Neha S. Singh

Designing appropriate complementary feeding recommendations: tools for programmatic action

Suboptimal complementary feeding practices contribute to a rapid increase in the prevalence of stunting in young children from age 6 months. The design of effective programmes to improve infant and young child feeding requires a sound understanding of the local situation and a systematic process for prioritizing interventions, integrating them into existing delivery platforms and monitoring their implementation and impact. The identification of adequate food-based feeding recommendations that respect locally available foods and address gaps in nutrient availability is particularly challenging. We describe two tools that are now available to strengthen infant and young child-feeding programming at national and subnational levels. ProPAN is a set of research tools that guide users through a step-by-step process for identifying problems related to young child nutrition; defining the context in which these problems occur; formulating, testing, and selecting behaviour-change recommendations and nutritional recipes; developing the interventions to promote them; and designing a monitoring and evaluation system to measure progress towards intervention goals. Optifood is a computer-based platform based on linear programming analysis to develop nutrient-adequate feeding recommendations at lowest cost, based on locally available foods with the addition of fortified products or supplements when needed, or best recommendations when the latter are not available. The tools complement each other and a case study from Peru illustrates how they have been used. The readiness of both instruments will enable partners to invest in capacity development for their use in countries and strengthen programmes to address infant and young child feeding and prevent malnutrition.

Progress and challenges in maternal health in western China: a Countdown to 2015 national case study

Summary Background China is one of the few Countdown countries to have achieved Millennium Development Goal 5 (75% reduction in maternal mortality ratio between 1990 and 2015). We aimed to examine the health systems and contextual factors that might have contributed to the substantial decline in maternal mortality between 1997 and 2014. We chose to focus on western China because poverty, ethnic diversity, and geographical access represent particular challenges to ensuring universal access to maternal care in the region. Methods In this systematic assessment, we used data from national census reports, National Statistical Yearbooks, the National Maternal and Child Health Routine Reporting System, the China National Health Accounts report, and National Health Statistical Yearbooks to describe changes in policies, health financing, health workforce, health infrastructure, coverage of maternal care, and maternal mortality by region between 1997 and 2014. We used a multivariate linear regression model to examine which contextual and health systems factors contributed to the regional variation in maternal mortality ratio in the same period. Using data from a cross-sectional survey in 2011, we also examined equity in access to maternity care in 42 poor counties in western China. Findings Maternal mortality declined by 8·9% per year between 1997 and 2014 (geometric mean ratio for each year 0·91, 95% CI 0·91–0·92). After adjusting for GDP per capita, length of highways, female illiteracy, the number of licensed doctors per 1000 population, and the proportion of ethnic minorities, the maternal mortality ratio was 118% higher in the western region (2·18, 1·44–3·28) and 41% higher in the central region (1·41, 0·99–2·01) than in the eastern region. In the rural western region, the proportion of births in health facilities rose from 41·9% in 1997 to 98·4% in 2014. Underpinning such progress was the Governments strong commitment to long-term strategies to ensure access to delivery care in health facilities—eg, professionalisation of maternity care in large hospitals, effective referral systems for women medically or socially at high risk, and financial subsidies for antenatal and delivery care. However, in the poor western counties, substantial disparity by education level of the mother existed in access to health facility births (44% of illiterate women vs 100% of those with college or higher education), antenatal care (17% vs 69%) had at least four visits), and caesarean section (8% vs 44%). Interpretation Despite remarkable progress in maternal survival in China, substantial disparities remain, especially for the poor, less educated, and ethnic minority groups in remote areas in western China. Whether Chinas highly medicalised model of maternity care will be an answer for these populations is uncertain. A strategy modelled after Chinas immunisation programme, whereby care is provided close to the womens homes, might need to be explored, with township hospitals taking a more prominent role. Funding Government of Canada, UNICEF, and the Bill & Melinda Gates Foundation.

