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

Drivers of success in global health outcomes: A content analysis of Exemplar studies

Applying a positive outlier lens is one effective approach for generating evidence to inform global health policy, program, and funding decisions. Exemplars in Global Health (EGH) is a program that studies positive outlier countries that have made extraordinary progress in health outcomes (despite limited resources) and disseminates their successes through multiple types of outputs. To date, EGH has studied, or is studying, 14 global health topics in 28 countries. This paper aims to identify findings, summarized as themes and sub-themes, that appear among all completed EGH studies. We developed a conceptual framework and used a content analysis approach to identify the top thematic areas that appear as drivers for programmatic success across EGH studies that were completed between June 2020-May 2023. The EGH studies (N = 31) spanned six topics including under-five child mortality (n = 6), childhood stunting (n = 5), community health workers (CHW) (n = 4), vaccine delivery (n = 3), COVID-19 response (n = 6), and newborn and maternal mortality reduction (n = 7) across 19 countries in sub-Saharan Africa, Latin America, South and Central Asia, and the Caribbean regions. Top drivers of success were defined as those critical or catalytic in achieving the intended outcome. Eight key drivers were identified: (1) efficient data collection and use for decision-making, (2) strong political commitment and health leadership, (3) effective stakeholder coordination, (4) a local, connected, and capacitated workforce, (5) intentional women's empowerment and engagement, (6) effective adoption and implementation of national policies, (7) effective and sustainable financing, and (8) equitable, efficient outreach and targeting. These cross-cutting drivers span a broad range of development outcomes, sectors, and populations, and indicate a need to effectively integrate people, systems, and sectors to improve global health outcomes. Findings from this study aim to support peer learning among countries and support evidence-based decision-making for funders, policymakers, and other key stakeholders.

Did aid to the Ebola crisis divert aid for reproductive, maternal, and newborn health? An analysis of donor-reported data in Sierra Leone

BACKGROUND

Infectious disease outbreaks like Ebola and Covid-19 are increasing in frequency. They may harm reproductive, maternal and newborn health (RMNH) directly and indirectly. Sierra Leone experienced a sharp deterioration of RMNH during the 2014-16 Ebola epidemic. One possible explanation is that donor funding may have been diverted away from RMNH to the Ebola response.

METHODS

We analysed donor-reported data from the Organisation for Economic Cooperation and Development (OECD)'s Creditor Reported System (CRS) data for Sierra Leone before, during and after the 2014-16 Ebola epidemic to understand whether aid flows for Ebola displaced aid for RMNH. We estimated aid for Ebola using key term searches and manual review of CRS records. We estimated aid for RMNH by applying the Muskoka-2 algorithm to the CRS and analysing CRS purpose codes.

RESULTS

We find substantial increases in aid to Sierra Leone (from $484 million in 2013 to $1 billion at the height of the epidemic in 2015), most of which was earmarked for the Ebola response. Overall, Ebola aid was additional to RMNH funding. RMNH aid was sustained during the epidemic (at $42 m per year) and peaked immediately after (at $77 m in 2016). There is some evidence of a small displacement of RMNH aid from the UK during the period when its Ebola funding increased.

CONCLUSIONS

Modest changes to RMNH donor aid patterns are insufficient to explain the severe decline in RMNH indicators recorded during the outbreak. Our findings therefore suggest the need for substantial increases in routine aid to ensure that basic RMNH services and infrastructure are strong before an epidemic occurs, as well as increased aid for RMNH during epidemics like Ebola and Covid-19, if reproductive, maternal and newborn healthcare is to be maintained at pre-epidemic levels.

Women's Health: Coming of Age on 2024

The focus of the life and work of an obstetrics and gynaecological specialist is improving women's health, hence it is imperative that this issue be addressed in the Journal of Obstetrics and Gynaecology of India while we are still fresh with our memories of the "International women's day" celebration. The multidimensional impact of health and well-being of women has now been realised not only in the medical field but also in the realms of socioeconomic development. Governments all over the world are now paying special attention towards improving infrastructure, policymaking and implementation strategies to uplift the quality of healthcare for women and children, which  are now also important components of the Sustainable Development Goals. It is heartening to see worldwide interdisciplinary collaboration and coordination to achieve this vital goal and include every aspect of women's healthcare through the "lifecycle" approach and "holistic care" protocols.

Progress towards health equity in Vietnam: evidence from nationwide official health statistics, 2010-2020

INTRODUCTION

One of the ultimate goals of strengthening the health system is to achieve health equity. Vietnam is considered one of the 'fast-track countries' to achieve the health-related Millennium Development Goals, but research on its equity strategies remains inadequate.

METHODS

Using Vietnamese official health statistics, we investigated inequity in four dimensions including health resources, service delivery, service utilisation and residents' health status from the perspectives of income levels, poverty rates and subnational regions. The Slope Index of Inequality, concentration curve/Concentration Index, absolute difference and Theil Index were used.

RESULTS

Four indicators showed 'pro-poor' inequality in health resources, including the per capita health budget, per capita health personnel, per capita health personnel at the community level and per capita hospital beds at the community level, while provincial hospital beds showed 'pro-rich' inequality. Two health service delivery indicators (delivery of antenatal care ≥3 times and proportion of community health service centres with medical doctors) show 'pro-rich' inequality, although two health status indicators, mortality and malnutrition rates for children under five, showed 'pro-poor' inequality. The Northern Midlands and Mountain Areas, and the Central Highlands were disadvantaged regarding service delivery and health status. Intraregional differences were the main factors contributing to the inequalities in delivery of antenatal care ≥3 times, provincial hospital beds and percentage of community health centres with medical doctors, with the Red River Delta and the South East region experiencing the greatest inequalities.

CONCLUSION

The overall level of health equity in Vietnam has increased over the past decade, although inequality in health service delivery has hindered progress towards health equity based on income, poverty and subnational regions. Targeted policies need to be introduced to reduce inequities relating to the health workforce and service delivery capacity.

Understanding rapid implementation from discovery to scale: Rwanda's implementation of rotavirus vaccines and PMTCT in the quest to reduce under-5 mortality

BACKGROUND

Over the last eight decades, many evidence-based interventions (EBIs) have been developed to reduce amenable under-5 mortality (U5M). Implementation research can help reduce the lag between discovery and delivery, including as new EBIs emerge, or as existing ones are adapted based on new research. Rwanda was the first low-income African country to implement the rotavirus vaccine (RTV) and also adopted Option B+ for effective prevention of mother-to-child transmission (PMTCT) before the World Health Organization's (WHO) recommendation. We use implementation research to identify contextual factors and strategies associated with Rwanda's rapid uptake of these two EBIs developed or adapted during the study period.

METHODS

We conducted a mixed methods case study informed by a hybrid implementation research framework to understand how Rwanda outperformed regional and economic peers in reducing U5M, focusing on the implementation of health system-delivered EBIs. The research included review of existing literature and data, and key informant interviews to identify implementation strategies and contextual factors that influenced implementation outcomes. We extracted relevant results from the broader case study and used convergent methods to understand successes and challenges of implementation of RTV, a newly introduced EBI, and PMTCT, an adapted EBI reflecting new research.

RESULTS

We found several cross-cutting strategies that supported the rapid uptake and implementation of PMTCT, RTV, and leveraging facilitating contextual factors and identifying and addressing challenging ones. Key implementation strategies included community and stakeholder involvement and education, leveraging of in-country research capacity to drive adoption and adaptation, coordination of donors and implementing partners, data audit and feedback of coverage, a focus on equity, and integration into pre-existing systems, including community health workers and primary care. The availability of donor funding, culture of evidence-based decision-making, preexisting accountability systems, and rapid adoption of innovation were facilitating contextual factors.

CONCLUSION

Implementation strategies which are generalizable to other settings were key to success in rapidly achieving high acceptability and coverage of both a new and an evolving EBI. Choosing strategies which leverage their facilitating factors and address barriers are important for other countries working to accelerate uptake of new EBIs and implement needed adaptations based on emerging evidence.

Integrated Management of Childhood Illness implementation in Nepal: understanding strategies, context, and outcomes

BACKGROUND

Health system-delivered evidence-based interventions (EBIs) are important to reducing amenable under-5 mortality (U5M). Implementation research (IR) can reduce knowledge gaps and decrease lags between new knowledge and its implementation in real world settings. IR can also help understand contextual factors and strategies useful to adapting EBIs and their implementation to local settings. Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). We use IR to identify strategies used in Nepal's adaptation and implementation of IMCI.

METHODS

We conducted a mixed methods case study using an implementation research framework developed to understand how Nepal outperformed its peers between 2000-2015 in implementing health system-delivered EBIs known to reduce amenable U5M. We combined review of existing literature and data supplemented by 21 key informant interviews with policymakers and implementers, to understand implementation strategies and contextual factors that affected implementation outcomes. We extracted relevant results from the case study and used explanatory mixed methods to understand how and why Nepal had successes and challenges in adapting and implementing one EBI, IMCI.

RESULTS

Strategies chosen and adapted to meet Nepal's specific context included leveraging local research to inform national decision-makers, pilot testing, partner engagement, and building on and integrating with the existing community health system. These cross-cutting strategies benefited from facilitating factors included community health system and structure, culture of data use, and local research capacity. Geography was a critical barrier and while substantial drops in U5M were seen in both the highest and lowest wealth quintiles, with the wealth equity gap decreasing from 73 to 39 per 1,000 live births from 2001 to 2016, substantial geographic inequities remained.

CONCLUSIONS

Nepal's story shows that implementation strategies that are available across contexts were key to adopting and adapting IMCI and achieving outcomes including acceptability, effectiveness, and reach. The value of choosing strategies that leverage facilitating factors such as investments in community-based and facility-based approaches as well as addressing barriers such as geography are useful lessons for countries working to accelerate adaptation and implementation of strategies to implement EBIs to continue achieving child health targets.

