Global Maternal Health Research Articles

Mobile Based Design for Strengthening Traditional Birth Attendant Health Care Systems in Low Resource Settings: The Case of Migori County, Kenya

Mobile health applications are established tools for healthcare management, patient education, and capacity building of healthcare providers. However, their use for strengthening Traditional Birth Attendant (TBA) health care systems is surprisingly limited in low resource settings where geographic, social, or economic barriers render the World Health Organization (WHO) policy of facility births untenable. The work presents a blueprint for implementing a mobile-health intervention for strengthening TBA health care systems in low resource settings. The objectives were to establish existing TBA structures, their challenges, TBA user requirements, and to develop and test a prototypical implementation. A mixed methods study facilitated the collection of quantitative and qualitative data from a population of pregnant mothers seeking care within public hospitals in Migori County, TBA & skilled birth attendants (SBAs). A survey instrument administered to 20 patients, 20 skilled birth attendants, and 20 traditional birth attendants was used in establishing challenges of existing structures, eliciting user requirements, and for the design and testing of the prototype mobile based design. Snowballing sampling enabled the researchers reach patients and TBAs who had visited the four public facilities in Rongo Sub County in the second quarter of the year. The focus group discussions method led to refined user requirements, while review of documents on maternal and newborn care protocols enabled the research to determine desired system functionalities for the new roles envisaged by the World Health Organization (WHO) for TBAs in low resource settings. Findings showed that TBA health Care systems were manual with weak links to the formal health care system. Users required a system that could support secure collaboration between TBAs and SBAs, address the problem of scarce SBAs and facilities, improve the convenience, cost and quality of care suitable for their social economic status. Figma was used as a user interface design tool to rapidly prototype the design. The prototypical design was implemented in MySQL and Java. The resulting mobile based design provided users with functionality to register and log into the system, capture, and avail patient data, access global maternal and child health protocols and offer telemedicine sessions between patients, TBA and SBAs. The prototypical TBA app was tested during a focus group session for performance, usability, and utility. The TBA app offers a convenient, cost effective and quality system while addressing the key challenges of manual TBA health care systems in low-income settings. Findings offer valuable design insights for implementing a mobile based initiative to address the challenge of reducing maternal mortality in low resource settings in Kenya and beyond.

Cross sectional survey of maternal and newborn quality of care in Niger: Selected findings, lessons learned and recommendations.

Comprehensive assessments of quality of care (QoC) are essential for monitoring progress towards meeting global and national maternal and newborn health (MNH) targets. Liverpool School of Tropical Medicine (LSTM) and the Niger Ministry of Public Health adapted a 2014 WHO QoC tool to cover antenatal care (ANC) and postnatal care (PNC) and include client voices through exit interviews. The objectives of the study were to assess quality of MNH care in Niger and to document lessons learnt from implementing the LSTM QoC tool. Quality of Care (QoC) was assessed using five tools: health facility survey (using register and official record data), partograph reviews, healthcare provider knowledge assessment, exit interviews with clients, and observation of antenatal and postnatal care. A nationally representative sample of 110 public healthcare facilities at three levels (integrated health centres, district hospitals and mother-child hospitals) and 2153 women were included. Descriptive analysis with 95% confidence intervals was presented. The health facility survey showed variable access to electricity (63% [53-72]), water (72% [62-81]), and transportation (40% [31-50]). Tests and treatment for HIV, TB, and malaria were found in more than 90% of relevant facilities. During observation of first ANC visit, 62% [48-74] women were tested for HIV; 13% [5-30] for pre-eclampsia and 22% [12-36] for anaemia. Observation of PNC showed much lower rates of screening (15% [7-27] tested for HIV and 4% [0;11] for malaria). Partographs were used in 86% of deliveries with inconsistent completion. At client interviews, respectful care indicators were variable, with providers not always explaining results to clients (59% [50-67]). Targeted allocation of resources and training could impact on QoC and reduce missed opportunities for prevention, screening and management of diseases among pregnant women and babies. The QoC assessment tool proved capable of offering a comprehensive overview of priorities in MNH, while maintaining feasibility in the Nigerien context.

