Maternal and Child Health Nutrition Faculty and Trainees Work Collaboratively with Community Partners to Assess Afterschool Nutrition Environments.

Purpose The purpose of this paper is to describe a collaborative service learning experience (SLE) which was part of the degree requirements of the Public Health Nutrition Graduate Program at the University of Tennessee. The SLE was collaboratively developed by the University of Tennessee's maternal and child health (MCH) nutrition leadership education and training (NLET) Program Director and the Knox County Health Department's healthy weight program manager. Description The SLE was a semester long project that included instructional time and fieldwork. Coursework focused on development of a community nutrition needs assessment, how to interpret and analyze assessment data, and how to use assessment data for program planning and policy development. Fieldwork consisted of interacting with an interprofessional team, assessing the nutrition environment at two afterschool sites, conducting a plate waste study to determine the amount of food consumed by children at the sites' dinner meals, interpreting and analyzing data, and developing and presenting recommendations for improvement. Assessment Trainees successfully completed all aspects of the SLE. They completed a community needs assessment of the neighborhoods surrounding the two afterschool program sites, conducted nutrition environment audits, including meal observations, and measured and analyzed plate waste from dinner meals served at the sites. Using the data gathered and collected, they prepared suggestions for nutrition environment improvements and policy development for community partners. Conclusion The SLE allowed trainees to develop MCH competencies and professional skills required in public health nutrition, while providing valuable data that subsequently was used to establish nutrition-related policies and interventions.

From Theory to Measurement: Recommended State MCH Life Course Indicators.

PURPOSE: In May 2012, the Association of Maternal and Child Health (MCH) Programs initiated a project to develop indicators for use at a state or community level to assess, monitor, and evaluate the application of life course principles to public health. DESCRIPTION: Using a developmental framework established by a national expert panel, teams of program leaders, epidemiologists, and academicians from seven states proposed indicators for initial consideration. More than 400 indicators were initially proposed, 102 were selected for full assessment and review, and 59 were selected for final recommendation as Maternal and Child Health (MCH) life course indicators. ASSESSMENT: Each indicator was assessed on five core features of a life course approach: equity, resource realignment, impact, intergenerational wellness, and life course evidence. Indicators were also assessed on three data criteria: quality, availability, and simplicity. CONCLUSION: These indicators represent a major step toward the translation of the life course perspective from theory to application. MCH programs implementing program and policy changes guided by the life course framework can use these initial measures to assess and influence their approaches.

How well do birth records serve maternal and child health programs? Birth registration system evaluation, New York City, 2008-2011.

National birth registration guidelines were revised in 2003 to improve data quality; however, few studies have evaluated the impact on local jurisdictions and their data users. In New York City (NYC), approximately 125,000 births are registered annually with the NYC Department of Health and Mental Hygiene, and data are used routinely by the department's maternal and child health (MCH) programs. In order to better meet MCH program needs, we used Centers for Disease Control and Prevention guidelines to assess birth data usefulness, simplicity, data quality, timeliness and representativeness. We interviewed birth registration and MCH program staff, reviewed a 2009 survey of birth registrars (n = 39), and analyzed 2008-2011 birth records for timeliness and completeness (n = 502,274). Thirteen MCH programs use birth registration data for eligibility determination, needs assessment, program evaluation, and surveillance. Demographic variables are used frequently, nearly 100 % complete, and considered the gold standard by programs; in contrast, medical variables' use and validity varies widely. Seventy-seven percent of surveyed birth registrars reported ≥1 problematic items in the system; 64.1 % requested further training. During 2008-2011, the median interval between birth and registration was 5 days (range 0-260 days); 11/13 programs were satisfied with timeliness. The NYC birth registration system provides local MCH programs useful, timely, and representative data. However, some medical items are difficult to collect, of low quality, and rarely used. We recommend enhancing training for birth registrars, continuing quality improvement efforts, increasing collaboration with program users, and removing consistently low-quality and low-use variables.

Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: To explore the clinical practices, risks, and maternal outcomes associated with postpartum haemorrhage (PPH). DESIGN: Secondary analysis of cross-sectional data. SETTING: A total of 352 health facilities in 28 countries. SAMPLE: A total of 274 985 women giving birth between 1 May 2010 and 31 December 2011. METHODS: We used multivariate logistic regression to examine factors associated with PPH among all births, and the Pearson chi-square test to examine correlates of severe maternal outcomes (SMOs) among women with PPH. All analyses adjust for facility- and country-level clustering. MAIN OUTCOME MEASURES: PPH, SMOs, and clinical practices for the management of PPH. RESULTS: Of all the women included in the analysis, 95.3% received uterotonic prophylaxis and the reported rate of PPH was 1.2%. Factors significantly associated with PPH diagnosis included age, parity, gestational age, induction of labour, caesarean section, and geographic region. Among those with PPH, 92.7% received uterotonics for treatment, and 17.2% had an SMO. There were significant differences in the incidence of SMOs by age, parity, gestational age, anaemia, education, receipt of uterotonics for prophylaxis or treatment, referral from another facility, and Human Development Index (HDI) group. The rates of death were highest in countries with low or medium HDIs. CONCLUSIONS: Among women with PPH, disparities in the incidence of severe maternal outcomes persist, even among facilities that report capacity to provide all essential emergency obstetric interventions. This highlights the need for better information about the role of institutional capacity, including quality of care, in PPH-related morbidity and mortality.

Pre-eclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: To assess the incidence of hypertensive disorders of pregnancy and related severe complications, identify other associated factors and compare maternal and perinatal outcomes in women with and without these conditions. DESIGN: Secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) database. SETTING: Cross-sectional study implemented at 357 health facilities conducting 1000 or more deliveries annually in 29 countries from Africa, Asia, Latin America and the Middle East. POPULATION: All women suffering from any hypertensive disorder during pregnancy, the intrapartum or early postpartum period in the participating hospitals during the study period. METHODS: We calculated the proportion of the pre-specified outcomes in the study population and their distribution according to hypertensive disorders' severity. We estimated the association between them and maternal deaths, near-miss cases, and severe maternal complications using a multilevel logit model. MAIN OUTCOME MEASURES: Hypertensive disorders of pregnancy. Potentially life-threatening conditions among maternal near-miss cases, maternal deaths and cases without severe maternal outcomes. RESULTS: Overall, 8542 (2.73%) women suffered from hypertensive disorders. Incidences of pre-eclampsia, eclampsia and chronic hypertension were 2.16%, 0.28% and 0.29%, respectively. Maternal near-miss cases were eight times more frequent in women with pre-eclampsia, and increased to up to 60 times more frequent in women with eclampsia, when compared with women without these conditions. CONCLUSIONS: The analysis of this large database provides estimates of the global distribution of the incidence of hypertensive disorders of pregnancy. The information on the most frequent complications related to pre-eclampsia and eclampsia could be of interest to inform policies for health systems organisation.

Overview of abortion cases with severe maternal outcomes in the WHO Multicountry Survey on Maternal and Newborn Health: a descriptive analysis.

OBJECTIVE: To summarise individual and institutional characteristics of abortion-related severe maternal outcomes reported at health facilities. DESIGN: Secondary analysis of data from the WHO Multicountry Survey on Maternal and Newborn Health. SETTING: 85 health facilities in 23 countries. SAMPLE: 322 women with abortion-related severe maternal outcomes. METHODS: Frequency distributions and comparisons of differences in characteristics between cases of maternal near miss and death using Fisher's exact tests of association. MAIN OUTCOME MEASURES: Individual and institutional characteristics and frequencies of potentially life-threatening conditions, and interventions provided to women with severe maternal outcomes, maternal near miss, and maternal death. RESULTS: Most women with abortion-related severe maternal outcomes (SMOs) were 20-34 years old (65.2%), married or cohabitating (92.3%), parous (84.2%), and presented with abortions resulting from pregnancies at less than 14 weeks of gestation (67.1%). The women who died were younger, more frequently without a partner, and had abortions at ≥14 weeks of gestation, compared with women with maternal near miss (MNM). Curettage was the most common mode of uterine evacuation. The provision of blood products and therapeutic antibiotics were the most common other interventions recorded for all women with abortion-related SMOs; those who died more frequently had antibiotics, laparotomy, and hysterectomy, compared with women with MNM. Although haemorrhage was the most common cause of abortion-related SMO, infection (alone and in combination with haemorrhage) was the most common cause of death. CONCLUSION: This analysis affirms a number of previously observed characteristics of women with abortion-related severe morbidity and mortality, despite the fact that facility-based data on abortion-related SMO suffers a number of limitations.

