Not all Medicaid for pregnancy care is delivered equally.

OBJECTIVES: Pregnant beneficiaries in the two primary Medicaid eligibility categories, traditional Medicaid and pregnancy Medicaid, have differing access to care especially in the preconception and postpartum periods. Pregnancy Medicaid has higher income limits for eligibility than traditional Medicaid but only provides coverage during and for a limited time period after pregnancy. Our objective was to determine the association between type of Medicaid (traditional Medicaid and pregnancy Medicaid) on receipt of outpatient care during the perinatal period. METHODS: This retrospective cohort study compared outpatient visits using linked birth certificate and Medicaid claims from all Medicaid births in Oregon and South Carolina from 2014 through 2019. Pregnancy Medicaid ended 60 days postpartum during the study. Our primary outcome was average number of outpatient visits per 100 beneficiaries each month during three perinatal time points: preconceputally (three months prior to conception), prenatally (9 months prior to birthdate) and postpartum (from birth to 12 months). RESULTS: Among 105,808 Medicaid-covered births in Oregon and 141,385 births in South Carolina, pregnancy Medicaid was the most prevelant categorical eligibility. Traditional Medicaid recipients had a higher average number of preconception, prenatal and postpartum visits as compared to those in pregnancy Medicaid. DISCUSSION: In South Carolina, those using traditional Medicaid had 450% more preconception visits and 70% more postpartum visits compared with pregnancy Medicaid. In Oregon, those using traditional Medicaid had 200% more preconception visits and 29% more postpartum visits than individuals using pregnancy Medicaid. Lack of coverage in both the preconception and postpartum period deprive women of adequate opportunities to access health care or contraception. Changes to pregnancy Medicaid, including extended postpartum coverage through the American Rescue Plan Act of 2021, may facilitate better continuity of care.

Modeling time to death for under-five children in Malawi using 2015/16 Demographic and Health Survey: a survival analysis.

BACKGROUND: Malawi has one of the highest under-five mortality rates in Sub Sahara Africa. Understanding the factors that contribute to child mortality in Malawi is crucial for the development and implementation of effective interventions to reduce child mortality. The aim of this study is to use survival analysis in modeling time to death for under-five children in Malawi. In turn, identify potential risk factors for child mortality and inform the development of interventions to reduce child mortality in the country. METHOD: This study used data from all births that occurred in the five years leading up to the 2015/16 Malawi Demographic and Health Survey. The Frailty hazard model was applied to predict infant survival in Malawi. In this analysis, the outcome of interest was death and it had two possible outcomes: "dead" or "alive". Age at death was regarded as the survival time variable. Infants who were still alive at the time of the study as of the day of the interview were considered as censored observations in the analysis. RESULTS: A total of 17,286 live births born during the 5 years preceding the survey were analysed. The study found that the risk of death was higher among children born to mothers aged 30-39 and 40 or older compared to teen mothers. Infants whose mothers attended fewer than four antenatal care visits were also found to be at a higher risk of death. On the other hand, the study found that using mosquito nets and early breastfeeding were associated with a lower risk of death, as were being male and coming from a wealthier household. CONCLUSION: The study reveals a notable decline in infant mortality rates as under-five children age, underscoring the challenge of ensuring newborn survival. Factors such as maternal age, birth order, socioeconomic status, mosquito net usage, early breastfeeding initiation, geographic location, and child's sex are key predictors of under-five mortality. To address this, public health strategies should prioritize interventions targeting these predictors to reduce under-five mortality rates.

The impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries: a systematic review of the evidence.

