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Summary Background Malnutrition is a major contributor to disease burden in India. To inform subnational action, we aimed to assess the disease burden due to malnutrition and the trends in its indicators in every state of India in relation to Indian and global nutrition targets. Methods We analysed the disease burden attributable to child and maternal malnutrition, and the trends in the malnutrition indicators from 1990 to 2017 in every state of India using all accessible data from multiple sources, as part of Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. The states were categorised into three groups using their Socio-demographic Index (SDI) calculated by GBD on the basis of per capita income, mean education, and fertility rate in women younger than 25 years. We projected the prevalence of malnutrition indicators for the states of India up to 2030 on the basis of the 1990–2017 trends for comparison with India National Nutrition Mission (NNM) 2022 and WHO and UNICEF 2030 targets. Findings Malnutrition was the predominant risk factor for death in children younger than 5 years of age in every state of India in 2017, accounting for 68·2% (95% UI 65·8–70·7) of the total under-5 deaths, and the leading risk factor for health loss for all ages, responsible for 17·3% (16·3–18·2) of the total disability-adjusted life years (DALYs). The malnutrition DALY rate was much higher in the low SDI than in the middle SDI and high SDI state groups. This rate varied 6·8 times between the states in 2017, and was highest in the states of Uttar Pradesh, Bihar, Assam, and Rajasthan. The prevalence of low birthweight in India in 2017 was 21·4% (20·8–21·9), child stunting 39·3% (38·7–40·1), child wasting 15·7% (15·6–15·9), child underweight 32·7% (32·3–33·1), anaemia in children 59·7% (56·2–63·8), anaemia in women 15–49 years of age 54·4% (53·7–55·2), exclusive breastfeeding 53·3% (51·5–54·9), and child overweight 11·5% (8·5–14·9). If the trends estimated up to 2017 for the indicators in the NNM 2022 continue in India, there would be 8·9% excess prevalence for low birthweight, 9·6% for stunting, 4·8% for underweight, 11·7% for anaemia in children, and 13·8% for anaemia in women relative to the 2022 targets. For the additional indicators in the WHO and UNICEF 2030 targets, the trends up to 2017 would lead to 10·4% excess prevalence for wasting, 14·5% excess prevalence for overweight, and 10·7% less exclusive breastfeeding in 2030. The prevalence of malnutrition indicators, their rates of improvement, and the gaps between projected prevalence and targets vary substantially between the states. Interpretation Malnutrition continues to be the leading risk factor for disease burden in India. It is encouraging that India has set ambitious targets to reduce malnutrition through NNM. The trends up to 2017 indicate that substantially higher rates of improvement will be needed for all malnutrition indicators in most states to achieve the Indian 2022 and the global 2030 targets. The state-specific findings in this report indicate the effort needed in each state, which will be useful in tracking and motivating further progress. Similar subnational analyses might be useful for other low-income and middle-income countries. Funding Bill & Melinda Gates Foundation; Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Background Continuous Positive Airway Pressure (CPAP) is a form of non-invasive ventilatory support which is increasingly used in low- and middle-income countries to treat neonates with acute respiratory distress. However, it may be harmful if used incorrectly. We aimed to explore the experiences of doctors and nurses using CPAP in neonatal units in India and their views on enablers and barriers to implementation of CPAP. Methods Participants from 15 neonatal units across Andhra Pradesh were identified through purposive sampling. Eighteen in-depth interviews (IDI) with doctors and eight focus group discussions (FGD) with 51 nurses were conducted. Data were analysed thematically using the framework approach. Results Common structural factors that limit the use of CPAP include shortages of staff, consumables and equipment, and problems with regard to the organisation of neonatal units in both district hospitals and medical colleges. This meant that CPAP was often not available for babies who were identified to need CPAP, or that CPAP use was not perceived to be of the highest quality. Providing care under constrained circumstances left staff feeling powerless to provide good quality care for neonates with acute respiratory distress. Despite this, staff were enthusiastic about the use of CPAP and its potential to save lives. CPAP use was mostly perceived as technically easier to provide than ventilation and allowed nurses to provide advanced neonatal care, independently of doctors. Conclusions Doctors and nurses embraced CPAP use but identified barriers to implementation which will need to be addressed in order not to impact on safety and quality of care. Ensuring a supportive and enabling environment is in place will be crucial if CPAP is to be scaled-up more widely. Electronic supplementary material The online version of this article (10.1186/s12887-018-1311-8) contains supplementary material, which is available to authorized users.

The WHO Safe Childbirth Checklist (the SCC) is a clinical tool developed to help health workers follow evidence-based maternal and perinatal care practices at childbirth. Newborn delivery care practices at facilities in seven countries in East Asia and the Pacific were compared to practices checked by the SCC. The analysis found that the SCC does not incorporate several key evidence-based practices around birth demonstrated to prevent newborn morbidity or mortality, or harmful practices associated with increased risks. A revision of the standard SCC is needed to maximise its potential to improve newborn outcomes. This can be initiated under the coordinating umbrella of WHO, but must ensure that the realities of labour and childbirth practices in low- and middle-income countries are considered and addressed.

Summary Background Progress in reducing maternal and neonatal deaths and stillbirths is impeded by data gaps, especially regarding coverage and quality of care in hospitals. We aimed to assess the validity of indicators of maternal and newborn health-care coverage around the time of birth in survey data and routine facility register data. Methods Every Newborn-BIRTH Indicators Research Tracking in Hospitals was an observational study in five hospitals in Bangladesh, Nepal, and Tanzania. We included women and their newborn babies who consented on admission to hospital. Exclusion critiera at admission were no fetal heartbeat heard or imminent birth. For coverage of uterotonics to prevent post-partum haemorrhage, early initiation of breastfeeding (within 1 h), neonatal bag-mask ventilation, kangaroo mother care (KMC), and antibiotics for clinically defined neonatal infection (sepsis, pneumonia, or meningitis), we collected time-stamped, direct observation or case note verification data as gold standard. We compared data reported via hospital exit surveys and via hospital registers to the gold standard, pooled using random effects meta-analysis. We calculated population-level validity ratios (measured coverage to observed coverage) plus individual-level validity metrics. Findings We observed 23 471 births and 840 mother–baby KMC pairs, and verified the case notes of 1015 admitted newborn babies regarding antibiotic treatment. Exit-survey-reported coverage for KMC was 99·9% (95% CI 98·3–100) compared with observed coverage of 100% (99·9–100), but exit surveys underestimated coverage for uterotonics (84·7% [79·1–89·5]) vs 99·4% [98·7–99·8] observed), bag-mask ventilation (0·8% [0·4–1·4]) vs 4·4% [1·9–8·1]), and antibiotics for neonatal infection (74·7% [55·3–90·1] vs 96·4% [94·0–98·6] observed). Early breastfeeding coverage was overestimated in exit surveys (53·2% [39·4–66·8) vs 10·9% [3·8–21·0] observed). “Don’t know” responses concerning clinical interventions were more common in the exit survey after caesarean birth. Register data underestimated coverage of uterotonics (77·9% [37·8–99·5] vs 99·2% [98·6–99·7] observed), bag-mask ventilation (4·3% [2·1–7·3] vs 5·1% [2·0–9·6] observed), KMC (92·9% [84·2–98·5] vs 100% [99·9–100] observed), and overestimated early breastfeeding (85·9% (58·1–99·6) vs 12·5% [4·6–23·6] observed). Inter-hospital heterogeneity was higher for register-recorded coverage than for exit survey report. Even with the same register design, accuracy varied between hospitals. Interpretation Coverage indicators for newborn and maternal health care in exit surveys had low accuracy for specific clinical interventions, except for self-report of KMC, which had high sensitivity after admission to a KMC ward or corner and could be considered for further assessment. Hospital register design and completion are less standardised than surveys, resulting in variable data quality, with good validity for the best performing sites. Because approximately 80% of births worldwide take place in facilities, standardising register design and information systems has the potential to sustainably improve the quality of data on care at birth. Funding Children's Investment Fund Foundation and Swedish Research Council.

