Essential components of postnatal care - a systematic literature review and development of signal functions to guide monitoring and evaluation.

BACKGROUND: Postnatal Care (PNC) is one of the healthcare-packages in the continuum of care for mothers and children that needs to be in place to reduce global maternal and perinatal mortality and morbidity. We sought to identify the essential components of PNC and develop signal functions to reflect these which can be used for the monitoring and evaluation of availability and quality of PNC. METHODS: Systematic review of the literature using MESH headings for databases (Cinahl, Cochrane, Global Health, Medline, PubMed, and Web of Science). Papers and reports on content of PNC published from 2000-2020 were included. Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders. RESULTS: Forty-Eight papers and reports are included in the systematic review from which 22 essential components of PNC were extracted and used to develop 14 signal functions. Signal functions are used in obstetrics to denote a list of interventions that address major causes of maternal and perinatal morbidity or mortality. For each signal function we identified the equipment, medication and consumables required for implementation. The prevention and management of infectious diseases (malaria, HIV, tuberculosis) are considered essential components of routine PNC depending on population disease burden or whether the population is considered at risk. Screening and management of pre-eclampsia, maternal anaemia and mental health are recommended universally. Promotion of and support of exclusive breastfeeding and uptake of a modern contraceptive method are also considered essential components of PNC. For the new-born baby, cord care, monitoring of growth and development, screening for congenital disease and commencing vaccinations are considered essential signal functions. Screening for gender-based violence (GBV) including intimate partner- violence (IPV) is recommended when counselling can be provided and/or a referral pathway is in place. Debriefing following birth (complicated or un-complicated) was agreed through consensus-building as an important component of PNC. CONCLUSIONS: Signal functions were developed which can be used for monitoring and evaluation of content and quality of PNC. Country adaptation and validation is recommended and further work is needed to examine if the proposed signal functions can serve as a useful monitoring and evaluation tool. TRIAL REGISTRATION: The systematic review protocol was registered: PROSPERO 2018 CRD42018107054 .

Where is the 'C' in antenatal care and postnatal care: A multi-country survey of availability of antenatal and postnatal care in low- and middle-income settings.

OBJECTIVE: Antenatal (ANC) and postnatal care (PNC) are logical entry points for prevention and treatment of pregnancy-related illness and to reduce perinatal mortality. We developed signal functions and assessed availability of the essential components of care. DESIGN: Cross-sectional survey. SETTING: Afghanistan, Chad, Ghana, Tanzania, Togo. SAMPLE: Three hundred and twenty-one healthcare facilities. METHODS: Fifteen essential components or signal functions of ANC and PNC were identified. Healthcare facility assessment for availability of each component, human resources, equipment, drugs and consumables required to provide each component. MAIN OUTCOME MEASURE: Availability of ANC PNC components. RESULTS: Across all countries, healthcare providers are available (median number per facility: 8; interquartile range [IQR] 3-17) with a ratio of 3:1 for secondary versus primary care. Significantly more women attend for ANC than PNC (1668 versus 300 per facility/year). None of the healthcare facilities was able to provide all 15 essential components of ANC and PNC. The majority (>75%) could provide five components: diagnosis and management of syphilis, vaccination to prevent tetanus, BMI assessment, gestational diabetes screening, monitoring newborn growth. In Sub-Saharan countries, interventions for malaria and HIV (including prevention of mother to child transmission [PMTCT]) were available in 11.7-86.5% of facilities. Prevention and management of TB; assessment of pre- or post-term birth, fetal wellbeing, detection of multiple pregnancy, abnormal lie and presentation; screening and support for mental health and domestic abuse were provided in <25% of facilities. CONCLUSIONS: Essential components of ANC and PNC are not in place. Focused attention on content is required if perinatal mortality and maternal morbidity during and after pregnancy are to be reduced. TWEETABLE ABSTRACT: ANC and PNC are essential care bundles. We identified 15 core components. These are not in place in the majority of LMIC settings.

Leveraging Global Fund investments for health systems strengthening: a qualitative case study on Morocco's Concept Note development.

