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The World Health Organization (WHO) has a mandate to promote maternal and child health and welfare through support to governments in the form of technical assistance, standards, epidemiological and statistical services, promoting teaching and training of healthcare professionals and providing direct aid in emergencies. The Strategic and Technical Advisory Group of Experts (STAGE) for maternal, newborn, child and adolescent health and nutrition (MNCAHN) was established in 2020 to advise the Director-General of WHO on issues relating to MNCAHN. STAGE comprises individuals from multiple low-income and middle-income and high-income countries, has representatives from many professional disciplines and with diverse experience and interests.Progress in MNCAHN requires improvements in quality of services, equity of access and the evolution of services as technical guidance, community needs and epidemiology changes. Knowledge translation of WHO guidance and other guidelines is an important part of this. Countries need effective and responsive structures for adaptation and implementation of evidence-based interventions, strategies to improve guideline uptake, education and training and mechanisms to monitor quality and safety. This paper summarises STAGE’s recommendations on how to improve knowledge translation in MNCAHN. They include support for national and regional technical advisory groups and subnational committees that coordinate maternal and child health; support for national plans for MNCAHN and their implementation and monitoring; the production of a small number of consolidated MNCAHN guidelines to promote integrated and holistic care; education and quality improvement strategies to support guidelines uptake; monitoring of gaps in knowledge translation and operational research in MNCAHN.

Background: Many policy makers deliberating on comprehensive sexual and reproductive health and rights services need reliable evidence to make choices that benefit women, adolescents, children and the wider society. While universal health coverage discourse provides an opportunity to expand access through evidence based interventions, many gaps exist. Research prioritization has proved to be very helpful in identifying relevant areas especially in constrained resource settings. The purpose of this paper is to present the results of the World Health Organization Africa Region research prioritization for sexual and reproductive health and rights. These priorities hope to guide the region for the next three years. Methods: We used the Child Health and Nutrition Research Initiative approach to identify priority questions among many potential areas for research prioritization on sexual and reproductive health and rights. The implementation process was organized in three phases. The first phase involved sending out an online survey to various experts with experience in sexual and reproductive health rights. These questions were received by a technical team from World Health Organization headquarters for review. 634 questions were identified for potential research and grouped into 12 themes. The second phase involved experts who reviewed the questions. The team merged questions with duplications, removed the questions that were out of scope and finally refined the wordings. In the final phase, experts worked in groups to score and rank top ten priority questions for each of the 12 thematic areas. Results: A list of 120 priority questions for sexual and reproductive health and rights were prioritized by 67 participants drawn from 16 organizations. Most of the priority research questions (45%) focused on the theme of gender-based violence, 35% prioritized services in sexual and reproductive health and rights in humanitarian settings while 15% prioritized preventing unsafe abortion. 5% of the participants prioritized cervical cancer prevalence, prevention and treatment as a thematic area out of the questions in the top 20 research priority questions. Conclusions: Key priority research questions in sexual and reproductive health and rights were identified around five themes. The priority list will be of significance to World Health Organization regional Office for Africa and her stakeholders for the next three years.

Background: There is an increasing emphasis on conducting research to identify gender based violence issues to enable development of appropriate programs and interventions. However, these efforts are mixed in quality and often raise ethical questions. The increased pressure on policy makers to move to a more evidence-based approach in addressing gender based issues creates the need for this research prioritization activity. Inadequate evaluative evidence in this area poses a challenge in the planning for responsive interventions especially in resource limited settings. The purpose of this paper is to present gender based violence research priority areas for the WHO Africa Region. Methods: We utilized a modified version of the Child Health and Nutrition Research Initiative approach to reach consensus on research priorities on the thematic area of gender based violence. In three phases, we first conducted an online survey with sexual and reproductive health and rights experts in academia, ministries of health, non-governmental organizations and other health actors with a wide range of experiences. These questions were consolidated by three experts from World Health Organization headquarters into themes. Secondly, experts were invited in a meeting in Cape Town South Africa to analyze and generate relevant areas of research based on the themes. Finally, a smaller group of experts prioritized research areas based on agreed criteria. Results: A list of 10 priority research questions for addressing gender based violence were scored and ranked. Four priority research questions scored 30 points out of the possible 30 points and were thus ranked as the highest priority. These included questions that “engage young adolescents in behavioral interventions to influence gender roles”, “determinants of gender based violence analysis”, “both long and short term complications of gender based violence on survivors” and “assessment of men’s involvement in addressing gender-based violence against women”. The second most highly ranked question was on the assessment of the extent and strategies to prevent gender-based violence in the context of humanitarian crises. Conclusions: Priority research questions for addressing gender based violence were identified. This exercise provides a three year investment case for research with high potential of effectively identifying interventions with high impact on addressing gender based violence.

Background: The use of mobile phones continues to rise rapidly in the provision of health related services. Many countries have adopted the use of mobiles to provide sexual and reproductive health and rights and especially among the adolescents where specific messages are tailored for various audiences with specific messages. The purpose of this paper is to present the results of a research priority setting exercise on mHealth and innovative strategies. Methods: We adapted Child Health and Nutrition Research Initiative methodology to identify and set research priorities on mHealth and innovative strategies that respond to sexual and reproductive health and rights services. General potential research questions were gathered online from multiple stakeholders in the region and sent for consolidation consolidated to technical experts in World Health Organization headquarters. The second phase involved a meeting with experts to review and thematically analyze the questions list of 33 questions producing a list of 22 research questions. The questions were scored against a six point criteria and ranked accordingly. Ten top priority research questions were identified. Results: Lists of 33 priority research questions for mHealth and innovative strategies were proposed for discussions by 67 stakeholders. The questions were reviewed, scored and ranked in a technical meeting by experts. The highest ranking questions at 87% include evaluation of mHealth for data management and sexual and reproductive health and rights decision making, assessment of innovative local financing techniques to support community based sexual reproductive health and rights and evaluation of the role of mobile technologies in referral and counter referral. Conclusions: Information and communication technology is developing drastically and has a great potential in improving health especially in sexual and reproductive health and rights service delivery. This potential must be demonstrated with more relevant and quality research on mHealth and innovative strategies priorities identified.

