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Essential interventions for maternal, newborn and child wellness: background and methodology

Reproductive Wellness book 11, Article number:S1 (2014) Cite this article

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Abstract

Worldwide, 250,000–280,000 women die during pregnancy and childbirth every year and an estimated six.55 one thousand thousand children die under the age of five. The majority of maternal deaths occur during or immediately subsequently childbirth, while 43% of kid expiry occurs during the first 28 days of life. However, the progress in limiting these has been boring and desultory. In this supplement of 5 papers, nosotros aim to systematically assess and summarize essential interventions for reproductive, maternal, newborn and kid health from relevant systematic reviews. This newspaper is an introductory paper detailing the background and methodology used for grading interventions. The post-obit three papers summarize the evidence on essential interventions for pre-pregnancy, pregnancy, childbirth, postnatal (female parent and neonatal) and child heath while the last paper describes the essential interventions as per the level of health care delivery and their proposed packages of care.

Why maternal, newborn and child health?

Poor maternal, newborn and child health care remains a significant trouble in low and middle income countries (LMICs). Worldwide, 250,000–280,000 women die during pregnancy and childbirth every year [i] and an estimated half dozen.55 one thousand thousand children die under the age of 5 [2]. The majority of maternal deaths occur during or immediately after childbirth. A child's take a chance of dying is highest during the first 28 days of life when about 3.5% of nether-five deaths take place, translating into 2.85 million deaths [2]. Upward to one half of all newborn deaths occur within the outset 24 hours of life and 75% occur in the starting time calendar week. Children in LMICs are almost 56 times more probable to die before the age of 5 than children in high-income countries (HICs) [2].

Practiced maternal health care and diet are of import contributors to child survival; maternal infections and other poor conditions often contribute to indices of neonatal morbidity and mortality (including stillbirths, neonatal deaths and other agin clinical outcomes) [iii]. Considering the fact that most maternal and child deaths are preventable using electric current knowledge, the burden of mortality and morbidities is unacceptably loftier. The bulk of maternal deaths occur during labour, delivery, and the immediate postpartum period, with obstetric haemorrhage being the primary medical cause of death. Hypertensive diseases, infections, obstructed labour, and abortion-related complications are the other causes of maternal mortality. The maternal bloodshed ratio is approximately 500 per 100,000 live births in sub-Saharan Africa, compared to around 150 per 100,000 alive births in South Asia and 16 per 100,000 live births in HICs [1]. Furthermore, the main direct causes of neonatal bloodshed and morbidity are infections, complications arising from preterm nativity, and intrapartum-related neonatal deaths, which account for nearly 80% of all neonatal deaths globally [4]. Nearly (99%) all maternal, newborn, and child deaths occurs in LMICs, unquestionably, appropriate interventions along with advisable wellness resources in these countries accept meaning potential for reducing the burden of maternal and child mortalities [five, six]. Although substantial progress has been fabricated towards achieving the Millennium Evolution Goals (MDGs) 4 and 5, the rates of refuse in maternal, newborn and under-five mortality remain insufficient to achieve these goals by 2015 [3]. Furthermore, progress is marked by larger inequities, non just across regions and countries, but as well within countries where maternal and child mortality rates and health care indicators differ substantially past geographic location (higher in rural areas versus urban areas) every bit well as past socioeconomic status.

While many factors contribute to maternal and neonatal deaths, one of the effective ways of reducing this burden is provision of effective preventive measures or early treatment provided to women and newborns, ofttimes at their dwelling or in master health care settings. Worldwide 50 one thousand thousand births take place at habitation without a skilled nascency bellboy (SBA) [7]. The rates of no access to skilled birth intendance and emergency obstetric care are higher in LMICs where majority of deaths and morbidity related to complications of childbirth accept place [eight]. Skilled attendance at nascency remains peculiarly low in sub-Saharan Africa and south asia and there are broad disparities within countries, across socio-economic condition, geographic location, and educational status. In sub-Saharan Africa, women are alone, with no attendant in more than half of domicile births while in S Asia, around one-tertiary of home births are without traditional nativity attendants. Therefore, effective interventions and improved coverage in low-resources settings have an enormous potential to avoid maternal and neonatal deaths. Bleeding, contributing to 35% of maternal deaths, apace leads to death without intervention, but with simple interventions like blood transfusions, oxytocics to prevent haemorrhage, and/or manual removal of the placenta by a SBA, severe haemorrhage can be averted in fourth dimension to prevent bloodshed [6, 9]. Similarly, access to antenatal health visits and medicines tin prevent death from hypertensive disorders, while death due to sepsis tin exist averted by screening for prenatal maternal infection and sexually transmitted infections (STIs) during antenatal visits and with hygienic infection control measures during birth provided by SBA. Other direct causes of maternal deaths, including obstructed labour, complications of anaesthesia or caesarean section, and ectopic pregnancy, can be prevented with access to antenatal care, skilled nascence attendance, and basic and comprehensive emergency obstetric care.

