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Background In South Sudan, the civil war in 2016 led to mass displacement in Juba that rapidly spread to other regions of the country. Access to health care was limited because of attacks against health facilities and workers and pregnant women and newborns were among the most vulnerable. Translation of newborn guidelines into public health practice, particularly during periods of on-going violence, are not well studied during humanitarian emergencies. During 2016 to 2017, we assessed the delivery of a package of community- and facility-based newborn health interventions in displaced person camps to understand implementation outcomes. This case analysis describes the challenges encountered and mitigating strategies employed during the conduct of an original research study. Discussion Challenges unique to conducting research in South Sudan included violent attacks against humanitarian aid workers that required research partners to modify study plans on an ongoing basis to ensure staff and patient safety. South Sudan faced devastating cholera and measles outbreaks that shifted programmatic priorities. Costs associated with traveling study staff and transporting equipment kept rising due to hyperinflation and, after the July 2016 violence, the study team was unable to convene in Juba for some months to conduct refresher trainings or monitor data collection. Strategies used to address these challenges were: collaborating with non-research partners to identify operational solutions; maintaining a locally-based study team; maintaining flexible budgets and timelines; using mobile data collection to conduct timely data entry and remote quality checks; and utilizing a cascade approach for training field staff. Conclusions The case analysis provides lessons that are applicable to other humanitarian settings including the need for flexible research methods, budgets and timelines; innovative training and supervision; and a local research team with careful consideration of sociopolitical factors that impact their access and safety. Engagement of national and local stakeholders can ensure health services and data collection continue and findings translate to public health action, even in contexts facing severe and unpredictable insecurity.

Background Maternal and perinatal death surveillance and response (MPDSR) systems aim to understand and address key contributors to maternal and perinatal deaths to prevent future deaths. From 2016–2017, the US Agency for International Development’s Maternal and Child Survival Program conducted an assessment of MPDSR implementation in Nigeria, Rwanda, Tanzania, and Zimbabwe. Methods A cross-sectional, mixed-methods research design was used to assess MPDSR implementation. The study included a desk review, policy mapping, semistructured interviews with 41 subnational stakeholders, observations, and interviews with key informants at 55 purposefully selected facilities. Using a standardised tool with progress markers defined for six stages of implementation, each facility was assigned a score from 0–30. Quantitative and qualitative data were analysed from the 47 facilities with a score above 10 (‘evidence of MPDSR practice’). Results The mean calculated MPDSR implementation progress score across 47 facilities was 18.98 out of 30 (range: 11.75–27.38). The team observed variation across the national MPDSR guidelines and tools, and inconsistent implementation of MPDSR at subnational and facility levels. Nearly all facilities had a designated MPDSR coordinator, but varied in their availability and use of standardised forms and the frequency of mortality audit meetings. Few facilities (9%) had mechanisms in place to promote a no-blame environment. Some facilities (44%) could demonstrate evidence that a change occurred due to MPDSR. Factors enabling implementation included clear support from leadership, commitment from staff, and regular occurrence of meetings. Barriers included lack of health worker capacity, limited staff time, and limited staff motivation. Conclusion This study was the first to apply a standardised scoring methodology to assess subnational- and facility-level MPDSR implementation progress. Structures and processes for implementing MPDSR existed in all four countries. Many implementation gaps were identified that can inform priorities and future research for strengthening MPDSR in low-capacity settings.

ObjectivesThis paper explores patient experiences and identifies barriers and opportunities for improving access to healthcare for patients from the Canadian north who travel to receive medical care in a Southern province.DesignA mixed-methods, cross-sectional study involved one-on-one interviews, focus group discussions and key informant interviews.Participants52 one-on-one interviews with Northwest Territories (NWT) patients and patient escorts and two focus group discussions (n=10). Fourteen key informant interviews were conducted with health workers, programme managers and staff of community organisations providing services for out-of-province patients. A Community Advisory Board guided the development of the questionnaires and interpretation of results.ResultsRespondents were satisfied with the care received overall, but described unnecessary burdens and bureaucratic challenges throughout the travel process. Themes relating to access to healthcare included: plans and logistics for travel; level of communication between services; clarity around jurisdiction and responsibility for care; indirect costs of travel and direct costs of uninsured services; and having a patient escort or advocate available to assist with appointments and navigate the system. Three themes related to healthcare experiences included: cultural awareness, respect and caring, and medical translation. Respondents provided suggestions to improve access to care.ConclusionsPatients from NWT need more information and support before and during travel. Ensuring that medical travellers and escorts are prepared before departing, that healthcare providers engage in culturally appropriate communication and connecting travellers to support services on arrival have the potential to improve medical travel experiences.

