Community-based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes

The impact of universal home visits with pregnant women and their spouses on maternal outcomes: a cluster randomised controlled trial in Bauchi State, Nigeria

Introduction

Maternal mortality in Nigeria is extremely high. Access to quality antenatal and obstetric care is limited. In Bauchi State, we found maternal morbidity was associated with domestic violence, heavy work in pregnancy, ignorance of danger signs, and lack of spousal communication. This cluster randomized controlled trial tested the impact of universal home visits that discussed these upstream risk factors with pregnant women and their spouses, to precipitate household actions protecting pregnant women.

Methods

We randomly allocated four wards in Toro Local Government Authority to immediate or delayed intervention. Female and male home visitors visited all pregnant women and their spouses in the two intervention wards every 2 months. We compared completed pregnancies between intervention and pre-intervention wards after 1 year. Primary outcomes were pregnancy, delivery, and postnatal complications, analysed with intention to treat using a cluster t-test. Ancillary analysis examined the influence of baseline and health service use differences.

Results

Among 1837 women in intervention wards and 1853 women in pre-intervention wards, the intervention reduced problems in pregnancy and post partum: raised blood pressure (relative risk reduction (RRR) 0.120, cluster-adjusted 95% CI (CIca) 0.045 to 0.194; risk difference (RD) 0.116, 95% CIca 0.042 to 0.190) and swelling of face or hands (RRR 0.271, 95% CIca 0.201 to 0.340; RD 0.264, 95% CIca 0.194 to 0.333) and postpartum sepsis (RRR 0.399, 95% CIca 0.220 to 0.577; RD 0.324, 95% CIca 0.155 to 0.493). The intervention reduced the targeted upstream risk factors such as heavy work during pregnancy (RRR 0.234, 95% CIca 0.085 to 0.383; RD 0.222, 95% CIca 0.073 to 0.370). It did not increase use of antenatal care, institutional delivery or skilled birth attendance.

Conclusion

Home visits reduced upstream maternal risks, improving maternal outcomes without increased use of health services. This could have implications in other settings with poor access to quality antenatal and delivery care services.

Trial registration

ISRCTN82954580.

A Program Model Describing a Community-Based Mother and Infant Health Program

BACKGROUND AND PURPOSE

The objective of this study was to formulate a MOMS Orange County program model to describe the components and function of a successful community-based maternal and infant health program.

METHODS

A logic framework was used to guide the development of the MOMS program model. Twenty-five MOMS staff members were interviewed; MOMS documents and existing research literature were reviewed. Content analyses were used to identify themes of interviews and the review guide was used to summarize the documents.

RESULTS

The key components of the MOMS program were identified to formulate a narrative and graphic model. The main elements of this model included: target population (underserved women who have low socioeconomic status and have limited access to healthcare in Orange County); theoretical assumptions (social determinants of health, human ecology, self-efficacy); goals (empower women, enhance health of infants, strengthen families); inputs (funded by public and private sources; 50 staff members); activities (care-coordination home visitation community-center group health education); outputs (the number of home visitations, referrals to medical and/or psychological services, and group health education classes); and outcomes (short-term: healthy pregnancy, birth outcomes, family support; medium-term: postpartum well-being, infant development, family functioning; long-term: women's well-being, children's development, family relationships. Future research should test how this model functions to empirically improve maternal, newborn, child, and family health.

IMPLICATIONS FOR PRACTICE

The MOMS program provides a new approach to community-based maternal and infant health interventions focusing on health promotion and disease prevention for underserved families in socioeconomically disadvantaged communities.

Causes of death in preterm neonates (<33 weeks) born in tertiary care hospitals in India: analysis of three large prospective multicentric cohorts

OBJECTIVE

To estimate the direct causes of mortality among preterm neonates <33 weeks' gestation by examining three large multisite, hospital-based datasets in India.

METHOD

Three prospective hospital-based datasets: the National Neonatal Perinatal Database (NNPD) of India, the Delhi Neonatal Infection Study (DeNIS) cohort, and the Goat Lung Surfactant Extract (GLSE)-Plus cohort were analyzed to study the causes of death among preterm neonates of less than 33 weeks' gestation admitted to the participating tertiary care hospitals in India.

RESULTS

A total of 8024 preterm neonates were admitted in the three cohorts with 2691 deaths. Prematurity-related complications and sepsis contributed to 53.5% and 19.8% of deaths in the NNPD cohort, 51.0% and 25.0% in the DeNIS cohort, and 39.7% and 40.9% in GLSE-Plus cohort, respectively.

CONCLUSIONS

Nearly a quarter (20-40%) of preterm neonates less than 33 weeks' gestation admitted to Indian NICUs died of sepsis. The study results have implications for health policies targeted to reduce the neonatal mortality rate in India.

A Retrospective Cross Sectional Study of the Effectiveness of a Project in Improving Infant Health in Bwindi, South Western Uganda

Introduction: Low-cost community-based interventions to improve infant health potentially offer an exciting means of progressing toward the Sustainable Development Goals (SDGs). However, the feasibility of such interventions in low-income settings remains unclear. Bwindi Community Hospital (BCH), Uganda implemented a 3-year nurse-led community project to address child-health issues. Nurses supported Community Health Volunteers (CHVs) and visited mothers pre- and/or postnatally to assess and educate mothers and infants. CHVs gathered data and gave basic advice on health and hygiene to mothers. We hypothesized that increased interventions by nurses and CHVs and increased contact with households, would improve health and reduce infant mortality.

Methods: This was a retrospective cohort study analyzing routine data of all children born between January 2015 and December 2016. There were three interventions: antenatal nurse visit, postnatal nurse visit and CHV participation. Children received different numbers of interventions. We defined four diverse outcomes: facility-based delivery, immunization completeness, nutritional status, and infant mortality. Odds ratios, adjusted odds ratios, and multivariate logistic regression were used to assess associations between interventions and outcomes.

Results: Of the 4,442 children born in 2015 and 2016, 91% were visited by a nurse (81% antenatally and 10% postnatally); 7% lived in villages with a high participating CHV. Households receiving a postnatal visit were more likely to complete immunization (aOR: 1.55, p = 0.016) and have the infant survive (aOR: 1.90, p = 0.05). Children from a hard-to-reach village (no road access) were less likely to be delivered in a health facility (aOR: 0.55, p < 0.001) and less likely to survive in their first year (aOR: 0.69, p = 0.03). Having two or more interventions was associated with a child having all four positive outcomes (aOR 0.78, p = 0.03). Lack of baseline data, a control area, or integrated assessment data limited more detailed evaluation.

Conclusion: Visits to mothers after birth, by a nurse to educate and identify child illness, were associated with lower infant mortality and improved infant health as measured by completion of immunizations. Community health interventions could potentially have a greater impact if focused on hard-to-reach areas. Building evaluation into all project designs, whether local or internationally funded, would enable greater learning, and hence better use of resources.

Is deployment of trained nurses to rural villages a remedy for the low skilled birth attendance in Ethiopia? A cluster randomized-controlled community trial

Background

Low coverage of Skilled Birth Attendance (SBA) is one of the major drivers of maternal mortality in many low- and middle-income countries (LMICs) including Ethiopia. We conducted a cluster-randomized controlled community trial to assess the effect of deploying trained community based nurses to rural communities on the uptake levels of SBA in Ethiopia.

Methods

A three-arm, parallel groups, cluster-randomized community trial was conducted to assess the effect of deploying trained community based reproductive health nurses (CORN) on the uptake of SBA services. A total of 282 villages were randomly selected and assigned to a control arm (n = 94) or 1 of 2 treatment arms (n = 94 each). The treatment groups differed by where these new service providers were deployed, a health post (HP) or health center (HC). Baseline and end line surveys were conducted to document and measure the effects of the intervention. Program impacts on SBA coverage were calculated using difference‐in‐difference (DID) analysis.

Results

After nine months of intervention, the coverage of SBA services increased significantly by 81.1% (from 24.61 to 44.59) in the HP based intervention arm, and by 122.9% (from 16.41 to 36.59) in the HC arm, respectively (p <0.01). Conversely, a small and non-significant (2%) decline in SBA coverage were observed in the control arm (P >0.05). The DID estimate indicated a net increase in SBA coverage of 21.32 and 20.52 percentage points (PP) across the HP and HC based intervention arms, respectively (p < 0.001).

Conclusions

Deployment of trained reproductive health nurses to rural communities in Ethiopia significantly improved utilization of SBA services. Therefore; in similar low income settings where coverage of SBA services is very low, deployment of trained community based nurses to grassroots level could potentiate rapid service uptake. Additional cost-effectiveness and validation studies at various setups are required, before scale-up of the innovation, however.

Trial registration

clinicaltrails.gov NCT02501252.

Combining task shifting and community-based care to improve maternal health: Practical approaches and patient perceptions

Globally, community-based care and task shifting strategies are used to address maternal healthcare shortages in low-income countries. Limited research exists on models that combine these strategies. Using a qualitative approach, we explored Haitian women's perceptions of the Midwives for Haiti model, which unites task shifting and community-based care by training nurses as skilled birth attendants and offering healthcare via rotating, mobile clinics. Eight focus groups (N = 52) were conducted in rural Haiti in March 2017. Thematic analysis of data indicated that perceptions of care were universally positive. Participants cited accessible patient-centred care, affordable services, and health education as primary motivators to attend. Results illustrated the importance of women's perceptions on the future use of mobile clinic sites or other formal care. Future efforts to address maternal healthcare shortages should consider the Midwives for Haiti model, combining task shifting and community-based care to address common social, topographical, or financial barriers to maternal healthcare.

What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers

OBJECTIVE

To synthesize current understanding of how community-based health worker (CHW) programs can best be designed and operated in health systems.

