The impact of accredited social health activists in India on uptake of modern contraception: A nationally representative multilevel modelling study.

The government of India introduced the Accredited Social Health Activist (ASHA) programme in 2006 to connect marginalised communities to the health system. ASHAs are mandated to increase the uptake of modern contraception through the doorstep provision of services. There is currently no evidence on the impact of ASHAs on the uptake of contraception at the national level. This paper examines the impact of ASHAs on the uptake of modern contraception using nationally representative National and Family Health Survey data collected in 2019-21 in India. A multilevel logistic regression analysis was performed to determine the effect of contact with ASHAs on the uptake of modern contraception, controlling for regional variability and socio-demographic variables. The data provide strong evidence that ASHAs have succeeded in increasing modern contraceptive use. Women exposed to ASHAs had twice the odds of being current users of modern contraception compared to those with no contact, even after controlling for household and individual characteristics. However, only 28.1% of women nationally reported recent contact with ASHA workers. The ASHA programme should remain central to the strategy of the government of India and should be strengthened to achieve universal access to modern contraception and meet sustainable development goals by 2030.

Baseline knowledge on risk factors, symptoms and intended behavior of women and men towards screening and treatment of cervical cancer in rural Uganda: a cross-sectional study.

BACKGROUND: Knowledge of risk factors and symptoms of cervical cancer has been found to promote uptake of screening of cervical cancer. Most interventions targeted women without much involvement of men (husbands/decision makers) who are often decision makers in many low- and middle-income countries. This study aimed at assessing baseline knowledge and intended behavior of both women and men to enable design specific targeted messages to increase uptake of cervical cancer screening and promote early detection of women with symptoms. METHODS: This cross-sectional study was conducted in two districts in Western Uganda using the modified African Women Awareness of CANcer (AWACAN) questionnaire. Women aged 30-49 years and their husbands/decision makers were interviewed. Knowledge on risk factors and symptoms, intended behavior and barriers towards participation in cervical cancer screening and treatment were assessed. Descriptive and logistic regression analyses were done to establish the association between knowledge levels and other factors comparing women to men. RESULTS: A total of 724 women and 692 men were enrolled. Of these, 71.0% women and 67.2% men had ever heard of cervical cancer and 8.8% women had ever been screened. Knowledge of risk factors and symptoms of cervical cancer was high and similar for both women and men. Lack of decision making by women was associated with low knowledge of risk factors (X2 = 14.542; p = 0.01), low education (X2 = 36.05, p < 0.01) and older age (X2 = 17.33, p < 0.01). Men had better help seeking behavior than women (X2 = 64.96, p < 0.01, OR = 0.39, 95% CI: 0.31-0.50) and were more confident and skilled in recognising a sign or symptom of cervical cancer (X2 = 27.28, p < 0.01, OR = 0.52, CI (0.40-0.67). CONCLUSION: The baseline knowledge for cervical cancer was high in majority of participants and similar in both women and men. Their intended behavior towards screening was also positive but screening uptake was very low. This study suggests developing messages on multiple interventions to promote screening behavior in addition to education, consisting of male involvement, women empowerment and making services available, accessible and women friendly.

Women's experience of childbirth care in health facilities: a qualitative assessment of respectful maternity care in Afghanistan.

BACKGROUND: Respectful maternity care (RMC) remains a key challenge in Afghanistan, despite progress on improving maternal and newborn health during 2001-2021. A qualitative study was conducted in 2018 to provide evidence on the situation of RMC in health facilities in Afghanistan. The results are useful to inform strategies to provide RMC in Afghanistan in spite of the humanitarian crisis due to Taliban's takeover in 2021. METHODS: Focus group discussions were conducted with women (4 groups, 43 women) who had used health facilities for giving birth and with providers (4 groups, 21 providers) who worked in these health facilities. Twenty key informant interviews were conducted with health managers and health policy makers. Motivators for, deterrents from using, awareness about and experiences of maternity care in health facilities were explored. RESULTS: Women gave birth in facilities for availability of maternity care and skilled providers, while various verbal and physical forms of mistreatment were identified as deterrents from facility use by women, providers and key informants. Low awareness, lack of resources and excessive workload were identified among the reasons for violation of RMC. CONCLUSION: Violation of RMC is unacceptable. Awareness of women and providers about the rights of women to respectful maternity care, training of providers on the subject, monitoring of care to prevent mistreatment, and conditioning any future technical and financial assistance to commitments to RMC is recommended.

