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Aim: Pregnancy after the death of a baby is associated with numerous, varied psychological challenges for pregnant women. This study aimed to explore women’s experiences of pregnancy whilst attending a specialist antenatal service for pregnancies after a perinatal death.\ud \ud Methods: Semi-structured interviews with twenty women in a subsequent pregnancy after a perinatal death were conducted and analyzed taking an inductive thematic analysis approach.\ud \ud Results: All women expressed a heightened “awareness of risk”. Two subthemes demonstrated how increased awareness of risk affected their experience and their desire regarding antenatal and postnatal support. Women talked about stillbirth being a “quiet, unspoken subject” causing them internal conflict as they had an awareness of pregnancy complications that other people did not. Navigating subsequent pregnancies relied on them “expecting the worst and hoping for the best” in terms of pregnancy outcomes. Women viewed specialist antenatal care in pregnancy after perinatal loss favorably, as it enabled them to receive tailored care that met their needs stemming from their increased awareness of and personal expectations of risk.\ud \ud Conclusion: Women’s experiences can be used to develop models of care but further studies are required to determine to identify which components are most valued.

Introduction\ud \ud Provision of emergency obstetric and newborn care (EmONC) by skilled health personnel reduces maternal and newborn mortality. Pre-service diploma midwifery and clinical medicine (reproductive health) curricula in Kenya were reviewed and updated integrating the competency based EmONC curriculum. A two-part (virtual for theoretical component and face-to-face for the skills-based component) capacity building workshop for national midwifery/clinical medicine trainers of trainers to improve their capacity to implement the updated curricula and cascade it to colleagues nationwide was conducted.\ud \ud Purpose\ud \ud This paper measured change in confidence of pre-service midwifery/clinical medicine educators to deliver the updated competency-based curricula in Kenya.\ud \ud Methods\ud \ud A before-after study among 51 midwifery/clinical medicine educators from 35 training colleges who participated in upskilling workshops as trainers-of-trainers for the updated curricula between September-November 2020. Assessment included self-reported confidence using a 3-point Likert scale (not confident, somewhat confident or extremely confident) in facilitating online teaching (as COVID-19 pandemic containment measure), EmONC skills teaching/demonstration; scenario/simulation teaching, small group discussions, peer review and giving effective feedback. Analysis involved test of proportions with p-values < 0.05 statistically significant.\ud \ud Results\ud \ud Educators’ confidence significantly improved in facilitating virtual teaching (46% to 70%, p = 0.0082). On the competency-based training, the confidence among educators significantly increased in facilitating EmONC skills teaching/demonstration (44% to 96%), facilitating scenario/simulation teaching (46% to 92%), facilitating small group discussions (46% to 94%), giving effective feedback (46% to 92%), and peer review and feedback (47% to 77%), p < 0.05).\ud \ud Conclusion\ud \ud The blended training improved the confidence of pre-service educators to deliver the updated midwifery/clinical medicine curricula.

BackgroundIron deficiency (ID) is common in malaria-endemic settings. Intermittent preventative treatment of malaria in pregnancy (IPTp) and iron supplementation are core components of antenatal care in endemic regions to prevent adverse pregnancy outcomes. ID has been associated with reduced risk of malaria infection, and correspondingly, iron supplementation with increased risk of malaria infection, in some studies.MethodsA secondary analysis was conducted amongst 1888 pregnant women enrolled in a malaria prevention trial in Papua New Guinea. Maternal ID was defined as inflammation-corrected plasma ferritin levels Plasmodium falciparum,Plasmodium vivax) was determined by light microscopy, polymerase chain reaction, and placental histology. Multiple logistic and linear regression analyses explored the relationship of ID or ferritin levels with indicators of malaria infection. Models were fitted with interaction terms to assess for modification of iron-malaria relationships by gravidity or treatment arm.ResultsTwo-thirds (n = 1226) and 13.7% (n = 258) of women had ID and peripheral parasitaemia, respectively, at antenatal enrolment (median gestational age: 22 weeks), and 18.7% (120/1,356) had evidence of malaria infection on placental histology. Overall, ID was associated with reduced odds of peripheral parasitaemia at enrolment (adjusted odds ratio [aOR] 0.50; 95% confidence interval [95% CI] 0.38, 0.66, P ConclusionsLow maternal ferritin at first antenatal visit was associated with a lower risk of malaria infection during pregnancy, most notably in primigravid women. The mechanisms by which maternal iron stores influence susceptibility to infection withPlasmodiumspecies require further investigation.Trial registration

Objective: Antenatal (ANC) and postnatal care (PNC) are logical entry points for prevention and treatment of pregnancy‐related illness and to reduce perinatal mortality. We developed signal functions and assessed availability of the essential components of care. \ud \ud Design: Cross‐sectional survey. \ud Setting: Afghanistan, Chad, Ghana, Tanzania, Togo.\ud Sample: Three hundred and twenty‐one healthcare facilities.\ud Methods: Fifteen essential components or signal functions of ANC and PNC were identified. Healthcare facility assessment for availability of each component, human resources, equipment, drugs and consumables required to provide each component. \ud Main outcome measure: Availability of ANC PNC components.\ud Results: Across all countries, healthcare providers are available (median number per facility: 8; interquartile range [IQR] 3–17) with a ratio of 3:1 for secondary versus primary care. Significantly more women attend for ANC than PNC (1668 versus 300 per facility/year). None of the healthcare facilities was able to provide all 15 essential components of ANC and PNC. The majority (>75%) could provide five components: diagnosis and management of syphilis, vaccination to prevent tetanus, BMI assessment, gestational diabetes screening, monitoring newborn growth. In Sub‐Saharan countries, interventions for malaria and HIV (including prevention of mother to child transmission [PMTCT]) were available in 11.7–86.5% of facilities. Prevention and management of TB; assessment of pre‐ or post‐term birth, fetal wellbeing, detection of multiple pregnancy, abnormal lie and presentation; screening and support for mental health and domestic abuse were provided in

Background Many women in sub-Saharan Africa initiate antenatal care (ANC) late in pregnancy, undermining optimal prevention of mother-to-child-transmission (PMTCT) of HIV. Questions remain about whether and how late initiation of ANC in pregnancy is related to adherence to antiretroviral therapy (ART) in the era of national dolutegravir roll-out. Methods This study employed a qualitative design involving individual interviews and focus group discussions conducted between August 2018 and March 2019. We interviewed 37 pregnant and lactating women living with HIV selected purposively for early or late presentation to ANC from poor urban communities in South Africa and Uganda. Additionally, we carried out seven focused group discussions involving 67 participants in both countries. Data were analysed thematically in NVivo12. Results Women described common underlying factors influencing both late ANC initiation and poor ART adherence in South Africa and Uganda. These included poverty and time constraints; inadequate health knowledge; perceived low health risk; stigma of HIV in pregnancy; lack of disclosure; and negative provider attitudes. Most late ANC presenters reported relationship problems, lack of autonomy and the limited ability to dialogue with their partners to influence household decisions on health and resource allocation. Perception of poor privacy and confidentiality in maternity clinics was rife among women in both study settings and compounded risks associated with early disclosure of pregnancy and HIV. Women who initiated ANC late and were then diagnosed with HIV appeared to be more susceptible to poor ART adherence. They were often reprimanded by health workers for presenting late which hampered their participation in treatment counselling and festered provider mistrust and subsequent disengagement in care. Positive HIV diagnosis in late pregnancy complicated women’s ability to disclose their status to significant others which deprived them of essential social support for treatment adherence. Further, it appeared to adversely affect women’s mental health and treatment knowledge and self-efficacy. Conclusions We found clear links between late initiation of ANC and the potential for poor adherence to ART based on common structural barriers shaping both health seeking behaviours, and the adverse impact of late HIV diagnosis on women’s mental health and treatment knowledge and efficacy. Women who present late are a potential target group for better access to antiretrovirals that are easy to take and decrease viral load rapidly, and counselling support with adherence and partner disclosure. A combination of strengthened health literacy, economic empowerment, improved privacy and patient-provider relationships as well as community interventions that tackle inimical cultural practices on pregnancy and unfair gender norms may be required.

Background The grief associated with the death of a baby is enduring, however most women embark on another pregnancy, many in less than a year following their loss. Symptoms of anxiety and depression are reported to be increased in pregnancies after perinatal death, although effect on maternal stress is less clear. Variation between individual studies may result from differences in gestation at sampling, the questionnaire used and the type of antecedent perinatal death. We aimed to describe quantitative measures of anxiety, depression, stress and quality of life at different timepoints in pregnancies after perinatal death and in the early postnatal period. Methods Women recruited from three sites in the North-West of England. Women were asked to participate if a previous pregnancy had ended in a perinatal death. Participants completed validated measures of psychological state (Cambridge Worry Score, Edinburgh Postnatal Depression Score (EPDS), Generalized Anxiety Disorder 7-item score) and health status (EQ-5D-5L™ and EQ5D-Visual Analogue Scale) at three time points, approximately 15 weeks’ and 32 weeks’ gestation and 6 weeks postnatally. A sample of hair was taken at approximately 36 weeks’ gestation for measurement of hair cortisol in a subgroup of women. The hair sample was divided into samples from each trimester and cortisol measured by ELISA. Results In total 112 women participated in the study. Measures of anxiety and depressive symptoms decreased from the highest levels at 15 weeks’ gestation to 6-weeks postnatal (for example mean GAD-7: 15 weeks 8.2 ± 5.5, 6 weeks postnatal 4.4 ± 5.0, p Conclusions This study demonstrated heightened anxiety and depressive symptoms and elevated cortisol levels in women in pregnancies after a stillbirth or neonatal death which decrease as pregnancy progresses. Further studies are needed to determine optimal care for women to address these negative psychological consequences.

