Short birth interval in the Asia-Pacific region: A systematic review and meta-analysis.

Background: Short birth interval is associated with an increased risk of adverse health outcomes for mothers and children. Despite this, there is a lack of comprehensive evidence on short birth interval in the Asia-Pacific region. Thus, this study aimed to synthesise evidence related to the definition, classification, prevalence, and predictors of short birth interval in the Asia-Pacific region. Methods: Five databases (MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature, Maternity and Infant Care, and Web of Science) were searched for studies published between September 2000 and May 2023 (the last search was conducted for all databases in May 2023). We included original studies published in English that reported on short birth interval in the Asia-Pacific region. Studies that combined birth interval with birth order, used multi-country data and were published as conference abstracts and commentaries were excluded. Three independent reviewers screened the articles for relevancy, and two reviewers performed the data extraction and quality assessment. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool. The findings were both qualitatively and quantitatively synthesised and presented. Results: A total of 140 studies met the inclusion criteria for this review. About 58% (n = 82) of the studies defined short birth interval, while 42% (n = 58) did not. Out of 82 studies, nearly half (n = 39) measured a birth-to-birth interval, 37 studies measured a birth-to-pregnancy, four measured a pregnancy-to-pregnancy, and two studies measured a pregnancy loss-to-conception. Approximately 39% (n = 55) and 6% (n = 8) of studies classified short birth intervals as <24 months and <33 months, respectively. Most of the included studies were cross-sectional, and about two-thirds had either medium or high risk of bias. The pooled prevalence of short birth interval was 33.8% (95% confidence interval (CI) = 23.0-44.6, I2 = 99.9%, P < 0.01) among the studies that used the World Health Organization definition. Conclusions: This review's findings highlighted significant variations in the definition, measurement, classification, and reported prevalence of short birth interval across the included studies. Future research is needed to harmonise the definition and classification of short birth interval to ensure consistency and comparability across studies and facilitate the development of targeted interventions and policies. Registration: PROSPERO CRD42023426975.

Effects of short birth interval on child malnutrition in the Asia-Pacific region: Evidence from a systematic review and meta-analysis.

Child malnutrition remains a significant concern in the Asia-Pacific region, with short birth intervals recognised as a potential risk factor. However, evidence of this association is inconclusive. This study aimed to systematically review the existing evidence and assess the summary effects of short birth interval on child malnutrition in the Asia-Pacific region. Five electronic databases were searched in May 2023 to identify relevant studies reporting the association between short birth interval and child malnutrition, including stunting, wasting, underweight, anaemia and overall malnutrition, in Asia-Pacific region between September 2000 and May 2023. Fixed-effects or random-effects meta-analysis was performed to estimate the summary effects of short birth interval on child malnutrition. Out of 56 studies meeting the inclusion criteria, 48 were included in quantitative synthesis through meta-analysis. We found a slightly higher likelihood of stunting (n = 25, odds ratio [OR] = 1.13; 95% confidence interval [CI]: 0.97-1.32) and overall malnutrition (n = 3, OR = 2.42; 95% CI: 0.88-6.65) among children born in short birth intervals compared to those with nonshort intervals, although the effect was not statistically significant. However, caution is warranted due to identified heterogeneity across studies. Subgroup analysis demonstrated significant effects of short birth intervals on child malnutrition in national-level studies and studies with larger sample sizes. These findings underscore short birth intervals as a significant contributor to child malnutrition in the Asia-Pacific region. Implementing effective policies and programs is vital to alleviate this burden, ultimately reducing child malnutrition and associated adverse outcomes, including child mortality.

Multi-level factors associated with utilization of water, sanitation and hygiene services by mothers in Nepal.

BACKGROUND: Providing improved water, sanitation, and hygiene (WASH) at a household level remains one of the major public health challenges in Nepal. Household mothers are likely to have limited access to combined WASH services, this is influenced by individual, and community factors. Individual components of an improved water source, sanitary toilet, fixed place for handwashing, and availability of soap and water were merged into one and called combined WASH. This paper aimed to identify the individual and community factors associated with combined WASH facilities and practices among mothers with children under five years in Nepal. METHODS: A cross-sectional study was conducted using data from the Nepal Demographic and Health Survey (NDHS), 2016. The weighted sample size of this study was 4887 mothers with children under five years. The independent variables within the mothers included age, education, occupation, and caste/ethnicity in addition to education of the husband, wealth index, exposure to the newspaper, radio and television, residence, ecological zones, provinces, distance and participation in health mother groups were analyzed with the outcome variable of combined WASH. A multi-level mixed effects logistic regression model was used to assess the relationship of explanatory variables with WASH. RESULTS: At an individual level, a rich wealth index was positively associated with combined WASH (AOR = 6.29; 95%CI: 4.63-8.54). Higher education levels and exposure to television had higher odds of having combined WASH. At the community level, the hill zone, urban residence, and Sudurpashim Provinces were positively associated with combined WASH while Madesh and Karnali Provinces and distance to water source greater than 31 minutes were associated with lower access to combined WASH. CONCLUSION: Educated and rich household have positive association with combined WASH. It is recommended that both the health and other sectors may be instrumental in improving the combined WASH service for mothers at households.

