Background and rationale: Good-quality obstetric and newborn care in health facilities is central to reducing maternal and neonatal deaths and stillbirths, as well as improving the future health of women and children. Institutional births have increased dramatically across the globe, but the places where births occur vary enormously and are poorly understood. Simply increasing institutional delivery coverage is very unlikely to reduce mortality if facilities lack basic requirements for emergency obstetric & neonatal care, have inadequate staffing, or cannot refer in emergencies.
In many parts of sub-Saharan Africa, births have mostly increased in facilities with lower capacity to handle obstetric emergency, low birth volume, or both. Lower quality of obstetric care and lack of emergency capabilities in such facilities has led some to recommend a policy of hospital births for all, though there is no global consensus. More evidence is needed to determine the best balance of childbirth care services across primary to tertiary levels to adequately provide life-saving and respectful childbirth care. A study involving 22 countries in sub-Saharan Africa is being conducted as part of the Countdown to 2030 phase III to generate evidence that will inform national and global decisions on future MNH strategies.
Research questions and study design:
- Where do women give birth, by what mode (vaginal or caesarean section), who attends them, by facility sector/volume/level, nationally, regionally, and by socio-economic group (DHS/MICS and HMIS data)?
- What are the health outcomes (neonatal mortality, stillbirths) by facility sector/volume/level, nationally, regionally, by socio-economic groups (DHS/MICS & HMIS)?
- What are facilities’ levels of readiness and accessibility to conduct routine deliveries and basic and comprehensive emergency obstetric and newborn care (health facility assessments and linked census or geospatial data)?
- What are the intended and actual health policy and system characteristics (e.g. organization of services, resources, quality service delivery, financing and information) in place for the provision of routine and emergency childbirth care (documents and health systems data)?
- To what extent do countries with higher levels of safe, effective, equitable, ready and accessible childbirth care have favourable MNH-related policy and systems characteristics, and where are adjustments or additions needed in future strategies to improve maternal and newborn outcomes?
Participating countries: Burkina Faso, Cameroon, Chad, Democratic Republic of Congo, Côte d’Ivoire, Ethiopia, Ghana, Guinea, Kenya, Liberia, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Uganda, Zambia, Zimbabwe
Core analyses will be conducted in Phase 1 in all 22 countries using DHS/MICS, HMIS and policy/health systems documents/data. Expanded analyses will be undertaken in Phase 2 in select countries that have SARA/SPA/health facility assessment, GIS, and other health systems data.
Planned outputs: Reports on MNH delivery strategies (each country), tools for MNH data analysis using multiple data sources, joint scientific paper (cross-country), additional country papers on select results, disseminations to inform reviews
Background and rationale - Place of residence is a major determinant of key reproductive, maternal, neonatal and child health outcomes, with those living in rural areas traditionally having worse health outcomes than those in urban areas. In recent years, many countries in sub-Saharan Africa have seen massive rural to urban migration, mostly to the capital cities. As a result, there has been a surge in informal settlements, accompanied by a decline in previous improvement of essential intervention coverage and child mortality in urban areas. The latest United Nations estimates indicate that 54% of the sub-Saharan urban population lives in informal settlements. Deceleration in urban intervention coverage, along with the projection that close to half of the population in sub-Sahara Africa will be urban by 2030, called for action to produce evidence addressing coverage trends and inequities in large cities.
Research questions and participating countries: Part One – Countdown collaborations in 14 countries conducted secondary analysis of survey and health facility data to analyze coverage trends, inequities, health services and utilization related to maternal, newborn and child health. The cities included were Accra, Ghana; Lusaka, Zambia; Dakar, Senegal; Bamako, Mali; Ouagadougou, Burkina Faso; Kampala, Uganda; Nairobi, Kenya; Dar es Salaam, Tanzania; and Addis Ababa, Ethiopia.
Research questions and participating countries: Part Two – Primary data were collected in four cities: Nairobi, Lusaka, Ouagadougou and Dakar. In Nairobi, Lusaka and Ouagadougou, the study objective was to evaluate the quality of maternal and newborn health services available to the urban poorest populations living in slums and informal settlements, specifically focusing on experience of person-centered maternity care, and readiness of facilities to offer essential maternal and newborn health services. In Dakar, the aim was to assess the spatial and financial accessibility of cesarean sections among urban slum dwellers.