Summary: Background: The association of air pollution with multiple adverse health outcomes is becoming well established, but its negative economic impact is less well appreciated. It is important to elucidate this impact for the states of India. Methods: We estimated exposure to ambient particulate matter pollution, household air pollution, and ambient ozone pollution, and their attributable deaths and disability-adjusted life-years in every state of India as part of the Global Burden of Disease Study (GBD) 2019. We estimated the economic impact of air pollution as the cost of lost output due to premature deaths and morbidity attributable to air pollution for every state of India, using the cost-of-illness method. Findings: 1·67 million (95% uncertainty interval 1·42–1·92) deaths were attributable to air pollution in India in 2019, accounting for 17·8% (15·8–19·5) of the total deaths in the country. The majority of these deaths were from ambient particulate matter pollution (0·98 million [0·77–1·19]) and household air pollution (0·61 million [0·39–0·86]). The death rate due to household air pollution decreased by 64·2% (52·2–74·2) from 1990 to 2019, while that due to ambient particulate matter pollution increased by 115·3% (28·3–344·4) and that due to ambient ozone pollution increased by 139·2% (96·5–195·8). Lost output from premature deaths and morbidity attributable to air pollution accounted for economic losses of US$28·8 billion (21·4–37·4) and $8·0 billion (5·9–10·3), respectively, in India in 2019. This total loss of $36·8 billion (27·4–47·7) was 1·36% of India's gross domestic product (GDP). The economic loss as a proportion of the state GDP varied 3·2 times between the states, ranging from 0·67% (0·47–0·91) to 2·15% (1·60–2·77), and was highest in the low per-capita GDP states of Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, and Chhattisgarh. Delhi had the highest per-capita economic loss due to air pollution, followed by Haryana in 2019, with 5·4 times variation across all states. Interpretation: The high burden of death and disease due to air pollution and its associated substantial adverse economic impact from loss of output could impede India's aspiration to be a $5 trillion economy by 2024. Successful reduction of air pollution in India through state-specific strategies would lead to substantial benefits for both the health of the population and the economy. Funding: UN Environment Programme; Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Background The use of obstetric early-warning-systems (EWS) has been recommended to improve timely recognition, management and early referral of women who have or are developing a critical illness. Development of such prediction models should involve a statistical combination of predictor clinical observations into a multivariable model which should be validated. No obstetric EWS has been developed and validated for low resource settings. We report on the development and validation of a simple prediction model for obstetric morbidity and mortality in resource-limited settings. Methods We performed a multivariate logistic regression analysis using a retrospective case-control analysis of secondary data with clinical indices predictive of severe maternal outcome (SMO). Cases for design and validation were randomly selected (n = 500) from 4360 women diagnosed with SMO in 42 Nigerian tertiary-hospitals between June 2012 and mid-August 2013. Controls were 1000 obstetric admissions without SMO diagnosis. We used clinical observations collected within 24 h of SMO occurrence for cases, and normal births for controls. We created a combined dataset with two controls per case, split randomly into development (n = 600) and validation (n = 900) datasets. We assessed the model’s validity using sensitivity and specificity measures and its overall performance in predicting SMO using receiver operator characteristic (ROC) curves. We then fitted the final developmental model on the validation dataset and assessed its performance. Using the reference range proposed in the United Kingdom Confidential-Enquiry-into-Maternal-and-Child-Health 2007-report, we converted the model into a simple score-based obstetric EWS algorithm. Results The final developmental model comprised abnormal systolic blood pressure-(SBP > 140 mmHg or 90 mmHg), respiratory rate-(RR > 40/min), temperature-(> 38 °C), pulse rate-(PR > 120/min), caesarean-birth, and the number of previous caesarean-births. The model was 86% (95% CI 81–90) sensitive and 92%- (95% CI 89–94) specific in predicting SMO with area under ROC of 92% (95% CI 90–95%). All parameters were significant in the validation model except DBP. The model maintained good discriminatory power in the validation (n = 900) dataset (AUC 92, 95% CI 88–94%) and had good screening characteristics. Low urine output (300mls/24 h) and conscious level (prolonged unconsciousness-GCS Conclusion We developed and validated statistical models that performed well in predicting SMO using data from a low resource settings. Based on these, we proposed a simple score based obstetric EWS algorithm with RR, temperature, systolic BP, pulse rate, consciousness level, urinary output and mode of birth that has a potential for clinical use in low-resource settings..

Background\ud To inform actions at the district level under the National Nutrition Mission (NNM), we assessed the prevalence trends of child growth failure (CGF) indicators for all districts in India and inequality between districts within the states.\ud \ud Methods\ud We assessed the trends of CGF indicators (stunting, wasting and underweight) from 2000 to 2017 across the districts of India, aggregated from 5 × 5 km grid estimates, using all accessible data from various surveys with subnational geographical information. The states were categorised into three groups using their Socio-demographic Index (SDI) levels calculated as part of the Global Burden of Disease Study based on per capita income, mean education and fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using coefficient of variation (CV). We projected the prevalence of CGF indicators for the districts up to 2030 based on the trends from 2000 to 2017 to compare with the NNM 2022 targets for stunting and underweight, and the WHO/UNICEF 2030 targets for stunting and wasting. We assessed Pearson correlation coefficient between two major national surveys for district-level estimates of CGF indicators in the states.\ud \ud Findings\ud The prevalence of stunting ranged 3.8-fold from 16.4% (95% UI 15.2–17.8) to 62.8% (95% UI 61.5–64.0) among the 723 districts of India in 2017, wasting ranged 5.4-fold from 5.5% (95% UI 5.1–6.1) to 30.0% (95% UI 28.2–31.8), and underweight ranged 4.6-fold from 11.0% (95% UI 10.5–11.9) to 51.0% (95% UI 49.9–52.1). 36.1% of the districts in India had stunting prevalence 40% or more, with 67.0% districts in the low SDI states group and only 1.1% districts in the high SDI states with this level of stunting. The prevalence of stunting declined significantly from 2010 to 2017 in 98.5% of the districts with a maximum decline of 41.2% (95% UI 40.3–42.5), wasting in 61.3% with a maximum decline of 44.0% (95% UI 42.3–46.7), and underweight in 95.0% with a maximum decline of 53.9% (95% UI 52.8–55.4). The CV varied 7.4-fold for stunting, 12.2-fold for wasting, and 8.6-fold for underweight between the states in 2017; the CV increased for stunting in 28 out of 31 states, for wasting in 16 states, and for underweight in 20 states from 2000 to 2017. In order to reach the NNM 2022 targets for stunting and underweight individually, 82.6% and 98.5% of the districts in India would need a rate of improvement higher than they had up to 2017, respectively. To achieve the WHO/UNICEF 2030 target for wasting, all districts in India would need a rate of improvement higher than they had up to 2017. The correlation between the two national surveys for district-level estimates was poor, with Pearson correlation coefficient of 0.7 only in Odisha and four small north-eastern states out of the 27 states covered by these surveys.\ud \ud Interpretation\ud CGF indicators have improved in India, but there are substantial variations between the districts in their magnitude and rate of decline, and the inequality between districts has increased in a large proportion of the states. The poor correlation between the national surveys for CGF estimates highlights the need to standardise collection of anthropometric data in India. The district-level trends in this report provide a useful reference for targeting the efforts under NNM to reduce CGF across India and meet the Indian and global targets.\ud \ud Keywords\ud Child growth failureDistrict-levelGeospatial mappingInequalityNational Nutrition MissionPrevalenceStuntingTime trendsUnder-fiveUndernutritionUnderweightWastingWHO/UNICEF targets

