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Beaujoin C, Bila A, Bicaba F, Plouffe V, Bicaba A, Druetz T. Women's decision-making power in a context of free reproductive healthcare and family planning in rural Burkina Faso. BMC WOMENS HEALTH 2021; 21:272. [PMID: 34294057 PMCID: PMC8296726 DOI: 10.1186/s12905-021-01411-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/24/2021] [Indexed: 11/29/2022]
Abstract
Background In 2016, the national user fee exemption policy for women and children under five was introduced in Burkina Faso. It covers most reproductive healthcare services for women including prenatal care, delivery, and postnatal care. In subsequent years, the policy was gradually extended to include family planning. While studies have shown that user fee abolition policies increase visits to health centers and improve access to reproductive healthcare and family planning, there are also indications that other barriers remain, notably women’s lack of decision-making power. The objective of the study is to investigate women’s decision-making power regarding access to reproductive health and family planning in a context of free healthcare in rural Burkina Faso. Methods A descriptive qualitative study was carried out in rural areas of the Cascades and Center-West regions. Qualitative data were collected using individual semi-structured interviews (n = 20 participants) and focus groups (n = 15 participants) with Burkinabe women of childbearing age, their husbands, and key informants in the community. Data was analyzed using thematic analysis. Results A conceptual framework describing women’s participation in the decision-making process was built from the analysis. Results show that the user fee exemption policy contributes to improving access to reproductive care and family planning by facilitating the negotiation processes between women and their families within households. However, social norms and gender inequalities still limit women’s decision-making power. Conclusion In light of these results, courses of action that go beyond the user fee exemption policy should be considered to improve women’s decision-making power in matters of health, particularly with regard to family planning. Interventions that involve men and community members may be necessary to challenge the social norms, which act as determinants of women’s health and empowerment. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01411-4.
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Affiliation(s)
- Camille Beaujoin
- School of Public Health, University of Montreal, Montreal, QC, Canada.
| | - Alice Bila
- Société d'Études et de Recherche en Santé Publique (SERSAP), Ouagadougou, Burkina Faso
| | - Frank Bicaba
- Société d'Études et de Recherche en Santé Publique (SERSAP), Ouagadougou, Burkina Faso
| | | | - Abel Bicaba
- Société d'Études et de Recherche en Santé Publique (SERSAP), Ouagadougou, Burkina Faso
| | - Thomas Druetz
- School of Public Health, University of Montreal, Montreal, QC, Canada.,Centre de Recherche en Santé Publique (CReSP), Montreal, QC, Canada.,Center for Applied Malaria Research and Evaluation, Department of Tropical Medicine, Tulane University, New Orleans, LA, USA
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User fees removal and community-based management of undernutrition in Burkina Faso: what effects on children's nutritional status? Public Health Nutr 2021; 24:3768-3779. [PMID: 33593454 DOI: 10.1017/s1368980021000732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To examine the effect of an intervention combining user fees removal with community-based management of undernutrition on the nutrition status in children under 5 years of age in Burkina Faso. DESIGN The study was a non-equivalent control group post-test-only design based on household survey data collected 4 years after the intervention onset in the intervention and comparison districts. Additionally, we used propensity score weighting to achieve balance on covariates between the two districts, followed by logistic multilevel modelling. SETTING Two health districts in the Sahel region. PARTICIPANTS Totally, 1116 children under 5 years of age residing in 41 intervention communities and 1305 from 51 control communities. RESULTS When comparing children living in the intervention district to children living in a non-intervention district, we determined no differences in terms of stunting (OR = 1·13; 95 % CI 0·83, 1·54) and wasting (OR = 1·21; 95 % CI 0·90, 1·64), nor in severely wasted (OR = 1·27; 95 % CI 0·79, 2·04) and severely stunted (OR = 0·99; 95 % CI 0·76, 1·26). However, we determined that 3 % of the variance of wasting (95 % CI 1·25, 10·42) and 9·4 % of the variance of stunting (95 % CI 6·45, 13·38) were due to systematic differences between communities of residence. The presence of the intervention in the communities explained 2 % of the community-level variance of stunting and 3 % of the community-level variance of wasting. CONCLUSIONS With the scaling-up of the national free health policy in Africa, we stress the need for rigorous evaluations and the means to measure expected changes in order to better inform health interventions.