Countdown to 2015 country case studies: systematic tools to address the “black box” of health systems and policy assessment

BackgroundEvaluating health systems and policy (HSP) change and implementation is critical in understanding reproductive, maternal, newborn and child health (RMNCH) progress within and across countries. Whilst data for health outcomes, coverage and equity have advanced in the last decade, comparable analyses of HSP changes are lacking. We present a set of novel tools developed by Countdown to 2015 (Countdown) to systematically analyse and describe HSP change for RMNCH indicators, enabling multi-country comparisons.MethodsInternational experts worked with eight country teams to develop HSP tools via mixed methods. These tools assess RMNCH change over time (e.g. 1990–2015) and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, we present results from Tanzania and Peru, two of eight Countdown case studies.ResultsThe Policy and Programme Timeline tool shows that Tanzania’s RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Contrastingly, Peru moved from standalone to integrated RMNCH programme implementation, combined with multi-sectoral, anti-poverty strategies.The HSP Tracer Indicators Dashboards show that Peru has adopted nine of 11 policy tracer indicators and Tanzania has adopted seven. Peru costed national RMNCH plans pre-2000, whereas Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. Both countries included all lifesaving RMNCH commodities on their essential medicines lists. Peru has twice the health worker density of Tanzania (15.4 vs. 7.1/10,000 population, respectively), although both are below the 22.8 WHO minimum threshold.ConclusionsThese are the first HSP tools using mixed methods to systematically analyse and describe RMNCH changes within and across countries, important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era.

How Ethiopia achieved Millennium Development Goal 4 through multisectoral interventions: a Countdown to 2015 case study

Summary Background 3 years before the 2015 deadline, Ethiopia achieved Millennium Development Goal 4. The under-5 mortality decreased 69%, from 205 deaths per 1000 livebirths in 1990 to 64 deaths per 1000 livebirths in 2013. To understand the underlying factors that contributed to the success in achieving MDG4, Ethiopia was selected as a Countdown to 2015 case study. Methods We used a set of complementary methods to analyse progress in child health in Ethiopia between 1990 and 2014. We used Demographic Health Surveys to analyse trends in coverage and equity of key reproductive, maternal health, and child health indicators. Standardised tools developed by the Countdown Health Systems and Policies working group were used to understand the timing and content of health and non-health policies. We assessed longitudinal trends in health-system investment through a financial analysis of National Health Accounts, and we used the Lives Saved Tool (LiST) to assess the contribution of interventions towards reducing under-5 mortality. Findings The annual rate of reduction in under-5 mortality increased from 3·3% in 1990–2005 to 7·8% in 2005–13. The prevalence of stunting decreased from 60% in 2000 to 40% in 2014. Overall levels of coverage of reproductive, maternal health, and child health indicators remained low, with disparities between the lowest and highest wealth quintiles despite improvement in coverage for essential health interventions. Coverage of child immunisation increased the most (21% of children in 2000 vs 80% of children in 2014), followed by coverage of satisfied demand for family planning by women of reproductive age (19% vs 63%). Provision of antenatal care increased from 10% of women in 2000 to 32% of women in 2014, but only 15% of women delivered with a skilled birth attendant by 2014. A large upturn occurred after 2005, bolstered by a rapid increase in health funding that facilitated the accelerated expansion of health infrastructure and workforce through an innovative community-based delivery system. The LiST model could explain almost 50% of the observed reduction in child mortality between 2000 and 2011; and changes in nutritional status were responsible for about 50% of the 469 000 lives saved between 2000 and 2011. These developments occurred within a multisectoral policy platform, integrating child survival and stunting goals within macro-level policies and programmes for reducing poverty and improving agricultural productivity, food security, water supply, and sanitation. Interpretation The reduction of under-5 mortality in Ethiopia was the result of combined activities in health, nutrition, and non-health sectors. However, Ethiopia still has high neonatal and maternal morbidity and mortality from preventable causes and an unfinished agenda in reducing inequalities, improving coverage of effective interventions, and strengthening multisectoral partnerships for further progress. Funding Bill & Melinda Gates Foundation and Government of Canada.

Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015

Introduction Despite recent gains, Kenya did not achieve its Millennium Development Goal (MDG) target for reducing under-five mortality. To accelerate progress to 2030, we must understand what impacted mortality throughout the MDG period. Methods Trends in the under-five mortality rate (U5MR) were analysed using data from nationally representative Demographic and Health Surveys (1989–2014). Comprehensive, mixed-methods analyses of health policies and systems, workforce and health financing were conducted using relevant surveys, government documents and key informant interviews with country experts. A hierarchical multivariable linear regression analysis was undertaken to better understand the proximal determinants of change in U5MR over the MDG period. Results U5MR declined by 50% from 1993 to 2014. However, mortality increased between 1990 and 2000, following the introduction of facility user fees and declining coverage of essential interventions. The MDGs, together with Kenya’s political changes in 2003, ushered in a new era of policymaking with a strong focus on children under 5 years of age. External aid for child health quadrupled from 40 million in 2002 to 180 million in 2012, contributing to the dramatic improvement in U5MR throughout the latter half of the MDG period. Our multivariable analysis explained 44% of the decline in U5MR from 2003 to 2014, highlighting maternal literacy, household wealth, sexual and reproductive health and maternal and infant nutrition as important contributing factors. Children living in Nairobi had higher odds of child mortality relative to children living in other regions of Kenya. Conclusions To attain the Sustainable Development Goal targets for child health, Kenya must uphold its current momentum. For equitable access to health services, user fees must not be reintroduced in public facilities. Support for maternal nutrition and reproductive health should be prioritised, and Kenya should acknowledge its changing demographics in order to effectively manage the escalating burden of poor health among the urban poor.

Effect of health system and policy on maternal and newborn health in China since 1949: a Countdown to 2015 case study

Abstract Background With the introduction of the Millennium Development Goals 4 and 5 in 1990, analyses of progress in maternal and newborn health have focused on the last 20 years. However, China already had low maternal and neonatal mortality rates in 1990, so it is important to understand the health policy environment and health systems inputs that have underpinned progress since 1949. Methods We used standard tools developed by Countdown to 2015s Health Systems and Policies Technical Working Group to examine national-level changes to the health system and health policies in China since 1949 and to describe the translation of macropolicies and strategies into the implementation of maternal and newborn health programmes. We used data from the Chinese Health and Family Planning Statistical Yearbook 2013 to calculate national and subnational health workforce densities. This study used open access secondary (and anonymous) data so did not require ethical approval. Results The Chinese maternal and newborn policy and programmatic environment from 1949 to present is complex. Initially, training of traditional midwives and barefoot doctors aimed to decrease maternal mortality and neonatal tetanus in rural areas. With vast economic growth from the late 1970s, well coordinated health initiatives, such as a perinatal health programme and cross-cutting strategies including the one-child policy, were implemented nationally. The 1995 Law on Maternal and Infant Health Care focused on training and service delivery for maternal and new-born health, and the 1999–2009 Safe Motherhood programme focused on increasing facility births. From 2003, the Rural Cooperative Medical System contributed to increases in hospital delivery by improving quality of service delivery, providing subsidies to pregnant women, and focusing on community health education. As a result, hospital births increased nationally from 61·7% of all live births in 1997 to 99·5% in 2013, and in western Provinces from 47·9% in 1997 to 98·5% in 2013. Enabling health system and policies substantially improved facility delivery rates in Western provinces, although large urban, rural, and provincial disparities still exist. In 2012, the density of health workforce per 1000 population in urban areas was nearly three times that of rural areas (8·54 vs 3·41), and the density of health workforce per 1000 population in Beijing Province was twice that of Sichuan Province (9·48 vs 4·82). Interpretation Chinas successes in implementing health services and policies to improve maternal and newborn health could be useful to other countries. More needs to be done to decrease inequities within the country. A strength of this study is its use of standardised, novel tools to examine the effect of health system and policies on maternal and newborn health in China over a long time frame (1949 to present). A limitation of the study is that this case study looks at plausibility rather than causality, as causality cannot be inferred from these analyses in view of the data limitations and multiple concurrent changes. Funding US Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn and Child Survival grant from the Bill & Melinda Gates Foundation, Government of Canada, Foreign Affairs, Trade and Development, and Sichuan University.

