Midwifery Research Articles

Temperature and photoperiod differentially impact maternal phenotypes in diapause egg-laying Aedes albopictus mosquitoes.

Aedes albopictus (Skuse 1894) mosquitoes can transmit deadly arboviruses and are globally invasive due to their ability to survive in both tropical and temperate climates. Although adults cannot survive harsh winters, females are capable of anticipating seasonal change and producing overwintering diapause (DP) eggs that remain in a state of arrested development over the winter and hatch when favorable conditions return in the spring. While low temperatures can facilitate DP entry under short photoperiods, temperature signals alone are not sufficient to induce DP. To identify maternal phenotypes predictive of DP egg production in laboratory conditions, we characterized aspects of maternal physiology and behavior to identify those that correlate with DP egg production and changes in photoperiod, versus changes in temperature. Neither changes in temperature nor photoperiod impacted protein preference, blood meal consumption, or total number of eggs produced per female. Egg retention and oviposition timing were influenced by temperature, independent of DP egg production. However, females housed under short photoperiod conditions showed increased starvation resistance, despite showing similar levels of locomotor activity and internal stores of triacylglycerols, glucose, glycogen, and trehalose compared to females housed in long photoperiods. These results suggest that temperature and photoperiod differentially affect maternal phenotypes and identify starvation resistance as a maternal phenotype that is influenced by photoperiod and correlates with DP egg status.

Development and Application of a Delivery Infrastructure Collapse Risk Assessment Tool: A Focus on Metropolitan Metropolitan Areas

Purpose: This study aims to develop a tool to systematically assess the risk of collapse in the delivery infrastructure and apply it to 42 districts in Gyeonggi Province. The ultimate goal is to provide data for preventive and improvement strategies tailored to regional needs.Methods: Hospitals performing over 50 deliveries annually were identified. Regions were categorized as 'none,' 'one,' or 'more than two' delivery hospitals, with further subdivision by annual delivery volume. Regions were then classified into 5 categories: 'relatively stable,' 'low-risk,' 'moderate-risk,' 'high-risk,' and 'collapsed.'Results: Of the 42 districts, 23 were classified as relatively stable, 3 as low-risk, 1 as moderate-risk, 4 as highrisk, and 11 as collapsed. Notably, areas where the delivery infrastructure has collapsed or is at high risk of collapse accounted for approximately 36% of the total.Conclusion: Tailored strategies and urgent policy support are required for high-risk regions. While perinatal regionalization may be a future direction, stable infrastructure must be maintained until the maternal care delivery system is established.

Provider perspectives on maternal care challenges for Black and Latine Women in Indiana: a qualitative interview study

Indiana consistently ranks among the states with the highest maternal and infant mortality in the United States, particularly affecting Black and Latine communities, endangering their right to safe and respectful maternal care. Providers working with these communities are crucial in identifying challenges faced by their clients, and to inform programmes and policies. We interviewed 32 clinical and community-based providers to understand their perspectives on the challenges faced by their Black and Latine clients from February to April 2021. Participants were identified through online sources and referrals. Interviews, conducted over online video, were recorded, transcribed, and analysed following a six-step thematic approach. Six areas of challenges emerged: non-medical infrastructure and policy problems, effects of systemic racism and bias, insecurity of the Latine community, dissatisfaction with maternal care delivery, issues in navigating maternal healthcare, and limitations to holistic models of care. The results demonstrate the interconnected structural, organisational, and interpersonal nature of the challenges. Though challenges were described at structural and organisational levels, the focus of state maternal care programs is largely at personal and interpersonal levels. Obstetric racism, citizenship restrictions, shortage of Black and Latine providers, and transportation issues are complex problems, requiring multilevel interventions and policies to ensure Black and Latine women can exercise their right to safe and respectful maternal care. A rights-based approach centring the needs of Black, Latine and other minoritised communities should be implemented to make effective changes with an equity focus.

Content and design of respectful maternity care training packages for health workers in sub-Saharan Africa: Scoping review.

