Proceedings of the 2023 International Maternal Newborn Health Conference

doi:10.1186/s12919-024-00289-y

Volume 18 Supplement 5

Proceedings of the 2023 International Maternal and Newborn Health Conference

Meeting abstracts
Open access
Published: 21 March 2024

Proceedings of the 2023 International Maternal Newborn Health Conference

BMC Proceedings volume 18, Article number: 6 (2024) Cite this article

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F1.1. Networks of care for maternal and newborn health: an approach to strengthening relational elements for quality and respectful care

Katherine Kalaris¹, Allisyn Moran²

¹University of Oxford; ²World Health Organization

BMC Proceedings 2024, 18(5):F1.1

Submission ID #: IMNHC96

Panel ID# (if applicable): DASKP1096

Panel description

Despite global progress in reducing preventable maternal and newborn deaths, high rates of maternal and newborn morbidity and mortality continue, mainly due to poor quality of care. Additional transformational and catalytic approaches are needed to provide high-quality respectful patient-centered care to further improve maternal and newborn well-being and survival. One documented successful approach is Networks of Care (NoC).

NoC are an innovative approach to optimize health system functioning, intentionally creating and strengthening health system relationships to support transformational change in maternal and newborn health. NoC emphasize relational elements, such as empowered multidisciplinary teams, respect, teamwork, trust, communication, collaboration, leadership, and supportive supervision and mentorship, which differentiate it from other health systems strengthening approaches. Functional NoC enable collaborative learning and coordinated continuity of respectful and quality care to optimize linkages for efficient and resilient health systems, and to ultimately improve maternal and newborn survival and well-being. Future opportunities include scaling up the NoC approach at national and sub-national levels and addressing gaps in the evidence base.

The NoC approach has been implemented in many contexts. This panel will provide an overview of the NoC approach, and highlight examples and results of NoC from three countries: Kenya (Makueni County), Nepal (One Heart Worldwide), and Zambia (integrated sexual, reproductive, maternal, and newborn health program).

F1.2. Improving quality of maternal and newborn care through the creation of networks of safety in rural Nepal

Surya Bhatta¹, Katherine Kalaris², Sibylle Kristensen¹

¹One Heart Worldwide; ²University of Oxford

BMC Proceedings 2024, 18(5):F1.2

Submission ID #: IMNHC204

Panel ID# (if applicable): DASKP1096

Background

Although improvements made in maternal and newborn health (MNH) have increased maternal and neonatal survival in Nepal, challenges remain for the country to reach Stage V of the obstetric transition. The international nongovernmental organization One Heart Worldwide (OHW) supports the Government of Nepal’s national plan to provide quality MNH services to pregnant women and their newborns living in rural areas. In collaboration with all levels of the health system, OHW forms Networks of Safety (NoS) to provide quality MNH care in some of Nepal’s most remote and difficult-to-access geographies. These NoS are examples of Networks of Care (NoC). All NoS exhibit core system-strengthening NoC functional elements, such as constructing new birthing centers and providing equipment, along with relational elements such as promoting local ownership, supporting mentorship, and connecting providers from the community level through to tertiary care.

Methods

NoS build local capacity through a participatory model and target infrastructure, local leadership, and local communities over a six-year period. Many network activities are co-financed by the municipalities leveraging a financially sustainable adoption-at-scale solution that addresses the systemic health care access disparities disproportionately affecting mothers and newborns in last-mile environments. NoS also spearhead innovative approaches such as a simulation-based mentorship program to maintain essential clinical skills among rural health care providers and an MNH helpline that supports these providers in clinical decision-making, particularly in emergencies.

Results

In 2022, OHW’s NoS have been expanded to 28 districts across Nepal, reaching a third of districts in the country. As of today, OHW is implementing NoS in 20 districts, covering a population of 6.6 million with 165,000 annual pregnancies, and has completed the program in eight districts. Since 2010, the NoS have improved quality MNH care for more than 414,000 pregnancies in rural Nepal.

Conclusions

OHW’s work shows how NoC are a sustainable approach to provide quality care for MNH in remote and rural areas through innovative strategies and solutions. We will continue to scale and adapt network interventions to ensure access and quality of MNH care and plan to reach 50% of districts by 2030.

F1.3. Reduction of maternal and neonatal mortality within networks of care in Northern Province, Zambia

Morrison Zulu¹, Katherine Kalaris², Andrew Storey¹, Angel Mwiche³

¹Clinton Health Access Initiative; ²University of Oxford; ³Ministry of Health, Zambia

BMC Proceedings 2024, 18(5):F1.3

Submission ID #: IMNHC203

Panel ID# (if applicable): DASKP1096

Note the full manuscript was published in 2022 in PLOS Global Public Health: https://0-www-ncbi-nlm-nih-gov.brum.beds.ac.uk/pmc/articles/PMC10021549/

F2.1. Black Mamas Matter Alliance: advancing the black maternal health, rights, and justice movement

Ayanna Robinson, Philicia Castillo, Angela Aina

Black Mamas Matter Alliance, Inc

BMC Proceedings 2024, 18(5):F2.1

Submission ID #: IMNHC1642

Panel ID# (if applicable): DBXIN211642

Panel Description

The United States (U.S.) is experiencing a maternal health crisis. To meet Sustainable Development Goals, many countries are working to decrease their maternal mortality ratios (MMR), currently achieving a 38% global decrease between 2000 and 2017. However, the U.S. continues to report a significant MMR increase and racial inequities with Black women dying at nearly three times the rate of white women. Black birthing women are also twice as likely as white women to experience severe pregnancy complications.

The Black Mamas Matter Alliance (BMMA), founded in 2016, serves as a national voice and coordinating entity for stakeholders advancing Black maternal health, rights, and justice. We envision a world where Black Mamas have the rights, respect, and resources to thrive before, during, and after pregnancy. BMMA believes that community empowerment and mobilization are vital to its strategy to involve small-scale organizations, health workers, and everyday citizens interacting to increase education and engagement in preventive health promotion activities. Our approach utilizes the strengths of doulas, midwives, and other skilled maternal health actors working with the communities they serve.

This panel will provide an overview of BMMA; the work conducted within our four key pillars of policy, research, care, and culture shift; and the impact on maternal health in the U.S. Speakers will describe BMMA’s process for leveraging Black women’s lived experiences and scholarship to decolonize research, develop policy priorities, identify principles for holistic maternity care, and apply BMMA’s research principles across a variety of projects addressing Black maternal health.

F2.2. Conducting research with, for, and by black birthing people and researchers: operationalizing black mamas matter alliance’s research principles

Sang Hee Won, Philicia Castillo, Ayanna Robinson, Angela Aina

Black Mamas Matter Alliance, Inc

BMC Proceedings 2024, 18(5):F2.2

Submission ID #: IMNHC1670

Panel ID# (if applicable): DBXIN211642

Background

Black women are three times more likely to die from pregnancy-related causes than white women in the United States (U.S.). Yet, research to understand the underlying causes of the inequities have historically marginalized and neglected Black birthing people. The Black Mamas Matter Alliance (BMMA), a national network of Black women-led organizations and professionals, developed best practices for conducting research with, for, and by Black Mamas to redefine how research can, and should, be done in the U.S. to improve Black maternal health outcomes.

Methods

Since 2017, BMMA has been applying its research principles to projects dedicated to addressing inequities in maternal health in the U.S. Two such projects include research examining the role of disrespectful maternity care among Black women in Atlanta, Georgia, and increasing community engagement efforts within state and local maternal mortality review processes. Key activities have included centering community needs, voices, and experts to lead the research; utilizing its alliance structure to uplift Black researchers; instituting regular feedback loops with communities participating in the research; and prioritizing communities in the dissemination of results.

Results

Applying these research principles has enabled BMMA to be responsive to community needs and embrace communities as equal partners in the conduct of research. Key results include elevating the voices of Black birthing people to share their experiences with disrespectful maternity care; empowering communities most affected to provide direct feedback to government entities and funders who have dictated how maternal mortality reviews should be done; and centering community-driven, innovative approaches to improving maternal health in the U.S.

Conclusions

BMMA’s research principles have led to a paradigm shift in how research is done with, for, and by Black Mamas. Application of the principles has transformed the ways in which research and programming around maternal health have traditionally been done in the U.S. by shifting decision-making power and ownership to communities that know best what they need. It has reframed the narrative of Black maternal health from that of deficit to asset-based thinking whereby the communities most affected have the expertise and solutions to fully address inequities in maternal health.

F2.3. Often discussed, but never consulted: leveraging the expertise of the black perinatal workforce, scholars, and birthing people to develop principles and priorities addressing the maternal mortality crisis in the United States

Philicia Castillo, Ayanna Robinson, Sang Hee Won, Angela Aina

Black Mamas Matter Alliance, Inc

BMC Proceedings 2024, 18(5):F2.3

Submission ID #: IMNHC1656

Panel ID# (if applicable): DBXIN211642

Background

The United States (U.S.) is experiencing a maternal health crisis with maternal mortality ratios increasing over the last 20 years and disproportionately affecting Black women who are dying from largely preventable causes at three times the rate of white women. Addressing this crisis requires maternal health care, policy, and research that is led by the group most affected but often left out of solution creation, Black birthing people. Recognizing this equity, the Black Mamas Matter Alliance (BMMA) created working groups that use strategies grounded in Black birthing people’s lived experience, wisdom, and leadership to advance care, change policy, and cultivate research. These working groups created principles and priorities that the perinatal workforce, researchers, advocates, funders, and other stakeholders can use as guiding posts to combat maternal mortality and collectively achieve Black maternal health, rights, and justice.

Methods

Between 2017 and 2019, BMMA convened alliance partners who are leading experts in maternal and reproductive health and created three working groups: Holistic Care, Policy, and Research. The working groups consisted of Black perinatal professionals, research scholars, policy professionals, and advocates. The groups assessed the current landscape of maternal, sexual, and reproductive health care, policy, and research, and identified gaps.

Results

Principles were created for achieving holistic maternity care, engaging in equitable research with Black communities, and advancing policy priorities grounded in frameworks around reproductive justice and human rights to improve Black maternal health outcomes. Each working group published a report with historical background and framing of the current public health problem that is the maternal mortality crisis among Black birthing people with a set of principles and priorities for widespread use.

Conclusions

The holistic care and research principles and policy priorities created by BMMA take a multi-pronged approach to equipping the perinatal workforce, researchers, advocates, funders, and other stakeholders with the tools and guidelines to collectively support Black Mamas and reduce maternal mortality and morbidity. These principles and priorities are leading the way in a paradigm shift that highlights the expertise Black scholars and the perinatal workforce possess, while supporting and centering Black Mamas in care, policy, and research practices and decisions in the U.S. and globally.

F2.4. Black Mamas Matter Alliance: advancing sexual, reproductive, and maternal health, rights, and justice

Ayanna Robinson, Philicia Castillo, Sang Hee Won, Angela Aina

Black Mamas Matter Alliance, Inc

BMC Proceedings 2024, 18(5):F2.4

Submission ID #: IMNHC1645

Panel ID# (if applicable): DBXIN211642

Background

The maternal mortality ratio for Black women in the United States is two to three times greater than white women, with 55.3 deaths per 100,000 live births in 2020. The Centers for Disease Control and Prevention notes that 80% of these deaths are preventable, acknowledging the role of racism and the need to address disparities in pregnancy-related mortality. The Black Mamas Matter Alliance (BMMA) is a national network of Black women-led organizations and professionals whose work is rooted in the birth/reproductive justice, respectful maternity care, and human rights framework. The alliance is made up of 40 community-based organizations and 25 individual collaborators.

Methods

BMMA approaches our work through four pillars: policy, research, care, and culture shift. We introduce and advance policy grounded in the human rights framework that addresses Black maternal health inequity and improves Black maternal health outcomes [Policy]; leverage talent and knowledge that exist in Black communities and cultivate innovative research methods to generate the evidence base for Black maternal health and inform the policy agenda to improve Black maternal health [Research]; promote holistic and comprehensive care for better outcomes for Black women, their children, families, and ultimately their communities [Care]; and redirect and reframe conversations on Black maternal health and amplify the voices of Black Mamas [Culture Shift].

Results

BMMA has made significant progress in advancing Black maternal health, rights, and justice in the United States. In 2018, BMMA founded the national Black Maternal Health Week, which led to the White House marking the first-ever federal Maternal Health Day of Action in 2021. BMMA also founded the Black Maternal Health Conference and Training Institute with more than 1,000 attendees in 2022. BMMA provides opportunities for professionals to gain continuing education credits and increase knowledge, skills, and competencies in Black maternal health through trainings and webinars. We convened our partners around strategic topic areas and created working groups, fellowships, and publications across our four focus areas.

Conclusions

By centering Black women’s leadership, BMMA’s work has the potential to change lives beyond maternal health and further support broader systems change by addressing racial and gender inequity and supporting holistic models of care.

F3.1. My job, my voice: harnessing midwives’ demands at scale to strengthen the enabling environment for midwifery

Kimberly Whipkey, Angela Nguku, Elena Ateva

White Ribbon Alliance

BMC Proceedings 2024, 18(5):F3.1

Submission ID #: IMNHC651

Panel ID# (if applicable): DDPCP78651

Panel Description

Midwives play a pivotal role in reducing maternal and neonatal mortality and stillbirths in low- and middle-income countries and providing women with sexual and reproductive health services. Yet, the midwifery workforce is in crisis. There is an estimated global shortage of 900,000 midwives due to fewer intakes into educational institutions; inadequate investment in recruitment, deployment, and remuneration; and a weak supportive environment.

White Ribbon Alliance (WRA) pioneered an innovative programmatic approach that both increases political will to invest in midwives and accelerates national policy change, all in accordance with midwives’ priorities. Midwives’ Voices, Midwives’ Demands (MVMD) is a groundbreaking campaign launched in 2021 by WRA, the International Confederation of Midwives (ICM), and partners. The campaign was based on an open-ended question: “What do you want most in your role as a midwife?” WRA and ICM selected nine focus countries in Africa, Asia, and Europe for intensive outreach. Trained mobilizers queried health care providers and recorded responses using the What Women Want Chatbot—a novel digital tool that uses WhatsApp and artificial intelligence to rapidly capture demands and analyze results. Responses from non-focus countries were collected via an e-survey.

MVMD reached 56,000+ midwives in 100 countries. The two largest demands were for more and better-supported personnel, including increased salaries, and for supplies and functional facilities. This panel will explore how campaign partners have used the MVMD process and results to strengthen midwifery policy development and implementation in their countries, creating a more conducive environment based on what midwives say.

F3.2. Amplifying midwives’ perspectives and priorities in the government of India’s rollout of midwifery-led care

Chaitanya Tupaki Sreepoorna¹, Kimberly Whipkey²

¹Centre for Catalyzing Change; ²White Ribbon Alliance

BMC Proceedings 2024, 18(5):F3.2

Submission ID #: IMNHC1419

Panel ID# (if applicable): DDPCP78651

Background

The Nurse Practitioner in Midwifery (NPM) is a new cadre launched by the Government of India (GoI) in 2018. Rollout of NPMs at the national and state levels was significantly stymied due to COVID-19. The Midwives’ Voices, Midwives’ Demands (MVMD) campaign refocused attention on midwives, mobilizing more than 10,000 responses nationwide from NPMs and other cadres providing maternal and newborn health services. Top asks included better facilities and adequate supplies, more staffing and better remuneration, better respect and recognition of the role, and improved autonomy and gender norms.

Methods

Following the mobilization effort, in 2022, the Centre for Catalyzing Change/White Ribbon Alliance India (WRAI) implemented strategic advocacy activities to disseminate MVMD findings and support midwifery research and action agendas. For example, WRA India developed a Charter of Demands with a Call to Action to maternal health experts at the national and state levels, and disseminated campaign findings with midwifery multi-stakeholders in consultations and convenings. WRA India also brought midwives’ demands to technical discussions on implementation research and practice and launched a communications campaign to mobilize policy and programmatic support for their demands.

Results

The MVMD campaign helped fortify government efforts to integrate midwifery-led care in India’s public health system, with demands being particularly useful in supporting implementation of new policies. For example, in June 2021, the GoI launched a first-ever Scope of Practice for midwives. Although the scope of practice has been rolled out, awareness and understanding among practitioners have been uneven. WRA India used its MVMD Call to Action—which elevates midwives’ demands for better recognition of their role and increased autonomy—to socialize the scope of practice and call for empowering midwives to legally practice to their full scope. WRA India is now working with State Nursing Councils on additional licensure needed for midwifery practice that includes the full scope of practice.

Conclusions

MVMD has contributed significantly to making midwives’ demands central to ensuring the success of the GoI’s national rollout of its midwifery program. An MVMD campaign effort can be especially valuable, formative, and catalytic in countries where midwifery cadres are being newly instituted.

F3.3. Creating a national vision and strategic framework for the practice of midwifery in Pakistan reflective of midwives’ priorities

Rafia Rauf Shakeel, Kimberly Whipkey

White Ribbon Alliance

BMC Proceedings 2024, 18(5):F3.3

Submission ID #: IMNHC1415

Panel ID# (if applicable): DDPCP78651

Background

Midwifery is at an inflection point in Pakistan. The country faces an eight-fold shortage of midwives, and the Community Midwives (CMWs) program has not been as successful as envisaged. The federal government, in response, has embarked on developing a new National Vision and Strategic Framework for Midwifery (Strategic Framework). At the same time, Forum for Safe Motherhood (FSM) launched its Midwives’ Voices, Midwives’ Demands campaign (MVMD). FSM heard from 6,145 midwives from across Pakistan including CMWs, Nurses, and Lady Health Visitors. More and better-supported personnel emerged as the top request.

Methods

To shape and align the Strategic Framework with midwives’ priorities, FSM first performed a deeper analysis of campaign demands, examining the geography and cadre. FSM augmented this analysis with midwives’ personal testimonials, especially those of CMWs, to further characterize their challenges and solutions for change. Next, FSM shared MVMD findings and stories with all key stakeholders from the public and private sectors. To build additional buy-in, especially for policy implementation, FSM and partners organized provincial and regional consultative sessions across Pakistan with major academic institutions, provincial departments of health, and directorates of nursing.

Results

MVMD campaign demands not only influenced the architecture of the Strategic Framework, but also shaped the policy actions contained therein. The largest asks from midwives, especially from CMWs, were for government jobs, better support and pay, and a career pathway—all of which were incorporated. Specifically, the Strategic Framework calls for regularization and creation of vacancies for midwives in the government health system; proper policy implementation of the pay scale, with time-scale promotion, remuneration, and upgradation with additional qualification; and development of a proper career ladder, job description, and monitoring mechanisms for midwives.

Conclusions

MVMD brought invaluable field evidence to policy discussions and compelled decision-makers to craft policy actions that responded directly to midwives’ concerns. It also enabled decision-makers to consider the perspectives of those rarely heard, such as CMWs working in rural and remote areas. In addition to guiding the national vision, the Strategic Framework will now serve as a roadmap for provincial midwifery strategies and midwives’ perspectives will once again serve as the evidence for action.

F3.4. Midwives’ voices inform and catalyze a robust national midwifery agenda in Kenya

Sandra Mwarania, Kimberly Whipkey

White Ribbon Alliance

BMC Proceedings 2024, 18(5):F3.4

Submission ID #: IMNHC1406

Panel ID# (if applicable): DDPCP78651

Background

Although midwives and nurses make up most of the health workforce in Kenya, government policies and investments have historically undervalued midwives. As part of the Midwives’ Voices, Midwives’ Demands (MVMD) campaign, White Ribbon Alliance (WRA) Kenya captured the perspectives of more than 3,500 midwives across the country, with top asks related to supplies, increased salaries, and more staff. The campaign coincided with the national government’s push to develop a new national policy on nursing and midwifery, presenting an opportunity to infuse midwives’ priorities.

Methods

In 2021, prior to the launch of MVMD, WRA Kenya implemented a listening exercise with midwives in the Lake Region counties. The challenges they surfaced—shortage of midwives, lack of equipment and supplies, and absence of career pathways—were a harbinger of the MVMD findings to come. WRA Kenya shared these findings with decision-makers to inform early drafts of the national policy. WRA Kenya also organized workshops with MVMD participants to strategize and develop collective advocacy strategies. Several of these midwives were influential members of the taskforce that developed the national policy. Finally, as the national policy was being readied, WRA Kenya partnered with the Midwives Association of Kenya to host a national roundtable with 150 stakeholders and disseminate MVMD results.

Results

In May 2022, the Kenyan Government launched its first-ever National Nursing and Midwifery Policy recognizing midwifery in Kenya as an independent profession. The policy responds directly to the needs of midwives, calling for strengthened education, better remuneration, increased supplies and facility-level investments to enable midwives to deliver quality care, and professional development pathways for the midwifery workforce. MVMD, moreover, helped accelerate other policy outcomes including an expanded scope of practice for midwives and positive governance changes in the professional midwives’ association.

Conclusions

Although many actors contributed to midwifery policy action in Kenya, MVMD has proven to be both insightful and catalytic. The campaign also supported and emboldened midwives to self-advocate at decision-making tables and witness uptake of their voices in policy. The launch of this policy serves as an important first step to lay a foundation toward a sustainable future for the profession.

F4.1. Innovations to support safe oxygen use with Continuous Positive Airway Pressure (CPAP) for the small or sick newborn care to achieve Every Newborn Action Plan (ENAP) target 4

Leah Greenspan¹, Tamah Kamlem², Robert Neighbour³, Martha Franklin Mkony⁴, Harish Kumar⁵

¹United States Agency for International Development; ²Chemonics International; ³Diamedica (UK) Ltd; ⁴Muhimbili National Hospital, Tanzania; ⁵IPE Global Limited

BMC Proceedings 2024, 18(5):F4.1

Submission ID #: IMNHC676

Panel ID# (if applicable): DDYBT47676

Panel Description

Eight years away from reaching the targets of the Sustainable Development Goals (SDGs), the UN Inter-agency Group for Child Mortality Estimation (UN IGME) database suggests that 63 countries are not on track to meet these targets, noting that no country will reach the SDGs without providing quality small and sick newborn care (SSNC) at the facility level 2, which includes high-impact interventions for the management of respiratory distress. Providing safe oxygen and effective pressures to newborns with respiratory distress and pneumonia is critical to providing quality care to 30 million newborns requiring inpatient care each year. The World Health Organization’s Standards call for specific medical equipment appropriate for SSNC. In response, global innovators have designed equipment for respiratory support that provides effective pressure generation, blended oxygen, and oxygen saturation monitoring to prevent oxygen toxicity in premature newborns.

ENAP sets national targets for 2025; 80% of districts to have at least one functional level 2 inpatient unit for small and sick newborns, including CPAP. To guide countries’ efforts toward achieving global targets, the World Health Organization and UNICEF have developed standards for improving the quality of SSNC in health facilities and a model of level 2 care for small and sick newborns.

This session will feature global innovators presenting innovative CPAP decision-making tools, three different categories of CPAP devices, and in-country user experiences from the perspectives of the patient, parent, and health care provider.

F4.2. Oxygen concentrator driven baby Continuous Positive Airway Pressure (CPAP)

The study will provide insight into the current state of respiratory mechanisms at level 2 facilities in Ghana for small and sick newborns and determine existing challenges regarding the supply chain of medical devices for newborn health. Results will inform the policy landscape of newborn health to stakeholders at the national level and beyond.

F4.5. Novel high-quality Bubble Continuous Positive Airway Pressure (bCPAP) and oxygen blender systems for global access

Martha Franklin Mkony¹, Thomas Burke², Leah Greenspan³

¹Muhimbili National Hospital, Tanzania; ²Vayu Global Health Foundation; ³United States Agency for International Development

BMC Proceedings 2024, 18(5):F4.5

Submission ID #: IMNHC685

Panel ID# (if applicable): DDYBT47676

Note the full manuscript published in December 2022 in PLOS ONE:

(https://0-www-ncbi-nlm-nih-gov.brum.beds.ac.uk/pmc/articles/PMC9803298/)

F5.1. Maternal mortality: levels, trends, and strengthening reporting

Jenny Cresswell¹, Lale Say¹, Imbulana Jayaratne², Affette McCaw-Binns³

Panel Description

Integration of service delivery components is a challenge in the best of circumstances, not least because vertical funding streams often work against it. Yet, in all settings, truly patient-centered care is integrated, maximizing efficiency of contact between care-seeking families and their care teams. In settings characterized by conflict, post-conflict, the effects of climate change, frequent government turnover, and other shocks and stresses, quality integrated care becomes that much more of an imperative.

This panel will feature Save the Children speaking about the importance of supporting integrated primary health care in Somaliland; MOMENTUM Integrated Health Resilience will share immediate postpartum and post-abortion family planning trends in supported counties in South Sudan; Building Foundation for Development will present its lessons learned implementing mobile medical teams providing an integrated package of services in Yemen; and the United Nations Population Fund will speak about its success improving outcomes through the offer of cash assistance for healthy pregnancies and safe births in the Philippines.

Each panelist will highlight the ways in which integration helped overcome difficulties particular to the setting in which they work and improved holistic care for mothers and their newborns.

F6.2. Cash assistance for healthy pregnancies and safe births in the Philippines

Grace Carina Viola¹, Christopher Lindahl², Renee Fiorentino², Alice Golay¹

¹United Nations Population Fund; ²MOMENTUM Integrated Health Resilience

BMC Proceedings 2024, 18(5):F6.2

Submission ID #: IMNHC1094

¹Save the Children US; ²MOMENTUM Integrated Health Resilience

BMC Proceedings 2024, 18(5):F6.5

Submission ID #: IMNHC1083

Panel ID# (if applicable): DHMBK931081

Background

In Somalia, more than 80% of newborn deaths are due to prematurity and asphyxia complications. Deaths can be prevented by well-trained midwives and nurses during antenatal and postnatal visits and delivering at a health facility.

The MNH program in Somalia focuses on improving the quality and availability of maternal and newborn care through contextualization and integration of the Helping Babies Survive (HBS) and Helping Mothers Survive (HMS) training programs.

Methods

Save the Children supported the translation into the Somali language of the adapted HMS curriculum obtained from Jhpiego and the HBS curriculum from the American Academy of Pediatrics. These translated training modules were endorsed by the Ministry of Health.

Twenty-eight master trainers were trained. The master trainers conducted cascade trainings for 154 health care providers. The trainees subsequently passed on knowledge gained to 300 colleagues through coaching and supportive supervision at their respective workplaces and provided needed care to 6,000 women and their newborn babies.

Save the Children then advocated for the scale-up of integrated newborn and maternal care training across the country to improve relevant practices and outcomes.

Results

The proportion of newborns who received two or more essential newborn care practices (including skin-to-skin contact, cord care, and early breastfeeding) improved from 19.9% to 94.7% post-intervention. The study also showed significant skills retention, and improvement in knowledge and confidence among providers.

Overall, the average change in knowledge was 22.54%, and 41.5% in skills. This indicates a huge baseline need among providers, crucial to fill in order to keep increasing the number of maternal and newborn lives saved. The skills retention score mean difference at 18 months after the trainings was 11.9 %.

Conclusions

Adequate training, supportive supervision, and on-the-job coaching of providers can prevent deaths by proper management of the critical events newborns face such as hemorrhage, obstructed labor, eclampsia, sepsis, pre-term birth, and respiratory distress. Scaling up trainings is recommended.

F7.1. A 13-year initiative to expand access to high-quality Emergency Obstetric and Newborn Care (EmONC) and family planning services in Tanzania

Sunday Dominico¹, Neena Prasad², Florina Serbanescu³, Samantha Lobis⁴

¹Thamini Uhai; ²Bloomberg Philanthropies; ³Centers for Disease Control and Prevention; ⁴Averting Maternal Death and Disability Program

BMC Proceedings 2024, 18(5):F7.1

Submission ID #: IMNHC409

Panel ID# (if applicable): DIPOP39409

Panel Description

The Program to Reduce Maternal Deaths in Tanzania was a 13-year initiative that worked to expand mostly rural communities’ access to high-quality EmONC and family planning services. The Tanzanian Ministry of Health and its partners worked together to enhance the quality of maternal and perinatal care and improve health outcomes in Kigoma region.

Sub-Saharan Africa accounts for only 15% of the world’s population but bears nearly 70% of the global burden of maternal deaths and about 40% of global newborn deaths. More than half of maternal and newborn deaths result from complications during childbirth and are largely preventable. However, poor quality of care in low-resource settings is often a greater contributor to poor health outcomes than health coverage. The Tanzanian Program model of decentralized obstetric, reproductive, and newborn care from distant hospitals to more accessible, lower-level health facilities through infrastructure upgrades and training the non-physician health care providers staffing these facilities demonstrated substantial reduction in maternal and perinatal deaths. The panel will present the history of the Program, key Program interventions, a population-based multilevel decomposition analysis that shows how a rapid increase in facility deliveries is mostly attributable to the increase in quality of health facilities, and an innovative birth companionship model that was scaled up and led to a policy change in Tanzania.

Lessons learned from the Program can inform policymakers and program managers in settings where similar approaches could be used to improve and sustain the utilization of quality facility care at birth.

