Transitioning from the "Three Delays" to a focus on continuity of care: a qualitative analysis of maternal deaths in rural Pakistan and Mozambique.

BACKGROUND: The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance. METHODS: The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial. RESULTS: Qualitative analysis of these maternal death narratives in both countries reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of care-seeking, to update the categories of seeking, reaching and receiving care. CONCLUSIONS: There is a need to supplement the pioneering "Three Delays Framework" to include focusing on continuity of care and the "Four Critical Connection Points": (1) between the stages of pregnancy, (2) between families and health care workers, (3) between health care facilities and (4) between multiple care-seeking journeys. TRIAL REGISTRATION: NCT01911494, Date Registered 30/07/2013.

Causes and circumstances of maternal death: a secondary analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials cohort.

BACKGROUND: Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. METHODS: The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. FINDINGS: Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43-0·66]) or InterVA-5 (κ=0·44 [0·30-0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60-0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38-0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27-0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59-0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00-0·15]). INTERPRETATION: Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. FUNDING: University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

Corrigendum: Autonomic Nervous System Correlates of Speech Categorization Revealed Through Pupillometry.

[This corrects the article DOI: 10.3389/fnins.2019.01418.].

Acoustic noise and vision differentially warp the auditory categorization of speech.

Speech perception requires grouping acoustic information into meaningful linguistic-phonetic units via categorical perception (CP). Beyond shrinking observers' perceptual space, CP might aid degraded speech perception if categories are more resistant to noise than surface acoustic features. Combining audiovisual (AV) cues also enhances speech recognition, particularly in noisy environments. This study investigated the degree to which visual cues from a talker (i.e., mouth movements) aid speech categorization amidst noise interference by measuring participants' identification of clear and noisy speech (0 dB signal-to-noise ratio) presented in auditory-only or combined AV modalities (i.e., A, A+noise, AV, AV+noise conditions). Auditory noise expectedly weakened (i.e., shallower identification slopes) and slowed speech categorization. Interestingly, additional viseme cues largely counteracted noise-related decrements in performance and stabilized classification speeds in both clear and noise conditions suggesting more precise acoustic-phonetic representations with multisensory information. Results are parsimoniously described under a signal detection theory framework and by a reduction (visual cues) and increase (noise) in the precision of perceptual object representation, which were not due to lapses of attention or guessing. Collectively, findings show that (i) mapping sounds to categories aids speech perception in "cocktail party" environments; (ii) visual cues help lattice formation of auditory-phonetic categories to enhance and refine speech identification.

Contrasting Semantic versus Inhibitory Processing in the Angular Gyrus: An fMRI Study.

Recent studies of semantic memory have focused on dissociating the neural bases of two foundational components of human thought: taxonomic categories, which group similar objects like dogs and seals based on features, and thematic categories, which group dissimilar objects like dogs and leashes based on events. While there is emerging consensus that taxonomic concepts are represented in the anterior temporal lobe, there is disagreement over whether thematic concepts are represented in the angular gyrus (AG). We previously found AG sensitivity to both kinds of concepts; however, some accounts suggest that such activity reflects inhibition of irrelevant information rather than thematic activation. To test these possibilities, an fMRI experiment investigated both types of conceptual relations in the AG during two semantic judgment tasks. Each task trained participants to give negative responses (inhibition) or positive responses (activation) to word pairs based on taxonomic and thematic criteria of relatedness. Results showed AG engagement during both negative judgments and thematic judgments, but not during positive judgments about taxonomic pairs. Together, the results suggest that activity in the AG reflects functions that include both thematic (but not taxonomic) processing and inhibiting irrelevant semantic information.

Autonomic Nervous System Correlates of Speech Categorization Revealed Through Pupillometry.

Human perception requires the many-to-one mapping between continuous sensory elements and discrete categorical representations. This grouping operation underlies the phenomenon of categorical perception (CP)-the experience of perceiving discrete categories rather than gradual variations in signal input. Speech perception requires CP because acoustic cues do not share constant relations with perceptual-phonetic representations. Beyond facilitating perception of unmasked speech, we reasoned CP might also aid the extraction of target speech percepts from interfering sound sources (i.e., noise) by generating additional perceptual constancy and reducing listening effort. Specifically, we investigated how noise interference impacts cognitive load and perceptual identification of unambiguous (i.e., categorical) vs. ambiguous stimuli. Listeners classified a speech vowel continuum (/u/-/a/) at various signal-to-noise ratios (SNRs [unmasked, 0 and -5 dB]). Continuous recordings of pupil dilation measured processing effort, with larger, later dilations reflecting increased listening demand. Critical comparisons were between time-locked changes in eye data in response to unambiguous (i.e., continuum endpoints) tokens vs. ambiguous tokens (i.e., continuum midpoint). Unmasked speech elicited faster responses and sharper psychometric functions, which steadily declined in noise. Noise increased pupil dilation across stimulus conditions, but not straightforwardly. Noise-masked speech modulated peak pupil size (i.e., [0 and -5 dB] > unmasked). In contrast, peak dilation latency varied with both token and SNR. Interestingly, categorical tokens elicited earlier pupil dilation relative to ambiguous tokens. Our pupillary data suggest CP reconstructs auditory percepts under challenging listening conditions through interactions between stimulus salience and listeners' internalized effort and/or arousal.

