supply chain for MNCH commodities, with the addition of CHWs as the distributors between the health facility and the TBAs. In Inhambane province, the supply chain experienced weaknesses in distribution between provincial to district warehouses. Misoprostol stock was procured 1 year prior to the official launch of the program and, as a result, the remaining shelf life of the initial supply was shortened by 1 year. Provincial MNCH coordinators were requested to lead the misoprostol program with support from the provincial CHW coordinator. Program execution varied widely depending on the leadership of the MNCH coordinators at the district level in each of the 35 implementing districts. Some MNCH coordinators stated that they felt strongly that misoprostol was a lifesaving medication and were committed to the misoprostol program. For example:I think it will help a lot as we are in the district, yes deliveries outside the maternity are reducing, for sure, but they continue to occur. This [misoprostol program] is a great asset for us to avoid maternal deaths in the community due to postpartum hemorrhage. Other MNCH coordinators were not very supportive and believed it was not “their program” and instead allocated responsibility to the implementing health facilities.MNCH nurses were directly responsible for the distribution of misoprostol in advance to pregnant women during antenatal care visits. Some were discouraged by the additional workload associated with the program . Several MNCH nurses believed the program was a pilot, especially in Inhambane province where they had experienced multiple hiccups in the supply chain. This negatively impacted their motivation to distribute misoprostol during antenatal care visits or monitor the program. Yet quantitative results revealed that over 80% of all misoprostol distributed was distributed to women in advance during antenatal care visits.CHWs and TBAs were recruited in coordination with the CHW program and the MNCH department. TBAs were recommended either by the health facility or the CHWs. As a result, recruited TBAs often lived close to the health facility. This was also identified as a key factor in the low coverage experienced in some districts:To map all TBAs was very difficult for the health facility and even at the district level. So we said to the MNCH nurses, “Please select first the ones that are reporting to you and then identify some that the CHWs recognize …” Those were the 2 inclusion criteria that we used. We didn't use distance because it was very difficult. … I don't know if we are reaching the TBAs that are really far away. In the planning phase, key members of the resource team included the MOH, AMOG, the United States Agency for International Development (USAID), WHO, Jhpiego's Maternal and Child Health Integrated Program (MCHIP), and the United Nations Population Fund (UNFPA). The latter 2 organizations also provided technical support to the program but were not direct implementers. Jhpiego's Maternal and Child Survival Project (MCSP), which followed from MCHIP, provided essential technical support to the program in Nampula and Sofala provinces. AMOG was involved in the development and implementation of the pilot, along with the NGO Venture Strategies Innovation. Using the evidence from the pilot study, AMOG played a critical role in advocating the need to scale up misoprostol.The resource team members also participate in the MNCH SWAp Technical Working Group. This group has made some critical decisions surrounding the misoprostol program, including the adoption of eligibility criteria for distribution of misoprostol during antenatal care visits. The group reportedly met regularly in 2015 and 2016; however, one informant revealed that the SWAp had not met during the first 10 months of 2017 due to changes in central government staff. The resource team's input and updates regarding progress on the misoprostol program was limited during this period.Management of the scale-up was categorized as: type of scale-up; dissemination and advocacy; organizational process; costs/resource mobilization; and monitoring and evaluation.The scaling-up strategy refers to the plans and actions taken to establish the innovation in policies and programs.Horizontal scale-up or expansion occurs when innovations are replicated in different geographic locations or are extended to serve larger or new populations. The innovation should be adapted to the new context in the additional location(s). Vertical scale-up occurs when governments reach a formal agreement to adopt the innovation nationally or sub-nationally, the adoption is institutionalized through national planning, policy, or legal processes, and it is implemented nationally or sub-nationally, including maintaining provisions to ensure ongoing effective delivery. Dimensions from both horizontal and vertical scale-up need to be incorporated for an innovation to be sustainable.The National PPH Strategy outlines a horizontal scale-up strategy, or the expansion of the innovation across different geographical locations to reach a larger populationMozambique's national PPH strategy outlines a horizontal scale-up strategy, focusing first on 35 districts in 10 provinces.In June 2016, results from Sofala and Inhambane were presented at the MNCH SWAp Technical Working Group meeting in Maputo. Progress in Sofala was limited to 1 district due to conflict that impacted both implementation and M&E. In September 2016, the MOH prioritized trainings to take place in the remaining 29 districts. By June 2017, all 35 districts had commenced distribution of misoprostol .Vertical scale-up began simultaneously to horizontal expansion via the development of the National PPH Strategy and the beginning of institutionalization into MOH systems, albeit in selected districts. The National PPH Strategy outlined the commitment to incorporating the program into routine MOH systemsAs PPH is a major cause of maternal death, prevention interventions are part of the larger Ministry of Health plan to reduce maternal mortality involving several National Directorates, Departments and Partners. Thus, during the implementation of the first phase of this strategy, every effort will be made to ensure that interventions and their resource needs are integrated into existing management, funding, coordination and service delivery mechanisms.The misoprostol program has yet to be institutionalized. In the early expansion phase, training was delivered to selected MOH staff in the selected districts; UNFPA procured medication and distributed it through the routine MOH supply chain; and M&E was developed parallel to the national health information system.Dissemination involves methods to promote, communicate, and encourage uptake of the innovation by the user organization.The National PPH Strategy was disseminated from the central to provincial level. The provincial health authorities were responsible for distributing the National PPH Strategy and informing the districts about the program. Memos about the program, particularly around stock, were sent from the central MOH to the provincial health authorities. Communication about the national PPH strategy was a challenge from the beginning, particularly between provincial and district levels but also from the district health offices to the health facilities. Weak flow of information was attributed to insufficient time to disseminate the strategy and induct health staff.In April 2015, the MOH began training MNCH nurses, CHWs, and TBAs on the distribution of misoprostol for PPH prevention and safe delivery methods. The initial trainings took place in 3 districts in Inhambane and 3 districts in Sofala provinces in 2015. Cadres in Nampula province underwent training for 3 days in August 2016, and distribution of misoprostol commenced in 5 districts in September 2016. In total, the resource team trained 36 master trainers, 548 provincial trainers, and 1,050 CHW supervisors at the health facility level.In Inhambane significantly more CHWs than TBAs were trained (337 CHWs vs. 47 TBAs), whereas in Nampula a significant number of TBAs were trained (189 CHWs and 980 TBAs). Staff mobility meant that some MNCH staff were not aware of the program or their role. For example:We trained the traditional midwives and a nurse from each health unit. We know that there is always movement of the nurses, some nurses do not even know what happened to the misol … if we want to have good results we need to involve all members of the maternal health team, regardless of being in the maternity or prenatal consultation. While nurses and midwives were generally supportive of the program some hesitated to distribute misoprostol without formal training.National-level advocacy played an important role in the decision to scale-up the innovation