Lawmakers' use of scientific evidence can be improved.

Core to the goal of scientific exploration is the opportunity to guide future decision-making. Yet, elected officials often miss opportunities to use science in their policymaking. This work reports on an experiment with the US Congress-evaluating the effects of a randomized, dual-population (i.e., researchers and congressional offices) outreach model for supporting legislative use of research evidence regarding child and family policy issues. In this experiment, we found that congressional offices randomized to the intervention reported greater value of research for understanding issues than the control group following implementation. More research use was also observed in legislation introduced by the intervention group. Further, we found that researchers randomized to the intervention advanced their own policy knowledge and engagement as well as reported benefits for their research following implementation.

Maternal multimorbidity - experiences of women seeking asylum during pregnancy and after childbirth: a qualitative study.

BACKGROUND: Many women seeking asylum during pregnancy and after childbirth have ill-health but detection and assessment of all physical, psychological, and social health needs (maternal multimorbidity) are often difficult as part of routine maternity care. Healthcare providers are key for the early identification and management of vulnerable pregnant women who have additional physical, psychological, and social health needs. We sought to explore the impact of the asylum-seeking process, understanding of wellbeing, expressed health needs (in terms of maternal multimorbidity), and the experiences of maternity care of women seeking asylum during pregnancy and after childbirth in Liverpool, United Kingdom. Enabling factors and barriers to access woman-centred care were also explored. METHODS: Key informant interviews (n = 10) and one focus group discussion (n = 4) were conducted with women attending a non-profit charitable pregnancy support group. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes. RESULTS: The asylum-seeking process negatively impacted women making them feel anxious and depressed with little control or choice over their future. Women reported feeling stressed regarding poor standard of accommodation, low income, dispersal and the uncertainty of their asylum application outcome. Wellbeing during pregnancy and after childbirth was understood to be multifactorial and women understood that their physical health needs were interlinked and negatively impacted by complex psychological and social factors. Women reported that their expectations of maternity services were often exceeded, but information giving, and the use of language interpreters needed to be improved. Women expressed the need for more psychological and social support throughout pregnancy and after childbirth. CONCLUSIONS: A multidisciplinary team, with links and effective referral pathways to maternal mental health and social services, are necessary for women seeking asylum, to ensure a more integrated, comprehensive assessment of maternal multimorbidity and to provide maternity care in a way that meets all health needs.

The prevalence of mental ill-health in women during pregnancy and after childbirth during the Covid-19 pandemic: a systematic review and Meta-analysis.

BACKGROUND: This systematic review aims to explore the prevalence of the impact of the COVID-19, MERS, and SARS pandemics on the mental health of pregnant women. METHODS: All COVID-19, SARS and MERS studies that evaluated the mental health of pregnant women with/without gynaecological conditions that were reported in English between December 2000 - July 2021 were included. The search criteria were developed based upon the research question using PubMed, Science Direct, Ovid PsycINFO and EMBASE databases. A wide search criterion was used to ensure the inclusion of all pregnant women with existing gynaecological conditions. The Newcastle-Ottawa-Scale was used to assess the risk of bias for all included studies. Random effects model with restricted maximum-likelihood estimation method was applied for the meta-analysis and I-square statistic was used to evaluate heterogeneity across studies. The pooled prevalence rates of symptoms of anxiety, depression, PTSD, stress, and sleep disorders with 95% confidence interval (CI) were computed. RESULTS: This systematic review identified 217 studies which included 638,889 pregnant women or women who had just given birth. There were no studies reporting the mental health impact due to MERS and SARS. Results showed that women who were pregnant or had just given birth displayed various symptoms of poor mental health including those relating to depression (24.9%), anxiety (32.8%), stress (29.44%), Post Traumatic Stress Disorder (PTSD) (27.93%), and sleep disorders (24.38%) during the COVID-19 pandemic. DISCUSSION: It is important to note that studies included in this review used a range of outcome measures which does not allow for direct comparisons between findings. Most studies reported self-reported measure of symptoms without clinical diagnoses so conclusions can be made for symptom prevalence rather than of mental illness. The importance of managing mental health during pregnancy and after-delivery improves the quality of life and wellbeing of mothers hence developing an evidence-based approached as part of pandemic preparedness would improve mental health during challenging times. OTHER: The work presented in this manuscript was not funded by any specific grants. A study protocol was developed and published in PROSPERO (CRD42021235356) to explore several key objectives.