F7.2. Introducing, sustaining, and scaling up birth companionship in Tanzania

The necessity of multistakeholder partnerships. A host of demand- and supply-side interventions are required to meaningfully address maternal and neonatal mortality—leveraging the comparative strengths of a diverse set of stakeholders working in close collaboration will make success more likely.
Program evaluation should be viewed not only as a tool to assess impact of interventions, but to inform program design. This approach requires flexibility on the part of donors to adapt the program’s design and a willingness to stay the course and invest longer-term.
The presence of health services does not automatically translate to high-quality and accessible services. Quality of care can be furthered by a supportive work environment, including ongoing mentorship of health care providers. Access can be strengthened by addressing the barriers women face in reaching a health facility and ensuring they are treated respectfully.
Sustainability cannot be an afterthought. Long-term sustainability requires centering government plans and priorities; strengthening the existing public health care system; and advocacy to ensures prioritization and funding.

F8.1. Implementing Maternal and Perinatal Death Surveillance and Response (MPDSR): new solutions and opportunities

Natasha Sobers¹, Francesca Palestra², Sylvia Deganus², Mary Kinney³, Gloria Mutimbwa Siseho³

Panel Description

This panel, led by in-country research partners, highlights key lessons emerging across nine countries that have been identified as positive outliers on the topics of maternal health, neonatal health, and family planning (FP). The three panelists focus on research findings from Bangladesh, Ethiopia, India, Kenya, Malawi, Morocco, Nepal, Niger, and Senegal, specifically spotlighting factors that have contributed toward progress in these countries. The presentations covers:

1.
Interrelated distal, intermediate, and proximal drivers that contribute toward declines in neonatal and maternal mortality in Exemplar countries. Key drivers typically contribute toward progress in a stepwise manner as countries progress through a transition from higher mortality to lower mortality. Lessons from Exemplars can provide useful insights for peer countries looking to emulate the successes of Exemplar countries.
2.
FP in low- and middle-income countries (LMICs) has generally made substantial progress in recent decades with select LMICs having demonstrated exemplary progress. This analysis considers drivers of change in FP within specific geographies, alongside a global analysis of drivers for FP. In tandem, this work contributes valuable insights from positive outliers that can be useful for other countries looking to achieve the third Sustainable Development Goal related to healthy lives and well-being.
3.
Voluntary FP empowers people to freely decide whether and when to have children and is also a key upstream contributor to improved health outcomes for mothers and children. Lessons from Exemplars demonstrate the importance of empowering women and improving access to quality health care services along the continuum of reproductive health.

F10.1. Re-visioning Emergency Obstetric and Newborn Care (EmONC): a revised EmONC framework and indicator set for the next two decades

Wei Lu¹, Caitlin Warthin¹, Lynn Freedman¹, Isabelle Moreira¹, Martin Aluvaala², Patience Afulani³

Methods

The Re-visioning EmONC process must respond to many changes in the health systems and MNH landscape over the last 30 years: increased facility-based childbirth; a push to integrate maternal and newborn care, and to consider continuity of care across the MNH continuum; advances in technology that change what is feasible for data collection and analysis; increased focus on quality of care (clinical and experiential), including more nuanced thinking on quality-of-care measurement; and gender and equity becoming key lenses for health system functionality. The revised framework and indicators must respond to these changes, striking the balance between being comprehensive vs. parsimonious, and aspirational vs. realistic.

Results

The revised EmONC framework and indicators provide a robust picture of the facility-based EmONC system and how it functions on essential parameters, including whether care is timely and appropriate, respectful and equitable, and fulfills the rights and expectations of users and providers. It tells us if the system is well-connected via communication, transportation, governance and accountability to the communities it serves. Above all, it provides essential evidence and information to enable planners and managers to develop short-, medium-, and long-term MNH strategies and to solve problems.

Conclusions

The revised EmONC framework and indicators will be an important tool to support countries in creating facility-based EmONC systems in which all women and newborns who experience complications access care that gives them the best chance to survive and thrive.

F11.1. Mother Newborn Care Unit (MNCU) experience in India: a paradigm shift in care of small and sick newborns

Sugandha Arya¹, Harish Chellani², Pratima Mittal³, Kilangnaro T Nokdy¹

¹Safdarjung Hospital; ²Center for Health Research and Development: Society for Applied Studies; ³Amrita Institute of Medical Sciences

BMC Proceedings 2024, 18(5):F11.1

Submission ID #: IMNHC1535

Panel ID# (if applicable): DMAPY701535

Note the full manuscript was previously published in the Indian Journal of Pediatrics: https://0-link-springer-com.brum.beds.ac.uk/article/10.1007/s12098-022-04145-9

F11.2. Mother newborn care unit: nurses’ experience

F12.1. World Health Organization (WHO) research to Improve survival of small and sick newborns: impact and implications for program

Suman Rao¹, Anshu Banerjee¹, Helga Naburi², Ayesha De Costa¹, Yasir Bin Nisar¹, Rajiv Bahl¹, Robinson Wammanda³

¹World Health Organization; ²Muhimbili University of Health and Allied Sciences; ³Ahmadu Bello University Teaching Hospital, Zaria

BMC Proceedings 2024, 18(5):F12.1

Submission ID #: IMNHC863

Panel ID# (if applicable): DMCHF35863

Panel Description

The WHO has been supporting multicountry research to support newborns to survive and thrive. This panel discussion brings together critical new evidence for the survival of newborns. Four large WHO randomized controlled trials, some of which have been published recently have led to new ongoing implementation research. The aim of the panel is to make the participants aware of the research and to discuss the implications of the results for country-level program and scale-up.

F12.2. Health, nutrition, psychosocial support, and water, sanitation, and hygiene interventions delivered during preconception, pregnancy, and early childhood periods on birth outcomes and on linear growth at 24 months of age

Rajiv Bahl¹, Suman Rao¹, Helga Naburi², Harish Chellani³

¹World Health Organization; ²Muhimbili University of Health and Allied Sciences; ³Center for Health Research and Development: Society for Applied Studies

BMC Proceedings 2024, 18(5):F12.2

Submission ID #: IMNHC881

Panel ID# (if applicable): DMCHF35863

Note the full manuscript published in September 2022 in BMJ:

(https://0-www-bmj-com.brum.beds.ac.uk/content/379/bmj-2022-072046.long)

F12.3. Improving management of Possible Serious Bacterial Infection (PSBI) in newborns in Low- and Middle-Income Countries (LMICs): evidence into policy and clinical practice

Robinson Wammanda¹, Suman Rao², Helga Naburi³, Yasir Bin Nisar², Shabina Ariff⁴

¹Ahmadu Bello University Teaching Hospital; ²World Health Organization, ³Muhimbili University of Health and Allied Sciences, Zaria, ⁴The Aga Khan University

BMC Proceedings 2024, 18(5):F12.3

Submission ID #: IMNHC879

Panel ID# (if applicable): DMCHF35863

Note the full manuscript published in June 2022 in PLOS ONE:

(https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0269524)

F12.4. Improving the survival of low birthweight infants in Low- and Middle-Income Countries (LMICs): expanding the scope, reach, and impact of kangaroo mother care

Shabina Ariff¹, Suman Rao², Helga Naburi³, Ayesha De Costa²

¹The Aga Khan University; ²World Health Organization; ³Muhimbili University of Health and Allied Sciences, Zaria

BMC Proceedings 2024, 18(5):F12.4

Submission ID #: IMNHC876

Panel ID# (if applicable): DMCHF35863

Background

Facility-initiated kangaroo mother care (KMC) for stable low birthweight (LBW) infants is a proven high-impact intervention to reduce mortality. However, many LBW infants die before stabilization and the coverage of KMC is low globally. The World Health Organization (WHO)-led research has proved that initiating immediate KMC soon after birth (iKMC) before stabilization is a promising strategy to improve coverage, in addition to developing context-adapted implementation models. There is a need to understand how to scale up iKMC in LMCIs.

Methods

The iKMC trial, a hospital-based randomized controlled trial (RCT) in five countries in Asia and Africa, enrolled infants 1–1.799 kg to iKMC at birth before stabilization or control group. All care in the maternal-neonatal intensive care unit (M-NICU) including respiratory support was provided with the baby in the KMC position. The S-KMC study used mixed methods to develop scalable models to deliver KMC. Currently, theWHO is coordinating the iKMC implementation research (IR) where the initial models based on formative research will be developed in routine care settings and evaluated in a step-wedge trial.

Results

In the iKMC trial enrolling 3,211 infants, the median duration of skin-to-skin contact (STS) in the NICU was 16.9 hours/day in the intervention group. Neonatal death was reduced by 25%. In the S-KMC study, the implementation models developed achieved high population-based coverage in the enrolled 3,804 LBW infants < 2,000 g. KMC was initiated in 68%-87% of infants and at discharge, effective KMC (> 8 hours of STS and exclusive breastfeeding) was provided to 53%-68% of infants. The iKMC IR study is recruiting.

Conclusions

The iKMC and S-KMC studies have shown how to exponentially improve coverage of KMC and reduce mortality. These studies have led to a revision of LBW guidelines and introduced the new paradigm of M-NICU, which will be evaluated in the iKMC IR.

F12.5. Improving the survival of preterm infants in Low- and Middle-Income Countries (LMICs): evaluating the role of and expanding access to Antenatal Corticosteroids (ACS) - The World Health Organization (WHO) coordinated ACS research program

Suman Rao¹, Helga Naburi²

¹World Health Organization; ²Muhimbili University of Health and Allied Sciences, Zaria

BMC Proceedings 2024, 18(5):F12.5

Submission ID #: IMNHC871

Panel ID# (if applicable): DMCHF35863

Background

Preterm birth contributes significantly to neonatal mortality. ACS are proven to improve preterm survival in high-income settings and are widely used across the world. However, the 2015 ACT trial in LMICs suggested that ACS results in an increase in neonatal mortality and maternal adverse outcomes. To resolve this ambiguity and inform WHO guidelines, the WHO initiated the ACS research program comprising two multicountry placebo-controlled trials of ACS on neonatal outcomes in the early and late preterm periods (ACTION I, ACTION III), respectively, in LMICs; and the ACS implementation research project (ACS-IR), to establish and test a strategy for the safe and effective use of ACS in LMICs.

Methods

ACTION-I and ACTION-III are individually randomized trials of ACS versus placebo on neonatal mortality and morbidity in Bangladesh, India, Kenya, Nigeria, and Pakistan. The ACS-IR project focuses on developing a strategy through iterative cycles to improve safe and effective coverage of ACS.

Results

ACTION-I (completed) showed a clear reduction in neonatal mortality (RR 0.84, 95% CI 0.72-0.97) and morbidity (respiratory) in LMICs. No difference in maternal and neonatal adverse outcomes was detected. Baseline work to inform strategy for improved ACS use has been completed in the ACS-IR.

Conclusions

Implications for country/program: ACTION 1 has confirmed the effectiveness in LMICs. ACTION III (late preterm) is presently recruiting. ACS-IR will inform strategies to improve access in the country/program. The ACS research program, which this panel discusses, will inform guidelines on preterm birth, thereby promoting newborn survival.

F13.1. Learning from the past, connecting to the future: insights from seven Maternal and Newborn Health (MNH) exemplar countries using a mortality transition model

Agbessi Amouzou¹, Ties Boerma², Oona Campbell³, Cheikh Mbacke Faye⁴

¹Johns Hopkins Bloomberg; ²University of Manitoba, South Africa; ³London School of Hygiene & Tropical Medicine; ⁴African Population and Health Research Center

BMC Proceedings 2024, 18(5):F13.1

Submission ID #: IMNHC718

Panel ID# (if applicable): DODJJ89718

Panel Description

Using results of the MNH Exemplars study conducted during 2020–2022 in seven countries in Africa and Asia (Bangladesh, India, Nepal, Morocco, Ethiopia, Niger, and Senegal), four presentations use a maternal mortality, stillbirth, and neonatal mortality transition model to address the key lessons learned from past progress for today’s programs and tomorrow’s strategies.

“Applying a Maternal and Neonatal Mortality Transition Model to Identify Drivers of Progress in India’s States” describes the transition model and its dimensions—causes of death, fertility, health systems, service delivery strategies, and inequalities—based on extensive analyses for 149 countries, and then applied to the seven MNH exemplar countries, with special attention to India’s subnational progress and present issues.

“Data Gaps in the Understanding of Progress in Maternal and Neonatal Mortality in the Exemplar Countries” synthesizes how major data gaps affect mortality and cause of death tracking and analyses, hampering the ability to assess trends and inequalities. High coverage of health facility births affords new opportunities to collect better data.

“Successful Strategies for Intrapartum Care: What Have Exemplar Countries Done and How Was This Achieved?” presents intrapartum service strategies, which vary considerably between countries. Future strategies can be informed by experiences of countries in more advanced stages of the transition model. High coverage of hospital deliveries with quality care and adequate cesarean section rates among women living in poverty appear to be key.

“Closing the Gap: Trends and Inequalities in Maternal and Newborn Health among Seven Exemplar Countries” analyzes the coverage and trends of inequalities in MNH interventions in the exemplar countries. Inequality patterns in neonatal mortality vary across the transition phases, but intervention coverage disparities decreased almost everywhere. A focus on women and neonates living in under-resourced areas is a critical driver, but strategies vary by transition stage.

The panel will conclude with invited comments from two policymakers on the utility of the transition model approach, followed by a moderated discussion with participants.

F13.2. Successful strategies for intrapartum care: what have exemplar countries done and how was this achieved?

Major improvements in coverage of health services and reductions in inequalities during the past two decades led to major reductions in maternal and neonatal mortality in the Indian states. Reference values for key indicators of change according to phases of the transition allowed further identification of drivers of success and potential strategic priorities for further progress, providing a tool for systematic cross-state exchange and learning.

F13.5. Data gaps in the understanding of progress in maternal and neonatal mortality in the exemplar countries

Agbessi Amouzou¹, Ties Boerma², Oona Campbell³

¹Johns Hopkins Bloomberg; ²University of Manitoba, South Africa; ³London School of Hygiene & Tropical Medicine

BMC Proceedings 2024, 18(5):F13.5

Submission ID #: IMNHC720

Panel ID# (if applicable): DODJJ89718

Background

The maternal and neonatal mortality exemplar study aimed to understand drivers of rapid mortality reduction in the period 2000–2020. Seven countries were identified in South-East Asia, the Eastern Mediterranean, and sub-Saharan Africa based on their exceptional progress. Their selection; analysis of levels, trends, and inequalities in maternal, late fetal, and neonatal mortality; identification of drivers; and conclusions faced major data challenges. We discuss these challenges and lessons for the understanding of current and future mortality trends.

Methods

The seven countries are Bangladesh, India, and Nepal in South-East Asia; Morocco in the Eastern Mediterranean; and Ethiopia, Niger, and Senegal in sub-Saharan Africa. The study systematically reviewed all available data for mortality and cause of death analysis, including empirical estimates from national surveys and model-based estimates from the United Nations and the Institute for Health Metrics and Evaluation.

Results

Enormous data availability gaps exist across all seven countries in maternal mortality, stillbirths, and cause of death, with higher challenges in African countries. On average, only three data points were available since 2000 across these countries for maternal mortality ratio (MMR) trends estimation, ranging from two in Bangladesh, Niger, and Senegal to seven in India. The wide uncertainty range of the MMR estimates challenges conclusions on trends and inequalities. Data on neonatal mortality rate (NMR) is better, with, on average, 19 data points used by the United Nations for trends estimation since 2000, ranging from three in Morocco to 39 in Bangladesh. However, data quality remains a challenge and, in many cases (as in Bangladesh, Ethiopia, and Niger), recent modeled estimates did not capture a suspected stall or rise in mortality indicated by empirical estimates. No country has satisfactory data for cause-specific maternal and neonatal mortality trends, forcing reliance on model-based estimates with limited empirical data inputs.

Conclusions

As countries progress through the transition for maternal, late fetal, and neonatal mortality, the need for better data on mortality and causes of death is critical for assessing current status and benchmarking future mortality decline and associated strategies. Countries with high coverage of facility births have opportunities to collect better mortality data, while linking community and facility information systems.

F14.1. Interactive dialogue on quality of care measurement

Francesca Conway¹, Paul Dsane-Aidoo², Margaret Titty Mannah³

¹World Health Organization; ²United Nations Children’s Fund; ³Ministry of Health and Sanitation of Sierra Leone

BMC Proceedings 2024, 18(5):F14.1

Submission ID #: IMNHC1542

Panel ID# (if applicable): DOEMC101542

Panel Description

In February 2017, Côte d’Ivoire, Ghana, Ethiopia, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, India, and Bangladesh, led by the World Health Organization, United Nations Children’s Fund, and United Nations Population Fund and with the support of partners, established the Quality of Care (QoC) Network for improving QoC for maternal, newborn, and child health. Improving QoC measurement is one of the core priorities of the QoC Network’s work. With attendees representing lead United Nations agencies, governments, civil society, and others, the interactive dialogue will seek to share the QoC Network’s evidence and experiences at the global and national levels in addressing challenges around QoC measurement. The interactive dialogue will also aim to share current trends, good practices, innovative approaches, and lessons learned; identify common challenges across countries regarding QoC measurement; and promote linkages between national strategies and the global normative framework for QoC measurement. The outcomes of the dialogue will help to enable pathways to drive collaboration, coordination, cross-country learning, and alignment; and to share evidence within the maternal and newborn health community.

F14.2. The journey to creating a robust data pipeline for common Maternal and Newborn Health (MNH) quality of care indicators in the quality of care network: challenges and prospects

Martin Dohlsten, Francesca Conway, Moise Muzigaba, Gerard Lopez, Theresa Diaz, Blerta Maliqi

World Health Organization

BMC Proceedings 2024, 18(5):F14.2

Submission ID #: IMNHC1563

Panel ID# (if applicable): DOEMC101542

Background

In February 2017, the Quality of Care (QoC) Network for improving QoC for maternal, newborn, and child health was established. The QoC Network is led by the World Health Organization, United Nations Children’s Fund, and United Nations Population Fund with support of partners. This paper describes how the QoC Network Secretariat has facilitated the collection, sharing, quality assurance, analysis, and use of common MNH QoC data from multiple health facilities and learning sites participating in the network, and some of the challenges faced in rolling out this strategy.

Methods

The QoC Network Secretariat went through the following process: (1) standardizing data collection forms for a minimum set of quality indicators, (2) disseminating and strengthening capacity on these tools and indicators, (3) developing a data exchange web-based knowledge hub to facilitate the exchange of data between global and country levels, (4) conducting data quality verifications to assess the completeness, accuracy, and currency of the data received, and (5) analyzing the data and utilizing and disseminating the findings.

Results

In most countries, the ministries of health and partners adopted these tools, resulting in a heightened culture of data use for MNH QoC across all levels. The tools were also seen as instrumental in capturing data on indicators outside of the District Health Information Software 2 (DHIS2) such as women’s experience of care and water, sanitation, and hygiene indicators. The results of the data quality assurance and verification process also saw an overall improvement in the completeness, accuracy, and currency of the data. Ultimately, data analysis results and results from independent reviews indicate positive improvements in some MNH indicators over time. Despite the good progress, challenges remain in ensuring optimal data quality and guaranteeing adequate financial and human resources for data management. Prospects include updating these tools to capture pediatric/small and sick newborn and women’s experience of care QoC indicators, as well as capturing other indicators that span the continuum of care. Improving data quality, use, and quality improvement documentation are also priorities.

Conclusions

More still needs to be done to institutionalize MNH QoC measurement for informed decision-making. Adequate financial and human resources and strategic partnerships will be vital.

F14.3. Lessons learned in measuring and monitoring the World Health Organization (WHO)-recommended Maternal and Newborn Health (MNH) experience of care indicators for the quality of care network: the Ghana case study

Francesca Conway¹, Paul Dsane-Aidoo²

¹World Health Organization; ²United Nations Children’s Fund

BMC Proceedings 2024, 18(5):F14.3

Submission ID #: IMNHC1552

Panel ID# (if applicable): DOEMC101542

Background

Access to high-quality person-centered experience of health care through effective communication with clients, respect and dignity, emotional support, and continuity of care during pregnancy and childbirth is a key priority advocated for by the Quality of Care (QoC) Network. This fundamental right influences health outcomes and future health care use. Despite its importance for accountability and action, measurement of experience of care is limited. This study analyzed the experiences of care of postnatal mothers received from primary and secondary health facilities in QoC Network regions in Ghana.

Methods

A multi-center cross-sectional survey was conducted among postpartum mothers in QoC Network implementing facilities (health centers, polyclinics, and district hospitals) in Ghana from April 2020 to December 2021. We adapted Ghana’s maternal and child health record book to develop a structured questionnaire using the Open Data Kit tool. We conducted pre-discharge postnatal clinic exit interviews of mothers, and collected sociodemographic and obstetric variables of mothers, health facility characteristics, and mothers’ feedback on the health care experience. We conducted descriptive analysis of quantitative data and, in the process of program implementation, shared monthly feedback with implementing facilities and districts.

Results

About 126 health facilities from 10 implementing regions submitted responses. Overall, 7,379 mothers were interviewed with 55% (4,059/7,379) receiving care in district hospitals. The median age of mothers was 28 years (12–52), 35.8% (2,644/7,379) had up to secondary-level education, and 30.5% (2,231/7,379) were first-time mothers. Of 5,502 mothers who wanted a birth companion, 68.9% (3,793) were granted one during labor and delivery. Up to 5.1% (379/7,379) reported maltreatment, with shouting, hitting, and insults being the predominant types of abuse experienced. As a measure of their overall satisfaction with care, approximately 99.0% (7,305/7,379) were willing to recommend the health facility to others for delivery.

Conclusions

Prevalence of mistreatment in labor was significantly lower in the QoC Network facilities across 10 regions in Ghana. One-third of facilities have challenges supporting birth companions as standard of care. An overwhelming majority of respondents were satisfied with the care experience and would recommend facility delivery to others. The QoC Network intervention in Ghana showed encouraging results for scaling up across all regions and other low- and middle-income countries.

F14.4. The process of integrating new Maternal and Newborn Health (MNH) Quality of Care (QoC) indicators in health information systems: experiences from Sierra Leone

Francesca Conway¹, Margaret Titty Mannah², Binyam Hailu¹, Ambrose Agweyu³

¹World Health Organization; ²Ministry of Health and Sanitation of Sierra Leone; ³KEMRI-Wellcome Research Programme

BMC Proceedings 2024, 18(5):F14.4

Submission ID #: IMNHC1547

Panel ID# (if applicable): DOEMC101542

Background

In February 2017, the Quality of Care (QoC) Network for improving QoC for maternal, newborn, and child health (MNCH) was established. The QoC Network is led by the World Health Organization, United Nations Children’s Fund, and United Nations Population Fund with support of partners. Improving QoC measurement is one of the core priorities of the QoC Network’s work.

Methods

To strengthen QoC measurement in supported countries, the QoC Network released a Measurement Monitoring and Evaluation Framework for MNH QoC along with specific guidance. This abstract summarizes the process and lessons learned by the Sierra Leone country team in operationalizing this guidance at the country level.

Results

The process of the Ministry of Health and partners involved ensuring governance structures and functional technical working groups were in place for QoC measurement in all learning districts and facilities to ensure a growing culture of data use. Further, the team developed and refined a minimum set of quality indicators; adapted and developed district and facility data collection tools to capture essential data on the new indicators; ensured the reporting systems for facility, district, and national levels captured the new indicators; and developed a QoC indicator dashboard, which is integrated in the District Health Information Software 2 (DHIS2). The MNCH QoC indicators in Sierra Leone were integrated in the reproductive, maternal, newborn, child, and adolescent health scorecard, and the country team developed a maternal death surveillance and response line listing, perinatal death surveillance and response line listing, and child death audit line listing tool to document health facility deaths. The audit line listing tool is integrated in the DHIS2, and efforts are underway to integrate the pediatric death audit line listing tool. The country team also hired a new cadre of committed district and hospital QoC Officers and strengthened their capacity to analyze and communicate quality indicators. Further data quality audits through periodic supportive supervision took place. Funding was secured for QoC and measurement efforts from the Swedish International Development Cooperation Agency (SIDA), Large Anonymous Donor (LAD), and MOMENTUM with funds from USAID.

Conclusions

Key challenges remain, including competing activities at the Ministry of Health, too frequent coordination meetings, poor data quality, and limited funding from the government to support QoC operations in facilities and districts. This is not unique to Sierra Leone, as other QoC Network countries have had similar experiences.

F15.1. What matters to you: centering women’s voices in designing dignified maternity care

Minara Chowdhury¹, Nana Amma Yeboaa Twum-Danso¹, Abiyou Alemayehu¹, Birkety Jembere², Shannon Welch¹

¹Institute for Healthcare Improvement; ²United States Agency for International Development

BMC Proceedings 2024, 18(5):F15.1

Submission ID #: IMNHC1450

Panel ID# (if applicable): DOKCH231450

Panel Description

The quality of the birthing experience is highly variable. Women describe how they are not listened to or believed when sharing concerns with their medical provider, and in turn do not feel valued or respected. While there has been much focus on supporting providers to deliver effective care, there has been less focus on the experience of care by the mothers themselves and the impact of the care they receive, the manner in which care is delivered, and the environment in which it is delivered. Designing a better care experience starts with asking mothers “what matters to you?” but their answers need to be turned into action. Those answers can drive the way facilities are designed, choice of care, and how care is co-designed and sensitively delivered. The presenters in this panel bring novel insights from Bangladesh, Ethiopia, and the United States about how women can be engaged to codesign safer, more dignified, respectful, and equitable care.

F16.1. Achieving country-wide high-quality Maternal, Newborn, and Child Health (MNCH) care: the path from innovation to scale and sustainability

Pierre Barker¹, Mamun Bhuiyan¹, Paulo Borem¹, Nebiyou Wendwessen Hailemariam¹, Mazharul Hoque², Abiyou Alemayehu¹

F17.2. The potential of routinely available data to support the uptake of actionable effective coverage measures for newborn care in Northeast Nigeria

F18.1. The power of compassion in Maternal, Newborn, and Child Health (MNCH) service delivery

Jessica Vandermark Moore¹, Lynn Van Lith², Chantalle Okondo³, Eva Lathrop⁴, Sandra Mwarania⁵

Conclusions

Misclassification between stillbirths and ENNDs appears to be common and may differ by place of birth and provider communication content and styles. A nonnegligible proportion of women reported not knowing their child’s time of death, hampering accurate classification based on retrospective surveys. To inform child survival policies and programs, more knowledge on magnitude and determinants of misclassification is needed.

F20.1. Emerging opportunities for improving the availability and quality of maternal and newborn health data

Barbara Rawlins¹, Gabriela Escudero², Louise Tina Day³

¹United States Agency for International Development; ²University of North Carolina at Chapel Hill; ³London School of Hygiene & Tropical Medicine

BMC Proceedings 2024, 18(5):F20.1

Submission ID #: IMNHC1079

Panel ID# (if applicable): DQKNH371079

Panel Description

High-quality data are essential to improve the quality and responsiveness of maternal and newborn health (MNH) services, yet significant gaps exist in the availability and quality of relevant data. This panel will cover three initiatives to strengthen measurement, address gaps in use of MNH indicators in national routine health information systems (RHISs), and examine quality of care (QoC) across the MNH continuum. The first paper describes a landscape analysis of indicators, including indicators for safe surgery for obstetric care and fistula in seven countries’ RHISs. This landscape analysis identifies indicators currently collected and reported on to better understand QoC at the time of delivery and provides country-specific recommendations for safe surgery. The second paper features country experiences implementing clinical vignettes among clinicians in the Democratic Republic of the Congo and Nigeria as a promising QoC survey measurement tool. The clinical vignettes aim to benchmark provider performance against national MNH guidelines, specifically for malaria in pregnancy, hypertension in pregnancy with signs of gender-based violence, pre-eclampsia, and fetal malpresentation. The final innovation discusses the experience in developing and piloting the Every Newborn-Measurement Improvement for Newborn and Stillbirth Indicators tools. These tools are designed to strengthen country newborn and stillbirth RHIS data to close the gap in quality and use of these data. The three papers will be followed by an interactive question-and-answer session that will dig further into experiences with these emergent measurement methods and their potential for wider application.

F20.2. Every Newborn-Measurement Improvement for Newborn and Stillbirth Indicators (EN-MINI) tools for routine health information systems

Jacqueline Minja¹, Louise Tina Day², Harriet Ruysen², Donat Shamba¹, Josephine Shabani¹, Getrud Joseph Mollel¹, Caroline Shayo¹, Kimberly Peven², Shema Mhajabin³, Honorati Masanja¹, Ahmed Ehsanur Rahman³, Shafiqul Ameen³, Tamanna Majid³, Barbara Knittel⁴, Gabriela Escudero⁵

¹Ifakara Health Institute; ²London School of Hygiene & Tropical Medicine; ³International Centre for Diarrhoeal Disease Research, Bangladesh; ⁴John Snow, Inc.; ⁵University of North Carolina at Chapel Hill

BMC Proceedings 2024, 18(5):F20.2

Submission ID #: IMNHC1099

Panel ID# (if applicable): DQKNH371079

Background

Timely and accurate core indicator data are essential to track progress toward ending preventable stillbirths, newborn deaths, and disabilities. Routine health information systems (RHIS) have potential, but an evidence gap for data quality in high-burden settings impedes data use for every newborn to survive and thrive. The purpose of the EN-MINI Tools is to enable countries to improve RHIS data for action in support of the Every Newborn Action Plan. The EN-MINI Tools include: (1) MAP newborn indicator availability, (2) Assess USE of newborn data for decisions, and (3) Identify actions to IMPROVE newborn data quality.

