Devices and furniture for small and sick newborn care: systematic development of a planning and costing tool.

BACKGROUND: High-quality neonatal care requires sufficient functional medical devices, furniture, fixtures, and use by trained healthcare workers, however there is lack of publicly available tools for quantification and costing. This paper describes development and use of a planning and costing tool regarding furniture, fixtures and devices to support scale-up of WHO level-2 neonatal care, for national and global newborn survival targets. METHODS: We followed a systematic process. First, we reviewed planning and costing tools of relevance. Second, we co-designed a new tool to estimate furniture and device set-up costs for a default 40-bed level-2 neonatal unit, incorporating input from multi-disciplinary experts and newborn care guidelines. Furniture and device lists were based off WHO guidelines/norms, UNICEF and national manuals/guides. Due to lack of evidence-based quantification, ratios were based on operational manuals, multi-country facility assessment data, and expert opinion. Default unit costs were from government procurement agency costs in Kenya, Nigeria, and Tanzania. Third, we refined the tool by national use in Tanzania. RESULTS: The tool adapts activity-based costing (ABC) to estimate quantities and costs to equip a level-2 neonatal unit based on three components: (1) furniture/fixtures (18 default but editable items); (2) neonatal medical devices (16 product categories with minimum specifications for use in low-resource settings); (3) user training at device installation. The tool was used in Tanzania to generate procurement lists and cost estimates for level-2 scale-up in 171 hospitals (146 District and 25 Regional Referral). Total incremental cost of all new furniture and equipment acquisition, installation, and user training were US$93,000 per District hospital (level-2 care) and US$346,000 per Regional Referral hospital. Estimated cost per capita for whole-country district coverage was US$0.23, representing 0.57% increase in government health expenditure per capita and additional 0.35% for all Regional Referral hospitals. CONCLUSION: Given 2.3 million neonatal deaths and potential impact of level-2 newborn care, rational and efficient planning of devices linked to systems change is foundational. In future iterations, we aim to include consumables, spare parts, and maintenance cost options. More rigorous implementation research data are crucial to formulating evidence-based ratios for devices numbers per baby. Use of this tool could help overcome gaps in devices numbers, advance efficiency and quality of neonatal care.

Priority Indicators for Adolescent Health Measurement - Recommendations From the Global Action for Measurement of Adolescent Health (GAMA) Advisory Group.

PURPOSE: This article describes the selection of priority indicators for adolescent (10-19 years) health measurement proposed by the Global Action for Measurement of Adolescent health advisory group and partners, building on previous work identifying 33 core measurement areas and mapping 413 indicators across these areas. METHODS: The indicator selection process considered inputs from a broad range of stakeholders through a structured four-step approach: (1) definition of selection criteria and indicator scoring; (2) development of a draft list of indicators with metadata; (3) collection of public feedback through a survey; and (4) review of the feedback and finalization of the indicator list. As a part of the process, measurement gaps were also identified. RESULTS: Fifty-two priority indicators were identified, including 36 core indicators considered to be most important for measuring the health of all adolescents, one alternative indicator for settings where measuring the core indicator is not feasible, and 15 additional indicators for settings where further detail on a topic would add value. Of these indicators, 17 (33%) measure health behaviors and risks, 16 (31%) health outcomes and conditions, eight (15%) health determinants, five (10%) systems performance and interventions, four (8%) policies, programmes, laws, and two (4%) subjective well-being. DISCUSSION: A consensus list of priority indicators with metadata covering the most important health issues for adolescents was developed with structured inputs from a broad range of stakeholders. This list will now be pilot tested to assess the feasibility of indicator data collection to inform global, regional, national, and sub-national monitoring.

Moving from community-based to health centre-based management: impact on urban community health worker performance in Ethiopia.

