Countdown to 2015 and beyond: fulfilling the health agenda for women and children

Geographical variation in the association of child, maternal and household health interventions with under-five mortality in Burkina Faso

Background

Over the past 15 years, scaling up of cost effective interventions resulted in a remarkable decline of under-five mortality rates (U5MR) in sub-Saharan Africa. However, the reduction shows considerable heterogeneity. We estimated the association of child, maternal, and household interventions with U5MR in Burkina Faso at national and subnational levels and identified the regions with least effective interventions.

Methods

Data on health-related interventions and U5MR were extracted from the Burkina Faso Demographic and Health Survey (DHS) 2010. Bayesian geostatistical proportional hazards models with a Weibull baseline hazard were fitted on the mortality outcome. Spatially varying coefficients were considered to assess the geographical variation in the association of the health interventions with U5MR. The analyses were adjusted for child, maternal, and household characteristics, as well as climatic and environmental factors.

Findings

The average U5MR was as high as 128 per 1000 ranging from 81 (region of Centre-Est) to 223 (region of Sahel). At national level, DPT3 immunization and baby post-natal check within 24 hours after birth had the most important association with U5MR (hazard rates ratio (HRR) = 0.89, 95% Bayesian credible interval (BCI): 0.86–0.98 and HRR = 0.89, 95% BCI: 0.86–0.92, respectively). At sub-national level, the most effective interventions are the skilled birth attendance, and improved drinking water, followed by baby post-natal check within 24 hours after birth, vitamin A supplementation, antenatal care visit and all-antigens immunization (including BCG, Polio3, DPT3, and measles immunization). Centre-Est, Sahel, and Sud-Ouest were the regions with the highest number of effective interventions. There was no intervention that had a statistically important association with child survival in the region of Hauts Bassins.

Interpretation

The geographical variation in the magnitude and statistical importance of the association between health interventions and U5MR raises the need to deliver and reinforce health interventions at a more granular level. Priority interventions are DPT3 immunization, skilled birth attendance, baby post-natal visits in the regions of Sud-Ouest, Sahel, and Hauts Bassins, respectively. Our methodology could be applied to other national surveys, as it allows an incisive, data-driven and specific decision-making approach to optimize the allocation of health interventions at subnational level.

Performance of Four Respiratory Rate Counters to Support Community Health Workers to Detect the Symptoms of Pneumonia in Children in Low Resource Settings: A Prospective, Multicentre, Hospital-Based, Single-Blinded, Comparative Trial

BACKGROUND

Pneumonia is one of the leading causes of death in children under-five globally. The current diagnostic criteria for pneumonia are based on increased respiratory rate (RR) or chest in-drawing in children with cough and/or difficulty breathing. Accurately counting RR is difficult for community health workers (CHWs). Current RR counting devices are frequently inadequate or unavailable. This study analysed the performance of improved RR timers for detection of pneumonia symptoms in low-resource settings.

METHODS

Four RR timers were evaluated on 454 children, aged from 0 to 59 months with cough and/or difficulty breathing, over three months, by CHWs in hospital settings in Cambodia, Ethiopia, South Sudan and Uganda. The devices were the Mark Two ARI timer (MK2 ARI), counting beads with ARI timer, Rrate Android phone and the Respirometer feature phone applications. Performance was evaluated for agreement with an automated RR reference standard (Masimo Root patient monitoring and connectivity platform with ISA CO2 capnography). This study is registered with ANZCTR [ACTRN12615000348550].

FINDINGS

While most CHWs managed to achieve a RR count with the four devices, the agreement was low for all; the mean difference of RR measurements from the reference standard for the four devices ranged from 0.5 (95% C.I. - 2.2 to 1.2) for the respirometer to 5.5 (95% C.I. 3.2 to 7.8) for Rrate. Performance was consistently lower for young infants (0 to < 2 months) than for older children (2 to ≤ 59 months). Agreement of RR classification into fast and normal breathing was moderate across all four devices, with Cohen's Kappa statistics ranging from 0.41 (SE 0.04) to 0.49 (SE 0.05).

INTERPRETATION

None of the four devices evaluated performed well based on agreement with the reference standard. The ARI timer currently recommended for use by CHWs should only be replaced by more expensive, equally performing, automated RR devices when aspects such as usability and duration of the device significantly improve the patient-provider experience.

FUNDING

Bill & Melinda Gates Foundation [OPP1054367].

Improving Efficiency and Quality of the Children's ASD Diagnostic Pathway: Lessons Learned from Practice

The 'autism diagnosis crisis' and long waiting times for assessment are as yet unresolved, leading to undue stress and limiting access to effective support. There is therefore a significant need for evidence to support practitioners in the development of efficient services, delivering acceptable waiting times and effectively meeting guideline standards. This study reports statistically significant reductions in waiting times for autism diagnostic assessment following a children's health service improvement programme. The average wait between referral and first appointment reduced from 14.2 to 10.4 weeks (t(21) = 4.3, p < 0.05) and between referral and diagnosis shared, reduced from 270 to 122.5 days, (t(20) = 5.5, p < 0.05). The proportion of girls identified increased from 5.6 to 2.7:1. Methods reported include: local improvement action planning; evidence based pathways; systematic clinical data gathering and a training plan. This is a highly significant finding for many health services wrestling with the challenges of demand and capacity for autism diagnosis and assessment.

Systematic review and meta-analysis of the association between dimensions of inequality and a selection of indicators of Reproductive, Maternal, Newborn and Child Health (RMNCH)

BACKGROUND

Globally, progress in Maternal and Child Health (MCH) has been inconsistent, with several evidence showing both between and within country disparities in several RMNCH outcome measures. In this study, we aim to meta-analyse existing literature on association between three major equity stratifiers and a selection of RMNCH indicators.

METHODS

We searched PubMed, Embase, Scopus databases and grey literatures from the WHO, UNICEF and World Bank publications. Using the PRISMA guidelines, we identified and reviewed studies from low and middle-income countries, that explored the effects of inequalities on RMNCH, with focus on studies that utilised data from a nationally representative survey. The review protocol was registered at the PROSPERO international prospective register of systematic reviews.

RESULTS

A total of 28 studies were included in the meta-analysis. Results revealed the existence of marked inequality based on income levels, education and place of residence. The most significant level of disparity was with regards to unmet need for contraception and antenatal coverage. For both respective indicators, those with secondary or higher education were 6 times more likely to have better coverage, than those with lesser level of education; (odds ratio (OR) = 6.25 (95% confidence interval (CI) = 1.68-23.23; I2 = 98%, P = 0.006) and (OR = 6.17 (95% CI = 3.03-12.56; I2 = 97%, P < 0.00001) respectively. In contrast, the lowest inequality was in the completion of 3 doses of diphtheria, pertussis and tetanus vaccines (DPT3), those with primary or no education, were equally as likely as those with secondary or higher education to have received DPT3; (OR = 1.21, 95% CI = 0.34-4.27; I2 = 96%, P = 0.77).

CONCLUSIONS

In developing countries, maternal and child health coverage remains highly inequitable and assess to maternal and child health services are governed by factors such as income, level of education, and place of residence.

Exploring the equity impact of a maternal and newborn health intervention: a qualitative study of participatory women's groups in rural South Asia and Africa

BACKGROUND

A consensus is developing on interventions to improve newborn survival, but little is known about how to reduce socioeconomic inequalities in newborn mortality in low- and middle-income countries. Participatory learning and action (PLA) through women's groups can improve newborn survival and home care practices equitably across socioeconomic strata, as shown in cluster randomised controlled trials. We conducted a qualitative study to understand the mechanisms that led to the equitable impact of the PLA approach across socioeconomic strata in four trial sites in India, Nepal, Bangladesh, and Malawi.

METHODS

We conducted 42 focus group discussions (FGDs) with women who had attended groups and women who had not attended, in poor and better-off communities. We also interviewed six better-off women and nine poor women who had delivered babies during the trials and had demonstrated recommended behaviours. We conducted 12 key informant interviews and five FGDs with women's group facilitators and fieldworkers.

RESULTS

Women's groups addressed a knowledge deficit in poor and better-off women. Women were engaged through visual learning and participatory tools, and learned from the facilitator and each other. Facilitators enabled inclusion of all socioeconomic strata, ensuring that strategies were low-cost and that discussions and advice were relevant. Groups provided a social support network that addressed some financial barriers to care and gave women the confidence to promote behaviour change. Information was disseminated through home visits and other strategies. The social process of learning and action, which led to increased knowledge, confidence to act, and acceptability of recommended practices, was key to ensuring behaviour change across social strata. These equitable effects were enabled by the accessibility, relevance, and engaging format of the intervention.

CONCLUSIONS

Participatory learning and action led to increased knowledge, confidence to act, and acceptability of recommended practices. The equitable behavioural effects were facilitated by the accessibility, relevance, and engaging format of the intervention across socioeconomic groups, and by reaching-out to parts of the population usually not accessed. A PLA approach improved health behaviours across socioeconomic strata in rural communities, around issues for which there was a knowledge deficit and where simple changes could be made at home.

Mental and physical support (MAPS) for moms: preliminary findings from a prenatal health support program

BACKGROUND

The low incidence of exercise during pregnancy and the high rates of prenatal depression indicate more opportunities are needed for mothers to engage in exercise and obtain health-related support and education. MAPS (mental & physical support) was developed to support mothers' psychological and physical health during pregnancy. MAPS consisted of physical activity classes 2×/week followed by either a speaker or group discussion regarding a parenting or health-related topic. The primary purpose of this study was to determine if the format was feasible prior to developing a main scale randomized trial.

