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The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths. The continuum for maternal, newborn, and child health usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). We define a population-level or public-health framework based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children. These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one. The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes. Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care. Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.

Although progress has been made to improve access to sexual and reproductive health services globally in the past two decades, in many low-income countries, improvements have been slow. Discrimination against vulnerable groups and failure to address health inequities openly and comprehensively play a role in this stagnation. Healthcare practitioners are important actors who, often alone, decide who accesses services and how. This study explores how health care practitioners perceive sexual and reproductive health and rights (SRHR) and how background factors influence them during service delivery. Participants were a purposefully selected sample of health practitioners from five low income countries attending a training in at Lund University, Sweden. Semi-structured interviews and qualitative content analysis were used. Three themes emerged. The first theme, \"one-size doesn't fit all' in SRHR\" reflects health practitioners' perception of SRHR. Although they perceived rights as fundamental to sexual and reproductive health, exercising of these rights was perceived to be context-specific. The second theme, \"aligning a pathway to service delivery\", illustrates a reflective balancing act between their personal values and societal norms in service delivery, while the third theme, \"health practitioners acting as gatekeepers\", describes how this balancing act oscillates between enabling and blocking behaviours. The findings suggest that, even though health care practitioners perceive SRHR as fundamental rights, their preparedness to ensure that these rights were upheld in service delivery is influenced by personal values and society norms. This could lead to actions that enable or block service delivery.

Background Maternal and perinatal death surveillance and response (MPDSR) was developed as a quality improvement intervention to reduce preventable maternal and newborn deaths and stillbirths. To gain deeper insight into the key components enabling sustained MPDSR implementation, we examined how MPDSR systems are organized and function in Nigeria, North Macedonia, and Sri Lanka. Methods We conducted 61 interviews with participants who were knowledgeable about the MPDSR system of their country, including policymakers, healthcare providers, and public health officials, at the national, subnational and facility levels. We applied content analysis to inductively identify themes and categories. Results Our findings suggest that participants perceive the goal of MPDSR as going beyond local quality improvement to encompass broader healthcare system strengthening. Four enabling components supporting sustained implementation were identified in all three countries: 1. coordination of the MPDSR “programme” through committees across levels; 2. adoption and integration of a data management and analysis system; 3. a confidential, nonpunitive approach supported by committed leadership; and 4. a multilevel, country-specific response strategy integrated with a broader health system strengthening. Sri Lanka demonstrated a highly centralized and structured approach, whereas Nigeria’s federal system showcased more diverse, multilevel stakeholder engagement. North Macedonia’s facility-based approach focused on the immediate implementation of quality improvements. Conclusions The findings reveal that a structured, multilevel approach that is interconnected with the broader health system is supporting sustained MPDSR implementation. The potential of MPDSR as a health system programme that goes beyond facility-level mortality reduction links to an integrated health system strengthening and accountability at multiple levels.

Background: Sexual and Reproductive Health and Rights (SRHR) is a concept of human rights applied to sexuality and reproduction. Suboptimal access to SRHR services in many low-income countries results in poor health outcomes. Sustainable development goals (3.7 and 5.6) give a new impetus to the aspiration of universal access to high-quality SRHR services. Indispensable stakeholders in this process are healthcare practitioners who, through their actions or inactions, determine a population's health choices. Often times, healthcare practitioners' SRHR decisions are rooted in religious and cultural influences. We seek to understand whether religious and cultural influences differ significantly according to individuals' characteristics and work environment. Objective: The purpose of this study was to examine the role of healthcare practitioners' individual characteristics and their work environment in predicting normative SRHR attitudes and behaviours (practices). We hypothesized that religion and culture could be significant predictors of SRHR attitudes and practices. Methods: A quantitative cross-sectional study of 115 participants from ten low-income countries attending a capacity-building programme at Lund University Sweden was conducted. Linear regression models were used to assess for the predictive values of different individual characteristics and workplace environment factors for normative SRHR attitudes and SRHR practices. Results: Self-rated SRHR knowledge was the strongest predictor for both normative SRHR attitudes and normative SRHR practices. However, when adjusted for other individual characteristics, self-rated knowledge lost its significant association with SRHR practices, instead normative SRHR attitudes and active knowledge-seeking behaviour independently predicted normative SRHR practices. Contrary to our hypothesis, importance of religion or culture in an individual's life was not correlated with the measured SRHR attitudes and practices. Conclusion: Healthcare practitioners' cultural and religious beliefs, which are often depicted as barriers for implementing full coverage of SRHR services, seem to be modified by active knowledge-seeking behaviour and accumulated working experience with SRHR over time.