BACKGROUND: Low- and middle-income countries have committed to achieving universal health coverage (UHC) as a means to enhance access to services and improve financial protection. One of the key health financing reforms to achieve UHC is the introduction or expansion of health insurance to enhance access to basic health services, including maternal and reproductive health care. However, there is a paucity of evidence of the extent to which these reforms have had impact on the main policy objectives of enhancing service utilization and financial protection. The aim of this systematic review is to assess the existing evidence on the causal impact of health insurance on maternal and reproductive health service utilization and financial protection in low- and lower middle-income countries. METHODS: The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search included six databases: Medline, Embase, Web of Science, Cochrane, CINAHL, and Scopus as of 23rd May 2023. The keywords included health insurance, impact, utilisation, financial protection, and maternal and reproductive health. The search was followed by independent title and abstract screening and full text review by two reviewers using the Covidence software. Studies published in English since 2010, which reported on the impact of health insurance on maternal and reproductive health utilisation and or financial protection were included in the review. The ROBINS-I tool was used to assess the quality of the included studies. RESULTS: A total of 17 studies fulfilled the inclusion criteria. The majority of the studies (82.4%, n = 14) were nationally representative. Most studies found that health insurance had a significant positive impact on having at least four antenatal care (ANC) visits, delivery at a health facility and having a delivery assisted by a skilled attendant with average treatment effects ranging from 0.02 to 0.11, 0.03 to 0.34 and 0.03 to 0.23 respectively. There was no evidence that health insurance had increased postnatal care, access to contraception and financial protection for maternal and reproductive health services. Various maternal and reproductive health indicators were reported in studies. ANC had the greatest number of reported indicators (n = 10), followed by financial protection (n = 6), postnatal care (n = 5), and delivery care (n = 4). The overall quality of the evidence was moderate based on the risk of bias assessment. CONCLUSION: The introduction or expansion of various types of health insurance can be a useful intervention to improve ANC (receiving at least four ANC visits) and delivery care (delivery at health facility and delivery assisted by skilled birth attendant) service utilization in low- and lower-middle-income countries. Implementation of health insurance could enable countries' progress towards UHC and reduce maternal mortality. However, more research using rigorous impact evaluation methods is needed to investigate the causal impact of health insurance coverage on postnatal care utilization, contraceptive use and financial protection both in the general population and by socioeconomic status. TRIAL REGISTRATION: This study was registered with Prospero (CRD42021285776).

Assessment of knowledge about neonatal danger signs among primiparous women at discharge from healthcare facilities.

This study explores the evaluation of knowledge regarding neonatal danger signs (NDS) among first-time mothers in Pakistan during their discharge from healthcare facilities. The investigation aimed to establish connections between their understanding of NDS and factors such as sociodemographic background, prenatal check-ups, and educational measures. Considering the persistently high neonatal mortality rates in low- and middle-income nations, recognizing maternal NDS awareness becomes crucial for promoting early medical attention and reducing neonatal health risks. Existing research highlights the role of maternal knowledge in shaping neonatal well-being; however, gaps in knowledge remain prevalent, especially among first-time mothers. Using a cross-sectional approach, data were gathered through structured questionnaires, revealing significant relationships among maternal NDS awareness, sociodemographic aspects, prenatal care, and educational interventions. It is noteworthy that first-time mothers demonstrated lower NDS knowledge than mothers with multiple childbirth experiences, while those with higher education displayed greater awareness The effects of educational interventions were diverse, and antenatal visits were linked to enhanced knowledge. This study highlights the significance of focused treatments that target knowledge deficiencies, which can empower women and contribute to the reduction of infant health problems and mortality. encouraging further exploration of effective strategies to augment maternal knowledge and proactive healthcare-seeking behaviors.

Cette étude explore l'évaluation des connaissances concernant les signes de danger néonatals (NDS) chez les primipares au Pakistan lors de leur sortie des établissements de santé. L'enquête visait à établir des liens entre leur compréhension du NDS et des facteurs tels que le contexte sociodémographique, les contrôles prénatals et les mesures éducatives. Compte tenu des taux de mortalité néonatale constamment élevés dans les pays à revenu faible ou intermédiaire, il devient crucial de reconnaître la sensibilisation maternelle aux NDS pour promouvoir des soins médicaux précoces et réduire les risques pour la santé néonatale. Les recherches existantes mettent en évidence le rôle des connaissances maternelles dans la formation du bien-être néonatal ; cependant, des lacunes dans les connaissances demeurent répandues, en particulier parmi les primo-mères. En utilisant une approche transversale, les données ont été recueillies au moyen de questionnaires structurés, révélant des relations significatives entre la sensibilisation maternelle au NDS, les aspects sociodémographiques, les soins prénatals et les interventions éducatives. Il convient de noter que les mères primipares ont démontré des connaissances NDS inférieures à celles des mères ayant eu plusieurs accouchements, tandis que celles ayant fait des études supérieures ont montré une plus grande conscience. Les effets des interventions éducatives étaient diversifiés et les visites prénatales étaient liées à une amélioration des connaissances. Cette étude met en évidence l'importance des traitements ciblés ciblant les déficits de connaissances, qui peuvent autonomiser les femmes et contribuer à la réduction des problèmes de santé et de la mortalité infantiles. encourager une exploration plus approfondie de stratégies efficaces pour accroître les connaissances maternelles et les comportements proactifs de recherche de soins de santé.