Objectives To map the integration of existing maternal tetanus immunization programmes within antenatal care (ANC) services for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with high performance maternal vaccine service delivery. Design A mixed methods, cross sectional study with four data collection phases including a desk review, online survey, telephone and face-to-face interviews and in country visits was undertaken between 2016 and 2018. Associations of different service delivery process components with protection at birth (PAB) and with country groups were established. PAB was defined as the proportion of neonates protected at birth against neonatal tetanus. Regression analysis and structural equation modelling was used to assess associations of different variables with maternal tetanus immunization coverage. Latent class analysis (LCA), was used to group country performance for maternal immunization, and to address the problem of multicollinearity. Setting LMICs. Results The majority of LMICs had a policy on recommended number of ANC visits, however most were yet to implement the WHO guidelines recommending eight ANC contacts. Countries that recommended > 4 ANC contacts were more likely to have high PAB > 90%. Passive disease surveillance was the most common form of disease surveillance performed but the maternal and neonatal morbidity and mortality indicators recorded differed between countries. The presence of user fees for antenatal care and maternal immunization was significantly associated with lower PAB ( Conclusions Recommendations include implementing the current WHO ANC guideline to facilitate increased opportunities for vaccination during each pregnancy. Improved utilisation of ANC services by increasing the demand side by increasing the quality of services, reducing any associated costs and supporting user fee exemptions, or the supply side can also enhance utilisation of ANC services which are positioned as an ideal platform for delivery of maternal vaccines.

Background Every year, an estimated 2.6 million stillbirths occur worldwide, with up to 98% occurring in low- and middle-income countries (LMIC). There is a paucity of primary data on cause of stillbirth from LMIC, and particularly from sub-Saharan Africa to inform effective interventions. This study aimed to identify the cause of stillbirths in low- and middle-income settings and compare methods of assessment. Methods This was a prospective, observational study in 12 hospitals in Kenya, Malawi, Sierra Leone and Zimbabwe. Stillbirths (28 weeks or more) were reviewed to assign the cause of death by healthcare providers, an expert panel and by using computer-based algorithms. Agreement between the three methods was compared using Kappa (κ) analysis. Cause of stillbirth and level of agreement between the methods used to assign cause of death. Results One thousand five hundred sixty-three stillbirths were studied. The stillbirth rate (per 1000 births) was 20.3 in Malawi, 34.7 in Zimbabwe, 38.8 in Kenya and 118.1 in Sierra Leone. Half (50.7%) of all stillbirths occurred during the intrapartum period. Cause of death (range) overall varied by method of assessment and included: asphyxia (18.5–37.4%), placental disorders (8.4–15.1%), maternal hypertensive disorders (5.1–13.6%), infections (4.3–9.0%), cord problems (3.3–6.5%), and ruptured uterus due to obstructed labour (2.6–6.1%). Cause of stillbirth was unknown in 17.9–26.0% of cases. Moderate agreement was observed for cause of stillbirth as assigned by the expert panel and by hospital-based healthcare providers who conducted perinatal death review (κ = 0.69; p p Conclusions For the majority of stillbirths, an underlying likely cause of death could be determined despite limited diagnostic capacity. In these settings, more diagnostic information is, however, needed to establish a more specific cause of death for the majority of stillbirths. Existing computer-based algorithms used to assign cause of death require revision.

Objectives\ud To determine the relation between place and skilled birth attendance at birth and early neonatal mortality.\ud \ud Design\ud Retrospective analysis using data from Demographic and Health Surveys on obstetric complications.\ud \ud Setting\ud Nine low and middle income countries between 2006 and 2013.\ud \ud Population\ud 71 758 women aged 15–49 years.\ud \ud Methods\ud A secondary analysis was carried out to investigate the occurrence and effect of obstetric complications on early neonatal mortality and association with place and attendance at birth. Obstetric complications studied were prolonged labour, puerperal infection and eclampsia.\ud \ud Main outcome measures\ud Association between early neonatal mortality and place and attendance at birth, unadjusted and adjusted for presence of severe obstetric complications.\ud \ud Results\ud Thirty-five percent of all births were at home: 70% of these were without skilled attendamts. Obstetric complications were reported in 17 079 women: 82% of these women gave birth in health facilities. Overall, no association was observed between place of birth or attendance at birth and early neonatal mortality. When adjusted for obstetric complications, the odds of early neonatal deaths for births at home without a skilled attendant were 1.3 (95% CI 1.1–1.5) compared with 1.2 (95% CI 1.0–1.5) with a skilled attendant and births in health facilities.\ud \ud Conclusions\ud When adjusted for obstetric complications, births in health facilities were associated with reduced early neonatal mortality. However, reporting and referral bias account for at least part of the association.\ud \ud Tweetable abstract\ud Births in health facilities are linked with fewer early newborn deaths when adjusted for obstetric complications.

Objective To apply the World Health Organization (WHO) Application of the International Classification of Diseases, tenth revision (ICD-10) to deaths during the perinatal period: ICD-Perinatal Mortality (ICD-PM) to existing perinatal death databases.Design Retrospective application of ICD-PM.Setting South Africa, UK.Population Perinatal death databases.Methods Deaths were grouped according to timing of death and then by the ICD-PM cause of death. The main maternal condition at the time of perinatal death was assigned to each case.Main outcome measures Causes of perinatal mortality, associated maternal conditions.Results In South Africa 344/689 (50%) deaths occurred antepartum, 11% (n = 74) intrapartum and 39% (n = 271) in the early neonatal period. In the UK 4377/9067 (48.3%) deaths occurred antepartum, with 457 (5%) intrapartum and 4233 (46.7%) in the neonatal period. Antepartum deaths were due to unspecified causes (59%), chromosomal abnormalities (21%) or problems related to fetal growth (14%). Intrapartum deaths followed acute intrapartum events (69%); neonatal deaths followed consequences of low birthweight/prematurity (31%), chromosomal abnormalities (26%), or unspecified causes in healthy mothers (25%). Mothers were often healthy; 53%, 38% and 45% in the antepartum, intrapartum and neonatal death groups, respectively. Where there was a maternal condition, it was most often maternal medical conditions, and complications of placenta, cord and membranes.Conclusions The ICD-PM can be a globally applicable perinatal death classification system that emphasises the need for a focus on the mother-baby dyad as we move beyond 2015.

IntroductionMaternal immunization (MI) with tetanus toxoid containing vaccine, is a safe and cost-effective way of preventing neonatal tetanus. Given the prospect of introducing new maternal vaccines in the near future, it is essential to identify and understand current policies, practices and unmet needs for introducing and/or scaling up MI in low-income and middle-income countries (LMICs).Methods and analysisThe Maternal Immunization and Antenatal Care Situation Analysis (MIACSA) is a mixed methods, cross-sectional study that will collect data in four phases: (1) a review of global databases for selected health indicators in 136 LMICs; (2) a structured online survey directed at Maternal, Newborn and Child Health and Expanded Programme on Immunization focal points in all 136 LMICs; (3) semistructured telephone interviews of 30 selected LMICs and (4) 10 week-long country visits, including key informant interviews, health facility visits and focus group discussions. The principal analyses will assess correlations between the various aspects of MI delivery strategies and proxy measures of health systems performance related to vaccine-preventable disease control. The primary outcome will be a typology of existing MI delivery models, and secondary outcomes will include country profiles of child and maternal health indicators, and a MI gaps and needs analysis.Ethics and disseminationThe protocol was approved by the WHO Ethics Review Committee (ERC.0002908). The results will be made available in a project report and submitted for publication in peer-reviewed journals that will be shared broadly among global health decision-makers, researchers, product developers and country-level stakeholders.

Background: To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn - Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels. Methods: EN-BIRTH is an observational study including >20000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses. Conclusions: To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths.

