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Palmer T, Leiva Granados R, Draper C, Norris SA, Batura N. Cost-effectiveness of a complex continuum of care intervention targeting women and children: protocol for an economic evaluation of the Bukhali trial in South Africa. BMJ Open 2024; 14:e080166. [PMID: 38740501 PMCID: PMC11097888 DOI: 10.1136/bmjopen-2023-080166] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 04/26/2024] [Indexed: 05/16/2024] Open
Abstract
INTRODUCTION As nearly two-thirds of women presenting at their first antenatal visit are either overweight or obese in urban South Africa, the preconception period is an opportunity to optimise health and offset transgenerational risk of both obesity and non-communicable diseases. This protocol describes the planned economic evaluation of an individually randomised controlled trial of a complex continuum of care intervention targeting women and children in Soweto, South Africa (Bukhali trial). METHODS AND ANALYSIS The economic evaluation of the Bukhali trial will be conducted as a within-trial analysis from both provider and societal perspectives. Incremental costs and health outcomes of the continuum of care intervention will be compared with standard care. The economic impact on implementing agencies (programme costs), healthcare providers, participants and their households will be estimated. Incremental cost-effectiveness ratios (ICERs) will be calculated in terms of cost per case of child adiposity at age years averted. Additionally, ICERs will also be reported in terms of cost per quality-adjusted life year gained. If Bukhali demonstrates effectiveness, we will employ a decision analytical model to examine the cost-effectiveness of the intervention over a child's lifetime. A Markov model will be used to estimate long-term health benefits, healthcare costs and cost-effectiveness. Probabilistic sensitivity analyses will be conducted to explore uncertainty and ensure robust results. An analysis will be conducted to assess the equity impact of the intervention, by comparing intervention impact within quintiles of socioeconomic status. ETHICS AND DISSEMINATION The Bukhali trial economic evaluation has ethical approval from the Human Ethics Research Committee of the University of the Witwatersrand, Johannesburg, South Africa (M240162). The results of the economic evaluation will be disseminated in a peer-reviewed journal and presented at a relevant international conference. TRIAL REGISTRATION NUMBER Pan African Clinical Trials Registry (PACTR201903750173871; https://pactr.samrc.ac.za).
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Affiliation(s)
- Tom Palmer
- Institute for Global Health, University College London, London, UK
| | | | - Catherine Draper
- MRC-Wits DPHRU, University of the Witwatersrand, Johannesburg, South Africa
| | - Shane A Norris
- MRC-Wits DPHRU, University of the Witwatersrand, Johannesburg, South Africa
- School of Human Development and Health, University of Southampton, Southampton, UK
| | - Neha Batura
- Institute for Global Health, University College London, London, UK
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Slomski A. Financial Vouchers Led to Higher Smoking Abstinence During Pregnancy. JAMA 2022; 328:2003. [PMID: 36413234 DOI: 10.1001/jama.2022.18484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Young N, Bowman A, Swedin K, Collins J, Blair-Stahn ND, Lindstedt PA, Troeger C, Flaxman AD. Cost-effectiveness of antenatal multiple micronutrients and balanced energy protein supplementation compared to iron and folic acid supplementation in India, Pakistan, Mali, and Tanzania: A dynamic microsimulation study. PLoS Med 2022; 19:e1003902. [PMID: 35192606 PMCID: PMC8863292 DOI: 10.1371/journal.pmed.1003902] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 01/04/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Malnutrition among women of childbearing age is especially prevalent in Asia and sub-Saharan Africa and can be harmful to the fetus during pregnancy. In the most recently available Demographic and Health Survey (DHS), approximately 10% to 20% of pregnant women in India, Pakistan, Mali, and Tanzania were undernourished (body mass index [BMI] <18.5 kg/m2), and according to the Global Burden of Disease (GBD) 2017 study, approximately 20% of babies were born with low birth weight (LBW; <2,500 g) in India, Pakistan, and Mali and 8% in Tanzania. Supplementing pregnant women with micro and macronutrients during the antenatal period can improve birth outcomes. Recently, the World Health Organization (WHO) recommended antenatal multiple micronutrient supplementation (MMS) that includes iron and folic acid (IFA) in the context of rigorous research. Additionally, WHO recommends balanced energy protein (BEP) for undernourished populations. However, few studies have compared the cost-effectiveness of different supplementation regimens. We compared the cost-effectiveness of MMS and BEP with IFA to quantify their benefits in 4 countries with considerable prevalence of maternal undernutrition. METHODS AND FINDINGS Using nationally representative estimates from the 2017 GBD study, we conducted an individual-based dynamic microsimulation of population cohorts from birth to 2 years of age in India, Pakistan, Mali, and Tanzania. We modeled the effect of maternal nutritional supplementation on infant birth weight, stunting and wasting using effect sizes from Cochrane systematic reviews and published literature. We used a payer's perspective and obtained costs of supplementation per pregnancy from the published literature. We compared disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs) in a baseline scenario with existing antenatal IFA coverage with scenarios where 90% of antenatal care (ANC) attendees receive either universal MMS, universal BEP, or MMS + targeted BEP (women with prepregnancy BMI <18.5 kg/m2 receive BEP containing MMS while women with BMI ≥18.5 kg/m2 receive MMS). We obtained 95% uncertainty intervals (UIs) for all outputs to represent parameter and stochastic uncertainty across 100 iterations of model runs. ICERs for all scenarios were lowest in Pakistan and greatest in Tanzania, in line with the baseline trend in prevalence of and attributable burden to LBW. MMS + targeted BEP averts more DALYs than universal MMS alone while remaining cost-effective. ICERs for universal MMS compared to baseline IFA were $52 (95% UI: $28 to $78) for Pakistan, $72 (95% UI: $37 to $118) for Mali, $70 (95% UI: $43 to $104) for India, and $253 (95% UI: $112 to $481) for Tanzania. ICERs for MMS + targeted BEP compared to baseline IFA were $54 (95% UI: $32 to $77) for Pakistan, $73 (95% UI: $40 to $104) for Mali, $83 (95% UI: $58 to $111) for India, and $245 (95% UI: $127 to $405) for Tanzania. Study limitations include generalizing experimental findings from the literature to our populations of interest and using population-level input parameters that may not reflect the heterogeneity of subpopulations. Additionally, our microsimulation fuses multiple sources of data and may be limited by data quality and availability. CONCLUSIONS In this study, we observed that MMS + targeted BEP averts more DALYs and remains cost-effective compared to universal MMS. As countries consider using MMS in alignment with recent WHO guidelines, offering targeted BEP is a cost-effective strategy that can be considered concurrently to maximize benefits and synergize program implementation.
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Affiliation(s)
- Nicole Young
- Institute for Health Metrics and Evaluation, Seattle, Washington, United States of America
- * E-mail:
| | - Alison Bowman
- Institute for Health Metrics and Evaluation, Seattle, Washington, United States of America
| | - Kjell Swedin
- Institute for Health Metrics and Evaluation, Seattle, Washington, United States of America
| | - James Collins
- Institute for Health Metrics and Evaluation, Seattle, Washington, United States of America
| | | | - Paulina A. Lindstedt
- Institute for Health Metrics and Evaluation, Seattle, Washington, United States of America
| | - Christopher Troeger
- Institute for Health Metrics and Evaluation, Seattle, Washington, United States of America
| | - Abraham D. Flaxman
- Institute for Health Metrics and Evaluation, Seattle, Washington, United States of America
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Abel L, Quaife M. A Pregnant Pause: Rethinking Economic Evaluation in Contraception and Pregnancy. Value Health 2022; 25:32-35. [PMID: 35031097 DOI: 10.1016/j.jval.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/03/2021] [Indexed: 06/14/2023]
Abstract
Pregnancy presents a unique challenge to economic evaluation, requiring methods that can account for both maternal and fetal outcomes. The ethical challenges to healthcare presented by pregnancy are well understood, but these have not yet been incorporated into cost-effectiveness approaches. Economic evaluations of pregnancy currently take an ad hoc approach to outcome valuation, opening the door to biased estimates and inconsistent resource allocation. We summarize the limitations of current economic evaluation methods and outline key areas for future work.
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Affiliation(s)
- Lucy Abel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UK.
| | - Matthew Quaife
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
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Eliason EL, Daw JR, Allen HL. Association of Medicaid vs Marketplace Eligibility on Maternal Coverage and Access With Prenatal and Postpartum Care. JAMA Netw Open 2021; 4:e2137383. [PMID: 34870677 PMCID: PMC8649838 DOI: 10.1001/jamanetworkopen.2021.37383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/09/2021] [Indexed: 11/25/2022] Open
Abstract
Importance Policy makers are considering insurance expansions to improve maternal health. The tradeoffs between expanding Medicaid or subsidized private insurance for maternal coverage and care are unknown. Objective To compare maternal coverage and care by Medicaid vs marketplace eligibility. Design, Setting, and Participants A retrospective cohort study using a difference-in-difference research design was conducted from March 14, 2020, to April 22, 2021. Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation. Participants included women aged 18 years or older from the 2011-2018 Pregnancy Risk Assessment Monitoring System survey. Exposures Eligibility for Medicaid or marketplace coverage under the Affordable Care Act. Main Outcomes and Measures Outcomes included coverage in the preconception and postpartum periods, early and adequate prenatal care, and postpartum checkups and effective contraceptive use. Results The study population included 11 432 women age 18 years and older (32% age 18-24 years, 33% age 25-29 years, 35% age ≥30 years) with incomes 100% to 138% FPL: 7586 in a Medicaid state (exposure group) and 3846 in a nonexpansion marketplace state (comparison group). Women in marketplace states were younger, had higher educational level and marriage rates, and had less racial and ethnic diversity. Medicaid relative to marketplace eligibility was associated with increased Medicaid coverage (20.3 percentage points; 95% CI, 12.8 to 30.0 percentage points), decreased private insurance coverage (-10.8 percentage points; 95% CI, -13.3 to -7.5 percentage points), and decreased uninsurance (-8.7 percentage points; 95% CI, -20.1 to -0.1 percentage points) in the preconception period, increased postpartum Medicaid (17.4 percentage points; 95% CI, 1.7 to 34.3 percentage points) and increased adequate prenatal care (4.4 percentage points; 95% CI, 0.1 to 11.0 percentage points) in difference-in-difference models. No evidence of significant differences in early prenatal care, postpartum check-ups, or postpartum contraception was identified. Conclusions and Relevance In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential importance of reducing financial barriers for the population with low incomes.
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Affiliation(s)
| | - Jamie R. Daw
- Columbia University Mailman School of Public Health, New York, New York
| | - Heidi L. Allen
- Columbia University School of Social Work, New York, New York
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Baatiema L, Tanle A, Darteh EKM, Ameyaw EK. Is quality maternal healthcare all about successful childbirth? Views of mothers in the Wa Municipality, Ghana. PLoS One 2021; 16:e0257401. [PMID: 34525128 PMCID: PMC8443026 DOI: 10.1371/journal.pone.0257401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction In spite of the countless initiatives of the Ghana government to improve the quality of maternal healthcare, Upper West Region still records poor childbirth outcomes. This study, therefore, explored women’s perception of the quality of maternal healthcare they receive in the Wa Municipality of the Upper West Region of Ghana. Materials and methods This is a qualitative cross-sectional study of 62 women who accessed maternal healthcare in the Wa Municipality of Ghana. We analysed the transcripts using the analytic inductive technique. An inter-coding technique (testing for inter-coding agreement) was employed. The iterative coding process resulted in a coding scheme with four main themes. We used peer-debriefing technique in ensuring credibility and trustworthiness. Results Logistics and equipment; referral service; empathic service delivery; inadequacy of care providers; affordability of service; satisfaction with services received; as well as experience and service delivery were the parameters used by the women in assessing quality maternity care. A number of gaps were reported in the healthcare system including limited healthcare providers, limited beds and inefficient referral system. Conversely, some of them reported that some healthcare providers offered empathetic healthcare. Contrary views were expressed with respect to satisfaction with maternity care. Conclusion Government and all stakeholders seeking to enhance quality of maternal health and accelerate the attainment of the third Sustainable Development Goal need to reconsider the financing of service delivery at health institutions. Indeed, our findings have illustrated that routine workshops on empathetic healthcare are required in efforts to increase the rate of facility-based childbirth, and thereby subside maternal mortality and all adverse pregnancy outcomes.
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Affiliation(s)
- Linus Baatiema
- Ghana Health Service, Upper West Regional Health Directorate, Wa, Ghana
- * E-mail:
| | - Augustine Tanle
- Department of Population and Health, College of Humanities and Legal Studies, University of Cape Coast, Cape Coast, Ghana
| | - Eugene Kofuor Maafo Darteh
- Department of Population and Health, College of Humanities and Legal Studies, University of Cape Coast, Cape Coast, Ghana
| | - Edward Kwabena Ameyaw
- Faculty of Health, The Australian Centre for Public and Population Health Research, University of Technology Sydney, Sydney, Australia
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Chingombe I, Mapingure MP, Balachandra S, Chipango TN, Gambanga F, Mushavi A, Apollo T, Suraratdecha C, Rogers JH, Ruangtragool L, Gonese E, Musuka GN, Mugurungi OM, Harris TG. Patient costs for prevention of mother-to-child HIV transmission and antiretroviral therapy services in public health facilities in Zimbabwe. PLoS One 2021; 16:e0256291. [PMID: 34407129 PMCID: PMC8372940 DOI: 10.1371/journal.pone.0256291] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 02/10/2021] [Accepted: 08/03/2021] [Indexed: 11/18/2022] Open
Abstract
Zimbabwe has made large strides in addressing HIV. To ensure a continued robust response, a clear understanding of costs associated with its HIV program is critical. We conducted a cross-sectional evaluation in 2017 to estimate the annual average patient cost for accessing Prevention of Mother-To-Child Transmission (PMTCT) services (through antenatal care) and Antiretroviral Treatment (ART) services in Zimbabwe. Twenty sites representing different types of public health facilities in Zimbabwe were included. Data on patient costs were collected through in-person interviews with 414 ART and 424 PMTCT adult patients and through telephone interviews with 38 ART and 47 PMTCT adult patients who had missed their last appointment. The mean and median annual patient costs were examined overall and by service type for all participants and for those who paid any cost. Potential patient costs related to time lost were calculated by multiplying the total time to access services (travel time, waiting time, and clinic visit duration) by potential earnings (US$75 per month assuming 8 hours per day and 5 days per week). Mean annual patient costs for accessing services for the participants was US$20.00 [standard deviation (SD) = US$80.42, median = US$6.00, range = US$0.00-US$12,18.00] for PMTCT and US$18.73 (SD = US$58.54, median = US$8.00, range = US$0.00-US$ 908.00) for ART patients. The mean annual direct medical costs for PMTCT and ART were US$9.78 (SD = US$78.58, median = US$0.00, range = US$0.00-US$ 90) and US$7.49 (SD = US$60.00, median = US$0.00) while mean annual direct non-medical cost for US$10.23 (SD = US$17.35, median = US$4.00) and US$11.23 (SD = US$25.22, median = US$6.00, range = US$0.00-US$ 360.00). The PMTCT and ART costs per visit based on time lost were US$3.53 (US$1.13 to US$8.69) and US$3.43 (US$1.14 to US$8.53), respectively. The mean annual patient costs per person for PMTCT and ART in this evaluation will impact household income since PMTCT and ART services in Zimbabwe are supposed to be free.
