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Solnes Miltenburg A, Kvernflaten B, Meguid T, Sundby J. Towards renewed commitment to prevent maternal mortality and morbidity: learning from 30 years of maternal health priorities. Sex Reprod Health Matters 2023; 31:2174245. [PMID: 36857112 PMCID: PMC9980022 DOI: 10.1080/26410397.2023.2174245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Affiliation(s)
- Andrea Solnes Miltenburg
- Associate Professor in Global Health, Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway; Resident in Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
| | - Birgit Kvernflaten
- Researcher, Department for Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Tarek Meguid
- Associate Professor, Consultant Obstetrician & Gynaecologist, Department of Maternal and Child Health, University of Namibia, Windhoek, Namibia
| | - Johanne Sundby
- Professor, Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
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Working lives of maternity healthcare workers in Malawi: an ethnography to identify ways to improve care. AJOG GLOBAL REPORTS 2022; 2:100032. [PMID: 36274966 PMCID: PMC9563393 DOI: 10.1016/j.xagr.2021.100032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Maternal mortality in East Africa is high with a maternal mortality rate of 428 per 100,000 live births. Malawi, whilst comparing favourably to East Africa as a whole, continues to have a high maternal mortality rate (349 per 100,000 live births) despite it being reduced by 53% since 2000. To make further improvements in maternal healthcare, initiatives must be carefully targeted and evaluated to achieve maximum influence. The Malawian Government is committed to improving maternal health; however, to achieve this goal, the quality of care must be high. Furthermore, such a goal requires enough staff with appropriate training. There are not enough midwives in Malawi; therefore, focusing on staff working lives has the potential to improve care and retain staff within the system. OBJECTIVE This study aimed to identify ways in which working lives of maternity healthcare workers could be enhanced to improve clinical care. STUDY DESIGN We conducted a 1-year ethnographic study of 3 district-level hospitals in Malawi. Data were collected through observations and discussions with staff and analyzed iteratively. The ethnography focused on the interrelationships among staff as these relationships seemed most important to working lives. The field jottings were transcribed into electronic documents and analyzed using NVivo. The findings were discussed and developed with the research team, participants, and other researchers and healthcare workers in Malawi. To understand the data, we developed a conceptual model, “the social order of the hospital,” using Bourdieu's work on political sociology. The social order was composed of the social structure of the hospital (hierarchy), rules of the hospital (how staff in different staff groups behaved), and precedent (following the example of those before them). RESULTS We used the social order to consider the different core areas that emerged from the data: processes, clinical care, relationships, and context. The Malawian system is underresourced with staff unable to provide high-quality care because of the lack of infrastructure and equipment. However, some processes hinder them on national and local level, for example staff rotations and poorly managed processes for labeling drugs. The staff are aware of the clinical care they should provide; however, they sometimes do not provide such care because they are working with the predefined system and they do not want to disrupt it. Within all of this, there are hierarchical relationships and a desire to move to the next level of the system to ensure a better life with more benefits and less direct clinical work. These elements interact to keep care at its most basic as disruption to the “usual” way of doing things is challenging and creates more work. CONCLUSION To improve the working lives of the Malawian maternity staff, it is necessary to focus on improving the working culture, relationships, and environment. This may help the next generation of Malawian maternity staff to be happier at work and to better provide respectful, comprehensive, high-quality care to women.
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Vestering A, de Kok BC, Browne JL, Adu-Bonsaffoh K. Navigating with logics: Care for women with hypertensive disorders of pregnancy in a tertiary hospital in Ghana. Soc Sci Med 2021; 289:114402. [PMID: 34600357 DOI: 10.1016/j.socscimed.2021.114402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 09/02/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
This paper explores how care for women with hypertensive disorders of pregnancy (HDP) is practiced in a tertiary hospital in Ghana. Partly in response to the persistently high maternal and neonatal mortality rates in Low- and Middle-income countries, efforts to improve quality of maternity care have increased. Quality improvement initiatives are shaped by the underlying conceptualisation of quality of care, often driven by global (WHO) standards and protocols. However, there are tensions between global standards of care and local clients' and providers' understandings of care practices and quality of care. Implementation of standards is further complicated by structural and organisational restrictions that influence providers' possibilities and priorities. Based on ethnographic fieldwork, we explore how clinical guidelines and professionals' and patients' perspectives converge and, more importantly, diverge. We illuminate local, situated care practices and show how professionals creatively deal with tensions that arise on the ground. In this middle-income setting, caring for women with HDP involves tinkering and navigating in contexts of uncertainty, scarcity, varying responsibilities and conflicting interests. We unravelled a complex web of, at times, contradictory logics, from which various forms of care arise and in which different notions of good care co-exist. While practitioners navigated through and with these varying logics of care, the logic of survival permeated all practices. This study provides important initial insights into how professionals might implement and innovatively adapt the latest quality of maternity care guidelines which seek to marry clinical standards and patients' needs, preferences and experiences.
