Wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions in 36 countries in the African Region.

OBJECTIVE: To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions. METHODS: We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index. FINDINGS: We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa. CONCLUSION: Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability.

Psychosocial interventions targeting mental health in pregnant adolescents and adolescent parents: a systematic review.

BACKGROUND: Pregnancy and parenthood are known to be high-risk times for mental health. However, less is known about the mental health of pregnant adolescents or adolescent parents. Despite the substantial literature on the risks associated with adolescent pregnancy, there is limited evidence on best practices for preventing poor mental health in this vulnerable group. This systematic review therefore aimed to identify whether psychosocial interventions can effectively promote positive mental health and prevent mental health conditions in pregnant and parenting adolescents. METHODS: We used the standardized systematic review methodology based on the process outlined in the World Health Organization's Handbook for Guidelines Development. This review focused on randomized controlled trials of preventive psychosocial interventions to promote the mental health of pregnant and parenting adolescents, as compared to treatment as usual. We searched PubMed/Medline, PsycINFO, ERIC, EMBASE and ASSIA databases, as well as reference lists of relevant articles, grey literature, and consultation with experts in the field. GRADE was used to assess the quality of evidence. RESULTS: We included 17 eligible studies (n = 3245 participants). Interventions had small to moderate, beneficial effects on positive mental health (SMD = 0.35, very low quality evidence), and moderate beneficial effects on school attendance (SMD = 0.64, high quality evidence). There was limited evidence for the effectiveness of psychosocial interventions on mental health disorders including depression and anxiety, substance use, risky sexual and reproductive health behaviors, adherence to antenatal and postnatal care, and parenting skills. There were no available data for outcomes on self-harm and suicide; aggressive, disruptive, and oppositional behaviors; or exposure to intimate partner violence. Only two studies included adolescent fathers. No studies were based in low- or middle-income countries. CONCLUSION: Despite the encouraging findings in terms of effects on positive mental health and school attendance outcomes, there is a critical evidence gap related to the effectiveness of psychosocial interventions for improving mental health, preventing disorders, self-harm, and other risk behaviors among pregnant and parenting adolescents. There is an urgent need to adapt and design new psychosocial interventions that can be pilot-tested and scaled with pregnant adolescents and adolescent parents and their extended networks, particularly in low-income settings.

Strong community-based health systems and national governance predict improvement in coverage of oral rehydration solution (ORS): a multilevel longitudinal model.

Diarrheal disease remains a leading cause of child death globally, especially in low and middle-income countries. Use of oral rehydration solution (ORS) for treatment of diarrhea in children, a very cost-effective intervention, remains below 50% in many countries. Here we use a multi-level longitudinal model to reveal important predictors of ORS use at the national level. The findings suggest that increasing government effectiveness along with increased implementation and affordability of community-based health programs can lead to substantial increases in ORS use. Key informant interviews with national health leaders in countries that significantly improved ORS coverage support these quantitative findings.

Closing the inequality gaps in reproductive, maternal, newborn and child health coverage: slow and fast progressors.

Introduction: Universal Health Coverage (UHC) is a critical goal under the Sustainable Development Goals (SDGs) for health. Achieving this goal for reproductive, maternal, newborn and child health (RMNCH) service coverage will require an understanding of national progress and how socioeconomic and demographic subgroups of women and children are being reached by health interventions. Methods: We accessed coverage databases produced by the International Centre for Equity in Health, which were based on reanalysis of Demographic and Health Surveys, Multiple Indicator Cluster Surveys and Reproductive and Health Surveys. We limited the data to 58 countries with at least two surveys since 2008. We fitted multilevel linear regressions of coverage of RMNCH, divided into four main components-reproductive health, maternal health, child immunisation and child illness treatment-to estimate the average annual percentage point change (AAPPC) in coverage for the period 2008-2017 across these countries and for subgroups defined by maternal age, education, place of residence and wealth quintiles. We also assessed change in the pace of coverage progress between the periods 2000-2008 and 2008-2017. Results: Progress in RMNCH coverage has been modest over the past decade, with statistically significant AAPPC observed only for maternal health (1.25, 95% CI 0.90 to 1.61) and reproductive health (0.83, 95% CI 0.47 to 1.19). AAPPC was not statistically significant for child immunisation and illness treatment. Progress, however, varied largely across countries, with fast or slow progressors spread throughout the low-income and middle-income groups. For reproductive and maternal health, low-income and lower middle-income countries appear to have progressed faster than upper middle-income countries. For these two components, faster progress was also observed in older women and in traditionally less well-off groups such as non-educated women, those living in rural areas or belonging to the poorest or middle wealth quintiles than among groups that are well off. The latter groups however continue to maintain substantially higher coverage levels over the former. No acceleration in RMNCH coverage was observed when the periods 2000-2008 and 2008-2017 were compared. Conclusion: At the dawn of the SDGs, progress in coverage in RMNCH remains insufficient at the national level and across equity dimensions to accelerate towards UHC by 2030. Greater attention must be paid to child immunisation to sustain the past gains and to child illness treatment to substantially raise its coverage across all groups.

