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Background: Hypertensive Disorders of Pregnancy (HDP) and Gestational Diabetes Mellitus (GDM) carry independent risks for future cardiometabolic disorders (CMDs), including Type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) - the leading cause of death in women in India. Two-thirds of the population live in rural areas, with limited health service access. Early identification of high-risk women is crucial to reducing CVD deaths. We conducted in-depth contextual work in rural areas of two diverse States in India to design a complex intervention (SMARThealth Pregnancy), using mobile clinical decision support for Community Health Workers (CHWs) to screen, refer and counsel pregnant women at high risk of future CMDs. The intervention was informed by behaviour change theory and embedded 15 behaviour change techniques. Objective: To assess the intervention’s feasibility and acceptability. Methods: We piloted the intervention in a prospective unblinded cluster randomised controlled trial (cRCT), embedding a qualitative sub-study. Four Primary Health Centres (PHCs): two in Jhajjar district, Haryana, and two in Guntur district, Andhra Pradesh, were randomised to intervention or control (enhanced standard care) groups. CHWs based at the intervention PHCs underwent targeted education and training, focusing on three priority conditions: anaemia in pregnancy, HDP and GDM, identified by key stakeholders within the study districts. Results: Two hundred pregnant women, equally randomised to intervention (n=100) and control (enhanced standard care, n=100), were recruited within 5 months across all study sites, with minimal loss to follow-up (2%) at 6 weeks postpartum. A total of 4 primary care doctors and 54 CHWs in the intervention clusters, took part in the study. Fidelity to intervention practices was 100% pre-pandemic. Baseline prevalence of moderate-severe anaemia in both intervention and control groups was high (47% and 58% of women, respectively). Prevalence of HDP (2.5%) and GDM (2%) was low in our study population. CHWs and pregnant/postpartum women found the SMARThealth Pregnancy intervention acceptable, easy to use, and perceived improvements in the quality of antenatal and postnatal care and their self-efficacy. Conclusions: SMARThealth Pregnancy is feasible and acceptable for CHWs to screen, refer and counsel pregnant women at high risk of future CMDs. Mobile clinical decision support for CHWs in rural India is as a useful method of task-sharing and health system strengthening and provides a model of integrated care during the transitions between antenatal, postnatal care and adult health services. Furthermore, the intervention has provided opportunities for home-based care for pregnant and postpartum women during the pandemic. Our experience has informed the decision to initiate a larger scale cRCT. Clinical Trial: Trial Registration: ClinicalTrials.gov (NCT03968952).

Background: Obstetric violence (OV) is a critical issue that is often overlooked and makes pregnant women reluctant to get proper access to maternity services. In Palestine, and particularly in Gaza strip, there is limited knowledge about the rates or experiences of OV during delivery. This study aimed to assess the prevalence, determinants and common types of OV among women who had given birth during the last four years at different hospitals in the Gaza strip. Methods: We conducted an online survey through social media and groups in a time period during January and February 2022 to explore women’s experiences of giving birth in Gaza Strip. Women who delivered between 2017-2021 in Gaza hospitals were invited to share their experiences by completing the questionnaire. Women were asked to share the experience of their most recent delivery if they had more than one delivery during the period. Consent was taken at the beginning of the questionnaire, which has with a full explanation of the research and the objectives of the study. The confidentiality and anonymity of the data handling were emphasized to encourage women to freely express their feelings and experiences. Results: A total of 722 women completed the online questionnaire. Most of them (67%) were aged between 21-30 years, and almost half were from low socioeconomic households. Governmental hospitals were the place of delivery for 70% of respondents. One in three women reported they had experienced at least one form of OV. Amongst these women, the types of OV reported were physical (47.8%), psychological (40.8%), verbal (36.4%), and sexual (4.4%). Delivery in private facilities (OR 0.45, 95% CI 0.32-0.74) and the woman knowing their care provider before birth (OR 0.37, 95% CI 0.23-0.59) were both independently protective for OV. In contrast, women who reported they had been aware of OV before birth were more likely to report it happening (OR 3.45, 95% CI 2.37-5.01). Conclusion: We found a concerningly high prevalence of reported OV among women in Gaza Strip in Palestine. Promoting awareness of these findings and the issue of OV amongst maternity staff, identifying the root causes and developing locally led initiatives to eliminate these practices needs to be a priority.

