The effect of Kenya's free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilities

Promoting childbirth in a rural health facility: A quasi-experimental study in western Kenya

BACKGROUND

The high maternal and neonatal mortality rate in sub-Saharan Africa could be reduced by using navigation by means of mobile devices to increase the number of women who choose to give birth in a health center (HC) with a skilled healthcare practitioner.

METHODS

A quasi-experimental design was used to test a midwife-delivered navigation by means of mobile phone. A total of 208 women were randomized to two groups (intervention and control). Women in the intervention group received up to three navigation calls from midwives. Women in the control group received usual antenatal education during prenatal visits. Data were collected using semistructured questionnaires. Childbirth location was determined through medical records.

RESULTS

Overall, 180 (87%) women gave birth in a HC with a 3% advantage for the intervention group. A total of 86% (88/102) of the control group gave birth in a HC versus 89% (92/103) for the intervention group (Χ2 = 0.44, p-value = 0.51), with an unadjusted odds ratio of 1.33 (95% CI: 0.57, 3.09). Among those with personal phones, 91% (138/152) had a birth in a HC versus 79% (42/53) in those without a personal phone (Χ2 = 4.89, p-value = 0.03).

CONCLUSIONS

The results of this study indicate that it is feasible to deliver phone-based navigation to support birth in a HC; personal phone ownership may be a factor in the success of this strategy.

Does a free maternity policy in Kenya work? Impact and cost-benefit consideration based on demographic health survey data

This paper evaluates the overall effect of the Kenyan free maternity policy (FMP) on the main outcomes (early neonatal and neonatal deaths) and intermediate outcomes (delivery through Caesarean Section (CS), skilled birth attendance (SBA), birth in a public hospital and low birth weight (LBW)) using the 2014 Demographic Health Survey. We applied the difference-in-difference (DID) approach to compare births (to the same mothers) happening before and after the start of the policy (June 2013) and a limited cost-benefit analysis (CBA) to assess the net social benefit of the FMP. The probabilities of birth resulting in early neonatal and neonatal mortality are significantly reduced by 17-21% and 19-20%, respectively, after the FMP introduction. The probability of birth happening through CS reduced by 1.7% after implementing the FMP, while that of LBW birth is increased by 3.7% though not statistically significant. SBA and birth in a public facility did not moderate the policy's effects on early neonatal mortality, neonatal mortality, and delivery through CS. They were not significant determinants of the policy effects on the outcomes. There is a significant causal impact of the FMP in reducing the probability of early neonatal and neonatal mortality, but not the delivery through CS. The FMP cost-to-benefit ratio was 21.22, and there were on average 4015 fewer neonatal deaths in 2013/2014 due to the FMP. The net benefits are higher than the costs; thus, there is a need to expand and sustainably fund the FMP to avert more neonatal deaths potentially.

Clinical readiness for essential maternal and child health services in Kenya: A cross-sectional survey

High rates of maternal and neonatal morbidity and mortality in Kenya may be influenced by provider training and knowledge in emergency obstetric and neonatal care in addition to availability of supplies necessary for this care. While post-abortion care is a key aspect of life-saving maternal health care, no validated questionnaires have been published on provider clinical knowledge in this arena. Our aim was to determine provider knowledge of maternal-child health (MCH) emergencies (post-abortion care, pre-eclampsia, postpartum hemorrhage, neonatal resuscitation) and determine factors associated with clinical knowledge. Our secondary aim was to pilot a case-based questionnaire on post-abortion care. We conducted a cross-sectional survey of providers at health facilities in western Kenya providing maternity services. Providers estimated facility capacity through perceived availability of both general and specialized supplies. Providers reported training on the MCH topics and completed case-based questions to assess clinical knowledge. Knowledge was compared between topics using a linear mixed model. Multivariable models identified variables associated with scores by topic. 132 providers at 37 facilities were interviewed. All facilities had access to general supplies at least sometime while specialized supplies were available less frequently. While only 56.8% of providers reported training on post-abortion care, more than 80% reported training on pre-eclampsia, postpartum hemorrhage, and neonatal resuscitation. Providers' clinical knowledge across all topics was low (mean score of 63.3%), with significant differences in scores by topic area. Despite less formal training in the subject area, providers answered 71.6% (SD 16.7%) questions correctly on post-abortion care. Gaps in supply availability, training, and clinical knowledge on MCH emergencies exist. Increasing training on MCH topics may decrease pregnancy and postpartum complications. Further, validated tools to assess knowledge in post-abortion care should be created, particularly in sub-Saharan Africa where legal restrictions on abortion services exist and many abortions are performed in unsafe settings.

Can a quality improvement intervention improve person-centred maternity care in Kenya?

Few evidence-based interventions exist to improve person-centred maternity care in low-resource settings. This study aimed to understand whether a quality improvement (QI) intervention could improve person-centred maternity care (PCMC) experiences for women delivering in public health facilities in Kenya. A pre-post design was used to examine changes in PCMC scores across three intervention and matched control facilities at baseline (n = 491) and endline (n = 677). A QI intervention, using the Model for Improvement, was implemented in three public health facilities in Nairobi and Kiambu Counties in Kenya. Difference-in-difference analyses using models that included main effects of both treatment group and survey round was conducted to understand the impact of the intervention on PCMC scores. Findings suggest that intervention facilities' average total PCMC score decreased by 5.3 points post-intervention compared to baseline (95% CI: -8.8, -1.9) and relative to control facilities, holding socio-demographic and facility variables constant. Additionally, the intervention was significantly associated with a 1.8-point decrease in clinical quality index pre-post-intervention (95% CI: -2.9, -0.7), decreased odds of provider visits, and less likelihood to plan to use postpartum family planning. While improving the quality of women's experiences during childbirth is a critical component to ensure comprehensive, high-quality maternity care experiences and outcomes, further research is required to understand which intervention methods may be most appropriate to improve PCMC in resource-constrained settings.

A realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes

BACKGROUND

Child and maternal health, a key marker of overall health system performance, is a policy priority area by the World Health Organization and the United Nations, including the Sustainable Development Goals. Previous realist work has linked child and maternal health outcomes to globalization, political tradition, and the welfare state. It is important to explore the role of other key policy-related factors. This paper presents a realist synthesis, categorising policy instruments according to the established NATO model, to develop an explanatory model of how policy instruments impact child and maternal health outcomes.

METHODS

A systematic literature search was conducted to identify studies assessing the relationships between policy instruments and child and maternal health outcomes. Data were analysed using a realist framework. The first stage of the realist analysis process was to generate micro-theoretical initial programme theories for use in the theory adjudication process. Proposed theories were then adjudicated iteratively to produce a set of final programme theories.

FINDINGS

From a total of 43,415 unique records, 632 records proceeded to full-text screening and 138 papers were included in the review. Evidence from 132 studies was available to address this research question. Studies were published from 1995 to 2021; 76% assessed a single country, and 81% analysed data at the ecological level. Eighty-eight initial candidate programme theories were generated. Following theory adjudication, five final programme theories were supported. According to the NATO model, these were related to treasure, organisation, authority-treasure, and treasure-organisation instrument types.

CONCLUSIONS

This paper presents a realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes from a large, systematically identified international body of evidence. Five final programme theories were supported, showing how policy instruments play an important yet context-dependent role in influencing child and maternal health outcomes.

Exploring the Adaptations of the Free Maternity Policy Implementation by Health Workers and County Officials in Kenya

BACKGROUND

In 2017, Kenya launched the free maternity policy (FMP) that aimed to provide all pregnant women access to maternal services in private, faith-based, and levels 3-6 public institutions. We explored the adaptive strategies health care workers (HCWs) and county officials used to bridge the implementation challenges and achieve the FMP objectives.

METHODS

We conducted an exploratory qualitative study using Lipsky's theoretical framework in 3 facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved in-depth interviews (n=21) with county officials, facility in-charges and HCWs, and key informants from national and development partner agencies. Data were audio-recorded, transcribed, and analyzed using a framework thematic approach.

RESULTS

The results show that HCWs and county officials applied several strategies that were critical in shaping the policymaking, working practice, and professionalism and ethical aspects of the FMP. Strategies of policymaking: hospitals employed additional staff, and the county developed bylaws to strengthen the flow of funds. Strategies of working practice: hospitals and HCWs enhanced patient referrals, and facilities enhanced communication. Strategies of professionalism and ethics: nurses registered and provided service to mothers, and facilities included employees in planning and budgeting. Maladaptations included facilities having leeway to provide FMP services to populations who were excluded from the policy but had to bear the costs. Some discharged mothers immediately after birth, even before offering the fully costed policy benefits, to avoid incurring additional costs.

CONCLUSIONS

The role of policy implementers and the built-in flexibility and agility in implementing the FMP could enhance service delivery, manage the administrative pressures of implementation, and provide mothers with personalized, responsive service. However, despite their benefits, some resulting unintended consequences may need interventions.

Costs and intermediate outcomes for the implementation of evidence-based practices of midwifery under a MIDWIZE framework in an urban health facility in Nairobi, Kenya

BACKGROUND

Three evidence-based midwife-led care practices: dynamic birth positions (DBP), immediate skin-to-skin contact (SSC) with zero separation between mother and newborn, and delayed cord clamping (DCC), were implemented in four sub-Saharan African countries after an internet-based capacity building program for midwifery leadership in quality improvement (QI). Knowledge on costs of this QI initiative can inform resource mobilization for scale up and sustainability.

METHODS

We estimated the costs and intermediate outcomes from the implementation of the three evidence-based practices under the midwife-led care (MIDWIZE) framework in a single facility in Kenya through a pre- and post-test implementation design. Daily observations for the level of practice on DBP, SSC and DCC was done at baseline for 1 week and continued during the 11 weeks of the training intervention. Three cost scenarios from the health facility perspective included: scenario 1; staff participation time costs ($515 USD), scenario 2; staff participation time costs plus hired trainer time costs, training material and logistical costs ($1318 USD) and scenario 3; staff participation time costs plus total program costs for the head trainer as the QI leader from the capacity building midwifery program ($8548 USD).

