Emotional and social competencies have been shown to be extremely desirable in young people for their successful entry into the labor market. Their development has been studied primarily as a result of formal training in the educational and work domains, whereas relatively little is known about the role played by extracurricular activities in promoting these types of competencies. Non-working personal experiences are often used as proxies to assess the emotional and social competencies of candidates in recruitment and selection phases. However, this inference is not based on clear scientific evidence. Drawing on experiential learning theory, this study investigated empirically the relationship between a range of extracurricular activities  and the competency portfolio of graduates. Data were collected from a sample of 324 graduates through a structured survey and a multi-rater assessment of their emotional and social competencies. The results of the Partial Least Square-Path Modeling in general provide support for the positive association between experiential extracurricular activities and emotional and social competencies, although not all relationships are supported. The present study contributes to advance in the understanding of the determinants of emotional and social competencies by examining their relationship with a broad range of extracurricular activities. Moreover, it discusses implications for higher education and human resource management. The current economic environment, characterized by increasing competition, flexibility, and continuous rapid change, has led companies to look for new employees with personal characteristics that go beyond their mere technical ability. Nowadays, people who want to enter the labor market are required to show a set socio-emotional competencies  in promoting specific sets of ESCs , and discuss the implication of these relationships for higher education and human resource management.Behavioral competencies are defined as “related but different sets of behavior organized around an underlying construct, which we call the ‘intent”  MIUR, . Sixty pWe asked students the intensity with which in the past they had participated in different types of ECA, using a scale from 1 (never) to 5 (more than twice a week). Previous studies suggest that frequent exposure to an activity is needed to experience the positive developmental outcomes associated with participation in that environment  was used . PLS–PM was adopted because it does not make assumptions on data distribution , Bachelor's degree final grade, and gender.Our analysis was carried out in three steps. First, we performed an exploratory data analysis. Correlations between the main variables are presented in Second, we assessed the quality of the measurement model. Convergent validity was assessed through the average variance extracted (AVE). All competency groups showed an AVE larger than the commonly accepted threshold of 0.5 . As for H2, we found support for the relationship between the participation in cultural activities and the relationship management competency group . Findings seemed also to support the positive influence of cultural activities on the cognitive group, with results significant at the p = 10% level . As for experiences abroad (H3), we predicted a positive relationship with self-management , social awareness , relationship management , and cognitive competencies . The relationship with social awareness was tentatively supported, whereas the positive relationship between experiences abroad and self-management, relationship management, and cognitive competencies found evidence in our empirical analysis. Concerning Hypothesis 4, partial support was found. According to our results, participation in sport activities is positively related to higher self-management competencies , but not significantly related to the relationship management competencies . The category of sport activity used in the model included both individual and team sports; nevertheless, when conducting the analysis by separating the two types of sport activities no significant difference was found.Hypothesis 1 on volunteering was not supported , involve several participants, offer supervision and guidance from adults, and are organized around developing particular skills and achieving goals”  may require a more conscious effort, thus are more likely to occur when stimulated by structured or supervised relationships. Coaches and teachers, who act as sources of support and feedback, may promote the process of making sense of events and understanding the linkages between them. Prior studies considered their role paramount in promoting a sustainable behavioral change (Kampa-Kokesch and Anderson, The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.LC and SB contributed to the conception and design of the study and manuscript revision. LC, SB, and FG contributed to the data collection. CP defined the method and performed the data analysis. LC wrote the first draft of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Salud Mesoamérica Initiative (SMI) is a public-private collaboration aimed to improve maternal and child health conditions in the poorest populations of Mesoamerica through a results-based aid mechanism. We assess the impact of SMI on the staffing and availability of equipment and supplies for delivery care, the proportion of institutional deliveries, and the proportion of women who choose a facility other than the one closest to their locality of residence for delivery.We used a quasi-experimental design, including baseline and follow-up measurements between 2013 and 2018 in intervention and comparison areas of Guatemala, Nicaragua, and Honduras. We collected information on 8754 births linked to the health facility closest to the mother’s locality of residence and the facility where the delivery took place . We fit difference-in-difference models, adjusting for women’s characteristics , household characteristics, exposure to health promotion interventions, health facility level, and country.Equipment, inputs, and staffing of facilities improved after the Initiative in both intervention and comparison areas. After adjustment for covariates, institutional delivery increased between baseline and follow-up by 3.1 percentage points  more in intervention areas than in comparison areas. The proportion of women in intervention areas who chose a facility other than their closest one to attend the delivery decreased between baseline and follow-up by 13 percentage points  more than in the comparison group.Results indicate that women in intervention areas of SMI are more likely to go to their closest facility to attend delivery after the Initiative has improved facilities’ capacity, suggesting that results-based aid initiatives targeting poor populations, like SMI, can increase the use of facilities closest to the place of residence for delivery care services. This should be considered in the design of interventions after the COVID-19 pandemic may have changed health and social conditions.The online version contains supplementary material available at 10.1186/s12884-021-04279-2. Maternal and child health has improved in recent years, but health conditions related to pregnancy and delivery and in children under five are still an important contributor to the burden of disease in Mesoamerica , 2. InstThe Salud Mesoamérica Initiative (SMI) is a public-private collaboration aimed to improve maternal and child health conditions in the poorest populations of Mesoamerica since 2011 through a comprehensive health care strategy to improve access to, use of, and quality of maternal, reproductive, neonatal, and pediatric health services. It is coordinated by the Inter-American Development Bank, and, through a results-based aid mechanism, works with countries in the region to reduce health disparities in geographic areas with the highest proportion of the population living in poverty .Data on background conditions of coverage and quality of institutional delivery among poor populations in Mesoamerica were collected prior to the start of SMI as an input for the design of its interventions. The main barriers to access to institutional delivery include economic and geographic barriers to travel to health facilities, including roads and transportation networks and availability of public or private transportation; lack of proper infrastructure and human resources in health facilities; negative perceptions about the health services; and cultural and religious barriers –12.This paper refers to three countries participating in SMI: Honduras, Nicaragua, and Guatemala. There are substantial differences in the coverage of institutional delivery across these countries, with very low coverage of institutional delivery in Guatemala (57.5%) as compared to Nicaragua (89.6%) or Honduras (74.0%) by 2017 . Health Previous work has documented barriers and facilitators for institutional delivery in these countries and found that women travel to more distant facilities to attend their deliveries, either complicated or uncomplicated, if they perceive facilities located farther away to be of better quality . By imprTherefore, we seek to evaluate if the Initiative has improved the capacity of health facilities to attend deliveries and if the patterns of delivery service utilization changed by assessing the impact of SMI on three outcomes: the availability of providers, equipment, and supplies, as well as quality of care around delivery ; the proportion of deliveries occurring in health facilities, identifying associated factors; and the proportion of women who attend a facility other than the closest one to give birth, identifying factors associated with this outcome.SMI was planned from the beginning to have two to three interconnected phases. A first phase of SMI (2013–2014) supported activities to improve the availability of staff, equipment, and supplies in MOH health facilities