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Permanent bilateral hearing loss (PBHL) is a serious condition in newborns, with a prevalence of at least one per 1000 live births. However, there has been no recent systematic review and meta-analysis of the effectiveness of universal newborn hearing screening programs (UNHS).We registered our study protocol on PROSPERO CRD42020175451. Primary outcomes were any identification of PBHL (ie, PBHL diagnosed at any time), age of identification of PBHL, and neurodevelopment. Two reviewers searched standard databases to March 2022 and extracted data. We used fixed and random effects meta-analysis to pool data and graded the certainty of evidence using standard methods.The search retrieved 2834 records. We identified five studies reporting on the effects of UNHS vs no UNHS in 1 023 610 newborns. The relative risk of being identified with PBHL before nine months in infants with UNHS compared to infants without UNHS was 3.28 (95% confidence interval (95% CI) = 1.84, 5.85, one study, 1 023 497 newborns, low certainty evidence). The mean difference in the age of identification of PBHL in infants with UNHS compared to infants without UNHS was 13.2 months earlier (95% CI = -26.3, -0.01, two studies, 197 newborns, very low certainty evidence). The relative risk of infants eventually being identified with PBHL in infants with UNHS compared to infants without UNHS was 1.01 (95% CI = 0.89, 1.14, three studies, 1 023 497 newborns, low certainty evidence). At the latest follow-up at 3-8 years, the standardised mean difference (SMD) in receptive language development between infants with UNHS compared to infants without UNHS was 0.60 z scores (95% CI = 0.07, 1.13, one study, 101 children, low certainty evidence) and the mean difference in developmental quotients was 7.72 (95% CI = -0.03, 15.47, three studies, 334 children, very low certainty evidence). The SMD in expressive language development was 0.39 z scores (95% CI = -0.20, 0.97, one study, 87 children, low certainty evidence) and the mean difference in developmental quotients was 10.10 scores (95% CI = 1.47, 18.73, 3 studies, 334 children, very low certainty evidence).UNHS programs result in earlier identification of PBHL and may improve neurodevelopment. UNHS should be implemented across high-, middle-, and low-income countries.PROSPERO (CRD42020175451).

BACKGROUND AND OBJECTIVES Preterm and low birth weight (LBW) infants are often separated from parents during hospitalization. Our objective was to assess effects of interventions to increase family involvement in the routine newborn care of preterm or LBW infants compared with standard NICU care on infant and parental outcomes. METHODS Data sources include Medline, Embase, CINAHL, and World Health Organization Global Index Medicus to August 2021. The study selection included randomized controlled trials (RCTs) of family involvement intervention packages. Data were extracted and pooled with random-effects models. RESULTS We included 15 RCTs with 5240 participants. All interventions included direct parental bedside care; packages varied with respect to additional components. Family involvement interventions decreased retinopathy of prematurity (odds ratio 0.52, 95% confidence interval [CI]: 0.34, 0.80; 8 RCTs), length of hospital stay (mean difference [MD] −2.91 days; 95% CI: −5.15,−0.82; 11 RCTs), and parental stress and anxiety (Parental Stress Scale: MD −0.29 points, 95% CI: −0.56,−0.01, 2 RCTs; Anxiety State-Trait scale: MD −1.79, 95% CI: −3.11,−0.48; 2 RCTs). Family involvement increased weight gain velocity (MD 2.09 g/day; 95% CI: 1.27, 2.91; 3 RCTs), neurobehavioral exam scores (MD: 1.11; 95% CI: 0.21, 2.01; 2 RCTs) and predominant or exclusive breastmilk intake (odds ratio 1.34; 95% CI: 1.01, 1.65; 3 RCTs). It may decrease rates of bronchopulmonary dysplasia, infection, and intraventricular hemorrhage. There were no effects on mortality or necrotizing enterocolitis. Certainty of evidence ranged from low to moderate. CONCLUSIONS Family involvement has a beneficial role on several infant and parental outcomes.

CONTEXTTwenty-four research questions (framed as population, intervention, comparator, and outcomes) for global health care interventions for preterm and low birth weight (LBW) infants were identified at a World Health Organization guideline development group expert meeting in December 2020.OBJECTIVETo describe which systematic reviews had addressed these research questions in the last 3 years.DATA SOURCESMedline (Ovid); the Cochrane Database of Systematic Reviews; the Cochrane Database of Systematic Review Protocols; and the PROSPERO International prospective register of systematic reviews databases from January 1, 2019 to December 31, 2021 were used.Randomized controlled trials or observational studies. Two reviewers independently extracted data.RESULTSWe found 9 systematic reviews. Eight reviews of 121 studies and 25 465 preterm or LBW infants published in the last 36 months “fully” addressed 8 of our 24 research questions (donor human milk, multicomponent fortifier, formula milk, probiotics, emollients, continuous positive airways pressure [CPAP] any, CPAP early, CPAP prophylactic); and 1 systematic review found no trials (mother’s own milk). All received a “high” AMSTAR quality rating. Fifteen research questions (kangaroo mother care, early initiation, responsive feeding, advancement, exclusive breastfeeding duration, iron, zinc, vitamin D, vitamin A, calcium and phosphorous, multiple micronutrients, CPAP pressure source, methyl xanthines, family involvement, and family support) had no systematic review. Limitations include that we restricted our search to those interventions identified as a priority at a World Health Organization scoping meeting. Other interventions that may be of importance to preterm or LBW infants were not able to be considered.CONCLUSIONSAlmost a third of our research questions were addressed by high quality systematic reviews. We found gaps in thermal care, feeding, and familysupport interventions, which need to be addressed.

Background Evidence suggests that Aboriginal babies in Western Australia are not receiving adequate primary health care in their first three months of life, leading to questions about enablers and constraints to delivering such care. This paper presents findings from a qualitative research project investigating health providers’ perceptions and experiences of best and current practice in discharge planning, postnatal care and health education for mothers and their Aboriginal newborn babies.Methods Constructivist grounded theory guided this research involving 58 semi-structured interviews conducted with health providers who deliver care to Aboriginal mothers and infants. Participants were recruited from hospital-based and primary health sites in metropolitan Perth, and regional and remote locations in Western Australia. Results Structural factors enabling best practice in discharge planning, postnatal care, and health education for mothers included health providers following best practice guidelines and adequate staffing levels. Organisational enablers included continuity of care throughout pregnancy, birth and postnatally. In particular, good communication between services around discharge planning, birth notifications, and training in culturally respectful care. Structural and organisational constraints to delivering best practice and compromising continuity of care were identified as beyond individual control. These included early discharge, poor communication between different health and social services, inadequate hospital staffing levels and cultural training, delayed receipt of birth notifications and discharge summaries received by Aboriginal primary health services. Conclusion. Findings highlight the importance of examining current policies and practices to promote best practice in postnatal care to improve health outcomes for mothers and their Aboriginal babies.

