The impact of health reform on maternal and child health indicators in developing countries: A systematic review

Maternal and child health indicators were the focused issues of both programs leading to a substantial improvement in reduction of mortality, providing services, and promoting their health. Health policy makers of the country executed health transformation plan in 2014 to respond to main challenges especially regarding the high cost of treatment, lack of enough coverage, improper facilities, and redundant therapies and procedures. Primary reports showed the success of the results of this plan. Aim: The study aims to investigate the impact of reform program on maternal and child health indicators in developing countries. Method: This study was conducted as a systematic review by searching on SID, Magiran, Pubmed, Science Direct, and Scopus during 20002017. The searched keywords in Farsi databases: health reforms, the impact of changes in health, consequences of health reforms, maternal and child health indicators, and their Latin equivalences on English databases. Then data were entered in summary tables and at the next step were investigated and concluded. Result: According to inclusion and exclusion criteria, the result of the searching was 2837 articles refined step by step, and finally 19 items were selected and analyzed. The results of national studies showed that after executing health reform program, the rate of cesarean section decreased about 2.5-4% in the country in the first three-month period of execution of the program and total status of realization of indicators was in a desirable level. Natural childbirth promotion program (free natural childbirth franchise indicator) was 90.8%. Global experiences also show that mortality rate of newborns decreased from 11.1% to 9.1% after reform and promotion of health system in Mozambique. Also, health reforms in Pakistan for developing the health of mothers and newborns showed that beneficiaries should support evidencebased interventions for the sake of the health of mothers and newborns. Finally, health reform in Indonesia, Nepal, Philippines, and India showed that the rate of mortality of mothers, newborns, and stillbirth had been reduced. Conclusion: The reforms have had a positive impact on maternal and child health indicators. The realization status of indicators has reached an acceptable level through execution of reform. The main reasons for improvement within indicators are the extension of the health system, increase in labor force, and more support by government for the health


INTRODUCTION
The primary objectives of the health system are to provide, maintain, and improve health level and meet the people's need alongside with establishing a fair system of financial contribution. 1 The managers of the system in these rapidly changing environments face various challenges resulted from technology development, knowledge explosion, growing demand of customers and politicians for improving quality, justice, and changing nature of diseases. They continually seek new solutions in response to increasing tensions such lack financial resources and reaching high efficiency. 2, 3 All around the world, the change in lifestyle and burden of diseases, boosting growth in medical expenses, aging population, high level of chronic diseases, inabilities, and developments of therapeutic technologies have revealed a shortage of traditional structures of the health system in response to recently appeared needs. 4,5 They also have made it inevitable to execute reforms. 6 Usually, reforms are designed and implemented aiming at increasing financial access and expanding coverage of services, reduction of injustice, infrastructure development, strengthening of the information system, and providing effective and high-quality health services. 7, 8 Iranian health system has also got some important issues in its history during recent decades including setting up health networks based on primary health care for accessing global goal of health for everyone up to 2000 in the 1980s. 7 It also executes family physician and rural insurance programs (2014) for the sake of general coverage of health and millennium development goals. 8

SYSTEMATIC REVIEW
child health indicators were the focused issues of both programs leading to a substantial improvement in reduction of mortality, providing services, and promoting their health. 11, 12 However, health policy makers of the country executed health transformation plan in 2014 to respond to main challenges especially regarding the high cost of treatment, lack of enough coverage, improper facilities, and redundant therapies and procedures. Primary reports showed the success of the results of this plan. 15-18 The mentioned program includes eight axes. One of the most important is natural childbirth promotion program and reduction of cesarean with the general goal of promoting maternal and child health indicators. 19 Cesarean as one of the health problems with many consequences for patients. It results in significant costs, various complications, and finally, decrease in quality of life of the patients. 20 But in Iran, a cesarean is much more than WHO advice (15 percent of all deliveries). 21-24 Those reports show the percentages about 26 to 60 and even 87 in some private centers which are higher than countries like America (22%), Brazil (25%), Chile (27%), and nineteen Latin American countries (17 to 40%). 25 The most important point is the rate is rapidly increasing. It is an underlying factor for an adverse effect on maternal and child health indicators. 26 Therefore, according to the importance of the subject of maternal and child health indicators, this study has been designed and executed aiming at investigating the effects of health reform on maternal and child health indicators in developing countries. Inclusion criteria involve health reforms, maternal and child health indicators, developing countries, as well as full articles and abstracts of articles in Farsi and English. On the other hands, exclusion criteria filter financial, structural, and educational reforms, health and non-health indicators of child, reports of health reforms, and lack of access to full article, abstracts, and books. Then the findings were extracted as summary tables, and investigation and conclusion were made at the next step as well. Qualitative content analysis method was used to analyze and combine the results of this study.