METHODS

We searched 11 databases for review articles published between 1 January 2005 and 15 June 2017. Review articles on CHWs, defined as non-professional paid or volunteer health workers based in communities, with less than 2 years of training, were included. We assessed the methodological quality of the reviews according to AMSTAR criteria, and we report our findings based on PRISMA standards.

FINDINGS

We identified 122 reviews (75 systematic reviews, of which 34 are meta-analyses, and 47 non-systematic reviews). Eighty-three of the included reviews were from low- and middle-income countries, 29 were from high-income countries, and 10 were global. CHW programs included in these reviews are diverse in interventions provided, selection and training of CHWs, supervision, remuneration, and integration into the health system. Features that enable positive CHW program outcomes include community embeddedness (whereby community members have a sense of ownership of the program and positive relationships with the CHW), supportive supervision, continuous education, and adequate logistical support and supplies. Effective integration of CHW programs into health systems can bolster program sustainability and credibility, clarify CHW roles, and foster collaboration between CHWs and higher-level health system actors. We found gaps in the review evidence, including on the rights and needs of CHWs, on effective approaches to training and supervision, on CHWs as community change agents, and on the influence of health system decentralization, social accountability, and governance.

CONCLUSION

Evidence concerning CHW program effectiveness can help policymakers identify a range of options to consider. However, this evidence needs to be contextualized and adapted in different contexts to inform policy and practice. Advancing the evidence base with context-specific elements will be vital to helping these programs achieve their full potential.

Socioeconomic inequalities in newborn care during facility and home deliveries: a cross sectional analysis of data from demographic surveillance sites in rural Bangladesh, India and Nepal

Background

In Bangladesh, India and Nepal, neonatal outcomes of poor infants are considerably worse than those of better-off infants. Understanding how these inequalities vary by country and place of delivery (home or facility) will allow targeting of interventions to those who need them most. We describe socio-economic inequalities in newborn care in rural areas of Bangladesh, Nepal and India for all deliveries and by place of delivery.

Methods

We used data from surveillance sites in Bangladesh, India and from Makwanpur and Dhanusha districts in Nepal, covering periods from 2001 to 2011. We used literacy (ability to read a short text) as indicator of socioeconomic status. We developed a composite score of nine newborn care practices (score range 0–9 indicating infants received no newborn care to all nine newborn care practices). We modeled the effect of literacy and place of delivery on the newborn care score and on individual practices.

Results

In all study sites (60,078 deliveries in total), use of facility delivery was higher among literate mothers. In all sites, inequalities in newborn care were observed: the difference in new born care between literate and illiterate ranged 0.35–0.80. The effect of literacy on the newborn care score reduced after adjusting for place of delivery (range score difference literate-illiterate: 0.21–0.43).

Conclusion

Socioeconomic inequalities in facility care greatly contribute to inequalities in newborn care. Improving newborn care during home deliveries and improving access to facility care are a priority for addressing inequalities in newborn care and newborn mortality.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0834-9) contains supplementary material, which is available to authorized users.

Prevalence, incidence and predictors of volunteer community health worker attrition in Kwale County, Kenya

Introduction

In underserved populations, the contribution of community health workers (CHWs) is vital to the healthcare systems. Attrition of these workers causes critical breakdowns in the delivery of essential services to these populations. Literature on reasons for attrition is limited, although some have been identified in studies on sustainability of CHW programmes. These factors are, however, likely to be influenced by context. We measured CHW attrition and its predictors in a rural area in Kenya.

Methods

We conducted a nested case–control study and focus group discussions among CHWs involved in a maternal and child health project. A training register of 1005 CHWs was used to sample and follow CHWs for attrition. Incidence of CHW attrition was calculated using a Poisson model. Separately, we used logistic regression to determine predictors of CHW attrition.

Results

Of the 1005 CHWs, 498 (49.6%) had left the project by the time of the study. The incidence of attrition was 46.8/1000 person-years (95% CI 38.7 to 56.5). In the case–control study, lack of interest in peer organisation membership (OR 5.3; 95% CI 1.3 to 20.6) was associated with attrition. Absence of refresher training (OR 4.0; 95% CI 2.2 to 7.1) and receiving no feedback from supervisors (OR 2.0; 95% CI 1.0 to 3.9) were also associated with attrition. Discordance in expectations and perceived heavy workload were also identified as key reasons for attrition in the qualitative study.

Conclusion

This study estimates high prevalence and incidence of CHW attrition in Kwale County, Kenya. Ongoing training, feedback and peer support are also important in enhancing retention of CHWs. Additionally, expectations regarding the roles and benefits of involvement in CHW work should be communicated clearly, and workload should be kept reasonable or negotiated with the CHWs.

Strengthening the capabilities of families and communities to improve child health in low and middle income countries

Audrey Prost and colleagues discuss how best to enable families and communities to improve child health

Mentor Mothers Program Improved Child Health Outcomes At A Relatively Low Cost In South Africa

In light of South Africa's high prenatal HIV prevalence and infant mortality rate, a cluster randomized controlled trial was conducted to evaluate an intervention called Philani+, which used community health workers (known as Mentor Mothers) to deliver pre- and postnatal home visits in Cape Town, South Africa, to improve maternal and child health. We assessed the costs and benefits of this intervention and made comparisons with other scenarios that depicted increased capacity and provision of nurse-delivered care. The recurrent cost of the twenty-four-month intervention was US$80,001. The major health outcomes analyzed were differences in the proportion of infants who were low birthweight, stunted, and suboptimally breastfed between intervention and control groups. Each case of low birthweight averted cost US$2,397; of stunted growth, US$2,454; and of suboptimal breastfeeding, US$1,618. Employment of community health workers was cost saving compared to that of nurses. Philani+ improved child health at a relatively low cost, considering the health system costs associated with low birthweight and undernutrition. The model could be suitable for replication in low-resource settings to improve child health in other countries.

Can community health worker home visiting improve care-seeking and maternal and newborn care practices in fragile states such as Afghanistan? A population-based intervention study

BACKGROUND

The effects of community health worker (CHW) home visiting during the antenatal and postnatal periods in fragile- and conflicted-affected countries such as Afghanistan are not known.

METHODS

We conducted a non-randomised population-based intervention study from March 2015 to February 2016. Two intervention and two control districts were selected. All female CHWs in the intervention districts were trained to provide eight home visits and behaviour change communication messages from pregnancy to 28 days postpartum. The primary outcome was the proportion of women who reported delivering in a health facility. Secondary outcomes were the proportion of women who reported attending a health facility for at least one antenatal and one postnatal visit. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering.

RESULTS

Overall, 289 female CHWs in the intervention districts performed home visits and 1407 eligible women (less than 12 months postpartum) at baseline and 1320 endline women provided outcome data (94% response rate). Facility delivery increased in intervention villages by 8.2% and decreased in the control villages by 6.3% (adjusted mean difference (AMD) 11.0%, 95% confidence interval (CI) 4.0-18.0%, p = 0.002). Attendance for at least one antenatal care visit (AMD 10.5%, 95% CI 4.2-16.9%, p = 0.001) and postnatal care visit (AMD 7.2%, 95% CI 0.2-14.2%, p = 0.040) increased in the intervention compared to the control districts.

CONCLUSIONS

CHW home visiting during the antenatal and postnatal periods can improve health service use in fragile- and conflict-affected countries. Commitment to scale-up from Ministries and donors is now needed.

TRIAL REGISTRATION

This trial was retrospectively registered at the Australian and New Zealand Clinical Trial Registry ( ACTRN12618000609257 ).

Health system barriers influencing perinatal survival in mountain villages of Nepal: implications for future policies and practices

BACKGROUND

This paper aims to examine the health care contexts shaping perinatal survival in remote mountain villages of Nepal. Health care is provided through health services to a primary health care level-comprising district hospital, village health facilities and community-based health services. The paper discusses the implications for future policies and practice to improve health access and outcomes related to perinatal health. The study was conducted in two remote mountain villages in one of the most remote and disadvantaged mountain districts of Nepal. The district is reported to rank as the country's lowest on the Human Development Index and to have the worst child survival rates. The two villages provided a diversity of socio-cultural and health service contexts within a highly disadvantaged region.

METHODS

The study findings are based on a qualitative study of 42 interviews with women and their families who had experienced perinatal deaths. These interviews were supplemented with 20 interviews with health service providers, female health volunteers, local stakeholders, traditional healers and other support staff. The data were analysed by employing an inductive thematic analysis technique.

RESULTS

Three key themes emerged from the study related to health care delivery contexts: (1) Primary health care approach: low focus on engagement and empowerment; (2) Quality of care: poor acceptance, feeling unsafe and uncomfortable in health facilities; and (3) Health governance: failures in delivering health services during pregnancy and childbirth.

CONCLUSIONS

The continuing high perinatal mortality rates in the mountains of Nepal are not being addressed due to declining standards in the primary health care approach, health providers' professional misbehaviour, local health governance failures, and the lack of cultural acceptance of formalised care by the local communities. In order to further accelerate perinatal survival in the region, policy makers and programme implementers need to immediately address these contextual factors at local health service delivery points.

mHealth intervention to improve the continuum of maternal and perinatal care in rural Guatemala: a pragmatic, randomized controlled feasibility trial

Background/objective

Guatemala’s indigenous Maya population has one of the highest perinatal and maternal mortality rates in Latin America. In this population most births are delivered at home by traditional birth attendants (TBAs), who have limited support and linkages to public hospitals. The goal of this study was to characterize the detection of maternal and perinatal complications and rates of facility-level referral by TBAs, and to evaluate the impact of a mHealth decision support system on these rates.

