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Maharjan M, Sharma S, Kaphle HP. Factors associated with bypassing primary healthcare facilities for childbirth among women in Devchuli municipality of Nepal. PLoS One 2024; 19:e0302372. [PMID: 38635554 PMCID: PMC11025753 DOI: 10.1371/journal.pone.0302372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 04/02/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND It is crucial to deliver a child at nearby primary healthcare facilities to prevent subsequent maternal or neonatal complications. In low-resource settings, such as Nepal, it is customary to forgo the neighboring primary healthcare facilities for child delivery. Reports are scanty about the extent and reasons for bypassing local health centers in Nepal. This study sought to determine the prevalence and contributing factors among women bypassing primary healthcare facilities for childbirth. METHOD A community-based cross-sectional study was carried out in the Devchuli municipality of Nawalparasi East district of Nepal. Utilizing an online data collection tool, structured interviews were conducted among 314 mothers having a child who is less than one year of age. RESULTS This study showed that 58.9% of the respondents chose to bypass their nearest primary healthcare facility to deliver their babies in secondary or tertiary hospitals. Respondent's husband's employment status; informal employment (AOR: 4.2; 95% CI: 1.8-10.2) and formal employment (AOR: 3.2; 95% CI: 1.5-6.8), wealth quintile (AOR: 3.7; 95% CI: 1.7-7.7), parity (AOR): 3.0; 95% CI: 1.6-5.7], distance to nearest primary healthcare facility by the usual mode of transportation (AOR: 3.0; 95% CI: 1.5-5.6) and perceived service quality of primary healthcare facility (AOR: 3.759; 95% CI: 2.0-7.0) were associated with greater likelihood of bypassing primary healthcare facility. CONCLUSION Enhancing the quality of care, and informing beneficiaries about the importance of delivering children at primary healthcare facilities are essential for improving maternal service utilization at local primary healthcare facilities.
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Affiliation(s)
- Manisha Maharjan
- School of Health and Allied Sciences, Pokhara University, Lekhnath, Nepal
| | - Sudim Sharma
- Faculty of Public Health, Mahidol University, Salaya, Thailand
| | - Hari Prasad Kaphle
- School of Health and Allied Sciences, Pokhara University, Lekhnath, Nepal
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Clarke-Deelder E, Afriyie DO, Nseluke M, Masiye F, Fink G. Health care seeking in modern urban LMIC settings: evidence from Lusaka, Zambia. BMC Public Health 2022; 22:1205. [PMID: 35710372 PMCID: PMC9202228 DOI: 10.1186/s12889-022-13549-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/24/2022] [Indexed: 11/15/2022] Open
Abstract
Background In an effort to improve population health, many low- and middle-income countries (LMICs) have expanded access to public primary care facilities and removed user fees for services in these facilities. However, a growing literature suggests that many patients bypass nearby primary care facilities to seek care at more distant or higher-level facilities. Patients in urban areas, a growing segment of the population in LMICs, generally have more options for where to seek care than patients in rural areas. However, evidence on care-seeking trajectories and bypassing patterns in urban areas remains relatively scarce. Methods We obtained a complete list of public health facilities and interviewed randomly selected informal sector households across 31 urban areas in Lusaka District, Zambia. All households and facilities listed were geocoded, and care-seeking trajectories mapped across the entire urban area. We analyzed three types of bypassing: i) not using health centers or health posts for primary care; ii) seeking care outside of the residential neighborhood; iii) directly seeking care at teaching hospitals. Results A total of 620 households were interviewed, linked to 88 health facilities. Among 571 adults who had recently sought non-emergency care, 65% sought care at a hospital. Among 141 children who recently sought care for diarrhea, cough, fever, or fast breathing, 34% sought care at a hospital. 71% of adults bypassed primary care facilities, 26% bypassed health centers and hospitals close to them for more distant facilities, and 8% directly sought care at a teaching hospital. Bypassing was also observed for 59% of children, who were more likely to seek care outside of the formal care sector, with 21% of children treated at drug shops or pharmacies. Conclusions The results presented here strongly highlight the complexity of urban health systems. Most adult patients in Lusaka do not use public primary health facilities for non-emergency care, and heavily rely on pharmacies and drug shops for treatment of children. Major efforts will likely be needed if the government wants to instate health centers as the principal primary care access point in this setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13549-3.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland. .,University of Basel, Basel, Switzerland.