Highest rates of neonatal mortality occur in countries that have recently experienced conflict. International Medical Corps implemented a package of newborn interventions in June 2016, based on the Newborn health in humanitarian settings: field guide, targeting community- and facility-based health workers in displaced person camps in South Sudan. We describe health workers' knowledge and attitudes toward newborn health interventions, before and after receiving clinical training and supplies, and recommend dissemination strategies for improved uptake of newborn guidelines during crises. A mixed methods approach was utilised, including pre-post knowledge tests and in-depth interviews. Study participants were community- and facility-based health workers in two internally displaced person camps located in Juba and Malakal and two refugee camps in Maban from March to October 2016. Mean knowledge scores for newborn care practices and danger signs increased among 72 community health workers (pre-training: 5.8 [SD: 2.3] vs. post-training: 9.6 [SD: 2.1]) and 25 facility-based health workers (pre-training: 14.2 [SD: 2.7] vs. post-training: 17.4 [SD: 2.8]). Knowledge and attitudes toward key essential practices, such as the use of partograph to assess labour progress, early initiation of breastfeeding, skin-to-skin care and weighing the baby, improved among skilled birth attendants. Despite challenges in conflict-affected settings, conducting training has the potential to increase health workers' knowledge on neonatal health post-training. The humanitarian community should reinforce this knowledge with key actions to shift cultural norms that expand the care provided to women and their newborns in these contexts.

Home visits for pregnancy and postnatal care were endorsed by the WHO and partners as a complementary strategy to facility-based care to reduce newborn and maternal mortality. This article aims to synthesise findings and implications from the economic analyses of community-based maternal and newborn care (CBMNC) evaluations in seven countries. The evaluations included five cluster randomized trials (Ethiopia, Ghana, South Africa, Tanzania, Uganda) and programmatic before/after assessments (Bolivia, Malawi). The economic analyses were undertaken using a standardized, comparable methodology the 'Cost of Integrated Newborn Care' Tool, developed by the South African Medical Research Council, with Saving Newborn Lives and a network of African economists. The main driver of costs is the number of community health workers (CHWs), determined by their time availability, as fixed costs per CHW (equipment, training, salary/stipend, supervision and management), independent from the level of activity (number of mothers visited) represented over 96% of economic and financial costs in five of the countries. Unpaid volunteers are not necessarily a cheap option. An integrated programme with multi-purpose paid workers usually has lower costs per visit but requires innovative management, including supervision to ensure that coverage, or quality of care are not compromised since these workers have many other responsibilities apart from maternal and newborn health. If CHWs reach 95% of pregnant women in a standardized 100 000 population, the additional financial cost in all cases would be under USD1 per capita. In five of the six countries, the programme would be highly cost-effective (cost per DALY averted

Background: Each year an estimated 2.6 million newborns die, mainly from complications of prematurity, neonatal infections, and intrapartum events. Reducing these deaths requires high coverage of good quality care at birth, and inpatient care for small and sick newborns. In low- and middle-income countries, standardised measurement of the readiness of facilities to provide emergency obstetric care has improved tracking of readiness to provide care at birth in recent years. However, the focus has been mainly on obstetric care; service readiness for providing inpatient care of small and sick newborns is still not consistently measured or tracked. Methods: We reviewed existing international guidelines and resources to create a matrix of the structural characteristics (infrastructure, equipment, drugs, providers and guidelines) for service readiness to deliver a package of inpatient care interventions for small and sick newborns. To identify gaps in existing measurement systems, we reviewed three multi-country health facility survey tools (the Service Availability and Readiness Assessment, the Service Provision Assessment and the Emergency Obstetric and Newborn Care Assessment) against our service readiness matrix. Findings: For service readiness to provide inpatient care for small and sick newborns, our matrix detailed over 600 structural characteristics. Our review of the SPA, the SARA and the EmONC assessment tools identified several measurement omissions to capture information on key intervention areas, such as thermoregulation, feeding and respiratory support, treatment of specific complications (seizures, jaundice), and screening and follow up services, as well as specialised staff and service infrastructure. Conclusions: Our review delineates the required inputs to ensure readiness to provide inpatient care for small and sick newborns. Based on these findings, we detail where questions need to be added to existing tools and describe how measurement systems can be adapted to reflect small and sick newborns interventions. Such work can inform investments in health systems to end preventable newborn death and disability as part of the Every Newborn Action Plan.

Background As efforts to scale up the delivery of Kangaroo Mother Care (KMC) in facilities are increasing, a standardized approach to measure implementation and progress towards effective coverage is needed. Here, we describe a consensus–based approach to develop a measurement framework and identify a core set of indicators for monitoring facility–based KMC that would be feasible to measure within existing systems. Methods The KMC measurement framework and core list of indicators were developed through: 1) scoping exercise to identify potential indicators through literature review and requests from researchers and program implementers; and 2) face–to–face consultations with KMC and measurement experts working at country and global levels to review candidate indicators and finalize selection and definitions. Results The KMC measurement framework includes two main components: 1) service readiness, based on the WHO building blocks framework; and 2) service delivery action sequence covering identification, service initiation, continuation to discharge, and follow–up to graduation. Consensus was reached on 10 core indicators for KMC, which were organized according to the measurement framework. We identified 4 service readiness indicators, capturing national level policy for KMC, availability of KMC indicators in HMIS, costed operational plans for KMC and availability of KMC services at health facilities with inpatient maternity services. Six indicators were defined for service delivery, including weighing of babies at birth, identification of those ≤2000 g, initiation of facility–based KMC, monitoring the quality of KMC, status of babies at discharge from the facility and levels of follow–up (according to country–specific protocol). Conclusions These core KMC indicators, identified with input from a wide range of global and country–level KMC and measurement experts, can aid efforts to strengthen monitoring systems and facilitate global tracking of KMC implementation. As data collection systems advance, we encourage program managers and evaluators to document their experiences using this framework to measure progress and allow indicator refinement, with the overall aim of working towards sustainable, country–led data systems.