METHODS

Program measurements included a pre/post survey, post-program focus group, attendance logs and scales for exercise, self-efficacy, and social support.

RESULTS

Findings indicated the program format is well-received by participants; however, issues in attendance warrant program format alterations. Further, larger scale studies and the addition of a control group are needed.

CONCLUSION

This format offers practitioners an effective strategy for supporting pregnant women's physical and psychological health.

Malnutrition and its associated factors: a cross-sectional study with children under 2 years in a suburban area in Angola

BACKGROUND

The prevalence of child malnutrition in Angola is still very high, and little is known about its associated factors. The aim of this study was to identify these factors in children under 2 years in a suburban area of the country's capital city.

METHODS

We used data from a cross-sectional population-based study conducted in 2010. The outcomes studied were stunting and underweight. Multivariable analysis was conducted; prevalence ratios were estimated by Poisson regression with robust variance using a hierarchical model.

RESULTS

Of the children studied (N = 749), 232 [32.0% (95% CI: 28.7-35.5%)] were stunted and 109 [15.1% (95% CI: 12.6-17.9%)] were underweight. In multivariable analysis, occurrence of diarrhea (PR 1.39 [95% CI: 1.07-1.87]) and the death of other children in the household (PR 1.52 [95% CI: 1.01-2,29]) were associated with stunting and underweight, respectively. In the model composed only of distal and intermediate factors, the primary caregiver not being the mother increased the prevalence of stunting by 42% (PR 1.42 [95% CI: 1.10-1.84], and a mother's working outside the house while not being self-employed was associated with its reduced prevalence (PR 0.55 [95% CI: 0.34-0.89]). In the intermediate model, each additional month of delay in the onset of prenatal care increased the relative prevalence of underweight by 20% (PR 1.20 [95% CI: 1.03-1.40]).

CONCLUSIONS

Despite the high prevalence rates of stunting and underweight, relatively few risk factors were identified for these conditions, suggesting that collective exposures are likely to play a major role in causing malnutrition in Angola. The individual factors identified can be useful for the development of strategies to deal with this public health problem.

Investigating pathways linking women's status and empowerment to skilled attendance at birth in Tanzania: A structural equation modeling approach

Maternal and newborn mortality remain unacceptably high in sub-Saharan Africa where use of a skilled birth attendant (SBA) at delivery has remained low. Despite the recognized importance of women's empowerment as a key determinant of maternal and newborn health, evidence from sub-Saharan Africa is more limited. Using data from the 2010 Tanzania Demographic and Health Survey (n = 4,340), this study employs a robust method-structural equation modeling (SEM)-to investigate the complex and multidimensional pathways through which women's empowerment affects SBA use. The results show that women's education and household decision-making are positively associated with SBA use. However, not all empowerment dimensions have similar effects. Attitudes towards sex negotiation and violence as well as early marriage are not significant factors in Tanzania. Mediation analysis also confirms the indirect effect of education on SBA use only through household decision-making. The findings underscore the utility of structural equation modeling when examining complex and multidimensional constructs, such as empowerment, and demonstrate potential causal inference to better inform policy and programmatic recommendations.

Health facility structure and maternal characteristics related to essential newborn care in Brazil: a cross-sectional study

OBJECTIVES

To assess the use of the WHO's Essential Newborn Care (ENC) programme items and to investigate how the non-use of such technologies associates with the mothers' characteristics and hospital structure.

DESIGN

A cross-sectional observational health facility assessment.

SETTING

This is a secondary analysis of the 'Birth in Brazil' study, a national population-based survey on postnatal women/newborn babies and of 266 publicly and privately funded health facilities (secondary and tertiary level of care).

PARTICIPANTS

Data on 23 894 postnatal women and their newborn babies were analysed.

MAIN OUTCOME MEASURES

The facility structure was assessed by evaluating the availability of medicines and equipment for perinatal care, a paediatrician on call 24/7, a neonatal intensive care unit (NICU) and kangaroo mother care. The use of each ENC item was assessed according to the health facility structure and the mothers' sociodemographic characteristics.

RESULTS

The utilisation of ENC items is low in Brazil. The factors associated with failure in pregnant woman reference were: pregnant adolescents (ORadj 1.17; 95% CI 1.06 to 1.29), ≤7 years of schooling (ORadj 1.47; 95% CI 1.22 to 1.78), inadequate antenatal care (ORadj 1.67; 95% CI 1.47 to 1.89). The non-use of corticosteroids was more frequently associated with the absence of an NICU (ORadj 3.93; 95% CI 2.34 to 6,66), inadequate equipment and medicines (ORadj 2.16; 95% CI 1.17 to 4.01). In caesarean deliveries, there was a less frequent use of a partograph (ORadj 4,93; 95% CI 3.77 to 6.46), early skin-to-skin contact (ORadj 3.07; 95% CI 3.37 to 4.90) and breast feeding in the first hour after birth (ORadj 2.55; 95% CI 2.21 to 2.96).

CONCLUSIONS

The coverage of ENC technologies use is low throughout Brazil and shows regional differences. We found a positive effect of adequate structure at health facilities on antenatal corticosteroids use and on partograph use during labour. We found a negative effect of caesarean section on early skin-to-skin contact and early breast feeding.

Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy

Background

Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood.

Methods

We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death.

Results

We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4–2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3–3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5–15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6–1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1–2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2–1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7–4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2–2.3), household size (aOR: 1.2; 95% CI: 1.0–1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2–3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4–1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0–1.8).

Conclusion

In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.

How to assure access of essential RMNCH medicines by looking at policy and systems factors: an analysis of countdown to 2015 countries

BACKGROUND

In 2000, the Millennium Development Goals set targets for social achievements by 2015 including goals related to maternal and child health, with mixed success. Several initiatives supported these goals including assuring availability of appropriate medicines and commodities to meet health service targets. To reach the new Sustainable Development Goals by 2030, information is needed to address policy and systems factors to improve access to lifesaving commodities.

METHODS

We compiled indicator data on 15 commodities related to reproductive, maternal, newborn, and child health (RMNCH) and analyzed them across 75 Countdown to 2015 countries from eight regions to identify problems with specific commodities and determinants of access. The determinants related to policy, regulatory environment, financing, pharmaceutical procurement and supply chain, and information systems. We mapped commodity information from four datasets from the World Health Organization and the United Nation's Commission on Life Saving Commodities creating a stoplight dashboard to illustrate countries' environment to assure access. We also developed a dashboard for policy and systems indicators for select countries.

RESULTS

The commodities we identified as having the fewest barriers to access had been in use longer, including oral rehydration solution and oxytocin injection. Looking across the different systems and policy determinants of access, only Zimbabwe had all 15 commodities on both its essential medicines list and in its standard treatment guidelines, and only Cameroon and Zambia had at least one product registered for each commodity. Senegal alone procured all tracer commodities centrally in the previous year, and 70% of responding countries had costed plans for maternal, newborn, and child health. No country reported recent stock-outs of all the 15 commodities at the central level-countries always had some of the 15 commodities available; however, products with frequent stock-outs included misoprostol, calcium gluconate, penicillin injections, ceftriaxone, and amoxicillin dispersible tablets.

CONCLUSIONS

This analysis highlights country deficiencies in policies and systems, such as incoherent policy guidelines, problems in product registration, lack of logistics data, and central-level stock-outs that may affect access to essential RMNCH commodities. To tackle these deficiencies, countries need to integrate commodity-related indicators into other health monitoring activities to improve service quality.

The Effects of Armed Conflict on Children

Children are increasingly exposed to armed conflict and targeted by governmental and nongovernmental combatants. Armed conflict directly and indirectly affects children's physical, mental, and behavioral health. It can affect every organ system, and its impact can persist throughout the life course. In addition, children are disproportionately impacted by morbidity and mortality associated with armed conflict. A children's rights-based approach provides a framework for collaboration by the American Academy of Pediatrics, child health professionals, and national and international partners to respond in the domains of clinical care, systems development, and policy formulation. The American Academy of Pediatrics and child health professionals have critical and synergistic roles to play in the global response to the impact of armed conflict on children.

The Effects of Armed Conflict on Children

More than 1 in 10 children worldwide are affected by armed conflict. The effects are both direct and indirect and are associated with immediate and long-term harm. The direct effects of conflict include death, physical and psychological trauma, and displacement. Indirect effects are related to a large number of factors, including inadequate and unsafe living conditions, environmental hazards, caregiver mental health, separation from family, displacement-related health risks, and the destruction of health, public health, education, and economic infrastructure. Children and health workers are targeted by combatants during attacks, and children are recruited or forced to take part in combat in a variety of ways. Armed conflict is both a toxic stress and a significant social determinant of child health. In this Technical Report, we review the available knowledge on the effects of armed conflict on children and support the recommendations in the accompanying Policy Statement on children and armed conflict.

Comparing individual-level clinical data from antenatal records with routine health information systems indicators for antenatal care in the West Bank: A cross-sectional study

BACKGROUND

In most low- and middle-income settings, national aggregate health data is the most consistently available source for policy-making and international comparisons. In the West Bank, the paper-based health information system with manual aggregations is transitioning to an individual-level data eRegistry for maternal and child health at the point-of-care. The aim of this study was to explore beforehand how routine health information systems indicators for antenatal care can change with the introduction of the eRegistry.