Assessment of clinical competence of graduating medical students and associated factors in Ethiopia.

BACKGROUND: Ethiopia has scaled up medical education to improve access to healthcare which presented challenges to maintaining training quality. We conducted a study to assess the clinical competence of graduating medical students and the associated factors. METHODS AND MATERIALS: A pretest assessment of a quasi-experimental study was conducted in 10 medical schools with a sample size of 240 students. We randomly selected 24 students per school. Clinical competence was assessed in a 12-station objective structured clinical examination. The clinical learning environment (CLE), simulation training, and practice exposure were self-rated. Mean scores for clinical competence, and satisfaction in the CLE and simulation training were calculated. Proportions of students with practice exposure, and who agreed on CLE and simulation items were done. Independent t-tests were used to look at competence differences among subgroups. Bivariate and multiple linear regression models were fitted for the outcome variable: competence score. A 95% statistical confidence interval and p-value < 0.05 were used for making statistical decisions. A 75% cut-off score was used to compare competence scores. RESULTS: Graduating medical students had a mean competence score of 72%. Low scores were reported in performing manual vacuum aspiration (62%), lumbar puncture (64%), and managing childbirth (66%). Female students (73%) had a significantly higher competence score than males (70%). Higher cumulative grade point average (CGPA), positive appraisal of the CLE, and conducting more clinical procedures were associated with greater competence scores. Nearly half of the students were not satisfied with the clinical practice particularly due to the large student number and issues affecting the performance assessment. About two-thirds of the students were not satisfied with the sufficiency of models and equipment, and the quality of feedback during simulation training. Nearly one-third of the students never performed lumbar puncture, manual vacuum aspiration, and venipuncture. CONCLUSIONS: Medical students had suboptimal clinical competence. A better clinical learning environment, higher cumulative GPA, and more practice exposure are associated with higher scores. There is a need to improve student clinical practice and simulation training. Strengthening school accreditation and graduates' licensing examinations is also a way forward.

Characteristics and outcomes of pregnant women hospitalized with severe maternal outcomes in eastern Ethiopia: Results from the Ethiopian Obstetric Surveillance System study.

OBJECTIVE: The aim of the present study was to identify facility-based incidence of severe obstetric complications through a newly established obstetric surveillance system in eastern Ethiopia. METHODS: Monthly registration of obstetric hemorrhage, eclampsia, uterine rupture, severe anemia and sepsis was introduced in 13 maternity units in eastern Ethiopia. At each hospital, a designated clinician reported details of women admitted during pregnancy, childbirth or within 42 days of termination of pregnancy from April 01, 2021 to March 31, 2022 developing any of these conditions. Detailed data on sociodemographic characteristics, obstetric complications and status at discharge were collected by trained research assistants. RESULTS: Among 38 782 maternities during the study period, 2043 (5.3%) women had any of the five conditions. Seventy women died, representing a case fatality rate of 3.4%. The three leading reasons for admission were obstetric hemorrhage (972; 47.6%), severe anemia (727; 35.6%), and eclampsia (438; 21.4%). The majority of the maternal deaths were from obstetric hemorrhage (27/70; 38.6%) followed by eclampsia (17/70; 24.3%). CONCLUSION: Obstetric hemorrhage, severe anemia and eclampsia were the leading causes of severe obstetric complications in eastern Ethiopia. Almost one in 29 women admitted with obstetric complications died. Audit of quality of care is indicated to design tailored interventions to improve maternal survival and obstetric complications.

Evaluation of the Emergency Obstetric and Newborn Care training in Gondar, Ethiopia; a mixed methods study.

