Journal of Family Planning and Reproductive Health Care, Oct 26, 2015
At different stages in their lives, most women and men alternate between wishing to prevent pregn... more At different stages in their lives, most women and men alternate between wishing to prevent pregnancy (requiring contraception) and planning/preparing to become pregnant (requiring preconception care), with various levels of ambiguity in between. However, the
Every year some eight million women suffer preventable or remediable pregnancy-related complicati... more Every year some eight million women suffer preventable or remediable pregnancy-related complications and over half a million will die unnecessarily. Most of these deaths could be averted at little or no extra cost, even where resources are limited, but in order to take action, and develop and implement changes to maternity services to save mothers and newborns lives, a change in cultural attitudes and political will, as well as improvements in the provision of health and social care, is required. Further, to aid programme planners, more in-depth information than that which may already be available through national statistics on maternal mortality rates or death certificate data is urgently needed. What is required is an in-depth understanding of the clinical, social, cultural or any other underlying factors which lead to mothers' deaths. Such information can be obtained by using any of the five methodologies outlined in the World Health Organizations programme and philosophy for maternal death or disability reviews, 'Beyond the Numbers', briefly described here and which are now being introduced in a number of countries around the world.
Whose faces are behind the numbers? What were their stories? What were their dreams? They left be... more Whose faces are behind the numbers? What were their stories? What were their dreams? They left behind children and families. They also left behind clues as to why their lives end so early 1 ' Avoiding maternal deaths is possible, even in resource-poor countries, but requires the right kind of information on which to base programmes. Knowing the level of maternal mortality is not enough; we need to understand the underlying factors that led to the deaths. Each maternal death or case of lifethreatening complication has a story to tell and can provide indications on practical ways of addressing its causes and determinants. Maternal death or morbidity reviews provide evidence of where the main problems in overcoming maternal mortality and morbidity may lie, produce an analysis of what can be done in practical terms and highlight the key areas requiring recommendations for health sector and community action as well as guidelines for improving clinical outcomes. The information gained from such enquiries must be used as a prerequisite for action. 'A pregnant woman has one foot in the grave' This traditional African saying summarizes the difficulties faced by pregnant women in many parts of the world. As discussed in Chapter 1, which provides a résumé of the global burden of maternal deaths and disability, each year throughout the world approximately eight million women are suffering pregnancy-related complications and over half a million will die 2. In some developing countries, one in 11 pregnant women may die of pregnancy-related complications compared to one in 5000-10,000 in some developed countries. The most recent world estimate of the overall maternal mortality ratio (MMR) is around 400 per 100,000 live births. By the Regions of the World Health Organization (WHO), the MMR is highest in Africa (830), followed by Asia (330),
Background Blood pressure measurement is a marker of antenatal care quality. In well resourced se... more Background Blood pressure measurement is a marker of antenatal care quality. In well resourced settings, lower blood pressure cutoffs for hypertension are associated with adverse pregnancy outcomes. We aimed to study the associations between blood pressure thresholds and adverse outcomes and the diagnostic test properties of these blood pressure cutoffs in low-resource settings. Methods We did a secondary analysis of data from 22 intervention clusters in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials (NCT01911494) in India (n=6), Mozambique (n=6), and Pakistan (n=10). We included pregnant women aged 15-49 years (12-49 years in Mozambique), identified in their community by trained community health workers, who had data on blood pressure measurements and outcomes. The trial was unmasked. Maximum blood pressure was categorised as: normal blood pressure (systolic blood pressure [sBP] <120 mm Hg and diastolic blood pressure [dBP] <80 mm Hg), elevated blood pressure (sBP 120-129 mm Hg and dBP <80 mm Hg), stage 1 hypertension (sBP 130-139 mm Hg or dBP 80-89 mm Hg, or both), non-severe stage 2 hypertension (sBP 140-159 mm Hg or dBP 90-109 mm Hg, or both), or severe stage 2 hypertension (sBP ≥160 mm Hg or dBP ≥110 mm Hg, or both). We classified women according to the maximum blood pressure category reached across all visits for the primary analyses. The primary outcome was a maternal, fetal, or neonatal mortality or morbidity composite. We estimated dose-response relationships between blood pressure category and adverse outcomes, as well as diagnostic test properties.
