Initiation and continuity of maternal healthcare: examining the role of vouchers and user-fee removal on maternal health service use in Kenya

Temporal changes in cause of death among adolescents and adults in six countries in eastern and southern Africa in 1995-2019: a multi-country surveillance study of verbal autopsy data

BACKGROUND

The absence of high-quality comprehensive civil registration and vital statistics systems across many settings in Africa has led to little empirical data on causes of death in the region. We aimed to use verbal autopsy data to provide comparative, population-based estimates of cause-specific mortality among adolescents and adults in eastern and southern Africa.

METHODS

In this surveillance study, we harmonised verbal autopsy and residency data from nine health and demographic surveillance system (HDSS) sites in Kenya, Malawi, Tanzania, South Africa, Uganda, and Zimbabwe, each with variable coverage from Jan 1, 1995, to Dec 31, 2019. We included all deaths to adolescents and adults aged 12 or over that were residents of the study sites and had a verbal autopsy conducted. InSilicoVA, a probabilistic model, was used to assign cause of death on the basis of the signs and symptoms reported in the verbal autopsy. Levels and trends in all-cause and cause-specific mortality rates and cause-specific mortality fractions were calculated, stratified by HDSS site, sex, age, and calendar periods.

FINDINGS

52 484 deaths and 5 157 802 person-years were reported among 1 071 913 individuals across the nine sites during the study period. 47 961 (91·4%) deaths had a verbal autopsy, of which 46 570 (97·1%) were assigned a cause of death. All-cause mortality generally decreased across the HDSS sites during this period, particularly for adults aged 20-59 years. In many of the HDSS sites, these decreases were driven by reductions in HIV and tuberculosis-related deaths. In 2010-14, the top causes of death were: road traffic accidents, HIV or tuberculosis, and meningitis or sepsis in adolescents (12-19 years); HIV or tuberculosis in adults aged 20-59 years; and neoplasms and cardiovascular disease in adults aged 60 years and older. There was greater between-HDSS and between-sex variation in causes of death for adolescents compared with adults.

INTERPRETATION

This study shows progress in reducing mortality across eastern and southern Africa but also highlights age, sex, within-HDSS, and between-HDSS differences in causes of adolescent and adult deaths. These findings highlight the importance of detailed local data to inform health needs to ensure continued improvements in survival.

FUNDING

National Institute of Child Health and Human Development of the US National Institutes of Health.

The continuum of care for maternal health in Africa: A systematic review and meta-analysis

BACKGROUND

The continuum of care for maternal health (COCM) is a critical strategy for addressing preventable causes of maternal and perinatal mortality. Despite notable progress in reducing maternal and infant deaths globally, the problem persists, particularly in low-resource settings. Additionally, significant disparities in the provision of continuous care exist both between continents and within countries on the same continent. This study aimed to assess the pooled prevalence of completion across the maternity care continuum in Africa and investigate the associated factors.

METHODS

Relevant articles were accessed through the EMBASE, CINAHL, Cochrane Library, PubMed, HINARI, and Google Scholar databases. Funnel plots and Egger's test were employed to assess publication bias, while the I-squared test was used to evaluate study heterogeneity. The inclusion criteria were limited to observational studies conducted exclusively in Africa. The quality of these studies was assessed using the JBI checklist. Data extraction from the included studies was performed using Microsoft Excel and then analysed using Stata 16 software.

RESULTS

A total of 23 studies involving 74,880 mothers met the inclusion criteria. The overall prevalence of women who successfully completed the COCM was 20.9% [95% CI: 16.9-25.0]. Our analysis revealed several factors associated with this outcome, including urban residency [OR: 2.3; 95% CI: 1.6-3.2], the highest wealth index level [OR: 2.1; 95% CI: 1.4-3.0], primiparous status [OR: 1.3; 95% CI: 2.2-5.1], planned pregnancy [OR: 3.0; 95% CI: 2.3-3.7], and exposure to mass media [OR: 2.7; 95% CI: 1.9-3.8].

CONCLUSION

The study revealed that only 20.9% of women fully completed the COCM. It also identified several factors associated with completion of the COCM, such as residing in urban areas, possessing a higher wealth index, being a first-time mother, experiencing a planned pregnancy, and having access to mass media. Based on the study's findings, it is recommended that targeted interventions be implemented in rural areas, financial assistance be provided to women with lower wealth index levels, educational campaigns be conducted through mass media, early antenatal care be promoted, and family planning services be strengthened.

REVIEW REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42020205736).

Private sector quality of care for maternal, new-born, and child health in low-and-middle-income countries: a secondary review

The private sector has emerged as a crucial source of maternal, newborn, and child health (MNCH) care in many low- and middle-income countries (LMICs). Quality within the MNCH private sector varies and has not been established systematically. This study systematically reviews findings on private-sector delivery of quality MNCH care in LMICs through the six domains of quality care (QoC) (i.e., efficiency, equity, effectiveness, people-centered care, safety, and timeliness). We registered the systematic review with PROSPERO international prospective register of systematic reviews (registration number CRD42019143383) and followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement for clear and transparent reporting of systematic reviews and meta-analyses. Searches were conducted in eight electronic databases and two websites. For inclusion, studies in LMICs must have examined at least one of the following outcomes using qualitative, quantitative, and/or mixed-methods: maternal morbidity, maternal mortality, newborn morbidity, newborn mortality, child morbidity, child mortality, service utilization, quality of care, and/or experience of care including respectful care. Outcome data was extracted for descriptive statistics and thematic analysis. Of the 139 included studies, 110 studies reported data on QoC. Most studies reporting on QoC occurred in India (19.3%), Uganda (12.3%), and Bangladesh (8.8%). Effectiveness was the most widely measured quality domain with 55 data points, followed by people-centered care (n = 52), safety (n = 47), timeliness (n = 31), equity (n = 24), and efficiency (n = 4). The review showed inconsistencies in care quality across private and public facilities, with quality varying across the six domains. Factors such as training, guidelines, and technical competence influenced the quality. There were also variations in how domains like "people-centered care" have been understood and measured over time. The review underscores the need for clearer definitions of "quality" and practical QoC measures, central to the success of Sustainable Development Goals (SDGs) and equitable health outcomes. This research addresses how quality MNCH care has been defined and operationalized to understand how quality is delivered across the private health sector and the larger health system. Numerous variables and metrics under each QoC domain highlight the difficulty in systematizing QoC. These findings have practical significance to both researchers and policymakers.