Screening for infectious maternal morbidity - knowledge, attitudes and perceptions among healthcare providers and managers in Malawi: a qualitative study.

BACKGROUND: Maternal morbidity and mortality related to infection is an international public health concern, but detection and assessment is often difficult as part of routine maternity care in many low- and middle-income countries due to lack of easily accessible diagnostics. Front-line healthcare providers are key for the early identification and management of the unwell woman who may have infection. We sought to investigate the knowledge, attitudes, and perceptions of the use of screening tools to detect infectious maternal morbidity during and after pregnancy as part of routine antenatal and postnatal care. Enabling factors, barriers, and potential management options for the use of early warning scores were explored. METHODS: Key informant interviews (n = 10) and two focus group discussions (n = 14) were conducted with healthcare providers and managers (total = 24) working in one large tertiary public hospital in Blantyre, Malawi. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes. RESULTS: Most healthcare providers are aware of the importance of the early detection of infection and would seek to better identify women with infection if resources were available to do so. In current practice, an early warning score was used in the high dependency unit only. Routine screening was not in place in the antenatal or postnatal departments. Barriers to implementing routine screening included lack of trained staff and time, lack of thermometers, and difficulties with the interpretation of the early warning scores. A locally adapted early warning screening tool was considered an enabler to implementing routine screening for infectious morbidity. Local ownership and clinical leadership were considered essential for successful and sustainable implementation for clinical change. CONCLUSIONS: Although healthcare providers considered infection during and after pregnancy and childbirth a danger sign and significant morbidity, standardised screening for infectious maternal morbidity was not part of routine antenatal or postnatal care. The establishment of such a service requires the availability of free and easy to access rapid diagnostic testing, training in interpretation of results, as well as affordable targeted treatment. The implementation of early warning scores and processes developed in high-income countries need careful consideration and validation when applied to women accessing care in low resource settings.

How women's experiences and perceptions of care influence uptake of postnatal care across sub-Saharan Africa: a qualitative systematic review.

BACKGROUND: The burden of maternal and neonatal morbidity and mortality is a global health concern with the highest burden documented after childbirth in women and babies living in sub-Saharan Africa. To date, there is limited information on the quality of postnatal care and/or whether evidence-based interventions to improve postnatal care in a way that meets the specific health needs of each mother and her baby have been lacking. There is also limited data related to how quality of care (respectful or disrespectful) influences women's decision to access postnatal care. OBJECTIVE: To systematically review available qualitative evidence for how quality of care (respectful or disrespectful) influences perceptions and experiences of, and decisions to, access postnatal care for women living in sub-Saharan Africa. SEARCH STRATEGY: CINAHL plus, Cochrane library, Global Health, Medline, PubMed, Web of Science were searched from 2009-2019. Grey literature was searched on Google Scholar. SELECTION CRITERIA: Qualitative literature in English describing women's perceptions and experiences of the quality of care they received after childbirth and how this influenced their perceptions of and decisions to access postnatal care. DATA ANALYSIS: Thematic analysis was performed to extract subthemes and themes. Outcomes were themes from the qualitative data used to form a thematic synthesis. RESULTS: Fifteen studies were included with data from 985 women interviewed face-to-face across eight countries. Descriptions of respectful care included healthcare providers being kind, supportive and attentive to women's needs. Women described preferring healthcare services where the healthcare providers communicated in a respectful and caring manner. Descriptions of disrespectful care included verbal and/or physical abuse and power imbalances between women and healthcare providers. Some women were denied postnatal care when attending a healthcare facility after giving birth at home. There is evidence to suggest that vulnerable women (adolescents; women with poor socioeconomic status; women who are HIV positive) are more likely to receive disrespectful care. CONCLUSIONS: This systematic review describes how aspects of respectful and disrespectful maternity care influence women's perceptions and experiences of, and decisions to access postnatal care services. There is a need for a renewed focus to prioritise respectful maternity care and to sustainably provide good quality postnatal care to all women and their babies in a way that meets their expectations and health needs.