Methods

A pragmatic one-year feasibility trial of an mHealth decisions support system was conducted in rural Maya communities in collaboration with TBAs. TBAs were individually randomized in an unblinded fashion to either early-access or later-access to the mHealth system. TBAs in the early-access arm used the mHealth system throughout the study. TBAs in the later-access arm provided usual care until crossing over uni-directionally to the mHealth system at the study midpoint. The primary study outcome was the monthly rate of referral to facility-level care, adjusted for birth volume.

Results

Forty-four TBAs were randomized, 23 to the early-access arm and 21 to the later-access arm. Outcomes were analyzed for 799 pregnancies (early-access 425, later-access 374). Monthly referral rates to facility-level care were significantly higher among the early-access arm (median 33 referrals per 100 births, IQR 22–58) compared to the later-access arm (median 20 per 100, IQR 0–30) (p = 0.03). At the study midpoint, the later-access arm began using the mHealth platform and its referral rates increased (median 34 referrals per 100 births, IQR 5–50) with no significant difference from the early-access arm (p = 0.58). Rates of complications were similar in both arms, except for hypertensive disorders of pregnancy, which were significantly higher among TBAs in the early-access arm (RR 3.3, 95% CI 1.10–9.86).

Conclusions

Referral rates were higher when TBAs had access to the mHealth platform. The introduction of mHealth supportive technologies for TBAs is feasible and can improve detection of complications and timely referral to facility-care within challenging healthcare delivery contexts.

Trial registration

Clinicaltrials.gov NCT02348840.

Optimal profile limits for maternal mortality rate (MMR) in South Sudan

Background

Reducing Maternal Mortality Rate (MMR) is considered by the international community as one of the eight Millennium Development Goals. Based on previous studies, Skilled Assistant at Birth (SAB), General Fertility Rate (GFR) and Gross Domestic Product (GDP) have been identified as the most significant predictors of MMR in South Sudan.

This paper aims for the first time to develop profile limits for the MMR in terms of significant predictors SAB, GFR, and GDP. The paper provides the optimal values of SAB and GFR for a given MMR level.

Methods

Logarithmic multi- regression model is used to model MMR in terms of SAB, GFR and GDP. Data from 1986 to 2015 collected from Juba Teaching Hospital was used to develop the model for predicting MMR. Optimization procedures are deployed to attain the optimal level of SAB and GFR for a given MMR level.

MATLAB was used to conduct the optimization procedures. The optimized values were then used to develop lower and upper profile limits for yearly MMR, SAB and GFR.

Results

The statistical analysis shows that increasing SAB by 1.22% per year would decrease MMR by 1.4% (95% CI (0.4–5%)) decreasing GFR by 1.22% per year would decrease MMR by 1.8% (95% CI (0.5–6.26%)).

The results also indicate that to achieve the UN recommended MMR levels of minimum 70 and maximum 140 by 2030, the government should simultaneously reduce GFR from the current value of 175 to 97 and 75, increase SAB from the current value of 19 to 50 and 76.

Conclusions

This study for the first time has deployed optimization procedures to develop lower and upper yearly profile limits for maternal mortality rate targeting the UN recommended lower and upper MMR levels by 2030. The MMR profile limits have been accompanied by the profile limits for optimal yearly values of SAB and GFR levels. Having the optimal level of predictors that significantly influence the maternal mortality rate can effectively aid the government and international organizations to make informed evidence-based decisions on resources allocation and intervention plans to reduce the risk of maternal death.

Pregnancy-related morbidity and risk factors for fatal foetal outcomes in the Taabo health and demographic surveillance system, Côte d'Ivoire

Background

Reliable, population-based data on pregnancy-related morbidity and mortality, and risk factors for fatal foetal outcomes are scarce for low- and middle-income countries. Yet, such data are essential for understanding and improving maternal and neonatal health and wellbeing.

Methods

Within the 4-monthly surveillance rounds of the Taabo health and demographic surveillance system (HDSS) in south-central Côte d’Ivoire, all women of reproductive age identified to be pregnant between 2011 and 2014 were followed-up. A questionnaire pertaining to antenatal care, pregnancy-related morbidities, delivery circumstances, and birth outcome was administered to eligible women. Along with sociodemographic information retrieved from the Taabo HDSS repository, these data were subjected to penalized maximum likelihood logistic regression analysis, to determine risk factors for fatal foetal outcomes.

Results

A total of 2976 pregnancies were monitored of which 118 (4.0%) resulted in a fatal outcome. Risk factors identified by multivariable logistic regression analysis included sociodemographic factors of the expectant mother, such as residency in a rural area (adjusted odds ratio (aOR) = 2.87; 95% confidence interval (CI) 1.31–6.29) and poorest wealth tertile (aOR = 1.79; 95% CI 1.02–3.14), a history of miscarriage (aOR = 23.19; 95% CI 14.71–36.55), non-receipt of preventive treatment such as iron/folic acid supplementation (aOR = 3.15; 95% CI 1.71–5.80), only two doses of tetanus vaccination (aOR = 2.59; 95% CI 1.56–4.30), malaria during pregnancy (aOR = 1.94; 95% CI 1.21–3.11), preterm birth (aOR = 4.45; 95% CI 2.82–7.01), and delivery by caesarean section (aOR = 13.03; 95% CI 4.24–40.08) or by instrumental delivery (aOR = 5.05; 95% CI 1.50–16.96). Women who paid for delivery were at a significantly lower odds of a fatal foetal outcome (aOR = 0.39; 95% CI 0.25–0.74).

Conclusions

We identified risk factors for fatal foetal outcomes in a mainly rural HDSS site of Côte d’Ivoire. Our findings call for public health action to improve access to, and use of, quality services of ante- and perinatal care.

Birth preparedness and complication readiness among pregnant women admitted in a rural hospital in Rwanda

BACKGROUND

With an aim to prevent adverse pregnancy outcomes, 'birth preparedness and complication readiness' (BP/CR) promotes timely access to skilled maternal and neonatal services. Objective of this study was to assess implementation of BP/CR among pregnant women admitted with obstetric emergencies in rural Rwanda.

METHODS

A cross-sectional study among pregnant women who were referred to Ruhengeri hospital between July and November 2015. The 'Safe Motherhood questionnaire' as developed by Jhpiego's Maternal and Neonatal Health Program was used to collect data. Women were asked to mention key danger signs and respond as to whether they had identified: (A) skilled birth attendant, (B) location to give birth, (C) mode of transport, (D) money to cover health care expenditure. Women who answered 'yes' to three or four items were labeled 'well prepared'. Multivariate logistic regression analysis was conducted to compare the 'well prepared' and 'less prepared'.

RESULTS

With regard to complication readiness, out of 350 women, 296 (84.6%), 271 (77.4%) and 288 (82.3%) could mention at least one key danger sign during pregnancy, labor and postpartum respectively, but only 23 (6.6%) could mention three or more key danger signs during all three periods. With regard to birth preparedness, 46 (13.1%) women had identified a skilled birth attendant, 68 (19.4%) birth location, 76 (21.7%) mode of transport, and 306 (87.4%) had saved money for health care costs. Seventy-eight women (22.3%) were 'well prepared', associated factors being first time pregnancy (adjusted Odds Ratio (aOR) = 3.2; 95% CI; 1.2-5.8), knowledge of at least two danger signs (aOR = 2.8; 95% CI; 1.7-3.9) and having been assisted by a community health worker at the antenatal clinic (aOR = 2.2, 95% CI; 1.3-3.7).

CONCLUSION

Knowledge of obstetric danger signs was suboptimal and birth preparedness low. We recommend review of practices regarding health promotion in antenatal care, taking care not to exclude multiparous women from messages related to birth preparedness, and do promote use of community health workers to enhance effectiveness of BP/CR.

Reference ranges of the WHO Disability Assessment Schedule (WHODAS 2.0) score and diagnostic validity of its 12-item version in identifying altered functioning in healthy postpartum women

OBJECTIVES

To compare scores on the 36-item WHO Disability Assessment Schedule 2.0 tool (WHODAS-36) for postpartum women across a continuum of morbidity and to validate the 12-item version (WHODAS-12).

METHODS

This is a secondary analysis of the Brazilian retrospective cohort study on long-term repercussions of severe maternal morbidity. We determined mean, median, and percentile values for WHODAS-36 total score and for each domain, and percentile values for WHODAS-12 total score in postpartum women divided into three groups: "no," "nonsevere," and "severe" morbidities.

RESULTS

The WHODAS-36 mean total scores were 11.58, 18.31, and 19.19, respectively for no, nonsevere, and severe morbidity. There was a dose-dependent effect on scores for each domain of WHODAS-36 according to the presence and severity of morbidity. The diagnostic validity of WHODAS-12 was determined by comparing it with WHODAS-36 as a "gold standard." The best cut-off point for diagnosing dysfunctionality was the 95th percentile.

CONCLUSION

The upward trend of WHODAS-36 total mean value scores of women with no morbidity compared with those with morbidity along a severity continuum may reflect the impact of morbidity on postpartum functioning.

Mobile-health tool to improve maternal and neonatal health care in Bangladesh: a cluster randomized controlled trial

BACKGROUND

In Bangladesh, the targets on reduction of maternal mortality and utilization of related obstetric services provided by skilled health personnel in Millennium Development Goals 5 remains unmet, and the progress in reduction of neonatal mortality lag behind that in the reduction of infant and under-five mortalities, remaining as an essential issue towards the achievement of maternal and neonatal health targets in health related Sustainable Development Goals (SDGs). As access to appropriate perinatal care is crucial to reduce maternal and neonatal deaths, recently several mobile platform-based health programs sponsored by donor countries and Non-Governmental Organizations have targeted to reduce maternal and child mortality. On the other hand, good health-care is necessary for the development. Thus, we designed this implementation research to improve maternal and child health care for targeting SDGs.