Methods

Every Newborn – Birth Indicators Research Tracking in Hospitals (EN-BIRTH) phase 2 researchers designed the EN-MINI Tools. These include a novel indicator mapping tool and adapted Performance of Routine Information System Management (PRISM) tools with open-access digital data collection and analysis platforms. The EN-MINI tools were piloted in public health facilities and district data offices in Tanzania (Tanga and Pangani districts) and Bangladesh (Kushtia district). Respondents included health and data professionals recording, reporting, analyzing, and using newborn/stillbirth data.

Results

Most newborn/stillbirth core indicators were available in national electronic RHIS (District Health Information Software 2 [DHIS2]) in Tanzania and Bangladesh. We found in in Tanzania that facility register and summary form completeness varied and gaps existed in district feedback mechanisms. Health workers described low motivation for RHIS tasks and high data burden from duplication and limited actionable discussion at supervisory visits.

Data quality assurance processes were lacking at facility and district levels. Timeliness of receiving reports varied. Data were accurately entered into DHIS2, 100% for 9 among10 indicators assessed. RHIS organizational factors and data use for decision-making was stronger at district level, e.g., data visualization. Respondents’ data confidence was higher than data competence.

Conclusions

The novel EN-MINI tools pilot identified strengths and weaknesses in RHIS performance for newborn/stillbirth core indicator data at district and health facility levels. Priority actions to improve data quality and data use include improving data culture in health facilities to enable health worker motivation to capture high-quality data. Pilot testing informed EN-MINI tools and training revisions. The EN-MINI tools are free, easy to use, and generate automated reports for subnational and national use to close the gap for newborn/stillbirths data quality and use.

F20.3. Using clinical vignettes to assess maternal and newborn health provider knowledge and practice: experience from the Democratic Republic of the Congo (DRC) and Nigeria

Emmanuel Adegbe¹, Gabriela Escudero¹, Kristen Brugh¹, Janna Wisniewski², Sian Curtis¹, Paul-Samson Lusamba-Dikassa³, Isobo Ekesunnie⁴, Jessica Fehringer¹

¹University of North Carolina at Chapel Hill; ²Tulane University School of Public Health and Tropical Medicine; ³Tulane International at Kinshasa School of Public Health; ⁴Data Research and Mapping Consult

BMC Proceedings 2024, 18(5):F20.3

Submission ID #: IMNHC1092

Panel ID# (if applicable): DQKNH371079

Background

Clinical vignettes (CVs) are a promising process quality of care (QoC) measurement tool for large-scale application. The objective of this research is to assess the ability of CVs to benchmark provider performance against national maternal and newborn health (MNH) guidelines and provide sufficient discrimination to determine actionable results. We examine a scoring methodology and analyze longitudinal MNH QoC data to develop recommendations for use of CVs.

Methods

Data are from nonexperimental evaluations conducted in DRC and Nigeria. CVs were administered to clinicians in 2019 (DRC) and 2021 (Nigeria and DRC). In Nigeria, CVs addressed malaria in pregnancy and hypertension in pregnancy with signs of gender-based violence, and were administered to 664 providers of antenatal care services from 360 primary health facilities in three states.

In DRC, CVs addressed pre-eclampsia (n=627) in 2019 and fetal malpresentation (n=521) in 2021, and were administered in six provinces. Both evaluations employed descriptive analyses of single-point process QoC indicators and examined associations between CV results and provider/facility characteristics. The Nigeria evaluation also applied a scoring methodology.

Results

The vignettes were well-received by clinicians. Providers in Nigeria performed well in testing, diagnosing, and treating malaria in pregnancy. The antenatal care vignette for hypertension in pregnancy did not perform well in distinguishing between hypertension in pregnancy and pre-eclampsia. Providers did not perform well in identifying risk of gender-based violence. In DRC, diagnosis rates for fetal malpresentation were low at 22%. There were also large differences in quality between provinces.

Conclusions

CV data can provide insights on the extent to which clinical guidelines are followed and common missteps in providers’ process of MNH service provision. Three lessons emerged: (1) an expert consultative process and pretesting are critical; (2) high frequencies of “other” responses increased data processing burden; and (3) MNH process QoC results should be interpreted alongside structural QoC and MNH outcome metrics.

F20.4. What are we missing? Safe surgical indicators for maternal Health in National Health Management Information Systems (HMISs): findings of a landscape analysis

Karen Levin¹, Gabriela Escudero², Oona Campbell³, Louise Tina Day³, Farhad Khan¹, Renae Stafford1, Maxine Pepper³

¹EngenderHealth; ²University of North Carolina at Chapel Hill; ³London School of Hygiene & Tropical Medicine

BMC Proceedings 2024, 18(5):F20.4

Submission ID #: IMNHC1089

Panel ID# (if applicable): DQKNH371079

Background

Baseline assessment and co-creation activities within the U.S. Agency for International Development-funded MOMENTUM Safe Surgery in Family Planning and Obstetrics project confirmed that lack of timely, relevant information at the country level is a persistent barrier in responding to shifting community and facility needs. Routine monitoring and evaluation systems are not currently capturing adequate data on quality of care and morbidity outcomes. As a result, MOMENTUM Safe Surgery initiated a comprehensive analysis, in project implementation countries, of indicators included in national HMISs and national monitoring and evaluation frameworks for surgical maternal health care to identify gaps and opportunities for advocacy for inclusion of key indicators in future HMIS revisions.

Methods

In 2022, a landscape analysis was conducted using comprehensive national HMIS data element and indicator lists for seven project implementation countries (Democratic Republic of the Congo, India, Nigeria, Mali, Mozambique, Rwanda, and Senegal) to (1) identify, by country, what safe surgery indicators were currently being collected and reported for obstetric care and fistula, (2) highlight commonalities and gaps across implementation countries, and (3) provide country-specific advocacy guidance for inclusion of missing key indicators in future HMIS revisions.

Results

Findings of the landscape analysis present a comprehensive picture of the current safe surgery indicators being captured in national HMISs in MOMENTUM Safe Surgery implementation countries, highlighting key indicators that are being adequately captured as well as those that are missing from national systems. Indicators that are included but for which data is of exceptionally poor quality or missing are also highlighted. Priority maternal health indicators for HMIS expansion that have already been identified by in-country actors or the project are noted.

Conclusions

To optimize national, district, and facility capacity to monitor the availability and quality of maternal health surgical services, and to ensure adequate human resources and budgeting to address service needs, it is crucial to have accurate facility-level data reported consistently into the national HMIS. The findings from this landscape analysis can be translated into concrete advocacy for future inclusion of data elements and indicators currently missing from national systems.

F21.1. An evidence review of four small and sick newborn care coverage indicators for measurement in Routine Health Information Systems (RHISs)

Harriet Ruysen¹, He Tang²

¹London School of Hygiene & Tropical Medicine; ²World Health Organization

BMC Proceedings 2024, 18(5):F21.1

Submission ID #: IMNHC1186

Panel ID# (if applicable): DRBEQ411186

Panel Description

The Ending Preventable Maternal Mortality (EPMM) and Every Newborn Action Plan (ENAP) partnership includes a mandate for national targets of fewer than 12 newborn deaths per 1,000 live births and fewer than 12 stillbirths per 1,000 live births by 2030. Given that around two-thirds of newborn deaths are associated with intrapartum complications, preterm birth, and infection, the plan includes a priority for improving coverage measurement of neonatal resuscitation, kangaroo mother care, antibiotic treatment of severe neonatal infections, and antenatal corticosteroids. A growing body of evidence suggests there are potential opportunities for more accurately capturing data on complex clinical interventions in RHISs, rather than population-based surveys. In response, we completed an evidence review for the measurement of these four indicators in RHISs. Linked with the updated EPMM/ENAP Measurement Improvement Roadmap, this panel will provide a deep dive into the availability and quality of RHIS data for action. We have less than seven years remaining to meet Sustainable Development Goal targets for ending preventable maternal and newborn deaths and stillbirths. We cannot succeed without improving the availability and quality of data for local use for these four high-impact interventions. The three abstracts in this panel aim to galvanize country-level data use for action, and outline the process and findings for each indicator. The panel discussion includes representatives from across the globe to discuss their experiences of how together, we can overcome barriers to quality and use of RHIS data.

F21.2. An evidence review of four small and sick newborn care coverage indicators for measurement in Routine Health Information Systems (RHISs): what does this mean for program implementation and what should we do next?

Harriet Ruysen¹, He Tang², Shaimaa Ibrahim³, Felix Bundala⁴, Isabella Sagoe-Moses⁵, Lily Kak⁶, Joy Lawn²

¹London School of Hygiene & Tropical Medicine; ²World Health Organization; ³United Nations Children’s Fund; ⁴Ministry of Health, Tanzania; ⁵Ghana Health Service; ⁶United States Agency for International Development

BMC Proceedings 2024, 18(5):F21.2

Submission ID #: IMNHC1206

Panel ID# (if applicable): DRBEQ411186

Background

Our recommendations for measuring coverage of newborn resuscitation, kangaroo mother care, antibiotics for newborn infections, and antenatal corticosteroids in RHISs are based on evidence review and expert consultation. We found potential opportunities for more accurately capturing data on these four interventions in RHISs, rather than population-based surveys.

This dynamic panel session showcases country-led work to create and implement targets and metrics, with improved measurement for these critical interventions.

Methods

Moderated by Prof. Joy Lawn, panelists from around the world will share their experiences of improving data quality, enabling better RHIS data use, and addressing barriers to local use of these four coverage indicators in Tanzania, Ghana, and in some humanitarian settings.

Results

We have invited panelists representing national and global policymakers, donors, and country leaders to share real-world examples of improving RHIS data collection and use. Key discussion topics will include:

Improving RHIS data quality and use: implementation of the Every Newborn-Measurement Improvement for Newborn and Stillbirth Indicator (EN-MINI) tools (Dr Felix Bundala, Tanzania Ministry of Health)
RHIS data availability in humanitarian settings: what can we measure now and what are the key gaps (Dr Shaimaa Ibrahim, United Nations Children’s Fund, Iraq)
What can be done next for scale-up: data systems, technology, tools, and indicator prioritization (Dr Barbara Rawlins, U.S. Agency for International Development)

Conclusions

With less than seven years to meet Sustaniable Development Goal targets, improving the coverage and quality of newborn resuscitation, kangaroo mother care, antibiotics for newborn infections, and antenatal corticosteroids is a priority. However, we cannot succeed without improving the availability and quality of RHIS data for local use, quality improvement, and service management. Experiences from Tanzania show the link between RHIS data quality and use. In RHISs, source data for these four indictors is aggregated from registers and requires standardized agreement on data elements. Increasing use of digital technologies will allow scale-up of individually linked systems with further opportunities for tracking measures of effective coverage. Panelists will share their insights into how new tools and innovations can be used in concert to improve the availability, quality, and use of RHIS data to drive progress.

F21.3. Improving measurement of Antenatal Corticosteroids (ACS) and antibiotics for neonatal infections in Routine Health Information Systems (RHISs)

He Tang¹, Harriet Ruysen², Ahmed Ehsanur Rahman³, Ayesha De Costa¹, Samira Aboubaker¹, Tina Lavin¹, Shams El Arifeen³

¹World Health Organization; ²London School of Hygiene & Tropical Medicine; ³International Centre for Diarrhoeal Disease Research, Bangladesh

BMC Proceedings 2024, 18(5):F21.3

Submission ID #: IMNHC1201

Panel ID# (if applicable): DRBEQ411186

Background

Every year, more than 10% of newborns are born preterm, and this number is rising. Prematurity and neonatal infections are leading causes of under-5 deaths. The Every Newborn Action Plan (ENAP) framework has adopted ACS and antibiotic treatment of newborn infections as indicators. Both need to be refined for measurement in RHISs.

Methods

We synthesized published evidence including a scoping review regarding validation of indicator numerators and denominators in RHISs for tracking coverage of ACS and antibiotic treatment of neonatal infections. Expert groups reviewed these findings and provided recommendations.

Results

To measure ACS initiation coverage, we recommend using the number of women who delivered between 24 and 34 weeks’ gestation and received at least one dose of ACS (numerator), divided by the number of women who delivered between 24 and 34 weeks’ gestation (denominator). There are some challenges in measuring this indicator, including obtaining accurate gestational assessment and other obstetric information. Data for ACS coverage may be captured in individually linked clinical records, but would be more challenging in registers/tally sheets. Contextual factors are important.

To calculate coverage of antibiotic treatment for newborn infection using RHIS data, we recommend the following numerator: number of newborns identified as infection cases who also received at least two days of appropriate injectable antibiotics, including cases of possible serious bacterial infection (critical illness or clinical severe infection) in outpatient settings or clinically suspected sepsis in inpatient settings. The denominator is the number of identified infection cases in both inpatient and outpatient settings.

For antibiotic treatment of newborn infections, work is needed to refine case definitions, link more than one dose, and operationalize combining data from inpatient and outpatient systems.

Conclusions

RHISs usually involve aggregate data from registers and tally sheets, which are likely to be challenging to collect for ACS and neonatal infection treatment. Individually linked datasets, drawing from patient notes, have potential to capture these indicators, e.g., in a core neonatal inpatient dataset on a newborn ward for infection treatment, or a maternity ward for ACS.

F21.4. Improving measurement of neonatal resuscitation and Kangaroo Mother Care (KMC) in Routine Health Information Systems (RHISs)

He Tang¹, Harriet Ruysen², Ashish KC³, Suman Rao¹

¹World Health Organization; ²London School of Hygiene & Tropical Medicine; ³Uppsala University

BMC Proceedings 2024, 18(5):F21.4

Submission ID #: IMNHC1191

Panel ID# (if applicable): DRBEQ411186

Background

Every year, 2.4 million neonates die, with preterm birth and intrapartum complications the leading causes of under-5 deaths. KMC and newborn resuscitation are high-impact interventions promoted by the Every Newborn Action Plan (ENAP) as necessary for achieving Sustainable Development Goal targets. Coverage indicators are key and have been validated in Every Newborn – Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study, but need to be clearly defined and adopted for measurement in RHISs.

Methods

We synthesized published evidence in a scoping review regarding validation of indicator numerators and denominators in RHISs for tracking coverage of neonatal resuscitation and KMC. Expert groups reviewed these findings and provided recommendations.

Results

For KMC coverage in RHISs, we recommend the numerator, number of newborns with birthweight <2500g initiated in kangaroo position (anywhere in a facility), divided by total admitted newborns with a birthweight <2500g (denominator). Kangaroo position is defined as a baby placed skin-to-skin in an upright position with the caregiver. Additionally, quality of KMC metrics could be added with individually linked data regarding KMC duration and exclusive breastfeeding. Improvements in gestational age metrics are required.

For newborn resuscitation coverage, we recommend the following numerator: number of newborns receiving positive pressure ventilation (PPV) (e.g., bag-and-mask ventilation) in the delivery room. The recommended denominator is total number of live births plus stillbirths. Evidence shows that RHIS data collection for the denominator, newborns who require resuscitation, has low accuracy and is challenging to collect. As with interpretation of cesarean section rates, it is important to understand if the newborns who require resuscitation, receive resuscitation. Benchmarking the proportion of newborns anticipated to require PPV at birth with the type of cases received in each facility could be helpful.

Conclusions

These coverage indicators are commonly captured by registers and/or tally sheets and are feasible in many countries. Individually linked data from clinical notes would add detail but requires reliable bedside digital technologies. Countries adapting their RHISs will be able to monitor scale-up linked to ENAP.

F21.5. An evidence review of four small and sick newborn care coverage indicators for measurement in Routine Health Information Systems (RHISs): why does it matter and what did we do?

He Tang¹, Harriet Ruysen²

¹World Health Organization; ²London School of Hygiene & Tropical Medicine

BMC Proceedings 2024, 18(5):F21.5

Submission ID #: IMNHC1187

Panel ID# (if applicable): DRBEQ411186

Background

Linked with the updated Ending Preventable Maternal Mortality/Every Newborn Action Plan (EPMM-ENAP) Measurement Improvement Roadmap, we reviewed the evidence for measurement in RHISs of antenatal corticosteroids use, neonatal resuscitation, kangaroo mother care, and antibiotic treatment of severe neonatal infections in low- and middle-income countries.

Our objectives were to:

Synthesize evidence for measurement in RHISs of these four indicators.
Update recommendations for numerators and denominators specific to RHISs.
Consider additional measures of effective coverage in RHISs.
Identify outstanding research gaps for measurement in RHISs of these four indicators.

Methods

Convened by the World Health Organization (WHO) (2020–2022), a technical steering group of maternal and newborn health (MNH) measurement experts appointed four intervention-specific subgroups to synthesize evidence from our scoping review. The review (October 2020–March 2021) aimed to identify validated RHIS measures for antenatal corticosteroids use, neonatal resuscitation, kangaroo mother care, and antibiotic treatment of severe neonatal infections in low- and middle-income countries. Data regarding indicator definitions (numerators, denominators), data sources, and details of indicator testing were extracted and submitted to the subgroups. The subgroups assessed if indicators were action focused, important, measurable, simple, and valued using pre-defined criteria adapted from the WHO consultation improving measurement of the quality of MNH measurement in health facilities (2013).

The findings were referenced against WHO clinical care guidelines, standards, and the Every Newborn Action Plan framework. Each subgroup undertook technical work to agree on recommendations regarding the definition (numerator/denominator), potential RHIS data sources, and research priorities.

Recommendations were reviewed in consultation with the MoNITOR group, a WHO-led initiative including more than 80 partners, aiming to provide technical support and coordination for efforts to strengthen MNH measurement (July 2022).

Results

The Every Newborn – Birth Indicators Research Tracking in Hospitals study included validation of measurement in RHISs for three of the indicators. Results are in 'Results are presented in the two related abstracts showing recommendations for:

What can be measured now in a RHIS:
- ◦ Indicator definition
- ◦ Data source
What are measurement gaps?
What next to improve RHIS data availability and quality?

Conclusions

RHIS count data have potential for near real-time use to inform health service planning. However, to avoid overburdening the least resourced systems, we need to assess which data can be realistically collected for accurate measurement of which indicators.

F22.1. Global guidance to country implementation: country experiences with scaling up small or sick newborn care to achieve Every Newborn Action Plan (ENAP) target 4

Lily Kak¹, Gagan Gupta², Felix Bundala³, Bibek Kumar Lal⁴, Tom Sesay⁵

¹United States Agency for International Development; ²United Nations Children’s Fund; ³Ministry of Health, Tanzania; ⁴Ministry of Health and Population, Nepal; ⁵Ministry of Health and Sanitation, Sierra Leone

BMC Proceedings 2024, 18(5):F22.1

Submission ID #: IMNHC517

Panel ID# (if applicable): DRPGF68517

Panel Description

Despite impressive reductions in newborn mortality rate (NMR) across the globe, advances are not equal among countries. A Lives Saved analysis revealed the impact of inpatient care of small and sick newborns (SSNB) to be the biggest in averting newborn mortality. Yet, 80% of the 30 million newborns that require inpatient care each year do not receive it. To address this critical gap, ENAP added a fourth target on SSNB for countries to achieve by 2025: 80% of countries have a national implementation plan for SSNB care and 80% of districts have a functional level 2 inpatient unit to care for SSNB with respiratory support, including continuous positive airway pressure. To guide countries’ efforts toward achieving this target, the World Health Organization and the United Nations Children’s Fund (UNICEF) have developed standards for improving the quality of care for SSNB in health facilities and a model of level 2 care.

This session will bring together global and country partners to discuss the global guidance and country implementation of SSNB care. The panel will begin with parents who will share their experience as partners caring for their hospitalized newborns. UNICEF will describe the SSNB model of care and share key insights on scale. A moderated panel discussion will follow, with government officials from Bangladesh, Nepal, Rwanda, Sierra Leone, and Tanzania, to delve into components of country-contextualized models of SSNB care and learn from experiences in organizing systems scale-up of services.

F22.2. Scaling up small and/or sick newborn care: implementation experience from countries —Bangladesh, Nepal, Rwanda, Sierra Leone, and Tanzania

Lily Kak¹, Felix Bundala², Bibek Kumar Lal³, Tom Sesay⁴, Francois Regis Cyiza⁵, Ahmedul Kabir⁶

¹United States Agency for International Development; ²Ministry of Health, Tanzania; ³Ministry of Health and Population, Nepal; ⁴Ministry of Health and Sanitation, Sierra Leone; ⁵Rwanda Biomedical Center; ⁶Ministry of Health, Bangladesh

BMC Proceedings 2024, 18(5):F22.2

Submission ID #: IMNHC521

Panel ID# (if applicable): DRPGF68517

Background

Several countries have made remarkable progress in scaling up level 2 small and sick newborn (SSNB) care. Their experiences have helped build consensus on the core components of the models of SSNB care. During this session, government representatives from five forerunner countries will summarize their experiences and share pragmatic aspects of scale-up in implementing special newborn care at level 2 facilities.

Methods

Countries that have demonstrated progress in scale-up of SSNB care have done so by addressing many of the 10 components of the model of care. During this session, the moderator will guide conversations that will allow countries to deep dive into specific components of their models of SSNB care and summarize key learnings from their experiences.

Results

All five countries scaled up SSNB care through strong leadership with nationally endorsed costed plans supported through domestic and partner resources. Sierra Leone has clear norms for staffing, while Bangladesh has proposed multidisciplinary staff teams. Rwanda has developed new cadres and staffing models. All countries have prioritized infrastructure, equipment, and commodities through government plans and budgets, with Tanzania’s procurement and maintenance system being exemplary. Strengthened data systems, functional referral systems within networks of care, and specialized health care workers that grew as systems of special newborn care matured, were other critical areas of focus. All countries started small and learned through implementation in select components of care. They added newer components and missing pieces based on emerging needs as they moved ahead.

Conclusions

All five participants in the panel represent low- and middle-income countries that were able to move the needle in newborn care. Their learning experience can support countries that have moved from scaling up basic preventative and promotive newborn care to scaling up essential newborn care and newborn resuscitation, and are now embarking on expanding facility-based newborn care that will ensure they achieve their Every Newborn Action Plan and Sustainable Development Goal targets.

F22.3. What does it take to scale up facility-based newborn care: lessons from forerunner countries

Lily Kak¹, Gagan Gupta²

¹United States Agency for International Development; ²United Nations Children’s Fund

BMC Proceedings 2024, 18(5):F22.3

Submission ID #: IMNHC519

Panel ID# (if applicable): DRPGF68517

Background

The World Health Organization’s Standards for Improving the Quality Care of Small and Sick Newborns in Health Facilities and the model of care provide the framework for countries to adapt and contextualize to strengthen the quality of nurturing small and sick newborn (SSNB) care in level 2 facilities. Several countries have taken global guidance and chalked out a path that has led programs to scale. This presentation summarizes key insights about the model of care and the nuts and bolts of scaling up SSNB care.

Methods

Understanding and capturing the learning from countries that are on the leading edge of scaling up SSNB facility care was the key methodology used to determine the critical elements for rolling out a nationally scalable model of care.

Results

Ten critical components are needed as per WHO-UNICEF supported model for scaling up care for small and sick newborn. They include long-term vision with a change team guiding and tracking the process at national level; an implementation plan that captures all components of the model of care for pilot testing in multiple geographies across the nation; high-level visibility through advocacy, including political attention and leadership; adequate budget lines for establishment and operating expenses; infrastructure planning and standardization; equipment procurement and maintenance systems; human resource requirements for establishing norms and policies that attract and retain capable staff for provision of care; robust data systems to track performance and outcomes across service delivery points; functional referral system, linkages of maternal and newborn care; a system for post-discharge follow-up care; and engagement of families in care right from the start. This model needs to build on a strong foundation of quality maternal and essential newborn care for all mothers and babies.

Conclusions

Scaling up inpatient SSNB care requires working simultaneously on different steps and not sequentially. While there are many implementation challenges, plenty of lessons are emerging from multiple countries that can help inform countries that are considering the rollout of SSNB care.

F22.4. Our baby: the trials and tribulations of living through the early days of life with our small and sick baby in inpatient care

Lily Kak

United States Agency for International Development

BMC Proceedings 2024, 18(5):F22.4

Submission ID #: IMNHC518

Panel ID# (if applicable): DRPGF68517

Background

Every birth is a joyous event as parents come face to face for the first time with their bundle of joy. Yet, parents of newborns can also be tired, overwhelmed, and uncertain as they learn to bond with and care for their babies. The stress escalates for parents of small and sick newborns, especially when separated in inpatient care units. Parents separated from their babies are more likely to experience anxiety and have feelings of helplessness. Involvement of mothers/parents in the care of their small and/or sick newborn improves developmental outcomes for their babies and the well-being of parents and prepares them to assume full responsibility after discharge.

Methods

In this session, parents who have lived through the experience of having a small and/or sick newborn in inpatient care will share their first-person stories. They will provide insights on what it means to be parents with small and/or sick newborns.

Results

One in six women worldwide experiences signs of depression during the postnatal period, which affects her capacity to care for her baby. Parents of newborns who were small and/or sick have noted that being able to participate as partners in the care of their baby enables them to learn to respond to their baby’s needs. Continuous family access, rooming in, and practicing skin-to-skin care ensures that parents are fully enabled to provide nurturing care to their newborn at all times, leading to developmentally supportive care. The hospital environment influences the experience of care for newborns and their families in inpatient care.

Conclusions

Being born too soon or too small, or being sick, necessitates extra care for these more vulnerable newborns. This care is best provided directly by the parents, in close partnership with health care professionals.

F23.1. Leveraging closer-to-reality travel time estimates from big data to address gaps and achieve equity in geographical accessibility to emergency obstetric care in Sub-Saharan Africa’s largest megacity

Aduragbemi Banke-Thomas¹, Bosede Afolabi², Kerry Wong¹, Babatunde Ajayi³, Charlotte Yandell Stanton⁴

Panel Description

Actions to achieve Sustainable Development Goal 2030 targets for maternal and newborn health (MNH) are supported by ENAP and EPMM partnerships. ENAP and EPMM have launched five joint coverage targets and milestones for tracking progress, and the first joint ENAP/EPMM progress report launches at the International Maternal Newborn Health Conference (IMNHC) in May 2023. Data for action is an important ENAP and EPMM milestone and includes strengthening data systems to better track these targets at subnational, national, and global levels. To this end, the ENAP/EPMM partnership has developed a joint Measurement Improvement Roadmap 2023–2025 to list priority indicators with a focus on ENAP/EPMM targets, identify what to do now to improve data (especially in routine systems), and outline what is next for improving measurement and use of data. The previous ENAP Measurement Improvement Roadmap 2015–2020 resulted in improved data guidance and also large multi-country validation studies to inform measurement change.

In this dynamic session, three presentations cover what to measure now and next for indicators regarding impact, coverage/quality, and service availability. A country-led panel discussion follows. Building on evidence from the 2023 EPMM/ENAP report, this session uses the roadmap to show current MNH data availability and how to drive improvements in data quantity, quality, and utility at local, district, and national levels. Panelists include national policymakers, donors, and thought leaders sharing experiences and realities of how we can transform data for action in MNH and move faster, including what can be achieved by the next IMNHC in 2025.

F24.2. Improving data for action: what to measure now and what next to best monitor progress toward achieving Ending Preventable Maternal Mortality/Every Newborn Action Plan (EPMM/ENAP) targets? Implementing the new measurement improvement roadmap

Joy Lawn¹, Harriet Ruysen¹, Allisyn Moran², Cheikh Mbacke Faye³, Mihretab Salasibew⁴, Dalya Eltayeb⁵, Jennifer Requejo⁶

¹London School of Hygiene & Tropical Medicine; ²World Health Organization; ³African Population and Health Research Center; ⁴Children's Investment Fund Foundation; ⁵Federal Ministry of Health, Sudan; ⁶United Nations Children’s Fund

BMC Proceedings 2024, 18(5):F24.2

Submission ID #: IMNHC907

Panel ID# (if applicable): DUBIC3274

Background

The original Measurement Improvement Roadmap (2015) was conceived as a five-year plan to improve, institutionalize, and use metrics to accelerate progress for women, newborns, and stillbirths. Now together for change, EPMM-ENAP have updated the roadmap, an important accountability milestone, showcasing progress and building consensus on the prioritization of remaining gaps for maternal and newborn health measurement. During this closing abstract, we will provide an overview of the Measurement Improvement Roadmap (2023–2025) and the implications for implementation. This will include a dynamic panel discussion led by multi-agency partners and country leaders.

Methods

Panelists from Countdown, the Children’s Investment Fund Foundation (CIFF), government ministries, and the United Nations Children’s Fund (UNICEF) will share their perspectives and experiences implementing the Measurement Improvement Roadmap.

