WHAT IS THE PROBLEM? Caesarean section is considered a life-saving procedure for pregnant women and their babies. Yet, in low- and middle-income countries, mothers who give birth by caesarean section are 100 times more likely to die than those having the procedure in high-income countries. In these settings, caesarean sections also contribute to life-long health problems that affect the women's quality of life and their ability to safely have more children. Their babies are also at high risk of dying during or soon after caesarean section. The three main reasons for poor outcomes after caesarean section in low- and middle-income countries are: 1. Inappropriate caesarean sections (e.g. performed 'too many, too soon' or 'too little, too late') 2. Unsafe practices in performing the procedure 3. Substandard care in labour (e.g. not culminating in vaginal birth which leads to complicated caesarean sections in advanced labour). Many issues contribute to the above problems such as lack of knowledge and skills to undertake safe caesarean section (and to achieve safe vaginal births - both normal and by using instruments). In addition, attitudes towards caesarean section and use of vacuum or forceps, marginalisation of midwives, dysfunctional teamwork, a culture of blame and medico-legal concerns, influence of family members and communities in decision-making, poor communication skills between women and healthcare providers and amongst clinicians, and inability to determine why caesarean sections are performed worsen the problem. WHAT IS NEEDED? There is no single solution to the above complex problems. We need to both improve the safety of caesarean sections and ensure they are only done when needed. To do this, we will co-develop evidence-based interventions that are acceptable, equitable, sustainable and which can be adapted or scaled-up cost-effectively across settings, by collaborating with women and their support networks, healthcare providers, policymakers and other relevant stakeholders. WHAT IS OUR AIM? We propose a 5-year Programme that aims to improve mother and baby outcomes following caesarean sections in low- and middle-income countries. The Programme (C-Safe) plans to (ii) ensure caesarean sections are done for the right reasons (C-Why), (ii) improve their safety (C-Op), and (iii) promote safe and respectful care in labour resulting in vaginal births, including safe delivery with instruments (C-Non). The C-Safe intervention will be implemented using a comprehensive training Programme, empowerment of local opinion leaders (C-Safe Champions) and mothers, team-based working, and learning through audit and feedback, in four hospitals each in India and Tanzania (30,000 births). WHAT WILL WE DO? The C-Safe Programme involves four work packages that will (i) identify and bring together evidence on the effects of interventions and outcomes, (ii) rank the interventions and outcomes according to their importance to key local professionals, local maternity care users, and community members, (iii) develop the interventions with regional healthcare providers, women and policymakers on what is considered to be beneficial, acceptable, relevant, accessible and feasible and (iv) test whether the C-Safe strategy changes practices and increases uptake of the intervention by healthcare providers, as well as the number of women receiving it. We will also assess costs and views of healthcare providers, women, their family and community members on being part of it. Building academic and training capacity and capability, and involving women and their communities in all aspects of the study, are core features. WHO ARE THE TEAM MEMBERS? The team includes doctors, , midwives, experts in study design, patient and public involvement groups, trainers, policymakers. They are supported by members of the World Health Organization, UNICEF, Jhpiego, Professional associations, ELLY Charity.

Every year around 30 000 women die from high blood pressure in pregnancy (pre-eclampsia). In South Asia alone it is responsible for 10 000 deaths annually. Many of these deaths are preventable with timely delivery of the baby, which is the only curative treatment. Vaginal delivery is safer than caesarean section (CS) but labour induction in preeclampsia presents additional challenges. It is more difficult as mothers are often preterm and in their first pregnancies, and more dangerous as babies can be growth restricted. Induction of labour occurs in two stages; softening and opening of the neck of the womb (cervical ripening) followed by stimulation of contractions (augmentation). Our previous study established low dose oral misoprostol (LDOM) as the optimal method for cervical ripening in the low and middle-income country (LMIC) setting, and this is now strongly recommended by the World Health Organization. Standard practice in these settings is cervical ripening with LDOM followed by augmentation using intravenous oxytocin through a gravity drip infusion (M/Ox). However, gravity drip infusions have a high potential for human error and equipment faults, so constant monitoring and accurate titration of oxytocin are essential. Excessive contractions put mothers and babies at risk; whereas inadequate contractions lead to a failed induction. Both these mechanisms could explain the high CS rate (41%) seen in our previous labour induction study 'INFORM' in India. There is an urgent need to establish a safe and effective induction method that does not rely on oxytocin for augmentation. Avoiding oxytocin and continuing LDOM into labour for augmentation, could have numerous clinical and logistic benefits: - A cold-chain is not required for LDOM as it is heat stable (unlike oxytocin). - The lack of an intravenous infusion means that women will be free to mobilise in labour. - LDOM does not need to be actively monitored or titrated against contractions. It