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MCH Matters
Health Research Program

October 2019

A quarterly newsletter sharing the latest information and implementation research to inform maternal and child health and nutrition programs, practices and policies.
In this edition, you will find links to upcoming events as well as articles and media reports from June 2019 - September 2019. To receive updates on the research we are following, subscribe to future editions of MCH Matters.
Upcoming Events
Join our Communities of Practice: PSBICare-Seeking & Referral, and Urban Health

Feature Article: A synthesis of implementation science frameworks and application to global health gaps. (BMC Global Health Research and Policy | August 27, 2019) 

Most implementation science frameworks are intended to guide the implementation of programs, focusing on identifying elements and stages that increase their success. This article aims to structure this discussion, proposing a simplified tool that synthesizes common elements of other frameworks, and highlights the usefulness of applying implementation science not only in identifying successful implementation strategies but also as a tool to assess gaps in global health initiatives. The analysis showed the usefulness of applying an implementation science approach to identify and prioritize gaps in implementation strategies in global health.

Peer-Reviewed Publications        JUNE - SEPT 2019
Inclusion of the peer-reviewed articles below is guided by the following defining characteristics of implementation research (IR) in global health.1
  • Context specific
  • Relevant and agenda setting purpose
  • Methods fit for purpose
  • Demand-driven
  • Multi-stakeholder and multidisciplinary
  • Real world
  • Real time
  • Focuses on processes and outcomes
1. Theobald S, Brandes N, Gyapong M, et al. Implementation research: new imperatives and opportunities in global health. The Lancet2018;392:2214–28.doi:10.1016/S0140-6736(18)32205-0.
Priority setting for maternal, newborn and child health in Uganda: a qualitative study evaluating actual practice
(BMC Health Services Research | July 8, 2019, 2019)
The overall objective of this paper was to describe and evaluate priority setting for maternal, newborn and child health interventions in Uganda. Fifty-four key informant interviews and a review of policies and media reports were used to describe priority setting for MNCH in Uganda. The authors found that processes were participatory and were guided by explicit tools, evidence, and criteria, however, the public and the districts were insufficiently involved in the priority setting process. While there were conducive contextual factors including strong political support, implementation was constrained by the presence of competing actors, with varying priorities, an unequal allocation of resources between child health and maternal health interventions, limited financial and human resources, a weak health system and limited institutional capacity.
Capacity building and innovation in caring for non-communicable diseases in maternal global health: the example of Haiti
(Journal of Obstetrics and Gynaecology Canada | August 5, 2019) 
Non-communicable diseases (NCDs) are important contributors to maternal morbidity and mortality worldwide. This collaborative research initiative on the screening and management of hypertensive disorders of pregnancy and gestational diabetes was conducted in Saint-Nicolas Hospital in Saint-Marc, Haiti. The report discusses methods used to overcome several local challenges to providing care for NCDs. It also describes how collaborative research initiatives are efficient strategies to innovate and build research capacity for NCD care delivery during pregnancy in low-income countries.
Qualitative formative implementation research to inform introduction of a new essential medicine. (Research in Social and Administrative Pharmacy | June 16, 2019)
This study explored the factors likely to influence introduction of a novel oxytocin formulation for the prevention of postpartum hemorrhage in Ethiopia. Qualitative research methods were used to assess barriers and enablers associated with pre-determined domains: regulatory approval, pricing, supply and demand side advocacy, policy inclusion, end-user training and drug supply. Data were collected through focus group discussions and in-depth interviews with community members, healthcare providers and key informants. This study highlighted several barriers and enablers associated with the introduction of a new drug product into the health system of Ethiopia.
Implementing the skilled birth attendance strategy in Uganda: a policy analysis. (BMC Health Services Research | June 12, 2019) 
Uganda's skilled birth attendance policy aimed to increase access to obstetric care. This is a case study of the implementation process, involving a document review and in-depth interviews among key informants selected from the Ministry of Health, professional organizations, Ugandan Parliament, the Health Service Commission, the private not-for-profit sector, non-government organizations, and District Health Officers. The authors found that recruitment of human resources, and infrastructural capacity to provide good quality care remain a challenge. This study highlights the complex issues and unexpected consequences of policy implementation.
Applying the model of diffusion of innovations to understand facilitators for the implementation of maternal and neonatal health programmes in rural Uganda. (BMC Globalization and Health | May 13, 2019)
