Quality of maternal and newborn hospital care in Brazil: a quality improvement cycle using the WHO assessment and quality tool.

BACKGROUND: Increasing efforts toward quality improvement (QI) are necessary in low- and middle-income countries (LMICs) to reduce maternal and perinatal mortality and morbidity and to promote respectful care. In Brazil, perinatal health indicators are below targets in several states despite universal access to perinatal services and very high rates of institutional births, indicating poor quality of care (QoC) as a key issue to be addressed. However, research efforts to develop and test QoC improvement interventions are scarce. OBJECTIVES: We assessed the effects of a 1-year comprehensive QI cycle using a World Health Organization (WHO) assessment and quality tool on maternal and newborn care at hospital level and documented QIs obtained after a 1-year comprehensive QI cycle. METHODS: Uncontrolled, unblinded, pre-post study carried out in six maternity hospitals in Pernambuco, Brazil, accounting for 29 128 live births in 2014. A standards-based and participatory approach based on a WHO quality assessment and improvement tool for maternal and neonatal care at hospital level was used. A national team of assessors supervised by international experts carried out baseline and final assessments. An action plan was developed and implemented to address key quality gaps emerging from the baseline assessment and from two supportive supervision visits. RESULTS: At baseline, hospitals presented a variety of quality gaps, the majority common to all participating centers. Gaps in case management of normal and complicated deliveries and in respectful and holistic care were predominant, in both teaching/tertiary and secondary care hospitals. After one year, several improvements were observed, particularly in respectful care during labor and at delivery, in case management of normal labor and delivery and in neonatal care. CONCLUSIONS: A systematic participatory approach based on a WHO tool produced important QIs in a relatively short time and should be considered for use for large-scale QI programs in Brazil and other LMICs. Its comprehensive, peer-to-peer and action-oriented nature and its capability to document QI over time and to build a QI culture represent important comparative advantages over other QI interventions.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 2: Review of the results of quality cycles and of factors influencing change.

BACKGROUND: Information about the use of the findings of quality assessments in maternal and neonatal (MN) care is lacking and the development of tools capable to effectively address quality gaps is a key priority. Furthermore, little is known about factors that act as barriers or facilitators to change at facility level. Based on the extensive experience made with the WHO Quality Assessment and Improvement MN (QA/QI MN) tool, an overview is provided of the improvements in quality of care (QoC) which were obtained over time and of the factors influencing change. METHODS: All documented reports on the implementation of the WHO QA/QI MN tool were searched and screened for inclusion. Reports were considered if bringing evidence from both the baseline assessment and the reassessment. Changes were considered in four domains: maternal care, neonatal care, infrastructure and policies, with reference made to WHO maternal and neonatal care standards. The observed improvements were categorized according to intensity and extent across the sample of health facilities. Factors influencing change were categorized into internal and external and further classified as barriers or facilitators. RESULTS: Changes were documented after an average period of 1.2 years from first assessment in 27 facilities belonging to 9 different countries in Central and Eastern Europe (3), Central Asia (3), sub-Saharan Africa (2) and Latin America (1). Improvements were observed in all areas of care but were greater and more frequently observed in areas related to appropriate case management and respectful care for both mothers and newborns. Although widespread across most facilities and countries, the observed improvements were not covering all the quality gaps observed at the baseline assessment nor were always sufficient to achieve standard care. Factors facilitating change as well as barriers were mainly related to the capacity of the managers and head of units to involve and motivate their staff members. CONCLUSIONS: The use of WHO QA/QI MN tool proved effective in promoting significant changes in quality of care. The review of observed improvements and of factors influencing change at facility level shows that participatory assessment tools that promote a constructive dialogue with hospital managers and staff and support them in acquiring capacity in this role are crucial to implement effective quality cycles.

Use of a participatory quality assessment and improvement tool for maternal and neonatal hospital care. Part 1: Review of implementation features and observed quality gaps in 25 countries.

