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Maternal and perinatal death surveillance and response (MPDSR) is a health systems process entailing the continuous cycle of identification, notification, and review of maternal and perinatal deaths (Surveillance), followed by actions to improve service delivery and quality of care and Response. Prior to the COVID-19 pandemic, there were an estimated 4.6 million maternal and newborn deaths and stillbirths each year. During the pandemic, maternal and perinatal health outcomes have worsened, especially in low- and middle-income countries, highlighting the urgent need to galvanize MPDSR to end preventable mortality and strengthen health systems.

Summary The 2030 Sustainable Development Goals agenda calls for health data to be disaggregated by age. However, age groupings used to record and report health data vary greatly, hindering the harmonisation, comparability, and usefulness of these data, within and across countries. This variability has become especially evident during the COVID-19 pandemic, when there was an urgent need for rapid cross-country analyses of epidemiological patterns by age to direct public health action, but such analyses were limited by the lack of standard age categories. In this Personal View, we propose a recommended set of age groupings to address this issue. These groupings are informed by age-specific patterns of morbidity, mortality, and health risks, and by opportunities for prevention and disease intervention. We recommend age groupings of 5 years for all health data, except for those younger than 5 years, during which time there are rapid biological and physiological changes that justify a finer disaggregation. Although the focus of this Personal View is on the standardisation of the analysis and display of age groups, we also outline the challenges faced in collecting data on exact age, especially for health facilities and surveillance data. The proposed age disaggregation should facilitate targeted, age-specific policies and actions for health care and disease management.

Summary Background Stillbirths are a major public health issue and a sensitive marker of the quality of care around pregnancy and birth. The UN Global Strategy for Women's, Children's and Adolescents’ Health (2016–30) and the Every Newborn Action Plan (led by UNICEF and WHO) call for an end to preventable stillbirths. A first step to prevent stillbirths is obtaining standardised measurement of stillbirth rates across countries. We estimated stillbirth rates and their trends for 195 countries from 2000 to 2019 and assessed progress over time. Methods For a systematic assessment, we created a dataset of 2833 country-year datapoints from 171 countries relevant to stillbirth rates, including data from registration and health information systems, household-based surveys, and population-based studies. After data quality assessment and exclusions, we used 1531 datapoints to estimate country-specific stillbirth rates for 195 countries from 2000 to 2019 using a Bayesian hierarchical temporal sparse regression model, according to a definition of stillbirth of at least 28 weeks’ gestational age. Our model combined covariates with a temporal smoothing process such that estimates were informed by data for country-periods with high quality data, while being based on covariates for country-periods with little or no data on stillbirth rates. Bias and additional uncertainty associated with observations based on alternative stillbirth definitions and source types, and observations that were subject to non-sampling errors, were included in the model. We compared the estimated stillbirth rates and trends to previously reported mortality estimates in children younger than 5 years. Findings Globally in 2019, an estimated 2·0 million babies (90% uncertainty interval [UI] 1·9–2·2) were stillborn at 28 weeks or more of gestation, with a global stillbirth rate of 13·9 stillbirths (90% UI 13·5–15·4) per 1000 total births. Stillbirth rates in 2019 varied widely across regions, from 22·8 stillbirths (19·8–27·7) per 1000 total births in west and central Africa to 2·9 (2·7–3·0) in western Europe. After west and central Africa, eastern and southern Africa and south Asia had the second and third highest stillbirth rates in 2019. The global annual rate of reduction in stillbirth rate was estimated at 2·3% (90% UI 1·7–2·7) from 2000 to 2019, which was lower than the 2·9% (2·5–3·2) annual rate of reduction in neonatal mortality rate (for neonates aged

Objectives To examine the characteristics of existing maternal tetanus immunization programmes for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with maternal vaccine service delivery that may impact the introduction and implementation of new maternal vaccines in the future. 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. Setting LMICs. Results The majority of countries (84/95; 88%) had a maternal tetanus immunization policy. Countries with high protection at birth (PAB) were more likely to report tetanus toxoid-containing vaccine (TTCV) coverage targets > 90%. Less than half the countries included in this study had a TTCV coverage target of > 90%. Procurement and distribution of TTCV was nearly always the responsibility of the Expanded Programme on Immunization (EPI), however planning and management of maternal immunization was often shared between EPI and Maternal, Newborn and Child Health (MNCH) programmes. Receipt of TTCV at the same time as the antenatal care visit correlated with high PAB. Most countries (81/95; 85%) had an immunization safety surveillance system in place although only 11% could differentiate an adverse event following immunization (AEFI) in pregnant and non-pregnant women. Conclusions Recommendations arising from the MIACSA project to strengthen existing services currently delivering maternal tetanus immunization in LMICs include establishing and maintaining vaccination targets, clearly defining responsibilities and fostering collaborations between EPI and MNCH, investing in strengthening the health workforce, improving the design and use of existing record keeping for immunization, adjusting current AEFI reporting to differentiate pregnant women and endeavoring to integrate the provision of TTCV within ANC services where appropriate.