RESULTS

At baseline, the level of DBP and SSC practices per the guidelines was at 0 % while that of DCC was at 80 %. After 11 weeks, we observed an adoption of DBP practice of 36 % (N = 111 births), SSC practice of 79 % (N = 241 births), and no change in DCC practice. Major cost driver(s) were midwives' participation time costs (56 %) for scenario 1 (collaborative), trainers' material and logistic costs (55 %) in scenario 2(collaborative) and capacity building program costs for the trainer (QI lead) (94 %) in scenario 3 (programmatic). Costs per intermediate outcome were $2.3 USD per birth and $0.5 USD per birth adopting DBP and SSC respectively in Scenario 1; $6.0 USD per birth adopting DBP and $1.4 USD per birth adopting SSC in Scenario 2; $38.5 USD per birth adopting DBP and $8.8 USD per birth adopting SSC in scenario 3. The average hourly wage of the facility midwife was $4.7 USD.

CONCLUSION

Improving adoption of DBP and SSC practices can be done at reasonable facility costs under a collaborative MIDWIZE QI approach. In a programmatic approach, higher facility costs would be needed. This can inform resource mobilization for future QI in similar resource-constrained settings.

Prediction of postpartum hemorrhage (PPH) using machine learning algorithms in a Kenyan population

Introduction

Postpartum hemorrhage (PPH) is a significant cause of maternal mortality worldwide, particularly in low- and middle-income countries. It is essential to develop effective prediction models to identify women at risk of PPH and implement appropriate interventions to reduce maternal morbidity and mortality. This study aims to predict the occurrence of postpartum hemorrhage using machine learning models based on antenatal, intrapartum, and postnatal visit data obtained from the Kenya Antenatal and Postnatal Care Research Collective cohort.

Method

Four machine learning models - logistic regression, naïve Bayes, decision tree, and random forest - were constructed using 67% training data (1,056/1,576). The training data was further split into 67% for model building and 33% cross validation. Once the models are built, the remaining 33% (520/1,576) independent test data was used for external validation to confirm the models' performance. Models were fine-tuned using feature selection through extra tree classifier technique. Model performance was assessed using accuracy, sensitivity, and area under the curve (AUC) of the receiver operating characteristics (ROC) curve.

Result

The naïve Bayes model performed best with 0.95 accuracy, 0.97 specificity, and 0.76 AUC. Seven factors (anemia, limited prenatal care, hemoglobin concentrations, signs of pallor at intrapartum, intrapartum systolic blood pressure, intrapartum diastolic blood pressure, and intrapartum respiratory rate) were associated with PPH prediction in Kenyan population.

Discussion

This study demonstrates the potential of machine learning models in predicting PPH in the Kenyan population. Future studies with larger datasets and more PPH cases should be conducted to improve prediction performance of machine learning model. Such prediction algorithms would immensely help to construct a personalized obstetric path for each pregnant patient, improve resource allocation, and reduce maternal mortality and morbidity.

Association between energy consumption preferences and macroeconomic stability: an empirical analysis from developing Asia

The study examined the impact of macroeconomic performance and energy consumption on carbon emissions in Asian developing countries. Although, macroeconomic performance is a critical measure for the determination of development in societies. Thus, the examination of macroeconomic performance variables is a core issue for policymakers. The panel quantile regression model assesses the macroeconomic performance at several quantiles, ranging from 0.05 to 0.95. The effect of macroeconomic performance and energy consumption on CO₂ emissions has also been established. The findings indicate that CO₂ emissions and macroeconomic performance are negatively associated in all quantiles of macroeconomic performance. Though, fossil fuel energy and population growth positively influence carbon emissions in all low and medium quantiles but this relationship becomes weaker in the upper quantiles. In addition, hydroelectricity consumption and carbon emissions are negatively and significantly associated in the quantile ranges of low and higher. Based on the aforementioned results, the study suggests the formulation of such policies that can improve macroeconomic performance in the region and the promotion of hydel energy instead of fossil fuels to reduce environmental pollution in developing Asian countries. Moreover, the population control program, promotion of renewable energy, and dangers of fossil fuel consumption should be a part of public policies to control environmental issues by reducing carbon emissions at the regional level.

An assessment of out of pocket payments in public sector health facilities under the free maternal healthcare policy in Ghana

BACKGROUND

The free maternal healthcare policy was introduced in Ghana in 2008 under the national health insurance scheme as a social intervention to improve access to maternal health services. This study investigated the prevalence of out of pocket (OOP) payment among pregnant women with valid national health insurance who sought skilled delivery services at public sector health facilities in Ghana. The study also assessed the health system factors associated with OOP payment.

METHODS

We used data from the Ghana Maternal Health Survey (GMHS), which was conducted in 2017. The study comprised 7681 women who delivered at a public sector health facility and had valid national health insurance at the time of delivery. We used multivariable logistic regression analysis to assess factors associated with OOP payment, whiles accounting for clustering, stratification, and sampling weights.

RESULTS

The prevalence of OOP payment for skilled delivery services was 19.0%. After adjustment at multivariable level, hospital delivery services (adjusted Odds Ratio [aOR] = 1.23, 95% Confidence Interval [CI] = 1.00, 1.52), caesarean section (aOR = 1.73, 95% CI = 1.36, 2.20), and receiving intravenous infusion during delivery (aOR = 1.31, 95% CI = 1.08, 1.60) were associated with higher odds of OOP payment. Women who were discharged home 2 to 7 days after delivery had 19% lower odds of OOP payment compared to those who were discharged within 24 hours after delivery.

CONCLUSION

This study provides evidence of high prevalence of OOP payment among women who had skilled delivery services in public sector health facilities although such women had valid national health insurance. Government may need to institute measures to reduce OOP payment in public sector facilities especially at the hospitals and for women undergoing caesarean sections.

Out-of-pocket payments during childbirth in Kenya under the free maternity services: Perspectives of mothers, healthcare workers and county officials

Background: This study seeks to determine the extent of women's out-of-pocket (OOP) payments for delivery under the free maternity policy (FMP).  Methods: We conducted a convergent parallel mixed-methods study using quantitative and qualitative data collection. The study was set in three facilities (levels 3, 4, and 5) in Kiambu County, Kenya. The study involved exit interview (EI) surveys with mothers (n = 553) who utilised FMP delivery services and focus group discussions (FGDs) with mothers who returned for postnatal visits (6, 10, and 14 weeks). There were 21 in-depth interviews (IDIs) with county officials and healthcare workers (HCWs). Quantitative data were analysed using descriptive statistics, while qualitative data were audio-recorded, transcribed and analysed using thematic analysis.  Results: Despite the FMP being free on paper, mothers incurred OOP payments in practice. The overall mean OOP payments incurred by mothers who underwent normal delivery was 9.50 USD (SD 8.20 USD), and caesarean section (CS) was 10.88 USD (SD 15.16 USD). The main cost drivers were transport, lack of adequate supply and medications, lack of policy clarity by health workers, failure to notify the NHIF office of available clients, and ultrasound scan services. While the OOP payments were not deemed catastrophic, some women perceived it as a barrier to care as they ended up using savings or selling their assets to meet the costs. There were no patient characteristics associated with OOP payments.  Conclusions: OOP payments during childbirth in Kenya place a considerable economic burden on mothers and their households. There is need to promote awareness of the policy and provide a sustainable form of transport, especially during emergencies, through collaboration with partners. Prioritising the supply of required medication used in maternal services in the universal health care benefits package to which Kenyan citizens are entitled, or sustainably financing the FMP is crucial.

Quality of care for postpartum hemorrhage: A direct observation study in referral hospitals in Kenya

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Kenya. The aim of this study was to measure quality and timeliness of care for PPH in a sample of deliveries in referral hospitals in Kenya. We conducted direct observations of 907 vaginal deliveries in three Kenyan hospitals from October 2018 through February 2019, observing the care women received from admission for labor and delivery through hospital discharge. We identified cases of "suspected PPH", defined as cases in which providers indicated suspicion of and/or took an action to manage abnormal bleeding. We measured adherence to World Health Organization and Kenyan guidelines for PPH risk assessment, prevention, identification, and management and the timeliness of care in each domain. The rate of suspected PPH among the observed vaginal deliveries was 9% (95% Confidence Interval: 7% - 11%). Health care providers followed all guidelines for PPH risk assessment in 7% (5% - 10%) of observed deliveries and all guidelines for PPH prevention in 4% (3% - 6%) of observed deliveries. Lowest adherence was observed for taking vital signs and for timely administration of a prophylactic uterotonic. Providers did not follow guidelines for postpartum monitoring in any of the observed deliveries. When suspected PPH occurred, providers performed all recommended actions in 23% (6% - 40%) of cases. Many of the critical actions for suspected PPH were performed in a timely manner, but, in some cases, substantial delays were observed. In conclusion, we found significant gaps in the quality of risk assessment, prevention, identification, and management of PPH after vaginal deliveries in referral hospitals in Kenya. Efforts to reduce maternal morbidity and mortality from PPH should emphasize improvements in the quality of care, with a particular focus on postpartum monitoring and timely emergency response.

Readiness of health facilities to provide safe childbirth in Liberia: a cross-sectional analysis of population surveys, facility censuses and facility birth records

BACKGROUND

The provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women's homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births.

METHODS

We assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019-20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019.

RESULTS

The percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days.

CONCLUSIONS

The increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.

Neonatal Mortality and Associated Factors in the Neonatal Intensive Care Unit of Gadarif Hospital, Eastern Sudan

Background: Neonatal mortality is a serious public-health issue, especially in Sub-Saharan African countries. There are limited studies on neonatal mortality in Sudan; particularly, there are none on eastern Sudan. Therefore, this study aimed to determine the incidence, causes and associated factors for mortality among neonates admitted to the neonatal intensive care unit (NICU) of Gadarif Hospital, eastern Sudan. Methods: This retrospective study included 543 neonates admitted to the NICU of Gadarif Hospital, eastern Sudan, between January and August 2019. Data were obtained from the hospital record using a questionnaire composed of sociodemographic data, neonatal and maternal information and neonatal outcomes. Logistic regression analyses were performed and the adjusted odds ratio (AOR) and 95% confidence interval (CI) were calculated. Results: Of the 543 neonates, 50.8% were female, 46.4% were low birth weight (LBW), 43.5% were preterm babies and 27% were newborns admitted after caesarean delivery. The neonatal mortality before discharge was 21.9% (119/543) of live-born babies at the hospital. Preterm birth and its complications (48.7%), respiratory distress syndrome (33.6%), birth asphyxia (21.0%) and infection (9.0%) were the most common causes of neonatal mortality. In multivariable logistic regression analysis, preterm birth (AOR 2.10, 95% CI 1.17−3.74), LBW (AOR 2.47, 95% CI 1.38−4.41), low 5 min APGAR score (AOR 2.59, 95% CI 1.35−4.99) and length of hospital stay <3 days (AOR 5.49, 95% CI 3.44−8.77) were associated with neonatal mortality. Conclusion: There is an increased burden of neonatal mortality in the NICU of Gadarif Hospital, eastern Sudan, predominantly among preterm and LBW babies.

