Article Analysis and Evaluation of Research Ethics

Search the GCU Library and find one new health care article that uses quantitative research. Do not use an article from a previous assignment, or that appears in the Topic Materials or textbook.

Complete an article analysis and ethics evaluation of the research using the “Article Analysis and Evaluation of Research Ethics” template. See Chapter 5 of your textbook as needed, for assistance.

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While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Rubic_Print_Format

N/A N/A

5.0%

N/A N/A

5.0%

Hypothesis is generally defined. There are some minor inaccuracies.

5.0%

10.0%

5.0%

Course Code

Class Code

Assignment Title

Total Points

HLT-362V

HLT-362V-OL191

Article Analysis and Evaluation of Research Ethics

140.0

Criteria

Percentage

1: Unsatisfactory (0.00%)

2: Less Than Satisfactory (65.00%)

3: Satisfactory (75.00%)

4: Good (85.00%)

5: Excellent (100.00%)

Comments

Points Earned

Content

100.0%

Article (Quantitative, APA Citation and Permalink)

5.0%

The article presented does not use quantitative research.

N/A

The article presented is based on quantitative research.

Article Citation and Permalink

Article citation and permalink are omitted.

Article citation and permalink are presented. There are significant errors. Page numbers are not indicated to cite information, or the page numbers are incorrect.

Article citation and permalink are presented. Article citation is presented in APA format, but there are errors. Page numbers to cite information are missing, or incorrect, in some areas.

Article citation and permalink are presented. Article citation is presented in APA format. Page numbers are used in to cite information. There are minor errors.

Article citation and permalink are presented. Article citation is accurately presented in APA format. Page numbers are accurate and used in all areas when citing information.

Broad Topic Area/Title

Broad topic area and title are omitted.

Broad topic area and title are referenced but are incomplete.

Broad topic area and title are summarized. There are inaccuracies.

Broad topic area and title are presented.

Hypothesis is generally defined. There are some minor inaccuracies.

Broad topic area and title are fully presented and accurate.

Problem Statement

Problem statement is omitted or incorrect.

Problem statement is referenced but is incomplete.

Problem statement is partially presented. There are inaccuracies.

Problem statement is summarized. There are some minor inaccuracies.

Problem statement is accurate and clearly summarized.

Purpose Statement

Purpose statement is omitted or incorrect.

Purpose statement is referenced but is incomplete.

Purpose statement is partially presented. There are inaccuracies.

Purpose statement is summarized. There are some minor inaccuracies.

Purpose statement is accurate and clearly summarized.

Research Questions

Research questions are omitted or incorrect.

Research questions are partially presented.

Research questions are presented and accurate.

Define Hypothesis (Or state the correct hypothesis based upon variables used.)

Definition of hypothesis is omitted. The definition of the hypothesis is incorrect.

Hypothesis is summarized. There are major inaccuracies or omissions.

Hypothesis is defined. Hypothesis is generally defined. There are some minor inaccuracies.

Hypothesis is accurate and clearly defined

Identify Variables and Type of Data for Variables

Variable type and data for variable are omitted.

Variable type and data for variable are presented. There are major inaccuracies or omissions.

Variable type and data for variable are presented. There are inaccuracies.

Variable type and data for variable are presented. Minor detail is needed for accuracy.

Variable type and data for variable are presented and accurate.

Population of Interest for Study

Population of interest for the study is omitted.

Population of interest for the study is presented. There are major inaccuracies or omissions.

Population of interest for the study is presented. There are inaccuracies.

Population of interest for the study is presented. Minor detail is needed for accuracy.

Population of interest for the study is presented and accurate.

Sample

Sample is omitted.

Sample is presented. There are major inaccuracies or omissions.

Sample is presented. There are inaccuracies.

Sample is presented. Minor detail is needed for accuracy. Page citation for sample information is provided.

Sample is presented and accurate. Page citation for sample information is provided.

Sampling Method

Sampling method is omitted.

Sampling method is presented. There are major inaccuracies or omissions.

Sampling method is presented. There are inaccuracies. Page citation for sample information is omitted.

Sampling method is presented. Minor detail is needed for accuracy.

Sampling method is presented and accurate.

Identify Data Collection

How data were collected is not identified.

How data were collected is presented but is incorrect.

How data were collected is partially presented. There are inaccuracies or omissions.

How data were collected is identified. There are minor inaccuracies

How data were collected is fully identified and accurate.

Summary of Data Collection Approach

The means of data collection are omitted.

The means of data collection are referenced. There are major inaccuracies or omissions.

The means of data collection are presented. There are inaccuracies. Page citation for sample information is omitted.

The means of data collection are summarized. Minor detail is needed for accuracy. Page citation for sample information is provided.

The means of data collection are thoroughly summarized and accurate. Page citation for sample information is provided.

Data Analysis

Data analysis is omitted.

Data analysis is incomplete. Not all types of statistical tests used for the variables are indicated. The types of statistical tests listed are incorrect or unrelated to the variables indicated.

Data analysis is summarized. Types of statistical tests used for the variables are indicated. There are inaccuracies or omissions.

Data analysis is generally discussed. Types of statistical tests used for the variables are indicated. There minor inaccuracies.

Data analysis is discussed. Types of statistical tests used for the variables are all indicated and accurate.

Summary Results of Study

Summary of the results of the study is omitted or incorrect.

The results of the study are partially presented. There are major inaccuracies or omissions. More information is needed.

The results of study are summarized. There are some inaccuracies. Some information or rationale is needed for support.

The results of study are summarized. Minor detail or information is needed for accuracy or clarity.

The results of study are well summarized. The summary is accurate and clearly represents the results of the study.

Summary Assumptions and Limitations

10.0%

Identification of assumptions and limitations by the author is omitted. Summary of potential assumptions and limitations not listed by the author is omitted or not relevant to the study.

Some assumptions and limitations from the article are identified. Other potential assumptions and limitations not listed by the author are partially presented. Significant information is needed.

Most assumptions and limitations from the article are identified. Other potential assumptions and limitations not listed by the author are summarized. There are some inaccuracies. More information or rationale is needed for support.

Assumptions and limitations from the article are identified and accurate. Potential assumptions and limitations not listed by the author are summarized. Some information or rationale is needed for support.

Assumptions and limitations from the article are identified and accurate. Potential assumptions and limitations not listed by the author are summarized. Strong rationale is provided to support summary.

Summary of Ethical Considerations

Summary of ethical considerations is omitted.

Ethical considerations related to sampling, collecting data, analyzing data, and publishing results are incomplete. There are major inaccuracies or omissions. Significant information and rationale are needed to support summary.

Ethical considerations related to sampling, collecting data, analyzing data, and publishing results are presented. There are some inaccuracies. Some information and rationale are needed to support summary.

Ethical considerations related to sampling, collecting data, analyzing data, and publishing results are summarized. The ethical considerations summarized are reasonable. Some rationale or evidence are needed to support summary.

Ethical considerations related to sampling, collecting data, analyzing data, and publishing results are clearly summarized. The ethical considerations summarized are reasonable. Strong rationale and support are provided.

Mechanics of Writing (includes spelling, punctuation, grammar, and language use)

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is employed.

Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied.

Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed.

Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.

The writer is clearly in command of standard, written, academic English.

Total Weightage

100%

Article Analysis and Evaluation of Research Ethics

Article Citation and Permalink

(APA format)

Article 1

LunLunze, K., Higgins-Steele, A., Simen-Kapeu, A., Vesel, L., Kim, J., & Dickson, K. (2015). Innovative approaches for improving maternal and newborn health – A landscape analysis. BMC Pregnancy and Childbirth, 15(

38). https://link.gale.com/apps/doc/A451670129/PPNU?u=canyonuniv&sid=PPNU&xid=6b4cba8d

https://link.gale.com/apps/doc/A451670129/PPNU?u=canyonuniv&sid=PPNU&xid=6b4cba8d

Point

Description

Broad Topic Area/Title

Citation metadata

Innovative Approaches for improving maternal, and newborn health â A landscape analysis

Problem Statement

(What is the problem research is addressing?)

Purpose Statement

(What is the purpose of the study?)

Research Questions

(What questions does the research seek to answer?)

Define Hypothesis

(Or state the correct hypothesis based upon variables used)

Identify Dependent and Independent Variables and Type of Data for the Variables

Population of Interest for Study

Sample

Sampling Method

Identify Data Collection

Identify how data were collected

Summarize Data Collection Approach

Discuss Data Analysis

Include what types of statistical tests were used for the variables.

Summarize Results of Study

Summary of Assumptions and Limitations

Identify the assumptions and limitations from the article.

Report other potential assumptions and limitations of your review not listed by the author.

Ethical Considerations

Evaluate the article and identify potential ethical considerations that may have occurred when sampling, collecting data, analyzing data, or publishing results. Summarize your findings below in 250-500 words. Provide rationale and support for your evaluation.

RESEARCH ARTICLE Open Access

Innovative approaches for improving
maternal and newborn health –
A landscape analysis
Karsten Lunze1,2*, Ariel Higgins-Steele2,3, Aline Simen-Kapeu2, Linda Vesel2,3, Julia Kim2,4 and Kim Dickson2

Abstract

Background: Essential interventions can improve maternal and newborn health (MNH) outcomes in low- and
middle-income countries, but their implementation has been challenging. Innovative MNH approaches have the
potential to accelerate progress and to lead to better health outcomes for women and newborns, but their added
value to health systems remains incompletely understood. This studyâs aim was to analyze the landscape of
innovative MNH approaches and related published evidence.