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Affiliation(s)
- Innocent Chingombe
- ICAP at Columbia University, New York, NY, United States of America
- * E-mail:
| | | | | | | | - Fiona Gambanga
- ICAP at Columbia University, New York, NY, United States of America
| | | | | | - Chutima Suraratdecha
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia United States of America
| | - John H. Rogers
- U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Leala Ruangtragool
- PHI/CDC Global HIV Surveillance Fellow, U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Elizabeth Gonese
- U.S. Centers for Disease Control and Prevention, Harare, Zimbabwe
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Rodriguez MI, Kaufman M, Lindner S, Caughey AB, DeFede AL, McConnell KJ. Association of Expanded Prenatal Care Coverage for Immigrant Women With Postpartum Contraception and Short Interpregnancy Interval Births. JAMA Netw Open 2021; 4:e2118912. [PMID: 34338791 PMCID: PMC8329738 DOI: 10.1001/jamanetworkopen.2021.18912] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE Access to prenatal and postpartum care is restricted among women with low income who are recent or undocumented immigrants enrolled in Emergency Medicaid. OBJECTIVE To examine the association of extending prenatal care coverage to Emergency Medicaid enrollees with postpartum contraception and short interpregnancy interval births. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a difference-in-differences design to compare the staggered rollout of prenatal care in Oregon with South Carolina, a state that does not cover prenatal or postpartum care. Linked Medicaid claims and birth certificate data from 2010 to 2016 were examined for an association between prenatal care coverage for women whose births were covered by Emergency Medicaid and subsequent short IPI births. Additional maternal and infant health outcomes were also examined, including postpartum contraceptive use, preterm birth, and neonatal intensive care unit admission. The association between the policy change and measures of policy implementation (number of prenatal visits) and quality of care (receipt of 8 guideline-based screenings) was also analyzed. Statistical analysis was performed from August 2020 to March 2021. EXPOSURES Medicaid coverage of prenatal care. MAIN OUTCOMES AND MEASURES Postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery; short IPI births, defined as occurring within 18 months of a previous pregnancy. RESULTS The study population consisted of 26 586 births to women enrolled in Emergency Medicaid in Oregon and South Carolina. Among these women, 14 749 (55.5%) were aged 25 to 35 years, 25 894 (97.4%) were Black, Hispanic, Native American, Alaskan, Pacific Islander, or Asian women or women with unknown race/ethnicity, and 17 905 (67.3%) lived in areas with urban zip codes. Coverage of prenatal care for women in Emergency Medicaid was associated with significant increases in mean (SD) prenatal visits (increase of 10.3 [0.9] prenatal visits) and prenatal quality. Prenatal care screenings (eg, anemia screening: increase of 65.7 percentage points [95% CI, 54.2 to 77.1 percentage points]) and vaccinations (eg, influenza vaccination: increase of 31.9 percentage points [95% CI, 27.4 to 36.3 percentage points]) increased significantly following the policy change. Although postpartum contraceptive use increased following prenatal care expansion (increase of 1.5 percentage points [95% CI, 0.4 to 2.6 percentage points]), the policy change was not associated with a reduction in short IPI births (-4.5 percentage points [95% CI, -9.5 to 0.5 percentage points), preterm births (-0.6 percentage points [95% CI, -3.2 to 2.0 percentage points]), or neonatal intensive care unit admissions (increase of 0.8 percentage points [95% CI, -2.0 to 3.6 percentage points]). CONCLUSIONS AND RELEVANCE This study found that expanding Emergency Medicaid benefits to include prenatal care significantly improved receipt of guideline-concordant prenatal care. Prenatal care coverage alone was not associated with a meaningful increase in postpartum contraception or a reduction in subsequent short IPI births.
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Affiliation(s)
- Maria I. Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Menolly Kaufman
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Stephan Lindner
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
| | - Aaron B. Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Ana Lopez DeFede
- Institute for Families in Society, University of South Carolina, Columbia
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland
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Rasella D, Alves FJO, Rebouças P, de Jesus GS, Barreto ML, Campello T, Paixao ES. Long-term impact of a conditional cash transfer programme on maternal mortality: a nationwide analysis of Brazilian longitudinal data. BMC Med 2021; 19:127. [PMID: 34059069 PMCID: PMC8166529 DOI: 10.1186/s12916-021-01994-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [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] [Received: 01/20/2021] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world's largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years. METHODS The study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004-2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables. RESULTS BFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81-0.95), 0.84 (0.75-0.96) and 0.83 (0.71-0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67-0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69-0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66-0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04-1.07). CONCLUSION Our findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.
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Affiliation(s)
- Davide Rasella
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
| | - Flávia Jôse Oliveira Alves
- Institute of Collective Health, Federal University of Bahia (UFBA), Salvador, Brazil
- Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Brazil
| | - Poliana Rebouças
- Institute of Collective Health, Federal University of Bahia (UFBA), Salvador, Brazil
- Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Brazil
| | | | - Maurício L Barreto
- Institute of Collective Health, Federal University of Bahia (UFBA), Salvador, Brazil
- Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Brazil
| | - Tereza Campello
- Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Brazil
- Future Food Beacon of Excellence, Centre for Research in Race and Rights, School of Biosciences, University of Nottingham, Nottingham, United Kingdom
| | - Enny S Paixao
- Center of Data and Knowledge Integration for Health (CIDACS), Instituto Gonçalo Muniz, Fundação Oswaldo Cruz (FIOCRUZ), Salvador, Brazil
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Enns JE, Nickel NC, Chartier M, Chateau D, Campbell R, Phillips-Beck W, Sarkar J, Burland E, Katz A, Santos R, Brownell M. An unconditional prenatal income supplement is associated with improved birth and early childhood outcomes among First Nations children in Manitoba, Canada: a population-based cohort study. BMC Pregnancy Childbirth 2021; 21:312. [PMID: 33879074 PMCID: PMC8059008 DOI: 10.1186/s12884-021-03782-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 01/28/2021] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Manitoba, Canada, low-income pregnant women are eligible for the Healthy Baby Prenatal Benefit, an unconditional income supplement of up to CAD $81/month, during their latter two trimesters. Our objective was to determine the impact of the Healthy Baby Prenatal Benefit on birth and early childhood outcomes among Manitoba First Nations women and their children. METHODS We used administrative data to identify low-income First Nations women who gave birth 2003-2011 (n = 8209), adjusting for differences between women who received (n = 6103) and did not receive the Healthy Baby Prenatal Benefit (n = 2106) with using propensity score weighting. Using multi-variable regressions, we compared rates of low birth weight, preterm, and small- and large-for-gestational-age births, 5-min Apgar scores, breastfeeding initiation, birth hospitalization length of stay, hospital readmissions, complete vaccination at age one and two, and developmental vulnerability in Kindergarten. RESULTS Women who received the benefit had lower risk of low birth weight (adjusted relative risk [aRR] 0.74; 95% CI 0.62-0.88) and preterm (aRR 0.77; 0.68-0.88) births, and were more likely to initiate breastfeeding (aRR 1.05; 1.01-1.09). Receipt of the Healthy Baby Prenatal Benefit was also associated with higher rates of child vaccination at age one (aRR 1.10; 1.06-1.14) and two (aRR 1.19; 1.13-1.25), and a lower risk that children would be vulnerable in the developmental domains of language and cognitive development (aRR 0.88; 0.79-0.98) and general knowledge/communication skills (aRR 0.87; 0.77-0.98) in Kindergarten. CONCLUSIONS A modest unconditional income supplement of CAD $81/month during pregnancy was associated with improved birth outcomes, increased vaccination rates, and better developmental health outcomes for First Nations children from low-income families.
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Affiliation(s)
- Jennifer E Enns
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada
| | - Nathan C Nickel
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada
| | - Mariette Chartier
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada
| | - Dan Chateau
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada
| | - Rhonda Campbell
- First Nations Health and Social Secretariat of Manitoba, Winnipeg, Canada
| | | | - Joykrishna Sarkar
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada
| | - Elaine Burland
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada
| | - Alan Katz
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Rob Santos
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada
| | - Marni Brownell
- Manitoba Centre for Health Policy, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Ave, Winnipeg, Manitoba, R3E 3P5, Canada.
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Lee H, Veliz PT, Ray ET, Chiboola NM, Phiri TK, Musonda G, Lori JR. Financial Preparedness for Birth Among Rural Zambian Women: Do Antenatal Care Contacts Make a Difference? Matern Child Health J 2020; 25:22-26. [PMID: 33222107 DOI: 10.1007/s10995-020-03043-w] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Financial constraints are one of the biggest barriers for women of low-income countries to receive necessary reproductive health services. Educating women about the importance of saving money has been incorporated as a component of antenatal care (ANC) contacts, but little is known whether ANC contacts influence women's saving. METHODS A secondary analysis was conducted on data from a cross-sectional household survey study of 1109 women who recently gave birth in two rural districts of Zambia. RESULTS Receiving ANC contacts early and often and discussing saving money during ANC were associated with saving money for the mother's birth, but not with saving enough money for the most recent birth. DISCUSSION Continued effort is needed to encourage women to attend ANC contacts earlier and more frequently. Additionally, the importance of saving money for birth should be discussed during ANC contacts. Future studies need to explore why women's action in saving does not necessarily lead to saving enough for childbirth.
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Affiliation(s)
- HaEun Lee
- School of Nursing, University of Michigan, 400 North Ingalls St, Ann Arbor, MI, 48109, USA.
| | - Philip T Veliz
- School of Nursing, University of Michigan, 400 North Ingalls St, Ann Arbor, MI, 48109, USA
| | - Earl T Ray
- Mercy, College of Health Professionals, University of Detroit, 4001 W. McNichols Road, Detroit, MI, 48221, USA
| | - Nchimunya M Chiboola
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road Ibex Hill, Box 33921, Lusaka, Zambia
| | - Tenford K Phiri
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road Ibex Hill, Box 33921, Lusaka, Zambia
| | - Gertrude Musonda
- Africare Zambia, Flat A, Plot 2407/10 MBX, Off Twin Palm Road Ibex Hill, Box 33921, Lusaka, Zambia
| | - Jody R Lori
- School of Nursing, University of Michigan, 400 North Ingalls St, Ann Arbor, MI, 48109, USA
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Awopegba OE, Kalu A, Ahinkorah BO, Seidu AA, Ajayi AI. Prenatal care coverage and correlates of HIV testing in sub-Saharan Africa: Insight from demographic and health surveys of 16 countries. PLoS One 2020; 15:e0242001. [PMID: 33166351 PMCID: PMC7652338 DOI: 10.1371/journal.pone.0242001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/26/2020] [Indexed: 11/19/2022] Open
Abstract
Background Prenatal screening of pregnant women for HIV is central to eliminating mother-to-child-transmission (MTCT) of HIV. While some countries in sub-Saharan Africa (SSA) have scaled up their prevention of MTCT programmes, ensuring a near-universal prenatal care HIV testing, and recording a significant reduction in new infection among children, several others have poor outcomes due to inadequate testing. We conducted a multi-country analysis of demographic and health surveys (DHS) to assess the coverage of HIV testing during pregnancy and also examine the factors associated with uptake. Methods We analysed data of 64,933 women from 16 SSA countries with recent DHS datasets (2015–2018) using Stata version 16. Adjusted and unadjusted logistic regression models were used to examine correlates of prenatal care uptake of HIV testing. Statistical significance was set at p<0.05. Results Progress in scaling up of prenatal care HIV testing was uneven across SSA, with only 6.1% of pregnant women tested in Chad compared to 98.1% in Rwanda. While inequality in access to HIV testing among pregnant women is pervasive in most SSA countries and particularly in West and Central Africa sub-regions, a few countries, including Rwanda, South Africa, Zimbabwe, Malawi and Zambia have managed to eliminate wealth and rural-urban inequalities in access to prenatal care HIV testing. Conclusion Our findings highlight the between countries and sub-regional disparities in prenatal care uptake of HIV testing in SSA. Even though no country has universal coverage of prenatal care HIV testing, East and Southern African regions have made remarkable progress towards ensuring no pregnant woman is left untested. However, the West and Central Africa regions had low coverage of prenatal care testing, with the rich and well educated having better access to testing, while the poor rarely tested. Addressing the inequitable access and coverage of HIV testing among pregnant women is vital in these sub-regions.
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Affiliation(s)
- Oluwafemi Emmanuel Awopegba
- Economics and Business Policy Department, Nigerian Institute of Social and Economic Research, Ibadan, Nigeria
| | - Amarachi Kalu
- Department of Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria
| | - Bright Opoku Ahinkorah
- The Australian Centre for Public and Population Health Research (ACPPHR), Faculty of Health, University of Technology, Sydney, Australia
| | - Abdul-Aziz Seidu
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia
| | - Anthony Idowu Ajayi
- Population Dynamics and Reproductive Health Unit, African Population and Health Research Centre, APHRC Campus, Nairobi, Kenya
- * E-mail:
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13
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van Montfort P, Scheepers HCJ, Dirksen CD, van Dooren IMA, van Kuijk SMJ, Meertens LJE, Wijnen EJ, Zelis M, Zwaan IM, Spaanderman MEA, Smits LJM. Impact on perinatal health and cost-effectiveness of risk-based care in obstetrics: a before-after study. Am J Obstet Gynecol 2020; 223:431.e1-431.e18. [PMID: 32112732 DOI: 10.1016/j.ajog.2020.02.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/11/2020] [Accepted: 02/20/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Obstetric health care relies on an adequate antepartum risk selection. Most guidelines used for risk stratification, however, do not assess absolute risks. In 2017, a prediction tool was implemented in a Dutch region. This tool combines first trimester prediction models with obstetric care paths tailored to the individual risk profile, enabling risk-based care. OBJECTIVE To assess impact and cost-effectiveness of risk-based care compared to care-as-usual in a general population. METHODS A before-after study was conducted using 2 multicenter prospective cohorts. The first cohort (2013-2015) received care-as-usual; the second cohort (2017-2018) received risk-based care. Health outcomes were (1) a composite of adverse perinatal outcomes and (2) maternal quality-adjusted life-years. Costs were estimated using a health care perspective from conception to 6 weeks after the due date. Mean costs per woman, cost differences between the 2 groups, and incremental cost effectiveness ratios were calculated. Sensitivity analyses were performed to evaluate the robustness of the findings. RESULTS In total 3425 women were included. In nulliparous women there was a significant reduction of perinatal adverse outcomes among the risk-based care group (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-0.94), but not in multiparous women. Mean costs per pregnant woman were significantly lower for risk-based care (mean difference, -€2766; 95% confidence interval, -€3700 to -€1825). No differences in maternal quality of life, adjusted for baseline health, were observed. CONCLUSION In the Netherlands, risk-based care in nulliparous women was associated with improved perinatal outcomes as compared to care-as-usual. Furthermore, risk-based care was cost-effective compared to care-as-usual and resulted in lower health care costs.
