Protocol for an intervention development and pilot implementation evaluation study of an e-health solution to improve newborn care quality and survival in two low-resource settings, Malawi and Zimbabwe: Neotree

INTRODUCTION

Every year 2.4 million deaths occur worldwide in babies younger than 28 days. Approximately 70% of these deaths occur in low-resource settings because of failure to implement evidence-based interventions. Digital health technologies may offer an implementation solution. Since 2014, we have worked in Bangladesh, Malawi, Zimbabwe and the UK to develop and pilot Neotree: an android app with accompanying data visualisation, linkage and export. Its low-cost hardware and state-of-the-art software are used to improve bedside postnatal care and to provide insights into population health trends, to impact wider policy and practice.

METHODS AND ANALYSIS

This is a mixed methods (1) intervention codevelopment and optimisation and (2) pilot implementation evaluation (including economic evaluation) study. Neotree will be implemented in two hospitals in Zimbabwe, and one in Malawi. Over the 2-year study period clinical and demographic newborn data will be collected via Neotree, in addition to behavioural science informed qualitative and quantitative implementation evaluation and measures of cost, newborn care quality and usability. Neotree clinical decision support algorithms will be optimised according to best available evidence and clinical validation studies.

ETHICS AND DISSEMINATION

This is a Wellcome Trust funded project (215742_Z_19_Z). Research ethics approvals have been obtained: Malawi College of Medicine Research and Ethics Committee (P.01/20/2909; P.02/19/2613); UCL (17123/001, 6681/001, 5019/004); Medical Research Council Zimbabwe (MRCZ/A/2570), BRTI and JREC institutional review boards (AP155/2020; JREC/327/19), Sally Mugabe Hospital Ethics Committee (071119/64; 250418/48). Results will be disseminated via academic publications and public and policy engagement activities. In this study, the care for an estimated 15 000 babies across three sites will be impacted.

TRIAL REGISTRATION NUMBER

NCT0512707; Pre-results.

Financial risk of seeking maternal and neonatal healthcare in southern Ethiopia: a cohort study of rural households

INTRODUCTION

Ethiopian households' out-of-pocket healthcare payments constitute one-third of the national healthcare budget and are higher than the global and low-income countries average, and even the global target. Such out-of-pocket payments pose severe financial risks, can be catastrophic, impoverishing, and one of the causal barriers for low utilisation of healthcare services in Ethiopia. This study aimed to assess the financial risk of seeking maternal and neonatal healthcare in southern Ethiopia.

METHODS

A population-based cohort study was conducted among 794 pregnant women, 784 postpartum women, and their 772 neonates from 794 households in rural kebeles of the Wonago district, southern Ethiopia. The financial risk was estimated using the incidence of catastrophic healthcare expenditure, impoverishment, and depth of poverty. Annual catastrophic healthcare expenditure was determined if out-of-pocket payments exceeding 10% of total household or 40% of non-food expenditure. Impoverishment was analysed based on total household expenditure and the international poverty line of ≈ $1.9 per capita per day.

RESULTS

Approximately 93% (735) of pregnant women, 31% (244) of postpartum women, and 48% (369) of their neonates experienced illness. However, only 56 households utilised healthcare services. The median total household expenditure was $527 per year (IQR = 390: 370,760). The median out-of-pocket healthcare payment was $46 per year (IQR = 46: 46, 92) with two episodes per household, and shared 19% of the household's budget. The poorer households paid more than did the richer for healthcare, during pregnancy-related and neonatal illness. However, the richer paid more than did the poorer during postpartum illness. Forty-six percent of households faced catastrophic healthcare expenditure at the threshold of 10% of total household expenditure, or 74% at a 40% non-food expenditure, and associated with neonatal illness (aRR: 2.56, 95%CI: 1.02, 6.44). Moreover, 92% of households were pushed further into extreme poverty and the poverty gap among households was 45 Ethiopian Birr per day. The average household size among study households was 4.7 persons per household.

CONCLUSIONS

This study demonstrated that health inequity in the household's budget share of total OOP healthcare payments in southern Ethiopia was high. Besides, utilisation of maternal and neonatal healthcare services is very low and seeking such healthcare poses a substantial financial risk during illness among rural households. Therefore, the issue of health inequity should be considered when setting priorities to address the lack of fairness in maternal and neonatal health.

Costs and cost-effectiveness analyses of mCARE strategies for promoting care seeking of maternal and newborn health services in rural Bangladesh

Objective

We examined the incremental cost-effectiveness between two mHealth programs, implemented from 2011 to 2015 in rural Bangladesh: (1) Comprehensive mCARE package as an intervention group and (2) Basic mCARE package as a control group.

