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Given the roll out of maternal antiretroviral therapy (ART) for prevention-of-perinatal-HIV-transmission, increasing numbers of children are perinatally HIV/antiretroviral exposed but uninfected (CAHEU). Some studies suggest CAHEU may be at increased risk for neurodevelopmental (ND) deficits. We aimed to assess ND performance among preschool CAHEU.This cross-sectional study assessed ND outcomes among 3-6-year-old CAHEU at entry into a multicountry cohort study.We used the Mullen Scales of Early Learning (MSEL) and Kaufman Assessment Battery for Children (KABC-II) to assess ND status among 3-6-year-old CAHEU at entry into the PROMISE Ongoing Treatment Evaluation (PROMOTE) study conducted in Uganda, Malawi, Zimbabwe and South Africa. Statistical analyses (Stata 16.1) was used to generate group means for ND composite scores and subscale scores, compared to standardized test score means. We used multivariable analysis to adjust for known developmental risk factors including maternal clinical/socioeconomic variables, child sex, growth-for-age measurements, and country.1647 children aged 3-6 years had baseline ND testing in PROMOTE; group-mean unadjusted Cognitive Composite scores on the MSEL were 85.8 (standard deviation [SD]: 18.2) and KABC-II were 79.5 (SD: 13.2). Composite score group-mean differences were noted by country, with South African and Zimbabwean children having higher scores. In KABC-II multivariable analyses, maternal age40 years, lower education, male sex, and stunting were associated with lower composite scores.Among a large cohort of 3-6 year old CAHEU from eastern/southern Africa, group-mean composite ND scores averaged within the low-normal range; with differences noted by country, maternal clinical and socioeconomic factors.

To estimate the prevalence of women who were admitted to health facilities with abortion-related complications who reported feeling anxious/stressed during their stay, and to identify sociodemographic, facility, and abortion-related characteristics associated with self-reported experience of anxiety/stress.We used data from four countries in Eastern and Southern Africa (Kenya, Malawi, Mozambique, and Uganda) collected from 2017-2018 as part of the World Health Organization (WHO) Multi-Country Survey on Abortion-related morbidity (MCS-A). Information was extracted from women's medical records and their participation in audio computer-assisted self-interviews (ACASI). Based on a question in the ACASI, "Did you encounter any anxiety or stress during your hospital stay?", the percentage of women who self-reported feeling anxious/stressed during their facility stay was calculated. Generalized estimating equations were used to identify the determinants of anxiety/stress following a hierarchical approach whereby potential determinants were grouped from most distal to most proximal and analyzed accordingly.There were 1254 women with abortion-related complications included in the analysis, of which 56.5% self-reported that they felt anxious/stressed during their facility stay. We found evidence that lower socioeconomic status, lower levels of education, no previous childbirth, no previous abortion, higher gestational age at abortion, and use of unsafe methods of abortion were independent determinants of self-reporting anxiety/stress.Action should be taken to reduce experience of anxiety/stress among women attending facilities for postabortion complications, including reducing the number of women experiencing abortion-related complications by improving access to safe abortion. This issue warrants further study using more comprehensive and validated tools to understand the levels and drivers of anxiety/stress self-reported by women attending facilities with abortion-related complications.

IntroductionDespite recommendation that all women receive an ultrasound in pregnancy prior to 24 weeks', this remains unavailable to many women in low-income countries where trained practitioners are scarce. Although many programmes have demonstrated efficacy, few have achieved longterm sustainability, with a lack of information about how best to implement such programmes. This mixed-methods study aimed to evaluate the implementation of a novel education package to teach ultrasound-naive midwives in Malawi basic obstetric ultrasound, assessing its impact in the context of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.MethodsThe study ran across six sites in Malawi between October 2020 and June 2021, encompassing three phases; pre-implementation, implementation and post-implementation. Twenty nine midwives underwent a bespoke education package with matched pre and post course surveys assessed their knowledge, attitudes and confidence and “hands on” assessments evaluating practical skills. Training evaluation forms and in-depth interviews explored their satisfaction with the package, with repeat assessment and remote image review evaluating maintenance of skills.Results28/29 midwives completed the training, with significant increases in knowledge, confidence and practical skills. Adherence to the education package varied, however many changes to the proposed methodology were adaptive and appeared to facilitate the efficacy of the programme. Unfortunately, despite reporting approval regarding the training itself, satisfaction regarding supervision and follow up was mixed, reflecting the difficulties encountered with providing ongoing in-person and remote support.ConclusionThis programme was successful in improving trainees' knowledge, confidence and skill in performing basic obstetric ultrasound, largely on account of an adaptive approach to implementation. The maintenance of ongoing support was challenging, reflected by trainee dissatisfaction. By evaluating the success of this education package based on its implementation and not just its efficacy, we have generated new insights into the barriers to sustainable upscale, specifically those surrounding maintenance.

