Effective coverage of facility delivery in Bangladesh, Haiti, Malawi, Nepal, Senegal, and Tanzania

Effective coverage of child immunisation service in Ethiopia

Vaccines are one of the safest and most cost-effective interventions to prevent disease and disabilities worldwide. Yet, nearly 19 million children do not receive basic vaccines and most of them are from low and middle-income countries. The Sustainable Development Goal 3 aims at eliminating preventable deaths of newborns and under-five children by 2030. However, Ethiopia has a high child mortality rate, and most of them are from preventable causes. Quality provision of immunisation could reduce vaccine-preventable morbidity and mortality. Despite this, the quality-adjusted coverage of immunisation services in Ethiopia has not been well-documented. We used the Kids' record from the 2019 Ethiopian Demographic and Survey (EDHS) and the health facility recode from the 2021-2022 Ethiopian Service Provision Assessment (ESPA). The EDHS and ESPA data were linked using administrative boundary linkage using administrative regions and city administrations. The crude coverage was weighted before linking with the ESPA dataset. Health facilities which provide child immunisation services were included. The quality of immunisation service provision was constructed from 14 indicators. The quality of immunisation was calculated as the sum of the availability of items in each domain, divided by the total number of items in the domain, and finally multiplied by 100. The effective coverage was measured as the product of contact coverage and quality of immunisation service provision. We use STATA 17 for analysis. A total of 951 respondents who have a live children aged 12-23 month were included. The national effective coverage of immunisation was 34.3% (95% Confidence interval (CI): 33.0, 35.5) with a large variation in different regions, ranged from 14.8% in Afar to 83.5% in Addis Ababa. The crude coverage of immunisation services was 39.6% (95% CI: 36.5, 42.7), ranged from 19.2% in Afar to 87.39% in Addis Ababa. The overall score for quality of immunisation service was 82% (95% CI: 80.44, 83.51). The quality ranged from 74.6% in SNNPR to 95.5% in Addis Ababa. The quality of immunisation varies with the managing authority of health facilities, private facilities had the highest quality (90% (95% CI: 85.35, 95.36)) and government facilities scored the lowest quality (82% (95% CI: 80.06, 83.22)). There was low effective coverage of immunisation services provision in Ethiopia. The effective coverage was lower in the pastoral regions (Afar and Somali). Government facilities and facilities in rural areas had lower-quality immunisation services. Facilities in SNNPR and Afar region had low-quality of immunisation service. Policymakers should focus on improving the quality of government facilities and the facilities in rural areas and pastoral regions to improve immunisation services.

Spatial distribution of effective coverage of child immunisation in Ethiopia

Introduction

Child immunisation is a cost-effective strategy to reduce vaccine-preventable diseases. While effective coverage is key to ensuring quality immunisation, little is known about its geographical distribution in Ethiopia. This study aims to assess the spatial distribution of effective coverage of child immunisation and identify areas with low coverage to inform targeted interventions.

Methods

We used the 2019 Ethiopia Mini Demographic and Health Survey and Ethiopia Service Provision Assessment datasets. After calculating the effective coverage of immunisation, Bayesian model-based geostatistics were employed to assess the spatial distribution of effective immunisation coverage in Ethiopia, using relevant covariates to estimate coverage rates across regions.

Results

The national effective coverage of immunisation was 34% (95% CI: 31.9% to 36.5%), with significant regional variation. Addis Ababa, western Benishangul-Gumuz, Dire Dawa city administrative, the northern part of South West Ethiopia and the northwest part of Amhara had hotspots for high level of effective coverage of child immunisation. On the other hand, central Amhara, northern Gambela, central Oromia, Sidama, northern Southern Nations, Nationalities and Peoples regions (SNNPR) and Somali had low effective coverage of child immunisation. Travel time to the nearest city (-0.292: 95% CI:-0.533 to -0.052) was found to be negative predictor of spatial distribution.

Conclusion

There were significant geographical variations in the effective coverage of immunisation services in Ethiopia. Travel time to nearest city was a significant predictor of spatial distribution. Policymakers are advised to prioritise underserved areas and improve spatial predictors to have a safe, effective and life-saving vaccination program in Ethiopia.

Linking Household and Service Provisioning Assessments to Estimate a Metric of Effective Health Coverage: A Metric for Monitoring Universal Health Coverage

BACKGROUND

The framework of measuring effective coverage is conceptually straightforward, yet translation into a single metric is quite intractable. An estimation of a metric linking need, access, utilization, and service quality is imperative for measuring the progress towards Universal Health Coverage. A coverage metric obtained from a household survey alone is not succinct as it only captures the service contact which cannot be considered as actual service delivery as it ignores the comprehensive assessment of provider-client interaction. The study was thus conducted to estimate a one-composite metric of effective coverage by linking varied datasets.

METHODS

The study was conducted in a rural, remote, and fragile setting in India. Tools encompassing a household survey, health facility assessment, and patient exit survey were administered to ascertain measures of contact coverage and quality. A gamut of techniques linking the varied surveys were employed such as (a) exact match linking and (b) ecological linking using GIS approaches via administrative boundaries, Euclidean buffers, travel time grid, and Kernel density estimates. A composite metric of effective coverage was estimated using linked datasets, adjusting for structural and process quality estimates. Further, the horizontal inequities in effective coverage were computed using Erreygers' concentration index. The concordance between linkage approaches were examined using Wald tests and Lin's concordance correlation.

RESULTS

A significantly steep decline in measurement estimates was found from crude coverage to effective coverage for an entire slew of linking approaches. The drop was more exacerbated for structural-quality-adjusted measures vis-à-vis process-quality-adjusted measures. Overall, the estimates for effective coverage and inequity-adjusted effective coverage were 36.4% and 33.3%, respectively. The composite metric of effective coverage was lowest for postnatal care (10.1%) and highest for immunization care (78.7%). A significant absolute deflection ranging from -2.1 to -5.5 for structural quality and -1.9 to -8.9 for process quality was exhibited between exact match linking and ecological linking.

CONCLUSIONS

Poor quality of care was divulged as a major factor of decline in coverage. Policy recommendations such as bolstering the quality via the effective implementation of government flagship programs along with initiatives such as integrated incentive schemes to attract and retain workforce and community-based monitoring are suggested.

Avoidable factors associated with maternal death from postpartum haemorrhage: a national Malawian surveillance study

BACKGROUND

Despite strong evidence-based strategies for prevention and management, global efforts to reduce deaths from postpartum haemorrhage (PPH) have failed, and it remains the leading cause of maternal mortality. We conducted a detailed review of all maternal deaths from 33 facilities in Malawi to identify health system weaknesses leading to deaths from PPH.

METHODS

Data were collected regarding every maternal death occurring across all district and central hospitals in Malawi. Deaths occurring from August 2020 to December 2022 were reviewed by multidisciplinary facility-based teams who compiled case narratives from clinical notes and then subsequently reviewed by obstetricians to confirm the cause of death according to international criteria. Data were summarised using proportions/frequencies, comparisons made using χ2 or Wilcoxon rank sum tests, and logistic regression conducted to calculate ORs with CIs.

RESULTS

PPH was the cause of 20.4% of maternal deaths. Most deaths from PPH occurred within 24 hours of birth (80.0%), among women who had been referred to a higher-level facility (57.0%) and were admitted in stable condition (60.0%). Vacuum births carried an increased risk of death from PPH (OR 4.25 (95% CI 1.15 to 20.13, p=0.039)). Detailed reviews identified that deaths from PPH were more likely to be associated with factors such as 'lack of obstetric lifesaving skills' (26.7% vs 10.1%, p<0.001), 'inadequate monitoring' (51.5% vs 40.7%, p=0.012) and 'communication problems between facilities' (11.5% vs 6.2%, p=0.019) than deaths from other causes.

