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Molenaar J, Beňová L, Christou A, Lange IL, van Olmen J. Travelling numbers and broken loops: A qualitative systematic review on collecting and reporting maternal and neonatal health data in low-and lower-middle income countries. SSM Popul Health 2024; 26:101668. [PMID: 38645668 PMCID: PMC11031824 DOI: 10.1016/j.ssmph.2024.101668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/27/2024] [Accepted: 04/02/2024] [Indexed: 04/23/2024] Open
Abstract
Data and indicator estimates are considered vital to document persisting challenges in maternal and newborn health and track progress towards global goals. However, prioritization of standardised, comparable quantitative data can preclude the collection of locally relevant information and pose overwhelming burdens in low-resource settings, with negative effects on the provision of quality of care. A growing body of qualitative studies aims to provide a place-based understanding of the complex processes and human experiences behind the generation and use of maternal and neonatal health data. We conducted a qualitative systematic review exploring how national or international requirements to collect and report data on maternal and neonatal health indicators are perceived and experienced at the sub-national and country level in low-income and lower-middle income countries. We systematically searched six electronic databases for qualitative and mixed-methods studies published between January 2000 and March 2023. Following screening of 4084 records by four reviewers, 47 publications were included in the review. Data were analysed thematically and synthesised from a Complex Adaptive Systems (CAS) theoretical perspective. Our findings show maternal and neonatal health data and indicators are not fixed, neutral entities, but rather outcomes of complex processes. Their collection and uptake is influenced by a multitude of system hardware elements (human resources, relevancy and adequacy of tools, infrastructure, and interoperability) and software elements (incentive systems, supervision and feedback, power and social relations, and accountability). When these components are aligned and sufficiently supportive, data and indicators can be used for positive system adaptivity through performance evaluation, prioritization, learning, and advocacy. Yet shortcomings and broken loops between system components can lead to unforeseen emergent behaviors such as blame, fear, and data manipulation. This review highlights the importance of measurement approaches that prioritize local relevance and feasibility, necessitating participatory approaches to define context-specific measurement objectives and strategies.
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Affiliation(s)
- Jil Molenaar
- Institute of Tropical Medicine Antwerp, Nationalestraat 155, 2000, Antwerp, Belgium
- University of Antwerp, Doornstraat 331, 2610, Wilrijk, Belgium
| | - Lenka Beňová
- Institute of Tropical Medicine Antwerp, Nationalestraat 155, 2000, Antwerp, Belgium
| | - Aliki Christou
- Institute of Tropical Medicine Antwerp, Nationalestraat 155, 2000, Antwerp, Belgium
| | - Isabelle L. Lange
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
- Center for Global Health, Technical University of Munich (TUM), Munich, Germany
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Solnes Miltenburg A, Kvernflaten B, Meguid T, Sundby J. Towards renewed commitment to prevent maternal mortality and morbidity: learning from 30 years of maternal health priorities. Sex Reprod Health Matters 2023; 31:2174245. [PMID: 36857112 PMCID: PMC9980022 DOI: 10.1080/26410397.2023.2174245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Affiliation(s)
- Andrea Solnes Miltenburg
- Associate Professor in Global Health, Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway; Resident in Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Akershus University Hospital, Lørenskog, Norway
| | - Birgit Kvernflaten
- Researcher, Department for Interdisciplinary Health Sciences, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Tarek Meguid
- Associate Professor, Consultant Obstetrician & Gynaecologist, Department of Maternal and Child Health, University of Namibia, Windhoek, Namibia
| | - Johanne Sundby
- Professor, Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
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Monfared IG, Garcia J, Vollmer S. Predictors of patients' choice of hospitals under universal health coverage: a case study of the Nicaraguan capital. BMC Health Serv Res 2021; 21:1356. [PMID: 34923972 PMCID: PMC8684609 DOI: 10.1186/s12913-021-07333-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study looks at the factors that can shape patients' choice of healthcare providers. Understanding this process can help with making high quality healthcare more accessible for all. We focus on distance, patient's health status, (perceived) quality of healthcare facility, and referrals to investigate how these factors compete in shaping patients' choice of hospitals. METHODS This study was carried out in Managua, the capital of Nicaragua. Utilizing an exit-survey, patients were interviewed across five public hospitals in 2017 and then six in 2019 when a new highly-equipped hospital was added to the system. We used a multinomial logit model to investigate patients' preference of a specific hospital over the rest within each wave. RESULTS Our results show that being referred to a hospital is the strongest predictor and in some cases, it can increase the relative risk ratio of choosing a facility by a factor of 49 (p < 0.01; 95% CI: 27.39-87.17). For the remaining factors, the hierarchy of importance was less clear-cut yet all these factors remained significantly important at various levels. CONCLUSIONS Overall, our results highlight the importance of referral systems in making quality healthcare more equitable. Moreover, with distance also being a key predictor and in the absence of an organized referral system, those with low-income would either be further deprived by having to settle with locally available healthcare (regardless of its quality) or face high amounts of out-of-pocket expenditure when seeking help from the private sector.
