Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival

Assessing the impact of geographical access to health facilities on maternal healthcare utilization: evidence from the Burkina Faso demographic and health survey 2010

BACKGROUND

Improving maternal and child health (MCH) remains a serious challenge for many developing countries. Geographical accessibility from a residence to the nearest health facility is suspected to be an important obstacle hampering the use of appropriate services for MCH especially in Sub-Sharan African countries. In Burkina Faso, a landlocked country in the Sahel region of West Africa, women's use of proper healthcare services during pregnancy and childbirth is still low. This study therefore assessed the impact of geographical access to health facilities on maternal healthcare utilization in Burkina Faso.

METHODS

We used the Burkina Faso demographic and health survey (DHS) 2010 dataset, with its sample of 10,364 mothers aged 15-49 years. Distance from residential areas to the closest health facility was measured by merging the DHS dataset with Geographic Information System data on the location of health centers in Burkina Faso. Multivariate logistic regressions were conducted to estimate the effects of distance on maternal healthcare utilization.

RESULTS

Regression results revealed that the longer the distance to the closest health center, the less likely it is that a woman will receive appropriate maternal healthcare services. The estimates show that one kilometer increase in distance to the closest health center reduces the odds that a woman will receive four or more antenatal care by 0.05 and reduces by 0.267 the odds that she will deliver her baby with the assistance of a skilled birth attendant.

CONCLUSIONS

Improving geographical access to health facilities increases the use of appropriate healthcare services during pregnancy and childbirth. Investment in transport infrastructure should be a prioritized target for further improvement in MCH in Burkina Faso.

Early childhood development: an imperative for action and measurement at scale

Experiences during early childhood shape biological and psychological structures and functions in ways that affect health, well-being and productivity throughout the life course. The science of early childhood and its long-term consequences have generated political momentum to improve early childhood development and elevated action to country, regional and global levels. These advances have made it urgent that a framework, measurement tools and indicators to monitor progress globally and in countries are developed and sustained. We review progress in three areas of measurement contributing to these goals: the development of an index to allow country comparisons of young children’s development that can easily be incorporated into ongoing national surveys; improvements in population-level assessments of young children at risk of poor early development; and the production of country profiles of determinants, drivers and coverage for early childhood development and services using currently available data in 91 countries. While advances in these three areas are encouraging, more investment is needed to standardise measurement tools, regularly collect country data at the population level, and improve country capacity to collect, interpret and use data relevant to monitoring progress in early childhood development.

Changes in inequality of childhood morbidity in Bangladesh 1993-2014: A decomposition analysis

INTRODUCTION

Child health remains an important public health concern at the global level, with preventable diseases such as diarrheal disease, acute respiratory infection (ARI) and fever posing a large public health burden in low- and middle-income countries including Bangladesh. Improvements in socio-economic conditions have tended to benefit advantaged groups in societies, which has resulted in widespread inequalities in health outcomes. This study examined how socioeconomic inequality is associated with childhood morbidity in Bangladesh, and identified the factors affecting three illnesses: diarrhea, ARI and fever.

MATERIALS AND METHODS

A total of 43,860 sample observations from the Bangladesh Demographic and Health Survey, spanning a 22-year period (1993-2014), were analysed. Concentration curve and concentration index methods were used to evaluate changes in the degree of household wealth-related inequalities and related trends in childhood morbidity. Regression-based decomposition analyses were used to attribute the inequality disparities to individual determinants for the three selected causes of childhood morbidity.

RESULTS

The overall magnitude of inequality in relation to childhood morbidity has been declining slowly over the 22-year period. The magnitude of socio-economic inequality as a cause of childhood morbidity varied during the period. Decomposition analyses attributed the inequalities to poor maternal education attainment, inadequate pre-delivery care, adverse chronic undernutrition status and low immunisation coverage.

CONCLUSIONS

High rates of childhood morbidity were observed, although these have declined over time. Socio-economic inequality is strongly associated with childhood morbidity. Socio-economically disadvantaged communities need to be assisted and interventions should emphasise improvements of, and easier access to, health care services. These will be key to improving the health status of children in Bangladesh and should reduce economic inequality through improved health over time.

Missed nursing care in newborn units: a cross-sectional direct observational study

BACKGROUND

Improved hospital care is needed to reduce newborn mortality in low/middle-income countries (LMIC). Nurses are essential to the delivery of safe and effective care, but nurse shortages and high patient workloads may result in missed care. We aimed to examine nursing care delivered to sick newborns and identify missed care using direct observational methods.

METHODS

A cross-sectional study using direct-observational methods for 216 newborns admitted in six health facilities in Nairobi, Kenya, was used to determine which tasks were completed. We report the frequency of tasks done and develop a nursing care index (NCI), an unweighted summary score of nursing tasks done for each baby, to explore how task completion is related to organisational and newborn characteristics.

RESULTS

Nursing tasks most commonly completed were handing over between shifts (97%), checking and where necessary changing diapers (96%). Tasks with lowest completion rates included nursing review of newborns (38%) and assessment of babies on phototherapy (15%). Overall the mean NCI was 60% (95% CI 58% to 62%), at least 80% of tasks were completed for only 14% of babies. Private sector facilities had a median ratio of babies to nurses of 3, with a maximum of 7 babies per nurse. In the public sector, the median ratio was 19 babies and a maximum exceeding 25 babies per nurse. In exploratory multivariable analyses, ratios of ≥12 babies per nurse were associated with a 24-point reduction in the mean NCI compared with ratios of ≤3 babies per nurse.

CONCLUSION

A significant proportion of nursing care is missed with potentially serious effects on patient safety and outcomes in this LMIC setting. Given that nurses caring for fewer babies on average performed more of the expected tasks, addressing nursing is key to ensuring delivery of essential aspects of care as part of improving quality and safety.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Magnitude and Risk of Dying among Low Birth Weight Neonates in Rural Ethiopia: A Community-Based Cross-Sectional Study

Background

Even if remarkable progress has been made in reducing preventable child deaths worldwide, neonatal mortality reduction has remained unsatisfactory. Low birth weight (LBW) is the major risk factor for child deaths during the neonatal period, yet only 5% of babies are weighed at birth in Ethiopia. The aim of the present study was to determine the magnitude and risk of dying among low birth weight neonates in rural Gedeo, Southern Ethiopia.

Methods

Community-based mixed-method approach design was employed between September and October 2016 to identify and enroll study participants in rural Gedeo, Southern Ethiopia. Records of 17,503 live birth babies, of whom 2,065 (11.8%) had LBW, born in the last 12 months were screened to identify 885 (42.8%) biological mother–LBW neonate pairs from eight health centers. The study subjects were randomly selected using a multistage stratified cluster sampling technique. Cox proportional hazards regression model was used to predict maternal and neonatal risk factors associated with the risk of neonatal death.

Results

The overall neonatal mortality rate (NMR) among LBW infants was 110 per 1000 live births (95% confidence interval: 75 –228). Close to half, 374 (42.3%), of the LBW neonates died during the first week of life. The estimated hazard ratios of mortality were higher among neonates whose mothers did not attend antenatal care (ANC) (HR=1.58, 95 % CI: 1.02-2.43), gave birth by assisted or cesarean delivery (HR=1.81 and 3.72; 95% CI: 1.10 - 3.02 and 2.11-6.55), and experienced some form of illness during pregnancy (HH=3.34, 95 % CI: 2.11-5.29), respectively. Similarly, neonates born with very low (<2000gm) birth weight and born prematurely (before 37 weeks of gestation) carried a higher (HR= 1.90 and 1.47; 95 % CI: 1.22 - 2.96 and 1.07-2.28) risk of death. On the other hand, maternal formal education was found to be the single protective factor (HR= 0.65,95 % CI: 0.43-0.99).

Conclusion

Nearly one in every ten (11%) of neonates die before celebrating their firth month of life, mainly during the first week in rural Ethiopia. The risk of dying from LBW during the neonatal period is almost fourfold of the current estimated national NMR. Maternal obstetric characteristics and fetal maturity were predictors of mortality.

