Improving implementation of health promotion interventions for maternal and newborn health

The preferences of people in Australia to respond and engage with advertisements to promote reproductive health: Results of a discrete choice experiment

Objectives

The health of people prior to pregnancy impacts pregnancy outcomes and childhood health, making the preconception period an important time to optimise health behaviours. Low awareness of the importance of this issue is a recognised barrier to achieving good preconception health. Public health messaging can help to address this barrier.

Methods

A discrete choice experiment to assess the preferences of people of reproductive age for a health promotion advertisement for preconception health was conducted. Attributes of the advertisement image, title, additional text content and positioning, and the location of advertisement were assessed by fitting a mixed logit model to the choices made.

Results

Three hundred and thirty-four responses were obtained, from people of reproductive age, both planning and not planning a pregnancy, in Australia. Participants placed most importance on the image, and the location in which they saw the advertisement. An image of adult and baby hands was preferred to adult hands only, and healthcare settings were preferred to more general media locations such as advertising online or on public transport. Preference was also given to the advertisement title of "Healthy you, Healthy baby", closely followed by "Are you ready for pregnancy?". The location and content of additional text did not significantly impact engagement with the advertisement.

Conclusion

The image and title on the advertisement, and the locations in which they are placed were the most significant features to impact engagement with a health promotion advertisement for preconception health. This can inform health promotion efforts for preconception health.

Assessing unConventional Evidence (ACE) tool: development and content of a tool to assess the strengths and limitations of 'unconventional' source materials

BACKGROUND

When deciding whether to implement an intervention, decision-makers typically have questions on feasibility and acceptability and on factors affecting implementation. Descriptions of programme implementation and of policies and systems are rich sources of information for these questions. However, this information is often not based on empirical data collected using explicit methods. To use the information in unconventional source materials in syntheses or other decision support products, we need methods of assessing their strengths and limitations. This paper describes the development and content of the Assessing unConventional Evidence (ACE) tool, a new tool to assess the strengths and limitations of these sources.

METHODS

We developed the ACE tool in four stages: first, we examined existing tools to identify potentially relevant assessment criteria. Second, we drew on these criteria and team discussions to create a first draft of the tool. Third, we obtained feedback on the draft from potential users and methodologists, and through piloting the tool in evidence syntheses. Finally, we used this feedback to iteratively refine the assessment criteria and to improve our guidance for undertaking the assessment.

RESULTS

The tool is made up of 11 criteria including the purpose and context of the source; the completeness of the information presented; and the extent to which evidence is provided to support the findings made. Users are asked to indicate whether each of the criteria have been addressed. On the basis of their judgements for each criterion, users then make an overall assessment of the limitations of the source, ranging from no or very minor concerns to serious concerns. These assessments can then facilitate appropriate use of the evidence in decision support products.

CONCLUSIONS

Through focussing on unconventional source materials, the ACE tool fills an important gap in the range of tools for assessing the strengths and limitations of policy-relevant evidence and supporting evidence-informed decision-making.

Reframing the Three Delays framework: factors influencing referrals to facilities by matrones in rural Haiti

In Haiti, there has been limited research on the experiences of traditional birth attendants/matrones when they decide to refer and accompany pregnant women to the facility for giving birth. Understanding this contextualised experience could help to strengthen programming aimed at improving maternal, neonatal, and child health (MNCH) outcomes in rural Haiti. This paper describes the qualitative findings from seven focus group discussions (FGDs) with matrones regarding their experience of referring pregnant women to facilities in Haiti's Central Plateau. Each FGD was conducted in Haitian Kreyol and audio recorded. Recordings were transcribed, translated to English, and thematically analysed. A conceptual model visualising factors influencing matrone decision-making was then developed using an adapted version of the Three Delays framework. Findings from this study show that matrones face a complex, multilayered web of intertwining factors related to attitudes and beliefs around their role, resource availability, and perceptions around quality of care and treatment. Each factor corresponds to a delay in the Three Delays framework. The factors can occur at the same time or each can occur individually at different times, and influence the decision to refer. The complexity of factors identified reflects the need to reassess the Three Delays framework so that it accounts for the intertwining, cyclical complexities faced by those trying to access the facility amidst the backdrop of both time and the community/social contexts. Results further reflect the need for strengthened health systems that better facilitate matrone facility-based referrals, improving outcomes for all parties involved and bridging the gap between homes/ communities and facilities. This calls for better integration of the matrones into the formal health system to systematically strengthen the continuum of MNCH health services provided from home to facility.

