Approaching the SDG targets with sustained political commitment: drivers of the notable decline in maternal and neonatal mortality in Morocco.

BACKGROUND: Between 2000 and 2017/2018, Morocco reduced its maternal mortality ratio by 68% and its neonatal mortality rate by 52%-a higher improvement than other North African countries. We conducted the Exemplars in Maternal and Neonatal Health study to systematically and comprehensively research factors associated with this rapid reduction in mortality over the past two decades. METHODS: The study was conducted from September 2020 to December 2021 using mixed methods, including: literature, database and document reviews, quantitative analyses of national data sets and qualitative key-informant interviews at national and district levels. Analyses were based on a conceptual framework of drivers of health and survival of mothers and neonates. RESULTS: A favourable political and economic environment, and a high political commitment encouraged prioritisation of maternal and neonatal health (MNH) by aligning evidence-based policy and technical approaches. Five main factors accounted for Morocco's success: (1) continuous increases in antenatal care and institutional delivery and reductions socioeconomically-based inequalities in MNH service usage; (2) health-system strengthening by expanding the network of health facilities, with increased uptake of facility birthing, scale-up of the production of midwives, reductions in financial barriers and, later in the process, attention to improving the quality of care; (3) improved underlying health status of women and changes in reproductive patterns; (4) a supportive policy and infrastructure environment; and 5) increased education and autonomy of women. CONCLUSION: Our study provides evidence that supportive changes in Morocco's policy environment for maternal health, backed by greater political will and increased resources, significantly contributed to the dramatic progress in reducing maternal and neonatal mortality. While these efforts were successful in improving MNH in Morocco, several implementation challenges still require special attention and renewed political attention is needed.

Aetiology and use of antibiotics in pregnancy-related infections: results of the WHO Global Maternal Sepsis Study (GLOSS), 1-week inception cohort.

BACKGROUND: Pregnancy-related infections are important contributors to maternal sepsis and mortality. We aimed to describe clinical, microbiological characteristics and use of antibiotics by source of infection and country income, among hospitalized women with suspected or confirmed pregnancy-related infections. METHODS: We used data from WHO Global Maternal Sepsis Study (GLOSS) on maternal infections in hospitalized women, in 52 low-middle- and high-income countries conducted between November 28th and December 4th, 2017, to describe the frequencies and medians of maternal demographic, obstetric, and clinical characteristics and outcomes, methods of infection diagnosis and causative pathogens, of single source pregnancy-related infection, other than breast, and initial use of therapeutic antibiotics. We included 1456 women. RESULTS: We found infections of the genital (n = 745/1456, 51.2%) and the urinary tracts (UTI) (n = 531/1456, 36.5%) to be the most frequent. UTI (n = 339/531, 63.8%) and post-caesarean skin and soft tissue infections (SSTI) (n = 99/180, 55.0%) were the sources with more culture samples taken and microbiological confirmations. Escherichia coli was the major uropathogen (n = 103/118, 87.3%) and Staphylococcus aureus (n = 21/44, 47.7%) was the commonest pathogen in SSTI. For 13.1% (n = 191) of women, antibiotics were not prescribed on the same day of infection suspicion. Cephalosporins (n = 283/531, 53.3%) were the commonest antibiotic class prescribed for UTI, while metronidazole (n = 303/925, 32.8%) was the most prescribed for all other sources. Ceftriaxone with metronidazole was the commonest combination for the genital tract (n = 98/745, 13.2%) and SSTI (n = 22/180, 12.2%). Metronidazole (n = 137/235, 58.3%) was the most prescribed antibiotic in low-income countries while cephalosporins and co-amoxiclav (n = 129/186, 69.4%) were more commonly prescribed in high-income countries. CONCLUSIONS: Differences in antibiotics used across countries could be due to availability, local guidelines, prescribing culture, cost, and access to microbiology laboratory, despite having found similar sources and pathogens as previous studies. Better dissemination of recommendations in line with antimicrobial stewardship programmes might improve antibiotic prescription.

L'expérience de l'accouchement en milieu surveillé dans la province d'Essaouira au Maroc: Quelle réalité?

