Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention Community Kangaroo Mother Care: implementation and potential for neonatal survival and health in very low-income settings Impact of an SMS advice programme on maternal and newborn health in rural China: study protocol for a quasi-randomised controlled trial Income Transfers and Maternal Health: Evidence from a National Randomized Social Cash Transfer Program in Zambia. Newborn Infection Control and Care Initiative for health facilities to accelerate reduction of newborn mortality (NICCI): study protocol for a randomized controlled trial Communities, birth attendants and health facilities: a continuum of emergency maternal and newborn care (the global network's EmONC trial) Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda. Continuum of Care Services for Maternal and Child Health using mobile technology – a health system strengthening strategy in low and middle income countries An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women? Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico's Oportunidades What impact does contact with the prenatal care system have on women's use of facility delivery? Evidence from low-income countries. Use of mobile phone consultations during home visits by Community Health Workers for maternal and newborn care: community experiences from Masindi and Kiryandongo districts, Uganda Impact of a maternal health voucher scheme on institutional delivery among low income women in Pakistan Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomised trial Implementing knowledge into practice for improved neonatal survival; a cluster-randomised, community-based trial in Quang Ninh province, Vietnam Effective treatment of perinatal depression for women in debt and lacking financial empowerment in a low-income country Systems analysis and improvement to optimize pMTCT (SAIA): a cluster randomized trial Low-Income First-Time Mothers Acceptability and trust of community health workers offering maternal and newborn health education in rural Uganda. Effects of a Large-Scale Unconditional Cash Transfer Program on Mental Health Outcomes of Young People in Kenya. Mexico's conditional cash transfer programme increases cesarean section rates among the rural poor. Effectiveness of the WHO Safe Childbirth Checklist program in reducing severe maternal, fetal, and newborn harm in Uttar Pradesh, India: study protocol for a matched-pair, cluster-randomized controlled trial Designing for action: adapting and implementing a community-based newborn care package to affect national change in Uganda
Background Dem and -side financing projects are now being implemented in many developing countries , yet evidence showing that they reach the poor is scanty . Methods A  maternal health voucher scheme provided voucher-paid services in Jhang , a predominantly rural district of Pakistan , during 2010 . A pre-test/post-test quasi-experimental design was used to assess the changes in the proportion of facility-based deliveries and related maternal health services among the poor . Household interviews were conducted with r and omly selected women in the intervention and control union councils , before and after the intervention . A strong outreach model was used . Voucher promoters were given basic training in identification of poor women using the Poverty Scorecard for Pakistan , in the types of problems women could face during delivery , and in the promotion of antenatal care ( ANC ) , institutional delivery and postnatal care ( PNC ) . Voucher booklets valued at Rs . 4,000 ( $ 48 ) , including three ANC visits , a PNC visit , an institutional delivery , and a postnatal family planning visit , were sold for Rs . 100 ( $ 1.2 ) to low-income women targeted by project outreach workers . Women suffering from complications were referred to emergency obstetric care services . Analysis was conducted at the bivariate and the multivariate levels . At the multivariate level , logistic regression analysis was conducted to determine whether the increase in institutional delivery was greater among poor women ( defined for this study as women in the fourth or fifth quintiles ) relative to non-poor women ( defined for this study as women in the first quintile ) in the intervention union councils compared to the control union councils . Results Bivariate analysis showed significant increases in the institutional delivery rate among women in the fourth or fifth wealth quintiles in the intervention union councils but no significant changes in this indicator among women in the same wealth quintiles in the control union councils . Multivariate analysis showed that the increase in institutional delivery among poor women relative to non-poor women was significantly greater in the intervention compared to the control union councils . Conclusions Dem and -side financing projects using vouchers can be an effective way of reducing inequities in institutional delivery Objective : Immediate Kangaroo Mother Care ( KMC ) , an intervention following childbirth whereby the newborn is placed skin-to-skin ( STS ) on mother 's chest to promote thermal regulation , breastfeeding and maternal-newborn bonding , is being taught in very low-income countries to improve newborn health  and survival . Existing data are review ed to document the association between community-based KMC ( CKMC ) implementation and its potential benefits . Study Design : New analyses of the sole r and omized controlled study of CKMC in Bangladesh and others ' experiences with immediate KMC are presented . Result : Newborns held STS less than 7 h per day in the first 2 days of life do not experience substantially better health or survival than babies without being held STS . Conclusion : Most women who were taught  CKMC  hold their newborns STS , but do so in a token manner unlikely to improve health or survival . Serious challenges exist to provide effective training and postpartum support to achieve