Short birth interval prevalence, determinants and effects on maternal and child health outcomes in Asia-Pacific region: a systematic review and meta-analysis protocol.

BACKGROUND: Short birth interval (SBI) has been linked to an increased risk of adverse maternal, perinatal, infant and child health outcomes. However, the prevalence and maternal and child health impacts of SBI in the Asia-Pacific region have not been well understood. This study aims to identify and summarise the existing evidence on SBI including its definition, measurement prevalence, determinants and association with adverse maternal and child health outcomes in the Asia-Pacific region. METHODS: Five databases (MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Maternity and Infant Care, and Web of Science (WoS)) will be systematically searched from September 2000 up to May 2023. Data will be extracted, charted, synthesised and summarised based on the outcomes measured, and where appropriate, meta-analysis will be performed. The risk of bias will be assessed using Joanna Briggs Institute quality appraisal. Grading of Recommendation Assessment, Development and Evaluation framework will be used to evaluate the quality of cumulative evidence from the included studies. ETHICS AND DISSEMINATION: This review does not require ethics approval. Findings will be disseminated through peer-reviewed publications, policy briefs and conference presentations. PROSPERO REGISTRATION NUMBER: A protocol will be registered on PROSPERO for each separate outcome before performing the review.Cite Now.

Maternal residential area effects on preterm birth, low birth weight and caesarean section in Australia: A systematic review.

INTRODUCTION: In Australia, area of residence is an important health policy focus and has been suggested as a key risk factor for preterm birth (PTB), low birth weight (LBW) and cesarian section (CS) due to its influence on socioeconomic status, access to health services, and its relationship with medical conditions. However, there is inconsistent evidence about the relationship of maternal residential areas (rural and urban areas) with PTB, LBW, and CS. Synthesising the evidence on the issue will help to identify the relationships and mechanisms for underlying inequality and potential interventions to reduce such inequalities in pregnancy outcomes (PTB, LBW and CS) in rural and remote areas. METHODS: Electronic databases, including MEDLINE, Embase, CINAHL, and Maternity & Infant Care, were systematically searched for peer-reviewed studies which were conducted in Australia and compared PTB, LBW or CS by maternal area of residence. Articles were appraised for quality using JBI critical appraisal tools. RESULTS: Ten articles met the eligibility criteria. Women who lived in rural and remote areas had higher rates of PTB and LBW and lower rate of CS compared to their urban and city counterparts. Two articles fulfilled JBI's critical appraisal checklist for observational studies. Compared to women living in urban and city areas, women living in rural and remote areas were also more likely to give birth at a younger age (<20 years) and have chronic diseases such as hypertension and diabetes. They were also less likely to have higher levels of completing university degree education, private health insurance and births in private hospitals. CONCLUSIONS: Addressing the high rate of pre-existing and/or gestational hypertension and diabetes, limited access of health services and a shortage of experienced health staff in remote and rural areas are keys to early identification and intervention of risk factors of PTB, LBW, and CS.

Patterns of Labour Interventions and Associated Maternal Biopsychosocial Factors in Australia: a Path Analysis.

