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Use of Service Provision Assessments and Service Availability and Readiness Assessments for monitoring quality of maternal and newborn health services in low-income and middl-income countries.
BMJ Global Health. 2018 Dec 1; 3(6):e001011.Improving the quality of maternal and newborn health (MNH) services is key to reducing adverse MNH outcomes in low-income and middle-income countries (LMICs). The Service Provision Assessment (SPA) and Service Availability and Readiness Assessment (SARA) are the most widely employed, standardised tools that generate health service delivery data in LMICs. We ascertained the use of SPA/SARA surveys for assessing the quality of MNH services using a two-step approach: a SPA/SARA questionnaire mapping exercise in line with WHO’s Quality of Care (QoC) Framework for pregnant women and newborns and the WHO quality standards for care around the time of childbirth; and a scoping literature review, searching for articles that report SPA/SARA data. SPA/SARA surveys are well suited to assess the WHO Framework’s cross-cutting dimensions (physical and human resources); SPA also captures elements in the provision and experience of care domains for antenatal care and family planning. Only 4 of 31 proposed WHO quality indicators around the time of childbirth can be fully generated using SPA and SARA surveys, while 19 and 23 quality indicators can be partially obtained from SARA and SPA surveys, respectively; most of these are input indicators. Use of SPA/SARA data is growing, but there is considerable variation in methods employed to measure MNH QoC. With SPA/SARA data available in 30 countries, MNH QoC assessments could benefit from guidance for creating standard metrics. Adding questions in SPA/SARA surveys to assess the WHO QoC Framework’s provision and experience of care dimensions would fill significant data gaps in LMICs.
Adaptation of the WHO maternal near miss tool for use in sub-Saharan Africa: an International Delphi study.
BMC Pregnancy and Childbirth. 2017 Dec 29; 17(1):445.BACKGROUND: Assessments of maternal near miss (MNM) are increasingly used in addition to those of maternal mortality measures. The World Health Organization (WHO) has introduced an MNM tool in 2009, but this tool was previously found to be of limited applicability in several low-resource settings. The aim of this study was to identify adaptations to enhance applicability of the WHO MNM tool in sub-Saharan Africa. METHODS: Using a Delphi consensus methodology, existing MNM tools were rated for applicability in sub-Saharan Africa over a series of three rounds. Maternal health experts from sub-Saharan Africa or with considerable knowledge of the context first rated importance of WHO MNM parameters using Likert scales, and were asked to suggest additional parameters. This was followed by two confirmation rounds. Parameters accepted by at least 70% of the panel members were accepted for use in the region. RESULTS: Of 58 experts who participated from study onset, 47 (81%) completed all three rounds. Out of the 25 WHO MNM parameters, all 11 clinical, four out of eight laboratory, and four out of six management-based parameters were accepted, while six parameters (PaO2/FiO2 < 200 mmHg, bilirubin >100 mumol/l or >6.0 mg/dl, pH <7.1, lactate >5 mumol/l, dialysis for acute renal failure and use of continuous vasoactive drugs) were deemed to not be applicable. An additional eight parameters (uterine rupture, sepsis/severe systemic infection, eclampsia, laparotomy other than caesarean section, pulmonary edema, severe malaria, severe complications of abortions and severe pre-eclampsia with ICU admission) were suggested for inclusion into an adapted sub-Saharan African MNM tool. CONCLUSIONS: All WHO clinical criteria were accepted for use in the region. Only few of the laboratory- and management based were rated applicable. This study brought forward important suggestions for adaptations in the WHO MNM criteria to enhance its applicability in sub-Saharan Africa and possibly other low-resource settings.
