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Donor human milk is recommended by the World Health Organization both for its advantageous nutritional and biological properties when mother's own milk is not available and for its recognized support for lactation and breastfeeding when used appropriately. An increasing number of human milk banks are being established around the world, especially in low- and middle-income countries, to facilitate the collection, processing and distribution of donor human milk. In contrast to other medical products of human origin, however, there are no minimum quality, safety and ethical standards for donor human milk and no coordinating global body to inform national policies. We present the key issues impeding progress in human milk banking, including the lack of clear definitions or registries of products; issues around regulation, quality and safety; and ethical concerns about commercialization and potential exploitation of women. Recognizing that progress in human milk banking is limited by a lack of comparable evidence, we recommend further research in this field to fill the knowledge gaps and provide evidence-based guidance. We also highlight the need for optimal support for mothers to provide their own breastmilk and establish breastfeeding as soon as and wherever possible after birth.Lorsque la mère est dans l'impossibilité d'allaiter, l'Organisation mondiale de la Santé recommande d'opter pour le lait humain provenant de donneuses, tant pour ses propriétés nutritionnelles et biologiques que pour la contribution avérée qu'il apporte à la lactation et à l'allaitement quand il est utilisé à bon escient. Un nombre croissant de banques de lait humain s'établissent dans le monde entier, en particulier dans les pays à faible et moyen revenu, afin de faciliter la collecte, le traitement et la distribution de lait humain provenant de donneuses. Cependant, contrairement à d'autres produits médicaux d'origine humaine, il n'existe aucune norme minimale de qualité, de sécurité et d'éthique en la matière, et aucun organe de coordination global n'a été créé pour guider les politiques nationales. Dans le présent document, nous évoquons les principaux obstacles à la progression des banques de lait humain, notamment l'absence de définition claire ou de registre de produits; les problèmes relatifs à la réglementation, la qualité et la sécurité; ainsi que les questions éthiques entourant la commercialisation et l'exploitation potentielle des femmes. Jugeant cette progression limitée par le manque de données comparables, nous encourageons à mener d'autres recherches dans ce domaine pour combler les lacunes et fournir des orientations fondées sur des preuves. Nous soulignons également la nécessité d'offrir un soutien optimal aux mères afin qu'elles puissent produire leur propre lait et allaiter autant que possible immédiatement après la naissance.La Organización Mundial de la Salud recomienda la leche humana donada tanto por sus ventajosas propiedades nutricionales y biológicas cuando no se dispone de la propia leche materna como por su reconocido apoyo a la lactancia y al amamantamiento cuando se utiliza de manera adecuada. Cada vez se crean más bancos de leche humana en todo el mundo, sobre todo en los países de ingresos bajos y medios, para facilitar la recogida, el procesamiento y la distribución de leche humana donada. Sin embargo, a diferencia de lo que ocurre con otros productos médicos de origen humano, no existen estándares mínimos de calidad, seguridad y ética para la leche humana donada ni un organismo mundial de coordinación que sirva de base a las políticas nacionales. En este documento se exponen los principales problemas que impiden el progreso de los bancos de leche humana, como la falta de definiciones claras o de registros de productos; los problemas relacionados con la regulación, la calidad y la seguridad; y las preocupaciones éticas sobre la comercialización y la posible explotación de las mujeres. Dado que el progreso de los bancos de leche humana se ve limitado por la falta de evidencias comparables, se recomienda seguir investigando en este campo para compensar los vacíos de conocimiento y proporcionar una guía asistencial. Asimismo, se destaca la necesidad de apoyar al máximo a las madres para que se provean de su propia leche materna y establezcan la lactancia materna tan pronto y siempre que sea posible después del nacimiento.توصي منظمة الصحة العالمية بلبن الأمهات من الأطراف المتبرعة به، وذلك لخصائصه التغذوية والبيولوجية المفيدة عندما لا يتوفر لبن الأم، ولدعمه المعترف به للرضاعة والرضاعة الطبيعية عند استخدامه بشكل مناسب. يتم الآن إنشاء عدد متزايد من بنوك لبن الأمهات في جميع أنحاء العالم، وخاصة في الدول ذات الدخل المنخفض والدخل المتوسط، لتسهيل جمع ومعالجة وتوزيع لبن الأمهات من الأطراف المتبرعة به. ومع ذلك، وعلى النقيض من المنتجات الطبية الأخرى من أصل بشري، ليس هناك حد أدنى للجودة والسلامة والمعايير الأخلاقية للبن الأمهات من الأطراف المتبرعة به، ولا توجد هيئة عالمية منسقة لتوجيه السياسات الوطنية. نحن نقدم القضايا الرئيسية التي تعوق التقدم في بنوك لبن الأمهات، بما في ذلك الافتقار إلى تعريفات أو سجلات واضحة للمنتجات؛ مثل المسائل المتعلقة بالتنظيم والجودة والسلامة؛ والمخاوف الأخلاقية المتعلقة بالجانب التجاري والاستغلال المحتمل للمرأة. مع إدراك أن التقدم في بنوك حليب الأمهات محدود بسبب الافتقار إلى أدلة قابلة للمقارنة، فإننا نوصي بإجراء مزيد من البحث في هذا المجال لسد الفجوات المعرفية وتقديم إرشادات قائمة على الأدلة. ونحن نسلط الضوء أيضًا على الحاجة إلى الدعم الأمثل للأمهات ليقمن بتقديم ألبانهن، وبدء الرضاعة الطبيعية بأسرع ما يمكن وحيثما أمكن بعد الولادة.世界卫生组织建议人们捐赠母乳，因为当母亲自身的母乳不可用时，捐赠母乳具有充足的营养价值和生物特性，若使用得当，它可以对哺乳和母乳喂养提供有利的支持。世界各地正在建立越来越多的母乳库，特别是在中低收入国家，以推进捐赠母乳的收集、加工和分配。但是，与其他人类制造的医疗产品相比，捐赠母乳没有最低质量、安全和道德标准，也没有全球协调机构为国家政策提供信息。我们提出了阻碍母乳储存进展的关键问题，包括缺乏明确的产品定义或注册信息；监管、质量和安全方面的问题；以及对妇女商业化和潜在剥削的道德问题。认识到母乳储存的进展因缺乏可比证据而受到限制，我们建议在该领域展开进一步研究以填补知识空白并提供循证指导。我们还强调需要为母亲提供最佳支持，以支持她们提供自己的母乳，在孩子出生后尽快并尽可能地进行母乳喂养。.В случае отсутствия материнского молока Всемирная организация здравоохранения рекомендует использование донорского грудного молока как из-за его полезных питательных и биологических свойств, так и из-за общепризнанной поддержки лактации и грудного вскармливания при правильном использовании. Во всем мире создается все больше банков грудного молока, особенно в странах с низким и средним уровнем доходов, для облегчения сбора, обработки и распределения донорского грудного молока. Однако, в отличие от другой медицинской продукции человеческого происхождения, для донорского грудного молока не существует минимальных стандартов качества, безопасности и этики, а также отсутствует координационный глобальный орган для разработки национальной политики. Авторы раскрыли ключевые проблемы, препятствующие прогрессу в создании банков грудного молока (включая отсутствие четких определений или реестров продуктов), вопросы регулирования, качества и безопасности, а также этические проблемы в связи с коммерциализацией и потенциальной эксплуатацией женщин. Признавая, что прогресс в создании банков грудного молока ограничен отсутствием сопоставимых данных, авторы рекомендуют продолжить исследования в этой области, чтобы заполнить пробелы в знаниях и предоставить рекомендации, основанные на фактических данных. Подчеркивается также необходимость оптимальной поддержки матерей, чтобы они сами кормили ребенка грудью и по мере возможности начинали грудное вскармливание как можно скорее после родов, где бы они ни находились.

