Addressing Critical Knowledge Gaps in Newborn Health

Blog

By Pragya Vats on September 2, 2014
India
Asia

This blog was originally published by Save the Children UK. Written by Pragya Vats

On 18 August, there were 500 days left to meet the Millennium Development Goals (MDGs).

That really isn’t very long.

The world is on the brink of a major breakthrough in ensuring mothers, newborns and children in the poorest parts of the world can survive and thrive.

And India is at the forefront of this revolution.

Celebrating success, building momentum

It is heartening to note that India is on track to meet MDG 5 by reducing the maternal mortality rate from 437 per 100,000 in 1990 to 178 per 100,000 by 2012.

That’s a decrease of 70% – particularly impressive given that the global figure for the same period has been 48%.

Bringing down the under-five mortality rate

India has also made dramatic progress in bringing down the under-five mortality rate from 114 per 1,000 live births  in 1990 to 52 in 2012. That’s a reduction of 58% – more than half, again ahead of the global rate (44.8%).

But it isn’t enough. We continue to lose 1.4 million children a year before they see their fifth birthday. More than half of those are newborn deaths – a particular challenge for India, which accounts for 26.6% of all newborn deaths globally.

A baby’s first day is his or her most vulnerable. If we want to see real progress on child survival it is vital that we find ways to protect these fragile new lives.

From pledges to action

India has already initiated a nationwide push to reach every mother and newborn with essential healthcare services.

The strategy aims to build on existing partnerships and forge new ones, bringing together the business sector, private individuals, training institutions, civil society and faith-based organisations to deliver unprecedented breakthroughs in newborn and child survival.

A Minister speaks out

India’s Health Minister, Dr Harshvardhan, has spelled out this government’s commitment to accelerating progress on maternal and child survival.

Speaking in Washington DC, he said: “It is now evident that with sustained efforts across the globe with a focus on equality, the goal of ending preventable child and maternal deaths by 2035 seems well within our reach.”

Political will is the most important initial factor in achieving any large-scale change. Dr Harshvardhan’s words made clear that we have that.

Keeping the momentum

We know that curbing child mortality levels in India will make a massive difference to global child mortality figures. The world is looking to India to turn our pledges into reality.

Today we are at a critical point and success seems within our grasp. Even with fewer than 500 days to go, one final push will indeed see India achieve the MDG targets on maternal and child survival.

Will India surprise the world?

By Ian Hurley on August 29, 2014
Middle East

Raeda, 33, recovers in a bed at Al Awda Hospital after giving birth to her firstborn, a daughter. Raeda lives in Jabalyia, northern Gaza Strip. Photo: Loulou d'Aki/Save the Children  

The conflict in Gaza has caused the upheaval of the health system. For women and newborns it has been much more difficult to secure health services like antenatal and postnatal care, which are critical for survival and a healthy start to life.

The Palestinian Ministry of Health has reported that over 4500 babies have been born during the 29 days of active fighting before the first 72-hour ceasefire was agreed to. Amnesty International has also reported that health workers and hospitals have been deliberately attached during the fighting. 

The needs of pregnant women and newborn babies are critical in the best of circumstances and in emergency and conflict settings there is an even greater need to prioritize and deliver care. 

Resources

By Manzi Anatole on August 28, 2014
Rwanda
Africa

MESH-QI mentor conducting training on neonatal resuscitation at health center level

This blog was originally published by the Maternal Health Task Force as part of their “Continuum of Care” blog series.

Partners In Health, in collaboration with the Rwandan Ministry of Health, implemented a program entitled Mentorship and Enhanced Supervision at Health Centers and Quality Improvement (MESH-QI) to address inefficiencies in current health center training and clinical practice of nurses. MESH-QI improves care delivery through:

  1. Decentralized pre-service training at the district level
  2. Building capacity of the existing district supervisory structure
  3. Initiation of a systems focus on clinical mentoring and coaching of health center teams
  4. Use of data for continuous quality improvement

Figure 1: Pillars of Mentorship, Enhanced Supervision and Quality Improvement Program

Current health center training for nurses consists of centralized pre-service training and limited in-service supervision. The pre-service training includes emergency obstetrics and newborn care (EmONC) and focused antenatal care (FANC), but periodic supervision visits by district hospital supervisors are largely consumed with data collection and reporting, with limited opportunities for on-site clinical mentoring and re-training.