ObjectivesDisrespectful care, which remains prevalent in low and middle-income countries (LMICs), acts as a barrier to women accessing skilled birth attendance, compromising care when services are available. Building on what was positive in facilities, we aimed to explore lay and healthcare providers’ experience of respectful care to inform future interventions.SettingFive maternity facilities in Mwanza Tanzania and Lilongwe Malawi.Participants94 participants in Malawi (N=46) and Tanzania (N=48) including 24 women birthing live baby within the previous 12 months; 22 family members and 48 healthcare providers who regularly provided maternity care in the included facilitiesDesignThe study was guided by Appreciative Inquiry (AI). Semistructured, one-to-one interviews were conducted between January and December 2019. Interviews were audio-recorded, translated where necessary, transcribed verbatim, and analysed using the framework approach.ResultsFour main themes describing participants positive experience and their vision of respectful care were identified: (1) empathic healthcare provider–woman interactions including friendly welcome and courteous language, well-timed appropriate care and information sharing, (2) an enabling environment, characterised by improvement of physical environment, the use of screens, curtains and wall partitions for privacy, availability of equipment and provision of incentives to staff, (3) supportive leadership demonstrated by the commitment of the government and facility leaders to provision of respectful care, ensuring availability of guidelines and policies, supportive supervision, reflective discussion and paying staff salaries timely, (4) providers’ attitudes and behaviours characterised by professional values through readiness, compassionate communication and commitment.ConclusionThe positive experiences of service users, families and healthcare providers provided insight into key drivers of respectful care in facilities in Tanzania and Malawi. Interventions targeting improved environment and privacy, healthcare provider communication and developing positive leadership structures in facilities could provide the basis for sustained improvement in respectful and dignified maternal and newborn care in LMICs.

Background\ud Globally too many mothers and their babies die during pregnancy and childbirth, a key element of optimizing outcomes is high-quality antenatal care (ANC). The Government of Nepal have significantly improved ANC and health outcomes through high-level commitment and investment, but still only 69% attend four recommended antenatal appointments.\ud \ud Objective\ud To evaluate the quality and perceptions of ANC in Nepal to understand the compliance with Nepalese standards.\ud \ud Study Design\ud This cross-sectional study took place at a tertiary referral and private hospital in Kathmandu, and a secondary hospital in Makwanpur. It recruited 538 female inpatients on postnatal wards during the two-week data collection period in May/June 2019. A case note review and verbal survey of women to understand the pregnancy information they received and their satisfaction with ANC was performed. We created a summary score of the completeness of ANC services received ranging 0-50 (50 indicating complete accordance with standards) and investigated the determinants of attending 4 ANC visits and patient satisfaction.\ud \ud Results\ud The median ANC attendance was 4 visits at the secondary and referral hospitals and 8 at the private hospital. 24% attended less than 4 visits. 22% (117/538) attended a first trimester visit and 12% (65/538) attended visits at all points recommended in the standards. Over 90% of women had blood pressure monitoring, hemoglobin estimation, blood grouping and Rhesus typing, HIV and syphilis screening. 50% of women had urinalysis at every visit (IQR 20 to 100). 95% (509/538) reported receiving pregnancy information, but retention was variable: 93% (509/538) received some information about danger signs, 58% (290/502) remembered headaches whereas 98% (491/502) remembered fluid leaking. The ANC completeness score revealed the private hospital offered the most complete clinical services (mean 28.7, SD=7.1) with the secondary hospital performing worst (mean 19.1, SD=7.1). The factors influencing attendance at 4 ANC visits in the multivariable model were beginning ANC in the first trimester (OR 2.74 (95% CI 1.36, 5.52) and having a lower level of education (no-school OR 0.46 (95% CI 0.23, 0.91), Grades 1-5 OR 0.49 (95%CI 0.26, 0.92)). Overall 56% (303/538) of women were satisfied with ANC. The multivariable analysis revealed satisfaction was more likely in women attending the private hospital compared to the referral hospital (OR 3.63 95% CI 1.68 to 7.82) and lower in women who felt the ANC facilities were not adequate (OR 0.35 95% CI 0.21 to 0.63) and who wanted longer antenatal appointments (OR 0.5 95% CI 0.33 to 0.75).\ud \ud Conclusions\ud Few women achieved full compliance with the Nepali ANC standards, however, some services were delivered well. To improve, each antenatal contact needs to meet its clinical aims and be respectful. To achieve this communication and counselling training for staff, investment in health promotion and delivery of core services is needed. It is important that these interventions address key issues, such as attendance in the first trimester, improving privacy and optimizing communication around danger signs. However, they must be designed alongside staff and service users and their efficacy tested prior to widespread investment or implementation.

BackgroundGlobally, an increasing number of women give birth in a healthcare facility. Improvement in the quality of care is crucial if preventable maternal mortality and morbidity are to be reduced. A Patient Reported Outcome Measure (PROM) can be used to measure quality of care and provide new information on the impact that treatment or interventions have on patient's self-assessed health and health-related quality of life. We conducted a systematic review to identify which condition-specific PROMs are currently available for use in pregnancy and childbirth, and to evaluate whether these could potentially be used to assess the quality of care provided for women using maternity services.MethodsWe searched for articles relating to the use of PROMs related to care during pregnancy, childbirth, the postnatal period and women's health more generally using PsycINFO, CINAHL, Medline and Web of Science databases as well as "grey literature", with no date limit. Any PROM identified was reviewed with regards to development, use, and potential applicability to assess quality of maternity care provision. A narrative synthesis was used to summarise findings.ResultsSix papers were identified; two related to aspects of pregnancy (hyperemesis gravidarum and gestational diabetes), and four related to childbirth and the postnatal period (obstetric haemorrhage and postnatal depression). Within these papers, a total of 14 different tools were identified, which assessed a variety of aspects of physical, psychological and social health, or were generic tools, not specific to childbirth. One PROM addressed childbirth generally, however, it did not ask for or provide specific outcome measures but required women to identify and then assess what they considered the most important areas in their life affected by childbirth.ConclusionsTo date, there is no PROM agreed which would be suitable as patient reported outcome measure for the assessment of the quality of care women receive during pregnancy or after childbirth. However, there are a variety of available assessment tools which could potentially be helpful in developing new and existing PROMs for maternity care.

The global COVID-19 pandemic is predicted to compromise the achievement of global reproductive, maternal, and newborn health (RMNH) targets. The objective of this study was to determine the health facility (HF) preparedness for RMNH service delivery during the outbreak from the perspective of RMNH providers and to determine what factors significantly predict this. An anonymous cross-sectional online survey of RMNH providers was conducted from to July 1–21, 2020 in Lagos State, Nigeria. We conducted a descriptive and ordinal regression analysis, with RMNH worker perception of HF preparedness for RMNH service delivery during the outbreak as the dependent variable. In all, 256 RMNH workers participated, 35.2% reported that RMNH services were unavailable at some time since March 2020, 87.1% felt work-related burnout, 97.7% were concerned about the availability of personal protective equipment (PPE) and related guidelines, and only 11.7% were satisfied with the preparedness of their HFs. Our final model was a statistically significant predictor of RMNH worker perception of HF preparedness explaining 54.7% of the variation observed. The most significant contribution to the model was communication by HF management (likelihood ratio chi-square [LRCS]: 87.94, P < 0.001) and the availability of PPE and COVID-19 guidelines (LRCS: 15.43, P < 0.001). A one-unit increase in the level of concern about the availability of PPE and COVID-19 guidelines would increase the odds of observing a higher category of satisfaction with HF COVID-19 preparedness. Adequate support of RMNH providers, particularly provision of PPE and guidelines, and appropriate communications about COVID-19 should be prioritized as part of HF preparedness.

Purpose\ud Evidence about the effect of maternal vitamin B12 supplementation on offspring’s vitamin B12 status is limited. The present interventional study sought to evaluate the association of antenatal vitamin B complex supplementation with neonatal vitamin B12 status.\ud \ud Methods\ud In an ongoing cluster randomized controlled trial conducted in three rural counties in northwest China, pregnant women

ObjectiveTo assess respectful maternity care (RMC) in health facilities.DesignCross-sectional study.SettingForty-three (43) facilities across 15 districts in Bangladesh, 16 in Ghana and 12 in Tanzania.ParticipantsFacility managers; 325 providers (nurses/midwives/doctors)—Bangladesh (158), Ghana (86) and Tanzania (81); and 849 recently delivered women—Bangladesh (295), Ghana (381) and Tanzania (173)—were interviewed. Observation of 641 client–provider interactions was conducted—Bangladesh (387), Ghana (134) and Tanzania (120).AssessmentTrained social scientists and clinicians assessed infrastructure, policies, provision and women’s experiences of RMC (emotional support, respectful care and communication).Primary outcomeRMC provided and/or experienced by women.ResultsThree (20%) facilities in Bangladesh, four (25%) in Ghana and three (25%) in Tanzania had no maternity clients’ toilets and one-half had no handwashing facilities. Policies for RMC such as identification of client abuses were available: 81% (Ghana), 73% (Bangladesh) and 50% (Tanzania), but response was poor. Ninety-four (60%) Bangladeshi, 26 (30%) Ghanaian and 20 (25%) Tanzanian providers were not RMC trained. They provided emotional support during labour care to 107 (80%) women in Ghana, 95 (79%) in Tanzania and 188 (48.5%) in Bangladesh, and were often courteous with them—236 (61%) in Bangladesh, 119 (89%) in Ghana and 108 (90%) in Tanzania. Due to structural challenges, 169 (44%) women in Bangladesh, 49 (36%) in Ghana and 77 (64%) in Tanzania had no privacy during labour. Care was refused to 13 (11%) Tanzanian and 2 Bangladeshi women who could not pay illegal charges. Twenty-five (7%) women in Ghana, nine (6%) in Bangladesh and eight (5%) in Tanzania were verbally abused during care. Providers in all countries highly rated their care provision (95%–100%), and 287 (97%) of Bangladeshi women, 368 (97%) Ghanaians and 152 (88%) Tanzanians reported ‘satisfaction’ with the care they received. However, based on their facility experiences, significant (pConclusionsFacilities in Bangladesh, Ghana and Tanzania have foundational systems that facilitate RMC. Structural inadequacies and policy gaps pose challenges. Many women were, however, unwilling to return to the same facilities for future deliveries although they (and providers) highly rated these facilities.

