Corrigendum: Lipid metabolism and tumor immunotherapy.

[This corrects the article DOI: 10.3389/fcell.2023.1187989.].

Pneumonia knowledge and care seeking behavior for children under-five years in Jigawa, Northwest Nigeria: a cross-sectional study.

Background: Between 2013 and 2022, Nigeria did not meet globally defined targets for pneumonia control, despite some scale-up of vaccinations, oxygen and antibiotics. A deliberate focus on community-based programs is needed to improve coverage of protective, preventive and treatment interventions. We therefore aimed to describe caregiver knowledge and care seeking behaviour for childhood pneumonia, in a high child mortality setting in Nigeria, to inform the development of effective community-based interventions for pneumonia control. Methods: We conducted a cross-sectional household survey in Kiyawa Local Government Area, Jigawa State, Nigeria between December 2019 and March 2020. We asked caregivers about their knowledge of pneumonia symptoms, prevention, risks, and treatment. A score of 1 was assigned for each correct response. We showed them videos of pneumonia specific symptoms and asked (1) if their child had any respiratory symptoms in the 2-weeks prior; (2) their subsequent care-seeking behaviour. Multivariate regressions explored socio-demographic and clinical factors associated with care seeking. Results: We surveyed 1,661 eligible women, with 2,828 children under-five. Only 4.9% of women could name both cough and difficulty/fast breathing as pneumonia symptoms, and the composite knowledge scores for pneumonia prevention, risks and treatment were low. Overall, 19.0% (536/2828) of children had a report of pneumonia specific symptoms in the prior two-weeks, and of these 32.3% (176/536) were taken for care. The odds of care seeking was higher among children: with fever (AOR:2:45 [95% CI: 1.38-4.34]); from wealthiest homes (AOR: 2:13 [95% CI: 1.03-4.38]) and whose mother first married at 20-26 years compared to 15-19 years (AOR: 5.15 [95% CI: 1.38-19.26]). Notably, the caregiver's knowledge of pneumonia was not associated with care seeking. Conclusion: While some socio-demographic factors were associated with care seeking for children with symptoms of Acute Respiratory Infection (ARI), caregiver's knowledge of the disease was not. Therefore, when designing public health interventions to address child mortality, information-giving alone is likely to be insufficient.

Lipid metabolism and tumor immunotherapy.

In recent years, the relationship between lipid metabolism and tumour immunotherapy has been thoroughly investigated. An increasing number of studies have shown that abnormal gene expression and ectopic levels of metabolites related to fatty acid synthesis or fatty acid oxidation affect tumour metastasis, recurrence, and drug resistance. Tumour immunotherapy that aims to promote an antitumour immune response has greatly improved the outcomes for tumour patients. However, lipid metabolism reprogramming in tumour cells or tumour microenvironment-infiltrating immune cells can influence the antitumour response of immune cells and induce tumor cell immune evasion. The recent increase in the prevalence of obesity-related cancers has drawn attention to the fact that obesity increases fatty acid oxidation in cancer cells and suppresses the activation of immune cells, thereby weakening antitumour immunity. This article reviews the changes in lipid metabolism in cells in the tumour microenvironment and describes the relationship between lipid metabolism reprogramming in multiple cell types and tumour immunotherapy.

Maternal mental well-being and recent child illnesses-A cross-sectional survey analysis from Jigawa State, Nigeria.

Child health indicators in Northern Nigeria remain low. The bidirectional association between child health and maternal well-being is also poorly understood. We aim to describe the association between recent child illness, socio-demographic factors and maternal mental well-being in Jigawa State, Nigeria. We analysed a cross-sectional household survey conducted in Kiyawa local government area, Jigawa State, from January 2020 to March 2020 amongst women aged 16-49 with at least one child under-5 years. We used two-stage random sampling. First, we used systematic random sampling of compounds, with the number of compounds based on the size of the community. The second stage used simple random sampling to select one eligible woman per compound. Mental well-being was assessed using the Short Warwick-Edinburgh Mental Wellbeing Score (SWEMWBS). We used linear regression to estimate associations between recent child illness, care-seeking and socio-demographic factors, and mental well-being. Overall 1,661 eligible women were surveyed, and 8.5% had high mental well-being (metric score of 25.0-35.0) and 29.5% had low mental well-being (metric score of 7.0-17.9). Increasing wealth quintile (adj coeff: 1.53; 95% CI: 0.91-2.15) not being a subsistence farmer (highest adj coeff: 3.23; 95% CI: 2.31-4.15) and having a sick child in the last 2-weeks (adj coeff: 1.25; 95% CI: 0.73-1.77) were significantly associated with higher mental well-being. Higher levels of education and increasing woman's age were significantly associated with lower mental well-being. Findings contradicted our working hypothesis that a recently sick child would be associated with lower mental well-being. We were surprised that education and late marriage, which are commonly attributed to women's empowerment and autonomy, were not linked to better well-being here. Future work could focus on locally defined tools to measure well-being reflecting the norms and values of communities, ensuring solutions that are culturally acceptable and desirable to women with low mental well-being are initiated.

