Impact of service provision platforms on maternal and newborn health in conflict areas and their acceptability in Pakistan: a systematic review

Interventions to enhance healthcare utilisation among pregnant women to reduce maternal mortality in low- and middle-income countries: a review of systematic reviews

BACKGROUND

Maternal mortality in low- and middle-income countries (LMIC) has reduced considerably over the past three decades, but it remains high. Effective interventions are available, but their uptake and coverage remain low. We reviewed and synthesised evidence from systematic reviews on interventions to increase healthcare services utilisation to reduce maternal mortality in LMICs.

METHODS

We searched Medline PubMed and Cochrane Library databases for systematic reviews published between January 2014 and December 2021, investigating interventions to increase healthcare services uptake among pregnant women in LMICs. We used the AMSTAR tool (A Measurement Tool to Assess Systematic Reviews) to assess the methodological quality of the included reviews. We extracted data on the interventions and their effects and grouped them into broad groups based on the outcomes reported in each systematic review.

RESULTS

We retrieved 4,022 articles. After removing duplicates and screening, we included 14 systematic reviews. Male-partner interventions were effective in increasing skilled birth attendance (SBA) postnatal visits and maternal antiretroviral (ART) uptake for HIV-positive pregnant women. However, there was no evidence of their effectiveness on increased early ANC initiation or adequate ANC visits. Mobile health interventions were effective in increasing adequate ANC visits, SBA, facility-based service utilisation, early ANC initiation, and adherence to nutritional supplements. Incentive-based interventions, particularly financial incentives, were effective in increasing the number of ANC visits but not postnatal visits. Facility-based interventions were effective in increasing postnatal visits, maternal ART initiation and uptake, immunisation uptake and follow-up ANC visits. None of the reviews assessed their impact on SBA or adequate ANC visits. Community-based interventions were effective in increasing SBA, ANC service utilisation, ART initiation and uptake, and nutritional supplements and immunisation uptake.

CONCLUSION

Our findings show that the different interventions effectively improved different outcomes on the maternal healthcare continuum. Implementing these interventions in combination has the potential to enhance healthcare service uptake further.

Non-use of modern contraceptives among women in humanitarian contexts: evidence from a qualitative study in Akwa Ibom State, Nigeria

The continuing conflict situation in Nigeria have created over 2 million displaced persons. In 2019, women and children accounted for about 80% of the internally displaced population in the country. Displacement increases the need for reproductive health services. This study explored the reasons for non-use of modern contraceptives among forcibly displaced Bakassi women in Akwa Ibom State, southern Nigeria. Focus group discussions were used to collect data from a convenience sample of 40 women of reproductive age (15-49 years) in two makeshift resettlement camps in the region in January and February 2020. Data were analysed using a qualitative inductive approach, with thematic organization and analysis of the transcribed responses from the focus group discussions. The findings revealed that many of the women were not using modern contraceptives at the time of the study, and the major reasons they gave for non-use were misconceptions, costs, religious beliefs, desire for more children and the inaccessibility and unavailability of contraceptive services. The use of family planning services can be a life-saving intervention in unstable, crisis environments. Programme implementation to address non-use of contraceptive services among women in crisis contexts should target social norm change, reproductive health education, empowerment programmes and health service provision.

Strengthening women's empowerment and gender equality in fragile contexts towards peaceful and inclusive societies: A systematic review and meta-analysis

BACKGROUND

Across the globe, gender disparities still exist with regard to equitable access to resources, participation in decision-making processes, and gender and sexual-based violence. This is particularly true in fragile and conflict-affected settings, where women and girls are affected by both fragility and conflict in unique ways. While women have been acknowledged as key actors in peace processes and post-conflict reconstruction (e.g., through the United Nations Security Council Resolution 1325 and the Women, Peace and Security Agenda) evidence on the effectiveness of gender-specific and gender-transformative interventions to improve women's empowerment in fragile and conflict-affected states and situations (FCAS) remains understudied.

OBJECTIVES

The purpose of this review was to synthesize the body of evidence around gender-specific and gender-transformative interventions aimed at improving women's empowerment in fragile and conflict-affected settings with high levels of gender inequality. We also aimed to identify barriers and facilitators that could affect the effectiveness of these interventions and to provide implications for policy, practice and research designs within the field of transitional aid.

