A perceptual approach to address complex water management issues in lowland permeable catchments.

Water quality management is a pressing global concern, and an increasingly complex issue due to climate and land-use change, legacy pollution, and the persistent release of well-known and emerging contaminants from diffuse and point sources. The increasing availability of high-frequency monitoring data is leading existing, often heuristic approaches, to be judged inadequate. Water managers frequently rely on simple qualitative and/or quantitative approaches for decision-making, but a lack of tangible improvement in freshwater quality outcomes is demanding new and innovative approaches that rely more on physical process understanding, rather than precedent. In this study, we drew upon local geological, hydrogeological, and hydrological data to infer a high-level perceptual model of surface/groundwater interactions in a chalk stream in Dorset, UK. We used the perceptual model to interrogate spatial and temporal trends in historical water quality data and to construct reach-scale nutrient mass balances. Through novel representation with Sankey diagrams, the perceptual model highlighted the relative importance of different hydrological features. Surface/groundwater interactions were found to occur predominantly by spring flow. We demonstrate that river flow accretion was dominated by the Chalk aquifer despite only occupying ca. 15 % of the surface bedrock area, and that spring sources, whilst vital to dilute treated sewage inputs in baseflow conditions, were also major sources of legacy nitrate. Nutrient mass balances showed that sewage treatment works contributed ca. 13 % to soluble reactive phosphorus load, with groundwater accounting for ca. 48 %. Thus, a determinand often associated with point-source pollution was shown to be diffuse dominated in this river. The study demonstrated how a multi-disciplinary approach to water management, based on a comprehensive perceptual modelling approach, could identify hitherto unknown sources and relative contributors to freshwater pollution and allow flow and load apportionment studies to provide useful decision-support to manage nutrient pollution. The novel application of perceptual modelling tools, such as the Sankey diagram, allows different source attributions to be presented in an accessible manner, and can be readily transferred to other study areas.

Wastewater monitoring for detection of public health markers during the COVID-19 pandemic: Near-source monitoring of schools in England over an academic year.

BACKGROUND: Schools are high-risk settings for infectious disease transmission. Wastewater monitoring for infectious diseases has been used to identify and mitigate outbreaks in many near-source settings during the COVID-19 pandemic, including universities and hospitals but less is known about the technology when applied for school health protection. This study aimed to implement a wastewater surveillance system to detect SARS-CoV-2 and other public health markers from wastewater in schools in England. METHODS: A total of 855 wastewater samples were collected from 16 schools (10 primary, 5 secondary and 1 post-16 and further education) over 10 months of school term time. Wastewater was analysed for SARS-CoV-2 genomic copies of N1 and E genes by RT-qPCR. A subset of wastewater samples was sent for genomic sequencing, enabling determination of the presence of SARS-CoV-2 and emergence of variant(s) contributing to COVID-19 infections within schools. In total, >280 microbial pathogens and >1200 AMR genes were screened using RT-qPCR and metagenomics to consider the utility of these additional targets to further inform on health threats within the schools. RESULTS: We report on wastewater-based surveillance for COVID-19 within English primary, secondary and further education schools over a full academic year (October 2020 to July 2021). The highest positivity rate (80.4%) was observed in the week commencing 30th November 2020 during the emergence of the Alpha variant, indicating most schools contained people who were shedding the virus. There was high SARS-CoV-2 amplicon concentration (up to 9.2x106 GC/L) detected over the summer term (8th June - 6th July 2021) during Delta variant prevalence. The summer increase of SARS-CoV-2 in school wastewater was reflected in age-specific clinical COVID-19 cases. Alpha variant and Delta variant were identified in the wastewater by sequencing of samples collected from December to March and June to July, respectively. Lead/lag analysis between SARS-CoV-2 concentrations in school and WWTP data sets show a maximum correlation between the two-time series when school data are lagged by two weeks. Furthermore, wastewater sample enrichment coupled with metagenomic sequencing and rapid informatics enabled the detection of other clinically relevant viral and bacterial pathogens and AMR. CONCLUSIONS: Passive wastewater monitoring surveillance in schools can identify cases of COVID-19. Samples can be sequenced to monitor for emerging and current variants of concern at the resolution of school catchments. Wastewater based monitoring for SARS-CoV-2 is a useful tool for SARS-CoV-2 passive surveillance and could be applied for case identification and containment, and mitigation in schools and other congregate settings with high risks of transmission. Wastewater monitoring enables public health authorities to develop targeted prevention and education programmes for hygiene measures within undertested communities across a broad range of use cases.