Tropical forests are a major component of the global carbon cycle and home to two-thirds of terrestrial species. Upper-canopy trees store the majority of forest carbon and can be vulnerable to drought events and storms. Monitoring their growth and mortality is essential to understanding forest resilience to climate change, but in the context of forest carbon storage, large trees are underrepresented in traditional field surveys, so estimates are poorly constrained. Aerial photographs provide spectral and textural information to discriminate between tree crowns in diverse, complex tropical canopies, potentially opening the door to landscape monitoring of large trees. Here we describe a new deep convolutional neural network method,Detectree2, which builds on the Mask R-CNN computer vision framework to recognise the irregular edges of individual tree crowns from airborne RGB imagery. We trained and evaluated this model with 3,797 manually delineated tree crowns at three sites in Malaysian Borneo and one site in French Guiana. As an example application, we combined the delineations with repeat lidar surveys (taken between 3 and 6 years apart) of the four sites to estimate the growth and mortality of upper-canopy trees.Detectree2delineated 65,000 upper-canopy trees across 14 km2of aerial images. The skill of the automatic method in delineating unseen test trees was good (F1score = 0.64) and for the tallest category of trees was excellent (F1score = 0.74). As predicted from previous field studies, we found that growth rate declined with tree height and tall trees had higher mortality rates than intermediate-size trees. Our approach demonstrates that deep learning methods can automatically segment trees in widely accessible RGB imagery. This tool (provided as an open-source Python package) has many potential applications in forest ecology and conservation, from estimating carbon stocks to monitoring forest phenology and restoration.Python package available to install athttps://github.com/PatBall1/Detectree2

Background The artemisinin derivatives are the preferred antimalaria drugs for treating severe Plasmodium falciparum malaria. However, their clinical effectiveness compared to each other is unknown. Our objective, therefore, was to evaluate the efficacy and safety of the artemisinin derivatives and quinine for treating severe P. falciparum malaria in children and adults using a network meta-analysis. Methods and findings Review protocol was registered with PROSPERO, CRD42020218190. We updated the search strategies of three Cochrane systematic reviews which included published and unpublished randomised control trials (RCTs) that have compared specific artemisinin derivatives to quinine in treating severe malaria. Search included CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science and trial registries up to February 2021. We screened studies, extracted data, assessed risk of bias, and quality of evidence in duplicate. Separate network meta-analyses in the frequentist framework, using a random effects model, with quinine as reference, were conducted for adults and children, and rankings were produced using p-scores to assess mortality, parasite clearance, coma recovery, fever clearance, neurological sequela and adverse events. Searches identified 818 citations, 33 RCTs were eligible. We pooled 7795 children and 3182 adults. The networks involved artesunate, artemether, rectal artemisinin, arteether and quinine. Compared to quinine, artesunate reduced mortality in children (risk ratio (RR), 0.76; 95%CI [0.65 to 0.89], moderate quality), adults (RR, 0.55; 95%CI [0.40 to 0.75], moderate quality) and in cerebral malaria (RR, 0.72; 95%CI [0.55 to 0.94], moderate quality). Compared to rectal artemisinin and intramuscular arteether, the efficacy and safety of parenteral artesunate, and intramuscular artemether in treating severe malaria are not clear. Rankings showed that none of the artemisinin drugs were consistently superior in all the outcomes assessed. Indirect evidence produced were of very low ratings due to suspected publication bias and imprecision. Conclusions Artesunate reduces mortality compared to quinine for both adults and children in Asia and Africa including cerebral malaria. The artemisinin derivatives remain the best treatment for severe malaria but their comparative clinical effectiveness is yet to be fully explored.