In Australia, nearly half of births involve labour interventions. Prior research in this area has relied on cross-sectional and administrative health data and has not considered biopsychosocial factors. The current study examined direct and indirect associations between biopsychosocial factors and labour interventions using 19 years of population-based prospective data. The study included singleton babies among primiparous women of the 1973-1978 cohort of the Australian Longitudinal Study on Women's Health. Data from 5459 women who started labour were analysed using path analysis. 42.2% of babies were born without intervention (episiotomy, instrumental, or caesarean delivery): Thirty-seven percent reported vaginal birth with episiotomy and instrumental birth interventions, 18% reported an unplanned caesarean section without episiotomy and/or instrumental interventions, and 3% reported unplanned caesarean section after episiotomy and/or instrumental interventions. Vaginal births with episiotomy and/or instrumental interventions were more likely among women with chronic hypertension (RRR(95%-CI):1.50(1.12-2.01)), a perceived length of labour of more than 36 h (RRR(95%-CI):1.86(1.45-2.39)), private health insurance (RRR(95%-CI):1.61(1.41-1.85)) and induced labour (RRR(95%-CI):1.69(1.46-1.94)). Risk factors of unplanned caesarean section without episiotomy and/or instrumental birth intervention included being overweight (RRR(95%-CI):1.30(1.07-1.58)) or obese prepregnancy (RRR(95%-CI):1.63(1.28-2.08)), aged ≥ 35 years (RRR(95%-CI):1.87(1.46-2.41)), having short stature (< 154 cm) (RRR(95%-CI):1.68(1.16-2.42)), a perceived length of labour of more than 36 h (RRR(95%-CI):3.26(2.50-4.24)), private health insurance (RRR(95%-CI):1.38(1.17-1.64)), and induced labour (RRR(95%-CI):2.56(2.16-3.05)). Prevention and management of hypertension, diabetes, and obesity during preconception and/or antenatal care are keys for reducing labour interventions and strengthening the evidence-base around delivery of best practice obstetric care.

Health-seeking behaviour of Ethiopian caregivers when infants are unwell: a descriptive qualitative study.

OBJECTIVES: To explore the health-seeking behaviour of Ethiopian caregivers when infants are unwell. DESIGN: A qualitative descriptive approach was employed using in-depth interviews and focus group discussions. Data were collected using semistructured interview guides. SETTING: The study was conducted in East Gojjam zone, Amhara region, northwest Ethiopia. PARTICIPANTS: Participants were selected using a maximum variation purposive sampling technique across the different study groups: caregivers, community members and healthcare providers. A total of 35 respondents, 27 individuals in the focus group discussions and 8 individuals in the in-depth interviews participated in the study. METHOD: In this study, a qualitative descriptive approach was employed to explore the health-seeking behaviour of caregivers. The data were collected from July to September 2019 and conventional content analysis was applied. RESULTS: The decision to take a sick child to healthcare facilities is part of a complex care-seeking process that involves many people. Some of the critical steps in the process are caregivers recognising that the child is ill, recognising the severity of the illness and deciding to take the child to a health institution based on the recognised symptoms and illness. In Ethiopia, a significant proportion of caregivers do not seek healthcare for childhood illness, and most caregivers do not know where and when to seek care for their child. This study points out that the health-seeking behaviour of caregivers can be influenced by different contextual factors such as caregivers' disease understanding, access to health services and family pressures to seek care. CONCLUSIONS: Healthcare-seeking practice plays an important role in reducing the impact of childhood illnesses and mortality. In Ethiopia, home-based treatment practice and traditional healing methods are widely accepted. Therefore, contextual understanding of the caregivers' health-seeking is important to design contextual healthcare interventions in the study area.

The effect of dietary patterns on maternal anaemia in North Shewa, Ethiopia: A case-control study with Propensity Score Analysis.

OBJECTIVE: This study aimed to assess the effect of dietary patterns during pregnancy on anaemia. DESIGN, SETTING AND PARTICIPANTS: A case-control study with propensity score analysis was conducted among pregnant women selected from five health facilities in North Shewa Zone, Ethiopia from November 2018 to March 2019. A multivariable conditional logistic regression model was applied after propensity score matching to assess the effect of dietary patterns on anaemia, and a p < 0.05 was taken as significant. Four hundred and seventeen pregnant women were included (105 cases and 312 controls) with a 1:3 case-to-control ratio. Cases were pregnant women with a haemoglobin level <11 gram/Deci litter (g/dL), and controls were pregnant women with a haemoglobin level ≥11.0 g/dL. RESULTS: A low dietary diversity score (adjusted odd ratio (AOR) = 2.14; 95% confidence interval (CI): 1.24, 3.69), reducing food intake (AOR = 6.89; 95% CI: 3.23, 14.70) and having no formal education (AOR = 3.13; 95% CI: 1.18, 8.32) were associated with higher odds of anaemia among pregnant women. CONCLUSIONS: During pregnancy, intake of a low diversified diet, reduced food intake and low educational status were associated with higher odds of anaemia. Dietary counselling should be emphasised and strengthened in the existing prenatal health service program, with women strongly encouraged to increase their diversified food intake instead of reducing it during pregnancy.

Spatial and hierarchical Bayesian analysis to identify factors associated with caesarean delivery use in Ethiopia: Evidence from national population and health facility data.

