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A reduction in maternal mortality has traditionally been used as a critical measure of progress in improving maternal health. If a 75% reduction in maternal mortality between 1990 and 2015 -- the target set under Millennium Development Goal 5 -- is to be attained, people must redouble their efforts. In this endeavour, governments, policy-makers, donors, researchers, civil society and other stakeholders have come together in unprecedented fashion. Yet despite the fact that the maternal mortality ratio is considered one of the main indicators of a country's status in the area of maternal health, the burden of maternal mortality is only a small fraction of the burden of maternal morbidity -- the health problems borne by women during pregnancy and the postpartum period. The true burden of maternal morbidity is still not known, however. Existing estimates and calculations are not based on standard, well documented and transparent methods. Such methods are not very useful and have poor validity for informing efforts to address the problem of maternal morbidity.

Background Maternal Death Surveillance and Response (MDSR) implementation is monitored globally, but not much is known about what works well, where and why in scaling up. We reviewed a series of country case studies in order to determine whether and to what extent these countries have implemented the four essential components of MDSR and identify lessons for improving implementation. Methods A secondary analysis of ten case studies from countries at different stages of MDSR implementation, using a policy analysis framework to draw out lessons learnt and opportunities for improvement. We identify the consistent drivers of success in countries with well-established systems for MDSR, and common barriers in countries were Maternal Death Review (MDR) systems have been less successful. Results MDR is accepted and ongoing at subnational level in many countries, but it is not adequately institutionalised and the shift from facility based MDR to continuous MDSR that informs the wider health system still needs to be made. Our secondary analysis of country experiences highlights the need for a) social and team processes at facility level, for example the existence of a ‘no shame, no blame’ culture, and the ability to reflect on practice and manage change as a team for recommendations to be acted upon, b) health system inputs including adequate funding and reliable health information systems to enable identification and analysis of cases c) national level coordination of dissemination, and monitoring implementation of recommendations at all levels and d) mandatory notification of maternal deaths (and enforcement of this) and a professional requirement to participate in MDRs. Conclusions Case studies from countries with established MDSR systems can provide valuable guidance on ways to set up the processes and overcome some of the barriers; but the challenge, as with many health system interventions, is to find a way to provide catalytic assistance and strengthen capacity for MDSR such that this becomes embedded in the health system.

Although 80% of children with disabilities live in developing countries, there are few culturally appropriate developmental assessment tools available for these settings. Often tools from the West provide misleading findings in different cultural settings, where some items are unfamiliar and reference values are different from those of Western populations. Following preliminary and qualitative studies, we produced a draft developmental assessment tool with 162 items in four domains of development. After face and content validity testing and piloting, we expanded the draft tool to 185 items. We then assessed 1,426 normal rural children aged 0-6 y from rural Malawi and derived age-standardized norms for all items. We examined performance of items using logistic regression and reliability using kappa statistics. We then considered all items at a consensus meeting and removed those performing badly and those that were unnecessary or difficult to administer, leaving 136 items in the final Malawi Developmental Assessment Tool (MDAT). We validated the tool by comparing age-matched normal children with those with malnutrition (120) and neurodisabilities (80). Reliability was good for items remaining with 94%-100% of items scoring kappas >0.4 for interobserver immediate, delayed, and intra-observer testing. We demonstrated significant differences in overall mean scores (and individual domain scores) for children with neurodisabilities (35 versus 99 [p<0.001]) when compared to normal children. Using a pass/fail technique similar to the Denver II, 3% of children with neurodisabilities passed in comparison to 82% of normal children, demonstrating good sensitivity (97%) and specificity (82%). Overall mean scores of children with malnutrition (weight for height <80%) were also significantly different from scores of normal controls (62.5 versus 77.4 [p<0.001]); scores in the separate domains, excluding social development, also differed between malnourished children and controls. In terms of pass/fail, 28% of malnourished children versus 94% of controls passed the test overall. A culturally relevant developmental assessment tool, the MDAT, has been created for use in African settings and shows good reliability, validity, and sensitivity for identification of children with neurodisabilities.

