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Introduction: Digital data systems have the potential to improve data quality and provide individual-level information to understand gaps in the quality of care. This study explored experiences and perceptions of a perinatal eRegistry in two hospitals in Mtwara region, Tanzania. Drawing from realist evaluation and systems thinking, we go beyond a descriptive account of stakeholders' experiences and provide insight into key structural drivers and underlying social paradigms., Methods: We carried out 6 weeks of focused ethnographic observations at the labour wards of the two hospitals and 29 semi-structured qualitative interviews with labour ward staff, as well as with administrative and managerial stakeholders at hospital, district and regional levels. Multi-stage reflexive thematic data analysis was carried out., Results: We provide an in-depth account of the day-to-day functioning of the eRegistry in the two hospitals, including both aspects of positive change and key challenges with its integration into routine documentation duties. Experiences with and perceptions of the eRegistry were inextricably linked to broader systemic constraints relating to staffing, workload and infrastructure. A key underlying theme shaping the way people engaged with the eRegistry was the notion of data ownership: the presence or absence of a feeling of being responsible, involved and in control of data., Conclusion: Some of the key systemic challenges in recording accurate, timely information about women and their babies are not solved by digital tools. Our findings also underline that when healthcare workers feel that data are not primarily for them, they document only for reporting purposes. The eRegistry increased a sense of data ownership among the nurse-midwives directly involved with data entry, but the potential for promoting and supporting data use feedback loops for improvement in care provision remained largely untapped. Our findings highlight the importance of local relevance and ownership in digitisation of routine health information systems., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: The COVID-19 pandemic has demanded crisis management at all governance levels. While most research has focused on responses of national governments, city-level governance had significant potential to develop tailored approaches. This study explored how the local COVID-19 response was organised and adapted to the specific city population and context in the City of Antwerp, Belgium., Methods: A case study using semi-structured interviews was set up with 20 key informants with a central role in the coordination and implementation of the city-level COVID-19 response in Antwerp. Thematic analysis of transcripts was guided by an adapted version of the OECD risk management cycle., Results: Respondents' accounts provide a granular understanding of pandemic preparedness, crisis management, and response and adaptation to the COVID-19 crisis in a mid-size European city. Its size was large enough to have a strong capacity within its government bodies, to utilise the expertise of strong partners in the area and to mobilise a critical mass for action, yet small enough to quickly establish connections and trust. In addition to a universal approach, they developed tailored responses to specific neighbourhoods and groups. Well-established community and organisational ties enhanced the effectiveness of grassroots initiatives. The perceived feeling of joint action contributed to a strong collective agency, but respondents noted the need for a system for monitoring and learning., Conclusions: Local governments are important to develop tailored strategies and organise a locally relevant crisis response in cities. They need expertise and agency, with enough flexibility to experiment. To harness promising practices and avoid repeating errors in future crises, it is crucial to develop a system that better evaluates and monitors local responses, before, during and after crises., (© 2024. The Author(s).)

Data and indicator estimates are considered vital to document persisting challenges in maternal and newborn health and track progress towards global goals. However, prioritization of standardised, comparable quantitative data can preclude the collection of locally relevant information and pose overwhelming burdens in low-resource settings, with negative effects on the provision of quality of care. A growing body of qualitative studies aims to provide a place-based understanding of the complex processes and human experiences behind the generation and use of maternal and neonatal health data. We conducted a qualitative systematic review exploring how national or international requirements to collect and report data on maternal and neonatal health indicators are perceived and experienced at the sub-national and country level in low-income and lower-middle income countries. We systematically searched six electronic databases for qualitative and mixed-methods studies published between January 2000 and March 2023. Following screening of 4084 records by four reviewers, 47 publications were included in the review. Data were analysed thematically and synthesised from a Complex Adaptive Systems (CAS) theoretical perspective. Our findings show maternal and neonatal health data and indicators are not fixed, neutral entities, but rather outcomes of complex processes. Their collection and uptake is influenced by a multitude of system hardware elements (human resources, relevancy and adequacy of tools, infrastructure, and interoperability) and software elements (incentive systems, supervision and feedback, power and social relations, and accountability). When these components are aligned and sufficiently supportive, data and indicators can be used for positive system adaptivity through performance evaluation, prioritization, learning, and advocacy. Yet shortcomings and broken loops between system components can lead to unforeseen emergent behaviors such as blame, fear, and data manipulation. This review highlights the importance of measurement approaches that prioritize local relevance and feasibility, necessitating participatory approaches to define context-specific measurement objectives and strategies., (© 2024 The Authors.)

Background: We aimed to assess risk factors for neonatal mortality, quality of neonatal resuscitation (NR) on videos and identify potential areas for improvement., Methods: This prospective cohort study included women in childbirth and their newborns at four district hospitals in Pemba, Tanzania. Videos were analysed for quality-of-care. Questionnaires on quality-of-care indicators were answered by health workers (HW) and women. Risk factors for neonatal mortality were analysed in a binomial logistic regression model., Results: 1440 newborns were enrolled. 34 newborns died within the neonatal period (23.6 per 1000 live births). Ninety neonatal resuscitations were performed, 20 cases on video. Positive pressure ventilation (PPV) was inadequate in 15 cases (75%). Half (10/20) did not have PPV initiated within the first minute, and in one case (5.0%), no PPV was performed. PPV was not sustained in 16/20 (80%) newborns. Of the 20 videos analysed, death occurred in 10 newborns: 8 after resuscitation attempts and two within the first 24 h. Most of HW 49/56 (87.5%) had received training in NR., Conclusions: Video analysis of NR revealed significant deviations from guidelines despite 87.5% of HW being trained in NR. Videos provided direct evidence of gaps in the quality of care and areas for future education, particularly effective PPV., Impact: Neonatal mortality in Pemba is 23.6 per 1000 livebirths, with more than 90% occurring in the first 24 h of life. Video assessment of neonatal resuscitation revealed deviations from guidelines and can add to understanding challenges and aid intervention design. The present study using video assessment of neonatal resuscitation is the first one performed at secondary-level hospitals where many of the world's births are conducted. Almost 90% of the health workers had received training in neonatal resuscitation, and the paper can aid intervention design by understanding the actual challenges in neonatal resuscitation., (© 2023. The Author(s).)

