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

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

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

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

A case for updating the WHO Safe Childbirth Checklist to improve newborn care: Experience from seven Asia and Pacific countries.

The WHO Safe Childbirth Checklist (the SCC) is a clinical tool developed to help health workers follow evidence-based maternal and perinatal care practices at childbirth. Newborn delivery care practices at facilities in seven countries in East Asia and the Pacific were compared to practices checked by the SCC. The analysis found that the SCC does not incorporate several key evidence-based practices around birth demonstrated to prevent newborn morbidity or mortality, or harmful practices associated with increased risks. A revision of the standard SCC is needed to maximise its potential to improve newborn outcomes. This can be initiated under the coordinating umbrella of WHO, but must ensure that the realities of labour and childbirth practices in low- and middle-income countries are considered and addressed.

Early Essential Newborn Care can still be used with mothers who have COVID-19 if effective infection control measures are applied.

We describe the first infant born to a woman with COVID-19 in Vietnam, by Caesarean section at 36 weeks and 5 days of gestation. The mother and baby remained together during their hospital stay and prolonged skin-to-skin contact and early and exclusive breastfeeding were achieved. This was in line with the World Health Organization's Early Essential Newborn Care (EENC) recommendations, the national Vietnamese standard of care since 2014. The baby remained virus-free throughout the 34-day postpartum follow-up. CONCLUSION: The EENC approach can still be used with mothers who have COVID-19 if effective infection control measures are applied.

Healthcare worker knowledge and skills following coaching in WHO early essential newborn care program in the Solomon Islands: a prospective multi-site cohort study.

BACKGROUND: Newborn mortality in Oceania declined slower than other regions in the past 25 years. The World Health Organization (WHO) introduced the Early Essential Newborn Care program (EENC) in 2015 in Solomon Islands, a Small Island Developing State, to address high newborn mortality. We explored knowledge and skills retention among healthcare workers following EENC coaching. METHODS: Between March 2015 and December 2017, healthcare workers in five hospitals were assessed: pre- and post-clinical coaching and at a later evaluation. Standardised written and clinical skills assessments for breathing and non-breathing baby scenarios were used. Additionally, written surveys were completed during evaluation for feedback on the EENC experience. RESULTS: Fifty-three healthcare workers were included in the evaluation. Median time between initial coaching and evaluation was 21 months (IQR 18-26). Median written score increased from 44% at baseline to 89% post-coaching (p < 0.001), and was 61% at evaluation (p < 0.001). Skills assessment score was 20% at baseline and 95% post-coaching in the Breathing Baby scenario (p < 0.001). In the Non-Breathing Baby scenario, score was 63% at baseline and 86% post-coaching (p < 0.001). At evaluation, median score in the Breathing Baby scenario was 82% a reduction of 13% from post-coaching (p < 0.001) and 72% for the Non-Breathing Baby, a reduction of 14% post-coaching (p < 0.001). Nurse aides had least reduction in evaluation scores of - 2% for the Breathing Baby and midwives - 10% for the Non-Breathing Baby respectively from post-coaching to evaluation. CONCLUSIONS: EENC coaching resulted in immediate improvements in knowledge and skills but declined over time. Healthcare workers who used the skills in regular practice had higher scores. Complementary quality improvement strategies are needed to sustain resuscitation skills following training over time. TRIAL REGISTRATION: Australia New Zealand Trial Registry, Retrospective Registration (12/2/2019), registration number ACTRN12619000201178.

Improving immediate newborn care practices in Philippine hospitals: impact of a national quality of care initiative 2008-2015.

OBJECTIVE: To determine whether intrapartum and newborn care practices improved in 11 large hospitals between 2008 and 2015. DESIGN: Secondary data analysis of observational assessments conducted in 11 hospitals in 2008 and 2015. SETTING: Eleven large government hospitals from five regions in the Philippines. PARTICIPANTS: One hundred and seven randomly sampled postpartum mother-baby pairs in 2008 and 106 randomly sampled postpartum mothers prior to discharge from hospitals after delivery. INTERVENTIONS: A national initiative to improve quality of newborn care starting in 2009 through development of a standard package of intrapartum and newborn care services, practice-based training, formation of multidisciplinary hospital working groups, and regular assessments and meetings in hospitals to identify actions to improve practices, policies and environments. Quality improvement was supported by policy development, health financing packages, health facility standards, capacity building and health communication. MAIN OUTCOME MEASURES: Sixteen intrapartum and newborn care practices. RESULTS: Between 2008 and 2015, initiation of drying within 5 s of birth, delayed cord clamping, dry cord care, uninterrupted skin-to-skin contact, timing and duration of the initial breastfeed, and bathing deferred until 6 h after birth all vastly improved (P<0.001). The proportion of newborns receiving hygienic cord handling and the hepatitis B birth dose decreased by 11-12%. Except for reduced induction of labor, inappropriate maternal care practices persisted. CONCLUSIONS: Newborn care practices have vastly improved through an approach focused on improving hospital policies, environments and health worker practices. Maternal care practices remain outdated largely due to the ineffective didactic training approaches adopted for maternal care.

