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This study evaluates the impact of results-based financing (RBF) on maternal health outcomes and the inequality of opportunity (IOP) in these outcomes in Zimbabwe. We employ a difference-in-differences approach that leverages the staggered implementation of the programme across 60 districts, exploiting temporal variation in the introduction of RBF and individual-level variation in birth timing. Our analysis uses nationally representative, pooled cross-sectional data from the 2005/2006, 2010/2011, and 2015 Zimbabwe demographic and health surveys. Employing the extended two-way fixed effects (ETWFE) estimator to address biases associated with staggered rollouts, we find significant positive effects of RBF on maternal health outcomes. The programme is associated with an increase in the number of prenatal care visits by 0.185 units (p < 0.01), first-trimester care by 7.7 percentage points (pp) (p < 0.01), facility births by 8.6 pp (p < 0.01), and professional delivery assistance by 3.4 pp (p < 0.01), while reducing C-section rates by 1.3 pp (p < 0.01). Additionally, RBF is associated with reductions in IOP in prenatal care visits, early prenatal care, facility births, and professional delivery assistance by 3.8, 1.3, 8.4, and 4.9 pp (p < 0.01), respectively. These findings underscore the potential of RBF to enhance maternal health outcomes and promote health equity. Integrating equity considerations into health system strengthening initiatives is essential. Policymakers should ensure that health interventions improve access and balance opportunities across various socio-economic and demographic groups. This evidence suggests that RBF schemes can improve access to and equity in healthcare services, particularly in low-income settings such as Zimbabwe., (Copyright © 2024 The Author. Published by Elsevier Ltd.. All rights reserved.)

Background: The Global Financing Facility (GFF) was launched in 2015 to catalyse increased domestic and external financing for reproductive, maternal, newborn, child, adolescent health, and nutrition. Half of the deaths along this continuum are neonatal deaths, stillbirths or maternal deaths; yet these topics receive the least aid financing across the continuum., Objectives: To conduct a policy content analysis of maternal and newborn health (MNH), including stillbirths, in GFF country planning documents, and assess the mortality burden related to the investment., Methods: Content analysis was conducted on 24 GFF policy documents, investment cases and project appraisal documents (PADs), from 11 African countries. We used a systematic data extraction approach and applied a framework for analysis considering mindset, measures, and money for MNH interventions and mentions of mortality outcomes. We compared PAD investments to MNH-related deaths by country., Results: For these 11 countries, USD$1,894 million of new funds were allocated through the PADs, including USD$303 million (16%) from GFF. All documents had strong content on MNH, with particular focus on pregnancy and childbirth interventions. The investment cases commonly included comprehensive results frameworks, and PADs generally had less technical content and fewer indicators. Mortality outcomes were mentioned, especially for maternal. Stillbirths were rarely included as targets. Countries had differing approaches to funding descriptions. PAD allocations are commensurate with the burden., Conclusions: The GFF country plans present a promising start in addressing MNH. Emphasising links between investments and burden, explicitly including stillbirth, and highlighting high-impact packages, as appropriate, could potentially increase impact.

Background: The COVID-19 pandemic resulted in the unprecedented popularity of digital financial services for contactless payments and government cash transfer programs to mitigate the economic effects of the pandemic. The effect of the pandemic on the use of digital financial services for health in low- and middle-income countries, however, is poorly understood., Objective: This study aimed to assess the effect of the first COVID-19 lockdown on the use of a mobile maternal health wallet, with a particular focus on delineating the age-dependent differential effects, and draw conclusions on the effect of lockdown measures on the use of digital health services., Methods: We analyzed 819,840 person-days of health wallet use data from 3416 women who used health care at 25 public sector primary care facilities and 4 hospitals in Antananarivo, Madagascar, between January 1 and August 27, 2020. We collected data on savings, payments, and voucher use at the point of care. To estimate the effects of the first COVID-19 lockdown in Madagascar, we used regression discontinuity analysis around the starting day of the first COVID-19 lockdown on March 23, 2020. We determined the bandwidth using a data-driven method for unbiased bandwidth selection and used modified Poisson regression for binary variables to estimate risk ratios as lockdown effect sizes., Results: We recorded 3719 saving events, 1572 payment events, and 3144 use events of electronic vouchers. The first COVID-19 lockdown in Madagascar reduced mobile money savings by 58.5% (P<.001), payments by 45.8% (P<.001), and voucher use by 49.6% (P<.001). Voucher use recovered to the extrapolated prelockdown counterfactual after 214 days, while savings and payments did not cross the extrapolated prelockdown counterfactual. The recovery duration after the lockdown differed by age group. Women aged >30 years recovered substantially faster, returning to prelockdown rates after 34, 226, and 77 days for savings, payments, and voucher use, respectively. Younger women aged <25 years did not return to baseline values. The results remained robust in sensitivity analyses using ±20 days of the optimal bandwidth., Conclusions: The COVID-19 lockdown greatly reduced the use of mobile money in the health sector, affecting savings, payments, and voucher use. Savings were the most significantly reduced, implying that the lockdown affected women's expectations of future health care use. Declines in payments and voucher use indicated decreased actual health care use caused by the lockdown. These effects are crucial since many maternal and child health care services cannot be delayed, as the potential benefits will be lost or diminished. To mitigate the adverse impacts of lockdowns on maternal health service use, digital health services could be leveraged to provide access to telemedicine and enhance user communication with clear information on available health care access options and adherence to safety protocols., (©Samuel Knauss, Gracia Andriamiadana, Roxane Leitheiser, Zavaniarivo Rampanjato, Till Bärnighausen, Julius Valentin Emmrich. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 30.07.2024.)

Introduction: Performance Based Financing (PBF) supports realization of universal health coverage by promoting bargaining between purchasers and health service providers through identifying priority services and monitoring indicators. In PBF, purchasers use health statistics and information to make decisions rather than merely reimbursing invoices. In this respect, PBF shares certain elements of strategic health purchasing. PBF implementation began in Ethiopia in 2015 as a pilot at one hospital and eight health centers. Prior to this the system predominantly followed input-based financing where providers were provided with a predetermined budget for inputs for service provision. The purpose of the study is to determine whether the implementation of PBF is cost-effective in improving maternal and child health in Ethiopia compared to the standard care., Methods: The current study used cost-effectiveness analysis to assess the effects of PBF on maternal and child health. Two districts implementing PBF and two following standard care were selected for the study. Both groups of selected districts share common grounds before initiating PBF in the selected group. The provider perspective costing approach was used in the study. Data at the district level were gathered retrospectively for the period of July 2018 to June 2021. Data from health service statistics were transformed to population level coverages and the Lives Saved Tool method used to compute the number of lives saved. Additionally for purpose of comparison, lives saved were translated into discounted quality-adjusted life years., Results: The number of lives saved under PBF was 261, whereas number of lives saved under standard care was 194. The identified incremental cost per capita due to PBF was $1.8 while total costs of delivering service at PBF district was 8,816,370 USD per million population per year while the standard care costs 9,780,920 USD per million population per year. QALYs obtained under PBF and standard care were 6,118 and 4,526 per million population per year, respectively., Conclusions: The conclusion made from this analysis is that, implementing PBF is cost-saving in Ethiopia compared to the standard care., Limitations of the Study: Due to lack of district-level survey-based data, such as prevalence and effects on maternal and child health, national-level estimates were used into the LiST tool.There may be some central-level PBF start-up costs that were not captured, which may have spillover effects on the existing health system performance that this study has not considered.There may be health statistics data accuracy differences between the PBF and non-PBF districts. The researchers considered using data from records as reported by both groups of districts., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Koricho et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Economic evaluations are being conducted with increasing frequency in the maternity care setting, with more randomized controlled trials containing a health economic component. Key emerging criticisms of economic evaluation in maternity care are lack of robust data collection and measurement, inconsistencies in methodology, and lack of adherence to reporting guidelines., Methods: This article provides a guide to the design of economic evaluations alongside clinical trials in maternal health. We include economic concepts and considerations for the maternity setting and provide examples from the UK and Australia., Results: There are many important considerations for the design of economic evaluations alongside clinical trials. To be effective, researchers must select types of economic evaluation, which align with their study objectives; choose an appropriate evaluation perspective, time horizon, and discount rate; and identify accurate ways to measure and evaluate health outcomes and costs., Discussion: This guide is written for noneconomists and can be used for designing economic evaluations to be conducted as a part of clinical trials. We seek to improve the quality, consistency, and transparency of economic evaluations in maternal health., (© 2023 The Authors. Birth published by Wiley Periodicals LLC.)

