Effective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review

Improving the quality of neonatal health care in Ethiopia: a systematic review

Background

Ensuring high-quality healthcare for newborns is essential for improving their chances of survival within Ethiopia's healthcare system. Although various intervention approaches have been implemented, neonatal mortality rates remain stable. Therefore, the present review seeks to identify initiatives for enhancing healthcare quality, their effects on neonatal wellbeing, and the factors hindering or supporting these Quality Improvement (QI) efforts' success in Ethiopia.

Methods

We searched for original research studies up to June 23, 2023, using PubMed/Medline, WHO-Global Health Library, Cochrane, Clinical Trials.gov, and Hinari. After selecting eligible studies, we assessed their quality using a mixed-method appraisal tool. Quality of care refers to how healthcare services effectively improve desired outcomes for individuals and patient populations. It encompasses vital principles such as safety, effectiveness, timeliness, efficiency, equity, and patient-centeredness.

Results

We found 3,027 publication records and included 13 studies during our search. All these interventions primarily aimed to provide safe healthcare, with a strong focus on Domain One, which deals with the evidence-based routine upkeep and handling of complications, and Domain Seven, which revolves around ensuring staff competency, emerged as a frequent target for intervention. Many interventions aimed at improving quality also concentrate on essential quality measure elements such as processes, focusing on the activities that occur during care delivery, and quality planning, involving distributing resources, such as basic medicine and equipment, and improving infrastructure. Moreover, little about the facilitators and barriers to QI interventions is investigated.

Conclusions

This review highlights the significance of introducing QI initiatives in Ethiopia, enhancing the healthcare system's capabilities, engaging the community, offering financial incentives, and leveraging mobile health technologies. Implementing QI interventions in Ethiopia poses difficulties due to resource constraints, insufficient infrastructure, and medical equipment and supplies shortages. It necessitates persistent endeavors to improve neonatal care quality, involving ongoing training, infrastructure enhancement, the establishment of standardized protocols, and continuous outcome monitoring. These efforts are crucial to achieving the optimal outcomes for newborns and their families.

Assessing Maternal Satisfaction: Patient-Centered Care, Hospital Environment, and Information-Seeking in Chanika Hospital in Tanzania

This study examined the impact of patient-centered care, satisfaction with the hospital environment, and maternal information-seeking on maternal healthcare satisfaction in Tanzania. A total of 707 mothers who delivered at Chanika Hospital in Tanzania were surveyed using a structured questionnaire. Multiple regression analyses were conducted to identify factors related to maternal satisfaction. Only 9.9% of the participants reported that they "usually" or "always" felt involved in treatment decisions. High levels of satisfaction were found for hospital cleanliness (93.6%) and safety (94.9%). However, there was a significant gap in satisfaction regarding the adequacy of water quality for medical services, with only 8.1% expressing satisfaction. Limited use of digital platforms was observed in terms of information-seeking behavior for fetal development, with only 19.5% of the participants using the internet and 14.3% using mobile apps. Patient-centered experiences with healthcare providers, especially midwives, had a significant positive impact on maternal satisfaction (β = 0.11, p = 0.021). Other significant variables were satisfaction with the hospital environment (β = 0.25, p < 0.001) and satisfaction with hospital water (β = 0.13, p < 0.001). It is recommended that healthcare improvements focus on patient-centered experiences and water quality for drinking and medical services to improve patient satisfaction.

Equity in prenatal healthcare services globally: an umbrella review

BACKGROUND

Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics.

METHODS

For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews.

RESULTS

The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors.

CONCLUSIONS

This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.

A multi-dimensional incomplete stepped-wedge trial design to estimate the impact of standards-based audit

