Meeting the Global Target in Reproductive, Maternal, Newborn, and Child Health Care Services in Low- and Middle-Income Countries

An empirical analysis of the demand for family planning satisfied by modern methods among married or in-union women in Nigeria: Application of multilevel binomial logistic modelling technique

BACKGROUND

Given the health and economic benefits of family planning (FP), Nigeria's very low demand for FP satisfied by modern methods (mDFPS) of less than 50% is therefore a major public health concern, especially considering the global target aimed at achieving an mDFPS of at least 75% by year 2030 for all countries. In view of this, together with recognising the possible contextual nature of health outcomes, this study aimed to empirically analyse the mDFPS among married or in-union women of reproductive age (WRA) in Nigeria.

MATERIALS AND METHODS

A multilevel binomial logistic model with two levels of analysis was used: individual and community levels. Secondary cross-sectional data were obtained from the 2018 Nigeria Demographic and Health Survey, and analyses were performed using Stata 15.0. The analytical sample size was 9,122 WRA nested in a total of 1,072 communities.

RESULTS

The mDFPS was approximately 31.0%. The median odds ratio (MOR) estimated from the final multilevel model was 2.245, which was greater than the adjusted odds ratio (aOR) for most of the individual-level variables, suggesting that the unexplained/residual between-community variation in terms of the odds of women having their mDFPS was more relevant than the regression effect of most of the individual-level variables. This was with the exception of the regression effects of the following individual-level variables: women's husbands that had higher education level in comparison to their counterparts who had husbands with no formal education (aOR = 2.539; 95% CI = 1.896 to 3.399; p<0.001); and women from the Yoruba ethnic group in comparison to their counterparts from the Hausa/Fulani/Kanuri ethnic group (aOR = 2.484; 95% CI = 1.654 to 3.731; p value<0.001). However, other individual-level variables with positive statistically significant regression effects on mDFPS were: women who mentioned that money for accessing health care was not a problem; women's empowerment in relation to the visitation of family and relatives; and women being exposed to FP messages through various media sources, all in comparison to their respective counterparts. On the other hand, at the community level, women in communities where a high percentage of them had at least a secondary education had statistically significant greater odds of having mDFPS than women in communities with lower education levels (aOR = 1.584; 95% CI = 1.259 to 1.991; p<0.001). We found similar findings regarding women residing in communities with exposure to FP messages through various media sources. However, using the 80% interval ORs (80% IORs) as a supplemental statistical measure for further understanding the regression effects of community-level variables showed that all of the 80% IORs had a value of '1', signifying considerable uncertainty in the regression effects of all community-level variables due to the substantial residual variation existing between communities.

CONCLUSIONS

Our study showed that to achieve the dire increase in mDFPS in Nigeria, policy interventions aimed at improving the education level of both females and males, especially beyond the secondary school level, should be implemented. Additionally, all of the various media sources should be extensively utilised, both at the individual and the community level, by the Nigerian government to spread information on the importance of women having their mDFPS.

Perceived progress toward scale of 14 maternal, newborn, child health, and nutrition (MNCHN) assets at subnational level in Burkina Faso, Ethiopia, India, Kenya, and Nigeria

Inequitable coverage of evidence-based MNCHN interventions is particularly pronounced in low and middle income countries where access and delivery of these interventions can vary dramatically at the subnational level. We conducted health system assessments in nine subnational geographies in five countries (Burkina Faso, Ethiopia, India, Kenya and Nigeria) to explore progress toward scale of 14 evidence-based MNCHN interventions (iron-folic acid, oxytocin, magnesium sulfate, misoprostol; 7.1% chlorhexidine for umbilical cord care, neonatal resuscitation, kangaroo mother care, community regimen for the treatment of possible severe bacterial infection; amoxicillin dispersible tablets, multiple micronutrient supplements, balanced energy protein supplementation, early and exclusive breastfeeding, feeding of small and sick newborns, and management of severe and moderate acute malnutrition in children less than five years old). Between March and October 2021, we conducted key informant interviews with a purposive sample of 275 healthcare providers and 94 district health management (DHMT) staff to better understand bottlenecks, facilitators and uptake of the interventions across varied subnational settings. Across all interventions and geographies, providers and DHMT staff perceived lack of robust HMIS data as the most significant barrier to scale followed by weak facility infrastructure. DHMT staff viewed limited budget allocation and training as a much larger barrier than healthcare providers, most likely given their purview as subnational managers. Healthcare providers were focused on supply chain and staffing, which affect workflows and service provision. Understanding provider and health facility management views of why interventions do or do not advance towards effective coverage can assist in creating enabling environments for the scale of best practices. These types of data are most helpful when collected at the subnational level, which allows for comparisons both within and between countries to show health disparities. Importantly, this strategic data collection can provide a starting point for improvement efforts to address existing health system gaps.

Utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa: A scoping review protocol

INTRODUCTION

There has been significant progress in maternal health outcomes in the sub-Saharan African region since the early 1990s, in part due to digital and mobile health interventions. However, critical gaps and disparities remain. Mobile phones in particular have potential to reach underserved, hard-to-reach populations with underdeveloped infrastructure. In spite of the opportunities for mobile phones to address maternal mortality in the region, there is no extensive mapping of the available literature on mobile phone interventions that aim to improve access of maternal care in sub-Saharan Africa. The proposed scoping review aims to map literature on the nature and extent of mobile phones interventions designed to improve maternal care health services in the region.

METHODS

Conduct of this scoping review will be guided by the Joanna Briggs Institute approach. Literature searches will be conducted in multiple electronic databases, including MEDLINE, Embase, CINAHL, APA PsycInfo, Cochrane Central Register of Controlled Trials, Global Health, African Index Medicus, Web of Science, and Applied Social Sciences Index & Abstracts. Grey literature will also be identified. Keyword searches will be used to identify articles. Two reviewers will independently screen eligible titles, abstracts and full articles with a third reviewer to help resolve any disputes. We will extract data on general study characteristics, population characteristics, concept, context, intervention details, study results, gaps and recommendations.

DISCUSSION

Understanding use of mobile phones among underserved, hard-to-reach populations with underdeveloped infrastructure to address maternal mortality in developing countries is very critical to informing health systems on potential effective strategies. This review will complement the evidence base on utilisation of mobile phone interventions to improve the delivery of maternal health services in sub-Saharan Africa.

Qualitative exploration of the constraints on mothers' and pregnant women's ability to turn available services into nutrition benefits in a low-resource urban setting, South Africa

OBJECTIVES

Despite free primary healthcare services and social protection system for mothers and children, significant nutrition inequalities occur across the globe, including in South Africa. This study aimed to explore what determines mothers' ability to access and turn available services into nutrition benefits.

DESIGN

An exploratory qualitative study was conducted including semistructured interviews with employees from community-based organisations and focus groups with pregnant women and mothers. Discussions focused on existing services perceived as important to nutrition, differences in mothers' ability to benefit from these services, and the underlying unmet needs contributing to these disparities. Data were analysed thematically using a novel social needs framework developed for this study where social needs are defined as the requisites that can magnify (if unmet) or reduce (if met) variation in the degree to which individuals can benefit from existing services.

SETTING

A resource-constrained urban township, Soweto in Johannesburg.

PARTICIPANTS

Thirty mothers of infants (<1 year old) and 21 pregnant women attending 5 primary healthcare facilities participated in 7 focus groups, and 18 interviews were conducted with employees from 10 community-based organisations.

RESULTS

Mothers identified social needs related to financial planning, personal income stability, appropriate and affordable housing, access to government services, social support and affordable healthier foods. The degree to which these needs were met determined mothers' capabilities to benefit from eight services. These were clinic-based services including nutrition advice and social work support, social grants, food aid, community savings groups, poverty alleviation projects, skills training workshops, formal employment opportunities and crèches/school feeding schemes.

CONCLUSION

Findings demonstrate that while current social protection mechanisms and free health services are necessary, they are not sufficient to address nutrition inequalities. Women's social needs must also be met to ensure that services are accessed and used to improve the nutrition of all mothers and their children.

