Assessing safe and personalised maternity and neonatal care through a pandemic: a case study of outcomes and experiences in two trusts in England using the ASPIRE COVID-19 framework.

BACKGROUND: The COVID-19 pandemic has resulted in profound and far-reaching impacts on maternal and newborn care and outcomes. As part of the ASPIRE COVID-19 project, we describe processes and outcome measures relating to safe and personalised maternity care in England which we map against a pre-developed ASPIRE framework to establish the potential impact of the COVID-19 pandemic for two UK trusts. METHODS: We undertook a mixed-methods system-wide case study using quantitative routinely collected data and qualitative data from two Trusts and their service users from 2019 to 2021 (start and completion dates varied by available data). We mapped findings to our prior ASPIRE conceptual framework that explains pathways for the impact of COVID-19 on safe and personalised care. RESULTS: The ASPIRE framework enabled us to develop a comprehensive, systems-level understanding of the impact of the pandemic on service delivery, user experience and staff wellbeing, and place it within the context of pre-existing challenges. Maternity services experienced some impacts on core service coverage, though not on Trust level clinical health outcomes (with the possible exception of readmissions in one Trust). Both users and staff found some pandemic-driven changes challenging such as remote or reduced antenatal and community postnatal contacts, and restrictions on companionship. Other key changes included an increased need for mental health support, changes in the availability and uptake of home birth services and changes in induction procedures. Many emergency adaptations persisted at the end of data collection. Differences between the trusts indicate complex change pathways. Staff reported some removal of bureaucracy, which allowed greater flexibility. During the first wave of COVID-19 staffing numbers increased, resolving some pre-pandemic shortages: however, by October 2021 they declined markedly. Trying to maintain the quality and availability of services had marked negative consequences for personnel. Timely routine clinical and staffing data were not always available and personalised care and user and staff experiences were poorly captured. CONCLUSIONS: The COVID-19 crisis magnified pre-pandemic problems and in particular, poor staffing levels. Maintaining services took a significant toll on staff wellbeing. There is some evidence that these pressures are continuing. There was marked variation in Trust responses. Lack of accessible and timely data at Trust and national levels hampered rapid insights. The ASPIRE COVID-19 framework could be useful for modelling the impact of future crises on routine care.

Evaluating the Contribution of Complex International Research-for-Development Programmes to the Sustainable Development Goals.

While evaluation of research-to-policy projects is a fundamental aspect of measuring the impact of new knowledge, limited studies have examined evaluation methods in such projects, as well as how the evaluation can generate learning to facilitate the progress towards the Sustainable Development Goals (SDGs). This study conducted a systematic literature review and found that the most commonly used methods for SDG contribution evaluation were Analytical Hierarchy Process (40.4%), Fuzzy TOPSIS (13.2%) and ELECTRE and SPADE Methodology (3.5% each). Ranking analysis was undertaken to determine priorities among the six "Big Wins" as defined for the UKRI-GCRF Trade Hub Project, as a case, where the ranking was exercised by the project partners across the globe. Results revealed that "nature and social factors" was better considered in international trade agreements as the priority (36.4%) among others. Moreover, among the four "mechanisms" of the project, "knowledge, networks, and connectivity" was ranked as the top priority (56.9%), followed by "capacity building" (28.5%), "metrics, tools and models" (7.2%), and "improving the knowledge base" (4.6%). Mapping and evaluation revealed that the Big Wins of the Trade Hub contributed to ten out of the 17 SDGs. The most fulfilled goals were SDG 12 (Sustainable Consumption and Production), SDG 15 (Life on Land), and SDG 2 (Zero Hunger) in descending order. Furthermore, interaction analysis of the core SDGs revealed both synergy and tradeoff between different outputs. The research articles reviewed for this paper showed no gold standard framework for assessing international development projects against the SDGs. Further research should develop a tool to capture holistic and synergistic contributions of the target outcomes of projects to sustainable development.

