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1.  Improving adolescent sexual and reproductive health in Latin America: reflections from an International Congress 
Reproductive Health  2015;12:11.
In February 2014, an international congress on Promoting Adolescent Sexual and Reproductive Health (ASRH) took place in Cuenca, Ecuador. Its objective was to share evidence on effective ASRH intervention projects and programs in Latin America, and to link this evidence to ASRH policy and program development. Over 800 people participated in the three-day event and sixty-six presentations were presented.
This paper summarizes the key points of the Congress and of the Community Embedded Reproductive Health Care for Adolescents (CERCA) project. It aims at guiding future ASRH research and policy in Latin America.
1. Context matters. Individual behaviors are strongly influenced by the social context in which they occur, through determinants at the individual, relational, family, community and societal levels. Gender norms/attitudes and ease of communication are two key determinants.
2. Innovative action. There is limited and patchy evidence of effective approaches to reach adolescents with the health interventions they need at scale. Yet, there exist several promising and innovative examples of providing comprehensive sexuality education through conventional approaches and using new media, improving access to health services, and reaching adolescents as well as families and community members using community-based interventions were presented at the Congress.
3. Better measurement. Evaluation designs and indicators chosen to measure the effect and impact of interventions are not always sensitive to subtle and incremental changes. This can create a gap between measured effectiveness and the impact perceived by the targeted populations.
Thus, one conclusion is that we need more evidence to better determine the factors impeding progress in ASRH in Latin American, to innovate and respond flexibly to changing social dynamics and cultural practices, and to better measure the impact of existing intervention strategies. Yet, this Congress offered a starting point from which to build a multi-agency and multi-country effort to generate specific evidence on ASRH with the aim of guiding policy and program decision-making. In a region that contains substantial barriers of access to ASRH education and services, and some of the highest adolescent pregnancy rates in the world, the participants agreed that there is no time to lose.
doi:10.1186/1742-4755-12-11
PMCID: PMC4320614  PMID: 25616439
Adolescents; Latin America; Sexual and reproductive health; Policy; Intervention strategies; Teenage pregnancies
2.  Drivers of facility deliveries in Africa and Asia: regional analyses using the demographic and health surveys 
Reproductive Health  2015;12:6.
Background
In the past few decades many countries have worked to increase the number of women delivering in facilities, with the goal of improving maternal and neonatal health outcomes. The purpose of this study is to explore the current situation of facility deliveries in Africa and Asia to understand where and with whom women deliver. Furthermore, we aim to test potential drivers of facility delivery at the individual, household, and community-level.
Methods
Demographic and Health Survey data collected since 2003 from 43 countries in Africa and Asia is explored to understand the patterns of where women are delivering. We look at patterns by region and wealth quintile and urban/rural status. We then run a series of multi-level models looking at relationships between individual, household and community-level factors and the odds of a woman delivering in a facility. We explore this for Asia and Africa separately. We also look at correlates of delivery with a trained provider, in a public facility, in a private facility, with a doctor and in a hospital.
Results
The majority of women deliver in a facility and with a provider; however, about 20% of deliveries are still with no one or a friend/relative or alone. Rates of facility delivery are lower in Asia overall, and a greater proportion of deliveries take place in private facilities in Asia compared to Africa. Most of the individual level factors that have been found in past studies to be associated with delivering in a facility hold true for the multi-country-level analyses, and small differences exist between Asia and Africa. Women who deliver in private facilities differ from women who deliver in public facilities or at home.
Conclusions
Most women in Africa and Asia are delivering in a facility, and drivers of facility delivery identified in smaller level or country specific studies hold true in multi-country national level data. More data and research is needed on other drivers, especially at the country-level and relating to the quality of care and maternal health complications.
doi:10.1186/1742-4755-12-6
PMCID: PMC4320522  PMID: 25595063
Facility delivery; Maternal health; Asia; Africa
3.  Safe and efficacious artemisinin-based combination treatments for African pregnant women with malaria: a multicentre randomized control trial 
Reproductive Health  2015;12:5.
Background
Asymptomatic and symptomatic malaria during pregnancy has consequences for both mother and her offspring. Unfortunately, there is insufficient information on the safety and efficacy of most antimalarials in pregnancy. Indeed, clinical trials assessing antimalarial treatments systematically exclude pregnancy for fear of teratogenicity and embryotoxicity. The little available information originates from South East Asia while in sub-Saharan Africa such information is still limited and needs to be provided.
Design
A Phase 3, non-inferiority, multicentre, randomized, open-label clinical trial on safety and efficacy of 4 ACT when administered during pregnancy was carried out in 4 African countries: Burkina Faso, Ghana, Malawi and Zambia. This is a four arm trial using a balanced incomplete block design. Pregnant women diagnosed with malaria are randomised to receive either amodiaquine-artesunate (AQ-AS), dihydroartemisinin-piperaquine (DHA-PQ), artemether-lumefantrine (AL), or mefloquine-artesunate (MQAS). They are actively followed up until day 63 post-treatment and then monthly until 4–6 weeks post-delivery. The offspring is visited at the time of the first birthday. The primary endpoint is treatment failure (PCR adjusted) at day 63 and safety profiles. Secondary endpoints included PCR unadjusted treatment failure up to day 63, gametocyte carriage, Hb changes, placenta malaria, mean birth weight and low birth weight. The primary statistical analysis will use the combined data from all 4 centres, with adjustment for any centre effects, using an additive model for the response rates. This will allow the assessment of all 6 possible pair-wise treatment comparisons using all available data.