Equity trends for the UHC service coverage sub-index for reproductive, maternal, newborn and child health in Pakistan: evidence from demographic health surveys

BACKGROUND

Pakistan, the world's sixth most populous country and the second largest in South Asia, is facing challenges related to reproductive, maternal, newborn and child health (RMNCH) that are exacerbated by various inequities. RMNCH coverage indicators such as antenatal care (ANC) and deliveries at health facilities have been improving over time, and the maternal mortality ratio (MMR) is gradually declining but not at the desired rates. Analysing and documenting inequities with reference to key characteristics are useful to unmask the disparities and to amicably implement targeted equity-oriented interventions.

METHODS

Pakistan Demographic Health Survey (PDHS) based UHC service coverage tracer indicators were derived for the RMNCH domain at the national and subnational levels for the two rounds of the PDHS in 2012 and 2017. These derivations were subgrouped into wealth quintiles, place of residence, education and mothers' age. Dumbbell charts were created to show the trends and quintile-specific coverage. The UHC service coverage sub-index for RMNCH was constructed to measure the absolute and relative parity indices, such as high to low absolute difference and high to low ratios, to quantify health inequities. The population attributable risk was computed to determine the overall population health improvement that is possible if all regions have the same level of health services as the reference point (national level) across the equity domains.

RESULTS

The results indicate an overall improvement in coverage across all indicators over time, but with a higher concentration of data points towards higher coverage among the wealthiest groups, although the poorest quintile continues to have low coverage in all regions. The UHC service coverage sub-index on RMNCH shows that Pakistan has improved from 45 to 63 overall, while Punjab improved from 50 to 59 and Sindh from 43 to 55. The highest improvement is evident in Khyber Pakhtunkhwa (KP) province, which has increased from 31 in 2012 to 51 in 2017. All regions made slow progress in narrowing the gap between the poorest and wealthiest groups, with particularly noteworthy improvements in KP and Sindh, as indicated by the parity ratio. The RMNCH service coverage sub-index gap was the greatest among women aged 15-19 years, those who belonged to the poorest wealth quintile, had no education, and resided in rural areas.

CONCLUSIONS

Analysing existing data sources from an equity lens supports evidence-based policies, programs and practices with a focus on disadvantaged subgroups.

Reproductive, maternal, newborn, and child health intervention coverage in 70 low-income and middle-income countries, 2000-30: trends, projections, and inequities

BACKGROUND

Monitoring the progress in reproductive, maternal, newborn, and child health (RMNCH) using the composite coverage index (CCI) is crucial to evaluate the advancement of low-income and middle-income countries (LMICs) towards the attainment of Sustainable Development Goal target 3. We present current benchmarking for 70 LMICs, forecasting to 2030, and an analysis of inequities within and across countries.

METHODS

In this cross-sectional secondary data analysis, we extracted 291 data points from the WHO Equity Monitor, and Demographic and Health Survey Statcompiler for 70 LMICs. We selected countries on the basis of whether they belonged to LMICs, had complete information about the predictors between 2000 and 2030, and had at least one data point related to CCI. CCI was calculated on the basis of eight types of RMNCH interventions in four domains, comprising family planning, antenatal care, immunisations, and management of childhood illnesses. This study examined CCI as the main outcome variable. Bayesian hierarchical models were used to estimate trends and projections of the CCI at regional and national levels, as well as the area of residence, educational level, and wealth quintile.

FINDINGS

Despite progress, only 18 countries are projected to reach the 80% CCI target by 2030. Regionally, CCI is projected to increase in all regions of Asia (in southern Asia from 51·8% in 2000 to 89·2% in 2030; in southeastern Asia from 58·8% to 84·4%; in central Asia from 70·3% to 87·0%; in eastern Asia from 76·8% to 82·1%; and in western Asia from 56·5% to 72·1%), Africa (in sub-Saharan Africa from 46·3% in 2000 to 72·2% in 2030 and in northern Africa from 55·0% to 81·7%), and Latin America and the Caribbean (from 67·0% in 2000 to 83·4% in 2030). By contrast, southern Europe is predicted to experience a decline in CCI over the same period (70·1% in 2000 to 55·2% in 2030). Across LMICs, CCIs are higher in urban areas, in populations in which women have higher education levels, and in populations with a high income.

INTERPRETATION

Governments of countries where the universal target of 80% CCI has not yet been reached must develop evidence-based policies aimed at enhancing RMNCH coverage. Additionally, they should focus on reducing the extent of existing inequalities within their populations to drive progress in RMNCH.

