The Global Maternal and Newborn Health Platform: study protocol for an observational, multi-country study on the quality of intrapartum and early postnatal care at health facilities

The Global Maternal and Newborn Health Platform: study protocol for an observational, multi-country study on the quality of intrapartum and early postnatal care at health facilities | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol The Global Maternal and Newborn Health Platform: study protocol for an observational, multi-country study on the quality of intrapartum and early postnatal care at health facilities Joshua Vogel This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5968904/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Good-quality care in the intrapartum and early postnatal period are critical to ensuring maternal, fetal and newborn survival and well-being. There is currently no standardised approach to assess the quality of intrapartum and early postnatal care provided in health facilities, women’s experiences of that care, and whether the services provided are aligned with the latest WHO recommendations. The Global Maternal and Newborn Health Platform (GMP) aims to establish and sustain a multi-country network of health facilities providing childbirth services, to measure and improve the quality of intrapartum and early postnatal care. The main objectives of this Platform are (i) to measure coverage of key intrapartum and early postnatal care practices and their alignment with WHO recommendations, (ii) to describe women’s experiences of care, (iii) to measure key maternal and newborn health outcomes. Methods: GMP will use periodic, cross-sectional, observational data collection in a multi-country network of health facilities from up to 63 low- and middle-income countries (LMICs). In the first wave, GMP is being implemented in 74 facilities in 10 Asia-Pacific countries. In participating facilities data will be collected at level of the individual woman/baby, maternal and newborn health providers, and facility. Discussion: This multi-country initiative aims to assess the quality of intrapartum and early postnatal care in health facilities, with a “person-centred” approach that emphasizes women’s experiences during birth and postnatal admission. In its first wave, data will be collected from over 100,000 women and their babies, alongside nearly 30,000 pre-discharge surveys on care experiences, complemented by responses from over 2,000 healthcare providers across 74 facilities in 10 Asia-Pacific countries. The resulting dataset will enable multi-country, country-specific, and facility-level analyses to identify actionable priorities for improving maternal and newborn health outcomes. GMP’s tools and methods are developed using an evidence-based approach and foster multidisciplinary networks among healthcare professionals, researchers, and policymakers. GMP provides a robust, scalable approach for periodic and standardised data collection, informing evidence-based policy and practice to enhance care quality. GMP will provide global situational analyses on intrapartum and early postnatal care quality to address the Sustainable Development Goals (SDG) and will help to addresses the WHA 77.5 resolution to accelerate progress towards reducing maternal, newborn and child mortality, including stillbirths. intrapartum maternal newborn postnatal quality of care Figures Figure 1 Figure 2 BACKGROUND In the past three decades, the proportion of women attending health facilities to give birth and having access to skilled care has grown worldwide, while maternal and newborn mortality rates have decreased.( 1 ) Yet, latest estimates of maternal and newborn mortality suggest progress has stagnated - around 287,000 maternal deaths, 1.9 million stillbirths and 2.3 million newborn deaths occur each year.( 2 – 4 ) The vast majority of deaths are in low- and middle-income countries (LMICs), mainly in Africa and Asia, where many countries are not on track to meet the Sustainable Development Goals (SDGs) mortality targets. ( 5 ) In response to these realities, the World Health Assembly (WHA) passed in 2024 a resolution to accelerate progress towards reducing maternal, newborn and child mortality, including stillbirths.( 6 ) High-quality care during labour, childbirth and the postnatal period is critical to ensuring maternal, fetal and newborn survival and well-being.( 7 , 8 ) The World Health Organization (WHO) quality of maternal and newborn care framework emphasises the need to optimise provision and experience of care, and ensure maternal and newborn health services have the appropriate resources to provide both (Supp. Figure 1 ). In line with these global agendas, WHO’s recommendations on intrapartum and postnatal care ( 9 , 10 ) emphasise respectful, individualized, evidence-based, person-centred care to optimise health and wellbeing for the woman and her baby. ( 11 ) A long-standing challenge for maternal and newborn care quality in many LMICs is the lack of actionable, reliable data systems. ( 12 , 13 ) Without such systems, the magnitude and causes of maternal and newborn mortality and morbidity, the coverage of key clinical and non-clinical interventions, the availability of resources, and whether these measures are improving over time cannot be tracked. Recent scoping reviews indicated that the measures used for intrapartum and early postnatal care monitoring are poorly aligned with current WHO recommendations for maternal and newborn care.( 12 , 13 ) A forthcoming systematic review found that, with the exception of Latin America, there are few sustained maternal and perinatal data systems in high-burden countries, and fewer still that align with WHO-recommended care practices (V Diaz, personal communication). Some LMIC-based research studies have comprehensively measured the quality of intrapartum care provision ( 14 – 16 ) however such systems are not harmonized for global implementation. A second, related challenge is that routine approaches to maternal and perinatal data collection systems have not caught up with the broader shift towards person-centred, respectful care, and the importance of women and parent’s experiences.( 12 ) The mistreatment of women and newborns around the time of birth is worryingly common.( 17 , 18 ) A more holistic approach is using person-centred data on women’s birth experiences to complement metrics on care provision and health outcomes. Together, these can produce a comprehensive evaluation of maternal and newborn care quality, and better direct quality improvement efforts. It is nonetheless complicated to implement at scale, requiring validated, reliable and culturally appropriate tools for measuring women’s care experiences.( 19 ) A third challenge is that international maternal and newborn care recommendations evolve over time. WHO’s intrapartum and postnatal care guidelines have shifted significantly in the past several years in response to new evidence. For example, major changes to how labour should be monitored and managed, and stronger emphasis on the role of supportive care interventions during the intrapartum and postnatal period.( 20 , 21 ) While several countries have rapidly adopted latest WHO recommendations,( 22 – 24 ) it is not well known to what extent these have reached real-world clinical practice. Rationale for the Global Maternal and Newborn Health Platform There is currently no comprehensive approach to evaluate the quality of intrapartum and early postnatal care against the latest WHO recommendations. Such an approach is needed to comprehensively evaluate the quality of care in facilities, monitor facility performance over time and prioritize interventions to improve quality of care, while incorporating measurement of provider practices as well as women’s experiences. Over the past 15 years, WHO has led several multi-country observational studies on maternal and perinatal health outcomes.( 8 , 25 – 27 ) These studies generated new, practice-changing evidence related to mode of birth, maternal near-miss, and prevention and management of complications of abortion and maternal infections. They also provide a platform by which large-scale observational studies and research strengthening activities can be conducted. The Global Maternal and Newborn Health Platform (GMP) builds on and extends these previous multi-country studies. The platform will conduct periodic analyses on intrapartum and early postnatal care quality, and associated maternal, fetal and early newborn health outcomes. It will help countries and health facilities assess their practices alongside WHO recommendations, and it will also provide opportunities to disseminate evidence-based guidance to facility and national level health stakeholders, accelerating improvements in quality of care. Focus on Asia-Pacific The Asia-Pacific region with 36 LMICs (22 in Asia and 14 in the South Pacific) exemplifies these challenges − 10 women in this region die every hour due to pregnancy-related causes.( 28 , 29 ) There is also a disproportionately high burden of severe maternal morbidity in health facilities in Asia-Pacific LMICs.( 30 ) Women and families accessing health services in many Asia-Pacific countries face numerous challenges including poor-quality antenatal, childbirth and postnatal care, significant shortages in the health workforce, and a lack of data on facility-based maternity care quality, coverage of essential interventions, and health outcomes.( 28 , 29 ) Furthermore, the Asia-Pacific region, especially the smaller countries, are rarely included in global research efforts to improve maternal and newborn health. Aim and objectives The overall aim of GMP is to establish and sustain a multi-country network of health facilities providing childbirth services, to measure and support improvement in the quality of intrapartum, and early postnatal care. Primary objectives: Measure coverage of key intrapartum and early postnatal care practices in participating health facilities and whether key WHO intrapartum and early postnatal care recommendations are being implemented; Measure women’s experience of intrapartum, and early postnatal care at participating health facilities; Measure frequency of key maternal and newborn health outcomes related to the intrapartum and immediate postnatal period; Secondary objectives: Support dissemination and uptake of WHO guidelines and associated tools related to intrapartum and early postnatal care in health facilities; Facilitate data-driven approaches to improving quality of intrapartum, and early postnatal care in participating health facilities; Strengthen maternal and newborn health research capacity in participating countries and health facilities. METHODS Study design GMP will use a prospective, facility-based, observational design. It collects data on intrapartum and postnatal care practices, the experiences of women giving birth, and their health outcomes (Figure 1). It employs a multi-stage sampling strategy similar to that used in previous WHO multi-country surveys of maternal and newborn health (8, 25, 31) (Figure 2). It is expected that this core GMP protocol will ultimately be implemented in over 1,000 health facilities in up to 63 LMICs, across six WHO regions (Supplementary Table 1). Selection of countries and health facilities, and data collection will follow a similar approach across all regions. Selection of countries: We pre-identified 17 countries in the South-East Asia (SEA) and Western Pacific (WP) WHO regions, hereafter referred to as the ‘Asia-Pacific’, (Table 1) that could potentially participate in the first round of the GMP. The initial list was informed by countries participating in previous WHO multi-country surveys, and consultations withWHO headquarters, WHO regional and country offices, and national Ministries of Health. This process aimed to ensure diversity in terms of burden of maternal and perinatal health outcomes, perceived quality of maternal and newborn health services, alignment with regional priorities and initiatives, leveraging existing research networks and previous research capacity investments, willingness of the country to participate, and financial costs and feasibility. It will also allow assessment of some maternal and perinatal indicators over time, through comparison with data from previous surveys. In the firstphase of GMP in the Asia-Pacific, 10 countries will participate: Bangladesh, Indonesia, Nepal, Sri Lanka, Thailand, and Timor-Leste in the SEA region; Fiji, Mongolia, Papua New Guinea, Solomon Islands in the WP region. Four rounds of data collection at 3-year intervals (2024, 2027, 2030, 2033) are planned to enable monitoring trends of quality of care at participating health facilities over time. It is expected the same countries will participate in subsequent rounds in the Asia-Pacific. Selection of provinces/states : From each participating country, three provinces/states are selected: the province/state where the country’s capital city is located, and two randomly sampled provinces/states (with probability proportional to the population size). In situations where one of the selected provinces/states has too few facilities (i.e. only one or two eligible facilities) a fourth province/state is selected (as described below). To be eligible, provinces/states needed to have an institutional birth coverage of at least 30%, and at least one eligible facility (Figure 2). Selection of facilities: Within each sampled province/state, up to 7 eligible facilities are randomly sampled, with a probability proportional to births per year. Eligible facilities are those with a minimum of 2,000 births per year, the capacity to perform Caesarean section and can be of any type (public, private or other). If less than 7 eligible facilities are in the province/state, all facilities are selected. Where there are only 1 or 2 eligible facilities in a province/state, an additional (fourth) province/state is selected. Facility networks in countries that participated in previous WHO surveys (8, 25, 32) will be re-activated wherever possible. (32) However, some of these facilities may no longer meet the eligibility criteria, or may decline participation. In such situations new facilities from the same province/state are sampled using the aforementioned sampling strategy (Figure 2). Data collection period : All participating health facilities will collect data for a minimum of 3 months. If a sample size of 1,000 births per facility cannot be reached by 3 months, data collection will continue to a maximum of 6 months. Study populations GMP will collect data at three levels: individual woman/baby level, provider level and facility level. Individual woman/baby level: Data is collected during the women’s admission for birth untildischarge, death, transfer or it is 7 days after birth, whichever comes first. All women giving birth at 22 weeks’ gestation (or if gestation is unknown, 500 grams birthweight) in the participating health facilities during the study period will comprise the study population, regardless of their maternal and perinatal outcomes. Women who give birth outside the study health facility, or pregnant women who are admitted but do not give birth, are excluded. If any maternal or newborn deaths or stillbirths are identified, further information on cause of death is collected. A random sample of women will be invited to complete a pre-discharge interview (Figure 1). Provider level: The study population are any skilled health workers employed at the participating health facility and who provide intrapartum or postnatal care during the study period. These may be doctors, nurses or midwives at any level of seniority. Students, such as midwifery, nursing or medical students, are not included (Figure 1). Facility level: One facility survey will be completed per facility (Figure 1). Information will be obtained through interviewing the Head of Department of Obstetrics and Gynaecology, and the Head of the Department of Neonatology/Paediatrics and/or the Head of Nursing and Midwifery (or their representatives), as well as facility managers or relevant department staff (e.g. pharmacy). Primary and secondary outcomes GMP has 17 primary (Table 2) and 29 secondary outcomes (Tables 3 and 4) spanning the intrapartum and early postnatal periods. These outcomes include coverage of key practices, people-centred care (experience) outcomes and health outcomes, for women and newborns. Operational definitions for all outcomes are presented in Supplementary Table 2. Sample sizes GMP will collect individual-level data on multiple outcomes, for which the prevalence may vary. For example, in the WHOMCS early breastfeeding rates ranged from 17.7% to 98.4%.