due to divisions among stakeholders about initiating the misoprostol program. The main hesitations were fears that misoprostol would potentially detract from facility-based births and/or would be used for abortion. The MNCH SWAp group reviewed global studies and the MOH requested that a pilot be conducted in Mozambique to assess whether misoprostol could be distributed safely during antenatal care visits and by TBAs.Organizing the process of scale-up involves those responsible for decision making and implementation.When you had misol at the provincial warehouse then it was difficult sometimes to get the misol to the district warehouse. So we had this challenge at the time - people, values, managing the system; all this was challenging to improve the system for misol to flow.The organizational process was also marked by gradual scale-up starting with only 6 districts in 1 year. Given the delays initiating the program, rapid rollout in the remaining 29 districts occurred over just 6 months in response to pressure from the national MOH to implement in all of the selected 35 districts. This limited time for monitoring and lessons learned to be considered.A budget of US$2.6 million was outlined in the National PPH Strategy for the first 2 years of the program.In 2015, Jhpiego's MSCP project also provided a 1-year grant to AMOG to provide technical support including supervision. In early 2017, the initial grant from UNFPA expired and the program continued on a limited budget. UNFPA received funding from the UK Department for International Development (DFID) for 2018–2020 to continue support for the program. However, limited funds were allocated to the program outside of those for procurement, training, and the production of communication materials. The lack of available funding was cited as a major barrier to ensuring the program's sustainability, ongoing supervision, and evaluation.The misoprostol M&E system was developed in parallel to both the national MNCH and CHW databases and separate to the national health information system. Data collection on misoprostol indicators represented additional tasks for the district MNCH nurses, who, without a clear system, were documenting returned doses of misoprostol by writing data on a separate paper or creating new columns in the prenatal registers. As a result, health staff at every level were concerned about the validity of monthly data collation:Sometimes we send a message, ‘Colleague tell me there, when and how many pills you distributed and to the CHW too,’ she [MNCH nurse] will give you that information. Then you add it and you feel that there is some number missing but you cannot confirm why because you do not have a concrete instrument for evaluating the information. The misoprostol M&E system was developed in parallel to the national health information system.Furthermore, no additional funding was provided at the provincial or district level to undertake supervision visits. Between 2015 and 2017, the MNCH staff alongside partners, including UNFPA, Jhpiego, and AMOG, conducted several isolated supervision visits, the findings of which were not widely disseminated. Some provincial MNCH coordinators were able to monitor alongside supervisory visits to other programs, but overall they felt that time spent was insufficient. Similarly, some district MNCH coordinators felt that they did not have the budget, time, or mandate to supervise the program. In other cases, district MNCH nurses were very involved in the program. Many stakeholders in Maputo and at the provincial level felt that the lack of M&E was a major barrier for the sustainability of the program.Program data, collated by the provincial MNCH coordinators for the MOH MNCH workshop held in Maputo in October 2017, were used to estimate access to and utilization of misoprostol for the first 9 months of 2017 . WeaknesThere was large variation in overall access and utilization between districts and the 2 provinces. Access to misoprostol in Nampula exceeded Inhambane province by 17%, and utilization was much greater in Nampula (91%) than in Inhambane (23%). Two districts in Nampula reported over 100% coverage of misoprostol of women who gave birth at home. Coverage is a combined measure of both access and utilization of misoprostol .Access to and utilization of misoprostol varied widely between districts and between the 2 provinces.In Inhambane, we found a number of possible reasons for low coverage. Health staff restricted access to misoprostol justified by using the eligibility criteria. There were also frequent stock-outs. TBAs and health staff reported that their priority was to ensure women gave birth at the health facility. Therefore, TBAs said they administered misoprostol only to women who had “surprise” births at home or who had “birthed along the way” to the health facility, as they indicated they always encouraged women to give birth at a health facility.In Nampula, higher coverage than Inhambane may be in part attributable to the institutional memory of the 2009–2010 pilot study: health staff and CHWs had previous training and were familiar with and supportive of the program. Distribution in Nampula started almost 1 year after Inhambane, such that we may have captured a period of initial high motivation. Political champions for misoprostol in Nampula province may also have positively impacted MNCH health staff attitudes and willingness to implement the program. There were significantly more TBAs trained and involved in the program than Inhambane . Further, the program in Nampula benefited from technical support from Jhpiego's MSCP program. See The majority of misoprostol was distributed during antenatal care visits rather than by TBAs.The initial quantity of misoprostol distributed from the central to the provincial level was based on the projection for 100% coverage of home deliveries in the chosen districts. The introduction of eligibility criteria in 2015 reduced the number of eligible women. This led to an excess of misoprostol available at all levels. Much of this stock was never distributed, resulting in the expiry and subsequent incineration of the first wave of commodities.As of October 2017, in Inhambane 87% of misoprostol stock was available at the provincial warehouse, but only 13% had been distributed to the district or health facility level. In contrast, in Nampula, almost all of the stock (99%) was distributed to the district health facilities. Informants in Inhambane stated that this was due in part to lack of leadership from some district medical chiefs to request adequate misoprostol stock, as well as hesitation by pharmacists to fill requisitions. Further inquiry suggested that pharmacists and some medical chiefs were hesitant to distribute what was previously a medication with the highest restrictions into the community and feared it would be used for abortion. One health staff said the medication was kept “locked under 7 doors” due to concerns about the controls in the community and the maternity units. Some informants felt that this was one of the largest barriers to reaching high coverage. Notably, pharmacists were not included in the dissemination of the National PPH Strategy.Lack of availability of the commodity at district level was a key reason for low coverage in Inhambane. From September 2016 through June 2017, misoprostol stock was rationed in Inhambane with only 5–10 doses distributed per participating health facility. One district pharmacist reported requesting 1,000 doses and received only 30 doses. Records revealed that other districts requested very small amounts—30 or 60 pills at a time (sufficient for 10–20 women).At the time of publication, the MOH had not yet set a timeline to achieve national scale-up. Between 2018 and 2020, the MOH will continue to focus on strengthening the program in the existing 35 districts and improving M&E mechanisms before further expansion.Mozambique Health Sector Strategic Plan 2014–2019. The misoprostol program was central to the National PPH Strategy and facilitated by national leadership, allowing for inclusion into some of the MOH infrastructure, systems, and human resources.Our analysis of factors that facilitated scale up of use of misoprostol to prevent postpartum hemorrhage  suggest While the MOH led the program planning and implementation process, misoprostol is being used for the prevention of postpartum hemorrhage only within selected districts and has yet to be incorporated into routine MOH systems. The inputs outlined in AMOG and partners employed a successful advocacy strategy to encourage the MOH and MNCH SWAp members of the potential high impact misoprostol had on improving incidence of PPH. The innovation was equally supported by international evidence and positive results from the local pilot study.The program benefited from the strong existing network of CHWs and TBAs who provided the local capacity for implementation and credibility. However, very few TBAs received misoprostol for direct distribution  comparedWeaknesses in distribution of misoprostol between CHWs and TBAs existed in both provinces.