Implementation of the Afya conditional cash transfer intervention to retain women in the continuum of care: a mixed-methods process evaluation

OBJECTIVES

We report the results of a mixed-methods process evaluation that aimed to provide insight on the Afya conditional cash transfer (CCT) intervention fidelity and acceptability.

INTERVENTION, SETTING AND PARTICIPANTS

The Afya CCT intervention aimed to retain women in the continuum of maternal healthcare including antenatal care (ANC), delivery at facility and postnatal care (PNC) in Siaya County, Kenya. The cash transfers were delivered using an electronic card reader system at health facilities. It was evaluated in a trial that randomised 48 health facilities to intervention or control, and which found modest increases in attendance for ANC and immunisation appointments, but little effect on delivery at facility and PNC visits.

DESIGN

A mixed-methods process evaluation was conducted. We used the Afya electronic portal with recorded visits and payments, and reports on use of the electronic card reader system from each healthcare facility to assess fidelity. Focus group interviews with participants (N=5) and one-on-one interviews with participants (N=10) and healthcare staff (N=15) were conducted to assess the acceptability of the intervention. Data analyses were conducted using descriptive statistics and qualitative content analysis, as appropriate.

RESULTS

Delivery of the Afya CCT intervention was negatively affected by problems with the electronic card reader system and a decrease in adherence to its use over the intervention period by healthcare staff, resulting in low implementation fidelity. Acceptability of cash transfers in the form of mobile transfers was high for participants. Initially, the intervention was acceptable to healthcare staff, especially with respect to improvements in attaining facility targets for ANC visits. However, acceptability was negatively affected by significant delays linked to the card reader system.

CONCLUSIONS

The findings highlight operational challenges in delivering the Afya CCT intervention using the Afya electronic card reader system, and the need for greater technology readiness before further scale-up.

TRIAL REGISTRATION NUMBER

NCT03021070.

Understanding gender dynamics in mHealth interventions can enhance the sustainability of benefits of digital technology for maternal healthcare in rural Nigeria

Introduction

Nigeria faces enormous challenges to meet the growing demands for maternal healthcare. This has necessitated the need for digital technologies such as mobile health, to supplement existing maternal healthcare services. However, mobile health programs are tempered with gender blind spots that continue to push women and girls to the margins of society. Failure to address underlying gender inequalities and unintended consequences of mobile health programs limits its benefits and ultimately its sustainability. The importance of understanding existing gender dynamics in mobile health interventions for maternal health cannot be overstated.

Objective

This study explores the gender dimensions of Text4Life, a mobile health intervention for maternal healthcare in Edo State, Nigeria by capturing the unique perspectives of women who are the primary beneficiaries, their spouses who are all men, and community leaders who oversaw the implementation and delivery of the intervention.

Method

This qualitative study used criterion-based purposive sampling to recruit a total of 66 participants: 39 women, 25 men, and two ward development committee chairpersons. Data collection involved 8 age and sex desegregated focus group discussions with women and men and in-depth interviews with ward development committee chairpersons in English or Pidgin English. Translated and transcribed data were exported to NVivo 1.6 and data analysis followed a conventional approach to thematic analysis.

Results

Women had some of the necessary resources to participate in the Text4Life program, but they were generally insufficient thereby derailing their participation. The program enhanced women's status and decision-making capacity but with men positioned as heads of households and major decision-makers in maternal healthcare, there remained the possibility of deprioritizing maternal healthcare. Finally, while Text4Life prioritized women's safety in various contexts, it entrenched systems of power that allow men's control over women's reproductive lives.

Conclusion

As communities across sub-Saharan Africa continue to leverage the use of mHealth for maternal health, this study provides insights into the gender implications of women's use of mHealth technologies. While mHealth programs are helpful to women in many ways, they are not enough on their own to undo entrenched systems of power through which men control women's access to resources and their reproductive and social lives.

Cost of childbirth in Upper West Region of Ghana: a cross-sectional study

Background

Out-of-pocket payment (OOPP) is reported to be a major barrier to seeking maternal health care especially among the poor and can expose households to a risk of catastrophic expenditure and impoverishment.This study examined the OOPPs women made during childbirth in the Upper West region of Ghana.

Methods

We carried out a cross-sectional study and interviewed women who gave birth between January 2013 and December 2017. Data on socio-demographic characteristics, place of childbirth, as well as direct cost (medical and non-medical) were collected from respondents. The costs of childbirth were estimated from the patient perspective. Logistics regression was used to assess the factors associated with catastrophic payments cost. All analyses were done using STATA 16.0.

Results

Out of the 574 women interviewed, about 71% (406/574) reported OOPPs on their childbirth. The overall average direct medical and non-medical expenditure women made on childbirth was USD 7.5. Cost of drugs (USD 8.0) and informal payments (UDD 5.7) were the main cost drivers for medical and non-medical costs respectively. Women who were enrolled into the National Health Insurance Scheme (NHIS) spent a little less (USD 7.5) than the uninsured women (USD 7.9). Also, household childbirth expenditure increased from primary health facilities level (community-based health planning and services compound = USD7.2; health centre = USD 6.0) to secondary health facilities level (hospital = USD11.0); while home childbirth was USD 4.8. Overall, at a 10% threshold, 21% of the respondents incurred catastrophic health expenditure. Regression analysis showed that place of childbirth and household wealth were statistically significant factors associated with catastrophic payment.

Conclusions

The costs of childbirth were considerably high with a fifth of households spending more than one-tenth of their monthly income on childbirth and therefore faced the risk of catastrophic payments and impoverishment. Given the positive effect of NHIS on cost of childbirth, there is a need to intensify efforts to improve enrolment to reduce direct medical costs as well as sensitization and monitoring to reduce informal payment. Also, the identified factors that influence cost of childbirth should be considered in strategies to reduce cost of childbirth.

Does direct settlement of intra-province medical reimbursements improve financial protection among middle-aged and elderly population in China? Evidence based on CHARLS data

In low- and middle-income countries, social health insurance schemes are the main focus of efforts to achieve universal health coverage (UHC) by promoting access to health care and financial protection. Problems with financial protection in China are caused mainly by health insurance fragmentation and a rapid rise in medical expenditure. In this context, China implemented a policy of direct settlement of intra-provincial medical reimbursement in 2014. We evaluated the impact of the policy on financial protection with a population aged 45 and above based on the China Health and Retirement Longitudinal Study from 2011 to 2018. We estimated the policy effects using the difference-in-differences method, based on coarsened exact matching. We found that the policy significantly reduced the catastrophic health expenditures (CHEs) rate by approximately 10% in the population, whether middle-aged or elderly. Subgroup analyses indicated that middle-aged and elderly people living in western China and with lower household incomes received greater protection from the policy. The CHEs rate for the two age groups in western China was reduced by 16.26% and 20.12%, respectively. The CHEs rate was reduced by 24.51% and 17.32% for middle-aged individuals in the lowest and second household income quartiles, respectively, and by 21.31% for older adults in the second household income quartile. The new rural cooperative medical scheme exerted a smaller protective effect than urban medical insurance among the participants aged 60 and older. We found that in addition to optimizing health insurance schemes, more health care reform measures, such as adopting more efficient payment methods and rationalizing medical expenditures, should be combined to help reduce health inequities and accelerate progress toward achieving UHC and the Sustainable Development Goals.

Implementation Outcomes Assessment of a Digital Clinical Support Tool for Intrapartum Care in Rural Kenya: Observational Analysis

Background

iDeliver, a digital clinical support system for maternal and neonatal care, was developed to support quality of care improvements in Kenya.

Objective

Taking an implementation research approach, we evaluated the adoption and fidelity of iDeliver over time and assessed the feasibility of its use to provide routine Ministry of Health (MOH) reports.

Methods

We analyzed routinely collected data from iDeliver, which was implemented at the Transmara West Sub-County Hospital from December 2018 to September 2020. To evaluate its adoption, we assessed the proportion of actual facility deliveries that was recorded in iDeliver over time. We evaluated the fidelity of iDeliver use by studying the completeness of data entry by care providers during each stage of the labor and delivery workflow and whether the use reflected iDeliver’s envisioned function. We also examined the data completeness of the maternal and neonatal indicators prioritized by the Kenya MOH.

Results

A total of 1164 deliveries were registered in iDeliver, capturing 45.31% (1164/2569) of the facility’s deliveries over 22 months. This uptake of registration improved significantly over time by 6.7% (SE 2.1) on average in each quarter-year (P=.005), from 9.6% (15/157) in the fourth quarter of 2018 to 64% (235/367) in the third quarter of 2020. Across iDeliver’s workflow, the overall completion rate of all variables improved significantly by 2.9% (SE 0.4) on average in each quarter-year (P<.001), from 22.25% (257/1155) in the fourth quarter of 2018 to 49.21% (8905/18,095) in the third quarter of 2020. Data completion was highest for the discharge-labor summary stage (16,796/23,280, 72.15%) and lowest for the labor signs stage (848/5820, 14.57%). The completion rate of the key MOH indicators also improved significantly by 4.6% (SE 0.5) on average in each quarter-year (P<.001), from 27.1% (69/255) in the fourth quarter of 2018 to 83.75% (3346/3995) in the third quarter of 2020.

Conclusions

iDeliver’s adoption and data completeness improved significantly over time. The assessment of iDeliver’ use fidelity suggested that some features were more easily used because providers had time to enter data; however, there was low use during active childbirth, which is when providers are necessarily engaged with the woman and newborn. These insights on the adoption and fidelity of iDeliver use prompted the team to adapt the application to reflect the users’ culture of use and further improve the implementation of iDeliver.

Analyzing the impact of energy consumption, the democratic process, and government service delivery on life expectancy: evidence from a global sample

Life expectancy is one of the crucial criteria for determining the quality of life in today's societies. As such, the study of factors affecting life expectancy is a key issue for policymakers. This study aims to investigate the impact of energy consumption, the democratic process, and government service delivery on life expectancy in 100 countries during 2000-2018, using panel quantile regression. The impact of these factors on life expectancy has been estimated in quantiles of 0.05, 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, and 0.95. Also, the impact of GDP, CO₂ emission, and Gini coefficient variables has been explored as controlling variables on life expectancy. The results show that the impact of CO₂ emissions and the democratic process on life expectancy is negative in all quantiles, and the impact of GDP is negative in all quantiles except 0.95. Moreover, the relationship between hydroelectricity consumption and life expectancy in the 0.05, 0.1, 0.2, 0.8, and 0.9 quantiles is negative and significant. Accordingly, based on the results, the impact of petroleum and other liquids consumption, government service delivery, and Gini coefficient on life expectancy in all quantiles is positive and only the impact of the Gini coefficient on life expectancy in all quantiles is significant.