METHODS

We searched for and screened over 100,000 experimental and quasi-experimental studies focused on FCAS at the individual and community levels. We used standard methodological procedures outlined by the Campbell Collaboration for the data collection and analysis, including quantitative and qualitative analyses, and completed the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology to assess the certainty around each body of evidence.

RESULTS

We identified 104 impact evaluations (75% randomised controlled trials) assessing the effects of 14 different types of interventions in FCAS. About 28% of included studies were assessed as having a high risk of bias (45% among quasi-experimental designs). Interventions supporting women's empowerment and gender equality in FCAS produced positive effects on the outcomes related to the primary focus of the intervention. There are no significant negative effects of any included interventions. However, we observe smaller effects on behavioural outcomes further along the causal chain of empowerment. Qualitative syntheses indicated that gender norms and practices are potential barriers to intervention effectiveness, while working with local powers and institutions can facilitate the uptake and legitimacy of interventions.

CONCLUSIONS

We observe gaps of rigorous evidence in certain regions (notably MENA and Latin America) and in interventions specifically targeting women as actors of peacebuilding. Gender norms and practices are important elements to consider in programme design and implementation to maximise potential benefits: focusing on empowerment only might not be enough in the absence of targeting the restrictive gender norms and practices that may undermine intervention effectiveness. Lastly, programme designers and implementation should consider explicitly targeting specific empowerment outcomes, promoting social capital and exchange, and tailoring the intervention components to the desired empowerment-related outcomes.

An assessment of the quality of care provided at primary health care centres in camps for internally displaced persons in Iraq in 2018

INTRODUCTION

The humanitarian crisis in Iraq remains one of the largest and most unstable in the world. In 2014, over 2.5 million civilians were displaced in Iraq; between 2015 and 2017 more than 3 million people continued to be displaced. While health-related research concerning internally displaced persons (IDPs) population has been conducted in many settings, very few have looked at the quality of care delivered in primary health care centres (PHCC) inside camps. The objective of this operational research is to assess the quality of health care services at PHCC in operational IDP camps supported by local and international NGOs (humanitarian partners) as well as the Directorate of Health (DoH) in Iraq at baseline and after 6 months.

METHOD

A framework based on five components was used to assess quality of care by assigning a quality-of-care index score. Using a longitudinal design; data were collected through observations of facilities and of patient consultations, as well as health worker and patient exit interviews, in static PHCC in operational IDP camps of Iraq during two different phases: in June (n = 55), and December 2018 (n = 47). These facilities supported more than 500,000 IDPs. Descriptive and statistical analyses were conducted, and the results compared.

RESULT

For all camps (n = 47), the average overall quality of care index score increased between the two phases. No specific type of organisation consistently provided a better quality of care. The camp size was unrelated to the quality of care provided at the respective facility. The domain indicators "Client Care" and "Environment and Safety" mostly related to the variation in the general assessment of quality. Patient satisfaction was unrelated to any other domain score. Compared at 0 and after 6-months, the quality of care index score between the type of organisation and governorate showed that feedback positively impacted service delivery after the first assessment. Positive differences in scores also appeared, with notable improvements in Client care and Technical competence.

CONCLUSION

Humanitarian partners and the DoH are able to provide quality care, independent of camp size or the number of camps managed, and their cooperation can lead to quick improvements. This research also shows that quality of care assessment in emergency settings can be carried out in formal IDP camps using non-emergency standards.

Mega-map of systematic reviews and evidence and gap maps on the interventions to improve child well-being in low- and middle-income countries

BACKGROUND

Despite a considerable reduction in child mortality, nearly six million children under the age of five die each year. Millions more are poorly nourished and in many parts of the world, the quality of education remains poor. Children are at risk from multiple violations of their rights, including child labour, early marriage, and sexual exploitation. Research plays a crucial role in helping to close the remaining gaps in child well-being, yet the global evidence base for interventions to meet these challenges is mostly weak, scattered and often unusable by policymakers and practitioners. This mega-map encourages the generation and use of rigorous evidence on effective ways to improve child well-being for policy and programming.

