CONTEXT: Although adolescent mental health interventions are widely implemented, little consensus exists about elements comprising successful models.OBJECTIVE: We aimed to identify effective program components of interventions to promote mental health and prevent mental disorders and risk behaviors during adolescence and to match these components across these key health outcomes to inform future multicomponent intervention development.DATA SOURCES: A total of 14 600 records were identified, and 158 studies were included.STUDY SELECTION: Studies included universally delivered psychosocial interventions administered to adolescents ages 10 to 19. We included studies published between 2000 and 2018, using PubMed, Medline, PsycINFO, Scopus, Embase, and Applied Social Sciences Index Abstracts databases. We included randomized controlled, cluster randomized controlled, factorial, and crossover trials. Outcomes included positive mental health, depressive and anxious symptomatology, violence perpetration and bullying, and alcohol and other substance use.DATA EXTRACTION: Data were extracted by 3 researchers who identified core components and relevant outcomes. Interventions were separated by modality; data were analyzed by using a robust variance estimation meta-analysis model, and we estimated a series of singlepredictor meta-regression models using random effects.RESULTS: Universally delivered interventions can improve adolescent mental health and reduce risk behavior. Of 7 components with consistent signals of effectiveness, 3 had significant effects over multiple outcomes (interpersonal skills, emotional regulation, and alcohol and drug education).LIMITATIONS: Most included studies were from high-income settings, limiting the applicability of these findings to low-and middle-income countries. Our sample included only trials.CONCLUSIONS: Three program components emerged as consistently effective across different outcomes, providing a basis for developing future multioutcome intervention programs.

BackgroundSkin–to–skin contact (SSC) between mother and newborn offers numerous protective effects, however it is an intervention that has been under–utilized. Our objectives are to understand which newborns in Bangladesh and Nigeria receive SSC and whether SSC is associated with the early initiation of breastfeeding.MethodsDemographic and Health Survey (DHS) data were used to study the characteristics of newborns receiving SSC for non–facility births in Nigeria (DHS 2013) and for both facility and non–facility births in Bangladesh (DHS 2014). Multivariable logistic regression was used to study the association between SSC and early initiation of breastfeeding after controlling for key socio–demographic, maternal and newborn–related factors.ResultsOnly 10% of newborns in Nigeria and 26% of newborns in Bangladesh received SSC. In the regression models, SSC was significantly associated with the early initiation of breastfeeding in both countries (OR = 1.42, 95% CI 1.15–1.76 for Nigeria; OR = 1.27, 95% CI 1.04–1.55, for Bangladesh). Findings from the regression analysis for Bangladesh revealed that newborns born by Cesarean section had a 67% lower odds of early initiation of breastfeeding than those born by normal delivery (OR = 0.33, 95% CI 0.26–0.43). Also in Bangladesh newborns born in a health facility had a 30% lower odds of early initiation of breastfeeding than those born in non–facility environments (OR = 0.70, 95% CI 0.53–0.92). Early initiation of breastfeeding was significantly associated with parity, urban residence and wealth in Nigeria. Geographic area was significant in the regression analyses for both Bangladesh and Nigeria.ConclusionsCoverage of SSC is very low in the two countries, despite its benefits for newborns without complications. SSC has the potential to save newborn lives. There is a need to prioritize training of health providers on the implementation of essential newborn care including SSC. Community engagement is also needed to ensure that all women and their families regardless of residence, socio–economic status, place or type of delivery, understand the benefits of SSC and early initiation of breastfeeding.

