Birth preparedness and complication readiness among the women beneficiaries of selected rural primary health centers of Dakshina Kannada district, Karnataka, India

Examining birth preparedness and complication readiness: a systematic review and meta-analysis of pregnant and recently delivered women in India

BACKGROUND

Birth preparedness and complication readiness (BPCR) is an essential component of safe motherhood programs. This study aims to systematically identify and synthesize available evidence on birth preparedness and complication readiness among pregnant and recently delivered women in India.

METHODS

The study followed PRISMA guidelines and used databases such as PubMed, Cochrane Library, and ProQuest. Joanna Briggs Institute [JBI] Tool was used for critical appraisal of studies. The meta-analysis was conducted using Comprehensive Meta-Analysis [CMA] tool and R studio software. Statistical heterogeneity was evaluated using visual inspection of the forest plot, Cochran's Q test, and the I2 statistic results. Funnel plot and Egger's tests were applied to explore the possibility of the publication bias in the studies [PROSPERO: CRD42023396109].

RESULT

Thirty-five cross-sectional studies reported knowledge on one or more components of birth preparedness [BP], whilst knowledge on complication readiness [CR] or danger signs was reported in 34 included studies. Utilizing the random effect model, the pooled result showed that only about half of the women [49%; 95% CI: 44%, 53%] were aware on BPCR components. This result ranged between 15% [95% CI: 12%, 19%] to 79% [95% CI: 72%, 84%] in Maharashtra and Karnataka respectively [I2 = 94%, p = < 0.01]. High heterogeneity [> 90%] is observed across all components [p < 0.01]. The result of subgroup analysis indicated no significant difference in the proportion on BPCR among pregnant women [50%; 95% CI: 45%, 55%] and recently delivered women [54%; 95% CI: 46%, 62%]. However, the southern region of India indicates relatively better [56%; 95% CI: 45%, 67%] prevalence.

CONCLUSION

Our study highlights the low prevalence of BPCR in India and the factors associated with it. Scaling up cost-effective interventions like BPCR that have a positive overall effect is necessary. Authors strongly suggests that birth preparedness and complication readiness should be given utmost importance to reduce maternal morbidity and mortality to achieve the Sustainable Development Goals. Consideration should be given to fortifying existing resources, such as frontline workers and primary healthcare, as a strategic approach to augmenting the effectiveness of awareness initiatives.

Maternal health literacy, utilisation of maternal healthcare services and pregnancy outcomes among newly delivered mothers: A cross-sectional study in Nigeria

Objectives

Study design

Methods

Results

Conclusions

Status of Birth Preparedness and Complication Readiness of Pregnant Women and Recently Delivered Women in Rural Varanasi: Assessment of Current Scenario

Background:

Birth Preparedness and Complication Readiness is practise of planning for events related to child birth and making necessary arrangements, so that timely and adequate medical care can be provided to the mother.

Objective:

The objective of the study was to assess the Birth Preparedness and Complication Readiness of pregnant and recently delivered women in rural areas of Varanasi.

Materials and Methods:

A total of 633 pregnant and recently delivered women were interviewed using 11 components related to antenatal care and preparations done for child birth.

Results:

Out of all the respondents, less than half (46.4%) among Pregnant women and nearly the same proportion (45.1%) among recently delivered women were found “Well Prepared.”

Conclusion:

The study revealed that there is a need to create awareness among the people about the importance of proper planning and making arrangements in advance to avert the danger to the life of mother and child.

"Why did our baby die soon after birth?"-Lessons on neonatal death in rural Cambodia from the perspective of caregivers

INTRODUCTION

Neonatal deaths represent around half the deaths of children less than five-years old in Cambodia. The process from live birth to neonatal death has not been well described. This study aimed to identify problems in health care service which hamper the reduction of preventable neonatal deaths in rural Cambodia.

METHODS

This study adopted a method of qualitative case study design using narrative data from the verbal autopsy standard. Eighty and forty villages were randomly selected from Kampong Cham and Svay Rieng provinces, respectively. All households in the target villages were visited between January and February 2017. Family caregivers were asked to describe their experiences on births and neonatal deaths between 2015 and 2016. Information on the process from birth to death was extracted with open coding, categorized, and summarized into several groups which represent potential problems in health services.

RESULTS

Among a total of 4,142 children born in 2015 and 2016, 35 neonatal deaths were identified. Of these deaths, 74% occurred within one week of birth, and 57% were due to low-birth weight. Narrative data showed that three factors should be improved, 1) the unavailability of a health-care professional, 2) barriers in the referral system, and 3) lack of knowledge and skill to manage major causes of neonatal deaths.

