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Home visits for pregnancy and postnatal care were endorsed by the WHO and partners as a complementary strategy to facility-based care to reduce newborn and maternal mortality. This article aims to synthesise findings and implications from the economic analyses of community-based maternal and newborn care (CBMNC) evaluations in seven countries. The evaluations included five cluster randomized trials (Ethiopia, Ghana, South Africa, Tanzania, Uganda) and programmatic before/after assessments (Bolivia, Malawi). The economic analyses were undertaken using a standardized, comparable methodology the 'Cost of Integrated Newborn Care' Tool, developed by the South African Medical Research Council, with Saving Newborn Lives and a network of African economists. The main driver of costs is the number of community health workers (CHWs), determined by their time availability, as fixed costs per CHW (equipment, training, salary/stipend, supervision and management), independent from the level of activity (number of mothers visited) represented over 96% of economic and financial costs in five of the countries. Unpaid volunteers are not necessarily a cheap option. An integrated programme with multi-purpose paid workers usually has lower costs per visit but requires innovative management, including supervision to ensure that coverage, or quality of care are not compromised since these workers have many other responsibilities apart from maternal and newborn health. If CHWs reach 95% of pregnant women in a standardized 100 000 population, the additional financial cost in all cases would be under USD1 per capita. In five of the six countries, the programme would be highly cost-effective (cost per DALY averted

Community-based maternal and newborn care with home visits by community health workers (CHWs) are recommended by WHO to complement facility-based care. As part of multi-country economic and systems analyses, we aimed to compare the content and financial costs associated with equipping CHWs or 'home visit kits' from seven studies in Bolivia, Ethiopia, Ghana, Malawi, South Africa, Tanzania and Uganda. We estimated the equivalent annual costs (EACs) of home visit kits per CHW in constant 2015 USD. We estimated EAC at scale in a population of 100 000 assuming four home visits per mother during the pregnancy and postnatal period. All seven packages were designed for health promotion; six included clinical assessments and one included curative care. The items used by CHWs differed between countries, even for the same task. The EAC per home visit kit ranged from $15 in Tanzania to $116 in South Africa. For health promotion and preventive care, between 82 and 100% of the cost of CHW commodities did not vary with the number of home visits conducted; however, in Ethiopia, the majority of EAC associated with curative care varied with the number of visits conducted. The EAC of equipping CHWs to meet the needs of 95% of expectant mothers in a catchment area of 100 000 people was highest in Bolivia, $40 260 for 633 CHWs, due to mothers being in hard-to-reach areas with CHW conducting few visits per year per, and lowest in Tanzania ($2693 for 172 CHWs), due to the greater number of CHW visits per week and lower EAC of items. To inform and ensure sustainable implementation at scale, national discussions regarding the cadre of CHWs and their workload should also consider carefully the composition and cost of equipping CHWs to carry out their work effectively and efficiently.

OBJECTIVE:: To analyse trends in under-five mortality rate in South Africa (1990-2011), particularly the contribution of AIDS deaths. METHODS:: Three nationally-used models for estimating AIDS deaths in children were systematically reviewed. The model outputs were compared with under-five mortality rate estimates for South Africa from two global estimation models. All estimates were compared with available empirical data. RESULTS:: Differences between the models resulted in varying point estimates for under-five mortality but the trends were similar, with mortality increasing to a peak around 2005. The three models showing the contribution of AIDS suggest a maximum of 37-39% of child deaths were due to AIDS in 2004-2005 which has since declined. While the rate of progress from 1990 is not the 4.4% needed to meet Millennium Development Goal 4 for child survival, South Africa's average annual rate of under-five mortality decline between 2006 and 2011 was between 6.3%-10.2%. CONCLUSION:: In 2005, South Africa was one of only four countries globally with an under-five mortality rate higher than the 1990 Millennium Development Goal baseline. Over the past five years the country has achieved a rate of child mortality reduction exceeded by only three other countries. This rapid turnaround is likely due to scale up of prevention of mother-to-child transmission of HIV, and to a lesser degree, the expanded roll-out of antiretroviral therapy. Emphasis on these programmes must continue, but failure to address other aspects of care including integrated high quality maternal and neonatal care means that the decline in child mortality could stall.

The Uganda Newborn Study (UNEST) was a two-arm cluster Randomized Control Trial to study the effect of pregnancy and postnatal home visits by local community health workers called 'Village Health Teams' (VHT) coupled with health systems strengthening. To inform programme planning and decision making, additional economic and financial costs of community and facility components were estimated from the perspective of the provider using the Excel-based Cost of Integrating Newborn Care Tool. Additional costs excluded costs already paid by the government for the routine health system and covered design, set-up, and 1-year implementation phases. Improved efficiency was modelled by reducing the number of VHT per village from two to one and varying the number of home visits/mother, the programme's financial cost at scale was projected (population of 100 000). 92% of expectant mothers (n = 1584) in the intervention area were attended by VHTs who performed an average of three home visits per mother. The annualized additional financial cost of the programme was $83 360 of which 4% ($3266) was for design, 24% ($20 026) for set-up and 72% ($60 068) for implementation. 56% ($47 030) went towards health facility strengthening, whereas 44% ($36 330) was spent at the community level. The average cost/mother for the community programme, excluding one-off design costs, amounted to $22.70 and the average cost per home visit was $7.50. The additional cost of the preventive home visit programme staffed by volunteer VHTs represents $1.04 per capita, 1.8% of Uganda's public health expenditure per capita ($59.00). If VHTs were to spend an average of 6 h a week on the programme, costs per mother would drop to $13.00 and cost per home visit to $3.20, in a population of 100 000 at 95% coverage. Additional resources are needed to rollout the government's VHT strategy nationally, maintaining high quality and linkages to quality facility-based care.

