Professional assistance during birth and maternal mortality in two Indonesian districts

Trends and causes of maternal mortality in Indonesia: a systematic review

BACKGROUND

The maternal mortality ratio (MMR) in Indonesia is among the highest in Southeast Asia. We aim to describe trends in the MMR and causes of maternal deaths in Indonesia over the past decades, regionally and nationally.

METHODS

We performed a systematic review and conducted a search using PubMed, Embase, Global Health, CINAHL, Cochrane, Portal Garuda, and Google Scholar from the inception of the database to April 2023. We included all studies on the incidence and/or the causes of maternal deaths in Indonesia. The MMR was defined as the number of maternal deaths per 100,000 live births. Maternal death causes were assessed and reclassified according to the WHO International Classification of Disease Maternal Mortality (ICD-MM).

RESULTS

We included 63 studies that reported the MMR (54 studies) and/or the causes of maternal deaths (44 studies) in Indonesia from 1970 to 2022, with a total of 254,796 maternal deaths. The national MMR declined from 450 to 249 (45%) between 1990 and 2020. Great differences in MMR exist across the country, with the lowest in Java-Bali and the highest (more than twice the national MMR) in Sulawesi and Eastern Indonesia. Between 1990 and 2022, the proportion of deaths due to hemorrhage and sepsis decreased, respectively from 48 to 18% and 15-5%, while the share of deaths due to hypertensive disorders and non-obstetric causes increased, respectively from 8 to 19% and 10-49%.

CONCLUSION

Despite the steady decline of maternal deaths in Indonesia, it remains one of the highest in Southeast Asia, with enormous disparities within the country. Hypertensive disorders and non-communicable diseases make up a growing share of maternal deaths, making maternal death reduction strategies increasingly challenging. National Maternal Death Surveillance and Response needs to be prioritized to eliminate preventable maternal deaths in Indonesia.

REGISTRATION OF SYSTEMATIC REVIEWS

PROSPERO, CRD42022320213.

Prevalence and determinants of early neonatal mortality in Ethiopia: findings from the Ethiopian Demographic and Health Survey 2016

BACKGROUND

Early neonatal death accounts for a significant number of under-5 mortality worldwide. However, the problem is under-researched and under-reported in low-income and middle-income countries, particularly in Ethiopia. The magnitude of mortality during the early neonatal period and associated factors should be studied for designing appropriate policies, and strategies that could help tackle the problem. Hence, this study aimed to determine the prevalence and identify factors associated with early neonatal mortality in Ethiopia.

METHODS

This study was conducted by using data from Ethiopian Demographic and Health Survey 2016. A total of 10 525 live births were enrolled in the study. A multilevel logistic regression model was used to identify determinants of early neonatal mortality. Adjusted OR (AOR) at a 95% CI was computed to assess the strength and significance of the association between outcome and explanatory variables. Factors with a p<0.05 were declared statistically significant.

RESULTS

The national prevalence of early neonatal mortality in Ethiopia was 41.8 (95% CI 38.1 to 45.8) early neonatal deaths per 1000 live births. The extreme ages of pregnancy (under 20 years (AOR 2.7, 95% CI 1.3 to 5.5) and above 35 years (AOR 2.4, 95% CI 1.5 to 4)), home delivery (AOR 2.4, 95% CI 1.3 to 4.3), low birth weight (AOR 3.3, 95% CI 1.4 to 8.2) and multiple pregnancies (AOR 5.3, 95% CI 4.1 to 9.9) were significantly associated early neonatal mortality.

CONCLUSIONS

This study revealed a higher prevalence of early neonatal mortality as compared with prevalence in other low-income and middle-income countries. Thus, it is determined to be essential to design maternal and child health policies and initiatives with a priority on the prevention of early neonatal deaths. Emphasis should be given to babies born to mothers at extreme ages of pregnancy, to those born of multiple pregnancies delivered at home and to low birthweight babies.

Supply-side readiness to deliver HIV testing and treatment services in Indonesia: Going the last mile to eliminate mother-to-child transmission of HIV

INTRODUCTION

Despite national efforts to integrate Prevention of Mother-to-Child Transmission (PMTCT) of HIV services into antenatal care in Indonesia, the rate of mother-to-child transmission of HIV remains the highest in the world. A range of barriers to uptake and long-term engagement in care have been identified, but far less is known about health system preparedness to deliver PMTCT of HIV services. This study explored supply-side barriers to the delivery of PMTCT services in Indonesia and whether these factors are associated with the uptake of antenatal HIV testing.

MATERIALS AND METHODS

An ecological analysis was undertaken, linking data from the World Bank Quality Service and Delivery Survey (2016) with routine data from Indonesia's HIV and AIDS case surveillance system and district health profile reports (2016). Supply-side readiness scores-generated from a readiness index that measures overall structural capacity and is often used as proxy for quality of care-were adapted from the WHO Service Availability and Readiness Assessment and presented by sector and geographic area. Univariate and multivariate regression analysis was used to explore factors associated with the uptake of antenatal HIV testing in public facilities.

RESULTS

In general, public facilities scored more highly in most inputs compared to private facilities. Facilities located in urban areas also scored more highly in the majority of inputs compared to ones in rural areas. Readiness scores were lowest for PMTCT services compared to Antenatal Care and HIV Care and Support services, especially for the availability of medicines such as zidovudine and nevirapine. The national composite readiness score for PMTCT was only 0.13 (based on a maximum score of 1) with a composite score of 0.21 for public facilities and 0.06 for private facilities. The multivariate analysis shows that the proportion of pregnant women tested for HIV was more likely to be greater than or equal to 10% in facilities with a higher readiness score and a higher number of trained counsellors available, and less likely in facilities located outside of Java-Bali and in facilities supporting a higher number of village midwives.

DISCUSSION

Despite targeted efforts by the Indonesian government and multinational agencies, significant gaps exist in the delivery of PMTCT that compromise the standard of care delivered in Indonesia. Future strategies should focus on improving the availability of tests and treatment, especially in the private sector and in rural areas.

The impact of institutional delivery on neonatal and maternal health outcomes: evidence from a road upgrade programme in India

INTRODUCTION

Persistently high rates of neonatal and maternal mortality have been associated with home births in many low-income and middle-income countries (LMICs). However, causal evidence of the effect of institutional deliveries on neonatal and maternal health outcomes is limited in these settings.

METHODS

We investigate the effect of institutional deliveries on neonatal mortality and maternal postpartum complications in rural India using data from the 2015-2016 Indian Demographic and Health Survey and an instrumental variable methodology to overcome selection bias issues inherent in observational studies. Specifically, we exploit plausibly exogenous variation in exposure to a road upgrade programme that quasi-randomly upgraded roads to villages across India.

RESULTS

We find large effects of the road construction programme on the probability that a woman delivered in a health facility: moving from an unconnected village to a connected village increased the probability of an institutional delivery by 13 percentage points, with the biggest increases in institutional delivery observed in public hospitals and among women with lower levels of education and from poorer households. However, we find no evidence that increased institutional delivery rates improved rates of neonatal mortality or postpartum complications, regardless of whether the delivery occurred in a public or private facility, or if it was with a skilled birth attendant.

CONCLUSION

Policies that encourage institutional delivery do not always translate into increased health outcomes and should thus be complemented with efforts to improve the quality of care to improve neonatal and maternal health outcomes in LMICs.

Estimating maternity ward birth attendant time use in India: a microcosting study

OBJECTIVES

Despite global concern over the quality of maternal care, little is known about the time requirements to complete the essential birth practices. Using three microcosting data collection methods within the BetterBirth trial, we aimed to assess time use and the specific time requirements to incorporate the WHO Safe Childbirth Checklist into clinical practice.

SETTING

We collected detailed survey data on birth attendant time use within the BetterBirth trial in Uttar Pradesh, India. The BetterBirth trial tested whether the peer-coaching-based implementation of the WHO Checklist was effective in improving the quality of facility-based childbirth care.

