Background: Efforts to improve national civil registration and vital statistics (CRVS) systems are focusing on transforming traditionally passive systems into active systems that have the ability to reach the household level. While community health agents remain at the core of many birth and death reporting efforts, previous literature has not explored elements for their successful integration into CRVS efforts. Objective: To inform future efforts to improve CRVS systems, we conducted a systematic review of literature to understand and describe the design features, resulting data quality, and factors impacting the performance of community health agents involved in tracking vital events. Methods: We reviewed 393 articles; reviewers extracted key information from 58 articles meeting the eligibility criteria: collection of birth and/or death information outside of a clinic environment by a community agent. Reviewers recorded information in an Excel database on various program aspects, and results were summarized into key themes and topic areas. Results: The majority of articles described work in rural areas of Africa or South-East Asia. Nearly all articles (86%) cited some form of household visitation by community health agents. Only one article described a process in which vital events tracking activities were linked to official vital events registers. Other factors commonly described included program costs, relationship of community agents to community, and use of mobile devices. About 1/3 of articles reported quantitative information on performance and quality of vital events data tracked; various methods were described for measuring completeness of reporting, which varied greatly across articles. Conclusions: The multitude of articles on this topic attests to the availability of community health agents to track vital events. Creating a programmatic norm of integrating with CRVS systems the vital events information collected from existing community health programs has the potential to provide governments with information essential for public health decision-making. ARTICLE HISTORY

Objective Low-dose aspirin is recommended for preeclampsia prevention among women with high-risk conditions, including chronic hypertension. Black women have higher rates of hypertensive disorders of pregnancy, and whether this is related to disparities in aspirin prophylaxis is unknown. We investigated the relationship between race and counseling/prescription and uptake of aspirin among a cohort of women with chronic hypertension. Study Design This is a single-institution, retrospective cohort study of women with chronic hypertension who delivered between 2016 and 2018. Medical record review was performed to assess counseling/prescription of aspirin prophylaxis and self-reported uptake. Self-reported uptake was determined by mention in the provider's notes or by inclusion in the medication reconciliation system. Demographic and obstetric outcome data were compared by self-reported race (Black vs. all other races) in univariate analysis. Multivariable logistic regression analysis was performed to evaluate the association between race and aspirin adherence. Results We included 872 women: 361 (41.4%) Black women and 511 (58.6%) white or other race women. Overall, 567 (65.0%) women were counseled and/or given a prescription for aspirin, and 411 (72.4%) of those women reported uptake. Black women were equally likely to be counseled and/or prescribed aspirin compared with all other races (67.3 vs. 63.4%; p = 0.7). However, Black women were less likely to report uptake of aspirin (63.8 vs. 79.0%; p < 0.001). After adjustment for total prenatal visits and tobacco use, Black race was associated with an adjusted odds ratio of 0.53 (95% confidence interval: 0.36–0.78) for uptake of aspirin. Conclusion In our cohort, recommendation for aspirin prophylaxis was suboptimal in all groups, reaching only 65% of eligible women. Black women were equally likely as women of other races to receive counseling about aspirin, but rates of uptake were lower. Our findings suggest that counseling and prescription of aspirin alone in high-risk Black women are not sufficient for utilization of this intervention. Key Points

INTRODUCTION: Low-dose aspirin prophylaxis is recommended for preeclampsia prevention among high-risk women, but not all eligible women receive it. We investigated whether site of prenatal care impacts rates of aspirin prophylaxis among a cohort of women with chronic hypertension (cHTN). METHODS: This is a single institution, retrospective cohort study of women with cHTN who delivered between 2016–2018. Women with no prenatal care or care outside the hospital system were excluded (n=196). Medical records were reviewed to determine prenatal care site and to assess counseling and prescription of aspirin. Demographic and obstetric outcomes were compared by prenatal care site in univariate analysis. Multivariable logistic regression analysis was performed with adjustment for race, blood pressure and gestational age at first prenatal visit. RESULTS: We included 870 women. 126 (14.5%) had prenatal care in a hospital-based academic practice, 280 (32.2%) in a resident clinic, 303 (34.8%) in private practice, 76 (8.7%) in Maternal-Fetal Medicine (MFM) practice and 85 (9.8%) in a midwife or family practice. There were no differences in blood pressure or gestational age at first prenatal visit. Overall 64.6% of women were counseled or prescribed aspirin. Rates differed by prenatal care site (P<.001) ranging from 44.4% (academic practice) to 92.1% (MFM practice). Counseling rates were 70.4% in resident clinic, 58.1% in private practice, 72.9% in midwife/family practice. Differences in counseling persisted in multivariable models. CONCLUSION: In a cohort of women at high-risk for preeclampsia, aspirin counseling was not universal and rates varied by prenatal care site, which is an area for quality improvement.

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