The Extent of Universal Health Coverage for Maternal Health Services in Eastern Uganda: A Cross Sectional Study.

OBJECTIVE: Monitoring essential health services coverage is important to inform resource allocation for the attainment of the Sustainable Development Goal 3. The objective was to assess service, effective and financial coverages of maternal healthcare services and their equity, using health and demographic surveillance site data in eastern Uganda. METHODS: Between Nov 2018 and Feb 2019, 638 resident women giving birth in 2017 were surveyed. Among them, 386 were randomly sampled in a follow-up survey (Feb 2019) on pregnancy and delivery payments and contents of care. Service coverage (antenatal care visits, skilled birth attendance, institutional delivery and one postnatal visit), effective coverage (antenatal and postnatal care content) and financial coverage (out-of-pocket payments for antenatal and delivery care and health insurance coverage) were measured, stratified by socio-economic status, education level and place of residence. RESULTS: Coverage of skilled birth attendance and institutional delivery was both high (88%), while coverage of postnatal visit was low (51%). Effective antenatal care was lower than effective postnatal care (38% vs 76%). Financial coverage was low: 91% of women made out-of-pocket payments for delivery services. Equity analysis showed coverage of institutional delivery was higher for wealthier and peri-urban women and these women made higher out-of-pocket payments. In contrast, coverage of a postnatal visit was higher for rural women and poorest women. CONCLUSION: Maternal health coverage in eastern Uganda is not universal and particularly low for postnatal visit, effective antenatal care and financial coverage. Analysing healthcare payments and quality by healthcare provider sector is potential future research.

Maternal death and obstetric care audits in Nigeria: a systematic review of barriers and enabling factors in the provision of emergency care.

BACKGROUND: Maternal death reviews and obstetric audits identify causes and circumstances related to occurrence of a maternal death or serious complication and inform improvements in quality of care. Given Nigeria's high maternal mortality, the lessons learned from past experiences can provide a good evidence base for informed decision making. We aimed to synthesise findings from maternal death reviews and other obstetric audits conducted in Nigeria through a systematic review, seeking to identify common barriers and enabling factors related to the provision of emergency obstetric care. METHODS: We searched for maternal death reviews and obstetric care audits reported in the published literature from 2000-2014. A 'best-fit' framework approach was used to extract data using a structured data extraction form. The articles that met the inclusion criteria were assessed using a nine point quality score. RESULTS: Of the 1,841 abstracts and titles at initial screening, 329 full text articles were reviewed and 43 papers fulfilled the inclusion criteria. Four types of barriers were reported related to: transport and referral; health workers; availability of services; and organisational factors. Three elements stand out in Nigeria as contributing to maternal mortality: delays in Caesarean section, unavailability of magnesium sulphate and lack of safe blood transfusion services. CONCLUSIONS: Obstetric care reviews and audits are useful activities to undertake and should be promoted by improving the processes used to conduct them, as well as extending their implementation to rural and basic level health facilities and to the community. Urgent areas for quality improvement in obstetric care, even in tertiary and teaching hospitals should focus on organisational factors to reduce delays in conducting Caesarean section and making blood and magnesium sulphate available for all who need these interventions.

Determinants of delays in travelling to an emergency obstetric care facility in Herat, Afghanistan: an analysis of cross-sectional survey data and spatial modelling.

BACKGROUND: Women's delays in reaching emergency obstetric care (EmOC) facilities contribute to high maternal and perinatal mortality and morbidity in low-income countries, yet few studies have quantified travel times to EmOC and examined delays systematically. We defined a delay as the difference between a woman's travel time to EmOC and the optimal travel time under the best case scenario. The objectives were to model travel times to EmOC and identify factors explaining delays. i.e., the difference between empirical and modelled travel times. METHODS: A cost-distance approach in a raster-based geographic information system (GIS) was used for modelling travel times. Empirical data were obtained during a cross-sectional survey among women admitted in a life-threatening condition to the maternity ward of Herat Regional Hospital in Afghanistan from 2007 to 2008. Multivariable linear regression was used to identify the determinants of the log of delay. RESULTS: Amongst 402 women, 82 (20%) had no delay. The median modelled travel time, reported travel time, and delay were 1.0 hour [Q1-Q3: 0.6, 2.2], 3.6 hours [Q1-Q3: 1.0, 12.0], and 2.0 hours [Q1-Q3: 0.1, 9.2], respectively. The adjusted ratio (AR) of a delay of the "one-referral" group to the "self-referral" group was 4.9 [95% confidence interval (CI): 3.8-6.3]. Difficulties obtaining transportation explained some delay [AR 2.1 compared to "no difficulty"; 95% CI: 1.5-3.1]. A husband's very large social network (> = 5 people) doubled a delay [95% CI: 1.1-3.7] compared to a moderate (3-4 people) network. Women with severe infections had a delay 2.6 times longer than those with postpartum haemorrhage (PPH) [95% CI: 1.4-4.9]. CONCLUSIONS: Delays were mostly explained by the number of health facilities visited. A husband's large social network contributed to a delay. A complication with dramatic symptoms (e.g. PPH) shortened a delay while complications with less-alarming symptoms (e.g. severe infection) prolonged it. In-depth investigations are needed to clarify whether time is spent appropriately at lower-level facilities. Community members need to be sensitised to the signs and symptoms of obstetric complications and the urgency associated with them. Health-enhancing behaviours such as birth plans should be promoted in communities.