BACKGROUND\ud Sulfadoxine-pyrimethamine (SP) is used as intermittent preventive therapy in pregnancy (IPTp) for malaria in sub-Saharan Africa. The resistance marker dhps A581G has been associated with reduced IPTp-SP efficacy and enhanced morbidity in SP-recipients.\ud METHODS\ud We measured SP-resistance allele frequencies in Malawian women participating in a trial (www.isrctn.com/ISRCTN69800930) comparing IPTp with SP against intermittent screening by rapid diagnostic tests (ISTp). We genotyped PCR-detected parasites using deep sequencing of SP-resistance alleles.\ud RESULTS\ud Among 125 placental infections, A581G-bearing parasites were associated with reduced birthweight (mean difference[MD]:252g, 95% CI:46,457, p=0.017). Relative to ISTp, IPTp-SP was associated with higher birthweights in women with wildtype parasites (MD:116g, 95% CI:-40,272; p=0.142) and lower birthweights in women with A581G-bearing parasites (MD:192g, 95% CI:-264,648; p=0.385) (pinteraction=0.033). Similar associations were noted on gestational age (pinteraction=0.075). Amongst only IPTp-SP recipients, relative to women who last received SP >4 weeks before delivery, recent SP receipt was associated with lower birthweight in women with wildtype parasites (MD:118g, 95% CI:-376,139; p=0.361) and higher birthweight in women with A581G-bearing parasites (MD:783g, 95% CI:-20,1586; p=0.054) (pinteraction=0.005).\ud CONCLUSIONS\ud The effectiveness on birthweight of IPTp-SP is compromised by A581G-bearing parasites, but there was no evidence that the adverse effects of these parasites are exacerbated by antenatal SP.

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 Conclusion We developed and validated statistical models that performed well in predicting SMO using data from a low resource settings. Based on these, we proposed a simple score based obstetric EWS algorithm with RR, temperature, systolic BP, pulse rate, consciousness level, urinary output and mode of birth that has a potential for clinical use in low-resource settings..

Objective To determine the prevalence and determinants of folic acid (FA) supplementation in Chinese couples planning for pregnancy and in women during early pregnancy. \ud Methods This was a cross-sectional study based on the Shanghai PreConception Cohort (SPCC) study. Data on FA supplementation and socio-demographic features were collected using questionnaires. Couples visiting clinics for pre-pregnancy examination and pregnant women at < 14 gestational weeks were recruited in Shanghai, China, between March 2016 and September 2018.\ud Results Among the pregnancy planners, 42.4% (4710/11,099) women and 17.1% (1377/8045) men used FA supplements, while 93.4% (14,585/15,615) of the pregnant women used FA supplements. FA supplement use was higher in female pregnancy planners who were older (RR:1.13, 95%CI:1.08–1.18), had higher education (RR:1.71, 95%CI:1.53–1.92), and were residing in urban districts (RR:1.06, 95%CI:1.01–1.11) of FA supplementation; female pregnancy planners with alcohol consumption (RR:0.95, 95%CI:0.90–0.99) had lower odds of FA supplementation. In early pregnancy, women with higher educational level (RR:1.04, 95%CI:1.03–1.06), who underwent pre-pregnancy examination (RR:1.02, 95%CI:1.01–1.03) had higher odds of using an FA supplement; older aged (RR:0.99, 95% CI:0.98–0.99), and multigravida (RR:0.97, 95% CI:0.96–0.98) had lower odds of FA supplementation

Plasmodium falciparum in pregnancy is a major cause of adverse pregnancy outcomes. We combine performance estimates of standard rapid diagnostic tests (RDT) from trials of intermittent screening and treatment in pregnancy (ISTp) with modelling to assess whether \ud screening at antenatal visits improves upon current intermittent preventative therapy with sulphadoxine-pyrimethamine (IPTp-SP). We estimate that RDTs in primigravidae at first antenatal visit are substantially more sensitive than in non-pregnant adults (OR=17.2, 95% Cr.I. 13.8-21.6), and that sensitivity declines in subsequent visits and with gravidity, likely driven by declining susceptibility to placental infection. Monthly ISTp with standard RDTs, even with highly effective drugs, is not superior to monthly IPTp-SP. However, a hybrid strategy, recently adopted in Tanzania, combining testing and treatment at first visit with IPTp-SP may offer benefit, especially in areas with high-grade SP resistance. Screening and treatment in the first trimester, when IPTp-SP is contraindicated, could substantially improve pregnancy outcomes.

Objectives:To map the integration of existing maternal tetanus immunization programmes within ante-natal care (ANC) services for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with high performance maternal vaccine service delivery.Design:A mixed methods, cross sectional study with four data collection phases including a desk review,online survey, telephone and face-to-face interviews and in country visits was undertaken between 2016 and 2018. Associations of different service delivery process components with protection at birth (PAB) andwithcountrygroupswereestablished.PABwasdefinedastheproportionofneonatesprotectedatbirthagainstneonataltetanus. Regression analysis and structural equation modelling was used to assess associations of different variables with maternal tetanus immunization coverage. Latent class analysis (LCA), was used to group country performance for maternal immunization, and to address the problem of multicollinearity.Setting:LMICs.Results: The majority of LMICs had a policy on recommended number of ANC visits, however most were yet toimplementtheWHOguidelinesrecommendingeightANCcontacts.Countriesthatrecommended>4ANC contacts were more likely to have high PAB > 90%. Passive disease surveillance was the most common form of dis-ease surveillance performed but the maternal and neonatal morbidity and mortality indicators recorded differed between countries. The presence of user fees for antenatal care and maternal immunization was significantly associated with lower PAB (

Introduction Maternal health services are effective in reducing the morbidity and mortality associated with pregnancy and childbirth. We conducted a systematic review on costs of maternal health services in low-income and middle-income countries from the provider’s perspective.\ud \ud Methods We searched multiple peer-reviewed databases (including African Journal Online, CINAHL Plus, EconLit, Popline, PubMed, Scopus and Web of Science) and grey literature for relevant articles published from year 2000. Articles meeting our inclusion criteria were selected with quality assessment done using relevant cost-focused criteria of the Consolidated Health Economic Evaluation Reporting Standards checklist. For comparability, disaggregated costs data were inflated to 2019 US$ equivalents. Costs and cost drivers were systematically compared. Where heterogeneity was observed, narrative synthesis was used to summarise findings.\ud \ud Results Twenty-two studies were included, with most studies costing vaginal and/or caesarean delivery (11 studies), antenatal care (ANC) (9) and postabortion care (PAC) (8). Postnatal care (PNC) has been least costed (2). Studies used different methods for data collection and analysis. Quality of peer-reviewed studies was assessed average to high while all grey literature studies were assessed as low quality. Following inflation, estimated provision cost per service varied (ANC (US$7.24–US$31.42); vaginal delivery (US$14.32–US$278.22); caesarean delivery (US$72.11–US$378.940; PAC (US$97.09–US$1299.21); family planning (FP) (US$0.82–US$5.27); PNC (US$5.04)). These ranges could be explained by intercountry variations, variations in provider type (public/private), facility type (primary/secondary) and care complexity (simple/complicated). Personnel cost was mostly reported as the major driver for provision of ANC, skilled birth attendance and FP. Economies of scale in service provision were reported.\ud \ud Conclusion There is a cost savings case for task-shifting and encouraging women to use lower level facilities for uncomplicated services. Going forward, consensus regarding cost component definitions and methodologies for costing maternal health services will significantly help to improve the usefulness of cost analyses in supporting policymaking towards achieving Universal Health Coverage.

Background Anaemia and malaria are both major contributors to maternal and child mortality, and morbidity, with some of the worst outcomes occurring in sub-Saharan Africa. Point of care tests (POCT), if used appropriately, provide a simple, inexpensive form of diagnostic testing, as a reliable alternative when laboratory tests are not readily available. In such resource limited settings, clinical staff tend to rely on symptom-based diagnosis and presumptive treatment. This study uses qualitative methods to identify the current practice of POCT use for malaria and anaemia, to explore the enablers and barriers to effective implementation of these POCT, and to determine how relationships between each of the stakeholder groups may impact on POCT use. Methods Staff (clinical and laboratory) and patients (pregnant women) at three antenatal care facilities within the Ashanti Region of Ghana participated in interviews and focus group discussions (FGDs). An initial coding framework was developed based on the pre-defined objectives of the study. Thematic analysis was used to identify subthemes and categories within each of the key themes. Results At the time data were collected all three facilities used malaria POCT either as an adjunct to microscopy, or as their only form of malaria testing. Although all three facilities were familiar with haemoglobin colour scale (HCS), none of the facilities used them routinely. Clinical staff perceived symptom-based diagnosis was a quick way to diagnosis because access to POCT during consultations was unreliable, but recognized disadvantages associated with symptom-based diagnosis. Perceived advantages of malaria and anaemia POCT were user-friendliness, improved diagnosis and opportunity for patient engagement, as well as lower cost implication for patients. Perceived disadvantages included likelihood of missed diagnosis of mild anaemia, as well as likelihood of human error leading to in accurate diagnosis which could impact on patient trust. Poor communication and lack of trust between staff groups was also identified as a barrier to effective uptake of POCT. Conclusions Consistent supply of POCT as well as staff training and staff and patient engagement, are fundamental to successful uptake of POCT for effective malaria and anaemia management.

