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Adolescent pregnancy and obesity are conditions with multifactorial etiologies and adverse medical consequences, linked to underlying deep-rooted social problems. This chapter first discusses global trends, factors contributing to and the consequences of adolescent pregnancies, followed by a discussion of trends, etiology, and complications of obesity. Lastly, the chapter describes the problems related to pregnancy in obese adolescents and the care options for obese pregnant adolescents.

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.

Background Response should be a key part of maternal death surveillance and response (MDSR) programmes, which include confidential enquiries into maternal deaths. The programmes investigate avoidable factors in maternal deaths and make recommendations for improving maternity care. There is a gap in information on how these recommendations are transformed into practice. Objective To explore the methods used to assess the implementation status of recommendations made in confidential enquiries into maternal deaths and other health outcomes. Data sources We searched PubMed, Web of Science, CINAHL, and Google Scholar databases and general web for grey literature using the “Arksey and O’Malley framework” in all major scientific databases and search engines. Study selection and data extraction An initial screening was followed by extraction of information using a data chart. Variables in the chart were based on the response component of maternal death and surveillance systems. Synthesis Information collected was summarised using content analysis method. Results We reviewed 13 confidential enquiry systems into maternal deaths. Many confidential enquiries into maternal deaths published reports with their recommendations and dissemination often involved national‐level scientific presentations. Only five reports provided strategies for implementing the recommendations. Follow‐up of previous recommendations was routinely published in only two reports. However, impact assessment of recommendations on other health outcomes was found only in the UK. Conclusion There is a gap in monitoring the response generated by confidential enquiries into maternal deaths. Actions to develop this are therefore needed.

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.

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.

Additional file 1: Table S1. Possible cause of stillbirth ranked according to likelihood of occurrence as determined from the literature, and as used in the computer algorithms.

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.

ObjectivesTo determine the availability of continuous positive airway pressure (CPAP) and to provide an overview of its use in neonatal units in government hospitals across India.SettingCross-sectional cluster survey of a nationally representative sample of government hospitals from across India.Primary outcomesAvailability of CPAP in neonatal units.Secondary outcomesProportion of hospitals where infrastructure and processes to provide CPAP are available. Case fatality rates and complication rates of neonates treated with CPAP.ResultsAmong 661 of 694 government hospitals with neonatal units that provided information on availability of CPAP for neonatal care, 68.3% of medical college hospitals (MCH) and 36.6% of district hospitals (DH) used CPAP in neonates. Assessment of a representative sample of 142 hospitals (79 MCH and 63 DH) showed that air-oxygen blenders were available in 50.7% (95% CI 41.4% to 60.9%) and staff trained in the use of CPAP were present in 56.0% (45.8% to 65.8%) of hospitals. The nurse to patient ratio was 7.3 (6.4 to 8.5) in MCH and 6.6 (5.5 to 8.3) in DH. Clinical guidelines were available in 31.0% of hospitals (22.2% to 41.4%). Upper oxygen saturation limits of above 94% were used in 72% (59.8% to 81.6%) of MCH and 59.3% (44.6% to 72.5%) of DH. Respiratory circuits were reused in 53.8% (42.3% to 63.9%) of hospitals. Case fatality rate for neonates treated with CPAP was 21.4% (16.6% to 26.2%); complication rates were 0.7% (0.2% to 1.2%) for pneumothorax, 7.4% (0.9% to 13.9%) for retinopathy and 1.4% (0.7% to 2.1%) for bronchopulmonary dysplasia.ConclusionsCPAP is used in neonatal units across government hospitals in India. Neonates may be overexposed to oxygen as the means to detect and treat consequences of oxygen toxicity are insufficient. Neonates may also be exposed to nosocomial infections by reuse of disposables. Case fatality rates for neonates receiving CPAP are high. Complications might be under-reported. Support to infrastructure, training, guidelines implementation and staffing are needed to improve CPAP use.

Targets for maternal mortality reduction have been set under the Sustainable Development Goals (h t t p: / / w w w. un. org / sustainabledevelopment/health/). However, obtaining reliable information on the levels and causes of maternal mortality, and thus measuring progress towards elimination of preventable maternal deaths, remains a challenge.

