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Background: While there has been a decline in maternal and perinatal mortality, deaths remain high in sub-Saharan Africa and Asia. With the sustainable development goals (SDGs) targets to reduce maternal and perinatal mortality, more needs to be done to accelerate progress and improve survival. Maternal and perinatal death surveillance and response (MPDSR) is a strategy to identify the clinical and social circumstances that contribute to maternal and perinatal deaths. Through MPDSR, an active surveillance and response cycle is established by bringing together different stakeholders to review and address these social and clinical factors. Community engagement in MPDSR provides a strong basis for collective action to address social factors and quality of care issues that contribute to maternal and perinatal deaths. Studies have shown that community members can support identification and reporting of maternal and/or perinatal deaths. Skilled care at birth has been increasing globally, but there are still gaps in quality of care. Through MPDSR, community members can collaborate with health workers to improve quality of care. But we do not know how community engagement in MPDSR works in practice; for whom it works and what aspects work (or do not work) and why. This realist review answers the question: which strategies of community engagement in MPDSR produce which outcomes in which contexts? Methods: For this realist review, we will identify published and grey literature by searching relevant databases for articles. We will include papers published from 2004 in all languages and from all countries. We have set up an advisory group drawn from academia, international organizations, and practitioners of both MPDSR and community engagement to guide the process. Conclusion: This protocol and the subsequent realist review will use theoretical approaches from the community engagement literature to generate theory on community engagement in MPDSR. Prospero registration number: CRD42022345216

BackgroundGlobally, low birthweight (LBW) infants (

Abstract Background Obstetric infections are the third most common cause of maternal mortality, with the largest burden in low and middle-income countries (LMICs). We analyzed causes of infection-related maternal deaths and near-miss identified contributing factors and generated suggested actions for quality of care improvement. Method An international, virtual confidential enquiry was conducted for maternal deaths and near-miss cases that occurred in 15 health facilities in 11 LMICs reporting at least one death within the GLOSS study. Facility medical records and local review committee documents containing information on maternal characteristics, timing and chain of events, case management, outcomes, and facility characteristics were summarized into a case report for each woman and reviewed by an international external review committee. Modifiable factors were identified and suggested actions were organized using the three delays framework. Results Thirteen infection-related maternal deaths and 19 near-miss cases were reviewed in 20 virtual meetings by an international external review committee. Of 151 modifiable factors identified during the review, delays in receiving care contributed to 71/85 modifiable factors in maternal deaths and 55/66 modifiable factors in near-miss cases. Delays in reaching a GLOSS facility contributed to 5/85 and 1/66 modifiable factors for maternal deaths and near-miss cases, respectively. Two modifiable factors in maternal deaths were related to delays in the decision to seek care compared to three modifiable factors in near-miss cases. Suboptimal use of antibiotics, missing microbiological culture and other laboratory results, incorrect working diagnosis, and infrequent monitoring during admission were the main contributors to care delays among both maternal deaths and near-miss cases. Local facility audits were conducted for 2/13 maternal deaths and 0/19 near-miss cases. Based on the review findings, the external review committee recommended actions to improve the prevention and management of maternal infections. Conclusion Prompt recognition and treatment of the infection remain critical addressable gaps in the provision of high-quality care to prevent and manage infection-related severe maternal outcomes in LMICs. Poor uptake of maternal death and near-miss reviews suggests missed learning opportunities by facility teams. Virtual platforms offer a feasible solution to improve routine adoption of confidential maternal death and near-miss reviews locally.

Background: While there has been a decline in maternal and perinatal mortality, deaths remain high in sub-Saharan Africa and Asia. With the sustainable development goals (SDGs) targets to reduce maternal and perinatal mortality, more needs to be done to accelerate progress and improve survival. Maternal and perinatal death surveillance and response (MPDSR) is a strategy to identify the clinical and social circumstances that contribute to maternal and perinatal deaths. Through MPDSR, an active surveillance and response cycle is established by bringing together different stakeholders to review and address these social and clinical factors. Community engagement in MPDSR provides a strong basis for collective action to address social factors and quality of care issues that contribute to maternal and perinatal deaths. Studies have shown that community members can support identification and reporting of maternal and/or perinatal deaths. Skilled care at birth has been increasing globally, but there are still gaps in quality of care. Through MPDSR, community members can collaborate with health workers to improve quality of care. But we do not know how community engagement in MPDSR works in practice; for whom it works and what aspects work (or do not work) and why. This realist review answers the question: which strategies of community engagement in MPDSR produce which outcomes in which contexts? Methods: For this realist review, we will identify published and grey literature by searching relevant databases for articles. We will include papers published from 2004 in all languages and from all countries. We have set up an advisory group drawn from academia, international organizations, and practitioners of both MPDSR and community engagement to guide the process. Conclusion: This protocol and the subsequent realist review will use theoretical approaches from the community engagement literature to generate theory on community engagement in MPDSR. Prospero registration number: CRD42022345216

