Temporal trends in coverage, quality and equity of maternal and child health services in Rwanda, 2000-2015

Quality adjusted coverage of family planning services in low- and middle-income countries: Analysis of 33 countries using Demographic and Health Survey data

Background

Monitoring service quality for family planning programmes in low- and middle-income countries (LMICs) has been challenging due to data availability. Self-reported service quality from Demographic and Health Surveys (DHS) can provide additional information on quality beyond simple service contact.

Methods

The DHS collects need, use and counselling for contraceptives. We used this data from 33 LMICs to develop quality-adjusted demand for modern family planning satisfied indicator (DFPSq). We compared it with the crude indicator (demand for family planning satisfied (DFPS)) and performed an equity analysis. Median, interquartile ranges (IQR) and the absolute and relative gap by country were used to describe the findings.

Results

The median DFPS was 49% (IQR = 41-57%) and the median DPFSq was 19% (IQR = 14-27%). We found similar relative differences in the gap stratified by SES indicating quality was universally low. One exception is that adolescents had a higher relative gap (70%, IQR = 57-79%) compared to adults (54%, IQR = 46-68%), indicating lower quality access.

Conclusions

Severe and pervasive quality gaps exist in family planning services across most LMICs. Our novel DFPSq indicator is one additional tool for monitoring access and quality of service that is critical to meet the family planning needs of women.

Poor coverage of quality-adjusted antenatal care services: a population-level assessment by visit and source of antenatal care services in Bihar state of India

Background

Despite the evidence on the poor quality of antenatal care (ANC) services, significant gap remains in the understanding of quality-adjusted coverage at the population-level for each ANC visit and by the source of ANC services, and in equity in this coverage.

Methods

All births between July 2020 and June 2021 were listed from 261,124 households (91.5% participation) representative of the Bihar state. Mothers of all stillbirths and neonatal deaths, and of 25% random sample of livebirths who survived the neonatal period provided data on each ANC visit up to a maximum of first 4 ANC visits, including the source of ANC services and the services received (weight measurement, blood pressure checked, abdomen checked, urine sample taken, and blood sample taken). An ANC visit was deemed of quality if all of these services were received in that visit. We report the coverage of quality-adjusted ANC services (Q-ANC) for ANC visits 1-4 disaggregated by source of ANC services and wealth index (WI). Weighted proportions are reported to take into account the sampling design.

Findings

A total of 30,412 births were reported by 29,517 women, and 7270 (82.1%) of the 8853 eligible women participated. Overall, 19,950 unique ANC visits from 6929 women were available for analysis, of which 41.7%, 13.8% and 44.5% were at Village Health and Nutrition Day (VNHD), public facility, and with a private provider, respectively. A total of 4409 (65.3%) of the 1st ANC visits were undertaken at VHND, with the proportion of private provider ANC visits increasing significantly from ANC visit 1 to ANC visit 4 (p < 0.001). Q-ANC coverage considering all ANC visits was 20.9% (95% CI 20.7-21.2); and was 0.9% (95% CI 0.8-1.0), 29.9% (95% CI 29.2-30.7) and 36.9% (95% CI 36.5-37.4) for ANC visits in VHND, public facilities, and with private provider, respectively. Q-ANC coverage in the public facility was significantly lower in the 4th ANC visit (25.1%; 95% CI 23.4-26.9) as compared with visits 1 to 3, whereas it was the highest for 1st ANC visit with private provider (50.2%; 95% CI 49.2-51.1) and then dropped for visits 2 to 4. Irrespective of the source of ANC services, Q-ANC coverage increased significantly with increasing WI quartile for ANC visits 1 and 2, with WI quartile 3 women having significantly less coverage for ANC visit 3 compared to the rest, and no significant difference seen in the coverage of ANC 4 visit. Varied pattern of Q-ANC coverage by WI for each ANC visit was seen for public facility and private provider visits.

Interpretation

With only 2 of 10 ANC visits deemed of adequate quality, sustainable delivery of quality ANC services are needed for every pregnant woman through-out the pregnancy irrespective of gestation period, number of ANC visit, and source of ANC services.

Funding

The funding was provided by the India office of the Bill & Melinda Gates Foundation, USA.

Quality of antenatal care in 13 sub-Saharan African countries in the SDG era: evidence from Demographic and Health Surveys

BACKGROUND

Maternal and neonatal mortality remains high in sub-Saharan Africa (SSA) with women having 1 in 36 lifetime risk. The WHO launched the new comprehensive recommendations/guidelines on antenatal care (ANC) in 2016, which stresses the essence of quality antenatal care. Consequently, the objective of this cross-sectional study is to investigate the quality of ANC in 13 SSA countries.

