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A full understanding of the pathways from efficacious interventions to population impact requires rigorous effectiveness evaluations conducted under realistic scale-up conditions at country level. In this paper, we introduce a deductive framework that underpins effectiveness evaluations. This framework forms the theoretical and conceptual basis for the 'Real Accountability: Data Analysis for Results' (RADAR) project, intended to address gaps in guidance and tools for the evaluation of projects being implemented at scale to reduce mortality among women and children. These gaps include needs for a framework to guide decisions about evaluations and practical measurement tools, as well as increased capacity in evaluation practice among donors and program planners at global, national and project levels. RADAR aimed to improve the evidence base for program and policy decisions in reproductive, maternal, newborn and child health and nutrition (RMNCH&N). We focus on five linked methodological steps – presented as core evaluation questions – for designing and implementing effectiveness evaluation of large-scale programs that support both the needs of program managers to improve their programs and the needs of donors to meet their accountability responsibilities. RADAR has operationalized each step with a tool to facilitate its application. We also describe cross-cutting methodological issues and broader contextual factors that affect the planning and implementation of such evaluations. We conclude with proposals for how the global RMNCH&N community can support rigorous program evaluations and make better use of the resulting evidence. [ABSTRACT FROM AUTHOR]

Background: There are limited existing approaches to generate estimates from Routine Health Information Systems (RHIS) data, despite the growing interest to these data. We calculated and assessed the consistency of maternal and child health service coverage estimates from RHIS data, using census-based and health service-based denominators in Sierra Leone.Methods: We used Sierra Leone 2016 RHIS data to calculate coverage of first antenatal care contact (ANC1), institutional delivery and diphtheria-pertussis-tetanus 3 (DPT3) immunization service provision. For each indicator, national and district level coverages were calculated using denominators derived from two census-based and three health service-based methods. We compared the coverage estimates from RHIS data to estimates from MICS 2017. We considered the agreement adequate when estimates from RHIS fell within the 95% confidence interval of the survey estimate.Results: We found an overall poor consistency of the coverage estimates calculated from the census-based methods. ANC1 and institutional delivery coverage estimates from these methods were greater than 100% in about half of the fourteen districts, and only 3 of the 14 districts had estimates consistent with the survey data. Health service-based methods generated better estimates. For institutional delivery coverage, five districts met the agreement criteria using BCG service-based method. We found better agreement for DPT3 coverage estimates using DPT1 service-based method as national coverage was close to survey data, and estimates were consistent for 8 out of 14 districts. DPT3 estimates were consistent in almost half of the districts (6/14) using ANC1 service-based method.Conclusion: The study highlighted the challenge in determining an appropriate denominator for RHIS-based coverage estimates. Systematic and transparent data quality check and correction, as well as rigorous approaches to determining denominators are key considerations to generate accurate coverage statistics using RHIS data. [ABSTRACT FROM AUTHOR]

The objective of this study was to examine regional variations in the self-reported causes of choosing not to give birth at a health facility in Nigeria. Cross-sectional data on 24,033 community dwelling women aged 15-49 years were collected from the Nigeria Demographic and Health Surveys (NDHS) conducted in 2008 and 2013. In both surveys a large proportion of the women mentioned facility childbirth as not necessary: 55.6% (53.3-57.8) in 2008 and 35.6% (34.0-37.2) in 2013. Poor transportation, not being customary, and costliness were each reported by around 10% of the respondents. The regression analysis showed significant regional variations in the prevalence of the self-reported causes of non-utilization. Women in the northern regions of the country were more likely to regard facility childbirth as unnecessary and to complain about transportation and financial difficulties. [ABSTRACT FROM AUTHOR]

Background: Ethiopia has experienced rapid improvements in its healthcare infrastructure, such as through the recent scale up of integrated community case management (iCCM) delivered by community-based health extension workers (HEWs) targeting children under the age of five. Despite notable improvements in child outcomes, the use of HEWs delivering iCCM remains very low. The aim of our study was to explain this phenomenon by examining care-seeking practices and treatment for sick children in two rural districts in the Oromia Region of Ethiopia.Methods: Using qualitative methods, we explored perceptions of child illness, influences on decision-making processes occurring over the course of a child's illness and caregiver perceptions of available community-based sources of child illness care. Sixteen focus group discussions (FGDs) and 40 in-depth interviews (IDIs) were held with mothers of children under age five. For additional perspective, 16 IDIs were conducted fathers and 22 IDIs with health extension workers and community health volunteers.Results: Caregivers often described the act of care-seeking for a sick child as a time of considerable uncertainty. In particular, mothers of sick children described the cultural, social and community-based resources available to minimize this uncertainty as well as constraints and strategies for accessing these resources in order to receive treatment for a sick child. The level of trust and familiarity were the most common dynamics noted as influencing care-seeking strategies; trust in biomedical and government providers was often low.Conclusions: Overall, our research highlights the multiple and dynamic influences on care-seeking for sick children in rural Ethiopia. An understanding of these influences is critical for the success of existing and future health interventions and continued improvement of child health in Ethiopia. [ABSTRACT FROM AUTHOR]

Bryce and colleagues, reflect on lessons that can be learned from the Real-Time Monitoring of Under-Five Mortality Collection. [ABSTRACT FROM AUTHOR]

Background: Malawi ratified a compulsory birth and death registration system in 2009. Until it captures complete coverage of vital events, Malawi relies on other data sources to calculate mortality estimates. We tested a community-based method to estimate annual under-five mortality rates (U5MR) through the Real-Time Monitoring of Under-Five Mortality (RMM) project in Malawi. We implemented RMM in two phases, and conducted an independent evaluation of phase one after 21 months of implementation. We present results of the phase two validation that covers the full project time span, and compare the results to those of the phase one validation. Methods and Findings: We assessed the completeness of the counts of births and deaths and the accuracy of disaggregated U5MR from the community-based method against a retrospective full pregnancy history for rolling twelve-month periods after the independent evaluation. We used full pregnancy histories collected through household interviews carried out between November 2013 and January 2014 as the validation data source. Health Surveillance Agents (HSAs) across the 160 catchment areas submitted routine reports on pregnancies, births, and deaths consistently. However, for the 15-month implementation period post-evaluation, average completeness of birth event reporting was 76%, whereas average completeness of death event reporting was 67% relative to that expected from a comparable pregnancy history. HSAs underestimated the U5MR by an average of 21% relative to that estimated from a comparable pregnancy history. Conclusions: On a medium scale, the community-based RMM method in Malawi produced substantial underestimates of annualized U5MR relative to those obtained from a full pregnancy history, despite the additional incentives and quality-control activities. We were not able to achieve an optimum level of incentive and support to make the system work while ensuring sustainability. Lessons learned from the implementation of RMM can inform programs supporting community-based interventions through HSAs in Malawi. [ABSTRACT FROM AUTHOR]