Background: Unsafe abortion is a commonly neglected sexual and reproductive health and rights issue despite the serious health problems it causes to women and girls in their reproductive ages. It is classified as a main cause of maternal mortality and morbidity. This paper has considered questions that have the greatest potential to successfully reduce unsafe abortions in the resource poor settings. Methods: We adapted the Child Health and Nutrition Research Initiative (CHNRI) to identify and prioritize many competing sexual and reproductive health and rights research ideas that impact the health of the populations. The implementation was done in three phases which included generation and collection of research ideas from various experts virtually in August 2019 consolidation of the potential questions through thematic analysis conducted in September 2019. Finally, scoring and ranking of the research questions was done in a workshop of experts. Results: Out of a list of 45 priority research questions, two questions were ranked the highest scoring 28 out of the possible 30. The research priorities include: “The effectiveness of interventions (e.g. counseling or incentives or home visits) to increase post abortion uptake and continuance”, “Reducing repeat abortion on improving maternal health outcomes” and “Evaluation of community-based awareness programs to reduce unwanted pregnancies and encourage women to seek help early”. Conclusions: Ten key research priorities in preventing unsafe abortion were identified. The priority list covers areas of focus that could effectively impact preventing unsafe abortions while also acting as a knowledge base for researchers, policy makers and other interested stakeholders who would want to invest in this area.

Background: Despite increased recognition of the need for sexual and reproductive health and rights in humanitarian settings, evidence focusing on mainstreaming reproductive health services such as maternal, neonatal mortality, human immunodeficiency virus transmission and unsafe abortion still remains inadequate. The ability to understand the magnitude of the needs and highlight existing gaps is supported by improved data which is critical to informing effective policies, programming and funding decisions. The purpose of this report is to present the results of a research prioritization exercise on sexual and reproductive health and rights services in humanitarian settings for the WHO Africa region for the next three years. Methods: We adapted the Child Health and Nutrition Research Initiative method in three phases. Experts from the region participated in an online survey to identify key areas for research in sexual and reproductive health and rights. To identify potential areas for research, the experts ensured answerability, effectiveness, deliverability, equity and potential impact of the questions. The research areas they identified were reviewed by World Health Organization technical team from headquarters. In a meeting of 67 participants, the questions were subjected to further review and analysis. Using a modified for scoring criteria, the questions were scored and ranked to provide the top ten priority questions to address sexual and reproductive health and rights services in humanitarian settings. Results: A list of 21 priority research questions on sexual and reproductive health and rights services in humanitarian settings were scored and ranked. Top ten priorities research questions were identified. Those that scored highly by scoring 30 points out of the possible maximum of 30 include: “determining the prevalence and associated factors of unwanted pregnancies and abortions performed in emergency and humanitarian settings”, “evidence on gender-based violence in humanitarian situations and its associated factors” and “defining an optimal model for coordinating sexual and reproductive health and rights interventions and responses in crisis situations”. Conclusions: Top ten research priorities in sexual and reproductive health and rights services in humanitarian settings were identified. The priority research areas have the potential to identify the best areas for programming of services in humanitarian settings. It is our hope that the identified research areas will be prioritized to support programming of services in humanitarian settings based on scientific evidence.

Background: Cervical cancer has been ranked among the leading causes of deaths among women in Africa. Despite this, priority setting mechanisms used in planning for programmes and interventions that respond to sexual and reproductive health and rights services particularly in cervical cancer prevalence, prevention and treatment have not adequately taken into account research based evidence to respond appropriately. Methods: We adapted the Child Health and Nutrition Research Initiative method. A wide range of stakeholders identified potential research areas in an online survey. A technical working group comprising of 67 participants reviewed the questions for modification and removal of out scope questions. Finally, scoring and ranking was done to provide the top ten priorities questions. Results: “Cost-benefit analysis of systematic human papillomavirus vaccination compared to the current cost of cervical cancer in public health care systems” scored 27. This was followed by two research questions ranked at 24 points: “assessment of women’s and girls’ knowledge on the importance of early cervical cancer screening,” and “human papilloma virus vaccination and contributions of new technologies to the supply and storage of vaccines, including human papillomavirus vaccine”. Conclusion: The study identified 10 priority research questions that can guide the agenda for cervical cancer prevalence, prevention and treatment in the WHO Africa region. The identified priorities will be of use to policy makers, researchers and programmers and other stakeholders who can invest in areas that greatly affect cervical cancer prevalence, prevention and treatment.

Objective: The neonatal mortality rate remains a serious problem in most countries in sub-Saharan Africa such as Burkina Faso, where, in 2010 this mortality rate was 28 per 1000 live births [1] [2]. Its reduction is possible and passes first by the strict prevention of infections in birth rooms. The objective of this study was to describe the practices of infection prevention in the birth rooms of seven referral hospitals in Ouagadougou from April 1 to July 31, 2016. Materials and Methods: This was a cross-sectional study on the knowledge, attitudes and practices of the rules of prevention and control of healthcare associated infections (PCHAI) among 123 consenting health workers who provided birth room care in 7 hospitals in Ouagadougou. Data were collected through individual interviews and direct observations. The study was authorized by the Institutional Ethics Committee in 2015 under the number 32. The data analysis was done with the Epi Info software version 2000. Results: The “five clean in the birth room” were known by 26.83%. Regarding the equipment used for PCHAI, sterile gloves were mentioned by 75.61% of the agents, the source of clean water by 62.60% and soap by 57.11%; in practice, 17.07% of the respondents had not washed their hands and 42 providers (34%) had not performed with complete mastery the wearing of sterile gloves before giving birth, and 55.28% had not cleaned the perineum. Conclusion: Deficiencies in the prevention and control of healthcare-associated infections have been identified. Training on infection prevention in the neonatal period is needed for the benefit of hospital providers.

