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Straneo M, Hanson C, van den Akker T, Afolabi BB, Asefa A, Delamou A, Dennis M, Gadama L, Mahachi N, Mlilo W, Pembe AB, Tsuala Fouogue J, Beňová L. Inequalities in use of hospitals for childbirth among rural women in sub-Saharan Africa: a comparative analysis of 18 countries using Demographic and Health Survey data. BMJ Glob Health 2024; 9:e013029. [PMID: 38262683 PMCID: PMC10806834 DOI: 10.1136/bmjgh-2023-013029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/21/2023] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION Rising facility births in sub-Saharan Africa (SSA) mask inequalities in higher-level emergency care-typically in hospitals. Limited research has addressed hospital use in women at risk of or with complications, such as high parity, linked to poverty and rurality, for whom hospital care is essential. We aimed to address this gap, by comparatively assessing hospital use in rural SSA by wealth and parity. METHODS Countries in SSA with a Demographic and Health Survey since 2015 were included. We assessed rural hospital childbirth stratifying by wealth (wealthier/poorer) and parity (nulliparity/high parity≥5), and their combination. We computed percentages, 95% CIs and percentage-point differences, by stratifier level. To compare hospital use across countries, we produced a composite index, including six utilisation and equality indicators. RESULTS This cross-sectional study included 18 countries. In all, a minority of rural women used hospitals for childbirth (2%-29%). There were disparities by wealth and parity, and poorer, high-parity women used hospitals least. The poorer/wealthier difference in utilisation among high-parity women ranged between 1.3% (Mali) and 13.2% (Rwanda). We found use and equality of hospitals in rural settings were greater in Malawi and Liberia, followed by Zimbabwe, the Gambia and Rwanda. DISCUSSION Inequalities identified across 18 countries in rural SSA indicate poor, higher-risk women of high parity had lower use of hospitals for childbirth. Specific policy attention is urgently needed for this group where disadvantage accumulates.
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Affiliation(s)
- Manuela Straneo
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Centre for Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Thomas van den Akker
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics & Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bosede B Afolabi
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
| | - Anteneh Asefa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Alexandre Delamou
- Africa Center for Excellence (CEA-PMCT), Universite Gamal Abdel Nasser de Conakry, Conakry, Guinea
- Maferinyah Training and Research Center, Forécariah, Guinea
| | | | - Luis Gadama
- Kamuzu University of Health Sciences, Blantyre, Southern Region, Malawi
| | - Nyika Mahachi
- Zimbabwe College of Public Health Physicians, Harare, Zimbabwe
| | - Welcome Mlilo
- Matabeleland North Provincial Medical Directorate, Zimbabwe Ministry of Health and Child Care, Bulawayo, Zimbabwe
| | - Andrea B Pembe
- Department of Obstetric and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jovanny Tsuala Fouogue
- Department of Obstetrics and Gynecology and Maternal Health, Faculty of Medicine and Pharmaceutical Sciences, Université de Dschang, Dschang, Cameroon
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Epidemiology and Population Health, LSHTM, London, UK
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Shabani J, Masanja H, Kagoye S, Minja J, Bajaria S, Mlacha Y, Msuya S, Masoud M, Simba D, Pembe AB, Makuwani AM, Ismail H, Chacha M, Kumalija C, Boerma T, Hanson C. Quality of reporting and trends of emergency obstetric and neonatal care indicators: an analysis from Tanzania district health information system data between 2016 and 2020. BMC Pregnancy Childbirth 2023; 23:716. [PMID: 37805475 PMCID: PMC10559477 DOI: 10.1186/s12884-023-06028-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/24/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Routine health facility data provides the opportunity to monitor progress in quality and uptake of health care continuously. Our study aimed to assess the reliability and usefulness of emergency obstetric care data including temporal and regional variations over the past five years in Tanzania Mainland. METHODS Data were compiled from the routine monthly district reports compiled as part of the health management information systems for 2016-2020. Key indicators for maternal and neonatal care coverage, emergency obstetric and neonatal complications, and interventions indicators were computed. Assessment on reliability and consistency of reports was conducted and compared with annual rates and proportions over time, across the 26 regions in of Tanzania Mainland and by institutional delivery coverage. RESULTS Facility reporting was near complete with 98% in 2018-2020. Estimated population coverage of institutional births increased by 10% points from 71.2% to 2016 to 81.7% in 2020 in Tanzania Mainland, driven by increased use of dispensaries and health centres compared to hospitals. This trend was more pronounced in regions with lower institutional birth rates. The Caesarean section rate remained stable at around 10% of institutional births. Trends in the occurrence of complications such as antepartum haemorrhage, premature rupture of membranes, pre-eclampsia, eclampsia or post-partum bleeding were consistent over time but at low levels (1% of institutional births). Prophylactic uterotonics were provided to nearly all births while curative uterotonics were reported to be used in less than 10% of post-partum bleeding and retained placenta cases. CONCLUSION Our results show a mixed picture in terms of usefulness of the District Health Information System(DHIS2) data. Key indicators of institutional delivery and Caesarean section rates were plausible and provide useful information on regional disparities and trends. However, obstetric complications and several interventions were underreported thus diminishing the usefulness of these data for monitoring. Further research is needed on why complications and interventions to address them are not documented reliably.