Indirect causes of severe adverse maternal outcomes: a secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: To assess the proportion of severe maternal outcomes resulting from indirect causes, and to determine pregnancy outcomes of women with indirect causes. DESIGN: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health. SETTING: A total of 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East. SAMPLE: A total of 314 623 pregnant women admitted to the participating facilities. METHODS: We identified the percentage of women with severe maternal outcomes arising from indirect causes. We evaluated the risk of severe maternal and perinatal outcomes in women with, versus without, underlying indirect causes, using adjusted odds ratios and 95% confidence intervals, by a multilevel, multivariate logistic regression model, accounting for clustering effects within countries and health facilities. MAIN OUTCOME MEASURES: Severe maternal outcomes and preterm birth, fetal mortality, early neonatal mortality, perinatal mortality, low birthweight, and neonatal intensive care unit admission. RESULTS: Amongst 314 623 included women, 2822 were reported to suffer from severe maternal outcomes, out of which 20.9% (589/2822; 95% CI 20.1-21.6%) were associated with indirect causes. The most common indirect cause was anaemia (50%). Women with underlying indirect causes showed significantly higher risk of obstetric complications (adjusted odds ratio, aOR, 7.0; 95% CI 6.6-7.4), severe maternal outcomes (aOR 27.9; 95% CI 24.7-31.6), and perinatal mortality (aOR 3.8; 95% CI 3.5-4.1). CONCLUSIONS: Indirect causes were responsible for about one-fifth of severe maternal outcomes. Women with underlying indirect causes had significantly increased risks of severe maternal and perinatal outcomes.

Advanced maternal age and pregnancy outcomes: a multicountry assessment.

OBJECTIVE: To assess the association between advanced maternal age (AMA) and adverse pregnancy outcomes. DESIGN: Secondary analysis of the facility-based, cross-sectional data of the WHO Multicountry Survey on Maternal and Newborn Health. SETTINGS: A total of 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East. SAMPLE: A total of 308 149 singleton pregnant women admitted to the participating health facilities. METHODS: We estimated the prevalence of pregnant women with advanced age (35 years or older). We calculated adjusted odds ratios of individual severe maternal and perinatal outcomes in these women, compared with women aged 20-34 years, using a multilevel, multivariate logistic regression model, accounting for clustering effects within countries and health facilities. The confounding factors included facility and individual characteristics, as well as country (classified by maternal mortality ratio level). MAIN OUTCOME MEASURES: Severe maternal adverse outcomes, including maternal near miss (MNM), maternal death (MD), and severe maternal outcome (SMO), and perinatal outcomes, including preterm birth (<37 weeks of gestation), stillbirths, early neonatal mortality, perinatal mortality, low birthweight (<2500 g), and neonatal intensive care unit (NICU) admission. RESULTS: The prevalence of pregnant women with AMA was 12.3% (37 787/308 149). Advanced maternal age significantly increased the risk of maternal adverse outcomes, including MNM, MD, and SMO, as well as the risk of stillbirths and perinatal mortalities. CONCLUSIONS: Advanced maternal age predisposes women to adverse pregnancy outcomes. The findings of this study would facilitate antenatal counselling and management of women in this age category.

Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health.