Bedside Rationing Under Resource Constraints-A National Survey of Ethiopian Physicians' Use of Criteria for Priority Setting

In low-income settings resource constraints force clinicians to make harsh choices. We examine the criteria Ethiopian physicians use in their bedside rationing decisions through a national survey at 49 public hospitals in Ethiopia. Substantial variation in weight given to different criteria were reported by the 587 participating physicians (response rate 91.7%). Young age, primary prevention, or the patient being the family's economic provider increased likelihood of offering treatment to a patient, while small expected benefit or low chance of success diminished likelihood. More than 50% of responding physicians were indifferent to patient's position in society, unhealthy behavior, and residence, while they varied widely in weight they gave to patient's poverty, ability to work, and old age. While the majority of Ethiopian physicians reported allocation of resources that was compatible with national priorities, more contested criteria were also frequently reported. This might affect distributional justice and equity in health care access.

Interventions to Improve Micronutrient Status of Women of Reproductive Age in Southeast Asia: A Narrative Review on What Works, What Might Work, and What Doesn't Work

Objectives To provide an overview of nutrition-specific and nutrition-sensitive interventions that could improve micronutrient status of women of reproductive age. Methods This narrative review has a special focus on Southeast Asia, as the work was undertaken within the framework of the SMILING (Sustainable Micronutrient Interventions to controL deficiencies and Improve Nutrition status and General health in Southeast Asia) project. Results In order for new interventions to become accepted, comprehension and interpretation of potential impact of different strategies by policymakers and non-nutritionists is needed. By presenting a wide overview of strategies, and discussing the context and current consensus on these strategies, the review aims to help with the formulation of new recommendations for national programs in Southeast Asia. Conclusions Current policies in Southeast Asia to improve micronutrient status of women of reproductive age are focused too much on single micronutrient supplementation for pregnant women (iron and folic acid supplements). A more holistic approach, including both nutrition-specific and nutrition-sensitive interventions, is needed.

Women's empowerment and the use of antenatal care services: analysis of demographic health surveys in five Southeast Asian countries

Women's empowerment and use of antenatal care (ANC) services remain important in the Association of Southeast Asian Nations (ASEAN). This assessed the association between women's empowerment and ANC use in five ASEAN countries. ANC information for the most recent births of 29,444 currently married women in the last 5 years preceding the Demographic Health Survey was analyzed (Cambodia [DHS2014], Indonesia [DHS2012], Myanmar [DHS2015-2016], Philippines [DHS2013], and Timor-Leste [DHS2009]). Analyses used multiple logistic regression adjusting for complex sampling designs. The number of ANC visits was positively associated with labor-force participation in Cambodia, the Philippines, and Timor-Leste; with disagreement with justification for wife beating and women's knowledge level in Cambodia, Indonesia, Myanmar; and with women's decision-making power in Cambodia and Indonesia. The association of women's empowerment variables with timing of the first ANC visit was not as evident as that for number of ANC visits. Compared to adult mothers, adolescent mothers with medium knowledge level had less odds of attending ≥4 ANC in Cambodia, and adolescent mothers with the poorest labor-force participation had lower odds of attending the first ANC early in Myanmar. Tailored policy on women's improved access to labor force and health information in each country may be needed to improve ANC use.

Equity in antenatal care quality: an analysis of 91 national household surveys

Background

Emerging data show that many low-income and middle-income country (LMIC) health systems struggle to consistently provide good-quality care. Although monitoring of inequalities in access to health services has been the focus of major international efforts, inequalities in health-care quality have not been systematically examined.

Methods

Using the most recent (2007–16) Demographic and Health Surveys and Multiple Indicator Cluster Surveys in 91 LMICs, we described antenatal care quality based on receipt of three essential services (blood pressure monitoring and urine and blood testing) among women who had at least one visit with a skilled antenatal-care provider. We compared quality across country income groups and quantified within-country wealth-related inequalities using the slope and relative indices of inequality. We summarised inequalities using random-effects meta-analyses and assessed the extent to which other geographical and sociodemographic factors could explain these inequalities.

Findings

Globally, 72·9% (95% CI 69·1–76·8) of women who used antenatal care reported blood pressure monitoring and urine and blood testing; this number ranged from 6·3% in Burundi to 100·0% in Belarus. Antenatal care quality lagged behind antenatal care coverage the most in low-income countries, where 86·6% (83·4–89·7) of women accessed care but only 53·8% (44·3–63·3) reported receiving the three services. Receipt of the three services was correlated with gross domestic product per capita and was 40 percentage points higher in upper-middle-income countries compared with low-income countries. Within countries, the wealthiest women were on average four times more likely to report good quality care than the poorest (relative index of inequality 4·01, 95% CI 3·90–4·13). Substantial inequality remained after adjustment for subnational region, urban residence, maternal age, education, and number of antenatal care visits (3·20, 3·11–3·30).

Interpretation

Many LMICs that have reached high levels of antenatal care coverage had much lower and inequitable levels of quality. Achieving ambitious maternal, newborn, and child health goals will require greater focus on the quality of health services and their equitable distribution. Equity in effective coverage should be used as the new metric to monitor progress towards universal health coverage.

Funding

Bill & Melinda Gates Foundation.

Changes in maternal and neonatal care after a quality improvement intervention in a sub-Saharan setting

Aim: Quality improvement approaches have been integrated into routine health care in high-resource settings, but not in low-resource settings. We aimed to report the achievements in maternal and neonatal care after a quality improvement intervention in a sub-Saharan setting.Methods: After a first quality assessment in 2012 at Tosamaganga hospital in Tanzania, main areas of intervention were identified and a quality improvement program was implemented. In 2016, a second quality assessment was conducted by the same assessment team by using the World Health Organization's maternal and neonatal quality of hospital care assessment tool. Some hospital indicators were also collected during the same period.Results: Access to hospital care, maternity ward and management of maternal complications improved from inadequate to substandard care, alongside with an increment of deliveries from 2145 to 2838 and a substantially stable rate of complicated deliveries (21-26%). The improvements in the maternity ward, maternal complications and emergency care coupled with the reduction of direct obstetric case fatality rate obstetric mortality that dropped from 2.9 to 0.27%. Some neonatal areas (neonatal ward, routine neonatal care, sick newborn care, monitoring, and follow-up) improved from poor to substandard care, while others (infection control and supportive care, emergency care, guidelines protocols, and audit) showed only limited improvements. These changes coupled with a decrease in the perinatal mortality rate from 5.8 to 2.9%.Conclusion: The quality improvement program resulted in substantial progress in most aspects of quality care, which coupled with a decrease in obstetric and perinatal mortality. Nevertheless, the overall quality of care remained substandard with the limited effect of the intervention on some areas, which require further efforts in order to achieve an acceptable level of care.

Maternity waiting areas - serving all women? Barriers and enablers of an equity-oriented maternal health intervention in Jimma Zone, Ethiopia

In Ethiopia, maternal waiting areas (MWAs) - residential areas near health facilities where women can stay while waiting to give birth - are community-based, equity-oriented interventions to improve maternal outcomes among rural populations. In this qualitative study we sought to explore the barriers and enablers that Health Extension Workers (HEWs) encounter when engaging with communities about MWAs. We conducted semi-structured interviews with HEWs across rural sites in Jimma Zone, Ethiopia. Drawing from an ecological model of social determinants of maternal and child health, we analysed data using thematic coding methods. HEWs reported a variety of factors that determined MWA use, including the number of children at home, previous childbirth experiences, community support networks, decision making practices within families, the availability and acceptability of health services, geographical access, and health beliefs. HEWs worked to increase the use of MWAs by engaging with husbands and communities, raising awareness in target groups of women, and managing community participation. Policies and practices that support enhanced training for HEWs, increased resources for communities, and greater opportunities for HEWs to liaise with decision makers at various levels of influence are possible ways forward to improve MWA use, specifically, and maternal and neonatal/child health outcomes more generally.

Quality gap in maternal and newborn healthcare: a cross-sectional study in Myanmar

Introduction

Access to maternal and newborn healthcare has improved in Myanmar. However, regular contact with skilled care providers does not necessarily result in quality care. We assessed adequate contact made by women and newborns with skilled care providers, reception of high-quality care and quality-adjusted contacts during antenatal care (ANC), peripartum care (PPC) and postnatal care (PNC) in Myanmar.