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Affiliation(s)
| | | | - Sophia Kagoye
- National Institute for Medical Research, Mwanza, Tanzania
| | | | | | | | - Sia Msuya
- Kilimanjaro Christian Medical University College, Kilimanjaro, Tanzania
| | | | - Daudi Simba
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Andrea B Pembe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | | | | | | | | | - Claudia Hanson
- London School of Hygiene & Tropical Medicine, London, UK
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Feng Y, Maimaitiming M, Shi J, Wang M, Li N, Jin Y, Zheng ZJ. Inequity of maternal-child health services in ASEAN member states from 1993 to 2021. Int J Equity Health 2023; 22:149. [PMID: 37550702 PMCID: PMC10408145 DOI: 10.1186/s12939-023-01974-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/24/2023] [Indexed: 08/09/2023] Open
Abstract
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.
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Affiliation(s)
- Yikai Feng
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Mailikezhati Maimaitiming
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Junyi Shi
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Minmin Wang
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Na Li
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China.
- Institute for Global Health and Development, Peking University, Beijing, China.
| | - Zhi-Jie Zheng
- Department of Global Health, School of Public Health, Peking University, 38 Xue Yuan Road, Haidian District, Beijing, 100191, China
- Institute for Global Health and Development, Peking University, Beijing, China
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Robbins T, Shennan A, Sandall J, Eshetu Guangul T, Demissew R, Abdella A, Mayston R, Hanlon C. Understanding challenges as they impact on hospital-level care for pre-eclampsia in rural Ethiopia: a qualitative study. BMJ Open 2023; 13:e061500. [PMID: 37068897 PMCID: PMC10111927 DOI: 10.1136/bmjopen-2022-061500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
OBJECTIVE To explore hospital-level care for pre-eclampsia in Ethiopia, considering the perspectives of those affected and healthcare providers, in order to understand barriers and facilitators to early detection, care escalation and appropriate management. SETTING A primary and a general hospital in southern Ethiopia. PARTICIPANTS Women with lived experience of pre-eclampsia care in the hospital, families of women deceased due to pre-eclampsia, midwives, doctors, integrated emergency surgical officers and healthcare managers. RESULTS This study identified numerous systemic barriers to provision of quality, person-centred care for pre-eclampsia in hospitals. Individual staff efforts to respond to maternal emergencies were undermined by a lack of consistency in availability of resources and support. The ways in which policies were applied exacerbated inequities in care. Staff improvised as a means of managing with limited material or human resources and knowledge. Social hierarchies and punitive cultures challenged adequacy of communication with women, documentation of care given and supportive environments for quality improvement. CONCLUSIONS Quality care for pre-eclampsia requires organisational change to create a safe space for learning and improvement, alongside efforts to offer patient-centred care and ensure providers are equipped with knowledge, resources and support to adhere to evidence-based practice.
