Maternal autonomy and child health care utilization in India: results from the National Family Health Survey

Of Money and Men: A Scoping Review to Map Gender Barriers to Immunization Coverage in Low- and Middle-Income Countries

Among the multiple factors impeding equitable childhood immunization coverage in low- and middle-income countries (LMICs), gender barriers stand out as perhaps the most universal. Despite increasing recognition of the importance of gender considerations in immunization programming, there has not yet been a systematic assessment of the evidence on gender barriers to immunization. We conducted a scoping review to fill that gap, identifying 92 articles that described gender barriers to immunization. Studies documented a range of gender influencers across 43 countries in Africa and South Asia. The barrier to immunization coverage most frequently cited in the literature is women's lack of autonomous decision-making. Access to immunization is significantly impacted by women's time poverty; direct costs are also a barrier, particularly when female caregivers rely on family members to cover costs. Challenges with clinic readiness compound female caregiver's time constraints. Some of the most important gender barriers lie outside of the usual purview of immunization programming but other barriers can be addressed with adaptations to vaccination programming. We can only know how important these barriers are with more research that measures the impact of programming on gender barriers to immunization coverage.

Role of Women's Empowerment in Improving the Nutritional Status of Children Under Five Years of Age: An Insight From the National Family Health Survey-5

Background Childhood malnutrition remains a global concern, especially in low- and middle-income countries, and is known to create an intergenerational cycle of illness and poverty. Women's empowerment has gained global recognition as a potential catalyst for improving child nutrition. The objective of this research was to investigate the association between women's empowerment factors and the nutritional status of children under five years of age. Methods The study used data from the National Family Health Survey-5, conducted in India between 2019 and 2021 by the International Institute of Population Sciences, Mumbai. A weighted sample of 29,491 mother-child pairs was analyzed. The odds ratio for women's empowerment and sociodemographic factors associated with the nutritional status of children under five years of age was calculated using Pearson's chi-square test and multiple logistic regression. Results The study found that the sex of the child (OR = 1.066, 95% CI: 1.017 to 1.117; p-value: 0.008), birth order (OR = 0.824, 95% CI: 0.780 to 0.871; p-value < 0.001), education of the mother (OR = 1.356, 95% CI: 1.255 to 1.464; p-value < 0.001), education of the father (OR = 1.227, 95% CI: 1.140 to 1.320; p-value < 0.001), having a bank or savings account that she uses (OR = 1.151, 95% CI: 1.084 to 1.221; p-value < 0.001), having a mobile phone that she uses (OR = 1.184, 95% CI: 1.125 to 1.246; p-value < 0.001), and wealth index (OR = 1.597, 95% CI: 1.514 to 1.684; p-value < 0.001) were significant predictors of undernutrition in children under the age of five (U5). Conclusion Women's empowerment factors play a significant role in improving childhood nutrition. In the study, male sex, higher birth order, lower parental education, poor wealth index, maternal lack of access to a bank or a savings account, and lack of mobile phone ownership were found to be significant predictors of undernutrition in children U5. The findings underscore the importance of family planning, financial inclusion, access to mobile phones, and higher education for women as important factors that can help improve the nutritional status of children under five years of age. Policymakers can utilize these insights to make targeted strategies for women's empowerment, thus improving the nutritional status of children. However, being a secondary data analysis, our research is constrained by the variables available in the dataset. Further research is required to better comprehend the complex relationship between women empowerment and child nutrition.

Maternal autonomy but not social support is a predictor of child feeding indicators in the Northern Region, Ghana

Background

Child malnutrition may be mediated by poor infant and young child feeding (IYCF) practices. This study sought to explore if maternal social support or autonomy was related to IYCF indicators in Northern Region, Ghana.

Methods

An analytical cross-sectional study was conducted with 395 randomly sampled mother–child pairs from 8 health facilities. Data were collected on socio-demographic characteristics, social support and autonomy statuses of mothers, and dietary intake and anthropometry of children. Maternal social support and autonomy statuses were derived and classified into tertiles and IYCF and child growth indicators were derived based on WHO protocol. Logistic regression analysis was used to explore the association of maternal social support and autonomy statuses to IYCF indicators and child nutritional status.

Results

The mean age of the women was 27 (± 5.10) years and most belonged to the lowest tertile of social support (52.4%), and autonomy (44.1%). About half of the children, 53.2% and 44.6%, received Minimum Dietary Diversity (MDD) and Minimum Acceptable Diet (MAD) respectively but the majority (72.9%) received Minimum Meal Frequency (MMF). About a fifth of the children, 21.0%, 24.1%, and 20.5%, were wasted, stunted, and underweight respectively. Maternal autonomy was associated with IYCF but not growth indicators of young children. Compared to children of mothers of richest autonomy tertile, children of women of middle autonomy tertile were 67% less likely to receive MDD [Adjusted Odds Ratio (AOR): 0.33; 95% Confidence Interval (CI): 0.18–0.59], and 56% less likely to receive MAD (AOR: 0.44; 95% CI: 0.24–0.77). Also, children belonging to mothers of poorest autonomy tertile were 56% less likely to receive MMF compared to children of richest maternal autonomy tertile (AOR: 0.44; 95% CI: 0.23–0.84).

