Geographic accessibility to obstetric care and maternal mortality in a large metropolitan area of Brazil

Challenges and coping strategies for providing maternal health care services among health care professionals in rural health facilities in Wolaita Zone, Southern Ethiopia: a qualitative study

BACKGROUND

Many factors can decrease job productivity and cause physical and psychological complications for health care professionals providing maternal care. Information on challenges and coping strategies among healthcare professionals providing maternal healthcare services in rural communities is crucial. However, there needs to be more studies, especially qualitative research, to explore challenges and coping strategies for providing maternal health care services in Ethiopia among health care professionals, particularly in the Wolaita zone.

OBJECTIVE

To explore the challenges and coping strategies of professionals providing maternal health care in rural health facilities in Wolaita Zone, Southern Ethiopia, in 2023.

METHOD

A phenomenological qualitative study design was applied from May 20 to June 20, 2023. The study was conducted in rural areas of the Wolaita Zone, southern Ethiopia. Healthcare professionals from rural areas were selected using purposive sampling, and in-depth interviews were conducted. A qualitative thematic analysis was employed to analyze the data. Field notes were read, recordings were listened to, and each participant's interview was written word for word and analyzed using ATLAS.ti 7 software.

RESULT

Five main themes emerged from the data analysis. These themes included inadequate funding from the government, societal barriers to health and access to health care, professionals' personal life struggles, infrastructure related challenges and health system responsiveness, and coping strategies. Reporting to responsible bodies, teaching mothers about maternal health care services, and helping poor mothers from their pockets were listed among their coping strategies.

CONCLUSION

Healthcare professionals have a crucial role in supporting women in delivering babies safely. This study revealed that they are working under challenging conditions. So, if women's lives matter, then this situation requires a call to action.

Investigating geographical accessibility and site suitability of medical laboratories in Kermanshah-Iran

Introduction

One of the major challenges in developing countries is the inappropriate spatial distribution of medical laboratory centers (MLCs) which can lead to injustice in access to health services. This study aimed to investigate the accessibility to and site suitability of MLCs in Kermanshah Metropolis by GIS.

Materials and methods

In this cross-sectional study, data were collected from the Iran Statistical Center and Deputy of Treatment of Kermanshah University of Medical Sciences. We used Arc/GIS 10.6 software, AHP technique, and network analysis tools to determine the access status of Kermanshah citizens to MLCs in 2019 and site selection for MLCs. The layers used in this study included population density, city development trends, compatible and incompatible land uses, pathways, land slope, river area, and access radius.

Results

About 70% of households had inappropriate access to all MLCs in walking scenario. This ratio was 31.26% for 5 min, 9.58% for 10 min, and 6.09% for 15 min driving. Comparisons between public and private MLCs showed that in walking scenario, 88% of households had improper access to public and 80% to private MLCs. Based on 5 and 10 min of driving, 57 and 19% of households had inappropriate access to public MLCs, and 45 and 17% to private MLCs, respectively. Also, with 15 min of driving, 8% of households had improper access to public and 18% to private MLCs. Findings showed that scores provided for population density criteria were (0.298), distance from existing laboratories (0.213), proximity to pathways (0.175), consistent land use (0.129), city development trend (0.087), distance from riverfront (0.053), distance from incompatible land uses (0.015), and land slope (0.03). The final model was obtained by overlaying the layers. The model showed a 9-degree range from very bad to very good in Kermanshah city for the construction of laboratory centers (CR<0.01).

Conclusion

The site selection model showed that the location of the proposed centers can be in the north and outskirts of the city to facilitate citizens' access to the MLCs. These results emphasize the justice in the spatial distribution of MLCs for the benefit of deprived populations as a global value.

Quantifying spatial heterogeneity of vulnerability to short-term PM2.5 exposure with data fusion framework

