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Win PP, Hlaing T, Win HH. Factors influencing maternal death in Cambodia, Laos, Myanmar, and Vietnam countries: A systematic review. PLoS One 2024; 19:e0293197. [PMID: 38758946 PMCID: PMC11101123 DOI: 10.1371/journal.pone.0293197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 10/08/2023] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND A maternal mortality ratio is a sensitive indicator when comparing the overall maternal health between countries and its very high figure indicates the failure of maternal healthcare efforts. Cambodia, Laos, Myanmar, and Vietnam-CLMV countries are the low-income countries of the South-East Asia region where their maternal mortality ratios are disproportionately high. This systematic review aimed to summarize all possible factors influencing maternal mortality in CLMV countries. METHODS This systematic review applied "The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist (2020)", Three key phrases: "Maternal Mortality and Health Outcome", "Maternal Healthcare Interventions" and "CLMV Countries" were used for the literature search. 75 full-text papers were systematically selected from three databases (PubMed, Google Scholar and Hinari). Two stages of data analysis were descriptive analysis of the general information of the included papers and qualitative analysis of key findings. RESULTS Poor family income, illiteracy, low education levels, living in poor households, and agricultural and unskilled manual job types of mothers contributed to insufficient antenatal care. Maternal factors like non-marital status and sex-associated work were highly associated with induced abortions while being rural women, ethnic minorities, poor maternal knowledge and attitudes, certain social and cultural beliefs and husbands' influences directly contributed to the limitations of maternal healthcare services. Maternal factors that made more contributions to poor maternal healthcare outcomes included lower quintiles of wealth index, maternal smoking and drinking behaviours, early and elderly age at marriage, over 35 years pregnancies, unfavourable birth history, gender-based violence experiences, multigravida and higher parity. Higher unmet needs and lower demands for maternal healthcare services occurred among women living far from healthcare facilities. Regarding the maternal healthcare workforce, the quality and number of healthcare providers, the development of healthcare infrastructures and human resource management policy appeared to be arguable. Concerning maternal healthcare service use, the provisions of mobile and outreach maternal healthcare services were inconvenient and limited. CONCLUSION Low utilization rates were due to several supply-side constraints. The results will advance knowledge about maternal healthcare and mortality and provide a valuable summary to policymakers for developing policies and strategies promoting high-quality maternal healthcare.
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Affiliation(s)
- Pyae Phyo Win
- Department of Public Health and Social Medicine, University of Medicine, Magwae, Myanmar
| | - Thein Hlaing
- District Public Health Department (Ministry of Health), Pyay District, Bago Region, Myanmar
| | - Hla Hla Win
- Department of Health and Social Sciences, STI Myanmar University, Yangon, Myanmar
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Worku S, Dheresa M, Ali T, Lodebo M. Early Postnatal Care Utilization and Associated Factors Among Women Who Give Birth in the Last Six Weeks in Hosanna Town, Southern Ethiopia, 2022. J Pregnancy 2024; 2024:1474213. [PMID: 38726388 PMCID: PMC11081751 DOI: 10.1155/2024/1474213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 03/11/2024] [Accepted: 03/29/2024] [Indexed: 05/12/2024] Open
Abstract
Background: The early postnatal period is defined as the first 48 h to 7 days after delivery. The early postnatal visit is especially the most critical time for the survival of mothers and newborns, particularly through early detection and management of postpartum complications. Despite the benefits, most mothers and newborns do not receive early postnatal care services from healthcare providers during the critical first few days after delivery. Objectives: This study is aimed at assessing the prevalence of early postnatal care utilization and associated factors among mothers who gave birth within the last 6 weeks in Hosanna town, Southern Ethiopia, from April 20 to May 30, 2022. Method: A community-based cross-sectional study was conducted in Hadiya Zone, Hosanna town, Southern Ethiopia. A simple random sample technique was used to recruit 403 mothers who had given birth in the previous 6 weeks from a family folder. Data was collected through face-to-face interviews using a standardized questionnaire. Binary logistic regression was used to assess the association between outcomes and explanatory variables, and the strength of the association was interpreted using an odds ratio with a 95% confidence interval. In our study, p values of 0.05 were considered statistically significant. Results: The prevalence of early postnatal care utilization among mothers who gave birth within 1 week of the study area was 25.8% (95% CI: 21.7-30.0). No formal and primary educational level of husband (AOR = 0.05, 95% CI: [0.02, 0.16]), antenatal care follow-up (AOR = 2.13, 95% CI: [1.11, 4.1]), length of hospital stay before discharge (≥24 h) (AOR = 0.3, 95% CI: [0.16, 0.55]), and information about early postnatal care utilization (AOR = 3.08, 95% CI: [1.72, 5.52]) were factors significantly associated with early postnatal care utilization. Conclusion: In comparison to World Health Organization standards, the study's overall prevalence of early postnatal care utilization was low. Early postnatal care use was significantly associated with antenatal care follow-up, the husband's educational level, knowledge of early postnatal care use, and length of stay at the health institution following birth. As a result, the strength of health facilities is to improve service provision, information education, and communication.
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Affiliation(s)
- Sintayehu Worku
- Department of Public Health, Hosanna Health Sciences College, Hosanna, Ethiopia
| | - Merga Dheresa
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Tilahun Ali
- School of Nursing and Midwifery, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Mengistu Lodebo
- Department of Midwifery, Hosanna Health Sciences College, Hosanna, Ethiopia
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Hone T, Gonçalves J, Seferidi P, Moreno-Serra R, Rocha R, Gupta I, Bhardwaj V, Hidayat T, Cai C, Suhrcke M, Millett C. Progress towards universal health coverage and inequalities in infant mortality: an analysis of 4·1 million births from 60 low-income and middle-income countries between 2000 and 2019. Lancet Glob Health 2024; 12:e744-e755. [PMID: 38614628 DOI: 10.1016/s2214-109x(24)00040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/14/2024] [Accepted: 01/19/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Expanding universal health coverage (UHC) might not be inherently beneficial to poorer populations without the explicit targeting and prioritising of low-income populations. This study examines whether the expansion of UHC between 2000 and 2019 is associated with reduced socioeconomic inequalities in infant mortality in low-income and middle-income countries (LMICs). METHODS We did a retrospective analysis of birth data compiled from Demographic and Health Surveys (DHSs). We analysed all births between 2000 and 2019 from all DHSs available for this period. The primary outcome was infant mortality, defined as death within 1 year of birth. Logistic regression models with country and year fixed effects assessed associations between country-level progress to UHC (using WHO's UHC service coverage index) and infant mortality (overall and by wealth quintile), adjusting for infant-level, mother-level, and country-level variables. FINDINGS A total of 4 065 868 births to 1 833 011 mothers were analysed from 177 DHSs covering 60 LMICs between 2000 and 2019. A one unit increase in the UHC index was associated with a 1·2% reduction in the risk of infant death (AOR 0·988, 95% CI 0·981-0·995; absolute measure of association, 0·57 deaths per 1000 livebirths). An estimated 15·5 million infant deaths were averted between 2000 and 2019 because of increases in UHC. However, richer wealth quintiles had larger associated reductions in infant mortality from UHC (quintile 5 AOR 0·983, 95% CI 0·973-0·993) than poorer quintiles (quintile 1 0·991, 0·985-0·998). In the early stages of UHC, UHC expansion was generally beneficial to poorer populations (ie, larger reductions in infant mortality for poorer households [infant deaths per 1000 per one unit increase in UHC coverage: quintile 1 0·84 vs quintile 5 0·59]), but became less so as overall coverage increased (quintile 1 0·64 vs quintile 5 0·57). INTERPRETATION Since UHC expansion in LMICs appears to become less beneficial to poorer populations as coverage increases, UHC policies should be explicitly designed to ensure lower income groups continue to benefit as coverage expands. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Thomas Hone
- Public Health Policy Evaluation Unit, Imperial College London, London, UK; Instituto de Estudos para Políticas de Saúde, São Paulo, Brazil.
| | - Judite Gonçalves
- Public Health Policy Evaluation Unit, Imperial College London, London, UK; NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, NOVA University Lisbon, Lisbon, Portugal
| | - Paraskevi Seferidi
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
| | | | - Rudi Rocha
- Instituto de Estudos para Políticas de Saúde, São Paulo, Brazil; São Paulo School of Business Administration, Fundação Getulio Vargas, São Paulo, Brazil
| | - Indrani Gupta
- Institute of Economic Growth, University of Delhi, Delhi, India
| | - Vinayak Bhardwaj
- South African Medical Research Council and Wits Centre for Health Economics and Decision Science, PRICELESS South Africa, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Taufik Hidayat
- Center for Health Economics and Policy Studies, Faculty of Public Health, Universitas Indonesia, Depok, Indonesia; Department of Economics, University of Sussex, Brighton, UK
| | - Chang Cai
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
| | - Marc Suhrcke
- Centre for Health Economics, University of York, Heslington, York, UK; Luxembourg Institute of Socio-economic Research, Esch-sur-Alzette, Luxembourg
| | - Christopher Millett
- Public Health Policy Evaluation Unit, Imperial College London, London, UK; NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, NOVA University Lisbon, Lisbon, Portugal
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Saing CH, Ung M, Suy S, Oy S, Dary C, Yam ELY, Chhorn S, Nagashima-Hayashi M, Khuon D, Mam S, Kim R, Saphonn V, Yi S. i-MoMCARE: Innovative Mobile Technology for Maternal and Child Health Care in Cambodia-study protocol of a cluster randomized controlled trial. Trials 2023; 24:692. [PMID: 37880782 PMCID: PMC10601211 DOI: 10.1186/s13063-023-07724-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: 04/14/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The Government of Cambodia established the village health support groups (VHSGs) in 2003 to facilitate primary healthcare activities, including maternal and child health (MCH) services. However, VHSGs face several challenges that hinder them from performing optimally, including a lack of regular structured training and remuneration and limited and inconsistent support and supervision from the health centers (HCs). This implementation research aims to develop, implement, and evaluate a digital health intervention to improve the performance of VHSGs through better support and supervision and increase the MCH service coverage in rural Cambodia. METHODS i-MoMCARE, a two-arm cluster randomized controlled trial, will be conducted between 2022 and 2025. Five operational districts (ODs) have been randomized to an intervention arm and the other five ODs to the control arm. The intervention will last for 24 months. Around 200 VHSGs in the intervention arm will be equipped with a mobile application as a job aid and 20 HC staff with a web interface to improve support and supervision of VHSGs. The potential beneficiaries will include pregnant women, mothers, and children under 2 years old. We will measure the outcomes at baseline and endline. The primary outcomes will consist of a composite MCH index constructed from maternal and newborn care indicators, child immunization, and treatment of under-two children. Secondary outcomes will include coverage of selected MCH services. We will conduct the intention-to-treat and per-protocol analyses. We will conduct qualitative interviews with selected beneficiaries and stakeholders to evaluate the intervention's acceptability, feasibility, and scalability. We will also conduct a cost-effective analysis using decision-analytic modeling incorporating a societal perspective that explores different time horizons, intervention effects, and when scaled up to the national level. DISCUSSION i-MoMCARE is expected to increase MCH service access and coverage in rural Cambodia. It will contribute to advancing digital health use in primary healthcare interventions, which remains in its infancy in the country. Furthermore, the study findings will be a valuable addition to a growing body of literature on the effectiveness and feasibility of mobile health to improve coverage of MCH services in rural low- and middle-income country settings. TRIAL REGISTRATION ClinicalTrial.gov NCT05639595. Registered on 06 December 2022.
