No association between long-chain n-3 fatty acid intake during pregnancy and risk of type 1 diabetes in offspring in two large Scandinavian pregnancy cohorts.

AIMS/HYPOTHESIS: The aim of this study was to investigate whether higher dietary intake of marine n-3 fatty acids during pregnancy is associated with a lower risk of type 1 diabetes in children. METHODS: The Danish National Birth Cohort (DNBC) and the Norwegian Mother, Father and Child Cohort Study (MoBa) together include 153,843 mother-child pairs with prospectively collected data on eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) intake during pregnancy from validated food frequency questionnaires. Type 1 diabetes diagnosis in children (n=634) was ascertained from national diabetes registries. RESULTS: There was no association between the sum of EPA and DHA intake during pregnancy and risk of type 1 diabetes in offspring (pooled HR per g/day of intake: 1.00, 95% CI 0.88, 1.14), with consistent results for both the MoBa and the DNBC. Robustness analyses gave very similar results. CONCLUSIONS/INTERPRETATION: Initiation of a trial of EPA and DHA during pregnancy to prevent type 1 diabetes in offspring should not be prioritised.

Evolution in key indicators of maternal and child health across the wealth gradient in 41 sub-Saharan African countries, 1986-2019.

BACKGROUND: Aggregate trends can be useful for summarizing large amounts of information, but this can obscure important distributional aspects. Some population subgroups can be worse off even as averages climb, for example. Distributional information can identify health inequalities, which is essential to understanding their drivers and possible remedies. METHODS: Using publicly available Demographic and Health Survey (DHS) data from 41 sub-Saharan African countries from 1986 to 2019, we analyzed changes in coverage for eight key maternal and child health indicators: first dose of measles vaccine (MCV1); Diphtheria-Pertussis-Tetanus (DPT) first dose (DPT1); DPT third dose (DPT3); care-seeking for diarrhea, acute respiratory infections (ARI), or fever; skilled birth attendance (SBA); and having four antenatal care (ANC) visits. To evaluate whether coverage diverged or converged over time across the wealth gradient, we computed several dispersion metrics including the coefficient of variation across wealth quintiles. Slopes and 5-year moving averages were computed to identify overall long-term trends. RESULTS: Average coverage increased for all quintiles and indicators, although the range and the speed at which they increased varied widely. There were small changes in the wealth-related gap for SBA, ANC, and fever. The wealth-related gap of vaccination-related indicators (DPT1, DPT3, MCV1) decreased over time. Compared to 2017, the wealth-gap between richest and poorest quintiles in 1995 was 7 percentage points larger for ANC and 17 percentage points larger for measles vaccination. CONCLUSIONS: Maternal and child health indicators show progress, but the distributional effects show differential evolutions in inequalities. Several reasons may explain why countries had smaller wealth-related gap trends in vaccination-related indicators compared to others. In addition to service delivery differences, we hypothesize that the allocation of development assistance for health, the prioritization of vaccine-preventable diseases on the global agenda, and indirect effects of structural adjustment programs on health system-related indicators might have played a role.

Impact of mHealth interventions on maternal, newborn, and child health from conception to 24 months postpartum in low- and middle-income countries: a systematic review.

BACKGROUND: Mobile health (mHealth) technologies have been harnessed in low- and middle-income countries (LMICs) to address the intricate challenges confronting maternal, newborn, and child health (MNCH). This review aspires to scrutinize the effectiveness of mHealth interventions on MNCH outcomes during the pivotal first 1000 days of life, encompassing the period from conception through pregnancy, childbirth, and post-delivery, up to the age of 2 years. METHODS: A comprehensive search was systematically conducted in May 2022 across databases, including PubMed, Cochrane Library, Embase, Cumulative Index to Nursing & Allied Health (CINAHL), Web of Science, Scopus, PsycINFO, and Trip Pro, to unearth peer-reviewed articles published between 2000 and 2022. The inclusion criteria consisted of (i) mHealth interventions directed at MNCH; (ii) study designs, including randomized controlled trials (RCTs), RCT variations, quasi-experimental designs, controlled before-and-after studies, or interrupted time series studies); (iii) reports of outcomes pertinent to the first 1000 days concept; and (iv) inclusion of participants from LMICs. Each study was screened for quality in alignment with the Cochrane Handbook for Systematic Reviews of Interventions and the Joanne Briggs Institute Critical Appraisal tools. The included articles were then analyzed and categorized into 12 mHealth functions and outcome domain categories (antenatal, delivery, and postnatal care), followed by forest plot comparisons of effect measures. RESULTS: From the initial pool of 7119 articles, we included 131 in this review, comprising 56 RCTs, 38 cluster-RCTs, and 37 quasi-experimental studies. Notably, 62% of these articles exhibited a moderate or high risk of bias. Promisingly, mHealth strategies, such as dispatching text message reminders to women and equipping healthcare providers with digital planning and scheduling tools, exhibited the capacity to augment antenatal clinic attendance and enhance the punctuality of child immunization. However, findings regarding facility-based delivery, child immunization attendance, and infant feeding practices were inconclusive. CONCLUSIONS: This review suggests that mHealth interventions can improve antenatal care attendance and child immunization timeliness in LMICs. However, their impact on facility-based delivery and infant feeding practices varies. Nevertheless, the potential of mHealth to enhance MNCH services in resource-limited settings is promising. More context-specific implementation studies with rigorous evaluations are essential.