METHODS/DESIGN

This cluster randomized trial will be conducted in Lohagora of Narail District and Dhamrai of Dhaka District. Participants are pregnant women in the respective areas. The total sample size is 3000 where 500 pregnant women will get Mother and Child Handbook (MCH) and messages using mobile phone on health care during pregnancy and antenatal care about one year in each area. The other 500 in each area will get health education using only MCH book. The rest 1000 participants will be controlled; it means 500 in each area. We randomly assigned the intervention and controlled area based on smallest administrative area (Unions) in Bangladesh. The data collection and health education will be provided through trained research officers starting from February 2017 to August 2018. Each health education session is conducting in their house. The study proposal was reviewed and approved by NCCD, Japan and Bangladesh Medical Research Council (BMRC), Bangladesh. The data will be analyzed using STATA and SPSS software.

DISCUSSION

For the improvement of maternal and neonatal care, this community-based intervention using mobile phone and handbook will do great contribution. Thus, a developing country where resources are limited received the highest benefit. Such intervention will guide to design for prevention of other diseases too.

TRIAL REGISTRATION

UMIN000025628 Registered June 13, 2016.

Integrated children's clinic care (ICCC) versus a self-directed care pathway for children with a chronic health condition: a multi-centre randomised controlled trial study protocol

Background

Children with chronic health conditions have better health-related outcomes when their care is managed in a personalised and coordinated way. However, increased demand on Australian ambulatory care hospital services has led to longer waitlist times to access specialists and appropriate intervention services; placing vulnerable children at increased risk of poorer short-term (e.g. social difficulties) and long-term (e.g. convictions) health and social outcomes. Traditional approaches to increasing frequency and service of delivery are expensive and can have minimal impact on caregiver burden. A community based service-integration approach, rather than self-directed care is proposed as increased service linkages are more likely to occur and improve the health outcomes of children with a chronic health condition.

Methods

An open, unblinded, multi-centre randomised controlled trial in two Australian public hospitals. 112 children (0–16 years) fulfilling the inclusion criteria will be randomised to one of two clinical pathways for management of their chronic health condition: (1) integrated children’s care clinic (ICCC) or (2) self-directed care pathway. All children and caregivers will be interviewed at 1 week, and 3, 6 and 12 month time intervals. Primary outcome measures include the Pediatric Quality of Life (PedQOL) questionnaire, Subjective Units of Distress Scale, Child Behaviour Checklist (CBCL) and Rotter’s Locus of Control Scale. Secondary outcome measures include the total number of medical appointments, school days missed and quantity of services accessed. Our main objectives are to determine if the ICCC results in better health and economics outcomes compared to the self-directed care pathway.

Discussion

The success of a health systems approach needs to be balanced against clinical, mortality and cost-effectiveness data for long-term sustainability within a publicly funded health system. A clinical pathway that is sustainable, cost-effective, provides efficient evidence-based care and improves the quality of life outcomes for children with chronic health conditions has the potential to reduce waitlist times, improve access to health services, increase consumer satisfaction; and prevent costs associated with poorly managed chronic health conditions into adulthood. This study will be the first to provide clinical and health economics data on an integrated care pathway for the management of chronic health conditions in children. On a broader scale, results from this study will help guide care coordination frameworks for children with chronic health conditions; particularly with the introduction and implementation of a National Disability Insurance Scheme (NDIS) across Australia.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR) ACTRN12617001188325. Registered: 14th August, 2017.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1034-x) contains supplementary material, which is available to authorized users.

Effect of Mobile-health on maternal health care service utilization in Eastern Ethiopia: study protocol for a randomized controlled trial

Background

Globally, the rapid development of mobile technology has created new ways of addressing public health challenges and shifted the paradigm of health care access and delivery. The primary aim of this study is to examine the effectiveness of Mobile-health on maternal health care service utilization in Eastern Ethiopia.

Methods/design

Through, a cluster-randomized controlled trial, 640 participants will be selected based on their districts and respective health centers as the unit of randomization. All pregnant mothers who fulfill the inclusion criteria will be allocated to a mobile-phone-based intervention and existing standard of care or control with a 1:1 allocation ratio. The intervention consists of a series of 24 voice messages which will be sent every 2 weeks from the date of enrollment until the close-out time. The control group will receive existing standard of care without voice messages. Data related to outcome variables will be assessed at three phases of the data collection periods. The primary outcome measures will be the proportion of antenatal care visits and institutional delivery, whereas the secondary outcome measures will consist of the proportion of postnatal care visits and pregnancy outcomes. Risk ratios will be used to a measure the effect of intervention on the outcomes which will be estimated with 95% confidence interval and all the analyses will be done with consideration of clustering effect.

Discussions

This study should generate evidence on the effectiveness of mobile-phone-based voice messages for the early initiation of maternal health care service use and its uptake. It has been carefully designed with the assumption of obtaining higher levels of maternal health care service use among the treatment group as compared to the control.

Trial registration

Pan African Clinical Trial Registry, www.panctr.org, ID: PACTR201704002216259. Registered on 28 April 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2446-5) contains supplementary material, which is available to authorized users.

Design and implementation of a health systems strengthening approach to improve health and nutrition of pregnant women and newborns in Ethiopia, Kenya, Niger, and Senegal

Maternal and neonatal mortality are unacceptably high in developing countries. Essential nutrition interventions contribute to reducing this mortality burden, although nutrition is poorly integrated into health systems. Universal health coverage is an essential prerequisite to decreasing mortality indices. However, provision and utilization of nutrition and health services for pregnant women and their newborns are poor and the potential for improvement is limited where health systems are weak. The Community-Based Maternal and Neonatal Health and Nutrition project was established as a set of demonstration projects in 4 countries in Africa with varied health system contexts where there were barriers to safe maternal health care at individual, community and facility levels. We selected project designs based on the need, context, and policies under consideration. A theory driven approach to programme implementation and evaluation was used involving developing of contextual project logic models that linked inputs to address gaps in quality and uptake of antenatal care; essential nutrition actions in antenatal care, delivery, and postnatal care; delivery with skilled and trained birth attendant; and postnatal care to outcomes related to improvements in maternal health service utilization and reduction in maternal and neonatal morbidity and mortality. Routine monitoring and impact evaluations were included in the design. The objective of this paper is to describe the rationale and methods used in setting up a multi-country study that aimed at designing the key maternal and neonatal health interventions and identifying indicators related to inputs, outcomes, and impact that were measured to track change associated with our interventions.

Effect of provision of home-based curative health services by public sector health-care providers on neonatal survival: a community-based cluster-randomised trial in rural Pakistan

BACKGROUND

Although the effectiveness of community mobilisation and promotive care delivered by community health workers in reducing perinatal and neonatal mortality is well established, evidence in support of home-based neonatal resuscitation and infection management is mixed. We assessed the effectiveness of adding training in neonatal bag and mask resuscitation and oral antibiotic therapy for suspected neonatal infections to a basic preventive and promotive interventions package delivered by public sector community-based lady health workers (LHWs) in rural Pakistan.

METHODS

We did a cluster-randomised controlled trial in two subdistricts of Naushahro Feroze in rural Sindh, Pakistan, between April 15, 2009, and Dec 10, 2012. LHWs, trained in basic newborn resuscitation and in recognition and treatment (with oral amoxicillin) of suspected neonatal respiratory infections, were linked with traditional birth attendants and encouraged to attend home births. Control clusters received routine care through the existing national programme. The primary outcome was all-cause neonatal mortality. Independent data collection teams recorded data for all pregnancies and their outcomes, morbidity, mortality, and household practices related to maternal and newborn care.

FINDINGS

Of the 27 randomised clusters with functional LHW programmes, 13 were allocated to the intervention group (n=242 749) and 14 to the control group (n=256 985). In the intervention group, LHWs did 80% of the planned community mobilisation sessions, but were able to attend only 1184 (14%) of 8425 deliveries and 4318 (25%) of 17 288 neonatal visits within 72 h of birth (p<0·0001 for both variables compared with the control group). The neonatal mortality rate was 42 deaths per 1000 livebirths in intervention clusters compared with 55 per 1000 in the control group (risk ratio 0·80, 95% CI 0·68-0·93; p=0·005).

INTERPRETATION

The reduction in neonatal mortality in intervention clusters occurred against a background of improvements in domiciliary practices for maternal and newborn care. However, the poor reach of LHWs in accessing newborn infants at birth and in the early postnatal period underscores the limitations of tasking community health workers in public sector programmes working in similar circumstances with such complex interventions. Such community-based interventions in health systems should be accompanied by concerted efforts to improve quality of care in facilities and referral systems.

FUNDING

Saving Newborn Lives, Save the Children USA.

Timing of maternal death: Levels, trends, and ecological correlates using sibling data from 34 sub-Saharan African countries

Millennium Development Goal 5 has not been universally achieved, particularly in sub-Saharan Africa. Understanding whether maternal deaths occur during pregnancy, childbirth, or puerperium is important to effectively plan maternal health programs and allocate resources. Our main research objectives are to (1) describe the proportions and rates of mortality for the antepartum, intrapartum, and postpartum periods; (2) document how these trends vary by sub-region; and (3) investigate ecological correlations between these rates and maternal care interventions. We used data from the Demographic and Health Survey program, which comprises 84 surveys from 34 sub-Saharan African countries conducted between 1990 and 2014. We calculated age-standardized maternal mortality rates and time-specific maternal mortality rates and proportions, and we assessed correlations with maternal care coverage. We found high levels of maternal mortality in all three periods. Time-specific maternal mortality rates varied by country and region, with some showing an orderly decline in all three periods and others exhibiting alarming increases in antepartum and postpartum mortality. Ecological analysis showed that antenatal care coverage was significantly associated with low antepartum mortality, whereas the presence of a skilled attendant at childbirth was significantly associated with low postpartum mortality. In sub-Saharan Africa, maternal deaths occur at high rates in all three risk periods, and vary substantially by country and region. The provision of maternal care is a predictor of time-specific maternal mortality. These results confirm the need for country-specific interventions during the continuum of care to achieve the global commitment to eliminating preventable maternal mortality.

