Determinants of the continuum of maternal health care in Cambodia: an analysis of the Cambodia demographic health survey 2014

In-depth reasons for the high proportion of zero-dose children in underserved populations of Ethiopia: Results from a qualitative study

Increasing attention is being given to reach children who fail to receive routine vaccinations, commonly designated as zero-dose children. A comprehensive understanding of the supply- and demand-side barriers is essential to inform zero-dose strategies in high-burden countries and achieve global immunization goals. This qualitative study aimed to identify the barriers for reaching zero-dose and under-immunized children and what and explore gender affects access to vaccination services for children in Ethiopia. Data was collected between March-June 2022 using key informant interviews and focus group discussions with participants in underserved settings. The high proportion of zero-dose children was correlated with inadequate information being provided by health workers, irregularities in service provision, suboptimal staff motivation, high staff turnover, closure and inaccessibility of health facilities, lack of functional health posts, service provision limited to selected days or hours, and gender norms viewing females as responsible for childcare. Demand-side barriers included religious beliefs, cultural norms, fear of vaccine side effects, and lack of awareness and sustained interventions. Recommendations to increase vaccination coverage include strengthening health systems such as services integration, human resources capacity building, increasing incentives for health staff, integrating vaccination services, bolstering the EPI budget especially from the government side, and supporting reliable outreach and static immunization services. Additionally, immunization policy should be revised to include gender considerations including male engagement strategies to improve uptake of immunization services.

A repeated cross-sectional study of the association of community health worker intervention with the maternal continuum of care in rural Liberian communities

BACKGROUND

The maternal continuum of care (CoC) (antenatal care, facility-based delivery, postnatal care) is critical to maternal and neonatal health and reducing mortality, but completion in rural areas of low- and middle-income countries is often limited. We used repeated cross-sectional household surveys from a rural Liberian county to explore changes in rates of completion of all steps and no steps in the maternal CoC after implementation of the National Community Health Assistant Program (NCHAP), a community health worker (CHW) intervention designed to increase care uptake for families over five kilometers from a facility.

METHODS

We analyzed repeated cross-sectional household surveys of women aged 18-49 served by NCHAP in Rivercess County, Liberia. We measured survey-weighted, before-to-after implementation difference in completion of all steps and no steps in the maternal CoC. We used multivariable regression to explore covariates associated with completion rates before and after NCHAP implementation.

RESULTS

Data from surveys conducted at three timepoints (2015, n = 354; 2018, n = 312; 2021, n = 302) were analyzed. A significant increase in completing the full maternal CoC (2015:23.6%, 2018:53.4%, change:29.7% points (pp), 95% confidence interval (CI) [21.0,38.4]) and a decrease in completing no steps in the CoC (2015:17.6%, 2018:4.0%, change: -12.4pp [-17.6, -7.2]) after implementation of NCHAP were observed from 2015 to 2018, with rates maintained from 2018 to 2021. Living farther from a facility was consistently associated with less care across the continuum. Following implementation, living in a motorbike accessible community was associated with completing the CoC while living in a mining community was negatively associated with omitting the CoC. Household wealth was associated with differences in rates pre-NCHAP but not post-NCHAP.

CONCLUSIONS

Following NCHAP implementation, completion rate of the full maternal CoC in Rivercess County more than doubled while the rate of completing no steps in the continuum fell below 5%. These rates were sustained over time including during COVID-19 with reduced differences across wealth groups, although far distances remained a risk for less care. CHW programs providing active outreach to remote communities can be important tools for improving uptake of interventions and reducing risk of no formal care during and after pregnancy.

