Assessment of obstetric and neonatal health services in developing country health facilities

A narrative review of course evaluation methods for continuing professional development: The case of paediatric and neonatal acute-care in-service courses in low and lower-middle income countries: BEME Guide No. 76

BACKGROUND

Training a skilled healthcare workforce is an essential part in reaching the United Nations Sustainable Development Goal to end preventable deaths in children and neonates. The greatest burden of mortality lies in low and lower-middle income countries (LLMIC). Short term, in-service courses have been implemented in many LLMIC to improve the quality of care delivered, but the evaluation methods of these courses are inconsistent.

METHOD

Studies describing evaluations of course and outcome measures were included if the course lasted seven days or less with postgraduate participants, included paediatric or neonatal acute or emergency training and was based in a LLMIC. This narrative review provides a detailed description of evaluation methods of course content, delivery and outcome measures based on 'Context, Input, Process and Product' (CIPP) and Kirkpatrick models.

RESULTS

5265 titles were screened with 93 articles included after full-text review and quality assessment. Evaluation methods are described: context, input, process, participant satisfaction, change in learning, behaviour, health system infrastructure and patient outcomes.

CONCLUSIONS

Outcomes, including mortality and morbidity, are rightly considered the fundamental aim of acute-care courses in LLMIC. Course evaluation can be difficult, especially with low resources, but this review outlines what can be done to guide future course organisers in providing well-conducted courses with consistent outcome measures for maximum sustainable impact.

Neonatal resuscitation from a global perspective

The majority of perinatal and neonatal mortality occurs in low-resource settings in low- and middle-income countries. Access and quality of care at delivery are major determinants of the health and survival of newborn infants. Availability of basic neonatal resuscitation care at birth has improved, but basic neonatal resuscitation at birth or high-quality care continues to be inaccessible in some settings, leading to persistently high perinatal and neonatal mortality. Low-resource settings of high-income countries and socially disadvantaged communities also suffer from inadequate access to quality perinatal healthcare. Quality improvement, implementation research, and innovation should focus on improving the quality of perinatal healthcare and perinatal and neonatal outcomes in low-resource settings. The current review presents an update on issues confronting universal availability of optimal resuscitation care at birth and provides an update on ongoing efforts to address them.

An economic analysis of the cost of survival of micro preemies: A systematic review

OBJECTIVE

This study aimed to systematically review the current literature on the economic costs of micro preemie as well as evidence on the cost-effectiveness of interventions to improve outcomes for micro preemie babies with a birth weight of ≤500 g.

METHOD

We searched MEDLINE, CINAHL, Scopus, ECONLIT, Business Source Premier and Cochrane Library for studies reporting costs of micro preemie from January 2000. Costs were inflated to 2019 United States dollars (US$). All full-text articles were assessed for eligibility and a quality assessment of included articles was conducted using the Drummond and the Larg and Moss checklists.

RESULTS

The search identified three studies that met the inclusion criteria; two cost-of-illness studies and one cost-effectiveness study. Across studies, the mean healthcare spending per micro preemie survivor (in 2019 US$) ranged from US$61,310 (birth admission) to US$263,958 (inpatient and outpatient for the first six months of life). One modelling study reported exclusive human milk diet for micro preemies at birth was more cost-effective compared to the standard approach with cow milk diet from the third-party payer and societal perspectives.

CONCLUSION

Despite significant advances in perinatal care and expanded access to life-saving equipment to improve survival outcomes of micro preemie, there remains a paucity of research on economic costs associated with these babies. No study has utilised quality-adjusted life-years as an outcome measure. Given the chronic conditions and long-term neurologic disability associated with micro preemie survivors, an estimate of the lifetime cost to the individual, healthcare providers and society would provide a benchmark of the potential cost-savings that could accrue from cost-effective interventions to improve the survival rate of micro preemies.

Evolution in caesarean section practices in North Kivu: Impact of caregiver training

INTRODUCTION

A caesarean section is a major obstetric procedure that can save the life of mother and child. Its purpose is to protect the mother's health from the complications of childbirth and to protect the baby's health. In sub-Saharan Africa (SSA), there are major inequalities in access to caesarean sections and significant variations in practices to determine the indications for the procedure. Periodic analyses of maternal deaths have shown that more than half of maternal and new born deaths are due to suboptimal care and are therefore potentially preventable. The objective of our study is to assess the impact of health staff training under the PADISS project (to support the health system's integrated development) on the quality of CS procedures in North Kivu, by comparing two periods.

MATERIAL AND METHODS

The populations compared were recruited from the referral hospitals in North Kivu, DRC (Democratic Republic of Congo). The first (group 1) was made up of patient files studied retrospectively for the period from 01/11/2013 to 01/01/2016. The second group (group 2), studied prospectively, comprised patient files from June 2019 to January 2020. Obstetric, maternal and foetal data were compared. Statistical analyses were performed using STATA/IC 15.0 for Windows. Univariate and multiple logistic regression was performed to determine which characteristics are associated with maternal and perinatal morbidity and mortality. A p value < 0.05 was considered statistically significant.

RESULTS

CS frequency was approximately 17% in both study periods. We observed a CS frequency of about 34% at North Kivu provincial hospital for the two populations studied. The main indications for CS were dystocia, foetal distress and scarred uterus for both populations. In the population studied prospectively, after the implementation of health staff training, there were fewer incidence rate of dystocia, foetal distress and neonatal death, a more complete patient record, shorter hospital stay, and fewer blood transfusions but more incidence rate of scarred uterus, post-operative complications and low birth weight. Intervention had no statistically significant impact on low birth weight (OR = 1.9, p = 0.13), on neonatal mortality (OR = 0.69, p = 0.21).

CONCLUSION

Our study shows a decrease in neonatal deaths, dystocia and foetal distress, but an increase in post-operative complications, maternal deaths and cases of scarred uterus and low birth weight. However, multiple logistic regression did no support the conclusion.