Dear Sir: The article by Amouzou and others1 presents findings from an evaluation of integrated community case management (iCCM) in Malawi using a National Evaluation Platform (NEP) design. While it is a welcome effort to document this child survival strategy that is being tested in many low- and middle-income countries, the study findings have implications both for iCCM and for approaches to evaluation, which would benefit from further scrutiny. An important consideration in the evaluation of community-based care is ascertaining true exposure to the intervention in the study population. The article by Amouzou and others used a dose–response approach, with 27 districts as the unit of analysis, to measure the effect of an intervention (iCCM) that was specifically targeted at hard-to-reach areas. Their approach ignored spatial variation within districts and led to a diluted estimate of the effect of iCCM, as not all communities sampled in the household surveys were exposed to iCCM-trained health surveillance assistants (HSAs). A more effective approach would have been to stratify the samples by a measure of spatial exposure, for instance average travel time to the nearest HSA and ratio of HSAs per population within a given buffer of the cluster.2 Moreover, the exposure was limited at 1.5 HSAs per 1,000 children under 5 years of age (lower than the Ministry of Health target of one per 1,000 population, equivalent to about one HSA per 200 children). For community-based nutrition programs, a ratio of one community worker per 100–200 children is associated with impact on child malnutrition.3 Furthermore, the regression analysis used overall care seeking from all formal providers as the dependent variable, not care seeking from HSAs who actually delivered iCCM. A more accurate approach would have been to use change in care seeking to HSAs as the dependent variable. In addition, care seeking does not necessarily result in appropriate treatment. Therefore, it may be misleading to conclude that iCCM had no impact on under-five mortality without assessing changes in coverage of appropriate treatment of childhood illnesses. As more countries are scaling up community-based delivery platforms,4 it is critical that methods to evaluate the impact of these services take into consideration spatial exposure to community health workers. National household surveys, which are the main source of exposure and outcome data in the NEP design, are designed to provide estimates at the district or regional level, and therefore cannot provide valid estimates among populations exposed to iCCM when exposure varies within the district or region. We agree with the authors' request for more investigation into why about one-third of HSAs do not live in the community they serve and how this may affect access for sick children.5 Given the considerations presented, we question the validity of the conclusion that iCCM had no impact on care seeking or mortality in Malawi. An alternative interpretation could be that at this exposure, the effects were too small to establish with the methods used; an estimate of the possible effect size, rather than negative conclusions, would be more useful. There are important policy and programmatic risks in concluding that iCCM has no impact. Policy makers could change the course of programs or plans, donors could shift priorities, and program managers could be demotivated by a sense of failure. Thus, there is need for caution when interpreting the findings. We support the authors' call for continuous large-scale evaluation in global health, including rigorous methodology with appropriate evaluation designs, to provide robust conclusions of relevance to improving health services.

Summary Background Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children. Methods We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels. Findings We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles. Interpretation Equity should be accounted for when planning the scaling up of interventions and assessing national progress. Funding Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.

Each year 3.6 million infants are estimated to die in the first 4 weeks of life (neonatal period)--but the majority continue to die at home, uncounted. This article reviews progress for newborn health globally, with a focus on the countries in which most deaths occur--what data do we have to guide accelerated efforts? All regions are advancing, but the level of decrease in neonatal mortality differs by region, country, and within countries. Progress also differs by the main causes of neonatal death. Three major causes of neonatal deaths (infections, complications of preterm birth, and intrapartum-related neonatal deaths or "birth asphyxia") account for more than 80% of all neonatal deaths globally. The most rapid reductions have been made in reducing neonatal tetanus, and there has been apparent progress towards reducing neonatal infections. Limited, if any, reduction has been made in reducing global deaths from preterm birth and for intrapartum-related neonatal deaths. High-impact, feasible interventions to address these 3 causes are summarized in this article, along with estimates of potential for lives saved. A major gap is reaching mothers and babies at birth and in the early postnatal period. There are promising community-based service delivery models that have been tested mainly in research studies in Asia that are now being adapted and evaluated at scale and also being tested through a network of African implementation research trials. To meet Millennium Development Goal 4, more can and must be done to address neonatal deaths. A critical step is improving the quantity, quality and use of data to select and implement the most effective interventions and strengthen existing programs, especially at district level.

