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Ward ZJ, Atun R, King G, Dmello BS, Goldie SJ. Global maternal mortality projections by urban/rural location and education level: a simulation-based analysis. EClinicalMedicine 2024; 72:102653. [PMID: 38800798 PMCID: PMC11126824 DOI: 10.1016/j.eclinm.2024.102653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024] Open
Abstract
Background Maternal mortality remains a challenge in global health, with well-known disparities across countries. However, less is known about disparities in maternal health by subgroups within countries. The aim of this study is to estimate maternal health indicators for subgroups of women within each country. Methods In this simulation-based analysis, we used the empirically calibrated Global Maternal Health (GMatH) microsimulation model to estimate a range of maternal health indicators by subgroup (urban/rural location and level of education) for 200 countries/territories from 1990 to 2050. Education levels were defined as low (less than primary), middle (less than secondary), and high (completed secondary or higher). The model simulates the reproductive lifecycle of each woman, accounting for individual-level factors such as family planning preferences, biological factors (e.g., anemia), and history of maternal complications, and how these factors vary by subgroup. We also estimated the impact of scaling up women's education on projected maternal health outcomes compared to clinical and health system-focused interventions. Findings We find large subgroup differences in maternal health outcomes, with an estimated global maternal mortality ratio (MMR) in 2022 of 292 (95% UI 250-341) for rural women and 100 (95% UI 84-116) for urban women, and 536 (95% UI 450-594), 143 (95% UI 117-174), and 85 (95% UI 67-108) for low, middle, and high education levels, respectively. Ensuring all women complete secondary school is associated with a large impact on the projected global MMR in 2030 (97 [95% UI 76-120]) compared to current trends (167 [95% UI 142-188]), with especially large improvements in countries such as Afghanistan, Chad, Madagascar, Niger, and Yemen. Interpretation Substantial subgroup disparities present a challenge for global maternal health and health equity. Outcomes are especially poor for rural women with low education, highlighting the need to ensure that policy interventions adequately address barriers to care in rural areas, and the importance of investing in social determinants of health, such as women's education, in addition to health system interventions to improve maternal health for all women. Funding John D. and Catherine T. MacArthur Foundation, 10-97002-000-INP.
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Affiliation(s)
- Zachary J. Ward
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Rifat Atun
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gary King
- Institute for Quantitative Social Sciences, Harvard University, Cambridge, MA, USA
| | - Brenda Sequeira Dmello
- Maternal and Newborn Healthcare, Comprehensive Community Based Rehabilitation in Tanzania (CCBRT), Dar Es Salaam, Tanzania
| | - Sue J. Goldie
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
- Global Health Education and Learning Incubator, Harvard University, Cambridge, MA, USA
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Miller H, Rudolfson N, Nkurunziza T, Cherian T, Kayitesi D, Mazimpaka C, Kateera F, Riviello R, Hedt-Gauthier B. Long travel times from health center to hospital reduce caesarean section access: a study from Kirehe District, Rwanda. Pan Afr Med J 2023; 46:30. [PMID: 38107338 PMCID: PMC10724031 DOI: 10.11604/pamj.2023.46.30.25504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/01/2020] [Indexed: 12/19/2023] Open
Abstract
Introduction timely access to safe cesarean section (c-section) delivery can save the lives of mothers and neonates. This paper explores how distance affects c-section access in rural sub-Saharan Africa, where women in labor present to health centers before being referred to district hospitals for surgical care. Methods this study included all adult women delivering via c-section between April 2017 and March 2018 in Kirehe District, Rwanda. We assessed the association between travel times and village-level c-section rates. Results the estimated travel time from home-to-health center was 26 minutes (IQR: 13, 41) and from health center-to-hospital was 43 minutes (IQR: 2, 59). There was no significant association between travel time from home-to-health center and c-section rates (RR=1.01, p=0.42), but the association was significant for health center-to-hospital travel times (RR=0.96, p=0.01); for every 15-minute increase in travel time, there was a 4% decrease in c-sections for a health center catchment area. Conclusion in the context of decentralized health services, minimizing health center to hospital referral barriers is of utmost importance for improving c-section access in rural sub-Saharan Africa.
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Affiliation(s)
- Hillary Miller
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, United States of America
| | - Niclas Rudolfson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Word Health Organization Collaborating Center for Surgery and Public Health, Department of Clinical Sciences Lund University, Lund, Sweden
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
| | - Theoneste Nkurunziza
- Partners In Health/Inshuti Mu Buzima, Kigali, Rwanda
- Department for Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Teena Cherian
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
| | | | | | | | - Robert Riviello
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
- Center for Surgery and Public Health, Brigham and Women´s Hospital, Boston, United States of America
| | - Bethany Hedt-Gauthier
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, United States of America
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Bhattarai HK, Bhusal S, Barone-Adesi F, Hubloue I. Prehospital Emergency Care in Low- and Middle-Income Countries: A Systematic Review. Prehosp Disaster Med 2023; 38:495-512. [PMID: 37492946 PMCID: PMC10445116 DOI: 10.1017/s1049023x23006088] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/08/2023] [Accepted: 06/17/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND An under-developed and fragmented prehospital Emergency Medical Services (EMS) system is a major obstacle to the timely care of emergency patients. Insufficient emphasis on prehospital emergency systems in low- and middle-income countries (LMICs) currently causes a substantial number of avoidable deaths from time-sensitive illnesses, highlighting a critical need for improved prehospital emergency care systems. Therefore, this systematic review aimed to assess the prehospital emergency care services across LMICs. METHODS This systematic review used four electronic databases, namely: PubMed/MEDLINE, CINAHL, EMBASE, and SCOPUS, to search for published reports on prehospital emergency medical care in LMICs. Only peer-reviewed studies published in English language from January 1, 2010 through November 1, 2022 were included in the review. The Newcastle-Ottawa Scale (NOS) and Critical Appraisal Skills Programme (CASP) checklist were used to assess the methodological quality of the included studies. Further, the protocol of this systematic review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (Ref: CRD42022371936) and has been conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Of the 4,909 identified studies, a total of 87 studies met the inclusion criteria and were therefore included in the review. Prehospital emergency care structure, transport care, prehospital times, health outcomes, quality of information exchange, and patient satisfaction were the most reported outcomes in the considered studies. CONCLUSIONS The prehospital care system in LMICs is fragmented and uncoordinated, lacking trained medical personnel and first responders, inadequate basic materials, and substandard infrastructure.
