La Maison Bleue: Strengthening resilience among migrant mothers living in Montreal, Canada.

INTRODUCTION: La Maison Bleue is a community-based perinatal health and social centre in Montreal that provides services during pregnancy up to age five to families living in vulnerable contexts. The study aimed to describe: 1) the challenges and protective factors that affect the well-being of migrant families receiving care at La Maison Bleue; and 2) how La Maison Bleue strengthens resilience among these families. METHODS: We conducted a focused ethnography. Immigrants, refugees, asylum seekers and undocumented migrants were invited to participate. We collected data from November to December 2017 via semi-structured interviews and participant observation during group activities at La Maison Bleue. Data were thematically analysed. RESULTS: Twenty-four mothers participated (9 interviewed, 17 observed). Challenges to well-being included family separation, isolation, loss of support, the immigration process, an unfamiliar culture and environment, and language barriers. Key protective factors were women's intrinsic drive to overcome difficulties, their positive outlook and ability to find meaning in their adversity, their faith, culture and traditions, and supportive relationships, both locally and transnationally. La Maison Bleue strengthened resilience by providing a safe space, offering holistic care that responded to both medical and psychosocial needs, and empowering women to achieve their full potential towards better health for themselves and their families. CONCLUSION: Migrant mothers have many strengths and centres like La Maison Bleue can offer a safe space and be an empowering community resource to assist mothers in overcoming the multiple challenges that they face while resettling and raising their young children in a new country.

Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools.

BACKGROUND: Ensuring quality of care during pregnancy and childbirth is crucial to improving health outcomes and reducing preventable mortality and morbidity among women and their newborns. In this pursuit, WHO developed a framework and standards, defining 31 quality statements and 352 quality measures to assess and improve quality of maternal and newborn care in health-care facilities. We aimed to assess the capacity of globally used, large-scale facility assessment tools to measure quality of maternal and newborn care as per the WHO framework. METHODS: We identified assessment tools through a purposive sample that met the following inclusion criteria: multicountry, facility-level, major focus on maternal and newborn health, data on input and process indicators, used between 2007 and 2017, and currently in use. We matched questions in the tools with 274 quality measures associated with inputs and processes within the WHO standards. We excluded quality measures relating to outcomes because these are not routinely measured by many assessment tools. We used descriptive statistics to calculate how many quality measures could be assessed using each of the tools under review. Each tool was assigned a 1 for fulfilling a quality measure based on the presence of any or all components as indicated in the standards. FINDINGS: Five surveys met our inclusion criteria: the Service Provision Assessment (SPA), developed for the Demographic and Health Surveys programme; the Service Availability and Readiness Assessment, developed by WHO; the Needs Assessment of Emergency Obstetric and Newborn Care developed by the Averting Maternal Death and Disability programme at Columbia University; and the World Bank's Service Delivery Indicator (SDI) and Impact Evaluation Toolkit for Results Based Financing in Health. The proportion of quality measures covered ranged from 62% for the SPA to 12% for the SDI. Although the broadest tool addressed parts of each of the 31 quality statements, 68 (25%) of 274 input and process quality measures were not measured at all. Measures of health information systems and patient experience of care were least likely to be included. INTERPRETATION: Existing facility assessment tools provide a valuable way to assess quality of maternal and newborn care as one element within the national measurement toolkit. Guidance is clearly needed on priority measures and for better harmonisation across tools to reduce measurement burden and increase data use for quality improvement. Targeted development of measurement modules to address important gaps is a key priority for research. FUNDING: None.

From Theory to Measurement: Recommended State MCH Life Course Indicators.

PURPOSE: In May 2012, the Association of Maternal and Child Health (MCH) Programs initiated a project to develop indicators for use at a state or community level to assess, monitor, and evaluate the application of life course principles to public health. DESCRIPTION: Using a developmental framework established by a national expert panel, teams of program leaders, epidemiologists, and academicians from seven states proposed indicators for initial consideration. More than 400 indicators were initially proposed, 102 were selected for full assessment and review, and 59 were selected for final recommendation as Maternal and Child Health (MCH) life course indicators. ASSESSMENT: Each indicator was assessed on five core features of a life course approach: equity, resource realignment, impact, intergenerational wellness, and life course evidence. Indicators were also assessed on three data criteria: quality, availability, and simplicity. CONCLUSION: These indicators represent a major step toward the translation of the life course perspective from theory to application. MCH programs implementing program and policy changes guided by the life course framework can use these initial measures to assess and influence their approaches.