| | - Doris Osei Afriyie
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Mweene Nseluke
- Directorate of Clinical Care and Diagnostic Services, Ministry of Health, Lusaka, Zambia
| | - Felix Masiye
- Department of Economics, University of Zambia, Lusaka, Zambia
| | - Günther Fink
- Department of Epidemiology and Public Health, Swiss Tropical & Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Kim C, Erim D, Natiq K, Salehi AS, Zeng W. Combination of Interventions Needed to Improve Maternal Healthcare Utilization: A Multinomial Analysis of the Inequity in Place of Childbirth in Afghanistan. Front Glob Womens Health 2021; 1:571055. [PMID: 34816155 PMCID: PMC8594015 DOI: 10.3389/fgwh.2020.571055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/19/2020] [Indexed: 11/17/2022] Open
Abstract
Giving birth with a skilled birth attendant at a facility that provides emergency obstetric care services has better outcomes, but many women do not have access to these services in low- and middle-income countries. Individual, household, and societal factors influence women's decisions about place of birth. Factors influencing birthplace preference by type of provider and level of public facility are not well understood. Applying the Andersen Behavioral Model of healthcare services use, we explored the association between characteristics of women and their choice of childbirth location using a multinomial logistic regression, and conducted a scenario analysis to predict changes in the childbirth location by imposing various interventions. Most women gave birth at home (68.1%), while 15.1% gave birth at a public clinic, 12.1% at a public hospital, and 4.7% at a private facility. Women with higher levels of education, from households in the upper two wealth quintiles, and who had any antenatal care were more likely to give birth in public or private facilities than at home. A combination of multisector interventions had the strongest signals from the model for increasing the predicted probability of in-facility childbirths. This study enhances our understanding of factors associated with the use of public facilities and the private sector for childbirth in Afghanistan. Policymakers and healthcare providers should seek to improve equity in the delivery of health services. This study highlights the need for decisionmakers to consider a combination of multisector efforts (e.g., health, education, and social protection), to increase equitable use of maternal healthcare services.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Daniel Erim
- Health Economics and Outcomes Research (HEOR) Modeling and Advanced Analytics, Parexel International, Durham, NC, United States
| | - Kayhan Natiq
- Silk Route Training and Research Organization, Kabul, Afghanistan
| | - Ahmad Shah Salehi
- Department of Global Health Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Wu Zeng
- Department of International Health, School of Nursing & Health Studies, Georgetown University, Washington, DC, United States
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Mizerero SA, Wilunda C, Musumari PM, Ono-Kihara M, Mubungu G, Kihara M, Nakayama T. The status of emergency obstetric and newborn care in post-conflict eastern DRC: a facility-level cross-sectional study. Confl Health 2021; 15:61. [PMID: 34380531 PMCID: PMC8356431 DOI: 10.1186/s13031-021-00395-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 07/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background Pregnancy-related mortality remains persistently higher in post-conflict areas. Part of the blame lies with continued disruption to vital care provision, especially emergency obstetric and newborn care (EmONC). In such settings, assessment of EmONC is essential for data-driven interventions needed to reduce preventable maternal and neonatal mortality. In the North Kivu Province (NKP), the epicentre of armed conflict in eastern Democratic Republic of the Congo (DRC) between 2006 and 2013, the post-conflict status of EmONC is unknown. We assessed the availability, use, and quality of EmONC in 3 health zones (HZs) of the NKP to contribute to informed policy and programming in improving maternal and newborn health (MNH) in the region. Method A cross-sectional survey of all 42 public facilities designated to provide EmONC in 3 purposively selected HZs in the NKP (Goma, Karisimbi, and Rutshuru) was conducted in 2017. Interviews, reviews of maternity ward records, and observations were used to assess the accessibility, use, and quality of EmONC against WHO standards. Results Only three referral facilities (two faith-based facilities in Goma and the MSF-supported referral hospital of Rutshuru) met the criteria for comprehensive EmONC. None of the health centres qualified as basic EmONC, nor could they offer EmONC services 24 h, 7 days a week (24/7). The number of functioning EmONC per 500,000 population was 1.5. Assisted vaginal delivery was the least performed signal function, followed by parenteral administration of anticonvulsants, mainly due to policy restrictions and lack of demand. The 3 HZs fell short of WHO standards for the use and quality of EmONC. The met need for EmONC was very low and the direct obstetric case fatality rate exceeded the maximum acceptable level. However, the proportion the proportion of births by caesarean section in EmONC facilities was within acceptable range in the HZs of Goma and Rutshuru. Overall, the intrapartum and very early neonatal death rate was 1.5%. Conclusion This study provides grounds for the development of coordinated and evidence-based programming, involving local and external stakeholders, as part of the post-conflict effort to address maternal and neonatal morbidity and mortality in the NKP. Particular attention to basic EmONC is required, focusing on strengthening human resources, equipment, supply chains, and referral capacity, on the one hand, and on tackling residual insecurity that might hinder 24/7 staff availability, on the other.
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Affiliation(s)
- Serge-André Mizerero
- Graduate School of Medicine, School of Public Health, Department of Health Informatics, Kyoto University, Kyoto, Japan.
