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Summary: Background: Infections and sepsis are leading causes of morbidity and mortality in women during pregnancy and the post-pregnancy period. Using data from the 2017 WHO Global Maternal Sepsis Study, we explored the use of early warning systems (EWS) in women at risk of sepsis-related severe maternal outcomes. Methods: On April 27, 2023, we searched the literature for EWS in clinical use or research in obstetric populations. We calculated the proportion of women for whom each existing EWS identified them as at risk for developing severe maternal outcomes by infection severity (complications and severe maternal outcomes). Sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratios, and J statistics were calculated to assess EWS performance. Machine learning was used to test the diagnostic potential of routine maternal sepsis markers. Findings: 21 EWS were assessed in 2560 women from 46 countries with suspected or confirmed infections. The NICE Risk Stratification tool, Modified Shock Index, maternity Systemic Inflammatory Response Syndrome, and Early Maternal Infection Prompts scores had high sensitivity (88.1–97.5%) for identifying sepsis-related severe maternal outcomes. The quick Sequential Organ Failure Assessment (SOFA) in Pregnancy score and Obstetrically modified SOFA had high specificity (90.4–100%) for identifying women with sepsis-related severe maternal outcomes. Furthermore, combinations of sepsis markers had very low sensitivity and high specificity using machine learning. Interpretation: No score demonstrated enough diagnostic accuracy to be used alone to identify sepsis. However, obstetric—and sepsis-specific EWS performed better for early identification of maternal sepsis than non-obstetric and non-sepsis-specific scoring systems. There are limitations to applying EWS to real-world data, mainly due to the incompleteness of medical data that hinders EWS effectiveness. There is a need to continue developing and testing criteria for early identification of maternal sepsis. Funding: UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), WHO, Merck for Mothers, U.S. Agency for International Development, Wellcome Trust, and National Institute for Health and Care Research.

Introduction Reducing neonatal deaths in premature infants in low- and middle-income countries is key to reducing global neonatal mortality. International neonatal networks, along with patient registries of premature infants, have contributed to improving the quality of neonatal care; however, the involvement of low-to-middle-income countries was limited. This project aims to form an international collaboration among neonatal networks in Asia (AsianNeo), including low-, middle- and high-income countries (or regions). Specifically, it aims to determine outcomes in sick newborn infants, especially very low birth weight (VLBW) infants or very preterm infants, with a view to improving the quality of care for such infants.Methods and analysis Currently, AsianNeo comprises nine neonatal networks from Indonesia, Japan, Malaysia, Philippines, Singapore, South Korea, Sri Lanka, Taiwan and Thailand. AsianNeo will undertake the following four studies: (1) institutional questionnaire surveys investigating neonatal intensive care unit resources and the clinical management of sick newborn infants, with a focus on VLBW infants (nine countries/regions); (2) a retrospective cohort study to describe and compare the outcomes of VLBW infants among Asian countries and regions (four countries/regions); (3) a prospective cohort study to develop the AsianNeo registry of VLBW infants (six countries/regions); and (4) implementation and evaluation of educational and quality improvement projects in AsianNeo countries and regions (nine countries/regions).Ethics and dissemination The study protocol was approved by the Research Ethics Board of the National Center for Child Health and Development, Tokyo, Japan (reference number 2020–244, 2022–156). The study findings will be disseminated through educational programmes, quality improvement activities, conference presentations and medical journal publications.

Introduction: World Health Organization (WHO) has identified essential newborn care interventions to improve the care of every newborn. In 2015, the WHO published evidence-based guidelines to improve pre-term birth. Though Sri Lanka also adheres to these recommendations on interventions to improve pre-term birth outcomes, coverage of them have not yet been assessed for the country and there is no recent assessment of essential newborn care coverage as well. Objectives: To describe the practice of essential newborn care (ENC) for babies born pre-term and WHO recommended interventions to improve pre-term birth outcomes in government hospitals of Colombo District. Methods: A descriptive cross-sectional study with two components was conducted in seven government hospitals with obstetric and neonatal care facilities in Colombo District in 2017-2018. The first component describes the coverage of essential newborn care (ENC) assessed by direct observation among convenient sample of 77 deliveries. The second component assessed the practice of recommended interventions to improve pre-term birth. Data were extracted by pre-intern doctors from the medical records using a checklist on 510 pre-terms. Descriptive analysis was done. Results: In relation to ENC, among 77 deliveries, preparation before delivery was satisfactory and it was >90%. Overall, the practice of immediate newborn care interventions were satisfactory, but a low coverage was found for maternal abdomen delivery 31(40.3%), delayed cord clamping 39 (50.6%), temperature measurement 8(10.4%), educating about vitamin K 29 (37.7%), breastfeeding counselling 40 (51.9%) and delayed weighing 26 (33.8%). Practising recommended pre-term interventions was satisfactory except for the use of magnesium sulphate which was received by only 38 (60.3%) and kangaroo mother care was given for only 74 (57.8%). Conclusions & Recommendations: Most of the ENC practices and adhering to recommended interventions for pre-term were satisfactory except for a few. A refresher course of care for the preterm baby and ENC is recommended to the labour room staff.