BACKGROUND: A substantial proportion of maternal and neonatal mortality and morbidity is attributable to gaps in quality of care. A systematic, standard-based tool for quality assessment and improvement for maternal and neonatal hospital care (QA/QI MN tool) was developed in 2009 by the World Health Organization (WHO). The tool guides the assessment process along the whole continuum from admission to discharge, collects the views of the recipients of care and engages hospital mangers and staff in identifying gaps and drafting an action plan. METHODS: Publications describing use of the WHO QA/QI MN tool from 2009 to 2017 and reports retrievable from WHO or other development partners' websites were searched and considered for inclusion in the review. Only assessments of hospitals were considered. Quality gaps were classified as regarding case management in maternal care, case management in neonatal care, hospital infrastructure, hospital policies and according to severity and frequency. Quotations from women regarding key issues in effective communication, respect and dignity, emotional support and costs incurred were selected. RESULTS: In the period 2009-2017, use of the WHO QA/QI MN tool was documented in 25 countries, belonging to Central and Eastern Europe (8), Central Asia (4), Sub-Saharan Africa (11), Latin America (1) and Middle East (1). Overall, 133 hospitals were assessed. The tool allowed to identify in great detail serious quality gaps including: insufficient or incomplete adherence to recommended evidence-based procedures for normal childbirth and maternal and neonatal complications; excess of inappropriate or unnecessary interventions; insufficient infection control; failure to provide respectful care, adequate communication and emotional support to mothers and babies; poor use of information generated locally to analyse processes and outcomes. These gaps were observed in all countries. Significant differences were observed among facilities belonging to the same health systems, ie, with very similar staffing, infrastructure and equipment. CONCLUSIONS: The experience made, the largest of this kind, provides comprehensive and detailed insight into the existing quality gaps in a wide variety of settings. QI cycles at facility level should be primarily based on assessments made by multidisciplinary teams of professionals to identify the parts of the care pathways which require improvement through a participatory approach involving managers, staff and patients.

Addressing inequities in child health and development: towards social justice.

Inequities have a profound impact on the health and development of children globally. While inequities are greatest in the world's poorest countries, even in rich nations poorer children have poorer health and developmental outcomes. From birth through childhood to adolescence, morbidity, mortality, growth and development are socially determined, resulting in the most disadvantaged having the highest risk of poor health outcomes. Inequities in childhood impact across the life course. We consider four categories of actions to promote equity: strengthening individuals, strengthening communities, improving living and working conditions, and promoting healthy macropolicies. Inequities can be reduced but action to reduce inequities requires political will. The International Society for Social Paediatrics and Child Health (ISSOP) calls on governments, policy makers, paediatricians and professionals working with children and their organisations to act to reduce child health inequity as a priority. ISSOP recommends the following: governments act to reduce child poverty; ensure rights of all children to healthcare, education and welfare are protected; basic health determinants such as adequate nutrition, clean water and sanitation are available to all children. Paediatric and child health organisations ensure that their members are informed of the impact of inequities on children's well-being and across the life course; include child health inequities in curricula for professionals in training; publish policy statements relevant to their country on child health inequities; advocate for evidence-based pro-equity interventions using a child rights perspective; advocate for affordable, accessible and quality healthcare for all children; promote research to monitor inequity as well as results of interventions in their child populations. Paediatricians and child health professionals be aware of the impact of social determinants of health on children under their care; ensure their clinical services are accessible and acceptable to all children and families within the constraints of their country's health services; engage in advocacy at community and national level.