Large and persistent subnational inequalities in reproductive, maternal, newborn and child health intervention coverage in sub-Saharan Africa.

Subnational inequalities have received limited attention in the monitoring of progress towards national and global health targets during the past two decades. Yet, such data are often a critical basis for health planning and monitoring in countries, in support of efforts to reach all with essential interventions. Household surveys provide a rich basis for interventions coverage indicators on reproductive, maternal, newborn and child health (RMNCH) at the country first administrative level (regions or provinces). In this paper, we show the large subnational inequalities that exist in RMNCH coverage within 39 countries in sub-Saharan Africa, using a composite coverage index which has been used extensively by Countdown to 2030 for Women's, Children's and Adolescent's Health. The analyses show the wide range of subnational inequality patterns such as low overall national coverage with very large top inequality involving the capital city, intermediate national coverage with bottom inequality in disadvantaged regions, and high coverage in all regions with little inequality. Even though nearly half of the 34 countries with surveys around 2004 and again around 2015 appear to have been successful in reducing subnational inequalities in RMNCH coverage, the general picture shows persistence of large inequalities between subnational units within many countries. Poor governance and conflict settings were identified as potential contributing factors. Major efforts to reduce within-country inequalities are required to reach all women and children with essential interventions.

Equitable coverage? The roles of the private and public sectors in providing maternal, newborn and child health interventions in South Asia.

INTRODUCTION: The private sector accounts for an important share of health services available in South Asia. It is not known to what extent socioeconomic and urban-rural inequalities in maternal, newborn and child health (MNCH) interventions are being affected by the presence of private providers. METHODS: Nationally representative surveys carried out from 2009 to 2015 were analysed for seven of the eight countries in South Asia, as data for Sri Lanka were not available. The outcomes studied included antenatal care (four or more visits), institutional delivery, early initiation of breast feeding, postnatal care for babies, and careseeking for diarrhoea and pneumonia. Results were stratified according to quintiles of household wealth and urban-rural residence. RESULTS: At regional level, the public sector played a larger role than the private sector in providing antenatal (24.8% vs 15.6% coverage), delivery (51.9% vs 26.8%) and postnatal care (15.7% vs 8.2%), as well as in the early initiation of breast feeding (26.1% vs 11.1%). The reverse was observed in careseeking for diarrhoea (15.0% and 46.2%) and pneumonia (18.2% and 50.5%). In 28 out of 37 possible analyses of coverage by country, socioeconomic inequalities were significantly wider in the private than in the public sector, and in only four cases the reverse pattern was observed. In 20 of the 37 analyses, the public sector was also more likely to be used by the wealthiest women and children. CONCLUSION: The private sector plays a substantial role in delivering MNCH interventions in South Asia but is more inequitable than the public sector.

Adolescent Mental Health Program Components and Behavior Risk Reduction: A Meta-analysis.