adequate STS practice s. These challenges must be overcome before scaling up Introduction Expectant mothers in low-income and middle-income countries often lack access to vital information about pregnancy , preparation for birth and best practice s when caring for their newborn . Innovative solutions are needed to bridge this knowledge gap and dramatically improve maternal and neonatal health in these setting s. This study aims to evaluate the impact of an innovative text messaging intervention on maternal and neonatal health outcomes . Methods and analysis This study offers expectant mothers in rural China a package of free short messages via cell phone regarding pregnancy and childbirth . These messages are tailored to each mother 's gestational week . It is hypothesised that delivering these short advice messages to pregnant women can improve maternal and newborn health . The study uses factorial quasi-r and omisation to compare psychological , behavioural and health outcomes between 4 groups : 2 groups receiving different sets of short message interventions ( ie , good household prenatal practice s and healthcare seeking ) , a group receiving both interventions and a control group . Treatment assignment occurs at the individual level . The primary outcome is newborn health , measured by appropriateness of weight for gestational age . Secondary outcomes include severe neonatal and maternal morbidity as well as psychological and behavioural measures . This study has enrolled pregnant women who attend county maternal and child health centres for their prenatal visits . Discussion This pilot is the first large-scale effort to build a comprehensive evidence base on the impact of prenatal text messages via cell phone on maternal and newborn health outcomes in China . The study has broad implication s for public health policy in China and the implementation of mobile health interventions in low-re source setting s around the world . Ethics This study was approved by the Ethics Committee of the School of Medicine at Xi'an Jiaotong University on 18 January 2013 . Trial registration number NCT02037087 ; Pre- results There is promising recent evidence that poverty-targeted social cash transfers have potential to improve maternal health outcomes ; however , questions remain surrounding design features responsible for impacts . In addition , virtually no evidence exists from the African region . This study explores the impact of Zambia 's Child Grant Program  on a range of maternal health utilization outcomes using a r and omized design and difference-in-differences multivariate regression from data collected over 24 months from 2010 to 2012 . Results indicate that while there are no measurable program impacts among the main sample , there are heterogeneous impacts on skilled attendance at birth among a sample of women residing in households having better access to maternal health services . The latter result is particularly interesting because of the overall low level of health care availability in program areas suggesting that dedicated program design or matching supply-side interventions may be necessary to leverage unconditional cash transfers in similar setting s to impact maternal health Background Newborn health is a key issue in addressing the survival of children under five years old , particularly in low and middle income countries , and the evidence base for newborn health interventions continues to evolve . Over the last decade , maternal and under five-year-old mortality and morbidity rates have been successfully reduced in Cambodia , but newborn health has lagged behind . Evidence suggests that an important proportion of newborn mortality both globally and in Cambodia is attributable to infections and sepsis . While initiatives are being implemented to address some causes of newborn illness ( related to pre-term birth and asphyxia ) , a country-level approach to reducing infections has not been formulated . The Newborn Infection Control and Care Initiative ( NICCI ) is a community and health facility linked intervention to improve health outcomes for newborns . Methods / Design The present study applies a cluster r and omized trial , using a stepped wedge design , to assess the impact of a package intervention on  newborn health . The intervention components include addressing infection control in the perinatal period in health facilities , promoting infection prevention and control practice s in health center and home environments , and improving the timeliness of referrals for newborns with suspected infections to appropriate health facilities , by linking families to the medical system through a network of community based volunteers who will make home visits to families in the first week of a newborn ’s life . Discussion The NICCI trial is design ed to complement and enhance the Cambodian Ministry of Health strategies and objectives for maternal and newborn care . Results of the study will help to inform policy and the possible scale-up of newborn health interventions in the country . Trial registration This trial was registered with Clinical trials.gov ( identifier : NCT02271737 ) on 5 October 2014 Background Maternal and newborn mortality rates remain unacceptably high , especially where the majority of births occur in home setting s or in facilities with inadequate re sources . The introduction of emergency obstetric and newborn care services has been proposed by several organizations in order to improve pregnancy outcomes . However , the effectiveness of emergency obstetric and neonatal care services has never been proven . Also unproven is the effectiveness of community mobilization and community birth attendant training to improve pregnancy outcomes . Methods / Design We have developed a cluster-r and omized controlled trial to evaluate the impact of a comprehensive intervention of community mobilization , birth attendant training and improvement of quality of care in health facilities on