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Affiliation(s)
- Pim van Montfort
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Carmen D Dirksen
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ivo M A van Dooren
- Department of Obstetrics and Gynecology, Sint Jans Gasthuis Weert, Weert, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Linda J E Meertens
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Ella J Wijnen
- Department of Obstetrics and Gynecology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Maartje Zelis
- Department of Obstetrics and Gynecology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Iris M Zwaan
- Department of Obstetrics and Gynecology, Laurentius Hospital, Roermond, The Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Luc J M Smits
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Baral R, Fleming J, Khan S, Higgins D, Hendrix N, Pecenka C. Inferring antenatal care visit timing in low- and middle-income countries: Methods to inform potential maternal vaccine coverage. PLoS One 2020; 15:e0237718. [PMID: 32817688 PMCID: PMC7446781 DOI: 10.1371/journal.pone.0237718] [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: 02/18/2020] [Accepted: 08/01/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The timing of antenatal care (ANC) visits directly affect health intervention coverage and impact, especially for those interventions requiring strict gestational age windows for administration, such as maternal respiratory syncytial virus (RSV) vaccine. Existing nationally representative population-based surveys do not record the timing of ANC visits beyond the first, limiting the availability of reliable data around timing of subsequent ANC visits in most low- and middle-income countries (LMICs). Here, we describe a model that estimates the timing of ANC visits by gestational age using publicly available multi-country survey data. METHODS AND FINDINGS We used the Demographic and Health Surveys (DHS) data from 69 LMICs. We used several factors to estimate the timing of subsequent ANC visits by gestation age: the timing of the first ANC visit (ANC1) in a given pregnancy, derived from the DHS; the country's reported average ANC coverage at each ANC visit (ANC1 through the fourth ANC visit [ANC4]); and the World Health Organization's guidance on recommended ANC visit. We then used the timing of ANC visit by gestation age to predict the coverage of a potential maternal RSV vaccine administered at 24-36 weeks of gestation. We calculated the maternal immunization coverage by summing the number of eligible women vaccinated at any ANC visit divided by the total number of pregnant women. We find, in general, countries with higher ANC1 coverage were predicted to have higher vaccination coverage. In 82% of countries, the modeled vaccine coverage is less than ANC4 coverage. CONCLUSIONS The methods illustrated in this paper have implications on the precision of estimating impact and programmatic feasibility of time-critical interventions, especially for pregnant women. The methods can be easily adapted to vaccine demand forecasts models, vaccine impact assessments, and cost-effectiveness analyses and can be adapted to other maternal interventions that have administration timing restrictions.
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Affiliation(s)
- Ranju Baral
- PATH, Seattle, WA, United States of America
- * E-mail:
| | | | - Sadaf Khan
- PATH, Seattle, WA, United States of America
| | | | - Nathaniel Hendrix
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, United States of America
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Musyimi CW, Mutiso VN, Nyamai DN, Ebuenyi I, Ndetei DM. Suicidal behavior risks during adolescent pregnancy in a low-resource setting: A qualitative study. PLoS One 2020; 15:e0236269. [PMID: 32697791 PMCID: PMC7375578 DOI: 10.1371/journal.pone.0236269] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 01/30/2020] [Accepted: 07/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background Suicide is one of the most common causes of death among female adolescents. A greater risk is seen among adolescent mothers who become pregnant outside marriage and consider suicide as the solution to unresolved problems. We aimed to investigate the factors associated with suicidal behavior among adolescent pregnant mothers in Kenya. Methods A total of 27 Focus Group Discussions (FGDs) and 8 Key Informant Interviews (KIIs) were conducted in a rural setting (Makueni County) in Kenya. The study participants consisted of formal health care workers and informal health care providers (traditional birth attendants and community health workers), adolescent and adult pregnant and post-natal (up to six weeks post-delivery) women including first-time adolescent mothers, and caregivers (husbands and/or mothers-in-law of pregnant women) and local key opinion leaders. The qualitative data was analyzed using Qualitative Solution for Research (QSR) NVivo version 10. Results Five themes associated with suicidal behavior risk among adolescent mothers emerged from this study. These included: (i) poverty, (ii) intimate partner violence (IPV), (iii) family rejection, (iv) social isolation and stigma from the community, and (v) chronic physical illnesses. Low economic status was associated with hopelessness and suicidal ideation. IPV was related to drug abuse (especially alcohol) by the male partner, predisposing the adolescent mothers to suicidal ideation. Rejection by parents and isolation by peers at school; and diagnosis of a chronic illness such as HIV/AIDS were other contributing factors to suicidal behavior in adolescent mothers. Conclusion Improved social relations, economic and health circumstances of adolescent mothers can lead to reduction of suicidal behaviour. Therefore, concerted efforts by stakeholders including family members, community leaders, health care workers and policy makers should explore ways of addressing IPV, economic empowerment and access to youth friendly health care centers for chronic physical illnesses. Prevention strategies should include monitoring for suicidal behavior risks during pregnancy in both community and health care settings. Additionally, utilizing lay workers in conducting dialogue discussions and early screening could address some of the risk factors and reduce pregnancy- related suicide mortality in LMICs.
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Affiliation(s)
| | | | - Darius N. Nyamai
- Africa Mental Health Research and Training Foundation, Nairobi, Kenya
| | - Ikenna Ebuenyi
- Department of Psychology and Assisting Living and Learning Institute, Maynooth University, Maynooth, Ireland
| | - David M. Ndetei
- Africa Mental Health Research and Training Foundation, Nairobi, Kenya
- University of Nairobi, Nairobi, Kenya
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Ochoa-Moreno I, Bautista-Arredondo S, McCoy SI, Buzdugan R, Mangenah C, Padian NS, Cowan FM. Costs and economies of scale in the accelerated program for prevention of mother-to-child transmission of HIV in Zimbabwe. PLoS One 2020; 15:e0231527. [PMID: 32433715 PMCID: PMC7239451 DOI: 10.1371/journal.pone.0231527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 06/27/2019] [Accepted: 03/25/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Despite a growing body of literature on HIV service costs in sub-Saharan Africa, only a few studies have estimated the facility-level cost of prevention of Mother-to-Child Transmission (PMTCT) services, and even fewer provide insights into the variation of PMTCT costs across facilities. In this study, we present the first empirical costs estimation of the accelerated program for the prevention of mother-to-child transmission of HIV in Zimbabwe and investigate the determinants of heterogeneity of the facility-level average cost per service. To understand such variation, we explored the association between average costs per service and supply-and demand-side characteristics, and quality of services. One aspect of the supply-side we explore carefully is the scale of production-which we define as the annual number of women tested or the yearly number of HIV-positive women on prophylaxis. METHODS We collected rich data on the costs and PMTCT services provided by 157 health facilities out of 699 catchment areas in five provinces in Zimbabwe for 2013. In each health facility, we measured total costs and the number of women covered with PMTCT services and estimated the average cost per woman tested and the average cost per woman on either ARV prophylaxis or ART. We refer to these facility-level average costs per service as unitary costs. We also collected information on potential determinants of the variation of unitary costs. On the supply-side, we gathered data on the scale of production, staff composition and on the types of antenatal and family planning services provided. On the demand side, we measured the total population at the catchment area and surveyed eligible pairs of mothers and infants about previous use of HIV testing and prenatal care, and on the HIV status of both mothers and infants. We explored the determinants of unitary cost variation using a two-stage linear regression strategy. RESULTS The average annual total cost of the PMTCT program per facility was US$16,821 (median US$8,920). The average cost per pregnant woman tested was US$80 (median US$47), and the average cost per HIV-positive pregnant woman initiated on ARV prophylaxis or treatment was US$786 annually (median US$420). We found substantial heterogeneity of unitary costs across facilities regardless of facility type. The scale of production was a strong predictor of unitary costs variation across facilities, with a negative and statistically significant correlation between the two variables (p<0.01). CONCLUSIONS These findings are the first empirical estimations of PMTCT costs in Zimbabwe. Unitary costs were found to be heterogeneous across health facilities, with evidence consistent with economies of scale.
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Affiliation(s)
- I. Ochoa-Moreno
- National Institute of Public Health, Cuernavaca, Mexico
- University of York, York, England, United Kingdom
| | - S. Bautista-Arredondo
- National Institute of Public Health, Cuernavaca, Mexico
- University of California, Berkeley, California, United States of America
| | - S. I. McCoy
- University of California, Berkeley, California, United States of America
| | - R. Buzdugan
- University of California, Berkeley, California, United States of America
| | - C. Mangenah
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | - N. S. Padian
- University of California, Berkeley, California, United States of America
| | - F. M. Cowan
- Liverpool School of Tropical Medicine, Liverpool, England, United Kingdom
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Blakeney EL, Herting JR, Zierler BK, Bekemeier B. The effect of women, infant, and children (WIC) services on birth weight before and during the 2007-2009 great recession in Washington state and Florida: a pooled cross-sectional time series analysis. BMC Pregnancy Childbirth 2020; 20:252. [PMID: 32345244 PMCID: PMC7189643 DOI: 10.1186/s12884-020-02937-5] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 04/13/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been shown to have positive effects in promoting healthy birth outcomes in the United States. We explored whether such effects held prior to and during the most recent Great Recession to improve birth outcomes and reduce differences among key socio-demographic groups. METHODS We used a pooled cross-sectional time series design to study pregnant women and their infants with birth certificate data. We included Medicaid and uninsured births from Washington State and Florida (n = 226,835) before (01/2005-03/2007) and during (12/2007-06/2009) the Great Recession. Interactions between WIC enrollment and key socio-demographic groupings were analyzed for binary and continuous birth weight outcomes. RESULTS Our study found beneficial WIC interaction effects on birth weight. For race, prenatal care, and maternal age we found significantly better birth weight outcomes in the presence of WIC compared to those without WIC. For example, being Black with WIC was associated with an increase in infant birth weight of 53.5 g (baseline) (95% CI = 32.4, 74.5) and 58.0 g (recession) (95% CI = 27.8, 88.3). For most groups this beneficial relationship was stable over time. CONCLUSIONS This paper supports previous research linking maternal utilization of WIC services during pregnancy to improved birth weight (both reducing LBW and increasing infant birth weight in grams) among some high-disadvantage groups. WIC appears to have been beneficial at decreasing disparity gaps in infant birth weight among the very young, Black, and late/no prenatal care enrollees in this high-need population, both before and during the Great Recession. Gaps are still present among other social and demographic characteristic groups (e.g., for unmarried mothers) for whom we did not find WIC to be associated with any detectable value in promoting better birth weight outcomes. Future research needs to examine how WIC (and/or other maternal and child health programs) could be made to work better and reach farther to address persistent disparities in birth weight outcomes. Additionally, in preparation for future economic downturns it will be important to determine how to preserve and, if possible, expand WIC services during times of increased need. TRIAL REGISTRATION Not applicable, this article reports only on secondary retrospective data (no health interventions with human participants were carried out).
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Affiliation(s)
- Erin L. Blakeney
- Department of Behavioral Nursing and Health Informatics, School of Nursing, University of Washington, Box # 357266, Seattle, WA 98195 USA
| | - Jerald R. Herting
- Department of Sociology, University of Washington, Box 353340, Seattle, WA 98195 USA
| | - Brenda Kaye Zierler
- Department of Behavioral Nursing and Health Informatics, School of Nursing, University of Washington, Box # 357266, Seattle, WA 98195 USA
| | - Betty Bekemeier
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Box # 357263, Seattle, WA 98195 USA
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Van De Griend KM, Billings DL, Frongillo EA, Hilfinger Messias DK, Crockett AH, Covington-Kolb S. Core strategies, social processes, and contextual influences of early phases of implementation and statewide scale-up of group prenatal care in South Carolina. Eval Program Plann 2020; 79:101760. [PMID: 31835150 DOI: 10.1016/j.evalprogplan.2019.101760] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 09/23/2019] [Accepted: 11/20/2019] [Indexed: 06/10/2023]
Abstract
This mixed-methods process evaluation examined a state-wide, interagency collaborative in South Carolina that expanded CenteringPregnancy group prenatal care from two to five additional healthcare practices from 2012 to 2015. The evaluation focused on delineating core processes, strategies, and external contextual elements of group prenatal care implementation and scale-up. Success of this scale-up was enhanced by the effective use and creation of windows of opportunity, which allowed stakeholders to pursue actions consistent with their own values, at both state and organizational levels. Most importantly, strong political advocacy and state-level financial commitment for group prenatal care made it possible for clinics throughout South Carolina to begin providing CenteringPregnancy to their patients. Improved understanding of the processes involved in scaling-up pilot interventions may enhance the effectiveness and efficiency of future expansion efforts.
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Affiliation(s)
- Kristin M Van De Griend
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, United States.
| | - Deborah L Billings
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, United States
| | - Edward A Frongillo
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, United States
| | | | - Amy H Crockett
- University of South Carolina School of Medicine Greenville, Prisma Health-Upstate, United States
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Dennis ML, Benova L, Goodman C, Barasa E, Abuya T, Campbell OMR. Examining user fee reductions in public primary healthcare facilities in Kenya, 1997-2012: effects on the use and content of antenatal care. Int J Equity Health 2020; 19:35. [PMID: 32171320 PMCID: PMC7073011 DOI: 10.1186/s12939-020-1150-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 09/24/2019] [Accepted: 02/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2004, The Kenyan government removed user fees in public dispensaries and health centers and replaced them with registration charges of 10 and 20 Kenyan shillings (2004 $US 0.13 and $0.25), respectively. This was termed the 10/20 policy. We examined the effect of this policy on the coverage, timing, source, and content of antenatal care (ANC), and the equity in these outcomes. METHODS Data from the 2003, 2008/9 and 2014 Kenya Demographic and Health Surveys were pooled to investigate women's ANC care-seeking. We conducted an interrupted time series analysis to assess the impact of the 10/20 policy on the levels of and trends in coverage for 4+ ANC contacts among all women; early ANC initiation and use of public facility-based care among 1+ ANC users; and use of public primary care facilities and receipt of good content, or quality, of ANC among users of public facilities. All analyses were conducted at the population level and separately for women with higher and lower household wealth. RESULTS The policy had positive effects on use of 4+ ANC among both better-off and worse-off women. Among users of 1+ ANC, the 10/20 policy had positive effects on early ANC initiation at the population-level and among better-off women, but not among the worse-off. The policy was associated with reduced use of public facility-based ANC among better-off women. Among worse-off users of public facility-based ANC, the 10/20 policy was associated with reduced use of primary care facilities and increased content of ANC. CONCLUSIONS This study highlights mixed findings on the impact of the 10/20 policy on ANC service-seeking and content of care. Given the reduced use of public facilities among the better-off and of primary care facilities among the worse-off, this research also brings into question the mechanisms through which the policy achieved any benefits and whether reducing user fees is sufficient for equitably increasing healthcare access.