METHODS

Data were collected from clinical antenatal paper records of pregnancy enrollments for 2015 from 17 primary healthcare clinics, selected by probability sampling from five districts in the West Bank. We used the individual-level data from clinical records to generate routinely reported health systems indicators. We weighted the data to produce population-level estimates, and compared these indicators with aggregate routine health information systems reports.

RESULTS

Antenatal anemia screening at 36 weeks was 20% according to the clinical records data, compared to 52% in the routine reports. The clinical records data showed considerably higher incidences of key maternal conditions compared to the routine reports, including fundal height discrepancy (20% vs. 0.01%); Rh-negative blood group (6.8% vs. 1.4%); anemia with hemoglobin<9.5 g/dl (6% vs. 0.6%); and malpresentation at term (1.3% vs. 0.03%). Only about a sixth of cases with these conditions were referred according to guidelines to designated referral clinics.

CONCLUSIONS

Differences between indicators from the clinical records data and routine health information systems reports can be attributed to human error, inconsistent denominators, and complexities of data processes. Key health systems indicators were prone to underestimations since their registration was dependent on referral of pregnant women. With a transition to individual-level data, as in the eRegistry under implementation, the public health authorities will be able to generate reliable health systems indicators reflective of the population's health status.

Performance, Acceptability, and Usability of Respiratory Rate Timers and Pulse Oximeters When Used by Frontline Health Workers to Detect Symptoms of Pneumonia in Sub-Saharan Africa and Southeast Asia: Protocol for a Two-Phase, Multisite, Mixed-Methods Trial

Background

Pneumonia is one of the leading causes of death in children aged under 5 years in both sub-Saharan Africa and Southeast Asia. The current diagnostic criterion for pneumonia is based on the increased respiratory rate (RR) in children with cough or difficulty breathing. Low oxygen saturation, measured using pulse oximeters, is indicative of severe pneumonia. Health workers often find it difficult to accurately count the number of breaths, and the current RR counting devices are often difficult to use or unavailable. Nonetheless, improved counting devices and low-cost pulse oximeters are now available on the market.

Objective

The objective of our study was to identify the most accurate, usable, and acceptable devices for the diagnosis of pneumonia symptoms by community health workers and first-level health facility workers or frontline health workers in resource-poor settings.

Methods

This was a multicenter, prospective, two-stage, observational study to assess the performance and usability or acceptability of 9 potential diagnostic devices when used to detect symptoms of pneumonia in the hands of frontline health workers. Notably, 188 possible devices were ranked and scored, tested for suitability in a laboratory, and 5 pulse oximeters and 4 RR timers were evaluated for usability and performance by frontline health workers in hospital, health facility, and community settings. The performance was evaluated against 2 references over 3 months in Cambodia, Ethiopia, South Sudan, and Uganda. Furthermore, acceptability and usability was subsequently evaluated using both qualitative and quantitative methodologies in routine practice, over 3 months, in the 4 countries.

Results

This project was funded in 2014, and data collection has been completed. Data analysis is currently under way, and the first results are expected to be submitted for publication in 2018.

Conclusions

This is the first large-scale evaluation of tools to detect symptoms of pneumonia at the community level. In addition, selecting an appropriate reference standard against which the devices were measured was challenging given the lack of existing standards and differences of opinions among experts. The findings from this study will help create a standardized and validated protocol for future studies and support further comparative testing of diagnostic devices in these settings.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12615000348550; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367306&isReview=true (Archived by Website at http://www.webcitation.org/72OcvgBcf)

International Registered Report Identifier (IRRID)

RR1-10.2196/10191

Population-based rates, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa: a multi-country prospective cohort study

BACKGROUND

Modelled mortality estimates have been useful for health programmes in low-income and middle-income countries. However, these estimates are often based on sparse and low-quality data. We aimed to generate high quality data about the burden, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa.

METHODS

In this prospective cohort study done in 11 community-based research sites in south Asia and sub-Saharan Africa, between July, 2012, and February, 2016, we conducted population-based surveillance of women of reproductive age (15-49 years) to identify pregnancies, which were followed up to birth and 42 days post partum. We used standard operating procedures, data collection instruments, training, and standardisation to harmonise study implementation across sites. Verbal autopsies were done for deaths of all women of reproductive age, neonatal deaths, and stillbirths. Physicians used standardised methods for cause of death assignment. Site-specific rates and proportions were pooled at the regional level using a meta-analysis approach.

FINDINGS

We identified 278 186 pregnancies and 263 563 births across the study sites, with outcomes ascertained for 269 630 (96·9%) pregnancies, including 8761 (3·2%) that ended in miscarriage or abortion. Maternal mortality ratios in sub-Saharan Africa (351 per 100 000 livebirths, 95% CI 168-732) were similar to those in south Asia (336 per 100 000 livebirths, 247-458), with far greater variability within sites in sub-Saharan Africa. Stillbirth and neonatal mortality rates were approximately two times higher in sites in south Asia than in sub-Saharan Africa (stillbirths: 35·1 per 1000 births, 95% CI 28·5-43·1 vs 17·1 per 1000 births, 12·5-25·8; neonatal mortality: 43·0 per 1000 livebirths, 39·0-47·3 vs 20·1 per 1000 livebirths, 14·6-27·6). 40-45% of pregnancy-related deaths, stillbirths, and neonatal deaths occurred during labour, delivery, and the 24 h postpartum period in both regions. Obstetric haemorrhage, non-obstetric complications, hypertensive disorders of pregnancy, and pregnancy-related infections accounted for more than three-quarters of maternal deaths and stillbirths. The most common causes of neonatal deaths were perinatal asphyxia (40%, 95% CI 39-42, in south Asia; 34%, 32-36, in sub-Saharan Africa) and severe neonatal infections (35%, 34-36, in south Asia; 37%, 34-39 in sub-Saharan Africa), followed by complications of preterm birth (19%, 18-20, in south Asia; 24%, 22-26 in sub-Saharan Africa).

INTERPRETATION

These results will contribute to improved global estimates of rates, timing, and causes of maternal and newborn deaths and stillbirths. Our findings imply that programmes in sub-Saharan Africa and south Asia need to further intensify their efforts to reduce mortality rates, which continue to be high. The focus on improving the quality of maternal intrapartum care and immediate newborn care must be further enhanced. Efforts to address perinatal asphyxia and newborn infections, as well as preterm birth, are critical to achieving survival goals in the Sustainable Development Goals era.

FUNDING

Bill & Melinda Gates Foundation.

Accountable Care Reforms Improve Women's And Children's Health In Nepal

Over the past decade the Ministry of Health of Nepal and the nonprofit Possible have partnered to deliver primary and secondary health care via a public-private partnership. We applied an accountable care framework that we previously developed to describe the delivery of their integrated reproductive, maternal, newborn, and child health services in the Achham district in rural Nepal. In a prospective pre-post study, examining pregnancies at baseline and 541 pregnancies in follow-up over the course of eighteen months, we found an improvement in population-level indicators linked to reducing maternal and infant mortality: receipt of four antenatal care visits (83 percent to 90 percent), institutional birth rate (81 percent to 93 percent), and the prevalence of postpartum contraception (19 percent to 47 percent). The intervention cost $3.40 per capita (at the population level) and $185 total per pregnant woman who received services. This study provides new analysis and evidence on the implementation of innovative care and financing models in resource-limited settings.

Examining horizontal inequity and social determinants of inequality in facility delivery services in three South Asian countries

Background

The utilization of maternal health care services has increased in many developing countries, but persistent wealth-related inequalities in use of maternal services remained an important public health issue. The paper examined the horizontal inequities and identified the key social determinants that can potentially explain such wealth-related inequalities in use of facility delivery services.

Methods

The countries studied are Bangladesh, Pakistan and Nepal. We used horizontal inequity index to measure the horizontal inequity and decomposition of concentration index method to assess the contribution of different social determinants towards the wealth-related inequality. We have used household and women data from demographic and health surveys of Bangladesh (BDHS 2014), Pakistan (PDHS 2012-13) and Nepal (NDHS 2010-11).

Results

All three countries showed pro-rich inequality in use of facility delivery services (Observed Concentration Index: Bangladesh = 0.235; Pakistan = 0.141; Nepal = 0.263). The study showed if the utilization were solely based on need factors there would have been little disparity between the rich and the poor (Need expected Concentration Index: Bangladesh = 0.004; Pakistan = 0.004; Nepal = 0.008). The use of facility delivery remained pro-rich in all three countries after taking the need factors into account (Horizontal inequity Index: Bangladesh = 0.231; Pakistan = 0.137; Nepal = 0.254). The decomposition analysis revealed that facility delivery is driven mostly by the social determinants of health rather than the individual health risk. Household socioeconomic condition, parental education, place of residence and parity emerged as the most important factors.

Conclusions

Our study reiterates the importance of addressing social determinants of health in tackling wealth-related inequalities in use of facility delivery services. Health policy makers should acknowledge the importance of social determinants in determining individual health-seeking behaviour and accordingly set their strategies to improve access to facility delivery.