Bridging evidence, policy, and practice to strengthen health systems for improved maternal and newborn health in Pakistan.

Policy and decision making should be based on evidence, but translating evidence into policy and practice is often sporadic and slow. It is recognised that the relationship between research and policy uptake is complex and that dissemination of research findings is necessary, but insufficient, for policy uptake. Political, social, and economic context, use of (credible) data and dialogues between and across networks of researchers and policymakers play important roles in evidence uptake. Advocacy is the process of mobilising political and public opinions to achieve specific aims and its role is crucial in mobilising key actors to push for policy uptake. Advocacy and research groups (i.e. those who would like to see research evidence used by policymakers) may use different approaches and tools to stimulate the diffusion of research findings. The use of mass- and social media, communication with study participants, and the involvement of stakeholders at the early stages of research development are examples of the approaches that can be employed to stimulate diffusion of evidence and increase evidence uptake. The Research and Advocacy Fund (RAF) for Maternal and Newborn Health (MNH) worked within the health system context in Pakistan with the aim of espousing the principles of evidence, advocacy, and dissemination to improve MNH outcomes. The articles included in this special issue are outputs of RAF and highlight where RAF's approaches contributed to MNH policy reforms. The papers discuss critical health system issues facing Pakistan, including service delivery components, demand creation, equitable access, transportation interventions for improved referrals, availability of medicines and equipment, and health workforce needs. In addition to these tangible elements, the health system 'software', i.e. the power and the political and social contexts, is also represented in the collection. These articles highlight three considerations for the future: the growing importance of implementation research, the crucial need for participation and ownership, and the recognition that policymaking can be 'informed' by rather than 'based-on' evidence. The future challenge will be to continue the momentum RAF has created and to welcome a new era of health, wealth, and growth for Pakistan.

Electrogenetic control of gene expression in Shewanella oneidensis MR-1 using Arc-dependent transcriptional promoters.

Electrochemically active bacteria (EAB) are capable of electrically interacting with electrodes, enabling their application in bioelectrochemical systems (BESs). As the performance of BES is related to the metabolic activities of EAB, the development of methods to control their metabolic activities is important to facilitate BES applications. A recent study found that the EAB Shewanella oneidensis MR-1 uses the Arc system to regulate the expression of catabolic genes in response to electrode potentials, suggesting that a methodology for electrical control of gene expression in EAB, referred to as electrogenetics, can be developed by using electrode potential-responsive, Arc-dependent transcriptional promoters. Here, we explored Arc-dependent promoters in the genomes of S. oneidensis MR-1 and Escherichia coli to identify electrode potential-responsive promoters that are differentially activated in MR-1 cells exposed to high- and low-potential electrodes. LacZ reporter assays using electrode-associated cells of MR-1 derivatives revealed that the activities of promoters located upstream of the E. coli feo gene (Pfeo) and the MR-1 nqrA2 (SO_0902) gene (Pnqr2) were significantly increased when S. oneidensis cells were exposed to electrodes poised at +0.7 V and -0.4 V (versus the standard hydrogen electrode), respectively. Additionally, we developed a microscopic system for in situ monitoring of promoter activity in electrode-associated cells and found that Pnqr2 activity was persistently induced in MR-1 cells associated with an electrode poised at -0.4 V. Our results indicate that these electrode potential-responsive promoters enable efficient regulation of gene expression in EAB, providing a molecular basis for the development of electrogenetics.