How well do birth records serve maternal and child health programs? Birth registration system evaluation, New York City, 2008-2011.

National birth registration guidelines were revised in 2003 to improve data quality; however, few studies have evaluated the impact on local jurisdictions and their data users. In New York City (NYC), approximately 125,000 births are registered annually with the NYC Department of Health and Mental Hygiene, and data are used routinely by the department's maternal and child health (MCH) programs. In order to better meet MCH program needs, we used Centers for Disease Control and Prevention guidelines to assess birth data usefulness, simplicity, data quality, timeliness and representativeness. We interviewed birth registration and MCH program staff, reviewed a 2009 survey of birth registrars (n = 39), and analyzed 2008-2011 birth records for timeliness and completeness (n = 502,274). Thirteen MCH programs use birth registration data for eligibility determination, needs assessment, program evaluation, and surveillance. Demographic variables are used frequently, nearly 100 % complete, and considered the gold standard by programs; in contrast, medical variables' use and validity varies widely. Seventy-seven percent of surveyed birth registrars reported ≥1 problematic items in the system; 64.1 % requested further training. During 2008-2011, the median interval between birth and registration was 5 days (range 0-260 days); 11/13 programs were satisfied with timeliness. The NYC birth registration system provides local MCH programs useful, timely, and representative data. However, some medical items are difficult to collect, of low quality, and rarely used. We recommend enhancing training for birth registrars, continuing quality improvement efforts, increasing collaboration with program users, and removing consistently low-quality and low-use variables.

Towards ending preventable maternal deaths by 2035.

Maternal mortality has been reduced by half from 1990 to 2010, yet a woman in sub-Saharan Africa has a lifetime risk of maternal death of 1 in 39 compared with around 1 in 10,000 in industrialized countries. Annual rates of reduction of maternal mortality of over 10% have been achieved in several countries. Highly cost-effective interventions exist and are being scaled up, such as family planning, emergency obstetric and newborn care, quality service delivery, midwifery, maternal death surveillance and response, and girls' education; however, coverage still remains low. Maternal mortality reduction is now high on the global agenda. We examined scenarios of reduction of maternal mortality by 2035. Ending preventable maternal deaths could be achieved in nearly all countries by 2035 with challenging yet realistic efforts: (1) massive scaling-up and skilling up of human resources for family planning and maternal health; (2) reaching every village in every district and every urban slum toward universal health coverage; (3) enhanced financing; (4) knowledge for action: enhanced monitoring, accountability, evaluation, and R&D.

The effects of performance incentives on the utilization and quality of maternal and child care in Burundi.

Africa's progress towards the health related Millennium Development Goals remains limited. This can be partly explained by inadequate performance of health care providers. It is therefore critical to incentivize this performance. Payment methods that reward performance related to quantity and quality, called performance based financing (PBF), have recently been introduced in over 30 African countries. While PBF meets considerable enthusiasm from governments and donors, the evidence on its effects is still limited. In this study we aim to estimate the effects of PBF on the utilization and quality of maternal and child care in Burundi. We use the 2010 Burundi Demographic and Health Survey (August 2010-January 2011, n = 4916 women) and exploit the staggered rollout of PBF between 2006 and 2010, to implement a difference-in-differences approach. The quality of care provided during antenatal care (ANC) visits improved significantly, especially among the better off, although timeliness and number of ANC visits did not change. The probability of an institutional delivery increased significantly with 4 percentage points among the better off but no effects were found among the poor. PBF does significantly increase this probability (with 5 percentage points) for women where PBF was in place from the start of their pregnancy, suggesting that women are encouraged during ANC visits to deliver in the facility. PBF also led to a significant increase of 4 percentage points in the probability of a child being fully vaccinated, with effects more pronounced among the poor. PBF improved the utilization and quality of most maternal and child care, mainly among the better off, but did not improve targeting of unmet needs for ANC. Especially types of care which require a behavioral change of health care workers when the patient is already in the clinic show improvements. Improvements are smaller for services which require effort from the provider to change patients' utilization choices.

[Supporting local communities in their actions for children living in a situation of poverty]. / Soutenir les communautes locales dans leurs actions envers les enfants vivant en situation de pauvrete.

Avenir d'Enfants [Future of Children] emerged from a partnership between the government of Quebec and the Lucie and André Chagnon Foundation. The organization aims to provide local communities with resources, in order to support synergy between the principal early childhood organizations: childcare services, healthcare services, schools, family community organizations and municipalities. This article presents the context in which Avenir d'Enfants came into being, explains how the organization helps create the right conditions for local and regional initiatives to have an impact on the development of children living in a situation of poverty, and presents the challenges and success factors of this approach.

