Perinatal morbidity among women with a previous caesarean delivery (PRISMA trial): a cluster-randomised trial.

BACKGROUND: Women with a previous caesarean delivery face a difficult choice in their next pregnancy: planning another caesarean or attempting vaginal delivery, both of which are associated with potential maternal and perinatal complications. This trial aimed to assess whether a multifaceted intervention, which promoted person-centred decision making and best practices, would reduce the risk of major perinatal morbidity among women with one previous caesarean delivery. METHODS: We conducted an open, multicentre, cluster-randomised, controlled trial of a multifaceted 2-year intervention in 40 hospitals in Quebec among women with one previous caesarean delivery, in which hospitals were the units of randomisation and women the units of analysis. Randomisation was stratified according to level of care, using blocked randomisation. Hospitals were randomly assigned (1:1) to the intervention group (implementation of best practices and provision of tools that aimed to support decision making about mode of delivery, including an estimation of the probability of vaginal delivery and an ultrasound estimation of the risk of uterine rupture), or the control group (no intervention). The primary outcome was a composite risk of major perinatal morbidity. This trial was registered with ISRCTN, ISRCTN15346559. FINDINGS: 21 281 eligible women delivered during the study period, from April 1, 2016 to Dec 13, 2019 (10 514 in the intervention group and 10 767 in the control group). None were lost to follow-up. There was a significant reduction in the rate of major perinatal morbidity from the baseline period to the intervention period in the intervention group as compared with the control group (adjusted odds ratio [OR] for incremental change over time, 0·72 [95% CI 0·52-0·99]; p=0·042; adjusted risk difference -1·2% [95% CI -2·0 to -0·1]). Major maternal morbidity was significantly reduced in the intervention group as compared with the control group (adjusted OR 0·54 [95% CI 0·33-0·89]; p=0·016). Minor perinatal and maternal morbidity, caesarean delivery, and uterine rupture rates did not differ significantly between groups. INTERPRETATION: A multifaceted intervention supporting women in their choice of mode of delivery and promoting best practices resulted in a significant reduction in rates of major perinatal and maternal morbidity, without an increase in the rate of caesarean or uterine rupture. FUNDING: Canadian Institutes of Health Research (CIHR, MOP-142448).

Socioeconomic and geographic inequities in vaccination among children 12 to 59 months in Mexico, 2012 to 2021.

Objective: To document the evolution of socioeconomic and geographical inequalities in childhood vaccination in Mexico from 2012 to 2021. Methods: Repeated cross-sectional analysis using three rounds of National Health and Nutrition Surveys (2012, 2018, and 2021). Dichotomous variables were created to identify the proportion of children who received no dose of each vaccine included in the national immunization schedule (BCG; diphtheria, pertussis, and tetanus-containing; rotavirus; pneumococcal conjugate; and measles, mumps, and rubella [MMR]), and the proportion completely unvaccinated. The distribution of unvaccinated children was analyzed by state, and by socioeconomic status using the concentration index. Results: The prevalence of completely unvaccinated children in Mexico was low, with 0.3% children in 2012 and 0.8% children in 2021 receiving no vaccines (p = 0.070). Notwithstanding, for each vaccine, an important proportion of children missed receiving any dose. Notably, the prevalence of MMR unvaccinated children was 10.2% (95% CI 9.2-11.1) in 2012, 22.3% (95% CI 20.9-23.8) in 2018, and 29.1% (95% CI 26.3-31.8) in 2021 (p < 0.001 for the difference between 2012 and 2021). The concentration index indicated pro-rich inequalities in non-vaccination for 2 of 5 vaccines in 2012, 3 of 5 vaccines in 2018, and 4 of 5 vaccines in 2021. There were marked subnational variations. The percentage of MMR unvaccinated children ranged from 3.3% to 17.9% in 2012, 5.5% to 36.5% in 2018, and 13.1% to 72.5% in 2021 across the 32 states of Mexico. Conclusions: Equitable access to basic childhood vaccines in Mexico has deteriorated over the past decade. Vigilant equity monitoring coupled with tailored strategies to reach those left out is urgently required.

The first 100 days: how has COVID-19 affected poor and vulnerable groups in India?