Methods

This cross-sectional study was conducted in a predominantly urban township of Yangon and a predominantly rural township of Ayeyawady in March 2016. We collected data from 1500 women. We measured quality-adjusted contact, which refers to adequate contact with high-quality care, as follows: ≥4 ANC contacts and receiving 11–14 of 14 intervention items; facility-based delivery assisted by skilled care providers, receiving 7 of 7 PPC intervention items; and receiving the first PNC contact ≤24 hours postpartum and ≥2 additional contacts, and receiving 16–17 of 17 intervention items. Using multilevel logistic regression analysis with a random intercept at cluster level, we identified factors associated with adequate contact and high-quality ANC, PPC and PNC.

Results

The percentage of crude adequate contact was 60.9% for ANC, 61.3% for PPC and 11.5% for PNC. However, the percentage of quality-adjusted contact was 14.6% for ANC, 15.2% for PPC and 3.6% for PNC. Adequate contact was associated with receiving high-quality care at ANC, PPC and PNC. Being a teenager, low educational level, multiparity and low level in the household wealth index were negatively associated with adequate contact with healthcare providers for ANC and PPC. Receiving a maternal and child health handbook was positively associated with adequate contact for ANC and PPC, and with receiving high-quality ANC, PPC and PNC.

Conclusion

Women and newborns do not receive quality care during contact with skilled care providers in Myanmar. Continuity and quality of maternal and newborn care programmes must be improved.

A Health Informatics Reporting System for Technology Illiterate Workforce Using Mobile Phone

BACKGROUND

The reduction and control over neonatal, infant, and maternal mortality is a collective mission of the World Health Organization under United Nations.

METHODS

This article summarizes the automation of verbal autopsy reporting for neonatal, infant, and maternal mortality with primary focus on user-centered design for technologically illiterate workforce with minimum available resources. The diminution in neonatal, infant, and maternal deaths is not possible until grassroot level quality data are available for mortality. The estimated data are less effective for developing countries like Pakistan because it has heterogeneous demographic pockets with respect to mortality causes. The Neonatal, Infant, and Maternal Death E-surveillance System is a project in which a real-time reporting system is innovated that is useful in detecting the causes of mortality and effective in adopting appropriate countermeasure policies. In a pilot study, the system was implemented initially in nine districts of Punjab, Pakistan. The initial system was refined after getting detailed feedback from district management staff including Lady Health Workers and Lady Health Supervisors. The refined surveillance system was finally implemented in all 36 districts of Punjab, Pakistan.

RESULTS

The results exhibited 31% improvement in infant data collection and 6% improvement in maternal data collection regarding mortality.

CONCLUSION

This research will be helpful in achieving the milestone of gathering real-time mortality data from grassroot level using user-centered design methodology.

Cost analysis and provider preferences of low-dose, high-frequency approach to in-service training programs in Uganda

Background

Many countries in sub-Saharan Africa still face significant challenges in maternal and child health where low numbers, uneven distribution, and training deficits of the health workforce impede quality care. Low-dose, high-frequency training (LDHF), an innovative approach to in-service training, focuses on competency, team-based repetitive learning and practice in the clinical setting. In Uganda, we conducted cost analyses of local organization LDHF training programs for Post-abortion care (PAC) and Pediatric HIV to assess cost drivers and cost efficiency and compare costs to traditional workshop based training.

Methods

We collected costs with bottom up, activity based costing in LDHF and workshop training programs. All costs reported from a programmatic perspective in US$2015 across a two year analytic time horizon. A survey of trained providers was conducted to understand costs and incentives of participation as well as experience and training preferences.

Findings

PAC training with the LDHF approach cost US$29 957 corresponding to US$936 per provider; the traditional training of the same content was delivered at a total US$10 551 corresponding to US$527 per provider. Pediatric HIV training with LDHF approach cost US$41 677 or US$631 per provider; traditional training of Pediatric HIV cost US$18 656 or US$888 per provider trained. In traditional training programs, costs to providers were nearly equal to incentives given. In LDHF training programs, financial incentives and costs to participate were not equal and varied by roles and programs; all district trainers’ incentives outweighed their costs of participation, trainee incentives were higher than costs of participation in the PAC training, but in the Pediatric HIV program, trainee incentives were lower than the costs of participation.

Conclusions

Local training programs differ widely in applying LDHF principles to design and implementation thus leading to variation in costs and cost-efficiency. LDHF can be more cost-efficient than workshop based trainings if programs take advantage of the wider scope of trainees available for the facility-based trainings. Incentive differences between district trainers and trainees may influence participation and perception of training. The perspectives of providers participating in LDHF or traditional workshop training should be integrated when developing future programs for maximum uptake and participation for in-service training.

Mobile Technology for Community Health in Ghana: Is Maternal Messaging and Provider Use of Technology Cost-Effective in Improving Maternal and Child Health Outcomes at Scale?

BACKGROUND

Mobile technologies are emerging as tools to enhance health service delivery systems and empower clients to improve maternal, newborn, and child health. Limited evidence exists on the value for money of mobile health (mHealth) programs in low- and middle-income countries.

OBJECTIVE

This study aims to forecast the incremental cost-effectiveness of the Mobile Technology for Community Health (MOTECH) initiative at scale across 170 districts in Ghana.

METHODS

MOTECH's "Client Data Application" allows frontline health workers to digitize service delivery information and track the care of patients. MOTECH's other main component, the "Mobile Midwife," sends automated educational voice messages to mobile phones of pregnant and postpartum women. We measured program costs and consequences of scaling up MOTECH over a 10-year analytic time horizon. Economic costs were estimated from informant interviews and financial records. Health effects were modeled using the Lives Saved Tool with data from an independent evaluation of changes in key services coverage observed in Gomoa West District. Incremental cost-effectiveness ratios were presented overall and for each year of implementation. Uncertainty analyses assessed the robustness of results to changes in key parameters.

RESULTS

MOTECH was scaled in clusters over a 3-year period to reach 78.7% (170/216) of Ghana's districts. Sustaining the program would cost US $17,618 on average annually per district. Over 10 years, MOTECH could potentially save an estimated 59,906 lives at a total cost of US $32 million. The incremental cost per disability-adjusted life year averted ranged from US $174 in the first year to US $6.54 in the tenth year of implementation and US $20.94 (95% CI US $20.34-$21.55) over 10 years. Uncertainty analyses suggested that the incremental cost-effectiveness ratio was most sensitive to changes in health effects, followed by personnel time. Probabilistic sensitivity analyses suggested that MOTECH had a 100% probability of being cost-effective above a willingness-to-pay threshold of US $50.

CONCLUSIONS

This is the first study to estimate the value for money of the supply- and demand-side of an mHealth initiative. The adoption of MOTECH to improve MNCH service delivery and uptake represents good value for money in Ghana and should be considered for expansion. Integration with other mHealth solutions, including e-Tracker, may provide opportunities to continue or combine beneficial components of MOTECH to achieve a greater impact on health.

Inequalities in sub-Saharan African women's and girls' health opportunities and outcomes: evidence from the Demographic and Health Surveys

Background

Maternal and reproductive health services are far from universalization and important gaps exist in their distribution across groups of women in sub-Saharan Africa (SSA). The aim of this study is to determine the magnitude of this unequal distribution of maternal and reproductive health-related opportunities and outcomes and to identify the major sources of inequality.

Methods

Demographic and Health Surveys data were used to analyse 15 opportunities for women of reproductive age (15-49), pregnant women and older adolescent girls (15-19), across 29 SSA countries. The tool employed is the Human Opportunity Index (HOI), a composite indicator that combines the availability of an opportunity (the coverage rate) with a measure of how equitably it is distributed among groups of women with different characteristics (or circumstances). Decompositions are used to assess the contribution of each individual circumstance to inequality.

Results

The maternity care package of services is found to have lowest average HOI (26%), while exclusive breastfeeding among children aged 0-6 months has the highest HOI (77%). The other indicators show low HOIs, sometimes lower than 50%, indicating low coverage and/or high inequality. Wealth, education and area of residence are the main contributors to inequality for women of reproductive age. Among adolescent girls, marital status is the major contributor.

