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Cavallaro FL, Cannings-John R, Lugg-Widger F, Gilbert R, Kennedy E, Kendall S, Robling M, Harron KL. Lessons learned from using linked administrative data to evaluate the Family Nurse Partnership in England and Scotland. Int J Popul Data Sci 2023; 8:2113. [PMID: 37670953 PMCID: PMC10476150 DOI: 10.23889/ijpds.v8i1.2113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Abstract
Introduction "Big data" - including linked administrative data - can be exploited to evaluate interventions for maternal and child health, providing time- and cost-effective alternatives to randomised controlled trials. However, using these data to evaluate population-level interventions can be challenging. Objectives We aimed to inform future evaluations of complex interventions by describing sources of bias, lessons learned, and suggestions for improvements, based on two observational studies using linked administrative data from health, education and social care sectors to evaluate the Family Nurse Partnership (FNP) in England and Scotland. Methods We first considered how different sources of potential bias within the administrative data could affect results of the evaluations. We explored how each study design addressed these sources of bias using maternal confounders captured in the data. We then determined what additional information could be captured at each step of the complex intervention to enable analysts to minimise bias and maximise comparability between intervention and usual care groups, so that any observed differences can be attributed to the intervention. Results Lessons learned include the need for i) detailed data on intervention activity (dates/geography) and usual care; ii) improved information on data linkage quality to accurately characterise control groups; iii) more efficient provision of linked data to ensure timeliness of results; iv) better measurement of confounding characteristics affecting who is eligible, approached and enrolled. Conclusions Linked administrative data are a valuable resource for evaluations of the FNP national programme and other complex population-level interventions. However, information on local programme delivery and usual care are required to account for biases that characterise those who receive the intervention, and to inform understanding of mechanisms of effect. National, ongoing, robust evaluations of complex public health evaluations would be more achievable if programme implementation was integrated with improved national and local data collection, and robust quasi-experimental designs.
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Affiliation(s)
- Francesca L. Cavallaro
- UCL Great Ormond Street Institute of Child Health, London, UK
- The Health Foundation, 8 Salisbury Square, London, UK
| | - Rebecca Cannings-John
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Fiona Lugg-Widger
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Ruth Gilbert
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Eilis Kennedy
- Children, Young Adults and Families Directorate, Tavistock and Portman NHS Foundation Trust, London, UK
| | - Sally Kendall
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Michael Robling
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Katie L. Harron
- UCL Great Ormond Street Institute of Child Health, London, UK
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Harron K, Cavallaro FL, Bunting C, Clery A, Kendall S, Cassidy R, Atkins J, Saloniki EC, Bedford H, Woodman J. Study protocol: evaluation of the 0-5 public health investment in England - a mixed-methods study integrating analyses of national linked administrative data with in-depth case studies. BMJ Open 2023; 13:e073313. [PMID: 37019495 PMCID: PMC10083857 DOI: 10.1136/bmjopen-2023-073313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
INTRODUCTION Health visiting is a long-established, nationally implemented programme that works with other services at a local level to improve the health and well-being of children and families. To maximise the impact and efficiency of the health visiting programme, policy-makers and commissioners need robust evidence on the costs and benefits of different levels and types of health visiting, for different families, in different local contexts. METHODS AND ANALYSIS This mixed-methods study will analyse individual-level health visiting data for 2018/2019 and 2019/2020 linked with longitudinal data from children's social care, hospitals and schools to estimate the association of number and type of health visiting contacts with a range of children and maternal outcomes. We will also use aggregate local authority data to estimate the association between local models of health visiting and area-level outcomes. Outcomes will include hospitalisations, breast feeding, vaccination, childhood obesity and maternal mental health. Where possible, outcomes will be valued in monetary terms, and we will compare total costs to total benefits of different health visiting service delivery models. Qualitative case studies and extensive stakeholder input will help explain the quantitative analyses and interpret the results in the context of local policy, practice and circumstance. ETHICS AND DISSEMINATION The University College London Research Ethics Committee approved this study (ref 20561/002). Results will be submitted for publication in a peer-reviewed journal and findings will be shared and debated with national policy-makers, commissioners and managers of health visiting services, health visitors and parents.
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Affiliation(s)
- Katie Harron
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | - Catherine Bunting
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Amanda Clery
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Sally Kendall
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Rebecca Cassidy
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | | | - Eirini-Christina Saloniki
- Department of Applied Health Research, University College London, London, UK
- NIHR Applied Research Collaboration North Thames, London, UK
| | - Helen Bedford
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
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Cavallaro FL, Kabore CP, Pearson R, Blackburn RM, Sobhy S, Betran AP, Ronsmans C, Dumont A. Does hospital variation in intrapartum-related perinatal mortality among caesarean births reflect differences in quality of care? Cross-sectional study in 21 hospitals in Burkina Faso. BMJ Open 2022; 12:e055241. [PMID: 36202588 PMCID: PMC9540846 DOI: 10.1136/bmjopen-2021-055241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To examine hospital variation in crude and risk-adjusted rates of intrapartum-related perinatal mortality among caesarean births. DESIGN Secondary analysis of data from the DECIDE (DECIsion for caesarean DElivery) cluster randomised trial postintervention phase. SETTING 21 district and regional hospitals in Burkina Faso. PARTICIPANTS All 5134 women giving birth by caesarean section in a 6-month period in 2016. PRIMARY OUTCOME MEASURE Intrapartum-related perinatal mortality (fresh stillbirth or neonatal death within 24 hours of birth). RESULTS Almost 1 in 10 of 5134 women giving birth by caesarean experienced an intrapartum-related perinatal death. Crude mortality rates varied substantially from 21 to 189 per 1000 between hospitals. Variation was markedly reduced after adjusting for case mix differences (the median OR decreased from 1.9 (95% CI 1.5 to 2.5) to 1.3 (95% CI 1.2 to 1.7)). However, higher and more variable adjusted mortality persisted among hospitals performing fewer caesareans per month. Additionally, adjusting for caesarean care components did not further reduce variation (median OR=1.4 (95% CI 1.2 to 1.8)). CONCLUSIONS There is a high burden of intrapartum-related perinatal deaths among caesarean births in Burkina Faso and sub-Saharan Africa more widely. Variation in adjusted mortality rates indicates likely differences in quality of caesarean care between hospitals, particularly lower volume hospitals. Improving access to and quality of emergency obstetric and newborn care is an important priority for improving survival of babies at birth. TRIAL REGISTRATION NUMBER ISRCTN48510263.
