Making It Happen: Training health-care providers in emergency obstetric and newborn care

An estimated 289,000 maternal deaths, 2.6 million stillbirths and 2.4 million newborn deaths occur globally each year, with the majority occurring around the time of childbirth. The medical and surgical interventions to prevent this loss of life are known, and most maternal and newborn deaths are in principle preventable. There is a need to build the capacity of health-care providers to recognize and manage complications during pregnancy, childbirth and the post-partum period. Skills-and-drills competency-based training in skilled birth attendance, emergency obstetric care and early newborn care (EmONC) is an approach that is successful in improving knowledge and skills. There is emerging evidence of this resulting in improved availability and quality of care. To evaluate the effectiveness of EmONC training, operational research using an adapted Kirkpatrick framework and a theory of change approach is needed. The Making It Happen programme is an example of this

Frameworks to assess health systems governance: a systematic review

Governance of the health system is a relatively new concept and there are gaps in understanding what health system governance is and how it could be assessed. We conducted a systematic review of the literature to describe the concept of governance and the theories underpinning as applied to health systems; and to identify which frameworks are available and have been applied to assess health systems governance. Frameworks were reviewed to understand how the principles of governance might be operationalized at different levels of a health system. Electronic databases and web portals of international institutions concerned with governance were searched for publications in English for the period January 1994 to February 2016. Sixteen frameworks developed to assess governance in the health system were identified and are described. Of these, six frameworks were developed based on theories from new institutional economics; three are primarily informed by political science and public management disciplines; three arise from the development literature and four use multidisciplinary approaches. Only five of the identified frameworks have been applied. These used the principal–agent theory, theory of common pool resources, North’s institutional analysis and the cybernetics theory. Governance is a practice, dependent on arrangements set at political or national level, but which needs to be operationalized by individuals at lower levels in the health system; multi-level frameworks acknowledge this. Three frameworks were used to assess governance at all levels of the health system. Health system governance is complex and difficult to assess; the concept of governance originates from different disciplines and is multidimensional. There is a need to validate and apply existing frameworks and share lessons learnt regarding which frameworks work well in which settings. A comprehensive assessment of governance could enable policy makers to prioritize solutions for problems identified as well as replicate and scale-up examples of good practice

Interventions for women who report domestic violence during and after pregnancy in low- and middle-income countries: a systematic literature review

Background Domestic violence is a leading cause of social morbidity and may increase during and after pregnancy. In high-income countries screening, referral and management interventions are available as part of standard maternity care. Such practice is not routine in low- and middle-income countries (LMIC) where the burden of social morbidity is high. Methods We systematically reviewed available evidence describing the types of interventions, and/or the effectiveness of such interventions for women who report domestic violence during and/or after pregnancy, living in LMIC. Published and grey literature describing interventions for, and/or effectiveness of such interventions for women who report domestic violence during and/or after pregnancy, living in LMIC was reviewed. Outcomes assessed were (i) reduction in the frequency and/or severity of domestic violence, and/or (ii) improved physical, psychological and/or social health. Narrative analysis was conducted. Results After screening 4818 articles, six studies were identified for inclusion. All included studies assessed women (n = 894) during pregnancy. Five studies reported on supportive counselling; one study implemented an intervention consisting of routine screening for domestic violence and supported referrals for women who required this. Two studies evaluated the effectiveness of the interventions on domestic violence with statistically significant decreases in the occurrence of domestic violence following counselling interventions (488 women included). There was a statistically significant increase in family support following counselling in one study (72 women included). There was some evidence of improvement in quality of life, increased use of safety behaviours, improved family and social support, increased access to community resources, increased use of referral services and reduced maternal depression. Overall evidence was of low to moderate quality. Conclusions Screening, referral and supportive counselling is likely to benefit women living in LMIC who experience domestic violence. Larger-scale, high-quality research is, however, required to provide further evidence for the effectiveness of interventions. Improved availability with evaluation of interventions that are likely to be effective is necessary to inform policy, programme decisions and resource allocation for maternal healthcare in LMIC

Implementation of the free maternity services policy and its implications for health system governance in Kenya.

Introduction To move towards universal health coverage, the government of Kenya introduced free maternity services in all public health facilities in June 2013. User fees are, however, important sources of income for health facilities and their removal has implications for the way in which health facilities are governed. Objective To explore how implementation of Kenya's financing policy has affected the way in which the rules governing health facilities are made, changed, monitored and enforced. Methods Qualitative research was carried out using semistructured interviews with 39 key stakeholders from six counties in Kenya: 10 national level policy makers, 10 county level policy makers and 19 implementers at health facilities. Participants were purposively selected using maximum variation sampling. Data analysis was informed by the institutional analysis framework, in which governance is defined by the rules that distribute roles among key players and shape their actions, decisions and interactions. Results Lack of clarity about the new policy (eg, it was unclear which services were free, leading to instances of service user exploitation), weak enforcement mechanisms (eg, delayed reimbursement to health facilities, which led to continued levying of service charges) and misaligned incentives (eg, the policy led to increased uptake of services thereby increasing the workload for health workers and health facilities losing control of their ability to generate and manage their own resources) led to weak policy implementation, further complicated by the concurrent devolution of the health system. Conclusion The findings show the consequences of discrepancies between formal institutions and informal arrangements. In introducing new policies, policy makers should ensure that corresponding institutional (re)arrangements, enforcement mechanisms and incentives are aligned with the objectives of the implementers