This state-of-the art manuscript highlights our current understanding of maternal immunization-the practice of vaccinating pregnant women to confer protection on them as well as on their young infants, and thereby reduce vaccine-preventable morbidity and mortality. Advances in our understanding of the immunologic processes that undergird a normal pregnancy, studies from vaccines currently available and recommended for pregnant women, and vaccines for administration in special situations are beginning to build the case for safe scale-up of maternal immunization. In addition to well-known diseases, new diseases are emerging which pose threats. Several new vaccines are currently under development and increasingly include pregnant women. In this manuscript, targeted at clinicians, vaccinologists, scientists, public health practitioners, and policymakers, we also outline key considerations around maternal immunization introduction and delivery, discuss noninfectious horizons for maternal immunization, and provide a framework for the clinician faced with immunizing a pregnant woman.

Advancements in neonatal care globally highlight ongoing disparities in neonatal outcomes between low-income countries (LICs) and high-income countries (HICs). Drivers of this gap are primarily prematurity, infection, and intrapartum-related events. Significant success is being achieved; however, for neonatal outcomes in LIC to approximate those of HICs within a generation, acceleration of the current trajectory of progress is needed. This requires a renewed focus on newborn-specific and newborn-sensitive strategies. Newborn-specific strategies are those directly affecting the well-being of the neonate. Newborn-sensitive strategies address the broader macro-environmental drivers that affect underlying neonatal outcomes such as decreased poverty, improved sanitation, and increased maternal empowerment and health. To create such an enabling macro-environment requires significant political will, financing, advocacy, and policy generation. This manuscript highlights recent advances in newborn research, programming, policy, and funding, and highlights key opportunities to bend the curve on advancing neonatal health globally.

Despite significant reduction in childhood mortality, infant - particularly neonatal - mortality continues to be unacceptably high. A substantial proportion of these deaths could be averted by vaccinating mothers during pregnancy (maternal immunization). However, in order to realize the full life-saving potential of maternal immunization, it is important to develop clear introduction and delivery strategies for maternal vaccines. This will necessitate close collaboration between maternal health and immunization stakeholders. This article examines key considerations and areas for action to support successful and sustainable introduction and scale-up of maternal immunization, from the perspective of maternal, newborn, child, and adolescent health stakeholders.

Background Responding to stagnating neonatal mortality rates in Ghana, a five-year collaboration called Making Every Baby Count Initiative (MEBCI) was undertaken to improve the quality of newborn care provided around the time of birth. A multi-pronged approach was used to build health worker (HW) capacity in resuscitation, essential newborn care, and infection prevention using a curriculum built on the American Academy of Pediatric’s (AAP) Helping Babies Breathe (HBB) and Essential Care for Every Baby (ECEB) modules with an added section on infection prevention (IP). Methods MEBCI used a training of trainer’s approach to train 3688 health workers from district-level facilities in four regions in Ghana between June 2015 and July 2017. Prior to training, HWs familiarized themselves with the learning materials. Concurrently, MEBCI worked to improve enabling environments that would sustain the increased capacity of trained health workers. Knowledge and skills gained were tested using AAP’s Knowledge checklist and validated single-scenario Objective Structured Clinical Examinations (OSCEs) tools. Findings: Majority of HWs trained were midwives (58.8%) and came from district-level hospitals (88.4%). Most HWs passed the HBB OSCE (99.9%, 3436/3440). Age of doctors was negatively associated with HBB scores (r = − 0.16, p = 0.0312). Similarly, older midwives had lower HBB scores (r = − 0.33, p value Initiating ventilation within the Golden Minute was challenging for HWs (78.5% passed) across all regions. Overall, the pass rate for ECEB OSCEs was 99.9% in all regions. Classify newborn for further care and communicate plan to family were frequent challenges observed in Volta Region (69.5% and 72.0% pass rate respectively). HWs less than 40 years of age performed significantly better than health workers older than 40 years (p = 0.023). Age of only paediatricians was positively associated with ECEB scores (r = 0.77, p r = − 0.08, p Conclusion MEBCI’s integrated HBB-ECEB-IP training resulted in significant mastery of the clinical knowledge and skills of HWs. Harmonization and standardization of the course delivery by trainers and having a core team to ensure training fidelity are essential to maintaining high quality while scaling a program nationally. Funding Children’s Investment Fund Foundation (CIFF).

Globally, no countries are on track to achieve the adopted global nutrition targets set for anemia in 2025. Given the linkages between water, sanitation, and hygiene (WASH) and nutrition, this secondary data analysis explores potential associations with anemia. Forty‐seven demographic and health surveys were used to explore the association between unimproved water and sanitation and anemia in women and children with adjusted odds ratios (ORs) calculated by country and cumulatively. In over 60% of countries, children with off‐premises water access had significantly increased odds of anemia. In over a quarter of countries, children exposed to surface water had higher odds of anemia. In Burundi, children were 1.65 times more likely to be anemic when reported to be living in households using surface water. However, in India, a protective effect was noted (adjusted OR: 0.70, P < 0.001) for surface water. In 60% and 65% of countries, women and children exposed to an open sanitation facility had higher odds of being anemic, respectively. There is evidence of an association between selected water and sanitation indicators and anemia. Promoting policies, practices and research that strengthen access to improved WASH should be considered for reducing anemia prevalence alongside standard nutrition interventions.

Objective To validate a novel objective structured clinical examination (OSCE) tool for assessing neonatal care skills among delivery attendants trained as part of the Essential Care for Every Baby (ECEB) program and to assess ECEB training effectiveness. Methods Between August 1 and September 30, 2015, a cross-sectional study enrolled ECEB-trained healthcare providers who attended deliveries from the Brong Ahafo and Eastern regions of Ghana. Participants completed a previously developed 21-item OSCE tool that assessed neonatal-care competency. Participant performance was scored independently by regional trainers and national master trainers. The inter-rater scoring reliability was assessed using the Cohen kappa coefficient and performance was compared across participant characteristics. Results The study enrolled 57 trained delivery attendants from 12 district hospitals. Inter-rater agreement was perfect (kappa 1.00) or almost perfect (kappa 0.81–0.99) for nine OSCE items, substantial (kappa 0.61–0.80) or moderate (kappa 0.41–0.60) for 11 items, and fair (kappa 0.21–0.40) for one item. Differences in OSCE-item performance were recorded based on participants’ regions, facility type, age, and education level ( P Conclusions In a resource-limited setting, the OSCE tool demonstrated substantial reliability and ECEB-trained healthcare practitioners exhibited satisfactory performance. The OSCE tool could be useful in similar settings and could have potential for up-scaled use in assessing neonatal-management skills.

