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Table 2 Overview of included studies

From: Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review

Country Strategy Description of strategy Type of MNH care Study design Study year Magnitude/Measure of effect Author (Year) Reference
Bangladesh Women’s groups & health system strengthening (HSS) Recruit & train facilitators to convene monthly women’s group meetings. Women’s groups encouraged to adopt strategies to improve MNH. In all clusters basic medical equipment supplied, TBAs trained in essential newborn care, physicians trained, and links established between communities and health services. MNH, especially newborn Cluster RCT 2009- 2011 NMR per 1000 LB Adj RR = 0.62 (95% CI: 0.43-0.89) Fottrell (2013) [18]
Bangladesh Vouchers for free MNH care, cash and in-kind transfers Family welfare assistants (FWAs) distribute vouchers to (eligible) pregnant women entitling them to free ANC, delivery, emergency referral & post-partum care. Cash stipends for transport & other costs. Cash incentive to deliver in facility or at home with skilled provider. In-kind items (including soap and newborn clothes) supplied. Providers reimbursed for services provided. All MNH Intervention & control areas 2008- 2009 % of deliveries with qualified provider: 58-70% (S), 27% (C) Hatt (2010) [19]
Bangladesh Improve health and family welfare clinics Staff & equip primary health facilities to provide delivery & newborn care (incl. additional staff, improved infrastructure, equipment and supplies). Facility-birth Cost projection 2011 Estimated number of clients per year Howlander (2011) [20]
Bangladesh Promotion of NGO health clinics: Smiling Sun communication campaign to promote NGO clinics (incl. 26 episode TV drama, TV adverts, radio spots, posters, billboards, adverts in daily newspapers, & local publicity efforts). Facility-based ANC Secondary data analysis 2001- 2004 Estimated number of new ANC users Hutchinson (2006) [21]
1. National media campaign
2. National media campaign & local activities
Bangladesh MNH services delivered at home, with community mobilization and health system strengthening (HSS) CHWs recruited and trained to conduct home visits during pregnancy and post-natal period (incl. treatment of newborns with antibiotics). Communities were mobilized. HSS in all clusters: facility-level providers trained in MNH care, drugs & supplies distributed, & system for tracking neonatal care established. All MNH Cluster RCT 2003- 2005 NMR per 1000 LB: 31.2 (S), 43.1 (C) LeFevre (2013) [22]
Bangladesh Outreach clinics for FP and ANC by facility staff† Increase number of outreach clinics and extend opening hours. Compared to services (ANC care) provided at primary care facilities. Pregnancy Intervention & control areas 1996- 1997 Number of ANC services provided Levin (1997 & 1999) [23, 24]
Bangladesh Alternative delivery strategies FP & MCH 1. FP & MCH services by government fieldworkers at community service points (e.g. clubs, schools); FP & MCH Intervention & control areas 1996- 1997 Number of ANC services provided Routh (2000) [25]
2. FP & MCH services provided at primary care facility Compared to FP & MCH services provided at home by government fieldworkers.
Bangladesh Train TBAs TBAs trained and encouraged to refer difficult births. Intra-partum Estimated from secondary data Not given Neonatal lives saved per 1000 LB: 7 (estimate) World Bank (2005) [26]
Benin & Guinea Bamako Initiative Various strategies to improve primary care, incl. integrated minimum package of preventive and curative MNCH care. ANC (incl. prophylaxis for malaria & anaemia) Secondary data analysis 1989- 1993 % of pregnant women having at least 3 ANC visits: 43% Benin, 55% Guinea Soucat (1997) [27]
Burkina Faso Train new cadres in EmOC Develop and implement training: EmOC Pre-Post 2004- 2007 Newborn case fatality rate per 1000 c-sections: 125 (S1), 198 (S2), 99 (C) Hounton (2009) [28]
S1. Six-months in essential surgery for medical doctors,
S2. Two-years in surgery (incl. C-section) for clinical officers.