Quantifying the Association Between Pump Use and Breastfeeding Duration.

OBJECTIVE: To quantify the extent to which pump use is associated with breastfeeding duration. STUDY DESIGN: We conducted a cross-sectional analysis of weighted CDC Pregnancy Risk Assessment Monitoring System data from Maine, Michigan, New Mexico, and Utah between 2016 and 2021. Included respondents had a live-born infant at survey completion, initiated breastfeeding, and had non-missing data for reported pump use and breastfeeding duration. Using Cox proportional hazard regression, we quantified the hazard of breastfeeding cessation and median duration (weeks) of breastfeeding by pump use. Pump use was suspected to be differentially impacted by race and ethnicity; an interaction was tested in our regression model. RESULTS: Our sample included 19,719 mothers (weighted N= 723,808) with mean age (SD) 29.5 years (5.6). Mothers with age <18 years, Medicaid enrollment, race and ethnicity other than non-Hispanic White, lower income or education, and unmarried status demonstrated lower pump use (p<0.001). Pump use was associated with 37% lower hazard of breastfeeding cessation (aHR 0.63; 95% CI: 0.56-0.70) and 21 additional weeks of breastfeeding on average. The association varied by race and ethnicity (significant interaction observed between pump use and non-Hispanic Black mothers, p=0.013); stratified analysis demonstrated the lowest hazard of breastfeeding cessation among non-Hispanic Black and Native American pump users (aHR 0.47 [0.40-0.54] and 0.51 [0.37-0.70], respectively). CONCLUSION: Pump use was associated with longer breastfeeding duration; the greatest magnitudes of association were found among non-Hispanic Black and Native American participants, groups disproportionately affected by breastfeeding inequities. Future research examining the context around and causal impact of pump use on breastfeeding outcomes is needed.

Inter-district and Wealth-related Inequalities in Maternal and Child Health Service Coverage and Child Mortality within Addis Ababa City.

In sub-Saharan Africa, urban areas generally have better access to and use of maternal, newborn, and child health (MNCH) services than rural areas, but previous research indicates that there are significant intra-urban disparities. This study aims to investigate temporal trends and geographic differences in maternal, newborn, and child health service utilization between Addis Ababa's poorest and richest districts and households. A World Bank district-based poverty index was used to classify districts into the top 60% (non-poor) and bottom 40% (poor), and wealth index data from the Ethiopian Demographic and Health Survey (EDHS) was used to classify households into the top 60% (non-poor) and bottom 40% (poor). Essential maternal, newborn, and child health service coverage was estimated from routine health facility data for 2019-2021, and five rounds of the EDHS (2000-2019) were used to estimate child mortality. The results showed that service coverage was substantially higher in the top 60% than in the bottom 40% of districts. Coverage of four antenatal care visits, skill birth attendance, and postnatal care all exceeded 90% in the non-poor districts but only ranged from 54 to 67% in the poor districts. Inter-district inequalities were less pronounced for childhood vaccinations, with over 90% coverage levels across all districts. Inter-district inequalities in mortality rates were considerable. The neonatal mortality rate was nearly twice as high in the bottom 40% of households' as in the top 60% of households. Similarly, the under-5 mortality rate was three times higher in the bottom 40% compared to the top 60% of households. The substantial inequalities in MNCH service utilization and child mortality in Addis Ababa highlight the need for greater focus on the city's women and children living in the poorest households and districts in maternal, newborn, and child health programs.

Investing in midwifery for sustainable development goals in low- and middle-income countries: a cost-benefit analysis.