BMC Pregnancy and Childbirth. 2017 Jun 19; 17(1):194.BACKGROUND: WHO proposed the WHO Maternal Near Miss (MNM) tool, classifying women according to several (potentially) life-threatening conditions, to monitor and improve quality of obstetric care. The objective of this study is to analyse merged data of one high- and two low-resource settings where this tool was applied and test whether the tool may be suitable for comparing severe maternal outcome (SMO) between these settings. METHODS: Using three cohort studies that included SMO cases, during two-year time frames in the Netherlands, Tanzania and Malawi we reassessed all SMO cases (as defined by the original studies) with the WHO MNM tool (five disease-, four intervention- and seven organ dysfunction-based criteria). Main outcome measures were prevalence of MNM criteria and case fatality rates (CFR). RESULTS: A total of 3172 women were studied; 2538 (80.0%) from the Netherlands, 248 (7.8%) from Tanzania and 386 (12.2%) from Malawi. Total SMO detection was 2767 (87.2%) for disease-based criteria, 2504 (78.9%) for intervention-based criteria and 1211 (38.2%) for organ dysfunction-based criteria. Including every woman who received >/=1 unit of blood in low-resource settings as life-threatening, as defined by organ dysfunction criteria, led to more equally distributed populations. In one third of all Dutch and Malawian maternal death cases, organ dysfunction criteria could not be identified from medical records. CONCLUSIONS: Applying solely organ dysfunction-based criteria may lead to underreporting of SMO. Therefore, a tool based on defining MNM only upon establishing organ failure is of limited use for comparing settings with varying resources. In low-resource settings, lowering the threshold of transfused units of blood leads to a higher detection rate of MNM. We recommend refined disease-based criteria, accompanied by a limited set of intervention- and organ dysfunction-based criteria to set a measure of severity.
An evidence map of social, behavioural and community engagement interventions for reproductive, maternal, newborn and child health.
Geneva, Switzerland, WHO, 2017. 190 p.The Every Woman Every Child (EWEC) Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) calls for action towards three objectives: Survive (end preventable deaths), Thrive (ensure health and well-being) and Transform (expand enabling environments). The strategy recognizes that “women, children and adolescents are potentially the most powerful agents for improving their own health and achieving prosperous and sustainable societies”. Social, behavioural and community engagement (SBCE) interventions are key to empowering individuals, families and communities to contribute to better health and well-being of women, children and adolescents. Policy-makers and development practitioners need to know which interventions work best. WHO has provided global guidance on some key SBCE interventions, and we recognize there is more work to be done as this will be an area of increasing importance in the era of the Sustainable Development Goals (SDGs) and the EWEC Global Strategy. This document provides an evidence map of existing research into a set of selected SBCE interventions for reproductive, maternal, newborn, and child health (RMNCH), the fruit of a collaboration between the WHO, the Partnership for Maternal, Newborn & Child Health (PMNCH) and the International Initiative for Impact Evaluations (3ie), supported by other partners. It represents an important way forward in this area, harnessing technical expertise, and academia to strengthen knowledge about the evidence base. The evidence map provides a starting point for making available existing research into the effectiveness of RMNCH SBCE interventions, a first step toward providing evidence for decision-making. It will enable better use of existing knowledge and pinpoint where new research investments can have the greatest impact. An online platform that complements the report provides visualization of the findings, displaying research concentrations and gaps.
Effectiveness of the WHO Safe Childbirth Checklist program in reducing severe maternal, fetal, and newborn harm in Uttar Pradesh, India: study protocol for a matched-pair, cluster-randomized controlled trial.
Trials. 2016 Dec 7; 17(1):576.BACKGROUND: Effective, scalable strategies to improve maternal, fetal, and newborn health and reduce preventable morbidity and mortality are urgently needed in low- and middle-income countries. Building on the successes of previous checklist-based programs, the World Health Organization (WHO) and partners led the development of the Safe Childbirth Checklist (SCC), a 28-item list of evidence-based practices linked with improved maternal and newborn outcomes. Pilot-testing of the Checklist in Southern India demonstrated dramatic improvements in adherence by health workers to essential childbirth-related practices (EBPs). The BetterBirth Trial seeks to measure the effectiveness of SCC impact on EBPs, deaths, and complications at a larger scale. METHODS/DESIGN: This matched-pair, cluster-randomized controlled, adaptive trial will be conducted in 120 facilities across 24 districts in Uttar Pradesh, India. Study sites, identified according to predefined eligibility criteria, were matched by measured covariates before randomization. The intervention, the SCC embedded in a quality improvement program, consists of leadership engagement, a 2-day educational launch of the SCC, and support through placement of a trained peer "coach" to provide supportive supervision and real-time data feedback over an 8-month period with decreasing intensity. A facility-based childbirth quality coordinator is trained and supported to drive sustained behavior change after the BetterBirth team leaves the facility. Study participants are birth attendants and women and their newborns who present to the study facilities for childbirth at 60 intervention and 60 control sites. The primary outcome is a composite measure including maternal death, maternal severe morbidity, stillbirth, and newborn death, occurring within 7 days after birth. The sample size (n = 171,964) was calculated to detect a 15% reduction in the primary outcome. Adherence by health workers to EBPs will be measured in a subset of births (n = 6000). The trial will be conducted in close collaboration with key partners including the Governments of India and Uttar Pradesh, the World Health Organization, an expert Scientific Advisory Committee, an experienced local implementing organization (Population Services International, PSI), and frontline facility leaders and workers. DISCUSSION: If effective, the WHO Safe Childbirth Checklist program could be a powerful health facility-strengthening intervention to improve quality of care and reduce preventable harm to women and newborns, with millions of potential beneficiaries. TRIAL REGISTRATION: BetterBirth Study Protocol dated: 13 February 2014; ClinicalTrials.gov: NCT02148952 ; Universal Trial Number: U1111-1131-5647.