Background: In most low and middle-income countries vital events registration for births and child deaths is poor, with reporting of pregnancy outcomes highly inadequate or non-existent. Health and Demographic Surveillance System (HDSS) sites and periodic population-based household-level surveys can be used to identify pregnancies and retrospectively capture pregnancy outcomes to provide data for decision making. However, little is known about the performance of different methods in identifying pregnancy and pregnancy outcomes, yet this is critical in assessing improvements in reducing maternal and newborn mortality and stillbirths. Objective: To explore differences between a population-based household pregnancy survey and prospective health demographic surveillance system in identifying pregnancies and their outcomes in rural eastern Uganda. Methods: The study was done within the Iganga-Mayuge HDSS site, a member centre of the INDEPTH Network. Prospective data about pregnancies and their outcomes was collected in the routine biannual census rounds from 2006 to 2010 in the HDSS. In 2011 a cross-sectional survey using the pregnancy history survey (PHS) tool was conducted among women aged 15 to 49 years in the HDSS area. We compared differences between the HDSS biannual census updates and the PHS capture of pregnancies identified as well as neonatal and child deaths, stillbirths and abortions. Findings: A total of 10,540 women aged 15 to 49 years were interviewed during the PHS. The PHS captured 12.8% more pregnancies than the HDSS in the most recent year (2010–2011), though between 2006 and 2010 (earlier periods) the PHS captured only 137 (0.8%) more pregnancies overall. The PHS also consistently identified more stillbirths (18.2%), spontaneous abortions (94.5%) and induced abortions (185.8%) than the prospective HDSS update rounds. Conclusions: Surveillance sites are designed to prospectively track population-level outcomes. However, the PHS identified more pregnancy-related outcomes than the HDSS in this study. Asking about pregnancy and its outcomes may be a useful way to improve measurement of pregnancy outcomes. Further research is needed to identify the most effective methods of improving the capture of pregnancies and their outcomes within HDSS sites, household surveys and routine health information systems.

Community-based maternal and newborn care with home visits by community health workers (CHWs) are recommended by WHO to complement facility-based care. As part of multi-country economic and systems analyses, we aimed to compare the content and financial costs associated with equipping CHWs or 'home visit kits' from seven studies in Bolivia, Ethiopia, Ghana, Malawi, South Africa, Tanzania and Uganda. We estimated the equivalent annual costs (EACs) of home visit kits per CHW in constant 2015 USD. We estimated EAC at scale in a population of 100 000 assuming four home visits per mother during the pregnancy and postnatal period. All seven packages were designed for health promotion; six included clinical assessments and one included curative care. The items used by CHWs differed between countries, even for the same task. The EAC per home visit kit ranged from $15 in Tanzania to $116 in South Africa. For health promotion and preventive care, between 82 and 100% of the cost of CHW commodities did not vary with the number of home visits conducted; however, in Ethiopia, the majority of EAC associated with curative care varied with the number of visits conducted. The EAC of equipping CHWs to meet the needs of 95% of expectant mothers in a catchment area of 100 000 people was highest in Bolivia, $40 260 for 633 CHWs, due to mothers being in hard-to-reach areas with CHW conducting few visits per year per, and lowest in Tanzania ($2693 for 172 CHWs), due to the greater number of CHW visits per week and lower EAC of items. To inform and ensure sustainable implementation at scale, national discussions regarding the cadre of CHWs and their workload should also consider carefully the composition and cost of equipping CHWs to carry out their work effectively and efficiently.

OBJECTIVE:: To analyse trends in under-five mortality rate in South Africa (1990-2011), particularly the contribution of AIDS deaths. METHODS:: Three nationally-used models for estimating AIDS deaths in children were systematically reviewed. The model outputs were compared with under-five mortality rate estimates for South Africa from two global estimation models. All estimates were compared with available empirical data. RESULTS:: Differences between the models resulted in varying point estimates for under-five mortality but the trends were similar, with mortality increasing to a peak around 2005. The three models showing the contribution of AIDS suggest a maximum of 37-39% of child deaths were due to AIDS in 2004-2005 which has since declined. While the rate of progress from 1990 is not the 4.4% needed to meet Millennium Development Goal 4 for child survival, South Africa's average annual rate of under-five mortality decline between 2006 and 2011 was between 6.3%-10.2%. CONCLUSION:: In 2005, South Africa was one of only four countries globally with an under-five mortality rate higher than the 1990 Millennium Development Goal baseline. Over the past five years the country has achieved a rate of child mortality reduction exceeded by only three other countries. This rapid turnaround is likely due to scale up of prevention of mother-to-child transmission of HIV, and to a lesser degree, the expanded roll-out of antiretroviral therapy. Emphasis on these programmes must continue, but failure to address other aspects of care including integrated high quality maternal and neonatal care means that the decline in child mortality could stall.

