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BackgroundFacility-based childbirth in low-resource settings has increased dramatically over the last two decades, yet quality of care gaps persist and mortality rates remain high. The World Health Organization (WHO) Safe Childbirth Checklist, a quality improvement tool, promotes systematic adherence to practices known to save lives and prevent harm during childbirth. MethodsWe conducted a matched-pair, cluster-randomized controlled trial in 60 pairs o facilities across 24 districts of Uttar Pradesh, India to test the effectiveness of the BetterBirth program, an 8-month coaching-based implementation of the Checklist, on a composite outcome of 7-day maternal/perinatal mortality and maternal morbidity. Outcomes—assessed 8-42 days post-partum—were compared between study arms adjusting for clustering and matching. We also compared birth attendants’ mean adherence to 18 essential birth practices in 15 matched pairs of facilities at 2 and 12 months after intervention initiation. ResultsOf 161,107 eligible women, we enrolled 157,689 (98%) and determined 7-day outcomes for 157,145 (99.7%) mother-newborn dyads. Of 4888 observed births, birth attendants’ adherence to practices was significantly higher in the intervention (I) than control (C) arm (I: 73% vs. C: 42% at 2 months, p≤0.01; I: 62% vs. C: 44% at 12 months, p≤0.01). However, we found no difference in the composite outcome (I: 15.1% C: 15.3%, RR: 0.99, 95% CI: 0.83-1.18, p=0.90). ConclusionThe coaching-based WHO Safe Childbirth Checklist program produced increased adherence to some essential birth practices, but did not reduce morbidity and mortality. (Clinical Trials #NCT02148952; The Bill & Melinda Gates Foundation)

Social marketing is a commonly used strategy in global health. Social marketing programmes may sell subsidized products through commercial sector outlets, distribute appropriately priced products, deliver health services through social franchises and promote behaviours not dependent upon a product or service. We aimed to review evidence of the effectiveness of social marketing in low- and middle-income countries, focusing on major areas of investment in global health: HIV, reproductive health, child survival, malaria and tuberculosis. We searched PubMed, PsycInfo and ProQuest, using search terms linking social marketing and health outcomes for studies published from 1995 to 2013. Eligible studies used experimental or quasi-experimental designs to measure outcomes of behavioural factors, health behaviours and/or health outcomes in each health area. Studies were analysed by effect estimates and for application of social marketing benchmark criteria. After reviewing 18 974 records, 125 studies met inclusion criteria. Across health areas, 81 studies reported on changes in behavioural factors, 97 studies reported on changes in behaviour and 42 studies reported on health outcomes. The greatest number of studies focused on HIV outcomes (n = 45) and took place in sub-Saharan Africa (n = 67). Most studies used quasi-experimental designs and reported mixed results. Child survival had proportionately the greatest number of studies using experimental designs, reporting health outcomes, and reporting positive, statistically significant results. Most programmes used a range of methods to promote behaviour change. Programmes with positive, statistically significant findings were more likely to apply audience insights and cost-benefit analyses to motivate behaviour change. Key evidence gaps were found in voluntary medical male circumcision and childhood pneumonia. Social marketing can influence health behaviours and health outcomes in global health; however evaluations assessing health outcomes remain comparatively limited. Global health investments are needed to (i) fill evidence gaps, (ii) strengthen evaluation rigour and (iii) expand effective social marketing approaches.

Although maternal and child mortality are on the decline in southeast Asia, there are still major disparities, and greater equity is key to achieve the Millennium Development Goals. We used comparable cross-national data sources to document mortality trends from 1990 to 2008 and to assess major causes of maternal and child deaths. We present inequalities in intervention coverage by two common measures of wealth quintiles and rural or urban status. Case studies of reduction in mortality in Thailand and Indonesia indicate the varying extents of success and point to some factors that accelerate progress. We developed a Lives Saved Tool analysis for the region and for country subgroups to estimate deaths averted by cause and intervention. We identified three major patterns of maternal and child mortality reduction: early, rapid downward trends (Brunei, Singapore, Malaysia, and Thailand); initially high declines (sustained by Vietnam but faltering in the Philippines and Indonesia); and high initial rates with a downward trend (Laos, Cambodia, and Myanmar). Economic development seems to provide an important context that should be coupled with broader health-system interventions. Increasing coverage and consideration of the health-system context is needed, and regional support from the Association of Southeast Asian Nations can provide increased policy support to achieve maternal, neonatal, and child health goals.