| | - Calistus Wilunda
- African Population and Health Research Centre, Manga Close, P.O. Box 10787-00100, Nairobi, Kenya
| | - Patou Masika Musumari
- Interdisciplinary Unit for Global Health, Centre for the Promotion of Interdisciplinary Education and Research, Kyoto University, Yoshida honmachi, Sakyo-ku, Kyoto, 606-8501, Japan.,International Institute of Socio-Epidemiology, Kitagosho-cho, Sakyo-ku, Kyoto, 606-8336, Japan
| | - Masako Ono-Kihara
- Interdisciplinary Unit for Global Health, Centre for the Promotion of Interdisciplinary Education and Research, Kyoto University, Yoshida honmachi, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Gerrye Mubungu
- Department of Paediatrics, University Hospital of Kinshasa, School of Medicine, Kinshasa, Democratic Republic of the Congo
| | - Masahiro Kihara
- Interdisciplinary Unit for Global Health, Centre for the Promotion of Interdisciplinary Education and Research, Kyoto University, Yoshida honmachi, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Takeo Nakayama
- Graduate School of Medicine, School of Public Health, Department of Health Informatics, Kyoto University, Kyoto, Japan
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Jang H. A model for measuring healthcare accessibility using the behavior of demand: a conditional logit model-based floating catchment area method. BMC Health Serv Res 2021; 21:660. [PMID: 34225720 PMCID: PMC8259122 DOI: 10.1186/s12913-021-06654-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/17/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Estimating realistic access to health services is essential for designing support policies for healthcare delivery systems. Many studies have proposed a metric to calculate accessibility. However, patients' realistic willingness to use a hospital was not explicitly considered. This study aims to derive a new type of potential accessibility that incorporates a patient's realistic preference in selecting a hospital. METHODS This study proposes a floating catchment area (FCA)-type metric combined with a discrete choice model. Specifically, a new FCA-type metric (clmFCA) was proposed using a conditional logit model. Such a model estimates patients' realistic willingness to use health services. The proposed metric was then applied to calculate the accessibility of obstetric care services in Korea. RESULTS The clmFCA takes advantage of patients' realistic preferences. Specifically, it can represent each patient's heterogeneous characteristics regarding hospital choice. Such characteristics include bypassing behavior, which could not be considered using prior FCA metrics. Empirical analysis reveals that the clmFCA avoids the misestimation of accessibility to health services to an extent. CONCLUSIONS The clmFCA offers a new framework that more realistically estimates patients' accessibility to health services. This is achieved by accurately estimating the potential demand for a service. The proposed method's effectiveness was verified through a case study using nationwide data.
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Affiliation(s)
- Hoon Jang
- College of Global Business, Korea University Sejong Campus, 2511 Sejong-ro, Sejong, Republic of Korea.
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Abere TM, Atnafu DD, Mulu Y. Self-referral and associated factors among patients attending adult outpatient departments in Debre tabor general hospital, North West Ethiopia. BMC Health Serv Res 2021; 21:607. [PMID: 34183005 PMCID: PMC8240286 DOI: 10.1186/s12913-021-06642-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Self-referral leads to diminished quality of health care service; increase resource depletion and poorer patient outcomes. However, a significant number of patients referred themselves to the higher health care facilities without having referral sheets globally including Ethiopia. Even though the problem is much exacerbated in Ethiopia, there is limited evidence regarding self-referral patients in Ethiopia in particular in the study area. OBJECTIVE To assess the magnitude and associated factors of self-referral among patients at the adult outpatient department in Debre Tabor general hospital, North West Ethiopia. METHOD Institution-based cross-sectional study was conducted from March 11-April 9, 2020 among 693 patients who attended adult outpatient departments. A systematic sampling technique was employed. Structured and pretested interviewer-administered questionnaire was used for data collection. Data were coded, cleaned and entered into Epi Info version 7.1 and exported to SPSS version 23 for further analysis. Binary logistic regression analysis was employed. In bivariable analysis p-value, less than 0.25 was used to select candidate variables for multivariable analysis. P-values less than 0.05 and 95% confidence intervals were used to select significant variables on the outcome of interest. RESULT The proportion of self-referral was 443(63.9%) with 95% CI (60.5; 67.5). Formally educated, (AOR = 1.83; (95% CI: 1.12, 3.01)), enrolled to Community Based Health Insurance (AOR = 1.57; (95% CI: 1.03, 2.39)), poor knowledge about referral system (AOR = 2.07; 95% CI: (1.28, 3.39)), not and partially available medication in the nearby Primary Health Care facilities (AOR = 2.12; (95% CI: 1.82, 6.15)) & (AOR = 3.24; (95% CI: 1.75, 5.97)) respectively and history of visiting general hospital (AOR = 1.52; (95%CI: 1.03, 2.25)) were factors statistically associated with self-referral. CONCLUSION AND RECOMMENDATION The proportion of self-referral was low compared to the Ethiopian health sector transformation plan 2015/16-20. Socio-demographic and institutional factors were associated with self-referral. Therefore, regional health bureau better to work to fulfill the availability of medications in the primary health care facilities. In addition, Community Based Health Insurance (CBHI) agency should work to implement the law of out-of-pocket expenditure which states to pay 50% for self-referred patients who claim utilization of healthcare.
