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This article is a part of a series that focuses on the current state of evidence and practice related to preterm birth prevention. We provide an overview of current knowledge (and limitations) on the global epidemiology of preterm birth, particularly around how preterm birth is defined, measured, and classified, and what is known regarding its risk factors, causes, and outcomes. Despite the reported associations between preterm birth and a wide range of socio-demographic, medical, obstetric, fetal, and environmental factors, approximately two-thirds of preterm births occur without an evident risk factor. Efforts to standardize definitions and compare preterm birth rates internationally have yielded important insights into the epidemiology of preterm birth and how it could be prevented.

Summary Background Preterm birth is the leading cause of death in children younger than 5 years worldwide. Although preterm survival rates have increased in high-income countries, preterm newborns still die because of a lack of adequate newborn care in many low-income and middle-income countries. We estimated global, regional, and national rates of preterm birth in 2014, with trends over time for some selected countries. Methods We systematically searched for data on preterm birth for 194 WHO Member States from 1990 to 2014 in databases of national civil registration and vital statistics (CRVS). We also searched for population-representative surveys and research studies for countries with no or limited CRVS data. For 38 countries with high-quality data for preterm births in 2014, data are reported directly. For countries with at least three data points between 1990 and 2014, we used a linear mixed regression model to estimate preterm birth rates. We also calculated regional and global estimates of preterm birth for 2014. Findings We identified 1241 data points across 107 countries. The estimated global preterm birth rate for 2014 was 10·6% (uncertainty interval 9·0–12·0), equating to an estimated 14·84 million (12·65 million–16·73 million) live preterm births in 2014. 12· 0 million (81·1%) of these preterm births occurred in Asia and sub-Saharan Africa. Regional preterm birth rates for 2014 ranged from 13·4% (6·3–30·9) in North Africa to 8·7% (6·3–13·3) in Europe. India, China, Nigeria, Bangladesh, and Indonesia accounted for 57·9 million (41×4%) of 139·9 million livebirths and 6·6 million (44×6%) of preterm births globally in 2014. Of the 38 countries with high-quality data, preterm birth rates have increased since 2000 in 26 countries and decreased in 12 countries. Globally, we estimated that the preterm birth rate was 9×8% (8×3–10×9) in 2000, and 10×6% (9×0–12×0) in 2014. Interpretation Preterm birth remains a crucial issue in child mortality and improving quality of maternal and newborn care. To better understand the epidemiology of preterm birth, the quality and volume of data needs to be improved, including standardisation of definitions, measurement, and reporting. Funding WHO and the March of Dimes.

Rationale, aims and objectives It has been proposed that delivery should be accomplished within 30 minutes after diagnosis of fetal distress. The objective of this study was to determine the decision-to-delivery interval (DDI) in emergency caesarean delivery for non-reassuring fetal heart rate (FHR). Methods A total of 272 term, singleton pregnant women who underwent an emergency caesarean section for non-reassuring FHR were included. Patient characteristics and clinical data were reviewed. The timing of the decision-to-delivery process was reviewed. Results The mean age was 28.7 years; the mean gestational age at delivery was 38.4 weeks; and 93.7% were in FHR category 2. The decision for emergency caesarean delivery was made during normal office hours in 31.6%. Median time for decision-to-operating room, decision-to-incision and decision-to-delivery was 42.3, 48.5 and 56 minutes, respectively. Only 6.6% of women had a DDI of 75 minutes. Significantly shorter intervals were observed for every endpoint among patients in FHR category 3, and they were significantly more likely to deliver within 30 minutes than were those in FHR category 2 (41.2% vs. 4.3%, P < 0.001). Similar results were observed for cases that occurred during normal and after hours. Neonatal outcomes were comparable among different DDI categories. Conclusion Only 6.6% of women with non-reassuring FHR achieved the 30-minute goal for caesarean delivery (median 56 minutes). Better performance was observed among patients in FHR category 3 regardless of diagnosis time, with 41.2% of these patients having a DDI of