Background: The United States has high and increasing rates of maternal morbidity and mortality, large proportions of which are related to cardiovascular health (CVH). Methods: We searched for National Institutes of Health (NIH) supported research as well as that of two other Agencies in the U.S. Department of Health and Human Services (DHHS) for fiscal years (FY) 2016-2021. Grants included maternal health conditions or exposures across all pregnancy stages, but excluded grants that focused entirely on birth, neonatal, infant/childhood outcomes. Results were manually curated by reviewing the abstract and specific aims. Grants deemed to be relevant were grouped by category. Results: Between FY 2016-2021, overall Maternal Health grants remained unchanged at an average of 1.4% of total DHHS grant funding. Maternal CVH-specific (MCVH) funding amounted to $278,926,105 for 755 grants, $191,344,649 was for 534 Type-1 grants, representing a twofold increase. Non-NIH DHHS agencies most commonly funded general Maternal Health related to CVH; NIH focused funding classified as hypertensive disorders of pregnancy, maternal morbidity and mortality, obesity, and diabetes. Non-NIH DHSS Agencies most commonly funded clinical applied research. In addition to clinical applied grants, NIH funded substantial proportions of grants classified as basic research, clinical trials, and/or translational. National Heart, Lung, and Blood Institute (NHLBI) MCVH grants studied participants in the pre-partum period (78.5%), followed by the post-partum period (50.5%), with relatively few in pre-pregnancy and peri-partum periods (10.8% and 9.7%, respectively); at the NIH level, the peri-partum period had better representation at 20.3%, whereas the pre-pregnancy period remained low at 9.9%. Conclusions: Federal grant funding for maternal health including MCVH increased at the same rate as its funding for overall research, and represented only 1.4% of overall total funding. The pre-pregnancy period was understudied in overall NIH funding and represents a gap area whereby funding agencies could further foster research advances.

Background   Evidence on the affordability and cost-effectiveness of interventions is critical to decision-making for clinical practice guidelines and development of national health policies. This study aimed to develop a repository of primary economic evaluations to support global maternal health guideline development and provide insights into the body of research conducted in this field. Methods   A scoping review was conducted to identify and map available economic evaluations of maternal health interventions. We searched six databases (NHS Economic Evaluation Database, EconLit, PubMed, Embase, CINAHL and PsycInfo) on 20 November 2020 with no date, setting or language restrictions. Two authors assessed eligibility and extracted data independently. Included studies were categorised by subpopulation of women, level of care, intervention type, mechanism, and period, economic evaluation type and perspective, and whether the intervention is currently recommended by the World Health Organization. Frequency analysis was used to determine prevalence of parameters. Results   In total 923 studies conducted in 72 countries were included. Most studies were conducted in high-income country settings (71.8%). Over half pertained to a general population of pregnant women, with the remainder focused on specific subgroups, such as women with preterm birth (6.2%) or those undergoing caesarean section (5.5%). The most common interventions of interest related to non-obstetric infections (23.9%), labour and childbirth care (17.0%), and obstetric complications (15.7%). Few studies addressed the major causes of maternal deaths globally. Over a third (36.5%) of studies were cost-utility analyses, 1.4% were cost-benefit analyses and the remainder were cost-effectiveness analyses. Conclusions   This review provides a navigable, consolidated resource of economic evaluations in maternal health. We identified a clear evidence gap regarding economic evaluations of maternal health interventions in low- and middle-income countries. Future economic research should focus on interventions to address major drivers of maternal morbidity and mortality in these settings., Competing Interests: No competing interests were disclosed., (Copyright: © 2023 Eddy KE et al.)

Background: Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs., Methods: We searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization's (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107)., Results: In a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed., Conclusion: The generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required., (© 2023. The Author(s).)

Competing Interests: Competing interests: NM is immediate past president of the UK Royal College of Paediatrics and Child Health and current president of the UK Medical Women’s Federation; the views expressed are her own.

Competing Interests: Competing interests: None declared.

Background: Performance-based financing (PBF) has attracted considerable attention in recent years in low and middle-income countries. Afghanistan's Ministry of Public Health (MoPH) implemented a PBF programme between 2010 and 2015 to strengthen the utilisation of maternal and child health services in primary health facilities. This study aimed to examine the political economy factors influencing the adoption, design and implementation of the PBF programme in Afghanistan., Methods: Retrospective qualitative research methods were employed using semi structured interviews as well as a desk review of programme and policy documents. Key informants were selected purposively from the national level (n = 9), from the province level (n = 6) and the facility level (n = 15). Data analysis was inductive as well as deductive and guided by a political economy analysis framework to explore the factors that influenced the adoption and design of the PBF programme. Thematic content analysis was used to analyse the data., Results: The global policy context, and implementation experience in other LMIC, shaped PBF and its introduction in Afghanistan. The MoPH saw PBF as a promise of additional resources needed to rebuild the country's health system after a period of conflict. The MoPH support for PBF was also linked to their past positive experience of performance-based contracting. Power dynamics and interactions between PBF programme actors also shaped the policy process. The PBF programme established a centralised management structure which strengthened MoPH and donor ability to manage the programme, but overlooked key stakeholders, such as provincial health offices and non-state providers. However, MoPH had limited input in policy design, resulting in a design which was not well tailored to the national setting., Conclusions: This study shows that PBF programmes need to be designed and adapted according to the local context, involving all relevant actors in the policy cycle. Future studies should focus on conducting empirical research to not only understand the multiple effects of PBF programmes on the performance of health systems but also the main political economy dynamics that influence the PBF programmes in different stages of the policy process.

Resilient societies respond rapidly and effectively to health challenges and the associated economic consequences, and adapt to be more responsive to future challenges. Although it is only possible to recognise resilience retrospectively, the COVID-19 pandemic has occurred at a point in human history when, uniquely, sufficient knowledge is available on the early-life determinants of health to indicate clearly that a focus on maternal, neonatal, and child health (MNCH) will promote later resilience. This knowledge offers an unprecedented opportunity to disrupt entrenched strategies and to reinvest in MNCH in the post-COVID-19 so-called new normal. Furthermore, analysis of the short-term, medium-term, and longer-term consequences of previous socioeconomic shocks provides important insights into those domains of MNCH, such as neurocognitive development and nutrition, for which investment will generate the greatest benefit. Such considerations apply to high-income countries (HICs) and low-income and middle-income countries (LMICs). However, implementing appropriate policies in the post-COVID-19 recovery period will be challenging and requires political commitment and public engagement., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Result-Based Financing (RBF) is an umbrella term for financial mechanisms that link incentives to outputs or outcomes. International development agencies are promoting RBF as a viable financing approach for the realization of universal health coverage, with numerous pilot trials, particularly in low- and middle-income countries (LMICs). There is limited synthesized evidence on the performance of these mechanisms and the reasons for the lack of RBF institutionalization. This study aims to review the evidence of RBF schemes that have been scaled or institutionalized at a national level, focusing on maternal, newborn, and child health (MNCH) programming in LMICs., Methods: A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors identified and reviewed country-level RBF evaluation reports for the period between January 2000 and June 2019. Data were extracted from both published and gray literature on RBF application in MNCH using a predesigned matrix. The matrix headers included country of application; program setting; coverage and duration; evaluation design and methods; outcome measures; and key findings. A content thematic analysis approach was used to synthesize the evidence and emerging issues., Results: The review identified 13 reports from 11 countries, predominantly from Sub-Saharan Africa. Performance-based financing was the most common form of RBF initiatives. The majority of evaluation designs were randomized trials. The evaluations focused on outputs, such as coverage and service utilization, rather than outcomes. RBF schemes in all 11 countries expanded their scope, either geographically or accordingly in terms of performance indicators. Furthermore, only three studies conducted a cost-effectiveness analysis, and only two included a discussion on RBF's sustainability. Only three countries have institutionalized RBF into their national policy. On the basis of the experience of these three countries, the common enabling factors for institutionalization seem to be political will, domestic fund mobilization, and the incorporation of demand-side RBF tools., Conclusion: RBF evidence is still growing, partial, and inconclusive. This limited evidence may be one of the reasons why many countries are reluctant to institutionalize RBF. Additional research is needed, particularly regarding cost-effectiveness, affordability, and sustainability of RBF programs., Competing Interests: Competing interestsThe authors declare that they have no competing interest., (© The Author(s) 2020.)