–We provide a number of recommendations for the MOH and resource team based on the lessons learned in the expansion phase . There iBOX 3The InnovationDistribute misoprostol directly to TBAs in situations where there are no CHWsIn areas without TBAs, allow CHWs to distribute misoprostol in advance to pregnant women in their catchment areaAdjust one or more criteria:Reduce the timeline to receive misoprostol at ANC from 28 weeks gestation to 24 weeksReduce the distance to 5 km or measure it in time Dissemination and AdvocacyWidely disseminate the National PPH Strategy to all health staff including pharmacists and provincial and district authoritiesImplement a human rights-based approach that advocates to health staff and communities that women have a right to access misoprostolIncrease demand in the community by disseminating information about the benefits of misoprostol, how to safely use it, and where to access it via CHWs, TBAs, and mobile health unitsOrganizational ProcessUndertake a formal review of the misoprostol program to identify needed adaptations and develop a systematic scale-up strategy for the next phasesMedical chiefs and pharmacists should ensure a consistent supply of misoprostol, which meets the demand; review the push/pull system to allow for timely requisitions of misoprostolTrain more TBAs and health staff to increase the number of qualified people who can distribute misoprostolCosts/Resource MobilizationDevelop a long-term plan for resource mobilization or redistribution of resources to fund the misoprostol program and next phase of scale-upMonitoring and EvaluationProvide technical support to introduce the misoprostol indicators within the national health information systemAppoint provincial focal persons to support timely reporting and data analysisProvide a formal record/system to accurately record misoprostol provided to CHWS and returns of misoprostol,–Overall, the innovation was well-defined, credible, and adapted to the context. However, the introduction of restrictive eligibility criteria further complicated the distribution, limiting which women were targeted. The distance criteria was particularly contested by stakeholders and corroborated by health staff who made arbitrary decisions about who could or could not feasibly walk to the health facility while in labor. Applying eligibility criteria placed emphasis on facility-based birth instead of increasing uterotonic coverage. Due to the difficulty in assessing who is likely to experience PPH, misoprostol is often implemented as a population-based universal prevention method.Four of the nurses and midwives interviewed had not received training in the misoprostol program, limiting their involvement and impact. Fewer than half of all TBAs have been trained on the use of misoprostol and distance was not considered in recruitment. As a result, many women who give birth at home are not receiving misoprostol via their TBA. Both of these factors may have contributed to reduced coverage. We recommend future expansion plans consider implementation of the misoprostol program within all health facilities in the selected districts and/or province and training all health staff including pharmacists, CHWs, and TBAs to avoid these gaps in program implementation.,The budget for the misoprostol program was not fully funded by the government and depended on external funding. Funding is an essential component of catalyzing and sustaining scale-up, and the nature of short-term donor grants can impede a government's capacity to achieve national scale-up.The study revealed disparity between the coverage and access of misoprostol for PPH prevention in Inhambane and Nampula provinces. A number of factors may have resulted in inflated numerators. Some CHWs may have maintained their supplies that had yet to be distributed to TBAs or returned to the health facilities. One supervisor found duplication, where both a TBA and her client had received misoprostol. Given our finding that there was no space in the MNCH registers for returned misoprostol  yet limited utilization (23% of women who received misoprostol used it). Limited utilization may have been due to the emphasis on facility births in the province resulting in women coming to the health facility to give birth, or perhaps due to limited communication to the community surrounding the purpose of misoprostol. The barriers presented in On the other hand, high coverage and utilization was found in Nampula province, resulting in high uterotonic coverage at home births. This was perhaps due to the program being in the first year of implementation, provincial MNCH champions who encouraged implementation, a greater number of participating TBAs, and the additional benefits of technical support from an NGO, particularly relating to supervision. The original pilot took place in Nampula, which may have also positively contributed to increased buy-in from local MNCH leaders, health staff, CHWs, and TBAs.The lack of a data collection tool to record returned misoprostol was a barrier. In Inhambane, approximately 200 doses provided to CHWs were unaccounted and there was no data provided regarding misoprostol returns from CHWs or TBAs in Nampula. This may be attributed to the following: (1) most CHWs kept the medication in their drug kit for months until the TBA requested the misoprostol; (2) recording returns was not a formal process in the antenatal care clinics and not always recorded; (3) some CHWs directly distributed the medication to women where there was no TBA available; or (4) potentially misdirected for abortion or induction; however, there was no evidence to support this.,The program experienced significant difficulties with the logistics system to distribute the misoprostol, which should be anticipated and addressed as part of program planning and M&E. The majority of misoprostol was distributed in advance at antenatal care clinics with less than 20% distributed to CHWs to provide to TBAs . The intConcerns that misoprostol for the prevention of PPH would be used by CHWs, TBAs, or women for abortion impacted implementation. First, the program faced initial delays at the central level due to stakeholder concerns about the potential of incorrect use at the community level, and the need for further supervision delayed initial donor support for the misoprostol program in Mozambique.Communication, advocacy, and a human rights-based approach that reinforces that women have a right to access this lifesaving medication is needed from health leaders and champions to shift this culture of fear and ensure all staff understand the aims and protocol of the misoprostol program. The delivery gap—when public health professionals know what is effective and yet a gap remains on how the intervention is executed—remains a critical issue to implementation of health innovations.We interviewed national-level stakeholders and analyzed national documents and meeting notes. However, fieldwork was based in only 2 of the 10 provinces undertaking the misoprostol program. Inhambane province and Nampula province experienced differences in program inputs, resources, and outcomes. This limits the generalizability of the study to Mozambique and to other countries. This case study cannot project the impact of the program and analysis is limited to the early expansion phase. It is also important to note that this was a retrospective analysis of the planning and management of the misoprostol program using the ExpandNet/WHO framework; the framework was not explicitly utilized by the user group or resource team in Mozambique as a guide in their scale-up efforts. Lack of availability of quantitative data limited analysis and therefore we were only able to provide estimates of the coverage of misoprostol in the first 9 months of 2017. Furthermore, data on access to and utilization of misoprostol were based primarily on calculated, indirect estimates, not directly reported data, leading to imprecision.This study provided a retrospective analysis of the planning and the management of the early expansion of the scale-up of misoprostol for PPH prevention. The ExpandNet/WHO framework is a useful tool to plan, track progress, and allow for continuous learning. While the framework was not used in the planning or management of the misoprostol program in Mozambique, the scale-up effort would have benefited from the development of a more systematic scale-up strategy during the initial planning phase.This case study identified barriers and facilitators to scale-up, as well as recommendations for the misoprostol program rooted in the ExpandNet/WHO framework. The Mozambican misoprostol program benefits from political support, inclusion within the National PPH Strategy, and integration into some of the MOH infrastructure, systems, and human resources. Between 2018 and 2020, the MOH and resource team will focus on implementation in the existing 35 districts. This study identifies the need to have a formal review of the misoprostol program with the MOH, resource team, and other stakeholders to identify lessons learned and needed adaptations, and to develop a systematic scale-up strategy to guide the continued national scale-up process.


