Predictors of parenting difficulties at the 18-month health checkups: A retrospective study using administrative data from infant health checkups.

OBJECTIVE: This study aimed to identify predictors of parenting difficulties at 18 months from the results of the 4-, 6-7-, and 9-10-month infant health checkups among caregivers who had not experienced difficulties at 4 months. DESIGN AND SAMPLES: This retrospective study used data from infant health checkups conducted in a city in Tokyo from November 2019 to October 2021. The participants were caregiver-child dyads of children who had undergone four checkups. Low birthweight, preterm, and multiple birth infants, and caregivers who experienced difficulties at 4 months were excluded. MEASUREMENTS: Data included caregiver, child-rearing environment, and child factors at the 4-, 6-7-, and 9-10-month checkups and caregivers' self-reported parenting difficulties at the 18-month checkup. RESULTS: Of the 555 caregivers, 48 (8.6%) experienced parenting difficulties at 18 months. Logistic regression analyses showed that mothers' physical condition (4 months), children being male, abnormal child growth (4 months), less than 10th percentile for children's height (6-7 and 9-10 months), and abnormal examination results (6-7 months) were significantly associated with parenting difficulties at 18 months. CONCLUSIONS: To prevent child abuse, public health nurses should consider the identified factors to detect and support caregivers with emerging parenting difficulties.

Who Delivers Maternal and Child Health Services? The Contributions of Public Health and Other Community Partners.

Policy Points Local health departments with direct maternal and child health service provisions exhibit greater social service collaboration, thereby enhancing community capacity to improve health care access and social determinant support. These findings may prioritize collaboration as a community-based effort to reduce disparities in maternal and child health and chronic disease. CONTEXT: Improving maternal and child health (MCH) care in the United States requires solutions to address care access and the social determinants that contribute to health disparities. Direct service provision of MCH services by local health departments (LHDs) may substitute or complement public health services provided by other community organizations, impacting local service delivery capacity. We measured MCH service provision among LHDs and examined its association with patterns of social service collaboration among community partners. METHODS: We analyzed the 2018 National Longitudinal Survey of Public Health Systems and 2016 National Association of County and City Health Officials Profile data to measure the LHD provision of MCH services and the types of social services involved in the implementation of essential public health activities. We compared the extensive and intensive margins of social service collaboration among LHDs with any versus no MCH service provision. We then used latent class analysis (LCA) to classify collaboration and logistic regression to estimate community correlates of collaboration. FINDINGS: Of 620 LHDs, 527 (85%) provided at least one of seven observed MCH services. The most common service was Special Supplemental Nutrition Program for Women, Infants, and Children (71%), and the least common was obstetric care (15%). LHDs with MCH service provision were significantly more likely to collaborate with all types of social service organizations. LCA identified two classes of LHDs: high (n = 257; 49%) and low (n = 270; 51%) collaborators. Between 74% and 96% of high collaborators were engaged with social service organizations that provided basic needs services, compared with 31%-60% of low collaborators. Rurality and very high maternal vulnerability were significantly correlated with low collaboration among MCH service-providing LHDs. CONCLUSIONS: LHDs with direct MCH service provision exhibited greater social service collaboration. Collaboration was lowest in rural communities and communities with very high maternal vulnerability. Over half of MCH service-providing LHDs were classified as low collaborators, suggesting unrealized opportunities for social service engagement in these communities.

Triple Benefit: Impact of an Integrated Early Childhood Development and PMTCT Intervention on ART Outcomes Among Mothers Living with HIV and Infants in Malawi-An Endline Evaluation.

We conducted a programmatic, observational cohort study with mother-infant pairs (MIPs) enrolled in prevention-of-mother-to-child-transmission (PMTCT) programs in Malawi to assess the feasibility and potential HIV-related benefits of integrating Early Childhood Development (ECD) services into PMTCT programs. Six health facilities were included in the intervention. We offered ECD counseling from the WHO/UNICEF Care for Child Development package in PMTCT waiting spaces while MIPs waited for PMTCT and broader treatment consultations. Primary outcomes were mothers' retention in HIV care at 12 months and infant HIV testing at 6 weeks and 12 months after birth. Routine facility-level data from six comparison health facilities were collected as an adhoc standard of care comparison and used to calculate the cost of delivering the intervention. A total of 607 MIPs were enrolled in the integrated ECD-PMTCT intervention between June 2018 and December 2019. The average age of MIPs was 30 years and 7 weeks respectively. We found that 86% of mothers attended ≥ 5 of the 8 ECD sessions over the course of 12 months; 88% of intervention mothers were retained in PMTCT versus 59% of mothers in comparison health facilities, and 96% of intervention infants were tested for HIV by six weeks compared to 66% of infants in comparison health facilities. Costing data demonstrated the financial feasibility of integrating ECD and PMTCT programs in government health facilities in Malawi. Integrating ECD into PMTCT programs was feasible, acceptable, resulted in better programmatic outcomes for both mothers and infants. Further investigation is required to determine optimal delivery design for scale-up.