CONTEXT: Although adolescent mental health interventions are widely implemented, little consensus exists about elements comprising successful models. OBJECTIVE: We aimed to identify effective program components of interventions to promote mental health and prevent mental disorders and risk behaviors during adolescence and to match these components across these key health outcomes to inform future multicomponent intervention development. DATA SOURCES: A total of 14 600 records were identified, and 158 studies were included. STUDY SELECTION: Studies included universally delivered psychosocial interventions administered to adolescents ages 10 to 19. We included studies published between 2000 and 2018, using PubMed, Medline, PsycINFO, Scopus, Embase, and Applied Social Sciences Index Abstracts databases. We included randomized controlled, cluster randomized controlled, factorial, and crossover trials. Outcomes included positive mental health, depressive and anxious symptomatology, violence perpetration and bullying, and alcohol and other substance use. DATA EXTRACTION: Data were extracted by 3 researchers who identified core components and relevant outcomes. Interventions were separated by modality; data were analyzed by using a robust variance estimation meta-analysis model, and we estimated a series of single-predictor meta-regression models using random effects. RESULTS: Universally delivered interventions can improve adolescent mental health and reduce risk behavior. Of 7 components with consistent signals of effectiveness, 3 had significant effects over multiple outcomes (interpersonal skills, emotional regulation, and alcohol and drug education). LIMITATIONS: Most included studies were from high-income settings, limiting the applicability of these findings to low- and middle-income countries. Our sample included only trials. CONCLUSIONS: Three program components emerged as consistently effective across different outcomes, providing a basis for developing future multioutcome intervention programs.

Scoping review to identify and map the health personnel considered skilled birth attendants in low-and-middle income countries from 2000-2015.

INTRODUCTION: The "percentage of births attended by a skilled birth attendant" (SBA) is an indicator that has been adopted by several global monitoring frameworks, including the Sustainable Development Goal (SDG) agenda for regular monitoring as part of target 3.1 for reducing maternal mortality by 2030. However, accurate and consistent measurement is challenged by contextual differences between and within countries on the definition of SBA, including the education, training, competencies, and functions they are qualified to perform. This scoping review identifies and maps the health personnel considered SBA in low-to-middle-income-countries (LMIC). METHODS AND ANALYSIS: A search was conducted inclusive to the years 2000 to 2015 in PubMed/MEDLINE, EMBASE, CINAHL Complete, Cochrane Database of Systematic Reviews, POPLINE and the World Health Organization Global Index Medicus. Original primary source research conducted in LMIC that evaluated the skilled health personnel providing interventions during labour and childbirth were considered for inclusion. All studies reported disaggregated data of SBA cadres and were disaggregated by country. RESULTS: The search of electronic databases identified a total of 23,743 articles. Overall, 70 articles were included in the narrative synthesis. A total of 102 unique cadres names were identified from 36 LMIC countries. Of the cadres included, 16% represented doctors, 16% were nurses, and 15% were midwives. We found substantial heterogeneity between and within countries on the reported definition of SBA and the education, training, skills and competencies that they were able to perform. CONCLUSION: The uncertainty and diversity of reported qualifications and competency of SBA within and between countries requires attention in order to better ascertain strategic priorities for future health system planning, including training and education. These results can inform recommendations around improved coverage measurement and monitoring of SBA moving forward, allowing for more accurate, consistent, and timely data able to guide decisions and action around planning and implementation of maternal and newborn health programmes.

Service readiness for inpatient care of small and sick newborns: what do we need and what can we measure now?

BACKGROUND: Each year an estimated 2.6 million newborns die, mainly from complications of prematurity, neonatal infections, and intrapartum events. Reducing these deaths requires high coverage of good quality care at birth, and inpatient care for small and sick newborns. In low- and middle-income countries, standardised measurement of the readiness of facilities to provide emergency obstetric care has improved tracking of readiness to provide care at birth in recent years. However, the focus has been mainly on obstetric care; service readiness for providing inpatient care of small and sick newborns is still not consistently measured or tracked. METHODS: We reviewed existing international guidelines and resources to create a matrix of the structural characteristics (infrastructure, equipment, drugs, providers and guidelines) for service readiness to deliver a package of inpatient care interventions for small and sick newborns. To identify gaps in existing measurement systems, we reviewed three multi-country health facility survey tools (the Service Availability and Readiness Assessment, the Service Provision Assessment and the Emergency Obstetric and Newborn Care Assessment) against our service readiness matrix. FINDINGS: For service readiness to provide inpatient care for small and sick newborns, our matrix detailed over 600 structural characteristics. Our review of the SPA, the SARA and the EmONC assessment tools identified several measurement omissions to capture information on key intervention areas, such as thermoregulation, feeding and respiratory support, treatment of specific complications (seizures, jaundice), and screening and follow up services, as well as specialised staff and service infrastructure. CONCLUSIONS: Our review delineates the required inputs to ensure readiness to provide inpatient care for small and sick newborns. Based on these findings, we detail where questions need to be added to existing tools and describe how measurement systems can be adapted to reflect small and sick newborns interventions. Such work can inform investments in health systems to end preventable newborn death and disability as part of the Every Newborn Action Plan.

Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries.

BACKGROUND: Latin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions. METHODS: We analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15-49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12-23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), woman's education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression. FINDINGS: Ethnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66-0·92), antenatal care (0·86, 0·75-0·94), and skilled birth attendants (0·75, 0·68-0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries. INTERPRETATION: The lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level-such as vaccines-show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes. FUNDING: The Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.

Thermal care of newborns: drying and bathing practices in Malawi and Bangladesh.

BACKGROUND: Thermal care of newborns is one of the recommended strategies to reduce hypothermia, which contributes to neonatal morbidity and mortality. However, data on these two topics have not been collected at the national level in many surveys. In this study, we examine two elements of thermal care: drying and delayed bathing of newborns after birth with the objectives of examining how two countries collected such data and then looking at various associations of these outcomes with key characteristics. Further, we examine the data for potential data quality issues as this is one of the first times that such data are available at the national level. METHODS: We use data from two nationally-representative household surveys: the Malawi Multiple Indicator Cluster Survey 2014 and the Bangladesh Demographic and Health Survey 2014. We conduct descriptive analysis of the prevalence of these two newborn practices by various socio-demographic, economic and health indicators. RESULTS: Our results indicate high levels of immediate drying/drying within 1 hour in Malawi (87%). In Bangladesh, 84% were dried within the first 10 minutes of birth. Bathing practices varied in the two settings; in Malawi, only 26% were bathed after 24 hours but in Bangladesh, 87% were bathed after the same period. While in Bangladesh there were few newborns who were never bathed (less than 5%), in Malawi, over 10% were never bathed. Newborns delivered by a skilled provider tended to have better thermal care than those delivered by unskilled providers. CONCLUSION: These findings reveal gaps in coverage of thermal care and indicate the need to further develop the role of unskilled providers who can give unspecialized care as a means to improve thermal care for newborns. Further work to harmonize data collection methods on these topics is needed to ensure comparable data across countries.

Determinants of Integrated Management of Childhood Illness (IMCI) non-severe pneumonia classification and care in Malawi health facilities: Analysis of a national facility census.

BACKGROUND: Research shows inadequate Integrated Management of Childhood Illness (IMCI)-pneumonia care in various low-income settings but evidence is largely from small-scale studies with limited evidence of patient-, provider- and facility-levels determinants of IMCI non-severe pneumonia classification and its management. METHODS: The Malawi Service Provision Assessment 2013-2014 included 3149 outpatients aged 2-59 months with completed observations, interviews and re-examinations. Mixed-effects logistic regression models quantified the influence of patient-, provider and facility-level determinants on having IMCI non-severe pneumonia and its management in observed consultations. FINDINGS: Among 3149 eligible outpatients, 590 (18.7%) had IMCI non-severe pneumonia classification in re-examination. 228 (38.7%) classified cases received first-line antibiotics and 159 (26.9%) received no antibiotics. 18.6% with cough or difficult breathing had 60-second respiratory rates counted during consultations, and conducting this assessment was significantly associated with IMCI training ever received (odds ratio (OR) = 2.37, 95% confidence interval (CI): 1.29-4.31) and negative rapid diagnostic test results (OR = 3.21, 95% CI: 1.45-7.13). Older children had lower odds of assessments than infants (OR = 48-59 months: 0.35, 95% CI: 0.16-0.75). Children presenting with any of the following complaints also had reduced odds of assessment: fever, diarrhea, skin problem or any danger sign. First-line antibiotic treatment for classified cases was significantly associated with high temperatures (OR = 3.26, 95% CI: 1.24-8.55) while older children had reduced odds of first-line treatment compared to infants (OR = 48-59 months: 0.29, 95% CI: 0.10-0.83). RDT-confirmed malaria was a significant predictor of no antibiotic receipt for IMCI non-severe pneumonia (OR = 10.65, 95% CI: 2.39-47.36). CONCLUSIONS: IMCI non-severe pneumonia care was sub-optimal in Malawi health facilities in 2013-2014 with inadequate assessments and prescribing practices that must be addressed to reduce this leading cause of mortality. Child's symptoms and age, malaria diagnosis and provider training were primary influences on assessment and treatment practices. Current evidence could be used to better target IMCI training and support to improve pneumonia care for sick children in Malawi facilities.