A demographic dividend of the FP2020 Initiative and the SDG reproductive health target: Case studies of India and Nigeria

Background: The demographic dividend, defined as the economic growth potential resulting from favorable shifts in population age structure following rapid fertility decline, has been widely employed to advocate improving access to family planning. The current framework focuses on the long-term potential, while the short-term benefits may also help persuade policy makers to invest in family planning.

Methods: We estimate the short- and medium-term economic benefits from two major family planning goals: the Family Planning 2020 (FP2020)’s goal of adding 120 million modern contraceptive users by 2020; Sustainable Development Goals (SDG) 3.7 of ensuring universal access to family planning by 2030. We apply the cohort component method to World Population Prospects and National Transfer Accounts data. India and Nigeria, respectively the most populous Asian and African country under the FP2020 initiative, are used as case studies.

Results: Meeting the FP2020 target implies that on average, the number of children that need to be supported by every 100 working-age people would decrease by 8 persons in India and 11 persons in Nigeria in 2020; the associated reduction remains at 8 persons in India, but increases to 14 persons in Nigeria by 2030 under the SDG 3.7. In India meeting the FP2020 target would yield a saving of US$18.2 billion (PPP) in consumption expenditures for children and youth in the year 2020 alone, and that increased to US$89.7 billion by 2030. In Nigeria the consumption saved would be US$2.5 billion in 2020 and $12.9 billion by 2030.

Conclusions: The tremendous economic benefits from meeting the FP2020 and SDG family planning targets demonstrate the cost-effectiveness of investment in promoting access to contraceptive methods. The gap already apparent between the observed and targeted trajectories indicates tremendous missing opportunities. Accelerated progress is needed to achieve the FP2020 and SDG goals and so reap the demographic dividend.

Predictors of Optimal Antenatal Care Service Utilization Among Adolescents and Adult Women in Bangladesh

Introduction

Utilization of recommended antenatal care (ANC) throughout the pregnancy period is a proven healthy behavior in reducing maternal mortalities and morbidities. The objective of this study is to identify the demand side factors that are associated with the recommended utilization of ANC services among adolescents and adult women in Bangladesh.

Method

This study utilized cross-sectional data from latest Bangladesh Demographic and Health Survey 2014. Data of a total of 4626 adolescents and adult women were analyzed. Bivariate and multivariate analyses were performed for identifying the significant determining factors associated with the ANC services utilization.

Results

Approximately, 32% adult and 30% adolescent women utilized the recommended ANC care. The higher educated adolescents and adult women were 8.08 times (P < .001) and 2.98 times (P < .001) more likely to receive 4 or more ANC, respectively, compared to uneducated women. The richest quintile showed higher tendency to utilize optimum ANC services and had 2.70 times (P < .05) and 6.51 times (P < .001) more likelihood to receive optimal ANC services for adolescent and adult groups, respectively, compared to poorest quintile.

Conclusion

Other than education and income, several other factors including mass -media, place of residence, working status, and geographical variations were significantly associated with recommended ANC. These findings might help health-care programmers and policy makers for initiating appropriate policy and programs for ensuring optimal ANC coverage for all. Ensuring adequate ANC regardless of economic status and residence of pregnant women could guarantee universal maternal health-care coverage as devoted to a national strategic guideline.

Pregnant women's experiences with an integrated diagnostic and decision support device for antenatal care in Ghana

Background

Quality antenatal care (ANC) is recognised as an opportunity for screening and early identification of pregnancy-related complications. In rural Ghana, challenges with access to diagnostic services demotivate women from ANC attendance and referral compliance, leading to absent or late identification and management of high-risk women. In 2016, an integrated diagnostic and clinical decision support system tagged ‘Bliss4Midwives’ (B4M), was piloted in Northern Ghana. The device facilitated non-invasive screening of pre-eclampsia, gestational diabetes and anaemia at the point-of-care. This study aimed to explore the experiences of pregnant women with B4M, and its influence on service utilisation (“pull effect”) and woman-provider relationships (“woman engagement”).

Methods

Through an embedded study design, qualitative methods including individual semi-structured interviews and non-participant observation were employed. Interviews were conducted with 20 pregnant women and 10 health workers, supplemented by ANC observations in intervention facilities. Secondary data on ANC registrations over a one-year period were extracted from health facility records to support findings on the perceived influence of B4M on service utilisation.

Results

Women’s first impressions of the device were mostly emotive (excitement, fear), but sometimes neutral. Although it is inconclusive whether B4M increased ANC registration, pregnant women generally valued the availability of diagnostic services at the point-of-care. Additionally, by fostering some level of engagement, the intervention made women feel listened to and cared for. Process outcomes of the B4M encounter also showed that it was perceived as improving the skills and knowledge of the health worker, which facilitated trust in diagnostic recommendations and was therefore believed to motivate referral compliance.

Conclusions

This study suggests that mHealth diagnostic and decision support devices enhance woman engagement and trust in health workers skills. There is need for further inquiry into how these interventions influence maternal health service utilization and women’s expectations of pregnancy care.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1853-7) contains supplementary material, which is available to authorized users.

Early changes in intervention coverage and mortality rates following the implementation of an integrated health system intervention in Madagascar

INTRODUCTION

The Sustainable Development Goals framed an unprecedented commitment to achieve global convergence in child and maternal mortality rates through 2030. To meet those targets, essential health services must be scaled via integration with strengthened health systems. This is especially urgent in Madagascar, the country with the lowest level of financing for health in the world. Here, we present an interim evaluation of the first 2 years of a district-level health system strengthening (HSS) initiative in rural Madagascar, using estimates of intervention coverage and mortality rates from a district-wide longitudinal cohort.

METHODS

We carried out a district representative household survey at baseline of the HSS intervention in over 1500 households in Ifanadiana district. The first follow-up was after the first 2 years of the initiative. For each survey, we estimated maternal, newborn and child health (MNCH) coverage, healthcare inequalities and child mortality rates both in the initial intervention catchment area and in the rest of the district. We evaluated changes between the two areas through difference-in-differences analyses. We estimated annual changes in health centre per capita utilisation from 2013 to 2016.

RESULTS

The intervention was associated with 19.1% and 36.4% decreases in under-five and neonatal mortality, respectively, although these were not statistically significant. The composite coverage index (a summary measure of MNCH coverage) increased by 30.1%, with a notable 63% increase in deliveries in health facilities. Improvements in coverage were substantially larger in the HSS catchment area and led to an overall reduction in healthcare inequalities. Health centre utilisation rates in the catchment tripled for most types of care during the study period.

CONCLUSION

At the earliest stages of an HSS intervention, the rapid improvements observed for Ifanadiana add to preliminary evidence supporting the untapped and poorly understood potential of integrated HSS interventions on population health.

Health inequalities: a global perspective

The objective of this article is to present health inequalities as a global problem which afflicts the populations of the poorest countries, but also those of the richest countries, and whose persistence represents one of the most serious and challenging health problems worldwide. Two components of global inequalities are highlighted: inequalities between groups within the same society, and inequalities between nations. The understanding that many of these inequalities are unjust, and therefore inequities, is largely derived from the inequalities that are identified between the various social groups of a given society. Inequalities between different societies and nations, while relevant and often of greater magnitude, are not always considered to be unjust. There have been several proposed solutions, which vary according to different theoretical interpretations and explanations. At the global level, the most plausible thesis has focused on improving global governance mechanisms. While that latter are attractive and have some arguments in their favor, they are insufficient because they do not incorporate an understanding of how the historical process of the constitution of the nations occurred and the importance of the position of each country in the global productive system.

A demographic dividend of the FP2020 Initiative and the SDG reproductive health target: Case studies of India and Nigeria

Background: The demographic dividend, defined as the economic growth potential resulting from favorable shifts in population age structure following rapid fertility decline, has been widely employed to advocate improving access to family planning. The current framework focuses on the long-term potential, while the short-term benefits may also help persuade policy makers to invest in family planning. Methods: We estimate the short- and medium-term economic benefits from two major family planning goals: the Family Planning 2020 (FP2020)’s goal of adding 120 million modern contraceptive users by 2020; Sustainable Development Goals (SDG) 3.7 of ensuring universal access to family planning by 2030. We apply the cohort component method to World Population Prospects and National Transfer Accounts data. India and Nigeria, respectively the most populous Asian and African country under the FP2020 initiative, are used as case studies. Results: Meeting the FP2020 target implies that on average, the number of children that need to be supported by every 100 working-age people would decrease by 8 persons in India and 11 persons in Nigeria in 2020; the associated reduction remains at 8 persons in India, but increases to 14 persons in Nigeria by 2030 under the SDG 3.7. In India meeting the FP2020 target would yield a saving of US$18.2 billion (PPP) in consumption expenditures for children and youth in the year 2020 alone, and that increased to US$89.7 billion by 2030. In Nigeria the consumption saved would be US$2.5 billion in 2020 and $12.9 billion by 2030. Conclusions: The tremendous economic benefits from meeting the FP2020 and SDG family planning targets demonstrate the cost-effectiveness of investment in promoting access to contraceptive methods. The gap already apparent between the observed and targeted trajectories indicates tremendous missing opportunities. Accelerated progress is needed to achieve the FP2020 and SDG goals and so reap the demographic dividend.

The Role of Health Extension Workers in Linking Pregnant Women With Health Facilities for Delivery in Rural and Pastoralist Areas of Ethiopia

Background

Women's preference to give birth at home is deeply embedded in Ethiopian culture. Many women only go to health facilities if they have complications during birth. Health Extension Workers (HEWs) have been deployed to improve the utilization of maternal health services by bridging the gap between communities and health facilities. This study examined the barriers and facilitators for HEWs as they refer women to mid-level health facilities for birth.