The objective of this study was to determine the prevalence of HPV-HR genotypes in the population of sexually active women in Bobo-Dioulasso, Burkina Faso. Methods: This study took place at Souro Sanou Teaching Hospital in Bobo-Dioulasso from September to June 2017. A total of 234 women in the gynecological period and also sexually active were enrolled after they gave an individual consent. Swabbing of the endocervical canal was done. From the sample stored at -20°C, the viral DNA was extracted using the “DNA-Sorb-A” kit from SACACE biotechnologies&reg. Amplification of the PCR of the extracted DNA was made, using the “HPV Genotypes 14 Real-TM Quant” V67-100 FRT kit. Data were analyzed with SPSS software version 17.0 and Epi Info 6. Chi-square and Fisher’s tests were used to compare proportions and averages; a link was significant when p 0.05. Results: The mean age was 30.7 ± 7.3 years (median: 30 years); 84.5% of them were married, 43.5% had a socio-professional activity and 61% were schooled. A total of 20.6% of women were positive for at least one of the following HPV-HR genotypes: HPV 18, 31, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68. Genotypes the most frequently found were HPV 52 with 11 cases (17.2%) and 66 with 10 cases (15.6%). Conclusion: Our results show a predominance of HPV-HR genotypes not covered by available vaccines. Mapping genotypes are needed to fully understand viral ecology at the national level. But for instance, the nonavalent vaccine, which has a better coverage of the predominant genotypes, is to be promoted.

In 1972, two landmark papers in this journal described the partograph,1,2 a chart designed to provide finite referral criteria for midwives working in peripheral clinics who needed to refer women in labour to Harare Hospital, Zimbabwe (then Rhodesia). This innovation coincided with influential reports from the National Maternity Hospital in Dublin of the ‘active management of labour’ (early amniotomy, proactive use of oxytocin and one‐to‐one nursing care) with the objective of achieving birth within a limited time frame.3 The partograph was globally adopted, and has been used as part of the assessment of labour progress for nearly half a century. It was recommended by the World Health Organization (WHO) in the early 1990s as a routine tool for displaying the progress of labour. Despite its global acceptance, utilization and correct completion rates as low as 31% and 3% respectively, have been reported.

Background The World Health Organization recommends regularly assessing the efficacy of artemisinin-based combination therapy (ACT), which is a critical tool in the fight against malaria. This study evaluated the efficacy of two artemisinin-based combinations recommended to treat uncomplicated Plasmodium falciparum malaria in Burkina Faso in three sites: Niangoloko, Nanoro, and Gourcy. Methods This was a two-arm randomized control trial of the efficacy of artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DP). Children aged 6–59 months old were monitored for 42 days. The primary outcomes of the study were uncorrected and PCR-corrected efficacies to day 28 for AL and 42 for DP. Molecular markers of resistance to artemisinin derivatives and partner drugs were also analysed. Results Of 720 children enrolled, 672 reached study endpoints at day 28, 333 in the AL arm and 339 in the DP arm. PCR-corrected 28-day per protocol efficacy in the AL arm was 74% (64–83%) in Nanoro, 76% (66–83%) in Gourcy, and 92% (84–96%) in Niangoloko. The PCR-corrected 42-day per protocol efficacy in the DP arm was 84% (75–89%) in Gourcy, 89% (81–94%) in Nanoro, and 97% (92–99%) in Niangoloko. No Pfk13 mutation previously associated with artemisinin-resistance was observed. No statistically significant association was found between treatment outcome and presence of the 86Y mutation in the Pfmdr1 gene. There was also no association observed between treatment outcome and Pfpm2 or Pfmdr1 copy number variation. Conclusion The results of this study indicate evidence of inadequate efficacy of AL at day 28 and DP at day 42 in the same two sites. A change of first-line ACT may be warranted in Burkina Faso. Trial Registry Pan African Clinical Trial Registry Identifier: PACTR201708002499311. Date of registration: 8/3/2017 https://pactr.samrc.ac.za/Search.aspx

Additional file 2: Table S1. Hemoglobin g/dl measured among participants in therapeutic efficacy monitoring, 2017-2018, Burkina Faso

In response to the World Health Organization (WHO) statements and international concerns regarding the coronavirus disease 2019 (COVID-19) outbreak, FIGO has issued the following guidance for the management of pregnant women at the four main settings of pregnancy: (1) ambulatory antenatal care in the outpatient clinics; (2) management in the setting of the obstetrical triage; (3) intrapartum management; and (4) postpartum management and neonatal care. We also provide guidance on the medical treatment of pregnant women with COVID-19 infection.

Competency-based training in postpartum family planning and postpartum IUD (PPIUD) service delivery of antenatal, maternity, and postnatal care providers from 5 francophone African countries generated an enthusiastic response from the providers and led to government and donor support for expansion of the approach. More than 2,000 women chose and received the PPIUD between 2014 and 2015. This model of South–South cooperation, when coupled with demand promotion, supportive supervision, and reliable collection of service outcome data, can help to expand PPIUD services in other regions as well., A global resurgence of interest in the intrauterine device (IUD) as an effective long-acting reversible contraceptive and in improving access to a wide range of contraceptive methods, as well as an emphasis on encouraging women to give birth in health care facilities, has led programs to introduce postpartum IUD (PPIUD) services into postpartum family planning (PPFP) programs. We describe strategic, organizational, and technical elements that contributed to early successes of a regional initiative in West and Central Africa to train antenatal, maternity, and postnatal care providers in PPFP counseling for the full range of available methods and in PPIUD service delivery. In November 2013, the initiative provided competency-based training in Guinea for providers from the main public teaching hospital in 5 selected countries (Benin, Chad, Côte d’Ivoire, Niger, and Senegal) with no prior PPFP counseling or PPIUD capacity. The training was followed by a transfer-of-learning visit and monitoring to support the trained providers. One additional country, Togo, replicated the initiative’s model in 2014. Although nascent, this initiative has introduced high-quality PPFP and PPIUD services to the region, where less than 1% of married women of reproductive age use the IUD. In total, 21 providers were trained in PPFP counseling, 18 of whom were also trained in PPIUD insertion. From 2014 to 2015, more than 15,000 women were counseled about PPFP, and 2,269 women chose and received the PPIUD in Benin, Côte d’Ivoire, Niger, Senegal, and Togo. (Introduction of PPIUD services in Chad has been delayed.) South–South collaboration has been central to the initiative’s accomplishments: Guinea’s clinical centers of excellence and qualified trainers provided a culturally resonant example of a PPFP/PPIUD program, and trainings are creating a network of regional trainers to facilitate expansion. Two of the selected countries (Benin and Niger) have expanded their PPFP/PPUID training programs to additional sites. Inspired after learning about the initiative at a regional meeting, Togo has outperformed the original countries involved in the initiative by training more providers than the other countries. Challenges to scale-up include a lack of formal channels for reporting PPFP and PPIUD service delivery outcomes, inconsistent coordination of services across the reproductive health continuum of care, and slow uptake in some countries. Continued success will rely on careful recordkeeping, regular monitoring and feedback, and strategic data use to advocate scale-up.