Protocol for a scoping review to identify and map the global health personnel considered skilled attendants at birth in low and middle-income countries between 2000 and 2015.

INTRODUCTION: Despite progress towards the Millennium Development Goals (MDG), maternal mortality remains high in countries where there are shortages of skilled personnel able to manage and provide quality care during pregnancy and childbirth. The 'percentage of births attended by skilled health personnel' (SAB, skilled attendants at birth) was a key indicator for tracking progress since the MDGs and is part of the Sustainable Development Goal agenda. However, due to contextual differences between and within countries on the definition of SAB, a lack of clarity exists around the training, competencies, and skills they are qualified to perform. In this paper, we outline a scoping review protocol that poses to identify and map the health personnel considered SAB in low and middle-income countries (LMIC). METHODS AND ANALYSIS: A search will be conducted for the years 2000-2015 in PubMed/MEDLINE, EMBASE, CINAHL Complete, Cochrane Database of Systematic Reviews, POPLINE and the WHO Global Health Library. A manual search of reference lists from identified studies or systematic reviews and a hand search of the literature from international partner organisations will be done. Original studies conducted in LMIC that assessed health personnel (paid or voluntary) providing interventions during the intrapartum period will be considered for inclusion. ETHICS AND DISSEMINATION: A scoping review is a secondary analysis of published literature and does not require ethics approval. This scoping review proposes to synthesise data on the training, competency and skills of identified SAB and expands on other efforts to describe this global health workforce. The results will inform recommendations around improved coverage measurement and reporting of SAB moving forward, allowing for more accurate, consistent and timely data able to guide decisions and action around planning and implementation of maternal and newborn health programme globally. Data will be disseminated through a peer-reviewed manuscript, conferences and to key stakeholders within international organisations.

Gap between contact and content in maternal and newborn care: An analysis of data from 20 countries in sub-Saharan Africa.

BACKGROUND: Over the last decade, coverage of maternal and newborn health indicators used for global monitoring and reporting have increased substantially but reductions in maternal and neonatal mortality have remained slow. This has led to an increased recognition and concern that these standard globally agreed upon measures of antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) only capture the level of contacts with the health system and provide little indication of actual content of services received by mothers and their newborns. Over this period, large household surveys have captured measures of maternal and newborn care mainly through questions assessing contacts during the antenatal, delivery and postnatal periods along with some measures of content of care. This study aims to describe the gap between contact and content -as a proxy for quality- of maternal and newborn health services by assessing level of co-coverage of ANC and PNC interventions. METHODS: We used Demographic and Health Surveys (DHS) data from 20 countries between 2010 and 2015. We analysed the proportion of women with at least 1 and 4+ antenatal care visit, who received 8 interventions. We also assessed the percentage of newborns delivered with a skilled birth attendant who received 7 interventions. We ran random effect logistic regression to assess factors associated with receiving all interventions during the antenatal and postnatal period. RESULTS: While on average 51% of women in the analysis received four ANC visits with at least one visit from a skilled health provider, only 5% of them received all 8 ANC interventions. Similarly, during the postnatal period though two-thirds (65%) of births were attended by a skilled birth attendant, only 3% of newborns received all 7 PNC interventions. The odds of receiving all ANC and PNC interventions were higher for women with higher education and higher wealth status. CONCLUSION: The gap between coverage and content as a proxy of quality of antenatal and postnatal care is excessively large in all countries. In order to accelerate maternal and newborn survival and achieve Sustainable Development Goals, increased efforts are needed to improve both the coverage and quality of maternal and newborn health interventions.

