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The proportion of pregnant women receiving 4 or more antenatal care (ANC) visits has no necessary relationship with the actual content of those visits. We propose a simple alternative to measure program performance that aggregates key services that are common across countries and measured in Demographic and Health Surveys, such as blood pressure measurement, tetanus toxoid vaccination, first ANC visit before 4 months gestation, urine testing, counseling about pregnancy danger signs, and iron–folate supplementation.

a b s t r a c t a r t i c l e i n f o Keywords:Community-based distribution Misoprostol Nepal Operations research Postpartum hemorrhage Self-administration Objective: To determine feasibility of community-based distribution of misoprostol for preventing postpartum hemorrhage (PPH) to pregnant woman through community volunteers working under government health services. Methods: Implemented in one district in Nepal. The primary measure of performance was uterotonic protection after childbirth, measured using pre-and postintervention surveys (28 clusters, each with 30 households). Maternal deaths were ascertained through systematic health facility and community-based surveillance; causes of death were assigned based on verbal autopsy. Results: Of 840 postintervention survey respondents, 73.2% received misoprostol. The standardized proportion of vaginal deliveries protected by a uterotonic rose from 11.6% to 74.2%. Those experiencing the largest gains were the poor, the illiterate, and those living in remote areas. Conclusion: Community-based distribution of misoprostol for PPH prevention can be successfully implemented under government health services in a low-resource, geographically challenging setting, resulting in much increased population-level protection against PPH, with particularly large gains among the disadvantaged.

As part of a broader evidence summit, USAID and UNICEF convened a literature review of effective means to empower communities to achieve behavioral and social changes to accelerate reductions in under-5 mortality and optimize early child development. The authors conducted a systematic review of the effectiveness of community mobilization and participation that led to behavioral change and one or more of the following: child health, survival, and development. The level and nature of community engagement was categorized using two internationally recognized models and only studies where the methods of community participation could be categorized as collaborative or shared leadership were eligible for analysis. The authors identified 34 documents from 18 countries that met the eligibility criteria. Studies with shared leadership typically used a comprehensive community action cycle, whereas studies characterized as collaborative showed clear emphasis on collective action but did not undergo an initial process of community dialogue. The review concluded that programs working collaboratively or achieving shared leadership with a community can lead to behavior change and cost-effective sustained transformation to improve critical health behaviors and reduce poor health outcomes in low- and middle-income countries. Overall, community engagement is an understudied component of improving child outcomes.

Problem Pneumonia is a leading cause of mortality of children aged under five in Nepal. Research conducted by John Snow Inc. in the 1980s determined that pneumonia case management by community-based workers decreased under-five mortality by 28%. Approach Female community health volunteers were selected as the national cadre to manage childhood pneumonia at community level using oral antibiotics. A technical working group composed of government officials, local experts and donor partners embarked on a process to develop a strategy to pilot the approach and expand it nationally. Local setting High under-five mortality rates, low access to peripheral health facilities and severe constraints in human resources led Nepal's Ministry of Health to test this innovative approach. Relevant changes Community-based management of pneumonia doubled the total number of cases treated compared with districts with facility-based treatment only. Over half of the cases were treated by the female community health volunteers. The programme was phased in over 14 years and now 69% of Nepal's under-five population has access to pneumonia treatment. Lessons learned Community-based management of pneumonia provides a medium-term solution to address a leading cause of child mortality while the efforts continue to strengthen and extend the reach of facility-based care. Trained community health workers can significantly increase the number of pneumonia cases receiving correct case management in resource-constrained settings, with appropriate health systems' support for logistics, supervision and monitoring. Community-based management of pneumonia can be scaled up and provides an effective approach to reducing child deaths in countries faced with insufficient human resources for health.

After almost a century of experience, innovation, adaptation, and evidence, national community health worker (CHW) programs are now recognized as one of the most valuable assets for reaching global health goals, including achieving universal health coverage and ending preventable child and maternal deaths by 2030. n In 2019, the United Nations General Assembly called urgently to accelerate progress in achieving these global health goals recognizing that, at the current pace, these goals will not be achieved for up to one-third of the world's population. n There is rapidly growing interest not only in CHWs but in community health more broadly, in engagement with communities for improving their own health, and in community-based surveillance for infectious disease outbreaks, especially now that the world is struggling to combat COVID-19 and is likely to face similar pandemics in the future. n Training more professionalized CHWs with better and longer training, better supervision, improved logistical support, and well-defined career paths, and linking them to lower-level volunteer workers, each serving a small number of households, will help strengthen program effectiveness and improve CHW morale and long-term retention. How to overcome the challenges of distance and geographic barriers to extend services to segments of the population that cannot easily reach better equipped and staffed health centers and hospitals?

BackgroundAlthough this is beginning to change, the content of antenatal care has been relatively neglected in safe-motherhood program efforts. This appears in part to be due to an unwarranted belief that interventions over this period have far less impact than those provided around the time of birth. In this par, we review available evidence for 21 interventions potentially deliverable during pregnancy at high coverage to neglected populations in low income countries, with regard to effectiveness in reducing risk of: maternal mortality, newborn mortality, stillbirth, prematurity and intrauterine growth restriction. Selection was restricted to interventions that can be provided by non-professional health auxiliaries and not requiring laboratory support.MethodsIn this narrative review, we included relevant Cochrane and other systematic reviews and did comprehensive bibliographic searches. Inclusion criteria varied by intervention; where available randomized controlled trial evidence was insufficient, observational study evidence was considered. For each intervention we focused on overall contribution to our outcomes of interest, across varying epidemiologies.ResultsIn the aggregate, achieving high effective coverage for this set of interventions would very substantially reduce risk for our outcomes of interest and reduce outcome inequities. Certain specific interventions, if pushed to high coverage have significant potential impact across many settings. For example, reliable detection of pre-eclampsia followed by timely delivery could prevent up to ¼ of newborn and stillbirth deaths and over 90% of maternal eclampsia/pre-eclampsia deaths. Other interventions have potent effects in specific settings: in areas of high P falciparum burden, systematic use of insecticide-treated nets and/or intermittent presumptive therapy in pregnancy could reduce maternal mortality by up to 10%, newborn mortality by up to 20%, and stillbirths by up to 25–30%. Behavioral interventions targeting practices at birth and in the hours that follow can have substantial impact in settings where many births happen at home: in such circumstances early initiation of breastfeeding can reduce risk of newborn death by up to 20%; good thermal care practices can reduce mortality risk by a similar order of magnitude.ConclusionsSimple interventions delivered during pregnancy have considerable potential impact on important mortality outcomes. More programmatic effort is warranted to ensure high effective coverage.

Strategies currently pursued in high-income and upper middle-income countries-aimed at radically suppressing incidence of COVID-19-may be unrealistic and counterproductive in most low-and lower middle-income countries. Instead, strategies need to be tailored to the setting, balancing expected benefits, potential harms, and feasibility.