Training health workers might facilitate respectful maternity care (RMC); however, the content and design of RMC training remain unclear. To explore the content and design of RMC training packages for health workers in sub-Saharan Africa. MEDLINE, EMBASE, CINAHL Complete, Web of Science Core Collections, SCOPUS, and grey literature sources (including websites of RMC-focused key organizations and Ministries of Health) were searched for journal papers, reports, and training guides from January 2006 up to August 2022. There were no restrictions on study designs, language, or health-worker cadre. Two reviewers independently screened results. Key data, including training content and methods used, were extracted and summarized. Thirty-two citations from 26 studies/programs were identified (24 journal papers, 5 manuals/guides, 2 reports and 1 PhD thesis), with 27 citations from 22 studies informing the review findings. About half of all conducted studies were from East Africa. The most common topics in RMC trainings were communication, privacy and confidentiality, and human resources. Most trainings were multicomponent and appear to be largely in-service training. Health workers providing direct care to women, compared with non-clinical staff such as receptionists and cleaners, were the only recipients of training in most studies (81.8%). Two broad categories of training methods/tools were identified: workshop-based and action-based. Over 90% of the studies assessed impact of the training, with a majority focused on impacts on maternal health and care; however, half of the latter studies did not appear to have feedback mechanisms in place for implementing change. The content and design of RMC training in sub-Saharan Africa are multifaceted, suggesting the complexity of implementing/promoting RMC. Some progress has been made; however, missed opportunities in training remain with respect to study populations, training topics, cadres, and feedback mechanisms.

Prolactin: structure, receptors, and functions.

Prolactin (PRL) is a 23-kDa protein synthesized and secreted by lactotroph cells of the anterior pituitary gland but also by other peripheral tissues. PRL binds directly to a unique transmembrane receptor (PRLR), and the JAK2/signal transducer and activator of transcription 5 (Stat5) pathway is considered the major downstream pathway for PRLR signaling. To a lesser extent, PRL may be cleaved into the shorter 16-kDa PRL, also called vasoinhibin, whose signaling is not fully known. According to rodent models of PRL signaling inactivation and the identification of human genetic alterations in PRL signaling, a growing number of biological processes are partly mediated by PRL or its downstream effectors. In this review, we focused on PRL structure and signaling and its canonical function in reproduction. In addition to regulating reproductive functions, PRL also plays a role in behavior, notably in initiating nurturing and maternal behavior. We also included recent insights into PRL function in several fields, including migraines, metabolic homeostasis, inflammatory and autoimmune disease, and cancer. Despite the complexity of understanding the many functions of PRL, new research in this field offers interesting perspectives on physiological and pathophysiological processes.

Mothers’ perception of husband support during breastfeeding: A qualitative study in Indonesia

The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted maternal and perinatal healthcare worldwide, including in Indonesia. Restrictions on access to health services have forced mothers to adapt to new challenges in breastfeeding during the pandemic. The aim of this study was to evaluate mothers’ breastfeeding experiences and the role of husbands in providing support during this period. This qualitative research used a phenomenological approach. Data were collected from August to October 2022 through a focus group discussion (FGD). Participants were selected using maximum variation sampling, with eight mothers participating in the FGD. Data were analyzed using qualitative content analysis, revealing four main themes: (1) not all husbands fully supported mothers’ efforts to provide exclusive breastfeeding; (2) supportive and inhibiting factors help to provide exclusive breastfeeding; (3) mothers understood the benefits and identified the causes of failure in providing exclusive breastfeeding and complementary food for breast milk; and (4) various stressors experienced by mothers did not impede breastfeeding efforts. In conclusion, the findings highlight the need for healthcare workers, especially maternity nurses, to encourage continued breastfeeding and emphasize the importance of husbands’ support in providing exclusive breastfeeding initiatives. Interventions should be designed to actively involve husbands in supporting exclusive breastfeeding practices.

Cerebral palsy in Australia: birth prevalence, 1995-2016, and differences by residential remoteness: a population-based register study.

