Young Infant Mortality Associated with Preterm and Small-for-Gestational-Age Births in Rural Bangladesh: A Prospective Cohort Study.

OBJECTIVE: To assess the relative risk of mortality in infants born preterm and small for gestational age (SGA) during the first and second months of life in rural Bangladesh. STUDY DESIGN: We analyzed data from a cohort of pregnant women and their babies in Sylhet, Bangladesh, assembled between 2011 and 2014. Community health workers visited enrolled babies up to 10 times from birth to age 59 days. Survival status was recorded at each visit. Gestational age was estimated from mother's reported last menstrual period. Birth weights were measured within 72 hours of delivery. SGA was defined using the INTERGROWTH-21st standard. We estimated unadjusted and adjusted hazard ratios (HRs) and corresponding 95% CIs for babies born preterm and SGA separately for the first and second month of life using bivariate and multivariable weighted Cox regression models. RESULTS: The analysis included 17 643 singleton live birth babies. Compared with infants born at term-appropriate for gestational age, in both unadjusted and adjusted analyses, infants born preterm-SGA had the greatest risk of death in the first (HR 13.25, 95% CI 8.65-20.31; adjusted HR 12.05, 95% CI 7.82-18.57) and second month of life (HR 4.65, 95% CI 1.93-11.23; adjusted HR 4.1, 95% CI 1.66-10.15), followed by infants born preterm-appropriate for gestational age and term-SGA. CONCLUSIONS: The risk of mortality in infants born preterm and/or SGA is increased and extends through the second month of life. Appropriate interventions to prevent and manage complications caused by prematurity and SGA could improve survival during and beyond the neonatal period.

Society for Maternal-Fetal Medicine Consult Series #71: Management of previable and periviable preterm prelabor rupture of membranes.

Previable and periviable preterm prelabor rupture of membranes are challenging obstetric complications to manage, given the substantial risk of maternal morbidity and mortality with no guarantee of fetal benefit. The following are Society for Maternal-Fetal Medicine recommendations for the management of previable and periviable preterm prelabor rupture of membranes prior to the period when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient: (1) we recommend that pregnant patients with previable and periviable preterm prelabor rupture of membranes receive individualized counseling about the maternal and fetal risks and benefits of both abortion care and expectant management to guide an informed decision. All patients with previable and periviable preterm prelabor rupture of membranes should be offered abortion care. Expectant management can also be offered in the absence of contraindications (GRADE 1C); (2) we recommend antibiotics for pregnant individuals who choose expectant management after preterm prelabor rupture of membranes at ≥ 24 0/7 weeks of gestation (GRADE 1B); (3) antibiotics can be considered after preterm prelabor rupture of membranes at 20 0/7 to 23 6/7 weeks of gestation (GRADE 2C); (4) administration of antenatal corticosteroids and magnesium are not recommended until the time when a trial of neonatal resuscitation and intensive care would be considered appropriate by the healthcare team and desired by the patient (GRADE 1B); (5) serial amnioinfusions and amniopatch are considered investigational and should be used only in a clinical trial setting; they are not recommended for routine care of previable and periviable preterm prelabor rupture of membranes (GRADE 1B); (6) cerclage management after preterm prelabor rupture of membranes is similar to cerclage management after preterm prelabor rupture of membranes at later gestational ages; it is reasonable to either remove the cerclage or leave it in situ after discussing the risks and benefits and incorporating shared decision-making (GRADE 2C); (7) in subsequent pregnancies after a history of previable or periviable preterm prelabor rupture of membranes, we recommend following guidelines for management of pregnant persons with a prior spontaneous preterm birth (GRADE 1C).

Cesarean delivery is associated with lower neonatal mortality among breech pregnancies: a systematic review and meta-analysis of preterm deliveries ≤32 weeks of gestation.