Maternal multimorbidity during pregnancy and after childbirth in women in low- and middle-income countries: a systematic literature review.

BACKGROUND: For every maternal death, 20 to 30 women are estimated to have morbidities related to pregnancy or childbirth. Much of this burden of disease is in women in low- and middle-income countries. Maternal multimorbidity can include physical, psychological and social ill-health. Limited data exist about the associations between these morbidities. In order to address all health needs that women may have when attending for maternity care, it is important to be able to identify all types of morbidities and understand how each morbidity influences other aspects of women's health and wellbeing during pregnancy and after childbirth. METHODS: We systematically reviewed published literature in English, describing measurement of two or more types of maternal morbidity and/or associations between morbidities during pregnancy or after childbirth for women in low- and middle-income countries. CINAHL plus, Global Health, Medline and Web of Science databases were searched from 2007 to 2018. Outcomes were descriptions, occurrence of all maternal morbidities and associations between these morbidities. Narrative analysis was conducted. RESULTS: Included were 38 papers reporting about 36 studies (71,229 women; 60,911 during pregnancy and 10,318 after childbirth in 17 countries). Most studies (26/36) were cross-sectional surveys. Self-reported physical ill-health was documented in 26 studies, but no standardised data collection tools were used. In total, physical morbidities were included in 28 studies, psychological morbidities in 32 studies and social morbidities in 27 studies with three studies assessing associations between all three types of morbidity and 30 studies assessing associations between two types of morbidity. In four studies, clinical examination and/or basic laboratory investigations were also conducted. Associations between physical and psychological morbidities were reported in four studies and between psychological and social morbidities in six. Domestic violence increased risks of physical ill-health in two studies. CONCLUSIONS: There is a lack of standardised, comprehensive and routine measurements and tools to assess the burden of maternal multimorbidity in women during pregnancy and after childbirth. Emerging data suggest significant associations between the different types of morbidity. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42018079526.

Interventions for women who report domestic violence during and after pregnancy in low- and middle-income countries: a systematic literature review.

BACKGROUND: Domestic violence is a leading cause of social morbidity and may increase during and after pregnancy. In high-income countries screening, referral and management interventions are available as part of standard maternity care. Such practice is not routine in low- and middle-income countries (LMIC) where the burden of social morbidity is high. METHODS: We systematically reviewed available evidence describing the types of interventions, and/or the effectiveness of such interventions for women who report domestic violence during and/or after pregnancy, living in LMIC. Published and grey literature describing interventions for, and/or effectiveness of such interventions for women who report domestic violence during and/or after pregnancy, living in LMIC was reviewed. Outcomes assessed were (i) reduction in the frequency and/or severity of domestic violence, and/or (ii) improved physical, psychological and/or social health. Narrative analysis was conducted. RESULTS: After screening 4818 articles, six studies were identified for inclusion. All included studies assessed women (n = 894) during pregnancy. Five studies reported on supportive counselling; one study implemented an intervention consisting of routine screening for domestic violence and supported referrals for women who required this. Two studies evaluated the effectiveness of the interventions on domestic violence with statistically significant decreases in the occurrence of domestic violence following counselling interventions (488 women included). There was a statistically significant increase in family support following counselling in one study (72 women included). There was some evidence of improvement in quality of life, increased use of safety behaviours, improved family and social support, increased access to community resources, increased use of referral services and reduced maternal depression. Overall evidence was of low to moderate quality. CONCLUSIONS: Screening, referral and supportive counselling is likely to benefit women living in LMIC who experience domestic violence. Larger-scale, high-quality research is, however, required to provide further evidence for the effectiveness of interventions. Improved availability with evaluation of interventions that are likely to be effective is necessary to inform policy, programme decisions and resource allocation for maternal healthcare in LMIC. TRIAL REGISTRATION: Systematic review registration number: PROSPERO CRD42018087713.

Maternal morbidity: a longitudinal study of women's health during and up to 22 months after pregnancy in Jamaica.