METHODS

This is a cross-sectional study that is premised on pre-existing secondary data, spanning 2015 to 2021. Data for the study was obtained from the Measure DHS Programme and included a total of 79,725 women aged 15-49 were included. The outcome variable was quality ANC and it was derived as a composite variable from four main ANC services: blood pressure taken, urine taken, receipt of iron supplementation and blood sample taken. Thirteen independent variables were included and broadly categorised into individual and community-level characteristics. Descriptive statistics were used to present the proportion of women who had quality ANC across the respective countries. A two-level multilevel regression analysis was conducted to ascertain the direction of association between quality ANC and the independent variables.

RESULTS

The overall average of women who had quality ANC was 53.8% [CI = 51.2,57.5] spanning from 82.3% [CI = 80.6,85.3] in Cameroon to 11% [CI = 10.0, 11.4] in Burundi. Women with secondary/higher education had higher odds of obtaining quality ANC compared with those without formal education [aOR = 1.23, Credible Interval [Crl] = 1.10,1.37]. Poorest women were more likely to have quality ANC relative to the richest women [aOR = 1.21, Crl = 1.14,1.27]. Married women were more likely to receive quality ANC relative to those cohabiting [aOR = 2.04, Crl = 1.94,3.05]. Women who had four or more ANC visits had higher odds of quality ANC [aOR = 2.21, Crl = 2.04,2.38]. Variation existed in receipt of quality ANC at the community-level [σ2 = 0.29, Crl = 0.24,0.33]. The findings also indicated that a 36.2% variation in quality ANC is attributable to community-level factors.

CONCLUSION

To achieve significant improvement in the coverage of quality ANC, the focus of maternal health interventions ought to prioritise uneducated women, those cohabiting, and those who are unable to have at least four ANCs. Further, ample recognition should be accorded to the existing and potential facilitators and barriers to quality ANC across and within countries.

Provider and client perspectives on the use of maternity waiting homes in rural Rwanda

BACKGROUND

The World Health Organization recommends the implementation of maternity waiting homes (MWH) to reduce delays in access to obstetric care, particularly for high-risk pregnancies and mothers living far from health facilities, and as a result, several countries have rolled out MWHs. However, Rwanda has not implemented this recommendation on a large scale. There is only one MWH in the country, hence a gap in knowledge regarding the potential utilisation and benefits of MWHs.

OBJECTIVE

To explore providers' and clients' perspectives on facilitators and barriers to the use of MWH in rural Rwanda.

METHODS

We conducted a qualitative study to explore health providers' and clients' perspectives on facilitators and barriers to the use of MWH in Rwanda, between December 2020 and January 2021. We used key informant interviews and focus group discussions to collect data. Data were analysed using NVivo qualitative analysis software version 11.

RESULTS

Facilitators included perceptions that the MWH offered either a peaceful and home-like environment, good-quality services, or timely obstetric services, and was associated with good maternal and neonatal outcomes. Barriers included limited awareness of the MWH among pregnant women, fear of health providers to operate the MWH at full capacity, women's lack of autonomy, uncertainty over funding for the MWH, and perceived high user fees.

CONCLUSION

The Ruli MWH offers a peaceful environment for pregnant women while providing quality and timely obstetric care, resulting in positive maternal and neonatal outcomes for women. However, its existence and benefits are not widely known, and its use is limited due to inadequate resources. There is a need for increased awareness of the MWH among healthcare providers and the community, and lessons from this MWH could inform the scale up of MWHs in Rwanda.

Association between adequacy of antenatal care and neonatal outcomes in Rwanda: a cross-sectional study design using the Rwanda demographic and health surveys

BACKGROUND

Maternal and neonatal health services are life-saving interventions for neonatal health outcomes. As Rwanda endeavors to accomplish sustainable development goals, adequate ANC is essential to lessen of neonatal mortality. The utilization of ANC continues to be inadequate and high neonatal mortality rate persevere in Rwanda. Understanding the direct and indirect factors that affect newborn health outcomes is necessary for well-targeted interventions. However, few studies had been conducted in Rwanda to evaluate the importance of ANC in improving neonatal health. This study therefore assessed the association between ANC and neonatal outcomes.

METHODS

The Demographic and Health Surveys (DHS) are household surveys that are cross-sectional, nationally representative, and used to collect data on population, health, and nutrition. Data from the 2010,2015 and 2020 Rwanda Demographic and Health Surveys (RDHS) were used. The study involved 17,747 women between the ages of 15 and 49 who had a single live birth and at least one ANC visit in five years prior to each survey. Bivariate and multivariable logistic regression, a survey adjusted for clusters at multiple level, and the estimation of adjusted odds ratios (aOR) and 95% confidence intervals were used to evaluate the relationship between the outcome and independent variables.