Summary Background WHO recommends hospital-based treatment for young infants aged 0–59 days with clinical signs of possible serious bacterial infection, but most families in resource-poor settings cannot accept referral. We aimed to assess whether use of simplified antibiotic regimens to treat young infants with clinical signs of severe infection was as efficacious as an injectable procaine benzylpenicillin–gentamicin combination for 7 days for situations in which hospital referral was not possible. Methods In a multisite open-label equivalence trial in DR Congo, Kenya, and Nigeria, community health workers visited all newborn babies at home, identifying and referring unwell young infants to a study nurse. We stratified young infants with clinical signs of severe infection whose parents did not accept referral to hospital by age (0–6 days and 7–59 days), and randomly assigned each individual within these strata to receive one of the four treatment regimens. Randomisation was stratified by age group of infants. An age-stratified randomisation scheme with block size of eight was computer-generated off-site at WHO. The outcome assessor was masked. We randomly allocated infants to receive injectable procaine benzylpenicillin–gentamicin for 7 days (group A, reference group); injectable gentamicin and oral amoxicillin for 7 days (group B); injectable procaine benzylpenicillin–gentamicin for 2 days, then oral amoxicillin for 5 days (group C); or injectable gentamicin for 2 days and oral amoxicillin for 7 days (group D). Trained health professionals gave daily injections and the first dose of oral amoxicillin. Our primary outcome was treatment failure by day 8 after enrolment, defined as clinical deterioration, development of a serious adverse event (including death), no improvement by day 4, or not cured by day 8. Independent outcome assessors, who did not know the infant's treatment regimen, assessed study outcomes on days 4, 8, 11, and 15. Primary analysis was per protocol. We used a prespecified similarity margin of 5% to assess equivalence between regimens. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12610000286044. Findings In Kenya and Nigeria, we started enrolment on April 4, 2011, and we enrolled the necessary number of young infants aged 7 days or older from Oct 17, 2011, to April 30, 2012. At these sites, we continued to enrol infants younger than 7 days until March 29, 2013. In DR Congo, we started enrolment on Sept 17, 2012, and continued until June 28, 2013. We randomly assigned 3564 young infants to either group A (n=894), group B (n=884), group C (n=896), or group D (n=890). We excluded 200 randomly assigned infants, who did not fulfil the predefined criteria of adherence to treatment and adequate follow-up. In the per-protocol analysis, 828 infants were included in group A, 826 in group B, 862 in group C, and 848 in group D. 67 (8%) infants failed treatment in group A compared with 51 (6%) infants in group B (risk difference −1·9%, 95% CI −4·4 to 0·1), 65 (8%) in group C (−0·6%, −3·1 to 2·0), and 46 (5%) in group D (−2·7%, −5·1 to 0·3). Treatment failure in groups B, C, and D was within the similarity margin compared with group A. During the 15 days after random allocation, 12 (1%) infants died in group A, compared with ten (1%) infants in group B, 20 (2%) infants in group C, and 11 (1%) infants in group D. An infant in group A had a serious adverse event other than death (injection abscess). Interpretation The three simplified regimens were as effective as injectable procaine benzylpenicillin–gentamicin for 7 days on an outpatient basis in young infants with clinical signs of severe infection, without signs of critical illness, and whose caregivers did not accept referral for hospital admission. Funding Bill & Melinda Gates Foundation grant to WHO.

Previous research suggests that care-seeking in rural northern Ghana is often governed by a woman's husband or compound head. This study was designed to explore the role grandmothers (typically a woman's mother-in-law) play in influencing maternal and newborn healthcare decisions. In-depth interviews were conducted with 35 mothers of newborns, 8 traditional birth attendants and local healers, 16 community leaders and 13 healthcare practitioners. An additional 18 focus groups were conducted with stakeholders such as household heads, compound leaders and grandmothers. In this region, grandmothers play many roles. They may act as primary support providers to pregnant mothers, care for newborns following delivery, preserve cultural traditions and serve as repositories of knowledge on local medicine. Grandmothers may also serve as gatekeepers for health-seeking behaviour, especially with regard to their daughters and daughters-in-law. This research also sheds light on the potential gap between health education campaigns that target mothers as autonomous decision-makers, and the reality of a more collectivist community structure in which mothers rarely make such decisions without the support of other community members.

Objective To evaluate the cost-effectiveness of a quality improvement intervention aimed at reducing maternal and fetal mortality in Accra, Ghana. Design Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis. Methods Data were collected on the cost and outcomes of a 5-year Kybele-Ghana Health Service Quality Improvement (QI) intervention conducted at Ridge Regional Hospital, a tertiary referral center in Accra, Ghana, focused on systems, personnel, and communication. Maternal deaths prevented were estimated comparing observed rates with counterfactual projections of maternal mortality and case-fatality rates for hypertensive disorders of pregnancy and obstetric hemorrhage. Stillbirths prevented were estimated based on counterfactual estimates of stillbirth rates. Cost-effectiveness was then calculated using estimated disability-adjusted life years averted and subjected to Monte Carlo and one-way sensitivity analyses to test the importance of assumptions inherent in the calculations. Main outcome measure Incremental Cost-effectiveness ratio (ICER), which represents the cost per disability-adjusted life-year (DALY) averted by the intervention compared to a model counterfactual. Results From 2007–2011, 39,234 deliveries were affected by the QI intervention implemented at Ridge Regional Hospital. The total budget for the program was $2,363,100. Based on program estimates, 236 (±5) maternal deaths and 129 (±13) intrapartum stillbirths were averted (14,876 DALYs), implying an ICER of $158 ($129-$195) USD. This value is well below the highly cost-effective threshold of $1268 USD. Sensitivity analysis considered DALY calculation methods, and yearly prevalence of risk factors and case fatality rates. In each of these analyses, the program remained highly cost-effective with an ICER ranging from $97-$218 Conclusion QI interventions to reduce maternal and fetal mortality in low resource settings can be highly cost effective. Cost-effectiveness analysis is feasible and should regularly be conducted to encourage fiscal responsibility in the pursuit of improved maternal and child health.