Bien que l'évaluation des projets sur le lien entre recherche et politique soit un aspect fondamental de la mesure de l'impact des nouvelles connaissances, peu d'études ont examiné les méthodes d'évaluation de tels projets, ainsi que la manière dont l'évaluation peut générer un apprentissage pour faciliter la progression vers les objectifs de développement durable (ODD). Cette étude a mené une revue systématique de la littérature et a constaté que les méthodes les plus couramment utilisées pour l'évaluation de la contribution aux ODD étaient le processus d'analyse hiérarchique (40,4%), la méthode TOPSIS floue (13,2%), et les méthodes ELECTRE et SPADE (3,5% chacune). Une analyse par classement a été entreprise pour déterminer les priorités parmi les six « Grands Succès¼ tels que définis pour le projet UKRI-GCRF Trade Hub, par exemple, où le classement a été réalisé par les partenaires du projet à travers le monde. Les résultats ont révélé que les « facteurs naturels et sociaux¼ étaient mieux considérés dans les accords commerciaux internationaux comme la priorité (36,4%), parmi d'autres. De plus, parmi les quatre « mécanismes¼ du projet, « les connaissances, les réseaux et la connectivité¼ ont été classés comme la première priorité (56,9%), suivis du « renforcement des capacités¼ (28,5%), « les mesures, les outils et les modèles¼ (7,2%) et « améliorer la base de connaissances¼ (4,6%). La cartographie et l'évaluation ont révélé que les Grands Succès du projet Trade Hub ont contribué à dix des 17 ODD. La contribution aux objectifs était la plus importante, par ordre décroissant, pour l'ODD 12 (Consommation et production durables), l'ODD 15 (Vie terrestre) et l'ODD 2 (Faim zéro). En outre, l'analyse des interactions des principaux ODD a révélé à la fois une synergie et un compromis entre les différents produits. Les études examinées pour cet article n'ont montré aucun cadre de référence pour évaluer les projets de développement international par rapport aux ODD. Des études supplémentaires devraient être conduites pour développer un outil permettant de mesurer les contributions holistiques et synergiques des résultats cibles des projets au développement durable.

Quality of maternal healthcare and travel time influence birthing service utilisation in Ghanaian health facilities: a geographical analysis of routine health data.

OBJECTIVES: To investigate how the quality of maternal health services and travel times to health facilities affect birthing service utilisation in Eastern Region, Ghana. DESIGN: The study is a cross-sectional spatial interaction analysis of birth service utilisation patterns. Routine birth data were spatially linked to quality care, service demand and travel time data. SETTING: 131 Health facilities (public, private and faith-based) in 33 districts in Eastern Region, Ghana. PARTICIPANTS: Women who gave birth in health facilities in the Eastern Region, Ghana in 2017. OUTCOME MEASURES: The count of women giving birth, the quality of birthing care services and the geographic coverage of birthing care services. RESULTS: As travel time from women's place of residence to the health facility increased up to two2 hours, the utilisation rate markedly decreased. Higher quality of maternal health services haves a larger, positive effect on utilisation rates than service proximity. The quality of maternal health services was higher in hospitals than in primary care facilities. Most women (88.6%) travelling via mechanised transport were within two2 hours of any birthing service. The majority (56.2%) of women were beyond the two2 -hour threshold of critical comprehensive emergency obstetric and newborn care (CEmONC) services. Few CEmONC services were in urban centres, disadvantaging rural populations. CONCLUSIONS: To increase birthing service utilisation in Ghana, higher quality health facilities should be located closer to women, particularly in rural areas. Beyond Ghana, routinely collected birth records could be used to understand the interaction of service proximity and quality.

Distance is "a big problem": a geographic analysis of reported and modelled proximity to maternal health services in Ghana.