OBJECTIVES

The aim of this mega-map is to identify, map and provide an overview of the existing evidence synthesis on the interventions aimed at improving child well-being in low- and middle-income countries (LMICs).

METHODS

Campbell evidence and gap maps (EGMs) are based on a review of existing mapping standards (Saran & White, 2018) which drew in particular of the approach developed by 3ie (Snilstveit, Vojtkova, Bhavsar, & Gaarder, 2013). As defined in the Campbell EGM guidance paper; "Mega-map is a map of evidence synthesis, that is, systematic reviews, and does not include primary studies" (Campbell Collaboration, 2020). The mega-map on child well-being includes studies with participants aged 0-18 years, conducted in LMICs, and published from year 2000 onwards. The search followed strict inclusion criteria for interventions and outcomes in the domains of health, education, social work and welfare, social protection, environmental health, water supply and sanitation (WASH) and governance. Critical appraisal of included systematic reviews was conducted using "A Measurement Tool to Assess Systematic Reviews"-AMSTAR-2 rating scale (Shea, et al., 2017).

RESULTS

We identified 333 systematic reviews and 23 EGMs. The number of studies being published has increased year-on-year since 2000. However, the distribution of studies across World Bank regions, intervention and outcome categories are uneven. Most systematic reviews examine interventions pertaining to traditional areas of health and education. Systematic reviews in these traditional areas are also the most funded. There is limited evidence in social work and social protection. About 69% (231) of the reviews are assessed to be of low and medium quality. There are evidence gaps with respect to key vulnerable populations, including children with disabilities and those who belong to minority groups.

CONCLUSION

Although an increasing number of systematic reviews addressing child well-being topics are being published, some clear gaps in the evidence remain in terms of quality of reviews and some interventions and outcome areas. The clear gap is the small number of reviews focusing explicitly on either equity or programmes for disadvantaged groups and those who are discriminated against.

Maternal Health Status in Tribal India: A 5-Year Intervention Program and its Outcome

Introduction:

There is poor penetration of evidence-based maternal health care provided under national health programs in resource-poor underserved regions. A well-planned locally acceptable community-driven comprehensive health promotion strategy and quality health care delivery mechanism is necessary to improve the situation.

Objective:

The main objective was to find the gaps in the existing system and promote health literacy and health-seeking behavior.

Methodology:

80,000 tribal population living in isolated conflict zone of Bastar district was covered for 5 years between 2012 and 2017. An integrated health-care plan was developed with community leaders, panchayat, and the local government to promote and provide quality evidence-based maternal health care. Available resources were mobilized and health technologies introduced.

Results:

Regular home visits, point of care diagnostics, identification of high-risk mothers and their timely referral, and behavioral change communication increased the trust of the community. It resulted in higher demand for evidence-based health interventions. The adolescent pregnancy rate (<19 years) reduced to 6.8% (2016) from 13.5% (2012). Hemoglobin level >9 g% (third trimester) improved. Supervised births and high-risk referrals increased from 19.5% (2014) to 58% (2017) and 8.5% (2014) to 13.1% (2017), respectively. Although significant improvement was noted, key indicators continued to remain below rural Bastar (National Family Health Survey-4).

Conclusion:

Promotion of existing good practices, behavior change, health technologies, and evidence-based emergency care improved the maternal health status of the secluded and underserved tribal community, but persistent effort is needed to enable women access the quality maternal health services provided under National Health Mission.

Women, children and adolescents in conflict countries: an assessment of inequalities in intervention coverage and survival

Introduction

Conflict adversely impacts health and health systems, yet its effect on health inequalities, particularly for women and children, has not been systematically studied. We examined wealth, education and urban/rural residence inequalities for child mortality and essential reproductive, maternal, newborn and child health interventions between conflict and non-conflict low-income and middle-income countries (LMICs).