Evaluation of harvesting urban water resources for sustainable water management: Case study in Filton Airfield, UK.

Filton Airfield in the UK is a new community under development aiming to become self-sufficient in its water supply toward a circular economy. Urban water management strategies, water demand minimization, urban resource reuse, and wastewater discharge minimization, can improve the urban circular economy. Understanding the practical impacts of those strategies is crucial for a new development area like Filton. As a site investigation, the physiochemical and microbial characteristics of raw rainwater showed acceptable for irrigation and drinking water, indicating no significant risk of using rainwater collected within Filton, but still requiring a treatment process depending on chosen applications. This study further conducted stochastic water demand profiles and urban water cycle simulations at a block scale, taking possible rainwater harvesting (RWH) and greywater recycling (GWR) options for non-potable purposes to quantitatively assess the impact of urban water management strategies on urban harvesting potential indicators (0-100%). When the RWH was implemented, the water demand minimization potential varied from 62% to 71%. Meanwhile, the combined use of RWH and GWR yielded even better results in terms of water demand minimization, peaking at 78% due to the additional supply from GWR. The combination also reduced wastewater production potential from 100% to 54% and consequently improves self-sustainability potential from 0 with no recycling, to 44% with only GWR, and to 100% with the combined use of RWH and GWR. The sensitivity analysis revealed that wastewater discharge is the most sensitive to variations in rainfall patterns (wet and dry conditions) and urban density (water demand patterns), indicating that both need to be balanced for better implementation of urban water harvesting strategies. This study can provide insights into the applicability of urban water resource harvesting and its assessment approaches in existing and new development areas.

Monitoring occurrence of SARS-CoV-2 in school populations: A wastewater-based approach.

Clinical testing of children in schools is challenging, with economic implications limiting its frequent use as a monitoring tool of the risks assumed by children and staff during the COVID-19 pandemic. Here, a wastewater-based epidemiology approach has been used to monitor 16 schools (10 primary, 5 secondary and 1 post-16 and further education) in England. A total of 296 samples over 9 weeks have been analysed for N1 and E genes using qPCR methods. Of the samples returned, 47.3% were positive for one or both genes with a detection frequency in line with the respective local community. WBE offers a low cost, non-invasive approach for supplementing clinical testing and can provide longitudinal insights that are impractical with traditional clinical testing.

From pollutant removal to resource recovery: A bibliometric analysis of municipal wastewater research in Europe.

Municipal wastewaters are abundant low-strength streams that require adequate treatment and disposal to ensure public and environmental health. This study aims to provide a comprehensive summary of municipal wastewater research in Europe in the 2010s in the form of bibliometric analysis. The work was based on the Science Citation Index Expanded (Web of Science) and carried out using the R-package bibliometrix for bibliometric data analysis and the software VOSviewer for science mapping. Analysing a dataset of 5645 publications, we identified the most influential journals, countries, authors, institutions, and publications, and mapped the co-authorship and keyword co-occurrence networks. Spain had produced the most publications while Switzerland had the highest average citations per publication. China was the most collaborative country from outside of Europe. Analysis of the most cited articles revealed the popularity of micropollutant removal in European municipal wastewater research. The keyword analysis visualized a paradigm shift from pollutant removal towards resource recovery and circular economy. We found that current challenges of resource recovery from municipal wastewater come from both technical and non-technical (e.g., environmental, economic, and social) aspects. We also discussed future research opportunities that can tackle these challenges.

Making Waves: Collaboration in the time of SARS-CoV-2 - rapid development of an international co-operation and wastewater surveillance database to support public health decision-making.

The presence of SARS-CoV-2 RNA in wastewater was first reported in March 2020. Over the subsequent months, the potential for wastewater surveillance to contribute to COVID-19 mitigation programmes has been the focus of intense national and international research activities, gaining the attention of policy makers and the public. As a new application of an established methodology, focused collaboration between public health practitioners and wastewater researchers is essential to developing a common understanding on how, when and where the outputs of this non-invasive community-level approach can deliver actionable outcomes for public health authorities. Within this context, the NORMAN SCORE "SARS-CoV-2 in sewage" database provides a platform for rapid, open access data sharing, validated by the uploading of 276 data sets from nine countries to-date. Through offering direct access to underpinning meta-data sets (and describing its use in data interpretation), the NORMAN SCORE database is a resource for the development of recommendations on minimum data requirements for wastewater pathogen surveillance. It is also a tool to engage public health practitioners in discussions on use of the approach, providing an opportunity to build mutual understanding of the demand and supply for data and facilitate the translation of this promising research application into public health practice.