In India, strict public health measures to suppress COVID-19 transmission and reduce burden have been rapidly adopted. Pandemic containment and confinement measures impact societies and economies; their costs and benefits must be assessed holistically. This study provides an evolving portrait of the health, economic and social consequences of the COVID-19 pandemic on vulnerable populations in India. Our analysis focuses on 100 days early in the pandemic from 13 March to 20 June 2020. We developed a conceptual framework based on the human right to health and the UN Sustainable Development Goals (SDGs). We analysed people's experiences recorded and shared via mobile phone on the voice platforms operated by the Gram Vaani COVID-19 response network, a service for rural and low-income populations now being deployed to support India's COVID-19 response. Quantitative and visual methods were used to summarize key features of the data and explore relationships between factors. In its first 100 days, the platform logged over 1.15 million phone calls, of which 793 350 (69%) were outbound calls related largely to health promotion in the context of COVID-19. Analysis of 6636 audio recordings by network users revealed struggles to secure the basic necessities of survival, including food (48%), cash (17%), transportation (10%) and employment or livelihoods (8%). Themes were mapped to shortfalls in 10 SDGs and their associated targets. Pre-existing development deficits and weak social safety nets are driving vulnerability during the COVID-19 crisis. For an effective pandemic response and recovery, these must be addressed through inclusive policy design and institutional reforms.

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

BACKGROUND: Social, behavioural and community engagement (SBCE) interventions are essential for global maternal, newborn and child health (MNCH) strategies. Past efforts to synthesise research on SBCE interventions identified a need for clear priorities to guide future research. WHO led an exercise to identify global research priorities for SBCE interventions to improve MNCH. METHODS: We adapted the Child Health and Nutrition Research Initiative method and combined quantitative and qualitative methods to determine MNCH SBCE intervention research priorities applicable across different contexts. Using online surveys and meetings, researchers and programme experts proposed up to three research priorities and scored the compiled priorities against four criteria - health and social impact, equity, feasibility, and overall importance. Priorities were then ranked by score. A group of 29 experts finalised the top 10 research priorities for each of maternal, newborn or child health and a cross-cutting area. RESULTS: A total of 310 experts proposed 867 research priorities, which were consolidated into 444 priorities and scored by 280 experts. Top maternal and newborn health priorities focused on research to improve the delivery of SBCE interventions that strengthen self-care/family care practices and care-seeking behaviour. Child health priorities focused on the delivery of SBCE interventions, emphasising determinants of service utilisation and breastfeeding and nutrition practices. Cross-cutting MNCH priorities highlighted the need for better integration of SBCE into facility-based and community-based health services. CONCLUSIONS: Achieving global targets for MNCH requires increased investment in SBCE interventions that build capacities of individuals, families and communities as agents of their own health. Findings from this exercise provide guidance to prioritise investments and ensure that they are best directed to achieve global objectives. Stakeholders are encouraged to use these priorities to guide future research investments and to adapt them for country programmes by engaging with national level stakeholders.

Implementation fidelity of village health and nutrition days in Hardoi District, Uttar Pradesh, India: a cross-sectional survey.

BACKGROUND: Village Health and Nutrition Days (VHNDs) are a cornerstone of the Government of India's strategy to provide first-contact primary health care to rural areas. Recent government programmes such as the Janani Suraksha Yojana (JSY) and Mission Indradhanush (MI) have catalysed important changes impacting VHNDs. To learn how VHNDs are currently being delivered, we assessed the fidelity of services provided as compared to government norms in a priority district of Uttar Pradesh. METHODS: We fielded a cross-sectional study of VHNDs to provide a snapshot of health services functioning. Process evaluation data were collected via administrative sources, non-participant observation using a standardised form, and structured questionnaires. Questionnaires were designed using a framework to assess implementation fidelity. Key respondents were VHND participants, front-line workers involved in VHND delivery, and VHND non-participants (pregnant women due for antenatal care or children due for vaccination as per administrative records). Results were summarised as counts, frequencies, and proportions. RESULTS: In the 30 villages randomly selected for inclusion, 36 VHNDs were scheduled but four (11.1%) were cancelled and one VHND was not surveyed. Vaccination and antenatal care were offered at 96.8% (30/31) and child weighing at 83.9% (26/31) of VHNDs. Other normed services were infrequently provided or completely absent. Health education and promotion were particularly weak; institutional delivery was the only topic discussed in a majority of VHNDs. The true proportion of any serious problem impeding vaccine delivery was 47.2% (17/36), comprising 4 VHND cancellations and 13 VHNDs experiencing vaccine shortages. Of the 13 incidents of vaccine shortage, 11 related to an unexpected global shortage of injectable polio vaccine (IPV). Over the 31 VHNDs, 37.8% (171 of the 452 scheduled beneficiaries) did not participate. Analysis of missed opportunities for vaccination highlighted inaccuracies in beneficiary identification and tracking and demand side-factors. CONCLUSIONS: The transformative potential of VHNDs to improve population health is only partially being met. A core subset of high-priority services for antenatal care, institutional delivery, and vaccination associated with high-priority government programmes (JSY, MI) is now being provided quite successfully. Other basic health promotion and prevention services are largely not provided, constituting a critical missed opportunity.