Objective To assess the use of assisted vaginal delivery (AVD) in low- and middle-income countries (LMICs), highlighting what level of care procedures were performed and identifying systemic barriers to its use. Design Cross-sectional health facility assessments. Setting Up to 40 countries in Latin America, sub-Saharan Africa and Asia. Population Assessments tended to be national in scope and included all hospitals and samples of midlevel facilities in public and private sectors. Methods Descriptive secondary data analysis. Main outcome measures Percentage of facilities where health workers performed AVD in the 3 months prior to the assessment, instrument preference, which health workers performed the procedure, and reasons AVD was not practiced. Results Fewer than 20% of facilities in Latin America reported performing AVD in the last 3 months. In sub-Saharan Africa, 53% of 1728 hospitals had performed AVD but only 6% of nearly 10 000 health centres had done so. It was not uncommon to find

Summary Introduction Pregnant women are more susceptible to vaginal colonization and infection by yeast. The role of Candida colonization in the occurrence of preterm birth is well established. The knowledge of local epidemiology and identification of risk factors for preterm birth is important for the prevention and management strategies. The purpose of the study was to determine the prevalence of Candida sp. in vaginal swabs of pregnant women. Methods Pregnant women attending routine antenatal visits in three primary health centres in Bobo-Dioulasso (Burkina Faso) were enrolled into a cross-sectional study carried out from February to April 2015. Vaginal swabs samples were taken from participants after obtaining oral consent. The swabs were inoculated into Sabouraud's glucose agar supplemented with chloramphenicol and incubated at 37 °C for 24 to 48 hours under aerobic conditions in order to perform fungal culture. The identification of the Candida species was done by culture on HiCrome Candida Differential Agar at 35 °C for 48 h for production of species-specific colors. Results A total of 229 pregnant women were included. The prevalence of vulvovaginal candidiasis (VVC) was 22.71%, (95% CI [17.45–28.69]). Candida albicans accounted for 40.39% and non- Candida albicans species for 59.61% of the isolates, with mainly C. glabrata (32.69%), C. tropicalis (15.38%) and C. krusei (11.54%). Conclusions This study revealed a high prevalence of non- C. albicans species. The syndromic management guidelines for VVC in Burkina Faso will be revised to include a specific protocol for pregnant women.

Objectif : decrire la faisabilite et les resultats d’un suivi a domicile d’accouchees sorties precocement de la maternite apres un accouchement normal. Methodologie : il s’agit d’une etude prospective et descriptive menee du 1er au 30 avril 2011, dans cinq maternites de la ville de Bobo-Dioulasso au Burkina Faso. Les accouchees par voie basse dont l’examen a la sixieme heure du postpartum a conclu a l’absence de complications pour la mere et le nouveau-ne ont ete incluses. Les sorties ont eu lieu entre 12 et 48 h. Le suivi a domicile a ete assure par telephone, par des visites a domicile ou des visites a l’hopital, avec une consultation postnatale systematique a J7. Resultats : au total, 630 accouchees et leurs nouveau-nes ont ete suivis. Il y a eu en tout 1 567 appels telephoniques. Vingt-sept accouchees n’ont pas pu etre jointes au telephone apres leur sortie, et 140 visites a domicile a la demande ont ete realisees. Nous avons releve en tout cinquante-cinq complications maternelles et 135 complications neonatales. Conclusion :le suivi postnatal a domicile est necessaire pour les accouchees et leurs nouveau-nes sortis precocement de la maternite, du fait des possibilites de complications. Il permet d’assurer le continuum de soins afin d’ameliorer la survie de la mere et du nouveau-ne. Le telephone mobile, du fait de sa propagation dans la population, est probablement un des moyens pour ce suivi.

To assess coverage, acceptability, and feasibility of a program to prevent postpartum hemorrhage (PPH) at community and facility levels, a study was conducted in 60 health facilities and their catchment areas in four districts in Rwanda. A total of 220 skilled birth attendants at these facilities were trained to provide active management of the third stage of labor and 1994 community health workers (ASMs) were trained to distribute misoprostol at home births. A total of 4,074 pregnant women were enrolled in the program (20.5% of estimated deliveries). Overall uterotonic coverage was 82.5%: 85% of women who delivered at a facility received a uterotonic to prevent PPH; 76% of women reached at home at the time of birth by an ASM ingested misoprostol--a 44.3% coverage rate. Administration of misoprostol at the time of birth for home births achieved moderate uterotonic coverage. Advancing the distribution of misoprostol through antenatal care services could further increase coverage.

Adolescent females are a key target audience in the fight against sexually transmitted infections and HIV in sub-Saharan Africa. One issue is that families in Africa play a very limited role in sex education. The objective of this study was to examine parent-child communication from a qualitative perspective by exploring the characteristics and quality of parent-child communication. A cross-sectional study was conducted between April and September 2009 in Bobo-Dioulasso (Burkina Faso). The study included 40 parent-child pairs (50% of in-school children and 50% of out-of-school children). Individual interviews and focus groups were conducted. The data were analyzed using Stata version 9.1 (quantitative data) and QSR Nvivo 2.0 (qualitative data). The study found that 74% (14/19) of out-of-school children communicated with their parents, compared to just 45% of in-school children (p = 0.07). Mother-child communication was found to be the most common type of parent-child communication, with 59% (13/22) of families who communicated about sexuality and HIV preferring mother-child communication. Further research is needed to identify the factors determining better communication among out-of-school children.