Optimal storage sizing for indoor arena rainwater harvesting: Hydraulic simulation and economic assessment.

This study demonstrates a large roof (30,000 m2) rainwater harvesting (RWH) system in an indoor arena by considering three water demand scenarios (toilet flushing, irrigation and combined demand) via hydraulic and economic assessments. The water saving efficiency (WSE) of the RWH system for each scenario was estimated by a simulation model using historical daily rainfall data (1968-2018). Depending on the water demand, the WSE was found to be independent of tank size when the tank size exceeded 1000 m3. The results suggest that the WSE of the RWH system is highly influenced by water demand scenarios, and a storage capacity of 400-1000 m3 would be enough for the applications considered in this study. The economic analysis results further showed that depending on the water demand, the RWH system with a rainwater storage capacity of between 100 and 600 m3 was more economically beneficial due to its positive cost saving values. The results also showed that depending on the water scenarios, the unit water cost between 0.37 and 0.40 £/m3 was lower than the mains water cost (0.40 £/m3). As a result, the use of the RWH system with a tank between 400 and 600 m3 can be the most favourable range under the conditions considered in this study. Given the variations in water price, rainfall patterns and discount rates, the sensitivity analysis showed that water tariffs and discount rates play a significant role in reducing the unit water cost of the system, maintaining it lower than the mains water cost. A payback period analysis of the RWH system with a 600 m3 tank revealed that a 5% discount rate and a water price of 3 £/m3 would be enough to make the RWH system cost effective and that the capital cost could be returned within 10-11 years. This study highlights the need for preliminary sizing of a rainwater tank and an economic analysis of a large rooftop RWH system to maximise the benefits.

Global Sensitivity Analysis of Metabolic Models for Phosphorus Accumulating Organisms in Enhanced Biological Phosphorus Removal.

The aim of this study was to identify, quantify and prioritize for the first time the sources of uncertainty in a mechanistic model describing the anaerobic-aerobic metabolism of phosphorus accumulating organisms (PAO) in enhanced biological phosphorus removal (EBPR) systems. These wastewater treatment systems play an important role in preventing eutrophication and metabolic models provide an advanced tool for improving their stability via system design, monitoring and prediction. To this end, a global sensitivity analysis was conducted using standard regression coefficients and Sobol sensitivity indices, taking into account the effect of 39 input parameters on 10 output variables. Input uncertainty was characterized with data in the literature and propagated to the output using the Monte Carlo method. The low degree of linearity between input parameters and model outputs showed that model simplification by linearization can be pursued only in very well defined circumstances. Differences between first and total-order sensitivity indices showed that variance in model predictions was due to interactions between combinations of inputs, as opposed to the direct effect of individual inputs. The major sources of uncertainty affecting the prediction of liquid phase concentrations, as well as intra-cellular glycogen and poly-phosphate was due to 64% of the input parameters. In contrast, the contribution to variance in intra-cellular PHA constituents was uniformly distributed among all inputs. In addition to the intra-cellular biomass constituents, notably PHB, PH2MV and glycogen, uncertainty with respect to input parameters directly related to anaerobic propionate uptake, aerobic poly-phosphate formation, glycogen formation and temperature contributed most to the variance of all model outputs. Based on the distribution of total-order sensitivities, characterization of the influent stream and intra-cellular fractions of PHA can be expected to significantly improve model reliability. The variance of EBPR metabolic model predictions was quantified. The means to account for this variance, with respect to each quantity of interest, given knowledge of the corresponding input uncertainties, was prescribed. On this basis, possible avenues and pre-requisite requirements to simplify EBPR metabolic models for PAO, both structurally via linearization, as well as by reduction of the number of non-influential variables were outlined.

Correction: New framework for automated article selection applied to a literature review of Enhanced Biological Phosphorus Removal.

[This corrects the article DOI: 10.1371/journal.pone.0216126.].

New framework for automated article selection applied to a literature review of Enhanced Biological Phosphorus Removal.