Ang2-Targeted Combination Therapy for Cancer Treatment.

Angiopoietin-2 (Ang2), a member of the angiopoietin family, is widely involved in the process of vascular physiology, bone physiology, adipose tissue physiology and the occurrence and development of inflammation, cardiac hypertrophy, rheumatoid, tumor and other diseases under pathological conditions. Proliferation and metastasis of cancer largely depend on angiogenesis. Therefore, anti-angiogenesis has become the target of tumor therapy. Due to the Ang2 plays a key role in promoting angiogenesis and stability in vascular physiology, the imbalance of its expression is an important condition for the occurrence and development of cancer. It has been proved that blocking Ang2 can inhibit the growth, invasion and metastasis of cancer cells. In recent years, research has been constantly supplemented. We focus on the mechanisms that regulate the expression of Ang2 mRNA and protein levels in different cancers, contributing to a better understanding of how Ang2 exerts different effects in different cancers and stages, as well as facilitating more specific targeting of relevant molecules in cancer therapy. At the same time, the importance of Ang2 in cancer growth, metastasis, prognosis and combination therapy is pointed out. And finally, we will discuss the current investigations and future challenges of combining Ang2 inhibition with chemotherapy, immunotherapy, and radiotherapy to increase its efficacy in cancer patients. This review provides a theoretical reference for the development of new targets and effective combination therapy strategies for cancer treatment in the future.

Pulse oximetry and oxygen services for the care of children with pneumonia attending frontline health facilities in Lagos, Nigeria (INSPIRING-Lagos): study protocol for a mixed-methods evaluation.

INTRODUCTION: The aim of this evaluation is to understand whether introducing stabilisation rooms equipped with pulse oximetry and oxygen systems to frontline health facilities in Ikorodu, Lagos State, alongside healthcare worker (HCW) training improves the quality of care for children with pneumonia aged 0-59 months. We will explore to what extent, how, for whom and in what contexts the intervention works. METHODS AND ANALYSIS: Quasi-experimental time-series impact evaluation with embedded mixed-methods process and economic evaluation. SETTING: seven government primary care facilities, seven private health facilities, two government secondary care facilities. TARGET POPULATION: children aged 0-59 months with clinically diagnosed pneumonia and/or suspected or confirmed COVID-19. INTERVENTION: 'stabilisation rooms' within participating primary care facilities in Ikorodu local government area, designed to allow for short-term oxygen delivery for children with hypoxaemia prior to transfer to hospital, alongside HCW training on integrated management of childhood illness, pulse oximetry and oxygen therapy, immunisation and nutrition. Secondary facilities will also receive training and equipment for oxygen and pulse oximetry to ensure minimum standard of care is available for referred children. PRIMARY OUTCOME: correct management of hypoxaemic pneumonia including administration of oxygen therapy, referral and presentation to hospital. SECONDARY OUTCOME: 14-day pneumonia case fatality rate. Evaluation period: August 2020 to September 2022. ETHICS AND DISSEMINATION: Ethical approval from University of Ibadan, Lagos State and University College London. Ongoing engagement with government and other key stakeholders during the project. Local dissemination events will be held with the State Ministry of Health at the end of the project (December 2022). We will publish the main impact results, process evaluation and economic evaluation results as open-access academic publications in international journals. TRIAL REGISTRATION NUMBER: ACTRN12621001071819; Registered on the Australian and New Zealand Clinical Trials Registry.

Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) through whole system strengthening in Jigawa, Nigeria: study protocol for a cluster randomised controlled trial.