International Journal of Gynecology & Obstetrics, 2007
Objective: Given interventions implemented in recent years to reduce maternal deaths, we sought t... more Objective: Given interventions implemented in recent years to reduce maternal deaths, we sought to determine the incidence and causes of maternal deaths for 1998-2003. Method: Records of public hospitals and state pathologists were reviewed to identify pregnancy-related deaths within 12 months of delivery and determine their underlying causes. Results: Maternal mortality declined (p = 0.023) since surveillance began in 1981-83. The fall in direct mortality (p = 0.0003) included 24% fewer hypertension deaths (introduction of clinical guidelines, reorganization of antenatal services) and 36% fewer hemorrhage deaths (introduction of plasma expanders). These improvements were tempered by growing indirect mortality (p = 0.057), moving to 31% of maternal deaths from 17% in 1993-95. Interpretation: Declines in direct mortality may be associated with surveillance and related improvements in obstetric care. Increased indirect deaths from HIV/AIDS, cardiac disease, sickle cell disease and asthma suggests the need to improve collaboration with medical teams to implement guidelines to care for pregnant women with chronic diseases.
Current Opinion in Obstetrics and Gynecology, 2011
Purpose of review This review discusses the unprecedented global commitment to improve maternal h... more Purpose of review This review discusses the unprecedented global commitment to improve maternal health and scientific advancements in the field achieved during the last year. Recent findings Achievements at political, scientific, and programmatic levels targeted at improving maternal health, especially in low-resource settings, are described. Remaining challenges are discussed and the most promising areas of research and practice aimed at addressing these challenges are identified. Summary For the first time in decades, it is evident that progress in reducing mortality on a global scale is possible. Results showing increases in coverage of key maternal health interventions and the establishment of a system for promoting accountability are key determinants of that progress.
Bjog: An International Journal Of Obstetrics And Gynaecology, Sep 1, 2014
The UK has a well-established programme of Confidential Enquiries into Maternal Deaths and a nati... more The UK has a well-established programme of Confidential Enquiries into Maternal Deaths and a national system for research into near-miss maternal morbidities, the UK Obstetric Surveillance System. The addition of a programme of near-miss case reviews, the Confidential Enquiries into Maternal Morbidity, permits a complete examination of the incidence, risk factors, care and outcomes of the severest complications in pregnancy, and enables the lessons learnt to improve future care to be identified more quickly. This in turn allows for more rapid inclusion of recommendations into national guidance and hence the potential of better health for both women and babies.
Background: The Three Delays Framework was instrumental in the reduction of maternal mortality le... more Background: The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance. Methods: The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial. Results: Qualitative analysis of these maternal death narratives reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of...
To reduce all-cause maternal and perinatal mortality and major morbidity through Lady Health Work... more To reduce all-cause maternal and perinatal mortality and major morbidity through Lady Health Worker (LHW)-facilitated community engagement and early diagnosis, stabilization and referral of women with preeclampsia, an important contributor to adverse maternal and perinatal outcomes given delays in early detection and initial management. Study design: In the Pakistan Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial (NCT01911494), LHWs engaged the community, recruited pregnant women from 20 union councils (clusters), undertook mobile health-guided clinical assessment for preeclampsia, and referral to facilities after stabilization. Main outcome measures: The primary outcome was a composite of maternal, fetal and newborn mortality and major morbidity. Findings: We recruited 39,446 women in intervention (N = 20,264) and control clusters (N = 19,182) with minimal loss to follow-up (3•7% vs. 4•5%, respectively). The primary outcome did not differ between intervention (26•6%) and control (21•9%) clusters (adjusted odds ratio, aOR, 1•20 [95% confidence interval 0•84-1•72]; p = 0•31). There was reduction in stillbirths (0•89 [0•81-0•99]; p = 0•03), but no impact on maternal death (1•08 [0•69, 1•71]; p = 0•74) or morbidity (1•12 [0•57, 2•16]; p = 0•77); early (0•95 [0•82-1•09]; p = 0•46) or late neonatal deaths (1•23 [0•97-1•55]; p = 0•09); or neonatal morbidity (1•22 [0•77, 1•96]; p = 0•40). Improvements in outcome rates were observed with 4-7 (p = 0•015) and ≥8 (p < 0•001) (vs. 0) CLIP contacts. Interpretation: The CLIP intervention was well accepted by the community and implemented by LHWs. Lack of effects on adverse outcomes could relate to quality care for mothers with pre-eclampsia in health facilities. Future strategies for community outreach must also be accompanied by health facility strengthening. Funding: The University of British Columbia (PRE-EMPT), a grantee of the Bill & Melinda Gates Foundation (OPP1017337).