BACKGROUND: Caesarean section has a significant role in reducing maternal and neonatal mortality. A linked analysis of population and health facility data is valuable to map and identify caesarean section use and associated factors. This study aimed to identify geographic variation and associated factors of caesarean delivery in Ethiopia. METHOD: Linked data analysis of the 2016 Ethiopia Demographic and Health Survey (EDHS) and the 2014 Ethiopian Service Provision Assessment Plus (ESPA+) survey was performed. Spatial analysis was conducted to identify geographic variations and factors associated with caesarean delivery. Hierarchical Bayesian analysis was also performed to identify factors associated with caesarean delivery using the SAS MCMC procedure. RESULTS: Women's age and education, household wealth, parity, antenatal care (ANC) visits, and distance to caesarean section facility were associated with caesarean delivery use. Women who had ≥4 ANC visits were 4.67 (95% Credible Interval (CrI): 2.17, 9.43) times more likely to have caesarean delivery compared to those who had no ANC visits. Women who had education and were from rich households were also 2.80 (95% CrI: 1.83, 4.19) and 1.80 (95% CrI: 1.08, 2.84) times more likely to have caesarean deliveries relative to women who had no education and were from poor households, respectively. A one-kilometer increase in distance to a caesarean section facility was associated with an 88% reduction in the odds of caesarean delivery (Adjusted Odds Ratio (AOR) = 0.12, 95% CrI: 0.01, 0.78). Hotspots of high caesarean section rates were observed in Addis Ababa, Dire Dawa, and the Harari region. In addition, women's age at first childbirth and ≥4 ANC visits showed significant spatially varying relations between caesarean delivery use across Ethiopia. CONCLUSION: Caesarean section is a lifesaving procedure, and it is essential to narrow disparities to reduce maternal and neonatal mortality and avoid unnecessary procedures.

The human right to safely give birth: data from 193 countries show that gender equality does affect maternal mortality.

BACKGROUND: While a reduction in the global maternal mortality ratio (MMR) has slowed, newer strategies are needed to achieve an ongoing and sustainable reduction of the MMR. Previous studies have investigated the association between health system-related factors such as wealth inequalities, healthcare access and use on maternal mortality. However, a women's rights-based approach to address MMR has not been studied, excluding the health system-related factors. This study aimed to analyse the association between gender equality and MMR globally. METHODS: Using structural equation modelling (SEM), secondary and open access data from the United Nations and other international agencies from 193 countries were analysed using structural equation modelling (SEM). Gender-sensitive variables that represented the theoretical, conceptual framework of the study were selected. The association between latent variable gender equality and the outcome, MMR, was examined in the SEM. A second SEM model (n = 158) was designed to include two variables related to gender-based violence. FINDINGS: The latent variable, gender equality, was negatively associated with MMR (p < 0‧001, Z = -6‧96, 95% CI: - 6508.98 to - 3141.89 for Model 1 and p < 0‧001, Z = -7‧23, 95% CI: - 6045.356 to - 3467.515 for Model 2). INTERPRETATION: Gender equality was significantly associated with maternal mortality. Investing in higher education for women, improving their paid employment opportunities, increasing participation in leadership roles and politics, reducing intimate partner violence (IPV) and ending child marriage can significantly reduce maternal mortality.

Preeclampsia and eclampsia: Its burden and distribution across facilities in Ethiopia.

BACKGROUND: This study aimed to analyse national health facility burden of preeclampsia/eclampsia and its regional distribution in Ethiopia. This evidence is an important aspect to work towards reducing maternal and newborn complications. METHODS: This study uses data from the 2016 Emergency Obstetrics and Newborn Care (EmONC) survey which national census of public and private health facilities that provided delivery services. Cross-tabulation of variables was conducted based on region, location, types of health facility, and the management authority of health facilities. Spatial analysis was conducted to investigate spatial regional distribution of preeclampsia/eclampsia. RESULTS: A total of 3804 health facilities were included in the survey. Nationally, preeclampsia/eclampsia contributes to 5.9% of all maternal complications and 10.5% of maternal deaths. While 82% of total deliveries were reported from health centres, hospitals and specialised centres reported nearly 10 times more cases of PE/E (23 per 1000 deliveries) than health centres (2.4 per l000 deliveries). The highest number of preeclampsia/eclampsia cases were reported in Addis Ababa and the Harari region where there were 32 and 24 cases per 1000 deliveries, respectively. A substantial proportion of direct obstetrics complications due to preeclampsia/eclampsia were reported from Afar, Somali, Harari and the Benishangul Gumuz regions (19.9%, 18.0%, 12.8%. 11.5%, respectively). CONCLUSIONS: Preeclampsia/eclampsia contributed to a high proportion of maternal complications and death. Disproportionally, the highest burden of preeclampsia/eclampsia was reported in developing regions of Ethiopia. These region's health facilities'effort on case detection, reporting and evidence generation should be strengthened to inform policy especially those located in rural location.

