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A summary of the findings in the Supplement, highlighting the heterogeneity in reported quality of maternity care and inequalities within and between countries in the European region.

The estimated number of forcibly displaced persons around the globe is at a record high--nearly 70.8 million (UNHCR 2019)--75 percent of whom are women and children. This includes 34 million adolescent girls and young women, who are among the groups with the highest risk for health concerns. Indeed, many of the countries with the worst maternal and child health indicators are currently experiencing or have recently experienced a humanitarian crisis. The breakdown of health systems in humanitarian settings can cause a dramatic rise in mortality that would otherwise be easily preventable (Al Gasseer et al. 2004). The concentration of adversities associated with humanitarian settings puts young children at great risk of impaired development. Despite the enormous need for early childhood services in humanitarian settings--some 250 million children are living in countries affected by armed conflict--there is a severe lack of such support. Issues related to the mental health and wellbeing of caregivers are often overlooked, despite evidence that attending to their needs is essential in effective interventions (Casey 2015; Chynoweth et al. 2018). The World Health Organization (WHO) has made it a priority to address health care in humanitarian emergencies, in keeping with the United Nations (UN) Sustainable Development Goals and the Global Strategy for Women's, Children's and Adolescents' Health. Understanding health-care needs in these contexts and developing effective guidance materials has been an increasingly important topic on the WHO's global health agenda over the last few years. In this commentary, the authors argue that while evidence-based programs for maternal mental health do exist, tailoring approaches to include content on nurturing care and acknowledging the link between maternal mental health and child development must be a priority for multiple interventions and platforms.

Current estimates are that more than one-third of the annual neonatal deaths worldwide occur in humanitarian and fragile settings (United Nations Population Fund 2015). In this article, we focus on the recent multistakeholder effort to produce the "Roadmap to Accelerate Progress for Every Newborn in Fragile and Humanitarian Settings 2020-2025." This effort, led by Save the Children, the UN Children's Fund, the UN High Commissioner for Refugees, and the World Health Organization, calls for a representation of newborn health issues and action across all phases of emergency response. It specifically emphasizes the need to "engage stakeholders from across humanitarian and development sectors to ensure that mothers and newborns survive and thrive even in the most difficult circumstances" (Save the Children et al. 2020, 5). This commentary also emphasizes basic needs that are vital to the survival and adequate development of newborns, such as avoiding separation from the mother, support for early and exclusive breastfeeding, infection prevention, basic resuscitation, and kangaroo mother care. At the same time, it is critical to establish interventions that create an environment of nurturing care to promote early childhood development.

The continued occurrence of congenital syphilis is an indictment of the inadequate antenatal care services and poor quality of programmes to control sexually transmitted infections. More than 1 million infants are born with congenital syphilis each year. Despite national policies on antenatal testing and the widespread use of antenatal services, syphilis screening is still implemented only sporadically in many countries, leaving the disease undetected and untreated among many pregnant women. The weak organization of services and the costs of screening are the principal obstacles facing programmes. Decentralization of antenatal syphilis screening programmes, on-site testing and immediate treatment can reduce the number of cases of congenital syphilis. Antenatal syphilis screening and treatment programmes are as cost effective as many existing public health programmes, e.g. measles immunization. Diagnosis of congenital syphilis is problematic since more than half of all infants are asymptomatic, and signs in symptomatic infants may be subtle and nonspecific. Newer diagnostic tests such as enzyme immunoassays, polymerase chain reaction and immunoblotting have made diagnosis more sensitive and specific but are largely unavailable in the settings where they are most needed. Guidelines developed for better-resourced settings are conservative and err on the side of overtreatment. They are difficult to implement in, or inappropriate for, poorly-resourced settings because of the lack of investigative ability and the pressure on health facilities to discharge infants early. This paper offers recommendations for treating infants, including an approach based solely on maternal serological status and clinical signs of syphilis in the infant.