BJOG: An International Journal of Obstetrics & Gynaecology, 2014
Improving the quality of care for maternal and newborn health is crucial if health outcomes for m... more Improving the quality of care for maternal and newborn health is crucial if health outcomes for mothers and babies are to continue to improve. This will require a renewed global focus. Estimates published in May 2014 show that, globally, an estimated 289 000 women die during pregnancy, childbirth or in the postnatal period, 2.6 million babies are stillborn and 3 million babies die within 1 month of birth. The majority of these happen in lowand middle-income settings, are preventable, and occur during labour and childbirth and in the first week after birth. Ensuring quality care is provided to every mother, fetus and newborn during this period is critical for maternal and newborn survival. Monitoring of progress towards the achievement of Millennium Development Goals (MDGs) has focused on coverage of key interventions; for example, antenatal and postnatal care attendance rates and skilled birth attendance rates (a proxy measure for MDGs). Although such coverage rates have been increasing rapidly in many settings, it is widely acknowledged that the quality of care provided for mothers and babies falls short of current evidence-based practice and is, in many cases, not ‘woman and baby friendly’. Indeed, it could be considered ‘substandard’ in many settings. Uptake (and coverage) of care and quality of care are closely linked; there are numerous examples in the literature describing where and how poor quality of care has stopped women from accessing healthcare services, even where these were available, close by and affordable. A variety of methods to improve quality of care have been successfully used in maternal and newborn health. These include: conducting mortality audit or review for maternal and perinatal deaths (stillbirths and newborn deaths), review of cases of ‘near-miss’ or severe acute maternal morbidity (SAMM) and standards-based (or clinical) audit. Documented experience of the use of these approaches, methodologies and tools suggests that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools generally depends on the available resources and healthcare system. Leadership and developing a ‘culture of quality’ are considered to be important prerequisites for (or part of) implementation of quality improvement methodology. This supplement highlights the experiences of leaders and colleagues across the globe with regard to introducing and implementing different types of audit to improve quality of maternal and newborn care. Mahmud et al., Hinton et al., and Flenady et al. highlight the importance of understanding the experiences of women and their families and how this should inform what we mean by ‘quality’. Heiby et al. remind us of the need for improving healthcare processes and adopting evidence-based guidelines. Several country case studies describe how maternal death audit (Moldova, Cameroon, Nigeria) and/or a confidential enquiry into maternal deaths (Kerala State in India, the Republic of South Africa, Malaysia) can be implemented at regional or national level. The authors give a ‘real life’ account of not only how difficult this can be but also how this careful and honest type of evaluation of care received by women who died helps to identify the specific areas of care that are substandard and require action. These country case studies illustrate the importance of support for change at all levels in the health system, a multidisciplinary approach and dedicated leadership. The new cause classification for maternal deaths (International Classification of Diseases; Maternal Mortality [ICD-MM]) was published in 2012 by WHO, Geneva. Ameh et al. and Owalabi et al. show how this can be applied in practice and demonstrate the need for standardisation of international terminology including for ‘underlying cause of death’ and ‘contributing factors’. Perinatal and stillbirth audit is still less widely practiced. Buchmann explains that this is a very powerful tool and should be an essential part of all obstetric services and the case studies from the Republic of South Africa (Rhoda) and Moldova (Stratulat) show how this can be done. Aminu et al. conducted a systematic review highlighting the need for a simple and comprehensive classification system to be able to assign cause of death in case of stillbirth as well as a need for much better collection of data that will allow aggregation and comparison across various settings. Finally, there are some excellent examples from Mali, Niger and Ghana showing how the quality of care can be improved using standards-based audit. Poor quality is often a function of weak health systems and processes or problems in implementation generally rather than the fault of individuals. Audit can be used to identify which areas of care require strengthening. This requires that a culture of improvement and solutions is developed rather than a culture of blame. With new classification systems developed for causes…
The spinal nucleus of the bulbocavernosus (SNB) neuromuscular system is a highly conserved and we... more The spinal nucleus of the bulbocavernosus (SNB) neuromuscular system is a highly conserved and well-studied model of sexual differentiation of the vertebrate nervous system. Sexual differentiation of the SNB is currently thought to be mediated by the direct action of perinatal testosterone on androgen receptors (ARs) in the bulbocavernosus/levator ani muscles, with concomitant motoneuron rescue. This model has been proposed based on surgical and pharmacological manipulations of developing rats as well as from evidence that male rats with the testicular feminization mutation (Tfm), which is a loss of function AR mutation, have a feminine SNB phenotype. We examined whether genetically replacing AR in muscle fibers is sufficient to rescue the SNB phenotype of Tfm rats. Transgenic rats in which wild-type (WT) human AR is driven by a human skeletal actin promoter (HSA-AR) were crossed with Tfm rats. Resulting male HSA-AR/Tfm rats express WT AR exclusively in muscle and nonfunctional Tfm ...