In Ethiopia maternal and perinatal morbidity and mortality remains high. Timely access to quality emergency obstetric and neonatal care is essential for the prevention of adverse outcomes. Training healthcare providers can play an important role in improving quality of care, thereby reducing maternal and perinatal mortality and morbidity. The aim of this study was to evaluate change of knowledge, skills and behaviour in health workers who attended a postgraduate Emergency Obstetric and Newborn Care training in Gondar, Ethiopia. A descriptive study with before-after approach, using a mix of quantitative and qualitative data, based on Kirkpatrick's model for training evaluation was conducted. The evaluation focussed on reaction, knowledge, skills, and change in behaviour in clinical practice of health care providers and facilitator's perspectives on performance. A 'lessons learned approach' was included to summarize facilitators' perspectives. Health care providers reacted positively to the Emergency Obstetric and Newborn Care training with significant improvement in knowledge and skills. Of the 56 participants who attended the training, 44 (79%) were midwives. The main evaluation score for lectures was 4,51 (SD 0,19) and for breakout sessions was 4,52 (SD 0.18) on scale of 1-5. There was a statistically significant difference in the pre and post knowledge (n = 28, mean difference 13.8%, SD 13.5, t = 6.216, p<0.001) and skills assessments (n = 23, mean difference 27.4%, SD 22.1%, t = 5.941, p<0.001). The results were the same for every component of the skills and knowledge assessment. Overall, they felt more confident in performing skills after being trained. Local sustainability, participant commitment and local context were identified as challenging factors after introducing a new training program. In Gondar Ethiopia, the Emergency Obstetric and Newborn Care training has the potential to increase skilled attendance at birth and improve quality of care, both vital to the reduction of maternal and perinatal mortality and morbidity.

Confidential Enquiry into Maternal Deaths in Namibia, 2018-2019: A Local Approach to Strengthen the Review Process and a Description of Review Findings and Recommendations.

OBJECTIVES: First objective was to strengthen the national maternal death review, by addressing local challenges with each step of the review cycle. Second objective was to describe review findings and compare these with available findings of previous reviews. METHODS: Confidential Enquiry into Maternal Deaths methodology was used to review maternal deaths. To improve reporting, the national committee focussed on addressing fear of blame among healthcare providers. Second focus was on dissemination of findings and acting on recommendations forthcoming the review. Reviewed were reported maternal deaths, that occurred between 1 April 2018 and 31 March 2019. RESULTS: Seventy maternal deaths were reported; for 69 (98.6%) medical records were available, compared to 80/119 (67.2%) in 2012-2015. Reported maternal mortality ratio increased with 48% (92/100,000 live births compared to 62/100,000 in 2012-2015). Obstetric haemorrhage was leading cause of death in the past three reviews. The "no name, no blame" policy, aiming to identify health system failures, rather than mistakes of individuals, was repeatedly explained to healthcare providers during facility visits. Recommendations based on findings of the review, such as retaining experienced staff, continuous in-service training and guidance, were shared with decision makers at regional and national levels. Healthcare providers received training based on review findings, which resulted in improved management of similar cases. CONCLUSIONS FOR PRACTICE: Enhanced implementation of Confidential Enquiry into Maternal Deaths was possible after addressing local challenges. Focussing on obtaining trust of healthcare providers and feeding back findings, resulted in better reporting and prevention of potential maternal deaths.

Artificial intelligence and visual inspection in cervical cancer screening.

INTRODUCTION: Visual inspection with acetic acid is limited by subjectivity and a lack of skilled human resource. A decision support system based on artificial intelligence could address these limitations. We conducted a diagnostic study to assess the diagnostic performance using visual inspection with acetic acid under magnification of healthcare workers, experts, and an artificial intelligence algorithm. METHODS: A total of 22 healthcare workers, 9 gynecologists/experts in visual inspection with acetic acid, and the algorithm assessed a set of 83 images from existing datasets with expert consensus as the reference. Their diagnostic performance was determined by analyzing sensitivity, specificity, and area under the curve, and intra- and inter-observer agreement was measured using Fleiss kappa values. RESULTS: Sensitivity, specificity, and area under the curve were, respectively, 80.4%, 80.5%, and 0.80 (95% CI 0.70 to 0.90) for the healthcare workers, 81.6%, 93.5%, and 0.93 (95% CI 0.87 to 1.00) for the experts, and 80.0%, 83.3%, and 0.84 (95% CI 0.75 to 0.93) for the algorithm. Kappa values for the healthcare workers, experts, and algorithm were 0.45, 0.68, and 0.63, respectively. CONCLUSION: This study enabled simultaneous assessment and demonstrated that expert consensus can be an alternative to histopathology to establish a reference standard for further training of healthcare workers and the artificial intelligence algorithm to improve diagnostic accuracy.

Stakeholders' perspectives on the acceptability and feasibility of maternity waiting homes: a qualitative synthesis.