Shortages of benzathine penicillin for prevention of mother-to-child transmission of syphilis: An evaluation from multi-country surveys and stakeholder interviews.
PLoS Medicine. 2017 Dec; 14(12):e1002473.BACKGROUND: Benzathine penicillin G (BPG) is the only recommended treatment to prevent mother-to-child transmission of syphilis. Due to recent reports of country-level shortages of BPG, an evaluation was undertaken to quantify countries that have experienced shortages in the past 2 years and to describe factors contributing to these shortages. METHODS AND FINDINGS: Country-level data about BPG shortages were collected using 3 survey approaches. First, a survey designed by the WHO Department of Reproductive Health and Research was distributed to 41 countries and territories in the Americas and 41 more in Africa. Second, WHO conducted an email survey of 28 US Centers for Disease Control and Prevention country directors. An additional 13 countries were in contact with WHO for related congenital syphilis prevention activities and also reported on BPG shortages. Third, the Clinton Health Access Initiative (CHAI) collected data from 14 countries (where it has active operations) to understand the extent of stock-outs, in-country purchasing, usage behavior, and breadth of available purchasing options to identify stock-outs worldwide. CHAI also conducted in-person interviews in the same 14 countries to understand the extent of stock-outs, in-country purchasing and usage behavior, and available purchasing options. CHAI also completed a desk review of 10 additional high-income countries, which were also included. BPG shortages were attributable to shortfalls in supply, demand, and procurement in the countries assessed. This assessment should not be considered globally representative as countries not surveyed may also have experienced BPG shortages. Country contacts may not have been aware of BPG shortages when surveyed or may have underreported medication substitutions due to desirability bias. Funding for the purchase of BPG by countries was not evaluated. In all, 114 countries and territories were approached to provide information on BPG shortages occurring during 2014-2016. Of unique countries and territories, 95 (83%) responded or had information evaluable from public records. Of these 95 countries and territories, 39 (41%) reported a BPG shortage, and 56 (59%) reported no BPG shortage; 10 (12%) countries with and without BPG shortages reported use of antibiotic alternatives to BPG for treatment of maternal syphilis. Market exits, inflexible production cycles, and minimum order quantities affect BPG supply. On the demand side, inaccurate forecasts and sole sourcing lead to under-procurement. Clinicians may also incorrectly prescribe BPG substitutes due to misperceptions of quality or of the likelihood of adverse outcomes. CONCLUSIONS: Targets for improvement include drug forecasting and procurement, and addressing provider reluctance to use BPG. Opportunities to improve global supply, demand, and use of BPG should be prioritized alongside congenital syphilis elimination efforts.
Updated WHO recommendation on tranexamic acid for the treatment of postpartum haemorrhage. Highlights and key messages from the World Health Organization's 2017 Global Recommendation.