Discussion
The strength of this trial is the involvement of several African countries, increasing the generalisability of the results. In addition, it assesses most ACTs currently available, determining their relative ‘-value-’ compared to others. The balanced incomplete block design was chosen because using all 4-arms in each site would have increased complexity in terms of implementation. Excluding HIV-positive pregnant women on antiretroviral drugs may be seen as a limitation because of the possible interactions between antiretroviral and antimalarial treatments. Nevertheless, the results of this trial will provide the evidence base for the formulation of malaria treatment policy for pregnant women in sub-Saharan Africa.
Trial registration
NCT00852423
doi:10.1186/1742-4755-12-5
PMCID: PMC4326323  PMID: 25592254
Artemisinin-based therapy; Malaria in pregnancy; Pregnant women; Malaria; Sub-Saharan
4.  Prevalence of birth defects in an Arctic Russian setting from 1973 to 2011: a register-based study 
Reproductive Health  2015;12:3.
Background
Birth defects (BD) constitute an important public health issue as they are the main cause of infant death. Their prevalence in Europe for 2008–2012 was 25.6 per 1000 newborns. To date, there are no population-based studies for the Russian Federation. The aim of the present study is to estimate the prevalence of BD, its forms, and changes over time in the Russian Arctic city of Monchegorsk (Murmansk County) for the period 1973–2011.
Methods
The Murmansk County Birth Register and the Kola Birth Register were the primary sources of information, covering 30448 pregnancy outcomes in Monchegorsk (Murmansk County, Russia) during the study period.
Results
The total perinatal prevalence of BD was 36.1/1000 live births (LB) and stillborn (SB) (95% CI = 34.0-38.2). After exclusions of minor malformations according to the European Surveillance of Congenital Anomalies guidelines, it decreased to 26.5/1000 LB plus SB (95% CI = 24.6-28.3). The perinatal prevalence of BD that are obligatory to report in Russia was 7.3/1000 LB plus SB (95% CI = 6.4-8.3). There was a significant positive time-trend in total perinatal prevalence of birth defects across the study period (p < 0.001 for trend). Prevalence of all BD increased from 23.5/1000 to 46.3/1000 (LB plus SB), while that excluding minor defects rose from 17.7/1000 to 35.7/1000 (LB plus SB). The most prevalent group of defects was malformations of the musculoskeletal system, which represented 35.4% of all BD. The most prominent increase was observed for the urinary system, rising from 0.2/1000 to 19.1/1000 (LB plus SB).
Conclusions
The observed perinatal prevalence of BD in Monchegorsk increased two-fold during the 38-year study period. Further investigations to identify the underlying bases for the observed progressive growth in BD are recommended.
doi:10.1186/1742-4755-12-3
PMCID: PMC4298118  PMID: 25577202
Birth register; Birth defects; Prevalence; Murmansk county birth registry; Russian Federation; Arctic
5.  The success factors of scaling-up Estonian sexual and reproductive health youth clinic network - from a grassroots initiative to a national programme 1991–2013 
Reproductive Health  2015;12:2.
Background
A growing number of middle-income countries are scaling up youth-friendly sexual and reproductive health pilot projects to national level programmes. Yet, there are few case studies on successful national level scale-up of such programmes. Estonia is an excellent example of scale-up of a small grassroots adolescent sexual and reproductive health initiative to a national programme, which most likely contributed to improved adolescent sexual and reproductive health outcomes. This study; 1) documents the scale-up process of the Estonian youth clinic network 1991–2013, and 2) analyses factors that contributed to the successful scale-up. This research provides policy makers and programme managers with new insights to success factors of the scale-up, that can be used to support planning, implementation and scale-up of adolescent sexual and reproductive health programmes in other countries.
Methods
Information on the scale-up process and success factors were collected by conducting a literature review and interviewing key stakeholders. The findings were analysed using the WHO-ExpandNet framework, which provides a step-by-step process approach for design, implementation and assessment of the results of scaling-up health innovations.
Results
The scale-up was divided into two main phases: 1) planning the scale-up strategy 1991–1995 and 2) managing the scaling-up 1996–2013. The planning phase analysed innovation, user organizations (youth clinics), environment and resource team (a national NGO and international assistance). The managing phase examines strategic choices, advocacy, organization, resource mobilization, monitoring and evaluation, strategic planning and management of the scale-up.
Conclusions
The main factors that contributed to the successful scale-up in Estonia were: 1) favourable social and political climate, 2) clear demonstrated need for the adolescent services, 3) a national professional organization that advocated, coordinated and represented the youth clinics, 4) enthusiasm and dedication of personnel, 5) acceptance by user organizations and 6) sustainable funding through the national health insurance system. Finally, the measurement and recognition of the remarkable improvement of adolescent SRH outcomes in Estonia would not have been possible without development of good reporting and monitoring systems, and many studies and international publications.
doi:10.1186/1742-4755-12-2
PMCID: PMC4298051  PMID: 25566785
Adolescents; Youth-friendly; Youth clinic; Sexual and reproductive health; Scale-up; Framework
6.  A matched case–control study of preterm birth in one hospital in Beijing, China 
Reproductive Health  2015;12:1.
Background
Preterm birth is an unresolved global health issue. The etiologies of preterm birth are complex and multifactorial. To examine risk factors related to preterm birth, a matched case–control study was conducted in a hospital in Beijing, China where little data on preterm birth have been published in the scientific literature.