Introduction: Ethiopian households' out-of-pocket healthcare payments constitute one-third of the national healthcare budget and are higher than the global and low-income countries average, and even the global target. Such out-of-pocket payments pose severe financial risks, can be catastrophic, impoverishing, and one of the causal barriers for low utilisation of healthcare services in Ethiopia. This study aimed to assess the financial risk of seeking maternal and neonatal healthcare in southern Ethiopia., Methods: A population-based cohort study was conducted among 794 pregnant women, 784 postpartum women, and their 772 neonates from 794 households in rural kebeles of the Wonago district, southern Ethiopia. The financial risk was estimated using the incidence of catastrophic healthcare expenditure, impoverishment, and depth of poverty. Annual catastrophic healthcare expenditure was determined if out-of-pocket payments exceeding 10% of total household or 40% of non-food expenditure. Impoverishment was analysed based on total household expenditure and the international poverty line of ≈ $1.9 per capita per day., Results: Approximately 93% (735) of pregnant women, 31% (244) of postpartum women, and 48% (369) of their neonates experienced illness. However, only 56 households utilised healthcare services. The median total household expenditure was $527 per year (IQR = 390: 370,760). The median out-of-pocket healthcare payment was $46 per year (IQR = 46: 46, 92) with two episodes per household, and shared 19% of the household's budget. The poorer households paid more than did the richer for healthcare, during pregnancy-related and neonatal illness. However, the richer paid more than did the poorer during postpartum illness. Forty-six percent of households faced catastrophic healthcare expenditure at the threshold of 10% of total household expenditure, or 74% at a 40% non-food expenditure, and associated with neonatal illness (aRR: 2.56, 95%CI: 1.02, 6.44). Moreover, 92% of households were pushed further into extreme poverty and the poverty gap among households was 45 Ethiopian Birr per day. The average household size among study households was 4.7 persons per household., Conclusions: This study demonstrated that health inequity in the household's budget share of total OOP healthcare payments in southern Ethiopia was high. Besides, utilisation of maternal and neonatal healthcare services is very low and seeking such healthcare poses a substantial financial risk during illness among rural households. Therefore, the issue of health inequity should be considered when setting priorities to address the lack of fairness in maternal and neonatal health.

Background: Monitoring universal health coverage in reproductive, maternal and child health requires appropriate indicators for assessing coverage and equity. In 2008, the composite coverage index (CCI)-a weighted average of eight indicators reflecting family planning, antenatal and delivery care, immunizations and management of childhood illnesses-was proposed. In 2017, the CCI formula was revised to update the family planning and diarrhea management indicators. We explored the implications of adding new indicators to the CCI., Methods: We analysed nationally representative surveys to investigate how addition of early breastfeeding initiation (EIBF), tetanus toxoid during pregnancy and post-natal care for babies affected CCI levels and the magnitude of wealth-related inequalities. We used Pearson's correlation coefficient to compare different formulations, and the slope index of inequalities [SII] and concentration index [CIX] to assess absolute and relative inequalities, respectively., Results: 47 national surveys since 2010 had data on the eight variables needed for the original and revised formulations, and on EIBF, tetanus vaccine and postnatal care, related to newborn care. The original CCI showed the highest average value (65.5%), which fell to 56.9% when all 11 indicators were included. Correlation coefficients between pairs of all formulations ranged from 0.93 to 0.99. When analysed separately, 10 indicators showed higher coverage with increasing wealth; the exception was EIBF (SII = -2.1; CIX = -0.5). Inequalities decreased when other indicators were added, especially EIBF-the SII fell from 24.8 pp. to 19.2 pp.; CIX from 7.6 to 6.1. The number of countries with data from two or more surveys since 2010 was 30 for the original and revised formulations and 15 when all the 11 indicators were included., Conclusions: Given the growing importance of newborn mortality, it would be desirable to include relevant coverage indicators in the CCI, but this would lead a reduction in data availability, and an underestimation of coverage inequalities. We propose that the 2017 version of the revised CCI should continue to be used., Competing Interests: The authors have declared that no competing interests exist.

Background: Four methods have previously been used to track aid for reproductive, maternal, newborn, and child health (RMNCH). At a meeting of donors and stakeholders in May, 2018, a single, agreed method was requested to produce accurate, predictable, transparent, and up-to-date estimates that could be used for analyses from both donor and recipient perspectives. Muskoka2 was developed to meet these needs. We describe Muskoka2 and present estimates of levels and trends in aid for RMNCH in 2002-17, with a focus on the latest estimates for 2017., Methods: Muskoka2 is an automated algorithm that generates disaggregated estimates of aid for reproductive health, maternal and newborn health, and child health at the global, donor, and recipient-country levels. We applied Muskoka2 to the Organisation for Economic Co-operation and Development's Creditor Reporting System (CRS) aid activities database to generate estimates of RMNCH disbursements in 2002-17. The percentage of disbursements that benefit RMNCH was determined using CRS purpose codes for all donors except Gavi, the Vaccine Alliance; the UN Population Fund; and UNICEF; for which fixed percentages of aid were considered to benefit RMNCH. We analysed funding by donor for the 20 largest donors, by recipient-country income group, and by recipient for the 16 countries with the greatest RMNCH need, defined as the countries with the worst levels in 2015 on each of seven health indicators., Findings: After 3 years of stagnation, reported aid for RMNCH reached $15·9 billion in 2017, the highest amount ever reported. Among donors reporting in both 2016 and 2017, aid increased by 10% ($1·4 billion) to $15·4 billion between 2016 and 2017. Child health received almost half of RMNCH disbursements in 2017 (46%, $7·4 billion), followed by reproductive health (34%, $5·4 billion), and maternal and newborn health (19%, $3·1 billion). The USA ($5·8 billion) and the UK ($1·6 billion) were the largest bilateral donors, disbursing 46% of all RMNCH funding in 2017 (including shares of their core contributions to multilaterals). The Global Fund and Gavi were the largest multilateral donors, disbursing $1·7 billion and $1·5 billion, respectively, for RMNCH from their core budgets. The proportion of aid for RMNCH received by low-income countries increased from 31% in 2002 to 52% in 2017. Nigeria received 7% ($1·1 billion) of all aid for RMNCH in 2017, followed by Ethiopia (6%, $876 million), Kenya (5%, $754 million), and Tanzania (5%, $751 million)., Interpretation: Muskoka2 retains the speed, transparency, and donor buy-in of the G8's previous Muskoka approach and incorporates eight innovations to improve precision. Although aid for RMNCH increased in 2017, low-income and middle-income countries still experience substantial funding gaps and threats to future funding. Maternal and newborn health receives considerably less funding than reproductive health or child health, which is a persistent issue requiring urgent attention., Funding: Bill & Melinda Gates Foundation; Partnership for Maternal, Newborn & Child Health., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Wealth-related inequalities in reproductive, maternal, neonatal and child health have been widely studied by dividing the population into quintiles. We present a comprehensive analysis of wealth inequalities for the composite coverage index (CCI) using national health surveys carried out since 2010, using wealth deciles and absolute income estimates as stratification variables, and show how these new approaches expand on traditional equity analyses., Methods: 83 low-income and middle-income countries were studied. The CCI is a combined measure of coverage with eight key reproductive, maternal, newborn and child health interventions. It was disaggregated by wealth deciles for visual inspection of inequalities, and the slope index of inequality (SII) was estimated. The correlation between coverage in the extreme deciles and SII was assessed. Finally, we used multilevel models to examine how the CCI varies according to the estimated absolute income for each wealth quintile in the surveys., Results: The analyses of coverage by wealth deciles and by absolute income show that inequality is mostly driven by coverage among the poor, which is much more variable than coverage among the rich across countries. Regardless of national coverage, in 61 of the countries, the wealthiest decile achieved 70% or higher CCI coverage. Well-performing countries were particularly effective in achieving high coverage among the poor. In contrast, underperforming countries failed to reach the poorest, despite reaching the better-off., Conclusion: There are huge inequalities between the richest and the poorest women and children in most countries. These inequalities are strongly driven by low coverage among the poorest given the wealthiest groups achieve high coverage irrespective of where they live, overcoming any barriers that are an impediment to others. Countries that 'punched above their weight' in coverage, given their level of absolute wealth, were those that best managed to reach their poorest women and children., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: The main policy thrust in many sub-Saharan Africa countries' aim at addressing maternal mortality is the elimination of the user fee for maternal healthcare services. While several studies have documented the effect of the user fee removal policy on the use of maternal health care services, the experiences of women seeking care in facilities offering free obstetrics services, their level of satisfaction and reasons for satisfaction or dissatisfaction are poorly understood., Methods: This study adopted a mixed study design involving a population survey of 1227 women of reproductive age who gave birth in the last five years preceding the study (2011-2015), 68 in-depth interviews, and six focus group discussions. Simple descriptive statistics were performed on 407 women who benefitted from the user fee removal policy, while the qualitative data were analysed using thematic analysis., Results: The overall level of satisfaction with care received was remarkably high (97.1%), with birth outcomes being the central reason for their satisfaction. Participants were also satisfied with both the process aspect of care (which includes health workers' attitude and privacy) and the structural dimension of care (such as, the cleanliness of health care facilities and availability of and access to medicine). From the qualitative analysis, prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space were the main reasons why a few women were dissatisfied with care under free maternal health care., Conclusion: The findings establish a high level of beneficiaries' satisfaction with care under free maternal health policy in Nigeria, raising the need for sustaining the policy in expanding access to maternal health services for the poor. Nevertheless, issues relating to prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space require attention from policymakers., Competing Interests: The author has declared that no competing interests exist.