Community health worker (CHW) performance is influenced by the way in which management arrangements are configured vis-a-vis the community and health services. While low-/middle-income contexts are changing, the literature provides few examples of country efforts to strategically modify management arrangements to support evolving CHW roles (e.g. chronic disease care) and operating environments (e.g. urbanization). This paper aims to understand the performance implications of changing from community-based to health centre-based management, on Ethiopia's Urban Health Extension Professionals (UHEPs), and the tensions/trade-offs associated with the respective arrangements. We conducted semi-structured interviews/focus groups to gather perspectives and preferences from those involved with the transition (13 managers/administrators, 5 facility-based health workers and 20 UHEPs). Using qualitative content analysis, we deductively coded data to four programme elements impacted by changed management arrangements and known to affect CHW performance (work scope; community legitimacy; supervision/oversight/ownership and facility linkages) and inductively identified tensions/trade-offs. Community-based management was associated with wider work scope, stronger ownership/regular monitoring, weak technical support and weak health centre linkages, with opposite patterns observed for health centre-led management. Practical trade-offs included: heavy UHEP involvement in political/administrative activities under Kebele-based management; resistance to working with UHEPs by facility-based workers and health centre capacity constraints in managing UHEPs. Whereas the Ministry of Health/UHEPs favoured the health centre-led management to capitalize on UHEPs' technical skills, Kebele officials were vested in managing UHEPs and argued for community interests over UHEPs' professional interests; health facility managers/administrators held divided opinions. Management arrangements influence the nature of CHW contributions towards the achievement of health, development and political goals. Decisions about appropriate management arrangements should align with the nature of CHW roles and consider implementation setting, including urbanization, political decentralization and relative capacity of managing institutions.

Challenges in Implementing Community-Based Healthcare Teams in a Low-Income Country Context: Lessons From Ethiopia's Family Health Teams.

BACKGROUND: Addressing chronic diseases and intra-urban health disparities in low- and middle-income countries (LMICs) requires new health service models. Team-based healthcare models can improve management of chronic diseases/complex conditions. There is interest in integrating community health workers (CHWs) into these teams, given their effectiveness in reaching underserved populations. However healthcare team models are difficult to effectively implement, and there is little experience with team-based models in LMICs and with CHW-integrated models more generally. Our study aims to understand the determinants related to the poor adoption of Ethiopia's family health teams (FHTs); and, raise considerations for initiating CHW-integrated healthcare team models in LMIC cities. METHODS: Using the Consolidated Framework for Implementation Research (CFIR), we examine organizational-level factors related to implementation climate and readiness (work processes/incentives/resources/leadership) and system-level factors (policy guidelines/governance/financing) that affected adoption of FHTs in two Ethiopian cities. Using semi-structured interviews/focus groups, we sought implementation perspectives from 33 FHT members and 18 administrators. We used framework analysis to deductively code data to CFIR domains. RESULTS: Factors associated with implementation climate and readiness negatively impacted FHT adoption. Failure to tap into financial, political, and performance motivations of key stakeholders/FHT members contributed to low willingness to participate, while resource constraints restricted capacity to implement. Workload issues combined with no financial incentives/perceived benefit contributed to poor adoption among clinical professionals. Meanwhile, staffing constraints and unavailability of medicines/supplies/transport contributed to poor implementation readiness, further decreasing willingness among clinical professionals/managers to prioritize non-clinic based activities. The federally-driven program failed to provide budgetary incentives or tap into political motivations of municipal/health centre administrators. CONCLUSION: Lessons from Ethiopia's challenges in implementing its FHT program suggest that LMICs interested in adopting CHW-integrated healthcare team models should closely consider health system readiness (budgets, staffing, equipment/medicines) as well as incentivization strategies (financial, professional, political) to drive organizational change.

Socioeconomic inequalities in effective service coverage for reproductive, maternal, newborn, and child health: a comparative analysis of 39 low-income and middle-income countries.

BACKGROUND: Reducing socioeconomic inequalities in access to good quality health care is key for countries to achieve Universal Health Coverage. This study aims to assess socioeconomic inequalities in effective coverage of reproductive, maternal, newborn and child health (RMNCH) in low- and middle-income countries (LMICs). METHODS: Using the most recent national health surveys from 39 LMICs (between 2014 and 2018), we calculated coverage indicators using effective coverage care cascade that consists of service contact, crude coverage, quality-adjusted coverage, and user-adherence-adjusted coverage. We quantified wealth-related and education-related inequality using the relative index of inequality, slope index of inequality, and concentration index. FINDINGS: The quality-adjusted coverage of RMNCH services in 39 countries was substantially lower than service contact, in particular for postnatal care (64 percentage points [pp], p-value<0·0001), family planning (48·7 pp, p<0·0001), and antenatal care (43·6 pp, p<0·0001) outcomes. Upper-middle-income countries had higher effective coverage levels compared with low- and lower-middle-income countries in family planning, antenatal care, delivery care, and postnatal care. Socioeconomic inequalities tend to be wider when using effective coverage measurement compared with crude and service contact measurements. Our findings show that upper-middle-income countries had a lower magnitude of inequality compared with low- and lower-middle-income countries. INTERPRETATION: Reliance on the average contact coverage tends to underestimate the levels of socioeconomic inequalities for RMNCH service use in LMICs. Hence, the effective coverage measurement using a care cascade approach should be applied. While RMNCH coverages vary considerably across countries, equitable improvement in quality of care is particularly needed for lower-middle-income and low-income countries. FUNDING: None.

