Outcomes and quality of care for women and their babies after caesarean section in Nigeria.

OBJECTIVE: To describe the outcomes and quality of care for women and their babies after caesarean section (CS) in Nigerian referral-level hospitals. DESIGN: Secondary analysis of a nationwide cross-sectional study. SETTING: Fifty-four referral-level hospitals. POPULATION: All women giving birth in the participating facilities between 1 September 2019 and 31 August 2020. METHODS: Data for the women were extracted, including sociodemographic data, clinical information, mode of birth, and maternal and perinatal outcomes. A conceptual hierarchical framework was employed to explore the sociodemographic and clinical factors associated with maternal and perinatal death in women who had an emergency CS. MAIN OUTCOME MEASURES: Overall CS rate, outcomes for women who had CS, and factors associated with maternal and perinatal mortality. RESULTS: The overall CS rate was 33.3% (22 838/68 640). The majority of CS deliveries were emergency cases (62.8%) and 8.1% of CS deliveries had complications after delivery, which were more common after an emergency CS. There were 179 (0.8%) maternal deaths in women who had a CS and 29.6% resulted from complications of hypertensive disorders of pregnancy. The overall maternal mortality rate in women who delivered by CS was 778 per 100 000 live births, whereas the perinatal mortality at birth was 51 per 1000 live births. Factors associated with maternal mortality in women who had an emergency CS were being <20 or >35 years of age, having a lower level of education and being referred from another facility or informal setting. CONCLUSIONS: One-third of births were delivered via CS (mostly emergency), with almost one in ten women experiencing a complication after a CS. To improve outcomes, hospitals should invest in care and remove obstacles to accessible quality CS services.

Incidence, predictors and immediate neonatal outcomes of birth asphyxia in Nigeria.

OBJECTIVE: To determine the incidence and sociodemographic and clinical risk factors associated with birth asphyxia and the immediate neonatal outcomes of birth asphyxia in Nigeria. DESIGN: Secondary analysis of data from the Maternal and Perinatal Database for Quality, Equity and Dignity Programme. SETTING: Fifty-four consenting referral-level hospitals (48 public and six private) across the six geopolitical zones of Nigeria. POPULATION: Women (and their babies) who were admitted for delivery in the facilities between 1 September 2019 and 31 August 2020. METHODS: Data were extracted and analysed on prevalence and sociodemographic and clinical factors associated with birth asphyxia and the immediate perinatal outcomes. Multilevel logistic regression modelling was used to ascertain the factors associated with birth asphyxia. MAIN OUTCOME MEASURES: Incidence, case fatality rate and factors associated with birth asphyxia. RESULTS: Of the available data, 65 383 (91.1%) women and 67 602 (90.9%) babies had complete data and were included in the analysis. The incidence of birth asphyxia was 3.0% (2027/67 602) and the case fatality rate was 16.8% (339/2022). The risk factors for birth asphyxia were uterine rupture, pre-eclampsia/eclampsia, abruptio placentae/placenta praevia, birth trauma, fetal distress and congenital anomaly. The following factors were independently associated with a risk of birth asphyxia: maternal age, woman's education level, husband's occupation, parity, antenatal care, referral status, cadre of health professional present at the birth, sex of the newborn, birthweight and mode of birth. Common adverse neonatal outcomes included: admission to a special care baby unit (SCBU), 88.4%; early neonatal death, 14.2%; neonatal sepsis, 4.5%; and respiratory distress, 4.4%. CONCLUSIONS: The incidence of reported birth asphyxia in the participating facilities was low, with around one in six or seven babies with birth asphyxia dying. Factors associated with birth asphyxia included sociodemographic and clinical considerations, underscoring a need for a comprehensive approach focused on the empowerment of women and ensuring access to quality antenatal, intrapartum and postnatal care.

Prevalence, perinatal outcomes and factors associated with neonatal sepsis in Nigeria.

