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Armah-Ansah EK, Budu E, Wilson EA, Oteng KF, Gyawu NO, Ahinkorah BO, Ameyaw EK. What predicts health facility delivery among women? analysis from the 2021 Madagascar Demographic and Health Survey. BMC Pregnancy Childbirth 2024; 24:116. [PMID: 38326785 PMCID: PMC10848540 DOI: 10.1186/s12884-024-06252-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/03/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND One of the pivotal determinants of maternal and neonatal health outcomes hinges on the choice of place of delivery. However, the decision to give birth within the confines of a health facility is shaped by a complex interplay of sociodemographic, economic, cultural, and healthcare system-related factors. This study examined the predictors of health facility delivery among women in Madagascar. METHODS We used data from the 2021 Madagascar Demographic and Health Survey. A total of 9,315 women who had a health facility delivery or delivered elsewhere for the most recent live birth preceding the survey were considered in this analysis. Descriptive analysis, and multilevel regression were carried out to determine the prevalence and factors associated with health facility delivery. The results were presented as frequencies, percentages, crude odds ratios and adjusted odds ratios (aORs) with corresponding 95% confidence intervals (CIs), and a p-value < 0.05 was used to declare statistical significance. RESULTS The prevalence of health facility delivery was 41.2% [95% CI: 38.9-43.5%]. In the multilevel analysis, women aged 45-49 [aOR = 2.14, 95% CI = 1.34-3.43], those with secondary/higher education [aOR = 1.62, 95% CI = 1.30-2.01], widowed [aOR = 2.25, 95% CI = 1.43-3.58], and those exposed to mass media [aOR = 1.18, 95% CI = 1.00-1.39] had higher odds of delivering in health facilities compared to those aged 15-49, those with no formal education, women who had never been in union and not exposed to mass media respectively. Women with at least an antenatal care visit [aOR = 6.95, 95% CI = 4.95-9.77], those in the richest wealth index [aOR = 2.74, 95% CI = 1.99-3.77], and women who considered distance to health facility as not a big problem [aOR = 1.28, 95% CI = 1.09-1.50] were more likely to deliver in health facilities compared to those who had no antenatal care visit. Women who lived in communities with high literacy levels [aOR = 1.54, 95% CI = 1.15-2.08], and women who lived in communities with high socioeconomic status [aOR = 1.72, 95% CI = 1.28-2.31] had increased odds of health facility delivery compared to those with low literacy levels and in communities with low socioeconomic status respectively. CONCLUSION The prevalence of health facility delivery among women in Madagascar is low in this study. The findings of this study call on stakeholders and the government to strengthen the healthcare system of Madagascar using the framework for universal health coverage. There is also the need to implement programmes and interventions geared towards increasing health facility delivery among adolescent girls and young women, women with no formal education, and those not exposed to media. Also, consideration should be made to provide free maternal health care and a health insurance scheme that can be accessed by women in the poorest wealth index. Health facilities should be provided at places where women have challenges with distance to other health facilities. Education on the importance of antenatal care visits should also be encouraged, especially among women with low literacy levels and in communities with low socioeconomic status.
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Affiliation(s)
- Ebenezer Kwesi Armah-Ansah
- Department of Population and Development, National Research University - Higher School of Economics, Moscow, Russia.
- Population Dynamics Sexual and Reproductive Health Unit, African Population and Health Research Center, Nairobi, Kenya.
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana.