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Affiliation(s)
- Tanya Robbins
- Department of Women and Children's Health, King's College London, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, London, UK
| | - Tigist Eshetu Guangul
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Rahel Demissew
- Department of Obstetrics and Gynaecology, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Ahmed Abdella
- Department of Obstetrics and Gynaecology, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Rosie Mayston
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - Charlotte Hanlon
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
- Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, King's College London, London, UK
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Roder-DeWan S, Madhavan S, Subramanian S, Nimako K, Lashari T, Bathula AN, Sathurappan R, Kumar S, Chopra M. Service delivery redesign is a process, not a model of care. BMJ 2023; 380:e071651. [PMID: 36914168 PMCID: PMC9999467 DOI: 10.1136/bmj-2022-071651] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Sanam Roder-DeWan and colleagues call for wider application of the principles of service delivery redesign to provide accessible, high quality services across healthcare
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Affiliation(s)
- Sanam Roder-DeWan
- World Bank, Washington, DC, USA
- Dartmouth Medical School, Hanover, NH, USA
| | | | | | - Kojo Nimako
- World Bank Group, Ghana Country Office, Accra, Ghana
| | - Talib Lashari
- Islamic Republic of Pakistan, Karachi, Sindh, Pakistan
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Egal JA, Kiruja J, Litorp H, Osman F, Erlandsson K, Klingberg‐Allvin M. Incidence and causes of severe maternal outcomes in Somaliland using the sub-Saharan Africa maternal near-miss criteria: A prospective cross-sectional study in a national referral hospital. Int J Gynaecol Obstet 2022; 159:856-864. [PMID: 35490394 PMCID: PMC9790269 DOI: 10.1002/ijgo.14236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/21/2022] [Accepted: 04/23/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe the incidence and causes of severe maternal outcomes and the unmet need for life-saving obstetric interventions among women admitted for delivery in a referral hospital in Somaliland. METHODS A prospective cross-sectional study was conducted from April 15, 2019 to March 31, 2020, with women admitted during pregnancy or childbirth or within 42 days after delivery. Data were collected using the World Health Organization (WHO) and sub-Saharan Africa (SSA) maternal near-miss (MNM) tools. Descriptive analysis was performed by computing frequencies, proportions, and ratios. RESULTS The MNM ratios were 56 (SSA criteria) and 13 (WHO criteria) per 1000 live births. The mortality index was highest among women with medical complications (63%), followed by obstetric hemorrhage (13%), pregnancy-related infection (10%), and hypertensive disorders (7.9%) according to the SSA MNM criteria. Most women giving birth received prophylactic oxytocin for postpartum hemorrhage prevention (97%), and most laparotomies (60%) for ruptured uterus were conducted after 3 h. CONCLUSION There is a need to improve the quality of maternal health services through implementation of evidence-based obstetric interventions and continuous in-service training for healthcare providers. Using the SSA MNM criteria could facilitate such preventive measures in this setting as well as similar low-resource contexts.
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Affiliation(s)
- Jama Ali Egal
- College of Medicine and Health ScienceUniversity of HargeisaHargeisaSomaliland,Institution of Health and WelfareDalarna UniversityDalarnaSweden
| | - Jonah Kiruja
- College of Medicine and Health ScienceUniversity of HargeisaHargeisaSomaliland,Institution of Health and WelfareDalarna UniversityDalarnaSweden
| | - Helena Litorp
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden,Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Fatumo Osman
- Institution of Health and WelfareDalarna UniversityDalarnaSweden,Department of Public Health and Caring ScienceUppsala UniversityUppsalaSweden
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Solomon H, Henry EG, Herlihy J, Yeboah-Antwi K, Biemba G, Musokotwane K, Bhutta A, Hamer DH, Semrau KEA. Intended versus actual delivery location and factors associated with change in delivery location among pregnant women in Southern Province, Zambia: a prespecified secondary observational analysis of the ZamCAT. BMJ Open 2022; 12:e055288. [PMID: 35256443 PMCID: PMC8905985 DOI: 10.1136/bmjopen-2021-055288] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This prespecified, secondary analysis of the Zambia Chlorhexidine Application Trial (ZamCAT) aimed to determine the proportion of women who did not deliver where they intended, to understand the underlying reasons for the discordance between planned and actual delivery locations; and to assess sociodemographic characteristics associated with