Assessment of service readiness for maternity care in primary health centres in rural Nigeria: implications for service improvement

Introduction

several scientific reports from studies across Nigeria revealed a higher incidence of maternal mortality in rural parts of the country as compared to the urban areas. Part of the reasons is the paucity of health care infrastructure and personnel. This study was designed as part of an intervention program with the goal to improve the access of pregnant women to skilled pregnancy care in rural Nigeria. The specific objective of the study was to determine the nature and readiness of Primary Health Centres (PHCs) in two Local Government Areas (LGAs) in rural parts of Edo State, Southern Nigeria to deliver effective maternal and child health services.

Methods

the study was conducted in 12 randomly selected PHCs in the two LGAs. Data were obtained with a semi-structured questionnaire administered on health workers and through direct observation and verification of the facilities in the PHCs. The results obtained were compared with the national standards established for PHCs in Nigeria by the National Primary Health Care Development Agency (NPHCDA). Descriptive statistics were used to analyze the data.

Results

the results showed severe deficits in buildings and premises, rooms, medical equipment, essential drugs, and personnel. Only 40% of items recommended by the NPHCDA were available for buildings; 41% of the PHCs had facilities available in the labour ward; while less than 30% had the recommended facilities in the antenatal care rooms. Only one PHC had a laboratory space, with only one item (a dipstick for urine analysis) identified in the laboratory. None of the PHCs had ambulances, mobile phones, internet or computers. There was no nurse/midwife in 4 PHCs; only one nurse/midwife each were available in 8 PHCs; while there was no Environmental/Medical Records Officer in any PHC. About 26% of the essential drugs were not available in the PHCs.

Conclusion

we conclude that PHCs in Edo State, Nigeria have severe deficits in infrastructural facilities, equipment, essential drugs and personnel for the delivery of maternal and child health care. Efforts to improve these facilities will help increase the quality of delivery of maternal and child health, and therefore reduce maternal and child mortality in the country.

Neonatal Resuscitation Research Priorities in Low- and Middle-Income Countries

Several critical physiological changes occur during birth. Optimal and timely resuscitation is essential to avoid morbidity and mortality. The International Liaison Committee on Resuscitation (ILCOR) is a multinational committee that publishes evidence-based consensus and treatment recommendations for resuscitation in various scenarios including that for neonatal resuscitation. The majority of perinatal deaths occur in low- and middle-income countries (LMICs); however, there is limited research output from LMICs to generate evidence-based practice recommendations specific for LMICs. The current review identifies key areas of neonatal resuscitation-related research needed from LMICs to inform evidence-based resuscitation of neonates in LMICs.

Human Resources for Health-Related Challenges to Ensuring Quality Newborn Care in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

A critical shortage of health workers with needed maternal and newborn competencies remains a major challenge for the provision of quality care for mothers and newborns, particularly in low- and middle-income countries. Supply-side challenges related to human resources for health (HRH) worsen shortages and can negatively affect health worker performance and quality of care. This review scoped country-focused sources to identify and map evidence on HRH-related challenges to quality facility-based newborn care provision by nurses and midwives.

METHODS

Evidence for this review was collected iteratively, beginning with pertinent World Health Organization documents and extending to articles identified via database and manual reference searches and country reports. Evidence from country-focused sources from 2000 onward was extracted using a data extraction tool that was designed iteratively; thematic analysis was used to map the 10 categories of HRH challenges.

FINDINGS

A total of 332 peer-reviewed articles were screened, of which 22 met inclusion criteria. Fourteen additional sources were added from manual reference search and gray literature sources. Evidence has been mapped into 10 categories of HRH-related challenges: (1) lack of health worker data and monitoring; (2) poor health worker preservice education; (3) lack of HW access to evidence-based practice guidelines, continuing education, and continuing professional development; (4) insufficient and inequitable distribution of health workers and heavy workload; (5) poor retention, absenteeism, and rotation of experienced staff; (6) poor work environment, including low salary; (7) limited and poor supervision; (8) low morale, motivation, and attitude, and job dissatisfaction; (9) weaknesses of policy, regulations, management, leadership, governance, and funding; and (10) structural and contextual barriers.

CONCLUSION

The mapping provides needed insight that informed new World Health Organization strategies and supporting efforts to address the challenges identified and strengthen human resources for neonatal care, with the ultimate goal of improving newborn care and outcomes.

Portable continuous wave Doppler ultrasound for primary healthcare in South Africa: can the EUnetHTA Core Model guide evaluation before technology adoption?

BACKGROUND

This study had a threefold aim: to test the value of stakeholder involvement in HTA to reduce evidence gaps and interpret findings; and to assess a medical device by applying the EUnetHTA Core Model (CM) in South Africa and thus ultimately provide a first overview of evidence for potential widespread adoption of the technology in a primary health care (PHC) setting. Used in primary healthcare setting for obstetric use, the technology under assessment is a low-cost continuous wave Doppler ultrasound (DUS).

METHODS

The scoping of the assessment was defined by involving policy makers in selecting the domains and corresponding questions relevant to the ultrasound and its use. Additionally, hospital managers were invited to respond to dichotomous questions on the criteria for procurement. To substantiate evidence obtained from an initial literature review, different stakeholders were identified and consulted. The evidence generated fromall steps was used to populate the high-ranked assessment elements of the CM.

RESULTS

The HTA on continuous-wave DUS incorporated the evidence on organizational, ethical, and social value of its use together with effectiveness, safety, and cost-effectiveness of the technology. The domains on "health problem" and "safety" had a higher rank than the rest of the nine domains. Unexplained fetal mortality is the largest single contributor to perinatal deaths in South Africa. Pregnant women in PHC setting were examined using a continuous-wave DUS, after their routine antenatal visit. The healthcare professionals interviewed, indicated the benefit in the use of continuous-wave DUS in the PHC setting and the need for training.

CONCLUSIONS

Collection and generation of evidence based on the HTA CM and the chosen decision criteria provided a generalized but structured guidance on the methodology. Several questions were not applicable for the technology and the context of its use and elimination of those that are inappropriate for the African context, resulted in a pragmatic solution. Engaging and consulting local stakeholders was imperative to understand the context, reduce evidence gaps, and address the uncertainties in the evidence, ultimately paving the way for technology adoption. Given the ongoing studies and the evolving evidence base, the potential of this technology should be reassessed.