PARTICIPANTS

We collected measurements of time to completion for 18 essential birth practices from July 2016 through October 2016 across 10 facilities in five districts (1559 total timed observations). An anonymous survey asked about the impact of the WHO Checklist on birth attendants at every intervention facility (15 facilities, 83 respondents) in the Lucknow hub. Additionally, data collectors visited facilities to conduct a census of patients and birth attendants across 20 facilities in seven districts between June 2016 and November 2016 (six hundred and ten 2-hour facility observations).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure of this study is the per cent of staff time required to complete the essential birth practices included in the WHO Checklist.

RESULTS

When birth attendants were timed, we found practices were completed rapidly (18 s to 2 min). As the patient load increased, time dedicated to clinical care increased but remained low relative to administrative and downtime. On average, WHO Checklist clinical care accounted for less than 7% of birth attendant time use per hour.

CONCLUSIONS

We did not find that a coaching-based implementation of the WHO Checklist was a burden on birth attendant's time use. However, questions remain regarding the performance quality of practices and how to accurately capture and interpret idle and break time.

TRIAL REGISTRATION NUMBER

NCT02148952.

Maternal and Child Health Handbook use for maternal and child care: a cluster randomized controlled study in rural Java, Indonesia

Background

Effectiveness of the Maternal and Child Health Handbook (MCHHB), a home-based booklet for pregnancy, delivery and postnatal/child health, was evaluated on care acquisition and home care in rural Java, a low service-coverage area.

Methods

We conducted a health centre-based randomized trial, with a 2-year follow-up. Intervention included (i) MCHHB provision at antenatal care visits; (ii) records and guides by health personnel on and with the MCHHB; and (iii) sensitization of care by volunteers using the MCHHB.

Results

The follow-up rate was 70.2% (183, intervention area; 271, control area). Respondents in the intervention area received consecutive MCH services including two doses of tetanus toxoid injections and antenatal care four times or more during pregnancy, professional assistance during child delivery and vitamin A supplements administration to their children, after adjustment for confounding variables and cluster effects (OR = 2.03, 95% CI: 1.19–3.47). In the intervention area, home care (continued breastfeeding; introducing complementary feeding; proper feeding order; varied foods feeding; self-feeding training; and care for cough), perceived support by husbands, and lower underweight rates and stunting rates among children were observed.

Conclusion

MCHHB use promoted continuous care acquisition and care at home from pregnancy to early child-rearing stages in rural Java.

Effects of a sister's death in childbirth on reproductive behaviors: Difference-in-difference analyses using sisterhood mortality data from Indonesia

RATIONALE

Risk of maternal mortality increases rapidly during the intrapartum period making skilled care at delivery an effective intervention to reduce the risk of maternal death. Demand generation for skilled care typically focuses on institutional channels; however, much less attention has been paid to whether what women may learn through their social networks can potentially influence their choice of delivery care.

OBJECTIVE

The objective of this study was to analyze whether a sister's death in childbirth has the potential to improve delivery care choices for women who experience this event.

METHODS

This study uses retrospective reports of sister deaths - either in childbirth or from some other cause - reported in the sisterhood moratlity module from five waves of the Indonesia Demographic and Health Surveys (IDHS) spanning 1989 to 2012. A cross-sectional, difference-in-difference strategy compares delivery care behavior of women before and after losing a sister in childbirth to women before and after losing a sister of reproductive age from some other cause in an intent-to-treat framework.

RESULTS

Women are less likely to give birth at home after losing a sister in childbirth relative to women who lose a sister from some other cause. Losing a sister in childbirth may trigger behaviors that help usher women of lower socioeconomic status into formal delivery care.

CONCLUSION

This study extends the literature on health behavior change through social networks to improve delivery care. Public health campaigns should consider social networks when designing messages around maternal mortality in order to help women at risk of maternal mortality make decisions that reduce their risk of and ultimately avoid maternal death.

Savings ownership and the use of maternal health services in Indonesia

In low- and middle-income countries (LMICs), many women of reproductive age experience morbidity and mortality attributable to inadequate access to and use of health services. Access to personal savings has been identified as a potential instrument for empowering women and improving access to and use of health services. Few studies, however, have examined the relation between savings ownership and use of maternal health services. In this study, we used data from the Indonesian Family Life Survey to examine the relation between women's savings ownership and use of maternal health services. To estimate the effect of obtaining savings ownership on our primary outcomes, specifically receipt of antenatal care, delivery in a health facility and delivery assisted by a skilled attendant, we used a propensity score weighted difference-in-differences approach. Our findings showed that acquiring savings ownership increased the proportion of women who reported delivering in a health facility by 22 percentage points [risk difference (RD) = 0.22, 95%CI = 0.08-0.37)] and skilled birth attendance by 14 percentage points (RD = 0.14, 95%CI = 0.03-0.25). Conclusions were qualitatively similar across a range of model specifications used to assess the robustness of our main findings. Results, however, did not suggest that savings ownership increased the receipt of antenatal care, which was nearly universal in the sample. Our findings suggest that under certain conditions, savings ownership may facilitate the use of maternal health services, although further quasi-experimental and experimental research is needed to address threats to internal validity and strengthen causal inference, and to examine the impact of savings ownership across different contexts.

Understanding the determinants of maternal mortality: An observational study using the Indonesian Population Census

BACKGROUND

For countries to contribute to Sustainable Development Goal 3.1 of reducing the global maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030, identifying the drivers of maternal mortality is critically important. The ability of countries to identify the key drivers is however hampered by the lack of data sources with sufficient observations of maternal death to allow a rigorous analysis of its determinants. This paper overcomes this problem by utilising census data. In the context of Indonesia, we merge individual-level data on pregnancy-related deaths and households' socio-economic status from the 2010 Indonesian population census with detailed data on the availability and quality of local health services from the Village Census. We use these data to test the hypothesis that health service access and quality are important determinants of maternal death and explain the differences between high maternal mortality and low maternal mortality provinces.

METHODS

The 2010 Indonesian Population Census identifies 8075 pregnancy-related deaths and 5,866,791 live births. Multilevel logistic regression is used to analyse the impacts of demographic characteristics and the existence of, distance to and quality of health services on the likelihood of maternal death. Decomposition analysis quantifies the extent to which the difference in maternal mortality ratios between high and low performing provinces can be explained by demographic and health service characteristics.

FINDINGS

Health service access and characteristics account for 23% (CI: 17.2% to 28.5%) of the difference in maternal mortality ratios between high and low-performing provinces. The most important contributors are the number of doctors working at the community health centre (8.6%), the number of doctors in the village (6.9%) and distance to the nearest hospital (5.9%). Distance to health clinics and the number of midwives at community health centres and village health posts are not significant contributors, nor is socio-economic status. If the same level of access to doctors and hospitals in lower maternal mortality Java-Bali was provided to the higher maternal mortality Outer Islands of Indonesia, our model predicts 44 deaths would be averted per 100,000 pregnancies.

CONCLUSION

Indonesia has employed a strategy over the past several decades of increasing the supply of midwives as a way of decreasing maternal mortality. While there is evidence of reductions in maternal mortality continuing to accrue from the provision of midwife services at village health posts, our findings suggest that further reductions in maternal mortality in Indonesia may require a change of focus to increasing the supply of doctors and access to hospitals. If data on maternal death is collected in a subsequent census, future research using two waves of census data would prove a useful validation of the results found here. Similar research using census data from other countries is also likely to be fruitful.

