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Summary: Background: India’s caesarean delivery (CD) rate of 21.5% suggests adequate national access to CD but may mask significant disparities. We examined variation in CD rates across states (geography), wealth, and health care sector (public versus private). We also aimed to determine relative inequality in CD rates across wealth quintiles. Methods: The current study was a cross-sectional analysis of CD rates from the National Family Health Survey-5 (2019–2021) disaggregated by asset-based household wealth quintiles for each state and by healthcare sector (public versus private). Data from 724,115 women aged 15–49 years across 28 states and eight union territories were analysed. Women who reported their most recent live birth within the past five years were included. Relative inequality was measured by comparing CD rates in the richest versus the poorest quintiles. Findings: Disaggregating the national CD rate of 21.5% showed substantial variation in CD rate across states, ranging from 5.2% in Nagaland to 60.7% in Telangana and across wealth quintiles, ranging from 0% to 76.7% (Assam). CD facility rates were higher in private than public facilities across all wealth quintiles. Over two-thirds of states (69%) had at least twice the CD rate in the richest wealth quintile versus the poorest quintile. Relative inequality in CD rates between the richest and poorest was 5.3 nationally and was higher in public (4.0) versus private (1.4) facilities. Interpretation: The national CD rate in India masks complex geographical, wealth, and sector-related inequalities in CD utilisation. Accounting for these variations is imperative when interpreting national-level rates to better assess the equity in the distribution of CD services. Funding: None.

Abstract Objective The objective of this study is to determine the proportion of women undergoing trial of labour after caesarean (TOLAC) and vaginal birth after caesarean (VBAC) in Sub‐Saharan Africa (SSA), and to estimate associated adverse events. Methods We searched PubMed, MEDLINE, CAB, EMBASE and African‐specific databases from 1966 to July 2023, including SSA studies reporting on women with previous caesarean section (CS). We extracted data on study design, planned (TOLAC versus elective repeat CS (ERCS)) and actual delivery mode, and adverse outcomes. We calculated mean TOLAC and VBAC proportions, and pooled proportion of adverse events, comparing between TOLAC and ERCS where available. We assessed bias using the methodological index for nonrandomized studies. Results From 62 studies with 36 611 births, the estimated proportion undergoing TOLAC and achieving VBAC, adjusted for study variability, were 79% (95% confidence interval [95% CI]: 74%, 85%) and 47% (95% CI: 42%, 51%), respectively, for all births. Mean estimated uterine rupture proportion and maternal mortality were 2.1% (95% CI: 1.1%, 3.2%) and 0.1% (95% CI: 0.02%, 0.2%) respectively. We found no differences between TOLAC and ERCS for uterine rupture (1.2% vs. 0.2%, pooled odds ratio [OR]: 1.54; 95% CI: 0.63, 3.8) or maternal mortality (0.3% vs.

Abstract Introduction Women who deliver via cesarean section (c-section) experience short- and long-term disability that may affect their physical health and their ability to function normally. While clinical complications are assessed, postpartum functional outcomes are not well understood from a patient’s perspective or well-characterized by previous studies. In Rwanda, 11% of rural women deliver via c-section. This study explores the functional recovery of rural Rwandan women after c-section and assesses factors that predict poor functionality at postoperative day (POD) 30. Methods Data were collected prospectively on POD 3, 11, and 30 from women delivering at Kirehe District Hospital between October 2019 and March 2020. Functionality was measured by self-reported overall health, energy level, mobility, self-care ability, and ability to perform usual activities; and each domain was rated on a 4-point likert scale, lower scores reflecting higher level of difficulties. Using the four functionality domains, we computed composite mean scores with a maximum score of 4.0 and we defined poor functionality as composite score of ≤ 2.0. We assessed functionality with descriptive statistics and logistic regression. Results Of 617 patients, 54.0%, 25.9%, and 26.8% reported poor functional status at POD3, POD11, and POD30, respectively. At POD30, the most self-reported poor functionality dimensions were poor or very poor overall health (48.1%), and inability to perform usual activities (15.6%). In the adjusted model, women whose surgery lasted 30–45 min had higher odds of poor functionality (aOR = 1.85, p = 0.01), as did women who experienced intraoperative complications (aOR = 4.12, 95% CI (1.09, 25.57), p = 0.037). High income patients had incrementally lower significant odds of poor physical functionality (aOR = 0.62 for every US$1 increase in monthly income, 95% CI (0.40, 0.96) p = 0.04). Conclusion We found a high proportion of poor physical functionality 30 days post-c-section in this Rwandan cohort. Surgery lasting > 30 min and intra-operative complications were associated with poor functionality, whereas a reported higher income status was associated with lower odds of poor functionality. Functional status assessments, monitoring and support should be included in post-partum care for women who delivered via c-section. Effective risk mitigating intervention should be implemented to recover functionality after c-section, particularly among low-income women and those undergoing longer surgical procedures or those with intraoperative complications.

