Validating the indicator "maternal death review coverage" to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record data.

BACKGROUND: Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility- versus district-level data. METHODS AND FINDINGS: We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of a review, the percentage of reviews that met the World Health Organization defined standard for maternal and perinatal death surveillance and response. Results were stratified by sociodemographic characteristics of women and facility location and type. We compared these estimates to that obtained using district-level data. and looked at evidence of the review at the district/provincial level. Study teams reviewed facility records at 34 facilities in Argentina, 51 facilities in Ghana, and 282 facilities in India. In total, we found 17 deaths in Argentina, 14 deaths in Ghana, and 58 deaths in India evidenced at facilities. Overall, >80% of deaths had evidence of a review at facilities. In India, a much lower percentage of deaths occurring at secondary-level facilities (61.1%) had evidence of a review compared to deaths in tertiary-level facilities (92.1%). In all three countries, only about half of deaths in each country had complete reviews: 58.8% (n = 10) in Argentina, 57.2% (n = 8) in Ghana, and 41.1% (n = 24) in India. Dramatic reductions in indicator value were seen in several subnational geographic areas, including Gonda and Meerut in India and Sunyani in Ghana. For example, in Gonda only three of the 18 reviews conducted at facilities met the definitional standard (16.7%), which caused the value of the indicator to decrease from 81.8% to 13.6%. Stratification by women's sociodemographic factors suggested systematic differences in completeness of reviews by women's age, place of residence, and timing of death. CONCLUSIONS: Our study assessed the validity of an important indicator for ending preventable deaths: the coverage of reviews of maternal deaths occurring in facilities in three study settings. We found discrepancies in deaths recorded at facilities and those reported to districts from facilities. Further, few maternal death reviews met global quality standards for completeness. The value of the calculated indicator masked inaccuracies in counts of both deaths and reviews and gave no indication of completeness, thus undermining the ultimate utility of the measure in achieving an accurate measure of coverage.

Validating the implementation of an indicator reporting policies and laws on free public maternal health-related services in the era of universal health coverage: A multi-country cross-sectional study.

BACKGROUND: The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization's Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, "Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?", captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries. METHODS AND FINDINGS: We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15-49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures. CONCLUSIONS: Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.

Production of 129mXe and 131mXe via neutron activation of 128Xe and 130Xe at ILL-RHF and NCBJ-MARIA high-flux reactors.

The long-lived xenon isomers 129mXe and 131mXe are of interest for the GAMMA-MRI project, which aims at developing a novel imaging modality based on magnetic resonance of polarized unstable tracers. Here, we present the steps leading to and following the production of these two isomers via neutron irradiation of highly-enriched 128Xe and 130Xe gas samples at two high-flux reactors, the High-Flux Reactor (Réacteur à haut flux, RHF) at the Institut Laue-Langevin (ILL) and the MARIA reactor at the National Centre for Nuclear Research (NCBJ). We describe the experimental setups and procedures used to prepare the stable xenon samples, to open the irradiated samples, and to transfer xenon isomers into reusable transport vials. The activity of 129mXe and 131mXe was measured to be in the range of tens of MBq per sample of 0.8(1)mg, and was proportional to thermal neutron flux density. A small activity of unstable contaminants was also visible in the samples, but their level is not limiting for the GAMMA-MRI project's objectives. In addition, the minimum thermal neutron flux density required to produce 129mXe and 131mXe sufficient for the project could be also determined.

Validation of a measure to assess decision-making autonomy in family planning services in three low- and middle-income countries: The Family Planning Autonomous Decision-Making scale (FP-ADM).