Interventions to avoid maternal mortalities can also preclude neonatal deaths; evidence suggests that 77% of all neonatal deaths occurs where the coverage of skilled birth attendance is 50% or even less [10]. Hygienic births through skilled nascence omnipresence can largely preclude neonatal infections through uncomplicated treatments such as cleansing of the umbilical cord, and promotion of early and exclusive breastfeeding. Furthermore, providing nascence attendants with simple equipment and training is a low-tech, low-toll opportunity to prevent neonatal deaths. Complications from preterm birth and depression birth weight (LBW) take the largest toll on neonatal deaths, with more advanced care being required for those born before 33 weeks' gestation. Apply of low price interventions such as kangaroo female parent care (KMC) yields a 51% reduction in mortality for newborns weighing less than 2000g [10, xi]. Amid children under the historic period of five years, infection is the major cause of severe morbidity and mortality. Simple interventions such equally proper nutrition, sanitation, hygiene, complete and timely immunization along with preventive and therapeutic interventions for the management of diarrhoea and pneumonia can salve a major portion of these preventable under-five deaths. According to the contempo estimates, scaling up of these key evidence-based interventions coverage to at to the lowest degree 80% and that for immunization to at least 90%, can eliminate 95% of diarrhoea and 67% of pneumonia deaths in children younger than five years by 2025 at a price of $6·715 billion [12].

The current burden of maternal, neonatal and child mortalities, heavily concentrated in LMICs, is particularly grave in the light of existing simple, cost-effective and low-technology interventions. Interventions and strategies for improving reproductive, maternal, newborn and child wellness intendance (RMNCH) and survival are closely related and must be provided through a continuum of care arroyo. When linked together and included as integrated programs, these interventions can lower costs, promote greater efficiencies, and reduce duplication of resources. Even so, few efforts have been made to identify synergies and integrate these interventions across the continuum of care. Despite of the existing plethora of knowledge, there is a lack of consensus on how best to move forrard in a coordinated fashion so equally to attain progress towards the MDG'due south. Furthermore consensus is also needed on the level of evidence [three]. The foremost aim of this global review is to compile existing show on the impact of various maternal, newborn and kid interventions on the major causes of maternal, newborn and under five deaths. The specific objectives of this review were to serve as a first step towards: developing consensus on the content of RMNCH packages of interventions at each level of the health system across the continuum of intendance; facilitating the scaling-up of these interventions; and identifying enquiry gaps in the content of core packages of interventions.

Methodology

Search strategy

A full of 142 RMNCH interventions were identified, assessed and selected for this review, based on current World Wellness Organization (WHO) recommendations contained in the post-obit publications: Guidelines on HIV and Infant Feeding (2010) [xiii]; Integrated Management of Childhood Affliction (2008) [14]; Integrated Management of Childhood Illness for High HIV Settings (2008) [xv], the Bag on Hospital Care For Children (2005) [16], Recommended interventions for improving maternal and newborn health - Integrated management of pregnancy and childbirth (2007) [17]. Interventions published in the Kid and Neonatal Lancet Series (2003 and 2005, respectively) [18, 19] (Refer Figure i for essential interventions). We further updated the evidence on these interventions from Lancet Diarrhoea and Pneumonia Series (2013) [twenty] and Lancet Maternal and Newborn Diet Series (2013) [21].

Pick and inclusion of Interventions

The interventions were prioritized according to the following criteria:

• Interventions expected to have a significant impact on maternal, newborn and child survival, addressing the main causes of maternal, newborn and child mortality.