Effective follow-up of mother–infant pairs is critical for ensuring the success of preventing mother-to-child transmission (PMTCT) programs. The objective of this study was to identify factors associated with health outcomes of exposed infants in a PMTCT program in the Democratic Republic of Congo (DRC). Data were collected from January 2005 through December 2008 in 2 maternities in Kinshasa, DRC. The exposed infant’s health status was used as outcome. Multiple logistic regressions were used to identify the determinants of infant outcomes. A total of 309 mother–infant pairs were included in this study. Younger maternal age, breast-feeding but weaning before the age of 6 months, and HIV testing of the child and a mother who is not sick were associated with better infant health outcome. The follow-up of mother–infant pairs in PMTCT programs remains critical and challenging. There is a need for innovative and efficient strategies to improve retention of mother–infant pairs in PMTCT programs.

Objective: to explore community and health-care provider attitudes towards maltreatment during delivery in rural northern Ghana, and compare findings against The White Ribbon Alliance's seven fundamental rights of childbearing women. Design: a cross-sectional qualitative study using in-depth interviews and focus groups. Setting: the Kassena-Nankana District of rural northern Ghana between July and October 2010. Participants: 128 community members, including mothers with newborn infants, grandmothers, household heads, compound heads, traditional healers, traditional birth attendants, and community leaders, as well as 13 formally trained health-care providers. Measurements and findings: 7 focus groups and 43 individual interviews were conducted with community members, and 13 individual interviews were conducted with health-care providers. All interviews were transcribed verbatim and entered into NVivo 9.0 for analysis. Despite the majority of respondents reporting positive experiences, unprompted, maltreatment was brought up in 6 of 7 community focus groups, 14 of 43 community interviews, and 8 of 13 interviews with health-care providers. Respondents reported physical abuse, verbal abuse, neglect, and discrimination. One additional category of maltreatment identified was denial of traditional practices. Key conclusions: maltreatment was spontaneously described by all types of interview respondents in this community, suggesting that the problem is not uncommon and may dissuade some women from seeking facility delivery. Implications for practice: provider outreach in rural northern Ghana is necessary to address and correct the problem, ensuring that all women who arrive at a facility receive timely, professional, nonjudgmental, high-quality delivery care.

In Egypt, rising maternal overweight and obesity is consistent with the transition to westernized diets and a growing reliance on energy‐dense, low nutrient foods. Although the first 1,000 days of life are the focus of many programmes designed to prevent many forms of malnutrition, little attention has been paid to maternal dietary practices and weight gain during pregnancy. This study used in‐depth interviews with pregnant women (N = 40), lactating women (N = 40), and nonlactating women (N = 40) to gain an understanding of behaviours, perceptions, and cultural beliefs in relation to maternal dietary intake during pregnancy, lactation, and nonlactation; weight gain during pregnancy; birth spacing; and family planning. Study findings reveal that food choice was driven by affordability, favoured foods, or foods considered appropriate for a specific life stage (pregnant, lactating, and nonlactating). Knowledge of weight gain during pregnancy is limited, especially with regards to excessive weight gain during pregnancy. Diet is often modified during lactation to support breast milk production, and a normal diet resumed when breastfeeding ceases. Within the context of breastfeeding, the lactational amenorrhea method provides an opportunity to improve exclusive breastfeeding practices, maternal diet during lactation, and the transition to other family planning methods by 6 months postpartum. Health care providers should discuss limiting maternal consumption of low nutrient foods such as junk foods, soda, and teas during pregnancy and postpartum. Dietary counselling should accompany information on appropriate weight gain during pregnancy and exercise to prevent excessive weight gain, in the context of the nutrition transition.

SummaryThis study aimed to explore pregnant women's attitudes towards the inclusion of a lay companion as a source of social support during labour and delivery in rural central Ghana. Quantitative demographic and pregnancy-related data were collected from 50 pregnant women presenting for antenatal care at a rural district hospital and analysed using STATA/IC 11.1. Qualitative attitudinal questions were collected from the same women through semi-structured interviews; data were analysed using NVivo 9.0. Twenty-nine out of 50 women (58%) preferred to have a lay companion during facility-based labour and delivery, whereas 21 (42%) preferred to deliver alone with the nurses in a facility. Women desiring a companion were younger, had more antenatal care visits, had greater educational attainment and were likely to be experiencing their first delivery. Women varied in the type of companion they prefer (male partner vs female relative). What was expected in terms of social support differed based upon the type of companion. Male companions were expected to provide emotional support and to ‘witness her pain’. Female companions were expected to provide emotional support as well as instrumental, informational and appraisal support. Three qualitative themes were identified that run counter to the inclusion of a lay helper: fear of an evil-spirited companion, a companion not being necessary or helpful, and being ‘too shy’ of a companion. This research challenges the assumption of a unilateral desire for social support during labour and delivery, and suggests that women differ in the type of companion and type of support they prefer during facility deliveries. Future research is needed to determine the direction of the relationship – whether women desire certain types of support and thus choose companions they believe can meet those needs, or whether women desire a certain companion and adjust their expectations accordingly.

Serious bacterial infections (SBIs) are a significant cause of infant morbidity and mortality. Based on disease onset, SBIs are categorized as early-onset or late-onset.1,2 Group B Streptococcus (GBS) and Escherichia coli (E. coli) are the 2 most common organisms associated with early-onset SBI.3–5 Intrapartum antibiotic prophylaxis (IAP) reduces the incidence of early-onset GBS infections; however, invasive disease still occurs and is an important contributor to infant mortality.6,7 Since the recommendations for risk-based screening for GBS and use of IAP in 1996 and universal screening in 2002, the incidence of GBS early-onset SBIs has decreased from 1.7/1000 to 0.34/1000 live births.8–11 Increased administration of IAP has led to a change in the epidemiology of early-onset SBI among very low birth weight (VLBW

To explore community understanding of perinatal illness in northern Ghana.A cross-sectional descriptive study design.253 community members participated in in-depth interviews and focus group discussions, including women with newborn infants, grandmothers and health care providers. Four overarching themes emerged: (1) Local understanding of illness affects treatment practices. Respondents recognized danger signs of illness spanning antenatal to early neonatal periods. Understanding of causation often had a distinctly local flavor, and thus treatment sometimes differed from mainstream recommendations; (2) Mothers are frequently blamed for their infant's illness; (3) Healthcare decisions regarding infant care are often influenced by community members aside from the infant's mother and (4) Confidence in healthcare providers is issue-specific, and many households use a blended approach to meet their health needs.Despite widespread recognition of danger signs and reported intentions to treat ill infants through the formal health care system, traditional approaches to perinatal illness remain common. Interventions need to be aligned with community perceptions if they are to succeed.