(33) Some adverse health outcomes (e.g. stillbirth) may be less frequent in low-burden facilities or countries. We explored different sample size scenarios for a range of GMP outcomes and levels of precision. For example, for a relatively rare outcome (e.g. 0.7% stillbirth rate) at +/-0.5% precision, 1068 women are required. For a more frequent outcome (e.g. 12% Caesarean rate) and +/-2.0% precision, 1,015 women are required. We also noted that in the WHOMCS, the average number of women per facility was 876. Through consultations with the study country investigators and advisory group and investigators, we opted for a pragmatic target of at least 1,000 women per facility. For the pre-discharge women’s survey, we estimate that ~80% of women giving birth will be eligible. For a given outcome on women’s birth experiences (hypothetical prevalence ranging from 5% to 95%) and +/- 5% precision, 385 women are needed. We therefore will sample a minimum of 385 women per facility. For the provider survey, acknowledging that survey response rates may be less than 50%, we aim to maximise participation and representativeness. Hence, all staff providing intrapartum, and postnatal care at GMP facilities are eligible, and will be approached invited to participate. Data collection instruments We sought a measurement approach that would be relatively low-cost and feasible to implement in limited-resource settings. First, we mapped all WHO intrapartum and early postnatal care recommendations and best practices, identifying where and how each of these could be measured (e.g. woman/baby, provider or health facility level). For example, the broad concept of pain relief during labour and birth could be identified from a medical record, by asking a woman whether she was offered pain relief, asking a provider if they routinely offer pain relief, or assessing whether a facility has pain relief options available. We considered this mapping and prioritised what to measure based on 1) clinical importance, 2) prevalence or coverage of the recommendation, 3) relative importance of that recommendation to quality of maternal and newborn care more broadly, 4) measurability, 5) balance of benefit and harm within evidence supporting the recommendation. We also ensured GMP’s primary and secondary outcomes were captured, which also evolved alongside this process. This was an iterative process, including literature reviews and expert consultations. We also reviewed existing instruments which had been used in previous multi-country studies to measure aspects quality of maternal and newborn care, identified from our scoping reviews.(12, 13) This resulted in the scope, content and first iterations of five GMP instruments. There are three instruments at the individual woman/baby level: 1) a medical record review form (for all women giving birth and their newborns), 2) a cause-of-death form (for any maternal, fetal or early neonatal death), and 3) a pre-discharge women’s experience survey (for randomly sampled postnatal women). GMP also measures at: 4) the provider level (provider survey) and 5) facility level (facility survey). All instruments were drafted, reviewed by GMP country investigators and advisory group members, field-tested in GMP sites, translated (where required) and refined prior to study implementation. We developed study manuals for each instrument - all investigators, facility co-ordinators and data collectors will undergo standardised training prior to data collection. Details for each instrument are provided below. 1) Medical Record Review Form: Items included in the medical record review form were developed based on the iterative process outlined above. GMP study data are abstracted from medical records into a digital study form, around the time of discharge. Data are non-identifiable and include maternal characteristics, maternal risk factors, coverage of essential intrapartum and early postnatal interventions, mode of birth, and maternal, perinatal and newborn health outcomes. Facility medical staff can be approached if there are doubts or clarifications are required. 2) Cause of death form: If any maternal death, stillbirth or early neonatal death is identified, data on cause of death will be collected using a dedicated form using the WHO ICD-MM (34) and ICD-PM (35) classifications. 3) Pre-discharge women’s experience survey: The aim of this instrument is to understand the women’s perspective on the characteristics of good-quality care. Our ideal instrument would have good validity (particularly face and content validity), reproducibility and reliability, and would be feasible to use in limited-resource settings. From the literature reviews we identified four tools (36-38) with the greatest alignment to GMP’s objectives and needs. We extracted specific items from these tools and mapped them to our prioritised list. We developed a first iteration (version 1) using items adopted or modified from these tools, created new items where required, and organised this into a logical workflow. This was revised following consultations with WHO staff and three independent experts working in measuring women’s experiences after birth (version 2) and finalized by the research group (version 2.1) based on face and content validity, feasibility and understandability. We pilot-tested version 2.1 on paper with four to six postnatal women (vaginal and caesarean birth) per each GMP country. This was done by the principal investigator in each country using a cognitive interview guide, resulting in further revisions (version 2.2). We then created a digital audio computer-assisted self-interviewing (ACASI) survey (Viewpoint, UK) for use on a tablet.(39) The participant listens to a recorded voice (in a language of their choosing) and responds to questions via a touchscreen. Pictures are used for responses, as well as visual cues. This means women can participate regardless of literacy or language; headphones help ensure privacy. We pilot-tested tablet-based ACASI in one GMP site with four women, which indicated it was acceptable and feasible. For the Asia-Pacific region we translated the survey into 14 languages; each version was reviewed by investigators and bilingual speakers, back-translated and refined. 4) Provider survey: The aim of this instrument is to provide a standardized tool for assessing self-reported intrapartum and early postnatal care practices of healthcare workers and the factors influencing the implementation of these practices. A total of 12 validated, reliable and relevant questionnaires were identified from a rapid review of the literature, and 164 items were extracted and evaluated, mapped against WHO recommendations and prioritized by key concepts and domains based on a pre-defined conceptual model. A first version of the survey (version 1) was revised through cognitive interviews, conducted by an experienced social scientist in October to November 2023, with nine skilled health providers from two countries (Thailand and Papua New Guinea) to assess the survey's clarity, comprehensibility, and response capacity. Four healthcare providers from a GMP facility in Fiji completed the revised survey (version 2) and participated in group interviews to further assess the instrument's clarity, relevance, length and scale structure. The survey was finalized by the research group, pilot-tested in anelectronic format, translated into eight languages for the Asia-Pacific, reviewed by investigators and bilingual speakers, and refined through back-translation (version 2.1). 5) Health facility survey: The facility survey captures data on the environment and context where intrapartum and early postnatal care is provided. It includes facility, volume and activity; organization and services (e.g. infrastructure, supplies, equipment, and human resources); and clinical policies and protocols for intrapartum and postnatal care.Following the recommendation mapping process described above, we reviewed WHO normative documents related to measuring intrapartum and early postnatal care at a facility level. This included WHO’s standards and monitoring framework for maternal and newborn care quality (40-42), WHO’s service availability and readiness assessment (SARA) tool (43), Harmonized Health Facility Assessment (HHFA)(44); Service Provision Assessments (SPA)(45); health facility surveys used in prior WHO multi-country studies (16, 25-27, 32) and a review of large-scale facility assessment tools to measure quality of maternal and newborn care as per the WHO framework.(43, 46) We extracted and consolidated specific, validated questions from these to form the first iteration of the facility survey (version 1). This was revised following consultations with GMP advisory members and measurement experts (version 2), field-testing in one GMP site, revised (version 3) and finalized in consultation with country teams (version 4). Data collection Research staff are trained according to a standardized manual of operations, which minimizes the need for judgement and interpretation. Training workshops at country and facility levels are held prior to commencement of data collection. All collected data are stored on an access-restricted database. Participant confidentiality and anonymity will be maintained at all times by the sponsor, regional and country coordinators, and research staff in participating facilities. Processes for specific levels of data collection are described below. Individual level data Trained data collectors are deployed to participating facilities to collect GMP study data using tablet devices. Each day, data collectors review medical records or registers in labour and postnatal wards, as well as other clinical areas where birthing women may be present (such as emergency rooms or operating theatres), to extract individual level data. The total number of women admitted and giving birth at the facility each day is monitored using a customised log. Individual electronic study records are compared to logs to ensure eligible women are not missed. The data system randomly selects women who have given birth to be invited to complete a pre-discharge survey. The sampling probability is based on the total number of expected births in that health facility and aims to ensure approximately 385 women are surveyed during a facility’s study period. Eligible women are those able to give informed consent and complete it (i.e. are not experiencing a serious adverse outcome). The data collector explains the survey to the woman using a participant information sheet in the woman’s language of preference. Informed consent is provided by agreeing to the consent statement on the tablet device. Survey completion occurs in a private environment within the health facility, on the tablet using headphones (if preferred). Provider level data The facility co-ordinator identifies all relevant skilled health workers (obstetrics, nursing, midwifery, neonatology, paediatrics) currently working at the facility in intrapartum and early postnatal care services. Providers are sent a unique link to complete the voluntary survey via email or mobile (WhatsApp or Line), or they can complete it using a study tablet. This survey obtains consent to participate, and captures data on their characteristics, as well as knowledge, attitudes and practices on intrapartum and early postnatal care. Facility level data Adigital form is used to collect health facility level information. This is completed by the facility co-ordinator collecting the required information from the Head of Obstetrics & Neonatology/Paediatrics Departments (or their authorised representative) in the health facility. Some questions require input from different staff or departments (heads of unit, laboratory, infection prevention and control unit, administrative services). Data management All data are collected electronically using tablets into Good Clinical Practice (GCP) compliant databases. Unique, pre-defined numbers are used for each participant. Where needed, study forms and manuals will be translated into relevant local languages. Data collection and entry procedures, storage, protection, ownership, sharing and retention will be compliant with the WHO standard operating procedures and GCP guidelines. The REDCap database system ( https://project-redcap.org/ ) is used to capture data for both the medical record review and the provider survey. REDCap uses data accuracy checks to minimize entry errors, facilitate monitoring and enable quick resolution of queries and missing data. For the medical record review form, a 10% random sample for the first 250 participants will undergo double data collection, with data compared for inconsistencies, and thereafter a 5% random sample of participants. Completed forms will be checked by facility, country and regional coordinators to ensure completeness, reliability and consistency of collected data. Data curation and validity cross-checks will be performed within the centralised database. In-person monitoring visits by regional and country investigators will be organised during and after the data collection period, to evaluate protocol adherence and perform data quality verification. Additional visits will be carried out depending upon facility or country activity and performance. Upon completion of the study and verification of data for accuracy and completeness, the database will be locked from any additional changes. Pre-discharge surveys will be prepared using ACASI in recordings of local languages. Data collected using the ACASI will be stored electronically in a central location associated with the woman’s unique identifying number and will not be available to the study site. Study governance The WHO’s Department of Sexual and Reproductive Health and Research is the global sponsor and is responsible for coordinating GMP in multiple WHO regions. In each region, there will be a Regional Coordinating institution. For Asia-Pacific countries this is the Burnet Institute, Australia. GMP is governed by a Steering Committee which includes the global sponsor (WHO-Geneva), regional coordinating institutions (e.g. Burnet Institute for the Asia-Pacific), independent advisors, and Country Principal Investigators. The Regional Co-ordinating Committee for the Asia-Pacific is responsible for overseeing implementation in this region, and comprises WHO-Geneva, Burnet Institute and Principal Investigators from the 10 participating Asia-Pacific countries. Each facility has a designated Facility Co-ordinator who will oversee all facility-level activities, and report to the Country Investigator. Ethics approval The study was approved by The Alfred Hospital Human Ethics Committee (HREC for Burnet Institute) on 27 July 2023 (approval number 96879, 340/23), and the World Health Organization Ethical Review Committee (ERC.0004050) on 5 February 2024. This study will obtain all required authorizations at country and institutional level, and the relevant consent to