A systematic review on identifying risk factors associated with early sexual debut and coerced sex among adolescents and young people in communities.

AIMS AND OBJECTIVES: To review literature on identifying the risk factors associated with early sexual coerced debut with the aim to facilitate the healthcare workers' planning of relevant health services to improve intervention strategies for delaying of early coerced sexual debut or forced sexual debut (CSD/FSD) in the communities. BACKGROUND: Identifying the risk factors associated with coercion at first sex is crucial for developing appropriate sexual and reproductive health information and health promotion in response. However, current knowledge about the risk factors associated with coercion, sexual debut (SD) and delayed SD among young people is limited. Health information programmes are important during adolescence, when young people are developing their values and beliefs about sexual activity and sexual norms. However, little is known about those risk factors on initiation of early sexual debut to plan relevant interventions that can delay SD and prevent CSD/FSD in this population. DESIGN: A systematic review. METHODS: An extensive literature search using MEDLINE (PubMed), Nursing Journals (PubMed), Web of Science, PsychINFO and CINAHL. RESULTS: The search generated 39 published studies that met our inclusion and exclusion criteria. Thirty-two articles passed the quality appraisal and were selected. This review identified six domains of risk factors, categorised as: (1) the individual domain, (2) the family domain, (3) the partner/peer domain, (4) the school domain, (5) the community domain and (6) the cultural domain. These factors highlight the influences on sexual decision-making among adolescents and young people and the timing of their first sexual intercourse. CONCLUSION: It is important to use the outcome of this review's categorisation of identified risk factors to facilitate the healthcare workers and plan relevant sexual and reproductive health programmes more accessible to adolescents, especially young females and their parents. There is a need to evaluate the impact of these programmes that can delay SD and prevent CSD/FSD in this population. RELEVANCE TO CLINICAL PRACTICE: The results of this study could provide guidance on the planning of effective interventions for delaying of early CSD/FSD in the communities.

Underuse of modern methods of contraception: underlying causes and consequent undesired pregnancies in 35 low- and middle-income countries.

STUDY QUESTION: What is the contribution of the underuse of modern methods (MM) of contraception to the annual undesired pregnancies in 35 low- and middle-income countries? SUMMARY ANSWER: Fifteen million out of 16.7 million undesired pregnancies occurring annually in 35 countries could have been prevented with the optimal use of MM of contraception. WHAT IS KNOWN ALREADY: Every year, 87 million women worldwide become pregnant unintentionally because of the underuse of MM of contraception. STUDY DESIGN, SIZE, DURATION: Demographic and health surveys (DHS) of 35 countries, conducted between 2005 and 2012, were analysed. PARTICIPANTS/MATERIALS, SETTING, METHODS: Contraceptive use of 12 874 unintentionally pregnant women was compared with 111 301 sexually active women who were neither pregnant nor desiring pregnancy. MAIN RESULTS AND THE ROLE OF CHANCE: An average of 96% of 15- to 49-year-old eligible women took part in the survey. When adjusted for covariates and compared with the use of MM of contraception, the use of traditional methods was associated with a 2.7 [95% confidence interval (CI): 2.3-3.4] times increase in odds of an undesired pregnancy, while non-use of any method was associated with a 14.3 (95% CI, 12.3-16.7) times increase. This corresponded to an estimated 16.7 million undesired pregnancies occurring annually in the 35 countries, of which 15.0 million could have been prevented with the optimal use of MM of contraception (13.5 million women did not use MM whilst 1.5 million women utilized MM incorrectly). Women with the lowest educational attainment and wealth quintile were 8.6 (95% CI: 8.2-9.1) and 2.6 (95% CI: 2.4-2.9) times less likely to use contraceptives compared with those with the highest level of each, respectively. Of the 14 893 women who neither desired pregnancy nor used contraception, 5559 (37.3%) cited fear of side effects and health concerns as the reason for non-use, 3331 (22.4%) cited they or their partner's opposition to contraception or religious prohibition and 2620 (17.6%) underestimated the risk of pregnancy. LIMITATIONS, REASONS FOR CAUTION: Despite the fact that DHS are considered high-quality studies, we should not underestimate the role played by recall bias for past pregnancies. Few women report a current pregnancy in the first trimester and undesired pregnancies at that time are probably prone to under-reporting. Some terminated pregnancies may not be included in the current pregnancy group. Furthermore, covariates measured at the time of the survey may not have reflected the same covariates at the time the currently pregnant women became pregnant. WIDER IMPLICATIONS OF THE FINDINGS: Underuse of MM of contraception burdens especially the poor and the less educated. National strategies should address unfounded health concerns, fear of side effects, opposition and underestimated risk of pregnancy, which are major contributors to undesired pregnancies. FUNDING/CONFLICTS OF INTEREST: No external funding was utilized for this report. There are no conflicts of interest to declare.

