Tuberculosis in pregnancy: an estimate of the global burden of disease

Background The estimated number of maternal deaths in 2013 worldwide was 289 000, a 45% reduction from 1990. Non-obstetric causes such as infectious diseases including tuberculosis now account for 28% of maternal deaths. In 2013, 3·3 million cases of tuberculosis were estimated to occur in women globally. During pregnancy, tuberculosis is associated with poor outcomes, including increased mortality in both the neonate and the pregnant woman. The aim of our study was to estimate the burden of tuberculosis disease among pregnant women, and to describe how maternal care services could be used as a platform to improve case detection. Methods We used publicly accessible country-level estimates of the total population, distribution of the total population by age and sex, crude birth rate, estimated prevalence of active tuberculosis, and case notifi cation data by age and sex to estimate the number of pregnant women with active tuberculosis for 217 countries. We then used indicators of health system access and tuberculosis diagnostic test performance obtained from published literature to determine how many of these cases could ultimately be detected. Findings We estimated that 216 500 (95% uncertainty range 192 100–247 000) active tuberculosis cases existed in pregnant women globally in 2011. The greatest burdens were in the WHO African region with 89 400 cases and the WHO South East Asian region with 67 500 cases in pregnant women. Chest radiography or Xpert RIF/MTB, delivered through maternal care services, were estimated to detect as many as 114 100 and 120 300 tuberculosis cases, respectively. Interpretation The burden of tuberculosis disease in pregnant women is substantial. Maternal care services could provide an important platform for tuberculosis detection, treatment initiation, and subsequent follow-up. Funding United States Agency for International Development

Assessing the Continuum of Care Pathway for Maternal Health in South Asia and Sub-Saharan Africa

We assess how countries in regions of the world where maternal mortality is highest - South Asia and Sub-Saharan Africa - are performing with regards to providing women with vital elements of the continuum of care

Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries.

INTRODUCTION: Antenatal care (ANC) provides a critical opportunity for women and babies to benefit from good-quality maternal care. Using 10 countries as an illustrative analysis, we described ANC coverage (number of visits and timing of first visit) and operationalised indicators for content of care as available in population surveys, and examined how these two approaches are related. METHODS: We used the most recent Demographic and Health Survey to analyse ANC related to women's most recent live birth up to 3 years preceding the survey. Content of care was assessed using six components routinely measured across all countries, and a further one to eight additional country-specific components. We estimated the percentage of women in need of ANC, and using ANC, who received each component, the six routine components and all components. RESULTS: In all 10 countries, the majority of women in need of ANC reported 1+ ANC visits and over two-fifths reported 4+ visits. Receipt of the six routine components varied widely; blood pressure measurement was the most commonly reported component, and urine test and information on complications the least. Among the subset of women starting ANC in the first trimester and receiving 4+ visits, the percentage receiving all six routinely measured ANC components was low, ranging from 10% (Jordan) to around 50% in Nigeria, Nepal, Colombia and Haiti. CONCLUSION: Our findings suggest that even among women with patterns of care that complied with global recommendations, the content of care was poor. Efficient and effective action to improve care quality relies on development of suitable content of care indicators

Summary findings from a mixed methods study on identifying and responding to maternal and newborn illness in seven countries: implications for programs

Background: There is a lack of systematic information documenting recognition of potentially life-threatening complications and decisions to seek care, as well as reaching care and the specific steps in that process. In response to this gap in knowledge, a multi-country mixed methods study was conducted to illuminate the dynamics driving Delays 1 and 2 across seven countries for maternal and newborn illness and death. Methods: A common protocol and tools were developed, adapted by each of seven study teams depending on their local context (Ethiopia, India, Indonesia, Nigeria, Tanzania, Uganda, and Nepal). Maternal and newborn illness, and maternal and newborn death cases were included. Trained interviewers conducted event narratives to elicit and document a detailed sequence of actions, from onset of symptoms to the resolution of the problem. Event timelines were constructed, and in-depth interviews with key informants in the community were conducted. Transcripts were coded and analyzed for common themes corresponding to the three main domains of recognition, decision-making, and care-seeking. Results: Maternal symptom recognition and decision-making to seek care is faster than for newborns. Perceived cause of the illness (supernatural vs. biological) influences the type of care sought (spiritual/traditional vs. formal sector, skilled). Mothers, fathers, and other relatives tend to be the decision-makers for newborns while husbands and elder females make decisions for maternal cases. Cultural norms such as confinement periods and perceptions of newborn vulnerability result in care being brought in to the home. Perceived and actual poor quality of care was repeatedly experienced by families seeking care. Conclusion: The findings link to three action points: (1) messaging around newborn illness needs to reinforce a sense of urgency and the need for skilled care regardless of perceived cause; (2) targeted awareness building around specific maternal danger signs that are not currently recognized and where quality care is available is needed; and (3) designing appropriate contextualized messages. This research links to and supports a number of current global initiatives such as Ending Preventable Maternal Mortality, the Every Newborn Action Plan, the WHO Quality of Care framework, and the WHO guidelines on simplified management of newborn sepsis at the community level. This type of research is invaluable for designing programs to improve maternal and newborn survival to achieve ambitious global targets