CONCLUSION

The current health system has limitations to achieve further reduction of neonatal deaths in rural Cambodia. The mere deployment of midwives at fixed service points such as health centers could not solve the problems occurring in rural communities. Community engagement revisiting the principle of primary health care, as well as health system transformation, is the key to the solution and potential breakthrough for the future.

Birth preparedness and complication readiness practice and associated factors among pregnant women in Northwest Ethiopia: 2018

BACKGROUND

Birth-preparedness and complication readiness is a comprehensive strategy aimed at promoting the timely utilization of skilled maternal and neonatal health care. Pregnancy-related complications both on the mother and the newborn could be largely alleviated if there is a well-consolidated birth preparedness and complication readiness plan developed during pregnancy and implemented at the time of delivery.

OBJECTIVE

To determine the prevalence of birth preparedness and complication readiness practice (BPCR) and associated factors among pregnant women in North Gondar Zone, Northwest Ethiopia, 2018.

METHODS

A community based cross-sectional study was conducted among pregnant women in North Gondar Zone from March 2017 to February 2018. A multistage clustered sampling technique was used to enroll a total of 1620 participants. The data were collected by face to face interviews using pretested and semi-structured questionnaires at baseline and following delivery. The data were entered using EPI-data version 3.1 and analyzed using STATA version 14 software. Bivariate and multivariable logistic regression model was fitted to assess factors with BPCR practice. Adjusted odds ratio (AOR) with 95% confidence interval was used to determine the association between covariates and the outcome variable.

RESULTS

From a total of 1620 pregnant women only 1523 (94.0%) mothers were followed at the end line. The prevalence of BPCR plan during pregnancy was 66.1% [95% CI: 63.8, 68.5] and the practice at the time of delivery was 73.5% [95% CI 71.3, 75.7]. Of the total respondents who mentioned having a BPCR plan, 76.4% practiced at the time of delivery. Frequency of ANC visits [AOR = 1.97; 95% CI: 1.67, 2.32], larger number of family in the household [AOR = 1.14; 95%CI: 1.00, 1.30], highest wealth asset [AOR = 1.87; 95%CI: 1.16, 3.01], Multigravidity [AOR = 0.30; 95% CI: 0.15, 0.62], husband involvement in decision making [AOR = 2.2; 95% CI: 1.25, 3.82], counseled on BPCR [AOR = 2.35; 95% CI: 1.51, 3.68], were found to be significantly associated with BPCR practice.

CONCLUSION

BPCR practice at the time of delivery was higher than previous studies conducted in the country. However, BPCR practice was found to be lower than the standard that every woman should practice the plan at the time of delivery. Intersectoral collaborative interventions required to improve the economic status and living standard of families in the community as well as various awareness creation strategies should be implemented to support women to attend ANC follow-up visits.

Prevalence and predictors of birth preparedness and complication readiness in the Kassena-Nankana district of Ghana: an analytical cross-sectional study

OBJECTIVES

To assess birth preparedness and complication readiness (BPACR) and associated factors among mothers who had given birth in the past 12 months prior to the study.

DESIGN

An analytical cross-sectional study.

SETTING

The study was carried out in the rural areas of Kassena-Nankana district located in the Upper East Region of Ghana.

PARTICIPANTS

The study population comprised 600 postpartum women who had delivered within the last 12 months prior to the study.

PRIMARY OUTCOME MEASURE

The primary outcome measure was BPACR.

RESULTS

The prevalence of BPACR among recently delivered women was very low as less than 15% were able to mention at least three of the five basic components of birth preparedness/complication readiness that were fulfilled. After adjustment for confounding effect using multivariable logistic regression analysis, high educational level (adjusted OR (AOR)=3.40 (95% CI: 1.88 to 6.15)), better knowledge about obstetric danger signs during pregnancy (AOR=4.88 (95% CI: 2.68 to 8.90)), older women (≥35 years) (AOR=2.59 (95% CI: 1.11 to 6.02)), women of low household wealth index (AOR=4.64 (95% CI: 1.97 to 10.91)) and women who received lower content of antenatal care services (AOR=3.34 (95% CI: 1.69 to 6.60)) were significant predictors of BPACR.

CONCLUSION

This study concludes that BPACR practices were low. High educational attainment of the woman, having adequate knowledge about obstetric danger signs during pregnancy, older women (≥35 years) and women of low household wealth index were significant predictors of BPACR. The predictors identified should be given high priority by health authorities in addressing low prevalence of BPACR.