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Affiliation(s)
- Chan Hang Saing
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | - Mengieng Ung
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | | | - Sreymom Oy
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | | | - Esabelle Lo Yan Yam
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
- College of Health and Medicine, Australian National University, Canberra, Australia
| | | | - Michiko Nagashima-Hayashi
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | - Dyna Khuon
- University of Health Sciences, Phnom Penh, Cambodia
| | - Sovatha Mam
- University of Health Sciences, Phnom Penh, Cambodia
| | - Rattana Kim
- National Maternal and Child Health Center, Phnom Penh, Cambodia
| | | | - Siyan Yi
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore.
- KHANA Center for Population Health Research, Phnom Penh, Cambodia.
- Public Health Program, College of Education and Health Sciences, Touro University California, Vallejo, CA, USA.
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Fentie EA, Asmamaw DB, Shewarega ES, Negash WD, Teklu RE, Alemu TG, Eshetu HB, Belay DG, Aragaw FM, Fetene SM. Socioeconomic inequality in modern contraceptive utilization among reproductive-age women in sub-Saharan African countries: a decomposition analysis. BMC Health Serv Res 2023; 23:185. [PMID: 36814248 PMCID: PMC9945375 DOI: 10.1186/s12913-023-09172-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Family planning services allow individuals to achieve desired birth spacing, family size, and contribute to improved health outcomes for infants, children, women, and families, and prevent unintended pregnancy. Births resulting from unintended pregnancies can have negative consequences Children from unintended pregnancies are more likely to experience poor mental and physical health during childhood. Even though many international organizations work to ensure universal access to sexual and reproductive health services, reproductive health service utilization is concentrated among individuals with rich socioeconomic status. Therefore, this study aimed to assess the presence of socioeconomic inequality in modern contraceptive utilization and its contributors in sub-Saharan African countries. METHODS A total of 466,282 weighted reproductive-aged women samples from DHS data SSA countries were included in the study. Erreygers normalized concentration index and its concentration curve were used to assess socioeconomic-related inequality in modern contraceptive utilization. Decomposition analysis was performed to identify factors contributing to socioeconomic-related inequality. RESULTS The weighted Erreygers normalized concentration index for modern contraceptive utilization was 0.079 with Standard error = 0.0013 (P value< 0.0001); indicating that There is small amount but statistically significant pro rich distribution of wealth related in equalities of modern contraceptive utilization among reproductive age women. The decomposition analysis revealed that mass media exposure, wealth index., place of residency, and distance of health facility were the major contributors to the pro-rich socioeconomic inequalities in modern contraceptive utilization. CONCLUSION AND RECOMMENDATION In this study, there is a small amount but statistically significant pro rich distribution of modern contraceptive utilization. Therefore, give priority to modifiable factors such as promoting the accessibility of health facilities, media exposure of the household, and improving their country's economy to a higher economic level to improve the wealth status of the population.
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Affiliation(s)
- Elsa Awoke Fentie
- Department of Reproductive Health, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Desale Bihonegn Asmamaw
- grid.59547.3a0000 0000 8539 4635Department of Reproductive Health, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ever Siyoum Shewarega
- grid.59547.3a0000 0000 8539 4635Department of Reproductive Health, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia ,grid.472268.d0000 0004 1762 2666Department of Reproductive Health, School of Public Health, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Wubshet Debebe Negash
- grid.59547.3a0000 0000 8539 4635Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Rediet Eristu Teklu
- grid.59547.3a0000 0000 8539 4635Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tewodros Getaneh Alemu
- grid.59547.3a0000 0000 8539 4635Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Habitu Birhan Eshetu
- grid.59547.3a0000 0000 8539 4635Department of Health Promotion and Health Behavior, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Daniel Gashaneh Belay
- grid.59547.3a0000 0000 8539 4635Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia ,grid.59547.3a0000 0000 8539 4635Department of Human Anatomy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Fantu Mamo Aragaw
- grid.59547.3a0000 0000 8539 4635Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Samrawit Mihret Fetene
- grid.59547.3a0000 0000 8539 4635Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Aji RS, Efendi F, Kurnia ID, Tonapa SI, Chan CM. Determinants of maternal healthcare service utilisation among Indonesian mothers: A population-based study. F1000Res 2022; 10:1124. [PMID: 35602669 PMCID: PMC9086521 DOI: 10.12688/f1000research.73847.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 11/20/2022] Open
Abstract
Background: In Indonesia, maternal health care services are widely available, aiming to improve health and survival among mothers. However, these services remain underutilised, and its determining factor was unknown. This study sought to identify determinant factors of maternal healthcare services utilisation among Indonesian mothers. Methods: This population-based cross-sectional study leveraged the 2017 Indonesia Demographic and Health Survey data. A total of 12,033 mothers aged from 15 to 49 years who had a live birth in the five years preceding the survey were included in the analysis. Multivariable logistic regressions were used to identify the determinant factors. Results: Approximately 93.44% of the mothers had adequate antenatal care, 83.73% had a delivery at the healthcare facility, and 71.46% received postnatal care. The mother’s age and household wealth index were the typical determinants of all maternal healthcare services. Determinants of antenatal care visits were husband’s occupational status, the number of children, and access to the healthcare facility. Next, factors that drive mothers’ delivery at the healthcare facility were the mother’s education level, husband’s educational level, and residential area. The use of postnatal care was determined by the mother’s occupational status, husband’s educational level, number of children, wealth index, access to the healthcare facility, and residential area. Conclusions: The utilisation of each maternal healthcare service was determined by various socio-structural and intermediary determinants, but the mother’s age and household wealth index were emerged as the typical determinants of all maternal healthcare services. Providing maternal healthcare services that are adjusted and tuned with these socio determinant factors may ensure that mothers can adequately utilise each service.
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Affiliation(s)
| | - Ferry Efendi
- Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia
- Research Group of Community Health, Surabaya, Indonesia
| | | | - Santo Imanuel Tonapa
- Research Group of Community Health, Surabaya, Indonesia
- School of Nursing, Faculty of Medicine Universitas Sam Ratulangi, Manado, Indonesia
| | - Chong-Mei Chan
- Department of Nursing Science, Faculty of Medicine University of Malaya, Kuala Lumpur, Malaysia
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Aregbeshola BS, Olaniyan O. Horizontal Inequity in the Utilization of Maternal and Reproductive Health Services: Evidence From the 2018 Nigeria Demographic and Health Survey. FRONTIERS IN HEALTH SERVICES 2022; 2:791695. [PMID: 36925856 PMCID: PMC10012694 DOI: 10.3389/frhs.2022.791695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 02/04/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Maternal mortality and poor reproductive health outcomes remain major public health challenges in low-resource countries. The Sustainable Development Goals have proposed new targets to reduce global maternal mortality ratio to 70 per 100,000 live births and ensure universal access to sexual and reproductive healthcare services by 2030. Inequity in the utilization of maternal and reproductive health services leads to poor reproductive health outcomes and maternal mortality. Despite reduction in global maternal mortality over the decades, the level of maternal mortality remains unacceptably high in Nigeria with limited attention given by governments to addressing health inequities. This study aimed to examine horizontal inequity in the utilization of maternal and reproductive health services in Nigeria. METHODS Secondary data from the 2018 Nigeria Demographic and Health Survey were utilized to examine horizontal inequity in the utilization of maternal and reproductive health services such as postnatal care, delivery by cesarean section, modern contraceptive use, and met need for family planning. Equity was measured using equity gaps, equity ratios, concentration curves, and concentration indices. All analyses were performed using ADePT 6.0 and STATA version 14.2 software. RESULTS The overall coverage level of postnatal care, delivery by cesarean section, modern contraceptive use, and met need for family planning was 20.81, 2.97, 10.23, and 84.22%, respectively. There is inequity in the utilization of postnatal care, delivery by cesarean section, and modern contraceptive favoring the rich, educated, and urban populations. Met need for family planning was found to be almost perfectly equitable. CONCLUSION There is inequity in the utilization of maternal and reproductive health services in Nigeria. Inequity in the utilization of maternal and reproductive health services is driven by socioeconomic status, education, and location. Therefore, governments and policymakers should give due attention to addressing inequities in the utilization of maternal and reproductive health services by economically empowering women, improving their level of education, and designing rural health interventions. Addressing inequities in the utilization of maternal and reproductive health services would also be important toward achieving the Sustainable Development Goal targets 3.1 and 3.7.
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Affiliation(s)
- Bolaji Samson Aregbeshola
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
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Rahman MM, Taniguchi H, Nsashiyi RS, Islam R, Mahmud SR, Rahman S, Jung J, Khan S. Trend and projection of skilled birth attendants and institutional delivery coverage for adolescents in 54 low- and middle-income countries, 2000-2030. BMC Med 2022; 20:46. [PMID: 35115000 PMCID: PMC8813474 DOI: 10.1186/s12916-022-02255-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/12/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Limitations to accessing delivery care services increase the risks of adverse outcomes during pregnancy and delivery for all pregnant women, particularly among adolescents in LMICs. In order to inform adolescent-specific delivery care initiatives and coverage, we conducted a comprehensive analysis of trends, projections and inequalities in coverage of delivery care services among adolescents at national, urban-rural and socio-economic levels in LMICs. METHODS Using 224 nationally representative cross-sectional survey data between 2000 and 2019, we estimated the coverage of institutional delivery (INSD) and skilled birth attendants (SBA). Bayesian hierarchical regression models were used to estimate trends, projections and determinants of INSD and SBA. RESULTS Coverage of delivery care services among adolescents increased substantially at the national level, as well as in both urban and rural areas in most countries between 2000 and 2018. Of the 54 LMICs, 24 countries reached 80% coverage of both INSD and SBA in 2018, and predictions for 40 countries are set to exceed 80% by 2030. The trends in coverage of INSD and SBA of adult mothers mostly align with those for adolescent mothers. Our findings show that urban-rural and wealth-based inequalities to delivery care remain persistent by 2030. In 2018, urban settings across 54 countries had higher rates of coverage exceeding 80% compared to rural for both INSD (45 urban, 16 rural) and SBA (50 urban, 19 rural). Several factors such as household head age ≥ 46 years, household head being female, access to mass media, lower parity, higher education, higher ANC visits and higher socio-economic status could increase the coverage of INSD and SBA among adolescents and adult women. CONCLUSIONS More than three-quarters of the LMICs are predicted to achieve 80% coverage of INSD and SBA among adolescent mothers in 2030, although with sustained inequalities.
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Affiliation(s)
- Md Mizanur Rahman
- Hitotsubashi Institute for Advanced Study, University of Hitotsubashi, 2-1 Naka, Kunitachi Tokyo, 186-8601, Japan.
| | - Hiroko Taniguchi
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | - Raïssa Shiyghan Nsashiyi
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
- Institute for Nature, Health, and Agricultural Research (INHAR), Yaoundé, Cameroon
| | - Rashedul Islam
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | | | - Shafiur Rahman
- Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Jenny Jung
- Global Public Health Research Foundation, Dhaka, Bangladesh
| | - Shahjahan Khan
- School of Sciences, Centre for Health Research, University of Southern Queensland, Toowoomba, Australia
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Li ZZ, Liu G, Tao R, Lobont OR. Do Health Expenditures Converge Among ASEAN Countries? Front Public Health 2021; 9:699821. [PMID: 34568255 PMCID: PMC8460855 DOI: 10.3389/fpubh.2021.699821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
This paper aims to determine the existence of convergence in health expenditures among Association for South East Asian Nations (ASEAN) countries. Based on the SPSM procedure and panel KSS unit root test results, the public health expenditures (PUHE) in Indonesia, Lao PDR, Cambodia, the Philippines, and Myanmar are converging, while that of Brunei Darussalam, Malaysia, Vietnam, Singapore, and Thailand are diverging. In addition, the sequences of private health expenditures (PRHE) in ASEAN member states are stationary, which implies convergence. This finding is in accordance with Wagner's law, that is, as nations develop, they are forced to expand public expenditure. Specifically, countries with low levels of PUHE tend to catch up with the high health spending countries. This research has policy implications with regard to the convergence of health expenditure across countries. The government in low- and lower-middle income countries should raise PUHE to provide access to health services for those who are unaffordable individuals.