RESULT
According to the inclusion and exclusion criteria, the result of this search was 2837 articles which were refined step by step leading to 11 full-text articles and two booklets of abstracts of conferences. There are eight abstracts which were related to the subject and involved in the study. Eleven full text included countries of Iran, Africa, Pakistan, India, Indonesia, and Nepal, as well as eight abstracts, were for Iran as summary tables. The conducted studies were about the impact of health reform on the rate of indicators of cesarean, natural childbirth, the rate of stillbirth, and maternal and child mortality.

DISCUSSION
Considering the importance of the subject and its expansion, as well as a comparison of the impact of health reforms on the third-world countries, they are suggested to conduct systematic, case, and pilot studies. Studies showed that executing reforms of delivery affects total indicators of maternal and child health in a way by increasing the rate of Diagram 1 Stages of extracting the studies Seventy-three percent of hospitals were public, and 27% were specialized. The lowest mean and the most undesirable standard deviation was for an increase in the number of natural childbirth and the highest mean and the most popular standard deviation was for specialized hospitals comparing with pre-reform plan execution. Dimensions of promoting natural birth program had got approximately beneficial status.
The study was conducted as descriptive-cross sectional for four months. The statistical population included 129 hospitals of 57 universities, sampling was random, and material was a standard checklist of ministry including 12 questions and five-axes. The analysis was made by SPSS software. The cesarean rate in all country was 56.1% in 2013, and in the first threemonth period of health reform plan, it was 53.6%. The cesarean rate in state hospitals was 47% before health reform and 43% after health reform.
It was a review study using data in mother and baby information registry system. Although there was an increase in natural childbirth rate in the 6-month period of health reform plan than before, this increase was not significant.
The study is descriptiveanalytical. Statistical population includes all public hospitals of Isfahan as census, and data collection was conducted through referring to Vice-Chancellor in Treatment Affairs. The analysis was made by SPSS software.
Comparison of rates of natural childbirth and cesarean between the first 6-month of executing health reform plan and the same period of the former year in general hospitals of Isfahan Due to development of health system in Mozambique, mortality of children has fallen from 11.1% to 9.1%. Mortality of children has severely reduced by increasing the ratio of nurse per mother and entirely by increasing labor force. The decrease in mortality of children was significant during 2000-2014which was due to development of health system especially human resources unit and higher support of government to the health system.  The results showed that in the prehealth-reform stage the rate of normal childbirth was 39.5% (799 cases in 200) while this rate increased to 57% after health reform (114 cases out of 200). Results of the deductive analysis showed that there was a significant difference in natural childbirth prevalence (t= -7.987, P<0.001) and cesarean prevalence (t= 6.988, P<0.001) before and after health reform plan.

SYSTEMATIC REVIEW
The study has been conducted as cross sectional and retrospective, and its statistical population includes all women referring to Ardabil Bou-Ali Educational Hospital for delivery (2013)(2014)(2015). A random sample was selected as 200 cases before health reform and 200 cases after health reform plan. The self-made checklist has been used to collect data and data have been analyzed by STATA software.

Iran 2017
Zandian et al. Impact of health reform plan on prevalence and costs of normal childbirth and cesarean Of 5 studied physicians employed in the hospital, four managed to decrease the percentage of cesarean to total delivery rate from 3 to 7 percent compared with base year. But the objective of 10 percent reduction in cesarean rate was not met in the performance of any physician. Of the total documents, a 2-percent decrease was observed in cesarean rate. This cross sectional research was conducted using information of activities of physicians and Obstetricians. Required data were collected from hospital information system and the statistics of deliveries in two methods of natural and cesarean were extracted separately for 2013 and 2014. Excel 2013 software was used for descriptive analysis of data.  Table 1 Continues