BACKGROUND: Geographic barriers to healthcare are associated with adverse maternal health outcomes. Modelling travel times using georeferenced data is becoming common in quantifying physical access. Multiple Demographic and Health Surveys ask women about distance-related problems accessing healthcare, but responses have not been evaluated against modelled travel times. This cross-sectional study aims to compare reported and modelled distance by socio-demographic characteristics and evaluate their relationship with skilled birth attendance. Also, we assess the socio-demographic factors associated with self-reported distance problems in accessing healthcare. METHODS: Distance problems and socio-demographic characteristics reported by 2210 women via the 2017 Ghana Maternal Health Survey were included in analysis. Geospatial methods were used to model travel time to the nearest health facility using roads, rivers, land cover, travel speeds, cluster locations and health facility locations. Logistic regressions were used to predict skilled birth attendance and self-reported distance problems. RESULTS: Women reporting distance challenges accessing healthcare had significantly longer travel times to the nearest health facility. Poverty significantly increased the odds of reporting challenges with distance. In contrast, living in urban areas and being registered with health insurance reduced the odds of reporting distance challenges. Women with a skilled attendant at birth, four or more skilled antenatal appointments and timely skilled postnatal care had shorter travel times to the nearest health facility. Generally, less educated, poor, rural women registered with health insurance had longer travel times to their nearest health facility. After adjusting for socio-demographic characteristics, the following factors increased the odds of skilled birth attendance: wealth, health insurance, higher education, living in urban areas, and completing four or more antenatal care appointments. CONCLUSION: Studies relying on modelled travel times to nearest facility should recognise the differential impact of geographic access to healthcare on poor rural women. Physical access to maternal health care should be scaled up in rural areas and utilisation increased by improving livelihoods.

Delineating natural catchment health districts with routinely collected health data from women's travel to give birth in Ghana.

BACKGROUND: Health service areas are essential for planning, policy and managing public health interventions. In this study, we delineate health service areas from routinely collected health data as a robust geographic basis for presenting access to maternal care indicators. METHODS: A zone design algorithm was adapted to delineate health service areas through a cross-sectional, ecological study design. Health sub-districts were merged into health service areas such that patient flows across boundaries were minimised. Delineated zones and existing administrative boundaries were used to provide estimates of access to maternal health services. We analysed secondary data comprising routinely collected health records from 32,921 women attending 27 hospitals to give birth, spatial demographic data, a service provision assessment on the quality of maternal healthcare and health sub-district boundaries from Eastern Region, Ghana. RESULTS: Clear patterns of cross border movement to give birth emerged from the analysis, but more women originated closer to the hospitals. After merging the 250 sub-districts in 33 districts, 11 health service areas were created. The minimum percent of internal flows of women giving birth within any health service area was 97.4%. Because the newly delineated boundaries are more "natural" and sensitive to observed flow patterns, when we calculated areal indicator estimates, they showed a marked improvement over the existing administrative boundaries, with the inclusion of a hospital in every health service area. CONCLUSION: Health planning can be improved by using routine health data to delineate natural catchment health districts. In addition, data-driven geographic boundaries derived from public health events will improve areal health indicator estimates, planning and interventions.

Breaking the silence about obstetric violence: Body mapping women's narratives of respect, disrespect and abuse during childbirth in Bihar, India.

BACKGROUND: Evidence on obstetric violence is reported globally. In India, research shows that almost every woman goes through some level of disrespect and abuse during childbirth, more so in states such as Bihar where over 70% of women give birth in hospitals. OBJECTIVE: 1) To understand how women experience and attach meaning to respect, disrespect and abuse during childbirth; and 2) document women's expectations of respectful care. METHODS: 'Body mapping', an arts-based participatory method, was applied. The analysis is based on in-depth interviews with eight women who participated in the body mapping exercise at their homes in urban slums and rural villages. Analysis was guided by feminist relational discourse analysis. FINDINGS: Women reported their experiences of birthing at home, public facilities, and private hospitals in simple terms of what they felt 'good' and 'bad'. Good experiences included being spoken to nicely, respecting privacy, companion of choice, a bed to rest, timely care, lesser interventions, obtaining consent for vaginal examination and cesarean section, and better communication. Bad experiences included unconsented interventions including multiple vaginal examinations by different care providers, unanesthetized episiotomy, repairs and uterine exploration, verbal, physical, sexual abuse, extortion, detention and lack of privacy. DISCUSSION: The body maps capturing birth experiences, created through a participatory method, accurately portray women's respectful and disrespectful births and are useful to understand women's experience of a sensitive issue in a patriarchal culture. An in-depth understanding of women's choices, experiences and expectations can inform changes practices in and policies and help to develop a culture of sharing birth experiences.