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Affiliation(s)
| | - Desta Debalkie Atnafu
- Department of Health System & Health Economics, Bahir Dar University College of Medicine and Health Science, School of Public Health, Bahir Dar, Ethiopia
| | - Yaread Mulu
- Department of Health System & Health Economics, Bahir Dar University College of Medicine and Health Science, School of Public Health, Bahir Dar, Ethiopia
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Kim C, Tappis H, Natiq L, Fried B, Lich KH, Delamater PL, Weinberger M, Trogdon JG. Travel time, availability of emergency obstetric care, and perceived quality of care associated with maternal healthcare utilisation in Afghanistan: A multilevel analysis. Glob Public Health 2021; 17:569-586. [PMID: 33460359 DOI: 10.1080/17441692.2021.1873400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Limited understanding of factors such as travel time, availability of emergency obstetric care (EmOC), and satisfaction/perceived quality of care on the utilisation of maternal health services exists in fragile and conflict-affect settings. We examined these key factors on three utilisation outcomes: at least one skilled antenatal care (ANC) visit, in-facility delivery, and bypassing the nearest public facility for childbirth in Afghanistan from 2010 to 2015. We used three-level multilevel mixed effects logistic regression models to assess the relationships between women's and their nearest public facilities' characteristics and outcomes. The nearest facility score for satisfaction/perceived quality was associated with having at least one skilled ANC visit (AOR: 2.02, 95% CI: 1.21, 3.36). Women whose nearest facility provided EmOC had a higher odds of in-facility childbirth compared to women whose nearest facility did not (AOR: 1.24, 95% CI: 1.04, 1.48). Nearest hospital travel time (AOR: 0.95, 95% CI: 0.93, 0.98) and nearest facility satisfaction/perceived quality (AOR: 0.34, 95% CI: 0.14, 0.82) were associated with lower odds of women bypassing their nearest facility. Afghanistan has made progress in expanding access to maternal healthcare services during the ongoing conflict. Addressing key barriers is essential to ensure that women have access to life-saving services.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hannah Tappis
- Technical Leadership and Innovations Department, Jhpiego, Baltimore, MD, USA
| | - Laila Natiq
- Silk Route Training and Research Organization, Kabul, Afghanistan
| | - Bruce Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Paul L Delamater
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kim C, Tappis H, McDaniel P, Soroush MS, Fried B, Weinberger M, Trogdon JG, Kristen Hassmiller Lich, Delamater PL. National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility. Health Place 2020; 66:102452. [PMID: 33011490 DOI: 10.1016/j.healthplace.2020.102452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 12/30/2022]
Abstract
In Afghanistan, the risk of maternal death is among the highest in the world, with wide variation across the country. One explanation may be wide geographic disparities in access and use of maternal health care services. This study describes the spatial distribution of public facilities providing maternal health care in Afghanistan, specifically emergency obstetric care (EmOC), and the differences in travel time estimates using different transportation modes from 2010 to 2015 at the national and subnational levels. We conducted mapping and spatial analyses to measure the proportion of pregnant women able to access any EmOC health facility within 2 h by foot, animal, motor vehicle and a combination of transport modes. In 2015, adequate coverage of active public health facilities within 2 h of travel time was 36.6% by foot and 71.2% by a combination of transport modes. We found an 8.3% and 63.2% increase in access to EmOC facilities within 2 h of travel time by a combination of transport modes and by foot only, respectively, by 2015. Access to a combination of transportation options such as motor vehicles and animals may benefit pregnant women in reaching health facilities efficiently. Afghanistan made impressive gains in maternal healthcare access; despite these improvements, large disparities remain in geographic access by province and overall access to facilities is still poor.
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Affiliation(s)
- Christine Kim
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Hannah Tappis
- Technical Leadership and Innovations Department, Jhpiego, Baltimore, MD, USA.
| | - Philip McDaniel
- Davis Library, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Bruce Fried
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paul L Delamater
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Asefa A, Morgan A, Gebremedhin S, Tekle E, Abebe S, Magge H, Kermode M. Mitigating the mistreatment of childbearing women: evaluation of respectful maternity care intervention in Ethiopian hospitals. BMJ Open 2020; 10:e038871. [PMID: 32883738 PMCID: PMC7473661 DOI: 10.1136/bmjopen-2020-038871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES There is a lack of evidence on approaches to mitigating mistreatment during facility-based childbirth. This study compares the experiences of mistreatment reported by childbearing women before and after implementation of a respectful maternity care intervention. DESIGN A pre-post study design was undertaken to quantify changes in women's experiences of mistreatment during facility-based childbirth before and after the respectful maternity care intervention. INTERVENTION A respectful maternity care intervention was implemented in three hospitals in southern Ethiopia between December 2017 and September 2018 and it included training of service providers, placement of wall posters in labour rooms and post-training supportive visits for quality improvement. OUTCOME MEASURES A 25-item questionnaire asking women about mistreatment experiences was administered to 388 women (198 in the pre-intervention, 190 in the post-intervention). The outcome variable was the number of mistreatment components experienced by women, expressed as a score out of 25. Multilevel mixed-effects Poisson modelling was used to assess the change in mistreatment score from pre-intervention to post-intervention periods. RESULTS The number of mistreatment components experienced by women was reduced by 18% when the post-intervention group was compared with the pre-intervention group (adjusted regression coefficient (Aβ)=0.82, 95% CI 0.74 to 0.91). Women who had a complication during pregnancy (Aβ=1.17, 95% CI 1.01 to 1.34) and childbirth (Aβ=1.16, 95% CI 1.03 to 1.32) experienced a greater number of mistreatment components. On the other hand, women who gave birth by caesarean birth after trial of vaginal birth (Aβ=0.76, 95% CI 0.63 to 0.92) and caesarean birth without trial of vaginal birth (Aβ=0.68, 95% CI 0.47 to 0.98) experienced a lesser number of mistreatment components compared with those who had vaginal birth. CONCLUSIONS Women reported significantly fewer mistreatment experiences during childbirth following implementation of the intervention. Given the variety of factors that lead to mistreatment in health facilities, interventions designed to mitigate mistreatment need to involve structural changes.
