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Hwang WJ, Lee TH. Safe delivery kits and newborn infection in rural Ethiopian communities. Front Public Health 2024; 12:1305255. [PMID: 39185109 PMCID: PMC11341469 DOI: 10.3389/fpubh.2024.1305255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 05/14/2024] [Indexed: 08/27/2024] Open
Abstract
Objectives Our goal in this study to investigate the impacts of using safe delivery kits, along with education on their appropriate use, has on preventing newborn and maternal infection. Design A cross-sectional study. Setting Participants, and Interventions: we conducted the study on 23 sites across a rural district in Oromia Region, Ethiopia. Safe delivery kits were distributed by health extension workers. Participants comprised 534 mothers between the ages of 17 and 45 years, who were given a safe delivery kit at 7 months' pregnancy for use during their subsequent delivery. Data collection was performed by the trained interviewers in rural Ethiopian communities. Results Multiple logistic regression analyses showed an independent association between using the cord tie provided in the kits and decreased newborn infection. Specifically, newborns whose mothers used the cord tie were 30 times less likely to develop cord infection than those not using the cord tie in the kits. Further, mothers who received education regarding safe delivery kit use had lower rates of puerperal infection. Conclusion Single-use delivery kits, when combined with education regarding the appropriate means of using the kit, can decrease the likelihood of maternal infection. Implications for nursing Nurses and health extension workers in low and middle-income countries should educate mothers on safe delivery kits by providing information regarding their usefulness and the importance of correct and consistent use. Implications for Health Policy: our findings emphasize the need for further interventions in vulnerable countries designed to increase the rate of hygienic birthing practices for deliveries outside health-care facilities.
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Affiliation(s)
- Won Ju Hwang
- East-West Nursing Research Institute, College of Nursing Science Kyung Hee University, Seoul, Republic of Korea
| | - Tae Hwa Lee
- School of Nursing, Yonsei University, Seoul, Republic of Korea
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Improving obstetric care in low-resource settings. Case Rep Womens Health 2022; 36:e00434. [PMID: 36589636 PMCID: PMC9801051 DOI: 10.1016/j.crwh.2022.e00434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 01/04/2023] Open
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Park JH, Hamer DH, Mbewe R, Scott NA, Herlihy JM, Yeboah-Antwi K, Semrau KEA. Components of clean delivery kits and newborn mortality in the Zambia Chlorhexidine Application Trial (ZamCAT): An observational study. PLoS Med 2021; 18:e1003610. [PMID: 33951036 PMCID: PMC8133479 DOI: 10.1371/journal.pmed.1003610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/19/2021] [Accepted: 04/03/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Neonatal infection, a leading cause of neonatal death in low- and middle-income countries, is often caused by pathogens acquired during childbirth. Clean delivery kits (CDKs) have shown efficacy in reducing infection-related perinatal and neonatal mortality. However, there remain gaps in our current knowledge, including the effect of individual components, the timeline of protection, and the benefit of CDKs in home and facility deliveries. METHODS AND FINDINGS A post hoc secondary analysis was performed using nonrandomized data from the Zambia Chlorhexidine Application Trial (ZamCAT), a community-based, cluster-randomized controlled trial of chlorhexidine umbilical cord care in Southern Province of Zambia from February 2011 to January 2013. CDKs, containing soap, gloves, cord clamps, plastic sheet, razor blade, matches, and candle, were provided to all pregnant women. Field monitors made a home-based visit to each participant 4 days postpartum, during which CDK use and newborn outcomes were ascertained. Logistic regression was used to study the association between different CDK components and neonatal mortality rate (NMR). Of 38,579 deliveries recorded during the study, 36,996 newborns were analyzed after excluding stillbirths and those with missing information. Gloves, cord clamps, and plastic sheets were the most frequently used CDK item combination in both home and facility deliveries. Each of the 7 CDK components was associated with lower NMR in users versus nonusers. Adjusted logistic regression showed that use of gloves (odds ratio [OR] 0.33, 95% CI 0.24-0.46), cord clamp (OR 0.51, 95% CI 0.38-0.68), plastic sheet (OR 0.46, 95% CI 0.34-0.63), and razor blade (OR 0.69, 95% CI 0.53-0.89) were associated with lower risk of newborn mortality. Use of gloves and cord clamp were associated with reduced risk of immediate newborn death (<24 hours). Reduction in risk of early newborn death (1-6 days) was associated with use of gloves, cord clamps, plastic sheets, and razor blades. In examining perinatal mortality (stillbirth plus neonatal death in the first 7 days of life), similar patterns were observed. There was no significant reduction in risk of late newborn mortality (7-28 days) with CDK use. Study limitations included potential recall bias of CDK use and inability to establish causality, as this was a secondary observational study. CONCLUSIONS CDK use was associated with reductions in early newborn mortality at both home and facility deliveries, especially when certain kit components were used. While causality could not be established in this nonrandomized secondary analysis, given these beneficial associations, scaling up the use of CDKs in rural areas of sub-Saharan Africa may improve neonatal outcomes. TRIAL REGISTRATION Name of trial: Zambia Chlorhexidine Application Trial (ZamCAT) Name of registry: Clinicaltrials.gov Trial number: NCT01241318.
