title: Demand-side interventions for maternal care: evidence of more use, not better outcomes.
abstract: BACKGROUND
  Reducing maternal and neonatal mortality is essential to improving population health. Demand-side interventions are designed to increase uptake of critical maternal health services, but associated change in service uptake and outcomes is varied. We undertook a literature review to understand current evidence of demand-side intervention impact on improving utilization and outcomes for mothers and newborn children.
  
  
  METHODS
  We completed a rapid review of literature in PubMed. Title and abstracts of publications identified from selected search terms were reviewed to identify articles meeting inclusion criteria: demand-side intervention in low or middle-income countries (LMIC), published after September 2004 and before March 2014, study design describing and reporting on >1 priority outcome: utilization (antenatal care visits, facility-based delivery, delivery with a skilled birth attendant) or health outcome measures (maternal mortality ratio (MMR), stillbirth rate, perinatal mortality rate (PMR), neonatal mortality rate (NMR)). Bibliographies were searched to identify additional relevant papers. Articles were abstracted using a standardized data collection template with double extraction on a sample to ensure quality. Quality of included studies was assessed using McMaster University's Quality Assessment Tool from the Effective Public Health Practice Project (EPHPP).
  
  
  RESULTS
  Five hundred and eighty two articles were screened with 50 selected for full review and 16 meeting extraction criteria (eight community mobilization interventions (CM), seven financial incentive interventions (FI), and one with both). We found that demand-side interventions were effective in increasing uptake of key services with five CM and all seven FI interventions reporting increased use of maternal health services. Association with health outcome measures were varied with two studies reporting reductions in MMR and four reporting reduced NMR. No studies found a reduction in stillbirth rate. Only four of the ten studies reporting on both utilization and outcomes reported improvement in both measures.
  
  
  CONCLUSIONS
  We found strong evidence that demand-side interventions are associated with increased utilization of services with more variable evidence of their impact on reducing early neonatal and maternal mortality. Further research is needed to understand how to maximize the potential of demand-side interventions to improve maternal and neonatal health outcomes including the role of quality improvement and coordination with supply-side interventions.
authors.affiliation: Department of Global Health and Population, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, USA. taylor.hurst@mail.harvard.edu.
authors.forename: Taylor E
authors.initials: TE
authors.lastname: Hurst
authors.affiliation: Ariadne Labs, 401 Park Drive 3 East, Boston, MA, USA. ksemrau@ariadnelabs.org.|Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA. ksemrau@ariadnelabs.org.
authors.forename: Katherine
authors.initials: K
authors.lastname: Semrau
authors.affiliation: Department of Obstetrics and Gynecology, Cambridge Health Alliance, Cambridge, MA, USA. mpatna@challiance.org.|Harvard Medical School, Boston, MA, USA. mpatna@challiance.org.
authors.forename: Manasa
authors.initials: M
authors.lastname: Patna
authors.affiliation: Ariadne Labs, 401 Park Drive 3 East, Boston, MA, USA. agawande@partners.org.|Harvard Medical School, Boston, MA, USA. agawande@partners.org.|Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. agawande@partners.org.
authors.forename: Atul
authors.initials: A
authors.lastname: Gawande
authors.affiliation: Ariadne Labs, 401 Park Drive 3 East, Boston, MA, USA. lhirschhorn@ariadnelabs.org.|Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA. lhirschhorn@ariadnelabs.org.|Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. lhirschhorn@ariadnelabs.org.
authors.forename: Lisa R
authors.initials: LR
authors.lastname: Hirschhorn
mesh_terms: D005260:Female; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D008427:Maternal Health Services / Q000600:supply & distribution*; D008428:Maternal Mortality; D054238:Perinatal Mortality; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data*; D058996:Quality Improvement; D050497:Stillbirth / Q000453:epidemiology*