• 1.
  

  a) T b) T c) F d) T e) F

The Edinburgh Postnatal Depression Scale is one of the most common measures used for postnatal depression. Patient Health Questionnaire is a general mental health questionnaire that is used to assess symptoms of common mental disorders, including depressive symptoms in women around the time of pregnancy. Psychiatric diagnosis is not commonly employed in large research studies because of cost. Instead, survey questionnaires of depressive symptoms are more common due to feasibility of implementation at scale. The General Health Questionnaire is a general mental health questionnaire that is used to assess depressive symptoms in women during pregnancy and in the postnatal period. There is no such questionnaire as the Depression Scale for Low Income Women.

• 2.
  

  a) F b) T c) F d) T e) T

Maternal depression is not randomly distributed in the population. Several psychosocial and economic correlates have been identified across multiple settings. Exposure to intimate partner violence is a risk factor for higher depressive symptoms in both the prenatal and postnatal period. Evidence indicates that women with fewer economic resources are at higher risk for depression or depressive symptoms. Previous history of depression or other mental disorders is related to depressive symptoms around the time of child birth. Poor relationships with family members, including spouse and mother-in-law, are correlates of perinatal depression.

• 3.
  

  a) T b) T c) T d) T e) T

All of the above have been shown to be associated with perinatal depression in meta-analyses.

• 4.
  

  a) T b) F c) F d) T e) F

Recent research such as the Thinking Healthy Program in Pakistan has highlighted the feasibility of successfully using non-specialist health workers in low-resource settings. Cognitive behavioral therapy is indicated for reducing maternal depressive symptoms. A meta-analysis based on 10 studies failed to show health promotion as effective. Based on guidelines from Zafar et al 2014, family engagement and assuring their support is important to the success of interventions. Although it may be costly and difficult to change cultural norms to improve empowerment, such upstream factors may ultimately be the key to improving peri-natal depressive symptoms.

• 5.
  

  a) F b) T c) F d) F e) F

Global annual maternal deaths from labour and delivery are falling – from 137 700 in 1990 to 91 100 in 2010, which also represents a fall in the cause-specific maternal mortality ratio. All-cause maternal mortality declined from 359 000 to 255 000 in the same period. Intrapartum and postpartum haemorrhage together made up 56% of labour-related maternal deaths in the recent WHO systematic analysis. In South Africa, the most common cause was haemorrhage after caesarean section. Probably, wherever one looks in low-and middle-income countries, haemorrhage is the dominant cause of deaths related to labour and delivery. Traumatic breech birth makes up only a small percentage of labour-related perinatal deaths. The most common ‘cause’ is the rather vague category of ‘intrapartum’ asphyxia, characterised by fetal or neonatal death in the absence of a catastrophic ‘sentinel’ event. Annual numbers of neonatal deaths decreased in Africa as they did worldwide, but the decline was only 1.1% annually, compared with the worldwide 2.4% annual reduction.

• 6.
  

  a) F b) F c) T d) T e) F

Caesarean section rates of around 5%, such as are found in Malawi, are likely too low to provide the best opportunities for reducing maternal and perinatal mortality rates. Recent ecological studies suggest that the ideal Caesarean section rate is probably between 10% and 20%. Spinal anaesthesia is the technique of choice, to avoid aspiration pneumonia and uncontrolled hypertension. However, spinal anaesthesia should not be used if the anaesthetic provider is unable to manage the airway (intubate) should there be a respiratory arrest. Studies, mainly from south-eastern Africa, have shown that task shifting of caesarean section to non-physician surgeons can be successfully and safely implemented. Intravenous antibiotic prophylaxis must be given at all caesarean sections whether emergency or elective. This is supported by evidence of reduced postpartum infections in treated women, from numerous randomised trials. Injury including iatrogenic fistula is a consequence of inadequate surgical skill and can largely be prevented by training and certification of competencies.

• 7.
  

  a) F b) F c) T d) F e) F

Standard ICU care is needed for these patients. High dependency units are intended for the majority of ‘very sick obstetric patients’, who should not require mechanical ventilation, invasive haemodynamic monitoring and inotropic support. HDU care can allow mothers and babies to be nursed together and facilitate breast feeding initiation. The ability to undertake adequate circulatory and respiratory monitoring and manage fluid balance are of prime importance. Oxygen is needed even where ventilation is not required as patients often have a reduced level of consciousness, may have lost blood or have respiratory compromise owing to sepsis. HDU care fills an intermediate care position between ICU and routine ward care and ‘step down’ arrangements are required for efficient patient flow. Women who are almost well enough to go home should not occupy beds in a HDU. HDU offers life-saving care to women in low-resource settings, where they might otherwise succumb to neglect, for example in crowded postnatal wards with healthy mothers. The numbers of beds, staffing and technologies required are not excessive.