Results

Moderated by Prof. Joy Lawn, the panelists, representing country leaders, program managers, measurement experts, and donors, will share their implementation experiences and how we can improve measurement of the indicators presented in previous abstracts, considering:

Multi-country routine data quality and capacity in DHIS—Dr. Cheikh Faye (Countdown, African Population and Health Research centre (APHRC))
Funding perspective—Mihretab Salasibew (CIFF)
Emergency obstetric and newborn care and maternal and perinatal death surveillance and response in Sudan—Dr. Dalya Eltayeb (Ministry of Health, Sudan)
Where do we go next for use of data and research?—Dr. Jennifer Requejo (UNICEF)

Conclusions

The updated EPMM/ENAP Measurement Improvement Roadmap reviews progress for the development of tools, validation of indicators, and institutionalization of metrics. The roadmap highlights ongoing opportunities for strengthening routine health information systems and scaling up digital innovations and systems for crosslinking different data platforms, and galvanizing progress toward individually linked digital data systems. However, gaps remain for disaggregation at local levels and may impede progress for populations and geographies most at risk of poor health outcomes. Change requires intentional transfer of leadership to the countries with the greatest disease burden, and it is imperative to be led by their experiences and priorities.

F24.3. Measuring availability of emergency care for every woman and every newborn: what can be measured now and what next toward achieving Ending Preventable Maternal Mortality/Every Newborn Action Plan (EPMM/ENAP) targets?

Allisyn Moran¹, Joy Lawn², Harriet Ruysen², Gagan Gupta³, Jean Pierre Monet⁴

¹World Health Organization; ²London School of Hygiene & Tropical Medicine; ³United Nations Children’s Fund; ⁴United Nations Population Fund

BMC Proceedings 2024, 18(5):F24.3

Submission ID #: IMNHC900

Panel ID# (if applicable): DUBIC3274

Background

Increasing service provision of emergency obstetric and neonatal care (EmONC) and small and sick newborn care (SSNC) is essential for countries to reach Sustainable Development Goal targets 3.1 (maternal) and 3.2 (newborn). Inequities to accessing high-quality services persist, with ongoing gaps for investment in many low- and middle-income countries. Joint EPMM/ENAP targets (2020–2025) for EmONC and SSNC are defined at district, national, and global levels. More comparable, yet feasible, tracking tools are required.

Methods

In support of EPMM/ENAP targets, evidence synthesis and consultations have been undertaken to review measures, tools, and data sources for EmONC and SSNC. These findings have informed the updated ENAP/EPMM Measurement Improvement Roadmap.

Results

What can be measured now?

EmONC signal functions are being updated in line with advances in maternal and newborn health, including proposals for newborn signal functions.
Standards for Improving the Quality of Care for Small and Sick Newborns in Health Facilities (2020) includes measures for tracking SSNC, some that can be measured in routine health information systems now.

Where do the data come from?

More than 120 countries are expected to complete the ENAP/EPMM tracking tool (February 2023). This includes self-reported progress toward ENAP target 4 (80% of districts with level 2 SSNC services) and EPMM target 4 (80% of women within two hours travel time of an EmOC facility).
Few countries have up-to-date assessments due to cost and expertise required for EmOC assessments. In 2017, 21/83 “Countdown countries” reported data for EmONC availability. In 2022, only 12 countries were measuring geographic access of population within two hours of travel time. The United Nations Population Fund is developing an EmOC Lite tool.
The SSNC United Nations Children’s Fund/NEST360 health facility assessment tool can measure if a facility is operational for World Health Organization level 2 SSNC and takes a day to implement. This tool is open source and has been used in more than 100 facilities in six countries so far.

Conclusions

What next?

Improved and simplified tools for assessing EmONC and SSNC availability with modeling for geographical access.
Strengthened measures of experience of care.
Increased use of routine health information systems for assessing the availability, quality, and access to EmONC with individually linked data.

F24.4. Coverage data for maternal and newborn health: what can be measured now and what next to best monitor progress toward achieving Ending Preventable Maternal Mortality/Every Newborn Action Plan (EPMM/ENAP) targets?

Allisyn Moran¹, Joy Lawn², Harriet Ruysen², Jennifer Requejo³, Agbessi Amouzou⁴

¹World Health Organization; ²London School of Hygiene & Tropical Medicine; ³United Nations Children’s Fund; ⁴Johns Hopkins Bloomberg School of Public Health

BMC Proceedings 2024, 18(5):F24.4

Submission ID #: IMNHC892

Panel ID# (if applicable): DUBIC3274

Background

To meet Sustainable Development Goal targets for every woman and every newborn, equitable coverage of high-quality antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) services are essential. Hence, joint EPMM/ENAP targets (2020–2025) have been agreed for these three indicators at district, national, and global levels. Increases in coverage of services are necessary but alone not sufficient to improve maternal and newborn survival or prevent stillbirths. Quality of care is also critical. We present findings in the ENAP/EPMM Measurement Improvement Roadmap regarding opportunities to better measure and use these data.

Methods

The United Nations and partners undertook technical reviews, evidence synthesis, and consultation regarding measures of coverage for ANC, SBA, and PNC, and linked effective coverage indicators. We considered measurement feasibility and interpretability. As part of the updated Measurement Improvement Roadmap, the findings inform what is measured now, gaps, and next steps.

Results

Where do the data come from?

Based on the United Nations Children’s Fund data warehouse, the number of countries with available household survey data in 2016–2021 was 90 for ANC 4+, 162 for SBA, 81 for maternal PNC, and 75 for newborn PNC.

What can be measured now and what is the data quality?

Population representative measures of ANC 4+, SBA, and PNC are collected through household surveys. Given new World Health Organization recommendations, ANC 4+ may be replaced by 8+.
Country-level variations in the definition of SBA present challenges for standardized and comparable measurement.
Measures of effective coverage for these services have been developed, but the assessment of more detailed quality of care is likely to be more accurate in routine health information systems than in surveys of maternal recall.

Conclusions

What next?

Household survey programs require continued support, especially in lower-income countries and humanitarian settings.
Strengthening routine health information systems is essential to ensure more data, more details on quality of care, and faster feedback for national and subnational monitoring. Implementation of global guidance on standardized definitions is key.
Increased investment in digital technologies with better links between data sources will improve data availability and quality.
Investment in data capacity and use is also crucial to drive progress toward achieving the Sustainable Development Goals.

F24.5. Impact data for maternal and newborn health: what can be measured now and what next to best monitor progress toward achieving Ending Preventable Maternal Mortality/Every Newborn Action Plan (EPMM/ENAP) targets?

Allisyn Moran¹, Joy Lawn², Harriet Ruysen²

¹World Health Organization; ²London School of Hygiene & Tropical Medicine

BMC Proceedings 2024, 18(5):F24.5

Submission ID #: IMNHC873

Panel ID# (if applicable): DUBIC3274

Background

Impact data on maternal mortality ratio (MMR), neonatal mortality rate (NMR), and stillbirth rate (SBR) are crucial to track for Sustainable Development Goal progress. These mortality data and linked outcomes, such as low birthweight (LBW) and preterm birth, are typically collected through a variety of data platforms: nationally representative surveys, routine health information systems (RHISs), or civil registration and vital statistics (CRVS) systems.

Methods

The United Nations and partners have led evidence synthesis and consultations to review the status of EPMM/ENAP impact indicators to inform the updated Measurement Improvement Roadmap, highlighting the following:

Where do the data come from?
Which countries have what data now, and from which data platform?
What can be measured now and what is the data quality?
Comparability, e.g., which definitions, quality (data completeness, etc.)
What next?
Gaps in research and opportunities for innovation

Results

Where do the data come from?

157/195 countries for SBR (UN Inter-agency Group for Child Mortality Estimation 2023)
158/195 countries for LBW rate (in press)
103/195 countries for preterm birth rate (in press)

What can be measured now and what is the data quality?

Impact indicator definitions are consistently applied for MMR, NMR, and LBW in almost all countries. SBR definition consistency has improved with the World Health Organization definition for international comparison (>28 weeks gestation). Preterm birth rate definitions are consistent but gestational age measurement methods and accuracy vary.
Many high mortality countries rely on household surveys for data on impact measures. Now that more than 80% of births are in facilities, coverage of facility RHISs and CRVS could be rapidly increased.

Conclusions

What next?

Improve RHIS data quantity and quality for facility births and deaths, linked to maternal and perinatal death surveillance/audits.
Birth registration for every facility birth.
Innovations to improve gestational age estimation and birthweight measurement with digital technologies for linking to individual data.
Investments in widely available, programmatically relevant data for use at local, district, and national levels to drive quality of care for every woman and every newborn.

F25.1. Building a conceptual and monitoring framework for emergency referral systems, with implementation perspectives from Mozambique and India

Emily Keyes¹, Prateek Gupta², Megan Lydon¹, Aguinaldo Mariano¹, GV Ramana Rao³

¹FHI 360; ²London School of Hygiene & Tropical Medicine; ³108 Emergency Management Research Institute Green Health Services

BMC Proceedings 2024, 18(5):F25.1

Submission ID #: IMNHC36

Panel ID# (if applicable): DUPVM2336

Panel Description

With timely access to skilled care, most maternal and newborn deaths in low-income countries are preventable. Reaching the right care at the right time remains a challenge, especially when emergency interfacility referral is required to manage complications.

Referral is a critical component of high-quality health systems that requires many elements within and outside of facilities to function properly. This panel brings together implementers and researchers to describe a consolidated conceptual framework and a proposed monitoring framework for emergency referral system performance, aimed to guide health planners and policymakers toward improved system functioning.

Panelists will summarize current evidence around emergency referral systems, including a multi-country analysis of referral system performance, and share perspectives of designing and managing referral systems in different contexts. The aim is to generate discussion of practical approaches to design, implement, and continuously monitor these complex systems to enable timely access to life-saving services in different contexts.

The conceptual framework was developed by members of the management committee for the global Community of Practice for Transport and Referral, based at London School of Hygiene and Tropical Medicine; the multi-country analysis was conducted by FHI 360 with funding from the Averting Maternal Death and Disability Program at Columbia University. Implementation perspectives come from a USAID-funded project in Mozambique and an emergency management institute in India.

F25.2. Toward a monitoring framework for emergency obstetric and neonatal referral system readiness: a multi-country analysis

Megan Lydon¹, Emily Keyes¹, Prateek Gupta², Bunsoth Mao³, Sarah Mercer⁴, Peter Acker⁵, Loveday Penn-Kekana²

¹FHI 360; ²London School of Hygiene & Tropical Medicine; ³University of Health Sciences, Cambodia; ⁴Columbia University; ⁵Stanford University School of Medicine

BMC Proceedings 2024, 18(5):F25.2

Submission ID #: IMNHC38

Panel ID# (if applicable): DUPVM2336

Background

There is a gap in referral system measurement and a need to identify the key elements of referral system inputs and processes that lead to a functioning system. Further, referral systems are complex systems difficult to summarize with any one indicator. Given this, we aimed to develop an initial composite indicator that captures multiple dimensions of referral systems through easily measured indicators that describe system readiness.

Methods

Based on the literature, WHO guidelines, and relevant experiences, we identified six key dimensions of referrals through consensus. We mapped existing data from national emergency obstetric and newborn care assessments to these dimensions. Using data from more than 6,000 health facilities across Ghana, Zambia, Cambodia, Ethiopia, and Malawi from 2010–2020, we performed descriptive analysis of indicators aligning with the referral dimensions. We then constructed a composite indicator: we scored and standardized variables, aggregated scores by dimension, weighted each dimension equally, and summed them for a total score presented as a percentage. We used descriptive analysis to compare referral system readiness across factors.

Results

The six dimensions comprise (1) transportation readiness, (2) referral efficiency and coordination of care, (3) care during transport, (4) financial accessibility of referral, (5) interfacility relational dynamics, and (6) family-centered care. Existing data aligned with dimensions 1-4; while important, data on dimensions 5-6 are rarely captured and represent a gap in current monitoring efforts. Composite indicator scores ranged from 41% to 54%. Financial accessibility of referral remained the strongest dimension across countries, with scores of 53% in Ghana to 97% in Zambia. Care during transport was consistently the weakest with scores of 10% in Malawi to 32% in Zambia. Across countries, the mean composite score was higher for hospitals than for other health facilities, with a 15% to 19% difference between groups. In most countries, health facilities ranking in the top quintile of referral readiness also represented the largest proportion of monthly deliveries.

Conclusions

These results demonstrate a method to succinctly measure referral system readiness. The proposed framework and composite indicator could be routinely used to monitor progress, identify gaps, and guide referral system strengthening efforts.

F25.3. Title: interfacility obstetric and neonatal transfers: clarifying their fit in theory and in practice

Prateek Gupta¹, Megan Lydon², Emily Keyes², Peter Acker³, Loveday Penn-Kekana¹

¹London School of Hygiene & Tropical Medicine; ²FHI 360; ³Stanford University School of Medicine

BMC Proceedings 2024, 18(5):F25.3

Submission ID #: IMNHC37

Panel ID# (if applicable): DUPVM2336

Background

Referral is a widely used and broad term that covers a range of journeys that women and newborns must make to and between health facilities. Referrals are a complicated concept that rely on the interactions between the personnel and structures of health systems, transportation, clinical guidelines, health-seeking behaviors of patients and caregivers, public and private providers, and sociodemographic factors, among other dimensions. Monitoring an effective interfacility health-related transfer system requires a framework that can conceptualize interactions between dimensions that contribute to the outcome of interest and highlight specific areas of focus for improved performance.

For this work, we have focused on interfacility emergency obstetric and neonatal transfers. We build on existing conceptual frameworks such as the Three Delays model, Social Determinants of Health, and WHO guidance on transport during emergencies, among others, to address aspects of interfacility health-related transfers. Each framework has its limitations largely because of the service use and service organization assumptions that underlie them. These frameworks were designed for different theoretical settings and propose varying operational and measurement approaches.

Methods

We conducted a narrative review of frameworks that describe dimensions of interfacility health-related transfers. In addition, content analysis was undertaken to conceptualize how the dimensions of each framework can be synthesized to address considerations for measurement.

Results

To inform future efforts to improve interfacility transfers, we propose an integrated conceptual framework that we believe can assist health care managers and researchers in synthesizing evidence, understanding phenomena, and informing attempts to improve service, ensuring that pregnant women and newborns get to the right place at the right time and receive the right care. In addition, we propose using specific terminology to describe aspects of interfacility health-related transfers to assist in harmonizing concepts across study settings, health conditions, and severity.

Conclusions

This proposed conceptual framework and common language for interfacility health-related transfers provide an overarching model and language that may help guide the development, validation, implementation, and interpretation of measures and suggests boundaries for the health system’s responsibilities.

F26.1. Small vulnerable newborns: measurement now and next to enable better care and faster progress to national targets around the world

Elizabeth A. Hazel¹, Yemi Okwaraji², Lorena Suarez-Idueta³, Mihretab Salasibew⁴, Aris Papageorghiou⁵, Hannah Blencowe²

¹Johns Hopkins Bloomberg School of Public Health; ²London School of Hygiene & Tropical Medicine; ³Mexican Society of Public Health; ⁴Children’s Investment Fund Foundation; ⁵University of Oxford

BMC Proceedings 2024, 18(5):F26.1

Submission ID #: IMNHC843

Panel ID# (if applicable): DUWEM47843

Panel Description

Globally, one in six babies is born with a low birthweight and one in 10 is born preterm. The Global Nutrition Target for 30% reduction in low birthweight by 2025 is off track, and preterm rates are rising in many countries.

Newborns with low birthweight include those born preterm, or small for gestational age, and those that have both conditions. Such infants are at risk of early mortality and poor health throughout their life course. However, birthweight and gestational age are often measured separately, meaning the two types of low birthweight cannot be distinguished; small for gestational age infants may not be recognized because of lack of knowledge of gestational age; and stillbirths are omitted. New approaches are needed.

The Vulnerable Newborn Measurement Collaboration includes > 250 members including governments, implementers, and researchers. The collaborative has enabled a massive dataset of 279.3 million live births from 23 high-income and 14 low- and middle-income countries, 2000 to 2021. This dataset allows newborn types to be determined by combining gestational age (preterm vs. term) and size (small-, appropriate-, and large-for-gestational age), enabling more targeted care and elucidating aetiology to accelerate health of vulnerable newborns globally.

We share novel findings, and then a panel of country representatives and experts will map out the way forward. This panel links to the Lancet Small Vulnerable Newborn series, “Born Too Soon Decade” report and Vulnerable Newborn supplement in BJOG: An International Journal of Obstetrics and Gynaecology, which will be launched at IMNHC. We aim to inform actions before IMNHC 2025.

F26.2. Policy talk show/panel: measurement now and next to enable better care and faster progress to national targets

Mihretab Salasibew¹, Elizabeth A. Hazel², Hannah Blencowe³, Robert Black², Joy Lawn³, Msandeni Chiume⁴, Aris Papageorghiou⁵, Lucia Hug⁶

¹Children’s Investment Fund Foundation; ²Johns Hopkins Bloomberg School of Public Health; ³London School of Hygiene & Tropical Medicine; ⁴Kamuzu University of Health Sciences; ⁵University of Oxford; ⁶United Nations Children’s Fund

BMC Proceedings 2024, 18(5):F26.2

Submission ID #: IMNHC854

Panel ID# (if applicable): DUWEM47843

Background

This dynamic TV talk show session will include diverse speakers and involve engaging conversations, enabling inputs from the audience, discussion points from the data presented, plus interactive voting. The focus will be a range of viewpoints on what next for metrics and action, and aiming to be as actionable as possible for change in the next two years before IMNHC reconvenes.

Methods

The MC with be Mihretab Salasibew in partnership with Joy Lawn to enable Mentimeter voting. Participants will cover the following topics:

National routine data systems: National government leaders for routine data from Nepal and Malawi, based on the most senior relevant person present at the conference. These national experts will discuss implication and challenges for changing their national systems to improve data for babies born too soon and/or too small.
Stillbirth inclusion: UN lead for improving and using stillbirth data, Dr. Danzhen You.
Interventions for nutrition and what’s next: Professor Bob Black as a world-leading expert on nutrition data for MNH and evidence for interventions.

F27.2. Health system and environmental influences on fear of maternity care litigation in India (Re-Judge Project)

Sunny Mannava¹, B.R. Shamanna¹, Indie Kaur², Gill Moncrieff³, Joanna Erdman⁴, Elena Altieri⁵, Sarah Elaraby⁶, Maria Regina Torloni⁷, Ana Pilar Betran⁵, Soo Downe³

¹University of Hyderabad; ²Fernandez Foundation; ³University of Central Lancashire; ⁴Dalhousie University; ⁵World Health Organization; ⁶University of Alexandria; ⁷São Paulo Federal University

BMC Proceedings 2024, 18(5):F27.2

Submission ID #: IMNHC400

Panel ID# (if applicable): DWOLL16332

Background

In the past few decades, India has witnessed a sharp increase in cesarean section (CS) rates (3% in 1992–1993 to 23% in 2019–2021). Although more surgical births were needed to reduce maternal and neonatal mortality and complications, current rates in some India states and hospitals are reaching more than 60%. Overuse of CS without a medical need can put both mother and baby at risk in the short and long term. Health provider fear of litigation has been associated with unnecessary CS worldwide.

Methods

The Re-Judge project aimed to use insights from behavioral science to develop a multimedia program for lawyers and judges that could address their knowledge and beliefs about the risks and benefits of CS, in the context of legal and human rights. In the process, we explored the extent to which medical fear of litigation might be a driver for CS in the India. We conducted in-depth interviews with lawyers, obstetricians, and women’s representatives, using a semi-structured interview guide. Framework analysis techniques were used to map interview data to behavioral drivers and mental models developed in the review phase of the project. Two workshops were then held to explore attitudes and intentions of medical and legal participants toward CS because of fear of litigation.

Results

Nineteen participants were interviewed. Twenty-four attended the workshops. Mean years of experience was 26 years; median age 52 years. Fear of litigation was a significant concern for the participating doctors. This was a surprise for some of the participating lawyers. However, medical fearfulness extended beyond litigation, including fear of physical attack from disgruntled families, and fear of being shamed and of suffering reputational loss on social media.

Conclusions

Although fear of litigation is an important driver of overuse of CS, fear of violence and of social media exposure are also relevant, if an adverse event occurs. Safe discussion spaces between doctors, lawyers, and service user representatives, such as the Re-Judge workshops, may enable different parties to understand and address misconceptions that underpin overuse of medical procedures carried out because of fear, rather than medical necessity or women’s choice.

F27.3. Fears driving women’s preference and decision-making on mode of birth: experience from Burkina Faso

Fadima Inna Kamina Yaya Bocoum¹, Charles Paulin Kaboré¹, Simon Tiendrebeogo¹, Saran Barro¹, Alexandre Dumont², Claudia Hanson³, Ana Pilar Betran⁴, Meghan Bohren⁵

¹Institut de Recherche en Sciences de la Santé; ²Institute of Research for Development; ³Karolinska Institutet; ⁴World Health Organzation; ⁵University of Melbourne

BMC Proceedings 2024, 18(5):F27.3

Submission ID #: IMNHC398

Panel ID# (if applicable): DWOLL16332

Background

In Burkina Faso, cesarean section (CS) rates have increased markedly since 2006 when the government deployed a national subsidy policy for childbirth and emergency obstetric care. There is concern that the policy may have also increased unnecessary CS. Suboptimal communication with health care providers, and women’s lack of information and involvement in decision-making during childbirth, are recognized problems in Burkina Faso. The increase in CS, coupled with the lack of information and communication, may place pregnant women in a vulnerable position. We aimed to explore women’s fears, and factors driving these fears, in Burkina Faso.

Methods

This formative qualitative research was conducted in 2020 to inform the QUALI-DEC project, to design, adapt, and implement a strategy to optimize use of CS. We conducted in-depth interviews with pregnant and postpartum women in four hospitals in Burkina Faso and used a thematic analysis approach to summarize findings on fear.

Results

A total of 38 in-depth interviews (22 with pregnant and 16 with postpartum women) were conducted. Most participants reported that they experienced fear and anxiety during pregnancy. Although women feared losing their life and having complications during childbirth that could influence outcomes, most did not talk about their fears. It was challenging to discuss fears with a birth companion, because most women did not choose this companion themselves, as they were typically a member of her family or in-laws who were available at the time of birth. Although most women did not discuss fears with providers, spouses, or parents, the few women who did talk about it benefited from the emotional support of providers and spouses, which helped to control their anxieties. Women preferred a vaginal birth and were afraid of needing a CS. This preference was based on fear of failing to be recognized as a “strong woman” by their in-laws.

Conclusions

Preferred mode of birth is mainly driven by the fear of undeserved social recognition as a “strong woman”. In particular, recognition by the family in-law is a cause of anxiety among pregnant women. The emotional and social impact of a CS on women should not be ignored.

F27.4. Behavioral factors associated with fear of litigation as a driver for the increased use of cesarean sections: a scoping review

Sarah Elaraby¹, Elena Altieri², Soo Downe³, Joanna Erdman⁴, Sunny Mannava⁵, Gill Moncrieff³, B.R. Shamanna⁵, Maria Regina Torloni⁶, Ana Pilar Betran², Meghan Bohren⁷

¹University of Alexandria; ²World Health Organization; ³University of Central Lancashire; ⁴Dalhousie University; ⁵University of Hyderabad; ⁶São Paulo Federal University; ⁷University of Melbourne

BMC Proceedings 2024, 18(5):F27.4

Submission ID #: IMNHC356

Panel ID# (if applicable): DWOLL16332

Please note the full manuscript published in April 2023 in BMJ Open:

(https://0-bmjopen-bmj-com.brum.beds.ac.uk/content/13/4/e070454)

F28.1. Can we address the complexity of childbirth and newborn care with multi-component and complex interventions? Experience from the ALERT, Quali-Dec, and SCSL projects from Sub-Saharan Africa, Latin America, and Asia

Claudia Hanson¹, Lenka Benova², Jean-Paul Dossou¹

¹Karolinska Institutet; ²Institute of Tropical Medicine

BMC Proceedings 2024, 18(5):F28.1

Submission ID #: IMNHC65

Panel ID# (if applicable): DXPLD1065

Panel Description

The complexity of childbirth care is characterized by three interfaces: First, the two continua of care from pre-pregnancy to postpartum care and community to referral hospital, meaning that the key health systems characteristics and the functioning of the linkages between services points including the referral systems have a major impact. Second, childbirth care includes preventive and promotive, thus routine care as well as time-sensitive emergency care. Third, quality childbirth care is provided by a team of nurses, midwives, obstetricians, as well as neonatologists and pediatric staff, thus a multi-professional team with different pre-service training and professional values and identities, creating frictions. Over- and underprovision of evidence-based interventions are seen in all settings, with the overuse of cesarean sections being a well-known example. Abuse and neglect have been raised and responsiveness during birth is high on the international agenda. Improving quality of care within these complex systems demand careful combination of strategies to address the complexity and the different drivers of this complex system. But complex interventions may also overburden implementers and systems. Complex interventions demand sufficient resources, long-term investments and sufficient patience to mentor and support implementing teams and institutions. Here we summarize our learning from three complex interventions. We apply a scalability and adaptability lens to highlight critical issues.

F28.2. Effect of collaborative quality improvement on stillbirths, neonatal mortality, and newborn care practices in hospitals of Telangana and Andhra Pradesh, India: evidence from a quasi-experimental mixed-methods study

Karen Zamboni¹, Lenka Benova², Claudia Hanson¹, Zelee Hill³, Samiksha Singh⁴, Joanna Schellenberg⁵

¹Karolinska Institutet; ²Institute of Tropical Medicine; ³University College London; ⁴Institute of Public Health, India; ⁵London School of Hygiene & Tropical Medicine

BMC Proceedings 2024, 18(5):F28.2

Submission ID #: IMNHC1376

Panel ID# (if applicable): DXPLD1065

Please note the full manuscript published in January 2021 in BMC:

(https://0-implementationscience-biomedcentral-com.brum.beds.ac.uk/articles/10.1186/s13012-020-01058-z#:~:text=We%20found%20no%20evidence%20that,high%20attrition%20from%20participating%20hospitals.)

F28.3. Quali-Dec: complex intervention to improve decision-making for cesarean section

Charles Paulin Kaboré¹, Claudia Hanson², Lenka Benova³, Alexandre Dumont⁴, Mac Quo Nhu Hung⁵, Pisake Lumbiganon⁶, Guillermo Carroli⁷, Ana Pilar Betran⁸

¹Institut de Recherche en Sciences de la Santé; ²Karolinska Institutet; ³Institute of Tropical Medicine; ⁴IRD-Université de Paris; ⁵Pham Ngoc Thach University; ⁶Khon Kaen University; ⁷Centro Rosarino de Estudios Périnatales Asociación; ⁸World Health Organization

BMC Proceedings 2024, 18(5):F28.3

Submission ID #: IMNHC1211

Panel ID# (if applicable): DXPLD1065

Background

The overuse of cesarean section diverts scarce resources and thereby reduces access to health care for women in need. Cesarean section decision-making is a complex process involving multiple actors at different levels. Changing behaviors to reduce unnecessary cesarean sections presents many challenges for fragile and developing health care systems. The appropriate use of cesarean section through QUALIty DECision-making by women and providers (QUALI-DEC) study aims to implement a four-component intervention of i) audits of Cesareansections , ii) opinionleaders and a decision analysis tool, plus emotional support through companionship for women in 32 hospitals in Argentina, Thailand, Vietnam, and Burkina Faso. Here we present implementation challenges and successes encountered when implementing this multi-faceted intervention.

Methods

The implementation strategy allows adaptations of the intervention to fit the context. Formative research in the baseline period assessed the main drivers and barriers to intervention implementation. Communication materials were developed to inform and educate the various stakeholders about the four components. The country-level coordinator conducts quarterly visits to each participating hospital to support the providers and collect data of implementation challenges.

Results

The formative research has shown that few local clinical protocols used for labor and delivery management are evidence-based. Most providers were comfortable with the idea of a local opinion leader to promote good clinical practice. After a five-day training, opinion leaders introduced WHO algorithms to participating hospitals and audit methods to evaluate clinical practices. The Robson classification is well accepted by providers, but its interpretation remains difficult without continuous support. The decision analysis tool to support an informed choice of the mode of delivery is welcomed by women and providers in both versions: a paper-based and web-based application “Providers are fairly supportive to help women choose a companion during labor and delivery, but lack of space and privacy is a main barrier in many contexts.

Conclusions

The combined approach targeting women and providers is necessary to introduce the concept of shared decision-making for cesarean section in health care facilities. Such an approach is a challenge to physician-centered models of care and in settings where women are less empowered and demands of support are high.