In pregnancy in well-resourced settings, limited data suggest that higher blood pressure (BP) vis... more In pregnancy in well-resourced settings, limited data suggest that higher blood pressure (BP) visit-to-visit variability may be associated with adverse pregnancy outcomes. Included were pregnant women in 22 intervention clusters of the CLIP (Community-Level Interventions for Preeclampsia) cluster randomized trials, who had received at least 2 prenatal contacts from a community health worker, including standardized BP measurement. Mixed-effects adjusted logistic regression assessed relationships between pregnancy outcomes and both BP level (median [interquartile range]) and visit-to-visit variability (SD and average real variability [ARV], adjusted for BP level), among all women and those who became hypertensive. The primary outcome was the CLIP composite of maternal and perinatal mortality and morbidity. Among 17 770 pregnancies, higher systolic and diastolic BP levels were associated with increased odds of the composite outcome per 5 mm Hg increase in BP (odds ratio [OR], 1.05 [95%...
Journal of Family Planning and Reproductive Health Care, Oct 26, 2015
At different stages in their lives, most women and men alternate between wishing to prevent pregn... more At different stages in their lives, most women and men alternate between wishing to prevent pregnancy (requiring contraception) and planning/preparing to become pregnant (requiring preconception care), with various levels of ambiguity in between. However, the
Every year some eight million women suffer preventable or remediable pregnancy-related complicati... more Every year some eight million women suffer preventable or remediable pregnancy-related complications and over half a million will die unnecessarily. Most of these deaths could be averted at little or no extra cost, even where resources are limited, but in order to take action, and develop and implement changes to maternity services to save mothers and newborns lives, a change in cultural attitudes and political will, as well as improvements in the provision of health and social care, is required. Further, to aid programme planners, more in-depth information than that which may already be available through national statistics on maternal mortality rates or death certificate data is urgently needed. What is required is an in-depth understanding of the clinical, social, cultural or any other underlying factors which lead to mothers' deaths. Such information can be obtained by using any of the five methodologies outlined in the World Health Organizations programme and philosophy for maternal death or disability reviews, 'Beyond the Numbers', briefly described here and which are now being introduced in a number of countries around the world.
Whose faces are behind the numbers? What were their stories? What were their dreams? They left be... more Whose faces are behind the numbers? What were their stories? What were their dreams? They left behind children and families. They also left behind clues as to why their lives end so early 1 ' Avoiding maternal deaths is possible, even in resource-poor countries, but requires the right kind of information on which to base programmes. Knowing the level of maternal mortality is not enough; we need to understand the underlying factors that led to the deaths. Each maternal death or case of lifethreatening complication has a story to tell and can provide indications on practical ways of addressing its causes and determinants. Maternal death or morbidity reviews provide evidence of where the main problems in overcoming maternal mortality and morbidity may lie, produce an analysis of what can be done in practical terms and highlight the key areas requiring recommendations for health sector and community action as well as guidelines for improving clinical outcomes. The information gained from such enquiries must be used as a prerequisite for action. 'A pregnant woman has one foot in the grave' This traditional African saying summarizes the difficulties faced by pregnant women in many parts of the world. As discussed in Chapter 1, which provides a résumé of the global burden of maternal deaths and disability, each year throughout the world approximately eight million women are suffering pregnancy-related complications and over half a million will die 2. In some developing countries, one in 11 pregnant women may die of pregnancy-related complications compared to one in 5000-10,000 in some developed countries. The most recent world estimate of the overall maternal mortality ratio (MMR) is around 400 per 100,000 live births. By the Regions of the World Health Organization (WHO), the MMR is highest in Africa (830), followed by Asia (330),
