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The WHO ACTION-I trial, the largest placebo-controlled trial on antenatal corticosteroids (ACS) efficacy and safety to date, reaffirmed the benefits of ACS on mortality reduction among early preterm newborns in low-income settings. We discuss here lessons learned from ACTION-I trial that are relevant to a strategy for ACS implementation to optimize impact. Key elements included (i) gestational age dating by ultrasound (ii) application of appropriate selection criteria by trained obstetric physicians to identify women with a likelihood of preterm birth for ACS administration; and (iii) provision of a minimum package of care for preterm newborns in facilities. This strategy accurately identified a large proportion of women who eventually gave birth preterm, and resulted in a 16% reduction in neonatal mortality from ACS use. Policy-makers, programme managers and clinicians are encouraged to consider this implementation strategy to effectively scale and harness the benefits of ACS in saving preterm newborn lives.

Summary The COVID-19 pandemic has raised concern about the possibility and effects of mother–infant transmission of SARS-CoV-2 through breastfeeding and close contact. The insufficient available evidence has resulted in differing recommendations by health professional associations and national health authorities. We present an approach for deciding public health policy on infant feeding and mother–infant contact in the context of COVID-19, or for future emerging viruses, that balances the risks that are associated with viral infection against child survival, lifelong health, and development, and also maternal health. Using the Lives Saved Tool, we used available data to show how different public health approaches might affect infant mortality. Based on existing evidence, including population and survival estimates, the number of infant deaths in low-income and middle-income countries due to COVID-19 (2020–21) might range between 1800 and 2800. By contrast, if mothers with confirmed SARS-CoV-2 infection are recommended to separate from their newborn babies and avoid or stop breastfeeding, additional deaths among infants would range between 188 000 and 273 000.

INTRODUCTION: Though interest is growing for trials comparing planned delivery mode (vaginal delivery [VD]; cesarean section [CS]) in low-risk nulliparous women, appropriate study design is unclear. Our objective was to assess feasibility of three designs (preference trial [PCT], randomized controlled trial [RCT], partially randomized patient preference trial [PRPPT]) for a trial comparing planned delivery mode in low-risk women. METHODS: A cross-sectional survey of low-risk, nulliparous pregnant women (N=416) and healthcare providers (N=168) providing prenatal care and/or labor/delivery services was conducted in Argentina (2 public, 2 private hospitals). Proportion of pregnant women and providers willing to participate in each design and reasons for not participating were determined. RESULTS: Few women (85%). Believing randomization unacceptable (RCT, PRPPT) and desiring choice of delivery mode (RCT) were women’s reasons for not participating. For providers, commonly cited reasons for not participating included unacceptability of performing CS without medical indication, difficulty obtaining informed consent, discomfort enrolling patients (all designs), and violating women’s right to choose (RCT). CONCLUSIONS FOR PRACTICE: Important limitations were found for each trial design evaluated. The necessity of stronger evidence regarding delivery mode in low-risk women suggests consideration of additional designs, such as a rigorously designed cohort study or an RCT within an obstetric population with equivocal CS indications.

Introduction Women experience high rates of depression, particularly during pregnancy and the postpartum periods. Using population-based data from Bangladesh and Pakistan, we estimated the burden of antenatal depression, its risk factors, and its effect on preterm birth. Methods The study uses the following data: maternal depression measured between 24 and 28 weeks of gestation using the 9–question Patient Health Questionnaire (PHQ-9); data on pregnancy including an ultrasound before 19 weeks of gestation; data on pregnancy outcomes; and data on woman’s age, education, parity, weight, height, history of previous illness, prior miscarriage, stillbirth, husband’s education, and household socioeconomic data collected during early pregnancy. Using PHQ-9 cutoff score of ≥12, women were categorized into none to mild depression or moderate to moderately severe depression. Using ultrasound data, preterm birth was defined as babies born Results About 6% of the women reported moderate to moderately severe depressive symptoms during the antenatal period. A parity of ≥2 and the highest household wealth status were associated with an increased risk of depression. The overall incidence of preterm birth was 13.4%. Maternal antenatal depression was significantly associated with the risk of preterm birth (ARR, 95% CI: 1.34, 1.02–1.74). Conclusion The increased risk of preterm birth in women with antenatal depression in conjunction with other significant risk factors suggests that depression likely occurs within a constellation of other risk factors. Thus, to effectively address the burden of preterm birth, programs require developing and providing integrated care addressing multiple risk factors.