Term Newborn Care Recommendations Provided in a Kenyan Postnatal Ward: A Rapid, Focused Ethnographic Assessment

BACKGROUND

Neonatal mortality (death within 0-28 d of life) in Kenya is high despite strong evidence that newborn care recommendations save lives. In public healthcare facilities, nurses counsel caregivers on term newborn care, but knowledge about the content and quality of nurses' recommendations is limited.

PURPOSE

To describe the term newborn care recommendations provided at a tertiary-level, public referral hospital in Western Kenya, how they were provided, and related content taught at a university nursing school.

METHODS

A rapid, focused ethnographic assessment, guided by the culture care theory, using stratified purposive sampling yielded 240 hours of participant observation, 24 interviews, 34 relevant documents, and 268 pages of field notes. Data were organized using NVivo software and key findings identified using applied thematic analysis.

RESULTS

Themes reflect recommendations for exclusive breastfeeding, warmth, cord care, follow-up examinations, and immunizations, which were provided orally in Kiswahili and some on a written English discharge summary. Select danger sign recommendations were also provided orally, if needed. Some recommendations conflicted with other providers' guidance. More recommendations for maternal care were provided than for newborn care.

IMPLICATIONS FOR PRACTICE

There is need for improved consistency in content and provision of recommendations before discharge. Findings should be used to inform teaching, clinical, and administrative processes to address practice competency and improve nursing care quality.

IMPLICATIONS FOR RESEARCH

Larger studies are needed to determine whether evidence-based recommendations are provided consistently across facilities and other populations, such as community-born and premature newborns, who also experience high rates of neonatal mortality in Kenya.

Neurological impairment and disability in children in rural Kenya

AIM

To investigate geographical change over time in the burden of neurological impairments in school-aged children in a demographic surveillance area.

METHOD

We investigated changes in neurological impairment prevalence in five domains (epilepsy and cognitive, hearing, vision, and motor impairments) using similar two-phase surveys conducted in 2001 (n=10 218) and 2015 (n=11 223) and determined changes in location-level prevalence, geographical clustering, and significant risk factors for children aged 6 to 9 years (mean 7y 6mo, SD 1y) of whom 50.4% were males. Admission trends for preterm birth, low birthweight (LBW), and encephalopathy were determined using admission data to a local hospital.

RESULTS

Overall prevalence for any neurological impairment decreased from 61 per 1000 (95% confidence interval [CI] 48.0-74.0) in 2001 to 44.7 per 1000 (95% CI 40.9-48.6) in 2015 (p<0.001). There was little evidence of geographical variation in the prevalence of neurological impairments in either survey. The association between neurological impairments and some risk factors changed significantly with year of survey; for example, the increased association of adverse perinatal events with hearing impairments (exponentiated coefficient for the interaction=5.94, p=0.03). Annual admission rates with preterm birth (rate ratio 1.08, range 1.07-1.09), LBW (rate ratio 1.08, range 1.06-1.10), and encephalopathy (rate ratio 1.08, range 1.06-1.09) significantly increased between 2005 and 2016 (p<0.001).

INTERPRETATION

There was a significant decline in the prevalence of neurological impairments and differential changes in the associations of some risk factors with neurological impairments over the study period. Limited geographical variation suggests that similar interventions are appropriate across the defined area.

Perspectives of stakeholders of the free maternity services for mothers in western Kenya: lessons for universal health coverage

Background

The strategic aim of universal health coverage (UHC) is to ensure that everyone can use health services they need without risk of financial hardship. Linda Mama (Taking care of the mother) initiative focuses on the most vulnerable women, newborns and infants in offering free health services. Financial risk protection is one element in the package of measures that provides overall social protection, as well as protection against severe financial difficulties in the event of pregnancy, childbirth, neonatal and perinatal health care for mothers and their children.

Purpose

The aim of this study was to find out the extent of awareness, and involvement among managers, service providers and consumers of Linda mama supported services and benefits of the initiative from the perspectives of consumers, providers and managers.

Methods

We carried out cross sectional study in four sub counties in western Kenya: Rachuonyo East, Nyando, Nyakach, and Alego Usonga. We used qualitative techniques to collect data from purposively selected Linda Mama project implementors, managers, service providers and service consumers. We used key informant interview guides to collect data from a total of thirty six managers, nine from each Sub -County and focus group discussion tools to collect data from sixteen groups of service consumers attending either antenatal or post-natal clinics, four from each sub county, selecting two groups from antenatal and two from postnatal clinics in each sub county. Data analysis was based on thematic content analysis.

Findings

Managers and service providers were well aware of the initiative and were involved in it. Participation in Linda Mama, either in providing or using, seemed to be more prominent among managers and service providers. Routine household visits by community health volunteers to sensitize mothers and community engagement was core to the initiative. The managers and providers of services displayed profound awareness of how requiring identification cards and telephone numbers had the potential to undermine equity by excluding those in greater need of care such as under-age pregnant adolescents. Maternity and mother child health services improved as a result of the funds received by health facilities. Linda Mama reimbursements helped to purchase drug and reduced workload in the facility by hiring extra hands.

Conclusion

The initiative seems to have influenced attitudes on health facility delivery through: Partnership among key stakeholders and highlighting the need for enhanced partnership with the communities. It enhanced the capacity of health facilities to deliver high quality comprehensive, essential care package and easing economic burden.

Trust, Care Avoidance, and Care Experiences among Kenyan Women Who Delivered during the COVID-19 Pandemic

We explore how the COVID-19 pandemic was associated with avoidance of, and challenges with, antenatal, childbirth and postpartum care among women in Kiambu and Nairobi counties, Kenya; and whether this was associated with a report of declined trust in the health system due to the pandemic. Women who delivered between March and November 2020 were invited to participate in a phone survey about their care experiences (n = 1122 respondents). We explored associations between reduced trust and care avoidance, delays and challenges with healthcare seeking, using logistic regression models adjusted for women's characteristics. Approximately half of respondents said their trust in the health care system had declined due to COVID-19 (52.7%, n = 591). Declined trust was associated with higher likelihood of reporting barriers accessing antenatal care (aOR 1.59 [95% CI 1.24, 2.05]), avoiding care for oneself (aOR 2.26 [95% CI 1.59, 3.22]) and for one's infant (aOR 1.77 [95% CI 1.11, 2.83]), and of feeling unsafe accessing care (aOR 1.52 [95% CI 1.19, 1.93]). Since March 2020, emergency services, routine care and immunizations were avoided most often. Primary reported reasons for avoiding care and challenges accessing care were financial barriers and problems accessing the facility. Declined trust in the health care system due to COVID-19 may have affected health care-seeking for women and their children in Kenya, which could have important implications for their health and well-being. Programs and policies should consider targeted special "catch-up" strategies that include trust-building messages and actions for women who deliver during emergencies like the COVID-19 pandemic.

Knowledge, Attitudes, and Preparedness for Managing Pregnant and Postpartum Women with COVID-19 Among Nurse-Midwives in Kenya

Introduction

Globally, maternal morbidity and mortality have increased during the COVID-19 pandemic. Given the high burden of maternal and neonatal mortality in Kenya prior to COVID-19, front line health workers, including nurse-midwives, must be competent to ensure continued quality maternal services. Knowledge and awareness of COVID-19 transmission influence nurse-midwives risk perception and ability to implement prevention strategies.

Objective

We examined nurse-midwives' knowledge, attitudes, and preparedness in managing pregnant and postpartum women with COVID-19 in Kenya.

Methods

A cross-sectional online survey was conducted among 118 nurse-midwives between July 2020 and November 2020. A 31-item survey comprising 15 knowledge, 11 attitude, and five preparedness questions was administered using SurveyMonkey. A link to the survey was distributed among nurse-midwives via email. Multiple logistic regression analysis was used to assess associations between the variables. A p-value <.05 was considered statistically significant.

Results

Eighty-five participants were included in the final analysis (response rate 72%). Most participants were female (n = 69, 81.2%), 52.9% (n = 45) worked in labor wards, and 57.6% (n = 49) worked in rural hospitals. Overall, 71% (n = 57) of participants had sufficient knowledge about managing COVID-19 in pregnant and postpartum women. However, only 63% were willing to receive COVID-19 vaccination. Nurse-midwives working in urban areas were 3.7 times more likely to have positive attitudes than those in rural areas (odds ratio 3.724, 95% confidence interval 1.042-13.31; p = .043).

Conclusion

Nurse-midwives' responses to the Kenyan government's COVID-19 guidelines for managing and caring for pregnant women were inconsistent. Continued professional development for nurse-midwives is important to ensure they stay abreast of evolving COVID-19 guidelines for maternal health. Our findings also suggest vaccine hesitancy may be a hurdle for ongoing COVID-19 vaccination.

Determinants of continued maternal care seeking during pregnancy, birth and postnatal and associated neonatal survival outcomes in Kenya and Uganda: analysis of cross-sectional, demographic and health surveys data

OBJECTIVES

To examine how maternal and sociodemographic factors determine continued care-seeking behaviour from pregnancy to postnatal period in Kenya and Uganda and to determine associated neonatal survival outcomes.

DESIGN

A population-based analysis of cross-sectional data using multinomial and binary logistic regressions.

SETTING

Countrywide, Kenya and Uganda.

PARTICIPANTS

Most recent live births of 24 502 mothers within 1-59 months prior to the 2014-2016 Demographic and Health Surveys.

OUTCOMES

Care-seeking continuum and neonatal mortality.

RESULTS

Overall, 57% of the mothers had four or more antenatal care (ANC) contacts, of which 73% and 41% had facility births and postnatal care (PNC), respectively. Maternal/paternal education versus no education was associated with continued care seeking in majority of care-seeking classes; relative risk ratios (RRRs) ranged from 2.1 to 8.0 (95% CI 1.1 to 16.3). Similarly, exposure to mass media was generally associated with continued care seekin; RRRs ranged from 1.8 to 3.2 (95% CI 1.2 to 5.4). Care-seeking tendency reduced if a husband made major maternal care-seeking decisions. Transportation problems and living in rural versus urban were largely associated with lower continued care use; RRR ranged from 0.4 to 0.7 (95% CI 0.3 to 0.9). The two lowest care-seeking categories with no ANC and no PNC indicated the highest odds for neonatal mortality (adjusted OR 4.2, 95% CI 1.6 to 10.9). 23% neonatal deaths were attributable to inadequate maternal care attendance.

