Towards achievement of Sustainable Development Goal 3: multilevel analyses of demographic and health survey data on health insurance coverage and maternal healthcare utilisation in sub-Saharan Africa

BACKGROUND

Improving maternal health and achieving universal health coverage (UHC) are important expectations in the global Sustainable Development Goals (SDGs) agenda. While health insurance has been shown as effective in the utilisation of maternal healthcare, there is a paucity of literature on this relationship in sub-Saharan Africa (SSA). We examined the relationship between health insurance coverage and maternal healthcare utilisation using demographic and health survey data.

METHODS

This was a cross-sectional study of 195 651 women aged 15-49 y from 28 countries in SSA. We adopted bivariable and multivariable analyses comprising χ2 test and multilevel binary logistic regression in analysing the data.

RESULTS

The prevalence of maternal healthcare utilisation was 58, 70.6 and 40.7% for antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC), respectively. The prevalence of health insurance coverage was 6.4%. Women covered by health insurance were more likely to utilise ANC (adjusted OR [aOR]=1.48, 95% CI 1.41 to 1.54), SBA (aOR=1.37, 95% CI 1.30 to 1.45) and PNC (aOR=1.42, 95% CI 1.37 to 1.48).

CONCLUSION

Health insurance coverage was an important predictor of maternal healthcare utilisation in our study. To accelerate progress towards the achievement of SDG 3 targets related to the reduction of maternal mortality and achievement of UHC, countries should adopt interventions to increase maternal insurance coverage, which may lead to higher maternal healthcare access and utilisation during pregnancy.

Inequalities in the prevalence of skilled birth attendance in Ghana between 1993 and 2014

BACKGROUND

Globally, maternal and neonatal health remains a public health priority, particularly for resource-constrained regions like sub-Saharan Africa (SSA). Skilled birth attendance (SBA) is essential in promoting maternal and neonatal health. This study investigated the inequalities in the prevalence of SBA in Ghana using data from the Ghana Demographic and Health Survey (GDHS) between 1993 and 2014.

METHODS

Data were analysed using the World Health Organization's Health Equity Assessment Toolkit software. In analysing the data, we first disaggregated SBA by four inequality stratifiers: wealth index, education, residence, and region. Second, we measured the inequality through summary measures, namely difference, population attributable risk, ratio, and population attributable fraction. A 95% confidence interval was constructed for point estimates to measure statistical significance.

RESULTS

Throughout the period, SBA was highest among women in the highest wealth quintile and those with a secondary or higher level of education. The analysis also indicated that SBA was highly concentrated among urban residents in 1993 (80.78 [95% uncertainty interval {UI} 76.20-84.66]) and persisted to 2014 (91.55 [95% UI 88.80-93.68]). In 1993, Northern region recorded the lowest prevalence of SBA in Ghana (15.69 [95% UI 11.20-21.54]) and the region consistently recorded the lowest SBA prevalence even into 2014 (38.21 [95% UI 27.44-50.27]).

CONCLUSIONS

There are significant inequalities in SBA across education, wealth, residence, and region in Ghana. To enhance SBA, there is the need for policymakers and interventionists to design and develop targeted policies and programs that are tailored to the needs of the subpopulations at risk of low SBA: women with no formal education, those within the poorest wealth quintile, rural-dwelling women and women in the Northern region. This will facilitate the uptake of SBA and ultimately translate into the realization of Sustainable Development Goals 3.1 and 3.2.

Understanding maternal choices and experiences of care by skilled providers: Voices of mothers who delivered at home in selected communities of Lusaka city, Zambia

Background

Significant proportions of women living in urban areas including the capital cities continue to deliver at home. We aimed to understand why mothers in a selected densely populated community of Lusaka city in Zambia deliver from home without assistance from a skilled provider during childbirth.

Methods

Using a phenomenological case study design, we conducted Focus Group Discussions and In-depth Interviews with mothers who delivered at home without assistance from a skilled provider. The study was conducted between November 2020 and January 2021 among 19 participants. Data were analysed using content analysis.

Results

Individual-related factors including the belief that childbirth is a natural and easy process that did not require assistance, lack of transport to get to the health facility, influence and preference for care from older women who were perceived to have the experience and better care, failure to afford baby supplies, and waiting for partner to provide the supplies that were required at the health facility influenced mothers' choices to seek care from skilled providers. Health system-related factors included mistreatment and disrespectful care such as verbal and physical abuse by skilled healthcare providers, stigma and discrimination, institutional fines, and guidelines such as need to attend antenatal care with a spouse and need to provide health facility demanded supplies.

Conclusion

Individual and health system access related factors largely drive the choice to involve skilled providers during childbirth. The socioeconomic position particularly contributes to limited decision-making autonomy of mothers, thus, creating challenges to accessing care in health facilities. The health system-related factors found in this study such as mistreatment and disrespectful care suggests the need for redesigning effective and sustainable urban resource-limited context maternal health strategies that are culturally acceptable, non-discriminatory, and locally responsive and inclusive. Rethinking these strategies this way has the potential to strengthening equitable responsive health systems that could accelerate attainment of sustainable developmental goal (SDG) 3 targets.

Evaluation of a WASH/MNCH targeted primary health care program in Uganda; a mixed methods study

Background

Evidence on the impact of Maternal Newborn and child health (MNCH) and Water, Sanitation and Hygiene (WASH) interventions on skilled birth attendance (SBA) and neonatal sepsis remains unclear. We conducted this study in Amuru district to generate evidence.

Methods

A before-and-after study design was conducted. Interventions implemented included; training of HCWs, construction of WASH facilities, and health education of communities. A digitized structured questionnaire was used to obtain data on ANC and SBA, WASH practices and prevalence of pneumonia and diarrhea among 466 expectant mothers and caretakers of under-fives at baseline, midterm and endline. Data on sepsis incidence, ANC, SBA and WASH status was obtained from six healthcare facilities. A total of 12 KIIs and 12 FGDs were conducted. Data were analyzed using STATA 15. Two sample tests of proportions were used to compare findings at baseline and endline. Qualitative data were analyzed using thematic content analysis.

Results

The number of women delivering at HCFs significantly increased from 41.4% to 63.0% (p < .0001). Incidence of neonatal sepsis reduced from 0.6% to 0.2% (p = .0687), although the difference was not significant. Community-level findings also indicated a decline in cases of water-borne illnesses; cases of dysentery decreased from 10.0% to 0.6%, cases of cholera decreased from 8.9% to 1.9% at endline, cases of typhoid decreased from 26.5% to 12.7% at endline.

Conclusion

This study revealed that integrated WASH/MNCH interventions can significantly increase ANC and SBA, reduce incidences of neonatal sepsis, diarrhea, pneumonia, and other related diseases and improve WASH practices in communities. Significant improvements in WASH/IPC and the capacity of HCWs to deliver safe MNCH services are realized.