Our study evaluated factors associated with ill-health in a population-based longitudinal study of women who delivered a singleton live-born baby in a 3-month period across Jamaica. Socio-demographics, perception of health, chronic illnesses, frequency and reasons for hospital admission were assessed. Relationships between ill-health and maternal characteristics were estimated using log-normal regression analysis. Of 9,742 women interviewed at birth, 1,311 were assessed at four stages, 27.7% of whom reported ill-health at least once. Hospitalization rates were 20.9% during pregnancy, 6.1% up to 12 months and 0.5% up to 22 months after childbirth. Ill-health, reported by 11% of women, was less likely with better education (RR=0.62, 95%; 0.42-0.84). Hospital admission was associated with higher socio-economic status (RR=1.33, 95% 1.04-1.70) and Caesarean section [CS] (RR=1.57, 95%; 1.21-2.04). One in three (33.7%) women reported chronic illnesses, and the likelihood increased with age, parity and delivery by elective CS (RR=1.44, 95%; 1.20-1.73). In multivariable analyses, ill-health was more likely with chronic illness (RR=2.06, 95%; CI: 1.71-2.48) and hospital admission from 12 to 22 months after childbirth (RR=1.54, 95% CI: 1.12-2.12). Ill-health during pregnancy and after childbirth represent a significant burden of disease and requires a standardised comprehensive approach to measuring and addressing this disease burden.

Correction to: "I just wish it becomes part of routine care": healthcare providers' knowledge, attitudes and perceptions of screening for maternal mental health during and after pregnancy: a qualitative study.

Following publication of the original article [1], we have been notified of a few mistakes in the display of the author names. The publisher apologizes for the inconvenience.

"I just wish it becomes part of routine care": healthcare providers' knowledge, attitudes and perceptions of screening for maternal mental health during and after pregnancy: a qualitative study.

BACKGROUND: Maternal mental health is an international public health concern. Many women experience mental ill-health during and after pregnancy, but assessment is not part of routine maternity care in many low- and middle-income countries. Healthcare providers are in a position to identify and support women who experience mental health disorders during and after pregnancy. We sought to investigate the knowledge, attitudes and perceptions of routine screening for maternal mental health during and after pregnancy among healthcare providers providing routine maternity care in Accra, Ghana. Enabling factors, barriers and potential management options to routinely screen maternal mental health during and after pregnancy were explored. METHODS: Semi-structured key informant interviews (n = 20) and one focus group discussion (n = 4) were conducted with healthcare providers working in one public hospital in Accra, Ghana. Transcribed interviews were coded by topic and then grouped into categories. Thematic framework analysis was undertaken to identify emerging themes. RESULTS: Most healthcare providers are aware of the importance of maternal mental health and would be keen to help women who experience mental ill-health during and after pregnancy, if resources were available to do so. An enabling factor was the suggestion of introducing a culturally appropriate mental health screening tool. However, compromised mental health was often considered a 'spiritual issue' and not routinely screened for by healthcare providers, nor requested by women. Barriers to the provision of quality maternal mental health care included lack of trained staff and lack of time. CONCLUSIONS: Healthcare providers are aware of the problem of the lack of maternal mental health provision during and after pregnancy and are open to developing protocols to improve care. Currently, screening for maternal mental ill-health is not part of routine maternity care. The establishment of such a service requires the reprioritisation of workloads, further training, and a change in the attitudes and practices of healthcare providers. Education to change the attitudes of healthcare providers, women and the wider community towards mental health is needed. The development and implementation of culturally appropriate guidelines would be beneficial and result in better quality of maternity care.

Patient reported outcome measures for use in pregnancy and childbirth: a systematic review.