Objective To investigate changes that took place between 2006 and 2010 in the inequity gap for antenatal care attendance and delivery at health facilities among women in Viet Nam. Methods Demographic, socioeconomic and obstetric data for women aged 15-49 years were extracted from Viet Nam's Multiple Indicator Cluster Survey for 2006 (MICS3) and 2010-2011 (MICS4). Multivariate logistic regression was performed to determine if antenatal care attendance and place of delivery were significantly associated with maternal education, maternal ethnicity (Kinh/Hoa versus other), household wealth and place of residence (urban versus rural). These independent variables correspond to the analytical framework of the Commission on Social Determinants of Health. Findings Large discrepancies between urban and rural populations were found in both MICS3 and MICS4. Although antenatal care attendance and health facility delivery rates improved substantially between surveys (from 86.3 to 92.1% and from 76.2 to 89.7%, respectively), inequities increased, especially along ethnic lines. The risk of not giving birth in a health facility increased significantly among ethnic minority women living in rural areas. In 2006 this risk was nearly five times higher than among women of Kinh/Hoa (majority) ethnicity (odds ratio, OR: 4.67; 95% confidence interval, CI: 2.94-7.43); in 2010-2011 it had become nearly 20 times higher (OR: 18.8; 95% CI: 8.96- 39.2). Conclusion Inequity in maternal health care utilization has increased progressively in Viet Nam, primarily along ethnic lines, and vulnerable groups in the country are at risk of being left behind. Health-care decision-makers should target these groups through affirmative action and culturally sensitive interventions. Objectif Etudier les modifications du fosse des inegalites, survenues entre 2006 et 2010, en termes de frequentation des soins prenatals et d'accouchement dans les etablissements de sante, chez les femmes du Vier Nam. Methodes Les donnees demographiques, socio-economiques et obstetriques des femmes agees de 15 a 49 ans ont ete extraites de l'Enquete en grappes a indicateurs multiples, effectuee au Viet Nam en 2006 (MICS3) et en 2010-2011 (MICS4). Une regression logistique multivariee a ete effectuee pour determiner si la frequentation des soins prenatals et le lieu de l'accouchement etaient significativement associes au niveau d'education de la mere, a l'origine ethnique de la mere (Kinh/ Hoa par rapport aux autres), a la richesse du foyer et au lieu de residence (urbain ou rural). Ces variables independantes correspondent au cadre d'analyse de la Commission sur les determinants sociaux de la sante. Resultats Des ecarts importants entre les populations urbaines et rurales ont ete constates dans le MICS3 et dans le MICS4. Bien que la frequentation des soins prenatals et les taux d'accouchement des etablissements de sante se soient nettement ameliores entre les enquetes (de 86,3 a 92,1% et de 76,2 a 89,7%, respectivement), les inegalites ont augmente, en particulier entre les ethnies. Le risque de ne pas accoucher dans un etablissement de sante a augmente de facon significative chez les femmes issues des minorites ethniques des zones rurales. En 2006, ce risque etait pres de cinq fois plus eleve que chez les femmes de l'ethnie majoritaire Kinh/Hoa (rapport des cotes, RC: 4,67, intervalle de confiance IC a 95%: de 2,94 a 7,43); en 2010-2011, il a presque ete multiplie par 20 (RC: 18,8; IC a 95%: de 8,96 a 39,2). Conclusion L'inegalite dans l'utilisation des soins de sante maternelle a augmente progressivement au Viet Nam, principalement chez les ethnies, et les groupes vulnerables du pays risquent d'etre laisses pour compte. Les decideurs des soins de sante devraient cibler ces groupes, en mettant en place une action positive et des interventions tenant compte de la culture. Objetivo Investigar los cambios que tuvieron lugar entre 2006 y 2010 en la brecha de desigualdad respecto a la asistencia a cuidados prenatales y la prestacion sanitaria en instalaciones sanitarias a mujeres de Viet Nam. Metodos Se obtuvieron datos demograficos, socio-economicos y obstetricos de mujeres de edades comprendidas entre los 15 y 49 anos, a partir de la encuesta a base de indicadores multiples de Viet Nam para los periodos 2006 (MICS3) y 2001-2011 (MICS4). Se realizo un analisis de regresion logistica multivariada para determinar si la asistencia a cuidados prenatales y el lugar de prestacion sanitaria estaban significativamente vinculados con la educacion de la madre, la etnia materna (Kinh y Hoa frente a otras), los recursos familiares, asi como el lugar de residencia (urbano frente a rural). Estas variables independientes corresponden al marco analitico de la Comision sobre Determinantes Sociales de la Salud. Resultados Se hallaron grandes diferencias entre las poblaciones rurales y urbanas, tanto en MICS3 como en MICS4. Pese a que los indices de la asistencia a cuidados prenatales y de la tasa de partos en instalaciones sanitarias mejoraron substancialmente entre las encuestas (del 86,3 al 92.1% y del 76,2 al 89,7%, respectivamente), aumentaron las desigualdades, sobre todo en funcion del origen etnico. El riesgo de no dar a luz en un centro de salud aumento significativamente entre las mujeres pertenecientes a minorias etnicas residentes en zonas rurales. En 2006, dicho riesgo era cinco veces mayor entre las mujeres de las etnias Kinh/Hoa (mayoria) (indice de probabilidad, IP: 4,67; 95% intervalo de confianza, IC: 2,94-7,43); en 2010-2011 llego a ser casi 20 vetes mayor (IP: 18,8; 95% IC: 8,96-39,2). Conclusion La desigualdad en la utilizacion de los servicios maternos ha aumentado progresivamente en Viet Nam, sobre todo, entre las distintas etnias. Asimismo, los grupos desfavorecidos del pais estan en riesgo de marginalidad. Las autoridades sanitarias deben orientarse hacia estos grupos par media de acciones afirmativas, asi coma de intervenciones culturalmente sensibles., Introduction Large disparities in health outcomes exist between countries and within them. These differences are largely defined and perpetuated by social structures and mediated by material and behavioural factors and [...]