Changes in Inequality in Use of Maternal Health Care Services: Evidence from Skilled Birth Attendance in Mauritania for the Period 2007-2015

Skilled birth attendance is critical to reduce infant and maternal mortality. Health development plans and strategies, especially in developing countries, consider equity in access to maternal health care services as a priority. This study aimed to measure and analyze the inequality in the use of skilled birth attendance services in Mauritania. The study identifies the inequality determinants and explores its changes over the period 2007−2015. The concentration curve, concentration index, decomposition of the concentration index, and Oaxaca-type decomposition technique were performed to measure socioeconomically-based inequalities in skilled birth attendance services utilization, and to identify the contribution of different determinants to such inequality as well as the changes in inequality overtime using data from Mauritania Multiple Indicator Cluster Surveys (MICS) 2007 and 2015. The concentration index for skilled birth attendance services use dropped from 0.6324 (p < 0.001) in 2007 to 0.5852 (p < 0.001) in 2015. Prenatal care, household wealth level, and rural−urban residence contributed most to socioeconomic inequality. The concentration index decomposition and the Oaxaca-type decomposition revealed that changes in prenatal care and rural−urban residence contributed positively to lower inequality, but household economic status had an opposite contribution. Clearly, the pro-rich inequality in skilled birth attendance is high in Mauritania, despite a slight decrease during the study period. Policy actions on eliminating geographical and socioeconomic inequalities should target increased access to skilled birth attendance. Multisectoral policy action is needed to improve social determinants of health and to remove health system bottlenecks. This will include the socioeconomic empowerment of women and girls, while enhancing the availability and affordability of reproductive and maternal health commodities. This policy action can be achieved through improving the availability of obstetric service providers in rural areas; ensuring better distribution and quality of health infrastructure, particularly health posts and health centers; and, ensuring user fees removal for equitable, efficient, and sustainable financial protection in line with the universal health coverage objectives.

Effect of Women's and Partners' Education on Maternal Health-care Services Utilization in Five Empowered Action Group States of India: An analysis of 13,443 Women of Reproductive Age

Background

Suboptimal utilization of maternal health-care services is a perennial problem in Empowered Action Group (EAG) states. This study examines role of women's and partners' education on usage of antenatal, postnatal care (PNC), and skilled birth attendance in these states.

Methodology

National Family Health Survey-4 (2015-2016) data for 13,443 women in reproductive age group of 15-49 years in Bihar, Madhya Pradesh (MP), Odisha, Rajasthan, and Uttar Pradesh (UP) were analyzed using logistic regression.

Results

Increasing level of education had a significant impact on utilization of antenatal services in all states, highest and lowest odds being observed with higher and primary level of partner's education, respectively. Skilled birth attendance universally showed rising trend with increasing women education, while it remained substantially low even at higher level of partner's education. For PNC, utilization increased with increasing level of maternal education. While significantly lower odds of PNC were seen with primary level of partner education in Rajasthan and UP, partner's secondary education showed positive and significant association in Bihar, Rajasthan, and UP. At higher level of partner education, positive and significant effects on PNC were observed only in Bihar, MP, and UP.

Conclusions

Universal education is vital to attain sustainable development goals at the grassroot level, which is happening relatively slowly in the EAG states.

Lived Experiences and Perceptions of Childbirth among Pastoralist Women in North-Eastern Ethiopia: A Multimethod Qualitative Analysis to the WHO Health Systems Responsiveness Framework

Maternity should be a time of hope and joy. However, for women in pastoralist communities in Ethiopia, the reality of motherhood is often grim. This problem is creating striking disparities of skilled birth uptake among the agrarian and pastoral communities in Ethiopia. So far, the depth and effects of the problem are not well understood. This study is intended to fill this research gap by exploring mothers’ lived experiences and perceptions during skilled birthing care in hard-to-reach communities of Ethiopia. An Interpretive Phenomenological approach was employed to analyse the exploratory data. Four key informant interviews, six in-depth interviews, six focus group discussions, and twelve focused observations were held. WHO responsiveness domains formed the basis for coding and analysis: dignity, autonomy, choice of provider, prompt attention, communication, social support, confidentiality, and quality of basic amenities. The skilled birthing experience of nomadic mothers is permeated by a deep-rooted and hidden perceived neglect, which constitutes serious challenges to the health system. Mothers’ experiences reflect not only the poor skilled delivery uptake, but also how health system practitioners are ignorant of Afar women’s way of life, their living contexts, and their values and beliefs regarding giving birth. Three major themes emerged from data analysis: bad staff attitude, lack of culturally acceptable care, and absence of social support. Nomadic mothers require health systems that are responsive and adaptable to their needs, beliefs, and values. The abuse and disrespect they experience from providers deter nomadic women from seeking skilled birthing care. Women’s right to dignified, respectful, skilled delivery care requires the promotion of woman-centred care in a culturally appropriate manner. Skilled birthing care providers should be cognizant of the WHO responsiveness domains to ensure the provision of culturally sensitive birthing care.

Utilization cost of maternity services for childbirth among pregnant women with coronavirus disease 2019 in Nigeria's epicenter

OBJECTIVE

To estimate utilization costs of spontaneous vaginal delivery (SVD) and cesarean delivery (CD) for pregnant women with coronavirus disease 2019 (COVID-19) at the largest teaching hospital in Lagos, the pandemic's epicenter in Nigeria.

METHODS

We collected facility-based and household costs of all nine pregnant women with COVID-19 managed at the hospital. We compared their mean facility-based costs with those paid by pregnant women pre-COVID-19, identifying cost-drivers. We also estimated what would have been paid without subsidies, testing assumptions with a sensitivity analysis.

RESULTS

Total utilization costs ranged from US $494 for SVD with mild COVID-19 to US $4553 for emergency CD with severe COVID-19. Though 32%-66% of facility-based cost were subsidized, costs of SVD and CD during the pandemic have doubled and tripled, respectively, compared with those paid pre-COVID-19. Of the facility-based costs, cost of personal protective equipment was the major cost-driver (50%). Oxygen was the major driver for women with severe COVID-19 (48%). Excluding treatment costs for COVID-19, mean facility-based costs were US $228 (SVD) and US $948 (CD).

CONCLUSION

Despite cost exemptions and donations, utilization costs remain prohibitive. Regulation of personal protective equipment and medical oxygen supply chains and expansion of advocacy for health insurance enrollments are needed in order to minimize catastrophic health expenditure.

Spatial inequalities in skilled attendance at birth in Ghana: a multilevel analysis integrating health facility databases with household survey data

Objective

This study aimed at using survey data to predict skilled attendance at birth (SBA) across Ghana from healthcare quality and health facility accessibility.

Methods

Through a cross-sectional, observational study, we used a random intercept mixed effects multilevel logistic modelling approach to estimate the odds of having SBA and then applied model estimates to spatial layers to assess the probability of SBA at high-spatial resolution across Ghana. We combined data from the Demographic and Health Survey (DHS), routine birth registers, a service provision assessment of emergency obstetric care services, gridded population estimates and modelled travel time to health facilities.

Results

Within an hour’s travel, 97.1% of women sampled in the DHS could access any health facility, 96.6% could reach a facility providing birthing services, and 86.2% could reach a secondary hospital. After controlling for characteristics of individual women, living in an urban area and close proximity to a health facility with high-quality services were significant positive determinants of SBA uptake. The estimated variance suggests significant effects of cluster and region on SBA as 7.1% of the residual variation in the propensity to use SBA is attributed to unobserved regional characteristics and 16.5% between clusters within regions.

Conclusion

Given the expansion of primary care facilities in Ghana, this study suggests that higher quality healthcare services, as opposed to closer proximity of facilities to women, is needed to widen SBA uptake and improve maternal health.