Background: Telling personal stories of violence has been central to recent advocacy efforts to prevent violence against women around the world. In this paper, we explore the use of personal storytelling as a form of activism to prevent femicide in Turkey. This study is part of a broader storytelling initiative called SHAER (Storytelling for Health: Acknowledgement, Expression and Recovery) to alleviate the psychological and emotional suffering of women who have experienced gender-based violence in high-prevalence settings. Objectives: We conceptually explore personal stories of violence as a form of both distributed agency and activism. This conceptual framework is used to answer the following research question in the Turkish context: How do women use their personal stories of interpersonal violence for their own benefit (support) and that of others (activism)? Methods: Our study is based on 20 in-depth semi-structured interviews with women who have experienced violence and were purposefully recruited by the ‘We Will End Femicide’ Platform in Istanbul. Interviews were conducted between March and August 2019. We used inductive and deductive thematic analysis to identify instances of personal storytelling at three levels: intrapersonal, relational and collective. Results: Our results show how the use of personal storytelling can provide a means of healing from experiences of violence. However, this process is not linear and is often influenced by the surrounding context including: the listener of the story, their reaction, and what social networks the woman has to support her. In supportive social contexts, personal storytelling can be an effective support for activism against violence: personal stories can provide opportunities for individuals to shape broader discourses about violence against women and the right of women to share their stories. Conclusions: Telling one’s personal story of violence can both support women’s agency and contribute to the collective struggle against violence against women more broadly.

