Measuring equity in utilization of emergency obstetric care at Wolisso Hospital in Oromiya, Ethiopia: a cross sectional study

Measuring equity of access to eye health outreach camps in rural Malawi

Introduction

Equity in the access and use of health services is critical if countries are to make progress towards universal health coverage and address the systematic exclusion of the most vulnerable groups. The purpose of this study was to assess if the Co-ordinated Approach To Community Health programme implemented by Sightsavers was successful in reaching the poorest population, women, and people living with disabilities in Kasungu district, Malawi.

Methods

Between April and September 2017, data on socio-economic status, household characteristics and functional disability were collected from patients attending at eye camps in Kasungu district, Malawi. Using asset-based tools to measure household wealth (EquityTool© and Simple Poverty Scorecard©) and the Washington Group Short Set of Questions, individuals were categorised by wealth quintiles, poverty status, and functional disability status and then compared to relevant representative national household surveys. In addition, a follow-up household survey was conducted to check the validity of self-reported household characteristics at eye camps.

Results

A total of 1,358 individuals participated in the study. The study shows that self-reported data on household characteristics and assets are reliable and can be collected in clinical settings (instead of relying on direct observations of assets). Individuals attending outreach camps were poorer in terms of relative wealth and absolute poverty rates compared to the rest of the population in Kasungu. It was estimated that 9% of the participants belonged to the poorest quintile compared to 4% for the population in Kasungu (DHS 2015–2016). The ultra-poverty rate was also lower among respondents (13%) compared to 15% for Kasungu district (IHS 2017). The functional disability rate was 27.5% for study participants, and statistically higher than the general population (5.6%, SENTIF 2017). Even though women are more at risks than men, 54% of the participants were men.

Conclusions

Our study shows that existing tools can be reliably used, and combined, if based on recent population data, to assess equity of access to health services for vulnerable groups of the population. The findings suggest that the programme was successful in reaching the poorest people of the Kasungu district population as well as those with disabilities through outreach camps but that more men than women were reach through the programme. Subsequently, our study showed that self-reported household characteristics are a reliable method to measure asset-based wealth of camps’ attendee. However, it is essential to use sub-national data (district or regional level) from recent surveys for the purpose of benchmarking in order to produce accurate results.

Comparison of weighted and unweighted methods of wealth indices for assessing SOCIO-ECONOMIC status

Due to some of the limitations of monetary measures, various non-monetary approaches for assessing household wealth have been developed as alternative tools for classifying household socio-economic status. Among them, wealth indices based on household durable assets are being used. The literature revealed that two basic methods of constructing wealth indices are employed: an unweighted method, where assets are weighted equally; and a weighted method, where specific weights are assigned to assets. In the case of using the weighted method, weighting can be assigned using various techniques. The overall objective of the study is to compare the wealth indices constructed by using weighted and unweighted methods for assessing the socio-economic status of households in rural Bangladesh. Firstly, the study attempts to construct wealth indices based on durable assets using the unweighted method and two techniques of the weighted method: weighted index using the inverse of proportion, and weighted index using principal component analysis (PCA). Following this, the study compares some distributional characteristics of these indices as well as monetary indicators. At the same time, the study evaluates and examines some attractive properties of these indices such as the extent of clumping and truncation, consistency with traditional monetary measures. Comparative analysis revealed that the unweighted asset index, as well as weighted asset index using PCA, can be treated as an efficient alternative to the monetary measures to evaluate the living standard of the households in the present study. However, due to some advantage's asset index using PCA can be considered to be somewhat better than the unweighted index. But, as the unweighted asset index is not very different from the weighted asset index using PCA, it can also be used as an alternative to the monetary measures without the need to use weighting.