RésuméUne expérience positive de l'accouchement (EPA) est fondamentale pour des soins maternels de qualité. Toutefois, de nombreuses femmes subissent des comportements non respectueux lors de ce moment crucial. Au Maroc, peu d'études ont mesuré cette expérience, et les éléments l'influençant demeurent insuffisamment documentés. Nous avons conduit une recherche mixte dans la province d'Essaouira entre avril et décembre 2021. Notre enquête, basée sur un questionnaire, a sollicité l'avis de 240 femmes issues de huit centres de santé choisis au hasard. Par ailleurs, des entretiens semi-directifs ont été conduits avec 20 femmes, 47 professionnels de santé et quatre responsables administratifs. Les données quantitatives ont été soumises à des analyses descriptives, bi- et multivariées, tandis que les entretiens ont été analysés selon une approche de contenu thématique. Les données révèlent que 59.2% des participantes ont eu une expérience défavorable lors de leur dernier accouchement. Parmi elles, la majorité a déploré des soins non consentis (86.7%), un manque de respect de leur intimité (45.4%) et des abus verbaux (25%). L'EPA était principalement associée à la qualité de l'environnement de l'accouchement, au soutien pour l'allaitement, à la propreté des installations, au type d'établissement (privé) et à l'absence de complications médicales pendant le travail. Les entretiens ont révélé que le manque de motivation des professionnels de santé, l'absence de formation continue appropriée et des lacunes organisationnelles et managériales ont affecté l'EPA. Notre étude souligne le besoin crucial de formation continue axée sur le respect des patients, l'éthique et la déontologie, et met en lumière l'importance d'une politique motivante pour les professionnels de santé, notamment dans le secteur public.

Perceptions and experiences of women with a history of gestational diabetes mellitus: A qualitative evidence synthesis.

Gestational Diabetes Mellitus (GDM) is strongly associated with the future risk of type 2 diabetes mellitus (T2DM). Women with GDM have a 10 times higher risk than women without GDM over a 10-year follow-up period. The objective of this review is to synthesise the existing evidence regarding women's views and experiences of the emotional and practical impact of GDM and its implications for diabetes prevention. Findings will be used to inform the design of interventions to prevent or delay T2DM. A systematic review of qualitative studies was conducted searching PubMed, MEDLINE, Science Direct, Scopus, and PsycINFO, from 2010 to 2021. Studies were eligible if they addressed how women's experiences and perceptions of GDM influenced women's adherence to postpartum follow-up and lifestyle interventions. The Social-Ecological Model guided the data analysis including five levels of influence specific to health behaviour: intrapersonal factors, interpersonal factors, health system organisational factors, public policy and environmental factors, and community factors. We included 31 articles after screening 22 943 citations and 51 full texts. We found that women's role as mother and caregiver is competing with one's own health priority resulting in poor postpartum screening and poor management of eating and physical activity behaviours. A supportive environment including partners, family, peers and health professionals is essential for lifestyle changes. Other environmental factors such as limited financial means or lack of health education were also barriers to adopting a healthy lifestyle. Many factors hinder T2DM postpartum screening and healthy lifestyle behaviours after GDM, yet the postpartum period is an opportunity to improve access to diabetes prevention, care and education. Women's experiences and needs should be considered when designing strategies and interventions to promote healthier lifestyles in this population.

Overall maternal morbidity during pregnancy using the WHO-WOICE tools.

INTRODUCTION: The objective of this study is to evaluate the prevalence of nonsevere maternal morbidities (including overall health, domestic and sexual violence, functionality, and mental health) in women during antenatal care in rural versus urban areas. This study aimed to describe the factors that affect women's health during pregnancy by administration of the WHO's WOICE 2.0 instrument. METHODS: This was a cross sectional study conducted at perinatal care health centers in Morocco (5 in rural and 5 in urban). We recruited n = 257 women in the third trimester of their pregnancy using a questionnaire developed by the WHO to assess maternal morbidity, which includes various instruments that measure different aspects of maternal health. This tool evaluates the functionality and ability to perform daily tasks includes a tool that evaluates mental health, the General Anxiety Disorder 7-item test (GAD-7), and the 9-item Patient Health Questionnaire (PHQ-9), to assess depression. Data on health conditions and socio-demographic characteristics were collected through structured interview, medical record review, and clinical examination. This paper presents descriptive data on the distribution of functioning status among antepartum women. RESULTS: In all, 257 women at a mean age of 30 years were included, and the majority had a partner (98%) and primary education (68.48%). Over one third of the population cannot read. Exposure to violence occurred in 12.23%. Sexual dissatisfaction was reported by 28.20% of antepartum women. Overall, women reported very good and good health (39.69%), and more than third had a medical condition (39.69%). There was an overall rate of anxiety in 83.65%, depression in 43.57%. Based on the χ2 test, Fisher exact test, or Kruskal-Wallis test, there was a significant relationship between the distribution of depression (p<0.001) and sexual satisfaction (p<0.01) between urban and rural women. CONCLUSION: Considering these results, antepartum depression and anxiety were highly prevalent in our sample and contributed substantially to perceived disability. These serious threats to health must be further investigated and more data are needed to comprehensively quantify the problem in Morocco.

