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Vaughan G, Dawson A, Peek M, Carapetis J, Wade V, Sullivan E. Caring for Pregnant Women with Rheumatic Heart Disease: A Qualitative Study of Health Service Provider Perspectives. Glob Heart 2021; 16:88. [PMID: 35141129 PMCID: PMC8698228 DOI: 10.5334/gh.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 11/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background Rheumatic heart disease (RHD) persists in low-middle-income countries and in high-income countries where there are health inequities. RHD in pregnancy (RHD-P) is associated with poorer maternal and perinatal outcomes. Our study examines models of care for women with RHD-P from the perspectives of health care providers. Methods A descriptive qualitative study exploring Australian health professionals' perspectives of care pathways for women with RHD-P. Thematic analysis of semi-structured interviews with nineteen participants from maternal health and other clinical and non-clinical domains related to RHD-P. Results A constellation of factors challenged the provision of integrated women-centred care, related to health systems, workforces and culture. Themes that impacted on the provision of quality woman-centred care included conduits of care - helping to break down silos of information, processes and access; 'layers on layers' - reflecting the complexity of care issues; and shared understandings - factors that contributed to improved understandings of disease and informed decision-making. Conclusions Pregnancy for women with RHD provides an opportunity to strengthen health system responses, improve care pathways and address whole-of-life health. To respond effectively, structural and cultural changes are required including enhanced investment in education and capacity building - particularly in maternal health - to support a better informed and skilled workforce. Aboriginal Mothers and Babies programs provide useful exemplars to guide respectful effective models of care for women with RHD, with relevance for non-Indigenous women in high-risk RHD communities.For key goals to be met in the context of RHD, maternal health must be better integrated into RHD strategies and RHD better addressed in maternal health.
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Affiliation(s)
- Geraldine Vaughan
- Central Queensland University, College of Science and Sustainability, Sydney campus, AU
| | - Angela Dawson
- University of Technology Sydney, Faculty of Health, Sydney, AU
| | - Michael Peek
- The Australian National University, College of Health and Medicine, Canberra, AU
| | - Jonathan Carapetis
- Telethon Kids Institute, University of Western Australia, and Perth Children’s Hospital, Nedlands WA, AU
| | - Vicki Wade
- Menzies School of Health Research, NT, AU
| | - Elizabeth Sullivan
- The University of Newcastle, Faculty of Health and Medicine, Newcastle, AU
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The Spectrum, Severity and Outcomes of Rheumatic Mitral Valve Disease in Pregnant Women in Australia and New Zealand. Heart Lung Circ 2021; 31:480-490. [PMID: 34840063 DOI: 10.1016/j.hlc.2021.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 08/16/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Rheumatic heart disease (RHD) poses significant perinatal risks. We aimed to describe the spectrum, severity and outcomes of rheumatic mitral valve disease in pregnancy in Australia and New Zealand. METHODS A prospective, population-based cohort study of pregnant women with RHD recruited 2013-14 through the hospital-based Australasian Maternity Outcomes Surveillance System. Outcome measures included maternal and perinatal morbidity and mortality. Univariable and multivariable logistic regression analyses were undertaken to test for predictors of adverse maternal and perinatal outcomes. RESULTS Of 274 pregnant women identified with RHD, 124 (45.3%) had mitral stenosis (MS) and 150 (54.7%) had isolated mitral regurgitation (MR). One woman with mild MS/moderate MR died. There were six (2.2%) stillbirths and two (0.7%) neonatal deaths. Babies born to women with MS were twice as likely to be small-for-gestational-age (22.7% vs 11.4%, p=0.013). In women with MS, use of cardiac medication (AOR 7.42) and having severe stenosis (AOR 16.35) were independently associated with adverse cardiac outcomes, while NYHA class >1 (AOR 3.94) was an independent predictor of adverse perinatal events. In women with isolated MR, use of cardiac medications (AOR 7.03) and use of anticoagulants (AOR 6.05) were independently associated with adverse cardiac outcomes. CONCLUSIONS Careful monitoring and specialist care for women with RHD in pregnancy is required, particularly for women with severe MS, those on cardiac medication, and those on anticoagulation, as these are associated with increased risk of adverse maternal cardiac outcomes. In the context of pregnancy, contraception and preconception planning are important for young women diagnosed with RHD.