OBJECTIVE: To examine the prevalence, perinatal outcomes and factors associated with neonatal sepsis in referral-level facilities across Nigeria. DESIGN: Secondary analysis of data from the Maternal and Perinatal Database for Quality, Equity and Dignity Programme in 54 referral-level hospitals across Nigeria. SETTING: Records covering the period from 1 September 2019 to 31 August 2020. POPULATION: Mothers admitted for birth during the study period, and their live newborns. METHODS: Analysis of prevalence and sociodemographic and clinical factors associated with neonatal sepsis and perinatal outcomes. Multilevel logistic regression modelling identified factors associated with neonatal sepsis. MAIN OUTCOME MEASURES: Neonatal sepsis and perinatal outcomes. RESULTS: The prevalence of neonatal sepsis was 16.3 (95% CI 15.3-17.2) per 1000 live births (1113/68 459) with a 10.3% (115/1113) case fatality rate. Limited education, unemployment or employment in sales/trading/manual jobs, nulliparity/grand multiparity, chronic medical disorder, lack of antenatal care (ANC) or ANC outside the birthing hospital and referral for birth increased the odds of neonatal sepsis. Birthweight of <2500 g, non-spontaneous vaginal birth, preterm birth, prolonged rupture of membranes, APGAR score of <7 at 5 min, birth asphyxia, birth trauma or jaundice were associated with neonatal sepsis. Neonates with sepsis were more frequently admitted to a neonatal intensive care unit (1037/1110, 93.4% vs 8237/67 346, 12.2%) and experienced a higher rate of death (115/1113, 10.3% vs 933/67 343, 1.4%). CONCLUSIONS: Neonatal sepsis remains a critical challenge in neonatal care, underscored by its high prevalence and mortality rate. The identification of maternal and neonatal risk factors underscores the importance of improved access to education and employment for women and targeted interventions in antenatal and intrapartum care.

Determinants of obstructed labour and associated outcomes in 54 referral hospitals in Nigeria.

OBJECTIVE: To estimate the prevalence of obstructed labour, associated risk factors and outcomes across a network of referral hospitals in Nigeria. DESIGN: Retrospective observational study. SETTING: A total of 54 referral-level hospitals across the six geopolitical regions of Nigeria. POPULATION: Pregnant women who were diagnosed with obstructed labour during childbirth and subsequently underwent an emergency caesarean section between 1 September 2019 and 31 August 2020. METHODS: Secondary analysis of routine maternity care data sets. Random-effects multivariable logistic regression was used to ascertain the factors associated with obstructed labour. MAIN OUTCOME MEASURES: Risk factors for obstructed labour and related postpartum complications, including intrapartum stillbirth, maternal death, uterine rupture, postpartum haemorrhage and sepsis. RESULTS: Obstructed labour was diagnosed in 1186 (1.7%) women. Among these women, 31 (2.6%) cases resulted in maternal death and 199 (16.8%) cases resulted in postpartum complications. Women under 20 years of age (OR 2.03, 95% CI 1.50-2.75), who lacked formal education (OR 1.88, 95% CI 1.55-2.30), were unemployed (OR 1.94, 95% CI 1.57-2.41), were nulliparous (OR 2.11, 95% CI 1.83-2.43), did not receive antenatal care (OR 3.34, 95% CI 2.53-4.41) or received antenatal care in an informal healthcare setting (OR 8.18, 95% CI 4.41-15.14) were more likely to experience obstructed labour. Ineffective referral systems were identified as a major contributor to maternal death. CONCLUSIONS: Modifiable factors contributing to the prevalence of obstructed labour and associated adverse outcomes in Nigeria can be addressed through targeted policies and clinical interventions.

Nutritional Challenges among African Refugee and Internally Displaced Children: A Comprehensive Scoping Review.