Survival analysis of early intention of antenatal care among women in Bangladesh

This study focuses on the importance of early and regular Antenatal Care (ANC) visits in reducing maternal and child mortality rates in Bangladesh, a country where such health indicators are a concern. The research utilized data from the Bangladesh Demographic and Health Survey (BDHS) conducted in 2017-18 and employed the Cox proportional hazard model to identify factors influencing women's intention of ANC services. The results revealed that 40.4% of women engaged in at least one ANC activity during the first trimester, which, although higher than in other countries, falls below the global average. Notably, women between the aged of 25 and 29 years took 15% less time for their first ANC visit compared to their younger counterparts, suggesting higher awareness and preparedness in this age group. Education, both for women and their partners, had a significant influence on the intention to visit ANC early. Women in the poor wealth quantile exhibited lower odds of seeking timely ANC, whereas those with a planned pregnancy were more likely to do so. Moreover, access to mass media decreased the timing of ANC visits by 26% compared to women who were not exposed. Moreover, living in rural areas was linked to a 17% delay in the timing of the first ANC visit compared to urban areas. These findings underscore the importance of addressing these determinants to improve the timeliness and accessibility of ANC services, thereby enhancing maternal and child health outcomes in Bangladesh.

Brain Maturation as a Fundamental Factor in Immune-Neurovascular Interactions in Stroke

Injuries in the developing brain cause significant long-term neurological deficits. Emerging clinical and preclinical data have demonstrated that the pathophysiology of neonatal and childhood stroke share similar mechanisms that regulate brain damage, but also have distinct molecular signatures and cellular pathways. The focus of this review is on two different diseases-neonatal and childhood stroke-with emphasis on similarities and distinctions identified thus far in rodent models of these diseases. This includes the susceptibility of distinct cell types to brain injury with particular emphasis on the role of resident and peripheral immune populations in modulating stroke outcome. Furthermore, we discuss some of the most recent and relevant findings in relation to the immune-neurovascular crosstalk and how the influence of inflammatory mediators is dependent on specific brain maturation stages. Finally, we comment on the current state of treatments geared toward inducing neuroprotection and promoting brain repair after injury and highlight that future prophylactic and therapeutic strategies for stroke should be age-specific and consider gender differences in order to achieve optimal translational success.

Management Practices and Quality of Care: Evidence from the Private Health Care Sector in Tanzania

We measure the adoption of management practices in over 220 private for-profit and non-profit health facilities in 64 districts across Tanzania and link these data to process quality-of-care metrics, assessed using undercover standardised patients and clinical observations. We find that better managed health facilities are more likely to provide correct treatment in accordance with national treatment guidelines, adhere to a checklist of essential questions and examinations, and comply with infection prevention and control practices. Moving from the 10th to the 90th percentile in the management practice score is associated with a 48% increase in correct treatment. We then leverage a large-scale field experiment of an internationally recognised management support intervention in which health facilities are assessed against comprehensive standards, given an individually tailored quality improvement plan and supported through training and mentoring visits. We find zero to small effects on management scores, suggesting that improving management practices in this setting may be challenging.

The impact of anthropogenic climate change on pediatric viral diseases

The adverse effects of climate change on human health are unfolding in real time. Environmental fragmentation is amplifying spillover of viruses from wildlife to humans. Increasing temperatures are expanding mosquito and tick habitats, introducing vector-borne viruses into immunologically susceptible populations. More frequent flooding is spreading water-borne viral pathogens, while prolonged droughts reduce regional capacity to prevent and respond to disease outbreaks with adequate water, sanitation, and hygiene resources. Worsening air quality and altered transmission seasons due to an increasingly volatile climate may exacerbate the impacts of respiratory viruses. Furthermore, both extreme weather events and long-term climate variation are causing the destruction of health systems and large-scale migrations, reshaping health care delivery in the face of an evolving global burden of viral disease. Because of their immunological immaturity, differences in physiology (e.g., size), dependence on caregivers, and behavioral traits, children are particularly vulnerable to climate change. This investigation into the unique pediatric viral threats posed by an increasingly inhospitable world elucidates potential avenues of targeted programming and uncovers future research questions to effect equitable, actionable change. IMPACT: A review of the effects of climate change on viral threats to pediatric health, including zoonotic, vector-borne, water-borne, and respiratory viruses, as well as distal threats related to climate-induced migration and health systems. A unique focus on viruses offers a more in-depth look at the effect of climate change on vector competence, viral particle survival, co-morbidities, and host behavior. An examination of children as a particularly vulnerable population provokes programming tailored to their unique set of vulnerabilities and encourages reflection on equitable climate adaptation frameworks.

Proximate and distant determinants of maternal and neonatal mortality in the postnatal period: A scoping review of data from low- and middle-income countries

Global maternal and neonatal mortality rates remain unacceptably high. The postnatal period, encompassing the first hour of life until 42 days, is critical for mother-baby dyads, yet postnatal care (PNC) coverage is low. Identifying mother-baby dyads at increased risk for adverse outcomes is critical. Yet few efforts have synthesized research on proximate and distant factors associated with maternal and neonatal mortality during the postnatal period. This scoping review identified proximate and distant factors associated with maternal and neonatal mortality during the postnatal period within low- and middle-income countries (LMICs). A rigorous, systematic search of four electronic databases was undertaken to identify studies published within the last 11 years containing data on risk factors among nationally representative samples. Results were synthesized narratively. Seventy-nine studies were included. Five papers examined maternal mortality, one focused on maternal and neonatal mortality, and the rest focused on neonatal mortality. Regarding proximate factors, maternal age, parity, birth interval, birth order/rank, neonate sex, birth weight, multiple-gestation, previous history of child death, and lack of or inadequate antenatal care visits were associated with increased neonatal mortality risk. Distant factors for neonatal mortality included low levels of parental education, parental employment, rural residence, low household income, solid fuel use, and lack of clean water. This review identified risk factors that could be applied to identify mother-baby dyads with increased mortality risk for targeted PNC. Given risks inherent in pregnancy and childbirth, adverse outcomes can occur among dyads without obvious risk factors; providing timely PNC to all is critical. Efforts to reduce the prevalence of risk factors could improve maternal and newborn outcomes. Few studies exploring maternal mortality risk factors were available; investments in population-based studies to identify factors associated with maternal mortality are needed. Harmonizing categorization of factors (e.g., age, education) is a gap for future research.

Evaluating equity across the continuum of care for maternal health services: analysis of national health surveys from 25 sub-Saharan African countries

BACKGROUND

Ensuring access to the continuum of care for maternal, neonatal, and child health is an effective strategy for reducing maternal and child mortality. We investigated the extent of dropout, wealth-related inequalities, and drivers of inequality in the continuum of care for maternal health services in sub-Saharan Africa.

METHODS

We analysed Demographic and Health Surveys (DHS) conducted between 2013 and 2019 across 25 sub-Saharan African countries. We defined the continuum of care for maternal health services as women who had received at least four ANC contacts (ANC 4 + contacts), skilled care at birth, and immediate postnatal care (PNC). We used concentration index to estimate wealth-related inequalities across the continuum of care. Multilevel logistic regression models were used to identify predictors of inequality in completing the continuum of care.

RESULTS

We included data on 196,717 women with the most recent live birth. About 87% of women reported having at least one ANC contact, but only 30% of women received the recommended care package that includes ANC 4 + contacts, skilled care at birth, and PNC. The proportion of women who had completed the continuum of care ranged from 6.5% in Chad to 69.5% in Sierra Leone. Nearly 9% of women reported not having contact with the health system during pregnancy or childbirth; this ranged from 0.1% in Burundi to 34% in Chad. Disadvantaged women were more likely to have no contact with health systems and less likely to have the recommended care package than women from wealthier households. Women with higher education levels, higher exposure to mass media (radio and TV), and higher household wealth status had higher odds of completing the continuum of care.

CONCLUSIONS

Persistent and increasing inequalities were observed along the continuum of care from pregnancy to the postnatal period, with socioeconomically disadvantaged women more likely to drop out of care. Improving access to and integration of services is required to improve maternal health. Initiatives and efforts to improve maternal health should prioritise and address the needs of communities and groups with low coverage of maternal health services.

Risk factors for neonatal mortality: an observational cohort study in Sarlahi district of rural southern Nepal

OBJECTIVES

To assess the association between maternal characteristics, adverse birth outcomes (small-for-gestational-age (SGA) and/or preterm) and neonatal mortality in rural Nepal.

DESIGN

This is a secondary observational analysis to identify risk factors for neonatal mortality, using data from a randomised trial to assess the impact of newborn massage with different oils on neonatal mortality in Sarlahi district, Nepal.

SETTING

Rural Sarlahi district, Nepal.

PARTICIPANTS

40 119 pregnant women enrolled from 9 September 2010 to 16 January 2017.

MAIN OUTCOME

The outcome variable is neonatal death. Cox regression was used to estimate adjusted Hazard Ratios (aHRs) to assess the association between adverse birth outcomes and neonatal mortality.

RESULTS

There were 32 004 live births and 998 neonatal deaths. SGA and/or preterm birth was strongly associated with increased neonatal mortality: SGA and preterm (aHR: 7.09, 95% CI: (4.44 to 11.31)), SGA and term/post-term (aHR: 2.12, 95% CI: (1.58 to 2.86)), appropriate-for-gestational-age/large-for-gestational-age and preterm (aHR: 3.23, 95% CI: (2.30 to 4.54)). Neonatal mortality was increased with a history of prior child deaths (aHR: 1.53, 95% CI: (1.24 to 1.87)), being a twin or triplet (aHR: 5.64, 95% CI: (4.25 to 7.48)), births at health posts/clinics or in hospital (aHR: 1.34, 95% CI: (1.13 to 1.58)) and on the way to facilities or outdoors (aHR: 2.26, 95% CI: (1.57 to 3.26)). Risk was lower with increasing maternal height from <145 cm to 145-150 cm (aHR: 0.78, 95% CI: (0.65 to 0.94)) to ≥150 cm (aHR: 0.57, 95% CI: (0.47 to 0.68)), four or more antenatal care (ANC) visits (aHR: 0.67, 95% CI: (0.53 to 0.86)) and education >5 years (aHR: 0.75, 95% CI: (0.62 to 0.92)).

CONCLUSION

SGA and/or preterm birth are strongly associated with increased neonatal mortality. To reduce neonatal mortality, interventions that prevent SGA and preterm births by promoting ANC and facility delivery, and care of high-risk infants after birth should be tested.