Conclusion

Maternal autonomy and not social support is associated with IYCF indicators of children in Northern Ghana; child survival programmes should incorporate or strengthen women empowerment interventions to improve child nutrition.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00630-8.

Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys

Background

To help provide a global understanding of the role of gender-related barriers to vaccination, we have used a broad measure of women’s empowerment and explored its association with the prevalence of zero-dose children aged 12-23 months across many low- and middle-income countries, using data from standardized national household surveys.

Methods

We used data from Demographic and Health Surveys (DHS) of 50 countries with information on both women’s empowerment and child immunisation. Zero-dose was operationally defined as the proportion of children who failed to receive any doses of the diphtheria, pertussis, and tetanus containing vaccines (DPT). We measured women’s empowerment using the SWPER Global, an individual-level indicator estimated for women aged 15-49 years who are married or in union and with three domains: social independence, decision-making and attitude towards violence. We estimated two summary measures of inequality, the slope index of inequality (SII) and the concentration index (CIX). Results were presented for individual and pooled countries.

Results

In the country-level (ecological) analyses we found that the higher the proportion of women with high empowerment, the lower the zero-dose prevalence. In the individual level analyses, overall, children with highly-empowered mothers presented lower prevalence of zero-dose than those with less-empowered mothers. The social independence domain presented more consistent associations with zero-dose. In 42 countries, the lowest zero-dose prevalence was found in the high empowerment groups, with the slope index of inequality showing significant results in 28 countries. When we pooled all countries using a multilevel Poisson model, children from mothers in the low and medium levels of the social independence domain had respectively 3.3 (95% confidence interval (CI) = 2.3, 4.7) and 1.8 (95% CI = 1.5, 2.1) times higher prevalence of zero-dose compared to those in the high level.

Conclusions

Our country-level and individual-level analyses support the importance of women’s empowerment for child vaccination, especially in countries with weaker routine immunisation programs.

A Women's Rights-Based Approach to Reducing Child Mortality: Data from 193 Countries Show that Gender Equality does Affect Under-five Child Mortality

OBJECTIVES

Mother's health and wellbeing significantly affects child health. Women's autonomy can improve healthcare-seeking behaviour, utilisation of healthcare services, and planned pregnancy, thereby improving child health. The global under-five mortality rate (U5MR) has seen the fastest decline in the past two decades, but the influence of gender equality on child mortality remains unaddressed. A strategic approach addressing gender equality is needed to reduce the U5MR further. The study aimed to identify and investigate the association between indicators of gender equality and U5MR using a human rights-based approach.

METHODS

We analysed open-source secondary data from international agencies comprising 521 gender-sensitive variables for 193 countries. Nine variables were included for the final Structural Equation Model based on the theoretical model. Model 1 consisted of 193 countries, and Model 2 comprised a subgroup analysis of 11 variables for 158 countries. Gender equality was a latent variable, and the U5MR was the outcome variable.

RESULTS

Gender equality was significantly associated with U5MR (Z = - 7.47, 95% CI = - 754.67 to - 440.98, p < 0‧001, n = 193 for Model 1, and Z = - 7.71, 95% CI = - 808.26 to - 480.72, p < 0‧001, n = 158 for Model 2). Female education, women's waged and salaried employment, women as employers, and women's representation in leadership and parliament enhanced gender equality, whereas the prevalence of child marriage and intimate partner violence (IPV) negatively affected gender equality. Improvement in gender equality significantly reduced U5MR. CONCLUSIONS FOR PRACTICE: Improving women's economic, educational, and social position and increasing female representation in higher leadership and policymaking positions is the key to reducing child mortality. Notably, eliminating child marriage and IPV is the key to achieving gender equality and is needed at the forefront of national policies. Gender equality can significantly improve women's reproductive autonomy, a critical factor in improving healthcare utilisation for women and their children.

Early childhood caries: Are maternal psychosocial factors, decision-making ability, and caries status risk indicators for children in a sub-urban Nigerian population?

OBJECTIVE

Early childhood caries (ECC) is caries in children below the age of 72 months. The aim of the study was to determine the association of maternal psychosocial factors (general anxiety, dental anxiety, sense of coherence, parenting stress, fatalism, social support, depressive symptoms, and executive dysfunction), decision-making abilities, education, income and caries status with the prevalence and severity of ECC among children resident in Ile-Ife, Nigeria.

