Community-Based Care to Improve Maternal, Newborn, and Child Health

Reproductive, maternal, newborn, and child health (RMNCH) has been a priority for both governments and civil society in low- and middle-income countries (LMICs). This priority was affirmed by world leaders in the Millennium Development Goals (MDGs) that called for countries to reduce child mortality by 67 percent and maternal mortality by 75 percent between 1990 and 2015. Although substantial progress on these targets has been made, few countries achieved the needed reductions. The United Nations (UN) Secretary-General’s Global Strategy for Women’s and Children’s Health, launched in 2010 and expanded in 2015 to include adolescents, is an indication of the continued global commitment to the survival and well-being of women and children (Ban 2010). Annual official development assistance for maternal, newborn, and child health has increased from US$2.7 billion in 2003 to US$8.3 billion in 2012, when there was an additional US$4.5 billion for reproductive health (Arregoces and others 2015). A continued focus on RMNCH is needed to address the remaining considerable burden of disease in LMICs from unwanted pregnancies; high maternal, newborn, and child mortality and stillbirths; high rates of undernutrition; frequent communicable and noncommunicable diseases; and loss of human capacity. Cost-effective interventions are available and can be implemented at high coverage in LMICs to greatly reduce these problems at an affordable cost.RMNCH encompasses health problems across the life course from adolescent girls and women before and during pregnancy and delivery, to newborns and children. An important conceptual framework is the continuum-of-care approach in two dimensions. One dimension recognizes the links from mother to child and the need for health services across the stages of the life course. The other is the delivery of integrated preventive and therapeutic health interventions through service platforms ranging from the community to the primary health center and the hospital.This volume presents the levels and trends of RMNCH indicators, proven interventions for prevention of mortality, costs of these interventions and potential health service delivery platforms, and system innovations. Other volumes in the third edition of Disease Control Priorities also cover topics of importance to women and children that are related to the RMNCH health services packages (box 1.1). These topics include the following:

Reducing Maternal and Perinatal Mortality Through a Community Collaborative Approach: Introduction to a Special Issue on the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP)

Editors' choice.

Post-2015 health goals: could country-specific targets supplement global ones?

Petra ten Hoope-Bender: a “midwife's midwife”

World Prematurity Day: improving survival and quality of life for millions of babies born preterm around the world

Overall this important area of quality of care will clearly require more research to be fully understood. Better quality monitoring tools also need to be developed with a focus on labour and labour outcome prediction. Meanwhile to complement Kruk and colleagues’ research efforts smaller facilities need to be better equipped with both the requisite and trained human resources for health care as well as with other inputs that are essential to quality provision of EmONC services. (Excerpt) Copyright © The Author(s). Published by Elsevier Ltd. Open Access.

