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Sample Proposal on “Boosting Maternal and Child Health through Targeted Immunization Interventions in West Africa”

Introduction.

Maternal and child health (MCH) remains a significant concern in West Africa, where high rates of maternal and child morbidity and mortality persist. According to the World Health Organization (WHO), West Africa has some of the highest maternal and child mortality rates globally, attributed to preventable diseases, inadequate healthcare access, and a lack of effective immunization programs. Immunization is a proven, cost-effective intervention that can significantly improve health outcomes for mothers and children.

This proposal outlines a targeted immunization initiative designed to enhance maternal and child health in West Africa by increasing vaccination coverage, improving health education, and fostering community engagement.

Problem Statement

In West Africa, maternal and child health outcomes remain critically poor, largely due to inadequate access to immunization services and a high prevalence of vaccine-preventable diseases. According to the World Health Organization (WHO), millions of children under five years old die each year from preventable illnesses such as measles, polio, and tetanus, with vaccination rates in some regions falling below the recommended coverage levels of 80%.

Despite improvements in healthcare infrastructure, several factors contribute to low immunization rates in West Africa:

• Lack of Awareness and Education: Many communities possess limited understanding of the importance of vaccinations, leading to widespread vaccine hesitancy. Misconceptions about vaccine safety and efficacy contribute to families choosing not to immunize their children.
• Barriers to Access: Geographic isolation, particularly in rural areas, creates significant barriers to accessing immunization services. Families often face long distances to health facilities, combined with a lack of transportation and financial resources to seek care.
• Inadequate Healthcare Infrastructure: Many healthcare facilities are under-resourced and lack the necessary personnel trained to deliver immunization services effectively. This results in inconsistent availability of vaccines and a decline in community trust in the healthcare system.
• Cultural Practices and Beliefs: Cultural norms and practices can also influence health-seeking behavior. In some communities, traditional beliefs may prioritize alternative health practices over modern medicine, including vaccinations.
• Impact of Infectious Diseases: The ongoing challenges posed by infectious diseases, such as COVID-19, have further strained healthcare resources and diverted attention from essential immunization programs, exacerbating existing health inequities.

The “Boosting Maternal and Child Health through Targeted Immunization Interventions in West Africa” initiative aims to achieve the following specific objectives:

• Achieve a minimum of 80% immunization coverage for children under five in targeted communities within two years of project implementation, focusing on routine vaccinations as well as catch-up immunizations.
• Increase the percentage of pregnant women receiving necessary vaccinations (such as tetanus toxoid and influenza) to at least 70%, thereby protecting both maternal and neonatal health.
• Conduct community education programs to raise awareness about the importance of vaccinations, targeting at least 5,000 community members, with a focus on dispelling myths and addressing vaccine hesitancy.
• Train at least 200 healthcare workers, including community health workers and nurses, on best practices in immunization delivery, community engagement, and maternal health education.
• Develop and implement a community health model that encourages ongoing participation in immunization programs, ensuring at least 50% of families engage with healthcare services on a regular basis.
• Implement a robust monitoring and evaluation system to track immunization rates, maternal and child health outcomes, and community engagement, providing quarterly reports and feedback to stakeholders.
• Collaborate with at least five local NGOs and community organizations to facilitate outreach, provide resources, and promote health initiatives, thereby increasing the reach and sustainability of the intervention.

Target Population

The “Boosting Maternal and Child Health through Targeted Immunization Interventions in West Africa” initiative focuses on the following key target populations:

• Women of childbearing age (15-49 years) who are pregnant or planning to become pregnant. This group will benefit from immunization services that protect both the mother and the unborn child from preventable diseases.
• Children aged 0 to 59 months, who are particularly vulnerable to vaccine-preventable diseases. This age group is prioritized for routine vaccinations as well as catch-up immunization for those who may have missed scheduled vaccinations.
• Parents, guardians, and other family members responsible for the health and well-being of pregnant women and young children. Engaging this population is essential to promote understanding and acceptance of immunization practices and to encourage participation in health services.
• Community health workers, nurses, and midwives who are directly involved in delivering immunization services and maternal health care. Strengthening their capacity through training and resources is critical to the success of the initiative.
• Local leaders, traditional healers, and influential figures within communities who can help promote the importance of immunization and maternal health services. Their involvement can facilitate outreach efforts and build trust within the community.
• Special attention will be given to underserved populations, including low-income families, rural communities, and ethnic minorities who may face barriers to accessing healthcare services. Addressing the needs of these groups is crucial for equitable health outcomes.

Proposed Activities

To achieve the objectives, the following activities will be implemented:

• Organize mobile vaccination clinics in remote areas to reach underserved populations.
• Conduct regular immunization drives in partnership with local health authorities.
• Develop and distribute educational materials on the importance of immunization and the schedule for vaccinations.
• Host community workshops and information sessions led by trained health educators.
• Provide training for healthcare workers on best practices for immunization, cold chain management, and community engagement.
• Supply health facilities with necessary vaccines, equipment, and resources to enhance service delivery.
• Establish a monitoring system to track immunization coverage rates and health outcomes.
• Conduct periodic evaluations to assess the effectiveness of the program and make necessary adjustments.

Expected Outcomes

• Achieve at least 80% immunization coverage for children under five within the targeted communities.
• Reduction in the incidence of vaccine-preventable diseases, such as measles, polio, and tetanus, leading to lower morbidity and mortality rates among children.
• Enhance maternal immunity through appropriate vaccinations during pregnancy, resulting in a decrease in maternal complications related to preventable diseases.
• Increase the number of pregnant women receiving antenatal care that includes vaccination education and services.
• Increase knowledge and understanding of the importance of immunization among community members, leading to greater community engagement in health initiatives.
• Reduce vaccine hesitancy through targeted educational campaigns, resulting in more families seeking immunization for their children.
• Improve the capabilities of local healthcare facilities to deliver effective immunization services through training and resource provision.
• Ensure healthcare workers are better equipped to engage with communities, address concerns about vaccinations, and promote preventive health measures.
• Establish a robust monitoring system to track immunization rates, health outcomes, and the overall effectiveness of the intervention.
• Generate data to inform future health policies and programs, ensuring continued improvement in maternal and child health strategies.
• Foster ongoing partnerships with local organizations, community leaders, and families to create a sustainable model for health promotion and immunization.
• Empower communities to take an active role in their health, resulting in long-term behavioral changes regarding immunization and preventive care.

Budget and Timelines

• Budget : The budget for implementing solutions for climate-resilient urban planning will depend on the scale and complexity of the projects, as well as the specific needs of the urban areas. A rough estimate for such initiatives could range from $XXXXXXX to $XXXXXXX, considering the need for comprehensive infrastructure and technology to ensure resilience to climate change impacts.
• Timelines : The timelines for implementing solutions for climate-resilient urban planning may span several years due to the intricate nature of urban development projects. It is reasonable to anticipate a timeline of 5 to 10 years to effectively integrate climate-resilient measures into urban planning and infrastructure, ensuring long-term sustainability and resilience to climate-related challenges.

In conclusion, the “Boosting Maternal and Child Health through Targeted Immunization Interventions in West Africa” initiative represents a comprehensive approach to tackling the pressing issues of maternal and child morbidity and mortality in the region. By prioritizing immunization as a key strategy, we can significantly reduce the burden of vaccine-preventable diseases and improve health outcomes for both mothers and children.

The proposed activities, including community education, capacity building for healthcare workers, and the establishment of mobile vaccination clinics, are designed to create a sustainable impact on public health. Increased vaccination coverage will not only protect vulnerable populations but also empower communities through enhanced health literacy and engagement.

We recognize that achieving our objectives requires collaboration and support from donors, government agencies, and local organizations. Together, we can foster a healthier future for West Africa, ensuring that every mother and child has access to essential healthcare services, including lifesaving vaccinations. By investing in this initiative, we are taking significant strides toward the realization of universal health coverage and the improvement of overall community well-being.

We urge stakeholders to join us in this mission and support our efforts to strengthen maternal and child health through targeted immunization interventions, ultimately paving the way for a healthier, more resilient West Africa.

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Community-based maternal and child health project on 4 + antenatal care in the Democratic Republic of Congo: a difference-in-differences analysis

• Hocheol Lee 1 , 2 ,
• Sung Jong Park 3 ,
• Grace O. Ndombi 1 , 2 &
• Eun Woo Nam 1 , 2  

Reproductive Health volume  16 , Article number:  157 ( 2019 ) Cite this article

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Despite efforts to achieve the Millennium Development Goals, the maternal mortality ratio in the Democratic Republic of Congo was 693 per 100,000 in 2015—the 6th highest in the world and higher than the average (547 per 100,000) in sub-Saharan Africa. Antenatal care (ANC) service is a cost-effective intervention for reducing the maternal mortality ratio in low-income countries. This study aimed to identify the intervention effect of the maternal and child health care (MCH) project on the use of four or more (4 + ) ANC services.

The MCH project was implemented using the three delays model in Kenge city by the Ministry of Public Health (MoPH) of the DRC with technical assistance from Korea International Cooperation Agency (KOICA) and the Yonsei Global Health Center from 2014 to 2017. Furthermore, Boko city was selected as the control group. A baseline and an endline survey were conducted in order to evaluate the effectiveness of this project. We interviewed 602 and 719 participants in Kenge, and 150 and 614 participants in Boko in the baseline and endline surveys, respectively. We interviewed married reproductive-aged women (19–45 years old) in both cities annually. The study instruments were developed based on the UNICEF Multiple Indicator Cluster Surveys. This study used the homogeneity test and the binary logistic regression difference-in-differences method of analysis.

The odds of reproductive-aged women’s 4+ ANC service utilization at the intervention site increased 2.280 times from the baseline (OR: 2.280, 95% CI: 1.332–3.902, p  = .003) as compared to the control site.

Conclusions

This study showed that the KOICA MCH project effectively increased the 4 + ANC utilization by reproductive-aged women in Kenge. As the 4+ ANC services are expected to reduce maternal deaths, this project might have contributed to reducing maternal mortality in Kenge. In the future, we expect these findings to inform MCH policies of the MoPH in the DRC.

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Plain English summary

The maternal mortality ratio (MMR) in the Democratic Republic of Congo is the sixth-highest in the world. In previous studies, the MMR in low-income countries was reduced by providing antenatal care (ANC) services. The World Health Organization also recommends that pregnant women should receive ANC services more than four times (4 + ) before giving birth. This study examined the impact of the maternal and child health (MCH) intervention using a difference-in-differences analysis. In this study, MCH interventions were provided to reproductive-aged women living in Kenge city from 2014 to 2017. Boko city was selected as the control city for comparative analysis. The MCH intervention activities included educational programs for reproductive-aged women, awareness-building programs using radio broadcasts, ambulance provision, a training program for health workers, construction of a health facility, and provision of equipment at the health facility. Reproductive-aged women participated in interviews: 602 and 719 women in Kenge; and 150 and 614 women in Boko in the baseline and endline surveys, respectively. The results of this study showed that the 4 + ANC service utilization rate was 2.28 times higher at the end of the intervention in 2017 as compared to before intervention in 2014. As the 4+ ANC service utilization has shown to have contributed to reduce the MMR, this study might inform the MoPH MCH policies in the DRC.

The United Nations (UN) adopted the Millennium Development Goals (MDGs) in September 2000 to increase the mother’s health status and decrease the maternal mortality ratio (MMR) worldwide. Although the global MMR per 100,000 newborns (MDG 5) decreased by 64% from 330 in 2000 to 210 in 2013, it has not been enough to achieve MDG 5 [ 1 ]. Therefore, UN member countries announced a sustainable development goal (SDG) target to decrease the MMR per 100,000 live births to 70 by 2030 [ 2 ]..