To address this gap in training, MESH-QI mentors make routine intensive visits to health centers, lasting at least two days, in which they provide on-site case management observation; support for higher level problem-solving, diagnostic, and decision-making skills; lead case discussions; and address quality improvement issues (see Figure 1). By routinely capturing valuable data on nurses’ clinical skills, facility conditions, and clinical indicators, clinical supervisors also enhance the feedback loop for quality improvement.

Key lessons learned

Mentorship catalyzes translation of theory to practice

Clinicians expressed this as one of the positive aspects of MESH-QI interventions. Mentors use various adult learning techniques to support nurses to address the “knowledge-practice gap.” This facilitates the implementation of FANC at MESH-QI supported sites.

Mentorship improves clinicians’ confidence, motivation and adherence to MCH protocols

Prior to the implementation of MESH-QI, there were challenges in learning how to effectively integrate and utilize national protocols, guidelines, and tools. One nurse mentee mentioned: “They built my confidence not only in screening and case management, but also in general nursing care I provide every day. I feel proud of the work when I can handle even the complicated cases that I could not manage before… their support.”

Mentoring checklists enable evidence-based feedback and continuous QI

Using mentoring and coaching tools, such as checklists for case management, facility, and systems observations, enables mentors to provide objective and constructive feedback and regular monitoring of ANC delivery.

MESH-QI is an effective strategy to improve the quality of antenatal care


Figure 2: Quality of ANC Assessments at Baseline and Post-mentoring

With mentoring, uniform improvement was observed regardless of baseline EmONC/FANC-training status (Figure 2). This demonstrated that mentorship is a promising intervention to help improve the quality of FANC regardless of baseline training status. Mentoring, therefore, is particularly applicable to resource-limited healthcare settings facing human resources challenges. While EmONC and other didactic trainings are still costly—particularly in developing countries—on-site mentorship is an option to mitigate these challenges.

MESH-QI integrates in-service training and systems improvement into routine care delivery

In-service training bypasses the challenge of extracting nurses from their health centers to attend workshops in main cities, which could be hours away. Mentorship and coaching sessions take place at the health facility level, which avoids worsening staff shortages, an already significant challenge in resource-limited settings.

In Summary

The MESH-QI approach is also proving successful in several other health domains, including neonatal care and integrated management of childhood illness (IMCI), by strengthening the entire spectrum of care for families. The Ministry of Health of Rwanda has a number of efforts underway to replicate and scale this mentorship approach.

To learn more about mentorship, enhanced supervision and quality improvement in Rwanda, please see the following:

 

By Adnan Sajid on August 27, 2014
Pakistan
Asia


Photo: Ayesha Vellani/Save the Children 

This blog was originally posted by the EveryOne Campaign. Written by Adnan Sajid

World Breastfeeding Week 2014 was celebrated in August all over the world from the 1st to 7th. The week provided a platform to orient people on how about 800,000 under five child deaths can be prevented if all 0-23 month old infants are optimally breastfed.

Breastfeeding is beneficial both for mother and her children. Breastfed babies have lesser chances of asthma, childhood obesity, ear infections, eczema (atopic dermatitis), diarrhoea and vomiting, low respiratory infections, necrotizing enterocolitis (a disease that affects the gastrointestinal tract in pre-term infants), sudden infant death syndrome (SIDS) and Type 2 diabetes. While mothers who breastfeed their children have lesser chances of breast cancer; breastfeeding assist mothers in healing following childbirth and getting back to their pre-pregnancy weight quicker.

In more than 175 countries worldwide, breastfeeding advocates celebrated the theme 'Breastfeeding: A winning goal - for life’ highlighting that achieving the Millennium Development Goals (especially MDGs 4 and 5) requires more early, exclusive and continued breastfeeding.

EVERY ONE Pakistan commemorated the week with advocacy activities across the country. In Khyber Pakhtunkhwa province, a press briefing session was jointly organised by EVERY ONE and Child Rights Movement Khyber Pakhtunkhwa chapter at the Peshawar Press Club on August 7th. Then again on August 11th, EVERY ONE in collaboration with Child Rights Movement Khyber Pakhtunkhwa held an advocacy seminar for civil society organizations.