Geneva, Switzerland, WHO, 2017 Oct. 5 p. (WHO/RHR/17.21)This summary brief highlights key messages from the updated World Health Organization’s recommendation on Tranexamic acid (TXA) for the treatment of postpartum haemorrhage (PPH), including policy and program implications for translating the TXA recommendation into action at the country level. In 2012, WHO published recommendations for the prevention and treatment of postpartum haemorrhage, including a recommendation on the use of tranexamic acid (TXA) for treatment of PPH. The 2017 updated WHO Recommendation on TXA is based on new evidence on use of TXA for treatment of PPH. Key messages include: 1) The World Health Organization (WHO) recommends early use of intravenous tranexamic acid (TXA) within 3 hours of birth in addition to standard care for women with clinically diagnosed postpartum haemorrhage (PPH) following vaginal birth or caesarean section; 2) Administration of TXA should be considered as part of the standard PPH treatment package and be administered as soon as possible after onset of bleeding and within 3 hours of birth. TXA for PPH treatment should not be initiated more than 3 hours after birth; 3) TXA should be used in all cases of PPH, regardless of whether the bleeding is due to genital tract trauma or other causes; 4) TXA should be administered at a fixed dose of 1 g in 10 mL (100 mg/mL) IV at 1 mL per minute (i.e., administered over 10 minutes), with a second dose of 1 g IV if bleeding continues after 30 minutes; and 5) TXA should be administered via an IV route only for treatment of PPH. Research on other routes of TXA administration is a priority.This summary brief is intended for policy-makers, programme managers, educators and providers.
Bulletin of the World Health Organization. 2017 Jun; 95(6):445-452I.Objective To assess the feasibility of applying the World Health Organization’s proposed 15 indicators of quality of care for maternal and newborn health at health-facility level in low- and middle-income settings. Methods Six of the indicators are about maternal health, five are for newborn health and four are general cross-cutting indicators. We used data collected routinely in facility registers and obtained as part of facility assessments from 963 health-care facilities specializing in maternity services in 10 countries in Africa and Asia. We made a feasibility assessment of the availability of data and the clarity of indicator definitions and identified additional information and data collection processes needed to apply the proposed indicators in real-life settings. Findings Of the indicators evaluated, 10 were clearly defined, of which four could be applied directly in the field and six would require revisions to operationalize them. The other five indicators require further development, with one of them being ready for implementation by using information readily available in registers and four requiring further information before deployment. For indicators that measure coverage of care or availability of services or products, there is a need to further strengthen measurement. Information on emergency obstetric complications was not recorded in a standard manner, thus limiting the reliability of the information. Conclusion While some of the proposed indicators can already be applied, other indicators need to be refined or will need additional sources and methods of data collection to be applied in real-world settings.
Pre-conception counselling for key cardiovascular conditions in Africa: optimising pregnancy outcomes.
Cardiovascular Journal of Africa. 2016 Mar-Apr; 27(2):79-83.The World Health Organisation (WHO) supports pre-conception care (PCC) towards improving health and pregnancy outcomes. PPC entails a continuum of promotive, preventative and curative health and social interventions. PPC identifies current and potential medical problems of women of childbearing age towards strategising optimal pregnancy outcomes, whereas antenatal care constitutes the care provided during pregnancy. Optimised PPC and antenatal care would improve civil society and maternal, child and public health. Multiple factors bar most African women from receiving antenatal care. Additionally, PPC is rarely available as a standard of care in many African settings, despite the high maternal mortality rate throughout Africa. African women and healthcare facilitators must cooperate to strategise cost-effective and cost-efficient PPC. This should streamline their limited resources within their socio-cultural preferences, towards short- and long-term improvement of pregnancy outcomes. This review discusses the relevance of and need for PPC in resource-challenged African settings, and emphasises preventative and curative health interventions for congenital and acquired heart disease. We also consider two additional conditions, HIV/AIDS and hypertension, as these are two of the most important co-morbidities encountered in Africa, with significant burden of disease. Finally we advocate strongly for PPC to be considered as a key intervention for reducing maternal mortality rates on the African continent.
Lancet. 2016 May 14; 387(10032):2060-2.Add to my documents.
Barriers, Facilitators and Priorities for Implementation of WHO Maternal and Perinatal Health Guidelines in Four Lower-Income Countries: A GREAT Network Research Activity.
PloS One. 2016 Nov 2; 11(11):e0160020.BACKGROUND: Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO's Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael's Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these. METHODS: We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers). RESULTS: Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators. CONCLUSION: This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed.