Measurement of maternal morbidity during postpartum with the WHO-WOICE tools in Morocco.

BACKGROUND: Maternal morbidity refers to any health problems or complications experienced by a woman during pregnancy, childbirth, or the postpartum period. Many studies have documented the, mostly negative, effects of maternal ill-health on functioning. Although, measurement of maternel morbidity remains underdeveloped. We aimed to evaluate the prevalence of non-severe maternal morbidities (including overall health, domestic and sexual violence, functionality, and mental health) in women during postpartum care and further analyze factors associated with compromised mental functioning and clinical health by administration of the WHO's WOICE 2.0 instrument. METHODS: A cross-sectional study was conducted at 10 Health centers in Marrakech, Morocco with WOICE questionnaire included three sections: the first with maternal and obstetric history, sociodemographic data, risk and environment factors, violence and sexual health; the second considers functionality and disability, general symptoms and mental health; and the third includes data on physical and laboratory tests. This paper presents descriptive data on the distribution of functioning status among postpartum women. RESULTS: A total of 253 women averaging 30 years of age participated. For self-reported health status of women, more than 40% reported good health, and just 9.09% of women had a health condition reported by the attending physician. Among postpartum women with clinical diagnoses, 16.34% had direct (obstetric) conditions and 15.56% indirect (medical) problems. When screening for factors in the expanded morbidity definition, about 20.95% reported exposure to violence. Anxiety was identified in 29.24% of cases, and depression in 17.78%. Looking into gestational results, just 14.6% delivered by cesarean section and 15.02% had preterm birth. We found also that 97% reported "good baby health" in the postpartum evaluation, with 92% of exclusive breastfeeding. CONCLUSION: Considering these results, improving the quality of care for women requires a multi-faceted approach, including increased research, better access to care, and improved education and resources for women and healthcare providers.

Sexual and reproductive health and gender-based violence among female migrants in Morocco: a cross sectional survey.

BACKGROUND: Over the past decade, Morocco has increasingly become the chosen destination for a growing number of migrants from neighbouring countries and especially from Sub-Saharan Africa. The aim of this study is to describe the sexual and reproductive health (SRH), as well as sexual and gender-based violence (SGBV) among female migrants in Morocco. METHODS: This is a descriptive cross-sectional study conducted between July and December 2021. Female migrants were recruited from one university maternity hospital and two primary healthcare centres in Rabat. Data were collected using a structured face-to-face questionnaire, which included information about sociodemographic characteristics, SRH, history of SGBV and its impact, as well as the utilization of preventive and supportive SGBV services. RESULTS: A total of 151 participants were included in this study. The majority of participants (60.9%) were aged 18 to 34 years old and 83.3% were single. Many participants (62.1%) did not use contraceptives. More than half (56%) of the participants who were pregnant at the time of the study were receiving pre-natal care. About 29.9% of interviewed participants reported experiencing female genital mutilation, and a significant majority (87.4%) experienced SGBV at least once during their lifetimes, while 76.2% experienced SGBV during migration. The most commonly reported form of violence was verbal abuse (75.8%). Among the victims of SGBV, a minority have visited a health facility (7%) or filed a complaint (9%) in the aftermath of violence. CONCLUSION: Overall, our findings showed low contraception coverage, moderate access to prenatal care, high prevalence of SGBV, and low utilization of preventive and supportive SGBV services among migrant women in Morocco. Further studies are needed to understand the contextual barriers to access, and utilization of SRH care and additional efforts should be undertaken to strengthen SGBV prevention and support systems.