Assessment of risk factors for preterm birth in a population with high incidence of preterm birth and HIV infection. Secondary analysis of data for 2,149 women included in a community based randomized placebo controlled trial for the prevention of preterm birth (APPLe trial (ISRCTN84023116) with gestational age at birth determined through ultrasound measurement in early pregnancy. Multivariate Logistic Regression analyses to obtain models for three outcome variables: all preterm, early preterm, and late preterm birth. No statistical differences were noted for the prevalence of HIV infection (p = 0.30) or syphilis (p = 0.12) between women who delivered preterm versus term. BMI (Adjusted OR 0.91 (0.85-0.97); p = 0.005) and weight gain (Adjusted OR 0.89 (0.82-0.97); p = 0.006) had an independent, protective effect. Previous preterm birth doubled the odds of preterm birth (Adjusted OR 2.13 (1.198-3.80); p = 0.01). Persistent malaria (despite malaria prophylaxis) increased the risk of late preterm birth (Adjusted OR 1.99 (1.05-3.79); p = 0.04). Age <20 (Adjusted OR 1.73 (1.03-2.90); p = 0.04) and anemia (Adjusted OR 1.95 (1.08-3.52); p = 0.03) were associated with early preterm birth (<34 weeks). Despite claims that HIV infection is an important cause of preterm birth in Africa, we found no evidence of an association in this population (unexposed to anti-retroviral treatment). Persistent malaria was associated with late preterm birth. Maternal undernourishment and anemia were independently associated with early preterm birth. The study did not assess whether the link was direct or whether a common precursor such as chronic infection was responsible for both maternal effects and early labour.

Governance of the health system is a relatively new concept and there are gaps in understanding what health system governance is and how it could be assessed. We conducted a systematic review of the literature to describe the concept of governance and the theories underpinning as applied to health systems; and to identify which frameworks are available and have been applied to assess health systems governance. Frameworks were reviewed to understand how the principles of governance might be operationalized at different levels of a health system. Electronic databases and web portals of international institutions concerned with governance were searched for publications in English for the period January 1994 to February 2016. Sixteen frameworks developed to assess governance in the health system were identified and are described. Of these, six frameworks were developed based on theories from new institutional economics; three are primarily informed by political science and public management disciplines; three arise from the development literature and four use multidisciplinary approaches. Only five of the identified frameworks have been applied. These used the principal–agent theory, theory of common pool resources, North’s institutional analysis and the cybernetics theory. Governance is a practice, dependent on arrangements set at political or national level, but which needs to be operationalized by individuals at lower levels in the health system; multilevel frameworks acknowledge this. Three frameworks were used to assess governance at all levels of the health system. Health system governance is complex and difficult to assess; the concept of governance originates from different disciplines and is multidimensional. There is a need to validate and apply existing frameworks and share lessons learnt regarding which frameworks work well in which settings. A comprehensive assessment of governance could enable policy makers to prioritize solutions for problems identified as well as replicate and scale-up examples of good practice. La gouvernance du système de santé est un concept relativement nouveau et il existe des lacunes dans la compréhension de la gouvernance du système de santé et de la meilleure manière de l’évaluer. Nous avons procédé à une revue systématique des publications pour décrire le concept de gouvernance et les théories sous-jacentes appliquées aux systèmes de santé; et pour identifier les cadres disponibles qui ont été appliqués afin d’évaluer la gouvernance des systèmes de santé. Les cadres ont été examinés pour comprendre comment les principes de gouvernance peuvent être opérationnels à différents niveaux d’un système de santé. Les bases de données électroniques et les portails Web des institutions internationales concernées par la gouvernance ont été consultés pour rechercher des publications en anglais au cours de la période de janvier 1994 à février 2016. On a procédé à l’identification et à la description de seize cadres élaborés pour évaluer la gouvernance dans le système de santé. Six de ces cadres ont été élaborés sur la base de théories tirées de la nouvelle économie institutionnelle; trois tirent leur substance des disciplines de la science politique et de la gestion publique; trois découlent de la littérature sur le développement et quatre utilisent des approches multidisciplinaires. Seuls cinq des cadres identifiés ont été appliqués. Ceux-ci ont eu recours à la théorie du « mandantmandataire », la théorie des ressources propriété commune, l’analyse institutionnelle de North et à la théorie de la cybernétique. La gouvernance est une pratique, dépendante des arrangements définis au niveau politique ou national, mais qui doit être mise en œuvre par des individus à des niveaux inférieurs du système de santé; cette approche est reconnue par les cadres multiniveaux. Trois cadres ont été utilisés pour évaluer la gouvernance à tous les niveaux du système de santé. La gouvernance du système de santé est complexe et difficile à évaluer; le concept de gouvernance provient de différentes disciplines et est multidimensionnel. Il est nécessaire de valider et d’appliquer les cadres existants, mais également de partager les leçons apprises des cadres qui fonctionnent bien dans certains contextes. Une évaluation globale de la gouvernance peut permettre aux décideurs de prioriser les solutions aux problèmes identifiés tout en reproduisant et en transposant les exemples de bonnes pratiques à grande échelle. 卫生体系治理是一个较新的概念, 关于什么是卫生体系治理, 如何评估卫生体系治理, 还存在理解上的空白。我们队文献进 行了系统综述, 描述卫生体系中治理的概念和理论基础, 总结 现有的以及被用于评估卫生体系治理的框架。我们回顾了这 些框架, 理解治理的原则在卫生体系的各个层级如何落实。检 索电子数据库和治理相关的国际机构的网站门户, 查找1994年 1月至2016年2月间以英语发表的文献。我们发现并描述了16 个评估卫生体系治理的框架。其中6个框架是基于新制度经济 学；三个主要受政治学和公共管理学科影响；三个源自发展 研究文献, 四个采用多学科方法。仅有五个框架得到实践。分 别采用委托代理理论、公共池塘资源理论、D. C. North 的制 度分析和控制论。治理是一种行为, 依赖政治或国家层面的部 署, 但需要卫生体系较低层级的个人来执行；这一点在多层框 架中得到了体现。有三个框架用于评估卫生体系所有层级的 治理。卫生体系治理非常复杂, 难以评估；治理的概念源自不 同学科, 是一个多维概念。有必要验证并应用现有的框架, 分 享何种框架适用于何种环境的经验。对治理的全面评估可帮 助决策者根据评估发现的问题优先选择解决方案, 并且复制推 广好的做法。 La gobernanza del sistema de salud es un concepto relativamente nuevo y hay vacíos en la comprensión de lo que es la gobernanza del sistema de salud y cómo podría ser evaluada. Llevamos a cabo una revisión sistemática de la literatura para describir el concepto de gobernanza, las teorías subyacentes y como son aplicadas a los sistemas de salud; y para identificar qué marcos están disponibles y han sido aplicados para evaluar la gobernanza de los sistemas de salud. Los marcos fueron revisados para entender cómo los principios de gobernanza podrían ser operados a diferentes niveles de un sistema de salud. Se hicieron búsquedas en bases de datos electrónicas y portales web de instituciones internacionales relacionadas con la gobernanza para encontrar publicaciones en inglés para el período enero 1994 a febrero 2016. Dieciséis marcos desarrollados para evaluar la gobernanza en el sistema de salud fueron identificados y se describen. De estos, seis marcos fueron desarrollados sobre la base de teorías de la nueva economía institucional; tres están principalmente informados por las disciplinas de ciencia política y gestión pública; tres surgen de la literatura de desarrollo y cuatro utilizan enfoques multidisciplinarios. Sólo cinco de los marcos identificados han sido aplicados. Estos usaron la teoría del agente-principal, la teoría de los recursos comunes agrupados, el análisis institucional de North y la teoría de la cibernética. La gobernanza es una práctica que depende de arreglos establecidos a nivel político o nacional, pero que necesitan ser operados por individuos en niveles inferiores en el sistema de salud; los marcos multinivel lo reconocen. Se usaron tres marcos para evaluar la gobernanza en todos los niveles del sistema de salud. La gobernanza del sistema de salud es compleja y difícil de evaluar; el concepto de gobernanza se origina en diferentes disciplinas y es multidimensional. Es necesario validar y aplicar los marcos existentes y compartir las lecciones aprendidas sobre qué marcos trabajan bien en qué entornos. Una evaluación exhaustiva de la gobernanza podría permitir a los formuladores de políticas dar prioridad a las soluciones para los problemas identificados, así como replicar y ampliar los ejemplos de buenas prácticas.