A call for standardised age-disaggregated health data.

The 2030 Sustainable Development Goals agenda calls for health data to be disaggregated by age. However, age groupings used to record and report health data vary greatly, hindering the harmonisation, comparability, and usefulness of these data, within and across countries. This variability has become especially evident during the COVID-19 pandemic, when there was an urgent need for rapid cross-country analyses of epidemiological patterns by age to direct public health action, but such analyses were limited by the lack of standard age categories. In this Personal View, we propose a recommended set of age groupings to address this issue. These groupings are informed by age-specific patterns of morbidity, mortality, and health risks, and by opportunities for prevention and disease intervention. We recommend age groupings of 5 years for all health data, except for those younger than 5 years, during which time there are rapid biological and physiological changes that justify a finer disaggregation. Although the focus of this Personal View is on the standardisation of the analysis and display of age groups, we also outline the challenges faced in collecting data on exact age, especially for health facilities and surveillance data. The proposed age disaggregation should facilitate targeted, age-specific policies and actions for health care and disease management.

A Scoping Review of Adolescent Health Indicators.

PURPOSE: A host of recent initiatives relating to adolescent health have been accompanied by varying indicator recommendations, with little stakeholder coordination. We assessed currently included adolescent health-related indicators for their measurement focus, identified overlap across initiatives, and determined measurement gaps. METHODS: We conducted a scoping review to map the existing indicator landscape as depicted by major measurement initiatives. We classified indicators as per 33 previously identified core adolescent health measurement areas across five domains and by age groups. We also identified indicators common across measurement initiatives even if differing in details. RESULTS: We identified 413 indicators across 16 measurement initiatives, with most measuring health outcomes and conditions (162 [39%]) and health behaviors and risks (136 [33%]); followed by policies, programs, and laws (49 [12%]); health determinants (44 [11%]); and system performance and interventions (22 [5%]). Age specification was available for 221 (54%) indicators, with 51 (23%) focusing on the full adolescent age range (10-19 years), 1 (<1%) on 10-14 years, 27 (12%) on 15-19 years, and 142 (64%) on a broader age range including adolescents. No definitional information, such as numerator and denominator, was available for 138 indicators. We identified 236 distinct indicators after accounting for overlap. CONCLUSION: The adolescent health measurement landscape is vast and includes substantial variation among indicators purportedly assessing the same concept. Gaps persist in measuring systems performance and interventions; policies, programs, and laws; and younger adolescents' health. Addressing these gaps and harmonizing measurement is fundamental to improve program implementation and accountability for adolescent health globally.

Early union, 'disgrasya', and prior adversity and disadvantage: pathways to adolescent pregnancy among Filipino youth.

BACKGROUND: Few studies explore what it means to be an adolescent parent in the Philippines from the young parents' perspective. This study sought to improve understanding of how adolescent mothers and young fathers experienced pregnancy in Palawan, Philippines. METHODS: We conducted narrative analysis of 27 semi-structured interviews with 15 Filipino young parents. FINDINGS: Our findings point to three pathways to adolescent pregnancy differentiated by life circumstances and perceived self-efficacy: through early unions, through 'disgrasya' (accident) in romantic relationships, and when pregnancy is directly related to adversity and disadvantage. Some young people adopted agentic narratives and had intended pregnancies within early unions. Young people who had unintended pregnancies in romantic relationships recounted constrained choice narratives, taking responsibility for their decisions while emphasising external factors' influence on their decision-making. Other young mothers described the ways that prior adversity and disadvantage gave rise to unfavourable circumstances-including sexual violence-that led to unintended pregnancy but shared narratives showing how they had reclaimed agency in their lives. CONCLUSION: Our findings highlight the need to (1) address underlying poverty and structural inequalities that limit Filipino young people's life choices and contribute to their pathways to adolescent pregnancy; (2) provide Filipino young people with access to essential sexual and reproductive health information, services, and supplies; and (3) change social norms to rectify gender-based power imbalances and sexual violence.