BACKGROUND: Children's nutrition in Africa, especially among those displaced by conflicts, is a critical global health concern. Adequate nutrition is pivotal for children's well-being and development, yet those affected by displacement confront distinctive challenges. This scoping review seeks to enhance our current knowledge, filling gaps in understanding nutritional and associated health risks within this vulnerable population. OBJECTIVE: We conducted a scoping review of the literature on the nutritional status and associated health outcomes of this vulnerable population with the goal of informing targeted interventions, policy development, and future research efforts to enhance the well-being of African refugee and internally displaced children. METHODS: This scoping review adopted Arksey and O'Malley (2005)'s methodology and considered studies published between 2000 and 2021. RESULTS: Twenty-three published articles met the inclusion criteria. These articles highlighted a wide variation in the levels of malnutrition among African refugee/internally displaced (IDP) children, with the prevalence of chronic malnutrition (stunting) and acute malnutrition (wasting) ranging from 18.8 to 52.1% and 0.04 to 29.3%, respectively. Chronic malnutrition was of 'high' or 'very high' severity (according to recent WHO classifications) in 80% of studies, while acute malnutrition was of 'high' or 'very high' severity in 50% of studies. In addition, anemia prevalence was higher than the 40% level considered to indicate a severe public health problem in 80% of the studies reviewed. CONCLUSION: In many settings, acute, chronic, and micronutrient malnutrition are at levels of great concern. Many countries hosting large, displaced populations are not represented in the literature, and research among older children is also lacking. Qualitative and intervention-focused research are urgently needed.

Vulnerabilities and reparative strategies during pregnancy, childbirth, and the postpartum period: moving from rhetoric to action.

Maternal outcomes throughout pregnancy, childbirth, and the postnatal period are influenced by interlinked and interdependent vulnerabilities. A comprehensive understanding of how various threats and barriers affect maternal and perinatal health is critical to plan, evaluate and improve maternal health programmes. This paper builds on the introductory paper of the Series on the determinants of maternal health by assessing vulnerabilities during pregnancy, childbirth, and the postnatal period. We synthesise and present the concept of vulnerability in pregnancy and childbirth, and map vulnerability attributes and their dynamic influence on maternal outcomes in early and late pregnancy and during childbirth and the postnatal period, with a particular focus on low-income and middle-income countries (LMICs). We summarise existing literature and present the evidence on the effects of various reparative strategies to improve pregnancy and childbirth outcomes. Lastly, we discuss the implications of the identified vulnerability attributes and reparative strategies for the efforts of policymakers, healthcare professionals, and researchers working towards improving outcomes for women and birthing people in LMICs.

Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward.

Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.

National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis.

BACKGROUND: Preterm birth is the leading cause of neonatal mortality and is associated with long-term physical, neurodevelopmental, and socioeconomic effects. This study updated national preterm birth rates and trends, plus novel estimates by gestational age subgroups, to inform progress towards global health goals and targets, and aimed to update country, regional, and global estimates of preterm birth for 2020 in addition to trends between 2010 and 2020. METHODS: We systematically searched population-based, nationally representative data on preterm birth from Jan 1, 2010, to Dec 31, 2020 and study data (26 March-14 April, 2021) for countries and areas with no national-level data. The analysis included 679 data points (86% nationally representative administrative data [582 of 679 data points]) from 103 countries and areas (62% of countries and areas having nationally representative administrative data [64 of 103 data points]). A Bayesian hierarchical regression was used for estimating country-level preterm rates, which incoporated country-specific intercepts, low birthweight as a covariate, non-linear time trends, and bias adjustments based on a data quality categorisation, and other indicators such as method of gestational age estimation. FINDINGS: An estimated 13·4 million (95% credible interval [CrI] 12·3-15·2 million) newborn babies were born preterm (<37 weeks) in 2020 (9·9% of all births [95% CrI 9·1-11·2]) compared with 13·8 million (12·7-15·5 million) in 2010 (9·8% of all births [9·0-11·0]) worldwide. The global annual rate of reduction was estimated at -0·14% from 2010 to 2020. In total, 55·6% of total livebirths are in southern Asia (26·8% [36 099 000 of 134 767 000]) and sub-Saharan Africa (28·7% [38 819 300 of 134 767 000]), yet these two regions accounted for approximately 65% (8 692 000 of 13 376 200) of all preterm births globally in 2020. Of the 33 countries and areas in the highest data quality category, none were in southern Asia or sub-Saharan Africa compared with 94% (30 of 32 countries) in high-income countries and areas. Worldwide from 2010 to 2020, approximately 15% of all preterm births occurred at less than 32 weeks of gestation, requiring more neonatal care (<28 weeks: 4·2%, 95% CI 3·1-5·0, 567 800 [410 200-663 200 newborn babies]); 28-32 weeks: 10·4% [9·5-10·6], 1 392 500 [1 274 800-1 422 600 newborn babies]). INTERPRETATION: There has been no measurable change in preterm birth rates over the last decade at global level. Despite increasing facility birth rates and substantial focus on routine health data systems, there remain many missed opportunities to improve preterm birth data. Gaps in national routine data for preterm birth are most marked in regions of southern Asia and sub-Saharan Africa, which also have the highest estimated burden of preterm births. Countries need to prioritise programmatic investments to prevent preterm birth and to ensure evidence-based quality care when preterm birth occurs. Investments in improving data quality are crucial so that preterm birth data can be improved and used for action and accountability processes. FUNDING: The Children's Investment Fund Foundation and the UNDP, United Nations Population Fund-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Antenatal corticosteroids in specific groups at risk of preterm birth: a systematic review.