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Affiliation(s)
- Ida G. Monfared
- Centre for Modern Indian Studies & Department of Economics, University of Göttingen, Waldweg 26, 37073 Göttingen, Germany
| | - Jonathan Garcia
- Centre for Modern Indian Studies & Department of Economics, University of Göttingen, Waldweg 26, 37073 Göttingen, Germany
| | - Sebastian Vollmer
- Centre for Modern Indian Studies & Department of Economics, University of Göttingen, Waldweg 26, 37073 Göttingen, Germany
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Steeves-Reece A, Yuan N, Green L. A qualitative study exploring the role of community health workers in promoting maternal postpartum mental health in Nicaragua. JOURNAL OF GLOBAL HEALTH REPORTS 2019. [DOI: 10.29392/joghr.3.e2019089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Sochas L. Women who break the rules: Social exclusion and inequities in pregnancy and childbirth experiences in Zambia. Soc Sci Med 2019; 232:278-288. [PMID: 31112919 DOI: 10.1016/j.socscimed.2019.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
Health inequities are a growing concern in low- and middle-income countries, but reducing them requires a better understanding of underlying mechanisms. This study is based on 42 semi-structured interviews conducted in June 2018 with women who gave birth in the previous year, across rural and urban clinic sites in Mansa district, Zambia. Findings show that health facility rules regulating women's behaviour during pregnancy and childbirth create inequities in women's maternity experiences. The rules and their application can be understood as a form of social exclusion, discriminating against women with fewer financial and social resources. This study extends existing frameworks of social exclusion by demonstrating that the rules do not only originate in, but also reinforce, the structural processes that underpin inequitable social institutions. Legitimising the rules supports a moral order where women with fewer resources are constructed as "bad women", while efforts to follow the rules widen existing power differentials between socially excluded women and others. This study's findings have implications for the literature on reversed accountability and the unintended consequences of global and national safe motherhood targets, and for our understanding of disrespectful maternity care.
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Affiliation(s)
- Laura Sochas
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK.
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Kingdon C, Downe S, Betran AP. Interventions targeted at health professionals to reduce unnecessary caesarean sections: a qualitative evidence synthesis. BMJ Open 2018; 8:e025073. [PMID: 30559163 PMCID: PMC6303601 DOI: 10.1136/bmjopen-2018-025073] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/10/2018] [Accepted: 10/15/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To establish the views and experiences of healthcare professionals in relation to interventions targeted at them to reduce unnecessary caesareans. DESIGN Qualitative evidence synthesis. SETTING Studies undertaken in high-income, middle-income and low-income settings. DATA SOURCES Seven databases (CINAHL, MEDLINE, PsychINFO, Embase, Global Index Medicus, POPLINE and African Journals Online). Studies published between 1985 and June 2017, with no language or geographical restrictions. We hand-searched reference lists and key citations using Google Scholar. STUDY SELECTION Qualitative or mixed-method studies reporting health professionals' views. DATA EXTRACTION AND SYNTHESIS Two authors independently assessed study quality prior to extraction of primary data and authors' interpretations. The data were compared and contrasted, then grouped into summary of findings (SoFs) statements, themes and a line of argument synthesis. All SoFs were Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) assessed. RESULTS 17 papers were included, involving 483 health professionals from 17 countries (nine high-income, six middle-income and two low-income). Fourteen SoFs were identified, resulting in three core themes: philosophy of birth (four SoFs); (2) social and cultural context (five SoFs); and (3) negotiation within system (five SoFs). The resulting line of argument suggests three key mechanisms of effect for change or resistance to change: prior beliefs about birth; willingness or not to engage with change, especially where this entailed potential loss of income or status (including medicolegal barriers); and capacity or not to influence local community and healthcare service norms and values relating to caesarean provision. CONCLUSION For maternity care health professionals, there is a synergistic relationship between their underpinning philosophy of birth, the social and cultural context they are working within and the extent to which they were prepared to negotiate within health system resources to reduce caesarean rates. These findings identify potential mechanisms of effect that could improve the design and efficacy of change programmes to reduce unnecessary caesareans. PROSPERO REGISTRATION NUMBER CRD42017059455.
