Using multi-country household surveys to understand who provides reproductive and maternal health services in low- and middle-income countries: a critical appraisal of the Demographic and Health Surveys

Collection of cancer-specific data in population-based surveys in low- and middle-income countries: A review of the demographic and health surveys

Population-based surveys, such as those conducted by the Demographic and Health Surveys (DHS) Programme, can collect and disseminate the data needed to inform cancer control efforts in a standardised and comparable manner. This review examines the DHS questionnaires, with the aim of describing and analysing how cancer-specific questions have been asked from the inception of the surveys to date. A systematic search of the DHS database was conducted to identify cancer-specific questions asked in surveys. Descriptive statistics were used to summarise the cancer-specific questions across survey years and countries. In addition, the framing and scope of questions were appraised. A total of 341 DHS surveys (including standard, interim, continuous and special DHS surveys) have been conducted in 90 countries since 1985, 316 of which have been completed. A total of 39 (43.3%) of the countries have conducted at least one DHS survey with one or more cancer-specific questions. Of the 316 surveys with available final reports and questionnaires, 81 (25.6%) included at least one cancer-specific question; 54 (17.1%) included questions specific to cervical cancer, 41 (13.0%) asked questions about breast cancer, and 8 (2.5%) included questions related to prostate cancer. Questions related to other cancers (including colorectal, laryngeal, liver, lung, oral cavity, ovarian and non-site-specific cancers) were included in 40 (12.6%) of the surveys. Cancer screening-related questions were the most commonly asked. The majority of the surveys included questions on alcohol and tobacco use, which are known cancer risk factors. The frequency of cancer-specific questions has increased, though unsteadily, since inception of the DHS. Overall, the framing and scope of the cancer questions varied considerably across countries and survey years. To aid the collection of more useful population-level data to inform cancer-control priorities, it is imperative to improve the scope and content of cancer-specific questions in future DHS surveys.

Validating midwifery professionals' scope of practice and competency: A multi-country study comparing national data to international standards

BACKGROUND

There is a global shortage of midwives, whose services are essential to meet the healthcare needs of pregnant women and newborns. Evidence suggests that if enough midwives, trained and regulated to global standards, were deployed worldwide, maternal, and perinatal mortality would decline significantly. Health workforce planning estimates the number of midwives needed to achieve population coverage of midwifery interventions. However, to provide a valid measure of midwifery care coverage, an indicator must consider not only the raw number of midwives, but also their scope and competency. The tasks midwives are authorized to deliver and their competency to perform essential skills and behaviors provide crucial information for understanding the availability of safe, high-quality midwifery services. Without reliable estimates for an adequate midwifery workforce, progress toward ending preventable maternal and perinatal mortality will continue to be uneven. The International Labor Organization (ILO) and the International Confederation of Midwives (ICM) suggest standards for midwifery scope of practice and competencies. This paper compares national midwifery regulations, scope, and competencies in three countries to the ILO and ICM standards to validate measures of midwife density. We also assess midwives' self-reported skills/behaviors from the ICM competencies and their acquisition.

METHODS AND FINDINGS

We compared midwives' scope of practice in Argentina, Ghana, and India to the ILO Tasks and ICM Essential Competencies for Midwifery Practice. We compared midwives self-reported skills/behaviors with the ICM Competencies. Univariate and bivariate analysis was conducted to describe the association between midwives' skills and selected characteristics. National scopes of practice matched two ILO tasks in Argentina, four in India, and all in Ghana. National standards partially reflected ICM skills in Categories 2, 3, and 4 (pre-pregnancy and antenatal care; care during labor and birth; and ongoing care of women and newborns, respectively) in Argentina (range 11% to 67%), mostly in India (range 74% to 100%) and completely in Ghana (100% match). 1,266 midwives surveyed reported considerable variation in competency for skills and behaviors across ICM Category 2, 3, and 4. Most midwives reported matching skills and behaviors around labor and childbirth (Category 2). Higher proportions of midwives reported gaining basic skills through in-service training and on-job-experience than in pre-service training.

CONCLUSION

Estimating the density of midwives needed for an adequate midwifery workforce capable of providing effective population coverage is predicated on a valid numerator. A reliable and valid count of midwives to meet population needs assumes that each midwife counted has the authority to exercise the same behaviors and reflects the ability to perform them with comparable competency. Our results demonstrate variation in midwifery scopes of practice and self-reported competencies in comparison to global standards that pose a threat to the reliability and validity of the numerator in measures of midwife density, and suggest the potential for expanded authorization and improved education and training to meet global reference standards for midwifery practice has not been fully realized. Although the universally recognized standard, this study demonstrates that the complex, composite descriptions of skills and behaviors in the ICM competencies make them difficult to use as benchmark measures with any precision, as they are not defined or structured to serve as valid measures for assessing workforce competency. A simplified, content-validated measurement system is needed to facilitate evaluation of the competency of the midwifery workforce.

Length-of-stay after a health facility birth and associated factors: analysis of data from three Sub-Saharan African countries

OBJECTIVES

We estimated the length-of-stay (LOS) in the health facility after childbirth and identified associated factors in three sub-Saharan African countries.

DESIGN

Secondary analysis using data from the most recent Multiple Indicator Cluster Surveys.

SETTING

Multiple Indicator Cluster Surveys from Ghana, Malawi and Eswatini were selected.

PARTICIPANTS

Women aged 15-49 years who had a facility delivery in the two years preceding the survey were included.

MAIN OUTCOME MEASURES

Length-of-stay recorded in days and weeks were converted to hours and analysed as a continuous variable.

RESULTS

Length-of-stay was estimated for 9147 women, wherein 6610 women (median LOS and IQR: 36 36,60 hours), 1698 women (median LOS and IQR 36 10,60 hours) and 839 women (median-length-stay 36 36,60 hours) were from Malawi, Ghana and Eswatini respectively. Being from Ghana [RC, -20.6 (95%CI:-25.2 - -16.0)] and then Eswatini [RC: -13.0 (95%CI: -19.9 - -9.8)] and delivery in a government hospital [RC: -4.9 (95%CI -9.9- -0.3)] were independently associated with having a shorter LOS. Having a caesarean section, assistance by Nurses/Midwives or Auxiliaries/CHOs, single birth, heavier birth weight, and death of newborn before discharge increased the duration of stay.