BACKGROUND: Maternity waiting homes (MHWs) are recommended to help bridge the geographical gap to accessing maternity services. This study aimed to provide an analysis of stakeholders' perspectives (women, families, communities and health workers) on the acceptability and feasibility of MWHs. METHODS: A qualitative evidence synthesis was conducted. Studies that were published between January 1990 and July 2020, containing qualitative data on the perspectives of the stakeholder groups were included. A combination of inductive and deductive coding and thematic synthesis was used to capture the main perspectives in a thematic framework. RESULTS: Out of 4,532 papers that were found in the initial search, a total of 38 studies were included for the thematic analysis. Six themes emerged: (1) individual factors, such as perceived benefits, awareness and knowledge of the MWH; (2) interpersonal factors and domestic responsibilities, such as household and childcare responsibilities, decision-making processes and social support; (3) MWH characteristics, such as basic services and food provision, state of MWH infrastructure; (4) financial and geographical accessibility, such as transport availability, costs for MWH attendance and loss of income opportunity; (5) perceived quality of care in the MWH and the adjacent health facility, including regular check-ups by health workers and respectful care; and (6) Organization and advocacy, for example funding, community engagement, governmental involvement. The decision-making process of women and their families for using an MWH involves balancing out the gains and losses, associated with all six themes. CONCLUSION: This systematic synthesis of qualitative literature provides in-depth insights of interrelating factors that influence acceptability and feasibility of MWHs according to different stakeholders. The findings highlight the potential of MWHs as important links in the maternal and neonatal health (MNH) care delivery system. The complexity and scope of these determinants of utilization underlines the need for MWH implementation strategy to be guided by context. Better documentation of MWH implementation, is needed to understand which type of MWH is most effective in which setting, and to ensure that those who most need the MWH will use it and receive quality services. These results can be of interest for stakeholders, implementers of health interventions, and governmental parties that are responsible for MNH policy development to implement acceptable and feasible MWHs that provide the greatest benefits for its users. Trial registration Systematic review registration number: PROSPERO 2020, CRD42020192219.

Effect of contacts with health professionals on modern contraceptives uptake during the first 6 weeks after child birth: a prospective cohort study in Arsi Zone.

BACKGROUND: Healthy timing and spacing of pregnancy refers to the spacing between deliveries and subsequent pregnancies. The World Health Organization recommends waiting at least 24 months between the date of the live birth and the conception of the subsequent pregnancy in order to lower the risk of unfavorable maternal, perinatal, and newborn outcomes. Low use of contraception contributes to the high level of short inter-pregnancy intervals. Different studies conclusively demonstrate that this is a reality existing in Ethiopia right now. Limited data is available regarding the effects of contacts with health professionals on the use of contraception during the postnatal period. METHODS: A prospective cohort study was performed from October 01, 2020 to March 01, 2021. The study included 418 postnatal women who gave birth during the previous week. They were followed throughout the full postnatal period. A pre-tested structured questionnaire was used to gather the data. Data were gathered twice: once during the first week following birth and once again from the eighth to the 42nd day after birth. Epi-Info version 7 was used to enter data, which was subsequently exported to SPSS version 21 for analysis. The effect of contacts with health professionals where contraceptives were discussed on contraception uptake was measured using adjusted relative risk and its 95% confidence interval. RESULTS: Modern contraceptive uptake rate during the postnatal period was 16% (95% CI: 12.50-19.50%). Contraceptive use was 3.56 times more likely in women who were counseled about contraceptives during a contacts with health professionals at a health facility compared to those who did not have a contact (aRR = 3.56, 95% CI: 1.97-6.32). Women's age, place of residence, knowledge of whether they can become pregnant before menses return, menses return after birth, and resuming sexual activity after birth were all significantly associated with contraceptive use during the first six weeks following child birth. CONCLUSIONS: Modern contraceptive uptake rate during the postnatal period among women in the study area was low. Contacts with health professionals where contraception is discussed was the main factor associated with contraception uptake during the postnatal period. We recommend that the Arsi Zone Health Office, the Weardas Health Office in the Arsi Zone, and the health care providers in the Arsi Zone health facilities strengthen contraceptive counseling in postnatal health services to reduce the proportion of women with short inter-pregnancy intervals.

Provider and client perspectives on the use of maternity waiting homes in rural Rwanda.