Background Maternal morbidity occurs several times more frequently than mortality, yet data on morbidity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and middle-income countries. We aimed to generate prospective, reliable population-based data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and postnatal periods and its association with maternal, foetal, and neonatal death in South Asia and sub-Saharan Africa. Methods and findings This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia and sub-Saharan Africa. We conducted population-based surveillance of women of reproductive age (15 to 49 years) to identify pregnancies. Pregnant women who gave consent were include in the study and followed up to birth and 42 days postpartum from 2012 to 2015. We used standard operating procedures, data collection tools, and training to harmonise study implementation across sites. Three home visits during pregnancy and 2 home visits after birth were conducted to collect maternal morbidity information and maternal, foetal, and newborn outcomes. We measured blood pressure and proteinuria to define hypertensive disorders of pregnancy and woman’s self-report to identify obstetric haemorrhage, pregnancy-related infection, and prolonged or obstructed labour. Enrolled women whose pregnancy lasted at least 28 weeks or those who died during pregnancy were included in the analysis. We used meta-analysis to combine site-specific estimates of burden, and regression analysis combining all data from all sites to examine associations between the maternal morbidities and adverse outcomes. Among approximately 735,000 women of reproductive age in the study population, and 133,238 pregnancies during the study period, only 1.6% refused consent. Of these, 114,927 pregnancies had morbidity data collected at least once in both antenatal and in postnatal period, and 114,050 of them were included in the analysis. Overall, 32.7% of included pregnancies had at least one major direct maternal morbidity; South Asia had almost double the burden compared to sub-Saharan Africa (43.9%, 95% CI 27.8% to 60.0% in South Asia; 23.7%, 95% CI 19.8% to 27.6% in sub-Saharan Africa). Antepartum haemorrhage was reported in 2.2% (95% CI 1.5% to 2.9%) pregnancies and severe postpartum in 1.7% (95% CI 1.2% to 2.2%) pregnancies. Preeclampsia or eclampsia was reported in 1.4% (95% CI 0.9% to 2.0%) pregnancies, and gestational hypertension alone was reported in 7.4% (95% CI 4.6% to 10.1%) pregnancies. Prolonged or obstructed labour was reported in about 11.1% (95% CI 5.4% to 16.8%) pregnancies. Clinical features of late third trimester antepartum infection were present in 9.1% (95% CI 5.6% to 12.6%) pregnancies and those of postpartum infection in 8.6% (95% CI 4.4% to 12.8%) pregnancies. There were 187 pregnancy-related deaths per 100,000 births, 27 stillbirths per 1,000 births, and 28 neonatal deaths per 1,000 live births with variation by country and region. Direct maternal morbidities were associated with each of these outcomes. Conclusions Our findings imply that health programmes in sub-Saharan Africa and South Asia must intensify their efforts to identify and treat maternal morbidities, which affected about one-third of all pregnancies and to prevent associated maternal and neonatal deaths and stillbirths. Trial registration The study is not a clinical trial., Author summary Why was this study done? Estimates of severe direct maternal morbidity are largely based on hospital-based studies with inconsistent definitions and varying selection criteria. Limited data are available from South Asia and sub-Saharan Africa, the 2 regions with the highest maternal and newborn morbidity and mortality, where a larger proportion of births occur at home. What did the researchers do and find? We collected data on maternal morbidities from a cohort of women in the community in multiple sites in sub-Saharan Africa and in South Asia. Out of a cohort of >114,000 women, we found that about 1 in 3 women suffer a maternal morbidity, which was notably higher than the previously reported data. We found that the prevalence of preeclampsia and eclampsia was about 1%, which was lower than previously reported. About 11% of women reported having prolonged or obstructed labour, which was somewhat higher than published estimates. The burden of pregnancy-related infection in postpartum period was higher in South Asia than in sub-Saharan Africa. This is the first study, to our knowledge, to describe the burden of antepartum haemorrhage and late antepartum infection and to clearly demonstrate the association of direct maternal morbidity with adverse pregnancy outcomes. What do these findings mean? Higher burden of direct maternal morbidity and its association with adverse outcomes highlights the need for improving health of women and mothers, including promotion of preconception health and nutrition, and high-quality antepartum, intrapartum and postpartum care.

Background Preterm birth-related complications are the leading cause of death in newborns and children under 5. Health outcomes of preterm newborns can be improved with appropriate use of antenatal corticosteroids (ACSs) to promote fetal lung maturity, tocolytics to delay birth, magnesium sulphate for fetal neuroprotection, and antibiotics for preterm prelabour rupture of membranes. However, there are wide disparities in the rate and consistency in the use of these interventions across settings, which may underlie the differential health outcomes among preterm newborns. We aimed to assess factors (barriers and facilitators) affecting the appropriate use of ACS, tocolytics, magnesium sulphate, and antibiotics to improve preterm birth management. Methods and findings We conducted a mixed-methods systematic review including primary qualitative, quantitative, and mixed-methods studies. We searched MEDLINE, EMBASE, CINAHL, Global Health, and grey literature from inception to 16 May 2022. Eligible studies explored perspectives of women, partners, or community members who experienced preterm birth or were at risk of preterm birth and/or received any of the 4 interventions, health workers providing maternity and newborn care, and other stakeholders involved in maternal care (e.g., facility managers, policymakers). We used an iterative narrative synthesis approach to analysis, assessed methodological limitations using the Mixed Methods Appraisal Tool, and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. Behaviour change models (Theoretical Domains Framework; Capability, Opportunity, and Motivation (COM-B)) were used to map barriers and facilitators affecting appropriate use of these interventions. We included 46 studies from 32 countries, describing factors affecting use of ACS (32/46 studies), tocolytics (13/46 studies), magnesium sulphate (9/46 studies), and antibiotics (5/46 studies). We identified a range of barriers influencing appropriate use of the 4 interventions globally, which include the following: inaccurate gestational age assessment, inconsistent guidelines, varied knowledge, perceived risks and benefits, perceived uncertainties and constraints in administration, confusion around prescribing and administering authority, and inadequate stock, human resources, and labour and newborn care. Women reported hesitancy in accepting interventions, as they typically learned about them during emergencies. Most included studies were from high-income countries (37/46 studies), which may affect the transferability of these findings to low- or middle-income settings. Conclusions In this study, we identified critical factors affecting implementation of 4 interventions to improve preterm birth management globally. Policymakers and implementers can consider these barriers and facilitators when formulating policies and planning implementation or scale-up of these interventions. Study findings can inform clinical preterm birth guidelines and implementation to ensure that barriers are addressed, and enablers are reinforced to ensure these interventions are widely available and appropriately used globally.