Effects of Part- and Whole-Object Primes on Early MEG Responses to Mooney Faces and Houses.

Results from neurophysiological experiments suggest that face recognition engages a sensitive mechanism that is reflected in increased amplitude and decreased latency of the MEG M170 response compared to non-face visual targets. Furthermore, whereas recognition of objects (e.g., houses) has been argued to be based on individual features (e.g., door, window), face recognition may depend more on holistic information. Here we analyzed priming effects of component and holistic primes on 20 participants' early MEG responses to two-tone (Mooney) images to determine whether face recognition in this context engages "featural" or "configural" processing. Although visually underspecified, the Mooney images in this study elicited M170 responses that replicate the typical face vs. house effect. However, we found a distinction between holistic vs. component primes that modulated this effect dependent upon compatibility (match) between the prime and target. The facilitatory effect of holistic faces and houses for Mooney faces and houses, respectively, suggests that both Mooney face and house recognition-both low spatial frequency stimuli-are based on holistic information.

Counting every stillbirth and neonatal death through mortality audit to improve quality of care for every pregnant woman and her baby.

BACKGROUND: While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking. METHODS: We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality. RESULTS: Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed. CONCLUSIONS: Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

The neural bases of taxonomic and thematic conceptual relations: an MEG study.

Converging evidence from behavioral and neuroimaging studies of human concepts indicate distinct neural systems for taxonomic and thematic knowledge. A recent study of naming in aphasia found involvement of the anterior temporal lobe (ATL) during taxonomic (feature-based) processing, and involvement of the temporoparietal junction (TPJ) during thematic (function-based) processing. We conducted an online magnetoencephalography (MEG) study to examine the spatio-temporal nature of taxonomic and thematic relations. We measured participants' brain responses to words preceded by either a taxonomically or thematically related item (e.g., cottage→castle, king→castle). In a separate experiment we collected relatedness ratings of the word pairs from participants. We examined effects of relatedness and relation type on activation in ATL and TPJ regions of interest (ROIs) using permutation t-tests to identify differences in ROI activation between conditions as well as single-trial correlational analyses to examine the millisecond-by-millisecond influence of the stimulus variables on the ROIs. Taxonomic relations strongly predicted ATL activation, and both kinds of relations influenced the TPJ. Our results further strengthen the view of the ATL's importance to taxonomic knowledge. Moreover, they provide a nuanced view of thematic relations as involving taxonomic knowledge.

Emerging lessons from the FIGO LOGIC initiative on maternal death and near-miss reviews.

This short paper describes some early findings from an overview of the maternal death or severe morbidity "near-miss" reviews that have been undertaken to improve clinical care by the eight societies participating in the FIGO Leadership in Obstetrics and Gynecology for Impact and Change (LOGIC) Initiative in Maternal and Newborn Health aimed at strengthening the role of professional obstetric associations. While it is expected that each will publish its own report, generalizable lessons emerged and valuable solutions were implemented that will help others planning such reviews and audits in future.

The role of visual representations during the lexical access of spoken words.

Do visual representations contribute to spoken word recognition? We examine, using MEG, the effects of sublexical and lexical variables at superior temporal (ST) areas and the posterior middle temporal gyrus (pMTG) compared with that of word imageability at visual cortices. Embodied accounts predict early modulation of visual areas by imageability--concurrently with or prior to modulation of pMTG by lexical variables. Participants responded to speech stimuli varying continuously in imageability during lexical decision with simultaneous MEG recording. We employed the linguistic variables in a new type of correlational time course analysis to assess trial-by-trial activation in occipital, ST, and pMTG regions of interest (ROIs). The linguistic variables modulated the ROIs during different time windows. Critically, visual regions reflected an imageability effect prior to effects of lexicality on pMTG. This surprising effect supports a view on which sensory aspects of a lexical item are not a consequence of lexical activation.

Amniotic fluid embolism incidence, risk factors and outcomes: a review and recommendations.