Measuring postnatal care contacts for mothers and newborns: An analysis of data from the MICS and DHS surveys.

BACKGROUND: The postnatal period represents a vulnerable phase for mothers and newborns where both face increased risk of morbidity and death. WHO recommends postnatal care (PNC) for mothers and newborns to include a first contact within 24 hours following the birth of the child. However, measuring coverage of PNC in household surveys has been variable over time. The two largest household survey programs in low and middle-income countries, the UNICEF-supported Multiple Indicator Cluster Surveys (MICS) and USAID-funded Demographic and Health Surveys (DHS), now include modules that capture these measures. However, the measurement approach is slightly different between the two programs. We attempt to assess the possible measurement differences that might affect comparability of coverage measures. METHODS: We first review the standard questionnaires of the two survey programs to compare approaches to collecting data on postnatal contacts for mothers and newborns. We then illustrate how the approaches used can affect PNC coverage estimates by analysing data from four countries; Bangladesh, Ghana, Kygyz Republic, and Nepal, with both MICS and DHS between 2010-2015. RESULTS: We found that tools implemented todate by MICS and DHS (up to MICS round 5 and up to DHS phase 6) have collected PNC information in different ways. While MICS dedicated a full module to PNC and distinguishes immediate vs later PNC, DHS implemented a more blended module of pregnancy and postnatal and did not systematically distinguish those phases. The two survey programs differred in the way questions on postnatal care for mothers and newbors were framed. Subsequently, MICS and DHS surveys followed different methodological approach to compute the global indicator of postnatal contacts for mothers and newborns within two days following delivery. Regardless of the place of delivery, MICS estimates for postnatal contacts for mothers and newbors appeared consistently higher than those reported in DHS. The difference was however, far more pronounced in case of newborns. CONCLUSIONS: Difference in questionnaires and the methodology adopted to measure PNC have created comparability issues in the coverage levels. Harmonization of survey instruments on postnatal contacts will allow comparable and better assessment of coverage levels and trends.

Evidence from household surveys for measuring coverage of newborn care practices.

BACKGROUND: Aside from breastfeeding, there are little data on use of essential newborn care practices, such as thermal protection and hygienic cord care, in high mortality countries. These practices have not typically been measured in national household surveys, often the main source for coverage data in these settings. The Every Newborn Action Plan proposed early breastfeeding as a tracer for essential newborn care due to data availability and evidence for the benefits of breastfeeding. In the past decade, a few national surveys have added questions on other practices, presenting an opportunity to assess the performance of early breastfeeding initiation as a tracer indicator. METHODS: We identified twelve national surveys between 2005-2014 that included at least one indicator for immediate newborn care in addition to breastfeeding. Because question wording and reference populations varied, we standardized data to the extent possible to estimate coverage of newborn care practices, accounting for strata and multistage survey design. We assessed early breastfeeding as a tracer by: 1) examining associations with other indicators using Pearson correlations; and 2) stratifying by early breastfeeding to determine differences in coverage of other practices for initiators vs non-initiators in each survey, then pooling across surveys for a meta-analysis, using the inverse standard error as the weight for each observation. FINDINGS: Associations between pairs of coverage indicators are generally weak, including those with breastfeeding. The exception is drying and wrapping, which have the strongest association of any two interventions in all five surveys where measured; estimated correlations for this range from 0.47 in Bangladesh's 2007 DHS to 0.83 in Nepal's 2006 DHS. The contrast in coverage for other practices by early breastfeeding is generally small; the greatest absolute difference was 6.7%, between coverage of immediate drying for newborns breastfed early compared to those who were not. CONCLUSIONS: Early initiation of breastfeeding is not a high performing tracer indicator for essential newborn care practices measured in previous national surveys. To have informative data on whether newborns are getting life-saving services, standardized questions about specific practices, in addition to breastfeeding initiation, need to be added to surveys.

Skilled attendant at birth and newborn survival in Sub-Saharan Africa.