BACKGROUND: Maternal and neonatal mortality in low- and middle-income countries is frequently caused by inadequate management of obstetric and neonatal complications and a shortage of skilled health workers. The availability of these workers is essential for effective and high-quality healthcare. To meet the needs of sexual, reproductive, maternal, new-born, child, and adolescent health by 2030, more than one million health workers, including 900 000 midwives, are required globally. Despite this, uncertainty persists regarding the return on investment in the health workforce. METHODS: The objective of this research was to determine the cost-benefit ratio of increasing investment in midwifery in Morocco from 2021 to 2030. A comparative analysis was conducted between scenarios "with" and "without" the additional investment. The costs and benefits were estimated using relevant data from national and international sources. RESULTS: Following the International Confederation of Midwives' recommendations, it is advised that Morocco recruit 760 midwives annually to achieve 95% of universal health coverage. This increase in midwifery could result in saving 120 593 lives by 2030, including reducing maternal deaths by 3 201, stillbirths by 48 399, and neonatal deaths by 68 993. The estimated economic benefit of investing in midwives was US$ 10 152 287 749, while the total cost was US$ 638 288 820. Consequently, the cost-benefit ratio was calculated as 15.91, indicating that investing in midwifery would provide 16 times more benefits than costs. CONCLUSION: Increasing investment in midwifery appears to be an efficient strategy for achieving comprehensive maternal and child health coverage in low- and middle-income countries.

The infant health effects of doulas: Leveraging big data and machine learning to inform cost-effective targeting.

Doula services represent an underutilized maternal and child health intervention with the potential to improve outcomes through the provision of physical, emotional, and informational support. However, there is limited evidence of the infant health effects of doulas despite well-established connections between maternal and infant health. Moreover, because the availability of doulas is limited and often not covered by insurers, existing evidence leaves unclear if or how doula services should be allocated to achieve the greatest improvements in outcomes. We use unique data and machine learning to develop accurate predictive models of infant health and doula service participation. We then combine these predictive models within the double machine learning method to estimate the effects of doula services. We show that while doula services reduce risk on average, the benefits of doula services increase as the risk of negative infant health outcomes increases. We compare these benefits to the costs of doula services under alternative allocation schemes and show that leveraging the risk predictions dramatically increases the cost effectiveness of doula services. Our results show the potential of big data and novel analytic methods to provide cost-effective support to those at greatest risk of poor outcomes.

Completion of maternal and child health continuum of care and associated factors among women in Gode district, Shebele Zone, Eastern Ethiopia, 2022.

BACKGROUND: The Continuum of care for reproductive, maternal, newborn, and child health includes integrated service delivery for mothers and children from pre-pregnancy to delivery, the immediate postnatal period, and childhood. In Ethiopia, the magnitude of antenatal care, skilled delivery, postnatal care, and immunization for children have shown improvement. Despite this, there was limited research on the percentage of mothers who have completed maternal and child continuum care. OBJECTIVE: To assess the Completion of Maternal and Child Health Continuum of Care and Associated Factors among women in Gode District, Shebele Zone, Eastern Ethiopia ,2022. METHOD: A community-based cross-sectional study design applied from November 1-15, 2022. A stratified sampling method was applied. A woman who had two 14-24 months child preceding the data collection period were included in the study. An interviewer-administered semi-structured questioner had been used for data collection. Data collected by using kobo collect and analyzed using STATA version 17. Both Bivariable and multivariable logistic regression analyses were done. In multivariable analysis, variables having P-values ≤ 0.05 were taken as factors associated with the completion of the maternal and child health continuum of care. RESULT: The Completion of maternal and child continuum of care was 13.5% (10.7-17.0%) in Gode district,2022. Accordingly, Husband occupation (Government employee) [AOR = 2.3, 95%CI 1.2-4.7] and perceived time to reach health facility (less than 30 min) [AOR = 2.96, 95%CI 1.2-7.5] were factors showing significant association with maternal and child health continuum of care among mothers in Gode district, Somali regional State;2022 at P-value ≤ 0.05. CONCLUSION AND RECOMMENDATION: Only 13.5% of mothers in Gode district received all of the recommended maternal and child health services during their pregnancy, childbirth, and postpartum period. The study found that two factors were associated with a higher likelihood of receiving Maternal and child continuum of care: Government employed husband and perceived time to reach a health facility. Governments can play a key role in increasing the maternal and child health continuum of care by investing by making health care facility accessible.

Comparison of Janani Suraksha Yojana (JSY) and augmented Arogya Laxmi scheme (ALS) in improving maternal and child health outcomes in urban settlements of Hyderabad, South India.