While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions such as tetanus toxoid immunisation to mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; clean umbilical cord care; management of infections in newborns, many require facility based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packages interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care. To assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes. We searched The Cochrane Pregnancy and Childbirth Group's Trials Register (January 2010), World Bank's JOLIS (12 January 2010), BLDS at IDS and IDEAS database of unpublished working papers (12 January 2010), Google and Google Scholar (12 January 2010). All prospective randomised and quasi-experimental trials evaluating the effectiveness of community-based intervention packages in reducing maternal and neonatal mortality and morbidities; and improving neonatal outcomes. Two review authors independently assessed trial quality and extracted the data. The review included 18 cluster-randomised/quasi-randomised trials, covering a wide range of interventional packages, including two subsets from one trial. We incorporated data from these trials using generic inverse variance method in which logarithms of risk ratio estimates were used along with the standard error of the logarithms of risk ratio estimates. Our review did not show any reduction in maternal mortality (risk ratio (RR) 0.77; 95% confidence interval (CI) 0.59 to 1.02, random-effects (10 studies, n = 144,956), I² 39%, P value 0.10. However, significant reduction was observed in maternal morbidity (RR 0.75; 95% CI 0.61 to 0.92, random-effects (four studies, n = 138,290), I² 28%; neonatal mortality (RR 0.76; 95% CI 0.68 to 0.84, random-effects (12 studies, n = 136,425), I² 69%, P value < 0.001), stillbirths (RR 0.84; 95% CI 0.74 to 0.97, random-effects (11studies, n = 113,821), I² 66%, P value 0.001) and perinatal mortality (RR 0.80; 95% CI 0.71 to 0.91, random-effects (10 studies, n = 110,291), I² 82%, P value < 0.001) as a consequence of implementation of community-based interventional care packages. It also increased the referrals to health facility for pregnancy related complication by 40% (RR 1.40; 95% CI 1.19 to 1.65, fixed-effect (two studies, n = 22,800), I² 0%, P value 0.76), and improved the rates of early breastfeeding by 94% (RR 1.94; 95% CI 1.56 to 2.42, random-effects (six studies, n = 20,627), I² 97%, P value < 0.001). We assessed our primary outcomes for publication bias, but observed no such asymmetry on the funnel plot. Our review offers encouraging evidence of the value of integrating maternal and newborn care in community settings through a range of interventions which can be packaged effectively for delivery through a range of community health workers and health promotion groups. While the importance of skilled delivery and facility-based services for maternal and newborn care cannot be denied, there is sufficient evidence to scale up community-based care through packages which can be delivered by a range of community-based workers.

Developmental potential is the ability to think, learn, remember, relate, and articulate ideas appropriate to age and level of maturity, and an estimated 39 percent of the world’s children under age five years do not attain this potential (Grantham-McGregor and others 2007).The main reason for giving prominent attention to mental development from conception through the first 24 months of life is that early unfavorable conditions can impair the normal development of the brain. The impairment is often incremental and unnoticed until schooling begins. The most striking example of impairment is the gradual deletion of unused brain synapses. The lack of use may be due to the absence of stimulation in the family environment or lack of available energy for brain activity. Regenerating those lost synapses may occur at an older age but with additional costs. For example, children who do not acquire a good vocabulary in the early years will have difficulty learning how to read; children who do not acquire simple problem-solving strategies in the first 24 months will have difficulty understanding math concepts; children who do not develop secure emotional attachments to adults will have difficulty coping with stresses and challenges throughout life. The plasticity of the brain diminishes with age, but greater plasticity in the very early years suggests that brain development has a greater chance of being modified by protective interventions than by interventions later in life (Werker and Hensch 2015).A second reason for attending to early mental development is that individuals, communities, and societies are healthier and more productive if they have mature mental skills. More educated adults are healthier and wealthier than less educated adults. Educated mothers have healthier children and are more likely to recognize symptoms of illness, follow medical advice, feed their children nutritious foods, and keep their homes clean (Boyle and others 2006; Cleland and van Ginneken 1988). Educated husbands are less likely to condone or use violence to resolve domestic conflicts (Abraham and others 2006). Follow-up data of adults who participated in early psychosocial stimulation programs demonstrate some of these long-term benefits (Gertler and others 2014).This chapter discusses mental development from birth to age 24 months in low- and middle-income countries (LMICs). We include recent literature published since the 2011 child development series in The Lancet. Although we focus on cognitive and language domains, we touch on socioemotional, fine motor, and gross motor development. First, a description of how these domains are measured provides an operational definition of the term mental development. Second, conditions that derail early child development are examined. These conditions arise during the prenatal period and continue throughout the next 24 months; they include psychosocial stimulation, prenatal and postnatal nutrition, the physical environment, and maternal mental health. Finally, the results of several systematic reviews and meta-analyses are presented to show the effects of stimulation and nutrition, along with disease-related interventions to promote mental development. Maternal interventions related to nutrition and mental health are also reviewed. A framework of critical components to include in programs is outlined.

