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Ariff S, Jiwani U, Rizvi A, Muhammad S, Hussain A, Ahmed I, Hussain M, Usman M, Iqbal J, Memon Z, Soofi SB, Bhutta ZA. Effect of Maternal and Newborn Care Service Package on Perinatal and Newborn Mortality: A Cluster Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2356609. [PMID: 38372998 PMCID: PMC10877450 DOI: 10.1001/jamanetworkopen.2023.56609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Importance In resource-constrained settings where the neonatal mortality rate (NMR) is high due to preventable causes and health systems are underused, community-based interventions can increase newborn survival by improving health care practices. Objectives To develop and evaluate the effectiveness of a community-based maternal and newborn care services package to reduce perinatal and neonatal mortality in rural Pakistan. Design, Setting, and Participants This cluster randomized clinical trial was conducted between November 1, 2012, and December 31, 2013, in district Rahim Yar Khan in the province of Punjab. A cluster was defined as an administrative union council. Any consenting pregnant resident of the study area, regardless of gestational age, was enrolled. An ongoing pregnancy surveillance system identified 12 529 and 12 333 pregnancies in the intervention and control clusters, respectively; 9410 pregnancies were excluded from analysis due to continuation of pregnancy at the end of the study, loss to follow-up, or miscarriage. Participants were followed up until the 40th postpartum day. Statistical analysis was performed from January to May 2014. Intervention A maternal and newborn health pack, training for community- and facility-based health care professionals, and community mobilization through counseling and education sessions. Main Outcomes and Measures The primary outcome was perinatal mortality, defined as stillbirths per 1000 births and neonatal death within 7 days per 1000 live births. The secondary outcome was neonatal mortality, defined as death within 28 days of life per 1000 live births. Systematic random sampling was used to allocate 10 clusters each to intervention and control groups. Analysis was conducted on a modified intention-to-treat basis. Results For the control group vs the intervention group, the total number of households was 33 188 vs 34 315, the median number of households per cluster was 3092 (IQR, 3018-3467) vs 3469 (IQR, 3019-4075), the total population was 229 155 vs 234 674, the mean (SD) number of residents per household was 6.9 (9.5) vs 6.8 (9.6), the number of males per 100 females (ie, the sex ratio) was 104.2 vs 103.7, and the mean (SD) number of children younger than 5 years per household was 1.0 (4.2) vs 1.0 (4.3). Altogether, 7598 births from conrol clusters and 8017 births from intervention clusters were analyzed. There was no significant difference in perinatal mortality between the intervention and control clusters (rate ratio, 0.86; 95% CI, 0.69-1.08; P = .19). The NMR was lower among the intervention than the control clusters (39.2/1000 live births vs 52.2/1000 live births; rate ratio, 0.75; 95% CI, 0.58-0.95; P = .02). The frequencies of antenatal visits and facility births were similar between the 2 groups. However, clean delivery practices were higher among intervention clusters than control clusters (63.2% [2284 of 3616] vs 13.2% [455 of 3458]; P < .001). Chlorhexidine use was also more common among intervention clusters than control clusters (55.9% [4271 of 7642] vs 0.3% [19 of 7203]; P < .001). Conclusions and Relevance This pragmatic cluster randomized clinical trial demonstrated a reduction in NMR that occurred in the background of improved household intrapartum and newborn care practices. However, the effect of the intervention on antenatal visits, facility births, and perinatal mortality rates was inconclusive, highlighting areas requiring further research. Nevertheless, the improvement in NMR underscores the effectiveness of community-based programs in low-resource settings. Trial Registration ClinicalTrials.gov Identifier: NCT01751945.