Low- and middle-income countries (LMICs) face many challenges and competing demands in the health sector, including maternal and newborn mortality. The allocation of financial and human resources for maximum health impact is important for social and economic development. Governments must prioritize carefully and allocate scarce resources to maximum effect, but also in ways that are politically acceptable, financially and institutionally feasible, and sustainable. Political economy analysis (PEA)-that gets what, when and why-can help explain that prioritization process. We used PEA to investigate how four Asian LMICs (Bangladesh, Indonesia, Nepal and the Philippines) allocate and utilize resources for maternal, newborn and child health (MNCH). Using mixed research methods including a literature review, field interviews at national and sub-national level, and policy, process and budget analysis in each country, we examined three political economy issues: (1) do these countries demonstrably prioritize MNCH at policy level; (2) if so, is this reflected in the allocation of financial and other resources and (3) if resources are allocated to MNCH, do they achieve the intended outputs and outcomes through actual programme implementation? We also considered the influence of transnational developments. We found that all four countries demonstrate political commitment to health, including MNCH. However, the health sector receives comparatively low public financing, governments often do not follow through on plans or pronouncements, and capacity for related action varies widely. Poor governance and decentralization, lack of data for monitoring and evaluation of progress, and weak public sector human resource capacity were frequent problems; engagement of the private or non-government sectors is an important consideration. Opportunities exist to greatly improve equity and MNCH outcomes in these nations, using a mix of evidence, improved governance, social engagement and the media to influence decisions, increase resource allocation to and improve accountability in the health sector., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To explore whether severe maternal morbidity (SMM) and adequate prenatal care (PNC) affect delivery cost., Design: Population-based retrospective cohort study., Setting: National Health Insurance Service National Sample Cohort in Korea., Population: A total of 90 035 deliveries in 2003 and 2013., Methods: Severe maternal morbidity was determined using the Centers for Disease Control and Prevention's algorithm. Delivery medical costs were calculated by estimating claimed total medical costs using year-specific inflation adjustment factors. Adequate PNC was estimated by the Kessner Adequacy of Prenatal Care Index. To estimate adjusted mean delivery medical costs related to SMM, we applied a generalised estimating equation model with log link and γ distribution, by adjusting for all covariates., Main Outcome Measures: Delivery cost was calculated by estimating claimed total medical cost during delivery hospitalisation using year-specific inflation., Results: Of the 90 035 deliveries, 2041 (2.27%) involved SMM. Women with SMM had a greater adjusted mean cost of delivery (US$ 1,263, 95% CI US$ 1,196-1,334) than those without (US$ 740, 95% CI US$ 729-750). Interestingly, women who had inadequate PNC had higher delivery medical costs than those with adequate PNC, adjusted for all covariates., Conclusion: Delivery involving SMM was associated with nearly doubled medical costs. Additionally, inadequate PNC increased the medical costs of delivery. The current study confirmed the burden of SMM and found that adequate PNC might be a useful preventive factor in reducing medical costs., Tweetable Abstract: We found that women with severe maternal morbidity and inadequate prenatal care had increased medical costs during delivery hospitalisation., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Background: Maternal and perinatal mortality is a major public health concern across the globe and more so in low and middle-income countries. In Kenya, more than 6000 maternal deaths, and 35,000 stillbirths occur each year. The Government of Kenya abolished user fee for maternity care under the Free Maternity Service policy, in June of 2013 in all public health facilities, a move to make maternity services accessible and affordable, and to reduce maternal and perinatal mortality., Method: An observational retrospective study was carried out in 3 counties in Kenya. Six maternal health output indicators were observed monthly, 2 years pre and 2 years post- policy implementation. Data was collected from daily maternity registers in 90 public health facilities across the 3 counties all serving an estimated population of 3 million people. Interrupted Time Series Analysis (ITSA) with a single group was used to assess the effects of the policy. Standard linear regression using generalized least squares (gls) model, was used to run the results for each of the six variables of interest. Absolute and relative changes were calculated using the gls model coefficients., Results: Significant sustained increase of 89, 97, and 98% was observed in the antenatal care visits, health facility deliveries, and live births respectively, after the policy implementation. An immediate and significant increase of 27% was also noted for those women who received Emergency Obstetric Care (EmONC) services in either the level 5, 4 and 3 health facilities. No significant changes were observed in the stillbirth rate and caesarean section rate following policy implementation., Conclusion: After 2 years of implementing the Free Maternity Service policy in Kenya, immediate and sustained increase in the use of skilled care during pregnancy and childbirth was observed. The study suggest that hospital cost is a major expense incurred by most women and their families whilst seeking maternity care services and a barrier to maternity care utilization. Overall, Free Maternity Service policy, as a health financing strategy, has exhibited the potential of realizing the full beneficial effects of maternal morbidity and mortality reduction by increasing access to skilled care.