In sub-Saharan Africa, the MMR decreased by 49% between 2010 and 2013, but it was still significantly higher than the worldwide average [ 3 ]. Despite efforts to achieve the MDGs and SDGs, the MMR in the Democratic Republic of Congo (DRC) was 693 per 100,000 in 2015—the 6th highest in the world and higher than the average (547 per 100,000) in sub-Saharan Africa [ 4 , 5 ]. Obstetrical complications such as bleeding, eclampsia, sepsis, and unsafe abortions accounted for nearly 80% of the cases of MMR, and the remaining 20% were caused by underlying diseases [ 6 ]. Primary health care that includes maternal and child health (MCH) services are essential for decreasing the MMR [ 7 ]. According to the results of studies from 2016, the MMR can be reduced by regular visits to health facilities that provide antenatal care (ANC) [ 8 ].

Previous studies showed that ANC is a cost-effective way of reducing the MMR in low-income countries [ 9 ]. The World Health Organization (WHO) recommends at least four visits (4 + ) to ANC services during pregnancy. ANC typically includes an obstetrical examination to determine complications, a tetanus toxoid immunization, intermittent preventive treatments for malaria during pregnancy, and the identification and management of infections including HIV, syphilis, and other sexually transmitted infections [ 5 ]. Moreover, the overall MCH can be improved by receiving 4 + ANC visits at health facilities [ 10 ].

The Ministry of Public Health (MoPH) in the DRC also identified ANC as a beneficial health service for improving MCH and recommended that pregnant women receive 4 + visits to ANC services [ 11 ]. Despite the recommendations by WHO and MoPH in the DRC, only 48% of pregnant women received ANC services more than four times [ 5 ]. Meanwhile, 85% of women received only 1 + ANC services: 92% in urban areas and 80.9% in rural areas [ 11 ]. This means that while pregnant women in the DRC visited health facilities for ANC services, the number of women that made regular visits was low.

According to previous studies in the DRC, the most effective way of providing sustainable ANC services is by attracting participants through community health workers, also known as relais communautaires (RECO) [ 12 ]. Studies have shown that the impact of RECO activity is expected to be a significant factor for the utilization of ANC services by pregnant women in the DRC [ 8 ]. Despite their positive impact on health outcomes, the DRC faces a RECO capacity shortage; their health worker numbers are not proportional to the population percentage [ 12 , 13 ].

According to Thaddeus and Maine [ 14 ], an MCH intervention must focus on three steps to effectively reduce the MMR, which they refer to as the three delays model. According to this model, these delays are: 1) delays in decision-making to seek care; 2) delays in arrivals to health facilities; and 3) delays in the provision of adequate care. These three delays can be reduced to improve the ANC utilization by developing appropriate interventions [ 14 ]. Therefore, KOICA, in cooperation with MoPH of the DRC under the official development assistance (ODA) projects for low income countries, designed and implemented an MCH intervention project based on the three delays model. KOICA funded Yonsei Global Health Center (YGHC) to implement and evaluate this MCH project. YGHC, in a previous study, calculated the cost-benefit ratio (BCR) of this MCH project at 3.41, which means that the project was “more than 3 times more likely to provide benefits than cost” [ 15 ]. Although this project calculated the BCR, the impact of the MCH intervention project on the ANC service utilization by the reproductive-aged women in the DRC remains unknown. Therefore, this study aimed to measure the effect of the KOICA MCH project on the 4+ ANC service utilization rate among the reproductive-aged women in the DRC using the three delays model.

Study design

This study used a community-based, quasi-experimental, pre- and post-, comparison group study design in the DRC. KOICA MCH intervention project based on the three delays model was implemented for 3 years and 7 months from February 2014 to July 2017 in the DRC. The project was conducted in Kenge city in the Kwango district, roughly 120 km from the DRC capital, Kinshasa. The target group was 15–49-year-old reproductive-aged women, who constituted 18.7% of the total population of Kenge (50,281). The project team evaluated the effect that the MCH project had on the target group each year. The baseline survey was conducted in October 2014, and the endline survey in May 2017. Boko city, an hour away from Kenge, was the control group. The Ministry of Health recommended this city because no MCH project was being implemented at this site. In addition, both Boko and Kenge cities belonged to the same administrative zone in the Kwango district, and they had similar population sizes and comparable distributions of religion and ethnic groups (Fig.  1 ).

Map of intervention and control site – Kenge and Boko cities – in Kwango district

Intervention activities

The KOICA MCH project was developed by the YGHC based on the three delays model (Fig.  2 ) [ 14 ].

Intervention activities in the three delays model

The first phase of the project included educational programs to increase the awareness of and promote MCH services among community residents to address the first delay of seeking ANC from health facilities. Educational programs were provided by RECO visiting each household once a month in cooperation with national health programs such as the Programme National de Santé de la Reproduction (PNSR), Programme National d’Approvisionnement en Médicaments Essentiels (PNAM), Programme National de Lutte contre les Infections Respiratoires Aigües (PNIRA), Programme National de Nutrition (PRONANUT), Programme National de Lutte contre les Maladies Diarrhéiques (PNLMD). In addition, promotional activities for reproductive-aged women via radio broadcasting and signboards were used to increase program awareness. The radio broadcasts were sent out in 30-s intervals four times a day at 7:20 AM, 8:50 AM, 6:00 PM, and 7:30 PM in the local languages of Lingala and Kikongo. The radio programs covered seven themes, including “introducing the MCH project,” “promotion of awareness of disease control for children under-five,” “health facility delivery,” “guidance for using emergency transportation,” and “continuously providing MCH intervention.” Signboards were installed to indicate the locations of secondary hospitals, health centers, and health posts.

The second phase of the program addressed the second delay of reaching the health facility to receive ANC by pregnant women during the pregnancy. Therefore, the KOICA provided a secondary hospital with an ambulance (a Toyota Land Cruiser). They also provided motorcycles (a Yamaha AG100) to 23 health centers per each health zone—i.e. “Aires de Santé (AS)”— as emergency transportation for referrals to health facilities.

Finally, the third phase of the program aimed to ensure that patients received adequate and appropriate treatment focused on ANC at health facilities. Therefore, the project team provided information regarding the capacity building of health workers to improve the quality of health services, the establishment and operation of maternal and newborn healthcare units (MNUs), and the provision of essential medicines. Training for the capacity-building of 76 health workers such as chief nurses, nurses, midwives, pharmacists, and nutritionists was conducted ten times in cooperation with PNSR, PNIRA, PNAM, and PRONANUT. The MNUs were a combination of obstetrics and gynecology outpatient clinics, delivery rooms, pediatric wards, and education rooms. The average number of deliveries per month in the MNUs was 191.

The sample size was calculated using the Raosoft calculator using a 95% confidence interval and a 5% margin of error. The sample population was 9403, which is 18.7% of Kenge’s total population (50,281) [ 16 ]. Therefore, the minimum sample size was determined to be 382 participants. Reproductive-aged women were selected through the Probability Proportionate to Size (PPS) method in 23 Aires de Santé (AS; health zones) in Kenge and ten AS in Boko. We randomly selected a minimum of 30 households per AS in Kenge and Boko based on the Central Limit Theorem [ 17 ]. Additionally, we selected one reproductive-aged woman from each household. This sampling method ensured that the sample was representative of the populations from each AS. Therefore, these participants were community-based cross-sectional samples for each year (Fig.  3 ). In the baseline, we collected data from 602 women in Kenge and 150 women in Boko. In the endline, we collected data from 719 women in Kenge and 614 in Boko. We checked the data quality to ensure it was appropriate for analysis. Consequently, we excluded cases or records with missing and censored data. The final sample consisted of 615 women in Kenge and 312 women in Boko in the baseline, and 719 women in Kenge and 614 women in Boko in the endline.

Flow diagram of the study

Data collection

Face-to-face interviews were conducted by visiting households with reproductive-aged women. The trained female interviewer questioned the selected reproductive-aged women, and the answers were noted in the questionnaire. We obtained written informed consent from all the respondents (i.e., reproductive-aged women/respondents on behalf of children under 5 years). Special emphasis on the respondents’ rights to refuse to answer questions was provided to the participants. Each survey team consisted of a team manager, a supervisor, and two interviewers. The manager directed the team and took care of the logistics while the supervisor ensured the quality of data. Each questionnaire took about 1 h to complete. Thus, out of 2279 women respondents, data of 2085 women (91.4%) were analyzed.

Study instrument

The questionnaire used in this study was adapted from the UNICEF Multiple Indicator Cluster Surveys 2011 [ 18 ]. After three meetings with three health experts from the School of Public Health at Kinshasa University in the DRC, this questionnaire was psychometrically tested to ensure the validity and reliability of the data. Thereafter, the questionnaire was validated by conducting a pre-survey among 36 reproductive-aged women in Maluku, which is similar to Kenge.

Statistical analysis

An evaluation of the MCH project effects in Kenge was conducted using IBM SPSS Statistics 24.0, and the detailed methods are as follows:

Homogeneity test

This study conducted the homogeneity test to confirm that Kenge and Boko were identical before the intervention. In this study, the homogeneity, which included the dependent variable (4 + ANC utilization rate), used six of the WHO recommended indicators to evaluate the MCH intervention [ 19 ]. These six indicators were ANC, PNC, neonatal examination, skilled birth attendants, exclusive breastfeeding, and using an improved water source. Table  1 shows the results of the chi-squared test of homogeneity between Kenge and Boko from the baseline to endline survey. In the case of the dependent variable in the baseline survey data, the 4+ ANC utilization rates were significantly different between Kenge and Boko at p  = .033, while, In the endline (2017), these two cities were significantly different at p  < .000. Using an improved water source showed a significant difference between Kenge and Boko from baseline to endline.

Binary logistic difference-in-differences analysis

We conducted a binary logistic difference-in-differences (DID) analysis to compare the MCH interventions between Kenge and Boko from baseline to endline. The binary logistic DID model included dependent, independent, and control variables.

The dependent variable in the binary logistic DID analysis was the 4 + ANC services utilization. To measure this dependent variable, women were asked: “How many times did you visit a health facility for ANC before your last delivery?” A response of “four times or more than four times” was coded “1”; others were coded “0.”

Characteristics of study participants

A total of 2279 reproductive-aged women between the intervention and control group participated. Thus, out of 2279 women respondents, data of 2085 women (91.4%) were analyzed. As depicted in Table  3 , the mean age of respondents in Kenge was 28.7 years in the baseline, 29.6 years in the endline. Women in Boko had the similar mean age. Some 86.8% of the women in Kenge and 81.8% of women in Boko had higher than or equal to secondary levels of education in the baseline. And 82.7% of women in Kenge and 73.1% women in Boko had higher than or equal to secondary levels of education in the endline. Thus, more than 80% of the respondents in Kenge and Boko completed higher than secondary level education. Some 41.4 and 53.4% of the women in Kenge had received 4+ ANC services in the baseline and endline, respectively. In contrast, 31.3 and 43.4% women in Boko had received these services in the baseline and endline, respectively.

Binary logistic DID analysis

In order to identify the effect of the MCH interventions on the use of 4 + ANC services, this study performed a binary logistic regression DID analysis between Kenge and Boko (Table  4 ). The odds of reproductive-aged women’s 4+ ANC service utilization at the intervention site in the endline increased 2.054 times from the baseline (OR: 2.054, 95% CI: 1.365–3.092, p  < .001) as compared to the control site in Model 1, which only included Time, Group, Time × Group (δ). Model 2 used the same independent variables and also controlled for additional variables including the number of household members, number of children under five, reading skills, writing skills, insurance, and income. After accounting for these controlled variables in Model 2, the odds of reproductive-aged women’s 4+ ANC service utilization at the intervention site in the endline increased 2.280 times from the baseline (OR: 2.280, 95% CI: 1.332–3.902, p  = .003) as compared to that in the control site.

This study aimed to identify the MCH intervention effect on 4 + ANC service utilization among reproductive-aged women in the DRC. The use of 4 + ANC services increased 2.280 times as a result of the intervention.

