Lassi et al.

Reproductive Health 2014, 11(Suppl 1):S1

http://www.reproductive-health-journal.com/content/11/S1/S1

REVIEW Open Access

Essential interventions for maternal, newborn and

child health: background and methodology
Zohra S Lassi, Rehana A Salam, Jai K Das, Zulfiqar A Bhutta*

Abstract
Worldwide, 250,000–280,000 women die during pregnancy and childbirth every year and an estimated 6.55 million
children die under the age of five. The majority of maternal deaths occur during or immediately after childbirth,
while 43% of child death occurs during the first 28 days of life. However, the progress in limiting these has been
slow and sporadic. In this supplement of five papers, we aim to systematically assess and summarize essential
interventions for reproductive, maternal, newborn and child health from relevant systematic reviews. This paper is
an introductory paper detailing the background and methodology used for grading interventions. The following
three papers summarize the evidence on essential interventions for pre-pregnancy, pregnancy, childbirth, postnatal
(mother and neonatal) and child heath while the last paper describes the essential interventions as per the level of
health care delivery and their proposed packages of care.

Why maternal, newborn and child health? haemorrhage being the main medical cause of death.
Poor maternal, newborn and child health care remains a Hypertensive diseases, infections, obstructed labour, and
significant problem in low and middle income countries abortion-related complications are the other causes of
(LMICs). Worldwide, 250,000–280,000 women die dur- maternal mortality. The maternal mortality ratio is
ing pregnancy and childbirth every year [1] and an esti- approximately 500 per 100,000 live births in sub-Saharan
mated 6.55 million children die under the age of five [2]. Africa, compared to around 150 per 100,000 live births in
The majority of maternal deaths occur during or immedi- South Asia and 16 per 100,000 live births in HICs [1].
ately after childbirth. A child’s risk of dying is highest Furthermore, the main direct causes of neonatal mortal-
during the first 28 days of life when about 3.5% of under- ity and morbidity are infections, complications arising
five deaths take place, translating into 2.85 million deaths from preterm birth, and intrapartum-related neonatal
[2]. Up to one half of all newborn deaths occur within deaths, which account for nearly 80% of all neonatal
the first 24 hours of life and 75% occur in the first week. deaths globally [4]. Almost (99%) all maternal, newborn,
Children in LMICs are nearly 56 times more likely to die and child deaths occurs in LMICs, unquestionably,
before the age of five than children in high-income coun- appropriate interventions along with appropriate health
tries (HICs) [2]. resources in these countries have significant potential for
Good maternal health care and nutrition are important reducing the burden of maternal and child mortalities
contributors to child survival; maternal infections and [5,6]. Although substantial progress has been made
other poor conditions often contribute to indices of neo- towards achieving the Millennium Development Goals
natal morbidity and mortality (including stillbirths, neo- (MDGs) 4 and 5, the rates of decline in maternal, new-
natal deaths and other adverse clinical outcomes) [3]. born and under-five mortality remain insufficient to
Considering the fact that most maternal and child deaths achieve these goals by 2015 [3]. Furthermore, progress is
are preventable using current knowledge, the burden of marked by larger inequities, not only across regions and
mortality and morbidities is unacceptably high. The countries, but also within countries where maternal and
majority of maternal deaths occur during labour, delivery, child mortality rates and health care indicators differ sub-
and the immediate postpartum period, with obstetric stantially by geographic location (higher in rural areas
versus urban areas) as well as by socioeconomic status.
While many factors contribute to maternal and neonatal
* Correspondence: zulfiqar.bhutta@aku.edu
Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
deaths, one of the effective means of reducing this burden
© 2014 Lassi et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Lassi et al. Reproductive Health 2014, 11(Suppl 1):S1 Page 2 of 7
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is provision of effective preventive measures or early treat- and therapeutic interventions for the management of diar-
ment provided to women and newborns, often at their rhoea and pneumonia can save a major portion of these
home or in primary health care settings. Worldwide 50 preventable under-five deaths. According to the recent
million births take place at home without a skilled birth estimates, scaling up of these key evidence-based interven-
attendant (SBA) [7]. The rates of no access to skilled birth tions coverage to at least 80% and that for immunization