Background: To examine changes in under-5 mortality, coverage of child survival interventions and nutritional status of children in Ethiopia between 2000 and 2011. Using the Lives Saved Tool, the impact of changes in coverage of child survival interventions on under-5 lives saved was estimated.Methods: Estimates of child mortality were generated using three Ethiopia Demographic and Health Surveys undertaken between 2000 and 2011. Coverage indicators for high impact child health interventions were calculated and the Lives Saved Tool (LiST) was used to estimate child lives saved in 2011.Results: The mortality rate in children younger than 5 years decreased rapidly from 218 child deaths per 1000 live births (95% confidence interval 183 to 252) in the period 1987-1991 to 88 child deaths per 1000 live births in the period 2007-2011 (78 to 98). The prevalence of moderate or severe stunting in children aged 6-35 months also declined significantly. Improvements in the coverage of interventions relevant to child survival in rural areas of Ethiopia between 2000 and 2011 were found for tetanus toxoid, DPT3 and measles vaccination, oral rehydration solution (ORS) and care-seeking for suspected pneumonia. The LiST analysis estimates that there were 60 700 child deaths averted in 2011, primarily attributable to decreases in wasting rates (18%), stunting rates (13%) and water, sanitation and hygiene (WASH) interventions (13%).Conclusions: Improvements in the nutritional status of children and increases in coverage of high impact interventions most notably WASH and ORS have contributed to the decline in under-5 mortality in Ethiopia. These proximal determinants however do not fully explain the mortality reduction which is plausibly also due to the synergistic effect of major child health and nutrition policies and delivery strategies.

The Uganda Newborn Study (UNEST) was a two-arm cluster Randomized Control Trial to study the effect of pregnancy and postnatal home visits by local community health workers called 'Village Health Teams' (VHT) coupled with health systems strengthening. To inform programme planning and decision making, additional economic and financial costs of community and facility components were estimated from the perspective of the provider using the Excel-based Cost of Integrating Newborn Care Tool. Additional costs excluded costs already paid by the government for the routine health system and covered design, set-up, and 1-year implementation phases. Improved efficiency was modelled by reducing the number of VHT per village from two to one and varying the number of home visits/mother, the programme's financial cost at scale was projected (population of 100 000). 92% of expectant mothers (n = 1584) in the intervention area were attended by VHTs who performed an average of three home visits per mother. The annualized additional financial cost of the programme was $83 360 of which 4% ($3266) was for design, 24% ($20 026) for set-up and 72% ($60 068) for implementation. 56% ($47 030) went towards health facility strengthening, whereas 44% ($36 330) was spent at the community level. The average cost/mother for the community programme, excluding one-off design costs, amounted to $22.70 and the average cost per home visit was $7.50. The additional cost of the preventive home visit programme staffed by volunteer VHTs represents $1.04 per capita, 1.8% of Uganda's public health expenditure per capita ($59.00). If VHTs were to spend an average of 6 h a week on the programme, costs per mother would drop to $13.00 and cost per home visit to $3.20, in a population of 100 000 at 95% coverage. Additional resources are needed to rollout the government's VHT strategy nationally, maintaining high quality and linkages to quality facility-based care.

Dear Sir: The article by Amouzou and others1 presents findings from an evaluation of integrated community case management (iCCM) in Malawi using a National Evaluation Platform (NEP) design. While it is a welcome effort to document this child survival strategy that is being tested in many low- and middle-income countries, the study findings have implications both for iCCM and for approaches to evaluation, which would benefit from further scrutiny. An important consideration in the evaluation of community-based care is ascertaining true exposure to the intervention in the study population. The article by Amouzou and others used a dose–response approach, with 27 districts as the unit of analysis, to measure the effect of an intervention (iCCM) that was specifically targeted at hard-to-reach areas. Their approach ignored spatial variation within districts and led to a diluted estimate of the effect of iCCM, as not all communities sampled in the household surveys were exposed to iCCM-trained health surveillance assistants (HSAs). A more effective approach would have been to stratify the samples by a measure of spatial exposure, for instance average travel time to the nearest HSA and ratio of HSAs per population within a given buffer of the cluster.2 Moreover, the exposure was limited at 1.5 HSAs per 1,000 children under 5 years of age (lower than the Ministry of Health target of one per 1,000 population, equivalent to about one HSA per 200 children). For community-based nutrition programs, a ratio of one community worker per 100–200 children is associated with impact on child malnutrition.3 Furthermore, the regression analysis used overall care seeking from all formal providers as the dependent variable, not care seeking from HSAs who actually delivered iCCM. A more accurate approach would have been to use change in care seeking to HSAs as the dependent variable. In addition, care seeking does not necessarily result in appropriate treatment. Therefore, it may be misleading to conclude that iCCM had no impact on under-five mortality without assessing changes in coverage of appropriate treatment of childhood illnesses. As more countries are scaling up community-based delivery platforms,4 it is critical that methods to evaluate the impact of these services take into consideration spatial exposure to community health workers. National household surveys, which are the main source of exposure and outcome data in the NEP design, are designed to provide estimates at the district or regional level, and therefore cannot provide valid estimates among populations exposed to iCCM when exposure varies within the district or region. We agree with the authors' request for more investigation into why about one-third of HSAs do not live in the community they serve and how this may affect access for sick children.5 Given the considerations presented, we question the validity of the conclusion that iCCM had no impact on care seeking or mortality in Malawi. An alternative interpretation could be that at this exposure, the effects were too small to establish with the methods used; an estimate of the possible effect size, rather than negative conclusions, would be more useful. There are important policy and programmatic risks in concluding that iCCM has no impact. Policy makers could change the course of programs or plans, donors could shift priorities, and program managers could be demotivated by a sense of failure. Thus, there is need for caution when interpreting the findings. We support the authors' call for continuous large-scale evaluation in global health, including rigorous methodology with appropriate evaluation designs, to provide robust conclusions of relevance to improving health services.