CONCLUSION

Strategies such as mobile health specifically for promoting continued maternal care use up to postnatal could be integrated in the existing structures. Another strategy would be to develop and employ a brief standard questionnaire to determine a mother's continued care-seeking level during the first ANC visit and to use the information to close the care-seeking gaps. Strengthening the community health workers system to be an integral part of promoting continued care seeking could enhance care seeking as a stand-alone strategy or as a component of aforementioned suggested strategies.

Cost of maternal near miss and potentially life-threatening conditions, Kenya

OBJECTIVE

To estimate the direct costs of treating women with maternal near misses and potentially life-threatening conditions in Kenya and the factors associated with catastrophic health expenditure for these women and their households.

METHODS

As part of a prospective, nationally representative study of all women with near misses during pregnancy and childbirth or within 42 days of delivery or termination of pregnancy, we compared the cost of treating maternal near-miss cases admitted to referral facilities with that of women with potentially life-threatening conditions. We used logistic regression analysis to assess clinical, demographic and household factors associated with catastrophic health expenditure.

FINDINGS

Of 3025 women, 1180 (39.0%) had maternal near misses and 1845 (61.0%) had potentially life-threatening conditions. The median cost of treating maternal near misses was 7135 Kenyan shillings (71 United States dollars, US$) compared with 2690 Kenyan shillings (US$ 27) for potentially life-threatening conditions. Of the women who made out-of-pocket payments, 26.4% (122/462) experienced catastrophic expenditure. The highest median costs for treatment of near misses were in Nairobi and Central region (22 220 Kenyan shillings; US$ 222). Women with ectopic pregnancy complications and pregnancy-related infections had the highest median costs of treatment, at 7800 Kenyan shillings (US$ 78) and 3000 Kenyan shillings (US$ 30), respectively. Pregnancy-related infections, abortion, ectopic pregnancy, and treatment in secondary and tertiary facilities were significantly associated with catastrophic expenditure.

CONCLUSION

The cost of treating maternal near misses is high and leads to catastrophic spending through out-of-pocket payments. Universal health coverage needs to be expanded to guarantee financial protection for vulnerable women.

Understanding Women's Choices: How Women's Perceptions of Quality of Care Influences Place of Delivery in a Rural Sub-County in Kenya. A Qualitative Study

BACKGROUND

Maternal mortality is still unacceptably high in Kenya. The Kenyan Government introduced a free maternity service to overcome financial barriers to access. This policy led to a substantial increase in women's delivery options. This increase in coverage might have led to a reduction in quality of care. This study explores women's perceptions of quality of delivery services in the context of the free policy and how the perceptions lead to the choice of a place for delivery.

METHODS

Our study site was Naivasha sub-County in Kenya, a rural context, whose geography encompasses pastoralists, rural agrarian, and high population density informal settlements near flower farms. Women from this area are from the lowest wealth quintile in Kenya. We conducted a qualitative study to explore the women's perceptions of quality of care based on their experiences during maternity care. The participants were women of reproductive age (18-49 years) attending antenatal care clinics at six health facilities in the sub-county. Six focus group discussions with 55 respondents were used. For inclusion, the women needed to have delivered a baby within the six months preceding the study. Interviews were recorded with consent, translated and transcribed. The interviews were analyzed using a thematic content approach.

RESULTS

Four broad themes that determined the choice of health facility for delivery were identified: women's perceptions of clinical quality of care; the cost of delivery; distance to the health facility and management of primary health facilities. An unexpected theme was the presence of home deliveries amongst pastoralist women. These findings suggest that in this setting both process and structural dimensions of quality of care and financial and physical accessibility influence women's choices for place of delivery.

CONCLUSION

This study expands our understanding of how women make choices regarding place of delivery. Understanding women's perceptions can provide useful insights to policy makers and facility managers on providing high quality patient centered maternity care necessary to sustain the increased utilization of maternity services at health facilities under the free maternity policy and further reductions in maternal mortality.

Assessment of malaria infection among pregnant women and children below five years of age attending rural health facilities of Kenya: A cross-sectional survey in two counties of Kenya

Background

In Kenya, health service delivery and access to health care remains a challenge for vulnerable populations, particularly pregnant women and children below five years. The aim of this study, therefore, was to determine the positivity rate of Plasmodium falciparum parasites in pregnant women and children below five years of age seeking healthcare services at the rural health facilities of Kwale and Siaya counties as well as their access and uptake of malaria control integrated services, like antenatal care (ANC), offered in those facilities.

Methods

Cluster random sampling method was used to select pregnant women and children below five years receiving maternal and child health services using two cross-sectional surveys conducted in eleven rural health facilities in two malaria endemic counties in western and coastal regions of Kenya. Each consenting participant provided single blood sample for determining malaria parasitaemia using microscopy and polymerase chain reaction (PCR) techniques.

Results

Using PCR technique, the overall malaria positivity rate was 27.9% (95%CI: 20.9–37.2), and was 34.1% (95%CI: 27.1–42.9) and 22.0% (95%CI: 13.3–36.3) in children below five years and pregnant women respectively. Additionally, using microscopy, the overall positivity rate was 39.0% (95%CI: 29.5–51.6), and was 50.4% (95%CI: 39.4–64.5) and 30.6% (95%CI: 22.4–41.7) in children below five years and pregnant women respectively. Siaya County in western Kenya showed higher malaria positivity rates for both children (36.4% and 54.9%) and pregnant women (27.8% and 38.5%) using both PCR and microscopy diagnosis techniques respectively, compared to Kwale County that showed positivity rates of 27.2% and 37.9% for children and 5.2% and 8.6% for pregnant women similarly using both PCR and microscopy techniques respectively. Pregnant women presenting themselves for their first ANC visit were up to five times at risk of malaria infection, (adjusted odds ratio = 5.40, 95%CI: 0.96–30.50, p = 0.046).

Conclusion

Despite evidence of ANC attendance and administration of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) dosage during these visits, malaria positivity rate was still high among pregnant women and children below five years in these two rural counties. These findings are important to the Kenyan National Malaria Control Programme and will help contribute to improvement of policies on integration of malaria control approaches in rural health facilities.

The Effects of Antenatal Depression and Women's Perception of Having Poor Health on Maternal Health Service Utilization in Northern Ghana

OBJECTIVES

To examine the effects of antenatal depression and women's perceived health during the antenatal period on maternal health service utilization in rural northern Ghana; including how the effect of antenatal depression on service use might be modified by women's perceived health.

METHODS

Probable antenatal depression was assessed using the Patient Health Questionnaire (PHQ-9). Linear regression was used for the outcome of number of antenatal care (ANC) visits, and logistic regression was used for the outcomes of facility delivery, postnatal care (PNC) within 7 days and completion of continuum of care. Continuum of care was defined as having had four or more ANC visits, delivered at a health facility and had PNC visit within 7 days.

RESULTS

Antenatal depression had very small or no association with maternal health service utilization. Women with self-perceived fair or poor health were significantly less likely to use PNC within 7 days and less likely to complete the continuum of care. As for effect modification, we found that for women with probable moderate or severe antenatal depression (a score of 10 or greater), those with perceived fair or poor health used fewer ANC visits and were less likely to use PNC within 7 days than those with perceived excellent, very good or good health.

CONCLUSIONS

Women experiencing moderate or severe antenatal depression and/or who self-perceive as having poor health should be identified and targeted for additional support to access and utilize maternal health services.

Stakeholders perceptions regarding implementing maternal and newborn health care programs in Rwanda

BACKGROUND

While maternal and newborn deaths has been decreasing since 2008 in Rwanda, there is room for improvement to meet its sustainable development goals. The maternal and newborn health care program needs to be monitored to ensure its effective implementation. This study therefore aimed to explore stakeholder's perceptions of the Rwandan maternal and newborn health care program to identify areas for improvement.

METHODS

The convergent, parallel, mixed method study used quantitative and qualitative data in a single phase. The quantitative data was obtained from 79 health care workers, ranging from maternal community health care workers to program supervisors. The 10 areas of the Project Implementation Profile (PIP) instrument checklist with a five-point Likert scale were used to indicate their perceptions (strongly disagree to strongly agree). The qualitative interviews of five nurse managers used a manifest inductive content analysis, directed approach that entailed using existing theory and prior research to develop the initial coding scheme before starting data analyse.

RESULTS

There was disagreement about the level of top management support, human resources was regarded as an area of concern, with 18.7% (n = 14/79) indicating that they did not agree that this was adequately provided for; urgent solutions for unexpected problems was regarded as an areas of concern by 46.8% (n = 36/79). Top management support weakness were inadequate support training, materials, money for home visits, supervision and leaderships, and training of newly recruited maternity health care workers. For human resources, there were insufficient trained staff to take care of mothers and newborns due to the shortages of health providers. The management of unexpected problems was also an area of concerns and related to getting patients to health facilities during pregnancy emergencies and the lack of qualified birth attendants at health facilities.

CONCLUSION

The study identified three areas for improvement: top management support, human resources and urgent solutions for unexpected problems, as they may be affecting the provision of maternal and newborn health care program services. Using the PIP enable managers to improve the country's maternal and newborn health care program, and to provide ongoing monitoring and evaluation of with respect to the desired outcomes of reducing maternal and neonatal mortality.

"We have either obsolete knowledge, obsolete equipment or obsolete skills": policy-makers and clinical managers' views on maternal health delivery in rural Nigeria

OBJECTIVE

The objective of this paper is to explore policy-makers and clinical managers' views on maternal health service delivery in rural Nigeria.

DESIGN

This is a qualitative study using key informant interviews. Participants' responses were audio recorded and reflective field notes supplemented the transcripts. Data were further analysed with a deductive approach whereby themes were organised based on existing literature and theories on service delivery.

SETTING

The study was set in Esan South East (ESE) and Etsako East (ETE), two mainly rural local government areas of Edo state, Nigeria.

PARTICIPANTS

The study participants consisted of 13 key informants who are policy-makers and clinical managers in ESE and ETE in Edo state. Key informants were chosen using a purposeful criterion sampling technique whereby participants were identified because they meet or exceed a specific criterion related to the subject matter.

