Can 3-dimensional cranial ultrasound be used to successfully reconstruct a 2-dimensional image without compromising on image quality in a neonatal population?

BACKGROUND: Cranial ultrasound is frequently performed in neonatal intensive care units and acquiring 2-dimensional (D) images requires significant training. Three-D ultrasound images can be acquired semi-automatically. OBJECTIVE: This proof-of-concept study aimed to demonstrate that 3-D study image quality compares well with 2-D. If this is successful, 3-D images could be acquired in remote areas and read remotely by experts. MATERIALS AND METHODS: This was a prospective study of 20 neonates, who underwent both routine 2-D and 3-D cranial ultrasounds. Images were reconstructed into standard views extracted from the 3-D volume and evaluated by three radiologists blinded to the acquisition method. The radiologists assessed for the presence of anatomical landmarks and overall image quality. RESULTS: More anatomical structures were identified in the 3-D studies (P<0.01). There was a trend that 3-D ultrasound demonstrated better image quality in the coronal plane, and 2-D in the sagittal plane, only reaching statistical significance for two coronal views and two sagittal views. CONCLUSION: Overall, this study has demonstrated that 3-D cranial ultrasound performs similarly to 2-D and could be implemented into neonatal practice.

Contraceptive Behavior Dynamics and Unintended Pregnancy: A Latent Transition Analysis.

The average U.S. woman wants to have two children; to do so, she will spend about three years pregnant, postpartum, or trying to become pregnant, and three decades trying to avoid pregnancy. However, few studies have examined individual patterns of contraceptive use over time. These trajectories are important to understand given the high rate of unintended pregnancy and how little we know about the complex relationship between contraceptive use, pregnancy intention, and patterns of reproductive behavior. We use data from the 2015-2017 National Survey of Family Growth to examine reproductive behavior and pregnancies across three years of calendar data. We identify seven behavior typologies, their prevalence, how women transition between them, and how pregnancies affect transitions. At any given time, half of women are reliably using contraception. A small proportion belong to a high pregnancy risk profile of transient contraceptive users, but some transition to using condoms or other methods consistently. An unintended pregnancy may initiate a transition into stable contraceptive use for some women, although that is primarily condom use. These findings have important implications for the ways contraception fits into women's lives and how that behavior interacts with relationships, sex, and life stage trajectories.

A comparison of approaches to measuring maternal mortality in Bangladesh, Mozambique, and Bolivia.

BACKGROUND: Many low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality. OBJECTIVE: The objective is to inform on potential options for measuring maternal mortality. METHODS: This paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia-national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS). RESULTS: For Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS' MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998-2003. CONCLUSIONS: Overall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches. CONTRIBUTION: Recommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system.

Assessing the Reliability of the Retrospective Reproductive Calendar: Evidence from Urban Kenya.

The reproductive calendar is a data collection tool that collects month-by-month retrospective histories of contraceptive use. This survey instrument is implemented in large-scale demographic surveys, but its reliability is not well-understood. Our analysis helps to address this research gap, using longitudinal panel data with overlapping calendars from urban Kenya. Our findings indicate calendar data collected in 2014 underestimated 2012 reports of current use by 5 percentage points. And while the overall percentage of women reporting at least one episode of contraceptive use was similar across the two calendars (67 percent vs. 70 percent), there was notable disagreement in contraceptive behavior when comparing the histories of individual women; less than 20 percent of women with any contraceptive use reported the exact same pattern of use in both calendars. Low calendar reliability was especially apparent for younger women and those with complicated contraceptive histories. Individual-level discordance resulted in a small difference in 12-month discontinuation rates for the period of calendar overlap; when surveyed in 2014, women reported a 12-month discontinuation rate of 39 percent, compared to a rate of 34 percent reported in 2012. When using retrospective calendar data, attention must be paid to the potential for individual reporting errors.

Facility-level characteristics associated with family planning and child immunization services integration in urban areas of Nigeria: a longitudinal analysis.