Progress The past ten years have seen uneven developments in women's and adolescents' health and reproductive rights. Globally, reductions of maternal and neonatal mortality rates and adolescent birth rates have been achieved along with improvements in coverage of key reproductive and maternal health services. However, preterm birth rates have not changed significantly. There is still large variation in these rates across the world, with the highest rates occurring in South Asia and sub-Saharan Africa. Programmatic priorities Effective interventions based on current clinical guidelines are available that can prevent preterm birth or reduce its negative impacts on newborns. These recommended interventions can be delivered as part of essential health service packages during the preconception, antenatal, intrapartum, and postnatal phases. They encompass comprehensive family planning services that enable women and adolescent girls to determine the timing and number of children they have, and the provision of prevention and treatment-related interventions during pregnancy, childbirth, and the postnatal period that improve maternal and newborn health including reducing preterm births as well as stillbirths. Health system improvements are needed so that all women are reached with these services and that they are provided respectfully and according to standards. Pivots To better prevent and manage preterm births as part of broader goals of improving maternal and newborn health, health systems need to be strengthened so that all women are reached with essential packages of care before, during, and after pregnancy and childbirth. Achieving this and integrating these service packages into universal health coverage strategies requires collaboration across government leaders, civil society members, private sector actors, and development partners. Increasing coverage of antenatal care, institutional delivery, and postnatal care represents an opportunity to improve the quality of care provided during those service contacts including through the provision of interventions that address modifiable risk factors for preterm birth such as prevention and treatment of infections, poor nutritional status, and substance use. Other pivots to enhance the quality of care include using existing tools to optimize the management of preterm birth, such as appropriate use of antenatal corticosteroids, and providing respectful person-centred care for women, adolescents, and families. Plain language summary Over the past decade, progress in women's and adolescents' health and reproductive rights has been uneven. Significant advancements have been made in family planning, antenatal care, skilled birth attendance, postnatal care, and the provision of sexual and reproductive health services. Maternal and neonatal mortality rates have dropped, although the pace of decline has slowed in recent years. Preterm birth rates, however, have remained relatively unchanged across regions, with most preterm births occurring in low- and middle-income countries. Programmatic priorities focus on the health sector's ability to offer evidence-based services to all women that can prevent preterm birth or mitigate the effects on newborns. This can be achieved through the implementation of high-quality service packages during the preconception, antenatal, intrapartum, and postnatal stages, based on current clinical guidelines. Also, well-coordinated intersectoral interventions are needed for countries to achieve substantial preterm birth reductions. Health systems must be strengthened so that they are ready to provide high quality services for the prevention and management of preterm birth, most of which are also effective at improving other aspects of maternal and newborn health including prevention of stillbirths. This requires collaboration among government leaders, civil society, the private sector, and development partners. Integrating sexual, reproductive, and maternal health services into primary health care systems and working towards universal health coverage are critical steps in achieving these goals. To reduce preterm births, service packages that improve women's nutrition, prevent infections and reduce stress and substance use during pregnancy should be scaled up. Additionally, enhancing the quality of care for women and adolescents before, during, and after childbirth is crucial. This includes optimizing preterm birth management with antenatal corticosteroids and providing respectful, person-centered care that values women's voices in the health care context.