Advanced maternal age and pregnancy outcomes: a multicountry assessment.

OBJECTIVE: To assess the association between advanced maternal age (AMA) and adverse pregnancy outcomes. DESIGN: Secondary analysis of the facility-based, cross-sectional data of the WHO Multicountry Survey on Maternal and Newborn Health. SETTINGS: A total of 359 health facilities in 29 countries in Africa, Asia, Latin America, and the Middle East. SAMPLE: A total of 308 149 singleton pregnant women admitted to the participating health facilities. METHODS: We estimated the prevalence of pregnant women with advanced age (35 years or older). We calculated adjusted odds ratios of individual severe maternal and perinatal outcomes in these women, compared with women aged 20-34 years, using a multilevel, multivariate logistic regression model, accounting for clustering effects within countries and health facilities. The confounding factors included facility and individual characteristics, as well as country (classified by maternal mortality ratio level). MAIN OUTCOME MEASURES: Severe maternal adverse outcomes, including maternal near miss (MNM), maternal death (MD), and severe maternal outcome (SMO), and perinatal outcomes, including preterm birth (<37 weeks of gestation), stillbirths, early neonatal mortality, perinatal mortality, low birthweight (<2500 g), and neonatal intensive care unit (NICU) admission. RESULTS: The prevalence of pregnant women with AMA was 12.3% (37 787/308 149). Advanced maternal age significantly increased the risk of maternal adverse outcomes, including MNM, MD, and SMO, as well as the risk of stillbirths and perinatal mortalities. CONCLUSIONS: Advanced maternal age predisposes women to adverse pregnancy outcomes. The findings of this study would facilitate antenatal counselling and management of women in this age category.

Nature and frequency of services provided by child and family health nurses in Australia: results of a national survey.

OBJECTIVE: Australia has a system of universal child and family health (CFH) nursing services providing primary health services from birth to school entry. Herein, we report on the findings of the first national survey of CFH nurses, including the ages and circumstances of children and families seen by CFH nurses and the nature and frequency of the services provided by these nurses across Australia. METHODS: A national survey of CFH nurses was conducted. RESULTS: In all, 1098 CFH nurses responded to the survey. Over 60% were engaged in delivering primary prevention services from a universal platform. Overall, 82.8% reported that their service made first contact with families within 2 weeks of birth, usually in the home (80.7%). The proportion of respondents providing regular support to families decreased as the child aged. Services were primarily health centre based, although 25% reported providing services in other locations (parks, preschools).The timing and location of first contact, the frequency of ongoing services and the composition of families seen by nurses varied across Australian jurisdictions. Nurses identified time constraints as the key barrier to the delivery of comprehensive services. CONCLUSIONS: CFH nurses play an important role in supporting families across Australia. The impact of differences in the CFH nursing provision across Australia requires further investigation. What is known about the topic? Countries that offer universal well child health services demonstrate better child health and developmental outcomes than countries that do not. Australian jurisdictions offer free, universal child and family health (CFH) nursing services from birth to school entry. What does this paper add? This paper provides nation-wide data on the nature of work undertaken by CFH nurses offering universal care. Across Australia, there are differences in the timing and location of first contact, the frequency of ongoing services and the range of families seen by nurses. What are the implications for practitioners? The impact for families of the variation in CFH nursing services offered across Australia is not known. Further research is required to investigate the outcomes of the service provision variations identified in the present study.

Building Economic Security Today: making the health-wealth connection in Contra Costa county's maternal and child health programs.

In recent years, maternal and child health professionals have been seeking approaches to integrating the Life Course Perspective and social determinants of health into their work. In this article, we describe how community input, staff feedback, and evidence from the field that the connection between wealth and health should be addressed compelled the Contra Costa Family, Maternal and Child Health (FMCH) Programs Life Course Initiative to launch Building Economic Security Today (BEST). BEST utilizes innovative strategies to reduce inequities in health outcomes for low-income Contra Costa families by improving their financial security and stability. FMCH Programs' Women, Infants, and Children Program (WIC) conducted BEST financial education classes, and its Medically Vulnerable Infant Program (MVIP) instituted BEST financial assessments during public health nurse home visits. Educational and referral resources were also developed and distributed to all clients. The classes at WIC increased clients' awareness of financial issues and confidence that they could improve their financial situations. WIC clients and staff also gained knowledge about financial resources in the community. MVIP's financial assessments offered clients a new and needed perspective on their financial situations, as well as support around the financial and psychological stresses of caring for a child with special health care needs. BEST offered FMCH Programs staff opportunities to engage in non-traditional, cross-sector partnerships, and gain new knowledge and skills to address a pressing social determinant of health. We learned the value of flexible timelines, maintaining a long view for creating change, and challenging the traditional paradigm of maternal and child health.