Methods
A 1:1 matched case–control study was conducted in 172 pairs of women with preterm birth (case group) and term delivery (control group). Eligible subjects were interviewed in person by well-trained investigators using a questionnaire. Information on obstetric diagnosis and newborns were abstracted from inpatients’ medical records. Univariate and multivariate conditional logistic regression models were used to measure the associations between related factors and preterm birth.
Results
Univariate analysis showed that 6 of 12 factors were associated with preterm birth. Multivariate results showed that gestational hypertension (OR = 7.76), low gestational weight gain (OR = 3.02), frequent prenatal care (OR = 0.16), balanced diet (OR = 0.36), and high gestational weight gain (OR = 0.41) were associated with preterm birth.
Conclusion
This study provides information on preterm birth in Beijing, China, and it also lends support to existing evidence about the role of maternal nutritional status, prenatal care and gestational hypertension as risk factors for preterm birth.
doi:10.1186/1742-4755-12-1
PMCID: PMC4290090  PMID: 25561377
Preterm birth; Case–control study; Risk factors
7.  The effects of situated learning and health knowledge involvement on health communications 
Reproductive Health  2014;11(1):93.
Background
Many patients use websites, blogs, or online social communities to gain health knowledge, information about disease symptoms, and disease diagnosis opinions. The purpose of this study is to use the online platform of blogs to explore whether the framing effect of information content, situated learning of information content, and health knowledge involvement would affect health communication between doctors and patients and further explore whether this would increase patient willingness to seek treatment.
Methods
This study uses a survey to collect data from patient subjects who have used online doctor blogs or patients who have discussed medical information with doctors on blogs. The number of valid questionnaire samples is 278, and partial least square is used to conduct structural equation model analysis.
Results
Research results show that situated learning and health knowledge involvement have a positive effect on health communication. The negative framing effect and health knowledge involvement would also affect the patient’s intention to seek medical help. In addition, situated learning and health knowledge involvement would affect the intention to seek medical help through communication factors.
Conclusions
Blogs are important communication channels between medical personnel and patients that allow users to consult and ask questions without time limitations and enable them to obtain comprehensive health information.
doi:10.1186/1742-4755-11-93
PMCID: PMC4297390  PMID: 25542070
Framing effects; Situated learning; Health knowledge involvement; Health communication; Visiting a doctor
8.  Decision making on unsafe abortions in Sri Lanka: a case-control study 
Reproductive Health  2014;11(1):91.
Background
Following an unintended pregnancy, not every woman would invariably choose to undergo an unsafe abortion. It suggests that in the decision making process, women face both ‘push’ factors that favour abortion and ‘pull’ factors that work against it. This study assessed the circumstances that surrounded a woman’s decision to undergo an unsafe abortion, compared to a decision to continue, when faced with an unintended pregnancy in Sri Lanka.
Methods
An unmatched case-control study was conducted among 171 women admitted to nine hospitals in eight districts following an unsafe abortion (Cases) and 600 women admitted to the same hospitals for delivery of an unintended term pregnancy (Controls). Interviewer-administered-questionnaires and in-depth interviews assessed women’s characteristics, decision making process and underlying reasons for their decision. The risk of abortion related to their decision making was assessed using odds ratio (OR) and 95% confidence interval (CI).
Results
Compared to controls, the cases were significantly less-educated, employed, unmarried and primi-gravid (p < 0.05). All knew the ‘illegal’ status of abortion, mainly through media (65.5% cases versus 80% controls). When making a decision, the risk of undergoing an unsafe abortion was significant among those who sought assistance (44% versus 32%; OR = 1.7 (95% CI = 1.2-2.4)), with more reliance placed on non-medical sources such as spouse/partner, friend, neighbour and family/relation. Speaking to women with past experience of induced abortions (31% versus 21.5%; OR = 1.6 (1.1-2.4) and failure in making the final decision with partners also imparted a significant risk for abortion (64% versus 34%; OR = 3.4; 2.4-4.8). A decision favouring unsafe abortion was predominantly based on their economic instability (29.5%) and poor support by partners (14%), whereas a decision against it was based on ethical considerations (44% religious beliefs: 12% social stigma) over its legal implications (4%). Most abortions were performed by unqualified persons (36.1% self proclaimed abortionists; 26.2% not revealed their qualifications) for a wide range of payment in non-sterile environments (45.9% unknown place) using septic procedures (38.5% trans-vaginal insertions; 24.6% unaware of the procedure).
Conclusions
Women’s risk of unsafe abortion was associated with unreliable sources of information during decision making that led to poor knowledge and positive attitudes on its safety; poor access to affordable abortion services; and their economic instability.
doi:10.1186/1742-4755-11-91
PMCID: PMC4280739  PMID: 25518959
Decision making; Unsafe abortion; Circumstances; Access and availability
9.  Can community health officer-midwives effectively integrate skilled birth attendance in the community-based health planning and services program in rural Ghana? 
Reproductive Health  2014;11:90.