Objective: To explore caregiver perspectives of their children’s journey through the specialist paediatric service, the Aboriginal Ambulatory Care Coordination Program (AACC), and non‐AACC services at the Perth Children’s Hospital. Methods: Eighteen semi‐structured interviews with families of Aboriginal children were completed. Indigenous research methodology and a phenomenological approach guided data collection and analysis. Results: Four key themes were identified from interviews: hospital admissions, discharge and follow‐up outpatient appointments; communication; financial burden; and cultural issues. Our findings suggest Aboriginal children and their caregivers using the AACC program had more positive and culturally secure experiences than those using non‐AACC services. However, barriers relating to health providers’ understanding of Aboriginal cultural issues and lived experience were commonly discussed, regardless of which service families received. Conclusions: Australian Aboriginal children have an increased use of tertiary hospital care compared to non‐Indigenous children. Healthcare programs specifically designed for Aboriginal children and their families can improve their experience of care in hospital. However, improvements in cultural awareness for other hospital staff is still needed. Implications for public health: Dedicated Aboriginal programs in mainstream services can successfully improve cultural care to their clients, which is fundamental to improving service delivery for families.

OBJECTIVES To assess effects of supplementation with 3 or more micronutrients (multiple micronutrients; MMN) compared to no MMN in human milk-fed preterm and low birth weight (LBW) infants. RESULTS Data on a subgroup of 414 preterm or LBW infants from 2 randomized controlled trials (4 reports) were included. The certainty of evidence ranged from low to very low. For growth outcomes in the MMN compared to the non-MMN group, there was a small increase in weight-for-age (2 trials, 383 participants) and height-for-age z-scores (2 trials, 372 participants); a small decrease in wasting (2 trials, 398 participants); small increases in stunting (2 trials, 399 participants); and an increase in underweight (2 trials, 396 participants). For neurodevelopment outcomes at 78 weeks, we found small increases in Bayley Scales of Infant Development, Version III (BISD-III), scores (cognition, receptive language, expressive language, fine motor, gross motor) in the MMN compared to the non-MMN group (1 trial, 27 participants). There were no studies examining dose or timing of supplementation. CONCLUSIONS Evidence is insufficient to determine whether enteral MMN supplementation to preterm or LBW infants who are fed mother's own milk is associated with benefit or harm. More trials are needed to generate evidence on mortality, morbidity, growth, and neurodevelopment.

IntroductionPreterm birth is the leading cause of child mortality. This study aimed to develop and validate programmatically feasible and accurate approaches to estimate newborn gestational age (GA) in low resource settings.MethodsThe WHO Alliance for Maternal and Newborn Health Improvement (AMANHI) study recruited pregnant women from population-based cohorts in five countries (Bangladesh, Ghana, Pakistan, Tanzania and Zambia). Women Results7428 liveborn infants were included (n=536 preterm, ConclusionThe best machine-learning model (10 neonatal characteristics and LMP) estimated GA within ±15.7 days of early ultrasound dating. Simpler models performed reasonably well with marginal increases in prediction error. These models hold promise for newborn GA estimation when ultrasound dating is unavailable.

Background Australia’s National Immunisation Program recommended a 3-dose primary Diphtheria-Tetanus-Pertussis (DTP) vaccination course at 2, 4 and 6 months and a booster dose at 4 years during 2003-2015. We examined vaccine effectiveness by time since doses 3 and 4, as studies to date have shown conflicting results. Methods Perinatal, immunisation, pertussis notification and death data were linked for 1,086,319 infants born in two Australian states in 2003-2012. Administration of DTP doses 3 and 4 from 5.5-7 months and 47-53 months respectively, was considered age-appropriate. Adjusted Cox proportional hazards models with time-varying vaccination status were used to estimate vaccine effectiveness (VE = 1–hazard ratio) against notified pertussis post age-appropriate doses 3 and 4 compared to unvaccinated children, with additional benefit of dose 4 compared to receipt of primary course alone. Results Dose 3 VE declined from 79% (CI 75%-83%) from 0-6 months to 64% (CI 60%-67%) at 6-36 months and 45% (CI 31%-56%) at 36-42 months post-vaccination. Compared to unvaccinated children, VE after dose 4 declined from 83% (CI 80%-86%) at 0-12 months to 67% (CI 60%-72%) and 55% (CI 46%-63%) in the following two 12-month periods post-vaccination. When compared to dose 3, the relative VE for dose 4 was 58% (CI 51%-64%) in 0-18 months post-vaccination. Conclusion and Key messages Our study adds to previous Australian evidence for substantial waning of vaccine induced immunity against pertussis over a 3-year period following dose 3. VE was significantly higher in the 18 months following dose 4 compared to receipt of primary course alone.