BACKGROUND: Integrating measures of respectful care is an important priority in family planning programs, aligned with maternal health efforts. Ensuring women can make autonomous reproductive health decisions is an important indicator of respectful care. While scales have been developed and validated in family planning for dimensions of person-centered care, none focus specifically on decision-making autonomy. The Mothers Autonomy in Decision-Making (MADM) scale measures autonomy in decision-making during maternity care. We adapted the MADM scale to measure autonomy surrounding a woman's decision to use a contraceptive method within the context of contraceptive counselling. This study presents a psychometric validation of the Family Planning Autonomous Decision-Making (FP-ADM) scale using data from Argentina, Ghana, and India. METHODS AND FINDINGS: We used cross-sectional data from women in four subnational areas in Argentina (n = 890), Ghana (n = 1,114), and India (n = 1,130). In each area, 20 primary sampling units (PSUs) were randomly selected based on probability proportional to size. Households were randomly selected in Ghana and India. In Argentina, all facilities providing reproductive and maternal health services within selected PSUs were included and women were randomly selected upon exiting the facility. Interviews were conducted with a sample of 360 women per district. In total, 890 women completed the FP-ADM in Argentina, 1,114 in Ghana and 1,130 in India. To measure autonomous decision-making within FP service delivery, we adapted the items of the MADM scale to focus on family planning. To assess the scale's psychometric properties, we first examined the eigenvalues and conducted a parallel analysis to determine the number of factors. We then conducted exploratory factor analysis to determine which items to retain. The resulting factors were then identified based on the corresponding items. Internal consistency reliability was assessed with Cronbach's alpha. We assessed both convergent and divergent construct validity by examining associations with expected outcomes related to the underlying construct. The Eigenvalues and parallel analysis suggested a two-factor solution. The two underlying dimensions of the construct were identified as "Bidirectional Exchange of Information" (Factor 1) and "Empowered Choice" (Factor 2). Cronbach's alpha was calculated for the full scale and each subscale. Results suggested good internal consistency of the scale. There was a strong, significant positive association between whether a woman expressed satisfaction with quality of care received from the healthcare provider and her FP-ADM score in all three countries and a significant negative association between a woman's FP-ADM score and her stated desire to switch contraceptive methods in the future. CONCLUSIONS: Our results suggest the FP-ADM is a valid instrument to assess decision-making autonomy in contraceptive counseling and service delivery in diverse low- and middle-income countries. The scale evidenced strong construct, convergent, and divergent validity and high internal consistency reliability. Use of the FP-ADM scale could contribute to improved measurement of person-centered family planning services.

"Factors associated with provider unwillingness to perform induced abortion in Argentina: A cross-sectional study in four provinces following the legalization of abortion on request".

BACKGROUND: The 2020 Law on Access to the Voluntary Interruption of Pregnancy is a landmark piece of legislation regarding access to abortion in Argentina. Under the new law, abortion is legal up to 14 weeks and 6 days gestation, with exceptions made to the gestational age limit to save a woman´s life, to preserve a woman´s health, and in case of rape. However, widespread refusal to provide care by authorized health providers (due to conscientious objection or lack of awareness of the new law) could hinder access to legal abortion. This study aimed to assess knowledge of the current legal framework and willingness to perform abortions by authorized professionals in Argentina, to compare perceptions about any requirements necessary to perform abortions on legal grounds between willing and unwilling providers and to explore factors associated with refusal to provide care. METHODS: We conducted a cross-sectional study based on a self-administered, anonymous survey to authorized abortion providers in public health facilities in four provinces of Argentina. FINDINGS: Most authorized providers knew the grounds upon which it is currently legal to perform abortions; however, almost half reported being unwilling to perform abortions, mainly due to conscientious objection. Both willing and unwilling providers believed there were additional requirements not actually stipulated by law. Using logistic regression, we found that province where providers serve, working in a tertiary level facility, and older age were factors associated with unwillingness to provide care. CONCLUSIONS: The results of our study indicate that, even in a favorable legal context, barriers at the provider level may hinder access to abortion in Argentina. They help to demonstrate the need for specific actions that can improve access such as training, further research and public policies that guarantee facilities have sufficient professionals willing to provide abortion care.

Validating indicators for monitoring availability and geographic distribution of emergency obstetric and newborn care (EmoNC) facilities: A study triangulating health system, facility, and geospatial data.

Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the indicator after incorporating data on facility performance and functionality while varying the reference population used. Further, we compared its value to the proportion of the population within two-hours travel time of an EmONC facility. Included in our study were 34 birthing facilities in Argentina, 51 in Ghana, and 282 in India. Facility performance of basic EmONC (BEmONC) and comprehensive EmONC (CEmONC) signal functions varied considerably. One facility (4.8%) in Ghana and no facility in India designated as BEmONC had performed all seven BEmONC signal functions. In Argentina, three (8.8%) CEmONC-designated facilities performed all nine CEmONC signal functions, all located in Buenos Aires Region V. Four CEmONC-designated facilities in Ghana (57.1%) and the three CEmONC-designated facilities in India (23.1%) evidenced full CEmONC performance. No sub-national study area in Argentina or India reached the target of 5 BEmONC-level facilities per 20,000 births after incorporating facility functionality yet 100% did in Argentina and 50% did in India when considering only facility designation. Demographic differences also accounted for important variation in the indicator's value. In Ghana, the total population in Tolon within 2 hours travel time of a designated EmONC facility was estimated at 99.6%; however, only 91.1% of women of reproductive age were within 2 hours travel time. Comparing the value of the indicator when calculated using different definitions reveals important inconsistencies, resulting in conflicting information about whether the threshold for sufficient coverage is met. This raises important questions related to the indicator's validity. To provide a valid measure of effective coverage of EmONC, the construct for measurement should extend beyond the most narrow definition of availability and account for functionality and geographic accessibility.

Measuring maternal improvement through multi-stakeholder engagement: Documenting developments in the dynamic programmatic context of the global COVID-19 pandemic through outcome harvesting.

Background: To bolster country efforts towards meeting the targets and strategies laid out in WHO's report "Strategies toward ending preventable maternal mortality" (EPMM), a series of seven consultations, known as National Dialogues, were conducted to better understand national priority areas for the improvement of maternal health and to support the adoption and use of EPMM indicators at the national level. The last Dialogue was conducted in March 2020, as the COVID-19 pandemic was beginning to have global impacts. We aimed to explore the circumstantial challenges and opportunities that countries have encountered in meeting the specific stakeholder commitments made in each country by National Dialogue participants during the COVID-19 pandemic. Methods: We based our study methodology on outcome harvesting, a qualitative approach that examines how incremental change contributes towards achieving a specified outcome. It collects evidence on what has changed and then works backwards to determine whether and how a programme or intervention led to the observed changes. We collected data from 20 participants in five countries (Bangladesh, India, Mexico, Nigeria, and Pakistan) through key informant interviews and focus group discussions. We analysed the data through inductive coding focused on emergent themes. Results: The onset of the global COVID pandemic overturned plans and upended health systems, bringing new opportunities in some countries and halting progress towards the agenda outlined in the National Dialogue elsewhere. Participants identified adaptations that facilitated continued progress, such as shifting the locus of advocacy and activity from national to sub-national focal areas, catalytic changes in response to the crisis (including the development and improvement of digital communication and data technology), and increased awareness of the importance of identified priorities (including a human rights approach to maternal health). Conclusions: Our data suggest that the priorities for maternal health system performance to drive improvement toward ending preventable maternal deaths and the advocacy commitments designed to increase the relevance of upstream policy and health system-level determinants of maternal health and survival have retained their urgency during the COVID-19 pandemic.

Understanding effective approaches to addressing the common challenges faced by global health networks: Mobilising multi-stakeholder networks to address the upstream determinants of maternal health in five low- and middle-income countries.

Background: Past case studies on global initiatives to address maternal health and survival have focused on global health networks, identifying four essential tasks that define their ability to successfully enact change. We applied the conceptual framework of global health networks at the country level to organisations sharing concerns on how to address national maternal health and the upstream determinants of maternal survival in five countries and explored how they addressed these four essential tasks. Methods: We conducted focus group discussions and key informant interviews with 20 members of national maternal health multi-stakeholder networks in Bangladesh, India, Mexico, Nigeria, and Pakistan. We drew on the principles and essential components of appreciative inquiry, an assets-based action research methodology that emerged from positivist theories of organisational development to understand how the networks addressed the four tasks. We used a deductive content analysis approach, developing initial themes based on pre-designed codes corresponding to the four tasks faced by global health networks and later identifying emergent themes in the four areas of the framework. Results: We identified themes related to each of the four tasks. Participants emphasised the need for structure and focus in defining the problem, strengths associated with network diversity, and the network's ability to pivot and redefine the problem to align with other sweeping priorities, such as COVID-19 pandemic. Themes related to inspiring action centred on aligning the issue with ongoing local and global initiatives, cultivating a sense of group ownership, and defining success incrementally. Themes related to forging alliances emphasised needing to engage high-level leadership, being opportunistic about timing, reducing barriers to participation by external players, and identifying rewards for participants. Themes related to establishing a governance structure centred on needing strong structure and organisation, cultivating individual commitment, sustaining advocacy efforts, and obtaining funding. Conclusions: Our results demonstrate that challenges commonly faced by global health networks are also relevant to networks operating on a national scale and may offer them strategies for future national networks to consider adopting to address these challenges.