Objective\ud To identify the causes and categories of stillbirth using the Application of ICD-10 to Deaths during the Perinatal Period (ICD-PM).\ud Methods\ud Prospective, observational study in 12 hospitals across Kenya, Malawi, Sierra Leone and Zimbabwe. Healthcare providers (HCPs) assigned cause of stillbirth following perinatal death audit. Cause of death was classified using the ICD-PM classification system.\ud Findings\ud 1267 stillbirths met the inclusion criteria. The stillbirth rate (per 1000 births) was 20.3 in Malawi (95% CI: 15.0–42.8), 34.7 in Zimbabwe (95% CI: 31.8–39.2), 38.8 in Kenya (95% CI: 33.9–43.3) and 118.1 in Sierra Leone (95% CI: 115.0–121.2). Of the included cases, \ud 532 (42.0%) were antepartum deaths, 643 (50.7%) were intrapartum deaths and 92 cases (7.3%) could not be categorised by time of death. Overall, only 16% of stillbirths could be classified by fetal cause of death. Infection (A2 category) was the most commonly identified\ud cause for antepartum stillbirths (8.6%). Acute intrapartum events (I3) accounted for the largest proportion of intrapartum deaths (31.3%). In contrast, for 76% of stillbirths, an associated maternal condition could be identified. The M1 category (complications of placenta, cord and membranes) was the most common category assigned for antepartum deaths (31.1%), while complications of labour and delivery (M3) accounted for the highest proportion of intrapartum deaths (38.4%). Overall, the proportion of cases for which no fetal or maternal cause\ud could be identified was 32.6% for antepartum deaths, 8.1% for intrapartum deaths and 17.4% for cases with unknown time of death.\ud Conclusion\ud Clinical care and documentation of this care require strengthening. Diagnostic protocols and guidelines should be introduced more widely to obtain better data on cause of death, especially antepartum stillbirths. Revision of ICD-PM should consider an additional category\ud to help accommodate stillbirths with unknown time of death.

Background: The Auxiliary nurse midwife (ANM) cadre was created to focus on maternal and child health. ANMs are respected members of their communities and established providers of maternal and child health care within the community and at the facility level. Over time, additional roles and responsibilities have been added. Despite the importance of ANMs in the primary healthcare system in India, studies that consider factors governing the performance of ANMs in their workplaces are limited. We aimed to study factors governing performance of ANMs in Pune district, India. Methods: Semi-structured interviews were conducted with 13 purposely selected key informants at facility, district, state, and national levels. Focus group discussions were conducted with 41 ANMs and 25 members of the community. Non-participatory observations with eight ANMs provided information to expand on and scrutinise findings that emerged from the other lines of inquiry. A realist lens was applied to identify ANMs’ performance as a result of “mechanisms” (training, supervision, accountability mechanisms) within the given “context” (regulatory system, infrastructure and resources, ANMs’ expanded scope of work, gender roles and norms). Results: Weak enforcement of regulatory system led to poor standardisation of training quality among training institutions. Challenges in internal accountability mechanisms governing ANMs within the health system hierarchy made it difficult to ensure individual accountability. Training and supervision received were inadequate to address current responsibilities. The supervisory approach focused on comparing information in periodic reports against expected outputs. Clinical support in workplaces was insufficient, with very little problem identification and solving. Conclusion: Focusing on the tasks of ANMs with technical inputs alone is insufficient to achieve the full potential of ANMs in a changing context. Systematic efforts tackling factors governing ANMs in their workplaces can produce a useful cadre, that can play an important role in achieving universal health coverage in India.

IntroductionSeveral versions of Early Warning Systems (EWS) are used in obstetrics to detect and treat early clinical deterioration to avert morbidity and mortality. EWS can potentially be useful to improve the quality of care and reduce the risk of maternal mortality in resource-limited settings. We conducted a systematic literature review of published obstetric early warning systems, define their predictive accuracy for morbidity and mortality, and their effectiveness in triggering corrective actions and improving health outcomes.MethodsWe systematically searched for primary research articles on obstetric EWS published in peer-reviewed journals between January 1997 and March 2018 in Medline, CINAHL, SCOPUS, Science Direct, and Science Citation Index. We also searched reference lists of relevant articles and websites of professional societies. We included studies that assessed the predictive accuracy of EWS to detect clinical deterioration, or/and their effectiveness in improving clinical outcomes in obstetric inpatients. We excluded studies with a paediatric or non-obstetric adult population. Cross-sectional and qualitative studies were also excluded. We performed a narrative synthesis since the outcomes reported were heterogeneous.ResultsA total of 381 papers were identified, 17 of which met the inclusion criteria. Eleven of the included studies evaluated the predictive accuracy of EWS for obstetric morbidity and mortality, 5 studies assessed the effectiveness of EWS in improving clinical outcomes, while one study addressed both. Sixteen published EWS versions were reviewed, 14 of which included five basic clinical observations (pulse rate, respiratory rate, temperature, blood pressure, and consciousness level). The obstetric EWS identified had very high median (inter-quartile range) sensitivity-89% (72% to 97%) and specificity-85% (67% to 98%) but low median (inter-quartile range) positive predictive values-41% (25% to 74%) for predicting morbidity or ICU admission. Obstetric EWS had a very high accuracy in predicting death (AUROC >0.80) among critically ill obstetric patients. Obstetric EWS improves the frequency of routine vital sign observation, reduces the interval between the recording of specifically defined abnormal clinical observations and corrective clinical actions, and can potentially reduce the severity of obstetric morbidity.ConclusionObstetric EWS are effective in predicting severe morbidity (in general obstetric population) and mortality (in critically ill obstetric patients). EWS can contribute to improved quality of care, prevent progressive obstetric morbidity and improve health outcomes. There is limited evidence of the effectiveness of EWS in reducing maternal death across all settings. Clinical parameters in most obstetric EWS versions are routinely collected in resource-limited settings, therefore implementing EWS may be feasible in such settings.

Objective The WHO application of the tenth edition of the International Classification of Diseases (ICD-10) to deaths during the perinatal period (ICD Perinatal Mortality, ICD-PM) captures the essential characteristics of the mother-baby dyad that contribute to perinatal deaths. We compare the capture of maternal conditions in the existing ICD-PM with the maternal codes from the WHO application of ICD-10 to deaths during pregnancy, childbirth, and the puerperium (ICD Maternal Mortality, ICD-MM) to explore potential benefits in the quality of data received.Design Retrospective application of ICD-PM.Setting South Africa and the UK.Population Perinatal death databases.Methods The maternal conditions were classified using the ICDPM groupings for maternal condition in perinatal death, and then mapped to the ICD-MM groupings of maternal conditions.Main outcome measures Main maternal conditions in perinatal deaths.Results We reviewed 9661 perinatal deaths. The largest group (4766 cases, 49.3%) in both classifications captures deaths where there was no contributing maternal condition. Each of the other ICD-PM groups map to between three and six ICD-MM groups. If the cases in each ICD-PM group are re-coded using ICD-MM, each group becomes multiple, more specific groups. For example, the 712 cases in group M4 in ICD-PM become 14 different and more specific main disease categories when the ICD-MM is applied instead.Conclusions As we move towards ICD-11, the use of the more specific, applicable, and relevant codes outlined in ICD-MM for both maternal deaths and the maternal condition at the time of a perinatal death would be preferable, and would provide important additional information about perinatal deaths.