Optimization and validation of the EconomicClusters model for facilitating global health disparities research: Examples from Cameroon and Ghana

Health disparities research in low- and middle-income countries (LMICs) is hampered by the difficulty of measuring economic status in low-resource settings. We previously developed the EconomicClusters k-medoids clustering-based algorithm for defining population-specific economic models based on few Demographic and Health Surveys (DHS) assets. The algorithm previously defined a twenty-group economic model for Cameroon. The aims of this study are to optimize the functionality of our EconomicClusters algorithm and app based on collaborator feedback from early use of this twenty-group economic model, to test the validity of the model as a metric of economic status, and to assess the utility of the model in another LMIC context. We condense the twenty Cameroonian economic groups into fewer, ordinally-ranked, groups using agglomerative hierarchical clustering based on mean cluster child height-for-age Z-score (HAZ), women’s literacy score, and proportion of children who are deceased. We develop an EconomicClusters model for Ghana consisting of five economic groups and rank these groups based on the same three variables. The proportion of variance in women’s literacy score accounted for by the EconomicClusters model was 5–12% less than the proportion of variance accounted for by the DHS Wealth Index model. The proportion of the variance in child HAZ and proportion of children who are deceased accounted for by the EconomicClusters model was similar to (0.4–2.5% less than) the proportion of variance accounted for by the DHS Wealth Index model. The EconomicClusters model requires asking only five questions, as opposed to greater than twenty Wealth Index questions. The EconomicClusters algorithm and app could facilitate health disparities research in any country with DHS data by generating ordinally-ranked, population-specific economic models that perform nearly as well as the Wealth Index in evaluating variability in health and social outcomes based on wealth status but that are more feasible to assess in time-constrained settings.

Barriers to access and utilization of emergency obstetric care at health facilities in sub-Saharan Africa: a systematic review of literature

BACKGROUND

Nearly 15% of pregnancies end in fatal perinatal obstetric complications including bleeding, infections, hypertension, obstructed labour and complications of abortion. Globally, an estimated 10.7 million women have died due to obstetric complications in the last two decades, and two thirds of these deaths occurred in sub-Saharan Africa. Though the majority of maternal mortalities can be prevented, different factors can hinder women's access to emergency obstetric services. Therefore, this review is aimed at synthesizing current evidence on barriers to access and utilization of emergency obstetric care in sub-Saharan Africa.

METHODS

Articles were searched from MEDLINE, CINAHL, EMBASE, and Maternity and Infant Care databases using predefined search terms and strategies. Articles published in English, between 2010 and 2017, were included. Two reviewers (AG and AM) independently screened the articles, and data extraction was conducted using the Joanna Briggs Institute data extraction format. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool. The identified barriers were qualitatively synthesized and reported using the Three Delays analytical framework. The PRISMA checklist was employed to present the findings.

RESULT

The search of the selected databases returned 3534 articles. After duplicates were removed and further screening undertaken, 37 studies fulfilled the inclusion criteria. The identified key barriers related to the first delay included younger age, illiteracy, lower income, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs. Poorly designed roads, lack of vehicles, transportation costs, and distance from facilities led to the second delay. Barriers related to the third delay included lack of emergency obstetric care services and supplies, shortage of trained staff, poor management of emergency obstetric care provision, cost of services, long waiting times, poor referral practices, and poor coordination among staff.

CONCLUSIONS

A number of factors were found to hamper access to and utilization of emergency obstetric care among women in sub-Saharan Africa. These barriers are inter-dependent and occurred at multiple levels either at home, on the way to health facilities, or at the facilities. Therefore, country-specific holistic strategies including improvements to healthcare systems and the socio-economic status of women need to be strengthened. Further research should focus on the assessment of the third delay, as little is known about facility-readiness.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017074102.

Examining changes in maternal and child health inequalities in Ethiopia

BACKGROUND

Ethiopia has made considerable progress in maternal, newborn, and child health in terms of health outcomes and health services coverage. This study examined how different groups have fared in the process. It also looked at possible factors behind the inequalities.

METHODS

The study examined 11 maternal and child health outcomes and services: stunting, underweight, wasting, neonatal mortality, infant mortality, under-5 mortality, measles vaccination, full immunization, modern contraceptive use by currently married women, antenatal care visits, and skilled birth attendance. It explored trends in inequalities by household wealth status based on Demographic and Health Surveys conducted in 2000, 2005, 2011, and 2014. The study also investigated the dynamics of inequality, using concentration curves for different years. Decomposition analysis was used to identify the role of proximate determinants.

RESULTS

The study found substantial improvements in health outcomes and health services: Although there is still a considerable gap between the rich and the poor, inequalities in health services have been reduced. However, child nutrition outcomes have mainly improved for the rich. The changes observed in wealth-related inequality tend to reflect the changing direct effect of household wealth on child health and health service use.