Exploring the intersection between country context and priority setting to prevent maternal mortality: A multi-methods study comparing expected vs observed priorities in five countries to validate the obstetric transition model.

Background: The obstetric transition model suggests that, as countries economically develop, the primary causes of maternal mortality change. Countries are assigned to one of five stages based on their maternal mortality ratio to identify priorities for reducing maternal deaths based on predominant determinants of mortality at each stage. We aim to validate the obstetric transition model using data from six diverse low- and middle-income countries representing self-identified priorities for improving maternal health and measurement compiled in a multi-stakeholder process. Methods: We used multiple data sources from Bangladesh, Cote d'Ivoire, India, Mexico, Nigeria, and Pakistan, which included secondary data on country context and primary data derived from two sources: the content of multi-stakeholder meetings, called National Dialogues, which were organised around the 11 key themes identified in the World Health Organization's "Strategies toward ending preventable maternal mortality" (EPMM) and follow-up key informant interviews conducted in five of the seven countries. We conducted the analysis in four phases examining, the country's contextual profile, mapping the key themes and indicators to the model, exploring stakeholder prioritisation, and examining reasons for divergence from the model. Results: Our results suggest that the stages of the obstetric transition generally align with the social, epidemiological, and health systems characteristics that the model predicts to be associated with countries at each stage, with some deviation related to health system deficiencies and barriers to access. Stakeholder priorities in maternal health generally align with those predicted by the model. Equity and women's rights emerged as a priority throughout all stages, not only within countries that are more advanced in the transition, as predicted by the model. Deviations between the model's predictions and country-level prioritisation were often explained by context-specific challenges. Conclusions: This study is one of the first to validate the obstetric transition model using real data. Our findings support the validity of the obstetric transition model as a useful guide to aid decisionmakers in prioritising attention towards addressing maternal mortality. Country context, including equity, remains important to further inform priority-setting.

Validating midwifery professionals' scope of practice and competency: A multi-country study comparing national data to international standards.

