BACKGROUND:Globally, complications of preterm birth are the leading cause of under-5-mortality. Respiratory distress syndrome (RDS) is a common and life-threatening complication among preterm infants. Continuous positive airway pressure (CPAP) is a relatively simple and effective intervention that is recommended for RDS treatment. However, appropriate infrastructure and processes are required to ensure that it is used safely, effectively and sustainably. This study describes how CPAP was used in newborn care in Kenya between 2017-2018. Our aim was to identify enablers, barriers and gaps in CPAP use. METHODS:A cross-sectional survey was carried out across all newborn baby units in Kenya between 2017-2018, as part of a evaluation of CPAP use in newborn care. Descriptive statistics were used to analyse the quantitative data. RESULTS:Twenty-three hospitals across 15 (32%) of the counties in Kenya were providing CPAP in newborn care. The survey was conducted in 19 hospitals, amounting to 83% of all hospitals providing CPAP in newborn care in the country. Sub-county (level 4) and county (level 5) referral had fewer resources (i.e., trained staff, infrastructure and equipment) than the national referral (level 6) and private hospitals. In addition, there was a wide variation in the CPAP devices used and the resources for supporting CPAP use across different hospitals. CONCLUSION:We found access to CPAP for neonates with RDS was inequitable in Kenya. There were also disparities in the availability of resources, personnel, and guidelines to support its implementation. Lack of standardisation of CPAP use in newborn care was especially evident in the public sector. To optimise coverage and standardisation of CPAP use in newborn care in Kenya, our results support ongoing partnerships to strengthen public and private healthcare sectors involving the implementation of strategies to improve infrastructure for newborn care, train and retain staff, and provide additional equipment.

Maternal and perinatal death surveillance and response (MPDSR) was developed as a quality improvement intervention to reduce preventable maternal and newborn deaths and stillbirths. To gain deeper insight into the key components enabling sustained MPDSR implementation, we examined how MPDSR systems are organized and function in Nigeria, North Macedonia, and Sri Lanka. We conducted 61 interviews with participants who were knowledgeable about the MPDSR system of their country, including policymakers, healthcare providers, and public health officials, at the national, subnational and facility levels. We applied content analysis to inductively identify themes and categories. Our findings suggest that participants perceive the goal of MPDSR as going beyond local quality improvement to encompass broader healthcare system strengthening. Four enabling components supporting sustained implementation were identified in all three countries: 1. coordination of the MPDSR “programme” through committees across levels; 2. adoption and integration of a data management and analysis system; 3. a confidential, nonpunitive approach supported by committed leadership; and 4. a multilevel, country-specific response strategy integrated with a broader health system strengthening. Sri Lanka demonstrated a highly centralized and structured approach, whereas Nigeria’s federal system showcased more diverse, multilevel stakeholder engagement. North Macedonia’s facility-based approach focused on the immediate implementation of quality improvements. The findings reveal that a structured, multilevel approach that is interconnected with the broader health system is supporting sustained MPDSR implementation. The potential of MPDSR as a health system programme that goes beyond facility-level mortality reduction links to an integrated health system strengthening and accountability at multiple levels.

Every two minutes a woman dies from complications of pregnancy and childbirth. Most maternal deaths occur within the first 24 hours following birth, highlighting the importance of immediate postnatal care (iPNC). Self-care strategies are increasingly being employed to promote women-centred, continuous care provision. Despite international calls for development of strategies promoting self-care, none have been developed for self-monitoring in the immediate postnatal period. Fundamental to the development of a self-monitoring strategy, is an understanding of which signs and symptoms are predictive of maternal morbidity and mortality and can be easily assessed by mothers and birth companions, in health facilities, without the need for equipment. The objective of this study was to develop and achieve international consensus on the key signs and symptoms. A multi-step approach involving a systematic scoping review, two- round Delphi Survey, and expert consensus was employed to identify key signs and symptoms that can be self- assessed and predict morbidity and mortality in the immediate postnatal period. A comprehensive list of 351 key signs and symptoms was identified from 44 clinical practice guidelines. Subsequently, 134 signs and symptoms were reviewed by Delphi respondents and international expert consensus was achieved for 19 key signs and symptoms across seven condition categories. The signs that were considered both important and able to be self-assessed by mothers and birth companions in the first 24 hours following birth included change in consciousness, seizure, severe headache, persistent visual impairment, urinary incontinence, chest pain, shortness of breath, severe pallor, fast heartbeat, rejection of baby, suicidal/infanticidal, fever, heavy blood loss, soft flabby uterus, unable to urinate easily, foul smelling discharge, rigors, syncope/dizziness, abnormal coloured urine. This study identified key signs and symptoms which can be easily assessed by mothers and birth companions in the immediate postnatal period to identify those most at risk of morbidity and mortality. Further work is needed to validate this screening tool, and adapt it regionally and nationally.

