Sources for and quality of neonatal care in 45 low- and middle-income countries.

Almost half of under-five deaths occur during the neonatal period. Delivery with a skilled attendant, adherence to essential newborn care (ENC) and postnatal care (PNC) standards, and immediate treatment of infections are essential to improve neonatal survival. This article uses Demographic and Health Survey data from 45 low- and middle-income countries to assess 1) levels of ENC and PNC that mothers and newborns receive and how this differs by place of delivery and 2) levels of and sources for care-seeking for neonates sick with fever. For five of the ten ENC and PNC indicators assessed, less than two-thirds of mothers and newborns received care in alignment with global standards. Adherence is higher in private facilities than public facilities for all indicators other than immediate breastfeeding and skin-to-skin contact. Except for immediate breastfeeding, adherence is lowest for newborns born at home with a skilled birth attendant (SBA). Socioeconomic disparities exist in access to skilled delivery and adherence to ENC and PNC, with the largest disparities among newborns delivered at home with a SBA. Private provider adherence to ENC and PNC standards was relatively high for newborns from the wealthiest families, indicating that meeting recommended guidelines is achievable. On average across the 45 countries, half of caregivers for neonates with fever sought care outside the home and 45 percent of those sought care from the private sector. There were substantial socioeconomic disparities in care-seeking for fever, but illness prevalence and sources of care seeking were consistent across wealth quintiles. Closing inequities in neonatal care and care seeking and ensuring that all families, including the poorest, can access high quality maternal and newborn care is crucial to ensure equity and accelerate reductions in neonatal and child mortality.

Measuring Service Quality and Assessing Its Relationship to Contraceptive Discontinuation: A Prospective Cohort Study in Pakistan and Uganda.

BACKGROUND: The quality of contraceptive counseling that women receive from their provider can influence their future contraceptive continuation. We examined (1) whether the quality of contraceptive service provision could be measured in a consistent way by using existing tools from 2 large-scale social franchises, and (2) whether facility quality measures based on these tools were consistently associated with contraceptive discontinuation. METHODS: We linked existing, routinely collected facility audit data from social franchise clinics in Pakistan and Uganda with client data. Clients were women aged 15-49 who initiated a modern, reversible contraceptive method from a sampled clinic. Consented participants completed an exit interview and were contacted 3, 6, and 12 months later. We collapsed indicators into quality domains using theory-based categorization, created summative quality domain scores, and used Cox proportional hazards models to estimate the relationship between these quality domains and discontinuation while in need of contraception. RESULTS: The 12-month all-modern method discontinuation rate was 12.5% among the 813 enrolled women in Pakistan and 5.1% among the 1,185 women in Uganda. We did not observe similar associations between facility-level quality measures and discontinuation across these 2 settings. In Pakistan, an increase in the structural privacy domain was associated with a 60% lower risk of discontinuation, adjusting for age and baseline method (P<.001). In Uganda, an increase in the management support domain was associated with a 33% reduction in discontinuation risk, controlling for age and baseline method (P=.005). CONCLUSIONS: We were not able to leverage existing, widely used quality measurement tools to create quality domains that were consistently associated with discontinuation in 2 study settings. Given the importance of contraceptive service quality and recent advances in indicator standardization in other areas, we recommend further effort to harmonize and simplify measurement tools to measure and improve contraceptive quality of care for all.

Where Do Caregivers Take Their Sick Children for Care? An Analysis of Care Seeking and Equity in 24 USAID Priority Countries.

Pneumonia, diarrhea, and malaria are leading causes of under-5 mortality. Accelerated reductions in illness burden are needed to meet childhood Sustainable Development Goals. Understand-ing where parents take sick children for care is key to improving equitable, high-quality treatment for these childhood illnesses and catalyzing reductions in morbidity and mortality. We analyzed the most recent Demographic and Health Survey data in 24 of the United States Agency for International Development's maternal and child health priority countries to examine levels and sources of care for children sick with 3 illness classifications: symptoms of acute respiratory infection, diarrhea, or fever. On average, across countries analyzed, one-third of children had recent experience with at least 1 of the 3 classifications. The majority (68.2%) of caregivers sought external advice or treatment for their sick children, though the level is far higher for the wealthiest (74.3%) than poorest (63.1%) families. Among those who sought out-of-home care, 51.1% used public sources and 42.5% used private-sector sources. Although sources for sick child care varied substantially by region and country, they were consistent across the 3 illness classifications. Urban and wealthier families reported more use of private sources compared with rural and poorer families. Though 35.2% of the poorest families used private sources, most of these (57.2%) were retail outlets like pharmacies and shops, while most wealthier families who sought care in the private sector went to health facilities (62.4%). Efforts to strengthen the quality of integrated management of sick child care must therefore reach both public and private facilities as well as private pharmacies, shops, and other retail outlets. Stakeholders across sectors must collaborate to reach all population groups with high-quality child health services and reduce disparities in care-seeking behaviors. Such cross-sectoral efforts will build clinical and institutional capacity and more efficiently allocate resources, ultimately resulting in stronger, more resilient health systems.