Systematic Review Registration

https://bmjopen.bmj.com/content/10/2/e033141.long, Identifier [CRD42019143383].

User Fee Exemption Policy Significantly Improved Adherence to Maternal Health Service Utilization in Bahir Dar City, Northwest Ethiopia: A Comparative Cross-Sectional Study

Background

Increasing free and skilled delivery is a top priority in the global effort to reduce maternal and newborn mortality. Reducing user-fees through exemption policy has contributed to universal health coverage. However, there is scant evidence regarding the effect of exempted maternal services on adherence to utilization in Ethiopia. Thus, this study aimed to assess the effect of fee exemption policy on adherence to maternal health service utilization and its predictors.

Methods

A community-based comparative cross-sectional study was conducted in Bahir Dar City. A two-stage multistage sampling was employed; 497 women participated. Data were collected by face-to-face interview; entered and cleaned using Epi-Data 3.1. SPSS version 25 was used for further analysis. Bivariable and multivariable logistic regression models were computed to assess the association between explanatory and outcome variables. An adjusted odds ratio with a 95% confidence interval was used to interpret the degree of association. The effect of fee exemption policy on adherence to maternal health service utilization was measured by propensity score matching.

Results

The overall adherence to maternal service utilization was 54.2%. Factors associated with adherence to maternal health service utilization were pregnancy complications [AOR: 4.1, 95% CI (2.32, 7.28)], secondary and above education [AOR: 4.6, 95% CI (1.38, 15.08)], early ANC1 booking [AOR: 3.1, 95% CI (1.83, 5.16)], autonomous women [AOR: 2.1, 95% CI (1.02, 4.39)], user fee exemption [AOR: 2.3, 95% CI (1.20, 4.47)] and high parity [AOR: 0.39, 95% CI (0.2, 0.75)]. User fee exemption induced a 22.7% increment in adherence to maternal service utilization (ATET=0.227, t=2.13).

Conclusion

User fee exemption policy significantly improved adherence to maternal health service utilization. Promoting a fee exemption policy through third-party financing can enhance maternal health service utilization adherence in hard-to-reach settings of Ethiopia by targeting mothers with higher pregnancies, no complications, no autonomy, and less education.

Complete continuum of maternity care and associated factors among mothers who gave birth in the last twelve months in Mekane Selam town North-East Ethiopia: A community-based cross-sectional study,2021

BACKGROUND

Complete continuum of maternity care has significant value in improving the health and wellbeing of mothers and newborns. Assessing the complete continuum of maternity care is a global priority, particularly in developing countries. Despite the fact that the complete continuum of maternity care prevents more than half of all maternal and neonatal deaths, Ethiopia remains one of the largest contributors to the global burden of maternal and neonatal deaths due to the low implementation of the complete continuum of maternity care. Thus, this study aimed to assess the coverage of the complete continuum of maternity care and associated factors among mothers who gave birth in the last 12 months in the study area.

METHODS

A community-based cross-sectional study with a multistage sampling technique was conducted among 479 mothers who gave birth in the last 12 months in Mekane Selam town. Data were collected from September 1 to November 30/2021 using an interviewer-administered questionnaire. Binary logistic regression analysis was computed. In multivariable logistic regression analysis, an adjusted odds ratio (AOR) with a 95% confidence interval (CI) and a P- value< 0.05 were used to identify significantly associated factors.

RESULTS

The coverage of a complete continuum of maternity care was 42.4% (95% CI: 37.9%, 47%). Respondents with higher educational status (AOR = 4.17, 95% CI: 1.52, 11.44), pre-pregnancy contraception utilization (AOR = 3.53, 95% CI: 1.80, 6.92), planned pregnancy (AOR = 2.97, 95% CI: 1.27, 6.97) and early initiation of antenatal care (AOR = 4.57, 95% CI: 2.86, 7.31) were significantly associated with complete continuum of maternity care.

CONCLUSION

The coverage of complete continuum of maternal care was low in the study area. The coverage could be expanded by making the necessary interventions on the associated factors. It is essential for women to acquire education, utilize contraception, plan their pregnancies, and begin antenatal care at an early age in order to enhance the coverage of complete continuum of maternity care.

