Addressing Critical Knowledge Gaps in Newborn Health


By Bina Valsangkar on October 15, 2014

This blog was co-authored by Bina Valsangkar, Stella Abwao, and Alyssa Om'Iniabohs. Photo Credit:Ida Neuman from Laerdal.

The American Academy of Pediatrics (AAP) has developed several newborn care modules under the Helping Babies Survive (HBS) series to assist healthcare providers everywhere, especially in low-resource settings, to deliver consistent, quality care for newborns. Essential Care for Every Baby (ECEB) is one module within the HBS package (ECEB, Helping Babies Breathe (HBB), and Care of the Small Baby). Learner workbooks and flipcharts are designed with an emphasis on clear and simple illustrations, case scenarios, checklists, and algorithms that direct the provider in caring for the newborn beginning immediately after birth. Consistent, user-friendly materials, is a key strength of ECEB and the HBS series.

ECEB responds to a need for a user-friendly training module to complement the existing WHO-UNICEF essential newborn care curriculum. The components of essential newborn care – ensuring warmth, immediate skin-to-skin care, early breastfeeding, umbilical cord care, eye care, Vitamin K administration, and immunization, are already incorporated into national guidelines, protocols and training materials. These components are routinely addressed in pre-service and in-service trainings for health care workers. ECEB does not necessarily aim to teach a new skill set to newborn care providers; rather, its purpose is to reinforce skills and build confidence. ECEB is not intended to replace existing in-country materials, but rather, complements what is already available. Countries have the option to adopt the ECEB materials or use them to augment their existing essential newborn care materials. ECEB takes what providers are already doing and helps them do it better.

The AAP is working with development partners and programs such as USAID/Maternal and Child Survival Program (MCSP) and Save the Children to introduce ECEB to health providers and policy-makers in countries with a high burden of newborn deaths. In May 2014, USAID’s Maternal and Child Health Integrated Program (MCHIP) and the Laerdal Global Health Foundation, in collaboration with the AAP and other partners, hosted a four-day regional workshop in Addis Ababa, Ethiopia to introduce and provide training for ECEB to participants from the Africa region. Countries already implementing HBB at scale shared their experiences and the potential use for ECEB. A total of 85 people attended the workshop, including ECEB trainers from AAP and represented countries, Ministry of Health representatives, national trainers, representatives of professional medical and midwifery associations, and implementing partners. A total of 55 participants from the following countries were trained as ECEB Master Trainers: Ethiopia, Ghana, Kenya, Liberia, Malawi, Nigeria, South Sudan, Tanzania, Uganda, Zambia, Zimbabwe and USA. After the workshop, participants are working with government and development and implementing partners to strategize how ECEB may become a part of newborn training. A similar ECEB workshop is planned for the Asia region in 2015.

ECEB and the HBS series have the potential to help countries realize their goals within the Every Newborn Action Plan and improve the quality of newborn care and neonatal outcomes.

By Bradley Wagenaar on October 13, 2014

The Lancet Global Health recently published the article Effects of health-system strengthening on under-5, infant, and neonatal mortality: 11-year provincial-level time-series analyses in Mozambique. In this blog, author Bradley Wagenaar shares insights from the study. Photo Credit: Suzanna Klaucke/Save the Children.

In Mozambique, when a child dies, chances are their death is not recorded in any official capacity. In part, this is because less than half of all children under-5 ever get birth certificates. Officially, they do not exist. If they die, in the eyes of the government, they never died because they never existed in the first place. Even if they were lucky enough to be registered, it is even less likely we will know why they died since less than seven percent of all deaths nationally are reported with their cause-of-death. What little information we do have about the causes and rates of child death come from large, infrequent, and expensive surveys, such as the Mozambican demographic and health survey where researchers physically go door-to-door and ask parents if they know of any children who died, and why.

In a recent article, a group of researchers from the Ministry of Health in Mozambique, the Mozambican National Institutes of Health, and Health Alliance International (HAI is a non-profit organization affiliated with the University of Washington, Seattle and focuses on improving public-sector health systems) used these large-scale population surveys to try to disentangle whether and which health system factors affect rates of child death in Mozambique. Since 90% of the population in Mozambique uses public-sector clinics run by the Ministry of Health that are available to everyone, usually free of charge, we focused on a few factors related to how critical health services are delivered in these facilities.

What we found was that Mozambique has made great strides in decreasing child death over the past decade – a 56% reduction from 2000 to 2010. We also found that three public-health-system factors seem to be most related to gains made in decreasing child death: (1) more women giving birth at public health facilities; (2) more qualified health workers at those facilities; and (3) ensuring there are enough public health facilities as population continues to grow.

What concerned us, however, was that these observed large decreases in the number of child deaths were not distributed equally across Mozambique. While mortality rates aggregated to the country level appear to have made these great reductions, at the provincial level (11 provinces in Mozambique, so ~2 million people per province) or district level (128 districts in Mozambique, so ~200,000 people per district), disparities in child death may actually be increasing.

There is an old adage, which appears to be borne out in some studies, that as the availability or quality of healthcare is improved, disparities in population health may increase in the short-term. This is because the people most likely to take advantage of new health care innovations are those who are more educated and already in better health. When these people access new services, their further separate themselves from the most disadvantaged; often reaching those who most need help is the hardest.

While some provinces in Mozambique showed decreases of up to 80% in neonatal mortality rate over the past decade, some provinces showed decreases as low as 5%. Even more concerning is that current designs of large-scale intermittent community surveys only allow analyses of child deaths to the provincial level in many countries. The differences in rates of death are not trivial. Comparing Provinces in Mozambique, some children are more than three times as likely to die in the first 30 days of life. Disparities in death rates across districts are likely significantly higher.

Alongside proven interventions such as investments in public-sector human resources for health, advocating for safe birth practices in health facilities, and health infrastructure improvements, urgent investments are needed in vital registration systems (births/deaths) and other ways to track district-level (or lower) health disparities. In an age of mobile technology and instant communication, the era of using community surveys to evaluate child deaths at the provincial level or higher should be over. The lack of data on health disparities or real-time statistics on child deaths impedes the development, targeting, and testing of novel innovations to save the lives of children and improve maternal and child health more generally.

We should all advocate for a world where, at the minimum, all children who tragically die before their fifth birthday have their birth, death, and cause-of-death recorded so that we can work to prevent these deaths for other unborn children.