Global maternal health country typologies: A framework to guide policy.

Maternal mortality remains a large challenge in global health. Learning from the experience of similar countries can help to accelerate progress. In this analysis we develop a typology of country groupings for maternal health and provide guidance on how policy implications vary by country typology. We used estimates from the Global Maternal Health (GMatH) microsimulation model, which was empirically calibrated to a range of fertility, process, and mortality indicators and provides estimates for 200 countries and territories. We used the 2022 estimates of the maternal mortality ratio (MMR) and lifetime risk of maternal death (LTR) and used a k-means clustering algorithm to define groups of countries based on these indicators. We estimated the means of other maternal indicators for each group, as well as the mean impact of different policy interventions. We identified 7 groups (A-G) of country typologies with different salient features. High burden countries (A-B) generally have MMRs above 500 and LTRs above 2%, and account for nearly 25% of global maternal deaths. Countries in these groups are estimated to benefit most from improving access to family planning and increasing facility births. Middle burden countries (C-E) generally have MMRs between 100-500 and LTRs between 0.5%-3%. Countries in these groups account for 55% of global maternal deaths and would benefit most from increasing facility births and improving quality of care. Low burden countries (F-G) generally have MMRs below 100 and LTRs below 0.5%, account for 20% of global maternal deaths, and would benefit most from improving access to family planning and community-based interventions and linkages to care. Indicators vary widely across groups, but also within groups, highlighting the importance of considering multiple indicators when assessing progress in maternal health. Policy impacts also differ by country typology, providing policymakers with information to help prioritize interventions.

Special Collection: Implementation Research Evidence for Prevention and Treatment of Postpartum Hemorrhage in High-Burden Low- and Middle-Income Countries.

Postpartum hemorrhage (PPH), defined as a blood loss of 500 mL or more within 24 hours after birth, remains the leading cause of maternal mortality globally, accounting for over 20% of all maternal deaths. The burden of mortality from PPH is predominantly in low- and middle-income countries and demands coordinated accelerated efforts from the global maternal health community to meet the Sustainable Development 3 maternal health target by 2030. The International Journal of Maternal and Child Health and AIDS and the Concept Foundation are proud to present this Special Collection demonstrating the evidence for introducing heat-stable carbetocin and tranexamic acid, showcasing the feasibility and acceptability of their utilization for PPH prevention and management in resource-limited high-burden settings.

Stillbirths Associated with Particle Pollution are Disproportionally Contributed by Sand Dust: Findings from 52 Low- and Middle-Income Countries.

Whether maternal exposure to dust-sourced particulate matter (hereafter, dust PM2.5) is associated with stillbirth remains unknown. We adopted a sibling-matched case-control design to analyze 9332 stillbirths and 17,421 live births. We associated the risk of stillbirth simultaneously with dust and nondust components of PM2.5 and developed a nonlinear joint exposure-response function. Next, we estimated the burden of stillbirths attributable to the PM2.5 mixture. The concentration index was used to evaluate whether the burden of PM2.5-related stillbirths was disproportionally distributed among pregnancies exposed to dust-rich particles. Each 10 μg/m3 increase in dust PM2.5 was associated with a 14.5% (95% confidence interval: 5.5, 24.2%) increase in the odds of stillbirth. Based on the risk assessment across 137 countries, sand dust contributed to about 15% of the PM2.5 exposure but to about 45% of the PM2.5-related stillbirths during 2003-2019. In 2015, 30% of the PM2.5-related stillbirths were concentrated within 15% of pregnancies exposed to the dust-richest PM2.5. The index increased in subregions, such as South Asia, suggesting the growth of health inequality due to exposure to dust PM2.5. Based on our findings, land management, such as halting desertification, will help prevent stillbirths and reduce global maternal health inequality.