Abstract Background The use of obstetric early-warning-systems (EWS) has been recommended to improve timely recognition, management and early referral of women who have or are developing a critical illness. Development of such prediction models should involve a statistical combination of predictor clinical observations into a multivariable model which should be validated. No obstetric EWS has been developed and validated for low resource settings. We report on the development and validation of a simple prediction model for obstetric morbidity and mortality in resource-limited settings. Methods We performed a multivariate logistic regression analysis using a retrospective case-control analysis of secondary data with clinical indices predictive of severe maternal outcome (SMO). Cases for design and validation were randomly selected (n = 500) from 4360 women diagnosed with SMO in 42 Nigerian tertiary-hospitals between June 2012 and mid-August 2013. Controls were 1000 obstetric admissions without SMO diagnosis. We used clinical observations collected within 24 h of SMO occurrence for cases, and normal births for controls. We created a combined dataset with two controls per case, split randomly into development (n = 600) and validation (n = 900) datasets. We assessed the model’s validity using sensitivity and specificity measures and its overall performance in predicting SMO using receiver operator characteristic (ROC) curves. We then fitted the final developmental model on the validation dataset and assessed its performance. Using the reference range proposed in the United Kingdom Confidential-Enquiry-into-Maternal-and-Child-Health 2007-report, we converted the model into a simple score-based obstetric EWS algorithm. Results The final developmental model comprised abnormal systolic blood pressure-(SBP > 140 mmHg or 90 mmHg), respiratory rate-(RR > 40/min), temperature-(> 38 °C), pulse rate-(PR > 120/min), caesarean-birth, and the number of previous caesarean-births. The model was 86% (95% CI 81–90) sensitive and 92%- (95% CI 89–94) specific in predicting SMO with area under ROC of 92% (95% CI 90–95%). All parameters were significant in the validation model except DBP. The model maintained good discriminatory power in the validation (n = 900) dataset (AUC 92, 95% CI 88–94%) and had good screening characteristics. Low urine output (300mls/24 h) and conscious level (prolonged unconsciousness-GCS

Abstract Auxiliary nurse midwives (ANMs) play a pivotal role in provision of maternal and newborn health at primary level in India. Effective in-service training is crucial for upgrading their knowledge and skills for providing appropriate healthcare services. This paper aims at assessing the effectiveness of a complementary mix of directed and self-directed learning approaches for building essential maternal and newborn health-related skills of ANMs in rural Pune District, India. Methods During directed learning, the master trainers trained ANMs through interactive lectures and skill demonstrations. Improvement and retention of knowledge and skills and feedback were assessed quantitatively using descriptive statistics. Significant differences at the 0.05 level using the Kruskal-Wallis test were analysed to compare improvement across age, years of experience, and previous training received. The self-directed learning approach fulfilled their learning needs through skills mall, exposure visits, newsletter, and participation in conference. Qualitative data were analysed thematically for perspectives and experiences of stakeholders. The Kirkpatrick model was used for evaluating the results. Results Directed and self-directed learning was availed by 348 and 125 rural ANMs, respectively. Through the directed learning, ANMs improved their clinical skills like maternal and newborn resuscitation and eclampsia management. Less work experience showed relatively higher improvement in skills, but not in knowledge. 56.6% ANMs either improved or retained their immediate post-training scores after 3 months. Self-directed learning helped them for experience sharing, problem-solving, active engagement through skill demonstrations, and formal presentations. The conducive learning environment helped in reinforcement of knowledge and skills and in building confidence. This intervention could evaluate application of skills into practice to a limited extent. Conclusions In India, there are some ongoing initiatives for building skills of the ANMs like skilled birth attendance and training in skills lab. However, such a complementary mix of skill-based ‘directed’ and ‘self-directed’ learning approaches could be a plausible model for building capacities of health workforce. In view of the transforming healthcare delivery system in India and the significant responsibility that rests on the shoulder of ANMs, a transponder mechanism to implement skill building exercises at regular intervals through such innovative approaches should be a priority.

Obstetric Early Warning Systems (EWS) use combined clinical observations to predict increased risk of deterioration and alert health workers to institute actions likely to improve outcomes. The objective of this study was to explore the experience of health workers about the implementation of an obstetric EWS and assess its effectiveness as an alternative clinical monitoring method compared to standard practice. This mixed-method study included obstetric admissions (n = 2400) to inpatient wards between 01/08/2018 and 31/03/2019 at three Nigerian tertiary hospitals (1 intervention and two control). Outcomes assessed were the efficiency of monitoring and recording vital signs using the patient monitoring index and speed of post-EWS trigger specialist review. These were evaluated through a review of case notes before and four months after EWS was introduced. Qualitative data was collected to explore healthcare workers' views on EWS' acceptability and usability. EWS was correctly used in 51% (n = 307) of the women in the intervention site. Of these women, 58.6% (n = 180) were predicted to have an increased risk of deterioration, and 38.9% (n = 70) were reviewed within 1 hour. There was a significant improvement in the frequency of vital signs recording in the intervention site: observed/expected frequency improved to 0.91 from 0.57, p