CONCLUSIONS

Necessitating and facility factors are important determinants of length of stay. Socio-demographic characteristics, however, have a restricted role in influencing the duration of postpartum stay in sub-Saharan Africa. Further prospective research is required to identify more determinants and provide evidence for policy formulation and clinical guidelines regarding the safest time for discharge after delivery.

FUNDING

None declared.

Tale of 22 cities: utilisation patterns and content of maternal care in large African cities

Introduction

Globally, the majority of births happen in urban areas. Ensuring that women and their newborns benefit from a complete package of high-quality care during pregnancy, childbirth and the postnatal period present specific challenges in large cities. We examine health service utilisation and content of care along the maternal continuum of care (CoC) in 22 large African cities.

Methods

We analysed data from the most recent Demographic and Health Survey (DHS) since 2013 in any African country with at least one city of ≥1 million inhabitants in 2015. Women with live births from survey clusters in the most populous city per country were identified. We analysed 17 indicators capturing utilisation, sector and level of health facilities and content of three maternal care services: antenatal care (ANC), childbirth care and postnatal care (PNC), and a composite indicator capturing completion of the maternal CoC. We developed a categorisation of cities according to performance on utilisation and content within maternal CoC.

Results

The study sample included 25 326 live births reported by 19 217 women. Heterogeneity in the performance in the three services was observed across cities and across the three services within cities. ANC utilisation was high (>85%); facility-based childbirth and PNC ranged widely, 77%–99% and 29%–94%, respectively. Most cities showed inconsistent levels of utilisation and content across the maternal CoC, Cotonou and Accra showed relatively best and Nairobi and Ndjamena worst performance.

Conclusion

This exploratory analysis showed that many DHS can be analysed on the level of large African cities to provide actionable information about the utilisation and content of the three maternal health services. Our comparative analysis of 22 cities and proposed typology of best and worst-performing cities can provide a starting point for extracting lessons learnt and addressing critical gaps in maternal health in rapidly urbanising contexts.

Family Welfare Expenditure, Contraceptive Use, Sources and Method-Mix in India

Making universal access to sexual and reproductive health care a reality, and thus building momentum for comprehensive family planning by 2030, is key for achieving sustainable development goals. However, in the last decade, India has been retreating from progress achieved in access to family planning. Family planning progress for a large country such as India is critical for achieving sustainable developmental goals. Against this backdrop, the paper investigated the question of how far family welfare expenditure affects contraceptive use, sources of contraceptive methods, and method-mix using triangulation of micro and macro data analyses. Our findings suggest that, except for female sterilizations, modern methods of contraception do not show a positive relationship with family welfare expenditure. Notwithstanding a rise in overall family welfare expenditure, spending on core family planning programs stagnates. State-wise and socio-economic heterogeneity in source-mix and method-mix continued to influence contraceptive access in India. Method-mix continued to skew towards female sterilization. Public sector access is helpful only for promoting female sterilization. Thus, the source-mix for modern contraceptives presents a clear public-private divide. Over time, access to all contraceptive methods by public sources declined while the private sector has failed to fill the gap. In conclusion, this study identified a need for revitalizing family planning programs to promote spacing methods in relatively lower-performing states and socio-economic groups to increase overall contraceptive access and use in India through the rise in core family planning expenditure.

Standard Survey Data: Insights Into Private Sector Utilization

Universal Health Coverage in Low- and Middle-Income Countries is increasingly expanding through incorporation of private clinics, pharmacies, and hospitals into an overall health system funded in whole or part through government-managed health insurance. This underscores the importance of policies on health provision which apply across the whole delivery system regardless of ownership status. To advance understanding of private-sector policies, and to facilitate sharing of lessons across countries with similar public-private distributions, we have analyzed data on the source of inpatient and outpatient care from 65 countries. While past studies have conducted similar analysis, ours advances the field in two ways. First, we limit our analysis to data sets from 2010 through 2019, making our study more up-to-date than past studies, while changing health seeking patterns for maternal health since 2010 means that our data set is more representative of overall inpatient care. Second, while past multi-country analysis of public-private ownership have been based on the Demographic Health Surveys, we have added to this data from the Multiple Indicator Cluster Surveys, significantly increasing the countries in our analysis. We have aggregated our analysis by WHO's regions. Outside of the EURO region, where the private sector delivers just 4% of all healthcare services, the private sector remains significant, and in many countries represents more than half of all care. The private sector provides nearly 40% of all healthcare in PAHO, AFRO, and WPRO regions, 57% in SEARO, and 62% in EMRO. While specific countries with two recent surveys show variation in the scale of both inpatient and outpatient private provision, we did not find regional or global trends toward or away from private care within LMICs. Private inpatient care is most important for the wealthy in many countries; public vs. private care varies less, by wealth, for outpatient services.

Using DHS and MICS data to complement or replace NGO baseline health data: an exploratory study

Background: Non-government organizations (NGOs) spend substantial time and resources collecting baseline data in order to plan and implement health interventions with marginalized populations. Typically interviews with households, often mothers, take over an hour, placing a burden on the respondents. Meanwhile, estimates of numerous health and social indicators in many countries already exist in publicly available datasets, such as the Demographic and Health Surveys (DHS) and the Multiple Indicator Cluster Surveys (MICS), and it is worth considering whether these could serve as estimates of baseline conditions. The objective of this study was to compare indicator estimates from non-governmental organizations (NGO) health projects’ baseline reports with estimates calculated using the Demographic and Health Surveys (DHS) or the Multiple Indicator Cluster Surveys (MICS), matching for location, year, and season of data collection.

Methods: We extracted estimates of 129 indicators from 46 NGO baseline reports, 25 DHS datasets and three MICS datasets, generating 1,996 pairs of matched DHS/MICS and NGO indicators. We subtracted NGO from DHS/MICS estimates to yield difference and absolute difference, exploring differences by indicator. We partitioned variance of the differences by geographical level, year, and season using ANOVA.

Results: Differences between NGO and DHS/MICS estimates were large for many indicators but 33% fell within 5% of one another. Differences were smaller for indicators with prevalence <15% or >85%. Difference between estimates increased with increasing year and geographical level differences. However, <1% of the variance of the differences was explained by year, geographical level, and season.

Conclusions: There are situations where publicly available data could complement NGO baseline survey data, most importantly when the NGO has tolerance for estimates of low or unknown accuracy.