Increasing the number of midwives is necessary but not sufficient: using global data to support the case for investment in both midwife availability and the enabling work environment in low- and middle-income countries

BackgroundMost countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries’ (LMICs’) midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration.MethodsUsing the most recent available data from publicly available global databases for the period 2000–2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality.ResultsIn LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10–15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country.ConclusionsA complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes.

World health assembly resolution for preventing micronutrient deficiencies and associated neural tube defects-A case study of global partnerships for a successful resolution adoption.

On May 29, 2023, the 76th World Health Assembly (WHA) unanimously adopted the resolution entitled, "Accelerating efforts for preventing micronutrient deficiencies and their consequences, including spina bifida and other neural tube defects, through safe and effective food fortification."The Society for Birth Defects Research and Prevention published their resolution in 2015 supporting mandatory fortification of staple foods with folic acid and recommendations aiming to achieve global total prevention of folate-sensitive spina bifida and anencephaly, setting a goal to achieve by the year 2024.The WHA resolution provides another global push for the cause, with recommendations to member nations for food fortification to be achieved by the year 2030. This short communication documents the steps, from inception up to the passage, of the 76th WHA resolution on food fortification, with a narrative on the nature of strategic advocacy efforts by multiple governmental and nongovernmental organizations. WHA resolutions can take many years to be introduced and passed by the assembly; however, this is a case study of the swiftness of the process enabled by powerful global partnership. The documentation of this process serves as an example for developing and processing future WHA resolutions aiming to improve global maternal and child health.

Global maternal mortality projections by urban/rural location and education level: a simulation-based analysis

Maternal mortality remains a challenge in global health, with well-known disparities across countries. However, less is known about disparities in maternal health by subgroups within countries. The aim of this study is to estimate maternal health indicators for subgroups of women within each country. In this simulation-based analysis, we used the empirically calibrated Global Maternal Health (GMatH) microsimulation model to estimate a range of maternal health indicators by subgroup (urban/rural location and level of education) for 200 countries/territories from 1990 to 2050. Education levels were defined as low (less than primary), middle (less than secondary), and high (completed secondary or higher). The model simulates the reproductive lifecycle of each woman, accounting for individual-level factors such as family planning preferences, biological factors (e.g., anemia), and history of maternal complications, and how these factors vary by subgroup. We also estimated the impact of scaling up women's education on projected maternal health outcomes compared to clinical and health system-focused interventions. We find large subgroup differences in maternal health outcomes, with an estimated global maternal mortality ratio (MMR) in 2022 of 292 (95% UI 250-341) for rural women and 100 (95% UI 84-116) for urban women, and 536 (95% UI 450-594), 143 (95% UI 117-174), and 85 (95% UI 67-108) for low, middle, and high education levels, respectively. Ensuring all women complete secondary school is associated with a large impact on the projected global MMR in 2030 (97 [95% UI 76-120]) compared to current trends (167 [95% UI 142-188]), with especially large improvements in countries such as Afghanistan, Chad, Madagascar, Niger, and Yemen. Substantial subgroup disparities present a challenge for global maternal health and health equity. Outcomes are especially poor for rural women with low education, highlighting the need to ensure that policy interventions adequately address barriers to care in rural areas, and the importance of investing in social determinants of health, such as women's education, in addition to health system interventions to improve maternal health for all women. John D. and Catherine T. MacArthur Foundation, 10-97002-000-INP.

Medicalisation, depoliticisation and reproductive stratification: lessons from Canada's Muskoka Initiative.