perinatal mortality in low and middle-income countries where the majority of births take place in homes or first level care facilities . This trial will take place in 106 clusters ( 300 - 500 deliveries per year each ) across 7 sites of the Global Network for Women 's and Children 's Health Research in Argentina , Guatemala , India , Kenya , Pakistan and Zambia . The trial intervention has three key elements , community mobilization , home-based life saving skills for communities and birth attendants , and training of providers at obstetric facilities to improve quality of care . The primary outcome of the trial is perinatal mortality . Secondary outcomes include rates of stillbirth , 7-day neonatal mortality , maternal death or severe morbidity ( including obstetric fistula , eclampsia and obstetrical sepsis ) and 28-day neonatal mortality . Discussion In this trial , we are evaluating a combination of interventions including community mobilization and facility training in an attempt to improve pregnancy outcomes . If successful , the results of this trial will provide important information for policy makers and clinicians as they attempt to improve delivery services for pregnant women and newborns in low-income countries . Trial Registration Clinical Trials.gov The maternal mortality ratio ( MMR ) in Ug and a has declined significantly during the last 20 years , but Ug and a is not on track to reach the millennium development goal of reducing MMR by 75 % by 2015 . More evidence on the cost-effectiveness of supply- and dem and -side financing programs to reduce maternal mortality could inform future strategies . This study analyses the cost-effectiveness of a voucher scheme ( VS ) combined with health system strengthening in rural Ug and a against the status quo . The VS , implemented in 2010 , provided vouchers for delivery services at public and private health facilities ( HF ) , as well as round-trip transportation provided by private sector workers ( bicycles or motorcycles generally ) . The VS was part of a quasi-experimental non-r and omized control trial . Improvements in institutional delivery coverage ( IDC ) rates can be estimated using a difference-in-difference impact evaluation method and the number of maternal lives saved is modelled using the evidence -based Lives Saved Tool . Costs were estimated from primary and secondary data . Results show that the dem and for births at HFs enrolled in the VS increased by 52.3 percentage points . Out of this value , conservative estimates indicate that at least 9.4 percentage points are new HF users . This 9.4 % bump in IDC implies 20 deaths averted , which is equivalent to 1356 disability-adjusted-life years ( DALYs ) averted . Cost-effectiveness analysis comparing the status quo and VS 's most conservative effectiveness estimates shows that the VS had an incremental cost-effectiveness ratio per DALY averted of US$ 302 and per death averted of US$ 20 756 . Although there are limitations in the data measures , a favourable cost-effectiveness ratio persists even under extreme assumptions . Dem and -side vouchers combined with supply-side financing programs can increase attended deliveries and reduce maternal mortality at a cost that is acceptable Background Mobile phone technology is utilized for better delivery of health services worldwide . In low- and -middle income countries mobile phones are now ubiquitous . Thus leveraging mHealth applications in health sector is becoming popular rapidly in these countries . To assess the effectiveness of the Continuum of Care Services ( CCS ) mHealth platform in terms of strengthening the delivery of maternal and child health ( MCH ) services in a district in Bihar , a re source -poor state in India . Methods The CommCare mHealth platform was customized to CCS as one of the innovations under a project funded by the Bill and Melinda Gates Foundation to improve the maternal and newborn health services in Bihar . The intervention was rolled out in one project district in Bihar , during July 2012 . More than 550 frontline workers out of a total of 3000 including Accredited Social Health Activists , Anganwadi Workers , Auxilliary Nurse Midwives and Lady Health Supervisors were trained to use the mHealth platform . The service delivery components namely early registration of pregnant women , three antenatal visits , tetanus toxoid immunization of the mother , iron and folic acid tablet supply , institutional delivery , postnatal home visits and early initiation of breastfeeding were used as indicators for good quality services . The result ant coverage of these services in the implementation area was compared with rest of Bihar and previous year statistics of the same area . The time lag between delivery of a service and its record capture in the maternal and child tracking system ( MCTS ) data base was computed in a r and om sample of 16,000 beneficiaries . The coverage of services among marginalized and non-marginalized castes was compared to indicate equity of service delivery . Health system strengthening was viewed from the angle of coverage , quality , equity and efficiency of services . Results The implementation blocks had higher coverage of all the eight indicator services compared to rest of Bihar and the previous year . There was equity of services across castes for all the indicators . Timely capture of data was also ensured compared to paper-based reporting . Conclusion By virtue of its impact on quality , efficiency and equity of service delivery , health care manpower efficiency and governance , the mHealth inclusion at service provision level can be one of the potential strategy to strengthen the health system Maternal health services continue to favour the wealthiest in lower and middle income countries . Debate about the potential of performance-based financing ( PBF ) to address these disparities continues . As PBF is adopted by countries , it is critical to underst and the equity effects for maternal services . The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population . In Rw and a , PBF was design ed to increase health service use , which was universally low . Paired districts were r and omly assigned to intervention and control for PBF implementation . Using Rw and a 's Demographic Health Survey data from 2005 ( pre-intervention ) and 2007 - 8 ( post-intervention ) , a cluster-level panel data set of 7899 women 15 - 49 years of age from intervention ( 4477 ) and control districts ( 3422 ) was created . The impact of PBF on reported use of facility deliveries , antenatal care ( ANC ) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects . Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women . The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts ( P = 0.014 ) , while no significant effects were noted for ANC visits or modern contraceptive use . Service use increased for intervention and control population s and across all wealth quintiles from 2005 to 2007 , with no evidence that PBF was a pro-poor or a pro-rich strategy . Insurance remained a positive predictor of service use . This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services , such as facility deliveries , may improve service use overall . However , if the equity gap is extreme , then a PBF programme without equity targets will do little to alleviate disparities BACKGROUND Many governments have implemented conditional cash transfer ( CCT ) programmes with the goal of improving options for poor families through interventions in health , nutrition , and education . Families enrolled in CCT programmes  receive cash in exchange for complying with certain conditions : preventive health requirements and nutrition supplementation , education , and monitoring design ed to improve health outcomes and promote positive behaviour change . Our aim was to disaggregate the effects of cash transfer from those of other programme components . METHODS In an intervention that began in 1998 in Mexico , low-income communities ( n=506 ) were r and omly assigned to be enrolled in a CCT programme  ( Oportunidades , formerly Progresa ) immediately or 18 months later . In 2003 , children ( n=2449 ) aged 24 - 68 months who had been enrolled in the programme their entire lives were assessed for a wide variety of outcomes . We used linear and logistic regression to determine the effect size for each outcome that is associated with a doubling of cash transfers while controlling for a wide range of covariates , including measures of household socioeconomic status . FINDINGS A doubling of cash transfers was associated with higher height-for-age Z score ( beta 0.20 , 95 % CI 0.09 - 0.30 ; p<0.0001 ) , lower prevalence of stunting ( -0.10 , -0.16 to -0.05 ; p<0.0001 ) , lower body-mass index for age percentile ( -2.85 , -5.54 to -0.15 ; p=0.04 ) , and lower prevalence of being overweight ( -0.08 , -0.13 to -0.03 ; p=0.001 ) . A doubling of cash transfers was also associated with children doing better on a scale of motor development , three scales of cognitive development , and with receptive language . INTERPRETATION Our results suggest that the cash transfer component of Oportunidades is associated with better outcomes in child health , growth , and development Prenatal and delivery care are critical both for maternal and newborn health . Using the Demographic and Health Surveys ( DHS ) data for thirty-two low-income countries across Asia , sub-Saharan Africa and Latin America , and employing a two-level r and om-intercept model , this paper empirically assesses the influence of prenatal attendance and a wide array of observed individual- , household- and community-level characteristics on a woman 's decision to give birth at a health facility or at home . The results show that  prenatal attendance does appreciably influence the use of facility delivery in all three geographical regions , with women having four visits being 7.3 times more likely than those with no prenatal care to deliver at a health facility . These variations are more pronounced for Sub-Saharan Africa . The influence of the number of prenatal visits , maternal age and education , parity level , and economic status of the  birthing women on the place of delivery is found to vary across the three geographical regions . The results also indicate that obstetrics care is geographically and economically more accessible to urban and rural women from the non-poor households than those from the poor households . The strong influence of number of visits , household wealth , education and regional poverty on the site of delivery setting suggests that policies aim ed at increasing the use of obstetric care programs should be linked with the objectives of social development programs such as poverty reduction , enhancing the status of women , and increasing primary and secondary school enrollment rate among girls Background Home visits by Community Health Workers [ In Ug and a Community Health Workers are given the collective term of Village Health Teams ( VHTs ) . Hereafter referred to as VHTs ] is recommended to improve maternal and newborn care . We investigated perceived maternal and newborn benefits of home visits made by VHTs , combined with mobile phone consultations with professional health workers for advice . Methods A qualitative study was conducted in Masindi and Kiry and ongo districts , Ug and a , in December-2013 to March-2014 . Study participants were drawn from the intervention arm of a r and omised community-intervention trial .  