ObjectivesWhile service integration has gained prominence as an objective of many global initiatives, there is no widely recognised single definition of integration nor a clear understanding of how programmes are integrated into health systems to achieve improved health outcomes. This study aims to review measurement approaches for integrated antenatal care (ANC) services, propose and operationalise indicators for measuring ANC service integration and inform an integrated ANC indicator recommendation for use in low-income and middle-income countries (LMICs).DesignFeasibility study.SettingBurkina Faso, Kenya, Malawi, Senegal and Sierra Leone.MethodsOur six-step approach included: (1) conceptualise ANC service integration models; (2) conduct a targeted literature review on measurement of ANC service integration; (3) develop criteria for ANC service integration indicators; (4) propose indicators for ANC service integration; (5) use extant data to operationalise the indicators; and (6) synthesise information to make an integrated ANC indicator recommendation for use in LMICs.ResultsGiven the multidimensionality of integration, we outlined three models for conceptualising ANC service integration: integrated health systems, continuity of care and coordinated care. Looking across ANC service integration estimates, there were large differences between estimates for ANC service integration depending on the model used, and in some countries, the ANC integration indicator definition within a model. No one integrated ANC indicator was consistently the highest estimate for ANC service integration. However, continuity of care was consistently the lowest estimate for ANC service integration.ConclusionsIntegrated ANC services are foundational to ensuring universal health coverage. However, our findings demonstrate the complexities in monitoring indicators of ANC service quality using extant data in LMICs. Given the challenges, it is recommended that countries focus on monitoring measures of service quality. In addition, efforts should be made to improve data collection tools and routine health information systems to better capture measures of service integration.

Background Preterm birth is a leading cause of death among children under five years. Previous estimates indicated global preterm birth rate of 10.6% (14.8 million neonates) in 2014. We aim to update preterm birth estimates at global, regional, and national levels for the period 2010 to 2019. Methods Preterm birth is defined as a live birth occurring before 37 completed gestational weeks, or Discussion Accurate measurement of preterm birth is challenging in many countries given incomplete or unavailable data from national administrative sources, compounded by limited gestational age assessment during pregnancy to define preterm birth. Up-to-date modelled estimates will be an important resource to measure the global burden of preterm birth and to inform policies and programs especially in settings with a high burden of neonatal mortality. Trial registration PROSPERO registration: CRD42021237861.

Background Postpartum haemorrhage (PPH) is a leading cause of preventable maternal mortality worldwide. The World Health Organization (WHO) recommends uterotonic administration for every woman after birth to prevent PPH. There are no standardised data collected in large-scale measurement platforms. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) is an observational study to assess the validity of measurement of maternal and newborn indicators, and this paper reports findings regarding measurement of coverage and quality for uterotonics. Methods The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data. We compared observation data for uterotonics to routine hospital register-records and women’s report at exit-interview survey. We analysed the coverage and quality gap for timing and dose of administration. The register design was evaluated against gap analyses and qualitative interview data assessing the barriers and enablers to data recording and use. Results Observed uterotonic coverage was high in all five hospitals (> 99%, 95% CI 98.7–99.8%). Survey-report underestimated coverage (79.5 to 91.7%). “Don’t know” replies varied (2.1 to 14.4%) and were higher after caesarean (3.7 to 59.3%). Overall, there was low accuracy in survey data for details of uterotonic administration (type and timing). Register-recorded coverage varied in four hospitals capturing uterotonics in a specific column (21.6, 64.5, 97.6, 99.4%). The average coverage measurement gap was 18.1% for register-recorded and 6.0% for survey-reported coverage. Uterotonics were given to 15.9% of women within the “right time” (1 min) and 69.8% within 3 min. Women’s report of knowing the purpose of uterotonics after birth ranged from 0.4 to 64.9% between hospitals. Enabling register design and adequate staffing were reported to improve routine recording. Conclusions Routine registers have potential to track uterotonic coverage – register data were highly accurate in two EN-BIRTH hospitals, compared to consistently underestimated coverage by survey-report. Although uterotonic coverage was high, there were gaps in observed quality for timing and dose. Standardisation of register design and implementation could improve data quality and data flow from registers into health management information reporting systems, and requires further assessment.