OBJECTIVE: To investigate the association between actual and planned modes of delivery, neonatal mortality, and short-term outcomes among preterm pregnancies ≤32 weeks of gestation. DATA SOURCES: A systematic literature search was conducted in 3 main databases (PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to November 16, 2022. The protocol was registered in advance in the International Prospective Register of Systematic Reviews (CRD42022377870). STUDY ELIGIBILITY CRITERIA: Eligible studies examined pregnancies ≤32nd gestational week. All infants received active care, and the outcomes were reported separately by different modes of delivery. Singleton and twin pregnancies at vertex and breech presentations were included. Studies that included pregnancies complicated with preeclampsia and abruptio placentae were excluded. Primary outcomes were neonatal mortality and intraventricular hemorrhage. STUDY APPRAISAL AND SYNTHESIS METHODS: Articles were selected by title, abstract, and full text, and disagreements were resolved by consensus. Random effects model-based odds ratios with corresponding 95% confidence intervals were calculated for dichotomous outcomes. Risk Of Bias In Non-randomized Studies - of Interventions-I was used to assess the risk of bias. RESULTS: A total of 19 observational studies were included involving a total of 16,042 preterm infants in this systematic review and meta-analysis. Actual cesarean delivery improves survival (odds ratio, 0.62; 95% confidence interval, 0.42-0.9) and decreases the incidence of intraventricular hemorrhage (odds ratio, 0.70; confidence interval, 0.57-0.85) compared to vaginal delivery. Planned cesarean delivery does not improve the survival of very and extremely preterm infants compared to vaginal delivery (odds ratio, 0.87; 95% confidence interval, 0.53-1.44). Subset analysis found significantly lower odds of death for singleton breech preterm deliveries born by both planned (odds ratio, 0.56; 95% confidence interval, 0.32-0.98) and actual (odds ratio, 0.34; 95% confidence interval, 0.13-0.88) cesarean delivery. CONCLUSION: Cesarean delivery should be the mode of delivery for preterm ≤32 weeks of gestation breech births due to the higher mortality in preterm infants born via vaginal delivery.

The clinical performance and population health impact of birthweight-for-gestational age indices at term gestation.

BACKGROUND: The assessment of birthweight for gestational age and the identification of small- and large-for-gestational age (SGA and LGA) infants remain contentious, despite the recent creation of the Intergrowth 21st Project and World Health Organisation (WHO) birthweight-for-gestational age standards. OBJECTIVE: We carried out a study to identify birthweight-for-gestational age cut-offs, and corresponding population-based, Intergrowth 21st and WHO centiles associated with higher risks of adverse neonatal outcomes, and to evaluate their ability to predict serious neonatal morbidity and neonatal mortality (SNMM) at term gestation. METHODS: The study population was based on non-anomalous, singleton live births between 37 and 41 weeks' gestation in the United States from 2003 to 2017. SNMM included 5-min Apgar score <4, neonatal seizures, need for assisted ventilation, and neonatal death. Birthweight-specific SNMM was modelled by gestational week using penalised B-splines. The birthweights at which SNMM odds were minimised (and higher by 10%, 50% and 100%) were estimated, and the corresponding population, Intergrowth 21st, and WHO centiles were identified. The clinical performance and population impact of these cut-offs for predicting SNMM were evaluated. RESULTS: The study included 40,179,663 live births and 991,486 SNMM cases. Among female singletons at 39 weeks' gestation, SNMM odds was lowest at 3203 g birthweight, and 10% higher at 2835 g and 3685 g (population centiles 11th and 82nd, Intergrowth centiles 17th and 88th and WHO centiles 15th and 85th). Birthweight cut-offs were poor predictors of SNMM, for example, the cut-offs associated with 10% and 50% higher odds of SNMM among female singletons at 39 weeks' gestation resulted in a sensitivity, specificity, and population attributable fraction of 12.5%, 89.4%, and 2.1%, and 2.9%, 98.4% and 1.3%, respectively. CONCLUSIONS: Reference- and standard-based birthweight-for-gestational age indices and centiles perform poorly for predicting adverse neonatal outcomes in individual infants, and their associated population impact is also small.

Antenatal corticosteroids and newborn respiratory outcomes in twins: A regression discontinuity study.