Background While maternal, infant and under-five child mortality rates in developing countries have declined significantly in the past two to three decades, newborn mortality rates have reduced much more slowly. While it is recognised that almost half of the newborn deaths can be prevented by scaling up evidence-based available interventions such as tetanus toxoid immunisation to mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; clean umbilical cord care; management of infections in newborns, many require facility based and outreach services. It has also been stated that a significant proportion of these mortalities and morbidities could also be potentially addressed by developing community-based packages interventions which should also be supplemented by developing and strengthening linkages with the local health systems. Some of the recent community-based studies of interventions targeting women of reproductive age have shown variable impacts on maternal outcomes and hence it is uncertain if these strategies have consistent benefit across the continuum of maternal and newborn care. The objective of this review is to assess the effectiveness of community-based intervention packages in reducing maternal and neonatal morbidity and mortality; and improving neonatal outcomes.

Background: Maternal and neonatal mortality is high in south Asia. Adolescent female fertility and healthcare spending are an important factor to reduce maternal and neonatal mortality. Objectives: The main objective of this study was used to examine the effect of adolescent female fertility and healthcare spending on maternal and neonatal mortality in south Asian countries. Methods: Using a retrospective panel study design, a total of 8 south Asian countries data from world development indicator 1990-2017 were analyzed. Descriptive statistics is used for summary measure and fixed and random effect regression using multiple imputations estimated with relevant variables of adolescent female fertility, healthcare spending, physician, and adult female literacy rate. Findings: Increasing adolescent female fertility significantly positive effect on neonatal and maternal mortality. We found neonatal and maternal mortality are more likely to decrease depends on healthcare spending. A change in the healthcare spending has a significantly negative effect on neonatal mortality (-0.125, 95% CI: [-0.208 to -.042; P-value < 0.001), that is one percent increases in healthcare spending should decrease by 0.125 neonatal mortality and maternal mortality by 0.163 (95% CI: [-0.301 to -0.026]; P-value < 0.001). Conclusions: Maternal and neonatal mortality could reduce through increase of healthcare spending and decreasing of adolescent female fertility in south Asian countries. Expansion of maternal and new-born health programs should consider that decreasing female fertility and increasing healthcare spending has potential to improve maternal and neonatal health.

Building resilient societies after COVID-19: the case for investing in maternal, neonatal, and child health