OBJECTIVE: This study aimed to synthesise available evidence on the efficacy of antenatal corticosteroid (ACS) therapy among women at risk of imminent preterm birth with pregestational/gestational diabetes, chorioamnionitis or fetal growth restriction (FGR), or planned caesarean section (CS) in the late preterm period. METHODS: A systematic search of MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Science and Global Index Medicus was conducted for all comparative randomised or non-randomised interventional studies in the four subpopulations on 6 June 2021. Risk of Bias Assessment tool for Non-randomised Studies and the Cochrane Risk of Bias tool were used to assess the risk of bias. Grading of Recommendations Assessment, Development and Evaluations tool assessed the certainty of evidence. RESULTS: Thirty-two studies involving 5018 pregnant women and 10 819 neonates were included. Data on women with diabetes were limited, and evidence on women undergoing planned CS was inconclusive. ACS use was associated with possibly reduced odds of neonatal death (pooled OR: 0.51; 95% CI: 0.31 to 0.85, low certainty), intraventricular haemorrhage (pooled OR: 0.41; 95% CI: 0.23 to 0.72, low certainty) and respiratory distress syndrome (pooled OR: 0.59; 95% CI: 0.45 to 0.77, low certainty) in women with chorioamnionitis. Among women with FGR, the rates of surfactant use (pooled OR: 0.38; 95% CI: 0.23 to 0.62, moderate certainty), mechanical ventilation (pooled OR: 0.42; 95% CI: 0.26 to 0.66, moderate certainty) and oxygen therapy (pooled OR: 0.48; 95% CI: 0.30 to 0.77, moderate certainty) were probably reduced; however, the rate of hypoglycaemia probably increased (pooled OR: 2.06; 95% CI: 1.27 to 3.32, moderate certainty). CONCLUSIONS: There is a paucity of evidence on ACS for women who have diabetes. ACS therapy may have benefits in women with chorioamnionitis and is probably beneficial in FGR. There is limited direct trial evidence on ACS efficacy in women undergoing planned CS in the late preterm period, though the totality of evidence suggests it is probably beneficial. PROSPERO REGISTRATION NUMBER: CRD42021267816.

Effect of antenatal corticosteroid administration-to-birth interval on maternal and newborn outcomes: a systematic review.