Introduction: Most low-income countries lack complete and accurate vital registration systems. As a result, measures of under-five mortality rates rely mostly on household surveys. In collaboration with partners in Ethiopia, Ghana, Malawi, and Mali, we assessed the completeness and accuracy of reporting of births and deaths by community-based health workers, and the accuracy of annualized under-five mortality rate estimates derived from these data. Here we report on results from Ethiopia, Malawi and Mali. Method: In all three countries, community health workers (CHWs) were trained, equipped and supported to report pregnancies, births and deaths within defined geographic areas over a period of at least fifteen months. In-country institutions collected these data every month. At each study site, we administered a full birth history (FBH) or full pregnancy history (FPH), to women of reproductive age via a census of households in Mali and via household surveys in Ethiopia and Malawi. Using these FBHs/FPHs as a validation data source, we assessed the completeness of the counts of births and deaths and the accuracy of under-five, infant, and neonatal mortality rates from the community-based method against the retrospective FBH/FPH for rolling twelve-month periods. For each method we calculated total cost, average annual cost per 1,000 population, and average cost per vital event reported. Results: On average, CHWs submitted monthly vital event reports for over 95 percent of catchment areas in Ethiopia and Malawi, and for 100 percent of catchment areas in Mali. The completeness of vital events reporting by CHWs varied: we estimated that 30%-90% of annualized expected births (i.e. the number of births estimated using a FPH) were documented by CHWs and 22%-91% of annualized expected under-five deaths were documented by CHWs. Resulting annualized under-five mortality rates based on the CHW vital events reporting were, on average, under-estimated by 28% in Ethiopia, 32% in Malawi, and 9% in Mali relative to comparable FPHs. Costs per vital event reported ranged from $21 in Malawi to $149 in Mali. Discussion: Our findings in Mali suggest that CHWs can collect complete and high-quality vital events data useful for monitoring annual changes in under-five mortality rates. Both the supervision of CHWs in Mali and the rigor of the associated field-based data quality checks were of a high standard, and the size of the pilot area in Mali was small (comprising of approximately 53,205 residents in 4,200 households). Hence, there are remaining questions about whether this level of vital events reporting completeness and data quality could be maintained if the approach was implemented at scale. Our experience in Malawi and Ethiopia suggests that, in some settings, establishing and maintaining the completeness and quality of vital events reporting by CHWs over time is challenging. In this sense, our evaluation in Mali falls closer to that of an efficacy study, whereas our evaluations in Ethiopia and Malawi are more akin to an effectiveness study. Our overall findings suggest that no one-size-fits-all approach will be successful in guaranteeing complete and accurate reporting of vital events by CHWs. [ABSTRACT FROM AUTHOR]

Background: Ethiopia has scaled up its community-based programs over the past decade by training and deploying health extension workers (HEWs) in rural communities throughout the country. Consequently, child mortality has declined substantially, placing Ethiopia among the few countries that have achieved the United Nations’ fourth Millennium Development Goal. As Ethiopia continues its efforts, results must be assessed regularly to provide timely feedback for improvement and to generate further support for programs. More specifically the expansion of HEWs at the community level provides a unique opportunity to build a system for real-time monitoring of births and deaths, linked to a civil registration and vital statistics system that Ethiopia is also developing. We tested the accuracy and completeness of births and deaths reported by trained HEWs for monitoring child mortality over 15 -month periods. Methods and Findings: HEWs were trained in 93 randomly selected rural kebeles in Jimma and West Hararghe zones of the Oromia region to report births and deaths over a 15-month period from January, 2012 to March, 2013. Completeness of number of births and deaths, age distribution of deaths, and accuracy of resulting under-five, infant, and neonatal mortality rates were assessed against data from a large household survey with full birth history from women aged 15–49. Although, in general HEWs, were able to accurately report events that they identified, the completeness of number of births and deaths reported over twelve-month periods was very low and variable across the two zones. Compared to household survey estimates, HEWs reported only about 30% of births and 21% of under-five deaths occurring in their communities over a twelve-month period. The under-five mortality rate was under-estimated by around 30%, infant mortality rate by 23% and neonatal mortality by 17%. HEWs reported disproportionately higher number of deaths among the very young infants than among the older children. Conclusion: Birth and death data reported by HEWs are not complete enough to support the monitoring of changes in childhood mortality. HEWs can significantly contribute to the success of a CRVS in Ethiopia, but cannot be relied upon as the sole source for identification of vital events. Further studies are needed to understand how to increase the level of completeness. [ABSTRACT FROM AUTHOR]

Background: As community case management of childhood illness expands in low-income countries, there is a need to assess the quality of care provided by community health workers. This study had the following objectives: 1) examine methods of recruitment of sick children for assessment of quality of care, 2) assess the validity of register review (RR) and direct observation only (DO) compared to direct observation with re-examination (DO+RE), and 3) assess the effect of observation on community health worker performance. Methods: We conducted a survey to assess the quality of care provided by Ethiopian Health Extension Workers (HEWs). The sample of children was obtained through spontaneous consultation, HEW mobilization, or recruitment by the survey team. We assessed patient characteristics by recruitment method. Estimates of indicators of quality of care obtained using RR and DO were compared to gold standard estimates obtained through DO+RE. Sensitivity, specificity, and the area under receiver operator characteristic curve (AUC) were calculated to assess the validity of RR and DO. To assess the Hawthorne effect, we compared estimates from RR for children who were observed by the survey team to estimates from RR for children who were not observed by the survey team. Results: Participants included 137 HEWs and 257 sick children in 103 health posts, plus 544 children from patient registers. Children mobilized by HEWs had the highest proportion of severe illness (27%). Indicators of quality of care from RR and DO had high sensitivity for most indicators, but specificity was low. The AUC for different indicators from RR ranged from 0.47 to 0.76, with only one indicator above 0.75. The AUC of indicators from DO ranged from 0.54 to 1.0, with three indicators above 0.75. The differences between estimates of correct care for observed versus not observed children were small. Conclusions: Mobilization by HEWs and recruitment by the survey teams were feasible, but potentially biased, methods of obtaining sick children. Register review and DO underestimated performance errors. Our data suggest that being observed had only a small positive effect on the performance of HEWs. [ABSTRACT FROM AUTHOR]

Quantification learning is the task of prevalence estimation for a test population using predictions from a classifier trained on a different population. Quantification methods assume that the sensitivities and specificities of the classifier are either perfect or transportable from the training to the test population. These assumptions are inappropriate in the presence of dataset shift, when the misclassification rates in the training population are not representative of those for the test population. Quantification under dataset shift has been addressed only for single-class (categorical) predictions and assuming perfect knowledge of the true labels on a small subset of the test population. We propose generalized Bayes quantification learning (GBQL) that uses the entire compositional predictions from probabilistic classifiers and allows for uncertainty in true class labels for the limited labeled test data. Instead of positing a full model, we use a model-free Bayesian estimating equation approach to compositional data using Kullback–Leibler loss-functions based only on a first-moment assumption. The idea will be useful in Bayesian compositional data analysis in general as it is robust to different generating mechanisms for compositional data and allows 0's and 1's in the compositional outputs thereby including categorical outputs as a special case. We show how our method yields existing quantification approaches as special cases. Extension to an ensemble GBQL that uses predictions from multiple classifiers yielding inference robust to inclusion of a poor classifier is discussed. We outline a fast and efficient Gibbs sampler using a rounding and coarsening approximation to the loss functions. We establish posterior consistency, asymptotic normality and valid coverage of interval estimates from GBQL, which to our knowledge are the first theoretical results for a quantification approach in the presence of local labeled data. We also establish finite sample posterior concentration rate. Empirical performance of GBQL is demonstrated through simulations and analysis of real data with evident dataset shift. for this article are available online. [ABSTRACT FROM AUTHOR]