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Belaid L, Ochola E, Bayo P, Alii GW, Ogwang M, Greco D, Zarowsky C. Exploring the impact of a community participatory intervention on women's capability: a qualitative study in Gulu Northern Uganda. BMC WOMENS HEALTH 2021; 21:28. [PMID: 33461541 PMCID: PMC7812725 DOI: 10.1186/s12905-020-01170-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022]
Abstract
Background Community participatory interventions mobilizing women of childbearing age are an effective strategy to promote maternal and child health. In 2017, we implemented this strategy in Gulu Northern Uganda. This study explored the perceived impact of this approach on women's capability. Methods We conducted a qualitative study based on three data collection methods: 14 in-depth individual interviews with participating women of childbearing age, five focus group discussions with female facilitators, and document analysis. We used the Sen capability approach as a conceptual framework and undertook a thematic analysis. Results Women adopted safe and healthy behaviors for themselves and their children. They were also able to respond to some of their family's financial needs. They reported a reduction in domestic violence and in mistreatment towards their children. The facilitators perceived improved communication skills, networking, self-confidence, and an increase in their social status. Nevertheless, the women still faced unfreedoms that deprived them of living the life they wanted to lead. These unfreedoms are related to their lack of access to economic opportunities and socio-cultural norms underlying gender inequalities. Conclusion To expand women's freedoms, we need more collective political actions to tackle gender inequalities and need to question the values underlying women's social status.
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Affiliation(s)
- Loubna Belaid
- Family Medicine Department, McGill University, 5858 Chemin de la Côte des Neiges, Montreal, QC, Canada.
| | | | - Pontius Bayo
- St. Mary's Lacor Hospital, P.O. Box 180, Gulu, Uganda
| | | | - Martin Ogwang
- St. Mary's Lacor Hospital, P.O. Box 180, Gulu, Uganda
| | - Donato Greco
- International Prevention Research Institute, Allée Claude Debussy, 69130, Écully, Lyon, France
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Plouffe V, Bicaba F, Bicaba A, Druetz T. User fee policies and women's empowerment: a systematic scoping review. BMC Health Serv Res 2020; 20:982. [PMID: 33109172 PMCID: PMC7590470 DOI: 10.1186/s12913-020-05835-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 10/20/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Over the past decade, an increasing number of low- and middle-income countries have reduced or removed user fees for pregnant women and/or children under five as a strategy to achieve universal health coverage. Despite the large number of studies (including meta-analyses and systematic reviews) that have shown this strategy's positive effects impact on health-related indicators, the repercussions on women's empowerment or gender equality has been overlooked in the literature. The aim of this study is to systematically review the evidence on the association between user fee policies in low- and middle-income countries and women's empowerment. METHODS A systematic scoping review was conducted. Two reviewers conducted the database search in six health-focused databases (Pubmed, CAB Abstracts, Embase, Medline, Global Health, EBM Reviews) using English key words. The database search was conducted on February 20, 2020, with no publication date limitation. Qualitative analysis of the included articles was conducted using a thematic analysis approach. The material was organized based on the Gender at Work analytical framework. RESULTS Out of the 206 initial records, nine articles were included in the review. The study settings include three low-income countries (Burkina Faso, Mali, Sierra Leone) and two lower-middle countries (Kenya, India). Four of them examine a direct association between user fee policies and women's empowerment, while the others address this issue indirectly -mostly by examining gender equality or women's decision-making in the context of free healthcare. The evidence suggests that user fee removal contributes to improving women's capability to make health decisions through different mechanisms, but that the impact is limited. In the context of free healthcare, women's healthcare decision-making power remains undermined because of social norms that are prevalent in the household, the community and the healthcare centers. In addition, women continue to endure limited access to and control over resources (mainly education, information and economic resources). CONCLUSION User fee removal policies alone are not enough to improve women's healthcare decision-making power. Comprehensive and multi-sectoral approaches are needed to bring sustainable change regarding women's empowerment. A focus on "gender equitable access to healthcare" is needed to reconcile women's empowerment and the efforts to achieve universal health coverage.
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Affiliation(s)
| | - Frank Bicaba
- Société d'Études et de Recherches en Santé Publique (SERSAP), Ouagadougou, Burkina Faso
| | - Abel Bicaba
- Société d'Études et de Recherches en Santé Publique (SERSAP), Ouagadougou, Burkina Faso
| | - Thomas Druetz
- University of Montreal School of Public Health, Montreal, Canada.