Health Care Readiness in Management of Preeclampsia/Eclampsia in Ethiopia: Evidence from National Facility-Based Survey.

Background: Early case detection, treatment, and timely referral for better services can significantly reduce the negative outcomes of preeclampsia and eclampsia. However, evidence on health facilities' readiness to provide such services and the associated challenges is limited in Ethiopia. Therefore, this study aimed to assess the readiness of Ethiopian health care facilities to manage preeclampsia and eclampsia. Methods: This study used the 2016 Ethiopia national emergency management of obstetrics and newborn care (EmONC) survey. This survey was a national cross-sectional census of health facilities that provided delivery services. Data on facility infrastructure, equipment and supplies were collected through a facility checklist, and interview health provider experiences. Cross tabulation, summarisation and chi square tests by facility type, location, and management authority were conducted. Results: There were 3804 health facilities included in the survey across all regions of Ethiopia. The majority of facilities (92%) were public/government managed with only 1% of available hospitals located in rural areas. Poor availability of dipsticks for proteinuria tests (55.3%), caesarean sections (7.9%), and ambulance services (18.4%) were reported across health facilities with high variations in terms of facility type, location, and type of managing authority. Diazepam was a widely available anticonvulsant compared with magnesium sulfate (MgSO4), with more available in private for-profit facilities compared with public facilities. Nearly one third of health care providers were not trained to administer MgSO4 intravenously. The result indicated that the chi-square test was statistically significant at P < 0.001. Conclusions and Recommendations: There were notable gaps in readiness of facilities in detection and management of preeclampsia/eclampsia that increase maternal and perinatal mortality in Ethiopia. Therefore, availability of essential supplies, medications, and referrals are required. In addition, refresher training to healthcare providers on screening, diagnosis and management of preeclampsia/eclampsia and continuous supervision should be provided.

Biopsychosocial factors influencing the occurrence and recurrence of preterm singleton births among Australian women: A prospective cohort study.

INTRODUCTION: In Australia, 8.6% of all births are premature, and this figure has relativelyincreased by 10% in the past decade. A range of biological, psychological, and socialfactors have previously been identified as predictors of preterm birth using cross sectionaldata; however, this lacks ascertainment of a cause-and-effect relationship.This study harnessed the power of longitudinal cohort data by investigating pretermbirth among women prospectively followed for 19 years using a comprehensiveframework that examines biological, psychological, and social factors concurrently. METHODS: Data from 5,292 women (11,256 newborns) who reported singleton birthsbetween 1996 and 2015 in the Australian Longitudinal Study on Women's Health wereincluded. RESULTS: The prevalence of preterm birth was 8.5% for first-births and 5.9% for allbirths.The recurrent preterm birth rate was 9.5% . Risk factors for first preterm birthswere chronic hypertension (OR 2.34; 95% CI: 1.67-3.27), gestational hypertension (OR2.87; 95% CI: 2.22-3.72), gestational diabetes (OR 1.66; 95% CI: 1.14-2.41),menarche before 12 years (OR 1.36; 95% CI: 1.02-1.82) and history of miscarriage(OR 1.35; 95% CI: 1.01-1.79). Risk factors for all preterm births were a history ofpreterm birth (OR 2.33; 95% CI: 1.46-3.70), menarche before 12 years (OR 1.33; 95%CI: 1.00-1.77), not being partnered (OR 1.31; 95% CI: 1.02-1.69), chronic hypertension(OR 2.02; 95% CI: 1.45-2.82), gestational hypertension (OR 3.22; 95% CI: 2.43-4.25),gestational diabetes (OR 1.67; 95% CI: 1.16-2.41), and asthma (OR 1.40; 95% CI:1.14-1.72). Premature birth was less likely for second or later births (OR 0.44; 95% CI:0.36-0.55) compared to first births. Premature birth was also less likely for women whocompleted a university degree compared to women with a high school certificate (OR0.73; 95% CI: 0.57-0.94). CONCLUSION: Further development of multi-sectoral policies for chronic diseaseprevention and reducing social inequalities is required to prevent preterm birth inAustralia.