Timely Initiation of Antenatal Care and Associated Factors among Pregnant Women Attending at Wachemo University Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital, Hossana, Ethiopia: A Cross-Sectional Study

Background. Timely detection and treatment of pregnancy-related or preexisting diseases, health education, and the promotion of adequate care provision improve the health of mothers and unborn children. As such, these factors are crucial within the first pregnancy trimester. However, very few women in low and middle-income countries initiate their first ANC in the recommended trimester of pregnancy. This study is aimed at assessing the prevalence of timely initiation of ANC and its associated factors among pregnant women attending antenatal clinics in Wachemo University Nigist Eleni Mohammed Memorial comprehensive specialized hospital, Hossana, Ethiopia. Methods. A hospital-based cross-sectional study was conducted from April 4, 2022 to May 19, 2022. A systematic sampling technique was used to select study participants. Data were collected from pregnant women using a pretested structured interview questionnaire. EpiData version 3.1 was used to enter the data, and SPSS version 24 was used to analyze it. Bivariate and multivariable logistic regression were used to identify the associated factors at a 95% confidence interval with a $p$ value < 0.05. Results. This study indicated that 118 (34.3%) of the women initiated ANC timely. The factors associated with timely initiation of ANC included women aged 25–34 years ( $\text{AOR}=0.3$ ; 95% CI: (0.1, 0.7)), tertiary maternal education ( $\text{AOR}=3.2$ , 95% CI: (1.0, 9.9)), zero parity ( $\text{AOR}=7.7$ ; 95% CI: (3.6, 15.3)), planned pregnancy ( $\text{AOR}=13.7$ ; 95% CI: (5.5, 34.3)), good knowledge about ANC services ( $\text{AOR}=3.1$ ; 95% (CI: (2.3, 11.3)), and good knowledge about danger signs in pregnancy ( $\text{AOR}=4.8$ ; 95% CI: (2.2, 8.1)). Conclusion. This study demonstrates the importance of making a significant effort to increase the coverage of timely ANC initiation in the study area. Therefore, increasing the awareness level of mothers regarding ANC services given during pregnancy and danger signs in pregnancy and advancing the academic level of mothers are essential to increase the coverage of timely initiation of ANC.

Effects of women's economic empowerment interventions on antenatal care outcomes: a systematic review

OBJECTIVES

Early and adequate antenatal care (ANC) has been shown to reduce maternal morbidity and mortality globally. Increasing evidence suggests that women's economic empowerment (WEE) is a critical factor that may influence uptake of ANC during pregnancy. However, existing literature lacks a comprehensive synthesis of studies on WEE interventions and their effects on ANC outcomes. This systematic review analyses WEE interventions at the household, community and national levels and their effects on ANC outcomes in low-income and middle-income countries, where the majority of maternal deaths occur.

METHODS

Six electronic databases were systematically searched as well as 19 websites of relevant organisations. Studies published in English and after 2010 were included.

RESULTS

Following abstract and full-text review, 37 studies were included in this review. Seven studies used an experimental study design, 26 studies used a quasi-experimental study design, 1 study used an observational design and 1 study was a systematic review with meta-analysis. Thirty-one included studies evaluated a household-level intervention, and six studies evaluated a community-level intervention. No included studies examined a national-level intervention.

CONCLUSION

Most included studies on household-level and community-level interventions found a positive association between the intervention and the number of ANC visits women received. This review emphasises the need for more WEE interventions that empower women at the national level, for the expansion of the definition of WEE to be more inclusive of the multidimensionality of WEE interventions and the social determinants of health, and the standardisation of ANC outcome measurement globally.

Health care providers’ knowledge of clinical protocols for postpartum hemorrhage care in Kenya: a cross-sectional study

Background

Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide despite its often-preventable nature. Understanding health care providers’ knowledge of clinical protocols is imperative for improving quality of care and reducing mortality. This is especially pertinent in referral and teaching hospitals that train nursing and medical students and interns in addition to managing emergency and referral cases.

Methods

This study aimed to (1) measure health care providers’ knowledge of clinical protocols for risk assessment, prevention, and management of PPH in 3 referral hospitals in Kenya and (2) examine factors associated with providers’ knowledge. We developed a knowledge assessment tool based on past studies and clinical guidelines from the World Health Organization and the Kenyan Ministry of Health. We conducted in-person surveys with health care providers in three high-volume maternity facilities in Nairobi and western Kenya from October 2018-February 2019. We measured gaps in knowledge using a summative index and examined factors associated with knowledge (such as age, gender, qualification, experience, in-service training attendance, and a self-reported measure of peer-closeness) using linear regression.

Results

We interviewed 172 providers including consultants, medical officers, clinical officers, nurse-midwives, and students. Overall, knowledge was lowest for prevention-related protocols (an average of 0.71 out of 1.00; 95% CI 0.69–0.73) and highest for assessment-related protocols (0.81; 95% CI 0.79–0.83). Average knowledge scores did not differ significantly between qualified providers and students. Finally, we found that being a qualified nurse, having a specialization, being female, having a bachelor's degree and self-reported closer relationships with colleagues were statistically significantly associated with higher knowledge scores.

Conclusion

We found gaps in knowledge of PPH care clinical protocols in Kenya. There is a clear need for innovations in clinical training to ensure that providers in teaching referral hospitals are prepared to prevent, assess, and manage PPH. It is possible that training interventions focused on learning by doing and teamwork may be beneficial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05128-6.

Individual-level and community-level determinants of use of maternal health services in Northwest Ethiopia: a prospective follow-up study

OBJECTIVE

The use of maternal health services is an important indicator of maternal health and socioeconomic development. Evidence on individual-level and community-level determinants of use of maternal health services in Benishangul Gumuz Region was not well known so far. Hence, this study fills this gap.

DESIGN

A prospective follow-up study SETTING: This study was conducted from March 2020 to January 2021 in Northwest Ethiopia.

PARTICIPANTS

A total of 2198 pregnant women participated in the study.

MAIN OUTCOME MEASURES

A multistage random sampling technique was used to select study subjects. Data were collected via face-to-face interviews using pretested semistructured questionnaires. Collected data were coded, cleaned and analysed using Stata software. Multilevel regression models were applied to determine individual-level and community-level factors of use of maternal health services.