METHODS

A dataset of 1549 mother-child (6-71-months-old) dyads collected through examinations and a household survey, using validated psychometric tools to measure the psychosocial factors, were analyzed. The DMFT for the mothers and the dmft for the child were determined. The association between maternal psychosocial factors, education, income, and decision-making ability, the prevalence of maternal caries, and the prevalence of ECC was determined using logistic regression analysis.

RESULTS

The prevalence of maternal caries was 3.3%, and the mean (standard deviation-SD) DMFT was 0.10 (0.76). The ECC prevalence was 4.3%, and the mean (SD) dmft was 0.13 (0.92). There was no significant difference between the prevalence and severity of maternal caries and ECC by maternal age, education, income, or decision-making abilities. There was also no significant difference in maternal caries, ECC prevalence and ECC severity by maternal psychosocial factors. The only significant association was between the prevalence of caries in the mother and children: children whose mothers had caries were over six times more likely to have ECC than were children with mothers who had no caries (AOR: 6.67; 95% CI 3.23-13.79; p < 0.001).

CONCLUSION

The significant association between ECC and maternal caries prevalence suggests that prenatal oral health care for mothers may reduce the risk for ECC.

Characterization of immunization secondary analyses using demographic and health surveys (DHS) and multiple indicator cluster surveys (MICS), 2006-2018

BACKGROUND

Infant immunization coverage worldwide has plateaued at about 85%. Using existing survey data to conduct analyses beyond estimating coverage may help immunization programmes better tailor strategies to reach un- and under-immunized children. The Demographic and Health Survey (DHS) and the Multiple Indicators Cluster Survey (MICS), routinely conducted in low and middle-income countries (LMICs), collect immunization data, yet vaccination coverage is often the only indicator reported and used. We conducted a review of published immunization-related analyses to characterize and quantify immunization secondary analyses done using DHS and MICS databases.

METHODS

We conducted a systematic search of the literature, of immunization-related secondary analyses from DHS or MICS published between 2006 and August 2018. We searched 15 electronic databases without language restrictions. For the articles included, relevant information was extracted and analyzed to summarize the characteristics of immunization-related secondary analyses. Results are presented following the PRISMA guidelines.

RESULTS

Among 1411 papers identified, 115 met our eligibility criteria; additionally, one article was supplemented by the Pan American Health Organization. The majority were published since 2012 (77.6%), and most (68.9%) had a first or corresponding author affiliated with institutions in high-income countries (as opposed to LMICs where these surveys are conducted). The median delay between survey implementation and publication of the secondary analysis was 5.4 years, with papers with authors affiliated to institutions in LMIC having a longer median publication delay (p < 0.001). Over 80% of the published analyses looked at factors associated with a specific vaccine or with full immunization. Quality proxies, such as reporting percent of immunization data from cards vs recall; occurrence and handling of missing data; whether survey analyses were weighted; and listing of potential biases or limitations of the original survey or analyses, were infrequently mentioned.

CONCLUSION

Our review suggests that more needs to be done to increase the increase the utilization of existing DHS and MICS datasets and improve the quality of the analyses to inform immunization programmes. This would include increasing the proportion of analyses done in LMICs, reducing the time lag between survey implementation and publication of additional analyses, and including more qualitative information about the survey in the publications to better interpret the results.

Vaccination assessments using the Demographic and Health Survey, 2005-2018: a scoping review

OBJECTIVE

To characterise studies which have used Demographic and Health Survey (DHS) datasets to evaluate vaccination status.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases including PubMed, EBSCOhost and POPLINE, from 2005 to 2018.

STUDY SELECTION

All English studies with vaccination status as the outcome and the use of DHS data.

DATA EXTRACTION

Studies were selected using a predetermined list of eligibility criteria and data were extracted independently by two authors. Data related to the study population, the outcome of interest (vaccination) and commonly seen predictors were extracted.

RESULTS

A total of 125 articles were identified for inclusion in the review. The number of countries covered by individual studies varied widely (1-86), with the most published papers using data from India, Nigeria, Pakistan and Ethiopia. Many different definitions of full vaccination were used although the majority used a traditional schedule recommended in the WHO's Expanded Programme on Immunisation. We found studies analysed a wide variety of predictors, but the most common were maternal education, wealth, urbanicity and child's sex. Most commonly reported predictors had consistent relationships with the vaccination outcome, outside of sibling composition.

CONCLUSIONS

Researchers make frequent use of the DHS dataset to describe vaccination patterns within one or more countries. A clearer idea of past use of DHS can inform the development of more rigorous studies in the future. Researchers should carefully consider whether a variable needs to be included in the multivariable model, or if there are mediating relationships across predictor variables.