Background Maternal morbidity occurs several times more frequently than mortality, yet data on morbidity burden and its effect on maternal, foetal, and newborn outcomes are limited in low- and middle-income countries. We aimed to generate prospective, reliable population-based data on the burden of major direct maternal morbidities in the antenatal, intrapartum, and postnatal periods and its association with maternal, foetal, and neonatal death in South Asia and sub-Saharan Africa. Methods and findings This is a prospective cohort study, conducted in 9 research sites in 8 countries of South Asia and sub-Saharan Africa. We conducted population-based surveillance of women of reproductive age (15 to 49 years) to identify pregnancies. Pregnant women who gave consent were include in the study and followed up to birth and 42 days postpartum from 2012 to 2015. We used standard operating procedures, data collection tools, and training to harmonise study implementation across sites. Three home visits during pregnancy and 2 home visits after birth were conducted to collect maternal morbidity information and maternal, foetal, and newborn outcomes. We measured blood pressure and proteinuria to define hypertensive disorders of pregnancy and woman’s self-report to identify obstetric haemorrhage, pregnancy-related infection, and prolonged or obstructed labour. Enrolled women whose pregnancy lasted at least 28 weeks or those who died during pregnancy were included in the analysis. We used meta-analysis to combine site-specific estimates of burden, and regression analysis combining all data from all sites to examine associations between the maternal morbidities and adverse outcomes. Among approximately 735,000 women of reproductive age in the study population, and 133,238 pregnancies during the study period, only 1.6% refused consent. Of these, 114,927 pregnancies had morbidity data collected at least once in both antenatal and in postnatal period, and 114,050 of them were included in the analysis. Overall, 32.7% of included pregnancies had at least one major direct maternal morbidity; South Asia had almost double the burden compared to sub-Saharan Africa (43.9%, 95% CI 27.8% to 60.0% in South Asia; 23.7%, 95% CI 19.8% to 27.6% in sub-Saharan Africa). Antepartum haemorrhage was reported in 2.2% (95% CI 1.5% to 2.9%) pregnancies and severe postpartum in 1.7% (95% CI 1.2% to 2.2%) pregnancies. Preeclampsia or eclampsia was reported in 1.4% (95% CI 0.9% to 2.0%) pregnancies, and gestational hypertension alone was reported in 7.4% (95% CI 4.6% to 10.1%) pregnancies. Prolonged or obstructed labour was reported in about 11.1% (95% CI 5.4% to 16.8%) pregnancies. Clinical features of late third trimester antepartum infection were present in 9.1% (95% CI 5.6% to 12.6%) pregnancies and those of postpartum infection in 8.6% (95% CI 4.4% to 12.8%) pregnancies. There were 187 pregnancy-related deaths per 100,000 births, 27 stillbirths per 1,000 births, and 28 neonatal deaths per 1,000 live births with variation by country and region. Direct maternal morbidities were associated with each of these outcomes. Conclusions Our findings imply that health programmes in sub-Saharan Africa and South Asia must intensify their efforts to identify and treat maternal morbidities, which affected about one-third of all pregnancies and to prevent associated maternal and neonatal deaths and stillbirths. Trial registration The study is not a clinical trial., Author summary Why was this study done? Estimates of severe direct maternal morbidity are largely based on hospital-based studies with inconsistent definitions and varying selection criteria. Limited data are available from South Asia and sub-Saharan Africa, the 2 regions with the highest maternal and newborn morbidity and mortality, where a larger proportion of births occur at home. What did the researchers do and find? We collected data on maternal morbidities from a cohort of women in the community in multiple sites in sub-Saharan Africa and in South Asia. Out of a cohort of >114,000 women, we found that about 1 in 3 women suffer a maternal morbidity, which was notably higher than the previously reported data. We found that the prevalence of preeclampsia and eclampsia was about 1%, which was lower than previously reported. About 11% of women reported having prolonged or obstructed labour, which was somewhat higher than published estimates. The burden of pregnancy-related infection in postpartum period was higher in South Asia than in sub-Saharan Africa. This is the first study, to our knowledge, to describe the burden of antepartum haemorrhage and late antepartum infection and to clearly demonstrate the association of direct maternal morbidity with adverse pregnancy outcomes. What do these findings mean? Higher burden of direct maternal morbidity and its association with adverse outcomes highlights the need for improving health of women and mothers, including promotion of preconception health and nutrition, and high-quality antepartum, intrapartum and postpartum care.

Background Impacts of early childhood development (ECD) interventions (such as fostering attachment and responsiveness through communication, play and stimulation) are well known. Globally, there is increasing recognition of the importance of the ‘golden’ minutes, hours and days after birth for infant health and development. However, only one systematic review has examined ECD interventions implemented in the neonatal period (0–27 days), and this review only assessed interventions implemented by specialised providers. Primary care providers have many potential contacts with mothers and infants throughout the neonatal period. However, it is unclear how many research studies or programmes have examined the effectiveness of ECD interventions commencing in the neonatal period and which methods were used. To date, there has been no systematic review of the effect of ECD interventions delivered by primary care providers commencing in the neonatal period. Methods Our overall aim is to conduct a systematic review of the effect of ECD interventions implemented by primary care providers in the neonatal period. We will assess effects by timing and number (‘dose’) of contacts with primary care providers. Subgroup assessment will include effects in disadvantaged infants such as those born with low birth weight and to mothers with mental health disorders. We will also assess effects in low- and high-income countries and by type of care provider. The primary outcome is cognitive status in children aged 0–23 months as measured using standardised scales. Secondary outcomes include other child neurodevelopment domains (speech, language, fine motor, gross motor, social, emotional, behaviour, executive functioning, adaptive functioning) in children aged 0–23 months. Effects on maternal mental health will also be assessed between 0–23 months postpartum. Databases such as MEDLINE (OVID), PsycINFO (OVID), EMBASE (OVID), CINAHL, Cochrane Library, WHO databases and reference lists of papers will be searched for relevant articles. Only randomised controlled trials will be included. A narrative synthesis for all outcomes will be reported. Meta-analyses will be performed where exposures and outcomes are sufficiently homogeneous. Guidelines for PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) will be followed. Discussion This review appears to be the first to be conducted in this area. The findings will be an important resource for policymakers, primary care providers and researchers who work with young infants in primary care settings. Systematic review registration PROSPERO CRD42019122021 Electronic supplementary material The online version of this article (10.1186/s13643-019-1142-1) contains supplementary material, which is available to authorized users.

ObjectiveTo assess whether sustained, scheduled mobile health team (MHT) services increase antenatal care (ANC), postnatal care (PNC) and childhood immunisation in conflict-affected and remote regions of Afghanistan.DesignCross-sectional, population-based study from 2013 to 2017. Proportions were compared using multivariable linear regression adjusted for clustering and socio-demographic variables.Setting54 intervention and 56 control districts in eight Afghanistan provinces.Participants338 796 pregnant women and 1 693 872 children aged under 5 years.Interventions‘Intervention districts’ that received MHT services for 3 years compared with ‘control districts’ in the same province without any MHT services over the same period.Main outcome measuresDistrict-level and clinic-level ANC, PNC, childhood immunisation (pentavalent 3, measles 1), integrated management of childhood immunisation services.ResultsProportion of pregnant women receiving at least one ANC visit was higher in intervention districts (83.6%, 161 750/193 482) than control districts (61.3%, 89 077/145 314) (adjusted mean difference (AMD) 14.8%;95% CI: 1.6% to 28.0%). Proportion of children under 1 year receiving their first dose of measles vaccine was higher in intervention (73.8%, 142 738/193 412) than control districts (57.3%, 83 253/145 293) (AMD 12.8;95% CI: 2.1% to 23.5%). There was no association with PNC (AMD 2.8%;95% CI: −5.1% to 10.7%). MHTs did not increase clinic-level service provision for ANC (AMD 41.32;95% CI: -52.46 to 135.11) or any other outcomes.ConclusionsSustained, scheduled MHT services to conflict-affected and remote regions were associated with improved coverage of important maternal and child health interventions. Outreach is an essential service and not just an ‘optional extra’ for the most deprived mothers and children.

