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BackgroundWidespread increases in caesarean section (CS) rates have sparked concerns about risks to mothers and infants and rising healthcare costs. A multicentre, two-arm, cluster-randomized trial in Quebec, Canada assessed whether an audit and feedback intervention targeting health professionals would reduce CS rates for pregnant women compared to usual care, and concluded that it reduced CS rates without adverse effects on maternal or neonatal health. The effect was statistically significant but clinically small. We assessed cost-effectiveness to inform scale-up decisions.MethodsA prospective economic evaluation was undertaken using individual patient data from the Quality of Care, Obstetrics Risk Management, and Mode of Delivery (QUARISMA) trial (April 2008 to October 2011). Analyses took a healthcare payer perspective. The time horizon captured hospital-based costs and clinical events for mothers and neonates from labour onset to 3 months postpartum. Resource use was identified and measured from patient charts and valued using standardized government sources. We estimated the changes in CS rates and costs for the intervention group (versus controls) between the baseline and post-intervention periods. We examined heterogeneity between clinical subgroups of high-risk versus low-risk pregnancies and estimated the joint uncertainty in cost-effectiveness over 20,000 trial simulations. We decomposed costs to identify drivers of change.ResultsThe intervention group experienced per-patient reductions of 0.005 CS (95% confidence interval (CI): -0.015 to 0.004, P = 0.09) and $180 (95% CI: -$277 to - $83, P

Introduction: Socialprotection programmes are considered HIV-sensitive when addressing risk, vulnerability or impact of HIV infection. Socio-economic interventions, like livelihood and employability programmes, address HIV vulnerabilities like poverty and gender inequality. We explored the HIV-sensitivity of socio-economic interventions for unemployed and out-of-school young women aged 15 to 30 years, in Fast and Southern Africa, a key population for HIV infection. Methods: We conducted a systematic review using a narrative synthesis method and the Mixed Methods AppraisalTool for quality appraisal. Interventions of interest were work skills training, microfinance, and employment support. Outcomes of interest were socio-economic outcomes (income, assets, savings, skills, (self-) employment) and HIV-related outcomes (behaviouraland biological). We searched published and grey literature (January 2005 to November 2019; English/French) in MFDLINF, Scopus, Web of Science and websites of relevant internationalorganizations. Results: We screened 3870 titles and abstracts and 188 full-text papers to retain 18 papers, representing 12 projects. Projects offered different combinations of HIV-sensitive socialprotection programmes, complemented with mentors, safe space and training (HIV, reproductive health and gender training). All 12 projects offered work skills training to improve life and business skills. Six offered formal(n = 2) or informal(n = 5) livelihood training. Fleven projects offered microfinance, including microgrants (n = 7), microcredit (n = 6) and savings (n = 4). One project offered employment support in the form of apprenticeships. In general, microgrants, savings, business and life skills contributed improved socio-economic and HIV-related outcomes. Most livelihood training contributed positive socio-economic outcomes, but only two projects showed improved HIV-related outcomes. Microcredit contributed little to either outcome. Programmes were effective when (i) sensitive to beneficiaries' age, needs, interests and economic vulnerability; (ii) adapted to local-implementation contexts; and (iii) included life skills. Programme delivery through mentorship and safe space increased social capital and may be critical to improve the HIV-sensitivity of socio-economic programmes. Conclusions: A wide variety of livelihood and employability programmes were leveraged to achieve improved socio-economic and HIV-related outcomes among unemployed and out-of-school young women. To be HIV-sensitive, programmes should be designed around their interests, needs and vulnerability, adapted to local implementation contexts, and include life skills. Fmployment support received little attention in this literature. Keywords: adolescent girls and young women; Africa region; HIV prevention; social support; structural drivers; structural interventions, 1 | INTRODUCTION In 2018, East and Southern Africa represented nearly one half of global human immunodeficiency virus (HIV) incident cases [1]. Adolescent girls and young women (AGYW) aged 15 [...]

