Call to Action: Maternal Health and Saving Mothers: A Policy Statement From the American Heart Association.

The United States has the highest maternal mortality rates among developed countries, and cardiovascular disease is the leading cause. Therefore, the American Heart Association has a unique role in advocating for efforts to improve maternal health and to enhance access to and delivery of care before, during, and after pregnancy. Several initiatives have shaped the time course of major milestones in advancing maternal and reproductive health equity in the United States. There have been significant strides in improving the timeliness of data reporting in maternal mortality surveillance and epidemiological programs in maternal and child health, yet more policy reforms are necessary. To make a sustainable and systemic impact on maternal health, further efforts are necessary at the societal, institutional, stakeholder, and regulatory levels to address the racial and ethnic disparities in maternal health, to effectively reduce inequities in care, and to mitigate maternal morbidity and mortality. In alignment with American Heart Association's mission "to be a relentless force for longer, healthier lives," this policy statement outlines the inequities that influence disparities in maternal outcomes and current policy approaches to improving maternal health and suggests additional potentially impactful actions to improve maternal outcomes and ultimately save mothers' lives.

Priorities for sexual and reproductive health in Morocco as part of universal health coverage: maternal health as a national priority.

Maternal health (MH) is a national priority of Morocco. Factors influencing the agenda set by the reproductive and maternal health policy process at the national level were evaluated using the Shiffman and Smith framework. This framework included the influence of the actors, the power of the ideas used, the nature of the political context, and the characteristics of the issue itself. Factors were evaluated by a review of documents and interviews with policy-makers, partners and individuals in the private sector, civil society and non-governmental organisations (NGOs) involved in MH, and decision-makers responsible for implementing health-financing strategies in Morocco. Evaluations showed that maternal mortality in Morocco was considered human rights and social development as well as a public health problem. The actors responsible for MH, including members of the government, researchers, national technical experts, members of the private sector, United Nations partners and NGOs, agreed on progress made in MH and universal health care (UHC). Stakeholders also agreed on the prioritisation process for MH and its inclusion in the health benefits package. Prioritisation of MH was found to depend on national health priorities set by the government and its close partners, as well as on the availability of human and financial resources. Interventions at the operational level were based on evidence, best practices, allocation of adequate financial and human resources, and rigorous monitoring and accountability. However, MH and health financing are experiencing difficulties in many areas, related to social and economic and health disparities, and gender inequality, and quality of care.

Monitoring the status of selected health related sustainable development goals: methods and projections to 2030.

Background: Monitoring Sustainable Development Goal indicators (SDGs) and their targets plays an important role in understanding and advocating for improved health outcomes for all countries. We present the United Nations (UN) Inter-agency groups' efforts to support countries to report on SDG health indicators, project progress towards 2030 targets and build country accountability for action. Objective: We highlight common principles and practices of each Inter-agency group and the progress made towards SDG 3 targets using seven health indicators as examples. The indicators used provide examples of best practice for modelling estimates and projections using standard methods, transparent data collection and country consultations. Methods: Practices common to the UN agencies include multi-UN agency participation, expert groups to advise on estimation methods, transparent publication of methods and data inputs, use of UN-derived population estimates, country consultations, and a common reporting platform to present results. Our seven examples illustrate how estimates, using mostly Bayesian models, make use of country data to track progress towards SDG targets for 2030. Results: Progress has been made over the past decade. However, none of the seven indicators are on track to achieve their respective SDG targets by 2030. Accelerated efforts are needed, especially in low- and middle-income countries, to reduce the burden of maternal, child, communicable and noncommunicable disease mortality, and to provide access to modern methods of family planning to all women. Conclusion: Our analysis shows the benefit of UN interagency monitoring which prioritizes transparent country data sources, UN population estimates and life tables, and rigorous but replicable modelling methods. Countries are supported to build capacity for data collection, analysis and reporting. Through these monitoring efforts we support countries to tackle even the most intransient health issues, including the pandemic caused by SARS-CoV-2 that is reversing the hard-earned gains of all countries.

Targeted client communication via mobile devices for improving maternal, neonatal, and child health.

