(1) Background: Every year, 2.5 million neonates die, mostly in low- and middle-income countries (LMIC), in total disregard of their fundamental human rights. Many of these deaths are preventable. For decades, the leading causes of neonatal mortality (prematurity, perinatal hypoxia, and infection) have been known, so why does neonatal mortality fail to diminish effectively? A bottom-up understanding of neonatal morbi-mortality and neonatal rights is essential to achieve adequate progress, and so is increased visibility. (2) Methods: We performed an overview on the leading causes of neonatal morbi-mortality and analyzed the key interventions to reduce it with a bottom-up approach: from the clinician in the field to the policy maker. (3) Results and Conclusions: Overall, more than half of neonatal deaths in LMIC are avoidable through established and well-known cost-effective interventions, good quality antenatal and intrapartum care, neonatal resuscitation, thermal care, nasal CPAP, infection control and prevention, and antibiotic stewardship. Implementing these requires education and training, particularly at the bottom of the healthcare pyramid, and advocacy at the highest levels of government for health policies supporting better newborn care. Moreover, to plan and follow interventions, better-quality data are paramount. For healthcare developments and improvement, neonates must be acknowledged as humans entitled to rights and freedoms, as stipulated by international law. Most importantly, they deserve more respectful care.

Antenatal care (ANC) has the potential to identify and manage obstetric complications, educate women about risks during pregnancy and promote skilled birth attendance during childbirth. The aim of this study was to assess women’s knowledge of obstetric danger signs and factors associated with this knowledge in Ambanja, Madagascar. It also sought to evaluate whether the participation in a mobile health (mHealth) project that aimed to provide comprehensive ANC to pregnant women in remote areas influenced women’s knowledge of obstetric danger signs. From April to October 2015, a non-random, convenience sample of 372 women in their first year postpartum were recruited, including 161 who had participated in the mHealth project. Data were analyzed using bivariate and multivariate logistic regression. Knowledge of at least one danger sign varied from 80.9% of women knowing danger sign(s) in pregnancy, to 51.9%, 50.8% and 53.2% at delivery, postpartum and in the newborn, respectively. Participation in the mHealth intervention, higher household income, and receipt of information about danger signs during pregnancy were associated with knowledge of danger signs during delivery, in bivariate analysis; only higher household income and mHealth project participation were independently associated. Higher educational attainment and receipt of information about danger signs in antenatal care were associated with significantly higher odds of knowing danger sign(s) for the newborn in both bivariate and multivariate analysis. Knowledge of obstetric danger signs is low. Information provision during pregnancy and with mHealth is promising. This trial was retrospectively registered at the International Standard Randomized Controlled Trial Register (identifier ISRCTN15798183 ; August 22, 2015).