Background Blood pressure measurement is a marker of antenatal care quality. In well resourced se... more Background Blood pressure measurement is a marker of antenatal care quality. In well resourced settings, lower blood pressure cutoffs for hypertension are associated with adverse pregnancy outcomes. We aimed to study the associations between blood pressure thresholds and adverse outcomes and the diagnostic test properties of these blood pressure cutoffs in low-resource settings. Methods We did a secondary analysis of data from 22 intervention clusters in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials (NCT01911494) in India (n=6), Mozambique (n=6), and Pakistan (n=10). We included pregnant women aged 15-49 years (12-49 years in Mozambique), identified in their community by trained community health workers, who had data on blood pressure measurements and outcomes. The trial was unmasked. Maximum blood pressure was categorised as: normal blood pressure (systolic blood pressure [sBP] <120 mm Hg and diastolic blood pressure [dBP] <80 mm Hg), elevated blood pressure (sBP 120-129 mm Hg and dBP <80 mm Hg), stage 1 hypertension (sBP 130-139 mm Hg or dBP 80-89 mm Hg, or both), non-severe stage 2 hypertension (sBP 140-159 mm Hg or dBP 90-109 mm Hg, or both), or severe stage 2 hypertension (sBP ≥160 mm Hg or dBP ≥110 mm Hg, or both). We classified women according to the maximum blood pressure category reached across all visits for the primary analyses. The primary outcome was a maternal, fetal, or neonatal mortality or morbidity composite. We estimated dose-response relationships between blood pressure category and adverse outcomes, as well as diagnostic test properties.
International Journal of Gynecology & Obstetrics, 2007
Objective: Given interventions implemented in recent years to reduce maternal deaths, we sought t... more Objective: Given interventions implemented in recent years to reduce maternal deaths, we sought to determine the incidence and causes of maternal deaths for 1998-2003. Method: Records of public hospitals and state pathologists were reviewed to identify pregnancy-related deaths within 12 months of delivery and determine their underlying causes. Results: Maternal mortality declined (p = 0.023) since surveillance began in 1981-83. The fall in direct mortality (p = 0.0003) included 24% fewer hypertension deaths (introduction of clinical guidelines, reorganization of antenatal services) and 36% fewer hemorrhage deaths (introduction of plasma expanders). These improvements were tempered by growing indirect mortality (p = 0.057), moving to 31% of maternal deaths from 17% in 1993-95. Interpretation: Declines in direct mortality may be associated with surveillance and related improvements in obstetric care. Increased indirect deaths from HIV/AIDS, cardiac disease, sickle cell disease and asthma suggests the need to improve collaboration with medical teams to implement guidelines to care for pregnant women with chronic diseases.
Current Opinion in Obstetrics and Gynecology, 2011
Purpose of review This review discusses the unprecedented global commitment to improve maternal h... more Purpose of review This review discusses the unprecedented global commitment to improve maternal health and scientific advancements in the field achieved during the last year. Recent findings Achievements at political, scientific, and programmatic levels targeted at improving maternal health, especially in low-resource settings, are described. Remaining challenges are discussed and the most promising areas of research and practice aimed at addressing these challenges are identified. Summary For the first time in decades, it is evident that progress in reducing mortality on a global scale is possible. Results showing increases in coverage of key maternal health interventions and the establishment of a system for promoting accountability are key determinants of that progress.
Bjog: An International Journal Of Obstetrics And Gynaecology, Sep 1, 2014
The UK has a well-established programme of Confidential Enquiries into Maternal Deaths and a nati... more The UK has a well-established programme of Confidential Enquiries into Maternal Deaths and a national system for research into near-miss maternal morbidities, the UK Obstetric Surveillance System. The addition of a programme of near-miss case reviews, the Confidential Enquiries into Maternal Morbidity, permits a complete examination of the incidence, risk factors, care and outcomes of the severest complications in pregnancy, and enables the lessons learnt to improve future care to be identified more quickly. This in turn allows for more rapid inclusion of recommendations into national guidance and hence the potential of better health for both women and babies.