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Affiliation(s)
- Zheng-Zheng Li
- Department of Economics, School of Economics, Qingdao University, Qingdao, China
| | - Guangzhe Liu
- Department of Graduate School, Graduate School, St. Paul University Philippines, Tuguegarao, Philippines
| | - Ran Tao
- Qingdao Municipal Center for Disease Control and Preventation, Qingdao, China
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Liverani M, Ir P, Jacobs B, Asante A, Jan S, Leang S, Man N, Hayen A, Wiseman V. Cross-border medical travels from Cambodia: pathways to care, associated costs and equity implications. Health Policy Plan 2021; 35:1011-1020. [PMID: 33049780 DOI: 10.1093/heapol/czaa061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2020] [Indexed: 11/13/2022] Open
Abstract
In low- and middle-income countries, patients may travel abroad to seek better health services or treatments that are not available at home, especially in regions where great disparities exist between the standard of care in neighbouring countries. While awareness of South-South medical travels has increased, only a few studies investigated this phenomenon in depth from the perspective of sending countries. This article aims to contribute to these studies by reporting findings from a qualitative study of medical travels from Cambodia and associated costs. Data collection primarily involved interviews with Cambodian patients returning from Thailand and Vietnam, conducted in 2017 in the capital Phnom Penh and two provinces, and interviews with key informants in the local health sector. The research findings show that medical travels from Cambodia are driven and shaped by an interplay of socio-economic, cultural and health system factors at different levels, from the effects of regional trade liberalization to perceptions about the quality of care and the pressure of relatives and other advisers in local communities. Furthermore, there is a diversity of medical travels from Cambodia, ranging from first class travels to international hospitals in Bangkok and cross-border 'medical tourism' to perilous overland journeys of poor patients, who regularly resort to borrowing or liquidating assets to cover costs. The implications of the research findings for health sector development and equitable access to care for Cambodians deserve particular attention. To some extent, the increase in medical travels can stimulate improvements in the quality of local health services. However, concerns remain that these developments will mainly affect high-cost private services, widening disparities in access to care between population groups.
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Affiliation(s)
- Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.,School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Bart Jacobs
- Social Health Protection Project, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289 Khan Toul Kork P.O. Box 1238 Phnom Penh, Cambodia
| | - Augustine Asante
- School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2052, Australia
| | - Stephen Jan
- The George Institute for Global Health, 1 King St, Newtown NSW 2042, Australia.,University of New South Wales, Sydney NSW 2052, Australia
| | - Supheap Leang
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Nicola Man
- School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2052, Australia
| | - Andrew Hayen
- University of Technology Sydney (UTS), 15 Broadway, Ultimo NSW 2007, Australia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.,The Kirby Institute, UNSW, Sydney NSW 2052, Australia
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Glaeser E, Jacobs B, Appelt B, Engelking E, Por I, Yem K, Flessa S. Costing of Cesarean Sections in a Government and a Non-Governmental Hospital in Cambodia-A Prerequisite for Efficient and Fair Comprehensive Obstetric Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8085. [PMID: 33147862 PMCID: PMC7663741 DOI: 10.3390/ijerph17218085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 11/18/2022]
Abstract
Knowing the cost of health care services is a prerequisite for evidence-based management and decision making. However, only limited costing data is available in many low- and middle-income countries. With a substantially increasing number of facility-based births in Cambodia, costing data for efficient and fair resource allocation is required. This paper evaluates the costs for cesarean section (CS) at a public and a Non-Governmental (NGO) hospital in Cambodia in the year 2018. We performed a full and a marginal cost analysis, i.e., we developed a cost function and calculated the respective unit costs from the provider's perspective. We distinguished fixed, step-fixed, and variable costs and followed an activity-based costing approach. The processes were determined by personal observation of CS-patients and all procedures; the resource consumption was calculated based on the existing accounting documentation, observations, and time-studies. Afterwards, we did a comparative analysis between the two hospitals and performed a sensitivity analysis, i.e., parameters were changed to cater for uncertainty. The public hospital performed 54 monthly CS with an average length of stay (ALOS) of 7.4 days, compared to 18 monthly CS with an ALOS of 3.4 days at the NGO hospital. Staff members at the NGO hospital invest more time per patient. The cost per CS at the current patient numbers is US$470.03 at the public and US$683.23 at the NGO hospital. However, the unit cost at the NGO hospital would be less than at the public hospital if the patient numbers were the same. The study provides detailed costing data to inform decisionmakers and can be seen as a steppingstone for further costing exercises.
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Affiliation(s)
- Eva Glaeser
- Department of General Business Administration and Health Care Management, University of Greifswald, 17489 Greifswald, Germany;
| | - Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), Phnom Penh 12302, Cambodia; (B.J.); (B.A.); (E.E.)
| | - Bernd Appelt
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), Phnom Penh 12302, Cambodia; (B.J.); (B.A.); (E.E.)
| | - Elias Engelking
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), Phnom Penh 12302, Cambodia; (B.J.); (B.A.); (E.E.)
| | - Ir Por
- National Institute of Public Health (NIPH), Phnom Penh 12150, Cambodia; (I.P.); (K.Y.)
| | - Kunthea Yem
- National Institute of Public Health (NIPH), Phnom Penh 12150, Cambodia; (I.P.); (K.Y.)
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, 17489 Greifswald, Germany;
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Bazzano AN, Stolow JA, Duggal R, Oberhelman RA, Var C. Warming the postpartum body as a form of postnatal care: An ethnographic study of medical injections and traditional health practices in Cambodia. PLoS One 2020; 15:e0228529. [PMID: 32027688 PMCID: PMC7004345 DOI: 10.1371/journal.pone.0228529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 01/14/2020] [Indexed: 11/18/2022] Open
Abstract
Postpartum care is a critical element for ensuring survival and health of mothers and newborns but is often inadequate in low- and middle-income countries due to barriers to access and resource constraints. Newly delivered mothers and their families often rely on traditional forms of postnatal care rooted in social and cultural customs or may blend modern and traditional forms of care. This ethnographic study sought to explore use of biomedical and traditional forms of postnatal care. Data were collected through unstructured observation and in-depth interviews with 15 mothers. Participants reported embracing traditional understandings of health and illness in the post-partum period centered on heating the body through diet, steaming, and other applications of heat, yet also seeking injections from private health care providers. Thematic analysis explored concepts related to transitioning forms of postnatal care, valuing of care through different lenses, and diverse sources of advice on postnatal care. Mothers also described concurrent use of both traditional medicine and biomedical postnatal care, and the importance of adhering to cultural traditions of postnatal care for future health. Maternal and newborn health are closely associated with postnatal care, so ensuring culturally appropriate and high-quality care must be an important priority for stakeholders including understand health practices that are evolving to include injections.
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MESH Headings
- Adult
- Anthropology, Cultural
- Body Temperature/physiology
- Cambodia/epidemiology
- Female
- Health Knowledge, Attitudes, Practice
- Hot Temperature/therapeutic use
- Humans
- Hyperthermia, Induced/methods
- Hyperthermia, Induced/psychology
- Hyperthermia, Induced/statistics & numerical data
- Infant Health
- Infant, Newborn
- Injections/psychology
- Injections/statistics & numerical data
- Male
- Medicine, Traditional/methods
- Medicine, Traditional/statistics & numerical data
- Mothers
- Patient Acceptance of Health Care
- Postnatal Care/methods
- Postnatal Care/statistics & numerical data
- Postpartum Period
- Practice Patterns, Physicians'/statistics & numerical data
- Pregnancy
- Surveys and Questionnaires
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Affiliation(s)
- Alessandra N. Bazzano
- Department of Global Community Health and Behavioral Sciences, Tulane School Public Health and Tropical Medicine, New Orleans, LA, United States of America
- * E-mail:
| | - Jeni A. Stolow
- Department of Global Community Health and Behavioral Sciences, Tulane School Public Health and Tropical Medicine, New Orleans, LA, United States of America
| | - Ryan Duggal
- Tulane University School of Medicine, New Orleans, LA, United States of America
| | - Richard A. Oberhelman
- Department of Global Community Health and Behavioral Sciences, Tulane School Public Health and Tropical Medicine, New Orleans, LA, United States of America
| | - Chivorn Var
- Reproductive Health Association of Cambodia, Phnom Penh, Cambodia
- National Institute of Public Health, Phnom Penh, Cambodia
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Annear PL, Tayu Lee J, Khim K, Ir P, Moscoe E, Jordanwood T, Bossert T, Nachtnebel M, Lo V. Protecting the poor? Impact of the national health equity fund on utilization of government health services in Cambodia, 2006-2013. BMJ Glob Health 2019; 4:e001679. [PMID: 31798986 PMCID: PMC6861123 DOI: 10.1136/bmjgh-2019-001679] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 09/25/2019] [Accepted: 10/12/2019] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Cambodia's health equity fund (HEF) is the country's most significant social security scheme, covering the poorest one-fifth of the national population. During the last two decades, the HEF system was scaled up from an initial two health districts to national coverage of public health facilities. This is the first national study to examine the impact of the HEF on the utilisation of public health facilities. METHODS We first investigated the level of national HEF population coverage and health service use made by HEF eligible members using an administrative HEF operational dataset. Second, through multilevel interrupted time series analysis of routine monthly utilisation statistics during 2006-2013, we evaluated the impact of the HEF on hospital and health centre utilisation. RESULTS The proportion of HEF beneficiaries using hospital services in a given year (4.6%) appeared to exceed rates in the general population (3.3%). The introduction of the HEF was associated with: a significant level change in the monthly number of consultations at HCs followed by a gradual slope increase in time trend and a significant level change in the monthly number of deliveries. Overall, this was equivalent to a 15.6% net increase in number of consultations and 5.3% in deliveries in the first year. At RHs: a significant level change in the number of RH inpatient cases, followed by a sustained slope increase; a significant slope increase in the number of outpatient consultations and in the overall number of newborn deliveries. Overall, this was equivalent to a 47.9% net increase in inpatient cases, 24.1% in outpatient cases and 31.4% in deliveries in the first year. CONCLUSION The implementation of the HEF scheme was associated with increased utilisation of primary and secondary care services by the poor.
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Affiliation(s)
| | - John Tayu Lee
- School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Keovathanak Khim
- Public Health Department, University of Health Sciences, Phnom Penh, Cambodia
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Ellen Moscoe
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | | | - Thomas Bossert
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | | | - Veasnakiry Lo
- Department of Planning and Health Information, Ministry of Health, Cambodia, Cambodia
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Shen Y, Li Q, Liu X, Xiao S, Yan H. Training and financial intervention for encouraging maternal health service utilization: Results of cluster randomized trials in Shaanxi Province. Medicine (Baltimore) 2019; 98:e17709. [PMID: 31702622 PMCID: PMC6855503 DOI: 10.1097/md.0000000000017709] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The rising maternal and child healthcare costs and the lack of training and educational resources for healthcare workers have reduced service quality in primary health centers of China. We sought to compare strategies promoting healthcare service utilization in rural western China. METHOD A randomized community trial was carried out in Zhen'an country between 2007 and 2009. Two cross-sectional surveys were conducted to compare the outcomes of financial subsidy for pregnant women seeking antenatal care and clinical training provided to healthcare workers by difference-in-difference estimation. RESULTS In all, 1113 women completed the questionnaires. The proportion of postnatal visits increased three times in the training group, reaching 35.7%. The number of women who received advice from their doctors regarding nutrition and warning signs necessitating immediate medical attention also improved significantly (5.8% and 8.2%, respectively). Furthermore, the percentage of women who underwent blood tests increased significantly to 19.5% in the training group. Compared to the financial group, the training group had more women who breastfed for longer than 4 months (15.8%) and provided timely complementary feeding (8.9%). CONCLUSION The training intervention appeared to have improved prenatal care utilization. Essential obstetric training helped enhance knowledge and self-efficacy among healthcare workers.