BACKGROUND: In 2014, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) introduced a new funding model. Following notice of their 2014-2016 allocation, Morocco took the bold decision to reallocate its entire allocated investment (US$ 8 029 632) for health systems strengthening (HSS) and submitted a comprehensive request for funding solely for interventions to strengthen the health system. AIMS: To explore the specific barriers and facilitators to Morocco's novel development and submission of a cross-cutting HSS funding request to the Global Fund and to document lessons learned and recommendations for policy and programme leaders interested in leveraging Global Fund investments for health systems. METHODS: A thorough desk review of key documents and 15 in-depth qualitative interviews were conducted with key stakeholders in Morocco in 2017. RESULTS: In preparation for the funding request, Morocco carried out a comprehensive assessment of the health system, which included extensive dialogue with stakeholders and partners. This action was critical to developing a shared understanding and support for adopting a cross-cutting HSS approach. Despite concerns about potential negative effects of diverting funding from disease-specific programmes, visionary leadership advocated effectively for investing in HSS, and this paved the way for the development of a clear Concept Note requesting Global Fund financial support for the health system more broadly. CONCLUSION: Morocco was the first country in the Global Fund's Middle/East North Africa region to invest its entire Global Fund allocation in strengthening the health system. Many important lessons have been learned from this novel experience and these are presented for shared learning. This opportunity for learning is timely as countries begin preparations for the upcoming funding cycle.

A renewed focus on preventing malaria in pregnancy.

While much progress has been achieved globally in the fight against malaria, the significant financial investments made to date have not translated into scaled-up malaria in pregnancy (MiP) prevention efforts. Mothers and newborns remain at risk, and now is the time to refocus efforts. Against the backdrop of a new global health architecture embodied by the principles of Every Women, Every Child and driven by the work of the H6 Partnership, Global Financing Facility, strong bilaterals and key financiers, there is a new and timely juncture to advocate for MiP. Recent updates in the WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience present an opportunity to strengthen MiP as a core maternal and child health issue and position MiP prevention as a priority.

Global Call to Action: maximize the public health impact of intermittent preventive treatment of malaria in pregnancy in sub-Saharan Africa.

Intermittent preventive treatment of malaria in pregnancy is a highly cost-effective intervention which significantly improves maternal and birth outcomes among mothers and their newborns who live in areas of moderate to high malaria transmission. However, coverage in sub-Saharan Africa remains unacceptably low, calling for urgent action to increase uptake dramatically and maximize its public health impact. The 'Global Call to Action' outlines priority actions that will pave the way to success in achieving national and international coverage targets. Immediate action is needed from national health institutions in malaria-endemic countries, the donor community, the research community, members of the pharmaceutical industry and private sector, along with technical partners at the global and local levels, to protect pregnant women and their babies from the preventable, adverse effects of malaria in pregnancy.

Global Call to Action to scale-up coverage of intermittent preventive treatment of malaria in pregnancy: seminar report.

In 2014, a global 'Call to Action' seminar for the scale-up of intermittent preventive treatment of malaria in pregnancy was held during the 63rd Annual Meeting of the American Society of Tropical Medicine and Hygiene. This report summarizes the presentations and main discussion points from the meeting.

Workforce interventions to improve access to emergency contraception pills: a systematic review of current evidence in low- and middle-income countries and recommendations for improving performance.

BACKGROUND: Emergency contraceptive pills (ECP) are one of the 13 essential commodities addressed by the UN Commission on Life-Saving Commodities for Women and Children. Although ECP have been available for 20 years, a number of barriers still limit women's access ECP in low and middle-income countries (LMIC). The workforce who prescribe or dispense ECP are diverse reflecting the varied contexts where ECP are available across the health, commercial and justice sectors and in the community. No reviews currently exist that examine the roles and experiences of the workforce that provide ECP in LMIC. METHOD: We present a narrative synthesis of research to: identify provider factors that facilitate and constraint access to ECP; assess the effectiveness of associated interventions and; explore associated health system issues in LMIC. A search of bibliographic databases, meta-indexes and websites was undertaken to retrieve peer reviewed and grey literature. Literature was screened and identified documents examined to appraise quality. RESULTS: Thirty-seven documents were included in the review. Studies focused on formal health workers revealing knowledge gaps concerning the role of private sector and non-health providers who increasingly provide ECP. Data from the findings section in the documents were coded under 4 themes: provider knowledge; provider attitudes and beliefs; provider practice and provider training. The analysis revealed provider knowledge gaps, less than favourable attitudes and practice issues. The findings provide limited insight into products prescribed and/or dispensed, the frequency of provision, and information and advice offered to consumers. Pre and in-service training needs were noted. CONCLUSION: As the provision of ECPs shifts from the clinic-based health sector to increasing provision by the private sector, the limited understanding of provider performance and the practice gaps revealed in this review highlight the need to further examine provider performance to inform the development of appropriate workforce interventions. A standardized approach to assessing performance using agreed outcomes measures may serve to ensure a systematic way forward that is inclusive of the diverse workforce that deliver ECP. Recommendations are outlined to enhance the performance of providers to improve access to ECP. A framework is offered to help guide this process with indicators.