RESULTS

Respondents generally depicted maternal care services in primary healthcare centres as inaccessible due to undue barriers of cost and geographic location but deemed it acceptable to women. Respondents' notion of quality of service delivery encompassed factors such as patient-provider relationships, hygienic conditions of primary healthcare centres, availability of skilled healthcare staff and infrastructural constraints.

CONCLUSION

This study revealed that while some key aspects of service delivery are inadequate in rural primary healthcare centres, there are promising policy reforms underway to address some of the issues. It is important that health officials advocate for strong policies and implementation strategies.

Urban-rural disparities in institutional delivery among women in East Africa: A decomposition analysis

BACKGROUND

Though institutional delivery plays a significant role in maternal and child health, there is substantial evidence that the majority of rural women have lower health facility delivery than urban women. So, identifying the drivers of these disparities will help policy-makers and programmers with the reduction of maternal and child death.

METHODS

The study used the data on a nationwide representative sample from the most recent rounds of the Demographic and Health Survey (DHS) of four East African countries. A Blinder-Oaxaca decomposition analysis and its extensions was conducted to see the urban-rural differences in institutional delivery into two components: one that is explained by residence difference in the level of the determinants (covariate effects), and the other components was explained by differences in the effect of the covariates on the outcome (coefficient effects).

RESULTS

The findings showed that institutional delivery rates were 21.00% in Ethiopia, 62.61% in Kenya, 65.29% in Tanzania and 74.64% in Uganda. The urban-rural difference in institutional delivery was higher in the case of Ethiopia (61%), Kenya (32%) and Tanzania (30.3%), while the gap was relatively lower in the case of Uganda (19.2%). Findings of the Blinder-Oaxaca decomposition and its extension showed that the covariate effect was dominant in all study countries. The results were robust to the different decomposition weighting schemes. The frequency of antenatal care, wealth and parity inequality between urban and rural households explains most of the institutional delivery gap.

CONCLUSIONS

The urban-rural institutional delivery disparities were high in study countries. By identifying the underlying factors behind the urban-rural institutional birth disparities, the findings of this study help in designing effective intervention measures targeted at reducing residential inequalities and improving population health outcomes. Future interventions to encourage institutional deliveries to rural women of these countries should therefore emphasize increasing rural women's income, access to health care facilities to increase the frequency of antenatal care utilization.

Impact of free maternity policies in Kenya: an interrupted time-series analysis

BACKGROUND

User fees have been reported to limit access to services and increase inequities. As a result, Kenya introduced a free maternity policy in all public facilities in 2013. Subsequently in 2017, the policy was revised to the Linda Mama programme to expand access to private sector, expand the benefit package and change its management.

METHODS

An interrupted time-series analysis on facility deliveries, antenatal care (ANC) and postnatal care (PNC) visits data between 2012 and 2019 was used to determine the effect of the two free maternity policies. These data were from 5419 public and 305 private and faith-based facilities across all counties, with data sourced from the health information system. A segmented negative binomial regression with seasonality accounted for, was used to determine the level (immediate) effect and trend (month-on-month) effect of the policies.

RESULTS

The 2013 free-maternity policy led to a 19.6% and 28.9% level increase in normal deliveries and caesarean sections, respectively, in public facilities. There was also a 1.4% trend decrease in caesarean sections in public facilities. A level decrease followed by a trend increase in PNC visits was reported in public facilities. For private and faith-based facilities, there was a level decrease in caesarean sections and ANC visits followed by a trend increase in caeserean sections following the 2013 policy.Furthermore, the 2017 Linda Mama programme showed a level decrease then a trend increase in PNC visits and a 1.1% trend decrease in caesarean sections in public facilities. In private and faith-based facilities, there was a reported level decrease in normal deliveries and caesarean sections and a trend increase in caesarean sections.

CONCLUSION

The free maternity policies show mixed effects in increasing access to maternal health services. Emphasis on other accessibility barriers and service delivery challenges alongside user fee removal policies should be addressed to realise maximum benefits in maternal health utilisation.

The benefits of an integrated social medical insurance for health services utilization in rural China: evidence from the China health and retirement longitudinal study

Background

Improving health equity is a fundamental goal for establishing social health insurance. This article evaluated the benefits of the Integration of Social Medical Insurance (ISMI) policy for health services utilization in rural China.

Methods

Using the China Health and Retirement Longitudinal study (2011‒2018), we estimated the changes in rates and equity in health services utilization by a generalized linear mixed model, concentration curves, concentration indices, and a horizontal inequity index before and after the introduction of the ISMI policy.

Results

For the changes in rates, the generalized linear mixed model showed that the rate of inpatient health services utilization (IHSU) nearly doubled after the introduction of the ISMI policy (8.78 % vs. 16.58 %), while the rate of outpatient health services utilization (OHSU) decreased (20.25 % vs. 16.35 %) after the implementation of the policy. For the changes in inequity, the concentration index of OHSU decreased significantly from − 0.0636 (95 % CL: −0.0846, − 0.0430) before the policy to − 0.0457 (95 % CL: −0.0684, − 0.0229) after it. In addition, the horizontal inequity index decreased from − 0.0284 before the implementation of the policy to − 0.0171 after it, indicating that the inequity of OHSU was further reduced. The concentration index of IHSU increased significantly from − 0.0532 (95 % CL: −0.0868, − 0.0196) before the policy was implemented to − 0.1105 (95 % CL: −0.1333, − 0.0876) afterwards; the horizontal inequity index of IHSU increased from − 0.0066 before policy implementation to − 0.0595 afterwards, indicating that more low-income participants utilized inpatient services after the policy came into effect.

Conclusions

The ISMI policy had a positive effect on improving the rate of IHSU but not on the rate of OHSU. This is in line with this policy’s original intention of focusing on inpatient service rather than outpatients to achieve its principal goal of preventing catastrophic health expenditure. The ISMI policy had a positive effect on reducing the inequity in OHSU but a negative effect on the decrease in inequity in IHSU. Further research is needed to verify this change. This research on the effects of integration policy implementation may be useful to policy makers and has important policy implications for other developing countries facing similar challenges on the road to universal health coverage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01457-8.

Improving maternal, newborn and child health outcomes through a community-based women's health education program: a cluster randomised controlled trial in western Kenya

Introduction

Community-based women’s health education groups may improve maternal, newborn and child health (MNCH); however, evidence from sub-Saharan Africa is lacking. Chamas for Change (Chamas) is a community health volunteer (CHV)-led, group-based health education programme for pregnant and postpartum women in western Kenya. We evaluated Chamas’ effect on facility-based deliveries and other MNCH outcomes.

Methods

We conducted a cluster randomised controlled trial involving 74 community health units in Trans Nzoia County. We included pregnant women who presented to health facilities for their first antenatal care visits by 32 weeks gestation. We randomised clusters 1:1 without stratification or matching; we masked data collectors, investigators and analysts to allocation. Intervention clusters were invited to bimonthly, group-based, CHV-led health lessons (Chamas); control clusters had monthly, individual CHV home visits (standard of care). The primary outcome was facility-based delivery at 12-month follow-up. We conducted an intention-to-treat approach with multilevel logistic regression models using individual-level data.

Results

Between 27 November 2017 and 8 March 2018, we enrolled 1920 participants from 37 intervention and 37 control clusters. A total of 1550 (80.7%) participants completed the study with 822 (82.5%) and 728 (78.8%) in the intervention and control arms, respectively. Facility-based deliveries improved in the intervention arm (80.9% vs 73.0%; risk difference (RD) 7.4%, 95% CI 3.0 to 12.5, OR=1.58, 95% CI 0.97 to 2.55, p=0.057). Chamas participants also demonstrated higher rates of 48 hours postpartum visits (RD 15.3%, 95% CI 12.0 to 19.6), exclusive breastfeeding (RD 11.9%, 95% CI 7.2 to 16.9), contraceptive adoption (RD 7.2%, 95% CI 2.6 to 12.9) and infant immunisation completion (RD 15.6%, 95% CI 11.5 to 20.9).

Conclusion

Chamas participation was associated with significantly improved MNCH outcomes compared with the standard of care. This trial contributes robust data from sub-Saharan Africa to support community-based, women’s health education groups for MNCH in resource-limited settings.

Trial registration number

NCT03187873.

[Improving provision of mother-and-child care in Chad at the community level: A quasi-experimental study]

BACKGROUND

Chad is among the countries with the highest maternal and infant mortality rates in the world. An initiative aimed at improving mother-and-child health services was implemented from 2016 to 2019 in three rural health districts in southern Chad, with strong community input, while concomitantly increasing the supply and demand for care. The objective of this study is to evaluate the effects of this program on health service use.

METHODS

Interrupted time-series analyses with a control group was used to measure the effects of the intervention by applying a quasi-experimental approach. Monthly attendance data were collected from the registries of the 18 health centres that participated in the program and 18 centres that did not participate (control group), before (18 months) and after (24 months) the start of implementation.

RESULTS

On average, there were 10.98 (95% CI: 6.57-15.39, P<0.001) additional paediatric visits and 0.68 additional deliveries (95% CI: 0.42-0.95, P<0.001) each month in the participation group compared to the control group. Community involvement decisively contributed to the change.

CONCLUSION

During the 24 months of implementation, the initiative significantly increased the use of essential mother-and-child health services in Chad. This study highlights the benefits of a strong partnership with communities trained and involved in health system activities, with the objective of achieving universal health coverage.

Men's and women's knowledge of danger signs relevant to postnatal and neonatal care-seeking: A cross sectional study from Bungoma County, Kenya

Background

Neonatal and maternal mortality rates remain high in Kenya. Knowledge of neonatal danger signs may reduce delay in deciding to seek care. Evidence is emerging on the influential role of male partners in improving maternal and newborn health. This study analysed the factors that determine men’s and women’s knowledge and practices in postnatal and neonatal care-seeking, in order to inform design of future interventions.

Methods

A quantitative, cross-sectional study was undertaken in Bungoma County, Kenya. Women who had recently given birth (n = 348) and men whose wives had recently given birth (n = 82) completed questionnaires on knowledge and care-seeking practices relating to the postnatal period. Univariate and multivariate logistic regression analyses were performed to investigate associations with key maternal and newborn health outcomes.

Results

51.2% of women and 50.0% of men knew at least one neonatal danger sign, however women knew more individual danger signs than men. In the univariate model, women’s knowledge of a least one neonatal danger sign was associated with attending antenatal care ≥4 times (OR 4.46, 95%CI 2.73–7.29, p<0.001), facility birth (OR 3.26, 95%CI 1.89–5.72, p<0.001), and having a male partner accompany them to antenatal care (OR 3.34, 95%CI 1.35–8.27, p = 0.009). Higher monthly household income (≥10,000KSh, approximately US$100) was associated with facility delivery (AOR 11.99, 95%CI 1.59–90.40, p = 0.009).