Based on critical discourse analysis of Canada's Muskoka Initiative (2010-15), this article outlines how medicalisation contributes to the depoliticisation and technocratisation of global maternal health, while reinforcing patterns of reproductive stratification. By constructing maternal health as a problem of managing medicalised risk, the Muskoka Initiative was able to position family planning as a risk-minimising practice that can improve health by averting pregnancy among populations deemed high risk. Interpreting this construction through the lenses of reproductive justice and biopolitics, I argue that this construction contributes to reproductive stratification and exemplifies how medicalised discourses have replaced overt discourses of population control within development policy, while continuing to discourage reproduction among racialised women in the Global South.

Exploring gestational age, and birth weight assessment in Thatta district, Sindh, Pakistan: Healthcare providers' knowledge, practices, perceived barriers, and the potential of a mobile app for identifying preterm and low birth weight.

Reliable methods for identifying prematurity and low birth weight (LBW) are crucial to ending preventable deaths in newborns. This study explored healthcare providers' (HCPs) knowledge, practice, perceived barriers in assessing gestational age and birth weight and their referral methods for preterm and LBW infants. The study additionally assessed the potential of using a mobile app for the identification and referral decision of preterm and LBW. This qualitative descriptive study was conducted in Thatta District, Sindh, Pakistan. Participants, including doctors, nurses, lady health visitors, and midwives, were purposefully selected from a district headquarter hospital, and private providers in the catchment area of Global Network's Maternal and Newborn Health Registry (MNHR). Interviews were conducted using an interview guide after obtaining written informed consent. Audio recordings of the interviews were transcribed and analyzed using NVIVO® software with an inductive approach. The HCPs had extensive knowledge about antenatal and postnatal methods for assessing gestational age. They expressed a preference for antenatal ultrasound due to the perceived accuracy, though accept practical barriers including workload, machine malfunctions, and cost. Postnatal assessment using the Ballard score was only undertaken sparingly due to insufficient training and subjectivity. All HCPs preferred electronic weighing scales for birth weight Barriers encountered included weighing scale calibration and battery issues. There was variation in the definition of prematurity and LBW, leading to delays in referral. Limited resources, inadequate education, and negative parent past experiences were barriers to referral. Foot length measurements were not currently being used. While mobile apps are felt to have potential, unreliable electricity supply and internet connectivity are barriers. The HCPs in this study were knowledgeable in terms of potential tools, but acknowledged the logistical and parental barriers to implementation.

Maternal and child oral health barriers and solutions: Case studies from South Africa, Brazil, and Indonesia.

The World Federation of Public Health Associations (WFPHA) has introduced a maternal oral health framework and launched its Global Maternal and Child Oral Health Initiative, advocating for maternal and child health as a strategic entry point for oral health to be integrated into primary healthcare systems. This article delves into maternal oral health initiatives in South Africa, Brazil, and Indonesia, exploring challenges and proposing context-specific solutions aligned with the WFPHA maternal oral health framework and its Global Maternal and Child Oral Health Initiative. The apartheid legacy in South Africa has led to the gross health inequalities, including oral health disparities characterized by maldistribution of dental facilities and dental professionals in the public sector. The proposed objectives focus on effective leadership, human resource capacity building, and integration of maternal and child oral health policy into existing health policies. Brazil faces challenges in reaching pregnant women, especially pregnant teens, due to workforce shortages. Brazil's Oral Health National Program mandates all pregnant women undergo at least one dental appointment, but a shortage of oral health teams persists and impedes timely access to dental care during pregnancy. Dental students' outreach to vulnerable pregnant teens can enhance the future oral health workforce's sensitivity to maternal oral health matters. In Indonesia, the Antenatal Care Innovative (iANC) Project has introduced a co-training model for midwives and oral health professionals addressing oral health needs of mothers and their spouses and fostering a comprehensive understanding of the interplay between oral health and maternal well-being. These country cases demonstrate the importance of tailored policies, health promotion, and care delivery interventions in maternal oral health. All cases highlight the importance of workforce training and distribution, fostering cross-disciplinary collaboration and future oral health workforce who can promote health beyond treatment delivery.

