Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from our analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.

ResultsOverall, 49.9% of women with ANC1+ and 44.3% of all women had timely ANC initiation; 11.3% achieved ANC8+ and 11.2% received no ANC. Women with timely ANC initiation had 5.2 (95% confidence interval (CI) = 5.0-5.5) and 4.7 (95% CI = 4.4-5.0) times higher odds of receiving four and eight ANC contacts, respectively (P < 0.001), and were more likely to receive a higher content of ANC than women with delayed ANC initiation. Regionally, women in Central and Southern Asia had the best performance of timely ANC initiation; Latin America and Caribbean had the highest proportion of women achieving ANC8+. Women who did not initiate ANC in the first trimester or did not achieve 8 contacts were generally poor, single women, with low education, living in rural areas, larger households, having short birth intervals, higher parity, and not giving birth in a health facility nor with a skilled attendant.Conclusions Timely ANC initiation is likely to be a major driving force towards meeting the 2016 WHO guidelines for a positive pregnancy experience. Electronic supplementary material:The online version of this article contains supplementary material.Antenatal care (ANC) is a platform for the delivery of essential services to prevent pregnancy complications, provide counselling for birth and emergency preparedness [1], and improve health outcomes for children [2]. Timely initiation of antenatal care, defined as the first antenatal care contact occurring within the first trimester of pregnancy, provides an opportunity for early screening of modifiable risk-factors and pre-existing conditions [3].The 2016 WHO recommendations on antenatal care for a positive pregnancy experience suggest a shift from the focused ANC model with a recommended minimum of four ANC visits (ANC4+) to a more expanded model empha-

BackgroundCountries across sub-Saharan Africa are scaling up Community Health Worker (CHW) programmes, yet there remains little high-quality research assessing strategies for CHW supervision and performance improvement. This randomised controlled trial aimed to determine the effect of a personalised performance dashboard used as a supervision tool on the quantity, speed, and quality of CHW care.MethodsWe conducted a randomised controlled trial in a large health catchment area in peri-urban Mali. One hundred forty-eight CHWs conducting proactive case-finding home visits were randomly allocated to receive individual monthly supervision with or without the CHW Performance Dashboard from January to June 2016. Randomisation was stratified by CHW supervisor, level of CHW experience, and CHW baseline performance for monthly quantity of care (number of household visits). With regression analysis, we used a difference-in-difference model to estimate the effect of the intervention on monthly quantity, timeliness (percentage of children under five treated within 24 hours of symptom onset), and quality (percentage of children under five treated without protocol error) of care over a six-month post-intervention period relative to a three-month pre-intervention period.ResultsUse of the Dashboard during monthly supervision significantly increased the mean number of home visits by 39.94 visits per month (95% CI = 3.56-76.3; P = 0.031). Estimated effects on secondary outcomes of timeliness and quality were positive but not statistically significant. Across both study arms, CHW quantity, timeliness, and quality of care significantly improved over the study period, during which time all CHWs received dedicated monthly supervision, although effects plateaued over time.ConclusionsOur findings suggest that dedicated monthly supervision and personalised feedback using performance dashboards can increase CHW productivity. Further operational research is needed to understand how to sustain the performance improvements over time.Trial registrationClinicalTrials.gov (NCT03684551).

Background: We conducted a systematic review and meta-analysis of existing data from observational studies to assess the strength of the association of alcohol drinking with second primary cancer risk in patients with upper aerodigestive tract (UADT; oral cavity, pharynx, larynx, and esophagus) cancer.Methods: PubMed and Embase were searched up to July 2012 and the reference lists of studies included in the analysis were examined. Random-effects models were used to estimate summary relative risks (RR) and 95% confidence interval (CI).Results: Nineteen studies, 8 cohort and 11 case-control studies, were included. In highest versus lowest meta-analyses, alcohol drinking was associated with significantly increased risk of UADT second primary cancers (RR, 2.97; 95% CI, 1.96-4.50). Significantly increased risks were also observed for UADT and lung combined (RR, 1.90; 95% CI, 1.16-3.11) and all sites (RR, 1.60; 95% CI, 1.22-2.10) second primary cancers. For an increase in the alcohol intake of 10 grams per day, dose-response meta-analysis resulted in a significantly increased RR of 1.09 (95% CI, 1.04-1.14) for UADT second primary cancers.Conclusions: Alcohol drinking in patients with UADT cancer is associated with an increased risk of second primary cancers. Studies conducted in alcohol drinking patients with UADT cancer and evaluating the effect of alcohol cessation on second primary cancer and other outcomes are needed.Impact: Our results emphasize the importance of prevention policies aiming to reduce alcohol drinking. Health-care professionals should encourage alcohol drinking patients with UADT cancer to reduce their consumption and reinforce the surveillance of this at-risk subpopulation. Cancer Epidemiol Biomarkers Prev; 23(2); 324-31. Ó2013 AACR.