A research agenda to improve incidence and outcomes of assisted vaginal birth.

Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.

L'accès aux soins obstétriques d'urgence, y compris l'accouchement vaginal assisté et la césarienne, est essentiel pour améliorer les effets de la maternité et de l'accouchement. Toutefois, bien que la proportion de césariennes ait augmenté ces dernières décennies, le recours à l'accouchement vaginal assisté a diminué. C'est particulièrement le cas dans les pays à revenu faible ou intermédiaire, bien que l'accouchement vaginal assisté soit souvent moins risqué qu'une césarienne. Nous avons donc mené un processus en trois étapes afin d'imaginer un programme de recherche qui permettrait d'augmenter le recours à l'accouchement vaginal assisté ou de le réintroduire. Après avoir réalisé une synthèse des données probantes, qui a servi de base à une consultation avec des experts techniques qui ont proposé un programme de recherche initial, nous avons sollicité et incorporé les avis des représentantes des femmes pour ce programme. Ce processus nous a permis d'imaginer un programme de recherche complet, avec des sujets classés comme suit: (i) la nécessité de comprendre la perception qu'ont les femmes de l'accouchement vaginal assisté et de fournir des informations appropriées et fiables; (ii) l'importance de la formation des prestataires de soins de santé en matière de compétences cliniques, mais aussi de respect dans les soins de santé, de communication efficace, de prise de décision partagée et de consentement éclairé; ou (iii) les obstacles à la mise en œuvre et à la durabilité et les facteurs qui les facilitent. Les réactions de femmes nous ont appris qu'il était urgent de reconnaître que l'accouchement, la naissance et le post-partum sont des processus humains intrinsèquement physiologiques et dignes au cours desquels les interventions ne devraient être mises en œuvre qu'en cas de nécessité. La promotion et/ou la réintroduction de l'accouchement vaginal assisté dans les régions à faibles ressources nécessitent que les pouvoirs publics, les décideurs politiques et les administrations d'hôpitaux soutiennent les prestataires de soins de santé qualifiés, qui pourront à leur tour soutenir respectueusement les femmes pendant l'accouchement.

El acceso a la atención obstétrica de emergencia, incluido el parto vaginal asistido y el parto por cesárea, es crucial para mejorar los resultados de la maternidad y el parto. No obstante, aunque el porcentaje de partos por cesárea ha aumentado en las últimas décadas, el uso del parto vaginal asistido ha disminuido. Esto ocurre especialmente en los países de ingresos bajos y medios, a pesar de que un parto vaginal asistido suele ser menos arriesgado que un parto por cesárea. Por lo tanto, llevamos a cabo un proceso de tres pasos para identificar un programa de investigación necesario para aumentar el uso del parto vaginal asistido o volver a incorporarlo: tras realizar una síntesis de la evidencia, que sirvió de base para una consulta con expertos técnicos que propusieron un programa de investigación inicial, buscamos e integramos las opiniones de las representantes de las mujeres sobre este programa. Este proceso nos ha permitido identificar un programa de investigación exhaustivo, con temas categorizados como: (i) la necesidad de comprender las percepciones de las mujeres sobre el parto vaginal asistido, y proporcionar información adecuada y fiable; (ii) la importancia de formar a los profesionales sanitarios en habilidades clínicas, pero también en atención respetuosa, comunicación efectiva, toma de decisiones compartida y consentimiento informado; o (iii) las barreras y los facilitadores de la implementación y la sostenibilidad. A partir de las opiniones de las mujeres, nos enteramos de la urgente necesidad de reconocer las experiencias del parto, el alumbramiento y el posparto como procesos humanos inherentemente fisiológicos y dignos, en los que las intervenciones solo deben aplicarse si son necesarias. La promoción o la reincoporación del parto vaginal asistido en regiones de escasos recursos exige que los gobiernos, los responsables de formular políticas y los administradores de hospitales apoyen a los profesionales sanitarios capacitados que, a su vez, pueden ayudar a las mujeres en el trabajo de parto y el alumbramiento de manera respetuosa.

Development of the WHO Antenatal Care Recommendations Adaptation Toolkit: a standardised approach for countries.