OBJECTIVE: To estimate the effect of antenatal corticosteroids on newborn respiratory morbidity in twins. DESIGN: Regression discontinuity applied to population-based birth registry data. SETTING: British Columbia, Canada, 2008-2018. POPULATION: Twin pregnancies admitted for birth between 31+0 and 36+6 weeks of gestation. METHODS: During our study period, Canadian clinical practice guidelines recommended antenatal corticosteroid administration for imminent preterm birth up to 33+6 weeks. We used a logistic model to compare the predicted risks of our outcomes among pregnancies admitted for birth immediately before this clinical cut-point (higher probability of exposure to antenatal corticosteroids) versus immediately after it (lower probability). MAIN OUTCOME MEASURES: Our primary outcome was a composite of newborn respiratory distress or in-hospital death. Our secondary outcome was a composite of newborn respiratory intervention or in-hospital death. RESULTS: Among 2524 pregnancies (5035 liveborn twins), 47% of admissions before 34+0 weeks of gestation were exposed to antenatal corticosteroids but only 4.2% of admissions after this cut-point were exposed. The risk of newborn respiratory distress or in-hospital mortality increased abruptly at 34+0 weeks, corresponding to a protective effect of treatment (risk ratio [RR] 0.69, 95% CI 0.53-0.90; risk difference [RD] -12 cases per 100 births, 95% CI -20 to -4.1). There was no clear evidence for or against an effect on newborn respiratory intervention or in-hospital death (RR 0.89, 95% CI 0.70-1.13; RD -4.2 per 100, 95% CI -13 to +4.2). CONCLUSIONS: Our findings provide evidence for the effectiveness of antenatal corticosteroids in preventing adverse newborn respiratory outcomes in twins.

Income inequality as a determinant of neonatal mortality in the Americas during 2000-2019: implications for the attainment of Sustainable Development Goal target 3.2.

BACKGROUND: The work of the WHO Commission on the Social Determinants of Health has been fundamental to provide a conceptual framework of the social determinants of health. Based on this framework, this study assesses the relationship of income inequality as a determinant of neonatal mortality in the Americas and relates it to the achievement of the Sustainable Development Goal target 3.2 (reduce neonatal mortality to at least as low as 12 deaths per 1,000 live births). The rationale is to evaluate if income inequality may be considered a social factor that influences neonatal mortality in the Americas. METHODS: Yearly data from 35 countries in the Americas during 2000-2019 was collected. Data sources include the United Nations Inter-agency Group for Child Mortality Estimation for the neonatal mortality rate (measured as neonatal deaths per 1,000 live births) and the United Nations University World Institute for Development Economics Research for the Gini index (measured in a scale from 0 to 100). This is an ecological study that employs a linear regression model that relates the neonatal mortality rate (dependent variable) to the Gini index (independent variable), while controlling for other factors that influence neonatal mortality. Coefficient estimates and their robust standard errors were obtained using panel data techniques. RESULTS: A positive relationship between income inequality and neonatal mortality is found in countries in the Americas during the period studied. In particular, the analysis suggests that a unit increase in a country's Gini index during 2000-2019 is associated with a 0.27 (95% CI [- 0.04, 0.57], P =.09) increase in the neonatal mortality rate. CONCLUSION: The analysis suggests that income inequality may be positively associated with the neonatal mortality rate in the Americas. Nonetheless, given the modest magnitude of the estimates and Gini values and trends during 2000-2019, the findings suggest a potential limited scope for redistributive policies to support reductions in neonatal mortality in the region. Thus, policies and interventions that address higher coverage and quality of services provided by national health systems and reductions in socio-economic inequalities in health are of utmost importance.

The effect of birth timing manipulation around carnival on birth indicators in Brazil.

This paper studies the patterns and consequences of birth timing manipulation around the carnival holiday in Brazil. We document how births are displaced around carnival and estimate the effect of displacement on birth indicators. We show that there is extensive birth timing manipulation in the form of both anticipation and postponement that results in a net increase in gestational length and reductions in neonatal and early neonatal mortality, driven by postponed births that would otherwise happen through scheduled c-sections. We also find a reduction in birthweight for high-risk births at the bottom of the weight distribution, driven by anticipation. Therefore, restrictions on usual delivery procedures due to the carnival holiday can be both beneficial and detrimental, raising a double-sided issue to be addressed by policymakers.

Servo-controlled therapeutic hypothermia during neonatal transport: a before-and-after quality improvement project.

