A research agenda to improve incidence and outcomes of assisted vaginal birth.

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

L'accès aux soins obstétriques d'urgence, y compris l'accouchement vaginal assisté et la césarienne, est essentiel pour améliorer les effets de la maternité et de l'accouchement. Toutefois, bien que la proportion de césariennes ait augmenté ces dernières décennies, le recours à l'accouchement vaginal assisté a diminué. C'est particulièrement le cas dans les pays à revenu faible ou intermédiaire, bien que l'accouchement vaginal assisté soit souvent moins risqué qu'une césarienne. Nous avons donc mené un processus en trois étapes afin d'imaginer un programme de recherche qui permettrait d'augmenter le recours à l'accouchement vaginal assisté ou de le réintroduire. Après avoir réalisé une synthèse des données probantes, qui a servi de base à une consultation avec des experts techniques qui ont proposé un programme de recherche initial, nous avons sollicité et incorporé les avis des représentantes des femmes pour ce programme. Ce processus nous a permis d'imaginer un programme de recherche complet, avec des sujets classés comme suit: (i) la nécessité de comprendre la perception qu'ont les femmes de l'accouchement vaginal assisté et de fournir des informations appropriées et fiables; (ii) l'importance de la formation des prestataires de soins de santé en matière de compétences cliniques, mais aussi de respect dans les soins de santé, de communication efficace, de prise de décision partagée et de consentement éclairé; ou (iii) les obstacles à la mise en œuvre et à la durabilité et les facteurs qui les facilitent. Les réactions de femmes nous ont appris qu'il était urgent de reconnaître que l'accouchement, la naissance et le post-partum sont des processus humains intrinsèquement physiologiques et dignes au cours desquels les interventions ne devraient être mises en œuvre qu'en cas de nécessité. La promotion et/ou la réintroduction de l'accouchement vaginal assisté dans les régions à faibles ressources nécessitent que les pouvoirs publics, les décideurs politiques et les administrations d'hôpitaux soutiennent les prestataires de soins de santé qualifiés, qui pourront à leur tour soutenir respectueusement les femmes pendant l'accouchement.

El acceso a la atención obstétrica de emergencia, incluido el parto vaginal asistido y el parto por cesárea, es crucial para mejorar los resultados de la maternidad y el parto. No obstante, aunque el porcentaje de partos por cesárea ha aumentado en las últimas décadas, el uso del parto vaginal asistido ha disminuido. Esto ocurre especialmente en los países de ingresos bajos y medios, a pesar de que un parto vaginal asistido suele ser menos arriesgado que un parto por cesárea. Por lo tanto, llevamos a cabo un proceso de tres pasos para identificar un programa de investigación necesario para aumentar el uso del parto vaginal asistido o volver a incorporarlo: tras realizar una síntesis de la evidencia, que sirvió de base para una consulta con expertos técnicos que propusieron un programa de investigación inicial, buscamos e integramos las opiniones de las representantes de las mujeres sobre este programa. Este proceso nos ha permitido identificar un programa de investigación exhaustivo, con temas categorizados como: (i) la necesidad de comprender las percepciones de las mujeres sobre el parto vaginal asistido, y proporcionar información adecuada y fiable; (ii) la importancia de formar a los profesionales sanitarios en habilidades clínicas, pero también en atención respetuosa, comunicación efectiva, toma de decisiones compartida y consentimiento informado; o (iii) las barreras y los facilitadores de la implementación y la sostenibilidad. A partir de las opiniones de las mujeres, nos enteramos de la urgente necesidad de reconocer las experiencias del parto, el alumbramiento y el posparto como procesos humanos inherentemente fisiológicos y dignos, en los que las intervenciones solo deben aplicarse si son necesarias. La promoción o la reincoporación del parto vaginal asistido en regiones de escasos recursos exige que los gobiernos, los responsables de formular políticas y los administradores de hospitales apoyen a los profesionales sanitarios capacitados que, a su vez, pueden ayudar a las mujeres en el trabajo de parto y el alumbramiento de manera respetuosa.

Witch Nails (Krt90whnl): A spontaneous mouse mutation affecting nail growth and development.

