Reverse innovation - South to North learnings in the provision of postpartum contraception: implementation in a high-income setting.

Despite the benefits of healthy birth spacing for mothers and infants, the use of postpartum family planning (PPFP) by women in India remains low. We qualitatively examined barriers to PPFP access and use to understand the intersections between women's reproductive agency, fertility and contraceptive norms, and community interactions with health providers in rural Maharashtra, India. We conducted 62 qualitative in-depth interviews with postpartum women, husbands and mothers-in-law of postpartum women, frontline health workers (FLWs) and key community stakeholders in rural Maharashtra from March to May 2022. Semi-structured interview guides included probes related to knowledge of and access to PPFP services, contraceptive decision-making dynamics, interactions with health providers, community norms related to fertility and family planning, and existing and aspirational models for PPFP service delivery. We used an inductive approach to organize emerging codes into themes using Bronfenbrenner's Ecological Systems Theory, categorizing findings into a thematic framework to inform PPFP programming. Five key themes emerged: (1) Few women received PPFP counseling or services, with marginalized communities disproportionately affected by poor access. (2) Postpartum women lacked agency in contraceptive decision-making and often needed their husband's approval to access PPFP services. (3) Clinicians identified misinformation, lack of education, and community beliefs in contraceptive myths for lack of informed choice. (4) While norms for limiting family size were strong, contraception was considered a 'sensitive' subject and sparked concerns regarding confidentiality in discussing PPFP. (5) Community reported that counseling services were prescriptive and lacked information on the side effects of contraception, leading to the perception of low-quality care and dissatisfaction with PPFP health services. There is an urgent need to enhance PPFP counseling and service provision within family planning programs in India, emphasize reproductive choice among women, broaden the public dialogue on contraceptive use and find ways to engage men in contraceptive decision making. Interventions that can enhance knowledge and change acceptability of contraception in the community will enhance informed choice for contraceptive use among couples as well as PPFP access and use.

How much is dementia care worth?

BackgroundFamily planning services in the post-partum period, termed post-partum family planning (PPFP) is critical to cover the unmet need for contraception, especially when institutional delivery rates have increased. However, the intention to choose PPFP methods such as post-partum intrauterine devices (PPIUD) remains low in countries such as Nepal. Community health workers such as Female Community Health Volunteers (FCHVs) could play an important role in improving the service coverage of PPFP in Nepal. However, their knowledge of PPFP and community-based services related to PPFP remain unclear. This study aims to assess the effect on community-based PPFP services by improving FCHV’s knowledge through orientation on PPFP.MethodsWe conducted this mixed-methods study in Morang District in Nepal. The intervention involved orientation of FCHVs on PPFP methods. We collected quantitative data from three sources; via a survey of FCHVs that assessed their knowledge before and after the intervention, from their monthly reporting forms on counseling coverage of women at different stages of pregnancy from the communities, and by interviewing mothers in their immediate post-partum period in two selected hospitals. We also conducted six focus group discussions with the FCHVs to understand their perception of PPFP and the intervention. We performed descriptive and multivariable analyses for quantitative results and thematic analysis for qualitative data.ResultsIn total, 230 FCHVs participated in the intervention and their knowledge of PPFP improved significantly after it. The intervention was the only factor significantly associated with their improved knowledge (adjusted odds ratio = 24, P < 0.001) in the multivariable analysis. FCHVs were able to counsel 83.3% of 1872 mothers at different stages of pregnancy in the communities. In the two hospitals, the proportion of mothers in their immediate post-partum period whom reported they were counseled by FCHVs during their pregnancy increased. It improved from 7% before the intervention to 18.1% (P < 0.001) after the intervention. The qualitative findings suggested that the intervention improved their knowledge in providing PPFP counseling.ConclusionThe orientation improved the FCHV’s knowledge of PPFP and their community-based counseling. Follow-up studies are needed to assess the longer term effect of the FCHV’s role in improving community-based PPFP services.

‘Reverse innovation,’ a principle well established in the business world, describes the flow of ideas from emerging to more developed economies. There is strong and growing interest in applying this concept to health care, yet there is currently no framework for describing the stages of reverse innovation or identifying opportunities to accelerate the development process. This paper combines the business concept of reverse innovation with diffusion of innovation theory to propose a model for reverse innovation as a way to innovate in health care. Our model includes the following steps: (1) identifying a problem common to lower- and higher-income countries; (2) innovation and spread in the low-income country (LIC); (3) crossover to the higher-income country (HIC); and (4) innovation and spread in the HIC. The crucial populations in this pathway, drawing from diffusion of innovation theory, are LIC innovators, LIC early adopters, and HIC innovators. We illustrate the model with three examples of current reverse innovations. We then propose four sets of specific actions that forward-looking policymakers, entrepreneurs, health system leaders, and researchers may take to accelerate the movement of promising solutions through the reverse innovation pipeline: (1) identify high-priority problems shared by HICs and LICs; (2) create slack for change, especially for LIC innovators, LIC early adopters, and HIC innovators; (3) create spannable social distances between LIC early adopters and HIC innovators; and (4) measure reverse innovation activity globally.

