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Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis.

ABSTRACT: Lack of appropriate health care seeking for ill mothers and neonates contributes to high mortality rates. A major challenge is the appropriate mix of strategies for creating demand as well as provision of services.Systematic review and meta-analysis of experimental studies (last search: Jan 2015) to assess the impact of different strategies to improve maternal and neonatal health care seeking in low- and middle-income countries (LMIC).Fifty-eight experimental [randomized controlled trials (RCTs), non-RCTs, and before-after studies] with 310,652 participants met the inclusion criteria. Meta-analyses from 29 RCTs with a range of different interventions (e.g. mobilization, home visitation) indicated significant improvement in health care seeking for neonatal illnesses when compared with standard/no care [risk ratio (RR) 1.40; 95 confidence interval (CI): 1.17-1.68, 9 studies, n=30,572], whereas, no impact was seen on health care seeking for maternal illnesses (RR 1.06; 95% CI: 0.92-1.22, 5 studies, n=15,828). These interventions had a significant impact on reducing stillbirths (RR 0.82; 95% CI: 0.73-0.93, 11 studies, n=176,683), perinatal deaths (RR 0.84; 95% CI: 0.77-0.90, 15 studies, n=279,618), and neonatal mortality (RR 0.80; 95% CI: 0.72-0.89, 20 studies, n=248,848). On GRADE approach, evidence was high quality except for the outcome of maternal health care seeking, which was moderate.Community-based interventions integrating strategies such as home visiting and counseling can help to reduce fetal and neonatal mortality in LMIC.

SUBMITTER: Lassi ZS

PROVIDER: S-EPMC4864851 | biostudies-other | 2016

REPOSITORIES: biostudies-other

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Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis.

Lassi Zohra S ZS Middleton Philippa F PF Bhutta Zulfiqar A ZA Crowther Caroline C

Global health action 20160510

<h4>Background</h4>Lack of appropriate health care seeking for ill mothers and neonates contributes to high mortality rates. A major challenge is the appropriate mix of strategies for creating demand as well as provision of services.<h4>Design</h4>Systematic review and meta-analysis of experimental studies (last search: Jan 2015) to assess the impact of different strategies to improve maternal and neonatal health care seeking in low- and middle-income countries (LMIC).<h4>Results</h4>Fifty-eight ...[more]

PMID: 27171766

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Project description:OBJECTIVES:The maternal near-miss case review (NMCR) has been promoted by WHO as an approach to improve quality of care (QoC) at facility level. This systematic review synthesises evidence on the effectiveness of the NMCR on QoC and maternal and perinatal health outcomes in low-income and middle-income countries (LMICs). METHODS:Studies were searched for in six electronic databases (MEDLINE, Index Medicus, Web of Science, the Cochrane library, Embase, LILACS), with no language restrictions. Two authors independently screened papers and selected them for inclusion and independently extracted data. Maternal mortality was the primary outcome. Secondary outcomes included any outcome informing on any of the six dimensions of QoC: efficacy, safety, efficiency, equity, accessibility and timely care, acceptability and patient-centred care. RESULTS:Out of 24?822 papers retrieved, 17 studies from 11 countries were included. Maternal mortality measured before and after the implementation of the NMCR cycle significantly decreased (OR 0.77, 95%?CI 0.61 to 0.98, eight studies, 55 573 043 women; I2=39%). A statistically significant reduction in the incidence of uterine rupture, postpartum haemorrhage and maternal sepsis was observed in three out of six studies. Ten studies reporting on maternal care process all showed some significant improvement when measured against predefined standards. All studies reported that the NMCR resulted in some amelioration of the facility structure (physical structure, staffing, equipment, training, organisation of care). Newborn outcomes were overall poorly reported; four studies showed no significant difference in perinatal mortality. Patient satisfaction and equity were also poorly reported. CONCLUSIONS:Policy makers may consider implementing the maternal NMCR cycle approach among strategies aiming at improving QoC and reducing maternal mortality and morbidity in LMIC. Future studies should better document the effectiveness of the NMCR cycle particularly on outcomes reflecting patient-centred care and cost-effectiveness.