The purpose of this paper is to compare the achievement of target temperature and the short-term neurological outcome according to the use of servo-controlled hypothermia in transport. This is a monocentric retrospective observational before-and-after uncontrolled study of newborns transported for neonatal encephalopathy. The first group was transported from 01/01/2019 to 12/31/2019 in passive hypothermia and the second group from 01/01/2021 to 12/31/2021 in controlled hypothermia. We included patients who had a total of 72 h of servo-controlled therapeutic hypothermia (CTH). We excluded those who had no or less than 72 h of CTH. There were 33 children transported in passive hypothermia in 2019 and 23 children transported in CTH in 2021. There were 9/28 (32%) patients in 2019 who reached the target temperature on arrival at the NICU compared with 20/20 (100%) in 2021 (p value < 0.01). There was a trend towards earlier age of therapeutic hypothermia if started in transport: 3.1 h ± 1.0 vs 4.0 h ± 2.4 for passive hypothermia (p value 0.07). There was no difference in age of arrival in NICU (4.0 h ± 1.2 with CTH vs 3.8 h ± 2.2 without CTH). We found no difference in short-term outcome (survival, abnormal MRI, seizures on EEG) between the two groups. CONCLUSION: The use of servo-controlled therapeutic hypothermia makes it possible to reach the temperature target, without increasing the age of arrival in the NICU. WHAT IS KNOWN: • CTH is rarely used during transport in France even if passive hypothermia rarely reaches temperature target, inducing overcooling and hyperthermia. WHAT IS NEW: • This study shows better temperature control on arrival in the NICU with CTH compared to passive hypothermia, with no increase in arrival time.

Increasing the number of midwives is necessary but not sufficient: using global data to support the case for investment in both midwife availability and the enabling work environment in low- and middle-income countries.

BACKGROUND: Most countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries' (LMICs') midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration. METHODS: Using the most recent available data from publicly available global databases for the period 2000-2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality. RESULTS: In LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10-15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country. CONCLUSIONS: A complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes.

A single base pair duplication in the SLC33A1 gene is associated with fetal losses and neonatal lethality in Manech Tête Rousse dairy sheep.

We recently discovered that the Manech Tête Rousse (MTR) deficient homozygous haplotype 2 (MTRDHH2) probably carries a recessive lethal mutation in sheep. In this study, we fine-mapped this region through whole-genome sequencing of five MTRDHH2 heterozygous carriers and 95 non-carriers from various ovine breeds. We identified a single base pair duplication within the SLC33A1 gene, leading to a frameshift mutation and a premature stop codon (p.Arg246Alafs*3). SLC33A1 encodes a transmembrane transporter of acetyl-coenzyme A that is crucial for cellular metabolism. To investigate the lethality of this mutation in homozygous MTR sheep, we performed at-risk matings using artificial insemination (AI) between heterozygous SLC33A1 variant carriers (SLC33A1_dupG). Pregnancy was confirmed 15 days post-AI using a blood test measuring interferon Tau-stimulated MX1 gene expression. Ultrasonography between 45 and 60 days post-AI revealed a 12% reduction in AI success compared with safe matings, indicating embryonic/fetal loss. This was supported by the MX1 differential expression test suggesting fetal losses between 15 and 60 days of gestation. We also observed a 34.7% pre-weaning mortality rate in 49 lambs born from at-risk matings. Homozygous SLC33A1_dupG lambs accounted for 47% of this mortality, with deaths occurring mostly within the first 5 days without visible clinical signs. Therefore, appropriate management of SLC33A1_dupG with an allele frequency of 0.04 in the MTR selection scheme would help increase overall fertility and lamb survival.

Neonatal mortality and associated factors among newborns in Mogadishu, Somalia: a multicenter hospital-based cross-sectional study.