Computer-coded verbal autopsy (CCVA) algorithms predict cause of death from high-dimensional family questionnaire data (verbal autopsy) of a deceased individual, which are then aggregated to generate national and regional estimates of cause-specific mortality fractions. These estimates may be inaccurate if CCVA is trained on non-local training data different from the local population of interest. This problem is a special case of transfer learning, i.e., improving classification within a target domain (e.g., a particular population) with the classifier trained in a source-domain. Most transfer learning approaches concern individual-level (e.g., a person's) classification. Social and health scientists such as epidemiologists are often more interested with understanding etiological distributions at the population-level. The sample sizes of their data sets are typically orders of magnitude smaller than those used for common transfer learning applications like image classification, document identification, etc. We present a parsimonious hierarchical Bayesian transfer learning framework to directly estimate population-level class probabilities in a target domain, using any baseline classifier trained on source-domain, and a small labeled target-domain dataset. To address small sample sizes, we introduce a novel shrinkage prior for the transfer error rates guaranteeing that, in absence of any labeled target-domain data or when the baseline classifier is perfectly accurate, our transfer learning agrees with direct aggregation of predictions from the baseline classifier, thereby subsuming the default practice as a special case. We then extend our approach to use an ensemble of baseline classifiers producing an unified estimate. Theoretical and empirical results demonstrate how the ensemble model favors the most accurate baseline classifier. We present data analyses demonstrating the utility of our approach. [ABSTRACT FROM AUTHOR]

Background: In sub-Saharan Africa, socioeconomic factors such as place of residence, mother's educational level, or household wealth, are strongly associated with risk factors of under-five mortality (U5M) such as health behavior or exposure to diseases and injuries. The aim of the study was to assess the relative contribution of four known socioeconomic factors to the variability in U5M in sub-Saharan countries.Methods: The study was based on birth histories from the Demographic and Health Surveys conducted in 32 sub-Saharan countries in 2010-2016. The relative contribution of sex of the child, place of residence, mother's educational level, and household wealth to the variability in U5M was assessed using a regression-based decomposition of a Gini-type index.Results: The Gini index - measuring the variability in U5M related to the four socioeconomic factors - varied from 0.006 (95%CI: 0.001-0.010) in Liberia 2013 to 0.034 (95%CI: 0.029-0.039) in Côte d'Ivoire 2011/12. The main contributors to the Gini index (with a relative contribution higher than 25%) were different across countries: mother's educational level in 13 countries, sex of the child in 12 countries, household wealth in 11 countries, and place of residence in 8 countries (in some countries, more than one main contributor was identified).Conclusions: Factors related to socioeconomic status exert varied effects on the variability in U5M in sub-Saharan African countries. The findings provide evidence in support of prioritizing intersectoral interventions aiming at improving child survival in all subgroups of a population. [ABSTRACT FROM AUTHOR]

Niger is afflicted with high rates of poverty, high fertility rates, frequent environmental crises, and climate change. Recurrent droughts and floods have led to chronic food insecurity linked to poor maternal and neonatal nutrition outcomes in vulnerable regions. We analyzed maternal and neonatal nutrition trends and subnational variability between 2000 and 2021 with a focus on the implementation of policies and programs surrounding two acute climate shocks in 2005 and 2010. We used four sources of data: (a) national household surveys for maternal and newborn nutritional indicators allowing computation of trends and differences at national and regional levels; (b) document review of food security reports; (c) 30 key informant interviews and; (d) one focus group discussion. Many food security policies and nutrition programs were enacted from 2000 to 2020. Gains in maternal and neonatal nutrition indicators were more significant in targeted vulnerable regions of Maradi, Zinder, Tahoua and Tillabéri, from 2006 to 2021. However, poor access to financial resources for policy execution and suboptimal implementation of plans have hindered progress. In response to the chronic climate crisis over the last 20 years, the Nigerien government and program implementers have demonstrated their commitment to reducing food insecurity and enhancing resilience to climate shocks by adopting a deliberate multisectoral effort. However, there is more that can be achieved with a continued focus on vulnerable regions to build resilience, targeting high risk populations, and investing in infrastructure to improve health systems, food systems, agriculture systems, education systems, and social protection. Key messages: Niger is ranked as the most vulnerable country in the world for exposure and sensitivity to the negative effects of disasters and climate change. Acute environmental shocks in 2005 and 2010 elevated government and development partner responses to the 'food security crises'.Multisectoral policy and program investments in vulnerable regions played a meaningful role in improving food security and subsequently maternal and neonatal nutrition but progress is slow or stagnant.The Nigerien government, program implementers, and donors should prioritize investments in infrastructure and shock resilience to improve health systems, food systems, agriculture systems, education systems, and social protection, particularly in high risk populations. [ABSTRACT FROM AUTHOR]

Background: Increased contraceptive use has been associated with a decrease in high parity births, births that occur close together in time, and births to very young or to older women. These types of births are also associated with high risk of under-five mortality. Previous studies have looked at the change in the level of contraception use and the average change in these types of high-risk births. We aim to predict the distribution of births in a specific country when there is a change in the level and method of modern contraception.Methods: We used data from full birth histories and modern contraceptive use from 207 nationally representative Demographic and Health Surveys covering 71 countries to describe the distribution of births in each survey based on birth order, preceding birth space, and mother's age at birth. We estimated the ecologic associations between the prevalence and method-mix of modern contraceptives and the proportion of births in each category. Hierarchical modelling was applied to these aggregated cross sectional proportions, so that random effects were estimated for countries with multiple surveys. We use these results to predict the change in type of births associated with scaling up modern contraception in three different scenarios.Results: We observed marked differences between regions, in the absolute rates of contraception, the types of contraceptives in use, and in the distribution of type of birth. Contraceptive method-mix was a significant determinant of proportion of high-risk births, especially for birth spacing, but also for mother's age and parity. Increased use of modern contraceptives is especially predictive of reduced parity and more births with longer preceding space. However, increased contraception alone is not associated with fewer births to women younger than 18 years or a decrease in short-spaced births.Conclusions: Both the level and the type of contraception are important factors in determining the effects of family planning on changes in distribution of high-risk births. The best predictions for how birth risk changes with increased modern contraception and for different contraception methods allow for more nuanced predictions specific to each country and can aid better planning for the scaling up of modern contraception. [ABSTRACT FROM AUTHOR]

Background: Verbal autopsy is the main method used in countries with weak civil registration systems for estimating community causes of neonatal and 1-59-month-old deaths. However, validation studies of verbal autopsy methods are limited and assessment has been dependent on hospital-based studies, with uncertain implications for its validity in community settings. If the distribution of community deaths by cause was similar to that of facility deaths, or could be adjusted according to related demographic factors, then the causes of facility deaths could be used to estimate population causes.Methods: Causes of neonatal and 1-59-month-old deaths from verbal/social autopsy (VASA) surveys in four African countries were estimated using expert algorithms (EAVA) and physician coding (PCVA). Differences between facility and community deaths in individual causes and cause distributions were examined using chi-square and cause-specific mortality fractions (CSMF) accuracy, respectively. Multinomial logistic regression and random forest models including factors from the VASA studies that are commonly available in Demographic and Health Surveys were built to predict population causes from facility deaths.Results: Levels of facility and community deaths in the four countries differed for one to four of 10 EAVA or PCVA neonatal causes and zero to three of 12 child causes. CSMF accuracy for facility compared to community deaths in the four countries ranged from 0.74 to 0.87 for neonates and 0.85 to 0.95 for 1-59-month-olds. Crude CSMF accuracy in the prediction models averaged 0.86 to 0.88 for neonates and 0.93 for 1-59-month-olds. Adjusted random forest prediction models increased average CSMF accuracy for neonates to, at most, 0.90, based on small increases in all countries.Conclusions: There were few differences in facility and community causes of neonatal and 1-59-month-old deaths in the four countries, and it was possible to project the population CSMF from facility deaths with accuracy greater than the validity of verbal autopsy diagnoses. Confirmation of these findings in additional settings would warrant research into how medical causes of deaths in a representative sample of health facilities can be utilized to estimate the population causes of child death. [ABSTRACT FROM AUTHOR]