Background Gestational Diabetes Mellitus (GDM) is common in South East Asia, occurring at relatively lean Body Mass Index (BMI). Outside pregnancy, cardiometabolic risks increase at lower BMI in Asian populations, justifying Asian-specific thresholds for overweight and obesity. We aimed to explore the effects of GDM and obesity on perinatal outcomes using a WHO expert consultation-recommended Asian-specific definition of obesity. Methods This is a secondary analysis of a prospective, hospital-based, cohort study in Ho Chi Minh City. Participants were recruited from antenatal clinics between 19+ 0-22+ 6 weeks gestation and followed until delivery. GDM screening occurred between 24 and 28 weeks using WHO criteria. Obesity was defined as BMI ≥ 27.5 kg/m2, based on weight and height at recruitment. We assessed associations between GDM (singly, and in combination with obesity) and perinatal outcomes. Participants were categorised into four groups: no GDM/non-obese (reference group), GDM/non-obese, no GDM/obese and GDM/obese. Outcomes included primary caesarean section, hypertensive disorders of pregnancy (HDP), large-for-gestational-age (LGA), birth weight, preterm birth, and composite adverse neonatal outcome. Logistic and linear regressions were performed with adjustment for differences in baseline characteristics. Results Among 4,970 participants, 908 (18%) developed GDM. Compared to women without GDM, GDM increased risks for preterm birth (OR: 1.40, 95% CI: 1.09–1.78), higher birthweight (birthweight z-score 0.16 versus 0.09, p = 0.027), and LGA (OR 1.14, 0.89–1.46). GDM without obesity was associated with an increased risk of preterm birth (OR 1.35, 1.04–1.74). Obese women without GDM were more likely to deliver by caesarean section and have an LGA baby (1.80, 1.33–2.44 and 2.75, 1.88–4.03). The highest risks were observed amongst women with both GDM and obesity: caesarean Sect. (2.43, 1.49–3.96), LGA (3.36, 1.94–5.80) and preterm birth (2.42, 1.32–4.44). Conclusions GDM was associated with an increased risk of preterm birth and larger newborn size. Using an Asian-specific definition of obesity, we demonstrate obese women with GDM are at the highest risk of adverse outcomes. Using a BMI threshold in pregnancy of 27.5 kg/m2 (between 19 and 22 weeks gestation) for Asian women can identify women who will benefit from intensified diabetes, nutritional, and obstetric care. This has relevance for obstetric service delivery within Asia, and other health systems providing pregnancy care for Asian expatriate women.

Background Physical activity (PA) interventions are an important but underutilised component in the management of gestational diabetes mellitus (GDM). The challenge remains how to deliver cost effective PA interventions that have impact on individual behaviour. Digital technologies can support and promote PA remotely at scale. We describe the development of a behaviourally informed smartphone application (Stay-Active) for women attending an NHS GDM clinic. Stay-Active will support an existing motivational interviewing intervention to increase and maintain PA in this population. Methods The behaviour change wheel (BCW) eight step theoretical approach was used to design the application. It provided a systematic approach to understanding the target behaviour, identifying relevant intervention functions, and specifying intervention content. The target behaviour was to increase and maintain PA. To obtain a behavioural diagnosis, qualitative evidence was combined with focus groups on the barriers and facilitators to PA in women with GDM. The findings were mapped onto the Capability Opportunity Motivation-Behaviour (COM-B) model and Theoretical Domains Framework to identify what needs to change for the target behaviour and linked to appropriate intervention functions. Finally, behaviour changes techniques (BCT) and modes of delivery that are most likely to serve the intervention functions were selected. Current evidence, patient focus groups and input from key stakeholders informed Stay-Active’s development. Results We found that psychological capability, reflective and automatic motivation, social and physical opportunity needed to change to increase PA in women with GDM. The four key intervention functions identified were Enablement, Education, Persuasion and Training. Stay-Active incorporates these four intervention functions delivering ten BCTs including: goal setting, credible source, self-monitoring, action planning, prompts and cues. The final design of Stay-Active delivers these BCTs via an educational resource centre, with goal setting and action planning features, personalised performance feedback and individualised promotional messages. Conclusion The BCW has enabled the systematic and comprehensive development of Stay-Active to promote PA in women with GDM within an NHS Maternity service. The next phase is to conduct a trial to assess the feasibility and acceptability of a multi-component intervention that combines Stay-Active with PA Motivational Interviewing.