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Affiliation(s)
- Francesca L Cavallaro
- Population, Policy and Practice, University College London Institute of Child Health, London, UK
- The Health Foundation, London, UK
| | - Charles P Kabore
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
- CEPED, Université Paris Cité, IRD, INSERM, Paris, France
| | - Rachel Pearson
- UCL Institute of Child Health, University College London, London, UK
| | - Ruth M Blackburn
- UCL Institute of Health Informatics, University College London, London, UK
| | - Soha Sobhy
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Ana Pilar Betran
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Cavallaro FL, Gilbert R, Wijlaars LP, Kennedy E, Howarth E, Kendall S, van der Meulen J, Calin MA, Reed L, Harron K. Characteristics of enrolment in an intensive home-visiting programme among eligible first-time adolescent mothers in England: a linked administrative data cohort study. J Epidemiol Community Health 2022; 76:991-998. [PMID: 36198485 DOI: 10.1136/jech-2021-217986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intensive home visiting for adolescent mothers may help reduce health disparities. Given limited resources, such interventions need to be effectively targeted. We evaluated which mothers were enrolled in the Family Nurse Partnership (FNP), an intensive home-visiting service for first-time young mothers commissioned in >130 local authorities in England since 2007. METHODS We created a population-based cohort of first-time mothers aged 13-19 years giving birth in English National Health Service hospitals between 1 April 2010 and 31 March 2017, using administrative hospital data linked with FNP programme, educational and social care data. Mothers living in a local authority with an active FNP site were eligible. We described variation in enrolment rates across sites, and identified maternal and FNP site characteristics associated with enrolment. RESULTS Of 110 520 eligible mothers, 25 680 (23.2% (95% CI: 23.0% to 23.5%)) were enrolled. Enrolment rates varied substantially across 122 sites (range: 11%-68%), and areas with greater numbers of first-time adolescent mothers achieved lower enrolment rates. Mothers aged 13-15 years were most likely to be enrolled (52%). However, only 26% of adolescent mothers with markers of vulnerability (including living in the most deprived areas and ever having been looked after as a child) were enrolled. CONCLUSION A substantial proportion of first-time adolescent mothers with vulnerability markers were not enrolled in FNP. Variation in enrolment across sites indicates insufficient commissioning of places that is not proportional to level of need, with mothers in areas with large numbers of other adolescent mothers least likely to receive support.
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Affiliation(s)
- Francesca L Cavallaro
- Population Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Ruth Gilbert
- Population Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Linda Pmm Wijlaars
- Population Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Eilis Kennedy
- Children, Young Adults and Families Directorate, Tavistock and Portman NHS Foundation Trust, London, UK
| | - Emma Howarth
- School of Psychology, University of East London, London, UK
| | - Sally Kendall
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Jan van der Meulen
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Maria Andreea Calin
- Family Nurse Partnership and Intensive Parenting National Unit, Office for Health Improvement and Disparities, London, UK
| | - Lynne Reed
- Family Nurse Partnership and Intensive Parenting National Unit, Office for Health Improvement and Disparities, London, UK
| | - Katie Harron
- Population Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK
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Adeoti IG, Cavallaro FL. Determinants of care-seeking behaviour for fever, acute respiratory infection and diarrhoea among children under five in Nigeria. PLoS One 2022; 17:e0273901. [PMID: 36107948 PMCID: PMC9477346 DOI: 10.1371/journal.pone.0273901] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/18/2022] [Indexed: 12/05/2022] Open
Abstract
Background Despite available, inexpensive and effective treatments, malaria, diarrhoea, and pneumonia still contribute the majority of the global burden of childhood morbidity and mortality. Nigeria has the highest absolute numbers of child deaths worldwide. Appropriate care-seeking is important for prompt diagnosis, appropriate and timely treatment, and prevention of complications. The objective of this cross-sectional study was to examine the prevalence of and factors associated with appropriate care-seeking for childhood illnesses. Methods We used the most recent Nigeria Demographic and Health Survey (2018) to assess the prevalence of appropriate care-seeking among mothers of children under five with symptoms of common childhood illnesses. For diarrhoea, we defined appropriate care-seeking as seeking care from a formal health provider. For fever and acute respiratory infection (ARI), appropriate care-seeking was defined as seeking care from a formal provider the day of or after symptom onset. Multivariate logistic regression was carried out to assess factors associated with optimal care-seeking for each illness. Results At least 25% of parents did not seek any care for children with fever or ARI; this figure was over one third for diarrhoea. Only 15% and 13% of caregivers showed appropriate care-seeking for their children with fever and ARI respectively, and 27% of mothers sought care from a formal provider for diarrhoea. Predictors of appropriate care-seeking varied according to childhood illness. Previous facility delivery was the only risk factor associated with increased odds of appropriate care-seeking for all three illnesses; other risk factors varied between illnesses. Conclusion Overall, care-seeking for childhood illnesses was suboptimal among caregivers in Nigeria. Interventions to increase caregivers’ awareness of the importance of appropriate care-seeking are needed alongside quality of care interventions that reinforce people’s trust in formal health facilities, to improve timely care-seeking and ultimately reduce the high burden of child deaths in Nigeria.
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Affiliation(s)
- Ifeoluwa Gbemisola Adeoti
- Children Specialist Hospital, Ilorin, Kwara State, Nigeria
- Institute of Child Health, University College London, London, United Kingdom
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Heri AB, Cavallaro FL, Ahmed N, Musheke MM, Matsui M. Changes over time in HIV testing and counselling uptake and associated factors among youth in Zambia: a cross-sectional analysis of demographic and health surveys from 2007 to 2018. BMC Public Health 2021; 21:456. [PMID: 33676482 PMCID: PMC7937241 DOI: 10.1186/s12889-021-10472-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 02/19/2021] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Zambia is among the countries with the highest HIV burden and where youth remain disproportionally affected. Access to HIV testing and counselling (HTC) is a crucial step to ensure the reduction of HIV transmission. This study examines the changes that occurred between 2007 and 2018 in access to HTC, inequities in testing uptake, and determinants of HTC uptake among youth. METHODS We carried out repeated cross-sectional analyses using three Zambian Demographic and Health Surveys (2007, 2013-14, and 2018). We calculated the percentage of women and men ages 15-24 years old who were tested for HIV in the last 12 months. We analysed inequity in HTC coverage using indicators of absolute inequality. We performed bivariate and multivariate logistic regression analyses to identify predictors of HTC uptake in the last 12 months. RESULTS HIV testing uptake increased between 2007 and 2018, from 45 to 92% among pregnant women, 10 to 58% among non-pregnant women, and from 10 to 49% among men. By 2018 roughly 60% of youth tested in the past 12 months used a government health centre. Mobile clinics were the second most common source reaching up to 32% among adolescent boys by 2018. Multivariate analysis conducted among men and non-pregnant women showed higher odds of testing among 20-24 year-olds than adolescents (aOR = 1.55 [95%CI:1.30-1.84], among men; and aOR = 1.74 [1.40-2.15] among women). Among men, being circumcised (aOR = 1.57 [1.32-1.88]) and in a union (aOR = 2.44 [1.83-3.25]) were associated with increased odds of testing. For women greater odds of testing were associated with higher levels of education (aOR = 6.97 [2.82-17.19]). Education-based inequity was considerably widened among women than men by 2018. CONCLUSION HTC uptake among Zambian youth improved considerably by 2018 and reached 65 and 49% tested in the last 12 months for women and men, respectively. However, achieving the goal of 95% envisioned by 2020 will require sustaining the success gained through government health centres, and scaling up the community-led approaches that have proven acceptable and effective in reaching young men and adolescent girls who are less easy to reach through the government facilities.