F28.4. The Action Leveraging Evidence to Reduce Perinatal Mortality and Morbidity (ALERT) study targeting high-caseload hospitals of Benin, Malawi, Tanzania, and Uganda: early implementation experience

Jean-Paul Dossou¹, Lenka Benova², Peter Waiswa³, Kristi Annerstedt¹, Helle Moelsted-Alvesson¹, Andrea Pembe⁴, Kidanto Hussein⁵, Mechthild Gross⁶, Effie Chipeta⁷, Claudia Hanson¹

¹Karolinska Institutet; ²Institute of Tropical Medicine; ³Makerere University; ⁴Muhimbili University of Health and Allied Sciences; ⁵The Aga Khan University; ⁶Hannover Medical School; ⁷Kamuzu University of Health Science

BMC Proceedings 2024, 18(5):F28.4

Submission ID #: IMNHC805

Panel ID# (if applicable): DXPLD1065

Background

Reductions in perinatal as well as maternal mortality are too slow to reach the ambitious Sustainable Development Goals targets. The complexity of underlying conditions to reduce perinatal mortality as well as the multi-disciplinary team involved in care around the time of birth and postpartum present major challenges.

The Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) study aims to implement a four-component intervention of co-design, training, quality improvement, and mentoring in 16 hospitals in Benin, Malawi, Tanzania, and Uganda. Here we present implementation challenges and successes encountered when implementing this multi-faceted intervention.

Methods

We implemented a comprehensive co-design strategy. We conducted interviews with laboring women, companions, and midwifery providers and observations in half and a context and facility assessment in all 16 hospitals. Our co-design structure allows adaptation of the implementation strategy and provides data of implementation challenges.

Results

Assessments of midwifery providers indicated important knowledge and skills deficits of routine labor monitoring, such as the frequency of fetal monitoring and the application of the APGAR score. Laboring women indicated unresponsive contexts, including long waiting time, negligence, and abusive provider. This was more often seen when labor was longer and complicated. Midwifery providers confirmed in reflexive sessions the unresponsiveness and explained being overburdened and their feeling of helplessness. Our competency-based training targeting the needs developed during the co-design phase supporting reflective exercises and to implement changes, such as sign boards and on-site payment to speed up formal admission. Our quality improvement component aiming to implement operational and structural innovations was difficult to implement in several facilities, probably as midwifery providers felt too disempowered and needed time to understand the structured nature of quality improvement. In contrast, mentoring was substantially easier to integrate. Physical mentoring was preferred over WhatsApp, which has cost and time implications.

Conclusions

Continued efforts appreciating the complexity of the context are needed to motivate and help midwifery staff to innovate changes for improved quality of care. Such a comprehensive approach is challenging to implement in view of monetary limitations, but also limited time and leadership skills.

F29.1. Strengthening the Quality of Practice of Maternal and Perinatal Death Surveillance and Response (MPDSR)

Francesca Palestra¹, Erna Mulati², Eszter Kismodi³, Brenda Kharono⁴, Florina Serbanescu¹, Mularsih Restianingrum MKM²

¹Centers for Disease Control and Prevention; ²Ministry of Health, Indonesia; ³Sexual and Reproductive Health Matters; ⁴FHI 360

BMC Proceedings 2024, 18(5):F29.1

Submission ID #: IMNHC460

Panel ID# (if applicable): DXYCD60460

Panel Description

The World Health Organization (WHO) and partners, part of the MPDSR technical working group, are committed together to strengthen implementation of maternal and perinatal death surveillance and response (MPDSR) to enhance the quality of maternal and perinatal care and to improve health outcomes.

A key intervention for improving maternal, perinatal, and neonatal survival is understanding the number and causes of deaths. This panel will show how creating a community of practice of MPDSR data use with specific implementation experiences from Uganda, Indonesia, and other countries is possible in order to actively track number of deaths and respond to these deaths. Moreover, we will present to the audience an important new tool: the manual on “Legislating maternal death surveillance and response.”It is based on a desk-review study of a cross-section of countries that have instituted a legal or regulatory framework for implementing MPDSR systems or are aspiring to develop such a framework. Countries increasingly find legislation as a useful accountability tool that has the capacity to supplement policy through establishing a legal or regulatory mandate for reporting and reviewing maternal deaths. This enhances transparency and promotes MPDSR as a system where confidentiality needs to be always observed and respected.

The panel presented two experiences from Indonesia and Uganda where MPDSR was effectively implemented. Indonesia highlighted the evidence on the increased budget allocation for MNH services due to the MPDSR implementation: In 2021 were allocated 37,738 USD to MNH services, however thanks to the recommendations coming from the MPDSR implementation the budget has been increased to 233,813 USD in 2023. Another example is Uganda where a strong community of practice on MPDSR has been created at national level: based on the recommendations from the MPDSR action plans they have invested in community dialogues for demand creation of MCH services, transport Vouchers for teenage mothers to attend ANC, Clinical mentorships and training, prioritizing nurses and midwives, Collaborative learning sessions and webinars; adoption of QI strategies to improve complication case management, recruitment of critical cadres such as anesthetic officers; Redistribution of supplies and commodities; Increase procurement of emergency supplies at all EmONC healthcare facilities. Advocacy efforts, data on causes of death, underlying contributing factors as well as the recommendations identified in the response plans to improve the health system were pivotal factors in driving resource mobilization.

Our session will actively seek contributions from the audience on what further the World Health Organization with partners and policymakers can do to ensure further improvement and implementation of MPDSR cycle at country and global level.

F29.2. Monitoring maternal death surveillance efforts: proposed notification and review coverage rate

Florina Serbanescu¹, Francesca Palestra², Jean Pierre Monet³, Lillian Whiting Collins⁴, Allisyn Moran², Jason Hsia¹, Michel Brun³

¹Centers for Disease Control and Prevention; ²World Health Organization; ³United Nations Population Fund

BMC Proceedings 2024, 18(5):F29.2

Submission ID #: IMNHC467

Panel ID# (if applicable): DXYCD60460

Please note the full manuscript published in February 2023 in BMJ Open:

(https://0-bmjopen-bmj-com.brum.beds.ac.uk/content/13/2/e066990)

F29.3. Creating a community of practice of Maternal and Perinatal Death Surveillance and Response (MPDSR) data use: implementation experiences from Uganda

Brenda Kharono¹, Francesca Palestra², Bruno Ssemwanga³, Patrick Walugembe¹,Nicholas Matsiko¹, Philip Wanduru⁴, Nathan Tumwesigye¹, Peter Waiswa⁵, Richard Mugahi³, Marya Plotkin¹

¹FHI 360; ²World Health Organization; ³Ministry of Health, Uganda; ⁴Makerere University College of Health Sciences; ⁵Makerere University

BMC Proceedings 2024, 18(5):F29.3

Submission ID #: IMNHC465

Panel ID# (if applicable): DXYCD60460

Background

In Uganda, the maternal mortality ratio remains unacceptably high at 336 per 100,000 live births, even though > 75% of births occur in health facilities. The institutional maternal mortality ratio is 92 per 100,000, and deaths among pregnant women occur with shocking regularity in health facilities from preventable causes. Utilization of the MPDSR cycle for quality improvement was prioritized by the Government of Uganda in 2018. As part of this effort, a community of practice (CoP) was convened to ensure discussion of data and follow-up of MPDSR recommendations.

Methods

The Ministry of Health Reproductive and Child Health (MOH/RCH), in collaboration with the USAID-funded Uganda Maternal, Child Health, and Nutrition Activity and various MNCH implementing partners started new platforms to increase accessibility/data visualization of MPDSR data and promote the “R” in the MPDSR cycle. In 2021, a forum for data-driven discussions, which provides professional development (CPD) credits for health care providers, was launched.

Results

A CoP was created comprising > 200 individuals representing > 50 organizations, including faith-based, public, and private sectors. Weekly MPDSR analyses go out to > 700 individuals; > 90 reports with filterable dashboards have been circulated. Weekly meetings led by MOH/RCH regularly attract > 150 participants. Selected results include: reduced unaudited deaths; improved submission of reports through DHIS2; procurement of refrigerators for blood storage; and inclusion of anesthesiologists in MPDSR committees.

Conclusions

The MPDSR CoP in Uganda is thriving and has resulted in trackable improvements, including > 90% on time, completed maternal death audits, quick provision of emergency supplies, and data driven regional mentorships. Inputs necessary to make the MPDSR CoP successful included: MOH-led platform for convening and mobilizing stakeholders; functional, routinely updated reporting system; and timely weekly submission of data, which informs development of interactive dashboards, weekly MPDSR summaries, maps, and detailed reports.

F29.4. Legislating Maternal Death Surveillance and Response (MDSR)

Eszter Kismodi¹, Charles Ngwena², Marcus Stahlhofer³, Francesca Palestra³

¹Sexual and Reproductive Health Matters; ²University of Pretoria; ³World Health Organization

BMC Proceedings 2024, 18(5):F29.4

Submission ID #: IMNHC464

Panel ID# (if applicable): DXYCD60460

Background

Recent global and national efforts have yielded significant progress. Reducing maternal mortality, however, remains a challenge. Establishing accountable MDSR systems that are mandated by law and are consistent with constitutional and human rights obligations and public health commitments of the state, have been highlighted as an important step forward in tackling the persistence of maternal mortality.

Methods

WHO has commissioned the development of a manual on “Legislating maternal death surveillance and response,” based on a desk-based study of a cross-section of countries that have instituted a legal or regulatory framework for implementing MDSR systems or are aspiring to develop such a framework. The choice of countries was based on: geographical diversity; history of using legislation or regulation to implement MDSR; history of maternal death-related litigation; development of maternal death-related jurisprudence; domestic proposals to introduce legislation for MDSR systems; and evidence of challenges of using law to implement MDSR. The study is based on what can be found in existing literature and does not engage in an empirical inquiry to confirm the accuracy of what is found in existing literature, for example, by engaging with informants and stakeholders in the respective countries.

Results

Countries increasingly find legislation as a useful accountability tool that has the capacity to supplement policy through establishing a legal or regulatory mandate for reporting and reviewing maternal deaths. In this context it has been considered that, apart from promoting accountability and transparency through revealing the magnitude of maternal deaths that may be underreported in death certificates, the normative force of law creates a clear chain of enforceable institutional responsibilities for reporting and enhancing the “surveillance” and “response” components of MDSR.

Conclusions

Legislation can facilitate the creation of an institutional framework that has requisite legal powers and duties to conduct surveillance, collate information and intervene timely in respect to modifiable factors at facilities and in the community. The law can be also essential for guaranteeing legal protections to individuals who take part as reviewers or respondents to ensure confidentiality of data and the review process, while ensuring access to remedies that is essential for legal accountability.

F29.5. Subnational government engagement to strengthen maternal and perinatal death surveillance and response implementation to improve maternal and newborn care in East Sumba District, Indonesia

Mularsih Restianingrum MKM¹, Francesca Palestra², Erna Mulati¹, Esty Febriani³, Ratih Indriyani Rakhmawati³, Siti Nurul Qomariyah³, Tenggudai Littik³, Hana K Wadoe³, Irwan Saptono³, Kusum Thapa³, Ni Made Diah Permata Laksmi D¹, Nida Rohmawati¹

¹Ministry of Health, Indonesia; ²World Health Organization; ³Jhpiego

BMC Proceedings 2024, 18(5):F29.5

Submission ID #: IMNHC462

Panel ID# (if applicable): DXYCD60460

Background

Maternal and Perinatal Death Surveillance and Response (MPDSR) is a form of continuous surveillance that links the health information system and quality improvement processes, which include identification, notification, quantification and determination of causes, and avoidability of maternal and perinatal deaths, and use of this information to respond with actions that will prevent future deaths. MOMENTUM Country and Global Leadership with provincial authorities strengthened the capacity of East Sumba MPDSR District committee, Indonesia by building capacity on maternal and perinatal deaths review and formulation of actionable recommendations to prevent future deaths. The recommendations were then shared to both health and non-health sectors for follow-up actions.

Methods

Using WHO guidelines, a series of online and offline training, were conducted in preparation for the MPDSR process with specific focus on formulation of Specific, Measurable, Achievable, Relevant, and Timebound (SMART) recommendations. MOMENTUM Country and Global Leadership facilitated use of Maternal and Perinatal Death Notification electronic system by the district team to conduct the process and assisted the death review workshop where actionable recommendations were formulated. Sharing the matrix of recommendations to both health and non-health sectors through consultative meetings was done, which was then analyzed using the three-delays model.

Results

During the 2021 MPDSR activity cycle, some of the recommendations included the needs to enhance the capacity of health providers on Emergency Obstetric and Newborn Care, provision of essential equipment, and budget allocation for strengthening the referral system. By April 2022, the local government approved to allocate budget to cover 80% of the recommendations.

Conclusions

Improving the capacity of the district MPDSR team in conducting the MPDSR cycle resulted in the formulation of Specific, Measurable, Achievable, Relevant, and Timebound recommendations. Armed with these recommendations, the district team was confident in convincing the stakeholders to take actions. This advocacy work has led to the formulation of the district budget allocation document 2022 for improving MNH quality of care. Routine monitoring is needed to ensure continuation of this quality MPDSR process, and this can be done more effectively using the electronic data system.

F30.1. Food fortification with folic acid to prevent life-threatening birth defects worldwide

Vijaya Kancherla¹, Homero Martinez², Scott Montgomery³, Jeffrey Blount⁴

¹Emory University; ²Nutrition International; ³Food Fortification Initiative; ⁴University of Alabama-Birmingham

BMC Proceedings 2024, 18(5):F30.1

Submission ID #: IMNHC1051

Panel ID# (if applicable): DYRON901051

Panel Description

Birth defects are one of the leading causes of stillbirths and child mortality globally. There is a global inequity in birth defects prevention through proven public health interventions such as staple food fortification with folic acid, an essential micronutrient. We present the epidemiology of neural tube birth defects that are largely preventable, and the method of preventing them through food fortification. Nutrition International and Food Fortification Initiative will present their work in achieving global prevention of neural tube defects. We will also present a story of advocacy, featuring the Global Alliance for Prevention of Folic Acid-Preventable Spina Bifida (GAPSBiF) and the International Federation for Spina Bifida and Hydrocephalus. These are two global organizations that are leading efforts on prevention through active advocacy. All the talks in this panel will cover the importance of primary prevention of major birth defects thus improving child health, especially in low- and middle-income countries.

F30.2. Food fortification initiative: providing technical guidance to countries to implement large-scale food fortification

Scott Montgomery¹, Vijaya Kancherla²

¹Food Fortification Initiative; ²Emory University

BMC Proceedings 2024, 18(5):F30.2

Submission ID #: IMNHC1056

Panel ID# (if applicable): DYRON901051

Background

Inadequate intake of micronutrients like folic acid can lead to neural tube defects and other serious health consequences. The large-scale fortification of wheat flour, maize flour, and rice with folic acid is a proven, cost-effective intervention to prevent folate deficiency in women of reproductive age and consequences like neural tube defects. The Food Fortification Initiative (FFI) is a public-private-civic partnership that has mapped the opportunity for grain fortification worldwide and provides technical guidance to countries to implement fortification programs. FFI’s goal is to help eliminate micronutrient deficiencies in every country in the world where industrially milled cereal grain is commonly consumed.

Methods

Before FFI begins working in a country, FFI uses data to determine two essential requirements: demonstrated need for fortification and the potential to make a positive impact on health through fortified grains. FFI’s data comes from varied sources and methods that include consumption and milling analyses, nutrition needs assessments, market analyses, political readiness assessments, systematic reviews, and partner interviews. Once an opportunity for fortification is determined, FFI uses a four-stage phased approach to help countries plan, implement, and monitor a fortification program that can generate and sustain large-scale impact.

Results

When providing technical assistance, FFI uses a four-stage approach: explore and engage, map the context, design and develop, and monitor for compliance and impact. To ensure that fortification programs have a positive health impact on the population and prevent neural tube defects, FFI encourages countries to create standards and mandatory legislation for folic acid fortification. As of September 2022, 92 countries currently mandate the fortification of wheat flour, maize flour, or rice. In 2021, FFI found that 31%, 30%, and 1% of industrially milled wheat flour, maize, and rice, respectively, is fortified.

Conclusions

FFI’s strategic approach to scaling grain fortification, which is based on two decades of experience conducting research and providing on-the-ground assistance, offers a replicable method to building and strengthening fortification programs. By relying on data to identify where the needs and opportunities are greatest, FFI helps high-priority countries build mandatory fortification programs that improve the lives of millions and prevent neural tube defects.

F30.3. Prevention of neural tube defects by improving folate status through large-scale food fortification: a global perspective

Homero Martinez¹, Vijaya Kancherla²

¹Nutrition International; ²Emory University

BMC Proceedings 2024, 18(5):F30.3

Submission ID #: IMNHC1054

Panel ID# (if applicable): DYRON901051

Note the full manuscript published in Springer Link in April 2023:

(https://0-link-springer-com.brum.beds.ac.uk/article/10.1007/s00381-023-05913-4?code=ff97a0ec-bbb1-4192-b6d0-a9400c423846&error=cookies_not_supported)

F30.4. Status of global folic acid-preventable Spina Bifida and Anencephaly

Vijaya Kancherla

Emory University

BMC Proceedings 2024, 18(5):F30.4

Submission ID #: IMNHC1052

Panel ID# (if applicable): DYRON901051

Background

Spina bifida and anencephaly are major neural tube defects largely preventable through maternal periconceptional intake of folic acid. We estimated the global proportion of folic acid-preventable spina bifida and anencephaly (FAP SBA) prevented through mandatory folic acid fortification of cereal grains, including wheat flour, maize flour, and rice, at the end of year 2020, a point marking the 30th anniversary of the publication of landmark British Medical Research Council (MRC) study providing unequivocal knowledge on folic acid’s FAP SBA prevention potential.

Methods

The Food Fortification Initiative database was used to identify countries with mandatory fortification policies with folic acid added to cereal grains. We examined status of FAP SBA prevention assuming mandatory folic acid fortification at 200 mcg/day fully protects against FAP SBA and reduces their prevalence to a minimum achievable rate of 0.5 cases/1,000 live births. The country-specific annual number of FAP SBA cases prevented was quantified as the maximum prevention potential possible for any of the fortified grain examined (wheat flour/maize flour/rice) based on the level of total folic acid consumption from fortified grain examined and the fortification program coverage.

Results

Our analysis showed that 61,677 FAP SBA cases were prevented in the year 2020 through mandatory folic acid fortification of cereal grains in 58 countries, translating to 22% prevention of total possible FAP SBA prevention globally. Many countries in Africa, Asia, and Europe are yet to implement fortification. In 2020, 30 years after the Medical Research Council study was published, 218,270 preventable FAP SBA cases still occurred globally.

Conclusions

Global prevention efforts for FAP SBA are inadequate even after three decades of knowledge on their prevention. Universal mandatory fortification of staples should be urgently implemented to prevent thousands of FAP SBA and associated elective terminations, stillbirths, and child mortality.

F31.1. Ending the silence on stillbirths: critical data gaps, challenges, and solutions

Lucia Hug¹, Danzhen You¹, Rakhi Dandona², Allisyn Moran³, Imbulana Jayaratne⁴

¹United Nations Children’s Fund; ²Public Health Foundation of India; ³World Health Organization; ⁴Ministry of Health, Sri Lanka

BMC Proceedings 2024, 18(5):F31.1

Submission ID #: IMNHC1357

Panel ID# (if applicable): DYSRS771357

Panel Description

Every 16 seconds, a baby is stillborn. This amounts to an estimated 2 million stillborn babies globally every year. These deaths reach far beyond the loss of life. Women and their families often face traumatic, long-lasting impacts after experiencing a stillbirth. Profound psychological suffering and stigma from their communities are common.

Even more tragically, most of these deaths could have been avoided with high-quality care during the antenatal period and birth. More than 40 percent of all stillbirths occur during labor; many could have been prevented with improved monitoring and access to emergency obstetric care.

Despite its magnitude, these losses remain a neglected issue. Worldwide, data on stillbirths are largely absent, resulting in serious gaps in service delivery for pregnant women and poor support services for mourning mothers. Among the 195 countries for which the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) generates stillbirth estimates, nearly a third have either no stillbirth data or no quality data.

These gaps in counting and reporting of stillbirths must be urgently addressed.

The panel will address three key questions:

1)
Which critical data gaps must be closed to end preventable stillbirths?
2)
Which challenges stand in the way of collecting stillbirth data?
3)
Where do we see innovative solutions to improved stillbirth data availability and quality?

The session will bring together governments, international organizations, and civil society to share expertise and experience, highlight best practices, and provide practical recommendations on collecting stillbirth data and improving evidence to end preventable stillbirths.

F31.2. International Classification of Diseases (ICD) 11 and perinatal audit

Allisyn Moran¹, Lucia Hug², Hannah Blencowe³

¹World Health Organization; ²United Nations Children’s Fund; ³London School of Hygiene & Tropical Medicine

BMC Proceedings 2024, 18(5):F31.2

Submission ID #: IMNHC1442

Panel ID# (if applicable): DYSRS771357

Background

There have been persistent challenges in the understanding and application of the standard ICD definitions for the recording of fetal deaths and stillbirths. In view of substantial misclassification between stillbirths and neonatal deaths, and stillbirths and miscarriages, especially around the threshold of viability, collecting comparable data for all births is imperative to monitor data quality and trends over time and an important first step in any data system before progressing to classifying cause of death.

Methods

As part of the stillbirth estimation process in 2018, the WHO, UNICEF and the London School of Hygiene & Tropical Medicine reviewed current ICD guidance and commonly used definitions of stillbirth and developed a proposal to clarify definitions in ICD-11 to improve the consistency and comparability of stillbirth data. The proposal was then reviewed and revised by the Core Stillbirth Estimation Group, the technical advisory group of United Nations Inter-Agency Group for Child Mortality Estimation. Further discussions were undertaken by the Mother and Newborn Information for Tracking Outcomes and Results advisory group to achieve a consensus on a revised definition, and a proposal was submitted to ICD-11 for consideration.

Results

Internationally it is now advised by WHO and others that vital status, gestational age at birth, and birthweight be recorded for all births—whether liveborn or stillborn. The following recommendations were adapted by ICD-11 to increase the programmatic relevance of stillbirth data and allow for comparable reporting between stillbirths and neonatal deaths.

a)
Use gestational age at birth criteria in all definitions where available in preference to birthweight.
b)
Make clearer the distinction between “fetal death” and “stillbirth.”
c)
Make clearer the guidance regarding signs of life at birth.
d)
Make explicit that “induced abortions” should not be classified as a “stillbirth,” even when they occur beyond the gestational age reporting threshold for stillbirths.

Conclusions

The revision of the ICD-11 definitions and classifications are a step forward for improving data consistency and quality for stillbirths. WHO, UNICEF, and partners are actively working with countries and regions to strengthen data systems, including civil and vital registration, to incorporate these revisions.

F31.3. Stillbirth surveillance and data compilation in Sri Lanka

F32.1. Paving the way forward for intravenous iron treatment for anemia in pregnancy: insights from a hybrid trial in Nigeria

Bosede Afolabi, Ochuwa Babah, Mobolanle Balogun, Opeyemi Akinajo

The MCMH program was implemented for seven months in a mountainous region with challenges for mothers in accessing health care. The Systems, Health, and Resiliency Project provided training to community midwives and 20 health workers in the nearest health facilities within the district on the use of KMC. Mothers with low birth weight newborns also received a “KMC Kit,” containing items such as a baby carrier.

Results

Since the launch of the MCMH program, 69 newborns have been supported, with 50 successfully discharged and with improved health outcomes for every baby. The average length of participation in the KMC program for discharged patients was 112 days, and all discharged babies received exclusive breastfeeding during their participation. Among discharged infants, 62% achieved all six thresholds of continued KMC, weight gain, exclusive breastfeeding, and routine immunizations during the course of 16 weeks. Participating mothers reported increased confidence in the effectiveness and cost-efficiency of KMC and improved health conditions for their newborns.

Conclusions

The MCMH program demonstrated that community-led KMC is a cost-effective and effective method of improving newborn health outcomes in resource-limited settings. The program was well-received by participating mothers and their families, who reported improved health conditions for their newborns. The program’s success highlights the importance of community engagement in addressing gaps in maternal and newborn health, particularly in rural, difficult to reach, and conflict-affected areas. This work has implications for similar programs in other resource-limited settings and has significance for addressing gaps in equity in maternal and newborn health care. By training community midwives and engaging local leaders and community members in the promotion of KMC, the program increased access to care for low birth weight newborns in a resource-limited setting, potentially reducing inequities in care for these vulnerable infants.

O34. From global to local: accelerating access to essential postpartum hemorrhage medicines

O39. Intrapartum oral azithromycin to prevent maternal and newborn sepsis or death: a multinational Randomized Controlled Trial (RCT)

Alan Tita¹, Elizabeth McClure², Waldemar Carlo¹

¹University of Alabama at Birmingham; ²RTI International

BMC Proceedings 2024, 18(5):O39

Submission ID #: IMNHC2157

Note the full manuscript was published earlier this year in NEJM: (https://www.nejm.org/doi/full/10.1056/nejmoa2212111)

P40. Maternal exposure to intimate partner violence and breastfeeding practices of children 0-23 months: findings from the 2018 Nigeria demographic and health survey

Tope Olubodun¹, Anteneh Asefa², Aduragbemi Banke-Thomas³, Mobolanle Balogun⁴, Ifeoma Okafor⁴, Oluwakemi Odukoya⁴, Lenka Benova²

The project was implemented in the Northwest and Southwest regions, from April 2022 to August 2022. Thirty SRHR volunteers (SRHRVs) were selected and trained to communicate the importance of SRHR and psychosocial health services. SRHRVs identified and referred PW for antenatal care, facility delivery, or FP, and provided service vouchers for the most vulnerable. A three-month stock of obstetric and FP supplies was donated to 30 health facilities, where 60 nurses were trained to provide skilled normal and assisted deliveries, effectively plot a partograph, and administer FP services. The project team conducted monthly supervision, data review, and validation missions.

Results

SRHRVs sensitized 63,4345 persons (25,978 males and 37,367 females) on the importance and availability of SRHR and psychosocial health services. A total of 184 vulnerable PW were given vouchers, with 319 PW referred. Two months before implementation, the 30 health facilities recorded only 121 of 234 (52%) deliveries were conducted by skilled personnel. After implementation, 518 of 544 (95.2%) deliveries were conducted by skilled personnel and 213 vulnerable PW received vouchers. Free modern FP services were provided to 574 women including 40 nursing mothers.

Conclusions

The total number of facility deliveries and those conducted by skilled personnel increased significantly. In conflict settings, barriers to quality SRHR services worsened. It is important that humanitarian responses integrate strategies that increase service demand, quality, and supply. Community-led-communication and cash voucher systems can break existing barriers for the most vulnerable and stimulate demand. Training of health facility staff to provide quality services ensures the population’s access to quality

O47. Can oxytocin and tranexamic acid be mixed for co-administration by IV infusion for the treatment of postpartum haemorrhage?

Pete Lambert¹, Alessandra Tomazzini², Philip Wright¹, Claire McEvoy¹, Ioannis Gallos³, Anne Ammerdorffer², Lester Chinery², Arri Coomarasamy⁴, Ahmet Metin Gülmezoglu²

O58. Increasing men’s support for and engagement in pregnancy and early childhood: adapting an evidence-based intervention from Rwanda to Ethiopia

Elizabeth Stones, Heran Abebe, Shailee Ghelani

EnCompass LLC

BMC Proceedings 2024, 18(5):O58

Submission ID #: IMNHC1664

Background

Ethiopia has experienced significant improvements in maternal and newborn health; however, maternal and infant mortality remain high. To address the gaps in men’s support and engagement in pregnancy and early childhood, the Transform: Primary Health Care Activity conducted formative research and a collaborative stakeholder consultation process to adapt Program P to the Ethiopian context.

Methods

The study took place in eight kebeles across Oromia and Southern Nations, Nationalities, and People’s Region from August 2019 to February 2020. Data collectors conducted key informant interviews with eight male leaders and eight health workers as well as focus group discussions and attitudes and behavior surveys with 96 couples. The team analyzed the data using Dedoose 7.0.23 and STATA 15 and triangulated the data during a participatory data analysis and interpretation workshop to develop findings and conclusions.

Results

Although the majority of respondents reported that couples make decisions together about the number of children and spacing, most respondents agree that men make the final decision on the number of children to have. Among the sampled population, 60% of women reported their partner accompanying them for at least one antenatal care visit. When asked if they took their youngest child to their vaccination appointment, 91% of women reported they took the child themselves and 6% reported taking the child together. Respondents reported that men’s role in income-generating activities constrained time available for antenatal care and child health visits, whereas caregiving and family tasks are considered the role of women. Several respondents also noted traditional gender roles and norms cause negative attitudes or criticism of male engagement.

Conclusions

The final curriculum underwent multiple rounds of revisions through a collaborative adaptation process involving a diverse array of stakeholders. The team made key modifications to enhance adherence to the contextual specificities highlighted by the findings, including emphasizing participant-centered approaches, including more sessions for couples, and adjusting men-only sessions to focus on power, violence, and decision-making. Ethiopia’s Ministry of Health plans to implement, evaluate, and scale the intervention in the coming years. This research serves as a collaborative, participatory, and gender-transformative model for adapting evidence based interventions.

O59. Development of a community-centred model for reclaiming community reproductive, maternal, and neonatal health in the context of the COVID-19 era in Kenya

DIPH was implemented in 12 (out of 24) randomly selected woredas in Ethiopia’s North Shoa zone between October 2020 and June 2022. A cluster-randomized controlled trial was conducted with a difference-in-differences analysis of health system outcomes to compare DIPH and non-DIPH arms.