Methods

We carried out a time-series multicountry ecological study using data for 137 LMICs between 1990 and 2017, as defined by the 2019 World Bank classification. The data set covers approximately 3.8 million surveyed mothers (15-49 years) and 1.1 million children under 5 years including newborns (<1 month), young children (1-59 months) and school-aged children and adolescents (5-14 years). Outcomes include annual maternal and child mortality rates and coverage (%) of family planning services, 1+antenatal care visit, skilled attendant at birth (SBA), exclusive breast feeding (0-5 months), early initiation of breast feeding (within 1 hour), neonatal protection against tetanus, newborn postnatal care within 2 days, 3 doses of diphtheria, pertussis and tetanus vaccine, measles vaccination, and careseeking for pneumonia and diarrhoea.

Results

Conflict countries had consistently higher maternal and child mortality rates than non-conflict countries since 1990 and these gaps persist despite rates continually declining for both groups. Access to essential reproductive and maternal health services for poorer, less educated and rural-based families was several folds worse in conflict versus non-conflict countries.

Conclusions

Inequalities in coverage of reproductive/maternal health and child vaccine interventions are significantly worse in conflict-affected countries. Efforts to protect maternal and child health interventions in conflict settings should target the most disadvantaged families including the poorest, least educated and those living in rural areas.

Associations Between Acute Conflict and Maternal Care Usage in Egypt: An Uncontrolled Before-and-After Study Using Demographic and Health Survey Data

Background: United Nations’ (UN) data indicate that conflict-affected low- and middle-income countries (LMICs) contribute considerably to global maternal deaths. Maternal care usage patterns during conflict have not been rigorously quantitatively examined for policy insights. This study analysed associations between acute conflict and maternal services usage and quality in Egypt using reliable secondary data (as conflict-affected settings generally lack reliable primary data).

Methods: An uncontrolled before-and-after study used data from the 2014 Egypt Demographic and Health Survey (EDHS). The ‘pre-conflict sample’ included births occurring from January 2009 to January 2011. The ‘peri-conflict sample’ included births from February 2011 to December 2012. The hierarchical nature of demographic and household survey (DHS) data was addressed using multi-level modelling (MLM).

Results: In total, 2569 pre-conflict and 4641 peri-conflict births were reported. After adjusting for socioeconomic variables, conflict did not significantly affect antenatal service usage. Compared to the pre-conflict period, periconflict births had slightly lower odds of delivery in public institutions (odds ratio [OR]: 0.987; 95% CI: 0.975-0.998; P<.05), institutional postnatal care (OR: 0.995; 95% CI: 0.98-1.00; P=.05), and at least 24 hours post-delivery stay (OR: 0.921; 95% CI: 0.906-0.935; P<.01). Peri-conflict births had relatively higher odds of doctor-assisted deliveries (OR: 1.021; 95% CI: 1.004-1.035; P<.05), institutional deliveries (OR: 1.022; 95% CI: 1.00-1.04; P<.05), private institutional deliveries (OR: 1.035; 95% CI: 1.017-1.05; P<.001), and doctor-assisted postnatal care (OR: 1.015; 95% CI: 1.003-1.027; P<.05). Sensitivity analysis did not change results significantly.

Conclusion: Maternal care showed limited associations with the acute conflict, generally reflecting pre-conflict usage patterns. Further qualitative and quantitative research could identify the effects of larger conflicts on maternal careseeking and usage, and inform approaches to building health system resilience.

Status and drivers of maternal, newborn, child and adolescent health in the Islamic world: a comparative analysis

BACKGROUND

The Millennium Development Goal (MDG) period saw dramatic gains in health goals MDG 4 and MDG 5 for improving child and maternal health. However, many Muslim countries in the south Asian, Middle Eastern, and African regions lagged behind. In this study, we aimed to evaluate the status of, progress in, and key determinants of reproductive, maternal, newborn, child, and adolescent health in Muslim majority countries (MMCs). The specific objectives were to understand the current status and progress in reproductive, maternal, newborn, child, and adolescent health in MMCs, and the determinants of child survival among the least developed countries among the MMCs; to explore differences in outcomes and the key contextual determinants of health between MMCs and non-MMCs; and to understand the health service coverage and contextual determinants that differ between best and poor or moderate performing MMCs.

