Table A
 

References

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Table A  Potential low cost interventions that may improve maternal and child health in South Asia at health system level
 

Intervention	Strength of evidence*	Potential impact or effect size	Relative ease of implementation	Barriers or remaining issues before nationwide implementation
Nutrition education to improve balanced energy protein intake and promotion of intake of iodised salt	I	Reduction of iodine deficiency of 80-100% Reduction in perinatal mortality demonstrated	Moderately easy for promotion of iodised salt use	Nutrition education is time consuming and labour intensive. Could be integrated with other sectors e.g. education, family planning using mass media.
Vaccination against tetanus twice during pregnancy	I	>95% for prevention of neonatal tetanus	Relatively easy	Public education and awareness
Maternal malaria prevention and treatment (bed nets or presumptive therapy)	I	25% reduction in low birth weight babies and reduction in perinatal mortality	Requires functional health systems	Selective benefit only in malaria endemic areas
Recognition of high risk pregnancy and timely referrals	II	Despite misgivings, up to 50% reduction of maternal mortality shown in functioning health system settings	Difficult outside of functional health systems	Development of core indicators and targeted training programmes. Linkages needed between health providers and first level facilities
Intrapartum care of mother including facilitation of skilled birth attendance and clean birth	I	15% reduction in perinatal complications and 4% reduction in maternal deaths	Difficult in areas where skilled birth attendants are sparse	Despite barriers and difficulties, must be an absolute goal for health systems in South Asia
Regular iron folate and maternal low dose vitamin A administration	II	Reduction in rates of iron deficiency anaemia difficult to estimate but significant reduction in maternal mortality	Compliance may be variable	Regular availability and quality of tablets are key. Commensurate need for public education and an integrated programme of nutrition education
Promotion of exclusive breastfeeding	I	Clear evidence of impact on mortality and morbidity reduction	Counselling skills required	No major barriers to widespread application. Especially required in early infancy
Appropriate complementary feeding of infants and use of iodised salt	I	Improved complementary feeding strategies result in an average 0.35 Z score increment and improvement in survival rates	Unlike complementary feeding the promotion and use of iodised salt is relatively easy	Must be integrated with the overall nutrition education programme
Management of diarrhoeal disease (including appropriate feeding and antibiotic use for dysentery) and oral replacement therapy	I	Evidence of benefit on morbidity and mortality	Easy to implement	Must be scaled up within health systems with assured availability of oral rehydration therapy and drugs
Recognition and management of acute respiratory infection	I	Community management leads to 24-27% reduction in all cause under 5 mortality and 36-42% in pneumonia mortality	Feasible for community health workers	Requires better "hands on" training programmes for community health workers
Promotion and administration of childhood vaccinations	I	Impact on health outcomes well established	Easy	Cold chain and vaccine availability remain issues
Care of the low birth weight infant	I	Benefits of skin to skin care or appropriate early care established	Easy but supervision needed	Some cultural barriers exist to skin to skin care in South Asia, but feasible
Recognition of serious neonatal illness, stabilisation and referral	I	Neonatal mortality reduced by 50% (76% for sepsis related mortality) if injectable antibiotics provided to community health workers	Moderately difficult to train community health workers	Strong demand for domiciliary or village based care in rural settings. Further evidence needed in health system settings
Provision of contraceptives including injectable preparations	I	Efficacy (over 98%) of depot-Provera well established	Easy	No significant barriers to inclusion in primary care programmes
Health education especially hand washing	I	Established efficacy of health and nutrition education in several studies, although rates of success vary	Feasible	Communication skills required. Limitations of restricted messages and media

*Level of evidence: I=established evidence (both efficacy and effectiveness), II=intermediate evidence (efficacy but not effectiveness)
 

Rapid Responses:

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South Asian women and children are ready for change but resources and political will lacking

Mridula Bandyopadhyay
bmj.com, 16 Apr 2004 [Full text]