- Centre de Recherche en Santé Publique, Montreal, Canada.
- Center for Applied Malaria Research and Evaluation, Tulane University, New Orleans, USA.
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Beaugé Y, De Allegri M, Ouédraogo S, Bonnet E, Kuunibe N, Ridde V. Do Targeted User Fee Exemptions Reach the Ultra-Poor and Increase their Healthcare Utilisation? A Panel Study from Burkina Faso. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186543. [PMID: 32911868 PMCID: PMC7559284 DOI: 10.3390/ijerph17186543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/25/2020] [Accepted: 09/02/2020] [Indexed: 12/22/2022]
Abstract
Background: A component of the performance-based financing intervention implemented in Burkina Faso was to provide free access to healthcare via the distribution of user fee exemption cards to previously identified ultra-poor. This study examines the factors that led to the receipt of user fee exemption cards, and the effect of card possession on the utilisation of healthcare services. Methods: A panel data set of 1652 randomly selected ultra-poor individuals was used. Logistic regression was applied on the end line data to identify factors associated with the receipt of user fee exemption cards. Random-effects modelling was applied to the panel data to determine the effect of the card possession on healthcare service utilisation among those who reported an illness six months before the surveys. Results: Out of the ultra-poor surveyed in 2017, 75.51% received exemption cards. Basic literacy (p = 0.03), living within 5 km from a healthcare centre (p = 0.02) and being resident in Diébougou or Gourcy (p = 0.00) were positively associated with card possession. Card possession did not increase health service utilisation (β = −0.07; 95% CI = −0.45; 0.32; p = 0.73). Conclusion: A better intervention design and implementation is required. Complementing demand-side strategies could guide the ultra-poor in overcoming all barriers to healthcare access.
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Affiliation(s)
- Yvonne Beaugé
- Heidelberg Institute for Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany; (M.D.A.); (N.K.)
- Correspondence: ; Tel.: +49-6221-56-35057; Fax: +49-6221-56-5948
| | - Manuela De Allegri
- Heidelberg Institute for Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany; (M.D.A.); (N.K.)
| | - Samiratou Ouédraogo
- The Canadian Institutes of Health Research (CIHR), Ottawa, ON K1A 0W9, Canada;
- National Public Health Institute of Quebec (INSPQ), Quebec City, QC G1V 5B3, Canada
- Department of Epidemiology, Biostatistics and Occupational Health (EBOH), Faculty of Medicine, McGill University, Montreal, QC H3A 1A2, Canada
| | - Emmanuel Bonnet
- French Institute for Research on Sustainable Development (IRD), Unité Mixte Internationale (UMI) Résiliences, 93143 Bondy, France;
| | - Naasegnibe Kuunibe
- Heidelberg Institute for Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany; (M.D.A.); (N.K.)
- Department of Economics and Entrepreneurship Development Studies, Faculty of Integrated Development Studies, University for Development Studies, P. O. Box 520, Wa, Upper West Region, Ghana
| | - Valéry Ridde
- French Institute for Research on sustainable Development (IRD), Centre Population et Développement (CEPED), Universités de Paris, ERL INSERM SAGESUD, 75006 Paris, France;
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Sia D, Dondbzanga BDG, Carabali M, Bonnet E, Enok Bonong PR, Ridde V. Effect of a free healthcare policy on health services utilisation for non-malarial febrile illness by children under five years in Burkina Faso: an interrupted time series analysis. Trop Med Int Health 2020; 25:1226-1234. [PMID: 32686252 DOI: 10.1111/tmi.13468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the effect of a free healthcare policy for children under five years old implemented in Burkina Faso since April 2016, on the use of health care of non-malarial febrile illnesses (NMFI). METHODS To assess the immediate and long-term effect of the free healthcare policy in place, we conducted an interrupted time series analysis of routinely collected data on febrile illnesses from three urban primary health centres of Ouagadougou between 1 January 2015 and 31 December 2016. RESULTS Of the 39 046 febrile cases reported in the study period, 17 017 NMFI were included in the study. Compared to the period before the intervention, we observed an immediate, non-statistically significant increase of 7% in the number of NMFI (IRR = 1.07; 95% CI = 0.75, 1.51). Compared to the trend that would have been expected in absence of the intervention, the results showed a small but sustained increase of 6% in the trend of monthly number of NMFI during the intervention period (IRR = 1.06; 95%CI = 1.01, 1.12). CONCLUSION Our study highlighted an increase in the uptake of healthcare services, specifically for NMFI by children under five years of age, after the implementation of a free care policy. This analysis contributes to informing decision makers on the need to strengthen the capacities of healthcare centres and to anticipate the challenges of the sustainability of this policy.
