Evolving narratives on signal functions for monitoring maternal and newborn health services: A meta-narrative inspired review.

Emergency obstetric care (EmOC) signal functions are a shortlist of key clinical interventions capable of averting deaths from the five main direct causes of maternal mortality; they have been used since 1997 as a part of an EmOC monitoring framework to track the availability of EmOC services in low- and middle-income settings. Their widespread use and proposed adaptation to include other types of care, such as care for newborns, is testimony to their legacy as part of the measurement architecture within reproductive health. Yet, much has changed in the landscape of maternal and newborn health (MNH) since the initial introduction of EmOC signal functions. As part of a project to revise the EmOC monitoring framework, we carried out a meta-narrative inspired review to reflect on how signal functions have been developed and conceptualised over the past two decades, and how different narratives, which have emerged alongside the evolving MNH landscape, have played a role in the conceptualisation of the signal function measurement. We identified three overarching narrative traditions: 1) clinical 2) health systems and 3) human rights, that dominated the discourse and critique around the use of signal functions. Through an iterative synthesis process including 19 final articles selected for the review, we explored patterns of conciliation and areas of contradiction between the three narrative traditions. We summarised five meta-themes around the use of signal functions: i) framing the boundaries; ii) moving beyond clinical capability; iii) capturing the woods versus the trees; iv) grouping signal functions and v) measurement challenges. We intend for this review to contribute to a better understanding of the discourses around signal functions, and to provide insight for the future roles of this monitoring approach for emergency obstetric and newborn care.

Current Approaches to Following Up Women and Newborns After Discharge From Childbirth Facilities: A Scoping Review.

INTRODUCTION: The postpartum period is critical for the health and well-being of women and newborns, but there is limited research on the most effective methods of post-childbirth follow-up. This scoping review synthesizes evidence from high-, middle-, and low-income countries on approaches to following up individuals after discharge from childbirth facilities. METHODS: Using a systematic search in Ovid MEDLINE, we identified quantitative studies describing post-discharge follow-up methods deployed up to 12 months postpartum. We searched for English-language, peer-reviewed articles published between January 1, 2007 and November 2, 2022, with search terms covering 2 broad areas: "postpartum/postnatal period" and "surveillance." We single-screened titles and abstracts and double-extracted all included articles, recording study design and location, population, health outcome, method, timing and frequency of data collection, and percentage of study participants reached. RESULTS: We identified 1,654 records, of which 31 studies were included. Eight studies used in-person visits to follow up participants, 10 used telephone calls, 7 used self-administered questionnaires, and 6 used multiple methods. Across studies, the minimum length of follow-up was 1 week after delivery, and up to 4 contacts were made within the first year after delivery. Follow-up (response) rates ranged from 23% to100%. Postpartum infection was the most common outcome investigated. Other outcomes included maternal (ill-)health, neonatal (ill-)health and growth, maternal mental health and well-being, care-giving/-seeking behaviors, and knowledge and intentions. CONCLUSION: Our scoping review identified multiple follow-up methods after discharge, ranging from home visits to self-administered electronic questionnaires, which could be implemented with high response rates. The studies demonstrated that post-discharge follow-up of women and newborns was feasible, well received, and important for identifying postpartum illness or complications that would otherwise be missed. Therefore, the identified methods have the potential to become an important component of fostering a continuum of care and measuring and addressing postpartum morbidity.

Establishment of a birth-to-education cohort of 1 million Palestinian refugees using electronic medical records and electronic education records.

Introduction: By linking datasets, electronic records can be used to build large birth-cohorts, enabling researchers to cost-effectively answer questions relevant to populations over the life-course. Currently, around 5.8 million Palestinian refugees live in five settings: Jordan, Lebanon, Syria, West Bank, and Gaza Strip. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) provides them with free primary health and elementary-school services. It maintains electronic records to do so.We aimed to establish a birth cohort of Palestinian refugees born between 1st January 2010 and 31st December 2020 living in five settings by linking mother obstetric records with child health and education records and to describe some of the cohort characteristics. In future, we plan to assess effects of size-at-birth on growth, health and educational attainment, among other questions. Methods: We extracted all available data from 140 health centres and 702 schools across five settings, i.e. all UNRWA service users. Creating the cohort involved examining IDs and other data, preparing data, de-duplicating records, and identifying live-births, linking the mothers' and children's data using different deterministic linking algorithms, and understanding reasons for non-linkage. Results: We established a birth cohort of Palestinian refugees using electronic records of 972,743 live births. We found high levels of linkage to health records overall (83%), which improved over time (from 73% to 86%), and variations in linkage rates by setting: these averaged 93% in Gaza, 89% in Lebanon, 75% in Jordan, 73% in West Bank and 68% in Syria. Of the 423,580 children age-eligible to go to school, 47% went to UNRWA schools and comprised of 197,479 children with both health and education records, and 2,447 children with only education records. In addition to year and setting, other factors associated with non-linkage included mortality and having a non-refugee mother. Misclassification errors were minimal. Conclusion: This linked open birth-cohort is unique for refugees and the Arab region and forms the basis for many future studies, including to elucidate pathways for improved health and education in this vulnerable, understudied population. Our characterization of the cohort leads us to recommend using different sub-sets of the cohort depending on the research question and analytic purposes.