Safe Motherhood Initiative

Abstract In the quest to create global maternal health care protocols, African Indigenous birthing epistemologies are often overlooked in research, policy, and advocacy aiming to improve maternal health and reduce the maternal mortality ratio (MMR). The global maternal health strategy, the Safe Motherhood Initiative (SMI), excludes Indigenous birthing knowledge by requiring all childbirth to be attended by only birth attendants trained in the Western medical paradigm. This forms the bedrock of the assumed authoritative expertise of the Western medical birthing approach. Despite the campaign for sole reliance on SMI, Africa’s MMR remains the highest compared to other regions. Nigeria, Africa’s most populous country, also has the third-highest MMR in the world as of 2020. This failure of SMI to reduce MMR for Nigeria and Africa more broadly calls for the inclusion of marginalized Indigenous birthing knowledge for its epistemological and practical significance. Using Nigeria as a case study, with a transnational connection with the United States, the article argues that excluding African birthing knowledge and methods in SMI promotes epistemic and obstetric violence. Adopting the reproductive justice framework as a decolonial tool, the article asserts that African Indigenous birthing knowledge is simultaneously valid and valuable for holistic approaches to maternal health.

A biosocial analysis of perinatal and late neonatal mortality among Indigenous Maya Kaqchikel communities in Tecpán, Guatemala: a mixed-methods study

IntroductionNeonatal mortality is a global public health challenge. Guatemala has the fifth highest neonatal mortality rate in Latin America, and Indigenous communities are particularly impacted. This study aims to understand...

POLICY AND GUIDELINE ON BREAST MILK BANK: A SYSTEMATIC REVIEW

This systematic review delves into global breast milk policies, addressing their impact on maternal and child health. Recognizing the pivotal role of breastfeeding in public health, the introduction underscores the need for a nuanced examination of existing policies. The problem statement highlights gaps in current approaches, prompting the systematic review to inform evidence-based improvements. Employing a rigorous methodology, we provided a systemically review analysis based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) technique for virtual reality implementation. The advanced searching into two powerful databases which are Scopus and Web of Science (WoS). Based on searching, final main data, n = 63 and will be analysis using synthesis approach. The five main themes, which are decided: (1) Acceptance and Perception (2), Operational Aspects and Guidelines and (3) Impact and Practices (4) Cultural Perspectives and Historical Context, and (5) Research and Innovation. Results reveal diverse policies and guidelines available across regions, influencing human milk bank initiation, duration, and associated health outcomes. The review identifies key determinants shaping human milk bank practices, assessing their alignment with global guidelines. The conclusion synthesizes findings, emphasizing the need for context-specific policies. This systematic review offers crucial insights for policymakers, healthcare professionals, and researchers dedicated to advancing global maternal and child health through informed breast milk bank policies.

Strengthening implementation of the Maternal and Child Health Handbook for global maternal, newborn, and child health

Strengthening implementation of the Maternal and Child Health Handbook for global maternal, newborn, and child health

A Bayesian Approach to Estimate Maternal Mortality Globally Using National Civil Registration Vital Statistics Data Accounting for Reporting Errors

Estimation and monitoring of mortality, across multiple population-periods, is vital to improving national and global health outcomes. Reducing maternal mortality is a key part of the Sustainable Development Goals (SGDs), which commit countries and international agencies to monitor progress toward improvement of global maternal health outcomes. Country-specific estimates of maternal mortality are used for monitoring country progress. Civil registration vital statistics (CRVS) data provide valuable information on maternal mortality but are often subject to substantial reporting errors due to misclassification of maternal deaths or incompleteness of CRVS-reporting on deaths to women of reproductive age. Motivated by the challenge of estimating maternal mortality using error-prone CRVS data, this article introduces a Bayesian two-stage approach to obtain country-specific trends in maternal mortality ratios (MMRs), accounting for CRVS-related misclassification errors. In the first stage, we produce country-specific trends of CRVS-related data quality metrics, in terms sensitivity and specificity, through a Bayesian hierarchical misclassification model. In the second stage, we produce data-driven country trends in MMRs and proportion maternal deaths out of all-cause deaths, which are constructed using a Bayesian maternal mortality estimation model, accounting for CRVS-related data quality assessed in Stage 1. We present the approach to estimating maternal mortality and illustrate its use for several country case studies. This approach is used by the United National Maternal Mortality Interagency Group (UN-MMEIG) to produce maternal mortality estimates for global monitoring.