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Affiliation(s)
- D Sia
- University of Québec in Outaouais, Saint-Jérôme, QC, Canada
| | | | - M Carabali
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - E Bonnet
- IRD (French Institute for Research on Sustainable Development), UMI Résiliences, Bondy, France
| | - P R Enok Bonong
- Department of Médecine Préventive, University of Montréal, Montreal, Canada
| | - V Ridde
- IRD (French Institute for Research on Sustainable Development), UMI Résiliences, Bondy, France
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Ogundele OJ, Pavlova M, Groot W. Socioeconomic inequalities in reproductive health care services across Sub-Saharan Africa. A systematic review and meta-analysis. SEXUAL & REPRODUCTIVE HEALTHCARE 2020; 25:100536. [PMID: 32526462 DOI: 10.1016/j.srhc.2020.100536] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 05/01/2020] [Accepted: 05/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Women in Sub-Saharan African experience socioeconomic barriers in the use of reproductive health care services. This paper analyzes the evidence on socioeconomic inequalities in reproductive health care utilization in Sub-Saharan Africa and identifies the variance in the estimates of these inequalities. METHODS We performed a systematic review and meta-analysis of studies on socioeconomic inequalities in the use of reproductive health care services published between January 2008 and June 2019. We used meta-regression to identify heterogeneity sources in reproductive care services use. RESULTS Twenty-two studies were included and they reported 305 estimates of the concentration index for different reproductive health care services. We grouped the services into ten categories of reproductive health care services. Socioeconomic status was associated with inequality in reproductive health care use and was on average high, with a pro-wealthy inequality magnitude of the concentration index of 0.202. The meta-analysis indicated that inequality was highest for skilled childbirth services with an average concentration index of 0.343. The average concentration index for family planning and components of antenatal care was 0.268 and 0.142 respectively. Random-effects meta-regression showed that the heterogeneity in reproductive health care use was explained by contextual differences between countries. CONCLUSION The magnitude of inequality in reproductive health care use varies with the type of service and the focus on skilled childbirth services through user fees removal appears to have fostered inequality. The one-size-fits-all approach to reproductive health care initiatives has ignored differences in reproductive health care needs and the ability to overcome use barriers.
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Affiliation(s)
- Oluwasegun Jko Ogundele
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands.
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands
| | - Wim Groot
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands; Top Institute Evidence-Based Education Research (TIER), Maastricht University, the Netherlands
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Ridde V, Pérez D, Robert E. Using implementation science theories and frameworks in global health. BMJ Glob Health 2020; 5:e002269. [PMID: 32377405 PMCID: PMC7199704 DOI: 10.1136/bmjgh-2019-002269] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 11/20/2022] Open
Abstract
In global health, researchers and decision makers, many of whom have medical, epidemiology or biostatistics background, are increasingly interested in evaluating the implementation of health interventions. Implementation science, particularly for the study of public policies, has existed since at least the 1930s. This science makes compelling use of explicit theories and analytic frameworks that ensure research quality and rigour. Our objective is to inform researchers and decision makers who are not familiar with this research branch about these theories and analytic frameworks. We define four models of causation used in implementation science: intervention theory, frameworks, middle-range theory and grand theory. We then explain how scientists apply these models for three main implementation studies: fidelity assessment, process evaluation and complex evaluation. For each study, we provide concrete examples from research in Cuba and Africa to better understand the implementation of health interventions in global health context. Global health researchers and decision makers with a quantitative background will not become implementation scientists after reading this article. However, we believe they will be more aware of the need for rigorous implementation evaluations of global health interventions, alongside impact evaluations, and in collaboration with social scientists.