Background Household surveys undertaken in Niger since 1998 have revealed steady declines in under-5 mortality which have placed the country ‘on track’ to reach the fourth Millennium Development goal (MDG). This paper explores Niger’s mortality and health coverage data for children under-5 years of age up to 2012 to describe trends in high impact interventions and the resulting impact on childhood deaths averted. The sustainability of these trends are also considered. Methods and Findings Estimates of child mortality using the 2012 Demographic and Health Survey were developed and maternal and child health coverage indicators were calculated over four time periods. Child survival policies and programmes were documented through a review of documents and key informant interviews. The Lives Saved Tool (LiST) was used to estimate the number of child lives saved and identify which interventions had the largest impact on deaths averted. The national mortality rate in children under-5 decreased from 286 child deaths per 1000 live births (95% confidence interval 177 to 394) in the period 1989–1990 to 128 child deaths per 1000 live births in the period 2011–2012 (101 to 155), corresponding to an annual rate of decline of 3.6%, with significant declines taking place after 1998. Improvements in the coverage of maternal and child health interventions between 2006 and 2012 include one and four or more antenatal visits, maternal Fansidar and tetanus toxoid vaccination, measles and DPT3 vaccinations, early and exclusive breastfeeding, oral rehydration salts (ORS) and proportion of children sleeping under an insecticide-treated bed net (ITN). Approximately 26,000 deaths of children under-5 were averted in 2012 due to decreases in stunting rates (27%), increases in ORS (14%), the Hib vaccine (14%), and breastfeeding (11%). Increases in wasting and decreases in vitamin A supplementation negated some of those gains. Care seeking at the community level was responsible for an estimated 7,800 additional deaths averted in 2012. A major policy change occurred in 2006 enabling free health care provision for women and children, and in 2008 the establishment of a community health worker programme. Conclusion Increases in access and coverage of care for mothers and children have averted a considerable number of childhood deaths. The 2006 free health care policy and health post expansion were paramount in reducing barriers to care. However the sustainability of this policy and health service provision is precarious in light of persistently high fertility rates, unpredictable GDP growth, a high dependence on donor support and increasing pressures on government funding.

Summary Background Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children. Methods We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels. Findings We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles. Interpretation Equity should be accounted for when planning the scaling up of interventions and assessing national progress. Funding Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.

Neonatal mortality accounts for 40% of under-five child mortality. Evidence-based interventions exist, but attention to implementation is recent. Nationally representative coverage data for these neonatal interventions are limited; therefore proximal measures of progress toward scale would be valuable for tracking change among countries and over time. We describe the process of selecting a set of benchmarks to assess scale up readiness or the degree to which health systems and national programmes are prepared to deliver interventions for newborn survival. A prioritization and consensus-building process was co-ordinated by the Saving Newborn Lives programme of Save the Children, resulting in selection of 27 benchmarks. These benchmarks are categorized into agenda setting (e.g. having a national newborn survival needs assessment); policy formulation (e.g. the national essential drugs list includes injectable antibiotics at primary care level); and policy implementation (e.g. standards for care of sick newborns exist at district hospital level). Benchmark data were collected by in-country stakeholders teams who filled out a standard form and provided evidence to support each benchmark achieved. Results are presented for nine countries at three time points: 2000, 2005 and 2010. By 2010, substantial improvement was documented in all selected countries, with three countries achieving over 75% of the benchmarks and an additional five countries achieving over 50% of the benchmarks. Progress on benchmark achievement was accelerated after 2005. The policy process was similar in all countries, but did not proceed in a linear fashion. These benchmarks are a novel method to assess readiness to scale up, an important construct along the pathway to scale for newborn care. Similar exercises may also be applicable to other global health issues.