Results

A total of 58 four-monthly DIPH cycles were conducted, each focusing on a specific MNCH health service delivery challenge at the district level. There were significant improvements in district health administrators’ competence in, and practice of, data-driven decision-making to manage services in the DIPH arm. For example, the likelihood of regular reviews of monthly MNCH performance increased by 34% (p-value< 0.001), and that of data-based feedback to health facilities increased by 45% (p-value< 0.001). Significant improvement was found in district health administrators’ analysis and use of information for MNCH services.

Conclusions

DIPH strengthened district health management and administration. By improving data management and appraisal practices, systemizing problem analysis to follow up on action points, and creating a positive stakeholder engagement culture, DIPH improved MNCH services.

O65. Women’s experience of birth companions and respectful maternity care in Malawi

Brady Zieman¹, Charlotte Warren¹, Abigail Kazembe², Martha Kamanga²

¹Population Council; ²University of Malawi Kamuzu College of Nursing

BMC Proceedings 2024, 18(5):O65

Submission ID #: IMNHC1620

Background

In Malawi, a family member or friend escorts women to a health facility for childbirth. These “guardians” or companions generally provide food, wash clothes, and support the woman during labor/childbirth. However, systematic use of birth companions (BC) attending women throughout labor and delivery is fragmented and not routine- even though it is Ministry of Health policy. We examine women’s experience including respectful maternity care (RMC) following the introduction of job aids/tools to formalize BCs.

Methods

As part of a broader research portfolio on advancing postpartum hemorrhage care, quantitative surveys with postnatal women (473 at baseline and 530 at endline) from 18 health facilities (11 intervention and 7 comparison sites) in Malawi were conducted. These included women’s experiences of a BC and RMC before and after the intervention. Questions from the person-centered maternity care (PCMC) scale were used to assess presence of BCs and women’s experiential quality of care. Data were analyzed using Stata 14.

Results

Approximately 37% of all women reported usually or always having a companion present during labor and delivery. At intervention facilities, the proportion of women with companions increased significantly between data collection rounds (27% vs. 47%, p< 0.001); the between-round decrease observed in comparison facilities (41% vs 30%, p=0.075) was not significant. Difference-in-difference method indicates a significant effect of the intervention (OR: 5.96, p< 0.001). Significantly more women reported mostly/always being treated with respect (78% vs. 61%; p< 0.001), felt involved in decisions (40% vs. 20%; p=0.000), were asked for consent for procedures (45% vs. 36%; p=0.007), and the medicines were explained (40% vs 22%; p< 0.001) if a BC was present. Women were significantly less likely to report extreme pain (31% vs 41%; p=0.001) if a BC was present. Rural and community hospitals had significantly reduced odds of allowing BCs compared to primary health care facilities.

Conclusions

The presence of a BC during labor and delivery significantly increased women’s perceptions of quality of care—as measured through the PCMC scale. Where companions are permitted, their presence improves communication between women and providers, resulting in a better experience of care. Empowering providers with basic roles and communication tools to help work.

O66. Improving access to Maternal, Newborn, and Child Health (MNCH) medical products in low- and middle-income countries: a mapping of registration of mnch medical products in nine countries

Jane Briggs¹, Lauren Herzog², Kate Kikule¹

¹Management Sciences for Health; ²USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program

BMC Proceedings 2024, 18(5):O66

Submission ID #: IMNHC1613

Background

Regulatory challenges in resource-limited countries can compromise the availability of quality lifesaving MNCH medical products. Quality-assured products of generic medicines may not be registered or their registration status expires without renewal, leaving a vacuum that may be filled by products that are substandard or falsified.

Methods

The U.S. Agency for International Development’s Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program conducted a nine-country study in 2020 to better understand the challenges to registration of MNCH medical products in low- and middle-income countries. To identify barriers, the registration status of 18 MNCH tracer medicines was assessed by reviewing policies, regulations, and other documents and interviewing the countries’ regulators and 11 pharmaceutical manufacturers.

Results

Most tracer medicines were registered in most of the nine countries, but the percentage of medicines with at least one registered product ranged from 28%–100%. Some countries only had one or two registered products for some MNCH tracer medicines. Five countries had not registered any of the four World Health Organization-prequalified products. The average registration timeline ranged from six months to four years due to national regulatory authority backlogs, complicated procedures, and insufficient numbers of competent staff. Few countries officially recognized or relied on regulatory decisions from other countries. No country had formal processes embedded in legislative provisions to prioritize and expedite registration of essential MNCH medical products.

Conclusions

Solutions to registration impediments involve legal, organizational, and procedural changes. MNCH medicines have specific challenges such as low profit margins due to the ease of production and variety of manufacturers, so an inconvenient registration process is a disincentive for manufacturers. Likewise, buyers who are more price than quality conscious may not procure costlier prequalified medicines.

Catalysts for registration include streamlining processes with electronic management information systems that provide market information, maintaining qualified staffing, and emphasizing reliance on and recognition of other regulatory authority decisions.

In response to the findings of the study, MTaPS is working to strengthen regional collaboration to streamline registration and prioritize the registration of MNCH medicines and supporting countries to build capacity of assessors and render registration procedures more efficient.

O67. Algorithms to predict newborn complications in the first 28 days of life in Eastern Uganda (N-COP Study)

Akuze Joseph Waiswa¹, Paul Mubiri², Frank Namugera³, Geraldine Agiraembamazi², Peter Waiswa³, Nicole Santos⁴, Harriet Nambuya⁵

¹London School of Hygiene & Tropical Medicine; ²Makerere University School of Public Health; ³Makerere University; ⁴University of California, San Francisco; ⁵Jinja Regional Referral Hospital

BMC Proceedings 2024, 18(5):O67

Submission ID #: IMNHC1610

Background

Complications following preterm birth cause morbidity and mortality. Globally, newborn complications account for approximately 28% of neonatal deaths. Preemies are between six and 26 times more likely to die during the neonatal period than term newborns. Mathematical and statistical algorithms can be used to predict the risk of development of complications and adverse outcomes among preemies and to drive proactive measures to anticipate, prevent, prepare management, and improve survival in the short and long run. We developed algorithms to predict newborn complications and estimate outcomes within the first 28 days of life.

Methods

Neonates were followed up for 28 days at Jinja regional referral and Iganga general hospitals using a prospective cohort study design. Mothers who consented after delivery and their neonates (terms and preterms) enrolled between January–August 2019. Prematurity was assessed using the last normal menstrual period and/or obstetric ultrasound in the first trimester if available. The gestational age was confirmed using the neuromuscular maturity score (Ballard score). Algorithms to predict newborn complications among preemies were developed using negative binomial and machine learning and data-mining techniques (Logistic Regression, Naïve Bayes and Decision trees).

Results

The incidence rate of complications was 46% (overall), 57% (preterms), and 34% (term) for infants. Children with chest-in drawing were 30 times more likely to develop a complication at birth than their counterparts without chest-in drawing (P< 0.001). Having an increased hemoglobin level at birth, or higher Ballard score, or a higher APGAR score at 1 minute was protective against complications at birth. Comparing the testing error (e=0. 1969) for the Logistic model fitted over the same training data with other fitted models, the Logistic model incorrectly classifies approximately 3, 3, 24, and 27 observations from the test data compared to the Naïve Bayes, SVM, Decision trees, and Random Forest algorithms.

Conclusions

The performance of all algothrims was consistently good for predicting any newborn complications; however, the performance of all algorithms that predict the number of newborn complications at birth correctly is 50:50. Further research about predicting newborn complications is need.

O68. Leveraging digital health coaching to improve exercise regimens in pregnant women

Esupat Lotasarwaki, Bih-Neh Estella, Divine Akpan, Maria Moosa, Nneka Mobisson

mDoc Healthcare Ltd

BMC Proceedings 2024, 18(5):O68

Submission ID #: IMNHC1599

Co-creation Hub

BMC Proceedings 2024, 18(5):O71

Submission ID #: IMNHC1565

Background

The Smiles for Mothers program (SfM) aims to collaborate with the State Governments of Kano, Lagos, and Niger to develop and implement costed roadmaps for the adoption and rollout of 2018 World Health Organization (WHO) recommendations for postpartum hemorrhage (PPH) prevention.

Methods

Human-centered design (HCD) is a problem-solving approach that starts with the end-user, with a focus to incorporate their perspective in the process of designing solutions. Critical stakeholders in these states, who are the end-users, were identified to champion the successful adoption and rollout of the 2018 WHO recommendation.

SfM applied HCD in three phases:

Co-research: We conducted 38 semi-structured interviews with health systems stakeholders, 68 immersion sessions with health care workers (HCWs) and influencers across 12 local government areas (LGAs), HCW surveys, and document reviews across the three states.
Co-design: More than 300 ideas were co-generated with stakeholders around four prioritized opportunity spaces during the ideation workshops. The ideas were clustered into themes, filtered, and consolidated into implementable solutions.
Co-refinement: State stakeholders categorized the solutions into high, medium, and low priority based on perceived impact and feasibility. Based on the states’ prioritization, the state stakeholders recommended rolling out 17 prioritized solutions in three waves over two years.

Results

Each of the three dates has achieved the following:

Developed and adopted costed roadmaps.

Policy adoption activities including constituting a technical working group for developing state guidelines.

A robust literature review on drug information centers (DICs) with findings on:

Objectives of DICs.

Challenges faced with running a DIC in low- and medium-income countries.

Recommendations to introduce the supply of uterotonics to relevant health facilities.

Conclusions

The successful adoption and rollout of the 2018 WHO recommendation for PPH prevention in the three states are linked to the use of the HCD approach. Seventeen implementable solutions were developed across four opportunity areas and these solutions were used to develop state-specific costed roadmaps for the adoption and rollout of 2018 WHO recommendations. Heat Stable Carbetocins (HSC) was included in Nigeria’s drug policies with the potential of contributing to improving the quality of maternal care in Nigeria even in resource-constrained settings.

O72. Tools to guide school-specific investments in pre-service midwifery education: results from a field test in three African countries

Nicole Warren¹, Phelelo Marole², Keoagetse Kgwabi³, Etta Forson-Addom⁴, Heloise Adanogou-d'Almeida⁵, Ashley Gresh¹, Julie Mann⁶, Frances Gange²

¹Johns Hopkins University School of Nursing; ²Jhpiego; ³ECSACON; ⁴West African College Of Nursing; ⁵Federation of Associations of Midwives of Francophone Africa; ⁶Seed Global Health

BMC Proceedings 2024, 18(5):O72

Submission ID #: IMNHC1555

Background

The COVID-19 pandemic exacerbated global challenges to quality pre-service midwifery education. In resource-constrained settings, educational institutions’ needs are complex and investments may not address the specific needs of a school, creating or even worsening inefficiencies. To address this challenge, African midwifery leaders co-created five educational capacity frameworks (ECFs), one for each of the five pre-service education domains: clinical sites, curriculum, faculty, students, and infrastructure/management. The ECFs quantify a school’s capacity, or ability to meet international and/or regional standards, in each domain. They are intended for internal school self-assessment that guides identification of school-specific investment and improvement priorities. The ECFs have recently been field-tested. Our objectives were to:

1.
Report the findings from a field test of ECFs for five domains of pre-service midwifery education.
2.
Describe participants’ feedback using the ECFs.

Methods

Teams in Ghana, Botswana, and Togo field-tested each of the five pre-service midwifery ECFs. Each team included representatives from a regional midwifery organization and a public midwifery school. We summarized each country’s self-assessment data and feedback on using the ECFs using descriptive statistics.

Results

In the three countries, capacity levels across domains ranged from 10% to 63%. Botswana reported the highest overall capacity (49%), followed by Ghana (41%), and Togo (24%). Overall, teams reported the highest capacity level for infrastructure and management; the lowest for clinical sites. Preliminary analyses suggest the ECFs are comprehensive, easy to use, and highlight school-specific challenges not previously recognized. Participants indicated the ECFs were acceptable, appropriate and feasible to use. The teams subsequently used the ECF data to draft a specific plan for investment and improvement in their priority domain.

Conclusions

The ECFs are a promising tool for midwifery schools to internally assess and prioritize areas for investment and improvement. Individual school results can guide internal budgetary decisions and help prepare for external assessments. Results from groups of schools have the potential to inform systems’ level investment. Additional research is needed to determine the ECFs’ appropriateness in other settings. Findings from this field test are being used to further refine the ECFs for future use.

O73. Root cause analysis of maternal mortality in Bong County, Liberia: a case series study

Jody Lori¹, HaEun Lee¹, Joseph Perosky², Madison Horton³, Aloysius Nyanplu⁴

¹University of Michigan; ²Michigan State University; ³Columbia University; ⁴Bong County Health Team

BMC Proceedings 2024, 18(5):O73

Submission ID #: IMNHC1543

Note the full manuscript published in April 2023 in BMJ Open:

(https://0-bmjopenquality-bmj-com.brum.beds.ac.uk/content/12/2/e002147)

O74. Immediate skin-to-skin contact may have beneficial effects on the cardiorespiratory stabilisation in very preterm infants

Agnes Linnér¹, Stina Klemming², Nils Bergman¹, Siri Lilliesköld¹, Hanne Markhus Pike³, Björn Westrup¹, Siren Rettedal³, Wibke Jonas¹, Karoline Lode³

Methods

A mixed methods study design was used, guided by the Kirkpatrick Model for training evaluation (levels 1 and 2) and cost analysis. Specifically designed questionnaires were used to assess reaction to the training and changes in competence. In-depth interviews with participants, trainers, and policymakers were conducted to explore perceptions and experiences with the CoE approach. We compared the cost of training each participant in USD for all three training approaches.

Results

Three hundred SHP were trained from May 2021–May 2022, with nearly two-thirds of them nurse-midwives 194 (64%). Ninety-two percent of them found the course enjoyable, and 86.3% had all their expectations met for the course. There was improved confidence to perform both newborn and maternal EmONC skills. The most improved skill was newborn resuscitation (98%). Pre and posttest showed mean difference in score for knowledge at 10.3% (standard deviation [SD] 9.5%) and mean difference in score for skills at 44.5% (SD 18.8%).

The LSS programme runs for 21 days (lectures: 40%, practical: 30%, and clinical posting: 30%, cost per participant [pp] is $1,247). The NMCN EmONC training runs for five days (lectures: 90%, clinical posting: 10%, cost pp: $47). The CoE EmONC training runs for four days (lectures: 25%, simulation-based education and practical: 75%, videos: 5%, cost pp: $47).

Conclusions

The CoE model of EmONC training is feasible and a potentially sustainable EmONC training approach in Nigeria.

P80. Onsite clinical mentoring strengthens Maternal and Newborn Health (MNH) care in Nepal’s devolved health system

Kamala Shrestha, Shanti Mahendra, Maureen Dar Iang, Alison Dembo-Rath

Options Consultancy Services Ltd

BMC Proceedings 2024, 18(5):P80

Submission ID #: IMNHC1452

Background

In 2015, Nepal became a federal state, creating seven Provinces and 753 local governments, each accountable for delivering quality health services. In this context of health sector devolution, the Nepal Health Sector Support Programme has worked alongside the Federal Department of Health Services to establish and develop a clinical mentoring program for maternal and newborn care staff. Provincial- and local-level governments implement the program based on the local context.

Methods

Onsite clinical mentoring focuses on improving knowledge, decision-making, and clinical skills of nurses at facilities that provide comprehensive or basic emergency obstetric care (CEmONC/BEmONC). There are two stages: potential mentors are identified from across health facilities and given a 7-day training on mentoring skills and refresher training on EmONC. Trained mentors then visit CEmONC/BEmONC facilities at the request of provincial and local governments to mentor maternity staff. During the visits, mentors also facilitate facility assessment for MNH readiness, covering eight domains of quality including patient dignity.

Results

Between 2017 and 2022, 330 mentors were trained at nine training sites. Collectively they have mentored more than 4,200 nurses and facilitated assessments and quality improvement plans at over 840 facilities. A total of 61% of mentees are based at facilities in mountains and hills, where the difficult terrain makes emergency referral of patients difficult, and good skills and confidence are crucial. Mentees scoring >85% increased from 26% to 65% by the third onsite mentoring visit. Facilities scoring >80% on service readiness increased from 67% to 78% over the program period. An online monitoring system now tracks implementation progress and improvement in skills. Coaching and mentoring guidelines have also been developed.

Conclusions

Clinical supervision and support has been historically weak in Nepal. The mentoring program, designed within the government system and funded through the annual work plan and budgets at all levels of government, is a sustainable method for providing structured, regular support to nursing staff. The program has enhanced communication between mentors and mentees, opening a channel of advice to staff via mobile phones and timely referral of patients from BEmONC facilities. Onsite mentoring avoids staff absences at short-staffed facilities and enables facility readiness.

P81. Trends and inequalities in use of caesarian sections in Nepal from 1996-2016

Preliminary findings from our three-pronged approach suggest that an ideal service package to support return to school of pregnant and mothering learners would include three primary components that would begin in the antenatal period and continue after birth: 1:1 case management, peer-based support groups, and onward referrals to/linkages with relevant health and social services, including available childcare services, social grants, and antenatal and postnatal care. The young research advisors also suggested that participatory methodology enabled them to express themselves more easily, and that participatory methods enabled social support and critical dialogue between young people on the issue of young parenthood.

Conclusions

Education is a clear social determinant of health, and it is thus critical to find ways to promote the continued school engagement of pregnant and mothering learners as a way to strengthen health and social outcomes for both them and their children. It will be important to consider how the identified services and provisions, and their synergies, can be successfully integrated into existing support structures to ensure that adolescent mothers are optimally supported.

O106. Evaluating the implementation of an integrated health systems approach to increase the use of chlorhexidine for newborn care in Madagascar

Ingabire Magera¹, Maya Gershtenson¹, Elmard Rabotovaosolo¹, Voahirana Ravelojaona¹, Bonaventure Nzeyimana¹, Feno Rakotoarimanana¹, Lovahasina Vahatriniaina², Vololoniaina Rasoanandrasana³, Azzah Al-Rashid⁴, Patricia Norolalao⁴, Aishling Thurow¹, Serge Xueref¹, Laurence Laumonier-Ickx¹, Tamar Chitashvili¹

¹Management Sciences for Health; ²Direction de la Santé Famille; ³Ministry of Public Health, Madagascar; ⁴United States Agency for International Development

BMC Proceedings 2024, 18(5):O106

Submission ID #: IMNHC1294

Background

The World Health Organization recommends umbilical cord care with chlorhexidine (CHX) in high newborn mortality settings. In Madagascar, the Ministry of Public Health has adopted this standard, but certain cultural practices and health system bottlenecks have hindered its implementation. The U.S. Agency for International Development-funded ACCESS program supports the Ministry of Public Health to promote facility-level CHX cord care in 11 regions. ACCESS supported the Ministry of Public Health in identifying root causes of limited CHX use and finding context-specific solutions, including orientation of community health volunteers and health workers on the importance of CHX, development of CHX job aids, supporting community health volunteers in educating the community, advocacy with stakeholders for sustainable procurement and distribution, and engaging expectant mothers in Savings and Internal Lending Communities to purchase CHX. This analysis aims to determine the potential effect of these interventions on CHX use in Madagascar.

Methods

Using national District Health Information Software II (DHIS2) data from 1,350 health facilities in 11 ACCESS-supported regions, we compared the number of newborns who received CHX at birth between January–June 2020 and January–June 2022 using a paired series mean comparison analysis.

Results

There was a significant increase in the mean proportion of newborns who received CHX (p < 0.001) from 15.6 (CI 95% [14.1–17.1]) in the first period to 67.2 (CI 95% [65.2.7–69.0]) in the second within ACCESS-supported regions. While this analysis focused on 11 ACCESS-supported regions, the increase in CHX cord care was also observed at the national level (from 19.1 to 64.4, p < 0.001) during the same period, as these activities were led by the Ministry of Public Health and scaled up by other partners throughout Madagascar.

Conclusions

CHX cord care improved both in intervention and nonintervention regions from the start of the intervention (2020). These results suggest the importance of implementing needs-based, multilevel holistic health system approaches to improve CHX cord care. Working with and through local systems and building local capacities to identify and address local problems has the potential to scale up CHX cord care and reduce preventable newborn mortality from infectious complications in Madagascar and similar settings.

O107. The state of midwifery education, regulation, and practice in East and Southern Africa Region, 2022

Muna Abdullah Ali, Jyoti Tewari

United Nations Population Fund

BMC Proceedings 2024, 18(5):O107

Submission ID #: IMNHC1291

Background

A Lancet article published in 2020 shows that achieving universal coverage of midwives could avert 67% of maternal deaths by 2035¹. Data and evidence-based programming is instrumental to guide and track investment on midwifery programs. This assessment is the second regional assessment (the first being in 2017) of the state of midwives in the East and Southern Africa (ESA) region commissioned by the United Nations Population Fund (UNFPA) ESA regional office. It provides a comprehensive assessment of the current state of the region’s sexual, reproductive, maternal, newborn, and adolescent health (SRMNAH) workforce in 23 countries. It gives clear evidence of the region’s progress and identifies bottlenecks and challenges that must be addressed.

Methods

The study relies on the methodology developed for the State of the World’s Midwifery Report 2014, co-chaired by UNFPA, the World Health Organization, and the International Confederation of Midwives. An online survey was sent to UNFPA country focal persons and midwifery associations who engage the Human Resources for Health directorate of ministries of health for the responses.

Results

Across the 23 countries in the ESA region, there are just over 800,000 SRMNAH workers. Over half (53%) are nurses without additional training in midwifery and 11% are doctors (general practitioners, obstetricians/gynecologists, and pediatricians). Just under one in five (18%) are professional or associate professional midwives or nurse-midwives.

The region needs more than 300,000 more midwives, and current education and deployment levels are not keeping up with rising needs. Availability of midwives varies significantly between countries, for example, the midwife to 10,000 population ratio is 33.2 in Seychelles and 0.1 in Burundi.

Only 12 countries have distinct regulatory processes for midwives. Only 10 countries require proof of continued professional development for re-licensing

Conclusions

Countries in the region will need to accelerate their progress in order to meet Sustainable Development Goal (SDG) targets. Investing in midwives is a key accelerator in the effort to achieve the SDG target of maternal mortality ratio of 70 per 100,000 live births by 2030. This study brings out gaps and challenges in the midwifery education, regulation, and practice in 23 countries in the ESA region that need to be addressed urgently.

Reference

1.
Nove A, Friberg IK, de Bernis L, et al. Potential impact of midwives in preventing and reducing maternal and neonatal mortality and stillbirths: a Lives Saved Tool modelling study. Lancet Glob Health. 2020; (published online Dec 1.) https://0-doi-org.brum.beds.ac.uk/10.1016/S2214-109X(20)30397-1

O108. Provider communication and coaching for parents of hospitalized newborns and sick young infants in Kenya: provider and caregiver perspectives

Chantalle Okondo, Charity Ndwiga, Timothy Abuya, Pooja Sripad, Charlotte Warren

Population Council

BMC Proceedings 2024, 18(5):O108

Submission ID #: IMNHC1283

Background

The relationship between health care providers and caregivers in the management of hospitalized newborns and sick young infants (SYIs) is an essential element of quality care. Meaningful participation in caring for infants during hospitalization has demonstrated improved caregiver-infant bonding, reduced parental stress, and greater confidence in caring for their children once at home. We developed a provider behavior change (PBC) approach to improve experiences of care for caregivers of hospitalized newborns in Kenya. The intervention oriented providers on communication skills and how to coach caregivers on nurturing care: optimizing nutrition, safeguarding sleep, protecting skin, minimizing stress and pain, positioning, and handling.

Methods

This analysis sits within a broader PBC activity. It draws on in-depth interviews with 15 parents of hospitalized newborns and SYIs and 16 health care providers from five Kenyan hospitals in August 2021. Inductive and deductive thematic analysis was used to describe the nature of provider-caregiver interactions. The data was triangulated based on the study sites and respondents to find similarities and differences across themes.

Results

Providers were able to confidently coach caregivers on three of the five elements: optimizing nutrition, including breastfeeding or how to feed using a nasogastric tube; safeguarding sleep and protecting skin, including keeping the baby warm and practicing skin-to-skin contact. The other two elements of minimizing stress and pain and positioning and handling were practiced less often. Some caregivers reported providers were attentive, listening to caregivers, while others were harsh, unfriendly, or dismissive of their opinions. Few caregivers could correctly state their newborn’s treatment plan or describe instances of shared decision-making with providers. The variability in care was associated with provider attitudes, increased workload, and insufficient support from administration to create spaces for caregivers to participate in care.

Conclusions

While many caregivers were satisfied with the care they received, some provider attitudes resulted in mixed reception and unwillingness to partner with caregivers in providing newborn care. While providers may work in unyielding environments, efforts to support providers, avail reference materials to standardize care, and improve infrastructure are integral to enhancing communication with caregivers and overall quality of care.

O109. Lessons learned from community referral and follow-up of sick young infants with possible severe bacterial infection in Turkana County, Kenya

Samuel Mbugua¹, Laura Oyiengo², Peter Mwaura¹, Wilson Laimbila³, Andrew Emuria⁴, Daniel Gatungu¹, Jesse Gitaka¹

¹Mount Kenya University; ²United Nations Children’s Fund; ³Population Council; ⁴Ministry of Health, Kenya

BMC Proceedings 2024, 18(5):O109

Submission ID #: IMNHC1277

Note the full manuscript published in June 2023 in Global Pediatrics:

(https://0-www-sciencedirect-com.brum.beds.ac.uk/science/article/pii/S2667009723000167)

O110. Beyond respectful maternity care: a research priority exercise and working group process on respectful newborn care

Hagar Palgi-Hacker¹, Emma Sacks²

The Nurturing Care Framework, launched in 2018, is a guide for multisectoral actors on improving early childhood development outcomes by supporting caregivers to provide nurturing care for newborns and young children, with a focus on the first 1,000 days when a child’s brain is developing rapidly.

In Indonesia, 45% of children under age 5 years are at risk of poor health, growth, and development. Although the Government of Indonesia has issued a policy, Holistic and Integrative Early Childhood Education and Development (HI-ECD), to promote comprehensive quality services for young children from survival to development, the policy practices are still dominated by interventions for children aged 4–6 years old, while interventions for the 0–3 age group remain limited. To address this gap, MOMENTUM Country and Global Leadership initiated a case study to examine the needs and opportunities of delivering nurturing care during antenatal and postnatal care visits as well as other health service touchpoints at the community level.

Methods

This case study collected information from three villages in Manggarai Barat District, representing urban, semi-urban, and remote-rural. Interviews, focus group discussions, and observations were done with caregivers and frontline health workers. Policy perspectives were gathered from village chiefs and district, provincial, and national stakeholders. The qualitative approach examined the enabling environment for nurturing care and current counseling practices, including the use of the maternal and newborn health (MNH) handbook to deliver nurturing care during visits to puskemas and posyandus.

Results

Preliminary findings suggest inadequate knowledge among frontline health workers to counsel on responsive care and early learning and limited training and use of the MNH handbook. Particularly, at the village level, health workers’ knowledge of child development was limited to nutrition and growth with little to no knowledge of responsive care and early learning aspects of nurturing care. Furthermore, maternity classes during antenatal care can be used to counsel on nurturing care.

Conclusions

Findings propose stronger advocacy and support for HI-ECD coordinating mechanisms at the local level, expansion of maternal, newborn, and child health interventions to include children’s growth and development and promoting the HI-ECD service package for children aged 0–3 years old.

O138. Mycoplasma genitalium and other reproductive tract infections in pregnancy associated with an increased risk of adverse birth outcomes in a high-burden setting

Michelle Scoullar¹, Philippe Boeuf¹, Elizabeth Peach¹, Ruth Fidelis¹, Pele Melepia¹, Catriona Bradshaw², Arthur Elijah³, Andrew Vallely⁴, Lisa Vallely⁴, Freya Fowkes¹, William Pomat⁵, Brendan Crabb¹, Christopher Morgan⁶, James Beeson¹

¹Burnet Institute; ²Monash University; ³University of Papua New Guinea; ⁴Kirby Institute; ⁵Papua New Guinea Institute of Medical Research; ⁶Jhpiego

BMC Proceedings 2024, 18(5):O138

Submission ID #: IMNHC1128

Background

Being born too small is a major risk factor for neonatal and infant mortality and childhood stunting. Sexually transmitted infections (STIs) are preventable and curable infections that can contribute to poor pregnancy outcomes. Mycoplasma genitalium is increasingly recognized as an STI with high prevalence in some populations and has a high propensity to develop antimicrobial resistance. Little data are available on the impact of M. genitalium on adverse birth outcomes, particularly in the context of other STIs. In Papua New Guinea, we previously demonstrated a high burden of multiple STIs (M. genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and bacterial vaginosis). Here, we have investigated the association between M. genitalium and other STIs and birthweight, preterm birth, and perinatal mortality.