RESULTS

Out of 17,747 women ;7638(42.91%) of the mothers had adequate ANC visits and low birth weight (LBW) was found among 833(4.63%) neonates. The birth of a LBW baby (aOR:4.64;95%CI:3.19,6.74) was directly related to increased odds of neonatal death. Mothers aged 20-34 years (aOR:0.40; 95%CI:0.20,0.81), a preceding birth interval of 24months or greater (aOR:0.41:95%CI:0.28,0.60), baby being female (aOR:0.72; 95%CI:0.54,0.96), having adequate ANC visits (aOR:0.64;95% CI:0.46,0.89) and the birth order of the newborn being ranked second or third (aOR:0.60; 95%CI:0.38,0.95) were negatively associated with neonatal death.

CONCLUSION

Health education programs targeting teen and primigravida mothers should be encouraged. Among the newborn survival interventions, addressing short birth intervals and the effective management of LBW cases should be explored. The findings confirm the fundamental importance of adequate ANC in the neonatal survival.

Effective coverage of newborn postnatal care in Ethiopia: Measuring inequality and spatial distribution of quality-adjusted coverage

Neonatal health is a significant global public health concern, and the first two days of life are crucial for newborn survival. Most studies on newborn postnatal care have focused on crude coverage measures, which limit the evaluation of care quality. However, evidence suggests a shift towards emphasising effective coverage, which incorporates the quality of care when measuring intervention coverage. This research aimed to assess the effective coverage of newborn postnatal care in Ethiopia while also examining its inequalities and spatial distribution. The study used secondary data from the 2016 Ethiopian Demographic and Health Survey, which was a cross-sectional community-based study. A total weighted sample of 4169 women was used for analyses. We calculated crude coverage, which is the proportion who received a postnatal check within 48 hours of birth and quality-adjusted coverage (effective coverage), which is the proportion who received a postnatal check within 48 hours of birth and reported receipt of 6 or more contents of care provided by health care providers. Concentration index and concentration curves were used to estimate the socioeconomic-related inequalities in quality-adjusted newborn postnatal care. The spatial statistic was analysed by using Arc-GIS. The crude coverage of newborn postnatal care was found to be 13.2%, while the effective coverage was 9%. High-quality postnatal care was disproportionately concentrated among the rich. A spatial variation was found in quality-adjusted coverage of newborn postnatal care across regions. The findings suggest that there is a significant gap in the coverage and quality of postnatal care for newborns across regions in Ethiopia. The low rates of coverage and effective coverage, combined with the concentration of high-quality care among the rich and the spatial variation across regions, highlight the need for targeted interventions and policies to address the inequalities in access to high-quality postnatal care for newborns.

Association between antenatal care facility readiness and provision of care at the client level and facility level in five low- and middle-income countries

BACKGROUND

Despite growing interest in monitoring improvements in quality of care, data on service quality in low-income and middle-income countries (LMICs) is limited. While health systems researchers have hypothesized the relationship between facility readiness and provision of care, there have been few attempts to quantify this relationship in LMICs. This study assesses the association between facility readiness and provision of care for antenatal care at the client level and facility level.

METHODS

To assess the association between provision of care and various facility readiness indices for antenatal care, we used multilevel, multivariable random-effects linear regression models. We tested an inflection point on readiness scores by fitting linear spline models. To compare the coefficients between models, we used a bootstrapping approach and calculated the mean difference between all pairwise comparisons. Analyses were conducted at client and facility levels.

RESULTS

Our results showed a small, but significant association between facility readiness and provision of care across countries and most index constructions. The association was most evident in the client-level analyses that had a larger sample size and were adjusted for factors at the facility, health worker, and individual levels. In addition, spline models at a facility readiness score of 50 better fit the data, indicating a plausible threshold effect.

CONCLUSIONS

The results of this study suggest that facility readiness is not a proxy for provision of care, but that there is an important association between facility readiness and provision of care. Data on facility readiness is necessary for understanding the foundations of health systems particularly in countries with the lowest levels of service quality. However, a comprehensive view of quality of care should include both facility readiness and provision of care measures.