Out-of-pocket expenditure for home and facility-based delivery among rural women in Zambia: a mixed-methods, cross-sectional study

Purpose

Out-of-pocket expenses associated with facility-based deliveries are a well-known barrier to health care access. However, there is extremely limited contemporary information on delivery-related household out-of-pocket expenditure in sub-Saharan Africa. We assess the financial burden of delivery for the most remote Zambian women and compare differences between delivery locations (primary health center, hospital, or home).

Methods

We conducted household surveys and in-depth interviews among randomly selected remote Zambian women who delivered a baby within the last 13 months. Women reported expenditures for their most-recent delivery for delivery supplies, transportation, and baby clothes, among others. Expenditures were converted to US dollars for analysis.

Results

Of 2280 women sampled, 2223 (97.5%) reported spending money on their delivery. Nearly all respondents in the sample (95.9%) spent money on baby clothes/blanket, while over 80% purchased delivery supplies such as disinfectant or cord clamps, and a third spent on transportation. Women reported spending a mean of USD28.76 on their delivery, with baby clothes/blanket (USD21.46) being the main expenditure and delivery supplies (USD3.81) making up much of the remainder. Compared to women who delivered at home, women who delivered at a primary health center spent nearly USD4 (p<0.001) more for their delivery, while women who delivered at a level 1 or level 2 hospital spent over USD7.50 (p<0.001) more for delivery.

Conclusion

These expenses account for approximately one third of the monthly household income of the poorest Zambian households. While the abolition of user fees has reduced the direct costs of delivering at a health facility for the poorest members of society, remote Zambian women still face high out-of-pocket expenses in the form of delivery supplies that facilities should provide as well as unofficial policies/norms requiring women to bring new baby clothes/blanket to a facility-based delivery. Future programs that target these expenses may increase access to facility-based delivery.

Are community health workers effective in retaining women in the maternity care continuum? Evidence from India

Objectives

Despite the recognised importance of adopting a continuum of care perspective in addressing the care of mothers and newborns, evidence on specific interventions to enhance engagement of women along the maternity care continuum has been limited. We use the example of the Accredited Social Health Activist (ASHA) programme in India, to understand the role of community health workers in retaining women in the maternity care continuum.

Methods

Using the Indian Human Development Survey data from 2011 to 2012, we assess the association between individual and cluster-level exposure to ASHA and four key components along the continuum of care—at least one antenatal care (ANC) visit, four or more ANC visits, presence of a skilled birth attendance (SBA) at the time of birth and postnatal care for the mother or child within 48 hours of birth, for 13 705 women with a live birth since 2005. To understand which of these services experience maximum dropout along the continuum, we use a linear probability model to calculate the weighted percentages of using each service. We assess the association between exposure to ASHA and number of services utilised using a multinomial logistic regression model adjusted for a range of confounding variables and survey weights.

Results

Our study indicates that exposure to the ASHA is associated with an increased probability of women receiving at least one ANC and SBA. In terms of numbers of services, exposure to ASHA accounts for a 12% (95% CI: 9.1 to 15.1) increase in women receiving at least some of the services, and an 8.8% (95% CI: −10.2 to −7.4) decrease in women receiving no services. However, exposure to ASHA does not increase the likelihood of women utilising all the services along the continuum.

Conclusions

While ASHA is effective in supporting women to initiate and continue care along the continuum, it does not significantly affect the completion of all services along the continuum.

The impact of maternal health care utilisation on routine immunisation coverage of children in Nigeria: a cross-sectional study

OBJECTIVE

To examine the impact of maternal healthcare (MHC) utilisation on routine immunisation coverage of children in Nigeria.

DESIGN

Individual level cross-sectional study using bivariate and multivariable logistic regression analyses to examine the association between MHC utilisation and routine immunisation coverage of children.

SETTING

Nigeria Demographic and Health Survey 2013.

PARTICIPANTS

5506 women aged 15-49 years with children aged 12-23 months born in the 5 years preceding the survey.

PRIMARY OUTCOME MEASURES

Fully immunised children and not fully immunised children.

RESULTS

The percentage of children fully immunised with basic routine childhood vaccines by the age of 12 months was 25.8%. Antenatal care (ANC) attendance irrespective of the number of visits (adjusted OR (AOR)_{1-3 visits} 2.4, 95% CI 1.79 to 3.27; AOR_{4-7 visits} 3.2, 95% CI 2.52 to 4.13; AOR_{≥ 8 visits} 3.5, 95% CI 2.64 to 4.50), skilled birth attendance (SBA) (AOR 1.9, 95% CI 1.65 to 2.35); and maternal postnatal care (PNC) (AOR 1.7, 95% CI 1.46 to 2.06) had positive effects on the child being fully immunised after adjusting for covariates (except for each other, ie, ANC, SBA and PNC). Further analyses (adjusting stepwise for each MHC service) showed a mediation effect that led to the effect of PNC not being significant.

CONCLUSIONS

The percentage of fully immunised children in Nigeria was very low. ANC attendance, SBA and maternal PNC attendance had positive impact on the child being fully immunised. The findings suggest that strategies aimed at maximising MHC utilisation in Nigeria could be effective in achieving the national coverage target of at least 80% for routine immunisation of children.

Opting for home birth in rural Bangladesh: An assessment of the current status and reasons

BACKGROUND

In Bangladesh, over half of women give birth at home, generally without the support of a skilled birth attendant. In this article, we examined the decision-making around birthplace and explored the reported reasons of preferring home birth over facility birth in a rural district of Bangladesh.

METHODS

A cross-sectional household survey with 1367 women was conducted in Brahmanbaria district. Choice of birthplace and actual place of birth were the main outcomes of interest. Associations between the outcomes of interest and background characteristics were analyzed through binary logistic regression. Effects of the covariates and confounders were adjusted through multiple logistic regression.

RESULTS

Sixty-four percent of women planned to give birth at home, and 62% gave birth at home. Planning to give birth at home was significantly associated with eventually giving birth at home (AOR [CI]: 4.93 [3.79-6.43]). Multiparous women and women from larger households were significantly more likely to give birth at home, whereas more educated and wealthier women and those attending antenatal care were significantly less likely to give birth at home. The main reported reasons for home birth were perceived lack of importance of facility birth, financial reasons, fear of cesarean section, and not being permitted by a husband of other family member to seek facility birth.

CONCLUSIONS

Home is the preferred birthplace and main actual place of birth in rural Bangladesh. The maternal health program of Bangladesh should look critically at the preferences of women and reasons for those preferences for further promotion of skilled attendance at birth in rural settings.

Determinants of antenatal care and skilled birth attendance in sub-Saharan Africa: A multilevel analysis

OBJECTIVE

To determine individual- and country-level determinants of utilization of key maternal health services in sub-Saharan Africa (SSA).

STUDY SETTING

We used the most recent standard demographic and health survey data from the period of 2005 to 2015 for 34 SSA countries. Predictors of key maternal health service indicators were determined using a sample of 245 178 women who had at least one live birth 5 years preceding the survey.

STUDY DESIGN

We used a two-level hierarchical model, considering individual predictors at level one and country factors at level two of the hierarchy.

PRINCIPAL FINDINGS

While the skilled birth attendance (SBA) utilization rate reached 53 percent during the study period, the recommended four or more antenatal care (ANC) coverage was commonly low with less significant differences among different groups of women and countries. Being in a middle-income country increased the individual-level association between ANC and SBA (OR = 2.34, 95% CI: 1.24, 4.44). Less privileged women with lower education level were less likely to receive maternal health services.