Abstract Background Every year, an estimated 2.6 million stillbirths occur worldwide, with up to 98% occurring in low- and middle-income countries (LMIC). There is a paucity of primary data on cause of stillbirth from LMIC, and particularly from sub-Saharan Africa to inform effective interventions. This study aimed to identify the cause of stillbirths in low- and middle-income settings and compare methods of assessment. Methods This was a prospective, observational study in 12 hospitals in Kenya, Malawi, Sierra Leone and Zimbabwe. Stillbirths (28 weeks or more) were reviewed to assign the cause of death by healthcare providers, an expert panel and by using computer-based algorithms. Agreement between the three methods was compared using Kappa (κ) analysis. Cause of stillbirth and level of agreement between the methods used to assign cause of death. Results One thousand five hundred sixty-three stillbirths were studied. The stillbirth rate (per 1000 births) was 20.3 in Malawi, 34.7 in Zimbabwe, 38.8 in Kenya and 118.1 in Sierra Leone. Half (50.7%) of all stillbirths occurred during the intrapartum period. Cause of death (range) overall varied by method of assessment and included: asphyxia (18.5–37.4%), placental disorders (8.4–15.1%), maternal hypertensive disorders (5.1–13.6%), infections (4.3–9.0%), cord problems (3.3–6.5%), and ruptured uterus due to obstructed labour (2.6–6.1%). Cause of stillbirth was unknown in 17.9–26.0% of cases. Moderate agreement was observed for cause of stillbirth as assigned by the expert panel and by hospital-based healthcare providers who conducted perinatal death review (κ = 0.69; p

Standardized case definitions strengthen post-marketing safety surveillance of new vaccines by improving generated data, interpretation and comparability across surveillance systems. The Global Alignment of Immunization Safety Assessment in Pregnancy (GAIA) project developed standardized case definitions for 21 key obstetric and neonatal terms following the Brighton Collaboration (BC) methodology.In this prospective cohort study, we assessed the applicability of GAIA definitions for maternal immunization exposure and for low birth weight (LBW), preterm birth, small for gestational age (SGA), stillbirth, neonatal death, neonatal infection, and congenital microcephaly. We identified the missing data elements that prevented identified cases and exposures from meeting the case definition (level 1–3 of BC diagnostic certainty). Over a one-year period (2019–2020), all births occurring in 21 sites (mostly secondary and tertiary hospitals) in 6 Low Middle Income Countries and 1 High Income Country were recorded and the 7 perinatal and neonatal outcome cases were identified from routine medical records. Up to 100 cases per outcome were recruited sequentially from each site.Most cases recruited for LBW, preterm birth and neonatal death met the GAIA case definitions. Birth weight, a key parameter for all three outcomes, was routinely recorded at all sites. The definitions for SGA, stillbirth, neonatal infection (particularly meningitis and respiratory infection) and congenital microcephaly were found to be less applicable. The main barrier to obtaining higher levels of diagnostic certainty was the lack of sonographic documentation of gestational age in first or second trimester. The definition for maternal immunization exposure was applicable, however, the highest level of diagnostic certainty was only reached at two sites. Improved documentation of maternal immunization will be important for vaccine safety studies. Following the field-testing of these 8 GAIA definitions, several improvements are suggested that may lead to their easier implementation, increased standardization and hence comparison across studies.

Abstract Background Continuous Positive Airway Pressure (CPAP) is a form of non-invasive ventilatory support which is increasingly used in low- and middle-income countries to treat neonates with acute respiratory distress. However, it may be harmful if used incorrectly. We aimed to explore the experiences of doctors and nurses using CPAP in neonatal units in India and their views on enablers and barriers to implementation of CPAP. Methods Participants from 15 neonatal units across Andhra Pradesh were identified through purposive sampling. Eighteen in-depth interviews (IDI) with doctors and eight focus group discussions (FGD) with 51 nurses were conducted. Data were analysed thematically using the framework approach. Results Common structural factors that limit the use of CPAP include shortages of staff, consumables and equipment, and problems with regard to the organisation of neonatal units in both district hospitals and medical colleges. This meant that CPAP was often not available for babies who were identified to need CPAP, or that CPAP use was not perceived to be of the highest quality. Providing care under constrained circumstances left staff feeling powerless to provide good quality care for neonates with acute respiratory distress. Despite this, staff were enthusiastic about the use of CPAP and its potential to save lives. CPAP use was mostly perceived as technically easier to provide than ventilation and allowed nurses to provide advanced neonatal care, independently of doctors. Conclusions Doctors and nurses embraced CPAP use but identified barriers to implementation which will need to be addressed in order not to impact on safety and quality of care. Ensuring a supportive and enabling environment is in place will be crucial if CPAP is to be scaled-up more widely.