| | - Eugene Budu
- Korle Bu Teaching Hospital, P. O. Box, 77, Accra, Ghana
| | - Elvis Ato Wilson
- Kintampo Health Research Centre, Ghana Health Service, Kintampo, Ghana
| | - Kenneth Fosu Oteng
- Ashanti Regional Health Directorate, Ghana Health Service, Kumasi, Ghana
| | - Nhyira Owusuaa Gyawu
- Quality management Unit, Korle Bu Teaching Hospital, P. O. Box, 77, Accra, Ghana
| | | | - Edward Kwabena Ameyaw
- Institute of Policy Studies and School of Graduate Studies, Lingnan University, Tuen Mun, Hong Kong
- L & E Research Consult Ltd, Upper West Region, Wa, Ghana
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Sully EA, Seme A, Shiferaw S, Chiu DW, Bell SO, Giorgio M. Impact of the global gag rule on women's contraceptive use and reproductive health outcomes in Ethiopia: a pre-post and difference-in-difference analysis. BMJ Open 2023; 13:e063099. [PMID: 37147096 PMCID: PMC10163537 DOI: 10.1136/bmjopen-2022-063099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVE To assess the impacts of the Protecting Life through Global Health Assistance policy (otherwise known as the expanded global gag rule (GGR)) on women's sexual and reproductive health (SRH) in Ethiopia. The GGR prohibits all non-US non-governmental organisations (NGOs) receiving US Government global health funding from providing, referring or advocating for abortion. DESIGN Pre-post analysis and difference-in-difference analysis. SETTING Six regions of Ethiopia (Tigray, Afar, Amhara, Oromiya, SNNPR and Addis Ababa). PARTICIPANTS Panel of 4909 reproductive-age women recruited from the Performance Monitoring for Accountability 2018 survey, administered face-to-face surveys in 2018 and 2020. MEASURES We assessed impacts of the GGR on contraceptive use, pregnancies, births and abortions. Due to the 2019 'Pompeo Expansion' and widespread application of the GGR, we use a pre-post analysis to investigate changes in women's reproductive outcomes. We then use a difference-in-differences design to measure the additional effect of NGOs refusal to comply with the policy and the resulting loss in funding; districts are classified as more exposed if organisations impacted by lost funding were providing services there and women are classified based on their district. RESULTS At baseline, 27% (n=1365) of women were using a modern contraceptive (7% using long-acting reversible contraceptive methods (LARCs) and 20% using short-acting methods. The pre-post analysis revealed statistically significant declines from 2018 to 2020 in the use of LARCs (-0.9, 95% CI: -1.6 to -0.2) and short-acting methods (-1.0, 95% CI: -1.8 to -0.2). These changes were deviations from prior trends. In our difference-in-differences analysis, women exposed to non-compliant organisations experienced greater declines in LARC use (-1.5, 95% CI: -2.9 to -0.1) and short-acting method use (-1.7, 95% CI: -3.2 to -0.1) as compared with less-exposed women. CONCLUSIONS The GGR resulted in a stagnation in the previous growth in contraceptive use in Ethiopia. Longer-term strategies are needed to ensure that SRH progress globally is protected from changes in US political administrations.
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Affiliation(s)
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Doris W Chiu
- Guttmacher Institute, New York city, New York, USA
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Scobie K, Lambin X, Telfer S, Rasahivelo MF, Raheliarison RN, Rajerison M, Young J. Living with rodent pests: Unifying stakeholder interests to prioritise pest management in rural Madagascar. PEOPLE AND NATURE 2023. [DOI: 10.1002/pan3.10438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
| | | | | | | | | | | | - Juliette Young
- Agroécologie, INRAE Institut Agro, Université de Bourgogne Franche‐Comté Dijon France
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Giorgio M, Makumbi F, Kibira SPS, Bell SO, Chiu DW, Firestein L, Sully E. An investigation of the impact of the Global Gag Rule on women's sexual and reproductive health outcomes in Uganda: a difference-in-differences analysis. Sex Reprod Health Matters 2022; 30:2122938. [PMID: 36259938 PMCID: PMC9586624 DOI: 10.1080/26410397.2022.2122938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In 2017, the Trump administration reinstated the Global Gag Rule (GGR), making non-U.S. non-governmental organisations ineligible for US government global health assistance if they provide access to or information about abortion. Little is known about the impact of the Trump administration’s GGR on women’s outcomes. Data for this analysis come from a panel of women surveyed in 2018 and 2019 in Uganda (n = 2755). We also used data from meetings with key stakeholders to create a detailed measure of exposure to the GGR within Uganda, classifying districts as more or less exposed to the GGR. Multivariable regression models were used to assess changes in contraceptive use, all births, unplanned births, and abortion from before to during implementation of the GGR. Difference-in-differences (DID) estimates were determined by calculating predicted probabilities from interaction terms for exposure/survey round. Descriptive analyses showed long-acting reversible contraceptive use increased more rapidly among women in less exposed districts after GGR implementation. DID estimates for contraceptive use were small. We observed a DID estimate of 3.5 (95% CI −0.9, 7.9) for all births and 2.9 (95% CI −0.2, 6.0) for unplanned births for women in more exposed districts during the period the policy was in effect. Our results suggest that the GGR may have attenuated Uganda’s recent progress in improving SRHR outcomes, with women in less exposed districts continuing to benefit from this progress, while previously increasing trends for women in more exposed districts levelled off. Although the GGR was rescinded in January 2021, the impact of these disruptions may be felt for years to come.