Rates and risk factors for preterm birth and low birthweight in the global network sites in six low- and low middle-income countries

Background

Preterm birth continues to be a major public health problem contributing to 75% of the neonatal mortality worldwide. Low birth weight (LBW) is an important but imperfect surrogate for prematurity when accurate assessment of gestational age is not possible. While there is overlap between preterm birth and LBW newborns, those that are both premature and LBW are at the highest risk of adverse neonatal outcomes. Understanding the epidemiology of preterm birth and LBW is important for prevention and improved care for at risk newborns, but in many countries, data are sparse and incomplete.

Methods

We conducted data analyses using the Global Network’s (GN) population-based registry of pregnant women and their babies in rural communities in six low- and middle-income countries (Democratic Republic of Congo, Kenya, Zambia, Guatemala, India and Pakistan). We analyzed data from January 2014 to December 2018. Trained study staff enrolled all pregnant women in the study catchment area as early as possible during pregnancy and conducted follow-up visits shortly after delivery and at 42 days after delivery. We analyzed the rates of preterm birth, LBW and the combination of preterm birth and LBW and studied risk factors associated with these outcomes across the GN sites.

Results

A total of 272,192 live births were included in the analysis. The overall preterm birth rate was 12.6% (ranging from 8.6% in Belagavi, India to 21.8% in the Pakistani site). The overall LBW rate was 13.6% (ranging from 2.7% in the Kenyan site to 21.4% in the Pakistani site). The overall rate of both preterm birth and LBW was 5.5% (ranging from 1.2% in the Kenyan site to 11.0% in the Pakistani site). Risk factors associated with preterm birth, LBW and the combination were similar across sites and included nulliparity [RR − 1.27 (95% CI 1.21–1.33)], maternal age under 20 [RR 1.41 (95% CI 1.32–1.49)] years, severe antenatal hemorrhage [RR 5.18 95% CI 4.44–6.04)], hypertensive disorders [RR 2.74 (95% CI − 1.21–1.33], and 1–3 antenatal visits versus four or more [RR 1.68 (95% CI 1.55–1.83)].

Conclusions

Preterm birth, LBW and their combination continue to be common public health problems at some of the GN sites, particularly among young, nulliparous women who have received limited antenatal care services.

Trial registration The identifier of the Maternal and Newborn Health Registry at ClinicalTrials.gov is NCT01073475.Trial registration: The identifier of the Maternal and Newborn Health Registry at ClinicalTrials.gov is NCT01073475.

Review of the evidence for interventions to reduce perinatal mortality in low- and middle-income countries

Low- and middle-income countries contribute to the overwhelming majority of the global perinatal and neonatal mortality. There is a growing amount of literature focused on interventions aimed at reducing the healthcare gaps and thereby reducing perinatal and neonatal mortality in low- and middle-income countries. The current review synthesizes available evidence for interventions that have shown to improve perinatal and neonatal outcomes. Reduction in important gaps in the availability and utilization of perinatal care practices is needed to end preventable deaths of newborns.

Dealing with neonatal emergencies in low-resource settings

We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.

Newborn Resuscitation in Settings Without Access to Supplemental Oxygen

Low- and middle-income countries and resource-limited regions are major contributors to perinatal and infant mortality. Oxygen is widely used for resuscitation in high- and middle-income settings. However, oxygen supplementation is not available in resource-limited regions. Oxygen supplementation for resuscitation at birth has adverse effects in human/animal model studies. There has been a change with resultant recommendations for restrictive oxygen use in neonatal resuscitation. Neonatal resuscitation without supplemental oxygen decreases mortality and morbidities. Oxygen in resource-limited settings for neonatal resuscitation is ideal as a backup for selected resuscitations but should not be a limiting factor for implementing basic life-saving efforts.

Trends and determinants of increasing caesarean sections from 2010 to 2013 in a prospective population-based registry in eastern rural Maharashtra, India

OBJECTIVE

Our objective was to describe trends in caesarean section (CS) rates, characteristics of women delivering by CS, reasons for CS and impact of CS on perinatal mortality, in a rural Indian population.

DESIGN

Secondary data analysis using a prospective population-based registry.

SETTING

Four districts in Eastern Maharashtra, India, 2010 to 2013.

PARTICIPANTS

39 026 pregnant women undergoing labour and delivery.

MAIN OUTCOMES

CS, single most likely reason, perinatal mortality.

RESULTS

Overall, 20% of the women delivered by CS. Rates increased from 17.4% in 2010 to 22.7% in 2013 (p<0.001) with an absolute risk increase from 1% to 5% during this time-period. Women aged 25+ years old, being nulliparous, having at least a secondary school education, a body mass index 25+ and a multiple gestation pregnancy were more likely to deliver by CS. Perinatal mortality was higher among babies delivered vaginally than those delivered by CS (4.5% vs 2.7%, p<0.001). Prolonged and obstructed labour as the reported reason for CS increased over time for both nulliparous and multiparous women (p<0.001), and 6% to 10% women had no clear reason for CS. Perinatal mortality was higher among babies born vaginally than those delivered by CS (adjusted OR: 0.65, 95% CI 0.56 to 0.76, p<0.001).

CONCLUSION

Rates of CS increased over time in rural Maharashtra, exceeding WHO recommendations. Characteristics associated with CS and outcomes of CS were similar to previous reports. Further studies are needed to ensure accuracy of reported reasons for CS, why obstructed and prolonged labour leading to CS is increasing in this population and what leads to CS without a clear indication. Such information may be helpful for implementing the Indian Government mandate that no CS be performed without strict medical indications, while ensuring that the overall CS rates are appropriate.

TRIAL REGISTRATION NUMBER

NCT01073475.

A Prospective, Population-Based Study of Trends in Operative Vaginal Delivery Compared to Cesarean Delivery Rates in Low- and Middle-Income Countries, 2010-2016

OBJECTIVE

Few data are available on cesarean delivery and operative vaginal delivery trends in low- and middle-income countries. Our objective was to analyze a prospective population-based registry including eight sites in seven low- and middle-income countries to observe trends in operative vaginal delivery versus cesarean delivery rates over time, across sites.