Numerous single gene mutations identified in humans and mice result in nail deformities with many similarities between the species. A spontaneous, autosomal, recessive mutation called witch nails (whnl) is described here where the distal nail matrix and nail bed undergo degenerative changes resulting in formation of an abnormal nail plate causing mice to develop long, curved nails. This mutation arose spontaneously in a colony of MRL/MpJ-Faslpr/J at The Jackson Laboratory. Homozygous mutant mice are recognizable by 8 weeks of age by their long, curved nails. The whnl mutation, mapped on Chromosome 15, is due to a 7-bp insertion identified in the 3' region of exon 9 in the Krt90 gene (formerly Riken cDNA 4732456N10Rik), and is predicted to result in a frameshift that changes serine 476 to arginine and subsequently introduces 36 novel amino acids into the protein before a premature stop codon (p. Ser476ArgfsTer36). By immunohistochemistry the normal KRT90 protein is expressed in the nail matrix and nail bed in control mice where lesions are located in mutant mice. Immunoreactivity toward equine KRT124, the ortholog of mouse KRT90, is restricted to the hoof lamellae (equine hoof wall and lamellae are homologous to the mouse nail plate and nail bed) and the mouse nail bed. Equine laminitis lesions are similar to those observed in this mutant mouse suggesting that the latter may be a useful model for hoof and nail diseases. This first spontaneous mouse mutation affecting the novel Krt90 gene provides new insight into the normal regulation of the molecular pathways of nail development.

Cesarean delivery rates, hospital readiness and quality of clinical management in Ethiopia: national results from two cross-sectional emergency obstetric and newborn care assessments.

BACKGROUND: Cesarean delivery (CD) rates have reached epidemic levels in many high and middle income countries while increasingly, low income countries are challenged both by high urban CD rates and high unmet need in rural areas. The managing authority of health care institutions often plays a role in these disparities. This paper shows changes between 2008 and 2016 in Ethiopian CD rates, readiness of hospitals to provide CD and quality of clinical care, while highlighting the role of hospital management authority. METHODS: This secondary data analysis draws from two national cross-sectional studies to assess emergency obstetric and newborn care. The sample includes 111 hospitals in 2008 and 316 hospitals in 2016, and 275 women whose CD chart was reviewed in 2008 and 568 in 2016. Descriptive statistics are used to describe our primary outcome measures: population- and institutional-based CD rates; hospital readiness to perform CD; quality of clinical management, including the relative size of Robson classification groups. RESULTS: The national population CD rate increased from 2008 to 2016 (< 1 to 2.7%) as did all regional rates. Rates in 2016 ranged from 24% in urban settings to less than 1% in several rural regions. The institutional rate was 54% in private for-profit hospitals in 2016, up from 46% in 2008. Hospital readiness to perform CDs increased in public and private for-profit hospitals. Only half of the women whose charts were reviewed received uterotonics after delivery of the baby, but use of prophylactic antibiotics was high. Partograph use increased from 9 to 42% in public hospitals, but was negligible or declined elsewhere. In 2016, 40% of chart reviews from public hospitals were among low-risk nulliparous women (Robson groups 1&2). CONCLUSIONS: Between 2008 and 2016, government increased the availability of CD services, improved public hospital readiness and some aspects of clinical quality. Strategies tailored to further reduce the high unmet need for CD and what appears to be an increasing number of unnecessary cesareans are discussed. Adherence to best practices and universal coverage of water and electricity will improve the quality of hospital services while the use of the Robson classification system may serve as a useful quality improvement tool.

Factors related to the practice of vacuum-assisted birth: findings from provider interviews in Kigoma, Tanzania.