Both the events shared how Pakistan is the South Asian country with the lowest exclusive breastfeeding and highest bottle feeding rates. Over the last seven years, only a 0.6% increase has been seen in infants who are exclusively breastfed. According to the Demographic Health Survey, the overall percentage stood at 37.7 in 2012-13: Whereas, the percentage of bottle feeding rose from 32.1 in 2006-07 to 41% in 2012-13. Experts opined that the increasing trends in bottle feeding across the country were due to a lack of awareness.

In the province of Khyber Pakhtunkhwa, the percentage of exclusive breastfeeding is at 27%; percentage of infants ever breastfed is 96.5%; the timely initiation of breastfeeding is at 26.4%; while the continued breastfeeding rate at 12-25 months is 83.6% and at 20-23 months is 55%.

Civil society organisations at these advocacy events were urged to undertake strong lobbying in the form of social mobilization events, meetings with local body members, provincial legislators and the media to put pressure on the Government of Khyber Pakhtunkhwa to expedite legislation for breastfeeding similar to the other three provinces in Pakistan. The protection of children and their mothers from different diseases will be easily possible following the passage of Khyber Pakhtunkhwa Protection of Breastfeeding and Child Nutrition Bill.

Dr. Qaisar Ali, Deputy Director Reproductive Health/Nutrition stated: Except Khyber Pakhtunkhwa where legislation is still pending, all provinces have adopted/passed provincial laws for the protection and promotion breastfeeding. Due to the absence of provincial legislation in Khyber Pakhtunkhwa, the federal Protection of Breast-Feeding and Child Nutrition Ordinance 2002 is still applicable in the province. However, in the context of 18th Constitutional Amendment, Government of Khyber Pakhtunkhwa should introduce provincial legislation keeping in view the provincial realties. Recently, after two and a half year delay, the Khyber Pakhtunkhwa Protection of Breastfeeding and Child Nutrition Bill has been sent to the provincial cabinet for a final nod; however, political will is needed for approval of the bill.

CRM members also urged the implementation of the breastfeeding and marketing code, improved breastfeeding counselling by healthcare providers, and a revision of the undergraduate curriculum with a greater emphasis on good infant and young child feeding practices. The creation of baby-friendly health facilities, behaviour change strategies to promote breastfeeding, the development of effective messages and counselling of women at all education levels was also urged.

Early marriages, the poor status of women, repeated pregnancies, poor maternal nutrition, food restrictions in pregnancies due to taboos/myths, and poor antenatal care were a few of the reasons cited for the poor breastfeeding practices among women in Pakistan.

CRM members also provided information on the MDGs and how they related to breastfeeding and infant young child feeding (IYCF) to showcase the progress made so far and key gaps in breastfeeding and IYCF; to call attention for stepping up actions to protect, promote and support breastfeeding as key intervention in MDGs and in the post 2015 era; and, to stimulate interest among young people of both genders to see the relevance of breastfeeding in today’s changing world.

A documentary on the breastfeeding practices in Pakistan was also launched at the advocacy seminar. Save the Children has always been at the forefront in advocating children’s rights and by launching this impressive documentary, we once again registered our concerns on deaths among children which can be prevented by breastfeeding practices in children.

It is the basic right of an infant to be breastfeed for at least two years. Exclusive breastfeeding for at least 6 months can strengthen the immunity of a child. It gives our babies the healthiest start that will last a life time. The choice to breastfeed is an investment in our babies’ future!

By Alexandra Shaphren on August 22, 2014
Research

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Background: Preterm birth is the leading cause of infant mortality globally, including Brazil. We will evaluate whether oral magnesium citrate reduces the risk of placental dysfunction and its negative consequences for both the fetus and mother, which, in turn, should reduce the need for indicated preterm delivery.
 