Outcomes by birth setting and caregiver for low risk women in Indonesia: a systematic literature review

BACKGROUND

Care for women during pregnancy, labour, birth and the postpartum period is essential to reducing maternal and neonatal mortality and morbidity, however the ideal place and organisation of care provision has not been established. The World Health Organization recommends a two-tier maternity care system involving first-level care in community facilities, with backup obstetric hospital care. However, evidence from high-income countries is increasingly showing benefits for low risk women birthing outside of hospital with skilled birth assistance and access to backup care, including lower rates of intervention. Indonesia is a lower middle-income country with a network of village based midwives who attend births at homes, clinics and hospitals, and has reduced mortality rates in recent decades while maintaining largely low rates of intervention. However, the country has not met its neonatal or maternal mortality reduction goals, and it is unclear whether greater improvements could be made if all women birthed in hospital. BODY: This paper reviewed the literature on birth outcomes by place of birth and/or caregiver for women considering their risk of complications in Indonesia. A systematic literature search of Pubmed, CINAHL, CENTRAL, Web of Science, Popline, WHOLIS and clinical trials registers in 2016 and updated in 2018 resulted in screening 2211 studies after removing duplicates. Twenty four studies were found to present outcomes by place of birth or caregiver and were included. The studies were varied in their findings with respect of the outcomes for women birthing at home and in hospital, with and without skilled care. The quality of most studies was rated as poor or moderate using the Effective Public Health Practice Project Quality Assessment Tool. Only one study gave an overall assessment of the risk status of the women included, making it impossible to draw conclusions about outcomes for low risk women specifically; other studies adjusted for various individual risk factors.

CONCLUSION

From the studies in this review, it is impossible to assess the outcomes for low risk women birthing with health professionals within and outside of Indonesian hospitals. This finding is supported by reviews from other countries with developing maternity systems. Better evidence and information is needed before determinations can be made about whether attended birth outside of hospitals is a safe option for low risk women outside of high income countries.

Cash on delivery: Results of a randomized experiment to promote maternal health care in Kenya

We conducted a randomized controlled experiment to test whether vouchers, cash transfers, and SMS messages were effective in boosting facility delivery rates among poor, pregnant women in rural Kenya. We find a strong effect of the full vouchers and the conditional cash transfers: 48% of women with access to both interventions delivered in a health facility, while only 36% of those with neither did. Amongst women who did not receive a cash transfer, we find that a small copayment dramatically reduced voucher effectiveness, suggesting a discontinuous impact of cost-sharing on the demand for health services. Both the unconditional cash transfer and the text messages had limited effect on the use of health services. Finally, we also find no evidence that a government policy to eliminate user fees increased demand for maternal health services.

District-level impacts of health system decentralization in Indonesia: A systematic review

The local-level impacts of decentralizing national health systems are significant yet infrequently examined. This review aims to assess whether localized health services delivery in Indonesia, which commenced a health system decentralization process in 2001, achieved its objectives or could be enhanced. A systematic review was undertaken to collate published evidence regarding this topic and synthesize key findings holistically using the six building blocks framework of the World Health Organization (WHO) to categorize health system performance. Four research databases were searched in 2016 for relevant evidence published between 2001 and 2015. The inclusion criteria were relevance to the topic of decentralization impacts at the district level, original research, and published in English. Included articles were appraised for quality using a standardized tool, with key findings synthesized using the WHO building blocks. Twenty-nine articles met the inclusion criteria and categorized under the WHO building blocks categories. The findings highlight problematic impacts of decentralization related to three building blocks: service delivery, health financing, and workforce. In the 15 years of post-decentralization in Indonesia, the service delivery, health workforce, and health financing blocks should be prioritized for further research and policy evaluation to improve the overall health system performance at the district level.

Expanding the scope beyond mortality: burden and missed opportunities in maternal morbidity in Indonesia

Background: Indonesia still faces challenges in maternal health. Specifically, the lack of information on community-level maternal morbidity. The relatively high maternal healthcare non-utilization in Indonesia intensifies this problem.

Objective: To describe the burden of community-level maternal morbidity in Indonesia. Additionally, to evaluate the extent and determinants of missed opportunities in women with maternal morbidity.

Methods: We used three cross-sectional surveys (Indonesian Demographic and Health Survey, IDHS 2002, 2007 and 2012). Crude and adjusted proportions of maternal morbidity burden were estimated from 43,782 women. We analyzed missed opportunities in women who experienced maternal morbidity during their last birth (n = 19,556). Multilevel mixed-effects logistic regressions were used to evaluate the determinants of non-utilization in IDHS 2012 (n = 6762).

Results: There were significant increases in the crude and adjusted proportion of maternal morbidity from IDHS 2002 to IDHS 2012 (p < 0.05). In 2012, the crude proportion of maternal morbidity was 53.7%, with adjusted predicted probability of 51.4%. More than 90% of these morbidities happened during labor. There were significant decreases in non-utilization of maternal healthcare among women with morbidity. In 2012, 20.0% of these women did not receive World Health Organization (WHO) standard antenatal care. In addition, 7.1% did not have a skilled provider at birth, and 25.0% delivered outside of health facilities. Higher proportions of non-utilization happened in women who were younger, multiparous, of low socioeconomic status (SES), and living in less-developed areas. In multilevel analyses, missed opportunities in healthcare utilization were strongly related to low SES and low-resource areas in Indonesia.

Conclusion: The prevalence of maternal morbidity in Indonesia is relatively high, especially during labor. This condition is amplified by the concerning missed opportunities in maternal healthcare. Efforts are needed to identify risk factors for maternal morbidity, as well as increasing healthcare coverage for the vulnerable population.

Can facility delivery reduce the risk of intrapartum complications-related perinatal mortality? Findings from a cohort study

Background

Intrapartum complications increase the risk of perinatal deaths. However, population-based data from developing countries assessing the contribution of intrapartum complications to perinatal deaths is scarce.

Methods

Using data from a cohort of pregnant women followed between 2011 and 2013 in Bangladesh, this study examined the rate and types of intrapartum complications, the association of intrapartum complications with perinatal mortality, and if facility delivery modified the risk of intrapartum-related perinatal deaths. Trained community health workers (CHWs) made two-monthly home visits to identify pregnant women, visited them twice during pregnancy and 10 times in the first two months postpartum. During prenatal visits, CHWs collected data on women’s prior obstetric history, socio-demographic status, and complications during pregnancy. They collected data on intrapartum complications, delivery care, and pregnancy outcome during the first postnatal visit within 7 days of delivery. We examined the association of intrapartum complications and facility delivery with perinatal mortality by estimating odds ratios (OR) and 95% confidence intervals (CI) adjusting for covariates using multivariable logistic regression analysis.

Results

The overall facility delivery rate was low (3922/24 271; 16.2%). Any intrapartum complications among pregnant women were 20.9% (5,061/24,271) and perinatal mortality was 64.7 per 1000 birth. Compared to women who delivered at home, the risk of perinatal mortality was 2.4 times higher (OR = 2.40; 95% CI = 2.08-2.76) when delivered in a public health facility and 1.3 times higher (OR = 1.32, 95% CI = 1.06-1.64) when delivered in a private health facility. Compared to women who had no intrapartum complications and delivered at home, women with intrapartum complications who delivered at home had a substantially higher risk of perinatal mortality (OR = 3.45; 95% CI = 3.04-3.91). Compared to women with intrapartum complications who delivered at home, the risk of perinatal mortality among women with intrapartum complications was 43.0% lower for women who delivered in a public health facility (OR = 0.57; 95% CI = 0.42-0.78) and 58.0% lower when delivered in a private health facility (OR = 0.42; 95% CI = 0.28-0.63).

Conclusions

Maternal health programs need to promote timely recognition of intrapartum complications and delivery in health facilities to improve perinatal outcomes, particularly in populations where overall facility delivery rates are low. The differential risk between public and private health facilities may be due to differences in quality of care. Efforts should be made to improve the quality of care in all health facilities.

Maternal mortality as a Millennium Development Goal of the United Nations: a systematic assessment and analysis of available data in threshold countries using Indonesia as example

Background

In 2015 the proposed period ended for achieving the Millennium Development Goals (MDG) of the United Nations targeting to lower maternal mortality worldwide by ~ 75%. 99% of these cases appear in developing and threshold countries; but reports mostly rely on incomplete or unrepresentative data. Using Indonesia as example, currently available data sets for maternal mortality were systematically reviewed.

Methods

Besides analysis of international and national data resources, a systematic review was carried out according to Cochrane methodology to identify all data and assessments regarding maternal mortality.

Results

Overall, primary data on maternal mortality differed significantly and were hardly comparable. For 1990 results varied between 253/100 000 and 446/100 000. In 2013 data appeared more conclusive (140–199/100 000). An annual reduction rate (ARR) of –2.8% can be calculated.