CONCLUSIONS

This study reveals the existence of wide gaps between ANC and SBA coverage in SSA. Urgent policy attention is required to improve access, utilization, and quality of maternal health services.

Knowledge and Skills of Ayurvedic and Homeopathic Practitioners to Provide Skilled Birth Attendance in India: An Observational Study

Background:

To overcome the dearth of trained skilled birth attendants, mainstreaming of doctors from the alternative systems of medicine has been adopted by some states in India.

Objectives:

The objectives of the study were to explore the adequacy of knowledge and clinical skills of AYUSH practitioners (APs) (ayurvedic and homeopathic) engaged by the state governments to provide maternity care services, with a view to identify gaps if any, and to suggest measures for improvement.

Materials and Methods:

A cross-sectional observational study was conducted in three states of India (Maharashtra, Rajasthan, and Odisha). The APs were assessed for (a) knowledge of essential obstetric care and identification and management of complications of pregnancy and (b) clinical skills during provision of antenatal and postnatal care (PNC) and during the conduct of deliveries. Adequate knowledge or skill demonstration was defined as a score of 70% or more.

Results:

A total of 109 APs engaged in 37 peripheral level facilities were assessed. Nearly 76% of APs had adequate theoretical knowledge of essential obstetric care and identification and management of complications of pregnancy. Most APs demonstrated adequate skills while providing antenatal care but were deficient in taking past history and counseling pregnant women for danger signs during pregnancy and childbirth. APs in Maharashtra and Rajasthan had adequate skills for conducting vaginal deliveries but performed poorly in Odisha. Skills for resuscitation of newborn were deficient. Skills for providing PNC were adequate only among APs in Maharashtra.

Conclusion:

Through provision of appropriate in-service training and an enabling environment, APs may be a useful human resource for providing maternity care in the primary health-care settings in India.

Labour & delivery monitoring patterns in facility births across five districts of India: A cross-sectional observational study

BACKGROUND & OBJECTIVES

India has recorded a marked increase in facility births due to government's conditional cash benefit scheme initiated in 2005. However, concerns have been raised regarding the need for improvement in the quality of care at facilities. Here we report the monitoring patterns during labour and delivery documented by direct observation in reference to the government's evidence-based guidelines on skilled birth attendance in five districts of India.

METHODS

A cross-sectional study design with multistage sampling was used for observation of labour and delivery processes of low-risk women with singleton pregnancy in five districts of the country. Trained research staff recorded the findings on pre-tested case record sheets.

RESULTS

A total of 1479 women were observed during active first stage of labour and delivery in 55 facilities. The overall frequency of monitoring of temperature, pulse and blood pressure was low at all facilities. The frequency of monitoring uterine contractions and foetal heart sounds was less than the expected norm, while the frequency of vaginal examinations was high at all levels of facilities. Partograph plotting was done in only 15.8 per cent deliveries, and labour was augmented in about half of the cases.

INTERPRETATION & CONCLUSIONS

The findings of our study point towards a need for improvement in monitoring of maternal and foetal parameters during labour and delivery in facility births and to improve adherence to government guidelines for skilled birth attendance.

Impact of maternity waiting homes on facility delivery among remote households in Zambia: protocol for a quasiexperimental, mixed-methods study

INTRODUCTION

Maternity waiting homes (MWHs) aim to improve access to facility delivery in rural areas. However, there is limited rigorous evidence of their effectiveness. Using formative research, we developed an MWH intervention model with three components: infrastructure, management and linkage to services. This protocol describes a study to measure the impact of the MWH model on facility delivery among women living farthest (≥10 km) from their designated health facility in rural Zambia. This study will generate key new evidence to inform decision-making for MWH policy in Zambia and globally.

METHODS AND ANALYSIS

We are conducting a mixed-methods quasiexperimental impact evaluation of the MWH model using a controlled before-and-after design in 40 health facility clusters. Clusters were assigned to the intervention or control group using two methods: 20 clusters were randomly assigned using a matched-pair design; the other 20 were assigned without randomisation due to local political constraints. Overall, 20 study clusters receive the MWH model intervention while 20 control clusters continue to implement the 'standard of care' for waiting mothers. We recruit a repeated cross section of 2400 randomly sampled recently delivered women at baseline (2016) and endline (2018); all participants are administered a household survey and a 10% subsample also participates in an in-depth interview. We will calculate descriptive statistics and adjusted ORs; qualitative data will be analysed using content analysis. The primary outcome is the probability of delivery at a health facility; secondary outcomes include utilisation of MWHs and maternal and neonatal health outcomes.

ETHICS AND DISSEMINATION

Ethical approvals were obtained from the Boston University Institutional Review Board (IRB), University of Michigan IRB (deidentified data only) and the ERES Converge IRB in Zambia. Written informed consent is obtained prior to data collection. Results will be disseminated to key stakeholders in Zambia, then through open-access journals, websites and international conferences.

TRIAL REGISTRATION NUMBER

NCT02620436; Pre-results.

The Role of Health Extension Workers in Linking Pregnant Women With Health Facilities for Delivery in Rural and Pastoralist Areas of Ethiopia

Background

Women's preference to give birth at home is deeply embedded in Ethiopian culture. Many women only go to health facilities if they have complications during birth. Health Extension Workers (HEWs) have been deployed to improve the utilization of maternal health services by bridging the gap between communities and health facilities. This study examined the barriers and facilitators for HEWs as they refer women to mid-level health facilities for birth.

Methods

A qualitative study was conducted in three regions: Afar Region, Southern Nations Nationalities and People's Region and Tigray Region between March to December 2014. Interviews and focus group discussions were conducted with 45 HEWs, 14 women extension workers (employed by Afar Pastoralist Development Association, Afar Region) and 11 other health workers from health centers, hospitals or health offices. Data analysis was done based on collating the data and identifying key themes.

Results

Barriers to health facilities included distance, lack of transportation, sociocultural factors and disrespectful care. Facilitators for facility-based deliveries included liaising with Health Development Army (HDA) leaders to refer women before their expected due date or if labour starts at home; the introduction of ambulance services; and, provision of health services that are culturally more acceptable for women.

Conclusion

HEWs can effectively refer more women to give birth in health facilities when the HDA is well established, when health staff provide respectful care, and when ambulance is available at any time.

Predictors of Antenatal Care, Skilled Birth Attendance, and Postnatal Care Utilization among the Remote and Poorest Rural Communities of Zambia: A Multilevel Analysis

Objective

Optimal utilization of maternal health-care services is associated with reduction of mortality and morbidity for both mothers and their neonates. However, deficiencies and disparity in the use of key maternal health services within most developing countries still persist. We examined patterns and predictors associated with the utilization of specific indicators for maternal health services among mothers living in the poorest and remote district populations of Zambia.

Methods

A cross-sectional baseline household survey was conducted in May 2012. A total of 551 mothers with children between the ages 0 and 5 months were sampled from 29 catchment areas in four rural and remote districts of Zambia using the lot quality assurance sampling method. Using multilevel modeling, we accounted for individual- and community-level factors associated with utilization of maternal health-care services, with a focus on antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC).

