BackgroundQuality of care is essential for further progress in reducing maternal and newborn deaths. The integration of educated, trained, regulated and licensed midwives into the health system is associated with improved quality of care and sustained decreases in maternal and newborn mortality. To date, research on barriers to quality of care for women and newborns has not given due attention to the care provider’s perspective. This paper addresses this gap by presenting the findings of a systematic mapping of the literature of the social, economic and professional barriers preventing midwifery personnel in low and middle income countries (LMICs) from providing quality of care.Methods and FindingsA systematic search of five electronic databases for literature published between January 1990 and August 2013. Eligible items included published and unpublished items in all languages. Items were screened against inclusion and exclusion criteria, yielding 82 items from 34 countries. 44% discussed countries or regions in Africa, 38% in Asia, and 5% in the Americas. Nearly half the articles were published since 2011. Data was extracted and presented in a narrative synthesis and tables. Items were organized into three categories; social; economic and professional barriers, based on an analytical framework. Barriers connected to the socially and culturally constructed context of childbirth, although least reported, appear instrumental in preventing quality midwifery care.ConclusionsSignificant social and cultural, economic and professional barriers can prevent the provision of quality midwifery care in LMICs. An analytical framework is proposed to show how the overlaps between the barriers reinforce each other, and that they arise from gender inequality. Links are made between burn out and moral distress, caused by the barriers, and poor quality care. Ongoing mechanisms to improve quality care will need to address the barriers from the midwifery provider perspective, as well as the underlying gender inequality.

BackgroundEmerging evidence and program experience indicate that engaging men in maternal and newborn health can have considerable health benefits for women and children in low- and middle-income countries. Previous reviews have identified male involvement as a promising intervention, but with a complex evidence base and limited direct evidence of effectiveness for mortality and morbidity outcomes.ObjectiveTo determine the effect of interventions to engage men during pregnancy, childbirth and infancy on mortality and morbidity, as well as effects on mechanisms by which male involvement is hypothesised to influence mortality and morbidity outcomes: home care practices, care-seeking, and couple relationships.MethodsUsing a comprehensive, highly sensitive mapping of maternal health intervention studies conducted in low- and middle-income countries between 2000 and 2012, we identified interventions that have engaged men to improve maternal and newborn health. Primary outcomes were care-seeking for essential services, mortality and morbidity, and home care practices. Secondary outcomes relating to couple relationships were extracted from included studies.ResultsThirteen studies from nine countries were included. Interventions to engage men were associated with improved antenatal care attendance, skilled birth attendance, facility birth, postpartum care, birth and complications preparedness and maternal nutrition. The impact of interventions on mortality, morbidity and breastfeeding was less clear. Included interventions improved male partner support for women and increased couple communication and joint decision-making, with ambiguous effects on women’s autonomy.ConclusionInterventions to engage men in maternal and newborn health can increase care-seeking, improve home care practices, and support more equitable couple communication and decision-making for maternal and newborn health. These findings support engaging men as a health promotion strategy, although evidence gaps remain around effects on mortality and morbidity. Findings also indicate that interventions to increase male involvement should be carefully designed and implemented to mitigate potential harmful effects on couple relationship dynamics.

Please cite this paper as: Tunc ßalp Ӧ, Pena-Rosas JP, Lawrie T, Bucagu M, Oladapo OT, Portela A, Metin G€ ulmezoglu A. WHO recommendations on antenatal care for a positive pregnancy experience-going beyond survival. BJOG 2017;124:860-862. In 2015, an estimated 303 000 women died from pregnancy-related causes and 2.6 million babies were stillborn, half occurring during the third trimester.1,2 Many of these adverse outcomes can be prevented by quality healthcare during pregnancy and childbirth. Within the continuum of care, antenatal care (ANC) provides a platform for critical healthcare functions including health promotion, prevention, screening and diagnosis of diseases. Implementing timely and appropriate evidence-based practices during ANC can improve maternal and fetal health. Furthermore, it is an opportunity to communicate with and support women, families and communities at this very pivotal time in the course of their lives.On 7 November 2016, the World Health Organization released its comprehensive recommendations on routine ANC for pregnant women and adolescent girls.3 In accordance with a human rights-based approach, the guidance is intended to respond to the complex nature of the issues surrounding the practice, organisation and delivery of ANC within the health systems, and to prioritise person-centred care and well-being-not only the prevention of death and morbidity.A positive pregnancy experience, defined as 'maintaining physical and sociocultural normality, maintaining a healthy pregnancy for mother and baby (including preventing or treating risks, illness and death), having an effective transition to positive labour and birth, and achieving positive motherhood (including maternal self-esteem, competence and autonomy)', is a key consideration for the guideline. 4 Recognising that improving a woman's experience of care can be critical to transforming ANC services and contributing to thriving families and communities, the guideline focuses on the following questions: 'What are the evidencebased practices during ANC that improve outcomes and lead to a positive pregnancy experience? How should these practices be delivered?'The guideline includes recommendations related to antenatal nutrition, maternal and fetal assessment, preventative measures, interventions for common physiological symptoms (e.g. nausea, heartburn, constipation), as well as health systems interventions to improve ANC utilisation and quality of care. In addition, current WHO recommendations on malaria, tuberculosis and HIV for women during pregnancy were integrated for a consolidated package of ANC. A full list of recommendations can be accessed in six languages.5 Focusing on routine ANC, 6 these recommendations aim to complement existing WHO guidelines on the management of complications during pregnancy.In developing these recommendations, evidence from different sources was synthesised, assessed and considered (effectiveness reviews, qualitative evidence syntheses, test accuracy reviews and mixed method reviews). Decision-makin...

IntroductionEvidence-to-decision (EtD) frameworks intend to ensure that all criteria of relevance to a health decision are systematically considered. This paper, part of a series commissioned by the WHO, reports on the development of an EtD framework that is rooted in WHO norms and values, reflective of the changing global health landscape, and suitable for a range of interventions and complexity features. We also sought to assess the value of this framework to decision-makers at global and national levels, and to facilitate uptake through suggestions on how to prioritise criteria and methods to collect evidence.MethodsIn an iterative, principles-based approach, we developed the framework structure from WHO norms and values. Preliminary criteria were derived from key documents and supplemented with comprehensive subcriteria obtained through an overview of systematic reviews of criteria employed in health decision-making. We assessed to what extent the framework can accommodate features of complexity, and conducted key informant interviews among WHO guideline developers. Suggestions on methods were drawn from the literature and expert consultation.ResultsThe new WHO-INTEGRATE (INTEGRATe Evidence) framework comprises six substantive criteria—balance of health benefits and harms, human rights and sociocultural acceptability, health equity, equality and non-discrimination, societal implications, financial and economic considerations, and feasibility and health system considerations—and the meta-criterion quality of evidence. It is intended to facilitate a structured process of reflection and discussion in a problem-specific and context-specific manner from the start of a guideline development or other health decision-making process. For each criterion, the framework offers a definition, subcriteria and example questions; it also suggests relevant primary research and evidence synthesis methods and approaches to assessing quality of evidence.ConclusionThe framework is deliberately labelled version 1.0. We expect further modifications based on focus group discussions in four countries, example applications and input across concerned disciplines.

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