Tackling antimicrobial resistance in primary health care through promoting the appropriate use of antibiotics in Estonia, EVIPNet evidence brief for policy, number 8

This report is the second evidence brief for policy produced in Estonia within the framework of the WHO European Evidence-informedPolicy Network. It was prepared by the Public Health Institute of University of Tartu in collaboration with the Ministry of Social Affairsof Estonia and WHO Country Office in Estonia. The working group identified, selected, appraised, and synthesized relevant researchevidence on the problem, three options for tackling it and considerations in implementing them. The three options are: (1) Strengthening post-graduate education and continuing the education of primary care clinicians about the appropriate use of antibiotics and antimicrobial resistance (AMR); (2) Providing clinical decision support to PHCP (primary health care providers) for the prudent use of antibiotics; and (3) Using audit and feedback to improve prescribing behaviour.

Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic

ObjectiveTo prospectively document experiences of frontline maternal and newborn healthcare providers during the COVID-19 pandemic. DesignCross-sectional study via an online survey disseminated through professional networks and social media in 12 languages. We analysed responses using descriptive statistics and qualitative thematic analysis disaggregating by low- and middle-income countries (LMICs) and high-income countries (HICs). Setting81 countries, between March 24 and April 10, 2020. Participants714 maternal and newborn healthcare providers. Main outcome measuresPreparedness for and response to COVID-19, experiences of health workers providing care to women and newborns, and adaptations to 17 outpatient and inpatient care processes during the pandemic. ResultsOnly one third of respondents received training on COVID-19 from their health facility and nearly all searched for information themselves. Half of respondents in LMICs received updated guidelines for care provision compared with 82% in HICs. Overall, only 47% of participants in LMICs, and 69% in HICs felt mostly or completely knowledgeable in how to care for COVID-19 maternity patients. Facility-level responses to COVID-19 (signage, screening, testing, and isolation rooms) were more common in HICs than LMICs. Globally, 90% of respondents reported somewhat or substantially higher levels of stress. There was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based. ConclusionsSubstantial knowledge gaps exist in guidance on management of maternity cases with or without COVID-19. Formal information sharing channels for providers must be established and mental health support provided. Surveys of maternity care providers can help track the situation, capture innovations, and support rapid development of effective responses. Key MessagesO_LSTWhat is already knownC_LSTO_LIIn addition to lack of healthcare worker protection, staffing shortages, heightened risk of nosocomial transmission and decreased healthcare use described in previous infectious disease outbreaks, maternal and newborn care during the COVID-19 pandemic has also been affected by large-scale lockdowns/curfews. C_LIO_LIThe two studies assessing the indirect effects of COVID-19 on maternal and child health have used models to estimate mortality impacts. C_LIO_LIExperiences of frontline health professionals providing maternal and newborn care during the COVID-19 pandemic have not been empirically documented to date. C_LI O_LSTWhat this study addsC_LSTO_LIRespondents in high-income countries more commonly reported available/updated guidelines, access to COVID-19 testing, and dedicated isolation rooms for confirmed/suspected COVID-19 maternity patients. C_LIO_LILevels of stress increased among health professionals globally, including due to changed working hours, difficulties in reaching health facilities, and staff shortages. C_LIO_LIHealthcare providers were worried about the impact of rapidly changing care practices on health outcomes: reduced access to antenatal care, fewer outpatient visits, shorter length-of-stay in facilities after birth, banning birth companions, separating newborns from COVID-19 positive mothers, and postponing routine immunisations. C_LIO_LICOVID-19 illustrates the susceptibility of maternity care services to emergencies, including by reversing hard-won gains in healthcare utilisation and use of evidence-based practices. These rapid findings can inform countries of the main issues emerging and help develop effective responses. C_LI

Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil / Atrasos no acesso ao tratamento das complicações relacionadas ao aborto: a experiência das mulheres no Nordeste brasileiro / Retrasos en el acceso a cuidados médicos para complicaciones relacionadas con el aborto: la experiencia de mujeres en el nordeste brasileño