is therefore less work-intensive than an oxytocin infusion, giving health practitioners more time to care for other aspects of the women's labour. - The simplicity of the protocol may allow task-shifting. - In the absence of close monitoring, an unattended patient on oxytocin could receive hours of inappropriate stimulation. In contrast, LDOM does not need constant monitoring, the stimulation will cease unless there is drug administration every 2 hours. - There will be significant health system savings by negating the need for IV infusion pumps and continuous presence of a health practitioner. A misoprostol-only induction protocol has been successfully used in three randomized trials in South Africa. The trial participants that received a misoprostol-only (M/M) protocol required 40% less CSs compared with those using a standard (M/Ox) protocol (15 vs 26%). Despite promise, these rates cannot be directly compared as they occurred in different trials. Indeed, no published study has ever directly compared the two protocols. We propose a randomized superiority trial in three large government hospitals in Nagpur, India. 1000 pregnant women with hypertensive disease will be randomly allocated to use the conventional (M/Ox) protocol or the misoprostol only (M/M) protocol. The primary objective is to investigate whether a misoprostol only labour induction (M/M) protocol, compared to the standard protocol (M/Ox), can reduce the rate of CS in women undergoing labour induction for pre-eclampsia in low-income settings. We also propose a qualitative study, a situational analysis and an economic evaluation to be conducted alongside the trial. The objectives of these studies are: to explore care providers' perspectives on the potential advantages, barriers and risks of each protocol; understand current knowledge, attitudes and practices concerning induction of labour; and compare the cost-effectiveness of the protocols.

During the twentieth century, Britain experienced several radical transformations of its sexual-health policies and services. These developments brought huge benefits and helped to break down the stigma and inequalities that impeded access to care. Yet fundamental problems remain. Compounding these problems, sexual-health services are threatened by a looming crisis of antibiotic resistance and funding cuts to Local Authorities. History has much to teach us as we face such challenges. Understanding the historical impact of clinical practices, social conditions, cultural attitudes and policy interventions enables us to recognise long-term trends and patterns. And it makes us better equipped to tackle persistent and emerging challenges in sexual-health outcomes, service delivery and service-user experiences. I am heading an interdisciplinary project that arms us with this knowledge, tracing sexual health in Britain from the end of the First World War to the beginning of the AIDS epidemic. Today, sexual health is defined as the ability to lead a pleasurable and safe sex life and is recognised as a vital component of overall health and wellbeing. Historically, its definition was much narrower. In clinical practice, it meant combating syphilis and gonorrhoea, the principle 'venereal' diseases (VDs) preoccupying health authorities. In the public imagination, it meant remaining morally and eugenically 'fit' to ensure the future health of the race and nation. Gradually, sexual health ballooned, becoming its own clinical field and encompassing a variety of other, newly identified VDs like chlamydia as well as diverse provisions for maternal welfare and family planning. Key to this project is Britain's state-funded VD Service. Established in 1918 and integrated into the NHS after 1948, it was a vital part of Britain's shift towards socialised medicine. Millions of patients passed through its nationwide network of clinics. Yet the entire scheme has been overlooked by all but a handful of scholars. Building on their work, we employ new methods and underused archives to push into understudied time periods, places and themes. We take inspiration from a growing collection of transnational sexual-heath histories, exploring Britain's involvement in initiatives set up by the League of Nations and, later, the WHO to understand how regional politics and culture has influenced responses to global challenges. And because the project prioritises service-user experiences, an important focus is on oral histories that we will conduct with people who accessed or staffed clinics between 1948 and 1980. The project addresses major gaps in the history of sexual health and provides vital context for current problems. But in exploring historical sexual health, it also foregrounds a range of themes in British history. For example, the VD Service was intended to help overcome gender, class and racial inequalities in access to healthcare. Certainly, this government initiative went a long way towards correcting a variety of social injustices and endemic health challenges. But in practice, within the clinics and wider society, prejudices and stigma persisted for decades and continue even into the present. Women and the working classes continued to be viewed as 'vectors' of contagion, in need of management and surveillance. The structural violence faced historically by LGBTQ+ communities within healthcare continues today to undermine their wellbeing and health outcomes. Similarly, institutional racism continues to have a damaging impact on BAME sexual-health experiences. With its robust research, policy and engagement programme, the project will enrich humanities and health research, build public understandings of sexual health, inform policy, augment clinical training and create more reflexive practices among health workers. In so doing, it will have long-term benefits in improved sexual-health outcomes and service-user experiences.