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Affiliation(s)
- Hari Krishna Bhattarai
- Program in Global Health, Humanitarian Aid and Disaster Medicine, Università del Piemonte Orientale, Novara, Italy, and Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Francesco Barone-Adesi
- CRIMEDIM – Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Ives Hubloue
- Department of Emergency Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium Research Group on Emergency and Disaster Medicine, Medical School, Vrije Universiteit Brussel, Brussels, Belgium
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Tolossa W, Bala ET, Mekuria M, Ifa M, Deriba BS, Dufera A. Magnitude and Factors Associated with Ambulance Service Utilization Among Women Who Gave Birth at Public Health Institutions in Central Ethiopia. Open Access Emerg Med 2022; 14:457-471. [PMID: 35990044 PMCID: PMC9384968 DOI: 10.2147/oaem.s373700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background Effective and well-organized ambulance services system forms the link between household and health facility for providing basic or comprehensive emergency obstetric care. Therefore, the establishment of a strong ambulance services network across the country based on evidences from local study is necessary for the improvement of ambulance service utilization among mothers who gave birth. This study aimed to assess magnitude and factors associated with ambulance service utilization among women who gave birth at public health institutions in central Ethiopia. Methods A community-based cross-sectional study supplemented by a qualitative method was employed. Data were collected via face-to-face interview. A simple random sampling and purposive sampling techniques were used to select study participants. Bivariate and multivariable logistic regression analyses were done to identify factors associated with ambulance services utilization, and variables with a p-value <0.25 were entered in the multivariable logistic regression analysis. Adjusted odds ratio (AOR) with 95% CI and a P-value <0.05 were used to declare statistically significant associations. Results Among study participants, only 214 (46%) utilized ambulance service. Mother who had no formal education (AOR=0.03, 95% CI [0.01, 0.07]), husband who completed primary school and above (AOR=7.03, 95% CI [1.83, 27.16]), rural residence (AOR=2.27, 95% CI [1.11, 4.65]), decision maker to get ambulance service (AOR=0.03, 95% CI [0.01, 0.07]), multigravida (AOR=4.8, 95% CI [2.48, 9.34]), having ambulance phone number (AOR=0.36, 95% CI [0.19, 0.68]), antenatal care attendance (AOR=0.07, 95% CI [0.04, 0.16]), and having discussion with health extension worker (AOR=0.14, 95% CI [0.084, 0.24]) were significantly associated with ambulance service utilization. Conclusion The magnitude of ambulance service utilization was low. Hence, health sector should improve the awareness of pregnant mothers on benefit of ambulance utilization through provision of information. Health care providers should provide antenatal services for pregnant mothers as early as possible.
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Affiliation(s)
- Wondwosen Tolossa
- Department of Public Health, Oromia Regional Health Bureau Chalia District Health Office, Gedo, Ethiopia
| | - Elias Teferi Bala
- Department of Public Health, College of Medicine and Health Sciences Ambo University, Ambo, Ethiopia
| | - Mulugeta Mekuria
- Department of Public Health, College of Medicine and Health Sciences Ambo University, Ambo, Ethiopia
| | - Meseret Ifa
- Department of Public Health, College of Medicine and Health Sciences Ambo University, Ambo, Ethiopia
| | - Berhanu Senbeta Deriba
- Department of Public Health, Salale University College of Medicine and Health Sciences, Fitche, Ethiopia
| | - Adugna Dufera
- Department of Public Health, Oromia Regional Health Bureau Chalia District Health Office, Gedo, Ethiopia
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Alemu SM, Tura AK, do Amaral GSG, Moughalian C, Weitkamp G, Stekelenburg J, Biesma R. How applicable is geospatial analysis in maternal and neonatal health in sub-Saharan Africa? A systematic review. J Glob Health 2022; 12:04066. [PMID: 35939400 PMCID: PMC9359463 DOI: 10.7189/jogh.12.04066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Sub-Saharan Africa (SSA) has the world's highest maternal and neonatal morbidity and mortality and has shown the slowest progress in reducing them. In addition, there is substantial inequality in terms of maternal and neonatal morbidity and mortality in the region. Geospatial studies can help prioritize scarce resources by pinpointing priority areas for implementation. This systematic review was conducted to explore the application of geospatial analysis to maternal and neonatal morbidity and mortality in SSA. Methods A systematic search of PubMed, SCOPUS, EMBASE, and Web of Science databases was performed. All observational and qualitative studies that reported on maternal or neonatal health outcomes were included if they used a spatial analysis technique and were conducted in a SSA country. After removing duplicates, two reviewers independently reviewed each study's abstract and full text for inclusion. Furthermore, the quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Finally, due to the heterogeneity of studies, narrative synthesis was used to summarize the main findings, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was strictly followed to report the review results. A total of 56 studies were included in the review. Results We found that geospatial analysis was used to identify inequalities in maternal and neonatal morbidity, mortality, and health care utilization and to identify gaps in the availability and geographic accessibility of maternal health facilities. In addition, we identified a few studies that used geospatial analysis for modelling intervention areas. We also detected challenges and shortcomings, such as unrealistic assumptions used by geospatial models and a shortage of reliable, up-to-date, small-scale georeferenced data. Conclusions The use of geospatial analysis for maternal and neonatal health in SSA is still limited, and more detailed spatial data are required to exploit the potential of geospatial technologies fully.