Conclusions

Reproductive and maternal health opportunities for women in SSA are scarce and far from reaching the global goals set by the post 2015 agenda. Further progress in improving women's and adolescents' health and well-being can only be achieved by a strong expansion of coverage to produce a more equitable and efficient distribution of health care. Failure to do so will compromise the likelihood of achieving the post-2015 Sustainable Development Goals (SDG). New metrics such as the HOI allows better understanding of the nature of challenges to achieving equity in perinatal and reproductive health, and offers a tool for monitoring progress in implementing a strong equity agenda as a part of the SDG initiative.

Depressive and anxiety symptoms and associated factors among postnatal women in Enugu-North Senatorial District, South-East Nigeria: a cross-sectional study

BACKGROUND

Postnatal depression (PND) and anxiety (PNA) among women are prevalent and impairing health problems, with adverse outcomes for mothers and their infants. This study assessed the prevalence of depression, anxiety and associated factors in a sample of postnatal women.

METHOD

A community-based cross-sectional study was conducted on 270 postpartum women attending public health facilities in the study area. Postnatal depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) and anxiety was measured using the Hospital Anxiety and Depression Scale (HADS-A). Data on maternal demographics, health characteristics, pregnancy-related characteristics, labor and birth characteristics, were collected via structured questionnaire. Binary Logistic and multinomial logistic regression analyses were carried out to identify the factors associated with depressive and anxiety symptoms in women.

RESULTS

The EPDS identified 92 women (34.6%) as possibly depressed (using a cut-off ≥13) while the HADS-A identified 89 women (33.3%) with anxiety symptoms (using a cut-off + 8). A total of 69 women were identified with symptoms of anxiety and depression (anxious-depression). The multinomial regression analysis (MLA) showed that the history of depression (AOR = 0.12, 95% (CI 0.02, 0.76), and being a mother aged 15-29 years (AOR = 10.31, 95% (CI 1.13, 94.11) had a significant effect on the development of anxiety symptoms in women. Although not significant, mother's income level (AOR = 1.53, 95% (CI 0.72, 3.25), and being a younger mother (AOR = 1.06, 95% (CI 0.21, 5.26) were more likely to predict depressive symptoms in postnatal women. Attendance at postnatal care services in the PHCs (AOR = 0.14, 95% CI (0.04, 0.48) was significantly associated with anxious-depressed in the studied postnatal women.

CONCLUSION

The findings of this study showed a direct association between depressive symptoms, anxiety and younger maternal age, rural residence, and low income. The higher prevalence of depressive and anxiety symptoms in this study is a call for postnatal care that is culturally sensitive, patient-centered, accessible and affordable by women, most importantly poor and rural women.

An extension of the Alma-Ata vision for primary health care in light of twenty-first century evidence and realities

This paper builds upon and extends the definition of primary health care in the 1978 Declaration of Alma-Ata. The definition proposes a stronger role for community-based delivery of services and community mobilization, participation and empowerment. It calls for a stronger integration with vertical, disease-specific programs. And, finally, it calls for a strong role for certain curative services (including basic and essential surgery) that many today would not consider as part of primary health care. There is growing evidence that communities can and should play a stronger role than has traditionally been the case, that community-level workers who are properly trained and supported can provide effective services outside of health facilities, and that primary health centers staffed with non-specialist physicians and even non-physician clinicians can perform many of the lower-level inpatient services now performed at first-level referral hospitals. An approach to primary health care that is appropriate to the local context and that merges local epidemiological priorities with the communities' perceived priorities will make it possible to engage communities as partners. Currently, essential and basic health care services are available to only one-half of the world's population. The full development of primary health care as envisioned here will accelerate progress in achieving Health for All as envisioned at the International Conference on Primary Health Care in 1978.

Assessment of Inequalities in Coverage of Essential Reproductive, Maternal, Newborn, Child, and Adolescent Health Interventions in Kenya

IMPORTANCE

Previous work has underscored subnational inequalities that could impede additional health gains in Kenya.

OBJECTIVE

To provide a comprehensive assessment of the burden, distribution, and change in inequalities in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) interventions in Kenya from 2003 to 2014.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study used data from the 2003, 2008, and 2014 Kenya Demographic and Health Surveys. The study included women of reproductive age (ages 15-49 years) and children younger than years, with national, regional, county, and subcounty level representation. Data analysis was conducted from April 2018 to November 2018.

EXPOSURES

Socioeconomic position that was derived from asset indices and presented as wealth quintiles. Urban and rural residence and regions of Kenya were also considered.

MAIN OUTCOMES AND MEASURES

Absolute and relative measures of inequality in coverage of RMNCAH interventions.

RESULTS

For this analysis, representative samples of 31 380 women of reproductive age and 29 743 children younger than 5 years from across Kenya were included. The RMNCAH interventions examined demonstrated pro-rich and bottom inequality patterns. The most inequitable interventions were skilled birth attendance, family planning needs satisfied, and 4 or more antenatal care visits, whereby the absolute difference in coverage between the wealthiest (quintile 5) and poorest quintiles (quintile 1) was 61.6% (95% CI, 60.1%-63.1%), 33.4% (95% CI, 31.9%-34.9%), and 31.0% (95% CI, 30.5%-31.6%), respectively. The most equitable intervention was early initiation of breastfeeding, with an absolute difference (quintile 5 minus quintile 1) of -7.9% (95% CI, -11.1% to -4.8%), although antenatal care (1 visit) and diphtheria-tetanus-pertussis immunization (3 doses) demonstrated the best combination of high coverage and low inequalities. Our geospatial analysis revealed significant socioeconomic disparities in the northern and eastern regions of Kenya that have translated to suboptimal intervention coverage. A significant gap remains for rural, disadvantaged populations.

CONCLUSIONS AND RELEVANCE

Coverage of RMNCAH interventions has improved over time, but wealth and geospatial inequalities in Kenya are persistent. Policy and programming efforts should place more emphasis on improving the accessibility of health facility-based interventions, which generally demonstrate poor coverage and high inequalities, and focus on integrated approaches to maternal health service delivery at the community level when access is poor. Scaling up of health services for the urban and, in particular, rural poor areas and those residing in Kenya's former north eastern province will contribute toward achievement of universal health coverage.

Successful implementation of a combined learning collaborative and mentoring intervention to improve neonatal quality of care in rural Rwanda

Background

Globally, neonatal mortality remains high despite interventions known to reduce neonatal deaths. The All Babies Count (ABC) initiative was a comprehensive health systems strengthening intervention designed by Partners In Health in collaboration with the Rwanda Ministry of Health to improve neonatal care in rural public facilities. ABC included provision of training, essential equipment, and a quality improvement (QI) initiative which combined clinical and QI mentorship within a learning collaborative. We describe ABC implementation outcomes, including development of a QI change package.

Methods

ABC was implemented over 18 months from 2013 to 2015 in two Rwandan districts of Kirehe and Southern Kayonza, serving approximately 500,000 people with 24 nurse-led health centers and 2 district hospitals. A process evaluation of ABC implementation and its impact on healthcare worker (HCW) attitudes and QI practice was done using program documents, standardized surveys and focus groups with facility QI team members attending ABC Learning Sessions. The Change Package was developed using mixed methods to identify projects with significant change according to quantitative indicators and qualitative feedback obtained during focus group discussions. Outcome measures included ABC implementation process measures, HCW-reported impact on attitudes and practice of QI, and resulting change package developed for antenatal care, delivery management and postnatal care.

Results

ABC was implemented across all 26 facilities with an average of 0.76 mentorship visits/facility/month and 118 tested QI change ideas. HCWs reported a reduction in barriers to quality care delivery related to training (p = 0.018); increased QI capacity (knowledge 37 to 89%, p <  0.001); confidence (47 to 89%, p <  0.001), QI leadership (59 to 91%, p <  0.001); and peer-to-peer learning (37 to 66%, p = 0.024). The final change package included 46 change ideas. Themes associated with higher impact changes included provision of mentorship and facility readiness support through equipment provision.