Methods : We will complete a multicenter, randomized double-blind clinical trial comparing oral magnesium citrate 150 mg twice daily (n = 2000 women) to matched placebo (n = 1000 women), starting at 121/7 to 206/7 weeks gestation and continued until delivery. We will include women at higher risk for placental dysfunction, based on clinical factors from a prior pregnancy (e.g., prior preterm delivery, stillbirth or preeclampsia) or the current pregnancy (e.g., chronic hypertension, pre-pregnancy diabetes mellitus, maternal age > 35 years or pre-pregnancy maternal body mass index > 30 kg/m2). The primary perinatal outcome is a composite of preterm birth < 37 weeks gestation, stillbirth > 20 weeks gestation, neonatal death < 28 days, or SGA birthweight < 3rd percentile. The primary composite maternal outcome is preeclampsia arising < 37 weeks gestation, severe non-proteinuric hypertension arising < 37 weeks gestation, placental abruption, maternal stroke during pregnancy or <= 7 days after delivery, or maternal death during pregnancy or <= 7 days after delivery.
 
Discussion: The results of this randomized clinical trial may be especially relevant in low and middle income countries that have high rates of prematurity and limited resources for acute newborn and maternal care.
 
Trial registration: ClinicalTrials.gov Identifier NCT02032186, registered December 19, 2013.
 
A.M. Bergh, K. Kerber, S. Abwao, et al. Implementing facility-based kangaroo mother care services: lessons from a multi-country study in Africa. BioMed Central (July,2014).
 
Background : Some countries have undertaken programs that included scaling up kangaroo mother care. The aim of this study was to systematically evaluate the implementation status of facility-based kangaroo mother care services in four African countries: Malawi, Mali, Rwanda and Uganda.
 
Methods: A cross-sectional, mixed-method research design was used. Stakeholders provided background information at national meetings and in individual interviews. Facilities were assessed by means of a standardized tool previously applied in other settings, employing semi-structured key-informant interviews and observations in 39 health care facilities in the four countries. Each facility received a score out of a total of 30 according to six stages of implementation progress.
 
Results: Across the four countries 95 per cent of health facilities assessed demonstrated some evidence of kangaroo mother care practice. Institutions that fared better had a longer history of kangaroo mother care implementation or had been developed as centres of excellence or had strong leaders championing the implementation process. Variation existed in the quality of implementation between facilities and across countries. Important factors identified in implementation are: training and orientation; supportive supervision; integrating kangaroo mother care into quality improvement; continuity of care; high-level buy in and support for kangaroo mother care implementation; and client-oriented care.
 
Conclusion: The integration of kangaroo mother care into routine newborn care services should be part of all maternal and newborn care initiatives and packages. Engaging ministries of health and other implementing partners from the outset may promote buy in and assist with the mobilization of resources for scaling up kangaroo mother care services. Mechanisms for monitoring these services should be integrated into existing health management information systems.
 
 
In Tanzania, the coverage of four or more antenatal care (ANC 4) visits among pregnant women has declined over time. We conducted an exploratory analysis to identify factors associated with utilization of ANC 4 and ANC 4 decline among pregnant women over time. We used data from 8035 women who delivered within two years preceding Tanzania Demographic and Health Surveys conducted in 1999, 2004/05 and 2010. Multivariate logistic regression models were used to examine the association between all potential factors and utilization of ANC 4; and decline in ANC 4 over time. Factors positively associated with ANC 4 utilization were higher quality of services, testing and counseling for HIV during ANC, receiving two or more doses of SP (Sulphadoxine Pyrimethamine)/Fansidar for preventing malaria during ANC and higher educational status of the woman. Negatively associated factors were residing in a zone other than Eastern zone, never married woman, reported long distance to health facility, first ANC visit after four months of pregnancy and woman's desire to avoid pregnancy. The factors significantly associated with decline in utilization of ANC 4 were: geographic zone and age of the woman at delivery. Strategies to increase ANC 4 utilization should focus on improvement in quality of care, geographic accessibility, early ANC initiation, and services that allow women to avoid pregnancy. The interconnected nature of the Tanzanian Health System is reflected in ANC 4 decline over time where introduction of new programs might have had unintended effects on existing programs. An in-depth assessment of the recent policy change towards Focused Antenatal Care and its implementation across different geographic zones, including its effect on the perception and understanding among women and performance and counseling by health providers can help explain the decline in ANC 4.
  