Reverse innovation in global health systems: towards global innovation flow

The term “reverse innovation”, also known as “trickle-up innovation” is being popularized since 2010 with an initial focus on corporate development and economics. In brief, reverse innovation refers to new ideas and solutions adopted and tested in low- and middle-income countries (LMICs), which subsequently spread to high-income countries (HICs). Reverse innovation very much applies to public health and wellbeing; indeed, a model for reverse innovation in global health has been proposed. Experience and lessons from reverse innovation in global health suggest system-wide benefits that arise from partnerships between LMICs and HICs. Further examples of reverse innovation in global health focus on integrated approaches to health and demonstrate potential for HICs. Intercultural and multilanguage competence are central elements for global partnerships to leverage reverse innovation as global innovation. Existing global product development partnerships have a high potential and should be expanded as platforms of global innovation hubs in health.

BackgroundThe World Health Organization recommends that a woman waits at least 24 months after a live birth before getting pregnant again; however, an estimated 25% of birth intervals in low-income countries do not meet this recommendation for adequate birth spacing, and the unmet need for postpartum family planning (PPFP) services is high. Few randomized controlled trials have assessed the causal impact of access to PPFP services, and even fewer evaluations have investigated how such interventions may affect postpartum contraceptive use, birth spacing, and measures of health and well-being.ObjectiveThis protocol paper aims to describe a randomized controlled trial that is being conducted to identify the causal impact of an intervention to improve access to PPFP services on contraceptive use, pregnancy, and birth spacing in urban Malawi. The causal effect of the intervention will be determined by comparing outcomes for respondents who are randomly assigned to an intervention arm against outcomes for respondents who are randomly assigned to a control arm.MethodsMarried women aged 18-35 years who were either pregnant or had recently given birth were randomly assigned to either the intervention arm or control arm. Women assigned to the intervention arm received a package of services over a 2-year intervention period. Services included a brochure and up to 6 home visits from trained family planning counselors; free transportation to a high-quality family planning clinic; and financial reimbursement for family planning services, consultations, and referrals for services. Two follow-up surveys were conducted 1 and 2 years after the baseline survey.ResultsA total of 2143 women were randomly assigned to either the intervention arm (n=1026) or the control arm (n=1117). Data collection for the first follow-up survey began in August 2017 and was completed in February 2018. A total of 1773 women, or 82.73% of women who were eligible for follow-up, were successfully contacted and reinterviewed at the first follow-up. Data collection for the second follow-up survey began in August 2018 and was completed in February 2019. A total of 1669 women, or 77.88% of women who were eligible for follow-up, were successfully contacted and reinterviewed at the second follow-up. The analysis of the primary outcomes is ongoing and is expected to be completed in 2021.ConclusionsThe results of this trial seek to fill the current knowledge gaps in the effectiveness of family planning interventions on improving fertility and health outcomes. The findings also show that the benefits of improving access to family planning are likely to extend beyond the fertility and health domain by improving other measures of women’s well-being.Trial RegistrationAmerican Economics Association Registry Trial Number AEARCTR-0000697; https://www.socialscienceregistry.org/trials/697 Registry for International Development Impact Evaluations (RIDIE) Trial Number RIDIE-STUDY-ID-556784ed86956; https://ridie.3ieimpact.org/index.php?r=search/detailView&id=320International Registered Report Identifier (IRRID)DERR1-10.2196/16697

Background Maternal and infant deaths can be prevented through integrated service delivery during pregnancy, postpartum, and early childhood. Our study analyses the gaps and opportunities associated with integrating maternal, newborn, and child health (MNCH) services with postpartum family planning (PPFP) and nutrition services at different points of contact in health facilities in a preintervention context in west Africa. Methods We conducted a qualitative study from June to July 2018 in Burkina Faso, Côte d’Ivoire and Niger. The points of contact studied at the health facility level were the prenatal care, postpartum care and immunisation/growth monitoring services. Individual in-depth interviews were used to collect data from key informants (providers, community health workers and mother-child health programme managers). To measure the degree of service integration, we used the dimensions and indicators included in the Integra Initiative framework concerning four aspects of integration: physical (the availability of multiple services in the health facility), temporal (the availability of care more than one day per week), provider level, and functional (the receipt of integrated services by the client). Results The findings of this study show that the integrated delivery of MNCH, PPFP, and nutrition services is configured in similar ways in Burkina Faso, Côte d’Ivoire and Niger and is insufficient at all points of contact. Physical integration is high. However, the study found important gaps in temporal, functional and provider-level integration. The main barriers to integrated service delivery are the shortage of providers, the lack of training in integrated service delivery, and insufficient service organisation. However, the availability of multiple services throughout the week, the multiple points of contact between the mother-child pair and the health system, and the multiple skills of providers represent opportunities for functional integration through the establishment of a formal referral system between the different care units with follow-up and feedback among service providers. Conclusions The provision of training and the development of a well-organised referral system in different health facilities, taking into account the specific characteristics of each health facility (urban/rural, primary health facility/district hospital), can improve the delivery of integrated MNCH, PPFP, and nutrition care to the mother-child pair.