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Affiliation(s)
- Shabina Ariff
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Uswa Jiwani
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Arjumand Rizvi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Muhammad
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Amjad Hussain
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Imran Ahmed
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Masawar Hussain
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Muhammad Usman
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Junaid Iqbal
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zahid Memon
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Sajid Bashir Soofi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar A. Bhutta
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
- Institute of Global Health and Development, Aga Khan University, Karachi, Pakistan
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Maximore LS, Mohammed AG, Issahaku GR, Sackey S, Kenu E. Prevalence and determinants of home delivery among reproductive age women, Margibi County, Liberia. BMC Pregnancy Childbirth 2022; 22:653. [PMID: 35986310 PMCID: PMC9389515 DOI: 10.1186/s12884-022-04975-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/05/2022] [Indexed: 11/11/2022] Open
Abstract
Background The use of institutional delivery services is essential for improving maternal and child health. However, studies in Liberia reveal over 20% of women still deliver at home. We assessed the prevalence and associated factors of home delivery among women of reproductive age in Margibi County, Liberia. Methods We conducted a cross-sectional study among 438 women of reproductive age in Margibi County. Data were obtained using a semi-structured questionnaire. A simple random sampling approach was used to select the participants for the study. We performed binary logistic regression to identify factors influencing home delivery. Findings were summarized into tables displaying the frequencies, percentages, crude, and adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results Prevalence of home delivery in the County was 90.6% (95% CI = 87.5 – 93.0). Women who were ≥ 31 years (aOR = 6.74, 95%CI = 2.86—15.90), women who had two or more children (aOR = 9.68, 95%CI = 4.07—22.99) and those who had rapid onset of labor (aOR = 6.35, 95%CI = 1.59 – 25.27) were associated with increased odds of home delivery. Good attitude of health workers (aOR = 0.01, 95%CI = 0.001 – 0.08) and the availability of transport to the nearest health facility (aOR = 0.01, 95%CI = 0.003 – 0.03) were factors associated with a decreased odds of home delivery among the study participants. Conclusion The high prevalence of home delivery in the county is a call for urgent interventions by the government of Liberia and various non-governmental organizations. The government may need to supply the county with ambulances and ensure in-service training of health workers on good attitudes. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04975-7.
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Kadota JL, Nabwire S, Nalugwa T, White JS, Cattamanchi A, Katamba A, Shete PB. Patient Perspectives and Willingness to Accept Incentives for Tuberculosis Diagnostic Evaluation in Uganda. Value Health Reg Issues 2021; 25:48-56. [PMID: 33773327 DOI: 10.1016/j.vhri.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/02/2020] [Accepted: 12/10/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES We assessed attitudes and perceptions and willingness to accept (WTA) varying incentive structures for completing tuberculosis (TB) diagnostic evaluation among patients in Uganda. METHODS We surveyed 177 adult patients undergoing TB evaluation at 10 health centers between September 2018 and March 2019. We collected household sociodemographic information and assessed attitudes and perceptions of incentives. We surveyed patients regarding their willingness to complete TB diagnostic evaluation in exchange for incentives ranging in value from 500 Ugandan shillings (USh) to 25 000USh (~$0.15-$6.75). We compared associations between WTA and patient characteristics using ordered logistic regression. RESULTS Participant willingness to return to the health center to complete TB diagnostic evaluation increased proportionally with incentive amount. The median participant accepted between 2000 and 5000 USh. Cash (52%) and transportation vouchers (34%) were the most popular incentive types. Half of respondents preferred unconditional incentives; for a multiday evaluation, 84% preferred conditioning incentive receipt upon returning to the health center. In multivariate models, we found the pairwise difference between the third and lowest income quartile (aOR = 2.38, 95% CI: 1.20-4.69; P = .01), younger age, and difficulty returning to the health center to be significantly associated with WTA higher incentive thresholds. CONCLUSIONS In Uganda, incentives such as cash transfers or transportation vouchers are an acceptable intervention for facilitating adherence to TB diagnostic evaluation. Household income is associated with preferred incentive structure and amount, especially for those at the cusp of the poverty threshold who are more likely to prefer unconditional and higher valued incentives. Targeted and context-specific socioeconomic supports for at-risk patients are needed to optimize outcomes.