Conclusion

Reported data quality of maternal mortality in Indonesia is very limited regarding comprehensive availability and methodology. This limitation appears to be of general importance for the targeted countries of the MDG. Primary data are rare, not uniformly obtained and not evaluated by comparable methods resulting in very limited comparability. Continuous small data set registration should have high priority for analysis of maternal health activities.

Skilled attendant at birth and newborn survival in Sub-Saharan Africa

BACKGROUND

Recent studies have shown higher neonatal mortality among births delivered by a skilled attendant at birth (SAB) compared to those who were not in sub-Saharan African countries. Deaths during the neonatal period are concentrated in the first 7 days of life, with about one third of these deaths occurring during the first day of life. We reassessed the relationship between SAB and neonatal mortality by distinguishing deaths on the first day of life from those on days 2-27.

METHODS

We used data on births in the past five years from recent demographic and health survey (DHS) between 2010 and 2014 in 20 countries in sub-Saharan Africa. The main categorical outcome was 1) newborns who died within the first day of birth (day 0-1), 2) newborns who died between days 2-27, and 3) newborns who survived the neonatal period. We ran generalized linear mixed model with multinomial distribution and random effect for country on pooled data. Additionally, we ran a separate model restricted to births with SAB and assessed the association of receipt of seven antenatal care (ANC) and two immediate postnatal care interventions on risk of death on days 0-1 and days 2-27. These variables were assessed as proxy of quality of antenatal and postnatal care.

RESULTS

We found no statistically significant difference in risk of death on first day of life between newborns with SAB compared to those without. However, after the first day of life, newborns delivered with SAB were 16% less likely to die within 2-27 days than those without SAB (OR = 0.84, 95% CI = 0.71-0.99). Among births with skilled attendant, those who were weighed at birth and those who were initiated early on breastfeeding were significantly less likely to die on days 0-1 (respectively OR = 0.42 95% CI = 0.29-0.62 and OR = 0.24, 95% CI 0.18-0.31) or on days 2-27 (OR = 0.60, 95% CI = 0.45-0.81 and OR = 0.59, 95% CI = 47-0.74, respectively). Newborns whose mothers received an additional ANC intervention had no improved survival chances during days 0-1 of life. However, there was significant association on days 2-27 where newborns whose mothers received an additional ANC interventions had higher survival chances (OR = 0.95, 95% CI = 0.93-0.98).

CONCLUSION

Findings demonstrate the vulnerability of newborns immediately after birth, compounded with insufficient quality of care. Improving the quality of care around the time of birth will significantly improve survival and therefore accelerate reduction in neonatal mortality in sub-Saharan African countries. Improved approaches for measuring skilled attendant at birth are also needed.

Exploring the associations between intimate partner violence victimization during pregnancy and delayed entry into prenatal care: Evidence from a population-based study in Bangladesh

OBJECTIVE

Intimate partner violence (IPV) during pregnancy can have serious health consequences for mothers and newborns. The aim of the study is to explore: 1) the influence of experiencing IPV during pregnancy on delayed entry into prenatal care; and 2) whether women's decision-making autonomy and the support for traditional gender roles act to mediate or moderate the relationship between IPV and delayed entry into prenatal care.

DESIGN

cross-sectional survey. Multivariate logistic regression models were estimated that control for various socio-demographic and pregnancy related factors to assess whether women who experienced IPV during pregnancy were more likely to delay entry into prenatal care compared with women who had not experienced IPV. The influence of traditional gender roles acceptance and decision-making autonomy were examined both as independent variables and in interaction with IPV, to assess their role as potential mediators or moderators.

SETTING

Chandpur district, Bangladesh.

PARTICIPANTS

the sample comprised of 426 Bangladeshi women, aged 15-49 years. Postpartum mothers who visited vaccinations centres to receive their children's vaccinations constitute the sampling frame.

RESULTS

almost 70% of the women surveyed reported patterns consistent with delayed entry into prenatal care. Accounting for the influence of other covariates, women who experienced physical IPV during pregnancy were 2.61 times more likely (95% CI [1.33, 5.09]) to have delayed entry into prenatal care than their counterparts who did not report physical IPV. Neither sexual nor psychological IPV victimization during pregnancy was linked with late entry into prenatal care. Both gender role attitudes and levels of autonomy mediate the effect of IPV on prenatal care.

KEY CONCLUSIONS

the results suggest that the high rates of IPV in Bangladesh have effects that can compromise women's health seeking behaviour during pregnancy, putting them and their developing fetus at risk. Specifically, Bangladeshi women who experience physical IPV during pregnancy are more likely to delay or forgo prenatal care, an effect that is further magnified by cultural ideals that emphasize women's traditional roles and limit their autonomy.

IMPLICATIONS FOR PRACTICE

this study reinforces the need to detect and assist women suffering IPV, not only to offer them help and support but also to increase entry into prenatal care. Healthcare professionals involved in obstetrics and midwifery need to be aware of the risk factors of IPV during pregnancy and be able to identify women who are at risk for delayed entry into prenatal care.

Regional differences in usage of antenatal care and safe delivery services in Indonesia: findings from a nationally representative survey

BACKGROUND

Indonesia has shown a nominal increase in antenatal care (ANC) coverage from 93% to 96% in the Indonesia Demographic Health Survey (IDHS)-2012. This is high but for a comprehensive assessment of maternal health coverage in Indonesia, safe delivery services need to be assessed in conjunction with ANC coverage.

MATERIALS AND METHODS

The study uses survey data from the IDHS-2012 that was conducted among women aged 15-49 years who gave birth during the past 3 years preceding the survey. Socioeconomic and demographic factors affecting ANC coverage and safe delivery services are analysed by segregating the data into 7 regions of Indonesia.

RESULTS

Multivariate results show that besides wealth and education differentials, regional differences significantly affect the usage of ANC and safe delivery services across the 7 regions. Univariate analyses show that Sulawesi, Maluku and Western New Guinea islands are at a disadvantage in accessing ANC and safe delivery services.

CONCLUSIONS

The study recommends that disaggregated regional targets be set in order to further reduce maternal mortality rates in Indonesia.

The scale, scope, coverage, and capability of childbirth care

All women should have access to high quality maternity services-but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

Inequalities in the coverage of place of delivery and skilled birth attendance: analyses of cross-sectional surveys in 80 low and middle-income countries

BACKGROUND

Having a health worker with midwifery skills present at delivery is one of the key interventions to reduce maternal and newborn mortality. We sought to estimate the frequencies of (a) skilled birth attendant coverage, (b) institutional delivery, and (c) the combination of place of delivery and type of attendant, in LMICs.

METHODS

National surveys (DHS and MICS) performed in 80 LMICs since 2005 were analyzed to estimate these four categories of delivery care. Results were stratified by wealth quintile based on asset indices, and by urban/rural residence. The combination of place of delivery and type of attendant were also calculated for seven world regions.

RESULTS

The proportion of institutional SBA deliveries was above 90 % in 25 of the 80 countries, and below 40 % in 11 countries. A strong positive correlation between SBA and institutional delivery coverage (rho: 0.97, p <0,001) was observed. Eight countries had over 10 % of home SBA deliveries, and two countries had over 10 % of institutional non-SBA deliveries. Except for South Asia, all regions had over 80 % of urban deliveries in the institutional SBA category, but in rural areas, only two regions (CEE & CIS, Middle East & North Africa) presented average coverage above 80 %. In all regions, institutional SBA deliveries were over 80 % in the richest quintile. Home SBA deliveries were more common in rural than in urban areas, and in the poorest quintiles in all regions. Facility non-SBA deliveries also tended to be more common in rural areas and among the poorest.

CONCLUSION

Four different categories of delivery assistance were identified worldwide. Pro-urban and pro-rich inequalities were observed for coverage of institutional SBA deliveries.