Background
The burden of maternal mortality in sub-Saharan Africa is very high. In Ghana maternal mortality ratio was 380 deaths per 100,000 live births in 2013. Skilled birth attendance has been shown to reduce maternal mortality and morbidity, yet in 2010 only 68 percent of mothers in Ghana gave birth with the assistance of skilled birth attendants. In 2005, the Ghana Health Service piloted a strategy that involved using the integrated Community-based Health Planning and Services (CHPS) program and training Community Health Officers (CHOs) as midwives to address the gap in skilled attendance in rural Upper East Region (UER). The study assesses the feasibility of and extent to which the skilled delivery program has been implemented as an integrated component of the existing CHPS, and documents the benefits and challenges of the integrated program.
Methods
We employed an intrinsic case study design with a qualitative methodology. We conducted 41 in-depth interviews with health professionals and community stakeholders. We used a purposive sampling technique to identify and interview our respondents.
Results
The CHO-midwives provide integrated services that include skilled delivery in CHPS zones. The midwives collaborate with District Assemblies, Non-Governmental Organizations (NGOs) and communities to offer skilled delivery services in rural communities. They refer pregnant women with complications to district hospitals and health centers for care, and there has been observed improvement in the referral system. Stakeholders reported community members’ access to skilled attendants at birth, health education, antenatal attendance and postnatal care in rural communities. The CHO-midwives are provided with financial and non-financial incentives to motivate them for optimal work performance. The primary challenges that remain include inadequate numbers of CHO-midwives, insufficient transportation, and infrastructure weaknesses.
Conclusions
Our study demonstrates that CHOs can successfully be trained as midwives and deployed to provide skilled delivery services at the doorsteps of rural households. The integration of the skilled delivery program with the CHPS program appears to be an effective model for improving access to skilled birth attendance in rural communities of the UER of Ghana.
doi:10.1186/1742-4755-11-90
PMCID: PMC4326211  PMID: 25518900
Community-based service delivery; Ghana; Maternal mortality; Skilled birth attendance
10.  Delivering the evidence to improve the health of women and newborns: State of the World’s Midwifery, report 2014 
Reproductive Health  2014;11:89.
The State of the World’s Midwifery Report 2014: A universal pathway, a women’s right to health (SoWMy2014) was published in June 2014 and joins the ranks of a number of publications which contribute to the growing body of evidence about a global midwifery workforce that can improve maternal and child health.
This editorial provides an overview of these publications that have been supported by global movements in the area of sexual, reproductive, maternal, and newborn and child health over the last four years. Background information is given on the methodology and data collection of SoWMy2014, the main findings cover the area of the availability, accessibility, acceptability and quality of midwifery services and a 2 page country brief shows the SRMNH data and workforce projections for each of the 73 “Countdown countries” that participated.
SoWMy 2014 report shows that midwives can provide 87% of the needed essential care for women and newborns, when educated and trained to international standards. Midwives however, are most effective when they work within a functional health system and enabling environment.
Also, a supportive team of auxiliaries, physicians and specialists is essential in order to ensure coverage of SRMNH services to women and newborns across the whole continuum of care, from pre-pregnancy through to pregnancy, childbirth and the post-natal period and from household to hospital.
Based on these findings, the report puts forward a vision of Midwifery2030, a pathway for women’s health and for midwifery policy and planning through the end of 2030. It promotes women-centered and midwife-led care to achieve the goal of universal health coverage for all women.
Electronic supplementary material
The online version of this article (doi:10.1186/1742-4755-11-89) contains supplementary material, which is available to authorized users.
doi:10.1186/1742-4755-11-89
PMCID: PMC4326403  PMID: 25518862
11.  Social networks and female reproductive choices in the developing world: a systematized review 
Reproductive Health  2014;11(1):85.
Continuing high global maternal mortality and morbidity rates in developing countries have resulted in an increasing push to improve reproductive health services for women. Seeking innovative ways for assessing how positive health knowledge and behaviors spread to this vulnerable population has increased the use of social network theories and analysis in health promotion research. Despite the increased research on social networks and health, no overarching review on social networks and maternal health literature in developing countries has been conducted. This paper attempts to synthesize this literature by identifying both published and unpublished studies in major databases on social networks and maternal and child health. This review examined a range of study types for inclusion, including experimental and non-experimental study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, cohort studies, case control studies, longitudinal studies, and cross-sectional observational studies. Only those that occurred in developing countries were included in the review. Eighteen eligible articles were identified; these were published between 1997 and 2012. The findings indicated that the most common social network mechanisms studied within the literature were social learning and social influence. The main outcomes studied were contraceptive use and fertility decisions. Findings suggest the need for continuing research on social networks and maternal health, particularly through the examination of the range of social mechanisms through which networks may influence health behaviors and knowledge, and the analysis of a larger variety of reproductive outcomes.
doi:10.1186/1742-4755-11-85
PMCID: PMC4275947  PMID: 25495334
Social network analysis; Maternal health; Reproductive health; Network mechanisms
12.  Differences in sexual behaviour and sexual practices of adolescents in Nigeria based on sex and self-reported HIV status 
Reproductive Health  2014;11(1):83.
Background
Sexual behaviour and sexual practices affect the risk for acquisition and transmission of HIV infection. This study tries to identify differences in sexual behaviour (condom use with non-marital partners, multiple sexual partnerships transactional sex and age mixing in sexual relationships), sexual practices (oral, anal and vagina sex), and forced sexual initiation based on sex and HIV status of adolescents in Nigeria.
Method
Face to face interviewer-administered questionnaires were used to collect information from a nationally representative sample of 10–19 years old adolescents residing in Nigeria. Data included information on age of sexual debut, sexual behaviour and sexual practices. Association between HIV status, sex, sexual behaviour and sexual practices, and predictors of use of condoms during the last vaginal sexual intercourse were determined.