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Affiliation(s)
- Aimé Bitakuya Heri
- Department of Global Health, Nagasaki University School of Tropical Medicine and Global Health, Sakamoto 1-12-4, Nagasaki, 852-8523, Japan
| | - Francesca L Cavallaro
- Institute of Child Health, University College London, 30 Guilford St, Holborn, London, WC1N 1EH, UK
| | - Nurilign Ahmed
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Maurice Mubuyaeta Musheke
- Centre for Infectious Disease Research in Zambia, Plot # 34620, Off Alick Nkhata Road, Lusaka, Zambia
| | - Mitsuaki Matsui
- Department of Global Health, Nagasaki University School of Tropical Medicine and Global Health, Sakamoto 1-12-4, Nagasaki, 852-8523, Japan.
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Cavallaro FL, Benova L, Owolabi OO, Ali M. A systematic review of the effectiveness of counselling strategies for modern contraceptive methods: what works and what doesn't? BMJ Sex Reprod Health 2020; 46:254-269. [PMID: 31826883 PMCID: PMC7569400 DOI: 10.1136/bmjsrh-2019-200377] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 11/15/2019] [Accepted: 11/21/2019] [Indexed: 05/21/2023]
Abstract
AIM The aim of this systematic review was to synthesise the evidence on the comparative effectiveness of different counselling strategies for modern contraception on contraceptive behaviour and satisfaction, and to examine their advantages and disadvantages. METHODS Six electronic databases (Medline, Embase, Global Health, Popline, CINAHL Plus, and Cochrane Library) were searched to identify publications comparing two or more contraceptive counselling strategies and reporting quantitative results on contraceptive use, uptake, continuation or switching, or client satisfaction. Studies of women or couples from any country, published in English since 1990 were considered. RESULTS A total of 63 publications corresponding to 61 studies met the inclusion criteria. There was substantial heterogeneity in study settings, interventions and outcome measures. Interventions targeting women initiating a method (including structured counselling on side effects) tended to show positive effects on contraceptive continuation. In contrast, the majority of studies of provider training and decision-making tools for method choice did not find evidence of an effect. Additional antenatal or postpartum counselling sessions were associated with increased postpartum contraceptive use, regardless of their timing in pregnancy or postpartum. Dedicated pre-abortion contraceptive counselling was associated with increased use only when accompanied by broader contraceptive method provision. Male partner or couples counselling was effective at increasing contraceptive use in two of five studies targeting non-users, women initiating implants or seeking abortion. High-quality evidence is lacking for the majority of intervention types. CONCLUSIONS The evidence base and quality of studies are limited, and further research is needed to determine the effectiveness of many counselling interventions in different settings.
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Affiliation(s)
| | - Lenka Benova
- Institute of Tropical Medicine, Antwerp, Belgium
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Moazzam Ali
- World Health Organization, Geneva, Switzerland
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Krug C, Cavallaro FL, Wong KLM, Gasparrini A, Faye A, Lynch CA. Evaluation of Senegal supply chain intervention on contraceptive stockouts using routine stock data. PLoS One 2020; 15:e0236659. [PMID: 32745110 PMCID: PMC7398546 DOI: 10.1371/journal.pone.0236659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/09/2020] [Indexed: 12/02/2022] Open
Abstract
Background Until 2011, stockouts of family planning commodities were common in Senegalese public health facilities. Recognizing the importance of addressing this problem, the Government of Senegal implemented the Informed Push Model (IPM) supply system, which involves logisticians to collect facility-level stock turnover data once a month and provide contraceptive supplies accordingly. The aims of this paper were to evaluate the impact of IPM on contraceptive availability and on stockout duration. Methods and findings To estimate the impact of the IPM on contraceptive availability, stock card data were obtained from health facilities selected through multistage sampling. A total number of 103 health facilities pertaining to 27 districts and nine regions across the country participated in this project. We compared the odds of contraceptive stockouts within the health facilities on the 23 months after the intervention with the 18 months before. The analysis was performed with a logistic model of the monthly time-series. The odds of stockout for any of the five contraceptive products decreased during the 23 months post-intervention compared to the 18 months pre-intervention (odds ratio, 95%CI: 0.34, 0.22–0.51). To evaluate the impact of the IPM on duration of stockouts, a mixed negative binomial zero-truncated regression analysis was performed. The IPM was not effective in reducing the duration of contraceptive stockouts (incidence rate ratio, 95%CI: 0.81, 0.24–2.7), except for the two long-acting contraceptives (intrauterine devices and implants). Our model predicted a decrease in stockout median duration from 23 pre- to 4 days post-intervention for intrauterine devices; and from 19 to 14 days for implants. Conclusions We conclude that the IPM has resulted in greater efficiency in contraceptive stock management, increasing the availability of contraceptive methods in health facilities in Senegal. The IPM also resulted in decreased duration of stockouts for intrauterine devices and implants, but not for any of the short-acting contraception (pills and injectables).
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Affiliation(s)
- Catarina Krug
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Francesca L. Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Kerry L. M. Wong
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Antonio Gasparrini
- Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Adama Faye
- Institut Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
| | - Caroline A. Lynch
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Semaan A, Audet C, Huysmans E, Afolabi B, Assarag B, Banke-Thomas A, Blencowe H, Caluwaerts S, Campbell OMR, Cavallaro FL, Chavane L, Day LT, Delamou A, Delvaux T, Graham WJ, Gon G, Kascak P, Matsui M, Moxon S, Nakimuli A, Pembe A, Radovich E, van den Akker T, Benova L. Voices from the frontline: findings from a thematic analysis of a rapid online global survey of maternal and newborn health professionals facing the COVID-19 pandemic. BMJ Glob Health 2020; 5:e002967. [PMID: 32586891 PMCID: PMC7335688 DOI: 10.1136/bmjgh-2020-002967] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic has substantially impacted maternity care provision worldwide. Studies based on modelling estimated large indirect effects of the pandemic on services and health outcomes. The objective of this study was to prospectively document experiences of frontline maternal and newborn healthcare providers. METHODS We conducted a global, cross-sectional study of maternal and newborn health professionals via an online survey disseminated through professional networks and social media in 12 languages. Information was collected between 24 March and 10 April 2020 on respondents' background, preparedness for and response to COVID-19 and their experience during the pandemic. An optional module sought information on adaptations to 17 care processes. Descriptive statistics and qualitative thematic analysis were used to analyse responses, disaggregating by low-income and middle-income countries (LMICs) and high-income countries (HICs). RESULTS We analysed responses from 714 maternal and newborn health professionals. Only one-third received training on COVID-19 from their health facility and nearly all searched for information themselves. Half of respondents in LMICs received updated guidelines for care provision compared with 82% in HICs. Overall, 47% of participants in LMICs and 69% in HICs felt mostly or completely knowledgeable in how to care for COVID-19 maternity patients. Facility-level responses to COVID-19 (signage, screening, testing and isolation rooms) were more common in HICs than LMICs. Globally, 90% of respondents reported somewhat or substantially higher levels of stress. There was a widespread perception of reduced use of routine maternity care services, and of modification in care processes, some of which were not evidence-based practices. CONCLUSIONS Substantial knowledge gaps exist in guidance on management of maternity cases with or without COVID-19. Formal information-sharing channels for providers must be established and mental health support provided. Surveys of maternity care providers can help track the situation, capture innovations and support rapid development of effective responses.