Multilevel and subnational analysis of the predictors of maternity continuum of care completion in Nigeria: a cross-sectional survey

Understanding population discrepancy in maternity continuum of care (CoC) completion, particularly in sub-Saharan Africa is significant for interventional plan to achieve optimal pregnancy outcome and child survival. This study thus investigated the magnitudes, distribution, and drivers of maternity CoC completion in Nigeria. A secondary analysis of 19,474 reproductive age (15-49 years) women with at least a birth (level 1) in 1400 communities (level 2) across 37 states covered in the 2018 cross-sectional survey. Stepwise regression initially identified important variables at 10% cutoff point. Multilevel analysis was performed to determine the likelihood and significance of individual and community factors. Intra-cluster correlation assessed the degree of clustering and deviance statistics identified the optimal model. Only 6.5% of the women completed the CoC. Completion rate is significantly different between communities "4.3% in urban and 2.2% in rural" (χ2 = 392.42, p < 0.001) and was higher in southern subnational than the north. Education (AOR = 1.61, 95% CI 1.20-2.16), wealth (AOR = 1.73, 95% CI 1.35-2.46), media exposure (AOR = 1.22, 95% CI 1.06-1.40), women deciding own health (AOR = 1.37, 95% CI 1.13-1.66), taking iron drug (AOR = 1.84, 95% CI 1.43-2.35) and at least 2 dose of tetanus-toxoid vaccine during pregnancy (AOR = 1.35, 95% CI 1.02-1.78) are associated individual factors. Rural residency (AOR = 1.84, 95% CI = 1.43-2.35), region (AOR = 1.84, 95% CI 1.43-2.35) and rural population proportion (AOR = 1.84, 95% CI 1.43-2.35) are community predictors of the CoC completion. About 63.2% of the total variation in CoC completion was explained by the community predictors. Magnitude of maternity CoC completion is generally low and below the recommended level in Nigeria. Completion rate in urban is twice rural and more likely in the southern than northern subnational. Women residence and region are harmful and beneficial community drivers respectively. Strengthening women health autonomy, sensitization, and education programs particularly in the rural north are essential to curtail the community disparity and optimize maternity CoC practice.

i-MoMCARE: Innovative Mobile Technology for Maternal and Child Health Care in Cambodia-study protocol of a cluster randomized controlled trial

BACKGROUND

The Government of Cambodia established the village health support groups (VHSGs) in 2003 to facilitate primary healthcare activities, including maternal and child health (MCH) services. However, VHSGs face several challenges that hinder them from performing optimally, including a lack of regular structured training and remuneration and limited and inconsistent support and supervision from the health centers (HCs). This implementation research aims to develop, implement, and evaluate a digital health intervention to improve the performance of VHSGs through better support and supervision and increase the MCH service coverage in rural Cambodia.

METHODS

i-MoMCARE, a two-arm cluster randomized controlled trial, will be conducted between 2022 and 2025. Five operational districts (ODs) have been randomized to an intervention arm and the other five ODs to the control arm. The intervention will last for 24 months. Around 200 VHSGs in the intervention arm will be equipped with a mobile application as a job aid and 20 HC staff with a web interface to improve support and supervision of VHSGs. The potential beneficiaries will include pregnant women, mothers, and children under 2 years old. We will measure the outcomes at baseline and endline. The primary outcomes will consist of a composite MCH index constructed from maternal and newborn care indicators, child immunization, and treatment of under-two children. Secondary outcomes will include coverage of selected MCH services. We will conduct the intention-to-treat and per-protocol analyses. We will conduct qualitative interviews with selected beneficiaries and stakeholders to evaluate the intervention's acceptability, feasibility, and scalability. We will also conduct a cost-effective analysis using decision-analytic modeling incorporating a societal perspective that explores different time horizons, intervention effects, and when scaled up to the national level.

DISCUSSION

i-MoMCARE is expected to increase MCH service access and coverage in rural Cambodia. It will contribute to advancing digital health use in primary healthcare interventions, which remains in its infancy in the country. Furthermore, the study findings will be a valuable addition to a growing body of literature on the effectiveness and feasibility of mobile health to improve coverage of MCH services in rural low- and middle-income country settings.

TRIAL REGISTRATION

ClinicalTrial.gov NCT05639595. Registered on 06 December 2022.