Results

Utilization rates of focused ANC, SBA, and PNC within 48 h were 30, 37, and 28%, respectively. The mother’s ability to take an HIV test and receiving test results and uptake of intermittent preventive treatment for malaria were positive predictors of focused ANC. Receiving ANC at least once from skilled personnel was a significant predictor of SBA and PNC within 48 h after delivery. Women who live in centralized rural areas were more likely to use SBA than those living in remote rural areas.

Conclusion

Utilization of maternal health services by mothers living among the remote and poor marginalized populations of Zambia is much lower than the national averages. Finding that women that receive ANC once from a skilled attendant among the remote and poorest populations are more likely to have a SBA and PNC, suggests the importance of contact with a skilled health worker even if it is just once, in influencing use of services. Therefore, it appears that in order for women in these marginalized communities to benefit from SBA and PNC, it is important for them to have at least one ANC provided by a skilled personnel, rather than non-skilled health-care providers.

Inequality trends in maternal health services for young Ghanaian women with childbirth history between 2003 and 2014

OBJECTIVE

To achieve universal coverage of reproductive healthcare and drastic reduction in maternal mortality, adequate attention and resources should be given to young women. This study therefore aimed to examine the inequality trends in the use of antenatal care (ANC) services and skilled birth attendance (SBA) within a subgroup of Ghanaian women aged 15-24 years between 2003 and 2014.

DESIGN

This is a cross-sectional study that used data from the Ghana Demographic and Health Surveys (DHS) 2003, 2008 and 2014. We applied regression-based total attributable fraction (TAF) as an index for measuring multiple dimensions of inequality in the use of ANC and SBA.

SETTING

Ghana.

PARTICIPANTS

Young women aged 15-24 years with at least one previous birth experience in the past 5 years prior to the surveys.

MAIN OUTCOME MEASURES

ANC visits and skilled attendance at birth.

RESULTS

Urbanicity-related, education-related and wealth-related inequality in non-use of SBA declined between 2003 and 2008, but increased between 2008 and 2014. A consistent decline was observed in urbanicity-related inequality in non-use of four or more ANC visits from 2003 through 2008 to 2014. A similar reduction was observed for education-related inequality in relation to the same outcome. In contrast, wealth-related inequality in ANC usage increased over time.

CONCLUSIONS

The rise in urbanicity-related, education-related and wealth-related inequality in the usage of SBA between 2008 and 2014 threatens the sustainability of the general progress made in the usage of maternal health services in Ghana within the same period.

Factors that hinder or enable maternal health strategies to reduce delays in rural and pastoralist areas in Ethiopia

OBJECTIVES

To document factors that hinder or enable strategies to reduce the first and second delays of the Three Delays in rural and pastoralist areas in Ethiopia.

METHODS

A key informant study was conducted with 44 Health Extension Workers in Afar Region, Kafa Zone (Southern Nation, Nationalities and Peoples' Region), and Adwa Woreda (Tigray Region). Health Extension Workers were trained to interview women and ask for stories about their recent experiences of birth. We interviewed the Health Extension Workers about their experiences referring women for Skilled Birth Attendance and Emergency Obstetric and Newborn Care. Data were analysed using thematic analysis.

RESULTS

Themes related to reducing the first delay, such as the tradition of home birth, decision-making, distance and unavailability of transport, did not differ between the three locations. Themes related to reducing the second delay differed substantially. Health Extension Workers in Adwa Woreda were more likely to call ambulances due to support from the Health Development Army and a functioning referral system. In Kafa Zone, some Health Extension Workers were discouraged from calling ambulances as they were used for other purposes. In Afar Region, few Health Extension Workers were called to assist women as most women give birth at home with Traditional Birth Attendants unless they need to travel to health facilities for Emergency Obstetric and Newborn Care.

CONCLUSIONS

Initiatives to reduce delays can improve access to maternal health services, especially when Health Extension Workers are supported by the Health Development Army and a functioning referral system, but district (woreda) health offices should ensure that ambulances are used as intended.

The Differential Impact of User-Fee Exemption Compared to Conditional Cash Transfers on Safe Deliveries in Nepal

OBJECTIVE

To assess the differential impact of a copayment exemption compared to a cash incentive on increasing skilled birth attendance (i.e., birth attended by a skilled health worker) in Nepal.

DATA SOURCES/STUDY SETTING

This study used data on 8,785 children born between July 2005 and December 2008, obtained from the nationally representative Demographic and Health Surveys, 2006 and 2011.

STUDY DESIGN

Twenty-five districts received both the policy interventions, and the remaining 50 control districts received only the cash incentive. We employed a difference-in-differences model to compare children born in districts with both interventions to those in districts with conditional cash transfers only. Average marginal effects of the difference-in-difference coefficient on skilled birth attendance measures are estimated.

PRINCIPAL FINDINGS

Skilled birth attendance in districts with both interventions was no higher on average than in districts with only the cash incentive. In areas with adequate road networks, however, significantly higher skilled birth attendance was observed in districts with both interventions compared to those with only the cash incentive.

CONCLUSIONS

The added incentive of the user-fee exemption did not significantly increase skilled birth attendance relative to the presence of the cash incentive. User-fee exemptions may not be effective in areas with inadequate road infrastructure.

The Relationship between Facility-Based Delivery and Infant Immunization in sub-Saharan Africa

This study explored the relationship between facility-based delivery and infant immunizations in sub-Saharan Africa, controlling for economic development indicators. Publically available data were collected and imported into Stata 11.0 for descriptive, correlation, and regression analyses. Facility delivery was significantly associated with full vaccination and BCG immunization in children aged 12-23 months. Facility delivery was associated with full vaccination (p<.019), even after controlling for antenatal care usage, Gross National Income per capita, percent of the country's population residing in an urban setting, and percent of the population with at least a secondary education (β: 0.45 (95% CI: 0.08 - 0.81)). The relationship between facility delivery and immunization is significant, and robust enough to remain after controlling for economic and social indicators linked to both. These results suggest the benefits of facility delivery transcend the immediate survival benefit for mothers and their babies, and may serve as a gateway to further interactions with the healthcare system.

Bypassing Primary Care Facilities for Childbirth: Findings from a Multilevel Analysis of Skilled Birth Attendance Determinants in Afghanistan

INTRODUCTION

The objective of this study was to assess the association between health facility characteristics and other individual/household factors with a woman's likelihood of skilled birth attendance in north-central Afghanistan.

METHODS

Data from a 2010 household survey of 6879 households in 9 provinces of Afghanistan were linked to routine facility data. Hierarchical logistic regression models were used to assess determinants of skilled birth attendance.

RESULTS

Women who reported having at least one antenatal visit with a skilled provider were 5.6 times more likely to give birth with a skilled attendant than those who did not. The odds of skilled birth attendance were 84% higher for literate women than those without literacy skills and 79% higher among women in the upper 2 wealth quintiles than women in the poorest quintile. This study did not show any direct linkages between facility characteristics and skilled birth attendance but provided insights into why studies assuming that women seek care at the nearest primary care facility may lead to misinterpretation of care-seeking patterns. Findings reveal a 36 percentage point gap between women who receive skilled antenatal care and those who received skilled birth care. Nearly 60% of women with a skilled attendant at their most recent birth bypassed the nearest primary care facility to give birth at a more distant primary care facility, hospital, or private clinic. Distance and transport barriers were reported as the most common reasons for home birth.