Inequity of maternal-child health services in ASEAN member states from 1993 to 2021

INTRODUCTION

Inequity in maternal-child health services is a challenge to global health as it hinders the achievement of Sustainable Development Goals (SDGs) and Universal Health Coverage. Though the Association of Southeast Asian Nations (ASEAN) has made remarkable achievements in maternal-child health, there remain gaps in reaching global goals. This study aimed to compare and investigate the inequity in maternal-child health (MCH) services in ASEAN member states to help guide policy decisions to improve equitable health services in the SDG era and beyond.

METHODS

Using the WHO Health Inequality Monitor, we identified inequity summary measures for five MCH services in ASEAN member states from 1993 to 2021: antenatal care, births attended by skilled health personnel, diphtheria, tetanus and pertussis (DTP3) immunization, measles immunization, and polio immunization. We divided the analysis dimension of inequity into urban-rural inequity, economic status inequity, and sub-regional inequity. Trends of absolute and relative inequity in every dimension of MCH services in ASEAN member states were examined with the principal component analysis (PCA).

RESULTS

The mean coverages of MCH services are 98.80% (Thailand), 86.72% (Cambodia), 84.54% (Viet Nam), 78.52 (Indonesia), 76.94% (Timor-Leste), 72.40% (Lao PDR), 68.10% (Philippines) and 48.52% (Myanmar) in 2021. Thailand have the lowest MCH services absolute inequity indexes of -1.945, followed by Vietnam (-1.449). Lao PDR and Myanmar have relatively higher MCH services absolute inequity indexes of 0.852 and 0.054 respectively. The service in Cambodia, Indonesia, and the Philippines is pro-specific regions (with subnational region absolute inequity indexes of -0.02, 0.01, and 1.01 respectively). The service in Myanmar is pro-rich (with economic status absolute inequity index of 0.43). The service in Lao PDR and Timor-Leste is pro-urban areas, pro-rich, and pro-specific regions.

CONCLUSION

The inequity of MCH services in ASEAN persists but is in a declining trend. Thailand and Vietnam have performed well in ensuring MCH services equity, while Laos and Myanmar are still facing serious inequity dilemmas. The progress of MCH service equity in Myanmar, Cambodia, the Philippines, and Indonesia is uneven. It is acceptable to learn from the successful experiences of Thailand and Vietnam to improve the equities in other ASEAN countries. Policies should be developed according to the specific types of MCH inequity in member states to improve equity levels.

Comparison of inequality in utilization of maternal healthcare services between Bangladesh and Pakistan: evidence from the demographic health survey 2017-2018

BACKGROUND

Inequality in maternal health has remained a challenge in many low-income countries, like Bangladesh and Pakistan. The study examines within-country and between-country inequality in utilization of maternal healthcare services for Bangladesh and Pakistan.

METHODS

The study used the latest Demographic Health Surveys (DHS, 2017-2018) datasets of Bangladesh and Pakistan for women aged 15-49 years who had given at least one live birth in three years preceding the survey. Equity strata were identified from the literature and conformed by binary logistic regressions. For ordered equity strata with more than two categories, the relative concentration index (RCI), absolute concentration index (ACI) and the slope index of inequality (SII) were calculated to measure inequalities in the utilization of four maternal healthcare services. For two-categories equity strata, rate ratio (RR), and rate difference (RD) were calculated. Concentration curves and equiplots were constructed to visually demonstrate inequality in maternal healthcare services.

RESULTS

In Bangladesh, there was greater inequality in skilled birth attendance (SBA) based on wealth (RCI: 0.424, ACI: 0.423, and SII: 0.612), women's education (RCI: 0.380, ACI: 0.379 and SII: 0.591), husband's education (RCI: 0.375, ACI: 0.373 and SII: 0.554) and birth order (RCI: - 0.242, ACI: - 0.241, and SII: -0.393). According to RCI, ACI, and SII, there was inequality in Pakistan for at least four ANC visits by the skilled provider based on wealth (RCI: 0.516, ACI: 0.516 and SII: 0.738), women's education (RCI: 0.470, ACI: 0.470 and SII: 0.757), and husband's education (RCI: 0.380, ACI: 0.379 and SII: 0.572). For Bangladesh, the RR (1.422) and RD (0.201) imply more significant urban-rural inequality in SBA. In Pakistan, urban-rural inequality was greater for at least four ANC visits by the skilled provider (RR: 1.650 and RD 0.279).

CONCLUSION

Inequality in maternal healthcare is greater among the underprivileged group in Pakistan than in Bangladesh. In Bangladesh, the SBA is the most inequitable maternal healthcare, while for Pakistan it is at least four ANC visits by the skilled provider. Customized policies based on country context would be more effective in bridging the gap between the privileged and underprivileged groups.