BACKGROUND: Recent studies have shown higher neonatal mortality among births delivered by a skilled attendant at birth (SAB) compared to those who were not in sub-Saharan African countries. Deaths during the neonatal period are concentrated in the first 7 days of life, with about one third of these deaths occurring during the first day of life. We reassessed the relationship between SAB and neonatal mortality by distinguishing deaths on the first day of life from those on days 2-27. METHODS: We used data on births in the past five years from recent demographic and health survey (DHS) between 2010 and 2014 in 20 countries in sub-Saharan Africa. The main categorical outcome was 1) newborns who died within the first day of birth (day 0-1), 2) newborns who died between days 2-27, and 3) newborns who survived the neonatal period. We ran generalized linear mixed model with multinomial distribution and random effect for country on pooled data. Additionally, we ran a separate model restricted to births with SAB and assessed the association of receipt of seven antenatal care (ANC) and two immediate postnatal care interventions on risk of death on days 0-1 and days 2-27. These variables were assessed as proxy of quality of antenatal and postnatal care. RESULTS: We found no statistically significant difference in risk of death on first day of life between newborns with SAB compared to those without. However, after the first day of life, newborns delivered with SAB were 16% less likely to die within 2-27 days than those without SAB (OR = 0.84, 95% CI = 0.71-0.99). Among births with skilled attendant, those who were weighed at birth and those who were initiated early on breastfeeding were significantly less likely to die on days 0-1 (respectively OR = 0.42 95% CI = 0.29-0.62 and OR = 0.24, 95% CI 0.18-0.31) or on days 2-27 (OR = 0.60, 95% CI = 0.45-0.81 and OR = 0.59, 95% CI = 47-0.74, respectively). Newborns whose mothers received an additional ANC intervention had no improved survival chances during days 0-1 of life. However, there was significant association on days 2-27 where newborns whose mothers received an additional ANC interventions had higher survival chances (OR = 0.95, 95% CI = 0.93-0.98). CONCLUSION: Findings demonstrate the vulnerability of newborns immediately after birth, compounded with insufficient quality of care. Improving the quality of care around the time of birth will significantly improve survival and therefore accelerate reduction in neonatal mortality in sub-Saharan African countries. Improved approaches for measuring skilled attendant at birth are also needed.

The importance of skin-to-skin contact for early initiation of breastfeeding in Nigeria and Bangladesh.

BACKGROUND: Skin-to-skin contact (SSC) between mother and newborn offers numerous protective effects, however it is an intervention that has been under-utilized. Our objectives are to understand which newborns in Bangladesh and Nigeria receive SSC and whether SSC is associated with the early initiation of breastfeeding. METHODS: Demographic and Health Survey (DHS) data were used to study the characteristics of newborns receiving SSC for non-facility births in Nigeria (DHS 2013) and for both facility and non-facility births in Bangladesh (DHS 2014). Multivariable logistic regression was used to study the association between SSC and early initiation of breastfeeding after controlling for key socio-demographic, maternal and newborn-related factors. RESULTS: Only 10% of newborns in Nigeria and 26% of newborns in Bangladesh received SSC. In the regression models, SSC was significantly associated with the early initiation of breastfeeding in both countries (OR = 1.42, 95% CI 1.15-1.76 for Nigeria; OR = 1.27, 95% CI 1.04-1.55, for Bangladesh). Findings from the regression analysis for Bangladesh revealed that newborns born by Cesarean section had a 67% lower odds of early initiation of breastfeeding than those born by normal delivery (OR = 0.33, 95% CI 0.26-0.43). Also in Bangladesh newborns born in a health facility had a 30% lower odds of early initiation of breastfeeding than those born in non-facility environments (OR = 0.70, 95% CI 0.53-0.92). Early initiation of breastfeeding was significantly associated with parity, urban residence and wealth in Nigeria. Geographic area was significant in the regression analyses for both Bangladesh and Nigeria. CONCLUSIONS: Coverage of SSC is very low in the two countries, despite its benefits for newborns without complications. SSC has the potential to save newborn lives. There is a need to prioritize training of health providers on the implementation of essential newborn care including SSC. Community engagement is also needed to ensure that all women and their families regardless of residence, socio-economic status, place or type of delivery, understand the benefits of SSC and early initiation of breastfeeding.