This study sought to improve understanding of how adolescent mothers and young fathers experienced adolescent pregnancy in Palawan, Philippines. By analysing the narratives of 15 Filipino young parents, we found three pathways to adolescent pregnancy differentiated by life circumstances and perceived self-efficacy: intended pregnancy through early, cohabiting unions; unintended pregnancy through 'disgrasya' (accident) in romantic relationships; and unintended pregnancy following prior difficult life circumstances where pregnancy led to reclaiming of agency. Our findings highlight the need to address poverty and inequalities, ensure that Filipino adolescents have access to sexual and reproductive health information, services and supplies, and change social norms that perpetuate gender-based power imbalances and sexual violence.

Transforming UNICEF's approach to health system strengthening: what place can a blended learning course play?

BACKGROUND: The United Nations Children's Fund (UNICEF) published their Health Systems Strengthening (HSS) approach to meet its strategic goals of ending preventable maternal, newborn and child deaths and promoting the health and development of all children and reducing inequities in health in 2016. UNICEF commissioned the University of Melbourne's Nossal Institute for Global Health to develop and deliver a pilot blended HSS program, involving 60 hours of online learning and 2 weeks of face-to-face teaching over a 6-month period. To assess the extent to which the HSS program had built the first 83 UNICEF 2017 graduates' capabilities to apply HSS actions by 2017, UNICEF funded an independent evaluator from the University of Melbourne. METHODS: A mixed-methods assessment was conducted using: online surveys of graduates at: enrolment, completion, 6 months post-HSS program; nine focus groups with graduates at face-to-face workshops; and interviews with purposive samples of UNICEF graduates and graduate Senior Managers 12 months post-HSS program. RESULTS: The HSS program content, structure and mode of delivery was positively received. Graduates reported increased confidence taking HSS actions and multiple changes in work practices (e.g., increased systems thinking and using of health system-based approaches). Graduates' Senior Manager interviews revealed mixed impressions of graduates applying HSS actions, partly explained by the fit between the HSS program learnings and UNICEF's workplace environment. Key contextual factors influencing graduates applying HSS actions included: workload; limited opportunities to apply HSS actions; limited HSS examples; and variable support to apply HSS actions. Graduate and Senior Manager suggestions to optimise applying HSS actions included: linking HSS program content with UNICEF priorities; increasing opportunities for graduates to apply HSS actions; increasing access to HSS support. CONCLUSIONS: The paper concludes by presenting HSS program and assessment suggestions from the 2017 UNICEF Pilot HSS program assessment and actions taken for the 2018 UNICEF staff cohorts by HSS program developers, funders and beneficiaries.

Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care.

Evidence of the health system challenges to promoting respectful maternity care (RMC) is limited in Ethiopia and globally. This study investigated the health system constraints to RMC in three Southern Ethiopian hospitals. We conducted a qualitative study (7 focus group discussions (FGDs) with providers of RMC and 12 in-depth interviews with focal persons and managers) before and after the implementation of an RMC intervention. We positioned childbirth services within the health system and applied complex adaptive system theory to analyse the opportunities and constraints to the promotion of RMC. Both system "hardware" and "software" factors influencing the promotion of RMC were identified, and their interaction was complex. The "hardware" factors included bed availability, infrastructure and supplies, financing, and health workforce. "Software" factors encompassed service providers' mindset, staff motivation, and awareness of RMC. Interactions between these factors included privacy breaches for women when birth companions were admitted in labour rooms. Delayed reimbursement following the introduction of fee-exemption for maternity services resulted in depleted revenues, supply shortages, and ultimately disrespectful behaviour among providers. Other financial constraints, including the insufficient and delayed release of funds, also led to complex interactions with the motivation of staff and the availability of workforce and supplies, resulting in poor adherence to RMC guidance. Interventions aimed at improving only behavioural components fall short of mitigating the mistreatment of women. System-wide interventions are required to address the complex interactions that constraint RMC.

Task shifting of emergency caesarean section in south Ethiopia: are we repeating the brain drain.