This paper describes the development of a tool that uses human rights concepts and methods to improve relevant laws, regulations and policies related to sexual and reproductive health. This tool aims to improve awareness and understanding of States' human rights obligations. It includes a method for systematically examining the status of vulnerable groups, involving non-health sectors, fostering a genuine process of civil society participation and developing recommendations to address regulatory and policy barriers to sexual and reproductive health with a clear assignment of responsibility. Strong leadership from the ministry of health, with support from the World Health Organization or other international partners, and the serious engagement of all involved in this process can strengthen the links between human rights and sexual and reproductive health, and contribute to national achievement of the highest attainable standard of health. Le present article decrit le developpement d'un outil faisant appel a des concepts eta des methodes relevant des droits de l'homme pour ameliorer les lois, les reglementations et les politiques pertinentes en rapport avec la sante sexuelle et genesique. Cet outil vise a faire prendre conscience et a ameliorer la comprehension des obligations des Etats en matiere de droits de I'homme. II comprend une methode pour examiner de maniere systematique la situation des groupes vulnerables, impliquer des secteurs autres que celui de la sante, promouvoir un processus veritable de participation de la societe civile et mettre au point des recommandations en vue d'eliminer les obstacles reglementaires et politiques a la sante sexuelle et genesique, avec une affectation claire des responsabilites. Un role moteur fort assume par le Ministere de la sante avec I'appui de l'Organisation mondiale de la Sante ou d'autres partenaires intemationaux ainsi que I'engagement serieux de tous les participants a ce processus peuvent renforcer les llene entre droits de I'homme et sante sexuelle et genesique et contribuer a I'obtention, au plan national, du niveau de sante le plus eleve possible. En este trabajo se describe el desarrollo de un instrumento que utiliza conceptos y metodos del campo de los derechos humanos para introducir mejoras en la legislacion, la normativa y las politicas relacionadas con la salud sexual y reproductiva. Dicho instrumento pretende ayudar a comprender mejor las obligaciones de los Estados en materia de derechos humanos y sensibilizar al respecto. Incluye un metodo que permite, de manera sistematica, estudiar la situacion de los grupos vulnerables, implicar a sectores distintos de la salud, promover un proceso de autentica participacion de la sociedad civil y formular recomendaciones para abordar las dificultades con que tropieza la salud sexual y reproductiva en materia de reglamentacion y politica, con una clara asignacion de responsabilidades. Un firme liderazgo del ministerio de salud, con el apoyo de la Organizacion Mundial de la Salud u otros asociados internacionales, y unido a un serio compromiso por parte de todos cuantos intervienen en este proceso, puede reforzar los vinculos entre los derechos humanos y la salud sexual y reproductiva, y contribuir a hacer realidad a nivel nacional el grado maximo de salud que se pueda lograr., Introduction The world health rePort2008 draws attention to the significance of policies for achieving primary health care objectives, including both those necessary to make health systems function properly and those [...]