Do tuition-free lower secondary education policies matter for antenatal care among women in sub-saharan African countries?

BACKGROUND: Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits. METHODS: To estimate the effect of women's exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries. RESULTS: Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics. CONCLUSIONS: The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs.

An evaluation of the quality, suitability and impact on equity of clinical practice guidelines relevant to preterm birth for use in Aotearoa New Zealand.

BACKGROUND: Preterm birth is a leading cause of perinatal morbidity and mortality and a defining event for pregnant people, infants, and whanau (extended families). Recommendations have been made for a national preterm birth prevention initiative focusing on equity in Aotearoa New Zealand, including the development of a national best practice guide. An understanding of the number and quality of guidelines, and consideration of their suitability and impact on equity is required. METHODS: Guidelines were identified through a systematic literature search, search of professional bodies websites, and invitation to regional health services in Aotearoa New Zealand. Obstetric and midwifery clinical directors were invited to report on guideline use. Identified guidelines were appraised by a 23-member trans-disciplinary Review Panel; quantitatively using the AGREE-II instrument and qualitatively using modified ADAPTE questions. The quality of guidelines available but not in use was compared against those in current use, and by health services by level of maternity and neonatal care. Major themes affecting implementation and impact on equity were identified using Braun and Clarke methodology. RESULTS: A total of 235 guidelines were included for appraisal. Guidelines available but not in use by regional health services scored higher in quality than guidelines in current use (median domain score Rigour and Development 47.5 versus 18.8, p < 0.001, median domain score Overall Assessment 62.5 versus 44.4, p < 0.001). Guidelines in use by regional health services with tertiary maternity and neonatal services had higher median AGREE II scores in several domains, than those with secondary level services (median domain score Overall Assessment 50.0 versus 37.5, p < 0.001). Groups identified by the Review Panel as experiencing the greatest constraints and limitations to guideline implementation were rural, provincial, low socioeconomic, Maori, and Pacific populations. Identified themes to improve equity included a targeted approach to groups experiencing the least advantage; a culturally considered approach; nationally consistent guidance; and improved funding to support implementation of guideline recommendations. CONCLUSIONS: We have systematically identified and assessed guidelines on preterm birth. High-quality guidelines will inform a national best practice guide for use in Taonga Tuku Iho, a knowledge translation project for equity in preterm birth care and outcomes in Aotearoa.

The timing of antenatal care access for adolescent pregnancies in Cape Town, South Africa.

BACKGROUND:  Late antenatal care (ANC)-seeking among pregnant adolescents threatens their health outcomes, and the health outcomes of their new-borns. South Africa has experienced a rapid increase in adolescent pregnancies during the COVID-19 pandemic, adding to the existing concerns around adolescent pregnancy care-seeking behaviour. AIM:  The main aim of this study was to investigate the causes and covariates of late ANC access among adolescents in the Cape Town Metropole, South Africa. SETTING:  Three public healthcare facilities in the Cape Town Metropole, 2018-2019. METHODS:  A retrospective, cross-sectional study on ANC seeking behaviour was conducted, surveying 202 adolescents. Late attendance was defined as attending ≥ 3 months. For this study, adolescents were defined as women aged 16-18 years. The sample was restricted to adolescents who used public healthcare facilities or who did not attend at all. Data were analysed using univariate, bivariate and multivariate methods. RESULTS:  A total of 50.8% (n = 99/195) of the pregnant adolescents in the sample had their first ANC visit 3 months. 14.9% (n = 29/195) did not attend at all. Major contributors to delayed care-seeking include poor pregnancy identification (n = 45/99, 45.5%), and a lack of information about ANC. Age, education, and alcohol consumption were significant predictors of delayed care-seeking. CONCLUSION:  Delayed ANC attendance contributes to negative long-term health outcomes for pregnant adolescents and their new-borns. Improving access to pregnancy tests in the public sector could benefit adolescents with earlier pregnancy identification. Adolescents need to be made aware of their care seeking options.Contribution: There is evidence of long-term health impacts of late ANC attendance by pregnant adolescents, but there is an absence of evidence on the timing and barriers of late care-seeking behaviour. In this study, late ANC attendance among adolescents was associated with late pregnancy identification and poor knowledge of care options.

