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The need to bolster primary health care (PHC) to achieve the Sustainable Development Goal (SDG) targets for health is well recognized. In Eastern and Southern Africa, where governments have progressively decentralized health decision-making, health management is critical to PHC performance. While investments in health management capacity are important, so is improving the environment in which managers operate. Governance arrangements, management systems and power dynamics of actors can have a significant influence on health managers’ ability to improve PHC access and quality. We conducted a problem-driven political economy analysis (PEA) in Kenya, Malawi and Uganda to explore local decision-making environments and how they affect management and governance practices for health. This PEA used document review and key informant interviews (N = 112) with government actors, development partners and civil societies in three districts or counties in each country (N = 9). We found that while decentralization should improve PHC by supporting better decisions in line with local priorities from community input, it has been accompanied by thick bureaucracy, path-dependent and underfunded budgets that result in trade-offs and unfulfilled plans, management support systems that are less aligned to local priorities, weak accountability between local government and development partners, uneven community engagement and insufficient public administration capacity to negotiate these challenges. Emergent findings suggest that coronavirus disease 2019 (COVID-19) not only resulted in greater pressures on health teams and budgets but also improved relations with central government related to better communication and flexible funding, offering some lessons. Without addressing the disconnection between the vision for decentralization and the reality of health managers mired in unhelpful processes and politics, delivering on PHC and universal health coverage goals and the SDG agenda will remain out of reach.

Objective To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings. Design Modified Delphi process. Setting Participants from 34 countries. Population Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group. Methods We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts. Main outcome measure Consensus on bundle items. Results Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’. Conclusion A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus. Tweetable abstract A maternal sepsis bundle for low resource settings has been developed by international consensus., Tweetable abstract A maternal sepsis bundle for low resource settings has been developed by international consensus.

ObjectiveTo evaluate whether the implementation of the FAST‐M complex intervention was feasible and improved the recognition and management of maternal sepsis in a low‐resource setting.DesignA before‐and‐after design.SettingFifteen government healthcare facilities in Malawi.PopulationWomen suspected of having maternal sepsis.MethodsThe FAST‐M complex intervention consisted of the following components: the FAST‐M maternal sepsis treatment bundle and the FAST‐M implementation programme. Performance of selected process outcomes was compared between a 2‐month baseline phase and 6‐month intervention phase with compliance used as a proxy measure of feasibility.Main outcome resultCompliance with vital sign recording and use of the FAST‐M maternal sepsis bundle.ResultsFollowing implementation of the FAST‐M intervention, women were more likely to have a complete set of vital signs taken on admission to the wards (0/163 [0%] versus 169/252 [67.1%], P P P = 0.091). In particular, women were more likely to receive antibiotics (3/12 [25.0%] versus 72/107 [67.3%], P = 0.004) within 1 hour of recognition of suspected sepsis.ConclusionImplementation of the FAST‐M complex intervention was feasible and led to the improved recognition and management of suspected maternal sepsis in a low‐resource setting such as Malawi.Tweetable AbstractImplementation of a sepsis care bundle for low‐resources improved recognition & management of maternal sepsis.

We describe hypoxemic pneumonia prevalence in outpatient and inpatient settings, in-hospital mortality, and clinical guideline performance for identifying hypoxemia in young infants in Malawi. In this retrospective analysis of a prospective cohort study, we investigate infants younger than 2 months participating in pneumonia surveillance at seven hospitals and 18 outpatient health centers in Malawi between 2011 and 2014. Logistic regression, multiple imputation with chained equations, and pattern mixture modeling were used to determine the association between peripheral capillary oxyhemoglobin saturation (SpO(2)) levels and hospital mortality. We describe outpatient clinician hospital referral recommendations based on clinical characteristics and SpO(2) distributions. Among 1,879 analyzed cases, SpO(2) < 90% was more prevalent among outpatient health center cases compared with hospitalized cases (22.6% versus 13.5%, 95% CI: 17.6–28.4% and 12.0–15.3%, respectively). A larger proportion of hospitalized infants had signs of respiratory distress compared with infants at health centers (67.7% versus 56.6%, P < 0.001) and most hospitalized infants were boys (56.7% versus 40.6%, P < 0.001). An SpO(2) of 90–92% and < 90% was associated with similarly increased odds of in-hospital mortality (adjusted odds ratio [aOR]: 4.3 and 4.4, 95% CI: 1.7–11.1 and 1.8–10.5, respectively). Unrecorded, or unobtainable, SpO(2) was highly associated with mortality (n = 127, aOR: 18.1; 95% CI: 7.6–42.8). Four of 22 (18%) infants at health centers who did not meet clinical referral criteria had an SpO(2) ≤ 92%. Clinicians should consider hospital referral in young infants with a SpO(2) ≤ 92%. Infants with unobtainable SpO(2) readings should be considered a high-risk group, and hospital referral of these cases may be appropriate.

Quality improvement approaches can strengthen action on a range of global health priorities. Quality improvement efforts are uniquely placed to reorient care delivery systems towards integrated people-centred health services and strengthen health systems to achieve Universal Health Coverage (UHC). This article makes the case for addressing shortfalls of previous agendas by articulating the critical role of quality improvement in the Sustainable Development Goal era. Quality improvement can stimulate convergence between health security and health systems; address global health security priorities through participatory quality improvement approaches; and improve health outcomes at all levels of the health system. Entry points for action include the linkage with antimicrobial resistance and the contentious issue of the health of migrants. The work required includes focussed attention on the continuum of national quality policy formulation, implementation and learning; alongside strengthening the measurement-improvement linkage. Quality improvement plays a key role in strengthening health systems to achieve UHC.

A lack of clear guidance for funders, evaluators and improvers on what to include in evaluation proposals can lead to evaluation designs that do not answer the questions stakeholders want to know. These evaluation designs may not match the iterative nature of improvement and may be imposed onto an initiative in a way that is impractical from the perspective of improvers and the communities with whom they work. Consequently, the results of evaluations are often controversial, and attribution remains poorly understood. Improvement initiatives are iterative, adaptive and context-specific. Evaluation approaches and designs must align with these features, specifically in their ability to consider complexity, to evolve as the initiative adapts over time and to understand the interaction with local context. Improvement initiatives often identify broadly defined change concepts and provide tools for care teams to tailor these in more detail to local conditions. Correspondingly, recommendations for evaluation are best provided as broad guidance, to be tailored to the specifics of the initiative. In this paper, we provide practical guidance and recommendations that funders and evaluators can use when developing an evaluation plan for improvement initiatives that seeks to: identify the questions stakeholders want to address; develop the initial program theory of the initiative; identify high-priority areas to measure progress over time; describe the context the initiative will be applied within; and identify experimental or observational designs that will address attribution.