Characterizing measles transmission in India: a dynamic modeling study using verbal autopsy data.

BACKGROUND: Decreasing trends in measles mortality have been reported in recent years. However, such estimates of measles mortality have depended heavily on assumed regional measles case fatality risks (CFRs) and made little use of mortality data from low- and middle-income countries in general and India, the country with the highest measles burden globally, in particular. METHODS: We constructed a dynamic model of measles transmission in India with parameters that were empirically inferred using spectral analysis from a time series of measles mortality extracted from the Million Death Study, an ongoing longitudinal study recording deaths across 2.4 million Indian households and attributing causes of death using verbal autopsy. The model was then used to estimate the measles CFR, the number of measles deaths, and the impact of vaccination in 2000-2015 among under-five children in India and in the states of Bihar and Uttar Pradesh (UP), two states with large populations and the highest numbers of measles deaths in India. RESULTS: We obtained the following estimated CFRs among under-five children for the year 2005: 0.63% (95% confidence interval (CI): 0.40-1.00%) for India as a whole, 0.62% (0.38-1.00%) for Bihar, and 1.19% (0.80-1.75%) for UP. During 2000-2015, we estimated that 607,000 (95% CI: 383,000-958,000) under-five deaths attributed to measles occurred in India as a whole. If no routine vaccination or supplemental immunization activities had occurred from 2000 to 2015, an additional 1.6 (1.0-2.6) million deaths for under-five children would have occurred across India. CONCLUSIONS: We developed a data- and model-driven estimation of the historical measles dynamics, CFR, and vaccination impact in India, extracting the periodicity of epidemics using spectral and coherence analysis, which allowed us to infer key parameters driving measles transmission dynamics and mortality.

A cluster-randomized trial to reduce caesarean delivery rates in Quebec: cost-effectiveness analysis.

BACKGROUND: Widespread increases in caesarean section (CS) rates have sparked concerns about risks to mothers and infants and rising healthcare costs. A multicentre, two-arm, cluster-randomized trial in Quebec, Canada assessed whether an audit and feedback intervention targeting health professionals would reduce CS rates for pregnant women compared to usual care, and concluded that it reduced CS rates without adverse effects on maternal or neonatal health. The effect was statistically significant but clinically small. We assessed cost-effectiveness to inform scale-up decisions. METHODS: A prospective economic evaluation was undertaken using individual patient data from the Quality of Care, Obstetrics Risk Management, and Mode of Delivery (QUARISMA) trial (April 2008 to October 2011). Analyses took a healthcare payer perspective. The time horizon captured hospital-based costs and clinical events for mothers and neonates from labour onset to 3 months postpartum. Resource use was identified and measured from patient charts and valued using standardized government sources. We estimated the changes in CS rates and costs for the intervention group (versus controls) between the baseline and post-intervention periods. We examined heterogeneity between clinical subgroups of high-risk versus low-risk pregnancies and estimated the joint uncertainty in cost-effectiveness over 20,000 trial simulations. We decomposed costs to identify drivers of change. RESULTS: The intervention group experienced per-patient reductions of 0.005 CS (95% confidence interval (CI): -0.015 to 0.004, P = 0.09) and $180 (95% CI: -$277 to - $83, P < 0.001). Women with low-risk pregnancies experienced statistically significant reductions in CS rates and costs; changes for the high-risk subgroup were not significant. The intervention was "dominant" (effective in reducing CS and less costly than usual care) in 86.08% of simulations. It reduced costs in 99.99% of simulations. Cost reductions were driven by lower rates of neonatal complications in the intervention group (-$190, 95% CI: -$255 to - $125, P < 0.001). Given 88,000 annual provincial births, a similar intervention could save $15.8 million (range: $7.3 to $24.4 million) in Quebec annually. CONCLUSIONS: From a healthcare payer perspective, a multifaceted intervention involving audits and feedback resulted in a small reduction in caesarean deliveries and important cost savings. Cost reductions are consistent with improved quality of care in intervention group hospitals. TRIAL REGISTRATION: International Clinical Trials Registry Platform, ISRCTN95086407 . Registered on 23 October 2007.