Adequacy of antenatal care services utilisation and its effect on anaemia in pregnancy

Anaemia in pregnancy remains a critical public health concern in many countries including Ghana and it poses severe consequences in the short to long-term for women and their unborn babies. Although antenatal care (ANC) is largely provided for pregnant women, the extent its utilisation protects against anaemia in pregnancy remains largely understudied. The study assessed the adequacy of ANC services utilisation and its effect on anaemia among pregnant women in the Wa Municipality of Ghana. A facility-based cross-sectional survey was conducted. Probability proportionate to size sampling and systematic random sampling were used to select the facilities and 353 respondents. While 80⋅2 % of the pregnant women reported having received a sufficient number of ANC services provided, the prevalence of the overall ANC adequacy was only 44⋅2 %. After adjusting for potential confounders, pregnant women who could not achieve adequate ANC attendance were 2⋅3 times more likely to be anaemic in the third trimester of gestation AOR = 2⋅26 (95 % CI 1⋅05, 4⋅89), compared to their counterparts who maintained adequate ANC attendance. Adequate ANC attendance was a consistent and significant predictor of anaemia in pregnancy in the third trimester. Health and nutrition education on the need for early initiation of ANC attendance and support for the consumption of diversified diets are two possible interventions that can help contain anaemia in pregnancy.

Maternal and child health handbook to improve continuum of maternal and child care in rural Bangladesh: Findings of a cluster randomized controlled trial

This study aimed to evaluate the effectiveness of maternal and child health handbook (MCH) enhanced by mobile tools and to generate evidence informing the adoption of the program in Bangladesh. A cluster randomized controlled trial (RCT) has been implemented in Lohagora of Narail District and Dhamrai of Dhaka District. Unions of the study settings were randomly allocated in either one of three groups: (1) Intervention 1 using both mobile platform and MCH, (2) Intervention 2 using MCH alone, or (3) the Control. A total of 3,002 participants were recruited. The interventions were designed to promote two-way communications between pregnant women/their families and community health workers by an empowering approach. A total of 3,002 pregnant women were recruited. As the results, the interventions both significantly improved the utilization of CoC, although the overall proportion of CoC was relevantly low: 2.79% in the Control (95% CI: 1.37–3.54%), 6.16% in Intervention 2 (95% CI: 4.67–7.86%), and 7.89% in Intervention 1 (95% CI: 6.29–9.90%). Neonatal mortality rate with and without CoC was 5.43 per 1,000 (95% CI: 3.63–9.57 per 1,000) and 34.8 per 1,000 (95% CI: 24.3–45.4 per 1,000), respectively. Our study indicated the effectiveness of the interventions by leveraging MCH and a mobile platform to promote uptake of CoC throughout prepartum, intrapartum and postpartum/neonatal periods, potentially bringing long-lasting benefits to mothers and their offspring. The explicit approach is expected to guide policy makers to adopt MCH interventions in primary healthcare strengthening at the community level.

Trial registration:UMIN000025628 Registered June 13, 2016.

Facility level factors that determine consistent delivery of essential newborn care at health centers in Ethiopia

BACKGROUND

Essential newborn care (ENC) is a package of interventions which should be provided for every newborn baby regardless of body size or place of delivery immediately after birth and should be continued for at least the seven days that follows. Even though Ethiopia has endorsed the implementation of ENC, as other many counties, it has been challenged. This study was conducted to measure the level of essential newborn care practice and identify health facility level attributes for consistent delivery of ENC services by health care providers.