Determinants of timing, adequacy and quality of antenatal care in Rwanda: a cross-sectional study using demographic and health surveys data

BACKGROUND

Antenatal care (ANC) is a recommended intervention to lessen maternal and neonatal mortality. The increased rate in ANC coverage in most Sub-Saharan African countries is not considerably reducing the maternal and neonatal mortality. This disconnection has raised concerns to study further the trend and determinants of the ANC timing and quality. We aimed to assess the determinants and trend of the timing, the adequacy and the quality of antenatal care in Rwanda.

METHOD

A population-based cross-sectional study design. We used data from the 2010,2015 and 2020 Rwanda demographic and health surveys (RDHS). The study included 18,034 women aged 15-49 years. High quality ANC is when a woman had her first ANC visit within 3 months of pregnancy, had 4 or more ANC visits, received services components of ANC during the visits by a skilled provider. Bivariate analysis and multivariable logistic regression were used to assess the ANC (timing and adequacy), the quality of the content of ANC services and the associated factors.

RESULTS

The uptake of antenatal services increased in the last 15 years. For instance, the uptake of adequate ANC was 2219(36.16%), 2607(44.37%) and 2925(48.58%) respectively for 2010;2015 and 2020 RDHS. The uptake of high quality ANC from 205(3.48%) in 2010 through 510(9.47%) in 2015 to 779(14.99%) in 2020. Women with unwanted pregnancies were less likely to have timely first ANC (aOR:0.76;95%CI:0.68,0.85) compared to planned pregnancies, they were also less likely to achieve a high-quality ANC (aOR: 0.65;95%CI:0.51,0.82) compared to the planned pregnancies. Mothers with a secondary and higher education were 1.5 more likely to achieve a high-quality ANC (aOR:1.50;95%CI:1.15,1.96) compared to uneducated mothers. Increasing maternal age is associated with reduced odds of update of ANC component services (aOR:0.44;95%CI:0.25,0.77) for 40 years and above when referred to teen mothers).

CONCLUSION

Low-educated mothers, advanced maternal age, and unintended pregnancies are the vulnerable groups that need to be targeted in order to improve ANC-related indicators. One of the credible measures to close the gap is to strengthen health education, promote family planning, and promote service utilization.

Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence

BACKGROUND

High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services.

METHODS

We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke's thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output).

RESULTS

Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services.

CONCLUSION

Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches.

Evaluating continuum of maternal and newborn healthcare in Rwanda: evidence from the 2019-2020 Rwanda demographic health survey

BACKGROUND

Access to a complete continuum of maternal and child health care has been recommended globally for better pregnancy outcomes. Hence this study determined the level (pooled prevalence) and predictors of successfully completing continuum of care (CoC) in Rwanda.

METHODS

We analyzed weighted secondary data from the 2019-2020 Rwanda Demographic and Health Survey (RDHS) that included 6,302 women aged 15 to 49 years who were selected using multistage stratified sampling. We analyzed complete continuum of care as a composite variable of three maternal care services: at least four ANC contacts, SBA, maternal and neonatal post-natal care. We used the SPSS version 25 complex samples package to conduct multivariable logistic regression.

RESULTS

Of the 6,302 women, 2,131 (33.8%) (95% CI: 32.8-35.1) had complete continuum of care. The odds of having complete continuum of care were higher among women who had exposure to newspapers (adjusted odds ratio (AOR): 1.30, 95% CI: 1.11-1.52), those belonging to the eastern region (AOR): 1.24, 95% CI: 1.01-1.52), southern region (AOR): 1.26, 95% CI: 1.04-1.53), those with health insurance (AOR): 1.55, 95% CI: 1.30-1.85), those who had been visited by a field health worker (AOR: 1.31, 95% CI: 1.15-1.49), those with no big problems with distance to health facility (AOR): 1.25, 95% CI: 1.07-1.46), those who were married (AOR): 1.35, 95% CI: 1.11-1.64), those with tertiary level of education (AOR): 1.61, 95% CI: 1.05-2.49), those belonging to richer households (AOR): 1.33, 95% CI: 1.07-1.65) and those whose parity was less than 2 (AOR): 1.52, 95% CI: 1.18-1.95).

CONCLUSION

We have identified modifiable factors (exposure to mass media, having been visited by a field health worker, having health insurance, having no big problems with distance to the nearest health facility, belonging to richer households, being married and educated), that can be targeted to improve utilization of the entire continuum of care. Promoting maternity services through mass media, strengthening the community health programmes, increasing access to health insurance and promoting girl child education to tertiary level may improve the level of utilization of maternity services.