Additional file 3. STROBE Checklist.

Additional file 15. Assessment of routine recording responsibilities for uterotonic provision, EN-BIRTH Study.

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

Additional file 1. STROBE checklist.

Additional file 5. Ethical approval of local institutional review boards, EN-BIRTH and NePeriQIP studies.

Additional file 9. Individual-level validation of exit-survey report for uterotonic administration, EN-BIRTH Study (n = 23,051).

Additional file 4. Data collection dates by site, EN-BIRTH study.

Additional file 5. Facility register design and completion approaches for uterotonics by site, EN-BIRTH study (n = 22,002).

Additional file 4. Mode of birth by ethnicity at Pokhara Hospital, Nepal, EN-BIRTH study.

Background: Stillbirths are a major public health issue and a sensitive marker of the quality of care around pregnancy and birth. The UN Global Strategy for Women’s, Children’s and Adolescents’ Health and the Every Newborn Action Plan (ENAP) call for ending preventable stillbirths. A first step to prevent stillbirths is obtaining standardized measurement of stillbirth levels and trends across countries. We estimated levels and trends in stillbirth rates at 28 weeks or more of gestation from 2000 to 2019 and assessed progress over time. Methods: Our dataset contained 2,800 country-year datapoints from 171 countries relevant to stillbirth rates, including data from registration systems, household-based surveys and population-based studies. We estimated country-specific stillbirth rates for all countries from 2000 to 2019 using a Bayesian hierarchical temporal sparse regression model. Our model combined covariates with a temporal smoothing process such that estimates were informed by data in country-periods with high-quality data and covariate-based for country-periods with limited or no data on stillbirth rates. Bias and additional uncertainty associated with observations using alternative stillbirth definitions, source types and observations that were subject to non-sampling errors were included in the model. Results: In 2019, an estimated 2.0 [90 percent uncertainty interval: 1.9, 2.2] million babies were stillborn at 28 weeks or more of gestation, with a global stillbirth rate of 13.9 [13.5, 15.4] stillbirths per 1,000 total births. Stillbirth rates varied widely across the world from 22.8 [19.8, 27.7] per 1,000 total births in West and Central Africa to 2.9 [2.7, 3.0] per 1,000 total births in Western Europe, with West and Central Africa, Eastern and Southern Africa and South Asia having the highest stillbirth rates in 2019. The global annual rate of reduction in the stillbirth rate was estimated at 2.3 [1.7, 2.7] per cent from 2000 to 2019, lower than the 2.9 [2.5, 3.2] percent reduction in the neonatal mortality rate and the 4.3 [3.8, 4.7] percent reduction in the mortality rate among children aged 1–59 months over the same period. Based on point estimates, 14 countries halved their stillbirth rate since 2000, and 115 countries reduced the stillbirth rate by more than 25 per cent. The remaining 80 countries for which we made estimates reduced their stillbirth rate by less than 25 percent since 2000, with the majority located in Sub-Saharan Africa. Interpretation: in reducing the stillbirth rate has been slow compared with declines in the mortality rate among children under 5 years of age. Accelerated improvements are most needed in the regions and countries with high stillbirth rates, particularly in sub-Saharan Africa where the increases in number of births has outpaced modest progress and declines in stillbirth rates, leading to a stagnation in the number of stillbirths since 2000. Increased efforts are needed to raise public awareness of stillbirths, to improve data collection and to prevent stillbirths. It’s not possible to assess progress going forward or understand public health priorities locally unless there is investment in gathering information about stillbirths. Funding Statement: UNICEF’s stillbirth estimation work was supported by the Bill & Melinda Gates Foundation (OPP1180460 OP190601 and INV-001395). We also acknowledge the Foreign, Commonwealth & Development Office (United Kingdom) for helping to initiate this work. Declaration of Interests: We declare that we have no conflicts of interest.

Additional file 3. Background characteristics of women enrolled in NePeriQIP and EN-BIRTH studies.

Additional file 2. Ethical approval of local institutional review boards, EN-BIRTH study.

Additional file 6. Inter-observer agreement for uterotonic administration using Kappa, EN-BIRTH study.