BACKGROUND: India accounts for the largest number of global neonatal deaths with around 20 per 1000 live births. To improve the utilization of government services for institutional deliveries, Augmented Arogya Laxmi Scheme (ALS) was launched in Telangana state of southern India. This study assessed the effectiveness of the Janani Suraksha Yojana (JSY), which combines cash assistance with delivery and post-delivery care, in comparison to ALS in improving the outcomes related to antenatal, natal, and postnatal care in urban settlements of Hyderabad, Telangana, southern India. METHODS: This was a two-year cross-sectional study conducted in 14 urban settlements of Hyderabad city from September 2017- August 2019. All mothers delivered during the 18 months preceding the survey were enrolled after a written informed consent. Field investigators collected data on variables related to socio-demographic characteristics, awareness, and utilization of JSY and ALS programs. Variables related to antenatal history, antenatal care, complications during birth, delivery outcomes, newborn care, and postnatal care till 28 days were assessed. We used multivariable logistic regression model to examine the association between the different maternal, child, and socio-demographic characteristics of the two study groups. RESULTS: A total of 926 mothers were beneficiaries of Janani Suraksha Yojana (JSY) program while 933 mothers were beneficiaries of augmented Arogya Laxmi Scheme (ALS). Mothers in ALS group (AOR 1.71; 95% CI 1.21-2.43) were at increased odds of having more than eight antenatal care (ANC) visits compared to the mothers availing JSY. Mothers in ALS group were at decreased odds of having complications like severe pain in the abdomen (AOR 0.43; 95% CI 0.22-0.86), swelling of legs or feet (AOR 0.59; 95% CI 0.44-0.80) compared to mothers in JSY group. Children of mothers in the ALS group had increased odds of receiving breastfeeding within 30 minutes of birth (AOR 1.46; 95% CI 1.13-1.88) compared to children of mothers in JSY group. CONCLUSIONS: The newly launched augmented ALS led to the increased utilization of the government health facilities and improved the maternal and child health outcomes.

Timeliness and quality of peripartum care provision during a health system strengthening initiative in rural Guinea-Bissau: a qualitative situation analysis.

Guinea-Bissau has among the world's highest maternal and perinatal mortality rates. To improve access to quality maternal and child health (MCH) services and thereby reduce mortality, a national health system strengthening initiative has been implemented. However, despite improved coverage of MCH services, perinatal mortality remained high. Using a systems-thinking lens, we conducted a situation analysis to explore factors shaping timeliness and quality of facility-based care during labour, childbirth, and the immediate postpartum period in rural Guinea-Bissau. We implemented in-depth interviews with eight peripartum care providers and participant observations at two health facilities (192 h) in 2021-22, and analysed interview transcripts and field notes using thematic network analysis. While providers considered health facilities as the only reasonable place of birth and promoted facility birth uptake, timeliness and quality of care were severely compromised by geographical, material and human-resource constraints. Providers especially experienced a lack of human resources and materials (e.g., essential medicines, consumables, appropriate equipment), and explained material constraints by discontinued donor supplies. In response, providers applied several adaptation strategies including prescribing materials for private purchase, omitting tests, and delegating tasks to birth companions. Consequences included financial barriers to care, compromised patient and occupational safety, delays, and diffusion of health worker responsibilities. Further, providers explained that in response to persisting access barriers, women conditioned care seeking on their perceived risk of developing birthing complications. Our findings highlight the need for continuous monitoring of factors constraining timeliness and quality of essential MCH services during the implementation of health system strengthening initiatives.

A mixed methods evaluation of the impact of ECHO® telementoring model for capacity building of community health workers in India.

INTRODUCTION: India has the largest cohort of community health workers with one million Accredited Social Health Activists (ASHAs). ASHAs play vital role in providing health education and promoting accessible health care services in the community. Despite their potential to improve the health status of people, they remain largely underutilized because of their limited knowledge and skills. Considering this gap, Extension for Community Healthcare Outcomes (ECHO)® India, in collaboration with the National Health System Resource Centre (NHSRC), implemented a 15-h (over 6 months) refresher training for ASHAs using a telementoring interface. The present study intends to assess the impact of the training program for improving the knowledge and skills of ASHA workers. METHODS: We conducted a pre-post quasi-experimental study using a convergent parallel mixed-method approach. The quantitative survey (n = 490) assessed learning competence, performance, and satisfaction of the ASHAs. In addition to the above, in-depth interviews with ASHAs (n = 12) and key informant interviews with other stakeholders (n = 9) examined the experience and practical applications of the training. Inferences from the quantitative and qualitative approaches were integrated during the reporting stage and presented using an adapted Moore's Expanded Outcomes Framework. RESULTS: There was a statistically significant improvement in learning (p = 0.038) and competence (p = 0.01) after attending the training. Participants were satisfied with the opportunity provided by the teleECHO™ sessions to upgrade their knowledge. However, internet connectivity, duration and number of participants in the sessions were identified as areas that needed improvement for future training programs. An improvement in confidence to communicate more effectively with the community was reported. Positive changes in the attitudes of ASHAs towards patient and community members were also reported after attending the training. The peer-to-peer learning through case-based discussion approach helped ensure that the training was relevant to the needs and work of the ASHAs. CONCLUSIONS: The ECHO Model ™ was found effective in improving and updating the knowledge and skills of ASHAs across different geographies in India. Efforts directed towards knowledge upgradation of ASHAs are crucial for strengthening the health system at the community level. The findings of this study can be used to guide future training programs. Trial registration The study has been registered at the Clinical Trials Registry, India (CTRI/2021/10/037189) dated 08/10/2021.