Measuring effective coverage of maternal and child health services in Cambodia: a retrospective analysis of Demographic and Health Surveys from 2005 to 2014

OBJECTIVE

To investigate effective, quality-adjusted, coverage and inequality of maternal and child health (MCH) services to assess progress in improving quality of care in Cambodia.

DESIGN

A retrospective secondary analysis using the three most recent (2005, 2010 and 2014) Demographic and Health Surveys.

SETTING

Cambodia.

PARTICIPANTS

53 155 women aged 15-49 years old and 23 242 children under 5 years old across the three surveys.

OUTCOME MEASURES

We estimated crude coverage, effective coverage and inequality in effective coverage for five MCH services over time: antenatal care (ANC), facility delivery and sick childcare for diarrhoea, pneumonia and fever. Quality was defined by the proportion of care seekers who received a set of interventions during healthcare visits. Effective coverage was estimated by combining crude coverage and quality. We used equiplots and risk ratios, to assess patterns in inequality in MCH effective coverage across wealth quintile, urban-rural and women's education levels and over time.

RESULTS

In 2014, crude and effective coverage was 80.1% and 56.4%, respectively, for maternal health services (ANC and facility delivery) and 59.1% and 26.9%, respectively, for sick childcare (diarrhoea, pneumonia and fever). Between 2005 and 2014, effective coverage improved for all services, but improvements were larger for maternal healthcare than for sick child care. In 2014, poorer children were more likely to receive oral rehydration solution for diarrhoea than children from richer households. Meanwhile, women from urban areas were more likely to receive a postnatal check before getting discharged.

CONCLUSIONS

Effective coverage has generally improved in Cambodia but efforts remain to improve quality for all MCH services. Our results point to substantial gaps in curative sick child care, a large share of which is provided by unregulated private providers in Cambodia. Policymakers should focus on improving effective coverage, and not only crude coverage, to achieve the health-related Sustainable Development Goals by 2030.

Provision and use of physical rehabilitation services for adults with disabilities in Rwanda: A descriptive study

Background

Physical rehabilitation interventions address functional deficits caused by impairments that affect someone’s performance. Whilst rehabilitation is important, it is assumed that these services are either minimal or nonexistent in low-resource settings. Our data expand on the data from the Situation Assessment of Rehabilitation in the Republic of Rwanda report to describe rehabilitation services and who access them at public and semiprivate facilities (primarily funded by the private sector).

Objectives

This article describes the use of the outpatient physical rehabilitation services across nine health facilities, the characteristics of adults attending these health facilities and some of the facilitators and barriers they encounter when attending rehabilitation.

Method

Data were collected between September and December 2018 from the heads of departments and adult patients attending outpatient rehabilitation services funded by the government, international nongovernmental organisations or faith-based organisations.

Results

Two hundred and thirteen adults were recruited from nine facilities. There is a sixfold difference in the number of rehabilitation personnel between public and semiprivate hospitals in these facilities’ catchment areas. However, most participants were recruited at public facilities (186 [87%]), primarily with physical disorders. Patients reported that family support (94%) was the most crucial facilitator for attending rehabilitation, whilst transportation cost (96%) was a significant barrier.

Conclusion

Rehabilitation service availability for Rwandan adults with disabilities is limited. Whilst family support helps patients attend rehabilitation, transportation costs remain a significant barrier to people attending rehabilitation. Strategies to address these issues include developing triage protocols, training community health workers and families.

Contribution

Data on rehabilitation service provision in Rwanda and most African countries are either non-existent or very limited. These data contain important information regarding the services provided and the people who used them across different health facilities (public versus private) and urban versus rural settings). To improve rehabilitation service provision, we first need to understand the current situation. These data are an important step to better understanding rehabilitation in Rwanda.

Evaluations of effective coverage of maternal and child health services: A systematic review

Conventionally used coverage measures do not reflect the quality of care. Effective coverage (EC) assesses the extent to which health care services deliver potential health gains to the population by integrating concepts of utilization, need and quality. We aimed to conduct a systematic review of studies evaluating EC of maternal and child health services, quality measurement strategies and disparities across wealth quantiles. A systematic search was performed in six electronic databases [MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), Scopus, Web of Science and Maternity and Infant Care] and grey literature. We also undertook a hand search of references. We developed search terms having no restrictions based on publication period, country or language. We included studies which reported EC estimates based on the World Health Organization framework of measuring EC. Twenty-seven studies, all from low- and middle-income settings (49 countries), met the criteria and were included in the narrative synthesis of the results. Maternal and child health intervention(s) and programme(s) were assessed either at an individual level or as an aggregated measure of health system performance or both. The EC ranged from 0% for post-partum care to 95% for breastfeeding. When crude coverage measures were adjusted to account for the quality of care, the EC values turned lower. The gap between crude coverage and EC was as high as 86%, and it signified a low quality of care. The assessment of the quality of care addressed structural, process and outcome domains individually or combined. The wealthiest 20% had higher EC of services than the poorest 20%, an inequitable distribution of coverage. More efforts are needed to improve the quality of maternal and child health services and to eliminate the disparities. Moreover, considering multiple dimensions of quality and the use of standard measurements are recommended to monitor coverage effectively.