Experiences from the field: maternal, reproductive and child health data collection in humanitarian and emergency situations

Background Humanitarian emergencies can disproportionately affect women of reproductive age, and children. Good data on reproductive maternal, newborn and child health (RMNCH) are vital to plan and deliver programmes to address RMNCH needs. There is currently a lack of information regarding the availability, use and applicability of data collection tools. Methods Key informant interviews (KII) were conducted with participants with experience of data collection in humanitarian settings, identified from relevant publications. Data were analysed using the thematic framework approach. Results All participants reported challenges, especially in the acute phase of an emergency and when there is insufficient security. Four common themes were identified: the importance of a mixed methods approach, language both with regard to development of data collection tools and data collection, the need to modify existing tools and build local capacity for data collection. Qualitative data collection was noted to be time consuming but considered to be important to understand the local context. Both those who have experienced trauma (including sexual violence) and data collectors require debriefing after documenting these experiences. Conclusions There were numerous challenges associated with data collection assessing the health status of, and services available, to women and children in humanitarian settings, and researchers should be well prepared

Challenges in the eradication of female genital mutilation/cutting.

Despite more than 40 y of discussion and debate regarding female genital mutilation/cutting (FGM/C), this topic remains controversial and emotive, and the practice continues. FGM/C is defined as ‘all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural or other non-therapeutic reasons’.1 There are four main classifications of FGM/C (Table 1).1 Type III, or ‘infibulation’, is the most severe form and accounts for 10% of cases.2 It is estimated that more than 200 million girls and women worldwide are living with the effects of FGM/C.2 Of these, 44 million are <15 y of age.2 FGM/C is practised mainly in Africa, with the highest prevalence in Somalia, Egypt, Mali and Sudan, where more than 80% of all women between 15 and 49 y of age have undergone FGM/C.2,3 However, FGM/C is also prevalent in other settings including the Middle East, India and Indonesia. The specific type of FGM/C varies within and between countries

Stillbirth in low- and middle-income countries: addressing the 'silent epidemic'.

Annually, an estimated 2.6 million stillbirths occur worldwide.1 With five deaths every single minute, stillbirth is the fifth leading global cause of death when compared with causes of death in all age categories—outranking diarrhoea, HIV/AIDS, TB, road traffic accidents and any form of cancer.2 The vast majority (98%) of stillbirths occur in low- and middle-income countries (LMICs). This has also been referred to as the ‘silent epidemic’

Vitamin A supplementation during pregnancy for maternal and newborn outcomes

Background The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin Ad eficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection. Objectives To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30March 2015) and reference lists of retrieved studies. Selection criteria All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results We reviewed 106 reports of 35 trials, published between 1931 and 2015. We included 19 trials including over 310,000 women, excluded 15 trials and one is ongoing. Overall, seven trials were judged to be of low risk of bias, three were high risk of bias and for nine it was unclear

Measuring maternal mortality using a Reproductive Age Mortality Study (RAMOS)

Background Assessing the feasibility of conducting a prospective Reproductive Age Mortality Survey (RAMOS) study in the low-income setting of Mangochi District, Malawi to obtain cotemporaneous estimates of the number, cause of and conditions associated with maternal deaths (MD) in all women of reproductive age (WRA) (n = 207 688). Methods MD among all deaths of WRA were identified using the ICD-10 definition. Cause of death and contributing conditions identified by a panel of experts using the classification system for deaths during pregnancy, childbirth and puerperium (ICD-MM). Results Out of 424 deaths of WRA, 151 were MD giving a Maternal Mortality Ratio (MMR) of 363 per 100,000 live births (95 % CI: 307–425). Only 86 MD had been reported via existing reporting mechanisms representing an underreporting of 43 %. The majority of MD (62.3 %) occurred in a health facility and were the result of direct obstetric causes (74.8 %) with obstetric haemorrhage as the leading cause (35.8 %), followed by pregnancy-related infections (19.4 %), hypertensive disorders (16.8 %) and pregnancy with abortive outcome (13.2 %). Malaria was the most frequently identified indirect cause (9.9 %). Contributing conditions were more frequently identified when both verbal autopsy and facility-based death review had taken place and included obstructed labour (28.5 %), anaemia (12.6 %) and positive HIV status (4.0 %). Conclusion The high number of MD that occur at health facility level, cause of death and contributing conditions reflect deficiencies in the quality of care at health facility level. A RAMOS is feasible in low- and middle-income settings and provides contemporaneous estimates of MMR

Continuous positive airway pressure (CPAP) to treat respiratory distress in newborns in low- and middle-income countries.

Severe respiratory distress is a serious complication common to the three major causes of neonatal mortality and morbidity (prematurity, intra-partum-related hypoxia and infections). In low- and middle-income countries (LMICs), 20% of babies presenting with severe respiratory distress die.Continuous positive airway pressure (CPAP), is an effective intervention for respiratory distress in newborns and widely used in high-income countries. Following the development of simple, safe and relatively inexpensive CPAP devices, there is potential for large-scale implementation in the developing world.In this article, we describe existing CPAP systems and present a review of the current literature examining the effectiveness of CPAP compared to standard care (oxygen) in newborns with respiratory distress. We also discuss the evidence gap which needs to be addressed prior to its integration into health systems in LMICs