Background Anemia rates are over 60% in disadvantaged children yet there is little information about the quality of anemia care for disadvantaged children. Methods Our primary objective was to assess the burden and quality of anemia care for disadvantaged children and to determine how this varied by age and geographic location. We implemented a cross-sectional study using clinical audit data from 2287 Indigenous children aged 6–59 months attending 109 primary health care centers between 2012 and 2014. Data were analysed using multivariable regression models. Results Children aged 6–11 months (164, 41.9%) were less likely to receive anemia care than children aged 12–59 months (963, 56.5%) (adjusted odds ratio [aOR] 0.48, CI 0.35, 0.65). Proportion of children receiving anemia care ranged from 10.2% (92) (advice about ‘food security’) to 72.8% (728) (nutrition advice). 70.2% of children had a hemoglobin measurement in the last 12 months. Non-remote area families (115, 38.2) were less likely to receive anemia care compared to remote families (1012, 56.4%) (aOR 0.34, CI 0.15, 0.74). 57% (111) aged 6–11 months were diagnosed with anemia compared to 42.8% (163) aged 12–23 months and 22.4% (201) aged 24–59 months. 49% (48.5%, 219) of children with anemia received follow up. Conclusions The burden of anemia and quality of care for disadvantaged Indigenous children was concerning across all remote and urban locations assessed in this study. Improved services are needed for children aged 6–11 months, who are particularly at risk.

BackgroundBiannual vitamin A supplementation is a well-established survival tool for preschool children 6 months and older in vitamin A deficient populations but this schedule misses the opportunity to intervene on most young infant deaths. Randomised trials of neonatal vitamin A supplementation (NVAS) in the first few days of life to assess its impact on under 6-month mortality in low/middle-income countries have had varying results.MethodsInvestigators of 11 published randomised placebo-controlled NVAS trials (n=163 567 children) reanalysed their data according to an agreed plan and pooled the primary outcomes of mortality from supplementation through 6 and 12 months of age using random effects models and meta-regression. One investigator withdrew but allowed use of the data.FindingsOverall there was no effect of NVAS on infant survival through 6 (risk ratio (RR) 0.97; 95% CI 0.89 to 1.06) or 12 months of age (RR 1.00; 95% CI 0.93 to 1.08) but results varied by study population characteristics.NVAS significantly reduced 6-month mortality among the trials conducted in Southern Asia (RR 0.87; 95% CI 0.77 to 0.98), in contexts with moderate or severe vitamin A deficiency (defined as 10% or higher proportion of women with serum retinol 32% mothers had no schooling (RR 0.88; 95% CI 0.80 to 0.96). NVAS did not reduce mortality in the first 6 months of life in trials conducted in Africa, in contexts characterised by a low prevalence of vitamin A deficiency, lower rates of infant mortality and where maternal education was more prevalent. There was a suggestion of increased infant mortality in trials conducted in Africa (RR 1.07; 95% CI 1.00 to 1.15).Individual-level characteristics such as sex, birth weight, gestational age and size, age at dosing, parity, time of breast feeding initiation, maternal education and maternal vitamin A supplementation did not modify the impact of NVAS.ConclusionNVAS reduced infant mortality in South Asia, in contexts where the prevalence of maternal vitamin A deficiency is moderate to severe and early infant mortality is high; but it had no beneficial effect on infant survival in Africa, in contexts where the prevalence of maternal vitamin A deficiency is lower, early infant mortality is low.

Background:\ud \ud The Unmet Obstetric Need (UON) indicator has been widely used to estimate unmet need for life‐saving surgery at birth; however, its assumptions have not been verified. The objective of this study was to test two UON assumptions: (a) Absolute maternal indications (AMIs) require surgery for survival and (b) 1%‐2% of deliveries develop AMIs, implying that rates of surgeries for AMIs below this threshold indicate excess mortality from these complications.\ud Methods:\ud \ud We used linked hospital and population‐based data in central Ghana. Among hospital deliveries, we calculated the percentage of deliveries with AMIs who received surgery, and mortality among AMIs who did not. At the population level, we assessed whether the percentage of deliveries with surgeries for AMIs was inversely associated with mortality from these complications, stratified by education.\ud \ud \ud Results:\ud \ud A total of 380 of 387 (98%) hospital deliveries with recorded AMIs received surgery; an additional eight women with no AMI diagnosis died of AMI‐related causes. Among the 50 148 deliveries in the population, surgeries for AMIs increased from 0.6% among women with no education to 1.9% among women with post‐secondary education (P < .001). However, there was no association between AMI‐related mortality and education (P = .546). Estimated AMI prevalence was 0.84% (95% CI: 0.76%‐0.92%), below the assumed 1% minimum threshold.\ud Discussion:\ud \ud Obstetric providers consider AMIs absolute indications for surgery. However, low rates of surgeries for AMIs among less educated women were not associated with higher mortality. The UON indicator should be used with caution in estimating the unmet need for life‐saving obstetric surgery; innovative approaches are needed to identify unmet need in the context of rising cesarean rates.

Aim To determine whether participation in the continuous quality improvement (CQI) Audit and Best Practice for Chronic Disease programme improved care and outcomes for Indigenous children. Methods Data were collected from 59 Australian primary health-care centres providing services to Indigenous people and participating in the programme (February 2008 and December 2013). Indigenous children aged less than 2 years and centres that completed three or more consecutive annual audits within the 6-year study period were included. Crude and adjusted logistic generalised estimating equation models were used to examine the effect of year of audit on the delivery of care. Odds ratio (OR) and 95% confidence interval (CI) were calculated. Outcomes were related to age-relevant health issues, including prevention and early intervention. These included administrative, health check, anticipatory guidance and specific health issues. Results During the audit period, there were 2360 files from 59 centres. Those that had a recall recorded, improved from 84 to 95% (OR 2.44, 95% CI 1.44–4.11). Hearing assessments improved from 52 to 89% (OR 1.37, 95% CI 1.22–1.54). Improvement in anticipatory guidance, treatment and follow-up of medical conditions was almost universal. Conclusion We documented significant improvements in quality of care of Indigenous children. Outcomes and their corresponding treatment and follow-ups improved over time. This appears to be related to services participating in annual CQI activities. However, these services may be more committed to CQI than others and therefore possibly better performing.