Factors associated with utilization of quality antenatal care: a secondary data analysis of Rwandan Demographic Health Survey 2020

Background

Over the last decade, progress in reducing maternal mortality in Rwanda has been slow, from 210 deaths per 100,000 live births in 2015 to 203 deaths per 100,000 live births in 2020. Access to quality antenatal care (ANC) can substantially reduce maternal and newborn mortality. Several studies have investigated factors that influence the use of ANC, but information on its quality is limited. Therefore, this study aimed to identify the determinants of quality antenatal care among pregnant women in Rwanda using a nationally representative sample.

Methods

We analyzed secondary data of 6,302 women aged 15–49 years who had given birth five years prior the survey from the Rwanda Demographic and Health Survey (RDHS) of 2020 data. Multistage sampling was used to select RDHS participants. Good quality was considered as having utilized all the ANC components. Multivariable logistic regression was conducted to explore the associated factors using SPSS version 25.

Results

Out of the 6,302 women, 825 (13.1%, 95% CI: 12.4–14.1) utilized all the ANC indicators of good quality ANC); 3,696 (60%, 95% CI: 58.6–61.1) initiated ANC within the first trimester, 2,975 (47.2%, 95% CI: 46.1–48.6) had 4 or more ANC contacts, 16 (0.3%, 95% CI: 0.1–0.4) had 8 or more ANC contacts. Exposure to newspapers/magazines at least once a week (aOR 1.48, 95% CI: 1.09–2.02), lower parity (para1: aOR 6.04, 95% CI: 3.82–9.57) and having been visited by a field worker (aOR 1.47, 95% CI: 1.23–1.76) were associated with more odds of receiving all ANC components. In addition, belonging to smaller households (aOR 1.34, 95% CI: 1.10–1.63), initiating ANC in the first trimester (aOR 1.45, 95% CI: 1.18–1.79) and having had 4 or more ANC contacts (aOR 1.52, 95% CI: 1.25–1.85) were associated with more odds of receiving all ANC components. Working women had lower odds of receiving all ANC components (aOR 0.79, 95% CI: 0.66–0.95).

Conclusion

The utilization of ANC components (13.1%) is low with components such as having at least two tetanus injections (33.6%) and receiving drugs for intestinal parasites (43%) being highly underutilized. Therefore, programs aimed at increasing utilization of ANC components need to prioritize high parity and working women residing in larger households. Promoting use of field health workers, timely initiation and increased frequency of ANC might enhance the quality of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08169-x.

A rapid systematic review and evidence synthesis of effective coverage measures and cascades for childbirth, newborn and child health in low- and middle-income countries

BACKGROUND

Effective coverage measures aim to estimate the proportion of a population in need of a service that received a positive health outcome. In 2020, the Effective Coverage Think Tank Group recommended using a 'coverage cascade' for maternal, newborn, child and adolescent health and nutrition (MNCAHN), which organises components of effective coverage in a stepwise fashion, with each step accounting for different aspects of quality of care (QoC), applied at the population level. The cascade outlines six steps that increase the likelihood that the population in need experience the intended health benefit: 1) the population in need (target population) who contact a health service; 2) that has the inputs available to deliver the service; 3) who receive the health service; 4) according to quality standards; 5) and adhere to prescribed medication(s) or health workers instructions; and 6) experience the expected health outcome. We examined how effective coverage of life-saving interventions from childbirth to children aged nine has been defined and assessed which steps of the cascade are captured by existing measures.

METHODS

We undertook a rapid systematic review. Seven scientific literature databases were searched covering the period from May 1, 2017 to July, 8 2021. Reference lists from reviews published in 2018 and 2019 were examined to identify studies published prior to May 2017. Eligible studies reported population-level contact coverage measures adjusted for at least one dimension of QoC.

RESULTS

Based on these two search approaches this review includes literature published from 2010 to 2021. From 16 662 records reviewed, 33 studies were included, reporting 64 effective coverage measures. The most frequently examined measures were for childbirth and immediate newborn care (n = 24). No studies examined measures among children aged five to nine years. Definitions of effective coverage varied across studies. Key sources of variability included (i) whether a single effective coverage measure was reported for a package of interventions or separate measures were calculated for each intervention; (ii) the number and type of coverage cascade steps applied to adjust for QoC; and (iii) the individual items included in the effective coverage definition and the methods used to generate a composite quality measure.