Inequity of maternal-child health services in ASEAN member states from 1993 to 2021.

INTRODUCTION: Inequity in maternal-child health services is a challenge to global health as it hinders the achievement of Sustainable Development Goals (SDGs) and Universal Health Coverage. Though the Association of Southeast Asian Nations (ASEAN) has made remarkable achievements in maternal-child health, there remain gaps in reaching global goals. This study aimed to compare and investigate the inequity in maternal-child health (MCH) services in ASEAN member states to help guide policy decisions to improve equitable health services in the SDG era and beyond. METHODS: Using the WHO Health Inequality Monitor, we identified inequity summary measures for five MCH services in ASEAN member states from 1993 to 2021: antenatal care, births attended by skilled health personnel, diphtheria, tetanus and pertussis (DTP3) immunization, measles immunization, and polio immunization. We divided the analysis dimension of inequity into urban-rural inequity, economic status inequity, and sub-regional inequity. Trends of absolute and relative inequity in every dimension of MCH services in ASEAN member states were examined with the principal component analysis (PCA). RESULTS: The mean coverages of MCH services are 98.80% (Thailand), 86.72% (Cambodia), 84.54% (Viet Nam), 78.52 (Indonesia), 76.94% (Timor-Leste), 72.40% (Lao PDR), 68.10% (Philippines) and 48.52% (Myanmar) in 2021. Thailand have the lowest MCH services absolute inequity indexes of -1.945, followed by Vietnam (-1.449). Lao PDR and Myanmar have relatively higher MCH services absolute inequity indexes of 0.852 and 0.054 respectively. The service in Cambodia, Indonesia, and the Philippines is pro-specific regions (with subnational region absolute inequity indexes of -0.02, 0.01, and 1.01 respectively). The service in Myanmar is pro-rich (with economic status absolute inequity index of 0.43). The service in Lao PDR and Timor-Leste is pro-urban areas, pro-rich, and pro-specific regions. CONCLUSION: The inequity of MCH services in ASEAN persists but is in a declining trend. Thailand and Vietnam have performed well in ensuring MCH services equity, while Laos and Myanmar are still facing serious inequity dilemmas. The progress of MCH service equity in Myanmar, Cambodia, the Philippines, and Indonesia is uneven. It is acceptable to learn from the successful experiences of Thailand and Vietnam to improve the equities in other ASEAN countries. Policies should be developed according to the specific types of MCH inequity in member states to improve equity levels.

Are pregnancy outcomes affected by the lack of legal status? A demographic study based on 850,288 live births in Switzerland.

BACKGROUND: In the context of increased global mobility, it is fundamental to understand migrants' needs and how governments can ensure equal health opportunities for both regular and irregular migrants simply by applying low-cost primary health care measures. To identify health issues in which to intervene, this study analysed the impact of a mother's lack of legal status, together with available biological and socioeconomic characteristics, on four indicators of adverse perinatal outcomes in Switzerland. METHODS: Based on the exhaustive records of the Swiss Federal Statistical Office (FSO) for its Vital Statistics (BEVNAT), different indicators of birth outcomes, including preterm birth (PTB), low and very low birth weight (LBW and VLBW), and small for gestational age (SGA), were analysed using logistic regressions on live births occurring from 2005 to 2018. These four adverse outcomes were defined as dependent variables. Statistical analysis was performed using the statistical package STATA, version 17. RESULTS: Selected pregnancy outcomes were conversely affected by an irregular legal status. Analysis run on the final sample showed that, compared to the neonates of mothers who are non-migrant legal residents in Switzerland, newborns of irregular migrants have higher risks of PTB (aOR 1.18 95% CI [1.05-1.32], p<0.01) and VLBW (aOR 1.43 [1.13-1.81], p < 0.01]). In contrast, we observed that in both irregular and regular migrant groups, the odds of SGA were lowered (aOR .76 [.68-.85] p<0.01) and aOR .93 [.91-.94], p< 0.01, respectively). A similar effect was observed when controlling for any adverse outcome (any AOs) (aOR  .90 [.83-.99] p 0.022; and aOR .93 [.91-.94] p< 0.01, respectively). CONCLUSIONS: Our results, together with those from the available literature, call for a more comprehensive assessment of all pregnancy outcomes as well as of the social determinants of health for which the analysis was adjusted. Given the complexity of the migration phenomenon, future studies should account for local structural restrictions in the organization of care, the extension of a person's network as a means of health care accessibility, diverse backgrounds and cultures and the recent arrival status of migrants. This would allow researchers to understand the long-term impact of social determinants of health on the wellbeing of a mother and child and take them into account in the adoption of health policies.