Methods: Systematic literature review and descriptive analysis based on the MNH continuum of care framework
and the World Health Organization health system building blocks, analyzing the range and nature of currently
published MNH approaches that are considered innovative. We used 11 databases (MedLine, Web of Science,
CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB direct, WHO Global Health Library and WHOLIS) as data source
and extracted data according to our study protocol.

Results: Most innovative approaches in MNH are iterations of existing interventions, modified for contexts in
which they had not been applied previously. Many aim at the direct organization and delivery of maternal and
newborn health services or are primarily health workforce interventions. Innovative approaches also include health
technologies, interventions based on community ownership and participation, and novel models of financing and
policy making. Rigorous randomized trials to assess innovative MNH approaches are rare; most evaluations are
smaller pilot studies. Few studies assessed intervention effects on health outcomes or focused on equity in health
care delivery.

Conclusions: Future implementation and evaluation efforts need to assess innovationsâ effects on health outcomes
and provide evidence on potential for scale-up, considering cost, feasibility, appropriateness, and acceptability.
Measuring equity is an important aspect to identify and target population groups at risk of service inequity.
Innovative MNH interventions will need innovative implementation, evaluation and scale-up strategies for their
sustainable integration into health systems.

Keywords: Innovation, Maternal health, Neonatal health, Continuum of care, LMIC, Review, Implementation

* Correspondence: karsten.lunze@post.harvard.edu
1Department of Medicine Boston, Boston University, Boston, MA, USA
2Health Section, UNICEF, 3 United Nations Plaza, New York, NY 10017, USA
Full list of author information is available at the end of the article

http://crossmark.crossref.org/dialog/?doi=10.1186/s12884-015-0784-9&domain=pdf

mailto:karsten.lunze@post.harvard.edu

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/publicdomain/zero/1.0/

MNH care [14]. As illustrated in Fig. 1, referring to The
Ouagadougou Declaration on Primary Health. Care and
Health Systems [15, 16], we modified the WHO building
blocks framework to include âCommunity ownership
and participationâ. We excluded the building block
âhealth information systemâ from our analytic frame-
work to somewhat limit the scope of this very broad
analysis and to avoid redundancy with recently pub-
lished reviews and work underway [17â20]. Thirdly, we
determined a combination of MNH and innovation
terms to search 11 databases (MedLine, Web of Science,
CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB
direct, WHO Global Health Library and WHOLIS).
These terms were (for Pubmed): [MeSH] OR (âinfan-
tâ[All Fields] AND ânewbornâ[All Fields]) OR ânewborn
infantâ[All Fields] OR ânewbornâ[All Fields] OR neonat*
OR preterm OR premat* OR âmothersâ[MeSH Terms]
OR âmothersâ[All Fields] OR âmaternalâ[All Fields] OR
Matern* OR Mother] AND [âQuality of Careâ OR Inno-
vati* OR scale-up OR scaling up OR supply OR demand
OR âProgram Evaluationâ]. We did not specifically con-
duct a search for gray literature, but included gray litera-
ture found in the database search. We searched without
language restrictions and included studies in English,
French, Spanish and Portuguese.
We included studies and gray literature from these da-

tabases fitting the following criteria: i) focus on interven-
tions for mothers or newborns (study population) within
the continuum of care from pregnancy to the post-natal
period (28 days after birth of the neonate), ii) provide a
meaningful description of the innovative MNH approach
(study interventions) iii) evaluate (see flow chart) or de-
scribe novel or newly packaged approaches or ones that
were new to a particular target population or context.
All peer-reviewed studies were eligible for inclusion, in-
cluding qualitative studies. To reach to a broad, inclusive
overview over the innovation landscape, we included
studies regardless of whether they reported outputs, out-
comes, or impact data, as long as they provided a de-
scription of the intervention. We limited our results to
research from LMICs published within the past 10 years.
The search was conducted from 15 September to 15 No-
vember 2012 (Fig. 2) and followed the PRISMA guide-
lines [21] where applicable.
Fourthly, we compiled all studies fitting the criteria in

a comprehesive inventory (available from authors upon
request), which was organized according to our concep-
tual framework and documented the existing evidence
(or lack hereof) on outputs, outcomes, or impact. Fi-
nally, two reviewers categorized innovations and graded
the evidence of included studies. Study appraisal and
grading followed the SIGN Grading System [22] and
standards on assessing qualitative research in mixed
studies reviews [23â25], as described Additional file 1:

Figure S1. The final inclusion and grading of studies was
agreed by consensus. Due to the heterogeneity of inter-
ventions and study types, we synthesized results
descriptively.

Results
We analyzed 208 innovative approaches reported in 259
studies and reports, including systematic and narrative
reviews, randomized controlled trials (RCTs), cluster
randomized controlled trials (cRCTs), controlled and un-
controlled pre-post and time series studies, cross sec-
tional studies, and expert perspectives papers (for a
complete listing of study results, see Additional file 2:
Table S1). Table 1 provides detail on the geographical
distribution and types of studies as well as the level of
evidence. In order to describe and map innovations into
a larger landscape, we categorized findings according to
the conceptual framework for MNH innovation we had
defined in Fig. 1. We found that innovative MNH ap-
proaches relate to all health systems building blocks
(Fig. 2, categorized by primary building block), often ad-
dressing more than one. Almost all approaches relate to
more than one component of the continuum of MNH
care â mainly to pregnancy and postnatal care â and ad-
dress an overlap of demand, supply, or quality. The ma-
jority of interventions (72 %) primarily addressed the
supply side of health care; only 14 % focused on de-
mand, 10 % on enabling environments (mostly policy
initatives), and 4 % on quality of care. Many interven-
tions aimed at serving pregnant women (48 %), often in
combination with their newborns (30 %), while others

Fig. 2 The health system building blocks which innovative MNH
approaches aimed to strengthen primarily, n = 208

Lunze et al. BMC Pregnancy and Childbirth (2015) 15:337 Page 3 of 19

Table 1 Characteristics of innovative approaches to maternal and newborn health care by building block

Health system building block Geographic region Setting (urban, rural) Type of study Level of evidencea

Health service delivery South Asia (26 %) n = 74 Interrupted time series- 5 SIGN level 1: n = 18

Eastern and Southern Africa (23 % ) Cross-sectional- 4

West Africa (14 %) Rural (34 %) Pre-post- 7 SIGN level 2: n = 1

East Asia and Pacific (11 %) Urban (24 %) Pre-post with control area- 1

Latin America and Caribbean (9 %) Rural and urban (1 %) Report- 1 SIGN level 3: n = 40

North Africa and Middle East (8 %) Unspecified (41 %) Case study- 5

Unspecified (9 %) RCT- 11 SIGN level 4: n = 11

RCT- 1

Qualitative study- 4 B: n = 1

Costing study- 1

Literature review- 1 C: n = 3

Mixed methods study- 2

Medical products and health technologies South Asia (6 %) n = 35 Pre-post- 4 SIGN level 1: n = 6

Eastern and Southern Africa (11 %) Narrative review- 9

North Africa and Middle East (6 %) Rural (9 %) Interrupted time series on SIGN level 3: n = 4

Unspecified (77 %) Urban (6 %) acceptance- 1

Unspecified (86 %) Systematic review- 5 SIGN level 4: n = 25

RCT- 1

Health workforce South Asia (31 %), n = 59 Pre-post- 17 SIGN level 1: n = 11

East and Southern Africa (29 %) Pre-post with control group- 4

Latin America and Caribbean (10 %) Rural (46 %) Narrative description, feedback- 1 SIGN level 3: n = 35

East Asia and Pacific (7 %) Urban (24 %)

West Africa (7 %) Unspecified (31 %) RCT-2 SIGN level 4: n = 13

Central and Eastern Europe (3 %)

cRCT- 1

Unspecified (14 %) Systematic review- 6

Case study- 1

Cross-sectional- 6

Cross-sectional survey on satisfaction- 1

Cross-sectional survey with control group- 1

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Table 1 Characteristics of innovative approaches to maternal and newborn health care by building block (Continued)

Costing study- 1

Narrative review- 13

Report- 2

Interrupted time series- 1

Study protocol- 1

Health financing South Asia (41 %) n = 32 Case study- 2 SIGN level 1: n = 7

West and Central Africa (28 %) Interrupted time series and

East and Southern Africa (19 %) Rural (25 %) qualitative- 1 SIGN level 2: n = 1

East Asia and Pacific (13 %) Urban (6 %) Protocol- 3

Rural and urban (59 %) Cross sectional- 3 SIGN level 3: n = 17

Unspecified (9 %) Cross sectional and qualitative- 1

RCT- 1 SIGN level 4: n = 4

cRCT- 1

Pre-post with control- 2 A: n = 1

Pre-post- 1

Qualitative- 3 B: n = 1

Non-random controlled trial- 2

Non-random controlled quasi experimental trial- 1 C: n = 1

Interrupted time series- 7

Interrupted time series with controls; and qualitative- 1

Systematic review- 1

Narrative review- 2

Community ownership and participation South Asia (66 %) n = 35 cRCT- 8 SIGN level 1: n = 9