Background: Antenatal corticosteroids (ACS) are highly effective at improving outcomes for preterm newborns. Evidence suggests the benefits of ACS may vary with the time interval between administration-to-birth. However, the optimal ACS administration-to-birth interval is not yet known. In this systematic review, we synthesised available evidence on the relationship between ACS administration-to-birth interval and maternal and newborn outcomes. Methods: This review was registered with PROSPERO (CRD42021253379). We searched Medline, Embase, CINAHL, Cochrane Library, Global Index Medicus on 11 Nov 2022 with no date or language restrictions. Randomised and non-randomised studies of pregnant women receiving ACS for preterm birth where maternal and newborn outcomes were reported for different administration-to-birth intervals were eligible. Eligibility screening, data extraction and risk of bias assessment were performed by two authors independently. Fetal and neonatal outcomes included perinatal and neonatal mortality, preterm birth-related morbidity outcomes and mean birthweight. Maternal outcomes included chorioamnionitis, maternal mortality, endometritis, and maternal intensive care unit admission. Findings: Ten trials (4592 women; 5018 neonates), 45 cohort studies (at least 22,992 women; 30,974 neonates) and two case-control studies (355 women; 360 neonates) met the eligibility criteria. Across studies, 37 different time interval combinations were identified. There was considerable heterogeneity in included administration-to-birth intervals and populations. The odds of neonatal mortality, respiratory distress syndrome and intraventricular haemorrhage were associated with the ACS administration-to-birth interval. However, the interval associated with the greatest improvements in newborn outcomes was not consistent across studies. No reliable data were available for maternal outcomes, though odds of chorioamnionitis might be associated with longer intervals. Intepretation: An optimal ACS administration-to-birth interval likely exists, however variations in study design limit identification of this interval from available evidence. Future research should consider advanced analysis techniques such as individual patient data meta-analysis to identify which ACS administration-to-birth intervals are most beneficial, and how these benefits can be optimised for women and newborns. Funding: This study was conducted with funding support from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research (SRH), a co-sponsored programme executed by the World Health Organization.

The forms and adverse effects of insecurities among internally displaced children in Ethiopia.

BACKGROUND: Ethiopia has seen an increase in the number of internally displaced persons (IDPs) due to conflict and violence related to border-based disputes and climate change. This study examines the insecurities experienced by IDPs in the Burayu camp and how they navigate and challenge them. Violence and insecurity have daunted Ethiopian regions for decades, violated children's rights, and impeded the achievement of the United Nation's sustainable development goals related to children, such as good healthcare and mental health, quality education, clean water, and sanitation. The deteriorating security concerns in Ethiopia could also expose IDP children to poor health outcomes associated with a lack of access to healthcare services. METHODS: This was an exploratory qualitative case study guided by intersectionality theoretical lens to explore the forms of insecurities perceived and experienced by IDPs in Ethiopia. Participants were selected using a purposeful sampling approach. We interviewed 20 children, 20 parents or guardians, and 13 service providers. Interviews were audio recorded and transcribed verbatim in Afan Oromo, then translated into English. We used NVivo 12 qualitative data analysis software to analyze data following Braun & Clarke's approach to thematic data analysis. RESULTS: The participants reported that IDP children in Burayu town faced many challenges related to poor socioeconomic conditions that exposed them to several insecurities and negatively affected their well-being. They reported inadequate access to clothing and shelter, clean water, sanitary facilities, food, and adequate healthcare due to financial barriers, lack of drugs, and quality of care. Our data analysis shows that socioeconomic and contextual factors intersect to determine the health and well-being of children in the Ethiopian IDP camp studied. The children experienced insecurities while navigating their daily lives. This is compounded by institutional practices that shape gender relations, income status, and access to healthcare, education, and food. These deficiencies expose children to traumatic events that could decrease future livelihood prospects and lead to compromised mental health, rendering them susceptible to prolonged post-traumatic stress disorder and depression. Results are presented under the following topics: (1) basic needs insecurity, (2) healthcare insecurity, (3) academic insecurity, (4) economic insecurity, (5) food insecurity, and (6) physical and mental health insecurity. CONCLUSION: Successful relocation and reintegration of IDPs would help to alleviate both parent and child post-conflict stressors. Managing and following up on economic reintegration efforts is needed in both the short and long term. Such measures will help to achieve goals for specific projects attached to donor support outcomes, consequently enabling social support and conflict resolution management efforts.