participate. Planned analyses A statistical analysis plan (SAP) will be developed in collaboration with country researchers, study statistician and WHO statisticians, and finalised prior to completion of recruitment. Primary objectives 1-3 will use descriptive statistics at the individual, facility, or country level. Individual, facility and country level characteristics will be summarised using n (%) or mean (Standard deviation, SD) as appropriate. To summarise individual level data for a facility or country (i.e., to pool data at the facility or country level), we will need to account for the sampling design and clustering by using appropriate survey weights. We will also explore possible associations between the use of interventions and women and newborn outcomes. DISCUSSION This ambitious, multi-country initiative aims to systematically assess the quality of intrapartum, and early postnatal care in health facilities across six WHO regions. A key novelty is GMP’s “person-centred” approach, collecting data on women’s experiences of care during birth and early postnatal admission. In the first wave of GMP in 74 health facilities in 10 Asia-Pacific countries, we anticipate collecting data from more than 100,000 women and their babies, as well as nearly 30,000 pre-discharge surveys on women’s experiences. This will be complemented by survey data from an estimated 2,000 providers or more working in these facilities. Collectively, the GMP model produces a world-first, comprehensive picture of intrapartum, and early postnatal care quality, inclusive of women’s and provider’s perspectives. This enables pooled analyses of multi-country data, as well as country- and facility-specific analyses to improve the quality of care. The GMP network will create new opportunities for nested sub-studies, or additional research projects (alongside or between rounds of data collection). In the Asia-Pacific, GMP is catalysed by Burnet’s Centre for Research Excellence on Maternal and Perinatal Health in the Asia-Pacific (CRE-ARPAN), the HRP Alliance (WHO-Switzerland) and its hubs located in Thailand and Viet Nam. The GMP Research Group is actively seeking further funding to address further maternal and newborn health priorities and continue strengthening research capacity. GMP’s intended impact is to improve the quality of intrapartum, and early postnatal care in health facilities. It will allow a standardised investigation of links between clinical environments and practices, women’s experiences, and maternal and perinatal outcomes. This enables a data-driven approach to setting priorities and taking action to improve maternal and newborn health. Results will be used for dialogue with healthcare providers, facility leadership, and state/national policymakers, and to target quality improvement initiatives. It will provide key data to guide policy and practice at a facility, provincial, country and regional level in the coming years. More broadly, GMP provides a validated, feasible approach to assess whether quality of intrapartum, and early postnatal care is consistent with current WHO evidence-based recommendations. GMP’s tools and methods will be made freely available for future use. GMP will help create and reinforce multidisciplinary networks between obstetricians, neonatologists, nurses, researchers, administrators, governments in participating facilities, countries and regions. Our ambition is that GMP data collection will be undertaken periodically (i.e. every 3 years). Strengths and limitations A major strength of GMP is that it provides a real-world picture of intrapartum and early postnatal care quality in participating facilities. In addition, it expands and strengthens research networks from previous WHO-led multi-country surveys on maternal and newborn health.( 8 , 25 ) Expertise across partners spans research, maternal and neonatal clinical care, epidemiology and health policy. The large sample size, geographic and health system diversity enhances the applicability of results in the Asia-Pacific region and in future regions as they come on-board. This study has some important limitations. In the facility selection criteria, including only those with at least 2,000 births per year means that this sample will be composed of mostly medium-to-large facilities, and many of which are tertiary referral hospitals. For relatively small countries (such as Solomon Islands, Fiji or Timor-Leste) this means only one or two health facilities are eligible. However, the inclusion of smaller countries, for the first time, in a WHO-led multi-country survey brings valuable diversity and generalisability. We anticipate that GMP’s tools and outputs will nonetheless be useful to lower-level or smaller facilities, though further investigation may be warranted. As GMP was not designed to cover home births the data cannot be generalised to births outside of health facilities. Conclusion The data generated from GMP will provide a comprehensive picture of the quality of intrapartum, and early postnatal care at a range of health facilities in low- and middle-income countries. The first wave of 74 facilities in 10 countries of the Asia-Pacific will demonstrate this approach is feasible, insightful and scalable. It will generate baseline data for monitoring trends in the coverage of key WHO recommendations, women’s experiences, provider practices and maternal, newborn health outcomes – these can be periodically assessed over time. Bringing women’s experiences into measurement of quality of care on such a large platform is an important step forward to holistic, woman-centred quality of care measurement and improvement. GMP will demonstrate the importance of collecting and use of high-quality data from both provider and user perspectives for research, clinical and policy purposes. We hope that this network of health facilities and methodology will serve to help drive improvements in quality of facility-based intrapartum, early postnatal and care in LMICs across the region and eventually the globe. Declarations Ethics approval and consent to participate The study was approved by The Alfred Hospital Human Ethics Committee (HREC for Burnet Institute) on 27 July 2023 (approval number 96879, 340/23), and the World Health Organization Ethical Review Committee (ERC.0004050) on 5 February 2024. This study will obtain all required authorizations at country and institutional level, and the relevant consent to participate. Availability of data and materials No data were generated during the current status of the study. Data generated in the future will be subject to World Health Organization rules related to data sharing. Data ownership and use, and authorship of publications generated from the GMP Asia-Pacific project is governed by a GMP Data Use and Authorship Policy. Once the study is finalized and the results are published, a specific procedure for obtaining access to the database from WHO will be made publicly available. Study instruments in multiple languages are available on request from the authors. Funding This study was funded by the Australian National Health and Medical Research Council (NHMRC), the ARPAN Centre of Excellence, Burnet Institute, the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland, the United States Agency for International Development (USAID) and Department of Foreign Affairs Trade and Development, Canada. The views of the funding bodies have not influenced the content of this protocol. Acknowledgements The Global Platform for Maternal and Newborn Health Asia-Pacific Research Group Bangladesh (Projahnmo Research Foundation): Salahuddin Ahmed, Mohammod Shahidullah, Farhana Dewan Ahad Mahmud Khan, Nur-A-Safrina Rahman, Sabbir Ahmed. Fiji (Fiji National University): Litia Narube, Nina Pio. Indonesia (Gadjah Mada University): Detty Siti Nurdiati, Bayu Satria Wiratama, Likke Prawidya Putri. Mongolia (Mongolian Association of Family Planning Physicians): Buyanjargal Yadamsuren. Nepal (Paropakar Maternity and Women’s Hospital): Sandesh Poudel, Gauri Pradham Shrestha. Papua New Guinea (Port Moresby General Hospital): Delly Babona, Robert Jones, Glen Mola, Wiliam Pomat. Sri Lanka (University of Colombo): Kapila Jayaratne, Harendra Dasanayake, Chandana Jayasundare, Athula Kaluarachchi. Solomon Islands (National Referral Hospital): Leeanne Panisi, Freda Pitaka. Thailand (Prince Songkla University): Tippawan Liabsuetrakul, Nurlisa Oomudee. Timor-Leste : Ram Chahar (WHO Country Office Timor-Leste), Jermias Da Cruz (WHO Country Office Timor-Leste), Milena dos Santos Lay (National Hospital). Independent Technical Advisory Group: Adama Baguiya (Institut de Recherche en Sciences de la Santé (IRSS), Burkina Faso), Kitty Bloemenkamp (University Medical Center, Utrecht, Netherlands), Louise-Tina Day (London School of Hygiene & Tropical Medicine (LSHTM), United Kingdom), Tina Lavender (Liverpool School of Tropical Medicine Liverpool, United Kingdom), Pisake Lumbiganon (Khon Kaen University, Thailand), Zenaida Dy Recidoro ( Independent Consultant , Philippines), Khalid Yunis (American University of Beirut, Lebanon). Instruments development, Data Management and Analysis: Mabel Berrueta (Institute of Clinical Effectiveness and Health Policy – IECS), Emily Karahalios (University of Melbourne), Long Nguyen (Burnet Institute), Khurshed Nosirov (WHO Consultant), Soe Soe Thwin (WHO HQ), Veronica Pingray (IECS). Asia-Pacific Regional Coordinating Unit (Burnet Institute): Kara Blackburn, Fiona Bruinsma, Caroline Homer, Skanda Jayaratnam, Minh Pham, Joshua Vogel. WHO Coordinating Unit: Mercedes Bonet, Tina Lavin, Olufemi T Oladapo. References UNICEF. Despite recent progress millions of births still occur without any assistance from a skilled attendant each year. Available from https://data.unicef.org/topic/maternal-health/delivery-care/ Accessed September 12, 2024. World Health Organization UNICEF, World Bank Group, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organisation. UNFPA, Division. UNP. Trends in maternal mortality: 1990–2015. Estimates by WHO, 2015. Available from https://iris.who.int/handle/10665/193994 . Accessed December 12, 2024. Hug L, You D, Blencowe H, Mishra A, Wang Z, Fix MJ, et al. Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. Lancet. 2021;398(10302):772–85. Perin J, Mulick A, Yeung D, Villavicencio F, Lopez G, Strong KL, et al. Global, regional, and national causes of under-5 mortality in 2000-19: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet Child Adolesc Health. 2022;6(2):106–15. World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division., Available from https://www.who.int/publications/i/item/9789240068759 . Accessed December 21, 2204. World Health Organization. Seventy-Seventh World Health Assembley. 2024. Accelerate progress towards reducing maternal, newborn and child mortality in order to achieve Sustainable Development Goal targets 3.1 and 3.2. Tuncalp Ӧ, Were WM, MacLennan C, Oladapo OT, Gulmezoglu AM, Bahl R, et al. Quality of care for pregnant women and newborns-the WHO vision. BJOG. 2015;122(8):1045–9. Souza JP, Gulmezoglu AM, Vogel J, Carroli G, Lumbiganon P, Qureshi Z, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet. 2013;381(9879):1747–55. World Health Organization. WHO recommendations: Intrapartum care for a positive childbirth experience. Geneva: World Health Organisation. 2018. Available from https://www.who.int/publications/i/item/9789241550215 . Accessed December 12, 2024. World Health Organization. WHO recommendations on maternal and newborn care for a positive postnatal experience. Geneva: World Health Organisation. 2022. Available from https://www.who.int/publications/i/item/9789240045989 . Accessed December 12, 2024. Oladapo OT, Tuncalp O, Bonet M, Lawrie TA, Portela A, Downe S, et al. WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing. BJOG. 2018;125(8):918–22. Vallely LH, Shalit A, Nguyen R, Althabe F, Pingray V, Bonet M, et al. Intrapartum care measures and indicators for monitoring the implementation of WHO recommendations for a positive childbirth experience: a scoping review. BMJ Open. 2023;13(11):e069081. Galle A, Moran AC, Bonet M, Graham K, Muzigaba M, Portela A, et al. Measures to assess quality of postnatal care: A scoping review. PLOS Glob Public Health. 2023;3(2):e0001384. Rios-Zertuche D, Zuniga-Brenes P, Palmisano E, Hernandez B, Schaefer A, Johanns CK, et al. Methods to measure quality of care and quality indicators through health facility surveys in low- and middle-income countries. Int J Qual Health Care. 2019;31(3):183–90. Tahsina T, Hossain AT, Ruysen H, Rahman AE, Day LT, Peven K, et al. Immediate newborn care and breastfeeding: EN-BIRTH multi-country validation study. BMC Pregnancy Childbirth. 2021;21(Suppl 1):237. Tukur J, Lavin T, Adanikin A, Abdussalam M, Bankole K, Ekott MI, et al. Quality and outcomes of maternal and perinatal care for 76,563 pregnancies reported in a nationwide network of Nigerian referral-level hospitals. EClinicalMedicine. 2022;47:101411. Bohren MA, Mehrtash H, Fawole B, Maung TM, Balde MD, Maya E, et al. How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys. Lancet. 2019;394(10210):1750–63. Sacks E, Mehrtash H, Bohren M, Balde MD, Vogel JP, Adu-Bonsaffoh K, et al. The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational study. Lancet Glob Health. 2021;9(1):e72–80. Larson E, Sharma J, Bohren MA, Tuncalp O. When the patient is the expert: measuring patient experience and satisfaction with care. Bull World Health Organ. 2019;97(8):563–9. World Health Organisation. WHO Labour Care Guide: User's Manual. Geneva: World Health Organisation; 2020. Hofmeyr GJ, Bernitz S, Bonet M, Bucagu M, Dao B, Downe S, et al. WHO next-generation partograph: revolutionary steps towards individualised labour care. BJOG. 2021;128(10):1658–62. Bangladesh Directorate General of Health Services (DGHS). Guideline on Intrapartum Care and Postnatal Care. Fiji Ministry of Health and Medical Services. Clinical practice guidelines in obstetric care. 2023. Nepal Ministry of Health and Population. National Medical Standard for Maternal and Newborn Care. Volume 3. Maternal and Newborn Care; 2022. Souza JP, Gulmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med. 2010;8:71. Qureshi Z, Mehrtash H, Kouanda S, Griffin S, Filippi V, Govule P et al. Understanding abortion-related complications in health facilities: results from WHO multicountry survey on abortion (MCS-A) across 11 sub-Saharan African countries. BMJ Glob Health. 2021;6(1). Group WHOGMSSR. Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study. Lancet Glob Health. 2020;8(5):e661–71. UNFPA. The State of the World’s Midwifery. New York: United Nations Population Fund. 2021. Available https://www.unfpa.org/publications/sowmy-2021 . Accessed December 21, 2024. UNFPA. UNFPA The State of the Pacific’s Reproductive, Maternal, Newborn, Child and Adolescent Health Workforce. Suva, Fiji: UNFPA. 2019. Available from https://pacific.unfpa.org/en/publications/state-pacifics-rmncah-workforce-2019-report . Accessed December 18, 2024. De Silva M, Panisi L, Lindquist A, Cluver C, Middleton A, Koete B, et al. Severe maternal morbidity in the Asia Pacific: a systematic review and meta-analysis. Lancet Reg Health West Pac. 2021;14:100217. Shah A, Faundes A, Machoki M, Bataglia V, Amokrane F, Donner A, et al. Methodological considerations in implementing the WHO Global Survey for Monitoring Maternal and Perinatal Health. Bull World Health Organ. 