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Puspa Pitaloka C, Secka A, Ernawati E, Sulistyono A, Juwono HT, Gumilar Dachlan E, Aditiawarman A. Characteristics shifting of heart disease in pregnancy: A report from low middle-income country. J Public Health Res 2021; 10:2137. [PMID: 34278766 PMCID: PMC8764548 DOI: 10.4081/jphr.2021.2137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Heart disease in pregnancy is one of the leading causes of maternal mortality and morbidity in developing countries. However, the characteristics of the disease vary between countries and regions. This study aimed to present the characteristics of pregnant women with heart disease in an economically advantageous region of a developing country. DESIGN AND METHODS A cross-sectional study was conducted using data from the Weekly Report of Obstetrics and Gynaecology Department to assess pregnant women with heart disease characteristics and pregnancy outcomes. A total sample of 69 pregnant women with heart disease regarding their gestational age was included in the study. Variables observed were maternal characteristics, heart disease's clinical parameters, and maternal and neonatal outcomes. Chi-square test was used to examine the different characteristics of congenital and acquired heart disease groups. RESULTS The prevalence of cardiac disease in pregnancy was 5.19%. Fifty-three point six percent of pregnant women with heart disease were suffered from congenital heart disease (CHD), while 46.4% were acquired heart disease (AHD). Most labor methods were Cesarean delivery, and 69.6% of women experienced cardiac complications. Maternal death was reported in 8.69% of cases. Four cases were CHD complicated by pulmonary hypertension, which leads to Eisenmenger syndrome. Two other cases were AHD complicated by Peripartum Cardiomyopathies. Although statistically insignificant, complications are more common in the AHD group than CHD. CONCLUSION Cardiac disease prevalence in pregnancy is considered high, with CHD as the most common case, which significantly differs from other developing countries.
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Affiliation(s)
- Cyntia Puspa Pitaloka
- Master Program of Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya.
| | - Absa Secka
- Master Program of Public Health, Faculty of Public Health, Universitas Airlangga, Surabaya.
| | - Ernawati Ernawati
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital; Department of Obstetrics and Gynaecology, Airlangga University Academic Hospital, Surabaya.
| | - Agus Sulistyono
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital.
| | - Hermanto Tri Juwono
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital.
| | - Erry Gumilar Dachlan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital.
| | - Aditiawarman Aditiawarman
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Airlangga, Surabaya / Dr. Soetomo General Hospital.
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Liaw J, Walker B, Hall L, Gorton S, White AV, Heal C. Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis. PLoS One 2021; 16:e0253581. [PMID: 34185797 PMCID: PMC8241043 DOI: 10.1371/journal.pone.0253581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/08/2021] [Indexed: 01/08/2023] Open
Abstract
Purpose Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy. Methods Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I2 statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529). Findings The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54–5.33), and perinatal death (6 studies, RR 3.23, 1.92–5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02–4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02–5.95). Interpretation RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.
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Affiliation(s)
- Joshua Liaw
- College of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
- * E-mail:
| | - Betrice Walker
- College of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Leanne Hall
- College of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Susan Gorton
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Andrew V. White
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Clare Heal
- College of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
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Vaughan G, Dawson A, Peek MJ, Carapetis JR, Sullivan EA. Standardizing clinical care measures of rheumatic heart disease in pregnancy: A qualitative synthesis. Birth 2019; 46:560-573. [PMID: 31150150 DOI: 10.1111/birt.12435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Rheumatic heart disease (RHD) is a preventable cardiac condition that escalates risk in pregnancy. Models of care informed by evidence-based clinical guidelines are essential to optimal health outcomes. There are no published reviews that systematically explore approaches to care provision for pregnant women with RHD and examine reported measures. The review objective was to improve understanding of how attributes of care for these women are reported and how they align with guidelines. METHODS A search of 13 databases was supported by hand-searching. Papers that met inclusion criteria were appraised using CASP/JBI checklists. A content analysis of extracted data from the findings sections of included papers was undertaken, informed by attributes of quality care identified previously from existing guidelines. RESULTS The 43 included studies were predominantly conducted in tertiary care centers of low-income and middle-income countries. Cardiac guidelines were referred to in 25 of 43 studies. Poorer outcomes were associated with higher risk scores (detailed in 36 of 41 quantitative studies). Indicators associated with increased risk include anticoagulation during pregnancy (28 of 41 reported) and late booking (gestation documented in 15 of 41 studies). Limited access to cardiac interventions was discussed (19 of 43) in the context of poorer outcomes. Conversely, early assessment and access to regular multidisciplinary care were emphasized in promoting optimal outcomes for women and their babies. CONCLUSIONS Despite often complex care requirements in challenging environments, pregnancy provides an opportunity to strengthen health system responses and address whole-of-life health for women with RHD. A standard set of core indicators is proposed to more accurately benchmark care pathways, outcomes, and burden.
