Quality of care in maternal, newborn and child health (MNCH) and sexual and reproductive health (SRH)

Publication date: 2016

1 Helpdesk: Quality of care in maternal, newborn and child health (MNCH) and sexual and reproductive health (SRH) Date: 15th June 2016 Content 1. Overview 2. Definitions 3. MNCH 4. Cost effectiveness 5. SRH 6. Additional information 1. Overview This helpdesk query looks at interventions to improve the quality of care in maternal, newborn, and child health (MNCH) and sexual and reproductive health (SRH). It includes evidence assessing which interventions are likely to have the best impact on service outputs and health outcomes, with an emphasis on cost effectiveness. Firstly, the issues to be included under each area are outlined, then the meaning of quality of care and the types of interventions to be considered are presented. The report is divided into sections presenting evidence on each topic area, but due to the time limitations of this report it has had to focus on literature on MNCH and SRH as a whole, rather than going into detail about specific issues related to each. There is also a section specifically on cost effectiveness. Section 2 focuses on the definitions and areas covered by MNCH and SRH as well as some of the literature on quality and interventions. Section 3 focuses on MNCH, and specifically the importance of continuum of care interventions. The continuum for MNCH usually refers to continuity of individual care through pre-pregnancy, pregnancy, childbirth, postpartum, newborn care and care of the child. 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). Several high quality studies have reviewed the literature and assessed different interventions and their outcomes, these have been included as they provide an excellent overview of which are likely to have the greatest effects on health outcomes and service delivery. Several overview tables outline which interventions have the greatest impact on health outcomes and service delivery. Section 4 is dedicated to the issue of cost effectiveness and includes several diagrams which can be used to assess this issue as well as a study showing key ways to improve cost effectiveness including increasing spending, efficiency, equity and ensuring there are incentives and integration. Section 5 includes literature on SRH. Health and rights in sexuality and reproduction are an integrated package, which includes SRH services (family planning, maternity care, safe abortion, prevention and treatment of sexually transmitted infections and HIV, among others); comprehensive sexuality education; and protection of SRH and rights. People cannot be healthy if they have one element of the Query: Which interventions in promoting quality of care in MNCH and SRH are likely to have the best impact on service outputs and health outcomes? 2 package but miss others. Progress on the components of SRH and rights has been uneven. While acknowledging that certain components may be more difficult or more costly to implement, progress in many instances has been hindered on ideological, rather than scientific, public health and cost- effectiveness grounds. There have been many accomplishments but aggregate gains mask stark inequalities, with low coverage of services for the poorest women (Snow et al., 2015, see page 28). While there have been notable declines in HIV incidence and prevalence, women affected by HIV are too often bereft of other SRH services, including family planning. Achieving universal access to SRH will require substantially greater investment in comprehensive and integrated services that reach the poor. There are three critical gaps, raised in other papers: inequalities in access to SRH information and services; the widespread need to improve SRH services to meet public health, human rights and medical ethics standards for quality of care; and the absence or inadequate use of accountability mechanisms to track and remedy the other two. The literature in this section includes priority actions to achieve equality, quality and accountability in SRH and rights policies, programmes and services, especially those that should be included in the post-2015 development agenda. One important issue to also consider is that almost all maternal, neonatal, infant and child deaths (99%) arise in low- and middle-income countries (LMICs), yet most research is focused on the 1% of these deaths that occur in high-income countries (HICs). This report focuses on research from LMICs as this is the most relevant. HEART has also produced an online learning resource called Quality of Maternal & Newborn Services. This can be accessed freely online at: http://qos.heart-resources.org/ 2. Definitions Areas included in SRH https://www.unfpa.org/sites/default/files/pub-pdf/SRH_Framework.pdf A major breakthrough at the International Conference on Population and Development (ICPD), reaffirmed repeatedly since, is that these services are essential for all people, married and unmarried, including adolescents and youth. For people to realise their reproductive rights, the ICPD Programme of Action calls for and defines reproductive and sexual health care in the context of primary health care to include (Para 7.6): (a) Family planning; (b) Antenatal, safe delivery and post-natal care; (c) Prevention and appropriate treatment of infertility; (d) Prevention of abortion and management of the consequences of abortion; (e) Treatment of reproductive tract infections; (f) Prevention, care and treatment of STIs and HIV/ AIDS; (g) Information, education and counselling, as appropriate, on human sexuality and reproductive health; (h) Prevention and surveillance of violence against women, care for survivors of violence and other actions to eliminate traditional harmful practices, such as FGM/C; (i) Appropriate referrals for further diagnosis and management of the above. Areas included in MNCH http://www.who.int/pmnch/knowledge/publications/201112_essential_interventions/en/ Poor MNCH remains a significant problem in developing countries. Worldwide, 358 000 women die during pregnancy and childbirth every year and an estimated 7.6 million children die under the age of five. The majority of maternal deaths occur during or immediately after childbirth. The common medical causes for maternal death include bleeding, high blood pressure, prolonged and obstructed labour, infections and unsafe abortions. A child’s risk of dying is highest during the first 28 days of life when about 40% of under-five deaths take place, translating into three million deaths. Up to one half of all newborn deaths occur within the first 24 hours of life and 75% occur in the first week. Globally, the main causes of neonatal death are preterm birth, severe infections and asphyxia. Children in low-income countries are nearly 18 times more likely to die before the age of five than children in high-income countries. ‘The choices [a woman or adolescent girl] can make for herself and her child… make a fundamental difference to current and future generations across the developing world.’ Partnership for Maternal, Newborn and Child Health and University of Aberdeen, 2010 3 Quality This section will outline what is meant by quality of care, but a key point that was raised in several works is: ‘The question should not be why do women not accept the service that we offer, but why do we not offer the service that women will accept’ (Fathalla, M. F., (1998) Paediatric and Perinatal Epidemiology, 1998, 12 (preface) http://onlinelibrary.wiley.com/doi/10.1046/j.1365-3016.12.s2.8.x/abstract) In fact, it is not possible to ‘assure’ or guarantee quality of care or services. Rather, initiatives can only aspire to improve quality of care, to make it ‘good’ or ‘better’ (see Donabedian 2003). What does quality improvement seek to change?  Better impact – expressed for example, as reduction in mortality.  Better outcomes e.g. performance of the health system.  Better outputs e.g. increased use of services, improved motivation of providers. There are several issues to consider when thinking about quality. Safety (doing no harm) was a concern in past and present discourse. Methodological rigour in producing high quality evidence for action in improving our approaches to providing a high quality MNH service is key. As well as the extent of the problem of acceptable MNH services. http://qos.heart-resources.org/?sfwd-lessons=introduction-why- quality-matters Key resources Batalden PB and Davidoff F, (2007) What is “quality improvement” and how can it transform healthcare? Donabedian, A., (2003) An introduction to quality assurance in health care Organisation for Economic Co-operation and Development (OECD), Improving Value in Health Care: Measuring Quality Forum on Quality of Care, Paris, 7-8 October 2010, http://www.oecd.org/health/ministerial/46098506.pdf Interventions The QQUIP (Quest for Quality and Improved Performance) research initiative of The Health Foundation (UK): This framework considers six main categories of quality enhancing interventions when reviewing evidence of the influence on quality of health services. These are: 1. Patient focused interventions 2. Regulatory interventions 3. Incentives 4. Data-driven and IT based interventions 5. Organisational interventions 6. Healthcare delivery models Effects of strategic interventions on quality In addition to quality improvement strategies a number of recent systematic reviews have investigated the effects of various strategic interventions. Some examples are listed in the following table. 4 Table 3.3 – Systematic Reviews on Effectiveness http://qos.heart-resources.org/?sfwd-topic=quality-improvement-strategies 5 Also outlined in the literature is the idea of continuum of care. 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 MNCH 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). Care interventions refer to specific actions provided within the continuum of care. Strategic interventions, or strategies, refer to the strategic approaches used to deliver care interventions. Examples of care interventions across the continuum of care The effectiveness of care interventions is well developed, in comparison with the evidence on effectiveness of strategic interventions, but too extensive to summarise in this resource. Key resources on effective MNH care interventions  World Health Organization’s Documents on Integrated Management of Pregnancy & Childbirth (IMPAC)  The Lancet Global Health series (articles pertaining to maternal and newborn health)  The Cochrane Pregnancy and Childbirth Group  Lawn JE, Cousens S, Zupan J, for the Lancet Neonatal Survival Steering Team. Neonatal survival. 