The characteristics of this study, childbirth in the life of reproductive-aged women in Kenge were identified on average 6.0 times that is similar to the 6.0 times reported by the World Bank in 2015 [ 24 ]. The education levels of respondents showed that more than 70% of reproductive-aged women in Kenge and Boko had completed secondary or higher levels of education. On the other hand, only 48% of reproductive-aged women in the completed higher than secondary levels of education [ 25 ].. This result shows that reproductive-aged women in Kenge and Boko have higher education levels than women living in other cities across the DRC. A previous study showed that interventions are more effective for reproductive-aged women with higher education levels [ 26 ]. Therefore, the interventions activities might have been effective due to women’s higher levels of education at Kenge. The monthly household income in Boko was lower than in Kenge, in part due to the UN implementing income generating activities in Kenge in 2014, which might have increased their monthly household income [ 27 ].

The results of this study indicated that the average medical expenditure in Kenge was $152.4 per year, and the medical expenditure in Boko was $158.4. The medical expenditures in Kenge and Boko were higher than the average ($128) in rural areas in the DRC but were lower than medical expenditure in urban areas ($376) and the overall average in the DRC ($206) [ 25 ].

This study provided interventions in Kenge based on the three delays model of factors that impede women from seeking the MCH, increasing the MMR. The first delay involves the delay in making decision to seek care. This delay stems from lack of awareness of services and health facility, which may be addressed by improving the educational interventions focused on decision-making behaviors. Therefore, we provided education programs to change the behavior of reproductive-aged women. Previous studies have shown that the fastest and most effective MCH interventions are those that focus on behavioral changes among reproductive-aged women [ 28 ]. Accordingly, a qualitative study in Kenge confirmed that the radio education intervention in the first phase was effective [ 29 ].

The second phase of delay involves the delay in identifying and ultimately reaching the medical facilities. According to a previous study in Tanzania, reproductive-aged women know that ANC is very important, but pregnant women find it difficult to visit the health facility at night because of dangerous animals and inequity of access to health facilities. Additionally, health workers interviewed in a previous study stated that “… I would like them to attend ANC from at least 8 weeks [of pregnancy], if we have a chance to identify the pregnancy that early then I think this lady has a chance to receive a good health service” [ 30 ]. In order to enhance access to health facilities, we provided emergency transportation, including ambulances and motorcycles, and these interventions were effective at increasing the number of health facility visit. However, unlike other studies [ 30 ] we did not calculate the accessibility cost of transportation; future studies need to calculate this cost to enable evidence-based decision-making.

The third phase of delay involves the delay in receiving adequate and appropriate treatment. In previous studies, the mortality of the mother or the children occurred in the third phase in the three delays model [ 30 , 31 ]. Results from this study indicated that MCH interventions had an effect of increasing 4 + ANC services utilization by 2.28 times. Based on previous studies, reproductive-aged women who received 4+ ANC have a lower mortality rate than reproductive-aged women with 4 − ANC. Moreover, children under five who were born from a mother that received 4+ ANC services have a lower mortality rate [ 32 , 33 ]. Therefore, it is expected that newborns that are born after this intervention will have positive effects on their health. Future studies in Kenge must conduct a study on the intervention’s effect on newborns .

Some issues may have affected the effectiveness of the interventions from 2014 to 2017. According to an announcement by WHO, there was a measles outbreak in the DRC in 2015. The outbreak occurred in the province of Katanga, which spread rapidly to nearby Kenge and Boko and resulted in 5000 deaths and 300,000 measles patients [ 34 ]. We assumed that this could be the cause of the decrease in the intervention effect in the second year. Because health facilities in Kenge are widely known to provide medical interventions, patients from other areas overcrowded these facilities, thus, pregnant women at the intervention site might not have received adequate ANC services.

According to previous studies, it was found that the main issue with MCH interventions in low-income countries is the frequent turnover of health workers [ 28 ]. Doctors, chief nurses, pharmacists, and midwives in Kenge had turnover around every 2 years. We confirmed that some of the health workers who had completed their intervention training had been moved out to other areas, which may have reduced specific possible outcomes in the intervention area due to provider turnover.

Many low-income countries, international organizations, and NGOs have been implementing the official development assistance (ODA) projects in the DRC. There are various focuses of ODA projects, such as health, construction, agriculture, education, and others. Despite the efforts of the ODA projects by international organizations and NGOs, the number of projects has been reduced due to safety issues in the DRC, such as civil war. And the DRC still lacks evidence studies on public health issues such as MCH, Ebola, and malaria. Although this study was conducted in one region of the DRC, it is expected to provide evidence for low-income countries, international organizations, NGOs, and research institutions to implement the MCH project across the DRC.

Strengths and limitations of the study

This study focused on MCH interventions based on the three delays model for reproductive-aged women in the DRC. The three delays model targets interventions to reduce the MMR by identifying the three phases that affect MCH. However, this study used the number of ANC services as dependent variable, not the MMR. For this reason, it was difficult to obtain the MMR data from the health facility, survey, and public data in the DRC, and we doubted the reliability of the obtained MMR data. Future studies must use the MMR indicator to identify the MCH intervention effect.

According to previous research, it is necessary to select the control area for conducting the DID analysis, which has similar characteristics to the intervention area before the study is implemented [ 35 ]. To test the homogeneity of the two areas, previous studies have used the Propensity Score Matching (PSM) method or Inverse Probability of Treatment Weighting (IPTW) [ 36 , 37 ]. However, this study used the chi-squared test of homogeneity because the PSM method would have decreased the sample size. In future studies, PSM method should be considered while calculating the sample size. In the baseline survey, 312 households in Boko were the control group from 10 AS, but only 150 households were analyzed because of missing data. Therefore, the sample size for analysis was not balanced. Future research should get balanced sampling by using RUSBoost or over-sampling methods [ 38 ].

In a previous study, the evaluation of intervention activities were conducted using multi-level analysis, suggesting standardized indicators [ 28 ]. This study, however, was conducted at a single level. Therefore, multi-level, DID analyses might be conducted to account for higher-level factors in the future.

The results show that the MCH project using the three delays model as framework was able to bring an improvement to reproductive-aged women’s 4+ ANC service utilization. ANC is an effective intervention for reducing MMR, so we expected this study to also reduce the MMR. In the future, we expect these results to inform the MoPH MCH policies in the DRC.

This study examined the effect of the MCH intervention based on the three delays model from 2014 to 2017 in Kenge, DRC. According to the WHO and the MoPH, less than half of reproductive-aged women in the DRC received 4+ ANC services [ 5 ]. According to previous studies, ANC is an effective intervention for reducing MMR [ 9 ]. As a result of implementing MCH intervention activities using the three delays model, the number of 4+ ANC visits increased 2.280 times from the baseline. Currently, there is a lack of research using the three delays model. Women who received 4+ ANC services had a lower mortality, so this study was expected to also show a reduced MMR. Therefore, we expect the findings of this study to inform the MCH policies by the MoPH in the DRC

Availability of data and materials

The data used for the current study is available from the corresponding author on reasonable request.

Abbreviations

More than four visits to antenatal care services

Aires de santé

Chi-squared Automatic Interaction Detection

Difference-in-differences

Inverse Probability of Treatment Weighting

Maternal and Child Healthcare

Maternal Mortality Ratio

Maternal and Newborn care Unit

Postnatal care

Propensity Score Matching

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Acknowledgements

We express our special thanks to the study participants, field enumerators, and all other partners in the DRC who made this survey possible.

This work was supported by the Korea International Cooperation Agency (KOICA) under the title of “The Project for Capacity Building on Maternal Newborn and Child Care in the Kwango Provincial Division of Health in the DRC” in 2014–2017 (No. P2013–00186-4).

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HCL designed the study, collected the data in the DRC, conducted the primary data analysis and prepared the manuscript. SJP performed statistical analyses alongside HCL. GO Ndombi advised on the intervention designs. EWN advised on all the processes of the article’s development from design to submission. All of the authors approved the final draft for submission and the revised draft.

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Correspondence to Eun Woo Nam .

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All four parts of this survey were approved annually by the Institutional Review Board (IRB) of Yonsei University in Korea and the Kinshasa University Bioethics Review Board (BRB). Each document had the following IRB numbers: 1041849–201406-BM-027-01, 1041849–201406-BM027–02, and 1041849–201406-BM-027-03. Kinshasa University’s BRB numbers were ESP/CE/021/14, ESP/CE/021/2015, and ESP/CE/057/2016. Informed consent was obtained from each respondent before the information was collected.

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Lee, H., Park, S.J., Ndombi, G.O. et al. Community-based maternal and child health project on 4 + antenatal care in the Democratic Republic of Congo: a difference-in-differences analysis. Reprod Health 16 , 157 (2019). https://doi.org/10.1186/s12978-019-0819-1

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• 4 + ANC services
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• The Democratic Republic of Congo

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Prioritising child health and maternity evidence-based interventions or service models: a stakeholder-driven process

• Camilla Forbes 1 ,
• Naomi Morley 1 ,
• Kristin Liabo 1 ,
• Gretchen Bjornstad 1 ,
• Heather Boult 2 ,
• Shafiq Ahmed 2 ,
• Kayley Ciesla 3 ,
• Yassaman Vafai 4 ,
• Sally Bridges 3 ,
• Stuart Logan 1 &
• Vashti Berry 1  

BMC Health Services Research volume  22 , Article number:  764 ( 2022 ) Cite this article

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A UK programme, led by the National Institute for Health Research (NIHR) ( https://www.nihr.ac.uk ) and coordinated by Applied Research Collaborations (ARC), ( https://www.nihr.ac.uk/explore-nihr/support/collaborating-in-applied-health-research.htm ) aimed to identify and select evidence-based, implementation-ready service innovations for evaluation. The programme focused on seven areas of health provision. We report on a prioritisation process designed to identify and assess innovations in one of these areas: child and maternal health (CH&M).

We developed a three-stage, online, stakeholder driven process to 1) identify, 2) assess and prioritise and 3) select evidence-based interventions or service models, using crowdsourcing to identify projects and the APEASE criteria to assess and select projects. A brief evidence review was conducted for all initial suggestions to identify those with the largest evidence-base to take forward for ranking by stakeholders. Stakeholder workshops considered and ranked these suggestions using the APEASE criteria. We then conducted in-depth evidence reviews for the highest ranked suggestions. The Project Management Group and Advisory Board used these reviews and the APEASE criteria to select the final projects.

We received 32 initial suggestions from a range of clinicians, practitioners and researchers. Fourteen of the most evidence-based suggestions were considered and ranked at four themed stakeholder workshops. Nine suggestions were ranked for further in-depth evidence review and a final four projects were selected for implementation evaluation using the APEASE criteria. These were: 1. Maternal Mental Health Services Multidisciplinary Teams 2. Early years tooth brushing programme 3. Trauma-focused CBT for young people in care and 4. Independent Domestic Violence Advisors in maternity settings. Feedback from participants suggested that having public representatives participating in all stakeholder meetings, rather than being consulted separately, focused discussions clearly on patient benefit rather than research aims.

Conclusions

The stakeholder-driven process achieved its aim of identifying, prioritising and assessing and selecting, evidence-based projects for wider implementation and evaluation. The concurrent process could be adapted by other researchers or policy makers.

Peer Review reports

Priority setting in healthcare, the process of making decisions about how best to allocate resources to improve population health, is a necessity as all healthcare systems have limited amounts of resources. In the UK and elsewhere, there has been an increased interest in bringing in different perspectives, including patients, health care professionals and members of the public into decision-making about which healthcare services to prioritise [ 1 ]. People with ‘lived’ or ‘professional’ expertise of health care services are considered to bring a particular type of knowledge to the prioritisation process, which would be missed if the process is informed by researchers and managers only. This is thought to improve service uptake and engagement further down the line, increase equity, and contribute to a more transparent process of prioritisation [ 1 ]. When working with a range of stakeholders it is important to find a process that feels inclusive and accessible to the different stakeholders involved. Without this, there is a risk of alienating stakeholders, which in turn might be detrimental to service engagement and uptake.