Community engagement in maternal and perinatal death surveillance and response (MPDSR) could support health systems in providing people-centred care and ensure accountability for the prevention of maternal and perinatal deaths. Although community engagement activities in MPDSR have been described, the literature does not adequately explain which community engagement in MPDSR strategies succeed, the contexts in which they work, the outcomes they produce, and for whom. We conducted a realist review, which involved the identification and refinement of programme theories. An initial literature search identified four initial programme theories (IPTs) that explain how community engagement works in the different parts of the MPDSR cycle. Six databases (Medline, Embase, Scopus, Global Health, CINAHL Plus and Web of Science) and Google were searched for papers and grey literature published between 2004 and August 2022. We used retroductive analysis on included articles to support the identification of generative causation using the heuristic of ‘context-mechanism-outcome configuration’ (CMOCs), which explained what mechanisms were triggered in different contexts and the outcomes that were produced. The findings were then used to refine the IPTs and produce final programme theories. Forty-five articles from 40 studies reported some form of community engagement in MPDSR. We identified 20 CMO configurations that were synthesised into five programme theories: Implementing community engagement in MPDSR requires a systems approach that addresses the five Programme Theories collectively, rather than implementing community engagement in specific parts of the MPDSR cycle as our initial programme theories had suggested. Establishing conducive participatory spaces that promote dialogue, trust and minimise blame culture is critical for the success of community engagement in MPDSR programmes. Community members can be engaged in MPDSR processes in health facilities and community settings and high- and low-income countries.

Continuing professional development for the health workforce is of paramount importance and can be implemented using locally available, competent trainers. However, guidelines for the selection, development, and mentorship of such trainers are lacking. Training intervention research conducted in Western Maharashtra, India, aimed to address these gaps by focusing on skills for maternal and newborn health (MNH). In this study, selected trainers from a pilot project in the Pune district received advanced training to become core trainers (CTs) for a scale-up project in Palghar district (2019 – 2022). The CTs trained master trainers (MTs) in Palghar (n = 32) with support from the United Kingdom-based technical partners, following a six-step approach: selection of trainers, training of trainers (ToT) (including knowledge and skills assessment), staggered induction as trainers, continuous support, regular quality assessment, and virtual refresher training. The process and outcomes of this six-step approach were evaluated using mixed-methods research. The skills of local trainers were augmented through hands-on training and further supported by long-term mentorship to develop training excellence. The CTs’ competency as mentors improved due to appreciative feedback. Regular assessments conducted by the expert team also contributed to maintaining quality control. Online learning has emerged as an effective method for refresher training. There was considerable improvement in the clinical knowledge and skills of the health providers from Palghar (n = 505), which attests to the quality of the training delivered by the Palghar MTs. This intervention enhanced both clinical competency and confidence. The approach demonstrated the importance of recruiting suitable participants who could consciously shift their teaching style to become more adult-learner-centric facilitators. However, there is a need for a systematic, long-term evaluation of this model, its application to MNH care, and its institutionalization within the public health system.