CONCLUSIONS

Our analysis represents the largest published review of maternal deaths from PPH. We demonstrate that key health system weaknesses are contributing to these preventable maternal deaths. Case reviews conducted by multidisciplinary facility-based teams identified common and recurrent avoidable factors associated with deaths from PPH. Global efforts must now be focused on strategies that address these weaknesses, strengthening health systems and empowering healthcare workers to reduce maternal deaths from PPH.

Effective coverage of maternal and neonatal healthcare services in low-and middle-income countries: a scoping review

BACKGROUND

There is no consistent operationalization of effective coverage (EC) across studies. Therefore, this scoping review synthesized evidence on the definitions and measurement approaches, outcomes reported, and the factors that are associated with variations in quality-adjusted EC estimates of maternal and neonatal healthcare services in low- and middle-income countries.

METHODS

Article search was conducted using PubMed, Embase, Google Scholar, and other databases. Then, title, abstract, and full text screenings for inclusion were performed by two authors independently and disagreements were resolved through discussion. In case of duplication, the full-text published articles were retained, and the results are presented using the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews checklist as a guide.

RESULTS

Overall, 36 articles were included in this scoping review. In most articles, EC has been defined from the perspectives of people in need utilizing healthcare services in well-equipped health facilities and from actual receipt of quality services. In addition, usage, instead of need, has been used as a domain in estimating EC in some instances. Effective coverage ranged from 0% for different services including for post-partum care, to 84% for antenatal care. Moreover, different socio-demographic factors including wealth index, education, and residence are found to have an association with variations in EC of maternal and neonatal healthcare services with the wealthiest, most educated, and those living in urban areas having higher estimates. From the supply side, numerous factors, particularly health facility capacity-related constraints, have been reported to be associated with low EC of those services.

CONCLUSIONS

The variability in the definition and measurement approaches of EC across studies emphasizes the need for standardization for better comparison in future research. We recommend that quality-adjusted EC be defined in two ways: intervention-specific service delivery EC and general service delivery EC. In addition, disparities in EC are observed among women with different socioeconomic status including educational level and wealth index. Organizational capacity constraints and other health system and societal factors also contributed to variations in EC.

Mapping inequalities in health service coverage in Africa: a scoping review

OBJECTIVE

In this scoping review, we aim to consolidate the evidence on inequalities in service coverage in Africa using a comprehensive set of stratifiers. These stratifiers include place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status and social capital. Our approach provides a more holistic understanding of the different dimensions of inequality in the context of universal health coverage (UHC).

DESIGN

We conducted a scoping review following the Joanna Briggs Institute Manual for Evidence Synthesis.

DATA SOURCES

We searched MEDLINE, Embase, Web of Science, CINAHL, PyscINFO, Cochrane Library, Google Scholar and Global Index Medicus for articles published between 1 January 2005 and 29 August 2022 examining inequalities in utilisation of health services for reproductive, maternal, newborn and child health (RMNCH), infectious or non-communicable diseases in Africa.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included any empirical research that assessed inequalities in relation to services for RMNCH (eg, family planning), infectious diseases (eg, tuberculosis treatment) and non-communicable diseases (eg, cervical cancer screening) in Africa.

DATA EXTRACTION AND SYNTHESIS

The data abstraction process followed a stepwise approach. A pilot-tested form capturing study setting, inequality assessment and service coverage indicators was developed and finalised. Data were extracted by one reviewer and cross-checked by another, with discrepancies resolved through consensus meetings. If a consensus was not reached, senior reviewers made the final decision. We used a narrative approach to describe the study characteristics and mapped findings against PROGRESS-Plus stratifiers and health service indicators. Quantitative findings were categorised as 'proequity', 'antiequity' or 'equal' based on service utilisation across social groups.

RESULTS

We included 178 studies in our review, most studies published within the last 5 years (61.1%). Most studies assessed inequality using socioeconomic status (70.6%), followed by age (62.4%), education (60.7%) and place of residence (59.0%). Few studies focused on disability, social capital and ethnicity/race and intersectionality of stratifiers. Most studies were on RMNCH services (53.4%) and infectious disease services (43.3%). Few studies were qualitative or behavioural analyses. Results highlight significant inequalities across different equity stratifiers and services with inconsistent trends of inequalities over time after the implementation of strategies to increase demand of services and strengthen health systems.

CONCLUSION

There is a need to examine equity in service coverage for a variety of health conditions among various populations beyond the traditional classification of social groups. This also requires using diverse research methods identifying disparities in service use and various barriers to care. By addressing these knowledge gaps, future research and health system reforms can support countries in moving closer to achievement of UHC targets.

Maternal mortality following caesarean section in a low-resource setting: a National Malawian Surveillance Study

BACKGROUND

Caesarean section (CS) is the most common major surgery conducted globally, with rates rising. CS also contributes to maternal morbidity and mortality, with increased risks in low-resource settings. We conducted a detailed review of maternal deaths from 2020 to 2022 in Malawi to determine the burden of deaths related to CS, avoidable health system factors, and causes of death associated with this procedure.

METHODS

Data were collected regarding every maternal death occurring across all district and central hospitals in Malawi, alongside facility-level aggregated birth data. Maternal deaths were reviewed by facility-based multidisciplinary teams with subsequent confirmation of cause of death by obstetricians according to international criteria. Logistic regression was applied to estimate the odds of associations of leading causes of death with CS while adjusting for potential confounders.

RESULTS

Despite a low national CS rate, most deaths occurred following CS (51.8%, 276/533). Women who delivered by CS were five times (OR 5.60, 95% CI 4.74 to 6.67) more likely to die than women who delivered vaginally. The leading causes of death following CS were postpartum haemorrhage (26.0%, 68/277), eclampsia (15.6%, 41/277) and infection (14.1%, 37/277). Deaths from pregnancy-related infection were more often associated with CS (OR 2.03, 95% CI 1.12 to 3.72). Health system factors more frequently associated with deaths following CS than vaginal birth included 'prolonged abnormal observations without action' (p=0.006), 'delay in starting treatment' (p=0.006) and 'lack of blood transfusion' (p=0.03).

CONCLUSIONS

We found a high burden of maternal death following CS in this low-resource setting. Until now, international attention and many clinical trials have been focused on improving the safety of vaginal birth. Our findings highlight the need to ensure the safe and appropriate use of this potentially life-saving intervention to reduce maternal deaths. To avoid the high burden of death following CS we highlight, there is urgent need to develop and trial CS-specific interventions.

Prevalence and determinants of readiness of health facilities for quality antenatal care services in Bangladesh

This study investigates the prevalence and determinants of readiness for quality antenatal care (ANC) services in Bangladesh using data from the 2017 Bangladesh Health Facility Survey (BHFS). We assessed the association between selected factors and the readiness index using multinomial logistic regression. We identified a significant gap in the availability and quality of ANC services, only 4.26% of health facilities provide quality ANC services, with rural facilities showing lower readiness compared to urban facilities (RRR:0.13; 95% CI: 0.06-0.31; p < 0.001). Community clinics and private hospitals have a lower likelihood of medium or high readiness compared to public hospitals or clinics. Health facilities with specialized care are more likely to demonstrate readiness for quality ANC services. Policy recommendations include increased healthcare funding, implementation of ANC guidelines, strengthened monitoring and evaluation of health facilities, and heightened community awareness. These measures should improve ANC, overall health outcomes, and public health policies.