TRIAL REGISTRATION NUMBER

NCT01177111.

Metagenomic sequencing of post-mortem tissue samples for the identification of pathogens associated with neonatal deaths

Postmortem minimally invasive tissue sampling together with the detailed review of clinical records has been shown to be highly successful in determining the cause of neonatal deaths. However, conventional tests including traditional culture methods and nucleic acid amplification tests have periodically proven to be insufficient to detect the causative agent in the infectious deaths. In this study, metagenomic next generation sequencing was used to explore for putative pathogens associated with neonatal deaths in post-mortem blood and lung tissue samples, in Soweto, South Africa. Here we show that the metagenomic sequencing results corroborate the findings using conventional methods of culture and nucleic acid amplifications tests on post-mortem samples in detecting the pathogens attributed in the causal pathway of death in 90% (18/20) of the decedents. Furthermore, metagenomic sequencing detected a putative pathogen, including Acinetobacter baumannii, Klebsiella pneumoniae, Escherichia coli, and Serratia marcescens, in a further nine of 11 (81%) cases where no causative pathogen was identified. The antimicrobial susceptibility profile was also determined by the metagenomic sequencing for all pathogens with numerous multi drug resistant organism identified. In conclusion, metagenomic sequencing is able to successfully identify pathogens contributing to infection associated deaths on postmortem blood and tissue samples.

Influencing factors associated with maternal delivery at home in urban areas: a cross-sectional analysis of the Bangladesh Demographic and Health Survey 2017-2018 data

BACKGROUND

The associated factors and patterns of giving birth in home settings of rural areas have been extensively studied in Bangladeshi literature. However, urban areas still need to be explored, particularly with recent data. Therefore, the authors aimed to investigate the influential determinants of delivery at home in urban areas of Bangladesh.

MATERIALS AND METHODS

In this study, 1699 urban-dwelling women who had given birth within the previous 60 months of the survey and lived in urban areas were used. The secondary data were extracted from the latest Bangladesh Demographic and Health Survey 2017-2018. Descriptive statistics and logistic regression were applied along with the association among selected variables were examined by the Chi-square test.

RESULTS

Findings depict that 36.49% of women who lived in urban areas of Bangladesh delivered at home, whereas, 63.51% delivered at different govt. and private health care facilities. Women who lived in Chittagong [adjusted odds ratio (AOR) = 2.11, 95% CI 1.24-3.60], Barisal [AOR = 2.05, 95% CI 1.16-3.64] and Sylhet [AOR = 1.92, 95% CI 1.08-3.43] divisions have more likelihood to deliver at home (36.85%). Urban women following Christian religion [AOR = 10.71, 95% CI 1.32-86.68] have higher odds of delivering child at home (0.47%). Urban women having three or more children before her latest delivery (22.37%) and who are employed (29.37%) have more likelihood to deliver at home. However, women aged between 25 and 34 years (43.50%), who have higher education (25.90%), play the role of household head (9.06%), have parity of more than two births (2.24%), and read daily newspapers (68.69%) had a lower chance of delivery at home. Furthermore, women from wealthier families (89.12%) and more antenatal care (ANC) visits (94.93%) were less likely to have a delivery at home.

CONCLUSION

Despite significant progress in women and reproductive health in Bangladesh, the proportion of delivery in the home in urban areas is alarming and should be emphasized more. The authors believe the identified factors will help design interventions and policy development on this issue.

Inequity of maternal-child health services in ASEAN member states from 1993 to 2021

INTRODUCTION

Inequity in maternal-child health services is a challenge to global health as it hinders the achievement of Sustainable Development Goals (SDGs) and Universal Health Coverage. Though the Association of Southeast Asian Nations (ASEAN) has made remarkable achievements in maternal-child health, there remain gaps in reaching global goals. This study aimed to compare and investigate the inequity in maternal-child health (MCH) services in ASEAN member states to help guide policy decisions to improve equitable health services in the SDG era and beyond.

METHODS

Using the WHO Health Inequality Monitor, we identified inequity summary measures for five MCH services in ASEAN member states from 1993 to 2021: antenatal care, births attended by skilled health personnel, diphtheria, tetanus and pertussis (DTP3) immunization, measles immunization, and polio immunization. We divided the analysis dimension of inequity into urban-rural inequity, economic status inequity, and sub-regional inequity. Trends of absolute and relative inequity in every dimension of MCH services in ASEAN member states were examined with the principal component analysis (PCA).

RESULTS

The mean coverages of MCH services are 98.80% (Thailand), 86.72% (Cambodia), 84.54% (Viet Nam), 78.52 (Indonesia), 76.94% (Timor-Leste), 72.40% (Lao PDR), 68.10% (Philippines) and 48.52% (Myanmar) in 2021. Thailand have the lowest MCH services absolute inequity indexes of -1.945, followed by Vietnam (-1.449). Lao PDR and Myanmar have relatively higher MCH services absolute inequity indexes of 0.852 and 0.054 respectively. The service in Cambodia, Indonesia, and the Philippines is pro-specific regions (with subnational region absolute inequity indexes of -0.02, 0.01, and 1.01 respectively). The service in Myanmar is pro-rich (with economic status absolute inequity index of 0.43). The service in Lao PDR and Timor-Leste is pro-urban areas, pro-rich, and pro-specific regions.

CONCLUSION

The inequity of MCH services in ASEAN persists but is in a declining trend. Thailand and Vietnam have performed well in ensuring MCH services equity, while Laos and Myanmar are still facing serious inequity dilemmas. The progress of MCH service equity in Myanmar, Cambodia, the Philippines, and Indonesia is uneven. It is acceptable to learn from the successful experiences of Thailand and Vietnam to improve the equities in other ASEAN countries. Policies should be developed according to the specific types of MCH inequity in member states to improve equity levels.

Navigating and manipulating childbirth services in Afar, Ethiopia: A qualitative study of cultural safety in the birthing room

Access to maternal health services has increased in Ethiopia during the past decades. However, increasing the demand for government birthing facility use remains challenging. In Ethiopia's Afar Region, these challenges are amplified given the poorly developed infrastructure, pastoral nature of communities, distinct cultural traditions, and the more nascent health system. This paper features semi-structured interviews with 22 women who were purposively sampled to explore their experiences giving birth in government health facilities in Afar. We used thematic analysis informed by a cultural safety framework to interpret findings. Our findings highlight how women understand, wield, and relinquish power and agency in the delivery room in government health facilities in Afar, Ethiopia. We found that Afari women are treated as 'others', that they manipulate their care as they negotiate 'cultural safety' in the health system, and that they use trust as a pathway towards more cultural safety. As the cultural safety framework calls for recognizing and navigating the diverse and fluid power dynamics of healthcare settings, the onus of negotiating power dynamics cannot be placed on Afari women, who are already multiply marginalized due to their ethnicity and gender. Health systems must adopt cultural safety in order to ensure health quality. Providers, particularly in regions with rich cultural diversity, must be trained in the cultural safety framework in order to be aware of and challenge the multidimensional power dynamics present in health encounters.

Inequalities in utilisation of essential antenatal services for women with disabilities in Pakistan: analysis of a cross-sectional demographic and health survey of Pakistan 2017-2018

OBJECTIVES

Although the number of disabled women entering motherhood is growing, there is little quantitative evidence about the utilisation of essential antenatal care (ANC) services by women with disabilities. We examined inequalities in the use of essential ANC services between women with and without disabilities.

DESIGN, SETTING AND ANALYSIS

A secondary analysis of cross-sectional data from recent Demographic and Health Survey of Pakistan 2017-2018 was performed using logistic regression.

PARTICIPANTS

A total weighted sample of 6791 ever-married women (age 15-49) who had a live birth in the 5 years before the survey were included.

OUTCOME MEASURES

Utilisation of ANC: (A) antenatal coverage: (1) received ANC and (2) completed four or more ANC visits and (B) utilisation of essential components of ANC.

RESULTS

The percentage of women who were at risk of disability and those living with disability in one or more domains was 11.5% and 2.6%, respectively. The coverage of ANC did not differ by disability status. With utilisation of essential ANC components, consumption of iron was lower (adjusted OR, aOR=0.6; p<0.05), while advice on exclusive breast feeding (aOR=1.6; p<0.05) and urine test (aOR=1.7; p<0.05) was higher among women with disabilities as compared with their counterparts. Similarly, the odds of receiving advice on maintaining a balanced diet was higher (aOR=1.3; p<0.05) among women at risk of any disability as opposed to their counterparts. Differences were also found for these same indicators in subgroup analysis by wealth status (poor/non-poor) and place of residence (urban-rural).

CONCLUSION

Our study did not find glaring inequalities in the utilisation of ANC services between women with disabilities and non-disabled women. This was true for urban versus rural residence and among the poor versus non-poor women. Some measures, however, should be made to improve medication compliance among women with disabilities.

Women's empowerment and contraceptive use: Recent evidence from ASEAN countries

BACKGROUND

A fundamental element of gender equity are women's rights to reproductive choice. Women's empowerment is often linked to enabling decisions around contraceptive use and reduced fertility worldwide, although limited evidence is currently available around contraceptive use and decision making in ASEAN countries.

OBJECTIVE

To examine the association between women's empowerment and contraceptive use in five selected ASEAN member states.

METHODS

Data from the latest Demographic and Health Survey of Cambodia, Indonesia, Myanmar, The Philippines, and Timor-Leste were used. The main outcome was contraceptive use among married women (15-49 years) from these five countries. We considered four indicators of empowerment: labor force participation; disagreement with reasons for wife beating; decision-making power over household issues; and knowledge level.

RESULTS

Labor force participation was found to be significantly associated with contraceptive use in all nations. Disagreement with justification of wife beating was not significantly related to contraceptive use in any country. Decision-making power (higher) was only associated with contraceptive use in Cambodia, while higher knowledge levels were associated with contraceptive use in Cambodia, and Myanmar.

CONCLUSION

This study suggests women's labor force participation is an important determinant of contraceptive use. Policies designed to open the labor market and empower women through education should be implemented to enable women's participation. Gender inequality may also be tackled by engaging women in decision-making processes at national, community and family levels.