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Affiliation(s)
- Mardieh L Dennis
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK.
| | - Lenka Benova
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Catherine Goodman
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Oona M R Campbell
- Faculty of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Levin CE, Self JL, Kedera E, Wamalwa M, Hu J, Grant F, Girard AW, Cole DC, Low JW. What is the cost of integration? Evidence from an integrated health and agriculture project to improve nutrition outcomes in Western Kenya. Health Policy Plan 2019; 34:646-655. [PMID: 31504504 PMCID: PMC6880337 DOI: 10.1093/heapol/czz083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Accepted: 08/01/2019] [Indexed: 11/12/2022] Open
Abstract
Integrated nutrition and agricultural interventions have the potential to improve the efficiency and effectiveness of investments in food security and nutrition. This article aimed to estimate the costs of an integrated agriculture and health intervention (Mama SASHA) focused on the promotion of orange-fleshed sweet potato (OFSP) production and consumption in Western Kenya. Programme activities included nutrition education and distribution of vouchers for OFSP vines during antenatal care and postnatal care (PNC) visits. We used expenditures and activity-based costing to estimate the financial costs during programme implementation (2011-13). Cost data were collected from monthly expense reports and interviews with staff members from all implementing organizations. Financial costs totalled US$507 809 for the project period. Recruiting and retaining women over the duration of their pregnancy and postpartum period required significant resources. Mama SASHA reached 3281 pregnant women at a cost of US$155 per beneficiary. Including both pregnant women and infants who attended PNC services with their mothers, the cost was US$110 per beneficiary. Joint planning, co-ordination and training across sectors drove 27% of programme costs. This study found that the average cost per beneficiary to implement an integrated agriculture, health and nutrition programme was substantial. Planning and implementing less intensive integrated interventions may be possible, and economies of scale may reduce overall costs. Empirical estimates of costs by components are critical for future planning and scaling up of integrated programmes.
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Affiliation(s)
- Carol E Levin
- Department of Global Health, University of Washington, NJB Box #359931, 325 Ninth Avenue, Seattle, WA, USA
| | - Julie L Self
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, USA
| | | | | | - Jia Hu
- Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, ON, Canada
| | | | - Amy Webb Girard
- Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, USA
| | - Donald C Cole
- Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, ON, Canada
| | - Jan W Low
- International Potato Center, Nairobi, Kenya
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Blakeney EL, Herting JR, Bekemeier B, Zierler BK. Social determinants of health and disparities in prenatal care utilization during the Great Recession period 2005-2010. BMC Pregnancy Childbirth 2019; 19:390. [PMID: 31664939 PMCID: PMC6819461 DOI: 10.1186/s12884-019-2486-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 08/30/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Early, regular prenatal care utilization is an important strategy for improving maternal and infant health outcomes. The purpose of this study is to better understand contributing factors to disparate prenatal care utilization outcomes among women of different racial/ethnic and social status groups before, during, and after the Great Recession (December 2007-June 2009). METHODS Data from 678,235 Washington (WA) and Florida (FL) birth certificates were linked to community and state characteristic data to carry out cross-sectional pooled time series analyses with institutional review board approval for human subjects' research. Predictors of on-time as compared to late or non-entry to prenatal care utilization (late/no prenatal care utilization) were identified and compared among pregnant women. Also explored was a simulated triadic relationship among time (within recession-related periods), social characteristics, and prenatal care utilization by clustering individual predictors into three scenarios representing low, average, and high degrees of social disadvantage. RESULTS Individual and community indicators of need (e.g., maternal Medicaid enrollment, unemployment rate) increased during the Recession. Associations between late/no prenatal care utilization and individual-level characteristics (including disparate associations among race/ethnicity groups) did not shift greatly with young maternal age and having less than a high school education remaining the largest contributors to late/no prenatal care utilization. In contrast, individual maternal enrollment in a supplemental nutrition program for women, infants, and children (WIC) exhibited a protective association against late/no prenatal care utilization. The magnitude of association between community-level partisan voting patterns and expenditures on some maternal child health programs increased in non-beneficial directions. Simulated scenarios show a high combined impact on prenatal care utilization among women who have multiple disadvantages. CONCLUSIONS Our findings provide a compelling picture of the important roles that individual characteristics-particularly low education and young age-play in late/no prenatal care utilization among pregnant women. Targeted outreach to individuals with high disadvantage characteristics, particularly those with multiple disadvantages, may help to increase first trimester entry to utilization of prenatal care. Finally, WIC may have played a valuable role in reducing late/no prenatal care utilization, and its effectiveness during the Great Recession as a policy-based approach to reducing late/no prenatal care utilization should be further explored.
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Affiliation(s)
- Erin L. Blakeney
- Department of Biobehavioral Nursing and Health Informatics, Center for Health Sciences Interprofessional Education, Research, and Practice (CHSIE), Seattle, USA
| | - Jerald R. Herting
- Department of Sociology, University of Washington, Box 353340, Seattle, WA 98195 USA
| | - Betty Bekemeier
- School of Nursing, University of Washington, UW Health Sciences Building, Box 357266, Seattle, WA 98195 USA
| | - Brenda K. Zierler
- Department of Biobehavioral Nursing and Health Informatics, Center for Health Sciences Interprofessional Education, Research, and Practice (CHSIE), Seattle, USA
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van den Heuvel JFM, Ganzevoort W, De Haan-Jebbink JM, van der Ham DP, Deurloo KL, Seeber L, Franx A, Bekker MN. HOspital care versus TELemonitoring in high-risk pregnancy (HOTEL): study protocol for a multicentre non-inferiority randomised controlled trial. BMJ Open 2019; 9:e031700. [PMID: 31662396 PMCID: PMC6830707 DOI: 10.1136/bmjopen-2019-031700] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 11/24/2022] Open
Abstract
INTRODUCTION Pregnant women faced with complications of pregnancy often require long-term hospital admission for maternal and/or fetal monitoring. Antenatal admissions cause a burden to patients as well as hospital resources and costs. A telemonitoring platform connected to wireless cardiotocography (CTG) and automated blood pressure (BP) devices can be used for telemonitoring in pregnancy. Home telemonitoring might improve autonomy and reduce admissions and thus costs. The aim of this study is to compare the effects on patient safety, satisfaction and cost-effectiveness of hospital care versus telemonitoring (HOTEL) as an obstetric care strategy in high-risk pregnancies requiring daily monitoring. METHODS AND ANALYSIS The HOTEL trial is an ongoing multicentre randomised controlled clinical trial with a non-inferiority design. Eligible pregnant women are >26+0 weeks of singleton gestation requiring monitoring because of pre-eclampsia (hypertension with proteinuria), fetal growth restriction, preterm rupture of membranes without contractions, recurrent reduced fetal movements or an intrauterine fetal death in a previous pregnancy.Randomisation takes place between traditional hospitalisation (planned n=208) versus telemonitoring (planned n=208) until delivery. Telemonitoring at home is facilitated with Sense4Baby CTG devices, Microlife BP monitor and daily telephone calls with an obstetric healthcare professional as well as weekly hospital visits.Primary outcome is a composite of adverse perinatal outcome, defined as perinatal mortality, 5 min Apgar <7 or arterial cord blood pH <7.05, maternal morbidity (eclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, thromboembolic event), neonatal intensive care admission and caesarean section rate. Patient satisfaction and preference of care will be assessed using validated questionnaires. We will perform an economic analysis. Outcomes will be analysed according to the intention to treat principle. ETHICS AND DISSEMINATION The study protocol was approved by the Ethics Committee of the Utrecht University Medical Center and the boards of all six participating centres. Trial results will be submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NTR6076.
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Affiliation(s)
| | - Wessel Ganzevoort
- Obstetrics and Gynaecology, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | | | | | - Koen L Deurloo
- Obstetrics and Gynaecology, Diakonessenhuis, Utrecht, The Netherlands
| | - Laura Seeber
- Obstetrics and Gynaecology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Arie Franx
- Obstetrics and Gynaecology, UMC Utrecht, Utrecht, The Netherlands
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Lang’at E, Mwanri L, Temmerman M. Effects of implementing free maternity service policy in Kenya: an interrupted time series analysis. BMC Health Serv Res 2019; 19:645. [PMID: 31492134 PMCID: PMC6729061 DOI: 10.1186/s12913-019-4462-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 08/26/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Maternal and perinatal mortality is a major public health concern across the globe and more so in low and middle-income countries. In Kenya, more than 6000 maternal deaths, and 35,000 stillbirths occur each year. The Government of Kenya abolished user fee for maternity care under the Free Maternity Service policy, in June of 2013 in all public health facilities, a move to make maternity services accessible and affordable, and to reduce maternal and perinatal mortality. METHOD An observational retrospective study was carried out in 3 counties in Kenya. Six maternal health output indicators were observed monthly, 2 years pre and 2 years post- policy implementation. Data was collected from daily maternity registers in 90 public health facilities across the 3 counties all serving an estimated population of 3 million people. Interrupted Time Series Analysis (ITSA) with a single group was used to assess the effects of the policy. Standard linear regression using generalized least squares (gls) model, was used to run the results for each of the six variables of interest. Absolute and relative changes were calculated using the gls model coefficients. RESULTS Significant sustained increase of 89, 97, and 98% was observed in the antenatal care visits, health facility deliveries, and live births respectively, after the policy implementation. An immediate and significant increase of 27% was also noted for those women who received Emergency Obstetric Care (EmONC) services in either the level 5, 4 and 3 health facilities. No significant changes were observed in the stillbirth rate and caesarean section rate following policy implementation. CONCLUSION After 2 years of implementing the Free Maternity Service policy in Kenya, immediate and sustained increase in the use of skilled care during pregnancy and childbirth was observed. The study suggest that hospital cost is a major expense incurred by most women and their families whilst seeking maternity care services and a barrier to maternity care utilization. Overall, Free Maternity Service policy, as a health financing strategy, has exhibited the potential of realizing the full beneficial effects of maternal morbidity and mortality reduction by increasing access to skilled care.
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Affiliation(s)
- Evaline Lang’at
- Department of Health, County Government of Kilifi, P. O Box 9-80108, Kilifi, Kenya
| | - Lillian Mwanri
- South Australia College of Medicine and Public Health, Flinders University, Flinders University Registry Road, Bedford Park, South Australia 5042 Australia
| | - Marleen Temmerman
- Director at Centre of Excellence in Women and Child Health, Aga Khan University, Aga Khan University Hospital, P.O. Box 30270-00100, Nairobi, Kenya
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Díaz JJ, Saldarriaga V. Encouraging use of prenatal care through conditional cash transfers: Evidence from JUNTOS in Peru. Health Econ 2019; 28:1099-1113. [PMID: 31394023 DOI: 10.1002/hec.3919] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 04/15/2019] [Accepted: 05/14/2019] [Indexed: 06/10/2023]
Abstract
We use a difference-in-differences strategy to estimate the effects of JUNTOS, a conditional cash transfer program targeted to poor rural households in Peru, on use of prenatal care. Using data from the Peruvian Demographic and Health Surveys over the period 2000-2011, we find that JUNTOS increased prenatal care utilization among program-eligible women. Even more, we find positive effects of JUNTOS on the probability of receiving prenatal care delivered by a skilled professional, including specific medical checkups during the prenatal visits, and a negative effect on the probability of experiencing obstetric emergencies during labor and childbirth.
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Affiliation(s)
- Juan-José Díaz
- Research Unit, Grupo de Análisis para el Desarrollo - GRADE, Lima, Peru
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Shibre G, Mekonnen W. Socio-economic inequalities in ANC attendance among mothers who gave birth in the past 12 months in Debre Brehan town and surrounding rural areas, North East Ethiopia: a community-based survey. Reprod Health 2019; 16:99. [PMID: 31286965 PMCID: PMC6615209 DOI: 10.1186/s12978-019-0768-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 10/02/2018] [Accepted: 06/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Ethiopia, socio-economic inequalities in the utilization of antenatal care (ANC) have long been an obstacle to the country's effort in achieving universal coverage of the service. The study aimed to investigate socio-economic inequalities in the use of ANC services among recently-delivered women in Debre Brehan and surrounding areas, North East Ethiopia. METHODS A community-based survey was carried out in Debre Brehan and surrounding areas in North East Ethiopia. Two-stage cluster sampling technique was followed to recruit study participants. Data was collected using interviewer-administered structured questionnaire from a sample of 412 mothers who gave birth in the 12 months prior to the study. The socio-economic inequalities were assessed by calculating a relative concentration index. Decomposition analysis was done to explain measured inequalities. Analysis was carried out in RStudio statistical environment using the 'decomp' package. RESULTS The first ANC attendance has slight pro-poor concentration, with a relative concentration index of-0.128, and 95%CI -0.175, - 0.082.Socio-Economic Status (SES) of a household, educational level and occupation of a woman and her husband were the most important contributors to the measured inequality in ANC attendance. We found no SES-based inequality in the attendance of four or more ANC visits between the poor and rich. CONCLUSIONS Attendance of the first ANC visit appeared to be slightly concentrated among women in the lower end of SES. The utilization of at least four ANC visits was found to be similar among the poor and rich. Population-based interventions that target all socio-economic groups are recommended to accelerate universal coverage of these process indicators.
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Affiliation(s)
- Gebretsadik Shibre
- Department of Reproductive Health and Health Services Management, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wubegzier Mekonnen
- Department of Reproductive Health and Health Services Management, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
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Abstract
BACKGROUND Antenatal care (ANC) is a core component of maternity care. However, both quality of care provision and rates of attendance vary widely between and within countries. Qualitative research can assess factors underlying variation, including acceptability, feasibility, and the values and beliefs that frame provision and uptake of ANC programmes.This synthesis links to the Cochrane Reviews of the effectiveness of different antenatal models of care. It was designed to inform the World Health Organization guidelines for a positive pregnancy experience and to provide insights for the design and implementation of improved antenatal care in the future. OBJECTIVES To identify, appraise, and synthesise qualitative studies exploring:· Women's views and experiences of attending ANC; and factors influencing the uptake of ANC arising from women's accounts;· Healthcare providers' views and experiences of providing ANC; and factors influencing the provision of ANC arising from the accounts of healthcare providers. SEARCH METHODS To find primary studies we searched MEDLINE, Ovid; Embase, Ovid; CINAHL, EbscoHost; PsycINFO, EbscoHost; AMED, EbscoHost; LILACS, VHL; and African Journals Online (AJOL) from January 2000 to February 2019. We handsearched reference lists of included papers and checked the contents pages of 50 relevant journals through Zetoc alerts received during the searching phase. SELECTION CRITERIA We included studies that used qualitative methodology and that met our quality threshold; that explored the views and experiences of routine ANC among healthy, pregnant and postnatal women or among healthcare providers offering this care, including doctors, midwives, nurses, lay health workers and traditional birth attendants; and that took place in any setting where ANC was provided.We excluded studies of ANC programmes designed for women with specific complications. We also excluded studies of programmes that focused solely on antenatal education. DATA COLLECTION AND ANALYSIS Two authors undertook data extraction, logged study characteristics, and assessed study quality. We used meta-ethnographic and Framework techniques to code and categorise study data. We developed findings from the data and presented these in a 'Summary of Qualitative Findings' (SoQF) table. We assessed confidence in each finding using GRADE-CERQual. We used these findings to generate higher-level explanatory thematic domains. We then developed two lines of argument syntheses, one from service user data, and one from healthcare provider data. In addition, we mapped the findings to relevant Cochrane effectiveness reviews to assess how far review authors had taken account of behavioural and organisational factors in the design and implementation of the interventions they tested. We also translated the findings into logic models to explain full, partial and no uptake of ANC, using the theory of planned behaviour. MAIN RESULTS We include 85 studies in our synthesis. Forty-six studies explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. We developed 52 findings in total and organised these into three thematic domains: socio-cultural context (11 findings, five moderate- or high-confidence); service design and provision (24 findings, 15 moderate- or high-confidence); and what matters to women and staff (17 findings, 11 moderate- or high-confidence) The third domain was sub-divided into two conceptual areas; personalised supportive care, and information and safety. We also developed two lines of argument, using high- or moderate-confidence findings:For women, initial or continued use of ANC depends on a perception that doing so will be a positive experience. This is a result of the provision of good-quality local services that are not dependent on the payment of informal fees and that include continuity of care that is authentically personalised, kind, caring, supportive, culturally sensitive, flexible, and respectful of women's need for privacy, and that allow staff to take the time needed to provide relevant support, information and clinical safety for the woman and the baby, as and when they need it. Women's perceptions of the value of ANC depend on their general beliefs about pregnancy as a healthy or a risky state, and on their reaction to being pregnant, as well as on local socio-cultural norms relating to the advantages or otherwise of antenatal care for healthy pregnancies, and for those with complications. Whether they continue to use ANC or not depends on their experience of ANC design and provision when they access it for the first time.The capacity of healthcare providers to deliver the kind of high-quality, relationship-based, locally accessible ANC that is likely to facilitate access by women depends on the provision of sufficient resources and staffing as well as the time to provide flexible personalised, private appointments that are not overloaded with organisational tasks. Such provision also depends on organisational norms and values that overtly value kind, caring staff who make effective, culturally-appropriate links with local communities, who respect women's belief that pregnancy is usually a normal life event, but who can recognise and respond to complications when they arise. Healthcare providers also require sufficient training and education to do their job well, as well as an adequate salary, so that they do not need to demand extra informal funds from women and families, to supplement their income, or to fund essential supplies. AUTHORS' CONCLUSIONS This review has identified key barriers and facilitators to the uptake (or not) of ANC services by pregnant women, and in the provision (or not) of good-quality ANC by healthcare providers. It complements existing effectiveness reviews of models of ANC provision and adds essential insights into why a particular type of ANC provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families/communities. Those providing and funding services should consider the three thematic domains identified by the review as a basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.