Background Current and expected problems such as ageing, increased prevalence of chronic conditions and multi‐morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005. Objectives Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on: • patient outcomes; • processes of care; and • utilisation, including volume and cost. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to ‘Studies awaiting classification’. Selection criteria Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded. Data collection and analysis Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis. Main results For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle‐income country, and all other studies in high‐income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow‐up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse‐doctor substitution for preventive services and health education in primary care has been less well studied. Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low‐ or moderate‐certainty evidence): • Nurse‐led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor‐led care. However, the results vary and it is possible that nurse‐led primary care makes little or no difference to the number of deaths (low‐certainty evidence). • Blood pressure outcomes are probably slightly improved in nurse‐led primary care. Other clinical or health status outcomes are probably similar (moderate‐certainty evidence). • Patient satisfaction is probably slightly higher in nurse‐led primary care (moderate‐certainty evidence). Quality of life may be slightly higher (low‐certainty evidence). We are uncertain of the effects of nurse‐led care on process of care because the certainty of this evidence was assessed as very low. The effect of nurse‐led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse‐led primary care (moderate‐certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high‐certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high‐certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low‐certainty evidence). We are uncertain of the effects of nurse‐led care on the costs of care because the certainty of this evidence was assessed as very low. Authors' conclusions This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse‐led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors., Nurses as substitutes for doctors in primary care What is the aim of this review? The aim of this Cochrane Review was to find out what happens when primary healthcare services are delivered by nurses instead of doctors. We collected and analysed all relevant studies to answer this question and found 18 studies for inclusion in the review. What are the key messages of this review? Delivery of primary healthcare services by nurses instead of doctors probably leads to similar or better patient health and higher patient satisfaction. Nurses probably also have longer consultations with patients. Using nurses instead of doctors makes little or no difference in the numbers of prescriptions and tests ordered. However, the impacts on the amount of information offered to patients, on the extent to which guidelines are followed and on healthcare costs are uncertain. What was studied in this review? In most countries, the population is growing older and more people have chronic disease. This means that the services that primary healthcare workers need to deliver are changing. At the same time, many countries lack doctors and other healthcare workers, or people struggle to pay for healthcare services. By using nurses instead of doctors, countries hope to deliver care of the same quality for less money. In this review, we searched for studies that compared nurses to doctors for delivery of primary care services. We looked at whether this made any difference in patients’ health, satisfaction, and use of services. We also looked at whether this made any difference in how services were delivered and in how much they cost. What are the main results of this review? We included in this review 18 studies, mainly from high‐income countries. In some studies, nurses were responsible for all patients who came to the clinic or for all patients who needed urgent consultation. In some studies, nurses were responsible for patients with particular chronic diseases, or were responsible for providing healthcare education or preventive services to certain groups of patients. Included studies compared these nurses to doctors carrying out the same tasks. Our review shows that nurse‐led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor‐led care. However, the results vary and it is possible that nurse‐led primary care makes little or no difference to the number of deaths. In addition, patients probably have similar or better results in areas of health such as heart disease, diabetes, rheumatism, and high blood pressure. Patients also are probably slightly more satisfied with their care and may have a slightly better quality of life when treated by nurses. This review also shows that, compared to doctors, nurses probably have longer consultations, and their patients are slightly more likely to keep follow‐up appointments. Studies found little or no difference in the number of prescriptions and there may be little or no difference in the numbers of tests and investigations ordered, or in patients’ use of other services. The effects of nurse‐led primary care on the amount of advice and information given to patients, and on whether guidelines are followed, are uncertain as the certainty of these findings is very low. Our review suggests that the impacts on the costs of care of using nurses instead of doctors to deliver primary care are uncertain. We assessed the certainty of this finding as very low. How up‐to‐date is this review? We searched for studies that had been published up to March 2017.

The official WHO estimates of preterm birth are an essential global resource for assessing the burden of preterm birth and developing public health programmes and policies. This protocol describes the methods that will be used to identify, critically appraise and analyse all eligible preterm birth data, in order to develop global, regional and national level estimates of levels and trends in preterm birth rates for the period 1990 – 2014. We will conduct a systematic review of civil registration and vital statistics (CRVS) data on preterm birth for all WHO Member States, via national Ministries of Health and Statistics Offices. For Member States with absent, limited or lower-quality CRVS data, a systematic review of surveys and/or research studies will be conducted. Modelling will be used to develop country, regional and global rates for 2014, with time trends for Member States where sufficient data are available. Member States will be invited to review the methodology and provide additional eligible data via a country consultation before final estimates are developed and disseminated. This research will be used to generate estimates on the burden of preterm birth globally for 1990 to 2014. We invite feedback on the methodology described, and call on the public health community to submit pertinent data for consideration. Registered at PROSPERO CRD42015027439 Contact: pretermbirth@who.int

In 2007, the World Health Organization (WHO) received a criticism for a lack of transparency and systematic methods in the development of guidelines, which were at that time perceived as substantially driven by expert opinion. In this paper we assessed the quality of maternal and perinatal health guidelines developed since then. We used the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool to evaluate the quality of methodological rigour and transparency of four different WHO guidelines published between 2007 and 2011. Our findings showed high scores among the most recent guidelines on maternal and perinatal health suggesting higher quality. However, there is still potential for improvement, especially in including different stakeholder views, transparency of guidelines regarding the role of the funding body and presentation of the guideline document.