Does gender equality and availability of contraception influence maternal and child mortality? A systematic review

BACKGROUND

Current global maternal and child health policies rarely value gender equality or women's rights and are restricted to policies addressing clinical interventions and family planning. Gender equality influences the knowledge, autonomy and utilisation of contraception and healthcare, thereby affecting maternal and child health. This systematic review aims to analyse the concurrent effect of gender equality and contraception on maternal and under-5 child mortality.

METHODS

A systematic review was conducted to investigate the current evidence. Studies were eligible if three themes-namely, indicators of gender equality (such as female education, labour force participation, gender-based violence), contraception, and maternal or child mortality-were present together in a single article analysing the same sample at the same time.

RESULTS

Even though extensive literature on this topic exists, only three studies managed to fit the selection criteria. Findings of two studies indicated an association between intimate partner violence (IPV) and infant mortality, and also reported that women's contraceptive use increased the risk of IPV. The third study found that the mother's secondary education attainment significantly reduced child mortality, while the mother's working status increased the odds of child mortality. The researchers of all included studies specified that contraceptive use significantly reduced the risk of child mortality.

CONCLUSION

Improvement in gender equality and contraception concurrently affect the reduction in child mortality. These findings provide strong support to address the research gaps and to include a gender equality approach towards maternal and child health policies.

Determinants and patterns of care-seeking for childhood illness in rural Pune District, India

BACKGROUND

An estimated 1.2 million children under five years of age die each year in India, with pneumonia and diarrhea among the leading causes. Increasing care-seeking is important to reduce mortality and morbidity from these causes. This paper explores the determinants and patterns of care-seeking for childhood illness in rural Pune district, India.

METHODS

Mothers having at least one child <5 years from the study area of the Vadu Health and Demographic Surveillance System were enrolled in a prospective cohort study. Household sociodemographic information was collected through a baseline questionnaire administered at enrollment. Participants were visited up to six times between July 2015 and February 2016 to collect information on recent childhood acute illness and associated care-seeking behavior. Multivariate logistic regression explored the associations between care-seeking and child, participant, and household characteristics.

RESULTS

We enrolled 743 mothers with 1066 eligible children, completing 2585 follow-up interviews (90% completion). Overall acute illness prevalence in children was 26% with care sought from a health facility during 71% of episodes. Multivariable logistic regression showed care-seeking was associated with the number of reported symptoms (Odds ratio (OR) = 2.4, 95% confidence interval (CI) = 1.5-3.9) and household insurance coverage (OR = 2.2, 95% CI = 1.1-4.3). We observed an interaction between the associations of illness severity and maternal employment on care-seeking. Somewhat-to-very severe illness was associated with increased care-seeking among both employed (OR = 5.0, 95% CI = 2.2-11.1) and currently unemployed mothers (OR = 7.0, 95% CI = 3.9-12.6). Maternal employment was associated with reduced care-seeking for non-severe illness (OR = 0.3, 95% CI = 0.1-0.7), but not associated with care-seeking for somewhat-to-very severe illness. Child sex was not associated with care-seeking.

CONCLUSIONS

This study demonstrates the importance of illness characteristics in determining facility-based care-seeking while also suggesting that maternal employment resulted in decreased care-seeking among non-severe illness episodes. The nature of the association between maternal employment and care-seeking is unclear and should be explored through additional studies. Similarly, the absence of male bias in care-seeking should be examined to assess for potential bias at other stages in the management of childhood illness.

Mothers' Healthcare Autonomy, Maternal-Health Utilization and Healthcare for Children under-3 Years: Analysis of the Nigeria DHS Data (2008-2018)

This study was designed to simultaneously examine if mothers’ personal healthcare autonomy within the household, and the level of their maternal-healthcare utilization, translates into better preventive (complete immunization) and curative (treatments for diarrhoea, fever and acute respiratory infection) efforts on morbidities in child healthcare. We analysed data pooled from three consecutive waves of the Nigeria Demographic and Health Survey: the surveys of 2008, 2013 and 2018. Using a multilevel logistic regression, we estimated the odds ratio for each of the outcome variables while adjusting for covariates. Findings revealed that mothers’ health autonomy is positively associated with child immunization and treatment of morbidities (except diarrhoea), a relationship moderated by the frequency of mothers’ exposure to media. Additionally, mothers’ healthcare utilization is positively associated with complete immunization, and all forms of morbidity treatment (except diarrhoea). Although the relationship between mothers’ healthcare-utilization and child immunization is not dependent on family wealth, however, the relationship between mothers’ healthcare utilization and treatment of morbidity is dependent. Policy effort should be geared towards stimulating mothers to seek appropriate and timely child healthcare and future studies could consider looking into the mediating role of paternal support in this relationship.