Background For every maternal death, 20 to 30 women are estimated to have morbidities related to pregnancy or childbirth. Much of this burden of disease is in women in low- and middle-income countries. Maternal multimorbidity can include physical, psychological and social ill-health. Limited data exist about the associations between these morbidities. In order to address all health needs that women may have when attending for maternity care, it is important to be able to identify all types of morbidities and understand how each morbidity influences other aspects of women’s health and wellbeing during pregnancy and after childbirth. Methods We systematically reviewed published literature in English, describing measurement of two or more types of maternal morbidity and/or associations between morbidities during pregnancy or after childbirth for women in low- and middle-income countries. CINAHL plus, Global Health, Medline and Web of Science databases were searched from 2007 to 2018. Outcomes were descriptions, occurrence of all maternal morbidities and associations between these morbidities. Narrative analysis was conducted. Results Included were 38 papers reporting about 36 studies (71,229 women; 60,911 during pregnancy and 10,318 after childbirth in 17 countries). Most studies (26/36) were cross-sectional surveys. Self-reported physical ill-health was documented in 26 studies, but no standardised data collection tools were used. In total, physical morbidities were included in 28 studies, psychological morbidities in 32 studies and social morbidities in 27 studies with three studies assessing associations between all three types of morbidity and 30 studies assessing associations between two types of morbidity. In four studies, clinical examination and/or basic laboratory investigations were also conducted. Associations between physical and psychological morbidities were reported in four studies and between psychological and social morbidities in six. Domestic violence increased risks of physical ill-health in two studies. Conclusions There is a lack of standardised, comprehensive and routine measurements and tools to assess the burden of maternal multimorbidity in women during pregnancy and after childbirth. Emerging data suggest significant associations between the different types of morbidity. Systematic review registration number PROSPERO CRD42018079526.

ObjectiveMaternal morbidity affects millions of women, the burden of which is highest in low resource settings. We sought to explore when this ill-health occurs and is most significant.SettingsA descriptive observational cross-sectional study at primary and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi.ParticipantsWomen attending for routine antenatal care, childbirth or postnatal care at the study healthcare facilities.Primary and secondary outcomesPhysical morbidity (infectious, medical, obstetrical), psychological and social comorbidity were assessed at five stages: first half of pregnancy (≤20 weeks), second half of pregnancy (>20 weeks), at birth (within 24 hours of childbirth), early postnatal (day 1–7) and late postnatal (week 2–12).Results11 454 women were assessed: India (2099), Malawi (2923), Kenya (3145) and Pakistan (3287) with similar numbers assessed at each of the five assessment stages in each country. Infectious morbidity and anaemia are highest in the early postnatal stage (26.1% and 53.6%, respectively). For HIV, malaria and syphilis combined, prevalence was highest in the first half of pregnancy (10.0%). Hypertension, pre-eclampsia and urinary incontinence are most common in the second half of pregnancy (4.6%, 2.1% and 6.6%). Psychological (depression, thoughts of self-harm) and social morbidity (domestic violence, substance misuse) are significant at each stage but most commonly reported in the second half of pregnancy (26.4%, 17.6%, 40.3% and 5.9% respectively). Of all women assessed, maternal morbidity was highest in the second half of pregnancy (81.7%), then the early postnatal stage (80.5%). Across the four countries, maternal morbidity was highest in the second half of pregnancy in Kenya (73.8%) and Malawi (73.8%), and in the early postnatal stage in Pakistan (92.2%) and India (87.5%).ConclusionsWomen have significant maternal morbidity across all stages of the continuum of pregnancy and childbirth, and especially in the second half of pregnancy and after childbirth.

Background\ud Effective antenatal care is fundamental to the promotion of positive maternal and new-born outcomes. International guidance recommends an initial visit in the first trimester of pregnancy, with a minimum of four antenatal visits in total: the optimum schedule being eight antenatal contacts. In low- and middle-income countries, many women do not access antenatal care until later in pregnancy and few have the recommended number of contacts.\ud \ud Aim\ud To gain understanding of women’s antenatal experiences in Tanzania and Zambia, and the factors that influence antenatal engagement.\ud \ud Methods\ud The study was underpinned by Strauss’s grounded theory methodology. Interviews were conducted with 48 women, 16 partners, 21 health care providers and 11 stakeholders, and analysed using constant comparison.\ud \ud Findings\ud The core category was ‘The tipping point of antenatal engagement’, supported by four categories: awareness of health benefits, experiential motivators, influential support, and environmental challenges. Although participants recognised the importance of antenatal care to health outcomes, individual motivations and external influences determined attendance or non-attendance. The ‘tipping point’ for antenatal engagement occurred when women believed that any negative impact could be offset by tangible gain. For some women non-attendance was a conscious decision, for others it was an unchallenged cultural norm.\ud \ud Conclusion\ud A complex interplay of factors determines antenatal engagement. Short-term modifiable factors to encourage attendance include the development of strategies for increasing respectful care; use of positive women’s narratives, and active community engagement. Further research is required to develop innovative, cost-effective care models that improve health literacy and meet women’s needs.

Purpose of Review This paper discusses the current issues in the development of foetal charts and is informed by a scoping review of studies constructing charts between 2012 and 2018. Recent Findings The scoping review of 20 articles revealed that there is still a lack of consensus on how foetal charts should be constructed and whether an international chart that can be applied across populations is feasible. Many of these charts are in clinical use today and directly affect the identification of at risk newborns that require treatment and nutritional strategies. However, there is no agreement on important design features such as inclusion and exclusion criteria; sample size and agreement on definitions such as what constitutes a healthy population of pregnant women that can be used for constructing foetal standards. Summary This paper therefore reiterates some of these current issues and the scoping review showcases the heterogeneity in the studies developing foetal charts between 2012 and 2018. There is no consensus on these pertinent issues and hence if not resolved will lead to continued surge of foetal reference and standard charts which will only exacerbate the current problem of not being able to make direct comparisons of foetal size and growth across populations.

Background\ud This study explores stakeholders’ perceptions of emergency obstetric care (EmOC) ‘skills-and-drills’-type training including the outcomes, strengths, weaknesses, opportunities and threats of the intervention in Kenya.\ud Methods\ud Stakeholders who either benefited from or contributed to EmOC training were purposively sampled. Semi-structured topic guides were used for key informant interviews and focus group discussions. Following verbatim transcriptions of recordings, the thematic approach was used for data analysis.\ud Results\ud Sixty-nine trained healthcare providers (HCPs), 114 women who received EmOC and their relatives, 30 master trainers and training organizers, and six EmOC facility/Ministry of Health staff were recruited. Following training, deemed valuable for its ‘hands-on’ approach and content by HCPs, women reported that they experienced improvements in the quality of care provided. HCPs reported that training led to improved knowledge, skills and attitudes, with improved care outcomes. However, they also reported an increased workload. Implementing stakeholders stressed the need to explore strategies that help to maximize and sustain training outcomes.\ud Conclusions\ud The value of EmOC training in improving the capacity of HCPs and outcomes for mothers and newborns is not just ascribed but felt by beneficiaries. However, unintended outcomes such as increased workload may occur and need to be systematically addressed to maximize training gains.

Background Despite WHO advocating for an integrated approach to antenatal care (ANC), testing coverage for conditions other than HIV remains low and women are referred to distant laboratories for testing. Using point-of-care tests (POCTs) at peripheral dispensaries could improve access to testing and timely treatment. However, the effect of providing additional services on nurse workload and client wait times are unknown. We use discrete-event simulation (DES) modelling to understand the effect of providing four point-of-care tests for ANC on nurse utilization and wait times for women seeking maternal and child health (MCH) services. Methods We collected detailed time-motion data over 20 days from one high volume dispensary in western Kenya during the 8-month implementation period (2014–2015) of the intervention. We constructed a simulation model using empirical arrival distributions, activity durations and client pathways of women seeking MCH services. We removed the intervention from the model to obtain wait times, length-of-stay and nurse utilization rates for the baseline scenario where only HIV testing was offered for ANC. Additionally, we modelled a scenario where nurse consultations were set to have minimum durations for sufficient delivery of all WHO-recommended services. Results A total of 183 women visited the dispensary for MCH services and 14 of these women received point-of-care testing (POCT). The mean difference in total waiting time was 2 min (95%CI: p = 0.026) for MCH women when integrated POCT was given, and 9 min (95%CI: 4–14 min, p p = 0.015) with integrated POCT and by 16 min (95%CI: 10–21 min, p Conclusion The intervention had a modest overall impact on wait times and length-of-stay for women seeking MCH services while ensuring pregnant women received essential diagnostic testing. Nurse utilization rates fluctuated among days: nurses experienced spikes in workload on some days but were under-utilized on the majority of days. Overall, our model suggests there was sufficient time to deliver all WHO’s required ANC activities and offer integrated testing for ANC first and re-visits with the current number of healthcare staff. Further investigations on improving healthcare worker, availability, performance and quality of care are needed. Delivering four point-of-care tests together for ANC at dispensary level would be a low burden strategy to improve ANC.

IntroductionA variety of community health workers (CHWs) provide maternal and newborn health (MNH) services in low-income and middle-income settings. However, there is a need for a better understanding of the diversity in type of CHW in each setting and responsibility, role, training duration and type of remuneration.MethodsWe identified CHWs providing MNH services in Bangladesh, India, Kenya, Malawi and Nigeria by reviewing 23 policy documents and conducting 36 focus group discussions and 131 key informant interviews. We analysed the data using thematic analysis.ResultsIrrespective of training duration (8 days to 3 years), all CHWs identify pregnant women, provide health education and screen for health conditions that require a referral to a higher level of care. Therapeutic care, antenatal care and skilled birth attendance, and provision of long-acting reversible contraceptives are within the exclusive remit of CHWs with training greater than 3 months. In contrast, community mobilisation and patient tracking are often done by CHWs with training shorter than 3 months. Challenges CHWs face include pressure to provide MNH services beyond their scope of practice during emergencies, and a tendency in some settings to focus CHWs on facility-based roles at the expense of their traditional community-based roles.ConclusionCHWs are well positioned geographically and socially to deliver some aspects of MNH care. However, there is a need to review and revise their scope of practice to reflect the varied duration of training and in-country legislation.