2016; Geneva, Switzerland, WHO, 2016. 38 p.This guideline provides a global, evidence-informed recommendation on iron supplementation in postpartum women, as a public health intervention for the purpose of improving maternal and infant health outcomes. The guideline aims to help Member States and their partners in their efforts to make informed decisions on the appropriate nutrition actions to achieve the Sustainable Development Goals (SDGs), in particular, Goal 2: End hunger, achieve food security and improved nutrition and promote sustainable agriculture.
Maintaining momentum to 2015? an impact evaluation of interventions to improve maternal and child health and nutrition in Bangladesh.
Washington, D.C., World Bank, 2005 Aug.  p. (World Bank Report No. 34462)Improving maternal and child health and nutrition is central to development goals. The importance of these objectives is reflected by their inclusion in poverty-reduction targets such as the Millennium Development Goals (MDGs) and Bangladesh’s Interim Poverty Reduction Strategy Paper, supported by major development partners, including the World Bank and the U.K. Department for International Development (DFID). This report addresses the issue of what publicly supported programs and external assistance from the Bank and other agencies can do to accelerate attainment of such targets as reducing infant mortality by two-thirds. The evidence presented here relates to Bangladesh, a country that has made spectacular progress, but needs to maintain momentum in order to achieve its own poverty-reduction goals. The report addresses the following issues: (1) What has happened to child health and nutrition outcomes and fertility in Bangladesh since 1990? Are the poor sharing in the progress being made? (2) What have been the main determinants of maternal and child health (MCH) outcomes in Bangladesh over this period? (3) Given these determinants, what can be said about the impact of publicly and externally supported programs—notably those of the World Bank and DFID—to improve health and nutrition? (4) To the extent that interventions have brought about positive impacts, have they done so in a cost-effective manner? (excerpt)
A number of factors explain why WHO guideline developers make strong recommendations inconsistent with GRADE guidance.
Journal of Clinical Epidemiology. 2016; 70:111-122.Objective: Many strong recommendations issued by the World Health Organization (WHO) are based on low- or very low-quality (low certainty) evidence (discordant recommendations). Many such discordant recommendations are inconsistent with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance. We sought to understand why WHO makes discordant recommendations inconsistent with GRADE guidance. Study Design and Setting: We interviewed panel members involved in guidelines approved by WHO (2007e2012) that included discordant recommendations. Interviews, recorded and transcribed, focused on use of GRADE including the reasoning underlying, and factors contributing to, discordant recommendations. Results: Four themes emerged: strengths of GRADE, challenges and barriers to GRADE, strategies to improve GRADE application, and explanations for discordant recommendations. Reasons for discordant recommendations included skepticism about the value of making conditional recommendations; political considerations; high certainty in benefits (sometimes warranted, sometimes not) despite assessing evidence as low certainty; and concerns that conditional recommendations will be ignored. Conclusion: WHO panelists make discordant recommendations inconsistent with GRADE guidance for reasons that include limitations in their understanding of GRADE. Ensuring optimal application of GRADE at WHO and elsewhere likely requires selecting panelists who have a commitment to GRADE principles, additional training of panelists, and formal processes to maximize adherence to GRADE principles. Copyright: 2016 Elsevier Inc.
Reproductive Health. 2015; 12:46.In September, the World Health Organization released a statement on preventing and eliminating disrespect and abuse during facility-based childbirth. In addition to this important agenda, attention is also needed for the dignified care of newborns, who also deserve basic human rights and dignified care. In this commentary, we provide examples from the literature and other sources of where respectful care for newborns has been lacking and we give examples of opportunities for integration of maternal and newborn health care going forward. We illustrate the need for respectful treatment and consideration across the continuum of care: for mothers, stillbirths, and all newborns, including those born too soon and those who die in infancy. We explain the need to document cases of neglect and abuse, count all births and deaths, and to include newborns and stillbirths in the respectful care agenda and the post-2015 global reproductive care frameworks.
A practical guide for engaging with mobile network operators in mHealth for reproductive, maternal, newborn and child health.