DISCUSSION

Assumptions that women who give birth with a skilled attendant do so at the closest health facility may mask the importance of supply-side determinants of skilled birth attendance. More research based on actual utilization patterns, not assumed catchment areas, is needed to truly understand the factors influencing care-seeking decisions in both emergency and nonemergency situations and to adapt strategies to reduce preventable mortality and morbidity in Afghanistan.

Context matters: Successes and challenges of intrapartum care scale-up in four districts of Afghanistan

Reducing preventable maternal mortality and achieving Sustainable Development Goal targets for 2030 will require increased investment in improving access to quality health services in fragile and conflict-affected states. This study explores the conditions that affect availability and utilisation of intrapartum care services in four districts of Afghanistan where mortality studies were conducted in 2002 and 2011. Information on changes in each district was collected through interviews with community members; service providers; and district, provincial and national officials. This information was then triangulated with programme and policy documentation to identify factors that affect the coverage of safe delivery and emergency obstetric care services. Comparison of barriers to maternal health service coverage across the four districts highlights the complexities of national health policy planning and resource allocation in Afghanistan, and provides examples of the types of challenges that must be addressed to extend the reach of life-saving maternal health interventions to women in fragile and conflict-affected states. Findings suggest that improvements in service coverage must be measured at a sub-national level, and context-specific service delivery models may be needed to effectively scale up intrapartum care services in extremely remote or insecure settings.

Effect of a policy to reduce user fees on the rate of skilled birth attendance across socioeconomic strata in Burkina Faso

BACKGROUND

In Sub-Saharan Africa, maternal and neonatal morbidity and mortality rates are associated with underutilization of skilled birth attendance (SBA). In 2007, Burkina Faso introduced a subsidy scheme for SBA fees. The objective of this study was to evaluate the effect of Burkina Faso's subsidy policy on SBA rate across socioeconomic status (SES) strata.

METHODS

We used a quasi-experimental design. The data sources were two representative surveys (n = 1408 and n = 1403) of women from Houndé and Ziniaré health districts of Burkina Faso, and a survey of health centres assessing structural quality of care. Multilevel Poisson regression models were used with robust variance estimators. We estimated adjusted rate ratios (RR) and rate differences (RD) as a function of time and SES.

RESULTS

For lowest-SES women, immediately upon the introduction of the subsidy policy, the rate of SBA was 45% higher (RR = 1.45, 95% confidence interval (CI): 1.19-1.77) than expected in the absence of subsidy introduction. The results indicated a sustained effect after introduction of the subsidy policy, based on RR estimate (95% CI) of 1.48 (1.21-1.81) at 2 years. For middle-SES women, the RR estimates were 1.28 (1.09-1.49) immediately after introduction of the subsidy policy and 1.30 (1.11-1.51) at 2 years, respectively. For highest-SES women, the RR estimates were 1.19 (1.02-1.38) immediately after subsidy introduction and 1.21 (1.06-1.38) at 2 years, respectively. The RD (95% CI) was 14% (3-24%) for lowest-SES women immediately after introduction of the policy, and the effect was sustained at 14% (4-25%) at 2 years.

CONCLUSION

Our study suggests that the introduction of a user-fee subsidy in Burkina Faso resulted in increased rates of SBA across all SES strata. The increase was sustained over time and strongest among the poorest women. These findings have important implications for evidence-informed policy making in Burkina Faso and other countries in Sub-Saharan Africa.

Home birth without skilled attendants despite millennium villages project intervention in Ghana: insight from a survey of women's perceptions of skilled obstetric care

BACKGROUND

Skilled birth attendance from a trained health professional during labour and delivery can prevent up to 75% of maternal deaths. However, in low- and middle-income rural communities, lack of basic medical infrastructure and limited number of skilled birth attendants are significant barriers to timely obstetric care. Through analysis of self-reported data, this study aimed to assess the effect of an intervention addressing barriers in access to skilled obstetric care and identified factors associated with the use of unskilled birth attendants during delivery in a rural district of Ghana.

METHODS

A cross-sectional survey was conducted from June to August 2012 in the Amansie West District of Ghana among women of reproductive age. Multi-stage, random, and population proportional techniques were used to sample 50 communities and 400 women for data collection. Weighted multivariate logistic regression analysis was used to identify factors associated with place of delivery.

RESULTS

A total of 391 mothers had attended an antenatal care clinic at least once for their most recent birth; 42.3% of them had unskilled deliveries. Reasons reported for the use of unskilled birth attendants during delivery were: insults from health workers (23.5%), unavailability of transport (21.9%), and confidence in traditional birth attendants (17.9%); only 7.4% reported to have had sudden labour. Other factors associated with the use of unskilled birth attendants during delivery included: lack of partner involvement aOR = 0.03 (95% CI; 0.01, 0.06), lack of birth preparedness aOR = 0.05 (95% CI; 0.02, 0.13) and lack of knowledge of the benefits of skilled delivery aOR = 0.37 (95% CI; 0.11, 1.20).

CONCLUSIONS

This study demonstrated the importance of provider-client relationship and cultural sensitivity in the efforts to improve skilled obstetric care uptake among rural women in Ghana.

Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study

To evaluate the effectiveness of decentralizing ambulatory reproductive and intrapartum services to increase rates of antenatal care (ANC) utilization and skilled attendance at birth (SAB) in Rwanda. A prospective cohort study was implemented with one control and two intervention sites: decentralized ambulatory reproductive healthcare and decentralized intrapartum care. Multivariate logistic regression analysis was performed with primary outcome of lack of SAB and secondary outcome of ≥3 ANC visits. 536 women were entered in the study. Distance lived from delivery site significantly predicted SAB (p = 0.007), however distance lived to ANC site did not predict ≥3 ANC visits (p = 0.81). Neither decentralization of ambulatory reproductive healthcare (p = 0.10) nor intrapartum care (p = 0.40) was significantly associated with SAB. The control site had the greatest percentage of women receive ≥3 ANC visits (p < 0.001). Receiving <3 ANC visits was associated with a 3.98 times greater odds of not having SAB (p = 0.001). No increase in adverse outcomes was found with decentralization of ambulatory reproductive health care or intrapartum care. The factors that predict utilization of physically accessible services in rural Africa are complex. Decentralization of services may be one strategy to increase rates of SAB and ANC utilization, but selection biases may have precluded accurate analysis. Efforts to increase ANC utilization may be a worthwhile investment to increase SAB.

Does the Janani Suraksha Yojana cash transfer programme to promote facility births in India ensure skilled birth attendance? A qualitative study of intrapartum care in Madhya Pradesh

BACKGROUND

Access to facility delivery in India has significantly increased with the Janani Suraksha Yojana (JSY) cash transfer programme to promote facility births. However, a decline in maternal mortality has only followed secular trends as seen from the beginning of the decade well before the programme began. We, therefore, examined the quality of intrapartum care provided in facilities under the JSY programme to study whether it ensures skilled attendance at birth.

DESIGN

1) Non-participant observations (n=18) of intrapartum care during vaginal deliveries at a representative sample of 11 facilities in Madhya Pradesh to document what happens during intrapartum care. 2) Interviews (n=10) with providers to explore reasons for this care. Thematic framework analysis was used.

