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Background Mental health has long fallen behind physical health in attention, funding, and action—especially in low- and middle-income countries (LMICs). It has been conspicuously absent from global reproductive, maternal, newborn, child, and adolescent health (MNCAH) programming, despite increasing awareness of the intergenerational impact of common perinatal mental disorders (CPMDs). However, the universal health coverage (UHC) movement and COVID-19 have brought mental health to the forefront, and the MNCAH community is looking to understand how to provide women effective, sustainable care at scale. To address this, MOMENTUM Country and Global Leadership (MCGL) commissioned a landscape analysis in December 2020 to assess the state of CPMDs and identify what is being done to address the burden in LMICs. Methods The landscape analysis (LA) used a multitiered approach. First, reviewers chose a scoping review methodology to search literature in PubMed, Google Scholar, PsychInfo, and Scopus. Titles and abstracts were reviewed before a multidisciplinary team conducted data extraction and analysis on relevant articles. Second, 44 key informant interviews and two focus group discussions were conducted with mental health, MNCAH, humanitarian, nutrition, gender-based violence (GBV), advocacy, and implementation research experts. Finally, reviewers completed a document analysis of relevant mental health policies from 19 countries. Results The LA identified risk factors for CPMDs, maternal mental health interventions and implementation strategies, and remaining knowledge gaps. Risk factors included social determinants, such as economic or gender inequality, and individual experiences, such as stillbirth. Core components identified in successful perinatal mental health (PMH) interventions at community level included stepped care, detailed context assessments, task-sharing models, and talk therapy; at health facility level, they included pre-service training on mental health, trained and supervised providers, referral and assessment processes, mental health support for providers, provision of respectful care, and linkages with GBV services. Yet, significant gaps remain in understanding how to address CPMDs. Conclusion These findings illuminate an urgent need to provide CPMD prevention and care to women in LMICs. The time is long overdue to take perinatal mental health seriously. Efforts should strive to generate better evidence while implementing successful approaches to help millions of women “suffering in silence.”

ObjectivesThe aim of this study was to prioritise a set of indicators to measure World Health Organization (WHO) quality-of-care standards for small and/or sick newborns (SSNB) in health facilities. The hypothesis is that monitoring prioritised indicators can support accountability mechanisms, assess and drive progress, and compare performance in quality-of-care (QoC) at subnational levels.DesignProspective, iterative, deductive, stepwise process to prioritise a list of QoC indicators organised around the WHO Standards for improving the QoC for small and sick newborns in health facilities. A technical working group (TWG) used an iterative four-step deductive process: (1) articulation of conceptual framework and method for indicator development; (2) comprehensive review of existing global SSNB-relevant indicators; (3) development of indicator selection criteria; and (4) selection of indicators through consultations with a wide range of stakeholders at country, regional and global levels.SettingThe indicators are prioritised for inpatient newborn care (typically called level 2 and 3 care) in high mortality/morbidity settings, where most preventable poor neonatal outcomes occur.ParticipantsThe TWG included 24 technical experts and leaders in SSNB QoC programming selected by WHO. Global perspectives were synthesised from an online survey of 172 respondents who represented different countries and levels of the health system, and a wide range of perspectives, including ministries of health, research institutions, technical and implementing partners, health workers and independent experts.ResultsThe 30 prioritised SSNB QoC indicators include 27 with metadata and 3 requiring further development; together, they cover all eight standard domains of the WHO quality framework. Among the established indicators, 10 were adopted from existing indicators and 17 adapted. The list contains a balance of indicators measuring inputs (n=6), processes (n=12) and outcome/impact (n=9).ConclusionsThe prioritised SSNB QoC indicators can be used at health facility, subnational and national levels, depending on the maturity of a country’s health information system. Their use in implementation, research and evaluation across diverse contexts has the potential to help drive action to improve quality of SSNB care. WHO and others could use this list for further prioritisation of a core set.