Ending Preventable Neonatal Deaths: Multicountry Evidence to Inform Accelerated Progress to the Sustainable Development Goal by 2030

INTRODUCTION

The Sustainable Development Goal (SDG) 3.2 aims for every country to reach a neonatal mortality rate (NMR) of ≤12/1,000 live births by 2030. More than 60 countries are off track, and 2.3 million newborns still die each year. Urgent action is needed, but varies by context, notably mortality level.

METHODS

We applied a five-phase NMR transition model based on national analyses for 195 UN member states: I (NMR >45), II (30-<45), III (15-<30), IV (5-<15), and V (<5). We analyzed data over the last century from selected countries to inform strategies to reach SDG3.2. We also undertook impact analyses for packages of care using the Lives Saved Tool software.

RESULTS

An NMR of <15/1,000 requires firstly wide-scale access to maternity care and hospital care for small and sick newborns, including skilled nurses and doctors, safe oxygen use, and respiratory support, such as CPAP. Neonatal mortality could be reduced to the SDG target of ≤12/1,000 with further scale-up of small and sick newborn care. To reduce neonatal mortality further, more investment is required in infrastructure, device bundles (e.g., phototherapy, ventilation), and careful attention to infection prevention. To reach phase V (NMR <5), which is closer to ending preventable newborn deaths, additional technologies and therapies such as mechanical ventilation and surfactant replacement therapy are needed, as well as higher staffing ratios.

CONCLUSIONS

Learning from high-income country is important, including what not to do. Introduction of new technologies should be according to the country's phase. Early focus on disability-free survival and family involvement is also crucial.

Measuring Coverage of Essential Maternal Postnatal Care Services in the Squatter Settlements of Islamabad Capital Territory in Pakistan

This study aimed to assess the coverage of essential postnatal maternal care services among women residing in the slums of Islamabad. A community-based, cross-sectional study was conducted to assess the coverage of essential postnatal care (PNC) services. Using random sampling, 416 women living in the squatter settlements of Islamabad Capital Territory were selected as study participants. Data was analyzed by using SPSS version 22. Descriptive statistics were employed to display frequencies for categorical variables, whereas mean, median, and standard deviation were calculated for continuous variables. The analysis of data showed that 93.5 percent of the women utilized postnatal services at least once after delivery. Approximately 9 percent and 4 percent of women received all eight recommended services within 24 h of birth and beyond 24 h of birth, respectively. Effective PNC services were received by only 1 percent of the women. The study revealed that the utilization of effective PNC was very low. The majority of the women delivered in health institutions and received their first PNC checkups, but follow-up for the recommended checkups was very low. These results can help health professionals and policymakers in designing programs and developing efficient strategies that would improve PNC service utilization in Pakistan.

Retrospective review of antimicrobial use for gastroschisis patients in Kigali, Rwanda: can improved stewardship reduce late inpatient deaths?

Gastroschisis mortality is 75-100% in low-resource settings. In Rwanda, late deaths are often due to sepsis. We aimed to understand the effect of antimicrobial use on survival. We conducted a retrospective review of gastroschisis patients at a tertiary hospital in Kigali, Rwanda between January 2016-June 2019. Demographics, antimicrobial use, microbiology, and outcomes were abstracted. Descriptive and univariate analyses were conducted to assess factors associated with improved survival. Among 92 gastroschisis patients, mortality was 77%(n = 71); 23%(n = 21) died within 48 h. 98%(n = 90) of patients received antibiotics on arrival. Positive blood cultures were obtained in 41%(n = 38). Patients spent 86%(SD = 20%) of their hospital stay on antibiotics and 38%(n = 35) received second-line agents. There was no difference in age at arrival, birth weight, gestational age, silo complications, or antimicrobial selection between survivors and non-survivors. Late death patients spent more total hospital days and post-abdominal closure days on antibiotics (p < 0.001) compared to survivors. There was no difference in the proportion of hospital stay on second-line antibiotics (p = 0.1).

CONCLUSION

We identified frequent late deaths, prolonged antibiotic courses, and regular use of second-line antibiotic agents in this retrospective cohort of Rwandan gastroschisis patients. Future studies are needed to evaluate antimicrobial resistance in pediatric surgical patients in Rwanda.

WHAT IS KNOWN

• Global disparities in gastroschisis outcomes are extreme, with <4% mortality in high-income settings and 75-100% mortality in low-income settings. • Antimicrobial surveillance data is sparse across Africa, but existing evidence suggests high levels of resistance to first-line antibiotics in Rwanda.

WHAT IS NEW

• In-hospital survival for gastroschisis was 23% from 2016-2019 and most deaths occurred late (>48hrs after admission) due to sepsis. • Rwandan gastroschisis patients received prolonged courses of antibiotics and second-line antibiotics were frequently used without culture data, raising concern for antimicrobial resistance.

Institutionalizing the Management of Sick Young Infants: Kenya's Experience in Revising National Guidelines on Integrated Management of Newborn and Childhood Illnesses

INTRODUCTION

In 2015, the World Health Organization (WHO) developed guidelines for the management of sick young infants (SYIs) with possible serious bacterial infection (PSBI) where referral is not feasible. The Ponya Mtoto project was designed as an implementation research project to demonstrate how to adopt the WHO PSBI guidelines in the Kenyan context.

PONYA MTOTO PROJECT DESCRIPTION

Between October 2017 and June 2021, Ponya Mtoto was implemented in 4 Kenyan counties with higher infant and newborn mortality rates than the national mean. A total of 48 health facilities stratified by level of services were selected as study sites.

IMPLEMENTATION APPROACH

The following activities were done to institutionalize the management of SYIs with PSBI where referral is not feasible in Kenya's health system: (1) participating in a cocreation workshop and development of a theory of change; (2) revising the national integrated management of newborn and childhood illnesses guidelines to incorporate the management of PSBI where referral is not feasible; (3) improving availability of essential commodities; (4) strengthening provider confidence in the management of SYIs; (5) strengthening awareness about PSBI services for SYIs at the community level; and (6) harmonizing the national integrated management of newborn and childhood illnesses guidelines to address discrepancies in the content on the management of PSBI. In addition, the project focused on strengthening quality of care for SYIs and using implementation research to track progress in achieving project targets and outcomes.

CONCLUSION

Using an implementation research approach to introduce new WHO guidelines on PSBI where referral is not feasible into Kenya's health care service was critical to fostering engagement of a diverse range of stakeholders, monitoring provider skills and confidence-building, strengthening provision of key commodities for managing SYIs with PSBI, and sustaining community-facility linkages.

What is the impact of national public expenditure and its allocation on neonatal and child mortality? A machine learning analysis

BACKGROUND

Understanding the impact of national public expenditure and its allocation on child mortality may help governments move towards target 3.2 proposed in the 2030 Agenda. The objective of this study was to estimate the impacts of governmental expenditures, total, on health, and on other sectors, on neonatal mortality and mortality of children aged between 28 days and five years.

METHODS

This study has an ecological design with a population of 147 countries, with data between 2012 and 2019. Two steps were used: first, the Generalized Propensity Score of public spending was calculated; afterward, the Generalized Propensity Score was used to estimate the expenditures' association with mortality rates. The primary outcomes were neonatal mortality rates (NeoRt) and mortality rates in children between 28 days and 5 years (NeoU5Rt).

RESULTS

The 1% variation in Int$ Purchasing Power Parity (Int$ PPP) per capita in total public expenditures, expenditure in health, and in other sectors were associated with a variation of -0.635 (95% CI -1.176, -0.095), -2.17 (95% CI -3.051, -1.289) -0.632 (95% CI -1.169, -0.095) in NeoRt, respectively The same variation in public expenditures in sectors other than health, was associates with a variation of -1.772 (95% CI -6.219, -1.459) on NeoU5Rt. The results regarding the impact of total and health public spending on NeoU5Rt were not consistent.

CONCLUSION

Public investments impact mortality in children under 5 years of age. Likely, the allocation of expenditures between the health sector and the other social sectors will have different impacts on mortality between the NeoRt and the NeoU5Rt.

Joint distribution of child mortality and wealth across 30 sub-Saharan African countries over 2000-2019

Background

While reductions in child mortality have been observed across sub-Saharan African countries in the last 30 years, narrowing the gaps in under-five mortality across socioeconomic groups also requires an understanding of the multiple associations between health and welfare and socioeconomic drivers. We examined the probability density distributions in under-five mortality within countries and joint pathways of under-five mortality and wealth over time.

Methods

We used 69 Demographic and Health Surveys and 19 Malaria Indicator Surveys from 30 sub-Saharan African countries, with each country having at least two surveys conducted since 2000. We constructed a cross-country wealth index and estimated under-five death prevalence. We examined the pure distribution in under-five mortality prevalence and the joint probability distribution of wealth and under-five mortality prevalence over time, including the area of confidence ellipse which spanned the two dimensions of mortality and wealth and covered 75% of the mass of the joint distribution.

Results

Most countries experienced decreases in under-five mortality along with increases in wealth over time. However, we observed great variations in the evolution of the joint distributions across countries over time. For instance, the areas of confidence ellipse ranged from 0.178 in Ethiopia (2000) to 1.119 in Angola (2006). The change (over time) in the area of confidence ellipses ranged from 0.010 in Tanzania to 0.844 in Angola between the 2000s and 2010s. The ranking of country performance on under-five mortality varied greatly, depending on whether performance summary indicators were based on disaggregation by wealth or on full non-disaggregated distributions.

Conclusions

Our analysis points to the relevance of full distributions of health and joint distributions of health and wealth as complementary indicators of distributions of health across socioeconomic status, in assessing country performance on health.