RESULTS

This study found that the proportions of women who visited recommended antenatal care (ANC), received skilled delivery care and postnatal care (PNC) were 66.1%, 58.3% and 58.6%, respectively. Being rural (adjusted OR (AOR)=3.82, 95% CI 1.35 to 10.78), having information on maternal health services (AOR=2.13, 95% CI 1.21 to 3.75), with a history of pregnancy-related problems (AOR=1.83, 95% CI 1.15 to 2.92) and women with decision-making power (AOR=1.74, 95% CI 1.14 to 2.68) were more likely to attend fourth ANC visits. Similarly, women who attended tertiary school (AOR=4.12, 95% CI 1.49 to 11.33) and who initiated the first ANC visit within 4-6 months of pregnancy (AOR=0.66, 95% CI 0.45 to 0.96) were determinants of skilled delivery care. Finally, women whose partners attended tertiary education (AOR=3.67, 95% CI 1.40 to 9.58), women with decision-making power (AOR=1.8, 95% CI 1.09 to 2.97), women who attended the fourth ANC visit (AOR=10.8, 95% CI 6.79 to 17.2), women received iron-folic acid during pregnancy (AOR=1.96, 95% CI 1.11 to 3.49) and women who received skilled delivery care (AOR=1.63, 95% CI 1.1 to 2.42) were more likely to get PNC services.

CONCLUSION

The proportion of women who attended ANC, received skilled delivery services and PNCs was low. Different individual-level and community-level factors that influenced the use of these services were discovered. Therefore, community-based interventions should target those identified factors to improve maternal health services.

Completion and determinants of a continuum of care in maternal health services in Benishangul Gumuz region: A prospective follow-up study

Introduction

The provision of a continuum of care to women throughout pregnancy, labor, and after delivery has become a fundamental strategy for improving maternal and neonatal health. A better understanding of where the gaps are in seeking care along the pathway and what factors contribute to the gaps is required for successful program implementation. Hence, this study was targeted to determine the status and determinant factors of the completion rate of a continuum of care in maternal health services.

Methods

A prospective follow-up study was conducted among 2,198 sampled pregnant women and followed for 11 months in Benishangul-Gumuz region. A multistage clustered sampling technique was employed to select the study participants. Data were collected via face-to-face interviews using a pretested, semi-structured questionnaire, and logbook registry. Collected data were edited, cleaned, and analyzed using STATA software. The multilevel regression model was used to examine the effects of individual- and community-level factors and expressed as AOR with 95% CI.

Results

The completion rate of a continuum of care via visit-based, content-based, and space dimensions was 33.1, 20, and 37.2%, respectively. The enabling factors were having information on maternal health services (AOR = 2.25; 95% CI: 1.11-4.55), iron and folic acid supplementation (AOR = 2.58; 95% CI: 1.37-4.86), tetanus toxoid vaccination during pregnancy (AOR = 2.21; 95% CI: 1.39-3.52), having pregnant-related problems (AOR = 2.1; 95% CI: 1.15-3.71), dry and stimulate newborn (AOR = 2.61; 95% CI: 1.42-4.77), appropriate cord care (AOR = 2.01; 95% CI: 1.07-3.79), and immunizing newborn (AOR = 6.9; 95% CI: 3.79-12.59), whereas risk factors were ever having a stillbirth (AOR = 0.52; 95% CI: 0.32-0.85) and delay of 1st ANC initiation at 4-6 months of pregnancy (AOR = 0.45; 95% CI: 0.3-0.68).

Conclusion

The completion rates via visit-based, content-based, and space dimensions were low. Different determinant factors which have a programmatically important implication were identified. Thus, interventions should focus on increasing women's awareness and improving the availability and accessibility of the whole packages of maternal health services to facilitate the completion rate.

Co-payments and equity in care: enhancing hospitalisation policy for Palestine refugees in Lebanon

Background

This paper measures the impact of introducing a 10% co-payment on secondary care hospitalization costs for Palestine refugees living in Lebanon (PRL) in all UNRWA contracted hospitals, except for the Red Crescent Society. This ex-post analysis provides a detailed insight on the direction and magnitude of the policy impact in terms of demand by hospital type, average length of stay and treatment costs.

Methods

With a complete population episode level dataset, we use multinomial logit, negative binomial, and linear models to estimate impacts on the different dependent variables, controlling for disease, patient and hospital characteristics.

Results

After the implementation patients were at least 4 pp (p <0.01) more likely to choose a Red Crescent Society hospital for secondary care, instead of one with co-payment. Average length of stay was not affected in general, despite the increase in control at all UNRWA contracted hospitals. Except for the decrease in UNRWA contribution, did not find a statistically significant impact of the co-payment on costs, nor for the provider or for the patient. Findings suggest that introducing a 10% co-payment for secondary hospital care had an impact on patients’ health care budget, leading to demand shifts towards cheaper options - i.e., patients had to chose care based on financial constraints rather than on their treatment preferences.

Conclusion

Before changing healthcare payment schemes in different types of hospitals, facilities offering free of charge treatment should be assessed and prepared for potential demand shifts to avoid overcapacity and the collapse of health care services for such a fragile population. In addition, exemptions from co-payments should be considered for patients with severe health conditions and financial constraints, who, according to our results, are the most likely to change their pattern of care due to an increase in treatment costs.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12913-021-07427-8).

Effectiveness of conditional cash transfers (Afya credits incentive) to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya: a cluster-randomised trial

OBJECTIVES

Given high maternal and child mortality rates, we assessed the impact of conditional cash transfers (CCTs) to retain women in the continuum of care (antenatal care (ANC), delivery at facility, postnatal care (PNC) and child immunisation).