Abstract: Around 18 million unsafe abortions occur in low and middle-income countries and are associated with numerous adverse consequences to women's health. The time taken by women with complications to reach facilities where they can receive appropriate post-abortion care can influence the risk of death and the extent of further complications. All women aged 18+ admitted for abortion complications to public-sector hospitals in three capital cities in the Northeastern Brazil between August-December 2010 were interviewed; medical records were extracted (N = 2,804). Nearly all women (94%) went straight to a health facility, mainly to a hospital (76.6%); the rest had various care-seeking paths, with a quarter visiting 3+ hospitals. Women waited 10 hours on average before deciding to seek care. 29% reported difficulties in starting to seek care, including facing challenges in organizing childcare, a companion or transport (17%) and fear/stigma (11%); a few did not initially recognize they needed care (0.4%). The median time taken to arrive at the ultimate facility was 36 hours. Over a quarter of women reported experiencing difficulties being admitted to a hospital, including long waits (15%), only being attended after pregnant women (8.9%) and waiting for a bed (7.4%). Almost all women (90%) arrived in good condition, but those with longer delays were more likely to have (mild or severe) complications. In Brazil, where access to induced abortion is restricted, women face numerous difficulties receiving post-abortion care, which contribute to delay and influence the severity of post-abortion complications.

Resumo: Cerca de 18 milhões de abortos são realizados por ano em condições inseguras nos países de renda baixa e média, associados a numerosas consequências negativas para a saúde das mulheres. O tempo despendido pelas mulheres com complicações até chegar aos serviços onde possam receber os cuidados adequados no período pós-aborto podem influenciar o risco de morte e o grau das complicações posteriores. Foram entrevistadas todas as mulheres com 18 anos ou mais internadas devido a complicações do aborto em hospitais públicos em capitais estaduais do Nordeste brasileiro entre agosto e dezembro de 2010, e os prontuários foram analisados (N = 2.804). Quase todas as mulheres (94%) se dirigiram diretamente a um serviço de saúde, principalmente hospitais (76,6%), enquanto as outras seguiram diversos itinerários em busca de atendimento. Uma em cada quatro mulheres percorreu três ou mais hospitais. As mulheres esperavam uma média de dez horas antes de decidir buscar atendimento. 29% relatavam dificuldades no início da busca, inclusive desafios na organização dos cuidados dos filhos, com acompanhantes ou transporte (17%) e medo/estigma (11%). Uma pequena minoria (0,4%) não se deu conta inicialmente da necessidade de cuidados médicos. O tempo mediano para chegar até o serviço de saúde finalmente utilizado foi 36 horas. Mais de uma em cada quatro mulheres relatava dificuldades em conseguir internação hospitalar, inclusive tempo de espera prolongado (15%), atendimento apenas depois que todas as mulheres grávidas estivessem sido atendidas (8,9%) e espera por um leito (7,4%). Quase todas as mulheres (90%) chegavam em boas condições, mas aquelas sujeitas a esperas mais prolongadas mostraram maior probabilidade de complicações (tanto leves quanto graves). No Brasil, onde o acesso ao aborto induzido é restrito, as mulheres enfrentam muitas dificuldades para receber cuidados pós-aborto, o que contribui aos atrasos e impacta a gravidade das complicações pós-aborto.

Resumen: Cerca de 18 millones de abortos inseguros se producen en países de renta media o baja y están asociados con numerosas consecuencias adversas para la salud de la mujer. El tiempo que tardan las mujeres con complicaciones en llegar a los servicios médicos, donde puedan recibir cuidados apropiados tras un aborto, puede tener influencia en el riesgo de muerte y existencia de futuras complicaciones de salud. Todas las mujeres con 18+ años, admitidas por complicaciones durante un aborto en hospitales del sector público de tres capitales del Nordeste brasileño, entre agosto y diciembre de 2010, fueron entrevistadas; y sus historiales médicos resumidos (N = 2.804). Casi todas las mujeres (94%) fueron directamente a una institución sanitaria, en su mayoría un hospital (76,6%); el resto buscaron diferentes vías de cuidados, con una cuarta parte visitando 3+ hospitales. Las mujeres esperaron 10 horas de media antes de decidir buscar cuidados. Un 29% informó de dificultades al empezar a buscar cuidados, incluyendo el hacer frente a los desafíos para organizar el cuidado infantil, un acompañante o transporte (17%) y miedo/estigma (11%); otras en un principio no reconocieron la necesidad de cuidados (0,4%). La media de tiempo que les llevaba llegar al servicio de salud definitivo era 36 horas. Más de un cuarto de las mujeres informaron vivir dificultades estando admitidas en un hospital, incluyendo largas esperas (15%), sólo siendo atendidas tras las mujeres embarazadas (8,9%) y esperando una cama (7,4%). Casi todas las mujeres (90%) llegaron en buenas condiciones, pero aquellas con retrasos más largos eran las que estaban más expuestas a tener complicaciones (leves o graves). En Brasil, donde el acceso al aborto inducido está limitado, las mujeres se enfrentan a numerosas dificultades para recibir cuidado tras un aborto, lo que contribuye a retrasos e influye en la gravedad de las complicaciones post aborto.