Since 2010, Malawi has been on track to reach Millennium Development Goal (MDG) 4 and is one of the first countries in sub–Saharan Africa to have reached the target [1], despite reporting one of the lowest gross national incomes per capita in the world [2]. According to the UN Inter–Agency Group for Child Mortality Estimation, under–5 mortality has declined steadily from 245 to 68 deaths per 1000 live births between 1990 and 2013 [3]. Malawi showed commitment to accelerating child survival and development through the establishment of the Accelerated Child Survival and Development policy in 2006 which was implemented through the Integrated Management of Childhood Illness (IMCI) five year strategic plan (2006–2011) and the Strategic Plan for Child Survival in 2007. The strategy aimed to reduce childhood morbidity and mortality by two–thirds between 2000 and 2015, and it focused on the scaling up of high impact interventions including integrated community case management of childhood illnesses and newborn care (iCCM) [4]. From 2008 iCCM was scaled up nationally under the coordination of the Ministry of Health with the support of partners in different districts including UNICEF, WHO, Save the Children, and others. UNICEF worked as an implementing partner in ten of twenty–eight districts throughout the country through the Catalytic Initiative (CI) Integrated Health Systems Strengthening (IHSS) programme (Figure 1) whilst other partners provided similar support in the remainder of the country. In 2013, an estimated 41 000 under–5 deaths occurred nationally with approximately 47% in the ten CI focus districts [3]. Figure 1 Map of Malawi showing 10 Catalytic Initiative districts (shaded in green). The CI/IHSS programme was established by UNICEF with joint funding from the Department of Foreign Affairs, Trade and Development Canada (DFATD) in late 2007 with the main aim of assisting low and middle–income countries in Central, West and Southern Africa with high maternal and child mortality rates, including Malawi, to scale up services to children and pregnant women [5]. The CI programme had a strong health systems strengthening focus through training of front line health workers, provision of drugs and supplies, support for supervision and development of monitoring and evaluation systems [6]. In the initial period the CI programme in Malawi supported mainly preventive interventions including provision of vitamin A supplementation, immunisations, counselling on infant and young child feeding as well as training almost 4000 nurses in Integrated Management of Childhood Illnesses (IMCI). Following the Ministry of Health decision to scale up iCCM, the focus was on training and equipping of community health workers called health surveillance assistants (HSAs) to deliver iCCM services for treatment of malaria, pneumonia and diarrhoea [7]. As one of six countries participating in the CI programme, Malawi received a total of US$ 19.4 million from DFATD (US$ 11.5) and UNICEF (US$ 7.9) over the grant period 2007– 2013 [8]. HSAs have played a central role in the delivery of health services in Malawi since the 1960s, delivering an increasingly broad array of services at the community level [9–11]. Initially operating as environmental health outreach assistants concentrating on water and sanitation; since 1995 HSAs have been formally recruited and salaried by the Ministry of Health. Required to have grade 10 (junior certificate of education) to qualify, HSAs receive 12 weeks of general training, and since 2008, an additional 6 days of specific training on iCCM. They split their working week between the village clinic (situated in hard–to–reach areas >5km from the nearest health centre) in which they spend 2–3 days per week, community–based outreach work and assisting in fixed health facilities. In 2011 there were over 10 000 HSAs in the country of which 3800 had been trained in iCCM with just over 1000 of these situated in the 10 districts where CI efforts were focused (Figure 1) [10]. Small–scale evaluations during the early period of iCCM implementation (2009–2011) revealed high demand for HSA services [10] and quality of care similar to that provided by nurses in first–level facilities [12]. An evaluation of changes in newborn survival identified areas for further work, including the integration of neonatal sepsis management into iCCM [13]. However, no evaluation has assessed the broader impact of child survival strategies, particularly iCCM, on child health indicators in Malawi. This paper explores factors influencing progress in child survival including coverage of interventions, the role of key national policies and impact of coverage change on under–5 deaths averted using data from an evaluation of the CI programme of support in Malawi.

Background: While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking.Methods: We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low-and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality.Results: Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed.Conclusions: Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

Each year 3.6 million infants are estimated to die in the first 4 weeks of life (neonatal period)--but the majority continue to die at home, uncounted. This article reviews progress for newborn health globally, with a focus on the countries in which most deaths occur--what data do we have to guide accelerated efforts? All regions are advancing, but the level of decrease in neonatal mortality differs by region, country, and within countries. Progress also differs by the main causes of neonatal death. Three major causes of neonatal deaths (infections, complications of preterm birth, and intrapartum-related neonatal deaths or "birth asphyxia") account for more than 80% of all neonatal deaths globally. The most rapid reductions have been made in reducing neonatal tetanus, and there has been apparent progress towards reducing neonatal infections. Limited, if any, reduction has been made in reducing global deaths from preterm birth and for intrapartum-related neonatal deaths. High-impact, feasible interventions to address these 3 causes are summarized in this article, along with estimates of potential for lives saved. A major gap is reaching mothers and babies at birth and in the early postnatal period. There are promising community-based service delivery models that have been tested mainly in research studies in Asia that are now being adapted and evaluated at scale and also being tested through a network of African implementation research trials. To meet Millennium Development Goal 4, more can and must be done to address neonatal deaths. A critical step is improving the quantity, quality and use of data to select and implement the most effective interventions and strengthen existing programs, especially at district level.