BackgroundOver the last decade, coverage of maternal and newborn health indicators used for global monitoring and reporting have increased substantially but reductions in maternal and neonatal mortality have remained slow. This has led to an increased recognition and concern that these standard globally agreed upon measures of antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC) only capture the level of contacts with the health system and provide little indication of actual content of services received by mothers and their newborns. Over this period, large household surveys have captured measures of maternal and newborn care mainly through questions assessing contacts during the antenatal, delivery and postnatal periods along with some measures of content of care. This study aims to describe the gap between contact and content –as a proxy for quality– of maternal and newborn health services by assessing level of co–coverage of ANC and PNC interventions.MethodsWe used Demographic and Health Surveys (DHS) data from 20 countries between 2010 and 2015. We analysed the proportion of women with at least 1 and 4+ antenatal care visit, who received 8 interventions. We also assessed the percentage of newborns delivered with a skilled birth attendant who received 7 interventions. We ran random effect logistic regression to assess factors associated with receiving all interventions during the antenatal and postnatal period.ResultsWhile on average 51% of women in the analysis received four ANC visits with at least one visit from a skilled health provider, only 5% of them received all 8 ANC interventions. Similarly, during the postnatal period though two–thirds (65%) of births were attended by a skilled birth attendant, only 3% of newborns received all 7 PNC interventions. The odds of receiving all ANC and PNC interventions were higher for women with higher education and higher wealth status.ConclusionThe gap between coverage and content as a proxy of quality of antenatal and postnatal care is excessively large in all countries. In order to accelerate maternal and newborn survival and achieve Sustainable Development Goals, increased efforts are needed to improve both the coverage and quality of maternal and newborn health interventions.

SummaryBackgroundLatin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions.MethodsWe analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15–49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12–23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), woman's education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression.FindingsEthnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66–0·92), antenatal care (0·86, 0·75–0·94), and skilled birth attendants (0·75, 0·68–0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries.InterpretationThe lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level—such as vaccines—show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes.FundingThe Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.

Background Pregnancy and parenthood are known to be high-risk times for mental health. However, less is known about the mental health of pregnant adolescents or adolescent parents. Despite the substantial literature on the risks associated with adolescent pregnancy, there is limited evidence on best practices for preventing poor mental health in this vulnerable group. This systematic review therefore aimed to identify whether psychosocial interventions can effectively promote positive mental health and prevent mental health conditions in pregnant and parenting adolescents. Methods We used the standardized systematic review methodology based on the process outlined in the World Health Organization’s Handbook for Guidelines Development. This review focused on randomized controlled trials of preventive psychosocial interventions to promote the mental health of pregnant and parenting adolescents, as compared to treatment as usual. We searched PubMed/Medline, PsycINFO, ERIC, EMBASE and ASSIA databases, as well as reference lists of relevant articles, grey literature, and consultation with experts in the field. GRADE was used to assess the quality of evidence. Results We included 17 eligible studies (n = 3245 participants). Interventions had small to moderate, beneficial effects on positive mental health (SMD = 0.35, very low quality evidence), and moderate beneficial effects on school attendance (SMD = 0.64, high quality evidence). There was limited evidence for the effectiveness of psychosocial interventions on mental health disorders including depression and anxiety, substance use, risky sexual and reproductive health behaviors, adherence to antenatal and postnatal care, and parenting skills. There were no available data for outcomes on self-harm and suicide; aggressive, disruptive, and oppositional behaviors; or exposure to intimate partner violence. Only two studies included adolescent fathers. No studies were based in low- or middle-income countries. Conclusion Despite the encouraging findings in terms of effects on positive mental health and school attendance outcomes, there is a critical evidence gap related to the effectiveness of psychosocial interventions for improving mental health, preventing disorders, self-harm, and other risk behaviors among pregnant and parenting adolescents. There is an urgent need to adapt and design new psychosocial interventions that can be pilot-tested and scaled with pregnant adolescents and adolescent parents and their extended networks, particularly in low-income settings.

Subnational inequalities have received limited attention in the monitoring of progress towards national and global health targets during the past two decades. Yet, such data are often a critical basis for health planning and monitoring in countries, in support of efforts to reach all with essential interventions. Household surveys provide a rich basis for interventions coverage indicators on reproductive, maternal, newborn and child health (RMNCH) at the country first administrative level (regions or provinces). In this paper, we show the large subnational inequalities that exist in RMNCH coverage within 39 countries in sub-Saharan Africa, using a composite coverage index which has been used extensively by Countdown to 2030 for Women’s, Children’s and Adolescent’s Health. The analyses show the wide range of subnational inequality patterns such as low overall national coverage with very large top inequality involving the capital city, intermediate national coverage with bottom inequality in disadvantaged regions, and high coverage in all regions with little inequality. Even though nearly half of the 34 countries with surveys around 2004 and again around 2015 appear to have been successful in reducing subnational inequalities in RMNCH coverage, the general picture shows persistence of large inequalities between subnational units within many countries. Poor governance and conflict settings were identified as potential contributing factors. Major efforts to reduce within-country inequalities are required to reach all women and children with essential interventions.

