Abstract
Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3–31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1–4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.
Highlights
In 2018, 2.5 million babies died in the 1st month of life, with most of these deaths occurring in the least developed countries and about a third occurring on the day of birth (UNICEF et al, 2019)
We have reported results of the review according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with the PRISMA flow diagram presented in Figure 1 and the PRISMA checklist in the Supplementary file
We were not able to show an association between implementation strategies and coverage of essential newborn care (ENC) it has been shown in other contexts
Summary
In 2018, 2.5 million babies died in the 1st month of life, with most of these deaths occurring in the least developed countries and about a third occurring on the day of birth (UNICEF et al, 2019). Evidence on effective methods for integration of newborn care into health systems in the low-income country context is lacking, limiting opportunities for learning—as we only know if something works and not why, how or for whom (Darmstadt et al, 2014). Well-established evidence of intervention efficacy has not translated to high coverage in low- and middle-income countries (LMICs) (The World Bank, 2019). This knowledge-to-practice gap is consistent with findings across other public health domains, where translation of research evidence to practice is slow and haphazard, and has cost lives (Eccles et al, 2009). The World Health Organization (WHO, 2013) has identified evaluating the effectiveness of different strategies to implement postnatal care recommendations as a high-priority research gap. A recent publication has called for an increase in implementation research in global health to improve health outcomes and bridge the gap among research, policy and practice (Theobald et al, 2018)
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