Objective: Cambodia is one of seven countries globally that met Millennium Development Goal 5A: reduction of maternal deaths by at least 75% between 1990 and 2015. To support improving maternal care, the Maternal Death Audit (MDA) was instituted in 2004. This report highlights changes in maternal health services and MDA implementation in Cambodia between 2010 and 2017. Methods: International experts and the national MDA Committee assessed all case abstracts, investigation questionnaires and audit meeting minutes covering all maternal deaths reported in Cambodia in 2010 and 2017 for quality of classification, data, care and recommendations. They convened provincial MDA committees to conduct similar assessments and develop evidence-informed recommended actions. Results: In 2010 and 2017, 176 and 59 maternal death cases were reported, respectively. Cases were more likely in 2017 than in 2010 to have antenatal care (90.0% vs 68.2%, P = 0.004), give birth in a facility (81.6% vs 55.3%, P = 0.01) and receive a prophylactic uterotonic (95.7% vs 73%, P < 0.05) for postpartum haemorrhage (PPH) and magnesium sulfate (66% vs 37%, P = 0.18) for pre-eclampsia/eclampsia. However, additional interventions and improved timeliness of referral with equipped and competent staff were identified as critical. Data quality prevented classifying one-fourth of cases during both periods. MDA recommendation quality improved from 2.8% in 2011 to 42% in 2018. Discussion: Improvements in maternal care are reflected in the increased antenatal care, facility births and better PPH and preeclampsia-eclampsia management. However, additional care management improvements are highlighted. The MDA reporting needs improved data completeness and more specific recommendations to address causes of death.

BackgroundGlobally, low birthweight (LBW) infants (<2,500 g) have the highest risk of mortality during the first year of life. Those who survive often have adverse health outcomes. Post-discharge outcomes of LBW infants in impoverished communities in Africa are largely unknown. This paper describes the design and implementation of a mother-to-mother peer training and mentoring programme for the follow-up of LBW infants in rural Kenya.MethodsKey informant interviews were conducted with 10 mothers of neonates (infants <28 days) from two rural communities in western Kenya. These data informed the identification of key characteristics required for mother-to-mother peer supporters (peer mothers) following up LBW infants post discharge. Forty potential peer mothers were invited to attend a 5-day training programme that focused on three main themes: supportive care using appropriate communication, identification of severe illness, and recommended care strategies for LBW infants. Sixteen peer mothers were mentored to conduct seven community follow-up visits to each mother-LBW infant pair with fifteen completing all the visits over a 6-month period. A mixed methods approach was used to evaluate the implementation of the programme. Quantitative data of peer mother socio-demographic characteristics, recruitment, and retention was collected. Two post-training focus group discussions were conducted with the peer mothers to explore their experiences of the programme. Descriptive statistics were generated from the quantitative data and the qualitative data was analysed using a thematic framework.ResultsThe median age of the peer mothers was 26 years (range 21–43). From March-August 2019, each peer mother conducted a median of 28 visits (range 7–77) with fourteen (88%) completing all their assigned follow-up visits. Post training, our interviews suggest that peer mothers felt empowered to promote appropriate infant feeding practices. They gave multiple examples of improved health seeking behaviours as a result of the peer mother training programme.ConclusionOur peer mother training programme equipped peer mothers with the knowledge and skills for the post-discharge follow-up of LBW infants in this rural community in Kenya. Community-based interventions for LBW infants, delivered by appropriately trained peer mothers, have the potential to address the current gaps in post-discharge care for these infants.

Understanding why a woman died during or immediately after pregnancy and childbirth is a crucial first step toward preventing other women from dying in the same way. Besides understanding the medical cause of death, it is also important to know the woman’s personal story and the other nonmedical factors that may have contributed to her death. In 2012, the World Health Organization (WHO) and partners launched maternal death surveillance and response (MDSR) as an approach to end preventable maternal mortality. MDSR follows a continuous cycle of notification, review, analysis, and response. Many lowand middle-income countries (LMICs) moved quickly to adopt MDSR in their national policies and practices. By 2016, 85% of LMICs reportedly had a national policy to review all maternal deaths. However, only 46% of LMICs reportedly had national maternal death review committees that met at least biannually, thus highlighting the need for countries to follow through on their policy commitments and “complete the loop” in the surveillance-response cycle. Ethiopia introduced national MDSR in 2013. It was among the first sub-Saharan countries to capture maternal deaths at the facility and community levels. The decision to make maternal mortality a weekly reportable condition within public health emergency management in 2014 led to its integrationwith the existing disease surveillance system in the country. However, the effective implementation of MDSR in Ethiopia has faced many challenges. While strong political support and leadership facilitated its introduction, reported barriers to implementation have included politicization of the reporting and review process, defensive attitudes, blame-shifting, poor attendance, and fear of legal repercussions.