Although the past decade has brought global reductions in maternal, infant and child mortality, many low-resource settings have failed to make significant gains relative to their high-income counterparts. In Ghana, nearly 50% of under-five mortality in 2014 could be attributed to deaths during the first 28 days after birth. This article analyses the data across a mixed-methods study of the factors impacting maternal and neonatal care in northern Ghana. The stillbirth and neonatal death study (SANDS) was conducted in 2010 and included both quantitative (N = 20 497) and qualitative data collection (N = 253) to explore the issues associated with the continuum of reproductive health care. Findings were compared against an adaptation of the WHO/UNICEF framework for integrated maternal and newborn care and used to generate concrete recommendations for clinicians, policymakers and programmers across the continuum of care, from pregnancy through delivery and postnatal care. SANDS elucidated epidemiological trends: 40% of neonatal deaths occurred on the first day after birth, and the leading causes of early neonatal mortality were birth asphyxia/injury, infection and complications of prematurity. Qualitative data reflect findings along two axes-community to facility-based care, and pre-pregnancy through the postnatal period. Resulting recommendations include the need to improving clinicians' understanding of and sensitization to local traditional practices, the need for policies to better address quality of care and coordination of training efforts, and the need for comprehensive, integrated programmes that ensure continuity of care from pre-pregnancy through the post-partum period. SANDS illustrates complex medical-social-cultural knowledge, attitudes and practices that span the reproductive period in rural northern Ghana. Data illustrate that not only are the first few days of life critical in infant survival but also there are significant social and cultural barriers to ensuring that mothers and their newborns are cared for in a timely, evidence-based manner.

As part of the "Grand Convergence: Aligning Technologies and Realities in Global Health" Collection, Cyril Engmann and colleagues discuss promising innovations that have the potential to move the RMNCH agenda forward.

OBJECTIVE: To assess the feasibility of using birth attendants instead of bereaved mothers as perinatal verbal autopsy respondents. METHODS: Verbal autopsy interviews for early neonatal deaths and stillbirths were conducted separately among mothers (reference standard) and birth attendants in 38 communities in four developing countries. Concordance between maternal and attendant responses was calculated for all questions, for categories of questions and for individual questions. The sensitivity and specificity of individual questions with the birth attendant as respondent were assessed. FINDINGS: For early neonatal deaths, concordance across all questions was 94%. Concordance was at least 95% for more than half the questions on maternal medical history, birth attendance and neonate characteristics. Concordance on any given question was never less than 80%. Sensitivity and specificity varied across individual questions, more than 80% of which had a sensitivity of at least 80% and a specificity of at least 90%. For stillbirths, concordance across all questions was 93%. Concordance was 95% or greater more than half the time for questions on birth attendance, site of delivery and stillborn characteristics. Sensitivity and specificity varied across individual questions. Over 60% of the questions had a sensitivity of at least 80% and over 80% of them had a specificity of at least 90%. Overall, the causes of death established through verbal autopsy were similar, regardless of respondent. CONCLUSION: Birth attendants can substitute for bereaved mothers as verbal autopsy respondents. The questions in existing harmonized verbal autopsy questionnaires need further refinement, as their sensitivity and specificity differ widely.

Of the estimated 8.8 million annual deaths that occur in children under the age of 5 years, 41% occur in neonates.1 Thus, per day, the newborn is 45 times more likely to die within the first 28 days of life than in the entire period from 4 weeks to 5 years of age. More than 98% of neonatal deaths occur in low- and middle-income countries and approximately 70% occur in community settings, often the home.2 These deaths frequently take place outside the formal health system and are rarely included in the vital registration process.3, 4

To determine the prevalence and identify risk factors for iron deficiency and anemia in pregnant Ghanaian women from urban areas.A cross-sectional study of 452 healthy pregnant women receiving prenatal care in Accra, Ghana, was conducted. A sociodemographic health questionnaire was performed and hematologic parameters were measured. Logistic regression methods were used to identify risk factors for anemia and iron status.Complete data were available for 428 women. Anemia (hemoglobin11 g/dL) was present in 144 (34%), iron deficiency (ferritinor =16 microg/L) in 69 (16%), and iron deficiency anemia in 32 (7.5%) women. The adjusted odds ratio (OR) for anemia was 3.4 and 9.8 if iron deficiency and malaria parasitemia were present, respectively; the OR was 0.6 if women were ator =36 weeks of pregnancy. The adjusted OR for iron deficiency was 2.7 if women were ator =36 weeks of pregnancy and 0.12 if they had sickle trait.Although anemia and iron deficiency remain substantial problems in pregnant Ghanaian women from urban areas, their prevalence is less than previously reported.

Summary Background WHO recommends referral to hospital for possible serious bacterial infection in young infants aged 0–59 days. We aimed to assess whether oral amoxicillin treatment for fast breathing, in the absence of other signs, is as efficacious as the combination of injectable procaine benzylpenicillin–gentamicin. Methods In a randomised, open-label, equivalence trial at five sites in DR Congo, Kenya, and Nigeria, community health workers followed up all births in the community, identified unwell young infants, and referred them to study nurses. We randomly assigned infants with fast breathing as a single sign of illness or possible serious bacterial infection, whose parents did not accept referral to hospital, to receive either injectable procaine benzylpenicillin–gentamicin once per day or oral amoxicillin treatment twice per day for 7 days. A person who was off-site generated randomisation lists using computer software. Trained health professionals gave injections, but outcome assessors were masked to group allocations. The primary outcome was treatment failure by day 8 after enrolment, defined as clinical deterioration, development of a serious adverse event including death, persistence of fast breathing on day 4, or recurrence up to day 8. The primary analysis was per protocol and we used a prespecified similarity margin of 5% to assess equivalence between regimens. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12610000286044. Findings From April 4, 2011, to March 29, 2013, we enrolled 2333 infants aged 0–59 days with fast breathing as the only sign of possible serious bacterial infection at the five study sites. We assigned 1170 infants to receive injectable procaine benzylpenicillin–gentamicin and 1163 infants to receive oral amoxicillin. In the per-protocol analysis, from which 137 infants were excluded, we included 1061 (91%) infants who fulfilled predefined criteria of adherence to treatment and adequate follow-up in the injectable procaine benzylpenicillin–gentamicin group and 1145 (98%) infants in the oral amoxicillin group. In the procaine benzylpenicillin–gentamicin group, 234 infants (22%) failed treatment, compared with 221 (19%) infants in the oral amoxicillin group (risk difference −2·6%, 95% CI −6·0 to 0·8). Four infants died within 15 days of follow-up in each group. We detected no drug-related serious adverse events. Interpretation Young infants with fast breathing alone can be effectively treated with oral amoxicillin on an outpatient basis when referral to a hospital is not possible. Funding Bill & Melinda Gates Foundation grant to WHO.

To assess midwives' baseline cognitive knowledge of evidence-based neonatal resuscitation practices, and short- and long-term educational effects of teaching a neonatal resuscitation program in a hospital setting in West Africa.All midwives (n=14) on the labor ward at Ridge Hospital in Ghana were trained using materials modified from the American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP). This training program included didactic and practical teaching and was assessed by direct observation within delivery rooms and written pre- and post-test evaluations. Written and practical modules 9-12 months after the initial training session were also conducted to assess retention of NRP knowledge and skills.Fourteen midwives received NRP training on the labor ward. Both written and practical evaluation of neonatal resuscitation skills increased after training. The percentage of items answered correctly on the written examination increased from 56% pre-training to 71% post-training (p0.01). The percentage of items performed correctly on the practical evaluation of skills increased from 58% pre-training to 81% (p0.01). These results were sustained 9-12 months after the initial training session.After receiving NRP training, neonatal resuscitation knowledge and skills increased among midwives in a hospital in West Africa and were sustained over a 9-month period. This finding demonstrates the sustained effectiveness of a modified neonatal resuscitation training program in a resource constrained setting.