BACKGROUND: Unmet need for postpartum contraception is high. Integration of family planning with routine child immunization services may help to satisfy unmet need. However, evidence about the determinants and effects of integration has been inconsistent, and more evidence is required to ascertain whether and how to invest in integration. In this study, facility-level family planning and immunization integration index scores are used to: (1) determine whether integration changes over time and (2) identify whether facility-level characteristics, including exposure to the Nigerian Urban Reproductive Health Initiative (NURHI), are associated with integration across facilities in six urban areas of Nigeria. METHODS: This study utilizes health facility data collected at baseline (n = 400) and endline (n = 385) for the NURHI impact evaluation. Difference-in-differences models estimate the associations between facility-level characteristics, including exposure to NURHI, and Provider and Facility Integration Index scores. The two outcome measures, Provider and Facility Integration Index scores, reflect attributes that support integrated service delivery. These indexes, which range from 0 (low) to 10 (high), were constructed using principal component analysis. Scores were calculated for each facility. Independent variables are (1) time period, (2) whether the facility received the NURHI intervention, and (3) additional facility-level characteristics. RESULTS: Within intervention facilities, mean Provider Integration Index scores were 6.46 at baseline and 6.79 at endline; mean Facility Integration Index scores were 7.16 (baseline) and 7.36 (endline). Within non-intervention facilities, mean Provider Integration Index scores were 5.01 at baseline and 6.25 at endline; mean Facility Integration Index scores were 5.83 (baseline) and 6.12 (endline). Provider Integration Index scores increased significantly (p = 0.00) among non-intervention facilities. Facility Integration Index scores did not increase significantly in either group. Results identify facility-level characteristics associated with higher levels of integration, including smaller family planning client load, family planning training among providers, and public facility ownership. Exposure to NURHI was not associated with integration index scores. CONCLUSION: Programs aiming to increase integration of family planning and immunization services should monitor and provide targeted support for the implementation of a well-defined integration strategy that considers the influence of facility characteristics and concurrent initiatives.

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria.

BACKGROUND: Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities. METHODS: This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high). RESULTS: Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high. CONCLUSION: Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

"If the Big Fish are Doing It Then Why Not Me Down Here?": Informal Fee Payments and Reproductive Health Care Provider Motivation in Kenya.

Informal fees are payments made by patients to their health care provider that are over and above the official cost of services. Payments may be motivated by a combination of factors such as low supervision, weak sanctions, and inadequate provider salaries. The practice of soliciting informal fees from patients may result in restricted access to medical care and reduced care-seeking behavior among vulnerable populations. The objective of this study is to examine nuanced health care provider perspectives on informal fee payments solicited from reproductive health patients in Kenya. We conducted in-depth semistructured interviews in 2015-2016 among a sample of 20 public and private-sector Kenyan health care workers. Interviews were coded and analyzed using an iterative thematic approach. More than half of participants reported that solicitation of informal fees is common practice in health care facilities. Providers reported low public-sector wages were a primary driver of informal fee solicitation coupled with collusion among senior staff. Additionally, patients may be unaware that they are being asked to pay more than the official cost of services. Strategies for reducing this behavior include more adequate and timely remuneration within the public sector, educating patient populations of free or low-cost services, and evidence-based methods to increase provider motivation.

The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study.

BACKGROUND: In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services. METHODS: We used data from Indian Human Development Surveys done in 2004-2005 and in 2011-2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility. RESULTS: Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8-22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI - 1.6-11.1), 26% increase in SBA (95% CI 20-31.1), and 28% increase (95% CI 22.4-32.8) in facility births. CONCLUSIONS: Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

Understanding healthcare provider absenteeism in Kenya: a qualitative analysis.

BACKGROUND: Healthcare worker absenteeism is common in resource limited settings and contributes to poor quality of care in maternal and child health service delivery. There is a dearth of qualitative information on the scope, contributing factors, and impact of absenteeism in Kenyan healthcare facilities. METHODS: In-depth semi-structured interviews were conducted between July 2015 and June 2016 with 20 healthcare providers in public and private healthcare facilities in Central and Western Kenya. Interviews were audio-recorded, transcribed, coded, and analyzed using an iterative thematic approach. RESULTS: Half of providers reported that absenteeism occurs in both private and public health facilities. Absenteeism was most commonly characterized by providers arriving late or leaving early during scheduled work hours. The practice was attributed to institutional issues including: infrequent supervision, lack of professional consequences, limited accountability, and low wages. In some cases, healthcare workers were frequently absent because they held multiple positions at different health facilities. Provider absences result in increased patient wait times and may deter patients from seeking healthcare in the future. CONCLUSION: There is a significant need for policies and programs to reduce provider absenteeism in Kenya. Intervention approaches must be cognizant of the contributors to absenteeism which occur at the institutional level.