in all participating countries —such as improving supply chains and inventory management systems, designing and beginning implementation of the EONC strategy, reviewing staffing policies, and creating capacities for emergency obstetric and neonatal care. In a second phase (2015–2017), SMI incorporated supply-side and demand-side interventions aiming to improve the coverage and quality of care. In addition to previous interventions, interventions in this phase included the implementation of community and individual birth plans, behavior change communication strategies with cultural adaptations , establishing or improving community platforms, strategies for early catchment of pregnant women in communities and facilities, funding systems for the transportation of pregnant women, operation of maternity homes, strengthening referral systems, establishing user management systems, training traditional birth attendants to detect risks and refer cases, implementing continuous quality improvement strategies and health care network management initiatives , among others –21. The The SMI impact evaluation has a quasi-experimental design, with three partial-panel measurements in health facilities and two repeated cross-sectional measurements in households. This analysis uses information collected in health facilities and households in intervention and comparison areas of the Initiative at baseline (2011–2013) and following implementation of two phases of interventions (2017–2018).This analysis is restricted to Honduras, Nicaragua, and Guatemala, countries for which we have the required information for this analysis. Further details on SMI measurement methodology have been published elsewhere . In summTo get information from households, we conducted our own census in a set of communities selected with probability proportional to size to identify eligible households with women aged 15 to 49 years and children under 5. Among eligible households, we selected a random sample of 30 households per community to conduct the full SMI survey. To get information from health facilities, at the baseline, among the facilities that provide services to communities selected for the household survey, facilities that provide ambulatory EONC were selected at random from the MOH roster of facilities. Given the small number of facilities providing basic or comprehensive EONC in the study areas, we included in our sample all facilities of those levels in the intervention and comparison areas. We used a similar procedure for the selection of health facilities in the follow-up measurement, with the only difference that half of selected ambulatory-level facilities included in the follow-up sample were selected from facilities visited in the baseline measurement. Due to safety issues, data collection in Nicaragua during the baseline measurement had to be interrupted, allowing us to get information from 31% of the facilities providing basic or comprehensive EONC in the proposed sample.The baseline surveys were conducted in Honduras between January 17 and June 1, in Nicaragua between March 1 and August 29, and in Guatemala between April 15 and August 11, all in 2013. Follow-up data were collected in Honduras between May 29 and October 25, 2017, in Nicaragua between June 14 and December 20, 2017, and in Guatemala between May 7 and August 29, 2018.SMI used a computer-assisted personal interviewing (CAPI) system for data collection. The household survey was conducted at each household by trained interviewers, who read the questions to the interviewees and registered the answers in the computer, and assessed utilization of health services, barriers to care, and population health outcomes alongside health system infrastructure and delivery care components. Interviews with indigenous-language speakers were conducted in the corresponding indigenous languages by interviewers fluent in them, using a standard translation. Respondents were asked to indicate which health facilities were visited for different types of care, allowing us to link household information with facility conditions and services. The household survey included an interview of the head of household or person best informed about the household to collect information on household services and materials, ownership of assets , household expenses, and sources of health care financing. All women of reproductive age (15 to 49 years) in the household were interviewed about their demographic characteristics, access to health care, current health status, recent history of illness and associated medical expenses, birth history, knowledge and use of family planning methods, exposure to health interventions, and satisfaction with community health workers. Women with children 0 to 59 months old were asked questions about health conditions and health services utilization of each child.The health facility survey was conducted by trained medical personnel using CAPI and collected data on facility conditions, service provision and utilization, and quality of care. Health facilities were grouped according to three levels of EONC – ambulatory, basic, and comprehensive – following the official classification of each country. Mainly, ambulatory facilities provide outpatient care; basic facilities are able to attend uncomplicated vaginal deliveries and provide immediate emergency obstetric and neonatal care; and comprehensive facilities have a surgery room and are able to attend most obstetric and neonatal complications (not including intensive care). The facility director or person in charge of the health facility was interviewed by a trained interviewer in the facility to capture information on general facility characteristics, infrastructure, human resources, supply logistics, infection control, child health care, vaccine availability, family planning service provision, availability of contraceptives, and antenatal, delivery, and postpartum care services. Surveyors used an observation checklist to record direct observations of the availability and functionality, as applicable, of essential equipment and supplies required for maternal and child health care, including pharmaceuticals.The health facility survey also included a medical record review (MRR) where information was extracted from a random sample of medical charts of women who had given birth in the facility in the 2 years prior to data collection. The methods for selection and review of records have been described elsewhere –24.The study received institutional review board (IRB) approval from the leading institution and the MOH in each country. Methods were carried out in accordance with the national guidelines and regulations of participant countries and the Declaration of Helsinki. All women and personnel responsible for health facilities responding to the interviews signed informed consent forms prior to data collection. Identifying personal information was not collected in any component of the study.We define as institutional delivery any delivery that took place in a health facility regardless of facility type (public/private) or level . For births in health facilities, our sample is restricted to births for which the nearest facility could be identified and was included in the study see Fig. . The houIn addition to recording municipality and locality of residence, the household survey asked women about the name of the closest health facility, the health facility she usually attends, and the most recently visited health facility; the name and type of the facility she attended for her delivery (if any), and the self-reported distance (km), travel time (hours or minutes), and mode(s) of transport to the delivery facility. Because women typically reported ambulatory care facilities, which are limited to outpatient care and do not routinely provide delivery services, as their nearest and usual health facilities, we determine as the “closest” health facility for delivery a public establishment where the woman would be expected to deliver based on municipality and locality of residence, the referral network of the public health system, and a locality-by-locality review of the facilities women reported attending for delivery and for other health care needs. In this manner, we matched each selected community to its expected delivery facility. This matched facility is hereafter referred to as the “closest” facility for delivery.The health system referral networks are based on municipal boundaries, and most municipalities have at least one basic or comprehensive EONC level facility, which in the majority of cases was also the nearest facility with capacity to attend delivery by travel time. Women in two municipalities  matched to facilities that were not included in the health facility survey; we excluded these deliveries from the analysis of delivery location since facility-level variables were not measured at their closest facility.We use the information from the health facility survey to construct a 6-point score of capacity to attend uncomplicated vaginal deliveries that included round-the-clock availability of skilled birth attendants , availability of all basic equipment for antenatal and postpartum care , and availability of basic inputs for delivery care such as oxytocin , methylergometrine or ergometrine maleate , and Ringer’s lactate/Hartmann’s solution or saline solution .Additionally, we use information extracted from the charts of patients with uncomplicated vaginal deliveries at these health facilities to construct two indicators for quality delivery care as defined through SMI. First, the survey recorded whether the patient was administered oxytocin or another uterotonic after delivery according to standards for active management of the third stage of labor. Second, it collected information on immediate postpartum care, including checks of the mother’s temperature and blood pressure during the first 2 h after delivery and at discharge from the health