Maternal characteristics and clinical diagnoses influence obstetrical outcomes in Indonesia

This Indonesian study evaluates associations between near-miss status/death with maternal demographic, health care characteristics, and obstetrical complications, comparing results using retrospective and prospective data. The main outcome measures were obstetric conditions and socio-economic factors to predict near-miss/death. We abstracted all obstetric admissions (1,358 retrospective and 1,240 prospective) from two district hospitals in East Java, Indonesia between 4/1/2009 and 5/15/2010. Prospective data added socio-economic status, access to care and referral patterns. Reduced logistic models were constructed, and multivariate analyses used to assess association of risk variables to outcome. Using multivariate analysis, variables associated with risk of near-miss/death include postpartum hemorrhage (retrospective AOR 5.41, 95 % CI 2.64-11.08; prospective AOR 10.45, 95 % CI 5.59-19.52) and severe preeclampsia/eclampsia (retrospective AOR 1.94, 95 % CI 1.05-3.57; prospective AOR 3.26, 95 % CI 1.79-5.94). Associations with near-miss/death were seen for antepartum hemorrhage in retrospective data (AOR 9.34, 95 % CI 4.34-20.13), and prospectively for poverty (AOR 2.17, 95 % CI 1.33-3.54) and delivering outside the hospital (AOR 2.04, 95 % CI 1.08-3.82). Postpartum hemorrhage and severe preeclampsia/eclampsia are leading causes of near-miss/death in Indonesia. Poverty and delivery outside the hospital are significant risk factors. Prompt recognition of complications, timely referrals, standardized care protocols, prompt hospital triage, and structured provider education may reduce obstetric mortality and morbidity. Retrospective data were reliable, but prospective data provided valuable information about barriers to care and referral patterns.

Estimating Suicide Rates in Developing Nations: A Low-Cost Newspaper Capture-Recapture Approach in Cambodia

This study tested a low-cost method for estimating suicide rates in developing nations that lack adequate statistics. Data comprised reported suicides from Cambodia's 2 largest newspapers. Capture-recapture modeling estimated a suicide rate of 3.8/100 000 (95% CI = 2.5-6.7) for 2012. That compares to World Health Organization estimates of 1.3 to 9.4/100 000 and a Cambodian government estimate of 3.5/100 000. Suicide rates of males were twice that of females, and rates of those <40 years were twice that of those ≥40 years. Capture-recapture modeling with newspaper reports proved a reasonable method for estimating suicide rates for countries with inadequate official data. These methods are low-cost and can be applied to regions with at least 2 newspapers with overlapping reports. Means to further improve this approach are discussed. These methods are applicable to both recent and historical data, which can benefit epidemiological work, and may also be applicable to homicides and other statistics.

Does a ban on informal health providers save lives? Evidence from Malawi

Informal health providers ranging from drug vendors to traditional healers account for a large fraction of health care provision in developing countries. They are, however, largely unlicensed and unregulated leading to concern that they provide ineffective and, in some cases, even harmful care. A new and controversial policy tool that has been proposed to alter household health seeking behavior is an outright ban on these informal providers. The theoretical effects of such a ban are ambiguous. In this paper, we study the effect of a ban on informal (traditional) birth attendants imposed by the Malawi government in 2007. To measure the effect of the ban, we use a difference-in-difference strategy exploiting variation across time and space in the intensity of exposure to the ban. Our most conservative estimates suggest that the ban decreased use of traditional attendants by about 15 percentage points. Approximately three quarters of this decline can be attributed to an increase in use of the formal sector and the remainder is accounted for by an increase in relative/friend-attended births. Despite the rather large shift from the informal to the formal sector, we do not find any evidence of a statistically significant reduction in newborn mortality on average. The results are robust to a triple difference specification using young children as a control group. We examine several explanations for this result and find evidence consistent with quality of formal care acting as a constraint on improvements in newborn health.

Life in a landfill slum, children's health, and the Millennium Development Goals

People living in slums can be considered left behind with regard to national successes in achieving Millennium Development Goals (MDGs). The objective of this study was to evaluate the living and working conditions of waste pickers and their children in a landfill slum located in the largest city in eastern Indonesia. A total of 113 people from the landfill slum and 1184 people from the general population participated in face-to-face interviews. Municipal solid waste (MSW) was analyzed for metals, metalloids and fecal indicator bacteria. Ambient air quality including particulate matter was measured in the landfill. Households in the landfill slum were 5.73 (p=0.04) times more likely to be below the international poverty line (MDG 1: Poverty) and 15.6 times (p<0.01) more likely to have no one in the household possessing a primary education (MDG 2: Universal Education), and 107 times (p<0.01) more likely not to have improved sanitation facilities (MDG 7: Environmental Sustainability) when compared to the general population. Diarrhea is one of the leading causes of death in children under five in Indonesia. Young children living in the landfill slum were 2.87 times (p=0.02) more likely to develop diarrhea than their general population counterparts. Other survey results and environmental measurements suggest that landfill slum children have additional adverse health effects (e.g. infections and poisoning). Poverty underlies several MDG issues that directly or indirectly affect child health. Therefore, eradicating extreme poverty will continue to be the most critical challenge for the MDGs beyond 2015.

Skilled health personnel attended delivery as a proxy indicator for maternal and perinatal mortality: a systematic review

Background

Several demographic and health surveys in Africa have shown the high prevalence of home delivery, but little is known how strongly skilled person unattended deliveries are associated with maternal and perinatal mortality. The aim of this review was to assess the gross correlation of maternal mortality ratios (MMR) and perinatal mortality rates (PMR) with the proportion of skilled health personnel attended deliveries

Methods

In this study, a systematic review was conducted after a computer based literature search was run in the electronic databases from 1990 through September 2013. Bivariate linear regression analyses were done for the proportion of skilled person attended deliveries in relation with MMR, stillbirth and neonatal mortality rates using national survey data of 41 African countries.

Results

African countries with relatively small population sizes and with middle to high income were found to have above 90% skilled person attended deliveries. Several African countries with a high proportion of skilled person attended deliveries (60%–100%) were able to reduce the MMR to the range of 56–370/100,000 live births. Several Sub Saharan African (SSA) countries were far from their northern counterparts. The regression analyses demonstrated a negative correlation of the proportion of skilled health personnel attended deliveries with the MMR, stillbirth rate and neonatal mortality rate.

Conclusion

According to the national data of the included African countries, skilled delivery attendance was associated with significant reduction of maternal, fetal and neonatal mortality. SSA countries need to benchmark the experience of the North African countries to reduce the high maternal and perinatal deaths.

Oxytocin in Uniject Disposable Auto-Disable Injection System versus Standard Use for the Prevention of Postpartum Hemorrhage in Latin America and the Caribbean: A Cost-Effectiveness Analysis

Postpartum hemorrhage (PPH) is a leading cause of maternal death. Despite strong evidence showing the efficacy of routine oxytocin in preventing PPH, the proportion of women receiving it after delivery is still below 100%. The Uniject injection system prefilled with oxytocin (Uniject) has the potential advantage, due to its ease of use, to increase oxytocin utilization rates. We aimed to assess its cost-effectiveness in Latin America and the Caribbean (LAC). We used an epidemiological model to estimate: a) the impact of replacing oxytocin in ampoules with Uniject on the incidence of PPH, quality-adjusted life years (QALYs) and costs from a health care system perspective, and b) the minimum increment in oxytocin utilization rates required to make Uniject a cost-effective strategy. A consensus panel of LAC experts was convened to quantify the expected increase in oxytocin rates as a consequence of making Uniject available. Deterministic and probabilistic sensitivity analyses were performed. In the base case, the incremental cost of Uniject with respect to oxytocin in ampoules was estimated to be USD 1.00 (2013 US dollars). In the cost-effectiveness analysis, Uniject ranged from being cost-saving (in 8 out of 30 countries) to having an incremental cost-effectiveness ratio (ICER) of USD 8,990 per QALY gained. In most countries these ICERs were below one GDP per capita. The minimum required increment in oxytocin rates to make Uniject a cost-effective strategy ranged from 1.3% in Suriname to 16.2% in Haiti. Switching to Uniject could prevent more than 40,000 PPH events annually in LAC. Uniject was cost-saving or very cost-effective in almost all countries. Even if countries can achieve only small increases in oxytocin rates by incorporating Uniject, this strategy could be considered a highly efficient use of resources. These results were robust in the sensitivity analysis under a wide range of assumptions.