Visitas domiciliares inovadoras e a saúde materno­infantil / Visitas domiciliarias innovadoras y la salud materno infantil / Innovative home visits and maternal and child health

OBJETIVO: Avaliar o efeito de um programa de Visitas Domiciliares Inovadoras (VDI), que é baseado em um guia de orientação, nos conhecimentos e práticas de saúde das mães em relação aos cuidados da criança e durante os períodos pré/pós-natal, e indicadores de saúde materno-infantil (ISMI). MÉTODOS: Estudo transversal e analítico que comparou 195 gestantes e mães que receberam VDI (grupo 1) com o grupo 2, de visitas domiciliares convencionais (VDC), realizado em Unidades de Saúde da Família (USF) de Recife, Pernambuco, entre 2015 a 2016. Dividiram-se 16 equipes de saúde da família em dois grupos: oito equipes receberam treinamento para VDI e oito não receberam. Houve dez VDI com a utilização do guia, durante a gestação e durante os nove meses da criança. As VDC ocorreram uma vez/mês, durante o mesmo período das VDI, mas sem o guia. Após nove meses, as participantes foram entrevistadas através de questionário com conteúdos relacionados à saúde materno-infantil. RESULTADOS: 93 gestantes (49 do grupo 1 e 44 do 2) e 102 mães de crianças (57 do grupo 1 e 45 do 2) responderam aos questionários. Os resultados mostraram melhores indicadores de pré-natal (p=0,005), melhor conhecimento sobre métodos contraceptivos (p<0,001) e melhores indicadores de amamentação exclusiva e de alimentação complementar adequada (p<0,001) no grupo 1. CONCLUSÃO: A VDI pode contribuir para melhorar os indicadores de saúde materno-infantil e os conhecimentos e as práticas de saúde das mães relacionados aos cuidados com as crianças e à gestação.

OBJECTIVE: To assess the effect of an Innovative Home Visits (IHV) program, which is based on an action-oriented guide, on mothers' knowledge and practices related to child health care, prenatal and postpartum care, and maternal and child health indicators (MCHI). METHODS: Analytical cross-sectional study that compared 195 pregnant women and mothers who received IHV (group 1) with group 2, which received conventional home visits (CHV). The study was carried out in Family Health Care (FHC) centers in Recife, Pernambuco, between 2015 and 2016. 16 family health teams were divided into 2 groups: eight teams received training to perform IHV and eight did not receive training. There were ten IHV using the guide during pregnancy and the first nine months of the child's life. CHV occurred once a month in the same period IHV were carried out, but they did not use the guide. After nine months, the participants were interviewed using a questionnaire with contents related to maternal and child health. RESULTS: 93 pregnant women (49 of group 1 and 44 of group 2) and 102 mothers (57 of group 1 and 45 of group 2) answered the questionnaire. The results showed better prenatal care indicators (p=0.005), better knowledge about contraceptive methods (p<0.001) and better indicators of exclusive breastfeeding and adequate complementary feeding (p<0.001) in group 1. CONCLUSION: The IHV program can contribute to improving MCHI and mothers' knowledge and practices related to child health care and pregnancy.

OBJETIVO: Evaluar el efecto de un programa de Visitas Domiciliarias Innovadoras (VDI) que está basado en una guía de orientación, en los conocimientos y las prácticas de salud de las madres con respecto a los cuidados del niño y durante los períodos pre/posnatal y los indicadores de salud materno infantil (ISMI). MÉTODOS: Estudio transversal y analítico que ha comparado 195 embarazadas y madres que recibieron las VDI (grupo 1) con el grupo 2 de las visitas domiciliarias convencionales (VDC) realizado en las Unidades de Salud de la Familia (USF) de Recife, Pernambuco, entre 2015 y 2016. Se dividieron 16 equipos de salud de la familia en dos grupos: ocho equipos recibieron el entrenamiento para las VDI y ocho no. Hubo diez VDI con la utilización de la guía durante el embarazo y durante los nueve meses del niño. Las VDC se dieron una vez/mes durante el mismo periodo de las VDI pero sin la guía. Después de los nueve meses las participantes fueron entrevistadas a través de cuestionario con contenidos relacionados con la salud materno infantil. RESULTADOS: 93 embarazadas (49 del grupo 1 y 44 del grupo 2) y 102 madres de niños (57 del grupo 1 y 45 del grupo 2) contestaron los cuestionarios. Los resultados mostraron mejores indicadores de prenatal (p=0,005), mejor conocimiento sobre los métodos de contracepción (p<0,001) y mejores indicadores para el amamantamiento exclusivo y de alimentación complementaria adecuada (p<0,001) en el grupo 1. CONCLUSIÓN: La VDI puede contribuir para la mejoría de los indicadores de la salud materno infantil y los conocimientos y las prácticas de salud de las madres relacionadas con los cuidados de los niños y el embarazo.