Equity in prenatal healthcare services globally: an umbrella review.

BACKGROUND: Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics. METHODS: For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews. RESULTS: The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors. CONCLUSIONS: This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.

A Two-Generation, Early Childhood Advanced Primary Care Model.

It is well recognized that early experiences produce long-term impacts on health outcomes, yet many children are at risk of not achieving their full potential because of health and service disparities related largely to poverty and racism. Although many pediatric primary care (PPC) models address these needs, most are isolated, add-on efforts that struggle to be scalable and sustainable. We describe 3-2-1 IMPACT (Integrated Model for Parents and Children Together), an initiative to transform the model of PPC delivered within New York City Health + Hospitals, the largest public hospital system in the United States, to address the full range of child and family needs in early childhood. Taking advantage of the frequent contact with PPC in the early years and linking to prenatal services, the model assesses family mental, social, and physical health needs and offers evidence-based parenting supports and integrated mental health services. Launching and sustaining the model in our large health system has required coalition building and sustained advocacy at the state, city, and health system levels. Long-term sustainability of the IMPACT model will depend on the implementation of early childhood-focused advanced payment models, on which we have made substantial progress with our major contracted Medicaid managed care plans. By integrating multiple interventions into PPC and prenatal care across a large public-healthcare system, we hope to synergize evidence-based and evidence-informed interventions that individually have relatively small effect sizes, but combined, could substantially improve child and maternal health outcomes and positively impact health disparities.

Socioeconomic inequality in timing of ANC visit among pregnant women in Ethiopia, 2019.

Background: Antenatal care (ANC) remains an invaluable approach to preventive care for ensuring maternal and infant health outcomes. Women in sub-Saharan Africa tend to delay their first antenatal care visits. In Ethiopia, only 20% of women received their first antenatal care during the first trimester of pregnancy. Timely and appropriate antenatal care practices can potentially save the lives of both mothers and children. Understanding socioeconomic inequality in the timing of antenatal care visits and its determinants may contribute to tackling disparities and achieving the sustainable development goals for maternal health. Objective: This study aimed to assess the socioeconomic inequality in the timing of antenatal care visit. Method: Secondary data sourced from the Mini Ethiopian Demographic Health Survey 2019 were used for this study. A total of 2,906 pregnant women were included in the study, and concentration curves were used to show inequality among sociodemographic and economic variables. Decomposition analysis was performed to estimate the contribution of each independent variable to the inequality in the timing of antenatal care visits. Result: The estimate of early initiation of antenatal care was 63%. The concentration index was 0.18 (P < 0.001). The inequality in the timing of antenatal care visit was more concentrated among the wealthiest pregnant women with a concentration index value of 0.18 (P < 0.001). Based on decomposition analysis results, the wealth index (81.9%.), education status (22.29%), and region (0.0642%) were identified as contributing factors to the inequality in the timing of antenatal care visits among women. Conclusion: The wealth index, educational status, and region were significant contributors to inequality in the early initiation of antenatal care visit. Improving women's wealth and education and narrowing the inequality gap are crucial for improving the health status of women and their children. We should focus on interventions targeted at early antenatal care visit to address the determinants of socioeconomic inequities.

A new classification allowing assessment of instrumental vaginal-birth practices.

BACKGROUND: Instrumental vaginal birth, a very common intervention in obstetrics, concerns nearly one in eight women in France. Instrumentally assisted vaginal childbirth can be for maternal and/or fetal indications. Although it reduces recourse to caesarean section, it is subject to risks. Practices concerning instrumental birth are disparate, varying among different practitioners, maternity units and countries, and it is essential to be able to evaluate them. Our objective was to create a classification tool of women requiring instrumental birth to facilitate the analysis of practices within our maternity unit as well as to enable temporal and geographical comparisons. MATERIALS AND METHODS: We propose a simple and robust classification based on the same principles as Robson's classification. It is made up of seven totally inclusive and mutually exclusive groups. Our classification was refined and validated using the Delphi method by a panel of 14 experts from throughout France, and tested in our maternity unit using data from throughout 2021. RESULTS: The seven clinically relevant groups are based on five obstetric criteria (multiplicity, presentation, gestational age, previous type of birth, induction of labor). To classify each woman in a group, five successive questions are posed in a predefined order. The classification has been validated by the experts with highly satisfactory overall agreement. CONCLUSION: In order to improve the quality of care, we propose a tool to standardize the evaluation of instrumental vaginal birth practice (called the "Isère classification", after the county where we work in south-eastern France). It will also facilitate the comparison the practices among different maternity units in a network, a country or even among different countries.

