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Relatively little progress has been made in reducing anemia prevalence among women of reproductive age (WRA anemia). Interventions, policies and programs aimed at reducing WRA anemia have the potential to improve overall not only women's, but also children's health and nutrition outcomes. To our knowledge, this is the first review that aimed to compile evidence on the determinants and drivers of WRA anemia reduction in low- and middle-income countries (LMICs). We synthesized the available evidence on the determinants and drivers, including government policies and programs, of WRA anemia and their mitigation strategies across a wide range of countries and geographies, thus contributing to the complex and multifactorial etiology of anemia. We carried out a systematic review of published peer-reviewed and grey literature assessing national or subnational decline in WRA anemia prevalence and the associated drivers in LMICs. Among the 21 studies meeting our inclusion criteria, proximal determinants of healthcare utilization, especially during pregnancy and with the use of contraceptives, were strong drivers of WRA anemia reduction. Changes in other maternal characteristics, such as an increase in age at first pregnancy, BMI, birth spacing, and reduction in parity, were associated with modest improvements in anemia prevalence. Access to fortified foods, especially iron-fortified flour, was also a predictor of a decrease in WRA anemia. Of the intermediate determinants, an increase in household wealth, educational attainment and access to improved sanitation contributed significantly to WRA anemia reduction. Although several common determinants emerged at the proximal and intermediate levels, the set of anemia determinants and the strength of the association between each driver and WRA anemia reduction were unique in each setting included in this review. Further research is needed to provide targeted recommendations for each country and region where WRA anemia prevalence remains high.

Background: Muslim majority countries have experienced a considerable burden of COVID-19 infection. However, there has been a relative lack of research comparing COVID-19 outbreaks and responses between Muslim-majority countries.Aims: This study aimed to analyse COVID-19 burden, epidemiology and mitigation strategies in Muslim-majority countries.Methods: We use a mixed-methods approach to describe the course of the COVID-19 pandemic throughout the Islamic world, highlight the range of non-pharmaceutical interventions used and the speed with which they were implemented, and investigate reasons behind the differing responses between Muslim-majority countries. The number of cases and deaths per million population, and the mean time taken to implement a range of policies, were compared across the Islamic world. Cases per million population and the mean estimated doubling time for cases was compared between Muslim- majority countries on the basis of governance systems, rapidity of institution of mitigation strategies and conflict groups. We also evaluated pushback to implementation of measures within MMCs, especially from religious quarters.Results: Non-democratic regimes had much shorter doubling time of cases compared to functional democratic Muslim- majority countries (mean 33.9 versus 66.5 days, P = 0.002) and a significantly greater proportion of countries appeared to have flattened the curve by 1 June 2020 (43.8% versus 12.5%, P < 0.03). The doubling time was also significantly greater among countries who implemented lockdown and mitigation measures early (66.7 versus 16.7 days, P < 0.003).Conclusion: Our analysis indicates wide diversity in the COVID-19 response across Muslim majority countries with clear indication that functional democracies were able to contain the epidemic significantly better than nondemocratic regimes. Future analysis should focus on determination of sub-national differentials and risks as well as targeting of interventions.