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Affiliation(s)
- Yuan Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi
| | - Qiang Li
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi
| | - Xiaoning Liu
- Department of Epidemiology and Health Statistics, School of Public Health, LanZhou University, Lanzhou, Gansu, China
| | - Shengbin Xiao
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi
| | - Hong Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, Shaanxi
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Jacobs B, Hui K, Lo V, Thiede M, Appelt B, Flessa S. Costing for universal health coverage: insight into essential economic data from three provinces in Cambodia. HEALTH ECONOMICS REVIEW 2019; 9:29. [PMID: 31667671 PMCID: PMC6822335 DOI: 10.1186/s13561-019-0246-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/04/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Knowledge of the costs of health services improves health facility management and aids in health financing for universal health coverage. Because of resource requirements that are often not present in low- and middle-income countries, costing exercises are rare and infrequent. Here we report findings from the initial phase of establishing a routine costing system for health services implemented in three provinces in Cambodia. METHODS Data was collected for the 2016 financial year from 20 health centres (including four with beds) and five hospitals (three district hospitals and two provincial hospitals). The costs to the providers for health centres were calculated using step-down allocations for selected costing units, including preventive and curative services, delivery, and patient contact, while for hospitals this was complemented with bed-day and inpatient day per department. Costs were compared by type of facility and between provinces. RESULTS All required information was not readily available at health facilities and had to be recovered from various sources. Costs per outpatient consultation at health centres varied between provinces (from US$2.33 to US$4.89), as well as within provinces. Generally, costs were inversely correlated with the quantity of service output. Costs per contact were higher at health centres with beds than health centres without beds (US$4.59, compared to US$3.00). Conversely, costs for delivery were lower in health centres with beds (US$128.7, compared to US$413.7), mainly because of low performing health centres without beds. Costs per inpatient-day varied from US$27.61 to US$55.87 and were most expensive at the lowest level hospital. CONCLUSIONS Establishing a routine health service costing system appears feasible if recording and accounting procedures are improved. Information on service costs by health facility level can provide useful information to optimise the use of available financial and human resources.
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Affiliation(s)
- Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia
- Social Health Protection Network P4H, Phnom Penh, Cambodia
| | - Kelvin Hui
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia
| | - Veasnakiry Lo
- Department of Planning and Health Information, Ministry of Health, Phnom Penh, Cambodia
| | | | - Bernd Appelt
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia
| | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Greifswald, Germany
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Ir P, Jacobs B, Asante AD, Liverani M, Jan S, Chhim S, Wiseman V. Exploring the determinants of distress health financing in Cambodia. Health Policy Plan 2019; 34:i26-i37. [PMID: 31644799 PMCID: PMC6807511 DOI: 10.1093/heapol/czz006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2019] [Indexed: 11/14/2022] Open
Abstract
Borrowing is a common coping strategy for households to meet healthcare costs in countries where social health protection is limited or non-existent. Borrowing with interest, hereinafter termed distress health financing or distress financing, can push households into heavy indebtedness and exacerbate the financial consequences of healthcare costs. We investigated distress health financing practices and associated factors among Cambodian households, using primary data from a nationally representative household survey of 5000 households. Multivariate logistic regression was used to determine factors associated with distress health financing. Results showed that 28.1% of households consuming healthcare borrowed to pay for that healthcare with 55% of these subjected to distress financing. The median loan was US$125 (US$200 for loans with interest and US$75 for loans without interest). Approximately 50.6% of healthcare-related loans were to pay for the costs of outpatient care in the past month, 45.8% for inpatient care and 3.6% for preventive care in the past 12 months. While the average period to pay off the loan was 8 months, 78% of households were still indebted from loans taken over 12 months before the survey. Distress financing is strongly associated with household poverty-the poorer the household the more likely it is to borrow, fall into debt and unable to pay off the debt-even for members of the health equity funds, a national scheme designed to improve financial access to health services for the poor. Other determinants of distress financing were household size, use of inpatient care and outpatient consultations with private providers or with both private and public providers. In order to ensure effective financial risk protection, Cambodia should establish a more comprehensive and effective social health protection scheme that provides maximum population coverage and prioritizes services for populations at risk of distress financing, especially poorer and larger households.
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Affiliation(s)
- Por Ir
- National Institute of Public Health, Lot No. 80, Street 289, Phnom Penh, Cambodia
| | - Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), Lot No. 80, Street 289, Phnom Penh, Cambodia
| | - Augustine D Asante
- School of Public Health & Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, UK
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, 1 King St Newtown, New South Wales, Australia
| | - Srean Chhim
- National Institute of Public Health, Lot No. 80, Street 289, Phnom Penh, Cambodia
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, UK
- Kirby Institute, University of New South Wales, Wallace Wurth Building, High St, Kensington NSW, Australia
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Pierce H. Increasing health facility deliveries in Cambodia and its influence on child health. Int J Equity Health 2019; 18:67. [PMID: 31088473 PMCID: PMC6515616 DOI: 10.1186/s12939-019-0964-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 04/17/2019] [Indexed: 11/23/2022] Open
Abstract
Background A growing number of women in Cambodia are seeking support from health facilities during delivery, up from 8% in 2000 to 82% in 2014. This growth may be attributed to increased national level attention to incentivize hospital births and reduce potential barriers. This paper address three related questions regarding the impact of increased utilization of health care in Cambodia. First, did increasing health facility deliveries occur most among disadvantaged women? Second, as health facility utilization increased, did the benefit of delivery location on child health outcomes weaken? Finally, did socioeconomic disparities in child outcomes decline as a result of increased health facility deliveries? Methods Data is from the 2010 and 2014 Cambodian Demographic and health surveys. Regression models include logistic regression to predict utilization of a health facility, linear regression to predict child nutritional status and Cox regression to measure child survival. Propensity score matching was used to account for selectivity. Results Analysis shows that health facility delivery is associated with better nutritional status and survival and the effectiveness of a health center delivery remains with this rapidly increasing care. However, the largest increases in delivery at a health facility did not occur among less educated, less wealthy, and rural Cambodian women, and inequalities in child health outcomes remain. Conclusions Cambodian women have participated in a rapid increase in health center deliveries and those health facility deliveries remain beneficial for future child outcomes. However, initiatives to increase care are not addressing inequity in access to care among disadvantaged women. Additionally, disparities in children’s health outcomes remain, suggesting that health facility births are not sufficient in reducing disparities among children of disadvantaged mothers. Moving forward, current initiatives are rapidly increasing facility deliveries and maintaining their efficacy, but further efforts need to be placed on targeting disadvantaged women and their children.
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Affiliation(s)
- Hayley Pierce
- Brigham Young University, 2036 JFSB, Provo, Ut, 86402, USA.
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Ali M, Azmat SK, Hamza HB, Rahman MM, Hameed W. Are family planning vouchers effective in increasing use, improving equity and reaching the underserved? An evaluation of a voucher program in Pakistan. BMC Health Serv Res 2019; 19:200. [PMID: 30922318 PMCID: PMC6440079 DOI: 10.1186/s12913-019-4027-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 03/20/2019] [Indexed: 11/10/2022] Open
Abstract
Background Low modern contraceptive prevalence rate and high unmet need in Pakistan aggravates the vulnerabilities of unintended pregnancies and births contributing to maternal morbidity and mortality. This research aims to assess the effectiveness of a free, single-purpose voucher approach in increasing the uptake, use and better targeting of modern contraceptives among women from the lowest two wealth quintiles in rural and urban communities of Punjab province, Pakistan. Methods A quasi-interventional study with pre- and post-phases was implemented across an intervention (Chakwal) and a control district (Bhakkar) in Punjab province (August 2012–January 2015). To detect a 15% increase in modern contraceptive prevalence rate compared to baseline, 1276 women were enrolled in each arm. Difference-in-Differences (DID) estimates are reported for key variables, and concentration curves and index are described for equity. Results Compared to baseline, awareness of contraceptives increased by 30 percentage points among population in the intervention area. Vouchers also resulted in a net increase of 16% points in current contraceptive use and 26% points in modern methods use. The underserved population demonstrated better knowledge and utilized the modern methods more than their affluent counterparts. Intervention area also reported a low method-specific discontinuation (13.7%) and high method-specific switching rates (46.6%) amongst modern contraceptive users during the past 24 months. The concentration index indicated that voucher use was more common among the poor and vouchers seem to reduce the inequality in access to modern methods across wealth quintiles. Conclusion Vouchers can substantially expand contraceptive access and choice among the underserved populations. Vouchers are a good financing tool to improve equity, increase access, and quality of services for the underserved thus contributing towards achieving universal health coverage targets.
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Affiliation(s)
- Moazzam Ali
- Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, CH-1211, Geneva 27, Switzerland.
| | - Syed Khurram Azmat
- Division of Health Information Systems, Hospital for Sick Children, Toronto, Canada.,Department of Uro-gynecology, University of Ghent, Ghent, Belgium
| | - Hasan Bin Hamza
- Health Policy, System Strengthening and Information Analysis Unit, Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Md Mizanur Rahman
- Department of Global Health Policy, School of International Health, The University of Tokyo, Tokyo, Japan
| | - Waqas Hameed
- Department of Research, Monitoring and Evaluation, Marie Stopes Society, Karachi, Pakistan
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Do N, Tran HTG, Phonvisay A, Oh J. Trends of socioeconomic inequality in using maternal health care services in Lao People's Democratic Republic from year 2000 to 2012. BMC Public Health 2018; 18:875. [PMID: 30005650 PMCID: PMC6045842 DOI: 10.1186/s12889-018-5811-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 07/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Socioeconomic inequalities in access to maternal health care have received more attention as it challenges the sustainability of the ongoing achievement in reducing maternal mortality. By promoting access to maternal health care as one of the core targets of the Health Sector Reform, Lao People's Democratic Republic has reduced maternal mortality dramatically over the last decade. In spite of this improvement, little has been known about the secular trends in disparities of service utilization across different socioeconomic subgroups. METHODS Two waves of the Multiple Indicator Cluster Survey in the years 2000 and 2012 were pooled for the analysis. We used logistic regression to estimate the likelihood of using antenatal care (ANC) and delivery services with skilled birth attendants (SBA) across different socioeconomic subgroups. Difference-in-difference method was applied to examine the inequality trends across the years by analyzing the interaction terms of the survey years and socioeconomic factors (education, wealth, ethnicity, and residential areas). RESULTS Urban-rural disparity was improved over time while there were no educational disparity changes. Rural residential areas showed significant changes than urban areas over time [OR = 2.40; 95% CI: 1.52-3.77 for ANC and OR = 2.16; 95% CI: 1.36-3.42 for SBA]. However, there were aggravations in the disparities between major and minor ethnic group as well as worsening disparities between the rich and poor: i.e. Ethnic minority showed significant aggravation over time [OR = 0.62; 95% CI: 0.44-0.89 for ANC and OR = 0.65; 95% CI: 0.44-0.97 for SBA]. CONCLUSIONS Efforts to increase maternal health service utilization in poor and minority ethnic groups should be emphasized to reduce social inequalities, thus encompassing multiple-sector interventions rather than focusing only on health sector related interventions.