A clinical audit is a low-cost process used for quality improvement in healthcare. Such audits are however infrequently used in resource poor countries, where the need for and potential impact of quality improvement is higher. Sets of standards for use in maternal and newborn care have been established based on internal guidelines and evidence. The before-after design of a clinical audit is prone to bias in the estimation of the impact of conducting a clinical audit. A trial design that would provide an unbiased estimate of the impact of implementing a clinical audit process on the attainment of standards selected (a standards-based audit) was needed. The aim of this paper is to introduce and describe the design of trials we developed to meet this need. A novel randomised stepped-wedge trial design to estimate the impact of conducting standards-based audits is presented. A multi-dimensional incomplete stepped-wedge cluster randomised trial design suitable for estimation of the impact of Standards-based audits on compliance with standard is proposed; two variants are described in detail. A method for sample size estimation is described. Analyses can be performed for the binary outcome using a generalised linear mixed model framework to estimate the impact of the approach on compliance with standards subjected to a standards-based audit; additional terms to consider including in sensitivity analyses are considered. The design presented has the potential to estimate the impact of introducing the standards-based audit process on compliance with standard, while providing participating healthcare providers opportunity to gain experience of implementing the standards-based audit process. The design may be applicable in other areas in which multiple processes are to be studied.

Reducing inequities in maternal and child health in rural Guatemala through the CBIO+ Approach of Curamericas: 6. Management of pregnancy complications at Community Birthing Centers (Casas Maternas Rurales)

BACKGROUND

In Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+.

METHODS

We undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff.

RESULTS

During the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere.

CONCLUSION

The Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right.

A Strategy for Reducing Maternal Mortality in Rural Kenya

Background

Migori County is categorized among regions with worst maternal survival rates in Kenya. The county's current maternal mortality ratio (MMR) is 673 deaths per 100 000 live births. A need exists for a context-specific strategy to mitigate the persistent high maternal mortalities in rural Kenya. The researchers aimed to develop a strategy for reducing the maternal mortality ratio (MMR) in Migori, Kenya.

Methods

An explanatory sequential mixed methods design was utilised. The design was characterised by two separate studies, an initial quantitative followed by a qualitative study. The final phase entailed integration of data from the two separate studies. The findings, extensive literature review and three delays of maternal mortality theoretical framework informed the development of the strategy.

Results

The strategy for implementation considered three strategic areas, namely, interventions targeting first delays, interventions targeting second delays, interventions targeting third delays.

Conclusion

The priority interventions needed are those that enable: 1) Pregnant mothers to receive quality peripartum care in Migori hospitals, 2) Strengthened and efficient referral systems of obstetric emergencies and 3) Community knowledge empowerment on safe pregnancy and culture shift. These interventions would significantly transform the health-care system towards maternal mortality reduction. The Kenyan government and non-profit organisations should be involved in the implementation of the proposed strategy.

The healthcare system and client failures contributing to maternal mortality in rural Kenya

BACKGROUND

The global maternal mortality ratio is estimated at 211/100 000 live births in 2017. In Kenya, progress on reducing maternal mortality appears to be slow and persistently higher than the global average, despite efforts by the government's provision of free maternity services in both private and public facilities in 2013. We aimed to explore and describe the experiences of midwives on maternal deaths that are associated with the healthcare system and client failures in Migori, Kenya.

METHODS

An explanatory, qualitative approach method was adopted. In-depth interviews were conducted with the purposively selected midwives working in peripartum units of the three sampled hospitals within Migori County in Kenya. The hospitals included two county referral hospitals and one private referral hospital. Saturation was reached with 37 respondents. NVivo 11 software was used for analysis. Content analysis using a qualitative approach was adopted. Accordingly, the data transcripts were synthesised, coded and organised into thematic domains.

RESULTS

Identified sub-themes: sub-optimal care, staff inadequacy, theatre delays, lack of blood and essential drugs, non-adherence to protocols, staff shortage, inadequate equipment and supplies, unavailable ICU wards, clients' ANC non-adherence.

CONCLUSION

In conclusion, the study notes that the healthcare system and client failures are contributing to maternal mortality in the study setting. The major failures are across the pregnancy continuum starting from antenatal care, and intrapartum to post-natal care. This can illustrate that some pregnant mothers are getting sub-optimal care reducing their survival chances. To reduce maternal mortality in Migori County, the key highlighted healthcare system and client failures should be addressed through a multidisciplinary approach mechanism.

Recognition and Management of Pediatric Sepsis in a Resource-Limited Emergency Department in Mwanza, Tanzania: A Qualitative Study

OBJECTIVE

The World Health Organization aims to reduce worldwide under-five mortality rates (U5MR), with a focus on resource-limited settings (RLS). Tanzania reports a mean U5MR of 54 per 1000 live births, largely due to treatable infectious diseases that may lead to sepsis, accounting for 40% of the under-five deaths. Bugando Medical Centre in Mwanza, Tanzania represents a resource-limited setting in Sub-Saharan Africa and estimates a 14% pediatric mortality rate. We sought to better understand provider experience in recognizing and managing pediatric sepsis in the emergency department (ED) at Bugando Medical Centre in Mwanza, Tanzania.