BACKGROUND: Globally, an increasing number of women give birth in a healthcare facility. Improvement in the quality of care is crucial if preventable maternal mortality and morbidity are to be reduced. A Patient Reported Outcome Measure (PROM) can be used to measure quality of care and provide new information on the impact that treatment or interventions have on patient's self-assessed health and health-related quality of life. We conducted a systematic review to identify which condition-specific PROMs are currently available for use in pregnancy and childbirth, and to evaluate whether these could potentially be used to assess the quality of care provided for women using maternity services. METHODS: We searched for articles relating to the use of PROMs related to care during pregnancy, childbirth, the postnatal period and women's health more generally using PsycINFO, CINAHL, Medline and Web of Science databases as well as "grey literature", with no date limit. Any PROM identified was reviewed with regards to development, use, and potential applicability to assess quality of maternity care provision. A narrative synthesis was used to summarise findings. RESULTS: Six papers were identified; two related to aspects of pregnancy (hyperemesis gravidarum and gestational diabetes), and four related to childbirth and the postnatal period (obstetric haemorrhage and postnatal depression). Within these papers, a total of 14 different tools were identified, which assessed a variety of aspects of physical, psychological and social health, or were generic tools, not specific to childbirth. One PROM addressed childbirth generally, however, it did not ask for or provide specific outcome measures but required women to identify and then assess what they considered the most important areas in their life affected by childbirth. CONCLUSIONS: To date, there is no PROM agreed which would be suitable as patient reported outcome measure for the assessment of the quality of care women receive during pregnancy or after childbirth. However, there are a variety of available assessment tools which could potentially be helpful in developing new and existing PROMs for maternity care.

Using electronic tablets for data collection for healthcare service and maternal health assessments in low resource settings: lessons learnt.

BACKGROUND: Health service and health outcome data collection across many low- and middle-income countries (LMICs) is, to date largely paper-based. With the development and increased availability of reliable technology, electronic tablets could be used for electronic data collection in such settings. This paper describes our experiences with implementing electronic data collection methods, using electronic tablets, across different settings in four LMICs. METHODS: Within our research centre, the use of electronic data collection using electronic tablets was piloted during a healthcare facility assessment study in Ghana. After further development, we then used electronic data collection in a multi-country, cross-sectional study to measure ill-health in women during and after pregnancy, in India, Kenya and Pakistan. All data was transferred electronically to a central research team in the UK where it was processed, cleaned, analysed and stored. RESULTS: The healthcare facility assessment study in Ghana demonstrated the feasibility and acceptability to healthcare providers of using electronic tablets to collect data from seven healthcare facilities. In the maternal morbidity study, electronic data collection proved to be an effective way for healthcare providers to document over 400 maternal health variables, in 8530 women during and after pregnancy in India, Kenya and Pakistan. CONCLUSIONS: Electronic data collection provides an effective platform which can be used successfully to collect data from healthcare facility registers and from patients during health consultations; and to transfer large quantities of data. To ensure successful electronic data collection and transfer between settings, we recommend that close attention is paid to study design, data collection, tool design, local internet access and device security.

"We know it's labour pain, so we don't do anything": healthcare provider's knowledge and attitudes regarding the provision of pain relief during labour and after childbirth.

BACKGROUND: Most women experience pain during labour and after childbirth. There are various options, both pharmacological and non-pharmacological, available to help women cope with and relieve pain during labour and after childbirth. In low resource settings, women often do not have access to effective pain relief. Healthcare providers have a duty of care to support women and improve quality of care. We investigated the knowledge and attitudes of healthcare providers regarding the provision of pain relief options in a hospital in Moshi, Tanzania. METHODS: Semi-structured key informant interviews (n = 24) and two focus group discussions (n = 10) were conducted with healthcare providers (n = 34) in Tanzania. Transcribed interviews were coded and codes grouped into categories. Thematic framework analysis was undertaken to identify emerging themes. RESULTS: Most healthcare providers are aware of various approaches to pain management including both pharmacological and non-pharmacological options. Enabling factors included a desire to help, the common use of non-pharmacological methods during labour and the availability of pharmacological pain relief for women who have had a Caesarean section. Challenges included shortage of staff, lack of equipment, no access to nitrous oxide or epidural medication, and fears regarding the effect of opiates on the woman and/or baby. Half of all healthcare providers consider labour pain as 'natural' and necessary for birth and therefore do not routinely provide pharmacological pain relief. Suggested solutions to increase evidence-based pain management included: creating an enabling environment, providing education, improving the use of available methods (both pharmacological and non-pharmacological), emphasising the use of context-specific protocols and future research to understand how best to provide care that meets women's needs. CONCLUSIONS: Many healthcare providers do not routinely offer pharmacological pain relief during labour and after childbirth, despite availability of some resources. Most healthcare providers are open to helping women and improving quality of pain management using an approach that respects women's culture and beliefs. Women are increasingly accessing care during labour and there is now a window of opportunity to adapt and amend available maternity care packages to include comprehensive provision for pain relief (both pharmacological and non-pharmacological) as an integral component of quality of care.