INTRODUCTION: Neonatal mortality is a significant public health problem in Sub-Saharan Africa, particularly in Somalia, where limited data exists about this. Mogadishu, the densely populated capital, faces a high rate of neonatal mortality, but this has not been widely studied on a national level. Healthcare providers and policymakers are working to reduce newborn deaths, but a comprehensive understanding of the contributing factors is crucial for effective strategies. Therefore, this study aims to determine the magnitude of neonatal death and identify factors associated with it in Mogadishu, Somalia. METHOD: A multicenter hospital-based cross-sectional study was conducted to collect data from participants at 5 purposively selected hospitals in Mogadishu, Somalia. A well-structured, reliable, self-developed, validated questionnaire containing socio-demographic, maternal, and neonatal characteristics was used as a research tool. Descriptive statistics were used for categorical and continuous variables presented. Chi-square and logistic regression were used to identify factors associated with neonatal mortality at a significant level of α = 0.05. RESULTS: A total of 513 participants were recruited for the study. The prevalence of neonatal mortality was 26.5% [95%CI = 22.6-30.2]. In a multivariable model, 9 variables were found: female newborns (AOR = 1.98, 95%CI = 1.22-3.19), those their mothers who did not attend ANC visits (AOR = 2.59, 95%CI = 1.05-6.45), those their mothers who did not take tetanus toxoid vaccination (AOR = 1.82, 95%CI = 1.01-3.28), those their mothers who delivered in instrumental assistant mode (AOR = 3.01, 95%CI = 1.38-6.56), those who had neonatal sepsis (AOR = 2.24, (95%CI = 1.26-3.98), neonatal tetanus (AOR = 16.03, 95%CI = 3.69-69.49), and pneumonia (AOR = 4.06, 95%CI = 1.60-10.31) diseases during hospitalization, premature (AOR = 1.99, 95%CI = 1.00-3.94) and postmature (AOR = 4.82, 95%CI = 1.64-14.16) neonates, those with a birth weight of less than 2500 gr (AOR = 4.82, 95%CI = 2.34-9.95), those who needed resuscitation after delivery (AOR = 2.78, 95%CI = 1.51-5.13), and those who did not initiate early breastfeeding (AOR = 2.28, 95%CI = 1.12-4.66), were significantly associated with neonatal mortality compared to their counterparts. CONCLUSION: In this study, neonatal mortality was high prevalence. Therefore, the intervention efforts should focus on strategies to reduce maternal and neonatal factors related to neonatal mortality. Healthcare workers and health institutions should provide appropriate antenatal, postnatal, and newborn care.

Association of socioeconomic disadvantage and ethnicity with perinatal neonatal, and infant mortality in Slovakia.

BACKGROUND: Infant mortality rates are reliable indices of the child and general population health status and health care delivery. The most critical factors affecting infant mortality are socioeconomic status and ethnicity. The aim of this study was to assess the association between socioeconomic disadvantage, ethnicity, and perinatal, neonatal, and infant mortality in Slovakia before and during the COVID-19 pandemic. METHODS: The associations between socioeconomic disadvantage (educational level, long-term unemployment rate), ethnicity (the proportion of the Roma population) and mortality (perinatal, neonatal, and infant) in the period 2017-2022 were explored, using linear regression models. RESULTS: The higher proportion of people with only elementary education and long-term unemployed, as well as the higher proportion of the Roma population, increases mortality rates. The proportion of the Roma population had the most significant impact on mortality in the selected period between 2017 and 2022, especially during the COVID-19 pandemic (2020-2022). CONCLUSIONS: Life in segregated Roma settlements is connected with the accumulation of socioeconomic disadvantage. Persistent inequities between Roma and the majority population in Slovakia exposed by mortality rates in children point to the vulnerabilities and exposures which should be adequately addressed by health and social policies.

Predictors of neonatal mortality among neonates admitted to the neonatal intensive care unit at Hawassa University Comprehensive Specialized Hospital, Sidama regional state, Ethiopia.

BACKGROUND: Despite promising efforts, substantial deaths occurred during the neonatal period. According to estimates from the World Health Organization (WHO), Ethiopia is among the top 10 nations with the highest number of neonatal deaths in 2020 alone. This staggering amount makes it difficult to achieve the SDG (Sustainable Development Goals) target that calls for all nations to work hard to meet a neonatal mortality rate target of ≤ 12 deaths per 1,000 live births by 2030. We evaluated neonatal mortality and it's contributing factors among newborns admitted to the Neonatal Intensive Care Unit (NICU) at Hawassa University Comprehensive Specialized Hospital (HUCSH). METHODS: A hospital-based retrospective cross-sectional study on neonates admitted to the NICU from May 2021 to April 2022 was carried out at Hawassa University Comprehensive Specialized Hospital. From the admitted 1044 cases over the study period, 225 babies were sampled using a systematic random sampling procedure. The relationship between variables was determined using bivariate and multivariable analyses, and statistically significant relations were indicated at p-values less than 0.05. RESULTS: The magnitude of neonatal death was 14.2% (95% CI: 0.099-0.195). The most common causes of neonatal death were prematurity 14 (43.8%), sepsis 9 (28.1%), Perinatal asphyxia 6 (18.8%), and congenital malformations 3 (9.4%). The overall neonatal mortality rate was 28 per 1000 neonate days. Neonates who had birth asphyxia were 7.28 times more probable (AOR = 7.28; 95% CI: 2.367, 9.02) to die. Newborns who encountered infection within the NICU were 8.17 times more likely (AOR = 8.17; 95% CI: 1.84, 36.23) to die. CONCLUSION: The prevalence of newborn death is excessively high. The most common causes of mortality identified were prematurity, sepsis, perinatal asphyxia and congenital anomalies. To avert these causes, we demand that antenatal care services be implemented appropriately, delivery care quality be improved, and appropriate neonatal care and treatment be made available.