METHODS

We conducted a qualitative study with a purposive sampling of 14 Bugando Medical Centre ED providers from January to February 2019, via minimally structured interviews, to identify factors influencing the recognition and management of children presenting to the ED with concern for sepsis. Interviews were conducted in English, audio recorded, and transcribed. Data saturation determined the sample size. Three primary coders independently coded all transcripts and developed an initial coding list. Consensus among all authors generated a final coding scheme. A grounded theory approach guided data analysis.

RESULTS

We achieved thematic saturation after 13 interviews. Responses identified patient-, provider-, and health care system-related factors influencing sepsis recognition and management in children presenting to the ED. Patient-related factors include the use of traditional healers, limited parent health literacy, and geographic factors impacting access to medical care. Provider-related factors include limited knowledge of pediatric sepsis, lack of a standard communication process among providers, and insufficient experience with procedural skills on children. Health care system-related factors include limited personnel and resources, delayed transfers from referral hospitals, and lack of standard antibiotic-use guidelines.

CONCLUSIONS

This qualitative study identified patient, provider, and health care system-related factors that influence the emergency care of children with suspected sepsis in a quaternary hospital in Mwanza, Tanzania. These factors may serve as a framework for educational opportunities to improve the early recognition and management of pediatric sepsis in a resource-limited setting.

Community mobilization to strengthen support for appropriate and timely use of antenatal and postnatal care: A review of reviews

Background

Antenatal care (ANC) and postnatal care (PNC) are critical opportunities for women, babies and parents/families to receive quality care and support from health services. Community-based interventions may improve the accessibility, availability, and acceptance of this vital care. For example, community mobilization strategies have been used to involve and collaborate with women, families and communities to improve maternal and newborn health.

Objective

To synthesize existing reviews of evidence on community mobilization strategies that strengthen support for appropriate and timely use of ANC and PNC.

Methods

Six databases (MEDLINE, Embase, CINAHL, PsychINFO, Cochrane Library, PROSPERO) were searched for published reviews that describe community mobilization related strategies for ANC and/or PNC. Reviews were eligible for inclusion if they described any initiatives or strategies targeting the promotion of ANC and/or PNC uptake that included an element of community mobilization in a low- or middle-income country (LMIC), published after 2000. Included reviews were critically appraised according to the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Evidence Syntheses. This review of reviews was conducted following JBI guidelines for undertaking and reporting umbrella reviews.

Results

In total 23 papers, representing 22 reviews were included. While all 22 reviews contained some description of community mobilization and ANC/PNC, 13 presented more in-depth details on the community mobilization processes and relevant outcomes. Seventeen reviews focused on ANC, four considered both ANC and PNC, and only one focused on PNC. Overall, 16 reviews reported at least one positive association between community mobilization activities and ANC/PNC uptake, while five reviews presented primary studies with no statistically significant change in ANC uptake and one included a primary study with a decrease in use of antenatal facilities. The community mobilization activities described by the reviews ranged from informative, passive communication to more active, participatory approaches that included engaging individuals or consulting local leaders and community members to develop priorities and action plans.

Conclusions

While there is considerable momentum around incorporating community mobilization activities in maternal and newborn health programs, such as improving community support for the uptake of ANC and PNC, there is limited evidence on the processes used. Furthermore, the spectrum of terminology and variation in definitions should be harmonized to guide the implementation and evaluation efforts.