Background: Diarrhea remains a high burden disease, responsible for nine percent of deaths in children under five globally. We analyzed diarrhea management practices in young children and their association with the source of care.Methods: We used Demographic and Health Survey data from 12 countries in sub-Saharan Africa with high burdens of childhood diarrhea. We classified the quality of diarrhea management practices as good, fair, or poor based on mothers' reports for children with diarrhea, using WHO/UNICEF recommendations for appropriate treatment. We described the prevalence of diarrhea management by type and assessed the association between good management and source of care, adjusting for potential confounders.Results: Prevalence of good diarrhea management is low in 11 of the 12 analyzed surveys, varying from 17 % in Cote d'Ivoire to 38 % in Niger. The exception is Sierra Leone, where prevalence of good practice is 67 %. Prevalence of good management was low even among children taken to health facilities [median 52 %, range: 34-64 %]. Diarrhea careseeking from health facilities or community providers was associated with higher odds of good management than care from traditional/informal sources or no care. Careseeking from facilities did not result systematically in a higher likelihood of good diarrhea management than care from community providers. The odds of good diarrhea management were similar for community versus facility providers in six countries, higher in community than facility providers in two countries, and higher in facility than in community providers in four countries.Conclusion: Many children's lives can be saved with correct management of childhood diarrhea. Too many children are not receiving adequate care for diarrhea in high-burden sub-Saharan African countries, even among those seen in health facilities. Redoubling efforts to increase careseeking and improve quality of care for childhood diarrhea in both health facilities and at community level is an urgent priority. [ABSTRACT FROM AUTHOR]

Background: In Mozambique, the Countrywide Mortality Surveillance for Action (COMSA) Program implemented a child mortality surveillance to strengthen vital events registration (pregnancies, births, and deaths) and investigate causes of death using verbal autopsies. In Quelimane district, in addition to the abovementioned cause of death determination approaches, minimally invasive tissue sampling (MITS) was performed on deceased children <5years of age. This study focused on understanding deceased children parents' and caretakers' experiences of the consent process to perform MITS in order to contribute to the improvement of approaches to cause of death investigation and inform efforts to maximize acceptability of mortality surveillance activities. Methods: A qualitative study was conducted in six urban and semi-urban communities in Quelimane district. A total of 40 semi-structured interviews with family members of deceased children and 50 non-participant observations of the consent process were conducted to explore their experience with informed consent request to perform MITS on their child. Data analysis of the interviews and observations was thematic, being initially deductive (predetermined codes) followed by the generation of new codes according to the data (inductive).The Consolidated criteria for reporting qualitative research (COREQ) guidelines for reporting qualitative studies were performed. Findings: Although most participants consented to the performance of MITS on their deceased child, some stated they had not fully understood the MITS procedure despite the informed consent process due to unclear information and their state of mind after their loss. Consenting to MITS and doing so with family members disagreeing were also identified as stress-enhancing factors. Participants also described dissatisfaction of family members, resulting from the condition of the body delivered after tissue collection. In addition, the waiting time to receive the body and resulting delays for the funeral were considered additional factors that may increase stress and compromise the acceptability of MITS. Conclusion: Family experiences were influenced by operational and logistical issues linked to the procedure itself and by it being in tension with social and cultural issues, which caused stress and discontentment on parents and caretakers of deceased children. The main factors that contributed to the experience of going through the MITS process were the state of mind after the death, complex decision making processes within the family, washing of the body for purification after MITS and seepage, and limited understanding of consent for MITS. When requesting consent for MITS, emphasis should be placed on transmitting clear and understandable information about MITS procedures to participants. [ABSTRACT FROM AUTHOR]

Background: Use of a standardized verbal autopsy (VA) questionnaire, such as the World Health Organization (WHO) instrument, can improve the consistency and reliability of the data it collects. Systematically revising a questionnaire, however, requires evidence about the performance of its questions. The purpose of this investigation was to use a mixed methods approach to evaluate the performance of questions related to 14 previously reported issues in the 2016 version of the WHO questionnaire, where there were concerns of potential confusion, redundancy, or inability of the respondent to answer the question. The results from this mixed methods analysis are discussed across common themes that may have contributed to the underperformance of questions and have been compiled to inform decisions around the revision of the current VA instrument. Methods: Quantitative analysis of 19,150 VAs for neonates, children, and adults from five project teams implementing VAs predominately in Sub-Saharan Africa included frequency distributions and cross-tabulations to evaluate response patterns among related questions. The association of respondent characteristics and response patterns was evaluated using prevalence ratios. Qualitative analysis included results from cognitive interviewing, an approach that provides a detailed understanding of the meanings and processes that respondents use to answer interview questions. Cognitive interviews were conducted among 149 participants in Morocco and Zambia. Findings from the qualitative and quantitative analyses were triangulated to identify common themes. Results: Four broad themes contributing to the underperformance or redundancy within the instrument were identified: question sequence, overlap within the question series, questions outside the frame of reference of the respondent, and questions needing clarification. The series of questions associated with one of the 14 identified issues (the series of questions on injuries) related to question sequence; seven (tobacco use, sores, breast swelling, abdominal problem, vomiting, vaccination, and baby size) demonstrated similar response patterns among questions within each series capturing overlapping information. Respondent characteristics, including relationship to the deceased and whether or not the respondent lived with the deceased, were associated with differing frequencies of non-substantive responses in three question series (female health related issues, tobacco use, and baby size). An inconsistent understanding of related constructs was observed between questions related to sores/ulcers, birth weight/baby size, and diagnosis of dementia/presence of mental confusion. An incorrect association of the intended construct with that which was interpreted by the respondent was observed in the medical diagnosis question series. Conclusions: In this mixed methods analysis, we identified series of questions which could be shortened through elimination of redundancy, series of questions requiring clarification due to unclear constructs, and the impact of respondent characteristics on the quality of responses. These changes can lead to a better understanding of the question constructs by the respondents, increase the acceptance of the tool, and improve the overall accuracy of the VA instrument. [ABSTRACT FROM AUTHOR]

Background: While community health workers are being recognized as an integral work force with growing responsibilities, increased demands can potentially affect motivation and performance. The ubiquity of mobile phones, even in hard-to-reach communities, has facilitated the pursuit of novel approaches to support community health workers beyond traditional modes of supervision, job aids, in-service training, and material compensation. We tested whether supportive short message services (SMS) could improve reporting of pregnancies and pregnancy outcomes among community health workers (Health Surveillance Assistants, or HSAs) in Malawi. Methods and Findings: We designed a set of one-way SMS that were sent to HSAs on a regular basis during a 12-month period. We tested the effectiveness of the cluster-randomized intervention in improving the complete documentation of a pregnancy. We defined complete documentation as a pregnancy for which a specific outcome was recorded. HSAs in the treatment group received motivational and data quality SMS. HSAs in the control group received only motivational SMS. During baseline and intervention periods, we matched reported pregnancies to reported outcomes to determine if reporting of matched pregnancies differed between groups and by period. The trial is registered as ISCTRN24785657. Conclusions: Study results show that the mHealth intervention improved the documentation of matched pregnancies in both the treatment (OR 1.31, 95% CI: 1.10–1.55, p<0.01) and control (OR 1.46, 95% CI: 1.11–1.91, p = 0.01) groups relative to the baseline period, despite differences in SMS content between groups. The results should be interpreted with caution given that the study was underpowered. We did not find a statistically significant difference in matched pregnancy documentation between groups during the intervention period (OR 0.94, 95% CI: 0.63–1.38, p = 0.74). mHealth applications have the potential to improve the tracking and data quality of pregnancies and pregnancy outcomes, particularly in low-resource settings. [ABSTRACT FROM AUTHOR]