Effectiveness of an action-oriented educational intervention in ensuring long term improvement of knowledge, attitudes and practices of community health workers in maternal and infant health: a randomized controlled study.

BACKGROUND: The potential role of Community Health Workers (CHWs) in improving maternal and child health outcomes, particularly in low and middle-income countries and in disadvantaged communities, is receiving increased attention. Adequate and focused training is among the key requisites for enhancing CHWs performances and research is necessary to identify effective training methods. METHODS: A randomized controlled study was designed to assess the effectiveness of a training course in improving knowledge, attitudes and practices (KAP) of CHWs regarding maternal and infant health. Seventy-eight CHWs belonging to Family Health Units in the city of Recife, Brazil were randomly allocated to intervention and control groups. The intervention group took part in a four-day interactive training course based on an action-oriented guide to perform home visits to pregnant women and their infants throughout pregnancy and infancy until 9 months of age. KAP in intervention group after training and after 1 year were compared to control group and to baseline. RESULTS: Fifty-nine CHWs completed all KAP assessments (31 in intervention and 28 in control group). Baseline characteristics were similar in both groups. At 1 year from training, the intervention group had higher overall KAP score (120.65 vs. 108.19, p <  0.001) as well as knowledge (47.45 vs. 40.54, p <  0.001), practice (53.45 vs. 49.11, p <  0.001) and attitudes scores (19.74 vs. 18.81, p = 0.047) than the control group. Moreover, at 1 year from training, the intervention group maintained significant improvements in overall KAP score (120.65 vs. 106.55, p <  0.001) as well as in knowledge (45.45 vs. 42.13, p <  0.001), and practice (53.45 vs. 45.29, p <  0.001) scores with respect to baseline. In the control group, overall KAP (106.59 vs. 108.19, p = 0.345) as well as separate knowledge, attitudes and practices scores remained unchanged. CONCLUSIONS: A four-day interactive training course on action-oriented home visits to pregnant women and infants produced a sustained improvement of CHWs' KAP and may represent a model to ensure retention of acquired competences. TRIAL REGISTRATION: RBR-9gchqr . Date registered: July 21, 2018 (Retrospectively registered).

Report on an international workshop on kangaroo mother care: lessons learned and a vision for the future.

BACKGROUND: Globally, complications of prematurity are the leading cause of death in children under five. Preterm infants who survive their first month of life are at greater risk for various diseases and impairments in infancy, childhood and later life, representing a heavy social and economic burden for families, communities and health and social systems. Kangaroo mother care (KMC) is recommended as a beneficial and effective intervention for improving short- and long-term preterm birth outcomes in low- and high-income settings. Nevertheless, KMC is not as widely used as it should be. The International Network on KMC runs biennial workshops and congresses to help improve the coverage and quality of KMC worldwide. This paper reports the results of the two-day workshop held in November 2016, where 92 participants from 33 countries shared experiences in a series of round tables, group work sessions and plenaries. FINDINGS: Barriers to and enablers of KMC are discussed with regard to parents, health workers and the health system. Key factors for effective implementation and uptake relate to appropriate training for health staff, adherence to protocols and the creation of a welcoming environment for families. Recommendations for planning for national programmes are made according to a six-stage change model. Resources and the cost of making progress are discussed in terms of investment, maintenance, and acceleration and scaling-up costs. KMC training requirements are presented according to three levels of care. To ensure quality KMC, key requisites are proposed for the different KMC components and for sensitive communication with caregivers. The group attending to the monitoring and evaluation of KMC at a national and subnational level highlight the lack of standard indicator definitions. Key priorities for investment include health services research, harmonisation of indicators, development of a costing tool, programming and scaling up, and the follow-up of preterm infants. CONCLUSION: It is hoped that this report will help to further scale-up and sustain KMC through a systematic approach that includes raising commitment, identifying key strategies to address the main barriers and using existing facilitators, ensuring training and quality, agreeing on indicators for monitoring and evaluation, and advancing implementation research.

