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BackgroundOne of the key mandates of the World Health Organization (WHO) is to develop guidelines, defined as “a document containing recommendations for clinical practice or public health policy.” Guidelines represent the global standard for information sources shaping clinical practice and public health policies. Despite the rigorous development process and the value of guidelines for setting standards, implementing such standards within local contexts and at the point of care is a well-documented challenge. Digital technologies enable agile information management and may facilitate the adaptation of guidelines to diverse settings of health services delivery. ObjectiveThe objective of this paper is to detail the systematic and iterative process involved in transforming the WHO Antenatal Care (ANC) guidelines into a digital decision-support and patient-record application for routine use in primary health care settings, known as the WHO digital ANC module. MethodsThe WHO convened a team of clinical and digital health experts to develop the WHO digital ANC module as a tool to assist health care professionals in the implementation of WHO evidence-based recommendations for pregnant women. The WHO digital ANC module’s creation included the following steps: defining a minimum viable product (MVP), developing clinical workflows and algorithms, algorithm testing, developing a data dictionary, and the creation of a user interface or application development. The overall process of development took approximately 1 year to reach a stable prototype and to finalize the underlying content requirements of the data dictionary and decision support algorithms. ResultsThe first output is a reference software reflecting the generic WHO ANC guideline content, known as the WHO digital ANC module. Within it, all actionable ANC recommendations have related data fields and algorithms to confirm whether the associated task was performed. WHO recommendations that are not carried out by the health care worker are saved as pending tasks on a woman’s health record, and those that are adequately fulfilled trigger messages with positive reinforcement. The second output consists of the structured documentation of the different components which contributed to the development of the WHO digital ANC module, such as the data dictionary and clinical decision support workflows. ConclusionsThis is a novel approach to facilitate the adoption and adaptation of recommendations through digital systems at the health service delivery level. It is expected that the WHO digital ANC module will support the implementation of evidence-based practices and provide information for monitoring and surveillance; however, further evidence is needed to understand how the WHO digital ANC module impacts the implementation of WHO recommendations. Further, the module’s implementation will inform the WHO’s ongoing efforts to create a pathway to adaptive and integrated (Smart) Guidelines in Digital Systems to improve health system quality, coverage, and accountability.

BackgroundIn 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013-2025.MethodsWe used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts.ResultsNine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour.ConclusionThese findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed.

BackgroundIn 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013-2025.MethodsWe used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts.ResultsNine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour.ConclusionThese findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed.

Introduction Elective labour induction without any medical or obstetric indication has been increasing in recent years. In some countries, 10% of all deliveries are electively induced. (1-4) This increase has [...], Objective To assess the frequency of elective induction of labour and its determinants in selected Latin America countries; quantify success in attaining vaginal delivery, and compare rates of caesarean and adverse maternal and perinatal outcomes after elective induction versus spontaneous labour in low-risk pregnancies. Methods Of 37 444 deliveries in women with low-risk pregnancies, 1847 (4.9%) were electively induced. The factors associated with adverse maternal and perinatal outcomes among cases of spontaneous and induced onset of labour were compared. Odds ratios for factors potentially associated with adverse outcomes were calculated, as were the relative risks of having an adverse maternal or perinatal outcome (both with their 95% confidence intervals). Adjustment using multiple logistic regression models followed these analyses. Findings Of 11 077 cases of induced labour, 1847 (16.7%) were elective. Elective inductions occurred in 4.9% of women with low-risk pregnancies (37 444). Oxytocin was the most common method used (83% of cases), either alone