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Affiliation(s)
- Ngan Do
- JW Lee Center for Global Medicine, Seoul National University College of Medicine, 71 Ihwajang-gil, Jongno-gu, Seoul, 13087 Republic of Korea
| | | | - Alay Phonvisay
- Department of Economics and Business Management, Graduate Division, National University of Laos, Vientiane, Lao People’s Democratic Republic
| | - Juhwan Oh
- JW Lee Center for Global Medicine, Seoul National University College of Medicine, 71 Ihwajang-gil, Jongno-gu, Seoul, 13087 Republic of Korea
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Gebre E, Worku A, Bukola F. Inequities in maternal health services utilization in Ethiopia 2000-2016: magnitude, trends, and determinants. Reprod Health 2018; 15:119. [PMID: 29973244 PMCID: PMC6031117 DOI: 10.1186/s12978-018-0556-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inequities in maternal health services utilization constitute a major challenge in maternal mortality reduction in Ethiopia. We sought to assess magnitude, trends, and determinants of inequities in maternal health services utilization in Ethiopia from 2000 to 2016. METHODS The study utilized data from the 2000 and 2016 Ethiopia Demographic and Health Surveys, which were done based on a cross sectional survey design. The wealth-related inequities were assessed by concentration curve and horizontal inequity indices. Trends in inequities were assessed by comparing the concentration indices of maternal health services utilization variables between the 2000 and 2016 surveys using Wagstaff two groups concentration indices comparison method. Finally, the inequities were decomposed into its contributing factors using Wagstaff method of analysis. RESULTS Wealth-related inequities were significantly high in 2016: with horizontal inequities indices and residual regression error of antenatal care, skilled birth attendance, and postnatal care service utilization (- 0.09 and - 0.01), (- 0.06 and 0.01), and (- 0.11 and 0.0001), respectively. These indices increased significantly in 2016 when it is compared with the 2000 indices' with the respective concentration indices difference of - 0.05, 0.05, and - 0.07. The related all p-values were < 0.0001. The main determinants of inequities were low-economic status, illiteracy, rural residence, no occupation, and fewer accesses to mass media. CONCLUSIONS In Ethiopia, maternal health services utilization inequities were significantly high and increased in 2016 compared to 2000. Women who are poor, rural resident, uneducated, unemployed, and fewer mass media exposed are the most disadvantaged. Targeting maternal health interventions for the underserved women is essential to reduce maternal mortality in the country.
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Affiliation(s)
- Emebet Gebre
- Department of Obstetrics and Gynaecology, College of Medicine, Pan Africa University Life and Earth Sciences Institute, University of Ibadan, Ibadan, Nigeria
| | - Alemayehu Worku
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Fawole Bukola
- Department of Obstetrics and Gynaecology, College of Medicine, Pan Africa University Life and Earth Sciences Institute, University of Ibadan, Ibadan, Nigeria
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Kikuchi K, Yasuoka J, Nanishi K, Ahmed A, Nohara Y, Nishikitani M, Yokota F, Mizutani T, Nakashima N. Postnatal care could be the key to improving the continuum of care in maternal and child health in Ratanakiri, Cambodia. PLoS One 2018; 13:e0198829. [PMID: 29889894 PMCID: PMC5995361 DOI: 10.1371/journal.pone.0198829] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 05/26/2018] [Indexed: 11/18/2022] Open
Abstract
In South-East Asia, the maternal and child mortality rate has declined over the past decades; however, it varies among and within the countries in the region, including Cambodia. The continuum of care is an integrated series of care that women and children are required to avail continuously from pregnancy to the child/motherhood period. This study aimed to assess the completion rate of the continuum of care and examine the factors associated with the continuum of care in Ratanakiri, Cambodia. A cross-sectional study was conducted in Ratanakiri. Overall, 377 women were included, and data were collected via face-to-face interviews using a semi-structured questionnaire. Among them, 5.0% completed the continuum of care (antenatal care at least four times, delivery by skilled birth attendant, and postnatal care at least once). Meanwhile, 18.8% did not receive any care during pregnancy, delivery, and after birth. The highest discontinuation rate was at the postnatal care stage (73.6%). Not receiving any perinatal care was associated with neonatal complications at 6 weeks after birth (adjusted odds ratio [AOR]: 3.075; 95% confidence interval [CI]: 1.310-7.215). Furthermore, a long distance to the health center was negatively associated with completion of the continuum of care (AOR: 0.877; 95% CI: 0.791-0.972). This study indicates the need for efforts to reduce the number of women who discontinue from the continuum of care, as well as who do not receive any care to avoid neonatal complications. Since the discontinuation rate was highest at the postnatal care, postnatal care needs to be promoted more through the antenatal care and delivery services. Furthermore, given that long distance to health facilities was a barrier for receiving the care continuously, our findings suggest the need for a village-based health care system that can provide the basic continuum of care in remote areas.
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Affiliation(s)
- Kimiyo Kikuchi
- Institute of Decision Science for a Sustainable Society, Kyushu University, Fukuoka, Japan
- * E-mail:
| | - Junko Yasuoka
- Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Keiko Nanishi
- Office of International Academic Affairs, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | - Ashir Ahmed
- Department of Advanced Information Technology, Kyushu University, Fukuoka, Japan
| | - Yasunobu Nohara
- Medical Information Center, Kyushu University Hospital, Fukuoka, Japan
| | - Mariko Nishikitani
- Institute of Decision Science for a Sustainable Society, Kyushu University, Fukuoka, Japan
| | - Fumihiko Yokota
- Institute of Decision Science for a Sustainable Society, Kyushu University, Fukuoka, Japan
| | - Tetsuya Mizutani
- Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Naoki Nakashima
- Department of Advanced Information Technology, Kyushu University, Fukuoka, Japan
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Benova L, Macleod D, Radovich E, Lynch CA, Campbell OMR. Should I stay or should I go?: consistency and switching of delivery locations among new mothers in 39 Sub-Saharan African and South/Southeast Asian countries. Health Policy Plan 2018; 32:1294-1308. [PMID: 28981668 PMCID: PMC5886240 DOI: 10.1093/heapol/czx087] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2017] [Indexed: 11/15/2022] Open
Abstract
The objective of this article is to assess the extent and determinants of switching delivery location between women’s first and second deliveries. We used Demographic and Health Survey data from 39 low- and middle-income countries on delivery locations from >30 000 women who had their first two deliveries in the 5-year survey recall period. Each delivery was characterized as occurring at home or in a health facility, facilities were classified as public- or private-sector. The extent of switching was estimated for each country, region and overall. Multivariable logistic regression models assessed determinants of switching (home to facility or facility to home), using four dimensions (perceived/biological need, socioeconomic characteristics, utilization of care and availability of care). Overall, 49.0% of first and 44.5% of second deliveries occurred in health facilities. Among women who had their first delivery at home, 11.8% used a facility for their second (7.0% public-sector and 4.8% private-sector). Among women who had their first delivery in a facility, 21.6% switched to a home location for their second. The extent of switching varied by country; but the overall net effect was either non-existent (n = 20) or away from facilities (n = 17) in all but two countries—Cambodia and Burkina Faso. Four factors were associated with switching to a facility after a home delivery: higher education, urban residence, non-poor household status and multiple gestation. Majority of women consistently used the same delivery location for their first two deliveries. We found some evidence that where switching occurred, women were being lost from facility care during this important transition, and that all four included dimensions were important determinants of women’s pattern of delivery care use. The relative importance of these factors should be understood in each specific context to improve retention in and provision of quality intrapartum care for women and their newborns.
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Affiliation(s)
- Lenka Benova
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
| | - David Macleod
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
| | - Emma Radovich
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
| | - Caroline A Lynch
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
| | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT London, United Kingdom
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Victora CG, Joseph G, Silva ICM, Maia FS, Vaughan JP, Barros FC, Barros AJD. The Inverse Equity Hypothesis: Analyses of Institutional Deliveries in 286 National Surveys. Am J Public Health 2018; 108:464-471. [PMID: 29470118 PMCID: PMC5844402 DOI: 10.2105/ajph.2017.304277] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To test the inverse equity hypothesis, which postulates that new health interventions are initially adopted by the wealthy and thus increase inequalities-as population coverage increases, only the poorest will lag behind all other groups. METHODS We analyzed the proportion of births occurring in a health facility by wealth quintile in 286 surveys from 89 low- and middle-income countries (1993-2015) and developed an inequality pattern index. Positive values indicate that inequality is driven by early adoption by the wealthy (top inequality), whereas negative values signal bottom inequality. RESULTS Absolute inequalities were widest when national coverage was around 50%. At low national coverage levels, top inequality was evident with coverage in the wealthiest quintile taking off rapidly; at 60% or higher national coverage, bottom inequality became the predominant pattern, with the poorest quintile lagging behind. CONCLUSIONS Policies need to be tailored to inequality patterns. When top inequalities are present, barriers that limit uptake by most of the population must be identified and addressed. When bottom inequalities exist, interventions must be targeted at specific subgroups that are left behind.
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Affiliation(s)
- Cesar Gomes Victora
- Cesar Gomes Victora, Gary Joseph, Inacio C. M. Silva, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Fatima S. Maia is with the Federal University of Rio Grande (FURG), Rio Grande, Brazil. J. Patrick Vaughan is with the Health Policy Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom. Fernando C. Barros is with Post Graduate Course in Health and Behavior, Catholic University of Pelotas, Pelotas
| | - Gary Joseph
- Cesar Gomes Victora, Gary Joseph, Inacio C. M. Silva, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Fatima S. Maia is with the Federal University of Rio Grande (FURG), Rio Grande, Brazil. J. Patrick Vaughan is with the Health Policy Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom. Fernando C. Barros is with Post Graduate Course in Health and Behavior, Catholic University of Pelotas, Pelotas
| | - Inacio C M Silva
- Cesar Gomes Victora, Gary Joseph, Inacio C. M. Silva, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Fatima S. Maia is with the Federal University of Rio Grande (FURG), Rio Grande, Brazil. J. Patrick Vaughan is with the Health Policy Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom. Fernando C. Barros is with Post Graduate Course in Health and Behavior, Catholic University of Pelotas, Pelotas
| | - Fatima S Maia
- Cesar Gomes Victora, Gary Joseph, Inacio C. M. Silva, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Fatima S. Maia is with the Federal University of Rio Grande (FURG), Rio Grande, Brazil. J. Patrick Vaughan is with the Health Policy Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom. Fernando C. Barros is with Post Graduate Course in Health and Behavior, Catholic University of Pelotas, Pelotas
| | - J Patrick Vaughan
- Cesar Gomes Victora, Gary Joseph, Inacio C. M. Silva, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Fatima S. Maia is with the Federal University of Rio Grande (FURG), Rio Grande, Brazil. J. Patrick Vaughan is with the Health Policy Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom. Fernando C. Barros is with Post Graduate Course in Health and Behavior, Catholic University of Pelotas, Pelotas
| | - Fernando C Barros
- Cesar Gomes Victora, Gary Joseph, Inacio C. M. Silva, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Fatima S. Maia is with the Federal University of Rio Grande (FURG), Rio Grande, Brazil. J. Patrick Vaughan is with the Health Policy Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom. Fernando C. Barros is with Post Graduate Course in Health and Behavior, Catholic University of Pelotas, Pelotas
| | - Aluisio J D Barros
- Cesar Gomes Victora, Gary Joseph, Inacio C. M. Silva, and Aluisio J. D. Barros are with the International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil. Fatima S. Maia is with the Federal University of Rio Grande (FURG), Rio Grande, Brazil. J. Patrick Vaughan is with the Health Policy Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom. Fernando C. Barros is with Post Graduate Course in Health and Behavior, Catholic University of Pelotas, Pelotas
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Boatin AA, Schlotheuber A, Betran AP, Moller AB, Barros AJD, Boerma T, Torloni MR, Victora CG, Hosseinpoor AR. Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. BMJ 2018; 360:k55. [PMID: 29367432 PMCID: PMC5782376 DOI: 10.1136/bmj.k55] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To provide an update on economic related inequalities in caesarean section rates within countries. DESIGN Secondary analysis of demographic and health surveys and multiple indicator cluster surveys. SETTING 72 low and middle income countries with a survey conducted between 2010 and 2014 for analysis of the latest situation of inequality, and 28 countries with a survey also conducted between 2000 and 2004 for analysis of the change in inequality over time. PARTICIPANTS Women aged 15-49 years with a live birth during the two or three years preceding the survey. MAIN OUTCOME MEASURES Data on caesarean section were disaggregated by asset based household wealth status and presented separately for five subgroups, ranging from the poorest to the richest fifth. Absolute and relative inequalities were measured using difference and ratio measures. The pace of change in the poorest and richest fifths was compared using a measure of excess change. RESULTS National caesarean section rates ranged from 0.6% in South Sudan to 58.9% in the Dominican Republic. Within countries, caesarean section rates were lowest in the poorest fifth (median 3.7%) and highest in the richest fifth (median 18.4%). 18 out of 72 study countries reported a difference of 20 percentage points or higher between the richest and poorest fifth. The highest caesarean section rates and greatest levels of absolute inequality were observed in countries from the region of the Americas, whereas countries from the African region had low levels of caesarean use and comparatively lower levels of absolute inequality, although relative inequality was quite high in some countries. 26 out of 28 countries reported increases in caesarean section rates over time. Rates tended to increase faster in the richest fifth (median 0.9 percentage points per year) compared with the poorest fifth (median 0.2 percentage points per year), indicating an increase in inequality over time in most of these countries. CONCLUSIONS Substantial within country economic inequalities in caesarean deliveries remain. These inequalities might be due to a combination of inadequate access to emergency obstetric care among the poorest subgroups and high levels of caesarean use without medical indication in the richest subgroups, especially in middle income countries. Country specific strategies should address these inequalities to improve maternal and newborn health.
