Pregnancy support grant, MASCOT and Wotro

1. Pregnancy support grant, MASCOT and Wotro Ashar Dhana, Elinor Kern, Loveday Penn-Kekana, Josephine Kavanagh, Matthew Chersich, Priya Mannava, Siphiwe Thwala Mascot study group Wotro study group

2. Maternity and early child support grant: Research methods • Desktop review: systematic review of models and evidence of impact • Analysis of population-level data (GHS 2010) • In-depth interviews with pregnant women and policy makers (n=33) • Summary of strategic case, policy options and cost • Identify research gaps, respond

3. Income and expenditure in pregnancy • Formal sector aware of effects of pregnancy on income (equity: only 25% pregnant women had income) • Pregnancy physically restricts ability to work, as does breastfeeding & childcare • Many asked to leave job, employers reluctant to hire them • Nationally, pregnant women 2.8-times less likely to have own income than other adults • Most pregnancies unplanned, can’t prepare for rapid changes of pregnancy, financial implications: • higher food needs, transport to health facility • preparation for newborn, needs of other children

4. Problem statement In already vulnerable women, earnings reduce, at a time when needs increase markedly; Heightened dependence on partners and families, mostly inconsistent or disempowering, conflict is common

5. Increased volume and range of foods required for healthy pregnancy BUT high food insecurity: • 35% of pregnant women live in households which ran out of money for food in past year, 37% of whom had this ≥5 times in past month (GHS) • 25% of pregnant women live in households that experienced food insufficiency with hunger in past year, 1 in 20 experienced this often or always • A third of pregnant women limited food variety due to resource constraints • In interviews, poor respondents had very limited diet range

6. International experience • 30 countries, about 40 programmes that specifically include pregnant women (13 only for pregnant women and newborns) • Half CCTs, rest mostly targeted at poor • Many multifaceted, attempt to link support to counselling or ANC/SBA attendance • Mostly not pregnancy alone, also cover childbirth and postpartum; or as general support for vulnerable families or children

7. Evidence of impact of MEC support IMPACT INPUTS ACTIVITIES OUTPUTS OUTCOMES

8. WOTRO: MH and Health systems • Main Focus Comparing Rwanda to South Africa, four years (2012-2016) • Four sub-projects run concurrently: • Systematic review (all LMIC) • Realist review (selected sub-Saharan countries); • Case studies in Gauteng and EC; • Interventional research

9. Maternal health and systems • Key causes of maternal deaths can only be addressed by improving health systems • EmOc requires coordinated inputs, a wide range of professionals, and access to different levels of care • Underlying organisational & system weaknesses responsible for deaths vary between settings Much unknown about how health systems’ knowledge can be applied to improve maternal health Assumption: MH would be improved if programme and policy leaders focused on system interventions

10. Research questions • Broadly, which health system interventions were prioritised in countries that achieved rapid declines in maternal mortality? • How do policy leaders and maternal health programme staff conceptualise interactions between the health system building blocks and maternal health? • What system interventions can improve MH (Rwanda, South Africa and case studies) Hypothesis: Identifying the health system components that were responsible for improving maternal health in sub-Saharan Africa, and applying these, would optimise future initiatives to improve maternal health

11. Rationale • Little known about optimising performance of health services, one of the worlds biggest and most important industries • Maternal health initiatives do not draw sufficiently on health systems knowledge, a missed opportunity • Health systems priorities for improving maternal health are poorly defined, and health systems frameworks seldom applied in maternal health • Maternal health has improved in many countries, at different rates, and worsened in others: the system factors that account for this should be identified The solution is too strengthen systems, but what does that mean practically: which aspects of the system are most important, and have positive effects on other blocks?