Background: The benefits of universal access to voluntary contraception have been widely documented in terms of maternal and newborn survival, women's empowerment, and human capital. Given population dynamics, the choices and opportunities adolescents have in terms of access to sexual and reproductive health information and services could significantly affect the burden of diseases and nations' human capital. Objectives: The objectives of this paper are to assess the patterns and trends of modern contraception use among sexually active adolescents by socio-economic characteristics and by birth spacing and parity; to explore predictors of use of modern contraception in relation to the health system; and to discuss implications of the findings for family planning policy and programmes. Design: Data are from the last three Demographic and Health Surveys of Ethiopia, Burkina Faso, and Nigeria. The descriptive analysis focused on sexually active adolescents (15- to 19-year age group), used modern contraception as the dependent variable, and a series of contact points with the health system (antenatal care, institutional delivery, postnatal care, immunisation) as covariates. The multivariate analysis used the same covariates, adjusting for socio-economic variables. Results: There are two different groups of sexually active adolescents: those married or in a union with very low use of modern contraception and lower socio-economic status, and those unmarried, among whom nearly 50% are using modern contraception. Younger adolescents have lower modern contraceptive prevalence. There are significant inequality issues in modern contraception use by education, residence, and wealth quintile. However, while there was no significant progress in Burkina Faso and Nigeria, the data in Ethiopia point to a significant and systematic reduction of inequalities. The narrowing of the equity gap was most notable for childbearing adolescents with no education or living in rural areas. In the three countries, after adjusting for socio-economic variables, the strongest factors affecting modern contraception use among childbearing adolescents were marriage and child immunisation. Conclusions: Addressing child marriage and adopting effective policies and strategies to reach married adolescents are critical for improving empowerment and human capital of adolescent girls. The reduction of the equity gap in coverage in Ethiopia warrants further studies and documentation. The results suggest a missed opportunity for maternal and newborn and family planning integration. [ABSTRACT FROM AUTHOR]

Background: In sub-Saharan Africa, few studies have stressed the importance of spatial heterogeneity analysis in modern contraceptive use and the relationships with high-risk births. Objective: This paper aims to analyse the association between modern contraceptive use, distribution of birth risk, and under-five child mortality at both national and regional levels in Burkina Faso. Design: The last three Demographic and Health Surveys - conducted in Burkina Faso in 1998, 2003, and 2010 - enabled descriptions of differentials, trends, and associations between modern contraceptive use, total fertility rates (TFR), and factors associated with high-risk births and under-five child mortality. Multivariate models, adjusted by covariates of cultural and socio-economic background and contact with health system, were used to investigate the relationship between birth risk factors and modern contraceptive prevalence rates (mCPR). Results: Overall, Burkina Faso's modern contraception level remains low (15.4% in 2010), despite significant increases during the last decade. However, there are substantial variations in mCPR by region, and health facility contact was positively associated with mCPR increase. Women's fertility history and cultural and socio-economic background were also significant factors in predicting use of modern contraception. Low modern contraceptive use is associated with higher birth risks and increased child mortality. This association is stronger in the Sahel, Est, and Sud-Ouest regions. Even though all factors in high-risk births were associated with under-five mortality, it should be stressed that short birth spacing ranked as the highest risk in relation to mortality of children. Conclusions: Programmes that target sub-national differentials and leverage women's health system contacts to inform women about family planning opportunities may be effective in improving coverage, quality, and equity of modern contraceptive use. Improving the demand satisfied for modern contraception may result in a reduction in the percentage of women experiencing high-risk births and may also reduce child mortality. [ABSTRACT FROM AUTHOR]

Background: Routinely collected health facility data usually captured and stored in Health Management Information Systems (HMIS) are potential sources of data for frequent and local disaggregated estimation of the coverage of reproductive, maternal, newborn, and child health interventions (RMNCH), but have been under-utilized due to concerns over data quality. We reviewed methods for estimation of national or subnational coverage of RMNCH interventions using HMIS data exclusively or in conjunction with survey data from low- and middle-income countries (LMICs).Methods: We conducted a comprehensive review of studies indexed in PubMed and Scopus to identify potential papers based on predefined search terms. Two reviewers screened the papers using defined inclusion and exclusion criteria. Following sequences of title, abstract and full paper reviews, we retained 18 relevant papers.Results: 12 papers used only HMIS data and 6 used both HMIS and survey data. There is enormous lack of standards in the existing methods for estimating RMNCH intervention coverage; all appearing to be highly author dependent. The denominators for coverage measures were estimated using census, non-census and combined projection-based methods. No satisfactory methods were found for treatment-based coverage indicators for which the estimation of target population requires the population prevalence of underlying conditions. The estimates of numerators for the coverage measures were obtained from the count of users or visits and in some cases correction for completeness of reporting in the HMIS following an assessment of data quality.Conclusions: Standard methods for correcting numerators from HMIS data for accurate estimation of coverage of RMNCH interventions are needed to expand the use of these data. More research and investments are required to improve denominators for health facility-derived statistics. Improvement in routine data quality and analytical methods would allow for timely estimation of RMNCH intervention coverage at the national and subnational levels. [ABSTRACT FROM AUTHOR]

Background: Kangaroo mother care (KMC) reduces mortality among stable neonates ≤2000 g. Lack of data tracking coverage and quality of KMC in both surveys and routine information systems impedes scale-up. This paper evaluates KMC measurement as part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study.Methods: The EN-BIRTH observational mixed-methods study was conducted in five hospitals in Bangladesh, Nepal and Tanzania from 2017 to 2018. Clinical observers collected time-stamped data as gold standard for mother-baby pairs in KMC wards/corners. To assess accuracy, we compared routine register-recorded and women's exit survey-reported coverage to observed data, using different recommended denominator options (≤2000 g and ≤ 2499 g). We analysed gaps in quality of provision and experience of KMC. In the Tanzanian hospitals, we assessed daily skin-to-skin duration/dose and feeding frequency. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine register design, filling and use.Results: Among 840 mother-baby pairs, compared to observed 100% coverage, both exit-survey reported (99.9%) and register-recorded coverage (92.9%) were highly valid measures with high sensitivity. KMC specific registers outperformed general registers. Enablers to register recording included perceptions of data usefulness, while barriers included duplication of data elements and overburdened health workers. Gaps in KMC quality were identified for position components including wearing a hat. In Temeke Tanzania, 10.6% of babies received daily KMC skin-to-skin duration/dose of ≥20 h and a further 75.3% received 12-19 h. Regular feeding ≥8 times/day was observed for 36.5% babies in Temeke Tanzania and 14.6% in Muhimbili Tanzania. Cup-feeding was the predominant assisted feeding method. Family support during admission was variable, grandmothers co-provided KMC more often in Bangladesh. No facility arrangements for other family members were reported by 45% of women at exit survey.Conclusions: Routine hospital KMC register data have potential to track coverage from hospital KMC wards/corners. Women accurately reported KMC at exit survey and evaluation for population-based surveys could be considered. Measurement of content, quality and experience of KMC need consensus on definitions. Prioritising further KMC measurement research is important so that high quality data can be used to accelerate scale-up of high impact care for the most vulnerable. [ABSTRACT FROM AUTHOR]