Different approaches and criteria suit different circumstances and decision-makers need to ensure that they select the best process and criteria for their specific context and remit [ 2 , 3 , 4 ]. Methods used in priority setting processes are varied, and include surveys, Delphi studies, one-day events, workshops or focus groups [ 5 , 6 , 7 ]. Each offers advantages and disadvantages and reflection is needed for the best method for a given prioritisation remit; for example Delphi studies can reach a larger number of stakeholders compared to workshops or focus groups but can also limit the pool of particular groups and may not operate at the same level of detail/depth as in-person events [ 8 ]. Lavallee et al. compared three approaches (Delphi survey, on-line crowd-voting and in-person focus groups) and reported that the focus group participants evaluated their experience the highest [ 5 ]. We found a limited number of approaches in priority setting health interventions for child and maternal health [ 9 , 10 ], each with a distinct concern. For example: the Child Health and Nutrition Research Initiative (CHNRI) [ 11 ], aims to inform those who invest in research about the risks associated with their investments and the James Lind Alliance (JLA) Priority Setting Partnerships [ 12 ], aims to identify areas where there are unanswered questions about treatments. Approaches use different multi or single criteria to assess initiatives depending on their particular remit, such as multi-criteria decision analysis (MCDA) [ 3 ], as opposed to single criteria, such as cost-effectiveness analysis. Multi criteria such as MCDA have been advocated [ 13 ], although found to have important challenges when used to assess patient preference [ 14 ]. APEASE (Table  1 ), designed by Mitchie et al., offers a multi-criterion tool that was developed for the design and evaluation of interventions [ 15 , 16 ]. It has been utilised in numerous ways to design and evaluate interventions however, it has rarely been used in priority setting [ 17 ]. APEASE has a simple set of six criterion, which is accessible for stakeholders with differing knowledge and experience. In addition, the APEASE criteria is flexible to different priority setting methodologies although to our knowledge, its only use to date has been in a survey capacity [ 17 ].

Study context

In 2019, the UK National Institute for Health Research (NIHR) reinvested in 15 Applied Research Collaborations (ARCs) to tackle some of the most pressing health and social care issues in England. In October 2020, it launched a national priority call focused on seven areas of health: 1) Prevention, 2) Health and care inequalities, 3) Mental health, 4) Multimorbidity, 5) Adult social care and social work, 6) Healthy ageing and 7) Children’s health and maternity [ 18 ]. This call allocated a lead ARC to each priority call and asked ARCs to work collaboratively to identify and prioritise evidence-based interventions or service models for wider implementation to affect the health and social care issues for those with the greatest burden. Proposals could be submitted to more than one priority call and the scope for innovations was broad. The key remit of this call, and unlike other priority setting processes, was for the interventions/service models to have funding in place for wider implementation with additional funding provided to ARCs to research and evaluate the implementation in a 3 year programme of work (2020-2023). NIHR did not specify a prioritisation process/method and the period for selecting interventions for implementation was 6 months. The focus of this paper is on the Child and Maternity health priority call.

Stakeholder and Public and Patient Involvement and Engagement (PPIE) Footnote 1 is established as an important aspect for priority setting health needs [ 19 ] and is a key aim of the NIHR ARC prioritisation process. There is limited information however, on how to best involve stakeholders with no one method meeting all our requirements in the priority setting process and limited evaluation on how successful engagement is, with time and funding limits highlighted as barriers [ 5 , 17 , 19 ]. Within the context of the CH&M programme, which has a strong PPIE ethos, we sought to engage with multiple stakeholders, who had an interest in the priority setting outcomes. This included public representatives, Footnote 2 clinicians, practitioners and researchers. Each of these stakeholders potentially has a different set of priorities and therefore it was important to design a process that would engage, accommodate and balance their different perspectives. Neither the CHNRI nor JLA approach fitted with the remit of the CH&M priority programme as we were interested in evidence-based interventions/service models that meet a balance of requirements. We therefore designed a process, using the APEASE criteria, which would fit the timeframe and remit of the CH&M priority programme; this flexible approach was needed to meet the challenges of conducting this process online during the Covid-19 pandemic The aim of this paper is to describe and present the results of the process and critically evaluate the use of this approach so others may learn from our experience.

This prioritisation process took place during the Covid-19 pandemic and therefore the methods accommodated an on-line platform. A three-stage process facilitated the identification and prioritisation of evidence-based interventions or service models (Fig.  1 ). Stage 1 was a crowdsourcing activity primarily to identify evidence-based interventions or service models. We contacted relevant stakeholders and partners through our networks of providers, commissioners, charities and ARCs to identify interventions. We also contacted PPIE leads in the collaborating ARCs to establish networks, introduce the programme of work and disseminate the call. We hosted an on-line briefing session to encourage, support proposals, and explain the remit. We set up a programme website [ 20 ] with up-to-date information and a system for submitting proposals. Each proposal completed a simple on-line pro forma (Additional files  1 and 2 ); this was developed to capture basic information of the submitter and the proposed intervention/service for wider implementation, any known detail about the intervention was captured using the APEASE criteria as a framework. We offered support to complete the pro forma to all submitters if needed. After receiving the proposals, we conducted an initial review of the evidence, based on references provided by the submitter or a scan of the available evidence if none were provided.

Child Health and Maternity prioritisation process

Stage 2 focused on prioritisation using the APEASE criteria. We divided the criteria into two parts to suit the next two stages of the process. We wrote a one-page summary, in plain English, for each short-listed proposal. Where any technical or topic-specific terms were necessary in the summaries, we added these to an accompanying glossary. If there was missing information, we contacted the submitter. Due to having a wide variety of stakeholders to involve, we conducted four separate, themed on-line workshops; themes were based on the overarching topic areas of the short-listed proposals. The workshops were chaired by a public collaborator Footnote 3 and supported by a member of the CH&M Programme Management Group (PMG) and programme staff.

At each workshop, we asked the collaborating ARCs to invite three relevant participants (one researcher, one clinician/practitioner and one public representative) from their network to ensure an even distribution of interests. For the workshops, we considered three of the APEASE criteria (Acceptability, Practicability and Equity) as these were most relevant to the expertise and experience of stakeholders attending, were considered critical to informing a comparison about readiness for implementation, and could be covered in the time available. Prior to the workshops, participants received document packs containing a proposal summary, glossary of terms, and explanations of the three relevant APEASE criteria. Public representatives also received contact details of the programme’s PPIE coordinator and details of two online support sessions that were held the week prior to the workshops. The support sessions were open discussions around topics that attendees felt needed clarification, such as the format of the workshop, where it fits within the programme, its agenda, attendees and their roles, and the APEASE criteria and scoring system. During the workshops someone from the submitting team presented their proposal in a five-minute slot framed around the 3 criteria with 10 min to answer follow-up questions from participants; the presenters then left the workshop. The participants had a general discussion about the proposals; speakers declared any conflicts of interest. Participants gave each proposal an overall score (scale range = 1-10) against the three criteria using an anonymous online poll built into the videoconferencing software. This scoring system resulted in a shortlist of the nine most highly scoring proposals across all four workshops.

We circulated a short survey (Additional file  4 ) after the workshops to capture stakeholders’, researchers’, clinicians’/practitioners’ and public representatives’ views of participating and their experience of the process. The survey contained five questions concerning the organisation, preparation and conduct of the workshops, as well as the participants’ perceived impact. Answers were collected by a mixture of multiple-choice checkboxes and open-ended entries. Additionally, the programme’s PPIE coordinator met online with the workshop chairs to provide a forum for feedback and discussion around the processes and support in stage 2. This was to collect information regarding the participants to help us assess the impact of the involvement process, generate learning and drive improvement.

Stage 3 concentrated on selecting 3-4 projects, from the stage 2 short-list. Priority Briefings were prepared for each of the nine short-listed proposals to evaluate the evidence in more depth, consider alignment with national health agendas and consider three further APEASE criteria (Effectiveness and cost-effectiveness, and Side-effects/safety). For the Priority Briefings, we created evidence search strategies, rapidly reviewed the top-ranking evidence and wrote a summary in plain English. The PMG (made up of ten representatives from the ARC collaborations and two public contributors) met, online, to discuss and rank the final proposals using the priority briefings and comments from the workshops. The ranking system involved all members anonymously selecting their first, second and third choices in an online poll, which resulted in a ranked list of proposals. The top three ranked proposals were removed from the list and members ranked their top three proposals from the remaining six. This process produced a set of top three ranked proposals and a reserve list of three proposals to consider if there were sufficient resources to adopt additional projects. Members declared any conflicts of interest. They also considered the final aspect of the APEASE criteria, Affordability, by assessing the immediate costs of each project in terms of committed funds for delivery and having commissioners as partners. The external Advisory Board (made up of nine external representatives from the Royal Colleges of Nursing, Obstetrics and Gynaecology, and Paediatrics, National Health Service Specialty Advisors, and other national health service leaders, and four PPIE members) sense-checked the PMG ranking against existing national priorities. We shared the short-listed proposals with collaborating ARCs and other cross-ARC priority programmes to identify any cross over projects.

The REPRISE guideline was used to report the methods of this priority setting process [ 21 ].

Figure  2 illustrates the results of the prioritisation process. Stage1: 86 participants attended the online briefing. After the initial call we received 32 proposals (Additional file  3 ), evenly split between child and maternity health. The initial review of the evidence eliminated 18 of the proposals because they were not sufficiently developed for this programme of work.

Results of Child Health and Maternity programme prioritisation

Stage 2: We sorted the 14 short-listed proposals into four themed online workshops (two maternity and two child health): 1) Antenatal care and maternity services; 2) Child mental health and Public Health; 3) Childhood disability and vulnerable populations; 4) Childbirth and maternal mental health. Table 2 indicates how each of the 14 short-listed proposals met the APEASE criteria, results of the workshop poll and Programme Management Group ranking.

Workshop 1 had 25 participants made up of eight clinicians/practitioners, eight public representatives and nine researchers.

Workshop 2 had 24 participants made up of five clinicians/practitioners, ten public representatives and nine researchers.

Workshop 3 had 22 participants made up of three clinicians/practitioners, eight public representatives and eleven researchers.

Workshop 4 had 24 participants made up of eight clinicians/practitioners, eight public representatives and eight researchers.

See Additional file  5 for details of clinicians/practitioner’s roles. Each workshop considered 3-4 proposals. This process produced six high-ranking proposals, three medium ranking and five low ranking.

Stage 3: We prepared nine priority briefings for the high and medium ranking proposals (Additional file  1 ). The PMG ranked three high ranking and three reserve projects. The high-ranking three (listed in order of ranking):

Maternal Mental Health Services Multidisciplinary Teams

Early years tooth brushing programme

Trauma-focused CBT for young people in care

The three in reserve (listed in order of ranking):

Independent Domestic Violence Advisors in maternity settings

Birmingham Symptom Specific Obstetric Triage System (BSOTS)

The external Advisory Board reviewed these six. We held three projects in reserve because negotiations with submitting teams had not taken place and we wanted to ensure that proposals had sufficient funding and staff available to enable implementation. We were also aware that some proposals had been submitted to and prioritised by other priority programmes within the national ARC programmes of work. This was the case for two of our highest ranked proposals (Trauma-focused CBT for young people in care and Independent Domestic Violence Advisors in maternity settings) which were also prioritised within the Health and Care Inequalities and Prevention priority themes. Negotiations therefore took place to achieve cross-programme working so that we could adopt both of these projects and prioritise four projects in total.

Sixteen out of the 84 participants responded to the post-workshop survey; 10 of those were PPIE contributors, three researchers, two clinicians and one project presenter. Overall, responders felt that the workshops were well organised and supported, although the response rate was low. The document pack they had received in advance was helpful in providing context to the process and support in preparing for the session. Most responders felt there was clear guidance on the process and their role within it. In addition, public members expressed that the sessions were interesting, well conducted and that they had enough opportunity to express their opinion.