 
Background: Considerable improvements in life expectancy and other human development indicators in Indonesia are thought to mask considerable disparities between populations in the country. We examine the existence and extent of these disparities by measuring trends and inequalities in the under-five mortality rate and neonatal mortality rate across wealth, education and geography.
 
Methodology: Using data from seven waves of the Indonesian Demographic and Health Surveys, direct estimates of under-five and neonatal mortality rates were generated for 1980–2011. Absolute and relative inequalities were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. Disparities were assessed by levels of rural/urban location, island groups, maternal education and household wealth.
 
Findings: Declines in national rates of under-five and neonatal mortality have accorded with reductions of absolute inequalities in clusters stratified by wealth, maternal education and rural/urban location. Across these groups, relative inequalities have generally stabilised, with possible increases with respect to mortality across wealth subpopulations. Both relative and absolute inequalities in rates of under-five and neonatal mortality stratified by island divisions have widened.
 
Conclusion: Indonesia has made considerable gains in reducing under-five and neonatal mortality at a national level, with the largest reductions happening before the Asian financial crisis (1997–98) and decentralisation (2000). Hasty implementation of decentralisation reforms may have contributed to a slowdown in mortality rate reduction thereafter. Widening inequities between the most developed provinces of Java-Bali and those of other island groupings should be of particular concern for a country embarking on an ambitious plan for universal health coverage by 2019. A focus on addressing the key supply side barriers to accessing health care and on the social determinants of health in remote and disadvantaged regions will be essential for this plan to be realised.
 
T. Houweling, J. Morrison, K. Azad, et al. How to reach every newborn: three key messages. The Lancet Global Health (July, 2014).
 
The Every Newborn Action Plan (ENAP) launched on June 30–July 1, 2014, envisages a world without
preventable deaths of newborn infants. The challenge is not technical (effective interventions exist), but instead social. The odds of a child surviving the first month of life are grossly unequal, even within one country, and are affected by wealth, education, caste, and access to health care. Large gains are achievable when interventions reach people who are in need, but this rarely occurs. Without dedicated efforts to reach poor people, ENAP initiatives are likely to favor wealthier people who have the lowest mortality risk. We summarise lessons from an international workshop, New Evidence Supporting Equity in Newborn and Maternal Health in South Asia, held for researchers, policy makers, and practitioners in Kathmandu, Nepal, on May 8–9, 2014. Three key messages on how to reach poor people emerged—universalise, soft-target, and monitor.
 
 
While the importance of mHealth scale-up has been broadly emphasized in the mHealth community, it is necessary to guide scale up efforts and investment in ways to help achieve the mortality reduction targets set by global calls to action such as the Millennium Development Goals, not merely to expand programs. We used the Lives Saved Tool (LiST)–an evidence-based modeling software–to identify priority areas for maternal and neonatal health services, by formulating six individual and combined interventions scenarios for two countries, Bangladesh and Uganda. Our findings show that skilled birth attendance and increased facility delivery as targets for mHealth strategies are likely to provide the biggest mortality impact relative to other intervention scenarios. Although further validation of this model is desirable, tools such as LiST can help us leverage the benefit of mHealth by articulating the most appropriate delivery points in the continuum of care to save lives.
  
N. Lira Huq, A.i Jahan Azmi, M. Quaiyum, et al. Toll free mobile communication: overcoming barriers in maternal and neonatal emergencies in Rural Bangladesh. Reproductive Health Journal (July, 2014).
 
Background: Toll free mobile telephone intervention to support mothers in pregnancy and delivery period was tested in one sub district of Bangladesh. Qualitative research was conducted to measure the changes of mobile phone use in increasing communication for maternal and neonatal complications.
 
Methods: In-depth interviews were conducted among twelve Community Skilled Birth Attendants and fourteen mothers along with their husbands prior to intervention. At intervention end, six Community Skilled Birth Attendants were purposively selected for in-depth interview. Semi structured interviews were conducted among all 27 Community Skilled Birth Attendants engaged in the intervention. One Focus Group Discussion was conducted with 10 recently delivered mothers. Thematic analysis and triangulation of different responses were conducted.
 