concordance of intention and practice. DESIGN Prespecified, secondary analysis from randomised controlled trial. SETTING Recruitment occurred in 90 primary health facilities (HFs) with follow-up in the community in Southern Province, Zambia. PARTICIPANTS Between 15 February 2011 and 30 January 2013, 39 679 pregnant women enrolled in ZamCAT. SECONDARY OUTCOME MEASURES The location where mothers gave birth (home vs HF) was compared with their planned delivery location. RESULTS When interviewed antepartum, 92% of respondents intended to deliver at an HF, 6.1% at home and 1.2% had no plan. However, of those who intended to deliver at an HF, 61% did; of those who intended to deliver at home, only 4% did; and of those who intended to deliver at home, 2% delivered instead at an HF. Among women who delivered at home, women who were aged 25-34 and ≥35 years were more likely to deliver where they intended than women aged 20-24 years (adjusted OR (aOR)=1.31, 95% CI=1.11 to 1.50 and aOR=1.32, 95% CI=1.12 to 1.57, respectively). Women who delivered at HFs had greater odds of delivering where they intended if they received any primary schooling (aOR=1.34, 95% CI=1.09 to 1.72) or more than a primary school education (aOR=1.54, 95% CI=1.17 to 2.02), were literate (aOR=1.33, 95% CI=1.119 to 1.58), and were not in the lowest quintile of the wealth index. CONCLUSION Discrepancies between intended and actual delivery locations highlight the need to go beyond the development of birth plans and exposure to birth planning messaging. More research is required to address barriers to achieving intentions of a facility-based childbirth. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT01241318).
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Affiliation(s)
- Hiwote Solomon
- Doctor of Public Health Program, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Elizabeth G Henry
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Julie Herlihy
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Kojo Yeboah-Antwi
- Public Health Unit, Fr Thomas Alan Rooney Memorial Hospital, Kumasi, Asankrangwa, Ghana
| | - Godfrey Biemba
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Zambia National Health Research Authority, Lusaka, Zambia
| | | | - Afsah Bhutta
- MBBS Department, Dow University of Health Sciences, Karachi, Pakistan
| | - Davidson H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Disease, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Katherine E A Semrau
- Ariadne Labs, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Global Health Equity & Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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Straneo M, Beňová L, van den Akker T, Pembe AB, Smekens T, Hanson C. No increase in use of hospitals for childbirth in Tanzania over 25 years: Accumulation of inequity among poor, rural, high parity women. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000345. [PMID: 36962703 PMCID: PMC10021586 DOI: 10.1371/journal.pgph.0000345] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 07/14/2022] [Indexed: 11/19/2022]
Abstract
Improving childbirth care in rural settings in sub-Saharan Africa is essential to attain the commitment expressed in the Sustainable Development Goals to leave no one behind. In Tanzania, the period between 1991 and 2016 was characterized by health system expansion prioritizing primary health care and a rise in rural facility births from 45% to 54%. Facilities however are not all the same, with advanced management of childbirth complications generally only available in hospitals and routine childbirth care in primary facilities. We hypothesized that inequity in the use of hospital-based childbirth may have increased over this period, and that it may have particularly affected high parity (≥5) women. We analysed records of 16,080 women from five Tanzanian Demographic and Health Surveys (1996, 1999, 2004, 2010, 2015/6), using location of the most recent birth as outcome (home, primary health care facility or hospital), wealth and parity as exposure variables and demographic and obstetric characteristics as potential confounders. A multinomial logistic regression model with wealth/parity interaction was run and post-estimation margins analysis produced percentages of births for various combinations of wealth and parity for each survey. We found no reduction in inequity in this 25-year period. Among poorest women, lowest use of hospital-based childbirth (around 10%) was at high parity, with no change over time. In women having their first baby, hospital use increased over time but with a widening pro-rich gap (poorest women predicted use increased from 36 to 52% and richest from 40 to 59%). We found that poor rural women of high parity were a vulnerable group requiring specifically targeted interventions to ensure they receive effective childbirth care. To leave no one behind, it is essential to look beyond the average coverage of facility births, as such a limited focus masks different patterns and time trends among marginalised groups.