An equity dashboard to monitor vaccination coverage.

Equity monitoring is a priority for Gavi, the Vaccine Alliance, and for those implementing The2030 agenda for sustainable development. For its new phase of operations, Gavi reassessed its approach to monitoring equity in vaccination coverage. To help inform this effort, we made a systematic analysis of inequalities in vaccination coverage across 45 Gavi-supported countries and compared results from different measurement approaches. Based on our findings, we formulated recommendations for Gavi's equity monitoring approach. The approach involved defining the vulnerable populations, choosing appropriate measures to quantify inequalities, and defining equity benchmarks that reflect the ambitions of the sustainable development agenda. In this article, we explain the rationale for the recommendations and for the development of an improved equity monitoring tool. Gavi's previous approach to measuring equity was the difference in vaccination coverage between a country's richest and poorest wealth quintiles. In addition to the wealth index, we recommend monitoring other dimensions of vulnerability (maternal education, place of residence, child sex and the multidimensional poverty index). For dimensions with multiple subgroups, measures of inequality that consider information on all subgroups should be used. We also recommend that both absolute and relative measures of inequality be tracked over time. Finally, we propose that equity benchmarks target complete elimination of inequalities. To facilitate equity monitoring, we recommend the use of a data display tool - the equity dashboard - to support decision-making in the sustainable development period. We highlight its key advantages using data from Côte d'Ivoire and Haiti.

Le suivi de l'équité est une priorité pour Gavi, l'Alliance du Vaccin et pour ceux qui mettent en œuvre le Programme de développement durable à l'horizon 2030. Dans le cadre de sa nouvelle phase d'opérations, Gavi a repensé son approche relative au suivi de l'équité en matière de couverture vaccinale. Afin de contribuer à cet effort, nous avons réalisé une analyse systématique des inégalités en matière de couverture vaccinale dans 45 pays soutenus par Gavi et comparé les résultats obtenus à partir de différentes méthodes de mesure. Nous nous sommes appuyés sur nos conclusions pour formuler des recommandations concernant l'approche adoptée par Gavi pour suivre l'équité. Cette approche impliquait de définir les populations vulnérables, de choisir des mesures appropriées pour quantifier les inégalités et d'établir des critères en matière d'équité qui reflètent les ambitions du programme de développement durable. Dans le présent article, nous expliquons la raison d'être de nos recommandations et le but de l'élaboration d'un meilleur outil de suivi de l'équité. L'approche précédemment utilisée par Gavi pour mesurer l'équité consistait à calculer la différence en matière de couverture vaccinale entre les quintiles de richesse les plus élevés et les plus bas d'un pays. Nous recommandons de suivre des dimensions de la vulnérabilité (éducation maternelle, lieu de résidence, sexe des enfants et indice de pauvreté multidimensionnelle) autres que l'indice de richesse. Lorsqu'une dimension inclut divers sous-groupes, il convient d'utiliser des mesures de l'inégalité prenant en compte les informations relatives à tous les sous-groupes. Nous conseillons également de suivre les mesures absolues mais aussi relatives d'inégalité au fil du temps. Enfin, nous suggérons que les critères en matière d'équité visent l'élimination complète des inégalités. Afin de faciliter le suivi de l'équité, nous recommandons l'utilisation d'un outil d'affichage de données ­ le tableau de bord de l'équité ­ pour favoriser la prise de décision dans le cadre du programme de développement durable. Nous mettons en avant les principaux avantages de cet outil à l'aide de données provenant de Côte d'Ivoire et d'Haïti.