“Yes, I did enjoy the process probably because it was well organised, and I got the information I needed before hand and afterwards.” (PPIE representative)

The workshop chairs also noted that the sessions flowed well, and the planning, material and support given before, after and during the sessions put them at ease. They were happy to be involved in something they are passionate about because of their own lived experiences, and found the process and projects interesting. Additionally, they emphasised that it was a great opportunity to connect with different people from all over the country.

“I think it was great to be involved in the workshop because I am passionate about maternity service. […] I feel privileged to have chaired the meeting cause we all did such a great job” (Workshop chair)

Some public members noted that it would have been beneficial to provide more time to discuss the individual proposals with the other panel members to come to a decision around scoring. They suggested that future events should plan for longer open discussions or breakout rooms after the presentations to continue the conversation.

“I enjoyed the process, but I felt maybe if were given more time to discuss with other members […] we could have been more sure about our choices.” (PPIE representative)

Two public representatives attended each of the PPIE support sessions held prior to the workshops. There was a strong sense that public representatives attending the support session were unsure how their knowledge/experience as a service user would fit into a mixed panel of professionals and sought clarification on their role within these panels. For example, attendees wanted to know whether their opinions and voting would be given equal weight and whether public representatives were represented in the workshops in equal numbers to the professionals. Attendees also appeared concerned about the level of detail in the scoring system and wondered how their personal experiences could be applied to the APEASE criteria so that they could make a well-informed decision. To address this concern, the criteria was discussed and applied to study examples to elicit questions they may want to think about during the workshop, to deduce if a proposal may or may not be worth pursuing from the perspective of their context and experiences as service users. For example: 1) is the project important to me and/or my community? 2) Is the project taking diverse communities and their needs into account? 3) Are the methods practical for me and/or my community? 4) Will the intervention reduce the burden of my community?

This paper outlines and reflects on the priority setting process that the CH&M priority programme designed to prioritise evidence-based interventions for implementation research projects during the Covid-19 pandemic. The need to involve a diverse group of stakeholders strongly influenced the design of this process and the specific use of the APEASE criteria in this process is unique. The results demonstrate the feasibility of the approach we took, however we acknowledge that few of the stakeholders responded to the post-workshop feedback survey and response bias may be influencing our conclusions.

There were a number of challenges to this priority setting process which took place during the Covid-19 pandemic and needed to be flexible to an online platform. Firstly, combining child health and maternity services into one priority theme with no parameters set for specific populations, problems, or settings limited the possible number of projects that the programme could adopt in either area; attention to ensure that both had equal opportunity was necessary. Secondly, the national focus is similar to priority setting in health generally, however it might exclude smaller, regional projects, which have strong local traction. There could be benefits of priority setting regionally where proposals meet the contextual needs of that locality. Arguably, however, a national focus allows for consistency of care and avoids a ‘postcode lottery’ of access to services. Thirdly, the research timeline of three years for this programme to deliver projects and achieve impact meant the deliverability of proposals needed careful consideration. Fourthly, there was a short time-line for proposals to be submitted which given we were in the winter months of a pandemic might have meant clinicians/practitioners were less able to contribute. Finally, we did not come across a process or framework that suited our CH&M priority programme and therefore designing a process and selecting methods that fitted with the needs of our stakeholders was required. A potential consequence of directing this call for evidence-based interventions that are ready and have funding for implementation could mean that projects that are less developed miss out on possible development and roll-out and thus making sure that these proposals are not lost is important.

The process we designed differs from other priority setting processes and reflects a few contextual concerns. Firstly, this process took place during the Covid-19 pandemic and therefore we needed a method that was flexible and would work in an online platform. There are advantages and disadvantages to this format, for instance it can mean stakeholders find it easier to attend, however conversely the online platform can change the nature of the exchange compared with face to face and make it harder for participants to engage and offer their views [ 22 ]. Our experience is that online meetings, when used effectively, can facilitate inclusion and opportunities for equal voice via strong chairing (limiting dominant voices and encouraging silent ones) and the use of additional technology, such as the ‘chat’ function and anonymous ranking/scoring, for those who find voicing perspectives difficult. Secondly, we wanted to ensure we had a balanced voice from our stakeholders; hence, we limited the number and type of participants invited to the workshops. As a third of the attendees were public representatives, we took advice from in-house PPIE staff (employed to facilitate and support public collaboration) on how to enable proactive contributions rather than passive responses, from public representatives. We were also aware that some submitters were non-researchers and might need support in preparing their proposal, which is why we hosted a briefing session and offered support if needed. Finally, we were aware of the need to limit the time of the online workshops for people’s comfort; hence, we split the APEASE criteria into two so that the stakeholders who attended the workshops only needed to consider the criteria that was relevant to their expertise.

The strengths of this process were its flexible approach, the resourcing of research, support and PPIE staff, being part of a national ARC network, regular team meetings with good and open communication and transparent methods. This process was, however, not without its limitations. A limitation of crowdsourcing intervention ideas is that we do not know to what extent we captured all relevant, scalable, evidence-based CH&M interventions/service models. However, a benefit of this approach is that we have captured the ideas that had support from providers/commissioners since this was a criterion for recommendation. A further limitation was that despite the aspiration to design a process that would encourage impartiality and objectivity, stakeholders inevitably have their own agendas, be it research interests, passions or particular perspectives. Notwithstanding the APEASE criteria working well, we reflected that it failed to capture the emotion or advocacy that stakeholders felt about the proposals and the potential for that to influence the prioritisation. It could be argued that adding a small ‘e’ for emotion after acceptability, A(e)PEASE, would acknowledge that it is not always possible to be objective in priority setting. Although stakeholders, PMG and Advisory Board members declared any conflicts of interest, this did not mean they ranked the proposals objectively. There is often a tension within stakeholder initiatives between objectivity and passion; however, we designed a transparent process with explicit criteria to allow for challenge if needed. Previous research acknowledges the missing component of emotion in policy deliberation in public health systems from participants with lived experience, and suggests encouraging techniques that support ‘emotional literacy’ in the process [ 23 , 24 ], however researchers and clinicians equally advocate for their areas of work. Arguably, this is not something that future processes can or even should avoid, but recognising it as part of the process and criteria could be important.

The priority setting process designed to select 3-4 projects in the CH&M programme during the Covid-19 pandemic achieved its aim. We had a well-balanced voice from our stakeholders and supported their involvement throughout the process. The use of APEASE criteria as an evaluative tool in the priority setting process was a novel, flexible approach that worked with the methods we selected and could be applicable to other priority setting programmes.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

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Acknowledgements

We gratefully acknowledge the support and valuable contributions of the public representatives in the programme’s PPIE reference group, Advisory Group and Project Management Group: Vicky Palmer, Anouska Cekalovic, Mary Fredlund, Gemma McHutchon, Hina Qureshi, Jane Whitehurst, Tejas Ramanan, Libby Davis, Heather Bolt and Shafiq Ahmed. We would also like to thank the public representatives chairing the prioritisation panels for their time and skilful hosting: Dorcas Akeju, Jane Ring, Rachel Daley and Samantha Russell. We also thankfully acknowledge Amy Coombe for administrative support and the Project Management Group and Advisory Group for their commitment and advice.

This report is independent research funded by the National Institute for Health Research Applied Research Collaboration South West Peninsula and Yorkshire and Humber. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.

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CF and NM wrote the main text of the manuscript. KL, HB, SA, KC, YV also helped draft the manuscript. CF, KL, HB, SA, SB, GB, SL, and VB contributed to the conception and design of the process. All authors read, edited and approved the final manuscript.

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Forbes, C., Morley, N., Liabo, K. et al. Prioritising child health and maternity evidence-based interventions or service models: a stakeholder-driven process. BMC Health Serv Res 22 , 764 (2022). https://doi.org/10.1186/s12913-022-08110-2

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DOI : https://doi.org/10.1186/s12913-022-08110-2

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Effective interventions to ensure MCH (Maternal and Child Health) services during pandemic related health emergencies (Zika, Ebola, and COVID-19): A systematic review

Subrata kumar palo, shubhankar dubey, mili roopchand sahay, kripalini patel, swagatika swain, bijaya kumar mishra, dinesh bhuyan, srikanta kanungo, brajesh raj merta, debdutta bhattacharya, jaya singh kshatri, sanghamitra pati.

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Received 2021 Aug 25; Accepted 2022 Apr 22; Collection date 2022.

This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Introduction

Ensuring accessible and quality health care for women and children is an existing challenge, which is further exacerbated during pandemics. There is a knowledge gap about the effect of pandemics on maternal, newborn, and child well-being. This systematic review was conducted to study maternal and child health (MCH) services utilization during pandemics (Zika, Ebola, and COVID-19) and the effectiveness of various interventions undertaken for ensuring utilization of MCH services.

Methodology

A systematic and comprehensive search was conducted in MEDLINE/PubMed, Cochrane CENTRAL, Embase, Epistemonikos, ScienceDirect, and Google Scholar. Of 5643 citations, 60 potential studies were finally included for analysis. The included studies were appraised using JBI Critical appraisal tools. Study selection and data extraction were done independently and in duplicate. Findings are presented narratively based on the RMNCHA framework by World Health Organization (WHO).

Maternal and child health services such as antenatal care (ANC) visits, institutional deliveries, immunization uptake, were greatly affected during a pandemic situation. Innovative approaches in form of health care services through virtual consultation, patient triaging, developing dedicated COVID maternity centers and maternity schools were implemented in different places for ensuring continuity of MCH care during pandemics. None of the studies reported the effectiveness of these interventions during pandemic-related health emergencies.

The findings suggest that during pandemics, MCH care utilization often gets affected. Many innovative interventions were adopted to ensure MCH services. However, they lack evidence about their effectiveness. It is critically important to implement evidence-based appropriate interventions for better MCH care utilization.

The health of women and children is critical for a happier and healthier world. They have been classified by the World Health Organization (WHO) as an important subgroup of the population that is most vulnerable in a pandemic or a disaster [ 1 ]. Globally, the COVID-19 pandemic has posed a challenge to the health systems leading to a compromise on health care services that embrace maternal and child health (MCH) care. Similar lapses were also witnessed during past health emergencies (Ebola and Zika), implying lessons are to be learned from the present and past epidemics or pandemics [ 2 , 3 ].

In developing countries, ensuring accessible and quality health care to women and children has been an existing challenge, further exacerbated due to pandemics (Zika, Ebola, and COVID-19). Maternal and child health care is affected due to various factors that influence MCH care administration, service provision, and uptake of the services by the beneficiaries (pregnant women, mothers, and children) [ 4 ]. Previous health emergencies like Ebola and Zika have reported a significant increase in the maternal mortality ratio (MMR) due to decreased approach to health facilities and increased risky home deliveries [ 5 ]. The administrator’s focus will likely to shift from MCH care to the pandemic. According to research, health workers in other Sub-Saharan African countries are not well-prepared to treat COVID patients and meet the demands of women during the pandemic [ 6 ]. Research has revealed a knowledge gap regarding the effect of pandemics on maternal well-being, especially in resource-constrained settings where marginalized women often receive poor health care [ 7 ]. A study conducted in low- and middle-income countries (LMICs) has found a declining trend in the utilization of maternal and child health (MCH) services such as institutional delivery, antenatal care (ANC), and child immunization [ 8 ]. These limitations may have severe consequences for women’s health in LMICs during the pandemic [ 9 ].

Furthermore, many pregnant women have found it challenging to access healthcare facilities due to the lockdown and movement limits. Due to lack of transportation, pregnant women in Panama and Zimbabwe have reported trouble getting to a health facility [ 10 , 11 ]. Owing to travel limits and far-flung pharmacies, pregnant women in Zimbabwe had problems finding treatment for their newborns [ 10 ]. Several Indian states have witnessed a decline in institutional deliveries [ 12 ]. There have been incidents of pregnant women giving birth on the road and in ambulances due to lockdown and delays in getting emergency services [ 13 – 15 ].