METHODS

This study employed a retrospective cross-sectional study design in 425 facilities. Descriptive statistics were formulated and presented in tables. Binary logistic regression was employed to assess the statistical association between the outcome variable and the independent variables. All variables with p < 0.2 in the bivariate analysis were identified as candidate variables. Then, multiple logistic regression analysis was performed using candidate variables to determine statistically significant predictors of the consistent delivery of ENC by adjusting for possible confounders.

RESULTS

A total of 273, (64.2%), of facilities demonstrated consistent delivery of ENC. Five factors-availability of essential obstetrics drugs in delivery rooms, high community score card (CSC) performances, availability of maternity waiting homes, consistent partograph use, and availability of women-friendly delivery services were included in the model. The strongest predictor of consistent delivery of essential newborn care (CD-ENC) was consistent partograph use, recording an odds ratio of 2.66 (AOR = 2.66, 95%CI: 1.71, 4.13). Similarly, providing women-friendly services was strongly associated with increased likelihood of exhibiting CD-ENC. Furthermore, facilities with essential obstetric drugs had 1.88 (AOR = 1.88, 95%CI: 1.15, 3.08) times higher odds of exhibiting consistent delivery of ENC.

CONCLUSION

The delivery of essential newborn care depends on both health provider and facility manager actions and availability of platforms to streamline relationships between the clients and health facility management.

The influence of community factors in the implementation of community-based interventions to improve antenatal care: a qualitative study based on the IMCHA programme in Tanzania

BACKGROUND

Efforts to improve antenatal care have been heightened to reduce global maternal deaths. In resource-limited settings, community-based interventions play a pivotal role in improving antenatal care services. However, effective implementation of community-based interventions is influenced by prevailing community-related factors. Drawing from the community-based interventions implemented in Iringa Region in Tanzania, this paper underscores how community factors influence implementation and ultimate improvement of antenatal care services.

METHODS

A qualitative case study design was employed using in-depth interviews, focus group discussions and document reviews. Data was collected in Kilolo and Mufindi districts in Iringa Region where community-based interventions were implemented. A total of one hundred and forty-six (146) participants were involved in the study. Eighty-six (86) participants were interviewed and sixty (n = 60) participated in focus group discussions. Data were analysed thematically and manually by categorizing and coding emerging issues to facilitate analysis and interpretation.

RESULTS

Key factors that influenced the implementation of the community-based interventions were the community readiness to adopt the interventions and effective local administrative systems. Stakeholders' engagement and local health system support were also pivotal for improving antenatal care services. However, the physical environment, bullying of implementers of interventions and family-related challenges constrained the implementation of the interventions.

CONCLUSION

This study has shown that the performance of community-based interventions is highly influenced by community-related factors. More specifically, inadequate community engagement may lead to community members' reluctance to adopt implemented interventions. Therefore, in-depth understanding and adequate management of community engagement are important during the planning, development and implementation of community-based interventions.

Adequacy of prenatal care services and associated factors in Southern Ethiopia

BACKGROUND

Prenatal care is an important component for the continuum of care in maternal and child health services. Despite increased attention on prenatal care service coverage, the adequacy of service provision has not been well addressed in Ethiopia. Therefore, this study aimed to describe the status of the adequacy of prenatal care and its associated factors in Southern Ethiopia.

METHOD

A longitudinal study done by the Performance care Monitoring and Accountability (PMA2020) project was used. The study was conducted from August 2016 to January 2017 in Southern Ethiopia. A multistage stratified cluster design in which all enumeration areas were randomly selected using probability proportional to size and all households were screened to identify 324 pregnant women of six or more months. Questions regarding early attendance of prenatal care, enough visits, and sufficient services were asked to measure the adequacy of prenatal care. Finally, an ordered logistic regression analysis was employed to assess factors associated with the adequacy of prenatal care services.

