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Background: Perinatal mental distress poses a heavy burden in low-and middle-income countries (LMICs). This study investigated perceptions and experiences of perinatal mental distress among women in a rural Ethiopian community, in an effort to advance understanding of cross-cultural experiences of perinatal mental distress. Methods: We employed a sequential explanatory study design. From a population-based cohort study of 1065 perinatal women in the Butajira Health and Demographic Surveillance Site, we purposively selected 22 women according to their scores on a culturally validated assessment of perinatal mental distress (the Self-Reporting Questionnaire). We examined concordance and discordance between qualitative semi-structured interview data ('emic' perspective) and the layperson-administered fully-structured questionnaire data ('etic' perspective) of perinatal mental distress. We analysed the questionnaire data using summary statistics and we carried out a thematic analysis of the qualitative data. Results: Most women in this setting recognised the existence of perinatal mental distress states, but did not typically label such distress as a discrete illness. Instead, perinatal mental distress states were mostly seen as nonpathological reactions to difficult circumstances. The dominant explanatory model of perinatal mental distress was as a response to poverty, associated with inadequate food, isolation, and hopelessness. Support from family and friends, both emotional and instrumental support, was regarded as vital in protecting against mental distress. Although some women considered their distress amenable to biomedical solution, many thought medical helpseeking was inappropriate. Integration of perspectives from the questionnaire and semi-structured interviews highlighted the important role of somatic symptoms and nutritional status. It also demonstrated the differential likelihood of endorsement of symptoms when screening tools versus in-depth interviews are used.

Background More than 2 million third-trimester stillbirths occur yearly, most of them in low- and middle-income countries. Data on stillbirths in these countries are rarely collected systematically. This study investigated the stillbirth rate and risk factors associated with stillbirth in four district hospitals in Pemba Island, Tanzania. Methods A prospective cohort study was completed between the 13th of September and the 29th of November 2019. All singleton births were eligible for inclusion. Events and history during pregnancy and indicators for adherence to guidelines were analysed in a logistic regression model that identified odds ratios [OR] with a 95% confidence interval [95% CI]. Results A stillbirth rate of 22 per 1000 total births in the cohort was identified; 35.5% were intrapartum stillbirths (total number of stillbirths in the cohort, n = 31). Risk factors for stillbirth were breech or cephalic malpresentation (OR 17.67, CI 7.5-41.64), decreased or no foetal movements (OR 2.6, CI 1.13–5.98), caesarean section [CS] (OR 5.19, CI 2.32–11.62), previous CS (OR 2.63, CI 1.05–6.59), preeclampsia (OR 21.54, CI 5.28–87.8), premature rupture of membranes or rupture of membranes 18 h before birth (OR 2.5, CI 1.06–5.94) and meconium stained amniotic fluid (OR 12.03, CI 5.23–27.67). Blood pressure was not routinely measured, and 25% of women with stillbirths with no registered foetal heart rate [FHR] at admission underwent CS. Conclusions The stillbirth rate in this cohort was 22 per 1000 total births and did not fulfil the Every Newborn Action Plan’s goal of 12 stillbirths per 1000 total births in 2030. Awareness of risk factors associated with stillbirth, preventive interventions and improved adherence to clinical guidelines during labour, and hence improved quality of care, are needed to decrease the stillbirth rate in resource-limited settings.

Background More than two years into the pandemic, many European countries have begun to evaluate their COVID-19 public health responses and draw lessons for future preparedness. As the COVID-19 crisis has exacerbated intersectional social and health inequalities, it is pertinent to evaluate the extent to which COVID-19 responses have successfully responded to the diverse needs of various vulnerable groups. We present a comparative analysis of how evaluations of European COVID-19 responses have assessed efforts to adapt or tailor COVID-19 responses to vulnerable groups, focusing on public testing and tracing strategies and vaccination campaigns. Methods We draw on data collected in the H2020 project COVINFORM. We combine insights from qualitative interviews conducted with public health policy- and decision makers in COVINFORM partner countries with a document review of available evaluations of COVID-19 responses published by both government and academic actors between March 2020 and June 2022. Results Across countries, evaluations of COVID-19 responses show that efforts to adapt or target public health responses to specific vulnerable groups became more common as the pandemic stretched on. Differences across countries were observed in relation to which groups were considered particularly vulnerable; the types of responses considered successful; as well as the organisational/governmental level at which responses were coordinated. Analyses reveal that the heavy emphasis on medical vulnerability distracted from efforts to address broader, structural inequalities, complicating the development of tailor-made policies. Conclusions The results inform ongoing policies that deal with the long-term consequences of the COVID-19 pandemic and aim to reduce disproportionate impacts faced by vulnerable groups. Our findings also add to a better understanding of how future preparedness structures should take into account how pandemic measures have unequal impacts. Key messages • As the COVID-19 crisis has exacerbated intersectional social and health inequalities, it is important to learn from efforts to adapt or tailor COVID-19 responses to vulnerable groups. • The findings demonstrate how across Europe, the combination of particular sets of country-specific COVID-19 responses, tailor-made or not, yield specific consequences for vulnerable groups.