What values drive communities' nutrition priorities in a resource constrained urban area in South Africa?

BACKGROUND: Voices of under-resourced communities are recognised as important yet are often unheard in decisions about healthcare resource allocation. Deliberative public engagement can serve as an effective mechanism for involving communities in establishing nutrition priorities. This study sought to identify the priorities of community members of a South African township, Soweto, and describe the underlying values driving their prioritisation process, to improve nutrition in the first 1000 days of life. METHODS: We engaged 54 community members (28 men and 26 women aged > 18 years) from Soweto. We conducted seven group discussions to determine how to allocate limited resources for prioritising nutrition interventions. We used a modified public engagement tool: CHAT (Choosing All Together) which presented 14 nutrition intervention options and their respective costs. Participants deliberated and collectively determined their nutritional priorities. Choices were captured quantitatively, while group discussions were audio-recorded. A thematic analysis was undertaken to identify the reasons and values associated with the selected priorities. RESULTS: All groups demonstrated a preference to allocate scarce resources towards three priority interventions-school breakfast provisioning, six-months paid maternity leave, and improved food safety. All but one group selected community gardens and clubs, and five groups prioritised decreasing the price of healthy food and receiving job search assistance. Participants' allocative decisions were guided by several values implicit in their choices, such as fairness and equity, efficiency, social justice, financial resilience, relational solidarity, and human development, with a strong focus on children. Priority interventions were deemed critical to supporting children's optimal development and well-being, interrupting the intergenerational cycle of poverty and poor human development in the community. CONCLUSION: Our study demonstrates how public engagement can facilitate the incorporation of community values and programmatic preferences into nutrition priority setting, enabling a responsive approach to local community needs, especially in resource constrained contexts. Findings could guide policy makers to facilitate more appropriate decisions and to improve nutrition in the first 1000 days of life.

Parent satisfaction with sustained home visiting care for mothers and children: an integrative review.

AIM: To synthesise and analyse the existing literature regarding parent satisfaction with sustained home visiting care for mothers and children. BACKGROUND: Sustained home visiting is a service delivery mechanism of both prevention and intervention, in which people receive structured support services within their home environment over an extended period of months or years. For the purposes of this paper, sustained home visiting refers to in-home nursing support to address health inequities for mothers and young children. Sustained home visiting programs have been found to support improved health, wellbeing, and developmental outcomes for children and families. However, there is limited knowledge with regards to the level of parent satisfaction with care provided at home, and the factors and elements of care parents perceive to be critical to their satisfaction. It is important for healthcare practitioners to understand what practices and process parents consider to be a priority in securing their ongoing engagement. DESIGN: Integrative review. DATA SOURCES: PubMed/Medline, CINAHL, Embase, and PsycINFO. METHODS: A multi-step approach was used to search and retrieve peer-reviewed studies from the databases. Study selection, data extraction, data synthesis and critical appraisal were undertaken by two independent researchers. RESULTS: A total of 13 studies met the inclusion criteria, including nine quantitative and four qualitative studies. The review found that parents provided with home visiting interventions had higher levels of satisfaction with care than those who received routine or facility-based care. Service dose was a factor associated with parent satisfaction, however, the direction of impact on parent satisfaction was mixed. Other elements of care parents perceived as important to service satisfaction included the nurse-client relationship, being treated with respect, empowerment, and emotional support. CONCLUSION: While it is critically important that home visiting practitioners provide evidence-based care and interventions, it is equally important that services are delivered in the context of positive and empowering relationships. Further research is recommended to understand the care process and mechanisms that enhance parent satisfaction and positive experiences, providing optimal quality of care.

Coverage, inequity and predictors of hepatitis B birth vaccination in Myanmar from 2011-2016: results from a national survey.