Basic newborn care and neonatal resuscitation: a multi-country analysis of health system bottlenecks and potential solutions.

BACKGROUND: An estimated two-thirds of the world's 2.7 million newborn deaths could be prevented with quality care at birth and during the postnatal period. Basic Newborn Care (BNC) is part of the solution and includes hygienic birth and newborn care practices including cord care, thermal care, and early and exclusive breastfeeding. Timely provision of resuscitation if needed is also critical to newborn survival. This paper describes health system barriers to BNC and neonatal resuscitation and proposes solutions to scale up evidence-based strategies. METHODS: The maternal and newborn bottleneck analysis tool was applied by 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" that hinder the scale up of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for BNC and neonatal resuscitation. RESULTS: Eleven of the 12 countries provided grading data. Overall, bottlenecks were graded more severely for resuscitation. The most severely graded bottlenecks for BNC were health workforce (8 of 11 countries), health financing (9 out of 11) and service delivery (7 out of 9); and for neonatal resuscitation, workforce (9 out of 10), essential commodities (9 out of 10) and service delivery (8 out of 10). Country teams from Africa graded bottlenecks overall more severely. Improving workforce performance, availability of essential commodities, and well-integrated health service delivery were the key solutions proposed. CONCLUSIONS: BNC was perceived to have the least health system challenges among the seven maternal and newborn intervention packages assessed. Although neonatal resuscitation bottlenecks were graded more severe than for BNC, similarities particularly in the workforce and service delivery building blocks highlight the inextricable link between the two interventions and the need to equip birth attendants with requisite skills and commodities to assess and care for every newborn. Solutions highlighted by country teams include ensuring more investment to improve workforce performance and distribution, especially numbers of skilled birth attendants, incentives for placement in challenging settings, and skills-based training particularly for neonatal resuscitation.

A gap analysis of midwifery competency, pre- and in-service education for reproductive, maternal, newborn, child and, adolescent health in Lao People's Democratic Republic.

Background: Ensuring midwives deliver quality essential services requires systematic and timely updates to midwifery education based on constantly evolving global evidence and local needs. However, midwifery curricula are often not updated to incorporate new evidence, consistent with national standards. This study supported the Ministry of Health of Lao People's Democratic Republic to identify gaps in the midwifery competency framework and training packages. Methods: Stakeholder consultations and a document review were conducted to define a core package of RMNCAH interventions and care tasks that midwives should provide based on the national Essential Health Service Package (EHSP). Nationally defined midwifery competencies, the higher diploma midwifery curriculum, and in-service training packages were mapped against required interventions and care tasks. Data were used to revise midwifery education standards. Findings: Midwives were expected to provide 47 RMNCAH interventions based on the EHSP. At baseline, 7 (14.9%), 11 (23.4%) and 35 (74.5%) of the 47 interventions were included in the midwifery competency, higher diploma in midwifery curriculum, and in-service training materials, respectively. After revision, the midwifery competency framework included 42 of 47 interventions (89.4%). The data are currently being used to review and update the national midwifery pre-service diploma curriculum. Interpretation: This analysis enabled the Ministry to identify RMNCAH content gaps in national midwifery education standards and align them with the EHSP. Regular use of a quantitative approach to review educational content is essential to ensure standards are consistent with changing evidence. The approach has potential application to other service areas, cadres, and countries. Funding: Korea Foundation for International Healthcare (KOFIH) supported research operation.