Result
More self-reported HIV positive than HIV negative females had experienced forced sexual initiation (p = 0.008). Significantly more female than male adolescents had engaged in transactional sex (p < 0.001) and had sex with partners who were older than them by 10 years or more (p < 0.001). Vaginal (95.2%), oral (26.6%) and anal (7.8%) sex were practiced by male and females irrespective of HIV status. More females reported oral sex (p = 0.001). Being a female (p = 0.001), having genital itching in the last 12 months (p = 0.04)and having engaged in anal sex in the last 12 months (p = 0.009) reduced the odds of using a condom at last vaginal intercourse. Having a HIV positive or negative status did not significantly increase the odds of using a condom at last vaginal intercourse.
Conclusion
Differences in sexual behaviour and sexual practices of adolescents was observed based on sex and not on HIV status. History of forced sex initiation however differed by HIV status. Tailored interventions for male and female adolescents are required to reduce their risk of HIV infection. Tailored interventions are also required for adolescents living with HIV to improve their sexual and reproductive health.
doi:10.1186/1742-4755-11-83
PMCID: PMC4266967  PMID: 25481734
Adolescents; Nigeria; HIV; Sex; Practices; Behaviour
13.  Sexual behaviours and associated factors among students at Bahir Dar University: a cross sectional study 
Reproductive Health  2014;11(1):84.
Background
Sexual behaviour is the core of sexuality matters in adolescents and youths. Their modest or dynamic behaviour vulnerable them to risky sexual behaviours. In Ethiopia, there is scarcity of multicentered representative data on sexual behaviours in students to have a national picture at higher education. This study therefore conducted to assess sexual behaviours and associated factors at Bahir Dar University, Ethiopia.
Methods
A cross sectional study was conducted among Bahir Dar University students from December to February 2013. Multistage sampling and self administered questionnaires were employed. Descriptive statistics such as frequency and mean were used to describe the study participants in relation to relevant variables. Multivariate analysis was carried for those variables that had a p-value of ≤ 0.2 in the bivariate analysis to identify the predictor variables.
Results
Of the 817 study participants, 297 (36.4%) students had ever had sex. The mean age at first sexual practice was 18.6 years. Unprotected sex, having multiple sex partners, sex with commercial sex workers and sex for the exchange of money was practiced by 184 (62%), 126 (42.7%), 22 (7.4%) and 12 (4%) of sexually active students, respectively. The proportion of attending night clubs and watching porn videos was 130 (15.8%) and 534 (65.4%), respectively. Male respondents had significant positive association with watching porn videos (AOR = 4.8, CI = 3.49 - 6.54) and attending night clubs (AOR = 3.9, CI = 2.3 – 6.7). Watching porn videos, attending night clubs, khat chewing and taking alcohol frequently were significantly associated for ever had sex and having multiple sexual partners. Khat chewing practice (AOR = 8.5, CI =1.31 - 55.5) and attending night clubs (AOR = 4.6, CI = 1.8 - 11.77) had statistical significant association with the purpose of sexual intercourse for the sake of money and for having sex with commercial sex workers, respectively.
Conclusions
Significant number of students had different risky sexual behaviours. Substance use, attending night clubs and watching porno video were predictor factors for practicing different sexual behaviours. Therefore, preventive intervention programmes should be strengthened, effectively implemented and monitored both in the earlier school and in the universities.
doi:10.1186/1742-4755-11-84
PMCID: PMC4271440  PMID: 25481831
Sexual behaviours; University students; Associated factors; Bahir Dar
14.  UNICEF Report: enormous progress in child survival but greater focus on newborns urgently needed 
Reproductive Health  2014;11:82.
The world has made enormous progress in improving child survival since 1990, reducing the under-five mortality rate by nearly half from 90 to 46 deaths per 1,000 live births in 2013. Currently, the global under-five mortality rate is falling faster than at any other time over the past two decades. Yet, progress is insufficient to meet the Millennium Development Goal 4 (MDG 4) which calls for reducing the under-five mortality rate by two-thirds between 1990 and 2015. If current trends continue in all countries, the world will not meet the target until 2026, 11 years behind schedule. To accelerate progress in child survival, focusing on the newborn is critical since the share of all under-five deaths occurring in the neonatal period (the first 28 days of life) is increasing. Globally, 44 per cent of the 6.3 million under-five deaths occurred in the neonatal period in 2013. Many of these deaths are easily preventable with simple, cost-effective interventions administered before, during and immediately after birth. However, UNICEF’s analysis reveals a remarkably high degree of variability in the utilization and quality of services provided to pregnant women and their babies. Furthermore, quality care is grossly lacking even for babies and mothers in contact with the health system. The latest levels and trends in child mortality as well as the coverage and quality of key maternal and newborn care from pregnancy through childbirth and the postnatal period are the subject of the new UNICEF report Committing to Child Survival: A Promise Renewed Progress Report 2014 released recently in September.
doi:10.1186/1742-4755-11-82
PMCID: PMC4320591  PMID: 25480451
Child mortality; Under-five mortality; Neonatal mortality; Newborns; Quality of care; A Promise Renewed
15.  The prevalence of Group B Streptococus recto-vaginal colonization and antimicrobial susceptibility pattern in pregnant mothers at two hospitals of Addis Ababa, Ethiopia 
Reproductive Health  2014;11(1):80.
