Determinants of use of supervised delivery care under Ghana's fee exemption policy for maternal healthcare: the case of the Central Region.

BACKGROUND: Improving access to supervised and emergency obstetric care resources through fee reduction/exemption maternity care initiatives has been touted as one major strategy to avoiding preventable maternal deaths. Evaluations on the effect of Ghana's fee exemption policy for maternal healthcare have largely focused on how it has influenced health outcomes and patterns of use of supervised care with little attention to understanding the main factors influencing use. This study therefore sought to explore the main individual and health system factors influencing use of delivery care services under the policy initiative in the Central Region. METHODS: A cross-sectional study was conducted using 412 mothers with children aged less than one year in one largely rural and another largely urban districts in the Central Region of Ghana from September to December 2013. Data were collected using a questionnaire survey on the socio-demographic characteristics of mothers, their knowledge and use of care under the fee free policy. Chi-square and Binary Logistic Regression tests were used to evaluate the main determinants of delivery care use under the policy. RESULTS: Out of the 412 mothers interviewed, 268 (65 %) reported having delivered their most recent birth under the fee exemption policy even though awareness about the policy was almost universal 401 (97.3 %) among respondents. Utilization however differed for the two study districts. Respondents in the Cape Coast Metropolis (largely urban) used delivery service more (75.7 %) than those in the largely rural Assin North Municipal area (54.4 %). Binary logistic regression results identified maternal age, parity, religion, place of residence, awareness and knowledge about the fee exemption policy for maternal healthcare as significantly associated with the likelihood of delivery care use under the policy. The likelihood of using supervised delivery care under the policy was lower for mothers aged 20-29 compared to those in the age bracket of 40-49 (Odds ratio (OR) = 0.069, p = 0.003). For their index (last child), mothers who already had 1, 2 or 3 births were more likely to deliver under the policy than those with five or more births. Mothers living in urban areas were 3.79 times more likely to use delivery services under the policy than those living in rural areas (OR = 3.793, p = 0.000). The likelihood of using delivery services under the policy was higher for mothers who were aware and had full knowledge of the total benefit package of the policy (OR = 13.820, p = 0.022 and OR = 2.985, p = 0.001 for awareness and full knowledge respectively). CONCLUSIONS: Delivery service use under the free maternal healthcare policy is relatively low (65 %) when compared with nearly universal awareness (97.3 %) about the policy. Factors influencing delivery service use under the policy operate at both individual and policy implementation levels. Effective interventions to improve delivery service use under the policy should target the underlying individual and health policy implementation factors identified in the study.

Global justice, capabilities approach and commercial surrogacy in India.

Inequalities, ineffective governance, unclear surrogacy regulations and unethical practices make India an ideal environment for global injustice in the process of commercial surrogacy. This article aims to apply the 'capabilities approach' to find possibilities of global justice through human fellowship in the context of commercial surrogacy. I draw primarily on my research findings supplemented by other relevant empirical research and documentary films on surrogacy. The paper reveals inequalities and inadequate basic entitlements among surrogate mothers as a consequence of which they are engaged in unjust contracts. Their limited entitlements also limit their opportunities to engage in enriching goals. It is the role of the state to provide all its citizens with basic entitlements and protect their basic human rights. Individuals in India evading their basic duty also contribute to the existing inequalities. Individual responsibilities of the medical practitioners and the intended parents are in question here as they are more inclined towards self-interest rather than commitment towards human fellowship. At the global level, the injustice in transnational commercial surrogacy practices in developing countries calls for an international declaration of women and child rights in third party reproduction with a normative vision of mutual fellowship and human dignity.

An ethnomethodological approach to examine exploitation in the context of capacity, trust and experience of commercial surrogacy in India.