Eastern and Southern Africa (14 %) Narrative review- 6

East Asia and Pacific (11 %) Rural (86 %) Qualitative study- 4 SIGN level 3: n = 13

Latin America and the Caribbean (3 %) Urban (11 %) Systematic literature review- 1

West and Central Africa (3 %), Unspecified (3 %) Pre-post with control- 2 SIGN level 4: n = 9

Unspecified (3 %) Pre-post- 6

Commentary- 1 B: n = 1

Cross sectional survey and qualitative- 1 C: n = 3

Study protocol- 2

Cross sectional study- 2

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Table 1 Characteristics of innovative approaches to maternal and newborn health care by building block (Continued)

Leadership and governance South Asia (38 %) n = 24 Pre-post- 1 SIGN level 3: n = 5

East Asia and Pacific (17 %) Pre-post with comparison areas- 1

Eastern and Southern Africa (13 %) Rural (33 %), SIGN level 4: n = 17

Latin America and the Caribbean (13 %) Urban (4 %) Narrative review- 3

North Africa and Middle East (8 %) Unspecified (63 %) Policy analysis- 7 B: n = 2

West and Central Africa (8 %), Case study- 10

Unspecified (4 %) Report- 1

Qualitative study- 1
aSee Additional file 1: Figure S1

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targeted primarily newborns (17 %) or postnatal women
and their newborns (5 %).
Most studies on innovative approaches included in this

review occurred in Africa (34 %), South Asia (32 %) or
East Asia (9 %), and only a few were from Latin America
(7 %) or Central/Eastern Europe (1 %) (17 % did not spe-
cify a country or region). Among the studies that speci-
fied the setting in which they were carried out, 35 %
were conducted in rural settings, 15 % in urban environ-
ments and 13 % in both. The vast majority of published
studies were observational studies or expert opinion pa-
pers (75 %).
The following sections describe the landscape of MNH

innovations by primary health system building block,
highlighting key approaches and their existing evidence
as substantiated by this review. Table 2 summarizes
these results.

MNH service delivery
The majority of currently published literature reflects
that innovative approaches in MNH care aim at improv-
ing health service delivery along the continuum of care
and ultimately MNH outcomes. Service delivery innova-
tions often combine their approaches with elements
from other building blocks, e.g. with innovative finan-
cing models, training of providers, and new technologies.
Studies evaluated both facility-based and community- or
family-based innovative approaches in implementation,
organization or quality of MNH care.
We included quality improvement projects where they

were described as innovative in their implementation ap-
proach [26â30]. Innovative organizational strategies
attempted to optimize care delivery and improve quality
for prenatal care, delivery [28â31] emergency obstetric
care (EmOC) [32], newborn care [33] and infection con-
trol [34, 35]. Several approaches aimed to improve ser-
vice processes and quality by providing management and
leadership skills to health workers at various levels of
the formal health system to empower them to identify and
address challenges [36]. For example, in Egypt, health
workers with management training implemented and
evaluated quality improvement approaches, which were
scaled-up after the study was completed [37]. Another in-
novative approach combined the organization of mater-
nity service delivery with quality improvement aspects
using a checklist for safe delivery practices, inspired from
one previously utilized for intraoperative safety [38]. In
Nepal, an effective quality of care model used for family
planning was applied to EmOC which involved the setup
of quality teams trained to evaluate quality of care on a
monthly basis, develop and implement an action plan for
quality improvement and remain accountable for progress
through regular reviews [32].

Various innovative approaches were identified which
relate to the delivery of facility-based mental health care
[39], community- or family-based MNH nutrition and
breastfeeding [40â51], kangaroo mother care (KMC)
and prenatal care at both levels [52â65]. A study in
South Africa incorporated mental health care for preg-
nant women into existing primary care services such as
antenatal care visits and postnatal telephone follow-up
[39]. Also in South Africa, facility-based KMC imple-
mentation has progressed through facilitated trainings,
achievement of specific indicators outlined in an imple-
mentation tool as well as progress monitoring performed
via in-depth interviews [40â51]. Implementation of
KMC has been found challenging, and several RCTs on
its use in low resource communities found no effect on
mortality outcomes [52, 53].
Innovative nutritional approaches to improve maternal

and newborn health include new micronutrient supple-
mentation program strategies, involving zinc, iron, cal-
cium or early prenatal food supplementation, and have
been tested to improve antenatal nutrition and child
health outcomes [40â46]. One pre-post study with control
areas in villages in Egypt, for example, evaluated a positive
deviance approach, basing an antenatal education and
supplementation intervention on practices of positive out-
liers. It found that with this approach, women were more
likely to report increased birth weights of their infants and
higher food intake [45]. Finally, efforts to increase aware-
ness and promotion of breastfeeding have involved the
use of new, targeted promotion strategies, delivery systems
and the mainstreaming of the practice in the scale-up of
MNH programmes [47â51].
Most service delivery studies were observational in de-

sign and investigated care delivery outcomes, such as
breastfeeding rates, satisfaction or knowledge scores.
Overall, studies provided limited data on the effective-
ness of health care delivery interventions on health
outcomes.

Medical products and health technologies
Innovative technology approaches and appropriate de-
vices and medicines to promote MNH in resource-
limited environments aim at improving service delivery
through the supply-side. Many novel medical products
and health technologies for safer births and improved
newborn care are in development globally, but strategies
to make them available in LMICs are unclear, and few
have been implemented [66]. The insufficient develop-
ment of distribution channels and lack of incentives for
various stakeholders to test and disseminate products
and technologies have been barriers to making them
available at the point of care [67].
Peer-reviewed studies describing the effect of novel

health technologies on health outcomes are limited in

Lunze et al. BMC Pregnancy and Childbirth (2015) 15:337 Page 7 of 19

Table 2 Summary of innovative approaches to maternal and newborn health care by building block

Health system building block Innovative Approaches/Strategies

Health service delivery Quality improvement

â¢ Management and leadership skills development activities
â¢ Safe childbirth checklist, a standardized protocol for MNH care
â¢ Implementation of redesigned care model/protocol based on selected evidence-based
recommendations and womenâs views
â¢ Collaborative quality improvement of a network of sites working together
â¢ Comprehensive intervention packages based on quality improvement approaches
(including certifications, delivery of services, incentives, promotion, etc.)
â¢ UNICEF Safe motherhood programme
â¢ Special care newborn units to provide high quality care
â¢ Infection control programme to reduce nosocomial infections
â¢ Package of MNH interventions at institutional level
â¢ Mental health care for pregnant women using existing primary care resources
â¢ Provision of equipment and training to facilities
â¢ Community education on maternal health
â¢ Application of quality of care model from family planning to EmOC

Skin-to-skin care / kangaroo mother care

â¢ Community-based kangaroo mother care
â¢ Kangaroo mother care implementation tool to monitor progress
â¢ Implementation of kangaroo mother care in government hospitals
â¢ Use of facilitation to implement kangaroo mother care in hospitals

MNH nutrition

â¢ New micronutrient supplementation programs (e.g. zinc, iron, calcium)
â¢ Positive deviance approach to improve antenatal nutrition

Breastfeeding

â¢ Innovative promotion strategies (e.g. postnatal visits, counselling by community volunteers,
mass media) and delivery systems (e.g. baby-friendly hospitals, peer facilitators) including
mainstreaming breastfeeding into the scale-up of MNH

Prenatal care

â¢ Maternity waiting homes, some combined with MCH services and income
generation activities
â¢ Yoga for high risk pregnancies
â¢ Education for first time childbearing women
â¢ Group prenatal care

Medical products and health technologies Maternal

â¢ Non-pneumatic anti-shock garment to stabilize and resuscitate hypovolemic shock
â¢ Automated blood pressure devices for low resource settings
â¢ Single use obstetric emergency kits
â¢ Misoprostol for community-based use, storage and application system for oxytocin
delivery and balloon condom catheter to treat intractable uterine bleeding
â¢ Foilized polyethylene pouch to store neviparine
â¢ Low-cost, low-tech devices: portable OB ultrasound and Doppler, simplified partograph,
vacuum delivery/EmOC devices, birth simulator, cell-phone-based malaria diagnostics,
hemoglobinmeter, EmOC transporter (eRanger)
â¢ Clean delivery kits

Neonatal

â¢ Low-cost devices: ventilator support, temperature measurement, pulse oximeter
and phototherapy
â¢ Devices to prevent PMTCT (e.g. breastfeeding shields)
â¢ Application of chlorhexidine for umbilical cord care
â¢ Topical application of emollients to reduce nosocomial infections and mortality
â¢ Thermoprotection mechanisms: cot-nursing using heated water-filled mattress,
infant warmers, wraps and foils

Health workforce Training

â¢ E-learning via internet and phone text messages
â¢ Training of community health worker cadres in tasks previously not assigned: antenatal care,
safe delivery, neonatal resuscitation, essential newborn care and PMTCT care, IMNCI
â¢ Low-technology obstetric and neonatal resuscitation simulation training
(e.g. Helping Babies Breathe Programme)

Lunze et al. BMC Pregnancy and Childbirth (2015) 15:337 Page 8 of 19

number and design. Several narrative reviews on maternal
or newborn technologies are based on gray literature and
provide limited analysis beyond descriptions of devices
[66, 67]. Many MNH technology approaches are low-cost

iterations of known devices based on simplified (low-tech)
construction and production principles [68]. However,
studies do not address criteria as to what makes these in-
novative approaches appropriate for LMICs.