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Affiliation(s)
- Carol Kingdon
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Soo Downe
- School of Community Health and Midwifery, Faculty of Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Ana Pilar Betran
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Pot H, de Kok BC, Finyiza G. When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi. REPRODUCTIVE HEALTH MATTERS 2018; 26:126-136. [DOI: 10.1080/09688080.2018.1535688] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Hanneke Pot
- PhD candidate, Centre for Development and the Environment (SUM), University of Oslo, Oslo, Norway
| | - Bregje C de Kok
- Assistant Professor, Department of Anthropology, University of Amsterdam, Amsterdam, the Netherlands
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Melberg A, Diallo AH, Storeng KT, Tylleskär T, Moland KM. Policy, paperwork and ‘postographs’: Global indicators and maternity care documentation in rural Burkina Faso. Soc Sci Med 2018; 215:28-35. [DOI: 10.1016/j.socscimed.2018.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 09/01/2018] [Accepted: 09/03/2018] [Indexed: 11/17/2022]
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Contractor SQ, Das A, Dasgupta J, Van Belle S. Beyond the template: the needs of tribal women and their experiences with maternity services in Odisha, India. Int J Equity Health 2018; 17:134. [PMID: 30244683 PMCID: PMC6151937 DOI: 10.1186/s12939-018-0850-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 08/22/2018] [Indexed: 11/24/2022] Open
Abstract
Background Over the past 15 years, several efforts have been made by the Government of India to improve maternal health, primarily through providing cash incentives to increase institutional child birth and strengthen services in the public health system. The result has been a definite but unequal increase in the proportion of institutional deliveries, across geographical areas and social groups. Tribal (indigenous) communities are one such group in which the proportion of institutional deliveries is low. The persistence of these inequities indicates that a different approach is required to address the maternal health challenges in these communities. Methods This paper describes an exploratory study in Rayagada District of Odisha which aimed to understand tribal women’s experiences with pregnancy and childbirth and their interactions with the formal health system. Methods included in-depth interviews with women, traditional healers and formal health care providers and outreach workers, observations in the community and health facilities. Results The exploration of traditional practices shows that in this community, pregnancy and childbirth is treated as part of a natural process, not requiring external intervention. There is a well-established practice of birthing in the community which also recognizes the need for health system interventions in case of high-risk births or complications. However, there has been no effort by the health system to build on this traditional understanding of safety of woman and child. Instead, the system continues to rely on incentives and disincentives to motivate women. Traditional health providers who are important stakeholders have not been integrated into the health system. Despite the immense difficulties that women face, however, they do access health facilities, but barriers of distance, language, cultural inappropriateness of services, and experiences of gross violations have further compounded their distrust. Conclusions The results of the study suggest a re-examining of the very approach to addressing maternal health in this community. The study calls for reorienting maternal health services, to be responsive to the requirements of tribal women, cater to their cultural needs, provide support to domiciliary deliveries, invest in building trust with the community, and preserve beneficial traditional practices.