Nepal Society of Obstetricians and Gynecologists jointly with the Nepalese government and with the support from the International Federation of Obstetrics and Gynecology has implemented an initiative to institutionalize postpartum family planning services in selected major referral facilities of Nepal to address the gap of low uptake of postpartum family planning in Nepal. The aim of the study is to find the prevalence of the service coverage of postpartum contraception in the selected facilities. A descriptive cross-sectional study was conducted in seven major referral facilities across Nepal. Data were collected from the hospital records of all women who delivered in these facilities between October 2018 and March 2019. Ethical approval for this study was obtained from Nepal Health Research Council. Data analysis was done with SPSS version 23. Among the 29,072 deliveries from all the facilities, postpartum family planning counseling coverage was 27,301 (93.9%). The prevalence of uptake of Postpartum Intrauterine Device is 1581 (5.4%) and female sterilization is 1830 (6.3%). In total 11387 mothers (52.2%) had the intention to choose a postpartum family planning method. However, 36% of mothers neither used nor had the intention to choose a postpartum family planning method. The coverage of Postpartum Intrauterine Device counseling service coverage in Nepal is higher in 2018 as compared to 2016-2017 and in other countries implementing Postpartum Intrauterine Device initiatives. However, the prevalence of service coverage of immediate Postpartum Family Planning methods, mainly Postpartum Intrauterine Device in 2018 is lower in Nepal as compared to 2016-2017, and other countries implementing Postpartum Intrauterine Device initiative. More efforts are needed to encourage mothers delivering in the facilities to use the postpartum family planning method.

There is a clear and evident need for mutual learning in global health systems. It is increasingly recognized that innovation needs to be sourced globally and that we need to think in terms of co-development as ideas are developed and spread from richer to poorer countries and vice versa. The Globalization and Health journal’s ongoing thematic series, “Reverse innovation in global health systems: learning from low-income countries” illustrates how mutual learning and ideas about so-called "reverse innovation" or "frugal innovation" are being developed and utilized by researchers and practitioners around the world. The knowledge emerging from the series is already catalyzing change and challenging the status quo in global health. The path to truly “global innovation flow”, although not fully established, is now well under way. Mobilization of knowledge and resources through continuous communication and awareness raising can help sustain this movement. Global health learning laboratories, where partners can support each other in generating and sharing lessons, have the potential to construct solutions for the world. At the heart of this dialogue is a focus on creating practical local solutions and, simultaneously, drawing out the lessons for the whole world.

To explore the rate and influencing factors of unmet need for postpartum family planning (PPFP) in China. We conducted a retrospective cohort study at 60 hospitals in 15 provinces that were in eastern, central, and western regions of China. Participants were women who delivered a live birth at the study sites with an interval of 13 to 24 months between delivery and interviews. We selected participants using cluster randomization approach, and the first 300 postpartum women who gave a birth at each study hospital after the initial month that had been selected were interviewed. Information on the women’s background characteristics, pregnancy history, time when menstruation and sexual activity resumed after childbirth, the adoption of contraceptive method, breastfeeding, and any pregnancy or pregnancy outcome after delivery were collected. We performed life-table analysis to estimate the rate of unmet need for PPFP and a 2-level logistic regression model to explore factors that influence unmet need for PPFP within the first 24 months postpartum. A total, 19,939 postpartum women were screened in this study, of which, 17,466 (87.6%) were eligible for this analysis. The rates of unmet needs for any FP methods were 23.9% (95% confidence interval [CI] 23.3–24.6%), 11.8% (95%CI 11.3–12.3%); 10.6% (95%CI 10.1–11.1%) at 6, 12, and 24 months postpartum; these rates for modern FP methods were 35.5% (95%CI 34.7–36.2%), 25.6% (95%CI 24.9–26.2%), and 24.6% (95%CI 23.9–25.2%), respectively. Results of 2-level logistic regression analysis showed that less-educated young women, those who had only one child or delivered by vaginal delivery at secondary hospitals, were associated with increased risk of unmet need for PPFP. Approximately 31% of women who had unmet need for PPFP reported a pregnancy during the first 24 months postpartum, which was significantly higher than the level for their counterparts (10.0%). The level of unmet need for PPFP in China was high, resulting in a high pregnancy rate within 24 months after delivery. Women’s age, education level, prior pregnancy and abortion histories, and delivery method were significantly associated with the risk of unmet need for PPFP. National PPFP guidelines that integrate PPFP services into prenatal and postnatal care are urgently needed and should be implemented throughout the country as soon as possible. PPFP services should promote the use of modern contraceptive methods.