La supervisión de la equidad es una prioridad para la Gavi, la Vaccine Alliance y para los que implementan la Agenda 2030 para el Desarrollo Sostenible. Para su nueva fase de operaciones, la Gavi reevaluó su enfoque para supervisar la equidad en la cobertura de vacunación. Para ayudar a informar este esfuerzo, se realizó un análisis sistemático de desigualdades en la cobertura de vacunación en 45 países apoyados por la Gavi y se compararon los resultados desde distintos enfoques de medición. En base a los resultados, se formularon recomendaciones para el enfoque de supervisión de equidad de la Gavi. El enfoque implicó la definición de las poblaciones vulnerables, la selección de las medidas adecuadas para cuantificar las desigualdades y la definición de las referencias de equidad que reflejan las ambiciones de la agencia de desarrollo sostenible. En este artículo, se explican los motivos de las recomendaciones y el desarrollo de una herramienta mejorada de supervisión de la equidad. El anterior enfoque de la Gavi para la medición de la equidad era la diferencia de la cobertura de vacunación entre los sectores demográficos más ricos y más pobres de un país. Además del índice patrimonial, se recomienda supervisar otras dimensiones de vulnerabilidad (educación de la madre, lugar de residencia, sexo de los niños y el índice de pobreza multidimensional). Para las dimensiones con múltiples subgrupos, deberían utilizarse medidas de desigualdad que tienen en cuenta información acerca de todos los subgrupos. También se recomienda que, con el paso del tiempo, se haga un seguimiento tanto de la medida de desigualdad absoluta como relativa. Por último, se propone que las referencias de equidad tengan como objetivo la eliminación completa de la desigualdad. Para facilitar la supervisión de la equidad, se recomienda utilizar una herramienta de indicación de datos (el tablero de equidad) para apoyar la toma de decisiones durante el periodo de desarrollo sostenible. Se destacan sus ventajas básicas utilizando datos de Côte d'Ivoire y de Haití.

Adding interventions to mass measles vaccinations in India.

OBJECTIVE: To quantify the impact on mortality of offering a hypothetical set of technically feasible, high-impact interventions for maternal and child survival during India's 2010-2013 measles supplementary immunization activity. METHODS: We developed Lives Saved Tool models for 12 Indian states participating in the supplementary immunization, based on state- and sex-specific data on mortality from India's Million Deaths Study and on health services coverage from Indian household surveys. Potential add-on interventions were identified through a literature review and expert consultations. We quantified the number of lives saved for a campaign offering measles vaccine alone versus a campaign offering measles vaccine with six add-on interventions (nutritional screening and complementary feeding for children, vitamin A and zinc supplementation for children, multiple micronutrient and calcium supplementation in pregnancy, and free distribution of insecticide-treated bednets). FINDINGS: The measles vaccination campaign saved an estimated 19 016 lives of children younger than 5 years. A hypothetical campaign including measles vaccine with add-on interventions was projected to save around 73 900 lives (range: 70 200-79 300), preventing 73 700 child deaths (range: 70 000-79 000) and 300 maternal deaths (range: 200-400). The most effective interventions in the whole package were insecticide-treated bednets, measles vaccine and preventive zinc supplementation. Girls accounted for 66% of expected lives saved (12 712/19 346) for the measles vaccine campaign, and 62% of lives saved (45 721/74 367) for the hypothetical campaign including add-on interventions. CONCLUSION: In India, a measles vaccination campaign including feasible, high-impact interventions could substantially increase the number of lives saved and mitigate gender-related inequities in child mortality.

Maternal Health Literacy Is Associated with Early Childhood Nutritional Status in India.

BACKGROUND: The global burden of child undernutrition is concentrated in South Asia, where gender inequality and female educational disadvantage are important factors. Maternal health literacy is linked to women's education and empowerment, can influence multiple malnutrition determinants, and is rapidly modifiable. OBJECTIVE: This study investigated whether maternal health literacy is associated with child undernutrition in 2 resource-poor Indian populations. METHODS: We conducted cross-sectional surveys in an urban and a rural site, interviewing 1 woman with a child aged 12-23 mo/household. Multivariate logistic regression analyses were conducted independently for each site. The main exposure was maternal health literacy. We assessed respondents' ability to understand, appraise, and apply health-related information with the use of Indian health promotion materials. The main outcomes were severe stunting, severe underweight, and severe wasting. We classified children as having a severe nutritional deficiency if their z score was <-3 SDs from the WHO reference population for children of the same age and sex. Analyses controlled for potential confounding factors including parental education and household wealth. RESULTS: Rural and urban analyses included 1116 and 657 mother-child pairs, respectively. In each site, fully adjusted models showed that children of mothers with high health literacy had approximately half the likelihood of being severely stunted (rural adjusted OR: 0.50; 95% CI: 0.33, 0.74; P = 0.001; urban adjusted OR: 0.58; 95% CI: 0.35, 0.94; P = 0.028) or severely underweight (rural adjusted OR: 0.57; 95% CI: 0.38, 0.87; P = 0.009; urban adjusted OR: 0.48; 95% CI: 0.25, 0.91; P = 0.025) than children of mothers with low health literacy. Health literacy was not associated with severe wasting. CONCLUSIONS: In resource-poor rural and urban settings in India, maternal health literacy is associated with child nutritional status. Programs targeting health literacy may offer effective entry points for intervention.

Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial.

BACKGROUND: Post-thrombotic syndrome (PTS) is a common and burdensome complication of deep venous thrombosis (DVT). Previous trials suggesting benefit of elastic compression stockings (ECS) to prevent PTS were small, single-centre studies without placebo control. We aimed to assess the efficacy of ECS, compared with placebo stockings, for the prevention of PTS. METHODS: We did a multicentre randomised placebo-controlled trial of active versus placebo ECS used for 2 years to prevent PTS after a first proximal DVT in centres in Canada and the USA. Patients were randomly assigned to study groups with a web-based randomisation system. Patients presenting with a first symptomatic, proximal DVT were potentially eligible to participate. They were excluded if the use of compression stockings was contraindicated, they had an expected lifespan of less than 6 months, geographical inaccessibility precluded return for follow-up visits, they were unable to apply stockings, or they received thrombolytic therapy for the initial treatment of acute DVT. The primary outcome was PTS diagnosed at 6 months or later using Ginsberg's criteria (leg pain and swelling of ≥1 month duration). We used a modified intention to treat Cox regression analysis, supplemented by a prespecified per-protocol analysis of patients who reported frequent use of their allocated treatment. This study is registered with ClinicalTrials.gov, number NCT00143598, and Current Controlled Trials, number ISRCTN71334751. FINDINGS: From 2004 to 2010, 410 patients were randomly assigned to receive active ECS and 396 placebo ECS. The cumulative incidence of PTS was 14·2% in active ECS versus 12·7% in placebo ECS (hazard ratio adjusted for centre 1·13, 95% CI 0·73-1·76; p=0·58). Results were similar in a prespecified per-protocol analysis of patients who reported frequent use of stockings. INTERPRETATION: ECS did not prevent PTS after a first proximal DVT, hence our findings do not support routine wearing of ECS after DVT. FUNDING: Canadian Institutes of Health Research.

Strategies to increase the demand for childhood vaccination in low- and middle-income countries: a systematic review and meta-analysis.

OBJECTIVE: To investigate which strategies to increase demand for vaccination are effective in increasing child vaccine coverage in low- and middle-income countries. METHODS: We searched MEDLINE, EMBASE, Cochrane library, POPLINE, ECONLIT, CINAHL, LILACS, BDSP, Web of Science and Scopus databases for relevant studies, published in English, French, German, Hindi, Portuguese and Spanish up to 25 March 2014. We included studies of interventions intended to increase demand for routine childhood vaccination. Studies were eligible if conducted in low- and middle-income countries and employing a randomized controlled trial, non-randomized controlled trial, controlled before-and-after or interrupted time series design. We estimated risk of bias using Cochrane collaboration guidelines and performed random-effects meta-analysis. FINDINGS: We identified 11 studies comprising four randomized controlled trials, six cluster randomized controlled trials and one controlled before-and-after study published in English between 1996 and 2013. Participants were generally parents of young children exposed to an eligible intervention. Six studies demonstrated low risk of bias and five studies had moderate to high risk of bias. We conducted a pooled analysis considering all 11 studies, with data from 11,512 participants. Demand-side interventions were associated with significantly higher receipt of vaccines, relative risk (RR): 1.30, (95% confidence interval, CI: 1.17-1.44). Subgroup analyses also demonstrated significant effects of seven education and knowledge translation studies, RR: 1.40 (95% CI: 1.20-1.63) and of four studies which used incentives, RR: 1.28 (95% CI: 1.12-1.45). CONCLUSION: Demand-side interventions lead to significant gains in child vaccination coverage in low- and middle-income countries. Educational approaches and use of incentives were both effective strategies.

Unexplained health inequality--is it unfair?