Improving health care involves many actors, often working in complex adaptive systems. Interventions tend to be multi-factorial, implementation activities diverse, and contexts dynamic and complicated. This makes improvement initiatives challenging to describe and evaluate as matching evaluation and program designs can be difficult, requiring collaboration, trust and transparency. Collaboration is required to address important epidemiological principles of bias and confounding. If this does not take place, results may lack credibility because the association between interventions implemented and outcomes achieved is obscure and attribution uncertain. Moreover, lack of clarity about what was implemented, how it was implemented, and the context in which it was implemented often lead to disappointment or outright failure of spread and scale-up efforts. The input of skilled evaluators into the design and conduct of improvement initiatives can be helpful in mitigating these potential problems. While evaluation must be rigorous, if it is too rigid necessary adaptation and learning may be compromised. This article provides a framework and guidance on how improvers and evaluators can work together to design, implement and learn about improvement interventions more effectively.

The recent WHO guidelines for optimising community health worker (CHW) programmes in health systems (December, 2018) are a welcome addition to the discourse on the contribution of CHWs to universal health coverage (UHC). These guidelines formalise the view that CHWs are a core component of expanding access to health care, while recognising that CHWs too often remain sidelined by the general health system. CHWs need to be integrated into the health workforce if the aspiration of UHC is to be realised; however, the overall quality of care delivered by CHW programmes is variable across settings.

IntroductionA recent WHO multi-country study on maternal and newborn health concluded that there was no evidence of an association between high coverage with essential interventions and reduced mortality in health care facilities, or improvement in other outcomes.1 According to Horton the missing ingredient in this relation is quality of care.2 Quality improvement in healthcare has adopted techniques mainly from industries such as manufacturing and has been used widely in Europe and US. However, evidence of success of these techniques in healthcare is not very conclusive, especially in low and middle-income countries. There have been limited efforts to critically analyse the techniques used in quality improvement interventions. One of the main challenges in evaluating quality improvement is the complexity of the interventions themselves and the complex nature of the systems in which they are implemented. Robust evidence regarding quality improvement interventions for resource poor settings is generally lacking.The MaiKhanda trial looked at the effect of QI interventions and community women's groups on maternal and newborn mortality in 3 central districts in Malawi.3 The impact evaluation measuring effect on newborn mortality for the QI interventions, using a cluster RCT approach, remained inconclusive. We use a Theory-Based Evaluation (TBE) approach to understand why improvement interventions undertaken by MaiKhanda for new-born care did not show an effect. Absence of effect could be attributed to a failure of theory, a failure of implementation, an evaluation failure or a combination of these.Our primary objective was to understand the mechanisms by which the QI interventions worked (or not) and explore the interaction between the various factors that mediated the lack of effect on neonatal mortality that was observed in the cluster randomized control trial.MethodsOur research strategy consisted of developing a post-hoc Theory of Change, consolidating and synthesizing all the available evidence using an appropriate framework, and analysing the program and implementation theory using theory based approaches to evaluation.Data synthesis was conducted using the Consolidate Framework for Implementation Research (CFIR).4 The synthesis takes into consideration the various reports and documents accumulated through the life of the project and complements the process evaluation studies conducted during the same period. In doing so, it draws a picture of the intervention with a multi-dimensional perspective, which provides insights into the evolution of the project. The framework is very comprehensive covering 5 major domains and a range of constructs, not all of which were included in our study. As this was post-hoc analysis, the choice of constructs was based on the availability of data rather than prioritizing the key constructs to consider.CFIR helps to produce structured and comprehensive data that is then used for analysing the program theory in relation to the intervention outcome. The program theory thus generated for the MaiKhanda intervention is compared with the program theories of the Michigan Keystone Project, which used similar collaborative methods to successfully reduce their central venous line blood stream infections in 106 participating ICUs.5 The rationale for such a comparison is that while the interventions per se are very unique and specific to their context, the program theories underlying the use of collaborative methods in both the interventions is the same and therefore comparable. Theories offer a higher level of abstraction that can be comparable across different settings.6 ResultsThe key finding from analysis of the program theory is that similar intervention strategies that triggered successful mechanisms for improvement in the Keystone Project failed to generate such mechanisms in MaiKhanda project.The Model for Improvement used in MaiKhanda was built around Deming's improvement theory7 and Roger's diffusion of innovation theory.8 The former theory considers improvement as a product of subject matter knowledge and profound knowledge. Subject matter knowledge on essential and emergency newborn care was generally lacking among health care providers in Malawi. Similarly, understanding variations within the health systems is an acquired skill. While the implementing partners, provided ample opportunities for the Malawian health system to learn the Institute for Healthcare Improvement (IHI) model for improvement, in general, QI teams lacked capacity to collate data and analyse the variations between the health facilities. QI was a fairly new concept in Malawi and MaiKhanda's attempts to embed it within existing health system was limited by challenges of the health systems context, MaiKhanda's own organizational transition and QI and clinical capacity of health care providers.The main challenge for MaiKhanda was to simultaneously implement and sustain the various change packages it had introduced in the different facilities. While there were isolated instances of successful intervention activities within MaiKhanda, it did not build enough momentum to generate mechanisms across a critical mass of the facilities that would eventually result in improved newborn outcomes. This can be attributed to the implementation strength, context and complexity of MaiKhanda's interventions. This is explored further using the implementation theory.Implementation was based on diffusion theories where better performing facilities were to act as role models for other facilities to emulate. The cRCT design for measuring impact evaluation required a random allocation of the improvement facilities and this conflicted with innovation diffusion theories, which prescribed a gradual organic spread of the interventions by strategically engaging the innovators and early adapters.Limitations of the evaluation design notwithstanding, the implementation strength characterized by the dose, duration, intensity and specificity of the intervention was sub-optimal.Implementation strength is not the only factor triggering an intervention mechanism and cannot be measured independent of the intervention complexity or the intervention context. For example, MaiKhanda struggled to show an effect of its interventions, despite having a long pre-intervention period to refine its interventions, while the Michigan study produced results within 18 month period. This could be because of other factors related to intervention complexity such as the long implementation chain for intervention delivery, the subjective perception of the agency (QI teams) regarding QI and contextual factors such as organizational readiness, the health systems context, QI team capacity to deliver QI interventions and MaiKhanda's own internal capacity.Human agency is at the heart of implementation and the intervention required a continuous and prolonged time and effort, than was anticipated, to engage and train the health facility QI teams on the improvement model.One of the key factors affecting the uptake of strategies was MaiKhanda's positioning within the health system and the degree of influence it could exert on other actors. This factor has a significant role to play in country where projects are donor supported and perhaps also donor driven. The period of the intervention also saw MaiKhanda going through a period of rapid organizational transition, which affected intervention implementation on the ground. Furthermore, MaiKhanda's own understanding of QI concepts was evolving gradually and this coupled with its long implementation chain, influenced the subjective understanding of the QI teams regarding QI concepts. Health facility staff also lacked the necessary skills and knowledge related to management of newborn health.Limited resources within the health facilities meant that gains achieved in some aspects of the intervention could not be sustained in the long run. External contextual factors such as fuel shortages contributed to poor implementation. Changes in policy such as government ban on TBAs, affected intervention uptake and resulted in an increase in health facility deliveries, overwhelming the already under-resourced staff capacity in the health facilities. It is conceivable that quality improvement was not on top of their priority list. But, ‘motivation’ to be involved in QI Collaboratives remained high. In resource constrained settings, ‘motivation’ can be influenced by the lure of personal incentives (such as per diems for attending workshops and meetings) as much as individual's commitment to broader social gains (ie reduction in newborn case fatality rates in their facility). The improvement model was competing against other existing models and it was difficult to get enough stakeholder commitment to the prescribed model as there were huge expectations fuelled by the poverty and poor governance structures and a culture of “perdiemitis” was prevalent in Malawian health care system.9 DiscussionAs is evident from the study, a single research method will not be able to provide justice to evaluation of a complex set of factors that influence newborn outcomes. We propose a research strategy that includes developing a Theory of Change, followed by evaluation of the program theory, measuring implementation strength, analysing implementation theory and comparing this in relation to the outcomes of the intervention observed through the impact evaluation. The results arising from such a comprehensive evaluation will contribute to the growth of improvement science with the accumulation of knowledge and explanation rather than being just a bedrock of observational facts.More generally, we propose that design, implementation and evaluation of QI activities, particularly in resource-poor settings, should consider five key principles i.e it should include whole systems thinking, accountability, participatory approach, should be evidence-based and adapt innovative methods.10