Background: The Three Delays Framework was instrumental in the reduction of maternal mortality le... more Background: The Three Delays Framework was instrumental in the reduction of maternal mortality leading up to, and during the Millennium Development Goals. However, this paper suggests the original framework might be reconsidered, now that most mothers give birth in facilities, the quality and continuity of the clinical care is of growing importance. Methods: The paper explores the factors that contributed to maternal deaths in rural Pakistan and Mozambique, using 76 verbal autopsy narratives from the Community Level Interventions for Pre-eclampsia (CLIP) Trial. Results: Qualitative analysis of these maternal death narratives reveals an interplay of various influences, such as, underlying risks and comorbidities, temporary improvements after seeking care, gaps in quality care in emergencies, convoluted referral systems, and arrival at the final facility in critical condition. Evaluation of these narratives helps to reframe the pathways of maternal mortality beyond a single journey of...
To reduce all-cause maternal and perinatal mortality and major morbidity through Lady Health Work... more To reduce all-cause maternal and perinatal mortality and major morbidity through Lady Health Worker (LHW)-facilitated community engagement and early diagnosis, stabilization and referral of women with preeclampsia, an important contributor to adverse maternal and perinatal outcomes given delays in early detection and initial management. Study design: In the Pakistan Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomized controlled trial (NCT01911494), LHWs engaged the community, recruited pregnant women from 20 union councils (clusters), undertook mobile health-guided clinical assessment for preeclampsia, and referral to facilities after stabilization. Main outcome measures: The primary outcome was a composite of maternal, fetal and newborn mortality and major morbidity. Findings: We recruited 39,446 women in intervention (N = 20,264) and control clusters (N = 19,182) with minimal loss to follow-up (3•7% vs. 4•5%, respectively). The primary outcome did not differ between intervention (26•6%) and control (21•9%) clusters (adjusted odds ratio, aOR, 1•20 [95% confidence interval 0•84-1•72]; p = 0•31). There was reduction in stillbirths (0•89 [0•81-0•99]; p = 0•03), but no impact on maternal death (1•08 [0•69, 1•71]; p = 0•74) or morbidity (1•12 [0•57, 2•16]; p = 0•77); early (0•95 [0•82-1•09]; p = 0•46) or late neonatal deaths (1•23 [0•97-1•55]; p = 0•09); or neonatal morbidity (1•22 [0•77, 1•96]; p = 0•40). Improvements in outcome rates were observed with 4-7 (p = 0•015) and ≥8 (p < 0•001) (vs. 0) CLIP contacts. Interpretation: The CLIP intervention was well accepted by the community and implemented by LHWs. Lack of effects on adverse outcomes could relate to quality care for mothers with pre-eclampsia in health facilities. Future strategies for community outreach must also be accompanied by health facility strengthening. Funding: The University of British Columbia (PRE-EMPT), a grantee of the Bill & Melinda Gates Foundation (OPP1017337).
BJOG: An International Journal of Obstetrics & Gynaecology, 2014
Improving the quality of care for maternal and newborn health is crucial if health outcomes for m... more Improving the quality of care for maternal and newborn health is crucial if health outcomes for mothers and babies are to continue to improve. This will require a renewed global focus. Estimates published in May 2014 show that, globally, an estimated 289 000 women die during pregnancy, childbirth or in the postnatal period, 2.6 million babies are stillborn and 3 million babies die within 1 month of birth. The majority of these happen in lowand middle-income settings, are preventable, and occur during labour and childbirth and in the first week after birth. Ensuring quality care is provided to every mother, fetus and newborn during this period is critical for maternal and newborn survival. Monitoring of progress towards the achievement of Millennium Development Goals (MDGs) has focused on coverage of key interventions; for example, antenatal and postnatal care attendance rates and skilled birth attendance rates (a proxy measure for MDGs). Although such coverage rates have been increasing rapidly in many settings, it is widely acknowledged that the quality of care provided for mothers and babies falls short of current evidence-based practice and is, in many cases, not ‘woman and baby friendly’. Indeed, it could be considered ‘substandard’ in many settings. Uptake (and coverage) of care and quality of care are closely linked; there are numerous examples in the literature describing where and how poor quality of care has stopped women from accessing healthcare services, even where these were available, close by and affordable. A variety of methods to improve quality of care have been successfully used in maternal and newborn health. These include: conducting mortality audit or review for maternal and perinatal deaths (stillbirths and newborn deaths), review of cases of ‘near-miss’ or severe acute maternal morbidity (SAMM) and standards-based (or clinical) audit. Documented experience of the use of these approaches, methodologies and