Background Escalation in the global rates of labour interventions, particularly cesarean section and oxytocin augmentation, has renewed interest in a better understanding of natural labour progression. Methodological advancements in statistical and computational techniques addressing the limitations of pioneer studies have led to novel findings and triggered a re-evaluation of current labour practices. As part of the World Health Organization's Better Outcomes in Labour Difficulty (BOLD) project, which aimed to develop a new labour monitoring-to-action tool, we examined the patterns of labour progression as depicted by cervical dilatation over time in a cohort of women in Nigeria and Uganda who gave birth vaginally following a spontaneous labour onset. Methods and findings This was a prospective, multicentre, cohort study of 5,606 women with singleton, vertex, term gestation who presented at ≤ 6 cm of cervical dilatation following a spontaneous labour onset that resulted in a vaginal birth with no adverse birth outcomes in 13 hospitals across Nigeria and Uganda. We independently applied survival analysis and multistate Markov models to estimate the duration of labour centimetre by centimetre until 10 cm and the cumulative duration of labour from the cervical dilatation at admission through 10 cm. Multistate Markov and nonlinear mixed models were separately used to construct average labour curves. All analyses were conducted according to three parity groups: parity = 0 (n = 2,166), parity = 1 (n = 1,488), and parity = 2+ (n = 1,952). We performed sensitivity analyses to assess the impact of oxytocin augmentation on labour progression by re-examining the progression patterns after excluding women with augmented labours. Labour was augmented with oxytocin in 40% of nulliparous and 28% of multiparous women. The median time to advance by 1 cm exceeded 1 hour until 5 cm was reached in both nulliparous and multiparous women. Based on a 95th percentile threshold, nulliparous women may take up to 7 hours to progress from 4 to 5 cm and over 3 hours to progress from 5 to 6 cm. Median cumulative duration of labour indicates that nulliparous women admitted at 4 cm, 5 cm, and 6 cm reached 10 cm within an expected time frame if the dilatation rate was ≥ 1 cm/hour, but their corresponding 95th percentiles show that labour could last up to 14, 11, and 9 hours, respectively. Substantial differences exist between actual plots of labour progression of individual women and the ‘average labour curves’ derived from study population-level data. Exclusion of women with augmented labours from the study population resulted in slightly faster labour progression patterns. Conclusions Cervical dilatation during labour in the slowest-yet-normal women can progress more slowly than the widely accepted benchmark of 1 cm/hour, irrespective of parity. Interventions to expedite labour to conform to a cervical dilatation threshold of 1 cm/hour may be inappropriate, especially when applied before 5 cm in nulliparous and multiparous women. Averaged labour curves may not truly reflect the variability associated with labour progression, and their use for decision-making in labour management should be de-emphasized., In a prospective cohort study, Olufemi Oladapo and colleagues investigated cervical dilation progression during the first stage of spontaneous labor in women from Nigeria and Uganda., Author summary Why was this study done? Dr Emmanuel Friedman’s studies on normal and abnormal labour progression have defined how labour should be managed since the mid-1950s until today. Although Friedman’s studies were conducted among pregnant women in the United States, the general belief that labour progression is the same in humans led to universal application of their findings, and the expectation that the cervix dilates by at least 1 cm/hour in all women during established labour. Since the early 2000s, however, researchers using new statistical methods to study labour found evidence to suggest that the patterns of labour progression as described by Friedman may not be accurate for the current generation of women giving birth. While these newer findings have informed changes in recommended labour practices in some settings, they have also generated a lot of controversy. As a result of persistent questions as to whether racial characteristics influence labour progression patterns, recent studies have been conducted among different populations, but not yet in any African population. What did the researchers do and find? We conducted an analysis of prospectively collected observational data of 5,606 women who presented in early labour (at or before 6 cm of cervical dilatation) following spontaneous labour onset and gave birth vaginally in 13 maternity hospitals in Nigeria and Uganda. None of these women experienced serious adverse outcomes for themselves or their babies. We applied advanced statistical and computational methods (survival analysis and Markov techniques) to determine how long it took the cervix to dilate by 1 cm from one level of dilatation to the next until full dilatation (10 cm) and how long it took the cervix to reach full dilatation based on the dilatation at the time of labour admission. We also used two separate methods to plot population average cervical dilatation time curves (labour curves) for the women in our sample. Contrary to the generally held view, we found that labour progressed more slowly in our study population than previously reported. On average, the rate of cervical dilatation was less than 1 cm/hour for some women until 5 cm of cervical dilatation was reached among those undergoing their first, second, or subsequent labours. Labour was very slow in some women throughout the first stage, including the early part of the period that is traditionally known as the ‘active phase’, when the ‘normal’ cervical dilatation rate is expected to be at least 1 cm/hour or faster. While on average the labour progression in first-time mothers was generally similar to their counterparts in the US, China, and Japan, there are also important differences in the slowest-yet-normal (95th percentile) group of women in our study population. What do these findings mean? The average labour curves derived from our study population are substantially different from those published from the pioneer work of Friedman. They also do not truly reflect the variations shown in the labour progression of individual women in our study. The application of population average labour curves could potentially misclassify women who are slowly but normally progressing as abnormal and therefore increase their chances of being subjected to unnecessary labour interventions. We propose that averaged labour progression lines or curves are not used for decision-making in the management of labour for individual women. As labour may not naturally accelerate in some women until a cervical dilatation of 5 cm is reached, labour practices to address perceived slow labour progression should not be routinely applied by clinicians until this threshold is achieved, provided the vital signs and other observations of the mother and baby are normal. In the absence of any problems other than a slower than expected cervical dilatation rate (i.e., 1 cm/hour) during labour, it is in the interest of the woman that expectant, supportive, and woman-centred labour care is continued.

We thank Marge Koblinksy for her considered editorial on the Maternal Death Surveillance and Response (MDSR) approach used in Kenya and lessons learned, described in our recent article published in GHSP. Her views on the potential effectiveness of MDSR in resource-limited settings, however, seem pessimistic.

A national coordinating structure was established but encountered significant challenges including: (1) a low number of estimated maternal deaths identified that only included some occurring within facilities, (2) only half of those identified were reviewed, (3) reviewers had difficulties assessing the cause of death largely because of limited documentation in clinical records; and (4) resulting actions were limited. Successful implementation will require addressing many issues, including building support for the process lower down in the health system., Maternal death surveillance and response (MDSR) constitutes a quality improvement approach to identify how many maternal deaths occur, what the underlying causes of death and associated factors are, and how to implement actions to reduce the number of preventable stillbirths and maternal and neonatal deaths. This requires a coordinated approach, ensuring both national- and district-level stakeholders are enabled and supported and can implement MDSR in a “no name, no blame” environment. This field action report from Kenya provides an example of how MDSR can be implemented in a “real-life” setting by summarizing the experiences and challenges faced thus far by maternal death assessors and Ministry of Health representatives in implementing MDSR. Strong national leadership via a coordinating secretariat has worked well in Kenya. However, several challenges were encountered including underreporting of data, difficulties with reviewing the data, and suboptimal aggregation of data on cause of death. To ensure progress toward a full national enquiry of all maternal deaths, we recommend improving the notification of maternal deaths, ensuring regular audits and feedback at referral hospitals lead to continuous quality improvement, and strengthening community linkages with health facilities to expedite maternal death reporting. Ultimately, both a top-down and bottom-up approach is needed to ensure success of an MDSR system. Perinatal death surveillance and response is planned as a next phase of MDSR implementation in Kenya. To ensure the process continues to evolve into a full national enquiry of all maternal deaths, we recommend securing longer-term budget allocation and financial commitment from the ministry, securing a national legal framework for MDSR, and improving processes at the subnational level.