AIMS: Enhanced Biological Phosphorus Removal (EBPR) is a technology widely used in wastewater treatment to remove phosphorus (P) and prevent eutrophication. Establishing its operating efficiency and stability is an active research field that has generated almost 3000 publications in the last 40 years. Due to its size, including over 119 review articles, it is an example of a field where it becomes increasingly difficult to manually recognize its key research contributions, especially for non-experts or newcomers. Therefore, this work included two distinct but complementary objectives. First, to assemble for the first time a collection of bibliometric techniques into a framework for automating the article selection process when preparing a literature review (section 2). Second, to demonstrate it by applying it to the field of EBPR, producing a bibliometric analysis and a review of the key findings of EBPR research over time (section 3). FINDINGS: The joint analysis of citation networks, keywords, citation profiles, as well as of specific benchmarks for the identification of highly-cited publications revealed 12 research topics. Their content and evolution could be manually reviewed using a selection of articles consisting of approximately only 5% of the original set of publications. The largest topics addressed the identification of relevant microorganisms, the characterization of their metabolism, including denitrification and the competition between them (Clusters A-D). Emerging and influential topics, as determined by different citation indicators and temporal analysis, were related to volatile fatty acid production, P-recovery from waste activated sludge and aerobic granules for better process efficiency and stability (Clusters F-H). CONCLUSIONS: The framework enabled key contributions in each of the constituent topics to be highlighted in a way that may have otherwise been biased by conventional citation-based ranking. Further, it reduced the need for manual input and a priori expertise compared to a traditional literature review. Hence, in an era of accelerated production of information and publications, this work contributed to the way that we are able to use computer-aided approaches to curate information and manage knowledge.

Is there evidence for man-made nanoparticles in the Dutch environment?

Only very limited information is available on measured environmental concentrations of nanoparticles. In this study, several environmental compartments in The Netherlands were probed for the presence of nanoparticles. Different types of water were screened for the presence of inorganic (Ag, Au, TiO2) and organic nanoparticles (C60, C70, [6,6]-phenyl-C61-butyric acid octyl ester, [6,6]-phenyl-C61-butyric acid butyl ester, [6,6]-phenyl-C61-butyric acid methyl ester, [6,6]-bis-phenyl-C61-butyric acid methyl ester, [6,6]-phenyl-C71-butyric acid methyl ester, [6,6]-thienyl-C61-butyric acid methyl ester). Air samples were analysed for the presence of nanoparticulate Mo, Ag, Ce, W, Pd, Pt, Rh, Zn, Ti, Si, B as well as Fe and Cu. ICP-MS, Orbitrap-HRMS, SEM and EDX were used for this survey. Water samples included dune and bank filtrates, surface waters and ground waters as well as influents, effluents and sludge of sewage treatment plants (STPs), and surface waters collected near airports and harbours. Air samples included both urban and rural samples. C60 was detected in air, sewage treatment plants, influents, effluents and sludge, but in no other aqueous samples despite the low detection limit of 0.1ng/L. C70 and functionalised fullerenes were not detected at all. In STP sludge and influent the occurrence of Ag and Au nanoparticles was verified by SEM/EDX and ICP-MS. In air up to about 25m% of certain metals was found in the nanosize fraction. Overall, between 1 and 6% of the total mass from metals in the air samples was found in the size fraction <100nm.

Different compositions of pharmaceuticals in Dutch and Belgian rivers explained by consumption patterns and treatment efficiency.

In the current study, 43 pharmaceuticals and 18 transformation products were studied in the river Meuse at the Belgian-Dutch border and four tributaries of the river Meuse in the southern part of the Netherlands. The tributaries originate from Belgian, Dutch and mixed Dutch and Belgian catchments. In total, 23 pharmaceuticals and 13 transformation products were observed in samples of river water collected from these rivers. Observed summed concentrations of pharmaceuticals and transformation products in river water ranged from 3.5 to 37.8 µg/L. Metformin and its transformation product guanylurea contributed with 53 to 80 % to this concentration, illustrating its importance on a mass basis. Data on the flow rate of different rivers and demographics of the catchments enabled us to calculate daily per capita loads of pharmaceuticals and transformation products. These loads were linked to sales data of pharmaceuticals in the catchment. Simple mass balance modelling accounting for human excretion and removal by sewage treatment plants revealed that sales could predict actual loads within a factor of 3 for most pharmaceuticals. Rivers that originated from Belgian and mixed Dutch and Belgian catchments revealed significantly higher per capita loads of pharmaceuticals (16.0 ± 2.3 and 15.7 ± 2.1 mg/inhabitant/day, respectively) than the Dutch catchment (8.7 ± 1.8 mg/inhabitant/day). Furthermore, the guanylurea/metformin ratio was significantly lower in waters originating from Belgium (and France) than in those from the Netherlands, illustrating that sewage treatment in the Belgian catchment is less efficient in transforming metformin into guanylurea. In summary, the current study shows that consumption-based modelling is suitable to predict environmental loads and concentrations. Furthermore, different consumption patterns and wastewater treatment efficiency are clearly reflected in the occurrence and loads of pharmaceuticals in regional rivers.