Methods

A qualitative study was conducted in three regions: Afar Region, Southern Nations Nationalities and People's Region and Tigray Region between March to December 2014. Interviews and focus group discussions were conducted with 45 HEWs, 14 women extension workers (employed by Afar Pastoralist Development Association, Afar Region) and 11 other health workers from health centers, hospitals or health offices. Data analysis was done based on collating the data and identifying key themes.

Results

Barriers to health facilities included distance, lack of transportation, sociocultural factors and disrespectful care. Facilitators for facility-based deliveries included liaising with Health Development Army (HDA) leaders to refer women before their expected due date or if labour starts at home; the introduction of ambulance services; and, provision of health services that are culturally more acceptable for women.

Conclusion

HEWs can effectively refer more women to give birth in health facilities when the HDA is well established, when health staff provide respectful care, and when ambulance is available at any time.

Examining the mechanisms by which women's status and empowerment affect skilled birth attendant use in Senegal: a structural equation modeling approach

BACKGROUND

Despite the reduction in maternal deaths globally, maternal mortality rates remain unacceptably high, particularly in some regions of the world. In sub-Saharan Africa, maternal mortality rates have even increased recently, with 201,000 deaths in 2015 as compared to 179,000 in 2013. Use of a skilled birth attendant (SBA) at delivery has remained low, despite evidence of the effectiveness of SBAs in reducing maternal deaths. Women's empowerment is increasingly recognized as a key determinant of maternal health care-seeking and outcomes, yet empirical examinations of the linkages between women's empowerment and delivery care use are particularly limited, especially from sub-Saharan Africa.

METHODS

Using data from the 2010 Senegal Demographic and Health Survey (n = 7451), in this study we employed structural equation modeling (SEM) to investigate the complex and multidimensional pathways by which three women's empowerment domains (household decision-making, attitudes towards violence, and sex negotiation) directly and indirectly affect SBA use.

RESULTS

Although variations were observed across measures, many of the women's status and empowerment measures were positively related to SBA use. Notably, women's education demonstrated a substantial indirect effect: higher education was related to older age at first marriage, which was associated with higher levels of empowerment and SBA use. In addition to age at first marriage, gender-role attitudes (e.g., progressive attitudes towards violence and sex negotiation) were significant mediators in the relationship between education and SBA use. However, household decision-making was not significantly associated with SBA use.

CONCLUSIONS

Findings indicate significant effects of women's education, early marriage, and some dimensions of women's empowerment on SBA use. SEM was particularly useful in examining the complex and multidimensional constructs of women's empowerments and their effects. This study informs policy recommendations and programmatic efforts to reduce maternal mortality in sub-Saharan Africa by strengthening support for women's access to higher education, delaying marriage and childbearing among girls and young women, and supporting more equitable gender norms.

Do mobile clinics provide high-quality antenatal care? A comparison of care delivery, knowledge outcomes and perception of quality of care between fixed and mobile clinics in central Haiti

BACKGROUND

Antenatal care (ANC) is an important health service for women in developing countries, with numerous proven benefits. Global coverage of ANC has steadily increased over the past 30 years, in part due to increased community-based outreach. However, commensurate improvements in health outcomes such as reductions in the prevalence of maternal anemia and infants born small-for-gestational age have not been achieved, even with increased coverage, indicating that quality of care may be inadequate. Mobile clinics are one community-based strategy used to further improve coverage of ANC, but their quality of care delivery has rarely been evaluated.

METHODS

To determine the quality of care of ANC in central Haiti, we compared adherence to national guidelines between fixed and mobile clinics by performing direct observations of antenatal care consultations and exit interviews with recipients of care using a multi-stage random sampling procedure. Outcome variables were eight components of care, and women's knowledge and perception of care quality.

RESULTS

There were significant differences in the predicted proportion or probability of recommended services for four of eight care components, including intake, laboratory examinations, infection control, and supplies, iron folic acid supplements and Tetanus Toxoid vaccine provided to women. These care components were more likely performed in fixed clinics, except for distribution of supplies, iron-folic acid supplements, and Tetanus Toxoid vaccine, more likely provided in mobile clinics. There were no differences between clinic type for the proportion of total physical exam procedures performed, health and communication messages delivered, provider communication or documentation. Women's knowledge about educational topics was poor, but women perceived extremely high quality of care in both clinic models.

CONCLUSIONS

Although adherence to guidelines differed by clinic type for half of the care components, both clinics had a low percentage of overall services delivered. Efforts to improve provider performance and quality are therefore needed in both models. Mobile clinics must deliver high-quality ANC to improve health and nutrition outcomes.

Determinants of maternal near miss among women in public hospital maternity wards in Northern Ethiopia: A facility based case-control study

Background

In Ethiopia, 20,000 women die each year from complications related to pregnancy, childbirth and post-partum. For every woman that dies, 20 more experience injury, infection, disease, or disability. “Maternal near miss” (MNM), defined by the World Health Organization (WHO) as a woman who nearly dies, but survives a complication during pregnancy, childbirth or within 42 days of a termination, is a proxy indicator of maternal mortality and quality of obstetric care. In Ethiopia, few studies have examined MNM. This study aims to identify determinants of MNM among a small population of women in Tigray, Ethiopia.

Methods

Unmatched case-control study was conducted in hospitals in Tigray Region, Northern Ethiopia, from January 30-March 30, 2016. The sample included 103 cases and 205 controls recruited from among women seeking obstetric care at six (6) public hospitals. Clients with life-threatening obstetric complications, including hemorrhage, hypertensive diseases of pregnancy, dystocia, infection, and anemia or clinical signs of severe anemia (in women without hemorrhage) were taken as cases and those with normal obstetric outcomes were controls. Cases were selected based on proportion to size allocation while systematic sampling was employed for controls. Binary and multiple variable logistic regression (“odds ratio”) analyses were calculated at 95% CI.

Results

Roughly 90% of cases and controls were married and 25% experienced their first pregnancy before the age of 16 years. About two-thirds of controls and 45.6% of cases had gestational ages between 37–41 weeks. Among cases, severe obstetric hemorrhage (44.7%), hypertensive disorders (38.8%), dystocia (17.5%), sepsis (9.7%) and severe anemia (2.9%) were leading causes of MNM. Histories of chronic maternal medical problems like hypertension, diabetes were reported in 55.3% of cases and 33.2% of controls. Women with no formal education [AOR = 3.2;95%CI:1.24, 8.12], being less than 16 years of age at first pregnancy [AOR = 2.5;95%CI:1.12,5.63], induced labor[AOR = 3.0; 95%CI:1.44, 6.17], history of cesarean section[AOR = 4.6; 95% CI: 1.98, 7.61] or chronic medical disorder[AOR = 3.5;95%CI:1.78, 6.93], and women who traveled more than 60 minutes before reaching their final place of care[AOR = 2.8;95% CI: 1.19,6.35] had higher odds of experiencing MNM.

Conclusions

Macro-developments like increasing road and health facility access as well as expanding education will all help reduce MNM. Work should be continued to educate women and providers about common predictors of MNM like history of C-section and chronic illness as well as teenage pregnancy. These efforts should be carried out at the facility, community, and individual levels. Targeted follow-up with women with history of chronic disease and C-section could also help reduce MNM.

Progress Toward Universal Health Coverage: A Comparative Analysis in 5 South Asian Countries

IMPORTANCE

Achieving universal health coverage is one of the key targets in the newly adopted Sustainable Development Goals of the United Nations.

OBJECTIVE

To investigate progress toward universal health coverage in 5 South Asian countries and assess inequalities in health services and financial risk protection indicators.

DESIGN AND SETTINGS

In a population-based study, nationally representative household (335 373 households) survey data from Afghanistan (2014 and 2015), Bangladesh (2010 and 2014), India (2012 and 2014), Nepal (2014 and 2015), and Pakistan (2014) were used to calculate relative indices of health coverage, financial risk protection, and inequality in coverage among wealth quintiles. The study was conducted from June 2012 to February 2016.

MAIN OUTCOMES AND MEASURES

Three dimensions of universal health coverage were assessed: access to basic services, financial risk protection, and equity. Composite and indicator-specific coverage rates, stratified by wealth quintiles, were then estimated. Slope and relative index of inequality were used to assess inequalities in service and financial indicators.

RESULTS

Access to basic care varied substantially across all South Asian countries, with mean rates of overall prevention coverage and treatment coverage of 53.0% (95% CI, 42.2%-63.6%) and 51.2% (95% CI, 45.2%-57.1%) in Afghanistan, 76.5% (95% CI, 61.0%-89.0%) and 44.8% (95% CI, 37.1%-52.5%) in Bangladesh, 74.2% (95% CI, 57.0%-88.1%) and 83.5% (95% CI, 54.4%-99.1%) in India, 76.8% (95% CI, 66.5%-85.7%) and 57.8% (95% CI, 50.1%-65.4%) in Nepal, and 69.8% (95% CI, 58.3%-80.2%) and 50.4% (95% CI, 37.1%-63.6%) in Pakistan. Financial risk protection was generally low, with 15.3% (95% CI, 14.7%-16.0%) of respondents in Afghanistan, 15.8% (95% CI, 14.9%-16.8%) in Bangladesh, 17.9% (95% CI, 17.7%-18.2%) in India, 11.8% (95% CI, 11.8%-11.9%) in Nepal, and 4.4% (95% CI, 4.0%-4.9%) in Pakistan reporting incurred catastrophic payments due to health care costs. Access to at least 4 antenatal care visits, institutional delivery, and presence of skilled attendant during delivery were at least 3 times higher among the wealthiest mothers in Afghanistan, Bangladesh, Nepal, and Pakistan compared with the rates among poor mothers. Access to institutional delivery was 60 to 65 percentage points higher among wealthy than poor mothers in Afghanistan, Bangladesh, Nepal, and Pakistan compared with 21 percentage points higher in India. Coverage was least equitable among the countries for adequate sanitation, institutional delivery, and the presence of skilled birth attendants.