A survey of healthcare providers' knowledge and attitudes regarding pain relief in labor for women in Ethiopia.

BACKGROUND: To explore healthcare providers' knowledge and attitudes to the need for pain relief for women in labor. METHODS: A structured questionnaire (n = 200) distributed to healthcare providers working in the obstetric departments, including theatres, of three public hospitals in different settings (rural, peri-urban and urban) in Ethiopia. Descriptive analysis was performed using Excel 2013 and SPSS version 22 for associations. RESULTS: The response rate was 81.5% with 164 questionnaires completed. The majority, 79% of respondents, understood that women can feel moderate to severe pain in labor and 77% were of the opinion that labor pain should be relieved. However, common practices included only supportive measures such as breathing and relaxation exercises, back massage and support from family. The general attitude of healthcare providers is that labor is a natural process, women should be able to cope and that pain relief is not a priority for women in labor. More than half, 52% of healthcare providers had safety concerns with using pharmacological methods to relieve pain in labor. CONCLUSION: The majority of healthcare providers understand that women suffer significant pain during labor. However, providing effective pain relief is currently not provided as part of routine intra-partum care in Ethiopia.

"Keeping family matters behind closed doors": healthcare providers' perceptions and experiences of identifying and managing domestic violence during and after pregnancy.

BACKGROUND: Violence against women is an international public health concern and a violation of women's rights. Domestic violence can first occur, and increase in frequency and severity, during and after pregnancy. Healthcare providers have the potential to identify and support women who experience domestic violence. We sought to investigate the knowledge and perceptions of domestic violence among doctors who provide routine antenatal and postnatal care at healthcare facilities in Pakistan. In addition, we explored possible management options from policy makers, and enabling factors of and barriers to the routine screening of domestic violence. METHODS: Semi-structured key informant interviews were conducted with doctors (n = 25) working in public and private hospitals and with officials involved in domestic violence policy development (n = 5) in Islamabad, Pakistan. Transcribed interviews were coded and codes grouped into categories. Thematic framework analysis was undertaken to identify emerging themes. RESULTS: Most doctors have a good awareness of domestic violence and a desire to help women who report domestic violence during and after pregnancy. Enabling factors included doctors' ability to build rapport and trust with women and their suggestion that further education of both healthcare providers and women would be beneficial. However, domestic violence is often perceived as a "family issue" that is not routinely discussed by healthcare providers. Lack of resources, lack of consultation time and lack of effective referral pathways or support were identified as the main barriers to the provision of quality care. CONCLUSIONS: Doctors and policy advisors are aware of the problem and open to screening for domestic violence during and after pregnancy. It is suggested that the provision of a speciality trained family liaison officer or healthcare provider would be beneficial. Clear referral pathways need to be established to provide quality care for these vulnerable women in Pakistan.

Vitamin A supplementation during pregnancy for maternal and newborn outcomes.