Quality and outcomes of maternal and perinatal care for 76,563 pregnancies reported in a nationwide network of Nigerian referral-level hospitals.

Background: The WHO in collaboration with the Nigeria Federal Ministry of Health, established a nationwide electronic data platform across referral-level hospitals. We report the burden of maternal, foetal and neonatal complications and quality and outcomes of care during the first year. Methods: Data were analysed from 76,563 women who were admitted for delivery or on account of complications within 42 days of delivery or termination of pregnancy from September 2019 to August 2020 across the 54 hospitals included in the Maternal and Perinatal Database for Quality, Equity and Dignity programme. Findings: Participating hospitals reported 69,055 live births, 4,498 stillbirths and 1,090 early neonatal deaths. 44,614 women (58·3%) had at least one pregnancy complication, out of which 6,618 women (8·6%) met our criteria for potentially life-threatening complications, and 940 women (1·2%) died. Leading causes of maternal death were eclampsia (n = 187,20·6%), postpartum haemorrhage (PPH) (n = 103,11·4%), and sepsis (n = 99,10·8%). Antepartum hypoxia (n = 1455,31·1%) and acute intrapartum events (n = 913,19·6%) were the leading causes of perinatal death. Predictors of maternal and perinatal death were similar: low maternal education, lack of antenatal care, referral from other facility, previous caesarean section, latent-phase labour admission, operative vaginal birth, non-use of a labour monitoring tool, no labour companion, and non-use of uterotonic for PPH prevention. Interpretation: This nationwide programme for routine data aggregation shows that maternal and perinatal mortality reduction strategies in Nigeria require a multisectoral approach. Several lives could be saved in the short term by addressing key predictors of death, including gaps in the coverage of internationally recommended interventions such as companionship in labour and use of labour monitoring tool. Funding: This work was funded by MSD for Mothers; and UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a co-sponsored programme executed by the World Health Organization (WHO).

Prevalence of abnormal umbilical arterial flow on Doppler ultrasound in low-risk and unselected pregnant women: a systematic review.

BACKGROUND: While Doppler ultrasound screening is beneficial for women with high-risk pregnancies, there is insufficient evidence on its benefits and harms in low- and unselected-risk pregnancies. This may be related to fewer events of abnormal Doppler flow, however the prevalence of absent or reversed end diastolic flow (AEDF or REDF) in such women is unknown. In this systematic review, we aimed to synthesise available data on the prevalence of AEDF or REDF. METHODS: We searched PubMed, Embase, CINAHL, CENTRAL and Global Index Medicus with no date, setting or language restrictions. All randomized or non-randomized studies reporting AEDF or REDF prevalence based on Doppler assessment of umbilical arterial flow > 20 weeks' gestation were eligible. Two authors assessed eligibility and extracted data on primary (AEDF and REDF) and secondary (fetal, perinatal, and neonatal mortality, caesarean section) outcomes, with results presented descriptively. RESULTS: A total of 42 studies (18,282 women) were included. Thirty-six studies reported zero AEDF or REDF cases. However, 55 AEDF or REDF cases were identified from just six studies (prevalence 0.08% to 2.13%). Four of these studies were in unselected-risk women and five were conducted in high-income countries. There was limited evidence from low- and middle-income countries. CONCLUSIONS: Evidence from largely observational studies in higher-income countries suggests that AEDF and REDF are rare among low- and unselected-risk pregnant women. There are insufficient data from lower-income countries and further research is required.

Evaluating Maternal Discharge Readiness in Kangaroo Mother Care.