CONCLUSIONS AND RELEVANCE

Health coverage and financial risk protection was low, and inequality in access to health care remains a serious issue for these South Asian countries. Greater progress is needed to improve treatment and preventive services and financial security.

The introduction of new policies and strategies to reduce inequities and improve child health in Kenya: A country case study on progress in child survival, 2000-2013

As of 2015, only 12 countries in the World Health Organization’s AFRO region had met Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Kenya was one of the countries selected for an in-depth case study due to its insufficient progress in reducing under-five mortality, with only a 28% reduction between 1990 and 2013. This paper presents indicators, national documents, and qualitative data describing the factors that have both facilitated and hindered Kenya’s efforts in reducing child mortality. Key barriers identified in the data were widespread socioeconomic and geographic inequities in access and utilization of maternal, neonatal, and child health (MNCH) care. To reduce these inequities, Kenya implemented three major policies/strategies during the study period: removal of user fees, the Kenya Essential Package for Health, and the Community Health Strategy. This paper uses qualitative data and a policy review to explore the early impacts of these efforts. The removal of user fees has been unevenly implemented as patients still face hidden expenses. The Kenya Essential Package for Health has enabled construction and/or expansion of healthcare facilities in many areas, but facilities struggle to provide Emergency Obstetric and Neonatal Care (EmONC), neonatal care, and many essential medicines and commodities. The Community Health Strategy appears to have had the most impact, improving referrals from the community and provision of immunizations, malaria prevention, and Prevention of Mother-to-Child Transmission of HIV. However, the Community Health Strategy is limited by resources and thus also unevenly implemented in many areas. Although insufficient progress was made pre-2015, with additional resources and further scale-up of new policies and strategies Kenya can make further progress in child survival.

Home delivery among antenatal care booked women in their last pregnancy and associated factors: community-based cross sectional study in Debremarkos town, North West Ethiopia, January 2016

BACKGROUND

In Ethiopia, nearly half of the mothers who were booked for antenatal care, who supposed to have institutional delivery, gave home delivery nationally. Home delivery accounts majority while few of childbirth were attended by the skilled provider in Amhara regional state. This study aimed to determine the proportion of home delivery and associated factors among antenatal care booked women who gave childbirth in the past 1 year in Debremarkos Town, Northwest Ethiopia.

METHODS

A community-based Cross sectional study was conducted from January 1st_- 25th 2016. Epi Info version 7 was used to determine a total sample size of 518 and simple random sampling procedure was employed. Data was collected through an interview by using pretested structured questionnaire. Data were entered into Epi Info version 7, cleaned and exported to SPSS version 21 for analysis. A p-value less than or equals to 0.05 at 95% Confidence Intervals of odds ratio were taken as significance level in the multivariable model.

RESULTS

A total of 127 (25.3%) women gave childbirth at home. Un-attending formal education (Adjusted Odds Ratio = 7.56, 95% CI: [3.28, 17.44]), absence of health facility within 30 min distance (AOR = 3.41, 95% CI: [1.42, 8.20]), not exposed to media (AOR = 4.46, 95% CI: [2.09, 9.49]), Unplanned pregnancy (AOR = 3.47, 95% CI [1.82, 6.61]), attending ANC at health post (AOR = 5.45, 95% CI: (1.21, 24.49) and health center (AOR = 2.74, 95% CI [1.29, 5.82]), perceived privacy during ANC (AOR = 3.69[1.25, 10.91]) and less than four times ANC visit (AOR = 5.04, 95% CI (2.30, 11.04]) were significantly associated with home delivery.

CONCLUSIONS

Home delivery in this study was found to be low. Educational level, media exposure, geographic access to a health facility, Unplanned pregnancy, an institution where ANC was booked, perceived privacy during ANC and number of ANC visit were found to be determinants of home delivery. Health institutions, health professionals, policy makers, community leaders and all concerned with the planning and implementation of maternity care in Ethiopia need to consider these associations in implementing services and providing care, for pregnant women.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 5. equity effects for neonates and children

BACKGROUND

The degree to which investments in health programs improve the health of the most disadvantaged segments of the population-where utilization of health services and health status is often the worst-is a growing concern throughout the world. Therefore, questions about the degree to which community-based primary health care (CBPHC) can or actually does improve utilization of health services and the health status of the most disadvantaged children in a population is an important one.

METHODS

Using a database containing information about the assessment of 548 interventions, projects or programs (referred to collectively as projects) that used CBPHC to improve child health, we extracted evidence related to equity from a sub-set of 42 projects, identified through a multi-step process, that included an equity analysis. We organized our findings conceptually around a logical framework matrix.

RESULTS

Our analysis indicates that these CBPHC projects, all of which implemented child health interventions, achieved equitable effects. The vast majority (87%) of the 82 equity measurements carried out and reported for these 42 projects demonstrated "pro-equitable" or "equitable" effects, meaning that the project's equity indicator(s) improved to the same degree or more in the disadvantaged segments of the project population as in the more advantaged segments. Most (78%) of the all the measured equity effects were "pro-equitable," meaning that the equity criterion improved more in the most disadvantaged segment of the project population than in the other segments of the population.

CONCLUSIONS

Based on the observation that CBPHC projects commonly provide services that are readily accessible to the entire project population and that even often reach down to all households, such projects are inherently likely to be more equitable than projects that strengthen services only at facilities, where utilization diminishes greatly with one's distance away. The decentralization of services and attention to and tracking of metrics across all phases of project implementation with attention to the underserved, as can be done in CBPHC projects, are important for reducing inequities in countries with a high burden of child mortality. Strengthening CBPHC is a necessary strategy for reducing inequities in child health and for achieving universal coverage of essential services for children.

Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania

Objective

To analyse factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries.

Methods

We pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006–2014). Based on World Health Organization protocols, we created indices of process quality for antenatal care (first visits) and for sick-child visits. We assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service.

Findings

Data were available for 2594 and 11  402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% (interquartile range, IQR: 50.0 to 75.0) of eight recommended antenatal care actions and 54.5% (IQR: 33.3 to 66.7) of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined.

Conclusion

The quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care.

Contraceptive availability leads to increase in use in conflict-affected Democratic Republic of the Congo: evidence from cross-sectional cluster surveys, facility assessments and service statistics

Background

Humanitarian assistance standards mandate specific attention to address the sexual and reproductive health (SRH) needs of conflict-affected populations. Despite these internationally recognised standards, access to SRH services is still often compromised in conflict settings. CARE in collaboration with the RAISE Initiative strengthened the Ministry of Health (MOH) to provide contraceptive services in Maniema province, Democratic Republic of the Congo. This study evaluated the effectiveness of this support for MOH health facility provision of contraception.

Methods

Cross-sectional surveys in 2008 (n = 607) and 2010 (n = 575) of women of reproductive age using a two-stage cluster sampling design were conducted in Kasongo health zone. Facility assessments were conducted to assess the capacity of supported government health facilities to provide contraceptive services in 2007 and 2010. Data on the numbers of clients who started a contraceptive method were also collected monthly from supported facilities for 2008–2014.

Results

Current use of any modern contraceptive method doubled from 3.1 to 5.9% (adjusted OR 2.03 [95%CI 1.3–3.2]). Current use of long-acting and permanent methods (LAPM) increased from 0 to 1.7% (p < .001), an increase that was no longer significant after adjustment. All current users except a few condom users reported a health facility as the source of the method. The 2010 facility assessments found that most supported facilities had the capacity to provide short-acting and long-acting methods. Service statistics indicated that the percentage of clients who accepted a long-acting method at supported facilities increased from 8% in 2008 to 83% in 2014 (p < .001).

Conclusions

This study demonstrated that contraceptive prevalence doubled between 2008 and 2010; service statistics indicate that utilization of long-acting methods continued to increase to a majority of new clients after 2010. Strengthening the health system to provide contraceptive services enabled individuals to exercise their right to prevent unintended pregnancies. These results suggest that demand for contraception, including long-acting methods, is present even in humanitarian settings, and that women will use them when they are available and of reasonable quality. It is critical that the humanitarian community ensure that such services are available to women affected by crises.

Breaking the cycles of poverty: Strategies, achievements, and lessons learned in Los Cuatro Santos, Nicaragua, 1990-2014

Background: In a post-war frontier area in north-western Nicaragua that was severely hit by Hurricane Mitch in 1998, local stakeholders embarked on and facilitated multi-dimensional development initiatives to break the cycles of poverty.