In early 2023, when Omicron was the variant of concern, we showed that vaccinating pregnant women decreased the risk of severe COVID-19 related complications, and maternal morbidity and mortality. To analyze the impact of COVID-19 during pregnancy on newborns and the effects of maternal COVID-19 vaccination on neonatal outcomes, when Omicron was the variant of concern. INTERCOVID-2022 is a large, prospective, observational study, conducted in 40 hospitals across 18 countries, from November 27, 2021 (the day after the World Health Organization declared Omicron the variant of concern) to June 30, 2022, to assess the effect of COVID-19 in pregnancy on maternal and neonatal outcomes, as well as vaccine effectiveness (VE). Women diagnosed with laboratory-confirmed COVID-19 in pregnancy were compared with two 'non-diagnosed', unmatched women recruited concomitantly and consecutively in pregnancy or at delivery. Mother/newborn dyads were followed until hospital discharge. Primary outcomes were a neonatal positive test for COVID-19, severe neonatal morbidity index (SNMI), severe perinatal morbidity and mortality index (SPMMI), preterm birth, neonatal death, referral to neonatal intensive care unit (NICU), and diseases during the neonatal period. VE was estimated adjusted by maternal risk profile. We enrolled 4707 neonates born to 1577 (33.5%) mothers diagnosed with COVID-19 and 3130 (66.5%) non-diagnosed mothers. Amongst diagnosed mothers, 642 (40.7%) were not vaccinated, 147 (9.3%) were partially vaccinated, 551 (34.9%) were completely vaccinated, and 237 (15.0%) also had a booster vaccine. Neonates of booster-vaccinated mothers had less than half (RR=0.46; 95%CI=0.23, 0.91) the risk of being diagnosed with COVID-19 compared to those of unvaccinated mothers; they also had the lowest rates of preterm birth, medically-indicated preterm birth, respiratory distress syndrome and number of days in NICU. Newborns of unvaccinated mothers had double the risk of neonatal death (RR=2.06; 95% CI=1.06, 4.00) compared to those of non-diagnosed mothers. Vaccination was not associated with any congenital malformations. Although all vaccines provided protection against neonatal test positivity, newborns of booster-vaccinated mothers had the significantly highest VE (64%; 95% CI=10-86%); VE was not as high for mRNA vaccines only. VE against moderate/severe neonatal outcomes was much lower: 13% in the booster-vaccinated group (all vaccines), and 25% and 28% in the completely and booster-vaccinated groups, respectively (mRNA vaccines only). Vaccines were fairly effective in protecting neonates when given to pregnant women 100 days (14 weeks) or less before birth; thereafter, the risk increased and was much higher after 200 days (29 weeks).. Finally, none of the neonatal practices studied, including skin-to-skin contact and direct breastfeeding, increased the risk of infecting newborns. When Omicron was the variant of concern, newborns of unvaccinated mothers had an increased risk of neonatal death. Neonates of vaccinated mothers had a decreased risk of preterm birth and adverse neonatal outcomes. As the protective effect of COVID-19 vaccination decreases with time, to ensure that newborns are maximally protected against COVID-19 mothers should receive a vaccine or booster dose no more than 14 weeks before the expected date of delivery.

Background: Madagascar’s maternal health mortality ratio in 2013 was 478 deaths per 100,000 live births. Most deaths are related to direct complications during pregnancy and childbirth and could be reduced by providing comprehensive antenatal care (ANC). Objective: The objective of the study was to assess the usability and feasibility of a mobile health system (mHealth) to provide high-quality ANC, according to World Health Organization (WHO) recommendations. Methods: PANDA (Pregnancy And Newborn Diagnostic Assessment) is an easy-to-use mHealth system that uses affordable communications technology to support diagnosis and health care worker decision-making regarding ANC. From January to March 2015, a cross-sectional pilot study was conducted in Ambanja District, Madagascar, in which ANC using PANDA was provided to 100 pregnant women. The collected data were transmitted to a database in the referral hospital to create individual electronic patient records. Accuracy and completeness of the data were closely controlled. The PANDA software was assessed and the number of abnormal results, treatments performed, and participants requiring referral to health care facilities were monitored. Results: The PANDA system facilitated creation of individual electronic patient records that included socio-demographic and medical data for 100 participants. Duration of ANC visits averaged 29.6 min. Health care providers were able to collect all variables (100%) describing personal and medical data. No major technical problems were encountered and no data were lost. During 17 ANC visits (17%), an alert function was generated to highlight abnormal clinical results requiring therapy or referral to an affiliated hospital. Participants’ acceptability of the system was very high. Conclusion: This pilot study proved the usability and feasibility of the PANDA mHealth system to conduct complete and standardised ANC visits according to WHO guidelines, thus providing a promising solution to increase access to high-quality and standardised ANC for pregnant women in remote areas.