Innovating home visiting to mothers and infants by community health workers: an action-oriented guide / Inovando visitas domiciliares a gestantes e crianças por agentes comunitários de saúde: um guia orientado por ações

Abstract Objectives: to describe the process of development and the structure of an action-oriented guide for home visits (HVs) to mothers and infants by Community Health Workers (CHWs). The guide was adopted in a controlled trial aimed at assessing its efficacy in improving CHWs' performance. Methods: steps to develop the guide included: 1) Review of international and national standards and recommendations for community interventions for maternal and child care; 2) Assessment of perceived needs of CHWs and other Family Health professionals regarding prenatal and postnatal HVs; 3) Identification of elements to construct the guide. Results: the Guide provides action-oriented instructions for 10 HVs during prenatal and postnatal period up to 9 months instead of the 18 HVs currently recommended by Ministry of Health. Specific tasks for each visit including assessment and promotion of early child development (ECD) and an action-oriented risk classification are introduced as standardized operational practice. Conclusions: the described approach to guide construction allows adapting the guide contents to the health system context in Brazil and other countries interested in improving quality of HVs by CHWs. The guide, by identifying tasks to be carried out and actions to be taken at each HV, provides an innovative approach and represents a requisite for a more efficient and effective use of their time.

Resumo Objetivos: descrever o processo de desenvolvimento e a estrutura de um guia orientado por ações para visitas domiciliares (VDs) a mães e crianças por Agentes Comunitários de Saúde (ACSs). O guia foi aplicado em um estudo controlado visando avaliar sua eficácia em melhorar o desempenho dos ACSs. Métodos: os passos para desenvolvimento do guia incluíram: 1)Revisão das recomendações nacionais e internacionais para intervenções na comunidade em saúde materno-infantil; 2) Avaliação das necessidades de ACSs e outros profissionais das Equipes de Saúde da Família sobre VDs nos períodos pré e pós-natal; 3)Identificação dos princípios para construir o guia. Resultados: o Guia traz instruções para 10 VDs nos períodos pré e pós natal até os 9 meses, ao invés de 18 VDs atualmente recomendadas pelo Ministério da Saúde. Tarefas específicas para cada visita incluindo avaliação e promoção do desenvolvimento da primeira infância (DPI) e classificação de risco orientada por ações foram introduzidas como prática padronizada. Conclusões: a abordagem descrita para a construção do guia permite adaptar os conteúdos ao contexto do sistema de saúde do Brasil e de outros países interessados em melhorar a qualidade das VDs por ACSs. O guia, identificando tarefas e ações a serem realizadas a cada VD, oferece uma abordagem inovadora e representa um requisito para utilização mais eficiente e efetiva do tempo.

Improving the quality of hospital care for children by supportive supervision: a cluster randomized trial, Kyrgyzstan.

OBJECTIVE: To determine whether periodic supportive supervision after a training course improved the quality of paediatric hospital care in Kyrgyzstan, where inappropriate care was common but in-hospital postnatal mortality was low. METHODS: In a cluster, randomized, parallel-group trial, 10 public hospitals were allocated to a 4-day World Health Organization (WHO) course on hospital care for children followed by periodic supportive supervision by paediatricians for 1 year, while 10 hospitals had no intervention. We assessed prospectively 10 key indicators of inappropriate paediatric case management, as indicated by WHO guidelines. The primary indicator was the combination of the three indicators: unnecessary hospitalization, increased iatrogenic risk and unnecessary painful procedures. An independent team evaluated the overall quality of care. FINDINGS: We prospectively reviewed the medical records of 4626 hospitalized children aged 2 to 60 months. In the intervention hospitals, the mean proportion of the primary indicator decreased from 46.9% (95% confidence interval, CI: 24.2 to 68.9) at baseline to 6.8% (95% CI: 1.1 to 12.1) at 1 year, but was unchanged in the control group (45.5%, 95% CI: 25.2 to 67.9, to 64.7%, 95% CI: 43.3 to 86.1). At 1 year, the risk ratio for the primary indicator in the intervention versus the control group was 0.09 (95% CI: 0.06 to 0.13). The proportions of the other nine indicators also decreased in the intervention group (P < 0.0001 for all). Overall quality of care improved significantly in intervention hospitals. CONCLUSION: Periodic supportive supervision for 1 year after a training course improved both adherence to WHO guidelines on hospital care for children and the overall quality of paediatric care.