OBJECTIVE: We aimed to determine the prevalence and risks of late fetal deaths (LFDs) and early neonatal deaths (ENDs) in women with medical and obstetric complications. DESIGN: Secondary analysis of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS). SETTING: A total of 359 participating facilities in 29 countries. POPULATION: A total of 308 392 singleton deliveries. METHODS: We reported on perinatal indicators and determined risks of perinatal death in the presence of severe maternal complications (haemorrhagic, infectious, and hypertensive disorders, and other medical conditions). MAIN OUTCOME MEASURES: Fresh and macerated LFDs (defined as stillbirths ≥ 1000 g and/or ≥28 weeks of gestation) and ENDs. RESULTS: The LFD rate was 17.7 per 1000 births; 64.8% were fresh stillbirths. The END rate was 8.4 per 1000 liveborns; 67.1% occurred by day 3 of life. Maternal complications were present in 22.9, 27.7, and 21.2% [corrected] of macerated LFDs, fresh LFDs, and ENDs, respectively. The risks of all three perinatal mortality outcomes were significantly increased with placental abruption, ruptured uterus, systemic infections/sepsis, pre-eclampsia, eclampsia, and severe anaemia. CONCLUSIONS: Preventing intrapartum-related perinatal deaths requires a comprehensive approach to quality intrapartum care, beyond the provision of caesarean section. Early identification and management of women with complications could improve maternal and perinatal outcomes.

Lifecourse health development: past, present and future.

During the latter half of the twentieth century, an explosion of research elucidated a growing number of causes of disease and contributors to health. Biopsychosocial models that accounted for the wide range of factors influencing health began to replace outmoded and overly simplified biomedical models of disease causation. More recently, models of lifecourse health development (LCHD) have synthesized research from biological, behavioral and social science disciplines, defined health development as a dynamic process that begins before conception and continues throughout the lifespan, and paved the way for the creation of novel strategies aimed at optimization of individual and population health trajectories. As rapid advances in epigenetics and biological systems research continue to inform and refine LCHD models, our healthcare delivery system has struggled to keep pace, and the gulf between knowledge and practice has widened. This paper attempts to chart the evolution of the LCHD framework, and illustrate its potential to transform how the MCH system addresses social, psychological, biological, and genetic influences on health, eliminates health disparities, reduces chronic illness, and contains healthcare costs. The LCHD approach can serve to highlight the foundational importance of MCH, moving it from the margins of national debate to the forefront of healthcare reform efforts. The paper concludes with suggestions for innovations that could accelerate the translation of health development principles into MCH practice.

Integrating the life course into MCH service delivery: from theory to practice.

To describe the efforts of a community-based maternal and child health coalition to integrate the life course into its planning and programs, as well as implementation challenges and results of these activities. Jacksonville-Duval County has historically had infant mortality rates that are significantly higher than state and national rates, particularly among its African American population. In an effort to address this disparity, the Northeast Florida Healthy Start Coalition embraced the life course approach as a model. This model was adopted as a framework for (1) community needs assessment and planning; (2) delivery of direct services, including case management, education and support in the Magnolia Project, its federal Healthy Start program; (3) development of community collaborations, education and awareness; and, (4) advocacy and grass roots leadership development. Implementation experience as well as challenges in transforming traditional approaches to delivering maternal and child health services are described. Operationalizing the life course approach required the Coalition to think differently about risks, levels of intervention and the way services are organized and delivered. The organization set the stage by using the life course as a framework for its required local planning and needs assessments. Based on these assessments, the content of case management and other key services provided by our federal Healthy Start program was modified to address not only health behaviors but also underlying social determinants and community factors. Individual interventions were augmented with group activities to build interdependence among participants, increasing social capital. More meaningful inter-agency collaboration that moved beyond the usual referral relationships were developed to better address participants' needs. And finally, strategies to cultivate participant advocacy and community leadership skills, were implemented to promote social change at the neighborhood-level. Transforming traditional approaches to delivering maternal and child health services and sustaining change is a long and laborious process. The Coalition has taken the first steps; but its efforts are far from complete. Based on the agency's initial implementation experience, three areas presented particular challenges: staff, resources and evaluation. The life course is an important addition to the MCH toolbox. Community-based MCH programs should assess how a life course approach can be incorporated into existing programs to broaden their focus, and, potentially, their impact on health disparities and birth outcomes. Some areas to consider include planning and needs assessment, direct service delivery, inter-agency collaboration, and community leadership development. Continued disparities for people of color, despite medical advances, demand new interventions that purposefully address social inequities and promote advocacy among groups that bear a disproportionate burden of infant mortality. Successful transformation of current approaches requires investment in staff training to garner buy-in, flexible resources and the development of new metrics to measure the impact of the life course approach on individual and programmatic outcomes.