Background: While there has been a decline in maternal and perinatal mortality, deaths remain high in sub-Saharan Africa and Asia. With the sustainable development goals (SDGs) targets to reduce maternal and perinatal mortality, more needs to be done to accelerate progress and improve survival. Maternal and perinatal death surveillance and response (MPDSR) is a strategy to identify the clinical and social circumstances that contribute to maternal and perinatal deaths. Through MPDSR, an active surveillance and response cycle is established by bringing together different stakeholders to review and address these social and clinical factors. Community engagement in MPDSR provides a strong basis for collective action to address social factors and quality of care issues that contribute to maternal and perinatal deaths. Studies have shown that community members can support identification and reporting of maternal and/or perinatal deaths. Skilled care at birth has been increasing globally, but there are still gaps in quality of care. Through MPDSR, community members can collaborate with health workers to improve quality of care. But we do not know how community engagement in MPDSR works in practice; for whom it works and what aspects work (or do not work) and why. This realist review answers the question: which strategies of community engagement in MPDSR produce which outcomes in which contexts? Methods: For this realist review, we will identify published and grey literature by searching relevant databases for articles. We will include papers published from 2004 in all languages and from all countries. We have set up an advisory group drawn from academia, international organizations, and practitioners of both MPDSR and community engagement to guide the process. Conclusion: This protocol and the subsequent realist review will use theoretical approaches from the community engagement literature to generate theory on community engagement in MPDSR. Prospero registration number: CRD42022345216

Obstetric Early Warning Systems (EWS) use combined clinical observations to predict increased risk of deterioration and alert health workers to institute actions likely to improve outcomes. The objective of this study was to explore the experience of health workers about the implementation of an obstetric EWS and assess its effectiveness as an alternative clinical monitoring method compared to standard practice. This mixed-method study included obstetric admissions (n = 2400) to inpatient wards between 01/08/2018 and 31/03/2019 at three Nigerian tertiary hospitals (1 intervention and two control). Outcomes assessed were the efficiency of monitoring and recording vital signs using the patient monitoring index and speed of post-EWS trigger specialist review. These were evaluated through a review of case notes before and four months after EWS was introduced. Qualitative data was collected to explore healthcare workers' views on EWS' acceptability and usability. EWS was correctly used in 51% (n = 307) of the women in the intervention site. Of these women, 58.6% (n = 180) were predicted to have an increased risk of deterioration, and 38.9% (n = 70) were reviewed within 1 hour. There was a significant improvement in the frequency of vital signs recording in the intervention site: observed/expected frequency improved to 0.91 from 0.57, p<0.005, but not in the control sites. Health workers reported that the EWS helped them cope with work demands while making it easier to detect and manage deteriorating patients. Nurses and doctors reported that the EWS was easy to use and that scores consistently correlated with the clinical picture of patients. Identified challenges included rotation of clinical staff, low staffing numbers and reduced availability of monitoring equipment. The implementation of EWS improved the frequency of patient monitoring, but a larger study will be required to explore the effect on health outcomes. The EWS is a feasible and acceptable tool in low-resource settings with implementation modifications. Trial registration: ISRCTN, ISRCTN15568048. Registration date; 9/09/2020- Retrospectively registered, http://www.isrctn.com/ISRCTN15568048.

Background Obstetric infections are the third most common cause of maternal mortality, with the largest burden in low and middle-income countries (LMICs). We analyzed causes of infection-related maternal deaths and near-miss identified contributing factors and generated suggested actions for quality of care improvement. Method An international, virtual confidential enquiry was conducted for maternal deaths and near-miss cases that occurred in 15 health facilities in 11 LMICs reporting at least one death within the GLOSS study. Facility medical records and local review committee documents containing information on maternal characteristics, timing and chain of events, case management, outcomes, and facility characteristics were summarized into a case report for each woman and reviewed by an international external review committee. Modifiable factors were identified and suggested actions were organized using the three delays framework. Results Thirteen infection-related maternal deaths and 19 near-miss cases were reviewed in 20 virtual meetings by an international external review committee. Of 151 modifiable factors identified during the review, delays in receiving care contributed to 71/85 modifiable factors in maternal deaths and 55/66 modifiable factors in near-miss cases. Delays in reaching a GLOSS facility contributed to 5/85 and 1/66 modifiable factors for maternal deaths and near-miss cases, respectively. Two modifiable factors in maternal deaths were related to delays in the decision to seek care compared to three modifiable factors in near-miss cases. Suboptimal use of antibiotics, missing microbiological culture and other laboratory results, incorrect working diagnosis, and infrequent monitoring during admission were the main contributors to care delays among both maternal deaths and near-miss cases. Local facility audits were conducted for 2/13 maternal deaths and 0/19 near-miss cases. Based on the review findings, the external review committee recommended actions to improve the prevention and management of maternal infections. Conclusion Prompt recognition and treatment of the infection remain critical addressable gaps in the provision of high-quality care to prevent and manage infection-related severe maternal outcomes in LMICs. Poor uptake of maternal death and near-miss reviews suggests missed learning opportunities by facility teams. Virtual platforms offer a feasible solution to improve routine adoption of confidential maternal death and near-miss reviews locally.