COVID-19 pandemic effects on neonatal inpatient admissions and mortality: interrupted time series analysis of facilities implementing NEST360 in Kenya, Malawi, Nigeria, and Tanzania.

BACKGROUND: The emergence of COVID-19 precipitated containment policies (e.g., lockdowns, school closures, etc.). These policies disrupted healthcare, potentially eroding gains for Sustainable Development Goals including for neonatal mortality. Our analysis aimed to evaluate indirect effects of COVID-19 containment policies on neonatal admissions and mortality in 67 neonatal units across Kenya, Malawi, Nigeria, and Tanzania between January 2019 and December 2021. METHODS: The Oxford Stringency Index was applied to quantify COVID-19 policy stringency over time for Kenya, Malawi, Nigeria, and Tanzania. Stringency increased markedly between March and April 2020 for these four countries (although less so in Tanzania), therefore defining the point of interruption. We used March as the primary interruption month, with April for sensitivity analysis. Additional sensitivity analysis excluded data for March and April 2020, modelled the index as a continuous exposure, and examined models for each country. To evaluate changes in neonatal admissions and mortality based on this interruption period, a mixed effects segmented regression was applied. The unit of analysis was the neonatal unit (n = 67), with a total of 266,741 neonatal admissions (January 2019 to December 2021). RESULTS: Admission to neonatal units decreased by 15% overall from February to March 2020, with half of the 67 neonatal units showing a decline in admissions. Of the 34 neonatal units with a decline in admissions, 19 (28%) had a significant decrease of ≥ 20%. The month-to-month decrease in admissions was approximately 2% on average from March 2020 to December 2021. Despite the decline in admissions, we found no significant changes in overall inpatient neonatal mortality. The three sensitivity analyses provided consistent findings. CONCLUSION: COVID-19 containment measures had an impact on neonatal admissions, but no significant change in overall inpatient neonatal mortality was detected. Additional qualitative research in these facilities has explored possible reasons. Strengthening healthcare systems to endure unexpected events, such as pandemics, is critical in continuing progress towards achieving Sustainable Development Goals, including reducing neonatal deaths to less than 12 per 1000 live births by 2030.

Implementation outcomes of the integrated district evidence to action (IDEAs) program to reduce neonatal mortality in central Mozambique: an application of the RE-AIM evaluation framework.

BACKGROUND: Scarce evidence exists on audit and feedback implementation processes in low-resource health systems. The Integrated District Evidence to Action (IDEAs) is a multi-component audit and feedback strategy designed to improve the implementation of maternal and child guidelines in Mozambique. We report IDEAs implementation outcomes. METHODS: IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces between 2016 and 2020 and evaluated using a quasi-experimental design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Reach is the proportion of pregnant women attending IDEAs facilities. Adoption is the proportion of facilities initiating audit and feedback meetings. Implementation is the fidelity to the strategy components, including readiness assessments, meetings (frequency, participation, action plan development), and targeted financial support and supervision. Maintenance is the sustainment at 12, 24, and 54 months. RESULTS: Across both provinces, 56% of facilities were exposed to IDEAs (target 57%). Sixty-nine and 73% of pregnant women attended those facilities' first and fourth antenatal consultations (target 70%). All facilities adopted the intervention. 99% of the expected meetings occurred with an average interval of 5.9 out of 6 months. Participation of maternal and child managers was high, with 3076 attending meetings, of which 64% were from the facility, 29% from the district, and 7% from the province level. 97% of expected action plans were created, and 41 specific problems were identified. "Weak diagnosis or management of obstetric complications" was identified as the main problem, and "actions to reinforce norms and protocols" was the dominant subcategory of micro-interventions selected. Fidelity to semiannual readiness assessments was low (52% of expected facilities), and in completing micro-interventions (17% were completed). Ninety-six and 95% of facilities sustained the intervention at 12 and 24 months, respectively, and 71% had completed nine cycles at 54 months. CONCLUSION: Maternal and child managers can lead audit and feedback processes in primary health care in Mozambique with high reach, adoption, and maintenance. The IDEAs strategy should be adapted to promote higher fidelity around implementing action plans and conducting readiness assessments. Adding effectiveness to these findings will help to inform strategy scale-up.