The Global Network Maternal Newborn Health Registry: a multi-country, community-based registry of pregnancy outcomes

BACKGROUND

The Global Network for Women's and Children's Health Research (Global Network) conducts clinical trials in resource-limited countries through partnerships among U.S. investigators, international investigators based in in low and middle-income countries (LMICs) and a central data coordinating center. The Global Network's objectives include evaluating low-cost, sustainable interventions to improve women's and children's health in LMICs. Accurate reporting of births, stillbirths, neonatal deaths, maternal mortality, and measures of obstetric and neonatal care is critical to determine strategies for improving pregnancy outcomes. In response to this need, the Global Network developed the Maternal Newborn Health Registry (MNHR), a prospective, population-based registry of pregnant women, fetuses and neonates receiving care in defined catchment areas at the Global Network sites. This publication describes the MNHR, including participating sites, data management and quality and changes over time.

METHODS

Pregnant women who reside in or receive healthcare in select communities are enrolled in the MNHR of the Global Network. For each woman and her offspring, sociodemographic, health care, and the major outcomes through 42-days post-delivery are recorded. Study visits occur at enrollment during pregnancy, at delivery and at 42 days postpartum.

RESULTS

From 2010 through 2018, the Global Network MNHR sites were located in Guatemala, Belagavi and Nagpur, India, Pakistan, Democratic Republic of Congo, Kenya, and Zambia. During this period at these sites, 579,140 pregnant women were consented and enrolled in the MNHR, nearly 99% of all eligible women. Delivery data were collected for 99% of enrolled women and 42-day follow-up data for 99% of those delivered. In this supplement, the trends over time and assessment of differences across geographic regions are analyzed in a series of 18 manuscripts utilizing the MNHR data.

CONCLUSIONS

Improving maternal, fetal and newborn health in countries with poor outcomes requires an understanding of the characteristics of the population, quality of health care and outcomes. Because the worst pregnancy outcomes typically occur in countries with limited health registration systems and vital records, alternative registration systems may prove to be highly valuable in providing data. The MNHR, an international, multicenter, population-based registry, assesses pregnancy outcomes over time in support of efforts to develop improved perinatal healthcare in resource-limited areas. Trial Registration The Maternal Newborn Health Registry is registered at Clinicaltrials.gov (ID# NCT01073475). Registered February 23, 2019. https://clinicaltrials.gov/ct2/show/NCT01073475.

The impact of the obstetrical risk insurance scheme in Mauritania on maternal healthcare utilization: a propensity score matching analysis

In Mauritania, obstetrical risk insurance (ORI) has been progressively implemented at the health district level since 2002 and was available in 25% of public healthcare facilities in 2015. The ORI scheme is based on pre-payment scheme principles and focuses on increasing the quality of and access to both maternal and perinatal healthcare. Compared with many community-based health insurance schemes, the ORI scheme is original because it is not based on risk pooling. For a pre-payment of 16-18 USD, women are covered during their pregnancy for antenatal care, skilled delivery, emergency obstetrical care [including caesarean section (C-section) and transfer] and a postnatal visit. The objective of this study is to evaluate the impact of ORI enrolment on maternal and child health services using data from the Multiple Indicator Cluster Survey (MICS) conducted in 2015. A total of 4172 women who delivered within the last 2 years before the interview were analysed. The effect of ORI enrolment on the outcomes was estimated using a propensity score matching estimation method. Fifty-eight per cent of the studied women were aware of ORI, and among these women, more than two-thirds were enrolled. ORI had a beneficial effect among the enrolled women by increasing the probability of having at least one prenatal visit by 13%, the probability of having four or more visits by 11% and the probability of giving birth at a healthcare facility by 15%. However, we found no effect on postnatal care (PNC), C-section rates or neonatal mortality. This study provides evidence that a voluntary pre-payment scheme focusing on pregnant women improves healthcare services utilization during pregnancy and delivery. However, no effect was found on PNC or neonatal mortality. Some efforts should be exerted to improve communication and accessibility to ORI.

Childbirth care in Egypt: a repeat cross-sectional analysis using Demographic and Health Surveys between 1995 and 2014 examining use of care, provider mix and immediate postpartum care content

Background

Egypt has achieved important reductions in maternal and neonatal mortality and experienced increases in the proportion of births attended by skilled professionals. However, substandard care has been highlighted as one of the avoidable causes behind persisting maternal deaths. This paper describes changes over time in the use of childbirth care in Egypt, focusing on location and sector of provision (public versus private) and the content of immediate postpartum care.

Methods

We used five Demographic and Health Surveys conducted in Egypt between 1995 and 2014 to explore national and regional trends in childbirth care. To assess content of care in 2014, we calculated the caesarean section rate and the percentage of women delivering in a facility who reported receiving four components of immediate postpartum care for themselves and their newborn.

Results

Between 1995 and 2014, the percentage of women delivering in health facilities increased from 35 to 87% and women delivering with a skilled birth attendant from 49 to 92%. The percentage of women delivering in a private facility nearly quadrupled from 16 to 63%. In 2010–2014, fewer than 2% of women delivering in public or private facilities received all four immediate postpartum care components measured.

Conclusions

Egypt achieved large increases in the percentage of women delivering in facilities and with skilled birth attendants. However, most women and newborns did not receive essential elements of high quality immediate postpartum care. The large shift to private facilities may highlight failures of public providers to meet women’s expectations. Additionally, the content (quality) of childbirth care needs to improve in both sectors. Immediate action is required to understand and address the drivers of poor quality, including insufficient resources, perverse incentives, poor compliance and enforcement of existing standards, and providers’ behaviours moving between private and public sectors. Otherwise, Egypt risks undermining the benefits of high coverage because of substandard quality childbirth care.

Time trends in facility-based and private-sector childbirth care: analysis of Demographic and Health Surveys from 25 sub-Saharan African countries from 2000 to 2016

Background

Africa, and sub-Saharan Africa in particular, remains one of the regions with modest improvements to maternal and newborn survival and morbidity. Good quality intrapartum and early postpartum care in a health facility as well as delivery under the supervision of trained personnel is associated with improved maternal and newborn health outcomes and decreased mortality. We describe and contrast recent time trends in the scale and socio-economic inequalities in facility-based and private facility-based childbirth in sub-Saharan Africa.

Methods

We used Demographic and Health Surveys in two time periods (2000-2007 and 2008-2016) to analyse levels and time trends in facility-based and private facility-based deliveries for all live births in the five-year survey recall period to women aged 15-49. Household wealth quintiles were used for equity analysis. Absolute numbers of births by facility sector were calculated applying UN Population Division crude birth rates to the total country population.