CONCLUSION

In the MNCAHN literature there is substantial heterogeneity in both definitions and construction of effective coverage, limiting the comparability of measures over time and place. Current measurement approaches are not closely aligned with the proposed cascade. For widespread adoption, there is a need for greater standardisation of indicator definitions and transparency in reporting, so governments can use these measures to improve investments in MNACHN and implement life-saving health policies and programs.

Developing and implementing a model of equitable distribution of mentorship in districts with spatial inequities and maldistribution of human resources for maternal and newborn care in Rwanda

Background

The shortage of health care providers (HCPs) and inequity in their distribution along with the lack of sufficient and equal professional development opportunities in low-income countries contribute to the high mortality and morbidity of women and newborns. Strengthening skills and building the capacity of all HCPs involved in Maternal and Newborn Health (MNH) is essential to ensuring that mothers and newborns receive the required care in the period around birth. The Training, Support, and Access Model (TSAM) project identified onsite mentorship at primary care Health Centers (HCs) as an approach that could help reduce mortality and morbidity through capacity building of HCPs in Rwanda. This paper presents the results and lessons learnt through the design and implementation of a mentorship model and highlights some implications for future research.

Methods

The design phase started with an assessment of the status of training in HCs to inform the selection of Hospital-Based Mentors (HBMs). These HBMs took different courses to become mentors. A clear process was established for engaging all stakeholders and to ensure ownership of the model. Then the HBMs conducted monthly visits to all 68 TSAM assigned HCs for 18 months and were extended later in 43 HCs of South. Upon completion of 6 visits, mentees were requested to assist their peers who are not participating in the mentoring programme through a process of peer mentoring to ensure sustainability after the project ends.

Results

The onsite mentorship in HCs by the HBMs led to equal training of HCPs across all HCs regardless of the location of the HC. Research on this mentorship showed that the training improved the knowledge and self-efficacy of HCPs in managing postpartum haemorrhage (PPH) and newborn resuscitation. The lessons learned include that well trained midwives can conduct successful mentorships at lower levels in the healthcare system. The key challenge was the inconsistency of mentees due to a shortage of HCPs at the HC level.

Conclusions

The initiation of onsite mentorship in HCs by HBMs with the support of the district health leaders resulted in consistent and equal mentoring at all HCs including those located in remote areas.

Critical Interpretive Synthesis of Qualitative Data on the Health Care Ecosystem for Vulnerable Newborns in Low- to Middle-Income Countries

OBJECTIVE

To critically assess and synthesize qualitative findings regarding the health care ecosystem for vulnerable (low-birth-weight or sick) neonates in low- to middle-income countries (LMICs).

DATA SOURCES

Between May 4 and June 2, 2020, we searched four databases (Medline [PubMed], SCOPUS, PsycINFO, and Web of Science) for articles published from 2010 to 2020. Inclusion criteria were peer-reviewed reports of original studies focused on the health care ecosystem for vulnerable neonates in LMICs. We also searched the websites of several international development agencies and included findings from primary data collected between May and July 2019 at a tertiary hospital in Kenya. We excluded studies and reports if the focus was on healthy neonates or high-income countries and if they contained only quantitative data, were written in a language other than English, or were published before 2010.

STUDY SELECTION

One of the primary authors conducted an initial review of titles and abstracts (n = 102) and excluded studies that were not consistent with the purpose of the review (n = 60). The two primary authors used a qualitative appraisal checklist to assess the validity of the remaining studies (n = 42) and reached agreement on the final 13 articles.

DATA EXTRACTION

The two primary authors independently conducted open and axial coding of the data. We incorporated data from studies with different units of analysis, types of methodology, research topics, participant types, and analytical frameworks in an emergent conceptual development process according to the critical interpretive synthesis methodology.

DATA SYNTHESIS

We synthesized our findings into one overarching theme, Pervasive Turbulence Is a Defining Characteristic of the Health Care Ecosystem in LMICs, and two subthemes: Pervasive Turbulence May Cause Tension Between the Setting and the Caregiver and Pervasive Turbulence May Result in a Loss of Synergy in the Caregiver-Parent Relationship.

CONCLUSION

Because pervasive turbulence characterizes the health care ecosystems in LMICs, interventions are needed to support the caregiver-parent interaction to mitigate the effects of tension in the setting.