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Affiliation(s)
- Anteneh Asefa
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Alison Morgan
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Samson Gebremedhin
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ephrem Tekle
- Maternal and Child Health Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | | | - Hema Magge
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
- Division of Global Health Equity, Boston Children's Hospital, Boston, Massachusetts, USA
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michelle Kermode
- Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Ocholla IA, Agutu NO, Ouma PO, Gatungu D, Makokha FO, Gitaka J. Geographical accessibility in assessing bypassing behaviour for inpatient neonatal care, Bungoma County-Kenya. BMC Pregnancy Childbirth 2020; 20:287. [PMID: 32397969 PMCID: PMC7216545 DOI: 10.1186/s12884-020-02977-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/30/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Neonatal mortality rate in Kenya continues to be unacceptably high. In reducing newborn deaths, inequality in access to care and quality care have been identified as current barriers. Contributing to these barriers are the bypassing behaviour and geographical access which leads to delay in seeking newborn care. This study (i) measured geographical accessibility of inpatient newborn care, and (ii), characterized bypassing behaviour using the geographical accessibility of the inpatient newborn care seekers. METHODS Geographical accessibility to the inpatient newborn units was modelled based on travel time to the units across Bungoma County. Data was then collected from 8 inpatient newborn units and 395 mothers whose newborns were admitted in the units were interviewed. Their spatial residence locations were geo-referenced and were used against the modelled travel time to define bypassing behaviour. RESULTS Approximately 90% of the sick newborn population have access to nearest newborn units (< 2 h). However, 36% of the mothers bypassed their nearest inpatient newborn facility, with lack of diagnostic services (28%) and distrust of health personnel (37%) being the major determinants for bypassing. Approximately 75% of the care seekers preferred to use the higher tier facilities for both maternal and neonatal care in comparison to sub-county facilities which mostly were bypassed and remained underutilised. CONCLUSION Our findings suggest that though majority of the population have access to care, sub-county inpatient newborn facilities have high risk of being bypassed. There is need to improve quality of care in maternal care, to reduce bypassing behaviour and improving neonatal outcome.
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Affiliation(s)
- Ian A. Ocholla
- Department of Geomatics Engineering and Geospatial Information System, Jomo Kenyatta University of Agriculture and Technology, P.O. Box 62000-00100, Nairobi, Kenya
| | - Nathan O. Agutu
- Department of Geomatics Engineering and Geospatial Information System, Jomo Kenyatta University of Agriculture and Technology, P.O. Box 62000-00100, Nairobi, Kenya
| | - Paul O. Ouma
- Department of Geomatics Engineering and Geospatial Information System, Jomo Kenyatta University of Agriculture and Technology, P.O. Box 62000-00100, Nairobi, Kenya
| | - Daniel Gatungu
- Research and Innovation Directorate, Mount Kenya University, P.O. Box 342-01000, Thika, Kenya
| | | | - Jesse Gitaka
- Research and Innovation Directorate, Mount Kenya University, P.O. Box 342-01000, Thika, Kenya
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Alba S, Sondorp E, Kleipool E, Yadav RS, Rahim AS, Juszkiewicz KT, Burnham G. Estimating maternal mortality: what have we learned from 16 years of surveys in Afghanistan? BMJ Glob Health 2020; 5:e002126. [PMID: 32371572 PMCID: PMC7228470 DOI: 10.1136/bmjgh-2019-002126] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/02/2020] [Accepted: 03/07/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sandra Alba
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Egbert Sondorp
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | | | | | - Arab S Rahim
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | | | - Gilbert Burnham
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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12
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Bhowmik J, Biswas RK, Ananna N. Women's education and coverage of skilled birth attendance: An assessment of Sustainable Development Goal 3.1 in the South and Southeast Asian Region. PLoS One 2020; 15:e0231489. [PMID: 32315328 PMCID: PMC7173780 DOI: 10.1371/journal.pone.0231489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/24/2020] [Indexed: 11/30/2022] Open
Abstract
Objective The objective of Sustainable Development Goal 3.1 is to reduce the global maternal mortality ratio (MMR) below 70 per 100,000 live births by 2030. One of the indicators for this objective is the proportion of births attended by skilled health attendants (SBA). This study assessed the progress of low- and middle-income countries from South and Southeast Asian (SSEA) region in SBA coverage and evaluated the contribution of women’s education in this progression. Methods The Demographic and Health Surveys were assessed, which included 38 nationally representative surveys on women aged between 15-49 years from 10 selected SSEA region countries in past 30 years. Binary Logistic regression models were fitted adjusting the survey clusters, strata and sampling weights. Meta-analyses were conducted by collapsing effect sizes and confidence intervals of education modeled on SBA coverage. Results Results indicated that Cambodia, Indonesia and Philippines had over 80% SBA coverage after 2010, whereas Bangladesh and Afghanistan had around 50% coverage. Women with primary, secondary and higher level of education were 1.65, 2.21 and 3.14 times significantly more likely to access SBA care during childbirth respectively as compared to women with no education, suggesting that education is a key factor to address skilled delivery cares in the SSEA region. Conclusion Evaluation of the existing skilled birth attendance policies at the national level could provide useful insight for the decision makers to improve access to skilled care at birth by investing on women’s education in remote and rural areas.