• 8.
  

  a) F b) T c) F d) T e) T

Room air (21% oxygen) is preferred in starting positive pressure ventilation. Use of pure oxygen (100%) is associated with neurocellular damage and poor clinical outcomes. Pure oxygen blended with air may be given, guided by oximetry readings. The two-thumb method has been shown, in low-quality evidence from randomised trials, to be associated with increased blood pressure generation, and less compressor fatigue. The correct compression: ventilation ratio is 3:1. In newborn resuscitation, asystole or severe bradycardia is primarily a reaction to hypoxia rather than to a cardiac event. The umbilical vein is the vascular access route of choice. Intraosseous infusion is acceptable as a temporary route for vascular access where umbilical vein access is not possible or feasible. In general, discontinuing resuscitation efforts in such circumstances (effectively a 10-minute Apgar score of zero) is reasonable, given the high likelihood of subsequent early mortality (50%) or moderate to major long-term disability (25%). The decision can however be individualised.

• 9.
  

  a) F b) F c) T d) F e) F

Current recommendation is for maternal treatment with triple antiretroviral therapy during pregnancy and at least until cessation of breastfeeding. Caesarean section is recommended only for standard obstetric indications. Initiation of lifelong ART in pregnant and breastfeeding women is preferred for programmatic and operational reasons and there is also evidence that ART at any CD4 cell count is associated with reduction in long-term morbidity and mortality. Breastfeeding has been associated with reduction in infant morbidity and mortality and should be avoided only if there are safe, acceptable, affordable, feasible, and sustainable alternatives. Exposed neonates should receive ARV prophylaxis for 6 weeks if breastfeeding and 4-6 weeks if on replacement feeding.

• 10.
  

  a) T b) T c) F d) F e) F

ITNs reduce adverse obstetrical outcomes related to reduced exposure to malaria. IPT can indeed suppress or clear existing asymptomatic infections, and provide prophylaxis against new infections. IPT should be given monthly beginning in the second trimester. HIV+ve pregnant women taking co-trimoxazole for OI prophylaxis need not also receive IPT. ACT should be reserved for the second and third trimesters due to limited information regarding safety with first trimester exposure.

• 11.
  

  a) F b) F c) T d) F e) T

The risk of congenital syphilis is greatest later in gestation as opposed to the severity of congenital syphilis which is greatest earlier in gestation. Congenital syphilis can indeed be prevented if maternal syphilis is diagnosed before the third trimester and effective treatment given at least 30 days before delivery. Congenital syphilis is associated with increased risk of stillbirth and preterm delivery, but also with an increased risk of serious sequelae for the infant/child. Deafness, blindness, and seizures are all recognised long term sequelae.

• 12.
  

  a) T b) F c) T d) F e) F

Patients who have already lost 1000mls of blood are at risk of haemodynamic instability should the bleeding continue and are risk of morbidity and even mortality. Once the doctor assesses the patient, decisions can be made for further management to move from medical to surgical manoeuvres or transfer to a higher level facility. Foley catheters can safely be used as part of mechanical induction and should not be discouraged in favour of misoprostol. Whereas misoprostol is safe when used at the correct dosage and at the appropriate time intervals it can lead to overstimulation. Training community health workers to educate pregnant women about obstetric haemorrhage and promote transport plans is part of emergency readiness. If obstetric haemorrhage were to occur and if aware of its dangers they would seek help quickly and put into action their transport plans in the shortest time to arrive at a facility where resuscitation and management can be initiated. Patients following CS and manual removal of placenta are at risk of PPH and should be monitored closely for at least the first few hours. Then when confirmed to be stable they can be transferred to the ward. As per the current WHO and FIGO guidelines Syntometrine and ergometrine are preferred as second line treatment for uterine atony in preference and the next medication for use should be Misoprostol.