Investments for effective functionality of health systems towards Universal Health Coverage in Africa: A scoping review

The health challenges in Africa underscore the importance of effectively investing in health systems. Unfortunately, there is no information on systems investments adequate for an effective functional health system. We aimed to address this by conducting a scoping review of existing evidence following the Joanna Briggs Institute Manual for Evidence Synthesis and preregistered with the Open Science Framework (https://osf.io/bvg4z). We included any empirical research describing interventions that contributed to the functionality of health systems in Africa or any low-income or lower-middle-income regions. We searched Web of Science, MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL, and ERIC from their inception, and hand-searched other relevant sources. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. We identified 554 unique reports describing 575 interventions, of which 495 reported evidence of effectiveness. Most interventions were undertaken in Africa (80.9%), covered multiple elements of health systems (median: 3), and focused on service delivery (77.4%) and health workforce (65.6%). Effective interventions contributed to improving single (35.6%) or multiple (64.4%) capacities of health systems: access to essential services (75.6%), quality of care (70.5%), demand for essential services (38.6%), or health systems resilience (13.5%). For example, telemedicine models which covered software (technologies) and hardware (health workers) elements were used as a strategy to address issues of access to essential services. We inventoried these effective interventions for improving health systems functionality in Africa. Further analyses could deepen understanding of how such interventions differ in their incorporation of evidence for potential scale across African countries.

Trends in socio-economic, sex and geographic disparities in childhood underweight in Mauritania: evidence from Multiple Indicator Cluster Surveys (2007-2015)

Background

Underweight is one of the largest contributors to child morbidity and mortality and is considered to be the largest contributor to the global burden of diseases in low-and middle-income countries. In Mauritania, where one-fifth of children are underweight, there is a dearth of evidence on socio-economic, sex and geographic disparities in childhood underweight. As a result, this study aimed at investigating the socio-economic, sex and geographic disparities in childhood underweight in Mauritania.

Methods

Using the World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) software, data from the Mauritania Multiple Indicator Cluster Surveys (MICSs) conducted between 2007 and 2015 were analysed. Childhood underweight was disaggregated by five equity stratifiers: education, wealth, residence, region and sex. In addition, absolute and relative inequality measures, namely difference (D), population attributable risk (PAR), ratio (R) and population attributable fraction (PAF) were calculated to understand inequalities from wider perspectives. Corresponding 95% confidence intervals (CIs) were computed to measure statistical significance.

Results

Substantial absolute and relative socio-economic, sex and geographic disparities in underweight were observed from 2007 to 2015. Children from the poorest households (PAR=−12.66 [95% CI −14.15 to −11.16]), those whose mothers were uneducated (PAF=−9.11 [95% CI −13.41 to −4.81]), those whose mothers were rural residents (R=1.52 [95% CI 1.37 to 1.68]), residents of HodhCharghy (PAF=−66.51 [95% CI −79.25 to −53.76]) and males (D=4.30 [95% CI 2.09 to 6.52]) experienced a higher burden of underweight. Education-related disparities decreased from 2007 to 2015. The urban–rural gap in underweight similarly decreased over time with the different measures showing slightly different reductions. Wealth-driven disparities decreased marginally from 2011 to 2015. The sex-based and regional disparities increased, at least on average, over the 8-y intersurvey period.

Conclusions

The burden of underweight was significantly higher among children from disadvantaged subpopulations, those with uneducated and poorest/poor mothers, those living in rural areas and those living in HodhCharghy. Special nutrition intervention and efforts focused on these deprived subpopulations are required to reduce childhood morbidity and mortality associated with underweight and help achieve the Sustainable Development Goals.

Outcomes of a multifaceted intervention to improve maternal satisfaction with care in secondary hospitals in Nigeria

Background: Data in Nigeria suggests a high level of dissatisfaction among women attending maternity care in health facilities due to long wait times, disrespectful care, and poor attention by healthcare personnel.

Objective: To examine the effectiveness of a multifaceted intervention in improving self-reported indicators of maternal healthcare satisfaction by women who use referral facilities in two regions of Nigeria.

Method: The design was quasi-experimental and consisted of two intervention facilities and two control facilities. The interventions included strategic planning, staff re-training, a computerized appointment system, health education/feedback, maternal death reviews and surveillance, and advocacy. A random sample of 2262 women was selected (1205 in the intervention sites and 1057 in the two control sites) to respond to a 24-item questionnaire on service satisfaction as they exited the health facilities. Adjusted Poisson and binary regression analyses were used to assess and compare proportions of reported satisfaction by women between the intervention and control sites.

Results: Women in the intervention sites were 54% more likely than those in control sites to report overall satisfaction with services. They were significantly less likely to report inadequate security arrangements in accessing the health facilities (p < .1); and three times more likely to agree that health workers were extremely thorough and careful in attending to them (p < .1).