Role of Women's Empowerment in Child Nutrition Outcomes: A Systematic Review

Women's empowerment has gained attention as critical for child nutrition during the first 1000 days of life. However, the ways in which various women's empowerment measures are applied and the evidence for how they are differentially related to child nutrition is unclear. In this systematic review, therefore, we 1) systematically parse the many ways in which women's empowerment has been quantitatively measured in the context of child nutrition through the use of a theoretically driven application of dimensions and domains of empowerment; 2) summarize evidence for each of the various pathways between women's empowerment and child nutrition, based on dimensions and domains of empowerment; and 3) offer suggestions for future research to better articulate the relationship between women's empowerment and child nutrition. A search of evidence yielded 62 quantitative studies that used 200 unique indicators of women's empowerment, tested in 1316 associations with various child nutrition outcomes. Despite the large number of unique indicators, indicators for time resource allocation and reproductive decisions and indicators for men's engagement in child care and nutrition, all pertinent to child nutrition, were missing. Overall, the findings indicated an inconclusive relationship between women's empowerment and child nutrition: 379 out of 461 (82% weighted) and 217 out of 258 (84% weighted) associations found with stunting and wasting outcomes, respectively, were not significant. The current lack of evidence is likely not due to the absence of an underlying relationship between women's empowerment and child nutrition, but rather limitations in study design. Future research should carefully select women's empowerment indicators in context-specific ways, aggregate them meaningfully, and use a longitudinal study design to conduct pathway and lifecycle analysis in appropriate populations to clarify the relationship between women's empowerment and child nutrition.

Vaccination status of children aged 1-4 years in Afghanistan and associated factors, 2015

BACKGROUND

Childhood mortality in Afghanistan fell by half between 1990 and 2015, due in part to the government's commitment to improving pediatric immunization services. Although progress has been made, immunization coverage has nonetheless remained low with only 65% of children receiving the third dose of Diphtheria-Pertussis-Tetanus (DPT3) based on WHO estimates. This study aims to calculate the proportion of Afghan children aged 1-4 years who were fully vaccinated, under-vaccinated, or non-vaccinated with government-recommended Expanded Program on Immunization vaccines and identify predictors related to the family's sociodemographic status and maternal autonomy.

METHODS

Data from the 2015 Afghanistan Demographic and Health Survey was used to calculate the proportion of children who were fully vaccinated (i.e. received all recommended vaccines), under-vaccinated (i.e. received some, but not all), and non-vaccinated (i.e. did not receive any vaccines) according to WHO guidelines. A multivariable multinomial logistic regression model generated odds ratios for under-vaccination and non-vaccination versus full vaccination, and examined associations between independent factors and full vaccination status.

RESULTS

We found 40.6% of Afghan children age 1-4 were fully vaccinated, 42.4% under-vaccinated, and 17% non-vaccinated. Large disparities characterized immunization coverage among provinces and between urban and rural regions. Birthing in a government institution (vs. non-institutional setting), a higher number of antenatal care visits, and a visit to a health facility in the past 12 months were all associated with increased odds of full immunization. Factors related to maternal autonomy including maternal decision-making and maternal attitudes towards beating were also significantly associated with vaccination status.

CONCLUSION

Approximately 60% of children in Afghanistan are under-vaccinated or non-vaccinated, leaving millions of children unnecessarily at risk for vaccine-preventable diseases. Engagement with community and religious leaders to create programs that increase women's autonomy and expand access to institutional delivery could lead to downstream increases in childhood vaccination coverage.

Socioeconomic factors associated with full childhood vaccination in Bangladesh, 2014

OBJECTIVES

Childhood vaccination in Bangladesh has improved, but there is room for improvement. This study estimated full immunization coverage in Bangladeshi children and characterized risk factors for incomplete immunization.

METHODS

Using the 2014 Bangladesh Demographic and Health Survey (DHS), full vaccination of children aged 12 to 24 months was examined; this was defined as the receipt of one dose of bacillus Calmette-Guérin (BCG), three doses of pentavalent vaccine, three doses of oral polio vaccine (OPV), and one dose of measles-containing vaccine (MCV). Associations between full vaccination and selected risk factors were assessed by logistic regression.

RESULTS

Overall, 83% of children were fully vaccinated. BCG had the highest completion (97%), followed by OPV (92%), pentavalent vaccine (91%), and MCV (85%). Full vaccination coverage ranged from 64.4% in Sylhet to 90.0% in Rangpur and was lowest among non-locals of all regions (78.4%). Children who were in the lowest wealth quintile, who had mothers without antenatal care visits, or who had mothers without autonomy in healthcare decision-making were less likely to be fully vaccinated.

CONCLUSIONS

Overall, full vaccination of children is high, but varies by vaccine type. Disparities still exist by wealth and by region. Maternal access to care and autonomy in healthcare decision-making are associated with higher vaccination coverage.