2008;86(2):126–31. Souza JP, Gulmezoglu AM, Carroli G, Lumbiganon P, Qureshi Z, Group WR. The world health organization multicountry survey on maternal and newborn health: study protocol. BMC Health Serv Res. 2011;11:286. Takahashi K, Ganchimeg T, Ota E, Vogel JP, Souza JP, Laopaiboon M, et al. Prevalence of early initiation of breastfeeding and determinants of delayed initiation of breastfeeding: secondary analysis of the WHO Global Survey. Sci Rep. 2017;7:44868. The WHO application of ICD-10 to deaths during pregnancy, childbirth and puerperium: ICD MM, Available. https://iris.who.int/bitstream/handle/10665/70929/9789241548458_eng.pdf;sequence=1 . Accessed December 18, 2024. The WHO application of ICD-10 to deaths during the perinatal period. ICD-PM. Available from https://iris.who.int/bitstream/handle/10665/249515/9789241549752-eng.pdf;sequence=1 . Accessed December 18, 2024. Afulani PA, Diamond-Smith N, Golub G, Sudhinaraset M. Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population. Reprod Health. 2017;14(1):118. Bohren M. al e. Women’s experiences of and satisfaction with childbirth: development and validation of a measurement scale for low- and middle-income countries. not yet submitted. Bohren MA, Vogel JP, Fawole B, Maya ET, Maung TM, Baldé MD, et al. Methodological development of tools to measure how women are treated during facility-based childbirth in four countries: labor observation and community survey. BMC Med Res Methodol. 2018;18(1):132. Lessler JT, O'Reilly JM. Mode of interview and reporting of sensitive issues: design and implementation of audio computer-assisted self-interviewing. NIDA Res Monogr. 1997;167:366–82. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities. 2016. Available from https://www.who.int/publications/i/item/9789241511216 . Accessed December 10. 2024. World Health Organization. Quality, equity, dignity: the network to improve quality of care for maternal, newborn and child health – strategic objectives Geneva: World Health Organization. 2018. Available from https://www.who.int/publications/i/item/9789241513951 . Accessed December 18, 2024. World Health Organization. Quality of care for Maternal and Newborn- a monitoring framework for network countries. 2019. Available https://www.who.int/publications/m/item/quality-of-care-for-maternal-and-newborn--a-monitoring-framework-for-network-countries . Accessed December 8, 2024. World Health Organization. Service Availability and Readiness Assessment (SARA) | Reference Manual, Version 2.2. 2015. Available from https://www.who.int/publications/i/item/WHO-HIS-HSI-2014.5-Rev.1 . Accessed December 8, 2024. World Health Organization. Harmonized Health Facility Assessment (HHFA). Available from https://www.who.int/data/data-collection-tools/harmonized-health-facility-assessment/introduction . Accessed December 8, 2024. Demographic and Health Survey - The Service Provision Assessment (SPA) [Internet]. 2022. Available from: https://dhsprogram.com/methodology/Survey-Types/SPA.cfm?ua=1 Brizuela V, Leslie HH, Sharma J, Langer A, Tunçalp Ö. Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools. Lancet Glob Health. 2019;7(5):e624–32. Tables Table 1. List of countries considered for participation in the Global Maternal and Newborn Health Platform (GMP) Asia-Pacific South-East Asia region Western Pacific Region region Bangladesh India* Indonesia Nepal * Sri Lanka * Thailand *† Timor-Leste Cambodia* China* Mongolia * Philippines* Viet Nam*† Fiji Laos Papua New Guinea Samoa Solomon Islands *Participated in previous WHO multi-country surveys (WHO Global Survey (25),WHO Multi-country Survey (32) and/or WHO Global Maternal Sepsis Study (GLOSS) (27); † HRP Alliance hubs are located in these countries; Countries participating in GMP Asia-Pacific are shown in bold. Table 2. Primary outcomes for the Global Maternal and Newborn Health Platform Woman Newborn Coverage of key practices (Medical record) Labour monitored using partograph* Prophylactic uterotonic administered immediately after birth* Pre-discharge counselling provided to woman prior to discharge* Breastfeeding initiation <1 hour after birth* Woman-centred outcomes (Pre-discharge survey) Companion of choice during labour and birth * Any experience of mistreatment during time in the health facility for childbirth* Effective communication – consent obtained for vaginal examinations Satisfaction with care Skin to skin contact during the first hour after birth* Health outcomes (Medical record) Caesarean section (Robson and overall)* Episiotomy 3 rd /4 th perineal tear* Hysterectomy Stillbirth (antepartum and intrapartum Early neonatal mortality Preterm birth <37 weeks Low birthweight <2500g Apgar score less than 7 at 5 minutes *Providers and facilities will also be asked about policy and practice relating to these outcomes Table 3. Secondary outcomes – intrapartum period Type Specific outcome Source Coverage of key practices Amniotomy (overall, early amniotomy) Medical record Oxytocin for augmentation Medical record Operative vaginal birth Medical record Routine antibiotic prophylaxis before birth Medical record; provider survey Fundal pressure Provider survey Routine use of cardiotocography Provider survey People-centred outcomes Use of pain relief during labour/birth and after birth Medical record survey; Pre-discharge women’s survey; Provider survey Oral food/fluid intake Provider survey Birth position Provider survey Mobilising during labour Pre-discharge women’s survey; Provider survey Health outcomes Maternal death occurring during admission for childbirth, up to 7 days postpartum. Medical record Maternal ICU admission for >24 hours Medical record Postpartum haemorrhage (PPH) requiring use of additional uterotonic/TXA, uterine balloon tamponade or surgical intervention (excluding hysterectomy), blood transfusion. Medical record Intrapartum related perinatal mortality: intrapartum stillbirth + very early neonatal death (in first 24 hours after birth) Medical record NICU admission >24 hours Medical record Table 4. Secondary outcomes – postnatal period Type Specific outcome Source Coverage of key practice Intramuscular vit K injection of newborn administered Medical record Newborn bathing delayed until 24 hours after birth Provider survey Screening for neonatal hyperbilirubinemia (using TcB) Medical record Newborn immunization with Hep B vaccine Medical record People-centred outcomes Pharmacological pain relief offered to woman Pre-discharge survey; Provider survey Pre-discharge counselling provided to woman prior to discharge Medical record, pre-discharge survey Postnatal contraceptive information provided to women Pre-discharge women’s survey; provider survey Newborns treated with respect/mistreated Pre-discharge survey Women separated from newborn for non-medical reasons Pre-discharge survey Maternity care Midwifery continuity of care Facility survey Policies around clinical interventions (e.g. episiotomy, routine amniotomy) Facility survey Cleanliness and sanitation Facility survey Availability of power/water Facility survey Availability of essential supplies (including medicines) Facility survey Additional Declarations Competing interest reported. Authors declare that they have no competing interests except Tina Lavendar is on the Advisory Board for Dehaa Rossun Research Centre, Lunaler Group in China. Supplementary Files GMPSupplementarymaterialsubmitted20250115.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 Aug, 2025 Editor assigned by journal 05 Feb, 2025 Submission checks completed at journal 05 Feb, 2025 First submitted to journal 05 Feb, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5968904","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":411994202,"identity":"00d38708-e579-4353-965a-e489c800c455","order_by":0,"name":"Joshua Vogel","email":"data:image/png;base64,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","orcid":"","institution":"Burnet Institute","correspondingAuthor":true,"prefix":"","firstName":"Joshua","middleName":"","lastName":"Vogel","suffix":""}],"badges":[],"createdAt":"2025-02-05 23:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5968904/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5968904/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81004008,"identity":"1b797881-20e5-4f50-9ce6-1cb65b7a2fd6","added_by":"auto","created_at":"2025-04-21 06:42:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":215346,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of GMP Study design and activities\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5968904/v1/e3997d459062f375835d9ae2.png"},{"id":81004012,"identity":"1e8cbe2c-3b6c-4249-9bb4-4b77408e491e","added_by":"auto","created_at":"2025-04-21 06:42:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":136590,"visible":true,"origin":"","legend":"\u003cp\u003eOverview of sampling strategy\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5968904/v1/aedeb972f425734263a4ed5e.png"},{"id":81005338,"identity":"2c33b818-02be-4874-b7dd-2d0aef78c8b4","added_by":"auto","created_at":"2025-04-21 06:58:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1116161,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5968904/v1/c62e96f0-224e-40e3-b4b1-070743fb406f.pdf"},{"id":81002440,"identity":"3c78ca41-ecdf-4366-9c3e-0ac47e3e9d36","added_by":"auto","created_at":"2025-04-21 06:34:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":193609,"visible":true,"origin":"","legend":"","description":"","filename":"GMPSupplementarymaterialsubmitted20250115.docx","url":"https://assets-eu.researchsquare.com/files/rs-5968904/v1/27ad24fc72ecb695a2501f12.docx"}],"financialInterests":"Competing interest reported. Authors declare that they have no competing interests except Tina Lavendar is on the Advisory Board for Dehaa Rossun Research Centre, Lunaler Group in China.","formattedTitle":"The Global Maternal and Newborn Health Platform: study protocol for an observational, multi-country study on the quality of intrapartum and early postnatal care at health facilities","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eIn the past three decades, the proportion of women attending health facilities to give birth and having access to skilled care has grown worldwide, while maternal and newborn mortality rates have decreased.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Yet, latest estimates of maternal and newborn mortality suggest progress has stagnated - around 287,000 maternal deaths, 1.9\u0026nbsp;million stillbirths and 2.3\u0026nbsp;million newborn deaths occur each year.(\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) The vast majority of deaths are in low- and middle-income countries (LMICs), mainly in Africa and Asia, where many countries are not on track to meet the Sustainable Development Goals (SDGs) mortality targets. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) In response to these realities, the World Health Assembly (WHA) passed in 2024 a resolution to accelerate progress towards reducing maternal, newborn and child mortality, including stillbirths.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eHigh-quality care during labour, childbirth and the postnatal period is critical to ensuring maternal, fetal and newborn survival and well-being.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) The World Health Organization (WHO) quality of maternal and newborn care framework emphasises the need to optimise provision and experience of care, and ensure maternal and newborn health services have the appropriate resources to provide both (Supp. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In line with these global agendas, WHO\u0026rsquo;s recommendations on intrapartum and postnatal care (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) emphasise respectful, individualized, evidence-based, person-centred care to optimise health and wellbeing for the woman and her baby. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA long-standing challenge for maternal and newborn care quality in many LMICs is the lack of actionable, reliable data systems. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Without such systems, the magnitude and causes of maternal and newborn mortality and morbidity, the coverage of key clinical and non-clinical interventions, the availability of resources, and whether these measures are improving over time cannot be tracked. Recent scoping reviews indicated that the measures used for intrapartum and early postnatal care monitoring are poorly aligned with current WHO recommendations for maternal and newborn care.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) A forthcoming systematic review found that, with the exception of Latin America, there are few sustained maternal and perinatal data systems in high-burden countries, and fewer still that align with WHO-recommended care practices (V Diaz, personal communication). Some LMIC-based research studies have comprehensively measured the quality of intrapartum care provision (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) however such systems are not harmonized for global implementation.\u003c/p\u003e \u003cp\u003eA second, related challenge is that routine approaches to maternal and perinatal data collection systems have not caught up with the broader shift towards person-centred, respectful care, and the importance of women and parent\u0026rsquo;s experiences.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) The mistreatment of women and newborns around the time of birth is worryingly common.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) A more holistic approach is using person-centred data on women\u0026rsquo;s birth experiences to complement metrics on care provision and health outcomes. Together, these can produce a comprehensive evaluation of maternal and newborn care quality, and better direct quality improvement efforts. It is nonetheless complicated to implement at scale, requiring validated, reliable and culturally appropriate tools for measuring women\u0026rsquo;s care experiences.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA third challenge is that international maternal and newborn care recommendations evolve over time. WHO\u0026rsquo;s intrapartum and postnatal care guidelines have shifted significantly in the past several years in response to new evidence. For example, major changes to how labour should be monitored and managed, and stronger emphasis on the role of supportive care interventions during the intrapartum and postnatal period.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) While several countries have rapidly adopted latest WHO recommendations,(\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) it is not well known to what extent these have reached real-world clinical practice.\u003c/p\u003e\n\u003ch3\u003eRationale for the Global Maternal and Newborn Health Platform\u003c/h3\u003e\n\u003cp\u003eThere is currently no comprehensive approach to evaluate the quality of intrapartum and early postnatal care against the latest WHO recommendations. Such an approach is needed to comprehensively evaluate the quality of care in facilities, monitor facility performance over time and prioritize interventions to improve quality of care, while incorporating measurement of provider practices as well as women\u0026rsquo;s experiences.\u003c/p\u003e \u003cp\u003eOver the past 15 years, WHO has led several multi-country observational studies on maternal and perinatal health outcomes.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) These studies generated new, practice-changing evidence related to mode of birth, maternal near-miss, and prevention and management of complications of abortion and maternal infections. They also provide a platform by which large-scale observational studies and research strengthening activities can be conducted.\u003c/p\u003e \u003cp\u003eThe Global Maternal and Newborn Health Platform (GMP) builds on and extends these previous multi-country studies. The platform will conduct periodic analyses on intrapartum and early postnatal care quality, and associated maternal, fetal and early newborn health outcomes. It will help countries and health facilities assess their practices alongside WHO recommendations, and it will also provide opportunities to disseminate evidence-based guidance to facility and national level health stakeholders, accelerating improvements in quality of care.