To examine recent changes in the birth prevalence of cerebral palsy in Australia; to examine the functional mobility of children with cerebral palsy by residential remoteness. Population-based register study; analysis of Australian Cerebral Palsy Register (ACPR) data. Children with cerebral palsy born in Australia, 1995-2016, and included in the ACPR at the time of the most recent state/territory data provision (31 July 2022). Change in birth prevalence of cerebral palsy, of cerebral palsy acquired pre- or perinatally (in utero to day 28 after birth), both overall and by gestational age group (less than 28, 28-31, 32-36, 37 or more weeks), and of cerebral palsy acquired post-neonatally (day 29 to two years of age); gross motor function classification by residential remoteness. Data for 10 855 children with cerebral palsy born during 1995-2016 were available, 6258 of whom were boys (57.7%). The birth prevalence of cerebral palsy in the three states with complete case ascertainment (South Australia, Victoria, Western Australia) declined from 2.1 (95% confidence interval [CI], 1.9-2.4) cases per 1000 live births in 1995-1996 to 1.5 (95% CI, 1.3-1.7) cases per 1000 live births in 2015-2016. The birth prevalence of pre- or perinatally acquired cerebral palsy declined from 2.0 (95% CI, 1.7-2.3) to 1.4 (95% CI, 1.2-1.6) cases per 1000 live births; statistically significant declines were noted for all gestational ages except 32-36 weeks. The decline in birth prevalence of post-neonatally acquired cerebral palsy, from 0.15 (95% CI, 0.11-0.21) to 0.08 (95% CI, 0.05-0.12) cases per 1000 live births, was not statistically significant. Overall, 3.4% of children with cerebral palsy (307 children) lived in remote or very remote areas, a larger proportion than for all Australians (2.0%); the proportion of children in these areas who required wheelchairs for mobility was larger (31.3%) than that of children with cerebral palsy in major cities or regional areas (each 26.1%). The birth prevalence of cerebral palsy declined markedly in Australia during 1995-2016, reflecting the effects of advances in maternal and perinatal care. Our findings highlight the need to provide equitable, culturally safe access to antenatal services for women, and to health and disability services for people with cerebral palsy, across Australia.

Maternal Question Use Relates to Syntactic Skills in 5- to 7-Year-Old Children.

This study examined how mothers' question-asking behavior relates to their child's syntactic skills. One important aspect of maternal question-asking behavior is the use of complex questions when speaking with children. These questions can differ based on both their purpose and structure. The purpose may be to seek out information, to teach, or to get a simple yes/no response. Questions may even be rhetorical, with no answer intended at all. Structurally, questions can include a wh-word (who, what, when, where, why, and how) or not; however, these wh-questions are important because they elicit utterances from the child and support vocabulary development. Despite wh-questions eliciting a response from children, it remains unknown how these questions relate to children's syntactic skills. Thirty-four mother-child dyads participated in a 15-min seminaturalistic play session. Children were between the ages of 5 and 7 years (M = 6.26 years, SD = 1.04 years; 20 girls/14 boys). The Diagnostic Evaluation of Language Variation (DELV) assessment was used to measure syntactic skills in children. Using the Systematic Analysis of Language Transcripts, questions were categorized based on structure (wh-questions vs. non-wh-questions) and purpose (information-seeking, pedagogical, or yes/no and rhetorical questions). A repeated-measures analysis of covariance and a linear regression model were implemented to address the frequency of different questions asked by mothers, as well as what types of questions are most related to children's concurrent syntactic skills. When controlling for total maternal utterances, results revealed that non-wh-questions and rhetorical/yes and no questions were the most frequent types of questions produced by mothers, in terms of structure and purpose, respectively. However, wh-questions were predominantly information-seeking questions. This is important, as the use of information-seeking wh-questions was positively associated with children's syntactic skills, as measured by the DELV, and resulted in children producing longer utterances in response to these questions, as determined by child mean length of utterance in words. Taken together, these findings suggest maternal use of wh-questions aids syntactic skills in children ages 5-7 years, likely because they require a more syntactically complex response on the child's behalf. https://doi.org/10.23641/asha.27276891.

Maternal care strategies differentially optimize the health and immunity of male and female South American fur seal pups

Maternal care strategies differentially optimize the health and immunity of male and female South American fur seal pups

Patient controlled epidural analgesia during labor: Protocol for a scoping review.