By Alexandra Shaphren on October 10, 2014

This month's Research Roundup contains five journal supplements. Click here to navigate directly to the supplements.

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P. Aliganyira, K. Kerber, K. Davy, et al. Helping small babies survive: an evaluation of facility-based Kangaroo Mother Care implementation progress in Uganda. PanAfrican Medical Journal (September, 2014).
Introduction: Prematurity is the leading cause of newborn death in Uganda, accounting for 38% of the nation's 39,000 annual newborn deaths. Kangaroo mother care is a high-impact; cost-effective intervention that has been prioritized in policy in Uganda but implementation has been limited.
Methods: A standardised, cross-sectional, mixed-method evaluation design was used, employing semi-structured key-informant interviews and observations in 11 health care facilities implementing kangaroo mother care in Uganda.
Results: The facilities visited scored between 8.28 and 21.72 out of the possible 30 points with a median score of 14.71. Two of the 3 highest scoring hospitals were private, not-for-profit hospitals whereas the second highest scoring hospital was a central teaching hospital. Facilities with KMC services are not equally distributed throughout the country. Only 4 regions (Central 1, Central 2, East-Central and Southwest) plus the City of Kampala were identified as having facilities providing KMC services.
Conclusion: KMC services are not instituted with consistent levels of quality and are often dependent on private partner support. With increasing attention globally and in country, Uganda is in a unique position to accelerate access to and quality of health services for small babies across the country.
R. Caleyachetty, C. Tait, A. Kengne, et al. Tobacco use in pregnant women: analysis of data from Demographic and Health Surveys from 54 low-income and middle-income countries. The Lancet Global Health (September, 2014).
Background: Worldwide, use of tobacco is viewed as an important threat to the health of pregnant women and their children. However, the extent of tobacco use in pregnant women in low-income and middle-income countries (LMICs) remains unclear. We assessed the magnitude of tobacco use in pregnant women in LMICs.
Methods: We used data from Demographic and Health Surveys (DHS) done in 54 LMICs between Jan 1, 2001, and Dec 1, 2012, comprising 58 922 pregnant women (aged 15–49 years), which were grouped by WHO region. Prevalence of current tobacco use (smoked and smokeless) was estimated for every country. Pooled estimates by regions and overall were obtained from random-eff ects meta-analysis.
Findings: Pooled prevalence of any tobacco use in pregnant women in LMICs was 2·6% (95% CI 1·8–3·6); the lowest prevalence was in the African region (2·0%, 1·2–2·9) and the highest was in the Southeast Asian region (5·1%, 1·3–10·9). The pooled prevalence of current tobacco smoking in pregnant women ranged from 0·6% (0·3–0·8) in the African region to 3·5% (1·5–12·1) in the Western Pacifi c region. The pooled prevalence of current smokeless tobacco use in pregnant women was lowest in the European region (0·1%, 0·0–0·3) and highest in the Southeast Asian region (2·6%, 0·0–7·6).
Interpretation: Overall, tobacco use in pregnant women in LMICs was low; however high prevalence estimates were noted in some LMICs. Prevention and management of tobacco use and exposure to second-hand smoke in pregnancy is crucial to protect maternal and child health in LMICs.
Background: Infant and child mortality rates are among the most important indicators of child health, nutrition, implementation of key survival interventions, and the overall social and economic development of a population. In this paper, we investigate the role of coverage of maternal and child health (MNCH) interventions in contributing to declines in child mortality in sub-Saharan Africa.
Design: Data are from 81 Demographic and Health Surveys from 35 sub-Saharan African countries. Using ecological time-series and child-level regression models, we estimated the effect of MNCH interventions (summarized by the percent composite coverage index, or CCI) on child mortality with in the first 5 years of life net of temporal trends and covariates at the household, maternal, and child levels.
Results: At the ecologic level, a unit increase in standardized CCI was associated with a reduction in under-5 child mortality rate (U5MR) of 29.0 per 1,000 (95% CI: -43.2, -14.7) after adjustment for survey period effects and country-level per capita gross domestic product (pcGDP). At the child level, a unit increase in standardized CCI was associated with an odds ratio of 0.86 for child mortality (95% CI: 0.82-0.90) after adjustment for survey period effect, country-level pcGDP, and a set of household-, maternal-, and child-level covariates.
Conclusions: MNCH interventions are important in reducing U5MR, while the effects of economic growth in sub-Saharan Africa remain weak and inconsistent. Improved coverage of proven life-saving interventions will likely contribute to further reductions in U5MR in sub-Saharan Africa
Background: Ethiopia is among the countries with the highest neonatal mortality with the rate of 37 deaths per 1000 live births. In spite of many efforts by the government and other partners, non-significant decline has been achieved in the last 15 years. Thus, identifying the determinants and causes are very crucial for policy and program improvement. However, studies are scarce in the country in general and in Jimma zone in particular.
Objective: To identify the determinants and causes of neonatal mortality in Jimma Zone, Southwest Ethiopia.
Methods: A prospective follow-up study was conducted among 3463 neonates from September 2012 to December 2013. The data were collected by interviewer-administered structured questionnaire and analyzed by SPSS V.20.0 and STATA 13. Verbal autopsies were conducted to identify causes of neonatal death. Mixed-effects multilevel logistic regression model was used to identify determinants of neonatal mortality.
Results: The status of neonatal mortality rate was 35.5 (95%CI: 28.3, 42.6) per 1000 live births. Though significant variation existed between clusters in relation to neonatal mortality, cluster-level variables were found to have non-significant effect on neonatal mortality. Individual-level variables such as birth order, frequency of antenatal care use, delivery place, gestation age at birth, premature rupture of membrane, complication during labor, twin births, size of neonate at birth and neonatal care practice were identified as determinants of neonatal mortality. Birth asphyxia (47.5%), neonatal infections (34.3%) and prematurity (11.1%) were the three leading causes of neonatal mortality accounting for 93%.
Conclusions: This study revealed high status of neonatal mortality in the study area. Higher-level variables had less importance in determining neonatal mortality. Individual level variables related to care during pregnancy, intra-partum complications and care, neonatal conditions and the immediate neonatal care practices were identified as determinant factors. Improving antenatal care, intra-partum care and immediate neonatal care are recommended.
*L. Groppi, E. Somigliana, V. Pisani, et al. A hospital-centered approach to improve emergency obstetric care in South Sudan. International Journal of Gynecology and Obstetrics (September, 2014).
Objective: To assess provision of emergency obstetric care (EmOC) in Greater Yirol, South Sudan, after implementation of a hospital-centered intervention with an ambulance referral system.
Methods: In a descriptive study, data were prospectively recorded for all women referred to Yirol County Hospital for delivery in 2012. An ambulance referral system had been implemented in October 2011. Access to the hospital and ambulance use were free of charge.
Results: The number of deliveries at Yirol County Hospital increased in 2012 to 1089, corresponding to 13.3% of the 8213 deliveries expected to have occurred in the catchment area. Cesareans were performed for 53 (4.9%) deliveries, corresponding to 0.6% of the expected number of deliveries in the catchment area. Among 950 women who delivered a newborn weighing at least 2500 g at the hospital, 6 (0.6%) intrapartum or very early neonatal deaths occurred. Of 1232 women expected to have major obstetric complications in 2012 in the catchment area, 472 (38.3%) received EmOC at the hospital. Of 115 expected absolute obstetric indications, 114 (99.1%) were treated in the hospital.
Conclusion: A hospital-centered approach with an ambulance referral system effectively improves the availability of EmOC in underprivileged remote settings.
