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Dasgupta T, De Allegri M, Brenner S, Kaminjolo-Kambala C, Lohmann J. Good while it lasted? Estimating the long-term and withdrawal effects of results-based financing in Malawi on maternal care utilisation using routine data. BMJ Open 2024; 14:e066115. [PMID: 38458806 DOI: 10.1136/bmjopen-2022-066115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024] Open
Abstract
OBJECTIVES This study aimed to evaluate the effect of introduction and subsequent withdrawal of the Results-based Financing for Maternal and Newborn Health Initiative (RBF4MNH) in Malawi on utilisation of facility-based childbirths, antenatal care (ANC) and postnatal care (PNC). DESIGN A controlled interrupted time series design was used with secondary data from the Malawian Health Management Information System. SETTING Healthcare facilities at all levels identified as providing maternity services in four intervention districts and 20 non-intervention districts in Malawi. PARTICIPANTS Routinely collected, secondary data of total monthly service utilisation of facility-based childbirths, ANC and PNC services. INTERVENTIONS The intervention is the RBF4MNH initiative, introduced by the Malawian government in 2013 to improve maternal and infant health outcomes and withdrawn in 2018 after ceasing of donor funding. OUTCOME MEASURES Differences in total volume and trends of utilisation of facility-based childbirths, ANC and PNC services, compared between intervention versus non-intervention districts, for the study period of 90 consecutive months. RESULTS No significant effect was observed, on utilisation trends for any of the three services during the first 2.5 years of intervention. In the following 2.5 years after full implementation, we observed a small positive increase for facility-based childbirths (+0.62 childbirths/month/facility) and decrease for PNC (-0.55 consultations/month/facility) trends of utilisation respectively. After withdrawal, facility-based childbirths and ANC consultations dropped both in immediate volume after removal (-10.84 childbirths/facility and -20.66 consultations/facility, respectively), and in trends of utilisation over time (-0.27 childbirths/month/facility and -1.38 consultations/month/facility, respectively). PNC utilisation levels seemed unaffected in intervention districts against a decline in the rest of the country. CONCLUSIONS Concurrent with wider literature, our results suggest that effects of complex health financing interventions, such as RBF4MNH, can take a long time to be seen. They might not be sustained beyond the implementation period if measures are not adopted to reform existing health financing structures.
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Affiliation(s)
- Tisha Dasgupta
- Department of Women & Children's Health, King's College London, London, UK
- London School of Hygiene & Tropical Medicine, London, UK
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Heidelberg, Germany
| | | | - Julia Lohmann
- London School of Hygiene & Tropical Medicine, London, UK
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Nyondo-Mipando AL, Chirwa M, Salimu S, Kumitawa A, Chinkonde JR, Chimuna TJ, Dohlsten M, Chikwapulo B, Senbete M, Gohar F, Hailegebriel TD, Jackson D. Exploring and prioritising strategies for improving uptake of postnatal care services in Thyolo, Malawi: A qualitative study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002992. [PMID: 38446818 PMCID: PMC10917263 DOI: 10.1371/journal.pgph.0002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024]
Abstract
Although postnatal care services form a critical component of the cascade of care in maternal, newborn, and child health the uptake of these services has remained low worldwide. This study explored and prioritised the strategies for optimising the uptake of postnatal care (PNC) services in Malawi. A qualitative descriptive study followed by nominal group techniques was conducted at three health facilities in Malawi from July to December 2020 and in October 2021. We conducted focus group discussions among postnatal mothers, fathers, healthcare workers, elderly women, and grandmothers. We conducted in-depth interviews with midwives and key health managers. Nominal group techniques were used to prioritise the main strategies for the provision of PNC. The demand strategies include appointment date reminders, provision of free health passport books, community awareness campaigns, and involvement of men in the services. The supply strategies included training health providers, improving clinic operations: task-shifting and hours of operation, having infrastructure for the services, and linkage to other services. Having services delivered near end-user residences was a crosscutting strategy. Refresher training and improvement in the clinic operations especially on hours of operation, appointment date reminders, and linkage to care were the prioritised strategies. There is a need to use acceptable and contextualised strategies to optimise the uptake and delivery of postnatal care services. Educating the healthcare workers and the community on postnatal services is key to increasing the demand and supply of the services.