Who is left behind on the road to universal facility delivery? A cross-sectional multilevel analysis in rural Tanzania

OBJECTIVES

To examine factors associated with home delivery among women in Pwani Region, Tanzania, which has experienced a rapid rise in facility delivery coverage.

METHODS

Cross-sectional data from a population-based survey of women residing in rural areas of Pwani Region were linked to health facility locations. We fitted multilevel logistic models to examine individual and community factors associated with home delivery.

RESULTS

A total of 752 (27.95%) of the 2691 women who completed the survey delivered their last child at home. Women were less likely to deliver at home if they had any primary education [odds ratio (OR) 0.62; 95% confidence interval (CI): 0.50, 0.79], were primiparous (OR: 0.52; 95% CI: 0.37, 0.73), had more exposure to media (OR: 0.80; 95% CI: 0.66, 0.96) or had received more (OR: 0.78; 95% CI: 0.63, 0.96) or better quality antenatal care (ANC) services (OR: 0.48; 95% CI: 0.34, 0.67). Increased wealth was strongly associated with lower odds of home delivery (OR: 0.27; 95% CI: 0.18, 0.39), as was living in a village that grew cash crops (OR: 0.56; 95% CI: 0.35, 0.88). Farther distance to hospital, but not to lower level facilities, was associated with higher likelihood of home delivery (OR 2.49; 95% CI: 1.60, 3.88).

CONCLUSIONS

Poverty, multiparity, weak ANC and distance to hospital were associated with persistence of home delivery in a region with high coverage of facility delivery. A pro-poor path to universal coverage of safe delivery requires a greater focus on quality of care and more intensive outreach to poor and multiparous women.

The effect of health-facility admission and skilled birth attendant coverage on maternal survival in India: a case-control analysis

Background

Research in areas of low skilled attendant coverage found that maternal mortality is paradoxically higher in women who seek obstetric care. We estimated the effect of health-facility admission on maternal survival, and how this effect varies with skilled attendant coverage across India.

Methods/Findings

Using unmatched population-based case-control analysis of national datasets, we compared the effect of health-facility admission at any time (antenatal, intrapartum, postpartum) on maternal deaths (cases) to women reporting pregnancies (controls). Probability of maternal death decreased with increasing skilled attendant coverage, among both women who were and were not admitted to a health-facility, however, the risk of death among women who were admitted was higher (at 50% coverage, OR = 2.32, 95% confidence interval 1.85–2.92) than among those women who were not; while at higher levels of coverage, the effect of health-facility admission was attenuated. In a secondary analysis, the probability of maternal death decreased with increasing coverage among both women admitted for delivery or delivered at home but there was no effect of admission for delivery on mortality risk (50% coverage, OR = 1.0, 0.80–1.25), suggesting that poor quality of obstetric care may have attenuated the benefits of facility-based care. Subpopulation analysis of obstetric hemorrhage cases and report of ‘excessive bleeding’ in controls showed that the probability of maternal death decreased with increasing skilled attendant coverage; but the effect of health-facility admission was attenuated (at 50% coverage, OR = 1.47, 0.95–1.79), suggesting that some of the effect in the main model can be explained by women arriving at facility with complications underway. Finally, highest risk associated with health-facility admission was clustered in women with education 8 years.

Conclusions

The effect of health-facility admission did vary by skilled attendant coverage, and this effect appears to be driven partially by reverse causality; however, inequitable access to and possibly poor quality of healthcare for primary and emergency services appears to play a role in maternal survival as well.

Why women choose to give birth at home: a situational analysis from urban slums of Delhi

OBJECTIVES

Increasing institutional births is an important strategy for attaining Millennium Development Goal -5. However, rapid growth of low income and migrant populations in urban settings in low-income and middle-income countries, including India, presents unique challenges for programmes to improve utilisation of institutional care. Better understanding of the factors influencing home or institutional birth among the urban poor is urgently needed to enhance programme impact. To measure the prevalence of home and institutional births in an urban slum population and identify factors influencing these events.

DESIGN

Cross-sectional survey using quantitative and qualitative methods.

SETTING

Urban poor settlements in Delhi, India.

PARTICIPANTS

A house-to-house survey was conducted of all households in three slum clusters in north-east Delhi (n=32 034 individuals). Data on birthing place and sociodemographic characteristics were collected using structured questionnaires (n=6092 households). Detailed information on pregnancy and postnatal care was obtained from women who gave birth in the past 3 months (n=160). Focus group discussions and in-depth interviews were conducted with stakeholders from the community and healthcare facilities.

RESULTS

Of the 824 women who gave birth in the previous year, 53% (95% CI 49.7 to 56.6) had given birth at home. In adjusted analyses, multiparity, low literacy and migrant status were independently predictive of home births. Fear of hospitals (36%), comfort of home (20.7%) and lack of social support for child care (12.2%) emerged as the primary reasons for home births.

CONCLUSIONS

Home births are frequent among the urban poor. This study highlights the urgent need for improvements in the quality and hospitality of client services and need for family support as the key modifiable factors affecting over two-thirds of this population. These findings should inform the design of strategies to promote institutional births.

A cross-sectional analytic study of postpartum health care service utilization in the Philippines

Background

The maternal mortality ratio in the Philippines remains high; thus, it will be difficult to achieve the Millennium Development Goals 5 by 2015. Approximately two-thirds of all maternal deaths occur during the postpartum period. Therefore, we conducted the present study to examine the current state of postpartum health care service utilization in the Philippines, and identify challenges to accessing postpartum care.

Methods

A questionnaire and knowledge test were distributed to postpartum women in the Philippines. The questionnaire collected demographical characteristics and information about their utilization of health care services during pregnancy and the postpartum period. The knowledge test consisted of 11 questions regarding 6 topics related to possible physical and mental symptoms after delivery. Sixty-four questionnaires and knowledge tests were analyzed.

Results

The mean time of first postpartum health care visit was 5.1±5.2 days after delivery. Postpartum utilization of health care services was significantly correlated with delivery location (P<0.01). Women who delivered at home had a lower rate of postpartum health care service utilization than women who delivered at medical facilities. The majority of participants scored low on the knowledge test.

Conclusion

We found inadequate postpartum health care service utilization, especially for women who delivered at home. Our results also suggest that postpartum women lack knowledge about postpartum health concerns. In the Philippines, Barangay health workers may play a role in educating postpartum women regarding health care service utilization to improve their knowledge of possible concerns and their overall utilization of health care services.

Maternal mortality, birth with a health professional and distance to obstetric care in Indonesia and Bangladesh

OBJECTIVE

To examine the relationship between distance to a health facility, consulting a health professional and maternal mortality.

METHODS

Retrospective cohort study in Matlab, Bangladesh (1987-2005), to collect data on all pregnancies, births and deaths. In Java, Indonesia (2004-2005), an informant-based approach identified maternal deaths and a population-based survey sampled women who survived birth. Logistic regression was used to examine the influence of distance to a health facility and uptake of a health professional on odds of dying.

RESULTS

Maternal mortality was 320 per 100 000 births (95% CI: 290, 353) in Indonesia and 318 per 100 000 (95% CI: 272, 369) in Bangladesh. Women who lived further from health centres in both countries were less likely to have their births attended by health professionals than those who lived closer. For women who were assisted by a health professional, the odds of dying increased with increasing distance from a health centre [odds ratio per km; Indonesia: 1.07 (95% CI: 1.02-1.11), Bangladesh: 1.47 (95% CI: 1.22-1.78)]. There was no evidence for an association between distance to a health centre and maternal death for women who were not assisted by a health professional.

CONCLUSIONS

Even in settings where health services are relatively close to women's homes, distance to a health facility affects maternal mortality for women giving birth with a health professional. Women may only seek professional care in an emergency and may be unable to reach timely care when living far away from a health centre.

The role of home-based records in the establishment of a continuum of care for mothers, newborns, and children in Indonesia

BACKGROUND

The provision of appropriate care along the continuum of maternal, newborn, and child health (MNCH) service delivery is a challenge in developing countries. To improve this, in the 1990s, Indonesia introduced the maternal and child health (MCH) handbook, as an integrated form of parallel home-based records.