OBJECTIVE: To develop and apply a tool for measuring hospital discharge readiness of mothers practicing continuous kangaroo mother care (KMC) in a tertiary setting. METHODS: A 22-item questionnaire was adapted from an existing tool. After a pilot (n=20), the survey was administered to 200 mothers in the KMC unit, Kalafong Hospital, South Africa from 2017-2018. Two items which asked participants how confident and ready they felt overall were used to categorize women as 'ready' or 'less ready' for discharge. RESULTS: Most women (n=168, 88.0%) were categorized as ready for discharge. The mean (SD) score for all 22 questions was 9.4 (0.7). Women categorized as 'less ready' scored lower overall (mean difference: 1.3) and within all four questionnaire categories compared to women who were discharge ready (P<0.05). CONCLUSIONS: Although most women in this study reported high levels of discharge readiness, further research is needed to see if results are comparable across settings.

The impact of implementing the 2016 WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience on perinatal deaths: an interrupted time-series analysis in Mpumalanga province, South Africa.

OBJECTIVES: To investigate if the implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience reduced perinatal mortality in a South African province. The recommendations were implemented which included increasing the number of contacts and also the content of the contacts. METHODS: Retrospective interrupted time-series analysis was conducted for all women accessing a minimum of one antenatal care contact from April 2014 to September 2019 in Mpumalanga province, South Africa. Retrospective interrupted time-series analysis of province level perinatal mortality and birth data comparing the pre-implementation period (April 2014-March 2017) and post-implementation period (April 2018-September 2019). The main outcome measure was unadjusted prevalence ratio (PR) for perinatal deaths before and after implementation; interrupted time-series analyses for trends in perinatal mortality before and after implementation; stillbirth risk by gestational age; primary cause of deaths (and maternal condition) before and after implementation. RESULTS: Overall, there was a 5.8% absolute decrease in stillbirths after implementation of the recommendations, however this was not statistically significant (PR 0.95, 95% CI 0.90% to 1.05%; p=0.073). Fresh stillbirths decreased by 16.6% (PR 0.86, 95% CI 0.77% to 0.95%; p=0.003) while macerated stillbirths (p=0.899) and early neonatal deaths remained unchanged (p=0.499). When stratified by weight fresh stillbirths >2500 g decreased by 17.2% (PR 0.81, 95% CI 0.70% to 0.94%; p=0.007) and early neonatal deaths decreased by 12.8% (PR 0.88, 95% CI 0.77% to 0.99%; p=0.041). The interrupted time-series analysis confirmed a trend for decreasing stillbirths at 0.09/1000 births per month (-0.09, 95% CI -1.18 to 0.01; p=0.059), early neonatal deaths (-0.09, 95% CI -0.14 to 0.04; p=<0.001) and perinatal mortality (-1.18, 95% CI -0.27 to -0.09; p<0.001) in the post-implementation period. A decrease in stillbirths, early neonatal deaths or perinatal mortality was not observed in the pre-implementation period. During the period when additional antenatal care contacts were implemented (34-38 weeks), there was a decrease in stillbirths of 18.4% (risk ratio (RR) 0.82, 95% CI 0.73% to 0.91%, p=0.0003). In hypertensive disorders of pregnancy, the risk of stillbirth decreased in the post-period by 15.1% (RR 0.85; 95% CI 0.76% to 0.94%; p=0.002). CONCLUSION: The implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience may be an effective public health strategy to reduce stillbirths in South African provinces.

The health of internally displaced children in sub-Saharan Africa: a scoping review.

BACKGROUND: Internally displaced children are those who have been forced to flee their homes due to severe unfavourable conditions (war, violence or disasters) but have not crossed international borders. Emerging research shows these children face multiple health challenges. However, we found no review focused solely on the health of such internally displaced children. Thus, this review sought to examine what is known about their health and their health concerns. METHODS: A scoping review of the literature was conducted. A total of 10 databases were searched in January 2019, yielding 6602 articles after duplicates were eliminated. Two research assistants independently selected articles that met inclusion criteria. A numerical summary and thematic analysis were conducted to facilitate data extraction and data analysis. RESULTS: A total of 25 articles met the inclusion criteria, including 16 quantitative, 6 qualitative and 3 mixed methods studies. The findings reveal elevated mental health problems and infectious diseases in this population. Findings on the nutritional status of internally displaced children as a broad group are mixed, with some studies showing poorer nutritional status among the children in this group and others showing poorer nutritional health status among host society children. Internally displaced children also experience challenges with access to health services. Premigration factors (trauma) and postmigration factors (humanitarian assistance on displacement) all contribute to the health of internally displaced children. CONCLUSION: Findings provide insight into the complex array of factors influencing the health of internally displaced children. More intervention studies are required to address the needs of this population.