INTRODUCTION: preventable mortality from complications which arise during pregnancy and childbirth continue to claim more than a quarter of million women´s lives every year, almost all in low- and middle-income countries. However, lifesaving emergency obstetric services, including caesarean section (CS), significantly contribute to prevention of maternal and newborn mortality and morbidity. Between 2009 and 2013, a task shifting intervention to train caesarean section (CS) teams involving 41 CS surgeons, 35 anesthetic nurses and 36 scrub nurses was implemented in 13 hospitals in southern Ethiopia. We report on the attrition rate of those upskilled to provide CS with a focus on the medium-term outcomes and the challenges encountered. METHODS: a cross-sectional study involving surveys of focal persons and a facility staff audit supplemented with a review of secondary data was conducted in thirteen hospitals. Mean differences were computed to appreciate the difference between numbers of CSs conducted for the six months before and after task shifting commenced. RESULTS: from the trained 112 professionals, only 52 (46.4%) were available for carrying out CS in the hospitals. CS surgeons (65.9%) and nurse anesthetists (71.4%) are more likely to have left as compared to scrub nurses (22.2%). Despite the loss of trained staff, there was an increase in the number of CSs performed after the task shifting (mean difference=43.8; 95% CI: 18.3-69.4; p=0.003). CONCLUSION: our study, one of the first to assess the medium-term effects of task shifting highlights the risk of ongoing attrition of well-trained staff and the need to reassess strategies for staff retention.

Progress towards reducing sociodemographic disparities in breastfeeding outcomes in Indonesia: a trend analysis from 2002 to 2017.

BACKGROUND: Improving breastfeeding practice is important for reducing child health inequalities and achieving several Sustainable Development Goals. Indonesia has enacted legislation to promote optimal breastfeeding practices in recent years. We examined breastfeeding practices among Indonesian women from 2002 to 2017, comparing trends within and across sociodemographic subgroups. METHODS: Data from four waves of the Indonesia Demographic and Health Surveys were used to estimate changes in breastfeeding practices among women from selected sociodemographic groups over time. We examined three breastfeeding outcomes: (1) early initiation of breastfeeding; (2) exclusive breastfeeding; and (3) continued breastfeeding at 1 year. Multivariate logistic regression was used to assess changes in time trends of each outcome across population groups. RESULTS: The proportion of women reporting early initiation of breastfeeding and exclusive breastfeeding increased significantly between 2002 to 2017 (p < 0.05), with larger increases among women who: were from higher wealth quintiles; worked in professional sectors; and lived in Java and Bali. However, 42.7% of women reported not undertaking early initiation of breastfeeding, and 48.9% of women reported not undertaking exclusive breastfeeding in 2017. Women who were employees had lower exclusive breastfeeding prevalence, compared to unemployed or self-employed women. Women in Java and Bali had higher increase in early initiation of breastfeeding and exclusive breastfeeding compared to women in Sumatra. We did not find statistically significant decline in continued breastfeeding at 1 year over time for the overall population, except among women who: were from the second poorest wealth quintile; lived in rural areas; did not have a health facility birth; and lived in Kalimantan and Sulawesi (p < 0.05). CONCLUSIONS: There were considerable improvements in breastfeeding practices in Indonesia during a period of sustained policy reform to regulate breastfeeding and community support of breastfeeding, but these were not distributed uniformly across socioeconomic, occupation and geographic subgroups. Concerted efforts are needed to further reduce inequities in breastfeeding practice through both targeted and population-based strategies.

Cost-effectiveness of inhaled oxytocin for prevention of postpartum haemorrhage: a modelling study applied to two high burden settings.

BACKGROUND: Access to oxytocin for prevention of postpartum haemorrhage (PPH) in resource-poor settings is limited by the requirement for a consistent cold chain and for a skilled attendant to administer the injection. To overcome these barriers, heat-stable, non-injectable formulations of oxytocin are under development, including oxytocin for inhalation. This study modelled the cost-effectiveness of an inhaled oxytocin product (IHO) in Bangladesh and Ethiopia. METHODS: A decision analytic model was developed to assess the cost-effectiveness of IHO for the prevention of PPH compared to the standard of care in Bangladesh and Ethiopia. In Bangladesh, introduction of IHO was modelled in all public facilities and home deliveries with or without a skilled attendant. In Ethiopia, IHO was modelled in all public facilities and home deliveries with health extension workers. Costs (costs of introduction, PPH prevention and PPH treatment) and effects (PPH cases averted, deaths averted) were modelled over a 12-month program. Life years gained were modelled over a lifetime horizon (discounted at 3%). Cost of maintaining the cold chain or effects of compromised oxytocin quality (in the absence of a cold chain) were not modelled. RESULTS: In Bangladesh, IHO was estimated to avert 18,644 cases of PPH, 76 maternal deaths and 1954 maternal life years lost. This also yielded a cost-saving, with the majority of gains occurring among home deliveries where IHO would replace misoprostol. In Ethiopia, IHO averted 3111 PPH cases, 30 maternal deaths and 767 maternal life years lost. The full IHO introduction program bears an incremental cost-effectiveness ratio (ICER) of between 2 and 3 times the per-capita Gross Domestic Product (GDP) ($1880 USD per maternal life year lost) and thus is unlikely to be considered cost-effective in Ethiopia. However, the ICER of routine IHO administration considering recurring cost alone falls under 25% of per-capita GDP ($175 USD per maternal life-year saved). CONCLUSIONS: IHO has the potential to expand access to uterotonics and reduce PPH-associated morbidity and mortality in high burden settings. This can facilitate reduced spending on PPH management, making the product highly cost-effective in settings where coverage of institutional delivery is lagging.