Background: Evidence is limited on the effectiveness of mobile health programs which provide stage-based health information messages to pregnant and postpartum women. Kilkari is an outbound service that delivers weekly, stage-based audio messages about pregnancy, childbirth, and childcare directly to families in 13 states across India on their mobile phones. In this protocol we outline methods for measuring the effectiveness and cost-effectiveness of Kilkari., Methods: The study is an individually randomized controlled trial (iRCT) with a parallel, partially concurrent, and unblinded design. Five thousand pregnant women will be enrolled from four districts of Madhya Pradesh and randomized to an intervention or control arm. The women in the intervention arm will receive Kilkari messages while the control group will not receive any Kilkari messages as part of the study. Women in both arms will be followed from enrollment in the second and early third trimesters of pregnancy until one year after delivery. Differences in primary outcomes across study arms including early and exclusive breastfeeding and the adoption of modern contraception at 1 year postpartum will be assessed using intention to treat methodology. Surveys will be administered at baseline and endline containing modules on phone ownership, geographical and demographic characteristics, knowledge, practices, respectful maternity care, and coverage for antenatal care, delivery, and postnatal care. In-depth interviews and focus group discussions will be carried out to understand user perceptions of Kilkari, and more broadly, experiences providing phone numbers and personal health information to health care providers. Costs and consequences will be estimated from a societal perspective for the 2018-2019 analytic time horizon., Discussion: Kilkari is the largest maternal messaging program, in terms of absolute numbers, currently being implemented globally. Evaluations of similar initiatives elsewhere have been small in scale and focused on summative outcomes, presenting limited evidence on individual exposure to content. Drawing upon system-generated data, we explore linkages between successful receipt of calls, user engagement with calls, and reported outcomes. This is the first study of its kind in India and is anticipated to provide the most robust and comprehensive evidence to date on maternal messaging programs globally., Trial Registration: Clinicaltrials.gov, 90075552, NCT03576157 . Registered on 22 June 2018.

Objective: To assess the relationship between government expenditure on maternal health (GE) and maternal mortality (MM) in Mexican poor population between 2000 and 2015 in the 2457 Mexican municipalities., Methods: Using administrative data, we performed the analysis in three stages: First, we tested the presence of selection bias in MM. Next, we assessed the presence of spatial dependence in the incidence and severity of MM. Finally, we estimated a spatial error model considering the correction of estimates for the spatial dependence and selection bias assessed before., Results: MM and GE were not randomly distributed throughout the Mexican territory; the most socially vulnerable municipalities exhibited the highest levels of MM severity but the lowest levels of GE and available human and physical resources for maternal health; the incidence of MM was independent of GE; elasticity of GE-severity in MM was -4% (P < 0.01)., Conclusions: Resource allocation for maternal health must move towards a more comprehensive vision, and efforts to achieve an effective delivery of universal health services must improve, particularly regarding the most vulnerable municipalities., (© 2019 John Wiley & Sons, Ltd.)

Maternal health still remains a major challenge in almost all developing countries. In Myanmar, the country met only 62% of its target for the maternal mortality rate (130 per 100,000 live birth) even though proportion of skilled birth attendant (SBA) and antenatal care (ANC) coverage was 80% in 2015. Despite the estimated large maternal complications, most maternal healthcare program ignored the burden of those morbidity because of limited understanding of the incidence and prevalence of morbidity conditions and cost of those morbidity burdens on society. The present study provides a general idea of the scope of obstetric complication, incidence of obstetric complication, and cost of those morbidity burdens on society. We conducted a retrospective incidence-based cost of illness study related to obstetric complication from the healthcare system perspective at 25 bedded township hospital in Yedashae during the fiscal year of 2015-2016. For the cost of obstetric complication, average treatment cost was 26.83 USD (±8.59). When looking by disease category, average treatment cost for incomplete abortion was 35.45 USD (±1.75); pelvic inflammatory disease (PID) was 16.01 USD; pregnancy-induced hypertension (PIH) was 21.02 USD (±4.68); ante-partum hemorrhage (APH) was 14.24(± 0.25); post-partum hemorrhage (PPH) was 27.04 USD (±1.56); prolonged labor was 37.55 USD (±0.42); and septicemia was 16.51 USD (±2.15). Significant predicting variables in obstetric complication cost model were incomplete abortion, prolonged labor, post-partum hemorrhage (PPH), pregnancy induced hypertension (PIH), patient age and septicemia. From this study, we can summarize the most frequently occurred obstetric complication in that township area, actual cost burden of those complications and obstetric complication cost model which can be useful for hospital financial management. This study can be considered as a starting point for cost of illness analysis in Myanmar to prioritize and target specific health problem at a country level for policy maker to set priorities for health care intervention., Competing Interests: The authors have declared that no competing interests exist.

Longer duration of breastfeeding is associated with a lower risk of type 2 diabetes, breast and ovarian cancer, myocardial infarction, and hypertension diseases in women. Mexico has one of the lowest breastfeeding rates worldwide; therefore, estimating the disease and economic burden of such rates is needed to influence public policy. We considered suboptimal breastfeeding when fewer than 95% of parous women breastfeed for less than 24 months per child, according to the World Health Organization recommendations. We quantified the lifetime excess cases of maternal health outcomes, premature death, disability-adjusted life years, direct costs, and indirect costs attributable to suboptimal breastfeeding practices from Mexico in 2012. We used a static microsimulation model for a hypothetical cohort of 100,000 Mexican women to estimate the lifetime economic cost and disease burden of type 2 diabetes, breast and ovarian cancer, myocardial infarction, and hypertension in mothers, due to suboptimal breastfeeding, compared with an optimal scenario of 95% of parous women breastfeeding for 24 months. We expressed cost in 2016 USD. We used a 3% discount rate and tested in sensitivity analysis 0% and 5% discount rates. We found that the 2012 suboptimal scenario was associated with 5,344 more cases of all analysed diseases, 1,681 additional premature deaths, 66,873 disability-adjusted life years, and 561.94 million USD for direct and indirect costs over the lifetime of a cohort of 1,116 million Mexican women. Findings suggest that investments in strategies to enable more women to optimally breastfeed could result in important health and cost savings., (© 2018 John Wiley & Sons Ltd.)

Background: Peru has increased substantially its domestic public expenditure in maternal and child health. Peruvian departments are heterogeneous in contextual and geographic factors, underlining the importance of disaggregated expenditure analysis up to the district level. We aimed to assess possible district level factors influencing public expenditure on reproductive, maternal, neonatal and child health (RMNCH) in Peru., Methods: We performed an ecological study in 24 departments, with specific RMNCH expenditure indicators as outcomes, and covariates of different hierarchical dimensions as predictors. To account for the influence of variables included in the different dimensions over time and across departments, we chose a stepwise multilevel mixed-effects regression model, with department-year as the unit of analysis., Results: Public expenditure increased in all departments, particularly for maternal-neonatal and child health activities, with a different pace across departments. The multilevel analysis did not reveal consistently influential factors, except for previous year expenditure on reproductive and maternal-neonatal health. Our findings may be explained by a combination of inertial expenditure, a results-based budgeting approach to increase expenditure efficiency and effectiveness, and by a mixed-effects decentralization process. Sample size, interactions and collinearity cannot be ruled out completely., Conclusions: Public district-level RMNCH expenditure has increased remarkably in Peru. Evidence on underlying factors influencing such trends warrants further research, most likely through a combination of quantitative and qualitative approaches.

Despite the strong global focus on improving maternal health during past decades, there is still a long way to go to ensure equitable access to services and quality of care for women and girls around the world. To understand widely acknowledged inequities and policy-to-practice gaps in maternal health, we must critically analyse the workings of power in policy and health systems. This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world's highest burdens of maternal mortality. Specifically, we analyse Malawi's recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of donor funding, a shift in political leadership and priorities, and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. Based on ethnographic research conducted in 2015/16, the article describes the perceptions and experiences of policy implementation among various local actors (health workers, village heads and women). The way in which maternity services "fall apart" and are "fixed" is the result of dynamic interactions between policy and webs of accountability. Policies meet with a cascade of dynamic responses, which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aims of global and national safe motherhood policies.