Coverage-level and predictors of maternity continuum of care in Nigeria: implications for maternal, newborn and child health programming

BACKGROUND

Completing maternity continuum of care from pregnancy to postpartum is a core strategy to reduce the burden of maternal and neonatal mortality dominant in sub-Saharan Africa, particularly Nigeria. Thus, we evaluated the level of completion, dropout and predictors of women uptake of optimal antenatal care (ANC) in pregnancy, continuation to use of skilled birth attendants (SBA) at childbirth and postnatal care (PNC) utilization at postpartum in Nigeria.

METHODS

A cross-sectional analysis of nationally representative 21,447 pregnancies that resulted to births within five years preceding the 2018 Nigerian Demographic Health Survey. Maternity continuum of care model pathway based on WHO recommendation was the outcome measure while explanatory variables were classified as; socio-demographic, maternal and birth characteristics, pregnancy care quality, economic and autonomous factors. Descriptive statistics describes the factors, backward stepwise regression initially assessed association (p < 0.10), multivariable binary logistic regression and complementary-log-log model quantifies association at a 95% confidence interval (α = 0.05).

RESULTS

Coverage decrease from 75.1% (turn-up at ANC) to 56.7% (optimal ANC) and to 37.4% (optimal ANC and SBA) while only 6.5% completed the essential continuum of care. Dropout in the model pathway however increase from 17.5% at ANC to 20.2% at SBA and 30.9% at PNC. Continuation and completion of maternity care are positively drive by women; with at least primary education (AOR = 1.27, 95%CI = 1.01-1.62), average wealth index (AOR = 1.83, 95%CI = 1.48 -2.25), southern geopolitical zone (AOR = 1.61, 95%CI = 1.29-2.01), making health decision alone (AOR = 1.39, 95%CI = 1.16-1.66), having nurse as ANC provider (AOR = 3.53, 95%CI = 2.01-6.17) and taking at least two dose of tetanus toxoid vaccine (AOR = 1.25, 95%CI = 1.06-1.62) while women in rural residence (AOR = 0.78, 95%CI = 0.68-0.90) and initiation of ANC as late as third trimester (AOR = 0.44, 95%CI = 0.34-0.58) negatively influenced continuation and completion.

CONCLUSIONS

6.5% coverage in maternity continuum of care completion is very low and far below the WHO recommended level in Nigeria. Women dropout more at postnatal care than at skilled delivery and antenatal. Education, wealth, women health decision power and tetanus toxoid vaccination drives continuation and completion of maternity care. Strategies optimizing these factors in maternity packages will be supreme to strengthen maternal, newborn and child health.

Socioeconomic inequalities in the continuum of care across women’s reproductive life cycle in Bangladesh

We examined the association between socioeconomic status (SES) and continuum of care (CoC) completion rate in maternal, neonatal, and child health among mothers in Bangladesh. We used data from the Bangladesh Demographic Health Survey (BDHS) from 2017 to 2018. Our findings were based on the responses of 1527 married women who had at least one child aged 12 to 23 months at the time of the survey. As a measure of SES, we focused on the standard of living (hereinafter referred to as wealth). The CoC for maternal and child health (MNCH) services is the study's outcome variable. The CoC was calculated using seven MNCH interventions: four or more antenatal care (ANC) visits with a skilled practitioner, delivery by a skilled birth attendant, post-natal care for mothers (PNCM) within two days of giving birth, post-natal care for newborns (PNCM) within two days of birth, immunization, age-appropriate breastfeeding, and maternal current use of modern family planning (FP) methods. Only 18.1% of Bangladeshi women completed all seven MNCH care interventions during the reproductive life span. Participants in the high SES group were 2.30 times (95% confidence interval [CI] 1.61–3.28) more likely than those in the low SES group to have higher composite care index (CCI) scores. Women with secondary or higher secondary education, as well as women who were exposed to mass media at least once a week, women who lived in an urban setting, women who had an intended pregnancy, and women with one parity, are associated with high CCI scores when other sociodemographic variables are considered. The complete CoC for MNCH reveals an extremely low completion rate, which may suggest that Bangladeshi mothers, newborns, and children are not receiving the most out of their present health care. Participants in the high SES group displayed higher CCI values than those in the low SES group, indicating that SES is one of the primary drivers of completion of CoC for MNCH services.