BACKGROUND: Child mortality remains unacceptably high, with Northern Nigeria reporting some of the highest rates globally (e.g. 192/1000 live births in Jigawa State). Coverage of key protect and prevent interventions, such as vaccination and clean cooking fuel use, is low. Additionally, knowledge, care-seeking and health system factors are poor. Therefore, a whole systems approach is needed for sustainable reductions in child mortality. METHODS: This is a cluster randomised controlled trial, with integrated process and economic evaluations, conducted from January 2021 to September 2022. The trial will be conducted in Kiyawa Local Government Area, Jigawa State, Nigeria, with an estimated population of 230,000. Clusters are defined as primary government health facility catchment areas (n = 33). The 33 clusters will be randomly allocated (1:1) in a public ceremony, and 32 clusters included in the impact evaluation. The trial will evaluate a locally adapted 'whole systems strengthening' package of three evidence-based methods: community men's and women's groups, Partnership Defined Quality Scorecard and healthcare worker training, mentorship and provision of basic essential equipment and commodities. The primary outcome is mortality of children aged 7 days to 59 months. Mortality will be recorded prospectively using a cohort design, and secondary outcomes measured through baseline and endline cross-sectional surveys. Assuming the following, we will have a minimum detectable effect size of 30%: (a) baseline mortality of 100 per 1000 livebirths, (b) 4480 compounds with 3 eligible children per compound, (c) 80% power, (d) 5% significance, (e) intra-cluster correlation of 0.007 and (f) coefficient of variance of cluster size of 0.74. Analysis will be by intention-to-treat, comparing intervention and control clusters, adjusting for compound and trial clustering. DISCUSSION: This study will provide robust evidence of the effectiveness and cost-effectiveness of community-based participatory learning and action, with integrated health system strengthening and accountability mechanisms, to reduce child mortality. The ethnographic process evaluation will allow for a rich understanding of how the intervention works in this context. However, we encountered a key challenge in calculating the sample size, given the lack of timely and reliable mortality data and the uncertain impacts of the COVID-19 pandemic. TRIAL REGISTRATION: ISRCTN 39213655 . Registered on 11 December 2019.

Measuring oxygen access: lessons from health facility assessments in Lagos, Nigeria.

The COVID-19 pandemic has highlighted global oxygen system deficiencies and revealed gaps in how we understand and measure 'oxygen access'. We present a case study on oxygen access from 58 health facilities in Lagos state, Nigeria. We found large differences in oxygen access between facilities (primary vs secondary, government vs private) and describe three key domains to consider when measuring oxygen access: availability, cost, use. Of 58 facilities surveyed, 8 (14%) of facilities had a functional pulse oximeter. Oximeters (N=27) were typically located in outpatient clinics (12/27, 44%), paediatric ward (6/27, 22%) or operating theatre (4/27, 15%). 34/58 (59%) facilities had a functional source of oxygen available on the day of inspection, of which 31 (91%) facilities had it available in a single ward area, typically the operating theatre or maternity ward. Oxygen services were free to patients at primary health centres, when available, but expensive in hospitals and private facilities, with the median cost for 2 days oxygen 13 000 (US$36) and 27 500 (US$77) Naira, respectively. We obtained limited data on the cost of oxygen services to facilities. Pulse oximetry use was low in secondary care facilities (32%, 21/65 patients had SpO2 documented) and negligible in private facilities (2%, 3/177) and primary health centres (<1%, 2/608). We were unable to determine the proportion of hypoxaemic patients who received oxygen therapy with available data. However, triangulation of existing data suggested that no facilities were equipped to meet minimum oxygen demands. We highlight the importance of a multifaceted approach to measuring oxygen access that assesses access at the point-of-care and ideally at the patient-level. We propose standard metrics to report oxygen access and describe how these can be integrated into routine health information systems and existing health facility assessment tools.

Effects of reconstruction techniques after proximal gastrectomy: a systematic review and meta-analysis.