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Affiliation(s)
- Soo Downe
- University of Central LancashireResearch in Childbirth and Health (ReaCH) unitPrestonUKPR1 2HE
| | - Kenneth Finlayson
- University of Central LancashireResearch in Childbirth and Health (ReaCH) unitPrestonUKPR1 2HE
| | - Özge Tunçalp
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Ahmet Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
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Dorji T, Das M, Van den Bergh R, Oo MM, Gyamtsho S, Tenzin K, Tshomo T, Ugen S. "If we miss this chance, it's futile later on" - late antenatal booking and its determinants in Bhutan: a mixed-methods study. BMC Pregnancy Childbirth 2019; 19:158. [PMID: 31064329 PMCID: PMC6505275 DOI: 10.1186/s12884-019-2308-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 01/08/2019] [Accepted: 04/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To achieve the Sustainable Development Goal related to maternal and neonatal outcomes, the World Health Organization advocates for a first antenatal care (ANC) contact before 12 weeks of gestation. In order to guide interventions to achieve early ANC in the lower middle-income setting of Bhutan, we conducted an assessment of the magnitude and determinants of late ANC in this context. METHODS This was a mixed-methods study with quantitative (cross-sectional study) and qualitative (in-depth interviews with pregnant women and ANC providers) component in a concurrent triangulation design. The quantitative component retrospectively analysed the socio-demographic and clinical characteristics, and the gestational age at booking of women who were provided care for delivery or miscarriages at the three tertiary hospitals in Bhutan from May-August 2018. The qualitative component involved thematic analysis of in-depth interviews with ten women attending ANC visits and four healthcare workers involved in ANC provision. RESULTS Among 868 women studied, 67% (n = 584) had a late booking (after 12 weeks), and 1% (n = 13) had no booking. Women with only primary education and those residing in rural areas were more likely to have a late first ANC booking. While many women achieved the recommended eight ANC visits, this did not necessarily reflect early booking. Late booking was common among multigravida women. The interviews illustrated a general understanding and recognition of the importance of early ANC. Support from peers, family and co-workers, and male participation in accessing ANC were seen as enablers. The outreach clinics (ORCs) at the primary healthcare level were an important means of reaching the ANC services to women in rural areas where geographical accessibility was a barrier. Specific barriers to early ANC were gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC. CONCLUSION Late ANC booking was common in Bhutan, and appeared to be associated with educational, geographic, socio-cultural and administrative characteristics. A comprehensive information package on ANC needs to be developed for pregnant mothers, and the quality of ANC coverage needs to be measured in terms of early ANC booking.
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Affiliation(s)
- Thinley Dorji
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.
- Kidu Mobile Medical Unit, His Majesty's People's Project, Thimphu, Bhutan.
| | - Mrinalini Das
- Médecins Sans Frontières, Operational Centre Brussels, New Delhi, India
| | - Rafael Van den Bergh
- Médecins Sans Frontières, Operational Centre Brussels, Operational Research Unit (LuxOR), Luxembourg City, Luxembourg
| | - Myo Minn Oo
- The International Union of Tuberculosis and Lung Diseases, Mandalay, Myanmar
| | - Sonam Gyamtsho
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Karma Tenzin
- Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan
| | - Tashi Tshomo
- Reproductive Health Programme, Ministry of Health, Thimphu, Bhutan
| | - Sonam Ugen
- Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
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Gyamfi-Bannerman C, Zupancic JAF, Sandoval G, Grobman WA, Blackwell SC, Tita ATN, Reddy UM, Jain L, Saade GR, Rouse DJ, Iams JD, Clark EAS, Thorp JM, Chien EK, Peaceman AM, Gibbs RS, Swamy GK, Norton ME, Casey BM, Caritis SN, Tolosa JE, Sorokin Y, VanDorsten JP. Cost-effectiveness of Antenatal Corticosteroid Therapy vs No Therapy in Women at Risk of Late Preterm Delivery: A Secondary Analysis of a Randomized Clinical Trial. JAMA Pediatr 2019; 173:462-468. [PMID: 30855640 PMCID: PMC6503503 DOI: 10.1001/jamapediatrics.2019.0032] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/01/2019] [Indexed: 01/12/2023]
Abstract
Importance Administration of corticosteroids to women at high risk for delivery in the late preterm period (34-36 weeks' gestation) improves short-term neonatal outcomes. The cost implications of this intervention are not known. Objective To compare the cost-effectiveness of treatment with antenatal corticosteroids with no treatment for women at risk for late preterm delivery. Design, Setting, and Participants This secondary analysis of the Antenatal Late Preterm Steroids trial, a multicenter randomized clinical trial of antenatal corticosteroids vs placebo in women at risk for late preterm delivery conducted from October 30, 2010, to February 27, 2015. took a third-party payer perspective. Maternal costs were based on Medicaid rates and included those of betamethasone, as well as the outpatient visits or inpatient stay required to administer betamethasone. All direct medical costs for newborn care were included. For infants admitted to the neonatal intensive care unit, comprehensive daily costs were stratified by the acuity of respiratory illness. For infants admitted to the regular newborn nursery, nationally representative cost estimates from the literature were used. Effectiveness was measured as the proportion of infants without the primary outcome of the study: a composite of treatment in the first 72 hours of continuous positive airway pressure or high-flow nasal cannula for 2 hours or more, supplemental oxygen with a fraction of inspired oxygen of 30% or more for 4 hours or more, and extracorporeal membrane oxygenation or mechanical ventilation. This secondary analysis was initially started in June 2016 and revision of the analysis began in May 2017. Exposures Betamethasone treatment. Main Outcomes and Measures Incremental cost-effectiveness ratio. Results Costs were determined for 1426 mother-infant pairs in the betamethasone group (mean [SD] maternal age, 28.6 [6.3] years; 827 [58.0%] white) and 1395 mother-infant pairs in the placebo group (mean [SD] maternal age, 27.9 [6.2] years; 794 [56.9%] white). Treatment with betamethasone was associated with a total mean (SD) woman-infant-pair cost of $4681 ($5798), which was significantly less than the mean (SD) amount of $5379 ($8422) for women and infants in the placebo group (difference, $698; 95% CI, $186-$1257; P = .02). The Antenatal Late Preterm Steroids trial determined that betamethasone use is effective: respiratory morbidity decreased by 2.9% (95% CI, -0.5% to -5.4%). Thus, the cost-effectiveness ratio was -$23 986 per case of respiratory morbidity averted. Inspection of the bootstrap replications confirmed that treatment was the dominant strategy in 5000 samples (98.8%). Sensitivity analyses showed that these results held under most assumptions. Conclusions and Relevance The findings suggest that antenatal betamethasone treatment is associated with a statistically significant decrease in health care costs and with improved outcomes; thus, this treatment may be an economically desirable strategy.
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Affiliation(s)
- Cynthia Gyamfi-Bannerman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - John A. F. Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Grecio Sandoval
- George Washington University Biostatistics Center, Washington, DC
| | - William A. Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Sean C. Blackwell
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Children’s Memorial Hermann Hospital, Houston
| | - Alan T. N. Tita
- Department of Obstetrics and Gynecology, University of Alabama, Birmingham
| | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Lucky Jain
- Department of Obstetrics and Gynecology, Emory University, Atlanta, Georgia
| | - George R. Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Jay D. Iams
- Department of Obstetrics and Gynecology, Ohio State University, Columbus
| | - Erin A. S. Clark
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill
| | - Edward K. Chien
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Alan M. Peaceman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Ronald S. Gibbs
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora
| | - Geeta K. Swamy
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
| | - Mary E. Norton
- Department of Obstetrics and Gynecology, Stanford University, Stanford, California
| | - Brian M. Casey
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - Steve N. Caritis
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jorge E. Tolosa
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
| | - J. Peter VanDorsten
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston
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Manthalu G. User fee exemption and maternal health care utilisation at mission health facilities in Malawi: An application of disequilibrium theory of demand and supply. Health Econ 2019; 28:461-474. [PMID: 30666749 DOI: 10.1002/hec.3856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 06/28/2017] [Revised: 06/14/2018] [Accepted: 12/23/2018] [Indexed: 06/09/2023]
Abstract
The literature on health care utilisation has focussed on the interaction of supply and demand factors in determining utilisation. At the aggregate level, studies have modelled the simultaneity of demand and supply, and different methods have been used. This study proposes an alternative framework for modelling utilisation, which yet separates demand and supply factors, the disequilibrium theory of demand and supply. This theory is useful in modelling data that reflect that not all health care demand is met by health care providers and not all health care supply is taken by consumers. Such disequilibrium arises due to rigid prices and quantity rationing. We use the theory to model maternal health care utilisation and user fee exemption at mission health care facilities in Malawi. The study uses switching regression methods and data from the Malawi Health Management Information System. Results show that user fee exemption is associated with increased utilisation of maternal health care. Demand and supply regime classification shows that many of the health facilities met much of the demand, whereas the rest only provided as much maternal care as their maximum capacity. In the latter case, intended maternal health care utilisation targets may not have been met.
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Affiliation(s)
- Gerald Manthalu
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
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Li R, Bauman B, D'Angelo DV, Harrison LL, Warner L, Barfield WD, Cox S. Affordable Care Act-dependent Insurance Coverage and Access to Care Among Young Adult Women With a Recent Live Birth. Med Care 2019; 57:109-114. [PMID: 30570588 PMCID: PMC10427222 DOI: 10.1097/mlr.0000000000001044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 11/26/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA)-dependent coverage Provision (the Provision), implemented in 2010, extended family insurance coverage to adult children until age 26. OBJECTIVES To examine the impact of the ACA Provision on insurance coverage and care among women with a recent live birth. RESEARCH DESIGN, SUBJECTS, AND OUTCOME MEASURES We conducted a difference-in-difference analysis to assess the effect of the Provision using data from the Pregnancy Risk Assessment Monitoring System among 22,599 women aged 19-25 (treatment group) and 22,361 women aged 27-31 years (control group). Outcomes include insurance coverage in the month before and during pregnancy, and at delivery, and receipt of timely prenatal care, a postpartum check-up, and postpartum contraceptive use. RESULTS Compared with the control group, the Provision was associated with a 4.7-percentage point decrease in being uninsured and a 5.9-percentage point increase in private insurance coverage in the month before pregnancy, and a 5.4-percentage point increase in private insurance coverage and a 5.9-percentage point decrease in Medicaid coverage during pregnancy, with similar changes in insurance coverage at delivery. Findings demonstrated a 3.6-percentage point increase in receipt of timely prenatal care, and no change in receipt of a postpartum check-up or postpartum contraceptive use. CONCLUSIONS Among women with a recent live birth, the Provision was associated with a decreased likelihood of being uninsured and increased private insurance coverage in the month before pregnancy, a shift from Medicaid to private insurance coverage during pregnancy and at delivery, and an increased likelihood of receiving timely prenatal care.
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Affiliation(s)
- Rui Li
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA
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Myint ANM, Liabsuetrakul T, Htay TT, Wai MM, Sundby J, Bjertness E. Impoverishment and catastrophic expenditures due to out-of-pocket payments for antenatal and delivery care in Yangon Region, Myanmar: a cross-sectional study. BMJ Open 2018; 8:e022380. [PMID: 30478109 PMCID: PMC6254407 DOI: 10.1136/bmjopen-2018-022380] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES (1) To assess the levels of impoverishment and catastrophic expenditure due to out-of-pocket (OOP) payments for antenatal care (ANC) and delivery care in Yangon Region, Myanmar; and (2) to explore the determinants of impoverishment and catastrophic expenditure. DESIGN, SETTING AND PARTICIPANTS A community-based cross-sectional survey among women giving birth within the past 12 months in Yangon, Myanmar, was conducted during October to November 2016 using three-stage cluster sampling procedure. OUTCOME MEASURES Poverty headcount ratio, normalised poverty gap and catastrophic expenditure incidence due to OOP payments in the utilisation of ANC and delivery care as well as the determinants of impoverishment and catastrophic expenditure. RESULTS Of 759 women, OOP payments were made by 75% of the women for ANC and 99.6% for delivery care. The poverty headcount ratios after payments increased to 4.3% among women using the ANC services, to 1.3% among those using delivery care and to 6.1% among those using both ANC and delivery care. The incidences of catastrophic expenditure after payments were found to be 12% for ANC, 9.1% for delivery care and 20.9% for both ANC and delivery care. The determinants of impoverishment and catastrophic expenditure were women's occupation, number of household members, number of ANC visits and utilisation of skilled health personnel and health facilities. The associations of the outcomes with these variables bear both negative and positive signs. CONCLUSIONS OOP payments for all ANC and delivery care services are a challenge to women, as one of fifteen women become impoverished and a further one-fifth incur catastrophic expenditures after visiting facilities that offer these services.