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Affiliation(s)
- Jahar Bhowmik
- Department of Health Science and Biostatistics, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Raaj Kishore Biswas
- Transport and Road Safety (TARS) Research Centre, School of Aviation, University of New South Wales, Sydney, Australia
- * E-mail:
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13
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Christou A, Alam A, Sadat Hofiani SM, Rasooly MH, Mubasher A, Rashidi MK, Dibley MJ, Raynes-Greenow C. Understanding pathways leading to stillbirth: The role of care-seeking and care received during pregnancy and childbirth in Kabul province, Afghanistan. Women Birth 2020; 33:544-555. [PMID: 32094034 DOI: 10.1016/j.wombi.2020.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/20/2020] [Accepted: 02/12/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND The underlying pathways leading to stillbirth in low- and middle-income countries are not well understood. Context-specific understanding of how and why stillbirths occur is needed to prioritise interventions and identify barriers to their effective implementation and uptake. AIM To explore the contribution of contextual, individual, household-level and health system factors to stillbirth in Afghanistan. METHODS Using a qualitative approach, we conducted semi-structured in-depth interviews with women and men that experienced stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. We used thematic analysis to identify contributing factors and developed a conceptual map describing possible pathways to stillbirth. FINDINGS We found that low utilisation and access to healthcare was a key contributing factor, as were unmanaged conditions in pregnancy that increased women's risk of complications and stillbirth. Sociocultural factors related to the treatment of women and perceptions about medical interventions deprived women of interventions that could potentially prevent stillbirth. The quality of care from public and private providers during pregnancy and childbirth was a recurring concern exacerbated by health system constraints that led to unnecessary delays; while environmental factors linked to the ongoing conflict were also perceived to contribute to stillbirth. These pathways were underscored by social, cultural, economic factors and individual perceptions that contributed to the three-delays. DISCUSSION Efforts are needed at the community-level to facilitate care-seeking and raise awareness of stillbirth risk factors and the facility-level to strengthen antenatal and childbirth care quality, ensure culturally appropriate and respectful care, and reduce treatment delays.
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Affiliation(s)
- Aliki Christou
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Ashraful Alam
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | - Mohammad Hafiz Rasooly
- Afghanistan National Public Health Institute, Ministry of Public Health, Kabul, Afghanistan
| | | | | | - Michael J Dibley
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Camille Raynes-Greenow
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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14
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Dotse-Gborgbortsi W, Dwomoh D, Alegana V, Hill A, Tatem AJ, Wright J. The influence of distance and quality on utilisation of birthing services at health facilities in Eastern Region, Ghana. BMJ Glob Health 2020; 4:e002020. [PMID: 32154031 PMCID: PMC7044703 DOI: 10.1136/bmjgh-2019-002020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/20/2019] [Accepted: 01/09/2020] [Indexed: 11/03/2022] Open
Abstract
Objectives Skilled birth attendance is the single most important intervention to reduce maternal mortality. However, studies have not used routinely collected health service birth data at named health facilities to understand the influence of distance and quality of care on childbirth service utilisation. Thus, this paper aims to quantify the influence of distance and quality of healthcare on utilisation of birthing services using routine health data in Eastern Region, Ghana. Methods We used a spatial interaction model (a model that predicts movement from one place to another) drawing on routine birth data, emergency obstetric care surveys, gridded estimates of number of pregnancies and health facility location. We compared travel distances by sociodemographic characteristics and mapped movement patterns. Results A kilometre increase in distance significantly reduced the prevalence rate of the number of women giving birth in health facilities by 6.7%. Although quality care increased the number of women giving birth in health facilities, its association was insignificant. Women travelled further than expected to give birth at facilities, on average journeying 4.7 km beyond the nearest facility with a recorded birth. Women in rural areas travelled 4 km more than urban women to reach a hospital. We also observed that 56% of women bypassed the nearest hospital to their community. Conclusion This analysis provides substantial opportunities for health planners and managers to understand further patterns of skilled birth service utilisation, and demonstrates the value of routine health data. Also, it provides evidence-based information for improving maternal health service provision by targeting specific communities and health facilities.
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Affiliation(s)
- Winfred Dotse-Gborgbortsi
- School of Geography and Environmental Science, University of Southampton, Southampton, UK.,WorldPop Research Group, School of Geography and Environmental Science, University of Southampton, Southampton, UK
| | - Duah Dwomoh
- Department of Biostatistics, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Victor Alegana
- School of Geography and Environmental Science, University of Southampton, Southampton, UK.,WorldPop Research Group, School of Geography and Environmental Science, University of Southampton, Southampton, UK.,Population Health Unit, Kenya Medical Research Institute - Wellcome Trust Research Programme P.O. Box 43640-00100, Nairobi, Kenya.,Faculty of Science and Technology, Lancaster University, Lancaster, UK
| | - Allan Hill
- Social Statistics and Demography, University of Southampton, Southampton, UK
| | - Andrew J Tatem
- School of Geography and Environmental Science, University of Southampton, Southampton, UK.,WorldPop Research Group, School of Geography and Environmental Science, University of Southampton, Southampton, UK
| | - Jim Wright
- School of Geography and Environmental Science, University of Southampton, Southampton, UK
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15
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Bitton A, Fifield J, Ratcliffe H, Karlage A, Wang H, Veillard JH, Schwarz D, Hirschhorn LR. Primary healthcare system performance in low-income and middle-income countries: a scoping review of the evidence from 2010 to 2017. BMJ Glob Health 2019; 4:e001551. [PMID: 31478028 PMCID: PMC6703296 DOI: 10.1136/bmjgh-2019-001551] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/25/2019] [Accepted: 06/15/2019] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The 2018 Astana Declaration reaffirmed global commitment to primary healthcare (PHC) as a core strategy to achieve universal health coverage. To meet this potential, PHC in low-income and middle-income countries (LMIC) needs to be strengthened, but research is lacking and fragmented. We conducted a scoping review of the recent literature to assess the state of research on PHC in LMIC and understand where future research is most needed. METHODS Guided by the Primary Healthcare Performance Initiative (PHCPI) conceptual framework, we conducted searches of the peer-reviewed literature on PHC in LMIC published between 2010 (the publication year of the last major review of PHC in LMIC) and 2017. We also conducted country-specific searches to understand performance trajectories in 14 high-performing countries identified in the previous review. Evidence highlights and gaps for each topic area of the PHCPI framework were extracted and summarised. RESULTS We retrieved 5219 articles, 207 of which met final inclusion criteria. Many PHC system inputs such as payment and workforce are well-studied. A number of emerging service delivery innovations have early evidence of success but lack evidence for how to scale more broadly. Community-based PHC systems with supportive governmental policies and financing structures (public and private) consistently promote better outcomes and equity. Among the 14 highlighted countries, most maintained or improved progress in the scope of services, quality, access and financial coverage of PHC during the review time period. CONCLUSION Our findings revealed a heterogeneous focus of recent literature, with ample evidence for effective PHC policies, payment and other system inputs. More variability was seen in key areas of service delivery, underscoring a need for greater emphasis on implementation science and intervention testing. Future evaluations are needed on PHC system capacities and orientation toward social accountability, innovation, management and population health in order to achieve the promise of PHC.