Coloniality in global health manifests as systemic inequalities, not based on merit, that benefit one group at the expense of another. Global surgery seeks to advance equity by inserting surgery into the global health agenda; however, it inherits the biases in global health. As a diverse group of global surgery practitioners, we aimed to examine inequities in global surgery. Using a structured, iterative, group Delphi consensus-building process drawing on the literature and our lived experiences, we identified five categories of non-merit inequalities in global surgery. These include Western epistemology, geographies of inequity, unequal participation, resource extraction, and asymmetric power and control. We observed that global surgery is dominated by Western biomedicine, characterised by the lack of interprofessional and interspecialty collaboration, incorporation of Indigenous medical systems, and social, cultural, and environmental contexts. Global surgery is Western-centric and exclusive, with a unidirectional flow of personnel from the Global North to the Global South. There is unequal participation by location (Global South), gender (female), specialty (obstetrics and anaesthesia) and profession (‘non-specialists’, non-clinicians, patients and communities). Benefits, such as funding, authorship and education, mostly flow towards the Global North. Institutions in the Global North have disproportionate control over priority setting, knowledge production, funding and standards creation. This naturalises inequities and masks upstream resource extraction. Guided by these five categories, we concluded that shifting global surgery towards equity entails building inclusive, pluralist, polycentric models of surgical care by providers who represent the community, with resource controlled and governance driven by communities in each setting.

Introduction. The global prevalence of maternal anemia is about 42%, and in sub-Saharan Africa, the prevalence of newborn anemia ranges from 25% to 30%. Anemia in newborn babies may cause complications such as delayed brain maturation and arrested growth. However, there is limited data on the prevalence of newborn anemia and its risk factors in people living in resource-limited settings. Objectives. We determined the prevalence and risk factors for newborn anemia and its correlation with maternal anemia in southwestern Uganda. Methods. This was a cross sectional study of 352 pregnant women presenting to the Mbarara Regional Referral Hospital for delivery. We collected maternal blood in labor and umbilical cord blood from the placental vein. We measured hemoglobin using a point-of-care Hemocue machine. We used summary statistics to characterize the study participants and compared demographic characteristics and outcomes using chi-square, t-test, and Wilcoxon rank sum analyses. We defined newborn anemia as umbilical cord hemoglobin

ObjectiveTo describe the clinical presentation, symptomology, and disease course of coronavirus disease 2019 (COVID-19) in pregnancy.MethodsThe PRIORITY (Pregnancy CoRonavIrus Outcomes RegIsTrY) study is an ongoing nationwide prospective cohort study of people in the United States who are pregnant or up to 6 weeks postpregnancy with known or suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed the clinical presentation and disease course of COVID-19 in participants who tested positive for SARS-CoV-2 infection and reported symptoms at the time of testing.ResultsOf 991 participants enrolled from March 22, 2020, until July 10, 2020, 736 had symptoms of COVID-19 at the time of testing; 594 tested positive for SARS-CoV-2 infection and 142 tested negative in this symptomatic group. Mean age was 31.3 years (SD 5.1), and 37% will nulliparous. Ninety-five percent were outpatients. Participants who tested positive for SARS-CoV-2-infection were a geographically diverse cohort: 34% from the Northeast, 25% from the West, 21% from the South, and 18% from the Midwest. Thirty-one percent of study participants were Latina, and 9% were Black. The average gestational age at enrollment was 24.1 weeks, and 13% of participants were enrolled after pregnancy. The most prevalent first symptoms in the cohort of patients who tested positive for SARS-CoV-2 infection were cough (20%), sore throat (16%), body aches (12%), and fever (12%). Median time to symptom resolution was 37 days (95% CI 35-39). One quarter (25%) of participants who tested positive for SARS-CoV-2 infection had persistent symptoms 8 or more weeks after symptom onset.ConclusionCOVID-19 has a prolonged and nonspecific disease course during pregnancy and in the 6 weeks after pregnancy.Clinical trial registrationClinicalTrials.gov, NCT04323839.

