BackgroundWhile there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking.MethodsWe reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality.ResultsMaternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed.ConclusionsHealth workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

Decisions made at the household level, for example, to seek antenatal care or breastfeed, can have a direct impact on the health of mothers and newborns. The SMART Community-based Initiatives program in Egypt worked with community development associations to encourage better household decision-making by training community health workers to disseminate information and encourage healthy practices during home visits, group sessions, and community activities with pregnant women, mothers of young children, and their families. A quasi-experimental design was used to evaluate the program, with household surveys conducted before and after the intervention in intervention and comparison areas. Survey questions asked about women’s knowledge and behaviors related to maternal and newborn care and child nutrition and, at the endline, exposure to SMART activities. Exposure to program activities was high in intervention areas of Upper Egypt: 91% of respondents reported receiving home visits and 84% attended group sessions. In Lower Egypt, these figures were 58% and 48%, respectively. Knowledge of danger signs related to pregnancy, delivery, and newborn illness increased significantly more in intervention than comparison areas in both regions (with one exception in Lower Egypt), after controlling for child’s age and woman’s education; this pattern also occurred for two of five behaviors (antenatal care visits and consumption of iron-folate tablets). Findings suggest that there may have been a significant dose-response relationship between exposure to SMART activities and certain knowledge and behavioral indicators, especially in Upper Egypt. The findings demonstrate the ability of civil society organizations with minimal health programming experience to increase knowledge and promote healthy behaviors among pregnant women and new mothers. The SMART approach offers a promising strategy to fill gaps in health education and counseling and strengthen community support for behavior change.

Optimal nutrition is critical to the attainment of healthy growth, human capital and sustainable development. In Egypt, infants and young children face overlapping forms of malnutrition, including micronutrient deficiencies, stunting and overweight. Yet, in this setting, little is known about the factors associated with growth during the first year of life. A rise in stunting in Lower Egypt from 2005 to 2008 prompted this implementation research study, which followed a longitudinal cohort of infants from birth to 1 year of age within the context of a USAID‐funded maternal and child health integrated programme. We sought to determine if growth patterns and factors related to early growth differed in Lower and Upper Egypt, and examined the relationship between weight loss and subsequent stunting at 12 months of age. Growth patterns revealed that length‐for‐age z‐score (LAZ) decreased and weight‐for‐length z‐score (WLZ) increased from 6 to 12 months of age in both regions. One‐quarter of infants were stunted and nearly one‐third were overweight by 12 months of age in lower Egypt. Minimum dietary diversity was significantly associated with WLZ in Lower Egypt (β = 0.22, P < 0.05), but not in Upper Egypt. Diarrhoea, fever and programme exposure were not associated with any growth outcome. Weight loss during any period was associated with a twofold likelihood of stunting at 12 months in Lower Egypt, but not Upper Egypt. In countries, like Egypt, facing the nutrition transition, infant and young child nutrition programmes need to address both stunting and overweight through improving dietary quality and reducing reliance on energy‐dense foods.

No abstract