BACKGROUND: The global burden of poor maternal, neonatal, and child health (MNCH) accounts for more than a quarter of healthy years of life lost worldwide. Targeted client communication (TCC) via mobile devices (MD) (TCCMD) may be a useful strategy to improve MNCH. OBJECTIVES: To assess the effects of TCC via MD on health behaviour, service use, health, and well-being for MNCH. SEARCH METHODS: In July/August 2017, we searched five databases including The Cochrane Central Register of Controlled Trials, MEDLINE and Embase. We also searched two trial registries. A search update was carried out in July 2019 and potentially relevant studies are awaiting classification. SELECTION CRITERIA: We included randomised controlled trials that assessed TCC via MD to improve MNCH behaviour, service use, health, and well-being. Eligible comparators were usual care/no intervention, non-digital TCC, and digital non-targeted client communication. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures recommended by Cochrane, although data extraction and risk of bias assessments were carried out by one person only and cross-checked by a second. MAIN RESULTS: We included 27 trials (17,463 participants). Trial populations were: pregnant and postpartum women (11 trials conducted in low-, middle- or high-income countries (LMHIC); pregnant and postpartum women living with HIV (three trials carried out in one lower middle-income country); and parents of children under the age of five years (13 trials conducted in LMHIC). Most interventions (18) were delivered via text messages alone, one was delivered through voice calls only, and the rest were delivered through combinations of different communication channels, such as multimedia messages and voice calls. Pregnant and postpartum women TCCMD versus standard care For behaviours, TCCMD may increase exclusive breastfeeding in settings where rates of exclusive breastfeeding are less common (risk ratio (RR) 1.30, 95% confidence intervals (CI) 1.06 to 1.59; low-certainty evidence), but have little or no effect in settings where almost all women breastfeed (low-certainty evidence). For use of health services, TCCMD may increase antenatal appointment attendance (odds ratio (OR) 1.54, 95% CI 0.80 to 2.96; low-certainty evidence); however, the CI encompasses both benefit and harm. The intervention may increase skilled attendants at birth in settings where a lack of skilled attendants at birth is common (though this differed by urban/rural residence), but may make no difference in settings where almost all women already have a skilled attendant at birth (OR 1.00, 95% CI 0.34 to 2.94; low-certainty evidence). There were uncertain effects on maternal and neonatal mortality and morbidity because the certainty of the evidence was assessed as very low. TCCMD versus non-digital TCC (e.g. pamphlets) TCCMD may have little or no effect on exclusive breastfeeding (RR 0.92, 95% CI 0.79 to 1.07; low-certainty evidence). TCCMD may reduce 'any maternal health problem' (RR 0.19, 95% CI 0.04 to 0.79) and 'any newborn health problem' (RR 0.52, 95% CI 0.25 to 1.06) reported up to 10 days postpartum (low-certainty evidence), though the CI for the latter includes benefit and harm. The effect on health service use is unknown due to a lack of studies. TCCMD versus digital non-targeted communication No studies reported behavioural, health, or well-being outcomes for this comparison. For use of health services, there are uncertain effects for the presence of a skilled attendant at birth due to very low-certainty evidence, and the intervention may make little or no difference to attendance for antenatal influenza vaccination (RR 1.05, 95% CI 0.71 to 1.58), though the CI encompasses both benefit and harm (low-certainty evidence). Pregnant and postpartum women living with HIV TCCMD versus standard care For behaviours, TCCMD may make little or no difference to maternal and infant adherence to antiretroviral (ARV) therapy (low-certainty evidence). For health service use, TCC mobile telephone reminders may increase use of antenatal care slightly (mean difference (MD) 1.5, 95% CI -0.36 to 3.36; low-certainty evidence). The effect on the proportion of births occurring in a health facility is uncertain due to very low-certainty evidence. For health and well-being outcomes, there was an uncertain intervention effect on neonatal death or stillbirth, and infant HIV due to very low-certainty evidence. No studies reported on maternal mortality or morbidity. TCCMD versus non-digital TCC The effect is unknown due to lack of studies reporting this comparison. TCCMD versus digital non-targeted communication TCCMD may increase infant ARV/prevention of mother-to-child transmission treatment adherence (RR 1.26, 95% CI 1.07 to 1.48; low-certainty evidence). The effect on other outcomes is unknown due to lack of studies. Parents of children aged less than five years No studies reported on correct treatment, nutritional, or health outcomes. TCCMD versus standard care Based on 10 trials, TCCMD may modestly increase health service use (vaccinations and HIV care) (RR 1.21, 95% CI 1.08 to 1.34; low-certainty evidence); however, the effect estimates varied widely between studies. TCCMD versus non-digital TCC TCCMD may increase attendance for vaccinations (RR 1.13, 95% CI 1.00 to 1.28; low-certainty evidence), and may make little or no difference to oral hygiene practices (low-certainty evidence). TCCMD versus digital non-targeted communication TCCMD may reduce attendance for vaccinations, but the CI encompasses both benefit and harm (RR 0.63, 95% CI 0.33 to 1.20; low-certainty evidence). No trials in any population reported data on unintended consequences. AUTHORS' CONCLUSIONS: The effect of TCCMD for most outcomes is uncertain. There may be improvements for some outcomes using targeted communication but these findings were of low certainty. High-quality, adequately powered trials and cost-effectiveness analyses are required to reliably ascertain the effects and relative benefits of TCCMD. Future studies should measure potential unintended consequences, such as partner violence or breaches of confidentiality.