BackgroundViolence against women by their male intimate partners (IPV) during pregnancy may lead to negative pregnancy outcomes. We examined the role of IPV as a potential risk factor for miscarriage in Guatemala. Our objectives were: (1) To describe the magnitude and pattern of verbal, physical and sexual violence by male intimate partners in the last 12 months (IPV) in a sample of pregnant Guatemalans; (2) To evaluate the influence of physical or sexual IPV on miscarriage as a pregnancy outcome.MethodsAll pregnant women reporting to the maternity of a major tertiary care public hospital in Guatemala City from June 1st to September 30th, 2006 were invited to participate in this cross-sectional study. The admitting physician assessed occurrence of miscarriage, defined as involuntary pregnancy loss up to and including 28 weeks gestation. Data on IPV, social and demographic characteristics, risk behaviours, and medical history were collected by interviewer-administered questionnaire. Laboratory testing was performed for HIV and syphilis. The relationship between IPV and miscarriage was assessed through multivariable logistic regression.ResultsIPV affected 18% of the 1897 pregnant Guatemalan women aged 15-47 in this sample. Verbal IPV was most common (16%), followed by physical (10%) and sexual (3%) victimisation. Different forms of IPV were often co-prevalent. Miscarriage was experienced by 10% of the sample (n = 190). After adjustment for potentially confounding factors, physical or sexual victimisation by a male intimate partner in the last 12 months was significantly associated with miscarriage (ORadj 1.1 to 2.8). Results were robust under a range of analytic assumptions.ConclusionsPhysical and sexual IPV is associated with miscarriage in this Guatemalan facility-based sample. Results cohere well with findings from population-based surveys. IPV should be recognised as a potential cause of miscarriage. Reproductive health services should be used to screen for spousal violence and link to assistance.

Equity monitoring is a priority for Gavi, the Vaccine Alliance, and for those implementing The2030agenda for sustainable development. For its new phase of operations, Gavi reassessed its approach to monitoring equity in vaccination coverage. To help inform this effort, we made a systematic analysis of inequalities in vaccination coverage across 45 Gavi-supported countries and compared results from different measurement approaches. Based on our findings, we formulated recommendations for Gavi's equity monitoring approach. The approach involved defining the vulnerable populations, choosing appropriate measures to quantify inequalities, and defining equity benchmarks that reflect the ambitions of the sustainable development agenda. In this article, we explain the rationale for the recommendations and for the development of an Improved equity monitoring tool. Gavi's previous approach to measuring equity was the difference in vaccination coverage between a country's richest and poorest wealth quintiles. In addition to the wealth index, we recommend monitoring other dimensions of vulnerability (maternal education, place of residence, child sex and the multidimensional poverty index). For dimensions with multiple subgroups, measures of inequality that consider information on all subgroups should be used. We also recommend that both absolute and relative measures of inequality be tracked over time. Finally, we propose that equity benchmarks target complete elimination of inequalities. To facilitate equity monitoring, we recommend the use of a data display tool--the equity dashboard--to support decision-making in the sustainable development period. We highlight its key advantages using data from Cote d'Ivoire and Haiti. Le suivi de l'equite est une priorite pour Gavi, l'Alliance du Vaccin et pour ceux qui mettent en oeuvre le Programme de developpement durable a l'horizon 2030. Dans le cadre de sa nouvelle phase d'operations, Gavi a repense son approche relative au suivi de l'equite en matiere de couverture vaccinale. Afin de contribuer a cet effort, nous avons