BACKGROUND: Vacuum-assisted birth is not widely practiced in Tanzania but efforts to re-introduce the procedure suggest some success. Few studies have targeted childbirth attendants to learn how their perceptions of and training experiences with the procedure affect practice. This study explores a largely rural cohort of health providers to determine associations between recent practice of the procedure and training, individual and contextual factors. METHODS: A cross-sectional knowledge, attitudes and practice survey of 297 providers was conducted in 2019 at 3 hospitals and 12 health centers that provided comprehensive emergency obstetric care. We used descriptive statistics and binary logistic regression to model the probability of having performed a vacuum extraction in the last 3 months. RESULTS: Providers were roughly split between working in maternity units in hospitals and health centers. They included: medical doctors, assistant medical officers (14%); clinical officers (10%); nurse officers, assistant nurse officers, registered nurses (32%); and enrolled nurses (44%). Eighty percent reported either pre-service, in-service vacuum extraction training or both, but only 31% reported conducting a vacuum-assisted birth in the last 3 months. Based on 11 training and enabling factors, a positive association with recent practice was observed; the single most promising factor was hands-on solo practice during in-service training (66% of providers with this experience had conducted vacuum extraction in the last 3 months). The logistic regression model showed that providers exposed to 7-9 training modalities were 7.8 times more likely to have performed vacuum extraction than those exposed to fewer training opportunities (AOR = 7.78, 95% CI: 4.169-14.524). Providers who worked in administrative councils other than Kigoma Municipality were 2.7 times more likely to have conducted vacuum extraction than their colleagues in Kigoma Municipality (AOR = 2.67, 95% CI: 1.023-6.976). Similarly, providers posted in a health center compared to those in a hospital were twice as likely to have conducted a recent vacuum extraction (AOR = 2.11, 95% CI: 1.153-3.850), and finally, male providers were twice as likely as their female colleagues to have performed this procedure recently (AOR = 1.95, 95% CI: 1.072-3.55). CONCLUSIONS: Training and location of posting were associated with recent practice of vacuum extraction. Multiple training modalities appear to predict recent practice but hands-on experience during training may be the most critical component. We recommend a low-dose high frequency strategy to skills building with simulation and e-learning. A gender integrated approach to training may help ensure female trainees are exposed to critical training components.

Triangulating data sources for further learning from and about the MDSR in Ethiopia: a cross-sectional review of facility based maternal death data from EmONC assessment and MDSR system.

BACKGROUND: Triangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women. METHODS: This paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system. RESULTS: A maternal death review committee was established in 64% of health facilities. 5.5% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10-27%) and severe preeclampsia/eclampsia (10-24.1%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7-33% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32% & 40% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22% of maternal deaths. From the EmONC data, 72% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48% of those dying of postpartum haemorrhage received uterotonics. CONCLUSION: The facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities.

Healthcare workers' clinical knowledge on maternal and newborn care in Ethiopia: findings from 2016 national EmONC assessment.

BACKGROUND: Improving maternal and newborn health indicators are key if Ethiopia is to achieve the Sustainable Development Goals. To do so, women need access to skilled attendance at birth and emergency obstetric and newborn care. To maximize their impact, understanding gaps in workers' knowledge is required to remedy the weakness. This assessment determines knowledge levels of clinical management of maternal and newborn healthcare and factors that influence knowledge. METHODS: This study used data from the National Emergency Obstetric and Neonatal Care assessment conducted in 2016. Provider knowledge for MNH was assessed by interviewing providers. Respondents were scored on each question by calculating the number of correct responses provided out of the total possible answers, and standardizing this to a scale of 100. Mixed linear regression was used to determine individual and contextual factors associated with the score. RESULTS: A total of 3800 interviews with complete data were included in this study. Most respondents were diploma midwives (73%), BSc midwives (11%) and diploma nurses (10%). On average, midwives scored 60 out of 100 on the question regarding the primary aspects of focused antenatal care and elements of a birth plan. Half of the midwives and health officers, and one-third of nurses knew to provide a loading dose of magnesium sulphate. Midwives scored 90% on the steps of active management of third stage of labor. In the mixed linear regression, working in a private for profit facility, health center/clinic, rural area, or in a facility with a protocol on referral/counter referral predicted lower knowledge scores. More positive scores were associated with work environments that had a computer, internet, and protocols on safe abortion care, management of selected obstetric topics, integrated management of pregnancy, childbirth, postnatal, and newborn, care for low birth weight including kangaroo mother care, and treatment of infection in young infants. CONCLUSION: With regard to most knowledge related questions, health officers and midwives scored similarly. Providers scored substantially better on routine intrapartum and newborn care than on aspects related to care for complications. A substantial proportion of providers indicated that they would never give a loading dose of magnesium sulphate.