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Affiliation(s)
- Aline Semaan
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
- Center for Research on Population and Health, American University of Beirut Faculty of Health Sciences, Beirut, Lebanon
| | - Constance Audet
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Elise Huysmans
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Bosede Afolabi
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Bouchra Assarag
- National School of Public Health, Ministry of Health, Rabat, Morocco
| | | | - Hannah Blencowe
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Séverine Caluwaerts
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Oona Maeve Renee Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Leonardo Chavane
- Department of Community Health, Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Louise Tina Day
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Alexandre Delamou
- Africa Centre of Excellence for Prevention and Control of Transmissible Diseases (CEA-PCMT), Universite Gamal Abdel Nasser de Conakry, Conakry, Guinea
| | - Therese Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Wendy Jane Graham
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Giorgia Gon
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Kascak
- Department of Obstetrics and Gynaecology, General Hospital Trencin, Trencin, Slovakia
| | - Mitsuaki Matsui
- Department of Global Health, Nagasaki University School of Tropical Medicine and Global Health, Nagasaki, Japan
| | - Sarah Moxon
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Annettee Nakimuli
- Department of Obstetrics & Gynaecology, Makerere University, Kampala, Uganda
- Department of Obstetrics and Gynaecology, Mulago Specialized Women and Neonatal Hospital, Kampala, Uganda
| | - Andrea Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Vrije Universiteit Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, VU Amsterdam Athena Institute, Vrije Universiteit Amsterdam, The Netherlands
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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Cavallaro FL, Gilbert R, Wijlaars L, Kennedy E, Swarbrick A, van der Meulen J, Harron K. Evaluating the real-world implementation of the Family Nurse Partnership in England: protocol for a data linkage study. BMJ Open 2020; 10:e038530. [PMID: 32430455 PMCID: PMC7239518 DOI: 10.1136/bmjopen-2020-038530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Almost 20 000 babies are born to teenage mothers each year in England, with poorer outcomes for mothers and babies than among older mothers. A nurse home visitation programme in the USA was found to improve a wide range of outcomes for young mothers and their children. However, a randomised controlled trial in England found no effect on short-term primary outcomes, although cognitive development up to age 2 showed improvement. Our study will use linked routinely collected health, education and social care data to evaluate the real-world effects of the Family Nurse Partnership (FNP) on child outcomes up to age 7, with a focus on identifying whether the FNP works better for particular groups of families, thereby informing programme targeting and resource allocation. METHODS AND ANALYSIS We will construct a retrospective cohort of all women aged 13-24 years giving birth in English NHS hospitals between 2010 and 2017, linking information on mothers and children from FNP programme data, Hospital Episodes Statistics and the National Pupil Database. To assess the effectiveness of FNP, we will compare outcomes for eligible mothers ever and never enrolled in FNP, and their children, using two analysis strategies to adjust for measured confounding: propensity score matching and analyses adjusting for maternal characteristics up to enrolment/28 weeks gestation. Outcomes of interest include early childhood development, childhood unplanned hospital admissions for injury or maltreatment-related diagnoses and children in care. Subgroup analyses will determine whether the effect of FNP varied according to maternal characteristics (eg, age and education). ETHICS AND DISSEMINATION The Nottingham Research Ethics Committee approved this study. Mothers participating in FNP were supportive of our planned research. Results will inform policy-makers for targeting home visiting programmes. Methodological findings on the accuracy and reliability of cross-sectoral data linkage will be of interest to researchers.
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Affiliation(s)
- Francesca L Cavallaro
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Ruth Gilbert
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Linda Wijlaars
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Eilis Kennedy
- Children, Young Adults and Families Directorate, Tavistock and Portman NHS Foundation Trust, London, UK
| | - Ailsa Swarbrick
- Family Nurse Partnership National Unit, Tavistock and Portman NHS Foundation Trust, London, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Katie Harron
- Great Ormond Street Institute of Child Health, University College London, London, UK
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11
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Cavallaro FL, Benova L, Dioukhane EH, Wong K, Sheppard P, Faye A, Radovich E, Dumont A, Mbengue AS, Ronsmans C, Martinez-Alvarez M. What the percentage of births in facilities does not measure: readiness for emergency obstetric care and referral in Senegal. BMJ Glob Health 2020; 5:e001915. [PMID: 32201621 PMCID: PMC7059423 DOI: 10.1136/bmjgh-2019-001915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Francesca L Cavallaro
- CEPED, Institut de Recherche Pour le Développement, Paris, France.,Institute of Child Health, University College London, London, UK
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Kerry Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Paula Sheppard
- Institute of Social and Cultural Anthropology, Oxford University, Oxford, UK
| | - Adama Faye
- Institut de Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
| | - Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alexandre Dumont
- CEPED, Institut de Recherche Pour le Développement, Paris, France
| | - Abdou Salam Mbengue
- IRESSEF: Institut de Recherche en Santé, de Surveillance Epidémiologique et de Formations, Dakar, Senegal
| | - Carine Ronsmans
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Melisa Martinez-Alvarez
- Medical Research Council Unit in The Gambia at the London School of Hygiene & Tropical Medicine, Fajara, The Gambia
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12
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Duclos D, Cavallaro FL, Ndoye T, Faye SL, Diallo I, Lynch CA, Diallo M, Faye A, Penn-Kekana L. Critical insights on the demographic concept of "birth spacing": locating Nef in family well-being, bodies, and relationships in Senegal. Sex Reprod Health Matters 2020; 27:1581533. [PMID: 31533565 PMCID: PMC7887960 DOI: 10.1080/26410397.2019.1581533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Birth spacing has emerged since the early 1980s as a key concept to improve maternal and child health, triggering interest in birth spacing practices in low-income countries, and drawing attention to prevailing norms in favour of long birth intervals in West Africa. In Senegal, the Wolof concept of Nef, which means having children too closely spaced in time, is morally condemned and connotes a resulting series of negative implications for family well-being. While Nef and “birth spacing” intersect in key ways, including acknowledging the health benefits of longer birth intervals, they are not translations of each other, for each is embedded in distinct broader cultural and political assumptions about social relations. Most notably, proponents of the demographic concept of birth spacing assume that the practice of using contraception after childbearing to postpone births could contribute to “empowering” women socially. In Senegal, by contrast, preventing Nef (or short birth intervals) is also viewed as strengthening family well-being by allowing women to care more fully for their family. This paper draws on policy documents and interviews to explore women's and men's understanding of Nef, and in turn critically reflect on the demographic concept of birth spacing. Our findings reinforce the relevance of the concept of birth spacing to engage with women and men around family planning services in Senegal. Accounts of the Nef taboo in Senegal also show that social norms stigmatising short birth intervals can legitimise constraints faced by women on control of their body.