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Affiliation(s)
- Valéry Ridde
- CEPED, IRD (French Institute for Research on sustainable Development), Université de Paris, ERL INSERM SAGESUD, Paris, France
| | - Dennis Pérez
- Epidemiology Division, Pedro Kouri Tropical Medicine Institute (IPK), Havana, Cuba
| | - Emilie Robert
- ICARES and Centre de recherche SHERPA (Institut Universitaire au regard des communautés ethnoculturelles, CIUSSS du Centre-Ouest-de-l'Île-de-Montréal), Montreal, Quebec, Canada
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Ajayi AI. "I am alive; my baby is alive": Understanding reasons for satisfaction and dissatisfaction with maternal health care services in the context of user fee removal policy in Nigeria. PLoS One 2019; 14:e0227010. [PMID: 31869385 PMCID: PMC6927641 DOI: 10.1371/journal.pone.0227010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 12/09/2019] [Indexed: 11/25/2022] Open
Abstract
Background The main policy thrust in many sub-Saharan Africa countries’ aim at addressing maternal mortality is the elimination of the user fee for maternal healthcare services. While several studies have documented the effect of the user fee removal policy on the use of maternal health care services, the experiences of women seeking care in facilities offering free obstetrics services, their level of satisfaction and reasons for satisfaction or dissatisfaction are poorly understood. Methods This study adopted a mixed study design involving a population survey of 1227 women of reproductive age who gave birth in the last five years preceding the study (2011–2015), 68 in-depth interviews, and six focus group discussions. Simple descriptive statistics were performed on 407 women who benefitted from the user fee removal policy, while the qualitative data were analysed using thematic analysis. Results The overall level of satisfaction with care received was remarkably high (97.1%), with birth outcomes being the central reason for their satisfaction. Participants were also satisfied with both the process aspect of care (which includes health workers’ attitude and privacy) and the structural dimension of care (such as, the cleanliness of health care facilities and availability of and access to medicine). From the qualitative analysis, prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space were the main reasons why a few women were dissatisfied with care under free maternal health care. Conclusion The findings establish a high level of beneficiaries’ satisfaction with care under free maternal health policy in Nigeria, raising the need for sustaining the policy in expanding access to maternal health services for the poor. Nevertheless, issues relating to prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space require attention from policymakers.
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Affiliation(s)
- Anthony Idowu Ajayi
- Population Dynamics and Reproductive Health and Right Unit, African Population and Health Research Center, APHRC Campus, Nairobi, Kenya
- * E-mail:
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Masiano SP, Green TL, Dahman B, Kimmel AD. The effects of community-based distribution of family planning services on contraceptive use: The case of a national scale-up in Malawi. Soc Sci Med 2019; 238:112490. [PMID: 31437769 DOI: 10.1016/j.socscimed.2019.112490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 07/17/2019] [Accepted: 08/10/2019] [Indexed: 11/19/2022]
Abstract
RATIONALE Although many sub-Saharan African countries have scaled-up pilot projects of community-based distribution (CBD) of family planning services, the effects of the scaled-up CBDs on contraceptive use remain unclear. OBJECTIVE We leveraged a national scale-up of Malawi's Learning and Innovation Population and Family Planning pilot to evaluate the effects of a scale-up of CBDs on contraceptive use. We also investigated whether education and income, two important determinants of contraceptive use behaviors, moderate the effects of the scaled-up CBDs. METHOD We used the 2000/2004 and 2010/2016 Malawi Demographic and Health Surveys (N = 57,978) and difference-in-differences analyses to estimate the effects of the 2005 national scale-up of CBDs on modern contraceptive use. We used rural and urban communities as the intervention and comparison groups because the national CBDs were implemented only in rural communities. Contraceptive use is defined as the current use of any modern contraceptive method (e.g., pills) and was modelled using multilevel logistic regression. RESULTS Prior to the implementation of the national scale CBDs (2000/2004), the probability of using contraceptives was 21.5% in rural communities and 26.3% in urban communities. After the scale-up (2010/2016), the probability of using contraceptives increased in both rural and urban communities but was greater in rural communities (44.9% vs. 42.9%). The effect attributable to the national scale CBDs was 6.8 percentage points (95% CI [3.3, 9.7]). The effects of the national CBDs were greater among uneducated and low-income women. CONCLUSIONS These findings suggest that national CBDs increase overall contraceptive use, particularly in rural communities, and that poor and uneducated women benefit more from family planning interventions that reduce communication and financial barriers.