FUNDING

Hitotsubashi University and Japan Society for the Promotion of Science.

Evaluation of maternal and child care continuum in Guinea: a secondary analysis of two demographic and health surveys using the composite coverage index (CCI)

INTRODUCTION

The composite coverage index (CCI) is the weighted average coverage of eight preventive and curative interventions received along the maternal and childcare continuum. This study aimed to analyse maternal and child health indicators using CCI.

METHODS

We performed a secondary analysis of demographic and health surveys (DHS) focused on women aged 15 to 49 and their children aged 1 to 4. This study took place in Guinea. The CCI (meeting the need for planning, childbirth assisted by qualified healthcare workers, antenatal care assisted by qualified healthcare workers, vaccination against diphtheria, pertussis, tetanus, measles and Bacillus Calmette-Guérin, taking oral rehydration salts during diarrhoea and seeking care for pneumonia) is optimal if the weighted proportion of interventions is > 50%; otherwise, it is partial. We identified the factors associated with CCI using the descriptive association tests, the spatial autocorrelation statistic and multivariate logistic regression.

RESULTS

The analyses involved two DHS surveys, with 3034 included in 2012 and 4212 in 2018. The optimal coverage of the CCI has increased from 43% in 2012 to 61% in 2018. In multivariate analysis, in 2012: the poor had a lower probability of having an optimal CCI than the richest; OR = 0.11 [95% CI; 0.07, 0.18]. Those who had done four antenatal care visits (ANC) were 2.78 times more likely to have an optimal CCI than those with less OR = 2.78 [95% CI;2.24, 3.45]. In 2018: the poor had a lower probability of having an optimal CCI than the richest OR = 0.27 [95% CI; 0.19, 0.38]. Women who planned their pregnancies were 28% more likely to have an optimal CCI than those who had not planned OR = 1.28 [95% CI;1.05, 1.56]. Finally, women with more than 4 ANC were 2.43 times more likely to have an optimal CCI than those with the least OR = 2.43 [95% CI; 2.03, 2.90]. The spatial analysis reveals significant disparities with an aggregation of high partial CCI in Labé between 2012 and 2018.

CONCLUSION

This study showed an increase in CCI between 2012 and 2018. Policies should improve access to care and information for poor women. Besides, strengthening ANC visits and reducing regional inequalities increases optimal CCI.

Adaptation of Essential Care for Every Baby educational program to improve infant outcomes in the context of Zika

BACKGROUND

The outbreak and ongoing transmission of Zika virus provided an opportunity to strengthen essential newborn care and early childhood development systems through collaboration with the US Agency for International Development Applying Science to Strengthen and Improve Systems (USAID ASSIST). The objective was to create a system of sustainable training dissemination which improves newborn care-related quality indicators in the context of Zika.

METHODS

From 2018-19, USAID ASSIST supported a series of technical assistance visits by the American Academy of Pediatrics (AAP) in four Caribbean countries to strengthen the clinical capacity in care of children potentially affected by Zika through dissemination of Essential Care for Every Baby (ECEB), teaching QI methodology, coaching visits, and development of clinical care guidelines. ECEB was adapted to emphasize physical exam findings related to Zika. The first series of workshops were facilitated by AAP technical advisors and the second series were facilitated by the newly trained local champions. Quality of care was monitored with performance indicators at 134 health facilities.

RESULTS

A repeated measures (pre-post) ANOVA was conducted, revealing significant pre-post knowledge gains [F(1) = 197.9, p < 0.001] on knowledge check scores. Certain performance indicators related to ECEB practices demonstrated significant changes and midline shift on the run chart in four countries.

CONCLUSION

ECEB can be adapted to incorporate important local practices, causes of neonatal morbidity and mortality, and differing healthcare system structures, which, as one part of a larger technical assistance package, leads to improved performance of health systems.