“It is not by choice that I gave birth at home”: the social determinants of home births during COVID-19 in peri-urban and urban Kenya, a qualitative study

BackgroundThe COVID-19 pandemic significantly impacted the provision of global maternal health services, with an increase in home births. However, there are little data on women’s decision-making and experiences leading up to home births during the pandemic. The objective of this study is to examine the economic, social, and health system factors associated with home births in Kenya.MethodsCommunity health volunteers (CHVs) and village leaders helped identify potential participants for an in-depth, one-on-one, qualitative telephone interview in Nairobi and Kiambu County in Kenya. In total, the study interviewed 28 mothers who had home births.ResultsThis study identified a number of economic, social, neighborhood, and health system factors that were associated with birthing at home during the COVID-19 pandemic. Only one woman had planned on birthing at home, while all other participants described various reasons they had to birth at home. Themes related to home births during the pandemic included: (1) unmet preferences related to location of birth; (2) burdens and fear of contracting COVID-19 leading to delayed or missed care; (3) lack of perceived community safety and fear of encounters with law enforcement; and (4) healthcare system changes and uncertainty that led to home births.ConclusionAddressing and recognizing women’s social determinants of health is critical to ensuring that preferences on location of birth are met.

Malaria in Pregnancy: Key Points for the Neonatologist.

In malaria-endemic regions, infection with the malaria parasite Plasmodium during pregnancy has been identified as a key modifiable factor in preterm birth, the delivery of low-birthweight infants, and stillbirth. Compared with their nonpregnant peers, pregnant persons are at higher risk for malaria infection. Malaria infection can occur at any time during pregnancy, with negative effects for the pregnant person and the fetus, depending on the trimester in which the infection is contracted. Pregnant patients who are younger, in their first or second pregnancy, and those coinfected with human immunodeficiency virus are at increased risk for malaria. Common infection prevention measures during pregnancy include the use of insecticide-treated bed nets and the use of intermittent preventive treatment with monthly doses of antimalarials, beginning in the second trimester in pregnant patients in endemic areas. In all trimesters, artemisinin-combination therapies are the first-line treatment for uncomplicated falciparum malaria, similar to treatment in nonpregnant adults. The World Health Organization recently revised its recommendations, now listing the specific medication artemether-lumefantrine as first-line treatment for uncomplicated malaria in the first trimester. While strong prevention and detection methods exist, use of these techniques remains below global targets. Ongoing work on approaches to treatment and prevention of malaria during pregnancy remains at the forefront of global maternal child health research.

Gender differences in the acceptance of wife-beating: evidence from 30 countries in Sub-Saharan Africa