This paper aims to inform those involved in the care of pregnant women in the UK about the relationship between social determinants of health and the risk of maternal death. Social determinants are the social conditions in which people are born, grow, live, work and age. These conditions can shape a person's health, their exposure to illness and access to care. The worse social and economic positions people are in, the worse their health outcomes are likely to be. Exploring these issues in relation to maternal outcomes is timely because the profile\ud of mothers giving birth in the UK is changing. Increasingly, babies are being born to older or obese mothers, or to women born outside of the UK. The evidence suggests a strong relationship between social determinants and poor maternal outcomes, including an increased risk of maternal death. Despite the provision of free reproductive and maternity services, current models of care are still failing those pregnant women living in adverse social circumstances prior to, during\ud and after pregnancy. The reasons are complex but maternal outcomes are particularly poor for socially disadvantaged women affected by pre- existing physical or mental health problems, those who misuse substances, have a low level of education, are overweight, undernourished or poorly sheltered, and those who are at increased risk because of abusive and unsupportive partners, families and peers. Some traditional, cultural and social norms, and reproductive laws and policies, also appear to influence a pregnant woman's relationships, behaviour and access to healthcare services. These factors can reinforce a web of social disadvantage and poor outcomes for some\ud pregnant women, which can persist for future generations. Public awareness of these issues has increased as a result of the COVID- 19 pandemic which has highlighted the ways in which health inequalities can adversely affect health outcomes beyond an individual's control. However, addressing the relationship between COVID- 19 and social determinants of health is outside the scope of this paper. While social determinants of maternal health also have an impact on offspring health, this is also outside the remit of this paper. Healthcare professionals have limited power on their own to modify social determinants of health, but this paper concludes with recommendations to improve the maternal outcomes of vulnerable pregnant women residing in the UK and proposes improvements to the collection and reporting of maternal outcome data, with further investment in prevention and intervention measures to better support these women. \ud \ud Within this document we use the terms pregnant woman and women's health. However, it is important to acknowledge that it is not only people who identify as women for whom it is necessary to access care. Obstetric and gynaecology services and delivery of care must therefore be appropriate, inclusive and sensitive to the needs of those individuals whose gender identity does not align with the sex they were assigned at birth.

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Background: Sepsis is a leading cause of maternal death. Antimicrobials save lives, but inappropriate overuse increases risk of antimicrobial resistance(AMR). Objectives: A scoping review comparing peripartum prophylactic antimicrobial use in low and middle-income countries(LMICs) with World Health Organization(WHO) recommendations for prevention and treatment of maternal peripartum infection. Search strategy:Medline, Embase, Global Health, LILACS and the WHO Library databases were searched. Selection criteria:Publications from LMICs since 2015 describing maternal prophlyactic antibiotics for Group B Streptococcus(GBS), preterm-prelabour rupture of membranes(PPROM), caesarean section(CS), manual placental removal(MROP) and 3rd/4th degree perineal tears[1]. Data collection and analysis: Publications were screened, and duplicates removed. A scoping review was conducted using PRISMA guidelines[9]. Owing to study heterogeneity, a narrative synthesis was performed. Main results: Of 1886 studies, 27 met eligibility criteria from 13 countries involving 43,774 women. Polymerase Chain Reaction (PCR) screening for GBS is feasible, though limited financially. In PPROM, up to 42% of GBS isolates demonstrated erythromycin resistance[2]. Evidence around CS antimicrobial prophylaxis largely supports WHO recommendations, however prolonged or multidrug regimes were reported. Conclusions: There is limited evidence to challenge current WHO recommendations to prevent peripartum infection in LMICs. However, implementation challenges exist. Given the emergence of AMR, research is needed to ensure peripartum prophylactic antimicrobial choices remain effective.

We have cloned and characterized members of a novel family of proteins, the GGAs. These proteins contain an NH(2)-terminal VHS domain, one or two coiled-coil domains, and a COOH-terminal domain homologous to the COOH-terminal "ear" domain of gamma-adaptin. However, unlike gamma-adaptin, the GGAs are not associated with clathrin-coated vesicles or with any of the components of the AP-1 complex. GGA1 and GGA2 are also not associated with each other, although they colocalize on perinuclear membranes. Immunogold EM shows that these membranes correspond to trans elements of the Golgi stack and the TGN. GST pulldown experiments indicate that the GGA COOH-terminal domains bind to a subset of the proteins that bind to the gamma-adaptin COOH-terminal domain. In yeast there are two GGA genes. Deleting both of these genes results in missorting of the vacuolar enzyme carboxypeptidase Y, and the cells also have a defective vacuolar morphology phenotype. These results indicate that the function of the GGAs is to facilitate the trafficking of proteins between the TGN and the vacuole, or its mammalian equivalent, the lysosome.