Background In high-income countries, national mortality audits are associated with improved quality of care, but there has been no previous systematic review of perinatal audit in low- and middle-income settings. Objectives To present a systematic review of facility-based perinatal mortality audit in low- and middle-income countries, and review information regarding community audit. Results Ten low-quality evaluations with mortality outcome data were identified. Meta-analysis of 7 before-and-after studies indicated a reduction in perinatal mortality of 30% (95% confidence interval, 21%–38%) after introduction of perinatal audit. The consistency of effect suggests that audit may be a useful tool for decreasing perinatal mortality rates in facilities and improving quality of care, although none of these evaluations were large scale. Few of the identified studies reported intrapartum-related perinatal outcomes. Novel experience of community audit and social autopsy is described, but data reporting mortality outcome effect are lacking. There are few examples of wide-scale, sustained perinatal audit in low-income settings. Two national cases studies (South Africa and Bangladesh) are presented. Programmatic decision points, challenges, and key factors for national or wide scale-up of sustained perinatal mortality audit are discussed. As a minimum standard, facilities should track intrapartum stillbirth and pre-discharge intrapartum-related neonatal mortality rates. Conclusion The effect of perinatal audit depends on the ability to close the audit loop; without effectively implementing the solutions to the problems identified, audit alone cannot improve quality of care.

The annual toll of losses resulting from poor pregnancy outcomes include half a million maternal deaths, more than three million stillbirths, of whom at least one million die during labour and 3.8 million neonatal deaths--up to half on the first day of life. Neonatal deaths account for an increasing proportion of child deaths (now 41%) and must be reduced to achieve Millennium Development Goal (MDG) 4 for child survival. Newborn survival is also related to MDG 5 for maternal health as the interventions are closely linked. This article reviews current progress for newborn health globally, with a focus on the countries where most deaths occur. Three major causes of neonatal deaths (infections, complications of preterm birth, intrapartum-related neonatal deaths) account for almost 90% of all neonatal deaths. The highest impact interventions to address these causes of neonatal death are summarised with estimates of potential for lives saved. Two priority opportunities to address newborn deaths through existing maternal health programmes are highlighted. First, antenatal steroids are high impact, feasible and yet under-used in low resource settings. Second, with increasing investment to scale up skilled attendance and emergency obstetric care, it is important to include skills and equipment for simple immediate newborn care and neonatal resuscitation. A major gap is care during the early postnatal period for mothers and babies. There are promising models that have been tested mainly in research studies in Asia that are now being adapted and evaluated at scale including through a network of African implementation research trials.

The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths. The continuum for maternal, newborn, and child health usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). We define a population-level or public-health framework based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children. These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one. The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes. Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care. Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.

Since 2010, Malawi has been on track to reach Millennium Development Goal (MDG) 4 and is one of the first countries in sub–Saharan Africa to have reached the target [1], despite reporting one of the lowest gross national incomes per capita in the world [2]. According to the UN Inter–Agency Group for Child Mortality Estimation, under–5 mortality has declined steadily from 245 to 68 deaths per 1000 live births between 1990 and 2013 [3]. Malawi showed commitment to accelerating child survival and development through the establishment of the Accelerated Child Survival and Development policy in 2006 which was implemented through the Integrated Management of Childhood Illness (IMCI) five year strategic plan (2006–2011) and the Strategic Plan for Child Survival in 2007. The strategy aimed to reduce childhood morbidity and mortality by two–thirds between 2000 and 2015, and it focused on the scaling up of high impact interventions including integrated community case management of childhood illnesses and newborn care (iCCM) [4]. From 2008 iCCM was scaled up nationally under the coordination of the Ministry of Health with the support of partners in different districts including UNICEF, WHO, Save the Children, and others. UNICEF worked as an implementing partner in ten of twenty–eight districts throughout the country through the Catalytic Initiative (CI) Integrated Health Systems Strengthening (IHSS) programme (Figure 1) whilst other partners provided similar support in the remainder of the country. In 2013, an estimated 41 000 under–5 deaths occurred nationally with approximately 47% in the ten CI focus districts [3]. Figure 1 Map of Malawi showing 10 Catalytic Initiative districts (shaded in green). The CI/IHSS programme was established by UNICEF with joint funding from the Department of Foreign Affairs, Trade and Development Canada (DFATD) in late 2007 with the main aim of assisting low and middle–income countries in Central, West and Southern Africa with high maternal and child mortality rates, including Malawi, to scale up services to children and pregnant women [5]. The CI programme had a strong health systems strengthening focus through training of front line health workers, provision of drugs and supplies, support for supervision and development of monitoring and evaluation systems [6]. In the initial period the CI programme in Malawi supported mainly preventive interventions including provision of vitamin A supplementation, immunisations, counselling on infant and young child feeding as well as training almost 4000 nurses in Integrated Management of Childhood Illnesses (IMCI). Following the Ministry of Health decision to scale up iCCM, the focus was on training and equipping of community health workers called health surveillance assistants (HSAs) to deliver iCCM services for treatment of malaria, pneumonia and diarrhoea [7]. As one of six countries participating in the CI programme, Malawi received a total of US$ 19.4 million from DFATD (US$ 11.5) and UNICEF (US$ 7.9) over the grant period 2007– 2013 [8]. HSAs have played a central role in the delivery of health services in Malawi since the 1960s, delivering an increasingly broad array of services at the community level [9–11]. Initially operating as environmental health outreach assistants concentrating on water and sanitation; since 1995 HSAs have been formally recruited and salaried by the Ministry of Health. Required to have grade 10 (junior certificate of education) to qualify, HSAs receive 12 weeks of general training, and since 2008, an additional 6 days of specific training on iCCM. They split their working week between the village clinic (situated in hard–to–reach areas >5km from the nearest health centre) in which they spend 2–3 days per week, community–based outreach work and assisting in fixed health facilities. In 2011 there were over 10 000 HSAs in the country of which 3800 had been trained in iCCM with just over 1000 of these situated in the 10 districts where CI efforts were focused (Figure 1) [10]. Small–scale evaluations during the early period of iCCM implementation (2009–2011) revealed high demand for HSA services [10] and quality of care similar to that provided by nurses in first–level facilities [12]. An evaluation of changes in newborn survival identified areas for further work, including the integration of neonatal sepsis management into iCCM [13]. However, no evaluation has assessed the broader impact of child survival strategies, particularly iCCM, on child health indicators in Malawi. This paper explores factors influencing progress in child survival including coverage of interventions, the role of key national policies and impact of coverage change on under–5 deaths averted using data from an evaluation of the CI programme of support in Malawi.