OBJECTIVES: To determine if double-dose levonorgestrel emergency contraception (EC) in combination with efavirenz or rifampicin, two drugs known to decrease levonorgestrel exposure, resulted in similar pharmacokinetics compared to standard-dose levonorgestrel EC without drug-drug interactions. STUDY DESIGN: We conducted a phase 2, open-label, multicenter, partially randomized, four parallel group trial in pre-menopausal females ≥16 years old without an indication for EC and not on hormonal contraception. Participants on dolutegravir-based antiretroviral therapy (ART) received levonorgestrel 1.5mg (control group); those on rifampicin-containing tuberculosis therapy received levonorgestrel 3mg; those on efavirenz-based ART were randomized 1:2 to levonorgestrel 1.5mg or 3mg. Plasma was collected through 48h post-dose to assess levonorgestrel pharmacokinetics. Area under the concentration-time curve (AUC) over 8 hours was the primary outcome. Levonorgestrel pharmacokinetic parameters were compared between groups using geometric mean ratios (GMR) with 90% confidence intervals. RESULTS: The median (Q1, Q3) age for all participants (n=118) was 34 (27, 41) years and BMI was 23.2 (20, 26.3) kg/m(2). Participants receiving levonorgestrel 1.5mg plus efavirenz (n=17) had 50% lower AUC(0–8h) compared to the control group (n=32) [0.50 (0.40, 0.62)]. Participants receiving levonorgestrel 3mg had a similar AUC(0–8h) when receiving either efavirenz (n=35) [0.99 (0.81, 1.20)] or rifampicin (n=34) [1.16 (0.99, 1.36)] compared to control. Levonorgestrel 3mg resulted in similar or higher maximum concentration with either efavirenz [1.17 (0.96, 1.41)] or rifampicin [1.27 (1.09, 1.49)] compared to the control group. CONCLUSIONS: Doubling the dose of levonorgestrel EC successfully increased levonorgestrel exposure over the first 8 hours in participants receiving either efavirenz-based ART or rifampicin-containing tuberculosis therapy.

Objective To assess satisfaction with care for abortion-related complications experienced among adolescents compared to older women. Methods A secondary analysis of the WHO Multi-Country Survey on Abortion-related Morbidity and Mortality-a cross-sectional study conducted in health facilities in 11 Sub-Saharan African countries. Women with abortion-related complications who participated in an audio computer-assisted self-interview were included. Two composite measures of overall satisfaction were created based on five questions: (1) study participants who were either satisfied or very satisfied across all five questions; and (2) study participants who reported being very satisfied only across all five questions. Multivariable general estimating equation analyses were conducted to assess whether there was any evidence that age (adolescents 12-19 years and older women 20+) was associated with each composite measure of satisfaction, controlling for key confounders. Results The study sample consisted of 2817 women (15% adolescents). Over 75% of participants reported being satisfied or very satisfied for four out of five questions. Overall, 52.9% of study participants reported being satisfied/very satisfied across all five questions and 22.4% reported being consistently very satisfied. Multivariable analyses showed no evidence of an association between age group and being either satisfied or very satisfied (OR 1.07; 95% CI, 0.82-1.41, P = 0.60), but showed strong evidence that adolescents were 50% more likely to be consistently very satisfied with their overall care than older women (OR 1.49; 95% CI, 1.13-1.96, P = 0.005). Conclusion Both adolescents and older women reported high levels of satisfaction with care when looking at different components of care individually, but the results of the composite measure for satisfaction showed that many study participants reported being less than satisfied with at least one element of their care. Further studies to explore the expectations, needs, and values of women's satisfaction with care for abortion-related complications are needed.