Socioeconomic inequality and urban-rural disparity of antenatal care visits in Bangladesh: A trend and decomposition analysis.

BACKGROUND: Socioeconomic inequality in antenatal care visits is a great concern in developing countries including Bangladesh; however, there is a scarcity of investigation to assess the factors of inequality and these changes over time. In this study, we investigated the trend of socioeconomic inequalities (2004-2017) in 1+ANC and 4+ANC visits, and extracted determinants contributions to the observed inequalities and urban-rural disparities in Bangladesh over the period from 2011 to 2017. METHODS: The data from the Bangladesh Demographic and Health Surveys (BDHS) conducted in 2004, 2007, 2011 and 2017 were analyzed in this study. The analysis began with exploratory and bivariate analysis, followed by the application of logistic regression models. To measure the inequalities, the Erreygers concentration index was used, and regression-based decomposition analyses were utilized to unravel the determinant's contribution to the observed inequalities. The Blinder-Oaxaca type decomposition is also used to decompose the urban-rural disparity into the factors. RESULTS: Our analysis results showed that the prevalence of 1+ANC and 4+ANC visits has increased across all the determinants, although the rate of 4+ANC visits remains notably low. The magnitudes of socioeconomic inequality in 4+ANC visits represented an irregular pattern at both the national and urban levels, whereas it increased gradually in rural Bangladesh. However, inequalities in 1+ANC visits declined substantially after 2011 across the national, rural and urban areas of Bangladesh. Decomposition analyses have suggested that wealth status, women's education, place of residence (only for 4+ANC visits), caesarean delivery, husband education, and watching television (TV) are the main determinants to attribute and changes in the level of inequality and urban-rural disparity between the years 2011 and 2017. CONCLUSIONS: According to the findings of our study, it is imperative for authorities to ensure antenatal care visits are more accessible for rural and underprivileged women. Additionally, should focus on delivering high-quality education, ensuring the completion of education, reducing income disparity as well as launching a program to enhance awareness about health facilities, and the impact of caesarean delivery.

Socioeconomic inequalities in skilled attendance at birth and caesarean section rates in Myanmar 2015-2016: a cross-sectional study.

OBJECTIVES: This study aims to assess inequalities in skilled birth attendance and utilisation of caesarean section (CS) in Myanmar. STUDY DESIGN: Cross-sectional study design. SETTING AND POPULATION: We used secondary data from the Myanmar Demographic and Health Survey (2015-2016). Our outcome measures of skilled birth attendance and utilisation of CS were taken from the most recent birth of interviewed women. Absolute and relative inequalities across several sociodemographic characteristics were assessed and evaluated by calculating rate differences, rate ratio and concentration indexes. RESULTS: More than one-third (36%, 95% CI 32.5% to 39.4%) of women gave birth without a skilled birth attendant present at their most recent birth. 40.7% (95% CI 37.8% to 43.7%) gave birth in healthcare facilities, and the CS rate was 19.7% (95% CI 17.9% to 21.8%) for their most recent birth. The highest proportion of birth without a skilled provider was found in the hilly regions and rural residents, poorest and less educated women, and those with less than four antenatal care visits. Inequalities in birth without a skilled provider were observed across regions, place of residence, wealth quintile, education level and number of antenatal care taken. The highest rate of CS was found among plain regions and urban residents, richest women, more than secondary education, those with more than four antenatal care visits and in private health facilities. Inequalities in CS utilisation were observed across place of residence, wealth quintiles, education level, number of antenatal care taken and type of health facilities. CONCLUSION: This study provides evidence regarding inequalities in maternal health service utilisation in Myanmar. Increasing maternal health service availability and accessibility, promoting quality of care and health education campaigns to increase maternal health services utilisation are recommended.