Background: Increasing women’s status and male involvement are important strategies in reducing preventable maternal morbidity and mortality. While efforts to both empower women and engage men in maternal health care-seeking can work synergistically, in practice they may result in opposing processes and outcomes. This study examines whether a woman’s empowerment status, in sum and across economic, socio-familial, and legal dimensions, is associated with male partner accompaniment to antenatal care (ANC).
Methods: Women’s empowerment was measured based on the sum of nine empowerment items in the 2010–2011 Demographic and Health Surveys in eight sub-Saharan African countries: Burkina Faso (n = 2,490), Burundi (n = 1,042), Malawi (n = 1,353), Mozambique (n = 414), Rwanda (n = 1,211), Senegal (n = 505), Uganda (n = 428) and Zimbabwe (n = 459). In cross-sectional analyses, bivariate and multivariable logistic regressions models were used to examine the odds of male partner accompaniment to ANC between women with above-average versus below-average composite and dimensional empowerment scores.
Results: In the majority of countries, male accompaniment to ANC was not uncommon. However, findings were mixed. Positive associations in women’s composite empowerment and male involvement were observed in Burkina Faso (OR = 1.27, 95% CI: 1.08, 1.50) and Uganda (OR = 1.53, 95% CI: 1.00-2.35), and in the economic empowerment dimension in Burkina Faso (OR = 1.24, 95% CI: 1.05-1.47). In Malawi, significant negative associations were observed in the odds of male accompaniment to ANC and women’s composite (OR = 0.77, 95% CI: 0.62-0.97) and economic empowerment scores (OR = 0.75, 95% CI: 0.59-0.94). No significant differences were observed in Burundi, Mozambique, Rwanda, Senegal, or Zimbabwe.
Conclusion: Women’s empowerment can be positively or negatively associated with male antenatal accompaniment. Male involvement efforts may benefit from empowerment initiatives that promote women’s participation in social and economic spheres, provided that antenatal participation does not undermine women’s preferences or autonomy. The observation of mixed and null findings suggests that additional qualitative and longitudinal research may enhance understanding of women’s empowerment in sub-Saharan African settings.
Background: Trend data for causes of child death are crucial to inform priorities for improving child survival by and beyond 2015. We report child mortality by cause estimates in 2000—13, and cause-specific mortality scenarios to 2030 and 2035.
Methods: We estimated the distributions of causes of child mortality separately for neonates and children aged 1—59 months. To generate cause-specific mortality fractions, we included new vital registration and verbal autopsy data. We used vital registration data in countries with adequate registration systems. We applied vital registration-based multicause models for countries with low under-5 mortality but inadequate vital registration, and updated verbal autopsy-based multicause models for high mortality countries. We used updated numbers of child deaths to derive numbers of deaths by causes. We applied two scenarios to derive cause-specific mortality in 2030 and 2035.
Findings: Of the 6·3 million children who died before age 5 years in 2013, 51·8% (3·257 million) died of infectious causes and 44% (2·761 million) died in the neonatal period. The three leading causes are preterm birth complications (0·965 million [15·4%, uncertainty range (UR) 9·8−24·5]; UR 0·615—1·537 million), pneumonia (0·935 million [14·9%, 13·0—16·8]; 0·817—1·057 million), and intrapartum-related complications (0·662 million [10·5%, 6·7—16·8]; 0·421—1·054 million). Reductions in pneumonia, diarrhoea, and measles collectively were responsible for half of the 3·6 million fewer deaths recorded in 2013 versus 2000. Causes with the slowest progress were congenital, preterm, neonatal sepsis, injury, and other causes. If present trends continue, 4·4 million children younger than 5 years will still die in 2030. Furthermore, sub-Saharan Africa will have 33% of the births and 60% of the deaths in 2030, compared with 25% and 50% in 2013, respectively.
Interpretation: Our projection results provide concrete examples of how the distribution of child causes of deaths could look in 15—20 years to inform priority setting in the post-2015 era. More evidence is needed about shifts in timing, causes, and places of under-5 deaths to inform child survival agendas by and beyond 2015, to end preventable child deaths in a generation, and to count and account for every newborn and every child.
A. Malik, C. Willis, S. Hamid, et al. Advancing the application of systems thinking in health: advice seeking behavior among primary health care physicians in Pakistan. Health Research Policy and Systems (August, 2014).
Background: Using measles and tuberculosis as case examples, with a systems thinking approach, this study examines the human advice-seeking behavior of primary health care (PHC) physicians in a rural district of Pakistan. This study analyzes the degree to which the existing PHC system supports their access to human advice, and explores in what ways this system might be strengthened to better meet provider needs.
Methods: The study was conducted in a rural district of Pakistan and, with a cross-sectional study design, it employed a range of research methods, namely extensive document review for mapping existing information systems, social network analysis of physicians’ advice-seeking practice, and key stakeholder interviews for an in-depth understanding of the experience of physicians. Illustrations were prepared for information flow mechanism, sociographs were generated for analyzing social networks, and content analysis of qualitative findings was carried out for in-depth interpretation of underlying meanings.
Results: The findings of this study reveal that non-availability of competent supervisory staff, a focus on improving performance indicators rather than clinical guidance, and a lack of a functional referral system have collectively created an environment in which PHC physicians have developed their own strategies to overcome these constraints. They are well aware of the human expertise available within and outside the district. However, their advice-seeking behavior was dependent upon existence of informal social interaction with the senior specialists. Despite the limitations of the system, the physicians proactively used their professional linkages to seek advice and also to refer patients to the referral center based on their experience and the facilities that they trusted.
Conclusions: The absence of functional referral systems, limited effective linkages between PHC and higher levels of care, and a focus on programmatic targets rather than clinical care have each contributed to the isolation of physicians and reactive information seeking behavior. The study findings underscore the need for a functional information system comprising context sensitive knowledge management and translation opportunities for physicians working in PHC centers. Such an information system needs to link people and resources in ways that transcend geography and discipline, and that builds on existing expertise, interpersonal relationships, and trust.
A. Manzi, F. Munyaneza, F. Mujawase, et al. Assessing predictors of delayed antenatal care visits in Rwanda: a secondary analysis of Rwanda demographic and health survey 2010. BMG Pregnancy & Childbirth (August, 2014).
Background: Early initiation of antenatal care (ANC) can reduce common maternal complications and maternal and perinatal mortality. Though Rwanda demonstrated a remarkable decline in maternal mortality and 98% of Rwandan women receive antenatal care from a skilled provider, only 38% of women have an ANC visit in their first three months of pregnancy. This study assessed factors associated with delayed ANC in Rwanda.
Methods: This is a cross-sectional study using data collected during the 2010 Rwanda DHS from 6,325 women age 15-49 that had at least one birth in the last five years. Factors associated with delayed ANC were identified using a multivariable logistic regression model using manual backward stepwise regression. Analysis was conducted in Stata v12 applying survey commands to account for the complex sample design.
Results: Several factors were significantly associated with delayed ANC including having many children (4-6 children, OR = 1.42, 95% CI: 1.22, 1.65; or more than six children, OR = 1.57, 95% CI: 1.24, 1.99); feeling that distance to health facility is a problem (OR = 1.20, 95% CI: 1.04, 1.38); and unwanted pregnancy (OR = 1.41, 95% CI: 1.26, 1.58). The following were protective against delayed ANC: having an ANC at a private hospital or clinic (OR = 0.29, 95% CI: 0.15, 0.56); being married (OR = 0.85, 95% CI: 0.75, 0.96), and having public mutuelle health insurance (OR = 0.81, 95% CI: 0.71, 0.92) or another type of insurance (OR = 0.33, 95% CI: 0.23, 0.46).