1.4 million neonatal deaths: when? where? why? Lancet 2005; 365:891–900. This question aligns with the pillars of DFIDs 2010 Framework for Results for Improving Reproductive Maternal and Newborn Health, particularly pillar 3. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/67640/RMNH- framework-for-results.pdf Pillar 3 ‘Expand the supply of quality services, delivering cost effective interventions delivered through stronger health systems with public and private providers’; the programme will support implementation and scale up of a package of high impact and cost-effective interventions that evidence demonstrates contribute to a reduction in maternal and under-5 mortality (MDGs 4 and 5) and numbers of underweight under-5s (MDG 1c), and that help combat HIV, malaria and other diseases (MDG 6). The interventions will include maternity and newborn care, immunisation, treatment of common childhood illnesses, nutrition and improving access to Anti-retroviral treatment for adults and children living with AIDS. Equity Finally, equity is also an important issue to consider; timely access to health services by women during pregnancy, delivery and the puerperium period is important should complications occur. This could be influenced by several aspects of access to health care, such as affordability, availability, geographical 6 location and acceptability of the health service. There is evidence that access to health care is not equitably distributed in many low and middle income countries. The following figure shows the median levels of various types of health care use across 47 to 55 LMICs, among population quintiles within countries. Source: http://qos.heart-resources.org/?sfwd-topic=indicators-for-mnh#references Figure: Median levels of health care use across 47 to 55 low- and middle-income countries (number of countries varies according to data availability for the four types of health care use), among population quintiles within countries. 3. Maternal and newborn child health (MNCH) A Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health (RMNCH) The Partnership for Maternal, Newborn & Child Health (2011) Geneva, Switzerland: PMNCH. http://www.who.int/pmnch/topics/part_publications/essential_interventions_18_01_2012.pdf?ua=1 Evidence on the efficacy of single components of interventions is readily available today. However, while interventions have been combined into packages across the ‘continuum of care’, there is insufficient evidence on the efficacy of these packages. Developing consensus on a core package, derived from the variety of packages available for MNCH, is critical to efforts to reduce child mortality and improve maternal health and requires input from implementation research. PMNCH with partners, the WHO and the Aga Khan University have spent several years consulting and developing the core package to define and guide the actions that need to be by national governments and local stakeholders, as well as international partners. A new global consensus has been agreed on the key evidence-based interventions that will sharply reduce the 358,000 women who still die each year during pregnancy and childbirth and the 7.6 million children who die before the age of 5, according to a massive, three-year global study. The study, Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health, is designed to facilitate decision-making in LMICs about how to allocate limited resources for maximum impact on the health of women and children. The study reviewed more than 50,000 scientific papers to determine the proven effectiveness of interventions and impact on survival, identifying 56 essential interventions that when implemented in "packages" relevant to local settings, are most likely to save lives. 7 Some of the interventions include:  Manage maternal anemia with iron;  Prevent and manage post-partum haemorrhage;  Immediate thermal care for newborns;  Extra support for feeding small and preterm babies;  Antibiotics for the treatment of pneumonia in children. "What is new," says Dr. Elizabeth Mason, Director of WHO’s department of Maternal, Newborn, Child and Adolescent Health, and an author of the study, "is putting together information in a different way and building consensus among physicians, scientists and professional organisations to lay out an evidence-based path to help women before, during and after birth and their children. Everyone now agrees on the 56 essential interventions." 8 9 Continuum of care for maternal, newborn, and child health: from slogan to service delivery Katie Kerber, Joseph E de Graft-Johnson, Zulfiqar A Bhutta, Pius Okong, Ann Starrs, Joy E Lawn (2007) The Lancet; 370: 1358-69 http://www.who.int/pmnch/topics/20071003lancet.pdf 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 MNCH usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). The articles defines a population-level 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 MNCH 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. Maternal Mortality in Zimbabwe Evidence, Costs and Implications United Nations Zimbabwe, 2013, Periodic Publication, Paper 1 http://www.zw.one.un.org/sites/default/files/UN-ZW_IssuePaperSeries-1_MMR_June2013.pdf Key message: Maternal mortality remains high despite high levels of antenatal care (ANC) and skilled birth attendance. Implication: Renewed efforts required to ensure quality of care in the provision of maternal health services. An estimated 3000 women die every year in Zimbabwe during child birth and at least 1.23% of GDP is lost annually due to maternal complications. According to the MMIEG, maternal mortality has worsened by 28% from 1990 to 2010. Most of what needs to be done is known. Past efforts have managed to sustain high levels of ANC visits among pregnant women and skilled birth deliveries yet maternal mortality estimates remain high. While innovative thinking supported by a stronger vital registration system is needed for progress towards reducing maternal mortality, quality of care in maternal health services seems to be the missing link. In addition, there is need to progressively expand the scope and entitlements of maternity protection and provide perspectives for policy and action. In 2010, an estimated 285,000 maternal deaths occurred globally marking a decline in the maternal mortality ratio (MMR) of 47% from the 1990 levels. However, the decline has not been uniform across the globe as Sub-Saharan Africa shoulders over half (56%) of the maternal mortality burden. For every woman who dies, roughly 20 suffer serious injury or disability. Babies and young children who have lost their mothers in childbirth are up to ten times more likely to die prematurely than their peers. Inequities and challenges such as armed conflict, natural disasters and HIV/ AIDS hamper progress, with child and maternal mortality concentrated in the world’s poorest countries, primarily in sub-Saharan Africa and South Asia. Zimbabwe is ranked among the 40 countries in the world with high MMR of over 960 maternal deaths per 100,000 live births. Having made remarkable progress during the first decade of independence in improving access to health services through the Primary Health Care approach. This enabled access to basic health care services for about 85% of the population and resulted in a 20% decline in mortality rate. Unfortunately the country then failed to sustain this progress. As a result, the country has not made any progress from the 1990 MDGs base year maternal mortality levels. This is partly due to the prolonged political and economic crisis in the country and has been exacerbated by the HIV/AIDS epidemic for the last two decades. It is estimated that around 3,000 maternal deaths occurred in Zimbabwe in 2010. 10 The Zimbabwe Maternal and Perinatal Mortality Study (ZMPMS) of 2007 identified the leading direct causes of maternal mortality in Zimbabwe as post-partum haemorrhage, pregnancy induced hypertension and puerperal sepsis. Leading indirect causes include HIV and AIDS which account for about 26% of all maternal deaths. The MMIEG attributes about 39% of maternal deaths to AIDS related indirect causes. Most causes of maternal deaths could be addressed successfully by access to emergency obstetric care (EmOC). Findings from the ZMPMS show that skilled antenatal care (ANC) and birth attendance are facilitators to addressing the delay in deciding to seek health care services and the delay to access care at the health facility which happen to account for about 67% of maternal deaths in Zimbabwe. Studies elsewhere have shown that higher skilled birth attendance is associated with lower maternal mortality rates. The country has sustained high levels of ANC visits (90%) among pregnant women and skilled birth deliveries (66%) over the past five years yet maternal mortality remains high. Part of the problem lays in the quality of care. The National Integrated Health Facility Assessment (NIFA) offers some explanation to the phenomenon. Of the observed ANC case management by health workers, only 14% met the standard to identify danger signs in pregnancy with only 4% and 2% inquiring for fever and convulsions respectively. Only about were 2% screened for pre-eclampsia signs during ANC while only about 11% were assessed for pre-eclampsia/eclampsia (testing urine for protein) during labour and delivery. Of the observed health workers, less than half (46%) provided all routine preventative medicines. Slightly more than a third (36%) provided education on birth preparation, while only 12% provided adequate counselling on danger signs in pregnancy. The deterioration in quality of care in health institutions could be partly responsible for the increasing maternal mortality in Zimbabwe. Maternal, Newborn and Child Health Framework International Federation of Red Cross and Red Crescent Societies, Geneva, 2013 http://www.ifrc.org/PageFiles/93927/1232600-MNCH%20Framework%20report_LR%20(2).pdf In 75 countries with the highest prevalence of maternal and child death (Countdown countries), the most common gaps in national coverage for essential interventions and selected approaches across the pregnancy-to-childhood continuum are as follows: • Pre-pregnancy: low prevalence of contraceptive use which demonstrates unmet need for family planning. • During pregnancy: low coverage of preventive treatment for malaria in pregnant women and of prevention of mother-to-child transmission (PMTCT) of HIV – both indicative of low coverage of skilled antenatal care. • At childbirth and during a postnatal period: poor access to skilled attendance, emergency obstetric and neonatal care; low prevalence of early initiation of breastfeeding. • During infancy: low average rates of exclusive breastfeeding. • During childhood: low use of insecticide treated nets (ITN) by children; poor access to treatment for pneumonia, malaria and diarrhoea. 