Table 2 Summary of innovative approaches to maternal and newborn health care by building block (Continued)

â¢ Training programs/courses for trainers and providers in antenatal care, EmOC, essential
newborn care and neonatal resuscitation: Making Pregnancy Safer, Promoting Effective
Perinatal Care, WHO Essential Newborn Care, acute care
of at-risk newborns, Perinatal Continuing Education Programme, Essential Surgical
Skills Emergency MCH Programme
â¢ Partnering international professional organizations for training of providers
â¢ Training TBAs in antenatal care, safe delivery, neonatal resuscitation and essential
newborn care, use of delivery mat and misoprostol
â¢ Training of nurses: quality improvement tools, oxytocin use

Task-shifting to non-physicians

â¢ Non-physician clinicans to provide EmOC
â¢ Anaesthesia services provided by mid-level cadres
â¢ NICU newborn aides to help staffing problems
â¢ Pictorial job aids used by providers

Health financing Enhancing demand for MNH services

â¢ Conditional cash transfers
â¢ Cash incentives for skilled delivery at facility
â¢ Vouchers for maternal health services and related costs (e.g. transport costs and cash
payment for delivery at facility)
â¢ Community-based health or obstetric insurance
â¢ Abolition or reduction of user fees

Incentives for health workers to increase supply and quality of services

â¢ Performance-based payment
â¢ Free reimbursement for training and costs

Community ownership and participation Womenâs groups and community-based intervention packages

â¢ Womenâs groups convened by female facilitators to identify problems and formulate
solutions
â¢ Female community health worker outreach
â¢ Community/home-based intervention packages including pregnancy, delivery and
ENC components

Linkage between community and facility

â¢ Integration of newborn care into existing community-based package and national
health system
â¢ Creating a network of providers/CHWs

Community mobilisation

â¢ Community-based quality improvement process involving learning and problem-solving
cycle
â¢ Home-based care and linkages to facility based services including distribution and use
of misoprostol, recognition of danger signs, improvements in transport
â¢ Community participatory learning activities
â¢ Positive deviance behavior change activities

Leadership and governance Partnerships

â¢ Public-private partnerships, international/regional partnerships and inter-agency task
teams to create capacity for MNH care

National MNH policies

â¢ Health system reforms
â¢ Use of research, data and policies to develop community-based newborn care package/
national newborn strategy and influence high-profile champions to act
â¢ Integration of skilled birth attendance into national plan/policy
â¢ Increase in political commitment
â¢ Rights-based programming and micro-planning strategy to increase access, coverage
and quality of MNH care
â¢ Use of situation analysis to develop newborn action plan

Lunze et al. BMC Pregnancy and Childbirth (2015) 15:337 Page 9 of 19

The array of maternal health technologies include
non-pneumatic anti-shock garments to stabilize and re-
suscitate hypovolemic shock in pregnant women, auto-
mated blood pressure devices tailored for low resource
settings, single use obstetric emergency kits, and low-
cost, low-tech devices such as portable obstetrical ultra-
sound equipment [38, 66]. Low-cost, low-tech birth
simulators are available and have been used to train vari-
ous cadres of providers in safe delivery techniques [38].
Partographs are an example of interventions aiming to
increase the quality of care, which have long been in use
and are now being adapted for further use in LMICs. A
simplified partograph has been developed by WHO to
monitor stages of delivery, and clinical RCTs conducted
suggest it is useful in improving care [38]. Other innova-
tive approaches aim at facilitating geographic access to
care through low-cost transport options to EmOC facil-
ities such as bicycles and motorbikes [68, 69].
Only a few studies provide clinical outcome data, such as

those on non-pneumatic anti-shock garments suggesting
that their use reduces observed blood loss and rates of hys-
terectomy [70, 71]. Clean birth kits have been suggested as
an innovative approach, but evidence to support their im-
pact on health outcomes is inconclusive, particularly in the
community setting [72, 73]. A study from Bangladesh de-
scribes a balloon condom catheter to treat intractable uter-
ine bleeding, but provides no clinical data [74]. Innovative
use and storage of medicines for women include
community-based administration of Misoprostol, simpler
and safer Oxytocin delivery using the Uniject device and a
foilized polyethylene pouch to store Nevirapine [74, 75].
Likewise, chlorhexidine is not a new intervention, but its
innovative delivery and use for umbilical cord care in the
first 24 h of life in LMIC have been shown to reduce neo-
natal nosocomial infections and mortality [76, 77].
A descriptive review on newborn health technology

[67] suggests that there is increasing attention to low-
cost, low-tech infant warmers [68], neonatal resuscita-
tors [78], and phototherapy devices for the therapy of
hyperbilirubinemia [79]. A variety of low-cost, low-tech
pulse oximeters are in development; some are cell-
phone based while others are marketed primarily for in-
traoperative patient safety purposes [80].
Although technologies and devices might need adapta-

tions to meet needs in different countries, they are usu-
ally not developed with a certain region or country in
mind. Few devices are being marketed and sold, with the
exception of low-cost thermal devices [67] and several
low-cost scales and temperature indicators distributed
by NGOs [81].

Health workforce
Innovative health workforce approaches address the
shortage in human resources by enhancing their

knowledge, skills, and competencies, while aiming at
their retention in LMICs. Many innovative workforce
approaches involve novel training programmes or ap-
proaches to improve the supply side of MNH and to ex-
pand the scope of existing health worker cadres. Various
innovative workforce approaches address skilled
workers, such as training of professional midwives in
newborn care [82, 83] or providing additional training
for medical doctors and other health workers in neonatal
resuscitation using simulations [84]. Various inter-
national organizations have come together to form a
network through which they have committed to train
providers [85]. To facilitate the connection between
trainers and trainees in settings where in-person train-
ings are difficult or impossible, innovative workforce
education strategies uses electronic teaching (e-learning
programmes) or continuing education through phone
texts [86â88].
Creating and training new types of health workers,

such as newborn aides in Neonatal Intensive Care Units
[89], has shown promise in expanding aspects of cover-
age and quality. A review of randomized and non-
randomized controlled studies that investigate strategies
incorporating training and support of traditional birth
attendants (TBAs) found significant reductions in peri-
natal and neonatal mortality [90]. A common approach
is task shifting, the delegation of duties from more
skilled medical personnel to non-physician or intermedi-
ate cadres of health workers. Other approaches directed
at community health workers (CHWs) and TBAs assign
them MNH responsibilities related to community-based
antenatal, delivery and postnatal care. A similar strategy
has also been used for the delivery of EmOC and
anesthesia services [91â94].
The scope of obstetrics practice of mid-level health

care providers (clinical officers) varies widely by country,
but their performances for the tasks they are assigned
are comparable to those of physicians. A meta-analysis
of non-randomized studies found that clinical officers
and doctors did not differ significantly in key outcomes
for caesarean section and detected no significant differ-
ences in maternal or neonatal mortality for cesarean sec-
tions performed by the non-physician clinical officers
versus medical doctors [91].

Health financing
Innovative health financing models address limitations
in access to quality care due to financial constraints, tar-
geting care recipients or providers. Various innovative fi-
nancial programmes aim at attenuating or reducing
financial barriers to care, and at improving coverage and
usage of MNH from supply, demand, or both sides.
Conditional cash transfers (CCT) provide financial as-

sistance to low income families; subsidies are contingent

Lunze et al. BMC Pregnancy and Childbirth (2015) 15:337 Page 10 of 19

upon various conditions such as meeting certain pre-
ventive health care requirements or school attendance
[95]. CCT programmes identified in South Asia tend to
be specifically focused on maternity care [96, 97], often
removing MNH service user fees. This method can also
improve demand for facility delivery as suggested in ob-
servational pilot studies conducted in Ghana, Senegal,
and Bolivia [95, 98â104].
Voucher programmes are intended to directly provide

funds for MNH services to target groups of mothers and
newborns, particularly among low income or high-risk
populations. Studies identified assessed programmes with
vouchers distributed free or highly subsidized to eligible
women to finance transport to a facility and to reimburse
providers for delivery services. Other approaches aimed at
lowering financial risks for households include
community-based health or obstetric insurance (mainly in
West Africa, South America, and China) [98, 105â109]
and cash incentives for skilled facility delivery [110, 111].
Incentives for health workers aim to increase supply

and quality of services through performance-based pay-
ments [112, 113] and full reimbursements of training
and other costs [104]. Performance-based incentives are
cash or other rewards and compensation to health
workers for certain services. Some incentive pro-
grammes are contingent on provider performance out-
puts, referred to as results-based funding or paying for
performance, such as the performance-based financing
scheme in Rwanda [98].
Most published innovative financial approaches were

developed, piloted, and implemented in South Asia.
Some were scaled-up on a state level (India) [96] or na-
tional level (Rwanda, Nepal) [106, 110, 111]. All studies
included in this review were retrospective and quasi-
experimental in design, investigating mostly changes in
health care supply or utilization, aside from an RCT of
pay-for-performance in Rwanda, which found a signifi-
cant increase (23 %) in the probability of a woman deliv-
ering in a facility [112].