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Affiliation(s)
- Diane Duclos
- Research Fellow , London School of Hygiene and Tropical Medicine , London , UK
| | | | - Tidiane Ndoye
- Senior Lecturer , University Cheikh Anta Diop , Dakar , Senegal
| | - Sylvain L Faye
- Senior Lecturer , University Cheikh Anta Diop , Dakar , Senegal
| | - Issakha Diallo
- Director , Convergence Santé pour le Développement , Dakar , Senegal
| | - Caroline A Lynch
- Assistant Professor , London School of Hygiene and Tropical Medicine , London , UK
| | - Mareme Diallo
- Researcher , University Cheikh Anta Diop , Dakar , Senegal
| | - Adama Faye
- Professor , University Cheikh Anta Diop , Dakar , Senegal
| | - Loveday Penn-Kekana
- Assistant Professor , London School of Hygiene and Tropical Medicine , London , UK
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13
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Cavallaro FL, Hurt LS, Cresswell JA, Edmond K, Amenga-Etego S, Kirkwood BR, Ronsmans C. Testing the assumptions of an indicator of unmet need for obstetric surgery in Ghana: A cross-sectional study of linked hospital and population-based delivery data. Birth 2019; 46:638-647. [PMID: 31512773 DOI: 10.1111/birt.12452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/16/2019] [Accepted: 08/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Unmet Obstetric Need (UON) indicator has been widely used to estimate unmet need for life-saving surgery at birth; however, its assumptions have not been verified. The objective of this study was to test two UON assumptions: (a) Absolute maternal indications (AMIs) require surgery for survival and (b) 1%-2% of deliveries develop AMIs, implying that rates of surgeries for AMIs below this threshold indicate excess mortality from these complications. METHODS We used linked hospital and population-based data in central Ghana. Among hospital deliveries, we calculated the percentage of deliveries with AMIs who received surgery, and mortality among AMIs who did not. At the population level, we assessed whether the percentage of deliveries with surgeries for AMIs was inversely associated with mortality from these complications, stratified by education. RESULTS A total of 380 of 387 (98%) hospital deliveries with recorded AMIs received surgery; an additional eight women with no AMI diagnosis died of AMI-related causes. Among the 50 148 deliveries in the population, surgeries for AMIs increased from 0.6% among women with no education to 1.9% among women with post-secondary education (P < .001). However, there was no association between AMI-related mortality and education (P = .546). Estimated AMI prevalence was 0.84% (95% CI: 0.76%-0.92%), below the assumed 1% minimum threshold. DISCUSSION Obstetric providers consider AMIs absolute indications for surgery. However, low rates of surgeries for AMIs among less educated women were not associated with higher mortality. The UON indicator should be used with caution in estimating the unmet need for life-saving obstetric surgery; innovative approaches are needed to identify unmet need in the context of rising cesarean rates.
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Affiliation(s)
- Francesca L Cavallaro
- Institut de Recherche pour le Développement, Institut de Recherche pour le Développement, Paris, France
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14
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Mulchandani R, Power HS, Cavallaro FL. The influence of individual provider characteristics and attitudes on caesarean section decision-making: a global review. J OBSTET GYNAECOL 2019; 40:1-9. [PMID: 31208243 DOI: 10.1080/01443615.2019.1587603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Caesarean section (CS) rates have risen worldwide in the past two decades, particularly in middle and high-income countries. In addition to changing maternal and health system factors, there is growing evidence that provider factors may contribute to rising unnecessary caesareans. The aim of this review was to assess the evidence for the association between individual provider characteristics, attitudes towards CS and decision-making for CS. A search was conducted in May 2018 in PubMed and Web of Science with 23 papers included in our final review. Our results show that higher anxiety scores and more favourable opinions of CS were associated with increased likelihood of performing CS. These findings highlight a need for appropriate interventions to target provider attitudes towards CS to reduce unnecessary procedures.
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Affiliation(s)
- Ranya Mulchandani
- Polygeia, Global Health Student Think Tank, London, United Kingdom.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Harvinder Singh Power
- Polygeia, Global Health Student Think Tank, London, United Kingdom.,Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Francesca L Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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15
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Radovich E, Dennis ML, Barasa E, Cavallaro FL, Wong KL, Borghi J, Lynch CA, Lyons-Amos M, Abuya T, Benova L. Who pays and how much? A cross-sectional study of out-of-pocket payment for modern contraception in Kenya. BMJ Open 2019; 9:e022414. [PMID: 30787074 PMCID: PMC6398787 DOI: 10.1136/bmjopen-2018-022414] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Out-of-pocket (OOP) payment for modern contraception is an understudied component of healthcare financing in countries like Kenya, where wealth gradients in met need have prompted efforts to expand access to free contraception. This study aims to examine whether, among public sector providers, the poor are more likely to receive free contraception and to compare how OOP payment for injectables and implants-two popular methods-differs by public/private provider type and user's sociodemographic characteristics. DESIGN, SETTING AND PARTICIPANTS Secondary analyses of nationally representative, cross-sectional household data from the 2014 Kenya Demographic and Health Survey. Respondents were women of reproductive age (15-49 years). The sample comprised 5717 current modern contraception users, including 2691 injectable and 1073 implant users with non-missing expenditure values. MAIN OUTCOME Respondent's self-reported source and payment to obtain their current modern contraceptive method. METHODS We used multivariable logistic regression to examine predictors of free public sector contraception and compared average expenditure for injectable and implant. Quintile ratios examined progressivity of non-zero expenditure by wealth. RESULTS Half of public sector users reported free contraception; this varied considerably by method and region. Users of implants, condoms, pills and intrauterine devices were all more likely to report receiving their method for free (p<0.001) compared with injectable users. The poorest were as likely to pay for contraception as the wealthiest users at public providers (OR: 1.10, 95% CI: 0.64 to 1.91). Across all providers, among users with non-zero expenditure, injectable and implant users reported a mean OOP payment of Kenyan shillings (KES) 80 (US$0.91), 95% CI: KES 78 to 82 and KES 378 (US$4.31), 95% CI: KES 327 to 429, respectively. In the public sector, expenditure was pro-poor for injectable users yet weakly pro-rich for implant users. CONCLUSIONS More attention is needed to targeting subsidies to the poorest and ensuring government facilities are equipped to cope with lost user fee revenue.