CONCLUSIONS

The country's efforts to improve access to health services have shown some positive results, but attention should now turn to service quality and to identifying multisectoral interventions that can change outcomes for the poorest.

Access barriers to obstetric care at health facilities in sub-Saharan Africa-a systematic review

BACKGROUND

Since 2000, the United Nations' Millennium Development Goals, which included a goal to improve maternal health by the end of 2015, has facilitated significant reductions in maternal morbidity and mortality worldwide. However, despite more focused efforts made especially by low- and middle-income countries, targets were largely unmet in sub-Saharan Africa, where women are plagued by many challenges in seeking obstetric care. The aim of this review was to synthesise literature on barriers to obstetric care at health institutions in sub-Saharan Africa.

METHODS

This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus databases were electronically searched to identify studies on barriers to health facility-based obstetric care in sub-Saharan Africa, in English, and dated between 2000 and 2015. Combinations of search terms 'obstetric care', 'access', 'barriers', 'developing countries' and 'sub-Saharan Africa' were used to locate articles. Quantitative, qualitative and mixed-methods studies were considered. A narrative synthesis approach was employed to synthesise the evidence and explore relationships between included studies.

RESULTS

One hundred and sixty articles met the inclusion criteria. Currently, obstetric care access is hindered by several demand- and supply-side barriers. The principal demand-side barriers identified were limited household resources/income, non-availability of means of transportation, indirect transport costs, a lack of information on health care services/providers, issues related to stigma and women's self-esteem/assertiveness, a lack of birth preparation, cultural beliefs/practices and ignorance about required obstetric health services. On the supply-side, the most significant barriers were cost of services, physical distance between health facilities and service users' residence, long waiting times at health facilities, poor staff knowledge and skills, poor referral practices and poor staff interpersonal relationships.

CONCLUSION

Despite similarities in obstetric care barriers across sub-Saharan Africa, country-specific strategies are required to tackle the challenges mentioned. Governments need to develop strategies to improve healthcare systems and overall socioeconomic status of women, in order to tackle supply- and demand-side access barriers to obstetric care. It is also important that strategies adopted are supported by research evidence appropriate for local conditions. Finally, more research is needed, particularly, with regard to supply-side interventions that may improve the obstetric care experience of pregnant women.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2014 CRD42014015549.

Evaluation of a maternal health care project in South West Shoa Zone, Ethiopia: before-and-after comparison

BACKGROUND

Despite recent achievements in health targets, Ethiopia still faces challenges in health service delivery. Between 2012 and 2015, a non-governmental organisation (NGO), Doctors with Africa CUAMM, implemented a multifaceted project aimed at improving access to maternal and child health services in three districts in Ethiopia. This paper evaluates the performance of this project, based on four maternal health indicators.

METHODS

A before-and-after study utilising data collected through cross-sectional surveys involving 999 women was conducted. The date of delivery was used to stratify the intervention period as follows: pre-intervention, early intervention, and late intervention. Changes during the intervention in the coverage of four antenatal care (ANC) visits, receipt of three basic components of ANC, skilled birth attendant (SBA) at delivery, and postnatal care (PNC) in seven days were assessed using logistic regression, adjusting for socio-demographic factors.

RESULTS

There was an increase in the coverage of receipt of all three ANC components and SBA at delivery between the pre-intervention period and the late intervention period. The percent of health centre deliveries increased from 7.3 % in the pre-intervention period to 35.6 % in the late intervention period. The odds of receiving all three components of ANC were twice higher in the late intervention period than in the pre-intervention period (OR 2.09; 95 % CI 1.12-3.89). The odds of SBA at delivery were five times higher in the late intervention period than in the pre-intervention period (OR 5.04; 95 % CI 2.53-10.06). There was no significant change in the coverage of four ANC visits and PNC after accounting for sociodemographic factors.

CONCLUSIONS

This NGO implemented maternal health project in three districts in Ethiopia was associated with increased likelihood that a pregnant woman would receive three basic components of ANC and be assisted by a SBA at delivery. Increase in skilled birth attendance was driven by increased utilisation of health centres. More efforts are needed to bolster the coverage of ANC and PNC.