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Affiliation(s)
- Steven P Masiano
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi.
| | - Tiffany L Green
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Sombié I, Méda ZC, Blaise Geswendé Savadogo L, Télesphore Somé D, Fatoumata Bamouni S, Dadjoari M, Windsouri Sawadogo R, Sanon-Ouédraogo D. [Is the fight against maternal mortality in Burkina Faso adapted to reduce the three delays?]. SANTE PUBLIQUE 2018; 30:273-282. [PMID: 30148315 DOI: 10.3917/spub.182.0273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE Maternal mortality remains high in Burkina Faso despite numerous interventions designed to reduce this mortality. It therefore appeared important to analyse attempts to lower maternal mortality in Burkina Faso over the last fifteen years in order to identify the strengths and weaknesses and to improve the national programme. METHODS Analysis according to the ?three delays? model using the strengths, weaknesses, opportunities and threats method was conducted. Data sources were scientific publications as well as national gray literature. RESULTS Many studies have identified factors predisposing to the first delay, but very few effective interventions covering all of the country have been conducted to reduce this delay. The development of infrastructures, a rapid transfer system and integration of the cost of transfer into the cost of delivery subsidy were interventions designed to reduce the second delay. The promotion of blood transfusion, emergency obstetric and neonatal care, an increased number of trained health professionals, delegation of tasks, subsidy and then free delivery costs were interventions designed to reduce the third delay. The analysis globally demonstrated that interventions on the first delay were insufficient and rarely implemented and weaknesses were observed in relation to the intervention designed to act on the last two delays. CONCLUSION Due to their inadequacy and poor quality, the interventions failed to significantly reduce the three delays. Priority needs to be given to new interventions, especially community-based interventions, and reinforcement of the quality of care by health training.
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Ravit M, Audibert M, Ridde V, De Loenzien M, Schantz C, Dumont A. Do free caesarean section policies increase inequalities in Benin and Mali? Int J Equity Health 2018; 17:71. [PMID: 29871645 PMCID: PMC5989420 DOI: 10.1186/s12939-018-0789-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benin and Mali introduced user fee exemption policies focused on caesarean sections (C-sections) in 2005 and 2009, respectively. These policies had a positive impact on access to C-sections and facility based deliveries among all women, but the impact on socioeconomic inequality is still highly uncertain. The objective of this study was to observe whether there was an increase or a decrease in urban/rural and socioeconomic inequalities in access to C-sections and facility based deliveries after the free C-section policy was introduced. METHODS We used data from three consecutive Demographic and Health Surveys (DHS): 2001, 2006 and 2011-2012 in Benin and 2001, 2006 and 2012-13 in Mali. We evaluated trends in inequality in terms of two outcomes: C-sections and facility based deliveries. Adjusted odds ratios were used to estimate whether the distributions of C-sections and facility based deliveries favoured the least advantaged categories (rural, non-educated and poorest women) or the most advantaged categories (urban, educated and richest women). Concentration curves were used to observe the degree of wealth-related inequality in access to C-sections and facility based deliveries. RESULTS We analysed 47,302 childbirths (23,266 in Benin and 24,036 in Mali). In Benin, we found no significant difference in access to C-sections between urban and rural women or between educated and non-educated women. However, the richest women had greater access to C-sections than the poorest women. There was no significant change in these inequalities in terms of access to C-sections and facility based deliveries after introduction of the free C-section policy. In Mali, we found a reduction in education-related inequalities in access to C-sections after implementation of the policy (p-value = 0.043). Inequalities between urban and rural areas had already decreased prior to implementation of the policy, but wealth-related inequalities were still present. CONCLUSIONS Urban/rural and socioeconomic inequalities in C-section access did not change substantially after the countries implemented free C-section policies. User fee exemption is not enough. We recommend switching to mechanisms that combine both a universal approach and targeted action for vulnerable populations to address this issue and ensure equal health care access for all individuals.
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Affiliation(s)
- Marion Ravit
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France.
- Centre Population et Développement (CEPED), UMR 196 IRD-Université Paris Descartes, 45 rue des Saints-Pères, 75006, Paris, France.
| | - Martine Audibert
- Université Clermont Auvergne, CNRS, CERDI, F-63000, Clermont-Ferrand, France
| | - Valéry Ridde
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
- Institut de Recherche en Santé Publique de Montréal (IRSPUM), Montréal, Canada
| | - Myriam De Loenzien
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
| | - Clémence Schantz
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
| | - Alexandre Dumont
- IRD (French Institute For Research on sustainable Development), CEPED (IRD-Université Paris Descartes), Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, Paris, France
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