• 13.
  

  a) T b) F c) F d) T e) F

The WHO multicentre doube-blind randomized controlled trial to evaluate the use of misoprostol in the management of the third stage of labour found Misoprostol to be much less effective than oxytocin for prevention of PPH (blood loss >1000ml). There was no statistically significant difference in maternal mortality for misoprostol compared with misoprostol versus placebo or for misoprostol versus other uterotonics as seen from the evidence of a Cochrane review. “Postpartum misoprostol for preventing maternal mortality and morbidity. The review of 78 studies (59,216 women) found no statistically significant difference in maternal mortality for misoprostol compared with control groups overall (11/19,715 versus 4/20,076 deaths); or for the trials of misoprostol versus placebo (6/4626 versus 1/4707 deaths) or for misoprostol versus other uterotonics (5/15,089 versus 3/15,deaths). All 11 deaths in the misoprostol arms occurred in studies of misoprostol ≥ 600 μg. There was no statistically significant difference in the composite outcome ‘maternal death or severe morbidity’. Advance distribution of misoprostol to pregnant women with instructions to be taken after birth is an attractive option, as the drug is heat stable tablet. Some countries have rolled this out – however robust evidence is lacking. As per the WHO guidelines Misoprostol is not the optimum choice in the prevention of PPH but is an effective and cost-saving choice where oxytocin is not or cannot be used due to a lack of skilled birth attendants, inadequate transport and storage facilities or where a quality assured oxytocin product is not available. The first line of medication is Oxytocin. 600mcgs of sublingual Misoprostol in addition to standard injectable uterotonics for the treatment of post-partum haemorrhage has not been shown to be effective and is not recommended. Evidence shows that 800mcgs Misoprostol orally was found to have no benefit over placebo for the treatment of PPH in women who had received convention uterotonics.

• 14.
  

  a) T b) F c) F d) T e) T

Increasing evidence is emerging on the importance of nutrition to health. With specific reference to haemorrhagic deaths, folate supplementation before pregnancy reduces the risk of placental abruption. Nutritional advice should include advice to aim for a diet with adequate folate and iron, especially in low income settings. The correct estimate is about 5 per 1000 pregnancies, as evidence from systematic review and meta-analysis. The vaginal route of delivery is usually safest, though Caesarean may be undertaken at times for fetal distress, or with other antecedent indications. The provision of essential and emergency obstetric and newborn care starts with preventive and promotional activities during the antenatal period and extends into the intrapartum/peri-partum period. Caesarean section rates are increasing worldwide. Apart from increased risk of maternal mortality overall, Caesarean section specifically increases the risk of PPH. This risk may be further increased by the use of general rather than neuraxial anaesthesia. In the 2011 to 2013 report of the Committee for Confidential Enquiries into Maternal Deaths in South Africa, Caesarean section was highlighted as a contributing factor to deaths from haemorrhage. A key general strategy to reduce deaths from haemorrhage is to avoid unnecessary Caesarean sections in the first place.

• 15.
  

  a) F b) F c) T d) F e) F

Accessing antenatal and delivery care are part of the three delays, however delay in becoming pregnant and identifying pregnant women are not. The three delays model has been used to explain non-proximate causes of maternal deaths and describe in a chronological order the barriers for a woman to access care. The first delay is being able to identify danger signs and to decide to seek care. The first delay is influenced by the socioeconomic status of the woman but also her value in the family as it may not be her own decision to seek care but that of the head of the household. The second delay comprises delay in seeking and accessing care which may be influenced by lack of transportation possibilities, either through lack of economical means but also lack of a vehicle. The third delay consists of the delay in receiving adequate care upon arrival which depends on staff being properly trained, enough number of staff and also equipment and emergency obstetric care services available.

• 16.
  

  a) T b) F c) F d) T e) F

There is a need for a universal definition for stillbirths and also a classification system. The difficulties are mainly due to different definitions in the time frames for the fetal period and during the neonatal period. There have also been a large number of classification systems proposed for classifying stillbirths but not all are feasible in the countries with the highest burdens, as there is a lack of diagnostic equipment to identify infections, ultrasound for detection of intrauterine growth impairment and pathological services for autopsies and placental examinations. On the contrary, the burden of stillbirths is high and in absolute numbers the burden is estimated to 2.6 million stillbirths per year. Although the reality shows that stillbirths have been prioritised on the global health agenda, it is of utter importance from a human rights perspective for all children. Stillbirths are not counted in national statistics due to the lack of a universal classification or definition in place. Further, stillbirths are not made part of the CRVS (civil registration and vital statistics) of many countries. While it is true that there is a proportion of stillbirths with an unknown cause and the proportion varies depending on the setting (access to diagnostics), this is not a valid reason for not making stillbirths count.

• 17.
  

  a) F b) F c) T d) T e) T

The three most prevalent causes for neonatal mortality globally are in the following order: preterm birth (35%), intrapartum –related complications (asphyxia) (23%) and sepsis/meningitis (13%).

