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Includes bibliographical references and index. Electronic reproduction. Other Form Print version Improving birth outcomes. Digital Library Federation, December Online version available for university members only.
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Public Private login e. Add a tag Cancel Be the first to add a tag for this edition. Other barriers exist at the household and community levels, such as insufficient demand for interventions or sociocultural barriers; at the health services level, such as a lack of resources and trained healthcare providers; and at the health sector policy and management level, such as poorly functioning, centralized systems.
Additional constraints involve weak governance and accountability, political instability, and challenges in the physical environment. Scaling up maternal, newborn and child health interventions requires strengthening health systems, but there is also a role for focused, targeted interventions. Choosing a strategy involves identifying appropriate channels for reaching high coverage, which depends on many factors such as access to and attendance at healthcare facilities. Delivery channels vary, and may include facility- and community-based healthcare providers, mass media campaigns, and community-based approaches and marketing strategies.
Issues related to scaling up are discussed in the context of four interventions that may be given to mothers at different stages throughout pregnancy or to newborns: 1 detection and treatment of syphilis; 2 emergency Cesarean section; 3 newborn resuscitation; and 4 kangaroo mother care.
Systematic reviews of the literature and large-scale implementation studies are analyzed for each intervention. Equitable and successful scale-up of preterm birth and stillbirth interventions will require addressing multiple barriers, and utilizing multiple delivery approaches and channels. Another important need is developing strategies to discontinue ineffective or harmful interventions. Preterm birth and stillbirth interventions must also be placed in the broader maternal, newborn and child health context to identify and prioritize those that will help improve several outcomes at the same time.
The next article discusses advocacy challenges and opportunities. Once cost-effective interventions are identified and prioritized, appropriate strategies must be used to scale-up delivery to reach high and equitable population coverage and reduce the global burden of disease see article 3 for a discussion on existing preterm birth and stillbirth interventions [ 1 ].
Prospects for Research in Reproductive Health and Birth Outcomes
Appropriate delivery strategies are those tailored to match the unique needs and capacities of specific regions or populations within each country. This article begins with a general discussion of barriers and approaches to scaling up interventions. While the focus is on low- and middle-income countries LMICs , some of the discussion will also be applicable to high-income countries. This is followed by a discussion of choosing cost-effective interventions. Four specific interventions are then used as examples.
The article concludes with a discussion of scaling interventions in the broader maternal, fetal, newborn and child health context. Table 1 summarizes barriers to achieving universal coverage of preterm birth and stillbirth interventions. This table is an adapted typology of the main constraints to scaling up child survival interventions in LMICs [ 2 , 3 ]. Barriers exist at multiple levels, from households to health services, and throughout different political and physical environments.
Depending on the intervention being implemented, different types of constraints may operate. Although many of the most significant barriers to delivery of effective interventions reside within the health systems and Ministries of Health, the solutions to these barriers often reside in more powerful areas of government such as Ministries of Finance and Planning, as well as in Ministries of Foreign Affairs which deal with foreign aid and international financial organizations.
This is essential for addressing a key constraint which limits the scaling up of interventions— namely, affordability. As Cleary and Mclntyre note, "even if a conclusion is reached that a particular strategy is deemed cost-beneficial… it does not follow that it is necessarily affordable, particularly given the extremely constrained health-care resources in many African countries [ 4 ]. An overarching constraint is the lack of political interest in preterm birth and stillbirth. This is largely attributed to low visibility associated with the inherent difficulties in measuring these outcomes.
Addressing these data gaps is an essential step in highlighting the importance of these problems, as discussed in the article 1 on data [ 5 ], article 2 on etiologies [ 6 ], and article 5 on ethics [ 7 ]. Authors reviewing strategies for preventing maternal [ 8 , 9 ] and neonatal [ 10 , 11 ] deaths emphasize the need to build functional health systems. This includes ensuring geographic and financial access to poor populations; training, deploying, and retaining health workers; and guaranteeing supplies of commodities and drugs. The recent revival of the "Health for All" approach adopted 30 years ago at the Alma-Ata Conference supports the need to strengthen health systems [ 12 ].
A distinct approach was adopted by a review [ 13 ] to assess the potential of scaling up maternal, fetal, newborn and child health interventions. The authors reviewed 43 promising health interventions portrayed as proven effective in reducing neonatal, child, and maternal morbidity and mortality. They excluded 22 interventions that required extensive behavioral changes, laboratory testing or advanced clinical skills. A "best-bets" analysis was done of the remaining 21 interventions.
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Two of these 21 best-bet interventions have a potential impact on preterm rates: insecticide-treated materials mainly bed nets for malaria prevention and intermittent presumptive treatment for malaria in pregnancy. A third intervention affects the survival of preterm infants— corticosteroids given during preterm labor. Six criteria were used to select promising interventions:. Although it is reassuring that three interventions related to preterm birth were included, the criteria employed by the authors favored stand-alone, vertically-delivered interventions as opposed to the horizontal approach of strengthening health systems to deliver packaged interventions.
However, even typically "vertical" approaches such as vaccination campaigns, for example, require trained health workers, supervision, an information system, consumables and equipment for the cold chain. In addition to its lifecycle or temporal dimension, the continuum also refers to the different levels or settings where care must be provided—households and communities, outreach and outpatient services, and inpatient care.
This strategy favors the horizontal delivery of packages through cost-effective interventions by strengthening health systems, in contrast to the vertical approach promoted by the Gillespie review of scalable, stand-alone interventions with limited emphasis on building a functional health system [ 13 ]. The "vertical vs. A combination of both is required for scaling up effective interventions namely the "diagonal" approach [ 3 , 15 ]. A recent analysis of the 30 low-income countries with the most progress for primary health care services and outcomes in the last 30 years found that the top band of countries who now have comprehensive health systems had built these in a similar manner—starting with packages of care that were selective and increased in complexity over time [ 16 ].
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Another key factor was an effective district health management system and willingness to adopt task-shifting, especially when building up the system. Functional health systems are a prerequisite for comprehensive antenatal and childbirth care, which may serve as a platform for delivering most of the interventions discussed in the previous sections.
It is possible that delivery and development research could contribute to delivering some of these interventions in a simpler way and at lower levels of care. Complex, facility-based interventions tend to have a higher level of inequity than simpler interventions that can be delivered closer to home.
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For example, there is low inequity for immunization and antenatal care, while higher disparities exist for skilled attendance coverage. Issues related to scaling up are discussed in detail in the following pages within the context of four specific interventions: syphilis screening and treatment, emergency cesarean sections, newborn resuscitation and kangaroo mother care.
Successful scale-up requires delivering cost-effective interventions to those who need them most. Approaches for reaching high coverage are known as "delivery channels," "delivery strategies" or "means of distribution" in the literature [ 17 ], and should not be confused with the use of the term "delivery" as in childbirth.