Geographic access to emergency obstetric services: a model incorporating patient bypassing using data from Mozambique / Geographic access to emergency obstetric services: a model incorporating patient bypassing using data from Mozambique

Targeted approaches to further reduce maternal mortality require thorough understanding of the geographic barriers that women face when seeking care. Common measures of geographic access do not account for the time needed to reach services, despite substantial evidence that links proximity with greater use of facility services. Further, methods for measuring access often ignore the evidence that women frequently bypass close facilities based on perceptions of service quality. This paper aims to adapt existing approaches for measuring geographic access to better reflect women's bypassing behaviour, using data from Mozambique. Using multiple data sources and modelling within a geographic information system, we calculated two segments of a patient's time to care: (1) home to the first preferred facility, assuming a woman might travel longer to reach a facility she perceived to be of higher quality; and (2) referral between the first preferred facility and facilities providing the highest level of care (eg, surgery). Combined, these two segments are total travel time to highest care. We then modelled the impact of expanding services and emergency referral infrastructure. The combination of upgrading geographically strategic facilities to provide the highest level of care and providing transportation to midlevel facilities modestly increased the percentage of the population with 2-hour access to the highest level of care (from 41% to 45%). The mean transfer time between facilities would be reduced by 39% (from 2.9 to 1.8 hours), and the mean total journey time by 18% (from 2.5 to 2.0 hours). This adapted methodology is an effective tool for health planners at all levels of the health system, particularly to identify areas of very poor access. The modelled changes indicate substantial improvements in access and identify populations outside timely access for whom more innovative interventions are needed.

Readiness to treat and factors associated with survival of newborns with breathing difficulties in Ethiopia.

BACKGROUND: Ethiopia is one of five countries that account for half of the world's 2.6 million newborn deaths. A quarter of neonatal deaths in Ethiopia are caused by birth asphyxia. Understanding different dimensions of the quality of care for newborns with breathing difficulties can lead to improving service provision environments and practice. We describe facility readiness to treat newborns with breathing difficulties, the extent to which newborn resuscitation is provided, and by modeling the survival of newborns with difficulties breathing, we identify key factors that suggest how mortality from asphyxia can be reduced. METHODS: We carried out a secondary analysis of the 2016 Ethiopia Emergency Obstetric and Newborn Care Assessment that included 3804 facilities providing childbirth services and 2433 chart reviews of babies born with difficulties breathing. We used descriptive statistics to assess health facilities' readiness to treat these newborns and a binary logistic regression to identify factors associated with survival. RESULTS: Over one-quarter of facilities did not have small-sized masks (size 0 or 1) to complete the resuscitation kits. Among the 2190 cases with known survival status, 49% died before discharge, and among 1035 cases with better data quality, 29% died. The odds of surviving birth asphyxia after resuscitation increased eightfold compared to newborns not resuscitated. Other predictors for survival were the availability of a newborn corner, born at term or post-term, normal birth weight (≥2500 g) and delivered by cesarean or assisted vaginal delivery. CONCLUSION: The survival status of newborns with birth asphyxia was low, particularly in the primary care facilities that lacked the required resuscitation pack. Newborns born in a facility with better data quality were more likely to survive than those born in facilities with poor data quality. Equipping health centers/clinics with resuscitation packs and reducing the incidence of preterm and low birth weight babies should improve survival rates.

Categorising interventions to levels of inpatient care for small and sick newborns: Findings from a global survey.

BACKGROUND: In 2017, 2.5 million newborns died, mainly from prematurity, infections, and intrapartum events. Preventing these deaths requires health systems to provide routine and emergency care at birth, and quality inpatient care for small and sick newborns. Defined levels of emergency obstetric care (EmOC) and standardised measurement of "signal functions" has improved tracking of maternal care in low- and middle-income countries (LMICs). Levels of newborn care, particularly for small and sick newborns, and associated signal functions are still not consistently defined or tracked. METHODS: Between November 2016-November 2017, we conducted an online survey of professionals working in maternal and newborn health. We asked respondents to categorise 18 clinical care interventions that could act as potential signal functions for small and sick newborns to 3 levels of care they thought were appropriate for health systems in LMICs to provide: "routine care at birth", "special care" and "intensive care". We calculated the percentage of respondents that classified each intervention at each level of care and stratified responses to look at variation by respondent characteristics. RESULTS: Six interventions were classified to specific levels by more than 50% of respondents as "routine care at birth," three interventions as "special care" and one as "intensive care". Eight interventions were borderline between these care levels. Responses were more consistent for interventions with relevant WHO clinical care guidelines while more variation in respondents' classification was observed in complex interventions that lack standards or guidelines. Respondents with experience in lower-income settings were more likely to assign a higher level of care for more complex interventions. CONCLUSIONS: Results were consistent with known challenges of scaling up inpatient care in lower-income settings and underline the importance of comprehensive guidelines and standards for inpatient care. Further work is needed to develop a shortlist of newborn signal functions aligned with emergency obstetric care levels to track universal health coverage for mothers and their newborns.