realise une analyse systematique des inegalites en matiere de couverture vaccinale dans 45 pays soutenus par Gavi et compare les resultats obtenus a partir de differentes methodes de mesure. Nous nous sommes appuyes sur nos conclusions pour formuler des recommandations concernant l'approche adoptee par Gavi pour suivre l'equite. Cette approche impliquait de definir les populations vulnerables, de choisir des mesures appropriees pour quantifier les inegalites et d'etablir des criteres en matiere d'equite qui refletent les ambitions du programme de developpement durable. Dans le present article, nous expliquons la raison d'etre de nos recommandations et le but de l'elaboration d'un meilleur outil de suivi de l'equite. L'approche precedemment utilisee par Gavi pour mesurer l'equite consistait a calculer la difference en matiere de couverture vaccinale entre les quintiles de richesse les plus eleves et les plus bas d'un pays. Nous recommandons de suivre des dimensions de la vulnerabilite (education maternelle, lieu de residence, sexe des enfants et indice de pauvrete multidimensionnelle) autres que l'indice de richesse. Lorsqu'une dimension inclut divers sous-groupes, il convient d'utiliser des mesures de l'inegalite prenant en compte les informations relatives a tous les sous-groupes. Nous conseillons egalement de suivre les mesures absolues mais aussi relatives d'inegalite au fil du temps. Enfin, nous suggerons que les criteres en matiere d'equite visent l'elimination complete des inegalites. Afin de faciliter le suivi de l'equite, nous recommandons l'utilisation d'un outil d'affichage de donnees--le tableau de bord de l'equite--pour favoriser la prise de decision dans le cadre du programme de developpement durable. Nous mettons en avant les principaux avantages de cet outil a l'aide de donnees provenant de Cote d'ivoire et d'Haiti. La supervision de la equidad es una prioridad para la Gavi, la Vaccine Alliance y para los que implementan la Agenda 2030 para el Desarrollo Sostenible. Para su nueva fase de operaciones, la Gavi reevaluo su enfoque para supervisar la equidad en la cobertura de vacunacion. Para ayudar a informar este esfuerzo, se realizo un analisis sistematico de desigualdades en la cobertura de vacunacion en 45 paises apoyados por la Gavi y se compararon los resultados desde distintos enfoques de medicion. En base a los resultados, se formularon recomendaciones para el enfoque de supervision de equidad de la Gavi. El enfoque implico la definicion de las poblaciones vulnerables, la seleccion de las medidas adecuadas para cuantificar las desigualdades y la definicion de las referencias de equidad que reflejan las ambiciones de la agencia de desarrollo sostenible. En este articulo, se explican los motivos de las recomendaciones y el desarrollo de una herramienta mejorada de supervision de la equidad. El anterior enfoque de la Gavi para la medicion de la equidad era la diferencia de la cobertura de vacunacion entre los sectores demograficos mas ricos y mas pobres de un pais. Ademas del indice patrimonial, se recomienda supervisar otras dimensiones de vulnerabilidad (educacion de la madre, lugar de residencia, sexo de los ninos y el indice de pobreza multidimensional). Para las dimensiones con multiples subgrupos, deberian utilizarse medidas de desigualdad que tienen en cuenta informacion acerca de todos los subgrupos.Tambien se recomienda que, con el paso del tiempo, se haga un seguimiento tanto de la medida de desigualdad absoluta como relativa. Por ultimo, se propone que las referencias de equidad tengan como objetivo la eliminacion completa de la desigualdad. Para facilitar la supervision de la equidad, se recomienda utilizar una herramienta de indicacion de datos (el tablero de equidad) para apoyar la toma de decisiones durante el periodo de desarrollo sostenible. Se destacan sus ventajas basicas utilizando datos de Cote d'ivoire y de Haiti., Introduction The 2030 agenda for sustainable development calls upon the international community to prioritize the needs and rights of the most vulnerable, so that no one is left behind. (1) [...]