Postpartum Haemorrhage and Eclampsia: Differences in Knowledge and Care-seeking Behaviour in Two Districts of Bangladesh

In high- and low-performing districts of Bangladesh, the study explored the demand-side of maternal healthcare by looking at differences in perceived knowledge and care-seeking behaviours of women in relation to postpartum haemorrhage or eclampsia. Haemorrhage and eclampsia are two major causes of maternal mortality in Bangladesh. The study was conducted during July 2006–December 2007. Both postpartum bleeding and eclampsia were recognized by women of different age-groups as severe and life-threatening obstetric complications. However, a gap existed between perception and actual care-seeking behaviours which could contribute to the high rate of maternal deaths associated with these conditions. There were differences in care-seeking practices among women in the two different areas of Bangladesh, which may reflect sociocultural differences, disparities in economic and educational opportunities, and a discrimination in the availability of care

Birth-Preparedness for Maternal Health: Findings from Koup\ueala District, Burkina Faso

Maternal mortality is a global burden, with more than 500,000 women dying each year due to preg\uadnancy and childbirth-related complications. Birth-preparedness and complication readiness is a com\uadprehensive strategy to improve the use of skilled providers at birth, the key intervention to decrease maternal mortality. Birth-preparedness and complication readiness include many elements, including: (a) knowledge of danger signs; (b) plan for where to give birth; (c) plan for a birth attendant; (d) plan for transportation; and (e) plan for saving money. The 2003 Burkina Faso Demographic and Health Survey indicated that only 38.5% of women gave birth with the assistance of a skilled pro\uadvider. The Maternal and Neonatal Health Program of JHPIEGO implemented a district-based model service-delivery system in Koup\ue9la, Burkina Faso, during 2001-2004, to increase the use of skilled providers during pregnancy and childbirth. In 2004, a cross-sectional survey with a random sample of respondents was conducted to measure the impact of birth-preparedness and complication readiness on the use of skilled providers at birth. Of the 180 women who had given birth within 12 months of the survey, 46.1% had a plan for transportation, and 83.3% had a plan to save money. Women with these plans were more likely to give birth with the assistance of a skilled provider (p=0.07 and p=0.03 respectively). Controlling for education, parity, average distance to health facility, and the number of antenatal care visits, planning to save money was associated with giving birth with the assistance of a skilled provider (p=0.05). Qualitative interviews with women who had given birth within 12 months of the survey (n=30) support these findings. Most women saved money for delivery, but had less concrete plans for transportation. These findings highlight how birth-preparedness and complication readiness may be useful in increasing the use of skilled providers at birth, especially for women with a plan for saving money during pregnancy

Improved measurement for mothers, newborns and children in the era of the Sustainable Development Goals.

BACKGROUND: An urgent priority in maternal, newborn and child health is to accelerate the scale-up of cost-effective essential interventions, especially during labor, the immediate postnatal period and for the treatment of serious infectious diseases and acute malnutrition.  Tracking intervention coverage is a key activity to support scale-up and in this paper we examine priorities in coverage measurement, distinguishing between essential interventions that can be measured now and those that require methodological development. METHODS: We conceptualized a typology of indicators related to intervention coverage that distinguishes access to care from receipt of an intervention by the population in need.  We then built on documented evidence on coverage measurement to determine the status of indicators for essential interventions and to identify areas for development. RESULTS: Contact indicators from pregnancy to childhood were identified as current indicators for immediate use, but indicators reflecting the quality of care provided during these contacts need development. At each contact point, some essential interventions can be measured now, but the need for development of indicators predominates around interventions at the time of birth and interventions to treat infections. Addressing this need requires improvements in routine facility based data capture, methods for linking provider and community-based data, and improved guidance for effective coverage measurement that reflects the provision of high-quality care. CONCLUSION: Coverage indicators for some essential interventions can be measured accurately through household surveys and be used to track progress in maternal, newborn and child health.  Other essential interventions currently rely on contact indicators as proxies for coverage but urgent attention is needed to identify new measurement approaches that directly and reliably measure their effective coverage