Experiences with facility-based maternal death reviews in northern Nigeria.

OBJECTIVE: To evaluate the effectiveness of the maternal death review (MDR) system and process in improving quality of maternal and newborn health care in northern Nigeria. METHODS: A combination of quantitative and qualitative methods was used, including review of MDR forms and of health management information system data on maternal deaths (MDs), as well as semi-structured interviews with members of 11 MDR committees. RESULTS: Facility-based MDRs were initiated in 75 emergency obstetric and newborn care facilities in northern Nigeria and were initially conducted in the 33 hospitals; however, the process stopped after some time and had to be revitalized. Main reasons were transfer of key members of MDR committees, lack of supportive supervision, and shortage of staff. Ninety-three (12.1%) of 768 identified MDs were recorded on MDR forms and 52 (6.7%) had been reviewed. MDRs resulted in improved quality of care, including mobilization of additional resources. Challenges were fear of blame, shortage of staff, transfer of MDR team members, inadequate supportive supervision, and poor record keeping. CONCLUSION: MDR requires teamwork, commitment, and champions at health facility level to spearhead the process. MDR needs to be institutionalized in the Ministry of Health, which provides oversight, policy guidance, and support, including supportive supervision.

Young people's perception of sexual and reproductive health services in Kenya.

BACKGROUND: Addressing the Sexual and Reproductive Health (SRH) needs of young people remains a big challenge. This study explored experiences and perceptions of young people in Kenya aged 10-24 with regard to their SRH needs and whether these are met by the available healthcare services. METHODS: 18 focus group discussions and 39 in-depth interviews were conducted at health care facilities and youth centres across selected urban and rural settings in Kenya. All interviews were tape recorded and transcribed. Data was analysed using the thematic framework approach. RESULTS: Young people's perceptions are not uniform and show variation between boys and girls as well as for type of service delivery. Girls seeking antenatal care and family planning services at health facilities characterise the available services as good and staff as helpful. However, boys perceive services at health facilities as designed for women and children, and therefore feel uncomfortable seeking services. At youth centres, young people value the non-health benefits including availability of recreational facilities, prevention of idleness, building of confidence, improving interpersonal communication skills, vocational training and facilitation of career progression. CONCLUSION: Providing young people with SRH information and services through the existing healthcare system, presents an opportunity that should be further optimised. Providing recreational activities via youth centres is reported by young people themselves to not lead to increased uptake of SRH healthcare services. There is need for more research to evaluate how perceived non-health benefits young people do gain from youth centres could lead to improved SRH of young people.

A bottom-up approach to estimate dry weather flow in minor sewer networks.

In order to evaluate the feasibility of installing decentralised installations for wastewater reuse in cities, information about flows at specific spots of a sewer is needed. However, measuring intermittent flows in partially filled conduits is a technical task which is sometimes difficult to accomplish. This paper describes a method to model intermittent discharges in small sewers by linking a stochastic model for wastewater discharge to a hydraulic model to predict the attenuation of the discharges and its impact on the arrival time to a defined spot. The method was validated in a case study. The model estimated adequately the wastewater discharges on working days.

Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.

BACKGROUND: Addressing the sexual and reproductive health (SRH) needs of young people remains a challenge for most developing countries. This study explored the perceptions and experiences of Health Service Providers (HSP) in providing SRH services to young people in Kenya. METHODS: Qualitative study conducted in eight health facilities; five from Nairobi and three rural district hospitals in Laikipia, Meru Central, and Kirinyaga. Nineteen in-depth interviews (IDI) and two focus group discussions (FGD) were conducted with HSPs. Interviews were tape recorded and transcribed. Data was coded and analysed using the thematic framework approach. RESULTS: The majority of HSPs were aware of the youth friendly service (YFS) concept but not of the supporting national policies and guidelines. HSP felt they lacked competency in providing SRH services to young people especially regarding counselling and interpersonal communication. HSPs were conservative with regards to providing SRH services to young people particularly contraception. HSP reported being torn between personal feelings, cultural and religious values and beliefs and their wish to respect young people's rights to accessing and obtaining SRH services. CONCLUSION: Supporting youth friendly policies and competency based training of HSP are two common approaches used to improve SRH services for adolescents. However, these may not be sufficient to change HSPs' attitude to adolescents seeking help. There is need to address the cultural, religious and traditional value systems that prevent HSPs from providing good quality and comprehensive SRH services to young people. Training updates should include sessions that enable HSPs to evaluate how their personal and cultural values and beliefs influence practice.