Background An estimated 70% of newborn lives could be saved globally if evidence-based interventions were successfully implemented. The ‘NeoTree’ application (app) addresses the need for quality care for sick newborns in resource-poor settings, particularly where care is nurse-led, by providing an integrated electronic platform for three functions; 1) immediate digital data capture on admission, 2) clinical decision support according to evidence-based clinical guidelines, and 3) newborn education. Here, we develop the first two functions and test the acceptability, feasibility and usability of The NeoTree in a district hospital, Malawi. Methods A mixed methods intervention development study was conducted with facility-based health care workers (HCWs) to co-develop and test the app. Methods included Focus Groups (FGs) exploring the acceptability and feasibility of digital health solutions, one-to-one usability workshops and a one-month ward-based usability study. Quantitative usability data (systems usability score – SUS) were collected before and after the ward study. Finally, end-line qualitative FGs were completed. Results Digital aids, specifically the NeoTree were reported to be acceptable, feasible and a potential facilitator to quality newborn care. Identified factors predicted to aid the success of the NeoTree included a positive staff attitude, training, strong leadership, teamwork and staff engagement. SUS score was high at baseline (under workshop conditions) and following the ward study (>68/100 average) and HCWs reported high perceptions of improved quality of care after embedding NeoTree into routine practice (see table 1). Conclusions The NeoTree has the potential to address multiple Malawian and global policy directives around improving quality of care and outcomes for newborns. It is an acceptable, feasible and highly usable tool. Co-production and user-focused, mixed methods iterative development have been key to its success thus far. The next phase of development will focus on the educational function and data linkage with national systems.

OBJECTIVE: Understanding the causes of death is key to tackling the burden of three million annual neonatal deaths. Resource-poor settings lack effective vital registration systems for births, deaths and causes of death. We set out to describe cause-specific neonatal mortality in rural areas of Malawi, Bangladesh, Nepal and rural and urban India using verbal autopsy (VA) data. DESIGN: We prospectively recorded births, neonatal deaths and stillbirths in seven population surveillance sites. VAs were carried out to ascertain cause of death. We applied descriptive epidemiological techniques and the InterVA method to characterise the burden, timing and causes of neonatal mortality at each site. RESULTS: Analysis included 3772 neonatal deaths and 3256 stillbirths. Between 63% and 82% of neonatal deaths occurred in the first week of life, and males were more likely to die than females. Prematurity, birth asphyxia and infections accounted for most neonatal deaths, but important subnational and regional differences were observed. More than one-third of deaths in urban India were attributed to asphyxia, making it the leading cause of death in this setting. CONCLUSIONS: Population-based VA methods can fill information gaps on the burden and causes of neonatal mortality in resource-poor and data-poor settings. Local data should be used to inform and monitor the implementation of interventions to improve newborn health. High rates of home births demand a particular focus on community interventions to improve hygienic delivery and essential newborn care.

