Understanding effective approaches to addressing the common challenges faced by global health networks: Mobilising multi-stakeholder networks to address the upstream determinants of maternal health in five low- and middle-income countries.

Background: Past case studies on global initiatives to address maternal health and survival have focused on global health networks, identifying four essential tasks that define their ability to successfully enact change. We applied the conceptual framework of global health networks at the country level to organisations sharing concerns on how to address national maternal health and the upstream determinants of maternal survival in five countries and explored how they addressed these four essential tasks. Methods: We conducted focus group discussions and key informant interviews with 20 members of national maternal health multi-stakeholder networks in Bangladesh, India, Mexico, Nigeria, and Pakistan. We drew on the principles and essential components of appreciative inquiry, an assets-based action research methodology that emerged from positivist theories of organisational development to understand how the networks addressed the four tasks. We used a deductive content analysis approach, developing initial themes based on pre-designed codes corresponding to the four tasks faced by global health networks and later identifying emergent themes in the four areas of the framework. Results: We identified themes related to each of the four tasks. Participants emphasised the need for structure and focus in defining the problem, strengths associated with network diversity, and the network's ability to pivot and redefine the problem to align with other sweeping priorities, such as COVID-19 pandemic. Themes related to inspiring action centred on aligning the issue with ongoing local and global initiatives, cultivating a sense of group ownership, and defining success incrementally. Themes related to forging alliances emphasised needing to engage high-level leadership, being opportunistic about timing, reducing barriers to participation by external players, and identifying rewards for participants. Themes related to establishing a governance structure centred on needing strong structure and organisation, cultivating individual commitment, sustaining advocacy efforts, and obtaining funding. Conclusions: Our results demonstrate that challenges commonly faced by global health networks are also relevant to networks operating on a national scale and may offer them strategies for future national networks to consider adopting to address these challenges.

Measuring maternal improvement through multi-stakeholder engagement: Documenting developments in the dynamic programmatic context of the global COVID-19 pandemic through outcome harvesting.

Background: To bolster country efforts towards meeting the targets and strategies laid out in WHO's report "Strategies toward ending preventable maternal mortality" (EPMM), a series of seven consultations, known as National Dialogues, were conducted to better understand national priority areas for the improvement of maternal health and to support the adoption and use of EPMM indicators at the national level. The last Dialogue was conducted in March 2020, as the COVID-19 pandemic was beginning to have global impacts. We aimed to explore the circumstantial challenges and opportunities that countries have encountered in meeting the specific stakeholder commitments made in each country by National Dialogue participants during the COVID-19 pandemic. Methods: We based our study methodology on outcome harvesting, a qualitative approach that examines how incremental change contributes towards achieving a specified outcome. It collects evidence on what has changed and then works backwards to determine whether and how a programme or intervention led to the observed changes. We collected data from 20 participants in five countries (Bangladesh, India, Mexico, Nigeria, and Pakistan) through key informant interviews and focus group discussions. We analysed the data through inductive coding focused on emergent themes. Results: The onset of the global COVID pandemic overturned plans and upended health systems, bringing new opportunities in some countries and halting progress towards the agenda outlined in the National Dialogue elsewhere. Participants identified adaptations that facilitated continued progress, such as shifting the locus of advocacy and activity from national to sub-national focal areas, catalytic changes in response to the crisis (including the development and improvement of digital communication and data technology), and increased awareness of the importance of identified priorities (including a human rights approach to maternal health). Conclusions: Our data suggest that the priorities for maternal health system performance to drive improvement toward ending preventable maternal deaths and the advocacy commitments designed to increase the relevance of upstream policy and health system-level determinants of maternal health and survival have retained their urgency during the COVID-19 pandemic.

Exploring the impact of COVID-19 on reported maternal and neonatal complications and access to maternal health care in five government health facilities in Blantyre, Malawi.