DESIGN

We conducted an unblinded 1:1 cluster-randomised controlled trial.

SETTING

48 health facilities in Siaya County, Kenya were randomised. The trial ran from May 2017 to December 2019.

PARTICIPANTS

2922 women were recruited to the control and 2522 to the intervention arm.

INTERVENTIONS

An electronic system recorded attendance and triggered payments to the participant's mobile for the intervention arm (US$4.5), and phone credit for the control arm (US$0.5). Eligibility criteria were resident in the catchment area and access to a mobile phone.

PRIMARY OUTCOMES

Primary outcomes were any ANC, delivery, any PNC between 4 and 12 months after delivery, childhood immunisation and referral attendance to other facilities for ANC or PNC. Given problems with the electronic system, primary outcomes were obtained from maternal clinic books if participants brought them to data extraction meetings (1257 (50%) of intervention and 1053 (36%) control arm participants). Attendance at referrals to other facilities is not reported because of limited data.

RESULTS

We found a significantly higher proportion of appointments attended for ANC (67% vs 60%, adjusted OR (aOR) 1.90; 95% CI 1.36 to 2.66) and child immunisation (88% vs 85%; aOR 1.74; 95% CI 1.10 to 2.77) in intervention than control arm. No intervention effect was seen considering delivery at the facility (90% vs 92%; aOR 0.58; 95% CI 0.25 to 1.33) and any PNC attendance (82% vs 81%; aOR 1.25; 95% CI 0.74 to 2.10) separately. The pooled OR across all attendance types was 1.64 (1.28 to 2.10).

CONCLUSIONS

Demand-side financing incentives, such as CCTs, can improve attendance for appointments. However, attention needs to be paid to the technology, the barriers that remain for delivery at facility and PNC visits and encouraging women to attend ANC visits within the recommended WHO timeframe.

TRIAL REGISTRATION

NCT03021070.

No increase in use of hospitals for childbirth in Tanzania over 25 years: Accumulation of inequity among poor, rural, high parity women

Improving childbirth care in rural settings in sub-Saharan Africa is essential to attain the commitment expressed in the Sustainable Development Goals to leave no one behind. In Tanzania, the period between 1991 and 2016 was characterized by health system expansion prioritizing primary health care and a rise in rural facility births from 45% to 54%. Facilities however are not all the same, with advanced management of childbirth complications generally only available in hospitals and routine childbirth care in primary facilities. We hypothesized that inequity in the use of hospital-based childbirth may have increased over this period, and that it may have particularly affected high parity (≥5) women. We analysed records of 16,080 women from five Tanzanian Demographic and Health Surveys (1996, 1999, 2004, 2010, 2015/6), using location of the most recent birth as outcome (home, primary health care facility or hospital), wealth and parity as exposure variables and demographic and obstetric characteristics as potential confounders. A multinomial logistic regression model with wealth/parity interaction was run and post-estimation margins analysis produced percentages of births for various combinations of wealth and parity for each survey. We found no reduction in inequity in this 25-year period. Among poorest women, lowest use of hospital-based childbirth (around 10%) was at high parity, with no change over time. In women having their first baby, hospital use increased over time but with a widening pro-rich gap (poorest women predicted use increased from 36 to 52% and richest from 40 to 59%). We found that poor rural women of high parity were a vulnerable group requiring specifically targeted interventions to ensure they receive effective childbirth care. To leave no one behind, it is essential to look beyond the average coverage of facility births, as such a limited focus masks different patterns and time trends among marginalised groups.

Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review

Despite the increasing transition from paper vouchers to mobile e-vouchers for maternal health in low- and middle-income countries, few studies have reviewed key elements for program planning, implementation, and evaluation. To bridge this gap, this study conducted an interpretive review and developed a logic model for mobile maternal health e-voucher programs. Pubmed, EMBASE, and Cochrane databases were searched to retrieve relevant studies; 27 maternal health voucher programs from 84 studies were identified, and key elements for the logic model were retrieved and organized systematically. Some of the elements identified have the potential to be improved greatly by shifting to mobile e-vouchers, such as payment via mobile money or electronic claims processing and data entry for registration. The advantages of transitioning to mobile e-voucher identified from the logic model can be summarized as scalability, transparency, and flexibility. The present study contributes to the literature by providing insights into program planning, implementation, and evaluation for mobile maternal health e-voucher programs.

Inequity in uptake of hospital-based childbirth care in rural Tanzania: analysis of the 2015-16 Tanzania Demographic and Health Survey

Proportions of facility births are increasing throughout sub-Saharan Africa, but obstetric services vary within the health system. In Tanzania, advanced management of childbirth complications (comprehensive emergency obstetric care) is offered in hospitals, while in frontline, primary health care (PHC) facilities (health centres and dispensaries) mostly only routine childbirth care is available. With over half (54%) of rural births in facilities, we hypothesized the presence of socio-economic inequity in hospital-based childbirth uptake in rural Tanzania and explored whether this relationship was modified by parity. This inequity may compound the burden of greater mortality among the poorest women and their babies. Records for 4456 rural women from the 2015-16 Tanzania Demographic and Health Survey with a live birth in the preceding 5 years were examined. Proportions of births at each location (home/PHC/hospital) were calculated by demographic and obstetric characteristics. Multinomial logistic regression was used to obtain crude and adjusted odds ratios of home/PHC and hospital/PHC births based on household wealth, including interaction between wealth and parity. Post-estimation margins analysis was applied to estimate childbirth location by wealth and parity. Hospital-based childbirth uptake was inequitable. The gap between poorest and richest was less pronounced at first birth. Hospital-based care utilization was lowest (around 10%) among the poorest multiparous women, with no increase at high parity (≥5) despite higher risk. PHC-based childbirth care was used by a consistent proportion of women after the first birth (range 30-51%). The poorest women utilized it at intermediate parity, but at parity ≥5 mostly gave birth at home. In an effort to provide effective childbirth care to all women, context-specific strategies are required to improve hospital-based care use, and poor, rural, high parity women are a particularly vulnerable group that requires specific attention. Improving childbirth care in PHC and strengthening referral linkages would benefit a considerable proportion of women.