Tobacco Use Among Dental Students in Morocco: Opportunities for Professional Cancer Education.

The study aimed to evaluate tobacco use, attitudes, knowledge, and perceptions about tobacco control policies and smoking cessation counseling among dental students in Morocco. This cross-sectional study was conducted at the Dentistry Faculty of the Mohammed VI University of Health Sciences of Casablanca, using the Global Health Professions Student Survey (GHPSS) tool. Participants completed a self-administered survey questionnaire, including information on socio-demographic characteristics, tobacco use, exposure to secondhand smoke, attitudes, behavior and cessation, curriculum, and training. A total of 426 dental students were included in the study. Over 15% of the participants were current smokers, and 31.2% had tried smoking at least once. About 29.3% reported having been exposed to secondhand smoke in family settings and 49.5% in other environments. The majority of the students had felt that health professionals were role models for their patients. However, only 20% had felt they had received formal training in smoking cessation approaches. More than 70% of smokers had tried to quit smoking in the past year; however, only 41.7% reported having received help or advice. It is crucial that education and public health officials join efforts to plan and carry out programs aimed at training dental students in evidence-based cessation counseling methods, in order to change their own smoking behavior and assist their future patients. Improving dental school curriculums with regard to tobacco use prevention and cessation is also a powerful means of alleviating the national burden of cancer.

Avortement au Maroc et virage au drame : femmes et professionnels de santé en parlent ! Une étude transversale mixte à Agadir.

RésuméLes avortements à risque constituent une problématique majeure de santé publique, responsable de la mortalité et de la morbidité maternelles et absorbant les ressources des systèmes de santé publique à l'échelle mondiale. Malgré l'ampleur très probable du problème de l'avortement non sécurisé au Maroc, peu de données sont accessibles sur cette question. Cette recherche vise à analyser la situation de l'avortement du point de vue des femmes et des professionnels de santé dans la préfecture d'Agadir Idaoutanane au Sud du Maroc. Nous avons conduit une étude transversale mixte. De janvier à septembre 2018, 266 femmes ont été recrutées pour répondre à un questionnaire, et 45 entretiens avec les femmes et les professionnels de la santé impliqués dans la santé sexuelle et reproductive (SSR) ont été menés. Nous avons procédé à une analyse descriptive des données quantitatives et à une analyse de contenu thématique des données recueillies par les entretiens individuels. Les résultats de l'étude révèlent que les avortements sont la conjugaison de plusieurs facteurs multidimensionnels. Le manque d'informations en SSR et l'échec de la contraception sont les facteurs majeurs de grossesses non désirées. L'avortement provoqué est un sujet tabou, fortement stigmatisant, portant à l'image sociale de la personne. L'accessibilité aux services d'avortement est marquée de grandes disparités et de trajectoires différentes. Cette étude apporte une contribution à l'analyse du phénomène de l'avortement au Maroc et appelle à une action politique urgente sur plusieurs niveaux: l'accès aux programmes d'éducation sexuelle et à la contraception appropriée, l'élargissement des indications d'avortement préconisées dans le projet de loi, la mise en place des stratégies de lutte contre la stigmatisation de l'avortement par les professionnels de santé et l'accès à des soins post-avortement de haute qualité.

Access to infertility care services towards Universal Health Coverage is a right and not an option.

BACKGROUND: In Morocco, the national health plan 2025 was developed to promote Sexual and Reproductive Health (SRH) services for all. The principal aim was to achieve the Universal Health Coverage of SRH by 2030. For many years, health authorities' efforts had focused on reducing maternal mortality through a widespread access to antenatal and obstetric care and family planning services. This has resulted in a significant gap between the availability of SRH components, namely obstetric and family planning care, and access to infertility services including Assisted Reproductive Technology (ART). The objective of this study is to answer two important questions. First, why some SRH programs and services are given priority by international and national political leaders while infertility care receives little attention; second, what are the factors that influence this prioritization? METHODS: We used Shiffman and Smith's framework composed of four elements: the strength of the actors involved in the initiative, the power of the ideas they use to represent the health problem, the nature of the political contexts in which they operate and the characteristics of the services. We added a fifth element to the framework, the outcome. We applied this framework to the case of infertility services in Morocco. We conducted a desk review and interviews with actors involved in SRH and infertility care advocates as well as with decision makers involved in implementing Universal Health Coverage (UHC). RESULTS: Our results showed that despite the efforts made by the advocates of infertility care; the enactment in 2019 of a law regulating infertility care services; and the presence of two Assisted Reproductive Technology Units in the public sector, infertility services remain at an early stage of development hampered by multiple challenges. Among others, a lack of political entrepreneurs to ensure a strong leadership; the political windows were often missed; community members lacked consensus on a coherent public positioning of the problem, and advocates' perception and power of the idea lacked evidence and precise indicators of the problem. CONCLUSION: To ensure the convergence and alignment of all stakeholders, it is recommended to translate the regulation of infertility into measurable activities with defined human and financial resources, equitable fertility health coverage, and quality fertility care to respond to women and infertile couples' needs, rights and dignity.