Abstract Background Postnatal care (PNC) is an important tool for reducing maternal and neonatal morbidity and mortality. However, what predicts receipt and maintenance in PNC, particularly events during pregnancy and the peripartum period, is not well understood. We hypothesized that fever or hypothermia during delivery would engender greater health consciousness among those attending antenatal care, leading to greater PNC engagement after hospital discharge and our objective was to evaluate this relationship. Methods Women were prospectively enrolled immediately postpartum at Mbarara Regional Referral Hospital (MRRH). We collected postpartum vital signs and surveyed women by telephone about PNC receipt, fever, and infection at two and six weeks postpartum. Our outcome of interest was receipt of PNC post-discharge, defined as whether a participant visited a health facility and/or was hospitalized in the postpartum period. Our explanatory variables were whether a participant was ever febrile (> 38.0˚C) or hypothermic (

BackgroundFew studies have evaluated the long-term effects of nutritional supplementation during the first 1000 d of life. We previously reported that maternal and child lipid-based nutrient supplements (LNS) increased child length by 18 mo.ObjectiveThe aim of this study was to examine the effects of LNS on later growth and body composition at 4-6 y of age.DesignThis was a follow-up of children in the International Lipid-based Nutrient Supplements (iLiNS)-DYAD trial in Ghana. Women (n = 1320) at ≤20 weeks of gestation were randomly assigned to: 1) iron and folic acid during pregnancy and 200 mg calcium/d for 6 mo postpartum, 2) multiple micronutrients (1-2 RDA of 18 vitamins and minerals) during both periods, or 3) maternal LNS during both periods plus child LNS from 6 to 18 mo. At 4-6 y, we compared height, height-for-age z score (HAZ), and % body fat (deuterium dilution method) between the LNS group and the 2 non-LNS groups combined.ResultsData were available for 961 children (76.5% of live births). There were no significant differences between LNS compared with non-LNS groups in height [106.7 compared with 106.3 cm (mean difference, MD, 0.36; P = 0.226)], HAZ [-0.49 compared with -0.57 (MD = 0.08; P = 0.226)], stunting (< -2 SD) [6.5 compared with 6.3% (OR = 1.00; P = 0.993)], or % body fat [15.5 compared with 15.3% (MD = 0.16; P = 0.630)]. However, there was an interaction with maternal prepregnancy BMI (kg/m2) (P-interaction = 0.046 before correction for multiple testing): among children of women with BMI

Abstract Background Women with previous cesarean deliveries, have a heightened risk of poor maternal and perinatal outcomes, associated with short interbirth intervals. We determined the prevalence of short interbirth interval, and associated factors, among women with antecedent cesarean deliveries who delivered at Mbarara Regional Referral Hospital (MRRH), in southwestern Uganda. Methods We conducted a cross-sectional study on the postnatal ward of MRRH from November 2020 to February 2021. We enrolled women who had antecedent cesarean deliveries through consecutive sampling. We obtained participants’ socio-demographic and obstetric characteristics through interviewer-administered structured questionnaires. We defined short interbirth interval as an interval between two successive births of