Delays in accessing high-quality care for newborns in East Africa: An analysis of survey data in Malawi, Mozambique, and Tanzania

Background

Despite the existence of evidence-based interventions, substantial progress in reducing neonatal mortality is lagging, indicating that small and sick newborns (SSNs) are likely not receiving the care they require to survive and thrive. The 'three delays model' provides a framework for understanding the challenges in accessing care for SSNs. However, the extent to which each delay impacts access to care for SSNs is not well understood. To fill this evidence gap, we explored the impact of each of the three delays on access to care for SSNs in Malawi, Mozambique, and Tanzania.

Methods

Secondary analyses of data from three different surveys served as the foundation of this study. To understand the impact of delays in the decision to seek care (delay 1) and the ability to reach an appropriate point of care (delay 2), we investigated time trends in place of birth disaggregated by facility type. We also explored care-seeking behaviours for newborns who died. To understand the impact of delays in accessing high-quality care after reaching a facility (delay 3), we measured facility readiness to manage care for SSNs. We used this measure to adjust institutional delivery coverage for SSN care readiness.

Results

Coverage of institutional deliveries was substantially lower after adjusting for facility readiness to manage SSN care, with decreases of 30 percentage points (pp) in Malawi, 14 pp in Mozambique, and 24 pp in Tanzania. While trends suggest more SSNs are born in facilities, substantial gaps remain in facilities' capacities to provide lifesaving interventions. In addition, exploration of care-seeking pathways revealed that a substantial proportion of newborn deaths occurred outside of health facilities, indicating barriers in the decision to seek care or the ability to reach an appropriate source of care may also prevent SSNs from receiving these interventions.

Conclusions

Investments are needed to overcome delays in accessing high-quality care for the most vulnerable newborns, those who are born small or sick. As more mothers and newborns access health services in low- and middle-income countries, ensuring that life-saving interventions for SSNs are available at the locations where newborns are born and seek care after birth is critical.

Assessing the readiness of health facilities to provide family planning services in low-resource settings: Insights from nationally representative service provision assessment surveys in 10 Countries

BACKGROUND

Many low-income countries continue to have high fertility levels and unmet need for family planning (FP) despite progress in increasing access to modern contraceptive methods and in reducing the total fertility rate (TFR). Health facilities in sub-Saharan Africa (SSA) and South Asia (SA) are thought to be unable to adequately deal with the burden of high unmet FP demands due to their weaker health systems. As a result, determining the readiness of health facilities that offer FP services is critical for identifying weaknesses and opportunities for continued development of FP health systems in those regions. Service Provision Assessment (SPA) tools-which break down health systems into measurable, trackable components-are one useful way to assess service readiness and the ability of health institutions to deliver FP services.

METHODS

Using data from nationally representative SPA surveys, we conducted a study that aimed to: (1) evaluate healthcare facilities' readiness to provide FP services; and (2) identify the factors that affect FP service readiness. Using a cross-sectional survey design, we used data from SPA surveys conducted in 10 low-resource SA and SSA countries: Afghanistan, Bangladesh, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and the Democratic Republic of the Congo (DRC). We analyzed data from public and private health facilities in Afghanistan (84), Bangladesh (1,303), Kenya (567), Malawi (810), Namibia (357), Nepal (899), Rwanda (382), Senegal (334), Tanzania (933), and the DRC (1,061) for a total of 6,730 facilities. We used 17 items/indicators recommended by the Service Availability and Readiness Assessment to measure a health facility's readiness to provide FP services across four domains.

RESULTS

Only 3.6% to 34.1% of the health facilities were reporting at least 75% (12-13 of 17) of the relevant items for FP service provision. Most of the health facilities in the countries under investigation suffered from lack of readiness, meaning that they did not fulfill at least 75% of the standards (12-13 items of 17 items on the availability of trained staff and guidelines, equipment, and commodities components). The factors associated with higher readiness scores varied among the 10 countries analyzed. Regression models showed that increases in the number of FP healthcare providers available at a health facility and infection control measures for FP exams were factors linked to increased readiness scores in all 10 countries. The low readiness of health facilities to provide FP services in the countries studied showed that the health systems in these low-resource settings faced significant problems with providing FP services. Differences in country-specific variability in the characteristics linked with better preparedness ratings could be attributed to data collected across different years in different nations or to country-specific healthcare financing policies.

CONCLUSIONS

To increase a health facility's readiness to offer FP services, country-specific factors must be addressed, in addition to common factors found in all 10 countries. Further research is required to determine the causes of country-level differences in FP tracer item availability to develop targeted and effective country-specific strategies to improve the quality of FP services in the SA and SSA regions and address unmet need for FP.

Association between antenatal care facility readiness and provision of care at the client level and facility level in five low- and middle-income countries

BACKGROUND

Despite growing interest in monitoring improvements in quality of care, data on service quality in low-income and middle-income countries (LMICs) is limited. While health systems researchers have hypothesized the relationship between facility readiness and provision of care, there have been few attempts to quantify this relationship in LMICs. This study assesses the association between facility readiness and provision of care for antenatal care at the client level and facility level.

METHODS

To assess the association between provision of care and various facility readiness indices for antenatal care, we used multilevel, multivariable random-effects linear regression models. We tested an inflection point on readiness scores by fitting linear spline models. To compare the coefficients between models, we used a bootstrapping approach and calculated the mean difference between all pairwise comparisons. Analyses were conducted at client and facility levels.

RESULTS

Our results showed a small, but significant association between facility readiness and provision of care across countries and most index constructions. The association was most evident in the client-level analyses that had a larger sample size and were adjusted for factors at the facility, health worker, and individual levels. In addition, spline models at a facility readiness score of 50 better fit the data, indicating a plausible threshold effect.

CONCLUSIONS

The results of this study suggest that facility readiness is not a proxy for provision of care, but that there is an important association between facility readiness and provision of care. Data on facility readiness is necessary for understanding the foundations of health systems particularly in countries with the lowest levels of service quality. However, a comprehensive view of quality of care should include both facility readiness and provision of care measures.

Evaluation of effective coverage for type 2 diabetes in Mexican primary care health information systems: a retrospective registry analysis

BACKGROUND

As the leading cause of disability and the fourth leading cause of premature death in Mexico, type 2 diabetes (T2D) represents a serious public health concern. The incidence of diabetes has increased dramatically in recent years, and data from the Mexican National Health and Nutrition Survey (ENSANUT) indicate that many people remain undiagnosed. Persistent socioeconomic health care barriers exacerbate this situation, as T2D morbidity and mortality are worsened in vulnerable populations, such as those without social security. We evaluated the performance of public primary health centers (PHCs) in T2D medical attention through the measure of effective coverage (EC, a combined measure of health care need, use, and quality) at national, state, health jurisdiction, and municipality levels.

METHODS

This retrospective analysis used blinded data recorded during 2017 in the Non-communicable Diseases National Information System (SIC) and T2D prevalence reported in 2018 ENSANUT to evaluate the EC achieved. We included individuals ≥ 20 years old without social security who did not declare the use of private health care services. Each EC component (need, use, and quality) was estimated based on the Shengelia adapted framework. The Kruskal-Wallis test was applied to evaluate the associations among EC quintiles and demographics.