Integrating the life course into MCH service delivery: from theory to practice.

To describe the efforts of a community-based maternal and child health coalition to integrate the life course into its planning and programs, as well as implementation challenges and results of these activities. Jacksonville-Duval County has historically had infant mortality rates that are significantly higher than state and national rates, particularly among its African American population. In an effort to address this disparity, the Northeast Florida Healthy Start Coalition embraced the life course approach as a model. This model was adopted as a framework for (1) community needs assessment and planning; (2) delivery of direct services, including case management, education and support in the Magnolia Project, its federal Healthy Start program; (3) development of community collaborations, education and awareness; and, (4) advocacy and grass roots leadership development. Implementation experience as well as challenges in transforming traditional approaches to delivering maternal and child health services are described. Operationalizing the life course approach required the Coalition to think differently about risks, levels of intervention and the way services are organized and delivered. The organization set the stage by using the life course as a framework for its required local planning and needs assessments. Based on these assessments, the content of case management and other key services provided by our federal Healthy Start program was modified to address not only health behaviors but also underlying social determinants and community factors. Individual interventions were augmented with group activities to build interdependence among participants, increasing social capital. More meaningful inter-agency collaboration that moved beyond the usual referral relationships were developed to better address participants' needs. And finally, strategies to cultivate participant advocacy and community leadership skills, were implemented to promote social change at the neighborhood-level. Transforming traditional approaches to delivering maternal and child health services and sustaining change is a long and laborious process. The Coalition has taken the first steps; but its efforts are far from complete. Based on the agency's initial implementation experience, three areas presented particular challenges: staff, resources and evaluation. The life course is an important addition to the MCH toolbox. Community-based MCH programs should assess how a life course approach can be incorporated into existing programs to broaden their focus, and, potentially, their impact on health disparities and birth outcomes. Some areas to consider include planning and needs assessment, direct service delivery, inter-agency collaboration, and community leadership development. Continued disparities for people of color, despite medical advances, demand new interventions that purposefully address social inequities and promote advocacy among groups that bear a disproportionate burden of infant mortality. Successful transformation of current approaches requires investment in staff training to garner buy-in, flexible resources and the development of new metrics to measure the impact of the life course approach on individual and programmatic outcomes.

Lifecourse health development: past, present and future.

During the latter half of the twentieth century, an explosion of research elucidated a growing number of causes of disease and contributors to health. Biopsychosocial models that accounted for the wide range of factors influencing health began to replace outmoded and overly simplified biomedical models of disease causation. More recently, models of lifecourse health development (LCHD) have synthesized research from biological, behavioral and social science disciplines, defined health development as a dynamic process that begins before conception and continues throughout the lifespan, and paved the way for the creation of novel strategies aimed at optimization of individual and population health trajectories. As rapid advances in epigenetics and biological systems research continue to inform and refine LCHD models, our healthcare delivery system has struggled to keep pace, and the gulf between knowledge and practice has widened. This paper attempts to chart the evolution of the LCHD framework, and illustrate its potential to transform how the MCH system addresses social, psychological, biological, and genetic influences on health, eliminates health disparities, reduces chronic illness, and contains healthcare costs. The LCHD approach can serve to highlight the foundational importance of MCH, moving it from the margins of national debate to the forefront of healthcare reform efforts. The paper concludes with suggestions for innovations that could accelerate the translation of health development principles into MCH practice.

The Ghana essential health interventions program: a plausibility trial of the impact of health systems strengthening on maternal & child survival.