Birth preparedness, utilization of skilled birth attendants and delivery outcomes among pregnant women in Ogun State, Nigeria

INTRODUCTION

Birth preparedness and complication readiness (BPCR) is an approach initiated to facilitate utilization of skill birth attendants (SBAs) for improved pregnancy outcomes. Despite its usefulness, many women still did not use skilled birth attendants. The purpose of this study is to assess the level of birth preparedness and complication readiness and its association with skilled birth attendants' utilization.

METHODS

A descriptive sequential mixed methods design was used. In all, 350 women in their third trimester were purposively selected from healthcare facilities. Of these, 340 completed the study yielding a 97% response rate. Structured interviewer-administered questionnaire, a checklist and an in-depth interview guide were used to collect data. Data analysis was done in Statistical Package for Social Sciences version 20 using descriptive and inferential statistics at 0.05 level of significance while qualitative data were analyzed through content analysis.

RESULTS

There was a significant association between level of birth preparedness and complication readiness and use of skilled birth attendants [χ²(2, 340)=19.96; p=0.0001]. Some negative delivery outcomes (complications) were significantly associated with nonutilization of skill birth attendants. Cost, family members' preference, distance, industrial action and irritation from the vaginal examination were factors that prevented women from using a skilled birth attendant.

CONCLUSIONS

The study concluded that BPCR is significantly associated with the use of SBAs and better outcomes were observed in women that used SBAs in Nigeria.

Transport Poverty with Special Reference to Sustainability: A Systematic Review of the Literature

The aim of this work is to analyse the state of the art of scientific research related to transport poverty with special reference to sustainability and to identify new research needs. To this end, a methodology has been used in line with the objective set out, choosing the systematic review of the literature as the most suitable method. The results show that transport poverty is an under-exploited issue and is not well articulated by researchers, and there are great differences between the different areas of knowledge studied. The subjects related to health and medicine have more publications, almost 58%, with the rest distributed among 11 different subjects. Of the works analysed, only 26.69% refer to the topic of sustainability, and therefore this is a branch which is little studied in the literature in this field. Another relevant finding is that all the articles analysed highlight the vulnerability and inequality of the groups affected by transport poverty, with the elderly being the least studied in the research work.

Study to Assess Birth Preparedness and Complication Readiness to Promote Safe Motherhood among Women from a Rural Area of Western Maharashtra

Background:

Promotion of maternal health should be an integrated approach comprising adequate planning of pregnancy coupled with the awareness of the available maternal and child health services and its utilization.

Objectives:

The aim of this study is to determine birth preparedness and complication readiness (BPACR) among antenatal and postnatal women and to assess the factors related to it.

Materials and Methods:

This hospital-based cross-sectional study was conducted on 400 antenatal and postnatal women attending a tertiary care hospital of Karad. Antenatal women in their third trimester and postnatal women up to Postnatal day-7 were included. Institutional ethical clearance was obtained before the commencement of the study. All the women were interviewed after their informed consent using the appropriately validated and modified BPACR tool developed with respect to the Indian setup. Chi-square and multivariate logistic regression analysis were carried out to determine the various associated factors with BPACR.

Results:

The study population comprised 55.5% antenatal mothers and 44.5% postnatal mothers. The BPACR index was found to be 59.56, and the maximum had a good BPACR 208 (52%). There was poor knowledge regarding blood transfusion, danger signs, and available community resources. A higher level of education had a statistically significant association with BPACR (46.2%) in women educated above high school). Women belonging to the upper class had two times, and postnatal women had 2.02 times increased chances for a good BPACR.

Conclusion:

An inclusion of components related to BPACR during pregnancy will improve timely and adequate access to healthcare, better management of complications, and thereby improve both maternal and fetal outcomes.

Distinct mortality patterns at 0-2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar

BACKGROUND

The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths.

METHODS

Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment.

RESULTS

The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days.

CONCLUSIONS

To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality.

Effect of focused birth preparedness and complication readiness counseling on pregnancy outcome among females attending tertiary care hospital in Barabanki district, Uttar Pradesh, India

CONTEXT

Measures related to birth preparedness and complication readiness (BPCR) during pregnancy play an important role in producing better pregnancy outcome. If the pregnant females are properly counseled during antenatal visits, it could help in bringing out desirable behavior changes.

AIMS

This study aims to study BPCR-related awareness and practices among the pregnant females and the effect of focused and structured birth preparedness counseling on complication readiness among pregnant females.

SUBJECT AND METHODS

A facility-based follow-up study was conducted from July to December 2016, and a total of 130 pregnant females were enrolled. All study participants were initially assessed for various domains of BPCR index consisting of seven key indicators. The index reassessment was done again, after 1 month, during follow-up visit. Information regarding any pregnancy-related complication in due course and behavior was also recorded during successive follow-up.