Effect of Vitamin A Supplementation on Cause-Specific Mortality in Women of Reproductive Age in Ghana: a Secondary Analysis from the ObaapaVitA trial

Objective:To determine the effect of weekly low-dose vitamin A supplementation on cause-specific mortality in women of reproductive age in Ghana. Methods: A cluster-randomized; triple-blind; placebo-controlled trial was conducted in seven districts of the Brong Ahafo region of Ghana. Women aged 15-45 years who were capable of giving informed consent and intended to live in the trial area for at least 3 months were enrolled and randomly assigned; according to their cluster of residence; to receive oral vitamin A (7500 ?g) or placebo once a week. Randomization was blocked; with two clusters in each fieldwork area allocated to vitamin A and two to placebo. Every 4 weeks; fieldworkers distributed capsules and collected data during home visits. Verbal autopsies were conducted by field supervisors and reviewed by physicians; who assigned a cause of death. Cause-specific mortality rates in both arms were compared by means of random-effects Poisson regression models to allow for the cluster randomization. Analysis was by intention-to-treat; based on cluster of residence; with women eligible for inclusion once they had consistently received the supplement or placebo capsules for 6 months. Findings The analysis was based on 581 870 woman-years and 2624 deaths. Cause-specific mortality rates were found to be similar in the two study arms.Conclusion: Low-dose vitamin A supplements administered weekly are of no benefit in programmes to reduce mortality in women of childbearing age

Risk-factors for antepartum fetal deaths in the city of São Paulo, Brazil

OBJECTIVE: To assess risk factors for antepartum fetal deaths. METHODS: A population-based case-control study was carried out in the city of São Paulo from August 2000 to January 2001. Subjects were selected from a birth cohort from a linked birth and death certificate database. Cases were 164 antepartum fetal deaths and controls were drawn from a random sample of 313 births surviving at least 28 days. Information was collected from birth and death certificates, hospital records and home interviews. A hierarchical conceptual framework guided the logistic regression analysis. RESULTS: Statistically significant factors associated with antepartum fetal death were: mother without or recent marital union; mother's education under four years; mothers with previous low birth weight infant; mothers with hypertension, diabetes, bleeding during pregnancy; no or inadequate prenatal care; congenital malformation and intrauterine growth restriction. The highest population attributable fractions were for inadequacy of prenatal care (40 percent), hypertension (27 percent), intrauterine growth restriction (30 percent) and absence of a long-standing union (26 percent). CONCLUSIONS: Proximal biological risk factors are most important in antepartum fetal deaths. However, distal factors - mother's low education and marital status - are also significant. Improving access to and quality of prenatal care could have a large impact on fetal mortality.

OBJETIVO: Analisar os fatores de risco para óbitos fetais anteparto. METODOS: Estudo de caso-controle de base populacional realizado no Município de São Paulo, SP, de agosto de 2000 a janeiro de 2001. Os indivíduos foram selecionados a partir de uma coorte de nascimentos, obtida por meio de vinculação de declarações de nascimento e óbito. Os casos foram 164 óbitos fetais anteparto e os controles, uma amostra aleatória de 313 de sobreviventes até 28 dias. Foram realizadas entrevistas domiciliares com as mães e aplicado protocolo hospitalar. Foi empregada regressão logística para análise dos dados, baseado em modelo conceitual hierárquico. RESULTADOS: Os fatores estatisticamente significantes associados aos óbitos fetais anteparto foram: mães com união recente ou sem união; escolaridade da mãe inferior a quatro anos; nascimentos anteriores de baixo peso; mães com hipertensão, diabetes, e sangramento durante a gestação; ausência ou pré-natal inadequado presença de malformação congênita e presença de pequeno para idade gestacional. As maiores frações de risco atribuível na população foram inadequação do pré-natal (40 por cento), hipertensão (27 por cento), presença de pequeno para idade gestacional (30 por cento), e ausência de união com mais de um ano (26 por cento). CONCLUSÕES: Os fatores de risco proximais são os mais importantes para a mortalidade fetal anteparto. Entretanto, fatores distais como mães de baixa escolaridade e união recente ou ausente também desempenham importante papel. Melhorar acesso e qualidade do pré-natal pode promover impacto positivo na mortalidade fetal.