RESULTS

Of the total pregnant women 44.21 % attended enough visits, 84.10 % had early visits, and 42.03 % received sufficient services. The women residing in urban areas had 2.35 odds of having adequate prenatal care in reference to rural areas (adjusted odds ratio (aOR) 2.35 [95 % CI 1.05-5.31]). Women who attended primary and secondary education had 2.42(aOR 2.42 [95 % C.I. 1.04, 5.65]), and 4.18 (aOR 4.18 [95 % CI 1.32, 13.29]) odds of adequate prenatal care in reference with those who never attended education respectively. The women participating in one to five networks have 2.18 odds of adequate prenatal care in reference to their counterparts (aOR 2.78 [95 % CI 1.01, 7.71]).

CONCLUSIONS

The adequacy of prenatal care services in Southern Ethiopia is very low. The Ethiopian health care system should strengthen one to five networks to discuss on family health issues. Further research, should validate the tools and measure the adequacy of the services in different contexts of Ethiopia using a mixed method study for an in-depth understanding of the problem.

The knowledge of danger signs of obstetric complications among women in rural India: evaluating an integrated microfinance and health literacy program

BACKGROUND

Maternal mortality can be prevented in low-income settings through early health care seeking during maternity complications. While health system reforms in India prioritised institutional deliveries, inadequate antenatal and postnatal services limit the knowledge of danger signs of obstetric complications to women, which delays the recognition of complications and seeking appropriate health care. Recently, a novel rapidly scalable community-based program combining maternal health literacy delivery through microfinance-based women-only self-help groups (SHG) was implemented in rural India. This study evaluates the impact of the integrated microfinance and health literacy (IMFHL) program on the knowledge of maternal danger signs in marginalised women from one of India's most populated and poorer states - Uttar Pradesh. Additionally, the study evaluates the presence of a diffusion effect of the knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages.

METHODS

Secondary data from the IMFHL program comprising 17,232 women from SHG and non-member households in rural Uttar Pradesh was included. Multivariate logistic regression models were used to identify the program's effects on the knowledge of maternal danger signs adjusting for a comprehensive range of confounders at the individual, household, and community level.

RESULTS

SHG member women receiving health literacy were 27% more likely to know all danger signs as compared with SHG members only. Moreover, the results showed that the SHG network facilitates diffusion of knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages. The study found that the magnitude of the program impact on outcome remained stable even after controlling for other confounding effects suggesting that the health message delivered through the program reaches all women uniformly irrespective of their socioeconomic and health system characteristics.

CONCLUSIONS

The findings can guide community health programs and policy that seek to impact maternal health outcomes in low resource settings by demonstrating the differential impact of SHG alone and SHG plus health literacy on maternal danger sign knowledge.

Global research priorities for social, behavioural and community engagement interventions for maternal, newborn and child health

Background

Social, behavioural and community engagement (SBCE) interventions are essential for global maternal, newborn and child health (MNCH) strategies. Past efforts to synthesise research on SBCE interventions identified a need for clear priorities to guide future research. WHO led an exercise to identify global research priorities for SBCE interventions to improve MNCH.

Methods

We adapted the Child Health and Nutrition Research Initiative method and combined quantitative and qualitative methods to determine MNCH SBCE intervention research priorities applicable across different contexts. Using online surveys and meetings, researchers and programme experts proposed up to three research priorities and scored the compiled priorities against four criteria – health and social impact, equity, feasibility, and overall importance. Priorities were then ranked by score. A group of 29 experts finalised the top 10 research priorities for each of maternal, newborn or child health and a cross-cutting area.

Results

A total of 310 experts proposed 867 research priorities, which were consolidated into 444 priorities and scored by 280 experts. Top maternal and newborn health priorities focused on research to improve the delivery of SBCE interventions that strengthen self-care/family care practices and care-seeking behaviour. Child health priorities focused on the delivery of SBCE interventions, emphasising determinants of service utilisation and breastfeeding and nutrition practices. Cross-cutting MNCH priorities highlighted the need for better integration of SBCE into facility-based and community-based health services.

