BACKGROUND: A birth companion is a simple and low-cost intervention that can improve both maternal and newborn health outcomes. The evidence that birth companionship improves labor outcomes and experiences of care has been available for many years. Global and national policies exist in support of birth companions. Many countries including Ethiopia, Kenya, and Nigeria have not yet incorporated birth companions into routine practice in health facilities. This paper presents the protocol for a trial that aims to assess if a package of interventions that addresses known barriers can increase the coverage of birth companions.
METHODS: This two parallel arm cluster randomized controlled trial will evaluate the impact of a targeted intervention package on scale-up of birth companionship at public sector health facilities in Ethiopia (five study sites encompassing 12 facilities), Kenya (two sites encompassing 12 facilities in Murang\'a and 12 facilities in Machakos counties), and Nigeria (two sites encompassing 12 facilities in Kano and 12 facilities in Nasarawa states). Baseline and endline assessments at each site will include 744 women who have recently given birth in the quantitative component. We will interview a maximum of 16 birth companions, 48 health care providers, and eight unit managers quarterly for the qualitative component in each country.
CONCLUSIONS: Ample evidence supports the contribution of birth companions to positive health outcomes for mothers and newborns. However, limited data are available on effective strategies to improve birth companion coverage and inform scale-up efforts. This trial tests a birth companion intervention package in diverse clinical settings and cultures to identify possible barriers and considerations to increasing uptake of birth companions. Findings from this study may provide valuable evidence for scaling up birth companionship in similar settings.
BACKGROUND: Trial is registered with ClinicalTrials.gov with identifier: NCT05565196, first posted 04/10/ 2022.

Traditional birth attendants (TBAs) provided delivery care throughout the world prior to the development of organized systems of medical care. In 2016, an estimated 22% of pregnant women delivered with a TBA, mostly in rural or remote areas that lacked formal health services. Still active in many regions of LMICs, they provide care, including support and advice, to women during pregnancy and childbirth. Even though they generally have no formal training and are not recognized as medical practitioners, TBAs enjoy a high societal standing and many families seek them as health care providers. They are generally older women who have acquired their skills acting as apprentices of other TBAs or are self-taught. WHO and other international organizations have focused maternal mortality reduction efforts on the availability of skilled birth attendance, which excludes TBAs as providers of care. However, as countries move towards SBA, policy makers need to make the best use of TBAs while simultaneously planning for their replacement with skilled attendants. They often serve as a bridge between the community and the formal health system; once women are inside an institution, TBAs could potentially act as doulas, providing company and making women feel more comfortable in an unknown environment. In this paper, we will review who TBAs are, how many births they attend worldwide worldwide, where they provide delivery care, and finally, their relationships with the formal health care system and the communities they serve.

Globally, countries have made impressive strides toward achieving targets set by the Millennium Development Goals (MDGs) to reduce maternal mortality. The subsequent Sustainable Development Goals (SDGs) have further challenged countries to accelerate these reductions. While Indonesia invested in several initiatives to improve care for mothers and newborns and made large gains in improving skilled care at birth, the country fell short of its MDG target. This paper outlines some of the remaining challenges and highlights the role of the US Agency for International Development-funded Expanding Maternal and Neonatal Survival (EMAS) program in eliminating the barriers to improved care. Achieving the SDGs by 2030 will require strong cross-sectoral collaboration and innovative approaches, such as the recent launch of Indonesia\'s national health insurance program, which can accelerate reductions in mortality by reaching women most in need of services.

The major causes of maternal and neonatal mortality in the Philippines are hemorrhages and obstructed labor due to placental implantation abnormalities (PIAs), twin pregnancies and fetal malpresentations. All of which are all easily detected by ultrasound. However, women in rural areas and low-income groups do not have access to ultrasound during their prenatal care. We aimed to provide additional evidence on the benefits of handheld ultrasound (HU) for screening pregnancy related abnormalities in order to avert maternal and neonatal deaths.
Using a HU, we trained community healthcare workers (CHWs) to identify 5 obstetrical conditions: fetal viability and number, placental localization, amniotic fluid volume (AFV) and fetal presentation. Women, between 20th and 24th weeks age of gestation from 2 regions of the Philippines, were scanned using the HU and the GE Logic 5 Premium ultrasound machine for validation. Maternal and neonatal deaths averted were estimated as health outcome measures of the study.
Four hundred sixty women were scanned of which 146 (31.7%) showed abnormal ultrasound readings consisting of 17 PIAs, 123 fetal malpresentation, 3 twins and 3 AFV abnormalities. The use of HU could have possibly averted 29 (6.3%) maternal deaths and 14.6% neonatal deaths at the time of delivery. Thirty-two out of the 460 women (~7%) delivered at home and 93% in hospitals or birthing facilities/lying-in centers. We observed approximately 95% agreement between the ultrasound readings of the trainees and the trainers, and 99% agreement between the readings made from the HU with the validation machine.
CHWs could be trained in the use of HU for scanning 5 obstetrical parameters. Early detection of abnormalities in these 5 obstetrical parameters can lead to early referral to facilities that are better equipped to manage obstetrical emergencies. Prenatal ultrasound can be an excellent point of care test for screening pregnant women at risk for possible complications and even death during labor and delivery.
Thai Clinical Trial Registry identification number TCTR20171128004 , retrospectively registered November 28, 2017.