A regulatory gap analysis of midwifery to deliver essential reproductive, maternal, newborn, child and adolescent health services in Lao People's Democratic Republic.

Background: In Lao Peoples Democratic Republic, midwives are the main providers of primary reproductive, maternal, newborn, child and adolescent (RMNCAH) services. We analyzed to what extent practice regulations allow midwives to provide nationally defined essential RMNCAH services. Methods: Stakeholder consultations and document reviews were conducted to identify the essential RMNCAH interventions and care tasks midwives are expected to provide without physicians. These were defined in: 1) the Essential Health Service Package (EHSP) and 2) 18 national standards and guidelines. We then mapped whether midwifery regulations, which provide the legal framework for clinical service provision, supported delivery of these standards to identify regulatory gaps. Data were used to update regulations. Findings: Midwives were expected to provide 39 RMNCAH interventions without physicians, representing 1100 care tasks. Midwifery practice regulations allowed eight of 39 interventions (20.5%) and 705 of 1100 care tasks (64.1%) at baseline. Of the 31 interventions not allowed for provision by midwives, 83.9% (26) required prescribing and giving medicines, 51.6% (16) ordering and conducting diagnostics, 38.7% (12) making a clinical diagnosis, and 22.6% (7) use of non-pharmacological interventions. The Ministry of Health convened a multi-stakeholder group to revise the midwifery practice regulations, which increased the legally supported interventions and care tasks to 37 (94.9%) and 1081 (98.3%), respectively. Interpretation: This novel methodology enabled systematic identification and quantification of regulatory gaps in midwifery practice and data-driven revisions. Consequently, regulatory support for delivery of primary RMNCAH interventions vastly improved. The approach can be applied to other clinical cadres, service areas and countries. Funding: Korea Foundation for International Health Care (KOFIH) supported research operation.

Experiences in COVID-19 clinical management and health-care pathways in the Western Pacific.

The coronavirus disease (COVID-19) pandemic has transformed clinical practice and health systems. This paper provides an overview of COVID-19 clinical management and health-care pathway challenges that the World Health Organization and its Member States in the Western Pacific Region have faced. The experiences and lessons identified can help countries to better prepare for future pandemics.

Maintaining health-system functionality in response to the surge of COVID-19 cases due to the Omicron variant, Japan.

Problem: The Omicron variant of severe acute respiratory syndrome coronavirus 2 caused the largest surge of coronavirus disease (COVID-19) cases in Japan starting in the summer of 2022. We describe the mechanisms introduced to provide appropriate health care to all Omicron cases, provide appropriate health care to all non-COVID-19 patients, and protect health-care workers (HCWs) while providing necessary health services. Optimization of care for elderly patients was particularly important. Context: Japan is home to 125 million people, of whom 28.6% are 65 years or older. Between January and June 2022, the country experienced 4.3 times more COVID-19 cases than in the previous 2 years (7.3 million vs 1.7 million). Action: To adjust care pathways, inpatient treatment capacity was increased, a home-based care system was established, and an on-site treatment scheme at long-term care facilities was started. Among essential health services, disruption of emergency care became most noticeable. Administrative and financial support was provided to hospitals with emergency departments to maintain emergency medical services. To protect HCWs while maintaining hospital services, flexible exemptions were introduced to enable those who became close contacts to return to work, and broadly targeted contact tracing and testing in case of nosocomial outbreaks were all helpful. Outcome: As a result of the adjustments made to inpatient capacity and patient flow, bed occupancy for COVID-19 patients decreased, mostly because many patients were cared for at home or in temporary-care facilities. Discussion: From this study, we extracted two essential lessons to aid in current and future health emergencies: how to balance the provision of acute medical care for elderly patients and maintain their well-being; and how to maintain essential health services.

Factors associated with high exclusive breastfeeding rates among preterm infants under 34 weeks of gestation in Da Nang, Vietnam: A retrospective cohort study.