BACKGROUND: Additional studies comparing several reconstruction methods after proximal gastrectomy have been published; of note, it is necessary to update systematic reviews and meta-analysis from the current evidence-based literature. AIM: To expand the current knowledge on feasibility and safety, and also to analyze postoperative outcomes of several reconstructive techniques after proximal gastrectomy. METHODS: PubMed, Google Scholar, and Medline databases were searched for original studies, and relevant literature published between the years 1966 and 2019 concerning various reconstructive techniques on proximal gastrectomy were selected. The postoperative outcomes and complications of the reconstructive techniques were assessed. Meta-analyses were performed using Rev-Man 5.0. A total of 29 studies investigating postoperative outcomes of double tract reconstruction, jejunal pouch interposition, jejunal interposition, esophagogastrostomy, and double flap reconstruction were finally selected in the quantitative analysis. RESULT: Pooled incidences of reflux esophagitis for double tract reconstruction, jejunal pouch interposition, jejunal interposition esophagogastrostomy, and double flap reconstruction were 8.6%, 13.8%, 13.8%, 19.3%, and 8.9% respectively. Meta-analysis showed a decreased length of hospital in the JI group as compared to the JPI group (heterogeneity: Chi2 = 1.34, df = 1 (P = 0.25); I2 = 26%, test for overall effect: Z = 2.22 (P = 0.03). There was also a significant difference between JI and EG in length of hospital stay with heterogeneity: Chi2 = 1.40, df = 3 (P = 0.71); I2 = 0%, test for overall effect: Z = 5.04 (P < 0.00001). Operative time was less in the EG group as compared to the JI group (heterogeneity: Chi2 = 31.09, df = 5 (P < 0.00001); I2 = 84%, test for overall effect: Z = 32.35 (P < 0.00001). CONCLUSION: Although current reconstructive techniques present excellent anti-reflux efficacy, the optimal reconstructive method remains to be determined. The double flap reconstruction proved to lower the rate of complication, but the DTR, JI, JPI, and EG groups showed higher incidence of complications in anastomotic leakage, anastomotic stricture, and residual food. In the meta-analysis result, the complications between the JI, JPI, and EG were comparable but the EG group showed to have better postoperative outcomes concerning the operative time, blood loss, and length of hospital stay.

A mixed-methods evaluation of stakeholder perspectives on pediatric pneumonia in Nigeria-priorities, challenges, and champions.

BACKGROUND: Interventions to reduce pneumonia mortality exist; however, stakeholder engagement is needed to prioritize these. We explored diverse stakeholder opinions on current policy challenges and priorities for pediatric pneumonia in Nigeria. METHODS: We conducted a mixed-methods study, with a web-survey and semi-structured interviews, to explore stakeholder roles, policy barriers, opportunities, and priorities. Web-survey participants were identified through stakeholder mapping, including researchers' networks, academic and grey literature, and "Every Breath Counts" coalition membership. Stakeholders included actors involved in pediatric pneumonia in Nigeria from non-governmental, government, academic, civil society, private, and professional organizations. Stakeholder interviews were conducted with local government, healthcare managers, professional associations, and local leaders in Lagos and Jigawa states. Quantitative data were analyzed descriptively; qualitative data were analyzed using a thematic framework. RESULTS: Of 111 stakeholders, 38 (34%) participated in the web-survey and 18 stakeholder interviews were conducted. Four thematic areas emerged: current policy, systems barriers, intervention priorities, and champions. Interviewees reported a lack of pneumonia-specific policies, despite acknowledging guidelines had been adopted in their settings. Barriers to effective pneumonia management were seen at all levels of the system, from the community to healthcare to policy, with key issues of resourcing and infrastructure. Intervention priorities were the strengthening of community knowledge and improving case management, focused on primary care. While stakeholders identified several key actors for pediatric pneumonia, they also highlighted a lack of champions. CONCLUSION: Consistent messages emerged to prioritize community and primary care initiatives, alongside improved access to oxygen, and pulse oximetry. There is a need for clear pneumonia policies, and support for adoption at a state level.

The burden and risks of pediatric pneumonia in Nigeria: A desk-based review of existing literature and data.