Summary Background Oxytocin, the gold-standard treatment for post-partum haemorrhage, needs refrigeration, intravenous infusion, and skilled providers for optimum use. Misoprostol, a potential alternative, is increasingly used ad hoc for treatment of post-partum haemorrhage; however, evidence is insufficient to lend support to recommendations for its use. This trial established whether sublingual misoprostol is non-inferior to intravenous oxytocin for treatment of post-partum haemorrhage in women receiving prophylactic oxytocin. Methods In this double-blind, non-inferiority trial, 31 055 women exposed to prophylactic oxytocin had blood loss measured after vaginal delivery at five hospitals in Burkina Faso, Egypt, Turkey, and Vietnam (two secondary-level and three tertiary-level facilities). 809 (3%) women were diagnosed with post-partum haemorrhage and were randomly assigned to receive 800 μg misoprostol (n=407) or 40 IU intravenous oxytocin (n=402). Providers and women were masked to treatment assignment. Primary endpoints were cessation of active bleeding within 20 min and additional blood loss of 300 mL or more after treatment. Clinical equivalence of misoprostol would be accepted if the upper bound of the 97·5% CI fell below the predefined non-inferiority margin of 6%. All outcomes were assessed from the time of initial treatment. This study is registered with ClinicalTrials.gov, number NCT00116350. Findings All randomly assigned participants were analysed. Active bleeding was controlled within 20 min after initial treatment for 363 (89%) women given misoprostol and 360 (90%) given oxytocin (relative risk [RR] 0·99, 95% CI 0·95–1·04; crude difference 0·4%, 95% CI −3·9 to 4·6). Additional blood loss of 300 mL or greater after treatment occurred for 139 (34%) women receiving misoprostol and 123 (31%) receiving oxytocin (RR 1·12, 95% CI 0·92–1·37). Shivering (152 [37%] vs 59 [15%]; RR 2·54, 95% CI 1·95–3·32) and fever (88 [22%] vs 59 [15%]; 1·47, 1·09–1·99) were significantly more common with misoprostol than with oxytocin. Six women had hysterectomies and two women died. Interpretation Misoprostol is clinically equivalent to oxytocin when used to stop excessive post-partum bleeding suspected to be due to uterine atony in women who have received oxytocin prophylactically during the third stage of labour. Funding The Bill & Melinda Gates Foundation.

OBJECTIVE: A survey of the knowledge of women about HIV and breastfeeding. METHOD AND PATIENTS: The study employed a voluntary questionnaire. Data were analyzed using Epi info 6 with chi(2) test and P < 0.05 was considered as statistically significant. RESULTS: Three hundred women agreed to participate in the study. Only 82 realized that HIV could be transmitted by breastmilk. After information about HIV transmission 37 stated that they would still breastfeed. On the other hand 220 (74.1%) stated that they would accept breastfeeding by a wet nurse. Two hundred and eighty (69.8%) would accept to serve as the wet nurse for an infant born to an HIV-infected woman. There was an association between acceptance of HIV screening and willingness to breastfeed (P = 0.00206529). CONCLUSION: Appropriate Prevention of Mother-To-Child Transmission (PMTCT) measures must be made available to HIV-infected women. Detailed studies must be performed to evaluate the feasibility of this approach in resource limited settings.

Objectives Previous research has demonstrated the effectiveness of misoprostol for treatment of incomplete abortion; however, few studies have systematically compared misoprostol’s effectiveness with that of standard surgical care. This study documents the effectiveness of a single 600 micrograms dose of oral misoprostol versus manual vacuum aspiration (MVA) for treatment of incomplete abortion in a developing country setting. Design Open-label randomised controlled trial. Setting Two university teaching hospitals in Burkina Faso, West Africa. Population Women of reproductive age presenting with incomplete abortion. Methods From April 2004 through October 2004, 447 consenting women with incomplete abortion were randomised to either a single dose of 600 micrograms oral misoprostol or MVA for treatment of their condition. Main outcome measure Completed abortion following initial treatment. Results Regardless of treatment assigned, nearly all participants had a complete uterine evacuation (misoprostol = 94.5%, MVA = 99.1%; relative risk [RR] = 0.95 [95% CI 0.92–0.99]). Acceptability and satisfaction ratings were similar and high for both misoprostol and MVA, with three out of four women indicating that the treatment’s adverse effects were tolerable (misoprostol = 72.9%, MVA = 75.8%; RR = 0.96 [95% CI 0.86–1.07]). The majority of women were ‘satisfied’ or ‘very satisfied’ with the method they received (misoprostol = 96.8%, MVA = 97.7%; RR = 0.99 [95% CI 0.96–1.02]), expressed a desire to choose that method again (misoprostol = 94.5%, MVA = 86.6%; RR = 1.09 [95% CI 1.03–1.16]) and to recommend it to a friend (misoprostol = 94.5%, MVA = 85.2%; RR = 1.11 [95% CI 1.04–1.18]). Conclusion Six hundred micrograms of oral misoprostol is as safe and acceptable as MVA for the treatment of incomplete abortion. Operations research is needed to ascertain the role of misoprostol within postabortion care programmes worldwide.

A Madagascar, la situation de la santé maternelle et néonatale demeure inquiétante avec un ratio de mortalité maternelle de 478 pour 100 000 naissances vivantes et des taux de mortalité néonatale et infantile de 26 pour 1000 naissances vivantes et de 42 pour 1000 naissances vivantes, pour les enfants âgés de moins d’un mois et les enfants âgés de moins d’un an respectivement. Plusieurs facteurs pourraient expliquer cet alarmant état de santé maternelle et néonatale, y compris la pénurie de personnel de santé qualifié. Etant donné que plusieurs interventions ont été réalisées pour l’atteinte des objectifs 4 et 5 de l’OMD et qu’elles n’ont pas été fructueuses, il est pertinent d’évaluer la disponibilité des agents de santé qualifiés pour offrir les services de santé maternelle et néonatale dans les établissements sanitaires publics. L’enquête transversale a utilisé et adapté l’outil SARA (Service Availability and Readiness Assessment) de l’Organisation Mondiale de la Santé dans les 52 établissements sanitaires publics, dans 15 des 22 régions de Madagascar. Les données ont été collectées sur tablette avec le logiciel CommCare ODK© et analysées par niveau des établissements sanitaires avec le SPSS20.0. Le médecin généraliste est absent dans 14%des hôpitaux de référence et 22% des centres de santé primaire. Le nombre médian de gynécologue obstétricien dans les hôpitaux pour pratiquer les opérations césariennes est de 1. Seulement 20% des 15 régions enquêtées ont une proportion élevée (> 80%) de personnels qualifiés en santé maternelle et néonatale dans les établissements sanitaires publics. Dans l’optique d’une réduction tangible des mortalités maternelles et néonatales, l’on devrait renforcer la capacité de de ressources humaines et leur disponibilité pour offrir les services de santé maternelle et néonatale dans les établissements sanitaires publics.