Objective: The aim of this paper is to describe the process of priority-setting, and the strategies, guiding principles, activities, achievements, and lessons learned in these local development efforts from 1990 to 2014 in the Cuatro Santos area, Nicaragua.

Methods: Data were derived from project records and a Health and Demographic Surveillance System that was initiated in 2004. The area had 25,893 inhabitants living in 5,966 households in 2014.

Results: A participatory process with local stakeholders and community representatives resulted in a long-term strategic plan. Guiding principles were local ownership, political reconciliation, consensus decision-making, social and gender equity, an environmental and public health perspective, and sustainability. Local data were used in workshops with communities to re-prioritise and formulate new goals. The interventions included water and sanitation, house construction, microcredits, environmental protection, school breakfasts, technical training, university scholarships, home gardening, breastfeeding promotion, and maternity waiting homes. During the last decade, the proportion of individuals living in poverty was reduced from 79 to 47%. Primary school enrolment increased from 70 to 98% after the start of the school breakfast program. Under-five mortality was around 50 per 1,000 live births in 1990 and again peaked after Hurricane Mitch and was approaching 20 per 1,000 in 2014. Several of the interventions have been scaled up as national programs.

Conclusions: The lessons learned from the Cuatro Santos initiative underline the importance of a bottom-up approach and local ownership of the development process, the value of local data for monitoring and evaluation, and the need for multi-dimensional local interventions to break the cycles of poverty and gain better health and welfare.

Rapid reduction of maternal mortality in Uganda and Zambia through the saving mothers, giving life initiative: results of year 1 evaluation

Background

Achieving maternal mortality reduction as a development goal remains a major challenge in most low-resource countries. Saving Mothers, Giving Life (SMGL) is a multi-partner initiative designed to reduce maternal mortality rapidly in high mortality settings through community and facility evidence-based interventions and district-wide health systems strengthening that could reduce delays to appropriate obstetric care.

Methods

An evaluation employing multiple studies and data collection methods was used to compare baseline maternal outcomes to those during Year 1 in SMGL pilot districts in Uganda and Zambia. Studies include health facility assessments, pregnancy outcome monitoring, enhanced maternal mortality detection in facilities, and population-based investigation of community maternal deaths. Population-based evaluation used standard approaches and comparable indicators to measure outcome and impact, and to allow comparison of the SMGL implementation in unique country contexts.

Results

The evaluation found a 30% reduction in the population-based maternal mortality ratio (MMR) in Uganda during Year 1, from 452 to 316 per 100,000 live births. The MMR in health facilities declined by 35% in each country (from 534 to 345 in Uganda and from 310 to 202 in Zambia). The institutional delivery rate increased by 62% in Uganda and 35% in Zambia. The number of facilities providing emergency obstetric and newborn care (EmONC) rose from 10 to 25 in Uganda and from 7 to 11 in Zambia. Partial EmONC care became available in many more low and mid-level facilities. Cesarean section rates for all births increased by 23% in Uganda and 15% in Zambia. The proportion of women with childbirth complications delivered in EmONC facilities rose by 25% in Uganda and 23% in Zambia. Facility case fatality rates fell from 2.6 to 2.0% in Uganda and 3.1 to 2.0% in Zambia.

Conclusions

Maternal mortality ratios fell significantly in one year in Uganda and Zambia following the introduction of the SMGL model. This model employed a comprehensive district system strengthening approach. The lessons learned from SMGL can inform policymakers and program managers in other low and middle income settings where similar approaches could be utilized to rapidly reduce preventable maternal deaths.

Care seeking for children with fever/cough or diarrhoea in Nepal: equity trends over the last 15 years

AIMS

Childhood illnesses such as diarrhoea and pneumonia remain major contributors to child mortality globally and need to be continually targeted in pursuit of universal health coverage. This study analyses time trends in the prevalence of fever/cough and diarrhoea in Nepal and applies an equity lens in order to identify disadvantaged groups.

METHODS

Data from the Nepal Demographic Health Surveys of 2001, 2006, and 2011, together with data from the most recent Multiple Indicator Cluster Survey of 2014 performed in Nepal, were utilized for analysis.

RESULTS

Analyses revealed improvements (lower prevalence) of diarrhoea and fever/cough in children under five in Nepal over the last 15 years, with an equitable distribution of symptoms over socio-economic determinants. There was, however, a marked and maintained inequity in care seeking for these symptoms, with less educated mothers and those from poor households being only approximately half as likely to seek care for their children.

CONCLUSIONS

Results highlight the persisting need for targeting care-seeking and societal barriers to treatment in order to achieve universal health access.

Setting an implementation research agenda for Canadian investments in global maternal, newborn, child and adolescent health: a research prioritization exercise

BACKGROUND

Improving global maternal, newborn, child and adolescent health (MNCAH) is a top development priority in Canada, as shown by the $6.35 billion in pledges toward the Muskoka Initiative since 2010. To guide Canadian research investments, we aimed to systematically identify a set of implementation research priorities for MNCAH in low- and middle-income countries.

METHODS

We adapted the Child Health and Nutrition Research Initiative method. We scanned the Child Health and Nutrition Research Initiative literature and extracted research questions pertaining to delivery of interventions, inviting Canadian experts on MNCAH to generate additional questions. The experts scored a combined list of 97 questions against 5 criteria: answerability, feasibility, deliverability, impact and effect on equity. These questions were ranked using a research priority score, and the average expert agreement score was calculated for each question.

RESULTS

The overall research priority score ranged from 40.14 to 89.25, with a median of 71.84. The average expert agreement scores ranged from 0.51 to 0.82, with a median of 0.64. Highly-ranked research questions varied across the life course and focused on improving detection and care-seeking for childhood illnesses, overcoming barriers to intervention uptake and delivery, effectively implementing human resources and mobile technology, and increasing coverage among at-risk populations. Children were the most represented target population and most questions pertained to interventions delivered at the household or community level.

INTERPRETATION

Investing in implementation research is critical to achieving the Sustainable Development Goal of ensuring health and well-being for all. The proposed research agenda is expected to drive action and Canadian research investments to improve MNCAH.

Assessing the Impact of U.S. Food Assistance Delivery Policies on Child Mortality in Northern Kenya

The U.S. is the main country in the world that delivers its food assistance primarily via transoceanic shipments of commodity-based in-kind food. This approach is costlier and less timely than cash-based assistance, which includes cash transfers, food vouchers, and local and regional procurement, where food is bought in or nearby the recipient country. The U.S.’s approach is exacerbated by a requirement that half of its transoceanic food shipments need to be sent on U.S.-flag vessels. We estimate the effect of these U.S. food assistance distribution policies on child mortality in northern Kenya by formulating and optimizing a supply chain model. In our model, monthly orders of transoceanic shipments and cash-based interventions are chosen to minimize child mortality subject to an annual budget constraint and to policy constraints on the allowable proportions of cash-based interventions and non-US-flag shipments. By varying the restrictiveness of these policy constraints, we assess the impact of possible changes in U.S. food aid policies on child mortality. The model includes an existing regression model that uses household survey data and geospatial data to forecast the mean mid-upper-arm circumference Z scores among children in a community, and allows food assistance to increase Z scores, and Z scores to influence mortality rates. We find that cash-based interventions are a much more powerful policy lever than the U.S.-flag vessel requirement: switching to cash-based interventions reduces child mortality from 4.4% to 3.7% (a 16.2% relative reduction) in our model, whereas eliminating the U.S.-flag vessel restriction without increasing the use of cash-based interventions generates a relative reduction in child mortality of only 1.1%. The great majority of the gains achieved by cash-based interventions are due to their reduced cost, not their reduced delivery lead times; i.e., the reduction of shipping expenses allows for more food to be delivered, which reduces child mortality.

Reproductive, maternal, newborn, and child health: key messages from Disease Control Priorities 3rd Edition

As part of Disease Control Priorities 3rd Edition, the World Bank will publish a volume on Reproductive, Maternal, Newborn, and Child Health that identifies essential cost-effective health interventions that can be scaled up to reduce maternal, newborn, and child deaths, and stillbirths. This Review summarises the volume's key findings and estimates the effect and cost of expanded implementation of these interventions. Recognising that a continuum of care from the adolescent girl, woman, or mother to child is needed, the volume includes details of preventive and therapeutic health interventions in integrated packages: Maternal and Newborn Health and Child Health (along with folic acid supplementation, a key reproductive health intervention). Scaling up all interventions in these packages from coverage in 2015 to hypothetically immediately achieve 90% coverage would avert 149 000 maternal deaths, 849 000 stillbirths, 1 498 000 neonatal deaths, and 1 515 000 additional child deaths. In alternative calculations that consider only the effects of reducing the number of pregnancies by provision of contraceptive services as part of a Reproductive Health package, meeting 90% of the unmet need for contraception would reduce global births by almost 28 million and consequently avert deaths that could have occurred at 2015 rates of fertility and mortality. Thus, 67 000 maternal deaths, 440 000 neonatal deaths, 473 000 child deaths, and 564 000 stillbirths could be averted from avoided pregnancies. Particularly effective interventions in the Maternal and Newborn Health and Child Health packages would be management of labour and delivery, care of preterm births, and treatment of serious infectious diseases and acute malnutrition. Nearly all of these essential interventions can be delivered by health workers in the community or in primary health centres, which can increase population access to needed services. The annual incremental cost of immediately scaling up these essential interventions would be US$6·2 billion in low-income countries, $12·4 billion in lower-middle-income countries, and $8·0 billion in upper-middle-income countries. With the additional funding, greater focus on high-effect integrated interventions and innovations in service delivery, such as task shifting to other groups of health workers and supply and demand incentives, can help rectify major gaps in accessibility and quality of care. In recent decades, reduction of avoidable maternal and child deaths has been a global priority. With continued priority and expansion of essential reproductive, maternal, newborn, and child health interventions to high coverage, equity, and quality, as well as interventions to address underlying problems such as women's low status in society and violence against women, these deaths and substantial morbidity can be largely eliminated in another generation.