Measuring effective coverage of maternal and child health services in Cambodia: a retrospective analysis of Demographic and Health Surveys from 2005 to 2014

OBJECTIVE

To investigate effective, quality-adjusted, coverage and inequality of maternal and child health (MCH) services to assess progress in improving quality of care in Cambodia.

DESIGN

A retrospective secondary analysis using the three most recent (2005, 2010 and 2014) Demographic and Health Surveys.

SETTING

Cambodia.

PARTICIPANTS

53 155 women aged 15-49 years old and 23 242 children under 5 years old across the three surveys.

OUTCOME MEASURES

We estimated crude coverage, effective coverage and inequality in effective coverage for five MCH services over time: antenatal care (ANC), facility delivery and sick childcare for diarrhoea, pneumonia and fever. Quality was defined by the proportion of care seekers who received a set of interventions during healthcare visits. Effective coverage was estimated by combining crude coverage and quality. We used equiplots and risk ratios, to assess patterns in inequality in MCH effective coverage across wealth quintile, urban-rural and women's education levels and over time.

RESULTS

In 2014, crude and effective coverage was 80.1% and 56.4%, respectively, for maternal health services (ANC and facility delivery) and 59.1% and 26.9%, respectively, for sick childcare (diarrhoea, pneumonia and fever). Between 2005 and 2014, effective coverage improved for all services, but improvements were larger for maternal healthcare than for sick child care. In 2014, poorer children were more likely to receive oral rehydration solution for diarrhoea than children from richer households. Meanwhile, women from urban areas were more likely to receive a postnatal check before getting discharged.

CONCLUSIONS

Effective coverage has generally improved in Cambodia but efforts remain to improve quality for all MCH services. Our results point to substantial gaps in curative sick child care, a large share of which is provided by unregulated private providers in Cambodia. Policymakers should focus on improving effective coverage, and not only crude coverage, to achieve the health-related Sustainable Development Goals by 2030.

Continuum of maternal and newborn health in Sierra Leone: a 2019 national survey

Introduction

Globally, Sierra Leone has some of the worst maternal and child health indicators. The situation is worsened by a dearth of evidence about the level of continuum of care, an evidence-based intervention aimed at reducing maternal and perinatal morbidity and mortality. Hence this study aimed to assess the level of and factors associated with continuum of maternal and newborn care in Sierra Leone.

Method

This study analyzed secondary data from the 2019 Sierra Leone Demographic Health Survey. Analysis was restricted to women who had a live birth in the 5 years preceding the survey (n = 7326). Complete continuum of care was considered when a woman reported having had at least eight antenatal care contacts, skilled birth attendance and mother and baby had at least one postnatal check-up. Bi-variable and multivariable logistic regression were performed using the statistical package for the social sciences software version 25.

Results

Only 17.9% (95% CI: 17.4–19.1) of the women utilized complete continuum of care for maternal and newborn health services in Sierra Leone. About 22% (95% CI: 21.3–23.1) utilized 8 or more antenatal care contacts, 88% (95% CI: 87.9–89.4) had skilled birth attendance while 90.7% (95% CI: 90.2–91.5) and 90.4% (95% CI: 89.9–91.2) of mothers and neonates utilized postnatal care respectively. Having started antenatal care within the first trimester (aOR 1.71, 95% CI: 1.46–2.00), being resident in the Southern region (aOR 1.85, 95% CI: 1.23–2.80), belonging to richer wealth quintile (aOR 1.76, 95% CI: 1.27–2.44), using internet (aOR 1.49, 95% CI: 1.12–1.98) and having no big problems seeking permission to access healthcare (aOR 1.34, 95% CI: 1.06–1.69) were significantly associated with utilization of continuum of care.

Conclusion

The overall completion of continuum of maternal care is low, with ANC being the lowest utilized component of continuum of care. These findings call for urgent attention for maternal health stakeholders to develop and implement tailored interventions prioritizing women empowerment, access to affordable internet services, timely initiation of ANC contacts, women in developed regions such as the Western and those from poor households.