Background: Immediate newborn care (INC) practices, notably early initiation of breastfeeding (EIBF), are fundamental for newborn health. However, coverage tracking currently relies on household survey data in many settings. "Every Newborn Birth Indicators Research Tracking in Hospitals" (EN-BIRTH) was an observational study validating selected maternal and newborn health indicators. This paper reports results for EIBF.Methods: The EN-BIRTH study was conducted in five public hospitals in Bangladesh, Nepal, and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data on EIBF and INC practices (skin-to-skin within 1 h of birth, drying, and delayed cord clamping). To assess validity of EIBF measurement, we compared observation as gold standard to register records and women's exit-interview survey reports. Percent agreement was used to assess agreement between EIBF and INC practices. Kaplan Meier survival curves showed timing. Qualitative interviews were conducted to explore barriers/enablers to register recording.Results: Coverage of EIBF among 7802 newborns observed for ≥1 h was low (10.9, 95% CI 3.8-21.0). Survey-reported (53.2, 95% CI 39.4-66.8) and register-recorded results (85.9, 95% CI 58.1-99.6) overestimated coverage compared to observed levels across all hospitals. Registers did not capture other INC practices apart from breastfeeding. Agreement of EIBF with other INC practices was high for skin-to-skin (69.5-93.9%) at four sites, but fair/poor for delayed cord-clamping (47.3-73.5%) and drying (7.3-29.0%). EIBF and skin-to-skin were the most delayed and EIBF rarely happened after caesarean section (0.5-3.6%). Qualitative findings suggested that focusing on accuracy, as well as completeness, contributes to higher quality with register reporting.Conclusions: Our study highlights the importance of tracking EIBF despite measurement challenges and found low coverage levels, particularly after caesarean births. Both survey-reported and register-recorded data over-estimated coverage. EIBF had a strong agreement with skin-to-skin but is not a simple tracer for other INC indicators. Other INC practices are challenging to measure in surveys, not included in registers, and are likely to require special studies or audits. Continued focus on EIBF is crucial to inform efforts to improve provider practices and increase coverage. Investment and innovation are required to improve measurement. [ABSTRACT FROM AUTHOR]

Objective To investigate whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions. Methods We analysed survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions, in which at least two surveys had been conducted since 1995. We calculated the composite coverage index, a function of essential maternal and child health intervention parameters. We adopted the wealth index, divided into quintiles from poorest to wealthiest, to investigate wealth-related inequalities in coverage. We quantified trends with time by calculating average annual change in index using a least-squares weighted regression. We calculated population attributable risk to measure the contribution of wealth to the coverage index. Findings We noted large differences between the four regions, with a median composite coverage index ranging from 50.8% for West Africa to 75.3% for Southern Africa. Wealth-related inequalities were prevalent in all subregions, and were highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as we observed a higher coverage in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and we found no evidence of inequality reduction in Central Africa. Conclusion Our data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability. [ABSTRACT FROM AUTHOR]

Background: The healthcare system in Mozambique is striving to reduce the high maternal and child mortality rates and stay on par with the Sustainable Development Goals (SDG 3.1). A key strategy to curb maternal and child mortality is to promote the use of professional childbirth services proven to be highly effective in averting maternal deaths. Currently, little is known about the use of childbirth services in Mozambique. The present study investigated the prevalence of professional healthcare delivery services and identified their sociodemographic correlates. Methods: This study used cross-sectional data on 7080 women aged 15–49 years who reported having a child during the past 5 years. The data were collected from the 2011Mozambique Demographic and Health Survey. The outcome variables were the choice of childbirth services that included 1) place of delivery (respondent's home versus health facility), and mode of delivery (caesarean section versus vaginal birth). Data were analyzed using descriptive and multivariate regression methods. Results: The prevalence of health facility and C-section delivery was 70.7 and 5.6%, respectively. There was a difference in the use of professional birthing services between urban and rural areas. Having better educational status and living in households of higher wealth quintiles showed a positive association with the use of facility delivery services among both urban and rural residents. Regarding ethnicity, women of Portugais [2.688,1.540,4.692], Cindau [1.876,1.423,2.474] and Xichangana [1.557,1.215,1.996] had relatively higher odds of using facility delivery services than others. Antenatal care (ANC) visits were a significant predictor of facility delivery services both in urban [OR = 1.655, 95%CI = 1.235,2.218] and rural [OR = 1.265, 95%CI = 1.108,1.445] areas. Among rural women, ANC visit was a significant predictor of C-section delivery [1.570,1.042,2.365]. Conclusion: More than a quarter of the women in Mozambique were not using health facility delivery services, with the prevalence being noticeably lower in the rural areas. [ABSTRACT FROM AUTHOR]

Background: Ensuring equitable access to maternal health care including antenatal, delivery, postnatal services and fertility control methods, is one of the most critical challenges for public health sector. There are significant disparities in maternal health care indicators across many geographical locations, maternal, economic, socio-demographic factors in many countries in sub-Sahara Africa. In this study, we comparatively explored the utilization level of maternal health care, and examined disparities in the determinants of major maternal health outcomes.Methods: This paper used data from two rounds of Benin Demographic and Health Survey (BDHS) to examine the utilization and disparities in factors of maternal health care indicators using logistic regression models. Participants were 17,794 and 16,599 women aged between15-49 years in 2006 and 2012 respectively. Women's characteristics were reported in percentage, mean and standard deviation.Results: Mean (±SD) age of the participants was 29.0 (±9.0) in both surveys. The percentage of at least 4 ANC visits was approximately 61% without any change between the two rounds of surveys, facility based delivery was 93.5% in 2012, with 4.9% increase from 2006; postnatal care was currently 18.4% and contraceptive use was estimated below one-fifth. The results of multivariable logistic regression models showed disparities in maternal health care service utilization, including antenatal care, facility-based delivery, postnatal care and contraceptive use across selected maternal factors. The current BHDS showed age, region, religion were significantly associated with maternal health care services. Educated women, those from households of high wealth index and women currently working were more likely to utilize maternal health care services, compared to women with no formal education, from poorest households or not currently employed. Women who watch television (TV) were 1.31 (OR = 1.31; 95% CI = 1.13-1.52), 1.69 (OR = 1.69; 95% CI = 1.20-2.37) and 1.38 (OR = 1.38; 95% CI = 1.16-1.65) times as likely to utilize maternal health care services after adjusting for other covariates.Conclusion: The findings would guide stakeholders to address inequalities in maternal health care services. More so, health care programmes and policies should be strengthened to enhance accessibility as well as improve the utilization of maternal care services, especially for the disadvantaged, uneducated and those who live in hard-to-reach rural areas in Benin. The Benin government needs to create strategies that cover both the supply and demand side factors at attain the universal health coverage. [ABSTRACT FROM AUTHOR]