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Affiliation(s)
- Emma Radovich
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mardieh L Dennis
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Francesca L Cavallaro
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kerry Lm Wong
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Josephine Borghi
- Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline A Lynch
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Lyons-Amos
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Lenka Benova
- Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Public Health, Instituut voor Tropische Geneeskunde, Antwerpen, Belgium
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16
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Cavallaro FL, Duclos D, Cresswell JA, Faye S, Macleod D, Faye A, Lynch CA. Understanding 'missed appointments' for pills and injectables: a mixed methods study in Senegal. BMJ Glob Health 2018; 3:e000975. [PMID: 30687521 PMCID: PMC6326323 DOI: 10.1136/bmjgh-2018-000975] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 10/25/2018] [Accepted: 10/28/2018] [Indexed: 11/03/2022] Open
Abstract
Introduction High discontinuation rates of contraceptive methods have been documented in sub-Saharan Africa. However, little is known about gaps within individual episodes of method use, despite their implications for unintended pregnancies. The objective of this mixed methods study was to examine the prevalence of, and explore the factors contributing to, delays in repeat appointments for pills and injectables in Senegal. Methods First, we constructed a longitudinal data set of women's contraceptive consultations using routine records from 67 facilities in Senegal. Consultations for pills and injectables were classified as on time, delayed or with unknown delay status based on time since previous appointment. We described the prevalence of delayed appointments and used backward stepwise regression to build a mixed-effects model to investigate risk factors for delay. Second, we conducted workshops with family planning (FP) providers, and indepth interviews and focus group discussions with women of reproductive age, to explore factors contributing to delays. Results Almost one-third (30%) of appointments for pills and injectables were delayed, resulting in risk of pregnancy. Previous delay, pill use, lower educational level, higher parity, third and subsequent visits, and Islamic faith were independently predictive of delays (p<0.04 for all). Although women's 'forgetfulness' was initially mentioned as the main reason for delays by women and providers, examining the routines around appointment attendance revealed broader contextual barriers to timely refills-particularly widespread covert use, illiteracy, financial cost of FP services and limited availability of FP services. Conclusion Delays in obtaining repeat pills and injections are common among contraceptive users in Senegal, exposing women to unintended pregnancies. Strategies to reduce such delays should move beyond a narrow focus on individual women to consider contraceptive behaviour within the broader socioeconomic and health systems context. In particular, effective interventions addressing low acceptability of contraception and appointment reminder strategies in high illiteracy contexts are needed.
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Affiliation(s)
- Francesca L Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Diane Duclos
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Jenny A Cresswell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sylvain Faye
- Départment de sociologie, Université Cheikh Anta Diop, Dakar, Senegal
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Adama Faye
- Institut Santé et Développement, Université Cheikh Anta Diop, Dakar, Senegal
| | - Caroline A Lynch
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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17
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McElwee E, Cresswell JA, Yao C, Bakeu M, Cavallaro FL, Duclos D, Lynch CA, Paintain L. Comparing time and motion methods to study personnel time in the context of a family planning supply chain intervention in Senegal. Hum Resour Health 2018; 16:60. [PMID: 30453991 PMCID: PMC6245801 DOI: 10.1186/s12960-018-0328-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/25/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND A family planning (FP) supply chain intervention was introduced in Senegal in 2012 to reduce contraceptive stock-outs. Labour is the highest cost in low- and middle-income country supply chains. In this paper, we (1) understand time use of personnel working in the FP supply chain at health facilities in Senegal, (2) estimate the validity of self-administered timesheets (STs) relative to continuous observations (COs), and (3) describe the cost of data collection for each method. METHODS We collected time use data for seven stockroom managers in six facilities using both ST and CO. Activities were categorized as follows: stock management associated with FP, non-FP stock management, other productive activities, non-productive activities, and waiting time. Paired t tests were used to compare the mean differences between the two methods in all categories and in productive time alone. RESULTS Among all activities, the absolute and relative time spent on productive activities was higher when estimated by ST compared to CO. Conversely, waiting time was underestimated by STs. There was no difference in the relative time spent on non-productive activities. When comparing the distribution of the three productive activity categories, we found no evidence of a difference in relative time percentage estimates between CO and ST (FP stockroom management - 3.0%, 95% CI - 7.4 to 1.4%; non-FP stockroom management 3.4%, 95% CI - 2.8 to 9.6%; and other productive activities - 0.1%, 95% CI - 6.3 to 6.0%). Data collection costs for CO are 140% more than ST. CONCLUSION STs were not a reliable method for measuring absolute labour time at health facilities in Senegal due to considerable underestimates of time waiting for clients. However, ST had acceptable reliability when examining distribution of productive time. Although CO provides more accurate absolute time estimates, the unit costs for data collection using this method are more than triple those for STs in Senegal.
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Affiliation(s)
- Elizabeth McElwee
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Washington, DC, United States of America
| | | | - Christian Yao
- CSD Convergence Santé pour le Développement, Dakar, Senegal
| | - Macaire Bakeu
- Centre Africain d’études Supérieures en Gestion, Dakar, Senegal
| | | | - Diane Duclos
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Caroline A. Lynch
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lucy Paintain
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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18
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Cavallaro FL, Pembe AB, Campbell O, Hanson C, Tripathi V, Wong KL, Radovich E, Benova L. Caesarean section provision and readiness in Tanzania: analysis of cross-sectional surveys of women and health facilities over time. BMJ Open 2018; 8:e024216. [PMID: 30287614 PMCID: PMC6173245 DOI: 10.1136/bmjopen-2018-024216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To describe trends in caesarean sections and facilities performing caesareans over time in Tanzania and examine the readiness of such facilities in terms of infrastructure, equipment and staffing. DESIGN Nationally representative, repeated cross-sectional surveys of women and health facilities. SETTING Tanzania. PARTICIPANTS Women of reproductive age and health facility staff. MAIN OUTCOME MEASURES Population-based caesarean rate, absolute annual number of caesareans, percentage of facilities reporting to perform caesareans and three readiness indicators for safe caesarean care: availability of consistent electricity, 24 hour schedule for caesarean and anaesthesia providers, and availability of all general anaesthesia equipment. RESULTS The caesarean rate in Tanzania increased threefold from 2% in 1996 to 6% in 2015-16, while the total number of births increased by 60%. As a result, the absolute number of caesareans increased almost fivefold to 120 000 caesareans per year. The main mechanism sustaining the increase in caesareans was the doubling of median caesarean volume among public hospitals, from 17 caesareans per month in 2006 to 35 in 2014-15. The number of facilities performing caesareans increased only modestly over the same period. Less than half (43%) of caesareans in Tanzania in 2014-15 were performed in facilities meeting the three readiness indicators. Consistent electricity was widely available, and 24 hour schedules for caesarean and (less systematically) anaesthesia providers were observed in most facilities; however, the availability of all general anaesthesia equipment was the least commonly reported indicator, present in only 44% of all facilities (34% of public hospitals). CONCLUSIONS Given the rising trend in numbers of caesareans, urgent improvements in the availability of general anaesthesia equipment and trained anaesthesia staff should be made to ensure the safety of caesareans. Initial efforts should focus on improving anaesthesia provision in public and faith-based organisation hospitals, which together perform more than 90% of all caesareans in Tanzania.
