Coverage Of Essential Interventions Research Articles

Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case study

SummaryBackgroundKyrgyzstan has made considerable progress in reducing child mortality compared with other countries in the region, despite a comparatively low economic standing. However, maternal mortality is still high. Given the availability of an established birth registration system, we aimed to comprehensively assess the trends and determinants of reproductive, maternal, newborn, and child health in Kyrgyzstan.MethodsFor this Countdown to 2030 country case study, we used publicly available data repositories and the national birth registry of Kyrgyzstan to examine trends and inequalities of reproductive, maternal, and newborn health and mortality between 1990 and 2018, at a national and subnational level. Coverage of newborn and maternal health interventions was assessed and disaggregated by equity dimensions. We did Oaxaca-Blinder decomposition to determine the contextual factors associated with the observed decline in newborn mortality rates. We also undertook a comprehensive review of national policies and programmes, as well as a prospective Lives Saved Tool analysis, to highlight interventions that have the potential to avert the most maternal, neonatal, and child deaths.FindingsOver the past two decades, Kyrgyzstan reduced newborn mortality rates by 46% and mortality rates of children younger than 5 years by 69%, whereas maternal mortality rates were reduced by 7% and stillbirth rates by 29%. The leading causes of neonatal deaths were prematurity and asphyxia or hypoxia, and preterm small-for-gestational-age infants were more than 80 times more likely to die in their first month of life compared with those born appropriate-for-gestational age at term. Except for contraceptive use, coverage of essential interventions has increased and is generally high, with limited sociodemographic inequities. With scale-up of a few essential neonatal and maternal interventions, 39% of neonatal deaths, 11% of stillbirths, and 19% of maternal deaths could be prevented by 2030.InterpretationKyrgyzstan has reduced newborn mortality rates considerably, with the potential for further reduction. To achieve and exceed the Sustainable Development Goal 3 targets for newborn survival and reducing stillbirths, Kyrgyzstan needs to scale up packages of interventions for the care of small and sick babies, assure quality of care in all health-care facilities with regionalised perinatal care, and create a linked national registry for mothers and neonates with rapid feedback and accountability.FundingUS Fund for UNICEF under the Countdown to 2015, UNICEF Kyrgyzstan Office.

COVID-19 pandemic and mitigation strategies: implications for maternal and child health and nutrition

ABSTRACTCoronavirus disease 2019 (COVID-19) continues to ravage health and economic metrics globally, including progress in maternal and child nutrition. Although there has been focus on rising rates of childhood wasting in the short term, maternal and child undernutrition rates are also likely to increase as a consequence of COVID-19 and its impacts on poverty, coverage of essential interventions, and access to appropriate nutritious foods. Key sectors at particular risk of collapse or reduced efficiency in the wake of COVID-19 include food systems, incomes, and social protection, health care services for women and children, and services and access to clean water and sanitation. This review highlights key areas of concern for maternal and child nutrition during and in the aftermath of COVID-19 while providing strategic guidance for countries in their efforts to reduce maternal and child undernutrition. Rooted in learnings from the exemplars in Global Health's Stunting Reduction Exemplars project, we provide a set of recommendations that span investments in sectors that have sustained direct and indirect impact on nutrition. These include interventions to strengthen the food-supply chain and reducing food insecurity to assist those at immediate risk of food shortages. Other strategies could include targeted social safety net programs, payment deferrals, or tax breaks as well as suitable cash-support programs for the most vulnerable. Targeting the most marginalized households in rural populations and urban slums could be achieved through deploying community health workers and supporting women and community members. Community-led sanitation programs could be key to ensuring healthy household environments and reducing undernutrition. Additionally, several COVID-19 response measures such as contact tracing and self-isolation could also be exploited for nutrition protection. Global health and improvements in undernutrition will require governments, donors, and development partners to restrategize and reprioritize investments for the COVID-19 era, and will necessitate data-driven decision making, political will and commitment, and international unity.