Antenatal care service utilization disparities between urban and rural communities in Ethiopia: A negative binomial Poisson regression of 2019 Ethiopian Demography Health Survey.

BACKGROUND: Although there have been consistent improvements in maternal mortality, it remains high in developing countries due to unequal access to healthcare services during pregnancy and childbirth. Thus, this study aimed to further analyze the variations in the number of antenatal care utilizations and associated factors among pregnant women in urban and rural Ethiopia. METHODS: A total of 3962 pregnant women were included in the analysis of 2019 Ethiopian Demographic and Health Survey data. A negative binomial Poisson regression statistical model was used to analyze the data using STATA version 14.0. An incident rate ratio with a 95% confidence interval was used to show the significantly associated variables. RESULTS: Of the 3962 (weighted 3916.67) pregnant women, about 155 (15.21%) lived in urban and 848 (29.29%) rural residences and did not use antenatal care services in 2019. Women age group 20-24 (IRR = 1.30, 95%CI:1.05-1.61), 25-29 (IRR = 1.56, 95%CI:1.27-1.92), 30-34 (IRR = 1.65, 95%CI:1.33-2.05), and 35-39 years old (IRR = 1.55, 95%CI:1.18-2.03), attending primary, secondary, and higher education (IRR = 1.18, 95%CI:1.07-1.30), (IRR = 1.26, 95%CI:1.13-1.42) and (IRR = 1.25, 95%CI:1.11-1.41) respectively, reside in middle household wealth (IRR = 1.31, 95%CI:1.13-1.52), richer (IRR = 1.45, 95%CI:1.26-1.66) and richest (IRR = 1.68, 95%CI:1.46-1.93) increases the number of antenatal care utilization among urban residences. While attending primary (IRR = 1.34, 95%CI:1.24-1.45), secondary (IRR = 1.54, 95%CI:1.34-1.76) and higher education (IRR = 1.58, 95%CI:1.28-1.95), following Protestant (IRR = 0.76, 95%CI:0.69-0.83), Muslim (IRR = 0.79, 95%CI:0.73-0.85) and Others (IRR = 0.56, 95%CI:0.43-0.71) religions, reside in poorer, middle, richer, and richest household wealth (IRR = 1.51, 95%CI:1.37-1.67), (IRR = 1.66, 95%CI:1.50-1.83), (IRR = 1.71, 95%CI:1.55-1.91) and (IRR = 1.89, 95%CI:1.72-2.09) respectively, being married and widowed/separated (IRR = 1.85, 95%CI:1.19-2.86), and (IRR = 1.95, 95%CI:1.24-3.07) respectively were significantly associated with the number of antenatal care utilization among rural residences. CONCLUSION: The utilization of antenatal care is low among rural residents than among urban residents. To increase the frequency of antenatal care utilization, health extension workers and supporting actors should give special attention to pregnant women with low socioeconomic and educational levels through a safety-net lens.

Good while it lasted? Estimating the long-term and withdrawal effects of results-based financing in Malawi on maternal care utilisation using routine data.

OBJECTIVES: This study aimed to evaluate the effect of introduction and subsequent withdrawal of the Results-based Financing for Maternal and Newborn Health Initiative (RBF4MNH) in Malawi on utilisation of facility-based childbirths, antenatal care (ANC) and postnatal care (PNC). DESIGN: A controlled interrupted time series design was used with secondary data from the Malawian Health Management Information System. SETTING: Healthcare facilities at all levels identified as providing maternity services in four intervention districts and 20 non-intervention districts in Malawi. PARTICIPANTS: Routinely collected, secondary data of total monthly service utilisation of facility-based childbirths, ANC and PNC services. INTERVENTIONS: The intervention is the RBF4MNH initiative, introduced by the Malawian government in 2013 to improve maternal and infant health outcomes and withdrawn in 2018 after ceasing of donor funding. OUTCOME MEASURES: Differences in total volume and trends of utilisation of facility-based childbirths, ANC and PNC services, compared between intervention versus non-intervention districts, for the study period of 90 consecutive months. RESULTS: No significant effect was observed, on utilisation trends for any of the three services during the first 2.5 years of intervention. In the following 2.5 years after full implementation, we observed a small positive increase for facility-based childbirths (+0.62 childbirths/month/facility) and decrease for PNC (-0.55 consultations/month/facility) trends of utilisation respectively. After withdrawal, facility-based childbirths and ANC consultations dropped both in immediate volume after removal (-10.84 childbirths/facility and -20.66 consultations/facility, respectively), and in trends of utilisation over time (-0.27 childbirths/month/facility and -1.38 consultations/month/facility, respectively). PNC utilisation levels seemed unaffected in intervention districts against a decline in the rest of the country. CONCLUSIONS: Concurrent with wider literature, our results suggest that effects of complex health financing interventions, such as RBF4MNH, can take a long time to be seen. They might not be sustained beyond the implementation period if measures are not adopted to reform existing health financing structures.