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Affiliation(s)
- Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Marumbo Chirwa
- Department of Health Systems and Policy, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sangwani Salimu
- Department of Health Systems and Policy, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Andrew Kumitawa
- Department of Epidemiology and Statistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | | | - Martin Dohlsten
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | | | | | | | - Tedbabe D. Hailegebriel
- Health Section, Programme Division, UNICEF Headquarters, New York, NY, United States of America
| | - Debra Jackson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- University of the Western Cape, Cape Town, South Africa
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Nyondo-Mipando AL, Chirwa M, Kumitawa A, Salimu S, Chinkonde J, Chimuna TJ, Dohlsten M, Chikwapulo B, Senbete M, Gohar F, Hailegebriel TD, Jackson D. Uptake of, barriers and enablers to the utilization of postnatal care services in Thyolo, Malawi. BMC Pregnancy Childbirth 2023; 23:271. [PMID: 37076801 PMCID: PMC10114368 DOI: 10.1186/s12884-023-05587-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 04/09/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Postnatal care (PNC) ensures early assessments for danger signs during the postpartum period and is to be provided within 24 h of birth, 48-72 h, 7-14 days, and six weeks after birth. This study assessed the uptake of and the barriers and facilitators to receiving PNC care among mothers and babies. METHODS A concurrent mixed-method study employing a retrospective register review and a qualitative descriptive study was conducted in Thyolo from July to December 2020. Postnatal registers of 2019 were reviewed to estimate the proportion of mothers and newborns that received PNC respectively. Focus Group Discussions (FGDs) among postnatal mothers, men, health care workers, and elderly women and in-depth interviews with midwives, and key health care workers were conducted to explore the barriers and enablers to PNC. Observations of the services that mothers and babies received within 24 h of birth, at 48-72 h, 7-14 days, and six weeks after birth were conducted. Descriptive statistics were tabulated for the quantitative data using Stata while the qualitative data were managed using NVivo and analysed following a thematic approach. RESULTS The uptake of PNC services was at 90.5%, 30.2%, and 6.1% among women and 96.5%, 78.8%, and 13.7% among babies within 48 h of birth, 3 to 7 and 8 to 42 days respectively. The barriers to PNC services included the absence of a baby or mother, limited understanding of PNC services, lack of male involvement, and economic challenges. Cultural and religious beliefs, advice from community members, community activities, distance, lack of resources, and poor attitude of health care workers also impeded the utilisation of PNC services. The enablers included the mother's level of education, awareness of the services, economic resources, community-based health support, adequacy and attitude of health workers, seeking treatment for other conditions, and other clinic activities. CONCLUSION Optimisation of uptake and utilization of PNC services for mothers and neonates will require the involvement of all stakeholders. The success of PNC services lies in the communities, health services, and mothers understanding the relevance, time points, and services that need to be delivered to create demand for the services. There is a need to assess the contextual factors for a better response in improving the uptake of PNC services and in turn inform the development of strategies for optimizing the uptake of PNC services.
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Affiliation(s)
- Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi.
- Maternal and Fetal Health Group, Malawi Liverpool Wellcome Programme, Blantyre, Malawi.
| | - Marumbo Chirwa
- Department of Health Systems and Policy, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Andrew Kumitawa
- Department of Epidemiology and Statistics, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Sangwani Salimu
- Department of Health Systems and Policy, School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Maternal and Fetal Health Group, Malawi Liverpool Wellcome Programme, Blantyre, Malawi
| | | | | | - Martin Dohlsten
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | | | | | | | | | - Debra Jackson
- London School of Hygiene and Tropical Medicine, London, UK
- University of the Western Cape, Cape Town, South Africa
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Manuama EO, Pali M, Morgan A. Barriers and enablers to the provision of postnatal newborn care at community health centres in Sikka district, East Nusa Tenggara province, Indonesia. Midwifery 2022; 110:103318. [DOI: 10.1016/j.midw.2022.103318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/15/2021] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
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Peven K, Taylor C, Purssell E, Mallick L, Burgert-Brucker CR, Day LT, Wong KLM, Kambala C, Bick D. Distance to available services for newborns at facilities in Malawi: A secondary analysis of survey and health facility data. PLoS One 2021; 16:e0254083. [PMID: 34234372 PMCID: PMC8263259 DOI: 10.1371/journal.pone.0254083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background Malawi has halved the neonatal mortality rate between 1990–2018, however, is not on track to achieve the Sustainable Development Goal 12 per 1,000 live births. Despite a high facility birth rate (91%), mother-newborn dyads may not remain in facilities long enough to receive recommended care and quality of care improvements are needed to reach global targets. Physical access and distance to health facilities remain barriers to quality postnatal care. Methods Using data We used individual data from the 2015–16 Malawi Demographic and Health Survey and facility data from the 2013–14 Malawi Service Provision Assessment, linking households to all health facilities within specified distances and travel times. We calculated service readiness scores for facilities to measure their capacity to provide birth/newborn care services. We fitted multi-level regression models to evaluate the association between the service readiness and appropriate newborn care (receiving at least five of six interventions). Results Households with recent births (n = 6010) linked to a median of two birth facilities within 5–10 km and one facility within a two-hour walk. The maximum service environment scores for linked facilities median was 77.5 for facilities within 5–10 km and 75.5 for facilities within a two-hour walk. While linking to one or more facilities within 5-10km or a two-hour walk was not associated with appropriate newborn care, higher levels of service readiness in nearby facilities was associated with an increased risk of appropriate newborn care. Conclusions Women’s choice of nearby facilities and quality facilities is limited. High quality newborn care is sub-optimal despite high coverage of facility birth and some newborn care interventions. While we did not find proximity to more facilities was associated with increased risk of appropriate care, high levels of service readiness was, showing facility birth and improved access to well-prepared facilities are important for improving newborn care.