Building Economic Security Today: making the health-wealth connection in Contra Costa county's maternal and child health programs.

In recent years, maternal and child health professionals have been seeking approaches to integrating the Life Course Perspective and social determinants of health into their work. In this article, we describe how community input, staff feedback, and evidence from the field that the connection between wealth and health should be addressed compelled the Contra Costa Family, Maternal and Child Health (FMCH) Programs Life Course Initiative to launch Building Economic Security Today (BEST). BEST utilizes innovative strategies to reduce inequities in health outcomes for low-income Contra Costa families by improving their financial security and stability. FMCH Programs' Women, Infants, and Children Program (WIC) conducted BEST financial education classes, and its Medically Vulnerable Infant Program (MVIP) instituted BEST financial assessments during public health nurse home visits. Educational and referral resources were also developed and distributed to all clients. The classes at WIC increased clients' awareness of financial issues and confidence that they could improve their financial situations. WIC clients and staff also gained knowledge about financial resources in the community. MVIP's financial assessments offered clients a new and needed perspective on their financial situations, as well as support around the financial and psychological stresses of caring for a child with special health care needs. BEST offered FMCH Programs staff opportunities to engage in non-traditional, cross-sector partnerships, and gain new knowledge and skills to address a pressing social determinant of health. We learned the value of flexible timelines, maintaining a long view for creating change, and challenging the traditional paradigm of maternal and child health.

Nature and frequency of services provided by child and family health nurses in Australia: results of a national survey.

OBJECTIVE: Australia has a system of universal child and family health (CFH) nursing services providing primary health services from birth to school entry. Herein, we report on the findings of the first national survey of CFH nurses, including the ages and circumstances of children and families seen by CFH nurses and the nature and frequency of the services provided by these nurses across Australia. METHODS: A national survey of CFH nurses was conducted. RESULTS: In all, 1098 CFH nurses responded to the survey. Over 60% were engaged in delivering primary prevention services from a universal platform. Overall, 82.8% reported that their service made first contact with families within 2 weeks of birth, usually in the home (80.7%). The proportion of respondents providing regular support to families decreased as the child aged. Services were primarily health centre based, although 25% reported providing services in other locations (parks, preschools).The timing and location of first contact, the frequency of ongoing services and the composition of families seen by nurses varied across Australian jurisdictions. Nurses identified time constraints as the key barrier to the delivery of comprehensive services. CONCLUSIONS: CFH nurses play an important role in supporting families across Australia. The impact of differences in the CFH nursing provision across Australia requires further investigation. What is known about the topic? Countries that offer universal well child health services demonstrate better child health and developmental outcomes than countries that do not. Australian jurisdictions offer free, universal child and family health (CFH) nursing services from birth to school entry. What does this paper add? This paper provides nation-wide data on the nature of work undertaken by CFH nurses offering universal care. Across Australia, there are differences in the timing and location of first contact, the frequency of ongoing services and the range of families seen by nurses. What are the implications for practitioners? The impact for families of the variation in CFH nursing services offered across Australia is not known. Further research is required to investigate the outcomes of the service provision variations identified in the present study.

Externalities of prevention of mother-to-child transmission programs: a systematic review.

There has been considerable debate about the effects of targeted global health assistance in low- and middle-income countries on health systems, specifically HIV/AIDS funding. Recently, a handful of studies have emerged that describe the implementation of PMTCT programs, which have many theoretical links to maternal and child health. Through a systematic review of research published between January 2000 and March 2011, this paper synthesizes evidence evaluating the impact of these programs. We assessed 5,855 papers, reviewed 154, and included 21 articles. They offer evidence of beneficial synergies between PMTCT programs and both STI prevention and early childhood immunization. Other data, including information about antenatal and delivery care, family planning, and nutrition supplementation varied considerably across studies demonstrating both positive and negative effects of PMTCT. More research is needed to allow countries and funders to make informed decisions regarding allocation of limited funds to targeted versus broad categories of health care.