Background: While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking.Methods: We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low-and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality.Results: Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed.Conclusions: Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

BACKGROUND: The Every Newborn Action Plan (ENAP), launched in 2014, aims to end preventable newborn deaths and stillbirths, with national targets of ≤12 neonatal deaths per 1000 live births and ≤12 stillbirths per 1000 total births by 2030. This requires ambitious improvement of the data on care at birth and of small and sick newborns, particularly to track coverage, quality and equity. METHODS: In a multistage process, a matrix of 70 indicators were assessed by the Every Newborn steering group. Indicators were graded based on their availability and importance to ENAP, resulting in 10 core and 10 additional indicators. A consultation process was undertaken to assess the status of each ENAP core indicator definition, data availability and measurement feasibility. Coverage indicators for the specific ENAP treatment interventions were assigned task teams and given priority as they were identified as requiring the most technical work. Consultations were held throughout. RESULTS: ENAP published 10 core indicators plus 10 additional indicators. Three core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) are well defined, with future efforts needed to focus on improving data quantity and quality. Three core indicators on coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content and quality of the interventions. Four core (antenatal corticosteroids, neonatal resuscitation, treatment of serious neonatal infections, kangaroo mother care) and one additional coverage indicator for newborns at risk or with complications (chlorhexidine cord cleansing) lack indicator definitions or data, especially for denominators (population in need). To address these gaps, feasible coverage indicator definitions are presented for validity testing. Measurable process indicators to help monitor health service readiness are also presented. A major measurement gap exists to monitor care of small and sick babies, yet signal functions could be tracked similarly to emergency obstetric care. CONCLUSIONS: The ENAP Measurement Improvement Roadmap (2015-2020) outlines tools to be developed (e.g., improved birth and death registration, audit, and minimum perinatal dataset) and actions to test, validate and institutionalise proposed coverage indicators. The roadmap presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys. Real measurement change requires intentional transfer of leadership to countries with the greatest disease burden and will be achieved by working with centres of excellence and existing networks.

Background : South Africa has made substantial progress on child and maternal mortality, yet many avoidable deaths of mothers and children still occur. This analysis identifies priority interventions to be scaled up nationally and projects the potential maternal and child lives saved. Design : We modelled the impact of maternal, newborn and child interventions using the Lives Saved Tools Projections to 2015 and used realistic coverage increases based on expert opinion considering recent policy change, financial and resource inputs, and observed coverage change. A scenario analysis was undertaken to test the impact of increasing intervention coverage to 95%. Results : By 2015, with realistic coverage, the maternal mortality ratio (MMR) can reduce to 153 deaths per 100,000 and child mortality to 34 deaths per 1,000 live births. Fifteen interventions, including labour and delivery management, early HIV treatment in pregnancy, prevention of mother-to-child transmission and handwashing with soap, will save an additional 9,000 newborns and children and 1,000 mothers annually. An additional US$370 million (US$7 per capita) will be required annually to scale up these interventions. When intervention coverage is increased to 95%, breastfeeding promotion becomes the top intervention, the MMR reduces to 116 and the child mortality ratio to 23. Conclusions : The 15 interventions identified were adopted by the National Department of Health, and the Health Minister launched a campaign to encourage Provincial Health Departments to scale up coverage. It is hoped that by focusing on implementing these 15 interventions at high quality, South Africa will reach Millennium Development Goal (MDG) 4 soon after 2015 and MDG 5 several years later. Focus on HIV and TB during early antenatal care is essential. Strategic gains could be realised by targeting vulnerable populations and districts with the worst health outcomes. The analysis demonstrates the usefulness of priority setting tools and the potential for evidence-based decision making in the health sector. Keywords : child health; maternal health; cost and cost analysis (Published: 21 April 2015) Citation : Glob Health Action 2015, 8 : 27265 - http://dx.doi.org/10.3402/gha.v8.27265