Trends and Determinants of Newborn Mortality in the Kyrgyz Republic: A Countdown Country Case Study

Background: The Kyrgyz Republic has made great progress in reducing neonatal mortality rate (NMR), compared to the region, despite its regional comparatively low GDP per capita. Given the availability of an established civil registration and vital statistics system, the country is uniquely positioned to undertake a comprehensive assessment of trends and determinants of newborn mortality. Methods: We used publicly available data repositories and the national birth registry data to examine trends and inequalities of reproductive, maternal and newborn health and mortality between 1990 and 2018 at a national and subnational level. Coverage of newborn and maternal health interventions were assessed and disaggregating by equity dimensions. Oaxaca-Blinder decomposition was done to determine the contextual factors associated with the observed decline in NMR. We undertook a comprehensive review of national policies and programs, as well as a prospective Lives Saved Tool (LiST) analysis to highlight interventions that will save the most lives. Findings: In the past two decades, with the help of investments and appropriate policies, the Kyrgyz Republic has reduced NMR by 54%, with the leading causes of death attributable to prematurity and asphyxia. Neonates born pre-term small-for-gestational age are over 80 times more likely to die in their first month of life, compared to those born full term, appropriate-for-gestational age. With the exception of contraceptive use, coverage of essential interventions is increasing and exceptionally high with limited sociodemographic inequities. By 2030, improved case management of premature babies will save the most neonatal lives. Interpretation: The Kyrgyz Republic has reduced NMR considerably, with the potential for further reduction given its remarkably high coverage and low inequities of preventative maternal and newborn health interventions. A particular focus is needed on scaling-up packages of interventions to care for small and sick babies, assuring quality of care in all healthcare facilities, and creating a linked national registry system for mothers and newborns. Funding Statement: US Fund for UNICEF under the Countdown to 2015 and UNICEF Kyrgyzstan Declaration of Interests: All authors declare no competing interests.

Status and drivers of maternal, newborn, child and adolescent health in the Islamic world: a comparative analysis

The Millennium Development Goal (MDG) period saw dramatic gains in health goals MDG 4 and MDG 5 for improving child and maternal health. However, many Muslim countries in the south Asian, Middle Eastern, and African regions lagged behind. In this study, we aimed to evaluate the status of, progress in, and key determinants of reproductive, maternal, newborn, child, and adolescent health in Muslim majority countries (MMCs). The specific objectives were to understand the current status and progress in reproductive, maternal, newborn, child, and adolescent health in MMCs, and the determinants of child survival among the least developed countries among the MMCs; to explore differences in outcomes and the key contextual determinants of health between MMCs and non-MMCs; and to understand the health service coverage and contextual determinants that differ between best and poor or moderate performing MMCs. In this country-level ecological study, we examined data from between 1990 and 2015 from multiple publicly available data repositories. We examined 47 MMCs, of which 26 were among the 75 high-burden Countdown to 2015 countries. These 26 MMCs were compared with 48 non-Muslim Countdown countries. We also examined characteristics of the eight best performing MMCs that had accelerated improvement in child survival (ie, that reached their MDG 4 targets). We estimated adolescent, maternal, under-5, and newborn mortality, and stillbirths, and the causes of death, essential interventions coverage, and contextual determinants for all MMCs and comparative groups using standardised methods. We also did a hierarchical multivariable analysis of determinants of under-5 mortality and newborn mortality in low-income and middle-income MMCs. Despite notable reductions between 1990 and 2015, MMCs compared with a global esimate of all countries including MMCs had higher mortality rates, and MMCs relative to non-MMCs within Countdown countries also performed worse. Coverage of essential interventions across the continuum of care was on average lower among MMCs, especially for indicators of reproductive health, prenatal care, delivery, and labour, and childhood vaccines. Outcomes within MMCs for mortality and many reproductive, maternal, newborn, child, and adolescent health indicators varied considerably. Structural and contextual factors, especially state governance, conflict, and women and girl's empowerment indicators, were significantly worse in MMCs compared with non-MMCs within the high-burden Countdown countries, and were shown to be strongly associated with child and newborn mortality within low-income and middle-income MMCs. In adjusted hierarchical models, among other factors, under-5 mortality in MMCs increased with more refugees originating from a country (β=23·67, p=0·0116), and decreased with better political stability or absence of terrorism (β=-0·99, p=0·0285), greater political rights or government effectiveness (β=-1·17, p<0·0001), improvements in log gross national income per capita (β=-4·44, p<0·0001), higher total adult literacy (β=-1·69, p<0·0001), higher female adult literacy (β=-0·97, p<0·0001), and greater female to male enrolment in secondary school (β=-16·1, p<0·0001). The best performing MMCs were Azerbaijan, Bangladesh, Egypt, Indonesia, Kyrgyzstan, Morocco, Niger, and Senegal, which had higher coverage of family planning interventions and newborn or child vaccinations, and excelled in many of the above contextual determinants when compared with moderate or poorly performing MMCs. The status and progress in reproductive, maternal, newborn, child, and adolescent health is heterogeneous among MMCs, with little indication that religion and its practice affects outcomes systemically. Some Islamic countries such as Niger and Bangladesh have made great progress, despite poverty. Key findings from this study have policy and programmatic implications that could be prioritised by national heads of state and policy makers, development partners, funders, and the Organization of the Islamic Cooperation to scale up and improve these health outcomes in Muslim countries in the post-2015 era. US Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn, and Child Survival, the Centre for Global Child Health, Hospital for Sick Children, and the Aga Khan University.

