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Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.

Women across the world are mistreated during childbirth. We aimed to develop and implement evidence-informed, validated tools to measure mistreatment during childbirth, and report results from a cross-sectional study in four low-income and middle-income countries.

(Abstracted from Lancet2019;394:1750–1763)Women around the world experience mistreatment during childbirth. This includes, but is not limited to, physical abuse, verbal abuse, discrimination, and procedures performed without consent.

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women's and health professionals' concerns, as well as health system and financial factors.

Many women experience mistreatment during childbirth in health facilities across the world. However, limited evidence exists on how social norms and attitudes of both women and providers influence mistreatment during childbirth. Contextually-specific evidence is needed to understand how normative factors affect how women are treated. This paper explores the acceptability of four scenarios of mistreatment during childbirth.

Efforts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2·6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for women's and children's health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure effect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.

(BJOG. 2021;128:1732–1743)Most postpartum hemorrhage (PPH) deaths occur due to uterine atony. While first-line interventions for PPH such as uterotonics, tranexamic acid, and uterine massage are effective for most patients, 10% to 20% of patients are unresponsive to these and are deemed to have “refractory” PPH. Uterine tamponade devices (UTD) used to treat refractory PPH include uterine balloon tamponade (UBT) and uterine suction tamponade (UST). The World Health Organization has previously issued a conditional recommendation for the use of UBT to treat refractory PPH due to uterine atony, based on case series and studies with no control population. Since then, several relevant studies, including randomized controlled trials, have been published. This systematic review aims to evaluate uterine tamponade devices for safety and effectiveness in treating atonic refractory PPH following vaginal birth and examine the effects of including uterine tamponade devices into institutional PPH protocols.

(N Engl J Med. 2020;383:2514–2525)Antenatal glucocorticoids are a common intervention in preventing adverse outcomes associated with preterm birth. The evidence supporting this intervention is based on trials in high-resource settings, however, and a 2015 trial in low-resource countries found scaling up this intervention caused an increase in neonatal death, stillbirth and suspected maternal infection. The World Health Organization (WHO) has issued guidelines restricting the use of antenatal glucocorticoids to certain situations. This study, the WHO ACTION-1 (Antenatal Corticosteroids for Improving Outcomes in Preterm Newborns) trial, aimed to determine the levels of safety and efficacy of dexamethasone in women at risk for early preterm birth in low-resource countries compared with placebo.

Although significant progress has been made towards Millennium Development Goal (MDG) 4 and 5 targets, maternal and neonatal mortality rates remain unacceptably high in low- and middle-income countries (LMICs). The potential for improvements in maternal and neonatal health outcomes with increased facility utilization in these countries is undermined by a lack of appropriate and timely treatment. Skilful emergency resuscitation can be the difference between life and death; therefore, training in emergency resuscitation is essential for health-care practitioners at all levels, with regular refresher sessions to ensure skill retention. Whilst there is little robust evidence on the impact of resuscitation training interventions on practitioner skills or patient outcomes, such training interventions are likely to have the greatest impact if integrated into a broader approach to improve the quality of care. Accelerated investments in training must go hand in hand with ensuring the availability of quality equipment and upgrading infrastructure to reduce the gap between current MDG status and what is achieved by the end of 2015; and to accelerate reductions in mortality rates beyond 2015 towards new Countdowntargets.

Duration of bladder catheterisation after female genital fistula repair varies widely. We aimed to establish whether 7 day bladder catheterisation was non-inferior to 14 days in terms of incidence of fistula repair breakdown in women with simple fistula.

Despite the global burden of morbidity and mortality associated with preterm birth, little evidence is available for use of antenatal corticosteroids and tocolytic drugs in preterm births in low-income and middle-income countries. We analysed data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) to assess coverage for these interventions in preterm deliveries.