11 Gaps in the home-to-hospital continuum include: • Health workforce shortages combined with limited task shifting: only 28% of the Countdown countries have a minimum health worker/per 10,000 people ratio required to deliver essential health services. • Poor quality of care attributed to health worker shortages, poor infrastructure and inadequate supply of commodities and medical equipment. • Low demand for care due to high out-of-pocket costs, provider attitude; low awareness, inadequate knowledge, local beliefs and misconceptions around health issues and health care services. • Ineffective referral systems and weak links between facility-based staff and community-based workers. A single major factor affecting health and survival across the entire continuum of care is undernutrition. Good maternal health and nutrition are important contributors to child survival. Undernourished women give birth to smaller infants than those nourished adequately. Low-birth infants, in turn, are at a higher risk of death due to infections and asphyxia. Further, undernutrition increases the likelihood that children will be stunted when they reach adulthood. As adults, those children tend to have lower educational attainment and hence lower economic status. On the other hand, maternal survival is also affected by the women’s nutritional status. Specifically, maternal short stature and iron deficiency are associated with a higher risk of death of the mother at delivery and account for at least 20% of maternal deaths. Addressing the issues of undernutrition through high coverage of proved interventions greatly increases the impact of all other services across the continuum and accelerates the achievement of goals for both maternal and child survival. The selection of communities and the women, newborns and children groups can be determined taking into consideration one or more of the factors below, which are not mutually exclusive: • Geographic factors: remoteness combined with poor roads, geographic obstacles, and proneness to natural hazards often referred to as “geographic targeting” • Socio-economic factors (social determinants of health): poverty (i.e. targeting the rural or urban poor – poverty targeting), unemployment, high illiteracy rate, ethnicity, etc. • Vulnerability factors: targeting the most vulnerable households (vulnerability targeting) identified based on household-level data collected through a community census • Health problem factors: targeting selected communities, populations or groups with interventions that are designed to address specific health problems that disproportionately affect the poor i.e. malnutrition, tuberculosis, malaria. It is important to ensure that interventions are: • evidence-based and can be effectively delivered by Red Cross Red Crescent volunteers with appropriate training in coordination with primary health care (see section 5) • consistent with national/regional health priorities as described in national health plans and programme-specific strategies • address the identified gaps in the coverage of key interventions across the continuum and/or improve the quality of their delivery • have gender and equity issues incorporated in their design and implementation • promote the adoption of healthy behaviours, self-care, and skilled care seeking; and where possible and appropriate, provide prevention and treatment • empower communities to demand and access quality, skilled care through the mobilisation of community resources • allow to balance demand and supply by ensuring that supply of services is in place to match the increase in demand • encourage male involvement and responsibilities in MNCH • improve linkages between communities and their health facilities and strengthen referral systems • use creative and innovative approaches that would contribute to better health outcomes for most vulnerable women, newborn and children 12 13 14 Maternal and child health interventions in Nigeria: a systematic review of published studies from 1990 to 2014 Musa Abubakar Kana, Henry Victor Doctor, Bárbara Peleteiro, Nuno Lunet, and Henrique Barros, BMC Public Health. 2015; 15: 334. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4429684/ Background: Poor maternal and child health indicators have been reported in Nigeria since the 1990s. Many interventions have been instituted to reverse the trend and ensure that Nigeria is on track to achieve the MDGs. This systematic review aims at describing and indirectly measuring the effect of the MNCH interventions implemented in Nigeria from 1990 to 2014. Methods: PubMed and ISI Web of Knowledge were searched from 1990 to April 2014 whereas POPLINE® was searched until 16 February 2015 to identify reports of interventions targeting MNCH in Nigeria. Narrative and graphical synthesis was done by integrating the results of extracted studies with trends of maternal mortality ratio (MMR) and under five mortality (U5MR) derived from a joint point regression analysis using Nigeria Demographic and Health Survey data (1990–2013). This was supplemented by document analysis of policies, guidelines and strategies of the Federal Ministry of Health developed for Nigeria during the same period. Results: The authors identified 66 eligible studies from 2,662 studies. Three interventions were deployed nationwide and the remainder at the regional level. Multiple study designs were employed in the enrolled studies: pre- and post-intervention or quasi-experimental (n = 40; 61%); clinical trials (n = 6;9%); cohort study or longitudinal evaluation (n = 3;5%); process/output/outcome evaluation (n = 17;26%). The national MMR shows a consistent reduction (Annual Percentage Change (APC) = −3.10%, 95% CI: −5.20 to −1.00 %) with marked decrease in the slope observed in the period with a cluster of published studies (2004–2014). Fifteen intervention studies specifically targeting under-five children were published during the 24 years of observation. A statistically insignificant downward trend in the U5MR was observed (APC = −1.25%, 95% CI: −4.70 to 2.40%) coinciding with publication of most of the studies and development of MNCH policies. Conclusions: The development of MNCH policies, implementation and publication of interventions corresponds with the downward trend of maternal and child mortality in Nigeria. This systematic review has also shown that more MNCH intervention research and publications of findings is required to generate local and relevant evidence. Strategies for improving the quality of health care in maternal and child health in low- and middle-income countries: an overview of systematic reviews Althabe, F., Bergelb, E., Cafferatac, M.L., Gibbonsa, L., Ciapponia, A., Colantonioa, A.A.L. and Palaciosa, A.R. (2008) Paediatric and Perinatal Epidemiology http://www.ncbi.nlm.nih.gov/pubmed/18237352 The study identified 30 systematic reviews that fulfilled inclusion criteria, covering a wide range of interventions and several specific behaviours related to MCH. One of the main challenges in developing countries is to make interventions of demonstrated efficacy widely available to underserved populations, thus bridging the ‘know-do gap.’ There is a series of interventions that could, if implemented, result in a significant reduction of maternal, infant and child morbidity and mortality globally. However, those interventions are not widely used in LMICs. Effective interventions to reduce neonatal mortality, such as newborn temperature management, are only used in 20% of births, and the administration of antenatal steroids is used in no more than 5% of preterm births. Theoretically, the implementation of known interventions could reduce neonatal and child mortality by 40–70% in less developed countries. There is an urgent need to use effective approaches in order to disseminate and scale up effective interventions. Decision-makers in LMICs should have access to evidence-based information regarding which strategies have been proven to be effective in ensuring that health care providers involved in maternal and child care administer beneficial, preventive or therapeutic interventions to the population of mothers and children. There is support for the concept that quality-improvement interventions (broadly defined as strategies to ensure delivery of effective services efficiently and equitably) can be used effectively to disseminate evidence-based practices among clinicians in industrialised countries. Whether this can be 15 shown in resource-poor developing countries is uncertain, as there is little research done in LMICs. Therefore, any summary of effective strategies needs to discuss their applicability in LMICs settings. Approximately 50% of births in LMICs occur at home; often, these births take place in rural areas without skilled attendants. Ignoring this fact could result in the selection of inappropriate strategies that fail to promote the use of beneficial practices among those who most need them, thus increasing health inequalities. It is widely recognised that a systematic approach to judging and summarising the evidence helps protect against errors, resolve disagreements, facilitate critical appraisal and communicate information. Therefore, when making decisions, policymakers should have access to information from systematic reviews of research studies. Interactive workshops, reminders and multifaceted interventions can improve professional practice, and they generally have moderate effects. Educational outreach visits consistently improve prescribing but have variable effects on other