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Affiliation(s)
- Francesca L Cavallaro
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Oona Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Claudia Hanson
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Kerry Lm Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Grollman C, Cavallaro FL, Duclos D, Bakare V, Martínez Álvarez M, Borghi J. Donor funding for family planning: levels and trends between 2003 and 2013. Health Policy Plan 2018. [PMID: 29534176 PMCID: PMC5894079 DOI: 10.1093/heapol/czy006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The International Conference on Population and Development in 1994 set targets for donor funding to support family planning programmes, and recent initiatives such as FP2020 have renewed focus on the need for adequate funding to rights-based family planning. Disbursements supporting family planning disaggregated by donor, recipient country and year are not available for recent years. We estimate international donor funding for family planning in 2003–13, the period covering the introduction of reproductive health targets to the Millennium Development Goals and up to the beginning of FP2020, and compare funding to unmet need for family planning in recipient countries. We used the dataset of donor disbursements to support reproductive, maternal, newborn and child health developed by the Countdown to 2015 based on the Organization for Economic Cooperation and Development Creditor Reporting System. We assessed levels and trends in disbursements supporting family planning in the period 2003–13 and compared this to unmet need for family planning. Between 2003 and 2013, disbursements supporting family planning rose from under $400 m prior to 2008 to $886 m in 2013. More than two thirds of disbursements came from the USA. There was substantial year-on-year variation in disbursement value to some recipient countries. Disbursements have become more concentrated among recipient countries with higher national levels of unmet need for family planning. Annual disbursements of donor funding supporting family planning are far short of projected and estimated levels necessary to address unmet need for family planning. The reimposition of the US Global Gag Rule will precipitate an even greater shortfall if other donors and recipient countries do not find substantial alternative sources of funding.
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Affiliation(s)
- Christopher Grollman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Francesca L Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and
| | - Diane Duclos
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and
| | - Victoria Bakare
- School of Medicine, King's College London, Guy's Campus, Great Maze Pond, London SE1 9RT, UK
| | - Melisa Martínez Álvarez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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Johnson SC, Cavallaro FL, Leon DA. A systematic review of allostatic load in relation to socioeconomic position: Poor fidelity and major inconsistencies in biomarkers employed. Soc Sci Med 2017; 192:66-73. [DOI: 10.1016/j.socscimed.2017.09.025] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/30/2017] [Accepted: 09/15/2017] [Indexed: 12/19/2022]
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Dennis ML, Radovich E, Wong KLM, Owolabi O, Cavallaro FL, Mbizvo MT, Binagwaho A, Waiswa P, Lynch CA, Benova L. Pathways to increased coverage: an analysis of time trends in contraceptive need and use among adolescents and young women in Kenya, Rwanda, Tanzania, and Uganda. Reprod Health 2017; 14:130. [PMID: 29041936 PMCID: PMC5645984 DOI: 10.1186/s12978-017-0393-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 10/06/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Despite efforts to make contraceptive services more "youth friendly," unmet need for contraception among young women in sub-Saharan Africa remains high. For health systems to effectively respond to the reproductive health needs of a growing youth population, it is imperative to understand their contraceptive needs and service seeking practices. This paper describes changes over time in contraceptive need, use, and sources of care among young women in four East African countries. METHODS We used three rounds of DHS data from Kenya, Rwanda, Tanzania, and Uganda to examine time trends from 1999 to 2015 in met need for modern contraception, method mix, and source of care by sector (public or private) and type of provider among young women aged 15-24 years. We assessed disparities in contraceptive coverage improvements over time between younger (15-24 years) and older women (25-49 years) using a difference-in-differences approach. RESULTS Met need for contraception among women aged 15-24 years increased over time, ranging from a 20% increase in Tanzania to more than a 5-fold increase in Rwanda. Improvements in met need were greater among older women compared to younger women in Rwanda and Uganda, and higher among younger women in Kenya. Injectables have become the most popular contraceptive choice among young women, with more than 50% of modern contraceptive users aged 15-24 years currently using the method in all countries except for Tanzania, where condoms and injectables are used by 38% and 35% of young users, respectively. More than half of young women in Tanzania and Uganda receive contraceptives from the private sector; however, while the private sector played an important role in meeting the growing contraceptive needs among young women in Tanzania, increased use of public sector services drove expanded access in Kenya, Rwanda, and Uganda. CONCLUSIONS Our study shows that contraceptive use increased among young East African women, yet, unmet need remains high. As youth populations continue to grow, governments must develop more targeted strategies for expanding access to reproductive health services for young women. Engaging the private sector and task-shifting to lower-level providers offer promising approaches; however, additional research is needed to identify the key facilitators and barriers to the success of these strategies in different contexts.
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Affiliation(s)
- Mardieh L. Dennis
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Emma Radovich
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Kerry L. M. Wong
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Onikepe Owolabi
- Guttmacher Institute, 125 Maiden Lane 7th Floor, New York, NY 10038 USA
| | - Francesca L. Cavallaro
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | | | - Agnes Binagwaho
- Department of Global Health and Social Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115 USA
- Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Rd, Hanover, NH 03755 USA
- University of Global Health Equity, Kigali Heights, Plot, 772 Kigali, Rwanda
| | - Peter Waiswa
- Makerere University School of Public Health, New Mulago Hill Road, Kampala, Uganda
| | - Caroline A. Lynch
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
| | - Lenka Benova
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Owolabi OO, Wong KLM, Dennis ML, Radovich E, Cavallaro FL, Lynch CA, Fatusi A, Sombie I, Benova L. Comparing the use and content of antenatal care in adolescent and older first-time mothers in 13 countries of west Africa: a cross-sectional analysis of Demographic and Health Surveys. Lancet Child Adolesc Health 2017; 1:203-212. [PMID: 30169169 DOI: 10.1016/s2352-4642(17)30025-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/20/2017] [Accepted: 06/21/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND West Africa has the highest proportion of married adolescents, and the highest adolescent childbirth rate and maternal death rate in sub-Saharan Africa. However, few studies have focused on the type and quality of health care accessed by pregnant young women in countries in this subregion. METHODS We obtained data from Demographic and Health Surveys done between 2010 and 2014, to compare the use, timing, source, and components of antenatal care between adolescent and older first-time mothers in 13 west African countries. The sample included primiparous women who were aged 15-49 years with a livebirth in the 5-year survey recall period, and women were assigned to one of three groups on the basis of age at the time of childbirth: adolescent (10-19 years), young adults (20-24 years), or adults (25 years or older). We calculated the percentage of women who: attended at least one antenatal care visit, completed at least one visit during the first trimester of pregnancy, attended four or more appointments in antenatal care, and received four components of antenatal care (blood pressure measurement, urine tests, blood tests, and information on complications), as well as the sector where the women received care. We primarily report the comparison between adolescents and young adults. FINDINGS In 2016, we acquired data from the Demographic Health Surveys from 13 west African countries between 2010 and 2014 on primiparous women. The study sample was 19 211 women, of whom 10 025 (52%) were adolescents, 6099 (32%) were young adults, and 3087 (16%) were adults. Overall, 17 386 (91%) of 19 211 first-time mothers made use of antenatal care facilities on at least one occasion. 3597 (41%) of 8741 adolescents compared with 8202 (47%) of all 17 386 women began the use of antenatal care during the first trimester. Across west Africa, 5430 (62%) of 8741 adolescents had four or more antenatal care visits compared with 4067 (71%) of 5717 young adults and 2358 (81%) of 2928 adults. Of those who had four or more visits to antenatal care, 2779 (51%) of 5430 adolescents received all the antenatal care components examined compared with 2488 (61%) of 4067 young adults and 1600 (68%) of 2358 adults. Although most women received antenatal care in the public sector, in nine of the 13 countries, the proportion of women that used the private sector was higher in older mothers. INTERPRETATION Although a large percentage of west African adolescents use some antenatal care for their first birth, they seek care later, make fewer visits during pregnancy, and receive fewer components of care than older first-time mothers. Governments must ensure the pregnancy care accessed by adolescent mothers is of high quality and tailored to meet their needs. FUNDING MSD for Mothers.