International virtual confidential reviews of infection-related maternal deaths and near-miss in 11 low- and middle-income countries - case report series and suggested actions.

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

Availability of facility resources and services and infection-related maternal outcomes in the WHO Global Maternal Sepsis Study: a cross-sectional study.

BACKGROUND: Infections are among the leading causes of maternal mortality and morbidity. The Global Maternal Sepsis and Neonatal Initiative, launched in 2016 by WHO and partners, sought to reduce the burden of maternal infections and sepsis and was the basis upon which the Global Maternal Sepsis Study (GLOSS) was implemented in 2017. In this Article, we aimed to describe the availability of facility resources and services and to analyse their association with maternal outcomes. METHODS: GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries and included 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections. All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4 were eligible for inclusion. In this study, we included all GLOSS participating facilities that collected facility-level data (446 of 713 facilities). We used data obtained from individual forms completed for each enrolled woman and their newborn babies by trained researchers who checked the medical records and from facility forms completed by hospital administrators for each participating facility. We described facilities according to country income level, compliance with providing core clinical interventions and services according to women's needs and reported availability, and severity of infection-related maternal outcomes. We used a logistic multilevel mixed model for assessing the association between facility characteristics and infection-related maternal outcomes. FINDINGS: We included 446 facilities from 46 countries that enrolled 2560 women. We found a high availability of most services and resources needed for obstetric care and infection prevention. We found increased odds for severe maternal outcomes among women enrolled during the post-partum or post-abortion period from facilities located in low-income countries (adjusted odds ratio 1·84 [95% CI 1·05-3·22]) and among women enrolled during pregnancy or childbirth from non-urban facilities (adjusted odds ratio 2·44 [1·02-5·85]). Despite compliance being high overall, it was low with regards to measuring respiratory rate (85 [24%] of 355 facilities) and measuring pulse oximetry (184 [57%] of 325 facilities). INTERPRETATION: While health-care facilities caring for pregnant and recently pregnant women with suspected or confirmed infections have access to a wide range of resources and interventions, worse maternal outcomes are seen among recently pregnant women located in low-income countries than among those in higher-income countries; this trend is similar for pregnant women. Compliance with cost-effective clinical practices and timely care of women with particular individual characteristics can potentially improve infection-related maternal outcomes. FUNDING: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and US Agency for International Development.

Priorities for sexual and reproductive health in Morocco as part of universal health coverage: maternal health as a national priority.

Maternal health (MH) is a national priority of Morocco. Factors influencing the agenda set by the reproductive and maternal health policy process at the national level were evaluated using the Shiffman and Smith framework. This framework included the influence of the actors, the power of the ideas used, the nature of the political context, and the characteristics of the issue itself. Factors were evaluated by a review of documents and interviews with policy-makers, partners and individuals in the private sector, civil society and non-governmental organisations (NGOs) involved in MH, and decision-makers responsible for implementing health-financing strategies in Morocco. Evaluations showed that maternal mortality in Morocco was considered human rights and social development as well as a public health problem. The actors responsible for MH, including members of the government, researchers, national technical experts, members of the private sector, United Nations partners and NGOs, agreed on progress made in MH and universal health care (UHC). Stakeholders also agreed on the prioritisation process for MH and its inclusion in the health benefits package. Prioritisation of MH was found to depend on national health priorities set by the government and its close partners, as well as on the availability of human and financial resources. Interventions at the operational level were based on evidence, best practices, allocation of adequate financial and human resources, and rigorous monitoring and accountability. However, MH and health financing are experiencing difficulties in many areas, related to social and economic and health disparities, and gender inequality, and quality of care.

Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has substantially impacted maternity care provision worldwide. Studies based on modelling estimated large indirect effects of the pandemic on services and health outcomes. The objective of this study was to prospectively document experiences of frontline maternal and newborn healthcare providers. METHODS: We conducted a global, cross-sectional study of maternal and newborn health professionals via an online survey disseminated through professional networks and social media in 12 languages. Information was collected between 24 March and 10 April 2020 on respondents' background, preparedness for and response to COVID-19 and their experience during the pandemic. An optional module sought information on adaptations to 17 care processes. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregating by low-income and middle-income countries (LMICs) and high-income countries (HICs). RESULTS: We analysed responses from 714 maternal and newborn health professionals. Only one-third received training on COVID-19 from their health facility and nearly all searched for information themselves. Half of respondents in LMICs received updated guidelines for care provision compared with 82% in HICs. Overall, 47% of participants in LMICs and 69% in HICs felt mostly or completely knowledgeable in how to care for COVID-19 maternity patients. Facility-level responses to COVID-19 (signage, screening, testing and isolation rooms) were more common in HICs than LMICs. Globally, 90% of respondents reported somewhat or substantially higher levels of stress. There was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based practices. CONCLUSIONS: Substantial knowledge gaps exist in guidance on management of maternity cases with or without COVID-19. Formal information-sharing channels for providers must be established and mental health support provided. Surveys of maternity care providers can help track the situation, capture innovations and support rapid development of effective responses.

Implementation of a new program of gestational diabetes screening and management in Morocco: a qualitative exploration of health workers' perceptions.

BACKGROUND: Gestational diabetes mellitus (GDM) is associated with an increased risk for a future type 2 diabetes mellitus in women and their children. As linkage between maternal health and non-communicable diseases, antenatal care plays a key role in the primary and secondary prevention of GDM associated adverse outcomes. While implementing a locally adapted GDM screening and management approach through antenatal care services at the primary level of care, we assessed its acceptability by the implementing health care providers. METHODS: As part of a larger implementation effectiveness study assessing a decentralized gestational diabetes screening and management approach in the prefecture of Marrakech and the rural district of Al Haouz in Morocco, we conducted four focus group discussions with 29 primary health care providers and seven in-depth interviews with national and regional key informants. After transcription of data, we thematically analyzed the data using a combined deductive and inductive approach. RESULTS: The intervention of screening and managing women with gestational diabetes added value to existing antenatal care services but presented an additional workload for first line health care providers. An existing lack of knowledge about gestational diabetes in the community and among private health care physicians required of public providers to spend more time on counselling women. Nurses had to adapt recommendations on diet to the socio-economic context of patients. Despite the additional task, especially nurses and midwives felt motivated by their gained capacity to detect and manage gestational diabetes, and to take decisions on treatment and follow-up. CONCLUSIONS: Detection and initial management of gestational diabetes is an acceptable strategy to extend the antenatal care service offer in Morocco and to facilitate service access for affected pregnant women. Despite its additional workload, gestational diabetes management can contribute to the professional motivation of primary level health care providers. TRIAL REGISTRATION: clinicaltrials.gov; NCT02979756.

The Role of the Global Health Development/Eastern Mediterranean Public Health Network and the Eastern Mediterranean Field Epidemiology Training Programs in Preparedness for COVID-19.

The World Health Organization (WHO) declared the current COVID-19 a public health emergency of international concern on January 30, 2020. Countries in the Eastern Mediterranean Region (EMR) have a high vulnerability and variable capacity to respond to outbreaks. Many of these countries addressed the need for increasing capacity in the areas of surveillance and rapid response to public health threats. Moreover, countries addressed the need for communication strategies that direct the public to actions for self- and community protection. This viewpoint article aims to highlight the contribution of the Global Health Development (GHD)/Eastern Mediterranean Public Health Network (EMPHNET) and the EMR's Field Epidemiology Training Program (FETPs) to prepare for and respond to the current COVID-19 threat. GHD/EMPHNET has the scientific expertise to contribute to elevating the level of country alert and preparedness in the EMR and to provide technical support through health promotion, training and training materials, guidelines, coordination, and communication. The FETPs are currently actively participating in surveillance and screening at the ports of entry, development of communication materials and guidelines, and sharing information to health professionals and the public. However, some countries remain ill-equipped, have poor diagnostic capacity, and are in need of further capacity development in response to public health threats. It is essential that GHD/EMPHNET and FETPs continue building the capacity to respond to COVID-19 and intensify support for preparedness and response to public health emergencies.