STATISTICAL ANALYSIS USED

The difference in pre- and postcounseling mean BPCR index was assessed using paired t-test, and McNemar's test was used for paired categorical data analysis. P < 0.05 was considered to be statistically significant.

RESULTS

The postcounseling BPCR index (70.65 ± 19.18) was found to be significantly much higher as compared to pre-counseling baseline BPCR index (41.12 ± 11.34). Knowledge about danger signs of pregnancy, transportation services provided by government, financial assistance provided in Government schemes, identification of skilled birth attendant, mode of transportation, and arrangement of emergency blood donor was found to increase significantly after counseling. Abortion was found to occur significantly higher (about thrice) among those who had postcounseling BPCR index below average, i.e., <50% (P < 0.05).

CONCLUSIONS

The results of the present study revealed that focused birth preparedness counseling on complication readiness could play an important role in increasing the baseline knowledge of pregnant females regarding pregnancy-related complications and bring out desirable ideal health-seeking behavior changes during pregnancy.

Birth preparedness and complication readiness practice and influencing factors among women in Sodo town, Wolaita zone, Southern Ethiopia, 2018; community based cross-sectional study

Background

Birth preparedness and complication readiness (BPCR) is a strategy that helps women to consider all available maternal health care services during pregnancy and prepare for potential complications. Though global annual number of maternal deaths decreased to an estimated 303,000 in 2015, avoidable morbidity and mortality remains a formidable challenge in many developing countries which account for approximately 99% (302,000) of the global maternal deaths in 2015. This study aims to assess the practice and factors associated with birth preparedness and complication readiness among women in Sodo town, Wolaita zone, Southern Ethiopia; 2018.

Methods

Community-based cross-sectional study was carried out from June 1–30, 2018. A total of 495 (pregnant and recently delivered women), were randomly selected and interviewed using pretested structured questionnaire. The data were entered using EPI Data version 3.1 and analyzed using SPSS version 20. Descriptive statistics were reported and bivariate and multivariable logistic regression was carried out to see the effect of each independent variable on the dependent variable.

Result

Of 506 sampled participants, 495 (49.5% pregnant and 50.5% recently delivered) participated, which made a response rate of 97.8%. 48.5% of women were prepared for birth and ready for its complication in the study area. From multivariable analysis, women in the age group of 15–24 (AOR = 2.39, 95% C. I = 1.19, 4.46) and 25–34 years (AOR = 1.89, 95% C. I = 1.10, 3.25); women who attended college and above level of education (AOR = 2.07, C. I = 1.11, 3.88); women counseled to prepare potential blood donors (AOR = 1.90, 95% C. I = 1.15, 3.12) and to identify skilled birth attendants prior to birth (AOR = 1.59, 95% C. I = 1.05, 2.39) and women whose partners and/or families were counseled (AOR = 2.16, 95%C.I = 1.25, 3.74) were factors positively associated with birth preparedness and complication readiness practice.

Conclusion

Although not satisfactory in view of expectations, a relatively higher practice of birth preparedness and complication readiness had been observed in the study area compared with the previous reports. Healthcare workers at the grassroots should be encouraged to involve women’s partners and/or family members while explaining birth preparedness and complication readiness with a special emphasis on older (> 35 years) and uneducated women in order to improve the practice in the study area.

Deferred and referred deliveries contribute to stillbirths in the Indian state of Bihar: results from a population-based survey of all births

BACKGROUND

The India Newborn Action Plan (INAP) aims for < 10 stillbirths per 1000 births by 2030. A population-based understanding of risk factors for stillbirths compared with live births that could assist with reduction of stillbirths is not readily available for the Indian population.

METHODS

Detailed interviews were conducted in a representative sample of all births between January and December 2016 from 182,486 households (96.2% participation) in 1657 clusters in the Indian state of Bihar. A stillbirth was defined as foetal death with gestation period of ≥ 7 months wherein the foetus did not show any sign of life. The association of stillbirth was investigated with a variety of risk factors among all births using a hierarchical logistic regression model approach.

