Background While the COVID-19 pandemic will increase mortality due to the virus, it is also likely to increase mortality indirectly. In this study, we estimate the additional maternal and under-5 child deaths resulting from the potential disruption of health systems and decreased access to food.Methods We modelled three scenarios in which the coverage of essential maternal and child health interventions is reduced by 9•8-51•9% and the prevalence of wasting is increased by 10-50%. Although our scenarios are hypothetical, we sought to reflect real-world possibilities, given emerging reports of the supply-side and demand-side effects of the pandemic. We used the Lives Saved Tool to estimate the additional maternal and under-5 child deaths under each scenario, in 118 low-income and middle-income countries. We estimated additional deaths for a single month and extrapolated for 3 months, 6 months, and 12 months.Findings Our least severe scenario (coverage reductions of 9•8-18•5% and wasting increase of 10%) over 6 months would result in 253 500 additional child deaths and 12 200 additional maternal deaths. Our most severe scenario (coverage reductions of 39•3-51•9% and wasting increase of 50%) over 6 months would result in 1 157 000 additional child deaths and 56 700 additional maternal deaths. These additional deaths would represent an increase of 9•8-44•7% in under-5 child deaths per month, and an 8•3-38•6% increase in maternal deaths per month, across the 118 countries. Across our three scenarios, the reduced coverage of four childbirth interventions (parenteral administration of uterotonics, antibiotics, and anticonvulsants, and clean birth environments) would account for approximately 60% of additional maternal deaths. The increase in wasting prevalence would account for 18-23% of additional child deaths and reduced coverage of antibiotics for pneumonia and neonatal sepsis and of oral rehydration solution for diarrhoea would together account for around 41% of additional child deaths.Interpretation Our estimates are based on tentative assumptions and represent a wide range of outcomes. Nonetheless, they show that, if routine health care is disrupted and access to food is decreased (as a result of unavoidable shocks, health system collapse, or intentional choices made in responding to the pandemic), the increase in child and maternal deaths will be devastating. We hope these numbers add context as policy makers establish guidelines and allocate resources in the days and months to come.Funding Bill & Melinda Gates Foundation, Global Affairs Canada.

Background The need for evidence-based decision-making in the health sector is well understood in the global health community. Yet, gaps persist between the availability of evidence and the use of that evidence. Most research on evidence-based decision-making has been carried out in higher-income countries, and most studies look at policy-making rather than decision-making more broadly. We conducted this study to address these gaps and to identify challenges and facilitators to evidence-based decision-making in Maternal, Newborn and Child Health and Nutrition (MNCH&N) at the municipality, district, and national levels in Mozambique. Methods We used a case study design to capture the experiences of decision-makers and analysts (n = 24) who participated in evidence-based decision-making processes related to health policies and interventions to improve MNCH&N in diverse decision-making contexts (district, municipality, and national levels) in 2014–2017, in Mozambique. We examined six case studies, at the national level, in Maputo City and in two districts of Sofala Province and two of Zambézia Province, using individual in-depth interviews with key informants and a document review, for three weeks, in July 2018. Results Our analysis highlighted various challenges for evidence-based decision-making for MNCH&N, at national, district, and municipality levels in Mozambique, including limited demand for evidence, limited capacity to use evidence, and lack of trust in the available evidence. By contrast, access to evidence, and availability of evidence were viewed positively and seen as potential facilitators. Organizational capacity for the demand and use of evidence appears to be the greatest challenge; while individual capacity is also a barrier. Conclusion Evidence-based decision-making requires that actors have access to evidence and are empowered to act on that evidence. This, in turn, requires alignment between those who collect data, those who analyze and interpret data, and those who make and implement decisions. Investments in individual, organizational, and systems capacity to use evidence are needed to foster practices of evidence-based decision-making for improved maternal and child health in Mozambique.

Background Gender is a crucial consideration of human rights that impacts many priority maternal health outcomes. However, gender is often only reported in relation to sex-disaggregated data in health coverage surveys. Few coverage surveys to date have integrated a more expansive set of gender-related questions and indicators, especially in low- to middle-income countries that have high levels of reported gender inequality. Using various gender-sensitive indicators, we investigated the role of gender power relations within households on women’s health outcomes in Simiyu region, Tanzania. Methods We assessed 34 questions around gender dynamics reported by men and women against 18 women’s health outcomes. We created directed acyclic graphs (DAGs) to theorize the relationship between indicators, outcomes, and sociodemographic covariates. We grouped gender variables into four categories using an established gender framework: (1) women’s decision-making, (2) household labor-sharing, (3) women’s resource access, and (4) norms/beliefs. Gender indicators that were most proximate to the health outcomes in the DAG were tested using multivariate logistic regression, adjusting for sociodemographic factors. Results The overall percent agreement of gender-related indicators within couples was 68.6%. The lowest couple concordance was a woman’s autonomy to decide to see family/friends without permission from her husband/partner (40.1%). A number of relationships between gender-related indicators and health outcomes emerged: questions from the decision-making domain were found to play a large role in women’s health outcomes, and condoms and contraceptive outcomes had the most robust relationship with gender indicators. Women who reported being able to make their own health decisions were 1.57 times (95% CI: 1.12, 2.20) more likely to use condoms. Women who reported that they decide how many children they had also reported high contraception use (OR: 1.79, 95% CI: 1.34, 2.39). Seeking care at the health facility was also associated with women’s autonomy for making major household purchases (OR: 1.35, 95% CI: 1.13, 1.62). Conclusions The association between decision-making and other gender domains with women’s health outcomes highlights the need for heightened attention to gender dimensions of intervention coverage in maternal health. Future studies should integrate and analyze gender-sensitive questions within coverage surveys.

Malnutrition-both undernutrition and overnutrition-is a public health concern worldwide and particularly in low-and middle-income countries (LMICs). The education sector has high potential to improve immediate nutrition outcomes by providing food in schools and to have more long-term impact through education. We developed a conceptual framework to show how the education sector can be leveraged for nutrition. We reviewed the literature to identify existing frameworks outlining how nutrition programs can be delivered by and through the education sector and used these to build a comprehensive framework. We first organized nutrition programs in the education sector into (1) school food, meals, and food environment;(2) nutrition and health education; (3) physical activity and education; (4) school health services; and (5) water, sanitation, and hygiene (WASH) sector. We then discuss how each one can be successfully implemented. We found high potential in improving nutrition standards and quality of school foods, meals and food environment, especially through collaboration with the agriculture sector. There is a need for well-integrated, culturally appropriate nutrition and health education into the existing school curriculum. This must be supported by a skilled workforce-including nutrition and public health professionals and school staff. Parental and community engagement is cornerstone for program sustainability and success. Current monitoring and evaluation of nutrition programming in schools is weak, and effectiveness, including cost-effectiveness, of interventions is not yet adequately quantified. Finally, we note that opportunities for leveraging the education sector in the fight against rising overweight and obesity rates are under-researched and likely underutilized in LMICs.