Determinants of continuum of care for maternal, newborn, and child health services in Ethiopia: Analysis of the modified composite coverage index using a quantile regression approach

Maternal and child mortality remain unacceptably high in the Sustainable Development Goals era. Continuum of care has become a key strategy for improving the health of mothers and newborns. Previous research on the continuum of care in Ethiopia is often limited to maternal health services. Maternal and child health services are inseparably linked, and an integrated approach to care is essential. This study assessed the continuum of maternal, newborn, and child health care and associated factors in Ethiopia. The analysis was based on the 2016 Ethiopian Demographic and Health Survey data. We restricted our analysis to women with their most recent children-alive and living with their mother- aged 12-23 months at the time of the survey (n  =  1891). The modified composite coverage index, constructed from twelve maternal and child health services, was calculated as an indicator of the continuum of care. Bivariable and multivariable quantile regression were used to analyse the relationship between the predictors and specific quantiles of the composite coverage index. The effect of each variable was examined at the 10th, 25th, 50th, 75th, and 95th quantiles. The results showed that the average composite coverage index value was 39%. The overall completion rate of the continuum of care was low (2%). Four % of the women did not receive any of the services along the continuum of care. Postnatal care for newborns had the lowest coverage (12%). This study provides evidence that factors such as the educational status of women, region, residence, socio-economic status, perceived distance to a health facility, pregnancy intention, mode of delivery, parity, and early antenatal care initiation influence the continuum of care differently across levels of the composite coverage index. The findings call for integrated and targeted strategies that aim to improve the continuum of care considering the determinants.

Postnatal care services in rural Zambia: a qualitative exploration of user, provider, and community perspectives on quality of care

BACKGROUND

Postnatal care (PNC) is an important set of services offered to the mother and her newborn baby immediately after birth for the first six weeks to prevent maternal and neonatal complications and death. This qualitative study explored user and provider perspectives on quality of PNC services in the selected health facilities within the context of the Maternity Homes Access in Zambia project in the Saving Mothers Giving Life districts in rural Zambia.

METHODS

Between October 2018 and February 2019, forty focus group discussions (FGDs) (n = 160 participants) and twelve in-depth interviews (IDIs) were conducted in four districts in Southern and Eastern provinces. FGDs comprised women who delivered within the last year, fathers, community elders, and volunteers. IDIs comprised health workers at facility, district, and provincial levels. Data were analysed using content analysis guided by the international quality of care domains derived from the World Health Organization quality of care framework. Findings were triangulated to understand perceptions.

RESULTS

Overall, study participants perceived PNC services to be beneficial. Nevertheless, respondents had mixed feelings on the quality of PNC services and expressed a stark difference in their perception of factors affecting service quality. Service users described challenges arising from ineffective communication about the new PNC guidelines, and non-adherence of service providers to quality standards regarding respect, preservation of dignity and emotional support. Other factors were long waiting hours, small examination rooms providing inadequate privacy, and low levels of confidentiality. In contrast, service providers attributed poor service quality to various health system-related factors including low staffing levels, dysfunctional referral services, low supply of essential medicines, supplies, vaccines and equipment for optimal routine emergency obstetric and newborn care and management of complications.

CONCLUSION

These findings highlight important intervention opportunities to improve quality of PNC services in Zambia through better communication and raising awareness on PNC guidelines, respect, preservation of dignity and emotional support to mothers. Interventions should also focus on addressing contextual health system challenges including staffing levels, supply chain for essential medicines and commodities, shortening waiting time, and ensuring functional referral system.

Effect of prenatal care quality on the risk of low birth weight, preterm birth and vertical transmission of HIV, syphilis, and hepatitis

BACKGROUND

Averse birth-outcomes still affect newborns worldwide. Although high-quality prenatal care is the main strategy to prevent these outcomes, the effect of prenatal care based on Kotelchuck index combined with consultation contents is still unclear. Thus, this article to evaluate the effect of the quality of prenatal care (PC) process on birth indicators in a cohort of puerperaes who attended maternity hospitals in Brazilian western Amazon, city of Rio Branco, in the state of Acre, Brazil, in 2015.

METHODS

This research was a hospital-based cohort study. The sample consisted of 1,030 women who gave birth in maternity hospitals in the city between April 6 and June 30, 2015. This research was a hospital-based cohort study. The sample consisted of 1,030 women who gave birth in maternity hospitals in Rio Branco between April 6th. and June 30th., 2015. Prenatal care was classified as fully adequate when started ≤4th month; ≥80.0-109% expected consultations for GA according to the Kotelchuck Index; ≥5 records of blood pressure, weight, GA, fundal height, ≥4 records of fetal heart rate, fetal movements or equivalent to 75% of the number of consultations; in addition to recording ABO/RH, hemoglobin, VDRL, urine, glucose, anti-HIV and anti-toxoplamosis during the 1st trimester. The evaluated outcomes were low birth weight (LBW), preterm birth and vertical transmission of human immunodeficiency virus (HIV)/hepatitis/syphilis. Differences between proportions were assessed using the X² test, and the crude and adjusted odds ratios (OR) (95% CI) were estimated using unconditional logistic regression.

RESULTS

Overall cohort, the outcomes incidences were 8.8% for LBW, 9.2% for preterm birth, and 1.1% for vertical transmission (syphilis/HIV/hepatitis). Crude and adjusted OR showed that inadequate PC increased the risk statistically significant of LBW (ORcrude: 1.84; 95%CI: 0.99-3.44; ORadjusted: 1.87; 95%CI: 1.00-3.52), and preterm birth (ORcrude: 1.79; 95%CI: 1.00-3.29; ORadjusted: 3.98; 95%CI: 1.40-11.29).

CONCLUSION

The results draw attention to the importance of quality PC in reducing the risks of LBW, preterm birth, and vertical transmission of syphilis/HIV/hepatitis. Moreover, using this proposed quality prenatal care indicator based on Kotelchuck index combined with consultations contents adjusted by GA may accurately predict unfavorable outcomes.

Socioeconomic inequity in coverage and quality of maternal postnatal care in Ethiopia

OBJECTIVE

High-quality postnatal care is vital for improving maternal health. This study examined the relationship between household socioeconomic status and both coverage and quality of postnatal care in Ethiopia.

METHOD

Cross-sectional household survey data were collected in October-November 2013 from 12 zones in 4 regions of Ethiopia. Women reporting a live birth in the 3-24 months prior to the survey were interviewed about the care they received before, during and after delivery and their demographic characteristics. Using mixed effect logistic and linear regression, the associations between household socioeconomic status and receiving postnatal care, location of postnatal care (health facility vs. non-health facility), cadre of person providing care and the number of seven key services (including physical checks and advice) provided at a postnatal visit, were estimated.

RESULTS

A total of 16% (358/2189) of women interviewed reported receiving at least one postnatal care visit within 6 weeks of delivery. Receiving a postnatal care visit was strongly associated with socioeconomic status with women from the highest socioeconomic group having twice the odds of receiving postnatal care compared to women in the poorest quintile (OR [95% CI]: 1.98 [1.29, 3.05]). For each increasing socioeconomic status quintile there was a mean increase of 0.24 postnatal care services provided (95% CI: 0.06-0.43, p = 0.009) among women who did not give birth in a facility. There was no evidence that number of postnatal care services was associated with socioeconomic status for women who gave birth in a facility. There was no evidence that socioeconomic status was associated with the provider or location of postnatal care visits.

CONCLUSION

Postnatal care in Ethiopia shows evidence of socio-economic inequity in both coverage and quality. This demonstrates the need to focus on quality improvement as well as coverage, particularly among the poorest women who did not deliver in a facility.

Effects of short birth interval on different forms of child mortality in Bangladesh: Application of propensity score matching technique with inverse probability of treatment weighting

BACKGROUND

The prevalence of Short Birth Interval (SBI) is higher in Low- and Middle-Income countries (LMICs), including Bangladesh. Previous studies in LMICs have estimated the effects of SBI on child mortality by comparing two unequal groups of mothers based on their socio-economic status. This approach may lead to overestimation or underestimation of the true effect of birth interval on child mortality, particularly when sample sizes are relatively small.

OBJECTIVE

We determined the effects of SBI on several forms of child mortality in Bangladesh by comparing two equal groups created by applying the propensity score matching technique.

METHODS

This study analyzed data from 5,941 mothers and 1,594 health facilities extracted from the 2017/18 Bangladesh Demographic and Health Survey and the 2017 Bangladesh Health Facility Survey. The exposure variable was SBI (defined as the interval between two subsequent births <33 months: yes, no), while the outcome variables were neonatal mortality (defined as mortality within 28 days of birth: yes, no), infant mortality (defined as mortality within 1 year of birth: yes, no), and under-five mortality (defined as mortality within 5 years of birth: yes, no). Multilevel Poisson regression based on inverse probability treatment weights was used to determine the association between exposure and outcome variables.

RESULTS

The prevalence rates of neonatal, infant, and under-five mortality were 48.8, 30.8, and 23.1 per 1000 live births, respectively. Newborns of SBI mothers were found to have a 63% higher likelihood of neonatal mortality (aPR, 1.63; 95% CI, 1.08-2.46) compared to newborns of non-SBI mothers. Furthermore, the prevalence of infant mortality and under-five mortality was 1.45 times higher (aPR, 1.45; 95% CI, 1.01-2.08) and 2.82 times higher (aPR, 2.82; 95% CI, 2.16-3.70), respectively, among babies born in a short interval of their immediately preceding sibling as compared to babies born in a normal interval of their immediately preceding sibling.

CONCLUSIONS

Findings of this study indicate that SBI is an important predictor of child mortality. Consequently, around 1 million children born in a short interval every year in Bangladesh are at risk of dying before reaching their fifth birthday. This indicates a challenge for Bangladesh to achieve the SDG 3 target to reduce neonatal and under-five mortality to 12 and 25 deaths per 1000 live births, respectively. Hence, awareness-building programs about the adverse effects of SBI and strengthening existing healthcare facilities are important.

Scaling up the "24/7 BHU" strategy to provide round-the-clock maternity care in Punjab, Pakistan: a theory-driven, coproduced implementation study

BACKGROUND

Pakistan's maternal mortality rate remains persistently high at 186/100,000 live births. The country's government-run first-level healthcare facilities, the basic health units (BHUs), are an important source of maternity care for rural women. However,BHUsonly operate on working days from 8:00 am to 2:00 pm. Recognizing that this severely constrains access to maternity services, the government is implementing the "24/7 BHU" initiative to upgrade BHUs to provide round-the-clock care. Although based on a successful pilot project, initial reports reveal challenges in scaling up the initiative. This implementation research project aims to address a key concern of the Government of Punjab: How can the 24/7 BHU initiative be successfully implemented at scale to provide high-quality, round-the-clock skilled maternity care in rural Punjab?

