Measuring the strength of maternal, newborn and child health care implementation and its association with childhood mortality risk in three rural districts of Tanzania

This observational cohort study explores the association between maternal, newborn and child health care implementation strength and child survival in rural Tanzania from 2011-2015. We used data from a 2011 service availability and readiness assessment that quantified primary health care facilities’ ability to implement maternal, newborn and child health services and a population-level household survey that measured the utilization of such services to develop domain-specific summary measures of the effective coverage of facility-based maternal, newborn and child health care. We reduced domain specific effective coverage scores into fewer, independent scales of implementation strength using principal components analysis, and integrated them into gradients of the collective implementation strength exerted by groups of facilities on villages they served using Bayesian mixed effects models. We linked these scales to longitudinal data on the survival of children that were born in the catchment areas of the surveyed health facilities during the assessment period and followed up until December 31, 2015. We fit survival time models to estimate the relationship between implementation strength and child mortality. Increases in the implementation strength gauged by our first scale, which represented general facility readiness and the provision of antenatal, postnatal, and early childhood preventive services, were associated with  child mortality risks that were, on average, 0.62 times lower. Increases in implementation strength gauged by our second scale, which represented sick childcare service provision, were associated with child mortality risks that were, on average,  0.56 times lower. We detected no significant child mortality response to our third scale, which represented intrapartum care provision. The findings suggest that strong implementation of antenatal, postnatal, early childhood preventive services and sick child care can accelerate child mortality reduction and that routine data on service availability and readiness can be used to measure health systems strengthening and its impacts. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Approval for this study was granted by the ethical review boards of the IHI (IHI/IRB/No. 16-2010), the National Institute for Medical Research of Tanzania (NIMR/HQ/R.8a/Vol.IX/1203), and the Institutional Review Board of Columbia University Medical Center (Protocol AAF3452). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data cannot be shared publicly but can be made available subject to the approval of a material transfer agreement between parties interested in obtaining the data and the National Medical Research Coordinating Committee of the National Institutes of Medical Research of Tanzania. The MTA and application instructions are available at: https://healthresearchwebafrica.org.za/files/MTA.pdf). Those interested in obtaining the data should also contact the corresponding author for assistance with the Material Transfer Agreement.