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Affiliation(s)
- Aye Nyein Moe Myint
- International Relations Division, Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | | | - Thein Thein Htay
- Department of Community and Global Health, University of Oslo, Norway
| | - Myint Myint Wai
- Department of Medical Services (Planning), Ministry of Health and Sports, Nay Pyi Taw, Myanmar
| | - Johanne Sundby
- Department of Community and Global Health, University of Oslo, Norway
| | - Espen Bjertness
- Department of Community and Global Health, University of Oslo, Norway
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Visser GHA, Ayres-de-Campos D, Barnea ER, de Bernis L, Di Renzo GC, Vidarte MFE, Lloyd I, Nassar AH, Nicholson W, Shah PK, Stones W, Sun L, Theron GB, Walani S. FIGO position paper: how to stop the caesarean section epidemic. Lancet 2018; 392:1286-1287. [PMID: 30322563 DOI: 10.1016/s0140-6736(18)32113-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 08/29/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Gerard H A Visser
- Department of Obstetrics, University Medical Center, Utrecht, Netherlands.
| | - Diogo Ayres-de-Campos
- Department of Obstetrics and Gynecology, Medical School-University of Lisbon, Santa Maria Hospital, Lisbon, Portugal
| | - Eytan R Barnea
- Society for the Investigation of Early Pregnancy, New York, NY, USA; BioIncept, LLC, New York, NY, USA
| | | | - Gian Carlo Di Renzo
- Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
| | | | - Isabel Lloyd
- Ginecólogo Obstetra, Clinica Hospital San Fernando, Consultorio 6-8, Panama
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Wanda Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill School of Medicine, NC, USA
| | - P K Shah
- Department of Obstetrics and Gynecology, Seth G S Medical College and K E M Hospital, Mumbai, India
| | - William Stones
- Departments of Public Health and Obstetrics and Gynaecology, Malawi College of Medicine, Blantyre, Malawi
| | - Luming Sun
- Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China
| | - Gerhard B Theron
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Salimah Walani
- Global Health Programs, March of Dimes Foundation, White Plains, NY, USA
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Prinja S, Gupta A, Bahuguna P, Nimesh R. Cost analysis of implementing mHealth intervention for maternal, newborn & child health care through community health workers: assessment of ReMIND program in Uttar Pradesh, India. BMC Pregnancy Childbirth 2018; 18:390. [PMID: 30285669 PMCID: PMC6171293 DOI: 10.1186/s12884-018-2019-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 10/02/2016] [Accepted: 09/23/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The main intervention under ReMiND program consisted of a mobile health application which was used by community health volunteers, called ASHAs, for counselling pregnant women and nursing mothers. This program was implemented in two rural blocks in Uttar Pradesh state of India with an overall aim to increase quality of health care, thereby increasing utilization of maternal & child health services. The aim of the study was to assess annual & unit cost of ReMiND program and its scale up in UP state. METHOD AND MATERIALS Economic costing was done from the health system and patient's perspectives. All resources used during designing & planning phase i.e., development of application; and implementation of the intervention, were quantified and valued. Capital costs were annualised, after assessing their average number of years for which a product could be used and accounting for its depreciation. Shared or joint costs were apportioned for the time value a resource was utilized under intervention. Annual cost of implementing ReMiND in two blocks of UP along and unit cost per pregnant woman were estimated. Scale-up cost for implementing the intervention in entire state was calculated under two scenarios - first, if no extra human resource were employed; and second, if the state government adopted the same pattern of human resource as employed under this program. RESULTS The annual cost for rolling out ReMiND in two blocks of district Kaushambi was INR 12.1 million (US $ 191,894). The annualised start-up cost constituted 9% of overall cost while rest of cost was attributed to implementation of the intervention. The health system program costs in ReMiND were estimated to be INR 31.4 (US $ 0.49) per capita per year and INR 1294 (US $ 20.5) per registered women. The per capita incremental cost of scale up of intervention in UP state was estimated to be INR 4.39 (US $ 0.07) when no additional supervisory staffs were added. CONCLUSION The cost of scale up of ReMiND in Uttar Pradesh is 6% of annual budget for 'reproductive and child health' line item under state budget, and hence appears to be financially sustainable.
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Affiliation(s)
- Shankar Prinja
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Aditi Gupta
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Pankaj Bahuguna
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
| | - Ruby Nimesh
- School of Public Health, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012 India
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Abstract
OBJECTIVE To evaluate impacts of state Medicaid expansions for low-income parents on the health insurance coverage, pregnancy intention, and use of prenatal care among mothers who became pregnant. DATA SOURCES/STUDY SETTING Person-level data for women with a live birth from the 1997-2012 Pregnancy Risk Assessment Monitoring System. DATA COLLECTION/EXTRACTION METHODS The sample was restricted to women who were already parents using information on previous live births and combined with information on state Medicaid policies for low-income parents. STUDY DESIGN I used a measure of expanded generosity of state Medicaid eligibility for low-income parents to estimate changes in health insurance, pregnancy intention, and prenatal care for pregnant mothers associated with Medicaid expansion. PRINCIPAL FINDINGS I found an increase in prepregnancy health insurance coverage and coverage during pregnancy among pregnant mothers, as well as earlier initiation of prenatal care, associated with the expansions. Among pregnant mothers with less education, I found an increase in the adequacy of prenatal care utilization. CONCLUSIONS Expanded Medicaid coverage for low-income adults has the potential to increase a woman's health insurance coverage prior to pregnancy, as well as her insurance coverage and medical care receipt during pregnancy.
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Affiliation(s)
- Laura R. Wherry
- Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at UCLALos AngelesCA
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de Mooij MJM, Hodny RL, O'Neil DA, Gardner MR, Beaver M, Brown AT, Barry BA, Ross LM, Jasik AJ, Nesbitt KM, Sobolewski SM, Skinner SM, Chaudhry R, Brost BC, Gostout BS, Harms RW. OB Nest: Reimagining Low-Risk Prenatal Care. Mayo Clin Proc 2018; 93:458-466. [PMID: 29545005 DOI: 10.1016/j.mayocp.2018.01.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 10/17/2022]
Abstract
Using a human-centered design method, our team sought to envision a new model of care for women experiencing low-risk pregnancy. This model, called OB Nest, aimed to demedicalize the experience of pregnancy by providing a supportive and empowering experience that fits within patients' daily lives. To explore this topic, we invited women to use self-monitoring tools, a text-based smartphone application to communicate with their care team, and moderated online communities to connect with other pregnant women. Through observations of tool use and patient- and care team-provided feedback, we found that self-measurement and access to a fetal heart monitor provided women with confidence and joy in the progress of their pregnancies while shifting their position to being an active participant in their care. The smartphone application gave women direct access to their care team, provided continuity, and removed hurdles in establishing communication. The online community platform was a space where women in the same obstetric clinic could share nonmedical questions and advice with one another. This created a sense of community, leveraged the knowledge of women, and provided a venue beyond the clinic visit for information exchange. These findings were integrated into the design of the Mayo Clinic OB Nest model. This model redistributes care based on the individual needs of patients by providing self-measurement tools and continuous flexible access to their care team. By enabling women to meaningfully participate in their care, there is potential for cost savings and improved patient satisfaction.
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Affiliation(s)
| | | | | | | | | | - Andrea T Brown
- Hennepin County Medical Center, Upstream Health Innovations, Minneapolis, MN
| | | | | | - Amy J Jasik
- Obstetrics & Gynecology, Mayo Clinic, Rochester, MN
| | | | | | | | - Rajeev Chaudhry
- Mayo Clinic College of Medicine, Primary Care Internal Medicine, Mayo Clinic, Rochester, MN
| | - Brian C Brost
- Wake Forest Baptist Medical Center, Maternal Fetal Medicine Division, Winston-Salem, NC
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Mortensen B, Lukasse M, Diep LM, Lieng M, Abu-Awad A, Suleiman M, Fosse E. Can a midwife-led continuity model improve maternal services in a low-resource setting? A non-randomised cluster intervention study in Palestine. BMJ Open 2018; 8:e019568. [PMID: 29567846 PMCID: PMC5875636 DOI: 10.1136/bmjopen-2017-019568] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To improve maternal health services in rural areas, the Palestinian Ministry of Health launched a midwife-led continuity model in the West Bank in 2013. Midwives were deployed weekly from governmental hospitals to provide antenatal and postnatal care in rural clinics. We studied the intervention's impact on use and quality indicators of maternal services after 2 years' experience. DESIGN A non-randomised intervention design was chosen. The study was based on registry data only available at cluster level, 2 years before (2011and2012) and 2 years after (2014and2015) the intervention. SETTING All 53 primary healthcare clinics in Nablus and Jericho regions were stratified for inclusion. PRIMARY AND SECONDARY OUTCOMES Primary outcome was number of antenatal visits. Important secondary outcomes were number of referrals to specialist care and number of postnatal home visits. Differences in changes within the two groups before and after the intervention were compared by using mixed effect models. RESULTS 14 intervention clinics and 25 control clinics were included. Number of antenatal visits increased by 1.16 per woman in the intervention clinics, while declined by 0.39 in the control clinics, giving a statistically significant difference in change of 1.55 visits (95% CI 0.90 to 2.21). A statistically significant difference in number of referrals was observed between the groups, giving a ratio of rate ratios of 3.65 (2.78-4.78) as number of referrals increased by a rate ratio of 3.87 in the intervention group, while in the control the rate ratio was only 1.06.Home visits increased substantially in the intervention group but decreased in the control group, giving a ratio of RR 97.65 (45.20 - 210.96) CONCLUSION: The Palestinian midwife-led continuity model improved use and some quality indicators of maternal services. More research should be done to investigate if the model influenced individual health outcomes and satisfaction with care. TRIAL REGISTRATION NUMBER NCT03145571; Results.
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Affiliation(s)
- Berit Mortensen
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mirjam Lukasse
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Faculty of Health and Social Sciences, University College of Southeast Norway, Oslo, Norway
| | - Lien My Diep
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Marit Lieng
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Amal Abu-Awad
- Department of Education in Health, Palestinian Ministry of Health, Nablus, Palestine
| | - Munjid Suleiman
- Department of Statistics, Palestinian Ministry of Education and Higher Education, Ramallah, Palestine
| | - Erik Fosse
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Institute for Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Scott NA, Vian T, Kaiser JL, Ngoma T, Mataka K, Henry EG, Biemba G, Nambao M, Hamer DH. Listening to the community: Using formative research to strengthen maternity waiting homes in Zambia. PLoS One 2018; 13:e0194535. [PMID: 29543884 PMCID: PMC5854412 DOI: 10.1371/journal.pone.0194535] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [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: 08/23/2017] [Accepted: 03/05/2018] [Indexed: 12/24/2022] Open
Abstract
Background The WHO recommends maternity waiting homes (MWH) as one intervention to improve maternal and newborn health. However, persistent structural, cultural and financial barriers in their design and implementation have resulted in mixed success in both their uptake and utilization. Guidance is needed on how to design a MWH intervention that is acceptable and sustainable. Using formative research and guided by a sustainability framework for health programs, we systematically collected data from key stakeholders and potential users in order to design a MWH intervention in Zambia that could overcome multi-dimensional barriers to accessing facility delivery, be acceptable to the community and be financially and operationally sustainable. Methods and findings We used a concurrent triangulation study design and mixed methods. We used free listing to gather input from a total of 167 randomly sampled women who were pregnant or had a child under the age of two (n = 59), men with a child under the age of two (n = 53), and community elders (n = 55) living in the catchment areas of four rural health facilities in Zambia. We conducted 17 focus group discussions (n = 135) among a purposive sample of pregnant women (n = 33), mothers-in-law (n = 32), traditional birth attendants or community maternal health promoters (n = 38), and men with a child under two (n = 32). We administered 38 semi-structured interviews with key informants who were identified by free list respondents as having a stake in the condition and use of MWHs. Lastly, we projected fixed and variable recurrent costs for operating a MWH. Respondents most frequently mentioned distance, roads, transport, and the quality of MWHs and health facilities as the major problems facing pregnant women in their communities. They also cited inadequate advanced planning for delivery and the lack of access to delivery supplies and baby clothes as other problems. Respondents identified the main problems of MWHs specifically as over-crowding, poor infrastructure, lack of amenities, safety concerns, and cultural issues. To support operational sustainability, community members were willing to participate on oversight committees and contribute labor. The annual fixed recurrent cost per 10-bed MWH was estimated as USD543, though providing food and charcoal added another $3,000USD. Respondents identified water pumps, an agriculture shop, a shop for baby clothes and general goods, and grinding mills as needs in their communities that could potentially be linked with an MWH for financial sustainability. Conclusions Findings informed the development of an intervention model for renovating existing MWH or constructing new MWH that meets community standards of safety, comfort and services offered and is aligned with government policies related to facility construction, ownership, and access to health services. The basic strategies of the new MWH model include improving community acceptability, strengthening governance and accountability, and building upon existing efforts to foster financial and operational sustainability. The proposed model addresses the problems cited by our respondents and challenges to MWHs identified by in previous studies and elicits opportunities for social enterprises that could serve the dual purpose of meeting a community need and generating revenue for the MWH.
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Affiliation(s)
- Nancy A. Scott
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Taryn Vian
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Jeanette L. Kaiser
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Thandiwe Ngoma
- Zambia Center for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia
| | - Kaluba Mataka
- Zambia Center for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia
| | - Elizabeth G. Henry
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Godfrey Biemba
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Zambia Center for Applied Health Research and Development (ZCAHRD), Lusaka, Zambia
| | - Mary Nambao
- Department of Public Health, Ministry of Health, Lusaka, Zambia
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, United States of America
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Dzielak DJ. The potential of a population health strategy to improve healthcare outcomes and reduce costs for Medicaid programs. Am J Manag Care 2018; 24:SP110-SP111. [PMID: 29689144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Demirel E, Kelekçi S, Ekmekci E, Şengül M, İri R, Atasever M. Is the management of Rh-Rh incompatibility with noninvasive fetal Rh genotyping for targeted prophylaxis cost-effective in the Turkish population? Turk J Med Sci 2018; 48:1-4. [PMID: 29479934 DOI: 10.3906/sag-1511-87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Background/aim: The aim of this study was to assess unnecessary immunization rates and compare the cost-effectiveness of targeted prophylaxis with fetal Rh genotyping with that of traditional management of Rh-Rh incompatibility in a virtual economic model.
Materials and methods: This retrospective data analysis was conducted at two tertiary centers between 2011 and 2015. The data of 1135 pregnant women were analyzed. The main outcome measure was to determine the unnecessary immunization rate among the whole Rh-Rh incompatibility group. The second outcome measure was to compare the cost-effectiveness of universal immunization with that of targeted prophylaxis with fetal Rh genotyping in a virtual economic model.
Results: Average cost per patient was found as $259.20 with universal prophylaxis and the total cost was $177,344, whereas if targeted prophylaxis had been applied to these patients the total cost would have been $263,392 and cost per patient would have been $385. Universal prophylaxis was more cost-effective than targeted prophylaxis in terms of both total cost and cost per patient (P < 0.0001).
Conclusion: Unless the cost of noninvasive fetal Rh genotyping is reduced, a universal approach of anti-D immune globulin prophylaxis is more cost-effective than noninvasive determination of fetal Rh genotyping with targeted prophylaxis.