Students’ Learning on Sustainable Development Goals through Interactive Lectures and Fieldwork in Rural Communities: Grounded Theory Approach

Sustainable social-resource-based community management and sustainable development goals (SDGs) are crucial for community sustainability and sustainable development, respectively, and SDG education is vital to motivate people to continue SDG-appropriate activities. This study aims to evaluate the effectiveness of the SDG education of Rural Japanese University students using the grounded theory approach and investigate how their ideas about future work subsequently change. This study analyzes the learning and attitude changes in students enrolled in an elective SDG course and establishes the learning theory behind SDG education in rural universities. In this approach, student SDG education consists of three themes and eleven concepts. Through SDG education based on interactive lectures and rural fieldwork, participants reconsider community and society concepts in an SDG-minded framework. Based on this new perspective, participants begin considering community sustainability by gaining new insight from a first-person standpoint. Participants acquire SDG-minded working competencies, such as collaborative advancement, respect for inclusive societies, community revitalization from different perspectives, and mindset reconstruction. SDG educational processes were conducted in rural communities through university student SDG education, which deepened their understanding of community sustainability. Thus, SDG education should employ real practitioners to university curricula and deal with cultural and traditional diversity via effective collaboration.

Measuring Quality of Maternal, Neonatal, Child, Reproductive Health and Nutrition Care with tools developed by the RADAR project and tested in Sub Saharan Africa

Increasing coverage of evidence-based maternal, neonatal, child, reproductive health and nutrition (MNCRHN) programs in low- and middle-income countries has coincided with dramatic improvements in health despite variable quality of implementation. Comprehensive evaluation to inform program improvement requires standardized but adaptable tools, which the Real Accountability, Data Analysis for Results (RADAR) project has developed. To inform selection of tools and methods packages (‘packages’) to measure program quality of care (QoC), we documented experiences testing the packages, which were developed and adapted based on global and local expertise, and pre- and pilot-testing. We conducted cross-sectional studies in 2018–2019 on the quality of 1) integrated community case management, 2) counseling on maternal, infant, and young child feeding, 3) intrapartum care, and 4) family planning counseling in Mali, Mozambique, Tanzania, and Malawi. Herein we describe package performance and highlight experiences that inform their selection and use. Direct observation packages provided high-quality, immediately applicable results but they required specialized expertise, in-person collection, adequate patient volume, reasonable wait times, and unambiguously ‘correct’ provision of care. General satisfaction questions from exit interview packages produced unvaryingly positive responses despite variable observed quality of care. Variation increased when questions were more targeted, but findings on caregiver and client’s recall of recommendations were more actionable. When interactive, clinical vignettes can capture knowledge of clinical care. But for conditions that can be simulated, like provision of family planning counseling, we could capture provider practice from simulated clients. Clinicians could more easily demonstrate tactile aspects of intrapartum care using observed structured clinical examinations, but this method required storage and transport of the required mannequins. Based on our findings we recommend ten questions upon which evaluators can base package selection. Findings from these packages inform programs and, in the context of comprehensive program evaluation enable us to link programs with impact.

Short message service (SMS) reminders for childhood immunisation in low-income and middle-income countries: a systematic review and meta-analysis

Introduction

Childhood vaccine delivery services in the low- and middle-income countries (LMIC) are struggling to reach every child with lifesaving vaccines. Short message service (SMS) reminders have demonstrated positive impact on a number of attrition-prone healthcare delivery services. We aimed to evaluate the effectiveness of SMS reminders in improving immunisation coverage and timeliness in LMICs.

Methods

PubMed, Embase, Scopus, Cochrane CENTRAL, CINAHL, CNKI, PsycINFO and Web of Science including grey literatures and Google Scholar were systematically searched for randomised controlled trials (RCTs) and non-RCTs that evaluated the effect of SMS reminders on childhood immunisation and timeliness in LMICs. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 assessment tool for RCTs and Cochrane Risk of Bias in Non-randomised Studies of Interventions tool for non-RCTs. Meta-analysis was conducted using random-effects models to generate pooled estimates of risk ratio (RR).