12. Health systems definition in review: 6 WHO Building Blocks 1. Service delivery: packages; delivery models; infrastructure; management; safety, quality, integration of care; adherence to treatment protocols; standards; licensing; certification; & accreditation 2. Health workforce: national workforce policies & investment plans; advocacy; norms, standards and data; and training. 3. Information: facility & population based information & surveillance systems; global standards, tools 4 Medical equipment, infrastructure, products, vaccines & technologies: norms, standards, policies; reliable procurement; equitable access; quality 5. Financing: national health financing policies; tools and data on health expenditures; costing; risk sharing/pooling; insurance; protection; & purchasing 6. Leadership and governance: health sector policies; harmonization and alignment; oversight and regulation; and support services such as standards and norms PLUS • Demand-side interventions, including community education; community needs, involvement, participation, responsiveness ; and male involvement • We will also assess relationships between the individual building blocks items (listed as 1-6 above) and how these components interact with each other, and with patient demand.

13. Partners Academic Medical Center, University of Amsterdam & Amsterdam Institute for Global Health and Development (AMC/AIGHD), The Netherlands Gauteng Province, Department of Health Human Rights Watch (HRW), Kenya Ministry of Health, Maternal and Child Health, Rwanda National University of Rwanda (NUR), Butare, Rwanda Nijmegen International Center for Health Systems Research and Education, Radboud University, Nijmegen Medical Center, The Netherlands School of Public Health, University of the Western Cape Society of Midwives South Africa (SOMSA)

14. MASCOT: MCH inequities and research systems • EU FP-7 project 2011-2014 • Collaboration between Africa, Europe and Latin America (12 countries) • Multilateral Association for Studying Health Inequalities and Enhancing North-South and South-South Cooperation • Map of MCH inequalities (DHS-type data) • Research systems tackling MCH inequities • SR of interventions to tackle MCH inequities

17. PROGRESS-Plus • This acronym defines disadvantage, the key nexus of social stratification. • Categories are: Place of Residence, Race/Ethnicity, Occupation, Gender, Religion, Education, Socioeconomic Status, and Social Capital, and Plus represents additional categories such as Age, Disability, and Sexual Orientation. • Acronym used by the Campbell and Cochrane Equity methods Group and the Cochrane Public Health Review Group.

18. Systematic review • Why not narrate?

19. 2-STAGE SYSTEMATIC REVIEW FOR WOTRO and MASCOT STAGE 1 Finalise protocol for Stage 1 Search databases, upload references Screen on title/abstract, applying broad inclusion criteria Map evidence on health systems interventions for MH Prioritise in-depth review topics STAGE 2 Several in-depth SRs (standard PICO SR except: no screening and you know how many studies there are) Apply inclusion criteria of each PICO to studies included from stage 1 Full data extraction, quality appraisal Narrative synthesis/Grade table/Meta-analysis (very unlikely)

20. 2 STAGES AND MIXED METHODS APPROACH STAGE 1: PROTOCOL and SCREEN STAGE 1: MAP of AVAILABLE STUDIES STAGE 2: SEVERAL PICO PROTOCOLS • CLASSIC SYSTEMATIC REVIEW • Quality appraisal extraction • Data extraction • Narrative synthesis/Grade table • REALIST REVIEW • Quality appraisal extraction • Data extraction • Meta-ethnography/narrative synthesis CROSS-STUDY SYNTHESIS?

22. Search filters and limits • Filters • Maternal health • LMICs • Limits • Dates 2000-2012 • Humans only • Search • CINAHL, EMBASE, Popline, PsycINFO, PubMED, Web of Knowledge, LILACS (+/-34,000 titles/abstracts after duplicates removed)

23. Stage 1 Review parameters • MH (pregnancy, childbirth, postpartum, including adolescents and abortion) • Health system interventions, multiple interventions, tracer conditions • Languages: English, French, Japanese, Portuguese, Spanish • Any study design (quantitative and qualitative) • Dates 2000-2012

24. Rationale • Little known about optimising performance of health services, one of the worlds biggest and most important industries • Maternal health initiatives do not draw sufficiently on health systems knowledge, a missed opportunity • Health systems priorities for improving maternal health are poorly defined, and health systems frameworks seldom applied in maternal health • Maternal health has improved in many countries, at different rates, and worsened in others: the system factors that account for this should be identified The solution is too strengthen systems, but what does that mean practically: which aspects of the system are most important, and have positive effects on other blocks?