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Affiliation(s)
- Adeline Adwoa Boatin
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne Schlotheuber
- Department of Information, Evidence and Research, World Health Organization, Geneva, 1211, Switzerland
| | - Ana Pilar Betran
- HRP-UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Ann-Beth Moller
- HRP-UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Ties Boerma
- Countdown to 2030 for Women's, Children's and Adolescents' Health; and Center for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Maria Regina Torloni
- Evidence Based Healthcare Post Graduate Program, São Paulo Federal University, São Paulo, Brazil
| | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Ahmad Reza Hosseinpoor
- Department of Information, Evidence and Research, World Health Organization, Geneva, 1211, Switzerland
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25
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Effective nutrition education and communication for sustainable maternal and child health. Proc Nutr Soc 2017; 76:504-515. [PMID: 28662730 DOI: 10.1017/s0029665117001070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Maternal and child health (MCH) consists of an interdependent reproductive system that collectively determines the survival of the mother during childbirth, and determines the health and survival of the child. This interdependency underscores the importance of appropriate and timely interventions during pregnancy through the first 1000 d at the minimum. The Millennium Development Goals (MDG) recommended the use of the continuum of care for the development of interventions by addressing all the stages of MCH. The purpose of the present paper is to review the factors that contributed to the attainment of the MDG 4 and MDG 5 by analysing the interventions conducted by the countries that achieved at least 5·0 and 5·5 %, respectively, and determine the level of their intervention based on the MCH conceptual framework. Out of the eighteen selected countries discussed, fifteen countries achieved their target for either MDG 4 or MDG 5 or both, while three countries did not achieve their target. The countries that were more likely to achieve their targets addressed the societal, underlying and direct causes, and implemented country wide policies. In contrast, the countries that did not succeed were more likely to address the direct causes with poor policy implementation. Understanding the motivation and limitations of the target population, including nutrition education and targeting behaviour change has the potential to result in sustainable MCH. This information has the potential to enlighten the policymakers as we progress to the sustainable development goals, specifically goals 2 and 3.
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Bobo FT, Yesuf EA, Woldie M. Inequities in utilization of reproductive and maternal health services in Ethiopia. Int J Equity Health 2017; 16:105. [PMID: 28629358 PMCID: PMC5477250 DOI: 10.1186/s12939-017-0602-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 06/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Disparities in health services utilization within and between regional states of countries with diverse socio-cultural and economic conditions such as Ethiopia is a frequent encounter. Understanding and taking measures to address unnecessary and avoidable differences in the use of reproductive and maternal health services is a key concern in Ethiopia. The aim of the study was to examine degree of equity in reproductive and maternal health services utilization in Ethiopia. METHOD Data from Ethiopia demographic health survey 2014 was analyzed. We assessed inequities in utilization of modern contraceptive methods, antenatal care, facility based delivery and postnatal checkup. Four standard equity measurement methods were used; equity gaps, rate-ratios, concertation curve and concentration index. RESULTS Inequities in service utilization were exhibited favoring women in developed regions, urban residents, most educated and the wealthy. Antenatal care by skilled provider was three times higher among women with post-secondary education than mothers with no education. Women in the highest wealth quantile had about 12 times higher skilled birth attendance than those in lowest wealth quantile. The rate of postnatal care use among urban resident was about 6 times that of women in rural area. Use of modern contraceptive methods was more equitably utilized service while, birth at health facility was less equitable across all economic levels, favoring the wealthy. CONCLUSION Considerable inequity between and within regions of Ethiopia in the use of maternal health services was demonstrated. Strategically targeting social determinants of health with special emphasis to women education and economic empowerment will substantially contribute for altering the current situation favorably.
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Affiliation(s)
- Firew Tekle Bobo
- Department of Public Health, College of Health sciences; Wollega University, Nekemte, Ethiopia
| | - Elias Ali Yesuf
- Department of Health Economics, Management, and Policy, Faculty of Public Health; Jimma University, Jimma, Ethiopia
- CIH-LMU Center for International Health, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Mirkuzie Woldie
- Department of Health Economics, Management, and Policy, Faculty of Public Health; Jimma University, Jimma, Ethiopia
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Mezmur M, Navaneetham K, Letamo G, Bariagaber H. Socioeconomic inequalities in the uptake of maternal healthcare services in Ethiopia. BMC Health Serv Res 2017; 17:367. [PMID: 28532407 PMCID: PMC5441003 DOI: 10.1186/s12913-017-2298-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 05/08/2017] [Indexed: 11/26/2022] Open
Abstract
Background The progress in coverage of maternal health services in Ethiopia has been rather slow over the past decade and consequently the maternal mortality ratio was very high (673 per 100,000 live births) among the countries in Sub-Saharan Africa and remained constant during 2005–11 period. Earlier studies have mostly focused on determinants of maternal health seeking behavior in Ethiopia. However, little is known about the inequality aspects. This study intends to examine socioeconomic inequalities in the uptake of maternal health services and to identify factors that contribute to such inequalities. Methods Data for the study is drawn from three rounds (year 2000, 2005 and 2011) of the Ethiopian Demographic and Health Surveys (EDHS). Concentration curves and the related concentration index (CI) were used to capture inequalities across the full range of socioeconomic status and highlight trends in the uptake of maternal health services in the country. Decomposition analysis was also employed to identify dominant factors that contribute to inequalities in the uptake of maternal healthcare services. Results In this study, there is a general improvement in the uptake of maternal health services in Ethiopia over the past decade which is inequitable to the disadvantage of the poor. Inequalities are much larger in care during giving birth than in other maternal healthcare indicators. Furthermore, despite the progress made in reducing inequalities in the uptake of four antenatal care consultation (ANC) and tetanus toxoid (TT) injection, inequalities in access to health facilities for delivery and skilled assistance during delivery have rather widened over the same period. In all the survey years, inequalities in education and media access significantly contribute to inequalities in maternal health service utilization favoring the non-poor. Conclusion The challenges to improving the uptake of maternal healthcare services in Ethiopia go beyond improving coverage of the maternal health services. Thus, addressing socioeconomic inequalities in accessing maternal health services is central to resolving challenges of maternal health. Furthermore, as Ethiopia moves forward with the sustainable development agenda, socioeconomic inequalities in uptake of maternal health services should also be continuously monitored.
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Affiliation(s)
- Markos Mezmur
- Department of Population Studies, University of Botswana, Private Bag: UB 705, Gaborone, Botswana.
| | - Kannan Navaneetham
- Department of Population Studies, University of Botswana, Private Bag: UB 705, Gaborone, Botswana
| | - Gobopamang Letamo
- Department of Population Studies, University of Botswana, Private Bag: UB 705, Gaborone, Botswana
| | - Hadgu Bariagaber
- Department of Population Studies, University of Botswana, Private Bag: UB 705, Gaborone, Botswana
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Ensor T, Chhun C, Kimsun T, McPake B, Edoka I. Impact of health financing policies in Cambodia: A 20 year experience. Soc Sci Med 2017; 177:118-126. [PMID: 28161669 DOI: 10.1016/j.socscimed.2017.01.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 12/12/2016] [Accepted: 01/22/2017] [Indexed: 11/28/2022]
Abstract
Improving financial access to services is an essential part of extending universal health coverage in low resource settings. In Cambodia, high out of pocket spending and low levels of utilisation have impeded the expansion of coverage and improvement in health outcomes. For twenty years a series of health financing policies have focused on mitigating costs to increase access particularly by vulnerable groups. Demand side financing policies including health equity funds, vouchers and community health insurance have been complemented by supply side measures to improve service delivery incentives through contracting. Multiple rounds of the Cambodia Socio-Economic Survey are used to investigate the impact of financing policies on health service utilisation and out of pocket payments both over time using commune panel data from 1997 to 2011 and across groups using individual data from 2004 and 2009. Policy combinations including areas with multiple interventions were examined against controls using difference-in-difference and panel estimation. Widespread roll-out of financing policies combined with user charge formalisation has led to a general reduction in health spending by the poor. Equity funds are associated with a reduction in out of pocket payments although the effect of donor schemes is larger than those financed by government. Vouchers, which are aimed only at reproductive health services, has a more modest impact that is enhanced when combined with other schemes. At the aggregate level changes are less pronounced although there is evidence that policies take a number of years to have substantial effect. Health financing policies and the supportive systems that they require provide a foundation for more radical extension of coverage already envisaged by a proposed social insurance system. A policy challenge is how disparate mechanisms can be integrated to ensure that vulnerable groups remain protected.
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Affiliation(s)
- Tim Ensor
- University of Leeds, United Kingdom.
| | - Chhim Chhun
- Cambodia Development Resource Institute, Cambodia.
| | - Ton Kimsun
- Cambodia Development Resource Institute, Cambodia.
| | | | - Ijeoma Edoka
- PRICELESS, School of Public Health University of the Witwatersrand, South Africa.
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Koblinsky M, Moyer CA, Calvert C, Campbell J, Campbell OMR, Feigl AB, Graham WJ, Hatt L, Hodgins S, Matthews Z, McDougall L, Moran AC, Nandakumar AK, Langer A. Quality maternity care for every woman, everywhere: a call to action. Lancet 2016; 388:2307-2320. [PMID: 27642018 DOI: 10.1016/s0140-6736(16)31333-2] [Citation(s) in RCA: 260] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 07/20/2016] [Accepted: 07/29/2016] [Indexed: 10/21/2022]
Abstract
To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal-perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal-perinatal health; and accelerate progress through evidence, advocacy, and accountability.