Community ownership and participation
Innovative approaches increasingly aim at strengthening
community-based health mechanisms that improve links
to and structures associated with primary health care.
Innovative community ownership and participation ap-
proaches are complex, multifactorial interventions which
often simultaneously address demand, supply, and qual-
ity aspects. Community-based intervention packages
(CBIPs) are usually facilitated by womenâs or mothersâ
groups or by community-based health workers, often fe-
males [114]. Interventions consist of health promotion
and disease prevention activities through care delivery
and health education conducted in the communities or

at the home during pregnancy, delivery and the postna-
tal period.
Various community-based MNH strategies involved

womenâs or mothersâ groups as channels of community
ownership. For example, female facilitators in Makwan-
pur, Nepal convened monthly womenâs group activities
to improve perinatal health and supported groups
through an action-learning cycle in which they identified
local perinatal problems and formulated strategies to ad-
dress them [115]. As a result, MMR was lower in inter-
vention clusters with the womenâs groups intervention
than in control clusters, and women were more likely to
have had antenatal care, institutional delivery, trained
birth attendance, and clean delivery care [115]. Results
from a cRCT in Sylhet (Bangladesh) indicated that a
home care strategy to promote an integrated package of
preventive and curative newborn care was effective in re-
ducing NMR, whereas womenâs group activities had no
statistically significant effect on NMR [116].
Further community-based intervention packages have

been evaluated in Hala, Pakistan [117, 118] and Mchinji
District, Malawi [119]. These studies were large cRCTs
including tens of thousands of mothers and newborns
each assessing maternal and neonatal mortality out-
comes, providing high-quality evidence in their respect-
ive local contexts. In a trial in Gadchiroli (India), home-
based care and health education reduced the incidence
of neonatal morbidities and low birth weight in the com-
munity and improved maternal knowledge and caretak-
ing behaviors [114]. A community-based intervention in
Shivgarh (Uttar Pradesh, India) focused on the provision
of essential newborn care and on prevention of newborn
hypothermia, and was associated with a reduction in the
neonatal mortality rate (NMR) of about 50 % [120].
In contrast to large reductions in mortality reported in

similar trials undertaken in Nepal and India, a large trial
in Bangladesh evaluating participatory action and learning
groups for women to develop and implement strategies to
address MNH problems did not detect a statistically
significant effect on NMR [121]. Contextual factors â
including socio-cultural aspects and gender-based barriers
â may influence participation in specific activities associ-
ated with community health. This study indicated that
process-related factors as well as local context may have
had a role in the interventionâs effectiveness. Specifically,
poor conditions for transport and signs of gender-based
barriers seemed to affect womenâs access and participation
in this setting. The Integrated Management of Neonatal
and Childhood Illness (IMNCI) programme in Haryana
(India) combined CHW postnatal home visits to treat or
refer sick newborns with womenâs group meetings [122].
A meta-analysis of data from studies showed that while
community participatory approaches are not associated
with improvements in MMR, they have been shown to

Lunze et al. BMC Pregnancy and Childbirth (2015) 15:337 Page 11 of 19

reduce maternal morbidity, stillbirths and NMR, and im-
prove referral to health facilities as well as breastfeeding
rates [123].
As careseeking and referral are core components of

community-based approaches, it is essential to make a
strong linkage between the facility and community. In-
novative strategies to foster this linkage include estab-
lishing an integrated package of care within the national
system at community and facility levels, and creating a
network of providers across all levels to enhance the
capacity and quality of care [124â128]. At the centre of
community-based approaches are ownership and partici-
pation, mobilized through community involvement and
engagement, participatory learning activities and prob-
lem solving with local community and facility represen-
tatives, as well as positive deviance behavior change
activities [129].
Most studies in this building block were conducted in

rural settings. Most of the community-based approaches
emphasize prevention and capacity building. The value
of community participation and ownership is well estab-
lished; however, besides mechanisms such as womenâs
groups and community-based approaches of follow-up
with CHWs, there is little research published on other
innovative mechanisms and approaches to facilitate
community participation and mobilization in MNH.

Leadership and governance
Innovative leadership and governance initiatives, related
to the formation of partnerships and the formulation
and implementation of national MNH policies, are con-
sidered part of the enabling environment for MNH and
address supply, demand and quality. Studies discuss sys-
tems issues and historical developments, and describe
efforts overarching the before mentioned areas in their
political context.
Partnerships for MNH include public-private partner-

ships between governments and private obstetricians,
nurses or midwives, international or regional partner-
ships and interagency task forces to enhance capacity
and quality of MNH care. Several large-scale public-
private partnerships were initiated in South Asia, where
district health authorities, as care providers, purchased
packages of services for the poor from the private sector.
For example, a public-private partnerships in Gujarat,
India connected 800 obstetric providers to provide
health care to poor women and increased the proportion
of women delivering at health facilities [94]. Additional
innovations include health system-wide reforms; use of
situational analyses, evidence and policies to develop im-
plementation packages and national strategies; integrat-
ing skilled birth attendance into national policy;
increasing political commitment; and creating rights-

based programming and micro-planning strategies to in-
crease access, coverage and quality of care.
The strategic use of global and national data and part-

nerships focused on newborn-related evidence for advo-
cacy and planning is a MNH policy-making strategy that
has influenced similar strategies in other countries [124].
Nepal was the first low-income country to create a data-
driven national newborn strategy, the Community-Based
Newborn Care Package [124, 130].
Most evidence on leadership and governance is docu-

mented in case studies and policy analyses, focusing on
enabling factors of policy making. In a quasi-experimental
setting in the Phillipines, a system reform for maternal
health was shown to be associated with an increase in the
rate of facility-based deliveries, as MMR declined more in
reform areas than in comparison areas during the time
period of gradual implementation [131]. Few observa-
tional policy evaluations included population data.

Discussion
As indicated by the results of this review, the landscape
of innovative MNH approaches is complex and diverse,
and knowledge management is a challenge for country
MNH programme planners and managers. This analysisâ
results provide a geographical orientation of innovations
and a summary of innovative MNH approaches within
relevant health system building blocks. Our study aims
to facilitate knowledge management and dissemination
about innovative MNH approaches by providing an
overiew of the landscape and related evidence. Thus, it
allows researchers and innovators to identify gaps and to
develop and appropriately evaluate new projects.
Most innovative MNH approaches identified in this re-

view are adaptations and iterations of solutions from other
settings. While the literature provides valuable lessons on
development and implementation, evidence for the health
outcomes and impact of such innovations in LMICs is
often limited. Innovative approaches address various bar-
riers to health care access in LMICs, often simultaneously:
geographic access, availability, affordability, acceptability,
and quality [132]. Some interventions target specifically
mothers, while others address both mothers and new-
borns, in a combination of elements across the continuum
of care. A continuum of care approach is supported by
empirical evidence suggesting positive, synergistic effects
of strategies emphasizing interconnected care of mothers
and neonates [133].

Innovative MNH approaches in every health system block
In LMICs, delivery of effective quality care is challenging
due to many barriers, which often relate to other health
system building blocks. Barriers to health service deliv-
ery in resource-constrained settings include lack of or
inadequate facilities and infrastructure including drug

Lunze et al. BMC Pregnancy and Childbirth (2015) 15:337 Page 12 of 19

and equipment supply, distribution of health facilities in-
consistent with population needs, insufficiencies in
health worker training and continuous education, lack of
incentives or other mechanisms for quality care and
health worker retention, and insufficient standardization
of care delivery. Studies of innovation in health service
delivery usually assess improvements in service coverage
[134]. Innovative packages often integrate multiple
MNH interventions (e.g. training in EmOC, placement
of care providers, refurbishment of existing health facil-
ity, infrastructure and improved supply of drugs and
consumables and equipment for obstetric care), both at
the district and sub-district level [135]. These are obser-
vational studies reporting performance or utilization
outcomes, or concurrent changes in maternal mortality
rate (MMR). A small cRCT assessed care utilization and
client satisfaction [136].
Improving access to and availability of health services,

including emergency services, are key strategies towards
achieving the health-related MDGs, but innovative ap-
proaches also need to address quality and equity. Conclu-
sions about the applicability and appropriateness of
innovative approaches in LMICs are limited by the relative
scarcety of controlled studies in the current published lit-
erature. While many interventions are specifically de-
signed to improve the quality of care, most lack evidence
on quality improvement of service delivery; few evalua-
tions of quality improvement programmes assessed indi-
cators of quality. Quality of care is not uniquely defined in
MNH generally [137]. This lack of a definition of quality
was also observed in studies on innovative approaches.
Few studies investigated measures related to safety, effect-
iveness, efficiency, patient-centeredness, timeliness, and
equity. Some papers on quality improvement projects did
not report data on quality of care at all. Given the observa-
tional study design, causality of the observed effects can-
not be attributed to the programme activities.
Most studies of the effects of innovative approaches in

MNH care delivery are observational and do not account
for potential confounders. EmOC evaluation studies
measured mostly programme outputs using process in-
dicators such as facilities per population [138], outputs
such as the proportion of cesarean sections among deliv-
eries [139], or outcome indicators such as met need for
EmOC services [139â141]. Few studies investigated ef-
fects of EmOC implementation or improvement inter-
ventions on mortality [142], and mortality was often
measured as procedure-related case fatality rate rather
than population-based MMR [143].
More rigorous, applied research would add valuable

evidence on the effectiveness, replicability, and scale-up
of current innovations. Future studies on innovative
health service delivery approaches should investigate
measurable health and social impact. For equitable

programming, outputs of care delivery and process out-
comes need to be measured, as well as indicators of
quality of care, of morbidity and mortality (including
among vulnerable populations), and cost-effectiveness.
Medical products and health technologies for use in