The distinctive roles of urban community health workers in low- and middle-income countries: a scoping review of the literature.

Addressing urban health challenges in low- and middle-income countries (LMICs) has been hampered by lack of evidence on effective mechanisms for delivering health services to the poor. The urban disadvantaged experience poor health outcomes (often worse than rural counterparts) and face service barriers. While community health workers (CHWs) have been extensively employed in rural communities to address inequities, little attention has been given to understanding the roles of CHWs in urban contexts. This study is the first to systematically examine urban CHW roles in LMICs. It aims to understand their roles vis-à-vis other health providers and raise considerations for informing future scope of practice and service delivery models. We developed a framework that presents seven key roles performed by urban CHWs and position these roles against a continuum of technical to political functions. Our scoping review included publications from four databases (MEDLINE, EMBASE, CINAHL and Social Sciences Citation Index) and two CHW resource hubs. We included all peer-reviewed, CHW studies situated in urban/peri-urban, LMIC contexts. We identify roles (un)commonly performed by urban CHWs, present the range of evidence available on CHW effectiveness in performing each role and identify considerations for informing future roles. Of 856 articles, 160 met the inclusion criteria. Programmes spanned 34 LMICs. Studies most commonly reported evidence on CHWs roles related to health education, outreach and elements of direct service provision. We found little overlap in roles between CHWs and other providers, with some exceptions. Reported roles were biased towards home visiting and individual-capacity building, and not well-oriented to reach men/youth/working women, support community empowerment or link with social services. Urban-specific adaptations to roles, such as peer outreach to high-risk, stigmatized communities, were limited. Innovation in urban CHW roles and a better understanding of the unique opportunities presented by urban settings is needed to fully capitalize on their potential.

Monitoring maternal and newborn health outcomes globally: a brief history of key events and initiatives.

OBJECTIVE: Over time, we have seen a major evolution of measurement initiatives, indicators and methods, such that today a wide range of maternal and perinatal indicators are monitored and new indicators are under development. Monitoring global progress in maternal and newborn health outcomes and development has been dominated in recent decades by efforts to set, measure and achieve global goals and targets: the Millennium Development Goals followed by the Sustainable Development Goals. This paper aims to review, reflect and learn on accelerated progress towards global goals and events, including universal health coverage, and better tracking of maternal and newborn health outcomes. METHODS: We searched for literature of key events and global initiatives over recent decades related to maternal and newborn health. The searches were conducted using PubMed/MEDLINE and the World Health Organization Global Index Medicus. RESULTS: This paper describes global key events and initiatives over recent decades showing how maternal and neonatal mortality and morbidity, and stillbirths, have been viewed, when they have achieved higher priority on the global agenda, and how they have been measured, monitored and reported. Despite substantial improvements, the enormous maternal and newborn health disparities that persist within and between countries indicate the urgent need to renew the focus on reducing inequities. CONCLUSION: The review has featured the long story of the progress in monitoring improving maternal and newborn health outcomes, but has also underlined current gaps and significant inequities. The many global initiatives described in this paper have highlighted the magnitude of the problems and have built the political momentum over the years for effectively addressing maternal and newborn health and well-being, with particular focus on improved measurement and monitoring.