Maternal health care in India: A reflection of 10 years of National Health Mission on the Indian maternal health scenario.

OBJECTIVE: Maternal healthcare coverage is the outcome of health service availability and utilization, and includes antenatal care (ANC), care at delivery, and postnatal care. This study examines the contribution of India's National Health Mission (NHM) to maternal health through a pre-post comparison of rates of delivery at a healthcare institution and use of ANC along with inequalities in the determinants of one of the major maternal health outcomes-at least four ANC visits. METHODS: Data came from the Indian National Family Health Surveys conducted between 1992-93 and 2015-16. A multivariate logistic regression model was used to estimate the odds ratios (ORs) associated with the predictors of at least four ANC visits. RESULTS: Institutional delivery increased by 12.6 percentage points between 1992-93 and 2005-06 (the pre-NRHM era), and thereafter interventions through the National Rural Health Mission/NHM contributed to a significant increase of 40.2 percentage points from 2005-06 to 2015-16. However, both inter- and intra-state disparities persist even now. Overall, the proportion of pregnant women who have at least four ANC visits is as low as 51.2 percent. The likelihood of having at least four ANC visits is almost four times higher for women in the richest households compared with those in the poorest (OR: 3.59; 95% CI: 3.44-3.75) CONCLUSION: Future public health efforts should focus on removing inter- and intra-state disparities in institutional delivery and ensuring at least four ANC visits for pregnant women, to meet the infant and maternal mortality targets set out in the Sustainable Development Goals (SDG).

Improving the validity, relevance and feasibility of the continuum of care framework for maternal health in South Africa: a thematic analysis of experts' perspectives.

BACKGROUND: The continuum of care is a key strategy for ensuring comprehensive service delivery for maternal health, while acknowledging the role of the social determinants of health. However, there is little research on the operationalisation of the framework by decision-makers and implementers to address maternal health challenges. The framework should be measurable and feasible for implementation in low- and middle-income country contexts. In this study, we explore experts' perspective on monitoring indicators for continuum of care and key issues related to their use in the South African context. METHODS: We conducted key informant interviews with a range of experts in decision-making and programme implementation roles in the health system and relevant sectors. Key informants provided their perspectives on systematically selected, nationally representative monitoring indicators in terms of validity, relevance and feasibility. We interviewed 13 key informants and conducted a thematic analysis of their responses using multi-stage coding techniques in Atlas.ti 8.4. RESULTS: Experts believed that the continuum of care framework and monitoring indicators offer a multisectoral perspective for maternal health intervention missing in current programmes. To improve validity of monitoring indicators, experts suggested reflection on the use of proxy indicators and improvement of data to allow for equity analysis. In terms of relevance and feasibility, experts believe there was potential to foster co-accountability using continuum of care indicators. However, as experts stated, new indicators should be integrated that directly measure intersectoral collaboration for maternal health. In addition, experts recommended that the framework and indicators should evolve over time to reflect evolving policy priorities and public health challenges. CONCLUSION: Experts, as decision-makers and implementers, helped identify key issues in the application of the continuum of care framework and its indicators. The use of local indicators can bring the continuum of care framework from an under-utilised strategy to a useful tool for action and decision-making in maternal health. Our findings point to measurement issues and systematic changes needed to improve comprehensive monitoring of maternal health interventions in South Africa. Our methods can be applied to other low- and middle-income countries using the continuum of care framework and locally available indicators.