OBJECTIVE: In Ghana, regional referral facilities by design receive a disproportionate number of high-risk obstetric and neonatal cases and therefore have mortality rates higher than the national average. High volumes and case complexity result in these facilities experiencing unique clinical, operational, and leadership challenges. In order to improve outcomes in these settings, an integrated approach to strengthen the overall system is needed.
METHODS: Clinical skills strengthening, quality improvement training, and leadership skill building have all been used to improve maternal and neonatal outcomes with some degree of success. We present here a customized model tailored to the particular context of tertiary referral hospitals that develops these three skills simultaneously, so that the complex interaction between clinical conditions, resource constraints, and organizational issues that affect the lives of mothers and babies can be considered together. This model uses local data to identify the drivers of poor maternal and neonatal outcomes and creates an integrated training package to focus on approaches to addressing these drivers. Based on this training, quality improvement projects are introduced to change the appropriate clinical or operational processes, or to strengthen organizational leadership.
RESULTS: In testing in one of the largest referral hospitals in Ghana, the model has been well received and has improved performance in several cross-cutting areas affecting the quality of maternal and neonatal care, such as triage, patient flow, and NICU hand hygiene.
CONCLUSIONS: An integrated approach to systems strengthening in referral hospitals holds much promise for improving outcomes for mothers with high-risk pregnancies and babies in Ghana and in other low-resource settings.
Objectif : Au Ghana, les établissements de recours régionaux reçoivent, de par leur nature, un nombre disproportionné de cas obstétricaux et néonataux exposés à des risques élevés; par conséquent, ces établissements comptent des taux de mortalité plus élevés que la moyenne nationale. Les volumes élevés et la complexité des cas font en sorte que ces établissements ont à faire face à des défis cliniques, opérationnels et de direction particuliers. Dans de telles situations, l’amélioration des issues nécessite la mise en œuvre d’une approche intégrée visant à renforcer le système dans sa globalité. Méthodes : Le renforcement des compétences cliniques, la formation en amélioration de la qualité et la consolidation des compétences propres au leadership sont des outils qui ont tous été utilisés, avec un certain succès, pour améliorer les issues maternelles et néonatales. Nous présentons ici un modèle, ayant été adapté au contexte particulier des hôpitaux de recours tertiaires, qui favorise la mise en œuvre simultanée de ces trois outils, de façon à ce que l’interaction complexe entre les conditions cliniques, les contraintes en matière de ressources et les facteurs organisationnels qui affectent la vie des mères et des enfants puisse être envisagée dans son ensemble. Ce modèle utilise des données locales pour identifier les éléments associés à l’obtention de piètres issues maternelles et néonatales, pour ensuite créer un programme intégré de formation axé sur des approches permettant d’aborder ces éléments. En fonction de ce programme de formation, des projets d’amélioration de la qualité sont mis en œuvre pour modifier les processus cliniques ou opérationnels appropriés, ou pour renforcer le leadership organisationnel. Résultats : Dans le cadre de sa mise à l’essai au sein de l’un des plus importants hôpitaux de recours du Ghana, ce modèle a été bien reçu et a permis une amélioration du rendement dans plusieurs domaines transsectoriels affectant la qualité des soins maternels et néonataux, comme le triage, le roulement des patientes et l’hygiène des mains en UNSI. Conclusion : La mise en œuvre d’une approche intégrée envers le renforcement des systèmes au sein des hôpitaux de recours s’avère fort prometteuse pour l’amélioration des issues chez les mères connaissant des grossesses exposées à des risques élevés et les nouveau-nés du Ghana et d’autres milieux ne disposant que de faibles ressources.