behaviours. Audit and feedback interventions have variable effects on professional practice, but most often these are small to moderate effects. Mass-media and patient- mediated interventions may change professional practice. Multifaceted interventions that combine several quality-improvement strategies are also effective but may not be more so than single interventions. While all of these strategies are applicable to MCH in LMICs, the applicability of the results to rural settings, in particular, may be limited. Use of these strategies could exacerbate inequalities, and this should be taken into consideration when planning implementation. Scaling up and sustainability may be difficult to achieve in LMIC contexts and need careful consideration. The use of financial interventions has not been well studied; financial incentives and disincentives may be difficult to use effectively and efficiently, although their impact on practice needs to be considered. Organisational interventions are likely to be important, given that there are often underlying organisational or system problems. Regulatory interventions have not been well evaluated, but may sometimes be both inexpensive and effective. There are no ‘magic bullets’ or simple solutions for ensuring the quality of health care services. Interventions should be selected or tailored to address the underlying reasons for a failure to deliver effective services. Decision-makers should select the most appropriate interventions for specific problems. This requires a governance structure that clearly assigns responsibility for quality-improvement activities, priority setting, selection and design of interventions, and evaluation. There are many systematic reviews of continuing education programmes and educational strategies for quality improvement in health care. Most of the reviewed studies are one-off evaluations rather than impact evaluations with long-term follow-up. There are few systematic reviews of organisational, financial and regulatory interventions, and few high-quality studies. These interventions are probably as or more important than educational strategies, although they are less well evaluated. Few studies have been undertaken in LMICs or that address MCH. Thus, the results of the available studies and reviews need to be interpreted cautiously when applied to LMICs. 16 Table 1. Summary of findings for each category of strategy Continuing education and quality assurance Intervention Description Targeted health care providers Number of reviews (range of studies included in the reviews) Review quality Observed results Comments Professional practice Health care outcomes Compared with other single strategies? Distribution of educational materials Passive distribution of printed or audiovisual educational materials Any health care provider (2 reviews), primary care health providers (4 reviews) 6 reviews (1–28 studies) 4.5–6 Mostly ineffective (4 reviews) or modest effect (1 review). Median effect +8.1% absolute improvement in performance (range +3.6 to +17.0) No statistically significant differences (1 review) Not compared (5 reviews). Less effective (1 review) Usually ineffective unless combined with other strategies Audit and feedback Any summary of clinical performance of health care over a specified period of time. The summary may also include recommendations for clinical action. The information may be given in a written, electronic or verbal format Any type of health care professionals responsible for patient care 10 reviews (2–51 studies) Median 5 (range 4.5–6) Small to moderate positive effects reported in the 9 reviews. Not effective in 1 review The magnitude of the effect varied from −17% to +49% change No statistically significant differences (1 review) Less effective than reminders (2 reviews) and opinion leaders (1 review). More effective than incentives (1 review). As effective as patient education, self- study education and practice-based education (1 review) – Reminders Any intervention (manual or computerised) that prompts the provider to perform a clinical action All type of providers 7 reviews (3–52 studies) 4.5–6 All reviews showed some degree of positive change (small to moderate changes). The effect size range from −1.0% to +34.0%) No statistically significant differences in most studies (1 review) Equally effective as giving the patient a handout and a questionnaire about her or his current preventive care status (1 review) – Educational meetings Planned educational activities: meetings, conferences, lectures, workshops, seminars, symposia, and courses that occurred off-site from the practice setting All types of health care providers 7 reviews (3–45 studies) 4.5–6 Small to moderately large effects (absolute change 1%–30%) observed in the 5 reviews with active approaches (interactive workshops, small group sessions, tutorial sessions). More passive approaches Unclear. Only one study in one review showed beneficial effects in asthma symptoms in children Less effective than multifaceted strategies that included education meetings as one component (3 reviews). Two reviews did not report such comparisons – 17 Table 1. Summary of findings for each category of strategy Continuing education and quality assurance Intervention Description Targeted health care providers Number of reviews (range of studies included in the reviews) Review quality Observed results Comments Professional practice Health care outcomes Compared with other single strategies? (didactic sessions like conferences or lectures) did not show effects Local consensus processes Inclusion of participating providers in discussion to ensure agreement that the chosen clinical problem is important and the approach to managing it appropriate All type of health care providers 1 review (10 studies) 5.5 No evidence of effectiveness – Not reported – Problem-based learning in continuing medical education Tutor facilitated, problem-based learning session in which a small, self-directed group starts with a brainstorming session. A problem is posed that challenges their knowledge and experience. Learning goals are formulated by consensus and new information is learnt by self-directed study. It ends with a group discussion and evaluation General practitioners 1 review (6 studies) 4.5 Not effective Unclear More effective than lectures – Education outreach visits Use of a trained person who meets with providers in their practice settings to provide information. The information given may include feedback on the provider's performance All types of health care providers 5 reviews (1–8 studies) 4.5–6 Effective for prescribing (50% of relative improvement in one study). Unclear if effective for preventive services Unclear Outreach visits are more effective than audit and feedback (1 review) – Local opinion leaders Those health providers perceived by their colleagues as ‘educationally influential’ Health care professionals in charge of patient care 2 reviews (8–12 studies) 5.5 Likely to produce small positive changes (ARD varied from −0.06 (favours control group) to +0.12 (favours intervention) – Shown to be more effective than feedback or didactic educational meetings – 18 Table 1. Summary of findings for each category of strategy Continuing education and quality assurance Intervention Description Targeted health care providers Number of reviews (range of studies included in the reviews) Review quality Observed results Comments Professional practice Health care outcomes Compared with other single strategies? Patient- mediated interventions Any interventions aimed at changing the performance of health care providers for which information was sought from or given directly to patients by others All types of health care providers 2 reviews (7–10 studies) 5.5–6 Not effective when implemented alone (1 review) Moderate to large effects. Median absolute effects of +20.8% (range +10.0 to +25.4%) (1 review) – Not reported – Mass media Channels of mass communication (including radio, television, newspapers, magazines, leaflets, posters and pamphlets) on the utilisation of health services Health care providers, patients and general public 1 review (20 studies) 5.5 Effective strategy. Change in effect size ranging from 0.1% to −13.1% in the desired direction – Not reported – Multifaceted interventions Any intervention that includes two or more of the following interventions: educational materials, conferences, outreach visits, local opinion leaders, patient-mediated, audit and feedback, office systems, and economic incentives All types of health care providers 10 reviews (1–117 studies) 4.5–6 Effective: 10 reviews found positive changes. The range of the absolute changes found was from 1% to 64% Unclear: 3 reviews reported evidence in favour and against Unclear: 3 reviews showed combined strategies were more effective than single; 2 reviews found heterogeneous results – Tailored interventions to overcome identified barriers to change Interventions tailored to address specified barriers to change in health providers: focus group discussions, surveys, interviews Health providers 2 reviews (3–15 studies) 5.5 Tailored interventions may improve health providers’ performance and health care outcomes, but the results are inconclusive. Combined OR in one review: 2.18 [1.09, 4.34] in favour of tailored interventions) – – Effectiveness remains uncertain and more rigorous trials (including process evaluations) are needed 19 Organisation of care Intervention Description Targeted health care providers Number of reviews (range of studies included in the reviews) Review quality Observed results Comment s Professional practice Health care outcomes Compared with other single strategies? Formal integration of services Integration of primary health care services Health workers delivering care at primary level 2 reviews (2 and 5 studies) 6 No consistency in the results, or partially effective (+2.1% relative improvement) – No consistent pattern of benefit – Improving office systems Organisation of office systems to increase the use of health service procedures Health workers 2 reviews (3 and 6 studies) 5–6 Effective to increase use of health services – Screening and referral by nurses, more effective than only screening by nurses. Screening during a routine visit more effective than physician reminder. Assistance from facilitators of nurses in the design and implementation of office routines and tools for increasing screening uptake more effective than continuing medical education – Structural interventions: changes in medical record systems Nursing record systems Nurses, students or health care assistants working under the direction of a qualified nurse 1 review (8 studies) 5.25 Inconclusive. Further research needed – – All RCT Financial interventions Intervention Description Targeted health care providers Number of reviews (range of studies included in the reviews) Review quality Observed results Comments Professional practice Health care outcomes Compared with other single strategies? 