The effect of distance on maternal institutional delivery choice: Evidence from Malawi

Good while it lasted? Estimating the long-term and withdrawal effects of results-based financing in Malawi on maternal care utilisation using routine data

OBJECTIVES

This study aimed to evaluate the effect of introduction and subsequent withdrawal of the Results-based Financing for Maternal and Newborn Health Initiative (RBF4MNH) in Malawi on utilisation of facility-based childbirths, antenatal care (ANC) and postnatal care (PNC).

DESIGN

A controlled interrupted time series design was used with secondary data from the Malawian Health Management Information System.

SETTING

Healthcare facilities at all levels identified as providing maternity services in four intervention districts and 20 non-intervention districts in Malawi.

PARTICIPANTS

Routinely collected, secondary data of total monthly service utilisation of facility-based childbirths, ANC and PNC services.

INTERVENTIONS

The intervention is the RBF4MNH initiative, introduced by the Malawian government in 2013 to improve maternal and infant health outcomes and withdrawn in 2018 after ceasing of donor funding.

OUTCOME MEASURES

Differences in total volume and trends of utilisation of facility-based childbirths, ANC and PNC services, compared between intervention versus non-intervention districts, for the study period of 90 consecutive months.

RESULTS

No significant effect was observed, on utilisation trends for any of the three services during the first 2.5 years of intervention. In the following 2.5 years after full implementation, we observed a small positive increase for facility-based childbirths (+0.62 childbirths/month/facility) and decrease for PNC (-0.55 consultations/month/facility) trends of utilisation respectively. After withdrawal, facility-based childbirths and ANC consultations dropped both in immediate volume after removal (-10.84 childbirths/facility and -20.66 consultations/facility, respectively), and in trends of utilisation over time (-0.27 childbirths/month/facility and -1.38 consultations/month/facility, respectively). PNC utilisation levels seemed unaffected in intervention districts against a decline in the rest of the country.

CONCLUSIONS

Concurrent with wider literature, our results suggest that effects of complex health financing interventions, such as RBF4MNH, can take a long time to be seen. They might not be sustained beyond the implementation period if measures are not adopted to reform existing health financing structures.

Determinants of partial and adequate maternal health services utilization in Nigeria: analysis of cross-sectional survey

BACKGROUND

Access to health services during pregnancy, childbirth and the period after birth provides a substantial opportunity to limit cases of maternal mortality. In sub-Saharan Africa, the proportions of women who utilize health services remain below 70%. This study examined the factors associated with partial and adequate maternal health services utilization in Nigeria.

METHODS

This paper used data from 2018 Nigeria Demographic and Health Survey (DHS) comprising 21,792 women aged 15-49 years who had given births within five years of the survey. The study focused on antenatal care attendance, place of birth and postnatal care using a combined model. Multinomial logistic regression was applied in the analysis.

RESULTS

About 74% of the women attended antenatal care, 41% gave birth in health facilities and 21% attended postnatal care. While 68% of the women partially utilized health services, 11% adequately utilized the services. The odds of partially and adequately utilizing health services increased for ever married women, women with secondary or higher education, from richest households, living in urban area, having no problem either getting permission to visit health facility or reaching health facility.

CONCLUSIONS

This study has revealed the factors associated with partial and adequate utilization of maternal health services in Nigeria. Such factors include education, household wealth, marital status, employment status, residence, region, media exposure, getting permission to use health service, unwillingness to visit health facility without being accompanied and distance to health facility. Efforts aimed at improving maternal health services utilization should place emphasis on these factors.

Travel time to health facilities in Papua New Guinea: Implications for coverage and equity in child vaccinations

With infant and child mortality rates that are among the highest in the Pacific region, and basic vaccination coverage rates that are 39% among children 12-23 months, increased coverage of vaccines is a high priority investment for Papua New Guinea (PNG). Using recently gathered household survey data for PNG, this paper contributes to the evidence-base for enhancing investments in frontline facilities by examining the implications of travel time to health facilities for basic vaccination coverage among children in PNG. We find that vaccination coverage rates among children 12-23 months old in PNG are decreasing in distance to healthcare facilities; and this holds whether the outcome is receipt of basic vaccinations (BCG; 3 dose pentavalent; OPV3; Measles), or basic vaccinations-plus (basic vaccinations + Hepatitis B + PCV3). We also find that travel time to health facilities lowers vaccination rates among children 12-23 months old in poor households to a greater extent than for children from richer households. Thus, enhanced geographical access to and resourcing of frontline facilities is likely to expand not only immunization coverage, lower mortality and increase aggregate economic gains, but also improve the distribution of immunization coverage in PNG across socioeconomic groups.

Association between childhood immunisation coverage and proximity to health facilities in rural settings: a cross-sectional analysis of Service Provision Assessment 2013-2014 facility data and Demographic and Health Survey 2015-2016 individual data in Malawi

OBJECTIVES

Despite significant progress in childhood vaccination coverage globally, substantial inequality remains. Remote rural populations are recognised as a priority group for immunisation service equity. We aimed to link facility and individual data to examine the relationship between distance to services and immunisation coverage empirically, specifically using a rural population.

DESIGN AND SETTING

Retrospective cross-sectional analysis of facility data from the 2013-2014 Malawi Service Provision Assessment and individual data from the 2015-2016 Malawi Demographic and Health Survey, linking children to facilities within a 5 km radius. We examined associations between proximity to health facilities and vaccination receipt via bivariate comparisons and logistic regression models.

PARTICIPANTS

2740 children aged 12-23 months living in rural areas.

OUTCOME MEASURES

Immunisation coverage for the six vaccines included in the Malawi Expanded Programme on Immunization schedule for children under 1 year at time of study, as well as two composite vaccination indicators (receipt of basic vaccines and receipt of all recommended vaccines), zero-dose pentavalent coverage, and pentavalent dropout.

FINDINGS

72% (706/977) of facilities offered childhood vaccination services. Among children in rural areas, 61% were proximal to (within 5 km of) a vaccine-providing facility. Proximity to a vaccine-providing health facility was associated with increased likelihood of having received the rotavirus vaccine (93% vs 88%, p=0.004) and measles vaccine (93% vs 89%, p=0.01) in bivariate tests. In adjusted comparisons, how close a child was to a health facility remained meaningfully associated with how likely they were to have received rotavirus vaccine (adjusted OR (AOR) 1.63, 95% CI 1.13 to 2.33) and measles vaccine (AOR 1.62, 95% CI 1.11 to 2.37).

CONCLUSION

Proximity to health facilities was significantly associated with likelihood of receipt for some, but not all, vaccines. Our findings reiterate the vulnerability of children residing far from static vaccination services; efforts that specifically target remote rural populations living far from health facilities are warranted to ensure equitable vaccination coverage.