Background
Group B streptococcus (GBS) has been implicated in adverse pregnancy outcomes. GBS recto-vaginal colonization rates significantly vary among different communities and geographic locations. Limited data is available on the prevalence and effects of GBS recto-vaginal colonization among pregnant mothers in developing countries like Ethiopia.
Objective
To assess the prevalence of GBS recto-vaginal colonization among near term pregnant mothers and the antimicrobial susceptibility pattern of the isolates.
Methods
A cross sectional descriptive study was conducted on pregnant mothers at gestational age of 35–37 weeks attending Ante Natal Clinics at Ghandi Memorial (GMH) and Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa. Samples from lower genital tract and rectum were collected and cultured for GBS on CHROM agar Strep B.
Results
Twenty two of the 300 pregnant mothers (7.2%) studied were found to have positive GBS recto-vaginal culture. Twelve isolates (55%) were sensitive to penicillin while 20 (91%) were sensitive to ampicilline. All isolates except one were sensitive to Erythromycin.
Conclusion
The study showed recto-vaginal GBS colonization among near term pregnant mothers is reasonably high in our community calling for the need to screen mothers near term and provide appropriate antimicrobial prophylaxis to prevent potential adverse maternal and neonatal outcome.
doi:10.1186/1742-4755-11-80
PMCID: PMC4265524  PMID: 25476269
Group B streptococcus (GBS); Recto-vaginal colonization; Prevalence
16.  A protocol to identify non-classical risk factors for preterm births: the Brazilian Ribeirão Preto and São Luís prenatal cohort (BRISA) 
Reproductive Health  2014;11(1):79.
Background
Preterm birth is the main cause of morbidity and mortality during the perinatal period. Classical risk factors are held responsible for only 1/3 of preterm births and no current intervention has produced an appreciable reduction of this event. It is necessary to explore new hypotheses and mechanisms of causality by using an integrated approach, collaboration among research groups and less fragmented theoretical-methodological approaches in order to detect new risk factors and to formulate more effective intervention strategies.
Methods
The study will be conducted on a convenience cohort of Brazilian pregnant women recruited at public and private prenatal health services. A total of 1500 pregnant women in São Luís, and 1500 in Ribeirão Preto, will be invited for an interview and for the collection of biological specimens from the 22nd to the 25th week of gestational age (GA). At the time of delivery they will be reinterviewed. GA will be determined using an algorithm based on two criteria: date of last menstruation (DLM) and obstetric ultrasound (OUS) performed at less than 20 weeks of GA. Illicit drug consumption during pregnancy will be determined using a self-applied questionnaire and the following instruments will be used: perceived stress scale, Beck anxiety scale, screening for depression of the Center of Epidemiological Studies (CES-D), experiences of racial discrimination, social network and social support scale of the Medical Outcomes Study and violence (Abuse Assessment Screening and violence questionnaire of the WHO). Bacterial vaginosis, urinary tract infection and periodontal disease will also be identified. Neuroendocrine, immunoinflammatory and medical intervention hypotheses will be tested. The occurrence of elective cesarean section in the absence of labor will be used as a marker of medical intervention.
Conclusion
Psychosocial, genetic and infectious mechanisms will be selected, since there are indications that they influence preterm birth (PTB). The studies will be conducted in two Brazilian cities with discrepant socioeconomic conditions. The expectation is to identify risk factors for PTB having a greater predictive power than classically studied factors. The final objective is to propose more effective interventions for the reduction of PTB, which, after being tested, might subsidize health policies.
doi:10.1186/1742-4755-11-79
PMCID: PMC4246428  PMID: 25410690
Cohort studies; Prenatal care; Premature birth; Risk factors; Stress, psychological; Infection
17.  Assisted reproductive technologies (ARTs): Evaluation of evidence to support public policy development 
Reproductive Health  2014;11(1):76.
Over the years, IVF/ICSI protocols have continued to evolve with efforts to improve outcomes. As a result, treatment success may be related to certain procedural factors, including number of embryos transferred and stage at which they are transferred. This review aims to assess the safety and effectiveness of IVF/ICSI in comparison to spontaneous conception and less invasive ARTs and the impact of procedure-related factors on the outcomes of IVF/ICSI in order to support the development of local clinical and policy guidance. Following Cochrane Collaboration guidelines and the PRISMA statement, a comprehensive systematic review of literature examining the impact of procedural characteristics on the safety or effectiveness of IVF/ICSI from 2007 to date was performed. 33 systematic reviews and 3 primary studies evaluating the impact of procedural differences, IVF/ICSI in comparison to less invasive ARTs, and ARTs in comparison to spontaneous conception were found. IVF was shown to offer significant benefits over no treatment and IUI in achieving pregnancy and live birth among couples with endometriosis or unexplained infertility. Frozen and blastocyst-stage embryo transfers were as effective as fresh and cleavage-stage embryo transfers, respectively. In comparison to single embryo transfer, double embryo transfer significantly increased pregnancy, live birth and multiple pregnancy/birth rates. IVF/ICSI was associated with more complications during pregnancy and delivery, and in infants compared to naturally conceived pregnancies, particularly when multiple embryo transfer was used. Frozen embryo transfer had fewer adverse events during pregnancy and delivery than fresh embryo transfer, and was at least as safe in terms of infant outcomes. The potential complications of IVF/ICSI may be minimized through procedural choices, but such choices often impact effectiveness. Thus, in developing clinical and policy guidance around IVF/ICSI, the risk-benefit trade-offs patients and providers are willing to accept must be carefully considered.