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Affiliation(s)
- Sisay Mulugeta Alemu
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, Groningen, the Netherlands
| | - Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.,Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Gabriel S Gurgel do Amaral
- Department of Health Sciences, Community and Occupational Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Catherine Moughalian
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, Groningen, the Netherlands
| | - Gerd Weitkamp
- Department of Cultural Geography, Faculty of Spatial Sciences, University of Groningen, Groningen, the Netherlands
| | - Jelle Stekelenburg
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, Groningen, the Netherlands.,Department Obstetrics & Gynaecology, Leeuwarden Medical Centre, Leeuwarden, the Netherlands
| | - Regien Biesma
- Global Health Unit, Department of Health Sciences, University Medical Center Groningen, Groningen, the Netherlands
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Singh A, Vellakkal S. Impact of public health programs on maternal and child health services and health outcomes in India: A systematic review. Soc Sci Med 2021; 274:113795. [PMID: 33667744 DOI: 10.1016/j.socscimed.2021.113795] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/18/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND In the last two decades, India's central and many state governments launched several public health programs with the goal of improving maternal and child health outcomes. Many individual studies assessed the impact of these programs; however, they focused on select health programs and few specific outcomes. OBJECTIVES AND METHODS This paper summarizes the literature, published during 2000-2019, investigating the impacts of public health programs on both the uptake of maternal and child health services and the related-health outcomes in India. We followed PRISMA guidelines of systematic review, and carried out a narrative synthesis of the study findings. FINDINGS AND CONCLUSION We found 66 relevant studies covering 11 health programs across India. Most studies had applied non-experimental study designs (n = 50), with few applying experimental (n = 1) and quasi-experimental (n = 15) designs. Most studies (n = 64) assessed the impact on the intermediate outcomes of the uptake of various health services rather on the long-term outcomes of improvement in health. Overall we found studies reporting positive impacts, however, we could not find any strong consensus emerging from these studies about the impact, partly due to differences in: outcome indicators; study designs; study population; data sets. Several studies also reported considerable beneficial impacts among low socioeconomic population groups. However, given that the outreach of the public health programs have been low across the country and population groups, we found that broader objectives of health programs remained unassessed: most studies assessed the impact on who actually participated in the program (average treatment effect on-the-treated) rather on the target population (intent-to-treat effect). Furthermore, there was dearth of research on the impacts of the state-level programs. Future research need to assess the impact of the programs on health outcomes, and on quality adjusted measures of maternal and child health services and its continuum of care.
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Affiliation(s)
- Abinash Singh
- Department of Economics, BITS Pilani K. K. Birla Goa Campus, Birla Institute of Technology and Science, Pilani, India
| | - Sukumar Vellakkal
- Department of Economics, BITS Pilani K. K. Birla Goa Campus, Birla Institute of Technology and Science, Pilani, India; Department of Economic Sciences, Indian Institute of Technology Kanpur, Uttar Pradesh, India.
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Nyati-Jokomo Z, Dabengwa IM, Makacha L, Nyapwere N, Dube YP, Chikoko L, Vidler M, Makanga PT. RoadMApp: a feasibility study for a smart travel application to improve maternal health delivery in a low resource setting in Zimbabwe. BMC Pregnancy Childbirth 2020; 20:501. [PMID: 32867716 PMCID: PMC7457488 DOI: 10.1186/s12884-020-03200-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/21/2020] [Indexed: 11/12/2022] Open
Abstract
Background Travel time and healthcare financing are critical determinants of the provision of quality maternal health care in low resource settings. Despite the availability of pregnancy-related mHealth and smart travel applications, there is a lack of evidence on their usage to travel to health facilities for routine antenatal care and emergencies. There is a shortage of information about the feasibility of using a custom-made mobile technology that integrates smart travel and mHealth. This paper explores the feasibility of implementing a custom-made geographically enabled mobile technology-based tool (RoadMApp) to counter the adverse effects of long travel times for maternal care in Kwekwe District, Zimbabwe. Methods We frame the paper using the first two steps (listen & plan) of the Spiral Technology Action Research (STAR model). The paper uses an exploratory case study design and Participatory Learning Approaches (PLA) with stakeholders (community members) and in-depth interviews with key informants (health care service providers, pregnant women, transport operators). One hundred ninety-three participants took part in the study. We conducted focus group discussions with pregnant women, women of childbearing age, men (household heads), and elderly women. The discussion questions centered on travel time, availability of transport, cellular network coverage, and perceptions of the RoadMApp application. Data were analysed thematically using Nvivo Pro 12. Results Most parts of rural Kwekwe are far from health facilities and have an inefficient road and telecommunications network. Hence, it is hard to predict if RoadMApp will integrate into the lives of the community - especially those in rural areas. Since these issues are pillars of the design of the RoadMApp mHealth, the implementation will probably be a challenge. Conclusion Communities are keen to embrace the RoadMApp application. However, the feasibility of implementing RoadMApp in Kwekwe District will be a challenge because of maternal health care barriers such as poor road network, poor phone network, and the high cost of transport. There is a need to investigate the social determinants of access to maternity services to inform RoadMApp implementation.
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Affiliation(s)
- Zibusiso Nyati-Jokomo
- The University of Zimbabwe, College of Health Sciences, Parirenyatwa Hospital, Harare, Zimbabwe.