STUDY DESIGN

A prospective population-based study, including home and facility births among women enrolled from 2010 to 2016, was performed in communities in Argentina, Democratic Republic of Congo, Guatemala, India, Kenya, Pakistan, and Zambia. Women were enrolled during pregnancy and delivery outcome data were collected.

RESULTS

We analyzed 354,287 women; 4,119 (1.2%) underwent an operative vaginal delivery and 45,032 (11.2%) delivered by cesarean. Across all sites with data for 7 years, rates of operative vaginal delivery decreased from 1.6 to 0.3%, while cesarean delivery increased from 6.4 to 14.4%. Similar trends were seen when individual country data were analyzed. Operative vaginal delivery rates decreased in both hospitals and clinics, except in the hospital setting at one of the Indian sites.

CONCLUSION

In low- and middle-income countries, operative vaginal delivery is becoming less utilized while cesarean delivery is becoming an increasingly common mode of delivery.

A system approach to improving maternal and child health care delivery in Kenyan communities and primary care facilities: baseline survey on maternal health

Background

Maternal, fetal and neonatal mortality are 10 to 100 fold higher in many low-income compared to high-income countries. Reasons for these discrepancies include limited antenatal care and delivery outside health facilities.

Objectives

The study aimed at conducting a baseline survey to assess the current levels of maternal health indicators in six counties in Western Kenya.

Methods

This was a cross sectional study conducted targeting women residing in Uasin-Gishu, ElgeyoMarakwet, TransNzoia, Bungoma, Busia and Kakamega counties who had given birth five years prior to the interview. Socio-demographic and maternal indicators were collected using forms adopted from KDHS 2009. Interviews were conducted in the homesteads between December 2015 and June 2016.

Results

A total of 6257 women participated in the study, median age 27 years IQR 23–32. Majority of the women had post-primary level of education, were married and 40% were members of an income-generating activity. 56.8% were using modern family planning method, 49% attended WHO recommended four plus antenatal clinic visits and only 20% attended in the first trimester. Majority, 85% had their most recent delivery in a health facility.

Conclusion

Findings suggest that women are not attending recommended four plus antenatal clinic visits and even those that attend are few are during the first trimester.

CUBES: A practical toolkit to measure enablers and barriers to behavior for effective intervention design

A pressing goal in global development and other sectors is often to understand what drives people’s behaviors, and how to influence them. Yet designing behavior change interventions is often an unsystematic process, hobbled by insufficient understanding of contextual and perceptual behavioral drivers and a narrow focus on limited research methods to assess them. We propose a toolkit (CUBES) of two solutions to help programs arrive at more effective interventions. First, we introduce a novel framework of behavior, which is a practical tool for programs to structure potential drivers and match corresponding interventions. This evidence-based framework was developed through extensive cross-sectoral literature research and refined through application in large-scale global development programs. Second, we propose a set of descriptive, experimental, and simulation approaches that can enhance and expand the methods commonly used in global development. Since not all methods are equally suited to capture the different types of drivers of behavior, we present a decision aid for method selection. We recommend that existing commonly used methods, such as observations and surveys, use CUBES as a scaffold and incorporate validated measures of specific types of drivers in order to comprehensively test all the potential components of a target behavior. We also recommend under-used methods from sectors such as market research, experimental psychology, and decision science, which programs can use to extend their toolkit and test the importance and impact of key enablers and barriers. The CUBES toolkit enables programs across sectors to streamline the process of conceptualizing, designing, and optimizing interventions, and ultimately to change behaviors and achieve targeted outcomes.

CUBES: A practical toolkit to measure enablers and barriers to behavior for effective intervention design

A pressing goal in global development and other sectors is often to understand what drives people’s behaviors, and how to influence them. Yet designing behavior change interventions is often an unsystematic process, hobbled by insufficient understanding of contextual and perceptual behavioral drivers and a narrow focus on limited research methods to assess them. We propose a toolkit (CUBES) of two solutions to help programs arrive at more effective interventions. First, we introduce a novel framework of behavior, which is a practical tool for programs to structure potential drivers and match corresponding interventions. This evidence-based framework was developed through extensive cross-sectoral literature research and refined through application in large-scale global development programs. Second, we propose a set of descriptive, experimental, and simulation approaches that can enhance and expand the methods commonly used in global development. Since not all methods are equally suited to capture the different types of drivers of behavior, we present a decision aid for method selection. We recommend that existing commonly used methods, such as observations and surveys, use CUBES as a scaffold and incorporate validated measures of specific types of drivers in order to comprehensively test all the potential components of a target behavior. We also recommend under-used methods from sectors such as market research, experimental psychology, and decision science, which programs can use to extend their toolkit and test the importance and impact of key enablers and barriers. The CUBES toolkit enables programs across sectors to streamline the process of conceptualizing, designing, and optimizing interventions, and ultimately to change behaviors and achieve targeted outcomes.

Factors influencing referrals for ultrasound-diagnosed complications during prenatal care in five low and middle income countries

Background

Ultrasound during antenatal care (ANC) is proposed as a strategy for increasing hospital deliveries for complicated pregnancies and improving maternal, fetal, and neonatal outcomes. The First Look study was a cluster-randomized trial conducted in the Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia to evaluate the impact of ANC-ultrasound on these outcomes. An additional survey was conducted to identify factors influencing women with complicated pregnancies to attend referrals for additional care.

Methods

Women who received referral due to ANC ultrasound findings participated in structured interviews to characterize their experiences. Cochran-Mantel-Haenszel statistics were used to examine differences between women who attended the referral and women who did not. Sonographers’ exam findings were compared to referred women’s recall.

Results

Among 700 referred women, 510 (71%) attended the referral. Among referred women, 97% received a referral card to present at the hospital, 91% were told where to go in the hospital, and 64% were told that the hospital was expecting them. The referred women who were told who to see at the hospital (88% vs 66%), where to go (94% vs 82%), or what should happen, were more likely to attend their referral (68% vs 56%). Barriers to attending referrals were cost, transportation, and distance. Barriers after reaching the hospital were substantial. These included not connecting with an appropriate provider, not knowing where to go, and being told to return later. These barriers at the hospital often led to an unsuccessful referral.

