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As maternal mortality and morbidity rates stagnate or increase worldwide, there is an urgent need to address health system issues that impede access to high-quality care. Learning from efforts to address the value, safety, and effectiveness of reproductive and maternal health care is essential to advancing quality improvement efforts.

Racism, segregation, and inequality contribute to health outcomes and drive health disparities across the life course, including for newborn infants and their families. In this review, we address their effects on the health and well-being of newborn infants and their families with a focus on preterm birth. We discuss three causal pathways: increased risk; lower-quality care; and socioeconomic disadvantages that persist into infancy, childhood, and beyond. For each pathway, we propose specific interventions and research priorities that may remedy the adverse effects of racism, segregation, and inequality. Infants and their families will not realize the full benefit of advances in perinatal and neonatal care until we, collectively, accept our responsibility for addressing the range of determinants that shape long-term outcomes.

Neonatal and maternal mortality remains high in low- and middle-income countries (LMIC), especially in sub-Saharan Africa. Quality data collection is crucial to understand the magnitude of these problems and to measure the impact of interventions aimed at improving neonatal and maternal mortality. However, data collection in the low-income country setting, especially in rural areas, has been a challenge for researchers, policy makers, and public health officials. Here, we describe the methodology, experience and lessons learned while collecting data at lower-level primary health care facilities in rural Uganda. Data collection was performed at Health Center III sites in rural Uganda, in partnership with Imaging the World and its affiliate Imaging the World Africa. The primary purpose of the data collection was to study the efficacy and clinical effect of introducing prenatal ultrasound services at these sites. Local data clerks were hired to perform the data collection through a combination of intensive training and on-the-ground support. Frequent oversight was used to support data collection. Of 2,397 enrolled pregnant women, 1,977 (82.5%) had complete outcome data. Upon independent expert audit, the data were >80% accurate for 10/11 variables and >90% accurate for 6/11 variables. Overall, the data collected at the rural HCs were 90% accurate. Accurate and complete data collection is possible in an LMIC setting if appropriate training and oversight are employed.

Background In 2006, the Vermont Oxford Network (VON) established the Neonatal Encephalopathy Registry (NER) to characterize infants born with neonatal encephalopathy, describe evaluations and medical treatments, monitor hypothermic therapy (HT) dissemination, define clinical research questions, and identify opportunities for improved care. Methods Eligible infants were ≥ 36 weeks with seizures, altered consciousness (stupor, coma) during the first 72 hours of life, a 5 minute Apgar score of ≤ 3, or receiving HT. Infants with central nervous system birth defects were excluded. Results From 2006–2010, 95 centers registered 4232 infants. Of those, 59% suffered a seizure, 50% had a 5 minute Apgar score of ≤ 3, 38% received HT, and 18% had stupor/coma documented on neurologic exam. Some infants experienced more than one eligibility criterion. Only 53% had a cord gas obtained and only 63% had a blood gas obtained within 24 hours of birth, important components for determining HT eligibility. Sixty-four percent received ventilator support, 65% received anticonvulsants, 66% had a head MRI, 23% had a cranial CT, 67% had a full channel encephalogram (EEG) and 33% amplitude integrated EEG. Of all infants, 87% survived. Conclusions The VON NER describes the heterogeneous population of infants with NE, the subset that received HT, their patterns of care, and outcomes. The optimal routine care of infants with neonatal encephalopathy is unknown. The registry method is well suited to identify opportunities for improvement in the care of infants affected by NE and study interventions such as HT as they are implemented in clinical practice.

The Ethiopian Neonatal Network (ENN) represents one of the first low-income country neonatal quality improvement (QI) communities. To determine if changes in structure, process and outcome measures were associated with formation of the ENN and to learn from teams, quantitative and qualitative analyses were completed. All infants discharged during 2018–2022 from 11 hospitals with consistent data collection over the 5-year period were included in infant-level analyses. Trends by year were evaluated using Cochran-Armitage tests. Annual surveys captured facility-level data. Nurse and physician leads at ENN hospitals participated in focus groups in 2023. Inductive and deductive approaches were used to extract themes and findings. Overall, 38 049 infants were discharged. Participating sites reduced nurse-to-patient ratios, increased newborn beds and implemented continuous positive airway pressure (CPAP) with blended oxygen. There were significant increases in antenatal steroid exposure, kangaroo mother care and receipt of oxygen or CPAP among infants with respiratory distress (p<0.0001). Admission hypothermia among inborn infants decreased (p<0.0001). Overall survival decreased (p<0.0001). Mortality due to prematurity-related complications decreased (p=0.0089) while mortality due to infection increased (p=0.0016). Three themes were determined from focus groups: positive changes to data utilisation and patient care following ENN membership, data entry, technical issues and buy-in as barriers to participation and recommendations on additional support. Development of the ENN was associated with adopting a culture of data-driven improvement, positive changes in measurable quality of care and improved patient outcomes. Sustaining, spreading and evaluating multidisciplinary neonatal QI communities are important components to global efforts targeting mortality reduction.

