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author:("Hill, delee")
1.  A strategy for reducing maternal and newborn deaths by 2015 and beyond 
Background
Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030.
Discussion
The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact.
Summary
Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.
doi:10.1186/1471-2393-13-216
PMCID: PMC3866510  PMID: 24261785
2.  Quality of newborn care: a health facility assessment in rural Ghana using survey, vignette and surveillance data 
BMJ Open  2013;3(5):e002326.
Objective
To assess the structural capacity for, and quality of, immediate and essential newborn care (ENC) in health facilities in rural Ghana, and to link this with demand for facility deliveries and admissions.
Design
Health facility assessment survey and population-based surveillance data.
Setting
Seven districts in Brong Ahafo Region, Ghana.
Participants
Heads of maternal/neonatal wards in all 64 facilities performing deliveries.
Main outcome measures
Indicators include: the availability of essential infrastructure, newborn equipment and drugs, and personnel; vignette scores and adequacy of reasons given for delayed discharge of newborn babies; and prevalence of key immediate ENC practices that facilities should promote. These are matched to the percentage of babies delivered in and admitted to each type of facility.
Results
70% of babies were delivered in health facilities; 56% of these and 87% of neonatal admissions were in four referral level hospitals. These had adequate infrastructure, but all lacked staff trained in ENC and some essential equipment (including incubators and bag and masks) and/or drugs. Vignette scores for care of very low-birth-weight babies were generally moderate-to-high, but only three hospitals achieved high overall scores for quality of ENC. We estimate that only 33% of babies were born in facilities capable of providing high quality, basic resuscitation as assessed by a vignette plus the presence of a bag and mask. Promotion of immediate ENC practices in facilities was also inadequate, with coverage of early initiation of breastfeeding and delayed bathing both below 50% for babies born in facilities; this represents a lost opportunity.
Conclusions
Unless major gaps in ENC equipment, drugs, staff, practices and skills are addressed, strategies to increase facility utilisation will not achieve their potential to save newborn lives.
Trial registration
http://clinicaltrials.gov NCT00623337.
doi:10.1136/bmjopen-2012-002326
PMCID: PMC3651975  PMID: 23667161
Epidemiology; Neonatology; Public health
3.  Measuring Coverage in MNCH: Indicators for Global Tracking of Newborn Care 
PLoS Medicine  2013;10(5):e1001415.
In a PLOS Medicine Review, Allisyn Moran and colleagues introduce the work of the Newborn Indicators Technical Working Group (TWG), which was convened by the Save the Children's Saving Newborn Lives program in 2008, and describe the indicators and survey questions agreed upon by the TWG to measure coverage of care in the immediate newborn period.
Neonatal mortality accounts for 43% of under-five mortality. Consequently, improving newborn survival is a global priority. However, although there is increasing consensus on the packages and specific interventions that need to be scaled up to reduce neonatal mortality, there is a lack of clarity on the indicators needed to measure progress. In 2008, in an effort to improve newborn survival, the Newborn Indicators Technical Working Group (TWG) was convened by the Saving Newborn Lives program at Save the Children to provide a forum to develop the indicators and standard measurement tools that are needed to measure coverage of key newborn interventions. The TWG, which included evaluation and measurement experts, researchers, individuals from United Nations agencies and non-governmental organizations, and donors, prioritized improved consistency of measurement of postnatal care for women and newborns and of immediate care behaviors and practices for newborns. In addition, the TWG promoted increased data availability through inclusion of additional questions in nationally representative surveys, such as the United States Agency for International Development–supported Demographic and Health Surveys and the United Nations Children's Fund–supported Multiple Indicator Cluster Surveys. Several studies have been undertaken that have informed revisions of indicators and survey tools, and global postnatal care coverage indicators have been finalized. Consensus has been achieved on three additional indicators for care of the newborn after birth (drying, delayed bathing, and cutting the cord with a clean instrument), and on testing two further indicators (immediate skin-to-skin care and applications to the umbilical cord). Finally, important measurement gaps have been identified regarding coverage data for evidence-based interventions, such as Kangaroo Mother Care and care seeking for newborn infection.