BACKGROUND: Hepatitis B virus birth dose (HepB-BD) vaccination is recommended to reduce mother to infant transmission. We evaluated the HepB-BD status of women who gave birth between 2011 and 2016 (N = 3,583) using the 2015-2016 Myanmar Demographic and Health Survey. METHODS: Frequency distributions of HepB-BD vaccination across maternal and health system factors, concentration indices, and logistic regression models were used to estimate coverage, inequity, and factors associated with vaccination. RESULTS: The majority of participants were younger than 30 years of age, lived in rural areas, and were multiparous. Almost all received antenatal care (ANC), but only 43% received recommended ANC services, and 60% gave birth at home. The overall HepB-BD coverage rate was 26%. Vaccination coverage was higher in urban areas and was inequitably concentrated among children of more educated and wealthier women. HepB-BD coverage was also positively associated with receipt of ANC at non-governmental facilities, and delivery at a facility, skilled provider at birth and Cesarean delivery. After adjusting for sociodemographic and health system factors, receipt of the HepB-BD was positively associated with weekly media exposure, receipt of recommended ANC, and Cesarean delivery, and inversely associated with home delivery. CONCLUSIONS: Both socioeconomic and health systems factors influenced suboptimal and inequitable vaccination coverage. Improved access to quality ANC and delivery services may increase HepB-BD coverage although targeted approaches to reach home births are likely required to achieve national goals.

Effect of integrating maternal and child health services, nutrition and family planning services on postpartum family planning uptake at 6 months post-partum in Burkina Faso, Cote d'Ivoire and Niger: a quasi-experimental study protocol.

BACKGROUND: Although several interventions integrating maternal, neonatal, child health and nutrition with family planning have been implemented and tested, there is still limited evidence on their effectiveness to guide program efforts and policy action on health services integration. This study aims to assess the effectiveness of a service delivery model integrating maternal and child health services, nutrition and family planning services, compared with the general standard of care in Burkina Faso, Cote d'Ivoire, and Niger. METHODS: This is a quasi experimental study with one intervention group and one control group of 3 to 4 health facilities in each country. Each facility was matched to a control facility of the same level of care that had similar coverage on selected reproductive health indicators such as family planning and post-partum family planning. The study participants are pregnant women (up to 28 weeks of gestational age) coming for their first antenatal care visit. They will be followed up to 6 months after childbirth, and will be interviewed at each antenatal visit and also during visits for infant vaccines. The analyzes will be carried out by intention to treat, using generalized linear models (binomial log or log Poisson) to assess the effect of the intervention on the ratio of contraceptive use prevalence between the two groups of the study at a significance level of 5%, while taking into account the cluster effect and adjusting for potential confounding factors (socio-demographic characteristics of women unevenly distributed at inclusion). DISCUSSION: This longitudinal study, with the provision of family planning services integrated into the whole maternal care continuum, a sufficiently long observation time and repeated measurements, will make it possible to better understand the timeline and the factors influencing women's decision-making on the use of post-partum family planning services. The results will help to increase the body of knowledge regarding the impact of maternal and child health services integration on the utilization of post-partum family planning taking into account the specific context of sub-Saharan Africa French speaking countries where such information is very needed.

One strategy to improve the utilization of health services by mothers and their children is the integration of maternal and child health services. For instance, a pregnant woman coming for an antenatal care visit would also receive counseling on post-partum family planning services and maternal nutrition. Similarly, a woman coming for her infant's vaccines would be offered counseling on post-partum family planning, maternal nutrition and breastfeeding. Although several interventions have been implemented and tested, there is still limited evidence on the conditions and factors required for successful maternal and child health services integration strategies. This study aims to assess the effectiveness of an intervention integrating maternal and child health services, nutrition and family planning services. For the purpose of the evaluation, 2 distincts groups of health facilities will be selected in each country, one group of 3 or 4 health facilities where the intervention will be implemented, and another group of 3 or 4 health facilities with the general standard of care. The study participants are pregnant women (up to 28 weeks of gestational age), coming for their first antenatal care visit, who will be followed up to 6 months after childbirth.The analyzes will be carried out to assess the effect of the intervention on contraceptive use prevalence between the two groups of health facilities. This study will make it possible to better understand the timeline and the factors influencing women's decision-making on the use of post-partum family planning services.

Variations in sustained home visiting care for mothers and children experiencing adversity.

OBJECTIVE: This study aimed to examine the variations in care received by mothers and families within a sustained home visiting program. We sought to identify the extent to which there were variations in home visiting care in response to the program schedule and families' risk factors. DESIGN AND SAMPLE: Data collected within the right@home program, a randomized controlled trial (RCT) for a sustained nurse home visiting intervention in Australia, were analyzed. A total of 352 women comprised the intervention arm of the trial. MEASUREMENTS: Visit content in the home visiting program, sociodemographic data, and families' risk factors were used for analysis. RESULTS: Our results confirmed that the majority of women received scheduled content on time or within an acceptable timeframe, except for the sleeping program. Women with identified risks were significantly more likely to receive content related to those risks than women without those risks (smoking: Odds Ratio [OR] = 15.39 [95%CI 3.7-64.7], mental health: OR = 15.04 [1.8-124.0], domestic violence: OR = 4.07 [2.0-8.3], and drugs and alcohol: OR = 1.81 [1.1-3.0]). CONCLUSIONS: The right@home program had high compliance with the scheduled content. Capacity development in responding to mothers with the risk of domestic violence and drugs and alcohol is recommended. Further research is required to explore the relationship between variations in care and critical outcomes.