Improving immunization in Afghanistan: results from a cross-sectional community-based survey to assess routine immunization coverage

BackgroundDespite progress in recent years, Afghanistan is lagging behind in realizing the full potential of immunization. The country is still endemic for polio transmission and measles outbreaks continue to occur. In spite of significant reductions over the past decade, the mortality rate of children under 5 years of age continues to remain high at 91 per 1000 live births.MethodsThe study was a descriptive community-based cross sectional household survey. The survey aimed to estimate the levels of immunization coverage at national and province levels. Specific objectives are to: establish valid baseline information to monitor progress of the immunization program; identify reasons why children are not immunized; and make recommendations to enhance access and quality of immunization services in Afghanistan. The survey was carried out in all 34 provinces of the country, with a sample of 6125 mothers of children aged 12–23 months.ResultsNationally, 51% of children participating in the survey received all doses of each antigen irrespective of the recommended date of immunization or recommended interval between doses. About 31% of children were found to be partially vaccinated. Reasons for partial vaccination included: place to vaccinate child too far (23%), not aware of the need of vaccination (17%), no faith in vaccination (16%), mother was too busy (15%), and fear of side effects (11%).ConclusionThe innovative mechanism of contracting out delivery of primary health care services in Afghanistan, including immunization, to non-governmental organizations is showing some positive results in quickly increasing coverage of essential interventions, including routine immunization. Much ground still needs to be covered with proper planning and management of resources in order to improve the immunization coverage in Afghanistan and increase survival and health status of its children.

Can surveys of women accurately track indicators of maternal and newborn care? A validity and reliability study in Kenya.

BackgroundTracking progress on maternal and newborn survival requires accurate information on the coverage of essential interventions. Despite widespread use, most indicators measuring maternal and newborn intervention coverage have not been validated. This study assessed the ability of women delivering in two Kenyan hospitals to recall critical elements of care received during the intrapartum and immediate postnatal period at two time points: hospital discharge and 13–15 months following delivery.MethodsWomen’s reports of received care were compared against observations by trained third party observers. Indicators selected for validation were either currently in use or have the potential to be included in population–based surveys. We used a mixed–methods approach to validate women’s reporting ability. We calculated individual–reporting accuracy using the area under the receiver operating curve (AUC), population–level accuracy using the inflation factor (IF), and compared the accuracy of women’s reporting at baseline and follow–up. We also assessed the consistency of women’s reporting over time. We used in–depth interviews with a sub–set of women (n = 20) to assess their understanding of key survey terms.ResultsOf 606 women who participated at baseline and agreed to follow–up, 515 were re–interviewed. Thirty–eight indicators had sufficient sample size for validation analysis; ten met criteria for high or moderate reporting accuracy (0.60<AUC) alone and ten met criteria for low population–level bias alone (0.75<IF<1.25). There was a significant decline in the individual level reporting accuracy between baseline and follow–up for ten indicators. Seven indicators had moderate or higher (0.4≤rphi) consistency between self–reports at baseline and follow–up. Four indicators met all criteria at follow–up: support person was present during the birth, episiotomy, caesarean section, and low birthweight infant (<2500 g).ConclusionThe few indicators that women reported accurately at baseline were consistently recalled with accuracy at 13–15 months follow–up. Although there is deterioration in women’s recall in some indicators over time, the extent of deterioration does not appreciably compromise reporting accuracy for indicators with high baseline validity. Indicators related to initial client assessment and the immediate postnatal period have generally low accuracy and poor reporting consistency over time.