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Affiliation(s)
- Geraldine Vaughan
- Faculty of Health, Australian Centre for Public and Population Health Research (ACPPHR), University of Technology Sydney, Sydney, New South Wales, Australia
| | - Angela Dawson
- Faculty of Health, Australian Centre for Public and Population Health Research (ACPPHR), University of Technology Sydney, Sydney, New South Wales, Australia
| | - Michael J Peek
- The Australian National University and Centenary Hospital for Women and Children, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Jonathan R Carapetis
- Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia.,Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Elizabeth A Sullivan
- Faculty of Health, Australian Centre for Public and Population Health Research (ACPPHR), University of Technology Sydney, Sydney, New South Wales, Australia.,Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
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Sullivan EA, Vaughan G, Li Z, Peek MJ, Carapetis JR, Walsh W, Frawley J, Rémond MGW, Remenyi B, Jackson Pulver L, Kruske S, Belton S, McLintock C. The high prevalence and impact of rheumatic heart disease in pregnancy in First Nations populations in a high‐income setting: a prospective cohort study. BJOG 2019; 127:47-56. [DOI: 10.1111/1471-0528.15938] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2019] [Indexed: 12/19/2022]
Affiliation(s)
- EA Sullivan
- Faculty of Health and Medicine The University of Newcastle Newcastle NSW Australia
- Australian Centre for Public and Population Health Research Faculty of Health University of Technology Sydney Sydney NSW Australia
| | - G Vaughan
- Australian Centre for Public and Population Health Research Faculty of Health University of Technology Sydney Sydney NSW Australia
| | - Z Li
- Australian Centre for Public and Population Health Research Faculty of Health University of Technology Sydney Sydney NSW Australia
| | - MJ Peek
- ANU Medical School College of Health and Medicine The Australian National University Canberra ACT Australia
| | - JR Carapetis
- Telethon Kids InstituteThe University of Western Australia Perth WA Australia
- Perth Children's Hospital Perth WA Australia
| | - W Walsh
- The University of New South Wales Sydney NSW Australia
- Prince of Wales Hospital Sydney NSW Australia
| | - J Frawley
- Australian Centre for Public and Population Health Research Faculty of Health University of Technology Sydney Sydney NSW Australia
| | - MGW Rémond
- Australian Centre for Public and Population Health Research Faculty of Health University of Technology Sydney Sydney NSW Australia
| | - B Remenyi
- Menzies School of Health Research Charles Darwin University Darwin NT Australia
| | | | - S Kruske
- The University of Queensland Brisbane Qld Australia
- Institute for Urban Indigenous Health Ltd Brisbane Qld Australia
| | - S Belton
- Menzies School of Health Research Charles Darwin University Darwin NT Australia
| | - C McLintock
- National Women's Health Auckland City Hospital Auckland New Zealand
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Farhan HA, Yaseen IF. Heart disease in pregnancy-clinical pattern and prevalence: initial data from the first cardio-maternal unit in Iraq. BMC Res Notes 2019; 12:491. [PMID: 31391105 PMCID: PMC6686471 DOI: 10.1186/s13104-019-4523-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 07/26/2019] [Indexed: 12/17/2022] Open
Abstract
Objectives The purpose of this study to determine the clinical pattern and prevalence of heart disease in pregnancy at the first established cardio-maternal unit in Iraq over the last 4 years; since January 2015 till May 2019. Data are presented as number and percentage. Results A total of 252 pregnant women presented to cardio-maternal unit included in this study. According to the collected data, among the main diagnosis of heart disease during pregnancy was valvular heart disease 34.1%, followed by congenital heart disease 30.5%, cardiomyopathy 29.8%, pulmonary hypertension 4%, and ischemic heart disease 1.6%. Among subtypes of the main heart diseases in pregnant women, the most clinical pattern was: the prosthetic heart valve (26.7%) in valvular heart disease, both atrial septal defect and ventricular septal defect (35%) in congenital heart disease, and peripartum cardiomyopathy (76%) among cardiomyopathies.