Optimizing integration of community-based management of possible serious bacterial infection (PSBI) in young infants into primary healthcare systems in Ethiopia and Kenya: successes and challenges.

BACKGROUND: Ethiopia and Kenya have adopted the community-based integrated community case management (iCCM) of common childhood illnesses and newborn care strategy to improve access to treatment of infections in newborns and young infants since 2012 and 2018, respectively. However, the iCCM strategy implementation has not been fully integrated into the health system in both countries. This paper describes the extent of integration of iCCM program at the district/county health system level, related barriers to optimal integration and implementation of strategies. METHODS: From November 2020 to August 2021, Ethiopia and Kenya implemented the community-based treatment of possible serious bacterial infection (PSBI) when referral to a higher facility is not possible using embedded implementation research (eIR) to mitigate the impact of COVID-19 on the delivery of this life-saving intervention. Both projects conducted mixed methods research from April-May 2021 to identify barriers and facilitators and inform strategies and summative evaluations from June-July 2022 to monitor the effectiveness of implementation outcomes including integration of strategies. RESULTS: Strategies identified as needed for successful implementation and sustainability of the management of PSBI integrated at the primary care level included continued coaching and support systems for frontline health workers, technical oversight from the district/county health system, and ensuring adequate supply of commodities. As a result, support and technical oversight capacity and collaborative learning were strengthened between primary care facilities and community health workers, resulting in improved bidirectional linkages. Improvement of PSBI treatment was seen with over 85% and 81% of estimated sick young infants identified and treated in Ethiopia and Kenya, respectively. However, perceived low quality of service, lack of community trust, and shortage of supplies remained barriers impeding optimal PSBI services access and delivery. CONCLUSION: Pragmatic eIR identified shared and unique contextual challenges between and across the two countries which informed the design and implementation of strategies to optimize the integration of PSBI management into the health system during the COVID-19 pandemic. The eIR participatory design also strengthened ownership to operationalize the implementation of identified strategies needed to improve the health system's capacity for PSBI treatment.

Abortion Legal Reform and Neonatal Mortality in Mozambique.

INTRODUCTION: Abortion law reforms have been hypothesized to influence reproductive, maternal, and neonatal health services and health outcomes, as well as social inequalities in health. In 2014, Mozambique legalized abortion in specific circumstances. However, due to challenges implementing the law, there is concern that it may have negatively influenced neonatal outcomes. METHODS: Using a difference-in-differences design, we used birth history data collected via the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) between 2004 and 2018 to assemble a panel of 476 939 live births across 17 countries including Mozambique. We estimated the effect of the abortion reform on neonatal mortality by comparing Mozambique to a series of control countries that did not change their abortion policies. We also conducted stratified analyses to examine heterogeneity in effect estimates by household wealth, educational attainment, and rural/urban residence. RESULTS: The reform was associated with an additional 5.6 (95% CI = 1.3, 9.9) neonatal deaths per 1,000 live birth. There was evidence of a differential effect of the reform, with a negative effect of the reform on neonatal outcomes for socially disadvantaged women, including those with no schooling, in poorer households, and living in rural areas. DISCUSSION: Given the delay in implementation, our analyses suggest that abortion reform in Mozambique was associated with an initial increase in neonatal mortality particularly among socially disadvantaged women. This may be due to the delay in effective implementation, including the dissemination of clear guidelines and expansion of safe abortion services. Longer-term follow-up is needed to assess the impact of the reform after 2018, when services were expanded. Abortion legal reform without adequate implementation and enforcement is unlikely to be sufficient to improve abortion access and health outcomes.

Why do women choose home births.