1. ARD, adjusted risk difference; OR, odds ratio; RCT, randomised controlled trials. Providers’ incentives Fundholding in practices Health providers 2 reviews (3–6 studies) 4.5 Unclear – – Well-designed trials of management were rarely found 20 Measuring Quality in Maternal-Newborn Care: Developing a Clinical Dashboard Ann E. Sprague, RN, PhD, Sandra I. Dunn, RN, PhD, Deshayne B. Fell, MSc, JoAnn Harrold, MD, FRCPC, Mark C. Walker, MD, FRCSC, Sherrie Kelly, MSc, Graeme N. Smith, MD, PhD, FRCSC; J Obstet Gynaecol Can; 35(1):29–38 (2013) http://www.jogc.com/article/S1701-2163(15)31045-8/pdf Pregnancy, birth, and the early newborn period are times of high use of health care services. As well as opportunities for providing quality care, there are potential missed opportunities for health promotion, safety issues, and increased costs for the individual and the system when quality is not well defined or measured. There has been a need to identify key performance indicators (KPIs) to measure quality care within the provincial maternal-newborn system. The authors also wanted to provide automated audit and feedback about these KPIs to support quality improvement initiatives in a large Canadian province with approximately 140,000 births per year. They therefore worked to develop a maternal- newborn dashboard to increase awareness about selected KPIs and to inform and support hospitals and care providers about areas for quality improvement. The authors mapped maternal-newborn data elements to a quality domain framework, sought feedback via survey for the relevance and feasibility of change, and examined current data and the literature to assist in setting provincial benchmarks. Six clinical performance indicators of maternal-newborn quality care were identified and evidence-informed benchmarks were set. A maternal-newborn dashboard with “drill down” capacity for detailed analysis to enhance audit and feedback is now available for implementation. While audit and feedback does not guarantee individuals or institutions will make practice changes and move towards quality improvement, it is an important first step. Practice change and quality improvement will not occur without an awareness of the issues. 21 Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation Basinga, P. Gertler, PJ. Binagwaho, A. Soucat, Agnes LB. Sturdy. Vermeersch, Christel MJ. (2011) The Lancet Volume 377, No. 9775 http://www.thelancet.com/article/S0140-6736%2811%2960177-3/abstract Background: Evidence about the best methods with which to accelerate progress towards achieving the MDGs was urgently needed. The authors assessed the effect of performance-based payment of health-care providers (payment for performance; P4P) on use and quality of child and maternal care services in health-care facilities in Rwanda. Methods: 166 facilities were randomly assigned at the district level either to begin P4P funding between June 2006, and October 2006 (intervention group; n=80), or to continue with the traditional input-based funding until 23 months after study baseline (control group; n=86). Randomisation was done by coin toss. Facilities and 2158 households were surveyed at baseline and after 23 months. The main outcome measures were prenatal care visits and institutional deliveries, quality of prenatal care, and child preventive care visits and immunisation. The authors isolated the incentive effect from the resource effect by increasing comparison facilities' input-based budgets by the average P4P payments made to the treatment facilities. A multivariate regression estimated specification of the difference-in-difference model in which an individual's outcome is regressed against a dummy variable, indicating whether the facility received P4P that year, a facility-fixed effect, a year indicator, and a series of individual and household characteristics. Findings: The model estimated that facilities in the intervention group had a 23% increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger (56%) and aged between 24 months and 59 months (132%). No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules. The authors also estimate an increase of 0·157 standard deviations (95% CI 0·026–0·289) in prenatal quality as measured by compliance with Rwandan prenatal care clinical practice guidelines. Interpretation: The P4P scheme in Rwanda had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider. P4P financial performance incentives can improve both the use and quality of maternal and child health services, and could be a useful intervention to accelerate progress towards MNCH development targets. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis Cousens et al (2011) The Lancet, Volume 377, No. 9774, p1319–1330 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62310-0/abstract This study draws attention to the dearth of reliable data in regions where most stillbirths occur. The estimated trend in stillbirth rate reduction is slower than that for maternal mortality and lags behind the increasing progress in reducing deaths in children younger than 5 years. Improved data and improved use of data are crucial to ensure that stillbirths count in global and national policy. Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care Renfrew, MJ. McFadden, A. Bastos, MH. Campbell, J. Channon, AA. Cheung, NF and others, (2014) The Lancet, Volume 384, No. 9948, p1129–1145 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60789-3/fulltext The authors identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Findings support a system-level shift from maternal and newborn care focused on 22 identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation. There are established and documented associations between maternal survival and child outcomes. These include clinical associations such as obstetric complications contributing to stillbirths and early neonatal deaths, and other repercussions such as low survival rates of infants following the death of their mother. Figures 1.8, 1.9 and 1.10 show global and regional variations in the maternal mortality data, overlaid with key neonatal and child indicators. Maternal mortality and early neonatal deaths Figure 1.8: Maternal and early neonatal mortality, global and regional Data sources: WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division 2014. | Wang, H., Liddell, C., Coates, M., Moobey, M., Levitz, C et al 2014. 23 4. Cost effectiveness Packages of interventions: Family planning, safe abortion care, maternal, newborn and child health UNICEF, UNFPA, WHO, World Bank, 2010 http://apps.who.int/iris/bitstream/10665/70428/1/WHO_FCH_10.06_eng.pdf The evidence shows that high maternal, perinatal, neonatal and child mortality rates are associated with inadequate and poor quality health services. Evidence also suggests that explicit, evidence-based, cost effective packages of interventions can improve the processes and outcomes of health care when appropriately implemented. This document describes the key effective interventions organised in packages across the continuum of care through pre-pregnancy, pregnancy, childbirth, postpartum, newborn care and care of the child. The packages are defined for community and/or facility levels in developing countries and provide guidance on the essential components needed to assure adequacy and quality of care. Assessing the costs and cost-effectiveness of rapid-scale up for the maternal, neonatal and child health: The economic component of the impact evaluation strategy for the Catalytic Initiative Johns, B, Opumi-Akuamoa, M, Walker, D, Draft version http://www.jhsph.edu/research/centers-and-institutes/institute-for-international- programs/_documents/rapid_scaleup/CI_costeffectiveness.pdf 24 Investing in Maternal, Newborn and Child Health WHO, 2009 http://www.who.int/pmnch/topics/investinginhealth.pdf Why is spending critical? This article focuses on Asia but makes some useful points on cost effectiveness, with detail on the five areas below. Spending in the region – on MNCH and health in general – must not only be increased but must also be improved. It currently suffers from five problems that governments and their development partners can fix. 1. Increase spending 2. Increase efficiency Dramatic reductions of mortality achieved in low-resource settings: evidence from Sri Lanka In 1950, the maternal mortality ratio (MMR) in Sri Lanka was very high, at more than 500 deaths per 100,000 live births. In the same period, gross national product (GNP) per capita was only US$270. Despite being constrained by its limited resources, Sri Lanka managed to reduce the MMR to below 100 by the mid- 1970s – far lower than many countries with similar or higher income levels. Today Sri Lanka’s MMR is about 50. A recent evaluation of Sri Lanka’s experience identified several critical success factors headed by political will to invest in maternal health. Services were free to those who could not pay, and the decision was taken to expand access to underserved areas, with a focus on the most appropriate interventions. Emergency obstetric care was developed. More skilled birth attendants were made available to help mothers in labour. This was achieved by training a large number of midwives and by promoting the service and improving its quality. Pregnant women were encouraged to consider they had a right to a skilled birth attendant. Progressive and sequenced investment was an important part of the programme’s success. This focused initially on recruiting more midwives and strengthening their capacity. Investments were then made in the primary health care system, and finally in hospitals. 