Objective To quantify the impact on mortality of offering a hypothetical set of technically feasible, high-impact interventions for maternal and child survival during India's 2010-2013 measles supplementary immunization activity. Methods We developed Lives Saved Tool models for 12 Indian states participating in the supplementary immunization, based on state-and sex-specific data on mortality from India's Million Deaths Study and on health services coverage from Indian household surveys. Potential add-on interventions were identified through a literature review and expert consultations. We quantified the number of lives saved for a campaign offering measles vaccine alone versus a campaign offering measles vaccine with six add-on interventions (nutritional screening and complementary feeding for children, vitamin A and zinc supplementation for children, multiple micronutrient and calcium supplementation in pregnancy, and free distribution of insecticide-treated bednets). Findings The measles vaccination campaign saved an estimated 19 016 lives of children younger than 5 years. A hypothetical campaign including measles vaccine with add-on interventions was projected to save around 73 900 lives (range: 70 200-79 300), preventing 73 700 child deaths (range: 70 000-79 000) and 300 maternal deaths (range: 200-400). The most effective interventions in the whole package were insecticide-treated bednets, measles vaccine and preventive zinc supplementation. Girls accounted for 66% of expected lives saved (12 712/19 346) for the measles vaccine campaign, and 62% of lives saved (45 721/74 367) for the hypothetical campaign including add-on interventions. Conclusion In India, a measles vaccination campaign including feasible, high-impact interventions could substantially increase the number of lives saved and mitigate gender-related inequities in child mortality. Objectif Quantifier l'impact sur la mortalite d'un hypothetique ensemble d'interventions a fort impact et techniquement realisables pour la survie de la mere et de l'enfant lors d'une activite de vaccination antirougeoleuse supplementaire menee en Inde de 2010 a 2013. Methodes Pour 12 des Etats indiens participant a l'activite de vaccination supplementaire, nous avons elabore des modeles LiST (Lives Saved Tool--Outil de Vies Sauvees) en fonction de donnees ventilees par Etat et par sexe sur la mortalite--tirees de l'etude indienne Million Deaths Study--, et sur la couverture des services de sante--tirees d'enquetes aupres des menages indiens. Des interventions supplementaires potentielles ont ete identifiees a l'aide d'un examen de la litterature et de consultations d'experts. Nous avons quantifie le nombre de vies sauvees dans le cadre d'une campagne de vaccination antirougeoleuse seule par rapport a une campagne de vaccination antirougeoleuse comportant six interventions supplementaires (analyse nutritionnelle et alimentation d'appoint pour les enfants, supplementation en vitamine A et en zinc pour les enfants, supplementation en micronutriments multiples et en calcium au cours de la grossesse et distribution gratuite de moustiquaires impregnees d'insecticide). Resultats D'apres nos estimations, la campagne de vaccination antirougeoleuse a permis de sauver 19 016 enfants ages de moins de 5 ans. Il a ete calcule qu'une hypothetique campagne de vaccination antirougeoleuse incluant des interventions supplementaires permet de sauver quelque 73 900 vies (etendue: 70 200-79 300), prevenant le deces de 73 700 enfants (etendue: 70 000-79 000) et de 300 meres (etendue: 200-400). Les interventions les plus efficaces se sont averees etre les moustiquaires impregnees, le vaccin contre la rougeole et la supplementation preventive en zinc. Les filles representaient 66% des vies sauvees escomptees (12712/19 346) dans le cadre de la campagne de vaccination antirougeoleuse et 62% des vies sauvees (45 721/74 367) dans le cadre de la campagne hypothetique incluant des interventions supplementaires. Conclusion En Inde, une campagne de vaccination antirougeoleuse comportant des interventions realisables a fort impact pourrait considerablement accroitre le nombre de vies sauvees et reduire les inegalites entre les sexes concernant la mortalite infantile. Objetivo Cuantificar el impacto en la mortalidad del hecho de ofrecer un conjunto hipotetico de intervenciones tecnicamente viables y de alto impacto para la supervivencia de madres e hijos durante