Background: Obstetric complications and maternal deaths can be prevented through safe delivery process. Facility based delivery significantly reduces maternal mortality by increasing women’s access to skilled personnel attendance. However, in sub-Saharan Africa, most deliveries take place without skilled attendants and outside health facilities. Utilization of facility-based delivery is affected by socio-cultural norms and several other factors including cost, long distance, accessibility and availability of quality services. This study examined country-level variations of the self-reported causes of not choosing to deliver at a health facility. Methods: Cross-sectional data on 37,086 community dwelling women aged between 15–49 years were collected from DHS surveys in Ethiopia (n = 13,053) and Nigeria (n = 24,033). Outcome variables were the self-reported causes of not delivering at health facilities which were regressed against selected sociodemographic and community level determinants. In total eight items complaints were identified for non-use of facility delivery: 1) Cost too much 2) Facility not open, 3) Too far/no transport, 4) don’t trust facility/poor service, 5) No female provider, 6) Husband/family didn’t allow, 7) Not necessary, 8) Not customary. Multivariable regression methods were used for measuring the associations. Results: In both countries a large proportion of the women mentioned facility delivery as not necessary, 54.9% (52.3–57.9) in Nigeria and 45.4% (42.0–47.5) in Ethiopia. Significant urban-rural variations were observed in the prevalence of the self-reported causes of non-utilisation. Women in the rural areas are more likely to report delivering at health facility as not customary/not necessary and healthy facility too far/no transport. However, urban women were more likely to complain that husband/family did not allow and that the costs were too high. Conclusion: Women in the rural were more likely to regard facility delivery as unnecessary and complain about transportation and financial difficulties. In order to achieving the maternal mortality related targets, addressing regional disparities in accessing maternal healthcare services should be regarded as a priority of health promotion programs in Nigeria and Ethiopia. [ABSTRACT FROM AUTHOR]

Background: Global stunting prevalence has been nearly halved between 1990 and 2016, but it remains unclear whether this decline has benefited poor and rural populations within low- and middle-income countries (LMICs).Objective: We assessed time trends in stunting among children <5 y of age (under-5) according to household wealth and place of residence in 67 LMICs.Methods: Stunting prevalence was analyzed in 217 nationally representative Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 67 countries with ≥2 surveys between 1993 and 2014. National estimates were stratified by wealth and area of residence, comparing the poorest 40% with the wealthiest 60%, and those residing in urban and rural areas. Time trends were calculated for LMICs by using multilevel regression models weighted by under-5 population, with stratification by wealth and by residence. Trends in absolute (slope index of inequality; SII) and relative (concentration index; CIX) inequalities were calculated.Results: Mean prevalences in 1993 were 53.7% in low-income and 48.2% in middle-income countries, with annual average linear declines of 0.76 and 0.72 percentage points (pp), respectively. Although similar slopes of declines were observed for the poorest 40% and wealthiest 60% groups in all countries (0.78 and 0.74 pp, respectively), absolute and relative inequalities increased over time in low-income countries (SII increased from -19.3% in 1993 to -23.7% in 2014 and CIX increased from -6.2% to -10.8% in the same period). In middle-income countries, socioeconomic inequalities remained stable. Overall, stunting prevalence decreased more rapidly among rural than for urban children (0.78 and 0.55 pp, respectively).Conclusions: The prevalence of stunting is decreasing. Poor-rich gaps are stable in middle-income countries and slightly increasing in low-income countries. Rural-urban inequalities are decreasing over time. [ABSTRACT FROM AUTHOR]

Background: Reducing neonatal and child mortality is a key component of the health-related sustainable development goal (SDG), but most low and middle income countries lack data to monitor child mortality on an annual basis. We tested a mortality monitoring system based on the continuous recording of pregnancies, births and deaths by trained community-based volunteers (CBV). Methods and findings: This project was implemented in 96 clusters located in three districts of the Northern Region of Ghana. Community-based volunteers (CBVs) were selected from these clusters and were trained in recording all pregnancies, births, and deaths among children under 5 in their catchment areas. Data collection lasted from January 2012 through September 2013. All CBVs transmitted tallies of recorded births and deaths to the Ghana Birth and deaths registry each month, except in one of the study districts (approximately 80% reporting). Some events were reported only several months after they had occurred. We assessed the completeness and accuracy of CBV data by comparing them to retrospective full pregnancy histories (FPH) collected during a census of the same clusters conducted in October-December 2013. We conducted all analyses separately by district, as well as for the combined sample of all districts. During the 21-month implementation period, the CBVs reported a total of 2,819 births and 137 under-five deaths. Among the latter, there were 84 infant deaths (55 neonatal deaths and 29 post-neonatal deaths). Comparison of the CBV data with FPH data suggested that CBVs significantly under-estimated child mortality: the estimated under-5 mortality rate according to CBV data was only 2/3 of the rate estimated from FPH data (95% Confidence Interval for the ratio of the two rates = 51.7 to 81.4). The discrepancies between the CBV and FPH estimates of infant and neonatal mortality were more limited, but varied significantly across districts. Conclusions: In northern Ghana, a community-based data collection systems relying on volunteers did not yield accurate estimates of child mortality rates. Additional implementation research is needed to improve the timeliness, completeness and accuracy of such systems. Enhancing pregnancy monitoring, in particular, may be an essential step to improve the measurement of neonatal mortality. [ABSTRACT FROM AUTHOR]

Improving the counting of stillbirths and neonatal deaths is important to tracking Sustainable Development Goal 3.2 and improving vital statistics in low- and middle-income countries (LMICs). However, the validity of self-reported stillbirths and neonatal deaths in surveys is often threatened by misclassification errors between the two birth outcomes. We assessed the extent and correlates of stillbirths being misclassified as neonatal deaths by comparing two recent and linked population surveys conducted in Malawi, one being a full birth history (FBH) survey, and the other a follow-up verbal/social autopsy (VASA) survey. We found that one-fifth of 365 neonatal deaths identified in the FBH survey were classified as stillbirths in the VASA survey. Neonatal deaths with signs of movements in the last few days before delivery reported were less likely to be misclassified stillbirths (OR = 0.08, p<0.05). Having signs of birth injury was found to be associated with higher odds of misclassification (OR = 6.17, p<0.05). We recommend replicating our study with larger sample size in other settings. Additionally, we recommend conducting validation studies to confirm accuracy and completeness of live births and neonatal deaths reported in household surveys with events reported in a full birth history and the extent of underestimation of neonatal mortality resulting from misclassifications. Questions on fetal movement, signs of life at delivery and improved probing among older mother may be useful to improve accuracy of reported events. [ABSTRACT FROM AUTHOR]

An estimated 2.6 million third trimester stillbirths occurred in 2015 (uncertainty range 2.4-3.0 million). The number of stillbirths has reduced more slowly than has maternal mortality or mortality in children younger than 5 years, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan has the target of 12 or fewer stillbirths per 1000 births in every country by 2030. 94 mainly high-income countries and upper middle-income countries have already met this target, although with noticeable disparities. At least 56 countries, particularly in Africa and in areas affected by conflict, will have to more than double present progress to reach this target. Most (98%) stillbirths are in low-income and middle-income countries. Improved care at birth is essential to prevent 1.3 million (uncertainty range 1.2-1.6 million) intrapartum stillbirths, end preventable maternal and neonatal deaths, and improve child development. Estimates for stillbirth causation are impeded by various classification systems, but for 18 countries with reliable data, congenital abnormalities account for a median of only 7.4% of stillbirths. Many disorders associated with stillbirths are potentially modifiable and often coexist, such as maternal infections (population attributable fraction: malaria 8.0% and syphilis 7.7%), non-communicable diseases, nutrition and lifestyle factors (each about 10%), and maternal age older than 35 years (6.7%). Prolonged pregnancies contribute to 14.0% of stillbirths. Causal pathways for stillbirth frequently involve impaired placental function, either with fetal growth restriction or preterm labour, or both. Two-thirds of newborns have their births registered. However, less than 5% of neonatal deaths and even fewer stillbirths have death registration. Records and registrations of all births, stillbirths, neonatal, and maternal deaths in a health facility would substantially increase data availability. Improved data alone will not save lives but provide a way to target interventions to reach more than 7000 women every day worldwide who experience the reality of stillbirth. [ABSTRACT FROM AUTHOR]