Results

The percentage of all live births occurring in health facilities varied across countries (5%-85%) in 2000-2007. In 2008-2016, this ranged from 22% to 92%. The lowest percentage of all births occurring in private facilities in 2000-2007 period was in Ethiopia (0.3%) and the highest in the Democratic Republic of Congo at 20.5%. By 2008-2016, this ranged from 0.6% in Niger to 22.3% in Gabon. Overall, the growth in the absolute numbers of births in facilities outpaced the growth in the percentage of births in facilities. The largest increases in absolute numbers of births occurred in public sector facilities in all countries. Overall, the percentage of births occurring in facilities was significantly lower for poorest compared to wealthiest women. As the percentage of facility births increased in all countries over time, the extent of wealth-based differences had reduced between the two time periods in most countries (median risk ratio in 2008-2016 was 2.02). The majority of countries saw a narrowing in both the absolute and relative difference in facility-based deliveries between poorest and wealthiest.

Conclusions

The growth in facility-based deliveries, which was largely driven by the public sector, calls for increased investments in effective interventions to improve service delivery and quality of life for the mother and newborn. The goal of universal health coverage to provide better quality services can be achieved by deploying interventions that are holistic in managing and regulating the private sector to enhance performance of the health care system in its entirety rather than interventions that only target service delivery in one sector.

'Who assisted with the delivery of (NAME)?' Issues in estimating skilled birth attendant coverage through population-based surveys and implications for improving global tracking

The percentage of live births attended by a skilled birth attendant (SBA) is a key global indicator and proxy for monitoring progress in maternal and newborn health. Yet, the discrepancy between rising SBA coverage and non-commensurate declines in maternal and neonatal mortality in many low-income and middle-income countries has brought increasing attention to the challenge of what the indicator of SBA coverage actually measures, and whether the indicator can be improved. In response to the 2018 revised definition of SBA and the push for improved measurement of progress in maternal and newborn health, this paper examines the evidence on what women can tell us about who assisted them during childbirth and methodological issues in estimating SBA coverage via population-based surveys. We present analyses based on Demographic and Health Surveys and Multiple Indicator Cluster Surveys conducted since 2015 for 23 countries. Our findings show SBA coverage can be reasonably estimated from population-based surveys in settings of high coverage, though women have difficulty reporting specific cadres. We propose improvements in how skilled cadres are classified and documented, how linkages can be made to facility-based data to examine the enabling environment and further ways data can be disaggregated to understand the complexity of delivery care. We also reflect on the limitations of what SBA coverage reveals about the quality and circumstances of childbirth care. While improvements to the indicator are possible, we call for the use of multiple indicators to inform local efforts to improve the health of women and newborns.

Equity in antenatal care quality: an analysis of 91 national household surveys

Background

Emerging data show that many low-income and middle-income country (LMIC) health systems struggle to consistently provide good-quality care. Although monitoring of inequalities in access to health services has been the focus of major international efforts, inequalities in health-care quality have not been systematically examined.

Methods

Using the most recent (2007–16) Demographic and Health Surveys and Multiple Indicator Cluster Surveys in 91 LMICs, we described antenatal care quality based on receipt of three essential services (blood pressure monitoring and urine and blood testing) among women who had at least one visit with a skilled antenatal-care provider. We compared quality across country income groups and quantified within-country wealth-related inequalities using the slope and relative indices of inequality. We summarised inequalities using random-effects meta-analyses and assessed the extent to which other geographical and sociodemographic factors could explain these inequalities.

Findings

Globally, 72·9% (95% CI 69·1–76·8) of women who used antenatal care reported blood pressure monitoring and urine and blood testing; this number ranged from 6·3% in Burundi to 100·0% in Belarus. Antenatal care quality lagged behind antenatal care coverage the most in low-income countries, where 86·6% (83·4–89·7) of women accessed care but only 53·8% (44·3–63·3) reported receiving the three services. Receipt of the three services was correlated with gross domestic product per capita and was 40 percentage points higher in upper-middle-income countries compared with low-income countries. Within countries, the wealthiest women were on average four times more likely to report good quality care than the poorest (relative index of inequality 4·01, 95% CI 3·90–4·13). Substantial inequality remained after adjustment for subnational region, urban residence, maternal age, education, and number of antenatal care visits (3·20, 3·11–3·30).

Interpretation

Many LMICs that have reached high levels of antenatal care coverage had much lower and inequitable levels of quality. Achieving ambitious maternal, newborn, and child health goals will require greater focus on the quality of health services and their equitable distribution. Equity in effective coverage should be used as the new metric to monitor progress towards universal health coverage.

Funding

Bill & Melinda Gates Foundation.

Is childbirth location associated with higher rates of favourable early breastfeeding practices in Sub-Saharan Africa?

Background

Favourable early breastfeeding practices have a beneficial impact throughout an infants’ lifespan. Childbirth location is likely to affect these practices through support during the intrapartum and immediate postpartum period. This study aimed to investigate the association between childbirth location and favourable early breastfeeding practices in Sub-Saharan Africa (SSA).

Methods

Demographic and Health Survey (2000–2013) data across 30 SSA countries were utilised. Childbirth location was categorised as home vs facility, and further into public vs private sector. Early breastfeeding practices included: early initiation of breastfeeding (EIBF) (within 1 hour of birth), and no prelacteal feeding (fed only breast milk in the first 3 days). Multivariate logistic regression models adjusted for confounders were used to assess this association.

Results

Overall, 50.0% (country range 32.6%-95.5%) of infants received EIBF and 61.0% had no prelacteal feeding. Compared with home births, facility deliveries had higher adjusted odds of EIBF (adjusted odds ratio, aOR = 1.39, 95% confidence interval (CI) = 1.30-1.48, P < 0.001) and no prelacteal feeding (aOR = 1.75, 95% CI = 1.63-1.89, P < 0.001). Private sector facilities had lower adjusted odds of no prelacteal feeding (aOR = 0.89, 95% CI = 0.81-0.99, P = 0.036) when compared to public sector facilities. There was no evidence to suggest delivery sector was associated with EIBF (aOR = 0.93, 95% CI = 0.85-1.03, P = 0.212).

Conclusions

This study showed early breastfeeding practices are suboptimal and are associated with delivery location in SSA. Further research is required to better understand how characteristics of care may explain these patterns in order to improve feeding practices.