C. Compared to training obstetricians
Burkina Faso Initiative to promote facility-birth Recruit & train of community link workers. Community mobilization by traditional leaders to promote assisted delivery. Also PHC staff trained, equipment supplied & infrastructure improved. Facility-birth Intervention & control areas 2002- 2005 20.8% point increase in births delivered in a facility Newlands (2008) & Hounton (2012) [29, 30]
Cambodia Introduce HIV testing: Facilities supplied HIV test kits. Five-day HIV training for midwives. Facility paid per person tested, and per person counselled and referred. Monthly staff meetings and regular supervision. HIV testing & mgmt Pre-Post 2008- 2009 % tested for HIV: 97.6% at ANC, 95% at labour Heller (2011) [31]
1. at ANC
2. at labour
Cambodia Community health education by midwives Midwives trained to lead focus group discussions to engage community on maternal health. Birth preparedness Pre-Post 2005- 2006 22% increase in ANC, 32% increase births with midwife, 19% decrease in women using TBAs, 281% increase in referrals Skinner (2009) [32]
Democratic Republic of Congo Distribute malaria ITNs at ANC Nurses trained to distribute ITNs to pregnant women attending ANC. Malaria prevention Economic model (incl. primary data) 2005- 2006 Number of ITNs delivered, and estimated number of infant deaths averted Becker-Dreps (2009) [33]
The Gambia Outreach maternal health care Outreach ANC clinics ran by midwives & community nurses. Activities to identify pregnant women, support for referral). Also train TBAs (incl. 6 month refresher). New fixed price for MNH care. Pregnancy & Intra-partum Intervention & control areas 1989- 1991 NMR per 1000 LB: 16 (S), 32.2 (C) MMR per 1000 LB: 3.1 (S), 7 (C) Fox-Rushby (1995 & 1996) [34, 35]
Honduras Hospital-based promotion of breastfeeding Hospital staff trained to educate & encourage mothers to breastfeed. Included changes to establish early breastfeeding contact, rooming-in of babies with mothers, withdrawal of routine bottle feeding, & post-partum counselling. Promote breastfeeding Intervention & control areas 1992- 1993 % exclusive breastfeeding: 42.7% (S), 22.2% (C) Horton (1996) [36]
Neonatal deaths averted per 1000: 1.02 (from acute respiratory infection), 3.48 (from diarrhoea)
India Women’s groups & health system strengthening (HSS) Recruited & trained facilitators to convene monthly women’s group meetings. Women’s groups encouraged to adopt strategies to improve MNH. HSS (incl. training in newborn care, equipment & supplies) in all areas. All MNH Cluster RCT 2005- 2008 NMR per 1000 LB: 42.9 (S), 59.1 (C); Adj OR = 0.71 (95% CI: 0.61-0.83) Tripathy (2010) [37]
India HIV testing at ANC: Activities include: health education using local media campaign and HIV testing, counselling, drug treatment at ANC. HIV testing & management Economic model 2005 Estimated number of cases of perinatal HIV prevented Kumar (2006) [38]
1. nationwide
2. in high prevalence states
India Home-based neonatal care by Village Health Workers (VHWs) Recruit and train female VHWs to identify & counsel pregnant women, & to undertake home-based neonatal care. Also VHWs may support TBAs at delivery. VHWs were supervised every 2 weeks. All MNH, esp. thermal care, birth asphyxia, breastfeeding, neonatal sepsis Pre-Post + Control 1993- 2003 70% reduction in NMR per 1000 LB: 62 (Pre), 25 (Post) Bang (2005a) [39]
India Home-based management of birth asphyxia by Village Health Workers (VHWs) Trained female VHWs to diagnose and manage birth asphyxia (when support TBAs at delivery) Compared to current practice (with TBAs trained to manage birth asphyxia. Birth asphyxia Pre-Post 1996- 2003 65% reduction in NMR per 1000 LB: 10.5 (Pre), 3.6 (Post) Bang (2005b) [40]
India Home-based neonatal care by Village Health Workers (VHWs) Recruit and train female VHWs to identify & counsel pregnant women, & to undertake home-based neonatal care. Also VHWs may support TBAs at delivery. VHWs were supervised every 2 weeks. All MNH, esp. thermal care, birth asphyxia, breastfeeding, neonatal sepsis Pre-Post + Control 1993- 1998 62% reduction in NMR per 1000 LB in year 3: 25.5 (S), 59.6 (C) Bang (1999) [41]
Indonesia Tetanus toxoid (TT) immunization campaign TT immunization campaign by new nursing graduates, supported by community mobilization using village heads and women’s groups. Compared to TT immunization at routine ANC. Tetanus toxoid immunization Intervention & control areas 1985 Number of women who received full TT dose, and estimated number of neonatal (tetanus) deaths averted Berman (1991) [42]
Kenya Distribute malaria ITN at ANC Facilities instructed to procure ITNs and distribute to pregnant women during ANC. Malaria prevention Prospective 2001 Reports number ITNs distributed. 77% were to pregnant women Guyatt (2002) [43]
Kenya Syphilis testing at ANC. On-site syphilis testing using rapid syphilis test, on-site same day treatment of RPR-positive, promotion of notification and presumptive treatment of women’s partners. Syphilis testing & treatment Pre-Post 1998- 2000 % clients at ANC screened: 81% (S1), 51% (S2) Population Council (2001) [44]
1. on-site
2. standard clinics (off-site)