Conclusions

Our study found that ultrasound screening at ANC alone does not adequately address barriers to referrals. Better communication between the sonographer and the patient increases the likelihood of a completed referral. These types of communication include describing the ultrasound findings, including the reason for the referral, to the mother and staff; providing a referral card; describing where to go in the hospital; and explaining the procedures at the hospital. Thus, there are three levels of communication that need to be addressed to increase completion of appropriate referrals-communication between the sonographer and the woman, the sonographer and the clinic staff, and the sonographer and the hospital.

Trial registration

NCT01990625.

Trends and determinants of stillbirth in developing countries: results from the Global Network's Population-Based Birth Registry

Background

Stillbirth rates remain high, especially in low and middle-income countries, where rates are 25 per 1000, ten-fold higher than in high-income countries. The United Nations’ Every Newborn Action Plan has set a goal of 12 stillbirths per 1000 births by 2030 for all countries.

Methods

From a population-based pregnancy outcome registry, including data from 2010 to 2016 from two sites each in Africa (Zambia and Kenya) and India (Nagpur and Belagavi), as well as sites in Pakistan and Guatemala, we evaluated the stillbirth rates and rates of annual decline as well as risk factors for 427,111 births of which 12,181 were stillbirths.

Results

The mean stillbirth rates for the sites were 21.3 per 1000 births for Africa, 25.3 per 1000 births for India, 56.9 per 1000 births for Pakistan and 19.9 per 1000 births for Guatemala. From 2010 to 2016, across all sites, the mean stillbirth rate declined from 31.7 per 1000 births to 26.4 per 1000 births for an average annual decline of 3.0%. Risk factors for stillbirth were similar across the sites and included maternal age < 20 years and age > 35 years. Compared to parity 1–2, zero parity and parity > 3 were both associated with increased stillbirth risk and compared to women with any prenatal care, women with no prenatal care had significantly increased risk of stillbirth in all sites.

Conclusions

At the current rates of decline, stillbirth rates in these sites will not reach the Every Newborn Action Plan goal of 12 per 1000 births by 2030. More attention to the risk factors and treating the causes of stillbirths will be required to reach the Every Newborn Action Plan goal of stillbirth reduction.

Trial registration

NCT01073475.

Clinical interventions to reduce stillbirths in sub-Saharan Africa: a mathematical model to estimate the potential reduction of stillbirths associated with specific obstetric conditions

OBJECTIVE

Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions.

DESIGN

We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered.

SETTING AND POPULATION

Pregnancies in SSA in 2012.

METHODS

For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates.

MAIN OUTCOME MEASURES

Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions.

RESULTS

Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth.

CONCLUSIONS

Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries.

TWEETABLE ABSTRACT

Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery.

[Tacit and explicit knowledge: comparative analysis of the prioritization of maternal health problems in Mexico]

OBJECTIVE

To identify coincidences and differences in the identification and prioritization of maternal healthcare service problems in Mexico based on the perspective of tacit knowledge and explicit knowledge that may offer evidence that can contribute to attaining the Sustainable Development Goals.

METHODS

Mixed study performed in three stages: 1) systematization of maternal healthcare service problems identified by tacit knowledge (derived from professional experience); 2) identification of maternal healthcare service problems in Latin America addressed by explicit knowledge (scientific publications); 3) comparison between the problems identified by tacit and explicit knowledge.

RESULTS

The main problems of maternal health services identified by tacit knowledge are related to poor quality of care, while the predominant problems studied in the scientific literature are related to access barriers to health services. Approximately, 70% of the problems identified by tacit knowledge are also mentioned in the explicit knowledge. Conversely, 70% of the problems identified in the literature are also considered by tacit knowledge. Nevertheless, when looking at the problems taken one by one, no statistically significant similarities were found.

CONCLUSIONS

The study discovered that the identification of maternal health service problems by tacit knowledge and explicit knowledge is fairly comparable, according to the comparability index used in the study, and highlights the interest of integrating both approaches in order to improve prioritization and decision making towards the Sustainable Development Goals.

Maternal predictors of neonatal outcomes after emergency cesarean section: a retrospective study in three rural district hospitals in Rwanda

Background

In sub-Saharan Africa, neonatal mortality post-cesarean delivery is higher than the global average. In this region, most emergency cesarean sections are performed at district hospitals. This study assesses maternal predictors for poor neonatal outcomes post-emergency cesarean delivery in three rural district hospitals in Rwanda.

Methods

This retrospective study includes a random sample of 441 neonates from Butaro, Kirehe and Rwinkwavu District Hospitals, born between 01 January and 31 December 2015. We described the demographic and clinical characteristics of the mothers of these neonates using frequencies and proportions. We assessed the association between maternal characteristics with poor neonatal outcomes, defined as death within 24 h or APGAR < 7 at 5 min after birth, using Fisher’s exact test. Factors significant at α = 0.20 significance level were considered for the multivariate logistic regression model, built using a backwards stepwise process. We stopped when all the factors were significant at the α = 0.05 level.

Results

For all 441 neonates included in this study, 40 (9.0%) had poor outcomes. In the final model, three factors were significantly associated with poor neonatal outcomes. Neonates born to mothers who had four or more prior pregnancies were more likely to have poor outcomes (OR = 3.01, 95%CI:1.23,7.35, p = 0.015). Neonates whose mothers came from health centers with ambulance travel times of more than 30 min to the district hospital had greater odds of having poor outcomes (for 30–60 min: OR = 3.80, 95%CI:1.07,13.40, p = 0.012; for 60+ minutes: OR = 5.82, 95%CI:1.47,23.05, p = 0.012). Neonates whose mothers presented with very severe indications for cesarean section had twice odds of having a poor outcome (95% CI: 1.11,4.52, p = 0.023).

Conclusions

Longer travel time to the district hospital was a leading predictor of poor neonatal outcomes post cesarean delivery. Improving referral systems, ambulance availability, number of equipped hospitals per district, and road networks may lessen travel delays for women in labor. Boosting the diagnostic capacity of labor conditions at the health center level through facilities and staff training can improve early identification of very severe indications for cesarean delivery for early referral and intervention.