Feasibility, usability and acceptability of a novel digital hybrid-system for reporting of routine maternal health information in Southern Tanzania: A mixed-methods study.

Health information systems are important for health planning and progress monitoring. Still, data from health facilities are often of limited quality in Low-and-Middle-Income Countries. Quality deficits are partially rooted in the fact that paper-based documentation is still the norm at facility level, leading to mistakes in summarizing and manual copying. Digitization of data at facility level would allow automatization of these procedural steps. Here we aimed to evaluate the feasibility, usability and acceptability of a scanning innovation called Smart Paper Technology for digital data processing. We used a mixed-methods design to understand users' engagement with Smart Paper Technology and identify potential positive and negative effects of this innovation in three health facilities in Southern Tanzania. Eight focus group discussions and 11 in-depth interviews with users were conducted. We quantified time used by health care providers for documentation and patient care using time-motion methods. Thematic analysis was used to analyze qualitative data. Descriptive statistics and multivariable linear models were generated to compare the difference before and after introduction and adjust for confounders. Health care providers and health care managers appreciated the forms' simple design features and perceived Smart Paper Technology as time-saving and easy to use. The time-motion study with 273.3 and 224.0 hours of observations before and after introduction of Smart Paper Technology, respectively, confirmed that working time spent on documentation did not increase (27.0% at baseline and 26.4% post-introduction; adjusted p = 0.763). Time spent on patient care was not negatively impacted (26.9% at baseline and 37.1% at post-intervention; adjusted p = 0.001). Health care providers described positive effects on their accountability for data and service provision relating to the fact that individually signed forms were filled. Health care providers perceived Smart Paper Technology as feasible, easy to integrate and acceptable in their setting, particularly as it did not add time to documentation.

The role of care-seeking delays in intrauterine fetal deaths among 'near-miss' women in Herat, Afghanistan.

BACKGROUND: Many pregnant women in resource-poor countries seek care only after developing severe complications during childbirth at home and often reach health facilities in moribund conditions. The objectives were to (i) investigate the association between care-seeking duration and fetal survival at admission; and (ii) assess the significance of care-seeking duration in relation to other determinants. METHODS: Data were analysed for 266 women who were pregnant with a singleton and admitted in life-threatening conditions to the maternity ward of Herat Regional Hospital in Afghanistan from February 2007 to January 2008. Information about the women's care-seeking durations, social and financial resources, reproductive factors, household economic status and household types were collected during interviews with the women and their husbands. Information about fetal heartbeats at admission was extracted from the women's medical records. RESULTS: Fifty-four per cent of the women had a decision delay lasting 3 h or more; 69% had a transport delay lasting 3 h or more. Multivariable logistic regression analyses suggest that a decision delay lasting an hour or more increased the odds of fetal death by 6.6 (95% confidence interval [CI] 1.6, 26.3) compared with a delay less than 1 h. A woman's lack of financial autonomy and a distance from her natal home increased the odds of fetal death by 3.1 [95% CI 1.1, 8.4] and 2.5 [95% CI 1.0, 6.3] respectively. CONCLUSION: An integrated approach to improving fetal and maternal health from pre-pregnancy through childbirth (including increasing women's social and financial resources) is crucial particularly where senior family members act as gatekeepers to women's access to health care.

Hydrogen-dependent current generation and energy conservation by Shewanella oneidensis MR-1 in bioelectrochemical systems.

Bioelectrochemical systems (BESs) are engineered systems that utilize electrochemical interactions between electrochemically active bacteria (EAB) and electrodes. BESs have attracted considerable attention for their utility in biotechnological processes. In a BES, hydrogen is generated by the reduction of water on low-potential cathode electrodes. However, limited information is available on the effect of hydrogen on the metabolism and growth of EAB and current generation in BESs. Here, we investigated the effect of hydrogen on current generation by a model EAB, Shewanella oneidensis MR-1. We found that this strain utilizes hydrogen as an electron donor for electrode respiration, thereby facilitating current generation and cell growth in the presence of organic substrates. Inner membrane (IM) quinones (i.e., ubiquinone and menaquinone), IM quinone-reactive hydrogenase Hya, and IM-bound quinone reductase CymA are involved in hydrogen-dependent current generation, suggesting that the redox cycling of IM quinones catalyzed by Hya and CymA contributes to the generation of the proton motive force and the synthesis of ATP via F0F1-ATPase. These findings indicate that the evolution of hydrogen on the cathode facilitates energy metabolism and growth of hydrogen-utilizing EAB associated with anodes. The results also suggest that hydrogen cycling between cathodes and anodes can hinder quantitative evaluation of organic substrate-dependent current generation in BESs.