• Interventions suitable for implementation in depression- and heart-income countries; minimal essential care.

• Interventions delivered through the health sector, from the customs up to the 1st referral level of health service provision.

Relevant reviews for each intervention were identified from the following electronic databases: the Cochrane database of systematic reviews, the Cochrane database of abstract reviews of effectiveness (DARE), the Cochrane database of systematic reviews of randomized command trials (RCT's), and PubMed. The reference lists of the reviews and recommendations from experts in the field were likewise used as sources to obtain boosted publications. The principal focus was on the existing systematic reviews and meta-analysis.

Classification of interventions

The interventions were classified into categories A, B and C, co-ordinate to the framework provided in Table ane.

Table 1 Nomenclature of interventions according to evidence and commitment strategies

Total size table

The classification of the effect of interventions according to the bear witness available was done based on that used by the Cochrane grouping. This classification benefited from being broadly known, recognized and accustomed since information technology is the classification used by the Cochrane systematic review process that has guided this exercise from the beginning. The "evidence" was restricted to published systematic reviews; not including single studies, but to list single studies as groundwork information for further review. Table 2.

Levels of delivery

The origin of evidence included the following three different levels of delivery of interventions and these were defined in the publication past the Earth Bank "Providing Interventions":

(1) Community level/home–wellness care providers at this level includes community wellness workers and outreach workers. It utilizes resources such as volunteers' fourth dimension, local knowledge, and community confidence and trust equally channels for delivery of interventions mostly related to safe motherhood, nutrition, and simple prevention and treatments. Many countries have attempted to construct links betwixt community-based wellness intendance resources and households for a range of health programs. These programs do not substitute for a wellness system, merely provide a channel for reaching families with information and resources. Customs health workers (CHWs) not only promote healthy behaviors and preventive action but can mobilize demand for appropriate services at other levels. The success of community health efforts depends critically on the context, including level of development of infrastructure, services, and socioeconomic resources.

(2) Commencement level/outreach - Wellness care providers at this level of care includes professionals, outreach workers besides as the community wellness workers. Information technology includes a range of initiatives that are associated with the Alma Ata Declaration on Principal Health Care approved past WHO in 1978. More recently, the WHO Commission on Macroeconomics and Health described the need for developing services that are shut to the client. The basic notion is a common i: recognition that a certain range of health care services must human action equally an interface betwixt families and customs programs on the one hand, and hospitals and national wellness policies on the other. There has been substantial convergence in the content of general starting time level principal care over time: maternity related care (for instance, prenatal care, skilled birth attendance, and family planning), interventions to address childhood diseases (such as vaccine preventable diseases, astute respiratory infections, diarrhea and prevention and treatment of major infectious diseases.

(3) Referral level - this level of delivery of interventions refers to hospitals in general. These tin exist either commune hospitals or referral hospitals. The health care providers at this level are professionals.

District hospitals - mostly designed to serve people with services that are more sophisticated, technically demanding, and specialized than those bachelor at a chief care facility/first level care, but not equally specialized every bit those provided by referral hospitals. Their range of services includes diagnostics, handling, care, counseling, and rehabilitation. District hospitals may also provide wellness information, preparation, and administrative and logistical support to chief and customs health care programs. It concentrates skills and resources in ane place for the delivery of interventions for weather that are either uncommon or difficult to care for. It is likewise a repository of cognition and diagnostic tools for assessing whether referral to an even more specialized facility is indicated.

Referral hospitals - referral hospitals provide complex clinical intendance interventions to patients referred from the community, chief/get-go, or commune hospital levels. Referral hospitals need to provide many forms of support, including advice on which patients to refer, proper post belch intendance, and long-term management of chronic conditions. Referral hospitals can also provide important managerial and administrative support to other facilities, serving as gateways for drugs and medical supplies, laboratory testing services, general procurement, data collection from wellness data systems, and epidemiological surveillance. They are also the vehicle for disseminating technologies by training new staff and providing continuing professional didactics for existing staff at different facilities.