Conclusions

Achieving global targets for MNCH requires increased investment in SBCE interventions that build capacities of individuals, families and communities as agents of their own health. Findings from this exercise provide guidance to prioritise investments and ensure that they are best directed to achieve global objectives. Stakeholders are encouraged to use these priorities to guide future research investments and to adapt them for country programmes by engaging with national level stakeholders.

Evaluation of a health promotion intervention associated with birthing centres in rural Nepal

INTRODUCTION

Birthing centres (BC) in Nepal are mostly situated in rural areas and provide care for women without complications. However, they are often bypassed by women and their role in providing good quality maternity services is overlooked. This study evaluated an intervention to increase access and utilisation of perinatal care facilities in community settings.

METHODS

This longitudinal cross-sectional study was conducted over five years in four villages in Nepal and included two BCs. An intervention was conducted in 2014-2016 that involved supporting the BCs and conducting a health promotion programme with local women. Population-based multi-stage sampling of women of reproductive age with a child below 24 months of age was undertaken. Household surveys were conducted (2012 and 2017) employing trained enumerators and using a structured validated questionnaire. The collected data were entered into SPSS and analysed comparing pre- and post-intervention surveys.

RESULTS

The intervention was associated with an increase in uptake in facility birth, with an increase in utilisation of perinatal services available from BCs. The post-intervention survey provided evidence that women were more likely to give birth at primary care facilities (OR 5.60, p-value <0.001) than prior to the intervention. Similarly, the likelihood of giving birth at a health facility increased if decision for birthplace was made jointly by women and family members for primary care facilities (OR 1.76, p-value 0.023) and hospitals/tertiary care facilities (OR 1.78, p-value 0.020. If women had less than four ANC visits, then they were less likely to give birth at primary care facilities (OR 0.39, p-value <0.001) or hospitals/tertiary care facilities (OR 0.63, p-value 0.014). Finally, women were less likely to give birth at primary care facilities if they had only primary level of education (OR 0.49, p-value 0.014).

CONCLUSION

BCs have the potential to increase the births at health facilities and decrease home births if their services are promoted by the local health promoters. In addition, socio-economic factors including women's education, the level of women's autonomy and having four or more ANC visits affect the utilisation of perinatal services at the health facility.

Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions

BACKGROUND

Emerging evidence and program experience indicate that engaging men in maternal and newborn health can have considerable health benefits for women and children in low- and middle-income countries. Previous reviews have identified male involvement as a promising intervention, but with a complex evidence base and limited direct evidence of effectiveness for mortality and morbidity outcomes.

OBJECTIVE

To determine the effect of interventions to engage men during pregnancy, childbirth and infancy on mortality and morbidity, as well as effects on mechanisms by which male involvement is hypothesised to influence mortality and morbidity outcomes: home care practices, care-seeking, and couple relationships.

METHODS

Using a comprehensive, highly sensitive mapping of maternal health intervention studies conducted in low- and middle-income countries between 2000 and 2012, we identified interventions that have engaged men to improve maternal and newborn health. Primary outcomes were care-seeking for essential services, mortality and morbidity, and home care practices. Secondary outcomes relating to couple relationships were extracted from included studies.

RESULTS

Thirteen studies from nine countries were included. Interventions to engage men were associated with improved antenatal care attendance, skilled birth attendance, facility birth, postpartum care, birth and complications preparedness and maternal nutrition. The impact of interventions on mortality, morbidity and breastfeeding was less clear. Included interventions improved male partner support for women and increased couple communication and joint decision-making, with ambiguous effects on women's autonomy.

CONCLUSION

Interventions to engage men in maternal and newborn health can increase care-seeking, improve home care practices, and support more equitable couple communication and decision-making for maternal and newborn health. These findings support engaging men as a health promotion strategy, although evidence gaps remain around effects on mortality and morbidity. Findings also indicate that interventions to increase male involvement should be carefully designed and implemented to mitigate potential harmful effects on couple relationship dynamics.