Factors affecting the initiation and continuation of maternal health service utilization among women who delivered in the past one year in Enemay district, East Gojjam, Ethiopia

Background

Maternity continuum of care is the continuity of maternal healthcare services that a woman uses, which includes antenatal care (ANC 4+), skilled birth attendant (SBA), and postnatal care (PNC) within 48 h of delivery. It is one of the essential strategies for reducing maternal and newborn morbidity and mortality. Therefore, this study aimed to assess the prevalence and factors affecting the initiation and continuation of maternal health service utilization among women who delivered in the past one year in Enemay district, East Gojjam zone, Ethiopia.

Methods

A community-based cross-sectional study was conducted among six hundred twenty-one (621) women who gave birth in the last one year in Enemay district from February 25 to March 10, 2019. A simple random sampling technique was used to select the study participants. Data were collected by face-to-face interviewer-administered, pretested, and semi-structured questionnaire. Binary logistic regressions (bi-variable and multivariable) were fitted to identify statistically significant variables. Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was used to declare statistically significant variables on the basis of p-value < 0.05 in the multivariable binary logistic regression.

Results

In this study, around 61% of women had antenatal care follow-up. Out of those women having ante natal care follow-up, about 77.5% (95% CI 73, 81.7%) had continued to receiving skilled birth delivery service. Age (AOR = 1.7 95% CI: (1.0, 2.88)), marital status (AOR = 1.6, 95% CI: (1.01, 2.76)), women’s educational status (AOR = 2.9, 95% CI: (1.30, 6.72)), autonomy for health care decision-making (AOR = 3.71, 95%CI: (2.36, 6.02)), exposure to media (AOR = 2.8, 95% CI: (1.78, 4.6)), wanted pregnancy (AOR = 3.6 95% CI: (2.2, 5.95)), and parity (AOR = 0.34, 95%CI: (0.16, 0.71)) were statistically significant variables associated with initiation of antenatal care, whereas educational status of women (AOR = 4.65, 95% CI: (1.37, 15.7)), autonomy for health care decision making (AOR = 2.62, 95% CI:(1.0, 6.82)), and had counseled during antenatal care (AOR = 2.88 95% CI: (1.21, 6.83)) were statistically significant variables associated with the continuation of maternal health care services.

Conclusions

This study demonstrated that the initiation and continuity of maternal health care services are low in the study area. Age, marital status, residence, women’s educational status, health care decision-making autonomy, exposure to media, wanted pregnancy, and parity were factors significantly affecting the initiation of antenatal care. Whereas, women’s educational status, health care decision-making autonomy, and counseling during antenatal care were predictors influencing the continuation of maternal health care services (antenatal care to skilled birth delivery).

'It was hell in the community': a qualitative study of maternal and child health care during health care worker strikes in Kenya

BACKGROUND

Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers.

METHODS

We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women's pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches.

RESULTS

Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care.

CONCLUSION

We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.

The inclusion of sexual and reproductive health services within universal health care through intentional design

In this paper, we argue that how sexual and reproductive health (SRH) services are included in UHC and health financing matters, and that this has implications for universality and equity. This is a matter of rights, given the differential health risks that women face, including unwanted pregnancy. How traditional vertical SRH services are compensated under UHC also matters and should balance incentives for efficiency with incentives for appropriate provision using the rights-based approach to user-centred care so that risks of sub-optimal outcomes are mitigated. This suggests that as UHC benefits packages are designed, there is need for the SRH community to advocate for more than simple “SRH inclusion”. This paper describes a practical approach to integrate quality of SRH care within the UHC agenda using a framework called the “5Ps”. The framework emphasises a “systems” and “design” lens as important steps to quality. The framework can be applied at different scales, from the health system to the individual user level. It also pays attention to how financing and resource policies intended to promote UHC may support or undermine the respect, protection and fulfilment of SRH and rights. The framework was originally developed with a specific emphasis on quality provision of family planning. In this paper, we have extended it to cover other SRH services.

A retrospective study of the impact of health worker strikes on maternal and child health care utilization in western Kenya

BACKGROUND

There have been dozens of strikes by health workers in Kenya in the past decade, but there are few studies of their impact on maternal and child health services and outcomes. We conducted a retrospective survey study to assess the impact of nationwide strikes by health workers in 2017 on utilization of maternal and child health services in western Kenya.

METHODS

We utilized a parent study to enroll women who were pregnant in 2017 when there were prolonged strikes by health workers ("strike group") and women who were pregnant in 2018 when there were no major strikes ("control group"). Trained research assistants administered a close-ended survey to retrospectively collect demographic and pregnancy-related health utilization and outcomes data. Data were collected between March and July 2019. The primary outcomes of interest were antenatal care (ANC) visits, delivery location, and early child immunizations. Generalized estimating equations were used to estimate risk ratios between the strike and control groups, adjusting for socioeconomic status, health insurance status, and clustering. Adjusted risk ratios (ARR) were calculated with 95% confidence intervals (95%CI).