Methods

Both programs included a core package of census enumeration and pregnancy surveillance provided by an established cadre of digitally enabled community health workers (CHWs). In the comprehensive mCARE package, short message service (SMS) and home visit reminders were additionally sent to pregnant women (n = 610) and CHWs (n = 70) to promote the pregnant women’s care-seeking of essential maternal and newborn care services. Economic costs were assessed from a program perspective inclusive of development, start-up, and implementation phases. Effects were calculated as disability adjusted life years (DALYs) and the number of newborn deaths averted. For comparative purposes, we normalized our evaluation to estimate total costs and total newborn deaths averted per 1 million people in a community for both groups. Uncertainty was assessed using probabilistic sensitivity analyses with Monte Carlo simulation.

Results

The addition of SMS and home visit reminders based on a mobile phone-facilitated pregnancy surveillance system was highly cost effective at a cost per DALY averted of $31 (95% uncertainty range: $19–81). The comprehensive mCARE program had at least 88% probability of being highly cost-effective as compared to the basic mCARE program based on the threshold of Bangladesh’s GDP per capita.

Conclusion

mHealth strategies such as SMS and home visit reminders on a well-established pregnancy surveillance system may improve service utilization and program cost-effectiveness in low-resource settings.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT02402855; pre-results.

Effects of state-level Earned Income Tax Credit laws in the U.S. on maternal health behaviors and infant health outcomes

The purpose of this paper is to investigate the effects of state-level Earned Income Tax Credit (EITC) laws in the U.S. on maternal health behaviors and infant health outcomes. Using multi-state, multi-year difference-in-differences analyses, we estimated effects of state EITC generosity on maternal health behaviors, birth weight and gestation weeks. We find little difference in maternal health behaviors associated with state-level EITC. In contrast, results for key infant health outcomes of birth weight and gestation weeks show small improvements in states with EITCs, with larger effects seen among states with more generous EITCs. Our results provide evidence for important health benefits of state-level EITC policies.

Effects of drought on child health in Marsabit District, Northern Kenya

This study uses five years of panel data (2009-2013) for Northern Kenya's Marsabit district to analyze the levels and extent of malnutrition among children aged five and under in that area. We measure drought based on the standardized normalized difference vegetation index (NDVI) and assess its effect on child health using mid-upper arm circumference (MUAC). The results show that approximately 20 percent of the children in the study area are malnourished and a one standard deviation increase in NDVI z-score decreases the probability of child malnourishment by 12-16 percent. These findings suggest that remote sensing data can be usefully applied to develop and evaluate new interventions to reduce drought effects on child malnutrition, including better coping strategies and improved targeting of food aid.

11 years of tracking aid to reproductive, maternal, newborn, and child health: estimates and analysis for 2003-13 from the Countdown to 2015

BACKGROUND

Tracking aid flows helps to hold donors accountable and to compare the allocation of resources in relation to health need. With the use of data reported by donors in 2015, we provided estimates of official development assistance and grants from the Bill & Melinda Gates Foundation (collectively termed ODA+) to reproductive, maternal, newborn, and child health for 2013 and complete trends in reproductive, maternal, newborn, and child health support for the period 2003-13.

METHODS

We coded and analysed financial disbursements to reproductive, maternal, newborn, and child health to all recipient countries from all donors reporting to the creditor reporting system database for the year 2013. We also revisited disbursement records for the years 2003-08 and coded disbursements relating to reproductive and sexual health activities resulting in the Countdown dataset for 2003-13. We matched this dataset to the 2015 creditor reporting system dataset and coded any unmatched creditor reporting system records. We analysed trends in ODA+ to reproductive, maternal, newborn, and child health for the period 2003-13, trends in donor contributions, disbursements to recipient countries, and targeting to need.

FINDINGS

Total ODA+ to reproductive, maternal, newborn, and child health reached nearly US$14 billion in 2013, of which 48% supported child health ($6·8 billion), 34% supported reproductive and sexual health ($4·7 billion), and 18% maternal and newborn health ($2·5 billion). ODA+ to reproductive, maternal, newborn, and child health increased by 225% in real terms over the period 2003-13. Child health received the most substantial increase in funding since 2003 (286%), followed by reproductive and sexual health (194%), and maternal and newborn health (164%). In 2013, bilateral donors disbursed 59% of all ODA+ to reproductive, maternal, newborn, and child health, followed by global health initiatives (23%), and multilateral agencies (13%). Targeting of ODA+ to reproductive, maternal, newborn, and child health to countries with the greatest health need seems to have improved over time.