facility.The household questionnaire collected information on which health personnel were present during delivery, reasons for not delivering in a health facility , accompaniment by a traditional birth attendant, type of delivery , seizures experienced during delivery, receipt of antenatal care, advice to have the delivery in a health facility, and advice to create a transportation plan.We collected information on the woman’s age, marital status, literacy, education , occupation , and number of previous pregnancies. In order to measure household conditions, we calculated a household asset index based on household assets . We collected information on the itemized monthly household expenditure as reported by the survey respondent and calculated per capita expenditure quintiles in each country and round. We use the countries’ census data –27 to deWe analyze the impact of SMI on three outcome variables: institutional delivery ; choosing a more distant facility for delivery (1 = delivery at a more distant facility vs. 0 = delivery at the closest facility) and the capacity score of facilities to attend deliveries. We restrict our sample to women who gave birth in a health facility, if the facility was included in the study, for the analysis of choice of delivery facility. Additionally, we exclude deliveries via C-section (to account only for uncomplicated deliveries) in the analysis of choice of delivery facility , problems with staff , and having care denied when they have tried to go to a health facility. Other obstacles groups not being advised to deliver in a health facility and other reasons.We used Stata version 15  and R veWe collected information on 14,012 women with births in the last 5 years. Our analysis on institutional delivery is based on 8754 births in the inclusion time frame for which data for the nearest facility are included in the study. For the analysis on facility choice, after excluding births at facilities not surveyed during the study, births in ambulatory facilities, and home births, we end up with a sample of 3906 births that occurred in facilities in the study. Finally, excluding deliveries by C-section, 2804 births of unique women with complete data are available for inclusion in the analysis . Almost all women attended antenatal care before their deliveries (91.4% in intervention and 96.1% in comparison). However, a smaller proportion received counseling about facility delivery, were advised to give birth in a facility, and were informed they should have a C-section. Only 26.5% of women in the intervention area and 29.5% in comparison areas were advised to create a transportation plan. The exposure to these antenatal interventions also varies by country, being lower in Guatemala. Additional characteristics of women at baseline are presented in Additional file Baseline characteristics of women included in the analysis are presented in Table Overall, 33.3% of the facilities in intervention and 26.3% in comparison group were classified as comprehensive EONC level at baseline. Most of the facilities had a skilled birth attendant available . The proportion of comprehensive-level facilities in the sample is lower in Guatemala and higher in Honduras and Nicaragua for both groups  and a decrease in the comparison group 82.6 to 63.1%)  and in comparison groups (49% at baseline and 86.1% at follow-up)  and an upward one in Nicaragua (from 15.5 to 22.6%)  or seizures  as women who delivered at a basic-level facility .We examine whether women who had stayed in a maternity home were more likely to have delivered in a more distant health facility. However, we find evidence of the opposite pattern – in Honduras in intervention areas at follow-up, women who had stayed in a maternity home were substantially less likely to choose a distant facility . In comparison areas, women chose to deliver at a more distant facility at the same rate regardless of use of a maternity home . In Nicaragua, women were slightly more likely to choose a more distant facility for delivery if they did not use a maternity home .This is the first study documenting a decrease in the choice to travel farther to attend a delivery after SMI, an initiative aimed to improve access and quality of delivery care in Guatemala, Honduras and Nicaragua. We found that women were more likely to deliver in a more distant facility when the facility attending the delivery had a higher capacity than the closest facility, as measured by our capacity score. This is a crucial finding since attending deliveries at local facilities indicates the use of resources was optimized, which can lead to more efficient performance of the health system and improvements in health conditions. Although other factors could play a role, results suggest a shift in care-seeking behavior that could be related to changes in the supply of care, including increased capacity of a facility to attend deliveries and reorganization of the health care network. Findings from SMI could be used to improve health care in other regions by improving the supplies and practice at the local level.It has been recognized that increasing access to health services without an improvement of quality of care is not enough to achieve health gains , 31. In The selection of place to attend a delivery is also affected by personal characteristics, some of which we were able to explore in this study. We found a higher proportion of institutional deliveries among women with more education and higher socioeconomic status. Institutional delivery was lower among multilingual women in Guatemala, the country with the highest proportion of multilingual population, which can also reflect differences in socioeconomic status of these groups. While SMI had a modest impact on institutional delivery itself, the analysis of the reasons for not delivering in a health facility indicates that cultural reasons are an important driver for choosing a home delivery, both before and after the intervention and in both intervention and comparison groups. Creating health services that are culturally sensitive and adapted to population needs should be a priority to encourage in-facility deliveries . BecauseEach country in this analysis has a public health system, organized as a network in which each facility is assigned a service population following geographical criteria, with a referral system in place where cases can transit from lower to more specialized levels of care, although referrals may face problems due to limited resources for transportation or functioning of facilities. Even when ambulatory healthcare facilities refer pregnant women for delivery care to a specific facility, which is usually the closest, women may decide to attend a different one. The selection of a place to receive delivery care is a complex process that involves individual aspects, but also cultural and social determinants (like race or socioeconomic status), other determinants of quality of care at the facility level and trust in health services. Under these conditions, SMI had a significant impact on the selection of facilities where delivery was attended, decreasing the likelihood that a woman chose to travel beyond her nearest birth facility to deliver. Attending delivery at the closest facility may reduce travel times for women, encourage institutional delivery, and reduce risks associated with delayed arrival to the health facility. In addition, delivery at the closest facility reduces the pressure on some facilities in the health systems of these countries, optimizing the capacity of the existing network. Although selecting a more distant facility for delivery is not necessarily harmful as long as women attend a facility with the proper capacity to attend a delivery, results of this study suggest that the improvement of facilities’ capacity to attend delivery supported by SMI has led to a reduction in “bypassing” behavior in cases in which the closest facility has adequate capacity, promoting a better use of health system resources.The increased use of nearby facilities for delivery care is an important finding as we move toward universal health coverage (UHC). UHC implies financial protection but also the need for improved health system performance, so health services need to achieve a given level of quality to be effective . SuccessFurthermore, SMI intervention focused on the health sector, specifically the MOH, while broader political, economic, or societal changes would be necessary to address the social determinants of health. Our results show that health interventions can have an impact on health behaviors, but broader multisector interventions may be needed to achieve deeper and long-lasting impact. Other factors related to social conditions that may affect the decision-making process to select a facility for care play an important role as discrimination has been documented in these countries, especially in Guatemala with indigenous populations , and itsWe recognize that the strongest evaluation model to assess the impact of an intervention like SMI would be an experimental design, in which areas are allocated at random to intervention and comparison groups, with pre and post measurements. A controlled experiment cannot be implemented on a large-scale health program. SMI instead has a quasi-experimental design in which areas with the highest concentration of poverty were assigned to receive the intervention, and comparison areas were identified in each country matching on socioeconomic characteristics. Because of this limitation, comparison and intervention groups are not always similar at baseline in observable and non-observable characteristics, including safety concerns and socioeconomic conditions. In addition, because the household measurement is not designed as a panel and the observation unit of the analysis is a birth, we do not have repeat measurements of the same women over time, but rather two independent cross-sectional samples of