RESULTS

Three themes emerged from the data: 1) delivery environment is chaotic: delivery rooms were not conducive to safe, women-friendly care provision, and coordination between providers was poor. 2) Staff do not provide skilled care routinely: this emerged from observations that monitoring was limited to assessment of cervical dilatation, lack of readiness to provide key elements of care, and the execution of harmful/unnecessary practices coupled with poor techniques. 3) Dominant staff, passive recipients: staff sometimes threatened, abused, or ignored women during delivery; women were passive and accepted dominance and disrespect. Attendants served as 'go-betweens' patients and providers. The interviews with providers revealed their awareness of the compromised quality of care, but they were constrained by structural problems. Positive practices were also observed, including companionship during childbirth and women mobilising in the early stages of labour.

CONCLUSIONS

Our observational study did not suggest an adequate level of skilled birth attendance (SBA). The findings reveal insufficiencies in the health system and organisational structures to provide an 'enabling environment' for SBA. We highlight the need to ensure quality obstetric care prior to increasing coverage of facility births if cash transfer programmes like the JSY are to improve health outcomes.

Insights in public health: a tale of two polities: health in Independent and American Samoa

Independent and American Samoa have a shared cultural, genetic, ethnolinguistic, and historical background but have been politically separated since 1899. In this essay, we examine the health of these two polities and identify two key health patterns that have emerged even as American Samoa has achieved a higher per capita income than Independent Samoa. Whereas the gender gap in life expectancy at birth has narrowed in Independent Samoa, this gap has not narrowed in American Samoa and its male life expectancy now lags behind that of Independent Samoa. Neonatal mortality rates in American Samoa are slightly higher than in Independent Samoa. These patterns may be linked to the higher rates of obesity and urbanization observed in American Samoa compared to Independent Samoa, as well as the differing political and institutional arrangements of the two polities. Limited data remains a persistent challenge to conducting analysis of public health in the Pacific islands, particularly in American Samoa.

Factors associated with delivery outside a health facility: cross-sectional study in rural Malawi

OBJECTIVE

To identify factors associated with delivery outside a health facility in rural Malawi.

METHOD

A cross-sectional survey was conducted in Balaka, Dedza, Mchinji and Ntcheu districts in Malawi in 2013 among women who had completed a pregnancy 12 months prior to the day of the survey. Multilevel logistic regression was used to assess factors associated with delivery outside a facility.

RESULTS

Of the 1812 study respondents, 9% (n = 159) reported to have delivered outside a facility. Unmarried women were significantly more likely [OR = 1.88; 95% CI (1.086-3.173)] to deliver outside a facility, while women from households with higher socio-economic status [third-quartile OR = 0.51; 95% CI (0.28-0.95) and fourth-quartile OR = 0.48; 95% CI (0.29-0.79)] and in urban areas [OR = 0.39; 95%-CI (0.23-0.67)] were significantly less likely to deliver outside a facility. Women without formal education [OR 1.43; 95% CI (0.96-2.14)] and multigravidae [OR = 1.14; 95% CI (0.98-1.73)] were more likely to deliver outside a health facility at 10% level of significance.

CONCLUSION

About 9% of women deliver outside a facility. Policies to encourage facility delivery should not only focus on health systems but also be multisectoral to address women's vulnerability and inequality. Facility-based delivery can contribute to curbing the high maternal illness burden if authorities provide incentives to those not delivering at the facility without losing existing users.

The effect of community maternal and newborn health family meetings on type of birth attendant and completeness of maternal and newborn care received during birth and the early postnatal period in rural Ethiopia

INTRODUCTION

Maternal and newborn deaths occur predominantly in low-resource settings. Community-based packages of evidence-based interventions and skilled birth attendance can reduce these deaths. The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) used community-level health workers to conduct prenatal Community Maternal and Newborn Health family meetings to build skills and care-seeking behaviors among pregnant women and family caregivers.

METHODS

Baseline and endline surveys provided data on a random sample of women with a birth in the prior year. An intention-to-treat analysis, plausible net effect calculation, and dose-response analysis examined increases in completeness of care (mean percentage of 17 maternal and newborn health care elements performed) over time and by meeting participation. Regression models assessed the relationship between meeting participation, completeness of care, and use of skilled providers or health extension workers for birth care-controlling for sociodemographic and health service utilization factors.

RESULTS

A 151% increase in care completeness occurred from baseline to endline. At endline, women who participated in 2 or more meetings had more complete care than women who participated in fewer than 2 meetings (89% vs 76% of care elements; P < .001). A positive dose-response relationship existed between the number of meetings attended and greater care completeness (P < .001). Women with any antenatal care were nearly 3 times more likely to have used a skilled provider or health extension worker for birth care. Women who had additionally attended 2 or more meetings with family members were over 5 times as likely to have used these providers, compared to women without antenatal care and who attended fewer than 2 meetings (odds ratio, 5.19; 95% confidence interval, 2.88-9.36; P < .001).

DISCUSSION

MaNHEP's family meetings complemented routine antenatal care by engaging women and family caregivers in self-care and care-seeking, resulting in greater completeness of care and more highly skilled birth care.

Trends in delivery with no one present in Nigeria between 2003 and 2013

PURPOSE

Skilled attendance at birth is a proven intervention to improve maternal and newborn health outcomes. Unfortunately, in Nigeria there are many women who give birth alone, with no one present (NOP). The purpose of this study was to document trends in women delivering with NOP between 2003 and 2013, and to identify the characteristics of women who are engaging in this risky practice.

METHODS

We utilized pooled data sets from the 2003, 2008, and 2013 Nigerian Demographic and Health Surveys. Married women, who had given birth in the 5 years before each survey were included, resulting in a sample size of 38,949 women. We used logistic regression to assess the unadjusted and adjusted odds of a woman delivering with NOP over time, by socio-demographic characteristics.

RESULTS

Prevalence of delivery with NOP in Nigeria declined by 30% between 2003 and 2013. The largest declines occurred in Sokoto State, where the number of women giving birth with NOP declined by almost 100% between 2003 and 2013. In the North West of the country, however, there was a 27% increase in the number of women giving birth alone over this time period. Older, poorer, less educated, higher parity, Muslim women residing in the Northern regions were significantly more likely to give birth with NOP. Women, who were involved in decisions surrounding their own health, and who had accessed antenatal care were significantly less likely to give birth with NOP.

CONCLUSION

Although there have been improvements in Nigeria's Maternal Mortality Ratio since 1990, recent estimates suggest a stagnation in this trend. One reason for this protracted decline may be lack of access to skilled delivery care. The 2013 national prevalence of Nigerian women giving birth with NOP was 14%, equivalent to over 1 million births in 2013. Nigeria must implement interventions to ensure every woman's timely access to, and use of skilled care to reduce preventable maternal mortality and morbidity.

Trends in health facility deliveries and caesarean sections by wealth quintile in Morocco between 1987 and 2012

OBJECTIVES

To examine trends in the utilisation of facility-based delivery care and caesareans in Morocco between 1987 and 2012, particularly among the poor, and to assess whether uptake increased at the time of introduction of policies or programmes aimed at improving access to intrapartum care.

METHODS

Using data from nationally representative household surveys and routine statistics, our analysis focused on whether women delivered within a facility, and whether the delivery was by caesarean; analyses were stratified by relative wealth quintile and public/private sector where possible. A segmented Poisson regression model was used to assess whether trends changed at key events.