Cesarean section in sub-Saharan Africa

Cesarean section is an essential maternal healthcare service. Its role in labor and delivery care in low- and middle-income countries is complex; in many low-resource settings it is underutilized in the most needy of populations and overused by the less needy, without clear methods to ensure that universal access is available. Additionally, even if universal access were available, it is not evident that these countries would have the capacity or the finances to appropriate meet demand for the procedure, or that patients would want to utilize the care. This review summarizes the literature and illustrates the complicated relationship that cesarean section, which is rapidly on the rise around the world, has with individuals, communities, and nations in sub-Saharan Africa.

The global network antenatal corticosteroids trial: impact on stillbirth

Background

Antenatal corticosteroids are commonly used to reduce neonatal mortality, but most research to date has been in high-resource settings and few studies have evaluated its impact on stillbirth. In the Antenatal Corticosteroids Trial (ACT), a multi-country trial to assess impact of a multi-faceted intervention including antenatal corticosteroids to reduce neonatal mortality associated with preterm birth, we found an overall increase in 28-day neonatal mortality and stillbirth associated with the intervention.

Methods

The ACT was a cluster-randomized trial conducted in 102 clusters across 7 research sites in 6 countries (India [2 sites], Pakistan, Zambia, Kenya, Guatemala and Argentina), comparing an intervention to train birth attendants at all levels of the health system to identify women at risk of preterm birth, administer corticosteroids and refer women at risk. Because of inadequate gestational age dating, the <5^th percentile birth weight was used as a proxy for preterm birth. A pre-specified secondary outcome of the trial was stillbirth.

Results

After adjusting for the pre-trial imbalance in stillbirth rates, the ACT intervention was associated with a non-significant increased risk of stillbirth (aRR 1.08, 95 % CI, 0.99–1.17, p–0.073). Additionally, the stillbirth rate was higher in the term births (1.20 95 % CI 1.06–1.37, 0.004) and among those with signs of maceration (RR 1.18 (1.04–1.35), p = 0.013) in the intervention vs. control clusters. Differences in obstetric care favored the control clusters and maternal infection was likely more common in the intervention clusters.

Conclusions

In this pragmatic trial, limited data were available to identify the causes of the increase in stillbirths in the intervention clusters. A higher rate of stillbirth in the intervention clusters prior to the trial, differences in obstetric care and an increase in maternal infection are potential explanations for the observed increase in stillbirths in the intervention clusters during the trial.

Trial registration

clinicaltrials.gov (NCT01084096)

Use of antenatal corticosteroids at health facilities and communities in low-and-middle income countries

Background

Antenatal corticosteroids (ACS) for women at high risk of preterm birth is an effective intervention to reduce neonatal mortality among preterm babies delivered in hospital settings, but has not been widely used in low-middle resource settings. We sought to assess the rates of ACS use at all levels of health care in low and middle income countries (LMIC).

Methods

We assessed rates of ACS in 7 sites in 6 LMIC participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Global Network for Women and Children’s Health Research Antenatal Corticosteroids Trial (ACT), a cluster-randomized trial to assess the feasibility, effectiveness, and safety of a multifaceted intervention designed to increase the use of ACS. We conducted this analysis using data from the control clusters, which did not receive any components of the intervention and intended to follow usual care. We included women who delivered an infant with a birth weight <5th percentile, a proxy for preterm birth, and were enrolled in the Maternal Newborn Health (MNH) Registry between October 2011 and March 2014 in all clusters. A survey of the site investigators regarding existing policies on ACS in health facilities and for health workers in the community was part of pre-trial activities.

Results

Overall, of 51,523 women delivered in control clusters across all sites, the percentage of <5th percentile babies ranged from 3.5 % in Kenya to 10.7 % in Pakistan. There was variation among the sites in the use of ACS at all hospitals and among those hospitals having cesarean section and neonatal care capabilities (bag and mask and oxygen or mechanical ventilation). Rates of ACS use for <5th percentile babies in all hospitals ranged from 3.8 % in the Kenya sites to 44.5 % in the Argentina site, and in hospitals with cesarean section and neonatal care capabilities from 0 % in Zambia to 43.5 % in Argentina. ACS were rarely used in clinic or home deliveries at any site. Guidelines for ACS use at all levels of the health system were available for most of the sites.

Conclusion

Our study reports an overall low utilization of ACS among mothers of <5th percentile infants in hospital and clinic deliveries in LMIC.

Trial Registration

clinicaltrials.gov (NCT01084096)

The Antenatal Corticosteroids Trial (ACT)'s explanations for neonatal mortality - a secondary analysis

BACKGROUND

The Antenatal Corticosteroid Trial assessed the feasibility, effectiveness, and safety of a multifaceted intervention to increase the use of antenatal corticosteroids (ACS) in mothers at risk of preterm birth at all levels of care in low and middle-income countries. The intervention effectively increased the use of ACS but was associated with an overall increase in neonatal deaths. We aimed to explore plausible pathways through which this intervention increased neonatal mortality.

METHODS

We conducted a series of secondary analyses to assess whether ACS or other components of the multifaceted intervention that might have affected the quality of care contributed to the increased mortality observed: 1) we compared the proportion of neonatal deaths receiving ACS between the intervention and control groups; 2) we compared the antenatal and delivery care process in all births between groups; 3) we compared the rates of possible severe bacterial infection between groups; and 4) we compared the frequency of factors related to ACS administration or maternal high risk conditions at administration between the babies who died and those who survived 28 days among all births in the intervention group identified as high risk for preterm birth and received ACS.

RESULTS

The ACS exposure among the infants who died up to 28 days was 29 % in the intervention group compared to 6 % in controls. No substantial differences were observed in antenatal and delivery care process between groups. The risk of pSBI plus neonatal death was significantly increased in intervention clusters compared to controls (2.4 % vs. 2.0 %, adjusted RR 1.17, 95 % CI 1.04-1.30, p = 0.008], primarily for infants with birth weight at or above the 25(th) percentile. Regarding factors related to ACS administration, term infants who died were more likely to have mothers who received ACS within 7 days of delivery compared to those who survived 28 days (26.5 % vs 17.9 %, p = 0.014), and their mothers were more likely to have been identified as high risk for hypertension and less likely for signs of preterm labor.