BACKGROUND: The cesarean section is one of the most common procedures to prevent health-threatening risks to the mother and infant. Increasing rate of cesarean section attracted the attention of professionals and the overall objective of this study was to determine the frequency of maternal and neonatal morbidity and mortality rates in the two methods of delivery.
METHODS: In a comparative cohort study, 300 cases undergoing caesarean section and 300 cases with vaginal delivery were selected in two main hospitals of Isfahan, Iran during 2013 and 2014. Demographic characteristics and factors related to mortality and morbidity of mothers and infants were studied. Mothers were also recruited 6 weeks after delivery to ask for complications. Mothers and infants mortality and morbidity were studied and analyzed by SPSS 22 software.
RESULTS: Follow-up of deliveries up to 1-month after delivery suggested 2 cases of infant death (7%) in vaginal delivery group, while no case of infant death was reported in cesarean delivery group (P = 0.5). Incidence of fever was observed in first 10 days after delivery in 7 cases in the vaginal delivery group and 11 cases in the cesarean delivery group (2.3% vs. 3.7%, P = 0.4).
CONCLUSIONS: Despite all the benefits of vaginal delivery compared with cesarean section, in many cases, especially in emergency cesarean section delivery can substantially reduce the maternal and neonatal mortality and morbidity. It is recommended to assess the complications of each method in all pregnant women about to give birth, and then decide on the method of delivery.

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3). Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans. The risks of fetal, perinatal, and neonatal mortality during TOLAC are low. Nonetheless, these risks are significantly higher than those associated with ERCD (LE2). The risks of mask ventilation, intubation for meconium-stained amniotic fluid, and neonatal sepsis all increase in TOLAC (LE2). The risk of transient respiratory distress increases in ERCD (LE2). To reduce this risk, and except in particular situations, ERCD must not be performed before 39 weeks (grade B). TOLAC is possible for women with a previous cesarean before 37 weeks, with 2 previous cesareans, with a uterine malformation, a low vertical incision or an unknown incision, with a myomectomy, postpartum fever, an interval of less than 6 months between the last cesarean delivery and the conception of the following pregnancy, if the obstetric conditions are favorable (professional consensus). ERCD is recommended in women with a scar in the uterine body (grade B) and a history of 3 or more cesareans (professional consensus). Ultrasound assessment of the risk of uterine rupture in women with uterine scars has not been shown to have any clinical utility and is therefore not recommended during pregnancy to help decide the mode of delivery (professional consensus). Use of X-ray pelvimetry to decide about TOLAC is associated with an increase in the repeat cesarean rate without any reduction in the rate of uterine rupture (LE2). It is unnecessary for deciding mode of delivery and for managing labor during TOLAC (grade C). TOLAC should be encouraged for women with a previous vaginal delivery either before or after the cesarean, a favorable Bishop score or spontaneous labor, and for preterm births (grade C). For women with a fetus with an estimated weight of more than 4500 g, especially in the absence of a previous vaginal delivery and those with supermorbid obesity (BMI>50), ERCD must be planned from the outset (grade C). For all of the other clinical situations envisioned (maternal age>35 years, diabetes, morbid obesity, prolonged pregnancy, breech presentation and twin pregnancy), TOLAC is possible but the available data do not allow specific guidelines about the choice of mode of delivery, in view of the low levels of proof (grade C). The decision about planned mode of delivery must be shared by the patient and her physician and made by the 8th month, taking into account the individual risk factors for TOLAC failure and uterine rupture (professional consensus). TOLAC is the preferred choice for women who do not have several risk factors (professional consensus). The availability onsite of an obstetrician and anesthetist must be pointed out to the patient. If the woman continues to prefer a repeat cesarean after adequate information and time to think about it, her preference should be honored (professional consensus). Labor should be induced in woman with a previous cesarean only for medical indications (professional consensus). Induction of labor increases the risk of uterine rupture, which can be estimated at 1% if oxytocin is used and 2% with vaginal prostaglandins (LE2). Mechanical methods of induction have not been studied sufficiently. Misoprostol appears to increase the risk of uterine rupture strongly (LE4). Based on the information now available, its use is not recommended (professional consensus). Routine use of internal tocodynamometry does not prevent uterine rupture (professional consensus). The increased risk of uterine rupture associated with oxytocin use is dose-dependent (LE3). In the active phase, it is recommended that the total duration of failure to progress should not exceed 3h; at that point, a cesarean should be performed (professional consensus). Epidural analgesia must be encouraged. The simple existence of a uterine scar is not an indication for a routine manual uterine examination after VBAC (grade C).

Tetanus is an acute disease manifested by motor system and autonomic nervous system instability. Maternal and neonatal tetanus occur where deliveries are performed under unsanitary circumstances and unhygienic umbilical cord practices are prevalent. Neonatal tetanus is almost always fatal in the absence of medical care. These deaths can be prevented with changes in traditional obstetrical practices and maternal immunization. This situation led to the development of the Maternal and Neonatal Elimination Initiative by the World Health Organization. Using a three-pronged approach, tetanus can be eliminated via promotion of hygienic practices during delivery, maternal and childhood immunization, and close surveillance.