Conclusion: The interventions had positive effects on improving women’s satisfaction with care. The findings from this study have implications for the design and implementation of interventions that address women’s concerns relating to the provision of care and consequently improve service utilization.

How can human resources for health interventions contribute to sexual, reproductive, maternal, and newborn healthcare quality across the continuum in low- and lower-middle-income countries? A systematic review

BACKGROUND

Well-trained, competent, and motivated human resources for health (HRH) are crucial to delivering quality service provision across the sexual, reproductive, maternal, and newborn health (SRMNH) care continuum to achieve the 2030 Sustainable Development Goals (SDGs) maternal and neonatal health targets. This review aimed to identify HRH interventions to support lay and/or skilled personnel to improve SRMNH care quality along the continuum in low- and lower-middle-income countries (LLMICs).

METHODS

A structured search of CINAHL, Cochrane Library/trials, EMBASE, PubMed, SCOPUS, Web of Science, and HRH Global Resource Centre databases was undertaken, guided by the PRISMA framework. The inclusion criteria sought to identify papers with a focus on 1. HRH management, leadership, partnership, finance, education, and/or policy interventions; 2. HRH interventions' impact on two or more quality SRMNH care packages across the continuum from preconception to pregnancy, intrapartum and postnatal care; 3. Skilled and/or lay personnel; and 4. Reported primary research in English from LLMICs. A deductive qualitative content analysis was employed using the World Health Organization-HRH action framework.

RESULTS

Out of identified 2157 studies, 24 intervention studies were included in the review. Studies where ≥ 4 HRH interventions had been combined to target various healthcare system components, were more effective than those implementing ≤ 3 HRH interventions. In primary care, HRH interventions involving skilled and lay personnel were more productive than those involving either skilled or lay personnel alone. Results-based financing (RBF) and its policy improved the quality of targeted maternity services but had no impact on client satisfaction. Local budgeting, administration, and policy to deliver financial incentives to health workers and improve operational activities were more efficacious than donor-driven initiatives. Community-based recruitment, training, deployment, empowerment, supportive supervision, access to m-Health technology, and modest financial and non-financial incentives for community health workers (CHWs) improved the quality of care continuum. Skills-based, regular, short, focused, onsite, and clinical simulation, and/or mobile phone-assisted in-service training of skilled personnel were more productive than knowledge-based, irregular, and donor-funded training. Facility-based maternal and perinatal death reviews, coupled with training and certification of skilled personnel, positively affected SRMNH care quality across the continuum. Preconception care, an essential component of the SRMNH care continuum, lacks studies and services in LLMICs.

CONCLUSIONS

We recommend maternal and perinatal death audits in all health facilities; respectful, woman-centered care as a critical criterion of RBF initiatives; local administration of health worker allowances and incentives; and integration of CHWs into the healthcare system. There is an urgent need to include preconception care in the SRMNH care continuum and studies in LLMICs.

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.

Emergency Transportation Interventions for Reducing Adverse Pregnancy Outcomes in Low- and Middle-Income Countries: A Systematic Review

Objective:

To assess the effect of emergency transportation interventions on the outcome of labor and delivery in low- and middle-income countries (LMICs).

Methods:

Eleven databases were searched through December 2019: Medline/PubMed, EMBASE, Web of Science, EBSCO (PsycINFO and CINAHL), SCIELO, LILACS, JSTOR, POPLINE, Google Scholar, the Cochrane Pregnancy and Childbirth Group’s Specialized Register, and the Cochrane Central Register of Controlled Trials. Methodological quality of included studies was assessed using the ROBINS-I tool.

Results:

Nine studies (three in Asia and six in Africa) were included: one cluster randomized controlled trial, three controlled before-and-after (CBA) studies, four uncontrolled before and after studies, and one case-control study. The means of emergency obstetric transportation evaluated by the studies included bicycle (n = 1) or motorcycle ambulances (n = 3), 4-wheel drive vehicles (n = 3), and formal motor-vehicle ambulances (n = 2). Transportation support was offered within multi-component interventions including financial incentives (n = 1), improved communication (n = 7), and community mobilization (n = 2). Two controlled before-and-after studies that implemented interventions including financial support, three-wheeled motorcycles, and use of mobile phones reported reduction of maternal mortality. One cluster-randomized study which involved community mobilization and strengthening of referral, and transportation, and one controlled before-and-after that implemented free-of-charge, 24-hour, 4 × 4 wheel ambulance and a mobile phone showed reductions in stillbirth, perinatal, and neonatal mortality. Six studies reported increases in facility delivery ranging from 12–50%, and one study showed a 19% reduction in home delivery. There was a significant increase of caesarian sections in two studies; use of motorcycle ambulances compared to car ambulance resulted in reduction in referral delay by 2 to 4.5 hours. Only three included studies had low risk of bias on all domains.