Why do some health care providers disrespect and abuse women during childbirth in India?

BACKGROUND: Disrespect and abuse during childbirth can result in fear of childbirth. Consequently, women may be discouraged to seek care, increasing the likelihood for women to choose elective cesarean section in order to avoid humiliation, postnatal depression and even maternal mortality. This study investigates the causes underlying mistreatment of women during childbirth by health care providers in India, where evidence of disrespect and abuse has been reported. METHODS: Qualitative research was undertaken involving 34 in-depth interviews with midwifery and nursing leaders from India who represent administration, advocacy, education, regulation, research and service provision at state and national levels. Data are analysed thematically with NVivo12. The analysis added value by bringing an international perspective from interviews with midwifery leaders from Switzerland and the United Kingdom. FINDINGS: The factors leading to disrespect and abuse of women relate to characteristics of both women and their midwives. Relevant woman-related attributes include her age, gender, physical appearance and education, extending to the social environment including her social status, family support, culture of abuse, myths around childbirth and sex-based discrimination. Midwife-related factors include gender, workload, medical hierarchy, bullying and powerlessness. DISCUSSION: The intersectionality of factors associated with mistreatment during childbirth operate at individual, infrastructural, social and policy levels for both the women and nurse-midwives, and these factors could exacerbate existing gender-based inequalities. Maternal health policies should address the complex interplay of these factors to ensure a positive birthing experience for women in India. CONCLUSION: Maternal health interventions could improve by integrating women-centred protocols and monitoring measures to ensure respectful and dignified care during childbirth.

The State of the World's Midwifery 2021 report: findings to drive global policy and practice.

The third global State of the World's Midwifery report (SoWMy 2021) provides an updated evidence base on the sexual, reproductive, maternal, newborn and adolescent health (SRMNAH) workforce. For the first time, SoWMy includes high-income countries (HICs) as well as low- and middle-income countries. This paper describes the similarities and differences between regions and income groups, and discusses the policy implications of these variations. SoWMy 2021 estimates a global shortage of 900,000 midwives, which is particularly acute in low-income countries (LICs) and in Africa. The shortage is projected to improve only slightly by 2030 unless additional investments are made. The evidence suggests that these investments would yield important returns, including: more positive birth experiences, improved health outcomes, and inclusive and equitable economic growth. Most HICs have sufficient SRMNAH workers to meet the need for essential interventions, and their education and regulatory environments tend to be strong. Upper-middle-income countries also tend to have strong policy environments. LICs and lower-middle-income countries tend to have a broader scope of practice for midwives, and many also have midwives in leadership positions within national government. Key regional variations include: major midwife shortages in Africa and South-East Asia but more promising signs of growth in South-East Asia than in Africa; a strong focus in Africa on professional midwives (rather than associate professionals: the norm in many South-East Asian countries); heavy reliance on medical doctors rather than midwives in the Americas and Eastern Mediterranean regions and parts of the Western Pacific; and a strong educational and regulatory environment in Europe but a lack of midwife leaders at national level. SoWMy 2021 provides stakeholders with the latest data and information to inform their efforts to build back better and fairer after COVID-19. This paper provides a number of policy responses to SoWMy 2021 that are tailored to different contexts, and suggests a variety of issues to consider in these contexts. These suggestions are supported by the inclusion of all countries in the report, because it is clear which countries have strong SRMNAH workforces and enabling environments and can be viewed as exemplars within regions and income groups.

A review of geospatial methods for population estimation and their use in constructing reproductive, maternal, newborn, child and adolescent health service indicators.