Influence of sociodemographic and obstetric factors on maternal mortality in Brazil from 2011 to 2021.

BACKGROUND: Obstetric causes are classified as direct (complications of pregnancy, childbirth or the puerperium) or indirect (caused by pregnancy but not directly caused by it). This study aimed to analyze maternal mortality from obstetric causes in Brazil from 2011 to 2021. METHODS: This was an ecological study on mortality and live births. The outcomes were the specific risk of mortality from direct and indirect cause adjustment and death during pregnancy and the puerperium. Binary and multiple linear logistic regressions were used to assess the influence of sociodemographic factors and maternal and child health indicators on maternal mortality and time of death (pregnancy and puerperium). RESULTS: Regarding mortality during pregnancy and during the puerperium, increased (p = 0.003) and decreased (p = 0.004) mortality over the years, respectively; residing in the northern region was associated with lower (p < 0.05) and greater (p = 0.035) odds; and the Maternal Mortality Committee was the primary and least active source of investigation, respectively (p < 0.0001). The number of deaths from indirect causes increased with age (p < 0.001) and in the northern region (p = 0.011) and decreased in the white (< 0.05) and stable union (0.002) regions. Specifically, for mortality risk, the age group [women aged 15-19 years presented an increase in cesarean section (p < 0.001) was greater than that of women who had < 4 antenatal visits (p < 0.001)], education [women who completed high school (8 to 11 years) was greater when they had < 4 prenatal visits (p = 0.018)], and marital status [unmarried women had more than 4 antenatal visits (p < 0.001); cesarean birth (p = 0.010) and < 4 antenatal visits (p = 0.009) were predictors of marriage; and women in a stable union who had < 4 prenatal visits and live births to teenage mothers (p < 0.001) were predictors]. Women who had no education (p = 0.003), were divorced (p = 0.036), had cesarean deliveries (p < 0.012), or lived in the north or northeast (p < 0.008) had higher indirect specific mortality risk. CONCLUSIONS: Sociodemographic factors and maternal and child health indicators were related to different patterns of obstetric mortality. Obstetric mortality varied by region, marital status, race, delivery, prenatal care, and cause of death.

Infant feeding experiences among Indigenous communities in Canada, the United States, Australia, and Aotearoa: a scoping review of the qualitative literature.

BACKGROUND: Although exclusive breastfeeding is recommended for the first six months of life, research suggests that breastfeeding initiation rates and duration among Indigenous communities differ from this recommendation. Qualitative studies point to a variety of factors influencing infant feeding decisions; however, there has been no collective review of this literature published to date. Therefore, the objective of this scoping review was to identify and summarize the qualitative literature regarding Indigenous infant feeding experiences within Canada, the United States, Australia, and Aotearoa. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses- Scoping Reviews and the Joanna Briggs Institute Guidelines, in October 2020, Medline, Embase, CINAHL, PsycINFO, and Scopus were searched for relevant papers focusing on Indigenous infant feeding experiences. Screening and full-text review was completed by two independent reviewers. A grey literature search was also conducted using country-specific Google searches and targeted website searching. The protocol is registered with the Open Science Framework and published in BMJ Open. RESULTS: Forty-six papers from the five databases and grey literature searches were included in the final review and extraction. There were 18 papers from Canada, 11 papers in the US, 9 studies in Australia and 8 studies conducted in Aotearoa. We identified the following themes describing infant feeding experiences through qualitative analysis: colonization, culture and traditionality, social perceptions, family, professional influences, environment, cultural safety, survivance, establishing breastfeeding, autonomy, infant feeding knowledge, and milk substitutes, with family and culture having the most influence on infant feeding experiences based on frequency of themes. CONCLUSIONS: This review highlights key influencers of Indigenous caregivers' infant feeding experiences, which are often situated within complex social and environmental contexts with the role of family and culture as essential in supporting caregivers. There is a need for long-term follow-up studies that partner with communities to support sustainable policy and program changes that support infant and maternal health.