OBJECTIVE: To investigate the level and determinants of nonreceipt of contraception among women admitted to facilities with abortion-related complications in East and Southern Africa. METHODS: Cross-sectional data from Kenya, Malawi, Mozambique, and Uganda collected as part of the World Health Organization (WHO) Multi-Country Survey on Abortion-related morbidity. Medical record review and the audio computer-assisted self-interviewing system were used to collect information on women's demographic and clinical characteristics and their experience of care. The percentage of women who did not receive a contraceptive was estimated and the methods of choice for different types of contraceptives were identified. Potential determinants of nonreceipt of contraception were grouped into three categories: sociodemographic, clinical, and service-related characteristics. Generalized estimating equations were used to identify the determinants of nonreceipt of a contraceptive following a hierarchical approach. RESULTS: A total of 1190 women with abortion-related complications were included in the analysis, of which 33.9% (n = 403) did not receive a contraceptive. We found evidence that urban location of facility, no previous pregnancy, and not receiving contraceptive counselling were risk factors for nonreceipt of a contraceptive. Women from nonurban areas were less likely not to receive a contraceptive than those in urban areas (AOR 0.52; 95% CI, 0.30-0.91). Compared with women who had a previous pregnancy, women who had no previous pregnancy were 60% more likely to not receive a contraceptive (95% CI, 1.14-2.24). Women who did not receive contraceptive counselling were over four times more likely to not receive a contraceptive (AOR 4.01; 95% CI, 2.88-5.59). CONCLUSION: Many women leave postabortion care having not received contraceptive counselling and without a contraceptive method. There is a clear need to ensure all women receive high-quality contraceptive information and counselling at the facility to increase contraceptive acceptance and informed decision-making.

The use of ultrasound to determine gestational age is fundamental to the optimum management of pregnancy and is recommended for all women by the World Health Organization. However, this modality remains unavailable to many women in low-income countries where trained practitioners are scarce. Although previous initiatives have demonstrated efficacy in training midwives and technicians to perform antenatal ultrasound, these programs have often been too long and too complex to be realistic within the specific constraints of this context, highlighting the need for a novel and pragmatic approach. We describe the development and piloting of a bespoke course to teach midwives 3 fundamental components of early antenatal ultrasound scanning: (1) to identify the number of fetuses, (2) to confirm fetal viability, and (3) to determine gestational age. Having established that 5 days is insufficient, we propose that the minimum duration required to train ultrasound-naive midwives to competency is 10 days. Our completed program therefore consists of one and one-half days of didactic teaching, followed by 8 and one-half days of supervised hands-on practical training in which trainees are assessed on their skills. This package has subsequently been successfully implemented across 6 sites in Malawi, where 28 midwives have achieved competency. By describing the processes involved in our cross-continental collaboration, we explain how unexpected challenges helped shape and improve our program, demonstrating the value of preimplementation piloting and a pragmatic and adaptive approach.

We conducted a cluster randomized trial of two models for integrating HPV self-collection into family-planning (FP) services at 16 health facilities in Malawi between March 2020–December 2021. Model 1 involved providing only clinic-based HPV self-collection, whereas Model 2 included both clinic-based and community-based HPV self-collection. An endline household survey was performed in sampled villages and households between October-December 2021 in the catchment areas of the health facilities. We analyzed 7664 surveys from 400 villages. Participants from Model 2 areas were more likely to have ever undergone cervical cancer screening (CCS) than participants from Model 1 areas, after adjusting for district, facility location (urban versus rural), and facility size (hospital versus health center) (adjusted odds ratio = 1.73; 95% CI: 1.29, 2.33). Among participants who had ever undergone CCS, participants from Model 2 were more likely to report having undergone HPV self-collection than participants from Model 1 (50.5% versus 22.8%, p = 0.023). Participants from Model 2 were more likely to be using modern FP (adjusted odds ratio = 1.01; 95% CI: 1.41, 1.98) than Model 1 participants. The integration of FP and HPV self-collection in both the clinic and community increases CCS and modern FP uptake more than integration at the clinic-level alone.