Effects Of Medicaid Expansions On Coverage, Prenatal Care, And Health Among American Indian/Alaska Native Women.

American Indian/Alaska Native (AI/AN) women experience distinct political and health care environments and possess unique health risks and resources. We tested whether state Medicaid expansions under the Affordable Care Act were associated with health insurance, prenatal care, health conditions, and birth outcomes among AI/AN women. Using data from the 2010-19 American Community Survey and 2010-19 US birth certificates, we used a difference-in-differences study design to compare outcomes among AI/AN women before and after Medicaid expansions. Medicaid expansions increased the proportion of AI/AN women reporting health care coverage from both Medicaid and the Indian Health Service (IHS), with larger effects among women living in areas with relatively high percentages of reservation land. Consistent with prior research on the broader population of women, Medicaid expansions had no effects on first-trimester prenatal care usage or birthweight among AI/AN women. We found mixed evidence of increased rates of prepregnancy chronic conditions after the expansions. Our findings demonstrate the importance of Medicaid, the IHS, and tribal health systems as sources of health care coverage for AI/AN women of childbearing age.

Artificial intelligence based cardiotocogram assessment during labor.

OBJECTIVE: To assess whether artificial intelligence, inspired by clinical decision-making procedures in delivery rooms, can correctly interpret cardiotocographic tracings and distinguish between normal and pathological events. STUDY DESIGN: A method based on artificial intelligence was developed to determine whether a cardiotocogram shows a normal response of the fetal heart rate to uterine activity (UA). For a given fetus and given the UA and previous FHR, the method predicts a fetal heart rate response, under the assumption that the fetus is still in good condition and based on how that specific fetus has responded so far. We hypothesize that this method, when having only learned from fetuses born in good condition, is incapable of predicting the response of a compromised fetus or an episode of transient fetal distress. The (in)capability of the method to predict the fetal heart rate response would then yield a method that can help to assess fetal condition when the obstetrician is in doubt. Cardiotocographic data of 678 deliveries during labor were selected based on a healthy outcome just after birth. The method was trained on the cardiotocographic data of 548 fetuses of this group to learn their heart rate response. Subsequently it was evaluated on 87 fetuses, by assessing whether the method was able to predict their heart rate responses. The remaining 43 cardiotocograms were segment-by-segment annotated by three experienced gynecologists, indicating normal, suspicious, and pathological segments, while having access to the full recording and neonatal outcome. This future knowledge makes the expert annotations of a quality that is unachievable during live interpretation. RESULTS: The comparison between abnormalities detected by the method (only using past and present input) and the annotated CTG segments by gynecologists (also looking at future input) yields an area under the curve of 0.96 for the distinction between normal and pathological events in majority-voted annotations. CONCLUSION: The developed method can distinguish between normal and pathological events in near real-time, with a performance close to the agreement between three gynecologists with access to the entire CTG tracing and fetal outcome. The method has a strong potential to support clinicians in assessing fetal condition in clinical practice.

A composite index; socioeconomic deprivation and coverage of reproductive and maternal health interventions.

Objective: To examine inequalities in the coverage of reproductive and maternal health interventions in low- and middle-income countries and territories using a composite index of socioeconomic deprivation status. Methods: We obtained data on education and living standards from national household surveys conducted between 2015 and 2019 to calculate socioeconomic deprivation status. We assessed the coverage of reproductive and maternal health interventions, using three indicators: (i) demand for family planning satisfied with modern methods; (ii) women who received antenatal care in at least four visits; and (iii) the presence of a skilled attendant at delivery. Absolute and relative inequalities were evaluated both directly and using the slope index of inequality and the concentration index. Findings: In the 73 countries and territories with available data, the median proportions of deprivation were 41% in the low-income category, 11% in the lower-middle-income category and less than 1% in the upper-middle-income category. The coverage analysis, conducted for 48 countries with sufficient data, showed consistently lower median coverage among deprived households across all health indicators. The coverage of skilled attendant at delivery showed the largest inequalities, where coverage among the socioeconomically deprived was substantially lower in almost all countries. Antenatal care visits and demand for family planning satisfied with modern methods also showed significant disparities, favouring the less deprived population. Conclusion: The findings highlight persistent disparities in the coverage of reproductive and maternal health interventions, requiring efforts to reduce those disparities and improve coverage, particularly for skilled attendant at delivery.