Conclusion

Knowledge of neonatal danger signs was low, however there was an association between knowledge of danger signs and increased healthcare service use, including male partner involvement in antenatal care. Future interventions should consider the extra costs of facility delivery and the barriers to men participating in antenatal and postnatal care.

The impact of child health interventions and risk factors on child survival in Kenya, 1993-2014: a Bayesian spatio-temporal analysis with counterfactual scenarios

BACKGROUND

During the millennium development goals period, reduction in under-five mortality (U5M) and increases in child health intervention coverage were characterised by sub-national disparities and inequities across Kenya. The contribution of changing risk factors and intervention coverage on the sub-national changes in U5M remains poorly defined.

METHODS

Sub-national county-level data on U5M and 43 factors known to be associated with U5M spanning 1993 and 2014 were assembled. Using a Bayesian ecological mixed-effects regression model, the relationships between U5M and significant intervention and infection risk ecological factors were quantified across 47 sub-national counties. The coefficients generated were used within a counterfactual framework to estimate U5M and under-five deaths averted (U5-DA) for every county and year (1993-2014) associated with changes in the coverage of interventions and disease infection prevalence relative to 1993.

RESULTS

Nationally, the stagnation and increase in U5M in the 1990s were associated with rising human immunodeficiency virus (HIV) prevalence and reduced maternal autonomy while improvements after 2006 were associated with a decline in the prevalence of HIV and malaria, increase in access to better sanitation, fever treatment-seeking rates and maternal autonomy. Reduced stunting and increased coverage of early breastfeeding and institutional deliveries were associated with a smaller number of U5-DA compared to other factors while a reduction in high parity and fully immunised children were associated with under-five lives lost. Most of the U5-DA occurred after 2006 and varied spatially across counties. The highest number of U5-DA was recorded in western and coastal Kenya while northern Kenya recorded a lower number of U5-DA than western. Central Kenya had the lowest U5-DA. The deaths averted across the different regions were associated with a unique set of factors.

CONCLUSION

Contributions of interventions and risk factors to changing U5M vary sub-nationally. This has important implications for targeting future interventions within decentralised health systems such as those operated in Kenya. Targeting specific factors where U5M has been high and intervention coverage poor would lead to the highest likelihood of sub-national attainment of sustainable development goal (SDG) 3.2 on U5M in Kenya.

Exploring women's childbirth experiences and perceptions of delivery care in peri-urban settings in Nairobi, Kenya

BACKGROUND

Kenya continues to have a high maternal mortality rate that is showing slow progress in improving. Peri-urban settings in Kenya have been reported to exhibit higher rates of maternal death during labor and childbirth as compared to the general Kenyan population. Although research indicates that women in Kenya have increased access to facility-based birth in recent years, a small percentage still give birth outside of the health facility due to access challenges and poor maternal health service quality. Most studies assessing facility-based births have focused on the sociodemographic determinants of birthing location. Few studies have assessed women's user experiences and perceptions of quality of care during childbirth. Understanding women's experiences can provide different stakeholders with strategies to structure the provision of maternity care to be person-centered and to contribute to improvements in women's satisfaction with health services and maternal health outcomes.

METHODS

A qualitative study was conducted, whereby 70 women from the peri-urban area of Embakasi in the East side of Nairobi City in Kenya were interviewed. Respondents were aged 18 to 49 years and had delivered in a health facility in the preceding six weeks. We conducted in-depth interviews with women who gave birth at both public and private health facilities. The interviews were recorded, transcribed, and translated for analysis. Braune and Clarke's guidelines for thematic analysis were used to generate themes from the interview data.

RESULTS

Four main themes emerged from the analysis. Women had positive experiences when care was person-centered-i.e. responsive, dignified, supportive, and with respectful communication. They had negative experiences when they were mistreated, which was manifested as non-responsive care (including poor reception and long wait times), non-dignified care (including verbal and physical abuse lack of privacy and confidentiality), lack of respectful communication, and lack of supportive care (including being denied companions, neglect and abandonment, and poor facility environment).

CONCLUSION

To sustain the gains in increased access to facility-based births, there is a need to improve person-centered care to ensure women have positive facility-based childbirth experiences.

Are Essential Women's Healthcare Services Fully Covered? A Comparative Analysis of Policy Documents in Shanghai and New York City from 1978-2017

This study aimed to analyze the changes in the 10 major categories of women's healthcare services (WHSs) in Shanghai (SH) and New York City (NYC) from 1978 to 2017, and examine the relationship between these changes and maternal mortality ratio (MMR). Content analysis of available public policy documents concerning women's health was conducted. Two indicators were designed to represent the delivery of WHSs: The essential women's healthcare service coverage rate (ESCR) and the assessable essential healthcare service coverage rate (AESCR). Spearman correlation was used to analyze the relationship between the two indicators and MMR. In SH, the ESCR increased from 10% to 90%, AESCR increased from 0% to 90%, and MMR decreased from 24.0/100,000 to 1.01/100,000. In NYC, the ESCR increased from 0% to 80%, the AESCR increased from 0% to 60%, and the MMR decreased from 24.7/100,000 to 21.4/100,000. The MMR significantly decreased as both indicators increased (p < 0.01). Major advances have been made in women's healthcare in both cities, with SH having a better improvement effect. A common shortcoming for both was the lack of menopausal health service provision. The promotion of women's health still needs to receive continuous attention from governments of SH and NYC. The experiences of the two cities showed that placing WHSs among policy priorities is effective in improving service status.

Subnational estimates of factors associated with under-five mortality in Kenya: a spatio-temporal analysis, 1993-2014

BACKGROUND

To improve child survival, it is necessary to describe and understand the spatial and temporal variation of factors associated with child survival beyond national aggregates, anchored at decentralised health planning units. Therefore, we aimed to provide subnational estimates of factors associated with child survival while elucidating areas of progress, stagnation and decline in Kenya.

METHODS

Twenty household surveys and three population censuses conducted since 1989 were assembled and spatially aligned to 47 subnational Kenyan county boundaries. Bayesian spatio-temporal Gaussian process regression models accounting for inadequate sample size and spatio-temporal relatedness were fitted for 43 factors at county level between 1993 and 2014.

RESULTS

Nationally, the coverage and prevalence were highly variable with 38 factors recording an improvement. The absolute percentage change (1993-2014) was heterogeneous ranging between 1% and 898%. At the county level, the estimates varied across space and over time with a majority showing improvements after 2008 which was preceded by a period of deterioration (late-1990 to early-2000). Counties in Northern Kenya were consistently observed to have lower coverage of interventions and remained disadvantaged in 2014 while areas around Central Kenya had and historically have had higher coverage across all intervention domains. Most factors in Western and South-East Kenya recorded moderate intervention coverage although having a high infection prevalence of both HIV and malaria.

CONCLUSION

The heterogeneous estimates necessitates prioritisation of the marginalised counties to achieve health equity and improve child survival uniformly across the country. Efforts are required to narrow the gap between counties across all the drivers of child survival. The generated estimates will facilitate improved benchmarking and establish a baseline for monitoring child development goals at subnational level.

Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya

INTRODUCTION

Improvements in maternal and infant health outcomes are policy priorities in Kenya. Achieving these outcomes depends on early identification of pregnancy and quality of primary healthcare. Quality improvement interventions have been shown to contribute to increases in identification, referral and follow-up of pregnant women by community health workers. In this study, we evaluate the cost-effectiveness of using quality improvement at community level to reduce maternal and infant mortality in Kenya.

METHODS

We estimated the cost-effectiveness of quality improvement compared with standard of care treatment for antenatal and delivering mothers using a decision tree model and taking a health system perspective. We used both process (antenatal initiation in first trimester and skilled delivery) and health outcomes (maternal and infant deaths averted, as well as disability-adjusted life years (DALYs)) as our effectiveness measures and actual implementation costs, discounting costs only. We conducted deterministic and probabilistic sensitivity analyses.

RESULTS

We found that the community quality improvement intervention was more cost-effective compared with standard community healthcare, with incremental cost per DALY averted of $249 under the deterministic analysis and 76% likelihood of cost-effectiveness under the probabilistic sensitivity analysis using a standard threshold. The deterministic estimate of incremental cost per additional skilled delivery was US$10, per additional early antenatal care presentation US$155, per maternal death averted US$5654 and per infant death averted US$37 536 (2017 dollars).

CONCLUSIONS

This analysis shows that the community quality improvement intervention was cost-effective compared with the standard community healthcare in Kenya due to improvements in antenatal care uptake and skilled delivery. It is likely that quality improvement interventions are a good investment and may also yield benefits in other health areas.

Development of a Mobile, Self-Sovereign Identity Approach for Facility Birth Registration in Kenya

Birth registration is a critical element of newborn care. Increasing the coverage of birth registration is an essential part of the strategy to improve newborn survival globally, and is central to achieving greater health, social, and economic equity as defined under the United Nations Sustainable Development Goals. Parts of Eastern and Southern Africa have some of the lowest birth registration rates in the world. Mobile technologies have been used successfully with mothers and health workers in Africa to increase coverage of essential newborn care, including birth registration. However, mounting concerns about data ownership and data protection in the digital age are driving the search for scalable, user-centered, privacy protecting identity solutions. There is increasing interest in understanding if a self-sovereign identity (SSI) approach can help lower the barriers to birth registration by empowering families with a smartphone based process while providing high levels of data privacy and security in populations where birth registration rates are low. The process of birth registration and the barriers experienced by stakeholders are highly contextual. There is currently a gap in the literature with regard to modeling birth registration using SSI technology. This paper describes the development of a smartphone-based prototype system that allows interaction between families and health workers to carry out the initial steps of birth registration and linkage of mothers-baby pairs in an urban Kenyan setting using verifiable credentials, decentralized identifiers, and the emerging standards for their implementation in identity systems. The goal of the project was to develop a high fidelity prototype that could be used to obtain end-user feedback related to the feasibility and acceptability of an SSI approach in a particular Kenyan healthcare context. This paper will focus on how this technology was adapted for the specific context and implications for future research.

Person-centered maternity care and postnatal health: associations with maternal and newborn health outcomes

BACKGROUND

Limited evidence exists on how women's experiences of care, specifically person-centered maternity care during childbirth, influence maternal and newborn health outcomes.