In recent years, the US has seen a significant rise in the rate of planned home births, with a 60 % increase from 2016 to 2023, reaching a total of 46,918. This trend positions the US as the leading developed country in terms of home birth prevalence. The American College of Obstetricians and Gynecologists (ACOG) suggests stringent criteria for selecting candidates for home births, but these guidelines have not been adopted by home birth midwives leading to poor outcomes including increased rates of neonatal morbidity and mortality. This paper explores the motivations behind choosing home births in the US despite the known risks. Studies highlight factors such as the desire for a more natural birth experience, previous negative hospital experiences, and the influence of the COVID-19 pandemic on perceptions of hospital safety. We provide new insights into why women choose home births by incorporating insights from Nobel laureate Daniel Kahneman's theories on decision-making, suggesting that cognitive biases may significantly influence these decisions. Kahneman's work provides a framework for understanding how biases and heuristics can lead to the underestimation of risks and overemphasis on personal birth experiences. We also provide recommendations ("nudges according to Richard Thaler") to help ensure women have access to clear, balanced information about home births. The development of this publication was assisted by OpenAI's ChatGPT-4, which facilitated the synthesis of literature, interpretation of data, and manuscript drafting. This collaboration underscores the potential of integrating advanced computational tools in academic research, enhancing the efficiency and depth of our analyses.

Disentangling the link between social determinants of health and child survival in Nigeria during the Sustainable Development Goals era: a hierarchical path analysis of time-to-event outcome.

While social determinants of health have been perennially linked to child survival in resource-limited countries, the precise and tested pathways to effect are not clearly understood. The objective of this study was therefore to identify the critical pathways as posited a priori in a model through which social factors (at maternal, household, and community levels) determine neonatal, infant, and under-five mortalities in Nigeria. Using a novel analytic approach (hierarchical path modelling for predicting accelerated failure time) to estimate (in)direct and total effects of social determinants of child survival, we analysed 30,960 live births (weighted data for representativeness), obtained from the 2016/2017 Nigeria Multiple Indicator Cluster Survey. There were three outcome variables: time until occurrence of neonatal, infant, and under-five mortalities. The independent variables were layered factors related to child, maternal, household and community. Geographical region, rurality of residence, infrastructural development, maternal education, contraceptive use, marital status, and maternal age at birth were found to operate more indirectly on neonatal, infant, and under-five survival. Child survival is due to direct effects of child's sex (female), gestational type (singleton), birth spacing (children whose mothers delivered at least two years apart), and maternal age at delivery (20-34 years). According to the path coefficients, the indirect effects of geographical regions are the most influential determinants of child survival, accounting for 30% (neonatal), 37.1% (infant) and 39.9% (under-five) of the total effects. This study offers comprehensive set of factors, and linked pathways, at the maternal, household, and community levels that are associated with child survival in Nigeria. To accelerate progress towards Sustainable Development Goal targets for child survival and reduce geographical inequities, stakeholders should implement more impactful policies that promote maternal education, contraceptive use and improve living conditions of women (especially in rural areas of northern Nigeria). Future research should focus on identifying the most effective interventions for addressing these social determinants of child survival in Nigeria.

Impact of intrapartum quality improvement interventions on stillbirths and other adverse pregnancy outcomes: A protocol for systematic review and meta-analysis.

BACKGROUND: Stillbirths are a major global health concern. Half of stillbirths occur during intrapartum period, mostly in low- and middle-income countries of sub-Saharan Africa and South Asia. Achieving a stillbirth rate of less than 12 per 1000 births by 2030 is the global target of Every Newborn Action Plan and Sustainable Development Goals. Evidence suggests that improving intrapartum quality of care can help reduce stillbirths and other adverse pregnancy outcomes. This study will explore whether quality improvement (QI) packages at intrapartum care points can reduce stillbirths and other outcomes such as maternal and neonatal mortality. METHODS: We will conduct a systematic literature review and meta-analysis. Comprehensive search strategy will be developed for databases PubMed, Web of Science, ScienceDirect, ProQuest, Cochrane and China National Knowledge Infrastructure. We will include randomized controlled trials, controlled non-randomized trials, controlled clinical trials, interrupted time series, cohort studies, case-control and nested case-control studies which assess the impact of QI interventions at intrapartum points of care on stillbirths and other adverse pregnancy outcomes. We will search grey literature such as unpublished research studies, dissertations and unfinished trials. English and non-English language articles will be included to avoid language bias. We will also evaluate reporting quality and risk of bias. Sensitivity tests will be carried out for heterogeneity. Pooled estimates of effect sizes will be computed with random-effects models. Supplementation of the quantitative synthesis with a qualitative narrative synthesis would be added, if deemed necessary. We will explore publication bias using funnel plot and Egger's regression test will be used for evaluation, if needed. DISCUSSION: We will report pooled effectiveness of different intrapartum QI interventions across multiple settings in averting stillbirths and other adverse outcomes such as maternal mortality and neonatal mortality.