Opportunities and Challenges in Global Perinatal Research

BACKGROUND

The global plight of stillbirths and neonatal mortality is concentrated in low- and middle-income countries. The ambitious targets introduced by the World Health Organization in the Every Newborn Action Plan demand a commitment to research that promotes equitable perinatal outcomes.

OBJECTIVES

The aim of this review was to understand the opportunities for global perinatal research and the accompanying challenges.

METHODS

We conducted a literature search to identify research prioritization exercises from 2014 to 2018 pertaining to global perinatal health. The top 50 questions with the highest research prioritization scores were extracted and analyzed.

RESULTS

The greatest priorities centered on community-based, implementation research targeting major causes of stillbirth and neonatal mortality in low-resource settings. The priorities are saddled with prerequisite conditions, design obstacles, and ethical considerations that require attention.

CONCLUSIONS

While the challenges are undeniable, the need to make the perinatal period healthier for babies worldwide has never been clearer.

The Research Cycle: Improving Care and Outcomes for Newborn Infants

Ensuring that policies and practice in perinatal care are informed by evidence from high-quality research is fundamental to improving outcomes for newborn infants and their families. Effective interventions in the perinatal period can have a life-long impact disproportionate to their costs. Many of the major advances in care that have transformed outcomes for preterm and sick newborn infants have been informed by empirical and applied health research. Conversely, there are examples of life-long adverse consequences for infants and families that are a legacy of practices based on poor-quality evidence. The challenge in the 21st century is to maintain the trajectory of improvements in care and outcomes. This will most likely be achieved via marginal gains from new or improved care practices underpinned by a range of research approaches, from preclinical and laboratory-based empirical studies that uncover pathogenic pathways or therapeutic mechanisms, to large-scale, applied research such as multicentre, randomised controlled trials. This will involve the coordination and collaboration of research efforts globally. Strategies to develop and prioritise research questions need to involve parents and families. Given the context in which much perinatal research is conducted, particularly in emergency situations around the time of birth, robust and transparent ethics and governance frameworks are essential to maintain the trust and engagement of communities. An ethical imperative exists to ensure that research output is disseminated effectively, and that effective and cost-effective interventions are implemented and integrated within a cycle that audits and benchmarks good practice and outcomes, and informs research evidence-based continuous quality improvement. This is the first in a series of articles on research methodology in neonatal medicine to be published in Neonatology, in response to a request from trainee researchers. We introduce the series by describing the research cycle, in particular how it is applied in neonatal medicine. Subsequent articles will cover translational research, clinical trials, diagnostic tests, global challenges, and the ethical issues relating to neonatal/perinatal research.

Tackling the hard problems: implementation experience and lessons learned in newborn health from the African Health Initiative

Background

The Doris Duke Charitable Foundation’s African Health Initiative supported the implementation of Population Health Implementation and Training (PHIT) Partnership health system strengthening interventions in designated areas of five countries: Ghana, Mozambique, Rwanda, Tanzania, and Zambia. All PHIT programs included health system strengthening interventions with child health outcomes from the outset, but all increasingly recognized the need to increase focus to improve health and outcomes in the first month of life. This paper uses a case study approach to describe interventions implemented in newborn health, compare approaches, and identify lessons learned across the programs’ collective implementation experience.

Methods

Case studies were built using quantitative and qualitative methods, applying the World Health Organization Health Systems Strengthening Framework, and maternal, newborn and child health continuum of care framework. We identified the following five primary themes in health systems strengthening intervention strategies used to target improvement in newborn health, which were incorporated by all PHIT projects with varying results: health service delivery at the community level (Tanzania), combining community and health facility level interventions (Zambia), participatory information feedback and clinical training (Ghana), performance review and enhancement (Mozambique), and integrated clinical and system-level improvement (Rwanda), and used individual case studies to illustrate each of these themes.

Results

Tanzania and Zambia included significant community-based components, including mobilization and sensitization for increased uptake of essential services, while Ghana, Mozambique, and Rwanda focused more efforts on improving the quality of services delivered once a patient enters a health facility. All countries included aspects that improved communication across levels of the health system, whether through district-wide data sharing and peer learning networks in Mozambique and Rwanda, or improved referral processes and systems in Tanzania, Zambia, and Ghana.

Conclusion

Key lessons learned include the importance of focusing intervention components on addressing drivers of neonatal mortality across the maternal and newborn care continuum at all levels of the health system, matching efforts to improve service utilization with provision of high quality facility-based services, and the critical role of leadership to catalyze improvements in newborn health.

Effectiveness of community health worker training programmes for cardiovascular disease management in low-income and middle-income countries: a systematic review

INTRODUCTION

Community health workers (CHWs) are increasingly being tasked to prevent and manage cardiovascular disease (CVD) and its risk factors in underserved populations in low-income and middle-income countries (LMICs); however, little is known about the required training necessary for them to accomplish their role. This review aimed to evaluate the training of CHWs for the prevention and management of CVD and its risk factors in LMICs.

METHODS

A search strategy was developed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and five electronic databases (Medline, Global Health, ERIC, EMBASE and CINAHL) were searched to identify peer-reviewed studies published until December 2016 on the training of CHWs for prevention or control of CVD and its risk factors in LMICs. Study characteristics were extracted using a Microsoft Excel spreadsheet and quality assessed using Effective Public Health Practice Project's Quality Assessment Tool. The search, data extraction and quality assessment were performed independently by two researchers.

RESULTS

The search generated 928 articles of which 8 were included in the review. One study was a randomised controlled trial, while the remaining were before-after intervention studies. The training methods included classroom lectures, interactive lessons, e-learning and online support and group discussions or a mix of two or more. All the studies showed improved knowledge level post-training, and two studies demonstrated knowledge retention 6 months after the intervention.

CONCLUSION

The results of the eight included studies suggest that CHWs can be trained effectively for CVD prevention and management. However, the effectiveness of CHW trainings would likely vary depending on context given the differences between studies (eg, CHW demographics, settings and training programmes) and the weak quality of six of the eight studies. Well-conducted mixed-methods studies are needed to provide reliable evidence about the effectiveness and cost-effectiveness of training programmes for CHWs.

NAITRE study on the impact of conditional cash transfer on poor pregnancy outcomes in underprivileged women: protocol for a nationwide pragmatic cluster-randomised superiority clinical trial in France

INTRODUCTION

Prenatal care is recommended during pregnancy to improve neonatal and maternal outcomes. Women of lower socioeconomic status (SES) are less compliant to recommended prenatal care and suffer a higher risk of adverse perinatal outcomes. Several attempts to encourage optimal pregnancy follow-up have shown controversial results, particularly in high-income countries. Few studies have assessed financial incentives to encourage prenatal care, and none reported materno-fetal events as the primary outcome. Our study aims to determine whether financial incentives could improve pregnancy outcomes in women with low SES in a high-income country.

METHODS AND ANALYSIS

This pragmatic cluster-randomised clinical trial includes pregnant women with the following criteria: (1) age above 18 years, (2) first pregnancy visit before 26 weeks of gestation and (3) belonging to a socioeconomically disadvantaged group. The intervention consists in offering financial incentives conditional on attending scheduled pregnancy follow-up consultations. Clusters are 2-month periods with random turnover across centres. A composite outcome of maternal and neonatal morbidity and mortality is the primary endpoint. Secondary endpoints include maternal or neonatal outcomes assessed separately, qualitative assessment of the perception of the intervention and cost-effectiveness analysis for which children will be followed to the end of their first year through the French health insurance database. The study started in June 2016, and based on an expected decrease in the primary endpoint from 18% to 14% in the intervention group, we plan to include 2000 women in each group.

ETHICS AND DISSEMINATION

Ethics approval was first gained on 28 September 2014. An independent data security and monitoring committee has been established. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02402855; pre-results.

Changes in cause-specific neonatal and 1-59-month child mortality in India from 2000 to 2015: a nationally representative survey

BACKGROUND

Documentation of the demographic and geographical details of changes in cause-specific neonatal (younger than 1 month) and 1-59-month mortality in India can guide further progress in reduction of child mortality. In this study we report the changes in cause-specific child mortality between 2000 and 2015 in India.

METHODS

Since 2001, the Registrar General of India has implemented the Million Death Study (MDS) in 1·3 million homes in more than 7000 randomly selected areas of India. About 900 non-medical surveyors do structured verbal autopsies for deaths recorded in these homes. Each field report is assigned randomly to two of 404 trained physicians to classify the cause of death, with a standard process for resolution of disagreements. We combined the proportions of child deaths according to the MDS for 2001-13 with annual UN estimates of national births and deaths (partitioned across India's states and rural or urban areas) for 2000-15. We calculated the annual percentage change in sex-specific and cause-specific mortality between 2000 and 2015 for neonates and 1-59-month-old children.