National and subnational coverage and inequalities in reproductive, maternal, newborn, child, and sanitary health interventions in Ecuador: a comparative study between 1994 and 2012.

BACKGROUND: Latin America (LA) has experienced constant economic and political crises that coincide with periods of greater inequality. Between 1996 and 2007 Ecuador went through one of the greatest political and socio-economic crises in Latin America, a product of neo-liberal economic growth strategies. Between 2007 and 2012 it regained political stability, promoted redistributive policies, and initiated greater social spending. To understand the possible influence on the political and economic context, we analyzed the coverage and inequalities in five Reproductive, Maternal, and Child Health (RMNCH) and two water and sanitation interventions using survey data from a broad time window (1994-2012), at a national and subnational level. METHODS: The series cross-sectional study used data from four representative national health surveys (1994, 1999, 2004 and 2012). Coverage of RMNCH and sanitary interventions were stratified by wealth quintiles (as a measure of the socio-economic level), urban-rural residence and the coverage for each province was mapped. Mean difference, Theil index and Variance-weighted least squares regression were calculated to indicate subnational and temporal changes. RESULTS: From 1994 to 2004, Ecuador evidenced large inequalities whose reduction becomes more evident in 2012. Coverage in RMNCH health service-related interventions showed a rather unequal distribution among the socioeconomic status and across provinces in 1994 and 2004, compared to 2012. Sanitary interventions on the contrary, showed the most unequal interventions, and failed to improve or even worsened in several provinces. While there is a temporary improvement also at the subnational level, in 2012 several provinces maintain low levels of coverage. CONCLUSIONS: The remarkable reduction of inequalities in coverage of RMNCH interventions in 2012 clearly coincides with periods of regained political stability, promoted redistributive policies, and greater social spending, different from the former neo-liberal reforms which is consistent with observations made in other Latin American countries. Territorial heterogeneity and great inequalities specially related with sanitation interventions persists. It is necessary to obtain high quality information with sharper geographic desegregation that allows to identify and understand local changes over time. This would help to prioritize intervention strategies, introduce multisectoral policies and investments that support local governments.

Knowledge and understanding of obstetric danger signs among pregnant women attending the antenatal clinic at the National Referral Hospital in Thimphu, Bhutan: a cross-sectional study.

BACKGROUND: The third Sustainable Development Goal for 2030 development agenda aims to reduce maternal and newborn deaths. Pregnant women's understanding of danger signs is an important factor in seeking timely care during emergencies. We assessed knowledge of obstetric danger signs using both recall and understanding of appropriate action required during obstetric emergencies. METHODS: This was a cross-sectional study among pregnant women attending antenatal clinic at Bhutan's largest hospital in Thimphu. Recall was assessed against seven obstetric danger signs outlined in the Mother and Child Health Handbook (7 points). Understanding of danger signs was tested using 13 multiple choice questions (13 points). Knowledge was scored out of 20 points and reported as 'good' (≥80%), 'satisfactory' (60-79%) and 'poor' (< 60%). Correlation between participant characteristics and knowledge score as well as number of danger signs recalled was tested using Pearson's correlation coefficient. Association between knowledge score and participant characteristics was tested using t-tests (and Kruskal-Wallis test) for numeric variables. Socio-demographic and clinical characteristics associated with the level of knowledge ('good' versus 'satisfactory' and 'poor' combined) were assessed with odds ratios using a log-binomial regression model. All results with p < 0.05 were considered significant. RESULTS: Four hundred and twenty-two women responded to the survey (response rate = 96.0%). Mean (±SD) knowledge score was 12 (±2.5). Twenty women (4.7%) had 'good' knowledge, 245 (58.1%) had 'satisfactory' knowledge and 157 (37.2%) had 'poor' knowledge. The median number of danger signs recalled was 2 (IQR 1, 3) while 68 women (20.3%) could not recall any danger signs. Most women were knowledgeable about pre-labour rupture of membranes (96.0%) while very few women were knowledgeable about spotting during pregnancy (19.9%). Both knowledge score and number of danger signs recalled had significant correlation with the period of gestation. Women with previous surgery on the reproductive tract had higher odds of having 'good' level of knowledge. CONCLUSIONS: Most pregnant women had 'satisfactory' knowledge score with poor explicit recall of danger signs. However, women recognized obstetric emergencies and identified the appropriate action warranted.