| | - Israel Mbekezeli Dabengwa
- National University of Science and Technology, Faculty of Medicine, Mpilo Hospital, Bulawayo, Zimbabwe
| | - Liberty Makacha
- Surveying and Geomatics, Midlands State University, Senga, Gweru, Zimbabwe
| | - Newton Nyapwere
- Surveying and Geomatics, Midlands State University, Senga, Gweru, Zimbabwe
| | | | - Laurine Chikoko
- Research and Postgraduate Studies, Midlands State University, Gweru, Zimbabwe
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, Canada
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Agarwal A, Banerji R, Boone P, Elbourne D, Fazzio I, Frost C, Gopal M, Karnati S, Nair R, Reddy H, Reddy P, Sharma D, Shekhawat SS, Shivalli S. Protocol for a cluster randomised trial in Madhya Pradesh, India: community health promotion and medical provision and impact on neonates (CHAMPION2); and support to rural India's public education system and impact on numeracy and literacy scores (STRIPES2). Trials 2020; 21:569. [PMID: 32586400 PMCID: PMC7318373 DOI: 10.1186/s13063-020-04339-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/23/2020] [Indexed: 12/03/2022] Open
Abstract
Background Rural areas of India exhibit high neonatal mortality, and low literacy and numeracy. We assess the effect of a complex package of health interventions on neonatal survival and the effect of out-of-school-hours teaching on children’s literacy and numeracy in rural Madhya Pradesh. Methods/design This is a cluster-randomised controlled trial with villages (clusters) receiving either a health (CHAMPION2) or education (STRIPES2) intervention. Building on the design of the earlier CHAMPION/STRIPES trial, villages receiving the health intervention are controls for the education intervention and vice versa. The clusters are 196 villages in Satna district, Madhya Pradesh, India: each is at least 5 km from a Community Health Centre, has a population below 2500, and has at least 15 children eligible for the education intervention. The participants in CHAMPION2 are resident married women younger than 50 years of age who had not undergone a family planning operation, provided they are enumerated pre-randomisation or marry a man enumerated pre-randomisation. The participants in STRIPES2 are resident children born 16 June 2010 to 15 June 2013, not in school before the 2018–2019 school year and intending to enrol in first grade in 2018–2019 or 2019–2020. Discussion In CHAMPION2, the NICE Foundation will deliver a 3.5-year programme comprising Accredited Social Health Activists or village health workers and midwives promoting health knowledge and providing antenatal, postnatal, and neonatal healthcare; community mobilisation; referrals to appropriate government health facilities; and a health education campaign. In STRIPES2, the Pratham Education Foundation will deliver a programme of village-based, before/after school support focusing on literacy and numeracy. As controls, the CHAMPION2 control villages will receive the usual health services (plus the STRIPES2 intervention). STRIPES2 control villages will receive the usual education services (plus the CHAMPION2 intervention). The primary outcome in CHAMPION2 is neonatal mortality. Secondary outcomes include antenatal, delivery, immediate neonatal and postnatal care practices, maternal mortality, stillbirths, early neonatal deaths, perinatal deaths, health knowledge, hospital admissions, maternal blood transfusions, and cost effectiveness. The primary outcome in STRIPES2 is a composite literacy and numeracy test score. Secondary outcomes include separate literacy and numeracy scores, reported school enrolment and attendance, parents’ engagement with children’s learning, and cost effectiveness. Independent research and implementation teams will conduct the trial. Trial Steering and Data Monitoring Committees, with independent members, will supervise the trial. Trial registration Clinical Trial Registry of India: CTRI/2019/05/019296. Registered on 23 May 2019. http://www.ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=31198&EncHid=&modid=&compid=%27,%2731198det%27
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Affiliation(s)
| | | | | | - Diana Elbourne
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Chris Frost
- London School of Hygiene and Tropical Medicine, London, UK
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Gautham M, Bruxvoort K, Iles R, Subharwal M, Gupta S, Jain M, Goodman C. Investigating the nature of competition facing private healthcare facilities: the case of maternity care in Uttar Pradesh, India. Health Policy Plan 2019; 34:450-460. [PMID: 31302699 PMCID: PMC6735944 DOI: 10.1093/heapol/czz056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2019] [Indexed: 12/02/2022] Open
Abstract
The private healthcare sector in low- and middle-income countries is increasingly seen as of public health importance, with widespread interest in improving private provider engagement. However, there is relatively little literature providing an in-depth understanding of the operation of private providers. We conducted a mixed methods analysis of the nature of competition faced by private delivery providers in Uttar Pradesh, India, where maternal mortality remains very high. We mapped health facilities in five contrasting districts, surveyed private facilities providing deliveries and conducted in-depth interviews with facility staff, allied providers (e.g. ambulance drivers, pathology laboratories) and other key informants. Over 3800 private facilities were mapped, of which 8% reported providing deliveries, mostly clustered in cities and larger towns. 89% of delivery facilities provided C-sections, but over half were not registered. Facilities were generally small, and the majority were independently owned, mostly by medical doctors and, to a lesser extent, AYUSH (non-biomedical) providers and others without formal qualifications. Recent growth in facility numbers had led to intense competition, particularly among mid-level facilities where customers were more price sensitive. In all facilities, nearly all payment was out-of-pocket, with very low-insurance coverage. Non-price competition was a key feature of the market and included location (preferably on highways or close to government facilities), medical infrastructure, hotel features, staff qualifications and reputation, and marketing. There was heavy reliance on visiting consultants such as obstetricians, surgeons and anaesthetists, and payment of hefty commission payments to agents who brought clients to the facility, for both new patients and those transferring from public facilities. Building on these insights, strategies for private sector engagement could include a foundation of universal facility registration, adaptation of accreditation schemes to lower-level facilities, improved third-party payment mechanisms and strategic purchasing, and enhanced patient information on facility availability, costs and quality.
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Affiliation(s)
- Meenakshi Gautham
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
| | - Katia Bruxvoort
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK.,Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles, Pasadena, CA, USA
| | - Richard Iles
- School of Economic Sciences, Washington State University, Pullman, WA, USA
| | - Manish Subharwal
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Sanjay Gupta
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Manish Jain
- IMPACT Partners in Social Development, JE-1/1, LGF, Khirki Extension, Malviya Nagar, New Delhi, India
| | - Catherine Goodman
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London, UK
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Oguntunde O, Yusuf FM, Nyenwa J, Dauda DS, Salihu A, Sinai I. Emergency transport for obstetric emergencies: integrating community-level demand creation activities for improved access to maternal, newborn, and child health services in northern Nigeria. Int J Womens Health 2018; 10:773-782. [PMID: 30568514 PMCID: PMC6276612 DOI: 10.2147/ijwh.s180415] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Ensuring adequate access to skilled birth attendants during and after childbirth is a key strategy to reducing maternal and newborn mortalities. Transportation difficulties in emergency situations continue to be a significant barrier to accessing emergency obstetric care, especially in rural and hard-to-reach areas. Emergency transport schemes (ETS) have been introduced in various settings to increase access to emergency care and reduce the second obstetric delay with varying degrees of success. This qualitative study assessed the perceptions of stakeholders and beneficiaries of ETS in two states in northern Nigeria, comparing two models of ETS: one in which the ETS were introduced as a stand-alone intervention, and another in which ETS were part of a package of interventions for increasing demand and improving utilization of maternal and newborn health services. Methods We carried out focus group discussions with ETS drivers, mothers who delivered in the past year and utilized ETS, husbands of women who benefited from the schemes in the past year, health care providers, traditional birth attendants, and religious leaders, supplemented by in-depth interviews with program focal persons. Results Demand creation activities – especially working with traditional birth attendants and religious leaders – provided a strong linkage between the ETS and families of women in need of emergency transport services. Community members perceived the ETS model that included demand-generating activities as being more reliable and responsive to women’s needs. Conclusion ETS remain a key solution to lack of transport as a barrier to utilizing maternal and newborn health services in emergency situations in many rural and hard-to-reach communities. Programs utilizing ETS to improve access to emergency obstetric care should explore the potential of increasing their utility and reach by integrating the schemes with additional demand-side interventions, especially engagement with traditional birth attendants and religious leaders.