LMIC have received considerable attention recently, in-
cluding from United Nations organizations [78, 144].
This reviewâs findings however point out that – with the
exception of smaller pilots on anti-shock garments or
clean delivery kits – the current body of published litera-
ture lacks rigorous evidence on safety, effectiveness, and
potential side effects. Studies describe novel MNH tech-
nologies, but data on effectiveness, safety, and unin-
tended effects are missing. Few technologies have been
scaled up to mass production, which might lower the re-
tail price and incentivize a supply chain to get appropri-
ate and affordable technologies to mothers and
newborns. Criteria for what makes technology appropri-
ate for LMICs are unclear, as are issues of affordablity
for end users in LMICs, and efficient strategies to make
health technologies suitable and acceptable. While pro-
duction costs or end user prices of technologies are not
specified in the papers reviewed, even scaled-down high-
tech versions are often too expensive for use in LMICs,
and will require user training and device maintenance.
Safety and potential adverse effects need scrutiny in

future studies. For example, women on antiretroviral
therapy do not need breast shields to prevent transmis-
sion of infection to their children, and it is conceivable
that these devices interfere with a motherâs ability to
consistently breastfeed as recommended by WHO [145].
Most importantly, while there is a promising pipeline of
innovative technologies in development, these need sus-
tainable distribution strategies to reach mothers and
newborns in resource-limited settings. Future clinical tri-
als need to measure not only health outcomes, but also
implementation, acceptability, and usage aspects to as-
sess adverse effects on currently recommended best
practices, in order to mitigate these risks and potentially
reverse them.
The scarcity of skilled providers represents one of the

main obstacles to the expansion of MNH care, especially
for basic and comprehensive emergency obstretric care
[146]. Many innovative health workforce approaches
concentrate on task shifting and training. While the
body of evidence is of varying rigor, evaluations indicate
that these approaches might help narrow MNH delivery
gaps due to the shortage in health workforce. While
most governments favor approaches encouraging deliv-
eries at health facilities, many health systems are still far
from being able to offer comprehensive, skilled-birth at-
tendance to all pregnant women. In the absence of suffi-
cient capacity in human resources for skilled birth
attendance, there is strong evidence from cRCTs and

Lunze et al. BMC Pregnancy and Childbirth (2015) 15:337 Page 13 of 19

non-randomized controlled studies that strategies incorp-
orating training and support of TBAs reduce perinatal and
neonatal deaths [90]. Most studies on innovative health
workforce approaches included in this review used indica-
tors such as short-term knowledge retention or skills
scores as outcomes. Few evaluated health outcomes, or
longer-term retention of knowledge and development of
skills.
In many LMICs, households bear most of the financial

burden of MNH care. Families who are unable to pay
out-of-pocket fees experience delays or even insur-
mountable barriers to accessing care, which can result in
fatal outcomes and catastrophic household expenditures
[101]. Recent innovative health financing models re-
moving or reducing MNH service user fees (e.g. fee ex-
emption for maternity care) have been shown to have
positive effects on supply of and demand for MNH. Usu-
ally equity-driven, these programmes are designed to tar-
get the poor to subsidize cost or exempt fees for specific
services, such as cesarean deliveries. Performance-based
financing including pay-for-performance, performance-
based incentives, results-based financing, or CCTs have
increased access and utilization of MNH services [147].
These approaches are often part of more complex initia-
tives to improve MNH service delivery, and their specific
effects on health worker performance, or on MNH indica-
tors, is often difficult to discern [148]. There are few con-
trolled evaluations of innovative financial approaches.
Included studies focus on utilization outcomes, and few
assess equity-focused targeting (i.e. how financial innova-
tions meet the most vulnerable populations or improve
MNH care among the poor). In the few observational
studies that include a control area or group for compari-
son, the allocation of programme versus control was often
unclear, and there was no or insufficient adjustment for
potential confounders in the between-group analyses. Sev-
eral studies included analyses of low-income subgroups to
assess the equity effects of targeting as part of vouchers
programmes [100, 149, 150]; positive equity effects have
been inferred from interventions predominantly used by
economically disadvantaged groups [151]. Study findings
suggest that demand-side financing projects can be an ef-
fective way of reducing inequities in institutional deliver-
ies, but an equity gap remains [103].
A rapidly increasing body of evidence from large RCTs

on innovative community ownership and participation
suggests that community-based care has positive effects
on maternal and neonatal mortality. Innovative participa-
tory approaches involve engagement of community
leaders, behavior change activities, community health edu-
cation, organization of community transport mechanisms,
community-based packages of MNH care, and other
forms of community participation and mobilization [129].
Community ownership and participation strategies can be

innovative in their application of practical, culturally
adapted processes, which build capacity for communities
to develop and scale-up their own solutions [129]. By tak-
ing ownership and building on existing structures [15],
community members can increase responsiveness to the
health needs of the community and adopt behaviors that
promote and preserve health [16]. These health effects in-
crease with higher participation and population coverage
[152]. The mechanism of how mothersâ and womenâs
groups achieve these effects are less clear [153].
Overall, the strong evidence confirmed in this analysis

suggests that community-based interventions are an in-
tegral building block of a health system delivering effect-
ive MNH care, and that the aspects of community
ownership and participation need particular attention.
Innovative leadership and governance initiatives at

national and decentralized levels are essential to influ-
ence action on key health determinants and access to
health services, and to ensure accountability [15]. These
were based on partnerships and political coalitions at
various levels to catalyze innovative approaches in MNH
care. Political and strategic leadership and governance in
resource-limited settings face tremendous challenges in
a complex landscape. In the studies on leadership and
governance, it is difficult to directly link policy changes
to observed population-level outcomes, or to control re-
sults for environmental confounders. However, there is
increasing recognition of the importance and commit-
ment for the implementation of innovative MNH ap-
proaches [154]. Funding is limited, and so is the
availability of reliable data and in many instances polit-
ical commitment for women and children [155]. Innova-
tive approaches in MNH will need concrete political and
financial investments in high-yield and cost-effective in-
terventions for approaches to succeed. Fueled with the
funding and political support required to develop and
implement innovative MNH approaches, our findings
suggest that international political partnerships might be
a decisive facilitating factor in the MNH care landscape.

Limitations
This study aimed at providing an overview over the
landscape of existing, published innovations in MNH.
Given the studyâs broad scope, it has has several limita-
tions. First, the review only includes published studies,
and not all studies might have been found during data-
base searches. We therefore set our search terms very
broad. Secondly, given the very nature of our scoping re-
view, we did not overlook all existing innovations at the
onset of our search. Due to the varied nature of inter-
ventions and study types included in the review, we
could not undertake a metaanalysis of existing evidence.
Third, we included studies with imperfect study designs
and limited or missing outcome data. This allowed us to

Lunze et al. BMC Pregnancy and Childbirth (2015) 15:337 Page 14 of 19

map a broader range of evidence, including indications
where it is missing, and we rated lower grades of evi-
dence accordingly. Finally, considerable time has elapsed
from database review to publication. This means that
while our study can give indications of the MNH inno-
vations landscape and existing evidence and gaps, it
should be considered potentially incomplete and inter-
preted with caution.

Conclusions
Innovative approaches are key to improving equity in
MNH services delivery. Our study suggests that import-
ant evidence gaps remain. Overall, very few studies
assessed intervention effects on health outcomes. Rigor-
ous randomized trials to assess interventions are rare;
most evaluations are smaller pilot studies. Countries
with the most progress in MNH did so by reaching out
to the poorest and most remote populations, thereby im-
proving equity in MNH service coverage. Measuring and
documenting equity in evaluation studies is important to
measure the potential of innovations to improve health
equityand to identify and target population groups at
higher risk of service inequity. Few studies focus on
equity in health care delivery, which is necessary to en-
sure that quality care is available to all. Inequities in ac-
cess, use, and outcomes of health care can be detected
in subgroup analyses, comparing data of disadvantaged
populations with national or regional data. We found
few data on vulnerable subgroups, which limits an equity
assessment for innovative health service delivery
approaches.
Furthermore, in order for any innovative intervention

to be scaled up in low-resource settings, evaluation stud-
ies need to consider cost, feasibility, and acceptability.
The process of innovation does not end with implemen-
tation. Ultimately, innovative MNH approaches are only
successful if they are sustainable and integrated into the
health system. Innovative approaches in MNH care also
will require innovative strategies for their evaluation.
This will allow programme and policy planners to assess
the potential of interventions and ultimately determine
which approaches may work, and why.

Additional file

Additional file 1: Figure S1. Flow chart study selection for the analysis.
(DOCX 52 kb)

Additional file 2: Table S1. Innovative approaches to maternal and
newborn health care (by WHO Health Systems Building Block), related
evidence, and implications for programming and implementation
research. (DOCX 332 kb)

Competing interest
The authors declare that they have no competing interests.