Objective To assess the quality of neonatal resuscitation (NR) through video recordings and identify potential areas for improvement. Design Prospective cohort study. Setting From September to December 2019, at four district hospitals in Pemba, Tanzania. Population All labouring women and their newborns were eligible for participation. Main Outcome Measures Videos were analysed for quality-of-care indicators based on the NR algorithm. Questionnaires on quality-of-care indicators were answered by health workers (HW) and mothers. Risk factors for neonatal mortality were analysed in a binomial logistic regression model. Results A total of 1440 newborns were enrolled. Within the neonatal period, 34 newborns died (23.6 per 1000 live births). During the study period, 90 neonatal resuscitations were performed, of which 20 were recorded. Meantime to initiate positive pressure ventilation (PPV) with bag-and-mask was 98 seconds (10 – 416 s), it was inadequately performed in 15 cases (75%). Half (10/20) did not have PPV initiated within the first minute, and in 1 case (5.0%) no PPV was performed. PPV was initiated but not sustained in 16/20 (80%) newborns. Of the 20 infants with videos, 10 died: Eight after failed resuscitation and two in the first 24 hours. The majority of HW 49/56 (87.5%) had received training in NR. Conclusions Despite nearly 90% of HW being trained in NR, video analysis revealed significant deviations from guidelines, provided direct evidence of gaps in the quality of care and identified areas for future education, particularly effective bag- and mask ventilation. Keywords PERINATAL NEONATAL MORTALITY RESUSCITATION VIDEO RECORDIN

Background: The COVID-19 pandemic has highlighted the need for structurally informed mental health services that are sensitive to social inequalities and cultural differences. Community-level services and organisations are often referred to as having the potential to play a key role in providing such services to migrants, yet not many studies have documented how these types of services have been organised and experienced during the COVID-19 pandemic. The objective of our case study in Antwerp’s districts of Borgerhout and Antwerpen-Noord (Belgium) was to explore how community-level responses to the mental health impact of the COVID-19 crisis were organised and experienced by first-generation migrants and members of community-level organisations. Methods: Semi-structured qualitative interviews were conducted with first-generation migrants in Borgerhout and Antwerpen-Noord (n=19) and with professionals in the local psycho-social care sector (n=13). Results: Our findings highlight the complex drivers of migrants’ mental health and the unique value and indispensability of local-level services and organisations in providing mental-health related services, particularly in a crisis context like the COVID-19 pandemic. Qualities that emerged to be particularly important included organisations’ awareness of local needs; their flexible nature which allows them to address bottlenecks and fill gaps left by other services; their capacity to respond holistically to a broad spectrum of needs; their ability to offer culturally sensitive care and support; and their physical accessibility. However, our findings also demonstrate the fragility and fragmentation of these local-level services and initiatives. In the face of the COVID-19 crisis, this related to serious challenges to the necessary physical accessibility of organisations’ services; services and initiatives becoming overloaded; and widespread fragmentation and lack of oversight of the available services forming a real barrier for both service users and providers. Conclusions: This study underlines the importance of prioritising physical accessibility of mental health services at the community level, improving cultural sensitivity through training and employing professionals with a shared background or language proficiency with migrants, and promoting stronger collaborations between community-level organizations and city governments. The findings are informative to guide mental health policy and future crisis responses in similar communities and neighbourhoods.

Background: The COVID-19 pandemic has highlighted the need for structurally informed mental health services that are sensitive to social inequalities and cultural differences. Community-level services and organisations are often referred to as having the potential to play a key role in providing such services to migrants, yet not many studies have documented how these types of services have been organised and experienced during the COVID-19 pandemic. The objective of our case study in Antwerp’s districts of Borgerhout and Antwerpen-Noord (Belgium) was to explore how community-level responses to the mental health impact of the COVID-19 crisis were organised and experienced by first-generation migrants and members of community-level organisations. Methods: Semi-structured qualitative interviews were conducted with first-generation migrants in Borgerhout and Antwerpen-Noord (n = 19) and with professionals in the local psycho-social care sector (n=13). Results: Our findings highlight the complex drivers of migrants’ mental health and the unique value and indispensability of local-level services and organisations in providing mental-health related services, particularly in a crisis context like the COVID-19 pandemic. Qualities that emerged to be particularly important included organisations’ awareness of local needs; their flexible nature which allows them to address bottlenecks and fill gaps left by other services; their capacity to respond holistically to a broad spectrum of needs; their ability to offer culturally sensitive care and support; and their physical accessibility. However, our findings also demonstrate the fragility and fragmentation of these local-level services and initiatives. In the face of the COVID-19 crisis, this related to serious challenges to the necessary physical accessibility of organisations’ services; services and initiatives becoming overloaded; and widespread fragmentation and lack of oversight of the available services forming a real barrier for both service users and providers. Conclusions: This study underlines the importance of prioritising physical accessibility of mental health services at the community level, improving cultural sensitivity through training and employing professionals with a shared background or language proficiency with migrants, and promoting stronger collaborations between community-level organizations and city governments. The findings are informative to guide mental health policy and future crisis responses in similar communities and neighbourhoods.