Background Health service and health outcome data collection across many low- and middle-income countries (LMICs) is, to date largely paper-based. With the development and increased availability of reliable technology, electronic tablets could be used for electronic data collection in such settings. This paper describes our experiences with implementing electronic data collection methods, using electronic tablets, across different settings in four LMICs. Methods Within our research centre, the use of electronic data collection using electronic tablets was piloted during a healthcare facility assessment study in Ghana. After further development, we then used electronic data collection in a multi-country, cross-sectional study to measure ill-health in women during and after pregnancy, in India, Kenya and Pakistan. All data was transferred electronically to a central research team in the UK where it was processed, cleaned, analysed and stored. Results The healthcare facility assessment study in Ghana demonstrated the feasibility and acceptability to healthcare providers of using electronic tablets to collect data from seven healthcare facilities. In the maternal morbidity study, electronic data collection proved to be an effective way for healthcare providers to document over 400 maternal health variables, in 8530 women during and after pregnancy in India, Kenya and Pakistan. Conclusions Electronic data collection provides an effective platform which can be used successfully to collect data from healthcare facility registers and from patients during health consultations; and to transfer large quantities of data. To ensure successful electronic data collection and transfer between settings, we recommend that close attention is paid to study design, data collection, tool design, local internet access and device security. Electronic supplementary material The online version of this article (10.1186/s12913-019-4161-7) contains supplementary material, which is available to authorized users.

Annually, an estimated 2.6 million stillbirths occur worldwide.1 With five deaths every single minute, stillbirth is the fifth leading global cause of death when compared with causes of death in all age categories—outranking diarrhoea, HIV/AIDS, TB, road traffic accidents and any form of cancer.2 The vast majority (98%) of stillbirths occur in low- and middle-income countries (LMICs). This has also been referred to as the ‘silent epidemic’.

Background: Experiences and perceptions of poor quality of care is a powerful determinant of utilisation of maternity services. With many reports of disrespect and abuse in healthcare facilities in low-resource settings, women’s and healthcare providers’ understanding and perception of disrespect and abuse are important in eliminating disrespect and abuse, but these are rarely explored together.\ud Methods: This was a qualitative study assessing the continuum of maternity care (antenatal, intrapartum and postnatal care) at the Maternity Unit of Bwaila Hospital in Lilongwe, Malawi. Focus group discussions (FGDs) were conducted separately for mothers attending antenatal clinic and those attending postnatal clinic. For women who accessed intrapartum care services, in-depth interviews were used.\ud Participants were recruited purposively. Key informant interviews were conducted with healthcare providers involved in the delivery of maternal and newborn health services. Topic guides were developed based on the seven domains of the Respectful Maternity Care (RMC) Charter. Data was transcribed verbatim, coded and analysed using the thematic framework approach.\ud Results: A total of 8 focus group discussions and 9 in-depth interviews involving 64 women and 9 key informant interviews with health care providers were conducted. Important themes that emerged included: the importance of a valued patient-provider relationship as determined by a good attitude and method of communication, the need for more education of women regarding the stages of pregnancy and labour, what happens at each stage and which complications could occur, the importance of a woman’s involvement in decision-making, the need to maintain confidentiality when required and the problem of insufficient human resources. Prompt and timely service was considered a priority. Neither women accessing maternity care nor trained healthcare providers providing this care were aware of the RMC Charter.\ud Conclusions: This study has highlighted the most essential aspects of respectful maternity care from the viewpoint of both women accessing maternity care and healthcare providers. Although RMC components are in place, healthcare providers were not aware of them. There is the need to promote the RMC Charter among both women who seek care and healthcare providers.

Introduction\ud Antenatal care (ANC) is a vital mechanism for women to obtain close attention during pregnancy and prevent death-related issues. Moreover, it improves the involvement of women in the continuum of health care and to survive high-risk pregnancies. This study was conducted to determine the prevalence of and identify the associated factors of eight or more ANC contacts in Nigeria.\ud \ud Methods\ud We used a nationally representative cross-sectional data from Nigeria Demographic and Health Survey—2018. A total sample of 7,936 women were included in this study. Prevalence was measured in percentages and the factors for eight or more ANC contacts were examined using multilevel multivariable binary logistic regression model. The level of significance was set at P

ObjectiveTo assess the effects of perinatal death (PND) audit on perinatal outcomes in a tertiary hospital in Kampala.DesignInterrupted time series (ITS) analysis.SettingNsambya Hospital, Uganda.ParticipantsLive births and stillbirths.InterventionsPND audit.Primary and secondary outcome measuresPrimary outcomes: perinatal mortality rate, stillbirth rate, early neonatal mortality rate. Secondary outcomes: case fatality rates (CFR) for asphyxia, complications of prematurity and neonatal sepsis.Results526 PNDs were audited: 142 (27.0%) fresh stillbirths, 125 (23.8%) macerated stillbirths and 259 (49.2%) early neonatal deaths. The ITS analysis showed a decrease in perinatal death (PND) rates without the introduction of PND audits (incidence risk ratio (IRR) (95% CI) for time=0.94, pConclusionThe introduction of PND audit showed no statistically significant effect on perinatal mortality or stillbirth rate, but a significant decrease in early neonatal mortality rate. No effect was detected on CFRs for prematurity, intrapartum-related hypoxia or infections. These findings should encourage more research to assess the effectiveness of PND reviews on perinatal deaths in general, but also on stillbirths and neonatal deaths in particular, in low-resource settings.

Introduction \ud Emergency obstetric care (EmOC) training is considered a key strategy for reducing maternal and perinatal morbidity and mortality. Although generally considered effective, there is minimal evidence on the broader social impact and/or value-for-money (VfM). This study assessed the social impact and VfM of EmOC training in Kenya using social return on investment (SROI) methodology.\ud \ud Methods \ud Mixed-methods approach was used, including interviews (n=21), focus group discussions (n=18) incorporating a value game, secondary data analysis and literature review, to obtain all relevant data for the SROI analysis. Findings were incorporated into the impact map and used to estimate the SROI ratio. Sensitivity analyses were done to test assumptions.\ud \ud Results \ud Trained healthcare providers, women and their babies who received care from those providers were identified as primary beneficiaries. EmOC training led to improved knowledge and skills and improved attitudes towards patients. However, increased workload was reported as a negative outcome by some healthcare providers. Women who received care expected and experienced positive outcomes including reduced maternal and newborn morbidity and mortality. After accounting for external influences, the total social impact for 93 5-day EmOC training workshops over a 1-year period was valued at I$9.5 million, with women benefitting the most from the intervention (73%). Total direct implementation cost was I$745 000 for 2965 healthcare providers trained. The cost per trained healthcare provider per day was I$50.23 and SROI ratio was 12.74:1. Based on multiple one-way sensitivity analyses, EmOC training guaranteed VfM in all scenarios except when trainers were paid consultancy fees and the least amount of training outcomes occurred.\ud \ud Conclusion \ud EmOC training workshops are a worthwhile investment. The implementation approach influences how much VfM is achieved. The use of volunteer facilitators, particularly those based locally, to deliver EmOC training is a critical driver in increasing social impact and achieving VfM for investments made.

Objective\ud To identify the causes and categories of stillbirth using the Application of ICD-10 to Deaths during the Perinatal Period (ICD-PM).\ud Methods\ud Prospective, 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.\ud Findings\ud 1267 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, \ud 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\ud 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\ud could be identified was 32.6% for antepartum deaths, 8.1% for intrapartum deaths and 17.4% for cases with unknown time of death.\ud Conclusion\ud Clinical 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\ud to help accommodate stillbirths with unknown time of death.

Importance \ud The association of micronutrient supplementation during pregnancy with the intellectual development of adolescent offspring is unknown.\ud Objective \ud To assess the long-term association of antenatal micronutrient supplementation with adolescent intellectual development.\ud Design, Setting, and Participants \ud This 14-year follow-up study of a randomized clinical trial of micronutrient supplementation in pregnancy was conducted in 2 counties in rural western China in 2118 adolescent offspring (aged 10 to 14 years) of mothers who were randomized to take a daily capsule of either folic acid, folic acid plus iron, or multiple micronutrients from August 1, 2002, through February 28, 2006. Follow-up was conducted from June 1, 2016, through December 31, 2016. Data analyses took place from April 1, 2017, to June 20, 2017.\ud Main Outcomes and Measures \ud Adolescent full-scale intelligence quotient and aspects of verbal comprehension, working memory, perceptual reasoning, and processing speed indexes were assessed by the Wechsler Intelligence Scale for Children.\ud Results \ud Of 2118 adolescent offspring, 1252 (59.1%) were boys and 866 (40.9%) were girls, with a mean (SD) age of 11.7 (0.87) years, representing 47.2% of the 4488 single live births that were eligible to participate. Compared with folic acid supplementation, multiple micronutrient supplementation was associated with a 1.13-point higher full-scale intelligence quotient (95% CI, 0.15-2.10) and a 2.03-point higher verbal comprehension index (95% CI, 0.61-3.45); similar results were found in comparison with folic acid plus iron. When mothers initiated supplementation early (