CONCLUSIONS

These results suggest that ACS more than other components of the intervention may have contributed to the overall increased neonatal mortality. ACS may have also been involved in the observed increased risk of neonatal infection and death. Further trials are urgently needed to clarify the effectiveness and safety of ACS on neonatal health in low resource settings.

An Intervention to Enhance Obstetric and Newborn Care in India: A Cluster Randomized-Trial

OBJECTIVES

This study assessed whether community mobilization and interventions to improve emergency obstetric and newborn care reduced perinatal mortality (PMR) and neonatal mortality rates (NMR) in Belgaum, India.

METHODS

The cluster-randomised controlled trial was conducted in Belgaum District, Karnataka State, India. Twenty geographic clusters were randomized to control or the intervention. The intervention engaged and mobilized community and health authorities to leverage support; strengthened community-based stabilization, referral, and transportation; and aimed to improve quality of care at facilities.

RESULTS

17,754 Intervention births and 15,954 control births weighing ≥1000 g, respectively, were enrolled and analysed. Comparing the baseline period to the last 6 months period, the NMR was lower in the intervention versus control clusters (OR 0.60, 95% CI 0.34-1.06, p = 0.076) as was the PMR (OR 0.74, 95% CI 0.46-1.19, p = 0.20) although neither reached statistical significance. Rates of facility birth and caesarean section increased among both groups. There was limited influence on quality of care measures.

CONCLUSIONS FOR PRACTICE

The intervention had large but not statistically significant effects on neonatal and perinatal mortality. Community mobilization and increased facility care may ultimately improve neonatal and perinatal survival, and are important in the context of the global transition towards institutional delivery.

Reducing stillbirths in low-income countries

Worldwide, 98% of stillbirths occur in low-income countries (LIC), where stillbirth rates are ten-fold higher than in high-income countries (HIC). Although most HIC stillbirths occur prenatally, in LIC most stillbirths occur at term and during labor/delivery. Conditions causing stillbirths include those of maternal origin (obstructed labor, trauma, antepartum hemorrhage, preeclampsia/eclampsia, infection, diabetes, other maternal diseases), and fetal origin (fetal growth restriction, fetal distress, cord prolapse, multiples, malpresentations, congenital anomalies). In LIC, aside from infectious origins, most stillbirths are caused by fetal asphyxia. Stillbirth prevention requires recognition of maternal conditions, and care in a facility where fetal monitoring and expeditious delivery are possible, usually by cesarean section (CS). Of major causes, only syphilis and malaria can be managed prenatally. Targeting single conditions or interventions is unlikely to substantially reduce stillbirth. To reduce stillbirth rates, LIC must implement effective modern antepartum and intrapartum care, including fetal monitoring and CS.

Midwives' intrapartum monitoring process and management resulting in emergency referrals in Tanzania: a qualitative study

Background

In the United Republic of Tanzania, the maternal mortality ratio, and neonatal mortality rate have remained high for the last 10 years. It is well documented that many complications of pregnancy are avoidable by providing skilled midwifery care during and immediately after childbirth. However, there have been delays in providing timely and necessary obstetric interventions, most likely due to lack of proper monitoring during labor. Yet, there has been little research concerning how midwives monitor the process of childbirth. Therefore, this study aimed to describe how midwives monitored and managed the process of childbirth to achieve early consulting and timely referral to obstetricians.

Methods

The design was qualitative and descriptive, using data from comprehensive semi-structured interviews of midwives. The interviews were conducted at one hospital and one health center in Dar es Salaam, Tanzania’s largest city. Eleven participants were purposively recruited and interviewed about their experiences managing complicated intrapartum cases. After the interviews, data were analyzed using content analysis.

Results

Derived from the data were three activity phases: initial encounter, monitoring, and acting. During these phases, midwives noticed danger signs, identified problems, revised and confirmed initial problem identification, and organized for medical intervention or referral. The timing of taking action was different for each midwife and depended on the nature of the prolonged and obstructed labor case.

Conclusions

For the majority of midwives, the processing of assessments and judgments was brief and without reflection, and only a few midwives took time to continue to monitor the labor after the initial identification of problems and before taking actions. To make a final judgment that the labor was becoming prolonged or obstructed, midwives should consider taking time to review and synthesize all their findings.

The Global Network for Women's and Children's Health Research: A model of capacity-building research

In response to the global effort to accelerate progress towards the Millennium Development Goals 4 and 5, a partnership was created between the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the Bill and Melinda Gates Foundation to establish the Global Network for Women's and Children's Health Research (Global Network) in 2000. The Global Network was developed with a goal of building local maternal and child health research capacity in resource-poor settings. The objective of the network was to conduct research focused on several high-need areas, such as preventing life-threatening obstetric complications, improving birth weight and infant growth, and improving childbirth practices in order to reduce mortality. Scientists from developing countries, together with peers in the USA, lead research teams that identify and address population needs through randomized clinical trials and other research studies. Global Network projects develop and test cost-effective, sustainable interventions for pregnant women and newborns and provide guidance for national policy and for the practice of evidence-based medicine. This article reviews the results of the Global Network's research, the impact on policy and practice, and highlights the capacity-building efforts and collaborations developed since its inception.

Institutional deliveries weakly associated with improved neonatal survival in developing countries: evidence from 192 Demographic and Health Surveys

BACKGROUND

Child and maternal mortality remain high in many developing countries. A principal strategy used in low- and middle-income countries is increasing the proportion of pregnancies delivered at facilities. Although this strategy is reasonable with high quality facilities, evidence for the protective effects of facility deliveries is mixed.

METHODS

We pooled 1.47 million birth records collected by the Demographic and Health Surveys to estimate the association between institutional deliveries and early neonatal mortality. Subsample analysis and instrumental variable estimation were used to assess and correct the extent to which mortality differentials are biased by an increased likelihood of facility attendance for high-risk deliveries.