Helping Babies Breathe (HBB) is an evidence-based neonatal resuscitation program designed for implementation in low-resource settings. While HBB reduces rates of early neonatal mortality and stillbirth, maintenance of knowledge and skills remains a challenge. The extent to which the inclusion of educational clinical videos impacts learners’ knowledge and skills acquisition, and retention is largely unknown. We conducted a cluster-randomized controlled trial at two public teaching hospitals in Addis Ababa, Ethiopia. We randomized small training group clusters of 84 midwives to standard HBB vs. standard HBB training supplemented with exposure to an educational clinical video on newborn resuscitation. Midwives were followed over a 7-month time period and assessed on their knowledge and skills using standard HBB tools. When comparing the intervention to the control group, there was no difference in outcomes across all assessments, indicating that the addition of the video did not influence skill retention. Pass rates for both the control and intervention group on bag and mask skills remained low at 7 months despite frequent assessments. There is more to learn about the use of educational videos along with low-dose, high-frequency training and how it relates to retention of knowledge and skills in learners.

The value of Source Data Verification (SDV) has been a common theme in the applied Clinical Translational Science literature. Yet, few published assessments of SDV quality exist even though they are needed to design risk-based and reduced monitoring schemes. This review was conducted to identify reports of SDV quality, with a specific focus on accuracy. A scoping review was conducted of the SDV and clinical trial monitoring literature to identify articles addressing SDV quality. Articles were systematically screened and summarized in terms of research design, SDV context, and reported measures. The review found significant heterogeneity in underlying SDV methods, domains of SDV quality measured, the outcomes assessed, and the levels at which they were reported. This variability precluded comparison or pooling of results across the articles. No absolute measures of SDV accuracy were identified. A definitive and comprehensive characterization of SDV process accuracy was not found. Reducing the SDV without understanding the risk of critical findings going undetected, i.e., SDV sensitivity, is counter to recommendations in Good Clinical Practice and the principles of Quality by Design. Reference estimates (or methods to obtain estimates) of SDV accuracy are needed to confidently design risk-based, reduced SDV processes for clinical studies.

Differences in race/ethnicity, gender, income and other social factors have long been associated with disparities in health, illness and premature death. Although the terms ‘health differences’ and ‘health disparities’ are often used interchangeably, health disparities has recently been reserved to describe worse health in socially disadvantaged populations, particularly members of disadvantaged racial/ethnic groups and the poor within a racial/ethnic group. Infants receiving disparate care based on race/ethnicity, immigration status, language proficiency, or social class may be discomforting to healthcare workers who dedicate their lives to care for these patients. Recent literature, however, has documented differences in neonatal intensive care unit (NICU) care quality that have contributed to racial and ethnic differences in mortality and significant morbidity. We examine the within-NICU and between-NICU mechanisms of disparate care and recommend approaches to address these disparities.

Objective The Downes score is a neonatal examination scoring tool frequently used to guide initiation of CPAP, but its ability to predict the need for surfactant has not been assessed. We assessed the extent to which the Downes score predicts the receipt of surfactant. Study design We calculated a simplified Downes score from nursing admission data for infants (≤ 2000 grams, and ≥ 25 weeks’ gestation) admitted on CPAP to a highly resourced level III NICU, to assess the predictive value for the receipt of surfactant. Results Fifty-three (31.5%) out of 168 infants admitted on CPAP received surfactant. A simplified Downes score of ≥ 4 predicted the receipt of surfactant with 90.6% sensitivity, 52.2% specificity, 46.6% positive predictive value, 92.3% negative predictive value, and 64.3% accuracy. Conclusion The high sensitivity and negative predictive value suggest utility for using the Downes score to help guide clinical decision making regarding surfactant therapy.

Very low birth weight (VLBW) infants require specialized care in neonatal intensive care units. In the United States (U.S.), such infants frequently are transferred between hospitals. Although these neonatal transfer networks are important, both economically and for infant morbidity and mortality, the national level pattern of neonatal transfers is largely unknown. Using data from Vermont Oxford Network on 44,753 births, 2122 hospitals, and 9722 interhospital infant transfers from 2015, we performed the largest analysis to date on the interhospital transfer network for VLBW infants in the U.S. We find that transfers are organized around regional communities, but that despite being largely within state boundaries, most communities often contain at least two hospitals in different states. To classify the structural variation in transfer pattern amongst these communities, we applied a spectral measure for regionalization and found an association between a community’s degree of regionalization and their infant transfer rate, which was not utilized in detecting communities. We also demonstrate that the established measures of network centrality and hierarchy, e.g., the community-wide entropy in PageRank or betweenness centrality and number of distinct “layers,” within a community, correlate weakly with our regionalization index and were not significantly associated with metrics on infant transfer rate. Our results suggest that the regionalization index captures novel information about the structural properties of VLBW infant transfer networks, have the practical implication of characterizing neonatal care in the U.S., and may apply more broadly to the role of centralizing forces in organizing complex adaptive systems.