METHODS

The project consists of two overlapping work packages (WP). WP1 includes three modules generating data at the directorate, district and BHU levels. Module 1 uses document analysis and policy-maker interviews to explicateprogrammetheory and begin to build a system model. Module 2 compares government-collected data with data generated from a survey of 1500 births to assess BHU performance. Module 3 uses institutional ethnographies in 4-5 BHUs in three districts to provide a detailed system for understanding and identifying processes that influence scale-up. WP2 includes two modules. First, two workshops and regular meetings with stakeholders integrate WP1 findings, identify feasible changes and establish priorities. Next, "change ideas" are selected for testing in one district and 2-3 BHUs through carefully documented pilots using the PDSA (plan-do-study-act) improvement approach. An integrated knowledge translation approach will engage key policy and practice stakeholders throughout the project.

DISCUSSION

This theory-driven implementation research project willcoproducesignificant new understandings of the wider system in which the 24/7 BHU initiative is being implemented, and actionable knowledge that will highlight ways the implementation processes might be modified to enable BHUs to meet service provision goals. This study will also produce insights that will be relevant for other South Asian and low- and middle-income countries (LMICs) that experience similar challenges of programme scale-up and delivery of maternal health services to remote and marginalized communities.

Timing of neonatal mortality and severe morbidity during the postnatal period: a systematic review

OBJECTIVE

The objective of this review was to determine the timing of overall and cause-specific neonatal mortality and severe morbidity during the postnatal period (1-28 days).

INTRODUCTION

Despite significant focus on improving neonatal outcomes, many newborns continue to die or experience adverse health outcomes. While evidence on neonatal mortality and severe morbidity rates and causes are regularly updated, less is known on the specific timing of when they occur in the neonatal period.

INCLUSION CRITERIA

This review considered studies that reported on neonatal mortality daily in the first week; weekly in the first month; or day 1, days 2-7, and days 8-28. It also considered studies that reported on timing of severe neonatal morbidity. Studies that reported solely on preterm or high-risk infants were excluded, as these infants require specialized care. Due to the available evidence, mixed samples were included (eg, both preterm and full-term infants), reflecting a neonatal population that may include both low-risk and high-risk infants.

METHODS

MEDLINE, Embase, Web of Science, and CINAHL were searched for published studies on December 20, 2019, and updated on May 10, 2021. Critical appraisal was undertaken by 2 independent reviewers using standardized critical appraisal instruments from JBI. Quantitative data were extracted from included studies independently by 2 reviewers using a study-specific data extraction form. All conflicts were resolved through consensus or discussion with a third reviewer. Where possible, quantitative data were pooled in statistical meta-analysis. Where statistical pooling was not possible, findings were reported narratively.

RESULTS

A total of 51 studies from 36 articles reported on relevant outcomes. Of the 48 studies that reported on timing of mortality, there were 6,760,731 live births and 47,551 neonatal deaths with timing known. Of the 34 studies that reported daily deaths in the first week, the highest proportion of deaths occurred on the first day (first 24 hours, 38.8%), followed by day 2 (24-48 hours, 12.3%). Considering weekly mortality within the first month (n = 16 studies), the first week had the highest mortality (71.7%). Based on data from 46 studies, the highest proportion of deaths occurred on day 1 (39.5%), followed closely by days 2-7 (36.8%), with the remainder occurring between days 8 and 28 (23.0%). In terms of causes, birth asphyxia accounted for the highest proportion of deaths on day 1 (68.1%), severe infection between days 2 and 7 (48.1%), and diarrhea between days 8 and 28 (62.7%). Due to heterogeneity, neonatal morbidity data were described narratively. The mean critical appraisal score of all studies was 84% (SD = 16%).

CONCLUSION

Newborns experience high mortality throughout the entire postnatal period, with the highest mortality rate in the first week, particularly on the first day. Ensuring regular high-quality postnatal visits, particularly within the first week after birth, is paramount to reduce neonatal mortality and severe morbidity.

Progress towards achieving child survival goals in Kenya after devolution: Geospatial analysis with scenario-based projections, 2015-2025

Subnational projections of under-5 mortality (U5M) have increasingly become an essential planning tool to support Sustainable Development Goals (SDGs) agenda and strategies for improving child survival. To support child health policy, planning, and tracking child development goals in Kenya, we projected U5M at units of health decision making. County-specific annual U5M were estimated using a multivariable Bayesian space-time hierarchical model based on intervention coverage from four alternate intervention scale-up scenarios assuming 1) the highest subnational intervention coverage in 2014, 2) projected coverage based on the fastest county-specific rate of change observed in the period between 2003-2014 for each intervention, 3) the projected national coverage based on 2003-2014 trends and 4) the country-specific targets of intervention coverage relative to business as usual (BAU) scenario. We compared the percentage change in U5M based on the four scale-up scenarios relative to BAU and examined the likelihood of reaching SDG 3.2 target of at least 25 deaths/1,000 livebirths by 2022 and 2025. Projections based on 10 factors assuming BAU, showed marginal reductions in U5M across counties with all the counties except Mandera county not achieving the SDG 3.2 target by 2025. Further, substantial reductions in U5M would be achieved based on the various intervention scale-up scenarios, with 63.8% (30), 74.5% (35), 46.8% (22) and 61.7% (29) counties achieving SDG target for scenarios 1,2,3 and 4 respectively by 2025. Scenario 2 yielded the highest reductions of U5M with individual scale-up of access to improved water, recommended treatment of fever and accelerated HIV prevalence reduction showing considerable impact on U5M reduction (≥ 20%) relative to BAU. Our results indicate that sustaining an ambitious intervention scale-up strategy matching the fastest rate observed between 2003-2014 would substantially reduce U5M in Kenya. However, despite this ambitious scale-up scenario, 25% (12 of 47) of the Kenya's counties would still not achieve SDG 3.2 target by 2025.

Establishing communities of practice to improve health policy, systems and reproductive, maternal, newborn, child and adolescent health in West Africa

Objectives

To explore and analyse factors that facilitate and inhibit the initiation and functioning of a national and transnational Community of Practice (CoP) for health policy and systems (HPS) and Reproductive, Maternal, New-born, Child and Adolescent Health (RMNCAH) in West Africa and to identify lessons for CoP interventions in similar multilingual low and middle-income contexts.

Design

A case study, with the case defined as processes, enablers and barriers to the initiation and functioning of a national and transnational CoP for HSP and RMNCAH in West Africa and drawing on a review and analysis of secondary data from the program, workshop, country team and project reports, and training sessions.

Setting

The Economic Community of West African States (ECOWAS).

Participants

Professionals from two Anglophone (Ghana and Sierra Leone) and four Francophone (Burkina Faso, Cote d'Ivoire, Niger e Senegal) ECOWAS countries.

Interventions

Training and mentoring of multi-disciplinary country teams supported by small research grants to undertake formative evaluation and advocacy of priority HPS and RMNCAH issues; support for CoP development within and across country teams.

Results

The desire to learn from peers and mentors was a major enabler of the process. Human and financial resource availability, competing demands for time, communication in the context of a Francophone-Anglophone official language divide and the arrival of COVID-19 were all constraints.

Conclusions

This study highlights the processes, achievements, and challenges of establishing country-level and transnational CoPs in West Africa. CoPs require sustained human and financial resource investments, communication and medium-to-long-term implementation support for sustainability and impact.

Funding

None declared.

Evaluations of effective coverage of maternal and child health services: A systematic review

Conventionally used coverage measures do not reflect the quality of care. Effective coverage (EC) assesses the extent to which health care services deliver potential health gains to the population by integrating concepts of utilization, need and quality. We aimed to conduct a systematic review of studies evaluating EC of maternal and child health services, quality measurement strategies and disparities across wealth quantiles. A systematic search was performed in six electronic databases [MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), Scopus, Web of Science and Maternity and Infant Care] and grey literature. We also undertook a hand search of references. We developed search terms having no restrictions based on publication period, country or language. We included studies which reported EC estimates based on the World Health Organization framework of measuring EC. Twenty-seven studies, all from low- and middle-income settings (49 countries), met the criteria and were included in the narrative synthesis of the results. Maternal and child health intervention(s) and programme(s) were assessed either at an individual level or as an aggregated measure of health system performance or both. The EC ranged from 0% for post-partum care to 95% for breastfeeding. When crude coverage measures were adjusted to account for the quality of care, the EC values turned lower. The gap between crude coverage and EC was as high as 86%, and it signified a low quality of care. The assessment of the quality of care addressed structural, process and outcome domains individually or combined. The wealthiest 20% had higher EC of services than the poorest 20%, an inequitable distribution of coverage. More efforts are needed to improve the quality of maternal and child health services and to eliminate the disparities. Moreover, considering multiple dimensions of quality and the use of standard measurements are recommended to monitor coverage effectively.

Uptake, Engagement and Acceptance, Barriers and Facilitators of a Text Messaging Intervention for Postnatal Care of Mother and Child in India-A Mixed Methods Feasibility Study

This study aimed to test the feasibility and to identify barriers and facilitators towards adherence of a text messaging intervention for postnatal care in India. Mixed methods research involving both quantitative and qualitative methods were used. A survey questionnaire for feasibility and focus group interviews to identify the barriers and facilitators to the intervention were conducted. The top three reasons for activation of service were: helped the new mother to understand the changes (95%); provided continuation of care (90%) and clarified conflicting information (89%). Over 90% read the messages daily. 80% were happy with the message frequency. About 75% shared the content with others. The main reasons for non-activation were: 30% had technical issues, 15% did not think it would be useful, 17% did not have time to activate and for 5%, husbands made the decision. These findings were triangulated through the qualitative focus groups. The main themes identified via the focus groups were: (1) reliable, current information; (2) issues and themes well aligned with new mothers' needs and priorities; (3) expanded the repertoire of information sources available; and (4) high-quality accessible information. The satisfaction and trust rates were high. This technology may be useful for health information intervention in specific postnatal areas.