Methods

Six hundred and ninety-nine pregnant women in rural and semi-urban Papua New Guinea were recruited at their first antenatal clinic and followed to evaluate birth outcomes. Fundal height was used for gestational age estimates as per national guidelines. Vaginal swabs were tested for M. genitalium, C. trachomatis, N. gonorrhoeae, and T. vaginalis, and a vaginal smear was examined for bacterial vaginosis. Linear and logistic regression models examined the association between STIs and adverse birth outcomes.

Results

Many women experienced adverse birth outcomes, with 11.5% of babies under 2.5 kgs, a stillbirth rate of 21/1,000 pregnancies, and 23% (123/535) of babies were preterm. In multivariable analysis, bacterial STIs (M. genitalium, C. trachomatis, and N. gonorrhoeae) were all associated with decreased mean birthweight with varying effect sizes. There was some association between bacterial vaginosis and an increase in mean birthweight.

Conclusions

To our knowledge, this is the first study to demonstrate an association between M. genitalium and birthweight whilst adjusting for other STIs, highlighting the negative impact of bacterial STIs in pregnancy. Prevention is an urgent priority and increasing access to prompt diagnosis and treatment in pre-pregnancy and early in pregnancy would likely have important benefits for women. Detailed results will be published shortly.

O139. Management of noncommunicable diseases in the context of pregnancy, childbirth, and postnatal care

iKMC in MNCUs leads to better physiological stabilization (post-KMC lower heart rate and respiratory rate, higher oxygen saturation, and higher temperature) and sleep state in sick low birthweight neonates.

Kiersten Israel-Ballard¹, Kimberly Mansen¹, Elizabeth Kimani-Murage², Taddese Zerfu², Milka Wanjohi², Calistus Wilunda², Emily Njuguna¹, Mary Waiyego³, Faith Njeru³, Laura Kiige⁴, Nelson Langat², Betty Samburu⁵, Thomas Ngwiri⁶, Waithera Mirie⁷, Rachel Musoke⁷, Minnie Kibor⁸

¹PATH; ²African Population and Health Research Center; ³Pumwani Maternity Hospital; ⁴United Nations Children’s Fund; ⁵Kenya Ministry of Health; ⁶Gertrude’s Children’s Hospital; ⁷University of Nairobi; ⁸Children’s Investment Fund Foundation

BMC Proceedings 2024, 18(5):O145

Submission ID #: IMNHC1072

Background

The World Health Organization recommends donor human milk (DHM) from a human milk bank (HMB) for small and sick newborns (SSNB) when the mother’s own milk is not available. Global implementation guidelines, especially for low- and middle-income country (LMIC) settings, do not exist, making HMB expansion a challenge. The Kenya Ministry of Health sought PATH’s technical assistance to pilot the Mother Baby Friendly Initiative Plus (MBFI+) integrated HMB model with the objective of developing an LMIC-appropriate model for providing DHM and enhanced lactation support to improve exclusive human milk diets for SSNB and reduce neonatal mortality.

Methods

A validated phased approach was used, with leadership from the county, hospital, and Ministry of Health, to establish a Kenya-specific MBFI+ model for HMB, integrated with breastfeeding support and specialized lactation for prioritizing mothers’ own milk at Pumwani Maternity Hospital in Nairobi County, Kenya. This five-year process included three phases:

Phase 1: Learning and building technical competency in the community through formative assessments to determine acceptability and facility readiness, learning exchanges to Vietnam and South Africa, guidelines and standard operating procedures development, quality control, and HMB trainings.
Phase 2: Implementing the pilot program through facility and equipment improvements, capacity strengthening, coaching, and quality assurance.
Phase 3: Research and stabilization through baseline and endline assessments to determine impact.

Humanitarian non-profit organization Kybele and the Ghana Health Service partnered to develop the Obstetric Triage Implementation Package (OTIP) to promote timely, quality care. Establishment of a Ghanaian technical advisory group (TAG) ensured local ownership and integration into the health system. A toolkit introduced interactive training content, an implementation manual, triage space and equipment guidelines, treatment protocols, a simulation game to role-play case scenarios, and monitoring tools.

From January 2019 to March 2022, OTIP was scaled to eight referral hospitals, cascading training two facilities at a time. The TAG established a national training team and prioritized target hospitals, each identifying clinical champions for training. Champions received a two-day intensive course on triage concepts and quality improvement and then co-led local training and implementation. Data was collected at baseline, 3, 6, and 12 months post-implementation to assess timeliness of care, documentation thoroughness, and accuracy of risk assessment.

Results

The introduction of OTIP resulted in training 510 frontline health workers in eight Ghanaian hospitals, serving over 50,000 women and newborns. Waiting time dramatically decreased. At baseline, only 6% (22/400) of women were evaluated within 10 minutes of arrival, the internationally recommended standard. This improved to 85% (367/431) 12 months following implementation. Thoroughness of documentation improved from 68% to 84% and risk status was correctly assigned in 83% (394/474) of patients. Midwives reported that OTIP improved workflow and enhanced communication with doctors.

Conclusions

Results

Participants shared the advantages of G-ANC. These included health education and learning through experience sharing and peer support where members provided and received emotional and in-kind support and learned to handle stigma, thus increased self-esteem and confidence. The challenges of G-ANC were long waiting times due to members who come late and a limited number of midwives to provide physical examination and manage complications; lack of professional counsellors to address more complex issues faced by adolescents; lack of privacy in the group setting to discuss more sensitive/personal challenges; unmet expectations of incentives and skilling in income generating activities; heavy workload for the few peer mothers and midwives; and inadequate space for group sessions.

Conclusions

G-ANC is an important mechanism to link pregnant AGYW to maternal services and provide health education and psychosocial support. Gaps in human resource and facility space should be addressed to optimize service provision.

P188. A structured approach to scale-up of Kangaroo Mother care for low birthweight newborns in Kenya: a critical review of the journey and progress

Sarah Williams, Teresa Akun, Rita Muchoma, Andrew Clarke, Lynn Kanyuuru, Tewodros Gebremichael

Save the Children

BMC Proceedings 2024, 18(5):P188

Submission ID #: IMNHC853

Background

Preterm birth is the leading cause of death in children under five globally. Kangaroo mother care (KMC), caring for a premature baby on the chest of their mother or other caregiver, skin-to-skin, and exclusively feeding breastmilk is recommended by the World Health Organization. Compared with conventional care, KMC is associated with a 40% lower risk of mortality at discharge. KMC is poorly adopted in many countries. In 2014 KMC was not an established part of care for preterm newborns in Kenya, we collaborated with Kenya’s Ministry of Health (MOH) on an eight-year programme to pilot, scale, and embed KMC.

Methods

Simultaneous interventions were adopted to secure political commitment, a supportive policy environment, a better equipped health workforce, and receptive community expectations towards sick and small newborns. Collaboration with MOH and the Neonatal Technical Working Group supported national guideline development. Policy-makers were exposed to experiences in Tanzania and Malawi. Facility readiness was assessed and five centers of excellence established as resources. National and local-level trainers were trained and supportive supervision and mentoring systems embedded. This was complemented by support to a national champions network, community awareness-raising about KMC, and prematurity and advocacy for KMC data inclusion in national Kenya health information system (KHIS) and supervision tools.

Results

In 18 program counties, from a baseline of zero, 85 health facilities now provide dedicated KMC services for low birthweight babies and their mothers. Between 2017 and 2021, the percentage of eligible newborns initiated on KMC rose from 8% to 54%. By 2021, 40 counties out of 47 in Kenya routinely report on KMC indicators within the KHIS.

Conclusions

Coordinated, targeted support facilitates piloting and scaling. Globally relevant lessons from a multi-stakeholder reflection exercise will be shared including importance of collaboration across health systems, development and provision of national guidelines, and incorporation of KMC indicators into HIS for visibility and QI. Support from managers and policy-makers enable necessary resources (space, staff, and equipment). Sharing lessons from neighbouring countries is valuable. Training alone is not enough; supervision and mentorship were critical, helping mitigate staff turnover. Maternal/carers ability to provide KMC is affected by family, community support, and cultural sensitisation.

O189. ReJudge: development and testing of an intervention to reduce Cesarean Section (CS) carried out due to fear of litigation

Gill Moncrieff¹, Soo Downe¹, B.R. Shamanna², Sunny Mannava², Indie Kaur³, Joanna Erdman⁴, Maria Regina Torloni⁵, Ana Pilar Betran⁶

¹University of Central Lancashire; ²University of Hyderabad; ³Fernandez Foundation; ⁴Dalhousie University; ⁵São Paulo Federal University; ⁶World Health Organization

BMC Proceedings 2024, 18(5):O189

Submission ID #: IMNHC851

Background

Obstetrics is a leading area for litigation worldwide, which can result in defensive health care practices including the use of intervention to protect against litigation. CS rates are over 80% in some regions of India, which is likely to result in medically generated harms. Existing interventions that aim to reduce unnecessary CS include educational interventions and clinical guidelines. Fear of litigation is recognized as a factor that stimulates unnecessary CS. We were unaware of an existing intervention specifically targeted to this driver of unnecessary CS.

The ReJudge project was designed to develop an intervention to reduce CS carried out due to fear of litigation.

Methods

We explored attitudes and knowledge relating to CS carried out due to fear of litigation over three phases. In phase one, we carried out scoping reviews to derive associated behavioral drivers and mental models. In phase two, we interviewed obstetricians, lawyers, and women’s representatives and mapped interview data to the behavioral drivers and mental models. In phase three, we held a seminar and vignette-based workshop with lawyers and obstetricians. A before and after survey tested knowledge and attitudes and whether the workshop altered these. An educational tool was designed based on the findings.

Results

CS due to fear of litigation is driven by complex social, environmental, and cognitive drivers. Social drivers include actual, perceived, and perpetuated social norms, including women’s choice. Environmental drivers include legal and obstetric structures that facilitate CS, including informed consent as a mechanism of distribution of responsibility and the lack of requirement to defend against unnecessary CS. Cognitive drivers include the consequences of adverse outcomes, including legal processes and violence, and resulting potential professional and/or psychological demise.

Our workshop intervention provided a valuable opportunity for interdisciplinary reflection. Striking variations in knowledge and attitudes were evident between professionals that need to be further explored and resolved.

Conclusions

The ReJudge intervention provided an opportunity for interdisciplinary knowledge sharing and offers the potential to develop solutions to similar challenges. Further refinement could provide a valuable tool to explore beliefs and unify relevant knowledge between obstetric and legal professionals and beyond.

O190. Novel, reusable postpartum blood loss monitoring tray: acceptability study and randomized trial

Mandisa Singata-Madliki, Justus Hofmeyr

Universities of Witwatersrand

BMC Proceedings 2024, 18(5):O190

Submission ID #: IMNHC848

Background

Monitoring blood loss after birth saves lives by prompting early treatment of postpartum hemorrhage. We developed a reusable blood loss monitoring tray with a wedge, which slips under the mother’s buttocks after birth, and two calibrated blood collection chambers. The first overflows to the second at 500ml to signal postpartum hemorrhage.

Methods

We evaluated acceptability and functionality among 41 women giving birth at the Frere Hospital Midwives Obstetric Unit, South Africa, using a structured questionnaire.

We plan to conduct a randomized trial comparing the tray with the disposable Brass V drape.

Results

The most positive option was chosen by 95% or more of midwives and mothers for all questions:

Mothers:

Was it easy or difficult to have the tray in place? 39 (95%) Very easy; 2 (5%) Fairly easy
Did you feel comfortable with the tray in place? 39 (95%) Very comfortable; 2 (5%) A little comfortable
Did you feel that the tray helped to keep you clean? 41 (100%) Helped a lot
Would you choose to use the tray for a future birth? 41 (100%) Yes I would be keen to use it

Midwives:

Was it easy or difficult to put the tray in place? 40 (98%) Very easy; 1 (2%) Fairly easy
Did the tray help with placement of the delivered placenta?40 (98%) Helped a lot; 1 (2%) Helped a little
Did the tray help you to monitor the ongoing volume of blood loss? 41 (100%) Helped a lot
Did the tray help to keep the mother clean? 41 (100%) Helped a lot
Would you choose to use the tray for every birth you attend? 41 (100%) Yes I would be keen to use it.

Conclusions

The Maternawell tray shows promise as a cost-effective, user-friendly device for monitoring blood loss after birth. To achieve sustainable global access, we have partnered with Maternova, a health technology company (U.S.) and Umoya, a social enterprise (South Africa) to commercialize the tray.

Disclosure

GJH declares a financial interest

Reference

1.
Singata-Madliki M, Hofmeyr GJ. A novel, re-usable ‘Safe birth Tray’ for postpartum blood loss monitoring: A preliminary acceptability assessment. Int J Gynaecol Obstet. 2021 Dec;155(3):553-555

Forty-five fistula clients were repaired and followed up by CSWs. Twenty had continued interactions with CSWs, returning to the center for follow-up visits. To date, there have been no reports of fistula recurrence among this group. One client returned to the facility for delivery. As a result of the home visits, a number of male partners of fistula patients became advocates for fistula prevention in the community.

Conclusions

Engaging social workers in targeted community follow-up of fistula patients can help prevent fistula recurrence and help address clients’ needs for holistic fistula intervention.

O209. Last mile interventions to eliminate mother-to-child transmission in post-disaster settings: experience from rural Haiti

Lourdes Marie Sandra Destin Damour, Brittany Aryeh, Anatole Manzi

Partners in Health

BMC Proceedings 2024, 18(5):O209

Submission ID #: IMNHC725

Background

Despite global ambition to end the AIDS epidemic, women from countries with civil and political conflicts live a different reality. With over 150,000 adults living with HIV, Haiti has the largest epidemic in the Caribbean. Haitian women pay the highest price, constituting 60% of people living with HIV. Following the 2010 earthquake in Haiti, political instability, collective fear, and poor readiness of public health facilities limited access to HIV testing, which contributed to persistently high mother-to-child transmission of HIV. In collaboration with Haiti’s Ministry of Health, Zanmi Lasante launched a breakthrough project to increase access to HIV testing at hard-to-reach facilities. We describe a model intervention to increase early HIV diagnosis among pregnant women and changes in HIV incidence among exposed infants.

Methods

A landscape analysis was conducted between December 2020-March 2021 to assess the state of HIV testing among pregnant women from Saint-Marc District. Frequencies and percentages were used to describe coverage and facility readiness for HIV diagnosis and treatment. Thereafter, we launched a breakthrough improvement intervention, which consists of engaging women through dynamic outreach and sensitization, building competencies for lab technicians and community health care workers, and equipping new remote testing centers. Run charts were used to track changes over time.

Results

Between April-December 2021, 2083 pregnant women were tested for HIV—an almost three-fold increase in HIV testing. The percent of women tested during the first trimester increased from 50% at baseline to 71% after the intervention, p=0.012. The overall seropositivity was 5%, and the rate was as low as 2% among women who had their test during their first trimester. The positivity among exposed infants declined by 50%. The percent of exposed infants with positive PCR reduced from 10% to 0%. At three peripheral health facilities providing testing kits and lab reagents, building staff competencies in elimination of mother-to-child transmission of HIV, and establishing simplified care pathways all improved early diagnosis of HIV among pregnant women.

Conclusions

Political conflicts and other humanitarian crises are always associated with fear and anxiety, limiting utilization of health services. Interventions to eliminate mother-to-child transmission of HIV should include forming or equipping first-level facilities and pay attention to hard-to-reach communities.

O210. Clinical evaluation of a novel, low-cost continuous respiratory rate and apnea monitor for newborns

Results

Models were created for maternal risk (postpartum hemorrhage [A] and prolonged labor[B]) and perinatal risk (stillbirth [C] and low birth weight [D]). Models C and D were created for antenatal risk stratification (ANC), whereas all four models were created for labor room admission (LR) risk stratification. The overall accuracy of models on the test dataset was:

The Sn, Sp, PPV, NPV and AC of the models were as below.

A(LR) 60.5%, 86.8%, 48.3%, 91.5%, 77.1%
B(LR) 93.5%, 88.6%, 3.8%, 100%, 88.6%
C(ANC) 97.8%, 99.1%, 74.6%, 99.9%, 99.1%
C(LR) 39.6%, 100%, 100%, 98.9%, 98.9%
D(ANC-3 levels) -, -, -, -, 95.4%
D(LR-3 levels) -, -, -, -, 95.9%

Using the risk scoring in ANC, the AUC (to predict adverse outcome) was 0.932 (0.903, 0.944, and 0.957 for trimester 1, 2, and 3, respectively), while for the LR admission the AUC (to predict adverse outcome) was 0.728 (0.696 for neonatal complications and 0.725 for maternal complications).

Conclusions

We provide proof of concept that machine learning algorithms and resultant risk scores can be potentially used to stratify pregnant women throughout the continuum of care. These need to be further validated. More comprehensive risk stratification models (including sepsis, eclampsia, neonatal asphyxia, and admission to neonatal intensive care unit) must also be created. However, risk scoring will not influence outcomes unless backed by care.

O241. Big babies and mortality risk: how to identify neonatal vulnerability?

Lorena Suarez-Idueta¹, Joy Lawn², Hannah Blencowe², Eric Ohuma², Ellen Bradley², Yemi Okwaraji², Judith Yargawa², Joanne Katz³, Robert Black³, Daniel Erchick³, Elizabeth A. Hazel³, Michael Diaz³, Anne CC Lee⁴, Vulnerable Newborn Measurement Collaborative Group

¹Mexican Society of Public Health; ²London School of Hygiene & Tropical Medicine; ³Johns Hopkins Bloomberg School of Public Health; ⁴Harvard Medical School

BMC Proceedings 2024, 18(5):O241

Submission ID #: IMNHC552

Background

Large for gestational age (LGA, >90^th centile) and macrosomia (≥4000g regardless of gestational age) have been associated with short-term complications including birth trauma, and long-term conditions such as overweight and obesity. To date, no worldwide systematic assessment of the proportion of big babies has been performed. We aimed to examine the prevalence and neonatal mortality risk of term (>37 weeks) LGA and macrosomic babies.

Methods

We identified 115.6 million nationwide records from 2000 to 2020, collected in 15 countries with high completeness (>80%) on birthweight, sex, and gestational age to assess size for gestational age (appropriate for gestational age [AGA], 10-90^th centiles or LGA) using INTERGROWTH-21^st standards. We excluded small-for-gestational-age or preterm livebirths. We calculated prevalence and relative risk (RR) of neonatal mortality among livebirths born at term + LGA vs term + AGA and macrosomic (≥4000g; ≥4500g; ≥5000g regardless of gestational age) vs 2500g-3999g.

Results

Almost a fifth of livebirths were term + LGA (median: 18.2%, Interquartile Range [IQR], 13.5, 22.0) and overall were associated with lower neonatal mortality risk compared to AGA (median RR, 0.75; IQR, 0.74, 0.82). Around one in ten babies were ≥4000g (median prevalence 9.6% (IQR 6.4, 13.3), with 1.2% (IQR 0.7, 2.0) ≥4500g and 0.2% (IQR 0.1, 0.2) ≥5000g. Overall macrosomia ≥4000g was not associated with increased neonatal mortality risk (median RR, 0.77; IQR, 0.67, 0.97), however a higher risk was observed for those ≥4500g (median RR, 1.10, IQR, 1.01, 2.44 ) and ≥5000g (median RR, 3.8, IQR, 1.6, 6.9), compared to those 2500g-3999g.

Conclusions

In this population, birthweight ≥4500g was the most useful marker for early mortality risk. Future research is needed to clarify the best categories to identify big newborns at the highest risk of dying, such as those on the right tail for size (>97th centile) or gestational age (post-term) distributions.

O242. Journey to 9: transforming care through patient accompaniment and community engagement

Marc Julmisse, Meredith Casella Jean-Baptiste, Monide Thamar Vital Julmiste

Partners in Health

BMC Proceedings 2024, 18(5):O242

Submission ID #: IMNHC551

Background

Haiti has the highest maternal and neonatal mortality rates in the western hemisphere, at 480 per 100,000 and 25 per 1,000 live births respectively; according to the World Bank. In 2018,

Partners In Health and Zanmi Lasante developed Journey 9 (J9) to reduce maternal and neonatal morbidity and mortality in Haiti’s Central Plateau through the detection of early warning signs in pregnancy and the neonatal period. J9 uses interprofessional patient accompaniment and community engagement and awareness to holistically address the needs of mothers and infants by providing high-quality clinical care while also building trust in the health system.

Methods

J9 accompanies women and newborns through four pillars: g1) group prenatal care throughout pregnancy, and postpartum; (2) group pediatric care of newborns through the first year of life; (3) psychosocial support and counseling throughout all aspects of the program including for PTSD and depression screening prenatally and post-partum; and (4) community-based care via home visits.

Results

J9: improves facility-to-community connections through home visits; creates supportive communities through group antenatal care and group pediatric care; and improves facility-level care by improving patient knowledge, promotion of early identification of obstetrical complications, building clinical competency and addressing gaps in lifesaving solutions to ensure excellent antepartum, intrapartum, and postpartum care. J9 increases antenatal care and facility-based deliveries, reduces maternal complications, reduces patients wait times, and improves birth outcomes.

J9 drives rapid improvements in health outcomes: 97% of women in the J9 pilot delivered at a facility, compared to 35% nationally, with 95% adherence to eight antenatal care visits and 84% adherence to six pediatric well child visits. The program has impacted more than 2,000 women and newborns, with graduates from J9 becoming champions of the model.

Conclusions

J9’s innovation is through an integrated, community-based care and accompaniment approach to create bonds among women and with care providers while providing supportive, high quality care. It is unique for a maternal health program to focus on women’s experiences through support groups through pregnancy with home and health facility interactions. This new accompaniment approach leads to earlier identification of warning signs, durable behavior change, an improved ability to address multiple social determinants, and improved access to lifesaving intrapartum and neonatal care.

O243. Quality of postabortion care in two African hospitals in fragile and conflict-affected settings: application of an adapted World Health Organization (WHO) Maternal and Newborn Health (MNH) Quality of Care Framework (AMoCo Study)

Estelle Pasquier¹, Onikepe Owolabi², Richard Ngbale³, Mariette Claudia Adame Gbanzi³, Timothy Williams¹, Daphne Lagrou¹, Claire Fotheringham¹, Tamara Fetters⁴, Catrin Schulte-Hillen¹, Huiwu Chen¹, Olivier Degomme⁵, Veronique Filippi⁶, Lenka Benova⁷, Bill Powell⁴

¹Medecins Sans Frontieres; ²IntraHealth International; ³Ministre de la Santé et de la Population, Central African Republic; ⁴Ipas; ⁵Ghent University; ⁶London School of Hygiene & Tropical Medicine; ⁷Institute of Tropical Medicine

BMC Proceedings 2024, 18(5):O243

Rana Islamiah Zahroh¹, Katy Sutcliffe², Dylan Kneale², Martha Vazquez Corona¹, Ana Pilar Betran³, Newton Opiyo³, Caroline Homer⁴, Meghan Bohren¹

¹The University of Melbourne; ²University of College London; ³World Health Organization; ⁴Burnet Institute

BMC Proceedings 2024, 18(5):O250

Submission ID #: IMNHC507

Note the full manuscript published in September 2023 in BMC Public Health:

(https://0-bmcpublichealth-biomedcentral-com.brum.beds.ac.uk/articles/10.1186/s12889-023-16718-0#:~:text=We%20identified%20four%20key%20essential,to%20interact%20with%20health%20providers.)

O251. Interventions targeting health care providers to optimize the use of cesarean section: a qualitative comparative analysis to identify important intervention features

Rana Islamiah Zahroh¹, Katy Sutcliffe², Dylan Kneale², Martha Vazquez Corona¹, Ana Pilar Betran³, Newton Opiyo³, Caroline Homer⁴, Meghan Bohren¹

¹The University of Melbourne; ²University of College London; ³World Health Organization; ⁴Burnet Institute

BMC Proceedings 2024, 18(5):O251

Submission ID #: IMNHC506

Note the full manuscript published in December 2022 in BMC Health Services Research:

(https://0-bmchealthservres-biomedcentral-com.brum.beds.ac.uk/articles/10.1186/s12913-022-08783-9)

O252. Use of digital technology for real-time reporting of maternal deaths: development of a Maternal and Perinatal Death Surveillance and Response (MPDSR) tool - an experience from Pakistan

Sabeen Afzal¹, Afifa-binte Irfan¹, Qudsia Uzma², Ellen Mpangananji Thom²

¹Ministry of National Health Services Regulations and Coordination, Pakistan; ²World Health Organization

BMC Proceedings 2024, 18(5):O252

Submission ID #: IMNHC501

Background

Maternal mortality is considered a key indicator of a country’s health status and its socio-economic development. Over the decades, Pakistan has managed to reduce the maternal mortality ratio from 276/100,000 (2006) to 186/100,000 (2018). However, subnational data shows variation being 140/100,000 in Punjab and 298/100,000 in Balochistan. Unfortunately, maternal mortality data is only available through population-based surveys and there is a dire need to have real-time data reporting with identification of the cause of mortality to guide programmatic decision making. The MPDSR system offers a workable solution and is being implemented in Pakistan since 2015.

Methods

Under the MPDSR system implementation, national protocols and training package were developed in 2017. Maternal death reporting forms 1, 2, and 4 were adapted in Pakistan for reporting of maternal deaths at facility level. A mobile application was also developed for real-time and paperless reporting. Training of hospital teams including obstetricians, nurses, administrators, anesthetists, pediatricians and statisticians were conducted on the manual as well as on the mobile app (web-based tool) involving sixteen (16)public sector hospitals mainly tertiary care teaching hospitals. This tool was then revised and customized by the national TWG on Reproductive, Maternal, Newborn, Child and Adolescent Health per professional feedback. Data is now being regularly received from the participating hospitals and uploaded to the MPDSR dashboard. Recently, the form on perinatal deaths including stillbirths and a response tracking sheet has also been added.

Results

With the introduction of the MPDSR mobile app tool, the data collected under MPDSR system including notification of deaths, status of the deceased at time of admission, status at the time of death (antenatal, natal, and postnatal), antenatal history, examination record, laboratory investigations, status of the fetus/neonate (gestational age, outcome of birth, vaccination, breastfeeding, resuscitation) and any interventions during antepartum, intrapartum, and postpartum. . The case summary along with challenges faced in the provision of care to the patient are also recorded. On the basis of this information, the maternal death review committees undertake the in-depth review, assign the cause of death and prepare response/ action plan for addressing the contributory factors. All of this information is available online through the dashboard linked to the mobile app. Since the introduction of the mobile app, the number of maternal deaths reported during 2021, 2022 and June 2023 are 87, 521 and 367, respectively. Postpartum hemorrhage was the most reported cause.

Conclusions

Digital technology can be used for informed decision-making and improvement in quality of care through provision of real-time data.

O253. An example of too much too soon? A review of cesarean sections performed in the first stage of labor in Kenya

Helen Allott¹, Fiona Dickinson¹, Nassir Shaban², Sheila Sawe³, Evans Ogoti³, Michael Odour⁴, Stephen Karangau⁵, Ephraim Ochola⁶, Charles A Ameh¹

¹Liverpool School of Tropical Medicine; ²Msambweni County Referral Hospital; ³Moi University; ⁴Bondo Subcounty Hospital; ⁵Muriranjas Subcounty Hospital; ⁶Homa Bay Subcounty Hospital

BMC Proceedings 2024, 18(5):O253

Submission ID #: IMNHC500

Background

Cesarean section (CS) is the most commonly performed major surgical procedure, with global rates rising. When performed for appropriate indications, CS can be lifesaving for mothers and babies. However, the procedure has potential short- and long-term complications, with reported rates of CS-associated death in sub-Saharan Africa at 10.9 per 1,000 procedures. In many health facilities, decisions to perform CS are made by non-specialist doctors, without support from experienced obstetricians. This can result in sub-optimal decision-making and inappropriate surgery. Our study assesses decision-making in CS performed in the first stage of labor.

Methods

Data extracted from 87 case notes, randomly selected from a series obtained from seven referral hospitals in five Kenyan counties over six months in 2020, was reviewed by a panel of seven UK and Kenyan expert obstetricians. Following a preliminary review of the data and an email discussion, an online panel was convened to discuss outstanding cases.

Results

There was consensus on all but five cases. In 41.3% cases, CS was considered appropriate by all assessors. The panel concluded that the CS was necessary but performed too late in 8% cases. The decision to delivery interval was longer than two hours in 58.6% cases, including 16 cases where the main reason given for the CS was non-reassuring fetal status. In 10.3% cases, it was considered that due to the decision to delivery delay, further reassessment should have occurred. In 9.1%, it was considered that the CS was done too soon and those providing care could have waited longer or attempted augmentation of labor. The quality of some records resulted in insufficient information to make a full assessment in 21.8% of cases and in 11.5% the CS was considered inappropriate.

In cases where agreement was not reached, meconium stained liquor was the stated reason for CS. Some panel members considered closer monitoring of the fetal heart was indicated, whereas others felt this was unlikely to be feasible due to staffing constraints.

Conclusions

This review demonstrates a need for improved support for decision-making, coupled with improved record-keeping and more timely surgery when necessary.