or combined with another. Of induced deliveries, 88.2% were vaginal. The most common maternal adverse events were: (i) a higher postpartum need for uterotonic drugs, (ii) a nearly threefold risk of admission to the intensive care unit; (iii) a fivefold risk of postpartum hysterectomy, and (iv) an increased need for anaesthesia/analgesia. Perinatal outcomes were satisfactory except for a 22% higher risk of delayed breastfeeding (i.e. initiation between 1 hour and 7 days postpartum). Conclusion Caution is mandatory when indicating elective labour induction because the increased risk of maternal and perinatal adverse outcomes is not outweighed by clear benefits. Objectif Evaluer la frequence du declenchement du travail sans indication medicale et ses determinants dans une selection de pays d'Amerique latine, quantifier la reussite d'un accouchement par voie vaginale et comparer les taux de cesariennes et d'issues perinatales et maternelles negatives apres le declenchement du travail sans indication medicale par rapport au travail spontane, dans des grossesses a faible risque. Methodes Sur 37 444 accouchements de femmes presentant des grossesses a faible risque, 1 847 (4,9%) ont ete declenches sans indication medicale. On a compare les facteurs associes aux issues perinatales et maternelles negatives dans des cas de debut de travail spontane et declenche. On a calcule les rapports des cotes des facteurs potentiellement associes aux issues negatives, ainsi que les risques relatifs d'issue perinatale ou maternelle negative (tous deux avec un intervalle de confiance de 95%). Suite a ces analyses, un ajustement a ete effectue a l'aide de plusieurs modeles de regression logistique. Resultats Sur 11 077 cas de travail declenche, 1 847 (16,7%) l'ont ete sans indication medicale. Un declenchement du travail sans indication medicale a ete effectue chez 4,9% des femmes des grossesses a faible risque (37 444). L'ocytocine etait la methode la plus communement utilisee (83% des cas), soit administree seule, soit combinee avec une autre methode. Pour les accouchements sans indication medicale, 88,2% ont eu lieu par voie vaginale. Les evenements maternels negatifs les plus communs etaient: (i) un besoin superieur de medicaments uterotoniques postpartum, (il) un risque presque multiplie par 3 d'admission en unite de soins intensifs; (iii) un risque multiplie par 5 d'hysterectomie postpartum et (iv) une augmentation du besoin d'anesthesie/analgesie. Les issues perinatales etaient satisfaisantes, a l'exception d'une augmentation de 22% du risque d'allaitement retarde (c'est-a-dire une initiation entre 1 heure et 7 jours apres l'accouchement). Conclusion II est indispensable de faire preuve de prudence lors de la preconisation d'un accouchement sans indication medicale, car l'augmentation du risque d'issues perinatales et maternelles negatives n'est pas compensee par des avantages clairs. Objetivo Evaluar la frecuencia de los partos inducidos electivos y sus factores determinantes en determinados paises de Latinoamerica; cuantificar el exito en la consecucion de partos vaginales y comparar los porcentajes de cesareas y de resultados maternos y perinatales adversos tras un parto inducido electivo con respecto a un parto espontaneo en embarazos de bajo riesgo. Metodos De 37 444 partos de mujeres con embarazos de bajo riesgo, 1847 (4,9%) fueron partos inducidos etectivos. Se compararon los factores asociados a resultados matemos y perinatales adversos en los casos de inicio del parto espontaneo e inducido. Se calcularon los cocientes de posibilidades para los factores posiblemente asociados a resultados adversos, asi como los riesgos relacionados con un resultado materno o perinatal adverso (ambos con un intervalo de confianza del 95%). Despues de llevar a cabo estos analisis, se realizo un ajuste empleando modelos de regresion logistica multiple. Resultados De los 11 077 casos de parto inducido, 1847 (16,7%) fueron electivos. Las inducciones electivas se produjeron en un 4,9% de mujeres con embarazos de bajo riesgo (37 444). El metodo mas utilizado fue la oxitocina (83% de los casos), como farmaco unico o en combinacion con otros medicamentos. Un 88,2% de los partos inducidos fueron vaginales. Los acontecimientos matemos adversos mas comunes fueron: (i) una mayor necesidad de medicamentos uterotonicos tras el parto, (ii) un riesgo casi tres veces mayor de ingreso en la unidad de cuidados intensivos; (iii) un riesgo cinco veces mayor de histerectomia posparto y (iv) una mayor necesidad de anestesicos/analgesicos. Los resultados perinataies fueron satisfactorios excepto por un riesgo un 22% mayor de lactancia materna retardada (es decir, el inicio de la misma entre 1 hora y 7 dias despues del parto). Conclusion La precaucion es obligatoria a la hora de recomendar una induccion electiva del parto, ya que el aumento del riesgo de resultados adversos matemos y perinatales no se ve compensado por unos beneficios claros.