births of women in the same study area. To address these limitations, we employ a difference-in-difference approach, and adjust for a set of covariates to control for the effect of socio-demographic characteristics that may confound the estimation of the impact of SMI.The information about health facility characteristics relies on observation and therefore is not prone to reporting bias. We faced limitations in the measurement of capacity of health care facilities. Our facility capacity index may have a limited ability to capture changes in the staffing and availability of inputs and equipment in the facility over time, and could not measure other aspects like competency of health professionals, waiting times, and availability of medications in a homogenous way across countries. We must recognize that having the minimum requirements of inputs and equipment does not fully explain quality of care. Due to small subsample sizes, it was not possible to incorporate quality of care indicators from the MRR to the capacity index. To overcome this limitation, we document the changes in staffing and specific equipment and inputs that may reflect progress in this area over time. The capacity score we constructed for this study builds on one we previously used that was able to distinguish levels of capacity in a sample of facilities included in the baseline measurement of SMI . FurtherInformation from the surveys allows us to link the locality of residence of women with their closest facility  and the facility they actually attended for delivery. For confidentiality issues, we did not collect geographical coordinates of the households of participants. The matching method chosen may be imprecise in a few cases where women live far from the center of the locality, and may be inaccurate in the case that a woman was living or visiting outside the municipality of current residence at the time of delivery. In addition, our sample for the choice of health facility analysis is restricted to births for which the nearest facility could be identified and was included in the study. Given that we restrict our sample for the choice of health facility analysis, our results do not necessarily depict SMI’s impact on institutional delivery coverage.Although the activities of SMI were focused in the areas selected for the intervention, it is possible they have a spillover effect, also generating changes in the health services in comparison areas. MOHs could scale-up SMI interventions to other areas of the country including comparison municipalities, which could have mitigated the impact of our evaluation. We anticipate higher potential for spillover effects in Nicaragua, where national policies encourage the application of innovations nationwide. In addition, due to the location of some comparison areas contiguous to intervention areas, it is possible for women in comparison areas to be referred or seek care at hospitals that also provide services to intervention areas. We would expect these biases to result in improved performance in comparison areas, in which case the results presented here may underestimate the true impact of the Initiative in intervention areas.This study is based on large probabilistic samples of households and health facilities in the participating countries, and it was possible to link information from both sources as part of the analysis. However, the level of confidence to make inferences for individual countries is limited by sample size, especially in the case of Nicaragua. The three countries included in this analysis have very different coverage of institutional delivery, which is higher in Nicaragua and Honduras and lower in Guatemala. Although the sample size for each country limits our capacity to make reliable conclusions for each individually, the findings from pooled analysis across countries indicate that an improvement in the capacity of health facilities through an intervention like SMI can generate higher utilization by the population. The timing of the evaluation and the occurrence of the COVID-19 pandemic indicate we need to reflect about our results considering the changes the pandemic has brought in health systems.The results of this study indicate that SMI had a positive impact on delivery care in Nicaragua, Honduras, and Guatemala, reducing women’s election to travel to a more distant facility to give birth in favor of local facilities where the Initiative aimed to increase capacity and quality of delivery care. This study occurred before the COVID-19 pandemic, which may have set back many of the improvements achieved. The SMI final evaluation will account for the impact of COVID-19 at the household and facility level to make recommendations on how best to address the challenges posed by the pandemic. So far, the main lesson of this experience is that if we can improve delivery care with adequate supplies and actions to improve its quality, the population will attend health services closer to their place of residence instead of traveling farther to seek care, increasing convenience and reducing costs for individuals, and improving efficiency in the health system. This intervention model can be applied in other countries with similar social and health conditions.Additional file 1: Supplemental Table 1. Additional characteristics of women at baseline in intervention and comparison groups, overall and by country. Supplemental Table 2. Characteristics of women at follow-up in intervention and comparison groups, overall and by country. Supplemental Table 3. Unweighted OLS models predicting facility score, overall and by country. Supplemental Table 4. Results of medical record review of uncomplicated deliveries in the last 2 years at baseline and follow-up for intervention and comparison groups by country. Supplemental Table 5. Reasons for not delivering in facility at baseline and follow-up in intervention and comparison groups by country.


Nanosponges are nanosized drug carriers with a three-dimensional structure created by crosslinking polymers. They have the advantage of being able to hold a wide range of drugs of various sizes. Nanosponges come in a variety of shapes and sizes. They are distinguished by the research method used, the type of polymer used, and the type of drug they may contain. Nanosponges are superior to other delivery systems because they can provide a controlled drug release pattern with targeted drug delivery. The period of action, as well as the drug’s residence time, may be regulated. Since it is made of biodegradable materials, it has a low toxicity and is safe to use. The efficiency of drug encapsulation is determined by the size of the drug molecule and the amount of void space available. Cancer, enzyme and biocatalyst carrier, oxygen delivery, solubility enhancement, enzyme immobilization, and poison absorbent are some of the applications for nanosponges. The method of preparation, characterization, factors affecting nanosponge development, drug loading and release mechanism, recent developments in this area, and patents filed in the area of nanosponges are all highlighted in this study. The nanosponges are nanostructures that can carry small drug molecules.These can be administered by multiple routes and have a variety of applications.Variety of drugs with hydrophilic and hydrophobic characteristics can be administered for the treatment of many diseases.They are porous in nature, crosslinked by the use of multiple polymers.Their internal portion is porous in nature and has voids, which has the capacity to hold drug molecules. This drug delivery system has a major accomplishment of providing a solution to the problems related to the release of the drug at the specific site at a determined rate . NanotecThere are many types of NS that are available and can be designed and formulated depending on the polymer added, its concentration, and the method of preparation used accordingly. The most common types of NS which are prepared and have been diversely used are beta CD-based NS. The formulation aspect for beta-CD NS is a relatively simple process and there are relatively multiple modifications that are possible Fig. .Fig. 1TyIt is a type of encapsulating nanoparticle which is able to hold the drug molecule in the core . The funThe NSs help in covering the unpleasant taste of drug especially for the drugs which have to be administered orally, or by buccal route. The side effects of the various ingredients used during formulation can be reduced because they are getting encapsulated within the NSs . They prThe NSs can incorporate small drug molecules. The drug loading capacity is affected by the degree of crosslinking since the crosslinking determines the void space available in the NSs which can be utilized in drug loading. There is a possibility of dose dumping due to early dissolution of crosslinker.Multiple compounds have provided positive results which can be used in the preparation of NSs and their use depends on the type of NS required and the with the level of crosslinking needed. The level of crosslinking is an important aspect in NSs, and depends on the concentration of crosslinkers used, since the drug release pattern and drug encapsulation depend on it. The compounds used in the method of preparation have been enlisted below Table .Table 1CSuitable solvents, like dimethylformamide and dimethyl sulfoxide which are polar aprotic solvents, were used in the process. To this, polymer was added and properly blended. The crosslinker/polymer ratio of 8:2 is ideally used into which the above mixture was added. The mixture got from the above mixing, was then left to react for 48 hours and in a temperature range of 10 °C and up to solvent’s reflux temperature. On completion of the reaction, the solution was cooled until it reached the room temperature . Excess The ultrasound-assisted method of synthesis utilizes polymer ultrasonics junction. Crosslinking is got without using any solvent, and