OBJECTIVE\ud To explore experiences of care during labour and birth from the perspectives of both the healthcare provider and women receiving care, to inform recommendations for how the quality of care can be improved and monitored, and, to identify the main aspects of care that are important to women.\ud \ud DESIGN\ud \ud A descriptive phenomenological approach. 53 interviews and 10KII as per table 1 took place including in-depth interviews (IDI), focus group discussions (FGD) and key informant interviews (KII) conducted with women, healthcare providers, managers and policy makers. Following verbatim transcription thematic framework analysis was used to describe the lived experience of those interviewed.\ud \ud SETTING\ud \ud 11 public healthcare facilities providing maternity care in urban Tshwane District, Gauteng Province (n = 4) and rural Waterberg District, Limpopo Province (n = 7), South Africa.\ud \ud PARTICIPANTS\ud \ud Women who had given birth in the preceding 12 weeks (49 women, 7 FGD and 23 IDI); healthcare providers working in the labour wards (33 healthcare providers; nurses, midwives, medical staff, 5 FGD, 18 IDI; managers and policy makers (10 KII).\ud \ud FINDINGS\ud \ud Both women and healthcare providers largely feel alone and unsupported. There is mutual distrust between women and healthcare providers exacerbated by word of mouth and the media. A lack of belief in women's ability to make appropriate choices negates principles of choice and consent. Procedure- rather than patient-centred care is prioritised by healthcare providers. Although healthcare providers know the principles of good quality care, this was not reflected in the care women described as having received. Beliefs and attitudes as well as structural and organisational problems make it difficult to provide good quality care. Caring behaviour and environment as well as companionship are the most important needs highlighted by women. Professional hierarchy is rarely seen as supportive by healthcare providers but when present, good leadership changes the culture and experience of women and care providers. The use of mobile phones to provide feedback regarding care was positively viewed by women.\ud \ud CONCLUSION\ud \ud Clarity regarding what a healthcare facility can (or cannot provide) is important in order to separate practice issues from structural and organisational constraints. Improvements in quality that focus on caring as well as competence should be prioritised. Increased dialogue between healthcare providers and users should be encouraged and prioritised.\ud \ud IMPLICATIONS FOR PRACTICE\ud \ud A renewed focus is needed to ensure companionship during labour and birth is facilitated. Training in respectful maternity care needs to prioritise caring behaviour and supportive leadership.

Background\ud An estimated 2.6 million stillbirths occur every year, with the majority occurring in low- and middle-income countries. Understanding the cause of and factors associated with stillbirth is important to help inform the design and implementation of interventions aimed at reducing preventable stillbirths.\ud \ud Methods\ud Population-based surveillance with identification of all stillbirths that occurred either at home or in a health facility was introduced in four districts in Bangladesh. Verbal autopsy was conducted for every fifth stillbirth using a structured questionnaire. A hierarchical model was used to assign likely cause of stillbirth.\ud \ud Results\ud Six thousand three hundred thirty-three stillbirths were identified for which 1327 verbal autopsies were conducted. 63.9% were intrapartum stillbirths. The population-based stillbirth rate obtained was 20.4 per 1000 births; 53.9% of all stillbirths occurred at home. 69.6% of mothers had accessed health care in the period leading up to the stillbirth. 48.1% had received care from a highly trained healthcare provider. The three most frequent causes of stillbirth were maternal hypertension or eclampsia (15.2%), antepartum haemorrhage (13.7%) and maternal infections (8.9%). Up to 11.3% of intrapartum stillbirths were caused by hypoxia. However, it was not possible to identify a cause of death with reasonable certainty using information obtained via verbal autopsy in 51.9% of stillbirths.\ud \ud Conclusions\ud Introducing surveillance for stillbirths at community level is possible. However, verbal autopsy yields limited data, and the questionnaire used for this needs to be revised and/or combined with information obtained through case note review.\ud Most women accessed and received care from a qualified healthcare provider. To reduce the number of preventable stillbirths, the quality of antenatal and intrapartum care needs to be improved.

Background\ud Many Kenyan adolescents die following pregnancy and childbirth complications. Maternal health services (MHS) utilisation is key to averting such poor outcomes. Our objectives were to understand the characteristics of adolescent mothers in Kenya, describe their MHS utilisation pattern and explore factors that influence this pattern.\ud \ud Methods\ud We collected demographic and MHS utilisation data of all 301 adolescent mothers aged 15–19 years included in the Kenya Demographic Health Survey 2008/2009. Descriptive statistics were used to characterise them and their MHS utilisation patterns. Bivariate and multivariate analyses were used to test associations between selected predictor variables and MHS utilisation.\ud \ud Findings\ud 86%, 48% and 86% of adolescent mothers used ante-natal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) respectively. Adolescent mothers from the richest quintile were nine (CI=2.00-81.24,p=0.001) and seven (CI=3.22-16.22,p

OBJECTIVE\ud to explore nurse-midwives understanding of their role in and ability to continue to provide routine and emergency maternity services during the time of the Ebola virus disease epidemic in Sierra Leone.\ud \ud DESIGN\ud a hermenuetic phenomenological approach was used to discover the lived experiences of nurse-midwives through 66 face to face interviews. Following verbatim transcription, an iterative approach to data analysis was adopted using framework analysis to discover the essence of the lived experience.\ud \ud SETTING\ud health facilities designated to provide maternity care across all 14 districts of Sierra Leone.\ud \ud PARTICIPANTS\ud nurses, midwives, medical staff and managers providing maternal and newborn care during the Ebola epidemic in facilities designated to provide basic or emergency obstetric care.\ud \ud FINDINGS\ud the healthcare system in Sierra Leone was ill prepared to cope with the epidemic. Fear of Ebola and mistrust kept women from accessing care at a health facility. Healthcare providers continued to provide maternity care because of professional duty, responsibility to the community and religious beliefs.\ud \ud KEY CONCLUSIONS\ud nurse-midwives faced increased risks of catching Ebola compared to other health workers but continued to provide essential maternity care.\ud \ud IMPLICATIONS FOR PRACTICE\ud future preparedness plans must take into account the impact that epidemics have on the ability of the health system to continue to provide vital routine and emergency maternal and newborn health care. Healthcare providers need to have a stronger voice in health system rebuilding and planning and management to ensure that health service can continue to provide vital maternal and newborn care during epidemics.

Responding to increasing demands to demonstrate value-for-money (VfM) for maternal and newborn health interventions, and in the absence of VfM analysis in peer-reviewed literature, this paper reviews VfM components and methods, critiques their applicability, strengths and weakness and proposes how VfM assessments can be improved. VfM comprises four components: economy, efficiency, effectiveness and cost-effectiveness. Both 'economy' and 'efficiency' can be assessed with detailed cost analysis utilising costs obtained from programme accounting data or generic cost databases. Before-and-after studies, case-control studies or randomised controlled trials can be used to assess 'effectiveness'. To assess 'cost-effectiveness', cost-effectiveness analysis (CEA), cost-utility analysis (CUA), cost-benefit analysis (CBA) or social return on investment (SROI) analysis are applicable. Generally, costs can be obtained from programme accounting data or existing generic cost databases. As such 'economy' and 'efficiency' are relatively easy to assess. However, 'effectiveness' and 'cost-effectiveness' which require establishment of the counterfactual are more difficult to ascertain. Either a combination of CEA or CUA with tools for assessing other VfM components, or the independent use of CBA or SROI are alternative approaches proposed to strengthen VfM assessments. Cross-cutting themes such as equity, sustainability, scalability and cultural acceptability should also be assessed, as they provide critical contextual information for interpreting VfM assessments. To select an assessment approach, consideration should be given to the purpose, data availability, stakeholders requiring the findings and perspectives of programme beneficiaries. Implementers and researchers should work together to improve the quality of assessments. Standardisation around definitions, methodology and effectiveness measures to be assessed would help.

INTRODUCTION: In the era of ambitious HIV targets, novel HIV testing models are required for hard-to-reach groups such as men, who remain underserved by existing services. Pregnancy presents a unique opportunity for partners to test for HIV, as many pregnant women will attend antenatal care (ANC). We describe the views of pregnant women and their male partners on HIV self-test kits that are woman-delivered, alone or with an additional intervention. METHODS: A formative qualitative study to inform the design of a multi-arm multi-stage cluster-randomized trial, comprised of six focus group discussions and 20 in-depth interviews, was conducted. ANC attendees were purposively sampled on the day of initial clinic visit, while men were recruited after obtaining their contact information from their female partners. Data were analysed using content analysis, and our interpretation is hypothetical as participants were not offered self-test kits. RESULTS: Providing HIV self-test kits to pregnant women to deliver to their male partners was highly acceptable to both women and men. Men preferred this approach compared with standard facility-based testing, as self-testing fits into their lifestyles which were characterized by extreme day-to-day economic pressures, including the need to raise money for food for their household daily. Men and women emphasized the need for careful communication before and after collection of the self-test kits in order to minimize the potential for intimate partner violence although physical violence was perceived as less likely to occur. Most men stated a preference to first self-test alone, followed by testing as a couple. Regarding interventions for optimizing linkage following self-testing, both men and women felt that a fixed financial incentive of approximately USD$2 would increase linkage. However, there were concerns that financial incentives of greater value may lead to multiple pregnancies and lack of child spacing. In this low-income setting, a lottery incentive was considered overly disappointing for those who receive nothing. Phone call reminders were preferred to short messaging service. CONCLUSIONS: Woman-delivered HIV self-testing through ANC was acceptable to pregnant women and their male partners. Feedback on additional linkage enablers will be used to alter pre-planned trial arms.