Conclusion: This analysis revealed potential barriers to ANC service utilization. Distance to health facility remains a major constraint which suggests a great need of infrastructure and decentralization of maternal ANC to health posts and dispensaries. Interventions such as universal health insurance coverage, family planning, and community maternal health system are underway and could be part of effective strategies to address delays in ANC.
Ministry of Health and Family Welfare, India Government. The India Newborn Action Plan.
In India, 760,000 newborns die each year mainly due to preventable causes, and policy makers are moving quickly to focus more attention on maternal and newborn health as a top national health priority.
India’s Newborn Action Plan, approved and launched by the national health ministry earlier this month, has been developed in response to the Global Every Newborn Action Plan (ENAP) approved last May at the World Health Assembly. The India plan outlines a targeted strategy for accelerating the reduction of preventable newborn deaths and still births in India.
The plan draws from the latest evidence on effective interventions, which will not only help in reducing the burden of stillbirths and neonatal mortality, but also maternal deaths.
With clearly marked timelines for implementation, monitoring and evaluation, and scaling up of proposed interventions, the plan calls for all stakeholders to work towards improving newborn health in India with the dual goals of dramatically reducing newborn and stillborn death rates by 2030.
The plan is guided by the principles of Integration, Equity, Gender, Quality of Care, Convergence, Accountability and Partnerships. Its strength is built on its six pillars of intervention packages impacting still births and newborn health.
The six pillars include:
  • Preconception and antenatal care;
  • Care during labour and child birth;
  • Immediate new born care;
  • Care of healthy newborn;
  • Care of small and sick newborn, and
  • Care beyond newborn survival.
India’s triumph over polio has proven that it can reach even the most hard-to-reach and vulnerable children despite demographic, economic, and socio-cultural challenges. While the country has witnessed dramatic reduction in maternal and child mortality rates over the past two decades, the reduction of deaths of babies less than a month old has been much less as compared to deaths of all children under the age of 5. As a result, newborns in 2012 accounted for 56 percent of all deaths of children under 5 as compared to 41% in 1990.
This is a major reason why the government has launched India’s Newborn Action Plan (#INAP). With a clear understanding that almost all of these deaths and subsequent disabilities are preventable, the plan is a concerted effort towards translating these commitments into meaningful change for newborns.
A Promise Renewed promotes two goals. The first is to keep the promise of Millennium Development Goal (MDG) 4 — to reduce the under-five mortality rate by two-thirds, between 1990 and 2015 — and by accelerating maternal survival, addressed in MDG 5. The second goal is to keep moving forward, beyond 2015, until no child or mother dies from preventable causes. A modelling exercise presented at the Child Survival Call to Action in June 2012 demonstrated that countries can lower their national under-five mortality rates to 20 or fewer deaths per 1,000 live births by 2035. Achieving 20 by 2035 represents an important milestone towards the ultimate goal of ending preventable child deaths.
Background: The UN will formulate ambitious Sustainable Development Goals for 2030, including one for health. Feasible goals with some quantifiable, measurable targets can influence governments. We propose, as a quatitative health target, “Avoid in each country 40% of premature deaths (under-70 deaths that would be seen in the 2030 population at 2010 death rates), and improve health care at all ages”. Targeting overall mortality and improved health care ignores no modifiable cause of death, nor any cause of disability that is treatable (or also causes many deaths). 40% fewer premature deaths would be important in all countries, but implies very different priorities in different populations. Reinforcing this target for overall mortality in each country are four global subtargets for 2030: avoid two-thirds of child and maternal deaths; two-thirds of tuberculosis, HIV, and malaria deaths; a third of premature deaths from non-communicable diseases (NCDs); and a third of those from other causes (other communicable diseases, undernutrition, and injuries). These challenging subtargets would halve under-50 deaths, avoid a third of the (mainly NCD) deaths at ages 50—69 years, and so avoid 40% of under-70 deaths. To help assess feasibility, we review mortality rates and trends in the 25 most populous countries, in four country income groupings, and worldwide.
Methods: UN sources yielded overall 1970—2010 mortality trends. WHO sources yielded cause-specific 2000—10 trends, standardised to country-specific 2030 populations; decreases per decade of 42% or 18% would yield 20-year reductions of two-thirds or a third.
Results: Throughout the world, except in countries where the effects of HIV or political disturbances predominated, mortality decreased substantially from 1970—2010, particularly in childhood. From 2000—10, under-70 age-standardised mortality rates decreased 19% (with the low-income and lower-middle-income countries having the greatest absolute gains). The proportional decreases per decade (2000—10) were: 34% at ages 0—4 years; 17% at ages 5—49 years; 15% at ages 50—69 years; 30% for communicable, perinatal, maternal, or nutritional causes; 14% for NCDs; and 13% for injuries (accident, suicide, or homicide).
Interpretation: Moderate acceleration of the 2000—10 proportional decreases in mortality could be feasible, achieving the targeted 2030 disease-specific reductions of two-thirds or a third. If achieved, these reductions avoid about 10 million of the 20 million deaths at ages 0—49 years that would be seen in 2030 at 2010 death rates, and about 17 million of the 41 million such deaths at ages 0—69 years. Such changes could be achievable by 2030, or soon afterwards, at least in areas free of war, other major effects of political disruption, or a major new epidemic.
Objectives: There are no international standards for relating fetal crown-rump length (CRL) to gestational age (GA), and most existing charts have considerable methodological limitations. The INTERGROWTH-21st Project aimed to produce the first, international standards for early fetal size and ultrasound dating of pregnancy based on CRL measurement.
Methods: Urban areas in eight geographically diverse countries that met strict eligibility criteria were selected for the prospective, population-based recruitment, between 9+0 to 13+6 weeks of gestation, of healthy well-nourished women with singleton pregnancies at low risk of fetal growth impairment. GA was calculated on the basis of a certain LMP, regular menstrual cycle and lack of hormonal medication or breastfeeding in the preceding two months. CRL was measured using strict protocols and quality control measures. All women were followed up throughout pregnancy until delivery and hospital discharge. Neonatal and fetal deaths, severe pregnancy complications and congenital abnormalities were excluded.
Results: A total of 4,607 women were enrolled in the Fetal Growth Longitudinal Study (FGLS), one of the three main components of the INTERGROWTH-21st Project, of whom 4,321 women had a live singleton birth in the absence of severe maternal conditions or congenital abnormalities detected by ultrasound or at birth. The CRL was measured in 56 women at <9+0 weeks of gestation, resulting in 4,265 women who contributed data to the final analysis. The mean CRL and standard deviation (SD) increased with GA almost linearly. Their relationship to GA is defined by the two equations: Mean CRL (mm) = -50.6562 + 0.815118*GA + 0.00535302*GA2, and SD of CRL (mm) = -2.21626 + 0.0984894*GA, where GA is expressed in days. The formula for GA estimation is defined by the two equations: GA (days) = 40.9041 + 3.21585*CRL0.5 + 0.348956*CRL, and SD of GA (days) = 2.39102 + 0.0193474*CRL, where CRL is expressed in mm.
Conclusions: We have produced international prescriptive standards for early fetal linear size and ultrasound dating of pregnancy in the first trimester that can be used throughout the world.
Background: In 2006, WHO produced international growth standards for infants and children up to age 5 years on the basis of recommendations from a WHO expert committee. Using the same methods and conceptual approach, the Fetal Growth Longitudinal Study (FGLS), part of the INTERGROWTH-21st Project, aimed to develop international growth and size standards for fetuses.