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Affiliation(s)
- Jillian L Kadota
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA USA.
| | - Sarah Nabwire
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Talemwa Nalugwa
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Justin S White
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Priya B Shete
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
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Hirai M, Morris J, Luoto J, Ouda R, Atieno N, Quick R. The impact of supply-side and demand-side interventions on use of antenatal and maternal services in western Kenya: a qualitative study. BMC Pregnancy Childbirth 2020; 20:453. [PMID: 32770963 PMCID: PMC7414717 DOI: 10.1186/s12884-020-03130-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 07/23/2020] [Indexed: 11/27/2022] Open
Abstract
Background Antenatal care (ANC) and delivery by skilled providers have been well recognized as effective strategies to prevent maternal and neonatal mortality. ANC and delivery services at health facilities, however, have been underutilized in Kenya. One potential strategy to increase the demand for ANC services is to provide health interventions as incentives for pregnant women. In 2013, an integrated ANC program was implemented in western Kenya to promote ANC visits by addressing both supply- and demand-side factors. Supply-side interventions included nurse training and supplies for obstetric emergencies and neonatal resuscitation. Demand-side interventions included SMS text messages with appointment reminders and educational contents, group education sessions, and vouchers to purchase health products. Methods To explore pregnant mothers’ experiences with the intervention, ANC visits, and delivery, we conducted focus group discussions (FGDs) at pre- and post-intervention. A total of 19 FGDs were held with pregnant mothers, nurses, and community health workers (CHWs) during the two assessment periods. We performed thematic analyses to highlight study participants’ perceptions and experiences. Results FGD data revealed that pregnant women perceived the risks of home-based delivery, recognized the benefits of facility-based delivery, and were motivated by the incentives to seek care despite barriers to care that included poverty, lack of transport, and poor treatment by nurses. Nurses also perceived the value of incentives to attract women to care but described obstacles to providing health care such as overwork, low pay, inadequate supplies and equipment, and insufficient staff. CHWs identified the utility and limitations of text messages for health education. Conclusions Future interventions should ensure that adequate workforce, training, and supplies are in place to respond to increased demand for maternal and child health services stimulated by incentive programs.
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Affiliation(s)
- Mitsuaki Hirai
- Division of Global Health Protection, Office of the Director, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, USA
| | - Jamae Morris
- Department of African American Studies, Georgia State University, 33 Gilmer Street SE, Atlanta, GA, 30303, USA
| | - Jill Luoto
- RAND Corporation, Santa Monica, CA, 90407, USA
| | - Rosebel Ouda
- Safe Water and AIDS Project, P.O Box 3323, Kisumu, 40100, Kenya
| | - Nancy Atieno
- Safe Water and AIDS Project, P.O Box 3323, Kisumu, 40100, Kenya
| | - Robert Quick
- National Center for Emerging and Zoonotic Infectious Diseases, Office of Infectious Diseases Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA, 30329, USA.