Detection and initial management of gestational diabetes through primary health care services in Morocco: An effectiveness-implementation trial.

BACKGROUND: Gestational Diabetes Mellitus (GDM) testing and management in Morocco is associated with delays resulting in late commencement of treatment. To reduce delays and to increase access of women to GDM care, a country-adapted intervention targeting primary health care providers was designed to test the hypothesis that detection and initial management of GDM at the primary level of care improves newborn outcomes in terms of lower birthweights and less cases of macrosomia and impacts on maternal weight gain, glucose balance and pregnancy outcomes. MATERIALS AND METHODS: We conducted a cluster randomized controlled trial in two districts of Morocco. In each district, 10 health centers were randomly selected to serve either as intervention or control sites. Pregnant women attending antenatal care in the study facilities were eligible to participate. At the intervention sites, women were offered GDM screening by capillary glucose testing following International Association of Diabetes in Pregnancy Study Groups/WHO criteria. Women diagnosed with GDM received counselling on nutrition and exercise and were followed up through their health center whereas at control facilities routine practice was applied. Primary outcome was birthweight and secondary outcomes maternal weight gain, glucose control and pregnancy complications. We further assessed GDM prevalence in the intervention arm. Statistical analysis was performed on 210 recruited women. Continuous variables were reported using means while categorical variables using frequencies with tests of independence applying chi-squared tests. Differences of outcome variables between the two groups were estimated by mixed-effects regression models and effect sizes adjusted for confounders. The trial is registered under NCT02979756 at ClinicalTrials.gov. RESULTS: GDM prevalence reached 23.7% in Marrakech. Birthweight in the intervention group was 147grams lower than in the control group (p = 0.08) as was the proportion of macrosomes (3.5% versus 18.4%; p< 0.001). In the intervention arm, women did two times more follow-ups than at control sites (p = 0.001) and mean follow-up intervals were shorter (11.3 days versus 18.7 days; p < 0.001). Overall, 30% more fasting blood sugar values were balanced (p = 0.005) and mean weekly maternal weight gain 49 grams lower (p = 0.032) in the intervention group. More women from control facilities had a delivery complication whereas more newborn complications were observed in women from intervention facilities. No difference between the two groups existed regarding mode of delivery and mean gestational age at delivery. One of the main limitations of the study was the Hawthorn-effect at control sites that might have led to an underestimation of the effect size. CONCLUSION: A high GDM prevalence in Morocco calls for a context-adapted screening and management approach to enable early interventions. GDM detection and care through antenatal care at primary health facilities may have positively impacted on newborn birthweight but findings are inconclusive. Results of this study will contribute to the decision on a potential upscaling of the intervention in Morocco. Future research could examine long term metabolic changes including diabetes type 2 in the cohort of women and their children.

Knowledge and practice related to gestational diabetes among primary health care providers in Morocco: Potential for a defragmentation of care?

INTRODUCTION: The objective of this study was to assess knowledge and practices of general practitioners, nurses and midwives working at primary health care facilities in Morocco regarding screening and management of gestational diabetes (GDM). METHODS: Structured interviews with 100 doctors, midwives and nurses at 44 randomly selected public health care centers were conducted in Marrakech and Al Haouz. All data were descriptively analyzed. Ethical approval for the study was granted by the institutional review boards in Belgium and Morocco. RESULTS: Public primary health care providers have a basic understanding of gestational diabetes but screening and management practices are not uniform. Although 56.8% of the doctors had some pre-service training on gestational diabetes, most nurses and midwives lack such training. After diagnosing GDM, 88.5% of providers refer patients to specialists, only 11.5% treat them as outpatients. DISCUSSION: Updating knowledge and skills of providers through both pre- and in-service-training needs to be supported by uniform national standards enabling first line health care workers to manage women with GDM and thus increase access and provide a continuity in care. Findings of this study will be used to pilot a model of GDM screening and initial management through the primary level of care.