Background Maternal Death Surveillance and Response (MDSR) implementation is monitored globally, but not much is known about what works well, where and why in scaling up. We reviewed a series of country case studies in order to determine whether and to what extent these countries have implemented the four essential components of MDSR and identify lessons for improving implementation. Methods A secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement. We identify the consistent drivers of success in countries with well-established systems for MDSR, and common barriers in countries were Maternal Death Review (MDR) systems have been less successful. Results MDR is accepted and ongoing at subnational level in many countries, but it is not adequately institutionalised and the shift from facility based MDR to continuous MDSR that informs the wider health system still needs to be made. Our secondary analysis of country experiences highlights the need for a) social and team processes at facility level, for example the existence of a ‘no shame, no blame’ culture, and the ability to reflect on practice and manage change as a team for recommendations to be acted upon, b) health system inputs including adequate funding and reliable health information systems to enable identification and analysis of cases c) national level coordination of dissemination, and monitoring implementation of recommendations at all levels and d) mandatory notification of maternal deaths (and enforcement of this) and a professional requirement to participate in MDRs. Conclusions Case studies from countries with established MDSR systems can provide valuable guidance on ways to set up the processes and overcome some of the barriers; but the challenge, as with many health system interventions, is to find a way to provide catalytic assistance and strengthen capacity for MDSR such that this becomes embedded in the health system.

To assess the feasibility of applying the World Health Organization's proposed 15 indicators of quality of care for maternal and newborn health at health-facility level in low- and middle-income settings.Six of the indicators are about maternal health, five are for newborn health and four are general cross-cutting indicators. We used data collected routinely in facility registers and obtained as part of facility assessments from 963 health-care facilities specializing in maternity services in 10 countries in Africa and Asia. We made a feasibility assessment of the availability of data and the clarity of indicator definitions and identified additional information and data collection processes needed to apply the proposed indicators in real-life settings.Of the indicators evaluated, 10 were clearly defined, of which four could be applied directly in the field and six would require revisions to operationalize them. The other five indicators require further development, with one of them being ready for implementation by using information readily available in registers and four requiring further information before deployment. For indicators that measure coverage of care or availability of services or products, there is a need to further strengthen measurement. Information on emergency obstetric complications was not recorded in a standard manner, thus limiting the reliability of the information.While some of the proposed indicators can already be applied, other indicators need to be refined or will need additional sources and methods of data collection to be applied in real-world settings.Évaluer s'il est faisable d'appliquer les 15 indicateurs proposés par l'Organisation mondiale de la Santé relatifs à la qualité des soins de santé maternelle et néonatale dans des centres de santé de régions à revenu faible et intermédiaire.Six indicateurs portent sur la santé maternelle, cinq sur la santé néonatale et quatre sur des facteurs transversaux d'ordre général. Nous avons utilisé les données consignées habituellement dans les registres des centres de santé et obtenues dans le cadre d'évaluations de ces centres; des données couvrant au total 963 centres de santé, spécialisés dans les services de maternité, dans 10 pays d'Afrique et d'Asie. Nous avons réalisé une étude de faisabilité portant sur la disponibilité des données et la clarté des définitions des indicateurs, et nous avons identifié les processus de collecte des données et informations complémentaires nécessaires pour pouvoir appliquer ces indicateurs en conditions réelles.Parmi tous les indicateurs évalués, 10 sont clairement définis, parmi lesquels quatre pourraient être directement appliqués sur le terrain, tandis que les six autres nécessiteraient des ajustements avant de pouvoir être mis en œuvre. Les cinq indicateurs restants nécessitent d'autres développements; même si l'un d'eux pourrait être exploité en utilisant les informations consignées dans les registres déjà disponibles, pour les quatre autres indicateurs, des informations complémentaires sont nécessaires. Pour les indicateurs relatifs à la couverture des soins ou à la disponibilité des services ou des produits, des évaluations plus détaillées seraient nécessaires. Les informations sur les complications obstétricales d'urgence n'ont pas été enregistrées de façon standardisée, ce qui limite la fiabilité de ces informations.Alors que certains des indicateurs proposés sont d'ores et déjà applicables, d'autres indicateurs doivent être affinés ou nécessitent des sources d’information supplémentaires et des méthodes complémentaires de collecte de données avant de pouvoir être appliqués en conditions réelles.Evaluar la viabilidad de aplicar los 15 indicadores de calidad de atención sanitaria materna y obstétrica propuestos por la Organización Mundial de la Salud en centros sanitarios de entornos con ingresos bajos y medios.Seis de los indicadores tratan sobre salud materna, cinco sobre salud obstétrica y cuatro son indicadores transversales generales. Se utilizaron datos recopilados de forma rutinaria en los registros de los centros y se obtuvieron como parte de las evaluaciones de las instalaciones de 963 centros sanitarios especializados en servicios de maternidad de 10 países de África y Asia. Se realizó una evaluación de viabilidad sobre la disponibilidad de datos y la claridad de las definiciones de los indicadores, y se identificó información adicional y los procesos de recopilación de datos necesarios para implementar los indicadores propuestos en centros reales.De los indicadores evaluados, 10 se definieron con claridad, de los cuales cuatro podían aplicarse directamente en el campo y seis necesitarían revisiones para hacerlos operativos. Los otros cinco indicadores requieren un mayor desarrollo: uno de ellos está listo para ser implementado utilizando información inmediatamente disponible en los registros y cuatro necesitan más información antes de su puesta en práctica. Para los indicadores que miden la cobertura de la atención o la disponibilidad de productos o servicios, se necesita fortalecer más la medición. No se ha registrado información sobre complicaciones obstétricas de emergencia de forma estándar, por lo que la fiabilidad de la información es limitada.Mientras que algunos de los indicadores propuestos ya pueden aplicarse, otros necesitan perfeccionarse o requerirán fuentes y métodos de recopilación de datos adicionales para poderse aplicar en entornos reales.تقييم جدوى تطبيق 15 مؤشرًا مقترحًا لمنظمة الصحة العالمية لقياس جودة الرعاية الصحية للأمهات وحديثي الولادة على مستوى المرافق الصحية والمواقع ذات الدخل المنخفض والمتوسط.تتعلق ستة مؤشرات بصحة الأمومة، فيما تتعلق خمسة مؤشرات بصحة الأطفال حديثي الولادة، فضلاً عن أربعة مؤشرات عامة وشاملة. وقد استخدمنا البيانات المجمعة بصورة روتينية في سجلات المرافق الصحية والتي تم الحصول عليها كجزء من تقييمات المرافق المأخوذة من 963 مرفقًا للرعاية الصحية متخصصة في خدمات الأمومة في 10 دول في أفريقيا وآسيا. وقمنا بإجراء تقييم جدوى لمدى إتاحة البيانات ووضوح تعريفات المؤشر، وقمنا بتحديد عمليات إضافية لجمع البيانات والمعلومات سيتكون لازمة لتطبيق المؤشرات المقترحة على أرض الواقع.من بين المؤشرات التي خضعت للتقييم، كان منها 10 مؤشرات تحمل تعريفات دقيقة، وكان من الممكن تطبيق أربعة مؤشرات منها مباشرةً على أرض الواقع، فيما تحتاج ستة منها إلى المراجعة قبل نقلها إلى مرحلة التنفيذ العملي. وتتطلب المؤشرات الخمسة الأخرى المزيد من التطوير، مع وجود أحد المؤشرات في حالة جاهزة للتطبيق باستخدام المعلومات المتوفرة بسهولة في السجلات، وأربعة مؤشرات بحاجة إلى المزيد من المعلومات قبل التنفيذ. بالنسبة للمؤشرات التي تقيس تغطية الرعاية أو مدى توافر الخدمات أو المنتجات، هناك حاجة إلى تعزيز القياس بشكل أكبر. لم يتم تسجيل المعلومات المتعلقة بمضاعفات الولادة في الحالات الطارئة بشكلٍ قياسي، مما حد من مدى اعتمادية المعلومات.بالرغم من إمكانية تطبيق بعض المؤشرات المقترحة بالفعل، فإن المؤشرات الأخرى بحاجة إلى إدخال التحسينات عليها أو قد تحتاج إلى مصادر وطرق إضافية لجمع البيانات ليتسنى تطبيقها في الواقع.旨在评估在中低收入国家卫生机构实施世界卫生组织提出的 15 个孕产妇和新生儿健康质量指标的可行性。.其中六个指标与孕产妇健康相关，五个与新生儿健康相关，四个是一般性综合指标。 我们使用定期从医疗机构登记处收集的数据，以及从 10 个亚非国家 963 个专门提供孕产服务的医疗机构中获取的数据作为机构评估的一部分。 我们对数据的可用性以及指标定义的清晰度进行了可行性评估，同时明确了将所提议指标应用于现实环境所需的其他信息和数据收集流程。.在评估的指标中，10 个定义明确，其中，4 个可直接应用到实际中，6 个需要修订以便于实施。 其他五个指标需要进一步制定，其中一个可通过使用登记处的现有信息投入实施，另外四个在部署之前，需要增添一些补充信息。 对于测量护理覆盖率或者服务或产品可用性的指标，有必要进一步加强测量。 有关紧急产科并发症的信息未采用标准形式记录，因此影响了信息的可靠性。.虽然提出的有些指标已能够实施，但是其他指标仍需要改进或者需要额外的数据收集资源和方法，以便应用于现实环境中。.Дать оценку практической возможности применения 15 предложенных Всемирной организацией здравоохранения показателей качества ухода за матерью и новорожденным ребенком в медицинских учреждениях в условиях с низким и средним уровнем доходов.Шесть показателей из них относятся к охране здоровья матери, пять — к охране здоровья новорожденного ребенка, и четыре являются показателями общего характера. Авторы статьи использовали данные, собранные в рабочем порядке в реестрах медицинских учреждений и полученные в ходе оценок работы медицинских учреждений, из 963 медико-санитарных учреждений, специализирующихся на оказании услуг по уходу за матерями, в 10 странах Африки и Азии. Была дана оценка практической возможности получения данных и точности формулировок определений показателей. Были определены дополнительные процессы сбора информации и данных, необходимые для применения предложенных показателей на практике.Из всех показателей, подвергнутых оценке, определения десяти были сформулированы точно, и четыре из них могли быть применены непосредственно на практике, а шесть показателей необходимо скорректировать, прежде чем их можно будет практически реализовать. Остальные пять показателей требуют доработки, причем один из них может быть применен с использованием имеющейся в реестрах информации, а для остальных четырех необходима дополнительная информация, прежде чем их можно будет реализовать. Для показателей, используемых для измерения охвата медицинской помощью или доступности услуг или продуктов, требуется дополнительно усовершенствовать процесс измерения. Информация о неотложной акушерской помощи при осложнениях не была зафиксирована в установленном порядке, и это сказалось на ее надежности.Хотя некоторые из предложенных показателей уже могут быть применены, для других показателей требуется доработка или дополнительные источники данных и методы их сбора, чтобы показатели можно было применить на практике.