No abstract available. (Published: 31 March 2015) Citation : Glob Health Action 2015, 8 : 27363 - http://dx.doi.org/10.3402/gha.v8.27363 SPECIAL ISSUE : This paper is part of the Special Issue: Newborn health in Uganda . More papers from this issue can be found at http://www.globalhealthaction.net

Background : Stillbirths do not register amongst national or global public health priorities, despite large numbers and known solutions. Although not accounted in statistics – these deaths count for families. Part of this disconnect is that very little is known about the lived experiences and perceptions of those experiencing this neglected problem. Objective : This study aimed to explore local definitions and perceived causes of stillbirths as well as coping mechanisms used by families affected by stillbirth in rural eastern Uganda. Design : A total of 29 in-depth interviews were conducted with women who had a stillbirth (14), men whose wives experienced a stillbirth (6), grandmothers (4), grandfathers (1), and traditional birth attendants (TBAs) (4). Participants were purposively recruited from the hospital maternity ward register, with additional recruitment done through community leaders and other participants. Data were analysed using content analysis. Results : Women and families affected by stillbirth report pregnancy loss as a common occurrence. Definitions and causes of stillbirth included the biomedical, societal, and spiritual. Disclosure of stillbirth varies with women who experience consecutive or multiple losses, subject to potential exclusion from the community and even the family. Methods for coping with stillbirth were varied and personal. Ritual burial practices were common, yet silent and mainly left to women, as opposed to public mourning for older children. There were no formal health system mechanisms to support or care for families affected by stillbirths. Conclusion : In a setting with strong collective ties, stillbirths are a burden borne by the affected family, and often just by the mother, rather than the community as a whole. Strategies are needed to address preventable stillbirths as well as to follow up with supportive services for those affected. Keywords : stillbirth; pregnancy loss; Uganda; maternal health; postpartum depression; traditional birth attendants (Published: 31 March 2015) Citation : Glob Health Action 2015, 8 : 24011 - http://dx.doi.org/10.3402/gha.v8.24011 SPECIAL ISSUE: This paper is part of the Special Issue: Newborn health in Uganda . More papers from this issue can be found at http://www.globalhealthaction.net

Background: The magnitude of the Ebola outbreak in West Africa is unprecedented. Liberia, Guinea, and Sierra Leone are in the bottom ten countries in the Human Development Index, but all had made gains in child survival prior to the outbreak. With closure of healthcare facilities and the loss of health workers secondary to the outbreak, the region risks reversing survival gains achieved in maternal and newborn health. Methods: Anonymized service utilization data were downloaded from the Liberia District Health Information Software (DHIS) 2 for selected maternal health services at PHC facilities in Margibi and Bong Counties from March 2014, when the first case of Ebola was reported in Liberia, through December 2014. Absolute numbers are provided instead of percentage measures because of the lack of a population-based denominator. Results: Overall, the data show a decrease in absolute utilization from the start of the outbreak, followed by a slow recovery after October or November. In Bong County, totals were less than 14% of the peak numbers during the outbreak for number of antenatal visits and pregnant women receiving intermittent preventive treatment for malaria in pregnancy (IPTp). For total deliveries, utilization was less than 33% of the highest month. In Margibi County, during what now appears to be the height of the outbreak, numbers dropped to less than 9% of peak utilization for antenatal care visits and 4% for IPTp. Total health facility deliveries dropped to less than 9% of peak utilization. Conclusion: It is clear that Bong and Margibi Counties in Liberia experienced a large drop in utilization of maternal health care services during what now appears to be the peak of the Ebola outbreak. As the health of women and their babies is being promoted in the post-2015 sustainable development agenda, it is critical that the issue of maternal and newborn survival in humanitarian emergency settings, like the Ebola outbreak, is prioritized.

Background : In Uganda and elsewhere, the private sector provides an increasing and significant proportion of maternal and child health services. However, little is known whether private care results in better quality services and improved outcomes compared to the public sector, especially regarding care at the time of birth. Objective : To describe the characteristics of care-seekers and assess newborn care practices and services received at public and private facilities in rural eastern Uganda. Design : Within a community-based maternal and newborn care intervention with health systems strengthening, we collected data from mothers with infants at baseline and endline using a structured questionnaire. Descriptive, bivariate, and multivariate data analysis comparing nine newborn care practices and three composite newborn care indicators among private and public health facilities was conducted. Results : The proportion of women giving birth at private facilities decreased from 25% at baseline to 17% at endline, whereas overall facility births increased. Private health facilities did not perform significantly better than public health facilities in terms of coverage of any essential newborn care interventions, and babies were more likely to receive thermal care practices in public facilities compared to private (68% compared to 60%, p =0.007). Babies born at public health facilities received an average of 7.0 essential newborn care interventions compared to 6.2 at private facilities ( p