polymer crosslinking occurs due to ultrasonic waves. In a flask, polymer and crosslinker were combined at a reasonable molar ratio. During the ultra-sonication process, ultrasound bath was used to place the flask, at a temperature of 90 °C and for a time period of 5 h. The temperature of the collected mixture was reduced after sonication, and the product was split harshly and cleaned to extract unreacted polymer and reagents with an excess volume of water . The wasThe crosslinker and the polymer are melted together in the melting process. All the ingredients were finely homogenized. NSs were collected by washing the acquired product repeatedly with a suitable liquid. Cleaning the product, extracts the waste polymer and reagents which are unreacted and divides the product into the form of NSs . Such blA conventional and typical electrospinning configuration consists primarily of a syringe, syringe pump, as defined in many literatures, a high-voltage power, and a grounded collector. But one of the major limitations that limits their applications is the amount of output of nanofibers.In bubble electrospinning, polyvinyl alcohol can also be used as polymer. By addition of distilled water into it, the solution of polymer (10%) was organized, which was then moved at 80–90 °C for 2 h to obtain a one-phase mixture. It was then left to achieve at room temperature with the polymer solution and then used to prepare nanoporous fibers  Fig. 5)5).Fig. 5This is the simple technique of microwave irradiation synthesis of CD NSs that significantly decreases the reaction time. These NSs have higher crystallinity levels. Synthesis of NSs by microwave radiation showed a four-fold decrease in reaction time compared to traditional heating methods and also produced homogeneous particle size distribution with uniform crystallinity. Singireddy et al.  performeArranged from β-CDs, their function as transporters for drug conveyance is carried out as nanosporous materials. Because of this 3-D structures, which could be a typically circular assembly about the extent of a protein with directs and openings in the inner portion, they are framed. For example, di-isocyanates, diaryl carbonates, carbonyl di-imidazoles, and so on, react to CD with a crosslinker . The meaTwo steps are used in this technique to vary the level of natural and aqueous (ethyl cellulose and polyvinyl liquor). In dichloromethane (20 ml) and an unmistakable measure of polyvinyl liquor added to 150 ml of fluid ceaseless process, the scattered stage with ethyl cellulose and moiety is dissolved. At this point, for 2 hours at 1000 rpm, the blend is thoroughly blended. The required NSs were collected by the filtration method and held for drying in an oven at 40 °C for 24 h. Dried NSs have been put away in desiccators and the evacuation of remaining solvents is assured  Fig. 6)6).Fig. 6Ilyas et al.  has prepThe NSs were arranged in different sums using the polymer. Using Eudragit RS 100, the inner stage is prepared and added to a fair dissolvable stage. The drug used produced a response and broke down at 35 °C under ultra-sonication . As an eThe NSs are suspended in water and, to prevent aggregation, they are sonicated. Then centrifugation process is carried out on the dispersion, to get a solution of colloidal nature, which upon freeze drying, separates into supernatant and the NSs are dried. Then in the next step, drug, in excess amount, is dispersed and constantly stirred for a specified duration of time which allows the process of complexation to occur and thus aid in the formation of NSs in an aqueous suspension. After complexation, the un-complexed drug is separated by repeating the process of centrifugation . Lastly,The NSs consist of multiple openings in their structures available in their core, which allow free passage of the drug molecule through and the liquid has achieved the state of saturation for the drug molecule. The end results are then enforced on the skin or taken internally, the moiety encapsulated achieves freedom to move into the vehicle and thus taken in by the skin , which cThere are multiple drugs that have been loaded in NSs and they have shown improved drug residence time in the body and hence less concentration of dosage form has to be administered. The drugs that have been administered in NS formulation are stated in the table below Table .Table 2DThere have been multiple improvements and advancements seen in the NSs drug delivery system over the past years. The list of drugs that have been loaded in them has also increased and so has their method of preparation. The EE and the type of polymers used as the components have also increased. The recent advancements seen in NSs have been mentioned in Table Crosslinkers assist in constructing a 3D structure of NSs. The degree of crosslinker used aids in determining the drug entrapment and also influences organ targeting . The typFor selecting molecule which is apt for being incorporated in NSs have to have certain characteristics which make it suitable for encapsulation . The druThere is a direct relation between the degree of crosslinking and number of substitution where greater the number of substituents can provide higher degree of crosslinking thus yielding highly porous NSs having a mesh type networking in the internal structure . A changThe change in temperature affects the drug and the NS complexation. Constancy constant of the drug and the composite formed with the NS decreases with increase in temperature, which thus decreases the contact forces for example Van der Waal forces and the water-hating forces .Multiple tests have been carried out on the NSs which test its strength, level of crosslinking and rate of drug delivery along with many other, which thus help in checking if the formulation is of suitable characteristics.For determining drug loading, high concentration of drug is dissolved in to make a solution where the CD NSs are suspended. The dispersion is mixed and shaken at room temperature for a certain time period and then filtered to get the NS portion . This pomax) in spectra is compared to that got by the pure drug [The equipment used for determining saturation state interaction is UV-Spectrophotometer. The increasing NSs concentration is added or mixed to fixed drug concentration and stored overnight. The formulation is scanned in UV range and the shift in absorbance maxima  was added to the bath. The exterior surface was then dehydrated and then measured using filter paper (Wh). The procedure was performed three times, and an average Wh value was calculated [The Brunauer–Emmett–Teller NS testing was performed using the Nlculated .\documenThe average diameter is calculated by particle size analyzer instrument. Polydispersity is calculated by the principle of dynamic light scattering which is also known as photon correlation spectroscopy, helps in correlating the intensity variation of deflected light to particle proportions with auto-correlation function .−1 for drugs, polymers, drug-polymer complex, blank NSs, drug-loaded NSs, and the possible interaction [The study of sample under FTIR shows structural elucidation especially the presence of the functional group in the structure. The range of detection for the same is from 4000 to 650 cmeraction . The FTIeraction . Infrareeraction .Powder X-ray deflection helps in defining chemical breakdown and encapsulation. The pattern of diffraction differs when drug is complexed to a CD or NS and if there is alteration in crystallinity of drug . The patTm), temperature for crystallization (Tc), crystallinity degree (Xc), and thermal steadiness of NS-moiety complex along with pure drug [The thermal analysis helps define the melting point  indicates transfer of proton among species in reaction and hence ascertains structure of the NSs [NMR techniques like  the NSs .The external charge of particle affects particle distribution and interaction and hence zeta potential is calculated. The parameters considered for calculating zeta potential are electrolyte concentration and pH. It can be measured in a particle size device by using additional electrodes. Samples of the NSs were thinned with 0.1 mol/L KCl for zeta potential determination and put in the electrophoretic cell, 15 V/cm electrical field was applied.In accelerated conditions and photodegradation experiments, the NSs have been subjected to stability studies. For 3 months, the formulation is tested annually. The changes in appearance, size, and physical characteristics, overall, the properties of the drug are investigated. The photodegradation analysis is carried out for 1 h under the UV lamp, stirring in the dark. At a distance of 10 cm from the lamp, the NSs are located. The sample is removed by HPLC and analyzed .The non-water absorbent role of NSs is established by dynamic vapor absorption studies and concerned preservation of crystalline assembly while adsorption and elution of dampness .During the study of NSs under the molecular modeling studies, very dense assembly in dry state is perceived by molecular dynamics simulations of a NS prototype. The simulations display the swelling of NSs .The use of circular dichroism spectroscopy is to assess the presence of CD inclusion compounds especially in aqueous solutions. The circular dichroic absorption requires chirality and electron optical absorption. Indeed, it was noticed that placing an achiral guest molecule into an asymmetric CD cavity produced extrinsic Cotton effects in the guest molecule’s absorption band, as calculated by circular dichroism. An outer surface association between guest molecules and CDs, on the other hand, only modifies other spectral properties without triggering the Cotton effect .For the analysis of topography of drug surface, NSs, and the product (drug/NS complex), SEM and TEM can be used. The alteration between the state of crystallization shown by initial materials and the resultants were observed under the electron