In-depth interviews were conducted with 20 prenatal and 16 postnatal women who were visited by VHTs ;  5 group discussion s and 16 key informant interviews were held with VHTs and 10 Key Informant Interviews with professional health workers . Data were analysed using latent content analysis techniques . Results Majority women and VHTs contend that the intervention improved access to maternal and newborn information ; reduced costs of accessing care and facilitated referral . Women , VHTs and professional health workers acknowledged that the intervention induced attitudinal change among women and VHTs towards adapting recommended maternal and newborn care practice s. Mobile phone consultations between VHTs and professional health workers were considered to reinforce VHT knowledge on maternal newborn care and boosted the social status of VHTs in community . A minority of VHTs perceived the implementation of recommended maternal and newborn care practice s as difficult . Some professional health workers did not approve of the transfer of promotional maternal and newborn responsibility to VHTs . For a range of reasons , a number of professional health workers were not always available on phone or at the health centre to address VHT concerns . Conclusions Results suggest that home visits made by VHTs for maternal and newborn care are reasonably well accepted . Our study highlights potential benefits of combining home visits with phone consultations between VHTs and professional health workers . However , the challenge of attitudinal change among VHTs towards certain strongly culturally-embedded behavioural post-partum practice s , resistance from part of the professional health workforce to collaborate with VHTs and the problematic availability of professional health workers are important systemic problems that need to be addressed . Trial registration Current Controlled Trials NCT02084680.Registered 14 March 2014 Background Only 39 % of deliveries in Pakistan are attended by skilled birth attendants , while Pakistan 's target for skilled birth attendance by 2015 is > 90 % . Methods A 12-month  maternal health voucher intervention was implemented in Dera Ghazi Khan City , located in Southern Punjab , Pakistan in 2009 . A pre-test/post-test non-experimental study was conducted to assess the impact of the intervention . Household interviews were conducted with r and omly selected women who delivered in 2008 ( the year prior to the voucher intervention ) , and with r and omly selected women who delivered in 2009 . A strong outreach model was used and voucher booklets valued at $ 50 , containing redeemable coupons for three antenatal care ( ANC ) visits , a postnatal care ( PNC ) visit and institutional delivery , were sold for $ 1.25 to low-income women targeted by project workers . Regression analysis was conducted to determine the impact of the voucher scheme on ANC , PNC , and institutional delivery . Marginal effects estimated from logistic regression analyses were used to assess the magnitude of the impact of the intervention . Results The women targeted by voucher outreach workers were poorer , less educated , and at higher parity .  After adjusting for these differences , women who delivered in 2009 and were sold voucher booklets were significantly more likely than women who delivered in 2008 to make at least three ANC visits , deliver in a health facility , and make a postnatal visit . Purchase of a voucher booklet was associated with a 22 percentage point increase in ANC use , a 22 percentage point increase in institutional delivery , and a 35 percentage point increase in PNC use . Conclusions A voucher intervention implemented for 12 months was associated with a substantial increase in institutional delivery . A substantial scale-up of maternal health vouchers that focus on institutional delivery is likely to bring Pakistan closer to achieving its 2015 target for institutional delivery BACKGROUND Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of dem and . In Latin America , some governments have been trying to increase dem and for health interventions by making direct payments to poor households contingent on them keeping up-to- date with preventive health services . We undertook a public health programme effectiveness trial in Honduras to assess this approach , contrasting it with a direct transfer of re sources to local health teams . METHODS 70 municipalities were selected because they had the country 's highest prevalence of malnutrition . They were allocated at r and om to four groups : money to households ; re sources to local health teams combined with a community-based nutrition intervention ; both packages ; and neither . Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later . Pregnant women and mothers of children younger than 3 years old were asked about use of health services ( primary outcome ) and coverage of interventions such as immunisation and growth monitoring  ( secondary outcome ) . Reports were supplemented with data from children 's health cards and government service utilisation data . Analysis was by mixed effects regression , accounting for the municipality-level r and omisation . FINDINGS The household-level intervention had a large impact ( 15 - 20 percentage points ; p<0.01 ) on the reported coverage of antenatal care and well-child check-ups . Childhood immunisation series could thus be started more opportunely , and the coverage of growth monitoring was markedly increased ( 15 - 21 percentage points ; p<0.01 . Measles and tetanus toxoid immunisation were not affected . The transfer of re sources to local health teams could not be implemented properly because of legal complications . INTERPRETATION Conditional payments to households increase the use and coverage of preventive health care interventions Background Globally , almost 4 million newborns die during the first 4 weeks of life every year . By increased use of evidence -based knowledge in the healthcare system a large proportion of these neonatal deaths could be prevented . But there is a severe lack of knowledge on effective methods for successful implementation of evidence into practice , particularly in low- and middle-income countries . Recent studies have demonstrated promising results with increased survival among both mothers and newborns using community-based approaches . In Vietnam  evidence -based guidelines on reproductive