Maternal and perinatal death surveillance and response (MPDSR) systems aim to understand and address key contributors to maternal and perinatal deaths to prevent future deaths. From 2016-2017, the US Agency for International Development's Maternal and Child Survival Program conducted an assessment of MPDSR implementation in Nigeria, Rwanda, Tanzania, and Zimbabwe. A cross-sectional, mixed-methods research design was used to assess MPDSR implementation. The study included a desk review, policy mapping, semistructured interviews with 41 subnational stakeholders, observations, and interviews with key informants at 55 purposefully selected facilities. Using a standardised tool with progress markers defined for six stages of implementation, each facility was assigned a score from 0-30. Quantitative and qualitative data were analysed from the 47 facilities with a score above 10 ('evidence of MPDSR practice'). The mean calculated MPDSR implementation progress score across 47 facilities was 18.98 out of 30 (range: 11.75-27.38). The team observed variation across the national MPDSR guidelines and tools, and inconsistent implementation of MPDSR at subnational and facility levels. Nearly all facilities had a designated MPDSR coordinator, but varied in their availability and use of standardised forms and the frequency of mortality audit meetings. Few facilities (9%) had mechanisms in place to promote a no-blame environment. Some facilities (44%) could demonstrate evidence that a change occurred due to MPDSR. Factors enabling implementation included clear support from leadership, commitment from staff, and regular occurrence of meetings. Barriers included lack of health worker capacity, limited staff time, and limited staff motivation. This study was the first to apply a standardised scoring methodology to assess subnational- and facility-level MPDSR implementation progress. Structures and processes for implementing MPDSR existed in all four countries. Many implementation gaps were identified that can inform priorities and future research for strengthening MPDSR in low-capacity settings.

Program managers routinely design and implement specialised maternal and newborn health trainings for health workers in low- and middle-income countries to provide better-coordinated care across the continuum of care. However, in these countries details on the availability of different training packages, skills covered in those training packages and the gaps in their implementation are patchy. This paper presents an assessment of maternal and newborn health training packages to describe differences in training contents and implementation approaches used for a range of training packages in Ethiopia and Nepal. We conducted a mixed-methods study. The quantitative assessment was conducted using a comprehensive assessment questionnaire based on validated WHO guidelines and developed jointly with global maternal and newborn health experts. The qualitative assessment was conducted through key informant interviews with national stakeholders involved in implementing these training packages and working with the Ministries of Health in both countries. Our quantitative analysis revealed several key gaps in the technical content of maternal and newborn health training packages in both countries. Our qualitative results from key informant interviews provided additional insights by highlighting several issues with trainings related to quality, skill retention, logistics, and management. Taken together, our findings suggest four key areas of improvement: first, training materials should be updated based on the content gaps identified and should be aligned with each other. Second, trainings should address actual health worker performance gaps using a variety of innovative approaches such as blended and self-directed learning. Third, post-training supervision and ongoing mentoring need to be strengthened. Lastly, functional training information systems are required to support planning efforts in both countries.

Decisions made at the household level, for example, to seek antenatal care or breastfeed, can have a direct impact on the health of mothers and newborns. The SMART Community-based Initiatives program in Egypt worked with community development associations to encourage better household decision-making by training community health workers to disseminate information and encourage healthy practices during home visits, group sessions, and community activities with pregnant women, mothers of young children, and their families. A quasi-experimental design was used to evaluate the program, with household surveys conducted before and after the intervention in intervention and comparison areas. Survey questions asked about women's knowledge and behaviors related to maternal and newborn care and child nutrition and, at the endline, exposure to SMART activities. Exposure to program activities was high in intervention areas of Upper Egypt: 91% of respondents reported receiving home visits and 84% attended group sessions. In Lower Egypt, these figures were 58% and 48%, respectively. Knowledge of danger signs related to pregnancy, delivery, and newborn illness increased significantly more in intervention than comparison areas in both regions (with one exception in Lower Egypt), after controlling for child's age and woman's education; this pattern also occurred for two of five behaviors (antenatal care visits and consumption of iron-folate tablets). Findings suggest that there may have been a significant dose-response relationship between exposure to SMART activities and certain knowledge and behavioral indicators, especially in Upper Egypt. The findings demonstrate the ability of civil society organizations with minimal health programming experience to increase knowledge and promote healthy behaviors among pregnant women and new mothers. The SMART approach offers a promising strategy to fill gaps in health education and counseling and strengthen community support for behavior change.