Methods: The multicentre, population-based FGLS assessed fetal growth in geographically defined urban populations in eight countries, in which most of the health and nutritional needs of mothers were met and adequate antenatal care was provided. We used ultrasound to take fetal anthropometric measurements prospectively from 14 weeks and 0 days of gestation until birth in a cohort of women with adequate health and nutritional status who were at low risk of intrauterine growth restriction. All women had a reliable estimate of gestational age confirmed by ultrasound measurement of fetal crown–rump length in the first trimester. The five primary ultrasound measures of fetal growth—head circumference, biparietal diameter, occipitofrontal diameter, abdominal circumference, and femur length—were obtained every 5 weeks (within 1 week either side) from 14 weeks to 42 weeks of gestation. The best fitting curves for the five measures were selected using second-degree fractional polynomials and further modelled in a multilevel framework to account for the longitudinal design of the study.
Findings: We screened 13 108 women commencing antenatal care at less than 14 weeks and 0 days of gestation, of whom 4607 (35%) were eligible. 4321 (94%) eligible women had pregnancies without major complications and delivered live singletons without congenital malformations (the analysis population). We documented very low maternal and perinatal mortality and morbidity, confirming that the participants were at low risk of adverse outcomes. For each of the five fetal growth measures, the mean differences between the observed and smoothed centiles for the 3rd, 50th, and 97th centiles, respectively, were small: 2·25 mm (SD 3·0), 0·02 mm (3·0), and –2·69 mm (3·2) for head circumference; 0·83 mm (0·9), –0·05 mm (0·8), and –0·84 mm (1·0) for biparietal diameter; 0·63 mm (1·2), 0·04 mm (1·1), and –1·05 mm (1·3) for occipitofrontal diameter; 2·99 mm (3·1), 0·25 mm (3·2), and –4·22 mm (3·7) for abdominal circumference; and 0·62 mm (0·8), 0·03 mm (0·8), and –0·65 mm (0·8) for femur length. We calculated the 3rd, 5th 10th, 50th, 90th, 95th and 97th centile curves according to gestational age for these ultrasound measures, representing the international standards for fetal growth.
Interpretation: We recommend these international fetal growth standards for the clinical interpretation of routinely taken ultrasound measurements and for comparisons across populations.
S. Phiri, K. Fylkesnes, A. Ruano, et al. ‘Born before arrival’: user and provider perspectives on health facility childbirths in Kapiri Mposhi district, Zambia. BMC Pregnancy & Childbirth (September, 2014).
Background: Maternal mortality remains high in sub-Saharan Africa. Health facility intra-partum strategies with skilled birth attendance have been shown to be most effective to address maternal mortality. In Zambia, the health policy for pregnant women is to have facility childbirth, but less than half of the women utilize the facilities for delivery. ‘Born before arrival’ (BBA) describes childbirth that occurs outside health facility. With the aim to increase our understanding of trust in facility birth care we explored how users and providers perceived the low utilization of health facilities during childbirth.
Methods: A qualitative study was conducted in Kapiri Mposhi, Zambia. Focus group discussions with antenatal clinic and outpatient department attendees were conducted in 2008 as part of the Response to Accountable priority setting and Trust in health systems project, (REACT). In-depth interviews conducted with women who delivered at home, their husbands, community leaders, traditional birth attendants, and midwives were added in 2011. Information was collected on perceptions and experiences of home and health facility childbirth, and reasons for not utilizing a facility at delivery. Data were analysed by inductive content analysis.
Results: Perspectives of users and providers were grouped under themes that included experiences related to promotion of facility childbirth, responsiveness of health care providers, and giving birth at home. Trust and quality of care were important when individuals seek facility childbirth. Safety, privacy and confidentiality encouraged facility childbirth. Poor attitudes of health providers, long distances and lack of transport to facilities, costs to buy delivery kits, and cultural ideals that local herbs speed up labour and women should exhibit endurance at childbirth discouraged facility childbirth.
Conclusion: Trust and perceived quality of care were important and influenced health care seeking at childbirth. Interventions that include both the demand and supply sides of services with prioritizing needs of the community could substantially improve trust and utilization of facilities at childbirth, and accelerate efforts to achieve MDG5.
R. Shah, L. Mullany, G. Darmstadt et al. Determinants and pattern of care seeking for preterm newborns in a rural Bangladeshi cohort. BioMed Central (September, 2014).
Background: Despite the increased burden of preterm birth and its complications, the dearth of care seeking data for preterm newborns remains a significant knowledge gap. Among preterm babies in rural Bangladesh, we examined: 1) determinants and patterns of care seeking, and 2) risk analysis for care-seeking from qualified and unqualified providers.
Method: Trained community health workers collected data prospectively from 27,460 mother-liveborn baby pairs, including 6,090 preterm babies, between June 2007 and September 2009. Statistical analyses included binomial and multinomial logistic regressions.
Results: Only one-fifth (19.7%) of preterm newborns were taken to seek either preventive or curative health care. Among care-seeker preterm newborns, preferred providers included homeopathic practitioners (50.0%), and less than a third (30.9%) sought care from qualified providers. Care-seeking from either unqualified or qualified providers was significantly lower for female preterm babies, compared to male babies [Relative Risk Ratio (RRR) for unqualified care: 0.68; 95% Confidence Interval (CI): 0.58, 0.80; RRR for qualified care: 0.52; 95% CI: 0.41, 0.66]. Among preterm babies, care-seeking was significantly higher among caregivers who recognized symptoms of illness [RR: 2.14; 95% CI: 1.93, 2.38] or signs of local infection (RR: 2.53; 95% CI: 2.23, 2.87), had a history of child death [RR: 1.21; 95% CI: 1.07, 1.37], any antenatal care (ANC) visit [RR: 1.41; 95% CI: 1.25, 1.59]. Birth preparedness (RRR: 1.24; 95% CI: 1.09, 1.68) and any ANC visit (RRR: 1.73; 95% CI: 1.50, 2.49) were also associated with increased likelihood of care seeking for preterm babies from qualified providers.
Conclusion: To improve care seeking practices for preterm babies and referral of sick newborns to qualified providers/facilities, we recommend: 1) involving community-preferred health care providers in community-based health education and awareness raising programs; 2) integrating postnatal care seeking messages into antenatal counselling; and 3) further research on care seeking packages for preterm babies.
Background: In 2006, WHO published international growth standards for children younger than 5 years, which are now accepted worldwide. In the INTERGROWTH-21st Project, our aim was to complement them by developing international standards for fetuses, newborn infants, and the postnatal growth period of preterm infants.
Methods: INTERGROWTH-21st is a population-based project that assessed fetal growth and newborn size in eight geographically defined urban populations. These groups were selected because most of the health and nutrition needs of mothers were met, adequate antenatal care was provided, and there were no major environmental constraints on growth. As part of the Newborn Cross-Sectional Study (NCSS), a component of INTERGROWTH-21st Project, we measured weight, length, and head circumference in all newborn infants, in addition to collecting data prospectively for pregnancy and the perinatal period. To construct the newborn standards, we selected all pregnancies in women meeting (in addition to the underlying population characteristics) strict individual eligibility criteria for a population at low risk of impaired fetal growth (labelled the NCSS prescriptive subpopulation). Women had a reliable ultrasound estimate of gestational age using crown–rump length before 14 weeks of gestation or biparietal diameter if antenatal care started between 14 weeks and 24 weeks or less of gestation. Newborn anthropometric measures were obtained within 12 h of birth by identically trained anthropometric teams using the same equipment at all sites. Fractional polynomials assuming a skewed t distribution were used to estimate the fitted centiles.