BACKGROUND: The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection.   OBJECTIVES: To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies. SELECTION CRITERIA: All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: We reviewed 106 reports of 35 trials, published between 1931 and 2015. We included 19 trials including over 310,000 women, excluded 15 trials and one is ongoing. Overall, seven trials were judged to be of low risk of bias, three were high risk of bias and for nine it was unclear. 1) Vitamin A alone versus placebo or no treatmentOverall, when trial results are pooled, vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.65 to 1.20; four trials Ghana, Nepal, Bangladesh, UK, high quality evidence), perinatal mortality (RR 1.01, 95% CI 0.95 to 1.07; one study, high quality evidence), neonatal mortality, stillbirth, neonatal anaemia, preterm birth (RR 0.98, 95% CI 0.94 to 1.01, five studies, high quality evidence), or the risk of having a low birthweight baby.Vitamin A supplementation reduces the risk of maternal night blindness (RR 0.79, 95% CI 0.64 to 0.98; two trials). There is evidence that vitamin A supplements may reduce maternal clinical infection (RR 0.45, 95% CI 0.20 to 0.99, five trials; South Africa, Nepal, Indonesia, Tanzania, UK, low quality evidence) and maternal anaemia (RR 0.64, 95% CI 0.43 to 0.94; three studies, moderate quality evidence). 2) Vitamin A alone versus micronutrient supplements without vitamin AVitamin A alone compared to micronutrient supplements without vitamin A does not decrease maternal clinical infection (RR 0.99, 95% CI 0.83 to 1.18, two trials, 591 women). No other primary or secondary outcomes were reported 3) Vitamin A with other micronutrients versus micronutrient supplements without vitamin AVitamin A supplementation (with other micronutrients) does not decrease perinatal mortality (RR 0.51, 95% CI 0.10 to 2.69; one study, low quality evidence), maternal anaemia (RR 0.86, 95% CI 0.68 to 1.09; three studies, low quality evidence), maternal clinical infection (RR 0.95, 95% CI 0.80 to 1.13; I² = 45%, two studies, low quality evidence) or preterm birth (RR 0.39, 95% CI 0.08 to 1.93; one study, low quality evidence).In HIV-positive women vitamin A supplementation given with other micronutrients was associated with fewer low birthweight babies (< 2.5 kg) in the supplemented group in one study (RR 0.67, 95% CI 0.47 to 0.96; one study, 594 women). AUTHORS' CONCLUSIONS: The pooled results of three large trials in Nepal, Ghana and Bangladesh (with over 153,500 women) do not currently suggest a role for antenatal vitamin A supplementation to reduce maternal or perinatal mortality. However, the populations studied were probably different with regard to baseline vitamin A status and there were problems with follow-up of women. There is good evidence that antenatal vitamin A supplementation reduces maternal night blindness, maternal anaemia for women who live in areas where vitamin A deficiency is common or who are HIV-positive. In addition the available evidence suggests a reduction in maternal infection, but these data are not of a high quality.

The occurrence of and factors associated with mental ill-health amongst humanitarian aid workers: A systematic review and meta-analysis.

BACKGROUND: Humanitarian crises and disasters affect millions of people worldwide. Humanitarian aid workers are civilians or professionals who respond to disasters and provide humanitarian assistance. In doing so, they face several stressors and traumatic exposures. Humanitarian aid workers also face unique challenges associated with working in unfamiliar settings. OBJECTIVE: To determine the occurrence of and factors associated with mental ill-health among humanitarian aid workers. SEARCH STRATEGY: CINAHL plus, Cochrane library, Global Health, Medline, PubMed, Web of Science were searched from 2005-2020. Grey literature was searched on Google Scholar. SELECTION CRITERIA: PRISMA guidelines were followed and after double screening, studies reporting occurrence of mental ill-health were included. Individual narratives and case studies were excluded, as were studies that reported outcomes in non-humanitarian aid workers. DATA ANALYSIS: Data on occurrence of mental ill-health and associated factors were independently extracted and combined in a narrative summary. A random effects logistic regression model was used for the meta-analysis. MAIN RESULTS: Nine studies were included with a total of 3619 participants, reporting on five types of mental ill-health (% occurrence) including psychological distress (6.5%-52.8%); burnout (8.5%-32%); anxiety (3.8%-38.5%); depression (10.4%-39.0%) and post-traumatic stress disorder (0% to 25%). Hazardous drinking of alcohol ranged from 16.2%-50.0%. Meta-analysis reporting OR (95% CI) among humanitarian aid workers, for psychological distress was 0.45 (0.12-1.64); burnout 0.34 (0.27-0.44); anxiety 0.22 (0.10-0.51); depression 0.32 (0.18-0.57) and PTSD 0.11 (0.03-0.39). Associated factors included young age, being female and pre-existing mental ill-health. CONCLUSIONS: Mental ill-health is common among humanitarian aid workers, has a negative impact on personal well-being, and on a larger scale reduces the efficacy of humanitarian organisations with delivery of aid and retention of staff. It is imperative that mental ill-health is screened for, detected and treated in humanitarian aid workers, before, during and after their placements. It is essential to implement psychologically protective measures for individuals working in stressful and traumatic crises.