Assessing the Development of Collective Impact Initiatives Addressing Maternal and Child Health.

PURPOSE: To examine the extent to which communities participating in the Collective Impact Learning Collaborative (CILC) increased capacity to create conditions for collective impact (CI) to address racial disparities in maternal and child health (MCH) and align local efforts with state MCH priorities over a 12-month period. DESCRIPTION: Eight communities participated in a learning collaborative that involved the provision of technical assistance via webinars, monthly team calls, and site visits to facilitate the development of a collective impact initiative. A Ready-Set-Go approach to technical assistance was used to guide the communities through each phase of development while also providing individual assistance to teams based on their capacity at the start of participation. ASSESSMENT: A pre/post design measured change in capacity to engage in CI efforts over time. A survey designed to assess the completion of core tasks related to early indicators of CI was completed at baseline and 12 months later. Wilcoxon Signed Ranks Test and Mann-Whitney test determined statistically significant progress towards outcomes over 12 months and differences in progress between high- and low- capacity teams. CONCLUSION: In 12 months, teams with little established groundwork made significant progress, in some ways exceeding progress of more established teams. Statistically significant progress was achieved in eleven of fourteen outcomes measured. Five teams aligned local efforts with state priorities after 12 months. Findings suggest technical assistance to establish conditions for collective impact can support progress even when pre-conditions for collective impact are not previously established.

District Governance and Improved Maternal, Neonatal and Child Health in South Africa: Pathways of Change.

District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not take governance as their primary lens on health system strengthening. This paper is a case study of a district and sub-district governance mechanism, the Monitoring and Response Unit (MRU), which aimed to improve MNCH outcomes in two districts of South Africa. The MRU was introduced as a decision-making and accountability structure, and constituted of a "triangle" of managers, clinicians and information officers. An independent evaluation of the MRU initiative was conducted, three years after establishment, involving interviews with 89 district actors. Interviewees reported extensive changes in the scope, quality and organization of MNCH services, attributing these to the introduction of the MRU and enhanced support from district clinicians. We describe both the formal and informal aspects of the MRU as a governance mechanism, and then consider the pathways through which the MRU plausibly acted as a catalyst for change, using the institutional constructs of credible commitment, coordination and cooperation. In particular, the MRU promoted the formation of non-hierarchical collaborative networks; improved coordination between community, PHC and hospital services; and shaped collective sense-making in positive ways. We conclude that innovations in governance could add significant value to the district health system strengthening for improved MNCH. However, this requires a shift in focus from strengthening the front-line of service delivery, to change at the meso-level of sub-district and district decision-making; and from purely technical, data-driven to more holistic approaches that engage collective mindsets, widen participation in decision-making and nurture political leadership skills.

Promoting equity in maternal, newborn and child health - how does gender factor in? Perceptions of public servants in the Ethiopian health sector.