However, grounded on the theory of affordances, it may also stem from direct perception-action processes, which enable the formation of immediate perceived functional, social or symbolic meaning of place . In the  According to the UNICEF report on the state of world children , childhoIndependent mobility of children or youth in the urban setting can be defined as permission for children to move without adult supervision in their neighborhood and city  so that Human movement through the environment becomes more complex throughout development simultaneously that person-place interactions gain further complexity and multidimensionality. According to A more in depth approach to place experience is necessary to understand the complexity of immediate person-place perceptual processes of interaction. Drawing on the work of several scholars, Therefore, in sense of place research it is popular to refer to place attachment and place meaning as slow social constructive processes. Nevertheless, place may also be addressed as a direct perception-action process, grounded on the theory of affordances, which enables the formation of an immediate perceived meaning of place . MeaningIn the present study, the youth in place immediate experience and place meaning is theoretically hinged on actualized affordances of places. These are relational, situational and dynamical properties that temporally co-emerge within an entanglement of relations between the mind, body, culture and the environment, nested in embodied socio-cultural ecosystems . Also, oSoftGIS integrates a wider spectrum of methods and processes addressed as Public Participation Geographic Information Systems (PPGIS). In SoftGIS methodology, people’s local knowledge of the environment is personal, place-based, action-driven and spatially referenced , stemminThe seminal work of children methodology, which was designed for research with children and youth about environment quality  enable or unable progressively complex interaction or activity in the immediate environment. In this article we underline the neighborhood area as a meaningful environmental setting where youth-place transactions take place. According to Neighborhoods are conceived as embodied socio-cultural ecosystems which are relational, situational and dynamical, the same way affordances are . The neiBullerby type is constituted by opportunities for independent mobility and diversity of actualized affordances, where children and young people establish a positive interrelated cycle between mobility licenses and the actualization of affordances leading to a continuous free roaming and perceived, utilized and shaping of affordances (most child-friendly). The Glasshouse type is constituted by the same number of actualized affordances as the previous one. This means that the spatial environment of the neighborhood is rich in transactional place experiences for children and youths to engage. However, due to independent mobility restrictions, the promoted and free fields of action are limited. The Wasteland type is composed by opportunities for independent mobility in the neighborhood and a low number of actualized affordances due to the monomorphic properties of the environment. The Cell type is any environment, or setting where children are trapped inside, constituted by restrictions to free roaming in the neighborhood, preventing children and youths of perceiving potential affordances. In the other aforementioned research , which provides an individualized approach of person in place relations. This represents a leap from an immediate sensory experience that takes place when the person is physically and spatially in contact with the immediate environment, because the person is actually in front of a computer screen looking at the daily environment and locating affordances of places through the use of web-map survey. Such assumption poses a risk to the original conception of the “affordance” as a functional significant environmental property detected by the individual in the immediate environment which provides an opportunity for action . In one Moreover, this research addresses the notion of actual versus ideal mobility in the urban environment according to youth’s perspectives. To the best of our knowledge, this is the first study using SoftGIS methodology that provides such an approach. Additionally, place based interactions and meanings, and actual and ideal mobility to meaningful places are pivotal to address children’s right to the city, in terms of place attachment, place meaning, social activity, play, leisure, and participation.According to several scholars, the study of mobility and person-place relationships in the socio-physical environment as intertwined topics offers a valuable perspective of social meaningful research for the development of healthier and happier communities . As an iMage = 12.41; SD = 1.43; girls = 48.3%), from three schools located in the Great Lisbon area, were included as participants of this research (“L” group). All places that were marked outside each participant’s municipality were excluded.A total of 145 sixth to ninth graders, aged 11–17 years old  in the west area is located in the parish of Belém, in Lisbon municipality. This parish has an area of 10.43 km2 with 16551 inhabitants. The school  in the coastal area is located in the parish of Paço de Arcos, in Oeiras municipality. The municipality of Oeiras faces the river/sea front and it is spread over an area of 45.72 km2, with a total of 172120 inhabitants. The school  in the northeast is located at the parish of Parque das Nações, in Lisbon municipality. This parish spreads over an area of 5.44 km2 with a total of 21025 residents.The characterization of our sample was devised through consultation of the Statistics Portugal web site (INE) and of other official web sites of the municipalities and parishes where the three schools are located. Although each school represents different geographical locations, west, coastal and northeast of the Great Lisbon area, as a whole these three areas share a similar degree of urbanization and cultural trends and are representative of the social and built tissue that characterizes the urban environment of the Great Lisbon Area in its diversity and complexity. The school  survey’s content, including the grouping of affordances in each expressional category, was inspired in the work of The list of social, functional, leisure, and emotional affordances of places , is presented in Tables “affordance sub-set” one criteria was devised and preceded by the phrase “place interactions where”  and Gender (girls and boys) were operationalized as categorical variables in the SPSS data sheet.School-home distance was calculated by determining mean linear distance (in meters and converted afterwards to kilometers) between participants’ homes and the school which was attended by them.Actual and ideal school-home mobility were determined by analyzing children’s single choice answers on travel mode and travel accompaniment. For the former (descriptive purpose), active travel, when choice included “on foot,” “by bicycle,” or “by other ; motorized travel, when choice included “by car”; hybrid travel, when choice included “by bus/by public transport.” When considering actual mobility vs. ideal mobility, travel mode was operationalized as a dichotomous variable, active travel and non-active travel (motorized or hybrid). As for travel accompaniment, it was operationalized as independent travel, when choice included “alone” or “with other children”; and non-Independent travel- when choice included “with adults” or “with adults and other children.”Meaningful affordances of places were operationalized as actualized affordances located in the web-map environment considering four predetermined expressional categories, social, functional, leisure and emotional, which were selected by participants when completing the web-map questionnaire. More specifically they were designated as social, functional, leisure, and emotional affordances of places considering each designated expressional category of place interaction. Subsequently, all