Geneva, Switzerland, WHO, 2015.  p.The field of mobile health (mHealth) is experiencing a real need for guidance on public-private partnerships among players as diverse as the mobile industry, technology vendors, government stakeholders and mHealth service providers. This guide provides a practical resource for mHealth service providers (e.g. developers and implementers) to partner more strategically with one of these critical players -- the mobile network operators (MNOs). Despite the growing literature on how to develop partnerships, there is a lack of clear, practical strategies for the health community to engage with MNOs to better scale up mHealth services. This document distils best practices and industry-wide lessons by providing key motivators, challenges and recommendations for mHealth service providers to engage with MNOs for scaling up their initiatives. (Excerpts)
The World Health Organization Multicountry Survey on Maternal and Newborn Health project at a glance: the power of collaboration.
BJOG: An International Journal of Obstetrics and Gynaecology. 2014 Mar; 121 Suppl 1:v-viii.Add to my documents.
Washington, D.C., Program for Appropriate Technology in Health [PATH], 2013.  p.This toolkit provides information about the UN Commission on Life-Saving Commodities (the Commission), 13 priority commodities, and examples of how its ten recommendations to improve access and availability are being applied globally and within countries. It also provides advocacy resources for utilizing the Commission platform to raise awareness and engage stakeholders in addressing commodity-related gaps in policy.
Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study.
Lancet. 2013 May 18; 381(9879):1747-1755.Background: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. Methods: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; i.e., maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (e.g., the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (i.e., the ability to produce a positive effect on health outcomes) through standardised mortality ratios. Results: From May 1, 2010, to Dec 31, 2011, we included 314 623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]). Interpretation: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy.
Lancet. 2013 May 18; 381(9879):1689.Although not to the same degree as in developing countries, maternal mortality remains a problem in the USA, especially among underserved populations. Pregnant women in the USA are affected by the same life-threatening health disorders as women worldwide: hypertension, hemorrhage, and sepsis, among others. The author discusses in a woman’s ability to obtain health insurance in the USA. The Affordable Care Act, the Department of Health and Human Services, and the Center for Medicare and Medicaid Innovation have changed the way women access health services during pregnancy and enhanced prenatal care models. The author encourages that all parties assess the state of women’s health in their home countries, which includes both developing and developed countries.
The special programme of research in human reproduction: forty years of activities to achieve reproductive health for all.
Gynecologic and Obstetric Investigation. 2012; 74(3):190-217.The Special Programme of Research in Human Reproduction (HRP), co-sponsored by the UNDP, UNFPA, WHO, and the World Bank, is celebrating 40 years of activities with an expansion of its mandate and new co-sponsors. When it began, in 1972, the main focus was on evaluating the acceptability, effectiveness, and safety of existing fertility-regulating methods, as well as developing new, improved modalities for family planning. In 1994, HRP not only made major contributions to the Plan of Action of the International Conference on Population and Development (ICPD); it also broadened its scope of work to include other aspects of health dealing with sexuality and reproduction, adding a specific perspective on gender issues and human rights. In 2002, HRP's mandate was once again broadened to include sexually transmitted infections and HIV/AIDS and in 2003 it was further expanded to research activities on preventing violence against women and its many dire health consequences. Today, the work of the Programme includes research on: the sexual and reproductive health of adolescents, women, and men; maternal and perinatal health; reproductive tract and sexually transmitted infections (including HIV/AIDS); family planning; infertility; unsafe abortion; sexual health; screening for cancer of the cervix in developing countries, and gender and reproductive rights. Additional activities by the Programme have included: fostering international cooperation in the field of human reproduction; the elaboration of WHO's first Global Reproductive Health Strategy; work leading to the inclusion of ICPD's goal 'reproductive health for all by 2015' into the Millennium Development Goal framework; the promotion of critical interagency statements on the public health, legal, and human rights implications of female genital mutilation and gender-biased sex selection. Finally, HRP has been involved in the creation of guidelines and tools, such as the 'Medical eligibility criteria for contraceptive use', the 'Global handbook for family planning providers', the 'Definition of core competencies in primary health care', and designing tools for operationalizing a human rights approach to sexual and reproductive health programmes. Copyright (c) 2012 S. Karger AG, Basel.