arshad Sanghvi, Jeffrey Michael Smith, Koki Agarwal, Blami Dao, onald Magarick Jhpiego In the past 15 years, Jhpiego has had the privilege of working with governments and other partners to implement interventions for maternal and newborn health (MNH) in nearly 40 countries. This Supplement to the International Journal of Gynecology and Obstetrics (IJGO) is our attempt to share our analysis and learning from those experiences as the global health community looks toward 2030 and beyond, and to ensure that implementation challenges, aswell as the resources required to address them, are an important part of the post-MillenniumDevelopment Goals conversation. The new global paradigm for MNH envisioned by the UN Secretary General’s Sustainable Development Goals and the Global Strategy for Women’s, Children’s, and Adolescents’ Health aims to bring evidencebased MNH interventions to national scale, setting ambitious targets to reach the unreached in every country and end all preventable deaths among women and children. Scale is not only about what works; it is about how to make that which has been proven to work in small, controlled areas apply equally well across all contexts. So wemust ask ourselves: What does it take for health systems to reach every woman, every child, everywhere, every time? The answer to this classic implementation science question is difficult to quantify, but we do have some evidence, and as with any scientific inquiry, we should startwith the evidence thatwe have. The papers in the Supplement have beenwritten by and for implementers, describing in detail what has been accomplished and highlighting lessons about what did and did not work. The lessons themselves will not be new to anyone who has worked in MNH as long as we have, but we believe that their thoughtful analysis and collective and inductive presentation is a unique illustration of the complexity of achieving—and then reinforcing—implementation results. Implementation science for MNH has a long road ahead. The papers in the first section directly confront the “how” of implementation. Even if we have all the right interventions, we need political commitment and partnerships to bring those interventions to populations in need. Sometimes these elements are beyond the control of implementers owing to contextual factors and prioritizations inherent in real-world public health environments, but there are common principles that can help navigate politics and partnerships more strategically and systematically to reach goals more rapidly and with longer-lasting efforts. We should not, however, sacrifice quality for speed; quality improvement, particularly the linkages between quality and health outcomes, remains a critical but under-funded area of our work. The second section examines the “who” of implementation, documenting ways to empower all cadres of frontline health workers with appropriate competencies to deliver evidence-based interventions, wherever women and children need them. It is our belief that those

Approximately 15% of expected births worldwide will result in life-threatening complications during pregnancy, delivery, or the postpartum period. Providers skilled in emergency obstetric and newborn care (EmONC) services are essential, particularly in countries with a high burden of maternal and newborn mortality. Jhpiego and its consortia partners have implemented three global programs to build provider capacity to provide comprehensive EmONC services to women and newborns in these resource-poor settings. Providers have been educated to deliver high-impact maternal and newborn health interventions, such as prevention and treatment of postpartum hemorrhage and pre-eclampsia/eclampsia and management of birth asphyxia, within the broader context of quality health services. This article describes Jhpiego’s programming efforts within the framework of the basic and expanded signal functions that serve as indicators of high-quality basic and emergency care services. Lessons learned include the importance of health facility strengthening, competency-based provider education, global leadership, and strong government ownership and coordination as essential precursors to scale-up of high impact evidence-based maternal and newborn interventions in low-resource settings.

Resume Objectif. – Faire le bilan des transferts realises entre une maternite et un service de reanimation dans un contexte africain. Patientes et methodes. – Analyse retrospective des dossiers de toutes les malades transferees de la maternite au service de reanimation du centre hospitalier Souro Sanou de Bobo Dioulasso (Burkina Faso), du 1er janvier 1996 au 30 juin 1998. Resultats. – Quatre-vingt-deux patientes ont ete transferees de la maternite en reanimation sur un total de 6119 accouchements, soit un taux de transfert de 1,34 %. Il s'agissait surtout de patientes jeunes (âge moyen de 24 ans), referees d'une maternite peripherique dans 52,45 % des cas et ayant deja accouche dans 64,63 %. Les deux principaux diagnostics retenus a l'admission en reanimation etaient l'eclampsie et le choc infectieux. La grande majorite des patientes (73 cas sur 82) avait un facteur de mauvais pronostic avant le transfert. Une mortalite de 60 % a ete notee, les principaux facteurs de risque de mortalite ayant ete l'existence d'une detresse respiratoire ou une anemie severe. Conclusion. – La mortalite parmi les patientes transferees en reanimation est tres elevee. La reduction de cette mortalite passe la creation d'une unite de reanimation au sein de la maternite ou a defaut l'identification rapide des cas a transferer (systeme de scoring ?).

Background: In the context of the DITRAME-ANRS 049 research program that evaluated interventions aimed at reducing mother-to-child transmission of HIV (MTCT) in Bobo-Dioulasso (Burkina Faso), Voluntary HIV counseling and testing (VCT) services were established for pregnant women. HIV-infected women were advised to disclose their HIV serostatus to their male partners who were also offered VCT, to use condoms to reduce sexual transmission, and to choose an effective contraception method to avoid unwanted pregnancies. This study aimed at assessing how HIV test results were shared with male sexual partners, the level of use of modern contraceptive methods, and the pregnancy incidence among these women informed of the risks surrounding sexual and reproductive health during HIV infection. Methods: From 1995 to 1999, a quarterly prospective follow-up of a cohort of HIV-positive women. Results: Overall, 306 HIV-positive women were monitored over an average period of 13.5 months following childbirth, accounting for a total of 389 person-years. The mean age at enrollment in the cohort was 25.1 (standard deviation, 5.2 years). In all, 18% of women informed their partners, 8% used condoms at each instance of sexual intercourse to avoid HIV transmission, and 39% started using hormonal contraception. A total of 48 pregnancies occurred after HIV infection was diagnosed, an incidence of 12.3 pregnancies per 100 person-years. Pregnancy incidence was 4 per 100 personyears in the first year of monitoring and this rose significantly to 18 per 100 person-years in the third year. The only predictor of the occurrence of a pregnancy after HIV diagnosis was the poor outcome of the previous pregnancy (stillbirth, infant death). Severe immunodeficiency and change in marital status were the only factors that prevented the occurrence of a pregnancy after HIV diagnosis. Conclusion: Our study shows a poor rate of HIV test sharing and a poor use of contraceptive methods despite regular advice and counseling. Pregnancy incidence remained comparable with the pregnancy rate in the general population. To improve this situation, approaches for involving husbands or partners in VCT and prevention of MTCT interventions should be developed, evaluated, and implemented.