Background : Care for women and babies before, during, and after the time of birth is a sensitive measure of the functionality of any health system. Engaging communities in preventing newborn deaths is a promising strategy to achieve further progress in child survival in sub-Saharan Africa. Objective : To assess the effect of a home visit strategy combined with health facility strengthening on uptake of newborn care-seeking, practices and services, and to link the results to national policy and scale-up in Uganda. Design : The Uganda Newborn Study (UNEST) was a two-arm cluster-randomised controlled trial in rural eastern Uganda. In intervention villages volunteer community health workers (CHWs) were trained to identify pregnant women and make five home visits (two during pregnancy and three in the first week after birth) to offer preventive and promotive care and counselling, with extra visits for sick and small newborns to assess and refer. Health facility strengthening was done in all facilities to improve quality of care. Primary outcomes were coverage of key essential newborn care behaviours (breastfeeding, thermal care, and cord care). Analyses were by intention to treat. This study is registered as a clinical trial, number ISRCTN50321130. Results : The intervention significantly improved essential newborn care practices, although many interventions saw major increases in both arms over the study period. Immediate breastfeeding after birth and exclusive breastfeeding were significantly higher in the intervention arm compared to the control arm (72.6% vs. 66.0%; p =0.016 and 81.8% vs. 75.9%, p =0.042, respectively). Skin-to-skin care immediately after birth and cord cutting with a clean instrument were marginally higher in the intervention arm versus the control arm (80.7% vs. 72.2%; p =0.071 and 88.1% vs. 84.4%; p =0.023, respectively). Half (49.6%) of the mothers in the intervention arm waited more than 24 hours to bathe the baby, compared to 35.5% in the control arm ( p

Summary Background Tanzania is on track to meet Millennium Development Goal (MDG) 4 for child survival, but is making insufficient progress for newborn survival and maternal health (MDG 5) and family planning. To understand this mixed progress and to identify priorities for the post-2015 era, Tanzania was selected as a Countdown to 2015 case study. Methods We analysed progress made in Tanzania between 1990 and 2014 in maternal, newborn, and child mortality, and unmet need for family planning, in which we used a health systems evaluation framework to assess coverage and equity of interventions along the continuum of care, health systems, policies and investments, while also considering contextual change (eg, economic and educational). We had five objectives, which assessed each level of the health systems evaluation framework. We used the Lives Saved Tool (LiST) and did multiple linear regression analyses to explain the reduction in child mortality in Tanzania. We analysed the reasons for the slower changes in maternal and newborn survival and family planning, to inform priorities to end preventable maternal, newborn, and child deaths by 2030. Findings In the past two decades, Tanzania's population has doubled in size, necessitating a doubling of health and social services to maintain coverage. Total health-care financing also doubled, with donor funding for child health and HIV/AIDS more than tripling. Trends along the continuum of care varied, with preventive child health services reaching high coverage (≥85%) and equity (socioeconomic status difference 13–14%), but lower coverage and wider inequities for child curative services (71% coverage, socioeconomic status difference 36%), facility delivery (52% coverage, socioeconomic status difference 56%), and family planning (46% coverage, socioeconomic status difference 22%). The LiST analysis suggested that around 39% of child mortality reduction was linked to increases in coverage of interventions, especially of immunisation and insecticide-treated bednets. Economic growth was also associated with reductions in child mortality. Child health programmes focused on selected high-impact interventions at lower levels of the health system (eg, the community and dispensary levels). Despite its high priority, implementation of maternal health care has been intermittent. Newborn survival has gained attention only since 2005, but high-impact interventions are already being implemented. Family planning had consistent policies but only recent reinvestment in implementation. Interpretation Mixed progress in reproductive, maternal, newborn, and child health in Tanzania indicates a complex interplay of political prioritisation, health financing, and consistent implementation. Post-2015 priorities for Tanzania should focus on the unmet need for family planning, especially in the Western and Lake regions; addressing gaps for coverage and quality of care at birth, especially in rural areas; and continuation of progress for child health. Funding Government of Canada, Foreign Affairs, Trade, and Development; US Fund for UNICEF; and the Bill & Melinda Gates Foundation.

Background: The time of labor, birth and the first days of life are the most vulnerable period for mothers and children. Despite significant global advocacy, there is insufficient understanding of the investment required to save additional lives. In particular, stillbirths have been neglected. Over 20 000 stillbirths are recorded annually in South Africa, many of which could be averted. This analysis examines available South Africa specific stillbirth data and evaluates the impact and cost-effectiveness of 13 interventions acknowledged to prevent stillbirths and maternal and newborn mortality. Methods: Multiple data sources were reviewed to evaluate changes in stillbirth rates since 2000. The intervention analysis used the Lives Saved tool (LiST) and the Family Planning module (FamPlan) in Spectrum. LiST was used to determine the number of stillbirths and maternal and neonatal deaths that could be averted by scaling up the interventions to full coverage (99%) in 2030. The impact of family planning was assessed by increasing FamPlan’s default 70% coverage of modern contraception to 75% and 80% coverage. Total and incremental costs were determined in the LiST costing module. Cost-effectiveness measured incremental cost effectiveness ratios per potential life years gained. Results: Significant variability exists in national stillbirth data. Using the international stillbirth definition, the SBR was 17.6 per 1 000 births in 2013. Full coverage of the 13 interventions in 2030 could reduce the SBR by 30% to 12.4 per 1 000 births, leading to an MMR of 132 per 100 000 and an NMR of 7 per 1 000 live births. Increased family planning coverage reduces the number of deaths significantly. The full intervention package, with 80% family planning coverage in 2030, would require US$420 million (US$7.8 per capita) annually, which is less than baseline costs of US$550 million (US$10.2 per capita). All interventions were highly cost-effective. Conclusion: This is the first analysis in South Africa to assess the impact of scaling up interventions to avert stillbirths. Improved coverage of 13 interventions that are already recommended could significantly impact the rates of stillbirth and maternal and neonatal mortality. Family planning should also be prioritized to reduce mortality and overall costs.