Postneonatal under-5 mortality in peri-urban and rural Eastern Uganda, 2005-2015.

INTRODUCTION: Community and individual sociodemographic characteristics play an important role in child survival. However, a question remains how urbanisation and demographic changes in sub-Saharan Africa affect community-level determinants for child survival. METHODS: Longitudinal data from the Iganga/Mayuge Health and Demographic Surveillance Site was used to obtain postneonatal under-5 mortality rates between March 2005 and February 2015 in periurban and rural areas separately. Multilevel survival analysis models were used to identify factors associated with mortality. RESULTS: There were 43 043 postneonatal under-5 children contributing to 116 385 person years of observation, among whom 1737 died. Average annual crude mortality incidence rate (IR) differed significantly between periurban and rural areas (9.0 (8.1 to 10.0) per 1000 person-years vs 18.1 (17.1 to 19.0), respectively). In periurban areas, there was evidence for decreasing mortality from IR=11.3 (7.7 to 16.6) in 2006 to IR=4.5 (3.0 to 6.9) in 2015. The mortality fluctuated with no evidence for reduction in rural areas (IR=19.0 (15.8 to 22.8) in 2006; IR=15.5 (13.0 to 18.6) in 2015). BCG vaccination was associated with reduced mortality in periurban and rural areas (adjusted rate ratio (aRR)=0.45; 95% CI 0.30 to 0.67 and aRR=0.56; 95% CI 0.41 to 0.76, respectively). Maternal education level within the community was associated with reduced mortality in both periurban and rural sites (aRR=0.83; 95% CI 0.70 to 0.99; aRR=0.90; 95% CI 0.81 to 0.99). The proportion of households in the poorest quintile within the community was associated with mortality in rural areas only (aRR=1.08; 95% CI 1.00 to 1.18). In rural areas, a large disparity existed between the least poor and the poorest (aRR=0.50; 95% CI 0.27 to 0.92). CONCLUSION: We found evidence for a mortality decline in peri-urban but not rural areas. Investments in the known key health (eg, vaccination) and socio-economic interventions (education, and economic development) continue to be crucial for mortality declines. Focused strategies to eliminate the disparity between wealth quintiles are also warranted. There may be equitable access to health services in peri-urban areas but improved metrics of socioeconomic position suitable for peri-urban residents may be needed.

Enhanced electricity generation in rice paddy-field microbial fuel cells supplemented with iron powders.

Microbial fuel cells installed in rice paddy fields (RP-MFCs) are able to serve as on-site batteries for operating low-power environmental sensors. In order to increase the utility and reliability of RP-MFCs, however, further research is necessary for boosting the power output. Here we examined several powdered iron species, including zero valent iron (ZVI), goethite, and magnetite, for their application to increasing power outputs from RP-MFCs. Soil around anodes was supplemented with either of these iron species, and RP-MFCs were operated for several months during the transplanting and harvesting. It was found that power outputs from RP-MFCs supplemented with ZVI were more than double the outputs from control (not supplemented with iron species) and other RP-MFCs, even after iron corrosion was ceased, and the maximum power density reached 130 mW/m2 (per projected area of the anode). Metabarcoding of 16S rRNA gene amplicons suggested that several taxa represented by fermentative and exoelectrogenic bacteria were substantially increased in MFCs supplemented with ZVI. Results suggest that ZVI lowers oxidation/reduction potential around anodes, activates anaerobic microbes involved in the conversion of organic matter into electricity and increases power output from RP-MFCs.

Towards development of electrogenetics using electrochemically active bacteria.

Owing to the ability for efficient electric interaction with electrodes, electrochemically active bacteria (EAB) attract considerable attention in biotechnology. These bacteria are involved not only in the generation of electricity from organic wastes in microbial fuel cells but also in the production of valued chemicals with the aid of electric energy in microbial electrosynthesis systems. It has been known that metabolic activities in EAB are affected by electrode potentials, while a recent work has found that in an EAB, Shewanella oneidensis MR-1, an Arc regulatory system regulates the expression of diverse catabolic genes by sensing electrode potentials. This finding suggests that the Arc system can be used for electrode potential-dependent control of gene expression in living cells and opens up a novel biotechnology platform, termed "electrogenetics". This article summarizes current knowledge on the catabolic and regulatory systems in EAB with a particular focus on the role of the Arc system and suggests the potential of electrogenetics in biotechnology.