Background The World Health Organization recommends participatory learning and action (PLA) in women’s groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women’s groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction. Methods and findings We conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women’s group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women’s groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02–4.22; I2 = 63.7%, 95% CI 4.4%–86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25–2.82; 67.6%, 16.1%–87.5%), birth attendant washing hands prior to delivery (1.87, 1.19–2.95; 79%, 53.8%–90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09–1.99; 68.0%, 29.2%–85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02–1.60; 0.0%, 0%–79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77–1.38; I2 = 86.3%, 95% CI 73.8%–92.8%), facility delivery (1.02, 0.93–1.12; 21.4%, 0%–65.8%), initiating breastfeeding within 1 hour (1.08, 0.85–1.39; 76.6%, 50.9%–88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93–1.48; 72.9%, 37.8%–88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women’s groups and context-specific effects. Conclusions This meta-analysis suggests that women’s groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents., In a meta-analysis of randomized controlled trials, Nadine Seward and colleagues find that in Asian and African settings with limited access to medical services, participatory learning women’s groups are associated with improved perinatal health behaviors., Author summary Why was this study done? A systematic review and meta-analysis of trials of participatory learning and action in women’s groups found a 25% reduction in neonatal mortality associated with these groups, but the pathways to improved survival have not been explored using available evidence from all trials. We used data from cluster-randomised trials of women’s groups to explore behaviours in the antenatal, delivery, and postnatal periods in order to better explain the reduction in neonatal mortality associated with these groups. We also examined whether women who were assigned to the intervention arm and attended group meetings were more likely to have improved care practices than women who were also in the intervention arm but did not attend group meetings. What did the researchers do and find? We conducted a meta-analysis using individual-level data to explore the relationship between women’s groups and key behaviours in the antenatal, delivery, and postnatal periods. Our findings suggest that women’s groups are able to improve key behaviours for home deliveries including clean delivery practices and thermal care practices. To determine whether women who attended group meetings were more likely to have improved behaviours compared with women who did not attend, we compared behaviours between these women separately for the different trials. Overall, we found that women who attended group meetings were more likely to have improved behaviours than women who did not attend. What do these findings mean? Our meta-analysis showed that women’s groups were associated with improvements in critical practices including clean deliveries and appropriate thermal care for home deliveries. Evidence suggests that these care practices are essential for reducing neonatal mortality because of the importance of sepsis and hypothermia in areas with high neonatal mortality and low rates of facility births. Although this finding explains how women’s groups improved survival in these contexts, we also found that women’s groups improved survival in areas with lower neonatal mortality, such as rural Bangladesh and rural Malawi. It is possible that women’s groups were able to help families make more timely, better informed decisions about care seeking. Women’s groups have demonstrated flexibility in adapting to a shifting environment to improve birth outcomes through important pathways. Key to the continued reduction in adverse birth outcomes will be sustained improvement in community-level practices, as well as ensuring that health facilities are equipped to support quality care.

More than two-thirds of newborn lives could be saved worldwide if evidence-based interventions were successfully implemented. We developed the NeoTree application to improve quality of newborn care in resource-poor countries. The NeoTree is a fully integrated digital health intervention that combines immediate data capture, entered by healthcare workers (HCW) on admission, while simultaneously providing them with evidence-based clinical decision support and newborn care education. We conducted a mixed-methods intervention development study, codeveloping and testing the NeoTree prototype with HCWs in a district hospital in Malawi. Focus groups explored the acceptability and feasibility of digital health solutions before and after implementation of the NeoTree in the clinical setting. One-to-one theoretical usability workshops and a 1-month clinical usability study informed iterative changes, gathered process and clinical data, System Usability Scale (SUS) and perceived improvements in quality of care. HCWs perceived the NeoTree to be acceptable and feasible. Mean SUS before and after the clinical usability study were high at 80.4 and 86.1, respectively (above average is >68). HCWs reported high-perceived improvements in quality of newborn care after using the NeoTree on the ward. They described improved confidence in clinical decision-making, clinical skills, critical thinking and standardisation of care. Identified factors for successful implementation included a technical support worker. Coproduction, mixed-methods approaches and user-focused iterative development were key to the development of the NeoTree prototype, which was shown to be an agile, acceptable, feasible and highly usable tool with the potential to improve the quality of newborn care in resource-poor settings.

Background Maternal, perinatal and neonatal mortality remains high in low-income countries. We evaluated community and facility-based interventions to reduce deaths in three districts of Malawi. Methods We evaluated a rural participatory women’s group community intervention (CI) and a quality improvement intervention at health centres (FI) via a two-by-two factorial cluster randomized controlled trial. Consenting pregnant women were followed-up to 2 months after birth using key informants. Primary outcomes were maternal, perinatal and neonatal mortality. Clusters were health centre catchment areas assigned using stratified computer-generated randomization. Following exclusions, including non-birthing facilities, 61 clusters were analysed: control (17 clusters, 4912 births), FI (15, 5335), CI (15, 5080) and FI + CI (14, 5249). This trial was registered as International Standard Randomised Controlled Trial [ISRCTN18073903]. Outcomes for 14 576 and 20 576 births were recorded during baseline (June 2007–September 2008) and intervention (October 2008–December 2010) periods. Results For control, FI, CI and FI + CI clusters neonatal mortality rates were 34.0, 28.3, 29.9 and 27.0 neonatal deaths per 1000 live births and perinatal mortality rates were 56.2, 55.1, 48.0 and 48.4 per 1000 births, during the intervention period. Adjusting for clustering and stratification, the neonatal mortality rate was 22% lower in FI + CI than control clusters (OR = 0.78, 95% CI 0.60–1.01), and the perinatal mortality rate was 16% lower in CI clusters (OR = 0.84, 95% CI 0.72–0.97). We did not observe any intervention effects on maternal mortality. Conclusions Despite implementation problems, a combined community and facility approach using participatory women’s groups and quality improvement at health centres reduced newborn mortality in rural Malawi.