Maternal Household Decision-Making Autonomy and Adolescent Education in Honduras

Maternal decision-making autonomy has been linked to positive outcomes for children's health and well-being early in life in low- and middle-income countries throughout the world. However, there is a dearth of research examining if and how maternal autonomy continues to influence children's outcomes into adolescence and whether it impacts other domains of children's lives beyond health, such as their education. The goal of this study was to determine whether high maternal decision-making was associated with school enrollment for secondary school-aged youth in Honduras. Further, we aimed to assess whether the relationships between maternal autonomy and school enrollment varied by adolescents' environmental contexts and individual characteristics such as gender. Our analytical sample included 6,579 adolescents ages 12-16 living with their mothers from the Honduran Demographic and Health Survey (DHS) 2011-12. We used stepwise logistic regression models to investigate the association between maternal household decision-making autonomy and adolescents' school enrollment. Our findings suggest that adolescents, especially girls, benefit from their mothers' high decision-making autonomy. Findings suggest that maternal decision-making autonomy promotes adolescents' school enrollment above and beyond other maternal, household, and regional influences.

Caregiver Decision-Making: Household Response to Child Illness in sub-Saharan Africa

We draw upon a framework outlining household recognition and response to child illness proposed by Colvin and colleagues (2013) to examine factors predictive of treatment sought for a recent child illness. In particular, we model whether no treatment, middle layer treatment (traditional healer, pharmacy, community health worker, etc.), or biomedical treatment was sought for recent episodes of diarrhea, fever, or cough. Based on multinomial, multilevel analyses of Demographic and Health Surveys from 19 countries in sub-Saharan Africa, we determine that if women have no say in their own healthcare, they are unlikely to seek treatment in response to child illness. We find that women in sub-Saharan Africa need healthcare knowledge, the ability to make healthcare decisions, as well as resources to negotiate cost and travel, in order to access biomedical treatment. Past experience with medical services such as prenatal care and a skilled birth attendant also increase the odds that biomedical treatment for child illness is sought. We conclude that caregiver decision-making in response to child illness within households is critical to reducing child morbidity and mortality in sub-Saharan Africa.

Associations between quantitative measures of women's empowerment and access to care and health status for mothers and their children: A systematic review of evidence from the developing world

Research on the association between women's empowerment and maternal and child health has rapidly expanded. However, questions concerning the measurement and aggregation of quantitative indicators of women's empowerment and their associations with measures of maternal and child health status and healthcare utilization remain unanswered. Major challenges include complexity in measuring progress in several dimensions and the situational, context dependent nature of the empowerment process as it relates to improvements in maternal and child health status and maternal care seeking behaviors. This systematic literature review summarizes recent evidence from the developing world regarding the role women's empowerment plays as a social determinant of maternal and child health outcomes. A search of quantitative evidence previously reported in the economic, socio-demographic and public health literature finds 67 eligible studies that report on direct indicators of women's empowerment and their association with indicators capturing maternal and child health outcomes. Statistically significant associations were found between women's empowerment and maternal and child health outcomes such as antenatal care, skilled attendance at birth, contraceptive use, child mortality, full vaccination, nutritional status and exposure to violence. Although associations differ in magnitude and direction, the studies reviewed generally support the hypothesis that women's empowerment is significantly and positively associated with maternal and child health outcomes. While major challenges remain regarding comparability between studies and lack of direct indicators in key dimensions of empowerment, these results suggest that policy makers and practitioners must consider women's empowerment as a viable strategy to improve maternal and child health, but also as a merit in itself. Recommendations include collection of indicators on psychological, legal and political dimensions of women's empowerment and development of a comprehensive conceptual framework that can guide research and policy making.

Determinants of basic public health services provision by village doctors in China: using non-communicable diseases management as an example

BACKGROUND

To ensure equity and accessibility of public health care in rural areas, the Chinese central government has launched a series of policies to motivate village doctors to provide basic public health services. Using chronic disease management and prevention as an example, this study aims to identify factors associated with village doctors' basic public health services provision and to formulate targeted interventions in rural China.

METHODS

Data was obtained from a survey of village doctors in three provinces in China in 2014. Using a multistage sampling process, data was collected through the self-administered questionnaire. The data was then analyzed using multilevel logistic regression models.

RESULTS

The high-level basic public health services for chronic diseases (BPHS) provision rate was 85.2% among the 1149 village doctors whom were included in the analysis. Among individual level variables, more education, more training opportunities, receiving more public health care subsidy (OR = 3.856, 95 % CI: 1.937-7.678, and OR = 4.027, 95% CI: 1.722-9.420), being under integrated management (OR = 1.978, 95% CI: 1.132-3.458), and being a New Cooperative Medical Scheme insurance program-contracted provider (OR = 2.099, 95% CI: 1.187-3.712) were associated with the higher BPHS provision by village doctors. Among county level factors, Foreign Direct Investment Index showed a significant negative correlation with BPHS provision, while the government funding for BPHS showed no correlation (P > 0.100).