Geographic access to emergency obstetric services: a model incorporating patient bypassing using data from Mozambique.

INTRODUCTION: Targeted approaches to further reduce maternal mortality require thorough understanding of the geographic barriers that women face when seeking care. Common measures of geographic access do not account for the time needed to reach services, despite substantial evidence that links proximity with greater use of facility services. Further, methods for measuring access often ignore the evidence that women frequently bypass close facilities based on perceptions of service quality. This paper aims to adapt existing approaches for measuring geographic access to better reflect women's bypassing behaviour, using data from Mozambique. METHODS: Using multiple data sources and modelling within a geographic information system, we calculated two segments of a patient's time to care: (1) home to the first preferred facility, assuming a woman might travel longer to reach a facility she perceived to be of higher quality; and (2) referral between the first preferred facility and facilities providing the highest level of care (eg, surgery). Combined, these two segments are total travel time to highest care. We then modelled the impact of expanding services and emergency referral infrastructure. RESULTS: The combination of upgrading geographically strategic facilities to provide the highest level of care and providing transportation to midlevel facilities modestly increased the percentage of the population with 2-hour access to the highest level of care (from 41% to 45%). The mean transfer time between facilities would be reduced by 39% (from 2.9 to 1.8 hours), and the mean total journey time by 18% (from 2.5 to 2.0 hours). CONCLUSION: This adapted methodology is an effective tool for health planners at all levels of the health system, particularly to identify areas of very poor access. The modelled changes indicate substantial improvements in access and identify populations outside timely access for whom more innovative interventions are needed.

Distribution of maternity waiting homes and their correlation with perinatal mortality and direct obstetric complication rates in Ethiopia.

BACKGROUND: Ethiopia has been expanding maternity waiting homes to bridge geographical gaps between health facilities and communities in order to improve access to skilled care. In 2015, the Ministry of Health revised its national guidelines to standardize the rapid expansion of waiting homes. Little has been done to document their distribution, service availability and readiness. This paper addresses these gaps as well as their association with perinatal mortality and obstetric complication rates. METHODS: We utilized data from the 2016 national Emergency Obstetric and Newborn Care assessment, a census of 3804 public and private health facilities. Data were collected between May and December 2016 through interviews with health care workers, record reviews, and observation of infrastructure. Descriptive statistics describe the distribution and characteristics of waiting homes and linear regression models examined the correlation between independent variables and institutional perinatal and peripartum outcomes. RESULTS: Nationally, about half of facilities had a waiting home. More than two-thirds of facilities in Amhara and half of the facilities in SNNP and Oromia had a home while the region of Gambella had none. Highly urbanized regions had few homes. Conditions were better among homes at hospitals than at health centers. Finished floors, electricity, water, toilets, and beds with mattresses were available at three (or more) out of four hospital homes. Waiting homes in pastoralist regions were often at a disadvantage. Health facilities with waiting homes had similar or lower rates of perinatal death and direct obstetric complication rates than facilities without a home. The perinatal mortality was 47% lower in hospitals with a home than those without. Similarly, the direct obstetric complication rate was 49% lower at hospitals with a home compared to hospitals without. CONCLUSIONS: The findings should inform regional maternal and newborn improvement strategies, indicating gaps in the distribution and conditions, especially in the pastoralist regions. The impact of waiting homes on maternal and perinatal outcomes appear promising and as homes continue to expand, so should efforts to regularly monitor, refine and document their impact.

Corrections and connection to the community: A diagnostic and service program for incarcerated adult men with FASD.