Childbirth remains one of the most painful experiences for women. Patient-controlled epidural analgesia provides the women in labor with self-control and thereby a shorter time interval between onset of pain and administration of analgesia, thus potentially improving the childbirth experience. This scoping review aims to investigate PCEA during labor involving maternal satisfaction, risks of adverse effects and obstetric interventions by mapping the evidence and identifying gaps in the current evidence base. The forthcoming review will adhere to the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) and the JBI methodology for scoping reviews. A systematic search will be carried out across major peer-reviewed databases and gray literature will be sought. All study types involving women in labor receiving PCEA will be eligible for inclusion. The extracted data will be charted regarding trial characteristics, population/participation characteristics, interventions, outcomes, and key findings. The results will be presented through relevant tables, figures, and graphs when appropriate. Alongside this, we present the data descriptively to explain how the results align with the objectives of the review. PCEA offers women greater autonomy during childbirth, making it essential to examine its effects and potential risks. By mapping current evidence regarding PCEA, this review aims to identify knowledge gaps and provide insights to enhance maternal care and improve childbirth experiences.

Temporal trends analysis of emergency obstetric and newborn care availability and readiness index of healthcare facilities in Burkina Faso

BackgroundEnsuring healthcare services are equipped to offer; emergency obstetric and newborn care (EmONC) is crucial for improving the quality of maternal and newborn care in low- and middle-income countries. We assessed the temporal trends of the availability and readiness of the healthcare system to provide EmONC in Burkina Faso.MethodsWe analyzed the data from three national health facilities surveys, conducted in 2014, 2016 and 2018, using the WHO Service Availability and Readiness Assessment tool. We performed multivariable linear regression models to examine the trends.ResultsBetween 2014 and 2018, the percentage of healthcare facilities providing delivery service and blood transfusion significantly decreased (88.1% to 75.4% for delivery services and 67.3% to 50.2% for blood transfusion, p < 0.001). The readiness index of healthcare facilities to provide basic EmONC showed a negative trend according to public healthcare, primary healthcare, and Centre-Nord, Centre-sud, Hauts-Bassins, Nord, Plateau Central and Sud-ouest health regions.ConclusionsWe observed multiple indications of a decline in the readiness of healthcare services to offer EmONC in Burkina Faso from 2014 to 2018. As such, bolstering the capabilities of health facilities to deliver EmONC is essential for hastening the decrease in maternal mortality.

ASARA-A technology-driven maternal and child healthcare model of Araku

Tribal populations form 8.6% of total India’s population. The health indicators of tribal populations lag behind their non-tribal counterparts. Limited access to healthcare services, poor transportation facilities, increased out-of-pocket expenditures for health, distinct cultural practices and remote settlement among many others contribute to the poor health status of the tribal populations. However, to achieve sustainable development goals by 2030, it is extremely important to address the healthcare needs of the tribal population. The current paper is the first part of the model of care working paper series that discusses the components of the ASARA project to highlight the impacts of the decade long efforts towards improving maternal and child care in the region.

Mixed-method study of women’s experiences of Respectful-Disrespectful Maternity Care in Cyprus

Abstract Background Since the WHO reports on Disrespect and Abuse (D&amp;A) in childbirth, there was an increase in studies across Europe exploring women’s experiences. Even though contentious, a 2024 EU Committee report adopts the term obstetric violence. With the highest caesarean section (C/S) in the EU, the birth environment in Cyprus raises questions about informed choices. Methods The RESPECT mixed-method study gained insights into the experiences of women in Cyprus with focus groups (N = 6, 28 women) and survey (online and in-person) tapping on Rights for Respectful Maternity Care (RMC), as measured by Person-Centred Maternity Care scale (PCMC), autonomy in decision making (MADM), dignity and respect (MoRi) and mistreatment (MIST). Results Among 516 responses (61% first childbirth, 38.5% vaginal, 15% public sector, consistent with official statistics), the 35-item PCMC (range 0-100%) represents a continuum of quality standards deviations (Med=81, IQR=61-92). Lowest scores were recorded for “Communication &amp; Autonomy”, with 28.5% reporting ‘feeling pushed into a decision’, with associations observed with younger age, first-time birth, mode and place of birth, highlighting social inequity. Based on MADM, 23.8%, 14.1% and 14.7% women were classified as having moderate, low or very low autonomy. For mistreatment, 32.0% reported at least one of 11 indicators, most commonly privacy violations and no freedom of movement. Formula feeding against wishes (13.6%), vaginal examinations (11.6%) and episiotomy (7.8%) where most common among 33.7% reporting procedures without consent. Deductive content analysis of narratives according to RMC triangulate findings of weak shared decision-making processes. Conclusions Given that C/S reduction was identified as a national priority in Cyprus, the RESPECT findings can widen the conversation about quality improvement and form the basis to engage with local stakeholders in an open-dialogue about RMC, guided by participatory action research principles. Key messages • In the medicalized birth environment of Cyprus, women report a range of sub-optimal practices, with ethical implications, primarily affecting the right to autonomy. • Adopting the Respectful Maternity Care framework, the findings can stimulate and shape quality improvement efforts in a participatory and inclusive process with local stakeholders.