In this paper, the authors describe two projects that were initially conceived to tackle the financial barriers to access to care - through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this report, the authors used an adaptation of Greenhalgh's Model of Diffusion to reflect on these projects' approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. The authors found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions.
Achievements and challenges of implementation in a mature iCCM programme: Malawi case study. (The Journal of Global Health | June 9, 2019) 
This paper examines Malawi’s integrated community case management (iCCM) program performance and implementation strength in RAcE districts to further strengthen the broader program. Baseline and endline household surveys were conducted in iCCM-eligible areas of RAcE districts. Primary caregivers of recently-sick children under five were interviewed to assess changes in care-seeking and treatment over the project period. Health surveillance assistants (HSAs) were surveyed at endline to assess iCCM implementation strength. Moderate access to iCCM was associated with increased care-seeking from HSAs, increased treatment by HSAs, and more positive perceptions of HSAs compared to areas with limited or no access. Areas with high access to iCCM did not show further improvements above areas with moderate access.
Comparison of perinatal outcomes in facilities before and after Global Network's Helping Babies Breathe Implementation Study in Nagpur, India. (BMC Pregnancy and Childbirth | September 4, 2019)
The objective of this study was to assess the effects of community-based antibiotics for neonatal PSBI in LMICs on neonatal mortality and to assess whether the effects of community-based antibiotics for neonatal PSBI differ according to the antibiotic regimen administered. Low‐quality data demonstrated that community‐based antibiotics reduced neonatal mortality when compared to the standard hospital referral for neonatal PSBI in resource‐limited settings. The use of co‐interventions, however, prevent disentanglement of the contribution from community‐based antibiotics. Moderate‐quality evidence showed that simplified, community‐based treatment of PSBI using regimens which rely on the combination of oral and injectable antibiotics did not result in increased neonatal mortality when compared to the standard treatment of using only injectable antibiotics. Overall, the evidence suggests that simplified, community‐based antibiotics may be efficacious to treat neonatal PSBI when hospitalization is not feasible. 
Scaling up breastfeeding in Myanmar through the Becoming Breastfeeding Friendly Initiative. (Current Developments in Nutrition | August 3, 2019) 
The aim of this study was to document the Becoming Breastfeeding Friendly (BBF) Initiative process and outcomes in Myanmar. A Working Group (WG) of 14 members, led by a chair and 2 co-chairs, conducted the BBF assessment using the BBF Index (BBFI), generated and prioritized recommendations, and disseminated the findings over the course of 5 meetings. Additional meetings were held to gain stakeholder endorsement and approval of the BBF process and WG before commencement and MoHS endorsement of the findings. The BBF Initiative was successfully conducted in Myanmar, resulting in 9 prioritized recommendations for strengthening the breastfeeding enabling environment and substantial interagency collaborations. Adaptations to the BBF process were made for the context, and the authors note numerous lessons learned that should be considered by other countries that plan to commit to the BBF Initiative.
Community engagement to manage acute malnutrition: implementation research in Kupang district, Indonesia. (Bulletin of the World Health Organization | September 1, 2019) 
The aim of this study was to improve the low coverage and performance of a program on community-based management of acute malnutrition, implemented between October 2015 and April 2018 in Kupang district in rural Indonesia. The authors used the results from a semiquantitative evaluation to inform program improvement, by developing and modifying community mobilization strategies. The authors employed a multi-pronged approach to improve community awareness on acute malnutrition and on community-based services for such condition. The authors measured the performance using three Sphere minimum standard performance indicators: proportion of children recovering (> 75%); defaulting (< 15%); and dying (<10%). The community mobilization efforts increased the screening rate and the program met the three performance indicators.
Let’s bring back theory to theory of change. (R&E Search for Evidence | August  22, 2019) This article explores theory of change framework and its application in international development. It argues that theory is what allows us to learn cumulatively from one program to another and from one evaluation to another. The article goes on to say that theory is our best hope for the external validity of any impact evaluation and for using small pilots to indicate what might happen at scale. 
Published Reports
Training course on ethics in implementation research: Facilitator's and participant's guides. (TDR | June 1, 2019) TDR and WHO's Global Health Ethics team have jointly developed a training course for researchers and research ethics committees on the important ethical considerations in IR. The course comprises six interactive modules interspersed with activities including case studies, role-play and quizzes.
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This newsletter is produced by the Coordinating Implementation Research to Communicate Learning and Evidence (CIRCLE) project.