care and emergency obstetric care are higher in LMICs to at least 90%, can eliminate 95% of diarrhoea and 67% of
where majority of deaths and morbidity related to compli- pneumonia deaths in children younger than 5 years by
cations of childbirth take place [8]. Skilled attendance at 2025 at a cost of $6·715 billion [12].
birth remains particularly low in sub-Saharan Africa and The current burden of maternal, neonatal and child
southern Asia and there are wide disparities within coun- mortalities, heavily concentrated in LMICs, is especially
tries, across socio-economic status, geographic location, grave in the light of existing simple, cost-effective and low-
and educational status. In sub-Saharan Africa, women are technology interventions. Interventions and strategies for
alone, with no attendant in more than half of home births improving reproductive, maternal, newborn and child
while in South Asia, around one-third of home births are health care (RMNCH) and survival are closely related and
without traditional birth attendants. Therefore, effective must be provided through a continuum of care approach.
interventions and improved coverage in low-resource set- When linked together and included as integrated pro-
tings have an enormous potential to avert maternal and grams, these interventions can lower costs, promote
neonatal deaths. Haemorrhage, contributing to 35% of greater efficiencies, and reduce duplication of resources.
maternal deaths, rapidly leads to death without interven- However, few efforts have been made to identify synergies
tion, but with simple interventions like blood transfusions, and integrate these interventions across the continuum of
oxytocics to prevent bleeding, and/or manual removal of care. Despite of the existing plethora of knowledge, there
the placenta by a SBA, severe bleeding can be averted in is a lack of consensus on how best to move forward in a
time to prevent mortality [6,9]. Similarly, access to antena- coordinated manner so as to achieve progress towards the
tal health visits and medicines can prevent death from MDG’s. Furthermore consensus is also needed on the level
hypertensive disorders, while death due to sepsis can be of evidence [3]. The foremost aim of this global review is
averted by screening for prenatal maternal infection and to compile existing evidence on the impact of various
sexually transmitted infections (STIs) during antenatal vis- maternal, newborn and child interventions on the major
its and with hygienic infection control measures during causes of maternal, newborn and under five deaths. The
birth provided by SBA. Other direct causes of maternal specific objectives of this review were to serve as a first
deaths, including obstructed labour, complications of step towards: developing consensus on the content of
anaesthesia or caesarean section, and ectopic pregnancy, RMNCH packages of interventions at each level of the
can be prevented with access to antenatal care, skilled health system across the continuum of care; facilitating the
birth attendance, and basic and comprehensive emergency scaling-up of these interventions; and identifying research
obstetric care. gaps in the content of core packages of interventions.
Interventions to avert maternal mortalities can also pre-
vent neonatal deaths; evidence suggests that 77% of all Methodology
neonatal deaths occurs where the coverage of skilled birth Search strategy
attendance is 50% or even less [10]. Hygienic births A total of 142 RMNCH interventions were identified,
through skilled birth attendance can largely prevent neo- assessed and selected for this review, based on current
natal infections through simple treatments such as cleans- World Health Organization (WHO) recommendations
ing of the umbilical cord, and promotion of early and contained in the following publications: Guidelines on HIV
exclusive breastfeeding. Furthermore, providing birth and Infant Feeding (2010) [13]; Integrated Management of
attendants with simple equipment and training is a low- Childhood Illness (2008) [14]; Integrated Management of
tech, low-cost opportunity to prevent neonatal deaths. Childhood Illness for High HIV Settings (2008) [15], the
Complications from preterm birth and low birth weight Pocketbook on Hospital Care For Children (2005) [16],
(LBW) take the largest toll on neonatal deaths, with more Recommended interventions for improving maternal and
advanced care being required for those born before 33 newborn health - Integrated management of pregnancy
weeks’ gestation. Use of low cost interventions such as and childbirth (2007) [17]. Interventions published in
kangaroo mother care (KMC) yields a 51% reduction in the Child and Neonatal Lancet Series (2003 and 2005,
mortality for newborns weighing less than 2000g [10,11]. respectively) [18,19] (Refer Figure 1 for essential inter-
Among children under the age of five years, infection is ventions). We further updated the evidence on these inter-