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Affiliation(s)
- Sana Q Contractor
- Centre for Health and Social Justice, Basement of Young Women's Hostel No. 2, Avenue 21, G Block, Saket, New Delhi, Delhi, 110017, India.
| | - Abhijit Das
- Centre for Health and Social Justice, Basement of Young Women's Hostel No. 2, Avenue 21, G Block, Saket, New Delhi, Delhi, 110017, India
| | | | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium
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Danielsen L. Mødrehelse som image og valuta. NORSK ANTROPOLOGISK TIDSSKRIFT 2018. [DOI: 10.18261/issn.1504-2898-2017-03-04-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
To achieve Millennium Development Goal 5 on maternal health, many countries have focused on marginalized women who lack access to care. Promoting facility-based deliveries to ensure skilled birth attendance and emergency obstetric care has become a main measure for preventing maternal deaths, so women who opt for home births are often considered 'marginal' and in need of targeted intervention. Drawing upon ethnographic data from Nicaragua, this paper critically examines the concept of marginality in the context of official efforts to increase institutional delivery amongst the rural poor, and discusses lack of access to health services among women living in peripheral areas as a process of marginalization. The promotion of facility birth as the new norm, in turn, generates a process of 're-marginalization', whereby public health officials morally disapprove of women who give birth at home, viewing them as non-compliers and a problem to the system. In rural Nicaragua, there is a discrepancy between the public health norm and women's own preferences and desires for home birth. These women live at the margins also in spatial and societal terms, and must relate to a health system they find incapable of providing good, appropriate care. Strong public pressure for institutional delivery makes them feel distressed and pressured. Paradoxically then, the aim of including marginal groups in maternal health programmes engenders resistance to facility birth.
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Affiliation(s)
- Birgit Kvernflaten
- a Centre for Development and the Environment , University of Oslo , Oslo , Norway
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Melberg A, Diallo AH, Ruano AL, Tylleskär T, Moland KM. Reflections on the Unintended Consequences of the Promotion of Institutional Pregnancy and Birth Care in Burkina Faso. PLoS One 2016; 11:e0156503. [PMID: 27258012 PMCID: PMC4892534 DOI: 10.1371/journal.pone.0156503] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/16/2016] [Indexed: 11/23/2022] Open
Abstract
The policy of institutional delivery has been the cornerstone of actions aimed at monitoring and achieving MDG 5. Efforts to increase institutional births have been implemented worldwide within different cultural and health systems settings. This paper explores how communities in rural Burkina Faso perceive the promotion and delivery of facility pregnancy and birth care, and how this promotion influences health-seeking behaviour. A qualitative study was conducted in South-Western Burkina Faso between September 2011 and January 2012. A total of 21 in-depth interviews and 8 focus group discussions with women who had given birth recently and community members were conducted. The data were analyzed using qualitative content analysis and interpreted through Merton’s concept of unintended consequences of purposive social action. The study found that community members experienced a strong pressure to give birth in a health facility and perceived health workers to define institutional birth as the only acceptable option. Women and their families experienced verbal, economic and administrative sanctions if they did not attend services and adhered to health worker recommendations, and reported that they felt incapable of questioning health workers’ knowledge and practices. Women who for social and economic reasons had limited access to health facilities found that the sanctions came with increased cost for health services, led to social stigma and acted as additional barriers to seek skilled care at birth. The study demonstrates how the global and national policy of skilled pregnancy and birth care can occur in unintentional ways in local settings. The promotion of institutional care during pregnancy and at birth in the study area compromised health system trust and equal access to care. The pressure to use facility care and the sanctions experienced by women not complying may further marginalize women with poor access to facility care and contribute to worsened health outcomes.
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Affiliation(s)
- Andrea Melberg
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- * E-mail:
| | - Abdoulaye Hama Diallo
- Centre MURAZ, Ministère de la Santé, Bobo-Dioulasso, Burkina Faso
- Department of Public Health, UFR-SDS, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Ana Lorena Ruano
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Center for the Study of Equity and Governance in Health Systems, Guatamala city, Guatemala
| | - Thorkild Tylleskär
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Karen Marie Moland
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
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