Outcomes of omicron-associated COVID-19 in pregnancy have not been reported from low-resource settings, and data from sub-Saharan Africa before the emergence of omicron are scarce. Using a national maternal surveillance platform (MATSurvey), we aimed to compare maternal and neonatal outcomes of COVID-19 in Malawi during the omicron wave to the preceding waves of beta and delta.All pregnant and recently pregnant patients, up to 42 days following delivery, admitted to 33 health-care facilities throughout Malawi with symptomatic, test-proven COVID-19 during the second (beta [B.1.351]: January to April, 2021), third (delta [B.1.617.2]: June to October, 2021), and fourth (omicron [B.1.1.529]: December 2021 to March, 2022) waves were included, with no age restrictions. Demographic and clinical features, maternal outcomes of interest (severe maternal outcome [a composite of maternal near-miss events and maternal deaths] and maternal death), and neonatal outcomes of interest (stillbirth and death during maternal stay in the health-care facility of enrolment) were compared between the fourth wave and the second and third waves using Fisher's exact test. Adjusted odds ratios (ORs) for maternal outcomes were estimated using mixed-effects logistic regression.Between Jan 1, 2021, and March 31, 2022, 437 patients admitted to 28 health-care facilities conducting MATSurvey had symptoms of COVID-19. SARS-CoV-2 infection was confirmed in 261 patients; of whom 76 (29%) had a severe maternal outcome and 45 (17%) died. These two outcomes were less common during the fourth wave (omicron dominance) than the second wave (adjusted OR of severe maternal outcome: 3·96 [95% CI 1·22-12·83], p=0·022; adjusted OR of maternal death: 5·65 [1·54-20·69], p=0·0090) and the third wave (adjusted OR: 3·18 [1·03-9·80], p=0·044; adjusted OR: 3·52 [0·98-12·60], p=0·053). Shortness of breath was the only symptom associated with poor maternal outcomes of interest (p0·0001), and was less frequently reported in the fourth wave (23%) than in the second wave (51%; p=0·0007) or third wave (50%; p=0·0004). The demographic characteristics and medical histories of patients were similar across the three waves. During the second and third waves, 12 (13%) of 92 singleton neonates were stillborn or died during maternal stay in the health-care facility of enrolment, compared with 0 of the 25 born in the fourth wave (p=0·067 vs preceding waves combined).Maternal and neonatal outcomes from COVID-19 were less severe during the fourth wave of the SARS-CoV-2 pandemic in Malawi, during omicron dominance, than during the preceding beta and delta waves.BillMelinda Gates Foundation, Wellcome Trust, and the National Institute for Health and Care Research.For the Chichewa translation of the abstract see Supplementary Materials section.

BackgroundThis paper reports on part of a larger study, the aim of which was to develop an intervention to collaboratively develop innovative strategies to promote effective collaborative practices among midwives and medical professionals working in intrapartum care unit. Collaborative practice is a critical marker for success in improving quality of maternity care. To date, there has been limited exploration of collaborative practices between midwives and medical professionals working in intrapartum care from the African perspective. Aim This paper reports findings of the discovery phase of appreciative inquiry (AI) set out tounderstand the perspectives of midwives and medical professionals on collaborative practices at Queen Elizabeth Central Hospital labour and delivery ward in Malawi. MethodsThe study used an exploratory qualitative approach framed in an Appreciative Inquiry theoretical perspective. Appreciative Inquiry consists of four phases :(discovery, dream, design and destiny).The discovery phase consisted of 16 in-depth interviews and 2 focus group discussions among purposively selected midwives (4 nurse midwives, 2 midwifery unit matrons) and medical professionals (2 obstetricians, 4 registrars, 2 intern doctors, 2 clinical officers) working in the labour ward. All interviews and discussions were audiotaped and transcribed verbatim. Data were analysed using thematic analysis. ResultsFive dominant themes emerged: collaborative breakdown, benefits of collaboration, the importance of positive and respectful attitude, barriers to effective collaborative practices and strategies to improve collaborative practice. Conclusion/RecommendationsAligning the perspectives of the members of the two disciplines is significant to effective implementation of collaborative intrapartum care. Participants demonstrated that there is increased parallel working of midwives and doctors at QECH. This is not professionally healthy. Therefore, putting together the viewpoints of the professions to create a mutually agreeable professional framework of collaborative intrapartum practice is significant. Additionally, there is an obvious need to address the professional concerns of both disciplines.

OBJECTIVE: To determine time from delivery to resumption of sexual activity and menses among HIV-infected women on antiretroviral treatment (ART) and HIV-uninfected women. METHODS: HIV-infected women on ART and HIV-uninfected women were recruited from five health facilities at delivery and followed prospectively for a maximum of 1 year in Blantyre, Malawi from January 2016 to September 2017. Sociodemographic, clinical, and laboratory data were collected at delivery and 1.5, 3, 6, 9, and 12 months. Descriptive, time to event Kaplan–Meier, and multivariable Cox proportional hazards analyses were conducted. RESULTS: Data on 878 women (460 [52.4%] HIV-uninfected and 418 [47.6%] HIV-infected, P=0.156) who attended at least one follow-up visit were analyzed. Among HIV-uninfected compared to HIV-infected women, respectively, the median number of days to resumption of sexual activity was 180 vs 181; to irregular menses was 82 vs 71; and to regular menses was 245 vs 366. In multivariable models, being married was associated with early resumption of sexual activity (hazard ratio [HR] 1.91, P