health were launched in 2003 and revised in 2009 . The overall objective of the current project is to evaluate if a facilitation intervention on the community level , with a problem-solving approach involving local representatives if the healthcare system and the community , results in improvements of neonatal health and survival . Methods / Design The study , which has been given the acronym NeoKIP ( Neonatal Health - Knowledge Into Practice ) , took place in 8 districts composed by 90 communes in a province in northern Vietnam , where neonatal mortality rate was 24/1000 in 2005 . A cluster r and omised design was used , allocating clusters , as defined as a commune and its correponding Commune Health Center ( CHC ) to either intervention or control arm . The facilitation intervention targeted staff at healthcare centres and key persons in the communes . The facilitator role was performed by lay women ( Women 's Union representatives ) using quality improvement techniques to initiate and sustain improvement processes targeting identified problem areas . The intervention has been running over 3 years and data were collected on the facilitation process , healthcare staff knowledge in neonatal care and their behaviour in clinical practice , and reproductive and perinatal health indicators . Primary outcome is neonatal mortality . Discussion The intervention is participatory and dynamic , focused on developing a learning process and a problem-solving cycle . The study recognises the vital role of the local community as actors in improving their own and their newborns ' health , and applies a bottom-up approach where change will be accomplished by an increasing awareness at and dem and from grass root level . By utilising the existing healthcare structure this intervention may , if proven successful , be well suited for scaling up . Trial registration Current Controlled Trials IS RCT Background Poverty may moderate the effect of treatment of depression in low-income countries . Aims To assess poverty and lack of empowerment as moderators of a cognitive – behavioural therapy (CBT)-based intervention for perinatal depression in rural Pakistan . Method Using secondary analysis of data from a r and omised controlled trial ( trial registration : IS RCT N65316374 ) we identified predictors of depression at 1-year follow-up and moderators of the intervention ( n = 791 ) . Results Predictors of follow-up depression included household debt , the participant not being empowered to manage household finance and the interaction terms for these variables with the trial arm . Effect sizes for women with and without household debt were 0.80 and 0.55 respectively . The effect size for women in debt and not empowered financially was 0.94 compared with 0.50 for women with neither of these factors . Conclusions Our findings demonstrate the importance of household debt and lack of financial empowerment of women as important maintaining factors of depression in low-income countries and our locally developed intervention tackled these problems successfully Background Despite significant increases in global health investment and the availability of low-cost , efficacious interventions to prevent mother-to-child HIV transmission ( pMTCT ) in low- and middle-income countries with high HIV burden , the translation of scientific advances into effective delivery strategies has been slow , uneven and incomplete . As a result , pediatric HIV infection remains largely uncontrolled . A five-step , facility-level systems analysis and improvement intervention ( SAIA ) was design ed to maximize effectiveness of pMTCT service provision by improving underst and ing of inefficiencies ( step one : cascade analysis ) , guiding identification and prioritization of low-cost workflow modifications ( step two : value stream mapping ) , and iteratively testing and re design ing these modifications ( steps three through five ) . This protocol describes the SAIA intervention and methods to evaluate the intervention ’s impact on reducing drop-offs along the pMTCT cascade . Methods This study employs a two-arm , longitudinal cluster r and omized trial design . The unit of r and omization is the health facility . A total of 90 facilities were identified in Côte d’Ivoire , Kenya and Mozambique ( 30 per country ) . A subset was r and omly selected and assigned to intervention and comparison arms , stratified by country and service volume , result ing in 18 intervention and 18 comparison facilities across all three countries , with six intervention and six comparison facilities per country . The SAIA intervention will be implemented for six months in the 18 intervention facilities . Primary trial outcomes are design ed to assess improvements in the pMTCT service cascade , and include the percentage of pregnant women being tested for HIV at the first antenatal care visit , the percentage of HIV-infected pregnant women receiving adequate prophylaxis or combination antiretroviral therapy in pregnancy , and the percentage of newborns exposed to HIV in pregnancy receiving an HIV diagnosis eight weeks postpartum . The Consoli date d Framework for Implementation Research ( CFIR ) will guide collection and analysis of qualitative data on implementation process . Discussion This study is a pragmatic trial that has the potential benefit of improving maternal and infant outcomes by reducing drop-offs along the pMTCT cascade . The SAIA intervention is design ed to provide simple tools to guide decision-making for pMTCT program staff at the facility level , and to identify low cost , context ually appropriate pMTCT improvement strategies . Trial registration Clinical Trials.gov Background . Low-income mothers have greater challenges in accessing health care services due changes in the health care system and budget cuts . The purpose of this r and omized clinical trial was to test a nurse practitioner ( NP ) intervention using cell phone and texting on maternal/infant