It is critical to determine whether and which of our interventions improves maternal survival in settings with substandard care, and thus reduce maternal mortality where most of it continues to occur.
Additional evaluations with other medicines, both falsified and substandard, and in other geographical settings are required.
Individuals with concurrent disorders (CD) are overrepresented in forensic settings, regularly inhabit substandard housing [ 2, 3] and constitute a significant percentage of the homeless population [ 4, 5].
It has been shown that delay by the professional is the most substantial contributor to substandard care even in high-income settings [ 37].
We know that the expense and complexity of measuring maternal mortality has hindered our efforts to conduct the rigorous research necessary to determine if our interventions are saving women's lives in settings where care is substandard; and if so, to what extent and how.
Some have proposed that the millions spent on programs to prevent postpartum hemorrhage have significantly reduced maternal mortality, yet this has not been directly assessed by rigorous research in the settings where there is substandard access to and/or quality of care, where most maternal mortality occurs [ 30].
We suggest that, above and beyond monitoring and evaluation, rigorous research is necessary to measure the impact of the interventions we promote for scale up on the theory that they may prevent maternal mortality in settings where women typically receive substandard care to understand if they are indeed effective in such settings without coexistent improvement of supportive care.
Moreover, in resource-poor post-conflict settings, training provision may have been substandard prior to conflict, and therefore national decision makers in conjunction with international partners may seize opportunities in the early post-conflict period to redress these deficiencies.
The small number of early neonatal deaths, compared with the much larger number of stillbirths, suggests that some early neonatal deaths may have been misclassified to conceal substandard care at birth, a relatively common phenomenon in low-resource settings [ 34].
To their credit the observations of labour and birth showed full adherence of the SBAs to the last five 'cleans', but hand washing was substandard and strategies to improve compliance have been challenging even in resource rich settings [ 26].