The Ghana essential health interventions program: a plausibility trial of the impact of health systems strengthening on maternal & child survival.

BACKGROUND: During the 1990s, researchers at the Navrongo Health Research Centre in northern Ghana developed a highly successful community health program. The keystone of the Navrongo approach was the deployment of nurses termed community health officers to village locations. A trial showed that, compared to areas relying on existing services alone, the approach reduced child mortality by half, maternal mortality by 40%, and fertility by nearly a birth - from a total fertility rate of 5.5 in only five years. In 2000, the government of Ghana launched a national program called Community-based Health Planning and Services (CHPS) to scale up the Navrongo model. However, CHPS scale-up has been slow in districts located outside of the Upper East Region, where the "Navrongo Experiment" was first carried out. This paper describes the Ghana Essential Health Intervention Project (GEHIP), a plausibility trial of strategies for strengthening CHPS, especially in the areas of maternal and newborn health, and generating the political will to scale up the program with strategies that are faithful to the original design. DESCRIPTION OF THE INTERVENTION: GEHIP improves the CHPS model by 1) extending the range and quality of services for newborns; 2) training community volunteers to conduct the World Health Organization service regimen known as integrated management of childhood illness (IMCI); 3) simplifying the collection of health management information and ensuring its use for decision making; 4) enabling community health nurses to manage emergencies, particularly obstetric complications and refer cases without delay; 5) adding $0.85 per capita annually to district budgets and marshalling grassroots political commitment to financing CHPS implementation; and 6) strengthening CHPS leadership at all levels of the system. EVALUATION DESIGN: GEHIP impact is assessed by conducting baseline and endline survey research and computing the Heckman "difference in difference" test for under-5 mortality in three intervention districts relative to four comparison districts for core indicators of health status and survival rates. To elucidate results, hierarchical child survival hazard models will be estimated that incorporate measures of health system strength as survival determinants, adjusting for the potentially confounding effects of parental and household characteristics. Qualitative systems appraisal procedures will be used to monitor and explain GEHIP implementation innovations, constraints, and progress. DISCUSSION: By demonstrating practical means of strengthening a real-world health system while monitoring costs and assessing maternal and child survival impact, GEHIP is expected to contribute to national health policy, planning, and resource allocation that will be needed to accelerate progress with the Millennium Development Goals.

Predictors of mortality of extremely low birthweight babies in a tertiary care centre of a developing country.

INTRODUCTION: Perinatal care has changed dramatically over last decade contributing to improved survival of extremely low birthweight (ELBW) babies. OBJECTIVE: We conducted the present study with the objective to identify immediate obstetric causes of preterm delivery; analyse the maternal risk factors and to evaluate the morbidity and mortality of ELBW babies delivered in our hospital. The results were compared with those of 10 years ago from the same hospital to determine whether there has been any significant change in the predictors of mortality METHODS: A retrospective analysis of case records of 283 ELBW babies delivered in our hospital over a period of 24 months from 1 April 2010 to 31 March 2012 was conducted. RESULTS: The total neonatal mortality rate was 38.7%. 85 babies (30%) were small for gestational age. Mean gestational age and mean birth weight was 28.5 weeks and 883.4 g, respectively. Using multivariate logistic regression analysis, significant risk factors for neonatal mortality in mothers were anaemia (p=0.00001, OR 3.13, CI 1.756 to 5.56), inadequate antenatal care (p=0.00001, OR 4.74, CI 2.59 to 8.69) premature rupture of membrane with antenatal antibiotic usage (p=0.003, OR 3.375, CI 1.512 to 7.53. Risk factors for mortality in babies were male sex (p=0.08, OR 3.48 CI 1.4 to 8.8), lower birth weight (p=0.000005), lower gestational age (p=0.00001) use of respiratory support in the form of continuous positive airway pressure (p=0.03), or mechanical ventilation (p=0.00001) and pulmonary or intraventricular haemorrhage (p=0.0001). CONCLUSIONS: Babies with lower gestational age lower birth weight and those babies whose mothers had not received adequate antenatal care or antenatal steroids had worse prognosis.

What constitutes 'support' for the role of the Aboriginal and Torres Strait Islander child health workforce?