The principal objective of this 5-year clinical study of Norplant implants was to introduce these implants into the family planning program in Senegal and to determine their overall acceptability and safety in Senegalese acceptors. A total of 300 subjects were enrolled into the trial from August 1986 to July 1991. All the women were followed-up for 5 years or until the implants were removed. The pooled cumulative discontinuation rate was 40.8 +/- 2.91 per 100 women resulting in a continuation rate of 59.2 +/- 2.91 per 100 women. Thirteen subjects (4.3%) were lost during the follow-up. Seven pregnancies were reported throughout the 5 years leading to a cumulative pregnancy rate of 3.3 +/- 1.25 per 100 women. Menstrual problems were the reason most often given for early removal during the first 2 years. After year 2, desire for another pregnancy was the main reason for implant removal. The results presented in this study show that the Norplant implant system is a safe, effective, and acceptable method that meets the needs of the Senegalese family planning program.A 5-year prospective, noncomparative clinical evaluation of Norplant implants was conducted to introduce these implants into the family planning program and to determine the acceptability among women users in Senegal from August 1986 to July 1991. Findings showed that the pooled discontinuation rate was 40.8 +or- 2.91 per 100 women, resulting in a continuation rate of 59.2 +or- 2.91 per 100 women. During follow-up, 13 (4.3%) subjects were lost. Throughout the 5 years, 7 pregnancies were reported leading to a cumulative pregnancy rate of 3.3 +or- 1.25 per 100 women. The most common reason for early removal during the first 2 years was menstrual problems, while the main reason for removal in the second year was the desire to have a child. Overall, the Norplant implant system is a safe, effective, and acceptable method that is suitable for the Senegalese family planning program.

Introduction: La présente étude prospective se propose dévaluer l’efficacité thérapeutique du traitement préventif intermittent à la sulfadoxine - pyriméthamine et son observance chez la femme enceinte dans deux hôpitaux urbains au Burkina Faso. Méthodes: Chaque femme répondant aux critères d’inclusion a été soumise à un questionnaire pour la collecte des données socio - démographiques et des renseignements sur la grossesse. A l’accouchement, une apposition placentaire a été réalisée systématiquement. La lecture a été faite au microscope à lobjectif 100 à immersion. Résultats: Au total, 542 femmes ont été incluses avec un âge moyen de 26,0 ± 6,45 ans (extrêmes 13- 43 ans). Le taux de couverture du TPI à la sulfadoxine- pyriméthamine a été de 80%. Le taux d’infestation placentaire a été de 4,7 %. Il a diminué avec le nombre de dose de traitement préventif intermittent. Il a augmenté cependant de juillet à octobre. De 42,9% en octobre, il a diminué significativement à 9,5% en novembre (p

Background In low-resource settings, where abortion is highly restricted and self-induced abortions are common, access to post-abortion care (PAC) services, especially treatment of incomplete terminations, is a priority. Standard post-abortion care has involved surgical intervention but can be hard to access in these areas. Misoprostol provides an alternative to surgical intervention that could increase access to abortion care. We sought to gather additional evidence regarding the efficacy of 400 mcg of sublingual misoprostol vs. standard surgical care for treatment of incomplete abortion in the environments where need for economical non-surgical treatments may be most useful. Methods A total of 860 women received either sublingual misoprostol or standard surgical care for treatment of incomplete abortion in a multi-site randomized trial. Women with confirmed incomplete abortion, defined as past or present history of vaginal bleeding during pregnancy and an open cervical os, were eligible to participate. Participants returned for follow-up one week later to confirm clinical status. If abortion was incomplete at that time, women were offered an additional follow-up visit or immediate surgical evacuation. Results Both misoprostol and surgical evacuation are highly effective treatments for incomplete abortion (misoprostol: 94.4%, surgical: 100.0%). Misoprostol treatment resulted in a somewhat lower chance of success than standard surgical practice (RR = 0.90; 95% CI: 0.89-0.92). Both tolerability of side effects and women’s satisfaction were similar in the two study arms. Conclusion Misoprostol, much easier to provide than surgery in low-resource environments, can be used safely, successfully, and satisfactorily for treatment of incomplete abortion. Focus should shift to program implementation, including task-shifting the provision of post-abortion care to mid- and low- level providers, training and assurance of drug availability. Trial registration This study has been registered at clinicaltrials.gov as NCT00466999 and NCT01539408

Adolescent females are a key target audience in the fight against sexually transmitted infections and HIV in sub-Saharan Africa. One issue is that families in Africa play a very limited role in sex education. The objective of this study was to examine parent-child communication from a qualitative perspective by exploring the characteristics and quality of parent-child communication. A cross-sectional study was conducted between April and September 2009 in Bobo-Dioulasso (Burkina Faso). The study included 40 parent-child pairs (50% of in-school children and 50% of out-of-school children). Individual interviews and focus groups were conducted. The data were analyzed using Stata version 9.1 (quantitative data) and QSR Nvivo 2.0 (qualitative data). The study found that 74% (14/19) of out-of-school children communicated with their parents, compared to just 45% of in-school children (p = 0.07). Mother-child communication was found to be the most common type of parent-child communication, with 59% (13/22) of families who communicated about sexuality and HIV preferring mother-child communication. Further research is needed to identify the factors determining better communication among out-of-school children.