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eFocus on Asia-Pacific\u003c/h2\u003e \u003cp\u003eThe Asia-Pacific region with 36 LMICs (22 in Asia and 14 in the South Pacific) exemplifies these challenges \u0026minus;\u0026thinsp;10 women in this region die every hour due to pregnancy-related causes.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) There is also a disproportionately high burden of severe maternal morbidity in health facilities in Asia-Pacific LMICs.(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) Women and families accessing health services in many Asia-Pacific countries face numerous challenges including poor-quality antenatal, childbirth and postnatal care, significant shortages in the health workforce, and a lack of data on facility-based maternity care quality, coverage of essential interventions, and health outcomes.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) Furthermore, the Asia-Pacific region, especially the smaller countries, are rarely included in global research efforts to improve maternal and newborn health.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAim and objectives\u003c/h3\u003e\n\u003cp\u003eThe overall aim of GMP is to establish and sustain a multi-country network of health facilities providing childbirth services, to measure and support improvement in the quality of intrapartum, and early postnatal care.\u003c/p\u003e \u003cp\u003ePrimary objectives:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMeasure coverage of key intrapartum and early postnatal care practices in participating health facilities and whether key WHO intrapartum and early postnatal care recommendations are being implemented;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMeasure women\u0026rsquo;s experience of intrapartum, and early postnatal care at participating health facilities;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMeasure frequency of key maternal and newborn health outcomes related to the intrapartum and immediate postnatal period;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eSecondary objectives:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSupport dissemination and uptake of WHO guidelines and associated tools related to intrapartum and early postnatal care in health facilities;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eFacilitate data-driven approaches to improving quality of intrapartum, and early postnatal care in participating health facilities;\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eStrengthen maternal and newborn health research capacity in participating countries and health facilities.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGMP will use a prospective, facility-based, observational design. It collects data on intrapartum and postnatal care practices, the experiences of women giving birth, and their health outcomes (Figure 1). It employs a multi-stage sampling strategy similar to that used in previous WHO multi-country surveys of maternal and newborn health (8, 25, 31) (Figure 2). It is expected that this core GMP protocol will ultimately be implemented in over 1,000 health facilities in up to 63 LMICs, across six WHO regions (Supplementary Table 1). Selection of countries and health facilities, and data collection will follow a similar approach across all regions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSelection of countries:\u0026nbsp;\u003c/em\u003eWe pre-identified 17 countries in the South-East Asia (SEA) and Western Pacific (WP) WHO regions, hereafter referred to as the \u0026lsquo;Asia-Pacific\u0026rsquo;, (Table 1) that could potentially participate in the first round of the GMP. The initial list was informed by countries participating in previous WHO multi-country surveys, and consultations withWHO headquarters, WHO regional and country offices, and national Ministries of Health. This process aimed to ensure diversity in terms of burden of maternal and perinatal health outcomes, perceived quality of maternal and newborn health services, alignment with regional priorities and initiatives, leveraging existing research networks and previous research capacity investments, willingness of the country to participate, and financial costs and feasibility. It will also allow assessment of some maternal and perinatal indicators over time, through comparison with data from previous surveys. In the firstphase of GMP in the Asia-Pacific, 10 countries will participate: Bangladesh, Indonesia, Nepal, Sri Lanka, Thailand, and Timor-Leste in the SEA region; Fiji, Mongolia, Papua New Guinea, Solomon Islands in the WP region. Four rounds of data collection at 3-year intervals (2024, 2027, 2030, 2033) are planned to enable monitoring trends of quality of care at participating health facilities over time. It is expected the same countries will participate in subsequent rounds in the Asia-Pacific.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSelection of provinces/states\u003c/em\u003e: From each participating country, three provinces/states are selected: the province/state where the country\u0026rsquo;s capital city is located, and two randomly sampled provinces/states (with probability proportional to the population size). In situations where one of the selected provinces/states has too few facilities (i.e. only one or two eligible facilities) a fourth province/state is selected (as described below). \u0026nbsp;To be eligible,\u0026nbsp;provinces/states needed to have an institutional birth coverage of at least 30%, and at least one eligible facility (Figure 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSelection of facilities:\u003c/em\u003e Within each sampled province/state, up to 7 eligible facilities are randomly sampled, with a probability proportional to births per year. Eligible facilities are those with a minimum of 2,000 births per year, the capacity to perform Caesarean section and can be of any type (public, private or other). If less than 7 eligible facilities are in the province/state, all facilities are selected. Where there are only 1 or 2 eligible facilities in a province/state, an additional (fourth) province/state is selected. Facility networks in countries that participated in previous WHO surveys (8, 25, 32) will be re-activated wherever possible. (32) However, some of these facilities may no longer meet the eligibility criteria, or may decline participation. In such situations new facilities from the same province/state are sampled using the aforementioned sampling strategy (Figure 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection period\u003c/em\u003e: All participating health facilities will collect data for a minimum of 3 months. If a sample size of 1,000 births per facility cannot be reached by 3 months, data collection will continue to a maximum of 6 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy populations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGMP will collect data at three levels: individual woman/baby level, provider level and facility level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIndividual woman/baby level:\u0026nbsp;\u003c/em\u003eData is collected during the women\u0026rsquo;s admission for birth untildischarge, death, transfer or it is 7 days after birth, whichever comes first.\u0026nbsp;All women giving birth at 22 weeks\u0026rsquo; gestation (or if gestation is unknown, 500 grams birthweight) in the participating health facilities during the study period will comprise the study population, regardless of their maternal and perinatal outcomes. Women who give birth outside the study health facility, or pregnant women who are admitted but do not give birth, are excluded. If any maternal or newborn deaths or stillbirths are identified, further information on cause of death is collected. A random sample of women will be invited to complete a pre-discharge interview (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProvider level:\u0026nbsp;\u003c/em\u003eThe study population are any skilled health workers employed at the participating health facility and who provide intrapartum or postnatal care during the study period. These may be doctors, nurses or midwives at any level of seniority. Students, such as midwifery, nursing or medical students, are not included (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFacility level:\u0026nbsp;\u003c/em\u003eOne facility survey will be completed per facility (Figure 1). Information will be obtained through interviewing the Head of Department of Obstetrics and Gynaecology, and the Head of the Department of Neonatology/Paediatrics and/or the Head of Nursing and Midwifery (or their representatives), as well as facility managers or relevant department staff (e.g. pharmacy).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary and secondary outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGMP has 17 primary (Table 2) and 29 secondary outcomes (Tables 3 and 4) spanning the intrapartum and early postnatal periods. These outcomes include coverage of key practices, people-centred care (experience) outcomes and health outcomes, for women and newborns. Operational definitions for all outcomes are presented in Supplementary Table \u0026nbsp; 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSample sizes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGMP will collect individual-level data on multiple outcomes, for which the prevalence may vary. For example, in the WHOMCS early breastfeeding rates ranged from 17.7% to 98.4%.(33) Some adverse health outcomes (e.g. stillbirth) may be less frequent in low-burden facilities or countries. We explored different sample size scenarios for a range of GMP outcomes and levels of precision. For example, for a relatively rare outcome (e.g. 0.7% stillbirth rate) at +/-0.5% precision, 1068 women are required. For a more frequent outcome (e.g. 12% Caesarean rate) and +/-2.0% precision, 1,015 women are required. We also noted that in the WHOMCS, the average number of women per facility was 876. Through consultations with the study country investigators and advisory group and investigators, we opted for a pragmatic target of at least 1,000 women per facility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the pre-discharge women\u0026rsquo;s survey, we estimate that ~80% of women giving birth will be eligible. For a given outcome on women\u0026rsquo;s birth experiences (hypothetical prevalence ranging from 5% to 95%) and +/- 5% precision, 385 women are needed. We therefore will sample a minimum of 385 women per facility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the provider survey, acknowledging that survey response rates may be less than 50%, we aim to maximise participation and representativeness. Hence, all staff providing intrapartum, and postnatal care at GMP facilities are eligible, and will be approached invited to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection instruments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sought a measurement approach that would be relatively low-cost and feasible to implement in limited-resource settings. First, we mapped all WHO intrapartum and early postnatal care recommendations and best practices, identifying where and how each of these could be measured (e.g. woman/baby, provider or health facility level). For example, the broad concept of pain relief during labour and birth could be identified from a medical record, by asking a woman whether she was offered pain relief, asking a provider if they routinely offer pain relief, or assessing whether a facility has pain relief options available.\u003c/p\u003e\n\u003cp\u003eWe considered this mapping and prioritised what to measure based on 1) clinical importance, 2) prevalence or coverage of the recommendation, 3) relative importance of that recommendation to quality of maternal and newborn care more broadly, 4) measurability, 5) balance of benefit and harm within evidence supporting the recommendation. We also ensured GMP\u0026rsquo;s primary and secondary outcomes were captured, which also evolved alongside this process. This was an iterative process, including literature reviews and expert consultations. We also reviewed existing instruments which had been used in previous multi-country studies to measure aspects quality of maternal and newborn care, identified from our scoping reviews.(12, 13) This resulted in the scope, content and first iterations of five GMP instruments. There are three instruments at the individual woman/baby level: 1) a medical record review form (for all women giving birth and their newborns), 2) a cause-of-death form (for any maternal, fetal or early neonatal death), and 3) a pre-discharge women\u0026rsquo;s experience survey (for randomly sampled postnatal women). GMP also measures at: \u0026nbsp;4) the provider level (provider survey) and 5) facility level (facility survey). All instruments were drafted, reviewed by GMP country investigators and advisory group members, field-tested in GMP sites, translated (where required) and refined prior to study implementation. We developed study manuals for each instrument - all investigators, facility co-ordinators and data collectors will undergo standardised training prior to data collection. Details for each instrument are provided below.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1) Medical Record Review Form:\u0026nbsp;\u003c/em\u003eItems included in the medical record review form were developed based on the iterative process outlined above. GMP study data are abstracted from medical records into a digital study form, around the time of discharge. Data are non-identifiable and include maternal characteristics, maternal risk factors, coverage of essential intrapartum and early postnatal interventions, mode of birth, and maternal, perinatal and newborn health outcomes. Facility medical staff can be approached if there are doubts or clarifications are required.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2) \u003cem\u003eCause of death form:\u0026nbsp;\u003c/em\u003eIf any maternal death, stillbirth or early neonatal death is identified, data on cause of death will be collected using a dedicated form using the WHO ICD-MM (34) and ICD-PM (35) classifications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e3) Pre-discharge women\u0026rsquo;s experience survey:\u0026nbsp;\u003c/em\u003eThe aim of this instrument is to understand the women\u0026rsquo;s perspective on the characteristics of good-quality care. Our ideal instrument would have good validity (particularly face and content validity), reproducibility and reliability, and would be feasible to use in limited-resource settings. From the literature reviews we identified four tools (36-38) with the greatest alignment to GMP\u0026rsquo;s objectives and needs. We extracted specific items from these tools and mapped them to our prioritised list. We developed a first iteration (version 1) using items adopted or modified from these tools, created new items where required, and organised this into a logical workflow. This was revised following consultations with WHO staff and three independent experts working in measuring women\u0026rsquo;s experiences after birth (version 2) and finalized by the research group (version 2.1) based on face and content validity, feasibility and understandability. We pilot-tested version 2.1 on paper with four to six postnatal women (vaginal and caesarean birth) per each GMP country. This was done by the principal investigator in each country using a cognitive interview guide, resulting in further revisions (version 2.2). We then created a digital audio computer-assisted self-interviewing (ACASI) survey (Viewpoint, UK) for use on a tablet.