Effect of maternal height on caesarean section and neonatal mortality rates in sub-Saharan Africa: An analysis of 34 national datasets

Rationale The lifecycle perspective reminds us that the roots of adult ill-health may start in-utero or in early childhood. Nutritional and infectious disease insults in early life, the critical first 1000 days, are associated with stunting in childhood, and subsequent short adult stature. There is limited or no opportunity for stunted children above 2 years of age to experience catch-up growth. Some previous research has shown short maternal height to lead to adverse birth outcomes. In this paper, we document the association between maternal height and caesarean section, and between maternal height and neonatal mortality in 34 sub-Saharan African countries. We also explore the appropriate height cut-offs to use. Our paper contributes arguments to support a focus on preventing non-communicable risk factors, namely early childhood under-nutrition, as part of the fight to reduce caesarean section rates and other adverse maternal and newborn health outcomes, particularly neonatal mortality. We focus on the Sub-Saharan Africa region because it carries the highest burden of maternal and neonatal ill-health. Methods We used the most recent Demographic and Health Survey for 34 sub-Saharan African countries. The distribution of heights of women who had given birth in the 5 years before the survey was explored. We adopted the following cut-offs: Very Short (<145.0cm), Short (145.0–149.9cm), Short-average (150.0–154.9cm), Average (155.0–159.9cm), Average-tall (160.0–169.9cm) and Tall (≥170.0cm). Multivariate logistic regression was used to assess the contribution of maternal stature to the odds ratio of caesarean section delivery, adjusting for other exposures, such as age at index birth, residence, maternal BMI, maternal education, wealth index quintile, previous caesarean section, multiple birth, birth order and country of survey. We also look at its contribution to neonatal mortality adjusting for age at index birth, residence, maternal BMI, maternal education, wealth index quintile, multiple birth, birth order and country of survey. Results There was a gradual increase in the rate of caesarean section with decreasing maternal height. Compared to women of Average height (155.0–159.9cm), taller women were protected. The adjusted odds ratio (aOR) for Tall women was 0.67 (95% CI:0.52–0.87) and for Average-tall women was 0.78 (95% CI:0.69–0.89). Compared to women of Average height, shorter women were at increased risk. The aOR for Short-average women was 1.19 (95% CI:1.03–1.37), for Short women was 2.06 (95% CI:1.71–2.48), and for Very Short women was 2.50 (95% CI:1.85–3.38). There was evidence that compared to Average height women, Very Short and Short women had increased odds of experiencing a neonatal death aOR = 1.95 (95% CI 1.17–3.25) and aOR = 1.66 (95% CI 1.20–2.28) respectively. When we focused on the period of highest risk, the day of delivery and first postnatal day, these aORs increased to 2.36 (95% CI 1.57–3.55) and 2.34 (95% CI 1.19–4.60) respectively. The aORs for the first week of life (early neonatal mortality) were 1.90 (95% CI 1.07–3.36) and 1.83 (95% CI 1.30–2.59) respectively. Conclusions Short stature is associated with an increased prevalence of caesarean section and neonatal mortality, particularly on the newborn’s first days. These results are even more striking because we know that caesarean section rates tend to be higher among wealthier and more educated women, who are often taller and that the same patterns may hold for neonatal survival; in such cases, adjusting for wealth, education and urban residence would attenuate these associations. Caesarean sections can be lifesaving operations; however, they cost the health system and families more, and are associated with worse health outcomes. We suggest that our findings be used to argue for policies targeting stunting in infant girls and potential catch-up growth in adolescence and early adulthood, aiming to increase their adult height and thus decrease their subsequent risk of experiencing caesarean section and adverse birth outcomes.