Although health systems around the globe have implemented extraordinary measures to prevent COVID-19 transmission, such measures have negatively impacted maternal and neonatal health and exacerbated the existing inequalities within societies [ 16 ]. Fighting with health emergencies and maintaining a continuum of care through routine essential services was challenging. The strict pandemic control policies on healthcare infrastructure, societies, and the global economy also affected maternal health [ 17 ]. The need of the situation is to maintain the “continuum of care” aiming at delivering the services to mothers and children through an integrated approach [ 18 ].

With this backdrop, the present systematic review was conducted to assess the impact of health emergencies (Zika, Ebola, and COVID-19) on facility and community-based MCH services utilization and identify various effective interventions or strategies adopted to ensure uptake/delivery of MCH care. This review will offer evidence to key stakeholders at different levels of the healthcare system for developing and implementing a straightforward approach with a context-specific strategic plan to overcome pandemic-related negative consequences on MCH care.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) [ 19 ] guidelines were followed for this systematic review. The protocol for this systematic review was registered in PROSPERO with ID: CRD42021233860.

A comprehensive search was conducted in MEDLINE/PubMed, Cochrane CENTRAL, Embase, ProQuest, Google Scholar, Epistemonikos, and ScienceDirect using a predefined search strategy based on population, intervention/phenomenon of interest, comparator/context, and outcomes ( S1 Data ).

Study selection

Based on predefined inclusion and exclusion criteria, reviewers (SD, SN, SS, and KP) screened the title and abstract of identified studies. Reviewers (SD, SN, SS, KP, and MRS) carried out the full-text screening of potentially relevant studies. The entire study selection was made independently and in duplicate.

Criteria for inclusion/exclusion of studies

Study design and period.

Any quantitative, qualitative, and mixed-method studies irrespective of settings were involved. Studies reporting on access and utilization of antenatal and postnatal services, intrapartum care, referral services, immunization services, and sick child care services were included. However, studies such as reviews, case reports, editorials, commentaries, perspectives, and articles with methodological flaws were excluded. Though grey literature regarding this topic was numerous, we restricted the search to peer-reviewed articles as it signifies that the quality of articles was checked before publication. No limit was applied to the language; non-English studies were handled using Google Translate. All studies published till January 2021 were included in this review.

Population/participants

Pregnant women, mothers, children, and health care professionals.

Intervention(s)/exposure(s)/phenomenon of interest

Any interventions or strategies related to providing or improving MCH services during health emergencies (Zika, Ebola, and COVID-19).

Comparator/context

There was no comparator group. Studies in the context of health emergencies (Zika, Ebola, and COVID-19) were included.

WHO MCH care indicators in alignment with the RMNCH (Reproductive, Maternal, Newborn and Child Health) “Continuum of Care” framework [ 18 , 20 ], such as demand for family planning, antenatal care coverage, institutional deliveries, maternal and perinatal outcomes, postnatal care within two days of birth, immunization services and pediatric health services during health emergencies (Zika, Ebola, and COVID-19) were studied.

Two reviewers (BKM, SKP) resolved the disagreement between authors through discussion to reach a consensus at each screening stage.

Appraisal of studies

The methodological quality of the included studies was appraised using JBI tools (Joanna Briggs Institute) [ 21 ] by the authors (SD, SN, KP, SS, MRS) independently. The quality rating in the included studies that scored > 70% were considered high quality, whereas articles scoring between 40–70% and < 40% were considered moderate and low quality, respectively based on the scores for the individual items as decided with consensus.

Any disagreements were resolved in concordance with the reviewers’ SKP and BKM.

Data extraction, synthesis, and analysis

Reviewers (SD, SN, KP, SS, and MRS) extracted data independently from the included studies and cross-checked it with other reviewers. Data were extracted for the following study characteristics viz. author/year, title, study year, objectives, study type, sample size, study design, study setting, country, participants, method of data collection, pandemic type (Zika, Ebola, and COVID-19), methods of analysis, outcomes (based on RMNCH indicators), results and conclusion.

PICO components of each study were summarized, characterized, and labeled into specific domains (Family Planning, Reproductive, Maternal, Newborn, and Child Health). Descriptive statistics were used to present quantitative data based on their characteristics and availability. The synthesis of the qualitative data was done using thematic analysis. The reviewers independently read and re-read the data line-by-line from the results of the included primary studies. The codes were grouped to generate the descriptive themes, which were further examined, compared, and refined to generate analytical themes. The data coding was done using identified themes with the help of MAXQDA 2020 (Version 20.4.1). The reviewers sorted the data by theme and presented the themes in the form of a table of analysis ( Table 1 ).

Table 1. Qualitative finding analysis.

Search results.

Our rigorous and comprehensive search identified 5643 citations including 107 duplicates. Of 5536 citations, 5436 were excluded during the title and abstract screening. Of included potential articles, 40 were rejected during the full-text screening ( S1 File ). A total of 60 studies were finally included in this review. The same is represented using the PRISMA flow diagram ( Fig 1 ).

Fig 1. PRISMA flow diagram for the study selection.

Study characteristics

Detailed characteristics of included studies are provided in the S2 File . Among included studies, 11 were qualitative, 8 were mixed methods, and 41 were quantitative. The included studies were from high-income countries (n = 23), LMICs (n = 34) and both (n = 3) ( Fig 2 ). Most of the included studies were from the African Region(38%), followed by European Region(25%), Region of the Americas(13%), South-East Asian Region(8%), Western Pacific Region(7%), and Eastern Mediterranean Region(2%) while 7% were not specific to any region ( Fig 3 ). Geographically, included studies were widely distributed across the globe comprising Australia, Cameroon, Chile, China, Colombia, Ethiopia, France, Germany, Guinea, Honduras, Iceland, India, Indonesia, Ireland, Italy, Kenya, Liberia, Nepal, Pakistan, Sierra Leone, Singapore, South Africa, United Kingdom, and the United States ( Fig 4 ).

Fig 2. Distribution of included studies across HICs and LMICs.

Fig 3. Distribution of included studies across WHO regions.

Fig 4. Geographical distribution of included studies.

The included studies were from healthcare facilities (n = 39), community (n = 5), in both facility and community (n = 3), conducted online mode (n = 6), and based on electronic databases or hospital records (n = 7). The targeted population under study included both MCH service beneficiaries and healthcare providers. However, the number of studies targeting beneficiaries (n = 38) was two times higher than that of health care providers (n = 16), and very few considered both groups (N = 6). Although the search retrieved articles published till January 2021, the included articles were published between 2015 and 2021. Out of 60 studies, 39 emphasized the COVID-19 pandemic, while 18 studies focused on the Ebola epidemic and three on the Zika virus epidemic. Twenty-two studies reported on the interventions or strategies employed to ensure MCH services; however, none reported their effectiveness. Thirty-three of sixty included studies were funded.

Assessment on quality of study methodology

The quality of each included study was evaluated for its validity, reliability, and results using JBI tools of critical appraisal which used a range of criteria that measured as being “met” or “not met” or “unclear” or “not applicable” and weighted accordingly. Of 60 studies, 37 were weighted above 70% and categorized as high quality, while 19 studies scored between 40–70% (moderate) and four scored below 40%, thus categorized as of low quality. However, articles rated low quality were not excluded due to the scope of study results. The detailed quality assessment of selected studies is presented in the S3 File .

Insufficient reporting of outcomes (on WHO RMNCH indicators) and no reporting on the effectiveness of identified interventions in included quantitative studies and heterogeneity made it impractical and inapt to conduct a statistical analysis/meta-analysis. Thus, a narrative approach was used to summarize the outcomes of quantitative studies, further complemented by qualitative findings. The findings are presented according to the WHO RMNCH framework.

1. Reproductive health

1 . 1 . Family planning services (FPS) . The utilization of FPS was affected during the unprecedented events, which were quite evident from the included studies. During the Ebola crisis, the utilization of FPS declined by 51% compared to pre-Ebola [ 22 ]. A study mentioned that contraceptives (viz. injectable, oral contraceptive pills, or condoms) and key medications went out of stock during Ebola [ 22 ]. Another study documented that utilization of family planning services declined by 6% during the Ebola outbreak [ 23 ]. Despite a drop in FPS utilization during the early phases of lockdown, a sharp reversal in FPS service uptake during the post-lockdown phase was reported [ 24 ]. Furthermore, distance from the health facility, restricted functioning hours of the facility, long waiting time [ 25 ], restrictions to getting inside the hospitals [ 25 ], and fear of contracting the infection were significant limiting factors for availing FPS.

2. Maternal and newborn health

2 . 1 . Antenatal services (ANC) . Few studies reported the changes in antenatal service utilization during pandemics. The utilization of prenatal services decreased by about 58% during the Ebola pandemic [ 26 – 29 ]. Conversely, 55.5% of expectant mothers said they missed or delayed their antenatal check-ups during COVID-19 [ 30 ]. Three studies revealed that women had attended fewer ANC check-ups than the recommended number during the COVID-19 pandemic [ 30 – 32 ]. Women in the second trimester of pregnancy attended more ANC visits (48%) compared to those in the first and third trimesters of pregnancy (39.5% and 35.2%, respectively) during the COVID-19 pandemic in China [ 33 ]. Inappropriateness in the quality of ANC services was reported by 27.8% of Indonesian women as ANC examination was not performed under the scope of ANC service provision by midwives [ 34 ]. During Ebola, studies indicated a 22% loss in achieving four or more ANC visits in Liberia, while a COVID-19 related study in Ethiopia revealed a 1.8% loss for the same [ 23 , 27 , 30 ]. In India, hampered transportation (50.9% respondents) and fear of infection (33.4% respondents) were primary reasons for missing ANC check-ups [ 32 ]. Similarly, an Ethiopian study found that missed ANC visits were associated with a lack of travel means during lockdown (28%), fear of infection (56.8%), stay-at-home instructions (17%), and redirection of maternal health services/personnel (33%) [ 30 ]. Higher demand for virtual patient consultation during the pandemics was noticed. Another study from China reported that 59.6% of beneficiaries used remote consultation, and 42.2% requested fewer in-person ANC visits [ 33 ]. However, 50% of women used telemedicine in the US, and 10.7% of face-to-face appointments were reduced during COVID-19 [ 35 ]. There were just two studies that looked at how tetanus immunization rates changed among pregnant women during pandemics. During the COVID-19 pandemic, a study in Ethiopia [ 30 ] reported a 38.3% drop in TT 1 st dosage and a 59.6% drop in TT 2 nd dosage; however, during Ebola in Sierra Leone, a 15% dip in TT 2 nd dosage was observed. Similarly, a 28.8% dip was observed in overall TT vaccination during the lockdown in Pakistan [ 36 ].

Likewise, the qualitative findings of the reviewed articles reported a decline in ANC service uptake. This decline was attributed to numerous factors including inadequate information, geographical barriers, high cost of institutional care, dread of infection, a lack of diagnostic services, and shortage of healthcare workers [ 25 , 37 – 46 ]. Beneficiaries in Zika-related studies claimed that they were aware of the potentially harmful effects of the infection on the fetus and preventive measures [ 25 ]. On the other hand, during Ebola and COVID-19, beneficiaries were apprehensive about the transmission of disease and pointed out that the media was disseminating misinformation or excessive information about the pandemic [ 39 , 46 ]. Various misconceptions such as “the deliberate creation of virus by medical workers for financial benefit” or “to create the need for more drugs” [ 37 ] further contributed to people’s mistrust of health workers [ 41 ]. Most of pregnant women were hesitant to visit health facilities for fear of acquiring the infection, thus missing their ANC visits or accessing facilities only in extreme situations [ 41 – 43 , 46 ].