BACKGROUND: There is a dearth of studies assessing the effects of SARS-CoV-2 on the healthcare system and access to care, especially in lower- and middle-income countries such as Malawi. We aimed to assess the impacts of COVID-19 on reported maternal and neonatal complications as well as potential changes in maternal care access to care among five primary care health facilities in Blantyre, Malawi. METHODS: This retrospective cohort study assessed maternal and neonatal register data from five participating health centers in Blantyre, Malawi using the Malawi District Health Information Software 2 (DHIS2) to compare outcomes from 15 months before COVID-19 emerged, defined as the pre-Covid period (January 2019 -March 2020) with nine months after COVID-19 (April 2020 -December 2020). RESULTS: There was a significant decrease in reported use of vacuum extraction, which went from <0.01%in the pre-COVID period to 0% in the COVID period (p = 0.01). The proportion of births reporting fetal distress almost tripled from 0.46% to 1.36% (p = 0.001) during the COVID-19 period. Additionally, reported anticonvulsant use significantly increased from 0.01% to 1.2% (p<0.01), and antibiotic use significantly increased from 0.45% to 1.6% (p = 0.01). Asphyxia was the only significant neonatal complication variable reported, increasing from 2.80% to 3.45% (p = 0.01). CONCLUSION: Our findings suggest that significant outcomes were mainly due to the indirect effects of COVID-19 rather than the virus itself. Based on our findings and the contextual qualitative interviews with two Malawian expert midwives, we concluded that mothers may have been affected more due to understaffing and shortage of skilled personnel in the study health facilities. Therefore, the development of highly skilled health workers may contribute to better outcomes, along with adequate staffing and a streamlined referral process.

The relationship between maternal health and neonatal low birth weight in Amman, Jordan: a case-control study.

This study aimed to examine the relationship between maternal health during pregnancy and low birth weight (LBW), as well as the impact of COVID-19 on the socio-economic status of pregnant women and its effect on LBW. The study was conducted in Amman, Jordan, and included 2260 mothers who visited Abu-Nusair comprehensive health center between January and December 2020. A matched case-control design was used with 72 cases and 148 controls selected for data collection through medical records and face-to-face interviews. Results showed that factors such as a monthly income of 400 JD or less, living with an extended family, exposure to passive smoking, maternal weight gain of 6-10 kg, maternal anemia, maternal hypertension, delivery by cesarean section, and previous history of LBW newborns were positively associated with an increased risk of LBW. Conversely, factors such as a monthly income above 700 JD, living with a core family, daily intake of iron, calcium, and vitamin D, prenatal visits, healthy food intake, and planning for pregnancy were associated with a lower risk of LBW. COVID-19 infection and its effects on work, family finances, antenatal care visits, and food supply were also positively linked with LBW. In conclusion, socioeconomic status, maternal health, COVID-19, and its impacts were significant risk factors for LBW.

Protocol for the effectiveness evaluation of an antenatal, universally offered, and remotely delivered parenting programme 'Baby Steps' on maternal outcomes: a Born in Bradford's Better Start (BiBBS) study.

BACKGROUND: Poor perinatal mental health and maternal sensitivity towards a child in the early years can carry a long-term cost to individuals and to society, and result in negative child outcomes such as poor mental health and social emotional issues. Despite the recognition of early intervention and prevention, there is mixed evidence regarding antenatal parenting interventions that aim to enhance perinatal mental health and maternal sensitivity to prevent negative child outcomes. 'Baby Steps' is a relationship-based antenatal and postnatal parenting programme. The service evaluated in this study is delivered in a low-income and ethnically diverse community via Better Start Bradford. This study aims to assess whether the universally, and remotely delivered Baby Steps programme is effective in improving postnatal maternal sensitivity (primary outcome) and postnatal maternal mental health (secondary outcome) when compared to services as usual 6-10 weeks post-birth. It will also assess differences in birth outcomes, and differences in the prevalence of poor perinatal mental ill health through routine data. The feasibility of collecting cost and health related resource use data for a future economic evaluation will be explored. METHODS: The study is a quasi-experimental evaluation in a single centre. All participants are drawn from Born in Bradford's Better Start (BiBBS) interventional family cohort study. Intervention participants will be matched to a demographically comparable control group using propensity score matching. The required minimum sample is n = 130 (ratio 1:1) to detect a medium effect (± 2.35, d = .50) on the primary outcome-maternal-child sensitivity, using the Mothers Object Relations Scale Short Form (MORS-SF). Secondary outcomes include the Patient Health Questionnaire (PHQ-8), Generalised Anxiety Disorder assessment 7 (GAD-7), identification of poor perinatal mental health through routine data, and birth outcomes (delivery method, gestation period, low birth weight). Service delivery costs and health resource use will be gathered from routine data. DISCUSSION: This study will evaluate the effectiveness of Baby Steps for enhancing maternal-child sensitivity and maternal mental health when delivered universally and remotely. The findings regarding programme effectiveness, process, and costs will be relevant for researchers, service commissioners, and service staff. TRIAL REGISTRATION: This study was prospectively registered with ISRCTN (22/04/2022, ISRCTN12196131).