Previous research has demonstrated that impaired social and adaptive behavior due to prenatal alcohol exposure can be associated with severe conduct disorders in adolescence, mental health concerns, school failure, employment difficulties, substance abuse, difficulty with the law, and incarceration. The Corrections and Connections to the Community research and service program was established to examine adult male offenders with frequent contact with the provincial corrections system. Individuals who participated in the program received neuropsychological testing, a functional assessment and a psychiatric interview. Results indicated that 90% of the participants identified within the spectrum of FASD. The functional profile indicated that many participants had impaired social functioning. A natural dichotomy emerged from the data which reflected those who connected early with the criminal justice system (65%) and those who did not connect within the 18 month project period. Significant differences emerged between those individuals who reconnected with the justice system and who also possessed a juvenile record and those who did not. Further analysis also indicated significant differences between scores on the Finger Tapping Test, Trail Making Test A, ILS and California Verbal Learning Test. Findings of this study highlight the importance of appropriate programming and services for incarcerated men with FASD.

Referral patterns through the lens of health facility readiness to manage obstetric complications: national facility-based results from Ghana.

INTRODUCTION: Countries with high maternal and newborn mortality can benefit from national facility level data that describe intra-facility emergency referral patterns for major obstetric complications. This paper assesses the relationship between referral and facilities' readiness to treat complications at each level of the health system in Ghana. We also investigate other facility characteristics associated with referral. METHODS: The National Emergency Obstetric and Newborn Care Assessment 2010 provided aggregated information from 977 health facilities. Readiness was defined in a 2-step process: availability of a health worker who could provide life-saving interventions and a minimum package of drugs, supplies, and equipment to perform the interventions. The second step mapped interventions to major obstetric complications. We used descriptive statistics and simple linear regression. RESULTS: Lower level facilities were likely to refer nearly all women with complications. District hospitals resolved almost two-thirds of all complicated cases, referring 9%. The most prevalent indications for referral were prolonged/obstructed labor and antepartum hemorrhage. Readiness to treat a complication was correlated with a reduction in referral for all complications except uterine rupture. Facility readiness was low: roughly 40% of hospitals and 10% of lower level facilities met the readiness threshold. Facilities referred fewer women when they had higher caseloads, more midwives, better infrastructure, and systems of communication and transport. DISCUSSION: Understanding how deliveries and obstetric complications are distributed across the health system helps policy makers contextualize decisions about the pathways to providing maternity services. Improving conditions for referral (by increasing access to communication and transport systems) and the management of obstetric complications (increasing readiness) will enhance quality of care and make referral more effective and efficient.

Service readiness for inpatient care of small and sick newborns: what do we need and what can we measure now?

BACKGROUND: Each year an estimated 2.6 million newborns die, mainly from complications of prematurity, neonatal infections, and intrapartum events. Reducing these deaths requires high coverage of good quality care at birth, and inpatient care for small and sick newborns. In low- and middle-income countries, standardised measurement of the readiness of facilities to provide emergency obstetric care has improved tracking of readiness to provide care at birth in recent years. However, the focus has been mainly on obstetric care; service readiness for providing inpatient care of small and sick newborns is still not consistently measured or tracked. METHODS: We reviewed existing international guidelines and resources to create a matrix of the structural characteristics (infrastructure, equipment, drugs, providers and guidelines) for service readiness to deliver a package of inpatient care interventions for small and sick newborns. To identify gaps in existing measurement systems, we reviewed three multi-country health facility survey tools (the Service Availability and Readiness Assessment, the Service Provision Assessment and the Emergency Obstetric and Newborn Care Assessment) against our service readiness matrix. FINDINGS: For service readiness to provide inpatient care for small and sick newborns, our matrix detailed over 600 structural characteristics. Our review of the SPA, the SARA and the EmONC assessment tools identified several measurement omissions to capture information on key intervention areas, such as thermoregulation, feeding and respiratory support, treatment of specific complications (seizures, jaundice), and screening and follow up services, as well as specialised staff and service infrastructure. CONCLUSIONS: Our review delineates the required inputs to ensure readiness to provide inpatient care for small and sick newborns. Based on these findings, we detail where questions need to be added to existing tools and describe how measurement systems can be adapted to reflect small and sick newborns interventions. Such work can inform investments in health systems to end preventable newborn death and disability as part of the Every Newborn Action Plan.