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

The increase in annual global investment in biomedical research—reaching US$240 billion in 2010—has resulted in important health dividends for patients and the public. However, much research does not lead to worthwhile achievements, partly because some studies are done to improve understanding of basic mechanisms that might not have relevance for human health. Additionally, good research ideas often do not yield the anticipated results. As long as the way in which these ideas are prioritised for research is transparent and warranted, these disappointments should not be deemed wasteful; they are simply an inevitable feature of the way science works. However, some sources of waste cannot be justified. In this report, we discuss how avoidable waste can be considered when research priorities are set. We have four recommendations. First, ways to improve the yield from basic research should be investigated. Second, the transparency of processes by which funders prioritise important uncertainties should be increased, making clear how they take account of the needs of potential users of research. Third, investment in additional research should always be preceded by systematic assessment of existing evidence. Fourth, sources of information about research that is in progress should be strengthened and developed and used by researchers. Research funders have primary responsibility for reductions in waste resulting from decisions about what research to do.

We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities.

Macrosomia is a risk factor for adverse delivery outcomes. We investigated the prevalence, risk factors, and delivery outcomes of babies with macrosomia in 23 developing countries in Africa, Asia, and Latin America.

Active management of the third stage of labour reduces the risk of post-partum haemorrhage. We aimed to assess whether controlled cord traction can be omitted from active management of this stage without increasing the risk of severe haemorrhage.

Definition of small for gestational age in various populations worldwide remains a challenge. References based on birthweight are deficient for preterm births, those derived from ultrasound estimates might not be applicable to all populations, and the individualised reference can be too complex to use in developing countries. Our aim was to create a generic reference for fetal weight and birthweight that overcame these deficiencies and could be readily adapted to local populations.

There has been concern about rising rates of caesarean section worldwide. This Article reports the third phase of the WHO global survey, which aimed to estimate the rate of different methods of delivery and to examine the relation between method of delivery and maternal and perinatal outcomes in selected facilities in Africa and Latin America in 2004–05, and in Asia in 2007–08.

(Lancet. 2019;394:1750–1763)While quality of obstetric care has been examined in low- and middle-income countries, including life-saving interventions and health outcomes, maternal experience is often left out of these evaluations. There is established evidence across the world of mistreatment during childbirth, including physical and verbal abuse, nonconsent for procedures performed, and discrimination. Previous studies on this mistreatment have varied widely in their methods, including location, timing and populations, presenting challenges in making cross-study comparisons. The current investigators aimed to develop tools for collecting data on the burden of mistreatment which can be compared across contexts. The study consisted of formative and measurement phases. The formative phase involved systematic reviews and qualitative research conducted in Nigeria, Ghana, Guinea, and Myanmar. Data from this phase informed the measurement phase, which included both continuous observations during labor and community-based postpartum surveys to measure the prevalence of mistreatment during childbirth in those countries. This article reported only on the measurement phase of the study.

(Abstracted from BJOG2019;126:1524–1533)Women and their offspring are at heightened risk of morbidity and mortality during childbirth. Tools, such as the partograph, have been used to assist in labor-related decision-making over the last couple of decades.

Despite the call for universal access to reproductive health at the 4th International Conference on Population and Development in Cairo in 1994, sexual and reproductive health was omitted from the Millennium Development Goals and remains neglected (panel 1). Unsafe sex is the second most important risk factor for disability and death in the world's poorest communities and the ninth most important in developed countries. Cheap effective interventions are available to prevent unintended pregnancy, provide safe abortions, help women safely through pregnancy and child birth, and prevent and treat sexually transmitted infections. Yet every year, more than 120 million couples have an unmet need for contraception, 80 million women have unintended pregnancies (45 million of which end in abortion), more than half a million women die from complications associated with pregnancy, childbirth, and the postpartum period, and 340 million people acquire new gonorrhoea, syphilis, chlamydia, or trichomonas infections. Sexual and reproductive ill-health mostly affects women and adolescents. Women are disempowered in much of the developing world and adolescents, arguably, are disempowered everywhere. Sexual and reproductive health services are absent or of poor quality and underused in many countries because discussion of issues such as sexual intercourse and sexuality make people feel uncomfortable. The increasing influence of conservative political, religious, and cultural forces around the world threatens to undermine progress made since 1994, and arguably provides the best example of the detrimental intrusion of politics into public health.