The current estimations of the burden of disease (BD) of PM_2.5 exposure is still potentially biased by two factors: ignorance of heterogeneous vulnerabilities at diverse urbanization levels and reliance on the risk estimates from existing literature, usually from different locations. Our objectives are (1) to build up a data fusion framework to estimate the burden of PM_2.5 exposure while evaluating local risks simultaneously and (2) to quantify their spatial heterogeneity, relationship to land-use characteristics, and derived uncertainties when calculating the disease burdens. The feature of this study is applying six local databases to extract PM_2.5 exposure risk and the BD information, including the risks of death, cardiovascular disease (CVD), and respiratory disease (RD), and their spatial heterogeneities through our data fusion framework. We applied the developed framework to Tainan City in Taiwan as a use case estimated the risks by using 2006-2016 emergency department visit data, air quality monitoring data, and land-use characteristics and further estimated the BD caused by daily PM_2.5 exposure in 2013. Our results found that the risks of CVD and RD in highly urbanized areas and death in rural areas could reach 1.20-1.57 times higher than average. Furthermore, we performed a sensitivity analysis to assess the uncertainty of BD estimations from utilizing different data sources, and the results showed that the uncertainty of the BD estimations could be contributed by different PM_2.5 exposure data (20-32%) and risk values (0-86%), especially for highly urbanized areas. In conclusion, our approach for estimating BD based on local databases has the potential to be generalized to the developing and overpopulated countries and to support local air quality and health management plans.

Comprehending the lack of access to maternal and neonatal emergency care: Designing solutions based on a space-time approach

OBJECTIVE

The objective of this study was to better understand how the lack of emergency child and obstetric care can be related to maternal and neonatal mortality levels.

METHODS

We performed spatiotemporal geospatial analyses using data from Brazilian municipalities. An emergency service accessibility index was derived using the two-step floating catchment area (2SFCA) for 951 hospitals. Mortality data from 2000 to 2015 was used to characterize space-time trends. The data was overlapped using a spatial clusters analysis to identify regions with lack of emergency access and high mortality trends.

RESULTS

From 2000 to 2015 Brazil the overall neonatal mortality rate varied from 11,42 to 11,71 by 1000 live births. The maternal mortality presented a slightly decrease from 2,98 to 2,88 by 100 thousand inhabitants. For neonatal mortality the Northeast and North regions presented the highest percentage of up trending. For maternal mortality the North region exhibited the higher volume of up trending. The accessibility index obtained highlighted large portions of the rural areas of the country without any coverage of obstetric or neonatal beds.

CONCLUSIONS

The analyses highlighted regions with problems of mortality and access to maternal and newborn emergency services. This sequence of steps can be applied to other low and medium income countries as health situation analysis tool.

SIGNIFICANCE STATEMENT

Low and middle income countries have greater disparities in access to emergency child and obstetric care. There is a lack of approaches capable to support analysis considering a spatiotemporal perspective for emergency care. Studies using Geographic Information System analysis for maternal and child care, are increasing in frequency. This approach can identify emergency child and obstetric care saturated or deprived regions. The sequence of steps designed here can help researchers, and policy makers to better design strategies aiming to improve emergency child and obstetric care.

[Tacit and explicit knowledge: comparative analysis of the prioritization of maternal health problems in Mexico]

OBJECTIVE

To identify coincidences and differences in the identification and prioritization of maternal healthcare service problems in Mexico based on the perspective of tacit knowledge and explicit knowledge that may offer evidence that can contribute to attaining the Sustainable Development Goals.

METHODS

Mixed study performed in three stages: 1) systematization of maternal healthcare service problems identified by tacit knowledge (derived from professional experience); 2) identification of maternal healthcare service problems in Latin America addressed by explicit knowledge (scientific publications); 3) comparison between the problems identified by tacit and explicit knowledge.

RESULTS

The main problems of maternal health services identified by tacit knowledge are related to poor quality of care, while the predominant problems studied in the scientific literature are related to access barriers to health services. Approximately, 70% of the problems identified by tacit knowledge are also mentioned in the explicit knowledge. Conversely, 70% of the problems identified in the literature are also considered by tacit knowledge. Nevertheless, when looking at the problems taken one by one, no statistically significant similarities were found.

CONCLUSIONS

The study discovered that the identification of maternal health service problems by tacit knowledge and explicit knowledge is fairly comparable, according to the comparability index used in the study, and highlights the interest of integrating both approaches in order to improve prioritization and decision making towards the Sustainable Development Goals.

Expectant Mother’s Preferences for Services in Public Hospitals of Tamil Nadu, India

Substantial programmatic efforts have been undertaken to improve the access to maternal care services in the public health system of India, yet the service users are often regarded as passive recipients. Limited research is available on the preferences of service users on what they regard the greatest issues in service delivery. A hospital-based discrete choice experiment (DCE) has been conducted in the public health facilities of Tamil Nadu, a southern state of India. This study uses a sample of 261 women who came for antenatal check-ups across six different public hospitals in Tamil Nadu. The DCE technique, which is rooted in random utility theory (RUT), and conditional logit model have been used to analyze the relative importance of health service attributes. The result showed that regular ward visits by specialist doctors like obstetricians and gynaecologists (O&G) and paediatricians were the most preferred attribute of the maternal care service. Expectant mothers are willing to wait the maximum and are prepared to tolerate health service characteristics in public hospitals, such as poor patient amenities, poor staff attitude and lack of privacy maintained during physical examination, provided specialist doctors are available in the hospitals.