Background In high-income countries, national mortality audits are associated with improved quality of care, but there has been no previous systematic review of perinatal audit in low- and middle-income settings. Objectives To present a systematic review of facility-based perinatal mortality audit in low- and middle-income countries, and review information regarding community audit. Results Ten low-quality evaluations with mortality outcome data were identified. Meta-analysis of 7 before-and-after studies indicated a reduction in perinatal mortality of 30% (95% confidence interval, 21%–38%) after introduction of perinatal audit. The consistency of effect suggests that audit may be a useful tool for decreasing perinatal mortality rates in facilities and improving quality of care, although none of these evaluations were large scale. Few of the identified studies reported intrapartum-related perinatal outcomes. Novel experience of community audit and social autopsy is described, but data reporting mortality outcome effect are lacking. There are few examples of wide-scale, sustained perinatal audit in low-income settings. Two national cases studies (South Africa and Bangladesh) are presented. Programmatic decision points, challenges, and key factors for national or wide scale-up of sustained perinatal mortality audit are discussed. As a minimum standard, facilities should track intrapartum stillbirth and pre-discharge intrapartum-related neonatal mortality rates. Conclusion The effect of perinatal audit depends on the ability to close the audit loop; without effectively implementing the solutions to the problems identified, audit alone cannot improve quality of care.

The annual toll of losses resulting from poor pregnancy outcomes include half a million maternal deaths, more than three million stillbirths, of whom at least one million die during labour and 3.8 million neonatal deaths--up to half on the first day of life. Neonatal deaths account for an increasing proportion of child deaths (now 41%) and must be reduced to achieve Millennium Development Goal (MDG) 4 for child survival. Newborn survival is also related to MDG 5 for maternal health as the interventions are closely linked. This article reviews current progress for newborn health globally, with a focus on the countries where most deaths occur. Three major causes of neonatal deaths (infections, complications of preterm birth, intrapartum-related neonatal deaths) account for almost 90% of all neonatal deaths. The highest impact interventions to address these causes of neonatal death are summarised with estimates of potential for lives saved. Two priority opportunities to address newborn deaths through existing maternal health programmes are highlighted. First, antenatal steroids are high impact, feasible and yet under-used in low resource settings. Second, with increasing investment to scale up skilled attendance and emergency obstetric care, it is important to include skills and equipment for simple immediate newborn care and neonatal resuscitation. A major gap is care during the early postnatal period for mothers and babies. There are promising models that have been tested mainly in research studies in Asia that are now being adapted and evaluated at scale including through a network of African implementation research trials.

The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths. The continuum for maternal, newborn, and child health usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). We define a population-level or public-health framework based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children. These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one. The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes. Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care. Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.

BACKGROUND: The Every Newborn Action Plan (ENAP), launched in 2014, aims to end preventable newborn deaths and stillbirths, with national targets of ≤12 neonatal deaths per 1000 live births and ≤12 stillbirths per 1000 total births by 2030. This requires ambitious improvement of the data on care at birth and of small and sick newborns, particularly to track coverage, quality and equity. METHODS: In a multistage process, a matrix of 70 indicators were assessed by the Every Newborn steering group. Indicators were graded based on their availability and importance to ENAP, resulting in 10 core and 10 additional indicators. A consultation process was undertaken to assess the status of each ENAP core indicator definition, data availability and measurement feasibility. Coverage indicators for the specific ENAP treatment interventions were assigned task teams and given priority as they were identified as requiring the most technical work. Consultations were held throughout. RESULTS: ENAP published 10 core indicators plus 10 additional indicators. Three core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) are well defined, with future efforts needed to focus on improving data quantity and quality. Three core indicators on coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content and quality of the interventions. Four core (antenatal corticosteroids, neonatal resuscitation, treatment of serious neonatal infections, kangaroo mother care) and one additional coverage indicator for newborns at risk or with complications (chlorhexidine cord cleansing) lack indicator definitions or data, especially for denominators (population in need). To address these gaps, feasible coverage indicator definitions are presented for validity testing. Measurable process indicators to help monitor health service readiness are also presented. A major measurement gap exists to monitor care of small and sick babies, yet signal functions could be tracked similarly to emergency obstetric care. CONCLUSIONS: The ENAP Measurement Improvement Roadmap (2015-2020) outlines tools to be developed (e.g., improved birth and death registration, audit, and minimum perinatal dataset) and actions to test, validate and institutionalise proposed coverage indicators. The roadmap presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys. Real measurement change requires intentional transfer of leadership to countries with the greatest disease burden and will be achieved by working with centres of excellence and existing networks.