RESULTS

In 2017, 26.5 million individuals, aged ≥ 20 years, without social security, and without the use of private health care services, were under the care of 12,086 PHCs. The national prevalence of T2D was 10.3%, equivalent to 2.6 million people living with T2D in need of primary health care. Large contrasts were seen among EC components between and within Mexican states. We found that only 37.1% of the above individuals received health services at PHCs and of them, 25.8% improved their metabolic condition. The national EC was 9.3%, and the range (by health jurisdiction) was 0.2%-38.6%, representing a large geographic disparity in EC. We found an evident disconnect among need, utilization, and quality rates across the country.

CONCLUSIONS

Expansion and improvement of EC are urgently needed to address the growing number of people living with T2D in Mexico, particularly in states with vulnerable populations.

Socioeconomic inequalities in utilizing facility delivery in Bangladesh: A decomposition analysis using nationwide 2017-2018 demographic and health survey data

BACKGROUND

In many low- and middle-income countries (LMICs), including Bangladesh, socioeconomic inequalities in access to maternity care remain a substantial public health concern. Due to the paucity of research, we attempted to determine the factors affecting the facility delivery, quantify wealth-related inequality, and identify potential components that could explain the inequality.

METHODS

We used the latest Bangladesh Demographic and Health Survey (BDHS 2017-18) data in this study. We utilized logistic regression to investigate the associated factors of facility delivery. The concentration curves (CC), concentration index (CIX) and decomposition of CIX techniques were used to analyze the inequality in-facility delivery.

RESULTS

Women living in the urban areas, age at first birth after (18-24 years ≥25 years), being overweight/obese, having secondary and higher-level education of the women and their husband, seeking four or more ANC, coming from more affluent households, and women with high enlightenment were significant determinants of facility delivery. The concentration curve was below the line of equality, and the relative concentration index (CIX) was 0.205 (p <0.001), indicating that women from wealthy groups were disproportionately more prevalent to facility delivery. The decomposition analysis reveals that wealth status of women (57.40%), age at first birth (10.24%), husband's education (8.96%), husband's occupation (7.35%), education of women (7.13%), women's enlightenment (6.15%), residence (8.64%) and ANC visit (6.84%) are the most major contributors to the inequalities in utilizing facility delivery.

CONCLUSION

The study demonstrates a clear disparity in the use of facility delivery among Bangladeshi women; hence, immediate action is required to lower the inequalities, with a special emphasis on the contributing factors.

Determinants and Trends of Health Facility Delivery in Bangladesh: A Hierarchical Modeling Approach

Background

Most maternal deaths occur during childbirth and after childbirth. This study was aimed at determining the trends of health facilities during delivery in Bangladesh, as well as their influencing factors.

Methods

This study used secondary data from three Bangladesh Multiple Indicator Cluster Surveys (MICSs) in 2006, 2012–13, and 2019. The study's target sample was those women who gave birth in the last two years of the survey. A two-level logistic regression was applied to determine the effects on health facility delivery separately in these two survey points (MICSs 2012–13 and 2019).

Results

The results show that the delivery of health facilities has increased by almost 37.4% in Bangladesh, from 16% in 2006 to 53.4% in 2019. The results of two-level logistic regression show that the total variation in health facility delivery across the community has decreased over recent years. After adding community variables, various individual-level factors such as women with secondary education (OR = 0.55 in 2012-13 vs. OR =0.60 in 2019), women from middle wealth status (OR = 0.49 in 2012-13 vs. OR = 0.65 in 2019), religion, and child ever born showed a strong relationship with health facility delivery in both survey years. At the community level, residents showed significant association only in the 2012-13 survey and indicated a 43% (OR = 1.43 for 2012-13) greater availability of health facilities in urban residences than in rural residences. Using media showed a highly significant connection with health facility delivery in both years as well as an increasing trend over the years in Bangladesh (OR = 1.19 in 2012-13 vs. OR = 1.38 in 2019). However, division, prenatal care, and skilled services all contribute greatly to increasing the delivery of health facilities in Bangladesh.

Conclusions

The results of this study suggest that policymakers need to pay attention to individual and community-level factors, especially women's education, poverty reduction, and adequate prenatal care provided by well-trained caregivers.

High coverage but low quality of maternal and newborn health services in the coverage cascade: who is benefitted and left behind in accessing better quality health services in Nepal?

BACKGROUND

Antenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits are vital to improve the health of mothers and newborns. Despite improved access to these routine maternal and newborn health (MNH) services in Nepal, little is known about the cascade of health service coverage, particularly contact coverage, intervention-specific coverage, and quality-adjusted coverage of MNH services. This study examined the cascade of MNH services coverage, as well as social determinants associated with uptake of quality MNH services in Nepal.

METHODS

We conducted a secondary analysis of data derived from the Nepal Demographic and Health Survey (NDHS) 2016, taking 1978 women aged 15-49 years who had a live birth in the 2 years preceding the survey. Three outcome variables were (i) four or more (4⁺) ANC visits, (ii) institutional delivery, and (iii) first PNC visit for mothers and newborns within 48 h of childbirth. We applied a cascade of health services coverage, including contact coverage, intervention-specific and quality-adjusted coverage, using a list of specific intervention components for each outcome variable. Several social determinants of health were included as independent variables to identify determinants of uptake of quality MNH services. We generated a quality score for each outcome variable and dichotomised the scores into two categories of "poor" and "optimal" quality, considering > 0.8 as a cut-off point. Binomial logistic regression was conducted and odds ratios (OR) were reported with 95% confidence intervals (CIs) at the significance level of p < 0.05 (two-tailed).

RESULTS

Contact coverage was higher than intervention-specific coverage and quality-adjusted coverage across all MNH services. Women with advantaged ethnicities or who had access to bank accounts had higher odds of receiving optimal quality MNH services, while women who speak the Maithili language and who had high birth order (≥ 4) had lower odds of receiving optimal quality ANC services. Women who received better quality ANC services had higher odds of receiving optimal quality institutional delivery. Women received poor quality PNC services if they were from remote provinces, had higher birth order and perceived problems when not having access to female providers.

CONCLUSIONS

Women experiencing ethnic and social disadvantages, and from remote provinces received poor quality MNH services. The quality-adjusted coverage can be estimated using household survey data, such as demographic and health surveys, especially in countries with limited routine data. Policies and programs should focus on increasing quality of MNH services and targeting disadvantaged populations and those living in remote areas. Ensuring access to female health providers and improving the quality of earlier maternity visits could improve the quality of health care during the pregnancy-delivery-postnatal period.

Bottleneck analysis of maternal and newborn health services in hard-to-reach areas of Bangladesh using ‘TANAHASHI’ framework’: An explanatory mixed-method study

Maternal and Newborn Health (MNH) is of paramount importance in the realm of attaining sustainable development goals that also focuses on universal health coverage (UHC). The study aimed at identifying and exploring the bottlenecks in MNH services in Hard-to-reach (HtR) areas of Bangladesh using the Tanahashi framework exploring the possible remedial approaches. The study was conducted in four different types of HtR areas (hilly, coastal, lowlands, and river islands) by utilizing a sequential explanatory mixed-method design. Overall, we collected information from 20 health facilities and 2,989 households by interviewing 2,768 recently delivered women (RDW) with a structured questionnaire and qualitative interviews (n = 55) of facility managers, local stakeholders, RDWs, and health care providers (HCP). The quantitative data were analyzed principally for descriptive statistics and the qualitative data was analyzed by utilizing the thematic approach. Antenatal care, under-5 care, and family planning services were available in almost all the facilities. However, Normal vaginal deliveries were performed in 55.6% of the union-level facilities. Only 40% of sub-district level facilities had provision for C-sections. Blood transfusion services were available in only 20.1% of facilities, whereas laboratory services were obtainable in 51.7% of facilities. Overall, the bottlenecks were identified in cases of availability of drugs, human resources, transportation, lack of knowledge regarding different essential services and health components, out of pocket expenditure etc. There have been several remedial approaches suggested from both the demand and supply side that included incentives for care providers for staying in these areas, a coordinated transport/referral system, and health education campaigns. More research works are warranted in HtR areas, especially to test the proposed interventions. Meanwhile, the government should take the necessary steps to overcome the bottlenecks identified.