tools suggests that none is sufficient by itself to achieve a desirable improvement in quality of care. The choice of methodologies and tools generally depends on the available resources and healthcare system. Leadership and developing a ‘culture of quality’ are considered to be important prerequisites for (or part of) implementation of quality improvement methodology. This supplement highlights the experiences of leaders and colleagues across the globe with regard to introducing and implementing different types of audit to improve quality of maternal and newborn care. Mahmud et al., Hinton et al., and Flenady et al. highlight the importance of understanding the experiences of women and their families and how this should inform what we mean by ‘quality’. Heiby et al. remind us of the need for improving healthcare processes and adopting evidence-based guidelines. Several country case studies describe how maternal death audit (Moldova, Cameroon, Nigeria) and/or a confidential enquiry into maternal deaths (Kerala State in India, the Republic of South Africa, Malaysia) can be implemented at regional or national level. The authors give a ‘real life’ account of not only how difficult this can be but also how this careful and honest type of evaluation of care received by women who died helps to identify the specific areas of care that are substandard and require action. These country case studies illustrate the importance of support for change at all levels in the health system, a multidisciplinary approach and dedicated leadership. The new cause classification for maternal deaths (International Classification of Diseases; Maternal Mortality [ICD-MM]) was published in 2012 by WHO, Geneva. Ameh et al. and Owalabi et al. show how this can be applied in practice and demonstrate the need for standardisation of international terminology including for ‘underlying cause of death’ and ‘contributing factors’. Perinatal and stillbirth audit is still less widely practiced. Buchmann explains that this is a very powerful tool and should be an essential part of all obstetric services and the case studies from the Republic of South Africa (Rhoda) and Moldova (Stratulat) show how this can be done. Aminu et al. conducted a systematic review highlighting the need for a simple and comprehensive classification system to be able to assign cause of death in case of stillbirth as well as a need for much better collection of data that will allow aggregation and comparison across various settings. Finally, there are some excellent examples from Mali, Niger and Ghana showing how the quality of care can be improved using standards-based audit. Poor quality is often a function of weak health systems and processes or problems in implementation generally rather than the fault of individuals. Audit can be used to identify which areas of care require strengthening. This requires that a culture of improvement and solutions is developed rather than a culture of blame. With new classification systems developed for causes…
The spinal nucleus of the bulbocavernosus (SNB) neuromuscular system is a highly conserved and we... more The spinal nucleus of the bulbocavernosus (SNB) neuromuscular system is a highly conserved and well-studied model of sexual differentiation of the vertebrate nervous system. Sexual differentiation of the SNB is currently thought to be mediated by the direct action of perinatal testosterone on androgen receptors (ARs) in the bulbocavernosus/levator ani muscles, with concomitant motoneuron rescue. This model has been proposed based on surgical and pharmacological manipulations of developing rats as well as from evidence that male rats with the testicular feminization mutation (Tfm), which is a loss of function AR mutation, have a feminine SNB phenotype. We examined whether genetically replacing AR in muscle fibers is sufficient to rescue the SNB phenotype of Tfm rats. Transgenic rats in which wild-type (WT) human AR is driven by a human skeletal actin promoter (HSA-AR) were crossed with Tfm rats. Resulting male HSA-AR/Tfm rats express WT AR exclusively in muscle and nonfunctional Tfm ...
In pregnancy in well-resourced settings, limited data suggest that higher blood pressure (BP) vis... more In pregnancy in well-resourced settings, limited data suggest that higher blood pressure (BP) visit-to-visit variability may be associated with adverse pregnancy outcomes. Included were pregnant women in 22 intervention clusters of the CLIP (Community-Level Interventions for Preeclampsia) cluster randomized trials, who had received at least 2 prenatal contacts from a community health worker, including standardized BP measurement. Mixed-effects adjusted logistic regression assessed relationships between pregnancy outcomes and both BP level (median [interquartile range]) and visit-to-visit variability (SD and average real variability [ARV], adjusted for BP level), among all women and those who became hypertensive. The primary outcome was the CLIP composite of maternal and perinatal mortality and morbidity. Among 17 770 pregnancies, higher systolic and diastolic BP levels were associated with increased odds of the composite outcome per 5 mm Hg increase in BP (odds ratio [OR], 1.05 [95%...
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Papers by Gwyneth lewis