RESULTS

Of 1341 women recruited in the parent study in 2017 (strike group), we re-consented 843 women (63%) to participate. Of 924 women recruited in the control arm of the parent study in 2018 (control group), we re-consented 728 women (79%). Women in the strike group were 17% less likely to attend at least four ANC visits during their pregnancy (ARR 0.83, 95%CI 0.74, 0.94) and 16% less likely to deliver in a health facility (ARR 0.84, 95%CI 0.76, 0.92) compared to women in the control group. Whether a child received their first oral polio vaccine did not differ significantly between groups, but children of women in the strike group received their vaccine significantly longer after birth (13 days versus 7 days, p = 0.002).

CONCLUSION

We found that women who were pregnant during nationwide strikes by health workers in 2017 were less likely to receive WHO-recommended maternal child health services. Strategies to maintain these services during strikes are urgently needed.

The impact of child health interventions and risk factors on child survival in Kenya, 1993-2014: a Bayesian spatio-temporal analysis with counterfactual scenarios

BACKGROUND

During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined.

METHODS

Sub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993-2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993.

RESULTS

Nationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors.

CONCLUSION

Contributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.

Subnational estimates of factors associated with under-five mortality in Kenya: a spatio-temporal analysis, 1993-2014

BACKGROUND

To improve child survival, it is necessary to describe and understand the spatial and temporal variation of factors associated with child survival beyond national aggregates, anchored at decentralised health planning units. Therefore, we aimed to provide subnational estimates of factors associated with child survival while elucidating areas of progress, stagnation and decline in Kenya.

METHODS

Twenty household surveys and three population censuses conducted since 1989 were assembled and spatially aligned to 47 subnational Kenyan county boundaries. Bayesian spatio-temporal Gaussian process regression models accounting for inadequate sample size and spatio-temporal relatedness were fitted for 43 factors at county level between 1993 and 2014.

RESULTS

Nationally, the coverage and prevalence were highly variable with 38 factors recording an improvement. The absolute percentage change (1993-2014) was heterogeneous ranging between 1% and 898%. At the county level, the estimates varied across space and over time with a majority showing improvements after 2008 which was preceded by a period of deterioration (late-1990 to early-2000). Counties in Northern Kenya were consistently observed to have lower coverage of interventions and remained disadvantaged in 2014 while areas around Central Kenya had and historically have had higher coverage across all intervention domains. Most factors in Western and South-East Kenya recorded moderate intervention coverage although having a high infection prevalence of both HIV and malaria.

CONCLUSION

The heterogeneous estimates necessitates prioritisation of the marginalised counties to achieve health equity and improve child survival uniformly across the country. Efforts are required to narrow the gap between counties across all the drivers of child survival. The generated estimates will facilitate improved benchmarking and establish a baseline for monitoring child development goals at subnational level.

Quality of care in the free maternal healthcare era in sub-Saharan Africa: a scoping review of providers' and managers' perceptions

BACKGROUND

Free maternal healthcare financing schemes play an essential role in the quality of services rendered to clients during antenatal care in sub-Saharan Africa (SSA). However, healthcare managers' and providers' perceptions of the healthcare financing scheme may influence the quality of care. This scoping review mapped evidence on managers' and providers' perspectives of free maternal healthcare and the quality of care in SSA.

METHODS

We used Askey and O'Malley's framework as a guide to conduct this review. To address the research question, we searched PubMed, CINAHL through EBSCOhost, ScienceDirect, Web of Science, and Google Scholar with no date limitation to May 2019 using keywords, Boolean terms, and Medical Subject Heading terms to retrieve relevant articles. Both abstract and full articles screening were conducted independently by two reviewers using the inclusion and exclusion criteria as a guide. All significant data were extracted, organized into themes, and a summary of the findings reported narratively.

RESULTS

In all, 15 out of 390 articles met the inclusion criteria. These 15 studies were conducted in nine countries. That is, Ghana (4), Kenya (3), and Nigeria (2), Burkina Faso (1), Burundi (1), Niger (1), Sierra Leone (1), Tanzania (1), and Uganda (1). Of the 15 included studies, 14 reported poor quality of maternal healthcare from managers' and providers' perspectives. Factors contributing to the perception of poor maternal healthcare included: late reimbursement of funds, heavy workload of providers, lack of essential drugs and stock-out of medical supplies, lack of policy definition, out-of-pocket payment, and inequitable distribution of staff.

CONCLUSION

This study established evidence of existing literature on the quality of care based on healthcare providers' and managers' perspectives though very limited. This study indicates healthcare providers and managers perceive the quality of maternal healthcare under the free financing policy as poor. Nonetheless, the free maternal care policy is very much needed towards achieving universal health, and all efforts to sustain and improve the quality of care under it must be encouraged. Therefore, more research is needed to better understand the impact of their perceived poor quality of care on maternal health outcomes.

Maternal perceptions of the quality of Care in the Free Maternal Care Policy in sub-Sahara Africa: a systematic scoping review

BACKGROUND

The world aims to achieve universal health coverage by removing all forms of financial barriers to improve access to healthcare as well as reduce maternal and child deaths by 2030. Although free maternal healthcare has been embraced as a major intervention towards this course in some countries in sub-Saharan Africa (SSA), the perception of the quality of healthcare may influence utilization and maternal health outcomes. We systematically mapped literature and described the evidence on maternal perceptions of the quality of care under the free care financing policies in SSA.

METHODS

We employed the Arskey and O'Malley's framework to guide this scoping review. We searched without date limitations to 19th May 2019 for relevant published articles in PubMed, Google Scholar, Web of Science, Science Direct, and CINAHL using a combination of keywords, Boolean terms, and medical subject headings. We included primary studies that involved pregnant/post-natal mothers, free maternal care policy, quality of care, and was conduct in an SSA country. Two reviewers independently screened the articles at the abstract and full-text screening guided by inclusion and exclusion criteria. All relevant data were extracted and organized into themes and a summary of the results reported narratively. The recent version of the mixed methods appraisal tool was used to assess the methodological quality of the included studies.