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Affiliation(s)
| | | | - Joyce L Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Kwame Adu-Bonsaffoh
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands; Department of Obstetrics and Gynaecology, School of Medicine and Dentistry, University of Ghana, Accra, Ghana
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Camara BS, Benova L, Delvaux T, Sidibé S, El Ayadi AM, Grietens KP, Delamou A. Women's progression through the maternal continuum of care in Guinea: Evidence from the 2018 Guinean Demographic and Health Survey. Trop Med Int Health 2021; 26:1446-1461. [PMID: 34310807 PMCID: PMC9292596 DOI: 10.1111/tmi.13661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objective To examine women's progression through the antenatal, birth, and post‐partum maternal care in Guinea in 2018. Methods Using the Guinea Demographic and Health Survey of 2018, we analysed data on most recent live births in the 24 months preceding the survey among women aged 15–49 and the determinants (health system, quality of care, reproductive and sociodemographic factors) of women's progression through three steps of the continuum of care, using multivariable logistic regression. Results In the sample of 3,018 women, 87% reported at least one ANC visit (ANC1) with a health professional and 36% reported ANC4+, at least one of which was with a health professional. In the study, 26% of women reported ANC4+ plus birth in a health facility, and 20% reported ANC4+, birth in a health facility, plus post‐partum check‐up. Predictors of woman's progression from ANC1 to ANC4+ visits included living in the administrative regions of Kindia (AOR: 1.96, 95% CI: 1.23–3.14) and Nzérékoré (AOR: 0.50, 95% CI: 0.32–0.79) vs. Kankan, being aged 15 to 17 (AOR: 0.55, 95% CI: 0.35–0.86) vs. aged 25 to 34, having primary or more education (AOR: 1.37, 95% CI: 1.09–1.72), and being from a middle (AOR: 1.52, 95% CI: 1.18–1.96) or wealthier (AOR: 2.38, 95% CI: 1.67–3.39) household vs. a poor household. Living in the administrative regions of Nzérékoré (AOR: 6.27, 95% CI: 1.57–25.05) vs. Kankan, in a middle (AOR: 1.64, 95% CI: 1.05–2.57) or wealthier (AOR: 3.23, 95% CI: 1.98–5.29) household vs. a poor household, nulliparity (AOR: 1.75, 95% CI: 1.03–2.97) vs. 2–4 previous births, the distance to health facility perceived as not being a problem (AOR: 1.75, 95% CI: 1.23–2.50), and higher ANC content score (AOR: 1.29, 95% CI: 1.10–1.52) remained independently associated with progression from ANC4+ to birth in a health facility. Predictors of progression from birth in the health facility to post‐partum check‐up included residing in the administrative regions of Labé (AOR: 0.22, 95% CI: 0.09–0.51) or Faranah (AOR: 0.43, 95% CI: 0.19–0.96) vs. Kankan, higher ANC content score (AOR: 1.76, 95% CI: 1.36–2.28), skin‐to‐skin contact after birth (AOR: 3.00, 95% CI: 1.70–5.31), and being attended at birth by a health professional (AOR: 17.52, 95% CI: 4.68–65.54). Conclusions Removing financial barriers and improving quality of care appear to be important to increase the percentage of women receiving the full maternal continuum of care.
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Affiliation(s)
- Bienvenu Salim Camara
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Amsterdam Institute of Social Science Research, University of Amsterdam, Amsterdam, The Netherlands.,Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Thérèse Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sidikiba Sidibé
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea.,Centre d'Excellence Africain pour la Prévention et le Contrôle des Maladies Transmissibles (CEA-PCMT), Université Gamal Abdel Nasser, Conakry, Guinea
| | - Alison Marie El Ayadi
- Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco, California, USA
| | | | - Alexandre Delamou
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea.,Centre d'Excellence Africain pour la Prévention et le Contrôle des Maladies Transmissibles (CEA-PCMT), Université Gamal Abdel Nasser, Conakry, Guinea
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Aberese-Ako M, Magnussen P, Gyapong M, Ampofo GD, Tagbor H. Managing intermittent preventive treatment of malaria in pregnancy challenges: an ethnographic study of two Ghanaian administrative regions. Malar J 2020; 19:347. [PMID: 32977827 PMCID: PMC7519547 DOI: 10.1186/s12936-020-03422-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/20/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Malaria in pregnancy (MiP) is an important public health problem across sub-Saharan Africa. The package of measures for its control in Ghana in the last 20 years include regular use of long-lasting insecticide-treated bed nets (LLINs), directly-observed administration (DOT) of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and prompt and effective case management of MiP. Unfortunately, Ghana like other sub-Saharan African countries did not achieve the reset Abuja targets of 100% of pregnant women having access to IPTp and 100% using LLINs by 2015. METHODS This ethnographic study explored how healthcare managers dealt with existing MiP policy implementation challenges and the consequences on IPTp-SP uptake and access to maternal healthcare. The study collected date using non-participant observations, conversations, in-depth interviews and case studies in eight health facilities and 12 communities for 12 months in two Administrative regions in Ghana. RESULTS Healthcare managers addressed frequent stock-outs of malaria programme drugs and supplies from the National Malaria Control Programme and delayed reimbursement from the NHIS, by instituting co-payment, rationing and prescribing drugs for women to buy from private pharmacies. This ensured that facilities had funds to pay creditors, purchase drugs and supplies for health service delivery. However, it affected their ability to enforce DOT and to monitor adherence to treatment. Women who could afford maternal healthcare and MiP services and those who had previously benefitted from such services were happy to access uninterrupted services. Women who could not maternal healthcare services resorted to visiting other sources of health care, delaying ANC and skipping scheduled ANC visits. Consequently, some clients did not receive the recommended 5 + doses of SP, others did not obtain LLINs early and some did not obtain treatment for MiP. Healthcare providers felt frustrated whenever they could not provide comprehensive care to women who could not afford comprehensive maternal and MiP care. CONCLUSION For Ghana to achieve her goal of controlling MiP, the Ministry of Health and other supporting institutions need to ensure prompt reimbursement of funds, regular supply of programme drugs and medical supplies to public, faith-based and private health facilities.