Summary Background Strengthening the capacity of midwives to deliver high-quality maternal and newborn health services has been highlighted as a priority by global health organisations. To support low-income and middle-income countries (LMICs) in their decisions about investments in health, we aimed to estimate the potential impact of midwives on reducing maternal and neonatal deaths and stillbirths under several intervention coverage scenarios. Methods For this modelling study, we used the Lives Saved Tool to estimate the number of deaths that would be averted by 2035, if coverage of health interventions that can be delivered by professional midwives were scaled up in 88 countries that account for the vast majority of the world's maternal and neonatal deaths and stillbirths. We used four scenarios to assess the effects of increasing the coverage of midwife-delivered interventions by a modest amount (10% every 5 years), a substantial amount (25% every 5 years), and the amount needed to reach universal coverage of these interventions (ie, to 95%); and the effects of coverage attrition (a 2% decrease every 5 years). We grouped countries in three equal-sized groups according to their Human Development Index. Group A included the 30 countries with the lowest HDI, group B included 29 low-to-medium HDI countries, and group C included 29 medium-to-high HDI countries. Findings We estimated that, relative to current coverage, a substantial increase in coverage of midwife-delivered interventions could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2·2 million deaths averted per year by 2035. Even a modest increase in coverage of midwife-delivered interventions could avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths, equating to 1·3 million deaths averted per year by 2035. Relative to current coverage, universal coverage of midwife-delivered interventions would avert 67% of maternal deaths, 64% of neonatal deaths, and 65% of stillbirths, allowing 4·3 million lives to be saved annually by 2035. These deaths averted would be particularly concentrated in the group B countries, which currently account for a large proportion of the world's population and have high mortality rates compared with group C. Interpretation Midwives can help to substantially reduce maternal and neonatal mortality and stillbirths in LMICs. However, to realise this potential, midwives need to have skills and competencies in line with recommendations from the International Confederation of Midwives, to be part of a team of sufficient size and skill, and to work in an enabling environment. Our study highlights the potential of midwives but there are many challenges to the achievement of this potential. If increased coverage of midwife-delivered interventions can be achieved, health systems will be better able to provide effective coverage of essential sexual, reproductive, maternal, newborn, and adolescent health interventions. Funding New Venture Fund.

Background The 2016 World Health Organization (WHO) guidelines for antenatal care (ANC) shift the recommended minimum number of ANC contacts from four to eight, specifying the first contact to occur within the first trimester of pregnancy. We quantify the likelihood of meeting this recommendation in 54 Countdown to 2030 priority countries and identify the characteristics of women being left behind. Methods Using 54 Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) since 2012, we reported the proportion of women with timely ANC initiation and those who received 8-10 contacts by coverage levels of ANC4+ and by Sustainable Development Goal (SDG) regions. We identified demographic, socio-economic and health systems characteristics of timely ANC initiation and achievement of ANC8+. We ran four multiple regression models to quantify the associations between timing of first ANC and the number and content of ANC received. Results Overall, 49.9% of women with ANC1+ and 44.3% of all women had timely ANC initiation; 11.3% achieved ANC8+ and 11.2% received no ANC. Women with timely ANC initiation had 5.2 (95% confidence interval (CI) = 5.0-5.5) and 4.7 (95% CI = 4.4-5.0) times higher odds of receiving four and eight ANC contacts, respectively (P

Background Postnatal care (PNC) for mothers and newborns is essential to monitor risks of morbidity and adverse conditions following delivery. Current estimates of the coverage of PNC show substantial discordance between mothers and newborns. We investigate the sources of this discordance in Demographic and Health Surveys (DHS). Methods We used DHS data from 48 countries collected since 2011, spanning phases 6 and 7 of the survey program with 32 and 16 surveys, respectively, analyzed. We assessed the distribution of the reported timing of PNC and conducted a sensitivity analysis that excludes/includes PNC reported within 0-1 hour or PNC in the day 2. Agreement in PNC reporting considered four groups: (1) Concordance, neither mother nor newborn received PNC; (2) Concordance, mother and newborn pair received PNC; (3) Discordance, mother received PNC and newborn did not; of (4) Discordance, mother did not receive PNC but the newborn did. We carried out logistic regressions to understand correlates of PNC discordance. All analyses distinguished phase 6 surveys from phase 7. Results We found substantial differences in the PNC coverage estimated between phase 6 and phase 7 surveys. The phase 7 PNC questions for newborns were improved to increase the understanding of the questions by respondent which probably led to reducing the large PNC gap between mothers and newborns observed in phase 6 surveys. With phase 6 surveys, PNC coverage for mother was estimated on average at 62% compared to only 31% for newborns. No such gap was observed for phase 7 surveys, where for both mothers and newborns, the PNC coverage estimate was similar, at 56%. For both phases, over half of the reported PNC for mothers and newborns occurred during 0-1 hour following delivery, leading to substantial overestimation of PNC coverage, due to confusion between intrapartum care and PNC. There were 37% discordant cases between mother and newborn, largely in favor of the mother in phase 6 surveys, compared to 16% in phase 7 surveys. In phase 6 surveys, discordant PNC cases were observed largely among facility deliveries vs non-facility deliveries (44% compared to 19%). Conclusions Current estimates of coverage of PNC from DHS phase 6 surveys appears to include substantial level of measurement noises that could explain substantial part of the mother-newborn discordance in PNC. The PNC estimates appear to capture a substantial number of intrapartum care. Current measurement approaches warrant further validation to ensure accurate monitoring of the PNC programs.