Background: Advancing gender equality and health equity are concurrent priorities of the Ethiopian health sector. While gender is regarded as an important determinant of health, there is a paucity of literature that considers the interface between how these two priorities are pursued.Objective: This article explores how government stakeholders understand gender issues (gender barriers and roles) in the promotion of maternal, newborn and child health equity in Ethiopia.Methods: Adopting an exploratory qualitative case study design, we conducted semi-structured interviews with 17 purposively-selected stakeholders working in leadership positions with the Federal Ministry of Health and Federal Ministry of Women and Children Affairs as part of a larger study regarding the promotion of health equity in maternal, newborn and child health. A post hoc content and thematic sub-analysis was done to explore how participants raised gender issues in conversations about health equity.Results: Efforts to address gender inequalities were synonymous with the promotion of a women's health agenda, which was largely oriented towards promoting health service use. Men were predominant decision makers with regards to women's health and health care seeking in both public and private spheres. Participants reported persisting gender-related barriers to health stemming from traditional gender roles, and noted the increased inclusion of women in the health workforce since the introduction of the Health Extension Program.Conclusions: The framing of gender as a women's health issue, advanced through patriarchal structures, does little to elevate the status of women, or promote power differentials that contribute to health inequity. Encouraging leadership roles for women as health decision makers and redressing certain gender-based norms, attitudes, practices and discrimination are possible ways forward in re-orienting gender equality efforts to align with the promotion of health equity.

Human rights in the Horn of Africa: an index of child and maternal health.

OBJECTIVE: To construct a territorial measure and classification of child and maternal health in the countries of the Horn of Africa based on the 2030 Agenda for Sustainable Development adopted by all United Nations Member States in 2015. METHOD: The design of our index includes the variables child and maternal health defined in the Sustainable Development Goals (SDGs) to enable territorial ranking of the countries. For this purpose, we used Pena's distance method for 2017. RESULTS: The results indicate a relatively high territorial disparity in maternal health between the countries of the Horn of Africa according to the differing values of the SDGs variables of child and maternal health. CONCLUSIONS: We propose a territorial classification in the countries of the Horn of Africa. We believe that the most striking differences between countries relate to basic variables of maternal health such as being attended by skilled health personnel.

An overview of advances in global maternal health: From broad to specific improvements.

After the declaration of the Millennium Development Goals in 2000 by the United Nations, many stakeholders allocated financial resources to "global maternal health." Research to expand care and improve delivery of maternal health services has exponentially increased. The present article highlights an overview, namely 10 of the health system, clinical, and technology-based advancements that have occurred in the past three decades in the field of global maternal health. The list of topics has been selected through the cumulative clinical and public health expertise of the authors and is certainly not exhaustive. Rather, the list is intended to provide a mapping of key topics arranged from broad to specific that span from the global policy level to the level of individual care. The list of health system, clinical, and technology-based advancements include: (10) Millennium Development Goals and Sustainable Development Goals; (9) Development of clinical training programs, including the potential for subspecialty development; (8) Prenatal care expansion and potential; (7) Decentralized health systems, including the use of skilled birth attendants; (6) Antiretroviral therapy for HIV; (5) Essential medicines; (4) Vaccines; (3) mHealth/eHealth; (2) Ultrasonography; and (1) Obstetric hemorrhage management. With the Sustainable Development Goals now underway, the field must build upon past successes to sustain maternal and neonatal well-being in the future global health agenda.

Agenda setting for maternal survival in Ghana and Tanzania against the backdrop of the MDGs.

High-level political support for the United Nations Millennium Development Goals (MDGs) drew international attention to included causes at the turn of the century. Influences of this normative framework on national-level health agenda setting remain little investigated. This study investigates the agenda status of maternal survival against the backdrop of the MDGs in two countries in sub-Saharan Africa. Informed by replicative case studies conducted in Ghana and Tanzania, the study finds the MDGs played a significant role in the issue's increasing status in both countries by helping to align several factors that facilitate the agenda setting process, including: ideas concerning the severity of the problem and expectations for its redress; institutions that shape policies, programs and monitoring; and economic and political interests. The agenda setting process was similar in the countries but for two dynamics. HIV/AIDS dominated Tanzania's health policy agenda in the early 2000s, crowding out attention to maternal and other health issues. A network of concerned actors that expanded to form a broad political coalition later facilitated agenda setting in Tanzania, including securing some budgetary commitments. By contrast, Ghana's core maternal health network remained technically oriented and closed to broader political and civil society engagement, limiting its capacity to expand issue attention and budgetary commitments beyond the health sector.

Monitoring quality of obstetric care from hospital discharge databases: A Delphi survey to propose a new set of indicators based on maternal health outcomes.