Kenya Decentralized programme of syphilis control Programme included: laboratory support; supplies and drugs; training ANC nurses in rapid syphilis testing and treatment of seroactive women; counselling; partner notification; supervision & monitoring. Syphilis diagnosis and treatment Pre-Post 1997- 1998 Number of women screened, number test-positive, & number treated Fonck (2001) [45]
Kenya Decentralized programme of syphilis control Programme included: laboratory support; supplies and drugs; training ANC nurses in rapid syphilis testing and treatment of seroactive women; counselling; partner notification; supervision & monitoring. Syphilis testing & mgmt Pre-Post 1992- 1993 Number of syphilis cases treated, and estimated number of congenital syphilis averted Jenniskens (1995) [46]
Malawi 1. Women’s groups 1. Recruited & trained facilitators to convene women's groups. Women's groups encouraged to identify and adopt local strategies to improve MNH. All MNH Factorial Cluster RCT 2008- 2010 NMR per 1000 LB: 27.0 (S3), 34.0 (C); Adj OR = 0.78 (95% CI: 0.60-1.01) Colbourn (2013a & 2013b) [47, 48],
2. Quality improvement at health facilities,
3. Both 1 & 2 2. Facility staff trained to initiate and run quality improvement initiative. Facility staff to identify & adopt local strategies to improve facility-based services (e.g. staff training needs).
Malawi 1. Women’s groups 1. Recruited & trained facilitators to convene women's groups. Women’s groups encouraged to identify and adopt local strategies to improve MNH. 2. Volunteer peer counsellors made home visits during pregnancy and post-birth to support breastfeeding and infant care. All MNH Factorial Cluster RCT 2005- 2009 Factorial analysis: NMR per 1000 LB (S1 vs C): OR = 0.85 (95% CI: 0.59-1.22) MMR per 100,000 LB (S1 vs C): OR = 0.48 (95% CI: 0.26-0.91) IMR per 1000 LB (S2 vs C): OR = 0.89 (95% CI: 0.72-1.10) Lewycka (2013) [49]
2. Peer counselling
3. Both 1 & 2
Mozambique Train Assistant Medical Officers in Emergency Obstetric Care (EmOC) Two-year classroom-based instruction followed by 1-year internship. (In comparison, physicians receive 6-years of medical training and 5-year residency in surgery and obstetrics). EmOC Economic model (primary data) 2004 Number of obstetric surgeries performed Kruk (2007) [50]
Nepal Women’s groups & health system strengthening (HSS) Recruited & trained facilitators to convene monthly women’s group meetings. Women’s groups encouraged to adopt strategies to improve MNH (e.g. community-fund, stretcher schemes, clean delivery kits, home visits). HSS (incl. training in newborn care, equipment & supplies) in all areas. All MNH Cluster RCT 1999- 2003 NMR per 1000 LB 26.2 (S), 36.9 (C). Borghi (2005) [51]
Adj OR = 0.70 (95% CI: 0.53-0.94)
Niger Quality improvement collaborative Used facility data to monitor indicators of common technical interventions. Staff worked collaboratively to identify strategies to overcome service delivery barriers and improve facility care. Intra-partum/Post-partum care (incl. AMTSL & PPH) Pre-Post 2006- 2008 MMR per 10,000 vaginal births (projected:) 7.11 (Pre), 0.98 (Post) Broughton (2013) [52]
Niger Programme to treat obstetric urogenital fistula Programme include hospital stay, hygiene education, medical and surgical treatment and social rehabilitation interventions. All provided free of charge. Obstetric urogential fistula Pre-Post 2006 Number of women benefitting from the programme during study period Ndiaye (2009) [53]
Nigeria Establish and train community contact persons Select and trained contact persons to provide community health education, visit pregnant women, & facilitate referral (if needed). Pregnancy; & support referral Pre-Post 1993- 1995 Number of women assisted by contact persons during study period Nwakoby (1997) [54]
Nigeria Establish emergency transport scheme Mobilize transport union, drivers given basic training & awareness on health topics. Also seed money to establish revolving petrol fund. Emergencies (pregnancy & intra-partum) Pre-Post 1994- 1995 Number of obstetric emergencies transported during study period. Shehu (1997) [55]
Papua New Guinea Improve standard of special neonatal care Special care nurses trained on management of neonatal illnesses, including new treatment protocol for low-birth weight babies. Special care units provided equipment (e.g. pulse oximetry). Also clinical supervision and a weekly mortality audit. Special neonatal care (incl. mgmt birth asphyxia, neonatal sepsis, pneumonia) Pre-Post 1995- 2000 In-hospital neonatal mortality: RR = 0.56 (95% CI: 0.45-0.69) Duke (2000) [56]
Senegal Remove user fees for intra-partum care Removed user fees for intra-partum care (including caesarean section) in poor regions. Facility-birth (incl. c-section) Pre-Post 2004- 2006 % births supervised by normal delivery: 40% (Pre), 44% (Post) Witter (2010) [57]
% of births by C-section 4.2% (Pre), 5.6% (Post)
Uganda Compare four strategies for abortion care Alternative strategies are defined along two dimensions: availability and type of practice: Abortion care Economic Model 1996 Not applicable estimates cost per abortion case Johnston (2007) [58]