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Affiliation(s)
- Asaf Bitton
- Ariadne Labs, Boston, Massachusetts, USA
- Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | - Hong Wang
- The Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Jeremy H Veillard
- World Bank Group, Washington, District of Columbia, USA
- Institute of Health Policy, Management and Evaluation, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Dan Schwarz
- Ariadne Labs, Boston, Massachusetts, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lisa R Hirschhorn
- Ariadne Labs, Boston, Massachusetts, USA
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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16
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Long Q, Madede T, Parkkali S, Chavane L, Sundby J, Hemminki E. Maternity care system in Maputo, Mozambique: Plans and practice? COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1412138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Qian Long
- Global Health Research Centre, Duke Kunshan University, No.8 Duke Avenue, Kunshan, Jiangshu, China
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Tavares Madede
- Faculty of Medicine, Department of Community Health, University Eduardo Mondlane (UEM), Maputo, Mozambique
| | - Saara Parkkali
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Leonardo Chavane
- Faculty of Medicine, Department of Community Health, University Eduardo Mondlane (UEM), Maputo, Mozambique
| | - Johanne Sundby
- Institute of Health and Society, University of Oslo, Olso, Norway
| | - Elina Hemminki
- National Institute for Health and Welfare (THL), Helsinki, Finland
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17
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Examining the structure and behavior of Afghanistan’s routine childhood immunization system using system dynamics modeling. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2017. [DOI: 10.1108/ijhg-04-2017-0015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to demonstrate how public health and systems science methods can be combined to examine the structure and behavior of Afghanistan’s routine childhood immunization system to identify the pathways through which health system readiness to deliver vaccination services may extend beyond immunization outcomes.
Design/methodology/approach
Using findings from an ecological study of Afghanistan’s immunization system and a literature review on immunization program delivery, the routine immunization system was mapped using causal loop diagrams. Next, a stock-and-flow diagram was developed and translated to a system dynamics (SD) model for a system-confirmatory exercise. Data are from annual health facility assessments and two cross-sectional household surveys. SD model results were compared with measured readiness and service outcomes to confirm system structure.
Findings
Readiness and demand-side components were associated with improved immunization coverage. The routine immunization system was mapped using four interlinking readiness subsystems. In the SD model, health worker capacity and demand-side factors significantly affected maternal health service coverage. System readiness components affected their future measures mostly negatively, which may indicate that the reinforcing feedback drives current system-structured behavior.
Originality/value
The models developed herein are useful to explore the potential impact of candidate interventions on service outcomes. This paper documents the process through which public health and systems investigators can collaboratively develop models that represent the feedback-driven behavior of health systems. Such models allow for more realistically addressing health policy and systems-level research questions.
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18
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Schleiff M, Kumapley R, Freeman PA, Gupta S, Rassekh BM, Perry HB. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 5. equity effects for neonates and children. J Glob Health 2017; 7:010905. [PMID: 28685043 PMCID: PMC5491949 DOI: 10.7189/jogh.07.010905] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The degree to which investments in health programs improve the health of the most disadvantaged segments of the population-where utilization of health services and health status is often the worst-is a growing concern throughout the world. Therefore, questions about the degree to which community-based primary health care (CBPHC) can or actually does improve utilization of health services and the health status of the most disadvantaged children in a population is an important one. METHODS Using a database containing information about the assessment of 548 interventions, projects or programs (referred to collectively as projects) that used CBPHC to improve child health, we extracted evidence related to equity from a sub-set of 42 projects, identified through a multi-step process, that included an equity analysis. We organized our findings conceptually around a logical framework matrix. RESULTS Our analysis indicates that these CBPHC projects, all of which implemented child health interventions, achieved equitable effects. The vast majority (87%) of the 82 equity measurements carried out and reported for these 42 projects demonstrated "pro-equitable" or "equitable" effects, meaning that the project's equity indicator(s) improved to the same degree or more in the disadvantaged segments of the project population as in the more advantaged segments. Most (78%) of the all the measured equity effects were "pro-equitable," meaning that the equity criterion improved more in the most disadvantaged segment of the project population than in the other segments of the population. CONCLUSIONS Based on the observation that CBPHC projects commonly provide services that are readily accessible to the entire project population and that even often reach down to all households, such projects are inherently likely to be more equitable than projects that strengthen services only at facilities, where utilization diminishes greatly with one's distance away. The decentralization of services and attention to and tracking of metrics across all phases of project implementation with attention to the underserved, as can be done in CBPHC projects, are important for reducing inequities in countries with a high burden of child mortality. Strengthening CBPHC is a necessary strategy for reducing inequities in child health and for achieving universal coverage of essential services for children.