Linking household and facility data for better coverage measures in reproductive, maternal, newborn, and child health care: systematic review

BACKGROUND

Currently many measures of intervention coverage obtained from household surveys do not measure actual health intervention/service delivery, resulting in a need for linking reports of care-seeking with assessments of the service environment in order to improve measurements. This systematic review aims to identify evidence of different methods used to link household surveys and service provision assessments, with a focus on reproductive, maternal, newborn and child health care, in low- and middle-income countries.

METHODS

Using pre-defined search terms, articles published in peer-reviewed journals and the grey literature after 1990 were identified, their reference lists scanned and linking methods synthesized.

FINDINGS

A total of 59 articles and conference presentations were carefully reviewed and categorized into two groups based on the linking method used: 1) indirect/ecological linking that included studies in which health care-seeking behavior was linked to all or the nearest facilities or providers of certain types within a geographical area, and 2) direct linking/exact matching where individuals were linked with the exact provider or facility where they sought care. The former approach was employed in 51 of 59 included studies, and was particularly common among studies that were based on independent sources of household and facility data that were nationally representative. Only eight of the 59 reviewed studies employed direct linking methods, which were typically done at the sub-national level (eg, district level) and often in rural areas, where the number of providers was more limited compared to urban areas.

CONCLUSIONS

Different linking methods have been reported in the literature, each category has its own set of advantages and limitations, in terms of both methodology and practicality for scale-up. Future studies that link household and provider/facility data should also take into account factors such as sources of data, the timing of surveys, the temporality of data points, the type of services and interventions, and the scale of the study in order to produce valid and reliable results.

Impacts on Breastfeeding Practices of At-Scale Strategies That Combine Intensive Interpersonal Counseling, Mass Media, and Community Mobilization: Results of Cluster-Randomized Program Evaluations in Bangladesh and Viet Nam

BACKGROUND

Despite recommendations supporting optimal breastfeeding, the number of women practicing exclusive breastfeeding (EBF) remains low, and few interventions have demonstrated implementation and impact at scale. Alive & Thrive was implemented over a period of 6 y (2009-2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries.

METHODS AND FINDINGS

A cluster-randomized evaluation design was employed in each country. For the evaluation sample, 20 sub-districts in Bangladesh and 40 communes in Viet Nam were randomized to either the intensive or the non-intensive group. Cross-sectional surveys (n ~ 500 children 0-5.9 mo old per group per country) were implemented at baseline (June 7-August 29, 2010, in Viet Nam; April 28-June 26, 2010, in Bangladesh) and endline (June 16-August 30, 2014, in Viet Nam; April 20-June 23, 2014, in Bangladesh). Difference-in-differences estimates (DDEs) of impact were calculated, adjusting for clustering. In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0-51.5, p < 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8-30.6, p = 0.021; 63.7% to 94.2%). In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7-38.1, p < 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI -1.3 to 21.4, p = 0.072). Our impact estimates may underestimate the full potential of such a multipronged intervention because the evaluation lacked a "pure control" area with no MM or national/provincial PA.

CONCLUSIONS

At-scale interventions combining intensive IPC with MM, CM, and PA had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs. Strategies to design and deliver similar programs could improve breastfeeding practices in other contexts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam).

From Advocacy to Action in Global Adolescent Health

In May 2016, The Lancet published a report titled, "Our Future: A Lancet Commission on Adolescent Health and Wellbeing," the culmination of three years of work from a geographically diverse interdisciplinary group. The report argued that healthy growth across adolescence and young adulthood shapes life course and intergenerational trajectories so that health investments yield a "triple dividend." With current global interest in adolescent health at an unprecedented level, it outlines three next steps to advance from advocacy to effective action: (1) there is a pressing need for comprehensive and integrated strategies, inclusive of, but extending beyond, sexual and reproductive health, and HIV; (2) interventions should address both adolescent health service coverage and determinants of health that lie in sectors such as education, justice, transport, and industry and employment, as well as families and local communities; and (3) scale-up of responses will require not only investments in country-level capacities for measuring need and responding with evidence-based practice but also the establishment of processes for accountability and meaningful youth engagement.

Combining Intensive Counseling by Frontline Workers with a Nationwide Mass Media Campaign Has Large Differential Impacts on Complementary Feeding Practices but Not on Child Growth: Results of a Cluster-Randomized Program Evaluation in Bangladesh

BACKGROUND

Complementary feeding (CF) contributes to child growth and development, but few CF programs are delivered at scale. Alive & Thrive addressed this in Bangladesh through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM).

OBJECTIVE

The objective was to evaluate the impact of providing IPC + MM + CM (intensive) compared with standard nutrition counseling + less intensive MM + CM (nonintensive) on CF practices and anthropometric measurements.

METHODS

We used a cluster-randomized, nonblinded evaluation with cross-sectional surveys [n = ∼600 and 1090 children 6-23.9 mo and 24-47.9 mo/group, respectively, at baseline (2010) and n = ∼500 and 1100 children of the same age, respectively, at endline (2014)]. We derived difference-in-difference impact estimates (DDEs), adjusting for geographic clustering, infant age, sex, differences in baseline characteristics, and differential change in characteristics over time.

RESULTS

Groups were similar at baseline. CF improvements were significantly greater in the intensive than in the nonintensive group [DDEs: 16.3, 14.7, 22.0, and 24.6 percentage points (pp) for minimum dietary diversity, minimum meal frequency, minimum acceptable diet, and consumption of iron-rich foods, respectively]. In the intensive group, CF practices were high: 50.4% for minimum acceptable diet, 63.8% for minimum diet diversity, 75.1% for minimum meal frequency, and 78.5% for consumption of iron-rich foods. Timely introduction of foods improved. Significant, nondifferential stunting declines occurred in intensive (6.2 pp) and nonintensive (5.2 pp) groups in children 24-47.9 mo.

CONCLUSIONS

The intensive program substantially improved CF practices compared with the nonintensive program. Large-scale program delivery was feasible and, with the use of multiple platforms, reached 1.7 million households. Nondifferential impacts on stunting were likely due to rapid positive secular trends in Bangladesh. Accelerating linear growth further could require accompanying interventions. This study establishes proof of concept for large-scale behavior change interventions to improve child feeding. This trial was registered at clinicaltrials.gov as NCT01678716.

Physical therapy guideline for children with malnutrition in low income countries: clinical commentary

Physical therapy intervention along with nutritional rehabilitation has recently become an inevitable combo after recent evidences suggesting a strong interaction between malnutrition and neuro-muscular disabilities which contribute to a significant burden in global settings. Recent studies confirm that appropriate physical assessment of neuro-musculo skeletal system, developmental assessment or cognitive tools along with nutritional assessments followed by exercise rehabilitation will yield positive results in children with malnutrition. There is an obvious need to make available a simple physical therapy exercise guidelines with simple measure and exercise to be used in resource limited settings of developing countries. The purpose of this clinical commentary is to summarize simple assessment tools to evaluate activity impairment, participation restriction, gross motor activity and simple physical therapy intervention program for children with disability secondary to malnutrition.

Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5?

Background

Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress.

Methods

Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing).

Results

The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30–40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns -- which require higher-level health workers, more infrastructure, and increased community engagement -- showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers.

Conclusions

These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3401-6) contains supplementary material, which is available to authorized users.

Countdown to 2015 country case studies: systematic tools to address the "black box" of health systems and policy assessment

BACKGROUND

Evaluating health systems and policy (HSP) change and implementation is critical in understanding reproductive, maternal, newborn and child health (RMNCH) progress within and across countries. Whilst data for health outcomes, coverage and equity have advanced in the last decade, comparable analyses of HSP changes are lacking. We present a set of novel tools developed by Countdown to 2015 (Countdown) to systematically analyse and describe HSP change for RMNCH indicators, enabling multi-country comparisons.

METHODS

International experts worked with eight country teams to develop HSP tools via mixed methods. These tools assess RMNCH change over time (e.g. 1990-2015) and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, we present results from Tanzania and Peru, two of eight Countdown case studies.

RESULTS

The Policy and Programme Timeline tool shows that Tanzania's RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Contrastingly, Peru moved from standalone to integrated RMNCH programme implementation, combined with multi-sectoral, anti-poverty strategies. The HSP Tracer Indicators Dashboards show that Peru has adopted nine of 11 policy tracer indicators and Tanzania has adopted seven. Peru costed national RMNCH plans pre-2000, whereas Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. Both countries included all lifesaving RMNCH commodities on their essential medicines lists. Peru has twice the health worker density of Tanzania (15.4 vs. 7.1/10,000 population, respectively), although both are below the 22.8 WHO minimum threshold.

CONCLUSIONS

These are the first HSP tools using mixed methods to systematically analyse and describe RMNCH changes within and across countries, important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era.