Findings: We identified 20 486 (35%) eligible women from the 59 137 pregnant women enrolled in NCSS between May 14, 2009, and Aug 2, 2013. We calculated sex-specific observed and smoothed centiles for weight, length, and head circumference for gestational age at birth. The observed and smoothed centiles were almost identical. We present the 3rd, 10th, 50th, 90th, and 97th centile curves according to gestational age and sex.
Interpretation: We have developed, for routine clinical practice, international anthropometric standards to assess newborn size that are intended to complement the WHO Child Growth Standards and allow comparisons across multiethnic populations.
Multiple Authors. Essential interventions for maternal, newborn and child health.Reproductive Health (September, 2014).
Background Paper: This paper is an introductory paper detailing the background and methodology used for grading interventions.
Supplement Papers: The following three papers summarize the evidence on essential interventions for pre-pregnancy, pregnancy, childbirth, postnatal (mother and neonatal) and child heath while the last paper describes the essential interventions as per the level of health care delivery and their proposed packages of care.
Multiple Authors. Preconception interventionsReproductive Health Journal (September, 2014).
Preconception care addresses the health risks before pregnancy and the health problems that could have negative consequences for both mother and child. It has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs as this article in the supplement describes.
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For nearly two decades we have been publishing hundreds of articles heralding the promise, impact, and value of communication in advancing the health of people globally. There has been unprecedented growth in the discipline, not only among academia and researchers, but in the field where practitioners hope to apply the ideal approach for advancing health at the individual and population level. Globally, multilateral institutions, donor agencies, and private sector and civil society also seek to advance health and well-being with sustainable social and behavioral change.
With that in mind, this issue of the Journal of Health Communication on Population-Level Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: A Review of the Evidence, edited by Elizabeth Fox and Robert L. Balster, addresses the challenges of finding and using the best evidence in health programs facing the global health community.
As the world recommitted to addressing child mortality with Promise Renewed in 2012 concomitant with the ongoing interest in progressing the Millennium Development Goals (MDGs) that relate to women's and children's health by the 2015 deadline, the Evidence Summit and articles in this issue offer the state of the evidence on a variety of areas. While I (the editor-in-chief of Journal of Health Communication) had the opportunity to chair the Science, Innovation, and Technology Evidence Review team, it became clear that an Evidence Summit and publication of results of our “knowledge” were necessary to help progress “evidence to practice” at scale.
Heretofore many have cited individual articles in prior issues of this journal as well as the systematic review of communication interventions in health, including child survival from 1998 through 2009 in the Lancet conducted by Wakefield, Loken, and Hornik (2010); we are fortunate to publish an updated review on the effectiveness of mass media interventions by Naugle and Hornik in this issue.
Finally, in the course of my editorship and academic work, I am pleased to have witnessed the growth and unprecedented reach with basic to advanced communication technologies on population-level behavior change. The challenges are still great in how to engage multiple actors, including those in the public and private sectors, to maximize impact with evidence-based approaches that require resources, competencies, and synergies.
All of these articles document the evidence-based approaches for social and behavior change that should offer support for global health leaders along with policymakers and practitioners at country and regional levels to invest in our future and advance child health and development. To this end, I congratulate the editors and the authors in this supplement for their contribution to global health and hope that together, we can all advance a better world.
Browse the Articles Below:
Commissioned Review Article:
Multiple Authors. Quality of CareBJOG: An International Journal of Obstetrics & Gynaecology (September, 2014).
With the achievements of the last few years in reducing maternal and child mortality, we face greater challenges going forward to ensure we make further vital progress.
The world's nations made a set of promises when committing to the UN's Millennium Development Goals and maternal and newborn health lie at the very heart of these with specific targets that are still off-track. We have a great shared responsibility to act to prevent avoidable death and injury during pregnancy and childbirth and to strive to come closer to the maternal and infant mortality targets.
The political promises and funding commitments from the 2010 G8 Muskoka Summit and the recent follow-up conference in Toronto this year need to be delivered in full. As President Jakaya Kikwete of Tanzania said at the Saving Every Mother, Every Child summit, ‘By doing what we are doing, we are able, around the world, to have mothers have healthy pregnancies, survive those pregnancies, nourish their children and provide their children with the basic resources.’
‘We have to do it because so many lives have been lost, mothers and children,’ added Kikwete. ‘No woman should die while giving life to another human being.’
As we hold political decision-makers and public health officials to account, we must also show that the delivery of funding does indeed result in further improvements at the grassroots level. This means ensuring the availability of health care, investment in quality and meaningful assessment. This supplement could not be timelier as it seeks to address the quality of care for mothers and babies. Its Editors are all long-standing champions of quality of care and bring their shared expertise to bear on the range of issues covered—maternal health, newborn health and stillbirth. The contributors are all internationally recognised experts whose thoughtful work brought together in this supplement makes the case as to why quality is so important.
This supplement is essential reading for anyone with any direct or even tangential professional interest—whether as a funder or a provider or an advocate—and will serve everyone well in the final months of the countdown to the Millennium Development Goal deadline at the end of 2015. Looking forward to a post-2015 global healthcare landscape, there will never be a time when quality is not important and we should start by encouraging the implementation now.
Quality of Care:
Maternal Health:
Newborn Health and Stillbirth:
Multiple Authors. Quality of Care in Maternal and Child Health SupplementReproductive Health (September, 2014).
Despite progress in recent years, an estimated 273,500 women died as a result of maternal causes in 2010. The burden of these deaths is disproportionately bourne by women who reside in low income countries or belong to the poorest sectors of the population of middle or high income ones, and it is particularly acute in regions where access to and utilization of facility-based services for childbirth and newborn care is lowest. Evidence has shown that poor quality of facility-based care for these women and newborns is one of the major contributing factors for their elevated rates of morbidity and mortality. In addition, women who perceive the quality of facility-based care to be poor, may choose to avoid facility-based deliveries, where life-saving interventions could be available. In this context, understanding the underlying factors that impact the quality of facility-based services and assessing the effectiveness of interventions to improve the quality of care represent critical inputs for the improvement of maternal and newborn health. This series of five papers assesses and summarizes information from relevant systematic reviews on the impact of various approaches to improve the quality of care for women and newborns. The first paper outlines the conceptual framework that guided this study and the methodology used for selecting the reviews and for the analysis. The results are described in the following three papers, which highlight the evidence of interventions to improve the quality of maternal and newborn care at the community, district, and facility level. In the fifth and final paper of the series, the overall findings of the review are discussed, research gaps are identified, and recommendations proposed to improve the quality of maternal and newborn health care in resource-poor settings.
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By Amy Boldosser-Boesch on October 9, 2014