To explore 400-μg sublingual misoprostol as primary treatment in lower-level facilities with no previous experience providing postabortion care.Women presenting with incomplete abortion were offered a single dose of 400-μg sublingual misoprostol. Incomplete abortion was defined as uterine size consistent with fewer than 12 weeks of gestation, open cervical os, and reports of past or present history of vaginal bleeding. Women returned to the clinic 1 week after misoprostol administration for follow-up. At that time, they were discharged if the uterine evacuation was a success or were offered a second follow-up visit or surgical completion if still incomplete.One-hundred women received misoprostol; outcome data were unavailable for 1 woman. Complete uterine evacuation was achieved for 97 (98.0%) women. Satisfaction was high, with nearly all women indicating that they were "satisfied" (n=57 [57.6%]) or "very satisfied" (n=41 [41.4%]) with their experience. Adverse effects were considered "tolerable" by 72 of 97 (74.2%) women. Ninety-seven of 99 (98.0%) participants indicated that they would choose misoprostol for incomplete abortion care in the future and 95 of 97 (97.9%) stated that they would recommend it to a friend.Misoprostol is a viable option for treatment of incomplete abortion at mid-level facilities.

A specific protein with an estimated molecular weight of 260 kDa was found to be synthesized and secreted into the incubation medium by rat uterus only during the estrus stage of the cycle. This secreted uterine protein was designated as estrus stage-specific protein (ESP). ESP was not produced by pregnant, lactating or immature pup rat uteri. Estradiol administered to ovariectomized rats induced production of ESP which was blocked by the antiestrogen, ICI 182, 780. The present results show that the synthesis and secretion of ESP is regulated by estradiol and this protein maybe involved in blastocyst implantation.

Introduction Les adolescentes sont très vulnérables face aux Infections Sexuellement Transmissibles (IST) et au VIH/SIDA. Notre étude a pour objectifs d’explorer la qualité de la communication entre les adolescentes et leurs parents sur les IST/VIH/SIDA et de recueillir leurs suggestions pour l’amélioration de cette communication. Méthodes L’étude était transversale qualitative sur 2 mois. La population de l’étude était composée par des adolescentes de 13 à 17 ans et leurs parents habitant la ville de Bobo Dioulasso. Vingt (20) adolescentes scolarisées ont été tirés au sort dans trois établissements secondaires et 20 autres non scolarisées choisies de façon accidentelle dans la ville. Les informations ont été collectées à l’aide de 8 focus groups. Les discussions ont été enregistrées sur cassettes, retranscrites en verbatim, et analysées à l’aide du logiciel QSR NVIVO 2.0. Résultats Les adolescentes et leurs parents communiquent très peu ou pas sur les questions des IST/VIH/SIDA; l’auto-information par les paires ou les médias est la première source d’information. Pour les parents, l’information existe et est accessible aux adolescentes alors que pour ces dernières, leurs connaissances de ces maladies sont parfois erronées. L’abstinence, la fidélité et le dépistage volontaire comme moyen de prévention sont très peu évoqués par les adolescentes de même que par leurs parents. Conclusion La communication parents-adolescentes est insuffisante voire absente dans certains milieux. Il est urgent de conduire des actions auprès des adolescentes et leurs parents pour mieux les informer sur les IST/VIH/SIDA et améliorer la communication sur ces maladies.

* Other members listed at end of paper. Objectives: To describe annual trends in syphilis seroprevalence and to identify risk factors of syphilis among pregnant women receiving antenatal care in Bobo-Dioulasso, Burkina Faso. Methods: Women were recruited between January 1995 and July 1998 in three antenatal clinics where counselling and HIV testing services had been established in the context of a trial evaluating a short course of zidovudine to reduce mother to child transmission of HIV (ANRS 049 trial). Sociodemographic variables were collected during HIV pretest counselling sessions. Syphilis diagnosis was considered when serum was positive with both rapid plasma reagin and Treponema pallidum haemagglutination assay (TPHA) tests. Results: Overall, 10 980 pregnant women were screened. Syphilis seroprevalence was 0.24% (95% confidence interval (CI): 0.15–0.35) without changes over time. HIV prevalence was 8.8% (CI: 8.3–9.3). In a multivariable analysis, having casual sex partners (odds ratio (OR) = 4.48; CI: 1.62–12.38), being HIV seropositive (OR = 2.62; CI: 1.02–6.74), and being illiterate (OR = 3.78; CI: 1.24–11.48) were independent risk factors for syphilis infection. Conclusions: This study suggests low syphilis seroprevalence in this city of Burkina Faso. Sexually transmitted disease programmes should be reinforced to offer free access to syphilis screening and treatment in order to eliminate this disease, in coordination with HIV prevention and care. Key Words: syphilis; HIV; pregnant women; Burkina Faso

In order to evaluate the prevalence rate of HBs antigen in children with a suspicion of HIV infection, 103 children were tested for HBs antigen and HIV. The mean age of the children was 2 years. The prevalence of HBs antigen was 39.8 per cent in children and the HIV ELISA test was positive in 57.7 per cent. A correlation was found between carrier of HBs antigen and HIV ELISA positivity (p = 0.04, RR = 1.46; 1.06 < RR < 2.02). There was a high prevalence of HBs antigen in children with a suspicion of HIV infection. This calls for the promotion of antenal screening for HIV and HBV along with immunization against hepatitis B in newborns in our setting.

Anordiol, an antiestrogen, was administered at doses of 2.5 and 10 mg/kg day-1 for 30 and 60 days to adult male rats. A significant decrease in serum LH, FSH, and testosterone levels occurred in the treated animals as compared to controls. Serum testosterone and LH levels decreased to about 15-35% of control value on day 15 of treatment and reached undetected levels thereafter. Serum FSH level also decreased to about 25-50% of control value by day 15 of treatment and remained at this level. Significant decrease in the weights of the tests and accessory reproductive organs occurred following anordiol treatment, while the body weights remained at pretreatment level. Histological examination of the tests revealed significant decrease in the diameter of the seminiferous tubules and in the number of germ cell elements. Spermatogenesis was arrested at the secondary spermatocyte stage. Leydig cells appeared atrophic and contained pyknotic nuclei. The epididymis, prostate, and seminal vesicle showed degenerative changes. The secretory activity of the glandular epithelium of the prostate gland appeared to be markedly reduced. In conclusion, anordiol acts by blocking gonadotropin production and/or release by the pituitary; thereby testosterone production by Leydig cells is not stimulated, causing spermatogenesis arrest.