BackgroundWe sought to determine the impact of the Ebola virus epidemic on the availability, uptake and outcome of routine maternity services in Sierra Leone.MethodsThe number of antenatal and postnatal visits, institutional births, availability of emergency obstetric care (EmOC), maternal deaths and stillbirths were assessed by month, by districts and by level of healthcare for 10 months during, and 12 months prior to, the Ebola virus disease (EVD) epidemic. All healthcare facilities designated to provide comprehensive (n=13) or basic (n=67) EmOC across the 13 districts of Sierra Leone were included.ResultsPreservice students were not deployed during the EVD epidemic. The number of healthcare providers in facilities remained constant (incidence rate ratio (IRR) 1.03, 95% CI 1.00 to 1.07). Availability of antibiotics, oxytocics, anticonvulsants, manual removal of placenta, removal of retained products of conception, blood transfusion and caesarean section were not affected by the EVD epidemic. Across Sierra Leone, following the onset of the EVD epidemic, there was a 18% decrease in the number of women attending for antenatal (IRR 0.82, 95% CI 0.79 to 0.84); 22% decrease in postnatal attendance (IRR 0.78, 95% CI 0.75 to 0.80) visits and 11% decrease in the number of women attending for birth at a healthcare facility (IRR 0.89, 95% CI 0.87 to 0.91). There was a corresponding 34% increase in the facility maternal mortality ratio (IRR 1.34, 95% CI 1.07 to 1.69) and 24% increase in the stillbirth rate (IRR 1.24, 95% CI 1.14 to 1.35).ConclusionsDuring the EVD epidemic, fewer pregnant women accessed healthcare. For those who did, an increase in maternal mortality and stillbirth was observed. In the post-Ebola phase, ‘readiness’ (or not) of the global partners for large-scale epidemics has been the focus of debate. The level of functioning of the health system with regard to ability to continue to provide high-quality effective routine care needs more attention.

