We need your care!

High rates of avoidable maternal and newborn mortality and morbidity in low-income and middle-income countries could be mitigated by improving quality of care. A Lancet Global Health Commission highlighted the need for high-quality health systems that improve health, and are valued, trusted, and responsive to dynamic population needs. Kruk and colleagues have called for health systems to “measure and report what matters most to people”, including user experiences, health outcomes, competent care, and confidence in the system. Maternal health indicators have historically focused on process and coverage outcomes related to life-saving interventions (eg, proportion of births with skilled attendance) and health outcomes (eg, maternal mortality).

These indicators do not fully reflect or correlate well with quality, nor account for women’s perceptions or experiences of care, particularly respect, communication, and emotional support. Poor experiences of maternity care can negatively affect both the woman herself and future health seeking behaviors but are typically not routinely assessed. For example, in a Cochrane review of continuous support for women during childbirth, only 11 (41%) of 27 trials reported women’s experiences, a primary review outcome.

Evidence suggests that women across the world experience mistreatment during childbirth, including physical abuse, verbal abuse, discrimination, non-consented procedures, and non-supportive care. Bowser and Hill’s landscape analysis brought this issue to global attention and our mixed-methods systematic review developed a typology of what constitutes mistreatment. The WHO intrapartum care guideline recommends respectful maternity care for all women, which is care that maintains “dignity, privacy, and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth.”

Manifestations and structural drivers of mistreatment are now well documented, but debate remains about measurement approaches, including the type (observation, woman-reported) and timing (exit interviews, community-based interviews) of measurement. For example, across 15 studies in seven low income and middle-income countries,18–32 location, timing, and populations varied substantially: facility-based exit interviews, facility-based interviews during postnatal immunization, and community-based interviews  with women from 3 to 5 years post partum. The use of different populations, sampling, tools, and data collection methods might influence the risk of bias (selection, social desirability, information, recall) and render cross-study and cross-context comparisons challenging. Accurate measurement is essential to improve accountability, design interventions, and measure impact over time.

In 2013, a technical consultation recommended that WHO initiate research to develop and validate tools to measure the mistreatment of women during childbirth. The aim of the present study was to use a systematic, evidence-informed approach to develop tools to provide comparable data on the burden of mistreatment across contexts. The formative phase consisted of systematic reviews and primary qualitative research in Nigeria, Ghana, Guinea, and Myanmar. Formative research and a review of existing tools informed the measurement phase, which used continuous observations of women during labour and childbirth, and community-based surveys with post-partum women to measure the prevalence of mistreatment in Nigeria, Ghana, Guinea, and Myanmar. We report the prevalence of mistreatment during childbirth based on continuous labour observations and a community-based survey with women.

Access the article below.


Breast is always best!


In 2011, South Africa committed to promoting exclusive breastfeeding (EBF) for six months for all mothers, regardless of HIV status, in line with World Health Organization recommendations. This was a marked shift from earlier policies, and with it, average EBF rates increased from less than 10% in 2011 to 32% by 2016.


The aim of this mixed-methods systematic review was to describe EBF practices in South Africa and their multi-level influences over four policy periods.


We applied PRISMA guidelines according to a published protocol (Prospero: CRD42014010512). We searched seven databases [Africa-Wide, PubMed, Popline, PsychINFO, CINAHL, Global Health, and The Cochrane Library] and conducted hand searches for eligible articles (all study designs, conducted in South Africa and published between 1980–2018). The quality of articles was assessed using published tools, as appropriate. Separate policy analysis was conducted to delineate four distinct policy periods. We compared EBF rates by these periods. Then, applying a three-level ecological framework, we analyzed EBF influences concurrently by method. Finally, the findings were synthesized to compare breastfeeding influences by policy period, maintaining an ecological framework.