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Affiliation(s)
| | - Farouk Musa Yusuf
- UKAid/Nigeria MNCH2 Programme, Kano, Nigeria, .,Society for Family Health, Abuja, Nigeria
| | - Jabulani Nyenwa
- UKAid/Nigeria MNCH2 Programme, Kano, Nigeria, .,Palladium, London, UK
| | | | - Abdulsamad Salihu
- UKAid/Nigeria MNCH2 Programme, Kano, Nigeria, .,Society for Family Health, Abuja, Nigeria
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11
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Gory E, Sinha RK, Saha D, Vinod TR, Crips NR, Gaikwad PA. Spatio-Temporal Risk-Analysis of Cancer Endemicity in Sulthan Bathery Taluk of Wayanad District of Kerala-A Geo-Informatics Approach. Indian J Community Med 2018; 43:199-203. [PMID: 30294088 PMCID: PMC6166500 DOI: 10.4103/ijcm.ijcm_52_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Asian countries have to confront with the global burden of cancer and various environmental factors predisposing the incidence. Geoinformatics can assist in spatial autocorrelation and statistical analysis in determining environmental and demographic correspondence to endemicity. What is of prime importance is the availability of the spatial datasets of cancer cases. Aims The aim of this study was to reveal the distribution pattern of cancer and its magnitude in the eight panchayats of Sulthan Bathery Taluk of Wayanad district. The present study also attempted to develop and implement a data frame facilitating better data collection. Settings and Design This was a taluk-level cross-sectional retrospective analysis and interventional study. Subjects and Methods A retrospective survey created a geodatabase with 547 cancer cases registered along the timeline of 2015-2016. Input datasets were geocoded using Google Earth Pro software. Statistical Analysis Used The analysis was performed using ArcMap-10.2 version. Results Registration revealed the high breast cancer incidences and temporal increment mainly in town areas. The incidence depicted male predominance and prevalence along the age group of 30-69 years. The pattern showed cancer incidence at a proximity to state borders and forest regions (Noolpuzha) which are high population density regions, instantiated relation of geographic variables, and cancer incidences. The implementation of data frame ensured structured data collection. Conclusions This study concluded the spatial association of cancer incidence demonstrating the high-risk regions with male predominance and role spatial risk analysis in cancer database management.
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Affiliation(s)
- Elmy Gory
- Department of Health Information Management, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Rajesh Kumar Sinha
- Department of Health Information Management, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dola Saha
- Department of Health Information Management, School of Allied Health Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - T R Vinod
- Center for Environment and Development, Trivandrum, Kerala, India
| | - N R Crips
- Center for Environment and Development, Trivandrum, Kerala, India
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12
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Sabde Y, Chaturvedi S, Randive B, Sidney K, Salazar M, De Costa A, Diwan V. Bypassing health facilities for childbirth in the context of the JSY cash transfer program to promote institutional birth: A cross-sectional study from Madhya Pradesh, India. PLoS One 2018; 13:e0189364. [PMID: 29385135 PMCID: PMC5791953 DOI: 10.1371/journal.pone.0189364] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 11/25/2017] [Indexed: 11/23/2022] Open
Abstract
Bypassing health facilities for childbirth can be costly both for women and health systems. There have been some reports on this from Sub-Saharan African and from Nepal but none from India. India has implemented the Janani Suraksha Yojana (JSY), a large national conditional cash transfer program which has successfully increased the number of institutional births in India. This paper aims to study the extent of bypassing the nearest health facility offering intrapartum care in three districts of Madhya Pradesh, India, and to identify individual and facility determinants of bypassing in the context of the JSY program. Our results provide information to support the optimal utilization of facilities at different levels of the healthcare system for childbirth. Data was collected from 96 facilities (74 public) and 720 rural mothers who delivered at these facilities were interviewed. Multilevel logistic regression was used to analyze the data. Facility obstetric care functionality was assessed by the number of emergency obstetric care (EmOC) signal functions performed in the last three months. Thirty eighth percent of the mothers bypassed the nearest public facility for their current delivery. Primiparity, higher education, arriving by hired transport and a longer distance from home to the nearest facility increased the odds of bypassing a public facility for childbirth. The variance partition coefficient showed that 37% of the variation in bypassing the nearest public facility can be attributed to difference between facilities. The number of basic emergency obstetric care signal functions (AOR = 0.59, 95% CI 0.37–0.93), and the availability of free transportation at the nearest facility (AOR = 0.11, 95% CI 0.03–0.31) were protective factors against bypassing. The variation between facilities (MOR = 3.85) was more important than an individual’s characteristics to explain bypassing in MP. This multilevel study indicates that in this setting, a focus on increasing the level of emergency obstetric care functionality in public obstetric care facilities will allow more optimal utilization of facilities for childbirth under the JSY program thereby leading to better outcomes for mothers.
