Maternal vaccination is considered a key component of the antenatal care package for improving maternal and child health. Low- and middle-income countries (LMICs) fall short of global targets to prevent maternal and neonatal deaths, with a disproportionate burden of vaccine-preventable diseases. Strategies towards ending preventable maternal mortality necessitate a health systems approach to adequately respond to this burden. This review explores the health systems determinants of delivery and uptake of essential maternal vaccines in LMICs. We conducted a qualitative systematic review of articles on maternal vaccination in LMICs, published between 2009 and 2023 in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Thematic analysis was conducted to identify key themes in the literature, interpreted within a conceptual framing that explores the systems determinants influencing maternal vaccines. Our search yielded 1309 records, of which 54 were included, covering 34 LMICs. Most of the included studies were from South America (28/54) and included pregnant women as the primary study population (34/54). The studies explored influenza (25/54) and tetanus toxoid (20/54) vaccines predominantly. The findings suggest that systems hardware (lack of clear policy guidelines, ineffective cold-chain management, limited reporting and monitoring systems) are barriers to vaccine delivery. Systems software (healthcare provider recommendations, increased trust, higher levels of maternal education) are enablers to maternal vaccine uptake. Findings show that formulation, dissemination and communication of context-specific policies and guidelines on maternal vaccines should be a priority for decision-makers in LMICs.
A bioarchaeological assessment of human skeletons provides an objective opportunity to study and understand past peoples. Crania were analysed to evaluate health and well‐being of a past Khoesan sample in southern Africa. These data were analysed temporally and spatially (coastal vs inland), and by sex and age. Cranial and dental pathology of 150 adult individuals from the Human Skeletal Collection at the University of Cape Town were assessed. Most individuals were of coastal origin, equally distributed between pre‐ and post‐2000 bp. The sample was nearly equally distributed by sex and consisted primarily of middle‐aged adults (35–50 years at time‐of‐death). Physiological stress was indicated by evidence of nutrient deficiencies and signs of metabolic stress, without significant differences by sex. Cribra orbitalia was more frequent post‐2 000 bp, and linear enamel hypoposlasias were common in those who died at younger ages. Signs of infection were observed in dental tissues as carious lesions, abscess and antemortem tooth loss. Trauma was found in 52% of the sample, 19% was antemortem, with a significant increase post‐2000 bp, 39% were caused perimortem and was significantly higher in women. Significant distributions of pathology indicate an increased stress load from 2000 bp onwards and it was higher among coastal individuals, indicating a critical period with an influx of people migrating into the region causing population displacement, forced internal migration and increased conflict at this time. Despite the seemingly high pathogen load, these individuals were resilient and living through health problems. Across this broad time‐period, the southern African Khoesan lifestyle proves to be adequate to maintain good health and longevity in their social and environmental context.
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