microscope which suggests that inclusion complexes are formed. The NS surface morphology was determined using the JEOL JSM-5610LV scanning electron microscope for 30 kV transmissions. JEOL JFC-1600 auto fine coater helps with covering of the product with gold-palladium alloy, and hence the sample was made. In another analysis, TEM JEOL 1400 was used at transmissions of 60 kV where approximately 10 μL of NS sample was diluted with Milli-Q water to 100 μL. In order to visualize the sample, 5 μL of the watery mixture, the sample was held on a network which was then held on glass plate for microscope and then microscopically observed [It is possible to adjust the toughness (viscoelastic properties) of NSs to create softer or firm beadlets according to the final product requirements. Increase in crosslinking gradually slows the release rate. Therefore, by consideration of the release pattern, as a function of crosslinking with time, the resilience of sponges can be studied and optimized as needed .The dissolution profile of NSs can be analyzed using the USP XXIII dissolution apparatus with the aid of modified basket consisting of 5 m stainless steel wire, with a rotation speed of 150 rpm. The selected dissolution medium ensures sink conditions is maintained when studying the solubility of active compounds. The final samples are analyzed by available analytical techniques .NSs can favorably bear drugs which cannot dissolve in water because of their composition containing voids. The mixing rate, dissolubility and constancy of moiety, the masking of undesirable tastes and the conversion of liquid substances to solids can be improved by using these complexes. β-NSs based on CD are stated to transport the drug three to five times more effectively to the target site than direct injection. In nature, the NSs are hard and hold potential to be designed as pharmaceutical form of inhalation, oral, parenteral and topical. Complexes can possibly be distributed in a mixture of lubricants, thinners, excipients and anticoagulants appropriate formulation tablets, capsules aimed at oral administration . The traOperational drawbacks are associated with many manufacturing processes that require chemical transformation. Reactions with no specific end point, showing yield of less quantity, and the constant requirement to work at high conditions in the downstream process requires the consumption of great quantities of energy and huge quantities of water for cooling. By utilizing enzymes as biocatalysts, all these disadvantages can be removed or greatly decreased. Under mild reaction circumstances, these enzymes work, have high speed for reaction, and are high specificity. They have a useful environment impact, since they reduce the utilization of energy and decrease pollutant output. The enzyme’s catalytic action rests on principally, proper orientation of the active site. In the biomedical and therapeutic sectors, there is use proteins, peptides, enzymes and their close imitative. Catalytic adjuvant can be utilized for treating tumor or type I mucopolysaccharidosis, while gene therapy utilizes DNA and oligonucleotides. There is presence of multiple issues and drawbacks about the administration of bulky molecules. Due to certain points, like bulky molecular dimensions, water-loving nature, excitation ratio, large value of topographic charge, synthetic and enzymatic variability and small entering capability via mucous membranes, and multiple drugs made of protein are badly taken in via biological membranes. Protein molecules can be easily removed from the blood following intravenous administration, join to plasma proteins, and are responsive to enzymes that can cause breakdown. Bioavailability is a major concern for oral drug administration . For med2 efficiently for a long duration. NSs of such type are capable of releasing O2, with or without ultrasound. However, the results of an in vitro release study have shown that ultrasound improves liberation and entry of O2 into the cell. The results of the study suggested that NSs can be effectively used as an O2 reservoir and carrier for its topical delivery. In the results of another research, alpha-CD-based NSs were evaluated for their in vitro O2 release and oximeter was used to calculate. Cell mortality reduced when formulations were given prior to hypoxia attacks and observations were made in contrast with oxygen-free samples. Extended and continuous release of O2 was observed from alpha-CD NSs with potential of controlled oxygenation [CD NSs based carbonates has been employed to form enclosure complexes with three different gases, i.e., 1-methylcyclopropene, oxygen and carbon dioxide. Carbon dioxide and oxygen complexion can be beneficial in many biomedical applications, wherein, NSs filled with oxygen can effectively deliver to the tissues that become hypoxic . Due to genation .Sometimes, in cancer patients, medications injected by physicians are made ineffective. This occurs mostly for two reasons: either they are unable penetration in the tumor site, or the immune system assaults and dismembers them. This obstacle has now been overcome to a certain degree by the use of NS. Experts indicated that fixing NS drugs guaranteed that the substance reach their destination in significant quantities. In Paclitaxel, the active ingredient is Taxol which is useful in the anticancer treatment, and is an effective medication which has been developed as a NS formulation . In animA system to deliver oxygen was developed by the use of CD and formulated as NSs. NSs consisting of alpha, β and γ-CD are mixed in aqua, then soaked with oxygen, and characterized in vitro for this purpose . Oxygen NSs with the interior adorned with various types of bait-molecules, have shown to be useful to selectively deceive unique blood protein families and shield them from blood enzyme degradation .For the industries that require very clean water, like the pharmaceutical industries, the presence of natural contaminants in water is an alarming concern. The water-insoluble CD polymers play an important role and are efficacious in discarding waste from water which is collected at a particular power plant. The aptitude to extract liquified organic carbon from raw water by as much as 84% has also been shown by the CD polymers, though total organic carbon removal was relatively poor .NSs have also been used to improvise the dissolvability and dissolution rate of drugs with low solubility and thus provide a regulated release profile. Molecular magnitudes and contour, however, are essential constraints affecting the complexity of inclusion in-bound NSs and therefore may not be uniformly relevant to all moieties. Cefpodoxime proxetil NSs have been prepared to increase the dissolution rate of the same .Some of the formulations for external use can be local anesthetics, antifungals, and antibiotics which show convenience to be formulated as NSs . Hence, In this context, the availability of acidic source, loss of water is seen in CD NSs, producing water vapor and char, thus protecting the copolymer against combustion .Drugs that are currently employed in nano-supply device are zidovudine, saquinavir, interferon-5-007, acyclovir (Eudragit based) .Recent studies have confirmed the highly hydrolytic efficiency shown by Pseudomonas fluorescence lipase when adsorbed to a new type of CD-dependent NS .NSs are prepared by encapsulating gamma-oryzanol with strong protection from photodegradation .The key downside to most traditional, commercially available drug delivery systems is constant administration. However, a drug that is loaded into a NS is stored and released slowly over time. Hydrophobic CD NSs are used as a continuous release carrier for water-soluble drugs, including peptide and protein drugs .NSs are used to extract harmful compounds that are detrimental to the blood by removing the toxin. NSs can absorb toxins when given by injection and are better than antidotes. NS appears like a red blood cell in a bloodstream that tricks toxins into targeting and consuming them. NSs can absorb toxin molecules depending on the toxin .One of the most feared diseases in the world is fungal infection. For the treatment of these cutaneous infections, topical treatment is an important option because of its multiple benefits, such as directing drugs to a specific disease site and reducing its adverse effects. An effective antifungal or fungicide that is topically used to treat various skin diseases such as vaginal thrush, tinea pityriasis Versicolor, ringworm, jock itch, and athlete’s foot is econazole nitrate which is available in the form of cream, ointments, lotions, and solutions. Econazole nitrate is only effective when mixed with a high concentration of active substances and applied to the skin. To this end, the use of emulsion solvent system econazole nitrate NSs was manufactured and then injected into a hydrogel to release the drug in a continuous manner as a topical application.