Recommendations for maternal mental health policy in India.

Mental illnesses are a serious concern in India where every seventh person suffers from mental health problems-with women more affected than men. While the burden of perinatal mental illnesses grows, India lacks exclusive policies to address it. The COVID-19 pandemic has had an impact on routine antenatal care and institutional deliveries and has also affected the mental health of pregnant women and mothers. We evaluated existing policies. Policy options were evaluated against criteria like cost-benefit analysis, administrative feasibility, human resources, and equity along with the intended and unintended consequences. We propose three policy options: (1) strengthening and focused implementation of the existing national mental health program (NMHP), (2) integrating mental health in the ongoing Reproductive, Maternal, Newborn, Child and Adolescent Health Program, and (3) including a 'maternal' component in NMHP. We offered policy recommendations to fill the gap in addressing the maternal mental health challenge in India.

Health and economic benefits of achieving contraceptive and maternal health targets in Small Island Developing States in the Pacific and Caribbean.

INTRODUCTION: Reducing unmet need for modern contraception and expanding access to quality maternal health (MH) services are priorities for improving women's health and economic empowerment. To support investment decisions, we estimated the additional cost and expected health and economic benefits of achieving the United Nations targets of zero unmet need for modern contraceptive choices and 95% coverage of MH services by 2030 in select Small Island Developing States. METHODS: Five Pacific (Kiribati, Samoa, Solomon Islands, Tonga and Vanuatu) and four Caribbean (Barbados, Guyana, Jamaica and Saint Lucia) countries were considered based on population survey data availability. For each country, the Lives Saved Tool was used to model costs, health outcomes and economic benefits for two scenarios: business-as-usual (BAU) (coverage maintained) and coverage-targets-achieved, which scaled linearly from 2022 (following COVID-19 disruptions) coverage of evidence-based family planning and MH interventions to reach United Nations targets, including modern contraceptive methods and access to complete antenatal, delivery and emergency care. Unintended pregnancies, maternal deaths, stillbirths and newborn deaths averted by the coverage-targets-achieved scenario were converted to workforce, education and social economic benefits; and benefit-cost ratios were calculated. RESULTS: The coverage-targets-achieved scenario required an additional US$12.6M (US$10.8M-US$15.9M) over 2020-2030 for the five Pacific countries (15% more than US$82.4M to maintain BAU). This additional investment was estimated to avert 126 000 (40%) unintended pregnancies, 2200 (28%) stillbirths and 121 (29%) maternal deaths and lead to a 15-fold economic benefit of US$190.6M (US$67.0M-US$304.5M) by 2050. For the four Caribbean countries, an additional US$17.8M (US$15.3M-US$22.4M) was needed to reach the targets (4% more than US$405.4M to maintain BAU). This was estimated to avert 127 000 (23%) unintended pregnancies, 3600 (23%) stillbirths and 221 (25%) maternal deaths and lead to a 24-fold economic benefit of US$426.2M (US$138.6M-US$745.7M) by 2050. CONCLUSION: Achieving full coverage of contraceptive and MH services in the Pacific and Caribbean is likely to have a high return on investment.

Maternal mental health during COVID-19 pandemic outbreak: A cross-sectional comparative study.