BACKGROUND: Increasingly, WHO recommendations are defined by context-specific factors and WHO is developing strategies to ensure that recommendations are successfully adapted and implemented at country level. This manuscript describes the development of a toolkit to support governments to adapt the WHO recommendations on antenatal care (ANC) for a positive pregnancy experience for their context in a systematic manner. METHODS: The toolkit was developed in three steps. It was created with input from methodologists and regional implementation experts (Step 1) followed by a user-testing phase (Step 2), implemented during country stakeholder meetings. User testing consisted of stakeholder interviews that were transcribed, and data was categorised according to the content analysis method. Suggestions for toolkit improvement and issues identified during the interviews were assessed as serious, moderately serious or minor/cosmetic. RESULTS: A total of 22 stakeholders - comprising five Ministry of Health (MoH) consultants, four MoH policy-makers, and 13 advisors/implementers - from Burkina Faso, India, Rwanda and Zambia participated in user-testing interviews during stakeholder meetings held in each country between August 2018 and February 2019. Most stakeholders had a medical or nursing background and half were women. Overall, responses to the toolkit were positive, with all stakeholders finding it useful and desirable. User testing interviews highlighted four serious, four moderately serious and five minor/cosmetic issues to be managed. These were addressed in the final step (Step 3), an updated version of the WHO ANC Recommendations Adaptation Toolkit, comprised of two main components - a baseline assessment tool with spreadsheets for data entry and a Slidedoc®, a dual-purpose document for reading and presentation, outlining the qualitative data that shaped the women-centred perspective of the guidelines, accompanied by an instruction manual detailing the components' use. CONCLUSIONS: The WHO ANC Recommendations Adaptation Toolkit was developed to support countries to systematically adapt the WHO ANC recommendations for country contexts. Using this approach, similar tools can be developed to support guideline implementation across different health domains and the continuum of care.

Impact of health systems strengthening on coverage of maternal health services in Rwanda, 2000-2010: a systematic review.

From 2000 to 2010, Rwanda implemented comprehensive health sector reforms to strengthen the public health system, with the aim of reducing maternal and newborn deaths in line with Millennium Development Goal 5, among many other improvements in national health. Based on a systematic review of the literature, national policy documents and three Demographic & Health Surveys (2000, 2005 and 2010), this paper describes the reforms and the policies they were based on, and provides data on the extent of Rwanda's progress in expanding the coverage of four key women's health services. Progress took place in 2000-2005 and became more rapid after 2006, mostly in rural areas, when the national facility-based childbirth policy, performance-based financing, and community-based health insurance were scaled up. Between 2006 and 2010, the following increases in coverage took place as compared to 2000-2005, particularly in rural areas, where most poor women live: births with skilled attendance (77% increase vs. 26%), institutional delivery (146% increase vs. 8%), and contraceptive prevalence (351% increase vs. 150%). The primary factors in these improvements were increases in the health workforce and their skills, performance-based financing, community-based health insurance, and better leadership and governance. Further research is needed to determine the impact of these changes on health outcomes in women and children.

Identifying barriers to emergency care services.

OBJECTIVE: This paper aims to present a review of published evidence of barriers to emergency care, with attention towards both financial and other barriers. METHOD: With the keywords (financial) accessibility, barriers and emergency care services, citations in PubMed were searched and further selected in the context of the objective of this article. RESULTS: Forty articles, published over a period of 15 years, showed evidence of significant barriers to emergency care. These barriers often tend to persist, despite the fact that the evidence was published many years ago. Several publications stressed the importance of the financial barriers in foregoing or delaying potentially life-saving emergency services, both in poor and rich countries. Other publications report non-financial barriers that prevent patients in need of emergency care (pre-hospital and in-patient care) from seeking care, from arriving in the proper emergency department without undue delay or from receiving proper treatment when they do arrive in these departments. CONCLUSION: It is clear that timely access to life-saving and disability-preventing emergency care is problematic in many settings. Yet, low-cost measures can likely be taken to significantly reduce these barriers. It is time to make an inventory of these measures and to implement the most cost-effective ones worldwide.

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.

Developing measures for WHO recommendations on antenatal care for a positive pregnancy experience: a conceptual framework and scoping review.

OBJECTIVES: In response to the newest WHO recommendations on routine antenatal care (ANC) for pregnant women and adolescent girls, this paper identifies the literature on existing ANC measures, presents a conceptual framework for quality ANC, maps existing measures to specific WHO recommendations, identifies gaps where new measures are needed to monitor the implementation and impact of routine ANC and prioritises measures for capture. METHODS: We conducted searches in four databases and five websites. Searches and application of inclusion/exclusion criteria followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow approach for scoping reviews. Data were extracted on measure information, methodology, methodological work and implementation. We adapted and refined a conceptual framework for routine ANC based on these measures. RESULTS: This scoping review uncovered 58 resources describing 46 existing measures that align with WHO recommendations and good clinical practices for ANC. Of the 42 WHO-recommended ANC interventions and four good clinical practices included in this scoping review, only 14 WHO-recommended interventions and three established good clinical practices could potentially be measured immediately using existing measures. Recommendations addressing the integration of ANC with allied fields are likelier to have existing measures than recommendations that focus on maternal health. When mapped to our conceptual framework, existing measures prioritise content of care and health systems; measures for girls' and women's experiences of care are notably lacking. Available data sources for non-existent measures are currently limited. CONCLUSION: Our research updates prior efforts to develop comprehensive measures of quality ANC and raises awareness of the need to better assess experiences of ANC. Given the inadequate number and distribution of existing ANC measures across the quality of care conceptual framework domains, new standardised measures are required to assess quality of routine ANC. Girls' and women's voices deserve greater acknowledgement when measuring the quality and delivery of ANC.

Developing and applying a 'living guidelines' approach to WHO recommendations on maternal and perinatal health.