Improving access to emergency contraception pills through strengthening service delivery and demand generation: a systematic review of current evidence in low and middle-income countries.

OBJECTIVES: Emergency contraception pills (ECP) are among the 13 essential commodities in the framework for action established by the UN Commission on Life-Saving Commodities for Women and Children. Despite having been on the market for nearly 20 years, a number of barriers still limit women's access to ECP in low- and middle-income countries (LMIC) including limited consumer knowledge and poor availability. This paper reports the results of a review to synthesise the current evidence on service delivery strategies to improve access to ECP. METHODS: A narrative synthesis methodology was used to examine peer reviewed research literature (2003 to 2013) from diverse methodological traditions to provide critical insights into strategies to improve access from a service delivery perspective. The studies were appraised using established scoring systems and the findings of included papers thematically analysed and patterns mapped across all findings using concept mapping. FINDINGS: Ten papers were included in the review. Despite limited research of adequate quality, promising strategies to improve access were identified including: advance provision of ECP; task shifting and sharing; intersectoral collaboration for sexual assault; m-health for information provision; and scale up through national family planning programs. CONCLUSION: There are a number of gaps in the research concerning service delivery and ECP in LMIC. These include a lack of knowledge concerning private/commercial sector contributions to improving access, the needs of vulnerable groups of women, approaches to enhancing intersectoral collaboration, evidence for social marketing models and investment cases for ECP.

Protocol for a drugs exposure pregnancy registry for implementation in resource-limited settings.

BACKGROUND: The absence of robust evidence of safety of medicines in pregnancy, particularly those for major diseases provided by public health programmes in developing countries, has resulted in cautious recommendations on their use. We describe a protocol for a Pregnancy Registry adapted to resource-limited settings aimed at providing evidence on the safety of medicines in pregnancy. METHODS/DESIGN: Sentinel health facilities are chosen where women come for prenatal care and are likely to come for delivery. Staff capacity is improved to provide better care during the pregnancy, to identify visible birth defects at delivery and refer infants with major anomalies for surgical or clinical evaluation and treatment. Consenting women are enrolled at their first antenatal visit and careful medical, obstetric and drug-exposure histories taken; medical record linkage is encouraged. Enrolled women are followed up prospectively and their histories are updated at each subsequent visit. The enrolled woman is encouraged to deliver at the facility, where she and her baby can be assessed. DISCUSSION: In addition to data pooling into a common WHO database, the WHO Pregnancy Registry has three important features: First is the inclusion of pregnant women coming for antenatal care, enabling comparison of birth outcomes of women who have been exposed to a medicine with those who have not. Second is its applicability to resource-poor settings regardless of drug or disease. Third is improvement of reproductive health care during pregnancies and at delivery. Facility delivery enables better health outcomes, timely evaluation and management of the newborn, and the collection of reliable clinical data. The Registry aims to improves maternal and neonatal care and also provide much needed information on the safety of medicines in pregnancy.