Results

18 studies, 13 RCTs and 5 non-RCTs involving 32 712 infants (17 135 in intervention groups and 15 577 in control groups) from 11 LMICs met inclusion criteria. Pooled estimates showed that SMS reminders significantly improved childhood immunisation coverage (RR=1.16; 95% CI: 1.10 to 1.21; I²=90.4%). Meta-analysis of 12 included studies involving 25 257 infants showed that SMS reminders significantly improved timely receipt of childhood vaccines (RR=1.21; 95% CI: 1.12 to 1.30; I²=87.3%). Subgroup analysis showed that SMS reminders are significantly more effective in raising childhood immunisation coverage in lower middle-income and low-income countries than in upper middle-income countries (p<0.001) and sending more than two SMS reminders significantly improves timely receipt of childhood vaccines than one or two SMS reminders (p=0.040).

Conclusion

Current evidence from LMICs, although with significant heterogeneity, suggests that SMS reminders can contribute to achieving high and timely childhood immunisation coverage.

PROSPERO registration number

CRD42021225843.

The Effects of Conflicts and Self-Reported Insecurity on Maternal Healthcare Utilisation and Children Health Outcomes in the Democratic Republic of Congo (DRC)

Background The Democratic Republic of Congo (DRC) has experienced political unrest, civil insecurity, and military disputes, resulting in extreme poverty and a severely impaired health care system. To reduce the morbidity and mortality in women and children by strengthening healthcare, this study aimed at exploring the relationship between self-reported insecurity of mothers and maternal health-seeking behaviours and diseases in children in the DRC. Method Data collected from 8144 mothers and 14,403 children from the Multiple Indicators Cluster Survey (MICS) conducted by the National Institute of Statistics in 2017-2018, in collaboration with the United Nations Children's Fund (UNICEF), was used. The severity of the conflict in different provinces was measured using the Uppsala Conflict Data Program (UCDP) reports. Multivariate logistic regression and stratified analysis were utilized to explore the association between conflicts with maternal health-seeking behaviours and diseases among children. Results High self-reported insecurity was positively associated with skilled antenatal care (OR1.93, 95%CI 1.50-2.49), skilled attendants at delivery (OR1.42, 95%CI 1.08-1.87), and early initiation of breastfeeding (OR1.32, 95%CI 1.04-1.68). These associations were more significant in regions with more armed conflict. It was also found that children of mothers with high self-reported insecurity were more likely to suffer from diarrhoea (OR1.47, 95%CI: 1.14-1.88), fever (OR1.23, 95%CI 1.01-1.50), cough (OR1.45, 95%CI 1.19-1.77), and dyspnea (OR2.04, 95%CI 1.52-2.73), than children of mothers with low self-reported insecurity. Conclusions Conflicts increases mothers' insecurities and negatively affects children's development. However, high conflict regions have to increase governmental and international assistance to promote the availability and access to maternal and child health services.

Temporal trends in between and within-country inequalities in caesarean delivery in low- and middle-income countries: a Bayesian analysis

OBJECTIVE

To provide updated information about between-country variations, temporal trends and changes in inequalities within countries in caesarean delivery (CD) rates.

DESIGN

Cross-sectional study of Demographic and Health Survey (DHS) during 1990-2018.

SETTING

74 low- and middle-income countries (LMICs).

POPULATION

Women 15-49 years of age who had live births in the last 3 years.

METHODS

Bayesian linear regression analysis was performed and absolute differences were calculated.

MAIN OUTCOME MEASURE

Population-level CD by countries and sociodemographic characteristics of mothers over time.

RESULTS

CD rates, based on the latest DHS rounds, varied substantially between the study countries, from 1.5% (95% CI 1.1-1.9%) in Madagascar to 58.9% (95% CI 56.0-61.6%) in the Dominican Republic. Of 62 LMICs with at least two surveys, 57 countries showed a rise in CD during 1990-2018, with the greatest increase in Sierra Leone (19.3%). Large variations in CD rates were observed across mother's wealth, residence, education and age, with a higher rate of CD by the richest and urban mothers. These inequalities have widened in many countries. Stratified analyses suggest greater provisioning of CD by the richest mothers in private facilities and poorest mothers in public facilities.

CONCLUSIONS

CD rates varied substantially across geographical locations and over time, irrespective of public or private health facilities. Changes in CD rates continue across wealth, place of residence, education, and age of mother, and are widening in most study countries.

TWEETABLE ABSTRACT

Increasing caesarean delivery rates were greater among the richest and urban mothers than their counterparts, with widened gaps in LMICs.