Can Available Interventions End Preventable Deaths in Mothers, Newborn Babies, and Stillbirths, and at What Cost?

Despite progress in lowering death rates in children younger than 5 years, progress in reducing newborn deaths has been slower and should focus on effective interventions, intentional investment, and implementation. This report offers an update of the evidence for interventions, the potential for lives saved, and running costs of implementation. Specific interventions across the continuum of pregnancy care were evaluated along with delivery platforms for these interventions and methods to improve care. All major databases were searched to identify quality systematic reviews in various domains using standardized methodology. Interventions before and between pregnancies include delaying the age at the first pregnancy, family planning, optimal interpregnancy intervals, and enhancement of prepregnancy nutrition. Antenatal interventions include maternal immunization, management of infections and preexisting chronic diseases or pregnancy-induced disorders, detection and management of significant in utero growth retardation, prevention of RhD alloimmunization, improvements in nutrition and psychosocial health, and treatment of drug misuse. Interventions during or close to labor include obstetric care with labor monitoring, skilled delivery and provision of emergency obstetric care as needed, and management of preterm labor and postterm pregnancy, as well as clean/sterile birth practices to reduce neonatal sepsis and tetanus deaths and use of antenatal steroids. Interventions at birth for every newborn include immediate drying and stimulation, provision of warmth, delaying of cord clamping, hygienic care, support for immediate breast-feeding, and administration of vitamin K. Neonatal resuscitation is crucial for babies who do not breathe immediately and could include prevention and management of meconium aspiration. Beginning breast-feeding within 1 hour of birth, exclusive breast-feeding of infants until age 6 months, and continuation of breast-feeding until age 2 years are strongly recommended. Interventions for small and ill newborn babies include prevention of hypothermia; management of respiratory distress syndrome, neonatal pneumonia, sepsis, and hyperbilirubinemia; and skin care with emollient and massage therapy. Kangaroo mother care involves early and continuous skin-to-skin contact, breast-feeding support, early discharge from hospital, and supportive care in stable neonates. Use of continuous positive airway pressure, anticonvulsants, and animal-derived surfactant can reduce neonatal morbidity and mortality. Care of neonates in intensive care units has become increasingly sophisticated in high-income countries, and creation of neonatal intensive care units is being implemented in low- and middle-income countries. Delivery platforms and strategies to reach mothers and neonates are important for delivery of high-quality care to underserved populations. Community-based delivery platforms, especially if linked to local health facilities, can increase coverage of essential interventions and reduce inequities. Changes in household behaviors and practices, tetanus immunization, use of clean birth kits, facility births, early initiation of breast-feeding, and seeking of health care for neonatal illnesses are all factors in reaching mothers and neonates. Community mobilization and antenatal and postnatal home visits by health workers can complement facility-based care and promote family contact with the health system at crucial times. Community-based packages of preventive and basic care, promoted by outreach workers and women's groups, empower women to facilitate these vital changes. One method to enhance these improvements is to create financial incentives as strategies to ease poverty, reduce financial barriers, and improve health outcomes in poor populations. To determine the financial aspects of these major changes to health care delivery in underserved populations, the Lives Saved Tool was used to model the effects of these interventions within the health systems of 75 countries that account for more than 95% of maternal, neonatal, and child deaths worldwide. The Lives Saved Tool estimates the country-by-country cause-specific effects of increasing coverage of individual interventions from baseline levels of 2012 on stillbirth and neonatal and maternal mortality. With high coverage by 2025, 71% (56%-76%) of neonatal mortality, 33% (23%-38%) of stillbirths, and 51% (44%-53%) of maternal deaths could be averted. If 90% of all women giving birth in facilities in 2020 received highly effective interventions, an estimated 113,000 maternal deaths (84% of the total deaths averted by 2020), 531,000 stillbirths (76%), and 1.325 million neonatal deaths (77%), including 300,000 preterm deaths, would be prevented. The incremental annual costs (in US dollars) of providing these care packages would be approximate to$4.5 billion ($0.91/person) by 2020, rising to $5.65 billion ($1.15/person) in 2025 (or $1928 for each maternal and infant life saved). Increased coverage and quality of preconception, antenatal, intrapartum, and postnatal interventions by 2025 could avert 71% of neonatal deaths (1.9 million [1.6-2.1 million]), 33% of stillbirths (0.82 million [0.60-0.93 million]), and 54% of maternal deaths (0.16 million [0.14-0.17 million]) annually. Available interventions can reduce preterm, intrapartum, and infection-related deaths by 58%, 79%, and 84%, respectively. Closing the quality gap for facility births is imperative. Many of the current differentials in quality relate to ethnicity, geography, and other forms of social marginalization. Strategies to overcome these obstacles are required to create and maintain health systems to benefit women, babies, development outcomes, and economic capital.