Chaque jour, environ 810 femmes meurent de causes évitables liées à la grossesse et à l'accouchement, près de 7.000 nouveau-nés décèdent et plus de 7.000 bébés sont mort-nés, selon les dernières estimations annuelles. Au fil du temps, nous avons assisté à une évolution majeure des initiatives, indicateurs et méthodes de mesure, de sorte qu'aujourd'hui un grand nombre d'indicateurs maternels et périnatals sont monitorés et de nouveaux indicateurs sont en cours d'élaboration. Le suivi des progrès mondiaux en matière de santé et de développement a été dominé au cours des dernières décennies par les efforts visant à définir, mesurer et atteindre les objectifs et cibles mondiaux: les Objectifs de Développement pour le Millénaire, suivis des Objectifs de Développement Durable. Le but de cette revue est d'encourager la réflexion et l'éducation en vue d'accélérer les progrès vers les objectifs mondiaux, y compris la couverture de santé universelle et un meilleur suivi des résultats pour la santé de la mère et du nouveau-né. Cet article décrit les événements et les initiatives clés des dernières décennies montrant comment la mortalité et la morbidité maternelles et néonatales, ainsi que les mortinaissances, ont été considérées lorsqu'elles ont atteint un rang de priorité plus élevé dans l'agenda mondial, et comment elles ont été mesurées, suivies et rapportées. En dépit des améliorations substantielles, les énormes disparités de santé maternelle et néonatale qui persistent dans et entre les pays indiquent qu'il est urgent de recentrer l'attention sur la réduction des inégalités. Nous devons intensifier les initiatives fondées sur des preuves et sur les droits de l'homme visant à améliorer la sécurité de la grossesse, de l'accouchement et des périodes néonatale et post-partum (en particulier l'amélioration de la couverture, de la qualité et de l'équité des soins pendant le travail et l'accouchement, ainsi que les soins pour les nouveau-nés petits et malades), ainsi que la qualité, et la rapidité des données de surveillance (notamment l'enregistrement précis des naissances et des décès).

Mismatch between antenatal care attendance and institutional delivery in south Ethiopia: A multilevel analysis.

OBJECTIVES: Uptake of maternal health services remains suboptimal in Ethiopia. Significant proportions of antenatal care attendees give birth at home. This study was conducted to identify the predictors of non-institutional delivery among women who received antenatal care in the Southern Nations Nationalities and Peoples Region, Ethiopia. DESIGN: A community-based cross-sectional survey was conducted among women who delivered in the year preceding the survey and who had at least one antenatal visit. Multistage cluster sampling was deployed to select 2390 women from all administrative zones of the region. A mixed-effects multivariable logistic regression analysis was performed to assess the predictors of non-institutional delivery; adjusted ORs (AOR) with 95% CIs are reported. RESULTS: The proportion of non-institutional deliveries among participants was 62.2% (95% CI 60.2% to 64.2%). Previous experience of short and simple labour (46.9%) and uncomplicated home birth (42.9%), night-time labour (29.7%), absence of pregnancy-related problem (18.8%) and perceived providers poor reception of women (17.8%) were the main reasons to have non-institutional delivery. Attending secondary school and above (AOR=0.51; 95% CI 0.30 to 0.85), being a government employee (AOR=0.27; 95% CI 0.10 to 0.78) and woman's autonomy in healthcare utilisation decision making (AOR=0.51; 95% CI 0.33 to 0.79) were among the independent predictors negatively associated with non-institutional delivery. On the other hand, unplanned pregnancy (AOR=1.67; 95% CI 1.16 to 2.42), not experiencing any health problem during pregnancy (AOR=8.1; 95% CI 3.12 to 24.62), not perceiving the risks associated with home delivery (AOR=6.64; 95% CI 4.35 to 10.14) were the independent predictors positively associated with non-institutional delivery. CONCLUSIONS: There is a missed opportunity among women attending antenatal care in southern Ethiopia. Further health system innovations that help to bridge the gap between antenatal care attendance and institutional delivery are highly recommended.

The determinants of vaccination in a semi-rural area of Vientiane City, Lao People's Democratic Republic: a qualitative study.

BACKGROUND: Immunisation is a cost-effective and highly efficacious public health intervention, saving over 20 million lives in the last two decades due to decreases in childhood bacterial infections. In the Lao People's Democratic Republic, significant gaps in childhood immunisation coverage rates remain, which are a cause for concern and a barrier to the country reaching its Sustainable Development Goal targets for child health. Efforts to increase coverage have had limited success, with widening inequities being observed between urban and remote and rural areas. METHODS: The objectives of this study were two-fold; firstly, to describe the knowledge, attitudes and practices of mothers regarding their children's immunisation status; and, secondly, to identify individual and health system determinants of access to immunisation in five rural villages within a rural district in Lao People's Democratic Republic. This qualitative research used observation and interviews with healthcare workers (n = 10) and mothers (n = 10) with at least one child aged 12-23 months. RESULTS: The study identified several health system barriers that lower community demand for immunisation. These included the use of multiple providers, inconsistent record keeping and an inadequate health information system. At the individual and household level, there was a lack of understanding of the role of immunisation and the role of the different services provided. CONCLUSIONS: The study suggests that increasing immunisation coverage in Lao People's Democratic Republic requires clearer immunisation pathways, an integrated or unified information recording system across the different levels of the health system, and strategies to increase demand, including increasing individual and household understanding of the role of immunisation in child health.