We describe the historical development of how maternal and neonatal mortality in the developing world came to be seen as a public-health concern, a human rights concern, and ultimately as both, leading to the development of approaches using human rights concepts and methods to advance maternal and neonatal health. We describe the different contributions of the international community, women's health advocates and human rights activists. We briefly present a recent effort, developed by WHO with the Harvard Program on International Health and Human Rights, that applies a human rights framework to reinforce current efforts to reduce maternal and neonatal mortality. Bulletin of the World Health Organization 2008;86:589-593. Nous decrivons comment, au cours de l'histoire, on en est venu a considerer la mortalite maternelle et neonatale dans le monde en developpement comme un probleme de sante publique, puis un comme une question relevant des droits de l'homme et enfin comme l'un et l'autre, ce qui a conduit au developpement d'approches utilisant des concepts et des methodes empruntes aux droits de l'homme pour faire progresser la sante maternelle et neonatale. Nous presentons les differentes contributions de la communaute internationale, des defenseurs de la sante des femmes et des activistes en faveur des droits de la personne humaine. Nous presentons aussi brievement une initiative recente, developpe par l'OMS et le Harvard Program on International Health and Human Rights, qui applique le cadre des droits de l'homme pour renforcer les tentatives actuelles de reduction de la mortalite maternelle et neonatale. Se describe aqui el proceso historico por el que se Ilego a considerar que la mortalidad materna y neonatal en el mundo en desarrollo era un problema de salud publica y un factor que limitaba Ios derechos humanos, asi como la manera en que esas dos perspectivas han Ilevado a idear formulas basadas en principios y metodos de Ios derechos humanos para hacer avanzar la salud de la madre y del recien nacido. Se exponen las diferentes aportaciones de la comunidad internacional, los defensores de la salud de la mujer y los activistas en favor de Ios derechos humanos, y se presenta sucintamente una iniciativa reciente, puesta en marcha por la OMS y el Programa de Harvard sobre Salud Internacional y Derechos Humanos, que aplica un marco de derechos humanos para reforzar Ios esfuerzos desplegados en la actualidad con miras a reducir la mortalidad materna y neonatal., Introduction Maternal and neonatal mortality have barely declined in the past two decades. The most recent estimates indicating that about 536 000 women die every year from pregnancy-related causes demonstrate [...]

Objective To report stillbirth and early neonatal mortality and to quantify the relative importance of different primary obstetric causes of perinatal mortality in 171 perinatal deaths from 7993 pregnancies that ended after 28 weeks in nulliparous women. Methods A review of all stillbirths and early newborn deaths reported in the WHO calcium supplementation trial for the prevention of pre-eclampsia conducted at seven WHO collaborating centres in Argentina, Egypt, India, Peru, South Africa and Viet Nam. We used the Baird--Pattinson system to assign primary obstetric causes of death and classified causes of early neonatal death using the International classification of diseases and related health problems, Tenth revision (ICD-10). Findings Stillbirth rate was 12.5 per 1000 births and early neonatal mortality rate was 9.0 per 1000 live births. Spontaneous preterm delivery and hypertensive disorders were the most common obstetric events leading to perinatal deaths (28.7% and 23.6%, respectively). Prematurity was the main cause of early neonatal deaths (62%). Conclusions Advancements in the care of premature infants and prevention of spontaneous preterm labour and hypertensive disorders of pregnancy could lead to a substantial decrease in perinatal mortality in hospital settings in developing countries. Objectif Faire etat de la mortinatalite et de la mortalite neonatale precoce et quantifier l'importance relative des principales causes obstetricales de mortalite perinatale observees pour 171 deces perinatals lies a 7993 grossesses interrompues apres la 28eme semaine chez des femmes nullipares. Methodes L'examen a porte sur tous les cas de mortinatalite et deces neonatals precoces signales dans l'essai OMS de supplementation calcique pour la prevention de la preeclampsie mene dans sept centres collaborateurs situes en Afrique du Sud, en Argentine, en Egypte, en Inde, au Perou et au Vietnam. On a utilise le systeme de Baird-Pattinson pour attribuer les principales causes obstetricales de deces et classe les causes des deces neonatals precoces sur la base de la Classification internationale des maladies et des problemes de sante connexes, dixieme revision (CIM 10). Resultats Le taux de mortinatalite est de 12,5 pour 1000 naissances et le taux de mortalite neonatale precoce de 9,0 pour 1000 naissances vivantes. L'accouchement premature spontane et l'hypertension gravidique sont les problemes obstetricaux les plus frequemment a l'origine d'un deces perinatal (respectivement 28,7% et 23,6 %). La prematurite est la principale cause de deces neonatal precoce (62 %). Conclusion Des progres dans les soins aux prematures et la prevention du travail premature spontane et de l'hypertension gravidique permettraient d'obtenir une diminution sensible de la mortalite perinatale en milieu hospitalier dans les pays en developpement. Objetivo Informar sobre la mortinatalidad y la mortalidad neonatal precoz y cuantificar la importancia relativa de diferentes causas obstetricas primarias de mortalidad perinatal en 171 defunciones perinatales correspondientes a 7993 embarazos de mas de 28 semanas en mujeres nuliparas. Metodos Se examinaron todos los casos de mortinatalidad y defuncion precoz de recien nacidos notificados en un ensayo OMS de administracion de suplementos de calcio para la prevencion de la preeclampsia, llevado a cabo en siete centros colaboradores de la OMS en la Argentina, Egipto, la India, el Peru, Sudafrica y Viet Nam. Usamos el sistema de Baird-Pattinson para asignar causas obstetricas primarias de muerte y causas clasificadas de mortalidad neonatal precoz mediante la Clasificacion Estadistica Internacional de Enfermedades y Problemas de Salud Conexos, decima revision (CIE-10). Resultados La tasa de mortinatalidad fue del 12,5 por 1000 nacimientos, y la tasa de mortalidad neonatal precoz, de 9,0 por 1000 nacidos vivos. EI parto pretermino espontaneo y los trastornos hipertensivos fueron los casos obstetricos mas comunes asociados a las defunciones perinatales (28,7% y 23,6%, respectivamente). La prematuridad fue la causa principal de las defunciones neonatales precoces (62%). Conclusiones Los progresos de la atencion a los lactantes prematuros y la prevencion del parto pretermino espontaneo y de los trastornos hipertensivos del embarazo podrian propiciar una disminucion sustancial de la mortalidad perinatal en los entornos hospitalarios en los paises en desarrollo., Introduction A two-thirds reduction of mortality in children less than 5 years old by 2015 is one of the UN Millennium Development Goals. (1) Despite a decline in mortality in [...]