Tracking pregnant women displacements in Sao Paulo, Brazil: a complex systems approach to regionalization through the emergence of patterns.

BACKGROUND: The healthcare system can be understood as the dynamic result of the interaction of hospitals, patients, providers, and government configuring a complex network of reciprocal influences. In order to better understand such a complex system, the analysis must include characteristics that are feasible to be studied in order to redesign its functioning. The analysis of the emergent patterns of pregnant women flows crossing municipal borders for birth-related hospitalizations in a region of São Paulo, Brazil, allowed to examine the functionality of the regional division in the state using a complex systems approach and to propose answers to the dilemma of concentration vs. distribution of maternal care regional services in the context of the Brazilian Unified Health System (SUS). METHODS: Cross-sectional research of the areas of influence of hospitals using spatial interaction methods, recording the points of origin and destination of the patients and exploring the emergent patterns of displacement. RESULTS: The resulting functional region is broader than the limits established in the legal provisions, verifying that 85% of patients move to hospitals with high technology to perform normal deliveries and cesarean sections. The region has high independence rates and behaves as a "service exporter." Patients going to centrally located hospitals travel twice as long as patients who receive care in other municipalities even when the patients' conditions do not demand technologically sophisticated services. The effects of regulation and the agents' preferences reinforce the tendency to refer patients to centrally located hospitals. CONCLUSIONS: Displacement of patients during delivery may affect indicators of maternal and perinatal health. The emergent pattern of movements allowed examining the contradiction between wider deployments of services versus concentration of highly specialized resources in a few places. The study shows the potential of this type of analysis applied to other type of patients' flows, such as cancer or specialized surgery, as tools to guide the regionalization of the Brazilian Health System.

Implementation fidelity of village health and nutrition days in Hardoi District, Uttar Pradesh, India: a cross-sectional survey.

BACKGROUND: Village Health and Nutrition Days (VHNDs) are a cornerstone of the Government of India's strategy to provide first-contact primary health care to rural areas. Recent government programmes such as the Janani Suraksha Yojana (JSY) and Mission Indradhanush (MI) have catalysed important changes impacting VHNDs. To learn how VHNDs are currently being delivered, we assessed the fidelity of services provided as compared to government norms in a priority district of Uttar Pradesh. METHODS: We fielded a cross-sectional study of VHNDs to provide a snapshot of health services functioning. Process evaluation data were collected via administrative sources, non-participant observation using a standardised form, and structured questionnaires. Questionnaires were designed using a framework to assess implementation fidelity. Key respondents were VHND participants, front-line workers involved in VHND delivery, and VHND non-participants (pregnant women due for antenatal care or children due for vaccination as per administrative records). Results were summarised as counts, frequencies, and proportions. RESULTS: In the 30 villages randomly selected for inclusion, 36 VHNDs were scheduled but four (11.1%) were cancelled and one VHND was not surveyed. Vaccination and antenatal care were offered at 96.8% (30/31) and child weighing at 83.9% (26/31) of VHNDs. Other normed services were infrequently provided or completely absent. Health education and promotion were particularly weak; institutional delivery was the only topic discussed in a majority of VHNDs. The true proportion of any serious problem impeding vaccine delivery was 47.2% (17/36), comprising 4 VHND cancellations and 13 VHNDs experiencing vaccine shortages. Of the 13 incidents of vaccine shortage, 11 related to an unexpected global shortage of injectable polio vaccine (IPV). Over the 31 VHNDs, 37.8% (171 of the 452 scheduled beneficiaries) did not participate. Analysis of missed opportunities for vaccination highlighted inaccuracies in beneficiary identification and tracking and demand side-factors. CONCLUSIONS: The transformative potential of VHNDs to improve population health is only partially being met. A core subset of high-priority services for antenatal care, institutional delivery, and vaccination associated with high-priority government programmes (JSY, MI) is now being provided quite successfully. Other basic health promotion and prevention services are largely not provided, constituting a critical missed opportunity.

Integrating Community Health Worker Roles to Improve Facility Delivery Utilization in Tanzania: Evidence from an Interrupted Time Series Analysis.

OBJECTIVES: Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania. METHODS: A 36-month time series data set (2014-2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility. RESULTS: There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals, from an average of 202-234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001). CONCLUSIONS FOR PRACTICE: Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care.

Maternal, Infant, and Early Childhood Home Visiting: A Call for a Paradigm Shift in States' Approaches to Funding.