P254. Factors influencing appropriate use of interventions for management of women experiencing preterm birth: a mixed-methods systematic review and narrative synthesis

Rana Islamiah Zahroh¹, Alya Hazfiarini¹, Katherine Eddy², Joshua Vogel², Özge Tunçalp³, Nicole Minckas³, Fernando Althabe³, Olufemi Oladapo³, Meghan Bohren¹

¹The University of Melbourne; ²Burnet Institute; ³World Health Organization

BMC Proceedings 2024, 18(5):P254

Submission ID #: IMNHC499

Note the full manuscript published in August 2023 in PLOS Medicine:

(https://journals.plos.org/plosmedicine/article?id=10.1371%2Fjournal.pmed.1004074)

O255. Interventions co-designed by providers and clients for improving their therapeutic relationships in maternal and child health care in rural Tanzania

Kahabi Isangula, Eunice Pallangyo, Eunice Ndirangu-Mugo

The Aga Khan University

BMC Proceedings 2024, 18(5):O255

Submission ID #: IMNHC497

Note the full manuscript published in September 2023 in BMC Nursing:

(https://0-bmcnurs-biomedcentral-com.brum.beds.ac.uk/articles/10.1186/s12912-023-01472-w)

O256. Strengthening post-discharge follow-up for small and sick newborns in Bangladesh

Munia Islam¹, Zubair Shams¹, Bal Ram Bhui¹, Mohammad Morshad Alam², Muhammad Ismail Hasan², Afsana Karim¹, Mohammod Shahidullah³, Joseph De Graft-Johnson¹

¹Save the Children; ²Ministry of Health & Family Welfare, Bangladesh; ³Bangabandhu Sheikh Mujib Medical University

BMC Proceedings 2024, 18(5):O256

Submission ID #: IMNHC492

Background

In Bangladesh, more than two-thirds of neonates die within seven days of birth, and half of them die within 24 hours of birth due to infections, birth asphyxia, prematurity, and low birth weight. USAID’s MaMoni MNCS project assists the Ministry of Health and Family Welfare in scaling up kangaroo mother care (KMC) and special care newborn unit (SCANU) services for small and sick newborns in public facilities across the country to end preventable newborn deaths. Post-discharge follow-up is a known challenge in the care of these babies. The project implemented and tested a combined post-discharge phone call and community follow-up mechanism for KMC and SCANU babies in selected public facilities.

Methods

A mixed-method study was conducted in one district hospital and one upazila health complex to examine the effect of the post-discharge strategy. Data was extracted from the national health management information system, facility registers, KMC community follow-up, and phone follow-up record books for the baseline (October 2018–September 2019), and for the post-intervention period (January 2020–July 2021). Twenty-seven key informant interviews with hospital providers, six focus group discussions with community health workers, and seven group interviews with mothers/family members of KMC/SCANU babies were conducted.

Results

The results show that 48% of discharged SCANU babies (post-intervention) received a first facility follow-up, compared to 0% at baseline. First post-discharge facility follow-up visits for discharged KMC babies increased from 47% to 76% in the district hospital and from 20% to 78% in the upazila health complex. Furthermore, 52% of discharged KMC babies from the district hospital and 89% from the upazila health complex received their first community follow-up visits. Mothers/family members and providers expressed that phone follow-up and counseling during discharge by nurses increased facility follow-up for both SCANU and KMC babies. Community follow-up by community health workers also prompted the families to complete KMC follow-up on time.

Conclusions

The combined phone and community follow-up strategy improved facility post-discharge follow-up for SCANU and KMC babies. The Ministry of Health and Family Welfare should consider adopting this approach to ensure optimal care and survival of sick newborns.

O257. Influence of expectations and intentions during pregnancy on postnatal care utilization among adolescent and young first-time mothers: lessons from a qualitative study in Bangladesh

Bidhan Krishna Sarker¹, Sarah Elaraby², Syeda Nabin Ara Nitu³, Musfikur Rahman¹, Tasnia Ishaque¹, Victoria Lwesha³

¹International Centre for Diarrhoeal Disease Research, Bangladesh; ²University of Alexandria; ³Save the Children

BMC Proceedings 2024, 18(5):O257

Submission ID #: IMNHC489

Background

In Bangladesh, 43% of women have started childbearing before turning 18. Despite high antenatal care coverage, less than a third of adolescent and young mothers receive postnatal care (PNC) services. We explored the intention to seek PNC for 15–24 years-old first-time mothers (FTMs), their expectations of postnatal services, and how expectations influence service utilization.

Methods

Using a longitudinal qualitative exploratory design in 2022 in Noakhali, Bangladesh, we conducted two in-depth interviews with 22 FTMs, during the third trimester and then within 42 days postpartum. Within and cross-case analyses were conducted to illustrate the influence of expectation on PNC utilization among those who sought care and those who did not.

Results

While the majority of FTMs interviewed sought multiple antenatal care visits, most did not recall receiving any counseling or information regarding PNC services. During pregnancy, most participants had no specific expectations of PNC due to lack of awareness of their existence and no previous birth experience. Almost all participants either did not consider seeking services postnatally, or only intended to seek PNC if there is a problem with mother or infant’s health. Some FTMs were able to cite some specific complications that would motivate them to seek PNC, including excessive bleeding or pain. A key theme was lack of decision-making power by FTMs on where to deliver their child and whether to seek care, where the decision lay with the spouses or in-laws. Intentions during pregnancy directly influenced FTM’s care-seeking behavior. Most FTMs receiving PNC solely sought it to address issues with their child’s health. In a few instances, negative experiences during a facility delivery dissuaded FTMs from seeking additional PNC. Others wanted to seek PNC but did not know where to receive services or were prevented by their husband’s families.

Conclusions

Increasing PNC utilization among FTMs is crucial to improve maternal and child outcomes. Improved antenatal care counseling quality regarding PNC availability and importance impacts expectations, intention, and utilization of services. Family engagement, particularly with husbands and in-laws, is essential to improve PNC coverage as they influence maternal decision-making.

O258. Maternal depressive symptoms increase risk for pregnancy loss, preterm birth, and low birthweight among Kenyan mother-infant pairs: a prospective cohort study

John Kinuthia¹, Anna Larsen², Jillian Pintye², Felix Abuna³, Amritha Bhat², Julia Dettinger², Lauren Gomez², Mary Marwa³, Nancy Ngumbau¹, Ben Odhiambo³, Amanda Phipps², Barbra Richardson², Salphine Watoyi³, Joshua Stern², Grace John-Stewart²

Results suggest that the multi-pronged strategy improved health outcomes for both mothers and newborns at supported facilities and can contribute to maternal and newborn mortality reductions in Kaduna State.

O269. Which first trimester risk-estimation method for pre-eclampsia is most suitable? A model-based impact study

Luc Smits¹, Lynn Strijbos¹, Manouk Hendrix², Salwan Al-Nasiry², Liesbeth Scheepers²

¹Maastricht University; ²Maastricht University Medical Centre

BMC Proceedings 2024, 18(5):O269

Submission ID #: IMNHC395

Note the full manuscript published in July 2023 in AJOG+MFM:

(https://0-www-sciencedirect-com.brum.beds.ac.uk/science/article/pii/S2589933323001167?via%3Dihub)

O270. Technology for Retinopathy of Prematurity (ROP) screening in resource-limited settings: development of a Target Product Profile (TPP)

Rebecca Kirby¹, Aeesha Malik², Kara Palamountain¹, Clare Gilbert²

¹Northwestern University Kellogg School of Management; ²London School of Hygiene & Tropical Medicine

BMC Proceedings 2024, 18(5):O270

Submission ID #: IMNHC385

Previously published: https://0-bmjophth-bmj-com.brum.beds.ac.uk/content/8/1/e001197

O271. Setting students up for success: an innovative orientation to clinical placement in Sierra Leone

O278. Social determinants of antenatal depression among women in rural Bangladesh: a cross-sectional study

Nafisa Insan¹, Simon Forrest², Aqil Jaigirdar³, Reduanul Islam³, Judith Rankin¹

¹Newcastle University; ²Durham University, ³Maternal Aid Association

BMC Proceedings 2024, 18(5):O278

Submission ID #: IMNHC326

Note the full manuscript published in January 2023 in Int. J. Environ. Res. Public Health:

(https://0-www-mdpi-com.brum.beds.ac.uk/1660-4601/20/3/2364)

O279. A quality improvement collaborative to enhance Maternal and Newborn Health (MNH) care delivery by adopting global guidance within local contexts in low-resource settings

Anuradha Pichumani¹, Pichumani Parthasarathi¹, Rose Molina², Katherine Semrau²

We used a pre/post-test, non-equivalent control group design, embedded within a mixed-methods approach to evaluate the intervention. This included quantitative data collection using surveys with 80 providers—40 in intervention and 43 in control arms—at baseline (before intervention) and endline (six months later), and in-depth interviews with 30 providers at endline. Quantitative analysis includes a difference-in-difference analysis to assess intervention effects and thematic analysis of qualitative data to assess acceptability.

Results

Perceived stress scores changed from 20.9 (SD=3.9) at baseline to 18.6 (SD=5.3) at endline in the intervention group (p=0.033); and from 20.6 (SD=4.5) to 20.1 (SD=5.6) in the control group (p=0.645). Burnout levels changed from 3.6 (SD=1.0) to 2.9 (SD=1.0) in the intervention group (p=0.003); and from 3.7 (SD=1.1) to 3.4 (SD=1.1) in the control group (p=0.255). Implicit and explicit bias scores decreased in both the intervention and control arms, but the difference was not statistically significant. A difference-in-difference analysis indicated that 82% and 34% of the change in stress and burnout scores respectively can be attributed to the intervention. Qualitative results indicate high degree of acceptability, with most respondents calling for expansion of the intervention to the whole county. Qualitative themes also illustrate how the intervention has contributed to reduced stress and bias and improved responsive and respectful care to mothers.

Conclusions

The CPIPE intervention is acceptable and preliminary analysis shows it is effective in improving providers stress and burnout, with potential to reduce bias. Improvements in these outcomes will lead to improvements in PCMC, especially for the most vulnerable women.

O302. Caring for Providers to Improve Patient Experience (CPIPE): intervention development process

Patience Afulani¹, Edwina Oboke², Beryl Ogolla², Monica Getahun¹, Joyceline Kinyua³, Iscar Oluoch⁴, James Odour⁵, Linnet Ongeri³

¹University of California, San Francisco; ²Global Programs for Research and Training; ³Kenya Medical Research Institute; ⁴County Executive Committee, Migori; ⁵Migori County Department of Health

BMC Proceedings 2024, 18(5):O302

Submission ID #: IMNHC70

Note the full manuscript published in December 2023 in Glob Health Action:

(https://0-www-tandfonline-com.brum.beds.ac.uk/doi/full/10.1080/16549716.2022.2147289)

O303. Service loss during COVID-19 for maternal health and immunization services in Bangladesh

Aminur Rahman Shaheen¹, Sadika Akhter¹, Farzana Basher¹, Iqbal Anwar², Manzoor Ahmed Hanifi¹

¹International Centre for Diarrhoeal Disease Research, Bangladesh; ²Obstetrical and Gynaecological Society of Bangladesh

BMC Proceedings 2024, 18(5):O303

Submission ID #: IMNHC66

Background

The indirect effect of COVID-19 pandemic upon mortality has been poorly monitored in low- and middle-income countries like Bangladesh, and the concern is that this effect might be substantial. In this context, our objective was to quantify and explore support the extent of service loss in routine immunization and preventive maternal health care services from health sector facilities in Bangladesh due to COVID-19 pandemic.

Methods

A mixed-method approach was applied to conduct this study. Secondary data was collected from the national data server District Health Information System 2 (DHIS2) and icddr,b surveillance data for the year March 2020–June 2022 and several key informant and in-depth interviews were performed from two subdistricts in Bangladesh. The uptake of all routine antigens and maternal health care services at facility level were evaluated to assess the loss in maternal and child health service uptake due to COVID-19 through comparing mean differences between three time periods (March to December during 2020 and June 2022) using ANOVA test.

Results

It is evident from our findings that during the COVID-19 pandemic, utilization of maternal care services (antenatal care, postnatal care, facility delivery, and c-section delivery) and routine immunization services (measles-rubella, BCG, pentavalent, and tetanus toxoid vaccine) significantly reduced from pre-COVID condition (p <0.05). Service utilization started to reduce from March 2020, further stepped down in April and May (in some cases June), and then started to rise upward from July. Maternal health care services was more affected in comparision to child immunization services. These finding were supplemented by qualitative data that the health managers and service providers iterate the strength of immunization services more than maternal health services in Bangladesh.

Conclusions

The COVID-19 pandemic had profound, negative impact on routine maternal, newborn, and child health services in Bangladesh. The strength of the immunization program was better than maternal health services. Policy-makers should take lessons from the strengths of immunization services in Bangladesh for maternal health services to continue service during pandemic-adverse situation like COVID-19 periods.

O304. Experiences of midwives regarding provision of culturally competent care to women receiving maternal care in South Africa

Khumoetsile Daphney Shopo, Tinda Rabie, Antoinette Du Preez, Petra Bester

Change history

17 April 2024
A Correction to this paper has been published: https://0-doi-org.brum.beds.ac.uk/10.1186/s12919-024-00293-2

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Sponsorship

AlignMNH with funding from Bill and Melinda Gates Foundation

Further information about conference

For further information please visit: https://imnhc2023.org/.

Presentations from the conference can be found here: https://imnhc2023.dryfta.com/program

List of editors

Alisha Horwitz¹, Edward Kenyi¹, Elizabeth Thompson¹, Emma Pence¹, Joan Caroline Taylor¹, Juliana Molina¹, Susi Wyss¹

¹Jhpiego

Numbering Key

F = Formed panel oral presentation

O = Oral presentation

P = Poster

The original version of this article was revised: The authors for abstract F8.2 have been added.

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Proceedings of the 2023 International Maternal Newborn Health Conference. BMC Proc 18 (Suppl 5), 6 (2024). https://0-doi-org.brum.beds.ac.uk/10.1186/s12919-024-00289-y

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Published: 21 March 2024
DOI: https://0-doi-org.brum.beds.ac.uk/10.1186/s12919-024-00289-y

Proceedings of the 2023 International Maternal and Newborn Health Conference

Proceedings of the 2023 International Maternal Newborn Health Conference

F1.1. Networks of care for maternal and newborn health: an approach to strengthening relational elements for quality and respectful care

Katherine Kalaris1, Allisyn Moran2

1University of Oxford; 2World Health Organization

F1.2. Improving quality of maternal and newborn care through the creation of networks of safety in rural Nepal

Surya Bhatta1, Katherine Kalaris2, Sibylle Kristensen1

1One Heart Worldwide; 2University of Oxford

F1.3. Reduction of maternal and neonatal mortality within networks of care in Northern Province, Zambia

Morrison Zulu1, Katherine Kalaris2, Andrew Storey1, Angel Mwiche3

1Clinton Health Access Initiative; 2University of Oxford; 3Ministry of Health, Zambia

F2.1. Black Mamas Matter Alliance: advancing the black maternal health, rights, and justice movement

Ayanna Robinson, Philicia Castillo, Angela Aina

Black Mamas Matter Alliance, Inc

F2.2. Conducting research with, for, and by black birthing people and researchers: operationalizing black mamas matter alliance’s research principles

Sang Hee Won, Philicia Castillo, Ayanna Robinson, Angela Aina

Black Mamas Matter Alliance, Inc

F2.3. Often discussed, but never consulted: leveraging the expertise of the black perinatal workforce, scholars, and birthing people to develop principles and priorities addressing the maternal mortality crisis in the United States

Philicia Castillo, Ayanna Robinson, Sang Hee Won, Angela Aina

Black Mamas Matter Alliance, Inc

F2.4. Black Mamas Matter Alliance: advancing sexual, reproductive, and maternal health, rights, and justice

Ayanna Robinson, Philicia Castillo, Sang Hee Won, Angela Aina

Black Mamas Matter Alliance, Inc

F3.1. My job, my voice: harnessing midwives’ demands at scale to strengthen the enabling environment for midwifery

Kimberly Whipkey, Angela Nguku, Elena Ateva

White Ribbon Alliance

F3.2. Amplifying midwives’ perspectives and priorities in the government of India’s rollout of midwifery-led care

Chaitanya Tupaki Sreepoorna1, Kimberly Whipkey2

1Centre for Catalyzing Change; 2White Ribbon Alliance

F3.3. Creating a national vision and strategic framework for the practice of midwifery in Pakistan reflective of midwives’ priorities

Rafia Rauf Shakeel, Kimberly Whipkey

White Ribbon Alliance

F3.4. Midwives’ voices inform and catalyze a robust national midwifery agenda in Kenya

Sandra Mwarania, Kimberly Whipkey

White Ribbon Alliance

F4.1. Innovations to support safe oxygen use with Continuous Positive Airway Pressure (CPAP) for the small or sick newborn care to achieve Every Newborn Action Plan (ENAP) target 4

Leah Greenspan1, Tamah Kamlem2, Robert Neighbour3, Martha Franklin Mkony4, Harish Kumar5

1United States Agency for International Development; 2Chemonics International; 3Diamedica (UK) Ltd; 4Muhimbili National Hospital, Tanzania; 5IPE Global Limited

F4.2. Oxygen concentrator driven baby Continuous Positive Airway Pressure (CPAP)

Robert Neighbour1, Leah Greenspan2

1Diamedica (UK) Ltd; 2United States Agency for International Development

F4.3. Implementation of low-cost Effective Continuous Positive Airway Pressure (CPAP) and Bubble CPAP (bCPAP) in Low- and Middle-Income Countries (LMICs) to Address Respiratory Distress Syndrome (RDS) for small and sick newborns

Kondwani Kawaza1, Leah Greenspan2, Harish Kumar3

1Kamuzu University of Health Sciences (KUHES); 2United States Agency for International Development; 3IPE Global Limited

F4.4. Situational analysis of prevalence of improvised Bubble Continuous Positive Airway Pressure (bCPAP), 100% oxygen use, and pulse oximetry monitoring use in level 2 facilities in Ghana

Tamah Kamlem1, Leah Greenspan2

1Chemonics International; 2United States Agency for International Development

F4.5. Novel high-quality Bubble Continuous Positive Airway Pressure (bCPAP) and oxygen blender systems for global access

Martha Franklin Mkony1, Thomas Burke2, Leah Greenspan3

1Muhimbili National Hospital, Tanzania; 2Vayu Global Health Foundation; 3United States Agency for International Development

F5.1. Maternal mortality: levels, trends, and strengthening reporting

Jenny Cresswell1, Lale Say1, Imbulana Jayaratne2, Affette McCaw-Binns3

1World Health Organization; 2Ministry of Health, Sri Lanka; 3University of the West Indies, Mona

F5.2. Structured processes built upon the original Maternal Death Surveillance and Response (MDSR) system: Sri Lanka

Imbulana Jayaratne1, Jenny Cresswell2

1Ministry of Health, Sri Lanka; 2World Health Organization

F5.3. Vital registration as a reliable source of maternal mortality information: Jamaica’s experience with efforts to improve data quality and completeness, 2018–2021

Affette McCaw-Binns1, Jenny Cresswell2

1University of the West Indies, Mona; 2World Health Organization

F5.4. Global and regional causes of maternal deaths 2009–2017: a World Health Organization (WHO) systematic analysis

Jenny Cresswell

World Health Organization

F5.5. Trends in maternal mortality 2000 to 2020: estimates by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), World Bank Group, and United Nations Population Division

Lale Say, Jenny Cresswell

World Health Organization

F6.1. Enhancing maternal and newborn health in humanitarian and fragile settings with integrated service delivery

Christopher Lindahl1, Renee Fiorentino1, Nancy Ibrahim2, Dan Wendo1, Samia Mohammed3, Grace Carina Viola4

1MOMENTUM Integrated Health Resilience; 2Save the Children US; 3Building Foundation for Development; 4United Nations Population Fund

F6.2. Cash assistance for healthy pregnancies and safe births in the Philippines

Grace Carina Viola1, Christopher Lindahl2, Renee Fiorentino2, Alice Golay1

1United Nations Population Fund; 2MOMENTUM Integrated Health Resilience

F6.3. Mobile medical teams responding to health emergencies in humanitarian settings via the provision of integrated health services

Samia Mohammed1, Christopher Lindahl2, Renee Fiorentino2

1Building Foundation for Development; 2MOMENTUM Integrated Health Resilience

F6.4. Immediate postpartum and postabortion family planning trends in counties supported by MOMENTUM integrated health resilience in South Sudan

Lou Eluzai, Renee Fiorentino, Christopher Lindahl, Dan Wendo, Mary Jackson, Zechariah James

MOMENTUM Integrated Health Resilience

F6.5. Improving quality and availability of maternal newborn services in Somalia Puntland through delivery of adapted capacity-building packages to health care workers: Maternal and Newborn Health (MNH) program, save the children

Nancy Ibrahim1, Christopher Lindahl2, Renee Fiorentino2, Sarah Ashraf1

1Save the Children US; 2MOMENTUM Integrated Health Resilience

Katherine Kalaris¹, Allisyn Moran²

¹University of Oxford; ²World Health Organization

Surya Bhatta¹, Katherine Kalaris², Sibylle Kristensen¹

¹One Heart Worldwide; ²University of Oxford

Morrison Zulu¹, Katherine Kalaris², Andrew Storey¹, Angel Mwiche³

¹Clinton Health Access Initiative; ²University of Oxford; ³Ministry of Health, Zambia

Chaitanya Tupaki Sreepoorna¹, Kimberly Whipkey²

¹Centre for Catalyzing Change; ²White Ribbon Alliance

Leah Greenspan¹, Tamah Kamlem², Robert Neighbour³, Martha Franklin Mkony⁴, Harish Kumar⁵

¹United States Agency for International Development; ²Chemonics International; ³Diamedica (UK) Ltd; ⁴Muhimbili National Hospital, Tanzania; ⁵IPE Global Limited

Robert Neighbour¹, Leah Greenspan²

¹Diamedica (UK) Ltd; ²United States Agency for International Development

Kondwani Kawaza¹, Leah Greenspan², Harish Kumar³

¹Kamuzu University of Health Sciences (KUHES); ²United States Agency for International Development; ³IPE Global Limited

Tamah Kamlem¹, Leah Greenspan²

¹Chemonics International; ²United States Agency for International Development

Martha Franklin Mkony¹, Thomas Burke², Leah Greenspan³

¹Muhimbili National Hospital, Tanzania; ²Vayu Global Health Foundation; ³United States Agency for International Development

Jenny Cresswell¹, Lale Say¹, Imbulana Jayaratne², Affette McCaw-Binns³

¹World Health Organization; ²Ministry of Health, Sri Lanka; ³University of the West Indies, Mona

Imbulana Jayaratne¹, Jenny Cresswell²

¹Ministry of Health, Sri Lanka; ²World Health Organization

Affette McCaw-Binns¹, Jenny Cresswell²

¹University of the West Indies, Mona; ²World Health Organization

Christopher Lindahl¹, Renee Fiorentino¹, Nancy Ibrahim², Dan Wendo¹, Samia Mohammed³, Grace Carina Viola⁴

¹MOMENTUM Integrated Health Resilience; ²Save the Children US; ³Building Foundation for Development; ⁴United Nations Population Fund

Grace Carina Viola¹, Christopher Lindahl², Renee Fiorentino², Alice Golay¹

¹United Nations Population Fund; ²MOMENTUM Integrated Health Resilience

Samia Mohammed¹, Christopher Lindahl², Renee Fiorentino²

¹Building Foundation for Development; ²MOMENTUM Integrated Health Resilience

Nancy Ibrahim¹, Christopher Lindahl², Renee Fiorentino², Sarah Ashraf¹

¹Save the Children US; ²MOMENTUM Integrated Health Resilience

Sunday Dominico¹, Neena Prasad², Florina Serbanescu³, Samantha Lobis⁴

¹Thamini Uhai; ²Bloomberg Philanthropies; ³Centers for Disease Control and Prevention; ⁴Averting Maternal Death and Disability Program

Alex Mputa¹, Sunday Dominico¹, Agness Mbanza¹, Nguke Mwakatundu¹, Dunstan Bishanga², Shanon McNab³, Irene Mashasi³, Selemani Mbuyita³, Samantha Lobis³

¹Thamini Uhai; ²Muhimbili University of Health and Allied Sciences; ³Averting Maternal Death and Disability Program

Florina Serbanescu¹, Paul Stupp¹, Alicia Ruiz¹, Michelle Schmitz¹, Sunday Dominico², Samantha Lobis³, Jason Hsia¹

¹Centers for Disease Control and Prevention; ²Thamini Uhai; ³Averting Maternal Death and Disability Program

Sunday Dominico¹, Nguke Mwakatundu¹, Mkambu Kassanga¹, Samantha Lobis²

¹Thamini Uhai; ²Averting Maternal Death and Disability Program

Neena Prasad¹, Sunday Dominico², Samantha Lobis³, Florina Serbanescu⁴

¹Bloomberg Philanthropies; ²Thamini Uhai; ³Averting Maternal Death and Disability Program; ⁴Centers for Disease Control and Prevention

Natasha Sobers¹, Francesca Palestra², Sylvia Deganus², Mary Kinney³, Gloria Mutimbwa Siseho³

¹Pan American Health Organization; ²World Health Organization; ³University of the Western Cape, South Africa

Gloria Mutimbwa Siseho¹, Thubelihle Mathole¹, Francesca Palestra², Syliva Deganus², Debra Jackson³

¹University of the Western Cape, South Africa; ²World Health Organization; ³London School of Hygiene and Tropical Medicine

Natasha Rhoda¹, Francesca Palestra², Sylvia Deganus², Mary Kinney³, Anne-Marie Bergh⁴, Robert Pattinson⁴, Asha S. George³

¹University of Cape Town; ²World Health Organization; ³University of the Western Cape, South Africa; ⁴University of Pretoria

Natasha Rhoda¹, Francesca Palestra², Sylvia Deganus², Selvi M Jeyaseelan³, Pablo Duran⁴

¹University of Cape Town; ²World Health Organization; ³University of the West Indies, Barbados; ⁴Pan American Health Organization

Ryan Fitzgerald¹, Asha S. George², Oona Campbell³, Sylvain Landry Birane Faye⁴, Sudha Sharma⁵

¹Gates Ventures; ²University of the Western Cape, South Africa; ³London School of Hygiene & Tropical Medicine; ⁴Cheikh Anta Diop University; ⁵CIWEC Hospital and Travel Medical Center

Jordan-Tate Thomas¹, Ryan Fitzgerald¹, Asha S. George², Oona Campbell³, Ties Boerma⁴, Sudha Sharma⁵, Agbessi Amouzou⁶, Allisyn Moran⁷, Ira Mrtopullo¹, Uzma Syed⁷

¹Gates Ventures; ²University of the Western Cape, South Africa; ³London School of Hygiene & Tropical Medicine; ⁴University of Manitoba; ⁵CIWEC Hospital and Travel Medical Center; ⁶Johns Hopkins Bloomberg School of Public Health; ⁷World Health Organization

Ryan Fitzgerald¹, Ties Boerma², Oona Campbell³, Sylvain Landry Birane Faye⁴, Sudha Sharma⁵, Agbessi Amouzou⁶, Allisyn Moran⁷, Jordan-Tate Thomas¹

¹Gates Ventures; ²University of Manitoba, South Africa; ³London School of Hygiene & Tropical Medicine; ⁴Cheikh Anta Diop University; ⁵CIWEC Hospital and Travel Medical Center; ⁶Johns Hopkins Bloomberg School of Public Health; ⁷World Health Organization

Ira Mrtopullo¹, Jordan-Tate Thomas¹, Ryan Fitzgerald¹, Allisyn Moran², Sylvia Landry Birane Faye³

¹Gates Ventures; ²World Health Organization; ³Cheikh Anta Diop University

Wei Lu¹, Caitlin Warthin¹, Lynn Freedman¹, Isabelle Moreira¹, Martin Aluvaala², Patience Afulani³

¹Coumbia University Mailman School of Public Health; ²University of Nairobi, Kenya, ³University of California, San Francisco

Patience Afulani¹, Caitlin Warthin²

¹University of California, San Francisco; ²Coumbia University Mailman School of Public Health

Martin Aluvaala¹; Caitlin Warthin²

¹University of Nairobi, Kenya; ²Coumbia University Mailman School of Public Health

Sugandha Arya¹, Harish Chellani², Pratima Mittal³, Kilangnaro T Nokdy¹

¹Safdarjung Hospital; ²Center for Health Research and Development: Society for Applied Studies; ³Amrita Institute of Medical Sciences

Sugandha Arya¹, Harish Chellani², Pratima Mittal³, Kilangnaro T Nokdy¹, Nitya Wadhwa⁴

¹Safdarjung Hospital; ²Center for Health Research and Development: Society for Applied Studies; ³Amrita Institute of Medical Sciences; ⁴Translational Health Science and Technology Institute

Sugandha Arya¹, Harish Chellani², Pratima Mittal³

¹Safdarjung Hospital; ²Center for Health Research and Development: Society for Applied Studies; ³Amrita Institute of Medical Sciences

Sugandha Arya¹, Harish Chellani²

¹Safdarjung Hospital; ²Center for Health Research and Development: Society for Applied Studies