To investigate implementation of outpatient pulse oximetry among children with pneumonia, in Malawi.In 2011, 72 health-care providers at 18 rural health centres and 38 community health workers received training in the use of pulse oximetry to measure haemoglobin oxygen saturations. Data collected, between 1 January 2012 and 30 June 2014 by the trained individuals, on children aged 2-59 months with clinically diagnosed pneumonia were analysed.Of the 14 092 children included in the analysis, 13 266 (94.1%) were successfully checked by oximetry. Among the children with chest indrawing and/or danger signs, those with a measured oxygen saturation below 90% were more than twice as likely to have been referred as those with higher saturations (84.3% [385/457] vs 41.5% [871/2099];Implementation of pulse oximetry by our trainees substantially increased the referrals of Malawian children with severe hypoxaemic pneumonia. When data from oximetry were excluded, retrospective application of the guidelines published by WHO in 2014 failed to identify a considerable proportion of severely hypoxaemic children eligible only via oximetry.Étudier l'utilisation de l'oxymétrie de pouls chez les enfants atteints de pneumonie en traitement ambulatoire au Malawi.En 2011, 72 prestataires de soins de santé de 18 centres de santé ruraux et 38 agents de santé communautaires ont été formés à l'utilisation de l'oxymétrie de pouls pour mesurer la saturation en oxygène de l'hémoglobine. Des données collectées entre le 1er janvier 2012 et le 30 juin 2014 par les individus formés sur des enfants âgés de 2 à 59 mois atteints d'une pneumonie cliniquement diagnostiquée ont été analysées.Sur les 14 092 enfants inclus dans l'analyse, 13 266 (94,1%) ont été examinés avec succès grâce à l'oxymétrie. Parmi les enfants présentant un tirage sous-costal et/ou des signes de danger, ceux dont la saturation en oxygène mesurée était inférieure à 90% avaient plus de deux fois plus de chances d'être orientés vers un spécialiste que ceux présentant une saturation plus importante (84,3% [385/457] contre 41,5% [871/2099]; P 0,001). L'utilisation de l'oxymétrie semble avoir augmenté de 0% à 27,2% (P 0.001) le taux d'orientation vers un spécialiste dans le cas des enfants souffrant d'hypoxémie sévère sans tirage sous-costal ni signes de danger. En l'absence d'oxymétrie, si les directives en la matière publiées par l'Organisation mondiale de la Santé (OMS) en 2014 avaient été appliquées, 390/568 (68,7%) enfants souffrant d'hypoxémie sévère examinés dans les centres de santé considérés et 52/84 (61,9%) enfants souffrant d'hypoxémie sévère examinés par des agents de santé communautaires n'auraient pas pu bénéficier d'une orientation vers un spécialiste.L'utilisation de l'oxymétrie de pouls par les individus formés a considérablement accru l'orientation vers un spécialiste des enfants malawites atteints de pneumonie sévère et ayant développé une hypoxémie. Lorsque les données provenant de l'oxymétrie étaient exclues, l'application rétrospective des directives publiées par l'OMS en 2014 ne permettait pas d'identifier une proportion considérable d'enfants souffrant d'hypoxémie sévère qui remplissaient les conditions requises uniquement au vu de l'oxymétrie.Investigar la implementación de la oximetría de pulso ambulatoria en niños con neumonía en Malawi.En 2011, 72 profesionales de la salud de 18 centros de salud en zonas rurales y 38 trabajadores de la salud comunitarios recibieron formación con respecto al uso de la oximetría de pulso para medir las saturaciones de oxígeno de la hemoglobina. Se analizaron los datos, que las personas formadas recopilaron entre el 1 de enero de 2012 y el 30 de junio de 2014, de niños de 2 a 59 meses de edad con un diagnóstico clínico de neumonía.De los 14 092 niños incluidos en el análisis, se realizaron las pruebas con oximetría de manera satisfactoria a 13 266 (94,1%). Entre los niños con retracción costal y/o signos de peligro, aquellos con una medida de saturación de oxígeno por debajo del 90% tenían más del doble de probabilidades de haber sido derivados que aquellos con saturaciones más elevadas (84,3% [385/457] frente al 41,5% [871/2 099];La implementación de la oximetría de pulso por las personas formadas incrementó de forma sustancial las derivaciones de los niños de Malawi con neumonía hipoxémica grave. Cuando se excluyeron los datos procedentes de la oximetría, la aplicación retrospectiva de las directrices publicadas por la OMS en 2014 no pudo identificar un porcentaje considerable de niños hipoxémicos graves que cumplían los requisitos únicamente a través de la oximetría.الاستقصاء بشأن تنفيذ عمليات قياس التأكسج في العيادات الخارجية للأطفال المصابين بالالتهاب الرئوي في ملاوي.حصل 72 من مقدمي خدمات الرعاية الصحية في 18 مركزًا طبيًا ريفيًا و38 عاملاً في مجال الخدمات الصحية المجتمعية في عام 2011 على تدريبات متعلقة باستخدام تقنية قياس التأكسج بهدف قياس نسب تشبع الأكسجين والهيموجلوبين. وتم تحليل البيانات المجمعة في الفترة بين 1 كانون الثاني/يناير 2012 و 30 حزيران/يونيو 2014 بواسطة الأفراد المدرّبين، وهذه البيانات خاصة بالأطفال البالغ أعمارهم ما بين 2 إلى 59 شهرًا والمصابين بمرض الالتهاب الرئوي الذي تم تشخيصه داخل العيادات.من بين 14092 طفلاً شملهم التحليل، كان 13266 طفلاً منهم (بنسبة ‏94.1‏%) قد تم فحصه بنجاح بواسطة تقنية قياس التأكسج. ومن بين الأطفال الذين يعانون من بروز القفص الصدري أثناء التنفس و/أو علامات الخطر، كان أولئك الذين لديهم نسبة تشبع الأكسجين أقل من 90‏% لديهم أرجحية مضاعفة لإحالتهم للعلاج باعتبارهم من الأطفال الذين لديهم نسبة تشبع أعلى (84.3‏% [385/457] مقابل ‏41.5‏% [871/2099[؛إن تنفيذ عملية قياس التأكسج بواسطة المتدربين لدينا أدى بشكل كبير إلى زيادة حالات الإحالة للعلاج بالنسبة للأطفال المصابين بالالتهاب الرئوي الحاد في ملاوي. وعندما تم استبعاد بيانات قياس التأكسج، فشل التطبيق بأثر رجعي للمبادئ التوجيهية الصادرة من منظمة الصحة العالمية في عام 2014 في تحديد نسبة كبيرة من الأطفال المصابين بخلل الجهاز التنفسي الحاد والذين كانوا مؤهلين للعلاج نتيجة استخدام تقنية قياس التأكسج فقط.旨在调查马拉维肺炎患儿门诊脉搏血氧饱和度检测的实施情况。.2011 年，18 个农村医疗中心的 72 位医疗护理人员和 38 位社区医疗工作者接受了培训，学习使用脉搏血氧饱和度检测法测量血氧饱和度。 我们分析了受训人员于 2012 年 1 月 1 日到 2014 年 6 月 30 日期间采集的年龄在 2-59 个月、临床诊断为肺炎的儿童的数据。.在我们分析的 14 092 位儿童中，13 266 (94.1%) 位已经成功接受血氧饱和度检测。 在出现胸部凹陷和/或危险症状的儿童中，测量的血氧饱和度低于 90% 的儿童转诊的可能性是饱和度更高儿童的两倍以上（分别为 84.3% [385/457] 和 41.5% [871/2099];受训人员对脉搏血氧饱和度检测的实施大幅度提高了马拉维重度低氧性肺炎患儿的转诊率。 但是如果不采用血氧饱和度检测中的数据，而是追溯式采纳 WHO 2014 年发布的指南，则相当大比例的仅通过血氧饱和度检测才能确诊的重度低氧血症儿童无法得到确诊。.Изучить амбулаторное применение пульсоксиметрии у больных пневмонией детей в Малави.В течение 2011 года 72 врача из 18 сельских больниц и 38 местных медицинских работников были обучены использованию пульсоксиметрии для измерения насыщенности гемоглобина кислородом. Были проанализированы данные, собранные обученными лицами на протяжении периода с 1 января 2012 года по 30 июня 2014 года у детей в возрасте от 2 до 59 месяцев, которым был поставлен диагноз «пневмония».Из 14 092 детей, включенных в анализ, у 13 266 (94,1%) удалось успешно провести пульсоксиметрию. Дети со впалой грудью и (или) опасными симптомами, у которых измеренная насыщенность кислородом была менее 90%, более чем в два раза чаще направлялись в больницу, чем дети с высокой оксигенацией (84,3% (385 из 457 детей) против 41,5% (871 ребенок из 2099), р 0,001). Доступность оксиметрии привела к повышению уровня направления в больницу для детей с серьезной гипоксемией без впалой груди или опасных симптомов с 0 до 27,2% (p 0,001). В отсутствие оксиметрии и при использовании соответствующих рекомендаций Всемирной организации здравоохранения (ВОЗ), опубликованных в 2014 году, 390 из 568 детей (68,7%) с серьезной гипоксемией в центрах проведения исследования и 52 из 84 детей (61,9%) с серьезной гипоксемией, которых осматривали местные медицинские работники, не были бы направлены в больницу ввиду отсутствия показаний.Внедрение пульсоксиметрии нашими стажерами значительно повысило частоту направления в больницу малавийских детей с серьезной гипоксемией пневмонийного происхождения. При исключении из анамнеза данных пульсоксиметрии ретроспективное применение рекомендаций ВОЗ от 2014 года не позволяло выявить значительное количество детей с серьезной гипоксемией, необходимость госпитализации которых оказалось возможным определить только с помощью оксиметрии.