Rethinking the definition of maternal near-miss in low-income countries using data from 104 health facilities in Tanzania and Uganda.

OBJECTIVE: To assess the consistency of maternal near-miss incidence and mortality index between two definitions across 104 facilities in Tanzania and Uganda. METHODS: Based on WHO guidance, cross-sectional near-miss data were collected in Tanzania (July 2015 to October 2016) and Uganda (June 2016 to September 2017). Prepartum hemorrhage and abortion were included as additional screening events and the number of blood units transfused was recorded. Near-miss incidence and mortality index were determined by using two near-miss definitions: the WHO standard definition, and a modified definition including women receiving at least 1 unit of blood. A sensitivity analysis excluded the additional screening events. RESULTS: Near-miss incidence differed between Tanzania and Uganda (1.79 and 4.00, respectively, per 100 deliveries) when estimated by the standard definition, but was similar (5.24 and 4.94, respectively) by the modified definition. The mortality index was higher in Tanzania than in Uganda when estimated by the standard definition (8.56% vs 3.54%), but was similar by the modified definition (3.10% vs 2.89%). CONCLUSION: The modified definition provided a more consistent estimate of near-miss incidence and mortality index. Lowering the threshold for units of blood transfusion might improve comparability between settings, but more research is needed.

Disentangling the contributions of maternal and fetal factors to estimate stillbirth risks for intrapartum adverse events in Tanzania and Uganda.

OBJECTIVE: To estimate the stillbirth risk associated with intrapartum adverse events, controlling for fetal and maternal factors. METHODS: The present study was an analysis of cross-sectional patient-record and facility-file data from women with viable fetuses who experienced obstetric adverse events at 23 hospitals and 38 health centers in Tanzania (between December 2015 and October 2016), and 22 hospitals, 16 level-4 health centers, and five level-3 health centers in Uganda (between May 2016 and September 2017). Adverse events were categorized in three severity groups (postpartum, intrapartum non-near-miss, and intrapartum near-miss) to calculate stillbirth rates and adjusted prevalence ratios. RESULTS: Data from 3816 women in Tanzania and 8305 in Uganda were included. Compared with postpartum adverse events, intrapartum near-miss was associated with a 3.73- and 4.55-fold higher prevalence of stillbirth in Uganda and Tanzania, respectively. Most women who experienced near-miss had organ dysfunction on arrival or developed it soon after. The risk of stillbirth was higher among preterm deliveries compared with term deliveries, and was 42% and 59% lower in Tanzania and Uganda, respectively, for cesarean deliveries compared with vaginal deliveries after intrapartum non-near-miss adverse events. CONCLUSION: Stillbirth risk increased with severity of complications and was higher among premature deliveries. Survival was higher for cesarean deliveries in intrapartum non-near-miss complications, identifying the opportunity to prevent deterioration by timely actions.

Effect of the competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training on maternal morbidity: a cluster-randomised trial in 20 districts in Tanzania.

BACKGROUND: Training health providers is an important strategy to improve health. We conducted a cluster-randomised two-arm trial in Tanzania to assess the effect of a 1-day competency-based training 'Helping Mothers Survive Bleeding after Birth (HMS BAB)' followed by eight weekly drills on postpartum haemorrhage (PPH)-related morbidity and mortality. METHODS: Twenty districts in four purposefully selected regions in Tanzania included 61 facilities. The districts were randomly allocated using matched pairs to ensure similarity in terms of district health services in intervention and comparison districts. In the 10 intervention districts 331 health providers received the HMS BAB training. The other half continued with standard practices. We used the WHO's near miss tool to collect information on severe morbidity (near misses) of all women admitted to study facilities. We performed interrupted time series analysis to estimate differences in the change of near miss per delivery rate and case fatality rates. We also assessed implementation of evidence-based preventive and basic management practices for PPH as secondary outcomes. RESULTS: We included 120 533 facility deliveries, 6503 near misses and 202 maternal deaths in study districts during study period (November 2014 to January 2017). A significant reduction of PPH near misses was found among women who suffered PPH in the intervention district compared with comparison districts (difference-in-differences of slopes -5.3, 95% CI -7.8 to -2.7, p<0.001) from a baseline PPH-related near miss rate of 71% (95% CI 60% to 80%). There was a significant decrease in the long-term PPH near miss case fatality (difference-in-differences of slopes -4 to 0) (95% CI -6.5 to -1.5, p<0.01) in intervention compared with the comparison districts. The intervention had a positive effect on the proportion of PPH cases treated with intravenous oxytocin (difference-in-differences of slopes 5.2, 95% CI 1.4 to 8.9) (p <0.01). CONCLUSION: The positive effect of the training intervention on PPH morbidity and case fatality suggests that the training addresses important deficits in knowledge and skills. TRIAL REGISTRATION NUMBER: PACTR201604001582128.