Background Established in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, financial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specific and cause-specific mortality among children under 5 years, and stillbirths by geography over time. Methods Drawing from analytical approaches developed and refined in previous iterations of the GBD study, we generated updated estimates of child mortality by age group (neonatal, post-neonatal, ages 1-4 years, and under 5) for 195 countries and territories and selected subnational geographies, from 1980-2015. We also estimated numbers and rates of stillbirths for these geographies and years. Gaussian process regression with data source adjustments for sampling and non-sampling bias was applied to synthesise input data for under-5 mortality for each geography. Age-specific mortality estimates were generated through a two-stage age-sex splitting process, and stillbirth estimates were produced with a mixed-effects model, which accounted for variable stillbirth definitions and data source-specific biases. For GBD 2015, we did a series of novel analyses to systematically quantify the drivers of trends in child mortality across geographies. First, we assessed observed and expected levels and annualised rates of decrease for under-5 mortality and stillbirths as they related to the Soci-demographic Index (SDI). Second, we examined the ratio of recorded and expected levels of child mortality, on the basis of SDI, across geographies, as well as differences in recorded and expected annualised rates of change for under-5 mortality. Third, we analysed levels and cause compositions of under-5 mortality, across time and geographies, as they related to rising SDI. Finally, we decomposed the changes in under-5 mortality to changes in SDI at the global level, as well as changes in leading causes of under-5 deaths for countries and territories. We documented each step of the GBD 2015 child mortality estimation process, as well as data sources, in accordance with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings Globally, 5.8 million (95% uncertainty interval [UI] 5.7-6.0) children younger than 5 years died in 2015, representing a 52.0% (95% UI 50.7-53.3) decrease in the number of under-5 deaths since 1990. Neonatal deaths and stillbirths fell at a slower pace since 1990, decreasing by 42.4% (41.3-43.6) to 2.6 million (2.6-2.7) neonatal deaths and 47.0% (35.1-57.0) to 2.1 million (1. 8-2.5) stillbirths in 2015. Between 1990 and 2015, global under-5 mortality decreased at an annualised rate of decrease of 3. 0% (2.6-3.3), falling short of the 4.4% annualised rate of decrease required to achieve MDG4. During this time, 58 countries met or exceeded the pace of progress required to meet MDG4. Between 2000, the year MDG4 was formally enacted, and 2015, 28 additional countries that did not achieve the 4.4% rate of decrease from 1990 met the MDG4 pace of decrease. However, absolute levels of under-5 mortality remained high in many countries, with 11 countries still recording rates exceeding 100 per 1000 livebirths in 2015. Marked decreases in under-5 deaths due to a number of communicable diseases, including lower respiratory infections, diarrhoeal diseases, measles, and malaria, accounted for much of the progress in lowering overall under-5 mortality in low-income countries. Compared with gains achieved for infectious diseases and nutritional deficiencies, the persisting toll of neonatal conditions and congenital anomalies on child survival became evident, especially in low-income and low-middle-income countries. We found sizeable heterogeneities in comparing observed and expected rates of under-5 mortality, as well as differences in observed and expected rates of change for under-5 mortality. At the global level, we recorded a divergence in observed and expected levels of under-5 mortality starting in 2000, with the observed trend falling much faster than what was expected based on SDI through 2015. Between 2000 and 2015, the world recorded 10.3 million fewer under-5 deaths than expected on the basis of improving SDI alone. Interpretation Gains in child survival have been large, widespread, and in many places in the world, faster than what was anticipated based on improving levels of development. Yet some countries, particularly in sub-Saharan Africa, still had high rates of under-5 mortality in 2015. Unless these countries are able to accelerate reductions in child deaths at an extraordinary pace, their achievement of proposed SDG targets is unlikely. Improving the evidence base on drivers that might hasten the pace of progress for child survival, ranging from cost-effective intervention packages to innovative financing mechanisms, is vital to charting the pathways for ultimately ending preventable child deaths by 2030. Copyright (C) The Author(s). Published by Elsevier Ltd.

Abstract This series of papers focuses on a quality of care framework for maternal health, and systematically reviews the evidence of interventions aimed at improving care at the community-, district- and factility-levels. While the systematic reviews highlight the effectiveness of specific quality improvement efforts on maternal and newborn health, it also illlustrates the dearth of evidence on community-, district- and facility-level interventions, particulary for issues specific to quality of maternal health care and maternal newborn health outcomes. Further evidence is now needed to evaluate the best possible combination of the strategies. Governments, stakeholders and donors need to work together to form these policies and develop models of health care to suit the needs of their own population.

Abstract Background There is limited evidence from community-based interventions to guide the development of effective maternal, perinatal and newborn care practices and services in developing countries. We evaluated the impact of a low-cost package of community-based interventions implemented through government sector lady health workers (LHWs) and community health workers (CHWs) of a NGO namely Aga Khan Health Services on perinatal and neonatal outcomes in a sub-population of the remote mountainous district of Gilgit, Northern Pakistan. Methods The package was evaluated using quasi experimental design included promotion of antenatal care, adequate nutrition, skilled delivery and healthy newborn care practices. Control areas continued to receive the routine standard health services. The intervention areas received intervention package in addition to the routine standard health services. Outcome measures included changes in maternal and newborn-care practices and perinatal and neonatal mortality rates between the intervention and control areas. Results The intervention was implemented in a population of 283324 over a 18 months period. 3200 pregnant women received the intervention. Significant improvements in antenatal care (92% vs 76%, p < .001), TT vaccination (67% vs 47%, p < .001), institutional delivery (85% vs 71%, p < .001), cord application (51% vs 71%, p < .001), delayed bathing (15% vs 43%, p < .001), colostrum administration (83% vs 64%, p < .001), and initiation of breastfeeding within 1 hour after birth (55% vs 40%, p < .001) were seen in intervention areas compared with control areas. Our results indicate significant reductions in mortality rates in intervention areas as compared to control areas from baseline in perinatal mortality rate (from 47.1 to 35.3 per 1000 births, OR 0.62; 95% CI: 0.56-0.69; P 0.02) and neonatal mortality rates (from 26.0 to 22.8 per 1000 live births, 0.58; 95% CI: 0.48-0.68; P 0.03). Conclusions The implementation of a set of low cost community-based intervention package within the health system settings in a mountainous region of Pakistan was found to be both feasible and beneficial. The interventions had a significant impact in reduction of the burden of perinatal and neonatal mortality. Trial registration This study is registered, ClinicalTrial.gov NCT02412293 .