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Affiliation(s)
- Yogesh Sabde
- Department of Community Medicine, R.D. Gardi Medical College, Ujjain, India
| | - Sarika Chaturvedi
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health and Environment, R.D. Gardi Medical College, Ujjain, India
| | - Bharat Randive
- Department of Public Health and Environment, R.D. Gardi Medical College, Ujjain, India
- Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden
| | - Kristi Sidney
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Mariano Salazar
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Ayesha De Costa
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Vishal Diwan
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Department of Public Health and Environment, R.D. Gardi Medical College, Ujjain, India
- International Centre for Health Research, R.D. Gardi Medical College, Ujjain, India
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13
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Chowdhury AI, Haider R, Abdullah AYM, Christou A, Ali NA, Rahman AE, Iqbal A, Bari S, Hoque DME, Arifeen SE, Kissoon N, Larson CP. Using geospatial techniques to develop an emergency referral transport system for suspected sepsis patients in Bangladesh. PLoS One 2018; 13:e0191054. [PMID: 29338012 PMCID: PMC5770043 DOI: 10.1371/journal.pone.0191054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 12/27/2017] [Indexed: 11/25/2022] Open
Abstract
Background A geographic information system (GIS)-based transport network within an emergency referral system can be the key to reducing health system delays and increasing the chances of survival, especially during an emergency. We employed a GIS to design an emergency transport system for the rapid transfer of pregnant or early post-partum women, newborns, and children under 5 years of age with suspected sepsis under the Interrupting Pathways to Sepsis Initiative (IPSI) project. Methods A GIS database was developed by mapping the villages, roads, and relevant physical features of the study area. A travel-time algorithm was developed to incorporate the time taken by different modes of local transport to reach the health complexes. These were used in a network analysis to identify the shortest routes to the hospitals from the villages, which were categorized into green, yellow, and red zones based on their proximity to the nearest hospitals to provide transport facilities. An emergency call-in centre established for the project managed the transport system, and its data was used to assess the uptake of this transport system amongst distant communities. Results Fifteen pre-existing and two new routes were identified as the shortest routes to the health complexes. The call-in centre personnel used this route information to direct both patients and transport drivers to the nearest transport hubs or pick-up points. Adherence with referral advice was high in areas where the IPSI transport operated. Over the study period, the utilisation of the project’s transport doubled and referral compliance from distant zones similarly increased. Conclusions The GIS system created for this study facilitated rapid referral of patients in emergency from distant zones, using locally available transport and resources. The methodology described in this study to develop and implement an emergency transport system can be applied in similar, rural, low-income country settings.
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Affiliation(s)
- Atique Iqbal Chowdhury
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- * E-mail:
| | - Rafiqul Haider
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Yousuf Md Abdullah
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Aliki Christou
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Nabeel Ashraf Ali
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ahmed Ehsnaur Rahman
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Afrin Iqbal
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sanwarul Bari
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - D. M. Emdadul Hoque
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shams El Arifeen
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles P. Larson
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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14
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Salehi F, Ahmadian L. The application of geographic information systems (GIS) in identifying the priority areas for maternal care and services. BMC Health Serv Res 2017; 17:482. [PMID: 28701226 PMCID: PMC5508661 DOI: 10.1186/s12913-017-2423-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 06/29/2017] [Indexed: 11/15/2022] Open
Abstract
Background Improving maternal health is globally introduced as an important health priority. The purpose of this study is to identify the high priority areas which require more maternal health services in Kerman, Iran. Methods This is a descriptive cross-sectional study, performed in 2015. The literatures were first explored in order to extract geographic indicators and sub indicators relevant to the maternal health. Data were collected by the use of a questionnaire designed on the basis of AHP (Analytic Hierarchy Process) method. The validity and reliability of the questionnaire were confirmed by three medical informatics experts and test-retest method, respectively. Data were analyzed by Expert Choice software in order to specify the weight and importance of each indicator. The information were then added to Geographic Information System (GIS) to analyze and create the related maps. Results Women’s access to hospitals plays an important role in identifying high priority areas which need maternal care and services. More than half of the mothers in Kerman have a moderate level of access to maternal care services. There is an association between facilities that are provided for pregnant women and the existence of healthcare centers. Moreover, there is a negative correlation between maternal death and the number of facilities provided for medical care and services for pregnant women. Conclusions The application of GIS provides us with the capability to identify high priority areas which need maternal care. According to current population policies in Iran and the probable increase in the fertility rate, it is wise to plan proper schedules to improve health care services for pregnant women in Kerman. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2423-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fatemeh Salehi
- Health Information Technology, School of Management and Medical Information, Kerman University of Medical Sciences, Kerman, Iran.,Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Leila Ahmadian
- Medical Informatics, Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Haftbagh Highway, Kerman, 7616911313, Iran.
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15
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Jha P, Larsson M, Christensson K, Skoog Svanberg A. Satisfaction with childbirth services provided in public health facilities: results from a cross- sectional survey among postnatal women in Chhattisgarh, India. Glob Health Action 2017; 10:1386932. [PMID: 29087240 PMCID: PMC5678347 DOI: 10.1080/16549716.2017.1386932] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/21/2017] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND A woman's satisfaction with childbirth services can have a significant impact on her mental health and ability to bond with her neonate. Knowing postnatal women's opinions and satisfaction with services makes the services more women-friendly. Indian women's satisfaction with childbirth services has been explored qualitatively, or by using non-standard local questionnaires, but scientific data gathered with standardised questionnaires are extremely limited. OBJECTIVE To measure postnatal Indian women's satisfaction with childbirth services at selected public health facilities in Chhattisgarh, India. METHODS Cross-sectional survey using consecutive sampling (n = 1004) was conducted from March to May 2015. Hindi-translated and validated versions of the Scale for Measuring Maternal Satisfaction for Vaginal Births (VB) and Caesarean Births (CB) were used for data collection. RESULTS Although most of the women (VB 68.7%; CB 79.2%) were satisfied with the overall childbirth services received, those who had VB were least satisfied with the processes around meeting their neonates (mean subscale score 1.8, SD 1.3), while women having CB were least satisfied with postpartum care received (mean subscale score 2.7, SD 1.2). Regression analyses revealed that among women having VB, interacting with care providers, being able to maintain privacy, and being free from fear of childbirth had a positive influence on overall satisfaction with the childbirth. Among women having CB, earning their own salary and having a positive perception of self-health had associations with overall birth satisfaction. CONCLUSIONS Improving interpersonal interaction with nurse-midwives, and ensuring privacy during childbirth and hospital stay, are recommended first steps to improve women's childbirth satisfaction, until the supply gap is eliminated.