Background: More than 2 million third-trimester stillbirths occur yearly, most of them in low- and middle-income countries. Data on stillbirths in these countries are rarely collected systematically. This study investigated the stillbirth rate and risk factors associated with stillbirth in four district hospitals in Pemba Island, Tanzania., Methods: A prospective cohort study was completed between the 13th of September and the 29th of November 2019. All singleton births were eligible for inclusion. Events and history during pregnancy and indicators for adherence to guidelines were analysed in a logistic regression model that identified odds ratios [OR] with a 95% confidence interval [95% CI]., Results: A stillbirth rate of 22 per 1000 total births in the cohort was identified; 35.5% were intrapartum stillbirths (total number of stillbirths in the cohort, n = 31). Risk factors for stillbirth were breech or cephalic malpresentation (OR 17.67, CI 7.5-41.64), decreased or no foetal movements (OR 2.6, CI 1.13-5.98), caesarean section [CS] (OR 5.19, CI 2.32-11.62), previous CS (OR 2.63, CI 1.05-6.59), preeclampsia (OR 21.54, CI 5.28-87.8), premature rupture of membranes or rupture of membranes 18 h before birth (OR 2.5, CI 1.06-5.94) and meconium stained amniotic fluid (OR 12.03, CI 5.23-27.67). Blood pressure was not routinely measured, and 25% of women with stillbirths with no registered foetal heart rate [FHR] at admission underwent CS., Conclusions: The stillbirth rate in this cohort was 22 per 1000 total births and did not fulfil the Every Newborn Action Plan's goal of 12 stillbirths per 1000 total births in 2030. Awareness of risk factors associated with stillbirth, preventive interventions and improved adherence to clinical guidelines during labour, and hence improved quality of care, are needed to decrease the stillbirth rate in resource-limited settings., (© 2023. The Author(s).)

The COVID-19 pandemic affects different people unequally, and migrants are frequently among the groups considered particularly vulnerable. However, conceptualizations of 'vulnerability' are often ambiguous and poorly defined. Using critical discourse analysis methods, this article analyses the academic use of the term 'vulnerable' applied to migrants in the context of the COVID-19 pandemic across public health and social science disciplines. Our findings indicate that the concept of vulnerability is frequently applied to migrants in the COVID-19 context as a descriptor with seemingly taken-for-granted applicability. Migrants are considered vulnerable for a wide variety of reasons, most commonly relating to exposure to and risk of contracting COVID-19; poverty or low socio-economic status; precarity; access to healthcare; discrimination; and language barriers. Drivers of migrants' vulnerability were frequently construed as immutable societal characteristics. Additionally, our analysis revealed widespread generalization in the use of the notion of vulnerability, with limited consideration of the heterogeneity among and between diverse groups of migrants. Conceptualizations of migrants' vulnerability in the COVID-19 pandemic were sometimes used to advance seemingly contradictory policy implications or conclusions, and migrants' own views and lived experiences were often marginalized or excluded within these discourses. Our analysis highlights that although some definable groups of people are certainly more likely to suffer harm in crisis situations like the COVID-19 pandemic, the use of 'vulnerable' as a fixed descriptor has potentially negative implications. As an alternative, we suggest thinking about vulnerability as the dynamic outcome of a process of 'vulnerabilisation' shaped by social order and power relations., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Background: Perinatal mental distress poses a heavy burden in low- and middle-income countries (LMICs). This study investigated perceptions and experiences of perinatal mental distress among women in a rural Ethiopian community, in an effort to advance understanding of cross-cultural experiences of perinatal mental distress., Methods: We employed a sequential explanatory study design. From a population-based cohort study of 1065 perinatal women in the Butajira Health and Demographic Surveillance Site, we purposively selected 22 women according to their scores on a culturally validated assessment of perinatal mental distress (the Self-Reporting Questionnaire). We examined concordance and discordance between qualitative semi-structured interview data ('emic' perspective) and the layperson-administered fully-structured questionnaire data ('etic' perspective) of perinatal mental distress. We analysed the questionnaire data using summary statistics and we carried out a thematic analysis of the qualitative data., Results: Most women in this setting recognised the existence of perinatal mental distress states, but did not typically label such distress as a discrete illness. Instead, perinatal mental distress states were mostly seen as non-pathological reactions to difficult circumstances. The dominant explanatory model of perinatal mental distress was as a response to poverty, associated with inadequate food, isolation, and hopelessness. Support from family and friends, both emotional and instrumental support, was regarded as vital in protecting against mental distress. Although some women considered their distress amenable to biomedical solution, many thought medical help-seeking was inappropriate. Integration of perspectives from the questionnaire and semi-structured interviews highlighted the important role of somatic symptoms and nutritional status. It also demonstrated the differential likelihood of endorsement of symptoms when screening tools versus in-depth interviews are used., Conclusions: This study highlights the importance of the wider social context within which mental health problems are situated, specificially the inseparability of mental health from gender disadvantage, physical health and poverty. This implies that public health prevention strategies, assessments and interventions for perinatal distress should be developed from the bottom-up, taking account of local contexts and explanatory frameworks.