Continuum of care for maternal and child health and child undernutrition in Angola.

BACKGROUND: Continuum of care (CoC) for maternal and child health provides opportunities for mothers and children to improve their nutritional status, but many children remain undernourished in Angola. This study aimed to assess the achievement level of CoC and examine the association between the CoC achievement level and child nutritional status. METHODS: We used nationally representative data from the Angola 2015-2016 Multiple Indicator and Health Survey. Completion of CoC was defined as achieving at least four antenatal care visits (4 + ANC), delivery with a skilled birth attendant (SBA), child vaccination at birth, child postnatal check within 2 months (PNC), and a series of child vaccinations at 2, 4, 6, 9 and 15 months of child age. We included under 5 years old children who were eligible for child vaccination questionnaires and their mothers. The difference in CoC achievement level among different nutritional status were presented using the Kaplan-Meier method and examined using the Log-Lank test. Additionally, the multivariable logistic regression analysis examined the associations between child nutritional status and CoC achievement levels. RESULTS: The prevalence of child stunting, underweight and wasting was 48.3%, 23.2% and 5.9% respectively. The overall CoC completion level was 1.2%. The level of achieving CoC of mother-child pairs was 62.8% for 4 + ANC, 42.2% for SBA, 23.0% for child vaccination at birth, and 6.7% for PNC, and it continued to decline over 15 months. The Log-Lank test showed that there were significant differences in the CoC achievement level between children with no stunting and those with stunting (p < 0.001), those with no underweight and those with underweight (p < 0.001), those with no wasting and those with wasting (p = 0.003), and those with malnutrition and those with a normal nutritional status (p < 0.001). Achieving 4 + ANC (CoC1), 4 + ANC and SBA (CoC 2), and 4 + ANC, SBA, and child vaccination at birth (CoC 3) were associated with reduction in child stunting and underweight. CONCLUSIONS: The completion of CoC is low in Angola and many children miss their opportunity of nutritional intervention. According to our result, improving care utilization and its continuity could improve child nutritional status.

Increasing the uptake of Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP) through seasonal malaria chemoprevention channel delivery: protocol of a multicenter cluster randomized implementation trial in Mali and Burkina Faso.

BACKGROUND: The uptake of Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP) remains unacceptably low, with more than two-thirds of pregnant women in sub-Saharan Africa still not accessing the three or more doses recommended by the World Health Organisation (WHO). In contrast, the coverage of Seasonal Malaria Chemoprevention (SMC), a more recent strategy recommended by the WHO for malaria prevention in children under five years living in Sahelian countries with seasonal transmission, including Mali and Burkina-Faso, is high (up to 90%). We hypothesized that IPTp-SP delivery to pregnant women through SMC alongside antenatal care (ANC) will increase IPTp-SP coverage, boost ANC attendance, and increase public health impact. This protocol describes the approach to assess acceptability, feasibility, effectiveness, and cost-effectiveness of the integrated strategy. METHODS AND ANALYSIS: This is a multicentre, cluster-randomized, implementation trial of IPTp-SP delivery through ANC + SMC vs ANC alone in 40 health facilities and their catchment populations (20 clusters per arm). The intervention will consist of monthly administration of IPTp-SP through four monthly rounds of SMC during the malaria transmission season (July to October), for two consecutive years. Effectiveness of the strategy to increase coverage of three or more doses of IPTp-SP (IPTp3 +) will be assessed using household surveys and ANC exit interviews. Statistical analysis of IPT3 + and four or more ANC uptake will use a generalized linear mixed model. Feasibility and acceptability will be assessed through in-depth interviews and focus group discussions with health workers, pregnant women, and women with a child < 12 months. DISCUSSION: This multicentre cluster randomized implementation trial powered to detect a 45% and 22% increase in IPTp-SP3 + uptake in Mali and Burkina-Faso, respectively, will generate evidence on the feasibility, acceptability, effectiveness, and cost-effectiveness of IPTp-SP delivered through the ANC + SMC channel. The intervention is designed to facilitate scalability and translation into policy by leveraging existing resources, while strengthening local capacities in research, health, and community institutions. Findings will inform the local national malaria control policies. TRIAL REGISTRATION: Retrospectively registered on August 11th, 2022; registration # PACTR202208844472053. Protocol v4.0 dated September 04, 2023. Trail sponsor: University of Sciences Techniques and Technologies of Bamako (USTTB), Mali.