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Affiliation(s)
- Manuela Straneo
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Athena Institute, VU University, Amsterdam, The Netherlands
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Lenka Beňová
- Institute of Tropical Medicine, Antwerp, Belgium
- London School of Hygiene &Tropical Medicine, London, United Kingdom
| | - Thomas van den Akker
- Athena Institute, VU University, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Andrea B Pembe
- Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Tom Smekens
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- London School of Hygiene &Tropical Medicine, London, United Kingdom
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9
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Radovich E, Banke-Thomas A, Campbell OMR, Ezeanochie M, Gwacham-Anisiobi U, Ande ABA, Benova L. Critical comparative analysis of data sources toward understanding referral during pregnancy and childbirth: three perspectives from Nigeria. BMC Health Serv Res 2021; 21:927. [PMID: 34488752 PMCID: PMC8420846 DOI: 10.1186/s12913-021-06945-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/09/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The highest risk of maternal and perinatal deaths occurs during and shortly after childbirth and is preventable if functional referral systems enable women to reach appropriate health services when obstetric complications occur. Rising numbers of deliveries in health facilities, including in high mortality settings like Nigeria, require formalised coordination across the health system to ensure that women and newborns get to the right level of care, at the right time. This study describes and critically assesses the extent to which referral and its components can be captured using three different data sources from Nigeria, examining issues of data quality, validity, and usefulness for improving and monitoring obstetric care systems. METHODS The study included three data sources on referral for childbirth care in Nigeria: a nationally representative household survey, patient records from multiple facilities in a state, and patient records from the apex referral facility in a city. We conducted descriptive analyses of the extent to which referral status and components were captured across the three sources. We also iteratively developed a visual conceptual framework to guide our critical comparative analysis. RESULTS We found large differences in the proportion of women referred, and this reflected the different denominators and timings of the referral in each data source. Between 16 and 34% of referrals in the three sources originated in government hospitals, and lateral referrals (origin and destination facility of the same level) were observed in all three data sources. We found large gaps in the coverage of key components of referral as well as data gaps where this information was not routinely captured in facility-based sources. CONCLUSIONS Our analyses illustrated different perspectives from the national- to facility-level in the capture of the extent and components of obstetric referral. By triangulating across multiple data sources, we revealed the strengths and gaps within each approach in building a more complete picture of obstetric referral. We see our visual framework as assisting further research efforts to ensure all referral pathways are captured in order to better monitor and improve referral systems for women and newborns.
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Affiliation(s)
- Emma Radovich
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.
| | | | - Oona M R Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Ezeanochie
- Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin, Edo State, Nigeria
| | | | - Adedapo B A Ande
- Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin, Edo State, Nigeria
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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10
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Amoro VA, Abiiro GA, Alatinga KA. Bypassing primary healthcare facilities for maternal healthcare in North West Ghana: socio-economic correlates and financial implications. BMC Health Serv Res 2021; 21:545. [PMID: 34078379 PMCID: PMC8173790 DOI: 10.1186/s12913-021-06573-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 05/21/2021] [Indexed: 12/11/2022] Open
Abstract
Background Bypassing primary health care (PHC) facilities for maternal health care is an increasing phenomenon. In Ghana, however, there is a dearth of systematic evidence on bypassing PHC facilities for maternal healthcare. This study investigated the prevalence of bypassing PHC facilities for maternal healthcare, and the socio-economic factors and financial costs associated with bypassing PHC facilities within two municipalities in Northwestern Ghana. Methods A quantitative cross-sectional design was implemented between December 2019 and March 2020. Multistage stratified sampling was used to select 385 mothers receiving postnatal care in health facilities for a survey. Using STATA 12 software, bivariate analysis with chi-square test and binary logistic regression models were run to determine the socio-economic and demographic factors associated with bypassing PHC facilities. The two-sample independent group t-test was used to estimate the mean differences in healthcare costs of those who bypassed their PHC facilities and those who did not. Results The results revealed the prevalence of bypassing PHC facilities as 19.35 % for antenatal care, 33.33 % for delivery, and 38.44 % for postnatal care. The municipality of residence, ethnicity, tertiary education, pregnancy complications, means of transport, nature of the residential location, days after childbirth, age, and income were statistically significantly (p < 0.05) associated with bypassing PHC facilities for various maternal care services. Compared to the non-bypassers, the bypassers incurred a statistically significantly (P < 0.001) higher mean extra financial cost of GH₵112.09 (US$19.73) for delivery, GH₵44.61 (US$7.85) for postnatal care and ₵43.34 (US$7.65) for antenatal care. This average extra expenditure was incurred on transportation, feeding, accommodation, medicine, and other non-receipted expenses. Conclusions The study found evidence of bypassing PHC facilities for maternal healthcare. Addressing this phenomenon of bypassing and its associated cost, will require effective policy reforms aimed at strengthening the service delivery capacities of PHC facilities. We recommend that the Ministry of Health and Ghana Health Service should embark on stakeholder engagement and sensitization campaigns on the financial consequences of bypassing PHC facilities for maternal health care. Future research, outside healthcare facility settings, is also required to understand the specific supply-side factors influencing bypassing of PHC facilities for maternal healthcare within the study area.