INTERPRETATION

The increase in reproductive, maternal, newborn, and child health funding over the period 2003-13 is encouraging. Further increases in funding will be needed to accelerate maternal mortality reduction while keeping a high level of investment in sexual and reproductive health and in child health.

FUNDING

Subgrant OPP1058954 from the US Fund for UNICEF under their Countdown to 2015 for Maternal, Newborn and Child Survival Grant from the Bill & Melinda Gates Foundation.

Using guidelines to improve neonatal health in China and Vietnam: a qualitative study

BACKGROUND

Neonatal health (NH) remains a major problem in many countries. Children dying before 28 days often suffer from conditions that are preventable or treatable with proven, cost-effective interventions. The knowledge gaps are no longer about what should be done, but to understand why guidelines including these interventions are not followed. Using a behaviour change framework, this study explores neonatal health guidelines use and the role of management in supporting effective usage in two rural settings in China and Vietnam.

METHODS

Semi-structured interviews with policy makers, health care managers and providers (n = 49) and focus group discussions with women, husbands and grandmothers who had experienced maternal and NH care services within the last year (n = 7) were conducted. Data were analysed using the framework approach.

RESULTS

Guidelines are not readily available at county, township and village levels in the study sites in China, whereas, in Vietnam, guidelines are available, accepted and being used at facility level. Improvements in implementation could be made in both settings. Factors influencing guidelines use common to both settings included: lack of equipment and supplies; shortage of staff with NH care experience; and guidelines not in line with patient practices. Factors specific to China included: poor guidelines dissemination; and disagreement with guidelines. There was limited community engagement in NH services in China, whereas in Vietnam, community members were actively involved in decision making and provision of services. Managers have an important role in supporting NH guidelines use through: ensuring guidelines are available; allocating appropriate resources; supporting and monitoring staff in their use; and engaging with local communities to promote effective practices.

CONCLUSIONS

Engaging managers to support implementation is crucial. Management systems that provide the necessary resources, competent staff, and monitoring, regulatory and incentive frameworks as well as community engagement are needed to promote adoption of guidelines. Further research on how best to strengthen local level management so that they tailor interventions to support guideline use to their specific context is needed. This will ensure that proven interventions to address NH problems are used, and that countries move closer to achieving the new Sustainable Development Goal 3 target.

Costs of Newborn Care Following Complications During Pregnancy and Delivery

The aim of this study is examine the impact of pregnancy and delivery complications on the healthcare costs of newborns during the first 3 months of life. We conducted a retrospective cohort study of newborns born to women ages 15-49 using de-identified medical and pharmacy claims from the Truven Health MarketScan Commercial Claims and Encounters database incurred between January 1, 2007 and December 31, 2011. Total healthcare costs and resource utilization were examined and compared for the first 3 months of life between cohorts of newborns either with or without evidence of categorized maternal complications. Incremental costs were also determined using multivariable analysis for the conditions found to be the most prevalent in the study population. A total of 137,040 infants were studied, 75.4% of which were born to mothers who had experienced at least one complication during pregnancy or delivery. Fetal abnormalities (26.2%), early or threatened labor (16.6%), and hemorrhage (10.8%) were the most frequently observed complications. Diabetes (8.0%) and hypertension (7.7%) were also common, with the majority of other conditions present in 1% or less of the study population. Adjusted analyses found significant differences for seven conditions where incremental costs ranged from $987 to $10,287. Complications are common during pregnancy and delivery and some complications may lead to increased healthcare costs for newborns immediately following birth.

Medicaid reimbursement, prenatal care and infant health

This paper evaluates the impact of state-level Medicaid reimbursement rates for obstetric care on prenatal care utilization across demographic groups. It also uses these rates as an instrumental variable to assess the importance of prenatal care on birth weight. The analysis is conducted using a unique dataset of Medicaid reimbursement rates and 2001-2010 Vital Statistics Natality data. Conditional on county fixed effects, the study finds a modest, but statistically significant positive relationship between Medicaid reimbursement rates and the number of prenatal visits obtained by pregnant women. Additionally, higher rates are associated with an increase in the probability of obtaining adequate care, as well as a reduction in the incidence of going without any prenatal care. However, the effect of an additional prenatal visit on birth weight is virtually zero for black disadvantaged mothers, while an additional visit yields a substantial increase in birth weight of over 20 g for white disadvantaged mothers.