25. INCLUSION CRITERIA: INFORMATION IN SYSTEMATIC MAP • Include Interventional Topic (multiple-response) • Health systems (and studies of multiple-clinical interventions) • Community-based interventions • Maternal HIV/STIs • Maternal malaria • Maternal BP/Hypertension • Antepartum postpartum haemorrhage • Pregnancy sepsis • Include Other • Service utilisation

26. EXCLUSION CRITERIA: INFORMATION IN MAP • On title or abstract, and reason (hierarchy approach: only highest applicable item on list): • Languages other than English, French, Japanese, Portuguese, Spanish • Publication pre-2000 • Population not maternal health • No intervention • Single clinical intervention (other than the 5 selected tracer conditions) • Not LIMC • Not research (opinion pieces)

27. Operationalising WHO building blocks & demand definition Studies reporting outcomes of: health systems interventions for improving maternal health; other multiple/complex interventions for improving maternal health; health services research; organisation of care interventions; outcomes of national or district-level maternal health programmes, including socio-economic interventions, such as improving water supply. Include general health systems strengthening interventions (such as building more PHC clinics), but that measure effects of such interventions on MH. Include single health system interventions (exclude single clinical interventions) Interventions around TBAs are included (human resources building block). Comparisons of different indicators of maternal health are included (information building block). Assessment of outcomes of implementing clinical practice guidelines or similar guidelines are included. Descriptions of clinical guidelines without any process or impact outcomes are excluded.

28. Maternal health definition in review • Classified as pregnancy, childbirth and the postpartum period (defined as the first two years after childbirth). Fertility treatment is excluded. Only family planning services specifically provided for women in the postpartum period will be included, not other family planning services. Women of all ages included in review, including adolescents

29. Community-based interventions Interventions delivered in community settings (any activities occurring outside of health facilities) are included provided they describe some outcome (including process/uptake outcomes), even delivery of single clinical interventions

30. Pre-specified single clinical interventions, as tracer conditions • Key health system lessons will be drawn from study of the effectiveness of interventions for these tracer conditions, and how such effectiveness varies across settings. • For example, the review team will compare the health system requirements of malaria versus PMTCT. The conditions considered tracers in this review are those addressing maternal: HIV/STIs (including PMTCT); malaria, hypertension, haemorrhage and pregnancy sepsis. • Outcomes of interventions must be described (even process or uptake outcomes, any outcome).

31. Search terms X

32. Stage 1: Mapping inclusion criteria in screening X

33. End in mind: Stage 2 In-depth reviews • Equity-framed systematic reviews of effectiveness of health systems interventions for MCH • Only certain MCH outcomes, or building blocks or tracer conditions • Updating of existing reviews, adopting an ‘equity lens’ • Country- or region-specific reviews • Methodology articles:Methods of assessing equity in coverage reports

34. Examples of Stage 2 themes • Can MH be improved through interventions to strengthen health system building blocks, or to enhance patient demand? Which building blocks (one review per block)? • Are some health system interventions more effective than others in particular contexts? (equity effects)

35. Stage 2 PICO examples • Effectiveness of male involvement in MH • Effectiveness of health financing in enhancing patient demand for MH services • Review of equity effects of interventions to increase skilled birth attendant use • Methodology reviews: Sum methods used to measure socio-economic status in MH studies, comparing Latin America to Africa • .... We open to review questions, sharing database etc.

36. For each Stage 2 PICO we will define • Research question • Inclusion criteria • Types of study design and participants • Exclusion criteria, including languages • Types of interventions to be compared • Outcome measures • Quality appraisal

37. Progress and timelines • Seven databases searched, duplicates removed • Codes piloted and protocol finalised • Codes applied in duplicate (+/-15,000 of about 32,000 unique items) • To complete screening end January 2013 • Clean database and map end Feb 2013 • Stage 2 begins March 2013

38. Review timelines

39. Review so far

41. Have not yet completed reconciling of discordancies of all screened items