Supplement1 December 2020Looking Outward to Look Within: The Health Resources and Services Administration Maternal Mortality Summit, and What It Means for Women EverywhereFREEDoris Chou, MDDoris Chou, MDUNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Geneva, Switzerland (D.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3259 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In 2015, when world leaders approved and became signatories to the Sustainable Development Goals 2015–2030 (SDG) Framework, a critical nuance was noted (1). Unlike the Millennium Development Goals, which focused on improving the status of lower-resourced countries between 1990 and 2015, this global pact intends for all countries, regardless of resource level, to collectively contribute to the global agenda. High-, middle-, and low-income countries alike are expected to report on and improve their populations' and countries' status across 17 goals as measured by targets with more than 200 indicators (2).In that framework, SDG 3.1/3.2 assesses the state of maternal and child health services and outcomes (2). As a vital barometer of any health system, SDG 3.1/3.2 asks whether a country can sustain itself by ensuring its future: the lives of women and their newborns. Unfortunately, the promise of the future often goes unfulfilled. In the United States, it is estimated that 2 women die every 3 days because of pregnancy (3–5). The absolute numbers may appear to be small, but any maternal death is unacceptable.To address this issue, the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services convened the HRSA Maternal Mortality Summit in June 2018. The purpose of the summit was to "discuss evidence-based approaches and identify innovative solutions to decreasing maternal mortality and morbidity rates in the U.S. and globally" (6). Participants included U.S. domestic experts as well as those from Brazil, Canada, Finland, India, Rwanda, and the United Kingdom.Although at first glance the experiences of Canada, Finland, and the United Kingdom are natural comparisons, U.S.-based practitioners readily found commonalities among all the shared experiences in the root causes of ill maternal health. Before the summit, it is unlikely that the general U.S. public would spontaneously identify with maternal health experiences from Brazil, India, and Rwanda. However, many of the participants found resonance in the discourse around the effects of nutrition, education, and social and cultural forces that shape care-seeking and implementation of medical advice (issues of access, accessibility, and acceptance). Above all, constructs of ethnicity, race, social status, and "women's agency and autonomy" amplified throughout the country-led discussions. The same themes could be found both between countries and across U.S. states.During the summit, countries shared openly on the challenges of measuring and documenting maternal deaths. All countries discussed the limitations of any one measurement system to accurately capture all the maternal deaths as it directly affects the ability of programs and efforts made by countries to address the causes of maternal death (and morbidity). The discussants shared how shifting demographics, social determinants, and risk factors could result in inequities, which often contributed to maternal morbidity and deaths.Nevertheless, maternal ill health is preventable. A positive pregnancy brings benefits not only to the individual, but also to her community, society, and country. Sweeping and long-standing changes do not come easily; there is no single "magic bullet." Concerted and transparent efforts are needed to change the rhetoric from "It's not my/our problem" to asking the difficult questions of "Why does maternal ill health occur?" and "How can we move forward?" by focusing on what can be done rather than focusing on what cannot.The World Health Organization (WHO) works worldwide to promote health, keep the world safe, and serve vulnerable persons. With partners, the WHO developed the Ending Preventable Maternal Mortality (EPMM) initiative to support countries as they determine the processes to assure appropriate resource allocation to strengthen health systems and enable them to move toward universal health coverage for all who are in need, with the aim of improving maternal and newborn health (7). Integrating EPMM principles and strategies enables countries to realize improved maternal health by prioritizing country leadership and supportive legal, regulatory, and financial mechanisms and integrating maternal and newborn health care to preserve the mother–baby dyad (7). The EPMM initiative calls for a human rights framework to ensure that high-quality sexual, reproductive, maternal, and newborn health care is accessible and available to all who need it and for the empowerment of women, girls, families, and communities (7).Focusing the EPMM lens on the United States, the HRSA summit highlighted essential areas to address. These include general health among women and the effects of inequities and disparities. Additional concerns are the availability of a robust health workforce and the relevant policies and financial implications that drive the overall U.S. health agenda. Readers of this supplement will find thoughtful consideration of these themes and articulation of some of the efforts undertaken to address American maternal mortality and morbidity.The first article provides a narrative landscape review of U.S. maternal health epidemiology (8). The robust series of papers that follow distill the U.S context of racial/ethnic, socioeconomic, and geographic disparities in the care and health outcomes of reproductive-aged women (9–11) and consider the availability of timely access to skilled health personnel and high-quality care, which provide opportunities for prevention and intervention (10–12). Finally, changes in care for mothers of the sickest newborns (13) and maternal comorbid conditions (14, 15) provide concrete strategies to improve health outcomes.Within HRSA sits the Maternal and Child Health Bureau, whose mission is to "improve the health of America's mothers, children, and families" (16). With the summit and this supplement, the HRSA and the United States have taken a step toward ensuring that maternal health is a priority both domestically and internationally. The global community welcomes the continuation and development of this initiative from the landmark meeting.Maternal mortality remains a scourge for every country. Although it can strike any woman, anywhere, fundamentally some predictable patterns can be addressed, with the result that fewer women will die during pregnancy and childbirth. Multilateral sharing and learning from mutual experiences provide potential paths forward in order to reach the collective SDG maternal mortality goal of a global maternal mortality ratio of less than 70 deaths per 100 000 live births (2, 7).

Women Deliver post–2015

Addressing Gaps in Maternal, Neonatal, and Child Health for Achieving SDG 2030 in West Africa.