FINDINGS

The MDS captured 52 252 deaths in neonates and 42 057 deaths at 1-59 months. Examining specific causes, the neonatal mortality rate from infection fell by 66% from 11·9 per 1000 livebirths in 2000 to 4·0 per 1000 livebirths in 2015 and the rate from birth asphyxia or trauma fell by 76% from 9·0 per 1000 livebirths in 2000 to 2·2 per 1000 livebirths in 2015. At 1-59 months, the mortality rate from pneumonia fell by 63% from 11·2 per 1000 livebirths in 2000 to 4·2 per 1000 livebirths in 2015 and the rate from diarrhoea fell by 66% from 9·4 per 1000 livebirths in 2000 to 3·2 per 1000 livebirths in 2015 (with narrowing girl-boy gaps). The neonatal tetanus mortality rate fell from 1·6 per 1000 livebirths in 2000 to less than 0·1 per 1000 livebirths in 2015 and the 1-59-month measles mortality rate fell from 3·3 per 1000 livebirths in 2000 to 0·3 per 1000 livebirths in 2015. By contrast, mortality rates for prematurity or low birthweight rose from 12·3 per 1000 livebirths in 2000 to 14·3 per 1000 livebirths in 2015, driven mostly by increases in term births with low birthweight in poorer states and rural areas. 29 million cumulative child deaths occurred from 2000 to 2015. The average annual decline in mortality rates from 2000 to 2015 was 3·3% for neonates and 5·4% for children aged 1-59 months. Annual declines from 2005 to 2015 (3·4% decline for neonatal mortality and 5·9% decline in 1-59-month mortality) were faster than were annual declines from 2000 to 2005 (3·2% decline for neonatal mortality and 4·5% decline in 1-59-month mortality). These faster declines indicate that India avoided about 1 million child deaths compared with continuation of the 2000-05 declines.

INTERPRETATION

To meet the 2030 Sustainable Development Goals for child mortality, India will need to maintain the current trajectory of 1-59-month mortality and accelerate declines in neonatal mortality (to >5% annually) from 2015 onwards. Continued progress in reduction of child mortality due to pneumonia, diarrhoea, malaria, and measles at 1-59 months is feasible. Additional attention to low birthweight is required.

FUNDING

National Institutes of Health, Disease Control Priorities Network, Maternal and Child Epidemiology Estimation Group, and University of Toronto.

Impact of the community-based newborn care package in Nepal: a quasi-experimental evaluation

OBJECTIVE

To evaluate the impact of the community-based newborn care package (CBNCP) on six essential practices to improve neonatal health.

METHODS

CBNCP pilot districts were matched to comparison districts using propensity scores. Impact on birth preparedness, antenatal care seeking, antenatal care quality, delivery by skilled birth attendant, immediate newborn care and postnatal care within 48 hours were assessed using Demographic and Health Survey (DHS) and Health Management Information System (HMIS) data through difference-in-differences and multivariate logistic regression analyses.

FINDINGS

Changes over time in intervention and comparison areas were similar in difference-in-differences analysis of DHS and HMIS data. Logistic regression of DHS data also did not reveal any significant improvement in combined outcomes: birth preparedness, adjusted OR (aOR)=0.8 (95% CI 0.4 to 1.7); antenatal care seeking, aOR=1.0 (0.6 to 1.5); antenatal care quality, aOR=1.4 (0.9 to 2.1); delivery by skilled birth attendant, aOR=1.5 (1.0 to 2.3); immediate newborn care, aOR=1.1 (0.7 to 1.9); postnatal care, aOR=1.3 (0.9 to 1.9). Health providers' knowledge and skills in intervention districts were fair but showed much variation between different providers and districts.

CONCLUSIONS

This study, while representing an early assessment of impact, did not identify significant improvements in newborn care practices and raises concerns regarding CBNCP implementation. It has contributed to revisions of the package and it being merged with the Integrated Management of Neonatal and Childhood Illness programme. This is now being implemented in 35 districts and carefully monitored for quality and impact. The study also highlights general challenges in evaluating the impacts of a complex health intervention under 'real life' conditions.

Improving the performance of community health workers in Swaziland: findings from a qualitative study

BACKGROUND

The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre.

METHODS

The CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance.

RESULTS

Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: (i) increased monetary compensation of CHWs, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) an expansion of CHW responsibilities to cover a wider array of the community's healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance.

CONCLUSIONS

While this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers.

Sharing Histories-a transformative learning/teaching method to empower community health workers to support health behavior change of mothers

BACKGROUND

One of the keys to improving health globally is promoting mothers' adoption of healthy home practices for improved nutrition and illness prevention in the first 1000 days of life from conception. Customarily, mothers are taught health messages which, even if simplified, are hard to remember. The challenge is how to promote learning and behavior change of mothers more effectively in low-resource settings where access to health information is poor, educational levels are low, and traditional beliefs are strong.

METHODS

In addressing that challenge, a new learning/teaching method called "Sharing Histories" is in development to improve the performance of female community health workers (CHWs) in promoting mothers' behaviors for maternal, neonatal and child health (MNCH).

RESULTS

This method builds self-confidence and empowerment of CHWs in learning sessions that are built on guided sharing of their own memories of childbearing and child care. CHWs can later share histories with the mother, building her trust and empowerment to change. For professional primary health care staff who are not educators, Sharing Histories is simple to learn and use so that the method can be easily incorporated into government health systems and ongoing CHW programs.

CONCLUSIONS

I present here the Sharing Histories method, describe how it differs from other social and behavior change methods, and discuss selected literature from psychology, communications, and neuroscience that helps to explain how and why this method works as a transformative tool to engage, teach, transform, and empower CHWs to be more effective change agents with other mothers in their communities, thereby contributing to the attainment of the Sustainable Development Goals.

Effects of the EQUIP quasi-experimental study testing a collaborative quality improvement approach for maternal and newborn health care in Tanzania and Uganda

BACKGROUND

Quality improvement is a recommended strategy to improve implementation levels for evidence-based essential interventions, but experience of and evidence for its effects in low-resource settings are limited. We hypothesised that a systemic and collaborative quality improvement approach covering district, facility and community levels, supported by report cards generated through continuous household and health facility surveys, could improve the implementation levels and have a measurable population-level impact on coverage and quality of essential services.

METHODS

Collaborative quality improvement teams tested self-identified strategies (change ideas) to support the implementation of essential maternal and newborn interventions recommended by the World Health Organization. In Tanzania and Uganda, we used a plausibility design to compare the changes over time in one intervention district with those in a comparison district in each country. Evaluation included indicators of process, coverage and implementation practice analysed with a difference-of-differences and a time-series approach, using data from independent continuous household and health facility surveys from 2011 to 2014. Primary outcomes for both countries were birth in health facilities, breastfeeding within 1 h after birth, oxytocin administration after birth and knowledge of danger signs for mothers and babies. Interpretation of the results considered contextual factors.

RESULTS

The intervention was associated with improvements on one of four primary outcomes. We observed a 26-percentage-point increase (95% CI 25-28%) in the proportion of live births where mothers received uterotonics within 1 min after birth in the intervention compared to the comparison district in Tanzania and an 8-percentage-point increase (95% CI 6-9%) in Uganda. The other primary indicators showed no evidence of improvement. In Tanzania, we saw positive changes for two other outcomes reflecting locally identified improvement topics. The intervention was associated with an increase in preparation of clean birth kits for home deliveries (31 percentage points, 95% CI 2-60%) and an increase in health facility supervision by district staff (14 percentage points, 95% CI 0-28%).

CONCLUSIONS

The systemic quality improvement approach was associated with improvements of only one of four primary outcomes, as well as two Tanzania-specific secondary outcomes. Reasons for the lack of effects included limited implementation strength as well a relatively short follow-up period in combination with a 1-year recall period for population-based estimates and a limited power of the study to detect changes smaller than 10 percentage points.

TRIAL REGISTRATION

Pan African Clinical Trials Registry: PACTR201311000681314.

Community health promotion and medical provision for neonatal health-CHAMPION cluster randomised trial in Nagarkurnool district, Telangana (formerly Andhra Pradesh), India

BACKGROUND

In the mid-2000s, neonatal mortality accounted for almost 40% of deaths of children under 5 years worldwide, and constituted 65% of infant deaths in India. The neonatal mortality rate in Andhra Pradesh was 44 per 1,000 live births, and was higher in the rural areas and tribal regions, such as the Nagarkurnool division of Mahabubnagar district (which became Nagarkurnool district in Telangana in 2014). The aim of the CHAMPION trial was to investigate whether a package of interventions comprising community health promotion and provision of health services (including outreach and facility-based care) could lead to a reduction of the order of 25% in neonatal mortality.

METHODS AND FINDINGS

The design was a trial in which villages (clusters) in Nagarkurnool with a population < 2,500 were randomised to the CHAMPION package of health interventions or to the control arm (in which children aged 6-9 years were provided with educational interventions-the STRIPES trial). A woman was eligible for the CHAMPION package if she was married and <50 years old, neither she nor her husband had had a family planning operation, and she resided in a trial village at the time of a baseline survey before randomisation or married into the village after randomisation. The CHAMPION intervention package comprised community health promotion (including health education via village health worker-led participatory discussion groups) and provision of health services (including outreach, with mobile teams providing antenatal check-ups, and facility-based care, with subsidised access to non-public health centres [NPHCs]). Villages were stratified by travel time to the nearest NPHC and tribal status, and randomised (1:1) within strata. The primary outcome was neonatal mortality. Secondary outcomes included maternal mortality, causes of death, health knowledge, health practices including health service usage, satisfaction with care, and costs. The baseline survey (enumeration) was carried out between August and November 2007. After randomisation on 18 February 2008, participants, data collectors, and data analysts were not masked to allocation. The intervention was initiated on 1 August 2008. After an inception period, the assessment start date was 1 December 2008. The intervention ended on 31 May 2011, and data collection was completed on 30 November 2011. Primary analyses followed the intention to treat principle. In all, 14,137 women were enrolled in 232 control villages, and 15,532 in 232 intervention villages. Of these, 4,885 control women had 5,474 eligible pregnancies and gave birth to 4,998 eligible children. The corresponding numbers in intervention villages were 5,664 women, 6,351 pregnancies, and 5,798 children. Of the live-born babies, 343 (6.9%) in the control arm and 303 (5.2%) in the intervention arm died in their first 28 days of life (risk ratio 0.76, 95% CI 0.64 to 0.90, p = 0.0018; risk difference -1.59%, 95% CI -2.63% to -0.54%), suggesting that there were 92 fewer deaths (95% CI 31 to 152) as a result of the intervention. There were 9 (0.16%) maternal deaths in the control arm compared to 13 (0.20%) in the intervention arm (risk ratio 1.24, 95% CI 0.53 to 2.90, p = 0.6176; 1 death was reported as a serious adverse event). There was evidence of improved health knowledge and health practices including health service usage in the intervention arm compared to the control arm. Women in the intervention arm were more likely to rate their delivery and postnatal care as good or very good. The total cost of the CHAMPION interventions was US$1,084,955 ($11,769 per life saved, 95% CI $7,115 to $34,653). The main limitations of the study included that it could not be masked post-randomisation and that fetal losses were not divided into stillbirths and miscarriages because gestational age was not reliably reported.