the major cause of severe morbidity and mortality. Simple ventions from Lancet Diarrhoea and Pneumonia Series
interventions such as proper nutrition, sanitation, hygiene, (2013) [20] and Lancet Maternal and Newborn Nutrition
complete and timely immunization along with preventive Series (2013) [21].
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Selection and inclusion of Interventions related to safe motherhood, nutrition, and simple pre-
The interventions were prioritized according to the follow- vention and treatments. Many countries have attempted
ing criteria: to construct links between community-based health care
• Interventions expected to have a significant impact resources and households for a range of health pro-
on maternal, newborn and child survival, addressing the grams. These programs do not substitute for a health
main causes of maternal, newborn and child mortality. system, but provide a channel for reaching families with
• Interventions suitable for implementation in low- information and resources. Community health workers
and middle-income countries; minimal essential care. (CHWs) not only promote healthy behaviors and pre-
• Interventions delivered through the health sector, ventive action but can mobilize demand for appropriate
from the community up to the 1st referral level of services at other levels. The success of community
health service provision. health efforts depends critically on the context, includ-
Relevant reviews for each intervention were identified ing level of development of infrastructure, services, and
from the following electronic databases: the Cochrane socioeconomic resources.
database of systematic reviews, the Cochrane database of (2) First level/outreach - Health care providers at this
abstract reviews of effectiveness (DARE), the Cochrane level of care includes professionals, outreach workers as
database of systematic reviews of randomized control trials well as the community health workers. It includes a range
(RCT’s), and PubMed. The reference lists of the reviews of initiatives that are associated with the Alma Ata
and recommendations from experts in the field were also Declaration on Primary Health Care approved by WHO in
used as sources to obtain additional publications. The 1978. More recently, the WHO Commission on Macroe-
principal focus was on the existing systematic reviews and conomics and Health described the need for developing
meta-analysis. services that are close to the client. The basic notion is a
common one: recognition that a certain range of health
Classification of interventions care services must act as an interface between families and
The interventions were classified into categories A, B community programs on the one hand, and hospitals and
and C, according to the framework provided in Table 1. national health policies on the other. There has been sub-
The classification of the effect of interventions according stantial convergence in the content of general first level
to the evidence available was done based on that used by primary care over time: maternity related care (for
the Cochrane group. This classification benefited from instance, prenatal care, skilled birth attendance, and family
being broadly known, recognized and accepted since it is planning), interventions to address childhood diseases
the classification used by the Cochrane systematic review (such as vaccine preventable diseases, acute respiratory
process that has guided this exercise from the beginning. infections, diarrhea and prevention and treatment of
The “evidence” was restricted to published systematic major infectious diseases.
reviews; not including single studies, but to list single stu- (3) Referral level - this level of delivery of interven-
dies as background information for further review. Table 2. tions refers to hospitals in general. These can be either
district hospitals or referral hospitals. The health care
Levels of delivery providers at this level are professionals.
The origin of evidence included the following three dif- District hospitals - generally designed to serve people
ferent levels of delivery of interventions and these were with services that are more sophisticated, technically
defined in the publication by the World Bank “Providing demanding, and specialized than those available at a pri-
Interventions": mary care facility/first level care, but not as specialized
(1) Community level/home–health care providers at as those provided by referral hospitals. Their range of
this level includes community health workers and out- services includes diagnostics, treatment, care, counsel-
reach workers. It utilizes resources such as volunteers’ ing, and rehabilitation. District hospitals may also pro-
time, local knowledge, and community confidence and vide health information, training, and administrative and
trust as channels for delivery of interventions generally logistical support to primary and community health care