Progress in Mozambique: Changes in the availability, use, and quality of emergency obstetric and newborn care between 2007 and 2012.

INTRODUCTION: Maternal mortality in Mozambique has not declined significantly in the last 10-15 years, plateauing around 480 maternal deaths per 100,000 live births. Good quality antenatal care and routine and emergency intrapartum care are critical to reducing preventable maternal and newborn deaths. MATERIALS AND METHODS: We compare the findings from two national cross-sectional facility-based assessments conducted in 2007 and 2012. Both were designed to measure the availability, use and quality of emergency obstetric and neonatal care. Indicators for monitoring emergency obstetric care were used as were descriptive statistics. RESULTS: The availability of facilities providing the full range of obstetric life-saving procedures (signal functions) decreased. However, an expansion in the provision of individual signal functions was highly visible in health centers and health posts, but in hospitals, performance was less satisfactory, with proportionally fewer hospitals providing assisted vaginal delivery, obstetric surgery and blood transfusions. All other key indicators showed signs of improvements: the institutional delivery rate, the cesarean delivery rate, met need for emergency obstetric care (EmOC), institutional stillbirth and early neonatal death rates, and cause-specific case fatality rates (CFRs). CFRs for most major obstetric complications declined between 17% and 69%. The contribution of direct causes to maternal deaths decreased while the proportion of indirect causes doubled during the five-year interval. CONCLUSIONS: The indicator of EmOC service availability, often used for planning and developing EmONC networks, requires close examination. The standard definition can mask programmatic weaknesses and thus, fails to inform decision makers of what to target. In this case, the decline in the use of assisted vaginal delivery explained much of the difference in this indicator between the two surveys, as did faltering hospital performance. Despite this backsliding, many signs of improvement were also observed in this 5-year period, but indicator levels continue below recommended thresholds. The quality of intrapartum care and the adverse consequences from infectious diseases during pregnancy point to priority areas for programmatic improvement.

Progress in Mozambique: Changes in the availability, use, and quality of emergency obstetric and newborn care between 2007 and 2012

Maternal mortality in Mozambique has not declined significantly in the last 10-15 years, plateauing around 480 maternal deaths per 100,000 live births. Good quality antenatal care and routine and emergency intrapartum care are critical to reducing preventable maternal and newborn deaths. Materials and methods: We compare the findings from two national cross-sectional facility-based assessments conducted in 2007 and 2012. Both were designed to measure the availability, use and quality of emergency obstetric and neonatal care. Indicators for monitoring emergency obstetric care were used as were descriptive statistics. Results: The availability of facilities providing the full range of obstetric life-saving procedures (signal functions) decreased. However, an expansion in the provision of individual signal functions was highly visible in health centers and health posts, but in hospitals, performance was less satisfactory, with proportionally fewer hospitals providing assisted vaginal delivery, obstetric surgery and blood transfusions. All other key indicators showed signs of improvements: the institutional delivery rate, the cesarean delivery rate, met need for emergency obstetric care (EmOC), institutional stillbirth and early neonatal death rates, and cause-specific case fatality rates (CFRs). CFRs for most major obstetric complications declined between 17% and 69%. The contribution of direct causes to maternal deaths decreased while the proportion of indirect causes doubled during the five-year interval. Conclusions: The indicator of EmOC service availability, often used for planning and developing EmONC networks, requires close examination. The standard definition can mask programmatic weaknesses and thus, fails to inform decision makers of what to target. In this case, the decline in the use of assisted vaginal delivery explained much of the difference in this indicator between the two surveys, as did faltering hospital performance. Despite this backsliding, many signs of improvement were also observed in this 5-year period, but indicator levels continue below recommended thresholds. The quality of intrapartum care and the adverse consequences from infectious diseases during pregnancy point to priority areas for programmatic improvement.

Reintroducing vacuum extraction in primary health care facilities: a case study from Tanzania.