Globally, an estimated 2.7 million babies die in the neonatal period annually, and of these, about 0.7 million die from intrapartum-related events. In Tanzania 51,000 newborn deaths and 43,000 stillbirths occur every year. Approximately two-thirds of these deaths could be potentially prevented with improvements in intrapartum and neonatal care. Routine measurement of fetal intrapartum deaths and newborn deaths that occur in health facilities can help to evaluate efforts to improve the quality of intrapartum care to save lives. However, few examples exist of indicators on perinatal mortality in the facility setting that are readily available through health management information systems (HMIS). From November 2016 to April 2017, health providers at 10 government health facilities in Kagera region, Tanzania, underwent refresher training on perinatal death classification and training on the use of handheld Doppler devices to assess fetal heart rate upon admission to maternity services. Doppler devices were provided to maternity services at the study facilities. We assessed the validity of an indicator to measure facility-based pre-discharge perinatal mortality by comparing perinatal outcomes extracted from the HMIS maternity registers to a gold standard perinatal death audit. Sensitivity and specificity of the HMIS neonatal outcomes to predict gold standard audit outcomes were both over 98% based on analysis of 128 HMIS-gold standard audit pairs. After this validation, we calculated facility perinatal mortality indicator from HMIS data using fresh stillbirths and pre-discharge newborn death as the numerator and women admitted in labor with positive fetal heart tones as the denominator. Further emphasizing the validity of the indicator, FPM values aligned with expected mortality by facility level, with lowest rates in health centers (range 0.3%- 0.5%), compared to district hospitals (1.5%- 2.9%) and the regional hospital (4.2%). This facility perinatal mortality indicator provides an important health outcome measure that facilities can use to monitor levels of perinatal deaths occurring in the facility and evaluate impact of quality of care improvement activities.

Background Helping Babies Breathe (HBB) is a competency-based educational method for an evidence-based protocol to manage birth asphyxia in low resource settings. HBB has been shown to improve health worker skills and neonatal outcomes, but studies have documented problems with skills retention and little evidence of effectiveness at large scale in routine practice. This study examined the effect of complementing provider training with clinical mentorship and quality improvement as outlined in the second edition HBB materials. This “system-oriented” approach was implemented in all public health facilities ( n  = 172) in ten districts in Rwanda from 2015 to 2018. Methods A before-after mixed methods study assessed changes in provider skills and neonatal outcomes related to birth asphyxia. Mentee knowledge and skills were assessed with HBB objective structured clinical exam (OSCE) B pre and post training and during mentorship visits up to 1 year afterward. The study team extracted health outcome data across the entirety of intervention districts and conducted interviews to gather perspectives of providers and managers on the approach. Results Nearly 40 % ( n =  772) of health workers in maternity units directly received mentorship. Of the mentees who received two or more visits ( n  = 456), 60 % demonstrated competence (received >  80% score on OSCE B) on the first mentorship visit, and 100% by the sixth. In a subset of 220 health workers followed for an average of 5 months after demonstrating competence, 98% maintained or improved their score. Three of the tracked neonatal health outcomes improved across the ten districts and the fourth just missed statistical significance: neonatal admissions due to asphyxia (37% reduction); fresh stillbirths (27% reduction); neonatal deaths due to asphyxia (13% reduction); and death within 30 min of birth (19% reduction, p  = 0.06). Health workers expressed satisfaction with the clinical mentorship approach, noting improvements in confidence, patient flow within the maternity, and data use for decision-making. Conclusions Framing management of birth asphyxia within a larger quality improvement approach appears to contribute to success at scale. Clinical mentorship emerged as a critical element. The specific effect of individual components of the approach on provider skills and health outcomes requires further investigation.