Project description:To assess the effectiveness of mHealth interventions for maternal, newborn and child health (MNCH) in low- and middle-income countries (LMIC).16 online international databases were searched to identify studies evaluating the impact of mHealth interventions on MNCH outcomes in LMIC, between January 1990 and May 2014. Comparable studies were included in a random-effects meta-analysis.Of 8593 unique references screened after de-duplication, 15 research articles and two conference abstracts met inclusion criteria, including 12 intervention and three observational studies. Only two studies were graded at low risk of bias. Only one study demonstrated an improvement in morbidity or mortality, specifically decreased risk of perinatal death in children of mothers who received SMS support during pregnancy, compared with routine prenatal care. Meta-analysis of three studies on infant feeding showed that prenatal interventions using SMS/cell phone (vs routine care) improved rates of breastfeeding (BF) within one hour after birth (odds ratio (OR) 2.01, 95% confidence interval (CI) 1.27-2.75, I(2) = 80.9%) and exclusive BF for three/four months (OR 1.88, 95% CI 1.26-2.50, I(2)?= 52.8%) and for six months (OR 2.57, 95% CI 1.46-3.68, I(2) = 0.0%). Included studies encompassed interventions designed for health information delivery (n = 6); reminders (n = 3); communication (n = 2); data collection (n = 2); test result turnaround (n = 2); peer group support (n = 2) and psychological intervention (n = 1).Most studies of mHealth for MNCH in LMIC are of poor methodological quality and few have evaluated impacts on patient outcomes. Improvements in intermediate outcomes have nevertheless been reported in many studies and there is modest evidence that interventions delivered via SMS messaging can improve infant feeding. Ambiguous descriptions of interventions and their mechanisms of impact present difficulties for interpretation and replication. Rigorous studies with potential to offer clearer evidence are underway.

Project description:BackgroundEach year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings.MethodsA systematic review was undertaken on the cost-effectiveness of strategies to improve the demand and supply of maternal and newborn health care in low-income and lower-middle-income countries. Peer-reviewed and grey literature published since 1990 was searched using bibliographic databases, websites of selected organizations, and reference lists of relevant studies and reviews. Publications were eligible for inclusion if they report on a behavioural or health systems strategy that sought to improve the utilization or provision of care during pregnancy, childbirth or the neonatal period; report on its cost-effectiveness; and were set in one or more low-income or lower-middle-income countries. The quality of the publications was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. Incremental cost per life-year saved and per disability-adjusted life-year averted were compared to gross domestic product per capita.ResultsForty-eight publications were identified, which reported on 43 separate studies. Sixteen were judged to be of high quality. Common themes were identified and the strategies were presented in relation to the continuum of care and the level of the health system. There was reasonably strong evidence for the cost-effectiveness of the use of women's groups, home-based newborn care using community health workers and traditional birth attendants, adding services to routine antenatal care, a facility-based quality improvement initiative to enhance compliance with care standards, and the promotion of breastfeeding in maternity hospitals. Other strategies reported cost-effectiveness measures that had limited comparability.ConclusionDemand and supply-side strategies to improve maternal and newborn health care can be cost-effective, though the evidence is limited by the paucity of high quality studies and the use of disparate cost-effectiveness measures.Trial registrationPROSPERO_ CRD42012003255.

Project description:Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.

Project description:IntroductionImproving reproductive, maternal, newborn, and child health (RMNCH) care services is imperative for reducing maternal and child mortality. Many low- and middle-income countries (LMICs) are striving to achieve RMNCH-related Sustainable Development Goals (SDGs). We monitored progress, made projections, and calculated the average annual rate of change needed to achieve universal (100%) access of RMNCH service indicators by 2030.MethodsWe extracted Demographic and Health Survey (DHS) data of 75 LMICs to estimate the coverage of RMNCH indicators and composite coverage index (CCI) to measure health system strengths. Bayesian linear regression models were fitted to predict the coverage of indicators and the probability of achieving targets.ResultsThe projection analysis included 64 countries with available information for at least 2 DHS rounds. No countries are projected to reach universal CCI by 2030; only Brazil, Cambodia, Colombia, Honduras, Morocco, and Sierra Leone will have more than 90% CCI. None of the LMICs will achieve universal coverage of all RMNCH indicators by 2030, although some may achieve universal coverage for specific services. To meet targets for universal service access by 2030, most LMICs must attain a 2-fold increase in the coverage of indicators from 2019 to 2030. Coverage of RMNCH indicators, the probability of target attainments, and the required rate of increase vary significantly across the spectrum of sociodemographic disadvantages. Most countries with poor historical and current trends for RMNCH coverage are likely to experience a similar scenario in 2030. Countries with lower coverage had higher disparities across the subgroups of wealth, place of residence, and women's/mother's education and age; these disparities are projected to persist in 2030.ConclusionNone of the LMICs will meet the SDG RMNCH 2030 targets without scaling up essential RMNCH interventions, reducing gaps in coverage, and reaching marginalized and disadvantaged populations.

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Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis.

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Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis.

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