Understanding coverage of antenatal care in Palestine: Cross-sectional analysis of Palestinian Multiple Indicator Cluster Survey, 2019-2020.

INTRODUCTION: Antenatal care is an essential component of primary healthcare, providing opportunities to screen, prevent, and treat morbidity to preserve the health of mothers and offspring. The World Health Organization now recommends a minimum of eight antenatal care contacts, instead of four, which is challenging in countries exposed to political violence and structural disparities in access to social, economic and healthcare resources as exist in Palestine. This study examines the compliance of the recommend standard of antenatal care in Palestine. METHODS: We analyzed data from the UNICEF's Palestinian Multiple Indicator Cluster Survey (MICS) 2019-2020. The eligible sample consisted of 2,028 women, 15-49 years of age, living in Palestine, on whom data were available on reported antenatal care services received during the most recent pregnancy within the last two years. Outcome variables of interest were the reported frequencies of antenatal care visits, gestational timing of 1st visit, and services received. Potential risk factors were assessed in women attending less than eight versus eight or more antenatal contacts, as recommended by WHO, by estimating prevalence ratios with 95% Confidence Intervals. RESULTS: Overall, 28% of women did not meet the WHO's recommendation of eight or more antenatal contacts, varying from 18% in Central West Bank to 33% in South West Bank across the four areas of Palestine (North, Central, and South West Bank and Gaza Strip). Twelve percent of women reported having had no antenatal contacts in the 1st trimester, and these women were two- to three-folds more unlikely to meet WHO recommendation of antenatal contacts than mothers who initiated the antenatal contact in the 1st trimester. Women who had less than eight antenatal contacts were generally poorer, higher in parity, lived in North and South West Bank, sought ANC from either doctor or nurse/midwife only, and initiated antenatal contact in 2nd-to-3rd trimesters. CONCLUSION: There were considerable socioeconomic and geographic inequalities in the prevalence of not meeting WHO recommended number of antenatal contacts in Palestine, offering the opportunity to inform, improve and continuously reassess coverage of antenatal care.

Socioeconomic inequalities in utilizing maternal health care in five South Asian countries: A decomposition analysis.

BACKGROUND: High maternal mortality rates still today remain a significant public health concern in South Asian countries. The majority of maternal deaths occur during pregnancy, and these deaths may typically be avoided by ensuring that women have access to reliable maternity care such as antenatal care (ANC) and facility delivery. The objectives of this research were to assess socioeconomic disparities in the utilization of health care services by mothers and to determine the factors influencing this utilization among women aged 15 to 49 in five South Asian countries. METHODS: For this study, nationally representative data from the Demographic and Health Survey (DHS) were analyzed. This research included a total of 262,531 women between the ages of 15 and 49. To determine the likely causes of maternal health care utilization, simple bivariate statistics and binary logistic regression were applied, and decomposition analysis and the concentration curve were used to quantify disparity (Lorenz curve). RESULTS: ANC and institutional delivery were both prevalent in 59.27% and 86.52% of cases, respectively. Among the five nations, Maldives has the greatest ANC (96.83%) and institutional delivery (99.39%), while Bangladesh has the lowest ANC (47.01%) and institutional delivery (49.81%). Women's and husbands' education, household wealth status, BMI, and urban residents are the most important factors influencing maternal health service utilization, whereas higher education level, affluent wealth quintiles, and place of residence are the major contributors to socioeconomic inequalities in access to maternal health care that favor the wealthy. CONCLUSION: Maternal health care services must be utilized properly in order to promote optimal health and prevent maternal mortality. Several socioeconomic and sociodemographic variables of the individual population, as well as policy issues, all have an impact on maternal mortality. This research recommends for concerted action to enhance how successfully women use maternity care services.