Background: Most low- and middle-income countries lack fully functional civil registration systems. Measures of under-five mortality are typically derived from periodic household surveys collecting detailed information from women on births and child deaths. However, such surveys are expensive and are not appropriate for monitoring short-term changes in child mortality. We explored and tested the validity of two new analysis methods for less-expensive summary histories of births and child deaths for such monitoring in five African countries. Methods and Findings: The first method we explored uses individual-level survey data on births and child deaths to impute full birth histories from an earlier survey onto summary histories from a more recent survey. The second method uses cohort changes between two surveys in the average number of children born and the number of children dead by single year of age to estimate under-five mortality for the inter-survey period. The first method produces acceptable annual estimates of under-five mortality for two out of six applications to available data sets; the second method produced an acceptable estimate in only one of five applications, though none of the applications used ideal data sets. Conclusions: The methods we tested were not able to produce consistently good quality estimates of annual under-five mortality from summary birth history data. The key problem we identified was not with the methods themselves, but with the underlying quality of the summary birth histories. If summary birth histories are to be included in general household surveys, considerable emphasis must be placed on quality control. [ABSTRACT FROM AUTHOR]

The author calls for a sustained and improved data system to measure interventions in reducing maternal, newborn and child mortality. Topics he covered include the importance for robust interconnected system of data collection and use for health workers, programme managers, and global actors, examples of household survey programmes which are considered indicators of progress in data collection and the key principles of an envisioned measurement system.

Background: Evidence shows that family planning contributes to the decline in child mortality by decreasing the proportions of births that are considered high risk. The main objective of the present analysis was to examine the trends in use of modern contraceptives and their relationship with total fertility rate (TFR) and distribution of births by demographic risk factors as defined by mother's age, birth interval, and birth order at the sub-national level in Ethiopia. Design: Analyses used data from three Demographic and Health Surveys in Ethiopia (2000, 2005, and 2011), which are nationally representative data collected through questionnaire-based interviews from women 15-49 using a stratified, two-stage cluster sampling. First, we examined the trends of and relationship between TFR (in the 3 years before each survey) and modern contraceptive use among currently married women in all administrative regions over the time period 2000-2011 using linear regression analysis. We also examined the relationship between birth risks and under-five mortality using the no-risk group as a reference. Finally, multiple logistic regression analysis was performed to estimate the relationship between the effect of being a resident in one of the regions and having an avoidable birth risk (which includes births to mothers younger than 18 and older than 34 years, birth interval of less than 24 months and birth order higher than third) after adjusting for select covariates including wealth, educational status, residence, religion and exposure to family planning information. Results: Sub-national-level regression analysis showed an inverse relationship between modern contraceptive use among married women and the TFR, with an average decrease of TFR by one child per woman associated with a 13 percentage point increase in modern contraceptive use between 2000 and 2011. A high percentage of births in Ethiopia (62%) fall in one of the risk categories (excluding first births), with wide regional variation from 55% in Gambela to 72% in the Somali region. The multivariate analysis showed women living in the Somali, Afar and Benishangul-Gumuz regions had significantly higher odds of having avoidable birth risk compared to those in Addis Ababa after controlling for observed covariates. The trend analysis showed there was a significant drop in the proportion of births from women above 34 years between 2000 and 2011. There was no significant decline in births to women less than 18 years between 2000 and 2011. Conclusions: A majority of births in Ethiopia fall in one of the risk categories, with substantial region-to-region variation in the percentage of births with avoidable risk factors, Somali and Afar having the highest burden. The analysis indicated that births in the three regions had significantly higher odds of having one of the avoidable risk factors compared to Addis Ababa, and we suggest family planning programmes need to identify differentials of modern contraceptive use at the sub-national level in order to better address coverage and equity issues. [ABSTRACT FROM AUTHOR]

Background: Family planning expansion has been identified as an impetus to harnessing Nigeria's demographic dividend. However, there is a need for data to address pockets of inequality and to better understand cultural and social factors affecting contraceptive use and health benefits. This paper contributes to addressing these needs by providing evidence on the trends and sub-national patterns of modern contraceptive prevalence in Nigeria and the association between contraceptive use and high-risk births in Nigeria. Design: The study utilised women's data from the last three Demographic and Health Surveys (2003, 2008, and 2013) in Nigeria. The analysis involved descriptive, bivariate, and multivariate analyses. The multivariate analyses were performed to examine the relationship between high-risk births and contraceptive use. Associations were examined using Poisson regression. Results: Findings showed that respondents in avoidable high-risk birth categories were less likely to use contraceptives compared to those at no risk [rate ratio 0.82, confidence interval: 0.76-0.89, p <0.001]. Education and wealth index consistently predicted significant differences in contraceptive use across the models. Conclusions:. The results of this study suggest that women in the high-risk birth categories were significantly less likely to use a modern method of contraception relative to those categorised as having no risk. However, there are huge sub-national variations at regional and state levels in contraceptive prevalence and subsequent high-risk births. These results further strengthen evidence-based justification for increased investments in family planning programmes at the state and regional levels, particularly regions and states with high unmet needs for family planning. [ABSTRACT FROM AUTHOR]

The world has made enormous progress in improving child survival since 1990, reducing the under-five mortality rate by nearly half from 90 to 46 deaths per 1,000 live births in 2013. Currently, the global under-five mortality rate is falling faster than at any other time over the past two decades. Yet, progress is insufficient to meet the Millennium Development Goal 4 (MDG 4) which calls for reducing the under-five mortality rate by two-thirds between 1990 and 2015. If current trends continue in all countries, the world will not meet the target until 2026, 11 years behind schedule. To accelerate progress in child survival, focusing on the newborn is critical since the share of all under five deaths occurring in the neonatal period (the first 28 days of life) is increasing. Globally, 44 per cent of the 6.3 million under-five deaths occurred in the neonatal period in 2013. Many of these deaths are easily preventable with simple, cost-effective interventions administered before, during and immediately after birth. However, UNICEF's analysis reveals a remarkably high degree of variability in the utilization and quality of services provided to pregnant women and their babies. Furthermore, quality care is grossly lacking even for babies and mothers in contact with the health system. The latest levels and trends in child mortality as well as the coverage and quality of key maternal and newborn care from pregnancy through childbirth and the postnatal period are the subject of the new UNICEF report Committing to Child Survival: A Promise Renewed Progress Report 2014 released recently in September. [ABSTRACT FROM AUTHOR]

Family planning expansion has been identified as an impetus to harnessing Nigeria's demographic dividend. However, there is a need for data to address pockets of inequality and to better understand cultural and social factors affecting contraceptive use and health benefits. This paper contributes to addressing these needs by providing evidence on the trends and sub-national patterns of modern contraceptive prevalence in Nigeria and the association between contraceptive use and high-risk births in Nigeria. The study utilised women's data from the last three Demographic and Health Surveys (2003, 2008, and 2013) in Nigeria. The analysis involved descriptive, bivariate, and multivariate analyses. The multivariate analyses were performed to examine the relationship between high-risk births and contraceptive use. Associations were examined using Poisson regression. Findings showed that respondents in avoidable high-risk birth categories were less likely to use contraceptives compared to those at no risk [rate ratio 0.82, confidence interval: 0.76–0.89, p<0.001]. Education and wealth index consistently predicted significant differences in contraceptive use across the models. The results of this study suggest that women in the high-risk birth categories were significantly less likely to use a modern method of contraception relative to those categorised as having no risk. However, there are huge sub-national variations at regional and state levels in contraceptive prevalence and subsequent high-risk births. These results further strengthen evidence-based justification for increased investments in family planning programmes at the state and regional levels, particularly regions and states with high unmet needs for family planning. [ABSTRACT FROM AUTHOR]