Micronutrient deficiency is an important cause of growth stunting. To avoid micronutrient deficiency, the World Health Organization recommends complementary feeding with animal-source foods. However, animal-source foods are not readily available in many parts of the Democratic Republic of Congo (DRC). In such areas, caterpillars are a staple in adult diets and may be suitable for complementary feeding for infants and young children. We developed a cereal made from dried caterpillars and other locally available ingredients (ground corn, palm oil, sugar and salt), measured its macro- and micronutrient contents and evaluated for microbiologic contamination. Maternal and infant acceptability was evaluated among 20 mothers and their 8-10-month-old infants. Mothers were instructed in the preparation of the cereal and asked to evaluate the cereal in five domains using a Likert scale. Mothers fed their infants a 30-g portion daily for 1 week. Infant acceptability was based on cereal consumption and the occurrence of adverse events. The caterpillar cereal contained 132 kcal, 6.9-g protein, 3.8-mg iron and 3.8-mg zinc per 30 g and was free from microbiologic contamination. Mothers' median ratings for cereal characteristics were (5 = like very much): overall impression = 4, taste = 5, smell = 4, texture = 4, colour = 5, and consistency = 4. All infants consumed more than 75% of the daily portions, with five infants consuming 100%. No serious adverse events were reported. We conclude that a cereal made from locally available caterpillars has appropriate macro- and micronutrient contents for complementary feeding, and is acceptable to mothers and infants in the DRC.

To explore the impact of social factors on place of delivery in northern Ghana. We conducted 72 in-depth interviews and 18 focus group discussions in the Upper East Region of northern Ghana among women with newborns, grandmothers, household heads, compound heads, community leaders, traditional birth attendants, traditional healers, and formally trained healthcare providers. We audiotaped, transcribed, and analyzed interactions using NVivo 9.0. Social norms appear to be shifting in favor of facility delivery, and several respondents indicated that facility delivery confers prestige. Community members disagreed about whether women needed permission from their husbands, mother-in-laws, or compound heads to deliver in a facility, but all agreed that women rely upon their social networks for the economic and logistical support to get to a facility. Socioeconomic status also plays an important role alone and as a mediator of other social factors. Several “meta themes” permeate the data: (1) This region of Ghana is undergoing a pronounced transition from traditional to contemporary birth-related practices; (2) Power hierarchies within the community are extremely important factors in women’s delivery experiences (“someone must give the order”); and (3) This community shares a widespread sense of responsibility for healthy birth outcomes for both mothers and their babies. Social factors influence women’s delivery experiences in rural northern Ghana, and future research and programmatic efforts need to include community members such as husbands, mother-in-laws, compound heads, soothsayers, and traditional healers if they are to be maximally effective in improving women’s birth outcomes.

[1] Brkic S, Bogavac MA, Simin N, Hrnjakovic-Cvetkovic I, Milosevic V, Maric D. Unusual high rate of asymptomatic maternal parvovirus B19 infection associated with severe fetal outcome. J Matern Fetal Neonatal Med 2011;24(4):647-9. [2] Lamont RF, Sobel JD, Vaisbuch E, Kusanovic JP, Mazaki-Tovi S, Kim SK, et al. Parvovirus B19 infection in human pregnancy. BJOG 2011;118(2):175-86. [3] Dijkmans AC, de Jong EP, Dijkmans BA, Lopriore E, Vossen A, Walther FJ, et al. Parvovirus B19 in pregnancy: prenatal diagnosis and management of fetal complications. Curr Opin Obstet Gynecol 2012;24(2):95–101. [4] de Jong EP, de Haan TR, Kroes AC, Beersma MF, Oepkes D, Walther FJ. Parvovirus B19 infection in pregnancy. J Clin Virol 2006;36(1):1-7.

OBJECTIVES: To determine the neonatal mortality rate in the Kassena-Nankana District (KND) of northern Ghana, and to identify the leading causes and timing of neonatal deaths. METHODS: The KND falls within the Navrongo Health Research Centre's Health and Demographic Surveillance System (HDSS), which uses trained field workers to gather and update health and demographic information from community members every four months. We utilized HDSS data from 2003-2009 to examine patterns of neonatal mortality. RESULTS: A total of 17,751 live births between January 2003 and December 2009 were recorded, including 424 neonatal deaths 64.8%(275) of neonatal deaths occurred in the first week of life. The overall neonatal mortality rate was 24 per 1000 live births (95%CI 22 to 26) and early neonatal mortality rate was 16 per 1000 live births (95% CI 14 to 17). Neonatal mortality rates decreased over the period from 26 per 1000 live births in 2003 to 19 per 1000 live births in 2009. In all, 32%(137) of the neonatal deaths were from infections, 21%(88) from birth injury and asphyxia and 18%(76) from prematurity, making these three the leading causes of neonatal deaths in the area. Birth injury and asphyxia (31%) and prematurity (26%) were the leading causes of early neonatal deaths, while infection accounted for 59% of late neonatal deaths. Nearly 46% of all neonatal deaths occurred during the first three postnatal days. In multivariate analysis, multiple births, gestational age

BACKGROUND: Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030. DISCUSSION: The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact. SUMMARY: Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.

Introduction Male participation is a crucial component in the optimization of Maternal and Child Health (MCH) services. This is especially so where prevention strategies to decrease Mother-to-Child Transmission (MTCT) of Human Immunodeficiency Virus (HIV) are sought. This study aims to identify determinants of male partners’ involvement in MCH activities, focusing specifically on HIV prevention of maternal to child transmission (PMTCT) in sub-Saharan Africa. Methods Literature review was conducted using the following data bases: Pubmed/MEDLINE; CINAHL; EMBASE; COCHRANE; Psych INFORMATION and the websites of the International AIDS Society (IAS), the International AIDS Conference and the International Conference on AIDS in Africa (ICASA) 2011. Results We included 34 studies in this review, which reported on male participation in MCH and PMTCT services. The majority of studies defined male participation as male involvement solely during antenatal HIV testing. Other studies defined male involvement as any male participation in HIV couple counseling. We identified three main determinants for male participation in PMTCT services: 1) Socio-demographic factors such as level of education, income status; 2) health services related factors such as opening hours of services, behavior of health providers and the lack of space to accommodate male partners; and 3) Sociologic factors such as beliefs, attitudes and communication between men and women. Conclusion There are many challenges to increase male involvement/participation in PMTCT services. So far, few interventions addressing these challenges have been evaluated and reported. It is clear however that improvement of antenatal care services by making them more male friendly, and health education campaigns to change beliefs and attitudes of men are absolutely needed.