Gender norms and modern contraceptive use in urban Nigeria: a multilevel longitudinal study.

BACKGROUND: Evidence suggests that gender equality positively influences family planning. However, the evidence from urban Africa is sparse. This study aimed to examine the association between changes in gender norms and modern contraceptive use over time among women in urban Nigeria. METHODS: Data were collected in 2010/2011 from 16,118 women aged 15-49 living in six cities in Nigeria (Abuja, Benin, Ibadan, Ilorin, Kaduna, and Zaria) and again in 2014 from 10,672 of the same women (34% attrition rate). The analytical sample included 9933 women living in 480 neighborhoods. A four-category outcome variable measured their change in modern contraceptive use within the study period. The exposure variables measured the changes in the level of gender-equitable attitudes towards: a) wife beating; b) household decision-making; c) couples' family planning decisions; and d) family planning self-efficacy. Multilevel multinomial logistic regression models estimated the associations between the exposure variables at the individual and neighborhood levels and modern contraceptive use controlling for the women's age, education, marital status, religion, parity, household wealth, and city of residence. RESULTS: The proportion of women who reported current use of modern contraceptive methods increased from 21 to 32% during the four-year study period. At both surveys, 58% of the women did not report using modern contraceptives while 11% reported using modern contraceptives; 21% did not use in 2010/2011 but started using by 2014 while 10% used in 2010/2011 but discontinued use by 2014. A positive change in the gender-equitable attitudes towards household decision-making, couples' family planning decisions, and family planning self-efficacy at the individual and neighborhood levels were associated with increased relative probability of modern contraceptive use (adoption and continued use) and decreased relative probability of modern contraceptive discontinuation by 2014. No such associations were found between the individual and neighborhood attitudes towards wife beating and modern contraceptive use. Accounting for the individual and neighborhood gender-equitable attitudes and controlling for the women's demographic characteristics accounted for 55-61% of the variation between neighborhoods in the change in modern contraceptive use during the study period. CONCLUSION: Interventions that promote gender equality have the potential to increase modern contraceptive use in Nigerian cities.

Contraceptive Practices, Preferences, and Barriers Among Abortion Clients in North Carolina.

OBJECTIVES: Abortion clinics provide an ideal setting for women to receive contraceptive care because the women served may not have other contacts with the health system and are at risk for unintended pregnancies. The objective of this study was to understand practices, preferences, and barriers to use of contraception for women obtaining abortions at clinics in North Carolina. METHODS: We conducted a cross-sectional survey of abortion clients and facilities at 10 abortion clinics in North Carolina. We collected data on contraceptive availability at each clinic. We collected individual responses on women's experiences obtaining contraception before the current pregnancy and their intentions for future use of contraception. RESULTS: From October 2015 to February 2016, 376 client surveys were completed at 9 clinics, and 10 clinic surveys were completed. Almost one-third of women (29%) reported that they had wanted to use contraception in the last year but were unable. Approximately three-fourths of respondents (76%) stated that they intend to use contraception after this pregnancy. Approximately one-fifth of women stated that would like to use long-acting reversible contraception (LARC) after this abortion. Only the clinics that accepted insurance for abortion and other services provided LARC at the time of the abortion (40%). CONCLUSIONS: This study provides a unique, statewide view into the contraceptive barriers for women seeking abortion in North Carolina. Addressing the relatively high demand for LARC after abortion could help significantly reduce unintended pregnancy and recourse to abortion in North Carolina.

Trends in Abortion Incidence and Availability in North Carolina, 1980-2013.