Background : There is a lack of literature on how to adapt new evidence-based interventions for maternal and newborn care into local health systems and policy for rapid scale-up, particularly for community-based interventions in low-income settings. The Uganda Newborn Study (UNEST) was a cluster randomised control trial to test a community-based care package which was rapidly taken up at national level. Understanding this process may help inform other studies looking to design and evaluate with scale-up in mind. Objective : This study aimed to describe the process of using evidence to design a community-based maternal and newborn care package in rural eastern Uganda, and to determine the dissemination and advocacy approaches used to facilitate rapid policy change and national uptake. Design : We reviewed UNEST project literature including meeting reports and minutes, supervision reports, and annual and midterm reports. National stakeholders, project and district staff were interviewed regarding their role in the study and perceptions of what contributed to uptake of the package under evaluation. Data related to UNEST formative research, study design, implementation and policy influence were extracted and analysed. Results : An advisory committee of key players in development of maternal and newborn policies and programmes in Uganda was constituted from many agencies and disciplines. Baseline qualitative and quantitative data collection was done at district, community and facility level to examine applicability of aspects of a proposed newborn care package to the local setting. Data were summarised and presented to stakeholders to adapt the intervention that was ultimately tested. Quarterly monitoring of key activities and events around the interventions were used to further inform implementation. The UNEST training package, home visit schedule and behaviour change counselling materials were incorporated into the national Village Health Team and Integrated Community Case Management packages while the study was ongoing. Conclusions : Designing interventions for national scale-up requires strategies and planning from the outset. Use of evidence alongside engagement of key stakeholders and targeted advocacy about the burden and potential solutions is important when adapting interventions to local health systems and communities. This approach has the potential to rapidly translate research into policy, but care must be taken not to exceed available evidence while seizing the policy opportunity. Keywords : newborn health; maternal health; community health worker; pregnancy; postnatal care; Uganda; formative research; health policy (Published: 31 March 2015) Citation : Glob Health Action 2015, 8 : 24250 - http://dx.doi.org/10.3402/gha.v8.24250 SPECIAL ISSUE: This paper is part of the Special Issue: Newborn health in Uganda . More papers from this issue can be found at http://www.globalhealthaction.net

Uganda's Ministry of Health, together with partners, has introduced integrated community case management (iCCM) for children under 5 years. We assessed how the iCCM program addresses newborn care in three midwestern districts through document reviews, structured interviews, and focus group discussions with village health team (VHT) members trained in iCCM, caregivers, and other stakeholders. Almost all VHT members reported that they refer sick newborns to facilities and could identify at least three newborn danger signs. However, they did not identify the most important clinical indicators of severe illness. The extent of compliance with newborn referral and quality of care for newborns at facilities is not clear. Overall iCCM is perceived as beneficial, but caregivers, VHTs, and health workers want to do more for sick babies at facilities and in communities. Additional research is needed to assess the ability of VHTs to identify newborn danger signs, referral compliance, and quality of newborn treatment at facilities.

Each year in Uganda 141 000 children die before reaching their fifth birthday; 26% of these children die in their first month of life. In a setting of persistently high fertility rates, a crisis in human resources for health and a recent history of civil unrest, Uganda has prioritized Millennium Development Goals 4 and 5 for child and maternal survival. As part of a multi-country analysis we examined change for newborn survival over the past decade through mortality and health system coverage indicators as well as national and donor funding for health, and policy and programme change. Between 2000 and 2010 Uganda's neonatal mortality rate reduced by 2.2% per year, which is greater than the regional average rate of decline but slower than national reductions in maternal mortality and under-five mortality after the neonatal period. While existing population-based data are insufficient to measure national changes in coverage and quality of services, national attention for maternal and child health has been clear and authorized from the highest levels. Attention and policy change for newborn health is comparatively recent. This recognized gap has led to a specific focus on newborn health through a national Newborn Steering Committee, which has been given a mandate from the Ministry of Health to advise on newborn survival issues since 2006. This multi-disciplinary and inter-agency network of stakeholders has been able to preside over a number of important policy changes at the level of facility care, education and training, community-based service delivery through Village Health Teams and changes to essential drugs and commodities. The committee's comprehensive reach has enabled rapid policy change and increased attention to newborn survival in a relatively short space of time. Translating this favourable policy environment into district-level implementation and high quality services is now the priority.