(39) The participant listens to a recorded voice (in a language of their choosing) and responds to questions via a touchscreen. Pictures are used for responses, as well as visual cues. This means women can participate regardless of literacy or language; headphones help ensure privacy. We pilot-tested tablet-based ACASI in one GMP site with four women, which indicated it was acceptable and feasible. For the Asia-Pacific region we translated the survey into 14 languages; each version was reviewed by investigators and bilingual speakers, back-translated and refined.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4) Provider survey:\u0026nbsp;\u003c/em\u003eThe aim of this instrument is to provide a standardized tool for assessing self-reported intrapartum and early postnatal care practices of healthcare workers and the factors influencing the implementation of these practices. A total of 12 validated, reliable and relevant questionnaires were identified from a rapid review of the literature, and 164 items were extracted and evaluated, mapped against WHO recommendations and prioritized by key concepts and domains based on a pre-defined conceptual model. A first version of the survey (version 1) was revised through cognitive interviews, conducted by an experienced social scientist in October to November 2023, with nine skilled health providers from two countries (Thailand and Papua New Guinea) to assess the survey\u0026apos;s clarity, comprehensibility, and response capacity. Four healthcare providers from a GMP facility in Fiji completed the revised survey (version 2) and participated in group interviews to further assess the instrument\u0026apos;s clarity, relevance, length and scale structure.\u0026nbsp;The survey was finalized by the research group, pilot-tested in anelectronic format, translated into eight languages for the Asia-Pacific, reviewed by investigators and bilingual speakers, and refined through back-translation (version 2.1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e5) Health facility survey:\u0026nbsp;\u003c/em\u003eThe facility survey captures data on the environment and context where intrapartum and early postnatal care is provided. It includes facility, volume and activity; organization and services (e.g. infrastructure, supplies, equipment, and human resources); and clinical policies and protocols for intrapartum and postnatal care.Following the recommendation mapping process described above, we reviewed WHO normative documents related to measuring intrapartum and early postnatal care at a facility level. This included WHO\u0026rsquo;s standards and monitoring framework for maternal and newborn care quality (40-42), WHO\u0026rsquo;s service availability and readiness assessment (SARA) tool (43), Harmonized Health Facility Assessment (HHFA)(44); Service Provision Assessments (SPA)(45); health facility surveys used in prior WHO multi-country studies (16, 25-27, 32) and a review of large-scale facility assessment tools to measure quality of maternal and newborn care as per the WHO framework.(43, 46) We extracted and consolidated specific, validated questions from these to form the first iteration of the facility survey (version 1). This was revised following consultations with GMP advisory members and measurement experts (version 2), field-testing in one GMP site, revised (version 3) and finalized in consultation with country teams (version 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch staff are trained according to a standardized manual of operations, which minimizes the need for judgement and interpretation. Training workshops at country and facility levels are held prior to commencement of data collection. All collected data are stored on an access-restricted database. Participant confidentiality and anonymity will be maintained at all times by the sponsor, regional and country coordinators, and research staff in participating facilities. Processes for specific levels of data collection are described below.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIndividual level data\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTrained data collectors are deployed to participating facilities to collect GMP study data using tablet devices. Each day, data collectors review medical records or registers in labour and postnatal wards, as well as other clinical areas where birthing women may be present (such as emergency rooms or operating theatres), to extract individual level data. \u0026nbsp;The total number of women admitted and giving birth at the facility each day is monitored using a customised log. Individual electronic study records are compared to logs to ensure eligible women are not missed.\u003c/p\u003e\n\u003cp\u003eThe data system randomly selects women who have given birth to be invited to complete a pre-discharge survey.\u0026nbsp;The sampling probability is based on the total number of expected births in that health facility and aims to ensure approximately 385 women are surveyed during a facility\u0026rsquo;s study period. Eligible women are those able to give informed consent and complete it (i.e. are not experiencing a serious adverse outcome). The data collector explains the survey to the woman using a participant information sheet in the woman\u0026rsquo;s language of preference. Informed consent is provided by agreeing to the consent statement on the tablet device. Survey completion occurs in a private environment within the health facility, on the tablet using headphones (if preferred).\u003c/p\u003e\n\u003ch4\u003eProvider level data\u003c/h4\u003e\n\u003cp\u003eThe facility co-ordinator identifies all relevant skilled health workers (obstetrics, nursing, midwifery, neonatology, paediatrics) currently working at the facility in intrapartum and early postnatal care services. Providers are sent a unique link to complete the voluntary survey via email or mobile (WhatsApp or Line), or they can complete it using a study tablet. This survey obtains consent to participate, and captures data on their characteristics, as well as knowledge, attitudes and practices on intrapartum and early postnatal care.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eFacility level data\u003c/h4\u003e\n\u003cp\u003eAdigital form is used to collect health facility level information. This is completed by the facility co-ordinator collecting the required information from the Head\u0026nbsp;of Obstetrics \u0026amp; Neonatology/Paediatrics Departments (or their authorised representative) in the health facility. Some questions require input from different staff or departments (heads of unit, laboratory, infection prevention and control unit, administrative services).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData management\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data are collected electronically using tablets into Good Clinical Practice (GCP) compliant databases. Unique, pre-defined numbers are used for each participant. Where needed, study forms and manuals will be translated into relevant local languages. Data collection and entry procedures, storage, protection, ownership, sharing and retention will be compliant with the WHO standard operating procedures and GCP guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe REDCap database system (\u003ca href=\"https://project-redcap.org/\"\u003ehttps://project-redcap.org/\u003c/a\u003e) is used to capture data for both the medical record review and the provider survey. REDCap uses data accuracy checks to minimize entry errors, facilitate monitoring and enable quick resolution of queries and missing data. For the medical record review form, a 10% random sample for the first 250 participants will undergo double data collection, with data compared for inconsistencies, and thereafter a 5% random sample of participants. Completed forms will be checked by facility, country and regional coordinators to ensure completeness, reliability and consistency of collected data.\u003c/p\u003e\n\u003cp\u003eData curation and validity cross-checks will be performed within the centralised database. In-person monitoring visits by regional and country investigators will be organised during and after the data collection period, to evaluate protocol adherence and perform data quality verification. Additional visits will be carried out depending upon facility or country activity and performance. Upon completion of the study and verification of data for accuracy and completeness, the database will be locked from any additional changes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePre-discharge surveys will be prepared using ACASI in recordings of local languages. Data collected using the ACASI will be stored electronically in a central location associated with the woman\u0026rsquo;s unique identifying number and will not be available to the study site.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy governance\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe WHO\u0026rsquo;s Department of Sexual and Reproductive Health and Research is the global sponsor and is responsible for coordinating GMP in multiple WHO regions. In each region, there will be a Regional Coordinating institution. For Asia-Pacific countries this is the Burnet Institute, Australia. GMP is governed by a Steering Committee which includes the global sponsor (WHO-Geneva), regional coordinating institutions (e.g. Burnet Institute for the Asia-Pacific), independent advisors, and Country Principal Investigators. The Regional Co-ordinating Committee for the Asia-Pacific is responsible for overseeing implementation in this region, and comprises WHO-Geneva, Burnet Institute and Principal Investigators from the 10 participating Asia-Pacific countries. Each facility has a designated Facility Co-ordinator who will oversee all facility-level activities, and report to the Country Investigator. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by The Alfred Hospital Human Ethics Committee (HREC for Burnet Institute) on 27 July 2023 (approval number 96879, 340/23), and the World Health Organization Ethical Review Committee (ERC.0004050) on 5 February 2024. This study will obtain all required authorizations at country and institutional level, and the relevant consent to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlanned analyses\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA statistical analysis plan (SAP) will be developed in collaboration with country researchers, study statistician and WHO statisticians, and finalised prior to completion of recruitment. Primary objectives 1-3 will use descriptive statistics at the individual, facility, or country level. \u0026nbsp;Individual, facility and country level characteristics will be summarised using n (%) or mean (Standard deviation, SD) as appropriate. \u0026nbsp;To summarise individual level data for a facility or country (i.e., to pool data at the facility or country level), we will need to account for the sampling design and clustering by using appropriate survey weights. We will also explore possible associations between the use of interventions and women and newborn outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e This ambitious, multi-country initiative aims to systematically assess the quality of intrapartum, and early postnatal care in health facilities across six WHO regions. A key novelty is GMP\u0026rsquo;s \u0026ldquo;person-centred\u0026rdquo; approach, collecting data on women\u0026rsquo;s experiences of care during birth and early postnatal admission. In the first wave of GMP in 74 health facilities in 10 Asia-Pacific countries, we anticipate collecting data from more than 100,000 women and their babies, as well as nearly 30,000 pre-discharge surveys on women\u0026rsquo;s experiences. This will be complemented by survey data from an estimated 2,000 providers or more working in these facilities. Collectively, the GMP model produces a world-first, comprehensive picture of intrapartum, and early postnatal care quality, inclusive of women\u0026rsquo;s and provider\u0026rsquo;s perspectives. This enables pooled analyses of multi-country data, as well as country- and facility-specific analyses to improve the quality of care.\u003c/p\u003e \u003cp\u003eThe GMP network will create new opportunities for nested sub-studies, or additional research projects (alongside or between rounds of data collection). In the Asia-Pacific, GMP is catalysed by Burnet\u0026rsquo;s Centre for Research Excellence on Maternal and Perinatal Health in the Asia-Pacific (CRE-ARPAN), the HRP Alliance (WHO-Switzerland) and its hubs located in Thailand and Viet Nam. The GMP Research Group is actively seeking further funding to address further maternal and newborn health priorities and continue strengthening research capacity.\u003c/p\u003e \u003cp\u003eGMP\u0026rsquo;s intended impact is to improve the quality of intrapartum, and early postnatal care in health facilities. It will allow a standardised investigation of links between clinical environments and practices, women\u0026rsquo;s experiences, and maternal and perinatal outcomes. This enables a data-driven approach to setting priorities and taking action to improve maternal and newborn health. Results will be used for dialogue with healthcare providers, facility leadership, and state/national policymakers, and to target quality improvement initiatives. It will provide key data to guide policy and practice at a facility, provincial, country and regional level in the coming years. More broadly, GMP provides a validated, feasible approach to assess whether quality of intrapartum, and early postnatal care is consistent with current WHO evidence-based recommendations. GMP\u0026rsquo;s tools and methods will be made freely available for future use. GMP will help create and reinforce multidisciplinary networks between obstetricians, neonatologists, nurses, researchers, administrators, governments in participating facilities, countries and regions. Our ambition is that GMP data collection will be undertaken periodically (i.e. every 3 years).\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eA major strength of GMP is that it provides a real-world picture of intrapartum and early postnatal care quality in participating facilities. In addition, it expands and strengthens research networks from previous WHO-led multi-country surveys on maternal and newborn health.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) Expertise across partners spans research, maternal and neonatal clinical care, epidemiology and health policy. The large sample size, geographic and health system diversity enhances the applicability of results in the Asia-Pacific region and in future regions as they come on-board.\u003c/p\u003e \u003cp\u003eThis study has some important limitations. In the facility selection criteria, including only those with at least 2,000 births per year means that this sample will be composed of mostly medium-to-large facilities, and many of which are tertiary referral hospitals. For relatively small countries (such as Solomon Islands, Fiji or Timor-Leste) this means only one or two health facilities are eligible. However, the inclusion of smaller countries, for the first time, in a WHO-led multi-country survey brings valuable diversity and generalisability. We anticipate that GMP\u0026rsquo;s tools and outputs will nonetheless be useful to lower-level or smaller facilities, though further investigation may be warranted. As GMP was not designed to cover home births the data cannot be generalised to births outside of health facilities.