CONCLUSIONS

The CHAMPION trial showed that a package of interventions addressing health knowledge and health seeking behaviour, buttressing existing health services, and contracting out important areas of maternal and child healthcare led to a reduction in neonatal mortality of almost the hypothesized 25% in small villages in an Indian state with high mortality rates. The intervention can be strongly justified in much of rural India, and is of potential use in other similar settings. Ongoing changes in maternal and child health programmes make it imperative that a similar intervention that establishes ties between the community and health facilities is tested in different settings.

TRIAL REGISTRATION

ISRCTN registry ISRCTN24104646.

Immunization, urbanization and slums - a systematic review of factors and interventions

Background

In 2014, over half (54%) of the world’s population lived in urban areas and this proportion will increase to 66% by 2050. This urbanizing trend has been accompanied by an increasing number of people living in urban poor communities and slums. Lower immunization coverage is found in poorer urban dwellers in many contexts. This study aims to identify factors associated with immunization coverage in poor urban areas and slums, and to identify interventions to improve coverage.

Methods

We conducted a systematic review, searching Medline, Embase, Global Health, CINAHL, Web of Science and The Cochrane Database with broad search terms for studies published between 2000 and 2016.

Results

Of 4872 unique articles, 327 abstracts were screened, leading to 63 included studies: 44 considering factors and 20 evaluating interventions (one in both categories) in 16 low or middle-income countries. A wide range of socio-economic characteristics were associated with coverage in different contexts. Recent rural-urban migration had a universally negative effect. Parents commonly reported lack of awareness of immunization importance and difficulty accessing services as reasons for under-immunization of their children. Physical distance to clinics and aspects of service quality also impacted uptake. We found evidence of effectiveness for interventions involving multiple components, especially if they have been designed with community involvement. Outreach programmes were effective where physical distance was identified as a barrier. Some evidence was found for the effective use of SMS (text) messaging services, community-based education programmes and financial incentives, which warrant further evaluation. No interventions were identified that provided services to migrants from rural areas.

Conclusion

Different factors affect immunization coverage in different urban poor and slum contexts. Immunization services should be designed in collaboration with slum-dwelling communities, considering the local context. Interventions should be designed and tested to increase immunization in migrants from rural areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4473-7) contains supplementary material, which is available to authorized users.

Community Health Workers and Use of mHealth: Improving Identification of Pregnancy Complications and Access to Care in the Dominican Republic

This article presents the feasibility and acceptability of using mobile health technology by community health workers (CHWs) in San Juan Province, Dominican Republic, to improve identification of pregnancy complications and access to care for pregnant women. Although most women in the Dominican Republic receive four antenatal care visits, poor women and adolescents in remote areas are more likely to have only one initial prenatal visit to verify the pregnancy. This community-based research began when community leaders raised concern about the numbers of their mothers who died in childbirth annually; San Juan's maternal mortality rate is 144/100,000 compared to the Caribbean rate of 85/100,000. Eight CHWs in three communities were taught to provide third-trimester antenatal assessment, upload the data on a mobile phone application, send the data to the local physician who monitored data for "red flags," and call directly if a mother had an urgent problem. Fifty-two pregnant women enrolled, 38 were followed to delivery, 95 antenatal care postintake were provided, 2 urgent complications required CHW home management of mothers, and there were 0 deaths. Stakeholders endorsed acceptability of intervention. Preliminary data suggest CHWs using mobile health technology is feasible, linking underserved and formal health care systems with provision of primary care in mothers' homes.

Prevalence of early initiation of breastfeeding and determinants of delayed initiation of breastfeeding: secondary analysis of the WHO Global Survey

Early initiation of breastfeeding (EIBF) within 1 hour of birth can decrease neonatal death. However, the prevalence of EIBF is approximately 50% in many developing countries, and data remains unavailable for some countries. We conducted a secondary analysis using the WHO Global Survey on Maternal and Perinatal Health to identify factors hampering EIBF. We described the coverage of EIBF among 373 health facilities for singleton neonates for whom breastfeeding was initiated after birth. Maternal and facility characteristics of EIBF were compared to those of breastfeeding >1 hour after birth, and multiple logistic regression analysis was performed. In total, 244,569 singleton live births without severe adverse outcomes were analysed. The EIBF prevalence varied widely among countries and ranged from 17.7% to 98.4% (average, 57.6%). There was less intra-country variation for BFI <24 hours. After adjustment, EIBF was significantly lower among women with complications during pregnancy and caesarean delivery. Globally, EIBF varied considerably across countries. Maternal complications during pregnancy, caesarean delivery and absence of postnatal/neonatal care guidelines at hospitals may affect EIBF. Our findings suggest that to better promote EIBF, special support for breastfeeding promotion is needed for women with complications during pregnancy and those who deliver by caesarean section.

Economic evaluation of interventions delivered by primary care providers to improve neurodevelopment in children aged under 5 years: protocol for a scoping review

BACKGROUND

Frequently cited benefit-cost ratios suggest that interventions to improve neurodevelopment have high economic returns when implemented during pregnancy and early childhood. However, there are many challenges when primary care providers implement these interventions at scale, and it is unclear how many research studies or programmes have examined cost-effectiveness and which methods were used. There are no current scoping or systematic reviews which have assessed economic evaluations of interventions delivered by primary care providers to improve child neurodevelopment.

METHODS/DESIGN

The aim of this review is to describe the economic evaluations of interventions delivered by primary care providers to improve neurodevelopment in children aged 0-4 years. Specific subgroup analyses will include income level of country (high, middle and low); population type (universal vs targeted); time period when intervention was implemented (antenatal vs infancy [0-11 months] vs early childhood [12-59 months]); and setting (research study vs programmes evaluation at scale). All study designs will be included. The primary outcomes of interest are cost per neurodevelopmental or cognitive health gain in children aged 0-4 years. All measures of cost, neurodevelopment or cognitive function that have been previously validated as an appropriate test in this domain will be included. Databases such as MEDLINE (OVID), PsycINFO (OVID), EMBASE (OVID), CINAHL, Cochrane Library (including CENTRAL, DARE, HTA and NHS EED), Paediatric Economic Database Evaluation (PEDE) and WHO databases and reference lists of papers will be searched for relevant articles. Five phases will be followed: identifying the research question, identifying relevant studies, study selection, charting data and collating, summarising and reporting results. We will present cost and effectiveness data descriptively.

DISCUSSION

This review appears to be the first to be conducted in this area. The findings will be an important resource for future systematic reviews on interventions that have a cost component. This information will be valuable for policy makers and programmers who work in public health or primary care settings.

Making the continuum of care work for mothers and infants: Does gender equity matter? Findings from a quasi-experimental study in Bihar, India

Background

Improvements in continuum of care (CoC) utilization are needed to address inadequate reductions in neonatal and infant mortality in India and elsewhere. This study examines the effect of Ananya, a health system training and community outreach intervention, on reproductive, maternal and newborn health continuum of care (RMNH CoC) utilization in Bihar, India, and explores whether that effect is moderated by gender equity factors (child marriage, restricted mobility and low decision-making control).

Methods

A two-armed quasi-experimental design compared districts in Bihar that did/did not implement Ananya. Cross-sections of married women aged 15–49 with a 0–5 month old child were surveyed at baseline and two year follow-up (baseline n = 7191 and follow-up n = 6143; response rates 88.9% and 90.7%, respectively). Difference-in-difference analyses assessed program impact on RMNH CoC co-coverage, defined by 9 health services/behaviors for the index pregnancy (e.g., antenatal care, skin-to-skin care). Three-way interactions assessed gender equity as a moderator of Ananya’s impact.

Findings

Participants reported low RMNH CoC co-coverage at baseline (on average 3.2 and 3.0 of the 9 RMNH services/behaviors for Ananya and control groups, respectively). The Ananya group showed a significantly greater increase in RMNH CoC co-coverage (.41 services) compared with the control group over time (p<0.001), with the primary drivers being increases in clean cord care, skin-to-skin care and postpartum contraceptive use. Gender equity interaction analyses revealed diminished intervention effects on antenatal care, skilled birth attendance and exclusive breastfeeding for women married as minors.

Conclusion

Ananya improved RMNH CoC co-coverage among these recent mothers, largely through positive health behavior changes. Child marriage attenuated Ananya’s impact on utilization of key health services and behaviors. Supporting the health system with training and community outreach can be beneficial to RMNH CoC utilization; additional support is needed to adequately address the unique issues faced by women married as minors.

Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models

BACKGROUND

Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models.

METHODS

A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions.

RESULTS

Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers.

CONCLUSIONS

Interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.