BACKGROUND: In rural Tanzania access to emergency obstetric and newborn care is threatened by poor roads and understaffed facilities among other challenges. Districts in Kigoma, Pwani and Morogoro regions were targeted by a local non-governmental organization to assist local government to build capacity and improve access to clinical management of severe obstetric and newborn complications. The program upgraded ten primary health care centres to provide comprehensive emergency obstetric and newborn care. This paper describes the process of reintroducing vacuum extraction into ten health centres and five hospitals, highlighting patterns in uptake, mode of delivery and lessons learned. METHODS: This observational study uses facility-based trend data collected between 2011 and 2016.Descriptive outcomes include institutional caesarean delivery rates, vacuum extraction rates, and the ratio of caesareans to vacuum-assisted deliveries. RESULTS: Institutional caesarean delivery rates remained stable at about 10-11% and the vacuum extraction rate rose from virtually no procedures in 2011 to about 2% in 2016. The increase was more visible in upgraded health centres than in hospitals. In 2016 vacuum extraction rates in newly upgraded health centres ranged from 0.5 to 7.8%. Between 2011 and 2016, the ratio of caesareans to vacuum extractions in hospitals changed from 304 caesareans to 1 vacuum extraction to 10:1, while in health centres the ratio changed from 22: 1 to 3: 1. CONCLUSIONS: Reintroduction of vacuum extraction into clinical practice in primary health care facilities with task-shifting is feasible. Reintroduction of this procedure was more successful when part of an integrated upgrading of health centres to provide comprehensive emergency obstetric care than when reintroduced into busy hospital environments. Turnover of trained staff in hospitals contributed to the uneven uptake of vacuum extraction. Lessons learned are applicable to further national scale up and to other countries.

Maternal death and delays in accessing emergency obstetric care in Mozambique.

BACKGROUND: Despite declining trends maternal mortality remains an important public health issue in Mozambique. The delays to reach an appropriate health facility and receive care faced by woman with pregnancy related complications play an important role in the occurrence of these deaths. This study aims to examine the contribution of the delays in relation to the causes of maternal death in facilities in Mozambique. METHODS: Secondary analysis was performed on data from a national assessment on maternal and neonatal health that included in-depth maternal death reviews, using patient files and facility records with the most comprehensive information available. Statistical models were used to assess the association between delay to reach the health facility that provides emergency obstetric care (delay type II) and delay in receiving appropriate care once reaching the health facility providing emergency obstetric care (delay type III) and the cause of maternal death within the health facility. RESULTS: Data were available for 712 of 2,198 maternal deaths. Delay type II was observed in 40.4% of maternal deaths and delay type III in 14.2%.and 13.9% had both delays. Women who died of a direct obstetric complication were more likely to have experienced a delay type III than women who died due to indirect causes. Women who experienced delay type II were less likely to have also delay type III and vice versa. CONCLUSIONS: The delays in reaching and receiving appropriate facility-based care for women facing pregnancy related complications in Mozambique contribute significantly to maternal mortality. Securing referral linkages and health facility readiness for rapid and correct patient management are needed to reduce the impact of these delays within the health system.

Institutional maternal and perinatal deaths: a review of 40 low and middle income countries.

BACKGROUND: Understanding the magnitude and clinical causes of maternal and perinatal mortality are basic requirements for positive change. Facility-based information offers a contextualized resource for clinical and organizational quality improvement. We describe the magnitude of institutional maternal mortality, causes of death and cause-specific case fatality rates, as well as stillbirth and pre-discharge neonatal death rates. METHODS: This paper draws on secondary data from 40 low and middle income countries that conducted emergency obstetric and newborn care assessments over the last 10 years. We reviewed 6.5 million deliveries, surveyed in 15,411 facilities. Most of the data were extracted from reports and aggregated with excel. RESULTS: Hemorrhage and hypertensive diseases contributed to about one third of institutional maternal deaths and indirect causes contributed another third (given the overrepresentation of sub-Saharan African countries with large proportions of indirect causes). The most lethal obstetric complication, across all regions, was ruptured uterus, followed by sepsis in Latin America and the Caribbean and sub-Saharan Africa. Stillbirth rates exceeded pre-discharge neonatal death rates in nearly all countries, possibly because women and their newborns were discharged soon after birth. CONCLUSIONS: To a large extent, facility-based findings mirror what population-based systematic reviews have also documented. As coverage of a skilled attendant at birth increases, proportionally more deaths will occur in facilities, making improvements in record-keeping and health management information systems, especially for stillbirths and early neonatal deaths, all the more critical.