A scoping review of geographic information systems in maternal health

Background

Geographic information systems (GIS) are increasingly recognized tools in maternal health.

Objectives

To evaluate the use of GIS in maternal health and to identify knowledge gaps and opportunities.

Search strategy

Keywords broadly related to maternal health and GIS were used to search for academic articles and gray literature.

Selection criteria

Reviewed articles focused on maternal health, with GIS used as part of the methods.

Data collection and analysis

Peer reviewed articles (n = 40) and gray literature sources (n = 30) were reviewed.

Main results

Two main themes emerged: modeling access to maternal services and identifying risks associated with maternal outcomes. Knowledge gaps included a need to rethink spatial access to maternal care in low- and middle-income settings, and a need for more explicit use of GIS to account for the geographical variation in the effect of risk factors on adverse maternal outcomes. Limited evidence existed to suggest that use of GIS had influenced maternal health policy. Instead, application of GIS to maternal health was largely influenced by policy priorities in global maternal health.

Conclusions

Investigation of the role of GIS in contributing to future policy directions is warranted, particularly for elucidating determinants of global maternal health.

The geography of maternal and newborn health: the state of the art

As the deadline for the millennium development goals approaches, it has become clear that the goals linked to maternal and newborn health are the least likely to be achieved by 2015. It is therefore critical to ensure that all possible data, tools and methods are fully exploited to help address this gap. Among the methods that are under-used, mapping has always represented a powerful way to ‘tell the story’ of a health problem in an easily understood way. In addition to this, the advanced analytical methods and models now being embedded into Geographic Information Systems allow a more in-depth analysis of the causes behind adverse maternal and newborn health (MNH) outcomes. This paper examines the current state of the art in mapping the geography of MNH as a starting point to unleashing the potential of these under-used approaches. Using a rapid literature review and the description of the work currently in progress, this paper allows the identification of methods in use and describes a framework for methodological approaches to inform improved decision-making. The paper is aimed at health metrics and geography of health specialists, the MNH community, as well as policy-makers in developing countries and international donor agencies.

Maternal mortality and accessibility to health services by means of transit-network estimated traveled distances

This study analyzed the relationship between maternal mortality and variables related to the use of health services (especially residence-hospital traveled distances estimated through transit networks). Deaths were identified for Rio de Janeiro and adjacent cities, from 2000 to 2002, and were matched by age and socio-economic level to birth admissions without maternal deaths (1 case to 3 controls). The variables used were: type of hospital (general × specialized maternity services), number of hospital beds, nature of hospital ownership (public × private-associated), main admission diagnostic, residence-hospital distance, age, income, and education. Distances were estimated by a geographic information system, and were based on most probable itineraries through the urban transit networks. The probability of death was estimated by conditional logistic regression models. 226 maternal deaths were studied, and another 10 were excluded due to incompleteness of information. The ROC area for the final model was 0.89 [95% CI (0.87-0.92)]. This model retained statistical significance for the variables admission diagnostic, type of hospital and residence-hospital distance. The death odds ratio for women who traveled 5-10 km (reference category: <5 km) was 3.84 [95% CI (1.96-7.55)]. The traveled distance measured through transit networks was an important risk factor for death in the studied population.

Pregnancy, prenatal care, and delivery of mothers with disabilities in Korea

The aim of this study was to investigate the whole picture regarding pregnancy, prenatal care, obstetrical complications, and delivery among disabled pregnant women in Korea. Using the data of National Health Insurance Corporation, we extracted the data of women who terminated pregnancy including delivery and abortion from January 1, 2010 to December 31, 2010. Pearson's chi-square test and Student-t test were conducted to examine the difference between disabled women and non-disabled women. Also, to define the factors affecting inadequate prenatal care, logistic regression was performed. The total number of pregnancy were 463,847; disabled women was 2,968 (0.6%) and 460,879 (99.4%) were by non-disabled women. Abortion rates (27.6%), Cesarean section rate (54.5%), and the rate of receiving inadequate prenatal care (17.0%), and the rate of being experienced at least one obstetrical complication (11.3%) among disabled women were higher than those among non-disabled women (P < 0.001). Beneficiaries of Medical Aid (OR, 2.21) (P < 0.001) and severe disabled women (OR, 1.46) (P = 0.002) were more likely to receive inadequate prenatal care. In conclusion, disabled women are more vulnerable in pregnancy, prenatal care and delivery. Therefore, the government and society should pay more attention to disabled pregnant women to ensure they have a safe pregnancy period up until the delivery.