Geneva, Switzerland, WHO, 2012. 41 p.Postpartum haemorrhage (PPH) is a major cause of mortality, morbidity and long term disability related to pregnancy and childbirth. Effective interventions to prevent and treat PPH exist and can largely reduce the burden of this life-threatening condition. Given the availability of new scientific evidence related to the prevention and treatment of PPH, this document updates previous WHO recommendations and adds new recommendations for the prevention and treatment of PPH. The primary goal of this guideline is to provide a foundation for the implementation of interventions shown to have been effective in reducing the burden of PPH. Health professionals responsible for developing national and local health policies constitute the main target audience of this document. Obstetricians, midwives, general medical practitioners, health care managers and public health policy-makers, particularly in under-resourced settings are also targeted. This document establishes general principles of PPH care and it is intended to inform the development of clinical protocols and health policies related to PPH.
Maternal & Newborn Health Road Maps: a review of progress in 33 sub-Saharan African countries, 2008-2009.
Reproductive Health Matters. 2012 Jun; 20(39):164-8.The 2006 Maputo Plan of Action aimed to help African nations to achieve the Millennium Development Goals related to reducing maternal mortality, combatting HIV and AIDS, and reducing infant and child mortality within integrated sexual and reproductive health care plans. In 2008 and 2009, UNFPA worked with senior Ministry of Health officials and national UNFPA, UNICEF and WHO teams in 33 African countries to review their development of national Maternal and Newborn Health strategies and plans through a self-assessment survey. The survey showed that many key components were missing, in particular there was poor integration of family planning; lack of budgetary, infrastructure and human resources plans; and weak monitoring and evaluation provisions. The maternal and newborn health Road Map initiative has been the single most important factor for the initiation and development of the national maternal and newborn health plans for many African countries. However the deficiencies within these national plans need to be addressed before a significant reduction in maternal and newborn mortality can realistically be achieved. Copyright (c) 2012 Reproductive Health Matters. Published by Elsevier Ltd. All rights reserved.
The Millennium Development Goals and the road to 2015: Building on progress and responding to crisis.
Washington, D.C., World Bank, 2010.  p.The Millennium Development Goals provide a multidimensional framework for attacking poverty in a world of multipolar growth. By focusing on measurable results, they provide a scorecard for assessing progress toward mutually agreed targets. And by enlisting the support of national governments, international agencies, and civil society in a development partnership, they have brought greater coherence to the global development effort. In this way they take us beyond the old, sterile opposition of “developed” and “developing” or “north” and “south.” The evidence from the last 20 years, documented in the statistical record of the MDGs, is that where conditions and policies are right for growth with equity, rapid and sustainable progress toward improving the lives of the poorest people can take place. Not every country will achieve the global MDG targets in the time allowed. Success has not been distributed evenly and there have been serious setbacks. Some countries are still burdened by legacies of bad policies, institutional failures, and civil and international conflict. For them, progress toward the MDGs has been delayed, but the examples of good progress by others point the way for their eventual success.
Focus UNFPA: Four recommendations for action. Report of the CGD Working Group on UNFPA’s Leadership Transition.
Washington, D.C., Center for Global Development, 2011.  p.The United Nations Population Fund (UNFPA) was established in 1969 to generate resources for family planning and provide global leadership on population issues. Since then, the diverse needs of countries and evolving global views of population have placed complex issues on UNFPA’s doorstep. The Center for Global Development Working Group on UNFPA’s Leadership Transition recommends that UNFPA narrow its focus to again become one of the most important and visible vehicles for promoting sexual and reproductive health and reproductive rights globally and in developing countries. Supported by experts within and outside the United Nations (UN), UNFPA should also help countries take account of population issues in the process of pursuing sustainable development. The time is right to reinvigorate UNFPA. Seventeen years after the groundbreaking International Conference on Population and Development, UNFPA needs to make itself the lead agency for population, sexual and reproductive health, and reproductive rights in the UN system, as well as be more visible externally. Recommendation 1: Establish and pursue a limited set of priorities closely related to UNFPA’s unique mission. Recommendation 2: Refine goals and transparently measure progress. Recommendation 3: Align human resources with a focused and renewed mission. Recommendation 4: Rebrand UNFPA as the lead agency for sexual and reproductive health and reproductive rights.