An Uninformed Decision-Making Process for Cesarean Section: A Qualitative Exploratory Study among the Slum Residents of Dhaka City, Bangladesh

The decision-making process and the information flow from physicians to patients regarding deliveries through cesarean section (C-section) has not been adequately explored in Bangladeshi context. Here, we aimed to explore the extent of information received by mothers and their family members and their involvement in the decision-making process. We conducted a qualitative exploratory study in four urban slums of Dhaka city among purposively selected mothers (n = 7), who had a cesarean birth within one-year preceding data collection, and their family members (n = 12). In most cases, physicians were the primary decision-makers for C-sections. At the household level, pregnant women were excluded from some crucial steps of the decision-making process and information asymmetry was prevalent. All interviewed pregnant women attended at least one antenatal care visit; however, they neither received detailed information regarding C-sections nor attended any counseling session regarding decisions around delivery type. In some cases, pregnant women and their family members did not ask health care providers for detailed information about C-sections. Most seemed to perceive C-sections as risk-free procedures. Future research could explore the best ways to provide C-section-related information to pregnant women during the antenatal period and develop interventions to promote shared decision-making for C-sections in urban Bangladeshi slums.

A rapid systematic review and evidence synthesis of effective coverage measures and cascades for childbirth, newborn and child health in low- and middle-income countries

BACKGROUND

Effective coverage measures aim to estimate the proportion of a population in need of a service that received a positive health outcome. In 2020, the Effective Coverage Think Tank Group recommended using a 'coverage cascade' for maternal, newborn, child and adolescent health and nutrition (MNCAHN), which organises components of effective coverage in a stepwise fashion, with each step accounting for different aspects of quality of care (QoC), applied at the population level. The cascade outlines six steps that increase the likelihood that the population in need experience the intended health benefit: 1) the population in need (target population) who contact a health service; 2) that has the inputs available to deliver the service; 3) who receive the health service; 4) according to quality standards; 5) and adhere to prescribed medication(s) or health workers instructions; and 6) experience the expected health outcome. We examined how effective coverage of life-saving interventions from childbirth to children aged nine has been defined and assessed which steps of the cascade are captured by existing measures.

METHODS

We undertook a rapid systematic review. Seven scientific literature databases were searched covering the period from May 1, 2017 to July, 8 2021. Reference lists from reviews published in 2018 and 2019 were examined to identify studies published prior to May 2017. Eligible studies reported population-level contact coverage measures adjusted for at least one dimension of QoC.

RESULTS

Based on these two search approaches this review includes literature published from 2010 to 2021. From 16 662 records reviewed, 33 studies were included, reporting 64 effective coverage measures. The most frequently examined measures were for childbirth and immediate newborn care (n = 24). No studies examined measures among children aged five to nine years. Definitions of effective coverage varied across studies. Key sources of variability included (i) whether a single effective coverage measure was reported for a package of interventions or separate measures were calculated for each intervention; (ii) the number and type of coverage cascade steps applied to adjust for QoC; and (iii) the individual items included in the effective coverage definition and the methods used to generate a composite quality measure.

CONCLUSION

In the MNCAHN literature there is substantial heterogeneity in both definitions and construction of effective coverage, limiting the comparability of measures over time and place. Current measurement approaches are not closely aligned with the proposed cascade. For widespread adoption, there is a need for greater standardisation of indicator definitions and transparency in reporting, so governments can use these measures to improve investments in MNACHN and implement life-saving health policies and programs.

Effect of emergency obstetric care and proximity to comprehensive facilities on facility-based delivery in Malawi and Haiti

Proximity of households to comprehensive obstetric care is a key determinant for preventing maternal mortality due to obstetric emergencies. The relationship between proximity to comprehensive care and facility delivery is further complicated by the use of varied methods in measuring facility obstetric capacity-which may misrepresent the real scenario of obstetric care availability in a service environment. We investigated the joint effects of proximity and two emergency obstetric care assessment (EmOC) methods on women's place of delivery in Malawi and Haiti. Household level and health facility data were obtained from the 2013-2018 Demographic and Health Surveys and Service Provision Assessment surveys. Records of women aged 15 to 49 years who had a childbirth in the last 5 years were linked to obstetric facilities within 5km, 10km and 15km from their households using Kernel Density Estimation. Log-binomial models were fitted to estimate the joint effects of proximity to comprehensive facilities on place of delivery and two EmOC methods (1. the facility's recent performance of signal functions only, and 2. a composite index of obstetric care), and whether this varied by urban/rural setting. Proximity to comprehensive facilities was significantly associated with facility delivery in Malawi among women living 5km of a comprehensive facility (using EmOC method 2), in addition, living further (15km) from facilities with high capacity of EmOC was associated with reduced likelihood for facility delivery in urban settings in stratified analyses. In contrast, positive associations were present in Haiti in both urban and rural settings, with the likelihood of facility delivery being higher with greater proximity of women to comprehensive facilities, regardless of methods to define EmOC. Women living within 5km of a comprehensive facility in Haiti were the most likely to deliver in facilities based on EmOC method 1 (APR: 1.81, 95% CI 1.56, 2.09). Findings from Malawi elucidates the relevance of context and suggests the need for research in diverse settings.

Operationalising effective coverage measurement of facility based childbirth in Gombe State; a comparison of data sources

Estimating effective coverage of childbirth care requires linking population based data sources to health facility data. For effective coverage to gain widespread adoption there is a need to focus on the feasibility of constructing these measures using data typically available to decision makers in low resource settings. We estimated effective coverage of childbirth care in Gombe State, northeast Nigeria, using two different combinations of facility data sources and examined their strengths and limitations for decision makers. Effective coverage captures information on four steps: access, facility inputs, receipt of interventions and process quality. We linked data from the 2018 Nigerian Demographic and Health Survey (NDHS) to two sources of health facility data: (1) comprehensive health facility survey data generated by a research project; and (2) District Health Information Software 2 (DHIS2). For each combination of data sources, we examined which steps were feasible to calculate, the size of the drop in coverage between steps and the resulting estimate of effective coverage. Analysis included 822 women with a recent live birth, 30% of whom attended a facility for childbirth. Effective coverage was low: 2% based on the project data and less than 1% using the DHIS2. Linking project data with NDHS, it was feasible to measure all four steps; using DHIS2 it was possible to estimate three steps: no data was available to measure process quality. The provision of high quality care is suboptimal in this high mortality setting where access and facility readiness to provide care, crucial foundations to the provision of high quality of care, have not yet been met. This study demonstrates that partial effective coverage measures can be constructed from routine data combined with nationally representative surveys. Advocacy to include process of care indicators in facility summary reports could optimise this data source for decision making.

Factors influencing place of delivery in Ethiopia: Linking individual, household, and health facility-level data

INTRODUCTION

Maternal mortality remains high, especially in sub-Saharan Africa. Institutional delivery is one of the key intervention to reduce it. Despite service utilization reflects an interplay of demand- and supply-side factors, previous studies mainly focused on either sides due to methodological challenges and data availability. But, a more comprehensive understanding can be obtained by assessing both sides. The aim of this study is to assess individual, household, community, and health facility factors associated with deliveryplace in Ethiopia.