BackgroundThe World Health Organization (WHO) has cited domestic violence as an urgent global maternal and child health priority. Gender differences in the acceptance of wife-beating have not been explored at the multi-country level in sub-Saharan Africa (SSA) where the occurrence of wife-beating (36%) is greater than the global average (30%). It is against this backdrop that we examine the gender differences in the acceptance of wife beating in SSA.MethodsWe used Demographic and Health Survey data from 30 SSA countries. Acceptance of wife beating among women and men was the principal outcome variable of interest. We employed Multiple correspondence analysis and logistic regression model as the primary estimation methods for this study. The descriptive statistics show that women had a higher acceptance rate (44%) of wife beating than men (25%). For the women sample, Mali, Democratic Republic of Congo, Chad, and Guinea had higher rates of acceptance of the wife beating (80.6%, 78.4%, 77.1% and 70.3% respectively) For the men, only Guinea had an acceptance rate above 50 percent.ResultsWe found that all else equal, women’s acceptance of wife beating is higher for male-headed households than for female-headed households. Women without formal education were 3.1 times more likely to accept wife beating than those with higher education. Men with no formal education were 2.3 times more likely to accept wife beating than men with higher education. We found that polygamous women were comparable to polygamous men. Polygamous women were 1.2 times more likely to accept wife beating than those in monogamous marriages. Women were 1.2 times more likely to accept wives beating if they had extramarital relationships. Contrarily, men who engaged in extramarital affairs were 1.5 times more likely to justify wife beating. We also found that women’s acceptance of wife beating decreases as they age. Men who decide on major household purchases and spending decisions on their earnings are more likely to accept wife beating. Corollary, women with similar gender and employment roles also accept wife beating. Finally, exposure to mass media is significantly associated with lower acceptance of wife beating for women and men.ConclusionWe conclude that women have a higher acceptance rate of wife beating than men in SSA. Acceptance of wife beating differs significantly by country. Given the same level of education, women are more likely to accept wife beating than men. If women and men have similar levels of employment and gender roles, acceptance of wife beating is higher when men make major household purchasing decisions and and it is still higher even when the woman makes these decisions. Acceptance of wife beating is higher among young women and men, the uneducated, those in polygamous marriages, women, and men who engage in extra marital affairs, poor households and in rural areas. The findings indicate the need for policies and programs by SSA countries to truncate the high acceptance rate of wife beating, especially among women.

Associations between ambient temperature and pregnancy outcomes from three south Asian sites of the Global Network Maternal Newborn Health Registry: A retrospective cohort study.

Growing evidence suggests that environmental heat stress negatively influences fetal growth and pregnancy outcomes. However, few studies have examined the impact of heat stress on pregnancy outcomes in low-resource settings. We combined data from a large multi-country maternal-child health registry and meteorological data to assess the impacts of heat stress. Retrospective cohort study. Three sites based in south Asia as part of the Global Network for Women's and Children's Health research in India (Belagavi and Nagpur) and Pakistan (Thatta). Data from women enrolled between 2014 and 2020 in the Global Network's Maternal Newborn Health Registry (MNHR), a prospective, population-based registry of pregnancies, were used. A total of 126 273 pregnant women were included in this analysis. Daily maximal air temperatures (Tmax ) were acquired from local meteorological records. Associations between averages of daily maximal temperatures for each trimester and main outcomes were analysed using a modified Poisson regression approach. Incidence of stillbirth, preterm birth, low birthweight (<2500 g) or evidence of pregnancy hypertension or pre-eclampsia. In the overall cohort, risk of preterm birth was positively associated with greater temperature in the second trimester (relative risk [RR] 1.05, 95% CI 1.02-1.07, p = 0.0002). Among individual sites, the risk of preterm birth was greatest in Nagpur (RR 1.07, 95% CI 1.03-1.11, p = 0.0005) and associated with second-trimester temperature. The overall risk of low birthweight was associated with ambient temperature in second trimester (RR 1.02, 95% CI 1.01-1.04, p = 0.01). The risk for LBW was associated with first-trimester heat in Thatta and with second-trimester heat in Nagpur. Finally, the overall risk of gestational hypertensive disease was associated with greater temperature in the third trimester among all sites (RR 1.07, 95% CI 1.02-1.12, p = 0.005) and was particularly significant for Nagpur (RR 1.13, 95% CI 1.05-1.23, p = 0.002). These findings highlight the increased risk of detrimental obstetric and neonatal outcomes with greater temperature. In a multi-country, community-based study, greater risk of adverse outcomes was observed with increasing temperature. The study highlights the need for deeper understanding of covarying factors and intervention strategies, especially in regions where high temperatures are common.