Background : South Africa has made substantial progress on child and maternal mortality, yet many avoidable deaths of mothers and children still occur. This analysis identifies priority interventions to be scaled up nationally and projects the potential maternal and child lives saved. Design : We modelled the impact of maternal, newborn and child interventions using the Lives Saved Tools Projections to 2015 and used realistic coverage increases based on expert opinion considering recent policy change, financial and resource inputs, and observed coverage change. A scenario analysis was undertaken to test the impact of increasing intervention coverage to 95%. Results : By 2015, with realistic coverage, the maternal mortality ratio (MMR) can reduce to 153 deaths per 100,000 and child mortality to 34 deaths per 1,000 live births. Fifteen interventions, including labour and delivery management, early HIV treatment in pregnancy, prevention of mother-to-child transmission and handwashing with soap, will save an additional 9,000 newborns and children and 1,000 mothers annually. An additional US$370 million (US$7 per capita) will be required annually to scale up these interventions. When intervention coverage is increased to 95%, breastfeeding promotion becomes the top intervention, the MMR reduces to 116 and the child mortality ratio to 23. Conclusions : The 15 interventions identified were adopted by the National Department of Health, and the Health Minister launched a campaign to encourage Provincial Health Departments to scale up coverage. It is hoped that by focusing on implementing these 15 interventions at high quality, South Africa will reach Millennium Development Goal (MDG) 4 soon after 2015 and MDG 5 several years later. Focus on HIV and TB during early antenatal care is essential. Strategic gains could be realised by targeting vulnerable populations and districts with the worst health outcomes. The analysis demonstrates the usefulness of priority setting tools and the potential for evidence-based decision making in the health sector. Keywords : child health; maternal health; cost and cost analysis (Published: 21 April 2015) Citation : Glob Health Action 2015, 8 : 27265 - http://dx.doi.org/10.3402/gha.v8.27265

No abstract available. (Published: 31 March 2015) Citation : Glob Health Action 2015, 8 : 27363 - http://dx.doi.org/10.3402/gha.v8.27363 SPECIAL ISSUE : This paper is part of the Special Issue: Newborn health in Uganda . More papers from this issue can be found at http://www.globalhealthaction.net

No abstract available. (Published: 31 March 2015) Citation : Glob Health Action 2015, 8 : 27363 - http://dx.doi.org/10.3402/gha.v8.27363 SPECIAL ISSUE : This paper is part of the Special Issue: Newborn health in Uganda . More papers from this issue can be found at http://www.globalhealthaction.net

Background : Stillbirths do not register amongst national or global public health priorities, despite large numbers and known solutions. Although not accounted in statistics – these deaths count for families. Part of this disconnect is that very little is known about the lived experiences and perceptions of those experiencing this neglected problem. Objective : This study aimed to explore local definitions and perceived causes of stillbirths as well as coping mechanisms used by families affected by stillbirth in rural eastern Uganda. Design : A total of 29 in-depth interviews were conducted with women who had a stillbirth (14), men whose wives experienced a stillbirth (6), grandmothers (4), grandfathers (1), and traditional birth attendants (TBAs) (4). Participants were purposively recruited from the hospital maternity ward register, with additional recruitment done through community leaders and other participants. Data were analysed using content analysis. Results : Women and families affected by stillbirth report pregnancy loss as a common occurrence. Definitions and causes of stillbirth included the biomedical, societal, and spiritual. Disclosure of stillbirth varies with women who experience consecutive or multiple losses, subject to potential exclusion from the community and even the family. Methods for coping with stillbirth were varied and personal. Ritual burial practices were common, yet silent and mainly left to women, as opposed to public mourning for older children. There were no formal health system mechanisms to support or care for families affected by stillbirths. Conclusion : In a setting with strong collective ties, stillbirths are a burden borne by the affected family, and often just by the mother, rather than the community as a whole. Strategies are needed to address preventable stillbirths as well as to follow up with supportive services for those affected. Keywords : stillbirth; pregnancy loss; Uganda; maternal health; postpartum depression; traditional birth attendants (Published: 31 March 2015) Citation : Glob Health Action 2015, 8 : 24011 - http://dx.doi.org/10.3402/gha.v8.24011 SPECIAL ISSUE: This paper is part of the Special Issue: Newborn health in Uganda . More papers from this issue can be found at http://www.globalhealthaction.net

Background: The magnitude of the Ebola outbreak in West Africa is unprecedented. Liberia, Guinea, and Sierra Leone are in the bottom ten countries in the Human Development Index, but all had made gains in child survival prior to the outbreak. With closure of healthcare facilities and the loss of health workers secondary to the outbreak, the region risks reversing survival gains achieved in maternal and newborn health. Methods: Anonymized service utilization data were downloaded from the Liberia District Health Information Software (DHIS) 2 for selected maternal health services at PHC facilities in Margibi and Bong Counties from March 2014, when the first case of Ebola was reported in Liberia, through December 2014. Absolute numbers are provided instead of percentage measures because of the lack of a population-based denominator. Results: Overall, the data show a decrease in absolute utilization from the start of the outbreak, followed by a slow recovery after October or November. In Bong County, totals were less than 14% of the peak numbers during the outbreak for number of antenatal visits and pregnant women receiving intermittent preventive treatment for malaria in pregnancy (IPTp). For total deliveries, utilization was less than 33% of the highest month. In Margibi County, during what now appears to be the height of the outbreak, numbers dropped to less than 9% of peak utilization for antenatal care visits and 4% for IPTp. Total health facility deliveries dropped to less than 9% of peak utilization. Conclusion: It is clear that Bong and Margibi Counties in Liberia experienced a large drop in utilization of maternal health care services during what now appears to be the peak of the Ebola outbreak. As the health of women and their babies is being promoted in the post-2015 sustainable development agenda, it is critical that the issue of maternal and newborn survival in humanitarian emergency settings, like the Ebola outbreak, is prioritized.