3. Increase equity Inequity in health access and outcomes is rising – with adverse social and political consequences. Where do households spend their money for health care for children less than five years of age? The Multi-Country Evaluation of the Integrated Management of Childhood Illness (IMCI) found that household out-of-pocket expenditure per child in Bangladesh was US$4.50 lower in areas with IMCI compared to areas without IMCI. Households were paid twice as much per child out of their own pockets in areas without IMCI. On the other hand, the costs per child to service providers almost doubled in IMCI areas. This apparent shift in source of funding for child health care in IMCI and comparison areas has important implications for programmatic and budgeting decisions. Clearly, providing services for under-fives through the IMCI model was beneficial to households by reducing their financial burden of seeking and obtaining care. Further work should explore if the poorest households were those who benefited the most. Equally important, the intervention in the study areas was associated with an additional cost to the provider of US$ 5.5 per child per year - more than doubling these costs. 4. Incentives matter Using the power of financing to influence incentives and improve access to maternal health services In India, the State Government of Gujarat launched the Chiranjeevi Scheme in 2005, which aims to improve access to institutional delivery among families living below the poverty line. This is accomplished through a voucher scheme that provides free treatment during delivery including all medicines. The scheme also covers the mother’s out-of-pocket travel costs to reach the health care facility, and offers financial support to cover loss of wages for the person who accompanies her. Private medical practitioners (mainly gynaecologists) have been enrolled in the scheme to provide maternal health services. The providers are reimbursed at a fixed rate for the deliveries they carry out. Recent evaluations of the scheme found that in 2007-2008 it led to a doubling of the number of deliveries taking place in health care facilities in the State. It has been estimated that the programme has helped to avert close to 1,000 maternal deaths and close to 1,000 newborn deaths. It has also been successful in reducing financial barriers. People using the scheme spent on average 727 Rupees (about US$14.50) on a delivery, compared to 1,658 Rupees (about US$33.50) previously. Almost all (96%) of women using the scheme had used antenatal care services before delivery (the average number of visits was 2.84). Only one delivery among beneficiaries of the scheme was conducted at home, whereas 21% of non-beneficiaries delivered at home. Beneficiaries of the scheme were also more likely to be attended by a skilled provider than non-beneficiaries. In recognition of its success, the Chiranjeevi Scheme 25 received the Asian Innovation Award in 2006 from the Wall Street Journal. The programme is being expanded to other areas in Gujarat and is also being replicated in other states of India. 5. Integration matters Too often, key programmes that build health systems and determine reproductive, MNCH outcomes are not fully implemented or their funding is curtailed. The reasons are often a fall in support from donors and inconsistent domestic political and financial support. Furthermore, programmes and interventions are often not integrated according to the continuum of care approach. This promotes access to care in line with levels of care (families and communities, outreach services, and clinical services) and at critical times for MNCH (including adolescence, pre-pregnancy, pregnancy, childbirth, the postnatal period, and childhood). There is often a lack of “one country” health plans and budgets that reflect all levels of care for MNCH along the continuum of care. This often results in fragmented and uncoordinated financing by donors and governments, which prevents a holistic and integrated approach to implementation and financing of MNCH interventions. Cost effectiveness analysis of strategies for child health in developing countries. Edejer TT, Aikins M, Black R, Wolfson L, Hutubessy R, Evans DB, BMJ. 2005 Nov 19;331(7526):1177. Epub 2005 Nov 10. http://www.ncbi.nlm.nih.gov/pubmed/16282378 Objective: To determine the costs and effectiveness of selected child health interventions-namely, case management of pneumonia, oral rehydration therapy, supplementation or fortification of staple foods with vitamin A or zinc, provision of supplementary food with counselling on nutrition, and immunisation against measles. Design: Cost effectiveness analysis. Data Sources: Efficacy data came from published systematic reviews and before and after evaluations of programmes. For resource inputs, quantities came from literature and expert opinion, and prices from the WHO Choosing Interventions that are Cost Effective (WHO-CHOICE) database. Results: Cost effectiveness ratios clustered in three groups, with fortification with zinc or vitamin A as the most cost effective intervention, and provision of supplementary food and counselling on nutrition as the least cost effective. Between these were oral rehydration therapy, case management of pneumonia, vitamin A or zinc supplementation, and measles immunisation. Conclusions: On the grounds of cost effectiveness, micronutrients and measles immunisation should be provided routinely to all children, in addition to oral rehydration therapy and case management of pneumonia for those who are sick. The challenge of malnutrition is not well addressed by existing interventions. 5. Sexual and reproductive health (SRH) Sexual and reproductive health for all: The challenge still stands Mahmoud F. Fathalla (2015) Glob Public Health; 10(2): 135–136. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4318116/ This Global Public Health Special Issue ‘SRHR for the next decades: What's been achieved? What lies ahead?’ assesses progress 20 years after the 1994 International Conference on Population and Development (ICPD), which established the SRH and rights framework for population and health policy (UN, 1995). Contributors from different regions demonstrate that the challenges recognised by the ICPD still stand, and that lessons learned provide a clear way forward for the world's governments as they convene at the UN to agree on priority actions, and a post-2015 global development agenda. Fulfilment of SRH and rights enables people to have a satisfying and safe sex life, to reproduce if and when they desire and to have access to the health services and information necessary to make informed decisions, free of discrimination, coercion and violence (UN, 1995). According to a recent UN Global 26 Review Report, progress has been made in the implementation of the ICPD agenda, but still falls short of the ICPD goal of SRH for all (UN, 2014). International and national commitments have not been matched with action to improve the lives of people, particularly women, across the UN’s one world. One of the starkest examples is the persistent pandemic of violence against women. Global and national indicators of progress are welcome, but mask harsh inequity, between and within countries (Barros et al., 2012). The better-off drive progress indicators upwards, while the marginalised and the underprivileged are left behind. The penalties for these shortfalls are heavy in terms of avoidable human suffering and lost opportunities for economic and human development. Health and rights in sexuality and reproduction are an integrated package (Fathalla, 2002), which, the ICPD agreed, includes SRH services (family planning, maternity care, safe abortion, prevention and treatment of STIs and HIV, among others); comprehensive sexuality education; and protection of sexual and reproductive rights. People cannot be healthy if they have one element of the package but miss others (Germain, Dixon-Mueller, & Sen, 2009). The papers in this Special Issue show that progress on the components of SRH and rights has been uneven. While acknowledging that certain components may be more difficult or more costly to implement, progress in many instances has been hindered on ideological, rather than scientific, public health and cost-effectiveness grounds. This Special Issue also considers the central role of addressing the underlying social and political determinants of SRH and rights, as well as work towards universal health coverage, currently facing an uphill struggle (The Lancet, 2012). Papers and commentaries stress that a human rights platform is essential for all of this work, along with strengthening of health systems, and design and delivery of comprehensive and integrated packages of health services and information. Sexual and reproductive health: Progress and outstanding needs Rachel C. Snow, Laura Laski & Massy Mutumba (2015) Global Public Health, Issue 2, Volume 15, pages 149-173. http://www.tandfonline.com/doi/abs/10.1080/17441692.2014.986178?src=recsys The authors examine progress towards the 1994 ICPD commitment to provide universal access to SRH services by 2014, with an emphasis on changes for those living in poor and emerging economies. Accomplishments include a 45% decline in the maternal mortality ratio (MMR) between 1990 and 2013; 11.5% decline in global unmet need for modern contraception; ~21% increase in skilled birth attendance; and declines in both the case fatality rate and rate of abortion. Yet aggregate gains mask stark inequalities, with low coverage of services for the poorest women. Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 80 developing countries highlight persistent disparities in skilled birth attendance by household wealth: in 70 of 80 countries (88%), ≥80% of women in the highest quintile were attended by a skilled provider at last birth; in only 23 of the same countries (29%) was this the case for women in the lowest wealth quintile. While there have been notable declines in HIV incidence and prevalence, women affected by HIV are too often bereft of other SRH services, including family planning. Achieving universal access to SRH will require substantially greater investment in comprehensive and integrated services that reach the poor. Advancing sexual and reproductive health and rights in low- and middle-income countries: Implications for the post-2015 global development agenda Adrienne Germain, Gita Sen, Claudia Garcia-Moreno & Mridula Shankar, (2015) Global Public Health, Issue 2, Volume 15, pages 137-148 http://www.tandfonline.com/doi/abs/10.1080/17441692.2014.986177?src=recsys The papers and commentaries in this special issue illuminate progress made by low- and middle-income countries towards implementation of the Programme of Action (PoA) agreed by 179 countries during the 1994 ICPD. The PoA presents a path-breaking SRH and rights (SRHR) framework for global and national population and health policies. While progress towards implementation has been made at global, regional and national levels, continuing and new challenges require that high priority be given to SRHR for all, particularly women and girls, during the remaining months of the millennium development goals and in the UN post-2015 development agenda. This paper highlights three critical gaps, raised in other papers: inequalities in access to SRH information and services; the widespread 27 need to improve SRH services to meet public health, human rights and medical ethics standards for quality of care; and the absence or inadequate use of accountability mechanisms to track and remedy the other two. We discuss priority actions to achieve equality, quality and accountability in SRHR policies, programmes and services, especially those that should be included in the post-2015 development agenda. Sexual and reproductive health and rights in changing health systems. Sen G, Govender V. (2015) Glob Public Health.;10(2):228-42. doi: 10.1080/17441692.2014.986161. http://www.ncbi.nlm.nih.gov/pubmed/25536851 SRH and rights (SRHR) are centrally important to health. However, there have been significant shortcomings in implementing SRHR to date. In the context of health systems reform and universal health coverage/care (UHC), this paper explores the following questions. What do these changes in health systems thinking mean for SRHR and gender equity in health in the context of renewed calls for increased investments in the health of women and girls? Can SRHR be integrated usefully into the call for UHC, and if so how? Can health systems reforms address the continuing sexual and reproductive ill health and violations of sexual and reproductive rights (SRR)? Conversely, can the attention to individual human rights that is intrinsic to the SRHR agenda and its continuing concerns about equality, quality and accountability provide impetus for strengthening the health system? The paper argues that achieving equity on the UHC path will require a combination of system improvements and services that benefit all, together with special attention to those whose needs are great and who are likely to fall behind in the politics of choice and voice (i.e., progressive universalism paying particular attention to gender inequalities). Adolescent girls are a specific group to consider. Although there is a variation in fertility rates among adolescents, prevention of pregnancy is of key importance because they are at a higher risk of complications and death than older women. However, if pregnancy does occur during adolescence, special needs have to be considered and the risks associated mean that antenatal care and skilled attendance at birth is crucial. Adolescent Sexual and Reproductive Health in Developing Countries: An Overview of Trends and Interventions Michelle J. Hindin Adesegun O. Fatusi, First published online: June 26, 2009 https://www.guttmacher.org/about/journals/ipsrh/2009/06/adolescent-sexual-and-reproductive-health- developing-countries-overview Because most youth obtain at least some education particularly with the international recognition of the importance of schooling (e.g. the MDGs), school-based programmes appear to be a logical choice for SRH education. However, according to recent reviews of school-based HIV interventions, such programmes have had mixed results In addition, such interventions miss adolescents who are not in school. At the same time, the provision of comprehensive SRH interventions in developing countries has been impeded by ideologically driven restrictions. Many community-based programmes have had to focus on HIV prevention rather than comprehensive SRH, again because of funding restrictions. Another potential avenue for improving SRH outcomes for young people is parent-child communication. However, most of today's parents were not taught about SRH by their own parents or even in school, leaving them unable to pass on crucial knowledge to their children. The discomfort many parents feel about talking to their children about sexuality further impedes their ability to provide guidance. A review of interventions addressing structural drivers of adolescents’ sexual and reproductive health vulnerability in sub-Saharan Africa: implications for sexual health programming Joyce Wamoy, Gerry Mshana, Aika Mongi, Nyasule Neke, Saidi Kapiga and John Changalucha (2014) Reproductive Health, 11:88 https://reproductive-health-journal.biomedcentral.com/articles/10.1186/1742-4755-11-88 Sub-Saharan Africa (SSA) continues to bear the brunt of the HIV epidemic, with two thirds of those infected residing in the region. Women and girls are the most affected accounting for 60% of the people 28 living with HIV from the region. Young people aged 15-24 years account for an estimated 45% of new infections globally. In this age group, women aged 15-24 years are eight times more likely to be infected than young men, pointing to the urgent need for prevention efforts to focus on girls to abate the epidemic. Young people, particularly women, are at increased risk of undesirable SRH outcomes. Structural factors have been reported as driving some of these risks. Although several interventions have targeted some of the structural drivers for adolescent’s SRH risk, little has been done to consolidate such work. This would provide a platform for coordinated efforts towards adolescent’s SRH. This article provides a narrative summary of interventions in SSA addressing the structural drivers of adolescents’ SRH risk, explore pathways of influence, and highlight areas for further work. Thirty-three abstracts and summary reports were retrieved and narrowed down by suitability. Fifteen documents met the inclusion criteria and were read in full. Papers and reports were manually reviewed and 15 interventions that met the criteria for inclusion were summarised in a table format. Most of the interventions addressed multiple structural factors, such as social norms, gender inequality, and poverty. Some interventions focused on reducing economic drivers that increased sexual risk behaviours. Others focused on changing social norms and thus sexual risk behaviours through communication. Social norms addressed included gender inequality, gender violence, and child socialisation. The interventions included components on comprehensive sexuality and behaviour change and communication and parenting, using different designs and evaluation methods. Important lessons from the narrative summary included the need for a flexible intervention design when addressing adolescents, the need for coordinated effort among different stakeholders. There are encouraging efforts towards addressing structural drivers among adolescents in SSA. There is, however, a need for interventions to have a clear focus, indicate the pathways of influence, and have a rigorous evaluation strategy assessing how they work to reduce vulnerability to HIV. There is also a need for coordinated effort among stakeholders working on adolescent vulnerability in SSA. Sexual and reproductive health for all: a call for action Mahmoud F Fathalla, Steven W Sinding, Allan Rosenfield, (2006) The Lancet Sexual and Reproductive Health Series http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69483-X/abstract At the ICPD in 1994, the international community agreed to make reproductive health care universally available no later than 2015. After a 5-year review of progress towards implementation of the Cairo programme of action, that commitment was extended to include sexual, as well as reproductive, health and rights. Although progress has been made towards this commitment, it has fallen a long way short of the original goal. SRH is achievable if cost-effective interventions are properly scaled up; political commitment is revitalised; and financial resources are mobilised, rationally allocated, and more effectively used. National action needs to be backed up by international action. Sustained effort is needed by governments in developing countries and in the donor community, by inter-governmental organisations, NGOs, civil society groups, the women's health movement, philanthropic foundations, the private for-profit sector, the health profession, and the research community. The rest of this section is adapted from a previous helpdesk report: Effective (and cost-effective) approaches to increase access and voluntary use of modern methods of contraception by marginalised and neglected groups Stephanie Bengtsson (August 2015) HEART Helpdesk (Available on request) School-based reproductive health programmes: great potential; mixed results Because most youth obtain at least some education, particularly with the international recognition of the importance of schooling (e.g. the MDGs), school-based programmes appear to be a logical choice for SRH education. However, according to recent reviews of school-based HIV interventions, such programmes have had mixed results. In addition, such interventions miss adolescents who are not in school. At the same time, the provision of comprehensive SRH interventions in developing countries 29 has been impeded by ideologically driven restrictions. Many community-based programmes have had to focus on HIV prevention rather than comprehensive SRH, again because of funding restrictions (Hindin & Fatusi, 2009, p.58). In Speizer et al.’s (2003) extensive review of adolescent reproductive health looks at studies of two different types of SRH school-based programmes – those that focus on HIV/AIDS/STI education and those that focus on general RH programmes. Well-constructed HIV/AIDS education programmes that are sustained over some time are effective in changing the sexual and contraceptive behaviours of sexually active young people and, consequently, indirectly reducing the number of unwanted or unsafe pregnancies among adolescents and young women. Fourteen of the school-based programmes reviewed focused on HIV/AIDS/STI education and 11 of those demonstrated at least a short-term effect on relevant knowledge and attitudes post- intervention. 