We compared expenditure trends for reproductive, maternal, neonatal and child health (RMNCH) with trends in RMNCH service coverage in Peru. We used National Health Accounts data to report on total health expenditure by source; the Countdown database for trends in external funding to RMNCH, and Ministry of Finance data for trends in domestic funding to RMNCH. We undertook over 170 interviews and group discussions to explore factors explaining expenditure trends. We describe trends in total health expenditure and RMNCH expenditure in constant 2012 US$ between 1995 and 2012. We estimated expenditure to coverage ratios. There was a substantial increase in domestic health expenditure over the period. However, domestic health expenditure as share of total government spending and GDP remained stable. Out-of-pocket health spending (OOPS) as a share of total health expenditure remained above 35%, and increased in real terms. Expenditure on reproductive health per woman of reproductive age varied from US$ 1.0 in 2002 to US$ 6.3 in 2012. Expenditure on maternal and neonatal health per pregnant woman increased from US$ 34 in 2000 to US$ 512 in 2012, and per capita expenditure on under-five children increased from US$ 5.6 in 2000 to US$ 148.6 in 2012. Increased expenditure on RMNCH reflects a greater political support for RMNCH, along with greater emphasis on social assistance, family planning, and health reforms targeting poor areas, and a recent emphasis on antipoverty and crosscutting equitable policies and programmes focused on nutrition and maternal and neonatal mortality. Increasing domestic RMNCH expenditure likely enabled Peru to achieve substantial health gains. Peru can provide useful lessons to other countries struggling to achieve sustained gains in RMNCH by relying on their own health financing., Competing Interests: The authors have declared that no competing interests exist.

Background: Four initiatives have estimated the value of aid for reproductive, maternal, newborn, and child health (RMNCH): Countdown to 2015, the Institute for Health Metrics and Evaluation (IHME), the Muskoka Initiative, and the Organisation for Economic Co-operation and Development (OECD) policy marker. We aimed to compare the estimates, trends, and methodologies of these initiatives and make recommendations for future aid tracking., Methods: We compared estimates of aid for RMNCH from the four initiatives for all years available at the time of our analysis (1990-2016). We used publicly available datasets for IHME and Countdown. We produced estimates for Muskoka and the OECD policy marker using data in the OECD Creditor Reporting System. We sought to explain differences in estimates by critically comparing the methods used by each approach to identify and analyse aid, and quantifying the effects of these choices on estimates., Findings: All four approaches indicated substantial increases over time in global aid for RMNCH, but estimates of aid amounts and year-on-year trends differed substantially, especially for individual donors and recipient countries. Muskoka (US$ 13·0 billion in 2013, constant 2015 US$) and Countdown's RMNCH estimates ($13·1 billion in 2013) tended to be the highest and most similar, although they often indicated different year-on-year trends. IHME produced lower estimates ($10·8 billion in 2013), which often indicated different trends from the other approaches. The OECD policy marker produced by far the lowest estimates ($2·0 billion in 2013) because half of bilateral donors did not report on it consistently and those who did tended to apply it narrowly. Estimates differed across approaches primarily because of differences in methods for distinguishing aid for RMNCH from aid for other purposes; adjustments for inflation, exchange rates, and under-reporting; whether donors were credited for their support to multilateral institutions; and the handling of aid to unspecified recipients., Interpretation: The four approaches are likely to lead to different conclusions about whether individual donors and recipient countries have fulfilled their obligations and commitments and whether aid was sufficient, targeted to countries with greater need, or effective. We recommend that efforts to track aid for the Sustainable Development Goals reflect their multisectoral and interconnected nature and make analytical choices that are appropriate to their objectives, recognising the trade-offs between simplicity, timeliness, precision, accuracy, efficiency, flexibility, replicability, and the incentives that different metrics create for donors., Funding: Subgrant OPP1058954 from the US Fund for UNICEF under their Countdown to 2015 for Maternal, Newborn and Child Survival Grant from the Bill & Melinda Gates Foundation., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Previous studies have shown maternal, inflammatory, and socioeconomic variables to be associated with growth and neurodevelopment in children from low-income countries. However, these outcomes are multifactorial and work describing which predictors most strongly influence them is lacking., Methodology/principal Findings: We conducted a longitudinal study of Bangladeshi children from birth to two years to assess oral vaccine efficacy. Variables pertaining to maternal and perinatal health, socioeconomic status, early childhood enteric and systemic inflammation, and anthropometry were collected. Bayley-III neurodevelopmental assessment was conducted at two years. As a secondary analysis, we employed hierarchical cluster and random forests techniques to identify and rank which variables predicted growth and neurodevelopment. Cluster analysis demonstrated three distinct groups of predictors. Mother's weight and length-for-age Z score (LAZ) at enrollment were the strongest predictors of LAZ at two years. Cognitive score on Bayley-III was strongly predicted by weight-for-age (WAZ) at enrollment, income, and LAZ at enrollment. Top predictors of language included Rotavirus vaccination, plasma IL 5, sCD14, TNFα, mother's weight, and male gender. Motor function was best predicted by fecal calprotectin, WAZ at enrollment, fecal neopterin, and plasma CRP index. The strongest predictors for social-emotional score included plasma sCD14, income, WAZ at enrollment, and LAZ at enrollment. Based on the random forests' predictions, the estimated percentage of variation explained was 35.4% for LAZ at two years, 34.3% for ΔLAZ, 42.7% for cognitive score, 28.1% for language, 40.8% for motor, and 37.9% for social-emotional score., Conclusions/significance: Birth anthropometry and maternal weight were strong predictors of growth while enteric and systemic inflammation had stronger associations with neurodevelopment. Birth anthropometry was a powerful predictor for all outcomes. These data suggest that further study of stunting in low-income settings should include variables relating to maternal and prenatal health, while investigations focusing on neurodevelopmental outcomes should additionally target causes of systemic and enteric inflammation., Competing Interests: The authors have declared that no competing interests exist.

Objective: To quantify the average and total hospital delivery costs associated with severe maternal morbidity in excess of nonsevere maternal morbidity deliveries over a 5-year period in New York City adjusting for other sociodemographic and clinical factors., Methods: We conducted a population-based cross-sectional study using linked birth certificates and hospital discharge data for New York City deliveries from 2008 to 2012. Severe maternal morbidity was defined using a published algorithm of International Classification of Diseases, 9 Revision, Clinical Modification disease and procedure codes. Hospital costs were estimated by converting hospital charges using factors specific to each year and hospital and to each diagnosis. These estimates approximate what it costs the hospital to provide services (excluding professional fees) and were used in all subsequent analyses. To estimate adjusted mean costs associated with severe maternal morbidity, we used multivariable regression models with a log link, gamma distribution, robust standard errors, and hospital fixed effects, controlling for age, race and ethnicity, neighborhood poverty, primary payer, number of deliveries, method of delivery, comorbidities, and year. We used the adjusted mean cost to determine the average and total hospital delivery costs associated with severe maternal morbidity in excess of nonsevere maternal morbidity deliveries from 2008 to 2012., Results: Approximately 2.3% (n=13,502) of all New York City delivery hospitalizations were complicated by severe maternal morbidity. Compared with nonsevere maternal morbidity deliveries, these hospitalizations were clinically complicated, required more and intensive clinical services, and had a longer stay in the hospital. The average cost of delivery with severe maternal morbidity was $14,442 (95% CI $14,128-14,756), compared with $7,289 (95% CI $7,276-7,302) among deliveries without severe maternal morbidity. After adjusting for other factors, the difference between deliveries with and without severe maternal morbidity remained high ($6,126). Over 5 years, this difference resulted in approximately $83 million in total excess costs (13,502×$6,126)., Conclusion: Severe maternal morbidity nearly doubled the cost of delivery above and beyond other drivers of cost, resulting in tens of millions of excess dollars spent in the health care system in New York City. These findings can be used to demonstrate the burden of severe maternal morbidity and evaluate the cost-effectiveness of interventions to improve maternal health.