Abstract Background Women in sub-Saharan Africa have the highest rates of morbidity and mortality during childbirth globally. Despite increases in facility-based childbirth, gaps in quality of care at facilities have limited reductions in maternal deaths. Infrequent physiologic monitoring of women around childbirth is a major gap in care that leads to delays in life-saving interventions for women experiencing complications. Methods We will conduct a type-2 hybrid effectiveness-implementation study over 12 months to evaluate using a wireless physiologic monitoring system to detect and alert clinicians of abnormal vital signs in women for 24 h after undergoing emergency cesarean delivery at a tertiary care facility in Uganda. We will provide physiologic data (heart rate, respiratory rate, temperature and blood pressure) to clinicians via a smartphone-based application with alert notifications if monitored women develop predefined abnormalities in monitored physiologic signs. We will alternate two-week intervention and control time periods where women and clinicians use the wireless monitoring system during intervention periods and current standard of care (i.e., manual vital sign measurement when clinically indicated) during control periods. Our primary outcome for effectiveness is a composite of severe maternal outcomes per World Health Organization criteria (e.g. death, cardiac arrest, jaundice, shock, prolonged unconsciousness, paralysis, hysterectomy). Secondary outcomes include maternal mortality rate, and case fatality rates for postpartum hemorrhage, hypertensive disorders, and sepsis. We will use the RE-AIM implementation framework to measure implementation metrics of the wireless physiologic system including Reach (proportion of eligible women monitored, length of time women monitored), Efficacy (proportion of women with monitoring according to Uganda Ministry of Health guidelines, number of appropriate alerts sent), Adoption (proportion of clinicians utilizing physiologic data per shift, clinical actions in response to alerts), Implementation (fidelity to monitoring protocol), Maintenance (sustainability of implementation over time). We will also perform in-depth qualitative interviews with up to 30 women and 30 clinicians participating in the study. Discussion This is the first hybrid-effectiveness study of wireless physiologic monitoring in an obstetric population. This study offers insights into use of wireless monitoring systems in low resource-settings, as well as normal and abnormal physiologic parameters among women delivering by cesarean. Trial registration ClinicalTrials.gov , NCT04060667 . Registered on 08/01/2019.

Abstract Background Collection of biospecimens is a critical first step to understanding the impact of COVID-19 on pregnant women and newborns - vulnerable populations that are challenging to enroll and at risk of exclusion from research. We describe the establishment of a COVID-19 perinatal biorepository, the unique challenges imposed by the COVID-19 pandemic, and strategies used to overcome them. Methods A transdisciplinary approach was developed to maximize the enrollment of pregnant women and their newborns into a COVID-19 prospective cohort and tissue biorepository, established on March 19, 2020 at Massachusetts General Hospital (MGH). The first SARS-CoV-2 positive pregnant woman was enrolled on April 2, and enrollment was expanded to SARS-CoV-2 negative controls on April 20. A unified enrollment strategy with a single consent process for pregnant women and newborns was implemented on May 4. SARS-CoV-2 status was determined by viral detection on RT-PCR of a nasopharyngeal swab. Wide-ranging and pregnancy-specific samples were collected from maternal participants during pregnancy and postpartum. Newborn samples were collected during the initial hospitalization. Results Between April 2 and June 9, 100 women and 78 newborns were enrolled in the MGH COVID-19 biorepository. The rate of dyad enrollment and number of samples collected per woman significantly increased after changes to enrollment strategy (from 5 to over 8 dyads/week, P

The objective of this study is to assess the cost-effectiveness of three different strategies with different availabilities of cesarean sections (CS). The setting was rural and urban areas of India with varying rates of CS and access to comprehensive emergency obstetric care (CEmOC) for women of reproductive age in India. Three strategies with different access to CEmOC and CS rates were evaluated: (A) India's national average (50.2% access, 17.2% CS rate), (B) rural areas (47.2% access, 12.8% CS rate) and(C) urban areas (55.7% access, 28.2% CS rate). We performed a first-order Monte Carlo simulation using a 1-year cycle time and 34-year time horizon. All inputs were derived from literature. A societal perspective was utilized with a willingness-to-pay threshold of $1,940. The outcome measures were costs and quality-adjusted life years were used to calculate the incremental cost-effectiveness ratio (ICER). Maternal and neonatal outcomes were calculated. Strategy C with the highest access to CEmOC despite the highest CS rate was cost-effective, with an ICER of 354.90. Two-way sensitivity analysis demonstrated this was driven by increased access to CEmOC. The highest CS rate strategy had the highest number of previa, accreta and ICU admissions. The strategy with the lowest access to CEmOC had the highest number of fistulae, uterine rupture, and stillbirths. In conclusion, morbidity and mortality result from lack of access to CEmOC and overuse of CS. While interventions are needed to address both, increasing access to surgical obstetric care drives cost-effectiveness and is paramount to optimize outcomes.