BACKGROUND: There is a global shortage of midwives, whose services are essential to meet the healthcare needs of pregnant women and newborns. Evidence suggests that if enough midwives, trained and regulated to global standards, were deployed worldwide, maternal, and perinatal mortality would decline significantly. Health workforce planning estimates the number of midwives needed to achieve population coverage of midwifery interventions. However, to provide a valid measure of midwifery care coverage, an indicator must consider not only the raw number of midwives, but also their scope and competency. The tasks midwives are authorized to deliver and their competency to perform essential skills and behaviors provide crucial information for understanding the availability of safe, high-quality midwifery services. Without reliable estimates for an adequate midwifery workforce, progress toward ending preventable maternal and perinatal mortality will continue to be uneven. The International Labor Organization (ILO) and the International Confederation of Midwives (ICM) suggest standards for midwifery scope of practice and competencies. This paper compares national midwifery regulations, scope, and competencies in three countries to the ILO and ICM standards to validate measures of midwife density. We also assess midwives' self-reported skills/behaviors from the ICM competencies and their acquisition. METHODS AND FINDINGS: We compared midwives' scope of practice in Argentina, Ghana, and India to the ILO Tasks and ICM Essential Competencies for Midwifery Practice. We compared midwives self-reported skills/behaviors with the ICM Competencies. Univariate and bivariate analysis was conducted to describe the association between midwives' skills and selected characteristics. National scopes of practice matched two ILO tasks in Argentina, four in India, and all in Ghana. National standards partially reflected ICM skills in Categories 2, 3, and 4 (pre-pregnancy and antenatal care; care during labor and birth; and ongoing care of women and newborns, respectively) in Argentina (range 11% to 67%), mostly in India (range 74% to 100%) and completely in Ghana (100% match). 1,266 midwives surveyed reported considerable variation in competency for skills and behaviors across ICM Category 2, 3, and 4. Most midwives reported matching skills and behaviors around labor and childbirth (Category 2). Higher proportions of midwives reported gaining basic skills through in-service training and on-job-experience than in pre-service training. CONCLUSION: Estimating the density of midwives needed for an adequate midwifery workforce capable of providing effective population coverage is predicated on a valid numerator. A reliable and valid count of midwives to meet population needs assumes that each midwife counted has the authority to exercise the same behaviors and reflects the ability to perform them with comparable competency. Our results demonstrate variation in midwifery scopes of practice and self-reported competencies in comparison to global standards that pose a threat to the reliability and validity of the numerator in measures of midwife density, and suggest the potential for expanded authorization and improved education and training to meet global reference standards for midwifery practice has not been fully realized. Although the universally recognized standard, this study demonstrates that the complex, composite descriptions of skills and behaviors in the ICM competencies make them difficult to use as benchmark measures with any precision, as they are not defined or structured to serve as valid measures for assessing workforce competency. A simplified, content-validated measurement system is needed to facilitate evaluation of the competency of the midwifery workforce.

Authorization of midwives to perform basic emergency obstetric and newborn care signal functions in Argentina, Ghana, and India: A multi-country validation study of a key global maternal and newborn health indicator.

BACKGROUND: Midwives' authorization to deliver the seven basic emergency obstetric and newborn care (BEmONC) functions is a core policy indicator in global monitoring frameworks, yet little evidence supports whether such data are captured accurately, or whether authorization demonstrates convergence with midwives' skills and actual provision of services. In this study, we aimed to validate the data reported in global monitoring frameworks (criterion validity) and to determine whether a measure of authorization is a valid indicator for BEmONC availability (construct validity). METHODS: We conducted a validation study in Argentina, Ghana, and India. To assess accuracy of the reported data on midwives' authorization to provide BEmONC services, we reviewed national regulatory documents and compared with reported country-specific data in Countdown to 2030 and the World Health Organization Maternal, Newborn, Child and Adolescent Health Policy Survey. To assess whether authorization demonstrates convergent validity with midwives' skills, training, and performance of BEmONC signal functions, we surveyed 1257 midwives/midwifery professionals and assessed variance. RESULTS: We detected discrepancies between data reported in the global monitoring frameworks and the national regulatory framework in all three countries. We found wide variations between midwives' authorization to perform signal functions and their self-reported skills and actual performance within the past 90 days. The percentage of midwives who reported performing all signal functions for which they were authorized per country-specific regulations was 17% in Argentina, 23% in Ghana, and 31% in India. Additionally, midwives in all three countries reported performing some signal functions that the national regulations did not authorize. CONCLUSION: Our findings suggest limitations in criterion and construct validity for this indicator in Argentina, Ghana, and India. Some signal functions such as assisted vaginal delivery may be obsolete based on current practice patterns. Findings suggest the need to re-examine the emergency interventions that should be included as BEmONC signal functions.

Measuring adequacy of the midwifery workforce using standards of competency and scope of work: Exploring the density and distribution of midwives in three low- and middle-income countries using cross-sectional and geospatial data.