OBJECTIVE

This study aimed to identify the roles of home-based records both before and after childbirth, especially in provinces where the MCH handbook (MCHHB) was extensively promoted, by examining their association with MNCH service uptake.

DESIGN

This was a cross-sectional study using nationally representative data sets, the Indonesia Demographic and Health Surveys (IDHSs) from 1997, 2002-2003, and 2007. The IDHS identifies respondents' ownership of home-based records before and after childbirth. Multivariate logistic regression was used to examine associations between record ownership and service utilisation in national data and data from two provinces, West Sumatra and North Sulawesi, where ownership of pre- and post-natal records served as a proxy for MCHHB ownership.

RESULTS

Pre- and post-natal record ownership increased from 1997 to 2007. Provincial data from 2007 showed that handbook ownership was associated with having delivery assisted by trained personnel [adjusted odds ratio (aOR): 2.12, 95% confidence interval (CI): 1.05-4.25], receiving maternal care (aOR: 3.92, 95% CI: 2.35-6.52), completing 12 doses of child immunisation for seven diseases (aOR: 4.86, 95% CI: 2.37-9.95), and having immunisation before and after childbirth (aOR: 5.40, 95% CI: 2.28-12.76), whereas national data showed that service utilisation was associated with ownership of both records compared with owning a single record or none.

CONCLUSION

Our results suggest that pre- and post-natal home-based record use may be effective for ensuring service utilisation. In addition, since the handbook is an efficient home-based record for use throughout children's life courses, it could be an effective tool for promoting the continuum of MNCH care in Indonesia.

Intimate partner violence and use of reproductive health services among married women: evidence from a national Bangladeshi sample

Background

Data from a statewide survey in India and clinic-based studies in developed settings have previously suggested an association between maternal physical intimate partner violence (IPV) experiences and the low use of antenatal care (ANC). This study aimed to explore the association between maternal experiences of physical and sexual IPV and the use of reproductive health care services, using a large nationally representative data set from Bangladesh.

Methods

This paper used data from the 2007 Bangladesh Demographic Health Survey. The analyses were based on the responses of 2001currently married women living with at least one child younger than 5 years. Exposure was determined from maternal reports of physical and sexual IPV. The utilization of ANC according to amount and type of provider and utilization of delivery assistance according to provider type were used as proxy outcome variables for reproductive health care utilization. Descriptive statistics and multivariate logistic regression analysis used in the study.

Results

Approximately two out of four (48.2%) respondents had experienced physical IPV. Maternal experience of physical IPV was associated with low use of receiving sufficient ANC (adjusted odds ratio [AOR] 0.69; 95% confidence interval [CI] 0.49–0.96), lower likelihood of receiving ANC (AOR 0.69; 95% CI 0.53–0.89), and assisted deliveries from skilled provider (AOR 0.54; 95% CI 0.37–0.78). Women who had been sexually abused were significantly less likely to have visited a skilled ANC and delivery care provider. Furthermore, severity of physical IPV appeared to have more profound consequences on the outcome measured.

Conclusions

The association between exposure to IPV and use of reproductive health care services suggests that partner violence plays a significant role in lower utilization of reproductive health services among women in Bangladesh. Our findings suggest that, in addition to a wide range of socio-demographic factors, preventing maternal physical and sexual IPV need to be considered as an important psychosocial determinates for the higher utilization of reproductive health care services in Bangladesh.

Relating the construction and maintenance of maternal ill-health in rural Indonesia

Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to ill-equipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality and access within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly.

Childbirth attendance strategies and their impact on maternal mortality and morbidity in low-income settings: a systematic review

OBJECTIVE

To review quantitative evidence of the effect on maternal health of different childbirth attendance strategies in low-income settings.

DESIGN

Systematic review.

METHODS

Studies using quantitative methods, referring to the period 1987-2011, written in English and reporting the impact of childbirth attendance strategies on maternal mortality or morbidity in low-income settings were included. Guidelines developed by the Cochrane collaboration and the Centre for Review and Dissemination, University of York were followed. The included articles were read and sorted by category of strategy that emerged from the reading.

RESULTS

The search criteria yielded 29 articles. The following three main categories of strategy emerged: (i) those primarily intended to improve quality of care; (ii) "centrifugal strategies," which sought to bring services to the women; and (iii) "centripetal strategies," which sought to bring the women to the services. Few of the studies had a design that provided strong evidence for the impact of the strategy concerned.

CONCLUSIONS

The evidence emerging from the studies was difficult to compare, because concepts were not defined in a consistent manner (such as "skilled birth attendance") and many studies examined the impact of a package of interventions without ferreting out the impact of individual components. Yet, some studies described individual aspects with great promise (such as cost, transport, outreach-friendly drugs or targeted training). There is a need for clearer conceptual frameworks, including some which permit assessment of packages of interventions.

Priorities and realities: addressing the rich-poor gaps in health status and service access in Indonesia

Introduction

Over the past four decades, the Indonesian health care system has greatly expanded and the health of Indonesian people has improved although the rich-poor gap in health status and service access remains an issue. The government has been trying to address these gaps and intensify efforts to improve the health of the poor following the economic crisis in 1998.

Methods

This paper examines trends and levels in socio-economic inequity of health and identifies critical factors constraining efforts to improve the health of the poor. Quantitative data were taken from the Indonesian Demographic Health Surveys and the National Socio-Economic Surveys, and qualitative data were obtained from interviews with individuals and groups representing relevant stakeholders.

Results

The health of the population has improved as indicated by child mortality decline and the increase in community access to health services. However, the continuing prevalence of malnourished children and the persisting socio-economic inequity of health suggest that efforts to improve the health of the poor have not yet been effective. Factors identified at institution and policy levels that have constrained improvements in health care access and outcomes for the poor include: the high cost of electing formal governance leaders; confused leadership roles in the health sector; lack of health inequity indicators; the generally weak capacity in the health care system, especially in planning and budgeting; and the leakage and limited coverage of programs for the poor.

Conclusions

Despite the government's efforts to improve the health of the poor, the rich-poor gap in health status and service access continues. Factors at institutional and policy levels are critical in contributing to the lack of efficiency and effectiveness for health programs that address the poor.

Reproductive health care utilization among young mothers in Bangladesh: does autonomy matter?

OBJECTIVE

To examine the linkage between the possible influences of the extent of autonomy on young mothers use of reproductive health care services.

METHODS

This paper used data from the 2007 Bangladesh Demographic Health Survey. The analyses were based on responses of 1,778 currently married women aged 15 to 24 years, living with at least one 0- to 35-month-old child. Utilization of antenatal health services (ANC) services by amount and type of provider, and utilization of delivery assistance according to provider type were used as proxy outcome variables of reproductive health care utilization. Descriptive statistics and multivariate logistic regression methods were employed in the analysis.

RESULTS

Approximately one third (31%) of the currently married young women in Bangladesh had a higher level of overall decision-making autonomy. Only 24.0% of the sampled women received sufficient ANC; 54% and 18% received ANC and assisted deliveries from a medically trained provider. respectively. In adjusted models, young women who had a higher level of overall autonomy were more likely to receive sufficient ANC (adjusted odds ratio [AOR], 1.64; 95% confidence interval [CI], 1.17-2.23) and receiving ANC from medically trained provider (AOR, 1.91; 95% CI, 1.42-2.45). Women who had medium overall autonomy were 1.40 times more likely (95% CI, 1.03-1.98) to have deliveries assisted by a medically trained provider than women who had low autonomy.

CONCLUSION

Association between young mother's autonomy and reproductive health care utilization suggest that maternal autonomy needs to be considered as an important sociocultural determinant for the higher utilization of reproductive health care services for young mothers in Bangladesh.