β-CD is widely used for the manufacture of different diagnostic materials. The properties provided by CD NSs such as high biocompatibility, prolonged circulation of the blood, uniform size distribution for permeability and easy access to the target make them excellent for use as a diagnostic agent .NSs has a range of uses in the cosmetics industry. NSs provide good protection for cosmetic ingredients that are prone to photodegradation. It can catch up and prolong the release of Volatile oils, guy. The bad smell of the body created by sweating can also be absorbed. It can release volatile ingredients slowly, thus providing a long-lasting fresh feel in oral cosmetics. It can also be used in items such as rouge or lipsticks to have a long-lasting effect.Recently, there have been new patents that have been filed and approved in the field of NSs where they have been employed to improve the method to preparation which thus makes the process efficient. The patents have been filed with their use as toxin absorbing agents, growth preservation, enzyme release and biocatalyst studies. They have also shown promising results as antitumoral agents. The new patents are also granted from the authority which helps to shift the demand towards NSs as a novel drug delivery system and have been described below Table .Table 4RToxicological assessment is a significant step in assessing the drug and excipient safety; along with assisting in choice of appropriate dosage form for humans and animals use. The important lead is that the destiny of the parent CDs in the gastrointestinal tract is decided by hydrolysis resistance and enzymatic degradation. There is resistance seen of Beta CDs to gastric fluid and amylases from pancreatic fluids and thus reach colon for complete hydrolysis. An evident proof was a study including healthy volunteers and ileostomists, that beta CDs are entirely digested in the colonic microflora, but are almost substandard breakdown in the human small intestine. In the human colon, the enzymatic degradation of beta CDs may be carried out by either glucose or maltodextrins. After oral administration to rats, the LD50 of beta CD is calculated to be 18.8 g/kg . PreviouThe advent of NSs, which have been shrunk down to nanoscale, has ushered in a revolution in medical science. In the field of medical science, a revolution has started as technology has been used to get to the nano-scale. When a targeted and managed drug release mechanism is used, drug toxicity is reduced because improved therapeutic results can be achieved. The role of NSs in the field of therapeutics and nanotechnology growth is critical. In the future, NS could be used as a standard water purifier. The main problem is lowering production costs, which will necessitate the exploration of new polymers and crosslinkers as well as the establishment of new production methods. Because of their unique nature, they play an important role in downstream production, necessitating extensive research. The influence of particle size, synthesis, crystallinity, porosity, and degree of crosslinking on drug release holds great promise. Up to this point, the most commonly recorded methods of preparation have been ultrasound-assisted synthesis and the traditional approach, but new methods such as bubble electrospinning and solvent evaporation are also being updated and developed. The new trend is to increase yields, cost-effective production, and reproducibility, both of which will help with mass production in a short period of time. While current NS preparation methods are simple, a major flaw in the chemical process is the presence of residual liquids or reaction leftovers in the final product, which can be a very likely cause of toxic effects .The NSs provide a flexible drug transportation medium as well as a controlled intermediate for drug delivery to the specified area. They can encapsulate a wide range of medications, allowing for oral and topical drug delivery. There is also the benefit of transporting and encapsulating both lipophilic and hydrophilic drugs, as well as a wide range of applications in areas such as solubility enhancement, entrapment of gases such as oxygen, cosmetics, diagnostics, and poisoning adsorbents. Multiple assessment tests are performed to determine the structural and chemical integrity of the product. They will be useful in a variety of fields in the future, and their scope of application will expand as research in this field expands.


Women in prison are a vulnerable group, often with a history of abuse, out-of-home care, mental health problems and unemployment. Many are mothers when they become involved in the criminal justice system and their gender and parenting related needs are often not considered. The aim of this rapid review was to thematically synthesize the existing research on the needs and experiences of mothers while in, and following release from, prison in Australia.We conducted a rapid systematic search of electronic databases, search engines, the websites of key agencies, and contacted key agencies and researchers.Twenty-two publications from 12 studies met the inclusion criteria and were thematically synthesized in relation to the mothers, their children, family and community, and systems and services which mothers had contact with. We found that mothers in prison have a history of disadvantage which is perpetuated by the trauma of imprisonment. Release from prison is a particularly challenging time for mothers. In relation to their children, the included studies showed that the imprisonment of mothers impacts their maternal identity and role and disrupts the mother-child relationship. Specific strategies are needed to maintain the mother-child relationship, and to ensure the needs and rights of the child are met. In relation to family and community, we found that although family and social support is an important need of women in prison, such support may not be available. Moreover, the stigma associated with having been in prison is a significant barrier to transitions into the community, including finding employment and housing. In relation to systems and services, although limited services exist to support women in prison and on release, these often do not consider the parenting role. Evaluations of parenting programs in prison found them to be acceptable and beneficial to participants but barriers to access limit the number of women who can participate.Mothers have gender- and parenting-specific needs which should be considered in planning for corrective services in Australia. Any service redesign must place the woman and her children at the centre of the service. Women in Australian prison constitute around 8% of the Australian prison population , have a history of depression (61.2% vs. 36.4%), self-harm (24.6% vs. 10.6%), report suicidal ideation (43.3% vs. 29.6%), and attempt suicide (28.6% vs. 17%)  seven electronic databases ; 2) search engines; and 3) websites of key agencies . We also 4) emailed key researchers in the field, and the National Correctives Services Research Group, requesting any additional relevant research, including PhD theses. The search terms were modified to reflect specific requirements of each database that was searched and to improve the efficiency of the search in each database. This process was undertaken iteratively for each database searched.Following the search, we exported the titles and abstracts of retrieved articles into Endnote  and removed duplicates. The remaining titles and abstracts were each screened by one member of the research team  using pre-defined inclusion and exclusion criteria  for eligibility in discussion with research team. Any research reports obtained from grey literature databases, websites or through contacting experts were downloaded and the full text was screened for inclusion. This process is recorded in the PRISMA Flow Diagram Fig.   using a data extraction form. The data extraction form included five critical appraisal prompts to assess the quality of the included publications ‘s care arrangements greatly restrict women’s ability to act and make decisions in relation to the needs of their children. These needs include housing and care arrangements, schooling, physical health, safety, emotional support and contact with their parents Baldry, .stripped of responsibility and autonomy.”  and 110-fold for non-Indigenous Australian children .Care arrangements for children while the mother is in prison fall into three categories: 1) Mother and Children Units where children are housed in prison with their mothers; 2) kinship or informal care where children are cared for by family members or others; and 3) placement in out-of-home care. Each of these has specific challenges. In Mother and Children Units, mothers report being watched and judged by prison staff, receiving no assistance with child raising and care , and trying to raise children when “The studies included in this review highlight the need for family and other social support in providing care for children during their mother’s imprisonment and on her release Baldry, . For exaMothers in, and following release from, prison are often stigmatized by prison staff, other government employees and the community , not culturally safe for Aboriginal women, and not coordinated with other services Baldry, . One stuChild protection services: women and other stakeholders report the following challenges in interactions with child protection services: the removal of children in domestic violence situations where the mother is not the perpetrator; lack of communication with parents about taking the child into state custody or whose custody the children were in; constantly changing custody requirements; and not facilitating access to mothers for visits  on entry into prison, prescription of outdated medications, lack of access to the Pharmaceutical Benefits Scheme and Medicare coverage for prisoners, and the power prison officers exercise in preventing access to healthcare  program  and therefore may not cover all the needs and experiences of Australian mothers in prison and on release. Further primary research is these areas is encouraged.The gender- and parenting-specific needs of mothers in and leaving prison should be considered a priority in planning for corrective services in Australia. This requires a wholistic review and redesign of corrective services, policies and systems to ensure that the needs of mothers are met in a variety of contexts: 1) as individuals who often have a history of disadvantage and trauma exacerbated by prison, 2) as parents who need to maintain and/or strengthen their relationships and parenting role with their children in order to ensure that the needs of their children are met; 3) as members of families and the broader community; and 4) as consumers of services that they engage with throughout their contact with the criminal justice system and on release.