BACKGROUND: A global midwifery shortage hampers the goal of ending preventable maternal/newborn mortality and stillbirths. Whether current measures of midwifery workforce adequacy are valid is unknown. We compare two measures of density and distribution of midwifery professionals to assess their consistency, and explore how incorporating midwifery scope, competency, and the adjusting reference population impacts this critical metric. METHODS AND FINDINGS: We collected a census of midwives employed in eligible facilities in our study settings, (422 in Ghana; 909 in India), assessed the number practicing within the scope of work for midwifery professionals defined in the International Labor Organization International Standard Classification of Occupations, and whether they reported possessing the ICM essential competencies for basic midwifery practice. We altered the numerator, iteratively narrowing it from a simple count to include data on scope of practice and competency and reported changes in value. We altered the denominator by calculating the number of midwives per 10,000 total population, women of reproductive age, pregnancies, and births and explored variation in the indicator. Across four districts in Ghana, density of midwives decreased from 8.59/10,000 total population when counting midwives from facility staffing rosters to 1.30/10,000 total population when including only fully competent midwives by the ICM standard. In India, no midwives met the standard, thus the midwifery density of 1.37/10,000 total population from staffing rosters reduced to 0.00 considering competency. Changing the denominator to births vastly altered subnational measures, ranging from ~1700% change in Tolon to ~8700% in Thiruvallur. CONCLUSION: Our study shows that varying underlying parameters significantly affects the value of the estimate. Factoring in competency greatly impacts the effective coverage of midwifery professionals. Disproportionate differences were noted when need was estimated based on total population versus births. Future research should compare various estimates of midwifery density to health system process and outcome measures.

Improving measures of access to legal abortion: A validation study triangulating multiple data sources to assess a global indicator.

BACKGROUND: Global mechanisms have been established to monitor and facilitate state accountability regarding the legal status of abortion. However, there is little evidence describing whether these mechanisms capture accurate data. Moreover, it is uncertain whether the "legal status of abortion" is a valid proxy measure for access to safe abortion, pursuant to the global goals of reducing preventable maternal mortality and advancing reproductive rights. Therefore, this study sought to assess the accuracy of reported monitoring data, and to determine whether evidence supports the consistent application of domestic law by health care professionals such that legality of abortion functions as a valid indicator of access. METHODS AND FINDINGS: We conducted a validation study using three countries as illustrative case examples: Argentina, Ghana, and India. We compared data reported by two global monitoring mechanisms (Countdown to 2030 and the Global Abortion Policies Database) against domestic source documents collected through in-depth policy review. We then surveyed health care professionals authorized to perform abortions about their knowledge of abortion law in their countries and their personal attitudes and practices regarding provision of legal abortion. We compared professionals' responses to the domestic legal frameworks described in the source documents to establish whether professionals consistently applied the law as written. This analysis revealed weaknesses in the criterion validity and construct validity of the "legal status of abortion" indicator. We detected discrepancies between data reported by the global monitoring and accountability mechanisms and the domestic policy reviews, even though all referenced the same source documents. Further, provider surveys unearthed important context-specific barriers to legal abortion not captured by the indicator, including conscientious objection and imposition of restrictions at the provider's discretion. CONCLUSIONS: Taken together, these findings denote weaknesses in the indicator "legal status of abortion" as a proxy for access to safe abortion, as well as inaccuracies in data reported to global monitoring mechanisms. This information provides important groundwork for strengthening indicators for monitoring access to abortion and for renewed advocacy to assure abortion rights worldwide.

Global Research Priorities for Understanding and Improving Respectful Care for Newborns: A Modified Delphi Study.

INTRODUCTION: As the respectful maternity care agenda expands, it is necessary to understand what the priorities are for improving respectful, dignified, and high-quality care for newborns. To catalyze and inform a developing research field, we undertook a prioritization exercise to identify global research questions. METHODS: We used a modified Delphi process to identify potential research priorities for understanding and addressing respectful care for newborns. Based on a literature review and expert discussions, we sent an open-ended questionnaire to participants in Round 1. The results were consolidated and used to create the Round 2 questionnaire, which asked participants to rank the preliminary list of research questions in 3 categories (descriptive, implementation, and measurement). Responses were weighted by rank and collated to generate a prioritized, consensus-based list of research questions. FINDINGS: Round 1 resulted in 70 research questions from 25 respondents, and 52 participants completed the Round 2 ranked survey. Most participants identified themselves as researchers (53.2%), program designers, implementers, or evaluators (56.5%). More than half of the participants reported working primarily in low-income countries (66%). Top descriptive questions were on understanding manifestations and definitions of disrespectful care among newborns and which perceptions and beliefs held by health workers affect the quality of care provided. Top implementation questions were around how to promote respectful care as a standard, challenges faced by health facilities, and identification of effective advocacy strategies. Top measurement questions were on quantitative and qualitative metrics and the impact of experiences on health outcomes. CONCLUSIONS: This study developed, for the first time, a prioritized list of research questions focusing exclusively on respectful care for newborns. The study highlighted the absence of agreed-upon terminology and tools needed to advance both theoretical and practical efforts. This list should guide researchers and other stakeholders in developing further research.