la actividad de inmunizacion suplementaria antisarampionosa en la India entre 2010 y 2013. Metodos Se desarrollaron los modelos de la herramienta 'Uve Saved Tool' para 12 estados indios participantes en la inmunizacion suplementaria, en base a informacion segun el estado y el sexo sobre la mortalidad recopilada en el estudio 'Million Deaths Study' de la India y sobre la cobertura de servicios sanitarios de las encuestas domesticas realizadas en la India. Se identificaron posibles intervenciones adicionales a traves de un analisis de documentos y consultas a expertos. Se cuantifico el numero de vidas salvadas durante una campana que ofrecia la vacuna antisarampionosa frente a una campana que ofrecia la vacuna antisarampionosa con seis intervenciones adicionales (revision nutricional y alimentacion complementaria para ninos, suplementos de vitamina A y zinc para ninos, varios micronutrientes, suplemento de calcio durante el embarazo y distribucion gratuita de mosquiteros tratados con insecticida). Resultados La campana de vacunacion antisarampionosa salvo unas 19016 vidas de ninos menores de 5 anos. Se estimo que una campana hipotetica que incluia la vacuna antisarampionosa e intervenciones adicionales salvaria unas 73 900 vidas (alcance: 70 200-79 300), evitando 73 700 muertes infantiles (alcance: 70000-79000) y 300 muertes maternas (alcance: 200-400). Las intervenciones mas eficaces de todo el paquete fueron los mosquiteros tratados con insecticida, la vacuna antisarampionosa y el suplemento preventivo de zinc. Las ninas representaron un 66% de las vidas salvadas (12 712/19 346) durante la campana de vacuna antisarampionosa y un 62% de las vidas salvadas (45 721/74 367) durante la campana hipotetica que incluye las intervenciones adicionales. Conclusion En la India, una campana de vacunacion antisarampionosa que Incluya intervenciones viables y de gran impacto podria incrementar enormemente el numero de vidas salvadas y mitigar la desigualdad de genero en la mortalidad infantil., Introduction Measles vaccination made an important contribution to the millennium development goal to reduce under-5 mortality (MDG4), (1) accounting for 23% of the estimated worldwide decline in all-cause child mortality [...]

Objective To investigate which strategies to increase demand for vaccination are effective in increasing child vaccine coverage in low- and middle-income countries. Methods We searched MEDLINE, EMBASE, Cochrane library, POPLINE, ECONLIT, CINAHL, LILACS, BDSP, Web of Science and Scopus databases for relevant studies, published in English, French, German, Hindi, Portuguese and Spanish up to 25 March 2014. We included studies of interventions intended to increase demand for routine childhood vaccination. Studies were eligible if conducted in low- and middle-income countries and employing a randomized controlled trial, non-randomized controlled trial, controlled before-and-after or interrupted time series design. We estimated risk of bias using Cochrane collaboration guidelines and performed random-effects meta-analysis. Findings We identified 11 studies comprising four randomized controlled trials, six cluster randomized controlled trials and one controlled before-and-after study published in English between 1996 and 2013. Participants were generally parents of young children exposed to an eligible intervention. Six studies demonstrated low risk of bias and five studies had moderate to high risk of bias. We conducted a pooled analysis considering all 11 studies, with data from 11512 participants. Demand-side interventions were associated with significantly higher receipt of vaccines, relative risk (RR): 1.30, (95% confidence Interval, CI: 1.17-1.44). Subgroup analyses also demonstrated significant effects of seven education and knowledge translation studies, RR: 1.40 (95% CI: 1.20-1.63) and of four studies which used incentives, RR: 1.28 (95% CI: 1.12-1.45). Conclusion Demand-side interventions lead to significant gains in child vaccination coverage in low- and middle-income countries. Educational approaches and use of incentives were both effective strategies. Objectif Determiner, parmi les strategies visant a accroitre la demande de vaccination, celles qui sont efficaces pour augmenter la couverture vaccinale des enfants dans les pays a revenu faible et intermediaire. Methodes Nous avons recherche, dans les bases de donnees MEDLINE, EMBASE, de la bibliotheque