BACKGROUND: Rigorous monitoring supports progress in achieving maternal and newborn mortality and morbidity reductions. Recent work to strengthen measurement for maternal and newborn health highlights the existence of a large number of indicators being used for this purpose. The definitions and data sources used to produce indicator estimates vary and challenges exist with completeness, accuracy, transparency, and timeliness of data. The objective of this study is to create a conceptual overview of how indicator validity is defined and understood by those who develop and use maternal and newborn health indicators. METHODS: A conceptual framework of validity was developed using mixed methods. We were guided by principles for conceptual frameworks and by a review of the literature and key maternal and newborn health indicator guidance documents. We also conducted qualitative semi-structured interviews with 32 key informants chosen through purposive sampling. RESULTS: We categorised indicator validity into three main types: criterion, convergent, and construct. Criterion or diagnostic validity, comparing a measure with a gold standard, has predominantly been used to assess indicators of care coverage and content. Studies assessing convergent validity quantify the extent to which two or more indicator measurement approaches, none of which is a gold-standard, relate. Key informants considered construct validity, or the accuracy of the operationalisation of a concept or phenomenon, a critical part of the overall assessment of indicator validity. CONCLUSION: Given concerns about the large number of maternal and newborn health indicators currently in use, a more consistent understanding of validity can help guide prioritization of key indicators and inform development of new indicators. All three types of validity are relevant for evaluating the performance of maternal and newborn health indicators. We highlight the need to establish a common language and understanding of indicator validity among the various global and local stakeholders working within maternal and newborn health.

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.

The worst rates of preventable mortality and morbidity among women and children occur in humanitarian settings. Reliable, easy-to-use, standardized, and efficient tools for data collection are needed to enable different organizations to plan and act in the most effective way. In 2015, the World Health Organization (WHO) commissioned a review of tools for data collection on the health of women and children in humanitarian emergencies. An update of this review was conducted to investigate whether the recommendations made were taken forward and to identify newly developed tools. Fifty-three studies and 5 new tools were identified. Only 1 study used 1 of the tools identified in our search. Little has been done in terms of the previous recommendations. Authors may not be aware of the availability of such tools and of the importance of documenting their data using the same methods as other researchers. Currently used tools may not be suitable for use in humanitarian settings or may not include the domains of the authors’ interests. The development of standardized instruments should be done with all key workers in the area and could be coordinated by the WHO.

IntroductionIn 2019, over 70 million people were forcibly displaced worldwide. Women and girls comprise nearly half of this population and are at heightened risk of negative sexual and reproductive health outcomes. With the collapse of health systems, reduced resources and increased vulnerabilities from displacement, there is a need to strengthen current practices and ensure the delivery of comprehensive sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) services. Recognising the need for consistency in data collection, analysis and use, the WHO developed a list of core SRMNCAH monitoring and evaluation indicators for services and outcomes in humanitarian settings. This research will explore the feasibility of collecting this core set of SRMNCAH indicators in displacement contexts.Methods and analysisWe will undertake a multimethods qualitative study in seven humanitarian settings: Afghanistan, Albania, Bangladesh, Cameroon, the Democratic Republic of the Congo, Iraq and Jordan. We selected sites that reflect diversity in geographic region, sociocultural characteristics, primary location(s) of displaced persons and nature and phase of the crisis. Our study consists of four components: key informant interviews, facility assessments, observational sessions at select facilities and focus group discussions with front-line healthcare personnel. We will analyse our data using descriptive statistics and for content and themes. We will begin by analysing data from each setting separately and will then combine these data to explore concordant and discordant results, triangulate findings and develop global recommendations.Ethics and disseminationThe University of Ottawa’s Research Ethics Board and the Research Project Review Panel (RP 2) of the World Health Organization-Department of Sexual and Reproductive Health as well as local IRBs of PIs’ research institutions reviewed and approved this protocol. We intend to disseminate findings through workshops at the WHO country, regional and headquarter levels, as well as through local, national and international conferences, workshops, peer-reviewed publications, and reports.