The hypertensive disorders of pregnancy (HDP; pre-existing hypertension, gestational hypertension, and pre-eclampsia) remain important causes of maternal morbidity and mortality, especially in low- and middle-income countries. The paper summarizes the current state of evidence around possible technologies to support community-based improvements in maternal and perinatal outcomes for women with pre-eclampsia. Through the testing and, where proven, introduction of these technologies, we believe that HDP-related progress toward achieving Millennium Development Goal 5 can best be accelerated. The evidence and discussion are presented under the following headings: (1) prediction; (2) prevention; (3) diagnosis; (4) risk stratification; (5) decision aids; (6) treatment; (7) geographic information systems; (8) communication; and (9) community and patient education.

Aim To describe the operational aspects of continuous positive airway pressure (CPAP) use in newborn care in Kenya. Methods An ongoing nationwide survey of all health facilities in Kenya that use CPAP in newborn care. The mixed method approach used includes a standard questionnaire to describe CPAP use; key informant interviews and focus group discussions with the health care providers, to explore facilitators and barriers to CPAP use in newborn care. Descriptive statistics are used to analyse the quantitative data. A thematic framework is used to analyse the qualitative data. Results Twenty-two health facilities in Kenya provide CPAP in newborn care, but only 18 (82%) have agreed to participate in the survey. To date the survey has been conducted in 9 (50%) of these facilities, all of which are public county referral facilities that have been using CPAP in for ≤2 years. All of them use commercial bubble CPAP acquired predominantly through donor funding and have ≤3 machines per newborn care unit. Only 7/9 (78%) of the newborn care units had a doctor or nurse who had received training on the use of CPAP, and this was often on the job clinical training. The main indications for initiating CPAP were respiratory distress and suspected pneumonia. The main barriers to CPAP use in newborn care were inadequate training of health care providers on the use of CPAP, health care provider strikes and staff shortages, and inadequate support with management of equipment when donor support ended. The main facilitators were good leadership both at the unit and facility level that supported the sustainability of CPAP use in newborn care and peer support from carers whose newborns had survived following CPAP use. Conclusion The scale-up of CPAP use in newborn care in Kenya is well accepted by health care providers, but there are significant challenges with the sustainability of this intervention. Going forward, implementation strategies need to ensure that all staff working in newborn care units are adequately trained to safely administer CPAP, and that the health facilities are empowered to maintain the CPAP machines or have ready access to this support.

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.

Topic Guide. Provides the topic guide used in the study. (DOCX 14 kb)

Characteristics of included hospitals. Provides information on level of care provided and workload relevant to CPAP use. (DOCX 13 kb)

Background: Continuous Positive Airway Pressure (CPAP) is increasingly used in low- and middle-income setting to manage respiratory distress in neonates. Methods: National cross-sectional cluster survey of neonatal care units (SNCU) in 79 medical colleges (MC) and 63 district hospitals (DH) to assess availability, use, and, outcomes of CPAP. Findings: 68·3% of MC and 36·6% of DH used CPAP. Basic infrastructure was widely available. Air-oxygen blenders were available in 50·7% (95%CI 41·4,60·9) of hospitals. Equipment needed for monitoring and/or the detection and management of complications was not always in place; screening for retinopathy in 89·9%(77·2,95·9) MC and 60·3%(44·0,75·6) DH, treatment for retinopathy in 44·3%(30·9,58·5) MC and 7·9%(2·9,20·0) DH, screening for bronchopulmonary dysplasia in 62·0%(49·0,73·5) MC and 22·2%(12·5,36·3) DH, management of pneumothorax in 63·3%(49·8,74·9) of MC and 20·6%(9·8,38·3) of DH. Medical staff trained in the use of CPAP was available in 56·0%(45·8,65·8) of hospitals. The nurse:patient ratio was 7·3(95% CI 6·4-8·5) in MC and 6·6 (5·5-8·3) in DH. 72% MC and 59·3% DH used an upper oxygen saturation limit of above 94%. Respiratory circuits were reused in 52·8% of hospitals. Case Fatality Rates for neonates admitted to a SNCU were 11·5%(9·7,13·3) [13·2%(10·7,15·7) at MC and 7·4%(5·7,9·1) at DC] and 21·4%(16·6,26·2) for neonates receiving CPAP [19·8%(14·6,24·9) MC; 26·3%(15·7,37·0) DH]. Complication rates ranged from 27·9%(21·2,34·5) for rescue mechanical ventilation and 0·7%(0·2,1·2) for pneumothorax. Interpretation: Further support to infrastructure, training, and revision of current guidelines is urgently needed to improve the quality of care and ensure successful scale up of CPAP. Funding Statement: World Health Organization (Reference:2016/613341-0) Declaration of Interests: The authors have no competing interests to declare. Ethics Approval Statement: The study was approved by the Ministry of Health and Family Welfare of India (Child Health Division) and by the Liverpool School of Tropical Medicine’s Research and Ethics Committee (Research protocol 15·032).