outcomes . Methods . The sample included 129 mother-infant pairs . Intervention group mothers received NP 2-way cell phone follow-up intervention post – hospital discharge for 6 months . Results . Intervention mothers ’ perceived social support was significantly higher . Intervention infants received their first newborn follow-up visit significantly earlier ( 6 vs 9 days ) ; significantly more infants were immunized at recommended times ( 2 , 4 , and 6 months of age ) ; and there were fewer infant morbidities compared to controls . The intervention saved between $ 51 030 and $ 104 277 in health care costs averted . Conclusion . This easy-to-use , safe intervention is an effective way to reach a wide range of population s and demonstrated improved maternal/infant outcomes and decreased cost When trusted , Community Health Workers ( CHWs ) can contribute to improving maternal and newborn health outcomes in low- and middle-income countries through education . Issues of acceptability of CHWs by communities were explored through experiences gained in a qualitative study that is part of a cluster r and omized trial in East Ug and a. Initially , focus group discussion s with key community members and leaders were undertaken regarding preventative health and 40 CHWs were observed making home visits by supervisors during the initial 6 months of fieldwork of the trial in eight villages in the Jinja District in Ug and a. The results were analyzed using the 5-SPICE framework . Observation of CHWs in the field identified a number of unanticipated issues including a general mistrust of the public health system by community members in areas that had an impact on maternal and newborn health . At the outset , CHWs often did not trust their own abilities and faced community expectations that they would provide curative rather than preventative care . Early community engagement , non-threatening home visits that enhanced friendship and supportive supervision improved the confidence of the CHWs and improved the trust and acceptance of the CHWs and the willingness of the community members to act on what was discussed PURPOSE This study investigates the causal effect of Kenya 's  unconditional cash transfer program on  mental health outcomes of young people . METHODS Selected locations in Kenya were r and omly assigned to receive unconditional cash transfers  in the first phase of Kenya 's Cash Transfer Program for orphans and Vulnerable Children . In intervention locations , low-income households and those with orphans and vulnerable childrens began receiving monthly cash transfers of $ 20 in 2007 . In 2011 , 4 years after program onset , data were collected on the psychosocial status for youth aged 15 - 24 years from households in intervention and control locations ( N = 1960 ) . The primary outcome variable was an indicator of depressive symptoms using the 10- question Center for Epidemiologic Studies Depression Scale . Secondary outcomes include an indicator for hopefulness and physical health measures . Logistic regression models that adjusted for individual and household characteristics were used to determine the effect of the cash transfer program . RESULTS The cash transfer reduced the odds of depressive symptoms by 24 percent among young persons living in households that received cash transfers . Further analysis by gender and age revealed that the effects were only significant for young men and were larger among men aged 20 - 24 years and orphans . CONCLUSIONS This study provides evidence that poverty-targeted unconditional cash transfer programs , can improve the mental health of young people in low-income countries BACKGROUND Caesarean section rates are increasing in Mexico and Latin America . This study evaluates the impact of a large-scale , conditional cash transfer programme in Mexico on caesarean section rates . The programme provides cash transfers to participating low income , rural households in Mexico conditional on accepting health care and nutrition supplements . METHODS The primary analyses uses retrospective reports from 979 women in poor rural communities participating in an effectiveness study and r and omly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states . Using multivariate and instrumental variable analyses , we estimate the impact of the programme on caesarean sections and predict the adjusted mean rates by clinical setting . Programme participation is measured by beneficiary status , programme months and cash transfers . RESULTS More than two-thirds of poor rural women delivered in a health facility . Beneficiary status is associated with a 5.1 percentage point increase in caesarean rates ; this impact increases to 7.5 percentage points for beneficiaries enrolled in the programme for > or=6 months before delivery . Beneficiaries had significantly higher caesarean delivery rates in social security facilities ( 24.0 compared with 5.6 % among non-beneficiaries ) and in other government facilities ( 19.3 compared with 9.5 % ) . CONCLUSION The Oportunidades conditional cash transfer programme is associated with higher caesarean section rates in social security and government health facilities . This effect appears to be driven by the increases in disposable income from the cash transfer . These findings are relevant to other countries implementing conditional cash transfer programmes and health care requirements Background Effective , scalable strategies to improve maternal , fetal , and newborn health and reduce preventable morbidity and mortality are urgently needed in low- and middle-income countries . Building on the successes of previous checklist-based programs , the World Health Organization ( WHO ) and partners led the development of the Safe Childbirth Checklist ( SCC ) , a 28-item list of evidence -based practice s linked with improved maternal and newborn outcomes . Pilot-testing of the Checklist in Southern India demonstrated dramatic improvements in adherence by health