OBJECTIVES: Abortion incidence has declined nationally during the last decade. In recent years, many states, including North Carolina, have passed legislation related to the provision of abortion services. Despite the changing political environment, there is no comprehensive analysis on past and current trends related to unintended pregnancy and abortion in North Carolina. METHODS: This study is a secondary analysis of vital registration data made publicly available by the North Carolina State Center for Health Statistics. Birth and induced abortion records were obtained for the years 1980 to 2013. We describe abortion incidence and demographic characteristics of women obtaining abortions over time. RESULTS: The number of North Carolina abortions declined 36% between 1980 and 2013. The abortion ratio declined from 26/100 pregnancies (live births and abortions) in 1980 to just 14/100 in 2013. These ratios, however, vary across demographic subgroups. In 2013, the abortion ratio was more than 2 times greater for non-Hispanic black women than non-Hispanic white women (22 and 9, respectively). Among non-Hispanic black and Hispanic women, the abortion ratio is greater among women with a previous pregnancy as compared with women in their first pregnancy. For non-Hispanic white women, the abortion ratios are similar for first and higher-order pregnancies. CONCLUSIONS: Trends in North Carolina are similar to national trends; however, detailed analyses by race/ethnicity, age, and parity demonstrate important distinctions among abortion patients over time in the state. We discuss these trends in relation to policy changes and increased access to effective contraceptives.

Trends in equity in use of maternal health services in urban and rural Bangladesh.

BACKGROUND: Maternal healthcare utilization is a major determinant of maternal mortality. Bangladesh is experiencing a rapid pace of urbanization with all future growth in population expected to be in urban areas. Health care infrastructure is different in urban and rural areas thus warranting an examination of equity in use rates of maternal healthcare. This paper addresses whether the urban-rural and rich-poor gaps in use of selected maternal healthcare indicators have narrowed or widened over the last decade. The paper also explores changes in the service provider environment in urban and rural domains. METHODS: The 2001 and 2010 Bangladesh Maternal Mortality and Health Care Survey data were used to examine trends in use of antenatal care from medically trained providers and in deliveries taking place at health facilities. Separate wealth quintiles were constructed for urban and rural areas. The concentration index was calculated for urban and rural areas to measure equity in distribution of antenatal care (ANC) and facility deliveries across wealth quintiles in urban and rural domains. RESULTS: The gap in use of ANC provided by medically trained personnel narrowed in urban and rural areas between 2001 and 2010 while that in facility deliveries widened. The difference in use of ANC by the rich and the poor was not as pronounced as that in utilization of facilities for deliveries. Over the last decade, equity in utilization of health facilities for deliveries has improved at a faster rate in urban areas. Private sector has surpassed the public sector and appears to be the dominant provider of maternal healthcare in both domains with the share of NGOs increasing in urban areas. CONCLUSIONS: The faster pace of improvement in equity in maternal healthcare utilization in urban areas is reflective of the changing service environment in urban and rural areas, among other factors.

The effect of performance-based financing on illness, care-seeking and treatment among children: an impact evaluation in Rwanda.

BACKGROUND: Performance-based financing (PBF) strategies are promoted as a supply-side, results-based financing mechanism to improve primary health care. This study estimated the effects of Rwanda's PBF program on less-incentivized child health services and examined the differential program impact by household poverty. METHODS: Districts were allocated to intervention and comparison for PBF implementation in Rwanda. Using Demographic Health Survey data from 2005 to 2007-08, a community-level panel dataset of 5781 children less than 5 years of age from intervention and comparison districts was created. The impacts of PBF on reported childhood illness, facility care-seeking, and treatment received were estimated using a difference-in-differences model with community fixed effects. An interaction term between poverty and the program was estimated to identify the differential effect of PBF among children from poorer families. RESULTS: There was no measurable difference in estimated probability of reporting illness with diarrhea, fever or acute respiratory infections between the intervention and comparison groups. Seeking care at a facility for these illnesses increased over time, however no differential effect by PBF was seen. The estimated effect of PBF on receipt of treatment for poor children is 45 percentage points higher (p = 0.047) compared to the non-poor children seeking care for diarrhea or fever. CONCLUSIONS: PBF, a supply-side incentive program, improved the quality of treatment received by poor children conditional on patients seeking care, but it did not impact the propensity to seek care. These findings provide additional evidence that PBF incentivizes the critical role staff play in assuring quality services, but does little to influence consumer demand for these services. Efforts to improve child health need to address both supply and demand, with additional attention to barriers due to poverty if equity in service use is a concern.