doi:10.1371/journal.pmed.1001415
PMCID: PMC3646209  PMID: 23667335
4.  Clean Home-delivery in Rural Southern Tanzania: Barriers, Influencers, and Facilitators 
The study explored the childbirth-related hygiene and newborn care practices in home-deliveries in Southern Tanzania and barriers to and facilitators of behaviour change. Eleven home-birth narratives and six focus group discussions were conducted with recently-delivering women; two focus group discussions were conducted with birth attendants. The use of clean cloth for delivery was reported as common in the birth narratives; however, respondents did not link its use to newborn's health. Handwashing and wearing of gloves by birth attendants varied and were not discussed in terms of being important for newborn's health, with few women giving reasons for this behaviour. The lack of handwashing and wearing of gloves was most commonly linked to the lack of water, gloves, and awareness. A common practice was the insertion of any family member's hands into the vagina of delivering woman to check labour progress before calling the birth attendant. The use of a new razor blade to cut the cord was near-universal; however, the cord was usually tied with a used thread due to the lack of knowledge and the low availability of clean thread. Applying something to the cord was near-universal and was considered essential for newborn's health. Three hygiene practices were identified as needing improvement: family members inserting a hand into the vagina of delivering woman before calling the birth attendant, the use of unclean thread, and putting substances on the cord. Little is known about families conducting internal checks of women in labour, and more research is needed before this behaviour is targeted in interventions. The use of clean thread as cord-tie appears acceptable and can be addressed, using the same channels and methods that were used for successfully encouraging the use of new razor blade.
PMCID: PMC3702365  PMID: 23617211
Clean delivery; Handwashing; Formative research; Newborn; Tanzania
5.  Impact of Free Delivery Care on Health Facility Delivery and Insurance Coverage in Ghana’s Brong Ahafo Region 
PLoS ONE  2012;7(11):e49430.
Background
Many sub-Saharan countries, including Ghana, have introduced policies to provide free medical care to pregnant women. The impact of these policies, particularly on access to health services among the poor, has not been evaluated using rigorous methods, and so the empirical basis for defending these policies is weak. In Ghana, a recent report also cast doubt on the current mechanism of delivering free care – the National Health Insurance Scheme. Longitudinal surveillance data from two randomized controlled trials conducted in the Brong Ahafo Region provided a unique opportunity to assess the impact of Ghana’s policies.
Methods
We used time-series methods to assess the impact of Ghana’s 2005 policy on free delivery care and its 2008 policy on free national health insurance for pregnant women. We estimated their impacts on facility delivery and insurance coverage, and on socioeconomic differentials in these outcomes after controlling for temporal trends and seasonality.
Results
Facility delivery has been increasing significantly over time. The 2005 and 2008 policies were associated with significant jumps in coverage of 2.3% (p = 0.015) and 7.5% (p<0.001), respectively after the policies were introduced. Health insurance coverage also jumped significantly (17.5%, p<0.001) after the 2008 policy. The increases in facility delivery and insurance were greatest among the poorest, leading to a decline in socioeconomic inequality in both outcomes.
Conclusion
Providing free care, particularly through free health insurance, has been effective in increasing facility delivery overall in the Brong Ahafo Region, and especially among the poor. This finding should be considered when evaluating the impact of the National Health Insurance Scheme and in supporting the continuation and expansion of free delivery care.
doi:10.1371/journal.pone.0049430
PMCID: PMC3500286  PMID: 23173061
6.  Interventions to Improve Motivation and Retention of Community Health Workers Delivering Integrated Community Case Management (iCCM): Stakeholder Perceptions and Priorities 
Despite resurgence in the use of community health workers (CHWs) in the delivery of community case management of childhood illnesses, a paucity of evidence for effective strategies to address key constraints of worker motivation and retention endures. This work reports the results of semi-structured interviews with 15 international stakeholders, selected because of their experiences in CHW program implementation, to elicit their views on strategies that could increase CHW motivation and retention. Data were collected to identify potential interventions that could be tested through a randomized control trial. Suggested interventions were organized into thematic areas; cross-cutting approaches, recruitment, training, supervision, incentives, community involvement and ownership, information and data management, and mHealth. The priority interventions of stakeholders correspond to key areas of the work motivation and CHW literature. Combined, they potentially provide useful insight for programmers engaging in further enquiry into the most locally relevant, acceptable, and evidence-based interventions.
doi:10.4269/ajtmh.2012.12-0030
PMCID: PMC3748511  PMID: 23136286
7.  Chlorhexidine cord cleansing to reduce neonatal mortality 
Lancet  2012;379(9820):984-986.
doi:10.1016/S0140-6736(12)60114-7
PMCID: PMC3428896  PMID: 22322125
8.  Effect of vitamin A supplementation in women of reproductive age on cause-specific early and late infant mortality in rural Ghana: ObaapaVitA double-blind, cluster-randomised, placebo-controlled trial 
BMJ Open  2012;2(1):e000658.