Improvements in health-care quality can contribute to healthier populations. However, many global and national health strategies are not sufficiently considering the issues of measuring and improving health-care quality in low-resource settings. (1) The barriers to delivering high-quality care are often similar across different health systems. However, the extent and mechanisms through which these barriers affect quality improvement interventions may be different in resource-poor settings. (2) Investments in health systems strengthening without continuous quality improvement is thought to be a useless effort. (3) Conversely, only focusing on quality improvement in a resource-poor context without engaging the broader health system for support is of limited value. Hence, both areas must be improved simultaneously. Here, we call for renewed focus on quality improvement of health-system delivery by policy-makers, managers and health-care providers, working at all levels of health-care systems in resource-poor settings. To maximize the potential of quality improvements, we propose an approach focusing on five elements: (i) systems thinking; (ii) stakeholders' participation; (iii) accountability; (iv) evidence-based interventions; and (v) innovative evaluation (Box 1). Some of the elements are well supported by peer-reviewed literature, while other elements are lacking good evidence. We base our ideas on our experience in diverse countries and settings. We hope that bringing all these elements together into a unified approach will stimulate debate, highlight important research gaps and support policy-makers, healthcare providers and patient and community representatives working in this field. The first element, systems thinking, views health-care systems in a holistic manner and is often described as operating at micro- (clinical team), meso- (health facilities) and macro-level (health-care system). Systems thinking offers a useful framework for addressing the interdependency of these different levels that influence health-care delivery and health outcomes. (4) Interventions targeted to improve quality of care are unlikely to succeed or be sustained if designed without an adequate understanding of relevant contextual factors at these different levels. (5) Researchers and implementers are now recognizing the importance of these factors and their dynamic interaction in delivering safer, more effective care. (6) Failure to address these interdependencies may be particularly damaging in resource-poor settings, where constrained resources, lack of infrastructure and weak governance can exacerbate the difficulties of implementing an intervention. Examples range from unused expensive equipment due to lack of trained staff or electricity to operate it, to scarce health workers migrating to national and international organizations leading to understaffed primary, maternal and child care. Cultural and behavioural factors also affect these interdependencies and can contribute to problems during implementation. Interventions in resource-poor settings have to consider improvement across the different levels of the health system when trying to improve care at the clinical microsystems level. (7) Box 1 Elements to consider when improving health-care quality in resource-poor settings Systems thinking Health systems are dynamic complex adaptive systems, where all parts need to be considered. These parts are (I) the Inter-relationships between the patient, clinical and noncllnlcal workers In the health system; (II) the different levels of the health system ranging from the community to tertiary referral system; and (III) the required human and material resources and training, supervision and management structures. Participatory approach Participatory, grounded and bottom-up approaches Involving health-care professionals, patients and communities as well as researchers-in-resldence are Important to understand health systems. …

BACKGROUND: Few studies have reported long-term data on mortality rates for children admitted to hospital with pneumonia in Africa. We examined trends in case fatality rates for all-cause clinical pneumonia and its risk factors in Malawian children between 2001 and 2012.METHODS: Individual patient data for children (FINDINGS: Between November, 2012, and May, 2013, we retrospectively collected all available hard copies of yellow forms from 40 of 41 participating hospitals. We examined 113 154 pneumonia cases, 104 932 (92·7%) of whom had mortality data and 6903 of whom died, and calculated an overall case fatality rate of 6·6% (95% CI 6·4-6·7). The case fatality rate significantly decreased between 2001 (15·2% [13·4-17·1]) and 2012 (4·5% [4·1-4·9]; ptrendINTERPRETATION: Pneumonia mortality and its risk factors have steadily improved in the past decade in Malawi; however, mortality remains high in specific subgroups. Improvements in hospital care may have reduced case fatality rates though a lack of sufficient data on quality of care indicators and the potential of socioeconomic and other improvements outside the hospital precludes adequate assessment of why case-fatality rates fell. Results from this study emphasise the importance of effective national systems for data collection. Further work combining this with data on trends in the incidence of pneumonia in the community are needed to estimate trends in the overall risk of mortality from pneumonia in children in Malawi.FUNDING: Bill & Melinda Gates Foundation.