Forgotten electrical accidents and the birth of shockproof X-ray systems.

OBJECTIVES: To commemorate victims of electrical accidents that occurred in the first decades of radiology and relate these accidents to the evolution of the X-ray apparatus. METHODS: Digitised newspapers, scientific journals, books and reports of legal procedures were searched for electrical accidents involving X-ray systems. Information on the historical systems was retrieved from the scientific literature and brochures from manufacturers. RESULTS: We found 51 fatal and 62 non-fatal but serious electrical accidents. Most of them occurred between 1920 and 1940 and involved transformers that provided output currents well above the threshold for the induction of ventricular fibrillation. The accidents led to recommendations and regulations to improve safety for operators and patients, and spurred manufacturers to technical developments that culminated in fully electrically shockproof systems by 1935. CONCLUSIONS: Although largely forgotten, the development of the shockproof X-ray systems we take for granted today lasted about 4 decades and was associated with considerable human suffering. The complete solution of the problem is a success story of engineering realised by contributions from all parties involved. MAIN MESSAGES: • The development of electrically shockproof X-ray systems took about 4 decades (1895-1935). • Between 1896 and 1920 electrical shocks from X-ray systems were common, but their consequences limited. • After 1920, transformers killed by delivering currents above the ventricular fibrillation threshold. • Inductors, static generators and high-frequency coils were generally low-current systems and safe. • We found 51 fatal and 62 serious non-fatal electrical accidents, most occurring from 1920 to 1940.

Status of emergency obstetric care in six developing countries five years before the MDG targets for maternal and newborn health.

BACKGROUND: Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population. METHODS AND FINDINGS: A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0-9.3% and still birth (SB) rates ranged from 1.9-6.8%. CONCLUSIONS: Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.

The impact of emergency obstetric care training in Somaliland, Somalia.

OBJECTIVE: To provide and evaluate in-service training in "Life Saving Skills - Emergency Obstetric and Newborn Care" in order to improve the availability of emergency obstetric care (EmOC) in Somaliland. METHODS: In total, 222 healthcare providers (HCPs) were trained between January 2007 and December 2009. A before-after study was conducted using quantitative and qualitative methods to evaluate trainee reaction and change in knowledge, skills, and behavior, in addition to functionality of healthcare facilities, during and immediately after training, and at 3 and 6 months post-training. RESULTS: The HCPs reacted positively to the training, with a significant improvement in 50% of knowledge and 100% of skills modules assessed. The HCPs reported improved confidence in providing EmOC. Basic and comprehensive EmOC healthcare facilities provided 100% of expected signal functions-compared with 43% and 56%, respectively, at baseline-with trained midwives performing skills usually performed by medical doctors. Lack of drugs, supplies, medical equipment, and supportive policy were identified as barriers that could contribute to nonuse of new skills and knowledge acquired. CONCLUSION: The training impacted positively on the availability and quality of EmOC and resulted in "up-skilling" of midwives.

Methodology and tools for quality improvement in maternal and newborn health care.

OBJECTIVE: To gain an overview of approaches, methodologies, and tools used in quality improvement of maternal and newborn health in low-income countries. METHODS: Electronic search of MEDLINE and organizational databases for literature describing approaches, methodologies, and tools used to improve the quality of maternal and newborn health care in low-income countries. Relevant papers and reports were reviewed and summarized. RESULTS: Developing a culture of quality is an important requisite for successful quality improvement. Methodologies to improve quality include the development of standards and guidelines and the performance of mortality, near-miss, and criterion-based audits. Tools for data collection and process description were identified, and examples of work to improve quality of care are provided. CONCLUSION: The documented experience with the identified approaches, methodologies, and tools indicates that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools depends on the healthcare system and its available resources. There is a lack of studies that describe the process of quality improvement and a need for research to provide evidence of the effectiveness of the identified methods and tools.