Electronic supplementary material
The online version of this article (doi:10.1186/1742-4755-11-76) contains supplementary material, which is available to authorized users.
doi:10.1186/1742-4755-11-76
PMCID: PMC4233043  PMID: 25376649
IVF; ICSI; Assisted reproductive technology; Outcomes; Systematic review
18.  Adolescent - parent communication on sexual and reproductive health issues among high school students in Dire Dawa, Eastern Ethiopia: a cross sectional study 
Reproductive Health  2014;11(1):77.
Background
Sexual and reproductive health communications are most likely promoting healthy sexual development and reduce sexual risks. Communication is the principal means for parents to transmit sexual values, beliefs, expectations and knowledge to their adolescents. However, there is a paucity of evidence about adolescent parent communication in Ethiopia. This study aimed to determine adolescent-parent communication on sexual and reproductive health issues and associated factors among high school students in Dire Dawa, Eastern Ethiopia.
Methods
Institution based cross sectional study was conducted among high school students in Dire Dawa administrative council from February to March 2011. Simple random sampling technique was used to select 695 students from 9–12 grades. Qualitative data were collected through focus group discussion separately for female and male parents. Data were entered in Epi info version 3.5.1 and analyzed by SPSS version 16.1. Logistic regression with OR and 95% confidence interval was used to identify the independent predictors of adolescent parent communication.
Results
Thirty seven percent of students had ever discussed on at least two sexual and reproductive health topics with their parents. Of which, majority of student preferred to discuss with their peers than parent. Condom use during first intercourse was associated with having communication about sexual and reproductive health [AOR = 1.9, 95% CI: 1.0, 3.8]. Cultural taboo, shame and lack of communication skill were reasons that hinder communication between parent and adolescent about sexual matters.
Conclusion
Communication on sexual and reproductive health issue between adolescent and their parent was low. School based education is important to improve adolescent parent communication about sexual and reproductive health issues.
doi:10.1186/1742-4755-11-77
PMCID: PMC4233096  PMID: 25380684
Communication; Sexual; Reproductive; Adolescent; Parent; Ethiopia
19.  Empowering adolescent girls: developing egalitarian gender norms and relations to end violence 
Reproductive Health  2014;11(1):75.
On the occasion of the International Day of the Girl Child (October 11), this commentary highlights the problem of violence against adolescent girls. It describes the nature and magnitude of violence faced by adolescent girls, what we know about factors that drive violence against women and against adolescent girls. It highlights the importance of promoting egalitarian gender norms, particularly during adolescence, and empowering women and girls in efforts to end such violence. Finally, it offers lessons learned from some promising interventions in this area.
doi:10.1186/1742-4755-11-75
PMCID: PMC4216358  PMID: 25335989
20.  Increasing literate and illiterate women’s met need for contraception via empowerment: a quasi-experiment in rural India 
Reproductive Health  2014;11(1):74.
Background
Virtually all the evidence on the relationship between women’s empowerment and use of contraception comes from cross-sectional studies that have emphasized macrosocial factors.
This analysis tested whether literate and illiterate women are empowered by an intervention designed to provide information addressing technical and gender concerns and expand contraceptive choice, and evaluated the effects of women’s decision-making power on contraceptive behavior.
Methods
The data came from a three-year quasi-experiment conducted in two comparable, yet not equivalent, rural blocks in Jharkhand, India. At the intervention block, a new contraceptive method was introduced at Ministry of Health health centers, providers were trained to offer family planning information and services which took into consideration gender power dynamics, and promotional messages and information about contraception were disseminated community-wide. Married women ages 15–49 who lived in the intervention and control blocks were sampled and interviewed before and after the intervention by a professional research firm. Data analyses included generalized linear models with interactions and covariate control.
Results
Women’s normative beliefs concerning wives’ power in decisions regarding money earned and visits to relatives and friends vis-à-vis their husbands’ power were increased by the intervention; similar was the case among illiterate, but not literate, women regarding decisions related to childbearing. Concerning met need for contraception, the change for women with relatively more power who were illiterate was greater in the intervention than in the control area.
Conclusion
The findings suggest that women were empowered by outreach visits that addressed gender dynamics and that their empowerment contributed to their met need for contraception. Generalizations to other settings, however, may be limited by cultural differences.
doi:10.1186/1742-4755-11-74
PMCID: PMC4221697  PMID: 25330906
Women’s empowerment; Literacy; Met need for contraception; Intervention
21.  Preconception care: it’s never too early 
Reproductive Health  2014;11(1):73.
The preconception window has been recognized as one of the earliest sensitive windows of human development, and interventions that focus on this period have the potential to affect not only pregnancy but long term outcomes as well. The journal Reproductive Health has published a supplement entitled ‘Preconception Interventions’ which includes a series of systematic reviews regarding the impact of public health interventions during the preconception period on maternal and child health. These articles describe the role that poor preconception health plays in creating health disparities across the globe. The reviews highlight our current understanding (or lack thereof) regarding how both maternal and paternal preconception health and knowledge shapes the long-term health of not only children, but of families, communities, and nations. Researchers and healthcare workers should take particular note of these interventions, as the preconception time period may be as important as the pregnancy and post-pregnancy periods, and is critical in terms of bridging the gap in the continuum of care, particularly for adolescents.
doi:10.1186/1742-4755-11-73
PMCID: PMC4196002  PMID: 25273543
22.  Preconception care: promoting reproductive planning 
Reproductive Health  2014;11(Suppl 3):S2.