Maternal anemia and baby birth size mediate the association between short birth interval and under-five undernutrition in Ethiopia: a generalized structural equation modeling approach.

BACKGROUND: Studies assessing the association between short birth interval, a birth-to-birth interval of less than 33 months, and under-five undernutrition have produced inconclusive results. This study aimed to assess the relationship between short birth interval and outcomes of stunting, underweight, and wasting among children aged under-five in Ethiopia, and potential mediation of any associations by maternal anemia and baby birth size. METHOD: Data from the 2016 Ethiopia Demographic and Health Survey (EDHS) was used. Stunting, wasting, and underweight among children aged under-five were outcome variables. Generalized Structural Equation Modeling (GSEM) was used to examine associations between short birth interval and outcomes, and to assess hypothesized mediation by maternal anemia and baby birth size. RESULTS: Significant associations between short birth interval and stunting (AOR = 1.49; 95% CI = 1.35, 1.66) and underweight (AOR = 1.43; 95% CI = 1.28, 1.61) were found. There was no observed association between short birth interval and wasting (AOR = 1.05; 95% CI = 0.90, 1.23). Maternal anemia and baby birth size had a significant partial mediation effect on the association between short birth interval and stunting (the coefficient reduced from ß = 0.337, p < 0.001 to ß = 0.286, p < 0.001) and underweight (the coefficient reduced from ß = 0.449, p < 0.001 to ß = 0.338, p < 0.001). Maternal anemia and baby birth size mediated 4.2% and 4.6% of the total effect of short birth interval on stunting and underweight, respectively. CONCLUSION: Maternal anemia and baby birth size were identified as mediators of the association between short birth interval and under-five undernutrition status. Policies and programs targeting the reduction of under-five undernutrition should integrate strategies to reduce maternal anemia and small baby birth size in addition to short birth interval.

Audit of Clinical Care for Women with Preeclampsia or Eclampsia and Perinatal Outcome in Ethiopia: Second National EmONC Survey.

BACKGROUND: Preeclampsia and eclampsia contribute to maternal and perinatal morbidity and mortality, especially in developing countries. However, the evidence on clinical practice in the management of preeclampsia/eclampsia and perinatal outcomes is limited. Therefore, the aim of this study was to assess clinical care and perinatal outcomes for women with preeclampsia/eclampsia admitted to health facilities in Ethiopia. METHODS: This study used the 2016 Emergency Obstetric and Newborn Care survey, which included 3804 health facilities. The last two cases of women with preeclampsia/eclampsia who were admitted for birth in each participating health facility were selected and their medical records were reviewed. Descriptive analyses by health facility type, location and management authority were conducted. A chi-squared test was used to test for differences. RESULTS: Out of the 3804 health-care facilities across the country, we could review a total of 959 medical records of women with preeclampsia or eclampsia. Of all cases, 90% (863) were hospitalised in public health facilities, 542 (56.6%) were admitted at health centre/clinics and 638 (66.3%) were in urban health facilities. A substantial proportion of maternal and newborn information was missing from their medical records. Of the 553 records that recorded perinatal outcomes, the proportion of perinatal mortality prior to discharge was 16.3% (95% CI: 13.4%, 19.6%). A significant perinatal death was recorded among mothers admitted to hospitals (P < 0.01), maternal age 15-24 (P < 0.04), facilities in urban areas (P < 0.01), referred cases (P < 0.007), high systolic and diastolic blood pressure (P < 0.001), unconscious and experience seizure (P < 0.001), newborn with morbidity (P < 0.001), and women who spent more hours before giving birth (P < 0.002). CONCLUSIONS AND RECOMMENDATIONS: High perinatal mortality in health facilities was reported and care toward mothers with preeclampsia/eclampsia was limited. Strengthening the health facility readiness to respond for management with data registration and reporting system needs to be improved for evidence-based decision-making on perinatal and maternal health.

Prevalence and Correlates of Water, Sanitation, and Hygiene (WASH) and Spatial Distribution of Unimproved WASH in Nepal.