Determinants of utilisation of antenatal care and skilled birth attendant at delivery in South West Shoa Zone, Ethiopia: a cross sectional study

Background

Ethiopia has high maternal mortality ratio and poor access to maternal health services. Attendance of at least four antenatal care (ANC) visits and delivery by a skilled birth attendant (SBA) are important in preventing maternal deaths. Understanding the reasons behind the poor use of these services is important in designing strategies to address the problem. This study aimed to determine the coverage of at least four ANC visits and delivery by a SBA and to identify determinants of utilisation of these services in three districts in South West Shoa Zone, Ethiopia.

Methods

A cross-sectional survey of 500 women aged 15–49 years with a delivery in two years prior to the survey was conducted in Wolisso, Wonchi and Goro districts in February 2013. Data were collected using an interviewer administered questionnaire. Logistic regression models were used to explore determinants of ANC attendance and SBA at delivery.

Results

Coverage of at least four ANC visits and SBA at delivery were 45.5 and 28.6 %, respectively. Most institutional deliveries (69 %) occurred at the single hospital that serves the study districts. Attendance of at least four ANC visits was positively associated with wealth status, knowledge of the recommended number of ANC visits, and attitude towards maternal health care, but was negatively associated with woman’s age. SBA at delivery was negatively associated with parity and time to the health facility, but was positively associated with urban residence, wealth, knowledge of the recommended number of ANC visits, perceived good quality of maternal health services, experience of a pregnancy/delivery related problem, involvement of the partner/family in decision making on delivery place, and birth preparedness.

Conclusions

Raising awareness about the minimum recommended number of ANC visits, tackling geographical inaccessibility, improving the quality of care, encouraging pregnant women to have a birth and complication readiness plan and community mobilisation targeting women, husbands, and families for their involvement in maternal health care have the potential to increase use of maternal health services in this setting. Furthermore, supporting health centres to increase uptake of institutional delivery services may rapidly increase coverage of delivery by SBA and reduce inequity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-015-0067-y) contains supplementary material, which is available to authorized users.

How Has the Free Obstetric Care Policy Impacted Unmet Obstetric Need in a Rural Health District in Guinea?

Introduction

In 2010, the Ministry of Health (MoH) of Guinea introduced a free emergency obstetric care policy in all the public health facilities of the country. This included antenatal checks, normal delivery and Caesarean section.

Objective

This study aims at assessing the changes in coverage of obstetric care according to the Unmet Obstetric Need concept before (2008) and after (2012) the implementation of the free emergency obstetric care policy in a rural health district in Guinea.

Methods

We carried out a descriptive cross-sectional study involving the retrospective review of routine programme data during the period April to June 2014.

Results

No statistical difference was observed in women’s sociodemographic characteristics and indications (absolute maternal indications versus non-absolute maternal indications) before and after the implementation of the policy. Compared to referrals from health centers of patients, direct admissions at hospital significantly increased from 49% to 66% between 2008 and 2012 (p = 0.001). In rural areas, this increase concerned all maternal complications regardless of their severity, while in urban areas it mainly affected very severe complications. Compared to 2008, there were significantly more Major Obstetric Interventions for Maternal Absolute Indications in 2012 (p<0.001). Maternal deaths decreased between 2008 and 2012 from 1.5% to 1.1% while neonatal death increased from 12% in 2008 to 15% in 2012.

Conclusion

The implementation of the free obstetric care policy led to a significant decrease in unmet obstetric need between 2008 and 2012 in the health district of Kissidougou. However, more research is needed to allow comparisons with other health districts in the country and to analyse the trends.

Assessing coverage, equity and quality gaps in maternal and neonatal care in sub-saharan Africa: an integrated approach

Background

Gaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries.

Methods

Data were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization’s maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care.

Results

All the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level.

Conclusion

Our findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.

Iranian women and care providers' perceptions of equitable prenatal care: A qualitative study

BACKGROUND

Equity as a basic human right builds the foundation of all areas of primary healthcare, especially prenatal care. However, it is unclear how pregnant women and their care providers perceive the equitable prenatal care.

OBJECTIVE

This study aimed to explore Iranian women's and care providers' perceptions of equitable prenatal care.

RESEARCH DESIGN

In this study, a qualitative approach was used. Individual in-depth unstructured interviews were conducted with a purposeful sample of pregnant women and their care providers. Data were analyzed using inductive content analysis method.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 10 pregnant women and 10 prenatal care providers recruited from six urban health centers across Ahvaz, a south western city in Iran, were participated in the study.