• 18.
  

  a) F b) T c) F d) T e) T

Under SDG 3, which states that the goal is to “ensure healthy lives and promote wellbeing for all ages”, is the goal to reduce child mortality to no more than 25 per 1000 live births. The global strategy has set targets for maternal and perinatal wellbeing setting the target that all individual countries have an MMR less than 140/100,000 live births and a stillbirth rate of no more than 12/1000 live births, by 2030.

• 19.
  

  a) F b) T c) T d) F e) F

Surveys are often retrospective or delayed at the point of collection. One of the issues with surveys is indeed that they do not generally provide disaggregated data that can address the disparities in populations geographically, ethnically and economically. Not all of the countdown priority countries have functioning civil registration systems. Death certificates do not always register whether or not women are pregnant.

• 20.
  

  a) T b) T c) F d) F e) T

Assessment of “near misses” does indeed provide critical information about the quality of care provided at facilities and most importantly can be used to improve clinical outcomes. The “near miss” approach can be effective with only one maternal death. Clinical audits have not been proven to result in substantial improvements in the care provided and in clinical outcomes, when applied to maternal death review as they highlight areas of practice in need of review – these cannot always be dealt with particularly in low resource settings. Social autopsies, when used to assess maternal and perinatal deaths, do examine the process of seeking care and what influences this, including household, community and health system factors form the heart of the local community.

• 21.
  

  a) T b) F c) F d) T e) T

The 2030 target for maternal mortality as included in Sustainable Development Goal 3 is every country should reduce its maternal mortality ratio by at least two thirds from the 2010 baseline, and no country should have a rate higher than 140 deaths per 100,000 live births (twice the global target). The global average target of maternal mortality ratio should be <70 maternal deaths per 100,000 live births. The Every Newborn Action Plan target as included in Sustainable Development Goal 3 is every country should have a national neonatal mortality rate of ≤12 per 1000 live births. These targets aim to end all maternal and neonatal deaths and stillbirths from preventable causes, for example lack of access to high quality intrapartum care and infections. Even with the highest level of health and health care, some deaths will still occur, for example some stillbirths due to complex congenital disorders. The target is that every country should have a stillbirth rate of ≤12 per 1000 total births.

• 22.
  

  a) T b) T c) T d) T e) T

All answers are true. However, as highlighted in the recent Lancet Maternal Health series that whilst haemorrhage, hypertensive disorders, sepsis, and complications of abortion remain important causes of maternal death, there is an increasing diversity of conditions and causes. Both communicable and non-communicable diseases occur in pregnant and recently-delivered women and can co-exist with obstetric complications, emphasizing a projected increase in high-risk cases with implications for the whole continuum of maternity services as well as for the fetus and newborn. Such conditions include diabetes, mental ill-health, HIV, malaria, cardiovascular conditions, and obesity.

• 23.
  

  a) T b) F c) F d) T e) T

Complications of preterm birth is the leading cause of both neonatal and total under 5 child deaths. Whilst the relative importance of congenital disorders increases as the absolute numbers of deaths due to readily preventable neonatal deaths, such as deaths due to intrapartum complications in term babies or sepsis in late preterm babies, reduces; currently globally these are the leading causes of death. Policy and programs should hence target these causes for maximum impact, especially in high burden settings. Whilst efforts to eliminate mother to child transmission of both HIV and syphilis are required to improve overall maternal and child health especially in high prevalence areas, neither are a leading cause of neonatal death (reducing HIV has the greatest effect on infant deaths and reducing syphilis has largest impact on stillbirths). Intrapartum related complications are the second leading cause of neonatal death worldwide. Infections such as neonatal sepsis and pneumonia remain an important cause of neonatal death worldwide.

• 24.
  

  a) T b) T c) T d) T e) T

Complications of preterm birth is the leading cause of both neonatal and total under 5 child deaths. Reducing HIV has the greatest effect on infant deaths and reducing syphilis has largest impact on stillbirths. Intrapartum related complications are the second leading cause of neonatal death worldwide.

• 25.
  

  a) T b) T c) F d) F e) T

Maternal mortality from direct obstetric causes is highest on the first and second days after birth, and requires a concerted focus on quality care at birth. However, the proportion of indirect causes of death, both communicable and non-communicable, is increasing in most countries, reflecting an epidemiological transition. In 2015, it was estimated that about half of stillbirths, 1.3 million, occurred during labour, despite two-thirds of births worldwide now being in health facilities. In the case of newborns, 36% of deaths occur on their day of birth, with an estimated 73% of all neonatal deaths occurring during the first week of life. Babies born preterm (<37 weeks) are at the highest risk of mortality. Analyses presented in The Lancet Every Newborn Series found that 42% of all stillbirths and neonatal deaths occur during this period resulting in 2.2 million child deaths. Although not yet fully quantified at a global level, there is an increasing recognition of that there are a substantial burden of morbidity and long term disability both for mothers and their children resulting from intrapartum and immediate post-partum complications. Many of these could be averted with improved coverage of high quality intrapartum and immediate post-partum care.