METHODS

We have used the 2019 Performance Monitoring for Action survey data set, which is a nationally representative sample of women linked with national sample of health facilities in Ethiopia. A total of 2547 women who recently delivered were linked with 170 health centers and 41 hospitals. Facility readiness index was calculated based on previous study conducted by Stierman EK on similar data set. We applied survey weights for descriptive statistics. Multilevel mixed-effects logistic regression was used to identify factors influencing delivery place.

RESULTS

Coverage of institutional delivery was 54.49%. Women aged 20-34 [AOR; 0.55 (0.32-0.85)] compared with those younger than 20 years; those with no formal education [AOR: 0.19 (10.05-0.76)] or attended only primary school [AOR: 0.20 (0.05-0.75)] compared with those attended above secondary; and women whose partners didn't encourage antinatal visit [AOR; 0.57 (0.33-0.98)] all have decreased odd of institutional delivery. Attending at least one antenatal visit [AOR: 3.09 (1.87-5.10)] and increased availability of medicines in the closest facility [AOR: 17.33 (1.32-26.4)] increase odds of institutional deliver.

CONCLUSION

In Ethiopia, nearly half of the total deliveries take place outside health facilities. In addition to improving women's education, utilization of antenatal care, and encouragement by partners, it is important to consider the availability of medicine and commodities in the nearby health facilities while designing and implementing programs to reduce home delivery.

Stability of healthcare quality measures for maternal and child services: Analysis of the continuous service provision assessment of health facilities in Senegal, 2012-2018

Objective

High‐quality healthcare is essential to ensuring maternal and newborn survival. Efficient measurement requires knowing how long measures of quality provide consistent insight for intended uses.

Methods

We used a repeated health facility assessment in Senegal to calculate structural and process quality of antenatal care (ANC), delivery and child health services in facilities assessed 2 years apart. We tested agreement of quality measures within facilities and regions. We estimated how much input‐adjusted and process quality‐adjusted coverage measures changed for each service when calculated using quality measurements from the same facilities measured 2 years apart.

Results

Over 6 waves of continuous surveys, 628 paired assessments were completed. Changes at the facility level were substantial and often positive, but inconsistent. Structural quality measures were moderately correlated (0.40–0.69) within facilities over time, more so in hospitals; correlation was <0.20 for process measures based on direct observation of ANC and child visits. Most measures were more strongly correlated once averaged to regions; process quality of child services was not (−0.32). Median relative difference in national‐adjusted coverage estimates was 6.0%; differences in subnational estimates were largest for process quality of child services (19.6%).

Conclusion

Continuous measures of structural quality demonstrated consistency at regional levels and in higher level facilities over 2 years; results for process measures were mixed. Direct observation of child visits provided inconsistent measures over time. For other measures, linking population data with health facility assessments from up to 2 years prior is likely to introduce modest measurement error in adjusted coverage estimates.

Measuring facility readiness to provide childbirth care: a comparison of indices using data from a health facility survey in Ethiopia

BACKGROUND

Actionable information about the readiness of health facilities is needed to inform quality improvement efforts in maternity care, but there is no consensus on the best approach to measure readiness. Many countries use the WHO's Service Availability and Readiness Assessment (SARA) or the Demographic and Health Survey (DHS) Programme's Service Provision Assessment to measure facility readiness. This study compares measures of childbirth service readiness based on SARA and DHS guidance to an index based on WHO's quality of maternal and newborn care standards.

METHODS

We used cross-sectional data from Performance Monitoring for Action Ethiopia's 2019 survey of 406 health facilities providing childbirth services. We calculated childbirth service readiness scores using items based on SARA, DHS and WHO standards. For each, we used three aggregation methods for generating indices: simple addition, domain-weighted addition and principal components analysis. We compared central tendency, spread and item variation between the readiness indices; concordance between health facility scores and rankings; and correlations between readiness scores and delivery volume.

RESULTS

Indices showed moderate agreement with one another, and all had a small but significant positive correlation with monthly delivery volume. Ties were more frequent for indices with fewer items. More than two-thirds of items in the relatively shorter SARA and DHS indices were widely (>90%) available in hospitals, and half of the SARA items were widely (>90%) available in health centres/clinics. Items based on the WHO standards showed greater variation and captured unique aspects of readiness (eg, quality improvement processes, actionable information systems) not included in either the SARA or DHS indices.

CONCLUSION

SARA and DHS indices rely on a small set of widely available items to assess facility readiness to provide childbirth care. Expanded selection of items based on the WHO standards can better differentiate between levels of service readiness.

Socioeconomic inequalities in early initiation and exclusive breastfeeding practices in Bangladesh: findings from the 2018 demographic and health survey

BACKGROUND

Optimal breastfeeding practices including early initiation of breastfeeding and exclusive breastfeeding (EBF) are associated with positive health outcomes. Socioeconomic inequalities in key breastfeeding indicators may play a role in the prevalence of breastfeeding practices. The objective of this study was to examine the socioeconomic inequalities in early initiation of breastfeeding and EBF practices in Bangladesh based on the 2018 Bangladesh Demographic and Health Survey (BDHS).

METHODS

This was a secondary data analysis of the nationally representative 2018 BDHS. Data on 4950 women of reproductive age who had ever given birth and 924 children aged 0-5 months were extracted, for early initiation of breastfeeding and EBF. Early initiation of breastfeeding was determined from children who were put to the breast within the first hour of birth. Exclusive breastfeeding was estimated from children aged 0-5 months who were exclusively breastfed.

RESULTS

The weighted prevalence of early initiation of breastfeeding and EBF were 60.8% (95% CI; 59.0, 62.6%) and 66.8% (95% CI; 63.1, 70.3%), respectively. The estimated prevalence of early initiation among the poorest, poorer, middle, richer and richest households were 67.8, 66.3, 58.4, 56.3 and 54.4%, respectively. Similarly, early initiation prevalence of 64.4, 65.0, 61.1 and 52.3% were estimated among women with no formal education, primary, secondary and higher education, respectively. The estimated prevalence of EBF among the poorest, poorer, middle, richer and richest households were 63.0, 65.2, 67.7, 66.7 and 69.9%, respectively. Similarly, the estimated EBF prevalence were 62.5, 66.0, 66.3 and 68.9% among women with no formal education, primary, secondary and higher education, respectively. Early initiation of breastfeeding was higher among lower household wealth (Conc. Index = - 0.049; SE = 0.006) and lower educational attainment groups (Conc. Index = - 0.035; SE = 0.006).

CONCLUSIONS

Improving optimal breastfeeding practices in Bangladesh should be given utmost priority. A need to address the socioeconomic inequalities in breastfeeding practices was also identified.

Utilisation of quality antenatal, delivery and postnatal care services in Nepal: An analysis of Service Provision Assessment

BACKGROUND

Nepal has improved access and utilisation of routine maternal and newborn health (MNH) services. Despite improved access to routine MNH services such as antenatal care (ANC), and delivery and postnatal care (PNC) services, the burden of maternal and neonatal deaths in Nepal remains high. Most of those deaths could be prevented by improving utilisation of evidence-informed clinical MNH interventions. However, little is known on determinants of utilisation of such clinical MNH interventions in health facilities (HFs). This study investigated the determinants of utilisation of technical quality MNH services in Nepal.