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Affiliation(s)
- Margaret Giorgio
- Senior Research Scientist, Guttmacher Institute, 125 Maiden Lane 7th Floor, New York, NY10038, USA. Correspondence:
| | - Fredrick Makumbi
- Senior Lecturer and Departmental Chair, Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Simon P. S. Kibira
- Lecturer, School of Public Health, College of Health Sciences, Makerere University, New Mulago Hill Road, Kampala, Uganda
| | - Suzanne O. Bell
- Assistant Professor, Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Doris W. Chiu
- Senior Research Assistant, Guttmacher Institute, New York, NY, USA
| | | | - Elizabeth Sully
- Senior Research Scientist, Guttmacher Institute, New York, NY, USA
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Maistrellis E, Juma K, Khanal A, Kimemia G, McGovern T, Midy AC, Rakotondratsara MA, Ratsimbazafy MR, Ravaoarisoa L, Razafimahatratra MJJ, Tamang A, Tamang J, Ushie BA, Casey S. Beyond abortion: impacts of the expanded global gag rule in Kenya, Madagascar and Nepal. BMJ Glob Health 2022; 7:bmjgh-2022-008752. [PMID: 35853673 PMCID: PMC9301792 DOI: 10.1136/bmjgh-2022-008752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/25/2022] [Indexed: 11/10/2022] Open
Abstract
Since 1984, Republican administrations in the US have enacted the global gag rule (GGR), which prohibits non-US-based non-governmental organisations (NGOs) from providing, referring for, or counselling on abortion as a method of family planning, or advocating for the liberalisation of abortion laws, as a condition for receiving certain categories of US Global Health Assistance. Versions of the GGR implemented before 2017 applied to US Family Planning Assistance only, but the Trump administration expanded the policy’s reach by applying it to nearly all types of Global Health Assistance. Documentation of the policy’s harms in the peer-reviewed and grey literature has grown considerably in recent years, however few cross-country analyses exist. This paper presents a qualitative analysis of the GGR’s impacts across three countries with distinct abortion laws: Kenya, Madagascar and Nepal. We conducted 479 in-depth qualitative interviews between August 2018 and March 2020. Participants included representatives of Ministries of Health and NGOs that did and did not certify the GGR, providers of sexual and reproductive health (SRH) services at public and private facilities, community health workers, and contraceptive clients. We observed greater breakdown of NGO coordination and chilling effects in countries where abortion is legal and there is a sizeable community of non-US-based NGOs working on SRH. However, we found that the GGR fractured SRH service delivery in all countries, irrespective of the legal status of abortion. Contraceptive service availability, accessibility and training for providers were particularly damaged. Further, this analysis makes clear that the GGR has substantial and deleterious effects on public sector infrastructure for SRH in addition to NGOs.
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Affiliation(s)
- Emily Maistrellis
- Global Health Justice and Governance, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Kenneth Juma
- African Population and Heath Research Center, Nairobi, Kenya
| | - Aagya Khanal
- Center for Research on Environment, Health and Population Activities, Kathmandu, Nepal
| | - Grace Kimemia
- African Population and Heath Research Center, Nairobi, Kenya
| | - Terry McGovern
- Global Health Justice and Governance, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Anne-Caroline Midy
- Global Health Justice and Governance, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
| | | | | | | | | | - Anand Tamang
- Center for Research on Environment, Health and Population Activities, Kathmandu, Nepal
| | - Jyotsna Tamang
- Center for Research on Environment, Health and Population Activities, Kathmandu, Nepal
| | | | - Sara Casey
- Global Health Justice and Governance, Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York, USA
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Sully EA, Shiferaw S, Seme A, Bell SO, Giorgio M. Impact of the Trump Administration's Expanded Global Gag Rule Policy on Family Planning Service Provision in Ethiopia. Stud Fam Plann 2022; 53:339-359. [PMID: 35639923 PMCID: PMC9328269 DOI: 10.1111/sifp.12196] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The Global Gag Rule (GGR) makes non‐U.S. nongovernmental organizations (NGOs) ineligible for U.S. Government global health funding if they provide, refer, or promote access to abortion. This study quantitatively examines the impacts of the GGR on family planning service provision in Ethiopia. Using a panel of health facilities (2017–2020), we conduct a pre–post analysis to investigate the overall changes in family planning service provision before and after the policy came into effect in Ethiopia. Our pre–post analyses revealed post‐GGR reductions in the proportions of facilities reporting family planning provision through community health volunteers (−5.6, 95% CI [−10.2, −1.0]), mobile outreach visits (−13.1, 95% CI [−17.8, −8.4]), and family planning and postabortion care service integration (−4.8, 95% CI: [−9.1, −0.5]), as well as a 6.1 percentage points increase in contraceptive stock‐outs over the past three months (95% CI [−0.6, 12.8]). We further investigate the impacts of the GGR on facilities exposed to noncompliant organizations that did not sign the policy and lost U.S. funding. We do not find any significant additional impacts on facilities in regions more exposed to noncompliant organizations. Overall, while the GGR was slow to fully impact NGOs in Ethiopia, it ultimately resulted in negative impacts on family planning service provision.
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Affiliation(s)
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
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McGovern T, Tamang A. Exporting bad policy: an introduction to the special issue on the GGR's impact. Sex Reprod Health Matters 2020; 28:1831748. [PMID: 33081627 PMCID: PMC7888030 DOI: 10.1080/26410397.2020.1831748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Terry McGovern
- Chair, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, USA
| | - Anand Tamang
- Director, Center for Research on Environment Health and Population Activities, Kathmandu, Nepal
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