OBJECTIVES: Most indicators proposed for assessing quality of care in obstetrics are process indicators and do not directly measure health effects, and cannot always be identified from routinely available databases. Our objective was to propose a set of indicators to assess the quality of hospital obstetric care from maternal morbidity outcomes identifiable in permanent hospital discharge databases. METHODS: Various maternal morbidity outcomes potentially reflecting quality of obstetric care were first selected from a systematic literature review. Then a three-round Delphi consensus survey was conducted online from 11/2016 through 02/2017 among a French panel of 37 expert obstetricians, anesthetists-critical-care specialists, midwives, quality-of-care researchers, and user representatives. For a given maternal outcome, several definitions could be proposed and the indicator (i.e. corresponding rate) could be applied to all women or restricted to specific subgroup(s). RESULTS: Of the 49 experts invited to participate, 37 agreed. The response rate was 92% in the second round and 97% in the third. Finally, a set of 13 indicators was selected to assess the quality of hospital obstetric care: rates of uterine rupture, postpartum hemorrhage, transfusion incident, severe perineal lacerations, episiotomy, cesarean, cesarean under general anesthesia, post-cesarean site infection, anesthesia-related complications, postpartum pulmonary embolism, maternal readmission and maternal mortality. Six were considered in specific subgroups, with, for example, the postpartum hemorrhage rate assessed among all women and also among women at low risk of PPH. IMPLICATIONS: This Delphi process enabled us to define consensually a set of indicators to assess the quality of hospital obstetrics care from routine hospital data, based on maternal morbidity outcomes. Considering 6 of them in specific subgroups of women is especially interesting. These indicators, identifiable through codes used in international classifications, will be useful to monitor quality of care over time and across settings.

Family socioeconomic status and maternal depressive symptoms: Mediation through household food insecurity across five years.

RATIONALE: Food insecurity is a significant social problem that has been found to co-occur with both poverty and depression. However, few studies have utilized longitudinal data to investigate the associations among poverty, depression, and food insecurity. OBJECTIVE: This study tested two competing hypotheses, the food inadequacy hypothesis and the mental health hypothesis, in examining the associations among family socioeconomic status (SES), maternal depression, and household food insecurity across children's first five years of life. METHODS: Data were drawn from the Early Childhood Longitudinal Study-Birth Cohort (ECLS-B), a dataset nationally representative of all children born in the United States in 2001. Mothers reported family SES and household food insecurity when their children were nine months, 24 months, four years, and at kindergarten entry; maternal self-rated depressive symptoms were included at nine months, four years, and kindergarten entry. RESULTS: An autoregressive cross-lagged model showed that family SES was predictive of later household food insecurity, which in turn was associated with later maternal depressive symptoms. Significant mediation pathways were found with household food insecurity mediating the link between family SES and maternal depressive symptoms. CONCLUSIONS: This study highlights the need to consider household food insecurity as an underlying mechanism of maternal depressive symptoms in under-resourced families. Findings of this study can inform public health policy by highlighting the importance of considering factors such as food insecurity in the delivery of services to depressed mothers and their children in under-resourced contexts, and emphasizing the need for coordinated, integrated care in responding to the needs of these high-risk, vulnerable families.

How does social accountability contribute to better maternal health outcomes? A qualitative study on perceived changes with government and civil society actors in Gujarat, India.