Impact of Quality Improvement Bundle on Neonatal Mortality in a District Hospital in Tanzania

Background: The poor quality of care received by mothers and neonates in many limited-resource countries represents a main determinant of newborn mortality. Small and sick hospitalized newborns are the highest-risk population, and they should be one of the prime beneficiaries of quality-of-care interventions. This study aimed to evaluate the impact on neonatal mortality of quality improvement interventions which were implemented at Tosamaganga Council Designated Hospital, Iringa, Tanzania, between 2016 and 2020. Methods: A retrospective comparison between pre- and post-intervention periods was performed using the chi-square test and Fisher’s exact test. Effect sizes were reported as odds ratios with 95% confidence intervals. Results: The analysis included 5742 neonates admitted to the Special Care Unit (2952 in the pre-intervention period and 2790 in the post-intervention period). A decrease in mortality among infants with birth weight between 1500 and 2499 g (overall: odds ratio 0.49, 95% confidence interval 0.27–0.87; inborn: odds ratio 0.50, 95% confidence interval 0.27–0.93) was found. The analysis of cause-specific mortality showed a decrease in mortality for asphyxia (odds ratio 0.33, 95% confidence interval 0.12–0.87) among inborn infants with birth weight between 1500 and 2499 g. Conclusions: A quality improvement intervention was associated with decreased mortality among infants with birth weight between 1500 and 2499 g. Further efforts are needed to improve prognosis in very-low-birth-weight infants.

An equity analysis on the household costs of accessing and utilising maternal and child health care services in Tanzania

BACKGROUND

Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap.

METHODS

We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index.

RESULTS

71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients.

CONCLUSIONS

Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility's construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration.

Effect of integrated nutrition-sensitive and nutrition-specific intervention package on maternal malnutrition among pregnant women in Rwanda

Maternal undernutrition remains a major public health concern in Rwanda despite significant gains and progress. An integration of nutrition‐specific and nutrition‐sensitive interventions was implemented in five districts of Rwanda to improve maternal and child nutrition. The package included nutrition education and counselling, promotion of agricultural productivity, promotion of financial literacy/economic resilience and provision of Water, Hygiene and Sanitation services. However, there is limited evidence about the effect of such interventions in reducing maternal undernutrition. A postintervention quasi‐experimental study was conducted among pregnant women to determine the effect of the integrated intervention on their nutritional status. It was carried out in two intervention districts, namely Kicukiro and Kayonza, and two control districts, namely Gasabo and Gisagara between November 2020 and June 2021. Five hundred and fifty‐two women were recruited for the intervention arm, while 545 were recruited for the control arm. Maternal undernutrition was defined as either having low mid‐upper arm circumference (<23 cm) during delivery or low body mass index (<18.5 kg/m²) in the first trimester or both. A multivariable logistic regression model was used to assess the effect of the integrated interventions. The prevalence of maternal undernutrition was significantly lower in the intervention group compared with the control group (4.7% vs. 18.2%; p < 0.001). After controlling the potential confounders, the risk of maternal undernutrition was 77.0% lower in the intervention group than in the control group [adjusted odds ratio= 0.23; 95% confidence interval = 0.15–0.36; p < 0.001]. Further studies are therefore recommended to establish causation and inform the potential scale‐up of these interventions nationally in Rwanda.

Empirical evidence on the effect of integrated nutrition‐specific and nutrition‐sensitive interventions on maternal undernutrition is limited as existing studies are mainly directed at the effectiveness of nutritional interventions on improving child nutritional status.

The results indicated that the integrated nutrition‐specific and nutrition‐sensitive intervention package was significantly associated with low maternal undernutrition.

This study adds more evidence to the 2008, 2013 and 2021 Lancet Series regarding the proposed effectiveness of integrated nutrition‐sensitive and nutrition‐specific interventions.

Further research should focus on follow‐up randomized controlled trials and the cost‐effectiveness of these integrated nutrition‐specific and nutrition‐sensitive interventions.

Geospatial mapping of timely access to inpatient neonatal care and its relationship to neonatal mortality in Kenya

Globally, 2.4 million newborns die in the first month of life, with neonatal mortality rates (NMR) per 1,000 livebirths being highest in sub-Saharan Africa. Improving access to inpatient newborn care is necessary for reduction of neonatal deaths in the region. We explore the relationship between distance to inpatient hospital newborn care and neonatal mortality in Kenya. Data on service availability from numerous sources were used to map hospitals that care for newborns with very low birth weight (VLBW). Estimates of livebirths needing VLBW services were mapped from population census data at 100 m spatial resolution using a random forest algorithm and adjustments using a systematic review of livebirths needing these services. A cost distance algorithm that adjusted for proximity to roads, road speeds, land use and protected areas was used to define geographic access to hospitals offering VLBW services. County-level access metrics were then regressed against estimates of NMR to assess the contribution of geographic access to VLBW services on newborn deaths while controlling for wealth, maternal education and health workforce. 228 VLBW hospitals were mapped, with 29,729 births predicted as requiring VLBW services in 2019. Approximately 80.3% of these births were within 2 hours of the nearest VLBW hospital. Geographic access to these hospitals, ranged from less than 30% in Wajir and Turkana to as high as 80% in six counties. Regression analysis showed that a one percent increase in population within 2 hours of a VLBW hospital was associated with a reduction of NMR by 0.24. Despite access in the country being above the 80% threshold, 17/47 counties do not achieve this benchmark. To reduce inequities in NMR in Kenya, policies to improve care must reduce geographic barriers to access and progressively improve facilities' capacity to provide quality care for VLBW newborns.

Mapping BCG vaccination coverage in Ethiopia between 2000 and 2019

Introduction

The Bacille-Calmette–Guerin (BCG) vaccination remains the primary strategy to prevent severe disseminated TB in young children, particularly in high TB-burden countries such as Ethiopia. Accurate knowledge of vaccination coverage in small geographical areas is critically important to developing targeted immunization campaigns. Thus, this study aimed to investigate the spatiotemporal distributions and ecological level determinants of BCG vaccination coverage in Ethiopia.

Method

Bacille-Calmette–Guerin immunization coverage and geographical information data were obtained from five different Demographic and Health Surveys, conducted in Ethiopia between 2000 and 2019. Data for independent variables were obtained from publicly available sources. Bayesian geostatistical models were used to predict the spatial distribution of BCG vaccination coverage in Ethiopia.

Result

The overall national BCG vaccination coverage between 2000 and 2019 was 65.5%. The BCG vaccine coverage was 53.5% in 2000, 56.9% in 2005, 64.4% in 2011, 79.6% in 2016, and 79.0% in 2019. BCG vaccination coverage increased by 47.6% in Ethiopia from 2000 to 2019, but substantial geographical inequalities in BCG coverage remained at sub-national and local levels. High vaccination coverage was observed in northern, western, and central parts of Ethiopia. Climatic and demographic factors such as temperature, altitude, and population density were positively associated with BCG vaccination coverage. Whereas, healthcare access factors such as distance to health facilities and travel time to the nearest cities were negatively associated with BCG vaccine coverage in Ethiopia.

Conclusion

Despite substantial progress in national BCG vaccination coverage, marked spatial variation in BCG coverage persists throughout the country at sub-national and local levels. Healthcare access and climatic and demographic factors determined the spatial distribution of BCG vaccination coverage. Maintaining a high level of vaccination coverage across geographical areas is important to prevent TB in Ethiopia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07547-4.

On the road to universal coverage of postnatal care: considerations for a targeted postnatal care approach for at-risk mother-baby dyads in low-income and middle-income countries informed by a consultation with global experts

INTRODUCTION

The potential of timely, quality postnatal care (PNC) to reduce maternal and newborn mortality and to advance progress toward universal health coverage (UHC) is well-documented. Yet, in many low-income and middle-income countries, coverage of PNC remains low. Risk-stratified approaches can maximise limited resources by targeting mother-baby dyads meeting the evidence-based risk criteria which predict poor postnatal outcomes.

OBJECTIVES

To review evidence-based risk criteria for identification of at-risk mother-baby dyads, drawn from a literature review, and to identify key considerations for their use in a risk-stratified PNC approach.

DESIGN/SETTING/PARTICIPANTS

A virtual, semi-structured group discussion was conducted with maternal and newborn health experts on Zoom. Participants were identified through purposive sampling based on content and context expertise.

RESULTS

Seventeen experts, (5 men and 12 women), drawn from policymakers, implementing agencies and academia participated and surfaced several key themes. The identified risk factors are well-known, necessitating accelerated efforts to address underlying drivers of risk. Risk-stratified PNC approaches complement broader UHC efforts by providing an equity lens to identify the most vulnerable mother-baby dyads. However, these should be layered on efforts to strengthen PNC service provision for all mothers and newborns. Risk factors should comprise context-relevant, operationalisable, clinical and non-clinical factors. Even with rising coverage of facility delivery, targeted postnatal home visits still complement facility-based PNC.

CONCLUSION

Risk-stratified PNC efforts must be considered within broader health systems strengthening efforts. Implementation research at the country level is needed to understand feasibility and practicality of clinical and non-clinical risk factors and identify unintended consequences.

Determinants of maternal healthcare service utilisation among Indonesian mothers: A population-based study

Background: In Indonesia, maternal health care services are widely available, aiming to improve health and survival among mothers. However, these services remain underutilised, and its determining factor was unknown. This study sought to identify determinant factors of maternal healthcare services utilisation among Indonesian mothers.

Methods: This population-based cross-sectional study leveraged the 2017 Indonesia Demographic and Health Survey data. A total of 12,033 mothers aged from 15 to 49 years who had a live birth in the five years preceding the survey were included in the analysis. Multivariable logistic regressions were used to identify the determinant factors.

Results: Approximately 93.44% of the mothers had adequate antenatal care, 83.73% had a delivery at the healthcare facility, and 71.46% received postnatal care. The mother’s age and household wealth index were the typical determinants of all maternal healthcare services. Determinants of antenatal care visits were husband’s occupational status, the number of children, and access to the healthcare facility. Next, factors that drive mothers’ delivery at the healthcare facility were the mother’s education level, husband’s educational level, and residential area. The use of postnatal care was determined by the mother’s occupational status, husband’s educational level, number of children, wealth index, access to the healthcare facility, and residential area.