The global community has committed to achieving universal access to sexual and reproductive health and rights (SRHR) services, but how to do it remains a challenge in many low-income countries. Capacity development is listed as a means of implementation for Agenda 2030. Although it has been a major element in international development cooperation, including SRHR, its effectiveness and circumstances under which it succeeds or fails have limited evidence. The study sought to examine whether improvement in team capacity of SRHR practitioners resulted in improved organisational effectiveness and/or improved SRHR outcomes in low-income countries. The study involved 99 SRHR interventions implemented in 13 countries from Africa and Asia. Self-reported evaluation data from healthcare practitioners who participated in a capacity development international training programme in SRHR was used. The training was conducted by Lund University in Sweden between 2015 and 2019. Logistic regression models were used to examine the association between improved team capacity, improved organizational effectiveness and improved SRHR outcomes, for all the 99 interventions. Adoption of new SRHR approaches (guidelines and policies), media engagement, support from partner organisations and involvement of stakeholders were assessed as possible confounders. Improved team capacity, support from partner organisations and media engagement were positively associated with improved organisational effectiveness. Improved team capacity was the strongest predictor of organisational effectiveness even after controlling for other covariates at multivariate analysis. However, adopting new SRHR approaches significantly reduced organisational effectiveness. Furthermore, support from partner organisations was positively associated with increased awareness of and demand for SRHR services. Successful implementation of capacity development interventions requires an enabling environment. In this study, an SRHR training programme aiming at improving team capacity resulted in an improvement in organisational effectiveness. Support from partner organisations and media engagement were key enablers of organisational effectiveness.

ObjectiveTo assess the effects of perinatal death (PND) audit on perinatal outcomes in a tertiary hospital in Kampala.DesignInterrupted time series (ITS) analysis.SettingNsambya Hospital, Uganda.ParticipantsLive births and stillbirths.InterventionsPND audit.Primary and secondary outcome measuresPrimary outcomes: perinatal mortality rate, stillbirth rate, early neonatal mortality rate. Secondary outcomes: case fatality rates (CFR) for asphyxia, complications of prematurity and neonatal sepsis.Results526 PNDs were audited: 142 (27.0%) fresh stillbirths, 125 (23.8%) macerated stillbirths and 259 (49.2%) early neonatal deaths. The ITS analysis showed a decrease in perinatal death (PND) rates without the introduction of PND audits (incidence risk ratio (IRR) (95% CI) for time=0.94, p<0.001), but an increase in PND (IRR (95% CI)=1.17 (1.0 to –1.34), p=0.0021) following the intervention. However, when overdispersion was included in the model, there were no statistically significant differences in PND with or without the intervention (p=0.06 and p=0.44, respectively). Stillbirth rates exhibited a similar pattern. By contrast, early neonatal death rates showed an overall upward trend without the intervention (IRR (95% CI)=1.09 (1.01 to 1.17), p=0.01), but a decrease following the introduction of the PND audits (IRR (95% CI)=0.35 (0.22 to 0.56), p<0.001), when overdispersion was included. The CFR for prematurity showed a downward trend over time (IRR (95% CI)=0.94 (0.88 to 0.99), p=0.04) but not for the intervention. With regards CFRs for intrapartum-related hypoxia or infection, no statistically significant effect was detected for either time or the intervention.ConclusionThe introduction of PND audit showed no statistically significant effect on perinatal mortality or stillbirth rate, but a significant decrease in early neonatal mortality rate. No effect was detected on CFRs for prematurity, intrapartum-related hypoxia or infections. These findings should encourage more research to assess the effectiveness of PND reviews on perinatal deaths in general, but also on stillbirths and neonatal deaths in particular, in low-resource settings.