Cochrane, POPLINE, ECONLIT, CINAHL, LILACS, BDSP, Web of Science et Scopus, des etudes a ce sujet, publiees en allemand, en anglais, en espagnol, en francais, en hindi, et en portugais, jusqu'au 25 mars 2014. Nous avons inclus les etudes relatives a des interventions visant a accroitre la demande de vaccination systematique des enfants. Les etudes etaient recevables si elles avaient ete menees dans des pays a revenu faible et intermediaire et si elles etaient de type essai controle randomise, essai controle non randomise, controle avant et apres ou etude de series temporelles Interrompues. Nous avons estime le risque de biais suivant les directives de la collaboration Cochrane et avons realise une meta-analyse a effets aleatoires. Resultats Nous avons releve 11 etudes, comprenant quatre essais controles randomises, six essais controles randomises en grappes et une etude controlee avant et apres, qui ont ete publiees en anglais entre 1996 et 2013. Les participants etaient generalement les parents de jeunes enfants exposes a une intervention eligible. Six etudes montraient un faible risque de biais et cinq etudes avalent un risque de biais moyen a eleve. Nous avons realise une analyse combinee en tenant compte des 11 etudes, avec des donnees provenant de 11 512 participants. Les interventions axees sur la demande etaient associees a une administration de vaccins sensiblement plus elevee, risque relatif (RR) : 1,30; intervalle de confiance de 95%, IC : 1,17-1,44). L'analyse de sous-groupes a egalement montre des effets importants pour sept etudes decrivant des interventions d'education ou d'application des connaissances, RR: 1,40 (IC de 95%: 1,20-1,63) et pour quatre etudes decrivant le recours a des incitations, RR: 1,28 (IC de 95%: 1,12-1,45). Conclusion Les interventions axees sur la demande entrainent des avantages notables pour la vaccination des enfants dans les pays a revenu faible et intermediaire. Les demarches educatives ainsi que le recours a des incitations etaient tous deux des strategies efficaces. Objetivo Investigar que estrategias para incrementar la demanda de vacunacion son efectivas en el incremento de la cobertura de vacunacion infantil en paises de ingresos bajos y medios. Metodos Se realizaron busquedas en las bases de datos de MEDLINE, EMBASE, Cochrane Library, POPLINE, ECONLIT, CINAHL, LILACS, BDSP, Web of Science y Scopus para encontrar estudios pertinentes, publicados en aleman, espanol, frances, hindi, ingles y portugues hasta el 25 de marzo de 2014. Se incluyeron estudios de intervenciones con el objetivo de Incrementar la demanda de vacunacion infantil sistematica. Los estudios fueron elegibles si se realizaron en paises de ingresos bajos y medios y utilizaron un diseno de ensayo controlado aleatorizado, ensayo controlado no aleatorizado, controlado antes y despues o de serles temporales interrumpidas. Se estimo un riesgo de sesgo mediante las directrices de colaboracion de Cochrane y se realizaron metanalisis de efectos aleatorios. Resultados Se identificaron 11 estudios que abarcan cuatro ensayos controlados aleatorizados, seis ensayos controlados aleatorizados por conglomerados y un estudio controlado antes y despues, publicados en ingles entre 1996 y 2013. En general, los participantes fueron padres de ninos pequenos expuestos a una intervencion elegible. Seis estudios demostraron un bajo riesgo de sesgo y cinco estudios presentaron un riesgo de sesgo entre moderado y elevado. Se realizo un analisis agrupado teniendo en cuenta los 11 estudios, con datos de 11,512 participantes. Las Intervenciones que afectan a la demanda se relacionaron con una recepcion de las vacunas significativamente superior, riesgo relativo (RR): 1,30, (intervalo de confianza, IC, del 95%: 1,17-1,44). Los analisis de los subgrupos tambien demostraron efectos importantes de siete estudios de educacion y traslacion de conocimientos, RR: 1,40 (IC del 95%: 1,20-1,63) y de cuatro estudios que utilizaron incentivos, RR: 1,28 (IC del 95%: 1,12-1,45). Conclusion Las intervenciones que afectan a la demanda llevan a mejoras significativas en la cobertura de vacunacion infantil en paises de ingresos bajos y medios. Los enfoques educativos y el uso de incentivos fueron estrategias efectivas., Introduction Almost 40 years after the launch of the World Health Organization's (WHO's) Expanded Programme on Immunization, one in five children worldwide still does not have access to basic vaccines. [...]