BACKGROUND: Pneumonia is a leading killer of children under-5 years, with a high burden in Nigeria. We aimed to quantify the regional burden and risks of pediatric pneumonia in Nigeria, and specifically the states of Lagos and Jigawa. METHODS: We conducted a scoping literature search for studies of pneumonia morbidity and mortality in under-5 children in Nigeria from 10th December 2018 to 26th April 2019, searching: Cochrane, PubMed, and Web of Science. We included grey literature from stakeholders' websites and information shared by organizations working in Nigeria. We conducted multivariable logistic regression using the 2016 to 2017 Multiple Cluster Indicators Survey data set to explore factors associated with pneumonia. Descriptive analyses of datasets from 2010 to 2019 was done to estimate trends in mortality, morbidity, and vaccination coverage. RESULTS: We identified 25 relevant papers (10 from Jigawa, 8 from Lagos, and 14 national data). None included data on pneumonia or acute respiratory tract infection burden in the health system, inpatient case-fatality rates, severity, or age-specific pneumonia mortality rates at state level. Secondary data analysis found that no household or caregiver socioeconomic indicators were consistently associated with self-reported symptoms of cough and/or difficulty breathing, and seasonality was inconsistently associated, dependant on region. CONCLUSION: There is a clear evidence gap around the burden of pediatric pneumonia in Nigeria, and challenges with the interpretation of existing household survey data. Improved survey approaches are needed to understand the risks of pediatric pneumonia in Nigeria, alongside the need for investment in reliable routine data systems to provide data on the clinical pneumonia burden in Nigeria.

Health system challenges for improved childhood pneumonia case management in Lagos and Jigawa, Nigeria.

BACKGROUND: Case fatality rates for childhood pneumonia in Nigeria remain high. There is a clear need for improved case management of pneumonia, through the sustainable implementation of the Integrated Management of Childhood Illnesses (IMCI) diagnostic and treatment algorithms. We explored barriers and opportunities for improved case management of childhood pneumonia in Lagos and Jigawa states, Nigeria. METHODS: A mixed-method analysis was conducted to assess the current health system capacity to deliver quality care. This was done through audits of 16 facilities in Jigawa and 14 facilities in Lagos, questionnaires (n = 164) and 13 focus group discussions with providers. Field observations provided context for data analysis and triangulation. RESULTS: There were more private providers in Lagos (4/8 secondary facilities) and more government providers in Jigawa (4/8 primary, 3/3 secondary, and 1/1 tertiary facilities). Oxygen and pulse oximeters were available in two of three in Jigawa and six of eight in Lagos of the sampled secondary care facilities. None of the eight primary facilities surveyed in Jigawa had oxygen or pulse oximetry available while in Lagos two of three primary facilities had oxygen and one of three had pulse oximeters. Other IMCI and emergency equipment were also lacking including respiratory rate timers, particularly in Jigawa state. Health care providers scored poorly on knowledge of IMCI, though previous IMCI training was associated with better knowledge. Key enabling factors in delivering pediatric care highlighted by health care providers included accountability procedures and feedback loops, the provision of free medication for children, and philanthropic acts. Common barriers to provide care included the burden of out-of-pocket payments, challenges in effective communication with caregivers, delayed presentation, and lack of clear diagnosis, and case management guidelines. CONCLUSION: There is an urgent need to improve how the prevention and treatment of pediatric pneumonia is directed in both Lagos and Jigawa. Priority areas for reducing pediatric pneumonia burden are training and mentoring of health care providers, community health education, and introduction of oximeters and oxygen supply.

Community and caregivers' perceptions of pneumonia and care-seeking experiences in Nigeria: A qualitative study.

BACKGROUND: Appropriate and timely care seeking can reduce pneumonia deaths, but are influenced by caregivers and community norms of health and illness. We explore caregiver and community perceptions, and care-seeking experience, of childhood pneumonia, to understand contexts that drive pediatric service uptake in Nigeria. METHODS: Community group discussions and qualitative interviews with caregivers in Lagos and Jigawa states were completed between 1 November 2018 and 31 May 2019. Participants were recruited from purposively sampled health facility catchment areas with assistance from facility staff. We used episodic interviews, asking caregivers (Jigawa = 20; Lagos = 15) to recount specific events linked to quests for therapy. Community group discussions (n = 3) used four vignettes from real pneumonia cases to frame a discussion around community priorities for healthcare and community-led activities to improve child survival. Data were analyzed using the framework method. RESULTS: We found poor knowledge of pneumonia-specific symptoms and risk factors among caregivers and community members, with many attributing pneumonia to cold air exposure. Interviews highlighted that care-seeking decision making involved both husbands and wives, but men often made final decisions. In Lagos, older female relatives also shaped quests for therapy. Cost was a major consideration. In both states, there were accounts of dissatisfaction with health workers' attitudes and a general acceptance of vaccination services. CONCLUSION: There is a need for community-based approaches to improve caregiver knowledge and care seeking for under-five children with pneumonia. Messaging should attend to knowledge of symptoms, risk factors, family dynamics, and community responsibilities in healthcare service delivery and utilization.