Conclusion:

Integrating emergency obstetric transportation with complimentary maternal health interventions may reduce adverse pregnancy outcomes and increase access to skilled obstetric services for women in LMICs. The strength of evidence is limited by the paucity of high-quality studies.

Herbal Medicine Use During Pregnancy: A Review of the Literature With a Special Focus on Sub-Saharan Africa

Herbal medicine use has grown considerably worldwide among pregnant women, and is particularly widespread in sub-Saharan Africa. However, herbal medicines used across sub-Saharan Africa are associated with important research gaps and a lack of regulatory framework. This is particularly problematic, as herbal medicine use during pregnancy raises several concerns attributed to the herbal ingredient itself, conventional drug-herbal medicine interactions, and contamination or adulteration of herbal remedies. Moreover, several local herbal remedies used by sub-Saharan African pregnant women have never been botanically identified. In this review, an overview of the practice of herbal medicine, including the regulations, challenges and overall safety, is provided. Then, we discuss the prevalence of herbal medicine use during pregnancy across different sub-Saharan African countries, as well as the indications, adverse outcomes, and effectiveness of the most commonly used herbal medicines during pregnancy in that region.

What interventions are effective in improving uptake and retention of HIV-positive pregnant and breastfeeding women and their infants in prevention of mother to child transmission care programmes in low-income and middle-income countries? A systematic review and meta-analysis

OBJECTIVE

This review was conducted to identify interventions effective in improving uptake and retention of HIV-positive mothers and their infants in prevention of mother to child transmission (PMTCT) services in low-income and middle-income countries (LMICs) in order to inform programme planning.

METHODS

We conducted a systematic review of studies comparing usual care with any intervention to improve uptake and retention of HIV-positive pregnant or breastfeeding women and their children from birth to 2 years of age in PMTCT services in LMICs. Twenty-two electronic databases were searched from inception to 15 January 2018, for randomised, quasi-randomised and non-randomised controlled trials, and interrupted time series studies; reference lists of included articles were searched for relevant articles. Risk of bias was assessed using the Cochrane Effective Practice and Organisation of Care group criteria. Random-effects meta-analysis was conducted for studies reporting similar interventions and outcomes.

RESULTS

We identified 29 837 articles, of which 18 studies were included in our review. Because of heterogeneity in interventions and outcome measures, only one meta-analysis of two studies and one outcome was conducted; we found a statistically significant increase in antiretroviral therapy (ART) use during pregnancy for integration of HIV and antenatal care relative to standard non-integrated care (pooled AOR=2.69; 95% CI 1.25 to 5.78, p=0.0113). The remaining studies assessing other patient, provider or health system interventions were synthesised narratively, with small effects seen across intervention categories for both maternal and infant PMTCT outcomes based predominately on evidence with moderate to high risk of bias.

CONCLUSIONS

Evidence on the effectiveness of interventions to improve uptake and retention of mothers and infants in PMTCT care is lacking. Our findings suggest that integration of HIV and antenatal care may improve ART use during pregnancy. Future studies to replicate promising approaches are needed. Improved reporting of key methodological criteria will facilitate interpretation of findings and improve the utility of evidence to PMTCT programme planners.

PROSPERO REGISTRATION NUMBER

CRD42015020829.

Impact of lay health worker programmes on the health outcomes of mother-child pairs of HIV exposed children in Africa: A scoping review

Background

Increased demand for healthcare services in countries experiencing high HIV disease burden and often coupled with a shortage of health workers, has necessitated task shifting from professional health workers to Lay Health Workers (LHWs) in order to improve healthcare delivery. Maternal and Child Health (MCH) services particularly benefit from task-shifting to LHWs or similar cadres. However, evidence on the roles and usefulness of LHWs in MCH service delivery in Sub-Saharan Africa (SSA) is not fully known.