ObjectiveTo describe the demographic characteristics, clinical manifestations, and clinical outcomes of hospitalised pregnant and recently pregnant women with COVID-19 in Malawi, a low-income country in Sub-Saharan Africa. This study responds to a critical gap in the global COVID-19 data.MethodsA national surveillance platform was established in Malawi by the Ministry of Health to record the impact of COVID-19 on pregnant and recently pregnant women and provide real-time data for decision making. We report this facility-based cohort that includes all pregnant and recently pregnant hospitalised women in Malawi suspected of having COVID-19 between 2nd June 2020 and 1st December 2021.Results398 women were admitted to hospital with suspected COVID-19 based on presenting symptoms and were tested; 246 (62%) were confirmed to have COVID-19. In women with COVID-19, the mean age was 27 ± 7 years.The most common presenting symptoms were cough (74%), breathlessness (45%), Fever (42%), headache (17%), and joint pain (10%). 53% of the women had COVID-19 symptoms severe enough to warrant admission.31% (76/246) of women admitted with COVID-19 suffered a severe maternal outcome, 47/246 (19%) died, and 29/246 (12%) had a near-miss event. 9/111 (8%) of recorded births were stillbirths, and 12/101 (12%) of the live births resulted in early neonatal death.ConclusionA national electronic platform providing real-time information on the characteristics and outcomes of pregnant and recently pregnant women with COVID-19 admitted to Malawian government hospitals. These women had much higher rates of adverse outcomes than those suggested in the current global data. These findings may reflect the differences in the severity of disease required for women to present and be admitted to Malawian hospitals, limited access to intensive care and the pandemic’s disruption to the health system.SUMMARY BOXWhat is already known?In pregnant and recently pregnant women, COVID-19 is associated with increased complications such as admission to an intensive care unit, invasive ventilation, and maternal death.In pregnant women with confirmed COVID-19, the current global estimate of all-cause mortality is 0.02%.Most countries in Africa rely on paper-based systems to collect key maternal health indicators such as maternal deaths and severe morbidity, which does not enable timely actions.What are the new findings?Maternal mortality and adverse perinatal outcomes are alarmingly high in a cohort of pregnant and recently pregnant women admitted to Malawian healthcare facilities located in a low-income country in Africa.A national facility-based maternal surveillance platform can be implemented during a pandemic and provide real-time data to aid policymakers in understanding its impacts on this key population.What do the new findings imply?In low-income countries in Sub-Saharan Africa, pregnant and recently pregnant women with COVID-19 admitted to hospital require enhanced care and a renewed focus on their needs to avert these adverse health outcomes.Global and national surveillance systems must specifically record outcomes for pregnant, recently pregnant women and their infants to understand the impact of public health emergencies on these groups, as they may be disproportionately affected and may require special considerations.

The SARS-CoV-2 pandemic has challenged health systems and healthcare workers worldwide. Access to personal protective equipment (PPE) is essential to mitigate the risk of excess mortality in healthcare providers. In Malawi, the cost of PPE represents an additional drain on available resources. In the event of repeated waves of disease over several years, the development of sustainable systems of PPE is essential. We describe the development, early implementation and rapid scale up of a reusable gown service at a tertiary-level hospital in Blantyre, Malawi. Challenges included healthcare worker perceptions around the potential of reduced efficacy of cotton gowns, the need to plan for surge capacity and the need for ongoing training of laundry staff in safety and hygiene procedures. Benefits of the system included increased coverage, decreased cost and reduced waste disposal. The implementation of a reusable cotton gown service is feasible, acceptable and cost-effective in tertiary centres providing specialist COVID-19 care at the height of the pandemic. This innovation could be expanded beyond low-income settings.

BACKGROUND. Adverse pregnancy outcomes such as preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA) remain major global problems. We compared pregnancy outcomes among HIV-infected women receiving antiretroviral treatment (ART) and with CD4 ≥350 cells, and HIV-uninfected women to assess if disparities associated with HIV infection have been eliminated through use of ART. SETTING: Observational study conducted at five health facilities in Blantyre, Malawi during 2016–2017. METHODS. HIV-infected women receiving the national ART regimen (efavirenz+lamuvidine+tenfovir) and HIV-uninfected women were consented and enrolled at delivery. Data collected included sociodemographic and clinical; gestational age (GA); birth weight (BW); infant/maternal anthropometry; and laboratory results. We defined PTB as GA0·05). Of 231 SGA infants, 78·8% were proportionate and 21% were disproportionate. Of the 614 HIV-infected women on ART, 75% had undetectable virus at delivery. CONCLUSION. ART use has reduced the high rates of adverse pregnancy outcomes among HIV-infected women. However, the rates remain high irrespective of HIV infection and require appropriate interventions.