BACKGROUND: Household survey data are frequently used to measure reproductive, maternal, newborn, child and adolescent health (RMNCAH) service utilisation in low and middle income countries. However, these surveys are typically only undertaken every 5 years and tend to be representative of larger geographical administrative units. Investments in district health management information systems (DHMIS) have increased the capability of countries to collect continuous information on the provision of RMNCAH services at health facilities. However, reliable and recent data on population distributions and demographics at subnational levels necessary to construct RMNCAH coverage indicators are often missing. One solution is to use spatially disaggregated gridded datasets containing modelled estimates of population counts. Here, we provide an overview of various approaches to the production of gridded demographic datasets and outline their potential and their limitations. Further, we show how gridded population estimates can be used as alternative denominators to produce RMNCAH coverage metrics in combination with data from DHMIS, using childhood vaccination as examples. METHODS: We constructed indicators on the percentage of children one year old for diphtheria, pertussis and tetanus vaccine dose 3 (DTP3) and measles vaccine dose (MCV1) in Zambia and Nigeria at district levels. For the numerators, information on vaccines doses was obtained from each country's respective DHMIS. For the denominators, the number of children was obtained from 3 different sources including national population projections and aggregated gridded estimates derived using top-down and bottom-up geospatial methods. RESULTS: In Zambia, vaccination estimates utilising the bottom-up approach to population estimation substantially reduced the number of districts with > 100% coverage of DTP3 and MCV1 compared to estimates using population projection and the top-down method. In Nigeria, results were mixed with bottom-up estimates having a higher number of districts > 100% and estimates using population projections performing better particularly in the South. CONCLUSIONS: Gridded demographic data utilising traditional and novel data sources obtained from remote sensing offer new potential in the absence of up to date census information in the estimation of RMNCAH indicators. However, the usefulness of gridded demographic data is dependent on several factors including the availability and detail of input data.

Geographical distribution of fertility rates in 70 low-income, lower-middle-income, and upper-middle-income countries, 2010-16: a subnational analysis of cross-sectional surveys.

BACKGROUND: Understanding subnational variation in age-specific fertility rates (ASFRs) and total fertility rates (TFRs), and geographical clustering of high fertility and its determinants in low-income and middle-income countries, is increasingly needed for geographical targeting and prioritising of policy. We aimed to identify variation in fertility rates, to describe patterns of key selected fertility determinants in areas of high fertility. METHODS: We did a subnational analysis of ASFRs and TFRs from the most recent publicly available and nationally representative cross-sectional Demographic and Health Surveys and Multiple Indicator Cluster Surveys collected between 2010 and 2016 for 70 low-income, lower-middle-income, and upper-middle-income countries, across 932 administrative units. We assessed the degree of global spatial autocorrelation by using Moran's I statistic and did a spatial cluster analysis using the Getis-Ord Gi* local statistic to examine the geographical clustering of fertility and key selected fertility determinants. Descriptive analysis was used to investigate the distribution of ASFRs and of selected determinants in each cluster. FINDINGS: TFR varied from below replacement (2·1 children per women) in 36 of the 932 subnational regions (mainly located in India, Myanmar, Colombia, and Armenia), to rates of 8 and higher in 14 subnational regions, located in sub-Saharan Africa and Afghanistan. Areas with high-fertility clusters were mostly associated with areas of low prevalence of women with secondary or higher education, low use of contraception, and high unmet needs for family planning, although exceptions existed. INTERPRETATION: Substantial within-country variation in the distribution of fertility rates highlights the need for tailored programmes and strategies in high-fertility cluster areas to increase the use of contraception and access to secondary education, and to reduce unmet need for family planning. FUNDING: Wellcome Trust, the UK Foreign, Commonwealth and Development Office, and the Bill & Melinda Gates Foundation.

Challenges and needed reforms in midwifery and nursing regulatory systems in India: Implications for education and practice.