Scoping review to identify and map the health personnel considered skilled birth attendants in low-and-middle income countries from 2000-2015

INTRODUCTION

The "percentage of births attended by a skilled birth attendant" (SBA) is an indicator that has been adopted by several global monitoring frameworks, including the Sustainable Development Goal (SDG) agenda for regular monitoring as part of target 3.1 for reducing maternal mortality by 2030. However, accurate and consistent measurement is challenged by contextual differences between and within countries on the definition of SBA, including the education, training, competencies, and functions they are qualified to perform. This scoping review identifies and maps the health personnel considered SBA in low-to-middle-income-countries (LMIC).

METHODS AND ANALYSIS

A search was conducted inclusive to the years 2000 to 2015 in PubMed/MEDLINE, EMBASE, CINAHL Complete, Cochrane Database of Systematic Reviews, POPLINE and the World Health Organization Global Index Medicus. Original primary source research conducted in LMIC that evaluated the skilled health personnel providing interventions during labour and childbirth were considered for inclusion. All studies reported disaggregated data of SBA cadres and were disaggregated by country.

RESULTS

The search of electronic databases identified a total of 23,743 articles. Overall, 70 articles were included in the narrative synthesis. A total of 102 unique cadres names were identified from 36 LMIC countries. Of the cadres included, 16% represented doctors, 16% were nurses, and 15% were midwives. We found substantial heterogeneity between and within countries on the reported definition of SBA and the education, training, skills and competencies that they were able to perform.

CONCLUSION

The uncertainty and diversity of reported qualifications and competency of SBA within and between countries requires attention in order to better ascertain strategic priorities for future health system planning, including training and education. These results can inform recommendations around improved coverage measurement and monitoring of SBA moving forward, allowing for more accurate, consistent, and timely data able to guide decisions and action around planning and implementation of maternal and newborn health programmes.

Meeting need vs. sharing the market: a systematic review of methods to measure the use of private sector family planning and childbirth services in sub-Saharan Africa

BACKGROUND

Ensuring universal access to maternal and reproductive health services is critical to the success of global efforts to reduce poverty and inequality. Engaging private providers has been proposed as a strategy for increasing access to healthcare in low- and middle-income countries; however, little consensus exists on how to estimate the extent of private sector use. Using research from sub-Saharan Africa, this study systematically compares and critiques quantitative measures of private sector family planning and childbirth service use and synthesizes evidence on the role of the private sector in the region.

METHODS

We conducted a systematic review of the Medline, Global Health, and Popline databases. All studies that estimated use of private sector of family planning or childbirth services in one or more sub-Saharan African countries were included in this review. For each study, we extracted data on the key study outcomes and information on the methods used to estimate private sector use.

RESULTS

Fifty-three papers met our inclusion criteria; 31 provided outcomes on family planning, and 26 provided childbirth service outcomes. We found substantial methodological variation between studies; for instance, while some reported on service use from any private sector source, others distinguished private sector providers either by their profit orientation or position within or outside the formal medical sector. Additionally, studies measured the use of private sector services differently, with some estimating the proportion of need met by the private sector and others examining the sector's share among the market of service users. Overall, the estimates suggest that the private sector makes up a considerable portion (> 20%) of the market for family planning and childbirth care, but its role in meeting women's need for these services is fairly low (< 10%).

CONCLUSIONS

Many studies have examined the extent of private sector family planning and childbirth service provision; however, inconsistent methodologies make it difficult to compare results across studies and contexts. Policymakers should consider the implications of both private market share and coverage estimates, and be cautious in interpreting data on the scale of private sector health service provision without a clear understanding of the methodology.

Associations of acute conflict with equity in maternal healthcare: an uncontrolled before-and-after analysis of Egypt demographic and health survey data

Background

Equity of usage of maternal services during conflict is considered key to reducing maternal health risks globally. However, evidence showing how conflict affects maternal care use among different population groups is minimal. This study examined how the Egyptian acute conflict of 2011–2012 affected maternal care use among different socioeconomic, demographic, and geographic groups.

Methods

An ‘uncontrolled before-and-after’ study design was used to perform multi-level modelling regression analysis on 2014 Egypt Demographic and Health Survey data. The pre-conflict sample included 2569 births occurring from January 2009 to January 2011 and the peri-conflict sample included 4641 births from February 2011 to December 2012.

Results

Interaction analysis indicated that the effect of conflict on some aspects of maternal care differed by mother’s age, residential status, employment, education level and household wealth. In the stratum-specific analysis, increased odds of skilled delivery during conflict was relatively greater among women who were rural (odds ratio [OR] 1.02; 95%CI 1.02–1.03), educated to primary level (OR 1.04; 95%CI 1.01–1.07), employed (OR 1.04; 95%CI 1.01–1.07), less poor (OR 1.03; 95%CI 1.02–1.05) or middle-income (OR 1.02; 95%CI 1.01–1.04), than pre-conflict. Similarly, increased odds of physician-assisted delivery during conflict was relatively greater for women who were rural (OR 1.03; 95%CI 1.02–1.04), educated to primary level (OR 1.05; 95% CI 1.01–1.10), employed (OR 1.07; 95%CI 1.02–1.11), or from less poor/middle-income (OR 1.03; 95%CI 1.01–1.05 each), and richest quintiles (OR 1.02; 95%CI 1.00–1.03). Decreased odds of postnatal care during conflict was relatively greater among women aged 25–29 (OR 0.92; 95%CI 0.88–0.96) compared to older women.

Conclusions

The association between acute conflict and maternal services usage indicated some vertical equity, as equity patterns during conflict differed from recent trends in Egypt. The association between conflict and maternal care usage among potentially marginalised groups was minimal and not notably inequitable. Specific strategies should be included in maternal health policies to mitigate the unpredictable effect of conflict on maternal care equity. Further research is needed to determine how conflict affects out-of-pocket expenditures and quality-of-care among different socioeconomic groups.

Linking data sources for measurement of effective coverage in maternal and newborn health: what do we learn from individual- vs ecological-linking methods?

Background

Improving maternal and newborn health requires improvements in the quality of facility-based care. This is challenging to measure: routine data may be unreliable; respondents in population surveys may be unable to accurately report on quality indicators; and facility assessments lack population level denominators. We explored methods for linking access to skilled birth attendance (SBA) from household surveys to data on provision of care from facility surveys with the aim of estimating population level effective coverage reflecting access to quality care.