BACKGROUND "Kangaroo mother care," a type of newborn care involving skin-to-skin contact with the mother or other caregiver, reduces mortality in infants with low birth weight (

IntroductionGlobally, a substantial number of women experience abusive and disrespectful care from health providers during childbirth. As evidence mounts on the nature and frequency of disrespect and abuse (D&A), little is known about the consequences of a negative experience of care on health and well-being of women and newborns. This review summarises available evidence on the associations of D&A of mother and newborns during childbirth and the immediate postnatal period (understood as the first 24 hours from birth) with maternal and neonatal postnatal care (PNC) utilisation, newborn feeding practices, newborn weight gain and maternal mental health.MethodsWe conducted a systematic review of all published qualitative, quantitative and mixed-methods studies on D&A and its postnatal consequences across all countries. Pubmed, Embase, Web of Science, LILACS and Scopus were searched using predetermined search terms. Quantitative and qualitative data were analysed and presented separately. Thematic analysis was used to synthesise the qualitative evidence.ResultsA total of 4 quantitative, 1 mixed-methods and 16 qualitative studies were included. Quantitative studies suggested associations between several domains of D&A and use of PNC as well as maternal mental health. Different definitions of exposure meant formal meta-analysis was not possible. Three main themes emerged from the qualitative findings associated with PNC utilisation: (1) women’s direct experiences; (2) women’s expectations and (3) women’s agency.ConclusionThis review is the first to examine the postnatal effect of D&A of women and newborns during childbirth. We highlight gaps in research that could help improve health outcomes and protect women and newborns during childbirth. Understanding the health and access consequences of a negative birth experience can help progress the respectful care agenda.

IntroductionViolence against women (VAW) affects one in three women globally. In some countries, women are at much higher risk. We examined risk factors for VAW in countries with the highest 12-month prevalence estimates of intimate partner violence (IPV) to develop understanding of this increased risk.MethodsFor this systematic review, we searched PUBMED, CINAHL, PROQUEST (Middle East and North Africa; Latin America and Iberia; East and South Asia), Web of Science, EMBASE and PsycINFO (Ovid) for records published between 1 January 2000 and 1 January 2021 in English, French and Spanish. Included records used quantitative, qualitative, or mixed-methods, reported original data, had VAW as the main outcome, and focused on at least one of 23 countries in the highest quintile of prevalence figures for women’s self-reported experiences of physical and/or sexual violence in the past 12 months. We used critical interpretive synthesis to develop a conceptual model for associations between identified risk factors and VAW.ResultsOur search identified 12 044 records, of which 241 were included for analysis (2 80 360 women, 40 276 men, 274 key informants). Most studies were from Bangladesh (74), Uganda (72) and Tanzania (43). Several quantitative studies explored community-level/region-level socioeconomic status and education as risk factors, but associations with VAW were mixed. Although fewer in number and representing just one country, studies reported more consistent effects for community-level childhood exposure to violence and urban residence. Theoretical explanations for a country’s high prevalence point to the importance of exposure to other forms of violence (armed conflict, witnessing parental violence, child abuse) and patriarchal social norms.ConclusionAvailable evidence suggests that heightened prevalence of VAW is not attributable to a single risk factor. Multilayered and area-level risk analyses are needed to ensure funding is appropriately targeted for countries where VAW is most pervasive.PROSPERO registration numberThe review is registered with PROSPERO (CRD42020190147).