BackgroundEach year an estimated 2.6 million newborns die, mainly from complications of prematurity, neonatal infections, and intrapartum events. Reducing these deaths requires high coverage of good quality care at birth, and inpatient care for small and sick newborns. In low- and middle-income countries, standardised measurement of the readiness of facilities to provide emergency obstetric care has improved tracking of readiness to provide care at birth in recent years. However, the focus has been mainly on obstetric care; service readiness for providing inpatient care of small and sick newborns is still not consistently measured or tracked.MethodsWe reviewed existing international guidelines and resources to create a matrix of the structural characteristics (infrastructure, equipment, drugs, providers and guidelines) for service readiness to deliver a package of inpatient care interventions for small and sick newborns. To identify gaps in existing measurement systems, we reviewed three multi-country health facility survey tools (the Service Availability and Readiness Assessment, the Service Provision Assessment and the Emergency Obstetric and Newborn Care Assessment) against our service readiness matrix.FindingsFor service readiness to provide inpatient care for small and sick newborns, our matrix detailed over 600 structural characteristics. Our review of the SPA, the SARA and the EmONC assessment tools identified several measurement omissions to capture information on key intervention areas, such as thermoregulation, feeding and respiratory support, treatment of specific complications (seizures, jaundice), and screening and follow up services, as well as specialised staff and service infrastructure.ConclusionsOur review delineates the required inputs to ensure readiness to provide inpatient care for small and sick newborns. Based on these findings, we detail where questions need to be added to existing tools and describe how measurement systems can be adapted to reflect small and sick newborns interventions. Such work can inform investments in health systems to end preventable newborn death and disability as part of the Every Newborn Action Plan.

BackgroundRecent studies have shown higher neonatal mortality among births delivered by a skilled attendant at birth (SAB) compared to those who were not in sub–Saharan African countries. Deaths during the neonatal period are concentrated in the first 7 days of life, with about one third of these deaths occurring during the first day of life. We reassessed the relationship between SAB and neonatal mortality by distinguishing deaths on the first day of life from those on days 2–27.MethodsWe used data on births in the past five years from recent demographic and health survey (DHS) between 2010 and 2014 in 20 countries in sub–Saharan Africa. The main categorical outcome was 1) newborns who died within the first day of birth (day 0–1), 2) newborns who died between days 2–27, and 3) newborns who survived the neonatal period. We ran generalized linear mixed model with multinomial distribution and random effect for country on pooled data. Additionally, we ran a separate model restricted to births with SAB and assessed the association of receipt of seven antenatal care (ANC) and two immediate postnatal care interventions on risk of death on days 0–1 and days 2–27. These variables were assessed as proxy of quality of antenatal and postnatal care.ResultsWe found no statistically significant difference in risk of death on first day of life between newborns with SAB compared to those without. However, after the first day of life, newborns delivered with SAB were 16% less likely to die within 2–27 days than those without SAB (OR = 0.84, 95% CI = 0.71–0.99). Among births with skilled attendant, those who were weighed at birth and those who were initiated early on breastfeeding were significantly less likely to die on days 0–1 (respectively OR = 0.42 95% CI = 0.29–0.62 and OR = 0.24, 95% CI 0.18–0.31) or on days 2–27 (OR = 0.60, 95% CI = 0.45–0.81 and OR = 0.59, 95% CI = 47–0.74, respectively). Newborns whose mothers received an additional ANC intervention had no improved survival chances during days 0–1 of life. However, there was significant association on days 2–27 where newborns whose mothers received an additional ANC interventions had higher survival chances (OR = 0.95, 95% CI = 0.93–0.98).ConclusionFindings demonstrate the vulnerability of newborns immediately after birth, compounded with insufficient quality of care. Improving the quality of care around the time of birth will significantly improve survival and therefore accelerate reduction in neonatal mortality in sub–Saharan African countries. Improved approaches for measuring skilled attendant at birth are also needed.