Background: Immediate newborn care (INC) practices, notably early initiation of breastfeeding (EIBF), are fundamental for newborn health. However, coverage tracking currently relies on household survey data in many settings. "Every Newborn Birth Indicators Research Tracking in Hospitals" (EN-BIRTH) was an observational study validating selected maternal and newborn health indicators. This paper reports results for EIBF.Methods: The EN-BIRTH study was conducted in five public hospitals in Bangladesh, Nepal, and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data on EIBF and INC practices (skin-to-skin within 1 h of birth, drying, and delayed cord clamping). To assess validity of EIBF measurement, we compared observation as gold standard to register records and women's exit-interview survey reports. Percent agreement was used to assess agreement between EIBF and INC practices. Kaplan Meier survival curves showed timing. Qualitative interviews were conducted to explore barriers/enablers to register recording.Results: Coverage of EIBF among 7802 newborns observed for ≥1 h was low (10.9, 95% CI 3.8-21.0). Survey-reported (53.2, 95% CI 39.4-66.8) and register-recorded results (85.9, 95% CI 58.1-99.6) overestimated coverage compared to observed levels across all hospitals. Registers did not capture other INC practices apart from breastfeeding. Agreement of EIBF with other INC practices was high for skin-to-skin (69.5-93.9%) at four sites, but fair/poor for delayed cord-clamping (47.3-73.5%) and drying (7.3-29.0%). EIBF and skin-to-skin were the most delayed and EIBF rarely happened after caesarean section (0.5-3.6%). Qualitative findings suggested that focusing on accuracy, as well as completeness, contributes to higher quality with register reporting.Conclusions: Our study highlights the importance of tracking EIBF despite measurement challenges and found low coverage levels, particularly after caesarean births. Both survey-reported and register-recorded data over-estimated coverage. EIBF had a strong agreement with skin-to-skin but is not a simple tracer for other INC indicators. Other INC practices are challenging to measure in surveys, not included in registers, and are likely to require special studies or audits. Continued focus on EIBF is crucial to inform efforts to improve provider practices and increase coverage. Investment and innovation are required to improve measurement. [ABSTRACT FROM AUTHOR]

OBJECTIVE. Our objective with this article was to describe the declining trend in neonatal mortality in Chile between 1990 and 2000 and examine potential causal factors. METHODS. Descriptive analysis of data that were provided by the Chilean Ministry of Health on all ~2 900 000 births occurred in Chile between 1990 and 2000. Total neonatal mortality rates ( RESULTS. The neonatal mortality rate between 1990 and 2000 decreased from 8.3 to 5.7 per 1000 live births. This decline was not associated with decreases in the proportion of low birth weight and preterm infants but rather with declines in birth weight-specific and gestational age-specific mortality rates. Examination of the trends in birth weight-specific and gestational age-specific mortality rates showed that a marked proportional decrease in mortality rates was achieved among infants who weighed < 1500 g and were delivered before 32 weeks. It is plausible, both biologically and temporally, that the observed trends in the reduction in birth weight-specific and gestational age-specific mortality rates are associated with the introduction of specific sector-wide interventions that aim to improve newborn care in very preterm and low birth weight infants. CONCLUSIONS. Important reductions in newborn mortality in developing countries are possible with the implementation of effective neonatal care interventions. KEY WORDS. health policy, public health, neonatal mortality, international child health, health services.