Summary: Background: The association of air pollution with multiple adverse health outcomes is becoming well established, but its negative economic impact is less well appreciated. It is important to elucidate this impact for the states of India. Methods: We estimated exposure to ambient particulate matter pollution, household air pollution, and ambient ozone pollution, and their attributable deaths and disability-adjusted life-years in every state of India as part of the Global Burden of Disease Study (GBD) 2019. We estimated the economic impact of air pollution as the cost of lost output due to premature deaths and morbidity attributable to air pollution for every state of India, using the cost-of-illness method. Findings: 1·67 million (95% uncertainty interval 1·42–1·92) deaths were attributable to air pollution in India in 2019, accounting for 17·8% (15·8–19·5) of the total deaths in the country. The majority of these deaths were from ambient particulate matter pollution (0·98 million [0·77–1·19]) and household air pollution (0·61 million [0·39–0·86]). The death rate due to household air pollution decreased by 64·2% (52·2–74·2) from 1990 to 2019, while that due to ambient particulate matter pollution increased by 115·3% (28·3–344·4) and that due to ambient ozone pollution increased by 139·2% (96·5–195·8). Lost output from premature deaths and morbidity attributable to air pollution accounted for economic losses of US$28·8 billion (21·4–37·4) and $8·0 billion (5·9–10·3), respectively, in India in 2019. This total loss of $36·8 billion (27·4–47·7) was 1·36% of India's gross domestic product (GDP). The economic loss as a proportion of the state GDP varied 3·2 times between the states, ranging from 0·67% (0·47–0·91) to 2·15% (1·60–2·77), and was highest in the low per-capita GDP states of Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, and Chhattisgarh. Delhi had the highest per-capita economic loss due to air pollution, followed by Haryana in 2019, with 5·4 times variation across all states. Interpretation: The high burden of death and disease due to air pollution and its associated substantial adverse economic impact from loss of output could impede India's aspiration to be a $5 trillion economy by 2024. Successful reduction of air pollution in India through state-specific strategies would lead to substantial benefits for both the health of the population and the economy. Funding: UN Environment Programme; Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Background: To inform actions at the district level under the National Nutrition Mission (NNM), we assessed the prevalence trends of child growth failure (CGF) indicators for all districts in India and inequality between districts within the states. Methods: We assessed the trends of CGF indicators (stunting, wasting and underweight) from 2000 to 2017 across the districts of India, aggregated from 5 × 5 km grid estimates, using all accessible data from various surveys with subnational geographical information. The states were categorised into three groups using their Socio-demographic Index (SDI) levels calculated as part of the Global Burden of Disease Study based on per capita income, mean education and fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using coefficient of variation (CV). We projected the prevalence of CGF indicators for the districts up to 2030 based on the trends from 2000 to 2017 to compare with the NNM 2022 targets for stunting and underweight, and the WHO/UNICEF 2030 targets for stunting and wasting. We assessed Pearson correlation coefficient between two major national surveys for district-level estimates of CGF indicators in the states. Findings: The prevalence of stunting ranged 3.8-fold from 16.4% (95% UI 15.2–17.8) to 62.8% (95% UI 61.5–64.0) among the 723 districts of India in 2017, wasting ranged 5.4-fold from 5.5% (95% UI 5.1–6.1) to 30.0% (95% UI 28.2–31.8), and underweight ranged 4.6-fold from 11.0% (95% UI 10.5–11.9) to 51.0% (95% UI 49.9–52.1). 36.1% of the districts in India had stunting prevalence 40% or more, with 67.0% districts in the low SDI states group and only 1.1% districts in the high SDI states with this level of stunting. The prevalence of stunting declined significantly from 2010 to 2017 in 98.5% of the districts with a maximum decline of 41.2% (95% UI 40.3–42.5), wasting in 61.3% with a maximum decline of 44.0% (95% UI 42.3–46.7), and underweight in 95.0% with a maximum decline of 53.9% (95% UI 52.8–55.4). The CV varied 7.4-fold for stunting, 12.2-fold for wasting, and 8.6-fold for underweight between the states in 2017; the CV increased for stunting in 28 out of 31 states, for wasting in 16 states, and for underweight in 20 states from 2000 to 2017. In order to reach the NNM 2022 targets for stunting and underweight individually, 82.6% and 98.5% of the districts in India would need a rate of improvement higher than they had up to 2017, respectively. To achieve the WHO/UNICEF 2030 target for wasting, all districts in India would need a rate of improvement higher than they had up to 2017. The correlation between the two national surveys for district-level estimates was poor, with Pearson correlation coefficient of 0.7 only in Odisha and four small north-eastern states out of the 27 states covered by these surveys. Interpretation: CGF indicators have improved in India, but there are substantial variations between the districts in their magnitude and rate of decline, and the inequality between districts has increased in a large proportion of the states. The poor correlation between the national surveys for CGF estimates highlights the need to standardise collection of anthropometric data in India. The district-level trends in this report provide a useful reference for targeting the efforts under NNM to reduce CGF across India and meet the Indian and global targets.

ObjectivesTo determine the availability of continuous positive airway pressure (CPAP) and to provide an overview of its use in neonatal units in government hospitals across India.SettingCross-sectional cluster survey of a nationally representative sample of government hospitals from across India.Primary outcomesAvailability of CPAP in neonatal units.Secondary outcomesProportion of hospitals where infrastructure and processes to provide CPAP are available. Case fatality rates and complication rates of neonates treated with CPAP.ResultsAmong 661 of 694 government hospitals with neonatal units that provided information on availability of CPAP for neonatal care, 68.3% of medical college hospitals (MCH) and 36.6% of district hospitals (DH) used CPAP in neonates. Assessment of a representative sample of 142 hospitals (79 MCH and 63 DH) showed that air-oxygen blenders were available in 50.7% (95% CI 41.4% to 60.9%) and staff trained in the use of CPAP were present in 56.0% (45.8% to 65.8%) of hospitals. The nurse to patient ratio was 7.3 (6.4 to 8.5) in MCH and 6.6 (5.5 to 8.3) in DH. Clinical guidelines were available in 31.0% of hospitals (22.2% to 41.4%). Upper oxygen saturation limits of above 94% were used in 72% (59.8% to 81.6%) of MCH and 59.3% (44.6% to 72.5%) of DH. Respiratory circuits were reused in 53.8% (42.3% to 63.9%) of hospitals. Case fatality rate for neonates treated with CPAP was 21.4% (16.6% to 26.2%); complication rates were 0.7% (0.2% to 1.2%) for pneumothorax, 7.4% (0.9% to 13.9%) for retinopathy and 1.4% (0.7% to 2.1%) for bronchopulmonary dysplasia.ConclusionsCPAP is used in neonatal units across government hospitals in India. Neonates may be overexposed to oxygen as the means to detect and treat consequences of oxygen toxicity are insufficient. Neonates may also be exposed to nosocomial infections by reuse of disposables. Case fatality rates for neonates receiving CPAP are high. Complications might be under-reported. Support to infrastructure, training, guidelines implementation and staffing are needed to improve CPAP use.