How should the WHO most efficiently keep its global recommendations up to date? In this article we describe how WHO developed and applied a 'living guidelines' approach to its maternal and perinatal health (MPH) recommendations, based on a systematic and continuous process of prioritisation and updating. Using this approach, 25 new or updated WHO MPH recommendations have been published in 2017-2018. The new approach helps WHO ensure its guidance is responsive to emerging evidence and remains up to date for end users.

Elimination of mother-to-child transmission of HIV and syphilis: A dual approach in the African Region to improve quality of antenatal care and integrated disease control.

The World Health Organization's (WHO) Strategic Framework for the Elimination of New HIV Infections among Children in Africa by 2015 identifies important synergies for the elimination of mother-to-child transmission of HIV and syphilis in terms of prevention interventions, implementation logistics and service delivery, monitoring and evaluation systems, and need for sustained political commitment. The WHO advocates the use of an integrated, rights-based dual approach with partnerships and collaboration to make the best use of available resources. Through a consultative approach, six countries in the African Region committed to dual elimination and developed and implemented action plans for this purpose. Where interest and commitment are high, this may also be possible and effective in other African countries.

Implementing primary health care-based PMTCT interventions: operational perspectives from Muhima cohort analysis (Rwanda).

INTRODUCTION: In countries with high burden of HIV, major programmatic challenges have been identified to preventing new infections among children and scaling up of treatment for pregnant mothers. We initiated this study to examine operational approaches that were used to enhance implementation of PMTCT interventions in Muhima health Centre (Kigali/Rwanda) from 2007 to 2010. METHODS: The prospective cohort study was conducted at Muhima health centre. A sample size of 656 was the minimum number required for the study. The main outcome was cumulative incidence of mother - to - child transmission of HIV-1 measured at 6 weeks of life among live born children. RESULTS: Among the 679 live born babies and followed up in this study, the overall cumulative rate of HIV-1 mother - to - child transmission observed was 3.2% at 6 weeks of age after birth. Disclosure of HIV status to partner was significantly associated with HIV-1 status of infants at 6 weeks of age (non-disclosure of HIV status adjusted odds ratio [AOR] 4.68, CI 1.39 to 15.77, p. CONCLUSION: The Muhima type of decentralized health facility offered an appropriate platform for implementation of PMTCT interventions, with the following operational features: family - centered approach; integrated service delivery for PMTCT/MCH interventions, task shifting; subsidized membership fees for people living with HIV, allowing for access to the community-based health insurance benefits.

Socio-economic, clinical and biological risk factors for mother - to - child transmission of HIV-1 in Muhima health centre (Rwanda): a prospective cohort study.

BACKGROUND: Three decades since the first HIV-1 infected patients in Rwanda were identified in 1983; the Acquired Immunodeficiency Syndrome epidemic has had a devastating history and is still a major public health challenge in the country. This study was aimed at assessing socioeconomic, clinical and biological risk factors for mother - to - child transmission of HIV- in Muhima health centre (Kigali/Rwanda). METHODS: The prospective cohort study was conducted at Muhima Health centre (Kigali/Rwanda).During the study period (May 2007 - April 2010), of 8,669 pregnant women who attended antenatal visits and screened for HIV-1, 736 tested HIV-1 positive and among them 700 were eligible study participants. Hemoglobin, CD4 count and viral load tests were performed for participant mothers and HIV-1 testing using DNA PCR technique for infants.Follow up data for eligible mother-infant pairs were obtained from women themselves and log books in Muhima health centre and maternity, using a structured questionnaire.Predictors of mother-to-child transmission of HIV-1 were assessed by multivariable logistic regression analysis. RESULTS: Among the 679 exposed and followed-up infants, HIV-1 status was significantly associated with disclosure of HIV status to partner both at 6 weeks of age (non-disclosure of HIV status, adjusted odds ratio [AOR] 4.68, CI 1.39 to 15.77, p < 0.05; compared to disclosure) and at 6 months of age (non-disclosure of HIV status, AOR, 3.41, CI 1.09 to 10.65, p < 0.05, compared to disclosure).A significant association between mother's viral load (HIV-1 RNA) and infant HIV-1 status was found both at 6 weeks of age (> = 1000 copies/ml, AOR 7.30, CI 2.65 to 20.08, p < 0.01, compared to <1000 copies/ml) and at 6 months of age (> = 1000 copies/ml, AOR 4.60, CI 1.84 to 11.49, p < 0.01, compared to <1000 copies/ml). CONCLUSION: In this study, the most relevant factors independently associated with increased risk of mother - to - child transmission of HIV-1 included non-disclosure of HIV status to partner and high HIV-1 RNA. Members of this cohort also showed socioeconomic inequalities, with unmarried status carrying higher risk of undisclosed HIV status. The monitoring of maternal HIV-1 RNA level might be considered as a routinely used test to assess the risk of transmission with the goal of achieving viral suppression as critical for elimination of pediatric HIV, particularly in breastfeeding populations.