Conclusions

ABC provides a feasible model of an integrated approach to QI in rural Rwanda. This model resulted in increases in HCW and facility capacity to design and implement effective QI projects and facilitated peer-to-peer learning. ABC and the change package are being scaled to accelerate improvement in neonatal outcomes.

Temporal trends in spatial inequalities of maternal and newborn health services among four east African countries, 1999-2015

BACKGROUND

Sub-Saharan Africa continues to account for the highest regional maternal mortality ratio (MMR) in the world, at just under 550 maternal deaths per 100,000 live births in 2015, compared to a global rate of 216 deaths. Spatial inequalities in access to life-saving maternal and newborn health (MNH) services persist within sub-Saharan Africa, however, with varied improvement over the past two decades. While previous research within the East African Community (EAC) region has examined utilisation of MNH care as an emergent property of geographic accessibility, no research has examined how these spatial inequalities have evolved over time at similar spatial scales.

METHODS

Here, we analysed temporal trends of spatial inequalities in utilisation of antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) among four East African countries. Specifically, we used Bayesian spatial statistics to generate district-level estimates of these services for several time points using Demographic and Health Surveys data in Kenya, Tanzania, Rwanda, and Uganda. We examined temporal trends of both absolute and relative indices over time, including the absolute difference between estimates, as well as change in performance ratios of the best-to-worst performing districts per country.

RESULTS

Across all countries, we found the greatest spatial equality in ANC, while SBA and PNC tended to have greater spatial variability. In particular, Rwanda represented the only country to consistently increase coverage and reduce spatial inequalities across all services. Conversely, Tanzania had noticeable reductions in ANC coverage throughout most of the country, with some areas experiencing as much as a 55% reduction. Encouragingly, however, we found that performance gaps between districts have generally decreased or remained stably low across all countries, suggesting countries are making improvements to reduce spatial inequalities in these services.

CONCLUSIONS

We found that while the region is generally making progress in reducing spatial gaps across districts, improvement in PNC coverage has stagnated, and should be monitored closely over the coming decades. This study is the first to report temporal trends in district-level estimates in MNH services across the EAC region, and these findings establish an important baseline of evidence for the Sustainable Development Goal era.

Nursing knowledge of essential maternal and newborn care in a high-mortality urban African setting: A cross-sectional study

Aims

To assess the knowledge of nurses of national guidelines for emergency maternity, routine newborn and small and sick newborn care in Nairobi County, Kenya.

Background

The vast majority of women deliver in a health facility in Nairobi. Yet, maternal and neonatal mortality remain high. Ensuring competency of health workers, in providing essential maternal and newborn interventions in health facilities will be key if further progress is to be made in reducing maternal and neonatal mortality in low‐resource settings.

Design

Cross‐sectional survey.

Methods

Questionnaires comprised of clinical vignettes and direct questions and were administered in 2015–2016 to nurses (n = 125 in 31 facilities) on duty in maternity and newborn units in public and private facilities providing 24/7 inpatient neonatal services. Composite knowledge scores were calculated and presented as weighted means. Associations were explored using regression. STROBE guidelines were followed.

Results

Nurses scored best for knowledge on active management of the mother after birth and immediate routine newborn care. Performance was worst for questions on infant resuscitation, checking signs and symptoms of sick newborns, and managing hypertension in pregnancy. Overall knowledge of care for sick newborns was particularly low (score 0.62 of 1). Across all areas assessed, nurses who had received training since qualifying performed better than those who had not. Poorly resourced and low case‐load facilities had lower average knowledge scores compared with better‐resourced and busier facilities.

Conclusion

Overall, we estimate that 31% of maternity patients, 3% of newborns and 39% of small and sick newborns are being cared for in an environment where nursing knowledge is very low (score <0.6).

Relevance to clinical practice

Focus on periodic training, ensuring retention of knowledge and skills among health workers in low‐case load setting, and bridging the know‐do gap may help to improve the quality of care delivered to mothers and newborns in Kenya.

"You Travel Faster Alone, but Further Together": Learning From a Cross Country Research Collaboration From a British Council Newton Fund Grant

Providing universal health coverage (UHC) through better maternal, neonatal, child and adolescent health (MNCAH) can benefit both parties through North–South research collaborations. This paper describes lessons learned from bringing together early career researchers, tutors, consultants and mentors from the United Kingdom, Kenya, and South Africa to work in multi-disciplinary teams in a capacity-building workshop in Johannesburg, co-ordinated by senior researchers from the three partner countries. We recruited early career researchers and research users from a range of sectors and institutions in the participating countries and offered networking sessions, plenary lectures, group activities and discussions. To encourage bonding and accommodate cross-cultural and cross-disciplinary partners, we asked participants to respond to questions relating to research priorities and interventions in order to allocate them into multidisciplinary and cross-country teams. A follow up meeting took place in London six months later. Over the five day initial workshop, discussions informed the development of four draft research proposals. Intellectual collaboration, friendship and respect were engendered to sustain future collaborations, and we were able to identify factors which might assist capacity-building funders and organizers in future. This was a modestly funded brief intervention, with a follow-up made possible through the careful stewardship of resources and volunteerism. Having low and middle-income countries in the driving seat was a major benefit but not without logistic and financial challenges. Lessons learned and follow-up are described along with recommendations for future funding of partnerships schemes.

Disentangling the contributions of maternal and fetal factors to estimate stillbirth risks for intrapartum adverse events in Tanzania and Uganda

OBJECTIVE

To estimate the stillbirth risk associated with intrapartum adverse events, controlling for fetal and maternal factors.

METHODS

The present study was an analysis of cross-sectional patient-record and facility-file data from women with viable fetuses who experienced obstetric adverse events at 23 hospitals and 38 health centers in Tanzania (between December 2015 and October 2016), and 22 hospitals, 16 level-4 health centers, and five level-3 health centers in Uganda (between May 2016 and September 2017). Adverse events were categorized in three severity groups (postpartum, intrapartum non-near-miss, and intrapartum near-miss) to calculate stillbirth rates and adjusted prevalence ratios.

RESULTS

Data from 3816 women in Tanzania and 8305 in Uganda were included. Compared with postpartum adverse events, intrapartum near-miss was associated with a 3.73- and 4.55-fold higher prevalence of stillbirth in Uganda and Tanzania, respectively. Most women who experienced near-miss had organ dysfunction on arrival or developed it soon after. The risk of stillbirth was higher among preterm deliveries compared with term deliveries, and was 42% and 59% lower in Tanzania and Uganda, respectively, for cesarean deliveries compared with vaginal deliveries after intrapartum non-near-miss adverse events.

CONCLUSION

Stillbirth risk increased with severity of complications and was higher among premature deliveries. Survival was higher for cesarean deliveries in intrapartum non-near-miss complications, identifying the opportunity to prevent deterioration by timely actions.

Two decades of antenatal and delivery care in Uganda: a cross-sectional study using Demographic and Health Surveys

Background

Uganda halved its maternal mortality to 343/100,000 live births between 1990 and 2015, but did not meet the Millennium Development Goal 5. Skilled, timely and good quality antenatal (ANC) and delivery care can prevent the majority of maternal/newborn deaths and stillbirths. We examine coverage, equity, sector of provision and content of ANC and delivery care between 1991 and 2011.

Methods

We conducted a repeated cross-sectional study using four Uganda Demographic and Health Surveys (1995, 2000, 2006 and 2011).Using the most recent live birth and adjusting for survey sampling, we estimated percentage and absolute number of births with ANC (any and 4+ visits), facility delivery, caesarean sections and complete maternal care. We assessed socio-economic differentials in these indicators by wealth, education, urban/rural residence, and geographic zone on the 1995 and 2011 surveys. We estimated the proportions of ANC and delivery care provided by the public and private (for-profit and not-for-profit) sectors, and compared content of ANC and delivery care between sectors. Statistical significance of differences were evaluated using chi-square tests.

Results

Coverage with any ANC remained high over the study period (> 90% since 2001) but was of insufficient frequency; < 50% of women who received any ANC reported 4+ visits. Facility-based delivery care increased slowly, reaching 58% in 2011. While significant inequalities in coverage by wealth, education, residence and geographic zone remained, coverage improved for all indicators among the lowest socio-economic groups of women over time. The private sector market share declined over time to 14% of ANC and 25% of delivery care in 2011. Only 10% of women with 4+ ANC visits and 13% of women delivering in facilities received all measured care components.