Background Good nutrition is essential for increasing survival rates of infants. This study explored infant feeding practices in a resource-poor setting and assessed implications for future interventions focused on improving newborn health. Methods The study took place in the Kassena-Nankana District of the Upper East Region of northern Ghana. In-depth interviews were conducted with 35 women with newborn infants, 8 traditional birth attendants and local healers, and 16 community leaders. An additional 18 focus group discussions were conducted with household heads, compound heads and grandmothers. All interviews and discussions were audio taped, transcribed verbatim and analyzed using NVivo 9.0. Results Community members are knowledgeable about the importance of breastfeeding, and most women with newborn infants do attempt to breastfeed. However, data suggest that traditional practices related to breastfeeding and infant nutrition continue, despite knowledge of clinical guidelines. Such traditional practices include feeding newborn infants water, gripe water, local herbs, or traditionally meaningful foods such as water mixed with the flour of guinea corn (yara’na). In this region in Ghana, there are significant cultural traditions associated with breastfeeding. For example, colostrum from first-time mothers is often tested for bitterness by putting ants in it – a process that leads to a delay in initiating breastfeeding. Our data also indicate that grandmothers – typically the mother-in-laws – wield enormous power in these communities, and their desires significantly influence breastfeeding initiation, exclusivity, and maintenance. Conclusion Prelacteal feeding is still common in rural Ghana despite demonstrating high knowledge of appropriate feeding practices. Future interventions that focus on grandmothers and religious leaders are likely to prove valuable in changing community attitudes, beliefs, and practices with regard to infant nutrition.

Six million stillbirths (SB) and early neonatal deaths (END) occur annually worldwide, mostly in rural settings distant from health facilities. We used verbal autopsy (VA), to understand causes of non-hospital, community-based SB and END from four low-income countries.This prospective observational study utilized the train-the-trainer method. VA interviewers conducted standardized interviews; in each country data were reviewed by two local physicians who assigned an underlying causes of deaths (COD).There were 252 perinatal deaths (118 END; 134 SB) studied from pooled data. Almost half (45%) the END occurred on postnatal day 1, 19% on the second day and 16% the third day. Major early neonatal COD were infections (49%), birth asphyxia (26%), prematurity (17%) and congenital malformations (3%). Major causes of SB were infection (37%), prolonged labor (11%), antepartum hemorrhage (10%), preterm delivery (7%), cord complications (6%) and accidents (5%).Many of these SB and END were from easily preventable causes. Over 80% of END occurred during the first 3 days of postnatal life, and90% were due to infection, birth asphyxia and prematurity. The causes of SB were more varied, and maternal infections were the most common cause. Increased attention should be targeting at interventions that reduce maternal and neonatal infections and prevent END, particularly during the first 3 days of life.

Background Knowledge, attitudes and practices of community members and healthcare providers in rural northern Ghana regarding clean delivery are not well understood. This study explores hand washing/use of gloves during delivery, delivering on a clean surface, sterile cord cutting, appropriate cord tying, proper cord care following delivery, and infant bathing and cleanliness. Methods In-depth interviews and focus group discussions were audiotaped, transcribed, and analyzed using NVivo 9.0. Results 253 respondents participated, including women with newborn infants, grandmothers, household and compound heads, community leaders, traditional birth attendants, and formally trained health care providers. There is widespread understanding of the need for clean delivery to reduce the risk of infection to both mothers and their babies during and shortly after delivery. Despite this understanding, the use of gloves during delivery and hand washing during and after delivery were mentioned infrequently. The need for a clean delivery surface was raised repeatedly, including explicit discussion of avoiding delivering in the dirt. Many activities to do with cord care involved non-sterile materials and practices: 1) Cord cutting was done with a variety of tools, and the most commonly used were razor blades or scissors; 2) Cord tying utilized a variety of materials, including string, rope, thread, twigs, and clamps; and 3) Cord care often involved applying traditional salves to the cord - including shea butter, ground shea nuts, local herbs, local oil, or “red earth sand.” Keeping babies and their surroundings clean was mentioned repeatedly as an important way to keep babies from falling ill. Conclusions This study suggests a widespread understanding in rural northern Ghana of the need for clean delivery. Nonetheless, many recommended clean delivery practices are ignored. Overarching themes emerging from this study included the increasing use of facility-based delivery, the disconnect between healthcare providers and the community, and the critical role grandmothers play in ensuring clean delivery practices. Future interventions to address clean delivery and prevention of neonatal infections include educating healthcare providers about harmful traditional practices so they are specifically addressed, strengthening facilities, and incorporating influential community members such as grandmothers to ensure success.

To calculate perinatal mortality (stillbirth and early neonatal death: END) rates in the Upper East region of Ghana and characterize community-based stillbirths and END in terms of timing, cause of death, and maternal and infant risk factors.Birth outcomes were obtained from the Navrongo Health and Demographic Surveillance System over a 7-year period.Twenty thousand four hundred and ninty seven pregnant women were registered in the study. The perinatal mortality rate was 39 deaths/1000 deliveries, stillbirth rate 23/1000 deliveries and END rates 16/1000 live births. Most stillbirths were 31 weeks gestation or less. Prematurity, first-time delivery and multiple gestation all significantly increased the odds of perinatal death. Approximately 70% of END occurred during the first 3 postnatal days, and the most common causes of death were birth asphyxia and injury, infections and prematurity.Stillbirths and END remain a significant problem in Navrongo. The main causes of END occur during the first 3 days and may be modifiable with simple targeted perinatal policies.

Background In many developing countries, the majority of births are attended by traditional birth attendants, who lack formal training in neonatal resuscitation and other essential care required by the newly born infant. In these countries, the major causes of neonatal mortality are birth asphyxia, infection, and low-birth-weight/prematurity. Death from these causes is potentially modifiable using low-cost interventions, including neonatal resuscitation training. The purpose of this study was to evaluate the effect on perinatal mortality of training birth attendants in a rural area of the Democratic Republic of Congo (DRC) using two established programs. Methods This study, a secondary analysis of DRC-specific data collected during a multi-country study, was conducted in two phases. The effect of training using the WHO Essential Newborn Care (ENC) program was evaluated using an active baseline design, followed by a cluster randomized trial of training using an adaptation of a neonatal resuscitation program (NRP). The perinatal mortality rates before ENC, after ENC training, and after randomization to additional NRP training or continued care were compared. In addition, the influence of time following resuscitation training was investigated by examining change in perinatal mortality during sequential three-month increments following ENC training. Results More than two-thirds of deliveries were attended by traditional birth attendants and occurred in homes; these proportions decreased after ENC training. There was no apparent decline in perinatal mortality when the outcome of all deliveries prior to ENC training was compared to those after ENC but before NRP training. However, there was a gradual but significant decline in perinatal mortality during the year following ENC training (RR 0.73; 95% CI: 0.56-0.96), which was independently associated with time following training. The decline was attributable to a decline in early neonatal mortality. NRP training had no demonstrable effect on early neonatal mortality. Conclusion Training DRC birth attendants using the ENC program reduces perinatal mortality. However, a period of utilization and re-enforcement of training may be necessary before a decline in mortality occurs. ENC training has the potential to be a low cost, high impact intervention in developing countries. Trial registration This trial has been registered at http://www.clinicaltrials.gov (identifier NCT00136708).