The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012

Abstract Background The paper’s primary purpose is to determine changes in magnitude and causes of institutional maternal mortality in Mozambique. We also describe shifts in the location of institutional deaths and changes in availability of prevention and treatment measures for malaria and HIV infection. Methods Two national cross-sectional assessments of health facilities with childbirth services were conducted in 2007 and 2012. Each collected retrospective data on deliveries and maternal deaths and their causes. In 2007, 2,199 cases of maternal deaths were documented over a 12 month period; in 2012, 459 cases were identified over a three month period. In 2007, data collection also included reviews of maternal deaths when records were available (n = 712). Results Institutional maternal mortality declined from 541 to 284/100,000 births from 2007 to 2012. The rate of decline among women dying of direct causes was 66 % compared to 26 % among women dying of indirect causes. Cause-specific mortality ratios fell for all direct causes. Patterns among indirect causes were less conclusive given differences in cause-of-death recording. In absolute numbers, the combination of antepartum and postpartum hemorrhage was the leading direct cause of death each year and HIV and malaria the main non-obstetric causes. Based on maternal death reviews, evidence of HIV infection, malaria or anemia was found in more than 40 % of maternal deaths due to abortion, ectopic pregnancy and sepsis. Almost half (49 %) of all institutional maternal deaths took place in the largest hospitals in 2007 while in 2012, only 24 % occurred in these hospitals. The availability of antiretrovirals and antimalarials increased in all types of facilities, but increases were most dramatic in health centers. Conclusions The rate at which women died of direct causes in Mozambique’s health facilities appears to have declined significantly. Despite a clear improvement in access to antiretrovirals and antimalarials, especially at lower levels of health care, malaria, HIV, and anemia continue to exact a heavy toll on child-bearing women. Going forward, efforts to end preventable maternal and newborn deaths must maximize the use of antenatal care that includes integrated preventive/treatment options for HIV infection, malaria and anemia

What is meant by validity in maternal and newborn health measurement? A conceptual framework for understanding indicator validation.

BACKGROUND: Rigorous monitoring supports progress in achieving maternal and newborn mortality and morbidity reductions. Recent work to strengthen measurement for maternal and newborn health highlights the existence of a large number of indicators being used for this purpose. The definitions and data sources used to produce indicator estimates vary and challenges exist with completeness, accuracy, transparency, and timeliness of data. The objective of this study is to create a conceptual overview of how indicator validity is defined and understood by those who develop and use maternal and newborn health indicators. METHODS: A conceptual framework of validity was developed using mixed methods. We were guided by principles for conceptual frameworks and by a review of the literature and key maternal and newborn health indicator guidance documents. We also conducted qualitative semi-structured interviews with 32 key informants chosen through purposive sampling. RESULTS: We categorised indicator validity into three main types: criterion, convergent, and construct. Criterion or diagnostic validity, comparing a measure with a gold standard, has predominantly been used to assess indicators of care coverage and content. Studies assessing convergent validity quantify the extent to which two or more indicator measurement approaches, none of which is a gold-standard, relate. Key informants considered construct validity, or the accuracy of the operationalisation of a concept or phenomenon, a critical part of the overall assessment of indicator validity. CONCLUSION: Given concerns about the large number of maternal and newborn health indicators currently in use, a more consistent understanding of validity can help guide prioritization of key indicators and inform development of new indicators. All three types of validity are relevant for evaluating the performance of maternal and newborn health indicators. We highlight the need to establish a common language and understanding of indicator validity among the various global and local stakeholders working within maternal and newborn health

Ending preventable maternal mortality: phase II of a multi-step process to develop a monitoring framework, 2016–2030

Background In February 2015, the World Health Organization (WHO) released “Strategies toward ending preventable maternal mortality (EPMM)” (EPMM Strategies), a direction-setting report outlining global targets and strategies for reducing maternal mortality in the Sustainable Development Goal (SDG) period. In May 2015, the EPMM Working Group outlined a plan to develop a comprehensive monitoring framework to track progress toward the achievement of these targets and priorities. This monitoring framework was developed in two phases. Phase I, which focused on identifying indicators related to the proximal causes of maternal mortality, was completed in October 2015. This paper describes the process and results of Phase II, which was completed in November 2016 and aimed to build consensus on a set of indicators that capture information on the social, political, and economic determinants of maternal health and mortality. Findings A total of 150 experts from more than 78 organizations worldwide participated in this second phase of the process to develop a comprehensive monitoring framework for EPMM. The experts considered a total of 118 indicators grouped into the 11 key themes outlined in the EPMM report, ultimately reaching consensus on a set of 25 indicators, five equity stratifiers, and one transparency stratifier. Conclusion The indicators identified in Phase II will be used along with the Phase I indicators to monitor progress towards ending preventable maternal deaths. Together, they provide a means for monitoring not only the essential clinical interventions needed to save lives but also the equally important political, social, economic and health system determinants of maternal health and survival. These distal factors are essential to creating the enabling environment and high-performing health systems needed to ensure high-quality clinical care at the point of service for every woman, her fetus and newborn. They complement and support other monitoring efforts, in particular the “Survive, Thrive, and Transform” agenda laid out by the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) and the SDG3 global target on maternal mortality