Citizen seismology helps decipher the 2021 Haiti earthquake.

On 14 August 2021, the moment magnitude (Mw) 7.2 Nippes earthquake in Haiti occurred within the same fault zone as its devastating 2010 Mw 7.0 predecessor, but struck the country when field access was limited by insecurity and conventional seismometers from the national network were inoperative. A network of citizen seismometers installed in 2019 provided near-field data critical to rapidly understand the mechanism of the mainshock and monitor its aftershock sequence. Their real-time data defined two aftershock clusters that coincide with two areas of coseismic slip derived from inversions of conventional seismological and geodetic data. Machine learning applied to data from the citizen seismometer closest to the mainshock allows us to forecast aftershocks as accurately as with the network-derived catalog. This shows the utility of citizen science contributing to our understanding of a major earthquake.

Multisite, mixed methods study to validate 10 maternal health system and policy indicators in Argentina, Ghana and India: a research protocol.

INTRODUCTION: Most efforts to assess maternal health indicator validity focus on measures of service coverage. Fewer measures focus on the upstream enabling environment, and such measures are typically not research validated. Thus, methods for validating system and policy-level indicators are not well described. This protocol describes original multicountry research to be conducted in Argentina, Ghana and India, to validate 10 indicators from the monitoring framework for the 'Strategies toward Ending Preventable Maternal Mortality' (EPMM). The overall aim is to improve capacity to drive and track progress towards achieving the priority recommendations in the EPMM strategies. This work is expected to contribute new knowledge on validation methodology and reveal important information about the indicators under study and the phenomena they target for monitoring. Validating the indicators in three diverse settings will explore the external validity of results. METHODS AND ANALYSIS: This observational study explores the validity of 10 indicators from the EPMM monitoring framework via seven discrete validation exercises that will use mixed methods: (1) cross-sectional review of policy data, (2) retrospective review of facility-level patient and administrative data and (3) collection of primary quantitative and qualitative cross-sectional data from health service providers and clients. There is a specific methodological approach and analytic plan for each indicator, directed by unique, relevant validation research questions. ETHICS AND DISSEMINATION: The protocol was approved by the Office of Human Research Administration at Harvard University in November 2019. Individual study sites received approval via local institutional review boards by January 2020 except La Pampa, Argentina, approved June 2020. Our dissemination plan enables unrestricted access and reuse of all published research, including data sets. We expect to publish at least one peer-reviewed publication per validation exercise. We will disseminate results at conferences and engage local stakeholders in dissemination activities in each study country.

The prioritization and development of key social and structural indicators to address gaps in a framework for monitoring the Strategies toward Ending Preventable Maternal Mortality (EPMM): Results of an iterative expert technical consultation.

BACKGROUND: Since 2014, iterative technical work has captured stakeholder demand and channeled it toward improving maternal health measurement, to support SDG 3.1. Strategies toward Ending Preventable Maternal Mortality (EPMM) (2015) turned a broad lens on upstream systemic determinants of maternal health and survival highlighted in 11 Key Themes. A monitoring framework was developed to help countries track progress across these domains. This process yielded requests for additional indicators where stakeholders identified gaps for tracking EPMM Key Themes. In response, two technical consultations aimed at affirming the measurement gaps, specifying the constructs for measurement, and fully elaborating the metadata to allow them to be monitored. METHODS: Measures for development were prioritized based on multi-stakeholder dialogues in five countries, and data collected from government officials and UN partners in twenty countries on perceived need for proposed additional indicators. Sixty-one participants representing expertise in measure development and the topical areas covered took part across both consultations. Measures were developed through two simultaneous participatory online consultations stratified by focus area, comprising videos, discussion forums, polls, and live Zoom meetings. RESULTS: Eight candidate indicators relevant to priority recommendations in the EPMM Strategies are presented. Each includes a definition, numerator and denominator (if applicable), method of estimation, disaggregation factors, preferred data source(s), and expected periodicity. Four address gaps in measures of fundamental rights-related determinants of maternal health at national and subnational level, including women's reproductive autonomy; participative accountability for maternal health outcomes; and Respectful Maternity Care. Four strengthen the ability to count, track, and link births and maternal deaths and causes of death. CONCLUSIONS: The proposed indicators correspond to specific EPMM Key Themes, filling gaps identified by multiple stakeholders, and respond to calls for a broadened approach to measurement and for indicators that track the social and health-systems determinants of maternal health. They reflect inputs and aspirations of numerous stakeholders, gathered over time and across various platforms. The iterative, discursive exploration of the concepts for measurement and the need for metrics to track them responds to recent calls for measure development to be carried out in more inclusive ways, and to be primarily concept- and user-driven.