BACKGROUND: In India, nursing regulation is generally weak, midwifery coexists with nursing, and 88% of nursing and midwifery education is provided by the private health sector. The Indian health system faces major challenges for health care provision due to poor quality, indeterminate regulatory functions and lack of reforms. METHODS: We undertook a qualitative investigation to understand midwifery and nursing education, and regulatory systems in India, through a review of the regulatory Acts, and an investigation of the perceptions and experiences of senior midwifery and nursing leaders representing administration, advocacy, education, regulation, research and service provision in India with an international perspective. RESULTS: There is a lack of importance accorded to midwifery roles within the nursing system. The councils and Acts do not adequately reflect midwifery practice, and remain a barrier to good quality care provision. The lack of required amendment of Acts, lack of representation of midwives and nurses in key governance positions in councils and committees have restrained and undermined leadership positions, which have also impaired the growth of the professions. A lack of opportunities for professional practice and unfair assessment practices are critical concerns affecting the quality of nursing and midwifery education in private institutions across India. Midwifery and nursing students are generally more vulnerable to discrimination and have less opportunities compared to medical students exacerbated by the gender-based challenges. CONCLUSIONS: India is on the verge of a major regulatory reform with the National Nursing and Midwifery Commission Bill, 2020 being drafted, which makes this study a crucial and timely contribution. Our findings present the challenges that need to be addressed with regulatory reforms to enable opportunities for direct-entry into the midwifery profession, improving nursing education and practice by empowering midwives and nurses with decision-making powers for nursing and midwifery workforce governance.

Hepatotoxicity of Two Progoitrin-Derived Nitriles in New Zealand White Rabbits.

Cattle occasionally develop brassica-associated liver disease (BALD) and photosensitisation when grazing turnip or swede (Brassica spp.) forage crops. The liver toxin in these brassica varieties has yet to be discovered. Progoitrin is the dominant glucosinolate in incriminated crops. Apart from goitrin, progoitrin hydrolysis yields the nitrile, 1-cyano-2-hydroxy-3-butene (CHB), and the epithionitrile, 1-cyano-2-hydroxy-3,4-epithiobutane (CHEB). The two compounds were custom-synthesised. In a small pilot trial, New Zealand White rabbits were given either CHB or CHEB by gavage. Single doses of 0.75 mmol/kg of CHB or 0.25 mmol/kg of CHEB were subtoxic and elicited subclinical effects. Higher doses were severely hepatotoxic, causing periportal to massive hepatic necrosis associated with markedly elevated serum liver biomarkers often resulting in severe illness or death within 24 h. The possibility that one or both of these hepatotoxic nitriles causes BALD in cattle requires further investigation.

Investigating the cause of Brassica-associated liver disease (BALD) in cattle: Progoitrin-derived nitrile toxicosis in rats.

A large outbreak of liver toxicity in dairy cows that were consuming swede (rutabaga, Brassica napus ssp. napobrassica) crops in Southland and Otago, New Zealand in 2014 prompted the search for the toxin(s) responsible for brassica-associated liver disease (BALD). Analysis of swede plant material showed that the ultra-dominant glucosinolate was progoitrin. The two nitrile derivatives of progoitrin, 1-cyano-2-hydroxy-3-butene (CHB, also known as crambene) and 1-cyano-2-hydroxy-3,4-epithiobutane (CHEB), were custom-synthesised. In this pilot trial, individual progoitrin nitriles were administered by gavage to rats in order to establish a "subtoxic" dose, i.e. the dose where apparently clinically normal rats show liver injury based on altered serum biochemical indicators and histological lesions. We found that consecutive daily doses of 1 mmol/kg CHB produced severe pancreatic and mild liver histological lesions in the absence of notable biochemical changes in clinically normal rats. No evidence of a cumulative effect was seen. Single doses of 1 mmol/kg of CHEB caused elevated concentrations of serum creatinine and distinctive renal and stomach histological lesions in apparently clinically normal rats. Consecutive daily 1 mmol/kg doses of CHEB had a considerable cumulative effect and proved severely hepato- and nephrotoxic with creatinine concentrations peaking after three daily doses. Three other commercially available nitriles (3-butenenitrile, 4-pentenenitrile and 5-hexenenitrile) derived from minor glucosinolates in the swedes were also investigated in this pilot trial. Single combined 1 mmol/kg doses of both progoitrin nitriles as well as these two nitriles plus small doses of the other three failed to demonstrate any synergism, however, the characteristic and apparently dominant effects of CHEB were consistently demonstrated. The results of this pilot study confirmed the previously reported pancreatotoxicity of CHB and nephrotoxicity of CHEB. CHEB also caused intraepithelial pustules, submucosal oedema, erosions and ulcers in the squamous portion of the stomach. These stomach lesions, as well as the renal lesions, appear identical to those caused by another epithionitrile, 1-cyano-3,4-epithiobutane, derived from gluconapin, which was a minor glucosinolate in the swedes. Because of the fact that cyanide can be released with the metabolism of some nitriles, we analysed cyanide in the livers of treated rats. The liver of a rat dosed with 1 mmol/kg of 3-butenenitrile contained 0.5 µg/g of cyanide. The hypothesis that BALD is due to nitrile toxicity requires further testing.