In this chapter, we outline emerging trends in frugal innovations in the context of global surgery, their transformative potential, and their diffusion as reverse innovations from low-income to high-income countries. With healthcare needs in low- and middle-income countries (LMICs) converging with those of high-income countries, both contexts are demanding affordable healthcare models. The former seek to provide healthcare where there is either sporadic or no healthcare services. The latter seek to deal with burden of chronic disease, ageing populations, and rising healthcare costs. Increasing attention is being afforded to bending the growth cost curve by developing new solutions or drawing from different solutions in LMICs. First, an overview of frugal and reverse innovation and relevance to global surgery is discussed. Second, the need to identify or assess frugality and reverse ability and understand key methods employed in frugal approaches to surgery is outlined. Third, the barriers and challenges to adopting frugal innovations into reverse innovations are discussed.

Background: Postpartum family planning (PPFP) is one of the strategic efforts mentioned in the National Family Planning Strategy 2011/12 and National FP Costed implementation plan 2015-2020 of Nepal. Postpartum women are recognized as one of the groups that need attention to strengthen FP services in the country. Methods: We conducted a situational analysis in Nepal from December 2019 to May 2020, to identify the needs, gaps and provide evidence for strengthening future programming in this area using a combination of three methods: (i) non-systematic literature review using Google Scholar, Pubmed, and grey literature, (ii) secondary analysis using the dataset from Nepal Demographic and Health Survey (NDHS) 2016 that was based on a two-stage, stratified, nationally representative sample of households, and (iii) virtual assessment in purposively selected eight health facilities using a standard checklist related to PPFP. Results: Results show a lower modern contraceptive uptake (22.6%) and higher unmet need (31.5%) among postpartum women compared to all currently married women (43% and 24% respectively). Three most commonly used modern contraceptive methods among postpartum women in Nepal are injectables (8%), male condoms (7%), and oral contraceptive pills (3%). The PPFP services are available only in limited health facilities and were not integrated in Antenatal care (ANC), Postnatal care (PNC), childbirth and immunization services. Provision of family planning counseling during the ANC period is not recorded in the ANC card. Male partners do not participate in family planning counseling. Similarly, the uptake of family planning services at immunization, child health, and postnatal clinics is not recorded. Conclusion: This analysis provided evidence of the current status of PPFP in the country. There are gaps and challenges especially in strategy and guidelines, training, regular supply of commodities, awareness of PPFP, recording and reporting of PPFP. These gaps should be addressed with appropriate strategies.

Dexamethasone for COVID-19: data needed from randomised clinical trials in Africa

The unmet need for family planning is a pervasive public health concern in many low- and middle-income countries (LMICs). Mobile health (mHealth) interventions have been designed and implemented in LMIC settings to address this issue through health information dissemination via voice calls, apps, and short message services (SMS). Although the impact of mHealth programmes on postpartum family planning outcomes have been systematically reviewed, the contexts, conditions, and mechanisms underpinning programme engagement and their impact on outcomes remain unclear. This study aims to formulate hypotheses in the form of context-mechanism-outcome configurations (CMOCs) of whether, how, why, for whom, and in what contexts mHealth interventions implemented in LMICs influence postpartum family planning (PPFP) outcomes. We conducted a realist review of peer-reviewed and grey literature. Peer-reviewed literature was identified through MEDLINE, Embase, Global Health, Web of Science, and Google Scholar. Grey Literature was identified through The National Grey Literature Conference, FHI 360, Guttmacher Institute, Population Council, and MSI Reproductive Choices. Inclusion criteria were updated as the review progressed. Narrative data were analysed using dimensional analysis to build CMOCs. Two overarching concepts (underpinned by 12 CMOCs) emerged from the 37 included records: mobile phone access, use, and ownership as well as women's motivation. Women's confidence to independently own, access, and operate a mobile phone was a central mechanism leading to mHealth programme engagement and subsequent change in PPFP knowledge, awareness, and outcomes. Receiving family and social support positively interacted with this while low digital literacy and harmful gender norms pertaining to prescribed domestic duties and women's household influence were barriers to programme engagement. Intrinsic motivation for health improvement functioned at times both as a context and potential mechanism influencing mHealth programme engagement and PPFP outcomes. However, these contexts rarely occur in isolation and need to be evaluated as co-occurring phenomena. (Review registration: PROSPERO CRD42023386841).