selected affordances within its expressional category were classified as nominal variables according the sub-sets proposed in each of those expressional categories. This data was then introduced in the SPSS data sheet and in the QGIS software.Distance between home and meaningful places was operationalized as “territorial distance” and calculated using the QGIS software by determining mean linear distance (in meters and converted afterwards to kilometers) between participants’ homes and meaningful places where affordances were actualized. Subsequently, this new variable was imported to the SPSS data sheet.Neighborhood area was defined by a circular buffer of 500 m around each participant’s home. This variable was created to classify affordances of places in terms of being located in or out of the neighborhood area. All affordances of places located within 500 m of the respective home place (linear distance) were classified as being “within the neighborhood,” while others marked over 500 m were classified as “beyond the neighborhood.”Mobility to meaningful places other than school was determined by analyzing participants’ multiple choice answers on travel mode and travel accompaniment, after locating each meaningful affordance in the web-map. This means that when analyzing mobility to meaningful places, focus is not on the actual participant but on the place determined via the location of an affordance, and its multiple possibilities of being traveled to regarding travel mode and travel accompaniment. Travel mode was operationalized as three variables . Active travel if choice included “on foot,” “by bicycle,” or “by other ; motorized travel if choice included “by car”; and hybrid travel if choice included “by bus/by public transport.” Travel accompaniment was operationalized as two variables . Independent travel if choice selection was “alone” or “with other children” and non-independent travel if it included “with adults” or “with adults and other children” (presence of both simultaneously and therefore not autonomous). In the SPSS data sheet, each of these variables was coded individually.t-tests were used to determine if travel accompaniment was related with traveling distance in the school-home journey and if actual mobility  was related with traveling distance to meaningful places. As for home-school accompaniment, participants’ choice was attributed in two mutually exclusive available possibilities (independent travel and non-independent travel). The dependent variable was distance and the independent variable was each travel type of accompaniment. Hence, statistically, two separate sub-groups (one according each travel accompaniment) were constituted from the whole research group (L). The differences between actual and ideal school-home mobility and actual and ideal mobility to meaningful affordances of places were investigated using McNemar tests.Frequency analysis and Chi-square tests were performed to investigate whether participants’ age groups or gender were associated with actual mobility and travel accompaniment in the school-home journey, and with actual mobility and travel accompaniment to meaningful places. A univariate analysis of variance was performed to determine if actual mobility  was related with school-home distance in the school-home journey. Concerning the home-school travel mode, participants’ choice was attributed in three mutually exclusive available possibilities . The dependent variable was distance and the independent variable was each travel mode. Hence, statistically, three separate sub-groups (one according each travel mode) were constituted from the whole research group (L). Independent samples Frequency analysis was performed to investigate: (i) which affordances of places were most actualized, (ii) how frequent was the actualization of each expressional category of affordances and (iii) which sub-sets of affordances of places were most actualized.Frequency analysis was performed to investigate variations on (i) actual mobility to meaningful places and (ii) the actualization of different categories of affordances of places when roaming in the neighborhood area.p < 0.001). Considering active travel mode , this value rises as participants’ age increases . As for hybrid travel (public transportation), this value also rises with participants’ age . Regarding motorized travel, conversely, and as expected, these values decrease as participants’ age increases . As for independent travel in the school-home journey, it was found to significantly increase as participants’ age rises, with values of 29.3, 65.1, and 84.6%, in the 11–12, 13–14, and 15–17 years old groups, respectively .A significant association was found between age groups and travel modes from home to school  and travel accompaniment (p > 0.05).Results indicate that there was no statistical significance relationship between gender and children’s actual school-home travel mode  = 8.65, p < 0.001]. Post hoc comparisons indicated that: (i) significant differences were found comparing mean distance traveled by the group of youths using active travel mode with mean distance traveled by the group using hybrid travel mode; (ii) significant differences were found comparing mean distance traveled by the group of youths using active travel mode with mean distance traveled by the group of youths using motorized travel mode; (iii) no significant differences were found comparing mean distances traveled by the group of youths using hybrid travel mode with mean distance traveled by the group of youths using motorized travel mode. Hence, the mean distance traveled by youths adopting active travel mode is significantly smaller  than mean distance traveled by youths using hybrid travel mode  (p = 0.001); and the mean distance traveled by youths adopting active travel mode  is also significant smaller than mean distance traveled by youths using motorized travel mode  (p = 0.003). These results indicate that participants’ active travel from school to home takes place if school-home mean distance is around 1.1 km. This is particularly relevant when taking in consideration that mean distance between school and home was found to be 2.3 km. In terms of school-home travel accompaniment, no significant differences were found comparing mean distance traveled by the group of youths who traveled independently with mean distance traveled by the group of youths who traveled non-independently.It was found a significant effect of school distance on children’s mode of travel from school to home in “L” research group . Children aged 15–17 years old significantly used more frequently hybrid travel mode to meaningful places when compared with participants from the other two age groups . Children aged 11–12 years old used motorized travel more often than children from the other two groups to access meaningful places . As for the relationship between age and travel type of accompaniment to meaningful places, traveling autonomously or in the company of other children (independent travel) was the most frequently used for the 13–14 years old and 15–17 years old age group; whereas for the youngest age group of children (11–12 years old), more often they traveled to meaningful places in the company of adults. Also, it were found statistical significant differences between the three age groups in terms of independent travel  and non-independent travel  to meaningful places. Particularly, older children travel autonomously more frequently to meaningful places and less often in company of adults than younger children do.In Figure 2(1) = 3.83, p = 0.050]. In terms of travel accompaniment to meaningful places, significant differences were found between girls and boys. Herein, more frequently boys (65.5%) than girls (59.9%) traveled independently (by themselves or in company of friends) to these places . Conversely, more frequently girls (60.4%) than boys (48.1%) traveled accompanied by adults (non-independently) to meaningful places .Gender was only found to be an influential variable when considering the option of hybrid travel to meaningful places, but not very significantly. More frequently girls (18.1%) used public transportation than boys (14.1%) when traveling to meaningful places . Mean distance for active travel was of 1.3 km , whereas for other modes of travel this value increased to 3 km .Our results showed an interplay between distance and use of different travel modes to meaningful places. Significant differences were found comparing mean distances traveled when adopting active travel and mean distances traveled when not using active travel [p < 0.001). The opposite trend was found in motorized travel mode, diminishing from 43.9 to 27.7%, respectively. As for hybrid travel, no significant differences were found on the real and ideal