Health workforce demography: a framework to improve understanding of the health workforce and support achievement of the Sustainable Development Goals.

The ambition of universal health coverage entails estimation of the number, type and distribution of health workers required to meet the population need for health services. The demography of the population, including anticipated or estimated changes, is a factor in determining the 'universal' needs for health and well-being. Demography is concerned with the size, breakdown, age and gender structure and dynamics of a population. The same science, and its robust methodologies, is equally applicable to the demography of the health workforce itself. For example, a large percentage of the workforce close to retirement will impact availability, a geographically mobile workforce has implications for health coverage, and gender distribution in occupations may have implications for workforce acceptability and equity of opportunity. In a world with an overall shortage of health workers, and the expectation of increasing need as a result of both population growth in the global south and population ageing in the global north, studying and understanding demographic characteristics of the workforce can help with future planning. This paper discusses the dimensions of health worker demography and considers how demographic tools and techniques can be applied to the analysis of the health labour market. A conceptual framework is introduced as a step towards the application of demographic principles and techniques to health workforce analysis and planning exercises as countries work towards universal health coverage, the reduction of inequities and national development targets. Some illustrative data from Nepal and Finland are shown to illustrate the potential of this framework as a simple and effective contribution to health workforce planning.

Using geospatial modelling to estimate the prevalence of adolescent first births in Nepal.

INTRODUCTION: Adolescent pregnancy is associated with significant risks and disadvantages for young women and girls and their children. A clear understanding of population subgroups with particularly high prevalence of first births in adolescence is vital if appropriate national responses are to be developed. This paper aims to provide detailed data on socioeconomic and geographic inequities in first births to adolescents in Nepal, including wealth quintile, education, rural/urban residence and geographic region. A key element is the use of geospatial modelling to develop estimates for the prevalence of adolescent births at the district level. METHODS: The study uses data from the 2011 Nepal Demographic and Health Survey. Initial cross-tabulations present disaggregated data by socioeconomic status and basic geographic region. Estimates of prevalence of adolescent first births at the district level are creating by regression modelling using the Integrated Nested Laplace Approximation package in R software. RESULTS: Our findings show that 40% of women had given birth before the age of 20 years, with 5% giving birth before 16 years. First births to adolescents remain common among poorer, less educated and rural women. Geographic disparities are striking, with estimates for the percentage of women giving birth before 20 years ranging from 35% to 53% by region. District level estimates showed even more marked differentials (26%-67% had given birth by 20 years), with marked heterogeneity even within regions. In some districts, estimates for the prevalence of first birth among the youngest age groups (<16 years) are high. CONCLUSION: Important geographic and socioeconomic inequities exist in adolescent first births. In some districts and within some subgroups, there remain high levels of adolescent first births, including births to very young adolescents. The use of Bayesian geospatial modelling techniques can be used by policymakers to target resources.

How accurate are modelled birth and pregnancy estimates? Comparison of four models using high resolution maternal health census data in southern Mozambique.