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Affiliation(s)
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Margaret Gyapong
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
| | - Gifty D Ampofo
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
| | - Harry Tagbor
- University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
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Nakovics MI, Brenner S, Bongololo G, Chinkhumba J, Kalmus O, Leppert G, De Allegri M. Determinants of healthcare seeking and out-of-pocket expenditures in a "free" healthcare system: evidence from rural Malawi. HEALTH ECONOMICS REVIEW 2020; 10:14. [PMID: 32462272 PMCID: PMC7254643 DOI: 10.1186/s13561-020-00271-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/08/2020] [Indexed: 06/01/2023]
Abstract
BACKGROUND Monitoring financial protection is a key component in achieving Universal Health Coverage, even for health systems that grant their citizens access to care free-of-charge. Our study investigated out-of-pocket expenditure (OOPE) on curative healthcare services and their determinants in rural Malawi, a country that has consistently aimed at providing free healthcare services. METHODS Our study used data from two consecutive rounds of a household survey conducted in 2012 and 2013 among 1639 households in three districts in rural Malawi. Given our explicit focus on OOPE for curative healthcare services, we relied on a Heckman selection model to account for the fact that relevant OOPE could only be observed for those who had sought care in the first place. RESULTS Our sample included a total of 2740 illness episodes. Among the 1884 (68.75%) that had made use of curative healthcare services, 494 (26.22%) had incurred a positive healthcare expenditure, whose mean amounted to 678.45 MWK (equivalent to 2.72 USD). Our analysis revealed a significant positive association between the magnitude of OOPE and age 15-39 years (p = 0.022), household head (p = 0.037), suffering from a chronic illness (p = 0.019), illness duration (p = 0.014), hospitalization (p = 0.002), number of accompanying persons (p = 0.019), wealth quartiles (p2 = 0.018; p3 = 0.001; p4 = 0.002), and urban residency (p = 0.001). CONCLUSION Our findings indicate that a formal policy commitment to providing free healthcare services is not sufficient to guarantee widespread financial protection and that additional measures are needed to protect particularly vulnerable population groups.
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Affiliation(s)
- Meike Irene Nakovics
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Grace Bongololo
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Jobiba Chinkhumba
- University of Malawi College of Medicine, Blantyre, Southern Region Malawi
| | - Olivier Kalmus
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Gerald Leppert
- German Institute for Development Evaluation (DEval), Bonn, Germany
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
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Wong KLM, Brady OJ, Campbell OMR, Banke-Thomas A, Benova L. Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania. Int J Equity Health 2020; 19:15. [PMID: 31992319 PMCID: PMC6988213 DOI: 10.1186/s12939-020-1123-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries. METHODS We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors. RESULTS The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play. CONCLUSIONS Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.
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Affiliation(s)
- Kerry L M Wong
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Oliver J Brady
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for Mathematical Modelling for Infectious Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Aduragbemi Banke-Thomas
- Department of Health Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Lenka Benova
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Department of Public Health, Institute of Tropical Medicine, Kronenburgstraat 43, 2000, Antwerp, Belgium
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Affiliation(s)
- Julia Hussein
- a Editor-in Chief, Reproductive Health Matters , London , UK
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Abstract
Adolescent girls are at the center of many health development interventions. Based on ethnographic research in rural Malawi, I analyze the design, implementation, and reception of an international non-government organization's project aiming to reduce teenage pregnancies by keeping girls in school. Drawing on Fassin's theorization of culturalism as ideology, I analyze how a tendency to overemphasize culture is inherent to the project's behavior change approach, but is reinforced locally by class-shaped notions of development, and plays out through reinforcing ethnic stereotypes. I argue that culturalism builds upon previous health development initiatives that dichotomized modernity and tradition, and is strengthened by short-term donor funding.
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Affiliation(s)
- Hanneke Pot
- a Centre for Development and the Environment , University of Oslo , Oslo , Norway
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