Conclusions: The utilisation of each maternal healthcare service was determined by various socio-structural and intermediary determinants, but the mother’s age and household wealth index were emerged as the typical determinants of all maternal healthcare services. Providing maternal healthcare services that are adjusted and tuned with these socio determinant factors may ensure that mothers can adequately utilise each service.

Equity in antenatal care visits among adolescent mothers: An analysis of 54 country levels trend and projection of coverage from 2000 to 2030

Background

Ensuring utilization of antenatal care (ANC) services by adolescent mothers (ages 10-19) is an enormous challenge in low-and middle-income countries (LMICs). This study provides the first comprehensive analysis of ANC visits among adolescent and adult mothers.

Methods

Using all available Demographic and Health Survey and Multiple Indicator Cluster Surveys between 2000 and 2019 in 54 LMICs, we estimated proportion of ANC visits among women. Bayesian hierarchical regression models were used to estimate trend, projection, and determinants of single and four ANC visits (ANC1 and ANC4) independently. Equity analysis were performed to assess the magnitude of wealth-based and urban-rural inequalities in access to ANC visits.

Results

Compared to women aged 36-49 years, coverage of ANC1 and ANC4 are expected to increase significantly for adolescent mothers and women aged 20-35 years. This increase was observed at the national level, as well as both urban and rural areas in most countries between 2000 and 2030. By 2030, the coverage of ANC1 is predicted to reach 80% or more in all countries except Angola, Central African Republic and Togo, whereas only 16 countries are predicted to reach 80% or more for ANC4. According to wealth quintile, the lowest inequalities with highest coverage of 80% or more ANC4 will be observed in Armenia, Cambodia, Dominican Republic, Ghana, Maldives, Indonesia, and Sao Tome and Principe in 2030. Determinant analysis found increased odds of receiving ANC visits during pregnancy for adolescent mothers with higher educational levels, frequency of listening/watching mass media, and various household socio-economic status factors.

Conclusions

This study calls for advanced, innovative and cost-effective approaches to increase ANC coverage among adolescent mothers, particularly in rural areas and/or in low socioeconomic groups.

Timing of maternal mortality and severe morbidity during the postpartum period

Objective:

The objective of this review was to determine the timing of overall and cause-specific maternal mortality and severe morbidity during the postpartum period.

Introduction:

Many women continue to die or experience adverse health outcomes in the postpartum period; however, limited work has explored the timing of when women die or present complications during this period globally.

Inclusion criteria:

This review considered studies that reported on women after birth up to 6 weeks postpartum and included data on mortality and/or morbidity on the first day, days 2–7, and days 8–42. Studies that reported solely on high-risk women (eg, those with antenatal or intrapartum complications) were excluded, but mixed population samples were included (eg, low-risk and high-risk women).

Methods:

MEDLINE, Embase, Web of Science, and CINAHL were searched for published studies on December 20, 2019, and searches were updated on May 11, 2021. Critical appraisal was undertaken by 2 independent reviewers using standardized critical appraisal instruments from JBI. Quantitative data were extracted from included studies independently by at least 2 reviewers using a study-specific data extraction form. Quantitative data were pooled, where possible. Identified studies were used to obtain the summary estimate (proportion) for each time point. Maternal mortality was calculated as the maternal deaths during a given period over the total number of maternal deaths known during the postpartum period. For cause-specific analysis, number of deaths due to a specific cause was the numerator, while the total number of women who died due to the same cause in that period was the denominator. Random effects models were run to pool incidence proportion for relative risk of overall maternal deaths. Subgroup analysis was conducted according to country income classification and by date (ie, data collection before or after 2010). Where statistical pooling was not possible, the findings were reported narratively.

Results:

A total of 32 studies reported on maternal outcomes from 17 reports, all reporting on mixed populations. Most maternal deaths occurred on the first day (48.9%), with 24.5% of deaths occurring between days 2 and 7, and 24.9% occurring between days 8 and 42. Maternal mortality due to postpartum hemorrhage and embolism occurred predominantly on the first day (79.1% and 58.2%, respectively). Most deaths due to postpartum eclampsia and hypertensive disorders occurred within the first week (44.3% on day 1 and 37.1% on days 2–7). Most deaths due to infection occurred between days 8 and 42 (61.3%). Due to heterogeneity, maternal morbidity data are described narratively, with morbidity predominantly occurring within the first 2 weeks. The mean critical appraisal score across all included studies was 85.9% (standard deviation = 13.6%).

Conclusion:

Women experience mortality throughout the entire postpartum period, with the highest mortality rate on the first day. Access to high-quality care during the postpartum period, including enhanced frequency and quality of postpartum assessments during the first 42 days after birth, is essential to improving maternal outcomes and to continue reducing maternal mortality and morbidity worldwide.

Systematic review registration number:

PROSPERO CRD42020187341

Trend and projection of skilled birth attendants and institutional delivery coverage for adolescents in 54 low- and middle-income countries, 2000-2030

BACKGROUND

Limitations to accessing delivery care services increase the risks of adverse outcomes during pregnancy and delivery for all pregnant women, particularly among adolescents in LMICs. In order to inform adolescent-specific delivery care initiatives and coverage, we conducted a comprehensive analysis of trends, projections and inequalities in coverage of delivery care services among adolescents at national, urban-rural and socio-economic levels in LMICs.

METHODS

Using 224 nationally representative cross-sectional survey data between 2000 and 2019, we estimated the coverage of institutional delivery (INSD) and skilled birth attendants (SBA). Bayesian hierarchical regression models were used to estimate trends, projections and determinants of INSD and SBA.

RESULTS

Coverage of delivery care services among adolescents increased substantially at the national level, as well as in both urban and rural areas in most countries between 2000 and 2018. Of the 54 LMICs, 24 countries reached 80% coverage of both INSD and SBA in 2018, and predictions for 40 countries are set to exceed 80% by 2030. The trends in coverage of INSD and SBA of adult mothers mostly align with those for adolescent mothers. Our findings show that urban-rural and wealth-based inequalities to delivery care remain persistent by 2030. In 2018, urban settings across 54 countries had higher rates of coverage exceeding 80% compared to rural for both INSD (45 urban, 16 rural) and SBA (50 urban, 19 rural). Several factors such as household head age ≥ 46 years, household head being female, access to mass media, lower parity, higher education, higher ANC visits and higher socio-economic status could increase the coverage of INSD and SBA among adolescents and adult women.

CONCLUSIONS

More than three-quarters of the LMICs are predicted to achieve 80% coverage of INSD and SBA among adolescent mothers in 2030, although with sustained inequalities.

Low utilisation of postnatal care among women with unwanted pregnancy: A challenge for Bangladesh to achieve Sustainable Development Goal targets to reduce maternal and newborn deaths

Pregnancy complications are the major cause of maternal and newborn deaths in low- and middle-income countries that are more frequently associated with unintended pregnancy. The World Health Organization (WHO) recommends postnatal care (PNC) for women and their newborns within 24 hr of birth to prevent pregnancy complications and associated adverse outcomes. We, therefore, examined the relationship between unintended pregnancy and PNC use in Bangladesh. Data from 4,493 women and newborn dyads were extracted from the 2014 Bangladesh Demographic and Health Survey and analysed. PNC was classified as: no PNC; some level of PNC (either the woman or her newborn missed PNC within 24 hr of birth but had at least one PNC visit within 42 days of birth); and WHO's recommended level of PNC (at least one PNC use for both the woman and her child within 24 hr of birth). Pregnancy intention at conception for the last live birth was categorised as wanted, mistimed or unwanted. Multilevel multinomial logistic regression modelling was used to assess the association between pregnancy intention and PNC use, adjusting for possible confounders. We found around 27% of participants had adhered to WHO's PNC use recommendations. Around 26% of pregnancies that resulted in live births were unintended at conception, including 15% of which were classified as mistimed and 11% as unwanted. Following adjustment of confounders, a 37% (OR = 0.63, 95% CI: 0.47-0.85) lower odds of using WHO's recommended level of PNC and a 33% (OR, 95% CI, 0.49-0.93) lower odds of some level of PNC were found for pregnancies that were unwanted relative to those that were wanted. No association was found between mistimed pregnancy and PNC use. Strengthening healthcare facilities and improving the linkage between women and existing healthcare facilities are important to ensure WHO's PNC recommendations are met for women experiencing an unwanted pregnancy.

Knowledge translation strategies for policy and action focused on sexual, reproductive, maternal, newborn, child and adolescent health and well-being: a rapid scoping review

OBJECTIVE

The aim of this study was to identify knowledge translation (KT) strategies aimed at improving sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) and well-being.

DESIGN

Rapid scoping review.

SEARCH STRATEGY

A comprehensive and peer-reviewed search strategy was developed and applied to four electronic databases: MEDLINE ALL, Embase, CINAHL and Web of Science. Additional searches of grey literature were conducted to identify KT strategies aimed at supporting SRMNCAH. KT strategies and policies published in English from January 2000 to May 2020 onwards were eligible for inclusion.

RESULTS

Only 4% of included 90 studies were conducted in low-income countries with the majority (52%) conducted in high-income countries. Studies primarily focused on maternal newborn or child health and well-being. Education (81%), including staff workshops and education modules, was the most commonly identified intervention component from the KT interventions. Low-income and middle-income countries were more likely to include civil society organisations, government and policymakers as stakeholders compared with high-income countries. Reported barriers to KT strategies included limited resources and time constraints, while enablers included stakeholder involvement throughout the KT process.

CONCLUSION

We identified a number of gaps among KT strategies for SRMNCAH policy and action, including limited focus on adolescent, sexual and reproductive health and rights and SRMNCAH financing strategies. There is a need to support stakeholder engagement in KT interventions across the continuum of SRMNCAH services. Researchers and policymakers should consider enhancing efforts to work with multisectoral stakeholders to implement future KT strategies and policies to address SRMNCAH priorities.

REGISTRATION

The rapid scoping review protocol was registered on Open Science Framework on 16 June 2020 (https://osf.io/xpf2k).