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Affiliation(s)
- Paridhi Jha
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Margareta Larsson
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Kyllike Christensson
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
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16
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Campbell OMR, Calvert C, Testa A, Strehlow M, Benova L, Keyes E, Donnay F, Macleod D, Gabrysch S, Rong L, Ronsmans C, Sadruddin S, Koblinsky M, Bailey P. The scale, scope, coverage, and capability of childbirth care. Lancet 2016; 388:2193-2208. [PMID: 27642023 DOI: 10.1016/s0140-6736(16)31528-8] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/23/2016] [Accepted: 06/17/2016] [Indexed: 12/15/2022]
Abstract
All women should have access to high quality maternity services-but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.
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Affiliation(s)
| | - Clara Calvert
- London School of Hygiene & Tropical Medicine, London, UK
| | - Adrienne Testa
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Lenka Benova
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - France Donnay
- Tulane University School of Public Health, New Orleans, LA, USA
| | - David Macleod
- London School of Hygiene & Tropical Medicine, London, UK
| | - Sabine Gabrysch
- Institute of Public Health, Heidelberg University, Heidelberg, Germany
| | - Luo Rong
- National Center for Women and Children Health, Chinese Disease Prevention Control Center, Beijing, China
| | - Carine Ronsmans
- London School of Hygiene & Tropical Medicine, London, UK; West China School of Public Health, Sichuan University, Chengdu, China
| | | | - Marge Koblinsky
- USAID, Office of Health, Infectious Diseases and Nutrition, Maternal and Child Health, Washington, DC, USA
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Sidney K, Salazar M, Marrone G, Diwan V, DeCosta A, Lindholm L. Out-of-pocket expenditures for childbirth in the context of the Janani Suraksha Yojana (JSY) cash transfer program to promote facility births: who pays and how much? Studies from Madhya Pradesh, India. Int J Equity Health 2016; 15:71. [PMID: 27142657 PMCID: PMC4855911 DOI: 10.1186/s12939-016-0362-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 04/27/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND High out-of-pocket expenditures (OOPE) make delivery care difficult to access for a large proportion of India's population. Given that home deliveries increase the risk of maternal mortality, in 2005 the Indian Government implemented the Janani Suraksha Yojana (JSY) program to incentivize poor women to deliver in public health facilities by providing a cash transfer upon discharge. We study the OOPE among JSY beneficiaries and women who deliver at home, and predictors of OOPE in two districts of Madhya Pradesh. METHODS September 2013 to April 2015 a cross-sectional community-based survey was performed. All recently delivered women were interviewed to elicit delivery costs, socio-demographic characteristics and delivery related information. RESULTS Most women (n = 1995, 84 %) delivered in JSY public health facility, the remaining 16 % (n = 386) delivered at home. Women who delivered under JSY program had a higher median, IQR OOPE ($8, 3-18) compared to home ($6, 2-13). Among JSY beneficiaries, poorest women had twice net gain ($20) versus wealthiest ($10) post cash transfer. Informal payments (64 %) and food/baby items (77 %) were the two most common sources of OOPE. OOPE made among JSY beneficiaries was pro-poor: poorer women made proportionally less expenditures compared to wealthier women. In an adjusted model, delivering in a JSY public facility increased odds of incurring expenditures (OR: 1.58, 95 % CI: 1.11-2.25) but at the same time to a 16 % (95 % CI: 0.73-0.96) decrease in the amount paid compared to home deliveries. CONCLUSIONS OOPE is prevalent among JSY beneficiaries as well in home deliveries. In JSY, OOPE varies by income quintile: wealthier quintiles pay more OOPE. However the cash incentive is adequate enough to provide a net gain for all quintiles. OOPE was largely due to indirect costs and not direct medical payments. The program seems to be effective in providing financial protection for the most vulnerable groups.
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Affiliation(s)
- Kristi Sidney
- Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden.
| | - Mariano Salazar
- Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden
| | - Gaetano Marrone
- Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden
| | - Vishal Diwan
- Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden
- Public Health and Environment, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India
- International Center for Health Research, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India
| | - Ayesha DeCosta
- Department of Public Health Sciences, Karolinska Institutet, Widerströmska, Tomtebodavägen 18A, plan 4, SE-171 77, Stockholm, Sweden
- International Center for Health Research, R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India
| | - Lars Lindholm
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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18
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Sidney K, Tolhurst R, Jehan K, Diwan V, De Costa A. 'The money is important but all women anyway go to hospital for childbirth nowadays' - a qualitative exploration of why women participate in a conditional cash transfer program to promote institutional deliveries in Madhya Pradesh, India. BMC Pregnancy Childbirth 2016; 16:47. [PMID: 26944258 PMCID: PMC4779242 DOI: 10.1186/s12884-016-0834-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 02/25/2016] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND In 2005-06, only 39 % of Indian women delivered in a health facility. Given that deliveries at home increase the risk of maternal mortality, it was in this context in 2005, that the Indian Government implemented the Janani Suraksha Yojana program that incentivizes poor women to give birth in a health facility by providing them with a cash transfer upon discharge. JSY helped raise institutional delivery to 74 % in the eight years since its implementation. Despite the success of the JSY in raising institutional delivery proportions, the large number of beneficiaries (105 million), and the cost of the program, there have been few qualitative studies exploring why women participate (or not) in the program. The objective of this paper was to explore this. METHODS In March 2013, we conducted 24 individual in-depth interviews with women who delivered within the previous 12 months in two districts of Madhya Pradesh, India. Qualitative framework analysis was used to analyze the data. RESULTS Our findings suggest that women's increased participation in the program reflect a shift in the social norm. Drivers of the shift include social pressure from the Accredited Social Health Activist (ASHA) to deliver in a health facility, and a growing individual perception of the importance for 'safe' and 'easy' delivery which was most likely an expression of the new social norm. While the incentive was an important influence on many women's choices, others did not perceive it as an important consideration in their decision to deliver in a health facility. Many women reported procedural difficulties to receive the benefit. Retaining the cash incentive was also an issue due to out-of-pocket expenditures incurred at the facility. Non-participation was often unintentional and caused by personal circumstances, poor geographic access or driven by a perception of poor quality of care provided in program facilities. CONCLUSIONS In summary, while the cash incentive was important for some women in facilitating an institutional birth, the shift in social norm (possibly in part facilitated by the program) and therefore their own perceptions has played a major role in them giving birth in facilities.