Authorsâ contributions
All authors contributed to the study conceptualisation and structuring of the
paper, and reviewed all drafts. KL wrote the initial draft of the paper and
appendices. All authors contributed to the survey design and search
strategy. KL conducted the online survey and database search, and KL and
AHS reviewed and graded included studies. KL, AHS, ASK, LV, JK, and KD
contributed to the conceptualization of the project, writing and review of
all drafts of the article. KD coordinated the overall study. KL as the lead
author and manuscriptâs guarantor affirms that the manuscript is an honest,
accurate, and transparent account of the study being reported; no important
aspects of the study have been omitted. All authors read and approved the
final manuscript.

Acknowledgements
Funding for this analysis was provided by UNICEF through a grant from
Department of Foreign Affairs, Trade and Development, Canada, to the H4+.
The study sponsor had no role in study design; in the collection, analysis,
and interpretation of data; in the writing of the manuscript; or in the
decision to submit the paper for publication. AHSâs participation is through
Concern Worldwideâs Innovations for Maternal, Newborn & Child Health
initiative, funded by the Bill & Melinda Gates Foundation.
We thank Kristen Wenz for survey collation and Christabel Nyange for her
thorough review of an earlier version of this manuscript.

Author details
1Department of Medicine Boston, Boston University, Boston, MA, USA.
2Health Section, UNICEF, 3 United Nations Plaza, New York, NY 10017, USA.
3Concern Worldwide, 355 Lexington Avenue, New York, NY 10017, USA.
4GNH Centre Bhutan, Jaffaâs Commercial Building, Room 302, Thimphu,
Bhutan.

Received: 5 January 2015 Accepted: 9 December 2015

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Application of Analysis By Elissa Torres

Essential Questions

Â· What are the essential elements in evaluating prior research?

Â· How does the analysis of quantitative versus qualitative studies differ?

Â· How are results communicated from data collection and analysis?

Introduction

The use of statistics and statistical analysis is part of the clinical practitionerâs role

This may appear in different ways from reviewing existing clinical research to participating in a study. There are some critical questions when understanding statistics and the role of clinician in health care:

Â· Why is it important to keep up-to-date on clinical research?

Â· Why is it important for health care facilities to conduct ongoing studies?

Â· What type of studies are important?

Previous chapters focused on understanding the elements of statistics and research, including how to select and conduct hypothesis testing based upon the type of data collected. This chapter focuses on the application of prior information to understand information written in prior research studies and set up statistical tests and interpret results both statistically and clinically.

Academic Research Study Extraction

In the evaluation of research articles, it is important that key areas can be identified for interpretation and understanding. In the review of both qualitative and quantitative research, it can be daunting to extract the relevant information to determine the primary goals and outcomes of the study. For clinical studies, this also means addressing the epidemiology.

The simplest way to extract relevant information is to first start with those key areas.

1. Topic: What is the broad topic research area/title?

. Problem statement: What is the problem that the research is attempting to address? In many studies, authors identify a lack of research in a specific area or population.

3. Purpose statement: Why did the author complete the study? In some studies, this often appears in a sentence containing the phrase, âthe focus of this study â¦ â

. Research questions: What specific questions does the author need to address? In many articles, this is not explicitly written but can be derived.

Hypothesis

, variables, or phenomena: What are the

variables

the author has identified to address the research goal (quantitative)? How is the phenomena described that the author seeks to better understand (qualitative)?

Sample

and location: What was the sample used, and where did the study take place?

Methodology

: Was the research quantitative or qualitative? Did the author provide any more details, such as quantitative correlational or qualitative case study?

. Data collection: How did the author approach data collection? For example, did the author use surveys, interviews, or clinical studies?

. Data analysis: What approach did the author use to analyze the data? Did the author mention statistical tests? What type of statistical data was provided? What type of information is provided with qualitative studies?

. Results: What were the results of the study? Did the author find anything significant? Did the study address epidemiology?

These 10 questions for article evaluation are useful to perform a quick review of the studyâs key elements; however, it is important to start the process by first reading the full article. The format in which information is displayed in Table 5.1 can be used as a template to organize information found for each of these article elements. In some studies, information can be easily located in the abstract and in clearly organized sections; however, this is not always the case.

Table 5.1

Quantitative Article Evaluation

Article Citation

Aljohani, A. H., Alrubyyi, M. A., Alharbi, A. B., Alomair, A. M., Alomair, A. A., Aldossari,

. A., & … Tallab, O. M. (2018). The relation between diabetes type II and anemia. The Egyptian Journal of Hospital Medicine, 70(4), 526. doi:10.

816/0043795

Point

Description

Broad Topic Area/Title

The Relation Between Diabetes Type II and Anemia

Problem Statement

âThere is consequently a need for more studies on the incidence and prevalence of anemia among patients with diabetes mainly those with renal malfunctionâ (p. 527).

Purpose Statement

âThis study consequently purposed to determine the pervasiveness of anemia due to renal insufficiency among patients with type 2 diabetesâ (p. 526, 527).

Research Questions

Is there a relationship between patients with anemia and patients with type II diabetes?

Define Variables/ Hypotheses

Categorical variable: Gender

Continuous variables: Age, Hb, Ferritin,

MCV

TIBC

, FBG, Erythroietin, eGFR, Urea, Na, K, CA, and HbA1c

(found on pages 528 and 529)

Sample

participants

Case group: 25 participants with diabetes (8 male/17 female)

Control group: 25 participants without diabetes (7 male/18 female (p. 528)

Methodology

Quantitative, case-control study (p. 527)

How was Data Collected?

Medical records for the patients were examined from physical examinations (p. 528)

How was Data Analyzed?

SPSS; descriptive statistics for categorical; summary statistics, independent t-test; and ANOVA test; Pearson correlation for Hb and HG for both male and female (p. 528)

What Were the Results?

The study indicated the following were statistically significant (low p-values) between the case group and control group.

Hb Male and Hb Female

Ferritin Male and Ferritin Female

MCV
TIBC

Of the biochemical parameters, the following were significant:

FBG, Erthropoietin, eGFR, Urea, K, C1, Ca, HbA1c

Creatinine was not significant

In the correlation test, HB and HG (female) was significant, but

HB and HG (male) was not significant.
(pp. 528-529)

Clinical implications:

The study did find a higher occurrence of anemia in patients with diabetes (87.5% males, 82.3% female). The study also concluded that the presence of anemia may increase the likelihood of poorly controlled diabetes (p. 529).

Check for Understanding

1. Would there be any additional evaluation of the article?

2. Did the researchers appear to follow ethical guidelines?

3. What were the assumptions and limitations of the study?

Table 5.2

Qualitative Article Evaluation

Article Citation

Jangland, E., Nyberg, B., & Yngman-Uhlin, P. (2017). It’s a matter of patient safety: Understanding challenges in everyday clinical practice for achieving good care on the surgical ward – a qualitative study. Scandinavian Journal of Caring Sciences, 31(2), 323-331. doi:10.

11/scs.12350

Point

Description

Broad Topic Area/Title

Identify the challenges and barriers linked to quality care and patient safety in the surgical ward.

Problem Statement

âIdentify the challenges and barriers linked to quality of care and patient safety in the surgical wardâ (p. 324). Study addresses gap where there were only a few studies that looked at both the nursesâ and leadersâ perspective.

Purpose Statement

âThe aim of this study was to explore, from the perspectives of care leaders, the situations and processes that support or hinder good and safe care on the surgical wardâ (p. 324).

Research Questions

What are the perspectives of leaders on the processes that support good quality care in the surgical ward?

What are the perspectives of leaders on processes that hinder good quality care in the surgical ward?

How do leadersâ experiences inform improvement in clinical practice?

Describe Phenomena

Categorical variable: Gender

Continuous variables: Age, Hb, Ferritin, MCV, TIBC, FBG, Erythroietin, eGFR, Urea, Na, K, CA, and HbA1c

(found on pages 528 and 529) Sample

â10 leaders in surgery departments (four department leaders and six nursing managers) from 1 university hospital and 2 county hospitals in different regions in Swedenâ (pp. 324-325).

Methodology

Qualitative-descriptive design

How was Data Collected?

Repeated reflective interviews using semistructured interviews

How was Data Analyzed?

Systematic text condensation

What Were the Results?

Study identified four major themes (pp. 326-328):

1. Constant demands for increased efficiency and production

2. Continual nursing turnover and loss of competence

3. A traditional hierarchical culture

4. Vague goals and responsibilities in the development of nursing care

Clinical implications:

Based upon the study, which has limitations as it was performed in one country (Sweden), organizational changes are required to ensure higher levels of competence of staff and resources available to surgical ward nurses to ensure higher quality care (p. 3

The two evaluations above provide a roadmap for reviewing prior research. Much of the research completed in the clinical setting may not be as comprehensive; however, it is important to understand the process. In a clinical setting, there may be opportunities to reduce cycle time, increase quality, or participate in studies that influence health outcomes. Understanding the process, knowing how to evaluate the data, and communicating the results enables contribution to the organization.

Application of

Statistic

s to Scenario

A medical office has noticed an increase in patient dissatisfaction and as well as an increase in usage of urgent care facility services rather than seeing their primary care physicians (PCPs). To increase understanding of the patient perception, the office surveyed the patients and received 81 responses. The survey includes a total of eight questions. The first five questions capture satisfaction and urgent care utilization responses, and the last three questions capture data on education, gender, and age group.