Methods

We used data from Mayuge District, Uganda. Data from household surveys on access to SBA were linked to health facility assessment census data on readiness to provide basic emergency obstetric and newborn care (BEmONC) in the same district. One individual- and two ecological-linking methods were applied. All methods used household survey reports on where care at birth was accessed. The individual-linking method linked this to data about facility readiness from the specific facility where each woman delivered. The first ecological-linking approach used a district-wide mean estimate of facility readiness. The second used an estimate of facility readiness adjusted by level of health facility accessed. Absolute differences between estimates derived from the different linking methods were calculated, and agreement examined using Lin's concordance correlation coefficient.

Results

A total of 1177 women resident in Mayuge reported a birth during 2012-13. Of these, 664 took place in facilities within Mayuge, and were eligible for linking to the census of the district's 38 facilities. 55% were assisted by a SBA in a facility. Using the individual-linking method, effective coverage of births that took place with an SBA in a facility ready to provide BEmONC was just 10% (95% confidence interval CI 3-17). The absolute difference between the individual- and ecological-level linking method adjusting for facility level was one percentage point (11%), and tests suggested good agreement. The ecological method using the district-wide estimate demonstrated poor agreement.

Conclusions

The proportion of women accessing appropriately equipped facilities for care at birth is far lower than the coverage of facility delivery. To realise the life-saving potential of health services, countries need evidence to inform actions that address gaps in the provision of quality care. Linking household and facility-based information provides a simple but innovative method for estimating quality of care at the population level. These encouraging findings suggest that linking data sets can result in meaningful evidence even when the exact location of care seeking is not known.

Effect of maternal age on facility-based delivery: analysis of first-order births in 34 countries of sub-Saharan Africa using demographic and health survey data

OBJECTIVES

Increasing access to skilled birth attendance, usually via childbirth in health facilities, is a key intervention to reduce maternal and perinatal mortality and morbidity. Yet, in some countries of sub-Saharan Africa, the uptake is <50%. Age and parity are determinants of facility-based delivery, but are strongly correlated in high fertility settings. This analysis assessed the independent effect of age on facility-based delivery by restricting to first-order births. It was hypothesised that older first-time mothers in this setting might have lower uptake of facility-based deliveries than women in the most common age groups for first birth.

SETTING

The most recent Demographic and Health Surveys from 34 sub-Saharan African countries were used to assess women's delivery locations.

PARTICIPANTS

72 772 women having their first birth in the 5 years preceding the surveys were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportions and 95% CIs of facility-based deliveries were estimated overall and by country. Multivariable logistic regression was used to calculate the odds of facility-based delivery for different maternal age groups (15-19, 20-24 and ≥25 years) for a pooled sample of all countries.

RESULTS

59.9% of women had a facility-based delivery for their first birth (95% CI 58.6 to 61.2), ranging from 19.4% in Chad to 96.6% in Rwanda. Compared with women aged 15-19 years, the adjusted odds of having a facility-based delivery for those aged 20-24 was 1.4 (95% CI 1.3 to 1.5, p<0.001) and for those aged ≥25, 1.9 (95% CI 1.6 to 2.2, p<0.001).

CONCLUSIONS

Older age at first birth was independently associated with significantly higher odds of facility-based delivery. This went against the hypothesis. Further mixed-method research is needed to explore how increased age improves uptake of facility-based delivery. Promoting facility-based delivery, while ensuring quality of care, should be prioritised to improve birth outcomes in sub-Saharan Africa.

Who Meets the Contraceptive Needs of Young Women in Sub-Saharan Africa?

PURPOSE

Despite efforts to expand contraceptive access for young people, few studies have considered where young women (age 15-24) in low- and middle-income countries obtain modern contraceptives and how the capacity and content of care of sources used compares with older users.

METHODS

We examined the first source of respondents' current modern contraceptive method using the most recent Demographic and Health Survey since 2000 for 33 sub-Saharan African countries. We classified providers according to sector (public/private) and capacity to provide a range of short- and long-term methods (limited/comprehensive). We also compared the content of care obtained from different providers.

RESULTS

Although the public and private sectors were both important sources of family planning (FP), young women (15-24) used more short-term methods obtained from limited-capacity, private providers, compared with older women. The use of long-term methods among young women was low, but among those users, more than 85% reported a public sector source. Older women (25+) were significantly more likely to utilize a comprehensive provider in either sector compared with younger women. Although FP users of all ages reported poor content of care across all providers, young women had even lower content of care.

CONCLUSIONS

The results suggest that method and provider choice are strongly linked, and recent efforts to increase access to long-term methods among young women may be restricted by where they seek care. Interventions to increase adolescents' access to a range of FP methods and quality counseling should target providers frequently used by young people, including limited-capacity providers in the private sector.

Pathways to increased coverage: an analysis of time trends in contraceptive need and use among adolescents and young women in Kenya, Rwanda, Tanzania, and Uganda

BACKGROUND

Despite efforts to make contraceptive services more "youth friendly," unmet need for contraception among young women in sub-Saharan Africa remains high. For health systems to effectively respond to the reproductive health needs of a growing youth population, it is imperative to understand their contraceptive needs and service seeking practices. This paper describes changes over time in contraceptive need, use, and sources of care among young women in four East African countries.

METHODS

We used three rounds of DHS data from Kenya, Rwanda, Tanzania, and Uganda to examine time trends from 1999 to 2015 in met need for modern contraception, method mix, and source of care by sector (public or private) and type of provider among young women aged 15-24 years. We assessed disparities in contraceptive coverage improvements over time between younger (15-24 years) and older women (25-49 years) using a difference-in-differences approach.

RESULTS

Met need for contraception among women aged 15-24 years increased over time, ranging from a 20% increase in Tanzania to more than a 5-fold increase in Rwanda. Improvements in met need were greater among older women compared to younger women in Rwanda and Uganda, and higher among younger women in Kenya. Injectables have become the most popular contraceptive choice among young women, with more than 50% of modern contraceptive users aged 15-24 years currently using the method in all countries except for Tanzania, where condoms and injectables are used by 38% and 35% of young users, respectively. More than half of young women in Tanzania and Uganda receive contraceptives from the private sector; however, while the private sector played an important role in meeting the growing contraceptive needs among young women in Tanzania, increased use of public sector services drove expanded access in Kenya, Rwanda, and Uganda.