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe data generated from GMP will provide a comprehensive picture of the quality of intrapartum, and early postnatal care at a range of health facilities in low- and middle-income countries. The first wave of 74 facilities in 10 countries of the Asia-Pacific will demonstrate this approach is feasible, insightful and scalable. It will generate baseline data for monitoring trends in the coverage of key WHO recommendations, women\u0026rsquo;s experiences, provider practices and maternal, newborn health outcomes \u0026ndash; these can be periodically assessed over time. Bringing women\u0026rsquo;s experiences into measurement of quality of care on such a large platform is an important step forward to holistic, woman-centred quality of care measurement and improvement. GMP will demonstrate the importance of collecting and use of high-quality data from both provider and user perspectives for research, clinical and policy purposes. We hope that this network of health facilities and methodology will serve to help drive improvements in quality of facility-based intrapartum, early postnatal and care in LMICs across the region and eventually the globe.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by The Alfred Hospital Human Ethics Committee (HREC for Burnet Institute) on 27 July 2023 (approval number 96879, 340/23), and the World Health Organization Ethical Review Committee (ERC.0004050) on 5 February 2024. This study will obtain all required authorizations at country and institutional level, and the relevant consent to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo data were generated during the current status of the study. Data generated in the future will be subject to World Health Organization rules related to data sharing. Data ownership and use, and authorship of publications generated from the GMP Asia-Pacific project is governed by a GMP Data Use and Authorship Policy. Once the study is finalized and the results are published, a specific procedure for obtaining access to the database from WHO will be made publicly available. Study instruments in multiple languages are available on request from the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Australian National Health and Medical Research Council (NHMRC), the ARPAN Centre of Excellence, Burnet Institute, the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland, the United States Agency for International Development (USAID) and Department of Foreign Affairs Trade and Development, Canada. The views of the funding bodies have not influenced the content of this protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Global Platform for Maternal and Newborn Health Asia-Pacific Research Group\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBangladesh\u0026nbsp;(Projahnmo Research Foundation):\u0026nbsp;Salahuddin Ahmed, Mohammod Shahidullah, Farhana Dewan\u0026nbsp;Ahad Mahmud Khan, Nur-A-Safrina Rahman, Sabbir Ahmed.\u0026nbsp;Fiji (Fiji National University): Litia Narube, Nina Pio. Indonesia (Gadjah Mada University): Detty Siti Nurdiati, Bayu Satria Wiratama, Likke Prawidya Putri. Mongolia (Mongolian Association of Family Planning Physicians): Buyanjargal Yadamsuren. Nepal (Paropakar Maternity and Women’s Hospital): Sandesh Poudel, Gauri Pradham Shrestha. Papua New Guinea (Port Moresby General Hospital): Delly Babona, Robert Jones, Glen Mola, Wiliam Pomat. Sri Lanka (University of Colombo): Kapila Jayaratne, Harendra Dasanayake, Chandana Jayasundare, \u0026nbsp;Athula Kaluarachchi. Solomon Islands (National Referral Hospital): Leeanne Panisi, Freda Pitaka. Thailand (Prince Songkla University): Tippawan Liabsuetrakul, Nurlisa Oomudee. Timor-Leste : Ram Chahar (WHO Country Office Timor-Leste), Jermias Da Cruz (WHO Country Office Timor-Leste), Milena dos Santos Lay (National Hospital).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIndependent Technical Advisory Group: Adama Baguiya (Institut de Recherche en Sciences de la Santé (IRSS), Burkina Faso), Kitty Bloemenkamp (University Medical Center, Utrecht, Netherlands),\u0026nbsp;Louise-Tina Day (London School of Hygiene \u0026amp; Tropical Medicine (LSHTM), United Kingdom),\u0026nbsp;Tina Lavender (Liverpool School of Tropical Medicine Liverpool, United Kingdom), Pisake Lumbiganon (Khon Kaen University, Thailand), Zenaida Dy Recidoro ( Independent Consultant , Philippines),\u0026nbsp;Khalid Yunis (American University of Beirut, Lebanon).\u003c/p\u003e\n\u003cp\u003eInstruments development, Data Management and Analysis: Mabel Berrueta (Institute of Clinical Effectiveness and Health Policy – IECS), Emily Karahalios (University of Melbourne), Long Nguyen (Burnet Institute), Khurshed Nosirov (WHO Consultant), Soe Soe Thwin (WHO HQ), Veronica Pingray (IECS). Asia-Pacific Regional Coordinating Unit (Burnet Institute): Kara Blackburn, Fiona Bruinsma, Caroline Homer, Skanda Jayaratnam, Minh Pham, Joshua Vogel. WHO Coordinating Unit: Mercedes Bonet, Tina Lavin, Olufemi T Oladapo.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF. Despite recent progress millions of births still occur without any assistance from a skilled attendant each year. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.unicef.org/topic/maternal-health/delivery-care/\u003c/span\u003e\u003cspan address=\"https://data.unicef.org/topic/maternal-health/delivery-care/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed September 12, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization UNICEF, World Bank Group, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organisation. UNFPA, Division. UNP. Trends in maternal mortality: 1990\u0026ndash;2015. Estimates by WHO, 2015. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/handle/10665/193994\u003c/span\u003e\u003cspan address=\"https://iris.who.int/handle/10665/193994\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 12, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHug L, You D, Blencowe H, Mishra A, Wang Z, Fix MJ, et al. Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. Lancet. 2021;398(10302):772\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerin J, Mulick A, Yeung D, Villavicencio F, Lopez G, Strong KL, et al. Global, regional, and national causes of under-5 mortality in 2000-19: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet Child Adolesc Health. 2022;6(2):106\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division., Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240068759\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240068759\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 21, 2204.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Seventy-Seventh World Health Assembley. 2024. Accelerate progress towards reducing maternal, newborn and child mortality in order to achieve Sustainable Development Goal targets 3.1 and 3.2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuncalp Ӧ, Were WM, MacLennan C, Oladapo OT, Gulmezoglu AM, Bahl R, et al. Quality of care for pregnant women and newborns-the WHO vision. BJOG. 2015;122(8):1045\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouza JP, Gulmezoglu AM, Vogel J, Carroli G, Lumbiganon P, Qureshi Z, et al. Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study. Lancet. 2013;381(9879):1747\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO recommendations: Intrapartum care for a positive childbirth experience. Geneva: World Health Organisation. 2018. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789241550215\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789241550215\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 12, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO recommendations on maternal and newborn care for a positive postnatal experience. Geneva: World Health Organisation. 2022. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240045989\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240045989\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 12, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOladapo OT, Tuncalp O, Bonet M, Lawrie TA, Portela A, Downe S, et al. WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing. BJOG. 2018;125(8):918\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVallely LH, Shalit A, Nguyen R, Althabe F, Pingray V, Bonet M, et al. Intrapartum care measures and indicators for monitoring the implementation of WHO recommendations for a positive childbirth experience: a scoping review. BMJ Open. 2023;13(11):e069081.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalle A, Moran AC, Bonet M, Graham K, Muzigaba M, Portela A, et al. Measures to assess quality of postnatal care: A scoping review. PLOS Glob Public Health. 2023;3(2):e0001384.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRios-Zertuche D, Zuniga-Brenes P, Palmisano E, Hernandez B, Schaefer A, Johanns CK, et al. Methods to measure quality of care and quality indicators through health facility surveys in low- and middle-income countries. Int J Qual Health Care. 2019;31(3):183\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTahsina T, Hossain AT, Ruysen H, Rahman AE, Day LT, Peven K, et al. Immediate newborn care and breastfeeding: EN-BIRTH multi-country validation study. BMC Pregnancy Childbirth. 2021;21(Suppl 1):237.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTukur J, Lavin T, Adanikin A, Abdussalam M, Bankole K, Ekott MI, et al. Quality and outcomes of maternal and perinatal care for 76,563 pregnancies reported in a nationwide network of Nigerian referral-level hospitals. EClinicalMedicine. 2022;47:101411.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBohren MA, Mehrtash H, Fawole B, Maung TM, Balde MD, Maya E, et al. How women are treated during facility-based childbirth in four countries: a cross-sectional study with labour observations and community-based surveys. Lancet. 2019;394(10210):1750\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSacks E, Mehrtash H, Bohren M, Balde MD, Vogel JP, Adu-Bonsaffoh K, et al. The first 2 h after birth: prevalence and factors associated with neonatal care practices from a multicountry, facility-based, observational study. Lancet Glob Health. 2021;9(1):e72\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarson E, Sharma J, Bohren MA, Tuncalp O. When the patient is the expert: measuring patient experience and satisfaction with care. Bull World Health Organ. 2019;97(8):563\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organisation. WHO Labour Care Guide: User's Manual. Geneva: World Health Organisation; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHofmeyr GJ, Bernitz S, Bonet M, Bucagu M, Dao B, Downe S, et al. WHO next-generation partograph: revolutionary steps towards individualised labour care. BJOG. 2021;128(10):1658\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBangladesh Directorate General of Health Services (DGHS). Guideline on Intrapartum Care and Postnatal Care.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFiji Ministry of Health and Medical Services. Clinical practice guidelines in obstetric care. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNepal Ministry of Health and Population. National Medical Standard for Maternal and Newborn Care. Volume 3. Maternal and Newborn Care; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouza JP, Gulmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004\u0026ndash;2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med. 2010;8:71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQureshi Z, Mehrtash H, Kouanda S, Griffin S, Filippi V, Govule P et al. Understanding abortion-related complications in health facilities: results from WHO multicountry survey on abortion (MCS-A) across 11 sub-Saharan African countries. BMJ Glob Health. 2021;6(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGroup WHOGMSSR. Frequency and management of maternal infection in health facilities in 52 countries (GLOSS): a 1-week inception cohort study. Lancet Glob Health. 2020;8(5):e661\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNFPA. The State of the World\u0026rsquo;s Midwifery. New York: United Nations Population Fund. 2021. Available \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unfpa.org/publications/sowmy-2021\u003c/span\u003e\u003cspan address=\"https://www.unfpa.org/publications/sowmy-2021\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 21, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNFPA. UNFPA The State of the Pacific\u0026rsquo;s Reproductive, Maternal, Newborn, Child and Adolescent Health Workforce. Suva, Fiji: UNFPA. 2019. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pacific.unfpa.org/en/publications/state-pacifics-rmncah-workforce-2019-report\u003c/span\u003e\u003cspan address=\"https://pacific.unfpa.org/en/publications/state-pacifics-rmncah-workforce-2019-report\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 18, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Silva M, Panisi L, Lindquist A, Cluver C, Middleton A, Koete B, et al. Severe maternal morbidity in the Asia Pacific: a systematic review and meta-analysis. Lancet Reg Health West Pac. 2021;14:100217.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShah A, Faundes A, Machoki M, Bataglia V, Amokrane F, Donner A, et al. Methodological considerations in implementing the WHO Global Survey for Monitoring Maternal and Perinatal Health. Bull World Health Organ. 2008;86(2):126\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSouza JP, Gulmezoglu AM, Carroli G, Lumbiganon P, Qureshi Z, Group WR. The world health organization multicountry survey on maternal and newborn health: study protocol. BMC Health Serv Res. 2011;11:286.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakahashi K, Ganchimeg T, Ota E, Vogel JP, Souza JP, Laopaiboon M, et al. Prevalence of early initiation of breastfeeding and determinants of delayed initiation of breastfeeding: secondary analysis of the WHO Global Survey. Sci Rep. 2017;7:44868.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe WHO application of ICD-10 to deaths during pregnancy, childbirth and puerperium: ICD MM, Available. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/70929/9789241548458_eng.pdf;sequence=1\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/70929/9789241548458_eng.pdf;sequence=1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 18, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe WHO application of ICD-10 to deaths during the perinatal period. ICD-PM. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/249515/9789241549752-eng.pdf;sequence=1\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/249515/9789241549752-eng.pdf;sequence=1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 18, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAfulani PA, Diamond-Smith N, Golub G, Sudhinaraset M. Development of a tool to measure person-centered maternity care in developing settings: validation in a rural and urban Kenyan population. Reprod Health. 2017;14(1):118.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBohren M. al e. Women\u0026rsquo;s experiences of and satisfaction with childbirth: development and validation of a measurement scale for low- and middle-income countries. not yet submitted.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBohren MA, Vogel JP, Fawole B, Maya ET, Maung TM, Bald\u0026eacute; MD, et al. Methodological development of tools to measure how women are treated during facility-based childbirth in four countries: labor observation and community survey. BMC Med Res Methodol. 2018;18(1):132.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLessler JT, O'Reilly JM. Mode of interview and reporting of sensitive issues: design and implementation of audio computer-assisted self-interviewing. NIDA Res Monogr. 1997;167:366\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Standards for improving quality of maternal and newborn care in health facilities. 2016. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789241511216\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789241511216\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 10. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Quality, equity, dignity: the network to improve quality of care for maternal, newborn and child health \u0026ndash; strategic objectives Geneva: World Health Organization. 2018. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789241513951\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789241513951\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 18, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Quality of care for Maternal and Newborn- a monitoring framework for network countries. 2019. Available \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/m/item/quality-of-care-for-maternal-and-newborn--a-monitoring-framework-for-network-countries\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/m/item/quality-of-care-for-maternal-and-newborn--a-monitoring-framework-for-network-countries\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 8, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Service Availability and Readiness Assessment (SARA) | Reference Manual, Version 2.2. 2015. Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/WHO-HIS-HSI-2014.5-Rev.1\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/WHO-HIS-HSI-2014.5-Rev.1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 8, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Harmonized Health Facility Assessment (HHFA). Available from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/data/data-collection-tools/harmonized-health-facility-assessment/introduction\u003c/span\u003e\u003cspan address=\"https://www.who.int/data/data-collection-tools/harmonized-health-facility-assessment/introduction\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed December 8, 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemographic and Health Survey - The Service Provision Assessment (SPA) [Internet]. 2022. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dhsprogram.com/methodology/Survey-Types/SPA.cfm?ua=1\u003c/span\u003e\u003cspan address=\"https://dhsprogram.com/methodology/Survey-Types/SPA.cfm?ua=1\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrizuela V, Leslie HH, Sharma J, Langer A, Tun\u0026ccedil;alp \u0026Ouml;. Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools. Lancet Glob Health. 2019;7(5):e624\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. List of countries considered for participation in the Global Maternal and Newborn Health Platform (GMP) Asia-Pacific\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"274\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSouth-East Asia region\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWestern Pacific Region region\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003col\u003e\n \u003cli\u003e\u003cstrong\u003eBangladesh\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eIndia*\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIndonesia\u003c/strong\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eNepal\u003c/strong\u003e*\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSri Lanka\u003c/strong\u003e*\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eThailand\u003c/strong\u003e*\u0026dagger;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTimor-Leste\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003col\u003e\n \u003cli\u003eCambodia*\u003c/li\u003e\n \u003cli\u003eChina*\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMongolia\u003c/strong\u003e*\u003c/li\u003e\n \u003cli\u003ePhilippines*\u003c/li\u003e\n \u003cli\u003eViet Nam*\u0026dagger;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFiji\u003c/strong\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eLaos\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePapua New Guinea\u003c/strong\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/li\u003e\n \u003cli\u003eSamoa\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSolomon Islands\u003c/strong\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Participated in previous WHO multi-country surveys (WHO Global Survey (25),WHO Multi-country Survey (32) and/or WHO Global Maternal Sepsis Study (GLOSS) (27); \u0026dagger; HRP Alliance hubs are located in these countries; Countries participating in GMP Asia-Pacific are shown in bold.\u003c/p\u003e\n\u003cp\u003eTable 2. Primary outcomes for the Global Maternal and Newborn Health Platform\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWoman\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNewborn\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoverage of key practices\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Medical record)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLabour monitored using partograph*\u003c/li\u003e\n \u003cli\u003eProphylactic uterotonic administered immediately after birth*\u003c/li\u003e\n \u003cli\u003ePre-discharge counselling provided to woman prior to discharge*\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eBreastfeeding initiation \u0026lt;1 hour after birth*\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWoman-centred outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Pre-discharge survey)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCompanion of choice during labour and birth *\u003c/li\u003e\n \u003cli\u003eAny experience of mistreatment during time in the health facility for childbirth*\u003c/li\u003e\n \u003cli\u003eEffective communication \u0026ndash; consent obtained for vaginal examinations\u003c/li\u003e\n \u003cli\u003eSatisfaction with care\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eSkin to skin contact during the first hour after birth*\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(Medical record)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eCaesarean section (Robson and overall)*\u003c/li\u003e\n \u003cli\u003eEpisiotomy\u003c/li\u003e\n \u003cli\u003e3\u003csup\u003erd\u003c/sup\u003e/4\u003csup\u003eth\u003c/sup\u003e perineal tear*\u003c/li\u003e\n \u003cli\u003eHysterectomy\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 220px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eStillbirth (antepartum and intrapartum\u003c/li\u003e\n \u003cli\u003eEarly neonatal mortality\u003c/li\u003e\n \u003cli\u003ePreterm birth \u0026lt;37 weeks\u003c/li\u003e\n \u003cli\u003eLow birthweight \u0026lt;2500g\u003c/li\u003e\n \u003cli\u003eApgar score less than 7 at 5 minutes\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Providers and facilities will also be asked about policy and practice relating to these outcomes\u003c/p\u003e\n\u003cp\u003eTable 3. Secondary outcomes \u0026ndash; intrapartum period\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eType\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecific outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eCoverage of key practices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAmniotomy (overall, early amniotomy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOxytocin for augmentation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperative vaginal birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRoutine antibiotic prophylaxis before birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record; provider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFundal pressure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProvider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRoutine use of cardiotocography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProvider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003ePeople-centred outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUse of pain relief during labour/birth and after birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record survey; Pre-discharge women\u0026rsquo;s survey; Provider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOral food/fluid intake\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProvider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBirth position\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProvider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMobilising during labour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-discharge women\u0026rsquo;s survey; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProvider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eHealth outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaternal death occurring during admission for childbirth, up to 7 days postpartum.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaternal ICU admission for \u0026gt;24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostpartum haemorrhage (PPH) requiring use of additional uterotonic/TXA, uterine balloon tamponade or surgical intervention (excluding hysterectomy), blood transfusion.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIntrapartum related perinatal mortality: \u0026nbsp; \u0026nbsp; intrapartum stillbirth + very early neonatal death (in first 24 hours after birth)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNICU admission \u0026gt;24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4. Secondary outcomes \u0026ndash; postnatal period\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eType\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecific outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eCoverage of key practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIntramuscular vit K injection of newborn administered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNewborn bathing delayed until 24 hours after birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProvider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eScreening for neonatal hyperbilirubinemia (using TcB)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNewborn immunization with Hep B vaccine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003ePeople-centred outcomes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePharmacological pain relief offered to woman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-discharge survey; Provider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-discharge counselling provided to woman prior to discharge\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedical record, pre-discharge survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostnatal contraceptive information provided to women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-discharge women\u0026rsquo;s survey; provider survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNewborns treated with respect/mistreated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-discharge survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWomen separated from newborn for non-medical reasons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-discharge survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eMaternity care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMidwifery continuity of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFacility survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePolicies around clinical interventions (e.g. episiotomy, routine amniotomy)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFacility survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCleanliness and sanitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFacility survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAvailability of power/water\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFacility survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAvailability of essential supplies (including medicines)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFacility survey\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"intrapartum, maternal, newborn, postnatal, quality of care","lastPublishedDoi":"10.21203/rs.3.rs-5968904/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5968904/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eGood-quality care in the intrapartum and early postnatal period are critical to ensuring maternal, fetal and newborn survival and well-being. There is currently no standardised approach to assess the quality of intrapartum and early postnatal care provided in health facilities, women’s experiences of that care, and whether the services provided are aligned with the latest WHO recommendations. The Global Maternal and Newborn Health Platform (GMP) aims to establish and sustain a multi-country network of health facilities providing childbirth services, to measure and improve the quality of intrapartum and early postnatal care. The main objectives of this Platform are (i) to measure coverage of key intrapartum and early postnatal care practices and their alignment with WHO recommendations, (ii) to describe women’s experiences of care, (iii) to measure key maternal and newborn health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eGMP\u003cstrong\u003e \u003c/strong\u003ewill use periodic, cross-sectional, observational data collection in a multi-country network of health facilities from up to 63 low- and middle-income countries (LMICs). In the first wave, GMP is being implemented in 74 facilities in 10 Asia-Pacific countries. In participating facilities data will be collected at level of the individual woman/baby, maternal and newborn health providers, and facility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion: \u003c/strong\u003eThis multi-country initiative aims to assess the quality of intrapartum and early postnatal care in health facilities, with a “person-centred” approach that emphasizes women’s experiences during birth and postnatal admission. In its first wave, data will be collected from over 100,000 women and their babies, alongside nearly 30,000 pre-discharge surveys on care experiences, complemented by responses from over 2,000 healthcare providers across 74 facilities in 10 Asia-Pacific countries. The resulting dataset will enable multi-country, country-specific, and facility-level analyses to identify actionable priorities for improving maternal and newborn health outcomes. GMP’s tools and methods are developed using an evidence-based approach and foster multidisciplinary networks among healthcare professionals, researchers, and policymakers. GMP provides a robust, scalable approach for periodic and standardised data collection, informing evidence-based policy and practice to enhance care quality. GMP will provide global situational analyses on intrapartum and early postnatal care quality to address the Sustainable Development Goals (SDG) and will help to addresses the WHA 77.5 resolution to accelerate progress towards reducing maternal, newborn and child mortality, including stillbirths.\u003c/p\u003e","manuscriptTitle":"The Global Maternal and Newborn Health Platform: study protocol for an observational, multi-country study on the quality of intrapartum and early postnatal care at health facilities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 06:34:25","doi":"10.21203/rs.3.rs-5968904/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-05T03:55:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-06T04:53:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-06T04:51:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-02-05T23:48:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"70ac5a27-d564-431f-8ebb-73cb46f11d49","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T07:08:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-21 06:34:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5968904","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5968904","identity":"rs-5968904","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}