Evidence from community level inputs to improve quality of care for maternal and newborn health: interventions and findings.

Annually around 40 million mothers give birth at home without any trained health worker. Consequently, most of the maternal and neonatal mortalities occur at the community level due to lack of good quality care during labour and birth. Interventions delivered at the community level have not only been advocated to improve access and coverage of essential interventions but also to reduce the existing disparities and reaching the hard to reach. In this paper, we have reviewed the effectiveness of care delivered through community level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined community level interventions and report findings from 43 systematic reviews.Findings suggest that home visitation significantly improved antenatal care, tetanus immunization coverage, referral and early initiation of breast feeding with reductions in antenatal hospital admission, cesarean-section rates birth, maternal morbidity, neonatal mortality and perinatal mortality. Task shifting to midwives and community health workers has shown to significantly improve immunization uptake and breast feeding initiation with reductions in antenatal hospitalization, episiotomy, instrumental delivery and hospital stay. Training of traditional birth attendants as a part of community based intervention package has significant impact on referrals, early breast feeding, maternal morbidity, neonatal mortality, and perinatal mortality. Formation of community based support groups decreased maternal morbidity, neonatal mortality, perinatal mortality with improved referrals and early breast feeding rates. At community level, home visitation, community mobilization and training of community health workers and traditional birth attendants have the maximum potential to improve a range of maternal and newborn health outcomes. There is lack of data to establish effectiveness of outreach services, mass media campaigns and community education as standalone interventions. Future efforts should be concerted on increasing the availability and training of the community based skilled health workers especially in resource limited settings where the highest burden exists with limited resources to mobilize.

What works in saving children: the essentials

Getting on with what works” was not merely a slogan in the 2006 Lancet Maternal Survival Series but defined the approach of the global reproductive maternal newborn and child health (RMNCH) community to prioritize a few highly cost-effective evidence-based interventions. Broad interagency consortia have defined the so-called essential interventions for RMNCH accompanied by commodities and guidelines and introduced the Lives Saved Tool (LiST) which provides guidance for how many lives interventions can save and at what cost. In The Lancet Neff Walker and colleagues suggest that for child survival more of the same could be the best way forward. Gathering data from between 1990 and 2011 to investigate patterns of change in coverage of interventions in 69 counties they then used LiST to estimate potential reductions in the numbers of newborn and child deaths. The researchers report that uptake of most interventions has been slow particularly in Africa. However it is unrealistic to believe that all countries will perform at the top of their class. The author suggests that with improved instruments to plan and monitor increased coverage of essential interventions the RMNCH community will hopefully prove Walker and colleagues too conservative in their predictions.