To investigate the effect of birth weight on infant mortality, illness and care seeking in rural Ghana.Using randomized controlled trial data, we compared infants weighing 2.00-2.49, 1.50-1.99 and 1.50 kg with non-low-birth-weight infants. We generated adjusted mortality hazard ratios (aHR), adjusted illness rate ratios (aRR) and adjusted odds ratios (aOR) for health-facility admissions and absence of care seeking for four time periods: infancy, the neonatal period, early infancy and late infancy - represented by ages of 0-364, 0-27, 28-182 and 183-364 days, respectively.Among 22 906 infants, compared with non-low-birth-weight infants: (i) infants weighing 2.00-2.49, 1.50-1.99 and 1.50 kg were about two (aHR: 2.13; 95% confidence interval, CI: 1.76-2.59), eight (aHR: 8.21; 95% CI: 6.26-10.76) and 25 (aHR: 25.38; 95% CI: 18.36-35.10) times more likely to die in infancy, respectively; (ii) those born weighing 1.50 kg were about 48 (aHR: 48.45; 95% CI: 32.81-71.55) and eight (aHR: 8.42; 95% CI: 3.09-22.92) times more likely to die in the neonatal period and late infancy, respectively; (iii) those born weighing 1.50-1.99 kg (aRR: 1.57; 95% CI: 1.27-1.95) or 1.50 kg (aRR: 1.58; 95% CI: 1.13-2.21) had higher neonatal illness rates; and (iv) for those born weighing 1.50-1.99 kg, care was less likely to be sought in the neonatal period (aOR: 3.30; 95% CI: 1.98-5.48) and early infancy (aOR : 1.74; 95% CI: 1.26-2.39).For low-birth-weight infants in Ghana, strategies to minimize mortality and improve care seeking are needed.Étudier l'effet du poids à la naissance sur la mortalité, la maladie et le recours à des soins de santé, pendant la période infantile, dans des régions rurales du Ghana.En utilisant les données d'un essai contrôlé randomisé, nous avons comparé les nourrissons nés avec un poids compris entre 2,00 et 2,49 kg, entre 1,50 et 1,99 kg et inférieur à 1,50 kg avec les nourrissons qui ne présentaient pas un faible poids à la naissance. Nous avons généré des ratios de risque de mortalité ajustés (RRa), des ratios de taux de maladies ajustés (RTa) et des rapports des cotes ajustés (RCa) pour les admissions dans des centres de santé et l'absence de recours à des soins, sur quatre périodes de vie: entre 0 et 364 jours, entre 0 et 27 jours, entre 28 et 182 jours et entre 183 et 364 jours.Dans l’échantillon étudié de 22 906 nourrissons, comparativement à ceux qui ne présentaient pas un faible poids à la naissance: (i) les nourrissons nés avec un poids compris entre 2,00 et 2,49 kg, entre 1,50 et 1,99 kg et inférieur à 1,50 kg ont été associés, respectivement, à un risque deux fois supérieur (RRa: 2,13; intervalle de confiance (IC) de 95%: 1,76–2,59), huit fois supérieur (RRa: 8,21; IC 95%: 6,26–10,76) et 25 fois supérieur (RRa: 25,38; IC 95%: 18,36–35,10) de décès durant la première année de vie; (ii) ceux pesant moins d'1,50 kg à la naissance ont été associés à un risque environ 48 fois supérieur (RRa: 48,45; IC 95%: 32,81-71,55) et huit fois supérieur (RRa: 8,42; IC 95%: 3,09–22,92) de décès entre 0 et 27 jours et entre 183 et 364 jours respectivement; (iii) ceux nés avec un poids compris entre 1,50 et 1,99 kg (RTa: 1,57; IC 95%: 1,27–1,95) ou inférieur à 1,50 kg (RTa: 1,58; IC 95%: 1,13–2,21) ont été associés à des taux supérieurs de maladies durant les 27 premiers jours de vie; et (iv) pour les nourrissons nés avec un poids compris entre 1,50 et 1,99 kg, le recours à des soins de santé a été moins fréquent durant les 27 premiers jours de vie (RCa: 3,30; IC 95%: 1,98–5,48) et sur la période allant du 28Au Ghana, pour les nourrissons nés avec un faible poids, des stratégies doivent être adoptées afin de réduire la mortalité et d’améliorer le recours aux soins.Investigar el efecto del peso al nacer en la mortalidad infantil, las enfermedades y la atención médica en la Ghana rural.Utilizando datos de ensayos controlados aleatorios, se comparó a los recién nacidos con un peso de 2,00–2,49, 1,50–1,99 y 1,50 kg con recién nacidos sin insuficiencia ponderal. Se generaron cocientes de riesgos instantáneos ajustados (aHR) relativos a la mortalidad, razones de tasa ajustadas (aRR) relativas a enfermedades y cocientes de posibilidades ajustados (CPa) para las admisiones en centros sanitarios y la ausencia de atención médica durante cuatro periodos de tiempo: infancia, período neonatal, primera infancia e infancia tardía, representados por las edades de 0–364, 0–27, 28–182 y 183–364 días, respectivamente.Entre 22 906 recién nacidos, comparados con recién nacidos sin insuficiencia ponderal: (i) los recién nacidos con un peso de 2,00–2,49, 1,50–1,99 y 1,50 kg tenían dos (aHR: 2,13; intervalo de confianza, IC, del 95%: 1,76–2,59), ocho (aHR: 8,21; IC del 95%: 6,26–10,76) y 25 (aHR: 25,38; IC del 95%: 18,36–35,10) veces más posibilidades de morir durante la infancia, respectivamente; (ii) aquellos que nacieron con un peso de 1,50 kg tenían 48 (aHR: 48,45; IC del 95%: 32,81-71,55) y ocho (aHR: 8,42; IC del 95%: 3,09–22,92) veces más posibilidades de morir durante el período neonatal y la infancia tardía, respectivamente; (iii) los que nacieron con un peso de 1,50–1,99 kg (aRR: 1,57; IC del 95%: 1,27–1,95) o 1,50 kg (aRR: 1,58; IC del 95%: 1,13–2,21) tenían las tasas de enfermedad neonatal más elevadas; y (iv) aquellos que nacieron con un peso de 1,50–1,99 kg, era menos probable que necesitaran atención médica en el período neonatal (CPa: 3,30; IC del 95%: 1,98–5,48) y en la primera infancia (CPa: 1,74; IC del 95%: 1,26–2,39).Se necesitan estrategias para minimizar la mortalidad y mejorar la atención médica de los recién nacidos con insuficiencia ponderal en Ghana.Se necesitan estrategias para minimizar la mortalidad y mejorar la atención médica de los recién nacidos con insuficiencia ponderal en Ghana.التحقيق في تأثير وزن الولادة على وفيات الرضع والإصابة بالمرض وطلب الرعاية في المناطق الريفية بغانا.باستخدام بيانات التجارب العشوائية التي تمت مراقبتها، قمنا بمقارنة الرضع الذين يتراوح وزنهم ما بين 2.00 و2.49، و1.50 و1.99 والأقل من 1.50 كلغ مع الرضع غير منخفضي الوزن عند الولادة. وأصدرنا نسب وفيات معدلة (aHR)، ونسب معدلات المرض المعدلة (aRR)، ونسب الاحتمالية المعدلة (aOR) لحالات القبول في المرافق الصحية وغياب طلب الرعاية لمدة أربع فترات زمنية تتمثل في: الرضع، وفترة حديثي الولادة، ومرحلة الطفولة المبكرة، ومرحلة الطفولة المتأخرة - ممثلة بالأعمار 0-364، 0-27، 28-182، 183-364 يومًا، على التوالي.من بين 22,906 أطفال تمت مقارنتهم بالأطفال غير منخفضي الوزن عند الولادة: (1) كان عدد الأطفال الذين يتراوح وزنهم ما بين 2.00–2.49، و1.50–1.99 والأقل من 1.50 كلغ حوالي اثنين (نسبة الوفيات المعدلة: 2.13؛ بنسبة أرجحية مقدارها ‏95‏‏%: 1.76-2.59)، وثمانية (نسبة الوفيات المعدلة: 8.21؛ ‏‏95% كمقدار لنسبة الأرجحية: 6.26-10.76) و25 (نسبة الوفيات المعدلة: 25.38؛ نسبة أرجحية تبلغ ‏95‏%: 18.36-35.10) مرة أكثر عرضة للموت في مرحلة الطفولة، على التوالي. (2) كان عدد أولئك الذين ولدوا ويقل وزنهم عن 1.50 كلغ حوالي 48 (نسبة الوفيات المعدلة: 48.45؛ ‏‏95% كمقدار لنسبة الأرجحية: 32.81 – 71.55) وثمانية (نسبة الوفيات المعدلة: 8.42؛ نسبة أرجحية تبلغ ‏95‏%: 3.09-22.92) مرة أكثر عرضة للموت في فترة حديثي الولادة والطفولة المتأخرة على التوالي؛ (3) كان عدد أولئك الذين يتراوح وزنهم ما بين 1.50 إلى 1.99 كلغ (معدل المرض المعدل: 1.57؛ ‏‏95% كمقدار لنسبة الأرجحية: 1.27-195) أو أقل من 1.50 كلغ (معدل المرض المعدل: 1.58؛ ‏‏95% كمقدار لنسبة الأرجحية: 1.13-2.21) كان لديهم معدلات مرض أعلى لحديثي الولادة؛ و(4) لأولئك الذين ولدوا وتتراوح أوزانهم ما بين 1.50 إلى 1.99 كلغ، كانت إمكانية الحصول على الرعاية أقل في فترة حديثي الولادة (نسبة الاحتمالية المعدلة: 3.30؛ ‏95% كمقدار لنسبة الأرجحية: 1.98-5.48) والطفولة المبكرة (نسبة الاحتمالية المعدلة: 1.74؛ نسبة أرجحية تبلغ ‏95‏%: 1.26–2.39).بالنسبة للرضع منخفضي الوزن في غانا، هناك حاجة إلى وضع استراتيجيات للحد من الوفيات وتحسين الرعاية الصحية.旨在调查加纳乡村地区出生体重对婴儿死亡率、患病及获取护理的影响。.我们使用随机对照试验数据将出生体重为 2.00–2.49 kg、1.50–1.99 kg 以及 1.50 kg 以下婴儿与非出生体重偏低婴儿进行了对比。 我们生成了四个阶段（婴儿期、新生儿期、婴儿早期、及婴儿晚期 ——分别代表 0–364 天、0–27 天、28–182 天 、183–364 天年龄段的婴儿）中能够获取卫生设施护理的婴儿及缺乏护理的婴儿的调整后死亡率危险比率 (aHR) 、调整后患病率比率 (aRR) 及调整后比值比 (aOR)。.与非出生体重偏低婴儿相比，22 906 名婴儿中： (i) 出生体重为 2.00–2.49 kg、1.50–1.99 kg 及 1.50 kg 以下的婴儿，其婴儿期死亡的可能性分别高出两倍（aHR: 2.13；95% 置信区间，CI： 1.76–2.59），八倍 (aHR: 8.21; 95% CI: 6.26–10.76) 和 25 倍 (aHR: 25.38; 95% CI: 18.36–35.10)；(ii) 出生体重为 1.50 kg 以下的婴儿，其新生儿期及婴儿晚期死亡的可能性分别高出 48 倍 (aHR: 48.45; 95% CI: 32.81-71.55) 和八倍 (aHR: 8.42; 95% CI: 3.09–22.92)；(iii) 出生体重为 1.50–1.99 kg (aRR: 1.57; 95% CI: 1.27–1.95) 或出生体重为 1.50 kg (aRR: 1.58; 95% CI: 1.13–2.21) 以下的婴儿，其新生儿期的患病率更高；(iv) 对于出生体重为 1.50–1.99 kg 的婴儿来说，其在新生儿期 (aOR: 3.30; 95% CI: 1.98–5.48) 及婴儿早期获取护理的可能性更低 (aOR : 1.74; 95% CI: 1.26–2.39)。.对于加纳地区出生体重偏低的婴儿，仍需采取措施以降低其死亡率并改善其获取护理的状况。.Изучить влияние веса при рождении на показатели младенческой смертности, заболеваемости и частоты обращения за медицинской помощью в сельских районах Ганы.Используя данные рандомизированных контролируемых испытаний, мы провели сравнение младенцев с весом 2,00–2,49, 1,50–1,99 и 1,50 кг и младенцев с нормальным весом при рождении. Мы установили скорректированные коэффициенты риска смертности (сРС), скорректированные коэффициенты риска заболеваемости (сРЗ) и скорректированное отношение шансов (сОШ) для случаев госпитализации и отсутствия обращения за медицинской помощью в течение четырех периодов времени (младенчество, неонатальный период, ранний младенческий возраст и поздний младенческий возраст), представленных по возрастным категориям: 0–364, 0–27, 28–182 и 183–364 дня соответственно.Среди 22 906 младенцев (при сравнении с младенцами, имевшими нормальный вес при рождении): (I) у младенцев, родившихся с весом 2,00–2,49, 1,50–1,99 и 1,50 кг, вероятность младенческой смертности была выше приблизительно в два раза (сРС: 2,13; 95%-й доверительный интервал, ДИ: 1,76–2,59), в восемь раз (сРС: 8,21; 95%-й ДИ: 6,26–10,76) и в 25 раз (сРС: 25,38; 95%-й ДИ: 18,36–35,10); (II) у младенцев, родившихся с весом 1,50 кг, вероятность смертности в неонатальный период и в период позднего младенческого возраста была выше примерно в 48 раз (сРС: 48,45; 95%-й ДИ: 32,81–71,55) и в восемь раз (сРС: 8,42; 95%-й ДИ: 3,09–22,92); (III) младенцы, родившиеся с весом 1,50–1,99 кг (сРЗ: 1,57; 95%-й ДИ: 1,27–1,95) или 1,50 кг (сРЗ: 1,58; 95%-й ДИ: 1,13–2,21), имели более высокие показатели неонатальной заболеваемости; (IV) для младенцев, родившихся с весом 1,50–1,99 кг, частота обращения за медицинской помощью была ниже в неонатальный период (сОШ: 3,30; 95%-й ДИ: 1,98–5,48) и в период раннего младенческого возраста (сОШ: 1,74; 95%-й ДИ: 1,26–2,39).В Гане для младенцев с низким весом при рождении необходима разработка стратегий для сведения к минимуму смертности и повышения мотивации для обращения за медицинской помощью.