Conclusions

The Ugandan health system had to cope with more than 30,000 additional births annually between 1991 and 2011. The majority of women in Uganda accessed ANC, but this contact did not result in care of sufficient frequency, content, and continuum of care (facility delivery). Providers in both sectors require quality improvements. Achieving universal health coverage and maternal/newborn SDGs in Uganda requires prioritising poor, less educated and rural women despite competing priorities for financial and human resources.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3546-3) contains supplementary material, which is available to authorized users.

Production and use of estimates for monitoring progress in the health sector: the case of Bangladesh

Background: In order to support the progress towards the post-2015 development agenda for the health sector, the importance of high-quality and timely estimates has become evident both globally and at the country level.

Objective and Methods: Based on desk review, key informant interviews and expert panel discussions, the paper critically reviews health estimates from both the local (i.e. nationally generated information by the government and other agencies) and the global sources (which are mostly modeled or interpolated estimates developed by international organizations based on different sources of information), and assesses the country capacity and monitoring strategies to meet the increasing data demand in the coming years. Primarily, this paper provides a situation analysis of Bangladesh in terms of production and use of health estimates for monitoring progress towards the post-2015 development goals for the health sector.

Results: The analysis reveals that Bangladesh is data rich, particularly from household surveys and health facility assessments. Practices of data utilization also exist, with wide acceptability of survey results for informing policy, programme review and course corrections. Despite high data availability from multiple sources, the country capacity for providing regular updates of major global health estimates/indicators remains low. Major challenges also include limited human resources, capacity to generate quality data and multiplicity of data sources, where discrepancy and lack of linkages among different data sources (local sources and between local and global estimates) present emerging challenges for interpretation of the resulting estimates.

Conclusion: To fulfill the increased data requirement for the post-2015 era, Bangladesh needs to invest more in electronic data capture and routine health information systems. Streamlining of data sources, integration of parallel information systems into a common platform, and capacity building for data generation and analysis are recommended as priority actions for Bangladesh in the coming years. In addition to automation of routine health information systems, establishing an Indicator Reference Group for Bangladesh to analyze data; building country capacity in data quality assessment and triangulation; and feeding into global, inter-agency estimates for better reporting would address a number of mentioned challenges in the short- and long-run.

A safe, low-cost, easy-to-use 3D camera platform to assess risk of obstructed labor due to cephalopelvic disproportion

Cephalopelvic disproportion (CPD)-related obstructed labor is accountable for 3-8% of the maternal deaths worldwide. The consequence of CPD-related obstructive labor in the absence of a Caesarian section (C/S) is often maternal or perinatal mortality or morbidity to the mother and/or the infant. Accurate and timely referral of at-risk mothers to health facilities where C/S is a delivery option could reduce maternal mortality in the developing world. The goal of this work was to develop and test the feasibility of a safe, low-cost, easy-to-use, portable tool, using a Microsoft Kinect 3D camera, to identify women at risk for obstructed labor due to CPD. Magnetic resonance imaging (MRI) scans, 3D camera imaging, anthropometry and clinical pelvimetry were collected and analyzed from women 18-40 years of age, at gestational age ≥36+0 weeks with previous C/S due to CPD (n = 43), previous uncomplicated vaginal deliveries (n = 96), and no previous obstetric history (n = 148) from Addis Ababa, Ethiopia. Novel and published CPD risk scores based on anthropometry, clinical pelvimetry, MRI, and Kinect measurements were compared. Significant differences were observed in most anthropometry, clinical pelvimetry, MRI and Kinect measurements between women delivering via CPD-related C/S versus those delivering vaginally. The area under the receiver-operator curve from novel CPD risk scores base on MRI-, Kinect-, and anthropometric-features outperformed novel CPD risk scores based on clinical pelvimetry and previously published indices for CPD risk calculated from these data; e.g., pelvic inlet area, height, and fetal-pelvic index. This work demonstrates the feasibility of a 3D camera-based platform for assessing CPD risk as a novel, safe, scalable approach to better predict risk of CPD in Ethiopia and warrants the need for further blinded, prospective studies to refine and validate the proposed CPD risk scores, which are required before this method can be applied clinically.

Trends in Socioeconomic Inequalities and Prevalence of Anemia Among Children and Nonpregnant Women in Low- and Middle-Income Countries

IMPORTANCE

Anemia remains a major challenge for women's and children's health in low- and middle-income countries (LMICs).

OBJECTIVE

To assess the socioeconomic inequalities and prevalence of anemia among children and nonpregnant girls and women in LMICs over time.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional and repeated cross-sectional analysis used data from the Demographic and Health Surveys collected from January 1, 2000, through December 31, 2014. Initial cross-sectional data sets constructed from the most recent surveys included 163 419 children aged 6 to 59 months and 304 202 nonpregnant girls and women aged 15 to 49 years (hereinafter referred to as nonpregnant women) from 45 LMICs. Repeated cross-sectional data sets from the most recent and the earliest surveys consisted of 322 088 nonpregnant women from 25 LMICs and 182 273 children from 24 LMICs. Analyses were conducted from June 1, 2016, through July 3, 2018.

MAIN OUTCOMES AND MEASURES

Total and severe anemia for children aged 6 to 59 months (hemoglobin level, <11 and <7 g/dL, respectively) and nonpregnant women aged 15 to 49 years (<12 and <8 g/dL, respectively) were defined according to the World Health Organization hemoglobin cutoff levels. The slope index of inequality (SII) and the relative index of inequality (RII) were calculated to determine anemia inequalities.

RESULTS

Among the 163 419 children aged 6 to 59 months and the 304 202 nonpregnant women aged 15 to 49 years in the initial cross-sectional data sets, 34 of 45 countries had anemia prevalence levels for children greater than 40% and 37 of 45 had anemia prevalence levels greater than 20% for nonpregnant women. Among the 182 273 children from 24 LMICs and 322 088 nonpregnant women from 25 LMICs in the repeated cross-sectional data sets, the annualized absolute decreases in the prevalence of anemia ranged from 0.67 to 3.98 percentage points in 16 of the 24 LMICs; for cases of severe anemia, the decrease was 0.03 to 0.82 percentage points in 15 LMICs. Among 322 088 nonpregnant women from 25 LMICs in the repeated cross-sectional data sets, the annualized absolute decreases in the prevalence of anemia ranged from 0.49 to 2.59 percentage points in 17 of 25 LMICs; for severe anemia, the decrease was 0.03 to 0.29 percentage points in 15 LMICs. The SII was significantly negative and the RII was significantly less than 1 in 37 of the 45 LMICs among children and in 26 of the 45 LMICs for nonpregnant women. The annualized changes in the SII approached 0 in 16 of the 24 LMICs among children and in 11 of 25 LMICs among nonpregnant women.

CONCLUSIONS AND RELEVANCE

Most LMICs continue to exhibit a high prevalence of anemia among children and nonpregnant women, although the prevalence of total and severe anemia have decreased in many LMICs. Anemia inequalities among children and nonpregnant women persist in most LMICs.

The Call and the Challenge of Pediatric Resuscitation and Simulation Research in Low-Resource Settings

STATEMENT

The greatest burden of younger than 5 years mortality is in low- and middle-income nations where education resources are often few. The World Health Organization recommends scale-up of simulation in these settings, but it has been poorly studied. Although there has been an increase of contextualized resuscitation simulation programs designed for these settings, sustaining clinical outcomes and provider skill retention have remained research gaps. Our team designed a study to evaluate skill retention after an initial Helping Babies Breathe training at a rural Kenya referral hospital between randomized learner groups receiving supervised mock codes with debriefing versus just-in-time training with a peer. Although we saw sustained skills retention and some clinical improvements, we were unable to answer our research question because of numerous challenges, mainly that hospital leadership preferred the implementation of 1 arm of the study over another because of lack of protected education time and resources, eliminating differences between randomized study groups. Further challenges included lack of familiarity with simulation and debriefing and lack of protected educational resources and time, cultural differences in giving feedback, undeveloped systems for documentation, and high acuity and clinical volume. Our experience teaches many important lessons in how best to implement and study simulation in low-resource settings. Best practices include long-term partnerships, flexibility, community and staff engagement, mixed methodologies including community-based participatory methods, and careful attention to educational and research capacity building.