Example of a summary matrix. Shows the summary matrix for an emergent theme â CPAP as a beneficial interventionâ . (DOCX 23 kb)

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.

Ӧ Tunc alp, WM Were, C MacLennan, OT Oladapo, AM G€ ulmezoglu, R Bahl, B Daelmans, M Mathai, L Say, F Kristensen, M Temmerman, F Bustreo a Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland b Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland c Family, Women and Children’s Health Cluster, World Health Organization, Geneva, Switzerland Correspondence: Dr Ӧ Tunc alp, Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland. Email tuncalpo@who.int

Task shifting—moving tasks to healthcare workers with a shorter training—for emergency obstetric care (EmOC) can potentially improve access to lifesaving interventions and thereby contribute to reducing maternal and neonatal morbidity and mortality. The present paper reviews studies on task shifting for the provision of EmOC. Most studies were performed in Sub-Saharan Africa and South Asia and focused primarily on task shifting for the performance of cesarean deliveries. Cesarean delivery rates increased following EmOC training without significant increase in adverse outcomes. The paper discusses the advantages and disadvantages of task shifting in EmOC and the role of this approach in improving maternal and newborn health in the short and long term.

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.

the partograph is a tool used globally to record labour progress. Although it has the potential to improve maternal and neonatal outcomes, some midwives struggle with using it in practice. Training in partograph use is limited, and the theory is often divorced from practice. Innovative ways of improving training are urgently required. We therefore aimed to determine whether the use of an e-learning tool is beneficial for learning partograph skills.an uncontrolled before-and-after study was conducted, informed by Kirkpatrick's four-stage model of evaluation; we report on the first two stages. We included a cohort of third and fourth year midwifery students who were studying at one university in Nairobi. The same hypothetical case scenario was used, pre- and post-implementation of the World Health Organization partograph e-learning tool, to assess students' partograph completion ability. Views on the tool were also sought, using semi-structured questionnaires. Data were analysed using standard statistical techniques and framework analysis.92 (88%) students participated. Students expressed positive views about the e-learning tool. However, the mean post-intervention score (27.21) was less than half of the maximum obtainable score. There was some improvement in test scores; year three mean score pre-intervention was 21.39 (SD 5.72), which increased to 25.10 (5.41) post-intervention (paired-t=3.47, p=0.001); year four mean score pre-intervention was 24.39 (5.98) which increased to 29.30 (6.77) post-intervention (paired t=3.85, df=91, p0.001). In the post-test, year four students scored higher than year three students (unpaired t=3.28, df=90, p=0.001). Students were unable to plot cervical dilatation correctly, once established labour had been confirmed.e-Learning training is acceptable to student midwives and has the potential to be an effective means of teaching the practical application of the partograph. However, in this study, their inability to correctly plot transference from the latent to active phase of labour suggests that the partograph itself may be too complicated. Modifications and further evaluation of the e-learning tool would be required before any widespread implementation. Furthermore, students need the clinical support to operationalise their learning; educating qualified midwives and obstetricians to be positive role models when completing the partograph would be one potential solution. Further research is required, taking on board the recommendations from our pilot study, to investigate the impact of partograph e-learning on practice and clinical outcomes.

Background Poor-quality care during institutional births in low- and middle-income countries is a major contributing factor to preventable maternal and newborn harm, but progress has been slow in identifying effective methods to address these deficiencies at scale. Based on the success of checklist programs in other disciplines, WHO led the design and field testing of the WHO Safe Childbirth Checklist—a 29-item tool that targets the major causes of maternal and newborn mortality globally. Methods The development process consisted of comprehensive evidence and guideline review, in-person consultation with content experts and other key stakeholders, iterative refinement through ongoing discussions with a wide collaborator network, and field evaluation for usability in 9 countries, primarily in Africa and Asia. Pilot testing in South India demonstrated major improvement in health workers’ delivery of essential safety practices after introduction of the program. Results WHO has launched a global effort to support further evaluation of the program in a range of contexts, and a randomized trial is underway in North India to measure the effectiveness of the program in reducing severe maternal, fetal, and newborn harm. Conclusion A novel checklist program has been developed to support health workers in low-resource settings to prevent avoidable childbirth-related deaths.