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Affiliation(s)
- Onikepe O Owolabi
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; Guttmacher Institute, New York, NY, USA.
| | - Kerry L M Wong
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Mardieh L Dennis
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Francesca L Cavallaro
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Caroline A Lynch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Adesegun Fatusi
- Department of Community Health, College of Health Sciences, Obafemi Awolowo University, Ile Ife, Nigeria
| | - Issiaka Sombie
- West African Health Organization, Bobo-Dioulasso, Burkina Faso
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Virgo S, Gon G, Cavallaro FL, Graham W, Woodd S. Who delivers where? The effect of obstetric risk on facility delivery in East Africa. Trop Med Int Health 2017. [DOI: 10.1111/tmi.12910] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Sandra Virgo
- Faculty of Epidemiology and Population Health; London School of Hygiene & Tropical Medicine; London UK
| | - Giorgia Gon
- Faculty of Epidemiology and Population Health; London School of Hygiene & Tropical Medicine; London UK
| | - Francesca L. Cavallaro
- Faculty of Epidemiology and Population Health; London School of Hygiene & Tropical Medicine; London UK
| | - Wendy Graham
- Faculty of Epidemiology and Population Health; London School of Hygiene & Tropical Medicine; London UK
| | - Susannah Woodd
- Faculty of Epidemiology and Population Health; London School of Hygiene & Tropical Medicine; London UK
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Abstract
Background The debate surrounding the optimal caesarean rate has been ongoing for several decades, with the WHO recommending an “acceptable” rate of 5–15% since 1997, despite a weak evidence base. Global expert opinion from obstetric care providers on the optimal caesarean rate has not been documented. The objective of this study was to examine providers’ opinions of the optimal caesarean rate worldwide, among all deliveries and within specific sub-groups of deliveries. Methods A global online survey of medical doctors who had performed at least one caesarean in the last five years was conducted between August 2013 and January 2014. Respondents were asked to report their opinion of the optimal caesarean rate—defined as the caesarean rate that would minimise poor maternal and perinatal outcomes—at the population level and within specific sub-groups of deliveries (including women with demographic and clinical risk factors for caesareans). Median reported optimal rates and corresponding inter-quartile ranges (IQRs) were calculated for the sample, and stratified according to national caesarean rate, institutional caesarean rate, facility level, and respondent characteristics. Results Responses were collected from 1,057 medical doctors from 96 countries. The median reported optimal caesarean rate was 20% (IQR: 15–30%) for all deliveries. Providers in private for-profit facilities and in facilities with high institutional rates reported optimal rates of 30% or above, while those in Europe, in public facilities and in facilities with low institutional rates reported rates of 15% or less. Reported optimal rates were lowest among low-risk deliveries and highest for Absolute Maternal Indications (AMIs), with wide IQRs observed for most categories other than AMIs. Conclusions Three-quarters of respondents reported an optimal caesarean rate above the WHO 15% upper threshold. There was substantial variation in responses, highlighting a lack of consensus around which women are in need of a caesarean among obstetric care providers worldwide.
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Affiliation(s)
- Francesca L. Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Jenny A. Cresswell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Cavallaro FL, Cresswell JA, França GV, Victora CG, Barros AJ, Ronsmans C. Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Bull World Health Organ 2013; 91:914-922D. [PMID: 24347730 DOI: 10.2471/blt.13.117598] [Citation(s) in RCA: 124] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 05/30/2013] [Accepted: 06/20/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To examine temporal trends in caesarean delivery rates in southern Asia and sub-Saharan Africa, by country and wealth quintile. METHODS Cross-sectional data were extracted from the results of 80 Demographic and Health Surveys conducted in 26 countries in southern Asia or sub-Saharan Africa. Caesarean delivery rates were evaluated - as percentages of the deliveries that ended in live births - for each wealth quintile in each survey. The annual rates recorded for each country were then compared to see if they had increased over time. FINDINGS Caesarean delivery rates had risen over time in all but 6 study countries but were consistently found to be lower than 5% in 18 of the countries and 10% or less in the other eight countries. Among the poorest 20% of the population, caesarean sections accounted for less than 1% and less than 2% of deliveries in 12 and 21 of the study countries, respectively. In each of 11 countries, the caesarean delivery rate in the poorest 40% of the population remained under 1%. In Chad, Ethiopia, Guinea, Madagascar, Mali, Mozambique, Niger and Nigeria, the rate remained under 1% in the poorest 80%. Compared with the 22 African study countries, the four study countries in southern Asia experienced a much greater rise in their caesarean delivery rates over time. However, the rates recorded among the poorest quintile in each of these countries consistently fell below 2%. CONCLUSION Caesarean delivery rates among large sections of the population in sub-Saharan Africa are very low, probably because of poor access to such surgery.
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Affiliation(s)
- Francesca L Cavallaro
- London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Jenny A Cresswell
- London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Giovanny Va França
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Cesar G Victora
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Aluísio Jd Barros
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Carine Ronsmans
- London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
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Cavallaro FL, Marchant TJ. Responsiveness of emergency obstetric care systems in low- and middle-income countries: a critical review of the "third delay". Acta Obstet Gynecol Scand 2013; 92:496-507. [PMID: 23278232 DOI: 10.1111/aogs.12071] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 12/06/2012] [Indexed: 11/29/2022]
Abstract
We reviewed the evidence on the duration, causes and effects of delays in providing emergency obstetric care to women attending health facilities (the third delay) in low- and middle-income countries. We performed a critical literature review using terms related to obstetric care, birth outcome, delays and developing countries. A manual search of reference lists of key articles was also performed. 69 studies met the inclusion criteria. Most studies reported long delays in providing care, and the mean waiting time for women admitted with complications was as much as 24 h before treatment. The three most cited barriers to providing timely care were shortage of treatment materials, surgery facilities and qualified staff. Existing evidence is insufficient to estimate the effect of delays on birth outcomes. Delays in providing emergency obstetric care seem common in resource-constrained settings but further research is necessary to determine the effect of the third delay on birth outcomes.
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Affiliation(s)
- Francesca L Cavallaro
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
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