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Dodd JM, Deussen AR, Louise J. Optimising gestational weight gain and improving maternal and infant health outcomes through antenatal dietary, lifestyle and physical activity advice: the OPTIMISE randomised controlled trial protocol. BMJ Open 2018; 8:e019583. [PMID: 29463591 PMCID: PMC5855335 DOI: 10.1136/bmjopen-2017-019583] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Obesity represents a significant health burden, and WHO recognises the importance of preventing weight gain and subsequent development of obesity among adults who are within the healthy weight range. Women of reproductive age have demonstrated high rates of weight gain during pregnancy placing them at risk of becoming overweight or obese. We will evaluate the effects of dietary and physical activity advice on maternal, fetal and infant health outcomes, among pregnant women of normal body mass index (BMI). METHODS AND ANALYSIS We will conduct a randomised controlled trial, consenting and randomising women with a live singleton pregnancy between 10+0 and 20+0 weeks and BMI 18.5-24.9 kg/m2 at first antenatal visit, from a tertiary maternity hospital. Women randomised to the Lifestyle Advice Group will receive three face-to-face sessions (two with a research dietitian and one with a trained research assistant) and three telephone calls over pregnancy, in which they will be provided with dietary and lifestyle advice and encouraged to make change using a SMART goals approach. Women randomised to the Standard Care Group will receive routine antenatal care. The primary outcome is infant birth weight >4 kg. Secondary outcomes will include adverse infant and maternal outcomes, maternal weight change, maternal diet and physical activity changes, maternal quality of life and emotional well-being, fetal growth and costs of healthcare. We will recruit 624 women to detect a reduction from 8.72% to 3.87% (alpha 0.05 (two-tailed); power 70%) in infants with birth weight >4 kg. Analyses will be intention to treat with estimates reported as relative risks and 95% CIs. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Women's and Children's Hospital ethics committee. Findings will be disseminated widely via journal publication and conference presentation(s), and participants informed of results. TRIAL REGISTRATION NUMBER ACTRN12614000583640.
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Affiliation(s)
- Jodie M Dodd
- Discipline of Obstetrics and Gynaecology, Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Perinatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Andrea R Deussen
- Discipline of Obstetrics and Gynaecology, Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jennie Louise
- School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
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Abstract
IMPORTANCE The effect of the Affordable Care Act (ACA) dependent coverage provision on pregnancy-related health care and health outcomes is unknown. OBJECTIVE To determine whether the dependent coverage provision was associated with changes in payment for birth, prenatal care, and birth outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study, using a differences-in-differences analysis of individual-level birth certificate data comparing live births among US women aged 24 to 25 years (exposure group) and women aged 27 to 28 years (control group) before (2009) and after (2011-2013) enactment of the dependent coverage provision. Results were stratified by marital status. MAIN EXPOSURES The dependent coverage provision of the ACA, which allowed young adults to stay on their parent's health insurance until age 26 years. MAIN OUTCOMES AND MEASURES Primary outcomes were payment source for birth, early prenatal care (first visit in first trimester), and adequate prenatal care (a first trimester visit and 80% of expected visits). Secondary outcomes were cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit (NICU) admission. RESULTS The study population included 1 379 005 births among women aged 24-25 years (exposure group; 299 024 in 2009; 1 079 981 in 2011-2013), and 1 551 192 births among women aged 27-28 years (control group; 325 564 in 2009; 1 225 628 in 2011-2013). From 2011-2013, compared with 2009, private insurance payment for births increased in the exposure group (36.9% to 35.9% [difference, -1.0%]) compared with the control group (52.4% to 51.1% [difference, -1.3%]), adjusted difference-in-differences, 1.9 percentage points (95% CI, 1.6 to 2.1). Medicaid payment decreased in the exposure group (51.6% to 53.6% [difference, 2.0%]) compared with the control group (37.4% to 39.4% [difference, 1.9%]), adjusted difference-in-differences, -1.4 percentage points (95% CI, -1.7 to -1.2). Self-payment for births decreased in the exposure group (5.2% to 4.3% [difference, -0.9%]) compared with the control group (4.9% to 4.3% [difference, -0.5%]), adjusted difference-in-differences, -0.3 percentage points (95% CI, -0.4 to -0.1). Early prenatal care increased from 70% to 71.6% (difference, 1.6%) in the exposure group and from 75.7% to 76.8% (difference, 0.6%) in the control group (adjusted difference-in-differences, 0.6 percentage points [95% CI, 0.3 to 0.8]). Adequate prenatal care increased from 73.5% to 74.8% (difference, 1.3%) in the exposure group and from 77.5% to 78.8% (difference, 1.3%) in the control group (adjusted difference-in-differences, 0.4 percentage points [95% CI, 0.2 to 0.6]). Preterm birth decreased from 9.4% to 9.1% in the exposure group (difference, -0.3%) and from 9.1% to 8.9% in the control group (difference, -0.2%) (adjusted difference-in-differences, -0.2 percentage points (95% CI, -0.3 to -0.03). Overall, there were no significant changes in low birth weight, NICU admission, or cesarean delivery. In stratified analyses, changes in payment for birth, prenatal care, and preterm birth were concentrated among unmarried women. CONCLUSIONS AND RELEVANCE In this study of nearly 3 million births among women aged 24 to 25 years vs those aged 27 to 28 years, the Affordable Care Act dependent coverage provision was associated with increased private insurance payment for birth, increased use of prenatal care, and modest reduction in preterm births, but was not associated with changes in cesarean delivery rates, low birth weight, or NICU admission.
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Affiliation(s)
- Jamie R. Daw
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Health Policy and Economics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts
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Breathett K, Filley J, Pandey M, Rai N, Peterson PN. Trends in Early Prenatal Care Among Women with Pre-Existing Diabetes: Have Income Disparities Changed? J Womens Health (Larchmt) 2018; 27:93-98. [PMID: 29023180 PMCID: PMC5771526 DOI: 10.1089/jwh.2016.6031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 11/12/2022] Open
Abstract
BACKGROUND Women with pre-existing diabetes are at high maternal risk for comorbidities and death, particularly when early prenatal care is not received. Low income is a known barrier to early prenatal care. It is unknown whether recent policies to expand access to prenatal care have reduced income disparities. We hypothesized that income disparities would be minimized and that the odds of receipt of first trimester prenatal care among women with pre-existing diabetes would become similar across income strata over time. MATERIAL AND METHODS Using the Colorado birth certificate registry from 2007 to 2014, receipt of prenatal care was assessed retrospectively in 2,497 women with pre-existing diabetes. Logistic regression was used to examine the association between high (>$50,000), medium ($25,000-50,000), and low (<$25,000) income strata and receipt of first trimester prenatal care by birth year, adjusted for demographics. RESULTS High, medium, and low income represented 29.5%, 19.0%, and 51.5% of the cohort, respectively. Women with high income were more likely to receive first trimester care than women with low income from 2007 [adjusted odds ratio, 95% confidence interval: 2.16 (1.18, 3.96)] through 2013 [1.66 (1.01, 2.73)], but significant differences were no longer observed in 2014 [1.59 (0.89, 2.84)]. The likelihood of receiving first trimester prenatal care was not significantly different between medium- and low-income strata from 2007 [1.07 (0.66, 1.74)] through 2014 [0.77 (0.48, 1.23)]. CONCLUSIONS From 2007 to 2013, women in Colorado with diabetes were more likely to receive early prenatal care if they were in the highest income stratum than in the lowest stratum. In 2014, receipt of first trimester care became equitable across all income strata. Future work should examine national patterns of income with receipt of prenatal care and outcomes among women with pre-existing diabetes.
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Affiliation(s)
- Khadijah Breathett
- Division of Cardiology, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
- Division of Cardiology, Sarver Heart Center, University of Arizona-Tucson, Tucson, Arizona
| | - Jessica Filley
- Department of Public Health, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| | - Madhaba Pandey
- Department of Public Health, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| | - Nayanjot Rai
- Department of Public Health, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| | - Pamela N. Peterson
- Division of Cardiology, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
- Denver Health Medical Center, Denver, Colorado
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Fawsitt CG, Bourke J, Murphy A, McElroy B, Lutomski JE, Murphy R, Greene RA. A Cost-Benefit Analysis of Two Alternative Models of Maternity Care in Ireland. Appl Health Econ Health Policy 2017; 15:785-794. [PMID: 28828573 PMCID: PMC5701951 DOI: 10.1007/s40258-017-0344-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
BACKGROUND The Irish government has committed to expand midwifery-led care alongside consultant-led care nationally, although very little is known about the potential net benefits of this reconfiguration. OBJECTIVES To formally compare the costs and benefits of the major models of care in Ireland, with a view to informing priority setting using the contingent valuation technique and cost-benefit analysis. METHODS A marginal payment scale willingness-to-pay question was adopted from an ex ante perspective. 450 pregnant women were invited to participate in the study. Cost estimates were collected primarily, describing the average cost of a package of care. Net benefit estimates were calculated over a 1-year cycle using a third-party payer perspective. RESULTS To avoid midwifery-led care, women were willing to pay €821.13 (95% CI 761.66-1150.41); to avoid consultant-led care, women were willing to pay €795.06 (95% CI 695.51-921.15). The average cost of a package of consultant- and midwifery-led care was €1,762.12 (95% CI 1496.73-2027.51) and €1018.47 (95% CI 916.61-1120.33), respectively. Midwifery-led care ranked as the best use of resources, generating a net benefit of €1491.22 (95% CI 989.35-1991.93), compared with €123.23 (95% CI -376.58 to 621.42) for consultant-led care. CONCLUSIONS While both models of care are cost-beneficial, the decision to provide both alternatives may be constrained by resource issues. If only one alternative can be implemented then midwifery-led care should be undertaken for low-risk women, leaving consultant-led care for high-risk women. However, pursuing one alternative contradicts a key objective of government policy, which seeks to improve maternal choice. Ideally, multiple alternatives should be pursued.
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Affiliation(s)
- Christopher G Fawsitt
- Health Economics at Bristol (HEB), Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland.
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland.
| | - Jane Bourke
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| | - Aileen Murphy
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| | - Brendan McElroy
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| | - Jennifer E Lutomski
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rosemary Murphy
- Department of Economics, Cork University Business School, University College Cork, Cork, Ireland
| | - Richard A Greene
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
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Bardou M, Crépon B, Bertaux AC, Godard-Marceaux A, Eckman-Lacroix A, Thellier E, Falchier F, Deruelle P, Doret M, Carcopino-Tusoli X, Schmitz T, Barjat T, Morin M, Perrotin F, Hatem G, Deneux-Tharaux C, Fournel I, Laforet L, Meunier-Beillard N, Duflo E, Le Ray I. NAITRE study on the impact of conditional cash transfer on poor pregnancy outcomes in underprivileged women: protocol for a nationwide pragmatic cluster-randomised superiority clinical trial in France. BMJ Open 2017; 7:e017321. [PMID: 29084796 PMCID: PMC5665235 DOI: 10.1136/bmjopen-2017-017321] [Citation(s) in RCA: 2] [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] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Prenatal care is recommended during pregnancy to improve neonatal and maternal outcomes. Women of lower socioeconomic status (SES) are less compliant to recommended prenatal care and suffer a higher risk of adverse perinatal outcomes. Several attempts to encourage optimal pregnancy follow-up have shown controversial results, particularly in high-income countries. Few studies have assessed financial incentives to encourage prenatal care, and none reported materno-fetal events as the primary outcome. Our study aims to determine whether financial incentives could improve pregnancy outcomes in women with low SES in a high-income country. METHODS AND ANALYSIS This pragmatic cluster-randomised clinical trial includes pregnant women with the following criteria: (1) age above 18 years, (2) first pregnancy visit before 26 weeks of gestation and (3) belonging to a socioeconomically disadvantaged group. The intervention consists in offering financial incentives conditional on attending scheduled pregnancy follow-up consultations. Clusters are 2-month periods with random turnover across centres. A composite outcome of maternal and neonatal morbidity and mortality is the primary endpoint. Secondary endpoints include maternal or neonatal outcomes assessed separately, qualitative assessment of the perception of the intervention and cost-effectiveness analysis for which children will be followed to the end of their first year through the French health insurance database. The study started in June 2016, and based on an expected decrease in the primary endpoint from 18% to 14% in the intervention group, we plan to include 2000 women in each group. ETHICS AND DISSEMINATION Ethics approval was first gained on 28 September 2014. An independent data security and monitoring committee has been established. Results of the main trial and each of the secondary analyses will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02402855; pre-results.
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Affiliation(s)
- Marc Bardou
- Centre d’Investigation Clinique INSERM 1432, Centre Hospitalier Universitaire de Dijon, Dijon, Bourgogne, France
- Centre de Recherche INSERM LNC-UMR1231, UFR Sciences Santé, Dijon, France
- Université Bourgogne-Franche Comté, Dijon, France
| | - Bruno Crépon
- Centre de Recherche en Economie Statistique (CREST), Malakoff, France
| | - Anne-Claire Bertaux
- Unité de Soutien Méthodologique à la Recherche, CHU Dijon-Bourgogne, Dijon, Bourgogne, France
| | - Aurélie Godard-Marceaux
- Neurosciences Intégratives et cliniques EA 481, Université Bourgogne Franche-Comté, Besançon, France
- “Ethique et Progrès médical”, CIC INSERM 1431, Centre Hospitalier et Universitaire de Besançon, Besançon, France
| | | | - Elise Thellier
- Service de Gynécologie Obstétrique, CHU de Bicetre, Paris, France
| | | | | | - Muriel Doret
- Service de Gynécologie Obstétrique, Hospices Civils de Lyon—Hôpital Femme Mère Enfant, Lyon, Rhône-Alpes, France
| | - Xavier Carcopino-Tusoli
- Service de Gynécologie Obstétrique, CHU de Marseille Hôpital Nord, Marseille, Provence-Alpes-Côte d’Azu, France
| | - Thomas Schmitz
- Service de Gynécologie Obstétrique, CHU Robert Debré, Paris, Île-de-France, France
| | - Thiphaine Barjat
- Service de Gynécologie Obstétrique, CHU de Saint Etienne, Saint Etienne, France
| | - Mathieu Morin
- Service de Gynécologie Obstétrique, CHU de Toulouse, Toulouse, Midi-Pyrénées, France
| | - Franck Perrotin
- Service de Gynécologie Obstétrique, CHU Bretonneau, Tours, France
| | - Ghada Hatem
- Service de Gynécologie Obstétrique, Centre Hospitalier de Saint Denis, Saint Denis, Île-de-France, France
| | - Catherine Deneux-Tharaux
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris France, Paris, France
| | - Isabelle Fournel
- Centre d’Investigation Clinique INSERM 1432, Centre Hospitalier Universitaire de Dijon, Dijon, Bourgogne, France
| | - Laurent Laforet
- Centre d’Investigation Clinique INSERM 1432, Centre Hospitalier Universitaire de Dijon, Dijon, Bourgogne, France
| | - Nicolas Meunier-Beillard
- Neurosciences Intégratives et cliniques EA 481, Université Bourgogne Franche-Comté, Besançon, France
| | - Esther Duflo
- Department of Economics, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Isabelle Le Ray
- Service de Gynécologie Obstétrique, CHRU Strasbourg, Strasbourg, Alsace, France
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Abstract
OBJECTIVE To analyse the effectiveness of a household conditional cash transfer programme (CCT) on antenatal care (ANC) coverage reported by women and ANC quality reported by midwives. DESIGN The CCT was piloted as a cluster randomised control trial in 2007. Intent-to-treat parameters were estimated using linear regression and logistic regression. SETTING Secondary analysis of the longitudinal CCT impact evaluation survey, conducted in 2007 and 2009. This included 6869 pregnancies and 1407 midwives in 180 control subdistricts and 180 treated subdistricts in Indonesia. OUTCOME MEASURES ANC component coverage index, a composite measure of each ANC service component as self-reported by women, and ANC provider quality index, a composite measure of ANC service provided as self-reported by midwives. Each index was created by principal component analysis (PCA). Specific ANC component items were also assessed. RESULTS The CCT was associated with improved ANC component coverage index by 0.07 SD (95% CI 0.002 to 0.141). Women were more likely to receive the following assessments: weight (OR 1.56 (95% CI 1.25 to 1.95)), height (OR 1.41 (95% CI 1.247 to 1.947)), blood pressure (OR 1.36 (95% CI 1.045 to 1.761)), fundal height measurements (OR 1.65 (95% CI 1.372 to 1.992)), fetal heart beat monitoring (OR 1.29 (95% CI 1.006 to 1.653)), external pelvic examination (OR 1.28 (95% CI 1.086 to 1.505)), iron-folic acid pills (OR 1.42 (95% CI 1.081 to 1.859)) and information on pregnancy complications (OR 2.09 (95% CI 1.724 to 2.551)). On the supply side, the CCT had no significant effect on the ANC provider quality index based on reports from midwives. CONCLUSIONS The CCT programme improved ANC coverage for women, but midwives did not improve ANC quality. The results suggest that enhanced ANC utilisation may not be sufficient to improve health outcomes, and steps to improve ANC quality are essential for programme impact.
