Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

Barriers to Intrauterine Device Uptake in a Rural Setting in Ghana.

Long-acting reversible contraception is an underutilized method in low-resource areas. Our study aims to: (a) assess knowledge and attitudes around contraception; (b) identify barriers to intrauterine device (IUD) uptake; and (c) develop interventions to address this gap in contraceptive care. We conducted focus group discussions with pregnant, postpartum, and reproductive-aged women, males, and health care workers in rural Ghana. Lack of IUD-specific knowledge, provider discomfort with insertion, and incomplete contraceptive counseling contribute to lack of IUD use. Participant- and provider-related barriers contribute to poor uptake of IUDs within the community. Targeted interventions are necessary to improve IUD use.

A novel obstetric medical device designed for autotransfusion of blood in life threatening postpartum haemorrhage.

Postpartum haemorrhage (PPH) is an obstetric emergency caused by excessive blood loss after delivery, which is the leading cause of maternal mortality worldwide. PPH can lead to volume depletion, hypovolemic shock, anaemia and ultimately death. The prevalence of PPH is disproportionately higher in low resource settings where there is limited access to skilled medical care and safe blood supplies. Current management strategies target both prevention and treatment of PPH however no alternatives currently exist to address the lack of safe blood supplies which are considered essential in emergency obstetrical care. Autotransfusion is used to salvage blood loss in a variety of clinical settings but has never been used in the context of vaginal delivery. We describe the development and testing of a novel device for the collection, filtration and autotransfusion of blood lost due to PPH. The prototype device is inexpensive and easily operated so that it may be practically deployed in low resource settings. The device is comprised of a blood collection drape, a pump apparatus, three leukocyte reduction filters and a reservoir for filtered blood. Preliminary testing demonstrates efficacy of microbial load reduction of up to 97.3%. To reduce cost and improve safety, the device is modular in design such that the drape, tubing, filters and transfusion bag may be stored sterile, used once and discarded; while the pump apparatus may be used indefinitely without the need for sterilisation. Preliminary results indicate the device confers a low cost and potentially effective means of collecting, pumping, filtering and returning blood to a patient following PPH in settings that lack safe blood supplies. This device shows promise as a method of stabilising patients suffering of PPH in low resource settings until definitive treatment is rendered with the ultimate goal of reducing maternal mortality globally.

Progestin-based contraceptive on the same day as medical abortion.

OBJECTIVE: To determine the success rate of medical abortion when a progestin-based contraceptive-either an etonogestrel implant or depot medroxyprogesterone acetate (DMPA) injection-is given on the same day as mifepristone for medical abortion. METHODS: In a retrospective chart review, data were assessed for women aged 15-49years who underwent medical abortion (≤63days of pregnancy) at two hospitals in KwaZulu Natal, South Africa, between August 2013 and July 2014. The women were given oral mifepristone (200mg) and buccal misoprostol (800µg), and received an etonogestrel implant or DMPA injection on the same day as mifepristone. The primary outcome was the success rate of medical abortion. Comparative data were obtained through a PubMed search. RESULTS: A total of 89 women were included. Complete termination was achieved in 87 (98%, 95% confidence interval 95%-100%) women. This success rate is similar to that reported in a previous systematic review of the rate of medical abortion success without progestin contraceptive administration (94.8%). CONCLUSIONS: Administration of a progestin-based contraceptive such as an etonogestrel implant or DMPA injection on the same day as mifepristone for medical abortion did not alter the success rates.

Global women's health is more than maternal health: a review of gynecology care needs in low-resource settings.

Women's health care efforts in low-resource settings are often focused primarily on prenatal and obstetric care. However, women all over the world experience significant morbidity and mortality related to cervical cancer, sexually transmitted infections, and urogynecologic conditions as well as gynecologic care provision including insufficient and ineffective family planning services. Health care providers with an interest in clinical care in low-resource settings should be aware of the scope of the burden of gynecologic issues and strategies in place to combat the problems. This review article discusses the important concerns both in the developing world as well as highlights similar disparities that exist in the United States by women's age, race and ethnicity, and socioeconomic status. Ultimately, this review article aims to inform and update health care providers on critical gynecologic issues in low-resource settings.

Recommendations for scale-up of community-based misoprostol distribution programs.

Community-based distribution of misoprostol for prevention of postpartum hemorrhage (PPH) in resource-poor settings has been shown to be safe and effective. However, global recommendations for prenatal distribution and monitoring within a community setting are not yet available. In order to successfully translate misoprostol and PPH research into policy and practice, several critical points must be considered. A focus on engaging the community, emphasizing the safe nature of community-based misoprostol distribution, supply chain management, effective distribution, coverage, and monitoring plans are essential elements to community-based misoprostol program introduction, expansion, or scale-up.

Avian circannual clocks: adaptive significance and possible involvement of energy turnover in their proximate control.

Endogenous circannual clocks are found in many long-lived organisms, but are best studied in mammal and bird species. Circannual clocks are synchronized with the environment by changes in photoperiod, light intensity and possibly temperature and seasonal rainfall patterns. Annual timing mechanisms are presumed to have important ultimate functions in seasonally regulating reproduction, moult, hibernation, migration, body weight and fat deposition/stores. Birds that live in habitats where environmental cues such as photoperiod are poor predictors of seasons (e.g. equatorial residents, migrants to equatorial/tropical latitudes) rely more on their endogenous clocks than birds living in environments that show a tight correlation between photoperiod and seasonal events. Such population-specific/interspecific variation in reliance on endogenous clocks may indicate that annual timing mechanisms are adaptive. However, despite the apparent adaptive importance of circannual clocks, (i) what specific adaptive value they have in the wild and (ii) how they function are still largely untested. Whereas circadian clocks are hypothesized to be generated by molecular feedback loops, it has been suggested that circannual clocks are either based upon (i) a de-multiplication ('counting') of circadian days, (ii) a sequence of interdependent physiological states, or (iii) one or more endogenous oscillators, similar to circadian rhythms. We tested the de-multiplication of days (i) versus endogenous regulation hypotheses (ii) and (iii) in captive male and female house sparrows (Passer domesticus). We assessed the period of reproductive (testicular and follicular) cycles in four groups of birds kept either under photoperiods of LD 12L:12D (period length: 24h), 13.5L:13.5D (27 h), 10.5L:10.5D (23 h) or 12D:8L:3D:1L (24-h skeleton photoperiod), respectively, for 15 months. Contrary to predictions from the de-multiplication hypothesis, individuals experiencing 27-h days did not differ (i.e. did not have longer) annual reproductive rhythms than individuals from the 21- or 24-h day groups. However, in line with predictions from endogenous regulation, birds in the skeleton group had significantly longer circannual period lengths than all other groups. Birds exposed to skeleton photoperiods experienced fewer light hours per year than all other groups (3285 versus 4380) and had a lower daily energy expenditure, as tested during one point of the annual cycle using respirometry. Although our results are tantalizing, they are still preliminary as birds were only studied over a period of 15 months. Nevertheless, the present data fail to support a 'counting of circadian days' and instead support hypotheses proposing whole-organism processes as the mechanistic basis for circannual rhythms. We propose a novel energy turnover hypothesis which predicts a dependence of the speed of the circannual clock on the overall energy expenditure of an organism.