2 programmes failed to demonstrate effect, while the remaining programme did not assess effects on knowledge. Six of the 14 school-based HIV/AIDS interventions demonstrated behavioural effects. In Ibadan, Nigeria, an adapted HIV/AIDS curriculum was implemented in two 6-hour sessions over 6 weeks. At 6-month follow-up, intervention youth reported fewer sexual partners than control youth (Fawole et al., 1999). In Namibia, a randomised control study found that female virgins from the intervention group were more likely to remain virgins at 12-month follow-up than female virgins from the control group (Fitzgerald et al., 1999; Stanton et al., 1998). Behavioural effects have also been observed in one-time, in-school interventions. In Zimbabwe, a skills-based 90-minute intervention using a randomised control group design found that at 4-month follow-up, the study participants reported fewer sexual partners, and fewer episodes of unprotected sex in the last month than the control students (Wilson, Mparadzi & Lavelle, 1991). Eight of the programmes reviewed were evaluations of general RH programmes. Impact knowledge and/or attitudes were observed in 6 of the 8 programmes. The 2 programmes that found no effect on knowledge or attitudes were a values-based fertility awareness and education curriculum (Teen Star) tested in private and public schools in Santiago, Chile (Seidman et al., 1995) and an integrated school- and facility-based programme in Brazil (Magnani et al., 2001). In the latter case, sexual RH education was introduced into control schools which likely explains the why there was no observable effect in comparison with control schools. A more recent but less comprehensive systematic review of school-based health interventions in sub- Saharan Africa found only 12 articles that met its inclusion criteria, suggesting evidence of evaluation of school-based programmes is limited (Ebhohimhen et al., 2008, as referred to in Hindin & Fatusi, 2009). Currently, it seems that “most interventions led to an improvement in knowledge, attitudes and intentions, but few found evidence of lasting behavioural changes” (p.58). Finally, an article by Renju et al. (2011) describes the effect of scaling up a school-based intervention called MEMA kwa Vijana from 62 to 649 schools on coverage and quality in the Northwest of Tanzania. This rigorous study demonstrated that despite various modifications, the 10-fold scale-up achieved high coverage, teachers were enthusiastic and engaged well with students, and students enjoyed the sessions. However, delays in training, teacher turnover and lack of incentive for teaching additional activities were barriers to implementation. The authors argue that high coverage of participatory school-based RH interventions can be maintained during scale-up, though this might require significant changes in programme content and delivery. The authors also note the importance of advanced teacher training, increased supervision, and underpinning of objectives by directives from the national level. Peer programmes & mentoring/role model programmes Peer-focused programmes: Peers play an important role in adolescent development and socialisation. Peers can influence one another either positively or negatively. A review of studies between 1990 and 2010 on risk and protective factors for adolescent SRH found that having peers or friends who had had sex was a risk factor across health outcomes (Mmari & Sabherwal, 2013). Five reviews that assessed the effectiveness of peer education found that some interventions increased SRH knowledge and condom use; delayed first intercourse; promoted gender-equitable attitudes; and prevented STIs. However, the reviews found that the effects of peer-led programmes tend to vary, 30 with the young people who receive the peer training often benefitting the most (Villa-Torres & Svanemyr, 2015). Mentoring and positive role modelling: Programmes in several settings have noted the importance of providing mentors and positive role models to young people as a key to improving SRH outcomes as well as aspirations for fertility, education, and work (Beaman et al., 2009). Research conducted in urban slums in Ethiopia, Kenya, and Nairobi suggests that girls typically have less opportunity than boys in interacting with peers and mentors (Population Council & UN Adolescent Girls Task Force, 2012). Yet, mentors can be a critical social capital to lessen girls’ health and economic risks. Being supported by a female adult role model who demonstrates leadership qualities or having girls themselves take on a visible role within the community and a sense of responsibility can be positive forces for change in the lives of young girls (Salem et al., 2003). Hence, some adolescent health interventions are including components that involve a strong emphasis on building leadership skills, particularly of older adolescents, and training them to run mentoring programmes for younger adolescents. These are yet to be evaluated to know whether they are effective or not. References from helpdesk report section Beaman, L., Chattopadhyay, R., Duflo, E., et al. (2009). Powerful women: Does exposure reduce bias? QJE, 124: 1497-1540 Ebhohimhen, V.A., Poobalan, A. & Van Teijlingen, E.R. (2008). A systematic review of school-based sexual health interventions to prevent STI/HIV in Sub-Saharan Africa. BMC Public Health, 8: 4. Fawole, I.O., Asuzu, M.C., Oduntan, S.O., et al. (1999). A school-based AIDS education programme for secondary school students in Nigeria: A review of effectiveness. Health Education Research, 14: pp.675-683. Fitzgerald, A.M., Stanton, B.F., Terrieri N., et al. (1999). Use of western-based HIV risk-reduction interventions targeting adolescents in an African setting. Journal of Adolescent Health, 25: pp.52- 61. Hindin, M. J., & Fatusi, A. O. (2009). Adolescent Sexual and Reproductive Health in Developing Countries: An Overview of Trends and Interventions. International Perspectives on Sexual and Reproductive Health, 35(2), 58–62. Retrieved from http://www.guttmacher.org/pubs/journals/3505809.html Magnani, R.J., Gaffikin, L., Leao de Aquino, E.M., et al. (2001). Impact of an integrated adolescent reproductive health program in Brazil. Studies in Family Planning, 32: 230-243. Mmari, K. & Sabherwal, S. (2013). A review of risk and protective factors for adoles- cent sexual and reproductive health in developing countries: An update. Journal of Adolescent Health, 53: 562- 572. Population Council and UN Adolescent Girls Task Force. (2012). Girls’ leadership and mentoring. Available at: http://www.popcouncil.org/pdfs/2012PGY_ GirlsFirst_Leadership.pdf. Renju, J. R., Andrew, B., Medard, L., Kishamawe, C., Kimaryo, M., Changalucha, J., & Obasi, A. (2011). Scaling up adolescent sexual and reproductive health interventions through existing government systems? A detailed process evaluation of a school-based intervention in Mwanza Region in the Northwest of Tanzania. Journal of Adolescent Health, 48(1), 79–86. http://doi.org/10.1016/j.jadohealth.2010.05.007 Salem, R., Ibrahim, B. & Brady, M. (2003). Negotiating leadership roles: Young women’s experiences in rural Upper Egypt. Women’s Studies Quarterly, 31: 174-191. Seidman, M., Vigil, P., Klaus, H., et al. (1995). Fertility Awareness Education in the Schools: A Pilot Program in Santiago Chile. Paper presented at the annual meeting of the American Public Health Association, San Diego, CA, October 31, 1995. Speizer, I. S., Magnani, R. J., & Colvin, C. E. (2003). The effectiveness of adolescent reproductive health interventions in developing countries: a review of the evidence. Journal of Adolescent Health, 33(5), 324–348. http://doi.org/10.1016/S1054-139X(02)00535-9 Stanton, B., Li, X., Kahihuata, J., et al. (1998). Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: A randomized, longitudinal study. AIDS, 12: pp.2473-2480. Svanemyr, J., Amin, A., Robles, O. J., & Greene, M. E. (2015). Creating an Enabling Environment for Adolescent Sexual and Reproductive Health: A Framework and Promising Approaches. Journal of Adolescent Health, 56(1), S7–S14. http://doi.org/10.1016/j.jadohealth.2014.09.011 Villa-Torres, L. & Svanemyr, J. (2015). Ensuring youth’s right to participation and promotion of youth leadership in development of sexual and reproductive health policies and programs. Journal of Adolescent Health, 56: S51-S57. 31 Wilson, D., Mparadzi, A., & Lavelle, S. (1991). An experimental comparison of two AIDS prevention interventions among young Zimbabweans. Journal of Social Psychology, 132: pp.415-417. 6. Additional information Author This query response was prepared by Catherine Grant, Institute of Development Studies . About Helpdesk reports: The HEART Helpdesk is funded by the DFID Human Development Group. Helpdesk reports are typically based on 3 days of desk-based research per query and are designed to provide a brief overview of the key issues, and a summary of some of the best literature available. Experts may be contacted during the course of the research, and those able to provide input within the short time-frame are acknowledged. For any further request or enquiry, contact info@heart-resources.org HEART Helpdesk reports are published online at www.heart-resources.org Disclaimer The Health & Education Advice & Resource Team (HEART) provides technical assistance and knowledge services to the British Government’s Department for International Development (DFID) and its partners in support of pro-poor programmes in education, health and nutrition. The HEART services are provided by a consortium of leading organisations in international development, health and education: Oxford Policy Management, CfBT, FHI360, HERA, the Institute of Development Studies, IPACT, the Liverpool School of Tropical Medicine and the Nuffield Centre for International Health and Development at the University of Leeds. HEART cannot be held responsible for errors or any consequences arising from the use of information contained in this report. Any views and opinions expressed do not necessarily reflect those of DFID, HEART or any other contributing organisation.

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