Background : The first week of life is the time of greatest risk of death and disability, and is also associated with many traditional beliefs and practices. Identifying sick newborns in the community and referring them to health facilities is a key strategy to reduce deaths. Although a growing area of interest, there remains a lack of data on the role of sociocultural norms and practices on newborn healthcare-seeking in sub-Saharan Africa and the extent to which these norms can be modified. Objective : This study aimed to understand the community’s perspective of potential sociocultural barriers and facilitators to compliance with newborn referral. Method : In this qualitative study, focus group discussions (n=12) were conducted with mothers and fathers of babies aged less than 3 months. In addition, in-depth interviews (n=11) were also held with traditional birth attendants and mothers who had been referred by community health workers to seek health-facility-based care. Participants were purposively selected from peri-urban and rural communities in two districts in eastern Uganda. Data were analysed using latent content analysis. Results : The community definition of a newborn varied, but this was most commonly defined by the period between birth and the umbilical cord stump falling off. During this period, newborns are perceived to be vulnerable to the environment and many mothers and their babies are kept in seclusion, although this practice may be changing. Sociocultural factors that influence compliance with newborn referrals to seek care emerged along three sub-themes: community understanding of the newborn period and cultural expectations; the role of community health actors; and caretaker knowledge, experience, and decision-making autonomy. Conclusion : In this setting, there is discrepancy between biomedical and community definitions of the newborn period. There were a number of sociocultural factors that could potentially affect compliance to newborn referral. The widely practised cultural seclusion period, knowledge about newborn sickness, individual experiences in households, perceived health system gaps, and decision-making processes were facilitators of or barriers to compliance with newborn referral. Designers of newborn interventions need to address locally existing cultural beliefs at the same time as they strengthen facility care. Keywords : care-seeking; newborn; neonatal; qualitative; referral; sociocultural influences; Uganda (Published: 31 March 2015) Citation : Glob Health Action 2015, 8 : 24386 - http://dx.doi.org/10.3402/gha.v8.24386 SPECIAL ISSUE : This paper is part of the Special Issue: Newborn health in Uganda . More papers from this issue can be found at http://www.globalhealthaction.net

BACKGROUND: The Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality targets cannot be achieved without high quality, equitable coverage of interventions at and around the time of birth. This paper provides an overview of the methodology and findings of a nine paper series of in-depth analyses which focus on the specific challenges to scaling up high-impact interventions and improving quality of care for mothers and newborns around the time of birth, including babies born small and sick. METHODS: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the ENAP process. Country workshops engaged technical experts to complete a tool designed to synthesise "bottlenecks" hindering the scale up of maternal-newborn intervention packages across seven health system building blocks. We used quantitative and qualitative methods and literature review to analyse the data and present priority actions relevant to different health system building blocks for skilled birth attendance, emergency obstetric care, antenatal corticosteroids (ACS), basic newborn care, kangaroo mother care (KMC), treatment of neonatal infections and inpatient care of small and sick newborns. RESULTS: The 12 countries included in our analysis account for the majority of global maternal (48%) and newborn (58%) deaths and stillbirths (57%). Our findings confirm previously published results that the interventions with the most perceived bottlenecks are facility-based where rapid emergency care is needed, notably inpatient care of small and sick newborns, ACS, treatment of neonatal infections and KMC. Health systems building blocks with the highest rated bottlenecks varied for different interventions. Attention needs to be paid to the context specific bottlenecks for each intervention to scale up quality care. Crosscutting findings on health information gaps inform two final papers on a roadmap for improvement of coverage data for newborns and indicate the need for leadership for effective audit systems. CONCLUSIONS: Achieving the Sustainable Development Goal targets for ending preventable mortality and provision of universal health coverage will require large-scale approaches to improving quality of care. These analyses inform the development of systematic, targeted approaches to strengthening of health systems, with a focus on overcoming specific bottlenecks for the highest impact interventions.

BACKGROUND: Over 40% of all deaths among children under 5 are neonatal deaths (0-28 days), and this proportion is increasing. In 2012, 2.9 million newborns died, with 99% occurring in low- and middle-income countries. Many of the countries with the highest neonatal mortality rates globally are currently or have recently been affected by complex humanitarian emergencies. Despite the global burden of neonatal morbidity and mortality and risks inherent in complex emergency situations, research investments are not commensurate to burden and little is known about the epidemiology or best practices for neonatal survival in these settings. METHODS: We used the Child Health and Nutrition Research Initiative (CHNRI) methodology to prioritize research questions on neonatal health in complex humanitarian emergencies. Experts evaluated 35 questions using four criteria (answerability, feasibility, relevance, equity) with three subcomponents per criterion. Using SAS 9.2, a research prioritization score (RPS) and average expert agreement score (AEA) were calculated for each question. RESULTS: Twenty-eight experts evaluated all 35 questions. RPS ranged from 0.846 to 0.679 and the AEA ranged from 0.667 to 0.411. The top ten research priorities covered a range of issues but generally fell into two categories- epidemiologic and programmatic components of neonatal health. The highest ranked question in this survey was "What strategies are effective in increasing demand for, and use of skilled attendance?" CONCLUSIONS: In this study, a diverse group of experts used the CHRNI methodology to systematically identify and determine research priorities for neonatal health and survival in complex humanitarian emergencies. The priorities included the need to better understand the magnitude of the disease burden and interventions to improve neonatal health in complex humanitarian emergencies. The findings from this study will provide guidance to researchers and program implementers in neonatal and complex humanitarian fields to engage on the research priorities needed to save lives most at risk.