BACKGROUND: The World Health Organization recommends the implementation of maternity waiting homes (MWH) to reduce delays in access to obstetric care, particularly for high-risk pregnancies and mothers living far from health facilities, and as a result, several countries have rolled out MWHs. However, Rwanda has not implemented this recommendation on a large scale. There is only one MWH in the country, hence a gap in knowledge regarding the potential utilisation and benefits of MWHs. OBJECTIVE: To explore providers' and clients' perspectives on facilitators and barriers to the use of MWH in rural Rwanda. METHODS: We conducted a qualitative study to explore health providers' and clients' perspectives on facilitators and barriers to the use of MWH in Rwanda, between December 2020 and January 2021. We used key informant interviews and focus group discussions to collect data. Data were analysed using NVivo qualitative analysis software version 11. RESULTS: Facilitators included perceptions that the MWH offered either a peaceful and home-like environment, good-quality services, or timely obstetric services, and was associated with good maternal and neonatal outcomes. Barriers included limited awareness of the MWH among pregnant women, fear of health providers to operate the MWH at full capacity, women's lack of autonomy, uncertainty over funding for the MWH, and perceived high user fees. CONCLUSION: The Ruli MWH offers a peaceful environment for pregnant women while providing quality and timely obstetric care, resulting in positive maternal and neonatal outcomes for women. However, its existence and benefits are not widely known, and its use is limited due to inadequate resources. There is a need for increased awareness of the MWH among healthcare providers and the community, and lessons from this MWH could inform the scale up of MWHs in Rwanda.

Establishing the Ethiopian Obstetric Surveillance System for Monitoring Maternal Outcomes in Eastern Ethiopia: A Pilot Study.

BACKGROUND: Although the majority of maternal deaths and complications occur in low-resource settings, almost all existing strong registration and confidential enquiry systems are found in high-resource settings. We developed and piloted the Ethiopian Obstetric Surveillance System (EthOSS), based on the successful United Kingdom Obstetric Surveillance System (UKOSS) methodology, in 3 regions in Ethiopia to improve ongoing surveillance and tracking of maternal morbidities and deaths, as well as confidential enquiry, compared to the currently used maternal death surveillance and response program in Ethiopia. METHODS: We launched the EthOSS monthly case notification system in 13 hospitals in eastern Ethiopia in April 2021. Study participants included women admitted to the hospitals from April to September 2021 with major adverse obstetric conditions during pregnancy, childbirth, or within 42 days of termination of pregnancy. Designated clinicians at the hospitals used a simple online system to report the number of cases and maternal deaths monthly to the EthOSS team. We present findings on the incidence and case fatality rates for adverse conditions included in the EthOSS. RESULTS: Over the 6-month pilot period, 904 women with at least 1 EthOSS condition were included in the study, of whom 10 died (case fatality rate, 1.1%). Almost half (46.6%, 421/904) sustained major obstetric hemorrhage, 38.7% (350/904) severe anemia, 29.5% (267/904) eclampsia, 8.8% (80/904) sepsis, and 2.2% (20/904) uterine rupture. To enable care improvement alongside surveillance, the local committee received training on confidential enquiry into maternal deaths from internal and external experts. CONCLUSIONS: In this facility-based project, data on severe adverse obstetric conditions were captured through voluntary reporting by clinicians. Further analysis is essential to assess the robustness of these data, and confidential enquiry into maternal deaths for specific cases is planned to investigate the appropriateness of care.

Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia.

OBJECTIVES: First, to describe the implementation process, benefits and challenges of a multidisciplinary service for pregnant women with cardiac disease in Namibia. Second, to assess pregnancy outcomes in this population. METHODS: In a tertiary hospital in Namibia, a multidisciplinary service was implemented by staff of obstetric and cardiology departments and included preconception counselling, provision of antenatal care and reliable contraception. Management guidelines developed for high-income settings were used, since no locally adapted guidelines were available. A cohort study was performed to assess cardiac, obstetric and fetal outcomes. Included were pregnant women with cardiac disease, referred to this service between 1 August 2016 and 31 July 2018. RESULTS: Important benefits of this service were the integrated approach, improved access to reliable contraception and insight into drivers of poor outcome. Several challenges with use of available guidelines were encountered, as contextual factors specific to lower-income settings were not taken into consideration, such as higher rates of infection or barriers to access care. The cohort consisted of 65 women. Cardiac disease was diagnosed for the first time in 16 (24.6%) women, of whom 11 had pre-existing cardiac disease. These women presented more often with heart failure than women with known heart disease (75.0% vs. 6.1%, RR 12.5, 95% CI 3.9-38.0). Five women died. Cardiac events occurred in twenty-two women of whom eight developed thromboembolic events and two endocarditis. The majority had no indication for prophylaxis, based on available guidelines. Fetal events occurred in 36 pregnancies. After pregnancy more than half of women (35/65, 53.8%) were using long-acting reversible contraception. CONCLUSIONS: Despite several barriers, it was possible to implement a multidisciplinary service in a high-burden setting. Cardiac and fetal event rates in this cohort were high. To improve outcomes the focus should be on availability of context-specific guidelines and better detection of cardiac disease.