settings. Considering travel type of accompaniment, a significant increase on real to ideal independent travel was found, 61.9–83.2%, respectively (p < 0.001); together with a significant decrease on non-independent travel on both settings, with the values of 54.6 and 31.8% (p < 0.001).When comparing real and ideal travel modes used by participants when visiting meaningful places to actualize affordances, the McNemar’s test showed significant differences on active travel with an increase from 68.7 to 79%, accordingly . A mean number of 12.26 affordances of places were actualized by each participant. In L group, the highest frequency of actualized affordances within the four conceptualized expressional categories was “social” (35.4%), followed by “leisure,” “functional,” and “emotional” types, with 27.7, 21.6, and 15.3%, respectively. This same decreasing trend in the actualized affordances of places was found for both boys and girls. Figure Within social expressional category of affordances, those most actualized by participants in L group were “being with friends” (20.1%), “being myself” (13.5%), “being with adults” (8.8%), “being with animals “ (8.8%) and “being in peace and quiet” (6.8%), as described in Figure In what concerns functional expressional category, most actualized affordances were “playing ball games” (13.9%), “riding a bike” (13.9%), “running” (13.3%) and “skating” (11%), as described in Figure Considering leisure expressional category, most actualized affordances were “shopping” (18.8%), “cinema” 16.4%), “going out for a meal” (9.7%), “show/concert/disco” (6.9%), and “sports” (6.4%) as described in Figure .4%, “goiAs for emotional type of affordances of places, the mostly expressive were “fun” (12%), “calm” (10%), “noisy” (8.8%), and “dangerous” (8.4%), as presented in Figure Descriptive findings revealed an interplay between participants’ actual mobility and territorial distance covered by their traveling to meaningful places in the urban environment Figure . More spConsidering the four expressional categories of affordances of places, descriptive results showed social affordances of places as the most expressive type (42.9%) within the neighborhood area (500 m around participants’ home). The values found for the other three categories are very similar, 18.6%, 19.6%, and 18.8%, for functional, leisure and emotional place types of affordances, respectively.In the Great Lisbon area, when returning home from school, an increasing trend of active and independent travel as children grow older is similar to evidence found in other studies . In the In terms of the school-home-journey, actions should be undertaken in order to increase levels of independent and active mobility for the younger ages.children study found that children aged 11 years old traveled significantly more often to meaningful places adopting active travel modes; whereas older children (aged 14) used public transportation and motorized car travel. In the present study, older children traveled autonomously more frequently to meaningful places and less often in company of adults than younger children did. On the contrary, In what concerns actual mobility to meaningful places in the Great Lisbon area, across all age groups active travel was the most frequently mode used to roam in the urban environment. It is interesting to notice that older children prefer hybrid travel mode to meaningful places, probably because it allows for them to move autonomously to further places, enhancing territorial range, and therefore mean distance traveling using hybrid mode was the highest one (3.3 km). Likewise, Our results revealed gender as an influential variable in terms of travel accompaniment to meaningful places. More frequently boys than girls traveled independently (by themselves or in company of friends) to these places; and more frequently girls than boys traveled accompanied by adults, which is in accordance with previous studies e.g., . NeverthOur findings on mobility to meaningful affordances of places linked with previous results from other research lead us to conclude that it is important for local muncipalities to raise existing moderate levels of independent and active mobility for both boys and girls, and increase their territorial range, by making enviornments safer and less hostile for children and youth. In a study focused on children’s independent mobility in three distinct urbanized environments , The participants of this study identified a total of 1777 meaningful places. Mean number of meaningful places by participant was of 12.26. Former research conducted by Playgroundian City” has been described as an urban environment which offers their citizens, including, children and youths, a transactional richness where actualization, shaping, reshaping and emergence of play, leisure, social, and emotional affordances are available across different urban spaces. It may be that the Finnish urban environment, due to urban planning and a conscious and deliberate design, offers more possibilities for youths to engage in functional affordances, and thus physical activity play and motor behaviors; as it does in what concerns opportunities for independent mobility, as it is clearly demonstrated by the Finnish rank position (1st) and the Portuguese one (14th) in an international study involving 16 countries on children’s independent mobility  in consonance with the environment multidimensional character. Through the use of the hypothetical taxonomy adopted to categorize social affordances of places, it was found that the most expressive sub-categories which were actualized in the neighborhood were of relational and affectivity types of affordances. Therefore, we propose that the urban neighborhood enables youth to detect relational and affectional properties that are emotionally rich and meaningful.In the present study, the type of relational and affective immediate place experience and meanings that neighborhood area was found to afford youth are, in our perspective, key emotional features for place attachment to take place at the neighborhood level. According to Bullerby” and considered “child-friendly.” Also, a more recent work , whereas the majority of hybrid travel and most of motorized travel (takes place beyond this radius). Also, our results found neighborhood area as most prevalent in social affordances of places, since nearly half of them, within the four expressional categories, were actualized there. To assess the degree of youth-friendliness of neighborhoods, we used the hypothetical model proposed by ent work  on assesent work  and as aent work . In a syent work . Previouent work ; and anoent work . Also, aent work . More spspecialists of space, or spatialists. Moreover, the use of SoftGISchildren surveys allows participants to inform about such place meanings and daily psycho-spatial narratives, which reinforces the perspective of youths as spatialists, in the sense of informing about their embodied spatialism.Concerning the production of places, We believe this research to be noteworthy as it provides a valuable and innovative insight to address the interplay of mobility, affordances of places and the neighborhood area. However, some limitations should be considered. Firstly, participants were asked to select affordances of places and localize them on the web map in the place where these interactions occurred. This means that some of the places which were marked on the web map may have been located in a nearby area, without really considering the place which was intended to. Consequently, it is possible to have existed place discrepancies between real intentioned place and the digital perspective of places. Nevertheless, and due to the nature of the research work and to the data collection instrument that was used, these limitations could not have been overcome. In spite of these setbacks, 1777 meaningful places were located. Secondly, the grouping of affordances on each of the expressional categories  was empirically driven and devised based on criteria defined by the author. Future studies should test these subsets of affordances using appropriate statistical based clustering. Likewise, other criteria for each category of affordances could have been selected. However, each of the four criteria was coherently justified and applied within those terms. Thirdly, most statistical analyzes used in this research were based on descriptive statistics and inferential statistics were just used when analyzing specific relations between variables. Although we believe that for the exploratory-descriptive kind of study this approach proved to be effective, we do realize that certain data assumptions which were made must be read bearing this statistical limitation.A careful consideration related with the use of linear distances has