BACKGROUND: Existence of inequalities in quality and access to healthcare services at subnational levels has been identified despite a decline in maternal and perinatal mortality rates at national levels, leading to the need to investigate such conditions using geographical analysis. The need to assess the accuracy of global demographic distribution datasets at all subnational levels arises from the current emphasis on subnational monitoring of maternal and perinatal health progress, by the new targets stated in the Sustainable Development Goals. METHODS: The analysis involved comparison of four models generated using Worldpop methods, incorporating region-specific input data, as measured through the Community Level Intervention for Pre-eclampsia (CLIP) project. Normalised root mean square error was used to determine and compare the models' prediction errors at different administrative unit levels. RESULTS: The models' prediction errors are lower at higher administrative unit levels. All datasets showed the same pattern for both the live birth and pregnancy estimates. The effect of improving spatial resolution and accuracy of input data was more prominent at higher administrative unit levels. CONCLUSION: The validation successfully highlighted the impact of spatial resolution and accuracy of maternal and perinatal health data in modelling estimates of pregnancies and live births. There is a need for more data collection techniques that conduct comprehensive censuses like the CLIP project. It is also imperative for such projects to take advantage of the power of mapping tools at their disposal to fill the gaps in the availability of datasets for populated areas.

Integrative analysis of Paneth cell proteomic and transcriptomic data from intestinal organoids reveals functional processes dependent on autophagy.

Paneth cells are key epithelial cells that provide an antimicrobial barrier and maintain integrity of the small-intestinal stem cell niche. Paneth cell abnormalities are unfortunately detrimental to gut health and are often associated with digestive pathologies such as Crohn's disease or infections. Similar alterations are observed in individuals with impaired autophagy, a process that recycles cellular components. The direct effect of autophagy impairment on Paneth cells has not been analysed. To investigate this, we generated a mouse model lacking Atg16l1 specifically in intestinal epithelial cells, making these cells impaired in autophagy. Using three-dimensional intestinal organoids enriched for Paneth cells, we compared the proteomic profiles of wild-type and autophagy-impaired organoids. We used an integrated computational approach combining protein-protein interaction networks, autophagy-targeted proteins and functional information to identify the mechanistic link between autophagy impairment and disrupted pathways. Of the 284 altered proteins, 198 (70%) were more abundant in autophagy-impaired organoids, suggesting reduced protein degradation. Interestingly, these differentially abundant proteins comprised 116 proteins (41%) that are predicted targets of the selective autophagy proteins p62, LC3 and ATG16L1. Our integrative analysis revealed autophagy-mediated mechanisms that degrade key proteins in Paneth cell functions, such as exocytosis, apoptosis and DNA damage repair. Transcriptomic profiling of additional organoids confirmed that 90% of the observed changes upon autophagy alteration have effects at the protein level, not on gene expression. We performed further validation experiments showing differential lysozyme secretion, confirming our computationally inferred downregulation of exocytosis. Our observations could explain how protein-level alterations affect Paneth cell homeostatic functions upon autophagy impairment.This article has an associated First Person interview with the joint first authors of the paper.

Estimating uncertainty in geospatial modelling at multiple spatial resolutions: the pattern of delivery via caesarean section in Tanzania.

Visualising maternal and newborn health (MNH) outcomes at fine spatial resolutions is crucial to ensuring the most vulnerable women and children are not left behind in improving health. Disaggregated data on life-saving MNH interventions remain difficult to obtain, however, necessitating the use of Bayesian geostatistical models to map outcomes at small geographical areas. While these methods have improved model parameter estimates and precision among spatially correlated health outcomes and allowed for the quantification of uncertainty, few studies have examined the trade-off between higher spatial resolution modelling and how associated uncertainty propagates. Here, we explored the trade-off between model outcomes and associated uncertainty at increasing spatial resolutions by quantifying the posterior distribution of delivery via caesarean section (c-section) in Tanzania. Overall, in modelling delivery via c-section at multiple spatial resolutions, we demonstrated poverty to be negatively correlated across spatial resolutions, suggesting important disparities in obtaining life-saving obstetric surgery persist across sociodemographic factors. Lastly, we found that while uncertainty increased with higher spatial resolution input, model precision was best approximated at the highest spatial resolution, suggesting an important policy trade-off between identifying concealed spatial heterogeneities in health indicators.