The report of the Lancet Commission on 70 years of reproductive, maternal, newborn, child, and adolescent health (RMNCAH) in China 1 Qiao J Wang Y Li X et al. A Lancet Commission on 70 years of women's reproductive, maternal, newborn, child, and adolescent health in China. Lancet. 2021; (published online May 24.)https://doi.org/10.1016/S0140-6736(20)32708-2 Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar describes the country's achievements and discusses policy and socioeconomic transitions, and their impact on epidemiological and demographic transitions. Current challenges are identified by the Commission, including low fertility, the ageing population, undernutrition and overnutrition, and emerging diseases as China moves towards its final stage of ending preventable maternal 2 Souza JP Tunçalp Ö Vogel JP et al. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG. 2014; 121: 1-4 Crossref PubMed Scopus (133) Google Scholar and neonatal deaths. To move from the goal of surviving to thriving, actions to ensure quality care, dignity, equity, and universal coverage of RMNCAH services should be implemented. Alongside emphasising China's unique history, sociocultural factors, and hierarchical RMNCAH system, the Commission presents some key lessons for low-income and low-middle-income countries (LMICs). A Lancet Commission on 70 years of women's reproductive, maternal, newborn, child, and adolescent health in ChinaWomen's reproductive, maternal, newborn, child, and adolescent health (RMNCAH) is a cornerstone for the healthy development of the next generation and a driving force for the progress of population and society in the future, especially in this era of population ageing and low fertility in China. In past decades, China's RMNCAH has made remarkable achievements in development goals related to reducing maternal and child mortality. However, as China moves towards a thriving goal—namely, towards ensuring health and wellbeing—the country faces emerging problems and new challenges in RMNCAH. Full-Text PDF

The WHO Safe Childbirth Checklist (the SCC) is a clinical tool developed to help health workers follow evidence-based maternal and perinatal care practices at childbirth. Newborn delivery care practices at facilities in seven countries in East Asia and the Pacific were compared to practices checked by the SCC. The analysis found that the SCC does not incorporate several key evidence-based practices around birth demonstrated to prevent newborn morbidity or mortality, or harmful practices associated with increased risks. A revision of the standard SCC is needed to maximise its potential to improve newborn outcomes. This can be initiated under the coordinating umbrella of WHO, but must ensure that the realities of labour and childbirth practices in low- and middle-income countries are considered and addressed.

Standardized case definitions strengthen post-marketing safety surveillance of new vaccines by improving generated data, interpretation and comparability across surveillance systems. The Global Alignment of Immunization Safety Assessment in Pregnancy (GAIA) project developed standardized case definitions for 21 key obstetric and neonatal terms following the Brighton Collaboration (BC) methodology. In this prospective cohort study, we assessed the applicability of GAIA definitions for maternal immunization exposure and for low birth weight (LBW), preterm birth, small for gestational age (SGA), stillbirth, neonatal death, neonatal infection, and congenital microcephaly. We identified the missing data elements that prevented identified cases and exposures from meeting the case definition (level 1-3 of BC diagnostic certainty). Over a one-year period (2019-2020), all births occurring in 21 sites (mostly secondary and tertiary hospitals) in 6 Low Middle Income Countries and 1 High Income Country were recorded and the 7 perinatal and neonatal outcome cases were identified from routine medical records. Up to 100 cases per outcome were recruited sequentially from each site. Most cases recruited for LBW, preterm birth and neonatal death met the GAIA case definitions. Birth weight, a key parameter for all three outcomes, was routinely recorded at all sites. The definitions for SGA, stillbirth, neonatal infection (particularly meningitis and respiratory infection) and congenital microcephaly were found to be less applicable. The main barrier to obtaining higher levels of diagnostic certainty was the lack of sonographic documentation of gestational age in first or second trimester. The definition for maternal immunization exposure was applicable, however, the highest level of diagnostic certainty was only reached at two sites. Improved documentation of maternal immunization will be important for vaccine safety studies. Following the field-testing of these 8 GAIA definitions, several improvements are suggested that may lead to their easier implementation, increased standardization and hence comparison across studies.