OBJECTIVE

This study aimed to examine the associations between person-centered maternity care and maternal and newborn health outcomes.

STUDY DESIGN

Longitudinal data were collected with 1014 women who completed baseline at a health facility and followed up at 2 weeks and 10 weeks after birth. A validated 30-item person-centered maternity care scale was administered to postpartum women within 48 hours after childbirth. The person-centered maternity care scale has 3 subscales: dignity and respect, communication and autonomy, and supportive care. Bivariate and multivariable log Poisson regressions were used to examine the relationship between person-centered maternity care and reported maternal complications, newborn complications, postpartum depression, postpartum family planning uptake, exclusive breastfeeding, and newborn immunizations.

RESULTS

Controlling for demographic characteristics, women with high total person-centered maternity care score at baseline had significantly lower risk of reporting maternal complications (adjusted relative risk, 0.63; 95% confidence interval, 0.42–0.95), screening positive for depression (adjusted relative risk, 0.55; 95% confidence interval, 0.38–0.81), and reporting newborn complications (adjusted relative risk, 0.74; 95% confidence interval, 0.56–0.97), respectively, than women with low total person-centered maternity care scores. Women with high scores on the supportive care subscale had significantly lower risk of reporting maternal and newborn complications than women with low scores on these subscales (adjusted relative risk, 0.52 [95% confidence interval, 0.42–0.65] and 0.74 [95% confidence interval, 0.60–0.91], respectively). Significant associations were found between all 3 subscale scores and screening positive for depression. Women with high total person-centered maternity care scores were also more likely to adopt a family planning method than those with low scores (adjusted relative risk, 1.25; 95% confidence interval, 1.02–1.52). In particular, women with high scores on the communication and autonomy subscale had significantly higher odds of adopting a family planning method than women with low scores (risk ratio, 1.15; 95% confidence interval, 1.08–1.23).

CONCLUSION

Improving person-centered maternity care may improve maternal and newborn health outcomes. Specifically, improving supportive care may decrease the risk of maternal and newborn complications, whereas improving communication and autonomy may increase postpartum family planning uptake.

Burden of disease and risk factors for mortality amongst hospitalized newborns in Nigeria and Kenya

OBJECTIVE

To describe the patient population, priority diseases and outcomes in newborns admitted <48 hours old to neonatal units in both Kenya and Nigeria.

STUDY DESIGN

In a network of seven secondary and tertiary level neonatal units in Nigeria and Kenya, we captured anonymised data on all admissions <48 hours of age over a 6-month period.

RESULTS

2280 newborns were admitted. Mean birthweight was 2.3 kg (SD 0.9); 57.0% (1214/2128) infants were low birthweight (LBW; <2.5kg) and 22.6% (480/2128) were very LBW (VLBW; <1.5 kg). Median gestation was 36 weeks (interquartile range 32, 39) and 21.6% (483/2236) infants were very preterm (gestation <32 weeks). The most common morbidities were jaundice (987/2262, 43.6%), suspected sepsis (955/2280, 41.9%), respiratory conditions (817/2280, 35.8%) and birth asphyxia (547/2280, 24.0%). 18.7% (423/2262) newborns died; mortality was very high amongst VLBW (222/472, 47%) and very preterm infants (197/483, 40.8%). Factors independently associated with mortality were gestation <28 weeks (adjusted odds ratio 11.58; 95% confidence interval 4.73-28.39), VLBW (6.92; 4.06-11.79), congenital anomaly (4.93; 2.42-10.05), abdominal condition (2.86; 1.40-5.83), birth asphyxia (2.44; 1.52-3.92), respiratory condition (1.46; 1.08-2.28) and maternal antibiotics within 24 hours before or after birth (1.91; 1.28-2.85). Mortality was reduced if mothers received a partial (0.51; 0.28-0.93) or full treatment course (0.44; 0.21-0.92) of dexamethasone before preterm delivery.

CONCLUSION

Greater efforts are needed to address the very high burden of illnesses and mortality in hospitalized newborns in sub-Saharan Africa. Interventions need to address priority issues during pregnancy and delivery as well as in the newborn.

Effect of Implementing a Free Delivery Service Policy on Women's Utilization of Facility-Based Delivery in Central Ethiopia: An Interrupted Time Series Analysis

Background

Access to and utilization of facility delivery services is low in Ethiopia. The government of Ethiopia introduced a free delivery service policy in all public health facilities in 2013 to encourage mothers to deliver in health facilities. Examining the effect of this intervention on the utilization of delivery services is very important.

Objective

In this study, we assessed the effect of provisions of free maternity care services on facility-based delivery service utilization in central Ethiopia.

Methods

Data on 108 time points were collected on facility-based delivery service utilization (72 pre- and 36 postintervention) for a period of nine years from July 2007 to June 2016. Routine monthly data were extracted from the District Health Information System and verified using data from the delivery ward logbooks across the study facilities. An interrupted time-series analysis was conducted to assess the effect of the intervention.

Results

The implementation of the free delivery services policy has significantly increased facility deliveries. During the study period, there was a statistically significant increase in the number of facility-based deliveries after the 24^th and 36^th months of intervention (p < 0.05). Program effects on the use of public facilities for deliveries were persisted over a longer exposure period.

Conclusion

The findings suggested that the provision of free delivery services at public health facilities increased facility delivery use. The improved utilization of facility delivery services was more marked over a longer exposure period. Policy-makers may consider mobilizing the communities aware of the program at its instigation.

The effect of the community midwifery model on maternal and newborn health service utilization and outcomes in Busia County of Kenya: a quasi-experimental study

BACKGROUND

Poor women in hard-to-reach areas are least likely to receive healthcare and thus carry the burden of maternal and perinatal mortality from complications of childbirth. This study evaluated the effect of an enhanced community midwifery model on skilled attendance during pregnancy/childbirth as well as on maternal and perinatal outcomes against the backdrop of protracted healthcare workers' strikes in rural Kenya.

METHODS

The study used a quasi-experimental (one-group pretest-posttest) design. The study spanned three time periods: December 2016-February 2017 when doctors were on strike (P1), March-May 2017 when no healthcare providers were on strike (P2), and June-October 2017 when nurses/midwives were on strike (P3), which was also the period when the project enhanced the capacity of community midwives (CMs) to provide services at the community level. Analysis entailed comparison of frequencies/means of maternal and newborn health service utilization data across the three periods.

RESULTS

The monthly average number of clients obtaining services from CMs across the three time periods was: first antenatal care (ANC) (P1-1.8, P2-2.3, P3-9.9), fourth ANC (P1-1.4, P2-1.0, P3-7.1), skilled birth (P1-1.5, P2-1.7, P3-13.1) and the differences in means were statistically significant (p < 0.05). Over the period, the monthly average number of clients obtaining services from health facilities was: first ANC (P1-55.7, P2-70.8, P3-4.0), fourth ANC (P1-29.6, P2-38.1, P3-1.2) and skilled birth (P1-63.1, P2-87.4, P3-5.6), p < 0.05. There were no statistically significant differences in the average number of clients obtaining services from CMs or health facilities between P1 and P2 (p > 0.05). There was, however, a statistically significant increase in the average number of clients obtaining services from CMs in P3 accompanied by a statistically significant decline in the average number of clients obtaining services from health facilities (p < 0.05). First ANC increased by 68%, fourth ANC by 75%, skilled births by 68%, and postnatal care by 33% in P3 (p < 0.0001). There was a non-significant decline in macerated stillbirths and neonatal deaths in P3.

CONCLUSIONS

The findings underscore the importance of integrating community-level health service providers (CMs and health volunteers) into the primary health care system to complement service delivery according to their level of expertise, especially in low-resource settings.

Incidence of maternal near-miss in Kenya in 2018: findings from a nationally representative cross-sectional study in 54 referral hospitals

Although the Kenyan government has made efforts to invest in maternal health over the past 15 years, there is no evidence of decline in maternal mortality. To provide necessary evidence to inform maternal health care provision, we conducted a nationally representative study to describe the incidence and causes of maternal near-miss (MNM), and the quality of obstetric care in referral hospitals in Kenya. We collected data from 54 referral hospitals in 27 counties. Individuals admitted with potentially life-threatening conditions (using World Health Organization criteria) in pregnancy, childbirth or puerperium over a three month study period were eligible for inclusion in our study. All cases of severe maternal outcome (SMO, MNM cases and deaths) were prospectively identified, and after consent, included in the study. The national annual incidence of MNM was 7.2 per 1,000 live births and the intra-hospital maternal mortality ratio was 36.2 per 100,000 live births. The major causes of SMOs were postpartum haemorrhage and severe pre-eclampsia/eclampsia. However, only 77% of women with severe preeclampsia/eclampsia received magnesium sulphate and 67% with antepartum haemorrhage who needed blood received it. To reduce the burden of SMOs in Kenya, there is need for timely management of complications and improved access to essential emergency obstetric care interventions.

'We just look at the well-being of the baby and not the money required': a qualitative study exploring experiences of quality of maternity care among women in Nairobi's informal settlements in Kenya

OBJECTIVE

To examine how women living in an informal settlement in Nairobi perceive the quality of maternity care and how it influences their choice of a delivery health facility.

DESIGN

Qualitative study.

SETTINGS

Dandora, an informal settlement, Nairobi City in Kenya.

PARTICIPANTS

Six focus group discussions with 40 purposively selected women aged 18-49 years at six health facilities.

RESULTS

Four broad themes were identified: (1) perceived quality of the delivery services, (2) financial access to delivery service, (3) physical amenities at the health facility, and (4) the 2017 health workers' strike.The four facilitators that influenced women to choose a private health facility were: (1) interpersonal treatment at health facilities, (2) perceived quality of clinical services, (3) financial access to health services at the facility, and (4) the physical amenities at the health facility. The three barriers to choosing a private facility were: (1) poor quality clinical services at low-cost health facilities, (2) shortage of specialist doctors, and (3) referral to public health facilities during emergencies.The facilitators that influenced women to choose a public facility were: (1) physical amenities for dealing with obstetric emergencies and (2) early referral to public maternity during antenatal care services. Barriers to choosing a public facility were: (1) perception of poor quality clinical services, (2) concerns over security for newborns at tertiary health facilities, (3) fear of mistreatment during delivery, (4) use of unsupervised trainee doctors for deliveries, (5) poor quality of physical amenities, and (6) inadequate staffing.

CONCLUSION

The study provides insights into decision-making processes for women when choosing a delivery facility by identifying critical attributes that they value and how perceptions of quality influence their choices.