Results: Prior to intervention, Community Skilled Birth Attendants reported that mobile communication was not a norm. It was also revealed that poor mothers had poor accessibility to mobile services. Mothers, who communicated through mobile phone with providers noted irritability from Community Skilled Birth Attendants and sometimes found phones switched off. At the end of the project, 85% of mothers who had attended orientation sessions of the intervention communicated with Community Skilled Birth Attendants through mobile phones during maternal health complications. Once a complication is reported or anticipated over phone, Community Skilled Birth Attendants either made a prompt visit to mothers or advised for direct referral. More than 80% Community Skilled Birth Attendants communicated with Solution Linked Group for guidance on maternal health management. Prior to intervention, Solution Linked Group was not used to receive phone call from Community Skilled Birth Attendants. Community Skilled Birth Attendants were valued by the mothers. Mothers viewed that Community Skilled Birth Attendants are becoming confident in managing complication due to communication with Solution Linked Group.
 
Conclusions: The use of mobile technology in this intervention took a leap from simply rendering information to providing more rapid services. Active participation of service providers along with mothers’ accessibility motivated both the service providers and mothers to communicate through mobile phone for maternal health issues. These altogether made the shift towards adoption of an innovation.
 
 
Background: Preterm birth (PB) and fetal growth restriction (FGR) convey the highest risk of perinatal mortality and morbidity, as well as increasing the chance of developing chronic disease in later life. Identifying early in pregnancy the unfavourable maternal conditions that can predict poor birth outcomes could help their prevention and management. Here we used an exploratory metabolic profiling approach (metabolomics) to investigate the association between birth outcomes and metabolites in maternal urine collected early in pregnancy as part of the prospective mother–child cohort Rhea study. Metabolomic techniques can simultaneously capture information about genotype and its interaction with the accumulated exposures experienced by an individual from their diet, environment, physical activity or disease (the exposome). As metabolic syndrome has previously been shown to be associated with PB in this cohort, we sought to gain further insight into PB-linked metabolic phenotypes and to define new predictive biomarkers.
 
Methods: Our study was a case–control study nested within the Rhea cohort. Major metabolites (n = 34) in maternal urine samples collected at the end of the first trimester (n = 438) were measured using proton nuclear magnetic resonance spectroscopy. In addition to PB, we used FGR in weight and small for gestational age as study endpoints.
 
Results: We observed significant associations between FGR and decreased urinary acetate (interquartile odds ratio (IOR) = 0.18 CI 0.04 to 0.60), formate (IOR = 0.24 CI 0.07 to 0.71), tyrosine (IOR = 0.27 CI 0.08 to 0.81) and trimethylamine (IOR = 0.14 CI 0.04 to 0.40) adjusting for maternal education, maternal age, parity, and smoking during pregnancy. These metabolites were inversely correlated with blood insulin. Women with clinically induced PB (IPB) had a significant increase in a glycoprotein N-acetyl resonance (IOR = 5.84 CI 1.44 to 39.50). This resonance was positively correlated with body mass index, and stratified analysis confirmed that N-acetyl glycoprotein and IPB were significantly associated in overweight and obese women only. Spontaneous PB cases were associated with elevated urinary lysine (IOR = 2.79 CI 1.20 to 6.98) and lower formate levels (IOR = 0.42 CI 0.19 to 0.94).
 
Conclusions: Urinary metabolites measured at the end of the first trimester are associated with increased risk of negative birth outcomes, and provide novel information about the possible mechanisms leading to adverse pregnancies in the Rhea cohort. This study emphasizes the potential of metabolic profiling of urine as a means to identify novel non-invasive biomarkers of PB and FGR risk.
 
 
Background: Each year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings.
 
Methods: A systematic review was undertaken on the cost-effectiveness of strategies to improve the demand and supply of maternal and newborn health care in low-income and lower-middle-income countries. Peer-reviewed and grey literature published since 1990 was searched using bibliographic databases, websites of selected organizations, and reference lists of relevant studies and reviews. Publications were eligible for inclusion if they report on a behavioural or health systems strategy that sought to improve the utilization or provision of care during pregnancy, childbirth or the neonatal period; report on its cost-effectiveness; and were set in one or more low-income or lower-middle-income countries. The quality of the publications was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. Incremental cost per life-year saved and per disability-adjusted life-year averted were compared to gross domestic product per capita.
 