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 (

Background: Recent studies show that ART is associated with an adverse birth outcome in HIV-infected women.Aim: To compare rates of low birthweight (LBW) and preterm birth (PTB) between HIV-infecte...

Background Cervical cancer is the leading cause of cancer incidence and mortality among Malawian women, despite being a largely preventable disease. Implementing a cervical cancer screening and preventive treatment (CCSPT) program that utilizes rapid human papillomavirus (HPV) testing on self-collected cervicovaginal samples for screening and thermal ablation for treatment may achieve greater coverage than current programs that use visual inspection with acetic acid (VIA) for screening and cryotherapy for treatment. Furthermore, self-sampling creates the opportunity for community-based screening to increase uptake in populations with low screening rates. Malawi’s public health system utilizes regularly scheduled outreach and village-based clinics to provide routine health services like family planning. Cancer screening is not yet included in these community services. Incorporating self-sampled HPV testing into national policy could address cervical cancer screening barriers in Malawi, though at present the effectiveness, acceptability, appropriateness, feasibility, and cost-effectiveness still need to be demonstrated. Methods We designed a cluster randomized feasibility trial to determine the effectiveness, acceptability, appropriateness, feasibility, and budget impact of two models for integrating a HPV-based CCSPT program into family planning (FP) services in Malawi: model 1 involves only clinic-based self-sampled HPV testing, whereas model 2 includes both clinic-based and community-based self-sampled HPV testing. Our algorithm involves self-collection of samples for HPV GeneXpert® testing, visual inspection with acetic acid for HPV-positive women to determine ablative treatment eligibility, and same-day thermal ablation for treatment-eligible women. Interventions will be implemented at 14 selected facilities. Our primary outcome will be the uptake of cervical cancer screening and family planning services during the 18 months of implementation, which will be measured through an Endline Household Survey. We will also conduct mixed methods assessments to understand the acceptability, appropriateness, and feasibility of the interventions, and a cost analysis to assess budget impact. Discussion Our trial will provide in-depth information on the implementation of clinic-only and clinic-and-community models for integrating self-sampled HPV testing CCSPT with FP services in Malawi. Findings will provide valuable insight for policymakers and implementers in Malawi and other resource-limited settings with high cervical cancer burden. Trial registration ClinicalTrials.gov identifier: NCT04286243. Registered on February 26, 2020.

Background Infections are among the leading causes of maternal mortality and morbidity. The Global Maternal Sepsis and Neonatal Initiative, launched in 2016 by WHO and partners, sought to reduce the burden of maternal infections and sepsis and was the basis upon which the Global Maternal Sepsis Study (GLOSS) was implemented in 2017. In this Article, we aimed to describe the availability of facility resources and services and to analyse their association with maternal outcomes. Methods GLOSS was a facility-based, prospective, 1-week inception cohort study implemented in 713 health-care facilities in 52 countries and included 2850 hospitalised pregnant or recently pregnant women with suspected or confirmed infections. All women admitted for or in hospital with suspected or confirmed infections during pregnancy, childbirth, post partum, or post abortion at any of the participating facilities between Nov 28 and Dec 4 were eligible for inclusion. In this study, we included all GLOSS participating facilities that collected facility-level data (446 of 713 facilities). We used data obtained from individual forms completed for each enrolled woman and their newborn babies by trained researchers who checked the medical records and from facility forms completed by hospital administrators for each participating facility. We described facilities according to country income level, compliance with providing core clinical interventions and services according to women's needs and reported availability, and severity of infection-related maternal outcomes. We used a logistic multilevel mixed model for assessing the association between facility characteristics and infection-related maternal outcomes. Findings We included 446 facilities from 46 countries that enrolled 2560 women. We found a high availability of most services and resources needed for obstetric care and infection prevention. We found increased odds for severe maternal outcomes among women enrolled during the post-partum or post-abortion period from facilities located in low-income countries (adjusted odds ratio 1middot84 [95% CI 1middot05-3middot22]) and among women enrolled during pregnancy or childbirth from non-urban facilities (adjusted odds ratio 2middot44 [1middot02-5middot85]). Despite compliance being high overall, it was low with regards to measuring respiratory rate (85 [24%] of 355 facilities) and measuring pulse oximetry (184 [57%] of 325 facilities). Interpretation While health-care facilities caring for pregnant and recently pregnant women with suspected or confirmed infections have access to a wide range of resources and interventions, worse maternal outcomes are seen among recently pregnant women located in low-income countries than among those in higher-income countries; this trend is similar for pregnant women. Compliance with cost-effective clinical practices and timely care of women with particular individual characteristics can potentially improve infection-related maternal outcomes. Funding UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Merck for Mothers, and US Agency for International Development. Copyright (c) 2021 World Health Organization; licensee Elsevier. This is an Open Access article under the CC BY 3.0 IGO license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products, or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