Objectives
To assess the effect of vitamin A supplementation in women of reproductive age in Ghana on cause- and age-specific infant mortality. In addition, because of recently published studies from Guinea Bissau, effects on infant mortality by sex and season were assessed.
Design
Double-blind, cluster-randomised, placebo-controlled trial.
Setting
7 contiguous districts in the Brong Ahafo region of Ghana.
Participants
All women of reproductive age (15–45 years) resident in the study area randomised by cluster of residence. All live born infants from 1 June 2003 to 30 September 2008 followed up through 4-weekly home visits.
Intervention
Weekly low-dose (25 000 IU) vitamin A.
Main outcome measures
Early infant mortality (1–5 months); late infant mortality (6–11 months); infection-specific infant mortality (0–11 months).
Results
1086 clusters, 62 662 live births, 52 574 infant-years and 3268 deaths yielded HRs (95% CIs) comparing weekly vitamin A with placebo: 1.04 (0.88 to 1.05) early infant mortality; 0.99 (0.84 to 1.18) late infant mortality; 1.03 (0.92 to 1.16) infection-specific infant mortality. There was no evidence of modification of the effect of vitamin A supplementation on infant mortality by sex (Wald statistic =0.07, p=0.80) or season (Wald statistic =0.03, p=0.86).
Conclusions
This is the largest analysis of cause of infant deaths from Africa to date. Weekly vitamin A supplementation in women of reproductive age has no beneficial or deleterious effect on the causes of infant death to age 6 or 12 months in rural Ghana.
Trial registration number
http://ClinicalTrials.gov: NCT00211341.
Article summary
Article focus
This paper reports the results of planned (a priori) analyses of the effect of vitamin A supplementation in women of reproductive age on cause- and age-specific infant mortality in the ObaapaVitA trial.
In addition, because of the recent interest in potential differential effects, we also assessed effects by sex and season.
Key messages
The analyses from this trial indicate that weekly vitamin A supplementation in women of reproductive age has no beneficial or deleterious effect on the causes of death in their babies of age 6 or 12 months, no effect on infection-specific infant mortality and no role for inclusion in child survival programs in Asia and Africa.
We also failed to demonstrate any benefit or harm from vitamin A supplementation in women of reproductive age and in infant males or females in our study population. There was also no modification of the effect of vitamin A supplementation and mortality by season.
Strengths and limitations of this study
There were some limitations to our trial. There was no direct observation of capsule taking; however, adherence was supported by an extensive Information, Education and Communication strategy, and we estimated that on average 75% of women both received and took all four capsules every month.
We also used verbal postmortems (VPMs) and physician coders to assign cause of death, and it was not possible to use health facility records or postmortem examinations to verify the cause of death. Misclassification is common in VPM studies, but this can be minimised when broad categories such as ‘infection’, ‘prematurity’ and ‘asphyxia’ are used. Our VPM tools were also validated in similar study populations, and acceptable sensitivity and specificity were reported in comparison to a gold standard.
Strengths included the fact that our study was large (62 000 infants) prospective and population-based. All resident women in the trial districts and their babies were enrolled, and loss to follow-up was low, even in women with babies who had died.
doi:10.1136/bmjopen-2011-000658
PMCID: PMC3330261  PMID: 22218721
9.  A Large Cross-Sectional Community-Based Study of Newborn Care Practices in Southern Tanzania 
PLoS ONE  2010;5(12):e15593.
Despite recent improvements in child survival in sub-Saharan Africa, neonatal mortality rates remain largely unchanged. This study aimed to determine the frequency of delivery and newborn-care practices in southern Tanzania, where neonatal mortality is higher than the national average. All households in five districts of Southern Tanzania were approached to participate. Of 213,220 female residents aged 13–49 years, 92% participated. Cross-sectional, retrospective data on childbirth and newborn care practices were collected from 22,243 female respondents who had delivered a live baby in the preceding year. Health facility deliveries accounted for 41% of births, with nearly all non-facility deliveries occurring at home (57% of deliveries). Skilled attendants assisted 40% of births. Over half of women reported drying the baby and over a third reported wrapping the baby within 5 minutes of delivery. The majority of mothers delivering at home reported that they had made preparations for delivery, including buying soap (84%) and preparing a cloth for drying the child (85%). Although 95% of these women reported that the cord was cut with a clean razor blade, only half reported that it was tied with a clean thread. Furthermore, out of all respondents 10% reported that their baby was dipped in cold water immediately after delivery, around two-thirds reported bathing their babies within 6 hours of delivery, and 28% reported putting something on the cord to help it dry. Skin-to-skin contact between mother and baby after delivery was rarely practiced. Although 83% of women breastfed within 24 hours of delivery, only 18% did so within an hour. Fewer than half of women exclusively breastfed in the three days after delivery. The findings suggest a need to promote and facilitate health facility deliveries, hygienic delivery practices for home births, delayed bathing and immediate and exclusive breastfeeding in Southern Tanzania to improve newborn health.