ObjectiveA scoping review of discharge instructions for women undergoing cesarean section (c-section) in sub-Saharan Africa (SSA).MethodStudies were identified from PubMed, Globus Index Medicus, NiPAD, EMBASE, and EBSCO databases. Eligible papers included research based in a SSA country, published in English or French, and containing information on discharge instructions addressing general postnatal care, wound care, planning of future births, or postpartum depression targeted for women delivering by c-section. For analysis, we used the PRISMA guidelines for scoping reviews followed by a narrative synthesis. We assessed quality of evidence using the GRADE system.ResultsWe identified 78 eligible studies; 5 papers directly studied discharge protocols and 73 included information on discharge instructions in the context of a different study objective. 37 studies addressed wound care, with recommendations to return to a health facility for dressing changes and wound checks between 3 days to 6 weeks. 16 studies recommended antibiotic use at discharge, with 5 specifying a particular antibiotic. 19 studies provided recommendations around contraception and family planning, with 6 highlighting intrauterine device placement immediately after birth or 6-weeks postpartum and 6 studies discussing the importance of counselling services. Only 5 studies provided recommendations for the evaluation and management of postpartum depression in c-section patients; these studies screened for depression at 4-8 weeks postpartum and highlighted connections between c-section delivery and the loss of self-esteem as well as connections between emergency c-section delivery and psychiatric morbidity.ConclusionFew studies in SSA directly examine discharge protocols and instructions for women following c-section. Those available demonstrate wide variation in recommendations. Research is needed to develop structured evidence-based instructions with clear timelines for women. These instructions should account for financial burden, access to resources, and education of patients and communities.

Background Physiologic and immunologic adaptations in pregnancy may increase the risk of adverse outcomes from respiratory viral infections. However, data are limited on longer-term outcomes after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy prior to widespread vaccine availability. Methods Using electronic health record data, we retrospectively compared 6-, 12-, and 18-month outcomes including death and rehospitalization between pregnant and nonpregnant reproductive-aged individuals hospitalized for SARS-CoV-2 infection between 2020 and 2021 at 2 academic referral hospitals. Results There were 190 nonpregnant and 70 pregnant participants. Mean age was 31 years for pregnant and 34 years for nonpregnant participants. For pregnant patients, mean gestational age at coronavirus disease 2019 (COVID-19) diagnosis was 36 weeks, 54% delivered by cesarean, and 97% delivered a live birth. Compared to pregnant participants, nonpregnant participants had a higher prevalence of baseline comorbidities and a higher proportion received mechanical ventilation (84% vs 55%). Index hospitalization complications (31% vs 17%) and mortality (3% vs 0%) were more common in nonpregnant participants. Over 18 months following index hospitalization, 39 (21%) nonpregnant and 5 (7%) pregnant participants were readmitted, most for infection (28/44 [64%]). Most readmissions occurred within 6 months. There were no posthospitalization deaths in the pregnant group. Conclusions Pregnant people with severe COVID-19 disease had a low rate of severe adverse outcomes after index hospitalization. The low readmission rate is reassuring that pregnant individuals may not be at higher risk for long-term severe adverse health outcomes after COVID-19 compared to the nonpregnant reproductive-aged population, possibly because any increased risk conferred by pregnancy resolves soon after delivery. [ABSTRACT FROM AUTHOR]

Abstract In a recent article we discussed the feasibility of onchocerciasis elimination in Africa by 2025. We expressed concern that elimination may be impeded by failure to build on the lessons learned in the African onchocerciasis control programmes and the introduction of strategies and tools from the Americas. Richards et al. and Cupp et al. wrote to refute our concern and described recent achievements with stopping treatment in some areas. In this response, we discuss their arguments which did not convince us. We point out several scientific flaws in the American conceptual framework of elimination which has led to longer periods of treatment than necessary, and in the use of an arbitrary threshold for stopping treatment. We show that recent achievements fall significantly short of what would be needed to achieve onchocerciasis elimination by 2025. We conclude our response by advocating for a more objective and inclusive debate on strategies and tools for onchocerciasis elimination.