The use of thermocoagulation for the treatment of cervical precancerous lesions has recently generated a great deal of interest. Our aim was to determine the feasibility of this outpatient procedure in the context of a cervical cancer (CC) screen-and-treat campaign in sub-Saharan Africa. Between July and December 2015, women living in the area of Dschang (Cameroon) aged between 30 and 49 years, were enrolled in a CC screening study. HPV self-sampling was performed as a primary screening test and women who were either “HPV 16/18/45-positive” or “positive to other HPV types and to VIA” were considered screen-positive, thus requiring further management. The primary outcome was the percentage of screen-positive patients who met the criteria to undergo thermocoagulation. The secondary outcome was the assessment of the procedure’s side effects immediately after treatment and at the 1-month follow-up visit. A total of 1012 women were recruited in the study period. Among 121 screen-positive women, 110 of them (90.9%) were eligible to be treated with thermocoagulation. No patients discontinued treatment because of pain or other side effects. The mean ± SD (Standard Deviation) score measured on the 10-point Visual Analogue Scale (VAS) was 3.0 ± 1.6. Women having less than 2 children were more likely to report a higher pain score than those with more than two (4.2 ± 2.0 versus 2.9 ± 1.5, respectively; p value = 0.016). A total of 109/110 (99.1%) patients came to the 1-month follow-up visit. Vaginal discharge was reported in 108/109 (99.1%) patients throughout the month following treatment. Three patients (2.8%) developed vaginal infection requiring local antibiotics. No hospitalizations were required. The majority of screen-positive women met the criteria and could be treated by thermocoagulation. The procedure was associated to minor side effects and is overall feasible in the context of a CC screen-and-treat campaign in sub-Saharan Africa. The trial was retrospectively registered on November 11, 2015 with the identifier: ISRCTN99459678 .

Background: Despite many efforts, maternal mortality remains a major burden in most developing countries. Mobile health (mHealth) has the potential to improve access to obstetric care through apps that help patients and providers. Objective: This study aimed to use mHealth to provide antenatal care (ANC) to 1446 pregnant women in a rural area in Madagascar and evaluate the quality of ANC provided by an mHealth system designed to change the behaviors of providers and patients. Methods: We included 1446 women who attended ANC visits in rural Madagascar from 2015 to 2019 using an mHealth system called Pregnancy and Newborn Diagnostic Assessment (PANDA). This cross-sectional study used data from different participants, with information collected over several years, to analyze the outputs related to the quality of ANC over time. Specifically, we examined the timing of the first ANC visit, the relationship between the visit duration and the risk factors among pregnant women, and the number of ANC visits per woman. Results: Following the implementation of the mHealth system in 2015, we observed that women started to come earlier for their first ANC visit; more women attended their first ANC visit in the second trimester of pregnancy in 2019 than in the previous years (P<.001). In 2019, fewer women attended their first ANC visit in the third trimester (57/277, 20.6%) than in 2015 (147/343, 42.9%). There were statistically significant associations between the ANC visit durations and the risk factors, including age (>35 years; 25.0 min, 95% CI 24.0-25.9), educational level (longer visit for women with lower than primary education and for women who attended university and shorter for women with primary school–level education; 40.7 min, 95% CI 30.2-51.3 and 25.3 min, 95% CI 24.4-26.3 vs 23.3 min, 95% CI 22.9-23.8; P=.001), experience of domestic violence during pregnancy, gravidity, parity, infectious diseases (HIV, malaria, and syphilis), and level of anemia. Statistically significant associations were observed for all quality indicator variables. We observed a statistically significant increase in the number of ANC visits per woman over time from 2015 to 2017; the number of ANC visits per woman then became stable after the third year of implementing the PANDA mHealth system. Conclusions: This study shows the potential of an mHealth system to improve the quality of ANC, change provider behavior by standardizing ANC visits, and change patient behavior by increasing the willingness to return for subsequent visits and encouraging ANC attendance early in pregnancy. As this is an exploratory study, further studies are necessary to better understand how mHealth can change behavior and identify the conditions required for behavioral changes to persist over time.