Background: Preterm infants have higher mortality than full-term infants. While breastfeeding dramatically reduces preterm death, it is limited by biological and practice barriers, particularly for babies born before 34 weeks gestational age. Da Nang Hospital for Women and Children developed a quality improvement approach to improve breastfeeding of preterm infants by strengthening feeding support, non-separation, and kangaroo mother care (KMC). Methods: To determine breastfeeding outcomes following discharge and explore factors associated with improved feeding, mothers of infants under 34 weeks gestational age born October 2021 to March 2022 and discharged alive were interviewed at six months and their medical records were reviewed. Results: Out of 104 preterm infants included, all were exclusively breastfed at discharge and one month, 86.5% at three months, and 63.5% at six months; 47.1% received immediate skin-to-skin contact, 31.7% immediate and continuous KMC, and the remaining 68.3% continuous KMC beginning at a median of three days. Exclusive breastfeeding at six months was associated with the mother antenatally seeking breastfeeding information (odds ratio (OR) = 14.5; 95% confidence interval (CI) = 1.2-173.6), avoiding bottle-feeding at home (OR = 7.7; 95% CI = 1.7-33.7) and reduced with each day delay between birth and full breastfeeding (OR = 0.8; 95% CI = 0.6-0.9). Conclusions: Hospital environments that limit mother-baby separations and feeding delays, including rooming-in of mothers and infants, KMC, and breastfeeding support from birth, enabled 100% of preterm infants born before 34 weeks gestational age to breastfeed exclusively with continued rates higher than previously reported. Addressing antenatal and post-natal factors limiting practice can further improve longer-term breastfeeding outcomes. The approach can be adapted to achieve high exclusive breastfeeding rates, regardless of gestational age.

Association of duration of skin-to-skin contact after cesarean delivery in China: a superiority, multicentric randomized controlled trial.

BACKGROUND: In China, the rates of early initiation and exclusive breastfeeding are low. The high cesarean delivery rates further contribute to low breastfeeding outcomes. Skin-to-skin contact, a key component of early essential newborn care, is known to be associated with improved breastfeeding initiation and exclusivity; however, the necessary duration has not been subjected to a randomized control trial. OBJECTIVE: This study aimed to determine the association of the duration of skin-to-skin contact after cesarean delivery with breastfeeding outcomes and maternal and neonatal health outcomes in China. STUDY DESIGN: This was a multicentric randomized controlled trial that was conducted at 4 hospitals in China. A total of 720 participants at ≥37 gestational weeks with a singleton pregnancy and who received an elective cesarean delivery with epidural anesthesia or spinal anesthesia or combined spinal-epidural anesthesia were randomly divided into 4 groups at a ratio of 1:1:1:1. The control group received routine care. Intervention group 1 (G1), 2 (G2), and 3 (G3) received 30, 60, and 90 minutes of skin-to-skin contact immediately after the cesarean delivery, respectively. RESULTS: Between January 3 and October 14, 2021, 659 participants were recruited, including 173 in the control group, 176 in G1, 146 in G2, and 164 in G3. Among G1, G2, and G3, the rate of early initiation of breastfeeding within 60 minutes of birth was 56%, 71%, and 72%, respectively, compared with 22% in the control group (P<.001). The exclusive breastfeeding rate at discharge was 69%, 62%, and 71%, respectively, compared with 57% in the control group (P=.003). Early essential newborn care practices were associated with a reduction in postpartum blood loss and neonatal intensive care unit or neonatal ward admission (P<.001; P=.022) . CONCLUSION: Our findings highlight that prolonged skin-to-skin contact after a cesarean delivery was associated with higher initiation and exclusive breastfeeding at discharge rates. It also found associations with reduced postpartum blood loss and neonatal intensive care unit or neonatal ward admission.

Integrating maternal, newborn, child health and non-communicable disease care in the sustainable development goal era.

Noncommunicable diseases (NCDs) and maternal newborn and child health (MNCH) are two deeply intertwined health areas that have been artificially separated by global health policies, resource allocations and programming. Optimal MNCH care can provide a unique opportunity to screen for, prevent and manage early signs of NCDs developing in both the woman and the neonate. This paper considers how NCDs, NCD modifiable risk factors, and NCD metabolic risk factors impact MNCH. We argue that integrated management is essential, but this faces challenges that manifest across all levels of domestic health systems. Progress toward Sustainable Development targets requires joined-up action.

Early essential newborn care for cesarean section newborns in China: study protocol for a multi-centered randomized controlled trial.