RESULTS

A total of 23,940 births including 338 stillbirths were identified giving the state stillbirth rate (SBR) of 15.4 (95% CI 13.2-17.9) per 1000 births, with no difference in SBR by sex. Antepartum and intrapartum SBR was 5.6 (95% CI 4.3-7.2) and 4.5 (95% CI 3.3-6.1) per 1000 births, respectively. Detailed interview was available for 20,152 (84.2% participation) births including 275 stillbirths (81.4% participation). In the final regression model, significantly higher odds of stillbirth were documented for deliveries with gestation period of ≤ 8 months (OR 11.36, 95% CI 8.13-15.88), for first born (OR 5.79, 95% CI 4.06-8.26), deferred deliveries wherein a woman was sent back home and asked to come later for delivery by a health provider (OR 5.51, 95% CI 2.81-10.78), and in those with forceful push/pull during the delivery by the health provider (OR 4.85, 95% CI 3.39-6.95). The other significant risk factors were maternal age ≥ 30 years (OR 3.20, 95% CI 1.52-6.74), pregnancies with multiple foetuses (OR 2.82, 95% CI 1.49-5.33), breech presentation of the baby (OR 2.70, 95% CI 1.75-4.18), and births in private facilities (OR 1.75, 95% CI 1.19-2.56) and home (OR 2.60, 95% CI 1.87-3.62). Varied risk factors were associated with antepartum and intrapartum stillbirths. Birth weight was available only for 40 (14.5%) stillborns. Among the facility deliveries, the women who were referred from one facility to another for delivery had significantly high odds of stillbirth (OR 3.32, 95% CI 2.03-5.43).

CONCLUSIONS

We found an increased risk of stillbirths in deferred and referred deliveries in addition to demographic and clinical risk factors for antepartum and intrapartum stillbirths, highlighting aspects of health care that need attention in addition to improving skills of health providers to reduce stillbirths. The INAP could utilise these findings to further strengthen its approach to meet the stillbirth reduction target by 2030.

Health-seeking behaviour among antenatal and postnatal rural women in Kancheepuram District of Tamil Nadu: A cross-sectional Study

Introduction:

Maternal morbidity and mortality is still a major public health challenge. Lack of proper birth plan and delay in identification of pregnancy complications is one of the major causes of maternal morbidities and deaths, especially in the rural areas.

Aim:

The study was conducted with the aim to evaluate the health-seeking behaviour for obstetric care services among the antenatal and postnatal mothers in a rural area of Tamil Nadu.

Materials and Methods:

This descriptive cross-sectional study was done among antenatal and postnatal mothers registered in the Rural Health Training Centre, in Sripuram area of Kancheepuram district, Tamil Nadu during 2017. About 150 antenatal and 150 postnatal mothers were selected by simple random sampling method. A pre-tested structured questionnaire was used to collect relevant data which was analysed using the SPSS version 22.

Results:

Only 21% of the study participants had adequate knowledge regarding the danger signs of pregnancy and the major determinants were maternal literacy and adequate prenatal care. Regarding the health-seeking behaviour, 62.3% of them preferred primary health centres as preferred place of delivery, 87.3% of them had received adequate prenatal care and it was found to have statistically significant association with adequate gestational weight gain, exclusive breastfeeding, proper weaning practices and consumption of iron and folic acid supplements.

Conclusion:

The study shows the need to provide health education regarding the danger signs of pregnancy and importance of adequate prenatal care to all pregnant women and expectant mothers, to make them aware of when and how to seek medical care, which in turn could reduce the overall maternal morbidity and mortality.

Maternal health care access among migrant women labourers in the selected brick kilns of district Faridabad, Haryana: mixed method study on equity and access

BACKGROUND

Socio-economic inequity leads to health inequity. Inequity is closely intertwined with internal migration. This study was planned with the objective of documenting the maternal health care utilization among women labourers working in brick kilns situated in an area of Haryana, north India.

METHODS

A community based mixed method study was done in select brick kilns of Faridabad district in north India. A mixed method study was done to assess maternal health care utilization in a sample of 500 women in the reproductive age group. Focus group discussions were also carried out. Descriptive analysis was done. Qualitative data was analysed using the thematic framework approach.

RESULTS

The mean age of the women was 30 (SD 0.3) years. Mean number of pregnancies per woman was 3.1 (SD 1.7). Only 22.9% ever had institutional delivery. About one third of women had ever received cash benefit under Janani SurakshaYojana (JSY) or had ever used free ambulance services. Seven major themes emerged from the qualitative analysis. Important themes include-Gaps in knowledge regarding local health system; Sub-standard private health care delivered at brick kilns prevent migrants from accessing the basic public health services; Misconceptions and mistrust about public health system influenced maternal health care utilization; Barriers to avail universal health coverage: location of brick kilns, time, apathy of public health system, partial health insurance cover.

CONCLUSIONS

A typical migrant woman labourer in the brick kiln was an illiterate, had migrated from poor states, belonged to a socially disadvantaged community and worked long hours, and had been doing so for many years. This study has identified migrant women working in brick kilns as a vulnerable population subgroup in terms of maternal health utilization. To achieve universal health care it is important to understand the needs of all population subgroups and make concerted efforts at the health system level.