BACKGROUND: Although a number of antenatal and intrapartum interventions have shown some evidence of impact on stillbirth incidence, much confusion surrounds ideal strategies for delivering these interventions within health systems, particularly in low-/middle-income countries where 98% of the world's stillbirths occur. Improving the uptake of quality antenatal and intrapartum care is critical for evidence-based interventions to generate an impact at the population level. This concluding paper of a series of papers reviewing the evidence for stillbirth interventions examines the evidence for community and health systems approaches to improve uptake and quality of antenatal and intrapartum care, and synthesises programme and policy recommendations for how best to deliver evidence-based interventions at community and facility levels, across the continuum of care, to reduce stillbirths. METHODS: We systematically searched PubMed and the Cochrane Library for abstracts pertaining to community-based and health-systems strategies to increase uptake and quality of antenatal and intrapartum care services. We also sought abstracts which reported impact on stillbirths or perinatal mortality. Searches used multiple combinations of broad and specific search terms and prioritised rigorous randomised controlled trials and meta-analyses where available. Wherever eligible randomised controlled trials were identified after a Cochrane review had been published, we conducted new meta-analyses based on the original Cochrane criteria. RESULTS: In low-resource settings, cost, distance and the time needed to access care are major barriers for effective uptake of antenatal and particularly intrapartum services. A number of innovative strategies to surmount cost, distance, and time barriers to accessing care were identified and evaluated; of these, community financial incentives, loan/insurance schemes, and maternity waiting homes seem promising, but few studies have reported or evaluated the impact of the wide-scale implementation of these strategies on stillbirth rates. Strategies to improve quality of care by upgrading the skills of community cadres have shown demonstrable impact on perinatal mortality, particularly in conjunction with health systems strengthening and facilitation of referrals. Neonatal resuscitation training for physicians and other health workers shows potential to prevent many neonatal deaths currently misclassified as stillbirths. Perinatal audit systems, which aim to improve quality of care by identifying deficiencies in care, are a quality improvement measure that shows some evidence of benefit for changes in clinical practice that prevent stillbirths, and are strongly recommended wherever practical, whether as hospital case review or as confidential enquiry at district or national level. CONCLUSION: Delivering interventions to reduce the global burden of stillbirths requires action at all levels of the health system. Packages of interventions should be tailored to local conditions, including local levels and causes of stillbirth, accessibility of care and health system resources and provider skill. Antenatal care can potentially serve as a platform to deliver interventions to improve maternal nutrition, promote behaviour change to reduce harmful exposures and risk of infections, screen for and treat risk factors, and encourage skilled attendance at birth. Following the example of high-income countries, improving intrapartum monitoring for fetal distress and access to Caesarean section in low-/middle-income countries appears to be key to reducing intrapartum stillbirth. In remote or low-resource settings, families and communities can be galvanised to demand and seek quality care through financial incentives and health promotion efforts of local cadres of health workers, though these interventions often require simultaneous health systems strengthening. Perinatal audit can aid in the development of better standards of care, improving quality in health systems. Effective strategies to prevent stillbirth are known; gaps remain in the data, the evidence and perhaps most significantly, the political will to implement these strategies at scale.