Kenya has one of the highest adolescent fertility rates in East-Africa, estimated at 106 births per 1000 females aged 15-19years. In addition to promoting safe sexual behaviour, utilisation of maternal health services (MHS) is essential to prevent poor outcomes of pregnancy and childbirth. To ensure optimum planning, particularly in the context of the Sustainable Development Goals, this study assesses the current service utilisation patterns of Kenyan adolescent mothers and the factors that affect this utilisation. Using data from the recently published 2014 Kenya Demographic Health Survey, we collected demographic and utilisation data of all three MHSs (antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC)) of adolescent mothers aged 15-19years. We then conducted bivariate and multivariate analyses to test associations between selected demographic and service utilisation variables. Our findings showed that half of Kenyan adolescent mothers have had their first birth by the age of 16. MHS utilisation rates amongst Kenyan adolescent mothers were 93%, 65%, 92% for ANC, SBA and PNC respectively. Mother's education, religion, ethnicity, place of residence, wealth quintile, mass media exposure, and geographical region were significant predictors for both ANC and SBA utilisation. Education level of partner was significant for ANC utilisation while parity was significant for both SBA and PNC. Adolescent MHS utilisation is not optimum in Kenya. More work that includes affordable care provision, cultural re-orientation, targeted mass-media campaigns and male involvement in care need to be done with emphasis on the most disadvantaged areas.

To assess the feasibility of applying the World Health Organization's proposed 15 indicators of quality of care for maternal and newborn health at health-facility level in low- and middle-income settings.Six of the indicators are about maternal health, five are for newborn health and four are general cross-cutting indicators. We used data collected routinely in facility registers and obtained as part of facility assessments from 963 health-care facilities specializing in maternity services in 10 countries in Africa and Asia. We made a feasibility assessment of the availability of data and the clarity of indicator definitions and identified additional information and data collection processes needed to apply the proposed indicators in real-life settings.Of the indicators evaluated, 10 were clearly defined, of which four could be applied directly in the field and six would require revisions to operationalize them. The other five indicators require further development, with one of them being ready for implementation by using information readily available in registers and four requiring further information before deployment. For indicators that measure coverage of care or availability of services or products, there is a need to further strengthen measurement. Information on emergency obstetric complications was not recorded in a standard manner, thus limiting the reliability of the information.While some of the proposed indicators can already be applied, other indicators need to be refined or will need additional sources and methods of data collection to be applied in real-world settings.Évaluer s'il est faisable d'appliquer les 15 indicateurs proposés par l'Organisation mondiale de la Santé relatifs à la qualité des soins de santé maternelle et néonatale dans des centres de santé de régions à revenu faible et intermédiaire.Six indicateurs portent sur la santé maternelle, cinq sur la santé néonatale et quatre sur des facteurs transversaux d'ordre général. Nous avons utilisé les données consignées habituellement dans les registres des centres de santé et obtenues dans le cadre d'évaluations de ces centres; des données couvrant au total 963 centres de santé, spécialisés dans les services de maternité, dans 10 pays d'Afrique et d'Asie. Nous avons réalisé une étude de faisabilité portant sur la disponibilité des données et la clarté des définitions des indicateurs, et nous avons identifié les processus de collecte des données et informations complémentaires nécessaires pour pouvoir appliquer ces indicateurs en conditions réelles.Parmi tous les indicateurs évalués, 10 sont clairement définis, parmi lesquels quatre pourraient être directement appliqués sur le terrain, tandis que les six autres nécessiteraient des ajustements avant de pouvoir être mis en œuvre. Les cinq indicateurs restants nécessitent d'autres développements; même si l'un d'eux pourrait être exploité en utilisant les informations consignées dans les registres déjà disponibles, pour les quatre autres indicateurs, des informations complémentaires sont nécessaires. Pour les indicateurs relatifs à la couverture des soins ou à la disponibilité des services ou des produits, des évaluations plus détaillées seraient nécessaires. Les informations sur les complications obstétricales d'urgence n'ont pas été enregistrées de façon standardisée, ce qui limite la fiabilité de ces informations.Alors que certains des indicateurs proposés sont d'ores et déjà applicables, d'autres indicateurs doivent être affinés ou nécessitent des sources d’information supplémentaires et des méthodes complémentaires de collecte de données avant de pouvoir être appliqués en conditions réelles.Evaluar la viabilidad de aplicar los 15 indicadores de calidad de atención sanitaria materna y obstétrica propuestos por la Organización Mundial de la Salud en centros sanitarios de entornos con ingresos bajos y medios.Seis de los indicadores tratan sobre salud materna, cinco sobre salud obstétrica y cuatro son indicadores transversales generales. Se utilizaron datos recopilados de forma rutinaria en los registros de los centros y se obtuvieron como parte de las evaluaciones de las instalaciones de 963 centros sanitarios especializados en servicios de maternidad de 10 países de África y Asia. Se realizó una evaluación de viabilidad sobre la disponibilidad de datos y la claridad de las definiciones de los indicadores, y se identificó información adicional y los procesos de recopilación de datos necesarios para implementar los indicadores propuestos en centros reales.De los indicadores evaluados, 10 se definieron con claridad, de los cuales cuatro podían aplicarse directamente en el campo y seis necesitarían revisiones para hacerlos operativos. Los otros cinco indicadores requieren un mayor desarrollo: uno de ellos está listo para ser implementado utilizando información inmediatamente disponible en los registros y cuatro necesitan más información antes de su puesta en práctica. Para los indicadores que miden la cobertura de la atención o la disponibilidad de productos o servicios, se necesita fortalecer más la medición. No se ha registrado información sobre complicaciones obstétricas de emergencia de forma estándar, por lo que la fiabilidad de la información es limitada.Mientras que algunos de los indicadores propuestos ya pueden aplicarse, otros necesitan perfeccionarse o requerirán fuentes y métodos de recopilación de datos adicionales para poderse aplicar en entornos reales.تقييم جدوى تطبيق 15 مؤشرًا مقترحًا لمنظمة الصحة العالمية لقياس جودة الرعاية الصحية للأمهات وحديثي الولادة على مستوى المرافق الصحية والمواقع ذات الدخل المنخفض والمتوسط.تتعلق ستة مؤشرات بصحة الأمومة، فيما تتعلق خمسة مؤشرات بصحة الأطفال حديثي الولادة، فضلاً عن أربعة مؤشرات عامة وشاملة. وقد استخدمنا البيانات المجمعة بصورة روتينية في سجلات المرافق الصحية والتي تم الحصول عليها كجزء من تقييمات المرافق المأخوذة من 963 مرفقًا للرعاية الصحية متخصصة في خدمات الأمومة في 10 دول في أفريقيا وآسيا. وقمنا بإجراء تقييم جدوى لمدى إتاحة البيانات ووضوح تعريفات المؤشر، وقمنا بتحديد عمليات إضافية لجمع البيانات والمعلومات سيتكون لازمة لتطبيق المؤشرات المقترحة على أرض الواقع.من بين المؤشرات التي خضعت للتقييم، كان منها 10 مؤشرات تحمل تعريفات دقيقة، وكان من الممكن تطبيق أربعة مؤشرات منها مباشرةً على أرض الواقع، فيما تحتاج ستة منها إلى المراجعة قبل نقلها إلى مرحلة التنفيذ العملي. وتتطلب المؤشرات الخمسة الأخرى المزيد من التطوير، مع وجود أحد المؤشرات في حالة جاهزة للتطبيق باستخدام المعلومات المتوفرة بسهولة في السجلات، وأربعة مؤشرات بحاجة إلى المزيد من المعلومات قبل التنفيذ. بالنسبة للمؤشرات التي تقيس تغطية الرعاية أو مدى توافر الخدمات أو المنتجات، هناك حاجة إلى تعزيز القياس بشكل أكبر. لم يتم تسجيل المعلومات المتعلقة بمضاعفات الولادة في الحالات الطارئة بشكلٍ قياسي، مما حد من مدى اعتمادية المعلومات.بالرغم من إمكانية تطبيق بعض المؤشرات المقترحة بالفعل، فإن المؤشرات الأخرى بحاجة إلى إدخال التحسينات عليها أو قد تحتاج إلى مصادر وطرق إضافية لجمع البيانات ليتسنى تطبيقها في الواقع.旨在评估在中低收入国家卫生机构实施世界卫生组织提出的 15 个孕产妇和新生儿健康质量指标的可行性。.其中六个指标与孕产妇健康相关，五个与新生儿健康相关，四个是一般性综合指标。 我们使用定期从医疗机构登记处收集的数据，以及从 10 个亚非国家 963 个专门提供孕产服务的医疗机构中获取的数据作为机构评估的一部分。 我们对数据的可用性以及指标定义的清晰度进行了可行性评估，同时明确了将所提议指标应用于现实环境所需的其他信息和数据收集流程。.在评估的指标中，10 个定义明确，其中，4 个可直接应用到实际中，6 个需要修订以便于实施。 其他五个指标需要进一步制定，其中一个可通过使用登记处的现有信息投入实施，另外四个在部署之前，需要增添一些补充信息。 对于测量护理覆盖率或者服务或产品可用性的指标，有必要进一步加强测量。 有关紧急产科并发症的信息未采用标准形式记录，因此影响了信息的可靠性。.虽然提出的有些指标已能够实施，但是其他指标仍需要改进或者需要额外的数据收集资源和方法，以便应用于现实环境中。.Дать оценку практической возможности применения 15 предложенных Всемирной организацией здравоохранения показателей качества ухода за матерью и новорожденным ребенком в медицинских учреждениях в условиях с низким и средним уровнем доходов.Шесть показателей из них относятся к охране здоровья матери, пять — к охране здоровья новорожденного ребенка, и четыре являются показателями общего характера. Авторы статьи использовали данные, собранные в рабочем порядке в реестрах медицинских учреждений и полученные в ходе оценок работы медицинских учреждений, из 963 медико-санитарных учреждений, специализирующихся на оказании услуг по уходу за матерями, в 10 странах Африки и Азии. Была дана оценка практической возможности получения данных и точности формулировок определений показателей. Были определены дополнительные процессы сбора информации и данных, необходимые для применения предложенных показателей на практике.Из всех показателей, подвергнутых оценке, определения десяти были сформулированы точно, и четыре из них могли быть применены непосредственно на практике, а шесть показателей необходимо скорректировать, прежде чем их можно будет практически реализовать. Остальные пять показателей требуют доработки, причем один из них может быть применен с использованием имеющейся в реестрах информации, а для остальных четырех необходима дополнительная информация, прежде чем их можно будет реализовать. Для показателей, используемых для измерения охвата медицинской помощью или доступности услуг или продуктов, требуется дополнительно усовершенствовать процесс измерения. Информация о неотложной акушерской помощи при осложнениях не была зафиксирована в установленном порядке, и это сказалось на ее надежности.Хотя некоторые из предложенных показателей уже могут быть применены, для других показателей требуется доработка или дополнительные источники данных и методы их сбора, чтобы показатели можно было применить на практике.