Good progress has been made in reducing maternal deaths from 1990–2015 but accelerated progress is needed to achieve the Sustainable Development Goals (SDGs) in ending preventable maternal deaths through a renewed focus on accountability and actions. This paper looks at how Maternal Death Surveillance and Response (MDSR) systems are strengthening response and accountability for better health outcomes by analyzing key findings from the WHO and UNFPA Global MDSR Implementation Survey across 62 countries. It examines two concrete examples from Nigeria and Ethiopia to demonstrate how findings can influence systematic changes in policy and practice. We found that a majority of countries have policies in place for maternal death notification and review, yet a gap remains when examining the steps beyond this, including reviewing and reporting at an aggregate level, disseminating findings and recommendations, and involving civil society and communities. As more countries move toward MDSR systems, it is important to continue monitoring the opportunities and barriers to full implementation, through quantitative means such as the Global MDSR Implementation Survey to assess country progress, but also through more qualitative approaches, such as case studies, to understand how countries respond to MDSR findings.

BackgroundMost maternal and child deaths are preventable or treatable with proven, cost-effective interventions for infectious diseases and maternal and neonatal complications. In 2015 sub-Saharan Africa accounted for up to 66% of global maternal deaths and half of the under-five deaths. Access to essential medicines and commodities and trained healthcare workers to provide life-saving maternal, newborn and post-natal care are central to further reductions in maternal and child mortality.MethodsAvailable data for 24 priority medicines for women and children were extracted from WHO service availability and readiness assessments conducted between 2012 and 2015 for eight countries in sub-Saharan Africa. The mean availability of medicines in facilities stating they provide services for women or children and differences by facility type, ownership and location are reported.ResultsThe mean availability of 12 priority essential medicines for women ranged from 22% to 40% (median 33%; IQR 12%) and 12 priority medicines for children ranged from 28% to 57% (median 50%; IQR 14%). Few facilities (ConclusionsThe survey results show unacceptably low availability of priority medicines for women and children in the eight countries. Governments should ensure the availability of medicines for mothers and children if they are to achieve the health sustainable development goals.

Objective We explore preterm-related neonatal deaths using the WHO application of the International Classification of Disease (ICD-10) to deaths during the perinatal period: ICD-PM as an informative case study, where ICD-PM can improve data use to guide clinical practice and programmatic decision-making.Design Retrospective application of ICD-PM.Setting South Africa, and the UK.Population Perinatal death databases.Methods Descriptive analysis of neonatal deaths and maternal conditions present.Main outcome measures Causes of preterm neonatal mortality and associated maternal conditions.Results We included 98 term and 173 preterm early neonatal deaths from South Africa, and 956 term and 3248 preterm neonatal deaths from the UK. In the South African data set, the main causes of death were respiratory/cardiovascular disorders (34.7%), low birthweight/prematurity (29.2%), and disorders of cerebral status (25.5%). Amongst preterm deaths, low birthweight/prematurity (43.9%) and respiratory/cardiovascular disorders (32.4%) were the leading causes. In the data set from the UK, the leading causes of death were low birthweight/prematurity (31.6%), congenital abnormalities (27.4%), and deaths of unspecified cause (26.1%). In the preterm deaths, the leading causes were low birthweight/prematurity (40.9%) and deaths of unspecified cause (29.6%). In South Africa, 61% of preterm deaths resulted from the maternal condition of preterm spontaneous labour. Among the preterm deaths in the data set from the UK, no maternal condition was present in 36%, followed by complications of placenta, cord, and membranes (23%), and other complications of labour and delivery (22%).Conclusions ICD-PM can be used to appraise the maternal and newborn conditions contributing to preterm deaths, and can inform practice.