Development and Optimization of a Starch-Based Co-processed Excipient for Direct Compression Using Mixture Design.

The development of novel excipients with enhanced functionality has been explored using particle engineering by co-processing. The aim of this study was to improve the functionality of tapioca starch (TS) for direct compression by co-processing with gelatin (GEL) and colloidal silicon dioxide (CSD) in optimized proportions. Design of Experiment (DoE) was employed to optimize the composition of the co-processed excipient using the desirability function and other supporting studies as a basis for selecting the optimized formulation. The co-processed excipient (SGS) was thereafter developed by the method of co-fusion. Flow and compaction studies of SGS were carried out in comparison to its parent component (TS) and physical mixture (SGS-PM). Tablets were prepared by direct compression (DC) containing ibuprofen (200 mg) as a model for poor compressibility using SGS, Prosolv®, and StarLac® as multifunctional excipients. The optimized composition of SGS corresponded to TS (90%), GEL (7.5%), and CSD (2.5%). The functionality of SGS was improved relative to SGS-PM in terms of flow and compression. Tablets produced with SGS were satisfactory and conformed to USP specifications for acceptable tablets. SGS performed better than Prosolv® in terms of disintegration and was superior to StarLac with respect to tensile strength and disintegration time. The application of DoE was successful in optimizing and developing a starch-based co-processed excipient that can be considered for direct compression tableting.

Mortality risk associated with surgical treatment of female genital fistula.

OBJECTIVE: To describe the mortality risk associated with surgical treatment of female genital fistula and the contributory and contextual factors. METHODS: In a descriptive study, confidential inquiries and clinical audits were conducted at 14 fistula repair sites in seven resource-poor countries between January 2005 and March 2013. Data collection included interviews with key personnel involved in the clinical management of the deceased, and a review of hospital records and patient files following an audit protocol. RESULTS: Overall, 26060 fistula repairs were performed at 44 sites located in 13 countries; 30 deaths were reported in this period. Twenty-one deaths were attributable to surgery, yielding a case fatality of 0.08 per 100 procedures. The cause of death in nearly half of the cases was various manifestations of sepsis and inflammation. CONCLUSION: The case fatality rate for fistula repair surgery in resource-poor countries was in the same range as that for comparable gynecologic operations in high-resource settings. Clinical and systemic issues to be addressed to reduce the case fatality rate include improvement of perioperative care and follow-up, assuring prudent referral or deferral of difficult cases, and maintaining better records.

Community-based screening for obstetric fistula in Nigeria: a novel approach.

BACKGROUND: Obstetric fistula continues to have devastating effects on the physical, social, and economic lives of thousands of women in many low-resource settings. Governments require credible estimates of the backlog of existing cases requiring care to effectively plan for the treatment of fistula cases. Our study aims to quantify the backlog of obstetric fistula cases within two states via community-based screenings and to assess the questions in the Demographic Health Survey (DHS) fistula module. METHODS: The screening sites, all lower level health facilities, were selected based on their geographic coverage, prior relationships with the communities and availability of fistula surgery facilities in the state. This cross-sectional study included women who presented for fistula screenings at study facilities based on their perceived fistula-like symptoms. Research assistants administered the pre-screening questionnaire. Nurse-midwives then conducted a medical exam. Univariate and bivariate analyses are presented. RESULTS: A total of 268 women attended the screenings. Based on the pre-screening interview, the backlog of fistula cases reported was 75 (28% of women screened). The backlog identified after the medical exam was 26 fistula cases (29.5% of women screened) in Kebbi State sites and 12 cases in Cross River State sites (6.7%). Verification assessment showed that the DHS questionnaire had 92% sensitivity, 83% specificity with 47% positive predictive value and 98% negative predictive value for identifying women afflicted by fistula among women who came for the screenings. CONCLUSIONS: This methodology, involving effective, locally appropriate messaging and community outreach followed up with medical examination by nurse-midwives at lower level facilities, is challenging, but represents a promising approach to identify the backlog of women needing surgery and to link them with surgical facilities.