Introduction Approximately 15 000 women die every year in Latin America and the Caribbean of causes related to pregnancy. The maternal mortality ratio (MMR) for the region, which is around [...], Objective To develop an indicator of maternal near miss as a proxy for maternal death and to study its association with maternal factors and perinatal outcomes. Methods In a multicenter cross-sectional study, we collected maternal and perinatal data from the hospital records of a sample of women admitted for delivery over a period of two to three months in 120 hospitals located in eight Latin American countries. We followed a stratified multistage cluster random design. We assessed the intra-hospital occurrence of severe maternal morbidity and the latter's association with maternal characteristics and perinatal outcomes. Findings Of the 97 095 women studied, 2964 (34 per 1000) were at higher risk of dying in association with one or more of the following: being admitted to the intensive care unit (ICU), undergoing a hysterectomy, receiving a blood transfusion, suffering a cardiac or renal complication, or having eclampsia. Being older than 35 years, not having a partner, being a primipara or para > 3, and having had a Caesarean section in the previous pregnancy were factors independently associated with the occurrence of severe maternal morbidity. They were also positively associated with an increased occurrence of low and very low birth weight, stillbirth, early neonatal death, admission to the neonatal ICU, a prolonged maternal postpartum hospital stay and Caesarean section. Conclusion Women who survive the serious conditions described could be pragmatically considered cases of maternal near miss. Interventions to reduce maternal and perinatal mortality should target women in these high-risk categories. Objectif Mettre au point un indicateur pour les deces maternels evites de justesse en tant qu'indicateur indirect des deces maternels et etudier son association avec des facteurs maternels et des evenements perinatals. Methodes Dans le cadre d'une etude transversale multicentrique, nous avons recueilli des donnees maternelles et perinatales a partir des dossiers hospitaliers d'un echantillon de femmes, constitue des parturientes admises pour accoucher dans 120 hopitaux appartenant a huit villes d'Amerique latine sur une periode de deux a trois mois. Nous avons applique une methode de sondage aleatoire stratifie a plusieurs degres et par grappe. Nous avons evalue l'occurrence en milieu hospitalier de ia morbidite maternelie severe et les associations de cette derniere avec les caracteristiques maternelles et les evenements perinatals. Resultats Sur les 97 095 femmes etudiees, 2964 (34 pour 1000) presentaient un risque important de deces en association avec une ou plusieurs des conditions suivantes : avoir ete admise dans une unite de soins intensifs, avoir subi une hysterectomie, avoir recu une transfusion sanguine, avoir souffert d'une complication cardiaque ou renale ou encore d'une eclampsie. Par ailleurs, avoir pius de 35 ans, ne pas avoir de partenaire, etre primipare ou quadripare et plus et avoir subi une cesarienne lors de la precedente grossesse etaient des facteurs independamment associes a l'occurrence de la morbidite maternelle severe. Ces facteurs etaient aussi positivement associes a une frequence accrue des petits poids et des tres petits poids de naissance, de la mortinatalite, des deces neonatals precoces, des admissions en soins intensifs neonatals, des sejours hospitaliers prolonges des meres pendant le postpartum et des cesariennes. Conclusion Les femmes qui survivent aux situations graves precedemment decrites peuvent etre considerees pratiquement comme des cas de deces maternel evite de justesse. Les interventions pour reduire la mortalite maternelle et perinatale doivent viser les femmes appartenant a ces categories a haut risque. Objetivo Elaborar un indicador de los cuasieventos maternos como medicion indirecta de las defunciones maternas y estudiar su relacion con diversos factores maternos y con Ios resultados perinatales. Metodos Mediante un estudio transversal multicentrico, a lo largo de un periodo de dos a tres meses reunimos datos maternos y perinatales de los registros hospitalarios de una muestra de mujeres ingresadas para dar a luz en 120 hospitales de ocho paises de America Latina. Aplicando un diseno aleatorio, polietapico, estratificado y por conglomerados, evaluamos les casos intrahospitalarios de morbilidad materna grave y la relacion entre esta y las caracteristicas de la madre y los resultados perinatales. Resultados De las 97 095 mujeres estudiadas, 2964 (34 por 1000) presentaron un mayor riesgo de morir asociado a alguno de los siguientes factores: ingreso en la unidad de cuidados intensivos, histerectomia, transfusion de sangre, complicacion cardiaca o renal, y eclampsia. Tener mas de 35 anos, carecer de pareja, ser primipara o acumular un minimo de tres partos anteriores y haber sido sometida a cesarea en el embarazo precedente fueron factores asociados independientemente a morbilidad materna grave. Se observo que estaban relacionados tambien positivamente con lo siguiente: un peso bajo o muy bajo al nacer, mortinatalidad, mortalidad neonatal precoz, ingreso en la UCI neonatal, estancia prolongada de la madre en el hospital tras el parto, y cesarea. Conclusion Los casos de las mujeres que sobreviven a los graves problemas aqui descritos pueden conceptuarse en la practica como cuasieventos maternos. Las intervenciones encaminadas a reducir la mortalidad materna y perinatal deberian focalizarse en las mujeres de esas categorias de riesgo.