Abstract Background Maternal Death Surveillance and Response (MDSR) implementation is monitored globally, but not much is known about what works well, where and why in scaling up. We reviewed a series of country case studies in order to determine whether and to what extent these countries have implemented the four essential components of MDSR and identify lessons for improving implementation. Methods A secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement. We identify the consistent drivers of success in countries with well-established systems for MDSR, and common barriers in countries were Maternal Death Review (MDR) systems have been less successful. Results MDR is accepted and ongoing at subnational level in many countries, but it is not adequately institutionalised and the shift from facility based MDR to continuous MDSR that informs the wider health system still needs to be made. Our secondary analysis of country experiences highlights the need for a) social and team processes at facility level, for example the existence of a ‘no shame, no blame’ culture, and the ability to reflect on practice and manage change as a team for recommendations to be acted upon, b) health system inputs including adequate funding and reliable health information systems to enable identification and analysis of cases c) national level coordination of dissemination, and monitoring implementation of recommendations at all levels and d) mandatory notification of maternal deaths (and enforcement of this) and a professional requirement to participate in MDRs. Conclusions Case studies from countries with established MDSR systems can provide valuable guidance on ways to set up the processes and overcome some of the barriers; but the challenge, as with many health system interventions, is to find a way to provide catalytic assistance and strengthen capacity for MDSR such that this becomes embedded in the health system.

IntroductionMaternal immunization (MI) with tetanus toxoid containing vaccine, is a safe and cost-effective way of preventing neonatal tetanus. Given the prospect of introducing new maternal vaccines in the near future, it is essential to identify and understand current policies, practices and unmet needs for introducing and/or scaling up MI in low-income and middle-income countries (LMICs).Methods and analysisThe Maternal Immunization and Antenatal Care Situation Analysis (MIACSA) is a mixed methods, cross-sectional study that will collect data in four phases: (1) a review of global databases for selected health indicators in 136 LMICs; (2) a structured online survey directed at Maternal, Newborn and Child Health and Expanded Programme on Immunization focal points in all 136 LMICs; (3) semistructured telephone interviews of 30 selected LMICs and (4) 10 week-long country visits, including key informant interviews, health facility visits and focus group discussions. The principal analyses will assess correlations between the various aspects of MI delivery strategies and proxy measures of health systems performance related to vaccine-preventable disease control. The primary outcome will be a typology of existing MI delivery models, and secondary outcomes will include country profiles of child and maternal health indicators, and a MI gaps and needs analysis.Ethics and disseminationThe protocol was approved by the WHO Ethics Review Committee (ERC.0002908). The results will be made available in a project report and submitted for publication in peer-reviewed journals that will be shared broadly among global health decision-makers, researchers, product developers and country-level stakeholders.

BACKGROUND:The Auxiliary nurse midwife (ANM) cadre was created to focus on maternal and child health. ANMs are respected members of their communities and established providers of maternal and child health care within the community and at the facility level. Over time, additional roles and responsibilities have been added. Despite the importance of ANMs in the primary healthcare system in India, studies that consider factors governing the performance of ANMs in their workplaces are limited. We aimed to study factors governing performance of ANMs in Pune district, India. METHODS:Semi-structured interviews were conducted with 13 purposely selected key informants at facility, district, state, and national levels. Focus group discussions were conducted with 41 ANMs and 25 members of the community. Non-participatory observations with eight ANMs provided information to expand on and scrutinise findings that emerged from the other lines of inquiry. A realist lens was applied to identify ANMs' performance as a result of "mechanisms" (training, supervision, accountability mechanisms) within the given "context" (regulatory system, infrastructure and resources, ANMs' expanded scope of work, gender roles and norms). RESULTS:Weak enforcement of regulatory system led to poor standardisation of training quality among training institutions. Challenges in internal accountability mechanisms governing ANMs within the health system hierarchy made it difficult to ensure individual accountability. Training and supervision received were inadequate to address current responsibilities. The supervisory approach focused on comparing information in periodic reports against expected outputs. Clinical support in workplaces was insufficient, with very little problem identification and solving. CONCLUSION:Focusing on the tasks of ANMs with technical inputs alone is insufficient to achieve the full potential of ANMs in a changing context. Systematic efforts tackling factors governing ANMs in their workplaces can produce a useful cadre, that can play an important role in achieving universal health coverage in India.