Background Oxidative stress plays a role in the pathogenesis of pre-eclampsia. Supplementing women with antioxidants during pregnancy may reduce oxidative stress and thereby prevent or delay the onset pre-eclampsia. The objective of this study was to evaluate the effect of supplementing vitamin C in pregnancy on the incidence of pre-eclampsia, at Mulago hospital, Kampala, Uganda. Methods This was a (parallel, balanced randomization, 1:1) placebo randomized controlled trial conducted at Mulago hospital, Department of Obstetrics and Gynecology. Participants included in this study were pregnant women aged 15-42 years, who lived 15 km or less from the hospital with gestational ages between 12-22 weeks. The women were randomized to take 1000mg of vitamin C (as ascorbic acid) or a placebo daily until they delivered. The primary outcome was pre-eclamsia. Secondary outcomes were: severe pre-eclampsia, gestational hypertension, preterm delivery, low birth weight and still birth delivery. Participants were 932 pregnant women randomized into one of the two treatment arms in a ratio of 1:1. The participants, the care providers and those assessing the outcomes were blinded to the study allocation. Results Of the 932 women recruited; 466 were randomized to the vitamin and 466 to the placebo group. Recruitment of participants was from November 2011 to June 2012 and follow up was up to January 2013. Outcome data was available 415 women in the vitamin group and 418 women in the placebo group. There were no differences in vitamin and placebo groups in the incidence of pre-eclampsia (3.1% versus 4.1%; RR 0.77; 95% CI: 0.37-1.56), severe pre-eclampsia (1.2% versus 1.0%; RR 1.25; 95% CI: 0.34-4.65), gestational hypertension(7.7% versus 11.5%; RR 0.67; 95% CI: 0.43-1.03), preterm delivery (11.3% versus 12.2%; RR 0.92; 95% CI: 0.63-1.34), low birth weight (11.1% versus 10.3%; RR 1.07; 95% CI: 0.72-1.59) and still birth delivery (4.6% versus 4.5%; RR 1.01; 95% CI: 0.54-1.87). Conclusions Supplementation with vitamin C did not reduce the incidence of pre-eclampsia nor did it reduce the adverse maternal or neonatal outcomes. We do not recommend the use of vitamin C in pregnancy to prevent pre-eclampsia. Trial registration This study was registered at the Pan African Clinical Trial Registry, PACTR201210000418271 on 25 th October 2012.

Several recent reviews of maternal, newborn, and child health (MNCH) and mortality have emphasised that a large range of interventions are available with the potential to reduce deaths and disability. The emphasis within MNCH varies, with skilled care at facility levels recommended for saving maternal lives and scale-up of community and household care for improving newborn and child survival. Systematic review of new evidence on potentially useful interventions and delivery strategies identifies 37 key promotional, preventive, and treatment interventions and strategies for delivery in primary health care. Some are especially suitable for delivery through community support groups and health workers, whereas others can only be delivered by linking community-based strategies with functional first-level referral facilities. Case studies of MNCH indicators in Pakistan and Uganda show how primary health-care interventions can be used effectively. Inclusion of evidence-based interventions in MNCH programmes in primary health care at pragmatic coverage in these two countries could prevent 20-30% of all maternal deaths (up to 32% with capability for caesarean section at first-level facilities), 20-21% of newborn deaths, and 29-40% of all postneonatal deaths in children aged less than 5 years. Strengthening MNCH at the primary health-care level should be a priority for countries to reach their Millennium Development Goal targets for reducing maternal and child mortality.

Background Uganda adopted maternal and perinatal death surveillance and response (MPDSR) in 2017 and has put concerted effort into scaling up and using data on MPDSR to avert preventable deaths. However, formal analysis of MPDSR implementation processes among health facilities in Uganda has been limited. The purpose of this study was to assess the implementation of MPDSR processes in referral hospitals in Uganda, using a tested measurement approach. Methods From November to December 2022, a cross-sectional study was conducted to assess MPDSR implementation processes in Uganda’s referral hospitals. The tool, adapted from previous studies, uses a 30-point scoring guide to measure progress markers across six stages of implementation. Data collectors visited 15 regional and national referral hospitals and conducted interviews with two members of the MPDSR committee per facility. Descriptive statistics were used to summarize scores by construct and total scores for the facilities. A content analysis from open-ended questions provided contextual insights. Results The average score for MPDSR implementation among referral hospitals in the study was 20.2 out of 30 (range 16 – 27) possible points, which falls in a category showing evidence of routine practice and integration. Progress markers which had particularly low scores included: written staff agreements about MPDSR and orientation of new staff to death reviews. No hospital reported having a budget to support death review meetings. Almost all committee members listed specific ways that MPDSR led to positive changes in quality of care. Conclusion The overall score of 20.2 was somewhat higher when compared to other countries who have applied this measurement approach (in four countries, average 18.98). Only four of the surveyed hospitals demonstrated sustained practice of MPDSR, suggesting that there is still much work to be done to institutionalize MPDSR in Uganda’s referral hospitals. Specific action areas can be pinpointed using the findings on progress markers. The scored MPDSR implementation assessment tool was easy to use and well accepted. We recommend annually updating the tool to reflect new directions and developments in MPDSR implementation, and routine use to self- or externally assess hospitals’ implementation of MPDSR.