CONCLUSION

Increasing public health care subsidies received by individual village doctors, availability and attendance of training opportunities, and integrated management and NCMS contracting of village clinics are important factors in increasing BPHS provision in rural areas.

Facility Delivery, Postnatal Care and Neonatal Deaths in India: Nationally-Representative Case-Control Studies

Objective

Clinical studies demonstrate the efficacy of interventions to reduce neonatal deaths, but there are fewer studies of their real-life effectiveness. In India, women often seek facility delivery after complications arise, rather than to avoid complications. Our objective was to quantify the association of facility delivery and postnatal checkups with neonatal mortality while examining the “reverse causality” in which the mothers deliver at a health facility due to adverse perinatal events.

Methods

We conducted nationally representative case-control studies of about 300,000 live births and 4,000 neonatal deaths to examine the effect of, place of delivery and postnatal checkup on neonatal mortality. We compared neonatal deaths to all live births and to a subset of live births reporting excessive bleeding or obstructed labour that were more comparable to cases in seeking care.

Findings

In the larger study of 2004–8 births, facility delivery without postnatal checkup was associated with an increased odds of neonatal death (Odds ratio = 2.5; 99% CI 2.2–2.9), especially for early versus late neonatal deaths. However, use of more comparable controls showed marked attenuation (Odds ratio = 0.5; 0.4–0.5). Facility delivery with postnatal checkup was associated with reduced odds of neonatal death. Excess risks were attenuated in the earlier study of 2001–4 births.

Conclusion

The combined effect of facility deliveries with postnatal checks ups is substantially higher than just facility delivery alone. Evaluation of the real-life effectiveness of interventions to reduce child and maternal deaths need to consider reverse causality. If these associations are causal, facility delivery with postnatal check up could avoid about 1/3 of all neonatal deaths in India (~100,000/year).

Barriers to Utilization of Antenatal Care Services in Eastern Nepal

Background

World Health Organization recommends at least four pregnancy check-ups for normal pregnancies. Ministry of Health and Population Nepal has introduced various strategies to promote prenatal care and institutional delivery to reduce maternal and child deaths. However, maternal health service utilization is low in some selected socio-economic and ethnic groups. Hence, this study aims to assess barriers to the recommended four antenatal care (4ANC) visits in eastern Nepal.

Methods

A cross-sectional quantitative study was conducted in Sunsari district. A total of 372 randomly selected women who delivered in the last year preceding the survey were interviewed using a semi-structured questionnaire. Bivariate and multivariate logistic regression analysis was carried out to identify barriers associated with 4ANC visits.

Results

More than two-third women (69%) attended at least 4ANC visits. The study revealed that women exposed to media had higher chance of receiving four or more ANC visits with an adjusted odds ratio (aOR = 3.5, 95% CI: 1.2–10.1) in comparison to women who did not. Women from an advantaged ethnic group had more chance of having 4ANC visits than respondents from a disadvantaged ethnic group (aOR = 2.4, 95% CI: 2.1–6.9). Similarly, women having a higher level of autonomy were nearly three times more likely (aOR = 2.9, 95% CI: 1.5–5.6) and richer women were twice (aOR = 2.3, 95% CI: 1.1–5.3) as likely to have at least 4ANC visits compared to women who had a lower level of autonomy and were economically poor.

Conclusion

Being from disadvantaged ethnicity, lower women’s autonomy, poor knowledge of maternal health service and incentive upon completion of ANC, less media exposure related to maternal health service, and lower wealth rank were significantly associated with fewer than the recommended 4ANC visits. Thus, maternal health programs need to address such socio-cultural barriers for effective health care utilization.

Individual and contextual determinants of adequate maternal health care services in Kenya

This study aimed to examine individual and community level factors associated with adequate use of maternal antenatal health services in Kenya. Individual and community level factors associated with adequate use of maternal health care (MHC) services were obtained from the 2008-09 Kenya Demographic and Health Survey data set. Multilevel partial-proportional odds logit models were fitted using STATA 13.0 to quantify the relations of the selected covariates to adequate MHC use, defined as a three-category ordinal variable. The sample consisted of 3,621 women who had at least one live birth in the five-year period preceding this survey. Only 18 percent of the women had adequate use of MHC services. Greater educational attainment by the woman or her partner, higher socioeconomic status, access to medical insurance coverage, and greater media exposure were the individual-level factors associated with adequate use of MHC services. Greater community ethnic diversity, higher community-level socioeconomic status, and greater community-level health facility deliveries were the contextual-level factors associated with adequate use of MHC. To improve the use of MHC services in Kenya, the government needs to design and implement programs that target underlying individual and community level factors, providing focused and sustained health education to promote the use of antenatal, delivery, and postnatal care.