Polish midwives’ experiences of providing maternity care to Ukrainian women in Poland

Abstract Background Migrants’ health has attracted the attention of researchers for many years, particularly from the perspective of barriers in access to healthcare systems. Providing high quality care to migrants and refugees, especially in contexts of significant and sudden arrivals, may be particularly challenging. Aim The aim of our research was to learn about the experiences and strategies of midwives providing maternity care for Ukrainian migrant women in Poland after the outbreak of the full-scale war in Ukraine. Methods Five focus group interviews with 32 midwives providing maternity care in Poland were conducted. The interviews were thematically analysed. Results Healthcare personnel experiences a number of barriers to the provision of high-quality care to the migrant population. Polish midwives expressed mainly experience of two groups of barriers on: (1) individual and interpersonal, (2) management and organization levels. Firstly, at the individual and interpersonal level midwives experienced: fear for life and well-being related to the threat of war in a neighbouring country, depleting resources and post-pandemic fatigue, language barriers, lack of knowledge on caring for woman fleeing the war. Secondly, at the management and organizational level midwives experienced: lack of organizational support, interpreting services and documentation in any other language than Polish. In the first months after the outbreak of the full-scale war in Ukraine, most strategies to improve the provision of maternity care for women fleeing the war took the form of grassroots initiatives by the staff of individual care units. Conclusions The Polish health care services need systemic solutions prepared jointly by state and local authorities and considering the voices of midwives to support the provision of high-quality care to migrant population. Key messages • Midwives were left to their own devices. • Midwives need better preparation for providing high-quality care to migrant population.

Migration and mental health: the case of postpartum depressive symptoms in Portugal

Abstract Background Postpartum depression (PPD) affects about 17% of healthy mothers within one year of childbirth. The etiology remains unknown, but PPD is influenced by a combination of genetic, physical, psychosocial, and obstetric factors, migration could influence the risk. Methods We analyzed data collected within the scope of baMBINO (Perinatal Health in Migrants: Barriers, Incentives, and Outcomes), a Portuguese prospective cohort study, aimed to investigate the maternity experiences and outcomes of migrant women, defined as foreign-born women, and compared to native women. Among the 5431 women enrolled at delivery, 3006 (55%) were considered eligible for this study and interviewed in their preferred language, within six months of recruitment. The Edinburgh Postnatal Depression Scale (EPDS) was administered during this interview, along with the Migrant-Friendly Maternity Care Questionnaire (MFMCQ). Results 2890 (96%) women were included in the analytical sample for this study. Among women included, 1475 (51%) were migrants or refugees. The proportions of women having EPDS scores ≥ 10 were overall greater among migrants than among native women (7.2% vs. 12.4%, p &amp;lt; 0.001) and the risk remained higher after multiple adjustment models. Conclusions Migration status, poor experience with maternal care and language proficiency increased the risk of PPDS and should be carefully addressed as part of perinatal care.