CONCLUSIONS

Our study shows that contraceptive use increased among young East African women, yet, unmet need remains high. As youth populations continue to grow, governments must develop more targeted strategies for expanding access to reproductive health services for young women. Engaging the private sector and task-shifting to lower-level providers offer promising approaches; however, additional research is needed to identify the key facilitators and barriers to the success of these strategies in different contexts.

Early breastfeeding practices: Descriptive analysis of recent Demographic and Health Surveys

The aim of this study was to describe early breastfeeding practices (initiation within 1 hr of birth, no prelacteal feeding, and a combination of both—“optimal” early breastfeeding) according to childbirth location in low‐ and middle‐income countries. Using data from the most recent Demographic and Health Survey (2000–2013) for 57 countries, we extracted information on the most recent birth for women aged 15–49 with a live birth in the preceding 24 months. Childbirth setting was self‐reported by location (home or facility) and subtype (home delivery with or without a skilled birth attendant; public or private facility). We produced overall world and four region‐level summary statistics by applying national population adjusted survey weights. Overall, 39% of children were breastfed within 1 hr of birth (region range 31–60%), 49% received no prelacteal feeding (41–65%), and 28% benefited from optimal early breastfeeding (21–46%). In South/Southeast Asia and Sub‐Saharan Africa, early breastfeeding outcomes were more favourable for facility births compared to home births; trends were less consistent in Latin America and Middle East/Europe. Among home deliveries, there was a higher prevalence of positive breastfeeding practices for births with a skilled birth attendant across all regions other than Latin America. For facility births, breastfeeding practices were more favourable among those taking place in the public sector. This study is the most comprehensive assessment to date of early breastfeeding practices by childbirth location. Our results suggest that skilled delivery care—particularly care delivered in public sector facilities—appears positively correlated with favourable breastfeeding practices.

Protocol for a scoping review to identify and map the global health personnel considered skilled attendants at birth in low and middle-income countries between 2000 and 2015

INTRODUCTION

Despite progress towards the Millennium Development Goals (MDG), maternal mortality remains high in countries where there are shortages of skilled personnel able to manage and provide quality care during pregnancy and childbirth. The 'percentage of births attended by skilled health personnel' (SAB, skilled attendants at birth) was a key indicator for tracking progress since the MDGs and is part of the Sustainable Development Goal agenda. However, due to contextual differences between and within countries on the definition of SAB, a lack of clarity exists around the training, competencies, and skills they are qualified to perform. In this paper, we outline a scoping review protocol that poses to identify and map the health personnel considered SAB in low and middle-income countries (LMIC).

METHODS AND ANALYSIS

A search will be conducted for the years 2000-2015 in PubMed/MEDLINE, EMBASE, CINAHL Complete, Cochrane Database of Systematic Reviews, POPLINE and the WHO Global Health Library. A manual search of reference lists from identified studies or systematic reviews and a hand search of the literature from international partner organisations will be done. Original studies conducted in LMIC that assessed health personnel (paid or voluntary) providing interventions during the intrapartum period will be considered for inclusion.

ETHICS AND DISSEMINATION

A scoping review is a secondary analysis of published literature and does not require ethics approval. This scoping review proposes to synthesise data on the training, competency and skills of identified SAB and expands on other efforts to describe this global health workforce. The results will inform recommendations around improved coverage measurement and reporting of SAB moving forward, allowing for more accurate, consistent and timely data able to guide decisions and action around planning and implementation of maternal and newborn health programme globally. Data will be disseminated through a peer-reviewed manuscript, conferences and to key stakeholders within international organisations.

Examining trends in family planning among harder-to-reach women in Senegal 1992-2014

Recent increases in family planning (FP) use have been reported among women of reproductive age in union (WRAU) in Senegal. However, trends have not been monitored among harder-to-reach groups (including adolescents, unmarried and rural poor women), key to understanding whether FP progress is equitable. We combined data from six Demographic and Health Surveys conducted in Senegal between 1992/93 and 2014. We examined FP trends over time among WRAU and subgroups, and trends in knowledge of FP and intention to use among women with unmet need for FP. Our results show that percent demand satisfied is lower among rural poor women and adolescents than WRAU, although higher among unmarried women. Marked recent increases have been observed in all subgroups, however fewer than 50% of women in need of FP use modern contraception in Senegal. Knowledge of FP has risen steadily among women with unmet need; however, intention to use FP has remained stable at around 40% since 2005 for all groups except unmarried women (75% of whom intend to use). Significant progress in meeting the need for FP has been achieved in Senegal, but more needs to be done particularly to improve acceptability of FP, and to strategically target interventions toward adolescents and rural poor women.

Geographic information system for improving maternal and newborn health: recommendations for policy and programs

This correspondence argues and offers recommendations for how Geographic Information System (GIS) applied to maternal and newborn health data could potentially be used as part of the broader efforts for ending preventable maternal and newborn mortality. These recommendations were generated from a technical consultation on reporting and mapping maternal deaths that was held in Washington, DC from January 12 to 13, 2015 and hosted by the United States Agency for International Development's (USAID) global Maternal and Child Survival Program (MCSP). Approximately 72 participants from over 25 global health organizations, government agencies, donors, universities, and other groups participated in the meeting.The meeting placed emphases on how improved use of mapping could contribute to the post-2015 United Nation's Sustainable Development Goals (SDGs), agenda in general and to contribute to better maternal and neonatal health outcomes in particular. Researchers and policy makers have been calling for more equitable improvement in Maternal and Newborn Health (MNH), specifically addressing hard-to-reach populations at sub-national levels. Data visualization using mapping and geospatial analyses play a significant role in addressing the emerging need for improved spatial investigation at subnational scale. This correspondence identifies key challenges and recommendations so GIS may be better applied to maternal health programs in resource poor settings. The challenges and recommendations are broadly grouped into three categories: ancillary geospatial and MNH data sources, technical and human resources needs and community participation.

Linking household and facility data for better coverage measures in reproductive, maternal, newborn, and child health care: systematic review

BACKGROUND

Currently many measures of intervention coverage obtained from household surveys do not measure actual health intervention/service delivery, resulting in a need for linking reports of care-seeking with assessments of the service environment in order to improve measurements. This systematic review aims to identify evidence of different methods used to link household surveys and service provision assessments, with a focus on reproductive, maternal, newborn and child health care, in low- and middle-income countries.

METHODS

Using pre-defined search terms, articles published in peer-reviewed journals and the grey literature after 1990 were identified, their reference lists scanned and linking methods synthesized.