Online Adaptive MRI-Guided Stereotactic Body Radiotherapy for Pancreatic and Other Intra-Abdominal Cancers.

A 1.5T MRI combined with a linear accelerator (Unity®, Elekta; Stockholm, Sweden) is a device that shows promise in MRI-guided stereotactic body radiation treatment (SBRT). Previous studies utilized the manufacturer's pre-set MRI sequences (i.e., T2 Weighted (T2W)), which limited the visualization of pancreatic and intra-abdominal tumors and organs at risk (OAR). Here, a T1 Weighted (T1W) sequence was utilized to improve the visualization of tumors and OAR for online adapted-to-position (ATP) and adapted-to-shape (ATS) during MRI-guided SBRT. Twenty-six patients, 19 with pancreatic and 7 with intra-abdominal cancers, underwent CT and MRI simulations for SBRT planning before being treated with multi-fractionated MRI-guided SBRT. The boundary of tumors and OAR was more clearly seen on T1W image sets, resulting in fast and accurate contouring during online ATP/ATS planning. Plan quality in 26 patients was dependent on OAR proximity to the target tumor and achieved 96 ± 5% and 92 ± 9% in gross tumor volume D90% and planning target volume D90%. We utilized T1W imaging (about 120 s) to shorten imaging time by 67% compared to T2W imaging (about 360 s) and improve tumor visualization, minimizing target/OAR delineation uncertainty and the treatment margin for sparing OAR. The average time-consumption of MRI-guided SBRT for the first 21 patients was 55 ± 15 min for ATP and 79 ± 20 min for ATS.

Physical morbidity and psychological and social comorbidities at five stages during pregnancy and after childbirth: a multicountry cross-sectional survey.

OBJECTIVE: Maternal morbidity affects millions of women, the burden of which is highest in low resource settings. We sought to explore when this ill-health occurs and is most significant. SETTINGS: A descriptive observational cross-sectional study at primary and secondary-level healthcare facilities in India, Pakistan, Kenya and Malawi. PARTICIPANTS: Women attending for routine antenatal care, childbirth or postnatal care at the study healthcare facilities. PRIMARY AND SECONDARY OUTCOMES: Physical morbidity (infectious, medical, obstetrical), psychological and social comorbidity were assessed at five stages: first half of pregnancy (≤20 weeks), second half of pregnancy (>20 weeks), at birth (within 24 hours of childbirth), early postnatal (day 1-7) and late postnatal (week 2-12). RESULTS: 11 454 women were assessed: India (2099), Malawi (2923), Kenya (3145) and Pakistan (3287) with similar numbers assessed at each of the five assessment stages in each country. Infectious morbidity and anaemia are highest in the early postnatal stage (26.1% and 53.6%, respectively). For HIV, malaria and syphilis combined, prevalence was highest in the first half of pregnancy (10.0%). Hypertension, pre-eclampsia and urinary incontinence are most common in the second half of pregnancy (4.6%, 2.1% and 6.6%). Psychological (depression, thoughts of self-harm) and social morbidity (domestic violence, substance misuse) are significant at each stage but most commonly reported in the second half of pregnancy (26.4%, 17.6%, 40.3% and 5.9% respectively). Of all women assessed, maternal morbidity was highest in the second half of pregnancy (81.7%), then the early postnatal stage (80.5%). Across the four countries, maternal morbidity was highest in the second half of pregnancy in Kenya (73.8%) and Malawi (73.8%), and in the early postnatal stage in Pakistan (92.2%) and India (87.5%). CONCLUSIONS: Women have significant maternal morbidity across all stages of the continuum of pregnancy and childbirth, and especially in the second half of pregnancy and after childbirth.