INTRODUCTION: Vital sign monitoring is a key component of safe facility-based obstetric care. We aimed to assess quality of care around vital sign monitoring during obstetric hospitalizations in a tertiary-care facility in a resource-limited setting. METHODS: Retrospective review of obstetric records at a tertiary care facility. We assessed documentation of vital signs including fetal and maternal heart rate, and maternal blood pressure, temperature, oxygen saturation, and urine output. The primary outcome was the quality of vital sign monitoring (high- versus low-quality based on frequency of monitoring). We compared quality of monitoring with timing of admission, presence of complication, and delivery mode using chi-squared tests. RESULTS: Among 360 records of obstetric admissions (94% of a planned random sample), 96% documented a delivery. Of these, 8% of pregnant women and 11% of postpartum women had high-quality vital sign monitoring documented on initial evaluation at admission. For women delivering during the hospitalization, 0.8% of women delivering had high-quality monitoring in the first four hours postpartum, with higher rates of high-quality monitoring in women delivering vaginally compared to those delivered by cesarean (1.4% versus 0%, p=.001). There were no differences in rates of quality monitoring by time of admission, or obstetric complication. CONCLUSION: Very few obstetric hospitalizations had high-quality vital sign monitoring. Attention towards improving vital sign monitoring is a critical need.

The neglected tropical diseases (NTDs) affect hundreds of millions of people, predominantly in rural, often difficult-to-access areas, poorly served by national health services. Here, we review the contributions of 4.8 million community-directed distributors (CDDs) of medicines over 2 decades in 146,000 communities in 27 sub-Saharan African countries to control or eliminate onchocerciasis and lymphatic filariasis (LF). We examine their role in the control of other NTDs, malaria, HIV/AIDS interventions, immunisation campaigns, and support to overstretched health service personnel. We are of the opinion that CDDs as community selected, trained, and experienced "foot soldiers," some of whom were involved in the Ebola outbreak responses at the community level in Liberia, if retrained, can assist community leaders and support health workers (HWs) in the ongoing Coronavirus Disease 2019 (COVID-19) crisis. The review highlights the improved treatment coverage where there are women CDDs, the benefits and lessons from the work of CDDs, their long-term engagement, and the challenges they face in healthcare delivery. It underscores the value of utilising the CDD model for strong community engagement and recommends the model, with some review, to hasten the achievement of the NTD 2030 goal and assist the health system cope with evolving epidemics and other challenges. We propose that, based on the unprecedented progress made in the control of NTDs directly linked to community engagement and contributions of CDDs "foot soldiers," they deserve regional and global recognition. We also suggest that the World Health Organization (WHO) and other international stakeholders promote policy and guidance for countries to adapt this model for the elimination of NTDs and to strengthen national health services. This will enhance the accomplishment of some Sustainable Development Goals (SDGs) by 2030 in sub-Saharan Africa.