Challenges of basic public health services provided by village doctors in Guizhou, China

This study was undertaken to uncover the challenges faced by village doctors in providing basic public health services (BPHS) in western rural areas of China. This field research for BPHS, with 12 managers and 82 village doctors of county Y in Guizhou province, was conducted in July 2012 using a combination of random and purposive sampling methods. Quantitative and qualitative methods were applied for data collection. EpiData 3.1, SPSS 15.0, and NVivo 10.0 were used to analyze the data. The results showed that the main challenges in delivering BPHS include heavy workload, poor working conditions, low income, lack of social security, and insufficient cooperation from rural residents. The Chinese government officials and policy makers can consider these challenges and focus on improving the quality and equity of BPHS by developing relevant strategies.

Rural-urban disparities in maternal immunization knowledge and childhood health-seeking behavior in Nigeria: a mixed method study

BACKGROUND

Immunization and appropriate health-seeking behavior are effective strategies to reduce child deaths.

OBJECTIVES

To compare maternal knowledge about immunization, use of growth chart and childhood health-seeking behavior in rural and urban areas.

METHODS

A cross-sectional comparative study done in Lagos, Nigeria. Questionnaire survey and focus group discussions were done. 300 respondents were selected by multi-stage sampling while discussants were purposively selected.

RESULTS

Awareness of immunization was high but knowledge of vaccine preventable diseases (VPDs) was poor in both areas. Urban women utilized preventive services more; growth monitoring (p<0.001) and immunization (p<0.001) while higher proportions of rural women utilized nutritional counseling (p=0.005) and treatment of illness (p<0.001). Growth chart utilization was better in the urban areas (p<0.001). Increasing maternal education increased use of growth chart in both areas. Both groups of women use multiple treatment sources for children (more in urban), determined by cost, time, perceived severity of illness and type of ailment (urban) and peculiarity of illness (rural). There is a preference for orthodox care in the rural area.

CONCLUSIONS

Knowledge of VPDs was poor and multiple treatment sources were common among rural and urban women. Education is vital to improve immunization knowledge and health-seeking behavior in both areas.

Healthcare utilisation and empowerment among women in Liberia

BACKGROUND

Many efforts have been undertaken to improve access to healthcare services in low-income settings; nevertheless, underutilisation persists. Women's lack of empowerment may be a central reason for underutilisation, but empirical literature establishing this relationship is sparse.

METHODS

We conducted a cross-sectional study using data from the 2007 Liberia Demographic and Health Survey. Our sample included all non-pregnant women who were currently married or living with a partner (N=3925 unweighted). We used multivariate logistic regression to assess the associations between constructs derived from the Theory of Gender and Power (TGP) and healthcare utilisation.

RESULTS

Two-thirds of women (65.6%) had been to a healthcare facility for herself or her children in the past 12 months. Constructs from the three major theoretical structures were associated with healthcare utilisation. Women with no education, compared with women with some education, were less likely to have been to a healthcare facility (OR=0.76; 95% CI 0.62 to 0.93) as were women who had experienced sexual abuse (OR=0.65; 95% CI 0.45 to 0.95) and women who were married (OR=0.69, 95% CI 0.54 to 0.88). Women in higher wealth quintiles, compared with women in the next lower wealth quintile, and women with more decision-making power had greater odds of having been to a healthcare facility (OR=1.22; 95% CI 1.10 to 1.36 and OR=1.10; 95% CI 1.01 to 1.20; respectively).

CONCLUSIONS

Strong associations exist between healthcare utilisation and empowerment among women in Liberia, and gender imbalances are prevalent. This fundamental issue likely needs to be addressed before large-scale improvement in health service utilisation can be expected.

Determinants of institutional delivery among women in Bangladesh

This study examines the factors that influence institutional delivery among women in Bangladesh extracting data from 2007 Bangladesh Demographic and Health Survey. We employed both bivariate and multivariate statistical analyses in this study. Findings revealed that, only 14.7% of the women went for institutional delivery and 28.8% births were delivered by trained birth attendance. The multivariate logistic regression analysis yielded quantitatively important and reliable estimates of facility delivery. The likelihood of institutional delivery was significantly higher for first-order pregnancy, couples' higher education, the richest, higher autonomy, TV ownership, non-Muslims, who received antenatal care services, pregnancy complications, and urban residents. Government should ensure quality of care, easy accessibility, and availability of all facilities free of cost in the public medical institutions. Women should be informed regarding the long-term benefit of institutional delivery through information, education, and communication program.