The socio-ethical concerns regarding exploitation in commercial surrogacy are premised on asymmetric vulnerability and the commercialization of women's reproductive capacity to suit individualistic motives. In examining the exploitation argument, this article reviews the social contract theory that describes an individual as an 'economic man' with moral and/or political motivations to satisfy individual desires. This study considers the critique by feminists, who argue that patriarchal and medical control prevails in the surrogacy contracts. It also explores the exploitative dynamics amongst actors in the light of Baier's conceptualization of trust and human relationship, within which both justice and exploitation thrive, and Foucault's concept of bio-power. Drawing on these concepts, this paper aims to investigate the manifestations of exploitation in commercial surrogacy in the context of trust, power and experiences of actors, using a case study of one clinic in India. The actors' experiences are evaluated at different stages of the surrogacy process: recruitment, medical procedures, living in the surrogate home, bonding with the child and amongst actors, financial dealings, relinquishment and post-relinquishment.This study applies ethnomethodology to identify phenomena as perceived by the actors in a situation, giving importance to their interpretations of the rules that make collective activity possible. The methods include semi-structured interviews, discussions, participant observation and explanation of the phenomena from the actors' perspectives. Between August 2009 and April 2010, 13 surrogate mothers (SMs), 4 intended parents (IPs) and 2 medical practitioners (MPs) from one clinic in Western India were interviewed.This study reveals that asymmetries of capacity amongst the MPs, SMs, IPs and surrogate agents (SAs) lead to a network of trust and designation of powers through rules, bringing out the relevance of Baier's conceptualization of asymmetric vulnerability, trust and potential exploitation in human relationships. The IPs are exploited, especially in monetary terms. The SMs are relatively the most exploited, given their vulnerability. Their remuneration through surrogacy is significant for them, and their acquired knowledge as ex-surrogates is used for their own benefit and for exploiting others. Foucault's conceptualization of power is hence relevant, since the ex-SMs re-invest the power of their exploitative experience in exploiting others.

Re-examining authoritative knowledge in the design and content of a TBA training in India.

UNLABELLED: Since the 1990s, the TBA training strategy in developing countries has been increasingly seen as ineffective and hence its funding was subsequently reallocated to providing skilled attendants during delivery. The ineffectiveness of training programmes is blamed on TBAs lower literacy, their inability to adapt knowledge from training and certain practices that may cause maternal and infant health problems. However most training impact assessments evaluate post-training TBA practices and do not assess the training strategy. There are serious deficiencies noted in information on TBA training strategy in developing countries. The design and content of the training is vital to the effectiveness of TBA training programmes. We draw on Jordan's concept of 'authoritative knowledge' to assess the extent to which there is a synthesis of both biomedical and locally practiced knowledge in the content and community involvement in the design of TBA a training programme in India. FINDINGS: The implementation of the TBA training programme at the local level overlooks the significance of and need for a baseline study and needs assessment at the local community level from which to build a training programme that is apposite to the local mother's needs and that fits within their 'comfort zone' during an act that, for most, requires a forum in which issues of modesty can be addressed. There was also little scope for the training to be a two way process of learning between the health professionals and the TBAs with hands-on experience and knowledge. The evidence from this study shows that there is an overall 'authority' of biomedical over traditional knowledge in the planning and implementation process of the TBA training programme. Certain vital information was not covered in the training content including advice to delay bathing babies for at least six hours after birth, to refrain from applying oil on the infant, and to wash hands again before directly handling mother or infant. Information on complication management and hypothermia was not adequately covered in the local TBA training programme. KEY CONCLUSIONS: The suggested improvements include the need to include a baseline study, appropriate selection criteria, improve information in the training manual to increase clarity of meaning, and to encourage beneficial traditional practices through training.

Traditional birth attendant training and local birthing practices in India.

Training birth attendants (TBAs) provide essential maternal and infant health care services during delivery and ongoing community care in developing countries. Despite inadequate evidence of relevance and effectiveness of TBA training programmes, there has been a policy shift since the 1990s in that many donor agencies funding TBA training programmes redirected funds to providing skilled attendants during delivery. This study aimed to assess the ways in which a TBA training programme in India has been successful in disseminating evidence-based knowledge on birthing practices. TBAs practicing within 16 villages targeted by training programme initiatives were administered with structured questionnaires. The post training birthing practices of trained (24) and untrained (14) TBAs was compared and birthing practices adopted by women assisted by trained (16) and untrained (9) TBAs was analysed. Positive post training practices were hand washing, use of a clean blade for cutting the cord, immediate breastfeeding and weighing of babies. Nevertheless, the training could be further improved with up to date and evidence-based information and more comprehensive instructions. The findings suggest an integration of local and evidence-based knowledge is needed to improve the training. Raising community awareness of public health measures related to maternal and child health is also recommended.