1 Restricted-conventional,
2. Restricted-recommended,
3. Liberal-conventional, 4. Liberal-recommended. Also examined strategies at different levels of care.
Uganda Home-based distribution of intermittent preventive treatment in pregnancy (IPTp) Community resource persons trained to identify pregnant women, make home visits and distribute IPTp, folic acid and iron supplements. Compared to IPTp distributed at PHC during ANC. Malaria prevention (IPTp) Prospective 2003- 2005 % of women with anaemia: 49% (S), 41% (C) % of LBW babies: 8% (S), 6% (C) Mbonye (2008a & (2008b) [59, 60]
Uganda Establish emergency transport Established local ambulance service available 24 hours. Emergencies (pregnancy & intra-partum) Pre-Post 2009- 2010 Number of obstetric referrals during study period Somigliana (2011) [61]
Ukraine Initiative on evidence-based practice in maternal and infant hospital care Eight-year project advocating reduction in (elective) c-sections and evidence-based medical practices (incl. amniotomies and episiotomies, early breastfeeding, skin-to-skin contact, rooming in). Maternity staff trained & sought to develop centres of excellence. Intra-partum & newborn care Pre-Post 2002- 2005 4.71% reduction in number of (elective) C-sections Nizalova (2010) [62]
Zambia Syphilis testing at ANC Facilities supplied syphilis tests. Five-day training on pregnancy care (incl. syphilis). Also used community health education via local leaders to improve ANC attendance. Syphilis testing & mgmt Pre-Post + Control 1986- 1987 % of adverse pregnancy outcomes among seroreactive women: 28.3% (S), 72.4% (C) Hira (1990) [63]
Zambia Train midwives in newborn care Clinic midwives trained using 5-day WHO course on neonatal care and management of neonatal illnesses. Newborn care (incl thermal care & breastfeeding) Pre-Post 2004- 2006 NMR per 1000 (by 7-day): 11.5 (Pre), 6.8 (Post) RR = 0.59 (95% CI: 0.48–0.77) Manasyan (2011) [64]
Zambia Train TBAs & supply clean delivery kits TBAs trained over 4-day training (with refresher training every 3–4 months), provided equipment and clean delivery kits. Intra-partum & newborn care Cluster RCT 2006- 2008 Estimated number of neonatal deaths averted Sabin (2012) [65]
  1. Note: The study also compared provision of family planning to groups of women at a centrally located house with home-based doorstep strategy.
  2. Acronyms used: Adj: adjusted; ANC: antenatal care; C: comparator; CHW: community health worker; CI: confidence interval; C-section: caesarean section; EmOC: emergency obstetric care; excl.: excluding; FP: family planning; FWA: family welfare assistant; HSS: health system strengthening; IMR: infant mortality rate; Incl.: including; ITNs: insecticide-treated bed nets; IPTp: intermittent preventive treatment in pregnancy; LB: live births; LBW: low birth weight; MCH: maternal and child health; MNCH: maternal, newborn, and child health; MNH: maternal and newborn health; MMR: maternal mortality rate; NGO: non-governmental organisation; NMR: neonatal mortality rate; OR: odds ratio; PHC: primary health care; RCT: randomized control trial; RR: relative risk; S: strategy; S1: strategy 1; S2: strategy 2; TBA: traditional birth attendant; TT: tetanus toxoid; VHWs: village health workers; WHO: World Health Organization.