Method Country Year Authors Title of study
Results of Indonesia have been provided in the format of 4 regions. In Sika region the reduction rate of mortality among mothers, newborns, and under-5-year children in a 5-year period were 24, 14, and 7 percent respectively. In Merakeh region reduction in mortality of mothers was 35%, newborns 33%, and under-5-year children 13%. In Puntik region reduction rate in mortality among mothers, newborns, and under-5-year children in a 5-year period were 15, 12, and 5 percent respectively. In Tasikmalaya region reduction in mortality of mothers was 14%, newborns 15%, and under-5-year children 7%. Results related to Nepal have been provided in 3 clusters. In the cluster of Tray reduction rate in mortality of mothers, newborns, and under-5-year children in a 5-year time interval were 23, 39, and 18 percent respectively. In the cluster of Hills reduction in mortality of mothers was 34%, newborns 57%, and under-5-year children 33%. In the cluster of Mountains reduction in mortality of mothers was 26%, newborns 40% and under-5-year children 24%. Results of Philippines has been provided in three regions. In Psay city the reduction rate of mortality among mothers, newborns, and under-5-year children in a 5-year period were 13, 5, and 5 percent respectively. In Northern Samar mortality of mothers decreased 39%, for newborns decreased 25% and for under-5-year children decreased 17%. In Eastern Samar the reduction rate of mortality among mothers, newborns, and under-5-year children in a 5-year period were 45, 26, and 20 percent respectively. Results related to India have been presented in two regions. In Kendrapara the reduction rate of mortality among mothers, newborns, and under-5-year children in a 5-year period were 34, 35, and 23 percent respectively. In Riagada mortality of mothers decreased 28%, for newborns decreased 35% and for under-5-year children decreased 25%.
Case investment has been provided in the mentioned countries for regional planning based on evidence and budgeting to present high quality maternal and child services. The framework of case investment includes foundations of strategic problem solving and decision support models. In this study identification and analysis of strategies of interventions of promoting maternal and child, cares were investigated through cohort study design. normal childbirth. Furthermore, they also consequently decrease the cesarean mortality rate of newborns and mothers. Additionally, it is possible for the rate of maternal complications to increase. 28 The study of Goudarzi, et al. in Iran showed that the lowest mean and the most unfavorable standard deviation is related to rise in the number of normal childbirth. In contrast, the highest mean and the most favorable standard deviation is similar to specialized hospitals. 16 Executing Iran health reform plan caused improvement in the status of maternal and child health indicators due to the decrease in cesarean rate (based on the study of Afshari et al.). 16 Fernandez et al. showed that mortality rate of newborns has decreased in Mozambique which could be due to the expansion of health system, increase in the ratio of nurse to mother, and an increase in labor force and higher support of government for health system. 28 On the other hand, Health Promotion Committee of India has estimated that maternal mortality in India reduced to 1000 in 1959 as the main reason was a decrease of malaria outbreak in pregnant women. 29 In a study conducted by Zendanian et al., they found out that the rate of normal delivery has increased after health reform plan. There are significant differences in prevalence of normal childbirth (t= -7.987, P<0.001) and cesarean prevalence (t= 6.988, P<0.001) before and after health reform plan. 30 In a study conducted by Rooyin Tan and Aghaei, they observed that the rates of natural delivery and cesarean were 35.3 and 64.7 in 2013 and were 41.4 and 58.6 in 2014 respectively. They show a 6-percent increase in natural childbirth. 32 In the study of Jamens Soto et al., they understood that maternal and child mortality has decreased in various amounts in different regions of understudied countries. They shows the effectiveness of health reform in promoting maternal and child mortality indicator in the mentioned countries. 33 In addition, the results of the study of Naderi Magham et al., showed that mortality rate of newborns following the execution of urban family physician plan had decreased 34%. 34, 35 The results of that study are similar to those of Gupeta et al. in India 36

CONCLUSION
Finally, according to conducted studies, it is possible to conclude that the most important indicators of maternal and child health which were affected by the health system reformation are natural childbirth, the ratio of cesarean to natural childbirth,

Method Country Year Authors Title of study
The results of this study showed that mortality rate of newborns had been decreased 34% as a result of urban family physician plan.
In this study, three separate regression models were designed to investigate the impact of the plan on mortality of newborns. Second-hand information resources were used in this study.