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Affiliation(s)
- Jason H. Park
- Department of Internal Medicine, University of Michigan Hospitals, Ann Arbor, Michigan, United States of America
- * E-mail:
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts, United States of America
| | - Reuben Mbewe
- Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia
| | - Nancy A. Scott
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Julie M. Herlihy
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | | | - Katherine E. A. Semrau
- Ariadne Labs, Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Woodward M, Ansari A, Draycott T, Winter C, Marjanovic S, Dixon-Woods M. Characterising and describing postpartum haemorrhage emergency kits in context: a protocol for a mixed-methods study. BMJ Open 2021; 11:e044310. [PMID: 33875443 PMCID: PMC8057548 DOI: 10.1136/bmjopen-2020-044310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 03/13/2021] [Accepted: 03/22/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Postpartum haemorrhage (PPH) is an obstetric emergency requiring prompt and accurate response. PPH emergency kits containing equipment and medications can facilitate this kind of intervention, but their design and contents vary, potentially introducing risk of confusion or delay. Designs may be suboptimal, and relying on localised kit contents may result in supply chain costs, increased waste and missed opportunities for economies of scale. This study aims to characterise contextual influences on current practice in relation to PPH kits and to describe the range of kits currently employed in UK maternity units. METHODS AND ANALYSIS This mixed-methods study comprises two phases. The first will use field observations and semistructured interviews to research PPH kits in a small number (3-5) of maternity units that will be selected to represent diversity. Analysis will be conducted both using an established human factors and ergonomics framework and using the constant comparative method for qualitative data analysis. The second phase will use a research and development platform (Thiscovery) to conduct a crowdsourced photography-based audit of PPH kits currently in use in the UK. Participants will tag images to indicate which objects have been photographed. Quantitative analysis will report the frequency of inclusion of each item in kits and the content differences between kit and unit types. All maternity units in the UK will be invited to take part, with additional targeted recruitment strategies used, if necessary, to ensure that the final sample includes different maternity unit types, sizes and PPH kit types. Study results will inform future work to develop consensus on effective PPH kit designs. ETHICS AND DISSEMINATION Approval has been received from the UK Health Research Authority (project ID 274147). Study results will be reported through the research institute's website, presented at conferences and published in peer-reviewed journals.