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Affiliation(s)
- Kristi Sidney
- Karolinska Institutet, Public Health Sciences, Tomtebodavägen 18, Stockholm, 171 77, Sweden.
| | - Rachel Tolhurst
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, Merseyside, UK.
| | - Kate Jehan
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, Merseyside, UK.
| | - Vishal Diwan
- R. D. Gardi Medical College, Agar Road, Surasa, Ujjain, 456006, Madhya Pradesh, India.
| | - Ayesha De Costa
- Karolinska Institutet, Public Health Sciences, Tomtebodavägen 18, Stockholm, 171 77, Sweden.
- R. D. Gardi Medical College, Agar Road, Surasa, Ujjain, 456006, Madhya Pradesh, India.
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19
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Fogliati P, Straneo M, Brogi C, Fantozzi PL, Salim RM, Msengi HM, Azzimonti G, Putoto G. How Can Childbirth Care for the Rural Poor Be Improved? A Contribution from Spatial Modelling in Rural Tanzania. PLoS One 2015; 10:e0139460. [PMID: 26422687 PMCID: PMC4589408 DOI: 10.1371/journal.pone.0139460] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 09/14/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Maternal and perinatal mortality remain a challenge in resource-limited countries, particularly among the rural poor. To save lives at birth health facility delivery is recommended. However, increasing coverage of institutional deliveries may not translate into mortality reduction if shortage of qualified staff and lack of enabling working conditions affect quality of services. In Tanzania childbirth care is available in all facilities; yet maternal and newborn mortality are high. The study aimed to assess in a high facility density rural context whether a health system organization with fewer delivery sites is feasible in terms of population access. Methods Data on health facilities’ location, staffing and delivery caseload were examined in Ludewa and Iringa Districts, Southern Tanzania. Geospatial raster and network analysis were performed to estimate access to obstetric services in walking time. The present geographical accessibility was compared to a theoretical scenario with a 40% reduction of delivery sites. Results About half of first-line health facilities had insufficient staff to offer full-time obstetric services (45.7% in Iringa and 78.8% in Ludewa District). Yearly delivery caseload at first-line health facilities was low, with less than 100 deliveries in 48/70 and 43/52 facilities in Iringa and Ludewa District respectively. Wide geographical overlaps of facility catchment areas were observed. In Iringa 54% of the population was within 1-hour walking distance from the nearest facility and 87.8% within 2 hours, in Ludewa, the percentages were 39.9% and 82.3%. With a 40% reduction of delivery sites, approximately 80% of population will still be within 2 hours’ walking time. Conclusions Our findings from spatial modelling in a high facility density context indicate that reducing delivery sites by 40% will decrease population access within 2 hours by 7%. Focused efforts on fewer delivery sites might assist strengthening delivery services in resource-limited settings.
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Affiliation(s)
| | | | - Cosimo Brogi
- Department of Physical Sciences, Earth and Environment, University of Siena, Siena, Italy
| | - Pier Lorenzo Fantozzi
- Department of Physical Sciences, Earth and Environment, University of Siena, Siena, Italy
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Khan R, Vandelaer J, Yakubu A, Raza AA, Zulu F. Maternal and neonatal tetanus elimination: from protecting women and newborns to protecting all. Int J Womens Health 2015; 7:171-80. [PMID: 25678822 PMCID: PMC4322871 DOI: 10.2147/ijwh.s50539] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
A total of 35 of the 59 countries that had not eliminated maternal and neonatal tetanus (MNT) as a public health problem in 1999 have since achieved the MNT-elimination goal. Neonatal tetanus deaths have decreased globally from 200,000 in 2000 to 49,000 in 2013. This is the result of increased immunization coverage with tetanus toxoid-containing vaccines among pregnant women, improved access to skilled birth attendance during delivery, and targeted campaigns with these vaccines for women of reproductive age in high-risk areas. In the process, inequities have been reduced, private–public partnerships fostered, and innovations triggered. However, lack of funding, poor accessibility to some areas, suboptimal surveillance, and a perceived low priority for the disease are among the main obstacles. To ensure MNT elimination is sustained, countries must build and maintain strong routine programs that reach people with vaccination and with clean deliveries. This should also be an opportunity to shift programs into preventing tetanus among all people. Regular assessments, and where needed appropriate action, are key to prevent increases in MNT incidence over time, especially in areas that are at higher risk. The main objective of the paper is to provide a detailed update on the progress toward MNT elimination between 1999 and 2014. It elaborates on the challenges and opportunities, and discusses how MNT elimination can be sustained and to shift the program to protect wider populations against tetanus.
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Affiliation(s)
- Rownak Khan
- Health Section, Programme Division, UNICEF, New York, NY, USA
| | - Jos Vandelaer
- Health Section, Programme Division, UNICEF, New York, NY, USA
| | - Ahmadu Yakubu
- Family, Women and Children's Health Cluster, World Health Organization, Geneva, Switzerland
| | - Azhar Abid Raza
- Health Section, Programme Division, UNICEF, New York, NY, USA
| | - Flint Zulu
- Health Section, Programme Division, UNICEF, New York, NY, USA
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