Table 1 Classification of interventions according to evidence and delivery strategies

Category Evidence for intervention GRADE Delivery strategies Action
categories
A Intervention evidence agreed Delivery strategy agreed Disseminate for rapid scale up
B Intervention evidence agreed Delivery strategy no Collate evidence and define gaps in evidence for delivery strategies –
consensus seek consensus
C Intervention evidence still questioned Delivery strategy no Prioritise action and further research required or delete
consensus
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Table 2
A B C D E
Interventions that Interventions likely Interventions with a trade-off between Interventions of unknown effect, Interventions likely to be
are beneficial to be beneficial beneficial and adverse effects including absence of reviews ineffective or harmful

programs. It concentrates skills and resources in one place child health that can be delivered over the continuum of
for the delivery of interventions for conditions that are care. Table 3 has enlisted the interventions graded as A
either uncommon or difficult to treat. It is also a reposi- on the previously defined criteria at any level of health
tory of knowledge and diagnostic tools for assessing care delivery across the continuum of care.
whether referral to an even more specialized facility is
indicated. Conclusion
Referral hospitals- referral hospitals provide complex Poor maternal, newborn and child health remains a signifi-
clinical care interventions to patients referred from the cant problem and represent two of the most difficult to
community, primary/first, or district hospital levels. Referral achieve targets among the MDGs particularly in LMICs.
hospitals need to provide many forms of support, including Majority of maternal deaths occur during pregnancy and
advice on which patients to refer, proper post discharge childbirth, while the risk of infant’s death is highest in the
care, and long-term management of chronic conditions. first 28 days of life. The situation is grave in Asia and Sub-
Referral hospitals can also provide important managerial Saharan Africa, where mortality among mothers and neo-
and administrative support to other facilities, serving as nates is the highest in the world. The rate of maternal
gateways for drugs and medical supplies, laboratory testing mortality is 129 times and rate of under-five mortality is
services, general procurement, data collection from health 71 times higher in LMIC compared to high income coun-
information systems, and epidemiological surveillance. tries. Several factors contribute to poor maternal, newborn
They are also the vehicle for disseminating technologies by and child deaths; and with simple, low cost interventions,
training new staff and providing continuing professional these deaths can be avoided particularly in low income
education for existing staff at different facilities. countries. Furthermore, the health and well-being of
mothers and infants are closely linked; the interventions
Data extraction and analysis for improving women health have beneficial impacts on
The review authors set up a triage process with standar- birth and neonatal outcomes. The aim of this exercise is
dized criteria for evaluating outputs from the search strat- to develop consensus on the content of RMNCH packages
egy and primary screening. Following an agreement on the of interventions at each level of the health system across
search strategy, the abstracts (and the full sources where the continuum of care. With this rationale, a total of 142
abstracts were not available) were screened by two RMNCH interventions were identified from several recent
abstractors to identify reviews adhering to the objectives. relevant bodies of work. Of these, 56 essential interven-
Any disagreements on selection of reviews between these tions were short listed based on the evidence of their effi-
two primary abstractors were resolved by the third cacy, effectiveness and impact on survival; their suitability
reviewer. After retrieval of the full texts of all the reviews for implementation in low- and middle- resource settings
that met the inclusion/exclusion criteria, each review was and their likelihood to be delivered through the health sec-
double data abstracted into a standardized form. Informa- tor from the community to the referral. These were
tion was extracted on the following criteria: further classified and allotted to different plausible level of
1. Characteristics of included reviews - description of health system delivery levels.
each review included brief description of objectives, inter- This introductory paper helps understand the back-
ventions, types of study design included, and outcomes ground and methodology in depth for the work which has
reported; been undertaken and detailed over next few papers. This
2. Whether the review was a Cochrane or non- series, in whole, is highlighting the essential reproductive,
Cochrane review maternal, newborn and child health interventions and
3. And if they pooled the studies included. their effectiveness for maternal, fetal, neonatal and child
Available systematic reviews were assessed for quality health. The last paper of this series is summarizing the
using the AMSTAR criteria (Assessment of the methodo- delivery of these essential interventions as per the level of
logical quality of systematic reviews) [22]. Any disagree- health care and in the form of care packages.
ments were resolved by discussion and the final decision
was taken by consensus within the team. Peer review
Over the next three papers we have discussed essential The reviewer reports for this article can be found in
interventions for reproductive, maternal, neonatal and Additional File 1.
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Table 3 Grading of interventions according to the level of health care delivery