IntroductionPreterm neonatal mortality contributes substantially to the high neonatal mortality globally. In Uganda, preterm neonatal mortality accounts for 31% of all neonatal deaths. Previous studies have shown variability in mortality rates by healthcare setting. Also, different predictors influence the risk of neonatal mortality in different populations. Understanding the predictors of preterm neonatal mortality in the low-resource setting where we conducted our study could guide the development of interventions to improve outcomes for preterm neonates. We thus aimed to determine the incidence and predictors of mortality among preterm neonates born at Mbarara Regional Referral Hospital (MRRH) in South Western Uganda.MethodsWe prospectively enrolled 538 live preterm neonates born at MRRH from October 2019 to September 2020. The neonates were followed up until death or 28 days, whichever occurred first. We used Kaplan Meier survival analysis to describe preterm neonatal mortality and Cox proportional hazards regression to assess predictors of preterm neonatal mortality over a maximum of 28 days of follow up.ResultsThe cumulative incidence of preterm neonatal mortality was 19.8% (95% C.I: 16.7-23.5) at 28 days from birth. Birth asphyxia (adjusted hazard ratio [aHR], 14.80; 95% CI: 5.21 to 42.02), not receiving kangaroo mother care (aHR, 9.50; 95% CI: 5.37 to 16.78), delayed initiation of breastfeeding (aHR, 9.49; 95% CI: 2.84 to 31.68), late antenatal care (ANC) booking (aHR, 1.81 to 2.52; 95% CI: 1.11 to 7.11) and no ANC attendance (aHR, 3.56; 95% CI: 1.51 to 8.43), vaginal breech delivery (aHR, 3.04; 95% CI: 1.37 to 5.18), very preterm births (aHR, 3.17; 95% CI: 1.24 to 8.13), respiratory distress syndrome (RDS) (aHR, 2.50; 95% CI: 1.11 to 5.64) and hypothermia at the time of admission to the neonatal unit (aHR, 1.98; 95% CI: 1.18 to 3.33) increased the risk of preterm neonatal mortality. Attending more than 4 ANC visits (aHR, 0.35; 95% CI: 0.12 to 0.96) reduced the risk of preterm neonatal mortality.ConclusionsWe observed a high cumulative incidence of mortality among preterm neonates born at a low-resource regional referral hospital in Uganda. The predictors of mortality among preterm neonates were largely modifiable factors occurring in the prenatal, natal and postnatal period (lack of ANC attendance, late ANC booking, vaginal breech delivery, birth asphyxia, respiratory distress syndrome, and hypothermia at the time of admission to the neonatal unit, not receiving kangaroo mother care and delayed initiation of breastfeeding). These findings suggest that investment in and enhancement of ANC attendance, intrapartum care, and the feasible essential newborn care interventions by providing the warm chain through kangaroo mother care, encouraging early initiation of breastfeeding, timely resuscitation for neonates when indicated and therapies reducing the incidence and severity of RDS could improve outcomes among preterm neonates in this setting.

Abstract Background Onchocerciasis is found predominantly in Africa where large scale vector control started in 1974. Registration and donation of ivermectin by Merck & Co in 1987 enabled mass treatment with ivermectin in all endemic countries in Africa and the Americas. Although elimination of onchocerciasis with ivermectin was considered feasible only in the Americas, recently it has been shown possible in Africa too, necessitating fundamental changes in technical and operational approaches and procedures. Main body The American programme(OEPA) operating in onchocerciasis epidemiological settings similar to the mild end of the complex epidemiology of onchocerciasis in Africa, has succeeded in eliminating onchocerciasis from 4 of its 6 endemic countries. This was achieved through biannual mass treatment with ivermectin of 85% of the eligible population, and monitoring and evaluation using serological tests in children and entomological tests. The first African programme(OCP) had a head start of nearly two decades. It employed vector control and accumulated lots of knowledge on the dynamics of onchocerciasis elimination over a wide range of epidemiological settings in the vast expanse of its core area. OCP made extensive use of modelling and operationalised elimination indicators for entomological evaluation and epidemiological evaluation using skin snip procedures. The successor African programme(APOC) employed mainly ivermectin treatment. Initially its objective was to control onchocerciasis as a public health problem but that objective was later expanded to include the elimination of onchocerciasis where feasible. Building on the experience with onchocerciasis elimination of the OCP, APOC has leveraged OCP’s vast modelling experience and has developed operational procedures and indicators for evaluating progress towards elimination and stopping ivermectin mass treatment of onchocerciasis in the complex African setting. Conclusions Following the closure of APOC in 2015, implementation of onchocerciasis elimination in Africa appears to overlook all the experience that has been accumulated by the African programmes. It is employing predominantly American processes that were developed in a dissimilar setting from the complex African onchocerciasis setting. This is impeding progress towards decisions to stop intervention in many areas that have reached the elimination point. This article summarizes lessons learned in Africa and their importance for achieving elimination in Africa by 2025.

Abstract Background There is a paucity of recent prospective data on the incidence of postpartum infections and associated risk factors in sub-Saharan Africa. Retrospective studies estimate that puerperal sepsis causes approximately 10% of maternal deaths in Africa. Methods We enrolled 4231 women presenting to a Ugandan regional referral hospital for delivery or postpartum care into a prospective cohort and measured vital signs postpartum. Women developing fever (> 38.0 °C) or hypothermia (