to be made when interpreting our findings on the interplay of distance between home and school and mobility behaviors and between home and meaningful places; and on the interplay of distance and actualization of affordances of places, namely, when considering the 500 m neighborhood buffer. Linear distances do not correspond to the real distances traveled by youths, adopting any type of travel mode or of travel accompaniment, from home to school and from home to other meaningful places. Whichever ways youths use to move around, traveling is conducted using the street network and thus distance is not linear. A better measurement would have been to adopt the cognitive distance related to the street networks using space syntax or place syntax tools. Nevertheless, the use of linear distances, the shorter path between two points (crow-flies) has been adopted in other studies on active living research with children and youths, such as children methodology to study children’s independent mobility and child-place interactions in the environment; and, internationally, the first time where grouping of affordances within expressional categories was implemented. Future research, should explore grouping of affordances of places, validate, or redefine the used taxonomy for different expressional categories of affordances of places. Studies using SoftGISchildren methodology have focused on children’s daily use of places, however, and as far as what we are concerned, less attention has been paid to how children’s and youths’ perspectives on how they would like their urban environment to be. Our research through the analyses of youth’s actual mobility vs. ideal mobility to meaningful places provides a starting and seminal point to address these concerns using SoftGISchildren methodology. Also, in our opinion, future studies using SoftGISchildren methodology should include children and youths as co-designers of the web-map place based enquiries by integrating functionalities in the web-map survey to allow participants to graphically imagine child-friendly structures and settings. Moreover, SoftGISchildren methodology should be combined with other data collection methods, such as, semi-structured interviews; mobility diaries, GPS data, accelerometers, photo-voice; neighborhood walking; etc. A very interesting example of this was the development of an application called Mappiness used in a study conducted in the United Kingdom. At random moments, participants were signaled through the app to answer to a small survey while their exact spatial location was recorded using GPS coordinates , we believe that neighborhoods should also be designed to youths with interesting, intriguing and challenging play, leisure and recreational opportunities.Urban neighborhoods should be planned with places and routes that afford independent and active mobility of children and youths, which is associated with physical activity, health and well-being. This type of planning also promotes a diversified place experience of the territory.versus ideal mobility to meaningful places.SoftGISchildren methodology enables the empowerment of children and youths as active-participants by providing relevant information to planners about their perceptions and experiences in the urban spheres, by digitally detecting affordances of places and reporting actual The use of SoftGIS real-ideal survey mapping has proved to be an effective youth-friendly process that enables participants to digitally report about their immediate place experiences and place meanings as real life actors that simultaneously influence and are influenced by the close environment. This perceptual communality between the physical and the digital place experience and meaning stresses place-based mapping as a more ecological methodology than the use of more traditional methods such as interviews, questionnaires and diaries. It is important to address the neighborhood area as a youth-friendly embodied ecosystem that promotes free roaming and social meaningful places and the claim of increased autonomy of movement by young people. Also, children and young people ought to be considered as pivotal actors and providers of meaningful information for urban planning processes. Public polices to promote youngsters’ health, well-being and happiness should therefore include active processes of participation, where the real and ideal city is critically discussed by youths.FL was the project leader and the corresponding author. FL did all of the field-work and did most of the writing with the contributions of RC. CN participated by discussing theoretical assumptions with FL and with RC.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Motherhood is a demanding part of any women’s life. Female interns could encounter difficulties during selection for residency program according to their plans of conceiving. Our aim is to explore the influence of female gender on the selection process of residency programs.A cross sectional study was conducted in 2016 at a University Hospital in Beirut, Lebanon. Female residents and chief of departments were interviewed about the impact of the timing of motherhood during residency on the interview for admission. The questionnaire reviewed concerns among female Lebanese medical residents as well as the head of departments revolving around the choice of opting for motherhood and the decision of integrating into a residency program while juggling motherhood responsibilities.Eighty nine female residents and 22 head of department agreed to participate in this study. During the interviews for residency acceptance, 29 residents (34.5%) were directly asked about their family and motherhood plans; 9% of them did not reveal their intention. 35% of the residents thought that this subject could affect the program directors’ decision. 47% of residents felt that having pregnant colleagues would add to their workload, and almost half of them (46%) believed that pregnant colleagues showed less productivity. 45% of program directors stated that it was an important factor taken into consideration during the interview, and 68% believed that residents tended to choose their specialty according to their life priorities.Pregnancy during residency training represents major challenges for female residents and their program directors. Rules and laws designed to set a balance between career and personal life are required to improve women’s ability to participate equally in the workforce. While women accounts for almost half of all medical students, problems encountered due to motherhood in the time of residency still remains an unresolved issue. We investigated the prevalent concerns among female Lebanese medical residents as well as the head of departments revolving around the choice of opting for motherhood and the decision of integrating into a residency program while juggling motherhood responsibilities. A cross sectional observational study on this research problem was conducted at a University Hospital in Beirut, Lebanon. Female residents and chief of departments were interviewed about their point of view regarding motherhood and maternity during residency. There were 89 residents and 22 head of department who agreed to participate in this study. During the interviews, 29 residents (34.5%) were directly asked about their family and motherhood plans, out of which 9% did not reveal their intention. Additionally, 35% of the residents thought that this subject could affect the program directors’ selection of residency candidates. Furthermore, half of them felt that having pregnant colleagues would add to their workload, and believed that pregnant colleagues showed less productivity. 