This year’s UN General Assembly was full of high-profile moments that reinforced the need for investment and action to improve reproductive, maternal, newborn and child health (RMNCH): the launch of a Global Financing Facility to Advance Women’s and Children’s Health; the release of reports tracking stakeholders’ fulfillment of commitments to Every Woman Every Child; new data on maternal, newborn and child survival from Countdown to 2015; and a plethora of side events focusing on strategies and country progress toward MDGs 4 and 5. For Family Care International, which advocates for improved reproductive, maternal, and newborn health, this unprecedented level of attention to women's and children's health is a welcome sign that our advocacy is having an impact, and that global commitment to ending all preventable maternal and child deaths is stronger than ever.
RMNCH was a key theme in many other important discussions during the week, demonstrating the centrality of the health of mothers and newborns to a range of development challenges.

  • Events began with a Climate Summit that brought together leaders from more than 120 countries. The Partnership for Maternal, Newborn & Child Health noted during the Summit that “women and children are the most vulnerable to the effects of a changing climate, and those who are more likely to suffer and die from problems such as diarrhoea, undernutrition, malaria, and from the harmful effects of extreme weather events such as floods or drought.”
  • There was a special session to review progress towards achieving the International Conference on Population and Development Programme of Action. The ICPD agenda highlights the importance of ensuring universal access to sexual and reproductive health and rights and the importance of quality and accessible maternal health care, recognizing that healthy girls and women can choose to become healthy moms of healthy babies.
  • The UN Security Council held an emergency meeting where President Obama called for swift action on the Ebola epidemic that is destroying lives and decimating African health systems. This crisis highlights already-fragile health systems that lack sufficient health workers, supplies, and essential medicines; the same failures that contribute to maternal and newborn mortality. A recent news story details how pregnant women who are not infected with Ebola risk dying in West Africa due to lack of access to maternal health services, and the same risk exists for newborns and young children. The loss of skilled healthworkers, particularly midwives, could have enormous long term impacts on the ability of women, newborns and children to access life-saving care.
  • Finally, the UNGA week included high-level meetings on humanitarian crises in Syria, South Sudan and many other countries. According to the State of the World’s Mothers 2014 report, more than half of all maternal and child deaths occur in crisis-affected places. Discussions of humanitarian response in crisis settings included recognition of the disproportionate impact on women and children of violence, including gender-based violence, displacement, lack of access to food and lack of access to crucial maternal health services and early interventions for newborns. These crises and fragile health systems make achieving the Every Newborn Action Plan recommendations on ensuring quality care for mothers and newborns during labor, childbirth and the first week of life more difficult, but also more critical.