Background: Pneumonia is a leading cause of death in Malawian infants under 2 months of age. Consensus defines hypoxaemia in infants as a peripheral capillary oxygen saturation (SpO2) of less than 90%. We aimed to estimate the incidence and degree of hypoxaemia and its correlation with mortality in infants younger than 2 months presenting to district hospitals in Malawi. Methods: We retrospectively analysed a child pneumonia surveillance dataset prospectively collected during routine care at seven hospitals in Malawi between 2011 and 2014. Infants aged 0–2 months with pneumonia according to 2012 WHO case management guidelines were included. We used logistic regression to determine correlation between degree of hypoxaemia and in-hospital death. Findings: 1810 infant pneumonia admissions were analysed. The case fatality rate was 3·6% (n=65). SpO2 could not be measured in 8·5% (n=154) of patients. Median SpO2 was 96% (IQR 91–98). Infants for whom SpO2 measurement was successful versus unsuccessful had similar rates of chest indrawing (85·6% vs 79·2%) and female sex (40·9% vs 39·6%), but a higher incidence of WHO danger signs (88·3% vs 81·8%, p=0·04). Compared with infants with an SpO2 of 93–100% (n=1160), infants with an SpO2 of 90–92% (n=187) or

ObjectiveTo gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries.DesignFocus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach.SettingCommunity, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care.ParticipantsHealthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors.ResultsWe conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability.ConclusionsPulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations.Trial registration numberNCT02941237.

Background Human resources are a major cost driver in childhood pneumonia case management. Introduction of 13-valent pneumococcal conjugate vaccine (PCV-13) in Malawi can lead to savings on staff time and salaries due to reductions in pneumonia cases requiring admission. Reliable estimates of human resource costs are vital for use in economic evaluations of PCV-13 introduction. Methods Twenty-eight severe and twenty-four very severe pneumonia inpatients under the age of five were tracked from admission to discharge by paediatric ward staff using self-administered timesheets at Mchinji District Hospital between June and August 2012. All activities performed and the time spent on each activity were recorded. A monetary value was assigned to the time by allocating a corresponding percentage of the health workers’ salary. All costs are reported in 2012 US$. Results A total of 1,017 entries, grouped according to 22 different activity labels, were recorded during the observation period. On average, 99 min (standard deviation, SD = 46) were spent on each admission: 93 (SD = 38) for severe and 106 (SD = 55) for very severe cases. Approximately 40 % of activities involved monitoring and stabilization, including administering non-drug therapies such as oxygen. A further 35 % of the time was spent on injecting antibiotics. Nurses provided 60 % of the total time spent on pneumonia admissions, clinicians 25 % and support staff 15 %. Human resource costs were approximately US$ 2 per bed-day and, on average, US$ 29.5 per severe pneumonia admission and US$ 37.7 per very severe admission. Conclusions Self-reporting was successfully used in this context to generate reliable estimates of human resource time and costs of childhood pneumonia treatment. Assuming vaccine efficacy of 41 % and 90 % coverage, PCV-13 introduction in Malawi can save over US$ 2 million per year in staff costs alone.

Background Improved referral algorithms for children with non-severe pneumonia at the community level are desirable. We sought to identify predictors of oral antibiotic failure in children who fulfill the case definition of World Health Organization (WHO) non-severe pneumonia. Predictors of greatest interest were those not currently utilized in referral algorithms and feasible to obtain at the community level. Methods We systematically reviewed prospective studies reporting independent predictors of oral antibiotic failure for children 2–59 months of age in resource-limited settings with WHO non-severe pneumonia (either fast breathing for age and/or lower chest wall indrawing without danger signs), with an emphasis on predictors not currently utilized for referral and reasonable for community health workers. We searched PubMed, Cochrane, and Embase and qualitatively analyzed publications from 1997–2014. To supplement the limited published evidence in this subject area we also surveyed respiratory experts. Results Nine studies met criteria, seven of which were performed in south Asia. One eligible study occurred exclusively at the community level. Overall, oral antibiotic failure rates ranged between 7.8-22.9 %. Six studies found excess age-adjusted respiratory rate (either WHO-defined very fast breathing for age or 10–15 breaths/min faster than normal WHO age-adjusted thresholds) and four reported young age as predictive for oral antibiotic failure. Of the seven predictors identified by the expert panel, abnormal oxygen saturation and malnutrition were most highly favored per the panel’s rankings and comments. Conclusions This review identified several candidate predictors of oral antibiotic failure not currently utilized in childhood pneumonia referral algorithms; excess age-specific respiratory rate, young age, abnormal oxygen saturation, and moderate malnutrition. However, the data was limited and there are clear evidence gaps; research in rural, low-resource settings with community health workers is needed. Electronic supplementary material The online version of this article (doi:10.1186/s12887-015-0392-x) contains supplementary material, which is available to authorized users.