Protocol for a drugs exposure pregnancy registry for implementation in resource-limited settings

Background: The absence of robust evidence of safety of medicines in pregnancy, particularly those for major diseases provided by public health programmes in developing countries, has resulted in cautious recommendations on their use. We describe a protocol for a Pregnancy Registry adapted to resource-limited settings aimed at providing evidence on the safety of medicines in pregnancy. Methods/design: Sentinel health facilities are chosen where women come for prenatal care and are likely to come for delivery. Staff capacity is improved to provide better care during the pregnancy, to identify visible birth defects at delivery and refer infants with major anomalies for surgical or clinical evaluation and treatment. Consenting women are enrolled at their first antenatal visit and careful medical, obstetric and drug-exposure histories taken; medical record linkage is encouraged. Enrolled women are followed up prospectively and their histories are updated at each subsequent visit. The enrolled woman is encouraged to deliver at the facility, where she and her baby can be assessed. Discussion: In addition to data pooling into a common WHO database, the WHO Pregnancy Registry has three important features: First is the inclusion of pregnant women coming for antenatal care, enabling comparison of birth outcomes of women who have been exposed to a medicine with those who have not. Second is its applicability to resource-poor settings regardless of drug or disease. Third is improvement of reproductive health care during pregnancies and at delivery. Facility delivery enables better health outcomes, timely evaluation and management of the newborn, and the collection of reliable clinical data. The Registry aims to improves maternal and neonatal care and also provide much needed information on the safety of medicines in pregnancy

Understanding methods for estimating HIV-associated maternal mortality.

The impact of HIV on maternal mortality and more broadly on the health of women, remains poorly documented and understood. Two recent reports attempt to address the conceptual and methodological challenges that arise in estimating HIV-related maternal mortality and trends. This paper presents and compares the methods and discusses how they affect estimates at global and regional levels. Country examples of likely patterns of mortality among women of reproductive age are provided to illustrate the critical interactions between HIV and complications of pregnancy in high-HIV-burden countries. The implications for collaboration between HIV and reproductive health programmes are discussed, in support of accelerated action to reach the Millennium Development Goals and improve the health of women.

The health impact of child labor in developing countries: evidence from cross-country data.

OBJECTIVES: Research on child labor and its effect on health has been limited. We sought to determine the impact of child labor on children's health by correlating existing health indicators with the prevalence of child labor in selected developing countries. METHODS: We analyzed the relationship between child labor (defined as the percentage of children aged 10 to 14 years who were workers) and selected health indicators in 83 countries using multiple regression to determine the nature and strength of the relation. The regression included control variables such as the percentage of the population below the poverty line and the adult mortality rate. RESULTS: Child labor was significantly and positively related to adolescent mortality, to a population's nutrition level, and to the presence of infectious disease. CONCLUSIONS: Longitudinal studies are required to understand the short- and long-term health effects of child labor on the individual child.

Why and how to invest in neonatal health.

The proportion of neonatal deaths in children has significantly increased, comprising at present almost 40% of all the nearly 11 million deaths of children under the age of five. In order to further reduce child mortality, substantial prompt attention to and reductions in neonatal mortality and morbidity are necessary. The reasons for insufficient investment in neonatal care are mostly based on incorrect assumptions about the importance, cost, and difficulty of tackling the issue. Further research is needed on the cost-effectiveness of neonatal interventions, but there is sufficient knowledge and evidence on the range, effect and cost-effectiveness of interventions to support significant increase in investments and broader programmatic implementation of available approaches. The continuum of care that follows the life-cycle is part of a high impact program delivery, supported by enabling environment, encompassing strong political commitment and strengthened comprehensive health system, from community level to clinical services. The international community needs to increase its funding and extend programs in close coordination with national health programs that are translated into partnerships at national and international level.

Essential newborn care training activities: 8 years of experience in Eastern European, Caucasian and Central Asian countries.

There is still an alarming gap in neonatal healthcare and outcome between Western and Eastern European countries and the former USSR countries in particular. Most of the causes of neonatal mortality and morbidity can be prevented or managed by simple cost-effective interventions aimed at improving quality of healthcare, health system organisation and family and community participation. Training of health professionals and health policy-makers in the field of essential neonatal care and breastfeeding promotion is one of the cornerstones of the World Health Organization (WHO) initiatives Making Pregnancy Safer (MPS) and Promoting Effective Perinatal Care (PEPC) - the latter specifically tailored to the European Region - aimed at ensuring safe pregnancy and childbirth through ensuring the availability, access and use of quality skilled care. After 8 years of experience of training in essential neonatal care, positive changes in planning for and delivering neonatal care are taking place, even in challenging contexts, and this model of intervention should be further implemented in the region.