Introduction: Prenatal care is recommended during pregnancy to improve neonatal and maternal outcomes. Women of lower socioeconomic status (SES) are less compliant to recommended prenatal care and suffer a higher risk of adverse perinatal outcomes. Several attempts to encourage optimal pregnancy follow-up have shown controversial results, particularly in high-income countries. Few studies have assessed financial incentives to encourage prenatal care, and none reported materno-fetal events as the primary outcome. Our study aims to determine whether financial incentives could improve pregnancy outcomes in women with low SES in a high-income country., Methods and Analysis: This pragmatic cluster-randomised clinical trial includes pregnant women with the following criteria: (1) age above 18 years, (2) first pregnancy visit before 26 weeks of gestation and (3) belonging to a socioeconomically disadvantaged group. The intervention consists in offering financial incentives conditional on attending scheduled pregnancy follow-up consultations. Clusters are 2-month periods with random turnover across centres. A composite outcome of maternal and neonatal morbidity and mortality is the primary endpoint. Secondary endpoints include maternal or neonatal outcomes assessed separately, qualitative assessment of the perception of the intervention and cost-effectiveness analysis for which children will be followed to the end of their first year through the French health insurance database. The study started in June 2016, and based on an expected decrease in the primary endpoint from 18% to 14% in the intervention group, we plan to include 2000 women in each group., Ethics and Dissemination: Ethics approval was first gained on 28 September 2014. An independent data security and monitoring committee has been established. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal., Trial Registration Number: NCT02402855; pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Despite remarkable progress in maternal and child health, inequity persists in maternal care utilization in Bangladesh. Government of Bangladesh (GOB) with technical assistance from United Nation Population Fund (UNFPA), United Nation Children's Fund (UNICEF) and World Health Organization (WHO) started implementing Maternal and Neonatal Health Initiatives in selected districts of Bangladesh (MNHIB) in 2007 with an aim to reduce inequity in healthcare utilization. This study examines the effect of MNHIB on inequity in maternal care utilization., Method: Two surveys were carried out in four districts in Bangladesh- baseline in 2008 and end-line in 2013. The baseline survey collected data from 13,206 women giving birth in the preceding year and in end-line 7,177 women were interviewed. Inequity in maternal healthcare utilization was calculated pre and post-MNHIB using rich-to-poor ratio and concentration index., Results: Mean age of respondents were 23.9 and 24.6 years in 2008 and 2013 respectively. Utilization of pregnancy-related care increased for all socioeconomic strata between these two surveys. The concentration indices (CI) for various maternal health service utilization in 2013 were found to be lower than the indices in 2008. However, in comparison to contemporary BDHS data in nearby districts, MNHIB was successful in reducing inequity in receiving ANC from a trained provider (CI: 0.337 and 0.272), institutional delivery (CI: 0.435 in 2008 to 0.362 in 2013), and delivery by skilled personnel (CI: 0.396 and 0.370)., Conclusions: Overall use of maternal health care services increased in post-MNHIB year compared to pre-MNHIB year and inequity in maternal service utilization declined for three indicators out of six considered in the paper. The reductions in CI values for select maternal care indicators imply that the program has been successful not only in improving utilization of maternal health services but also in lowering inequality of service utilization across socioeconomic groups. Maternal health programs, if properly designed and implemented, can improve access, partially overcoming the negative effects of socioeconomic disparities.

In some countries, conditional cash transfer (CCT) programmes show an impact on maternal and child health. Juntos, the CCT programme in Peru, has been evaluated several times operationally, but seldom for maternal and child health outcomes. The objective of this study is to evaluate the impact of Juntos on children under 6 years, pregnant women and mothers of children under 17 years. Outcomes evaluated included (1) anaemia in women and children; (2) acute malnutrition in children; (3) post-partum complications in mothers; and (4) underweight and overweight in mothers. We identified Juntos eligible respondents from the Demographic and Health Surveys of Peru for years 2007 to 2013. Propensity score matching was used to identify comparable treatment and control groups, including eligible respondents enrolled in Juntos vs. those not enrolled in Juntos (individual-level analysis), as well as eligible respondents living in Juntos districts vs. those not residing in Juntos districts (district-level analysis). We then used generalized linear models to estimate prevalence ratios. Individual level analysis showed that Juntos reduced underweight in women (PR:0.39, 95%CI:0.18 - 0.85) and anaemia in children (PR:0.93, 95%CI:0.86 - 1.00). In the district level analysis, the programme was associated with a reduction of overweight in women (PR:0.94, 95%CI:0.90 - 0.98) and acute malnutrition in children (PR:0.49, 95%CI:0.32 - 0.73), but an increase in the prevalence of anaemia in children (PR:1.09, 95%CI:1.01 - 1.17). We found that Juntos had an effect on maternal and child health indicators, but further studies are required to overcome some limitations encountered here., (© 2016 John Wiley & Sons Ltd.)

The aim of this study was to quantify the excess cases of pediatric and maternal disease, death, and costs attributable to suboptimal breastfeeding rates in the United States. Using the current literature on the associations between breastfeeding and health outcomes for nine pediatric and five maternal diseases, we created Monte Carlo simulations modeling a hypothetical cohort of U.S. women followed from age 15 to age 70 years and their children from birth to age 20 years. We examined disease outcomes using (a) 2012 breastfeeding rates and (b) assuming that 90% of infants were breastfed according to medical recommendations. We measured annual excess cases, deaths, and associated costs, in 2014 dollars, using a 2% discount rate. Annual excess deaths attributable to suboptimal breastfeeding total 3,340 (95% confidence interval [1,886 to 4,785]), 78% of which are maternal due to myocardial infarction (n = 986), breast cancer (n = 838), and diabetes (n = 473). Excess pediatric deaths total 721, mostly due to Sudden Infant Death Syndrome (n = 492) and necrotizing enterocolitis (n = 190). Medical costs total $3.0 billion, 79% of which are maternal. Costs of premature death total $14.2 billion. The number of women needed to breastfeed as medically recommended to prevent an infant gastrointestinal infection is 0.8; acute otitis media, 3; hospitalization for lower respiratory tract infection, 95; maternal hypertension, 55; diabetes, 162; and myocardial infarction, 235. For every 597 women who optimally breastfeed, one maternal or child death is prevented. Policies to increase optimal breastfeeding could result in substantial public health gains. Breastfeeding has a larger impact on women's health than previously appreciated., (© 2016 John Wiley & Sons Ltd.)

Objectives: Postnatal maternal mental health problems, including depression and anxiety, entail a significant burden globally, and finding cost-effective preventive solutions is a public policy priority. This paper presents a cost-effectiveness analysis of the intervention, What Were We Thinking (WWWT), for the prevention of postnatal maternal mental health problems., Design: The economic evaluation, including cost-effectiveness and cost-utility analyses, was conducted alongside a cluster-randomised trial., Setting: 48 Maternal and Child Health Centres in Victoria, Australia., Participants: Participants were English-speaking first-time mothers attending participating Maternal and Child Health Centres. Full data were collected for 175 participants in the control arm and 184 in the intervention arm., Intervention: WWWT is a psychoeducational intervention targeted at the partner relationship, management of infant behaviour and parental fatigue., Outcome Measures: The evaluation considered public sector plus participant out-of-pocket costs, while outcomes were expressed in the 30-day prevalence of depression, anxiety and adjustment disorders, and quality-adjusted life years (QALYs). Incremental costs and outcomes were estimated using regression analyses to account for relevant sociodemographic, prognostic and clinical characteristics., Results: The intervention was estimated to cost $A118.16 per participant. The analysis showed no statistically significant difference between the intervention and control groups in costs or outcomes. The incremental cost-effectiveness ratios were $A36 451 per QALY gained and $A152 per percentage-point reduction in 30-day prevalence of depression, anxiety and adjustment disorders. The estimate lies under the unofficial cost-effectiveness threshold of $A55 000 per QALY; however, there was considerable uncertainty surrounding the results, with a 55% probability that WWWT would be considered cost-effective at that threshold., Conclusions: The results suggest that, although WWWT shows promise as a preventive intervention for postnatal maternal mental health problems, further research is required to reduce the uncertainty over its cost-effectiveness as there were no statistically significant differences in costs or outcomes., Trial Registration Number: ACTRN12613000506796; results., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. Research and policy will need to reflect the changing maternal health landscape., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Maternal and child health is an important issue throughout the world. Given their impact on maternal and child health, nutritional issues need to be carefully addressed. Accordingly, the effect of maternal, child, and nutritional disorders on disability-adjusted life years (DALYs) should be calculated. The present study used DALYs to estimate the burden of disease of maternal, neonatal, and nutritional disorders in the Korean population in 2012. For this purpose, we used claim data of the Korean National Health Insurance Service, DisMod II, and death data of the Statistics Korea and adhered to incidence-based DALY estimation methodology. The total DALYs per 100,000 population were 376 in maternal disorders, 64 in neonatal disorders, and 58 in nutritional deficiencies. The leading causes of DALYs were abortion in maternal disorders, preterm birth complications in neonatal disorders, and iron-deficiency anemia in nutritional deficiencies. Our findings shed light on the considerable burden of maternal, neonatal, and nutritional conditions, emphasizing the need for health care policies that can reduce morbidity and mortality., Competing Interests: The authors have no potential conflicts of interest to disclose.