FINDINGS

A total of 59 articles and conference presentations were carefully reviewed and categorized into two groups based on the linking method used: 1) indirect/ecological linking that included studies in which health care-seeking behavior was linked to all or the nearest facilities or providers of certain types within a geographical area, and 2) direct linking/exact matching where individuals were linked with the exact provider or facility where they sought care. The former approach was employed in 51 of 59 included studies, and was particularly common among studies that were based on independent sources of household and facility data that were nationally representative. Only eight of the 59 reviewed studies employed direct linking methods, which were typically done at the sub-national level (eg, district level) and often in rural areas, where the number of providers was more limited compared to urban areas.

CONCLUSIONS

Different linking methods have been reported in the literature, each category has its own set of advantages and limitations, in terms of both methodology and practicality for scale-up. Future studies that link household and provider/facility data should also take into account factors such as sources of data, the timing of surveys, the temporality of data points, the type of services and interventions, and the scale of the study in order to produce valid and reliable results.

The scale, scope, coverage, and capability of childbirth care

All women should have access to high quality maternity services-but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

Who, What, Where: an analysis of private sector family planning provision in 57 low- and middle-income countries

OBJECTIVE

Family planning service delivery has been neglected; rigorous analyses of the patterns of contraceptive provision are needed to inform strategies to address this neglect.

METHODS

We used 57 nationally representative Demographic and Health Surveys in low- and middle-income countries (2000-2013) in four geographic regions to estimate need for contraceptive services, and examined the sector of provision, by women's socio-economic position. We also assessed method mix and whether women were informed of side effects.

RESULTS

Modern contraceptive use among women in need was lowest in sub-Saharan Africa (39%), with other regions ranging from 64% to 72%. The private sector share of the family planning market was 37-39% of users across the regions and 37% overall (median across countries: 41%). Private sector users accessed medical providers (range across regions: 30-60%, overall mean: 54% and median across countries 23%), specialised drug sellers (range across regions: 31-52%, overall mean: 36% and median across countries: 43%) and retailers (range across regions: 3-14%, overall mean: 6% and median across countries: 6%). Private retailers played a more important role in sub-Saharan Africa (14%) than in other regions (3-5%). NGOs and FBOs served a small percentage. Privileged women (richest wealth quintile, urban residents or secondary-/tertiary-level education) used private sector services more than the less privileged. Contraceptive method types with higher requirements (medical skills) for provision were less likely to be acquired from the private sector, while short-acting methods/injectables were more likely. The percentages of women informed of side effects varied by method and provider subtype, but within subtypes were higher among public than private medical providers for four of five methods assessed.

CONCLUSION

Given the importance of private sector providers, we need to understand why women choose their services, what quality services the private sector provides, and how it can be improved. However, when prioritising one of the two sectors (public vs. private), it is critical to consider the potential impact on contraceptive prevalence and equity of met need.

Role of the private sector in childbirth care: cross-sectional survey evidence from 57 low- and middle-income countries using Demographic and Health Surveys

OBJECTIVE

Maternal mortality rates have decreased globally but remain off track for Millennium Development Goals. Good-quality delivery care is one recognised strategy to address this gap. This study examines the role of the private (non-public) sector in providing delivery care and compares the equity and quality of the sectors.

METHODS

The most recent Demographic and Health Survey (2000-2013) for 57 countries was used to analyse delivery care for most recent birth among >330 000 women. Wealth quintiles were used for equity analysis; skilled birth attendant (SBA) and Caesarean section rates served as proxies for quality of care in cross-sectoral comparisons.

RESULTS

The proportion of women who used appropriate delivery care (non-facility with a SBA or facility-based births) varied across regions (49-84%), but wealth-related inequalities were seen in both sectors in all regions. One-fifth of all deliveries occurred in the private sector. Overall, 36% of deliveries with appropriate care occurred in the private sector, ranging from 9% to 46% across regions. The presence of a SBA was comparable between sectors (≥93%) in all regions. In every region, Caesarean section rate was higher in the private compared to public sector. The private sector provided between 13% (Latin America) and 66% (Asia) of Caesarean section deliveries.

CONCLUSION

This study is the most comprehensive assessment to date of coverage, equity and quality indicators of delivery care by sector. The private sector provided a substantial proportion of delivery care in low- and middle-income countries. Further research is necessary to better understand this heterogeneous group of providers and their potential to equitably increase the coverage of good-quality intrapartum care.

The Global Network Maternal Newborn Health Registry: a multi-national, community-based registry of pregnancy outcomes

BACKGROUND

The Global Network for Women's and Children's Health Research (Global Network) supports and conducts clinical trials in resource-limited countries by pairing foreign and U.S. investigators, with the goal of evaluating low-cost, sustainable interventions to improve the health of women and children. Accurate reporting of births, stillbirths, neonatal deaths, maternal mortality, and measures of obstetric and neonatal care is critical to efforts to discover strategies for improving pregnancy outcomes in resource-limited settings. Because most of the sites in the Global Network have weak registration within their health care systems, the Global Network developed the Maternal Newborn Health Registry (MNHR), a prospective, population-based registry of pregnancies at the Global Network sites to provide precise data on health outcomes and measures of care.

METHODS

Pregnant women are enrolled in the MNHR if they reside in or receive healthcare in designated groups of communities within sites in the Global Network. For each woman, demographic, health characteristics and major outcomes of pregnancy are recorded. Data are recorded at enrollment, the time of delivery and at 42 days postpartum.

RESULTS

From 2010 through 2013 Global Network sites were located in Argentina, Guatemala, Belgaum and Nagpur, India, Pakistan, Kenya, and Zambia. During this period, 283,496 pregnant women were enrolled in the MNHR; this number represented 98.8% of all eligible women. Delivery data were collected for 98.8% of women and 42-day follow-up data for 98.4% of those enrolled. In this supplement, there are a series of manuscripts that use data gathered through the MNHR to report outcomes of these pregnancies.

CONCLUSIONS

Developing public policy and improving public health in countries with poor perinatal outcomes is, in part, dependent upon understanding the outcome of every pregnancy. Because the worst pregnancy outcomes typically occur in countries with limited health registration systems and vital records, alternative registration systems may prove to be highly valuable in providing data. The MNHR, an international, multicenter, population-based registry, assesses pregnancy outcomes over time in support of efforts to develop improved perinatal healthcare in resource-limited areas.