Some papers from this study have been published in the Journal of Urban Health, while others are still in peer review. The papers published so far are:
Sy and co-authors (2024) Spatial and Socioeconomic Inequalities in Cesarean Section Deliveries in Urban Settings in Dakar, Senegal
Kananura and co-authors (2024) Deprivation and Its Association with Child Health and Nutrition in the Greater Kampala Metropolitan Area of Uganda
Kagoye and co-authors (2024) High Child Mortality and Interventions Coverage in the City of Dar e Salam, Tanzania: Are the Poorest Paying an Urban Penalty?
Wehrmeister and co-authors (2024) Identifying and Characterizing the Poorest Urban Population Using National Household Surverys in 38 Cities in Sub-Saharan Africa
Blumenberg and co-authors (2023) Coverage, Trends and Inequalities of Maternal, Newborn and Child Health Inidicators among the Poor and Non-Poor in the Most Populous Cities from 38 Sub-Saharan African Countries
Dwomoh and co-authors (2023) Impact of Urban Slum Residence on Coverage of Maternal, Neonatal, and Child Health Service Indicators in the Greater Accra Region of Ghana: an Ecological Time-Series Analysis, 2018–2021
Countdown previously analyzed whether the Covid-19 pandemic impacted utilization of maternal and child health services in 12 African countries. Those results were published in 2022. Current research is focused on three countries - Brazil, Peru and Bangladesh.
Background and rationale - The disruptive effects of the Covid-19 pandemic on health systems, both delivery and utilization of health services, have been recognized as a global threat to maternal and child health. This predominantly affects vulnerable population groups including women, newborns, children and older people, particularly in low resource settings.
The COVID-19 pandemic has further highlighted the need to make health services equitably available. This study will generate evidence to inform national and global decisions on future strategies to maintain the delivery and utilization of essential MNCAH services and prevent disruptions in health services due to COVID-19.
Research questions and participating countries: Researchers in Brazil, Peru and Bangladesh, are studying the impact of the Covid-19 pandemic on mortality and maternal, neonatal and child health (MNCH) service utilization. Analysis will be conducted using interrupted time series modeling to compare the pre-Covid period (2017-2019) to during Covid (2020-2021).
Planned outputs: Findings from the study will be reported in a supplement of papers for a forthcoming issue of the Journal of Global Health.
Background and rationale - Immunization is one the most cost-effective and safest method to curb the spread of communicable diseases and reduce neonatal and child morbidity and mortality. In addition to offering protection from preventable diseases, immunization facilitates contact between families and health systems, providing a channel for the delivery of other basic health services. Ensuring universal access to vaccines is a critical entry point for universal health coverage (UHC). However, disparities in vaccine coverage and childhood mortality continue to persist. In 2021, globally approximately 25 million children did not receive basic vaccinations. The sub-Saharan African region has the highest under-five mortality rate globally, and basic childhood vaccination coverage remains low in many countries.
Research questions and participating countries:
A study involving 25 countries in sub-Saharan Africa will strengthen country analytical capacity in immunization coverage and equity; will support the generation of the best possible estimates of immunization coverage at national and subnational levels and produce in-depth analyses that help to build the understanding of progress and target un- and under-immunized populations. The participating countries are:
Eastern and Southern Africa (12): Ethiopia, Kenya, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, Zimbabwe, Somalia, South Sudan, and Madagascar.
West and Central Africa (13): Burkina Faso, Cameroon, Chad, Cote d’Ivoire, Democratic Republic of Congo, Ghana, Guinea, Liberia, Mali, Niger, Nigeria, Senegal, and Sierra Leone.
Planned outputs:
Enhanced country analytical capacity for coverage and equity of immunization in public health institutions and ministries of health (MOH)
Improved quality of country annual report on immunization coverage and equity, using all data sources, with a focus on subnational levels, that can be used to inform country, regional and global (WUENIC) monitoring of progress (all countries in 2024 and again in 2025)
This study is still in the planning phase and will be conducted in collaboration with Track20. Some planned analyses include:
- Subnational analysis with the Survey-based Women's emPowERment index ( SWPER) as indicator of contextual empowerment or social norms and explore differences in mDFPS across wealth and age groups.
- Contraceptive prevalence among young unmarried women.
- Method mix and choice and its relationship with women’s empowerment.
- Intimate partner violence and how it relates to family planning method discontinuation and coverage
- Local family modeling with survey data to identify vulnerable populations.