Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health
A global review of the key interventions related to reproductive, maternal, newborn and child Health
Why reproductive, maternal, newborn and child health?
Poor maternal, newborn and child health remains a significant problem in developing countries. Worldwide, 358 000 women die during pregnancy and childbirth every year and an estimated 7.6 million children die under the age of five. The majority of maternal deaths occur during or immediately after childbirth. The common medical causes for maternal death include bleeding, high blood pressure, prolonged and obstructed labour, infections and unsafe abortions. A child’s risk of dying is highest during the first 28 days of life when about 40% of under-five deaths take place, translating into three million deaths. Up to one half of all newborn deaths occur within the first 24 hours of life and 75% occur in the first week. Globally, the main causes of neonatal death are preterm birth, severe infections and asphyxia. Children in low-income countries are nearly 18 times more likely to die before the age of five than children in high-income countries.
Good maternal health and nutrition are important contributors to child survival. The lack of essential interventions to address these and other health conditions often contribute to indices of neonatal morbidity and mortality (including stillbirths, neonatal deaths and other adverse clinical outcomes).
The highest maternal, neonatal and under-five mortality rates are in sub-Saharan Africa and in Southern Asia. Although substantial progress has been made towards achieving the Millennium Development Goals (MDGs) 4 and 5, the rates of decline in maternal, newborn and under-five mortality remain insufficient to achieve these goals by 2015. Interventions and strategies for improving reproductive, maternal, newborn and child health and survival are closely related and must be provided through a continuum of care approach. When linked together and included as integrated programmes, these interventions can lower costs, promote greater efficiencies and reduce duplication of resources. However, few efforts have been made to identify synergies and integrate these interventions across the continuum of care. Despite the existing plethora of knowledge, there is a lack of consensus on how best to move forward in a coordinated manner so as to achieve progress towards the MDGs. Furthermore, consensus is also needed on the level of evidence.
The foremost aim of this global review is to compile existing evidence on the impact of different interventions on the main causes of maternal, newborn and child deaths. The specific objectives of this review were to serve as a first step towards:
- Developing consensus on the content of RMNCH packages of interventions at each level of the health system across the continuum of care.
- Facilitating the scaling-up of these interventions.
- Identifying research gaps in the content of core packages of interventions.
Policy and regulatory environment
Policy and regulations are crucial to the implementation of any interventions. The recommended list of interventions should be reviewed in light of the existing national policy and regulatory environment. All interventions provided should comply with the laws and policies of the country. When required, these laws and policies may be reviewed and updated to ensure that priority life saving interventions are delivered.
A total of 142 RMNCH interventions were identified, assessed and selected for this review (there is a 700 page compilation of the evidence which underpins this short summary available at the PMNCH), based on current WHO recommendations contained in the following publications: Guidelines on HIV and Infant Feeding (2010); Integrated Management of Childhood Illness (2008); Integrated Management of Childhood Illness for high HIV settings (2008), the Pocket Book on Hospital Care for Children (2005), Integrated Management of Pregnancy and Childbirth clinical guidelines (2007); recommended interventions for improving maternal and newborn health - Integrated management of pregnancy and childbirth (2007). Interventions published in the Child and Neonatal Lancet Series (2003 and 2005, respectively) as well as in the WHO Recommended interventions for improving maternal and newborn health (2010).
Inclusion criteria comprised the following: (i) the intervention has an alleged impact on reducing maternal, neonatal and child mortality; (ii) the intervention is suitable for delivery in low- and middle-income countries, and/or settings where minimal essential care is generally available; and (iii) the intervention is delivered through the health sector (community level up to the referral level of health care).
Relevant reviews for each intervention were identified from the following electronic databases: the Cochrane database of systematic reviews, the Cochrane database of abstract reviews of effectiveness (DARE), the Cochrane database of systematic reviews of randomized control trials (RCTs), and PubMed. The reference lists of reviews and recommendations from experts in the field were also used as sources to obtain additional publications. The principal focus was on the existing systematic reviews and meta-analysis.
Classification of interventions
The interventions were classified into categories A, B and C, according to the framework provided in Box 1.
The classification of the effect of interventions according to the evidence available was done based on that used by the Cochrane group, as follows:
|Interventions that are beneficial||Interventions likely to be beneficial||Interventions with a trade-off between beneficial and adverse effects||Interventions of unknown effect, including absence of reviews||Interventionsl likely to be ineffective or harmful|
This classification benefited from being broadly known, recognized and accepted since it is the classification used by the Cochrane systematic review process that has guided this exercise from the beginning. The “evidence” was restricted to published systematic reviews; not including single studies.
The origin of evidence included the following three different levels of delivery of interventions and these were defined in the publication by the World Bank “Priorities in Health”:
Health care providers at this level include community health workers and outreach workers. It utilizes resources such as volunteers’ time, local knowledge, and community confidence and trust as channels for delivery of interventions generally related to safe motherhood, nutrition, and simple prevention and treatments. Many countries have attempted to construct links between community-based health care resources and households for a range of health programmes. These programmes do not substitute for a health system, but provide a channel for reaching families with information and resources. Community health workers (CHWs) not only promote healthy behaviours and preventive action but can mobilize demand for appropriate services at other levels. The success of community health efforts depends critically on the context, including level of development of infrastructure, services, and socioeconomic resources.
Health care providers at this level of care includes professionals, outreach workers as well as the community health workers. It includes a range of initiatives that are associated with the Alma Ata Declaration on Primary Health Care approved by WHO in 1978. More recently, the WHO Commission on Macroeconomics and Health described the need for developing services that are close to the client. The basic notion is a common one: recognition that a certain range of health care services must act as an interface between families and community programmes on the one hand, and hospitals and national health policies on the other. There has been substantial convergence in the content of general first level primary care over time: maternity related care (for instance, prenatal care, skilled birth attendance, and family planning), interventions to address childhood diseases (such as vaccine preventable diseases, acute respiratory infections, diarrhoea) and prevention and treatment of major infectious diseases.
This level of delivery of interventions refers to hospitals in general. These can be either district hospitals or referral hospitals. The health care providers at this level are professionals.
District hospitals - Generally designed to serve people with services that are more sophisticated, technically demanding, and specialized than those available at a primary care facility/first level care, but not as specialized as those provided by referral hospitals. Their range of services includes diagnostics, treatment, care, counselling, and rehabilitation. District hospitals may also provide health information, training, and administrative and logistical support to primary and community health care programmes. It concentrates skills and resources in one place for the delivery of interventions for conditions that are either uncommon or difficult to treat. It is also a repository of knowledge and diagnostic tools for assessing whether referral to an even more specialized facility is indicated.
Referral hospitals - Referral hospitals provide complex clinical care interventions to patients referred from the community, primary/first, or district hospital levels. Referral hospitals need to provide many forms of support, including advice on which patients to refer, proper post discharge care, and long-term management of chronic conditions. Referral hospitals can also provide important managerial and administrative support to other facilities, serving as gateways for drugs and medical supplies, laboratory testing services, general procurement, data collection from health information systems, and epidemiological surveillance. They are also the vehicle for disseminating technologies by training new staff and providing continuing professional education for existing staff at different facilities.