Assessment of core teaching competency of health professional educators in Ethiopia: an institution-based cross-sectional study.

OBJECTIVES: Understanding the competency of educators is key to informing faculty development, recruitment and performance monitoring. This study aimed to assess the core teaching competency of nursing, midwifery and biomedical educators, and associated factors in Ethiopia. DESIGN: An institution-based cross-sectional study was conducted in January 2020 using structured tools adapted from the WHO's nurse and midwifery educator competency frameworks. SETTING: Two health science colleges and nine student practice sites in Ethiopia. PARTICIPANTS: All classroom instructors and clinical preceptors of nursing, midwifery and biomedical technician training programmes, and all the graduating class students. MEASURES: Overall teaching competency scores, teaching domain competency scores, competency gaps and performance gaps of educators were outcome measures. Past training on teaching skills courses, teaching experiences and sociodemographic characteristics of educators are associated factors. RESULTS: Most educators were not trained in teaching methods (82%). The teaching competency scores of classroom instructors and clinical preceptors were 61.1% and 52.5%, respectively. Competency gaps were found in using active learning methods, performance assessment, feedback and digital learning. Professional background of classroom instructors had a significant and strong association with their competency score (p=0.004; V=0.507). Age and teaching experience of clinical preceptors had significant associations with their competency score (p=0.023 and p=0.007, respectively) and had strong associations (V=0.280 and 0.323, respectively). Sex of students and their perceptions of how well the educators give education resources had a significant and strong association (p<0.001; V = 0.429). CONCLUSIONS: Nursing, midwifery and biomedical educators lacked the competency to undertake important teaching roles, which could contribute to the low quality of education. More attention should be given to strengthening faculty development.

Is collaborative care a key component for treating pregnant women with psychiatric symptoms (and additional psychosocial problems)? A systematic review.

Mental disorders during pregnancy are common, with long-lasting negative effects on mother and child. Treatment of these women is challenging, because of the high incidence of additional psychosocial problems and barriers on population and healthcare level. Collaborative care, collaboration between mental health and obstetric care professionals, may help to overcome these problems. The aim of this review is to review antenatal mental health interventions and analyse the impact of collaborative care. Two independent reviewers searched for RCT's in PubMed, Embase and PsycINFO. Trials studying the effect of psychological or pharmacological interventions on the mental health of pregnant women with psychiatric symptoms (and psychosocial problems) were eligible for inclusion. Two reviewers independently abstracted data and assessed study quality and risk of bias. Each study was scored on collaborative care criteria: multi-professional approach to patient care, structured management plan, scheduled patient follow-ups and enhanced interprofessional communication. Thirty-five studies were included. Most trials studied the effect of cognitive behavioural therapy and interpersonal psychotherapy on antenatal depression. Almost all interventions met at least one collaborative care criteria. Interventions were mostly provided by multiple professionals, but interprofessional communication rarely took place. Interventions that met more criteria did not more often show a positive effect on maternal mental health. There is lack of research on antenatal psychiatric disorders other than depressive and on long-term treatment outcomes. Collaborative care is partly implemented in most current interventions, but more trials (including interprofessional communication) are needed to be conclusive whether collaborative care is a key component in antenatal mental healthcare.

How applicable is geospatial analysis in maternal and neonatal health in sub-Saharan Africa? A systematic review.