Early home visiting is a vital health promotion strategy that is widely associated with positive outcomes for vulnerable families. To expand access to these services, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program was established under the Affordable Care Act, and over $2 billion have been distributed from the Health Resources and Services Administration to states, territories, and tribal entities to support funding for early home visiting programs serving pregnant women and families with young children (birth to 5 years of age). As of October 2018, 20 programs met Department of Health and Human Services criteria for evidence of effectiveness and were approved to receive MIECHV funding. However, the same few eligible programs receive MIECHV funding in almost all states, likely due to previously established infrastructure prior to establishment of the MIECHV program. Fully capitalizing on this federal investment will require all state policymakers and bureaucrats to reevaluate services currently offered and systematically and transparently develop a menu of home visiting services that will best match the specific needs of the vulnerable families in their communities. Federal incentives and strategies may also improve states' abilities to successfully implement a comprehensive and diverse menu of home visiting service options. By offering a menu of home visiting program models with varying levels of service delivery, home visitor education backgrounds, and targeted domains for improvement, state agencies serving children and families have an opportunity to expand their reach of services, improve cost-effectiveness, and promote optimal outcomes for vulnerable families. Nurses and nursing organizations can play a key role in advocating for this approach.

Equity dimensions of the availability and quality of reproductive, maternal and neonatal health services in Zambia.

OBJECTIVE: To assess how quality and availability of reproductive, maternal, neonatal (RMNH) services vary by district wealth and urban/rural status in Zambia. METHODS: We conducted a retrospective analysis of data from the Millennium Development Goal Acceleration Initiative baseline assessment of 117 health facilities in 9 districts. Quality was assessed through a composite score of 23 individual RMNH indicators, ranging from 0 to 1. Availability was evaluated by density of providers and facilities. Districts were divided into wealth groups based on the multidimensional poverty index (MPI). Relative inequity was calculated using the concentration index for quality indicators (positive favours rich, negative favours poor). Multivariable linear regression was performed for the dependent variable composite quality indicator using MPI, urban/rural, and facility level of care as independent variables. RESULTS: 13 hospitals, 85 health centres and 19 health posts were included. The RMNH composite quality indicator was 0.64. Availability of facilities and providers was universally low. The concentration index for the composite quality indicator was -0.015 [-0.043, 0.013], suggesting no clustering to favour either rich or poor districts. Rich districts had the highest absolute numbers of health facilities and providers, but lowest numbers per facility per 1 000 000 population. Urban districts had slightly better service quality, but not availability. Using regression analysis, only facility level of care was significantly associated with quality outcome. CONCLUSIONS: Composite quality of RMNH services did not vary by district wealth, but was slightly higher in urban districts. The availability data suggest that the higher population in richer districts outpaces health infrastructure.

Social support and marginalization as determinants of prenatal care in women with social security in Mexico. / Apoyo social y marginación como determinantes de la atención prenatal en mujeres con seguridad social en México.

Introduction: Prenatal care ensures favorable results for maternal-fetal health and, to that end, it must be provided early, periodically, comprehensively and with high coverage. Objective: To find out the social determinants of prenatal care in women affiliated to the Mexican Institute of Social Security during 2014. Method: Cross-sectional study where the association of social conditions, social support and family functioning with inadequate prenatal care was analyzed. A descriptive analysis was performed; hypothesis tests were used with chi-square (95% level of confidence). The prevalence ratio and Mann-Whitney's U-test were estimated to compare medians and logistic regression. Results: Of the interviewed women, 58.1% had inadequate prenatal care, mainly associated with unplanned pregnancy, poor social support, low level of education and higher marginalization. Not having leaves of absence granted by employers was the main barrier in those women who did not attend health services. Conclusions: There is a need for strategies to be designed and implemented to enable understanding the interaction between different biological and social dimensions of the health-disease process and reduce health inequities that affect pregnant women, in order to achieve good prenatal care and to implement alternative models guaranteeing its efficiency.

Introducción: La atención prenatal garantiza resultados favorables para la salud materno-fetal, para ello es necesario que se realice de forma precoz, periódica, completa y con alta cobertura. Objetivo: Conocer los determinantes sociales para la atención prenatal en mujeres derechohabientes del Instituto Mexicano del Seguro Social durante 2014. Método: Estudio transversal en el que se analizó la asociación de condiciones sociales, apoyo social y funcionalidad familiar con atención prenatal inadecuada. Se realizó análisis descriptivo; se utilizaron pruebas de hipótesis con chi cuadrada (nivel de confianza de 95 %). Se estimó la razón de prevalencias y U de Mann-Whitney para comparar medianas y regresión logística. Resultados: De las mujeres entrevistadas, 58.1 % presentó atención prenatal inadecuada, asociada principalmente con no planificación del embarazo, bajo apoyo social, menor nivel educativo y mayor marginalidad. No contar con el permiso laboral fue la principal barrera en las mujeres que no acudieron a los servicios de salud. Conclusión: Es necesario diseñar e implementar estrategias que permitan conocer la interacción entre las distintas dimensiones biológicas y sociales del proceso salud-enfermedad y disminuir las inequidades en salud que afectan a las mujeres embarazadas, para lograr buena atención prenatal y modelos alternativos que garanticen su eficiencia.