There continues to be slow progress in preventing stillbirths. It is estimated that globally, more than 2 million stillbirths1 occur each year, adding to 2.9 million neonatal deaths.2 Ending preventable perinatal deaths is high on the international public health agenda.3,4 In countries with the highest mortality burden, limited or non-existent vital registration and medical records mean that perinatal deaths are often not recorded.5 Thus the first step in addressing high perinatal mortality is the accurate capture and classification of the causes of those deaths across all settings. Many classification systems have been used to identify the cause of perinatal deaths, highlighting the need for a unifying global system.6 The World Health Organization (WHO) is developing a system to enable comparisons within and between diverse settings, including low-, middle- and high-income countries. This will allow benchmarking and the identification of trends, gaps and modifiable factors and help to focus local and global efforts on prevention. Using the coding rules of the 10th revision of the International classification of diseases and related health problems (ICD-10), WHO, in collaboration with partners, has developed The WHO application of ICD-10 to perinatal deaths: ICD-perinatal mortality (ICD-PM).7 This is closely modelled on the WHO application of ICD-10 to deaths during pregnancy, childbirth, and the puerperium: ICD-maternal mortality (ICD-MM), which aims to “facilitate the consistent collection, analysis and interpretation of information on maternal deaths”.8 Perinatal death reviews should include classification of the cause of death, to enhance our understanding of why babies die and what actions we can take to reduce preventable deaths. A guide to using ICD-PM as part of perinatal audit is being developed to aid this process. ICD-PM builds upon the reportable variables in ICD-10 guidelines for certification of perinatal death and allows tabulation of cases for comparison between settings. There are three distinct features of ICD-PM. First, it captures the time of a perinatal death in the antepartum, intrapartum or neonatal period. The timing of a perinatal death may be the only piece of information captured when classifying a death in resource-poor settings.9 This information can be used to make international comparisons as well as decisions on where to focus local efforts and interventions. Bringing stillbirth and neonatal deaths together in a standardized system of definitions and coding rules improves comparability. Since the ICD is widely used – 117 countries use ICD for mortality reporting10 – ICD-PM has great potential to bring to the foreground those deaths that have previously gone unnoticed. Second, ICD-PM applies a multilayered approach to the classification of cause of death, such that it reflects varying levels of available information depending on the setting. Mutually exclusive clinical conditions that lead to the identification of a single cause of perinatal death are determined and linked with an ICD code. It is critical that a standardized classification system is globally relevant. A great deal of consideration has gone into ensuring ICD-PM is applicable in low-resource settings where the burden of perinatal mortality is greatest, as well as in high-resource settings, where perinatal mortality is lower but present across all perinatal periods.11 Accordingly, the ICD-PM approach for classification of cause of death allows investigations such as postmortem or placental histology to be captured, in settings where they are available. Third, ICD-PM links contributing maternal conditions with perinatal deaths, given that a maternal condition is frequently found in the context of a perinatal death.12,13 Capturing the chain of maternal and fetal events that led to perinatal death can inform preventative and therapeutic measures. Programmes aimed at one unifying pathology (e.g. hypertension) or clinical scenario (e.g. intrapartum care) can benefit both mother and baby. Including maternal conditions as an integral part of the classification of perinatal death aligns with WHO action plans.3 There is no perfect classification system, however ICD-PM adopts the features of many other systems in a way that allows applicability in all settings and encourages international comparisons. Perinatal mortality remains high and we must unify our approach to classifying these deaths and use this information to drive interventions and allocate resources to reduce preventable stillbirths and neonatal deaths.

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. Fil: de Bernis, Luc. UN Population Fund; Suiza Fil: Kinney, Mary V.. Save the Children; Sudáfrica Fil: Stones, William. University of St. Andrews; Reino Unido. University of Malawi; Malaui. International Federation of Gynecology and Obstetrics; Reino Unido Fil: ten Hoope-Bender, Petra. Independent Consultant; Suiza Fil: Vivio, Donna. Agency for International Development; Estados Unidos Fil: Hopkins Leisher, Susannah. International Stillbirth Alliance; Estados Unidos. University of Queensland; Australia Fil: Bhutta, Zulfiqar A.. The Hospital for Sick Children; Canadá. The Aga Khan University, Karachi; Pakistán. World Health Organization; Suiza Fil: Gülmezoglu, Metin. World Health Organization; Suiza Fil: Mathai, Matthews. World Health Organization; Suiza Fil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Franco, Lynne. EnCompass LLC; Estados Unidos Fil: McDougall, Lori. Newborn and Child Health; Suiza Fil: Zeitlin, Jennifer. Paris Descartes University; Francia Fil: Malata, Address. Kamuzu College of Nursing University of Malawi; Malaui Fil: Dickson, Kim E.. UNICEF; Estados Unidos Fil: Lawn, Joy E.. London School of Hygiene & Tropical Medicine; Reino Unido. Save the Children; Estados Unidos

An estimated 2·6 million third trimester stillbirths occurred in 2015 (uncertainty range 2·4-3·0 million). The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan has the target of 12 or fewer stillbirths per 1000 births in every country by 2030. 94 mainly high-income countries and upper middle-income countries have already met this target, although with noticeable disparities. At least 56 countries, particularly in Africa and in areas aff ected by confl ict, will have to more than double present progress to reach this target. Most (98%) stillbirths are in low-income and middle-income countries. Improved care at birth is essential to prevent 1·3 million (uncertainty range 1·2-1·6 million) intrapartum stillbirths, end preventable maternal and neonatal deaths, and improve child development. Estimates for stillbirth causation are impeded by various classifi cation systems, but for 18 countries with reliable data, congenital abnormalities account for a median of only 7·4% of stillbirths. Many disorders associated with stillbirths are potentially modifi able and often coexist, such as maternal infections (population attributable fraction: malaria 8·0% and syphilis 7·7%), non-communicable diseases, nutrition and lifestyle factors (each about 10%), and maternal age older than 35 years (6·7%). Prolonged pregnancies contribute to 14·0% of stillbirths. Causal pathways for stillbirth frequently involve impaired placental function, either with fetal growth restriction or preterm labour, or both. Two-thirds of newborns have their births registered. However, less than 5% of neonatal deaths and even fewer stillbirths have death registration. Records and registrations of all births, stillbirths, neonatal, and maternal deaths in a health facility would substantially increase data availability. Improved data alone will not save lives but provide a way to target interventions to reach more than 7000 women every day worldwide who experience the reality of stillbirth.

The WHO Safe Childbirth Checklist (SCC) was developed to ensure the delivery of essential maternal and perinatal care practices around the time of childbirth. A research collaboration was subsequently established to explore factors that influence use of the Checklist in a range of settings around the world. This analysis article presents an overview of the WHO SCC Collaboration and the lessons garnered from implementing the Checklist across a diverse range of settings. Project leads from each collaboration site were asked to distribute two surveys. The first was given to end users, and the second to implementation teams to describe their respective experiences using the Checklist. A total of 134 end users and 38 implementation teams responded to the surveys, from 19 countries across all levels of income. End users were willing to adopt the SCC and found it easy to use. Training and the provision of supervision while using the Checklist, alongside leadership engagement and local ownership, were important factors which helped facilitate initial implementation and successful uptake of the Checklist. Teams identified several challenges, but more importantly successfully implemented the WHO SCC. A critical step in all settings was the adaptation of the Checklist to reflect local context and national protocols and standards. These findings were invaluable in developing the final version of the WHO SCC and its associated implementation guide. Our experience will provide useful insights for any institution wishing to implement the Checklist.

Objective:\ud Most literature on length of stay (LOS) for childbirth focuses on ‘early’ discharge as opposed to ‘optimal’ time of discharge and has conflicting results due to heterogeneous definitions of ‘early’ discharge and differing eligibility criteria for these programmes. We aimed to determine the LOS associated with the lowest neonatal readmission rate following childbirth by examining the incidence pattern of neonatal readmission for different LOS using the Kitagawa decomposition.\ud Design: Retrospective cohort study using administrative hospitalisation data.\ud Setting: Canada (excluding Quebec) from 2003 to 2010.\ud Patients: Term, singleton live births without congenital anomalies.\ud Interventions: LOS for childbirth.\ud Main outcome measure: Neonatal readmissions within 30 days of birth.\ud Results:\ud 1 875 322 live births were included. Neonatal LOS peaked at day 1 (47.3%) after vaginal birth and day 3 (49.3%) following caesarean section; 4.2% of infants were readmitted following vaginal birth and 2.2% after caesarean section. In 2008–2010, most readmissions occurred among infants discharged in the first 2 days (83.8%) following a vaginal birth and among infants discharged in the first 3 days (81.7%) following a caesarean birth. Readmissions increased from 4.1% in 2003–2005 to 4.6% in 2008–2010 among vaginal births and from 2.0% to 2.4% among caesarean births and occurred mostly due to changes in the day-specific readmission rates and not due to reductions in LOS.\ud Conclusions:\ud Patterns of readmission suggest that readmission rates are lowest following a 1–2-day stay following a vaginal birth and a 2–4-day stay following a caesarean birth given the outpatient support in the community.