IntroductionComplications due to unsafe abortions are an important cause of morbidity and mortality in many sub-Saharan African countries. We aimed to characterise abortion-related complication severity, describe their management, and to report women’s experience of abortion care in Africa.MethodsA cross-sectional study was implemented in 210 health facilities across 11 sub-Saharan African countries. Data were collected on women’s characteristics, clinical information and women’s experience of abortion care (using the audio computer-assisted self-interviewing (ACASI) system). Severity of abortion complications were organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Descriptive bivariate analysis was performed for women’s characteristics, management of complications and reported experiences of abortion care by severity. Generalised linear estimation models were used to assess the association between women’s characteristics and severity of complications.ResultsThere were 13 657 women who had an abortion-related complication: 323 (2.4%) women were classified with severe maternal outcomes, 957 (7.0%) had potentially life-threatening complications, 7953 (58.2%) had moderate complications and 4424 (32.4%) women had mild complications. Women who were single, multiparous, presenting ≥13 weeks of gestational age and where expulsion of products of conception occurred prior to arrival to facility were more likely to experience severe complications. For management, the commonly used mechanical methods of uterine evacuation were manual vacuum aspiration (76.9%), followed by dilation and curettage (D&C) (20.1%). Most frequently used uterotonics were oxytocin (50∙9%) and misoprostol (22.7%). Via ACASI, 602 (19.5%) women reported having an induced abortion. Of those, misoprostol was the most commonly reported method (54.3%).ConclusionThere is a critical need to increase access to and quality of evidence-based safe abortion, postabortion care and to improve understanding around women’s experiences of abortion care.

Introduction The World Health Organization’s (WHO) Labour Care Guide (LCG) is a “next‐generation” partograph based on WHO’s latest intrapartum care recommendations. It aims to optimize clinical care provided to women and their experience of care. We evaluated the LCG’s usability, feasibility, and acceptability among maternity care practitioners in clinical settings. Methods Mixed‐methods evaluation with doctors, midwives, and nurses in 12 health facilities across Argentina, India, Kenya, Malawi, Nigeria, and Tanzania. Purposively sampled and trained practitioners applied the LCG in low‐risk women during labor and rated experiences, satisfaction, and usability. Practitioners were invited to focus group discussions (FGDs) to share experiences and perceptions of the LCG, which were subjected to framework analysis. Results One hundred and thirty‐six practitioners applied the LCG in managing labor and birth of 1,226 low‐risk women. The majority of women had a spontaneous vaginal birth (91.6%); two cases of intrapartum stillbirths (1.63 per 1000 births) occurred. Practitioner satisfaction with the LCG was high, and median usability score was 67.5%. Practitioners described the LCG as supporting precise and meticulous monitoring during labor, encouraging critical thinking in labor management, and improving the provision of woman‐centered care. Conclusions The LCG is feasible and acceptable to use across different clinical settings and can promote woman‐centered care, though some design improvements would benefit usability. Implementing the LCG needs to be accompanied by training and supportive supervision, and strategies to promote an enabling environment (including updated policies on supportive care interventions, and ensuring essential equipment is available).