Background: Sub-Saharan Africa (SSA) has the world's highest maternal and neonatal morbidity and mortality and has shown the slowest progress in reducing them. In addition, there is substantial inequality in terms of maternal and neonatal morbidity and mortality in the region. Geospatial studies can help prioritize scarce resources by pinpointing priority areas for implementation. This systematic review was conducted to explore the application of geospatial analysis to maternal and neonatal morbidity and mortality in SSA. Methods: A systematic search of PubMed, SCOPUS, EMBASE, and Web of Science databases was performed. All observational and qualitative studies that reported on maternal or neonatal health outcomes were included if they used a spatial analysis technique and were conducted in a SSA country. After removing duplicates, two reviewers independently reviewed each study's abstract and full text for inclusion. Furthermore, the quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Finally, due to the heterogeneity of studies, narrative synthesis was used to summarize the main findings, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was strictly followed to report the review results. A total of 56 studies were included in the review. Results: We found that geospatial analysis was used to identify inequalities in maternal and neonatal morbidity, mortality, and health care utilization and to identify gaps in the availability and geographic accessibility of maternal health facilities. In addition, we identified a few studies that used geospatial analysis for modelling intervention areas. We also detected challenges and shortcomings, such as unrealistic assumptions used by geospatial models and a shortage of reliable, up-to-date, small-scale georeferenced data. Conclusions: The use of geospatial analysis for maternal and neonatal health in SSA is still limited, and more detailed spatial data are required to exploit the potential of geospatial technologies fully.

Investigating feasibility of 2021 WHO protocol for cervical cancer screening in underscreened populations: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC).

BACKGROUND: High-risk human papillomavirus (hrHPV) testing has been recommended by the World Health Organization as the primary screening test in cervical screening programs. The option of self-sampling for this screening method can potentially increase women's participation. Designing screening programs to implement this method among underscreened populations will require contextualized evidence. METHODS: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC) will use a multi-method approach to investigate the feasibility of implementing a cervical cancer screening strategy with hrHPV self-testing as the primary screening test in Bangladesh, India, Slovak Republic and Uganda. The primary outcomes of study include uptake and coverage of the screening program and adherence to follow-up. These outcomes will be evaluated through a pre-post quasi-experimental study design. Secondary objectives of the study include the analysis of client-related factors and health system factors related to cervical cancer screening, a validation study of an artificial intelligence decision support system and an economic evaluation of the screening strategy. DISCUSSION: PRESCRIP-TEC aims to provide evidence regarding hrHPV self-testing and the World Health Organization's recommendations for cervical cancer screening in a variety of settings, targeting vulnerable groups. The main quantitative findings of the project related to the impact on uptake and coverage of screening will be complemented by qualitative analyses of various determinants of successful implementation of screening. The study will also provide decision-makers with insights into economic aspects of implementing hrHPV self-testing, as well as evaluate the feasibility of using artificial intelligence for task-shifting in visual inspection with acetic acid. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05234112 . Registered 10 February 2022.

Confidential enquiry into maternal deaths in the Netherlands, 2006-2018.

INTRODUCTION: To calculate the maternal mortality ratio (MMR) for 2006-2018 in the Netherlands and compare this with 1993-2005, and to describe women's characteristics, causes of death and improvable factors. MATERIAL AND METHODS: We performed a nationwide, cohort study of all maternal deaths between January 1, 2006 and December 31, 2018 reported to the Audit Committee Maternal Mortality and Morbidity. Main outcome measures were the national MMR and causes of death. RESULTS: Overall MMR was 6.2 per 100 000 live births, a decrease from 12.1 in 1993-2005 (risk ratio [RR] 0.5). Women with a non-western ethnic background had an increased MMR compared with Dutch women (MMR 6.5 vs. 5.0, RR 1.3). The MMR was increased among women with a background from Surinam/Dutch Antilles (MMR 14.7, RR 2.9). Half of all women had an uncomplicated medical history (79/161, 49.1%). Of 171 pregnancy-related deaths within 1 year postpartum, 102 (60%) had a direct and 69 (40%) an indirect cause of death. Leading causes within 42 days postpartum were cardiac disease (n = 21, 14.9%), hypertensive disorders (n = 20, 14.2%) and thrombosis (n = 19, 13.5%). Up to 1 year postpartum, the most common cause of death was cardiac disease (n = 32, 18.7%). Improvable care factors were identified in 76 (47.5%) of all deaths. CONCLUSIONS: Maternal mortality halved in 2006-2018 compared with 1993-2005. Cardiac disease became the main cause. In almost half of all deaths, improvable factors were identified and women with a background from Surinam/Dutch Antilles had a threefold increased risk of death compared with Dutch women without a background of migration.

