title: Effective Linkages of Continuum of Care for Improving Neonatal, Perinatal, and Maternal Mortality: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Continuum of care has the potential to improve maternal, newborn, and child health (MNCH) by ensuring care for mothers and children. Continuum of care in MNCH is widely accepted as comprising sequential time (from pre-pregnancy to motherhood and childhood) and space dimensions (from community-family care to clinical care). However, it is unclear which linkages of care could have a greater effect on MNCH outcomes. The objective of the present study is to assess the effectiveness of different continuum of care linkages for reducing neonatal, perinatal, and maternal mortality in low- and middle-income countries.
  
  
  METHODS
  We searched for randomized and quasi-randomized controlled trials that addressed two or more linkages of continuum of care and attempted to increase mothers' uptake of antenatal care, skilled birth attendance, and postnatal care. The outcome variables were neonatal, perinatal, and maternal mortality.
  
  
  RESULTS
  Out of the 7,142 retrieved articles, we selected 19 as eligible for the final analysis. Of these studies, 13 used packages of intervention that linked antenatal care, skilled birth attendance, and postnatal care. One study each used packages that linked antenatal care and skilled birth attendance or skilled birth attendance and postnatal care. Four studies used an intervention package that linked antenatal care and postnatal care. Among the packages that linked antenatal care, skilled birth attendance, and postnatal care, a significant reduction was observed in combined neonatal, perinatal, and maternal mortality risks (RR 0.83; 95% CI 0.77 to 0.89, I2 79%). Furthermore, this linkage reduced combined neonatal, perinatal, and maternal mortality when integrating the continuum of care space dimension (RR 0.85; 95% CI 0.77 to 0.93, I2 81%).
  
  
  CONCLUSIONS
  Our review suggests that continuous uptake of antenatal care, skilled birth attendance, and postnatal care is necessary to improve MNCH outcomes in low- and middle-income countries. The review was conclusive for the reduction of neonatal and perinatal deaths. Although maternal deaths were not significantly reduced, composite measures of all mortality were. Thus, the evidence is sufficient to scale up this intervention package for the improvement of MNCH outcomes.
authors.affiliation: Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Tokyo, Japan.
authors.forename: Kimiyo
authors.initials: K
authors.lastname: Kikuchi
authors.affiliation: Research and Development Division, Ghana Health Service, Accra, Ghana.
authors.forename: Evelyn Korkor
authors.initials: EK
authors.lastname: Ansah
authors.affiliation: Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Tokyo, Japan.
authors.forename: Sumiyo
authors.initials: S
authors.lastname: Okawa
authors.affiliation: Kintampo Health Research Centre, Kintampo, Brong-Ahafo, Ghana.
authors.forename: Yeetey
authors.initials: Y
authors.lastname: Enuameh
authors.affiliation: Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Tokyo, Japan.
authors.forename: Junko
authors.initials: J
authors.lastname: Yasuoka
authors.affiliation: Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Tokyo, Japan.
authors.forename: Keiko
authors.initials: K
authors.lastname: Nanishi
authors.affiliation: Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Tokyo, Japan.
authors.forename: Akira
authors.initials: A
authors.lastname: Shibanuma
authors.affiliation: Dodowa Health Research Centre, Dodowa, Greater Accra, Ghana.
authors.forename: Margaret
authors.initials: M
authors.lastname: Gyapong
authors.affiliation: Kintampo Health Research Centre, Kintampo, Brong-Ahafo, Ghana.
authors.forename: Seth
authors.initials: S
authors.lastname: Owusu-Agyei
authors.affiliation: Navrongo Health Research Centre, Navrongo, Upper-East, Ghana.
authors.forename: Abraham Rexford
authors.initials: AR
authors.lastname: Oduro
authors.affiliation: Ghana Health Service, Ministries, Accra, Ghana.
authors.forename: Gloria Quansah
authors.initials: GQ
authors.lastname: Asare
authors.affiliation: Research and Development Division, Ghana Health Service, Accra, Ghana.
authors.forename: Abraham
authors.initials: A
authors.lastname: Hodgson
authors.affiliation: Department of Community and Global Health, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Tokyo, Japan.
authors.forename: Masamine
authors.initials: M
authors.lastname: Jimba
mesh_terms: D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008427:Maternal Health Services; D008428:Maternal Mortality; D011247:Pregnancy; D011295:Prenatal Care