Multiple behaviour change intervention for diarrhoea control in Lusaka, Zambia: a cluster randomised trial

BACKGROUND

Effective prevention and control of diarrhoea requires caregivers to comply with a suite of proven measures, including exclusive breastfeeding, handwashing with soap, correct use of oral rehydration salts, and zinc administration. We aimed to assess the effect of a novel behaviour change intervention using emotional drivers on caregiver practice of these behaviours.

METHODS

We did a cluster randomised controlled trial in Lusaka Province, Zambia. A random sample of 16 health centres (clusters) were selected from a sampling frame of 81 health centres in three of four districts in Lusaka Province using a computerised random number generator. Each cluster was randomly assigned 1:1 to either the intervention-clinic events, community events, and radio messaging-or to a standard care control arm, both for 6 months. Primary outcomes were exclusive breastfeeding (self-report), handwashing with soap (observation), oral rehydration salt solution preparation (demonstration), and zinc use in diarrhoea treatment (self-report). We measured outcome behaviours at baseline before start of intervention and 4-6 weeks post-intervention through repeat cross-sectional surveys with mothers of an infant younger than 6 months and primary caregivers of a child younger than 5 years with recent diarrhoea. We compared outcomes on an intention-to-treat population between intervention and control groups adjusted for baseline behaviour. The study was registered with ClinicalTrials.gov, number NCT02081521.

FINDINGS

Between Jan 20 and Feb 3, 2014, we recruited 306 mothers of an infant aged 0-5 months (156 intervention, 150 standard care) and 343 primary caregiver of a child aged 0-59 months with recent diarrhoea (176 intervention, 167 standard care) at baseline. Between Oct 20 to Nov 7, 2014, we recruited 401 mothers of an infant 0-5 months (234 intervention, 167 standard care) and 410 primary caregivers of a child 0-59 months with recent diarrhoea (257 intervention, 163 standard care) at endline. Intervention was associated with increased prevalence of self-reported exclusive breastfeeding of infants aged 0-5 months (adjusted difference 10·5%, 95% CI 0·9-19·9). Other primary outcomes were not affected by intervention. Cluster intervention exposure ranged from 11-81%, measured by participant self-report with verification questions. Comparison of control and intervention clusters with coverage greater than 35% provided strong evidence of an intervention effect on oral rehydration salt solution preparation and breastfeeding outcomes.

INTERPRETATION

The intervention may have improved exclusive breastfeeding (assessed by self-reporting), but intervention effects were diluted in clusters with low exposure. Complex caregiver practices can improve through interventions built around human motives, but these must be implemented more intensely.

FUNDING

Absolute Return for Kids (ARK) and Comic Relief.

Barriers, Facilitators and Priorities for Implementation of WHO Maternal and Perinatal Health Guidelines in Four Lower-Income Countries: A GREAT Network Research Activity

BACKGROUND

Health systems often fail to use evidence in clinical practice. In maternal and perinatal health, the majority of maternal, fetal and newborn mortality is preventable through implementing effective interventions. To meet this challenge, WHO's Department of Reproductive Health and Research partnered with the Knowledge Translation Program at St. Michael's Hospital (SMH), University of Toronto, Canada to establish a collaboration on knowledge translation (KT) in maternal and perinatal health, called the GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge). We applied a systematic approach incorporating evidence and theory to identifying barriers and facilitators to implementation of WHO maternal heath recommendations in four lower-income countries and to identifying implementation strategies to address these.

METHODS

We conducted a mixed-methods study in Myanmar, Uganda, Tanzania and Ethiopia. In each country, stakeholder surveys, focus group discussions and prioritization exercises were used, involving multiple groups of health system stakeholders (including administrators, policymakers, NGOs, professional associations, frontline healthcare providers and researchers).

RESULTS

Despite differences in guideline priorities and contexts, barriers identified across countries were often similar. Health system level factors, including health workforce shortages, and need for strengthened drug and equipment procurement, distribution and management systems, were consistently highlighted as limiting the capacity of providers to deliver high-quality care. Evidence-based health policies to support implementation, and improve the knowledge and skills of healthcare providers were also identified. Stakeholders identified a range of tailored strategies to address local barriers and leverage facilitators.

CONCLUSION

This approach to identifying barriers, facilitators and potential strategies for improving implementation proved feasible in these four lower-income country settings. Further evaluation of the impact of implementing these strategies is needed.

Feasibility of community level interventions for pre-eclampsia: perspectives, knowledge and task-sharing from Nigeria, Mozambique, Pakistan and India

Hypertensive disorders of pregnancy (HDP), particularly pre-eclampsia and eclampsia, remain one of the leading causes of maternal mortality and are contributory in many foetal/newborn deaths. This editorial discusses a supplement of seven papers which provide the results of the first round of the CLIP (Community Level Interventions for Pre-eclampsia) Feasibility Studies. These studies report a number of enablers and barriers in each setting, which have informed the implementation of a cluster-randomized trial (cRCT) aimed at reducing pre-eclampsia-related, and all-cause, maternal and perinatal mortality and major morbidity using community-based identification and treatment of pre-eclampsia in selected geographies of Nigeria, Mozambique, Pakistan and India. This supplement unpacks the diverse community perspectives on determinants of maternal health, variant health worker knowledge and routine management of HDP, and viability of task sharing for preeclampsia identification and management in select settings. These studies demonstrate the need for strategies to improve health worker knowledge and routine management of HDP and consideration of expanding the role of community health workers to reach the most remote women and families with health education and access to health services.

Effectiveness of the Home Based Life Saving Skills training by community health workers on knowledge of danger signs, birth preparedness, complication readiness and facility delivery, among women in Rural Tanzania

Background

In spite of government efforts, maternal mortality in Tanzania is currently at more than 400 per 100,000 live births. Community-based interventions that encourage safe motherhood and improved health-seeking behaviour through acquiring knowledge on the danger signs and improving birth preparedness, and, ultimately, reduce maternal mortality, have been initiated in different parts of low-income countries. Our aim was to evaluate if the Home Based Life Saving Skills education by community health workers would improve knowledge of danger signs, birth preparedness and complication readiness and facility-based deliveries in a rural community in Tanzania.

Methods

A quasi-experimental study design was used to evaluate the effectiveness of Home Based Life Saving Skills education to pregnant women and their families through a community intervention. An intervention district received training with routine care. A comparison district continued to receive routine antenatal care. A structured household questionnaire was used in order to gather information from women who had delivered a child within the last two years before the intervention. This questionnaire was used in both the intervention and comparison districts before and after the intervention. The net intervention effect was estimated using the difference between the differences in the intervention and control districts at baseline and endline.

Results

A total of 1,584 and 1,486 women were interviewed at pre-intervention and post intervention, respectively. We observed significant improvement of knowledge of three or more danger signs during pregnancy (15.2 % vs. 48.1 %) with a net intervention effect of 29.0 % (95 % CI: 12.8–36.2; p < .0001) compared to the comparison district. There was significant effect on the knowledge of three or more danger signs during childbirth (15.3 % vs. 43.1 %) with a net intervention effect of 18.3 % (95 % CI: 11.4–25.2; p < .0001) and postpartum for those mentioning three or more of the signs (8.8 % vs. 19.8 %) with net effect of 9.4 % (95 % CI: 6.4–15.7; p < .0001). Birth preparedness practice improved for those who made more than three actions (20.8 vs. 35.3 %) with a net intervention effect of 10.3 % (95 % CI: 10.3–20.3; p < .0001) between the intervention and control district at pre-intervention and post intervention. Utilisation of antenatal care with four visits improved significantly (43.4 vs. 67.8 %) with net effect of 25.3 % (95 % CI: 16.9–33.2; p < .0001), use of facility delivery improved in the intervention area (75.6 vs. 90.2 %; p = 0.0002) but there was no significant net effect 11.5 % (95 % CI: -5.1–39.6; p = 0.123) compared to comparison district.

Conclusion

This study shows that a community-based intervention employing community health workers as teachers in delivering Home Based Life Saving Skills program to pregnant women and their families improved their knowledge of danger signs during pregnancy, childbirth and postpartum, preparedness for childbirth and increased deliveries at health facilities which employ skilled health workers in this rural community.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-0916-x) contains supplementary material, which is available to authorized users.

Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Lack of appropriate health care seeking for ill mothers and neonates contributes to high mortality rates. A major challenge is the appropriate mix of strategies for creating demand as well as provision of services.

DESIGN

Systematic review and meta-analysis of experimental studies (last search: Jan 2015) to assess the impact of different strategies to improve maternal and neonatal health care seeking in low- and middle-income countries (LMIC).

RESULTS

Fifty-eight experimental [randomized controlled trials (RCTs), non-RCTs, and before-after studies] with 310,652 participants met the inclusion criteria. Meta-analyses from 29 RCTs with a range of different interventions (e.g. mobilization, home visitation) indicated significant improvement in health care seeking for neonatal illnesses when compared with standard/no care [risk ratio (RR) 1.40; 95 confidence interval (CI): 1.17-1.68, 9 studies, n=30,572], whereas, no impact was seen on health care seeking for maternal illnesses (RR 1.06; 95% CI: 0.92-1.22, 5 studies, n=15,828). These interventions had a significant impact on reducing stillbirths (RR 0.82; 95% CI: 0.73-0.93, 11 studies, n=176,683), perinatal deaths (RR 0.84; 95% CI: 0.77-0.90, 15 studies, n=279,618), and neonatal mortality (RR 0.80; 95% CI: 0.72-0.89, 20 studies, n=248,848). On GRADE approach, evidence was high quality except for the outcome of maternal health care seeking, which was moderate.

CONCLUSIONS

Community-based interventions integrating strategies such as home visiting and counseling can help to reduce fetal and neonatal mortality in LMIC.