To describe tools used for the assessment of maternal and child health issues in humanitarian emergency settings. We systematically searched MEDLINE, Web of Knowledge and POPLINE databases for studies published between January 2000 and June 2014. We also searched the websites of organizations active in humanitarian emergencies. We included studies reporting the development or use of data collection tools concerning the health of women and children in humanitarian emergencies. We used narrative synthesis to summarize the studies. We identified 100 studies: 80 reported on conflict situations and 20 followed natural disasters. Most studies (76/100) focused on the health status of the affected population while 24 focused on the availability and coverage of health services. Of 17 different data collection tools identified, 14 focused on sexual and reproductive health, nine concerned maternal, newborn and child health and four were used to collect information on sexual or gender-based violence. Sixty-nine studies were done for monitoring and evaluation purposes, 18 for advocacy, seven for operational research and six for needs assessment. Practical and effective means of data collection are needed to inform life-saving actions in humanitarian emergencies. There are a wide variety of tools available, not all of which have been used in the field. A simplified, standardized tool should be developed for assessment of health issues in the early stages of humanitarian emergencies. A cluster approach is recommended, in partnership with operational researchers and humanitarian agencies, coordinated by the World Health Organization.

Background The three delays model proposes that maternal mortality is associated with delays in: 1) deciding to seek care; 2) reaching the healthcare facility; and 3) receiving care. Previously, the majority of women who died were reported to have experienced type 1 and 2 delays. With increased coverage of healthcare services, we sought to explore the relative contribution of each type of delay. Method 151 maternal deaths were identified during a 12-month reproductive age mortality survey (RAMOS) conducted in Malawi; verbal autopsy and facility-based medical record reviews were conducted to obtain details about the circumstances surrounding each death. Using the three delays framework, data were analysed for women who had; 1) died at a healthcare facility, 2) died at home but had previously accessed care and 3) died at home and had not accessed care. Results 62.2% (94/151) of maternal deaths occurred in a healthcare facility and a further 21.2% (32/151) of mothers died at home after they had accessed care at a healthcare facility. More than half of all women who died at a healthcare facility (52.1%) had experienced more than one type of delay. Type 3 delays were the most significant delay for women who died at a healthcare facility or women who died at home after they had accessed care, and was identified in 96.8% of cases. Type 2 delays were experienced by 59.6% and type 1 delays by 39.7% of all women. Long waiting hours before receiving treatment at a healthcare facility, multiple delays at the time of admission, shortage of drugs, non-availability and incompetence of skilled staff were some of the major causes of type 3 delays. Distance to a healthcare facility was the main problem resulting in type 2 delays. Conclusion The majority of women do try to reach health services when an emergency occurs, but type 3 delays present a major problem. Improving quality of care at healthcare facility level will help reduce maternal mortality.

For more accurate estimation of the global burden of pregnancy associated disease, clarity is needed on definition and assessment of non-severe maternal morbidity. Our study aimed to define maternal morbidity with clear criteria for identification at primary care level and estimate the distribution of and evaluate associations between physical (infective and non-infective) and psychological morbidities in two different low-income countries. Cross sectional study with assessment of morbidity in early pregnancy (34%), late pregnancy (35%) and the postnatal period (31%) among 3459 women from two rural communities in Pakistan (1727) and Malawi (1732). Trained health care providers at primary care level used semi-structured questionnaires documenting signs and symptoms, clinical examination and laboratory tests which were bundled to reflect infectious, non-infectious and psychological morbidity. One in 10 women in Malawi and 1 in 5 in Pakistan reported a previous pregnancy complication with 1 in 10 overall reporting a previous neonatal death or stillbirth. In the index pregnancy, 50.1% of women in Malawi and 53% in Pakistan were assessed to have at least one morbidity (infective or non-infective). Both infective (Pakistan) and non-infective morbidity (Pakistan and Malawi) was lower in the postnatal period than during pregnancy. Multiple morbidities were uncommon (<10%). There were marked differences in psychological morbidity: 26.9% of women in Pakistan 2.6% in Malawi had an Edinburgh Postnatal Depression Score (EPDS) > 9. Complications during a previous pregnancy, infective morbidity (p <0.001), intra or postpartum haemorrhage (p <0.02) were associated with psychological morbidity in both settings. Our findings highlight the need to strengthen the availability and quality of antenatal and postnatal care packages. We propose to adapt and improve the framework and criteria used in this study, ensuring a basic set of diagnostic tests is available, to ensure more robust assessment of non-severe maternal morbidity.