Background: As COVID-19 spread in several countries, social distancing measures was implemented around the world, affecting the quality of lives for millions of people. The impact was more pronounced on vulnerable populations such as pregnant women, who are at even more risk due to their suppressed immune system. Moreover, mental health disorders are more common among pregnant women compared to non-pregnant. This study aims to assess the influence of social isolation measures due to the COVID-19 pandemic on the mental health of women in their third trimester and postpartum. Material and methods: This is a cross-sectional survey-based study conducted in Khalid University Hospital, Riyadh, Saudi Arabia, between the months of April to May 2021, to explore depression and anxiety levels in females who gave birth during the COVID-19 pandemic. In addition to background demographic data, the survey included Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Scale-7 (GAD-7) were utilized to detect symptoms of depression and anxiety, respectively. Results: A total of 283 women were included in this study, almost half of them were ante-natal (n-141) and the rest were post-natal (n = 124). 62.3% were in the age groups of 25-35 years. Based on the PHQ-9 scoring, 65% of the study sample had depression (ranging from mild to severe). Moreover, based on GAD-7 scoring, 49.1% had anxiety (ranging from mild to severe). No association was found between PHQ-9 and GAD-7 scores and different sociodemographic and obstetric factors. Additionally, the mean scores of women infected with COVID-19 vs. women who has never been diagnosed with COVID-19 were closely comparable. Conclusions: We reported a high prevalence of depression and anxiety among pregnant women during COVID-19 pandemic. Policymakers and health care providers are advised to implement targeted preventive measures for pregnant women to improve mental health in times of epidemics.

The effects of universal child allowance on maternal health: Evidence from South Korea.

BACKGROUND: Child allowance (CA) in South Korea was first introduced in September 2018. CA provides a monthly allowance to children from birth to age 5. To date, existing studies on the effects of CA in Korea have focused mainly on household economic outcomes. The current study is the first to examine the effect of CA on maternal physical and mental health, measured by self-reported health status, depression, and life satisfaction. METHODS: We use nationally representative data from the Korea Welfare Panel Study (KOWEPS) from 2017 to 2018. The analytic sample consists of 772 Korean mothers whose youngest child is between age 2 and age 7. Taking advantage of an exogenous policy change and the age eligibility of the policy, we employ a difference-in-regression-discontinuities (DRD) strategy to identify the effects of CA on self-reported health status, depression, and life satisfaction. RESULTS: Overall, we find suggestive evidence that the introduction of CA contributed to reducing depression while improving self-reported health and life satisfaction. In particular, the policy reform had a significant effect on life satisfaction, showing that CA improves life satisfaction by 0.497 points. CONCLUSIONS: Results suggest that CA can improve both physical and mental health for eligible mothers. Such findings are indicative of a causal link between income and health. There has been a recent political movement to raise the age threshold of CA to up to age 18 to cover older children and increase benefit levels. Our findings provide important policy implications for the political discussion on CA expansion.

Protracted armed conflict and maternal health: a scoping review of literature and a retrospective analysis of primary data from northwest Syria.

INTRODUCTION: Syria's protracted conflict has devastated the health system reversing progress made on maternal health preconflict. Our aim is to understand the state of maternal health in Syria focused on underage pregnancy and caesarean sections using a scoping review and quantitative analysis; the latter draws on data from the Syrian American Medical Society's (SAMS) maternal health facilities in northwest Syria. METHODS: We performed a scoping review of academic and grey literature on the state of maternal health across Syria since the onset of conflict (taken as March 2011). Identified articles were screened using pre-established criteria and themes identified. We also performed a retrospective quantitative analysis of maternal health data from SAMS' facilities in a microcontext in north-west Syria between March 2017 and July 2020, analysing the trends in the proportion of births by caesarean section and age at pregnancy. RESULTS: Scoping review: of 2824 articles, 21 remained after screening. Main themes related to maternal mortality rates, caesarean sections, maternal age and perinatal care. 12 studies reported caesarean section rates; these varied from 16% to 64% of all births: northern Syria (19%-45%,) Damascus (16%-54%,) Lattakia (64%) and Tartous (59%.) Quantitative analysis: Of 77 746 births across 17 facilities, trend data for caesarean sections showed a decrease from 35% in March 2017 to 23% in July 2020 across SAMS facilities. Girls under 18 years accounted for 10% of births and had a lower proportion of caesarean section births. There was notable geographical and interfacility variation in the findings. CONCLUSION: The quality of available literature was poor with country-level generalisations. Research which explores microcontexts in Syria is important given the different effects of conflict across the country and the fragmented health system. Our quantitative analysis provides some evidence around the changes to caesarean section rates in northwest Syria. Despite limitations, this study adds to sparse literature on this important topic.

Telehealth Strategies for the Delivery of Maternal Health Care : A Rapid Review.