doi:10.1371/journal.pone.0015593
PMCID: PMC3006340  PMID: 21203574
10.  NEWHINTS cluster randomised trial to evaluate the impact on neonatal mortality in rural Ghana of routine home visits to provide a package of essential newborn care interventions in the third trimester of pregnancy and the first week of life: trial protocol 
Trials  2010;11:58.
Background
Tackling neonatal mortality is essential for the achievement of the child survival millennium development goal. There are just under 4 million neonatal deaths, accounting for 38% of the 10.8 million deaths among children younger than 5 years of age taking place each year; 99% of these occur in low- and middle-income countries where a large proportion of births take place at home, and where postnatal care for mothers and neonates is either not available or is of poor quality. WHO and UNICEF have issued a joint statement calling for governments to implement "Home visits for the newborn child: a strategy to improve survival", following several studies in South Asia which achieved substantial reductions in neonatal mortality through community-based approaches. However, their feasibility and effectiveness have not yet been evaluated in Africa. The Newhints study aims to do this in Ghana and to develop a feasible and sustainable community-based approach to improve newborn care practices, and by so doing improve neonatal survival.
Methods
Newhints is an integrated intervention package based on extensive formative research, and developed in close collaboration with seven District Health Management Teams (DHMTs) in Brong Ahafo Region. The core component is training the existing community based surveillance volunteers (CBSVs) to identify pregnant women and to conduct two home visits during pregnancy and three in the first week of life to address essential care practices, and to assess and refer very low birth weight and sick babies. CBSVs are supported by a set of materials, regular supervisory visits, incentives, sensitisation activities with TBAs, health facility staff and communities, and providing training for essential newborn care in health facilities.
Newhints is being evaluated through a cluster randomised controlled trial, and intention to treat analyses. The clusters are 98 supervisory zones; 49 have been randomised for implementation of the Newhints intervention, with the other 49 acting as controls. Data on neonatal mortality and care practices will be collected from approximately 15,000 babies through surveillance of women of child-bearing age in the 7 districts. Detailed process, cost and cost-effectiveness evaluations are also being carried out.
Trial registration
http://www.clinicaltrials.gov (identifier NCT00623337)
doi:10.1186/1745-6215-11-58
PMCID: PMC2890650  PMID: 20478070
11.  Missed opportunities for participation in prevention of mother to child transmission programmes: Simplicity of nevirapine does not necessarily lead to optimal uptake, a qualitative study 
Background
The objective of this study was to examine missed opportunities for participation in a prevention of mother-to-child transmission (PMTCT) programme in three sites in South Africa. A rapid anthropological assessment was used to collect in-depth data from 58 HIV-positive women who were enrolled in a larger cohort study to assess mother-to-child HIV transmission. Semi-structured interviews were conducted with the women in order to gain an understanding of their experiences of antenatal care and to identify missed opportunities for participation in PMTCT.
Results
15 women actually missed their nevirapine not because of stigma and ignorance but because of health systems failures. Six were not tested for HIV during antenatal care. Two were tested but did not receive their results. Seven were tested and received their results, but did not receive nevirapine. Health Systems failure for these programme leakages ranged from non-availability of counselors, supplies such as HIV test kits, consent forms, health staff giving the women incorrect instructions about when to take the tablet and health staff not supplying the women with the tablet to take.
Conclusion
HIV testing enables access to PMTCT interventions and should therefore be strengthened. The single dose nevirapine regimen is simple to implement but the all or nothing nature of the regimen may result in many missed opportunities. A short course dual or triple drug regimen could increase the effectiveness of PMTCT programmes.
doi:10.1186/1742-6405-4-27
PMCID: PMC2211501  PMID: 18034877

Results 1-11 (11)