Determinants of knowledge of critical danger signs, safe childbirth and immediate newborn care practices among auxiliary midwives: a cross sectional survey in Myanmar.

OBJECTIVES: The re-emergence of community-based health workers such as the auxiliary midwives (AMWs) in Myanmar, who are local female volunteers, has been an important strategy to address global health workforce shortages. The Myanmar government recommends one AMW for every village. The aim of this study is to investigate the current knowledge of critical danger signs and practices for safe childbirth and immediate newborn care of AMWs to inform potential task shifting of additional healthcare responsibilities. METHODS: A cross-sectional survey was conducted from July 2015 to June 2016 in three hard-to-reach areas in Myanmar. Face-to-face interviews were conducted using a pretested questionnaire. RESULTS: Among 262 AMWs participating in the study, only 8% of AMWs were able to identify at least 80% of 20 critical danger signs. Factors associated with greater knowledge of critical danger signs included older age over 35 years (adjusted OR (AOR) 2.19, 95% CI 0.99 to 4.83), having received refresher training within the last year (AOR 2.20, 95% CI 1.21 to 4.01) and receiving adequate supervision (AOR 5.04, 95% CI 2.74 to 9.29). Those who employed all six safe childbirth and immediate newborn care practices were more likely to report greater knowledge of danger signs (AOR 2.81, 95% CI 1.50 to 5.26), adequate work supervision (AOR 3.18 95% CI 1.62 to 6.24) and less education (AOR 0.44, 95% CI 0.23 to 0.88). CONCLUSION: The low level of knowledge of critical danger signs and reported practices for safe childbirth identified suggest that an evaluation of the current AMW training and supervision programme needs to be revisited to ensure that existing practices, including recognition of danger signs, meet quality care standards before new interventions are introduced or new responsibilities given to AMWs.

Utilisation of health services and geography: deconstructing regional differences in barriers to facility-based delivery in Nepal.

While established that geographical inaccessibility is a key barrier to the utilisation of health services, it remains unknown whether disparities are driven only by limited access to these services, or are also attributable to health behaviour. Significant disparities exist in health outcomes and the coverage of many critical health services between the mountains region of Nepal and the rest of the country, yet the principal factors driving these regional disparities are not well understood. Using national representative data from the 2011 Nepal Demographic and Health Survey, we examine the extent to which observable factors explain the overall differences in the utilisation of maternal health services. We apply nonlinear Blinder-Oaxaca-type decomposition methods to quantify the effect that differences in measurable characteristics have on the regional coverage gap in facility-based delivery. The mean coverage of facility-based deliveries was 18.6 and 36.3 % in the mountains region and the rest of Nepal, respectively. Between 54.8 and 74.1 % of the regional coverage gap was explained by differences in observed characteristics. Factors influencing health behaviours (proxied by mothers' education, TV viewership and tobacco use, and household wealth) and subjective distance to the health facility were the major factors, contributing between 52.9 and 62.5 % of the disparity. Mothers' birth history was also noteworthy. Policies simultaneously addressing access and health behaviours appear necessary to achieve greater coverage and better health outcomes for women and children in isolated areas.

Provider perspectives on the enabling environment required for skilled birth attendance: a qualitative study in western Nepal.

OBJECTIVES: In Nepal, where difficult geography and an under-resourced health system contribute to poor health care access, the government has increased the number of trained skilled birth attendants (SBAs) and posted them in newly constructed birthing centres attached to peripheral health facilities that are available to women 24 h a day. This study describes their views on their enabling environment. METHODS: Qualitative methods included semi-structured interviews with 22 SBAs within Palpa district, a hill district in the Western Region of Nepal; a focus group discussion with ten SBA trainees, and in-depth interviews with five key informants. RESULTS: Participants identified the essential components of an enabling environment as: relevant training; ongoing professional support; adequate infrastructure, equipment and drugs; and timely referral pathways. All SBAs who practised alone felt unable to manage obstetric complications because quality management of life-threatening complications requires the attention of more than one SBA. CONCLUSIONS: Maternal health guidelines should account for the provision of an enabling environment in addition to the deployment of SBAs. In Nepal, referral systems require strengthening, and the policy of posting SBAs alone, in remote clinics, needs to be reconsidered to achieve the goal of reducing maternal deaths through timely management of obstetric complications.