Background: Information technology is a rapidly increasing means of communication in education and healthcare. This is also true in low resource settings, where electronic communication provides an opportunity for sharing information about health and wellbeing and enhancing learning for healthcare professionals. Methods: A qualitative study whereby 51 year 3 and 4 student nurses at the University of Nairobi participated in 5 focus group discussions. Data were recorded, transcribed verbatim and analyzed using a framework approach. Results: Four main themes were identified, ‘moving with the times’, ‘global networking’, ‘inequity as a barrier’ and ‘transfer of internet learning into practice’. Conclusions: Information technology is already integral to students' lives both personally and professionally and the students had a strong desire to find out what is happening globally. The familiarity of the internet contributes to the acceptance of e-learning programs as part of educational curricula. Students felt that e-learning ‘is here to stay’ and wanted to ‘embrace the concept.’ E-learning was generally welcomed however students suggested that it should be ‘supplementary’ to face-to-face learning. In order to incorporate e-learning ethically in low resource settings, resources should be sustainable, for example CDROMs and DVDs which are not dependant on internet access. Researching the views of qualified midwives might be the next step in promoting this valuable teaching method.

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.

Countdown to 2015 health systems and policy tools and protocols. (DOCX 241Â kb)

Background: While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking.Methods: We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low-and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality.Results: Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed.Conclusions: Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

Background: Previous research has demonstrated the likely benefits of partograph use in low-resourced settings. However, the challenges of completing a partograph are also reported. The objective of this study was to examine students’ views and experiences of partograph use to gain understanding of the realities of using this tool in the labour ward. Methods: In a qualitative study, 51 student nurses, undertaking their maternity placement at a university in Nairobi, Kenya, participated in five focus group discussions. Data were audio recorded, transcribed verbatim and analysed thematically. Results: Four main themes emerged from the analyses: challenges to ‘doing the right thing’; theory-practice disconnectedness; negative role models; and retrospective recording. Conclusions: The results provide insight into the challenges faced by students when practising in the labour ward environment. A more effective approach to partograph training and implementation should be adopted to support students. However, student midwife training is unlikely to be implemented into practice unless the qualified team supports their learning. Given that the partograph had little status in the labour ward, change may only happen when senior health professionals (midwives and obstetricians) lead by example. Further research is required to explore the views of obstetricians and qualified midwives on partograph use. Appropriate implementation strategies also warrant further investigation.

Obstructed labor is an important cause of maternal and perinatal mortality and morbidity. The partograph graphically represents key events in labor and provides an early warning system. The World Health Organization partographs are the best known partographs in low resource settings. Experiences with World Health Organization and other types of partographs in low resource settings suggest that when used with defined management protocols, this inexpensive tool can effectively monitor labor and prevent obstructed labor. However, challenges to implementation exist and these should be addressed urgently.

The major medical causes of maternal death and the effective interventions to prevent maternal death due to these causes are known. Yet, every year, an estimated 529,000 women die during and following pregnancy and childbirth. Most of these deaths occur in developing countries where other non-medical determinants of maternal health influence the accessibility to these interventions. Improvements in maternal health can be achieved through a health systems approach. Care should be provided as a continuum throughout the life cycle and across health facilities through the health system. Communities, professional organizations and academic institutions should work actively with the government to: provide a package of service, based on population health needs, that is close to home; ensure availability of essential medicines and commodities; address financial barriers to receiving care; strengthen the health workforce; and gather and use information to improve maternal health.

OBJECTIVE To assess antimicrobial resistance (AMR) in Tamil Nadu, India. METHODS Data on AMR of commensal and uropathogenic Escherichia coli were collected from one urban (Christian Medical College Hospital, Vellore) and one rural (CMCH Rural Unit for Health and Social Affairs) centre in Tamil Nadu at monthly intervals for 1 year. RESULTS Forty-two per cent of commensal E. coli was resistant to one or more of the tested antimicrobials. 8.4% were resistant to three drugs commonly used for the treatment of urinary tract infections, namely ampicillin, co-trimoxazole and nalidixic acid. 1.5% of isolates were resistant to nitrofurantoin. There was no significant difference between resistance rates in commensal E. coli collected in rural and urban areas. Resistance was more common in infecting than commensal strains. DISCUSSION Resistance to most antimicrobials is high both in urban and rural areas. Higher resistance to antimicrobials used widely for the treatment suggests that drug use contributes to it. Hence unnecessary use of antimicrobials must be avoided. Surveillance among commensal E. coli can be used to monitor changes in AMR over time.