RESULTS

No associations between institutional deliveries and early neonatal mortality were found in the pooled sample [adjusted odds ratio (aOR) 0.995, 95% confidence interval (CI) 0.966-1.025)]. When stratified by facility type, protective effects were found for private facilities (aOR 0.876, 95% CI 0.840-0.914), but not for public hospitals or health centres. Significant protective effects were found when past behaviour was used to eliminate selection bias generated by short-term responses to medical need (aOR 0.884, 95% CI 0.814-0.961). At the community and country levels, strong positive associations were found between early neonatal mortality among facility deliveries and the prevalence of institutional deliveries.

CONCLUSION

Facility deliveries have the potential to reduce early neonatal mortality in developing countries. The results presented suggest that the quality, utilization and protective effects of institutional deliveries vary widely across countries; major improvements in both utilization and quality of care will be needed to achieve further improvements in maternal and child health.

Neonatal mortality and coverage of essential newborn interventions 2010 - 2013: a prospective, population-based study from low-middle income countries

Background

Approximately 3 million neonatal deaths occur each year worldwide. Simple interventions have been tested and found to be effective in reducing the neonatal mortality. In order to effectively implement public health interventions, it is important to know the rates of neonatal mortality and understand the contributing risk factors. Hence, this prospective, population-based, observational study was carried out to inform these needs.

Methods

The Global Network’s Maternal Newborn Health Registry was initiated in the seven sites in 2008. Registry administrators (RAs) attempt to identify and enroll all eligible women by 20 weeks gestation and collect basic health data, and outcomes after delivery and at 6 weeks post-partum. All study data were collected, reviewed, and edited by staff at each study site. The study was reviewed and approved by each sites’ ethics review committee.

Results

Overall, the 7-day neonatal mortality rate (NMR) was 20.6 per 1000 live births and the 28-day NMR was 25.7 per 1000 live births. Higher neonatal mortality was associated with maternal age > 35 and <20 years relative to women 20-35 years of age. Preterm births were at increased risk of both early and 28-day neonatal mortality (RR 8.1, 95% CI 7.5-8.8 and 7.5, 95% CI 6.9-8.1) compared to term as were those with low birth weight (<2500g). Neonatal resuscitation rates were 4.8% for hospital deliveries compared to 0.9% for home births. In the hospital, 26.5% of deliveries were by cesarean section with an overall cesarean section rate of 12.5%. Neonatal mortality rates were highest in the Pakistan site and lowest in Argentina.

Conclusions

Using prospectively collected data with high follow up rates (99%), we documented characteristics associated with neonatal mortality. Low birth weight and prematurity are among the strongest predictors of neonatal mortality. Other risk factors for neonatal deaths included male gender, multiple gestation and major congenital anomalies. Breech presentation/transverse lie, and no antenatal care were also significant risk factors for neonatal death. Coverage of interventions varied by setting of delivery, with the overall population rate of most evidence-based interventions low. This study informs about risk factors for neonatal mortality which can serve to design strategies/interventions to reduce risk of neonatal mortality.

Trial registration

The trial is registered at clinicaltrials.gov. ClinicalTrial.gov Trial Registration: NCT01073475

Universal combination antiretroviral regimens to prevent mother-to-child transmission of HIV in rural Zambia: a two-round cross-sectional study

OBJECTIVE

To evaluate if a pilot programme to prevent mother-to-child transmission (PMTCT) of the human immunodeficiency virus (HIV) was associated with changes in early childhood survival at the population level in rural Zambia.

METHODS

Combination antiretroviral regimens were offered to pregnant and breastfeeding, HIV-infected women, irrespective of immunological status, at four rural health facilities. Twenty-four-month HIV-free survival among children born to HIV-infected mothers was determined before and after PMTCT programme implementation using community surveys. Households were randomly selected and women who had given birth in the previous 24 months were asked to participate. Mothers were tested for HIV antibodies and children born to HIV-infected mothers were tested for viral deoxyribonucleic acid. Multivariable models were used to determine factors associated with child HIV infection or death.

FINDINGS

In the first survey (2008-2009), 335 of 1778 women (18.8%) tested positive for HIV. In the second (2011), 390 of 2386 (16.3%) tested positive. The 24-month HIV-free survival in HIV-exposed children was 0.66 (95% confidence interval, CI: 0.63-0.76) in the first survey and 0.89 (95% CI: 0.83-0.94) in the second. Combination antiretroviral regimen use was associated with a lower risk of HIV infection or death in children (adjusted hazard ratio: 0.33, 95% CI: 0.15-0.73). Maternal knowledge of HIV status, use of HIV tests and use of combination regimens during pregnancy increased between the surveys.

CONCLUSION

The PMTCT programme was associated with an increased HIV-free survival in children born to HIV-infected mothers. Maternal utilization of HIV testing and treatment in the community also increased.

A combined community- and facility-based approach to improve pregnancy outcomes in low-resource settings: a Global Network cluster randomized trial

BACKGROUND

Fetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries. These differences have been related to poor access to and poor quality of obstetric and neonatal care.

METHODS

This trial tested the hypothesis that teams of health care providers, administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations. In seven geographic areas in five low-income and one middle-income country, most with high perinatal mortality rates and substantial numbers of home deliveries, we performed a cluster randomized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport, community birth attendant training in problem recognition, and facility staff training in the management of obstetric and neonatal emergencies. The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g.

RESULTS

Despite extensive effort in all sites in each of the three intervention areas, no differences emerged in the primary or any secondary outcome between the intervention and control clusters. In both groups, the mean perinatal mortality was 40.1/1,000 births (P = 0.9996). Neither were there differences between the two groups in outcomes in the last six months of the project, in the year following intervention cessation, nor in the clusters that best implemented the intervention.

CONCLUSIONS

This cluster randomized comprehensive, large-scale, multi-sector intervention did not result in detectable impact on the proposed outcomes. While this does not negate the importance of these interventions, we expect that achieving improvement in pregnancy outcomes in these settings will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial, and without them provider training and community mobilization will not be sufficient. Our results highlight the critical importance of evaluating outcomes in randomized trials, as interventions that should be effective may not be.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01073488.