OBJECTIVE: This pilot study investigated the feasibility of delivering a package of community-based interventions for improving perinatal care using lady health workers (LHWs) and traditional birth attendants (Dais) in rural Pakistan. METHODS: The intervention was implemented in four of eight village clusters (315 villages, total population 138,600), while four served as a comparison group. The LHWs in intervention clusters received additional training focused on essential maternal and newborn care, conducted community education group sessions, and were encouraged to link up with local Dais. The intervention was delivered within the regular government LHW programme and was supported by the creation of voluntary community health committees. FINDINGS: In intervention villages, there were significant reductions from baseline in stillbirth (from 65.9 to 43.1 per 1000 births, P < 0.001) and neonatal mortality rates (from 57.3 to 41.3 per 1000 live births, P < 0.001). The proportion of deliveries conducted by skilled attendants at public sector facilities also increased, from 18% at baseline to 30%, while the proportion of home births decreased from 79% to 65%. A household survey indicated a higher frequency of key behaviours (e.g. early and exclusive breastfeeding, delayed bathing and cord care) in intervention villages. CONCLUSION: The improved stillbirth and neonatal mortality rates observed indicate that community health workers (i.e. LHWs and Dais) can be effective in implementing a community and outreach package that leads to improved home care practices by families, increased care-seeking behaviour and greater utilization of skilled care providers. These preliminary observations require confirmation in an adequately powered trial.

Most child deaths in the region are preventable and occur in just a few of the 22 countries in the region. The interventions are not expensive, but governments need to implement them

INTRODUCTION: While health is one of the Sustainable Development Goals (SDGs), many other 'health-related' goals comprise determinants of health. Integrated implementation across SDGs is needed for the achievement of Agenda 2030. While existing literature is rich in normative recommendations about potentially useful approaches, evidence of implementation strategies being adopted by countries is limited. METHODS: We conducted a systematic review with qualitative synthesis of findings using peer reviewed and grey literature from key databases. We included publications examining implementation of health and health-related SDGs (HHSDGs) at national or subnational level published between June 2013 and July 2019. RESULTS: Of the 32 included publications, 24 provided information at the national level while eight provided information for multiple countries or regions. Our findings indicate that high-level political commitment is evident in most countries and HHSDGs are being aligned with existing national development strategies and plans. A multisectoral, integrated approach is being adopted in institutional setups but evidence on effectiveness of these approaches is limited. Funding constraints are a major challenge for many countries. HHSDGs are generally being financed from within existing funded plans and, in some instances, through SDG-specific budgeting and tracking; additional funding is being mobilised by increasing domestic taxation and subsidisation, and by collaborating with development partners and private sector. Equity is being promoted by improving health service access through universal health coverage and social insurance schemes, especially for disadvantaged populations. Governments are collaborating with development partners and UN agencies for support in planning, institutional development and capacity building. However, evidence on equity promotion, capacity building initiatives and implementation approaches at subnational level is limited. Lack of coordination among various levels of government ...

BACKGROUND: A substantial portion of child deaths take place in countries with recent history of armed conflict and political instability. However, the extent to which armed conflict is an important cause of child mortality, especially in Africa, remains unknown. METHODS: Using information on (1) geocoded location, timing, and intensity of armed conflicts and (2) the location, timing, and survival of under-1 and under-5 children in 35 African countries from 1995 to 2015, we matched child survival with proximity to armed conflict. We measured the increase in mortality risk for children exposed to armed conflicts within 50km in the year of birth and, to study conflicts' extended health risks, up to 250km away and 10 years prior to birth. We also examined the effects of conflicts of varying intensity and chronicity (conflicts lasting several years), and effect heterogeneity by residence and child sex. We then estimate the number and portion of under-1 and under-5 deaths related to conflict. FINDINGS: We analyzed 15,441 armed conflict events that led to 968,444 armed conflict deaths, 1.99 million births, and 133,361 infant deaths (infant mortality rate of 67 deaths per 1,000 births). A child born within 50km of an armed conflict had a risk of dying before reaching age one of 5.2 per 1,000 births higher than being born in the same region during periods without conflict (95% CI 3.7-6.7; a 7.7% increase above baseline). This ranged from 3.0% increase for armed conflicts with 1-4 deaths to 26.7% increase for armed conflicts with >1,000 deaths. We find evidence of increased mortality risk from an armed conflict up to 100km away, and for 8 years after conflicts, with cumulative increase in infant mortality 2-4 times higher than the contemporaneous increase. In the entire continent, the number of infant deaths related to conflict from 1995 to 2015 were between 3.2 and 3.6 times the number of direct deaths from armed conflicts. CONCLUSIONS: Child mortality in Africa is substantially and sustainably increased in times of ...