‘‘When you visited the hospital, you saw that they started bringing Ebola patients and this was the reason you started to fear hospitals." [Gizelis et al. 2017]

Studies have also reported that other factors for missing ANC visits were the difficulties in reaching out to health facilities due to the distance and the lack of public transport facilities during pandemics [ 37 , 41 , 44 , 45 ]. Even those who reached the facility faced difficulties accessing the health services as a priority, and preferences were given for COVID activities. The beneficiaries felt that even the health workers were reluctant to touch them for examination [ 40 , 41 , 47 ]. Furthermore, the facilities were not promptly providing diagnostic services to pregnant women [ 44 ].

‘‘No one wanted to touch a pregnant woman, everyone was afraid. So it was a difficult problem" [Gizelis et al. 2017]

Healthcare providers reported insufficient knowledge and training on the usage of personal protective equipment (PPE) during the outbreak. As a result, they were terrified to touch the patients. They also perceived that community members have a low level of trust in healthcare providers [ 39 , 40 ]. Moreover, the frequent changes in hospital protocols during COVID-19 created confusion among the health care providers [ 48 ]. So, they tried to avoid face-to-face consultation and preferred virtual consultation [ 48 ].

2 . 2 . Intrapartum services . A total of 13 studies focused on how the pandemic influenced intrapartum services. Studies from Guinea, Sierra Leone, and Liberia during the Ebola outbreak revealed a dramatic drop in institutional delivery rates between 9% to 20% [ 23 , 27 , 49 – 51 ]. However, there was no variation in the percentages of home births. Conversely, a study found a 62% reduction in institutional delivery during peaks of Ebola in one district of Liberia [ 26 ]. During Ebola, it was reported that under the most conservative scenario, a decrease in utilization of life-saving health services resulted in 3600 extra stillbirths, maternal and neonatal deaths in 2014–15 [ 23 ]. In Guinea, a 14% increase in MMR and a 24% rise in the stillbirth rate are reported during the Ebola epidemic [ 49 ]. A study in Monrovia found no significant differences in the proportions between home and facility deliveries; however, there was a considerable shift from the public (31% decline) to private health facilities (increased to 47%) for deliveries [ 40 ].

Studies reported that institutional delivery rates fell by nearly half during COVID-19 and other pandemics (Zika and Ebola) [ 29 , 32 , 52 ]. In India, there was a 45% decrease in institutional deliveries and a 7.2% increase in high-risk pregnancies, whereas, in Nepal, a 52.4% decrease in facility births was reported. Furthermore, the neonatal mortality rate rose from 13/1000 live births to 40/1000 live births (p = 0.0022), and similarly, the stillbirth rate rose from 14/1000 live births to 21/1000 live births (p = 0.0002) [ 32 , 52 ]. A study conducted in South Africa reported a 47% increase in neonatal in-facility mortality due to disruption of health services during COVID-19 [ 53 ].

The qualitative articles explained the decrease in institutional deliveries and women’s preference for private facilities. According to studies, women living further away from a healthcare facility were less likely to undergo institutional delivery [ 40 , 45 , 49 ]. Furthermore, many government healthcare facilities were closed during the COVID-19 pandemic, which caused them to seek care in private clinics if they could afford it or give birth at home [ 41 ].

"During COVID-19, there were no delivery services in government, so they chose to seek the services at the private facilities. Private facilities received a high number of mothers; therefore, they hiked the charges which most mothers could not afford." (Luignaah et al. 2016)

Many women feared that they would be sent to quarantine centers and face exorbitant treatment costs if they tested positive [ 41 , 45 , 49 ]. The majority of women believed that going to the facility would put them at more risk of contracting the infection, which could harm their baby. Moreover, if they are detected to be COVID-19 positive, they may not deliver their child normally or will be separated from their child [ 41 , 43 , 44 , 46 ]. Another noteworthy finding was a restriction for birth companions to accompany the women during labor [ 42 – 44 , 46 ]. Even for women who visited hospitals, it was studied that due to the “No-touch policy”, the healthcare workers did not use partographs or fetoscopes during labor, jeopardizing the quality of care [ 49 , 54 ]. Other reported attributing factors to the quality of intrapartum care included shortage of qualified staff and basic supplies such as thermometers and gloves [ 39 ] and insufficient or inappropriate size PPE [ 20 , 42 ].

2 . 3 . Postnatal services . The influence of pandemics on postnatal services was evident in three studies. A drop of 13–22% in postnatal attendance was reported in Sierra Leone during the Ebola epidemic [ 23 , 49 ]. On the other hand, it was found that postnatal attendance remained stable during COVID-19 in South Africa [ 24 ].

The qualitative evidence suggests that the decreased utilization of postnatal services was due to poor access to healthcare services, a shortage of healthcare staff in facilities and a short hospital stay [ 42 ]. Postnatal mothers were discharged earlier from health facilities due to fear of infection transmission [ 44 , 46 ]. During the COVID-19 pandemic, postnatal outpatient services were either cancelled or postponed [ 42 ] and, it was substituted with virtual consultation (which was not accessible to all) [ 43 , 42 ].

“The lack of time and staff will lead to mothers and babies going home with very little feeding support or knowledge which will have a short and long term impact on their health and ability to deal with infections” [Semaan et al. 2020]

3. Child health

During the COVID-19 crisis, a significant decrease in acute respiratory infection (ARI) and diarrhea cases were reported among under-5 children. Studies reported a 66–92% decrease in diarrhoea cases, while a 10.3% to 89% decline in ARI was reported [ 22 , 53 , 55 , 56 ]. A drop in utilization of emergency department (ED) services was documented. The reasons for reluctance among parents to consult health services were fear of catching infections, especially in health institutions (96%), strict compliance with confinement (30.7%), and financial difficulties (13.9%) [ 57 ]. A decline of 46% - 83.8% in pediatric ED admission was demonstrated at the pediatric ED during the COVID-19 pandemic [ 51 , 55 , 56 , 58 – 60 ]. A 36% decline in under-5 children consultation was reported during the Ebola outbreak at the primary healthcare level [ 61 ].

3 . 1 . Immunization . A fall in the immunization uptake and reduced compliance with vaccination among parents, was reported due to the COVID-19 crisis [ 31 , 62 , 63 ]. A decline for BCG vaccination reported in the range of 21–56.6% [ 27 , 29 , 36 ], 0.4% to 40% decline in Pentavalent [ 22 , 27 , 62 , 64 ], 51% decline for polio doses [ 27 , 65 ], 5–30% decline in measles first dose [ 53 , 65 ] and 25.6% to 73.6% drop in measles, mumps and rubella uptake were reported irrespective of the settings (public or private) [ 64 ]. Vaccination coverage was stable among a few communities during Ebola due to the doorstep vaccination strategy [ 66 ]. Qualitative findings attributed multiple factors to a decline in immunization uptake. Perceived fear of catching infection affected BCG and Pentavalent vaccination; also women failed to turn up to session sites due to lack of familial support [ 41 ].

"Just near our facility here, we came across a mother who had her child miss the immunization for nine-month because her husband did not allow that to happen." [Lusambili et al. 2020]

Other commonly reported barriers to accessing immunization services included lockdown-related mobility restrictions, inadequate staff, infrastructure, and logistic issues [ 67 ]. In LMICs, barriers were mostly skewed towards vaccine inadequacy, vaccine hesitancy, and calling-off clinics. In high-income countries, fear of contracting COVID-19 and changes in management norms like shifting towards virtual consultations attributed to a decline in vaccine uptake [ 67 ].

Interventions/strategies for MCH services

Various studies reported on implementing interventions ( Table 2 ) or strategies ( Table 3 ) to improve maternal and child health services irrespective of the type of crisis but none of them assessed their effectiveness.

Table 2. Interventions to ensure MCH services with quality care during pandemic related health emergencies (Zika, Ebola and COVID-19).

Table 3. strategies to ensure mch services with quality care during pandemic related health emergencies (zika, ebola and covid-19)..

Telemedicine utilization has been reported to have increased by 22.4% during the pandemic compared to normal situations [ 68 – 70 ]. An upsurge in virtual prescriptions (55.6%) and consultation (127%) was reported from the primary health centers during the COVID-19 crisis compared to normal conditions [ 71 ]. About 79.5% of healthcare providers (HCPs) strongly agreed that telemedicine was a successful technique for contraceptive counseling, with 84% of HCPs agreeing to continue with this technology even after the pandemic [ 68 , 72 ]. Upsurge in telemedicine uptake by the women for various services viz. surgical abortion (41.7%; 2.9% prior to COVID-19), medical abortion (32.1%; 17.1% prior to COVID-19), prenatal care (19.2%; 5.7% prior to COVID-19), contraception (15.4%; 25.7% prior to COVID-19) has been reported [ 69 ]. Patient satisfaction with telemedicine increased by 8.7% for its access, but it decreased for the payment process by 5.3% and infrastructure requirements by 3.4%. Although beneficial, challenges have been reported concerning its mode of functioning, ensuring accessibility to patients, scheduling, and resource requirements [ 73 ].

Telephonic consultation/Telecommunication was reported to be another mode for ensuring MCH care during crises [ 42 , 74 ]. It imparted more comprehensive coverage with less travel, so it was adopted for consultation with lesser hesitancy [ 68 ]. Concern over poor connectivity and injustice among those not acquainted with the technologies were reported for causing disparity in service uptake or delivery [ 68 ]. The unavailability of technology for virtual (video) consultation led to the uptake of telecommunication as an alternative to serving the purpose[ 75 ]. HCPs appreciated and preferred the virtual consultation mode.

"I am currently doing virtual visits and my mommies [clients] are liking it. They are liking that we take them into consideration and not going and spreading germs from one house to the other. Some mommies have shared and voiced that they would not allow me to come to visit them if I came in person because they are not the only family I see.–Home Visitor." [Marshall et al. 2020]

Awareness and educational activitie s during post-Ebola gradually enhanced the number of ANC visits, immunization, and family planning care [ 66 ]. Engaging pregnant women and health care providers in promoting activities sensitized the community to utilize hospital-based care [ 66 ]. To manage the patients’ flow and infection transmission, providers reported a shift in their service delivery methods through rigorously following sanitization measures [ 22 ] and allocating dedicated areas for the infected cases [ 76 ].

Incentivizing and rewarding were suggested by the healthcare workers and community members towards encouraging ANC registration and utilization of facility care during the Ebola epidemic [ 66 ].

Training and engaging the traditional birth attendants [TBAs] for community sensitization and mobilization for institutional care was an important measure, as they were the primary contact point of care and most trusted by the community [ 66 ]. During the Ebola outbreak, TTMS (trained traditional midwives) and TBAs were designated as the primary point of care for pregnant and delivering women, carrying out the majority of births and continuing to do so even after the epidemic was over [ 38 ].

Along with the interventions mentioned above, various other strategies were adopted to ensure MCH services like postponing or cancelling non-essential consultations through triage, reorganizing the flow of patients (to prevent cross-infection) [ 63 , 69 , 70 ], avoiding physical consultation, and practicing virtual consultation [ 43 ]. Visit on appointment was preferred by 87.7% of pregnant women (to avoid crowding), while 59.6% wanted remote consultation and 45.3% wished for joining online maternity schools [ 33 ]. It is estimated that a 50% reduction in kangaroo mother care (KMC) coverage can increase a 2.3% - 4.6% neonatal mortality across 127 nations [ 77 ]. For low birth weight neonates, KMC was recommended, as it is 65 times more beneficial than the risk of death from COVID-19 [ 77 ].