Emergency obstetric and neonatal care availability, use, and quality: a cross-sectional study in the city of Lubumbashi, Democratic Republic of the Congo, 2011.

BACKGROUND: While emergency obstetric and neonatal care (EmONC) is a proxy indicator for monitoring maternal and perinatal mortalities, in Democratic Republic of the Congo (DRC), data on this care is rarely available. In the city of Lubumbashi, the second largest in DRC with an estimated population of 1.5 million, the availability, use and quality of EmONC are not known. This study aimed to assess these elements in Lubumbashi. METHODS: This cross-sectional survey was conducted in April and May 2011. Fifty-three of the 180 health facilities that provide maternity care in Lubumbashi were included in this study. Only health facilities with at least six deliveries per month over the course of 2010 were included. The availability, use and quality of EmONC at each level of the health care system were assessed according to the WHO standards. RESULTS: The availability of EmONC in Lubumbashi falls short of WHO standards. In this study, we found one facility providing Comprehensive EmONC (CEmONC) for a catchment area of 918,819 inhabitants. Apart from the tertiary hospital (Sendwe), no other facility provided all the basic emergency obstetric and neonatal care (BEmONC) signal functions. However, all had carried out at least one of the nine signal functions during the 3 months preceding our survey: 73.6% of 53 facilities had administered parenteral antibiotics, 79.2% had systematically offered oxytocics, 39.6% had administered magnesium sulfate, 73.6% had manually evacuated placentas, 81.1% had removed retained placenta products, 54.7% had revived newborns, 35.8% had performed caesarean sections, and 47.2% had performed blood transfusions. Function 6, vaginal delivery assisted by ventouse or forceps, was performed in only two (3.8%) facilities. If this signal function was not taken into account in our assessment of EmONC availability, there would be five facilities providing CEmONC for 918,819 inhabitants, rather than one. In 2010, all the women in the surveyed facilities with obstetric complications delivered in facilities that had carried out at least one signal function in the 3 months before our survey; 7.0% of these women delivered in the facility which provided CEmONC. Mortality due to direct obstetric causes was 3.9% in the health facility that provided CEmONC. The intrapartum mortality was also high in this facility (5.1%). None of the maternity ward managers in any of the facilities surveyed had received training on the EmONC package. Essential supplies and equipment for performing certain EmONC functions were not available in all the surveyed facilities. CONCLUSION: Audits of maternal and neonatal deaths and near-misses should be established and used as a basis for monitoring the quality of care in Lubumbashi. To reduce maternal and perinatal mortality, it is essential that staff skills regarding EmONC be strengthened, the availability of supplies and equipment be increased, and that care processes be standardized in all health facilities in Lubumbashi.

[Regional inequalities of health status of pregnant women in Hungary - Long-term series analysis]. / Területi egyenlotlenségek hosszú idosoros elemzése a várandós nok egészségi állapotát vizsgálva.

INTRODUCTION: Monitoring the health status of populations is essential for good health policy decisions. This is particularly true in maternal and child health where targeted and timely interventions may have long-term consequences. AIM: Our objective was to describe changes in the health status of pregnant women at the national and county level during the period of 1997-2012. METHOD: Data were extracted from the mandatory annual reports of district nurses responsible for primary maternal care. Information on the smoking status of expecting mothers, special care during pregnancy, pregnant women entering into maternity care after 28 weeks of pregnancy, borne woman without district nurse care were analysed using Microsoft Excel and STATA 13.0. RESULTS: The mean prevalence of smoking was 13.8% among pregnant women during the investigation period. The ratio of smoking pregnant women was higher (p<0.01) in Borsod-Abaúj-Zemplén, Nógrád, Heves, Szabolcs-Szatmár-Bereg, and Somogy counties. The ratio of pregnants requiring special care was higher (p<0.01) than the national average in Somogy, Szabolcs-Szatmár-Bereg, Borsod-Abaúj-Zemplén and Nógrád counties. More, than 1% of the pregnant women entered into care only after the 28th week of the pregnancy. Women who were registered by district nurses and gave birth less than 1% did not participate in pregnant nursing. CONCLUSION: National data hide significant regional disparities within the country which should be amended by targeted interventions, taking into account the large regional inequalities in the country. Orv Hetil. 2017; 158(29): 1131-1142.