workers to essential childbirth-related practice s ( EBPs ) . The BetterBirth Trial seeks to measure the effectiveness of SCC impact on EBPs , deaths , and complications at a larger scale . Methods / design This matched-pair , cluster-r and omized controlled , adaptive trial will be conducted in 120 facilities across 24 districts in Uttar Pradesh , India . Study sites , identified according to predefined eligibility criteria , were matched by measured covariates before r and omization . The intervention , the SCC embedded in a quality improvement program , consists of leadership engagement , a 2-day educational launch of the SCC , and support through placement of a trained peer “ coach ” to provide supportive supervision and real-time data feedback over an 8-month period with decreasing intensity . A facility-based childbirth quality coordinator is trained and supported to drive sustained behavior change after the BetterBirth team leaves the facility . Study participants are birth attendants and women and their newborns who present to the study facilities for childbirth at 60 intervention and 60 control sites . The primary outcome is a composite measure including maternal death , maternal severe morbidity , stillbirth , and newborn death , occurring within 7 days after birth . The sample size ( n = 171,964 ) was calculated to detect a 15 % reduction in the primary outcome . Adherence by health workers to EBPs will be measured in a subset of births ( n = 6000).The trial will be conducted in close collaboration with key partners including the Governments of India and Uttar Pradesh , the World Health Organization , an expert Scientific Advisory Committee , an experienced local implementing organization ( Population Services International , PSI ) , and frontline facility leaders and workers . Discussion If effective , the WHO Safe Childbirth Checklist program could be a powerful health facility-strengthening intervention to improve quality of care and reduce preventable harm to women and newborns , with millions of potential beneficiaries . Trial registration BetterBirth Study Protocol date d : 13 February 2014 ; Clinical Trials.gov : NCT02148952 ; Universal Trial Number : U1111 - 1131 - 5647 Background There is a lack of literature on how to adapt new evidence -based interventions for maternal and newborn care into local health systems and policy for rapid scale-up , particularly for community-based interventions in low-income setting s. The Ug and a Newborn Study ( UNEST ) was a cluster r and omised control trial to test a community-based care package which was rapidly taken up at national level . Underst and ing this process may help inform other studies looking to design and evaluate with scale-up in mind . Objective This study aim ed to describe the process of using evidence to design a community-based maternal and newborn care package in rural eastern Ug and a , and to determine the dissemination and advocacy approaches used to facilitate rapid policy change and national uptake . Design We review ed UNEST project literature including meeting reports and minutes , supervision reports , and annual and midterm reports . National stakeholders , project and district staff were interviewed regarding their role in the study and perceptions of what contributed to uptake of the package under evaluation . Data related to UNEST formative research , study design , implementation and policy influence were extracted and analysed . Results An advisory committee of key players in development of maternal and newborn policies and programmes in Ug and a was constituted from many agencies and disciplines . Baseline qualitative and quantitative data collection was done at district , community and facility level to examine applicability of aspects of a proposed newborn care package to the local setting . Data were summarised and presented to stakeholders to adapt the intervention that was ultimately tested . Quarterly monitoring of key activities and events around the interventions were used to further inform implementation . The UNEST training package , home visit schedule and behaviour change counselling material s were incorporated into the national Village Health Team and Integrated Community Case Management packages while the study was ongoing . Conclusions Design ing interventions for national scale-up requires strategies and planning from the outset . Use of evidence alongside engagement of key stakeholders and targeted advocacy about the burden and potential solutions is important when adapting interventions to local health systems and communities . This approach has the potential to rapidly translate research into policy , but care must be taken not to exceed available evidence while seizing the policy opportunity
Studies that documented improved care-seeking indicated the importance of adequate programme scope ( in terms of programme eligibility , size and timing of payments and voucher entitlements ) to address the issue of concern , concurrent investments in supply-side capacity to sustain and /or improve quality of care , and awareness generation using community-based workers , leaders and women ’s groups .
Conclusions Evaluations spanning more than 15 years of implementation of DSF programmes reveal a complex picture of experiences that reflect the importance of financial and other social , geographical and health systems factors as barriers to accessing care .
Background Dem and -side financing ( DSF ) interventions , including cash transfers and vouchers , have been introduced to promote maternal and newborn health in a range of low- and middle-income countries .
These interventions vary in design but have typically been used to increase health service utilisation by off setting some financial costs for users , or increasing household income and incentivising ‘ healthy behaviours ’ .
This article documents experiences and implementation factors associated with use of DSF in maternal and newborn health .