Â·

: You meet with your Primary Care Physician greater than one time per year. Responses Strongly Disagree to Strongly Agree.

Â·

: You spend more than 10 minutes with your Primary Care Physician discussing health concerns. Responses Strongly Disagree to Strongly Agree.

Â·

: You are more likely to go to urgent care versus your Primary Care Physician. Responses Strongly Disagree to Strongly Agree.

Â·

: What is the number of times you went to urgent care in the past 12 months? Numerical response requested.

Â·

: Rate your overall satisfaction with the medical office. Responses Strongly Disagree to Strongly Agree.

Â· Q6: What is the highest level of education you completed?

Â· Q7: What is your gender?

Â· Q8: What is your age?

To review the responses from the data collected in the scenario, click on the button below.

Scenario Data

Table 5.3

Patient Dissatisfaction Application Scenario

Point

Description

Broad Topic Area/Title	Understand the relationship between patient satisfaction and usage of services at urgent care facilities.
Problem Statement	Recent indicator identified lower patient satisfaction and higher incidence of using services at urgent care facilities. There is a need to understand the perception of patient satisfaction for the XYZ medical office and decrease usage of urgent care.
Research Questions	What is the patient perception of satisfaction with the medical office? Do patients use urgent care as an alternative to the primary care physician (PCP)? Is there a relationship between patient satisfaction and usage of urgent care facilities?
Hypothesis	H10: There is no relationship between the perception for number of visits and perception of time spent with PCP. H1A: There is a relationship between the perception for number of visits and perception of time spent with PCP. H20: There is no relationship between the perception for number of visits and the likelihood to go to urgent care. H2A: There is a relationship between the perception for number of visits and the likelihood to go to urgent care. H30: There is no relationship between the perception for number of visits and the overall satisfaction. H3A: There is a relationship between the perception for number of visits and the overall satisfaction. H40: There is no relationship between the perception time spent with PCP and likelihood to go to urgent care. H4A: There is a relationship between the perception of time spent with PCP and likelihood to go to urgent care. H50: There is no relationship between the perception of time spent with PCP and overall satisfaction. H5A: There is a relationship between the perception of time spent with PCP and overall satisfaction. H50: There is no relationship between the number of visits to urgent care in past 12 months and overall satisfaction. H5A: There is no relationship between the number of times went to urgent care in past 12 months and overall satisfaction.
Describe Phenomena (qualitative) or Define Variables/ Hypotheses (quantitative)	Nominal: education, gender, age group Ordinal: Survey Questions 1-3 and 5 Continuous: Survey Question 4: Number of visits to urgent care in last 12 months
Sample	80 patients from XYZ medical office
How is Data Being Collected?	Sent electronic survey to 300 patients, and received 80 responses.
How Will Data be Analyzed	Descriptive statistics Correlation analysis
What Were the Results?	Statistical relationships were identified. The null hypothesis would be rejected and the alternative hypothesis would be accepted in all cases. From a practical perspective, while the results indicated higher scores for the likelihood to go to urgent care versus the PCP, the actual descriptive statistics for urgent care visits do not support this.

Communicating Results

The data can be sorted for communication based upon summary and descriptive statistics for some of the variables prior to the hypothesis tests. As an example, to describe the sample respondents by age group and gender, the data can be converted in Excel to percentages (see Table 5.4). These percentages can be written out or included in a table.

Table 5.4

Converting Frequency to Percentage Example

13.8%

13.3%

20.0%

Total

Age Group	Female	Percent Female	Male	Percent Male		Total	Percent Total by Age Group
< 20	9	18.0%	2	6.7%			11		13.8%
20-25	7	14.0%			4			13.3%
23-31			10		20.0%	5	16.7%	15	18.8%
32-37	8	16.0%	12	15.0%
38-43	6	12.0%	12.5%
> 44	36.7%	21	26.3%
50	30									80

Even though the responses to the survey questions were ordinal as they were translated from Strongly Disagree (1) to Strongly Agree (5), with larger samples, responses can be treated as continuous. Frequently, the three most common forms of descriptive statistics are displayed in a chart. These include the mean, median, and standard deviation (see Table 5.5).

Table 5.5

Example of Descriptive Statistics

2.00

1.41

Question		n	M	Mdn	SD
		Q1	1.93		2.00	1.11
		Q2	2.15	1.29
	Q3	3.31	4.00		1.41
	Q4	1.00	1.37
	Q5	3.13	3.00	1.31

Beyond addressing some information on descriptive statistics, the hypothesis tests need to be addressed. Prior to conducting statistical testing, the data needs to be assessed for normality. When assessing for normality, a statistical program, such as SPSS, determines if the data meets the conditions of a normal distribution. Often, when data is derived from survey data responses with ranges from strongly disagree to strongly agree, the data is not normally distributed unless the samples are very large. In this case, the sample received was only 80. Table 5.6 displays the normality tests for the variables that will be tested. Because the sample size is lower, the

Shapiro-Wilk

results should be used. The Kolmogorov-Smirnov test is most applicable for samples of more than 2,000 data points. Based upon a 0.05 level of significance, a researcher would reject the null hypothesis, which stated that the data was normally distributed.

Table 5.6

Test for Normality

Statistic

Sig.

.000

Tests of Normality
Kolmogoroz-Smirnova	Shapiro-Wilk
	Statistic	df	Sig.
.247				.000	.771
.250	.810
.237	.866
.256	.801
.211	.895
a. Lilliefors Significance Correction

Because the test results identified that the data was not normally distributed, a nonparametric test would be used to conduct the hypothesis testing for correlation. The correlation test to use in this scenario is the Spearman Rho test. If the data was normally distributed, the commonly used Pearson Product Moment test would be used. Table 5.7 demonstrates the SPSS output for the Spearman Rho correlation test between survey Questions 1 and 2. Correlation coefficients are reviewed on a scale of -1 to +1. The relationship is stronger if the calculated coefficient is closer to either -1 or +1. In this case, there is a strong relationship between meeting with the PCP more than one time per year and spending more than 10 minutes with the PCP discussing health concerns. Another statistic to review in the output is the

p value

. If the p-value is less than the level of significance identified in the study, the null hypothesis would be rejected and the alternative hypothesis would be accepted.

Table 5.7

Test for Correlation

Q1&Q2

.000

Correlation Coefficient

.777**

1.000

Sig. (2-tailed)

.000

Spearmanâs rho

Correlation Coefficient

1.000

.777

Sig. (2-tailed)

Correlation coefficients are reviewed on a scale of -1 to +1. The relationship is stronger if the calculated coefficient is closer to either -1 or +1. If the correlation coefficient is positive, then the two variables are moved upward in the same direction. If the statistic is negative, then one variable increases as the other variable results decrease (Levine, Krehbiel, Berenson, 2013). In this case, there is a strong relationship between meeting with PCP more than one time per year and spending more than 10 minutes with the PCP discussing health concerns. Another statistic to review in the output is the p-value. If the p-value is less than the level of significance identified in the study, the null hypothesis would be rejected and the alternative hypothesis would be accepted. Table 5.8 displays the remaining correlation coefficients depicted in the table as r and the corresponding p-values for the test.

Table 5.8

Correlation tests from Example

.000*

Variable	râs	p-value
Q1&Q2	.777		.000*
Q1&Q3	.566
Q1&Q5	-.313	.005*
Q2&Q3	.419
Q2&Q5	-.348	.002*
Q4&Q5	-.212	.060*

Table 5.8 demonstrates that there is a statistical correlation between all variables tested at a 0.05 level significance except Q4 (number of times visited urgent care in the last 12 months) and Q5 (overall satisfaction with the medical office). The data output requires analysis to the original hypothesis questions in the study.

Reflective Summary

This chapter reviewed the application of statistics to research, how to identify data, select the appropriate tests, and apply this to data sets. The chapter also explored how to review articles or studies for the key elements for understanding. This understanding was further applied to a practical scenario including analysis of data collected. The statistical and practical analysis of results for communication are essential in the roles of a clinician and the tools learned in this course provided the framework for increased understanding.

Key Terms

Hypothesis: A testable statement of a relationship; an epidemiologic hypothesis is the relationship is between the exposure (person, time, and/or place) and the occurrence of a disease or condition.

M: Table notation for statistical mean of data array.

Mdn: Table notation for statistical median of data array.

N: Table notation representing the sample size.

P values: The probability that there is enough evidence to make conclusions resulting from the data collected in the study.

r: Table notation representing the coefficient of correlation.

SD: Table notation representing the standard deviation of the data array.

Variable: A data item such as characteristics, numbers, properties, or quantities that can be measured or counted. The value of the data item can vary or be manipulated from one entity to another. There are three different types of variablesâdependent, independent, and extraneous.

References

Aljohani, A. H., Alrubyyi, M. A., Alharbi, A. B., Alomair, A. M., Alomair, A. A., Aldossari, N. A., & … Tallab, O. M. (2018). The relation between diabetes type II and anemia. The Egyptian Journal of Hospital Medicine, 70(4), 526. doi:10.12816/0043795

Levine, D. M., Krehbiel, T. C., & Berenson, M. L. (2013). Business statistics: A first course (6th ed.). Upper Saddle River, NJ: Pearson.

What Will You Get?

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