ObjectivesOur overall aim was to evaluate the Western Australian Intellectual Disability Exploring Answers (IDEA) surveillance system. The primary objective was to evaluate the attributes of the system. The secondary objective was to provide recommendations to data custodians and stakeholders to strengthen the system.MethodThe IDEA system was evaluated using process observation, interviews and secondary data analysis of system attributes: usefulness, simplicity, data quality, acceptability, representativeness, timeliness and stability. 2001 US Centers for Disease Control and Prevention guidelines were used.ResultsWe found that the IDEA system was useful, simple, flexible, acceptable, representative, timely and stable. We compared individuals from the IDEA system (n=10 593) with those with cerebral palsy and intellectual disability (ID) (n=582) from another surveillance system. Of the 582 with cerebral palsy and ID, 501 (86.1%) were in the IDEA system and 81 (13.9%) were not. In total, 0.7% of cases (81/10674) with ID were not identified in the IDEA system. There were little differences in cases that were not identified in the IDEA system between Indigenous status, sex and place of residence.ConclusionsThe strengths of the IDEA system include having a high data quality resource contributing to national and international data on ID, strong government support and a dedicated management team. Output from studies linking to IDEA data have had major contributions to the international literature about ID. However, limited resources have prevented it from realising its full potential in relation to translational activities. The IDEA system is a valuable resource to address the needs of people living with ID.