From an initial sample of 20,226 articles, 72 unique articles were reviewed, three of which contributed to both quantitative and qualitative analysis. Despite the large sample, several provinces were poorly represented (if at all) and many studies were assessed as low to moderate quality. Despite these limitations, our historical lens enabled us to explore why South African progress on increasing EBF practices has been slow. The review reflects a context that increasingly supports EBF, but falls short in accounting for family, community, and workplace influences. The findings also highlight the unintended damage caused by rapidly adopting and introducing global guidelines to an unsupported health workforce.


From a South African perspective, we identified geographic and methodological biases, as well as gaps in our understanding and potential explanations of inequities in EBF. Our recommendations relate to policy, programming, and research to inform changes that would be required to further improve EBF practice rates in South Africa. While our review is South Africa-specific, our findings have broader implications for investing in multi-level interventions and limiting how often infant feeding guidelines are changed.

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Zir Chinar Kham, Afghanistan—In Ghutai’s third home delivery, her newborn struggled to breathe and died before help could be found. When the Afghan mother of two went into labor with her next child, she was determined that the outcome would be different. With the help of a neighbor, she made it 10 kilometers to her local health facility.

Just like before, Ghutai’s newborn had breathing problems. But thankfully, Dehdadi District Hospital’s midwife Enjila Yaqoobi knew what to do. A recent training on newborn resuscitation had given Yaqoobi the confidence and skills to resuscitate Ghutai’s baby. Today, baby Muzda is healthy and growing strong.

Midwife Yaqoobi attributes her lifesaving actions to the Helping Mothers and Children Thrive project—known as HEMAYAT— a training and mentorship program funded by the United States Agency for International Development (USAID) and led by Jhpiego, in collaboration with Afghanistan’s Ministry of Public Health.

Read more by clicking the link below.


Routine health information systems (RHIS), based on data reported by health facilities, are an important source of health statistics that feature prominently in national and subnational health plans and program. Multiple indicators generated by the RHIS data can be used to track national and subnational progress towards universal health coverage, often in combination with household survey and other data. Scorecards and dashboards are increasingly popular tools to visualize the statistics based on health facility data, aiming to facilitate the interpretation, communication and use of data.

Countries and development partners have been investing in the improvement of the data generation and use through the RHIS. A notable development is the introduction of the District Health Information System (DHIS), which is an open-source software platform for reporting, quality checks, visualization, analysis and dissemination of data for all health program. From 2010 onwards, an increasing number of countries began to introduce the web-based DHIS2 platform, and today many countries are using this electronic platform.

Common RHIS data-based indicators include causes of death and morbidity patterns among persons using health services, health service utilization and efficiency indicators, as well as a range of program-specific indicators on the coverage of interventions. Several programs such as immunization and HIV have been relying extensively on facility data-based coverage statistics for country and global monitoring.

Studies have shown multiple issues regarding the quality of data generated by health facilities that affect the credibility and utility of RHIS-based statistics at local and national levels. The main challenges are associated with incomplete and inaccurate reporting of events, as well as problems with defining accurate denominators (ie, target populations) for the computation of coverage statistics.

This paper describes the situation in 14 countries in Eastern and Southern Africa in 2017, based on an analysis project involving teams of Ministry of Health and country public health institutions analysts, organized by the African Population Health Research Centre, Countdown to 2030 for Women’s, Children’s and Adolescents’ Health, WHO and UNICEF. The focus was on ‘endline’ analysis where all relevant health facility data are compiled and systematically assessed, including assessment and adjustment for incomplete reporting, detection and correction of extreme outliers, assessment and revision of denominators, comparison with survey-based results and computation of statistics based on the adjusted data set. These analyses were done in MS Excel 2013, using data exported from the DHIS2 country databases.

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Manzou Diarra, born premature, is in good health thanks to kangaroo mother care. He is 4 months old. Photo credit: Amadou Keita, SSGI/Save the Children.