Community-based maternal and newborn care interventions have been shown to improve neonatal survival and other key health indicators. It is important to evaluate whether the improvement in health indicators is accompanied by a parallel increase in the equitable distribution of the intervention activities, and the uptake of healthy newborn care practices. We present an analysis of equity improvements after the implementation of a Community Based Newborn Care Package (CB- NCP) in the Bardiya district of Nepal. The package was implemented alongside other programs that were already in place within the district. We present changes in concentration indices (CIndices) as measures of changes in equity, as well as percentage changes in coverage, between baseline and endline. The CIndices were derived from wealth scores that were based on household assets, and they were compared using t-tests. We observed statistically significant improvements in equity for facility delivery [CIndex:?0.15 (?0.24,?0.06)], knowledge of at least three newborn danger signs [?0.026 (?0.06,?0.003)], breastfeeding within 1 h [?0.05 (?0.11,?0.0001)], at least one antenatal visit with a skilled provider [?0.25 (?0.04,?0.01)], at least four antenatal visits from any provider [?0.15 (?0.19,?0.10)] and birth preparedness [?0.09 (?0.12,?0.06)]. The largest increases in practices were observed for facility delivery (50 %), immediate drying (34 %) and delayed bathing (29 %). These results and those of similar studies are evidence that community-based interventions delivered by female community health volunteers can be instrumental in improving equity in levels of facility delivery and other newborn care behaviours. We recommend that equity be evaluated in other similar settings within Nepal in order to determine if similar results are observed. Les interventions médicales auprès des mamans et des nouveau-nés, qui reposent sur la communauté ont eu pour effet d’améliorer la survie néonatale ainsi que d’autres indicateurs-clés sanitaires. Il est important de déterminer si l’amélioration des indicateurs sanitaires s’accompagne en parallèle d ’une répartition plus équitable des activités d’intervention, et de l’intégration des pratiques de soins aux nouveaux nés sains. Nous présentons une analyse des améliorations de l’équité, après la mise en place d’un Projet de Soins Communautaire aux Nouveau-Nés (CBNCP) dans le district de Bardiya au Népal. La mise en œuvre de ce projet est venue s’ajouter à d’autres programmes déj à en place dans ce district. Nous mettons en évidence les changements dans les indices de concentration (Cindices) comme mesures de changements dans l’équité, ainsi que les modifications du taux de couverture entre la base de référence et le résultat final. Les Cindices ont été déduits des niveaux de richesse basée sur les biens des ménages, et ont fait l’objet de tests comparatifs. Nous avons observé des améliorations notables des statistique de l’équité dans le domaine de l’accouchement en maternité (Cindex0.15 (_0.24, _0.06)], la connaissance de signes de danger chez 3 nouveau-nés au moins[_0.026(_0.06, _0.003)], l’allaitement dans l’heure[_0.05(_0.11, _0.0001)], au moins une visite prénatale avec un prestataire qualifié[_0.25(_0.04, _0.01)], au moins 4 visites prénatales avec n’importe quel prestataire, et la préparation à l’accouchement. Les augmentations les plus notables des pratiques concernaient les l’accouchements en maternité (50%), le séchage immédiat (34%) et le bain différé (29%). Ces résultats, comme ceux d’études similaires sont la preuve que les interventions qui reposent sur la communauté, et qui sont effectuées par des femmes volontaires de la communauté sanitaire peuvent jouer un rôle dans l’amélioration de l’équité au niveau des accouchements en maternité autres comportements de soins aux nouveau-nés. Nous recommandons que l’équité soit évaluée au sein d d’autres milieux similaires sur le territoire du Népal, afin de déterminer si des résultats comparables sont observés. Las intervenciones de atención materna y neonatal basadas en la comunidad han demostrado mejorar la supervivencia neonatal y otros indicadores claves de la salud. Es importante evaluar si la mejora de los indicadores de salud va acompañada de un aumento paralelo en la distribución equitativa de las actividades de intervención, y de la adopción de prácticas saludables para el cuidado del recién nacido. Se presenta un análisis de mejorías equitativas después de la implementación de un Paquete del Cuidado del Recién Nacido Basado en la Comunidad (PCR-BC) en el distrito de Bardiya en Nepal. El paquete se implementó junto con otros programas que ya existían dentro del distrito. Presentamos los cambios en los índices de concentración (Índices C) como medidas de cambios en la equidad, así como los cambios porcentuales en la cobertura, entre la línea base y la línea final. Los Índices C se derivaron de las puntuaciones de riqueza que se basaban en los activos del hogar, y se compararon mediante pruebas t. Observamos mejorías estadísticamente significativas en equidad en los partos en instalaciones [Índices C: -0.15 (-0.24, -0.06)], conocimiento de por lo menos tres señales de peligro del recién nacido [-0.026 (-0.06, -0.003)], lactancia dentro de 1 hora [-0.05 (-0.11, -0.0001)], por lo menos una visita prenatal con un proveedor calificado [-0.25 (-0.04, -0.01)], por lo menos cuatro visitas prenatales de cualquier proveedor [-0.15 (-0.19, -0.10)] y la preparación para el parto [-0.09 (-0.12, -0.06)]. Se observaron los mayores incrementos en las prácticas de parto en las instalaciones (50%), secado inmediato (34%) y baño demorado (29%). Estos resultados y los de estudios similares son una prueba de que las intervenciones llevadas a cabo por voluntarias de la comunidad pueden contribuir a mejorar la equidad en los niveles de partos en las instalaciones y otros comportamientos del cuidado neonatal. Recomendamos que la equidad sea evaluada en otros entornos similares dentro de Nepal con el fin de determinar si se observan resultados similares. 以社区为基础的孕妇和新生儿保健措施被证明可以提高新生 儿存活率以及其他关键的健康指标。评估在健康指标提高的 同时是否伴有干预活动的分配公平性提高, 以及对健康新生儿 的医疗实践的上升是非常重要的。我们呈现了在尼泊尔巴迪 亚地区实施了以社区为基础的新生儿护理项目 （CBNCP） 之 后, 对公平性提高的分析。这个项目是与该地区其他一些已经 正在实施的项目共同进行的。我们用集中指数的变化 （CIndices） 来测量公平性的变化, 以及在基线和端线之间覆 盖的比率变化。CIndices 来自基于家庭资产的财富分数, 使用 T检验对其进行比较。我们观察到以下几个指标的公平性提高 在统计上具有显著性：机构妊娠[CIndex：-0.15 （-0.24, -0.06） ], 对至少三个新生儿危险指标的了解[-0.026 （-0.06, -0.003） ], 一小时哺乳[-0.05 （-0.11, -0.0001） ], 到技术熟练 的服务提供者处进行至少一次产前检查[-0.25 （-0.04, -0.01） ], 至少四次产检[-0.15 （-0.19, -0.10） ], 出生准备 [-0.09 （-0.12, -0.06） ]。我们观察到的最大增长分别是：机 构妊娠 （50%）, 立刻干燥 （34%）, 延迟洗澡 （29%） 。这些 研究结果和其他相似研究证明由女性医疗志愿者提供的以社 区为基础的措施有助于提高机构妊娠和其他新生儿保健行为 的公平性。我们建议在尼泊尔的其他类型环境中评估公平性, 观察是否得到同样的结果。

