Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade.

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.

Leaving no one behind: Is the achievement of the Sustainable Development Goals possible without securing the dignity, rights, and well-being of those who are "invisible"?

The persistence of obstetric fistula-a devastating childbirth injury occurring largely among poor, marginalized women and girls-constitutes a human rights violation and a public health crisis. The Sustainable Development Goals (SDGs) aim to "leave no one behind." Failing to eliminate fistula jeopardizes attainment of several of the SDGs. Member States of the United Nations adopted a UN Resolution on ending fistula in 2018, calling for an end to fistula within a decade. Building upon recommendations of the UN Secretary General's 2018 Report on Obstetric Fistula, the Resolution calls for significantly increased commitments and investments to end fistula. Crucial interventions for eliminating fistula include high-quality, equitable, accessible health systems; implementing costed national strategies for eliminating fistula; integrating fistula into national plans to achieve the SDGs; strengthening national fistula task forces; and significantly increased, sustained financial support. Fistula elimination necessitates protecting women's/girls' human rights and addressing social determinants that affect women's/girls' ability to "survive, thrive and transform," including social and economic inequities; gender-based violence; child marriage and early childbearing; and access to education. Enhanced awareness-raising and advocacy; improved research, data, monitoring and evaluation; holistic social reintegration and survivor empowerment; and community engagement are additional key strategies for realizing this ambitious goal.

Unmasking inequalities: Sub-national maternal and child mortality data from two urban slums in Lagos, Nigeria tells the story.

INTRODUCTION: Nigeria has one of the highest maternal mortality ratios in the world as well as high perinatal mortality. Unfortunately, the country does not have the resources to assess this critical indicator with the conventional health information system and measuring its progress toward the goal of ending preventable maternal deaths is almost impossible. Médecins Sans Frontières (MSF) conducted a cross-sectional study to assess maternal and perinatal mortality in Makoko Riverine and Badia East, two of the most vulnerable slums of Lagos. MATERIALS AND METHODS: The study was a cross-sectional, community-based household survey. Nearly 4,000 households were surveyed. The sisterhood method was utilized to estimate maternal mortality and the preceding births technique was used to estimate newborn and child mortality. Questions regarding health seeking behavior were posed to female interviewees and self-reported data were collected. RESULTS: Data was collected from 3963 respondents for a total of 7018 sisters ever married. The maternal mortality ratio was calculated at 1,050/100,000 live births (95% CI: 894-1215), and the lifetime risk of maternal death at 1:18. The neonatal mortality rate was extracted from 1967 pregnancies reported and was estimated at 28.4/1,000; infant mortality at 43.8/1,000 and under-five mortality at 103/1,000. Living in Badia, giving birth at home and belonging to the Egun ethnic group were associated with higher perinatal mortality. Half of the last pregnancies were reportedly delivered in private health facilities. Proximity to home was the main influencing factor (32.4%) associated with delivery at the health facility. DISCUSSION: The maternal mortality ratio found in these urban slum populations within Lagos is extremely high, compared to the figure estimated for Lagos State of 545 per 100,000 live births. Urgent attention is required to address these neglected and vulnerable neighborhoods. Efforts should be invested in obtaining data from poor, marginalized, and hard-to-reach populations in order to identify pockets of marginalization needing additional resources and tailored approaches to guarantee equitable treatment and timely access to quality health services for vulnerable groups. This study demonstrates the importance of sub-regional, disaggregated data to identify and redress inequities that exist among poor, remote, vulnerable populations-as in the urban slums of Lagos.

Losing women along the path to safe motherhood: why is there such a gap between women's use of antenatal care and skilled birth attendance? A mixed methods study in northern Uganda.

BACKGROUND: Thousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings. Delivery with a skilled birth attendant is a vital intervention for saving lives. Yet many women, particularly where maternal mortality ratios are highest, do not have a skilled birth attendant at delivery. In Uganda, only 58 % of women deliver in a health facility, despite approximately 95 % of women attending antenatal care (ANC). This study aimed to (1) identify key factors underlying the gap between high rates of antenatal care attendance and much lower rates of health-facility delivery; (2) examine the association between advice during antenatal care to deliver at a health facility and actual place of delivery; (3) investigate whether antenatal care services in a post-conflict district of Northern Uganda actively link women to skilled birth attendant services; and (4) make recommendations for policy- and program-relevant implementation research to enhance use of skilled birth attendance services. METHODS: This study was carried out in Gulu District in 2009. Quantitative and qualitative methods used included: structured antenatal care client entry and exit interviews [n = 139]; semi-structured interviews with women in their homes [n = 36], with health workers [n = 10], and with policymakers [n = 10]; and focus group discussions with women [n = 20], men [n = 20], and traditional birth attendants [n = 20]. RESULTS: Seventy-five percent of antenatal care clients currently pregnant reported they received advice during their last pregnancy to deliver in a health facility, and 58 % of these reported having delivered in a health facility. After adjustment for confounding, women who reported they received advice at antenatal care to deliver at a health facility were significantly more likely (aOR = 2.83 [95 % CI: 1.19-6.75], p = 0.02) to report giving birth in a facility. Despite high antenatal care coverage, a number of demand and supply side barriers deter use of skilled birth attendance services. Primary barriers were: fear of being neglected or maltreated by health workers; long distance and other difficulties in access; poverty, and material requirements for delivery; lack of support from husband/partner; health systems deficiencies such as inadequate staffing/training, work environment, and referral systems; and socio-cultural and gender issues such as preferred birthing position and preference for traditional birth attendants. CONCLUSIONS: Initiatives to improve quality of client-provider interaction and respect for women are essential. Financial barriers must be abolished and emergency transport for referrals improved. Simultaneously, supply-side barriers must be addressed, notably ensuring a sufficient number of health workers providing skilled obstetric care in health facilities and creating habitable conditions and enabling environments for them.

Being strategic about contraceptive introduction: the experience of the Standard Days Method.

BACKGROUND: Many national and institutional family planning policies explicitly include fertility awareness-based methods among the method options that should be made available, but these methods are often not offered for a variety of reasons. After testing the efficacy of the Standard Days Method (SDM), which is a fertility awareness-based method that identifies Days 8-19 of the menstrual cycle as fertile for women with cycles lasting between 26 and 32 days, pilot studies were conducted to introduce it into programs. STUDY DESIGN: Through 14 pilot studies around the world, ministries of health, family planning associations and community development organizations introduced the SDM. Follow-up interviews with users and other data collection methodologies were used to track user characteristics and experiences. Supervision data and simulated clients assessed the effects on service delivery. RESULTS: The SDM appeals to a broad range of women throughout the world. Clients report using abstinence or condoms to manage the fertile days. Both men and women report high levels of satisfaction with the method. The cross-study first-year failure rate of 14.1 pregnancies per 100 woman-years of use is similar to typical-use rates found in the SDM efficacy trial. CONCLUSIONS: The results of the pilot studies offer guidance for scaling up service delivery of the SDM. Condom counseling can help many users manage the fertile window effectively. Because out-of-range cycles can lead to method failure, users must understand the importance of tracking cycle length and be willing to switch to another method when the SDM is contraindicated. Community providers can offer the method; within clinical settings, SDM counseling typically takes no more time than allowed in most program norms. Training providers to address alcohol use and gender-based violence improves SDM method use and contributes to better quality of care.