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Affiliation(s)
- Matthew Woodward
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Akbar Ansari
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Tim Draycott
- Women and Children's Health Research Unit, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
- PROMPT Maternity Foundation, Bristol, UK
| | - Cathy Winter
- Women and Children's Health Research Unit, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
- PROMPT Maternity Foundation, Bristol, UK
| | | | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Lassi ZS, Fisher Z, Andraweera P, Cummins A, Roberts CT. Effectiveness of birthing kits for clean childbirth: a systematic review. Int Health 2020; 12:3-10. [PMID: 31340003 PMCID: PMC6964231 DOI: 10.1093/inthealth/ihz022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/05/2019] [Accepted: 03/20/2019] [Indexed: 11/12/2022] Open
Abstract
Poor infection control practices during childbirth are recognised as a critical factor leading to life-threatening maternal and newborn sepsis. Therefore, this paper assesses the effectiveness of clean birth kits (CBKs) to ensure a safe birthing environment. We searched PubMed, Cochrane Library and CINAHL, as well as Google Scholar, to identify both qualitative and quantitative studies on CBKs published in English up to November 2018. Studies were included if the pregnant women or women giving birth intended to use or used a CBK. The methodological quality of included papers was assessed. A total of 37 studies, 26 quantitative and 11 qualitative studies, were included. Quantitative studies showed a positive impact of CBKs on reducing the incidence of puerperal sepsis and neonatal tetanus. The review also identified CBK use to be associated with a reduction in perinatal, neonatal and young infant mortality. Qualitative studies suggested that a lack of awareness of the importance of CBKs and clean delivery practices, unavailability of CBKs and financial constraints to purchase CBKs were the potential barriers. CBKs appear to be a promising strategy to reduce maternal and neonatal morbidity and mortality. However, the current evidence is limited and further large-scale trials are required.
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Affiliation(s)
- Zohra S Lassi
- Robinson Research Institute, The University of Adelaide, North Terrace, Adelaide, South Australia, Australia
| | - Zeshi Fisher
- Birthing Kit Foundation Australia, PO Box 330 Belair South Australia, Australia
| | - Prabha Andraweera
- Robinson Research Institute, The University of Adelaide, North Terrace, Adelaide, South Australia, Australia
| | - Alexandra Cummins
- Birthing Kit Foundation Australia, PO Box 330 Belair South Australia, Australia
| | - Claire T Roberts
- Robinson Research Institute, The University of Adelaide, North Terrace, Adelaide, South Australia, Australia
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Popescu CR, Cavanagh MMM, Tembo B, Chiume M, Lufesi N, Goldfarb DM, Kissoon N, Lavoie PM. Neonatal sepsis in low-income countries: epidemiology, diagnosis and prevention. Expert Rev Anti Infect Ther 2020; 18:443-452. [PMID: 32070161 DOI: 10.1080/14787210.2020.1732818] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: Sepsis accounts for up to one-third of neonatal deaths in the world each year. The World Health Organization acknowledges neonatal sepsis as a major global health concern, and that the highest burden occurs in low- and middle-income countries (LMICs). Despite major research and clinical progress in this area, we still lack accurate diagnostic tools for neonatal sepsis, complicating the management of this condition.Areas covered: The purpose here is to review the latest data on the incidence, diagnosis, prevention, and management of neonatal sepsis in LMIC. We discuss the limitations of current diagnostic tests - including their lack of availability - and how this may influence global estimates of cases. We review the benefits of antenatal, intrapartum, and post-natal preventive measures. We briefly discuss the management, highlighting the emergence of antimicrobial resistance. Finally, we expose some high priority areas.Expert opinion: Neonatal sepsis is a challenging condition requiring a multifaceted approach to address the major diagnostic issues, but also the underlying socio-economic causes that nourish epidemic cases in LMIC. Focusing on antibiotics as a main pillar of intervention is likely to engender antimicrobial resistance, eventually hindering the appreciable gains LMICs have achieved in neonatal health outcomes.