As well as providing primary health care services, Aboriginal and Torres Strait Islander health workers are known to significantly contribute to the overall acceptability, access and use of health services through their role of cultural brokerage in the communities within which they work. As such they are uniquely positioned to positively influence health improvements for this vulnerable population. This study sought to identify key areas that both Aboriginal and Torres Strait Islander and non-Indigenous health professionals working within Indigenous communities felt were important in providing support for their roles. This group of workers require support within their roles particularly in relation to cultural awareness and capability, resource provision, educational opportunities, collaboration with colleagues and peers, and professional mentorship.

Courses in reproductive and child health in India: an overview.

Defining the human resource needs for providing quality maternal, newborn, and child health services across such a large and diverse population country like India is truly challenging. The effective response to significant challenges and increased requirements of evidence-based effectiveness of the public health projects on maternal and child health is putting pressure on existing program managers to acquire new advanced academic training and information. The data regarding the existing courses on reproductive and child health and related fields in the country were obtained by a predefined search made on the Internet through the Google search engine in December 2011. The collected data were the name and location of the institution offering the respective course, theme, course duration, course structure, eligibility criteria, and mode of learning. In India, around 15 institutes are offering certificate/postgraduate diploma courses on maternal and child health either as a regular program or through distance education program. The admission procedure for each institute is independent of others. The courses vary in terms of duration, eligibility criteria, and fee structure. Conceptualizing an educational initiative in response to national demands for increased workforce capacity to eliminate key medical and nonmedical educational barriers and financial and nonfinancial barriers to advanced academic preparation would enhance the quality of services available in the region.

Service users and care providers' experiences of tertiary combined fetal medicine clinics.

OBJECTIVE: To explore service users and care providers' experiences of combined fetal medicine and specialist paediatric clinics. METHOD: A brief survey of service users and care providers at combined fetal medicine clinics, which bring together multiple specialists and expertise for the management of pregnancies complicated by fetal cardiac, renal, neurological or surgical abnormalities. RESULTS: Two hundred and sixty-one patients and 22 health professionals participated. More than 85% of women rated the clinic highly, 61% reported that the service had changed how they viewed the abnormality, and 53% reported that they would welcome further visits to the combined clinic. The majority of health professionals reported that combined clinics improved the accuracy of parental counselling and enhanced communication between specialties involved in the management of complicated pregnancies. The clinics are generally regarded as being useful for the training of junior staff. CONCLUSION: A service model that combines fetal medicine and paediatric specialists in a single clinic can efficiently modify parental perspective on fetal anomalies and enhance professional communication and training. Condition-specific information leaflets could further enhance service quality. A larger study involving a socio-demographically stratified sample of service users is needed to provide more authoritative data.

Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries.

BACKGROUND: A maternity waiting home (MWH) is a facility within easy reach of a hospital or health centre which provides emergency obstetric care (EmOC). Women may stay in the MWH at the end of their pregnancy and await labour. Once labour starts, women move to the health facility so that labour and giving birth can be assisted by a skilled birth attendant. The aim of the MWH is to improve accessibility to skilled care and thus reduce morbidity and mortality for mother and neonate should complications arise. Some studies report a favourable effect on the outcomes for women and their newborns. Others show that utilisation is low and barriers exist. However, these data are limited in their reliability. OBJECTIVES: To assess the effects of a maternity waiting facility on maternal and perinatal health. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 January 2012), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to January 2012), EMBASE (1980 to January 2012), CINAHL (1982 to January 2012), African Journals Online (AJOL) (January 2012), POPLINE (January 2012), Dissertation Abstracts (January 2012) and reference lists of retrieved papers. SELECTION CRITERIA: Randomised controlled trials including quasi-randomised and cluster-randomised trials that compared perinatal and maternal outcome in women using a MWH and women who did not. DATA COLLECTION AND ANALYSIS: There were no randomised controlled trials or cluster-randomised trials identified from the search. MAIN RESULTS: There were no randomised controlled trials or cluster-randomised trials identified from the search. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine the effectiveness of maternity waiting facilities for improving maternal and neonatal outcomes.