Satisfaction with maternity care among immigrant women compared to non-immigrant women

Abstract Introduction Migration is a worldwide phenomenon leading to challenges for the health care system. There is conflicting evidence on the effect of migration on the satisfaction with obstetric care. Our hypothesis was that satisfaction with obstetric care was lower in immigrant women with and without self-defined (sd) refugee status than in non-immigrant women. Methods In the Pregnancy and Obstetric Care for Refugees (PROREF)-study between June 2020 and April 2022 in Berlin women were interviewed 1-3 days after giving birth with the Migrant Friendly Maternity Care Questionnaire (MFMCQ). The interview data was linked to the routine perinatal data of the hospital charts. Descriptive analysis and logistic regression analysis were performed to identify factors influencing satisfaction with obstetric care. Results A total of 3420 women (Frauen (247 with sd refugee status, 1356 immigrant women und 1817 non-immigrant women) could be included in the study, with an overall response rate of 77.5%. Satisfaction measured generally high with over 80% of women being satisfied with obstetric care at all three time points: during pregnancy, during labor and birth and after giving birth. We identified two factors associated with an increased chance of being satisfied with obstetric care: sd refugee status (OR 2.57, 95% Cl 1.48 - 4.44, p-value 0.0008) and being multipara (OR 1.40, 95% Ci 1.18 - 1.67, p-value 0.000). Conclusions Efforts on improving birth experience should focus on primipara. Among the reasons for non-immigrant women being less satisfied with care than women with sd refugee status might be different expectations and the timing of data collection. Key messages • Refugee women might have different expectations regarding birth experience than other immigrant women and non-immigrant women. • Satisfaction with obstetric care in Berlin is generally high among immigrant women and non-immigrant women.

Institutional Discrimination in Health Security Policies against Immigrants in South Korea

Abstract Background South Korea is poised to become Asia’s first mult-iethnic society with over 5% of its population, totaling more than 2.5 million, being immigrants. This demographic shift presents significant public health challenges linked to widespread, and even intensifying, institutional discrimination in healthcare services. Methods This study reviews discriminatory practices across ten essential health security programs, including National Health Insurance (NHI) system, disability assistance, occupational health services, maternal and child care services, national immunization program, health screening program, and assistance for catastrophic medical expenses. Government data and personal narratives were also reviewed to identify the discriminatory elements that can have significant consequences, including increased disease prevalence, higher incidence of occupational injuries, and broader socio-economic instability among migrants. Results Discriminatory elements were found in most programs, with the exception of emergency medical services. These programs commonly provide fewer benefits or impose stricter eligibility criteria for migrants compared to nationals. In particular, the Korean NHI system demands migrants to pay higher premiums and more rigorous maintenance requirements. Conclusions The findings emphasize the need for urgent reforms to equalize health insurance costs, simplify eligibility criteria for migrants, and broaden the scope of benefits to encompass all residency statuses. Implementing these changes will enhance public health infrastructure, improve occupational safety, and foster better integration of the diverse population, ultimately promoting social cohesion and a fairer health system for all. Key messages • A number of discriminatory elements against migrants have been identified in South Korea’s social security policies that can exacerbate health disparities. • Reforms are needed to expand benefits and relax eligibility criteria for migrants in key healthcare policies, including the National Health Insurance system.

Intervention Strategies to Reduce Maternal Mortality in the Context of the Sustainable Development Goals: A Scoping Review

According to the United Nations Population Fund, approximately every two minutes, a woman dies, totalling approximately 800 deaths per day for reasons related to a maternal causes. Therefore, within the Sustainable Development Goals of the 2030 Agenda, the goal is to reduce the global maternal mortality rate to less than 70 deaths per 100,000 live births by 2030. We aim to analyse strategies to reduce maternal mortality in the context of the Sustainable Development Goals, identify barriers that hinder their implementation, and analyse the impact of the COVID-19 pandemic on their achievement. We performed a scoping review of the following databases and distributors of specialised information in the health area: PubMed, Medes, Lilacs, Cuiden, Cinahl, Scopus, SciELO, and websites of the United Nations (UN), United Nations Population Fund (UNFPA), and Cooperanda. A total of 24 articles were reviewed. The results obtainded determined that reviewed studies agree that despite efforts to reduce maternal mortality, significant social and structural barriers still exist in developing countries that slow the implementation of strategies to protect maternal health, especially in the most at-risk populations, and the improvement of the health system. The main strategy consists of increasing the number of deliveries attended by qualified personnel, which is the greatest indicator of progress in reducing maternal mortality. To conclude, Economic, social, and political barriers remain in developing countries in the context of the Sustainable Development Goals. The intervention that has shown the most success is the attendance of deliveries by qualified personnel. It is essential to prioritise maternal care, triangular cooperation, and effective connection between the different Sustainable Development Goals.