Maternal health is a big issue and is central to sustainable development. Each year, about 210 million women become pregnant and about 140 million newborn babies are delivered-the sheer scale of maternal health alone makes maternal well being and survival vital concerns. In this Series paper, we adopt primarily a numerical lens to illuminate patterns and trends in outcomes, but recognise that understanding of poor maternal health also warrants other perspectives, such as human rights. Our use of the best available evidence highlights the dynamic burden of maternal health problems. Increased diversity in the magnitude and causes of maternal mortality and morbidity between and within populations presents a major challenge to policies and programmes aiming to match varying needs with diverse types of care across different settings. This diversity, in turn, contributes to a widening gap or differences in levels of maternal mortality, seen most acutely in vulnerable populations, predominantly in sub-Saharan Africa. Strong political and technical commitment to improve equity-sensitive information systems is required to monitor the gap in maternal mortality, and robust research is needed to elucidate major interactions between the broad range of health problems. Diversity and divergence are defining characteristics of poor maternal health in the 21st century. Progress on this issue will be an ultimate judge of sustainable development., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: To assess the impact on health-related outcomes, of group microfinance schemes based on collective empowerment., Methods: We searched the databases Social Sciences Citation Index, Embase, MEDLINE, MEDLINE In-Process, PsycINFO, Social Policy & Practice and Conference Proceedings Citation Index for articles published between 1 January 1980 and 29 February 2016. Articles reporting on health impacts associated with group-based microfinance were included in a narrative synthesis., Findings: We identified one cluster-randomized control trial and 22 quasi-experimental studies. All of the included interventions targeted poor women living in low- or middle-income countries. Some included a health-promotion component. The results of the higher quality studies indicated an association between membership of a microfinance scheme and improvements in the health of women and their children. The observed improvements included reduced maternal and infant mortality, better sexual health and, in some cases, lower levels of interpersonal violence. According to the results of the few studies in which changes in empowerment were measured, membership of the relatively large and well-established microfinance schemes generally led to increased empowerment but this did not necessarily translate into improved health outcomes. Qualitative evidence suggested that increased empowerment may have contributed to observed improvements in contraceptive use and mental well-being and reductions in the risk of violence from an intimate partner., Conclusion: Membership of the larger, well-established group-based microfinance schemes is associated with improvements in some health outcomes. Future studies need to be designed to cope better with bias and to assess negative as well as positive social and health impacts.

Background: Results Based Financing (RBF) interventions have recently gained significant momentum, especially in sub-Saharan Africa. However, most of the research has focused on the evaluation of the impacts of this approach, providing little insight into how the contextual circumstances surrounding the implementation have contributed to its success or failure. This study aims to fill a void in the current literature on RBF by focusing explicitly on the process of implementing a RBF intervention rather than on its impact. Specifically, this study focuses on the acceptability and adoption of the RBF intervention's implementation among local and international key stakeholders with the aim to inform further implementation., Methods: The Results Based Financing for Maternal and Neonatal Health (RBF4MNH) Initiative is currently being implemented in Malawi. Our study employed an exploratory cross-sectional qualitative design to explore the factors affecting the acceptability and adoption of the intervention's implementation. Purposeful sampling techniques were used to identify each key stakeholder who participated in all or parts of the implementation process. In-depth interviews were conducted and analyzed using a deductive open coding approach. The final interpretation of the findings emerged through active discussion among the co-authors., Results: Despite encountering several challenges, such as delay in procurement of equipment and difficulties in arranging local bank accounts, all stakeholders responded positively to the RBF4MNH Initiative. Stakeholders' acceptance of the RBF4MNH Initiative grew stronger over time as understanding of the intervention improved and was supported by early inclusion during the design and implementation process. In addition, stakeholders took on functions not directly incentivized by the intervention, suggesting that they turned adoption into actual ownership. All stakeholders raised concerns that the intervention may not be sustainable after its initial program phase would end, which contributed to hesitancy in fully accepting the intervention., Conclusions: Based on the results of this study, we recommend the inclusion of local stakeholders into the intervention's implementation process at the earliest stages. We also recommend setting up continuous feedback mechanisms to tackle challenges encountered during the implementation process. The sustainability of the intervention and its incorporation into national budgets should be addressed from the earliest stages.

Background: Low and middle income countries have adopted targeting mechanisms as a means of increasing program efficiency in reaching marginalized people in the community given the available resources. Design of targeting mechanisms has been changing over time and it is important to understand implementers' experience with such targeting mechanisms since such mechanisms impact equity in access and use of maternal health care services., Methods: The case study approach was considered as appropriate method for exploring implementers' and decision-makers' experiences with the two targeting mechanisms. In-depth interviews in order to explore implementer experience with the two targeting mechanisms. A total of 10 in-depth interviews (IDI) and 4 group discussions (GDs) were conducted with implementers at national level, regional, district and health care facility level. A thematic analysis approach was adopted during data analysis., Results: The whole process of screening and identifying poor pregnant women resulted in delay in implementation of the intervention. Individual targeting was perceived to have some form of stigmatization; hence beneficiaries did not like to be termed as poor. Geographical targeting had a few cons as health care providers experienced an increase in workload while staff remained the same and poor quality of information in the claim forms. However geographical targeting increase in the number of women going to higher level of care (district/regional referral hospital), increase in facility revenue and insurance coverage., Conclusion: Interventions which are using targeting mechanisms to reach poor people are useful in increasing access and use of health care services for marginalized communities so long as they are well designed and beneficiaries as well as all implementers and decision makers are involved from the very beginning. Implementation of demand side financing strategies using targeting mechanisms should go together with supply side interventions in order to achieve project objectives.

We explore the relationship between public expenditure, coverage of adequate ANC (including timing, frequent and content), and the maternal mortality ratio--adjusted by coverage of adequate ANC--observed in Mexico in 2012 at the State level. Additionally, we examine the inequalities and concentration of public expenditure between populations with and without Social Security. Results suggest that in the 2003-2011 period, the public expenditure gap between women with and without Social Security decreased 74%, however, the distribution is less equitable among women without Social Security, across the States. Despite high levels of coverage on each dimension of ANC explored, coverage of adequate ANC was lower among Social Security than non-Social Security women. This variability results in differences up to 1.5 times in State-adjusted maternal mortality rate at the same level of expense and maternal mortality rate, respectively. The increase in the economic resources is only a necessary condition for achieving improved health outcomes. Providing adequate health services and achieving efficient, effective and transparent use of resources in health, are critical elements for health systems performance. The attainment of universal effective coverage of maternal health and reducing maternal mortality in Mexico, requires the adjustment of policy innovations including the rules of allocation and execution of health resources. Health policies should be designed on a more holistic view promoting a balance between accessibility, effective implementation and rigorous stewardship.