BACKGROUND: Early essential newborn care (EENC) is a package of evidence-based and cost-effective interventions delivered around birth mainly including delayed cord clamping, immediate and sustained skin-to-skin contact, and early initiation of exclusive breastfeeding. EENC is proven effective in promoting breastfeeding and improving women's and newborns' health. However, there is little evidence on implementation of EENC on newborns born by cesarean section in China. Therefore, the objective of this study is to assess the effectiveness of EENC intervention on rates of exclusive breastfeeding and early initiation of breastfeeding for cesarean section newborns in China. METHODS: This is a multi-centered, randomized controlled trial conducted in 4 tertiary hospitals in China. A total of 720 eligible women who will receive cesarean section are being randomized into four groups: control group (n=180), intervention group 1 (skin-to-skin contact for 30 min, n=180), intervention group 2 (skin-to-skin contact for 60 min, n=180), and intervention group 3 (skin-to-skin contact for 90 min, n=180). The control group will receive routine care, whereas the intervention groups will receive EENC with different duration of skin-to-skin contact. Demographic characteristics, clinical information, and breastfeeding outcomes will be collected. The primary outcome is rates of exclusive breastfeeding and early initiation of breastfeeding, and the secondary outcomes include maternal and neonatal morbidity and admissions. DISCUSSION: This study will provide evidence of the impact of EENC on improvement of breastfeeding outcomes and maternal and neonatal health for cesarean section newborns in China, and evidence-based recommendation to inform optimal duration of skin-to-skin contact for cesarean deliveries. The results of this study have potential to inform national-level guidelines and policy-making for optimizing EENC implementation for cesarean section newborns. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2100048997. Retrospectively registered on 19 July 2021.

Immediate newborn care practices delay thermoregulation and breastfeeding initiation.

AIM: A deadly nosocomial outbreak in a Philippine hospital drew nationwide attention to neonatal sepsis. Together with specific infection control measures, interventions that protect newborns against infection-related mortality include drying, skin-to-skin contact, delayed cord clamping, breastfeeding initiation and delayed bathing. This evaluation characterized hospital care in the first hours of life with the intent to drive policy change, strategic planning and hospital reform. METHODS: Trained physicians observed 481 consecutive deliveries in 51 hospitals using a standardized tool to record practices and timing of immediate newborn care procedures. RESULTS: Drying, weighing, eye care and vitamin K injections were performed in more than 90% of newborns. Only 9.6% were allowed skin-to-skin contact. Interventions were inappropriately sequenced, e.g. immediate cord clamping (median 12 sec), delayed drying (96.5%) and early bathing (90.0%). While 68.2% were put to the breast, they were separated two minutes later. Unnecessary suctioning was performed in 94.9%. Doctors trained in neonatal resuscitation were 2.5 (1.1-5.7) times more likely to unnecessarily suction vigorous newborns. Two per cent died and 5.7% developed sepsis/pneumonia. CONCLUSIONS: This minute-by-minute observational assessment revealed that performance and timing of immediate newborn care interventions are below WHO standards and deprive newborns of basic protections against infection and death.

Scaling up kangaroo mother care in the Philippines using policy, regulatory and systems reform to drive changes in birth practices.

The WHO recommends kangaroo mother care (KMC) for stable preterm and low birthweight babies because it has been demonstrated to reduce mortality by up to half compared with conventional incubator-based care. Uptake of KMC in low/middle-income countries has been limited, despite its suitability for low-resource environments. This paper reviews factors that contributed to the adoption and expansion of KMC in the Philippines. Early introduction began in 1999 but national scale-up was slow until 2014 after which a significant improvement in national adoption was observed. The proportion of target hospitals implementing KMC rose from 3% to 43% between 2014 and 2019, with 53% of preterm and low birthweight babies receiving KMC by the end of this period. Expansion was led by the government which committed resources and formed partnerships with development partners and non-governmental organisations. Scale-up of KMC was built on the introduction of evidence-based newborn care practices around birth. Practice changes were promoted and supported by consensus-based policy, protocol, regulatory and health insurance changes led by multidisciplinary teams. A new approach to changing and sustaining clinical practice used hospital teams to conduct on-the-job clinical coaching and use local data to make environmental changes to support practices. Institutionalisation of early skin-to-skin contact, non-separation of mother and newborn and early initiation of exclusive breast feeding, with increased responsibility given to mothers, drove a cultural change among staff and families which allowed greater acceptance and uptake of KMC. Financial and programmatic support must be sustained and expanded to address ongoing challenges including staffing gaps, available space for KMC, willingness of some staff to adopt new practices and lack of resources for clinical coaching and follow-up.