Objectives

To examine evidence of the roles and impact of lay health worker programmes focusing on Women Living with HIV (WLH) and their HIV-exposed infants (HEIs).

Methods

A scoping review approach based on Arksey and O’Malley’s guiding principles was used to retrieve, review and analyse existing literature. We searched for articles published between January 2008 and July 2018 in seven (7) databases, including: MEDLINE, Embase, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews and Web of Science. The critical constructs used for the literature search were “lay health worker”, “community health worker”, “peer mentor”, “mentor mother,” “Maternal and Child health worker”, “HIV positive mothers”, “HIV exposed infants” and PMTCT.

Results

Thirty-three (33) full-text articles meeting the eligibility criteria were identified and included in the final analysis. Most (n = 13, 39.4%) of the included studies were conducted in South Africa and used a cluster RCT design (n = 13, 39.4%). The most commonly performed roles of LHWs in HIV specific MCH programmes included: community engagement and sensitisation, psychosocial support, linkage to care, encouraging women to bring their infants back for HIV testing and supporting default tracing. Community awareness on Mother to Child Transmission of HIV (MTCT), proper and consistent use of condoms, clinic attendance and timely HIV testing of HEIs, as well as retention in care for infected persons, have all improved because of LHW programmes.

Conclusion

LHWs play significant roles in the management of WLH and their HEIs, improving MCH outcomes in the process. LHW interventions are beneficial in increasing access to PMTCT services and reducing MTCT of HIV, though their impact on improving adherence to ART remains scanty. Further research is needed to evaluate ART adherence in LHW interventions targeted at WLH. LHW programmes can be enhanced by increasing supportive supervision and remuneration of LHWs.

A scoping review on community mobilisation for maternal and child health in sub-Saharan Africa: Impact on empowerment

This review integrates evidence on community mobilisation (CM) for maternal and child health in sub-Saharan Africa (SSA) to identify the impact on empowerment. For the purposes of this review we use the following definition of CM: 'a capacity-building process through which community members, groups or organizations plan, carry out and evaluate activities on a participatory and sustained basis to improve their health and other conditions, either on their own initiative or stimulated by others', [Howard-Grabman, L., Storti, C., Hummer, P., Pooler, B., & Geneva: USAID (2007). Demystifying community mobilization: An effective strategy to improve maternal and newborn health. Retrieved from http://pdf.usaid.gov/pdf_docs/pnadi338.pdf, p. 5]. A scoping review was chosen to conduct a search and analysis of the literature due to the broad, complex nature of the topic. The search yielded 136 articles, and 19 met the inclusion criteria. This review illustrates CM as an important research process for engaging the community, ensuring that interventions are meeting the needs of the community, take context into account and are sustainable. Community mobilisation was associated with positive behaviour change and/or health outcomes. However, community mobilisation was not defined or operationalised consistently among the identified studies. Empowerment was also not defined, measured, or reported on in the articles. This review provides recommendations for the reporting of CM and its influence on empowerment in communities in sub-Saharan Africa.

Use of expenditure analysis to enhance returns on investments in HIV services

PURPOSE OF REVIEW

Globally, the response to the HIV epidemic is at a crisis point. International investments in the HIV response have been essentially flat for 8 years and domestic budgets in low and middle-income countries - still recovering from the global recession - have not been able to fill the resource gap to drive a full-fledged HIV response. Still, efficiencies and prioritization of evidence-based interventions enable a significant scale-up of treatment, but millions more people remain without treatment. This review looks at recent data and research to evaluate interventions that may help close gaps in service provision that undermine testing and treatment programs.

RECENT FINDINGS

The President's Emergency Plan for AIDS Relief recently began publicly releasing vast programmatic and expenditure data. These data reveal potential efficiency gaps in testing and treatment programs, particularly in the area of linkage and retention. Interventions such as HIV self-testing have been proposed to help, but whether they can deliver better results remains unclear. Same-day initiation on treatment improves initiation, retention, and viral suppression rates.

SUMMARY

Near real-time analysis of data and active response is critical in improving efficiencies in programs. More investment in implementation research is necessary to improve linkage to care and treatment to reach 90-90-90 goals.