Electrochemically active bacteria sense electrode potentials for regulating catabolic pathways.

Electrochemically active bacteria (EAB) receive considerable attention for their utility in bioelectrochemical processes. Although electrode potentials are known to affect the metabolic activity of EAB, it is unclear whether EAB are able to sense and respond to electrode potentials. Here, we show that, in the presence of a high-potential electrode, a model EAB Shewanella oneidensis MR-1 can utilize NADH-dependent catabolic pathways and a background formate-dependent pathway to achieve high growth yield. We also show that an Arc regulatory system is involved in sensing electrode potentials and regulating the expression of catabolic genes, including those for NADH dehydrogenase. We suggest that these findings may facilitate the use of EAB in biotechnological processes and offer the molecular bases for their ecological strategies in natural habitats.

Technical quality of delivery care in private- and public-sector health facilities in Enugu and Lagos States, Nigeria.

Private-sector providers are increasingly being recognized as important contributors to the delivery of healthcare. Countries with high disease burdens and limited public-sector resources are considering using the private sector to achieve universal health coverage. However, evidence for the technical quality of private-sector care is lacking. This study assesses the technical quality of maternal healthcare during delivery in public- and private-sector facilities in resource-limited settings, from a systems and programmatic perspective. A summary index (the skilled attendance index, SAI), was used. Two-staged cluster sampling with stratification was used to select representative samples of case records in public- and private-sector facilities in Enugu and Lagos States, Nigeria. Information to assess criteria was extracted, and the SAI calculated. Linear regression models examined the relationship between SAI and the private and public sectors, controlling for confounders. The median SAI was 54.8% in Enugu and 85.7% in Lagos. The private for-profit sector's SAI was lower than and the private not-for-profit sector's SAI was higher than the public sector in Enugu [coefficient = -3.6 (P = 0.018) and 12.6 (P < 0.001), respectively]. In Lagos, the private for-profit sector's SAI was higher and the private not-for-profit sector's SAI was lower than the public sector [3.71 (P = 0.005) and -3.92 (P < 0.001)]. Results indicate that the technical quality of private for-profit providers' care was poorer than public providers where the public provision of care was weak, while private for-profit facilities provided better technical quality care than public facilities where the public sector was strong and there was a relatively strong regulatory body. Our findings raise important considerations relating to the quality of maternity care, the public-private mix and needs for regulation in global efforts to achieve universal healthcare.

Systematic review of obstetric care from a women-centered perspective in Nigeria since 2000.

BACKGROUND: A women-centered approach can improve the quality of patient care. OBJECTIVE: To review issues in the provision of obstetric care from a patient-centered care perspective in Nigeria. SEARCH STRATEGY: Using terms related to maternal and perinatal mortality, in combination with "Nigeria", MEDLINE, Embase, CINAHL, Web of Knowledge, and African Journal Online were searched, between December 1, 2013 and January 31, 2014, for articles in any language. SELECTION CRITERIA: Articles published in a Nigerian setting after 2000 that investigated causes of and circumstance surrounding maternal deaths and complications, or clinical practice related to maternal care were included. DATA COLLECTION AND ANALYSIS: Data were extracted by two reviewers using a standardized abstraction form and were analyzed from a patient-centered perspective. MAIN RESULTS: The analysis included 57 studies. Clandestine induced abortions, lack of prenatal care, delays in seeking care, and the use of spiritual churches for delivery were found to contribute to adverse pregnancy outcomes. CONCLUSIONS: Healthcare systems respond inadequately to patients' needs in terms of abortion care, information sharing, transitioning between prenatal and obstetric care, and patients' non-medical needs. Data from clinician-led maternal death audits provided insights into how women-centered care can be provided; nonetheless, more-focused studies from a primarily patient-centered perspective are warranted.