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Affiliation(s)
- Kimberly Peven
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Kings College London, London, United Kingdom
- Maternal and Newborn Health Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Cath Taylor
- School of Health Sciences, University of Surrey, Guildford, United Kingdom
| | | | - Lindsay Mallick
- University of Maryland, College Park, MD, United States of America
- Avenir Health, Glastonbury, CT, United States of America
| | - Clara R. Burgert-Brucker
- RTI International, Washington, DC and London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Louise T. Day
- Maternal and Newborn Health Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kerry L. M. Wong
- Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christabel Kambala
- Environmental Health Department, Malawi University of Business and Applied Sciences, Blantyre, Malawi
| | - Debra Bick
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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Dey T, Ononge S, Weeks A, Benova L. Immediate postnatal care following childbirth in Ugandan health facilities: an analysis of Demographic and Health Surveys between 2001 and 2016. BMJ Glob Health 2021; 6:bmjgh-2020-004230. [PMID: 33888487 PMCID: PMC8070850 DOI: 10.1136/bmjgh-2020-004230] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Progress in reducing maternal and neonatal mortality, particularly in sub-Saharan Africa, is insufficient to achieve the Sustainable Developmental Goals by 2030. The first 24 hours following childbirth (immediate postnatal period), where the majority of morbidity and mortality occurs, is critical for mothers and babies. In Uganda,<50% of women reported receiving such care. This paper describes the coverage, changes over time and determinants of immediate postnatal care in Uganda after facility births between 2001 and 2016. Methods We analysed the 2006, 2011 and 2016 Ugandan Demographic and Health Surveys, including women 15–49 years with most recent live birth in a healthcare facility during the survey 5-year recall period. Immediate postnatal care coverage and changes over time were presented descriptively. Multivariable logistic regression was used to examine determinants of immediate postnatal care. Results Data from 12 872 mothers were analysed. Between 2006 and 2016, births in healthcare facilities increased from 44.6% (95% CI: 41.9% to 47.3%) to 75.2% (95% CI: 73.4% to 77.0%) and coverage of immediate maternal postnatal care from 35.7% (95% CI 33.4% to 38.1%) to 65.0% (95% CI: 63.2% to 66.7%). The majority of first checks occurred between 1 and 4 hours post partum; the median time reduced from 4 hours to 1 hour. The most important factor associated with receipt of immediate postnatal care was women having a caesarean section birth adjusted OR (aOR) 2.93 (95% CI: 2.28 to 3.75). Other significant factors included exposure to mass media aOR 1.38 (95% CI: 1.15 to 1.65), baby being weighed at birth aOR 1.84 (95% CI: 1.58 to 2.14) and receipt of antenatal care with 4+Antenatal visits aOR 2.34 (95% CI: 1.50 to 3.64). Conclusion In Uganda, a large gap in coverage remains and universal immediate postnatal care has not materialised through increasing facility-based births or longer length of stay. To ensure universal coverage of high-quality care during this critical time, we recommend that maternal and newborn services should be integrated and actively involve mothers and their partners.
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Affiliation(s)
- Teesta Dey
- Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda
| | - Andrew Weeks
- Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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