The expected improvement in maternal and perinatal health in developing countries has not yet materialized. In addition to the factors related to socioeconomic conditions, we have identified areas where large gaps between evidence and practice are apparent. These gaps are in clinical care, implementation of effective practices and in selecting research priorities. We present examples from our own research and the literature to illustrate these points.

With more than 15 million infants born preterm annually, preterm birth is the largest cause of death among newborns and the second among children younger than 5 years. Antenatal corticosteroids can improve neonatal outcomes when given at 26 to 34 weeks plus 6 days’ gestation, even if given less than 24 hours before delivery. The use of antenatal corticosteroids outside this gestational age range is controversial, but they can be beneficial at 22 to 26 weeks. Tocolytic drugs inhibit labor progression, but their use alone does not reduce perinatal mortality. No reports have been published on patterns of tocolytic drug use in preterm labor in low- and middle-income countries. This analysis of the World Health Organization Multicountry Survey of Maternal and Newborn Health data set for facility-based deliveries in 29 countries was performed to assess patterns of use of antenatal corticosteroids in preterm deliveries and tocolytic drugs in spontaneous preterm deliveries.

This is an overview of 126 randomized controlled trials (RCTs) evaluating 36 prenatal interventions to prevent or treat impaired fetal growth (IFG). Results are based on systematic reviews including the meta-analyses of these RCTs. Most of the prenatal interventions do not show any significant effects on short-term perinatal outcomes. There are, however, a few interventions likely to be beneficial smoking cessation, antimalarial chemoprophylaxis in primigravidae, and balanced protein/energy supplementation. Others merit further research zinc, folate, and magnesium supplementation during gestation. Appropriate combinations of interventions should be a priority for evaluation because it is unlikely that a single intervention will reduce a multicausal outcome like IFG that is so dependent on socioeconomic disparities. Of concern is the discrepancy between the importance given in the epidemiological and clinical literature to the problem of IFG and the methodological quality and sample size of the RCTs conducted for the evaluation of preventive or treatment modalities.

Objective To select the misoprostol dose to be used in a large multicentre randomised trial comparing misoprostol with oxytocin in the routine management of the third stage of labour.

(Abstracted from New Engl J Med2018;379:743–752)Postpartum hemorrhage is the most common cause of maternal death. Oxytocin is the standard therapy for the prevention of postpartum hemorrhage, but it requires cold storage, which is not available in many countries, and has unsatisfactory real-world efficacy as a result of heat sensitivity and quality issues such as insufficient active ingredient or impurities.

A common prophylactic intervention used in the third stage of labor to reduce postpartum hemorrhage (PPH) can be labeled as active management. In the full management package used for active management, oxytocin is administered soon after delivery in combination with controlled cord traction. However, because the proper use of controlled cord traction requires manual skills, this procedure has been recommended only for skilled birth attendants. Unfortunately, a substantial proportion of maternal deaths from hemorrhage occur in settings in which skilled birth attendants are not available. Some evidence suggests that a simplified active package omitting controlled cord traction may have a similar effect on preventing blood loss, indicating that the uterotonic component in active management may be effective on its own. The contribution of controlled cord traction to blood loss is largely unknown.

The hypothesis underlying this study was that hospital obstetrical practices can be improved by interactive workshops that promote the use of evidence-based measures based on the World Health Organization’s Reproductive Health Library (RHL). The RHL is an annually updated electronic publication featuring Cochrane reviews in the area of reproductive health along with expert commentary, practical guidance documents, and various aids such as educational videos. Participating in the trial were 22 hospitals in Mexico City and 18 in northeast Thailand, whose maternity units conducted more than a thousand deliveries each year, and which had no direct affiliation with a university or other academic or research facility. Three workshops were held during a 6-month period: the first provided information about the project and principles of evidence-based decision-making; the second focused on RHL content; and the third concerned how best to implement desired changes. A stratified cluster randomized design took country, type of hospital, and number of births per year into account. The chief outcome measures were changes in 10 clinical practices as recommended in the RHL, implemented within 4 to 6 months after the third workshop.