Introduction
Preconception care recognizes that many adolescent girls and young women will be thrust into motherhood without the knowledge, skills or support they need. Sixty million adolescents give birth each year worldwide, even though pregnancy in adolescence has mortality rates at least twice as high as pregnancy in women aged 20-29 years. Reproductive planning and contraceptive use can prevent unintended pregnancies, unsafe abortions and sexually-transmitted infections in adolescent girls and women. Smaller families also mean better nutrition and development opportunities, yet 222 million couples continue to lack access to modern contraception.
Method
A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.
Results
Comprehensive interventions can prevent first pregnancy in adolescence by 15% and repeat adolescent pregnancy by 37%. Such interventions should address underlying social and community factors, include sexual and reproductive health services, contraceptive provision; personal development programs and emphasizes completion of education. Appropriate birth spacing (18-24 months from birth to next pregnancy compared to short intervals <6 months) can significantly lower maternal mortality, preterm births, stillbirths, low birth weight and early neonatal deaths.
Conclusion
Improving adolescent health and preventing adolescent pregnancy; and promotion of birth spacing through increasing correct and consistent use of effective contraception are fundamental to preconception care. Promoting reproductive planning on a wider scale is closely interlinked with the reliable provision of effective contraception, however, innovative strategies will need to be devised, or existing strategies such as community-based health workers and peer educators may be expanded, to encourage girls and women to plan their families.
doi:10.1186/1742-4755-11-S3-S2
PMCID: PMC4196558  PMID: 25415259
teen pregnancy; preconception; pregnancy intervals; birth spacing
23.  Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health 
Reproductive Health  2014;11(Suppl 3):S1.
Introduction
Preconception care includes any intervention to optimize a woman’s health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.
Methods
A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.
Results
Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.
Conclusion
Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.
doi:10.1186/1742-4755-11-S3-S1
PMCID: PMC4196556  PMID: 25414942
preconception; women of reproduction age; pre-pregnancy; continuum of care; adolescents
24.  Preconception care: nutritional risks and interventions 
Reproductive Health  2014;11(Suppl 3):S3.
Introduction
There is increasingly a double burden of under-nutrition and obesity in women of reproductive age. Preconception underweight or overweight, short stature and micronutrient deficiencies all contribute to excess maternal and fetal complications during pregnancy.
Methods
A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on maternal, newborn and child health (MNCH) outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.
Results
Maternal pre-pregnancy weight is a significant factor in the preconception period with underweight contributing to a 32% higher risk of preterm birth, and obesity more than doubling the risk for preeclampsia, gestational diabetes. Overweight women are more likely to undergo a Cesarean delivery, and their newborns have higher chances of being born with a neural tube or congenital heart defect. Among nutrition-specific interventions, preconception folic acid supplementation has the strongest evidence of effect, preventing 69% of recurrent neural tube defects. Multiple micronutrient supplementation shows promise to reduce the rates of congenital anomalies and risk of preeclampsia. Although over 40% of women worldwide are anemic in the preconception period, only one study has shown a risk for low birth weight.
Conclusion
All women, but especially those who become pregnant in adolescence or have closely-spaced pregnancies (inter-pregnancy interval less than six months), require nutritional assessment and appropriate intervention in the preconception period with an emphasis on optimizing maternal body mass index and micronutrient reserves. Increasing coverage of nutrition-specific and nutrition-sensitive strategies (such as food fortification; integration of nutrition initiatives with other maternal and child health interventions; and community based platforms) is necessary among adolescent girls and women of reproductive age. The effectiveness of interventions will need to be simultaneously monitored, and form the basis for the development of improved delivery strategies and new nutritional interventions.
doi:10.1186/1742-4755-11-S3-S3
PMCID: PMC4196560  PMID: 25415364
preconception; overweight; folic acid; nutrition
25.  Preconception care: preventing and treating infections 
Reproductive Health  2014;11(Suppl 3):S4.
Introduction
Infections can impact the reproductive health of women and hence may influence pregnancy related outcomes for both the mother and the child. These infections range from sexually transmitted infections (STIs) to TORCHS infections to periodontal disease to systemic infections and may be transmitted to the fetus during pregnancy, labor, delivery or breastfeeding.
Methods
A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.
Results
Preconception behavioral interventions significantly declines re-infection or new STI rates by 35% (95% CI: 20-47%). Further, condom use has been shown to be the most effective way to prevent HIV infection (85% protection in prospective studies) through sexual intercourse. Intervention trials showed that preconception vaccination against tetanus averted a significant number of neonatal deaths (including those specifically due to tetanus) when compared to placebo in women receiving more than 1 dose of the vaccine (OR 0.28; 95% CI: 0.15-0.52); (OR 0.02; 95% CI: 0.00-0.28) respectively.
Conclusion
Preconception counseling should be offered to women of reproductive age as soon as they test HIV-positive, and conversely women of reproductive age should be screened with their partners before pregnancy. Risk assessment, screening, and treatment for specific infections should be a component of preconception care because there is convincing evidence that treatment of these infections before pregnancy prevents neonatal infections.
doi:10.1186/1742-4755-11-S3-S4
PMCID: PMC4196562  PMID: 25415557
preconception; infection; HIV; Sexually transmitted infections

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