The emergency obstetric care (EmOC) monitoring framework has been used for decades to monitor the availability and use of EmOC services in low- and middle-income countries (LMICs). EmOC monitoring is based around eight signal functions, a shortlist of key clinical interventions capable of averting deaths from the main direct causes of maternal mortality, categorised between two levels of care: basic and comprehensive, with a newborn resuscitation signal function added in 2009. The Re-Visioning Emergency Obstetric and Newborn Care (EmONC) Project (2020–2024) aimed to update the EmOC approach to reflect new knowledge in maternal and newborn health (MNH), and to expand the scope of the original EmOC monitoring framework. The project used technical workstreams and workshops to arrive at new proposals. This paper reports on the approach used to build consensus on a revised set of EmONC signal functions and levels of care. Using a three-round online Delphi approach, consensus (≥85%) was sought from a diverse panel of global MNH experts on EmONC signal functions and their placement at different levels of care, based on existing evidence-based guidelines. The process was iterative, each round building on the previous, and embedded in the wider Re-Visioning EmONC project; the output from each round involved coordination of inputs from multiple tiers of technical experts, including UN agencies, via technical expert groups, workstreams and workshops. The Delphi study recruited 113 experts in MNH from a range of geographic and economic settings, specialities and professions, including clinical, academic and programme expertise. The output from the three rounds included substantial convergence, resulting in set of 25 signal functions (11 obstetric, 13 neonatal and 1 referral) that reflect the spectrum of EmONC required for women and newborns. The revised EmONC signal functions are intended as a simple approach to allow health system managers to visualise their EmONC services, and as a means to hold health systems accountable to provide the main interventions to avert preventable maternal and newborn morbidity and mortality, and stillbirths.

ObjectiveTo present information on the quality of newborn care services and health facility readiness to provide newborn care in 6 African countries, and to advocate for the improvement of providers' essential newborn care knowledge and skills.DesignCross-sectional observational health facility assessment.SettingEthiopia, Kenya, Madagascar, Mozambique, Rwanda and Tanzania.ParticipantsHealth workers in 643 facilities. 1016 health workers were interviewed, and 2377 babies were observed in the facilities surveyed.Main outcome measuresIndicators of quality of newborn care included (1) provision of immediate essential newborn care: thermal care, hygienic cord care, and early and exclusive initiation of breast feeding; (2) actual and simulated resuscitation of asphyxiated newborn infants; and (3) knowledge of health workers on essential newborn care, including resuscitation.ResultsSterile or clean cord cutting instruments, suction devices, and tables or firm surfaces for resuscitation were commonly available. 80% of newborns were immediately dried after birth and received clean cord care in most of the studied facilities. In all countries assessed, major deficiencies exist for essential newborn care supplies and equipment, as well as for health worker knowledge and performance of key routine newborn care practices, particularly for immediate skin-to-skin contact and breastfeeding initiation. Of newborns who did not cry at birth, 89% either recovered on their own or through active steps taken by the provider through resuscitation with initial stimulation and/or ventilation. 11% of newborns died. Assessment of simulated resuscitation using a NeoNatalie anatomic model showed that less than a third of providers were able to demonstrate ventilation skills correctly.ConclusionsThe findings shared in this paper call attention to the critical need to improve health facility readiness to provide quality newborn care services and to ensure that service providers have the necessary equipment, supplies, knowledge and skills that are critical to save newborn lives.