Global Contraceptive Failure Rates: Who Is Most at Risk?

Contraceptive failure is a major contributor to unintended pregnancy worldwide. DHS retrospective calendars, which are the most widely used data source for estimating contraceptive failure in low-income countries, vary in quality across countries and surveys. We identified surveys with the most reliable calendar data and analyzed 105,322 episodes of contraceptive use from 15 DHSs conducted between 1992 and 2014. We estimate contraceptive method-specific 12-month failure rates. We also examined how failure rates vary by age, education, socioeconomic status, contraceptive intention, residence, and marital status using multilevel piecewise exponential hazard models. Our failure rate estimates are significantly lower than results from the United States and slightly higher than previous studies that included more DHS surveys, including some with lower-quality data. We estimate age-specific global contraceptive failure rates and find strong, consistent age patterns with the youngest users experiencing failure rates up to ten times higher than older women for certain methods. Failure also varies by socioeconomic status, with the poorest, and youngest, women at highest risk of experiencing unintended pregnancy due to failure.

Typical-use contraceptive failure rates in 43 countries with Demographic and Health Survey data: summary of a detailed report.

BACKGROUND: While most unintended pregnancies occur because couples do not use contraception, contraceptive failure is also an important underlying cause. However, few recent studies outside of the United States have estimated contraceptive failure rates, and most such studies have been restricted to married women, to a limited number of countries and to 12-month failure rate estimates. METHODS: Using self-reported data from 43 countries with Demographic and Health Survey data, we estimated typical-use contraceptive failure rates for seven contraceptive methods at 12, 24 and 36months of use. We provide a median estimate for each method across 43 countries overall, in seven subregions and in individual countries. We assess differences by various demographic and socioeconomic characteristics. Estimates are not corrected for potential errors in retrospective reporting contraceptive use or potential underreporting of abortion, which may vary by country and subgroups within countries. RESULTS: Across all included countries, reported 12-month typical-use failure rates were lowest for users of longer-acting methods such as implants (0.6 failures per 100 episodes of use), intrauterine devices (1.4) and injectables (1.7); intermediate for users of short-term resupply methods such as oral contraceptive pills (5.5) and male condoms (5.4); and highest for users of traditional methods such as withdrawal (13.4) or periodic abstinence (13.9), a group largely using calendar rhythm. CONCLUSIONS: Our findings help us to highlight those methods, subregions and population groups that may be in need of particular attention for improvements in policies and programs to address higher contraceptive failure rates.

Reassessing Unmet Need for Family Planning in the Postpartum Period.

Despite renewed interest in postpartum family planning programs, the question of the time at which women should be expected to start contraception after a birth remains unanswered. Three indicators of postpartum unmet need consider women to be fully exposed to the risk of pregnancy at different times: right after delivery (prospective indicator), after six months of amenorrhea (intermediate indicator), and at the end of amenorrhea (classic indicator). DHS data from 57 countries in 2005-13 indicate that 62 percent (prospective), 43 percent (intermediate), and 32 percent (classic) of women in the first year after a birth have an unmet need for contraception (40 percent when including abstinence). While the protection afforded by postpartum abstinence and lactational amenorrhea lowers unmet need, further analysis shows that women also often rely on these methods without being actually protected. Programs should acknowledge these methods' widespread use and inform women about their limits. Also, the respective advantages of targeting the postnatal period, the end of six months of amenorrhea/exclusive breastfeeding, or the resumption of sexual intercourse to offer contraceptive services should be tested.

Understanding unmet need: history, theory, and measurement.

During the past two decades, estimates of unmet need have become an influential measure for assessing population policies and programs. This article recounts the evolution of the concept of unmet need, describes how demographic survey data have been used to generate estimates of its prevalence, and tests the sensitivity of these estimates to various assumptions in the unmet need algorithm. The algorithm uses a complex set of assumptions to identify women: who are sexually active, who are infecund, whose most recent pregnancy was unwanted, who wish to postpone their next birth, and who are postpartum amenorrheic. The sensitivity tests suggest that defensible alternative criteria for identifying four out of five of these subgroups of women would increase the estimated prevalence of unmet need. The exception is identification of married women who are sexually active; more accurate measurement of this subgroup would reduce the estimated prevalence of unmet need in most settings.