IntroductionSeveral versions of Early Warning Systems (EWS) are used in obstetrics to detect and treat early clinical deterioration to avert morbidity and mortality. EWS can potentially be useful to improve the quality of care and reduce the risk of maternal mortality in resource-limited settings. We conducted a systematic literature review of published obstetric early warning systems, define their predictive accuracy for morbidity and mortality, and their effectiveness in triggering corrective actions and improving health outcomes.MethodsWe systematically searched for primary research articles on obstetric EWS published in peer-reviewed journals between January 1997 and March 2018 in Medline, CINAHL, SCOPUS, Science Direct, and Science Citation Index. We also searched reference lists of relevant articles and websites of professional societies. We included studies that assessed the predictive accuracy of EWS to detect clinical deterioration, or/and their effectiveness in improving clinical outcomes in obstetric inpatients. We excluded studies with a paediatric or non-obstetric adult population. Cross-sectional and qualitative studies were also excluded. We performed a narrative synthesis since the outcomes reported were heterogeneous.ResultsA total of 381 papers were identified, 17 of which met the inclusion criteria. Eleven of the included studies evaluated the predictive accuracy of EWS for obstetric morbidity and mortality, 5 studies assessed the effectiveness of EWS in improving clinical outcomes, while one study addressed both. Sixteen published EWS versions were reviewed, 14 of which included five basic clinical observations (pulse rate, respiratory rate, temperature, blood pressure, and consciousness level). The obstetric EWS identified had very high median (inter-quartile range) sensitivity-89% (72% to 97%) and specificity-85% (67% to 98%) but low median (inter-quartile range) positive predictive values-41% (25% to 74%) for predicting morbidity or ICU admission. Obstetric EWS had a very high accuracy in predicting death (AUROC >0.80) among critically ill obstetric patients. Obstetric EWS improves the frequency of routine vital sign observation, reduces the interval between the recording of specifically defined abnormal clinical observations and corrective clinical actions, and can potentially reduce the severity of obstetric morbidity.ConclusionObstetric EWS are effective in predicting severe morbidity (in general obstetric population) and mortality (in critically ill obstetric patients). EWS can contribute to improved quality of care, prevent progressive obstetric morbidity and improve health outcomes. There is limited evidence of the effectiveness of EWS in reducing maternal death across all settings. Clinical parameters in most obstetric EWS versions are routinely collected in resource-limited settings, therefore implementing EWS may be feasible in such settings.

ObjectiveTo identify the causes and categories of stillbirth using the Application of ICD-10 to Deaths during the Perinatal Period (ICD-PM).MethodsProspective, observational study in 12 hospitals across Kenya, Malawi, Sierra Leone and Zimbabwe. Healthcare providers (HCPs) assigned cause of stillbirth following perinatal death audit. Cause of death was classified using the ICD-PM classification system.Findings1267 stillbirths met the inclusion criteria. The stillbirth rate (per 1000 births) was 20.3 in Malawi (95% CI: 15.0-42.8), 34.7 in Zimbabwe (95% CI: 31.8-39.2), 38.8 in Kenya (95% CI: 33.9-43.3) and 118.1 in Sierra Leone (95% CI: 115.0-121.2). Of the included cases, 532 (42.0%) were antepartum deaths, 643 (50.7%) were intrapartum deaths and 92 cases (7.3%) could not be categorised by time of death. Overall, only 16% of stillbirths could be classified by fetal cause of death. Infection (A2 category) was the most commonly identified cause for antepartum stillbirths (8.6%). Acute intrapartum events (I3) accounted for the largest proportion of intrapartum deaths (31.3%). In contrast, for 76% of stillbirths, an associated maternal condition could be identified. The M1 category (complications of placenta, cord and membranes) was the most common category assigned for antepartum deaths (31.1%), while complications of labour and delivery (M3) accounted for the highest proportion of intrapartum deaths (38.4%). Overall, the proportion of cases for which no fetal or maternal cause could be identified was 32.6% for antepartum deaths, 8.1% for intrapartum deaths and 17.4% for cases with unknown time of death.ConclusionClinical care and documentation of this care require strengthening. Diagnostic protocols and guidelines should be introduced more widely to obtain better data on cause of death, especially antepartum stillbirths. Revision of ICD-PM should consider an additional category to help accommodate stillbirths with unknown time of death.

Abstract Background Evaluating health systems and policy (HSP) change and implementation is critical in understanding reproductive, maternal, newborn and child health (RMNCH) progress within and across countries. Whilst data for health outcomes, coverage and equity have advanced in the last decade, comparable analyses of HSP changes are lacking. We present a set of novel tools developed by Countdown to 2015 (Countdown) to systematically analyse and describe HSP change for RMNCH indicators, enabling multi-country comparisons. Methods International experts worked with eight country teams to develop HSP tools via mixed methods. These tools assess RMNCH change over time (e.g. 1990–2015) and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, we present results from Tanzania and Peru, two of eight Countdown case studies. Results The Policy and Programme Timeline tool shows that Tanzania’s RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Contrastingly, Peru moved from standalone to integrated RMNCH programme implementation, combined with multi-sectoral, anti-poverty strategies. The HSP Tracer Indicators Dashboards show that Peru has adopted nine of 11 policy tracer indicators and Tanzania has adopted seven. Peru costed national RMNCH plans pre-2000, whereas Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. Both countries included all lifesaving RMNCH commodities on their essential medicines lists. Peru has twice the health worker density of Tanzania (15.4 vs. 7.1/10,000 population, respectively), although both are below the 22.8 WHO minimum threshold. Conclusions These are the first HSP tools using mixed methods to systematically analyse and describe RMNCH changes within and across countries, important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era.