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Affiliation(s)
| | - Cheryl A Moyer
- Department of Learning Health Sciences and Department of Obstetrics and Gynecology, Global REACH, University of Michigan Medical School, Ann Arbor, MI
| | - Clara Calvert
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Wendy J Graham
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Steve Hodgins
- Saving Newborn Lives, Save the Children, Washington, DC, USA
| | - Zoe Matthews
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | - Lori McDougall
- Partnership for Maternal Newborn and Child Health, Geneva, Switzerland
| | | | | | - Ana Langer
- Maternal Health Task Force, Women and Health Initiative, Harvard TH Chan School of Public Health, Boston, MA, USA
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Kamal N, Curtis S, Hasan MS, Jamil K. Trends in equity in use of maternal health services in urban and rural Bangladesh. Int J Equity Health 2016; 15:27. [PMID: 26883742 PMCID: PMC4756462 DOI: 10.1186/s12939-016-0311-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 02/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maternal healthcare utilization is a major determinant of maternal mortality. Bangladesh is experiencing a rapid pace of urbanization with all future growth in population expected to be in urban areas. Health care infrastructure is different in urban and rural areas thus warranting an examination of equity in use rates of maternal healthcare. This paper addresses whether the urban-rural and rich-poor gaps in use of selected maternal healthcare indicators have narrowed or widened over the last decade. The paper also explores changes in the service provider environment in urban and rural domains. METHODS The 2001 and 2010 Bangladesh Maternal Mortality and Health Care Survey data were used to examine trends in use of antenatal care from medically trained providers and in deliveries taking place at health facilities. Separate wealth quintiles were constructed for urban and rural areas. The concentration index was calculated for urban and rural areas to measure equity in distribution of antenatal care (ANC) and facility deliveries across wealth quintiles in urban and rural domains. RESULTS The gap in use of ANC provided by medically trained personnel narrowed in urban and rural areas between 2001 and 2010 while that in facility deliveries widened. The difference in use of ANC by the rich and the poor was not as pronounced as that in utilization of facilities for deliveries. Over the last decade, equity in utilization of health facilities for deliveries has improved at a faster rate in urban areas. Private sector has surpassed the public sector and appears to be the dominant provider of maternal healthcare in both domains with the share of NGOs increasing in urban areas. CONCLUSIONS The faster pace of improvement in equity in maternal healthcare utilization in urban areas is reflective of the changing service environment in urban and rural areas, among other factors.
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Affiliation(s)
- Nahid Kamal
- MEASURE Evaluation, University of North Carolina at Chapel Hill, Chapel Hill, USA. .,Seconded to International Center for Diarrheal Disease Research (icddr,b), Dhaka, Bangladesh.
| | - Sian Curtis
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA.
| | - Mohammad S Hasan
- Department of Population Sciences, University of Dhaka, Dhaka, Bangladesh.
| | - Kanta Jamil
- Office of Population, Health, Nutrition and Education, USAID, Dhaka, Bangladesh.
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Ensor T, So S, Witter S. Exploring the influence of context and policy on health district productivity in Cambodia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2016; 14:1. [PMID: 26807044 PMCID: PMC4724134 DOI: 10.1186/s12962-016-0051-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 01/05/2016] [Indexed: 11/18/2022] Open
Abstract
Background Cambodia has been reconstructing its economy and health sector since the end of conflict in the 1990s. There have been gains in life expectancy and increased health expenditure, but Cambodia still lags behind neighbours One factor which may contribute is the efficiency of public health services. This article aims to understand variations in efficiency and the extent to which changes in efficiency are associated with key health policies that have been introduced to strengthen access to health services over the past decade. Methods The analysis makes use of data envelopment analysis (DEA) to measure relative efficiency and changes in productivity and regression analysis to assess the association with the implementation of health policies. Data on 28 operational districts were obtained for 2008–11, focussing on the five provinces selected to represent a range of conditions in Cambodia. DEA was used to calculate efficiency scores assuming constant and variable returns to scale and Malmquist indices to measure productivity changes over time. This analysis was combined with qualitative findings from 17 key informant interviews and 19 in-depth interviews with managers and staff in the same provinces. Results The DEA results suggest great variation in the efficiency scores and trends of scores of public health services in the five provinces. Starting points were significantly different, but three of the five provinces have improved efficiency considerably over the period. Higher efficiency is associated with more densely populated areas. Areas with health equity funds in Special Operating Agency (SOA) and non-SOA areas are associated with higher efficiency. The same effect is not found in areas only operating voucher schemes. We find that the efficiency score increased by 0.12 the year any of the policies was introduced. Conclusions This is the first study published on health district productivity in Cambodia. It is one of the few studies in the region to consider the impact of health policy changes on health sector efficiency. The results suggest that the recent health financing reforms have been effective, singly and in combination. This analysis could be extended nationwide and used for targeting of new initiatives. The finding of an association between recent policy interventions and improved productivity of public health services is relevant for other countries planning similar health sector reforms. Electronic supplementary material The online version of this article (doi:10.1186/s12962-016-0051-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tim Ensor
- International Health Systems, Leeds Institute of Health Sciences, Leeds, UK
| | - Sovannarith So
- Cambodia Development and Research Institute, Phnom Penh, Cambodia
| | - Sophie Witter
- International Health Financing and Systems, IIHD, Queen Margaret University, Edinburgh, UK
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Duc NHC, Nakamura K, Kizuki M, Seino K, Rahman M. Trends in inequalities in utilization of reproductive health services from 2000 to 2011 in Vietnam. J Rural Med 2015; 10:65-78. [PMID: 26705431 PMCID: PMC4689735 DOI: 10.2185/jrm.2902] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 09/25/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study aimed to examine changes in utilization of reproductive health services by wealth status from 2000 to 2011 in Vietnam. METHODS Data from the Vietnam Multiple Indicator Cluster Surveys in 2000, 2006, and 2011 were used. The subjects were 550, 1023, and 1363 women, respectively, aged between 15 and 49 years who had given birth in the previous one or two years. The wealth index, a composite measure of a household's ownership of selected assets, materials used for housing construction, and types of water access and sanitation facilities, was used as a measure of wealth status. Main utilization indicators were utilization of antenatal care services, receipt of a tetanus vaccine, receipt of blood pressure measurement, blood examination and urine examination during antenatal care, receipt of HIV testing, skilled birth attendance at delivery, health-facility-based delivery, and cesarean section delivery. Inequalities by wealth index were measured by prevalence ratios, concentration indices, and multivariable adjusted regression coefficients. RESULTS Significant increase in overall utilization was observed in all indicators (all p < 0.001). The concentration indices were 0.19 in 2000 and 0.06 in 2011 for antenatal care, 0.10 in 2000 and 0.06 in 2011 for tetanus vaccination, 0.23 in 2000 and 0.08 in 2011 for skilled birth attendance, 0.29 in 2006 and 0.12 in 2011 for blood examination, and 0.18 in 2006 and 0.09 in 2011 for health-facility-based delivery. The multivariable adjusted regression coefficients of reproductive health service utilization by wealth category were 0.06 in 2000 and 0.04 in 2011 for antenatal care, 0.07 in 2000 and 0.05 in 2011 for skilled birth attendance, and 0.07 in 2006 and 0.05 in 2011 for health-facility-based delivery. CONCLUSIONS More women utilized reproductive health services in 2011 than in 2000. Inequality by wealth status in utilization of antenatal care, skilled birth attendance, and health-facility-based delivery had been reduced.
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Affiliation(s)
- Nguyen Huu Chau Duc
- Department of Global Health Promotion, Division of Public
Health, Graduate School of Tokyo Medical and Dental University, Japan
- Department of Pediatrics, Hue University of Medicine and
Pharmacy, Vietnam
| | - Keiko Nakamura
- Department of Global Health Promotion, Division of Public
Health, Graduate School of Tokyo Medical and Dental University, Japan
| | - Masashi Kizuki
- Department of Global Health Promotion, Division of Public
Health, Graduate School of Tokyo Medical and Dental University, Japan
| | - Kaoruko Seino
- Department of Global Health Promotion, Division of Public
Health, Graduate School of Tokyo Medical and Dental University, Japan
| | - Mosiur Rahman
- Department of Global Health Promotion, Division of Public
Health, Graduate School of Tokyo Medical and Dental University, Japan
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Alkenbrack S, Chaitkin M, Zeng W, Couture T, Sharma S. Did Equity of Reproductive and Maternal Health Service Coverage Increase during the MDG Era? An Analysis of Trends and Determinants across 74 Low- and Middle-Income Countries. PLoS One 2015; 10:e0134905. [PMID: 26331846 PMCID: PMC4558013 DOI: 10.1371/journal.pone.0134905] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 07/16/2015] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Despite widespread gains toward the 5th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. As countries enter the post-MDG era and strive toward UHC, it will be important to monitor the extent to which countries are achieving equity of RH and MH service coverage. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country's progress, or lack thereof, toward more equitable RH and MH service coverage. METHODS We used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014. We examined trends in both relative and absolute equity, and measured relative equity using a concentration index of coverage data grouped by wealth quintile. Through multivariate analysis we examined the relative importance of policy factors, such as political commitment to health, governance, and the level of prepayment, in determining countries' progress toward greater equity in RH and MH service coverage. RESULTS Relative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity. CONCLUSION Equity in RH and MH service coverage has improved but varies considerably across countries and over time. Even among the subset of countries that are close to achieving the MDGs, progress made on equity varies considerably across countries. Enduring disparities in access and outcomes underpin mounting support for targeted reforms within the broader context of universal health coverage (UHC).
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Affiliation(s)
- Sarah Alkenbrack
- Health Policy Project, Center for Policy and Advocacy, Futures Group, Washington, DC, United States of America
| | - Michael Chaitkin
- Health Policy Project, Center for Policy and Advocacy, Futures Group, Washington, DC, United States of America
| | - Wu Zeng
- Health Policy Project, Center for Policy and Advocacy, Futures Group, Washington, DC, United States of America
| | - Taryn Couture
- Health Policy Project, Center for Policy and Advocacy, Futures Group, Washington, DC, United States of America
| | - Suneeta Sharma
- Health Policy Project, Center for Policy and Advocacy, Futures Group, Washington, DC, United States of America
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Çalışkan Z, Kılıç D, Öztürk S, Atılgan E. Equity in maternal health care service utilization: a systematic review for developing countries. Int J Public Health 2015; 60:815-25. [PMID: 26298441 DOI: 10.1007/s00038-015-0711-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 06/25/2015] [Accepted: 06/26/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES The objective was to explore progress of equity in the utilization of maternal health care services in developing countries since maternal care is a crucial factor in reducing maternal mortality, which is targeted by the Millennium Development Goal 5. METHODS A systematic review of quantitative studies was done. PubMed Central, Web of Science, and Science Direct databases were searched for peer-reviewed and English-language articles published between 2005 and 2015. RESULTS Thirty-six articles were included in the review. The results reveal the lack of equity in the utilization of maternal health care in developing countries. Thirty-three out of 36 studies found evidence supporting severe inequities while three studies found evidence of equity or at least improvement in terms of equity. CONCLUSIONS Most of the literature devoted to utilization of maternal health care generally provides information on the level of maternal care used and ignore the equity problem. Research in this area should focus not only on the level of maternal care used but also on the most disadvantaged segments of the population in terms of utilization of maternal care in order to reach the set targets.
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Affiliation(s)
- Zafer Çalışkan
- Department of Economics, Hacettepe University, Ankara, Turkey.
| | - Dilek Kılıç
- Department of Economics, Hacettepe University, Ankara, Turkey.
| | - Selcen Öztürk
- Department of Economics, Hacettepe University, Ankara, Turkey.
| | - Emre Atılgan
- Department of Health Management, Trakya University, Edirne, Turkey.