ETHICAL CONSIDERATIONS

The study was approved by the Ethics Committee affiliated to Ahvaz Jundishapur University of Medical Sciences. The ethical principles of voluntary participation, confidentiality, and anonymity were considered.

FINDINGS

Analysis of participants' interviews resulted in seven themes: guideline-based care, time-saving care, nondiscriminatory care, privacy-respecting care, affordable comprehensive care, effective client-provider relationships, and caregivers' competency.

CONCLUSION

The findings explain the broader and less discussed dimensions of equitable care that are valuable information for the realization of equity in care. Understanding and focusing on these dimensions will help health policy-makers in designing more equitable healthcare services for pregnant women.

Using the unmet obstetric needs indicator to map inequities in life-saving obstetric interventions at the local health care system in Kenya

BACKGROUND

Developing countries with high maternal mortality need to invest in indicators that not only provide information about how many women are dying, but also where, and what can be done to prevent these deaths. The unmet Obstetric Needs (UONs) concept provides this information. This concept was applied at district level in Kenya to assess how many women had UONs and where the women with unmet needs were located.

METHODS

A facility based retrospective study was conducted in 2010 in Malindi District, Kenya. Data on pregnant women who underwent a major obstetric intervention (MOI) or died in facilities that provide comprehensive Emergency Obstetric Care (EmOC) services in 2008 and 2009 were collected. The difference between the number of women who experienced life threatening obstetric complications and those who received care was quantified. The main outcome measures in the study were the magnitude of UONs and their geographical distribution.

RESULTS

566 women in 2008 and 724 in 2009 underwent MOI. Of these, 185 (32.7%) in 2008 and 204 (28.1%) in 2009 were for Absolute Maternal Indications (AMI). The most common MOI was caesarean section (90%), commonly indicated by Cephalopelvic Disproportion (CPD)-narrow pelvis (27.6% in 2008; 26.1% in 2009). Based on a reference rate of 1.4%, the overall MOI for AMI rate was 1.25% in 2008 and 1.3% in 2009. In absolute terms, 22 (11%) women in 2008 and 12 (6%) in 2009, who required a life saving intervention failed to get it. Deficits in terms of unmet needs were identified in rural areas only while urban areas had rates higher than the reference rate (0.8% vs. 2.2% in 2008; 0.8% vs. 2.1% in 2009).

CONCLUSIONS

The findings, if used as a proxy to maternal mortality, suggest that rural women face higher risks of dying during pregnancy and childbirth. This indicates the need to improve priority setting towards ensuring equity in access to life saving interventions for pregnant women in underserved areas.

Understanding inequalities in child health in Ethiopia: health achievements are improving in the period 2000-2011

Objective

In Ethiopia, coverage of key health services is low, and community based services have been implemented to improve access to key services. This study aims to describe and assess the level and the distribution of health outcomes and coverage for key services in Ethiopia, and their association with socioeconomic and geographic determinants.

Methods

Data were obtained from the 2000, 2005 and 2011 Ethiopian Demographic and Health Surveys. As indicators of access to health care, the following variables were included: Under-five and neonatal deaths, skilled birth attendance, coverage of vaccinations, oral rehydration therapy for diarrhoea, and antibiotics for suspected pneumonia. For each of the indicators in 2011, inequality was described by estimating their concentration index and a geographic Gini index. For further assessment of the inequalities, the concentration indices were decomposed. An index of health achievement, integrating mean coverage and the distribution of coverage, was estimated. Changes from 2000 to 2011 in coverage, inequality and health achievement were assessed.

Results

Significant pro-rich inequalities were found for all indicators except treatment for suspected pneumonia in 2011. The geographic Gini index showed significant regional inequality for most indicators. The decomposition of the 2011 concentration indices revealed that the factor contributing the most to the observed inequalities was different levels of wealth. The mean of all indicators improved from 2000 to 2011, and the health achievement index improved for most indicators. The socioeconomic inequalities seem to increase from 2000 to 2011 for under-five and neonatal deaths, whereas they are stable or decreasing for the other indicators.

Conclusion

There is an unequal socioeconomic and geographic distribution of health and access to key services in Ethiopia. Although the health achievement indices improved for most indicators from 2000 to 2011, socioeconomic determinants need to be addressed in order to achieve better and more fairly distributed health.