BackgroundEscalation in the global rates of labour interventions, particularly cesarean section and oxytocin augmentation, has renewed interest in a better understanding of natural labour progression. Methodological advancements in statistical and computational techniques addressing the limitations of pioneer studies have led to novel findings and triggered a re-evaluation of current labour practices. As part of the World Health Organization's Better Outcomes in Labour Difficulty (BOLD) project, which aimed to develop a new labour monitoring-to-action tool, we examined the patterns of labour progression as depicted by cervical dilatation over time in a cohort of women in Nigeria and Uganda who gave birth vaginally following a spontaneous labour onset.Methods and findingsThis was a prospective, multicentre, cohort study of 5,606 women with singleton, vertex, term gestation who presented at ≤ 6 cm of cervical dilatation following a spontaneous labour onset that resulted in a vaginal birth with no adverse birth outcomes in 13 hospitals across Nigeria and Uganda. We independently applied survival analysis and multistate Markov models to estimate the duration of labour centimetre by centimetre until 10 cm and the cumulative duration of labour from the cervical dilatation at admission through 10 cm. Multistate Markov and nonlinear mixed models were separately used to construct average labour curves. All analyses were conducted according to three parity groups: parity = 0 (n = 2,166), parity = 1 (n = 1,488), and parity = 2+ (n = 1,952). We performed sensitivity analyses to assess the impact of oxytocin augmentation on labour progression by re-examining the progression patterns after excluding women with augmented labours. Labour was augmented with oxytocin in 40% of nulliparous and 28% of multiparous women. The median time to advance by 1 cm exceeded 1 hour until 5 cm was reached in both nulliparous and multiparous women. Based on a 95th percentile threshold, nulliparous women may take up to 7 hours to progress from 4 to 5 cm and over 3 hours to progress from 5 to 6 cm. Median cumulative duration of labour indicates that nulliparous women admitted at 4 cm, 5 cm, and 6 cm reached 10 cm within an expected time frame if the dilatation rate was ≥ 1 cm/hour, but their corresponding 95th percentiles show that labour could last up to 14, 11, and 9 hours, respectively. Substantial differences exist between actual plots of labour progression of individual women and the 'average labour curves' derived from study population-level data. Exclusion of women with augmented labours from the study population resulted in slightly faster labour progression patterns.ConclusionsCervical dilatation during labour in the slowest-yet-normal women can progress more slowly than the widely accepted benchmark of 1 cm/hour, irrespective of parity. Interventions to expedite labour to conform to a cervical dilatation threshold of 1 cm/hour may be inappropriate, especially when applied before 5 cm in nulliparous and multiparous women. Averaged labour curves may not truly reflect the variability associated with labour progression, and their use for decision-making in labour management should be de-emphasized.

Abstract Objective To describe tools used for the assessment of maternal and child health issues in humanitarian emergency settings. Methods We systematically searched MEDLINE, Web of Knowledge and POPLINE databases for studies published between January 2000 and June 2014. We also searched the websites of organizations active in humanitarian emergencies. We included studies reporting the development or use of data collection tools concerning the health of women and children in humanitarian emergencies. We used narrative synthesis to summarize the studies. Findings We identified 100 studies: 80 reported on conflict situations and 20 followed natural disasters. Most studies (76/100) focused on the health status of the affected population while 24 focused on the availability and coverage of health services. Of 17 different data collection tools identified, 14 focused on sexual and reproductive health, nine concerned maternal, newborn and child health and four were used to collect information on sexual or gender-based violence. Sixty-nine studies were done for monitoring and evaluation purposes, 18 for advocacy, seven for operational research and six for needs assessment. Conclusion Practical and effective means of data collection are needed to inform life-saving actions in humanitarian emergencies. There are a wide variety of tools available, not all of which have been used in the field. A simplified, standardized tool should be developed for assessment of health issues in the early stages of humanitarian emergencies. A cluster approach is recommended, in partnership with operational researchers and humanitarian agencies, coordinated by the World Health Organization.

Objective: Verbal autopsy (VA) is a systematic approach for determining causes of death (CoD) in populations without routine medical certification. It has mainly been used in research contexts and involved relatively lengthy interviews. Our objective here is to describe the process used to shorten, simplify, and standardise the VA process to make it feasible for application on a larger scale such as in routine civil registration and vital statistics (CRVS) systems. Methods: A literature review of existing VA instruments was undertaken. The World Health Organization (WHO) then facilitated an international consultation process to review experiences with existing VA instruments, including those from WHO, the Demographic Evaluation of Populations and their Health in Developing Countries (INDEPTH) Network, InterVA, and the Population Health Metrics Research Consortium (PHMRC). In an expert meeting, consideration was given to formulating a workable VA CoD list [with mapping to the International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) CoD] and to the viability and utility of existing VA interview questions, with a view to undertaking systematic simplification. Findings: A revised VA CoD list was compiled enabling mapping of all ICD-10 CoD onto 62 VA cause categories, chosen on the grounds of public health significance as well as potential for ascertainment from VA. A set of 221 indicators for inclusion in the revised VA instrument was developed on the basis of accumulated experience, with appropriate skip patterns for various population sub-groups. The duration of a VA interview was reduced by about 40% with this new approach. Conclusions: The revised VA instrument resulting from this consultation process is presented here as a means of making it available for widespread use and evaluation. It is envisaged that this will be used in conjunction with automated models for assigning CoD from VA data, rather than involving physicians.