Operationalizing respectful maternity care at the healthcare provider level: a systematic scoping review.

BACKGROUND: Ensuring the right to respectful care for maternal and newborn health, a critical dimension of quality and acceptability, requires meeting standards for Respectful Maternity Care (RMC). Absence of mistreatment does not constitute RMC. Evidence generation to inform definitional standards for RMC is in an early stage. The aim of this systematic review is clear provider-level operationalization of key RMC principles, to facilitate their consistent implementation. METHODS: Two rights-based frameworks define the underlying principles of RMC. A qualitative synthesis of both frameworks resulted in seven fundamental rights during childbirth that form the foundation of RMC. To codify operational definitions for these key elements of RMC at the healthcare provider level, we systematically reviewed peer-reviewed literature, grey literature, white papers, and seminal documents on RMC. We focused on literature describing RMC in the affirmative rather than mistreatment experienced by women during childbirth, and operationalized RMC by describing objective provider-level behaviors. RESULTS: Through a systematic review, 514 records (peer-reviewed articles, reports, and guidelines) were assessed to identify operational definitions of RMC grounded in those rights. After screening and review, 54 records were included in the qualitative synthesis and mapped to the seven RMC rights. The majority of articles provided guidance on operationalization of rights to freedom from harm and ill treatment; dignity and respect; information and informed consent; privacy and confidentiality; and timely healthcare. Only a quarter of articles mentioned concrete or affirmative actions to operationalize the right to non-discrimination, equality and equitable care; less than 15%, the right to liberty and freedom from coercion. Provider behaviors mentioned in the literature aligned overall with seven RMC principles; yet the smaller number of available research studies that included operationalized definitions for some key elements of RMC illustrates the nascent stage of evidence-generation in this area. CONCLUSIONS: Lack of systematic codification, grounded in empirical evidence, of operational definitions for RMC at the provider level has limited the study, design, implementation, and comparative assessment of respectful care. This qualitative systematic review provides a foundation for maternity healthcare professional policy, training, programming, research, and program evaluation aimed at studying and improving RMC at the provider level.

Respectful care for mothers and newborns is a right and important part of ensuring that their care is high quality and acceptable to them. Just because there is no mistreatment does not mean that Respectful Maternity Care (RMC) was given. Without a clear framework for provider behaviors that reflect RMC principles, it is hard to ensure every woman and newborn gets respectful care in practice. We compared and combined two frameworks summarizing maternal and newborn rights and came out with seven categories. Then we searched for articles that mentioned provider behaviors reflecting RMC. We found 514 articles and ended up with 54 after careful review, from which we pulled the observable behaviors for providers in each category. Almost all papers mentioned actions to protect women and newborns from harm and mistreatment, to treat them with dignity and respect, and to give information and respect choices. About half of papers mentioned actions to protect privacy and to make sure every mother and newborn gets care when needed. Only 25% of papers mentioned actions to make sure all women and newborns receive equal care, and only 15% included actions to make sure women and newborns are physically free to leave facilities at will, and get care whether or not they can pay. This framework defining RMC behaviors for providers is based on data from many studies and can be useful to look at whether maternal newborn care in facilities meets these standards and to inform training and more research to improve RMC.