Summary Background Maternal and perinatal mortality are still unacceptably high in many countries despite steep increases in facility birth. The evidence that childbirth in facilities reduces mortality is weak, mainly because of the scarcity of robust study designs and data. We aimed to assess this link by quantifying the influence of major determinants of facility birth (cluster-level facility birth, wealth, education, and distance to childbirth care) on several mortality outcomes, while also considering quality of care. Methods Our study is a secondary analysis of surveillance data on 119 244 pregnancies from two large population-based cluster-randomised controlled trials in Brong Ahafo, Ghana. In addition, we specifically collected data to assess quality of care at all 64 childbirth facilities in the study area. Outcomes were direct maternal mortality, perinatal mortality, first-day and early neonatal mortality, and antepartum and intrapartum stillbirth. We calculated cluster-level facility birth as the percentage of facility births in a woman's village over the preceding 2 years, and we computed distances from women's regular residence to health facilities in a geospatial database. Associations between determinants of facility birth and mortality outcomes were assessed in crude and multivariable multilevel logistic regression models. We stratified perinatal mortality effects by three policy periods, using April 1, 2005, and July 1, 2008, as cutoff points, when delivery-fee exemption and free health insurance were introduced in Ghana. These policies increased facility birth and potentially reduced quality of care. Findings Higher proportions of facility births in a cluster were not linked to reductions in any of the mortality outcomes. In women who were wealthier, facility births were much more common than in those who were poorer, but mortality was not lower among them or their babies. Women with higher education had lower mortality risks than less-educated women, except first-day and early neonatal mortality. A substantially higher proportion of women living in areas closer to childbirth facilities had facility births and caesarean sections than women living further from childbirth facilities, but mortality risks were not lower despite this increased service use. Among women who lived in areas closer to facilities offering comprehensive emergency obstetric care (CEmOC), emergency newborn care, or high-quality routine care, or to facilities that had providers with satisfactory competence, we found a lower risk of intrapartum stillbirth (14·2 per 1000 deliveries at >20 km from a CEmOC facility vs 10·4 per 1000 deliveries at ≤1 km; odds ratio [OR] 1·13, 95% CI 1·06–1·21) and of composite mortality outcomes than among women living in areas where these services were further away. Protective effects of facility birth were restricted to the two earlier policy periods (from June 1, 2003, to June 30, 2008), whereas there was evidence for higher perinatal mortality with increasing wealth (OR 1·09, 1·03–1·14) and lower perinatal mortality with increasing distance from childbirth facilities (OR 0·93, 0·89–0·98) after free health insurance was introduced in July 1, 2008. Interpretation Facility birth does not necessarily convey a survival benefit for women or babies and should only be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safe-guarding uncomplicated births. Funding The Baden-Wurttemberg Foundation, the Daimler and Benz Foundation, the European Social Fund and Ministry of Science, Research, and the Arts Baden-Wurttemberg, WHO, US Agency for International Development, Save the Children, the Bill & Melinda Gates Foundation, and the UK Department for International Development.

AIM To systematically review the effectiveness of education and/or training for traditional (informal) and formal health service providers in infant male circumcision on morbidity or mortality outcomes. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, Global Health, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects and clinical trial registries in all languages from January 1985 to June 2018. Our primary outcomes were all-cause morbidity and all-cause mortality. RESULTS We identified 1399 publications. Only four non-controlled before and after studies from the USA and Uganda satisfied our criteria, all of which examined the effect of training on the skills and knowledge of medical doctors, midwives and clinical officers. No study involved informal traditional circumcision providers. All included studies were low quality. CONCLUSIONS High-quality studies of simple training packages to improve education and training of circumcision providers, especially informal non-medical providers in low income countries are needed.