OBJECTIVE: To estimate the amount of additional resources needed to scale up maternal and newborn health services within the context of the Millennium Development Goals, and to inform countries, donors and multilateral agencies about the resources needed to achieve these goals. METHODS: A costing model based on WHO’s clinical guidelines was used to estimate the incremental resource needs for maternal and newborn health care in 75 countries. The model estimated the costs for care during pregnancy, childbirth, the neonatal period and the postpartum period, as well as the costs for postpartum family planning and counselling, abortion and post-abortion care; programme-level costs were also estimated. An ingredients-based approach, with financial costs for the years 2006 to 2015 as the output, allowed estimates to be made of country-specific and year-specific populations, unit costs and scale-up rates. Two scenarios using different scale-up rates were used (moderate and rapid). FINDINGS: The results show that a minimum yearly average increase in resources of US$ 3.9 billion is needed, although annual costs increase over the time period of the model. When more rapid rates of scale-up are assumed, this minimum figure may be as high as US$ 5.6 billion per year. The 10-year estimated incremental costs range from US$ 39.3 billion for a moderate scale-up scenario to US$ 55.7 billion for the rapid scale-up scenario. CONCLUSION: These projections of future financial costs may be used as a starting point for mobilizing global resources. Countries will have to further refine these estimates, but these figures may serve as goals towards which donors can direct their plans. Further research is needed to measure the costs of health system reforms, such as recruiting, training and retaining a sufficient number of personnel.

In 2007, the World Health Organization (WHO) received a criticism for a lack of transparency and systematic methods in the development of guidelines, which were at that time perceived as substantially driven by expert opinion. In this paper we assessed the quality of maternal and perinatal health guidelines developed since then. We used the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool to evaluate the quality of methodological rigour and transparency of four different WHO guidelines published between 2007 and 2011. Our findings showed high scores among the most recent guidelines on maternal and perinatal health suggesting higher quality. However, there is still potential for improvement, especially in including different stakeholder views, transparency of guidelines regarding the role of the funding body and presentation of the guideline document.

BackgroundEnsuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population.Methods and findingsA cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be ConclusionsAvailability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.

Based upon an expert survey and consensus method, Sabine Gabrysch and colleagues recommend new signal functions to monitor and track facilities' provision of routine and emergency newborn care.

BACKGROUND: Most maternal deaths, intrapartum-related stillbirths, and newborn deaths in low income countries are preventable but simple, effective methods for improving safety in institutional births have not been devised. Checklist-based interventions aid management of complex or neglected tasks and have been shown to reduce harm in healthcare. We hypothesized that implementation of the WHO Safe Childbirth Checklist program, a novel childbirth safety program for institutional births incorporating a 29-item checklist, would increase delivery of essential childbirth practices linked with improved maternal and perinatal health outcomes. METHODS AND FINDINGS: A pilot, pre-post-intervention study was conducted in a sub-district level birth center in Karnataka, India between July and December 2010. We prospectively observed health workers that attended to women and newborns during 499 consecutively enrolled birth events and compared these with observed practices during 795 consecutively enrolled birth events after the introduction of the WHO Safe Childbirth Checklist program. Twenty-nine essential practices that target the major causes of childbirth-related mortality, such as hand hygiene and uterotonic administration, were evaluated. The primary end point was the average rate of successful delivery of essential childbirth practices by health workers. Delivery of essential childbirth-related care practices at each birth event increased from an average of 10 of 29 practices at baseline (95%CI 9.4, 10.1) to an average of 25 of 29 practices afterwards (95%CI 24.6, 25.3; p

Abstract Background Induction of labor is being increasingly used to prevent adverse outcomes in the mother and the newborn.This study assessed the prevalence of induction of labor and determinants of its use in Africa. Methods We performed secondary analysis of the WHO Global Survey of Maternal and Newborn Health of 2004 and 2005. The African database was analyzed to determine the use of induction of labor at the country level and indications for induction of labor. The un-met needs for specific obstetric indications and at country level were assessed. Determinants of use of induction of labor were explored with multivariate regression analysis. Results A total of 83,437 deliveries were recorded in the 7 participating countries. Average rate of induction was 4.4% with a range of 1.4 – 6.8%. Pre-labor rupture of membranes was the commonest indication for induction of labor. Two groups of women were identified: 2,776 women with indications had induction of labor while 7,996 women although had indications but labor was not induced. Induction of labor was associated with reduction of stillbirths and perinatal deaths [OR – 0.34; 95% CI (0.27 – 0.43)]. Unmet need for induction of labor ranged between 66.0% and 80.2% across countries. Determinants of having an induction of labor were place of residence, duration of schooling, type of health facility and level of antenatal care. Conclusion Utilization of induction of labor in health facilities in Africa is very low. Improvements in social and health infrastructure are required to reverse the high unmet need for induction of labor.

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.