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Affiliation(s)
- Constantin Radu Popescu
- Department of Pediatrics, Division of Neonatology, Université Laval, Québec, QC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Miranda M M Cavanagh
- Division of Neonatology, BC Women's Hospital and Health Centre, Vancouver, BC, Canada
| | - Bentry Tembo
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Msandeni Chiume
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Norman Lufesi
- Directorate of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, BC, Canada
| | - Niranjan Kissoon
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Pascal M Lavoie
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Division of Neonatology, BC Women's Hospital and Health Centre, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Leight J, Sharma V, Brown W, Costica L, Abdulaziz Sule F, Bjorkman Nyqvist M. Associations between birth kit use and maternal and neonatal health outcomes in rural Jigawa state, Nigeria: A secondary analysis of data from a cluster randomized controlled trial. PLoS One 2018; 13:e0208885. [PMID: 30586441 PMCID: PMC6306201 DOI: 10.1371/journal.pone.0208885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 11/27/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The burden of maternal and neonatal mortality remains persistently high in Nigeria. Sepsis contributes significantly to both maternal and newborn mortality, and safe delivery kits have long been promoted as a cost-effective intervention to ensure hygienic delivery practices and reduce sepsis. However, there is limited evidence on the effectiveness of home birth kit distribution by community health workers, and particularly the impact of this intervention on health outcomes. This paper reports a secondary analysis of data from a cluster randomized trial in rural northern Nigeria in which birth kits were distributed by community health workers to pregnant women in their homes, analyzing non-experimental variation in receipt and use of birth kits. More specifically, associations between pregnant women's baseline characteristics and receipt and use of birth kits, and associations between birth kit use, care utilization and maternal and newborn outcomes were assessed. METHODS AND FINDINGS Baseline, post-birth and endline data related to 3,317 births observed over a period of three years in 72 intervention communities in Jigawa state, Nigeria, were analyzed using hierarchical, logistic regression models. In total, 140 women received birth kits, and 72 women used the kits. There were no associations between baseline demographic characteristics, health history, and knowledge and attitudes and receipt of a kit, suggesting that community health workers did not systematically target the distribution of birth kits. However, women who used the kit reported reduced odds of past pregnancy complications (OR = 0.44, 95% CI: 0.19-1.00) as well as significantly higher odds of feeling generally healthy at baseline (OR = 2.00, 95% CI: 1.06-3.76), of exposure to radio media (OR = 1.97, 95% CI: 1.21-3.22), and of perceiving themselves as having a low-risk pregnancy (OR = 3.05, 95% CI:1.39-6.68). While there were no significant associations between birth kit use and facility based delivery, skilled birth attendance or post-natal care, women who used a kit exhibited significantly lower odds of completing four or more ANC visits (adjusted OR = 0.39, 95% CI: 0.18-0.85) and significantly higher odds of reporting prolonged labor (adjusted OR = 4.75, 95% CI: 1.36-16.59), and post-partum bleeding (adjusted OR = 3.25, 95% CI: 1.11-9.52). CONCLUSIONS This evidence suggests that use of birth kits is low in a rural population characterized by minimal baseline utilization of maternal and neonatal health services, and the use of birth kits was not associated with reductions in maternal or neonatal morbidity. While further research is required to understand how the effectiveness of birth kits may be shaped by the mechanism through which women access and utilize the kits, our findings suggest that the provision of kits to women outside of the formal health system may be associated with increased risk of adverse outcomes.
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Affiliation(s)
- Jessica Leight
- Economics Department, American University, Washington, D.C., United States of America
| | - Vandana Sharma
- Harvard T.H. Chan School of Public Health, Cambridge, MA, United States of America
| | - Willa Brown
- Abdul Latif Jameel Poverty Action Lab, Massachusetts Institute of Technology, Cambridge, MA, United States of America
| | - Laura Costica
- Planned Parenthood Federation of Nigeria, Abuja, Nigeria
| | - Fatima Abdulaziz Sule
- Economics Department, American University, Washington D.C., United States of America
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Maternal critical care in resource-limited settings. Narrative review. Int J Obstet Anesth 2018; 37:86-95. [PMID: 30482717 DOI: 10.1016/j.ijoa.2018.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 12/20/2022]
Abstract
Maternal critical care reflects interdisciplinary care in any hospital area according to the severity of illness of the pregnant woman. The admission rate to intensive care units is below 1% (0.08-0.76%) of deliveries in high-income countries, and ranges from 0.13% to 4.6% in low- and middle-income countries. Mortality in these patients is high and varies from 0% to 4.9% of admissions in high-income countries, and from 2% to 43.6% in low- and middle-income countries. Obstetric haemorrhage, sepsis, preeclampsia, human immunodeficiency virus complications and tropical diseases are the main reasons for intensive care unit admission in low middle-income countries. Bedside assessment tools, such as early warning scores, may help to identify critically ill patients and those at risk of deterioration. There is a lack of uniformity in definitions, identification and treatment of critically ill pregnant patients, especially in resource-limited settings. Our aims were to (i) propose a more practical definition of maternal critical care, (ii) discuss maternal mortality in the setting of limited accessibility of critical care units, (iii) provide some accessible tools to improve identification of obstetric patients who may become critically ill, and (iv) confront challenges in providing maternal critical care in resource-limited settings. To improve maternal critical care, training programmes should embrace modern technological educational aids and incorporate new tools and technologies that assist prediction of critical illness in the pregnant patient. The goal must be improved outcomes following early interventions, early initiation of resuscitation, and early transfer to an appropriate level of care, whenever possible.