Maternal near-miss and mortality associated with being referred: a case control study in Luanda

Abstract Background Understanding of determinants of severe maternal morbidity is crucial for reducing Maternal Near Misses (MNM) and Maternal Deaths (MD). We aimed to assess whether being referred from lower level to tertiary-level hospitals is a determinant of MNM and MD in Luanda, capital of Angola. Methods A facility-based case control study was conducted (June-September 2022) at 2 referral hospitals in Luanda. Consecutive sampling for the cases (women admitted with life-threatening conditions) and systematic sampling for the controls (women admitted for vaginal delivery) was used. Cases were classified by the outcome at discharge: MD or MNM. Multivariate multinomial regression was conducted to assess whether being referred is associated with MNM and MD (controls as reference). Sociodemographic, clinical and obstetric factors and circumstances at admission related with MNM or MM (p-value &amp;lt;0.05) were included in the models. Reduced models (forward technic) were fitted for obtaining adjusted odds ratio (AOR) and respective 95% confidence interval (95%CI). Results Data from 331 cases (245 MNM and 86 MD) and 662 controls were analyzed and bivariate analysis revealed large differences between groups in regards to the sociodemographic, clinical and obstetric characteristics and circumstances of admission. The proportion of being transferred from another facility was 7.9%, 51.0% and 65.1% among controls, MNM and MD, respectively. After adjusting for pre-existing diseases during pregnancy, previous cesarean section and delay in seeking care, being referred from another facility increased the odds of MNM (AOR=10.97; 95%CI: 7.19-16.75) and MD (AOR=18.89; 95%CI: 10.50-33.89). Conclusions According to our findings, being referred from lower level facilities is a strong determinant of MNM and MD. Strategies for improving lower level of healthcare services and the referral system for pregnant women could have a positive impact on prevention of MNM and MD in our setting. Key messages • Awareness should be given to the conditions of maternal transfer from lower level to tertiary level hospitals in Angola. • Public health strategies should address the quality of maternal care at primary and secondary level hospitals, before maternal transfer, as well as, the maternal referral system in this setting.

Using electronic health records in assessing the prevalence of hypertension in Kyrgyzstan

Abstract Background Non-communicable diseases are an increasing challenge in Kyrgyzstan as well as in other parts of Central Asia. However, there is very little epidemiological data on disease burden in the country. The development of electronic health records in primary health care provides an opportunity to assess the disease incidence and prevalence among patient population. Methods All patients with hypertension (HT) diagnoses (ICD-10 I10-I15) were identified from electronic health records used in primary health care in Kyrgyzstan from years 2021, 2022 and 2023 from all 7 regions and Bishkek and Osh cities (n = 132621-152743). Each year, all patients diagnosed with HT during that year or in previous years were included, while those who had passed away were excluded. The incidence and prevalence of patients was calculated using as denominator both the patients who had visited the services as well as registered patients. Results The prevalence of patients with hypertension calculated using patients with service use as denominator varied by region between 10.2% to 14.0% and was pretty stable during the observed period. The prevalence was the lowest in Chui region and the highest in Bishkek city. When the prevalence was calculated using the registered patient population the prevalence was only between 1.5% to 3.1%. Conclusions The observed prevalences were notably lower compared with data from WHO Steps surveys, which have reported a hypertension prevalence more than 40% among individuals aged 25 to 64. It is known that only approximately 25% of the population in Kyrgyzstan utilize primary healthcare services, with maternity care comprising the largest portion. This factor, coupled with cases that go undiagnosed, could potentially account for the observed low prevalence in electronic patient data. However, the electronic patient records provide useful information on diagnostics and disease burden in the country that can be used in developing the services. Key messages • Electronic health records have developed quickly in Kyrgyzstan and enable extraction of patient data from primary health care. • The low use of primary health care services complicates the use of register data in assessing the disease prevalences.