Consequences of maternal morbidity on health-related functioning: a systematic scoping review.

OBJECTIVES: To assess the scope of the published literature on the consequences of maternal morbidity on health-related functioning at the global level and identify key substantive findings as well as research and methodological gaps. METHODS: We searched for articles published between 2005 and 2014 using Medline, Embase, Popline, CINAHL Plus and three regional bibliographic databases in January 2015. DESIGN: Systematic scoping review PRIMARY OUTCOME: Health-related functioning RESULTS: After screening 17 706 studies, 136 articles were identified for inclusion. While a substantial number of papers have documented mostly negative effects of morbidity on health-related functioning and well-being, the body of evidence is not spread evenly across conditions, domains or geographical regions. Over 60% of the studies focus on indirect conditions such as depression, diabetes and incontinence. Health-related functioning is often assessed by instruments designed for the general population including the 36-item Short Form or disease-specific tools. The functioning domains most frequently documented are physical and mental; studies that examined physical, mental, social, economic and specifically focused on marital, maternal and sexual functioning are rare. Only 16 studies were conducted in Africa. CONCLUSIONS: Many assessments have not been comprehensive and have paid little attention to important functioning domains for pregnant and postpartum women. The development of a comprehensive instrument specific to maternal health would greatly advance our understanding of burden of ill health associated with maternal morbidity and help set priorities. The lack of attention to consequences on functioning associated with the main direct obstetric complications is of particular concern. REVIEW REGISTRATION: CRD42015017774.

Catabolic and regulatory systems in Shewanella oneidensis MR-1 involved in electricity generation in microbial fuel cells.

Shewanella oneidensis MR-1 is a facultative anaerobe that respires using a variety of inorganic and organic compounds. MR-1 is also capable of utilizing extracellular solid materials, including anodes in microbial fuel cells (MFCs), as electron acceptors, thereby enabling electricity generation. As MFCs have the potential to generate electricity from biomass waste and wastewater, MR-1 has been extensively studied to identify the molecular systems that are involved in electricity generation in MFCs. These studies have demonstrated the importance of extracellular electron-transfer (EET) pathways that electrically connect the quinone pool in the cytoplasmic membrane to extracellular electron acceptors. Electricity generation is also dependent on intracellular catabolic pathways that oxidize electron donors, such as lactate, and regulatory systems that control the expression of genes encoding the components of catabolic and electron-transfer pathways. In addition, recent findings suggest that cell-surface polymers, e.g., exopolysaccharides, and secreted chemicals, which function as electron shuttles, are also involved in electricity generation. Despite these advances in our knowledge on the EET processes in MR-1, further efforts are necessary to fully understand the underlying intra- and extracellular molecular systems for electricity generation in MFCs. We suggest that investigating how MR-1 coordinates these systems to efficiently transfer electrons to electrodes and conserve electrochemical energy for cell proliferation is important for establishing the biological basis for MFCs.

Metabolic Characteristics of a Glucose-Utilizing Shewanella oneidensis Strain Grown under Electrode-Respiring Conditions.

In bioelectrochemical systems, the electrode potential is an important parameter affecting the electron flow between electrodes and microbes and microbial metabolic activities. Here, we investigated the metabolic characteristics of a glucose-utilizing strain of engineered Shewanella oneidensis under electrode-respiring conditions in electrochemical reactors for gaining insight into how metabolic pathways in electrochemically active bacteria are affected by the electrode potential. When an electrochemical reactor was operated with its working electrode poised at +0.4 V (vs. an Ag/AgCl reference electrode), the engineered S. oneidensis strain, carrying a plasmid encoding a sugar permease and glucose kinase of Escherichia coli, generated current by oxidizing glucose to acetate and produced D-lactate as an intermediate metabolite. However, D-lactate accumulation was not observed when the engineered strain was grown with a working electrode poised at 0 V. We also found that transcription of genes involved in pyruvate and D-lactate metabolisms was upregulated at a high electrode potential compared with their transcription at a low electrode potential. These results suggest that the carbon catabolic pathway of S. oneidensis can be modified by controlling the potential of a working electrode in an electrochemical bioreactor.