Assessing coverage, equity and quality gaps in maternal and neonatal care in sub-saharan Africa: an integrated approach.

BACKGROUND: Gaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries. METHODS: Data were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization's maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care. RESULTS: All the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level. CONCLUSION: Our findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.

Promoting effective child development practices in the first year of life: does timing make a difference?

BACKGROUND: There is an increasing need for parenting programs aimed at promoting parent-child interaction. A variety of interventions have been proposed. The use of audiovisual materials for parents has been shown to be effective but limited information is available on the optimal timing for its use, particularly for new parents during the first year of life of their children. The aim of this study is to compare the effectiveness of a video administered at two different times to first-time parents in modifying parental knowledge, attitudes and intentions with regards to effective care practices. METHODS: Open randomized controlled trial carried out in a referral mother and child hospital. Eligible parents were randomly assigned to receive a video at one month (early intervention) or at seven months (late intervention) of age of their child. The video addressed four specific activities related to early child development: reading aloud to the baby, early exposure to music, promotion of early socialization for parents and for children. The primary outcome was the proportion of parents who declared that their knowledge, attitudes and intentions changed after having seen the video at one or seven months of age of the child. RESULTS: One hundred and five families were randomly allocated either to the early (53) or to the late (52) intervention group. For 99 families (52 in the early and 47 in the late group) a complete outcome evaluation was available. Parents included in the early administration group more frequently reported modifications in their knowledge of the suggested practices while parents in the late group more frequently reported a change in their attitudes. This finding was consistent across all four practices. The video was found to influence parental intentions in the great majority of interviewed parents with no significant difference between groups (82.7% and 87.2% in the early and late intervention group, respectively). CONCLUSIONS: Audiovisual materials can be an effective complementary tool in programs aimed at supporting parents, particularly those dealing with their first baby. The results provide some useful insights into the differential benefits of using audiovisual aids at different times during the first year of life of the baby. TRIAL REGISTRATION: ClinicalTrials.gov NCT02120430.

Развитие детей в раннем возрастев Европейском регионе: потребности, тенденции и разработка политики: обзор на основе оценки пяти стран

Раннее детство - это период, требующий от родителей выполнения наиболее многочисленных (и интенсивных) обязанностей, связанных со всеми аспектами благополучия ребенка, охватываемыми Конвенцией: их выживанием, здоровьем, физической безопасности и эмоциональной защиты, качеством условий жизни иухода, возможностями участия в играх и обучении, а также свободой выражения своих взглядов. В этой связи осуществление прав детей в значительной степени зависит от благосостояния и наличия ресурсов у тех, кто отвечает за заботу о них. Признание этой взаимосвязи является важной отправной точкой в планировании помощи и услуг, предоставляемых родителям, законным опекунам и другим лицам, предоставляющим услуги по уходу за детьми. Государствам-участникам предлагается оказывать надлежащую помощь родителям, законным опекунам и расширенным семьям в выполнении ими своих обязанностей по воспитанию детей (статьи 18.2 и 18.3), в том числе помощь родителям в создании условий жизни, необходимых для развития ребенка (статья 27.2) и в обеспечении ребенку необходимой защиты и заботы (статья 3.2).