METHODS

In this country-level ecological study, we examined data from between 1990 and 2015 from multiple publicly available data repositories. We examined 47 MMCs, of which 26 were among the 75 high-burden Countdown to 2015 countries. These 26 MMCs were compared with 48 non-Muslim Countdown countries. We also examined characteristics of the eight best performing MMCs that had accelerated improvement in child survival (ie, that reached their MDG 4 targets). We estimated adolescent, maternal, under-5, and newborn mortality, and stillbirths, and the causes of death, essential interventions coverage, and contextual determinants for all MMCs and comparative groups using standardised methods. We also did a hierarchical multivariable analysis of determinants of under-5 mortality and newborn mortality in low-income and middle-income MMCs.

FINDINGS

Despite notable reductions between 1990 and 2015, MMCs compared with a global esimate of all countries including MMCs had higher mortality rates, and MMCs relative to non-MMCs within Countdown countries also performed worse. Coverage of essential interventions across the continuum of care was on average lower among MMCs, especially for indicators of reproductive health, prenatal care, delivery, and labour, and childhood vaccines. Outcomes within MMCs for mortality and many reproductive, maternal, newborn, child, and adolescent health indicators varied considerably. Structural and contextual factors, especially state governance, conflict, and women and girl's empowerment indicators, were significantly worse in MMCs compared with non-MMCs within the high-burden Countdown countries, and were shown to be strongly associated with child and newborn mortality within low-income and middle-income MMCs. In adjusted hierarchical models, among other factors, under-5 mortality in MMCs increased with more refugees originating from a country (β=23·67, p=0·0116), and decreased with better political stability or absence of terrorism (β=-0·99, p=0·0285), greater political rights or government effectiveness (β=-1·17, p<0·0001), improvements in log gross national income per capita (β=-4·44, p<0·0001), higher total adult literacy (β=-1·69, p<0·0001), higher female adult literacy (β=-0·97, p<0·0001), and greater female to male enrolment in secondary school (β=-16·1, p<0·0001). The best performing MMCs were Azerbaijan, Bangladesh, Egypt, Indonesia, Kyrgyzstan, Morocco, Niger, and Senegal, which had higher coverage of family planning interventions and newborn or child vaccinations, and excelled in many of the above contextual determinants when compared with moderate or poorly performing MMCs.

INTERPRETATION

The status and progress in reproductive, maternal, newborn, child, and adolescent health is heterogeneous among MMCs, with little indication that religion and its practice affects outcomes systemically. Some Islamic countries such as Niger and Bangladesh have made great progress, despite poverty. Key findings from this study have policy and programmatic implications that could be prioritised by national heads of state and policy makers, development partners, funders, and the Organization of the Islamic Cooperation to scale up and improve these health outcomes in Muslim countries in the post-2015 era.

FUNDING

US Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn, and Child Survival, the Centre for Global Child Health, Hospital for Sick Children, and the Aga Khan University.

Public Health Platforms: An Emerging Informatics Approach to Health Professional Learning and Development

Health informatics has a major role to play in optimising the management and use of data, information and knowledge in health systems. As health systems undergo digital transformation, it is important to consider informatics approaches not only to curriculum content but also to the design of learning environments and learning activities for health professional learning and development. An example of such an informatics approach is the use of large-scale, integrated public health platforms on the Internet as part of health professional learning and development. This article describes selected examples of such platforms, with a focus on how they may influence the direction of health professional learning and development.

Context matters: Successes and challenges of intrapartum care scale-up in four districts of Afghanistan

Reducing preventable maternal mortality and achieving Sustainable Development Goal targets for 2030 will require increased investment in improving access to quality health services in fragile and conflict-affected states. This study explores the conditions that affect availability and utilisation of intrapartum care services in four districts of Afghanistan where mortality studies were conducted in 2002 and 2011. Information on changes in each district was collected through interviews with community members; service providers; and district, provincial and national officials. This information was then triangulated with programme and policy documentation to identify factors that affect the coverage of safe delivery and emergency obstetric care services. Comparison of barriers to maternal health service coverage across the four districts highlights the complexities of national health policy planning and resource allocation in Afghanistan, and provides examples of the types of challenges that must be addressed to extend the reach of life-saving maternal health interventions to women in fragile and conflict-affected states. Findings suggest that improvements in service coverage must be measured at a sub-national level, and context-specific service delivery models may be needed to effectively scale up intrapartum care services in extremely remote or insecure settings.