Background Globally, about 15% of newborns are born with a low birth weight (LBW) as a result of preterm birth or intrauterine growth restriction or both. Up to 70% of neonatal deaths occur in this group within the first 3 days after birth. Kangaroo Mother Care (KMC) applied after stabilization of the infant has been shown to reduce mortality by 40% among hospitalized infants with a birth weight of less than 2.0 kg. In these studies, infants were randomly assigned and KMC was initiated after about 3 days of age, when the majority of neonatal deaths would have already occurred. The aim of this trial is to evaluate the safety and efficacy of continuous KMC initiated as soon as possible after birth compared with the current recommendation of initiating continuous KMC after stabilization in neonates with a birth weight between 1.0 and less than 1.8 kg. Methods This randomized controlled trial is being conducted in tertiary-care hospitals in five low- to middle-income countries (LMICs) in South Asia and sub-Saharan Africa. All pregnant women admitted to these hospitals for childbirth are pre-screened. After delivery, all neonates with a birth weight between 1.0 and less than 1.8 kg are screened for enrollment. Eligible infants are randomly assigned to intervention and control groups. The intervention consists of continuous skin-to-skin contact initiated as soon as possible after birth, promotion and support for early exclusive breastfeeding, and provision of health care for mother and baby with as little separation as possible. This efficacy trial will primarily evaluate the impact of KMC started immediately after birth on neonatal death (between enrollment and 72 h of age and deaths between enrollment and 28 days of age) and other key outcomes. Discussion This is the first large multi-country trial studying immediate KMC in LMICs. Implementation of this intervention has already resulted in an important enhancement of the paradigm shift in LMIC settings in which mothers are not separated from their baby in neonatal intensive care units (NICUs). The findings of this trial will have future global implications not only on how the LBW newborns are cared for immediately after birth but also for the dissemination of designing NICUs in accordance with the mother-neonatal intensive care unit (M-NICU) model. Trial registration Clinical Trials Registry - India (CTRI): CTRI/2018/08/01536 (retrospectively registered); Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618001880235 (retrospectively registered).

Wilms’ tumour is the most common renal neoplasm in children with an incidence of 10 cases per 1 million children and a median age at diagnosis of 3.5 years. In Western countries its occurrence in adults is 0.2 cases per million people in western countries and carries a poorer prognosis. The co-existence of Adult Wilms’ tumour and pregnancy is extremely rare with less than 20 cases published in the English literature. We present a case of a Malawian woman who had progressive high-risk metastatic Adult Wilms’ tumour in pregnancy after nephrectomy, radiotherapy and two lines of chemotherapy.

To field test a standardized instrument to measure nonsevere morbidity among antenatal and postpartum women.A cross-sectional study was conducted in Jamaica, Kenya, and Malawi (2015-2016). Women presenting for antenatal care (ANC) or postpartum care (PPC) were recruited if they were at least 28 weeks into pregnancy or 6 weeks after delivery. They were interviewed and examined by a doctor, midwife, or nurse. Data were collected and securely stored electronically on a WHO server. Diagnosed conditions were coded and summarized using ICD-MM.A total of 1490 women (750 ANC; 740 PPC) averaging 26 years of age participated. Most women (61.6% ANC, 79.1% PPC) were healthy (no diagnosed medical or obstetric conditions). Among ANC women with clinical diagnoses, 18.3% had direct (obstetric) conditions and 18.0% indirect (medical) problems. Prevalences among PPC women were lower (12.7% and 8.6%, respectively). When screening for factors in the expanded morbidity definition, 12.8% (ANC) and 11.0% (PPC) self-reported exposure to violence.Nonsevere conditions are distinct from the leading causes of maternal death and may vary across pregnancy and the puerperium. This effort to identify and measure nonsevere morbidity promotes a comprehensive understanding of morbidity, incorporating maternal self-reporting of exposure to violence, and mental health. Further validation is needed.

Purpose Sub-Saharan African prisons have seen a substantial increase in women prisoners, including those incarcerated with children. There is very little strategic literature available on the health situation and needs of women prisoners and their circumstantial children in Malawi. The study aims to explore this issue. Design/methodology/approach A qualitative exploratory study using in-depth key informant interviews with senior correctional stakeholders (commissioner of prison farms, senior correctional management staff, senior health officials and senior officers in charge) (n = 5) and focus group discussions (FGD) with women in prison of age between 18 and 45 years (n = 23) and two FGD with correctional staff (n = 21) was conducted in two prisons in Malawi, Chichiri and Zomba. Narratives were transcribed and analysed using thematic analysis. Findings Three key themes emerged and are as follows: “hygiene and sanitary situation across multiple prison levels and subsequent health implications for women”; “nutritional provision and diets of women and children in prison”; and “women’s access to prison-based and external health services”. Divergence or agreement across perspectives around sanitation and disease prevention, adequacy of nutrition for pregnant or breast-feeding women, health status and access to prison-based health care are presented. Practical implications Garnering a contemporary understanding of women’s situation and their health-care needs in Malawian prisons can inform policy and correctional health practice change, the adaptation of technical guidance and improve standards for women and their children incarcerated in Malawi. Originality/value There is a strong need for continued research to garner insight into the experiences of women prisoners and their children, with a particular emphasis on health situation.