Early essential newborn care is associated with improved newborn outcomes following caesarean section births in a tertiary hospital in Da Nang, Vietnam: a pre/post-intervention study.

BACKGROUND: To improve maternal and neonatal outcomes, Vietnam implemented early essential newborn care (EENC) using clinical coaching and quality improvement self-assessments in hospitals to introduce policy, practice and environmental changes. Da Nang Hospital for Women and Children began EENC with caesarean section births to inform development of national guidelines. This study compared newborn outcomes after caesarean sections pre/post-EENC introduction. METHODS: Maternity records of all live in-born hospital caesarean births and separate case records of the subpopulation admitted to the neonatal intensive care unit (NICU) were reviewed pre-EENC (November 2013-October 2014) and post-EENC (November 2014-October 2015) implementation. NICU admissions and adverse outcomes on NICU admission were compared using descriptive statistics. FINDINGS: A total of 16 927 newborns were delivered by caesarean section: 7928 (46.8%) pre-EENC and 8999 post-EENC (53.2%). Total NICU admissions decreased from 16.7% to 11.8% (relative risk 0.71; 95% CI 0.66 to 0.76) after introduction of EENC. Compared with the pre-EENC period, babies with hypothermia on admission to the NICU declined from 5.0% to 3.7% (relative risk 0.73; 95% CI 0.63 to 0.84) and cases of sepsis from 3.2% to 0.8% (relative risk 0.26; 95% CI 0.20 to 0.33) post-EENC implementation. While more than half of all newborns in the NICU were fed something other than breastmilk pre-EENC introduction, 85.8% were exclusively breast fed post-EENC (relative risk 1.86; 95% CI 1.75 to 1.98). Preterm newborns <2000 g receiving kangaroo mother care (KMC) increased from 50% to 67% (relative risk 1.33; 95% CI 1.12 to 1.59). CONCLUSION: The EENC quality improvement approach with caesarean section births was associated with reduced NICU admissions, admissions with hypothermia and sepsis, and increased rates of exclusive breast feeding and KMC in the NICU.

School-based interventions to promote adolescent health: A systematic review in low- and middle-income countries of WHO Western Pacific Region.

BACKGROUND: In the World Health Organization Western Pacific Region (WHO WPRO), most adolescents enroll in secondary school. Safe, healthy and nurturing school environments are critical for adolescent health and development. Yet, there were no systematic reviews found on the efficacy of school-based interventions among adolescents living in low and middle income countries (LMIC) in the Region. There is an urgent need to identify effective school-based interventions and facilitating factors for successful implementation in adolescent health in WPRO. METHODS: For this systematic review, we used five electronic databases to search for school-based interventions to promote adolescent health published from January 1995 to March 2019. We searched RCT and non-RCT studies among adolescents between 10 to 19 years old, done in LMIC of WHO WPRO, and targeted health and behaviour, school environment and academic outcomes. Quality of studies, risk of bias and treatment effects were analyzed. Effective interventions and implementation approaches were summarized for consideration in scale-up. RESULTS: Despite a broad key term search strategy, we identified only eight publications (with 18,774 participants). Most of the studies used knowledge, attitudes and behaviours as outcome measures. A few also included changes in the school policy and physical environment as outcome measures while only one used BMI, waist circumference and quality of life as their outcome measures. The topics in these studies included: AIDS, sexual and reproductive health, de-worming, nutrition, obesity, tobacco use, and suicide. Some interventions were reported to be successful in improving knowledge, attitudes and behaviours, but their impact and scale were limited. The interventions used by the different studies varied from those that addressed a single action area (e.g. developing personal skills) or a combination of action areas in health promotion, e.g. developing a health policy, creating a supportive environment and developing personal skills. No intervention study was found on other important issues such as screening, counseling and developing safe and nurturing school environments. CONCLUSIONS: Only eight school-based health interventions were conducted in the Region. This study found that school-based interventions were effective in changing knowledge, attitudes, behaviors, healthy policies and environment. Moreover, it was clarified that policy support, involving multiple stakeholders, incorporating existing curriculum, student participation as crucial factors for successful implementation.