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Affiliation(s)
- Meike Schleiff
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Paul A Freeman
- Independent consultant, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | - Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Najafizada SAM, Bourgeault IL, Labonté R. Social Determinants of Maternal Health in Afghanistan: A Review. Cent Asian J Glob Health 2017; 6:240. [PMID: 29138735 PMCID: PMC5675389 DOI: 10.5195/cajgh.2017.240] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Afghanistan has a high maternal mortality rate of 400 per 100,000 live births. Although direct causes of maternal morbidity and mortality in Afghanistan include hemorrhage, obstructed labor, infection, high blood pressure, and unsafe abortion, the high burden of diseases responsible for maternal mortality arises in large part due to social determinants of health. The focus of this literature review is to examine the impact of various social determinants of health on maternal health in Afghanistan, filling an important gap in the existing literature. METHODS This narrative review was conducted using Arksey and O'Malley's framework of (1) defining the question, (2) searching the literature, (3) assessing the studies, (4) synthesizing selected evidence in context, and (5) summarizing potential programmatic implication of the context. We searched Medline, CABI global health database, and Google Scholar for relevant publications. RESULTS A total of 38 articles/reports were included in this review. We found that social determinants such as maternal education, sociocultural practices, and social infrastructure have a significant impact on maternal health. Health care may be the immediate determinant, but it is influenced by other determinants that must be addressed in order to alleviate the burden on health care, as well as to achieve long-term reduction in maternal mortality. CONCLUSION Because of the importance of social factors for maternal health outcomes, committed involvement of multiple government sectors (i.e. education, labor and social affairs, information and culture, transport and rural development among others, alongside health care) is the long-term solution to the maternal health problems in Afghanistan. National and international organizations' long-term commitment to social investment such as education, local economy, cultural change, and social infrastructure is recommended for Afghanstan and globally.
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Affiliation(s)
| | | | - Ronald Labonté
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Canada
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20
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Salazar M, Vora K, Costa AD. Bypassing health facilities for childbirth: a multilevel study in three districts of Gujarat, India. Glob Health Action 2016; 9:32178. [PMID: 27545454 PMCID: PMC4992671 DOI: 10.3402/gha.v9.32178] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 07/20/2016] [Accepted: 07/22/2016] [Indexed: 11/28/2022] Open
Abstract
Background Bypassing available facilities for childbirth has important implications for maternal health service delivery and human resources within a health system. The results are the additional expenses imposed on the woman and her family, as well as the inefficient use of health system resources. Bypassing often indicates a lack of confidence in the care provided by the facility nearest to the mother, which implies a level of dysfunctionality that the health system needs to address. Over the past decade, India has experienced a steep rise in the proportion of facility births. The initiation of programs promoting facility births resulted in a rise from 39% in 2005 to 85% in 2014. There have been no reports on bypassing facilities for childbirth from India. In the context of steeply rising facility births, it is important to quantify the occurrence of and study the relative contributions of maternal characteristics and facility functionality to bypassing. Objectives 1) To determine the extent of bypassing health facilities for childbirth among rural mothers in three districts of Gujarat, India, 2) to identify associations between the functionality of an obstetric care (OC) facility and it being bypassed, and 3) to assess the relative contribution of maternal and facility characteristics to bypassing. Design A cross-sectional survey of 166 public and private OC facilities reporting ≥30 births in the 3 months before the survey was conducted in three purposively selected districts (Dahod, Sabarkantha, and Surendranagar) in the state of Gujarat, India. Besides information on each facility, data from 946 women giving birth at these facilities were also gathered. Data were analyzed using a multilevel mixed-effects logistic regression model. Results Off all mothers, 37.7% bypassed their nearest facility for childbirth. After adjusting for maternal characteristics, for every one-unit increase in the facility's emergency obstetric care (EmOC) signal functions, the odds of bypassing a facility for childbirth decreased by 37% (adjusted odds ratio [AOR] 0.63, 95% confidence interval [CI]: 0.53–0.76). Conclusions This study shows that independent of maternal characteristics, in our setting, women will bypass obstetric facilities that are not adequately functional, and travel further to others that are more functional. It is important that the health system should focus on facility functionality, especially in the context of sharply rising hospital births.
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Affiliation(s)
- Mariano Salazar
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden;
| | - Kranti Vora
- Department of Reproductive and Child Health, Indian Institute of Public Health, Ahmedabad, India
| | - Ayesha De Costa
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,Department of Reproductive and Child Health, Indian Institute of Public Health, Ahmedabad, India
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