A Review and Framework for Categorizing Current Research and Development in Health Related Geographical Information Systems (GIS) Studies

OBJECTIVES

The application of GIS in health science has increased over the last decade and new innovative application areas have emerged. This study reviews the literature and builds a framework to provide a conceptual overview of the domain, and to promote strategic planning for further research of GIS in health.

METHOD

The framework is based on literature from the library databases Scopus and Web of Science. The articles were identified based on keywords and initially selected for further study based on titles and abstracts. A grounded theory-inspired method was applied to categorize the selected articles in main focus areas. Subsequent frequency analysis was performed on the identified articles in areas of infectious and non-infectious diseases and continent of origin.

RESULTS

A total of 865 articles were included. Four conceptual domains within GIS in health sciences comprise the framework: spatial analysis of disease, spatial analysis of health service planning, public health, health technologies and tools. Frequency analysis by disease status and location show that malaria and schistosomiasis are the most commonly analyzed infectious diseases where cancer and asthma are the most frequently analyzed non-infectious diseases. Across categories, articles from North America predominate, and in the category of spatial analysis of diseases an equal number of studies concern Asia.

CONCLUSION

Spatial analysis of diseases and health service planning are well-established research areas. The development of future technologies and new application areas for GIS and data-gathering technologies such as GPS, smartphones, remote sensing etc. will be nudging the research in GIS and health.

A spatial analysis to study access to emergency obstetric transport services under the public private "Janani Express Yojana" program in two districts of Madhya Pradesh, India

BACKGROUND

The government in Madhya Pradesh (MP), India in 2006, launched "Janani Express Yojana" (JE), a decentralized, 24X7, free emergency transport service for all pregnant women under a public-private partnership. JE supports India's large conditional cash transfer program, the "Janani Suraksha Yojana" (JSY) in the province and transports on average 60,000 parturients to hospital every month. The model is a relatively low cost one that potentially could be adopted in other parts of India and South Asia. This paper describes the uptake, time taken and geographic equity in access to the service to transport women to a facility in two districts of MP.

METHODS

This was a facility based cross sectional study. We interviewed parturients (n = 468) who delivered during a five day study period at facilities with >10 deliveries/month (n = 61) in two study districts. The women were asked details of transportation used to arrive at the facility, time taken and their residential addresses. These details were plotted onto a Geographic Information System (GIS) to estimate travelled distances and identify statistically significant clusters of mothers (hot spots) reporting delays >2 hours.

RESULTS

JE vehicles were well dispersed across the districts and used by 236 (50.03%) mothers of which 111(47.03%) took >2 hours to reach a facility. Inability of JE vehicle to reach a mother in time was the main reason for delays. There was no correlation between the duration of delay and distance travelled. Maps of the travel paths and travel duration of the women are presented. The study identified hot spots of mothers with delays >2 hours and explored the possible reasons for longer delays.

CONCLUSIONS

The JE service was accessible in all parts of the districts. Relatively high utilization rates of JE indicate that it ably supported JSY program to draw more women for institutional deliveries. However, half of the JE users experienced long (>2 hour) delays. The delayed mothers clustered in difficult terrains of the districts. Additional support particularly for the identified hot spots, enhanced monitoring by state agencies and GIS tools can facilitate better effectiveness of the JE program.

Brazilian adolescents' knowledge and beliefs about abortion methods: a school-based internet inquiry

Background

Internet surveys that draw from traditionally generated samples provide the unique conditions to engage adolescents in exploration of sensitive health topics.

Methods

We examined awareness of unwanted pregnancy, abortion behaviour, methods, and attitudes toward specific legal indications for abortion via a school-based internet survey among 378 adolescents aged 12–21 years in three Rio de Janeiro public schools.