Background\ud \ud Adolescent mothers aged 15–19 years are known to have greater risks of maternal morbidity and mortality compared with women aged 20–24 years, mostly due to their unique biological, sociological and economic status. Nowhere Is the burden of disease greater than in low-and middle-income countries (LMICs). Understanding factors that influence adolescent utilisation of essential maternal health services (MHS) would be critical in improving their outcomes.\ud \ud Methods\ud \ud We systematically reviewed the literature for articles published until December 2015 to understand how adolescent MHS utilisation has been assessed in LMICs and factors affecting service utilisation by adolescent mothers. Following data extraction, we reported on the geographical distribution and characteristics of the included studies and used thematic summaries to summarise our key findings across three key themes: factors affecting MHS utilisation considered by researcher(s), factors assessed as statistically significant, and other findings on MHS utilisation.\ud \ud Results\ud \ud Our findings show that there has been minimal research in this study area. 14 studies, adjudged as medium to high quality met our inclusion criteria. Studies have been published in many LMICs, with the first published in 2006. Thirteen studies used secondary data for assessment, data which was more than 5 years old at time of analysis. Ten studies included only married adolescent mothers.\ud \ud While factors such as wealth quintile, media exposure and rural/urban residence were commonly adjudged as significant, education of the adolescent mother and her partner were the commonest significant factors that influenced MHS utilisation. Use of antenatal care also predicted use of skilled birth attendance and use of both predicted use of postnatal care. However, there may be some context-specific factors that need to be considered.\ud \ud Conclusions\ud \ud Our findings strengthen the need to lay emphasis on improving girl child education and removing financial barriers to their access to MHS. Opportunities that have adolescents engaging with health providers also need to be seized. These will be critical in improving adolescent MHS utilisation. However, policy and programmatic choices need to be based on recent, relevant and robust datasets. Innovative approaches that leverage new media to generate context-specific dis-aggregated data may provide a way forward.

Background Despite high rates of antenatal care and relatively good access to health facilities, maternal and neonatal mortality remain high in Bangladesh. There is an immediate need for implementation of evidence-based, cost-effective interventions to improve maternal and neonatal health outcomes. The aim of the study is to assess the effect of the intervention namely Group Prenatal Care (GPC) on utilization of standard number of antenatal care, post natal care including skilled birth attendance and institutional deliveries instead of usual care. Methods The study is quasi-experimental in design. We aim to recruit 576 pregnant women (288 interventions and 288 comparisons) less than 20 weeks of gestational age. The intervention will be delivered over around 6 months. The outcome measure is the difference in maternal service coverage including ANC and PNC coverage, skilled birth attendance and institutional deliveries between the intervention and comparison group. Discussion Findings from the research will contribute to improve maternal and newborn outcome in our existing health system. Findings of the research can be used for planning a new strategy and improving the health outcome for Bangladeshi women. Finally addressing the maternal health goal, this study is able to contribute to strengthening health system.

Purpose \ud The Maternal Malaria and Malnutrition (M3) initiative has pooled together 13 studies with the hope of improving understanding of malaria–nutrition interactions during pregnancy and to foster collaboration between nutritionists and malariologists.\ud \ud Participants \ud Data were pooled on 14 635 singleton, live birth pregnancies from women who had participated in 1 of 13 pregnancy studies. The 13 studies cover 8 countries in Africa and Papua New Guinea in the Western Pacific conducted from 1996 to 2015.\ud \ud Findings to date \ud Data are available at the time of antenatal enrolment of women into their respective parent study and at delivery. The data set comprises essential data such as malaria infection status, anthropometric assessments of maternal nutritional status, presence of anaemia and birth weight, as well as additional variables such gestational age at delivery for a subset of women. Participating studies are described in detail with regard to setting and primary outcome measures, and summarised data are available from each contributing cohort.\ud \ud Future plans \ud This pooled birth cohort is the largest pregnancy data set to date to permit a more definite evaluation of the impact of plausible interactions between poor nutritional status and malaria infection in pregnant women on fetal growth and gestational length. Given the current comparative lack of large pregnancy cohorts in malaria-endemic settings, compilation of suitable pregnancy cohorts is likely to provide adequate statistical power to assess malaria–nutrition interactions, and could point towards settings where such interactions are most relevant. The M3 cohort may thus help to identify pregnant women at high risk of adverse outcomes who may benefit from tailored intensive antenatal care including nutritional supplements and alternative or intensified malaria prevention regimens, and the settings in which these interventions would be most effective.

Placental malaria causes low birth weight and neonatal mortality in malaria-endemic areas. The diagnosis of placental malaria is important for program evaluation and clinical care, but is compromised by the suboptimal performance of current diagnostics. Using placental and peripheral blood specimens collected from delivering women in Malawi, we compared estimation of the operating characteristics of microscopy, rapid diagnostic test (RDT), polymerase chain reaction, and histopathology using both a traditional contingency table and a latent class analysis (LCA) approach. The prevalence of placental malaria by histopathology was 13.8%; concordance between tests was generally poor. Relative to histopathology, RDT sensitivity was 79.5% in peripheral and 66.2% in placental blood; using LCA, RDT sensitivities increased to 93.7% and 80.2%, respectively. Our results, if replicated in other cohorts, indicate that RDT testing of peripheral or placental blood may be suitable approaches to detect placental malaria for surveillance programs, including areas where intermittent preventive therapy in pregnancy is not used.

Periconceptional supplementation could extend the period over which maternal and fetal nutrition is improved,\ud but there are many challenges facing early-life intervention studies. Periconceptional trials differ from pregnancy\ud supplementation trials, not only because of the very early or pre-gestational timing of nutrient exposure but also\ud because they generate subsidiary information on participants who remain non-pregnant. The methodological\ud challenges are more complex although, if well designed, they provide opportunities to evaluate concurrent\ud hypotheses related to the health of non-pregnant women, especially nulliparous adolescents. This review examines\ud the framework of published and ongoing randomised trial designs. Four cohorts typically arise from the\ud periconceptional trial design — two of which are non-pregnant and two are pregnant — and this structure\ud provides assessment options related to pre-pregnant, maternal, pregnancy and fetal outcomes. Conceptually the\ud initial decision for single or micronutrient intervention is central — as is the choice of dosage and content — in\ud order to establish a comparative framework across trials, improve standardisation, and facilitate interpretation of\ud mechanistic hypotheses. Other trial features considered in the review include: measurement options for baseline\ud and outcome assessments; adherence to long-term supplementation; sample size considerations in relation to\ud duration of nutrient supplementation; cohort size for non-pregnant and pregnant cohorts as the latter is influenced\ud by parity selection; integrating qualitative studies and data management issues. Emphasis is given to low resource\ud settings where high infection rates and the possibility of nutrient-infection interactions may require appropriate\ud safety monitoring. The focus is on pragmatic issues that may help investigators planning a periconceptional trial.

Given the high morbidity for mother and fetus associated with malaria in pregnancy, safe and efficacious drugs are needed for treatment. Artemisinin derivatives are the most effective antimalarials, but are associated with teratogenic and embryotoxic effects in animal models when used in early pregnancy. However, several organ systems are still under development later in pregnancy. We conducted a systematic review and meta-analysis of the occurrence of adverse pregnancy outcomes among women treated with artemisinins monotherapy or as artemisinin-based combination therapy during the 2nd or 3rd trimesters relative to pregnant women who received non-artemisinin antimalarials or none at all. Pooled odds ratio (POR) were calculated using Mantel-Haenszel fixed effects model with a 0.5 continuity correction for zero events. Eligible studies were identified through Medline, Embase, and the Malaria in Pregnancy Consortium Library. Twenty studies (11 cohort studies and 9 randomized controlled trials) contributed to the analysis, with 3,707 women receiving an artemisinin, 1,951 a non-artemisinin antimalarial, and 13,714 no antimalarial. The PORs (95% confidence interval (CI)) for stillbirth, fetal loss, and congenital anomalies when comparing artemisinin versus quinine were 0.49 (95% CI 0.24–0.97, I2 = 0%, 3 studies); 0.58 (95% CI 0.31–1.16, I2 = 0%, 6 studies); and 1.00 (95% CI 0.27–3.75, I2 = 0%, 3 studies), respectively. The PORs comparing artemisinin users to pregnant women who received no antimalarial were 1.13 (95% CI 0.77–1.66, I2 = 86.7%, 3 studies); 1.10 (95% CI 0.79–1.54, I2 = 0%, 4 studies); and 0.79 (95% CI 0.37–1.67, I2 = 0%, 3 studies) for miscarriage, stillbirth and congenital anomalies respectively. Treatment with artemisinin in 2nd and 3rd trimester was not associated with increased risks of congenital malformations or miscarriage and may be was associated with a reduced risk of stillbirths compared to quinine. This study updates the reviews conducted by the WHO in 2002 and 2006 and supports the current WHO malaria treatment guidelines malaria in pregnancy.