Prematurity is one of the leading causes of newborn deaths. In Mali, 29% of neonatal deaths are due to babies born before 37 weeks of gestation (CHERG 2010). Kangaroo Mother Care (KMC) is an intervention where the mother carries her baby skin-to-skin at the chest, with breastfeeding support and close monitoring by a health provider. KMC gives a chance to premature babies or those born low birth weight to survive and thrive, especially in countries where access to specialized neonatal care services are still lacking.

Read this success story about the USAID-funded Services de Santé à Grand Impact (SSGI), which supports the Ministry of Health to improve the quality of maternal and newborn health services in Mali through training, supervision and coaching on obstetric and neonatal care, including KMC

Read more by clicking the link below.


Will this precious one survive?

Children born too soon (preterm) or too small are at the highest risk of dying in utero, during birth and in the neonatal period, and also have increased health and development risks throughout their lifetime. Of the 2.5 million neonatal deaths in 2018, over 80% were born too small–of which two thirds are preterm and one third are small for gestational age (SGA).

Quantifying the full burden of affected children born too soon or too small or both is critical for health system response and planning. Estimates of the global, regional and national burden of preterm birth and LBW are especially needed because data for both are sparse and incomplete in many countries. In the past year, The Lancet Global Health has published two new sets of estimates – preterm birth and low birthweight (see facts about each below).

Estimates allow health system stakeholders, policies, and programmes to be better informed, enabling more precise targeting of interventions. Estimates can also be used to raise awareness of the issues as global public health priorities, and can help mobilise resources for research and maternal and child health programs. They also allow for comparison between countries or between countries and regions. Learn more about how estimates can be used at global and national levels here.

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Too Precious!

An estimated 15 million babies are born prematurely, before 37 weeks of gestation, every year worldwide. Of those, about 5–6% are born extremely prematurely, before 28 weeks of gestation. Progress in the perinatal care of these babies has continued to improve outcomes in high-income countries.

The British Association of Perinatal Medicine has issued new guidance, Perinatal Management of Extreme Preterm Birth before 27 weeks of gestation. For example, even at the lowest end of viability, at 22 weeks of gestation, 30% of those babies who were given active treatment survived to discharge in cohort studies from Sweden, the US, and Germany. And in the UK, 88% of babies born at 23 weeks of gestation will receive active respiratory care, with 38% surviving to age 1 year.

The guidance offers a welcome new framework for decision making and managing these infants.


#WorldPrematurityDay #Health4all #RMC

Women and adolescent girls have the right to decide whether, when and with whom they want to have children. #genderinequalities still impact the ability of women and girls to achieve good health outcomes and realize their human rights and full potential.
Respectful care before, during and after pregnancy should become a standard.
Give all women and adolescent girls information and access to care, including family planning and knowledge around risk factors.
Implement high quality, equitable healthcare to women and girls, including midwife-led continuity of care, and nutrition throughout their life-course, irrespective of their pregnancy intentions.
Women have the right to access quality care for preterm babies.

Go purple! by wearing purple, lighting your home or office purple, light a purple candle in your window, inviting to a purple meal, or coming up with your own ways to turn the world purple for this day in support of preterm birth awareness. Share on social media with #WorldPrematurityDay.
Hang up a sock-line with 9 (white) baby socks and one smaller (purple) baby sock as a symbol to raise awareness for preterm birth. Share on social media with #WorldPrematurityDay. Host public talks, exhibitions of preemie “sock-lines” in market squares

Have parents of preterm children lead information sessions, create posters and lead public petitions.

Work with staff at hospitals and health facilities to organize a “Week of Purple,” holding education and information sessions, or organizing celebration events for preterm infants.

Make or renew a commitment of action on preterm birth and newborn survival as part of your commitment to the Global Strategy for Women’s, Children’s and Adolescents’ Health through the Every Woman Every Child platform: www.everywomaneverychild.org /commitments

Take the Kangaroo Mother Care Challenge and post photos on social media – with #KMCChallenge and #WorldPrematurityDay