Lessons from Peru to reduce under-5 mortality: understanding program implementation and context.

BACKGROUND: Health policymakers aiming to reduce under-5 mortality (U5M) often lack data regarding how successful interventions in other countries were implemented. The Exemplars in U5M Study identified countries that achieved significant reductions in amenable U5M. This case study in Peru used implementation research to explore the contextual factors and strategies that contributed to the successful implementation of key evidence-based interventions (EBIs). METHODS: This research utilized a hybrid implementation research framework and a mixed-methods approach to understand the factors associated with EBI implementation and the successful reduction of U5M between 2000-2015. A desk review of existing literature on EBIs and U5M in Peru was completed, and in-depth interviews were performed with key Peruvian informants to understand the implementation strategies employed and the contextual factors that facilitated or were barriers to success. For the purposes of this analysis, three EBIs were selected and evaluated: antenatal care visits (ANC), facility-based deliveries, and infant vaccination. RESULTS: Between 2000-2015, the percent of mothers attending at least four antenatal care visits rose from 69% to 96.9%, and the percent of facility-based deliveries increased from 56 to 91%. Three doses of the tetanus/diphtheria/pertussis vaccine, widely acknowledged as a key global health indicator, reached 90% by 2015. Key informants noted that economic growth, financial reforms, strong national commitment to reduce poverty in Peru, and national prioritization of maternal and child health, were important contextual factors that contributed to the successful reduction of U5M. They noted key strategies that helped achieve success during the implementation of EBIs, including utilization of data for decision-making, adaptation driven by cultural sensitivity to address gaps in coverage, and a focus on equity and anti-poverty initiatives with the participation of government, civil society, and political parties to assure continuity of policies. CONCLUSION: Several EBIs contributed to the successful reduction of U5M in Peru between 2000-2015. Strategies such as the focus on equity throughout the study period contributed to an increase in coverage of EBIs like ANC visits, facility-based deliveries and infant vaccination which worked to reduce U5M. Understanding how Peru successfully implemented programs that reduced preventable infant and child deaths could be useful to replicating this substantial public health success in other low- and middle-income countries.

Understanding rapid implementation from discovery to scale: Rwanda's implementation of rotavirus vaccines and PMTCT in the quest to reduce under-5 mortality.

BACKGROUND: Over the last eight decades, many evidence-based interventions (EBIs) have been developed to reduce amenable under-5 mortality (U5M). Implementation research can help reduce the lag between discovery and delivery, including as new EBIs emerge, or as existing ones are adapted based on new research. Rwanda was the first low-income African country to implement the rotavirus vaccine (RTV) and also adopted Option B+ for effective prevention of mother-to-child transmission (PMTCT) before the World Health Organization's (WHO) recommendation. We use implementation research to identify contextual factors and strategies associated with Rwanda's rapid uptake of these two EBIs developed or adapted during the study period. METHODS: We conducted a mixed methods case study informed by a hybrid implementation research framework to understand how Rwanda outperformed regional and economic peers in reducing U5M, focusing on the implementation of health system-delivered EBIs. The research included review of existing literature and data, and key informant interviews to identify implementation strategies and contextual factors that influenced implementation outcomes. We extracted relevant results from the broader case study and used convergent methods to understand successes and challenges of implementation of RTV, a newly introduced EBI, and PMTCT, an adapted EBI reflecting new research. RESULTS: We found several cross-cutting strategies that supported the rapid uptake and implementation of PMTCT, RTV, and leveraging facilitating contextual factors and identifying and addressing challenging ones. Key implementation strategies included community and stakeholder involvement and education, leveraging of in-country research capacity to drive adoption and adaptation, coordination of donors and implementing partners, data audit and feedback of coverage, a focus on equity, and integration into pre-existing systems, including community health workers and primary care. The availability of donor funding, culture of evidence-based decision-making, preexisting accountability systems, and rapid adoption of innovation were facilitating contextual factors. CONCLUSION: Implementation strategies which are generalizable to other settings were key to success in rapidly achieving high acceptability and coverage of both a new and an evolving EBI. Choosing strategies which leverage their facilitating factors and address barriers are important for other countries working to accelerate uptake of new EBIs and implement needed adaptations based on emerging evidence.

Association between obtaining injury prevention information and maternal and child health services during COVID-19.