Background Violence against women and girls (VAWG) is a public health problem and one of the most prevalent human rights violations in the world. Recently practitioners and researchers have taken an interest in community participation as a strategy for preventing VAWG. Despite the recent enthusiasm however, there has been little articulation of how participation in VAWG prevention programmes mobilises communities to challenge social norms and prevent VAWG. Objectives In an attempt to help address this gap, this article seeks to answer two research questions: (1) How does participation theoretically mobilise communities to prevent VAWG, and (2) how do nominally participatory programmes make use of these theoretical concepts in their (explicit or implicit) theories of change? Methods To answer the first question, we draw on two well-recognised theories of participation and community mobilisation – Rifkin and Pridmore’s continuum of participation and Freire’s steps towards achieving critical consciousness – to clarify theoretical assumptions about how participation can mobilise community to reduce VAWG. To answer our second research question, we present the results from a review of primary prevention programmes that seek to reduce VAWG through community participation. Our analysis examines the explicit and implicit theories of change for these prevention programmes against the assumptions outlined from the theoretical literature. Results Our results help to better articulate realistic goals for community mobilisation and outline a theoretical basis for how participation as part of programming can effectively mobilise communities to reduce violence. Conclusion We argue that, in order to be both effective and sustainable, the role of external agents in introducing programmes needs to be secondary to the ownership and empowerment of communities in designing and delivering their own strategies for VAWG prevention.

Argentina passed a law for humanized birth in 2004 and another law against obstetric violence in 2009, both of which stipulate the rights of women to achieve respectful maternity care. Clinicians and women might still be unaware of these laws, however. In this article, we discuss the case of a fourth-year medical student who, while visiting Argentina from the United States for his obstetric rotation, witnesses an act of obstetric violence. We show that the student's situation can be understood as one of moral distress and argue that, in this specific instance, it would be appropriate for the student to intervene by providing supportive care to the patient. However, we suggest that medical schools have an obligation to better prepare students for rotations conducted abroad.

IntroductionThe COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers’ experiences and proposed mitigation strategies.MethodsUsing a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions.ResultsWe analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother–baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families’ fear of visiting hospitals (~73%).ConclusionNewborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better.

Background The feminisation of the global health workforce presents a unique challenge for human resource policy and health sector reform which requires an explicit gender focus. Relatively little is known about changes in the gender composition of the health workforce and its impact on drivers of global health workforce dynamics such as wage conditions. In this article, we use a gender analysis to explore if the feminisation of the global health workforce leads to a deterioration of wage conditions in health. Methods We performed an exploratory, time series analysis of gender disaggregated WageIndicator data. We explored global gender trends, wage gaps and wage conditions over time in selected health occupations. We analysed a sample of 25 countries over 9 years between 2006 and 2014, containing data from 970,894 individuals, with 79,633 participants working in health occupations (48,282 of which reported wage data). We reported by year, country income level and health occupation grouping. Results The health workforce is feminising, particularly in lower- and upper-middle-income countries. This was associated with a wage gap for women of 26 to 36% less than men, which increased over time. In lower- and upper-middle-income countries, an increasing proportion of women in the health workforce was associated with an increasing gender wage gap and decreasing wage conditions. The gender wage gap was pronounced in both clinical and allied health professions and over lower-middle-, upper-middle- and high-income countries, although the largest gender wage gaps were seen in allied healthcare occupations in lower-middle-income countries. Conclusion These results, if a true reflection of the global health workforce, have significant implications for health policy and planning and highlight tensions between current, purely economic, framing of health workforce dynamics and the need for more extensive gender analysis. They also highlight the value of a more nuanced approach to health workforce planning that is gender sensitive, specific to countries’ levels of development, and considers specific health occupations.