Information extraction and analysis

The review authors ready a triage process with standardized criteria for evaluating outputs from the search strategy and master screening. Post-obit an agreement on the search strategy, the abstracts (and the full sources where abstracts were non bachelor) were screened by two abstractors to identify reviews adhering to the objectives. Any disagreements on pick of reviews between these two principal abstractors were resolved by the third reviewer. After retrieval of the full texts of all the reviews that met the inclusion/exclusion criteria, each review was double data abstracted into a standardized course. Information was extracted on the following criteria:

1. 1.

   Characteristics of included reviews - description of each review included brief description of objectives, interventions, types of study pattern included, and outcomes reported;

2. two.

   Whether the review was a Cochrane or non-Cochrane review

3. iii.

   And if they pooled the studies included.

Available systematic reviews were assessed for quality using the AMSTAR criteria (Assessment of the methodological quality of systematic reviews) [22]. Any disagreements were resolved by give-and-take and the terminal decision was taken by consensus inside the team.

Over the side by side 3 papers we have discussed essential interventions for reproductive, maternal, neonatal and kid health that can be delivered over the continuum of care. Table 3 has enlisted the interventions graded equally A on the previously defined criteria at whatever level of health care commitment across the continuum of care.

Tabular array 3 Grading of interventions according to the level of health care delivery

Full size table

Decision

Poor maternal, newborn and child health remains a significant trouble and correspond two of the virtually difficult to achieve targets among the MDGs particularly in LMICs. Majority of maternal deaths occur during pregnancy and childbirth, while the hazard of infant'due south death is highest in the showtime 28 days of life. The situation is grave in Asia and Sub-Saharan Africa, where mortality among mothers and neonates is the highest in the world. The rate of maternal mortality is 129 times and rate of under-five mortality is 71 times higher in LMIC compared to high income countries. Several factors contribute to poor maternal, newborn and kid deaths; and with elementary, low cost interventions, these deaths tin can exist avoided particularly in depression income countries. Furthermore, the health and well-being of mothers and infants are closely linked; the interventions for improving women health have benign impacts on birth and neonatal outcomes. The aim of this exercise is to develop consensus on the content of RMNCH packages of interventions at each level of the wellness system across the continuum of intendance. With this rationale, a total of 142 RMNCH interventions were identified from several recent relevant bodies of piece of work. Of these, 56 essential interventions were curt listed based on the evidence of their efficacy, effectiveness and affect on survival; their suitability for implementation in low- and eye- resource settings and their likelihood to be delivered through the health sector from the community to the referral. These were farther classified and allotted to different plausible level of health organisation delivery levels.

This introductory newspaper helps sympathize the background and methodology in depth for the work which has been undertaken and detailed over next few papers. This serial, in whole, is highlighting the essential reproductive, maternal, newborn and child health interventions and their effectiveness for maternal, fetal, neonatal and child health. The last paper of this series is summarizing the delivery of these essential interventions every bit per the level of wellness care and in the course of intendance packages.

Peer review

The reviewer reports for this commodity can be constitute in Boosted File 1.

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Acquittance

The publication of these papers and supplement was supported by an unrestricted grant from The Partnership for Maternal, Newborn and Child Health

Declarations

This article has been published equally part of Reproductive Health Book xi Supplement 1, 2014: Essential intervention for maternal, newborn and child wellness. The total contents of the supplement are available online at http://www.reproductive-wellness-journal.com/supplements/11/S1. Publication charges for this collection were funded by the Partnership for Maternal, Newborn & Kid Health (PMNCH).

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Affiliations

1. Segmentation of Women and Child Health, Aga Khan Academy, Karachi, Islamic republic of pakistan

   Zohra S Lassi, Rehana A Salam, Jai K Das & Zulfiqar A Bhutta

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Correspondence to Zulfiqar A Bhutta.

Additional data

Competing interests

Nosotros practice not have any fiscal or non-financial competing interests for this review.

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Lassi, Z.Due south., Salam, R.A., Das, J.K. et al. Essential interventions for maternal, newborn and child health: groundwork and methodology. Reprod Health 11, S1 (2014). https://doi.org/10.1186/1742-4755-11-S1-S1

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• Published: 21 Baronial 2014

• DOI : https://doi.org/x.1186/1742-4755-11-S1-S1

Keywords

• Maternal health
• newborn health
• child health
• essential interventions
• mortality

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