This article discusses Kybele Inc a non-profit humanitarian organization dedicated to improve childbirth conditions worldwide through medical education partnerships specifically Kybeles work in Ghana. Kybele partnered with the Ghana Health Service to employ systems improvement methodologies to reduce maternal and perinatal mortality in a hospital setting.

OBJECTIVES To develop a standardized verbal autopsy (VA) training program and evaluate whether its implementation resulted in comparable knowledge required to classify perinatal cause of death (COD) by physicians and non-physicians. METHODS Training materials, case studies, and written and mock scenarios for this VA program were developed using conventional VA and ICD-10 guidelines. This program was used to instruct physicians and non-physicians in VA methodology using a train-the-trainer model. Written tests of cognitive and applied knowledge required to classify perinatal COD were administered before and after training to evaluate the effect of the VA training program. RESULTS Fifty-three physicians and non-physicians (nurse-midwives/nurses and Community Health Workers [CHW]) from Pakistan, Zambia, the Democratic Republic of Congo, and Guatemala were trained. Cognitive and applied knowledge mean scores among all trainees improved significantly (12.8 and 28.8% respectively, P < 0.001). Cognitive and applied knowledge post-training test scores of nurse-midwives/nurses were comparable to those of physicians. CHW (high-school graduates with 15 months or less formal health/nursing training) had the largest improvements in post-training applied knowledge with scores comparable to those of physicians and nurse-midwives/nurses. However, CHW cognitive knowledge post-training scores were significantly lower than those of physicians and nurses. CONCLUSIONS With appropriate training in VA, cognitive and applied knowledge required to determine perinatal COD is similar for physicians and nurses-midwives/nurses. This suggests that midwives and nurses may play a useful role in determining COD at the community level, which may be a practical way to improve the accuracy of COD data in rural, remote, geographic areas.

Objective To develop a prospective perinatal registry that characterizes all deliveries, differentiates between stillbirths and early neonatal deaths (ENDs), and determines the ratio of fresh to macerated stillbirths in the northwest Democratic Republic of Congo. Method Birth outcomes were obtained from 4 rural health districts. Results A total of 8230 women consented, END rate was 32 deaths per 1000 live births, and stillbirth rate was 33 deaths per 1000 deliveries. The majority (75%) of ENDs and stillbirths occurred in neonates weighing 1500 g or more. Odds of stillbirth and END increased in mothers who were single or who did not receive prenatal care, and among premature, low birth weight, or male infants. The ratio of fresh to macerated stillbirths was 4:1. Conclusion Neonates weighing 1500 g or more at birth represent a group with a high likelihood of survival in remote areas, making them potentially amenable to targeted intervention packages. The ratio of fresh to macerated stillbirths was approximately 10-fold higher than expected, suggesting a more prominent role for improved intrapartum obstetric interventions.

Kangaroo mother care (KMC) is an evidence-based approach to reducing mortality and morbidity in preterm infants. Although KMC is a key intervention package in newborn health initiatives, there is limited systematic information available on the barriers to KMC practice that mothers and other stakeholders face while practicing KMC. This systematic review sought to identify the most frequently reported barriers to KMC practice for mothers, fathers, and health practitioners, as well as the most frequently reported enablers to practice for mothers. We searched nine electronic databases and relevant reference lists for publications reporting barriers or enablers to KMC practice. We identified 1,264 unique publications, of which 103 were included based on pre-specified criteria. Publications were scanned for all barriers / enablers. Each publication was also categorized based on its approach to identification of barriers / enablers, and more weight was assigned to publications which had systematically sought to understand factors influencing KMC practice. Four of the top five ranked barriers to KMC practice for mothers were resource-related: "Issues with the facility environment / resources," "negative impressions of staff attitudes or interactions with staff," "lack of help with KMC practice or other obligations," and "low awareness of KMC / infant health." Considering only publications from low- and middle-income countries, "pain / fatigue" was ranked higher than when considering all publications. Top enablers to practice were included "mother-infant attachment" and "support from family, friends, and other mentors." Our findings suggest that mother can understand and enjoy KMC, and it has benefits for mothers, infants, and families. However, continuous KMC may be physically and emotionally difficult, and often requires support from family members, health practitioners, or other mothers. These findings can serve as a starting point for researchers and program implementers looking to improve KMC programs.

This article discusses a study that investigated the beliefs delivery intentions and subsequent delivery locations among women receiving prenatal care in the Eastern Region of Ghana where the reported rate of deliveries in healthcare facilties with skilled birth attendance (SBA) is 59%. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Our goal was to determine stillbirth rates in a multisite population-based study in community settings in the developing world.Outcomes of all community deliveries in 5 resource-poor countries (Democratic Republic of Congo, Guatemala, India, Zambia, and Pakistan) and in 1 mid-level country (Argentina) were evaluated prospectively over an 18-month period. Births of1000 g with no signs of life were defined as stillbirth.Outcomes of 60,324 deliveries were included. Stillbirth rates ranged from 34 per 1000 in Pakistan to 9 per 1000 births in Argentina. Increased stillbirth rates were associated significantly with lower skilled providers, out-of-hospital births, and low cesarean section rates. Maceration was present in 17.2% of stillbirths.The stillbirth rates among births ofor = 1000 g in these developing countries were substantially higher than reported stillbirth rates in developed countries (3-5/1000 births). Because most developed countries define stillbirth asor = 20 weeks of gestation oror = 500 g and because almost one-half of all stillbirths are1000 g, the developing/developed country difference is actually larger than apparent from this study. Maceration was uncommon, which indicates that most of the deaths probably occurred during labor. The low rates of physician attendance, hospital delivery, and cesarean section deliveries suggest that stillbirth rates could be reduced by access to higher quality institutional deliveries.

This research examines whether maternal optimism/pessimism is associated with unplanned Cesarean section deliveries in China. If so, does the association remain after controlling for clinical factors associated with C-sections? A sample of 227 mostly primiparous women in the third trimester of pregnancy was surveyed in a large tertiary care hospital in Beijing, China. Post-delivery data were collected from medical records. In bivariate analysis, both optimism and pessimism were related to unplanned c-section. However, when optimism and pessimism were entered into a regression model together, optimism was no longer statistically significant. Pessimism remained significant, even when adjusting for clinical factors such as previous abortion, previous miscarriage, pregnancy complications, infant gestational age, infant birthweight, labor duration, birth complications, and self-rated difficulty of the pregnancy. This research suggests that maternal mindset during pregnancy has a role in mode of delivery. However, more research is needed to elucidate potential causal pathways and test potential interventions.