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Affiliation(s)
- Margaret Triyana
- Keough School of Global Affairs, University of Notre Dame, Notre Dame, Indiana 46556, USA
- Harvard Ash Center, Harvard Kennedy School, Cambridge, MA, USA
| | - Anuraj H Shankar
- Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA
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Won RP, Friedlander S, Lee SL. Management and Outcomes of Appendectomy during Pregnancy. Am Surg 2017; 83:1103-1107. [PMID: 29391104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Acute appendicitis is a common nonobstetric indication for surgical intervention during pregnancy with serious potential complications for the mother and fetus. The aim of this study was to evaluate the presentation, management practices, outcomes, and costs of appendectomy during pregnancy. We did a retrospective analysis of 62,118 nonincidental appendectomies performed in women (age 15-45 years) identified from the California State Inpatient Database (2005-2011). Primary outcomes included diagnosis or type of appendicitis, use of laparoscopy, morbidity, length of stay, and cost. Pregnant women were less likely to undergo laparoscopy (OR = 0.51, P < 0.01). Pregnancy had no effect on perforation rates, but was associated with higher rates of negative appendectomy (OR = 9.29, P < 0.01). Pregnancy was not associated with nonpregnancy-related complications after appendectomy. Pregnant women had longer length of stay (RR = 1.07, P < 0.01) but similar costs. Appendectomy did increase risk of preterm delivery at the time of surgical admission (19.5 vs 8.8%, P < 0.01). However, once discharged, there was no difference in rates of preterm delivery (9.1 vs 8.9%, P = 0.23). Pregnant women had higher rates of negative appendectomy with lower rates of laparoscopy. Despite these differences, there was no difference in nonpregnancy-related morbidity and cost. Appendectomy did increase risk of preterm birth, but the increased risk normalized over time.
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Affiliation(s)
- Roy P Won
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California, USA
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Visser L, de Boer MA, de Groot CJM, Nijman TAJ, Hemels MAC, Bloemenkamp KWM, Bosmans JE, Kok M, van Laar JO, Sueters M, Scheepers H, van Drongelen J, Franssen MTM, Sikkema JM, Duvekot HJJ, Bekker MN, van der Post JAM, Naaktgeboren C, Mol BWJ, Oudijk MA. Low dose aspirin in the prevention of recurrent spontaneous preterm labour - the APRIL study: a multicenter randomized placebo controlled trial. BMC Pregnancy Childbirth 2017; 17:223. [PMID: 28705190 PMCID: PMC5513323 DOI: 10.1186/s12884-017-1338-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/19/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Preterm birth (birth before 37 weeks of gestation) is a major problem in obstetrics and affects an estimated 15 million pregnancies worldwide annually. A history of previous preterm birth is the strongest risk factor for preterm birth, and recurrent spontaneous preterm birth affects more than 2.5 million pregnancies each year. A recent meta-analysis showed possible benefits of the use of low dose aspirin in the prevention of recurrent spontaneous preterm birth. We will assess the (cost-)effectiveness of low dose aspirin in comparison with placebo in the prevention of recurrent spontaneous preterm birth in a randomized clinical trial. METHODS/DESIGN Women with a singleton pregnancy and a history of spontaneous preterm birth in a singleton pregnancy (22-37 weeks of gestation) will be asked to participate in a multicenter, randomized, double blinded, placebo controlled trial. Women will be randomized to low dose aspirin (80 mg once daily) or placebo, initiated from 8 to 16 weeks up to maximal 36 weeks of gestation. The primary outcome measure will be preterm birth, defined as birth at a gestational age (GA) < 37 weeks. Secondary outcomes will be a composite of adverse neonatal outcome and maternal outcomes, including subgroups of prematurity, as well as intrauterine growth restriction (IUGR) and costs from a healthcare perspective. Preterm birth will be analyzed as a group, as well as separately for spontaneous or indicated onset. Analysis will be performed by intention to treat. In total, 406 pregnant women have to be randomized to show a reduction of 35% in preterm birth from 36 to 23%. If aspirin is effective in preventing preterm birth, we expect that there will be cost savings, because of the low costs of aspirin. To evaluate this, a cost-effectiveness analysis will be performed comparing preventive treatment with aspirin with placebo. DISCUSSION This trial will provide evidence as to whether or not low dose aspirin is (cost-) effective in reducing recurrence of spontaneous preterm birth. TRIAL REGISTRATION Clinical trial registration number of the Dutch Trial Register: NTR 5675 . EudraCT-registration number: 2015-003220-31.
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Affiliation(s)
- Laura Visser
- Department of Obstetrics and Gynecology, VU University Medical Center, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Marjon A. de Boer
- Department of Obstetrics and Gynecology, VU University Medical Center, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Christianne J. M. de Groot
- Department of Obstetrics and Gynecology, VU University Medical Center, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Tobias A. J. Nijman
- Department of Obstetrics and Gynecology, Birth Centre Wilhelmina Children Hospital, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Marieke A. C. Hemels
- Department of Neonatology, Isala Clinic, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Kitty W. M. Bloemenkamp
- Department of Obstetrics and Gynecology, Birth Centre Wilhelmina Children Hospital, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Judith E. Bosmans
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Marjolein Kok
- Department of Obstetrics and Gynecology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Judith O. van Laar
- Department of Obstetrics and Gynecology, Maxima Medical Center in Veldhoven, De Run 4600, 5504 DB Veldhoven, The Netherlands
| | - Marieke Sueters
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Hubertina Scheepers
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Joris van Drongelen
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Geert Grooteplein-Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Maureen T. M. Franssen
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - J. Marko Sikkema
- Department of Obstetrics and Gynecology, Hospital Group Twente, Zilvermeeuw 1, 7609 PP Almelo, The Netherlands
| | - Hans J. J. Duvekot
- Department of Obstetrics and Gynecology, Erasmus Medical Center, ‘s- Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Mireille N. Bekker
- Department of Obstetrics and Gynecology, Birth Centre Wilhelmina Children Hospital, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Joris A. M. van der Post
- Department of Obstetrics and Gynecology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Christiana Naaktgeboren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Ben W. J. Mol
- Department of Obstetrics and Gynecology, Robinson Research Institute, University of Adelaide, 72 King William St, North Adelaide, SA 5006 Australia
| | - Martijn A. Oudijk
- Department of Obstetrics and Gynecology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Ditkowsky J, Shah KH, Hammerschlag MR, Kohlhoff S, Smith-Norowitz TA. Cost-benefit analysis of Chlamydia trachomatis screening in pregnant women in a high burden setting in the United States. BMC Infect Dis 2017; 17:155. [PMID: 28214469 PMCID: PMC5316151 DOI: 10.1186/s12879-017-2248-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 09/13/2016] [Accepted: 02/07/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI) in the United States (U.S.) [1] and remains a major public health problem. We determined the cost- benefit of screening all pregnant women aged 15-24 for Chlamydia trachomatis infection compared with no screening. METHODS We developed a decision analysis model to estimate costs and health-related effects of screening pregnant women for C. trachomatis in a high burden setting (Brooklyn, NY). Outcome data was from literature for pregnant women in the 2015 US population. A virtual cohort of 6,444,686 pregnant women, followed for 1 year was utilized. Using outcomes data from the literature, we predicted the number of C. trachomatis cases, associated morbidity, and related costs. Two comparison arms were developed: pregnant women who received chlamydia screening, and those who did not. Costs and morbidity of a pregnant woman-infant pair with C. trachomatis were calculated and compared. RESULTS Cost and benefit of screening relied on the prevalence of C. trachomatis; when rates are above 16.9%, screening was proven to offer net cost savings. At a pre-screening era prevalence of 8%, a screening program has an increased expense of $124.65 million ($19.34/individual), with 328 thousand more cases of chlamydia treated, and significant reduction in morbidity. At a current estimate of prevalence, 6.7%, net expenditure for screening is $249.08 million ($38.65/individual), with 204.63 thousand cases of treated chlamydia and reduced morbidity. CONCLUSIONS Considering a high prevalence region, prenatal screening for C. trachomatis resulted in increased expenditure, with a significant reduction in morbidity to woman-infant pairs. Screening programs are appropriate if the cost per individual is deemed acceptable to prevent the morbidity associated with C. trachomatis.
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Affiliation(s)
- Jared Ditkowsky
- Department of Pediatrics, Division of Infectious Diseases, State University of New York Downstate Medical Center, Box 49, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
| | - Khushal H Shah
- Department of Pediatrics, Division of Infectious Diseases, State University of New York Downstate Medical Center, Box 49, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
| | - Margaret R Hammerschlag
- Department of Pediatrics, Division of Infectious Diseases, State University of New York Downstate Medical Center, Box 49, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
| | - Stephan Kohlhoff
- Department of Pediatrics, Division of Infectious Diseases, State University of New York Downstate Medical Center, Box 49, 450 Clarkson Ave, Brooklyn, NY, 11203, USA
| | - Tamar A Smith-Norowitz
- Department of Pediatrics, Division of Infectious Diseases, State University of New York Downstate Medical Center, Box 49, 450 Clarkson Ave, Brooklyn, NY, 11203, USA.
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Abstract
In 2013, physician-researchers announced that a baby in Mississippi had been 'functionally cured' of HIV [Persaud, D., Gay, H., Ziemniak, C. F., Chen, Y. H., Piatak, M., Chun, T.-W., … Luzuriaga, K. (2013b, March). Functional HIV cure after very early ART of an infected infant. Paper presented at the 20th conference on retroviruses and opportunistic infections, Atlanta, GA]. Though the child later developed a detectable viral load, the case remains unprecedented, and trials to build on the findings are planned [National Institute of Allergy and Infectious Diseases. (2014). 'Mississippi baby' now has detectable HIV, researchers find. Retrieved from http://www.niaid.nih.gov/news/newsreleases/2014/pages/mississippibabyhiv.aspx ]. Whether addressing HIV 'cure' or 'remission', scrutiny of this case has focused largely on scientific questions, with only introductory attention to ethics. The social inequalities and gaps in care that made the discovery possible - and their ethical implications for paediatric HIV remission - have gone largely unexamined. This paper describes structural inequalities surrounding the 'Mississippi baby' case and a parallel case in South Africa, where proof-of-concept studies are in the early stages. We argue that an ethical programme of research into infant HIV remission ought to be 'structurally competent', and recommend that paediatric remission studies consider including a research component focused on social protection and barriers to care.
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Affiliation(s)
- Johanna T Crane
- a Department of Anthropology, School of Interdisciplinary Arts and Sciences , University of Washington-Bothell , Bothell , WA , USA
| | - Theresa M Rossouw
- b Department of Immunology, Institute for Cellular and Molecular Medicine , University of Pretoria , Pretoria , South Africa
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Fleming E, Gaines J, O’Connor K, Ogutu J, Atieno N, Atieno S, Kamb ML, Quick R. Can incentives reduce the barriers to use of antenatal care and delivery services in Kenya?: Results of a qualitative inquiry. J Health Care Poor Underserved 2017; 28:153-174. [PMID: 28238994 PMCID: PMC5427715 DOI: 10.1353/hpu.2017.0015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 11/11/2022]
Abstract
A qualitative inquiry was used to assess if incentives consisting of a hygiene kit, protein-fortified flour, and delivery kit reduced barriers to antenatal care and delivery services in Nyanza Province, Kenya. We conducted 40 interviews (baseline: five nurses, six mothers, one focus group of five mothers; follow-up: nine nurses, 19 mothers) to assess perceptions of these services. Mothers and nurses identified poor quality of care, fear of HIV diagnosis and stigma, inadequate transport, and cost of care as barriers. Nurses believed incentives encouraged women to use services; mothers described wanting good birth outcomes as their motivation. While barriers to care did not change during the study, incentives may have increased service use. These findings suggest that structural improvements-upgraded infrastructure, adequate staffing, improved treatment of women by nurses, low or no-cost services, and provision of transport-could increase satisfaction with and use of services, improving maternal and infant health.
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Affiliation(s)
- Eleanor Fleming
- Centers for Disease Control and Prevention; National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; Office of the Director; Atlanta, GA; USA
- Centers for Disease Control and Prevention; Division of Applied Sciences, Epidemic Intelligence Service; Scientific Education and Professional Development Program Office; Atlanta, GA; USA
| | - Joanna Gaines
- Centers for Disease Control and Prevention; Division of Applied Sciences, Epidemic Intelligence Service; Scientific Education and Professional Development Program Office; Atlanta, GA; USA
- Centers for Disease Control and Prevention; National Center for Emerging and Zoonotic Infectious Diseases; Division of Foodborne, Waterborne and Environmental Diseases; Atlanta, GA; USA
| | - Katherine O’Connor
- Centers for Disease Control and Prevention; Division of Applied Sciences, Epidemic Intelligence Service; Scientific Education and Professional Development Program Office; Atlanta, GA; USA
- Centers for Disease Control and Prevention; National Center for Emerging and Zoonotic Infectious Diseases; Division of Foodborne, Waterborne and Environmental Diseases; Atlanta, GA; USA
| | | | | | | | - Mary L. Kamb
- Centers for Disease Control and Prevention; National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; Office of the Director; Atlanta, GA; USA
| | - Robert Quick
- Centers for Disease Control and Prevention; National Center for Emerging and Zoonotic Infectious Diseases; Division of Foodborne, Waterborne and Environmental Diseases; Atlanta, GA; USA
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