RESULTS

Uptake of facility-based deliveries and caesareans in Morocco has risen considerably over the past two decades, particularly among the poor. The rate of increase in facility deliveries was much faster in the poorest quintile (annual increase RR: 1.09; 95% CI: 1.07-1.11) than the richest quintile (annual increase RR: 1.01; 95% CI: 1.02-1.02). A similar pattern was observed for caesareans (annual increase among poorest RR: 1.13; 95% CI: 1.07-1.19 vs. annual increase among richest RR: 1.08; 95% CI: 1.06-1.10). We found no significant acceleration in trend coinciding with any of the events investigated.

CONCLUSIONS

Morocco's success in improving uptake of facility deliveries and caesareans is likely to be the result of the synergistic effects of comprehensive demand and supply-side strategies, including a major investment in human resources and free delivery care. Equity still needs to be improved; however, the overall trend is positive.

Factors associated with maternal healthcare services utilization in nine high focus states in India: a multilevel analysis based on 14 385 communities in 292 districts

BACKGROUND

Studies have often ignored examining the role of community- and district-level factors in the utilization of maternity healthcare services, particularly in Indian contexts. The Social Determinants of Health framework emphasizes the role of governance and government policies, the measures for which are rarely incorporated in single-level individual analysis. This study examines factors associated with maternal healthcare utilization in nine high focus states in India, which shares more than half of the total maternal deaths in the country; accounting for individual-, household-, community- and district-level characteristics.

METHODS

The required data are extracted from the third round of the nationally representative District Level Household and Facility Survey conducted during 2007-08. Multilevel analyses were applied to three maternity outcomes, namely, four or more antenatal care visits, skilled birth attendance and post-natal care after birth.

FINDINGS

Results show that along with individual-/household-level factors, community and district-level factors influence the pattern of utilization of maternal healthcare services significantly. At the community level, the odds of maternal healthcare utilization were lower in rural areas and in communities with a high concentration of poor and illiterate women. Moreover, the average population coverage of primary health centres (PHCs), availability of labour room in PHC and percentage of registered pregnancies were significant factors at the district level that influenced the use of maternity care services. The study also found a strong association between the extent of previous use of maternal healthcare and its effect on subsequent usage patterns.

CONCLUSION

This study highlights the role of strengthening public health infrastructure at district level in the study area, and promoting awareness about available healthcare services and subsidized schemes in the community. To reach out to rural and underprivileged communities and to apply a participatory approach from the programme officials are issues to delve into.

Inequity in maternal health care service utilization in Gujarat: analyses of district-level health survey data

Background

Two decades after the launch of the Safe Motherhood campaign, India still accounts for at least a quarter of maternal death globally. Gujarat is one of the most economically developed states of India, but progress in the social sector has not been commensurate with economic growth. The purpose of this study was to use district-level data to gain a better understanding of equity in access to maternal health care and to draw the attention of the policy planers to monitor equity in maternal care.

Methods

Secondary data analyses were performed among 7,534 ever-married women who delivered since January 2004 in the District Level Household and Facility Survey (DLHS-3) carried out during 2007–2008 in Gujarat, India. Based on the conceptual framework designed by the Commission on the Social Determinants of Health, associations were assessed between three outcomes – Institutional delivery, antenatal care (ANC), and use of modern contraception – and selected intermediary and structural determinants of health using multiple logistic regression.

Results

Inequities in maternal health care utilization persist in Gujarat. Structural determinants like caste group, wealth, and education were all significantly associated with access to the minimum three antenatal care visits, institutional deliveries, and use of any modern method of contraceptive. There is a significant relationship between being poor and access to less utilization of ANC services independent of caste category or residence.

Discussion and conclusions

Poverty is the most important determinant of non-use of maternal health services in Gujarat. In addition, social position (i.e. caste) has a strong independent effect on maternal health service use. More focused and targeted efforts towards these disadvantaged groups needs to be taken at policy level in order to achieve targets and goals laid out as per the MDGs. In particular, the Government of Gujarat should invest more in basic education and infrastructural development to begin to remove the structural causes of non-use of maternal health services.

Are community midwives addressing the inequities in access to skilled birth attendance in Punjab, Pakistan? Gender, class and social exclusion

BACKGROUND

Pakistan is one of the six countries estimated to contribute to over half of all maternal deaths worldwide. To address its high maternal mortality rate, in particular the inequities in access to maternal health care services, the government of Pakistan created a new cadre of community-based midwives (CMW). A key expectation is that the CMWs will improve access to skilled antenatal and intra-partum care for the poor and disadvantaged women. A critical gap in our knowledge is whether this cadre of workers, operating in the private health care context, will meet the expectation to provide care to the poorest and most marginalized women. There is an inherent paradox between the notions of fee-for-service and increasing access to health care for the poorest who, by definition, are unable to pay.

METHODS/DESIGN

Data will be collected in three interlinked modules. Module 1 will consist of a population-based survey in the catchment areas of the CMW's in districts Jhelum and Layyah in Punjab. Proportions of socially excluded women who are served by CMWs and their satisfaction levels with their maternity care provider will be assessed. Module 2 will explore, using an institutional ethnographic approach, the challenges (organizational, social, financial) that CMWs face in providing care to the poor and socially marginalized women. Module 3 will identify the social, financial, geographical and other barriers to uncover the hidden forces and power relations that shape the choices and opportunities of poor and marginalized women in accessing CMW services. An extensive knowledge dissemination plan will facilitate uptake of research findings to inform positive developments in maternal health policy, service design and care delivery in Pakistan.

DISCUSSION

The findings of this study will enhance understanding of the power dynamics of gender and class that may underlie poor women's marginalization from health care systems, including community midwifery care. One key outcome will be an increased sensitization of the special needs of socially excluded women, an otherwise invisible group. Another expectation is that the poor, socially excluded women will be targeted for provision of maternity care. The research will support the achievement of the 5th Millennium Development Goal in Pakistan.

Maternal health: a case study of Rajasthan

This case study has used the results of a review of literature to understand the persistence of poor maternal health in Rajasthan, a large state of north India, and to make some conclusions on reasons for the same. The rate of reduction in Rajasthan's maternal mortality ratio (MMR) has been slow, and it has remained at 445 per 1000 livebirths in 2003. The government system provides the bulk of maternal health services. Although the service infrastructure has improved in stages, the availability of maternal health services in rural areas remains poor because of low availability of human resources, especially midwives and clinical specialists, and their non-residence in rural areas. Various national programmes, such as the Family Planning, Child Survival and Safe Motherhood and Reproductive and Child Health (phase 1 and 2), have attempted to improve maternal health; however, they have not made the desired impact either because of an earlier emphasis on ineffective strategies, slow implementation as reflected in the poor use of available resources, or lack of effective ground-level governance, as exemplified by the widespread practice of informally charging users for free services. Thirty-two percent of women delivered in institutions in 2005-2006. A 2006 government scheme to give financial incentives for delivering in government institutions has led to substantial increase in the proportion of institutional deliveries. The availability of safe abortion services is limited, resulting in a large number of informal abortion service providers and unsafe abortions, especially in rural areas. The recent scheme of Janani Suraksha Yojana provides an opportunity to improve maternal and neonatal health, provided the quality issues can be adequately addressed.