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Bhattacharyya S, Srivastava A, Saxena M, Gogoi M, Dwivedi P, Giessler K. Do women's perspectives of quality of care during childbirth match with those of providers? A qualitative study in Uttar Pradesh, India. Glob Health Action 2019; 11:1527971. [PMID: 30295161 PMCID: PMC6179056 DOI: 10.1080/16549716.2018.1527971] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Background: Persistently high maternal mortality levels are a concern in developing countries. In India, monetary incentive schemes have increased institutional delivery rates appreciably, but have not been equally successful in reducing maternal mortality. Maternal outcomes are affected by quality of obstetric care and socio-cultural norms. In this light there is need to examine the quality of care provided to women delivering in institutions. Objective: This study aimed to examine pregnant women’s expectations of high-quality care in public health facilities in Uttar Pradesh, India, and to contrast this with provider’s perceptions of the same, as well as the barriers that limit their ability to provide high-quality care. Methods: A qualitative descriptive analysis was conducted on data from two studies – focus group discussions with rural women in their last trimester of pregnancy (conducted in 2014) to understand women’s experience and satisfaction with maternal care services, and in-depth interviews with care providers (conducted in 2016–17) to understand provision of person-centred care. Provider perspectives were matched with themes of women’s perspectives on quality of childbirth care in facilities. Results: Major themes of care prioritised by women included availability of doctors at the facility; availability of medicines; food; ambulance services; maintenance of cleanliness and hygiene; privacy; good and safe delivery with no complications; client-provider interaction; financial cost of care. Many women also voiced no expectation of care, indicating disillusionment from the existing system. Providers concurred with women on all themes of care except availability of doctors, as they felt that trained nurses were proficient in conducting deliveries. Conclusions: This study shows that women have clear expectations of quality care from facilities where they go to deliver. Understanding their expectations and matching them with providers’ perspectives of care is critical for efforts to improve the quality of care and thereby impact maternal outcomes.
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Affiliation(s)
| | - Aradhana Srivastava
- a Research Department , Public Health Foundation of India , NCR Delhi , India
| | - Malvika Saxena
- a Research Department , Public Health Foundation of India , NCR Delhi , India
| | - Mousumi Gogoi
- a Research Department , Public Health Foundation of India , NCR Delhi , India
| | - Pravesh Dwivedi
- a Research Department , Public Health Foundation of India , NCR Delhi , India
| | - Katie Giessler
- b Global Health Sciences , University of California , San Francisco , CA , USA
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Fagerli K, O'Connor K, Kim S, Kelley M, Odhiambo A, Faith S, Otieno R, Nygren B, Kamb M, Quick R. Impact of the Integration of Water Treatment, Hygiene, Nutrition, and Clean Delivery Interventions on Maternal Health Service Use. Am J Trop Med Hyg 2017; 96:1253-1260. [PMID: 28193744 DOI: 10.4269/ajtmh.16-0709] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractReducing barriers associated with maternal health service use, household water treatment, and improved hygiene is important for maternal and neonatal health outcomes. We surveyed a sample of 201 pregnant women who participated in a clinic-based intervention in Kenya to increase maternal health service use and improve household hygiene and nutrition through the distribution of water treatment products, soap, protein-fortified flour, and clean delivery kits. From multivariable logistic regression analyses, the adjusted odds of ≥ 4 antenatal care (ANC4+) visits (odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.9-4.5), health facility delivery (OR = 5.3, 95% CI = 3.4-8.3), and any postnatal care visit (OR = 2.8, 95% CI = 1.9-4.2) were higher at follow-up than at baseline, adjusting for demographic factors. Women who completed primary school had higher odds of ANC4+ visits (OR = 1.8, 95% CI = 1.1-2.9) and health facility delivery (OR = 4.2, 95% CI = 2.5-7.1) than women with less education. For women who lived ≤ 2.5 km from the health facility, the estimated odds of health facility delivery (OR = 2.4, 95% CI = 1.5-4.1) and postnatal care visit (OR = 1.6, 95% CI = 1.0-2.6) were higher than for those who lived > 2.5 km away. Compared with baseline, a higher percentage of survey participants at follow-up were able to demonstrate proper handwashing (P = 0.001); water treatment behavior did not change. This evaluation suggested that hygiene, nutritional, clean delivery incentives, higher education level, and geographical contiguity to health facility were associated with increased use of maternal health services by pregnant women.
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Affiliation(s)
- Kirsten Fagerli
- Waterborne Diseases Prevention Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katherine O'Connor
- Waterborne Diseases Prevention Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sunkyung Kim
- Biostatistics and Information Management Office, Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maureen Kelley
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | | | | | | | - Benjamin Nygren
- Waterborne Diseases Prevention Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary Kamb
- Division of Sexually Transmitted Infections, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Robert Quick
- Waterborne Diseases Prevention Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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