This study aims to estimate the prevalence and correlation of household levels of water, sanitation, and hygiene (WASH), including the identification of areas where WASH facilities are unimproved in Nepal. The study population was 11,040 household heads, using the data collected in the Nepal Demographic and Health Survey 2016. Logistic regression analysis was performed and crude odds ratios (OR) with 95% confidence intervals (CI) using a 0.05 significance level are presented. Getis-Ord Gi* statistics were used to identify the hot and cold spot areas of unimproved WASH. GPS locations of WASH points were used for spatial analysis. Approximately 95% of households had an improved water source, 84% had improved sanitation facilities, 81% had a fixed place for handwashing, and 47% had soap and water. Education, wealth, and ecology were significantly associated with WASH. The people from the hills were less likely to have an improved water source (OR = 0.32; 95% CI: 0.16-0.64) than those from the plain. Households with a poor wealth index had 78% lower odds of having an improved water source compared to households with a rich wealth index. Respondents from Madhes Province had lower odds (OR = 0.15; 95% CI: 0.08-0.28) and Gandaki Pradesh had the highest odds (OR = 2.92; 95% CI: 1.52-5.61) of having improved sanitation facilities compared to Province 1. Respondents aged 35-44 years had higher odds (OR = 1.16; 95% CI: 1.04-1.29) of having soap and water available compared to those aged 45 years and older. Education and geographical disparities were the factors associated with having reduced access to WASH. These findings suggest the need to focus on advocacy, services, and policy approaches.

Severe Maternal Outcomes and Quality of Maternal Health Care in South Ethiopia.

OBJECTIVE: To assess the incidence of severe maternal outcomes (SMO) and quality of maternal health care in south Ethiopia. METHODS: A facility-based prospective study was conducted in three hospitals among all women who presented while pregnant, during and after childbirth between 12 July and 26 November 2018. Participants were followed from the time of admission to discharge. The World Health Organization (WHO) maternal near-miss (MNM) approach was used to assess SMO indicators and quality of maternal health care. RESULTS: Of 2880 live births, 315 had potentially life-threatening conditions and 108 had SMOs (90 MNM and 18 maternal deaths). The SMO incidence ratio was 37.5 per 1000 live births (95% CI 30.6-44.4) and MNM incidence ratio was 31.3 per 1000 live births (95% CI 24.9-37.7). The ratio of near-miss to maternal deaths was 5:1. The hospitals' maternal mortality ratio (MMR) was 625 per 100,000 live births. Most (82.1%) SMO cases were referred from other health facilities. The most common cause of SMO was eclampsia (37%) followed by postpartum haemorrhage (33.3%). The highest mortality index (MI) was among women with sepsis (27.3%). The intensive care unit (ICU) admission rate was 13% for women with SMO and 83.3% of maternal deaths occurred without ICU admission. CONCLUSION: The SMO ratio was comparable to other studies in the country. Most women with SMO were referred from other health facilities, which demonstrate the presence of the first delay (seeking care) and/or the second delay (reaching care) in the study area. The study suggests that effectively using the ICU, reducing delays, and improving the referral system may reduce SMO and improve the quality of care in the hospitals. Furthermore, continuous reviewing of SMO is needed to learn what treatment was given to women who experienced complications in the hospitals.

The utility of delivery ward register data for determining the causes of perinatal mortality in one specialized and one general hospital in south Ethiopia.

BACKGROUND: Globally, the burden of perinatal mortality is high. Reliable measures of perinatal mortality are necessary for planning and assessing prenatal, obstetric, and newborn care services. However, accurate record-keeping is often a major challenge in low resource settings. In this study we aimed to assess the utility of delivery ward register data, captured at birth by healthcare providers, to determine causes of perinatal mortality in one specialized and one general hospital in south Ethiopia. METHODS: Three years (2014-2016) of delivery register for 13,236 births were reviewed from July 12 to September 29, 2018, in two selected hospitals in south Ethiopia. Data were collected using a structured pretested data extraction form. Descriptive statistics assessed early neonatal mortality rate, stillbirth rate, perinatal mortality rate and causes of neonatal deaths. Factors associated with early neonatal deaths and stillbirths were examined using logistic regression. The adjusted odds ratios with a 95% confidence interval were reported to show the strength of the association. RESULT: The perinatal mortality ratio declined from 96.6 to 75.5 per 1000 births during the three-year study period. Early neonatal mortality and stillbirth rates were 29.3 per 1000 live births and 55.2 per 1000 total births, respectively. The leading causes of neonatal death were prematurity 47.5%, and asphyxia 20.7%. The cause of death for 15.6% of newborns was not recorded in the delivery registers. Similarly, the cause of neonatal morbidity was not recorded in 1.5% of the delivery registers. Treatment given for 94.5% of neonates were blank in the delivery registers, so it is unknown if the neonates received treatment or not. Factors associated with increased early neonatal deaths were maternal deaths and complications, vaginal births, APGAR scores less than 7 at five minutes and low birth weight (2500 g). Maternal deaths and complications and vaginal births were associated with increased stillbirths. CONCLUSION: Our findings show that an opportunity exists to identify perinatal death and newborn outcomes from the delivery ward registers, but some important neonatal outcomes were not recorded/missing. Efforts towards improving the medical record systems are needed. Furthermore, there is a need to improve maternal health during pregnancy and birth, especially neonatal care for those neonates who experienced low APGAR scores and birth weight to reduce the prevalence of perinatal deaths.