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Alam N, Hajizadeh M, Dumont A, Fournier P. Inequalities in maternal health care utilization in sub-Saharan African countries: a multiyear and multi-country analysis. PLoS One 2015; 10:e0120922. [PMID: 25853423 PMCID: PMC4390337 DOI: 10.1371/journal.pone.0120922] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 01/27/2015] [Indexed: 11/28/2022] Open
Abstract
To assess social inequalities in the use of antenatal care (ANC), facility based delivery (FBD), and modern contraception (MC) in two contrasting groups of countries in sub-Saharan Africa divided based on their progress towards maternal mortality reduction. Six countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three (Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average annual reduction rate. All of these countries had at least three rounds of Demographic and Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as relative and absolute concentration indices in order to examine within-country geographical and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use increased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by 4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators remained stagnant or increased. Absolute measures for geographical and wealth-based inequalities remained high invariably in all six countries. The increasing trend in the utilization of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in countries which made progress towards reducing maternal mortality.
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Affiliation(s)
- Nazmul Alam
- Research Centre of the University of Montreal Hospital (CR-CHUM), Montreal, Quebec, Canada
- School of Public Health, University of Montreal, Montreal, Canada
- * E-mail:
| | | | - Alexandre Dumont
- Research Institute for Development, Université Paris Descartes, Paris, France
| | - Pierre Fournier
- Research Centre of the University of Montreal Hospital (CR-CHUM), Montreal, Quebec, Canada
- School of Public Health, University of Montreal, Montreal, Canada
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Woods J, Gagliardi L, Nara S, Phally S, Varang O, Viphou N, Grundmann C, Liljestrand J. An innovative approach to in-service training of maternal health staff in Cambodian hospitals. Int J Gynaecol Obstet 2015; 129:178-83. [PMID: 25593108 DOI: 10.1016/j.ijgo.2014.10.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 10/27/2014] [Accepted: 12/22/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To demonstrate the feasibility of implementing evidence-based continuing medical education (CME) to improve key skills among maternity staff in Cambodia. METHODS A skills-based CME program was implemented in 33 Cambodian hospitals. Each clinical skills practice (CSP) module consisted of a 1-day practice session, focusing on three maternal and newborn interventions, followed by support visits to participating hospitals. Skills were assessed at 27 intervention hospitals and five control hospitals 7-11 months after the practice sessions through observation of neonatal resuscitation, magnesium sulfate dilution, and aortic compression simulations. RESULTS A total of 559 healthcare workers attended at least one CSP practice session. The skills assessment included 47 doctors and 210 midwives. Hospital staff who participated in CSP performed significantly better than did those from control hospitals on neonatal resuscitation (mean score 31.22 vs 17.00; P<0.001), magnesium sulfate dilution (mean score 11.01 vs 8.47; P<0.001), and aortic compression (mean score 13.87 vs 4.33; P<0.001). CSP participants were also significantly more likely to score higher than the 70% cutoff for neonatal resuscitation and magnesium sulfate dilution than were those from control hospitals, after adjustment for hospital level and profession (P≤0.05). CONCLUSION Key clinical skills in low-resource settings can be improved by implementing CME using simulations and supportive follow-up.
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Affiliation(s)
- Joan Woods
- University Research Co. Better Health Services project, Phnom Penh, Cambodia.
| | - Laina Gagliardi
- School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Sun Nara
- University Research Co. Better Health Services project, Phnom Penh, Cambodia
| | - Sim Phally
- University Research Co. Better Health Services project, Phnom Penh, Cambodia
| | - Ouk Varang
- Kampong Cham Provincial Hospital, Kampong Cham, Cambodia
| | - Nget Viphou
- Battambang Provincial Hospital, Battambang, Cambodia
| | | | - Jerker Liljestrand
- Department of Social Medicine and Global Health, Lund University, Lund, Sweden
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Hajizadeh M, Alam N, Nandi A. Social inequalities in the utilization of maternal care in Bangladesh: Have they widened or narrowed in recent years? Int J Equity Health 2014; 13:120. [PMID: 25492512 PMCID: PMC4272805 DOI: 10.1186/s12939-014-0120-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/26/2014] [Indexed: 01/16/2023] Open
Abstract
Background Notwithstanding the significant progress in reducing maternal mortality in recent years, social inequalities in the utilization of maternal care continue to be a challenge in Bangladesh. In this study, we aim to provide a comprehensive analysis of trends in social inequalities in utilization of antenatal care (ANC), facility based delivery (FBD), and skilled birth attendance (SBA) in Bangladesh between 1995 and 2010. Methods Data were extracted from the five latest rounds of Bangladesh Demographic Health Surveys (BDHS). The Theil index (T) and between-group variance (BGV) were used to calculate relative and absolute disparities in the utilization of three measures (ANC, FBD, and SBA) of maternal care across six administrative regions. The relative and slope indices of inequality (RII and SII, respectively) were also used to calculate wealth- and education-based inequality in the utilization of maternal care. Results The results of the T-index suggest that relative inequality in SBA has declined by 0.2% per year. Nevertheless, the estimated BGV demonstrated that absolute inequalities in all three measures of maternal care have increased across administrative divisions. For all three measures of maternal care, the RII and SII indicated consistent socioeconomic inequalities favouring wealthier and more educated women. The adjusted RII suggested that wealth- and education-related inequalities for ANC declined by 9% and 6%, respectively, per year during the study period. The adjusted SII, however, showed that wealth- and education-related inequalities for FBD increased by 0.6% per year. Conclusions Although socially disadvantaged mothers increased their utilization of care relative to mothers of higher socioeconomic status, the absolute gap in utilization of care between socioeconomic groups has increased over time. Our findings indicate that wealthier and more educated women, as well as those living in urban areas, are the major users of ANC, FBD and SBA in Bangladesh. Thus, priority focus should be given to implementing and evaluating interventions that benefit women who are poorer, less educated and live in rural areas.
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Affiliation(s)
- Mohammad Hajizadeh
- School of Health Administration, Faculty of Health Professions, Dalhousie University, 5161 George Street, Suite 700, Halifax, NS, B3H 4R2, Canada.
| | - Nazmul Alam
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Canada.
| | - Arijit Nandi
- Institute for Health and Social Policy & Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada.
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Entrenched geographical and socioeconomic disparities in child mortality: trends in absolute and relative inequalities in Cambodia. PLoS One 2014; 9:e109044. [PMID: 25295528 PMCID: PMC4189958 DOI: 10.1371/journal.pone.0109044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/03/2014] [Indexed: 11/23/2022] Open
Abstract
Background Cambodia has made considerable improvements in mortality rates for children under the age of five and neonates. These improvements may, however, mask considerable disparities between subnational populations. In this paper, we examine the extent of the country's child mortality inequalities. Methods Mortality rates for children under-five and neonates were directly estimated using the 2000, 2005 and 2010 waves of the Cambodian Demographic Health Survey. Disparities were measured on both absolute and relative scales using rate differences and ratios, and where applicable, slope and relative indices of inequality by levels of rural/urban location, regions and household wealth. Findings Since 2000, considerable reductions in under-five and to a lesser extent in neonatal mortality rates have been observed. This mortality decline has, however, been accompanied by an increase in relative inequality in both rates of child mortality for geography-related stratifying markers. For absolute inequality amongst regions, most trends are increasing, particularly for neonatal mortality, but are not statistically significant. The only exception to this general pattern is the statistically significant positive trend in absolute inequality for under-five mortality in the Coastal region. For wealth, some evidence for increases in both relative and absolute inequality for neonates is observed. Conclusion Despite considerable gains in reducing under-five and neonatal mortality at a national level, entrenched and increased geographical and wealth-based inequality in mortality, at least on a relative scale, remain. As expected, national progress seems to be associated with the period of political and macroeconomic stability that started in the early 2000s. However, issues of quality of care and potential non-inclusive economic growth might explain remaining disparities, particularly across wealth and geography markers. A focus on further addressing key supply and demand side barriers to accessing maternal and child health care and on the social determinants of health will be essential in narrowing inequalities.
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Magnitude and trends of inequalities in antenatal care and delivery under skilled care among different socio-demographic groups in Ghana from 1988 - 2008. BMC Pregnancy Childbirth 2014; 14:295. [PMID: 25169877 PMCID: PMC4155087 DOI: 10.1186/1471-2393-14-295] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 08/24/2014] [Indexed: 11/29/2022] Open
Abstract
Background Improving maternal and reproductive health still remains a major challenge in most low-income countries especially in sub-Saharan Africa. The growing inequality in access to maternal health interventions is an issue of great concern. In Ghana, inadequate attention has been given to the inequality gap that exists amongst women when accessing antenatal care during pregnancy and skilled attendance at birth. This study therefore aimed at investigating the magnitude and trends in income-, education-, residence-, and parity-related inequalities in access to antenatal care and skilled attendance at birth. Methods A database was constructed using data from the Ghana Demographic and Health Surveys (DHS) 1988, 1993, 1998, 2003, and 2008. The surveys employed standard DHS questionnaires and techniques for data collection. We applied regression-based Total Attributable Fraction (TAF) as an index for measuring socioeconomic inequalities in antenatal care and skilled birth attendance utilization. Results The rural–urban gap and education-related inequalities in the utilization of antenatal care and skilled birth attendants seem to be closing over time, while income- and parity-related inequalities in the use of antenatal care are on a sharp rise. Income inequality regarding the utilization of skilled birth attendance was rather low and stable from 1988 to 1998, increased sharply to a peak between 1998 and 2003, and then leveled-off after 2003. Conclusions The increased income-related inequalities seen in the use of antenatal care and skilled birth attendance should be addressed through appropriate strategies. Intensifying community-based health education through media and door-to-door campaigns could further reduce the mentioned education- and parity-related inequalities. Women should be highly motivated and incentivized to attend school up to secondary level or higher. Education on the use of maternal health services should be integrated into basic schools so that women at the lowest level would be inoculated with the appropriate health messages.
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McKinnon B, Harper S, Kaufman JS, Bergevin Y. Socioeconomic inequality in neonatal mortality in countries of low and middle income: a multicountry analysis. LANCET GLOBAL HEALTH 2014; 2:e165-73. [PMID: 25102849 DOI: 10.1016/s2214-109x(14)70008-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Neonatal mortality rates (NMRs) in countries of low and middle income have been only slowly decreasing; coverage of essential maternal and newborn health services needs to increase, particularly for disadvantaged populations. Our aim was to produce comparable estimates of changes in socioeconomic inequalities in NMR in the past two decades across these countries. METHODS We used data from Demographic and Health Surveys (DHS) for countries in which a survey was done in 2008 or later and one about 10 years previously. We measured absolute inequalities with the slope index of inequality and relative inequalities with the relative index of inequality. We used an asset-based wealth index and maternal education as measures of socioeconomic position and summarised inequality estimates for all included countries with random-effects meta-analysis. FINDINGS 24 low-income and middle-income countries were eligible for inclusion. In most countries, absolute and relative wealth-related and educational inequalities in NMR decreased between survey 1 and survey 2. In five countries (Cameroon, Nigeria, Malawi, Mozambique, and Uganda), the difference in NMR between the top and bottom of the wealth distribution was reduced by more than two neonatal deaths per 1000 livebirths per year. By contrast, wealth-related inequality increased by more than 1·5 neonatal deaths per 1000 livebirths per year in Ethiopia and Cambodia. Patterns of change in absolute and relative educational inequalities in NMR were similar to those of wealth-related NMR inequalities, although the size of educational inequalities tended to be slightly larger. INTERPRETATION Socioeconomic inequality in NMR seems to have decreased in the past two decades in most countries of low and middle income. However, a substantial survival advantage remains for babies born into wealthier households with a high educational level, which should be considered in global efforts to further reduce NMR. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Britt McKinnon
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
| | - Sam Harper
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Jay S Kaufman
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
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