While this long list of world crisis may seem overwhelming, there is some good news on maternal, newborn and child survival. As the UN Secretary-General reminded us, the world is reducing deaths of children under the age of five faster than at any time in the past two decades and significant declines in maternal mortality have occurred in the past 10 years. As the world works together to shape the post-2015 development goals, these experiences during UNGA show that the new agenda must prioritize continuing to address maternal, newborn and child mortality which is linked to many of the world's pressing development challenges, including poverty. As a recent editorial in The Lancet says, “As governments slowly come to an agreement about development priorities post-2015, it is clear that maternal and newborn health will be essential foundations of any vision for sustainable development between 2015 and 2030.”


By Gary Darmstadt on October 8, 2014

This blog was originally published on Impatient Optimist. It was written by Gary Darmstadt, Sarah Henry and Luca Passerini. 

Over the last decade the Grand Challenges family of programs has fostered innovation and partnership to address some of the world’s most difficult global health and development challenges for the poor and marginalized. This week, as part of an exciting evolution at the Bill & Melinda Gates Foundation, we are launching a new Grand Challenge to more effectively reach and empower the most vulnerable women and girls.

This will be our first Grand Challenge on gender equality and women’s and girls’ empowerment, and it signals a more concerted push to put women and girls at the center of our work.

As Melinda Gates advanced in a recent publication in Science Magazine at the Gates Foundation we are committing to being more intentional about addressing gender inequalities and enhancing women’s and girls’ empowerment. Being unintentional about gender issues – essentially ignoring gender inequalities – causes many development projects to fall short of their objective, and in the worst instances exacerbates gender inequalities and does harm. And when development organizations do not focus on women’s empowerment, they neglect the fact that women empowered with agency and voice – the ability to make decisions about their own life and act on them to achieve a desired outcome, free of violence, retribution, or fear – have the potential to transform their societies. As Melinda expressed in her commentary, we recognize that many other organizations have been working ardently to address gender inequalities for a long time. We committed to joining partners more actively in addressing and confronting inequalities for women and girls as a fundamental right, as well as a key driver of improved health and social and economic progress.

Smart development intentionally addresses and integrates a gender equality perspective alongside sector interventions and measures the impact of health and development programs. Measures, however, not only include sector outcomes – such as contraceptive prevalence rates, agricultural productivity or access to digital financial services – but also gender outcomes – such as equitable decision-making power, shared control over assets and income, personal safety, mobility, and equitable interpersonal relations (Figure 1).

Putting Women and Girls at the Center of Development seeks to accelerate understanding of how to effectively address gender inequalities and empower women and girls, and how to better measure women’s and girls’ empowerment. Although program approaches to improve gender equality and women’s empowerment do exist, we need to better understand how to do this most efficiently and under what conditions the various approaches will be most effective. That is why we have focused the Grand Challenge on developing and testing solutions and generating evidence for approaches – particularly on how to promote equitable decision-making – that are sustainable and cost-effective, with potential for scale. We understand that to achieve gender equality between the sexes we need to engage and transform the attitudes and beliefs of men and boys and encourage and support solutions targeting and engaging them as partners and agents of change.

Among the different approaches to promoting gender equality and women's empowerment, in this first round call for proposals, we have the greatest interest in moving beyond the evidence associating equitable decision-making with improved health and development outcomes to better understanding how to go about achieving equitable decision-making at individual, household and societal levels. However, we also welcome good ideas on other effective approaches that lead to increased women’s and girls’ agency and voice (e.g., control over assets/resources, personal safety, mobility, equitable interpersonal relationships).

We are encouraging multisectoral (e.g. nutrition, agriculture, sanitation, etc. working together) projects that intentionally and effectively address gender inequalities and empower women and girls while improving outcomes in more than one sector. Putting Women and Girls at the Center of Development is a collaborative initiative involving technical and financial contributions from 11 teams at the Bill and Melinda Gates Foundation, representing one of our most collaborative investments ever launched across Agriculture; Water, Sanitation and Hygiene; Financial Services for the Poor; HIV; Strategy, Measurement and Evaluation; Integrated Delivery; Nutrition; Family Planning; Maternal, Newborn and Child Health; Emergency Relief; and the India Country Office. This is part of a broader effort in which we are trying to come together as a Foundation and with our partners and global innovators to put women and girls at the center of our work.

The challenge will fund larger and longer awards ($2.5M over 4 years) as well as smaller exploratory grants ($500K over 2 years). Awards will require low and middle income country leadership, and women-led applications will be particularly encouraged. Based on the results of the 2014 challenge call, we have the potential to issue subsequent rounds as the evidence dictates and we are encouraging funding partners to join us in further supporting and shaping this challenge.

It is our hope that “Putting Women and Girls at the Center of Development” will create opportunities to develop and test bold ideas leading to concrete and effective solutions benefiting women and girls as well as men and boys, and empowering women and girls as agents of change in their families, communities and societies. We also envision the development of new partnerships spanning the fields of gender, global health and development, leading to the creation of a community of practice where partners and grantees collaborate to exchange experiences, overcome challenges and build on each other’s successes. We know this will be a long and difficult path, but this represents the first step we are taking to address what we believe is a monumental grand challenge that must be tackled in order to fulfill our mission of helping all people lead healthy and productive lives.