Background: Postpartum maternal and infant mortality is high in sub-Saharan Africa and improving postpartum care as a strategy to enhance maternal and infant health has been neglected. We describe the design and selection of suitable, context-specific interventions that have the potential to improve postpartum care. Methods: The study is implemented in rural districts in Burkina Faso, Kenya, Malawi and Mozambique. We used the four steps 'systems thinking' approach to design and select interventions: 1) we conducted a stakeholder analysis to identify and convene stakeholders; 2) we organised stakeholders causal analysis workshops in which the local postpartum situation and challenges and possible interventions were discussed; 3) based on comprehensive needs assessment findings, inputs from the stakeholders and existing knowledge regarding good postpartum care, a list of potential interventions was designed, and; 4) the stakeholders selected and agreed upon final context-specific intervention packages to be implemented to improve postpartum care. Results: Needs assessment findings showed that in all study countries maternal, newborn and child health is a national priority but specific policies for postpartum care are weak and there is very little evidence of effective postpartum care implementation. In the study districts few women received postpartum care during the first week after childbirth (25 % in Burkina Faso, 33 % in Kenya, 41 % in Malawi, 40 % in Mozambique). Based on these findings the interventions selected by stakeholders mainly focused on increasing the availability and provision of postpartum services and improving the quality of postpartum care through strengthening postpartum services and care at facility and community level. This includes the introduction of postpartum home visits, strengthening postpartum outreach services, integration of postpartum services for the mother in child immunisation clinics, distribution of postpartum care guidelines among health workers and upgrading postpartum care knowledge and skills through training. Conclusion: There are extensive gaps in availability and provision of postpartum care for mothers and infants. Acknowledging these gaps and involving relevant stakeholders are important to design and select sustainable, context-specific packages of interventions to improve postpartum care.

Background In Malawi, maternal mortality remains high. Existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system. We assessed the value of community involvement to improve capture and response to community maternal deaths. Methods We designed and piloted a community-linked maternal death review (CLMDR) process in Mchinji District, Malawi, which partnered community and health facility stakeholders to identify and review maternal deaths and generate actions to prevent future deaths. The CLMDR process involved five stages: community verbal autopsy, community and facility review meetings, a public meeting and bimonthly reviews involving both community and facility representatives. Results The CLMDR process was found to be comparable to a previous research-driven surveillance system at identifying deaths in Mchinji District (population 456 500 in 2008). 52 maternal deaths were identified between July 2011 and June 2012, 27 (52%) of which would not have been identified without community involvement. Based on district estimates of population (500 000) and crude birth rate (35 births per 1000 population), the maternal mortality ratio was around 300 maternal deaths per 100 000 live births. Of the 41 cases that started the CLMDR process, 28 (68%) completed all five stages. We found the CLMDR process to increase the quantity of information available and to involve a wider range of stakeholders in maternal death review (MDR). The process resulted in high rates of completion of community-planned actions (82%), and district hospital (67%) and health centre (65%) actions to prevent maternal deaths. Conclusions CLMDR is an important addition to the established forms of MDR. It shows potential as a maternal death surveillance system, and may be applicable to similar contexts with high maternal mortality.

Background Millennium Development Goal 5 (MDG 5) targets a 75% reduction in maternal mortality from 1990 to 2015, yet accurate information on trends in maternal mortality and what drives them is sparse. We aimed to fill this gap for Malawi, a country in sub-Saharan Africa with high maternal mortality. Methods We reviewed the literature for population-based studies that provide estimates of the maternal mortality ratio (MMR) in Malawi, and for studies that list and justify variables potentially associated with trends in MMR. We used all population-based estimates of MMR representative of the whole of Malawi to construct a best-fit trend-line for the range of years with available data, calculated the proportion attributable to HIV and qualitatively analysed trends and evidence related to other covariates to logically assess likely candidate drivers of the observed trend in MMR. Results 14 suitable estimates of MMR were found, covering the years 1977–2010. The resulting best-fit line predicted MMR in Malawi to have increased from 317 maternal deaths/100 000 live-births in 1980 to 748 in 1990, before peaking at 971 in 1999, and falling to 846 in 2005 and 484 in 2010. Concurrent deteriorations and improvements in HIV and health system investment and provisions are the most plausible explanations for the trend. Female literacy and education, family planning and poverty reduction could play more of a role if thresholds are passed in the coming years. Conclusions The decrease in MMR in Malawi is encouraging as it appears that recent efforts to control HIV and improve the health system are bearing fruit. Sustained efforts to prevent and treat maternal complications are required if Malawi is to attain the MDG 5 target and save the lives of more of its mothers in years to come.

The major challenge for health care planners lies in integrating health promotion and disease prevention on the one hand and treatment of acute illness and chronic care on the other. This has to be done at all levels of the health system with the aim of delivering quality services equitably and efficiently to the whole population. This is a particular problem as many governments spend less than US $10 per person per year on health. Acute sector healthcare, including anaesthesia, is often deficient under these circumstances.

Summary Background Maternal and neonatal mortality rates remain high in many low-income and middle-income countries. Different approaches for the improvement of birth outcomes have been used in community-based interventions, with heterogeneous effects on survival. We assessed the effects of women's groups practising participatory learning and action, compared with usual care, on birth outcomes in low-resource settings. Methods We did a systematic review and meta-analysis of randomised controlled trials undertaken in Bangladesh, India, Malawi, and Nepal in which the effects of women's groups practising participatory learning and action were assessed to identify population-level predictors of effect on maternal mortality, neonatal mortality, and stillbirths. We also reviewed the cost-effectiveness of the women's group intervention and estimated its potential effect at scale in Countdown countries. Findings Seven trials (119 428 births) met the inclusion criteria. Meta-analyses of all trials showed that exposure to women's groups was associated with a 23% non-significant reduction in maternal mortality (odds ratio 0·77, 95% CI 0·48–1·23), a 20% reduction in neonatal mortality (0·80, 0·67–0·96), and a 7% non-significant reduction in stillbirths (0·93, 0·82–1·05), with high heterogeneity for maternal ( I 2 =64·0%, p=0·011) and neonatal results ( I 2 =73·2%, p=0·001). In the meta-regression analyses, the proportion of pregnant women in groups was linearly associated with reduction in both maternal and neonatal mortality (p=0·019 and p=0·009, respectively). A subgroup analysis of the four studies in which at least 30% of pregnant women participated in groups showed a 49% reduction in maternal mortality (0·51, 0·29–0·89) and a 33% reduction in neonatal mortality (0·67, 0·60–0·75). The intervention was cost effective by WHO standards and could save an estimated 283 000 newborn infants and 36 600 mothers per year if implemented in rural areas of 74 Countdown countries. Interpretation With the participation of at least a third of pregnant women and adequate population coverage, women's groups practising participatory learning and action are a cost-effective strategy to improve maternal and neonatal survival in low-resource settings. Funding Wellcome Trust, Ammalife, and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Birmingham and the Black Country programme.