A Women's Rights-Based Approach to Reducing Child Mortality: Data from 193 Countries Show that Gender Equality does Affect Under-five Child Mortality.

OBJECTIVES: Mother's health and wellbeing significantly affects child health. Women's autonomy can improve healthcare-seeking behaviour, utilisation of healthcare services, and planned pregnancy, thereby improving child health. The global under-five mortality rate (U5MR) has seen the fastest decline in the past two decades, but the influence of gender equality on child mortality remains unaddressed. A strategic approach addressing gender equality is needed to reduce the U5MR further. The study aimed to identify and investigate the association between indicators of gender equality and U5MR using a human rights-based approach. METHODS: We analysed open-source secondary data from international agencies comprising 521 gender-sensitive variables for 193 countries. Nine variables were included for the final Structural Equation Model based on the theoretical model. Model 1 consisted of 193 countries, and Model 2 comprised a subgroup analysis of 11 variables for 158 countries. Gender equality was a latent variable, and the U5MR was the outcome variable. RESULTS: Gender equality was significantly associated with U5MR (Z = - 7.47, 95% CI = - 754.67 to - 440.98, p < 0‧001, n = 193 for Model 1, and Z = - 7.71, 95% CI = - 808.26 to - 480.72, p < 0‧001, n = 158 for Model 2). Female education, women's waged and salaried employment, women as employers, and women's representation in leadership and parliament enhanced gender equality, whereas the prevalence of child marriage and intimate partner violence (IPV) negatively affected gender equality. Improvement in gender equality significantly reduced U5MR. CONCLUSIONS FOR PRACTICE: Improving women's economic, educational, and social position and increasing female representation in higher leadership and policymaking positions is the key to reducing child mortality. Notably, eliminating child marriage and IPV is the key to achieving gender equality and is needed at the forefront of national policies. Gender equality can significantly improve women's reproductive autonomy, a critical factor in improving healthcare utilisation for women and their children.

Factors Associated with Gender-Based Violence Perpetration by Male High School Students in Eastern Ethiopia.

Gender-based violence (GBV) perpetration is a severe problem among youths in schools and the community at large. As most studies focused on adults, this study aimed to investigate factors associated with GBV by male high school students in eastern Ethiopia. An institutional based cross-sectional survey was conducted with 1,109 male students aged 15-24 years in eastern Ethiopia in December 2018 using self-administered WHO Multi-Country Study on Women's Health and Life Events and UN Multi-Country study on perpetration. Poisson regression model was used to determine the prevalence ratio. Multivariable analysis showed that having girlfriend, chewing khat, drinking alcohol, watching pornography and being sexually active increased the prevalence of perpetrating any type of GBV (emotional, physical, sexual, and overall GBV) by young male in the last 12 months. Compared to those who did not smoke tobacco, smokers had an prevalence of perpetrating emotional violence (adj. PrR = 1.22, 95% CI = 1.03-1.44) and any type of GBV (adj. PrR = 1.15, 95% CI = 1.00-1.31). Young males who had a mother who had completed Grade 9-12 (adj. PrR = 0.75, 95% CI = 0.59-0.96) had a 25% lower prevalence of perpetrating emotional violence compared to male students who had an illiterate mother. Young males who had used illicit drugs, smoked shisha (adj. PrR = 1.39, 95% CI = 1.10-1.77), and were married (adj. PrR = 1.89, 95% CI = 1.15-3.12) had a higher prevalence of perpetrating sexual violence compared to young males who hadn't used smoked shisha and were not married, respectively. Young males who had discussed reproductive health with their family (adj. PrR = 1.13, 95% CI = 1.03-1.24) and who chewed khat (adj. PrR = 1.26, 95% CI = 1.02-1.55) had a higher prevalence of perpetrating any GBV compared to young men who hadn't discussed reproductive health with their parents and who hadn't chewed khat, respectively. Any type of GBV (emotional, sexual, or physical violence) was significantly associated with several individual and relationship factors. Effective prevention and intervention programs should be focused on education of the influence of pornography, prevention of substance use and interventions for those in romantic relationships could all assist in reducing GBV.