BACKGROUND: During the 1990s, researchers at the Navrongo Health Research Centre in northern Ghana developed a highly successful community health program. The keystone of the Navrongo approach was the deployment of nurses termed community health officers to village locations. A trial showed that, compared to areas relying on existing services alone, the approach reduced child mortality by half, maternal mortality by 40%, and fertility by nearly a birth - from a total fertility rate of 5.5 in only five years. In 2000, the government of Ghana launched a national program called Community-based Health Planning and Services (CHPS) to scale up the Navrongo model. However, CHPS scale-up has been slow in districts located outside of the Upper East Region, where the "Navrongo Experiment" was first carried out. This paper describes the Ghana Essential Health Intervention Project (GEHIP), a plausibility trial of strategies for strengthening CHPS, especially in the areas of maternal and newborn health, and generating the political will to scale up the program with strategies that are faithful to the original design. DESCRIPTION OF THE INTERVENTION: GEHIP improves the CHPS model by 1) extending the range and quality of services for newborns; 2) training community volunteers to conduct the World Health Organization service regimen known as integrated management of childhood illness (IMCI); 3) simplifying the collection of health management information and ensuring its use for decision making; 4) enabling community health nurses to manage emergencies, particularly obstetric complications and refer cases without delay; 5) adding $0.85 per capita annually to district budgets and marshalling grassroots political commitment to financing CHPS implementation; and 6) strengthening CHPS leadership at all levels of the system. EVALUATION DESIGN: GEHIP impact is assessed by conducting baseline and endline survey research and computing the Heckman "difference in difference" test for under-5 mortality in three intervention districts relative to four comparison districts for core indicators of health status and survival rates. To elucidate results, hierarchical child survival hazard models will be estimated that incorporate measures of health system strength as survival determinants, adjusting for the potentially confounding effects of parental and household characteristics. Qualitative systems appraisal procedures will be used to monitor and explain GEHIP implementation innovations, constraints, and progress. DISCUSSION: By demonstrating practical means of strengthening a real-world health system while monitoring costs and assessing maternal and child survival impact, GEHIP is expected to contribute to national health policy, planning, and resource allocation that will be needed to accelerate progress with the Millennium Development Goals.

Performance based financing and uptake of maternal and child health services in yobe sate, northern Nigeria.

Reported maternal and child health (MCH) outcomes in Nigeria are amongst the worst in the world, with Nigeria second only to India in the number of maternal deaths. At the national level, maternal mortality ratios (MMRs) are estimated at 630 deaths per 100,000 live births (LBs) but vary from as low as 370 deaths per 100,000 LBs in the southern states to over 1,000 deaths per 100,000 LBs in the northern states. We report findings from a performance based financing (PBF) pilot study in Yobe State, northern Nigeria aimed at improving MCH outcomes as part of efforts to find strategies aimed at accelerating attainment of Millennium Development Goals for MCH. Results show that the demand-side PBF led to increased utilization of key MCH services (antenatal care and skilled delivery) but had no significant effect on completion of child immunization using measles as a proxy indicator. We discuss these results within the context of PBF schemes and the need for a careful consideration of all the critical processes and risks associated with demand-side PBF schemes in improving MCH outcomes in the study area and similar settings.

Tailoring clinical services to address the unique needs of adolescents from the pregnancy test to parenthood.

Clinicians across disciplines and practice settings are likely to encounter adolescents who are at risk for a pregnancy. In 2010, 34.2/1000 15-19-year-old teens had a live birth in the United States, many more will seek care for a pregnancy scare or options counseling. Teen mothers are also at risk for a second or higher-order pregnancy during adolescence. This paper provides clinicians with adolescent-friendly clinical and counseling strategies for pregnancy prevention, pre- and post-pregnancy test counseling, pregnancy-related care, and a review of the developmental challenges encountered by teens in the transition to parenthood. Clinicians are in a better position to approach the developmental, health and mental health needs of adolescents related to pregnancy if they understand and appreciate the obstacles adolescents may face negotiating the healthcare system. In addition, when clinical services are specially tailored to the needs of the adolescent, fewer opportunities will be lost to prevent unintended pregnancies, assist teens into timely prenatal services, and improve outcomes for their pregnancies and the transition to parenthood.

Externalities of prevention of mother-to-child transmission programs: a systematic review.

There has been considerable debate about the effects of targeted global health assistance in low- and middle-income countries on health systems, specifically HIV/AIDS funding. Recently, a handful of studies have emerged that describe the implementation of PMTCT programs, which have many theoretical links to maternal and child health. Through a systematic review of research published between January 2000 and March 2011, this paper synthesizes evidence evaluating the impact of these programs. We assessed 5,855 papers, reviewed 154, and included 21 articles. They offer evidence of beneficial synergies between PMTCT programs and both STI prevention and early childhood immunization. Other data, including information about antenatal and delivery care, family planning, and nutrition supplementation varied considerably across studies demonstrating both positive and negative effects of PMTCT. More research is needed to allow countries and funders to make informed decisions regarding allocation of limited funds to targeted versus broad categories of health care.