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Affiliation(s)
- Hasan Ali Farhan
- Scientific Council of Cardiology, Iraqi Board for Medical Specializations, Baghdad, Iraq. .,Baghdad Heart Center, Baghdad Teaching Hospital, Medical City, Baghdad, Iraq.
| | - Israa Fadhil Yaseen
- Baghdad Heart Center, Baghdad Teaching Hospital, Medical City, Baghdad, Iraq
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Frøen JF, Myhre SL, Frost MJ, Chou D, Mehl G, Say L, Cheng S, Fjeldheim I, Friberg IK, French S, Jani JV, Kaye J, Lewis J, Lunde A, Mørkrid K, Nankabirwa V, Nyanchoka L, Stone H, Venkateswaran M, Wojcieszek AM, Temmerman M, Flenady VJ. eRegistries: Electronic registries for maternal and child health. BMC Pregnancy Childbirth 2016; 16:11. [PMID: 26791790 PMCID: PMC4721069 DOI: 10.1186/s12884-016-0801-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/07/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The Global Roadmap for Health Measurement and Accountability sees integrated systems for health information as key to obtaining seamless, sustainable, and secure information exchanges at all levels of health systems. The Global Strategy for Women's, Children's and Adolescent's Health aims to achieve a continuum of quality of care with effective coverage of interventions. The WHO and World Bank recommend that countries focus on intervention coverage to monitor programs and progress for universal health coverage. Electronic health registries - eRegistries - represent integrated systems that secure a triple return on investments: First, effective single data collection for health workers to seamlessly follow individuals along the continuum of care and across disconnected cadres of care providers. Second, real-time public health surveillance and monitoring of intervention coverage, and third, feedback of information to individuals, care providers and the public for transparent accountability. This series on eRegistries presents frameworks and tools to facilitate the development and secure operation of eRegistries for maternal and child health. METHODS In this first paper of the eRegistries Series we have used WHO frameworks and taxonomy to map how eRegistries can support commonly used electronic and mobile applications to alleviate health systems constraints in maternal and child health. A web-based survey of public health officials in 64 low- and middle-income countries, and a systematic search of literature from 2005-2015, aimed to assess country capacities by the current status, quality and use of data in reproductive health registries. RESULTS eRegistries can offer support for the 12 most commonly used electronic and mobile applications for health. Countries are implementing health registries in various forms, the majority in transition from paper-based data collection to electronic systems, but very few have eRegistries that can act as an integrating backbone for health information. More mature country capacity reflected by published health registry based research is emerging in settings reaching regional or national scale, increasingly with electronic solutions. 66 scientific publications were identified based on 32 registry systems in 23 countries over a period of 10 years; this reflects a challenging experience and capacity gap for delivering sustainable high quality registries. CONCLUSIONS Registries are being developed and used in many high burden countries, but their potential benefits are far from realized as few countries have fully transitioned from paper-based health information to integrated electronic backbone systems. Free tools and frameworks exist to facilitate progress in health information for women and children.
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Affiliation(s)
- J Frederik Frøen
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway.
| | - Sonja L Myhre
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
| | - Michael J Frost
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
- John Snow, Inc., Boston, MA, USA.
| | - Doris Chou
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Garrett Mehl
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Lale Say
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Socheat Cheng
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
- Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Ingvild Fjeldheim
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
| | - Ingrid K Friberg
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
| | - Steve French
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
| | - Jagrati V Jani
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway.
| | - Jane Kaye
- HeLEX - Centre for Health, Law and Emerging Technologies, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - John Lewis
- Health Information System Programme (HISP) Vietnam, Ho Chí Minh, Vietnam.
- Department of Informatics, University of Oslo, Oslo, Norway.
| | - Ane Lunde
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
| | - Kjersti Mørkrid
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
| | - Victoria Nankabirwa
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
- Department of Epidemiology and Biostatics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Linda Nyanchoka
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
| | - Hollie Stone
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
| | - Mahima Venkateswaran
- Department of International Public Health, Norwegian Institute of Public Health, Pb 4404 Nydalen, N-0403, Oslo, Norway.
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway.
| | - Aleena M Wojcieszek
- Mater Research Institute, The University of Queensland, Brisbane, Australia.
- International Stillbirth Alliance, Millburn, NJ, USA.
| | | | - Vicki J Flenady
- Mater Research Institute, The University of Queensland, Brisbane, Australia.
- International Stillbirth Alliance, Millburn, NJ, USA.
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