A retrospective analysis was performed of 1637 questionnaires among students of immediate pediatric life support (IPLS) courses. All theory and practice classes and organization and methods received an average score higher than 8.5 except for the schedule and time devoted to developing contents. All parameters evaluating instructors’ skills received a score higher than 9. Participants requested more time to practice and for course adaptation to their specific professionals needs. IPLS courses are highly valued by students. The duration of IPLS practice sessions should be increased and the course should be adapted to the specific professional needs of participants. Health professionals receive training in cardiopulmonary resuscitation (CPR) primarily through CPR courses. In the past, healthcare professionals attended Advanced Life Support (ALS) courses, whereas Basic Life Support (BLS) courses were offered to laypersons ,2,3. HowTo bridge this gap, life support courses were designed to train health professionals who are not regular members of a resuscitation team in the prevention and immediate care of patients with cardiac arrest until the arrival of a resuscitation team. The European Resuscitation Council designed Immediate Life Support (ILS) and Pediatric Immediate Life Support (PILS) courses that include lectures, skill stations, and different cardiac arrest scenarios .Despite the spread of ILS courses, only a few studies have been conducted to evaluate the knowledge and skills acquired by physicians, nurses ,6,7,8,9 The main objective of our study was to assess the quality of the methodology of the PILS course using an anonymous survey of the students.A retrospective study analyzing the anonymous questionnaire of students about the quality of the immediate pediatric life support (IPLS) courses was performed.A PILS course was designed by the Spanish Pediatric and Neonatal Resuscitation Group (SPNRG) to train participants in the recognition and care of children with cardiac arrest, CPR measures, with special focus on initial CPR maneuvers , and team and work coordination. This 8–12 h PILS course was adapted to meet students’ needs, thus it occasionally included a module of basic training in initial management of trauma, neonatal CPR, or arrhythmia, depending on the center where students work. Theory sessions were either face-to-face or online via a learning platform .A specific survey was created by the authors to analyze the opinion of the students regarding the course  and each of the theoretical and practical classes. Once the PILS course was completed, participants were asked to answer a questionnaire anonymously. The questionnaire collected demographic data such as occupation and place of work. In addition, respondents were asked to perform an individual appraisal of each theory and practice session, course organization, methods, and instructors’ skills. Questions of the survey are included in Students have to evaluate each item between 0 (very poor) and 10 (excellent).t-test and ANOVA with Bonferroni’s/Games–Howell correction. A comparison between each theoretical class, practice and each item of the methodology between the different professional categories was performed. When significant differences were found, a two-by-two comparison was made using the Bonferroni adjustment if the variable had a normal distribution or Games–Howell if it did not. A p value < 0.05 was considered statistically significant.All statistical analyses were performed using the SPSS package version 20 . Chi-squared test was used for comparison of categorical variables. Scores on professional categories were compared by Student’s A total of 338 PILS courses were delivered by SPNRG-credited coordinators and instructors to 6858 participants between 1999 and 2019. We could only analyze the 1637 questionnaires corresponding to the 92.5% of the students of 80 courses in 34 different centers held between 2014 and 2019. The distribution of participants by occupation is shown in p < 0.001). Theory sessions related to vascular access, arrhythmias, trauma and neonatal cardiopulmonary resuscitation, as well as practice sessions on vascular access, trauma and neonatal CPR were scored significantly lower (p < 0.001)  . GeneralThe most frequent comments and suggestions among participants were:General comments: excellent course essential to clinical practice.Organization: extend the duration of the course, increase the number of days and reduce the number of daily hours. Augment the duration of practice sessions so that all participants are given enough time to practice.Materials: improve the quality of European Neonatal Pediatric Life Support guidelines; replace mannequins. Methods: adapt the course to nursing and primary care.Updating: it is important to repeat the course periodically.Evaluating the organization, and quality of theory and practice sessions of training courses is essential to improving the quality of CPR courses. Therefore, students should not be asked to perform a general evaluation of the course, but a specific appraisal of the quality of each theory and practice session.The number of studies performed to evaluate learning outcomes of PILS courses is extremely limited ,9,11. ThParticipants had a very positive opinion of the organization, methods, theory and practice sessions, and teaching abilities of instructors. However, there is room for improvement in a number of important aspects, that would enhance the quality of the course. In our opinion, the PILS course should be more flexible. In addition, the course should be adapted to health professionals who work in centers without advanced CPR equipment. The course should be converted from an immediate CPR course into an intermediate CPR course that includes theory–practice modules of initial neonatal CPR, trauma or arrhythmias, as has already been achieved in some of our courses. This adaptation would better meet the professional needs of participants. However, it runs the risk of becoming an advanced course or a primarily theoretical course, thereby reducing the essential time devoted to practice. In this sense, some participants, mainly nurses and primary care professionals, suggested that the course should be better adapted to their professional needs. In our opinion, with a core program, each course should be adapted to the professional profile of its participants to meet their learning needs.The schedule and duration of the program were the worst rated parameters. Most participants deemed that the duration of the course should be extended, and that it should be divided into two days for it to be less stressing and to allow more time for practice. This may entail some challenges to course planning, but is likely to facilitate learning and practice. All participants remarked the relevance of increasing the time devoted to practice, with more clinical cases simulating real settings of cardiopulmonary resuscitation and team-work being necessary ,16. The theory and practice sessions of complementary modules  obtained lower scores than the core modules. The reason may be that these modules were not adapted to the professional profile of participants or the difficulty in summarizing these issues, which may be very complex, in a short period of time. According to these comments, we have performed some changes in the structure and methodology of the PILS courses. We offer different complementary modules depending on the characteristic of the students to adapt to their professional needs .In each course we adapt the schedule to the characteristics of the students and the possibilities of the organization center.Moreover, we increased the previous online time devoted to theory, thus decreasing the presential theory time and increasing the time devoted to practice.The study revealed some differences in the upraising of some modules based on the occupation of participants. This inconsistency could perhaps be explained by differences in the previous knowledge and skills and professional needs of participants. Finally, the teaching skills, coordination and attitude of instructors were scored very highly, which demonstrates the efficacy of the paediatric life support instructor courses designed by the SPNRG .Our study contains some limitations. Firstly, participation in the study was voluntary and a selection bias may have occurred. However, a high proportion of participants answered the questionnaire, which suggests that the sample of participants was representative.In order to better analyse the overall quality of the course, it would be ideal to analyse not only the opinion of the students but also their achievement results.In addition, for this evaluation to be more comprehensive, it would be more appropriate to compare the opinions of the students with opinions of instructors and learning outcomes of participants, which was not possible due to the anonymity of the questionnaire. Evaluation questionnaires are an essential tool for evaluating the quality of training courses. PILS courses are highly rated by students both in terms of theory and practice, organization, teaching methods, and instructors’ skills. Participants highlight the need for a longer course with more time devoted to practice, and remark that the structure of the course should be adapted to their professional needs.