Background The use of obstetric early-warning-systems (EWS) has been recommended to improve timely recognition, management and early referral of women who have or are developing a critical illness. Development of such prediction models should involve a statistical combination of predictor clinical observations into a multivariable model which should be validated. No obstetric EWS has been developed and validated for low resource settings. We report on the development and validation of a simple prediction model for obstetric morbidity and mortality in resource-limited settings. Methods We performed a multivariate logistic regression analysis using a retrospective case-control analysis of secondary data with clinical indices predictive of severe maternal outcome (SMO). Cases for design and validation were randomly selected ( n = 500) from 4360 women diagnosed with SMO in 42 Nigerian tertiary-hospitals between June 2012 and mid-August 2013. Controls were 1000 obstetric admissions without SMO diagnosis. We used clinical observations collected within 24 h of SMO occurrence for cases, and normal births for controls. We created a combined dataset with two controls per case, split randomly into development ( n = 600) and validation ( n = 900) datasets. We assessed the model’s validity using sensitivity and specificity measures and its overall performance in predicting SMO using receiver operator characteristic (ROC) curves. We then fitted the final developmental model on the validation dataset and assessed its performance. Using the reference range proposed in the United Kingdom Confidential-Enquiry-into-Maternal-and-Child-Health 2007-report, we converted the model into a simple score-based obstetric EWS algorithm. Results The final developmental model comprised abnormal systolic blood pressure-(SBP > 140 mmHg or < 90 mmHg), high diastolic blood pressure-(DBP > 90 mmHg), respiratory rate-(RR > 40/min), temperature-(> 38 °C), pulse rate-(PR > 120/min), caesarean-birth, and the number of previous caesarean-births. The model was 86% (95% CI 81–90) sensitive and 92%- (95% CI 89–94) specific in predicting SMO with area under ROC of 92% (95% CI 90–95%). All parameters were significant in the validation model except DBP. The model maintained good discriminatory power in the validation ( n = 900) dataset (AUC 92, 95% CI 88–94%) and had good screening characteristics. Low urine output (300mls/24 h) and conscious level (prolonged unconsciousness-GCS < 8/15) were strong predictors of SMO in the univariate analysis. Conclusion We developed and validated statistical models that performed well in predicting SMO using data from a low resource settings. Based on these, we proposed a simple score based obstetric EWS algorithm with RR, temperature, systolic BP, pulse rate, consciousness level, urinary output and mode of birth that has a potential for clinical use in low-resource settings..

Auxiliary nurse midwives (ANMs) play a pivotal role in provision of maternal and newborn health at primary level in India. Effective in-service training is crucial for upgrading their knowledge and skills for providing appropriate healthcare services. This paper aims at assessing the effectiveness of a complementary mix of directed and self-directed learning approaches for building essential maternal and newborn health-related skills of ANMs in rural Pune District, India. Methods During directed learning, the master trainers trained ANMs through interactive lectures and skill demonstrations. Improvement and retention of knowledge and skills and feedback were assessed quantitatively using descriptive statistics. Significant differences at the 0.05 level using the Kruskal-Wallis test were analysed to compare improvement across age, years of experience, and previous training received. The self-directed learning approach fulfilled their learning needs through skills mall, exposure visits, newsletter, and participation in conference. Qualitative data were analysed thematically for perspectives and experiences of stakeholders. The Kirkpatrick model was used for evaluating the results. Results Directed and self-directed learning was availed by 348 and 125 rural ANMs, respectively. Through the directed learning, ANMs improved their clinical skills like maternal and newborn resuscitation and eclampsia management. Less work experience showed relatively higher improvement in skills, but not in knowledge. 56.6% ANMs either improved or retained their immediate post-training scores after 3 months. Self-directed learning helped them for experience sharing, problem-solving, active engagement through skill demonstrations, and formal presentations. The conducive learning environment helped in reinforcement of knowledge and skills and in building confidence. This intervention could evaluate application of skills into practice to a limited extent. Conclusions In India, there are some ongoing initiatives for building skills of the ANMs like skilled birth attendance and training in skills lab. However, such a complementary mix of skill-based 'directed' and 'self-directed' learning approaches could be a plausible model for building capacities of health workforce. In view of the transforming healthcare delivery system in India and the significant responsibility that rests on the shoulder of ANMs, a transponder mechanism to implement skill building exercises at regular intervals through such innovative approaches should be a priority.