IntroductionThe IDEA system is a population-based data linkage system for intellectual disability (ID), which combines data from two government departments. Due to recent policy changes the future of the IDEA system is unknown. Understanding the IDEA system's strengths and limitations will provide data custodians with the opportunity to re-design the system. Objectives and ApproachAn evaluation of the IDEA surveillance system was undertaken to assess the quality, efficiency and usefulness of the system. The primary objectives were to evaluate systematically and objectively the attributes of the system and provide recommendations to data custodians and stakeholders to strengthen the surveillance system. The evaluation was based on the methods from the 2001 U.S. Centers for Disease Control and Prevention guidelines on evaluation of public health surveillance systems. We assessed the following system attributes: usefulness, simplicity, flexibility, data quality, acceptability, representativeness, timeliness, and stability. This was completed by process observation, semi-structured interviews and data analysis. ResultsOur results found the IDEA system was flexible, acceptable, representative, timely and stable. Given data linkage process and maintaining confidentiality the data linkage process was considered relatively simple. We compared individuals in the IDEA surveillance system to a sub-group of individuals, cerebral palsy with ID, to the mandatory reporting surveillance system WARDA-CP. There were 582 individuals identified in the WARDA-CP surveillance system as having cerebral palsy and ID. Of those identified 501 (86.1%) were also in the IDEA database and 81 (13.9%) were not. There were little differences in WARDA-CP cases that were not identified in the IDEA system between Indigenous status, sex and place of residence. Conclusion/ImplicationsThe IDEA system has successfully been used to understand prevalence rates and inform resource allocation. Advocacy organisations could play an important role in the sustainability of the system. Additional variables or enhanced surveillance for functional capacity could strengthen the system and provide important information to inform policy and practice.

Background The effects of conditional cash transfer (CCT) programs on maternal and child health (MCH) service use in conflicted affected countries such as Afghanistan are not known. Methods We conducted a non-randomised population based intervention study in six Afghanistan districts from December 2016 to December 2017. Six control districts were purposively matched. Women were eligible to be included in the baseline and endline evaluation surveys if they had given birth to one or more children in the last 12 months. The intervention was a CCT program including information, education, communication (IEC) program about CCT to community members and financial incentives to community health workers (CHWs) and families if mothers delivered their child at a health facility. Control districts received standard care. The primary objective was to assess the effect of CCT on use of health facilities for delivery. Secondary objectives were to assess the effect of CCT on antenatal care (ANC), postnatal care (PNC) and CHW motivation to perform home visits. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering and socio demographic variables. Results Overall, facility delivery increased in intervention villages by 14.3% and control villages by 8.4% (adjusted mean difference [AMD] 3.3%; 95% confidence interval [− 0.14 to 0.21], p value 0.685). There was no effect in the poorest quintile (AMD 0.8% [− 0.30 to 0.32], p value 0.953). ANC (AMD 45.0% [0.18 to 0.72] p value 0.004) and PNC (AMD 31.8% [− 0.05 to 0.68] p value 0.080) increased in the intervention compared to the control group. CHW home visiting changed little in intervention villages (− 3.0%) but decreased by − 23.9% in control villages (AMD 12.2% [− 0.27 to 0.51], p value 0.508). CCT exposure was 27.3% (342/1254) overall and 10.2% (17/166) in the poorest quintile. Conclusions Our study demonstrated that a CCT program provided to women aged 16–49 years can be implemented in a highly conservative conflict affected population. CCT should be scaled up for the poorest women in Afghanistan.

Background The effects of community health worker (CHW) home visiting during the antenatal and postnatal periods in fragile- and conflicted-affected countries such as Afghanistan are not known. Methods We conducted a non-randomised population-based intervention study from March 2015 to February 2016. Two intervention and two control districts were selected. All female CHWs in the intervention districts were trained to provide eight home visits and behaviour change communication messages from pregnancy to 28 days postpartum. The primary outcome was the proportion of women who reported delivering in a health facility. Secondary outcomes were the proportion of women who reported attending a health facility for at least one antenatal and one postnatal visit. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering. Results Overall, 289 female CHWs in the intervention districts performed home visits and 1407 eligible women (less than 12 months postpartum) at baseline and 1320 endline women provided outcome data (94% response rate). Facility delivery increased in intervention villages by 8.2% and decreased in the control villages by 6.3% (adjusted mean difference (AMD) 11.0%, 95% confidence interval (CI) 4.0–18.0%, p = 0.002). Attendance for at least one antenatal care visit (AMD 10.5%, 95% CI 4.2–16.9%, p = 0.001) and postnatal care visit (AMD 7.2%, 95% CI 0.2–14.2%, p = 0.040) increased in the intervention compared to the control districts. Conclusions CHW home visiting during the antenatal and postnatal periods can improve health service use in fragile- and conflict-affected countries. Commitment to scale-up from Ministries and donors is now needed. Trial registration This trial was retrospectively registered at the Australian and New Zealand Clinical Trial Registry (ACTRN12618000609257).

Background In the past fifteen years, Afghanistan has made substantial progress in extending primary health care. However, coverage of essential health interventions proven to improve maternal and neonatal health outcomes, particularly skilled birth attendance, remains unacceptably low. This is especially true for those in the poorest quintile of the population. This cross-sectional quantitative and qualitative study assessed barriers associated with care-seeking for institutional delivery among rural Afghan women in three provinces. Methods The study was conducted from November to December 2016 in 12 districts across three provinces – Badghis, Bamyan, and Kandahar – which are predominately rural. Districts were used as the primary sampling unit with district-level sample sizes reflecting the ratio of that district’s population to provincial population. Villages within these districts, the secondary sampling units, were randomly selected. A household survey was used to collect data on: demographics, socio-economic status, childbearing history, health transport and service costs, maternal health seeking behavior and barriers to service uptake. Data on barriers to facility delivery were compared across provinces using chi square tests. Results Of the 2479 women of child bearing age interviewed, one-third were from each province (33% n = 813 Badghis, 34% n = 840 Bamyan, 33% n = 824 Kandahar). Among those respondents who had delivered none of their children in a health center, money to pay for services appeared to be most important barrier to accessing institutional delivery (56%, n = 558). No transportation available was the second most widely cited reason (37%, n = 368), followed by family restrictions (n = 30%, n = 302). Respondents in Badghis reported the highest levels of barriers compared to the other two provinces. Respondents in Badghis were more likely to report familial or cultural constraints as the most important barrier to institutional delivery (43%) compared to Bamyan (2%) and Kandahar (12%) (p