Prevalence and safety of acamprosate use in pregnant alcohol-dependent women in New South Wales, Australia.

AIMS: To estimate the prevalence of exposure to acamprosate in pregnancy in New South Wales (NSW), Australia, to compare the maternal health of women exposed to acamprosate during pregnancy with non-exposed women, and to compare neonatal outcomes in neonates exposed to acamprosate in utero with non-exposed neonates. DESIGN: A population-based retrospective cohort study, comparing maternal and neonatal health outcomes in women exposed to acamprosate during pregnancy with women with a recent history of problematic alcohol use (alcohol comparison group), and women from the general community (community comparison group) using state-wide linked health data. SETTING: New South Wales, Australia. PARTICIPANTS: The study included women treated with acamprosate for more than 30 days during pregnancy between 2003 and 2012 (n = 54) and two matched comparison groups (1 : 3); an alcohol comparison group (n = 162) and a community comparison group (n = 162). MEASUREMENTS: The prevalence of acamprosate exposure was calculated per 100 000 pregnancies. Three primary measures of maternal and neonatal health were used: maternal hospital admissions, birth weight and fetal alcohol syndrome (FAS). FINDINGS: Exposure to acamprosate occurred in 7.7 [95% confidence interval (CI) = 6.0-9.7] in every 100 000 pregnancies. Rates of hospital admissions during pregnancy and 42 days post-partum in acamprosate-treated women were not significantly different from women in the community comparison group [adjusted rate ratio (RR) = 0.85, 95% CI = 0.65-1.11], but were significantly lower compared with the alcohol comparison group (adjusted RR = 1.26, 95% CI = 1.00-1.60). Acamprosate-exposed neonates were not significantly different from the alcohol comparison group or the community comparison group in terms of birth weight or proportion of small-for-gestational-age neonates or incidence of congenital abnormalities (including FAS). CONCLUSIONS: The prevalence of acamprosate use in pregnancy in New South Wales, Australia is low. Acamprosate exposure in utero is not clearly associated with poor maternal or neonatal health outcomes.

Applying the international classification of diseases to perinatal mortality data, South Africa.

OBJECTIVE: To examine the feasibility of applying the International Classification of Diseases-perinatal mortality (ICD-PM) coding to an existing data set in the classification of perinatal deaths. METHODS: One author, a researcher with a non-clinical public health background, applied the ICD-PM coding system to South Africa's national perinatal mortality audit system, the Perinatal Problem Identification Program. The database for this study included all perinatal deaths (n = 26 810), defined as either stillbirths (of birth weight > 1000 g and after 28 weeks of gestation) or early neonatal deaths (age 0-7 days), that occurred between 1 October 2013 and 31 December 2016. A clinical obstetrician verified the coding. FINDINGS: The South African classification system does not include the timing of death; however, under the ICD-PM system, deaths could be classified as antepartum (n = 15 619; 58.2%), intrapartum (n = 3725; 14.0%) or neonatal (n = 7466; 27.8%). Further, the South African classification system linked a maternal condition to only 40.3% (10 802/26 810) of all perinatal deaths; this proportion increased to 68.9% (18 467/26 810) under the ICD-PM system. CONCLUSION: The main benefit of using the clinically relevant and user-friendly ICD-PM system was an enhanced understanding of the data, in terms of both timing of death and maternal conditions. We have also demonstrated that it is feasible to convert an existing perinatal mortality classification system to one which is globally comparable and can inform policy-makers internationally.