Summary: Background: Heart disease (HD) is one of the leading indirect causes of maternal deaths worldwide, both in high- and low- and middle-income countries (LMICs). This study aims to describe maternal deaths due to cardiovascular disease complicating pregnancy in Sri Lanka. Methods: The national Maternal Death Surveillance Response (MDSR) system in Sri Lanka investigates all female deaths during pregnancy and 12 months after delivery. These maternal death investigation records were perused in this analysis. Maternal deaths from 2006 to 2018 with HD complicating pregnancy as the immediate or underlying cause of death were re-coded using the ICD-11 classification. Findings: Of the 2855 pregnancy-related deaths reported to the MDSR from 2006 to 2018, 1646 (57.7%) were confirmed as maternal deaths. Of those, 284 (17.25%) were attributed to HD complicating pregnancy. The cause-specific maternal mortality ratio due to heart disease from 2006 to 2018 was 7.24 per 100,000 live births. Rheumatic heart disease was the leading cause of HD (60, 21.1%), while cardiomyopathies (59, 20.7%) and congenital anomalies (34, 12.0%) accounted for a sizeable share. Medically contraindicated pregnancies accounted for 54 (19%) deaths. Application of the 3-delay model identified 186 (65.5%) cases with possible delays. Out of all deaths, 158 (55.6%) cases were categorized as preventable. Interpretation: Preventing maternal mortality from HD in LMICs requires a lifecycle approach with situation-specific interventions and highly specialized care. Community awareness, capacity building related to management, and specific infrastructure development will be key strategies. Funding: None.

Introduction: Preterm birth is a major challenge as a contributor to neonatal and child mortality in low- and middle-income countries (LMIC). Many countries toil to prevent and care for preterm babies. Country-specific solid data on risk factors of preterm births are crucial to formulate preventive strategies. Objectives: To determine the antenatal risk factors of preterm births in Sri Lanka Methods: An unmatched case-control study was conducted in seven Government hospitals with obstetric and neonatal care facilities in Colombo District in Sri Lanka. Live-born, spontaneous or provider-initiated, 374 preterm babies (24 weeks of gestation) as cases and live-born 374 term babies as controls were recruited from mothers who had a dating scan before 22 weeks. A risk factor profile worked out by extensive literature search and consultation of experts was subjected to multivariable analysis to identify risk factors. Results: Risk factors identified were: multiple pregnancy (adjusted odds ratio (aOR)=10.57; 95% CI: 3.48, 32.08); bleeding/spotting during pregnancy (aOR=3.51; 95% CI: 1.77, 6.98), past preterm birth (aOR= 2.83; 95% CI: 1.09, 7.36), recent stressful life event (aOR=2.62; 95% CI: 1.43, 4.81), higher gravidity (aOR=2.58; 95% CI: 1.35, 4.9), dissatisfaction with self-assessed own health (aOR=2.54; 95% CI: 1.52, 4.22), pregnancy induced hypertension (aOR=2.25; 95% CI: 1.16, 4.38), no antenatal dental assessment (aOR=2.16; 95% CI: 1.23, 3.81), unsatisfactory oral hygiene (aOR=2.01; 95% CI: 1.33, 3.04), long standing hours during 3rd trimester (aOR=1.91; 95% CI: 1.24, 2.94) and cooking using firewood (aOR=1.51; 95% CI: 1.01, 2.25). Sexual abstinence (aOR=0.46; 95% CI: 0.26, 0.81) was a protective factor. Conclusions & Recommendations: Modifiable and unmodifiable factors for preterm births were identified. Special care during pregnancy and early admission is recommended for multiple pregnancy, those had spotting during pregnancy and those had past preterm delivery. Avoiding stress during pregnancy and emphasizing oral hygiene are recommended.

Abstract Background Obstetric infections are the third most common cause of maternal mortality, with the largest burden in low and middle-income countries (LMICs). We analyzed causes of infection-related maternal deaths and near-miss identified contributing factors and generated suggested actions for quality of care improvement. Method An international, virtual confidential enquiry was conducted for maternal deaths and near-miss cases that occurred in 15 health facilities in 11 LMICs reporting at least one death within the GLOSS study. Facility medical records and local review committee documents containing information on maternal characteristics, timing and chain of events, case management, outcomes, and facility characteristics were summarized into a case report for each woman and reviewed by an international external review committee. Modifiable factors were identified and suggested actions were organized using the three delays framework. Results Thirteen infection-related maternal deaths and 19 near-miss cases were reviewed in 20 virtual meetings by an international external review committee. Of 151 modifiable factors identified during the review, delays in receiving care contributed to 71/85 modifiable factors in maternal deaths and 55/66 modifiable factors in near-miss cases. Delays in reaching a GLOSS facility contributed to 5/85 and 1/66 modifiable factors for maternal deaths and near-miss cases, respectively. Two modifiable factors in maternal deaths were related to delays in the decision to seek care compared to three modifiable factors in near-miss cases. Suboptimal use of antibiotics, missing microbiological culture and other laboratory results, incorrect working diagnosis, and infrequent monitoring during admission were the main contributors to care delays among both maternal deaths and near-miss cases. Local facility audits were conducted for 2/13 maternal deaths and 0/19 near-miss cases. Based on the review findings, the external review committee recommended actions to improve the prevention and management of maternal infections. Conclusion Prompt recognition and treatment of the infection remain critical addressable gaps in the provision of high-quality care to prevent and manage infection-related severe maternal outcomes in LMICs. Poor uptake of maternal death and near-miss reviews suggests missed learning opportunities by facility teams. Virtual platforms offer a feasible solution to improve routine adoption of confidential maternal death and near-miss reviews locally.