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Affiliation(s)
| | - Gilbert Abotisem Abiiro
- Department of Health Services, Policy, Planning, Management and Economics, School of Public Health, University for Development Studies, Tamale, Ghana.,Department of Planning, Faculty of Planning and Land Management, Simon Diedong Dombo University of Business and Integrated Development Studies, Wa, Ghana
| | - Kennedy A Alatinga
- Department of Community Development, Faculty of Planning and Land Management, Simon Diedong Dombo University of Business and Integrated Development Studies, Wa, Ghana
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Ashish KC, Peterson SS, Gurung R, Skalkidou A, Gautam J, Malla H, Paudel P, Bhattarai K, Joshi N, Tinkari BS, Adhikari S, Shrestha D, Ghimire B, Sharma S, Khanal L, Shrestha S, Graham WJ, Kinney M. The perfect storm: Disruptions to institutional delivery care arising from the COVID-19 pandemic in Nepal. J Glob Health 2021; 11:05010. [PMID: 34055329 PMCID: PMC8141327 DOI: 10.7189/jogh.11.05010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has led to system-wide disruption of health services globally. We assessed the effect of the pandemic on the disruption of institutional delivery care in Nepal. METHODS We conducted a prospective cohort study among 52 356 women in nine hospitals to assess the disruption of institutional delivery care during the pandemic (comparing March to August in 2019 with the same months in 2020). We also conducted a nested follow up cohort study with 2022 women during the pandemic to assess their provision and experience of respectful care. We used linear regression models to assess the association between provision and experience of care with volume of hospital births and women's residence in a COVID-19 hotspot area. RESULTS The mean institutional births during the pandemic across the nine hospitals was 24 563, an average decrease of 11.6% (P < 0.0001) in comparison to the same time-period in 2019. The institutional birth in high-medium volume hospitals declined on average by 20.8% (P < 0.0001) during the pandemic, whereas in low-volume hospital institutional birth increased on average by 7.9% (P = 0.001). Maternity services halted for a mean of 4.3 days during the pandemic and there was a redeployment staff to COVID-19 dedicated care. Respectful provision of care was better in hospitals with low-volume birth (β = 0.446, P < 0.0001) in comparison to high-medium-volume hospitals. There was a positive association between women's residence in a COVID-19 hotspot area and respectful experience of care (β = 0.076, P = 0.001). CONCLUSIONS The COVID-19 pandemic has had differential effects on maternity services with changes varying by the volume of births per hospital with smaller volume facilities doing better. More research is needed to investigate the effects of the pandemic on where women give birth and their provision and experience of respectful maternity care to inform a "building-back-better" approach in post-pandemic period.
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Affiliation(s)
- K C Ashish
- Department of Women's and Children's Health, Uppsala University, Sweden
| | - Stefan Swartling Peterson
- Department of Women's and Children's Health, Uppsala University, Sweden
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Rejina Gurung
- Department of Women's and Children's Health, Uppsala University, Sweden
- Research Division, Golden Community, Lalitpur, Nepal
| | | | | | - Honey Malla
- Research Division, Golden Community, Lalitpur, Nepal
| | - Punya Paudel
- Family Welfare Division, Department of Health Services, Nepal
| | | | - Nisha Joshi
- Family Welfare Division, Department of Health Services, Nepal
| | | | | | | | | | | | | | | | | | - Mary Kinney
- School of Public Health, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
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