• 26.
  

  a) T b) T c) T d) T e) T

Maternal mortality from direct obstetric causes is highest on the first and second days after birth, and requires a concerted focus on quality care at birth. In 2015, it was estimated that about half of stillbirths, 1.3 million, occurred during labour, despite two-thirds of births worldwide now being in health facilities. In the case of newborns, 36% of deaths occur on their day of birth, with an estimated 73% of all neonatal deaths occurring during the first week of life.

• 27.
  

  a) F b) F c) T d) T e) T

When faced with an unintended pregnancy many women will decide to seek an abortion. Measures to prevent access to abortion, do not prevent women from seeking an abortion and abortion rates are not significantly different in countries with restrictive laws and countries with more liberal laws. If access to safe abortion is not available, women will turn to clandestine and less safe options. Treatment of complications for unsafe abortion does help to prevent mortality from unsafe abortion but does not prevent the complications themselves. Providing better access to contraception and family planning services helps preventing or postponing pregnancy in those at high risk of complications and among those who do not wish to be pregnant. This reduces the levels of unintended pregnancies and can in turn reduce the need for abortion and is an important intervention. However, not all unintended pregnancies can be prevented; contraceptive failures may occur, pregnancies may occur as a result of sexual assault or other reasons may necessitate pregnancy discontinuation. In all these situations, access to safe abortion is the most effective method of preventing recourse to unsafe abortion.

• 28.
  

  a) T b) T c) T d) T e) T

Abortion is a very safe medical procedure and the risk of a woman dying following a legal safe abortion is as low as 0.7 deaths per 100,000 pregnancies and even lower at 0.3 per 100,000 pregnancies for procedures performed at 8 weeks or less. This is much lower than the risk of dying from other complications of pregnancy and childbirth. Such safe abortion in the first trimester of pregnancy can be provided using simple primary care level interventions such as vacuum aspiration and medical abortion. Unsafe abortion however does contribute to both maternal mortality and maternal morbidity. While still lower than the risks of other pregnancy related complications, the risk for even a safely performed abortion does increase with increasing gestation. Bartlett and colleagues found a 38% increase for every increasing week, rising to 8.9 /100,000 procedures at > 21 weeks. It has been estimated that there were approximately 56.3 million abortions worldwide every year in the period 2010-2014. This means an abortion rate of 35 abortions (90% uncertainty interval [UI] 33 to 44) per 1000 women aged 15–44 years worldwide.

• 29.
  

  a) F b) F c) T d) F e) F

Right answer: 1987. This is a remarkably late date given the facts that Save the Children was founded already in 1919 and UNICEF in 1946. Other big international conferences were held in 1990 (World Summit for Children) and 1994 (Cairo ICPD, International Conference on Population and Development).

• 30.
  

  a) T b) T c) T d) T e) F

A study in India, where about one fifth of all maternal deaths in the world occur, concluded that increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality. It was estimated that if over a period of 5 years the unmet need for spacing and limiting births was met, more than 150,000 maternal deaths would be prevented; more than US$1 billion saved; and at least one of every two abortion-related deaths averted. Other studies suggest that the reduction in maternal mortality is probably due to a decline in the proportion of births among women with higher risk of maternal death during pregnancy and childbirth. Most of these studies are based on analyses of the Demographic and Health Survey (DHS) data that offer similar information from many countries and from different time periods. Stover and Ross used data from 146 DHSs (1990 and 2005) on contraceptive use and distribution of births by risk factors, as well as special country data sets on MMR by parity and age, to explore the impact of contraceptive use on high-risk births and, thus, on the MMR. Over one million maternal deaths were averted between 1990 and 2005 because fertility rates in developing countries declined. Furthermore, by reducing “demographically high-risk births” in particular, especially high-parity births, family planning reduced the MMR, and thus indirectly averted additional maternal deaths. Brown at al examined data from 205 DHSs, conducted between 1985 and 2013, to describe the trends in high-risk births and their association with the yearly increase in modern contraceptive prevalence rate (MCPR) in 57 developing countries. Countries that had the fastest progress in improving MCPR experienced the greatest declines in high-risk births related to short birth intervals (<24 months), higher parity births (birth order >3) and older maternal age (>35 years). Births among younger women <18 years, however, did not decline significantly during this period.