BACKGROUND: Amniotic fluid embolism (AFE) is a rare but severe complication of pregnancy. A recent systematic review highlighted apparent differences in the incidence, with studies estimating the incidence of AFE to be more than three times higher in North America than Europe. The aim of this study was to examine population-based regional or national data from five high-resource countries in order to investigate incidence, risk factors and outcomes of AFE and to investigate whether any variation identified could be ascribed to methodological differences between the studies. METHODS: We reviewed available data sources on the incidence of AFE in Australia, Canada, the Netherlands, the United Kingdom and the USA. Where information was available, the risk factors and outcomes of AFE were examined. RESULTS: The reported incidence of AFE ranged from 1.9 cases per 100 000 maternities (UK) to 6.1 per 100 000 maternities (Australia). There was a clear distinction between rates estimated using different methodologies. The lowest estimated incidence rates were obtained through validated case identification (range 1.9-2.5 cases per 100 000 maternities); rates obtained from retrospective analysis of population discharge databases were significantly higher (range 5.5-6.1 per 100 000 admissions with delivery diagnosis). Older maternal age and induction of labour were consistently associated with AFE. CONCLUSIONS: Recommendation 1: Comparisons of AFE incidence estimates should be restricted to studies using similar methodology. The recommended approaches would be either population-based database studies using additional criteria to exclude false positive cases, or tailored data collection using existing specific population-based systems.Recommendation 2: Comparisons of AFE incidence between and within countries would be facilitated by development of an agreed case definition and an agreed set of criteria to minimise inclusion of false positive cases for database studies.Recommendation 3: Groups conducting detailed population-based studies on AFE should develop an agreed strategy to allow combined analysis of data obtained using consistent methodologies in order to identify potentially modifiable risk factors.Recommendation 4: Future specific studies on AFE should aim to collect information on management and longer-term outcomes for both mothers and infants in order to guide best practice, counselling and service planning.

Saving Mothers' Lives: the continuing benefits for maternal health from the United Kingdom (UK) Confidential Enquires into Maternal Deaths.

The actions that have followed the recommendations of successive publications of the UK Confidential Enquiries into Maternal Deaths have helped save mothers' lives and reduced ill health and morbidity. Through the implementation of their recommendations, they have helped improve access to, and the quality of, the maternity care provided for all pregnant women in the United Kingdom. The enquires help review, assess, and identify the underlying remediable factors that contributed to mothers' deaths and aggregate the lessons learned to make recommendations to develop services that help overcome many of the barriers to safe, high-quality maternity care, which vulnerable women continue to face. This chapter provides a short summary of the positive contributions the successive reports on Confidential Enquiries into Maternal Deaths, "Saving Mothers' Lives," have made to maternal health outcomes in the United Kingdom for more than half a century. It also demonstrates why such systems continue to be beneficial around the world, including countries with very low maternal mortality rates.

The neural basis of obligatory decomposition of suffixed words.

Recent neurolinguistic studies present somewhat conflicting evidence concerning the role of the inferior temporal cortex (IT) in visual word recognition within the first 200 ms after presentation. On the one hand, fMRI studies of the Visual Word Form Area (VWFA) suggest that the IT might recover representations of the orthographic form of words. On the other hand, influential MEG studies of responses from the occipito-temporal regions around 150 ms post-stimulus onset indicate recognition of letters as opposed to symbols but not a sensitivity to statistical properties of letter strings associated with word form representations. Recent MEG experiments support the position that the IT does represent the visual word forms of morphemes and performs morphological decomposition modulated by the statistical relations between morphemes by 170 ms post presentation (at the M170 response). Responses to heteronyms show that the M170 does not make contact with the mental lexicon where word forms are connected to meanings. We report here an MEG study of pseudo-affixed words like brother, which masked priming studies have shown are decomposed in recognition. If the M170 response from IT does index obligatory morphological decomposition based on visual word forms but not lexical entries, we should find that the statistical relation between pseudo-stem and pseudo-suffix modulates the M170 for pseudo-affixed words, as for truly affixed words. The results of this experiment confirm this prediction. In addition, surface form frequency for these words also modulates the M170, providing some support for dual route recognition for words for which decomposition is a garden path.

Risk factors for progression from severe maternal morbidity to death: a national cohort study.

BACKGROUND: Women continue to die unnecessarily during or after pregnancy in the developed world. The aim of this analysis was to compare women with severe maternal morbidities who survived with those who died, to quantify the risk associated with identified factors to inform policy and practice to improve survival. METHODS AND FINDINGS: We conducted a national cohort analysis using data from two sources obtained between 2003 and 2009: the Centre for Maternal and Child Enquiries maternal deaths database and the United Kingdom Obstetric Surveillance System database. Included women had eclampsia, antenatal pulmonary embolism, amniotic fluid embolism, acute fatty liver of pregnancy or antenatal stroke. These conditions were chosen as major causes of maternal mortality and morbidity about which data were available through both sources, and include 42% of direct maternal deaths over the study period. Rates, risk ratios, crude and adjusted odd ratios were used to investigate risks factors for maternal death. Multiple imputation and sensitivity analysis were used to handle missing data. We identified 476 women who survived and 100 women who died. Maternal death was associated with older age (35+ years aOR 2.36, 95%CI 1.22-4.56), black ethnicity (aOR 2.38, 95%CI 1.15-4.92), and unemployed, routine or manual occupation (aOR 2.19, 95%CI 1.03-4.68). An association was also observed with obesity (BMI≥30 kg/m(2) aOR 2.73, 95%CI 1.15-6.46). CONCLUSIONS: Ongoing high quality national surveillance programmes have an important place in addressing challenges in maternal health and care. There is a place for action to reverse the rising trends in maternal age at childbirth, and to reduce the burden of obesity in pregnancy, as well as ongoing recognition of the impact of older maternal age on the risks of pregnancy. Development and evaluation of services to mitigate the risk of dying associated with black ethnicity and lower socioeconomic status is also essential.