METHODS

This study used data from the 2015 Nepal Services Provision Assessment. A total of 523 pregnant and 309 postpartum women were included for the analysis of utilisation of technical quality of ANC, and delivery and PNC services, respectively. Outcome variables were utilisation of better quality i) ANC services, and ii) delivery and PNC services while independent variables included features of HFs and health workers, and demographic characteristics of pregnant and postpartum women. Binomial logistic regression was conducted to identify the determinants associated with utilisation of quality MNH services. The odds ratio with 95% confidence interval (CIs) were reported at the significance level of p < 0.05 (two-tailed).

RESULTS

Women utilised quality ANC services if they attended facilities with better HF capacity (aOR = 2.12;95% CI: 1.03, 4.35). Women utilised better quality delivery and PNC services from private HFs compared to public HFs (aOR = 2.63; 95% CI: 1.14, 6.08). Women utilised better technical quality ANC provided by nursing staff compared to physicians (adjusted odds ratio (aOR) =2.89; 95% CI: 1.33, 6.29), and from staff supervised by a higher authority compared to those not supervised (aOR = 1.71; 95% CI: 1.01, 2.92). However, compared to province one, women utilised poor quality delivery and PNC services from HFs in province two (aOR = 0.15; 95% CI: 0.03, 0.63).

CONCLUSIONS

Women utilised quality MNH services at facilities with better HF capacity, service provided by nursing staff, and attended at supervised HFs/health workers. Provincial and municipal governments require strengthening HF capacities (e.g., supply equipment, medicines, supplies), recruiting trained nurse-midwives, and supervising health workers.

Methodological considerations for linking household and healthcare provider data for estimating effective coverage: a systematic review

OBJECTIVE

To assess existing knowledge related to methodological considerations for linking population-based surveys and health facility data to generate effective coverage estimates. Effective coverage estimates the proportion of individuals in need of an intervention who receive it with sufficient quality to achieve health benefit.

DESIGN

Systematic review of available literature.

DATA SOURCES

Medline, Carolina Population Health Center and Demographic and Health Survey publications and handsearch of related or referenced works of all articles included in full text review. The search included publications from 1 January 2000 to 29 March 2021.

ELIGIBILITY CRITERIA

Publications explicitly evaluating (1) the suitability of data, (2) the implications of the design of existing data sources and (3) the impact of choice of method for combining datasets to obtain linked coverage estimates.

RESULTS

Of 3805 papers reviewed, 70 publications addressed relevant issues. Limited data suggest household surveys can be used to identify sources of care, but their validity in estimating intervention need was variable. Methods for collecting provider data and constructing quality indices were diverse and presented limitations. There was little empirical data supporting an association between structural, process and outcome quality. Few studies addressed the influence of the design of common data sources on linking analyses, including imprecise household geographical information system data, provider sampling design and estimate stability. The most consistent evidence suggested under certain conditions, combining data based on geographical proximity or administrative catchment (ecological linking) produced similar estimates to linking based on the specific provider utilised (exact match linking).

CONCLUSIONS

Linking household and healthcare provider data can leverage existing data sources to generate more informative estimates of intervention coverage and care. However, existing evidence on methods for linking data for effective coverage estimation are variable and numerous methodological questions remain. There is need for additional research to develop evidence-based, standardised best practices for these analyses.

Distance to available services for newborns at facilities in Malawi: A secondary analysis of survey and health facility data

Background

Malawi has halved the neonatal mortality rate between 1990–2018, however, is not on track to achieve the Sustainable Development Goal 12 per 1,000 live births. Despite a high facility birth rate (91%), mother-newborn dyads may not remain in facilities long enough to receive recommended care and quality of care improvements are needed to reach global targets. Physical access and distance to health facilities remain barriers to quality postnatal care.

Methods

Using data We used individual data from the 2015–16 Malawi Demographic and Health Survey and facility data from the 2013–14 Malawi Service Provision Assessment, linking households to all health facilities within specified distances and travel times. We calculated service readiness scores for facilities to measure their capacity to provide birth/newborn care services. We fitted multi-level regression models to evaluate the association between the service readiness and appropriate newborn care (receiving at least five of six interventions).

Results

Households with recent births (n = 6010) linked to a median of two birth facilities within 5–10 km and one facility within a two-hour walk. The maximum service environment scores for linked facilities median was 77.5 for facilities within 5–10 km and 75.5 for facilities within a two-hour walk. While linking to one or more facilities within 5-10km or a two-hour walk was not associated with appropriate newborn care, higher levels of service readiness in nearby facilities was associated with an increased risk of appropriate newborn care.

Conclusions

Women’s choice of nearby facilities and quality facilities is limited. High quality newborn care is sub-optimal despite high coverage of facility birth and some newborn care interventions. While we did not find proximity to more facilities was associated with increased risk of appropriate care, high levels of service readiness was, showing facility birth and improved access to well-prepared facilities are important for improving newborn care.

Equity in newborn care, evidence from national surveys in low- and middle-income countries

BACKGROUND

High coverage of care is essential to improving newborn survival; however, gaps exist in access to timely and appropriate newborn care between and within countries. In high mortality burden settings, health inequities due to social and economic factors may also impact on newborn outcomes. This study aimed to examine equity in co-coverage of newborn care interventions in low- and low middle-income countries in sub-Saharan Africa and South Asia.

METHODS

We analysed secondary data from recent Demographic and Health Surveys in 16 countries. We created a co-coverage index of five newborn care interventions. We examined differences in coverage and co-coverage of newborn care interventions by country, place of birth, and wealth quintile. Using multilevel logistic regression, we examined the association between high co-coverage of newborn care (4 or 5 interventions) and social determinants of health.

RESULTS

Coverage and co-coverage of newborn care showed large between- and within-country gaps for home and facility births, with important inequities based on individual, family, contextual, and structural factors. Wealth-based inequities were smaller amongst facility births compared to non-facility births.

CONCLUSION

This analysis underlines the importance of facility birth for improved and more equitable newborn care. Shifting births to facilities, improving facility-based care, and community-based or pro-poor interventions are important to mitigate wealth-based inequities in newborn care, particularly in countries with large differences between the poorest and richest families and in countries with very low coverage of care.

Effective coverage of nutrition interventions across the continuum of care in Bangladesh: insights from nationwide cross-sectional household and health facility surveys

INTRODUCTION

Improving the impact of nutrition interventions requires adequate measurement of both reach and quality of interventions, but limited evidence exists on advancing coverage measurement. We adjusted contact-based coverage estimates, taking into consideration the inputs required to deliver quality nutrition services, to calculate input-adjusted coverage of nutrition interventions across the continuum of care from pregnancy through early childhood in Bangladesh.

METHODS

We used data from the 2014 Bangladesh Demographic and Health Surveys to assess use of maternal and child health services and the 2014 Service Provision Assessment to determine facility readiness to deliver nutrition interventions. Service readiness captured availability of nutrition-specific inputs (including human resources and training, equipment, diagnostics and medicines). Contact coverage was combined with service readiness to create a measure of input-adjusted coverage at the national and regional levels, across place of residence, and by maternal education and household socioeconomic quintiles.

RESULTS

Contact coverage varied from 28% for attending at least four ANC visits to 38% for institutional delivery, 35% for child growth monitoring and 81% for sick child care. Facilities demonstrated incomplete readiness for nutrition interventions, ranging from 48% to 51% across services. Nutrition input-adjusted coverage was suboptimal (18% for ANC, 23% for institutional delivery, 20% for child growth monitoring and 52% for sick child care) and varied between regions within the country. Inequalities in input-adjusted coverage were large during ANC and institutional delivery (14-17 percentage points (pp) between urban and rural areas, 15 pp between low and high education, and 28-34 pp between highest and lowest wealth quintiles) and less variable for sick child care (<2 pp).