Improving program targeting to combat early-life mortality by identifying high-risk births: an application to India

Background

It is widely recognized that there are multiple risk factors for early-life mortality. In practice most interventions to curb early-life mortality target births based on a single risk factor, such as poverty. However, most premature deaths are not from the targeted group. Thus interventions target many births that are at not at high risk and miss many births at high risk.

Methods

Using data from the second wave of Demographic and Health Surveys from India and a hierarchical Bayesian model, we estimate infant mortality risk for 73.320 infants in India as a function of 4 risk factors. We show how this information can be used to improve program targeting. We compare our novel approach against common programs that target groups based on a single risk factor.

Results

A conventional approach that targets mothers in the lowest quintile of income correctly identifies only 30% of infant deaths. By contrast, using four risk factors simultaneously we identify a group of births of the same size that includes 57% of all deaths. Using the 2012 census to translate these percentages into numbers, there were 25.642.200 births in 2012 and 4.4% died before the age of one. Our approach correctly identifies 643.106 of 1.128.257 infant deaths while poverty only identifies 338.477 infant deaths.

Conclusion

Our approach considerably improves program targeting by identifying more infant deaths than the usual approach that targets births based on a single risk factor. This leads to more efficient program targeting. This is particularly useful in developing countries, where resources are lacking and needs are high.

Electronic supplementary material

The online version of this article (10.1186/s12963-018-0172-6) contains supplementary material, which is available to authorized users.

Systematic review to identify proxy indicators to quantify the impact of eHealth tools on maternal and neonatal health outcomes in low-income and middle-income countries including Delphi consensus

OBJECTIVE

To identify interventions that could serve as reliable proxy indicators to measure eHealth impact on maternal and neonatal outcomes.

DESIGN

Systematic review and Delphi study.

METHODS

We searched PubMed, Embase and Cochrane from January 1990 to May 2016 for studies and reviews that evaluated interventions aimed at improving maternal/neonatal health and reducing mortality. Interventions that are not low-income and middle-income context appropriate and that cannot currently be diagnosed, managed or impacted by eHealth (eg, via telemedicine distance diagnostic or e-learning) were excluded. We used the Cochrane risk of bias, Risk Of Bias In Non- randomised Studies - of Interventions and ROBIS tool to assess the risk of bias. A three-step modified Delphi method was added to identify additional proxy indicators and prioritise the results, involving a panel of 13 experts from different regions, representing obstetricians and neonatologists.

RESULTS

We included 44 studies and reviews, identifying 40 potential proxy indicators with a positive impact on maternal/neonatal outcomes. The Delphi experts completed and prioritised these, resulting in a list of 77 potential proxy indicators.

CONCLUSIONS

The proxy indicators propose relevant outcome measures to evaluate if eHealth tools directly affect maternal/neonatal outcomes. Some proxy indicators require mapping to the local context, practices and available resources. The local mapping facilitates the utilisation of the proxy indicators in various contexts while allowing the systematic collection of data from different projects and programmes. Based on the mapping, the same proxy indicator can be used for different contexts, allowing it to measure what is locally and temporally relevant, making the proxy indicator sustainable.

PROSPERO REGISTRATION NUMBER

CRD42015027351.

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.

Intimate partner violence victimization increases the risk of under-five morbidity: A stratified multilevel analysis of pooled Tanzania Demographic Health Surveys, 2010-2016

INTRODUCTION

A hidden determinant such as intimate partner violence victimization has been associated with under-five morbidity and mortality. However, there is lack of information regarding which exactly age group of under-five is more vulnerable to morbidity when their mothers exposed to intimate partner violence victimization. This study aimed to determine the effect of mothers' exposure to intimate partner violence victimization on age groups specific under-five morbidity that could lead to mortality.

MATERIAL AND METHODS

The current study pooled and analyzed data from 2010 and 2016 Tanzania Demographic Health Survey datasets. We used a stratified multilevel modeling to assess the association between under-five morbidity and intimate partner violence victimization according to age groups. The Statistical approach using Stata 14 was used to adjust for clustering effect and weighted the estimates to correct for non-responses and disproportionate sampling employed during designing of the surveys.

RESULTS

A total of 13,639 singleton live-births babies within three years prior to interview dates from the ever-married women were included in the analysis. We found a significant reduction of the three main symptoms of under-five morbidity namely; a cough with difficult or fast breathing from 21.7 to 15.7%, fever from 22.5 to 18.3%, and diarrhoea from 15.5 to 12.7% for the survey years from 2010 to 2016 respectively (P<0.05). Overall, about 40% of mothers reported experiencing any forms of intimate partner violence victimization. After adjusting for individual and cluster variables, we found that under-five in post-neonatal period (Adjusted odds ratios = 1.50; 95%CI, 1.21-1.86) and childhood period (Adjusted odds ratios = 1.40; 95%CI, 1.24-1.57) were significantly affected with morbidity when their mothers' exposed to any form of intimate partner violence victimization.

CONCLUSION

This analysis revealed that intimate partner violence victimization is still a major and public health problem in Tanzania that threatens child health during the period of post-neonatal and childhood. There is a need to introduce screening for intimate partner violence victimization in maternal and child care for effective monitoring and prevention of the problem.

Knowledge Accrual Following Participation in Pediatric Fundamental Critical Care Support Course in Gaborone, Botswana

OBJECTIVES

To describe provider characteristics, knowledge acquisition, perceived relevance, and instruction quality of the Society of Critical Care Medicine's Pediatric Fundamentals of Critical Care Support course pilot implementation in Botswana.

DESIGN

Observational, single center.

SETTING

Academic, upper middle-income country.

SUBJECTS

Healthcare providers in Botswana.

INTERVENTIONS

A cohort of healthcare providers completed the standard 2-day Pediatric Fundamentals of Critical Care Support course and qualitative survey during the course. Cognitive knowledge was assessed prior to and immediately following training using standard Pediatric Fundamentals of Critical Care Support multiple choice questionnaires. Data analysis used Fisher exact, chi-square, paired t test, and Wilcoxon rank-sum where appropriate.

MAIN RESULTS

There was a significant increase in overall multiple choice questionnaires scores after training (mean 67% vs 77%; p < 0.001). Early career providers had significantly lower mean baseline scores (56% vs 71%; p < 0.01), greater knowledge acquisition (17% vs 7%; p < 0.02), but no difference in posttraining scores (73% vs 78%; p = 0.13) compared with more senior providers. Recent pediatric resuscitation or emergency training did not significantly impact baseline scores, posttraining scores, or decrease knowledge acquisition. Eighty-eight percent of providers perceived the course was highly relevant to their clinical practice, but only 71% reported the course equipment was similar to their current workplace.

CONCLUSIONS

Pediatric Fundamentals of Critical Care Support training significantly increased provider knowledge to care for hospitalized seriously ill or injured children in Botswana. Knowledge accrual is most significant among early career providers and is not limited by previous pediatric resuscitation or emergency training. Further contextualization of the course to use equipment relevant to providers work environment may increase the value of training.