​Objective To explore the experiences of using continuous positive airway pressure (CPAP) in newborn care among healthcare workers in Kenya, and to identify factors that would promote successful scale-up. ​Design and setting A qualitative study using key informant interviews and focus group discussions, based at secondary and tertiary level hospitals in Kenya. ​Participants Healthcare workers in the newborn units providing CPAP. ​Primary and secondary outcome measure Facilitators and barriers of CPAP use in newborn care in Kenya. ​Results 16 key informant interviews and 15 focus group discussions were conducted across 19 hospitals from September 2017 to February 2018. Main barriers reported were: (1) inadequate infrastructure to support the effective delivery of CPAP, (2) shortage of skilled staff rendering it difficult for the available staff to initiate or monitor infants on CPAP and (3) inadequate knowledge and training of staff that inhibited the safe care of infants on CPAP. Key facilitators reported were positive patient outcomes after CPAP use that increased staff confidence and partnership with caregivers in the management of newborns on CPAP. Healthcare workers in private/mission hospitals had more positive experiences of using CPAP in newborn care as the relevant support and infrastructure were available. ​Conclusion CPAP use in newborn care is valued by healthcare workers in Kenya. However, we identified key challenges that threaten its safe use and sustainability. Further scale-up of CPAP in newborn care should ensure that staff members have ready access to optimal training on CPAP and that there are enough resources and infrastructure to support its use. Ethics This study was approved through the appropriate ethics committees in Kenya and the UK (see in text) with written informed consent for each participant.

Objectives To determine the availability of continuous positive airway pressure (CPAP) and to provide an overview of its use in neonatal units in government hospitals across India. Setting Cross-sectional cluster survey of a nationally representative sample of government hospitals from across India. Primary outcomes Availability of CPAP in neonatal units. Secondary outcomes Proportion of hospitals where infrastructure and processes to provide CPAP are available. Case fatality rates and complication rates of neonates treated with CPAP. Results Among 661 of 694 government hospitals with neonatal units that provided information on availability of CPAP for neonatal care, 68.3% of medical college hospitals (MCH) and 36.6% of district hospitals (DH) used CPAP in neonates. Assessment of a representative sample of 142 hospitals (79 MCH and 63 DH) showed that air-oxygen blenders were available in 50.7% (95% CI 41.4% to 60.9%) and staff trained in the use of CPAP were present in 56.0% (45.8% to 65.8%) of hospitals. The nurse to patient ratio was 7.3 (6.4 to 8.5) in MCH and 6.6 (5.5 to 8.3) in DH. Clinical guidelines were available in 31.0% of hospitals (22.2% to 41.4%). Upper oxygen saturation limits of above 94% were used in 72% (59.8% to 81.6%) of MCH and 59.3% (44.6% to 72.5%) of DH. Respiratory circuits were reused in 53.8% (42.3% to 63.9%) of hospitals. Case fatality rate for neonates treated with CPAP was 21.4% (16.6% to 26.2%); complication rates were 0.7% (0.2% to 1.2%) for pneumothorax, 7.4% (0.9% to 13.9%) for retinopathy and 1.4% (0.7% to 2.1%) for bronchopulmonary dysplasia. Conclusions CPAP is used in neonatal units across government hospitals in India. Neonates may be overexposed to oxygen as the means to detect and treat consequences of oxygen toxicity are insufficient. Neonates may also be exposed to nosocomial infections by reuse of disposables. Case fatality rates for neonates receiving CPAP are high. Complications might be under-reported. Support to infrastructure, training, guidelines implementation and staffing are needed to improve CPAP use.