CONCLUSION

Nutrition input-adjusted coverage was suboptimal and varied subnationally and across the continuum of care in Bangladesh. Special efforts are needed to improve the reach as well as the quality of health and nutrition services to achieve the Sustainable Development Goals.

Facility readiness and counseling during antenatal care and the relationship with early breastfeeding in Haiti and Malawi

BACKGROUND

Early initiation of breastfeeding (within an hour of birth) has benefits for newborn health and survival. Optimal breastfeeding supports growth, health, and development. Health facilities provide essential pregnancy, maternal, and newborn care and offer support for early breastfeeding. We examined the relationship between the breastfeeding-related health service environment during antenatal care (ANC) and early initiation of breastfeeding.

METHODS

Using data from recent Service Provision Assessment (SPA) surveys in Haiti and Malawi, we defined three indicators of the health service environment: availability of facilities with ANC services reporting routine breastfeeding counseling; provider training on breastfeeding; and breastfeeding counseling during ANC. We linked SPA data geographically to Demographic and Health Surveys (DHS) data from Haiti and Malawi. Multilevel, multivariable logistic regressions examined associations between the health service environment and early initiation of breastfeeding, controlling for women's background characteristics, with separate analyses for urban and rural residence.

RESULTS

Over 95% of facilities in Haiti and Malawi reported routinely providing breastfeeding counseling during ANC. Only 40% of both urban and rural providers in Malawi and 29 and 26% of providers at urban and rural facilities in Haiti (respectively) received recent training in counseling on breastfeeding. Further, only 4-10% of clients received counseling. Breastfeeding counseling was generally more common among clients who attended ANC with a provider who had received recent training. After linking SPA and DHS data, our analysis showed that having more providers recently trained on breastfeeding was significantly associated with increased odds of early breastfeeding among women in urban areas of Haiti and Malawi. Additionally, women in urban areas of Malawi lived near facilities with more counseling during ANC were more likely to begin breastfeeding within an hour of birth compared with women in areas with less counseling.

CONCLUSIONS

Our study identified gaps in the health system's capacity to implement the recommended global guidelines in support of optimal breastfeeding practices. While breastfeeding counseling during ANC can promote early breastfeeding, counseling was not common. The study provides evidence that provider training could help improve counseling and support for early initiation of breastfeeding.

Is it home delivery or health facility? Community perceptions on place of childbirth in rural Northwest Tanzania using a qualitative approach

BACKGROUND

In low and middle-income countries, pregnancy and delivery complications may deprive women and their newborns of life or the realization of their full potential. Provision of quality obstetric emergency and childbirth care can reduce maternal and newborn deaths. Underutilization of maternal and childbirth services remains a public health concern in Tanzania. The aim of this study was to explore elements of the local social, cultural, economic, and health systems that influenced the use of health facilities for delivery in a rural setting in Northwest Tanzania.

METHODS

A qualitative approach was used to explore community perceptions of issues related to low utilization of health facilities for childbirth. Between September and December 2017, 11 focus group discussions were conducted with women (n = 33), men (n = 5) and community health workers (CHWs; n = 28); key informant interviews were conducted with traditional birth attendants (TBAs; n = 2). Coding, identification, indexing, charting, and mapping of these interviews was done using NVIVO 12 after manual familiarization of the data. Data saturation was used to determine when no further interviews or discussions were required.

RESULTS

Four themes emerge; self-perceived obstetric risk, socio-cultural issues, economic concerns and health facility related factors. Health facility delivery was perceived to be crucial for complicated labor. However, the idea that childbirth was a "normal" process and lack of social and cultural acceptability of facility services, made home delivery appealing to many women and their families. In addition, out of pocket payments for suboptimal quality of health care was reported to hinder facility delivery.

CONCLUSION

Home delivery persists in rural settings due to economic and social issues, and the cultural meanings attached to childbirth. Accessibility to and affordability of respectful and culturally acceptable childbirth services remain challenging in this setting. Addressing barriers on both the demand and supply side could result in improved maternal and child outcomes during labor and delivery.

Variance estimation for effective coverage measures: A simulation study

Background

Effective coverage research is increasing rapidly in global health and development, as researchers use a range of measures and combine data sources to adjust coverage for the quality of services received. However, most estimates of effective coverage that combine data sources are reported only as point estimates, which may be due to the challenge of calculating the variance for a composite measure. In this paper, we evaluate three methods to quantify the uncertainty in the estimation of effective coverage.

Methods

We conducted a simulation study to evaluate the performance of the exact, delta, and parametric bootstrap methods for constructing confidence intervals around point estimates that are calculated from combined data on coverage and quality. We assessed performance by computing the number of nominally 95% confidence intervals that contain the truth for a range of coverage and quality values and data source sample sizes. To illustrate these approaches, we applied the delta and exact methods to estimates of adjusted coverage of antenatal care (ANC) in Senegal. We used household survey data for coverage and health facility assessments for readiness to provide services.

Results

With small sample sizes, when the true effective coverage value was close to the boundaries 0 or 1, the exact and parametric bootstrap methods resulted in substantial over or undercoverage and, for the exact method, a high proportion of invalid confidence intervals, while the delta method yielded modest overcoverage. The proportion of confidence intervals containing the truth in all three methods approached the intended 95% with larger sample sizes and as the true effective coverage value moved away from the 0 or 1 boundary. Confidence intervals for adjusted ANC in Senegal were largely overlapping across the delta and exact methods, although at the sub-national level, the exact method produced invalid confidence intervals for estimates near 0 or 1. We provide the code to implement these methods.

Conclusions

The uncertainty around an effective coverage estimate can be characterized; this should become standard practice if effective coverage estimates are to become part of national and global health monitoring. The delta method approach outperformed the other methods in this study; we recommend its use for appropriate inference from effective coverage estimates that combine data sources, particularly when either sample size is small. When used for estimates created from facility type or regional strata, these methods require assumptions of independence that must be considered in each example.

What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal

Introduction

Increases in facility deliveries in sub-Saharan Africa have not yielded expected declines in maternal mortality, raising concerns about the quality of care provided in facilities. The readiness of facilities at different health system levels to provide both emergency obstetric and newborn care (EmONC) as well as referral is unknown. We describe this combined readiness by facility level and region in Senegal.

Methods

For this cross-sectional study, we used data from nine Demographic and Health Surveys between 1992 and 2017 in Senegal to describe trends in location of births over time. We used data from the 2017 Service Provision Assessment to describe EmONC and emergency referral readiness across facility levels in the public system, where 94% of facility births occur. A national global positioning system facility census was used to map access from lower-level facilities to the nearest facility performing caesareans.

Results

Births in facilities increased from 47% in 1992 to 80% in 2016, driven by births in lower-level health posts, where half of facility births now occur. Caesarean rates in rural areas more than doubled but only to 3.7%, indicating minor improvements in EmONC access. Only 9% of health posts had full readiness for basic EmONC, and 62% had adequate referral readiness (vehicle on-site or telephone and vehicle access elsewhere). Although public facilities accounted for three-quarters of all births in 2016, only 16% of such births occurred in facilities able to provide adequate combined readiness for EmONC and referral.

Conclusions

Our findings imply that many lower-level public facilities—the most common place of birth in Senegal—are unable to treat or refer women with obstetric complications, especially in rural areas. In light of rising lower-level facility births in Senegal and elsewhere, improvements in EmONC and referral readiness are urgently needed to accelerate reductions in maternal and perinatal mortality.