BACKGROUND: Social accountability mechanisms have been highlighted as making a contribution to improving maternal health outcomes and reducing inequities. But there is a lack of evidence on how they contribute to such improvements. This study aims to explore social accountability mechanisms in selected districts of the Indian state of Gujarat in relation to maternal health, the factors they address and how the results of these mechanisms are perceived. METHODS: We conducted qualitative research through in-depth interviews and focus group discussions with actors of civil society and government health system. Data were analyzed using a framework of social determinants of maternal health in terms of structural and intermediary determinants. RESULTS: There are social accountability mechanisms in the government and civil society in terms of structure and activities. But those that were perceived to influence maternal health were mainly from civil society, particularly women's groups, community monitoring and a maternal death review. The social accountability mechanisms influenced structural determinants - governance, policy, health beliefs, women's status, and intermediary determinants - social capital, maternal healthcare behavior, and availability, accessibility and the quality of the health service delivery system. These further positively influenced the increased use of maternal health services. The social accountability mechanisms, through the process of information, dialogue and negotiation, particularly empowered women to make collective demands of the health system and brought about changed perceptions of women among actors in the system. It ultimately improved relations between women and the health system in terms of trust and collaboration, and generated appropriate responses from the health system to meeting women's groups' demands. CONCLUSION: Social accountability mechanisms in Gujarat were perceived to improve interaction between communities and the health system and contribute to improvements in access to and use of maternal health services. The influence of social accountability appeared to be limited to the local/district level and there was lack of capacity and ownership of the government structures.

Is the Salut Programme an effective and cost-effective universal health promotion intervention for parents and their children? A register-based retrospective observational study.

OBJECTIVES: This study investigates the effectiveness and cost-effectiveness of the Salut Programme, a universal health promotion intervention, compared with care-as-usual, over the periods of pregnancy, delivery and the child's first 2 years of life. METHOD: We adopted a register-based retrospective observational design using existing data sources with respect to both exposures and outcomes. Health outcomes and costs were compared between geographical areas that received care-as-usual (non-Salut area) and areas where the programme was implemented (Salut area). We included mothers and their children from both the Salut and non-Salut areas if: (1) the child was born 2002-2004 (premeasure period) or (2) the child was born 2006-2008 (postmeasure period). The effectiveness study adopted two strategies: (1) a matched difference-in-difference analysis using data from all participants and (2) a longitudinal analysis restricted to mothers who had given birth twice, that is, both in the premeasure and postmeasure periods. The economic evaluation was performed from a healthcare and a limited societal perspective. Outcomes were clustered during pregnancy, delivery and birth and the child's first 2 years. RESULTS: Difference-in-difference analyses did not yield any significant effect on the outcomes. Longitudinal analyses resulted in significant positive improvement in Apgar scores, reflecting the newborn's physical condition, with more children having a normal Apgar score (1 min +3%, 5 min +1%). The cost of the programme was international dollar (INT$)308/child. From both costing perspectives, the programme yielded higher effects and lower costs than care-as-usual, being thus cost-saving (probability of around 50%). CONCLUSIONS: Our findings suggest that the Salut Programme is an effective universal intervention to improve maternal and child health, and it may be good value for money; however, there is large uncertainty around the cost estimates.

How seasonality and weather affect perinatal health: Comparing the experiences of indigenous and non-indigenous mothers in Kanungu District, Uganda.

Maternal and newborn health disparities and the health impacts of climate change present grand challenges for global health equity, and there remain knowledge gaps in our understanding of how these challenges intersect. This study examines the pathways through which mothers are affected by seasonal and meteorological factors in sub-Saharan Africa in general, and Kanungu District (Uganda), in particular. We conducted a community-based study consisting of focus group discussions with mothers and interviews with health care workers in Kanungu District. Using a priori and a posteriori coding, we found a diversity of perspectives on the impacts of seasonal and weather exposures, with reporting of more food available in the rainy season. The rainy season was also identified as the period in which women performed physical labour for longer time periods, while work conditions in the dry season were reported to be more difficult due to heat. The causal pathways through which weather and seasonality may be affecting size at birth as reported by Kanungu mothers were consistent with those most frequently reported in the literature elsewhere, including maternal energy balance (nutritional intake and physical exertion output) and seasonal illness. While both Indigenous and non-Indigenous mothers described similar pathways, however, the severity of these experiences differed. Non-Indigenous mothers frequently relied on livestock assets or opportunities for less taxing physical work than Indigenous women, who had fewer options when facing food shortages or transport costs. Findings point to specific entry points for intervention including increased nutritional support in dry season periods of food scarcity, increased diversification of wage labour opportunities, and increased access to contraception. Interventions should be particularly targeted towards Indigenous mothers as they face greater food insecurity, may have fewer sources of income, and face greater overall deprivation than non-Indigenous mothers.