Utilization of full postnatal care services among rural Myanmar women and its determinants: a cross-sectional study

Background: Mothers and their newborns are vulnerable to threats to their health and survival during the postnatal period. Full postnatal care (PNC) uptake decreases maternal deaths and is also essential for first 1,000 days of newborn's life, but PNC usage is usually inadequate in rural areas. Little is known about the full PNC utilization among rural Myanmar women. This study, therefore, aimed to study the situation of the utilization of full PNC and examine its determinants. Methods: This community-based cross-sectional study was conducted in selected villages of the Magway Region, Myanmar. A total of 500 married women who had children aged under 2 years were selected using multistage cluster sampling and interviewed with semi-structured questionnaires. The determinants of full PNC usage were identified by generalized estimating equation (GEE) under a logistic regression framework. Results: Among 500 rural women, around a quarter (25.20%; 95% confidence interval (CI), 21.58-29.21%) utilized full PNC. Multivariable analysis revealed that factors associated with full PNC usage included mothers attaining educational level of secondary or higher (adjusted odds ratio (AOR), 2.16; 95% CI, 1.18-3.94), belonging to higher income level (AOR, 2.02; 95% CI, 1.11-3.68), having male involvement (AOR, 2.19; 95% CI, 1.02-4.69), being of low birth order (i.e. the first birth) (AOR, 3.26; 95% CI, 1.80-5.91), and having awareness of postnatal danger signs (AOR, 2.10; 95% CI, 1.15-3.83). Moreover, the presence of misconceptions on postnatal practice was identified as a strong barrier to adequate PNC usage (AOR, 0.12; 95% CI, 0.04-0.36). Conclusion: Most of the rural women practiced inadequate PNC in Myanmar. Maternal healthcare services at rural areas should be intensively promoted, particularly among women who had high birth order (greater number of births). Health education regarding perinatal misconceptions and danger signs, and benefits of full PNC services usage should be emphasized and urgently extended.

Quantifying nursing care delivered in Kenyan newborn units: protocol for a cross-sectional direct observational study

INTRODUCTION

In many African countries, including Kenya, a major barrier to achieving child survival goals is the slow decline in neonatal mortality that now represents 45% of the under-5 mortality. In newborn care, nurses are the primary caregivers in newborn settings and are essential in the delivery of safe and effective care. However, due to high patient workloads and limited resources, nurses may often consciously or unconsciously prioritise the care they provide resulting in some tasks being left undone or partially done (missed care). Missed care has been associated with poor patient outcomes in high-income countries. However, missed care, examined by direct observation, has not previously been the subject of research in low/middle-income countries.

METHODS AND ANALYSIS

The aim of this study is to quantify essential neonatal nursing care provided to newborns within newborn units. We will undertake a cross-sectional study using direct observational methods within newborn units in six health facilities in Nairobi City County across the public, private-for-profit and private-not-for-profit sectors. A total of 216 newborns will be observed between 1 September 2017 and 30 May 2018. Stratified random sampling will be used to select random 12-hour observation periods while purposive sampling will be used to identify newborns for direct observation. We will report the overall prevalence of care left undone, the common tasks that are left undone and describe any sharing of tasks with people not formally qualified to provide care.

ETHICS AND DISSEMINATION

Ethical approval for this study has been granted by the Kenya Medical Research Institute Scientific and Ethics Review Unit. Written informed consent will be sought from mothers and nurses. Findings from this work will be shared with the participating hospitals, an expert advisory group that comprises members involved in policy-making and more widely to the international community through conferences and peer-reviewed journals.

Cost-effectiveness and economies of scale of a mass radio campaign to promote household life-saving practices in Burkina Faso

Introduction

Child health promotion through mass media has not been rigorously evaluated for cost-effectiveness in low-income and middle-income countries. We assessed the cost-effectiveness of a mass radio campaign on health-seeking behaviours for child survival within a trial in Burkina Faso and at national scale.

Methods

We collected provider cost data prospectively alongside a 35-month cluster randomised trial in rural Burkina Faso in 2012–2015. Out-of-pocket costs of care-seeking were estimated through a household survey. We modelled intervention effects on child survival based on increased care-seeking and estimated the intervention’s incremental cost-effectiveness ratio (ICER) in terms of the cost per disability-adjusted life year (DALY) averted versus current practice. Model uncertainty was gauged using one-way and probabilistic sensitivity analyses. We projected the ICER of national-scale implementation in five sub-Saharan countries with differing media structures. All costs are in 2015 USD.

Results

The provider cost of the campaign was $7 749 128 ($9 146 101 including household costs). The campaign broadcast radio spots 74 480 times and 4610 2-hour shows through seven local radio stations, reaching approximately 2.4 million people including 620 000 direct beneficiaries (pregnant women and children under five). It resulted in an average estimated 24% increase in care-seeking for children under five and a 7% reduction in child mortality per year. The ICER was estimated at $94 ($111 including household costs (95% CI −38 to 320)). The projected provider cost per DALY averted of a national level campaign in Burkina Faso, Burundi, Malawi, Mozambique and Niger in 2018–2020, varied between $7 in Malawi to $27 in Burundi.

Conclusion

This study suggests that mass-media campaigns can be very cost-effective in improving child survival in areas with high media penetration and can potentially benefit from considerable economies of scale.

Trial registration number

NCT01517230; Results.

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

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

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

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

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

Does government expenditure reduce inequalities in infant mortality rates in low- and middle-income countries?: A time-series, ecological analysis of 48 countries from 1993 to 2013

Inequalities in infant mortality rates (IMRs) are rising in some low- and middle-income countries (LMICs) and decreasing in others, but the explanation for these divergent trends is unclear. We investigate whether government expenditures and redistribution are associated with reductions in inequalities in IMRs. We estimated country-level fixed-effects panel regressions for 48 LMICs (142 country observations). Slope and Relative Indices of Inequality in IMRs (SII and RII) were calculated from Demographic and Health Surveys between 1993 and 2013. RII and SII were regressed on government expenditure (total, health and non-health) and redistribution, controlling for gross domestic product (GDP), private health expenditures, a democracy indicator, country fixed effects and time. Mean SII and RII was 39.12 and 0.69, respectively. In multivariate models, a 1 percentage point increase in total government expenditure (% of GDP) was associated with a decrease in SII of −2.468 [95% confidence intervals (CIs): −4.190, −0.746] and RII of −0.026 (95% CIs: −0.048, −0.004). Lower inequalities were associated with higher non-health government expenditure, but not higher government health expenditure. Associations with inequalities were non-significant for GDP, government redistribution, and private health expenditure. Understanding how non-health government expenditure reduces inequalities in IMR, and why health expenditures may not, will accelerate progress towards the Sustainable Development Goals.

Socioeconomic inequality in maternal healthcare: An analysis of regional variation in Bangladesh

Socioeconomic inequality in the utilisation of maternal healthcare services is well-documented in Bangladesh. However, the spatial dimension of this inequality is largely unexplored in the literature. This study examined the regional variation of wealth-related inequality in the utilisation of maternal healthcare services using data from Bangladesh Demographic and Health Survey, 2014. The highest extent of pro-wealthy inequality was found in Chittagong and Sylhet for ANC services compared to Khulna and Rangpur where inequality was the lowest. Pro-wealthy inequality was the lowest in Rangpur while Dhaka and Barisal tended to have the greatest degree of inequality for delivery care services. Policy efforts aiming to tackle socioeconomic inequality in maternal healthcare should consider this spatial dimension of inequality in Bangladesh.

Does quality influence utilization of primary health care? Evidence from Haiti

Background

Expanding coverage of primary healthcare services such as antenatal care and vaccinations is a global health priority; however, many Haitians do not utilize these services. One reason may be that the population avoids low quality health facilities. We examined how facility infrastructure and the quality of primary health care service delivery were associated with community utilization of primary health care services in Haiti.

Methods

We constructed two composite measures of quality for all Haitian facilities using the 2013 Service Provision Assessment survey. We geographically linked population clusters from the Demographic and Health Surveys to nearby facilities offering primary health care services. We assessed the cross-sectional association between quality and utilization of four primary care services: antenatal care, postnatal care, vaccinations and sick child care, as well as one more complex service: facility delivery.

Results

Facilities performed poorly on both measures of quality, scoring 0.55 and 0.58 out of 1 on infrastructure and service delivery quality respectively. In rural areas, utilization of several primary cares services (antenatal care, postnatal care, and vaccination) was associated with both infrastructure and quality of service delivery, with stronger associations for service delivery. Facility delivery was associated with infrastructure quality, and there was no association for sick child care. In urban areas, care utilization was not associated with either quality measure.

Conclusions

Poor quality of care may deter utilization of beneficial primary health care services in rural areas of Haiti. Improving health service quality may offer an opportunity not only to improve health outcomes for patients, but also to expand coverage of key primary health care services.

Electronic supplementary material

The online version of this article (10.1186/s12992-018-0379-0) contains supplementary material, which is available to authorized users.