Results

Forty-five percent knew peers who had undergone an abortion. Most students (66.0%) did not disclose abortion method knowledge. However, girls (aOR 4.2, 95% CI 2.4-7.2), those who had experienced their sexual debut (aOR1.76, 95% CI 1.1-3.0), and those attending a prestigious magnet school (aOR 2.7 95% CI 1.4-6.3) were more likely to report methods. Most abortion methods (79.3%) reported were ineffective, obsolete, and/or unsafe. Herbs (e.g. marijuana tea), over-the-counter medications, surgical procedures, foreign objects and blunt trauma were reported. Most techniques (85.2%) were perceived to be dangerous, including methods recommended by the World Health Organization. A majority (61.4%) supported Brazil’s existing law permitting abortion in the case of rape. There was no association between gender, age, sexual debut, parental education or socioeconomic status and attitudes toward legal abortion. However, students at the magnet school supported twice as many legal indications (2.7, SE.27) suggesting a likely role of peers and/or educators in shaping abortion views.

Conclusions

Abortion knowledge and attitudes are not driven simply by age, religion or class, but rather a complex interplay that includes both social spaces and gender. Prevention of abortion morbidity and mortality among adolescents requires comprehensive sexuality and reproductive health education that includes factual distinctions between safe and unsafe abortion methods.

Equity of access to reproductive health services among youths in resource-limited suburban communities of Mandalay City, Myanmar

BACKGROUND

Inequity of accessibility to and utilization of reproductive health (RH) services among youths is a global concern, especially in resource-limited areas. The level of inequity also varies by cultural and socio-economic contexts. To tailor RH services to the needs of youths, relevant solutions are required. This study aimed to assess baseline information on access to and utilization of RH services and unmet needs among youths living in resource-limited, suburban communities of Mandalay City, Myanmar.

METHODS

A community-based, cross-sectional study was conducted in all resource-limited, suburban communities of Mandalay City, Myanmar. A total of 444 randomly selected youths aged between 15 and 24 years were interviewed for three main outcomes, namely accessibility to and utilization of RH services and youth's unmet needs for these services. Factors associated with these outcomes were determined using multivariate logistic regression.

RESULTS

Although geographical accessibility was high (79.3%), financial accessibility was low (19.1%) resulting in a low overall accessibility (34.5%) to RH services. Two-thirds of youths used some kind of RH services at least once in the past. Levels of unmet needs for sexual RH information, family planning, maternal care and HIV testing were 62.6%, 31.9%, 38.7% and 56.2%, respectively. Youths living in the south or south-western suburbs, having a deceased parent, never being married or never exposed to mass media were less likely to access RH services. Being a young adult, current student, working as a waste recycler, having ever experienced a sexual relationship, ever being married, ever exposed to mass media, having a high knowledge of RH services and providers or a high level of accessibility to RH services significantly increased the likelihood of utilization of those services. In addition to youths' socio-demographic characteristics, exposure to mass media, norm of peer exposure and knowledge on types of providers and services significantly influenced the unmet needs of youths towards RH services.

CONCLUSION

Despite the availability of RH services, youth's accessibility to and utilization of those services were unsatisfactory. The levels of youths' unmet RH needs were alarmingly high.

Using a GIS to model interventions to strengthen the emergency referral system for maternal and newborn health in Ethiopia

OBJECTIVES

To show how GIS can be used by health planners to make informed decisions about interventions to increase access to emergency services.

METHODS

A combination of data sources, including the 2008 national Ethiopian baseline assessment for emergency obstetric and newborn care that covered 797 geo-coded health facilities, LandScan population data, and road network data, were used to model referral networks and catchment areas across 2 regions of Ethiopia. STATA and ArcGIS software extensions were used to model different scenarios for strengthening the referral system, defined by the structural inputs of transportation and communication, and upgrading facilities, to compare the increase in access to referral facilities.

RESULTS

Approximately 70% of the population of Tigray and Amhara regions is served by facilities that are within a 2-hour transfer time to a hospital with obstetric surgery. By adding vehicles and communication capability, this percentage increased to 83%. In a second scenario, upgrading 7 strategically located facilities changed the configuration of the referral networks, and the percentage increased to 80%. By combining the 2 strategies, 90% of the population would be served by midlevel facilities within 2 hours of obstetric surgery. The mean travel time from midlevel facilities to surgical facilities would be reduced from 121 to 64 minutes in the scenario combining the 2 interventions.

CONCLUSIONS

GIS mapping and modeling enable spatial and temporal analyses critical to understanding the population's access to health services and the emergency referral system. The provision of vehicles and communication and the upgrading of health centers to first level referral hospitals are short- and medium-term strategies that can rapidly increase access to lifesaving services.