Results: Forty-eight publications were identified, which reported on 43 separate studies. Sixteen were judged to be of high quality. Common themes were identified and the strategies were presented in relation to the continuum of care and the level of the health system. There was reasonably strong evidence for the cost-effectiveness of the use of women’s groups, home-based newborn care using community health workers and traditional birth attendants, adding services to routine antenatal care, a facility-based quality improvement initiative to enhance compliance with care standards, and the promotion of breastfeeding in maternity hospitals. Other strategies reported cost-effectiveness measures that had limited comparability.
 
Conclusion: Demand and supply-side strategies to improve maternal and newborn health care can be cost-effective, though the evidence is limited by the paucity of high quality studies and the use of disparate cost-effectiveness measures.
 
*B. McKinnon, S. Harper, J. Kaufman, et al. Distance to emergency obstetric services and early neonatal mortality in Ethiopia. Tropical Medicine & International Health (July, 2014).
 
Objectives: To assess the effect of distance to emergency obstetric and newborn care (EmONC) services on early neonatal mortality in rural Ethiopia and examine whether proximity to services contributes to socio-economic inequalities in early neonatal mortality.
 
Methods: We linked data from the 2011 Ethiopian Demographic and Health Survey with facility data from the 2008 Ethiopian National EmONC Needs Assessment based on geographical coordinates collected in both surveys. Health facilities were classified based on the performance of nine EmONC signal functions (e.g. neonatal resuscitation, Caesarean section). We used multivariable logistic regression to assess the relationship between distance to services and early neonatal mortality. A decomposition approach was used to quantify the relative contributions of distance to EmONC services and other determinants to overall and socio-economic inequality in early neonatal mortality.
 
Results: In general, closer proximity to EmONC services and higher level of care were associated with lower early neonatal mortality. Living more than 80 km from the nearest comprehensive EmONC facility able to perform all nine signal functions compared to living within 10 km was associated with an increase of 14.4 early neonatal deaths per 1000 live births (95% CI: 0.1, 28.7). Closer proximity to a substandard EmONC facility compared with no facility was not associated with lower early neonatal mortality. Distance to EmONC services was an important determinant of early neonatal mortality, although it did not make a significant contribution to explaining socio-economic inequality.
 
Conclusions: Our results suggest that recent initiatives by the Ethiopian government to improve geographical access to EmONC services have the potential to reduce early neonatal mortality but may not affect inequalities.
 
S. Phiri, T. Kiserud, G. Kvåle, et al. Factors associated with health facility childbirth in districts of Kenya, Tanzania and Zambia: a population based survey. BMC Pregnancy & Childbirth (July, 2014).
 
Background: Maternal mortality continues to be a heavy burden in low and middle income countries where half of all deliveries take place in homes without skilled attendance. The study aimed to investigate the underlying and proximate determinants of health facility childbirth in rural and urban areas of three districts in Kenya, Tanzania and Zambia.
 
Methods: A population-based survey was conducted in 2007 as part of the 'REsponse to ACcountable priority setting for Trust in health systems' (REACT) project. Stratified random cluster sampling was used and the data included information on place of delivery and factors that might influence health care seeking behaviour. A total of 1800 women who had childbirth in the previous five years were analysed. The distal and proximate conceptual framework for analysing determinants of maternal mortality was modified for studying factors associated with place of delivery. Socioeconomic position was measured by employing a construct of educational attainment and wealth index. All analyses were stratified by district and urban-rural residence.
 
Results: There were substantial inter-district differences in proportion of health facility childbirth. Facility childbirth was 15, 70 and 37% in the rural areas of Malindi, Mbarali and Kapiri Mposhi respectively, and 57, 75 and 77% in the urban areas of the districts respectively. However, striking socio-economic inequities were revealed regardless of district. Furthermore, there were indications that repeated exposure to ANC services and HIV related counselling and testing were positively associated with health facility deliveries. Perceived distance was negatively associated with facility childbirth in rural areas of Malindi and urban areas of Kapiri Mposhi. Conclusion: Strong socio-economic inequities in the likelihood of facility childbirths were revealed in all the districts added to geographic inequities in two of the three districts. This strongly suggests an urgent need to strengthen services targeting disadvantaged and remote populations. The finding of a positive association between HIV counselling/testing and odds in favor of giving birth at a health facility suggests potential positive effects can be achieved by strengthening integrated approaches in maternal health service delivery.
 