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Betrán AP, Bergel E, Griffin S, Melo A, Nguyen MH, Carbonell A, Mondlane S, Merialdi M, Temmerman M, Gülmezoglu AM. Provision of medical supply kits to improve quality of antenatal care in Mozambique: a stepped-wedge cluster randomised trial. LANCET GLOBAL HEALTH 2018; 6:e57-e65. [PMID: 29241615 PMCID: PMC5732314 DOI: 10.1016/s2214-109x(17)30421-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/09/2017] [Accepted: 10/17/2017] [Indexed: 12/02/2022]
Abstract
Background High levels of maternal and newborn mortality and morbidity remain a daunting reality in many low-income countries. Several interventions delivered during antenatal care have been shown to improve maternal and newborn outcomes, but stockouts of medical supplies at point of care can prevent implementation of these services. We aimed to evaluate whether a supply chain strategy based on the provision of kits could improve quality of care. Methods We did a pragmatic, stepped-wedge, cluster-randomised controlled trial at ten antenatal care clinics in Mozambique. Clinics were eligible if they were not already implementing the proposed antenatal care package; they served at least 200 new pregnant women per year; they had Maternal and Child Health (MCH) nurses; and they were willing to participate. All women attending antenatal care visits at the participating clinics were included in the trial. Participating clinics were randomly assigned to shift from control to intervention on prespecified start dates. The intervention involved four components (kits with medical supplies, a cupboard to store these supplies, a tracking sheet to monitor stocks, and a one-day training session). The primary outcomes were the proportion of women screened for anaemia and proteinuria, and the proportion of women who received mebendazole in the first antenatal care visit. The intervention was delivered under routine care conditions, and analyses were done according to the intention-to-treat principle. This trial is registered with the Pan African Clinical Trial Registry, number PACTR201306000550192. Findings Between March, 2014, and January, 2016, 218 277 antenatal care visits were registered, with 68 598 first and 149 679 follow-up visits. We found significant improvements in all three primary outcomes. In first visits, 5519 (14·6%) of 37 826 women were screened for anaemia in the control period, compared with 30 057 (97·7%) of 30 772 in the intervention period (adjusted odds ratio 832·40; 99% CI 666·81–1039·11; p<0·0001); 3739 (9·9%) of 37 826 women were screened for proteinuria in the control period, compared with 29 874 (97·1%) of 30 772 in the intervention period (1875·18; 1447·56–2429·11; p<0·0001); and 17 926 (51·4%) of 34 842 received mebendazole in the control period, compared with 24 960 (88·2%) of 28 294 in the intervention period (1·88; 1·70–2·09; p<0·0001). The effect was immediate and sustained over time, with negligible heterogeneity between sites. Interpretation A supply chain strategy that resolves stockouts at point of care can result in a vast improvement in quality during antenatal care visits, when compared with the routine national process for procurement and distribution of supplies. Funding Government of Flanders and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.
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Affiliation(s)
- Ana Pilar Betrán
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Eduardo Bergel
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland; Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Sally Griffin
- International Center for Reproductive Health, Maputo, Mozambique
| | - Armando Melo
- Mozambique Ministry of Health, Maputo, Mozambique
| | - My Huong Nguyen
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Alicia Carbonell
- Mozambique Country Office, World Health Organization, Maputo, Mozambique
| | - Santos Mondlane
- Consultório de Estatística e Serviço de Soluções, Maputo, Mozambique
| | - Mario Merialdi
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland; BD Global Health, Franklin Lakes, NJ, USA
| | - Marleen Temmerman
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland; International Center for Reproductive Health Global, Ghent, Belgium; Aga Khan University East Africa, Nairobi, Kenya
| | - A Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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