BACKGROUND: Coronavirus disease 2019 disrupted the delivery of public maternal and child health services to caregivers of preschool children, leading to decreased opportunities for injury prevention education. We aim to 1) explore the timing, content, and methods of providing injury prevention information desired by pregnant women and mothers and 2) identify mothers who experienced difficulty in obtaining injury prevention information owing to reduced maternal and child health services. METHODS: From March 24 to 29, 2022, we conducted a population-based cross-sectional study and web-based survey. Of the registered monitors of the internet research company Rakuten Insight, 675 mothers raising their first child aged 0-2 during the COVID-19 period (February 2020 to March 2022) were included in the analysis. RESULTS: Over half of the mothers wanted injury prevention information throughout their pregnancy. They preferred receiving information through traditional face-to-face services provided by local governments, such as antenatal classes or checkups. However, 34.1% of mothers said they did not obtain the information they needed; this was particularly true of unemployed mothers, had children aged 0-1, and had children with illnesses requiring hospital visits. CONCLUSIONS: Mothers who could not obtain injury prevention information were originally disadvantaged mothers concerning access to information. The decrease in maternal and child health services may have widened this information gap. These findings can inform recommendations for caregivers, particularly those susceptible to information gaps during emergencies, and offer insights into future injury prevention education strategies.

Implementation outcomes of the integrated district evidence to action (IDEAs) program to reduce neonatal mortality in central Mozambique: an application of the RE-AIM evaluation framework.

BACKGROUND: Scarce evidence exists on audit and feedback implementation processes in low-resource health systems. The Integrated District Evidence to Action (IDEAs) is a multi-component audit and feedback strategy designed to improve the implementation of maternal and child guidelines in Mozambique. We report IDEAs implementation outcomes. METHODS: IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces between 2016 and 2020 and evaluated using a quasi-experimental design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Reach is the proportion of pregnant women attending IDEAs facilities. Adoption is the proportion of facilities initiating audit and feedback meetings. Implementation is the fidelity to the strategy components, including readiness assessments, meetings (frequency, participation, action plan development), and targeted financial support and supervision. Maintenance is the sustainment at 12, 24, and 54 months. RESULTS: Across both provinces, 56% of facilities were exposed to IDEAs (target 57%). Sixty-nine and 73% of pregnant women attended those facilities' first and fourth antenatal consultations (target 70%). All facilities adopted the intervention. 99% of the expected meetings occurred with an average interval of 5.9 out of 6 months. Participation of maternal and child managers was high, with 3076 attending meetings, of which 64% were from the facility, 29% from the district, and 7% from the province level. 97% of expected action plans were created, and 41 specific problems were identified. "Weak diagnosis or management of obstetric complications" was identified as the main problem, and "actions to reinforce norms and protocols" was the dominant subcategory of micro-interventions selected. Fidelity to semiannual readiness assessments was low (52% of expected facilities), and in completing micro-interventions (17% were completed). Ninety-six and 95% of facilities sustained the intervention at 12 and 24 months, respectively, and 71% had completed nine cycles at 54 months. CONCLUSION: Maternal and child managers can lead audit and feedback processes in primary health care in Mozambique with high reach, adoption, and maintenance. The IDEAs strategy should be adapted to promote higher fidelity around implementing action plans and conducting readiness assessments. Adding effectiveness to these findings will help to inform strategy scale-up.

Recognizing Excellence in Maternal and Child Health (MCH) Epidemiology: The National MCH Epidemiology Awards.

PURPOSE: Professionals in the field of maternal and child health (MCH) epidemiology are publicly recognized by the Coalition for Excellence in MCH Epidemiology representing 16 national MCH agencies and organizations. DESCRIPTION: During the CityMatCH Leadership and MCH Epidemiology Conference, the national awards are presented to public health professionals for improving the health of women, children, and families. The awards have evolved over the last two decades with focus on awardees that represent more types of MCH public health professionals. ASSESSMENT: Since 2000, the Coalition has presented 111 national awards in the areas of advancing knowledge, effective practice, outstanding leadership, excellence in teaching and mentoring, early career professional achievement, and lifetime achievement. Effective practice awards were most often presented at 45 awards, followed by early career professional achievement with 20. The awardees varied by place of employment with 37 employed at academic institutions, 33 in federal government positions, 32 in state or county government, seven in non-profit and two in clinical organizations. Awards were almost equally distributed by gender with 49 presented to women and 48 to men. Assessment of career advancement among previous awardees and acknowledging workforce challenges are gaps identified within the national awards process. CONCLUSION: Recognition of deserving MCH professionals sets the standard for those entering the field of MCH epidemiology and offers opportunity to recognize those who have built capacity and improved the health of women, children, and families.