*J. Trujillo, B. Carrillo, W. Iglesias, et al.Relationship between professional antenatal care and facility delivery: an assessment of Colombia. Health Policy and Planning (July, 2014).
 
The determinants of maternal and child health have been the recurrent topics of study in developing countries. Using the Demographic and Health Survey (2010) of Colombia, this study aimed to identify the determinants for professional antenatal care and institutional delivery, taking into account the interdependence of these two decisions, which we consider using a bivariate probit model. This study found that when certain factors affecting both the decision to seek prenatal care and giving birth in a hospital are neglected, the results of the estimates are inefficient. Estimates show that the effects of education, parity, regional location and economic status on institutional delivery tend to be underestimated in a univariate probit model. The results indicate that economic status, level of education, parity and medical-insurance affiliation influenced the joint likelihood of accessing professional antenatal care and delivering in a health facility. An important finding is that mothers with a higher level of education are 9 percentage points more likely to access these two health services compared with mothers who are illiterate. Another observed finding is the regional disparities. The evidence indicates that mothers in the Pacific Region, the poorest region of Colombia, are 6 percentage points less likely to access such services. Thus, the results indicate that the Colombian health policy should emphasize increasing the level of schooling of mothers and establish health facilities in the poorest regions of the country to ensure that women in need are provided with social health insurance.
 
 
This report summarizes the final recommendation and the process for developing the guideline on the effectiveness of community mobilization through facilitated participatory learning and action cycles with women’s groups for maternal and newborn health. The primary audience for this guideline is health programme managers, including governmental and non-governmental organizations, and policy makers who are responsible for designing maternal, newborn and child health programmes, primarily in low-income settings.
 
The guideline is also aimed at health providers and teaching institutions, to increase knowledge of interventions important for: (i) improving maternal and newborn health; (ii) improving the care provided within the household by women and families; (iii) increasing community support for maternal and newborn health; and (iv) increasing access to, and use of, skilled care. Development programmes and organizations supporting women’s empowerment and rights will also find this guideline of use.
 
Countdown Coverage Writing Group. Fulfilling the Health Agenda for Women and Children: The 2014 Report. Countdown to 2015 (June, 2014).
 
Countdown launched its 2014 Report on June 30, 2014, at the Partners' Forum of the Partnership for Maternal, Newborn & Child Health (PMNCH), held in Johannesburg, South Africa. Countdown was a co-sponsor of the Forum, together with PMNCH, A Promise Renewed, and the independent Expert Review Group (iERG).
 
The 2014 Report, Fulfilling the Health Agenda for Women and Children, was released exactly 18 months to the day from the deadline for the Millennium Development Goals at the end of 2015. Like previous Countdown reports, it includes an updated, detailed profile for each of the 75 Countdown countries, which together account for more than 95% of the global burden of maternal, newborn and child death. The report shows that progress has been impressive in some areas, but it also highlights the vast areas of unfinished business that must be prioritized in the post-2015 framework.
 
The 2014 Report also provides an assessment of the state of the data to support evidence-based decisions in women's and children's health, and describes elements of the Countdown process that might inform ongoing efforts to hold the world to account for progress. It concludes by laying out concrete action steps that can be taken now to ensure continued progress for women and children in the years ahead.
 
The headlines and data highlights from the 2014 Report can be viewed here.
 
Included in the 2014 Report:
  • "Unfinished business, achievable goals"
  • Nutrition: a building block for progress
  • Coverage across the continuum of care, globally and at the country level
  • Equity: no women and children left behind
  • Determinants of coverage and equity — policies, systems and financing
  • Data revolution and evolution: the foundation for accountability and progress
  • The Countdown process—what we have learned so far
  • Countdown speaks: priorities for the next 500 days and beyond

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