Type of delivery attendant, place of delivery and risk of early neonatal mortality: analyses of the 1994-2007 Indonesia Demographic and Health Surveys

Access to skilled birth attendants and emergency obstetric care are thought to prevent early neonatal deaths. This study aims to examine the association between the type of delivery attendant and place of delivery and early neonatal mortality in Indonesia. Four Indonesia Demographic and Health Surveys from 1994, 1997, 2002/2003 and 2007 were used, including survival information from 52 917 singleton live-born infants of the most recent birth of a mother within a 5-year period before each survey. Cox proportional hazards regression models were used to obtain the hazard ratio for univariable and multivariable analyses. Our study found no significant reduction in the risk of early neonatal death for home deliveries assisted by the trained attendants compared with those assisted by untrained attendants. In rural areas, the risk of early neonatal death was higher for home deliveries assisted by trained attendants than home deliveries assisted by untrained attendants. In urban areas, a protective role of institutional deliveries was found if mothers had delivery complications. However, an increased risk was associated with deliveries in public hospitals in rural areas. Infants of mothers attending antenatal care services were significantly protected against early neonatal deaths, irrespective of the urban or rural setting. An increased risk of early neonatal death was also associated with male infants, infants whose size at birth was smaller than average and/or infants reported to be born early. A reduced risk was observed amongst mothers with high levels of education. Continuous improvement in the skills and the quality of the village midwives might benefit maternal and newborn survival. Efforts to strengthen the referral system and to improve the quality of delivery and newborn care services in health facilities are important, particularly in public hospitals and in rural areas.

Quality assessment of capture-recapture studies in resource-limited countries

OBJECTIVES

Resource-limited countries often lack robust routine surveillance systems to accurately assess the burden of human attributes and diseases. In these settings capture-recapture analysis can be an alternative tool to obtain prevalence and incidence rates. Performance of capture-recapture analyses in resource-limited countries has not been systematically reviewed.

METHODS

Systematic review of the performance of capture-recapture analyses in the categories of human attributes, non-infectious and infectious diseases in resource-limited countries, assessing individual study quality criteria and a minimum quality criterion per category, using PRISMA methodology.

RESULTS

A total of 1671 potentially relevant PubMed citations were screened, resulting in 52 eligible publications: 36% in human attributes, i.e. hidden populations, injuries and mortality; 48% in non-infectious and 15% in infectious disease categories. Twenty-one per cent of selected studies were from low income countries, 40% from lower-middle-income countries and 38% from upper-middle-income countries. Thirteen per cent achieved good individual study quality criteria, 25% were intermediate and 19% were poor. Of the good studies, six were performed on human attributes and one on a non-infectious disease. The proportions of publications meeting the minimum quality criterion per category were 42%, 20% and 37%, respectively.

CONCLUSIONS

Few capture-recapture studies in resource-limited countries achieved good individual quality criteria and a minority met the minimum quality criterion per category. Capture-recapture techniques in these settings should be carefully considered and implemented rigorously and are not a panacea for strengthening of routine surveillance systems.

Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data

BACKGROUND

In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed "not necessary" by a household decision maker. Among the poorest women, "not necessary" was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended.

CONCLUSIONS

In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.

Current situation of midwives in indonesia: Evidence from 3 districts in West Java Province

Background

The village midwife is a central element of Indonesia's strategy to improve maternal and child health and family planning services. Recently there has been concern that the midwives were not present in the villages to which they had been assigned. To determine the extent to which this was the case we conducted a field-based census and survey of village midwives in three districts in West Java Province, Indonesia.

Findings

In June 2009 we interviewed a random sample of village midwives from three districts - Ciamis, Garut and Sukabumi - in West Java Province. Trained interviewers visited all villages represented in the sample to interview the midwives. We also obtained information about the midwives and their professional activities in the last year.

Thirty percent of village midwives had moved to another location in the 12 months between the end of 2008, when the sampling frame was constructed, and December 2009 when the survey was conducted; most had moved to a government health center or another village. Of those who were present, there was considerable variation between districts in age distribution and qualifications. The total number of services provided was modest, also with considerable variation between districts. The median number of deliveries assisted in the last year was 64; the amount and mix of family planning services provided varied between districts and were dominated by temporary methods.

Conclusions

Compared to an earlier survey in an adjacent province, the village midwives in these three districts were younger, had spent less time in the village and a higher proportion were permanent civil servants. A high proportion had moved in the previous year with most moving to a health center or another village. The decision to move, as well as the mix of services offered, seems to be largely driven by opportunities to increase their private practice income. These opportunities are greater in urban areas. As urbanization procedes the forces drawing village midwives away from the village are certain to strengthen. This will require a reassessment of the original service model embodied in the village midwife concept and a new approach to reducing maternal mortality.

Why don't some women attend antenatal and postnatal care services?: a qualitative study of community members' perspectives in Garut, Sukabumi and Ciamis districts of West Java Province, Indonesia

Background

Antenatal, delivery and postnatal care services are amongst the recommended interventions aimed at preventing maternal and newborn deaths worldwide. West Java is one of the provinces of Java Island in Indonesia with a high proportion of home deliveries, a low attendance of four antenatal services and a low postnatal care uptake. This paper aims to explore community members' perspectives on antenatal and postnatal care services, including reasons for using or not using these services, the services received during antenatal and postnatal care, and cultural practices during antenatal and postnatal periods in Garut, Sukabumi and Ciamis districts of West Java province.

Methods

A qualitative study was conducted from March to July 2009 in six villages in three districts of West Java province. Twenty focus group discussions (FGDs) and 165 in-depth interviews were carried out involving a total of 295 respondents. The guidelines for FGDs and in-depth interviews included the topics of community experiences with antenatal and postnatal care services, reasons for not attending the services, and cultural practices during antenatal and postnatal periods.

Results

Our study found that the main reason women attended antenatal and postnatal care services was to ensure the safe health of both mother and infant. Financial difficulty emerged as the major issue among women who did not fulfil the minimum requirements of four antenatal care services or two postnatal care services within the first month after delivery. This was related to the cost of health services, transportation costs, or both. In remote areas, the limited availability of health services was also a problem, especially if the village midwife frequently travelled out of the village. The distances from health facilities, in addition to poor road conditions were major concerns, particularly for those living in remote areas. Lack of community awareness about the importance of these services was also found, as some community members perceived health services to be necessary only if obstetric complications occurred. The services of traditional birth attendants for antenatal, delivery, and postnatal care were widely used, and their roles in maternal and child care were considered vital by some community members.

Conclusions

It is important that public health strategies take into account the availability, affordability and accessibility of health services. Poverty alleviation strategies will help financially deprived communities to use antenatal and postnatal health services. This study also demonstrated the importance of health promotion programs for increasing community awareness about the necessity of antenatal and postnatal services.

A lost cause? Extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in Burkina Faso and Indonesia

Maternal mortality in developing countries is characterised by disadvantage and exclusion. Women who die whilst pregnant are typically poor and live in low-income and rural settings where access to quality care is constrained and where deaths, within and outside hospitals, often go unrecorded and unexamined. Verbal autopsy (VA) is an established method of determining cause(s) of death for people who die outside health facilities or without proper registration. This study extended VA to investigate socio-cultural factors relevant to outcomes. Interviews were conducted with relatives of 104 women who died during pregnancy, childbirth or postpartum in two rural districts in Indonesia and for 70 women in a rural district in Burkina Faso. Information was collected on medical signs and symptoms of the women prior to death and an extended section collected accounts of care pathways and opinions on preventability and cause of death. Illustrative quantitative and qualitative analyses were performed and the implications for health surveillance and planning were considered. The cause of death profiles were similar in both settings with infectious diseases, haemorrhage and malaria accounting for half the deaths. In both settings, delays in seeking, reaching and receiving care were reported by more than two-thirds of respondents. Relatives also provided information on their experiences of the emergencies revealing culturally-derived systems of explanation, causation and behaviour. Comparison of the qualitative and quantitative results suggested that the quantified delays may have been underestimated. The analysis suggests that broader empirical frameworks can inform more complete health planning by situating medical conditions within the socio-economic and cultural landscapes in which healthcare is situated and sought. Utilising local knowledge, extended VA has potential to inform the relative prioritisation of interventions that improve technical aspects of life-saving services with those that address the conditions that underlie health, for those whom services typically fail to reach.