Intervention Referral 1st level / Community
level outreach
Adolescents & pre-pregnancy
Family planning A A A
Prevent& manage sexually transmitted illness including HIV for prevention and mother to child A A A
transmission for HIV and syphilis
Folic acid fortification and/or supplementation for preventing neural tube defects A A A
Pregnancy
Management of unintended pregnancy A B -
a) Availability and provision of safe abortion care when indicated and legally permitted
b) Provision of post abortion care
Appropriate antenatal care package: A A C
Screening for maternal illness
Screening for hypertensive disorders of pregnancy
Screening for anemia
Screening for fetal growth problems (IUGR)
Iron and folic acid to prevent maternal anemia
Tetanus immunization
Counseling on family planning, birth and emergency preparedness
Prevention and management of HIV, including with antireterovirals
Prevent and manage malaria with insecticide treated nets and antimalarial
Smoking cessation
Reduce malpresentation at term with external cephalic version A - -
Management of pre-eclampsia A B -
• Calcium to prevent hypertension
• Low dose aspirin to prevent hypertension
Magnesium sulphate for eclampsia A C -
Induction of labor to manage premature rupture of membranes at term A - -
Antibiotics for preterm rupture of membranes A B -
Corticosteroids to prevent respiratory distress syndrome in newborns A - -
Childbirth
Prophylactic antibiotics for caesarean section A - -
Management of postpartum hemorrhage (e.g. uterotonics, uterine massage) A B C
Active management of third stage of labor to prevent postpartum hemorrhage A A -
Cesarean section for absolute maternal indication A - -
Induction of labor for prolonged pregnancy A - -
Prophylactic uterotonics to prevent postpartum hemorrhage A B C
Management of postpartum hemorrhage (e.g. uterotonics, manual removal of placenta, uterine
massage)
Post natal (Mother)
Family planning A A A
Prevent and treat maternal anemia A B -
Detect and manage postpartum sepsis A B -
Screen and initiate or continue antiretroviral therapy for HIV A A -
Post natal (newborn)
Immediate thermal care A B B
Initiation of exclusive breastfeeding (within first hour) A A A
Hygienic cord and skin care A B B
Neonatal resuscitation with bag and mask (professional health worker) A B -
Case management of neonatal sepsis, meningitis and pneumonia A B -
Kangaroo mother care for preterm and for less than 2000g babies A B -
Management of newborns with jaundice A B -
Surfactant to prevent respiratory distress syndrome in preterm babies A - -
Continuous positive airway pressure (CPAP) to manage babieswith respiratory distress syndrome A - -
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Table 3 Grading of interventions according to the level of health care delivery (Continued)
Extra support for feeding small and preterm babies A B -
Presumptive antibiotic therapy for newborns at risk of bacterial infections A - -
Infancy and childhood
Exclusive breastfeeding for 6 months A A A
Continued breastfeeding and complementary feeding from 6 months A A A
Prevention and case management of childhood malaria A A A
Vitamin A supplementation from 6 months of age A A A
Comprehensive care of children infected with or exposed to HIV infection A A -
Routine Immunization and H. influenzae, meningococcal, pneumococcal and Rota virus vaccines A A B
Management of severe acute malnutrition A A -
Case management of childhood pneumonia A A A
Case management of diarrhea A A A
Cross cutting community strategies
Home visits for women and children across the continuum of care - - A

Additional material 7. UNICEF: THE STATE OF THE WORLD’S CHILDREN 2008. New York; 2008.
8. Darmstadt GL, Lee ACC, Cousens S, Sibley L, Bhutta ZA, Donnay F, Osrin D,
Bang A, Kumar V, Wall SN: 60 million non-facility births: Who can deliver
Additional file 1: Peer review. in community settings to reduce intrapartum-related deaths? Int J
Gynaecol Obstet 2009, 107:S89-S112.
9. Reproductive Health Module: Section V: Maternal Mortality. The Harriet
and Robert Heilbrunn Department of Population and Family Health.
Competing interests Columbia University. [http://www.columbia.edu/itc/hs/pubhealth/
We do not have any financial or non-financial competing interests for this modules/reproductiveHealth/mortality.html]..
review. 10. Lawn JE, Kerber K, Enweronu-Laryea C, Cousens S: 3.6 Million Neonatal
Deaths- What Is Progressing and What Is Not? Seminars in Perinatology
Acknowledgment 2010, 34(6):371-386.
The publication of these papers and supplement was supported by an 11. Lawn JE, Cousens S, Zupan J: 4 million neonatal deaths: When? Where?
unrestricted grant from The Partnership for Maternal, Newborn and Child Why? Lancet 2005, 365(9462):891-900.
Health 12. Bhutta ZA, Das JK, Walker N, Rizvi A, Campbell H, Rudan I, Black RE:
Interventions to address deaths from childhood pneumonia and
Declarations diarrhoea equitably: what works and at what cost? Lancet 2013,
This article has been published as part of Reproductive Health Volume 11 381(9875):1417-1429.
Supplement 1, 2014: Essential intervention for maternal, newborn and child 13. WHO: WHO Guidelines on HIV and infant feeding 2010. An updated
health. The full contents of the supplement are available online at www. Framework for Priority action Available at: [http://www.unicef.org/
reproductive-health-journal.com/supplements/11/S1. Publication charges for nutrition/files/HIV_Inf_feeding_Framework_2012.pdf]. World Health
this collection were funded by the Partnership for Maternal, Newborn & Organization 2012, [accessed on March 3, 2014].
Child Health (PMNCH). 14. WHO: Integrated management of childhood illnesses Available at:
[http://whqlibdoc.who.int/publications/2008/9789241597289_eng.pdf].
Published: 21 August 2014 Department of child and adolescent health and development. WHO and
UNICEF 2008, [accessed on March 3, 2014].
15. WHO: Integrated Management of Childhood Illness for High HIV
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doi:10.1186/1742-4755-11-S1-S1
Cite this article as: Lassi et al.: Essential interventions for maternal,
newborn and child health: background and methodology. Reproductive
Health 2014 11(Suppl 1):S1.

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