Early child development in the European Region: needs, trends and policy development: an overview based on five country assessments

Early childhood is the period of most extensive (and intensive) parental responsibilities related to all aspects of children’s well-being covered by the Convention: their survival, health, physical safety and emotional security, standards of living and care, opportunities for play and learning, and freedom of expression. Accordingly, realizing children’s rights is in large measure dependent on the well-being and resources available to those with responsibility for their care. Recognizing these interdependencies is a sound starting point for planning assistance and services to parents, legal guardians and other caregivers. State parties are required to render appropriate assistance to parents, legal guardians and extended families in the performance of their child-rearing responsibilities (arts. 18.2 and 18.3), including assisting parents in providing living conditions necessary for the child’s development (art. 27.2) and ensuring that children receive necessary protection and care (art. 3.2) (United Nations General Assembly, General Comment No.7, 2005)

Improving the quality of maternal and neonatal care: the role of standard based participatory assessments.

BACKGROUND: Gaps in quality of care are seriously affecting maternal and neonatal health globally but reports of successful quality improvement cycles implemented at large scale are scanty. We report the results of a nation-wide program to improve quality of maternal and neonatal hospital care in a lower-middle income country focusing on the role played by standard-based participatory assessments. METHODS: Improvements in the quality of maternal and neonatal care following an action-oriented participatory assessment of 19 areas covering the whole continuum from admission to discharge were measured after an average period of 10 months in four busy referral maternity hospitals in Uzbekistan. Information was collected by a multidisciplinary national team with international supervision through visit to hospital services, examination of medical records, direct observation of cases and interviews with staff and mothers. Scores (range 0 to 3) attributed to over 400 items and combined in average scores for each area were compared with the baseline assessment. RESULTS: Between the first and the second assessment, all four hospitals improved their overall score by an average 0.7 points out of 3 (range 0.4 to 1), i.e. by 22%. The improvements occurred in all main areas of care and were greater in the care of normal labor and delivery (+0.9), monitoring, infection control and mother and baby friendly care (+0.8) the role of the participatory action-oriented approach in determining the observed changes was estimated crucial in 6 out of 19 areas and contributory in other 8. Ongoing implementation of referral system and new classification of neonatal deaths impede the improved process of care to be reflected in current statistics. CONCLUSIONS: Important improvements in the quality of hospital care provided to mothers and newborn babies can be achieved through a standard-based action-oriented and participatory assessment and reassessment process.

Associations of prenatal mercury exposure from maternal fish consumption and polyunsaturated fatty acids with child neurodevelopment: a prospective cohort study in Italy.

BACKGROUND: Mercury is a neurotoxin, and limited prenatal exposure to it can affect long-term child neurodevelopment. However, results of epidemiologic studies of such exposure have been inconsistent. We examined the association of prenatal mercury exposure from maternal fish consumption with child neurodevelopment in northern Italy. METHODS: A population-based cohort of 606 children and their mothers was studied from pregnancy to age 18 months. Mercury levels were measured in maternal hair and blood during pregnancy and in umbilical cord blood and breast milk. Levels of polyunsaturated fatty acids (PUFAs) were measured in maternal serum. Maternal and child intakes of fish were assessed by using a food frequency questionnaire. The Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) was used to evaluate child neurodevelopment. Multivariate linear regression was used to examine the association of mercury exposure with BSID-III scores, after controlling for maternal fish intake, PUFAs during pregnancy, and several other confounders. RESULTS: Mean weekly fish intake during pregnancy was less than 2 servings. Mercury concentrations in biological samples were low (mean, 1061 ng/g in hair) and moderately correlated with fish intake, particularly of carnivorous species. Maternal ω-3 PUFA concentrations were poorly correlated with fish intake. Maternal intelligence quotient (IQ) and child intake of fish were significantly associated with neurodevelopment scores. In multivariate models, the level of Hg exposure was not associated with neurodevelopmental performance at 18 months. CONCLUSIONS: In this Italian population, neurodevelopment at 18 months was associated with child intake of fresh fish and maternal IQ rather than with mercury exposure. The expected beneficial effect of maternal fish intake (from maternal ω-3 PUFAs) was not found.