Nationwide confidential enquiries into maternal deaths because of obstetric hemorrhage in the Netherlands between 2006 and 2019.

INTRODUCTION: Obstetric hemorrhage-related deaths are rare in high income countries. Yet, with increasing incidences of obstetric hemorrhage in these countries, it is of utmost importance to learn lessons from each obstetric hemorrhage-related death to improve maternity care. Our objective was to calculate the obstetric hemorrhage-related maternal mortality ratio (MMR), assess causes of obstetric hemorrhage-related deaths, and identify lessons learned. MATERIAL AND METHODS: Nationwide mixed-methods prospective case-series with confidential enquiries into maternal deaths due to obstetric hemorrhage in the Netherlands from January 1, 2006 to December 31, 2019. RESULTS: The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 was 0.7 per 100 000 livebirths and was not statistically significantly different compared with the previous MMR of 1.0 per 100 000 livebirths in 1993-2005 (odds ratio 0.70, 95% confidence interval 0.38-1.30). Leading underlying cause of hemorrhage was retained placenta. Early recognition of persistent bleeding, prompt involvement of a senior clinician and timely management tailored to the cause of hemorrhage with attention to coagulopathy were prominent lessons learned. Also, timely recourse to surgical interventions, including hysterectomy, in case other management options fail to stop bleeding came up as an important lesson in several obstetric hemorrhage-related deaths. CONCLUSIONS: The obstetric hemorrhage-related MMR in the Netherlands in 2006-2019 has not substantially changed compared to the MMR of the previous enquiry in 1993-2005. Although obstetric hemorrhage is commonly encountered by maternity care professionals, it is important to remain vigilant for possible adverse maternal outcomes and act upon an ongoing bleeding following birth in a more timely and adequate manner. Our confidential enquiries still led to important lessons learned with clinical advice to professionals as how to improve maternity care and avoid maternal deaths. Drawing lessons from maternal deaths should remain a qualitative and moral imperative.

Quality of pre-service midwifery education in public and private midwifery schools in Afghanistan: a cross sectional survey.

BACKGROUND: Midwives are the key skilled birth attendants in Afghanistan. Rapid assessment of public and private midwifery education schools was conducted in 2017 to examine compliance with national educational standards. The aim was to assess midwifery education to inform Afghanistan Nurses and Midwives Council and other stakeholders on priorities for improving quality of midwifery education. METHODS: A cross-sectional assessment of midwifery schools was conducted from September 12-December 17, 2017. The Midwifery Education Rapid Assessment Tool was used to assess 29 midwifery programs related to infrastructure, management, teachers, preceptors, clinical practice sites, curriculum and students. A purposive sample of six Institute of Health Sciences schools, seven Community Midwifery Education schools and 16 private midwifery schools was used. Participants were midwifery school staff, students and clinical preceptors. RESULTS: Libraries were available in 28/29 (97%) schools, active skills labs in 20/29 (69%), childbirth simulators in 17/29 (59%) and newborn resuscitation models in 28/29 (97%). School managers were midwives in 21/29 (72%) schools. Median numbers of students per teacher and students per preceptor were 8 (range 2-50) and 6 (range 2-20). There were insufficient numbers of teachers practicing midwifery (132/163; 81%), trained in teaching skills (113/163; 69%) and trained in emergency obstetric and newborn care (88/163; 54%). There was an average of 13 students at clinical sites in each shift. Students managed an average of 15 births independently during their training, while 40 births are required. Twenty-four percent (7/29) of schools used the national 2015 curriculum alone or combined with an older one. Ninety-one percent (633/697) of students reported access to clinical sites and skills labs. Students mentioned, however, insufficient clinical practice due to low case-loads in clinical sites, lack of education materials, transport facilities and disrespect from school teachers, preceptors and clinical site providers as challenges. CONCLUSIONS: Positive findings included availability of required infrastructure, amenities, approved curricula in 7 of the 29 midwifery schools, appropriate clinical sites and students' commitment to work as midwives upon graduation. Gaps identified were use of different often outdated curricula, inadequate clinical practice, underqualified teachers and preceptors and failure to graduate all students with sufficient skills such as independently having supported 40 births.