A study [ 48 ] reported that 70.9% of HCPs chose to provide ANC services via video conference/phone. However, 79.1% planned to reduce ANC attendance, 44.6% changed the antenatal screening pathway, 39.9% changed the protocol to speed up post-delivery patient discharge, and 78.4% decided on a dedicated area for COVID-19 positive women’s care. During COVID-19, the length of hospital stay (LOS) was reduced by 30% by expediting early discharge for uncomplicated births (LOS after vaginal birth and cesarean section was 14–24 hours and 23–48 hours, respectively) [ 24 , 78 ]. Qualitative findings suggest suspending of elective gynecological services, reducing post-delivery hospital stay, and restricting ANC meetings as adopted strategies during the COVID pandemic [ 48 ].

Other strategies adopted during the COVID-19 pandemic include strict screening and testing for patients, restricting attendants, virtual follow-up of cases [ 76 ], patient triage, and screening before the appointment [ 43 , 48 ]. In some facilities, signposts were used to guide the patients to screening and triage areas [ 42 ]. Proper staff management used a weekly roster to maintain the rhythm of services by dedicated team and space to keep a check on existing pandemics [ 76 ]. Based on the above interventions and strategies, a framework is developed ( Fig 5 ) for ensuring MCH care during emergencies.

Fig 5. Framework for ensuring quality MCH care services during pandemic related health emergencies (Zika, Ebola and COVID-19).

This review found that all study settings had positive trends in MCH indicators before pandemics despite several unmet goals. However, these improvements were halted and even reversed during the pandemics. A significant decline was observed across all maternal and child-related health services. It was evident from this review that the utilization of MCH services was hampered due to various attributes in the event of pandemics.

Family planning service utilization was disproportionately affected during health emergencies(Zika, Ebola, and COVID-19). The unmet need for family planning services was further exacerbated due to reduced access to family planning methods due to the pandemic. According to the UNFPA report, COVID-19 containment measures were supposed to prevent approximately 47 million women from using birth control methods in 114 LMICs, resulting in 7 million unintended pregnancies [ 79 ]. Hence, to avoid unwanted pregnancies and prevent related maternal mortality and morbidity, each country needs to have a comprehensive health system that ensures family planning services during pandemics. Alternative models of outreach services, such as a home visit by frontline staff, telemedicine, and involvement of private institutions, could be planned, ensuring adequate protection for HCPs [ 80 ]. Disease outbreaks often negatively affect women’s healthcare to a broader extent. According to a systematic review, the increased adverse maternal consequences result from of health system incompetence and their inability to cope with the pandemic [ 81 ]. Thus, it is strongly advised that adequate staffing for MCH care needs to be prioritized. Training and capacity building of frontline workers should be emphasized to provide safe maternity care during emergencies. Moreover, a separate task force should be formulated to keep frontline workers free to provide maternal health services [ 82 ]. Promoting safe and accessible maternity care is essential even during pandemics by having an efficient and sustainable MCH care model to prevent preterm births, stillbirths, and maternal mortality [ 81 ].

A significant drop in utilization of pediatric ED services and immunization services during pandemics is also demonstrated. A decline in ARI and diarrhea cases was found among under-5 children during the pandemic. This significant fall could be attributed to improved hand hygiene practices and reduced outdoor exposure due to lockdown and isolation [ 83 ]. Factors such as limited information about the availability of health services at facilities, prevailing rumors about the pandemic, and fear of contracting the infection reduced the uptake and utilization of routine MCH care [ 5 ]. A study conducted in Pakistan found that around 25,000 polio workers were reallocated to assist with the COVID-19 response [ 84 ]. Similarly, measles immunization campaigns in 23 countries were halted, affecting nearly 80 million eligible children during COVID-19 [ 85 ]. The cessation of immunization may result in the global spread of vaccine-preventable diseases. Vaccinations are time-sensitive, and if children are not vaccinated within the due time, they will miss out on the benefits of lifelong immunity, exposing the whole cohort to vaccine-preventable diseases [ 84 ].

The evidence suggests that telehealth and virtual platforms have the potential to aid in response to large-scale outbreaks and emergencies. Telemedicine was found to have quite a similar impact to face-to-face consultation [ 86 ]. Allowing patients and their families to receive telehealth care at home instead of a healthcare facility has improved access to care [ 87 ]. Telehealth allows patients and clinicians to communicate faster, enabling self-management and modifications to avoid inpatient care and promoting access to care [ 87 ]. However, there may not be sufficient resources for providing telemedicine and virtual patient care at certain medical facilities in some countries. With adequate funding and proper planning, telemedicine could be an instrumental model in the continuity of MCH healthcare services in future emergencies.

Appointment-based visits for routine care reduced the patient loads at the health facilities. Beneficiaries, as well as providers, have shown their acceptance of this strategy. Triage has also been reported to positively influence the utilization and delivery of the services through postponing or canceling trivial patients [ 88 ]. Modifications to existing protocols/guidance for service delivery effectively increase healthcare uptake and service delivery.

Study limitation

Although we tried to explore all available databases, some (CINAHL, Web of Science, others) went unexplored due to limitations to access. Most of the included studies were in the LMICs context; thus, results may be interpreted accordingly. Despite the rigorous review, there was limited evidence on the effectiveness of interventions in the pandemic(Zika, Ebola, and COVID-19) context, which also restricted us from conducting statistical analysis/ meta-analysis.

Policy implication

The study findings have far-reaching implications. Virtual clinics/web-based consultations have emerged as a novel model for treating patients remotely in emergencies like pandemics. As a result, more rigorous studies are required to assess its long-term impact on patients, healthcare workers, and the healthcare system. Moreover, there is a need to rebuild the trust among beneficiaries in health services by addressing their fear of contracting an infection through adequate protection. Building the trust and confidence of mothers (beneficiaries) and the health care workers, addressing transportation-related challenges to health facilities during pandemics are critically important. Governments might also invest in employing more health professionals and incentivize current workers to boost their work efficiency morally for ensuring quality maternal and child health services. Moreover, Community health workers played a pivotal role in providing MCH services even in the event of pandemics. Hence, their training and capacity building should be prioritized.

The provision of MCH services has been an uphill battle globally due to the unique situations created by pandemics. However, it allows us to re-evaluate the lacunae in the service provision of the existing health system. This systematic review highlights that pandemics have negatively influenced maternal and child health services. Nonetheless, virtual consultation, patient triage, and the development of dedicated COVID maternity centers and maternity schools have emerged as new concepts in ensuring continuity of care during emergencies like pandemics. However, there is a need for evidence about their effectiveness. It is critically important to have appropriate evidence-based interventions for better MCH care utilization.

Supporting information

Acknowledgments.

The authors would like to acknowledge Dr. Banamber Sahoo for taking care of data sources. The authors would also like to acknowledge Dr. Snehashish Tripathi, Dr. Subhralaxmi Dwivedi, Subhashree Panda, Aparna Aparajita Dash, Sonam Karna, and Sumit Kumar Dash for their assistance in developing the search strategy and identifying the relevant resources during the review process.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

SP BHU/100/2020/31 United Nations Children's Fund(UNICEF) www.unicef.in The funders had role in decision to publish the manuscript.

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Maternal and Child Health Research

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House Budget Proposal Seeks to Eliminate Healthy Start, a Proven Program to Reduce Maternal and Infant Mortality

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By Kay Johnson

For more than 30 years, the federal Healthy Start program has been investing in community-based solutions to reduce maternal and infant mortality in communities with infant mortality rates at least 1.5 times the U.S. national average. At a time when many are rightly calling for more community and family engagement to reduce maternal and infant mortality, Healthy Start is the only federal program with that explicit design and purpose. Beyond maternal and infant mortality reduction, the goals of Healthy Start include: reducing disparities in access to and utilization of health services, improving the local health care system, and increasing consumer and community input into health care decisions.

Healthy Start was first established as a presidential initiative. I was in the Rose Garden that day in 1991 President George H. W. Bush announced his commitment to reducing infant mortality in communities with elevated risks. Since that time, urban and rural communities across the country have engaged in direct service delivery, care coordination, and community partnerships to reduce risks and deaths. Today, it serves more than 100 communities and nearly 50,000 women, most of whom are Black and Native American/Alaska Native mothers who face 2-3 times the risk of maternal mortality.

Healthy Start has a clear track record of improving the lives of the families it serves. Compared to national averages, Healthy Start clients receive more early prenatal care, more well-woman visits, more screening for depression, more fathers engaged, and more support for family survival and self-sufficiency.

A series of national evaluations and program wide research has found positive impact from focusing on community      engagement to improve access to care using care coordination with individuals. Multiple studies of specific communities point to the impact of Healthy Start on use of prenatal care , access to doula services ,  identification of perinatal depression , increase in breastfeeding initiation, satisfaction with care, reduction in low-birthweight births, and reductions in infant mortality.

The Office of Management and Budget (OMB) has also confirmed that Healthy Start funding is “being used directly and effectively to meet the program’s purpose.” It is also the basis for the design of the “Benefits Bundle” project designed by the OMB and collaborating agencies to connect families of new babies with a bundle of supportive services in the transition to parenthood.

Despite its track record, pending legislation in the House Appropriations Committee proposes to eliminate funding for Healthy Start, which has successfully served moms, babies, and families for decades. Some confusion about Healthy Start versus federal home visiting programs, also funded by HHS’s Health Resources and Services Administration, led lawmakers to consider these cuts. But Healthy Start’s program approach is distinct from the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, with greater emphasis and demonstrated impact on maternal and infant mortality. Whereas home visiting has more impact on child development and parent success, Healthy Start aims to help moms and babies survive and thrive. Even combined the two programs are not reaching nearly the number of families who could benefit. 

In response, a bipartisan letter signed by nearly 100 Members of Congress and sent to the House Appropriations Subcommittee on Labor, Health and Human Services, Education & Related Agencies on April 30, 2024 emphasized the importance of Healthy Start.

“ The Healthy Start program provides funding to support community-based strategies to improve perinatal outcomes for women and children in communities with acute infant mortality rates. […] This approach saves money; promotes equity, as pregnant women respond better to women with the same lived experiences; bolsters employment rates; and serves as a workforce pipeline, making the Healthy Start program a critical component of federal efforts to reduce maternal and infant mortality .”

Another bi-partisan letter signed by 34 Senators and sent on May 14, 2024 to the Senate Appropriations Subcommittee on Labor, Health and Human Services, further emphasized how:

“ In particular, the Healthy Start program seeks to reduce disparities in infant and maternal mortality by empowering women and their families to identify and access maternal and infant health services in their communities. Locally funded Healthy Start programs provide services such as prenatal care, nutrition assistance, and help to connect low-income families with other vital resources .”

In June, the House Appropriations Committee press release said: “ Investments in this bill also support the well-being of the most precious among us: America’s children .” At the same time, the bill proposed to eliminate funding for the Healthy Start program.

In April 2024, HRSA invested $105 million from previous appropriations in the Healthy Start community-based organizations who anchor our nation’s efforts to improve maternal and infant health among those at greatest risk. Stretching from the border area of San Diego County, CA to Flint, MI and Columbus, OH in the Midwest to Macon, GA and Miami, FL in the Southeast, to the Bronx, NY and Boston, MA in the Northeast, the 100+ Healthy Start communities need continued federal funding at the current level of $145 million. Mothers’ and babies’ lives depend upon it. These communities lift up important examples of the kinds of investments and models that can surround Medicaid-covered services and work together to more effectively serve and reach more young families. Healthy Start communities represent our most basic efforts to direct maternal and infant mortality prevention dollars where they are needed. Maternal and infant mortality rates remain at critical levels; now is not the time to undercut communities making a difference. As Congress returns to finish this year’s budget, will it keep this widely lauded program?

Kay Johnson has been a leader in health policy for women, children, and families for 40 years, focusing on Medicaid and MCH policy at the federal and state levels since 1984 and advising more than 45 state health and/or Medicaid agencies. Her work on this analysis of federal maternal health policy was supported by the David and Lucile Packard Foundation.

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A look at maternal health legislation in the 118th congress, congressional appropriations proposals cut maternal health investments, maternal mortality rates decreased in 2022, but disparities persist, ccf.georgetown.edu.