BACKGROUND: Telehealth strategies to supplement or replace in-person maternity care may affect maternal health outcomes. PURPOSE: To conduct a rapid review of the effectiveness and harms of telehealth strategies for maternal health care given the recent expansion of telehealth arising from the COVID-19 pandemic, and to produce an evidence map. DATA SOURCES: Systematic searches of MEDLINE, the Cochrane Library, CINAHL, Embase, and Scopus for English-language studies (January 2015 to April 2022). STUDY SELECTION: Randomized controlled trials (RCTs) and observational studies of maternal care telehealth strategies versus usual care. DATA EXTRACTION: Dual data extraction and risk-of-bias assessment of studies, with disagreements resolved through consensus. DATA SYNTHESIS: 28 RCTs and 14 observational studies (n = 44 894) were included. Maternal telehealth interventions supplemented in-person care for most studies of mental health and diabetes during pregnancy, primarily resulting in similar, and sometimes better, clinical and patient-reported outcomes versus usual care. Supplementing in-person mental health care with phone- or web-based platforms or mobile applications resulted in similar or better mental health outcomes versus in-person care. A reduced-visit prenatal care schedule using telehealth to replace in-person general maternity care for low-risk pregnancies resulted in similar clinical outcomes and higher patient satisfaction versus usual care. Overall, telehealth strategies were heterogeneous and resulted in similar obstetric and patient satisfaction outcomes. Few studies addressed disparities, health equity, or harms. LIMITATIONS: Interventions varied, and evidence was inadequate for some clinical outcomes. CONCLUSION: Replacing or supplementing in-person maternal care with telehealth generally results in similar, and sometimes better, clinical outcomes and patient satisfaction compared with in-person care. The effect on access to care, health equity, and harms is unclear. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42021276347).

Commentary: Implications of SARS-Cov-2 infection for pregnancy with diabetes: achievements and open questions for feto-maternal medicine.

SARS-Cov-2 (Severe Acute Respiratory Coronavirus 2) infection confers a non-negligible risk for younger pregnant women with diabetes, which is still less well investigated. This topic was recently addressed by a systematic scoping review in BMC Pregnancy and Childbirth, aiming to summarize the complex interaction between SARS-Cov-2 infection, pregnancy and diabetes. This commentary will summarize and discuss the main findings of this article and its implications for future research.

SARS-CoV-2 in diabetic pregnancies: a systematic scoping review.

BACKGROUND: Currently, we suffer from an increasing diabetes pandemic and on the other hand from the SARS-CoV-2 pandemic. Already at the beginning of the SARS-CoV-2 pandemic, it was quickly assumed that certain groups are at increased risk to suffer from a severe course of COVID-19. There are serious concerns regarding potential adverse effects on maternal, fetal, and neonatal outcomes. Diabetic pregnancies clearly need special care, but clinical implications as well as the complex interplay of diabetes and SARS-CoV-2 are currently unknown. We summarized the evidence on SARS-CoV-2 in diabetic pregnancies, including the identification of novel potential pathophysiological mechanisms and interactions as well as clinical outcomes and features, screening, and management approaches. METHODS: We carried out a systematic scoping review in MEDLINE (PubMed), EMBASE, CINAHL, Cochrane Library, and Web of Science Core Collection in September 2020. RESULTS: We found that the prognosis of pregnant women with diabetes mellitus and COVID-19 may be associated with potential underlying mechanisms such as a simplified viral uptake by ACE2, a higher basal value of pro-inflammatory cytokines, being hypoxemic as well as platelet activation, embolism, and preeclampsia. In the context of "trans-generational programming" and COVID-19, life-long consequences may be "programmed" during gestation by pro-inflammation, hypoxia, over- or under-expression of transporters and enzymes, and epigenetic modifications based on changes in the intra-uterine milieu. COVID-19 may cause new onset diabetes mellitus, and that vertical transmission from mother to baby might be possible. CONCLUSIONS: Given the challenges in clinical management, the complex interplay between COVID-19 and diabetic pregnancies, evidence-based recommendations are urgently needed. Digital medicine is a future-oriented and effective approach in the context of clinical diabetes management. We anticipate our review to be a starting point to understand and analyze mechanisms and epidemiology to most effectively treat women with SARS-COV-2 and diabetes in pregnancy.