45% of program directors stated that it was an important factor taken into consideration during the interview, and 68% believed that residents tended to choose their specialty according to their life priorities. Pregnancy during residency training represents major challenges for female residents and their program directors. Rules and laws designed to set a balance between career and personal life are required to simplify decision-making in this critical period.The existing literature on the subject matter of pregnancy during residency reports that residents struggle with the conflicting identities and roles of a mother, a student, and a physician . The imbThe number of women pursuing a career in medicine is gradually increasing. Most data comes from North American centers. In 1997, women comprised 43% of the medical students in the United States and 22% of practicing physicians [Other than their medical profession, women physicians remain responsible for the majority of domestic tasks and the upbringing of their children, making it difficult for them to devote the hours that a profession in medicine necessitates. Women students are hindered by family concerns, while male students are less influenced by them .Pregnancies during residency do occur, and they can cause professional setbacks for many residents . Long hoIn 2012, a random survey was distributed among 600 female physicians who had graduated from medical school in 1995. Infertility issues occurred in 24% of the respondents, with the average age of diagnosis at 33.7 years. In these cases, when asked what they would have changed in hindsight, 29% stated that they could have considered attempting conception earlier, 17% felt that they should have opted for a different specialty, and 7% wished they had utilized cryopreservation to extend fertility .Another issue frequently encountered by residents concerns the reaction of their colleagues. Fellow residents or practicing physicians may oppose any increase in work that they need to assume in the occasion where pregnant residents reduce their hours of work due to pregnancy or take maternity leaves. Pregnant residents found the physical demands sought by residency and lack of support from fellow residents and their departments to be the most taxing stressors. Feelings of anger and resentment toward the pregnant residents were common among the other residents .This study aims to study the intricate relationship between the personal life and career of female doctors, and the way it impacts the selection into a residency program.A cross sectional study was conducted in 2016 at the Hotel-Dieu de France University Hospital in Beirut, Lebanon, in order to evaluate how maternity and motherhood influence the specialty choice of residents.A 30-question survey was sent to 143 female residents. A separate 13-question survey was distributed electronically to program directors of all medical and surgical specialties at our University Hospital . There were no exclusion criteria pertaining to residents.The study protocol was approved by the institution’s ethical committee and the study was registered under the number: tfem/2017/16.Following an informed consent to participate, the survey was completed anonymously. The consent form was independent from the questionnaire, making the questionnaire anonymous for authors who analyzed the results. Several questions were drafted to address key issues. The survey was pilot tested with a small group; and subsequently, a final check was performed. Residents were asked about their demographics . The survey focused on maternity and included questions designed to explore issues surrounding the timing of pregnancy during residency and perceptions regarding the impact of maternity and marriage on the residents’ training as well as on their career and specialty choice.Head of departments were questioned about their demographics , their opinion concerning maternity during residency, and its impact on the resident’s productivity, as well as the impact during the specialty interview.Questionnaires included closed-end items and open questions for mentioning particular comments. All the questionnaires were submitted over a period of 2 months.Among the 143 residents, 89 completed the survey (response rate of 62%). Among the 23 head of departments, 22 completed the survey (95.6%).The mean age of the residents is 28 years . Among the 89 residents, only 14 were married (15.7%) and only 5 had kids (35.7% of the married residents). All of them had only one child, and the pregnancy occurred during their third or fourth year. The characteristics of resident respondents and program directors are summarized in Tables With regard to the timing and the opinion of our residents, at the end of their 7th year of medical school, 60/89 (68%) declared that maternity was not an influencing factor for their specialty choice. At the end of PGY1, 63 residents (81%) also declined that maternity was an influencing factor guiding their specialty choice.During interviews, 29 residents (34.5%) were asked questions pertaining to maternity and parenthood, and most of them (91%) declared that they were honest about their response, while 9% stated that they were not. Indeed, 35% thought that this subject could influence the program director’s selection choice, 24% thought it would not, and 41% were unsure. Conversely, 45% (10 of 22) of program directors revealed that it was an important factor to be taken into consideration during the interview, and 68.1% believed that residents chose their specialty according to their life priorities.When questioned about their actual priorities, 87.1% of residents confirmed that their education and career came first, and only 12.9% were found to be family-oriented at that stage. Moreover, 63.6% of doctors thought that residents can simultaneously manage both a career and a family. Although 17 program directors (77%) thought that the best time for a resident to have a child was after their subspecialty, 32% of them had their first child during residency.Despite all the difficulties and obstacles that female residents have to encounter during pregnancy, the motivating factors that lead to their pregnancy include the desire to start a family (85%), encouragement from parents (38%), fear of future infertility (37%), financial independence (16%), and flexible schedules (14%) in that order.An analysis of the impact of pregnancy on their work revealed that among the 7 residents who have children, during their first trimester, 4 (57%) did not leave work before 6 pm and 2 (29%) stayed back extra hours. During their second trimester, 5 (71%) did not leave work before 6 pm and the other 2 worked extra hours. During their last trimester, 3 (43%) could not stay until 6 pm and had to leave early.With respect to the point of view of their colleagues, 41 of 88 respondents (46.6%) felt that their pregnant colleagues increased their personal workloads and almost half of them  believed that they were less productive.n = 18) and 91% (n = 20) thought motherhood affects their residents’ productivity even further. Details of the effects of motherhood based on these perspectives are summarized in Table Program directors thought that marriage alone affects productivity and work  has to be taken toward the end of medical school, and the second specialty decision takes place at the end of the first year for surgical specialties or the second year for internal medicine specialties. One hypothesis explaining the reasons behind motherhood not being planned before the third year is the simple fact of postponing its stress and effect on career decisions and maybe the program directors’ decision.In fact, it was found that 34.8% of residents thought that this subject could influence the program director’s choice unfavorably, and 45.4% (10 of 22) of program directors revealed that it was indeed an important factor during the interview.Trying hard to strike a balance between family life and medical career exerts an impact on future choices  and education. Choosing the right time to start a family is a crucial decision for women pursuing medicine, especially considering that women’s prime child-bearing years coincide with the peak of her medical studies and residency, when work constraints are considerable and finances are tight, with little disposable income to hire professional assistants (the late 20s and early 30s).These are popular opinions in many parts of the world—70% of American physicians in their response to a national survey stated that the best time for a pregnancy would be after residency, although 44% of these respondents had been pregnant during residency . A 1996 All these problems can be solved by planning for residents’ pregnancies and clear maternity/parental leave policies . Stress The authors are aware that the results of this pilot study are limited by the number of participants and also by the limited response rate among residents (62%); larger studies involving universities in various countries and societies would be necessary to have a clear view over this important aspect of female physicians.The combination of a medical career and motherhood continues to pose challenges for women—a subject matter that warrants further investigation and targeted support. Lebanese training programs can successfully enhance the experience of motherhood during residency by providing policies or laws creating a healthy balance between the competing demands of family, work, and student life. This will certainly have a positive impact on the resident’s productivity and will decrease the extra workload faced by the colleagues of pregnant residents. Authors hope that pointing out this issue will lead authorities in many countries to design targeted rules and laws to set a balance between career and personal life to reinforce women’s ability to participate equally in the workforce during the female residency training period.