Evaluating the effectiveness of sexual and reproductive health services during humanitarian crises: A systematic review

Background An estimated 32 million women and girls of reproductive age living in emergency situations, all of whom require sexual and reproductive health (SRH) information and services. This systematic review assessed the effect of SRH interventions, including the Minimum Initial Service Package (MISP) on a range of health outcomes from the onset of emergencies. Methods and findings We searched EMBASE, Global Health, MEDLINE and PsychINFO databases from January 1, 1980 to April 10, 2017. This review was registered with the PROSPERO database with identifier number CRD42017082102. We found 29 studies meet the inclusion criteria. We found high quality evidence to support the effectiveness of specific SRH interventions, such as home visits and peer-led educational and counselling, training of lower-level health care providers, community health workers (CHWs) to promote SRH services, a three-tiered network of health workers providing reproductive and maternal health services, integration of HIV and SRH services, and men’s discussion groups for reducing intimate partner violence. We found moderate quality evidence to support transport-based referral systems, community-based SRH education, CHW delivery of injectable contraceptives, wider literacy programmes, and birth preparedness interventions. No studies reported interventions related to fistulae, and only one study focused on abortion services. Conclusions Despite increased attention to SRH in humanitarian crises, the sector has made little progress in advancing the evidence base for the effectiveness of SRH interventions, including the MISP, in crisis settings. A greater quantity and quality of more timely research is needed to ascertain the effectiveness of delivering SRH interventions in a variety of humanitarian crises.

A long way to go: a systematic review to assess the utilisation of sexual and reproductive health services during humanitarian crises

Introduction Women and girls are affected significantly in both sudden and slow-onset emergencies, and face multiple sexual and reproductive health (SRH) challenges in humanitarian crises contexts. There are an estimated 26 million women and girls of reproductive age living in humanitarian crises settings, all of whom need access to SRH information and services. This systematic review aimed to assess the utilisation of services of SRH interventions from the onset of emergencies in low- and middle-income countries. Methods We searched for both quantitative and qualitative studies in peer-reviewed journals across the following four databases: EMBASE, Global Health, MEDLINE and PsychINFO from 1 January 1980 to 10 April 2017. Primary outcomes of interest included self-reported use and/or confirmed use of the Minimum Initial Service Package services and abortion services. Two authors independently extracted and analysed data from published papers on the effect of SRH interventions on a range of SRH care utilisation outcomes from the onset of emergencies, and used a narrative synthesis approach. Results Of the 2404 identified citations, 23 studies met the inclusion criteria. 52.1% of the studies (n=12) used quasi-experimental study designs, which provided some statistical measure of difference between intervention and outcome. 39.1% of the studies (n=9) selected were graded as high quality, 39.1% moderate quality (n=9) and 17.4% low quality (n=4). Evidence of effectiveness in increasing service utilisation was available for the following interventions: peer-led and interpersonal education and mass media campaigns, community-based programming and three-tiered network of community-based reproductive and maternal health providers. Conclusions Despite increased attention to SRH service provision in humanitarian crises settings, the evidence base is still very limited. More implementation research is required to identify interventions to increase utilisation of SRH services in diverse humanitarian crises settings and populations.

Understanding for whom, why and in what circumstances payment for performance works in low and middle income countries: protocol for a realist review

Background Many low and middle income countries (LMIC) are implementing payment for performance (P4P) schemes to strengthen health systems and make progress towards universal health coverage. A number of systematic reviews have considered P4P effectiveness but did not explore how P4P works in different settings to improve outcomes or shed light on pathways or mechanisms of programme effect. This research will undertake a realist review to investigate how, why and in what circumstances P4P leads to intended and unintended outcomes in LMIC. Methods Our search was guided by an initial programme theory of mechanisms and involved a systematic search of Medline, Embase, Popline, Business Source Premier, Emerald Insight and EconLit databases for studies on P4P and health in LMIC. Inclusion and exclusion criteria identify literature that is relevant to the initial programme theory and the research questions underpinning the review. Retained evidence will be used to test, revise or refine the programme theory and identify knowledge gaps. The evidence will be interrogated by examining the relationship between context, mechanisms and intended and unintended outcomes to establish what works for who, in which contexts and why. Discussion By synthesising current knowledge on how P4P affects health systems to produce outcomes in different contexts and to what extent the programme design affects this, we will inform more effective P4P programmes to strengthen health systems and achieve sustainable service delivery and health impacts.