RESULTS

Out of 390 studies, 13 were identified to have evidence of free maternal healthcare and client perceived quality of care. All the 13 studies were conducted in 7 different countries. We found three studies each from Ghana and Kenya, two each in Burkina Faso and Nigeria, and a study each from Niger, Sierra Leone, and Tanzania. Of the 13 included studies, eight reported that pregnant women perceived the quality of care under the free maternal healthcare policy to be poor. The following reasons accounted for the poor perception of service quality: long waiting time, ill-attitudes of providers, inadequate supply of essential drugs and lack of potable water, unequal distribution of skilled birth attendants, out-of-pocket payment and weak patient complaint system.

CONCLUSION

This study suggests few papers exist that looked at maternal perceptions of the quality of care in the free care policy in SSA. Considering the influence mothers perceptions of the quality of care can have on future health service utilisation, further studies at the household, community, and health facility levels are needed to help unearth and address all hidden quality of care challenges and improve maternal health services towards attaining the sustainable development goals on maternal and child health.

Determinants of subnational disparities in antenatal care utilisation: a spatial analysis of demographic and health survey data in Kenya

BACKGROUND

The spatial variation in antenatal care (ANC) utilisation is likely associated with disparities observed in maternal and neonatal deaths. Most maternal deaths are preventable through services offered during ANC; however, estimates of ANC coverage at lower decision-making units (sub-county) is mostly lacking. In this study, we aimed to estimate the coverage of at least four ANC (ANC4) visits at the sub-county level using the 2014 Kenya Demographic and Health Survey (KDHS 2014) and identify factors associated with ANC utilisation in Kenya.

METHODS

Data from the KDHS 2014 was used to compute sub-county estimates of ANC4 using small area estimation (SAE) techniques which relied on spatial relatedness to yield precise and reliable estimates at each of the 295 sub-counties. Hierarchical mixed-effect logistic regression was used to identify factors influencing ANC4 utilisation. Sub-county estimates of factors significantly associated with ANC utilisation were produced using SAE techniques and mapped to visualise disparities.

RESULTS

The coverage of ANC4 across sub-counties was heterogeneous, ranging from a low of 17% in Mandera West sub-county to over 77% in Nakuru Town West and Ruiru sub-counties. Thirty-one per cent of the 295 sub-counties had coverage of less than 50%. Maternal education, household wealth, place of delivery, marital status, age at first marriage, and birth order were all associated with ANC utilisation. The areas with low ANC4 utilisation rates corresponded to areas of low socioeconomic status, fewer educated women and a small number of health facility deliveries.

CONCLUSION

Suboptimal coverage of ANC4 and its heterogeneity at sub-county level calls for urgent, focused and localised approaches to improve access to antenatal care services. Policy formulation and resources allocation should rely on data-driven strategies to guide national and county governments achieve equity in access and utilisation of health interventions.

Influence of China's 2009 healthcare reform on the utilisation of continuum of care for maternal health services: evidence from two cross-sectional household surveys in Shaanxi Province

Background

Continuum of care for maternal health services (CMHS) is a proven approach to improve health and safety for mothers and newborns. This study aims to explore the influence of China’s 2009 healthcare reform on improving the CMHS utilisation.

Methods

This population-based cross-sectional quantitative study included 2332 women drawn from the fourth and fifth National Health Service Surveys of Shaanxi Province, conducted in 2008 and 2013 respectively, before and after China’s 2009 healthcare reform. A generalised linear mixed model (GLMM) was applied to analyse the influence of this healthcare reform on utilisation of CMHS. Concentration curves, concentration indexes and its decomposition method were used to analyse the equity of changes in utilisation.

Results

This study showed post-reform CMHS utilisation was higher in both rural and urban women than the CMHS utilisation pre-reform (according to China’s policy defining CMHS). The rate of CMHS utilisation increased from 24.66 to 41.55% for urban women and from 18.31 to 50.49% for rural women (urban: χ² = 20.64, P < 0.001; rural: χ² = 131.38, P < 0.001). This finding is consistent when the WHO’s definition of CMHS is applied for rural women after reform (12.13% vs 19.26%; χ² = 10.99, P = 0.001); for urban women, CMHS utilisation increased from 15.70 to 20.56% (χ² = 2.57, P = 0.109). The GLMM showed that the rate of CMHS utilisation for urban women post-reform was five times higher than pre-reform rates (OR = 5.02, 95%CL: 1.90, 13.31); it was close to 15 times higher for rural women (OR = 14.70, 95%CL: 5.43, 39.76). The concentration index for urban women decreased from 0.130 pre-reform (95%CI: − 0.026, 0.411) to − 0.041 post-reform (95%CI: − 0.096, 0.007); it decreased from 0.104 (95%CI: − 0.012, 0.222) to 0.019 (95%CI: − 0.014, 0.060) for rural women. The horizontal inequity index for both groups of women also decreased (0.136 to − 0.047 urban and 0.111 to 0.019 for rural).

Conclusions

China’s 2009 healthcare reform has positively influenced utilisation rates and equity of CMHS’s utilisation among both urban and rural women in Shaanxi Province. Addressing economic and educational attainment gaps between the rich and the poor may be effective ways to improve the persistent health inequities for rural women.

Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania

BACKGROUND

In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries.

METHODS

We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors.

RESULTS

The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play.

CONCLUSIONS

Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.