INTRODUCTION: Accurate measurement of health inequities is indispensable to track progress or to identify needs for health equity policy interventions. A key empirical task is to measure the extent to which observed inequality in health - a difference in health - is inequitable. Empirically operationalizing definitions of health inequity has generated an important question not considered in the conceptual literature on health inequity. Empirical analysis can explain only a portion of observed health inequality. This paper demonstrates that the treatment of unexplained inequality is not only a methodological but ethical question and that the answer to the ethical question - whether unexplained health inequality is unfair - determines the appropriate standardization method for health inequity analysis and can lead to potentially divergent estimates of health inequity. METHODS: We use the American sample of the 2002-03 Joint Canada/United States Survey of Health and measure health by the Health Utilities Index (HUI). We model variation in the observed HUI by demographic, socioeconomic, health behaviour, and health care variables using Ordinary Least Squares. We estimate unfair HUI by standardizing fairness, removing the fair component from the observed HUI. We consider health inequality due to factors amenable to policy intervention as unfair. We contrast estimates of inequity using two fairness-standardization methods: direct (considering unexplained inequality as ethically acceptable) and indirect (considering unexplained inequality as unfair). We use the Gini coefficient to quantify inequity. RESULTS: Our analysis shows that about 75% of the variation in the observed HUI is unexplained by the model. The direct standardization results in a smaller inequity estimate (about 60% of health inequality is inequitable) than the indirect standardization (almost all inequality is inequitable). CONCLUSIONS: The choice of the fairness-standardization method is ethical and influences the empirical health inequity results considerably. More debate and analysis is necessary regarding which treatment of the unexplained inequality has the stronger foundation in equity considerations.

Estimation of maternal and child mortality one year after user-fee elimination: an impact evaluation and modelling study in Burkina Faso.

OBJECTIVE: To estimate the impact on maternal and child mortality after eliminating user fees for pregnant women and for children less than five years of age in Burkina Faso. METHODS: Two health districts in the Sahel region eliminated user fees for facility deliveries and curative consultations for children in September 2008. To compare health-care coverage before and after this change, we used interrupted time series, propensity scores and three independent data sources. Coverage changes were assessed for four variables: women giving birth at a health facility, and children aged 1 to 59 months receiving oral rehydration salts for diarrhoea, antibiotics for pneumonia and artemesinin for malaria. We modelled the mortality impact of coverage changes in the Lives Saved Tool using several scenarios. FINDINGS: Coverage increased for all variables, however, the increase was not statistically significant for antibiotics for pneumonia. For estimated mortality impact, the intervention saved approximately 593 (estimate range 168-1060) children's lives in both districts during the first year. This lowered the estimated under-five mortality rate from 235 deaths per 1000 live births in 2008 to 210 (estimate range 189-228) in 2009. If a similar intervention were to be introduced nationwide, 14,000 to 19,000 (estimate range 4000-28,000) children's lives could be saved annually. Maternal mortality showed a modest decrease in all scenarios. CONCLUSION: In this setting, eliminating user fees increased use of health services and may have contributed to reduced child mortality.

A three-stage approach to measuring health inequalities and inequities.

INTRODUCTION: Measurement of health inequities is fundamental to all health equity initiatives. It is complex because it requires considerations of ethics, methods, and policy. Drawing upon the recent developments in related specialized fields, in this paper we incorporate alternative definitions of health inequity explicitly and transparently in its measurement. We propose a three-stage approach to measuring health inequities that assembles univariate health inequality, univariate health inequity, and bivariate health inequities in a systematic and comparative manner. METHODS: We illustrate the application of the three-stage approach using the Joint Canada/United States Survey of Health, measuring health by the Health Utilities Index (HUI). Univariate health inequality is the distribution of the observed HUI across individuals. Univariate health inequity is the distribution of unfair HUI--components of HUI associated with ethically unacceptable factors--across individuals. To estimate the unfair HUI, we apply two popular definitions of inequity: "equal opportunity for health" (health outcomes due to factors beyond individual control are unfair), and "policy amenability" (health outcomes due to factors amenable to policy interventions are unfair). We quantify univariate health inequality and inequity using the Gini coefficient. We assess bivariate inequities using a regression-based decomposition method. RESULTS: Our analysis reveals that, empirically, different definitions of health inequity do not yield statistically significant differences in the estimated amount of univariate inequity. This derives from the relatively small explanatory power common in regression models describing variations in health. As is typical, our model explains about 20% of the variation in the observed HUI. With regard to bivariate inequities, income and health care show strong associations with the unfair HUI. CONCLUSIONS: The measurement of health inequities is an excitingly multidisciplinary endeavour. Its development requires interdisciplinary integration of advances from relevant disciplines. The proposed three-stage approach is one such effort and stimulates cross-disciplinary dialogues, specifically, about conceptual and empirical significance of definitions of health inequities.

Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis.

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria. THE GUIDANCE WAS DEVELOP THROUGH A SERIES OF EXPERT CONSULTATION MEETINGS AND INVOLVED THREE STEPS: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders. The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).

Birth Preparedness and Complication Readiness (BPCR) interventions to reduce maternal and neonatal mortality in developing countries: systematic review and meta-analysis.

BACKGROUND: Birth Preparedness and Complication Readiness (BPCR) interventions are widely promoted by governments and international agencies to reduce maternal and neonatal health risks in developing countries; however, their overall impact is uncertain, and little is known about how best to implement BPCR at a community level. Our primary aim was to evaluate the impact of BPCR interventions involving women, families and communities during the prenatal, postnatal and neonatal periods to reduce maternal and neonatal mortality in developing countries. We also examined intervention impact on a variety of intermediate outcomes important for maternal and child survival. METHODS: We conducted a systematic review and meta-analysis of randomized trials of BPCR interventions in populations of pregnant women living in developing countries. To identify relevant studies, we searched the scientific literature in the Pubmed, Embase, Cochrane library, Reproductive health library, CINAHL and Popline databases. We also undertook manual searches of article bibliographies and web sites. Study inclusion was based on pre-specified criteria. We synthesised data by computing pooled relative risks (RR) using the Cochrane RevMan software. RESULTS: Fourteen randomized studies (292 256 live births) met the inclusion criteria. Meta-analyses showed that exposure to BPCR interventions was associated with a statistically significant reduction of 18% in neonatal mortality risk (twelve studies, RR = 0.82; 95% CI: 0.74, 0.91) and a non-significant reduction of 28% in maternal mortality risk (seven studies, RR = 0.72; 95% CI: 0.46, 1.13). Results were highly heterogeneous (I2 = 76%, p < 0.001 and I2 = 72%, p = 0.002 for neonatal and maternal results, respectively). Subgroup analyses of studies in which at least 30% of targeted women participated in interventions showed a 24% significant reduction of neonatal mortality risk (nine studies, RR = 0.76; 95% CI: 0.69, 0.85) and a 53% significant reduction in maternal mortality risk (four studies, RR = 0.47; 95% CI: 0.26, 0.87).Pooled results revealed that BPCR interventions were also associated with increased likelihood of use of care in the event of newborn illness, clean cutting of the umbilical cord and initiation of breastfeeding in the first hour of life. CONCLUSIONS: With adequate population coverage, BPCR interventions are effective in reducing maternal and neonatal mortality in low-resources settings.

HIV-sensitive social protection for unemployed and out-of-school young women in Botswana: An exploratory study of barriers and solutions.

Promotive social protection programs aim to increase income and capabilities and could help address structural drivers of HIV-vulnerability like poverty, lack of education and gender inequality. Unemployed and out-of-school young women bear the brunt of HIV infection in Botswana, but rarely benefit from such economic empowerment programs. Using a qualitative exploratory study design and a participatory research approach, we explored factors affecting perceived program benefit and potential solutions to barriers. Direct stakeholders (n = 146) included 87 unemployed and out-of-school young women and 59 program and technical officers in five intervention districts. Perceived barriers were identified in 20 semi-structured interviews (one intervention district) and 11 fuzzy cognitive maps. Co-constructed improvement recommendations were generated in deliberative dialogues. Analysis relied on Framework and the socioecological model. Overall, participants viewed existing programs in Botswana as ineffective and inadequate to empower vulnerable young women socially or economically. Factors affecting perceived program benefit related to programs, program officers, the young women, and their social and structural environment. Participants perceived barriers at every socioecological level. Young women's lack of life and job skills, unhelpful attitudes, and irresponsible behaviors were personal-level barriers. At an interpersonal level, competing care responsibilities, lack of support from boyfriends and family, and negative peer influence impeded program benefit. Traditional venues for information dissemination, poverty, inequitable gender norms, and lack of coordination were community- and structural-level barriers. Improvement recommendations focused on improved outreach and peer approaches to implement potential solutions. Unemployed and out-of-school young women face multidimensional, interacting barriers that prevent benefit from available promotive social protection programs in Botswana. To become HIV-sensitive, these socioeconomic empowerment programs would need to accommodate or preferentially attract this key population. This requires more generous and comprehensive programs, a more client-centered program delivery, and improved coordination. Such structural changes require a holistic, intersectoral approach to HIV-sensitive social protection.