Assessing gaps and poverty-related inequalities in the public and private sector family planning supply environment of urban Nigeria.

Nigeria is the most populous country in Africa, and its population is expected to double in <25 years (Central Intelligence Agency 2012; Fotso et al. 2011). Over half of the population already lives in an urban area, and by 2050, that proportion will increase to three quarters (United Nations, Department of Economic and Social Affairs, Population Division 2012; Measurement Learning & Evaluation Project, Nigerian Urban Reproductive Health Initiative, National Population Commission 2012). Reducing unwanted and unplanned pregnancies through reliable access to high-quality modern contraceptives, especially among the urban poor, could make a major contribution to moderating population growth and improving the livelihood of urban residents. This study uses facility census data to create and assign aggregate-level family planning (FP) supply index scores to 19 local government areas (LGAs) across six selected cities of Nigeria. It then explores the relationships between public and private sector FP services and determines whether contraceptive access and availability in either sector is correlated with community-level wealth. Data show pronounced variability in contraceptive access and availability across LGAs in both sectors, with a positive correlation between public sector and private sector supply environments and only localized associations between the FP supply environments and poverty. These results will be useful for program planners and policy makers to improve equal access to contraception through the expansion or redistribution of services in focused urban areas.

Postpartum family planning service provision in Durban, South Africa: client and provider perspectives.

Researchers in Sub-Saharan Africa have found that health facility factors influence client contraceptive use. We sought to understand how client-provider interactions, discussions of side effects, and HIV status influence women's contraceptive use postpartum. We conducted in-depth interviews with eight HIV negative clients and six HIV positive clients in Zulu, and with five nurses in English. Interviews were translated and transcribed into English. We created a codebook and coded all transcripts. Nurses and clients reported limited time to discuss contraception, side effects, and HIV. Nurses did not comply with national contraceptive policies and created unnecessary barriers to contraceptive use.

Neighborhood-level racialized socioeconomic deprivation and contraceptive use in the United States, 2011-2019.

INTRODUCTION: The social and structural environments where people live are understudied in contraceptive research. We assessed if neighborhood measures of racialized socioeconomic deprivation are associated with contraceptive use in the United States. METHODS: We used restricted geographic data from four waves of the National Survey of Family Growth (2011-2019) limited to non-pregnant women ages 15-44 who had sex in the last 12 months. We characterized respondent neighborhoods (census tracts) with the Index of Concentration at the Extremes (ICE), a measure of spatial social polarization, into areas of concentrated privilege (predominantly white residents living on high incomes) and deprivation (predominantly people of color living on low incomes). We used multivariable binary and multinomial logistic regression with year fixed effects to estimate adjusted associations between ICE tertile and contraceptive use and method type. We also assessed for an interactive effect of ICE and health insurance type. RESULTS: Of the 14,396 respondents, 88.4% in neighborhoods of concentrated deprivation used any contraception, compared to 92.7% in the most privileged neighborhoods. In adjusted models, the predicted probability of using any contraception in neighborhoods of concentrated deprivation was 2.8 percentage points lower than in neighborhoods of concentrated privilege, 5.0 percentage points higher for barrier/coital dependent methods, and 4.3 percentage points lower for short-acting methods. Those with Medicaid were less likely to use any contraception than those with private insurance irrespective of neighborhood classification. CONCLUSIONS: This study highlights the salience of structural factors for contraceptive use and the need for continued examination of structural oppressions to inform health policy.

Stagnation of maternal mortality decline in Bangladesh between 2010 and 2016 in spite of an increase in health services utilisation: Examining data from three large cross-sectional surveys.

Background: After a 40% reduction in maternal mortality ratio (MMR) during 2001-2010 in Bangladesh, the MMR level stagnated between 2010 and 2016 despite a steady increase in maternal health services use and improvements in overall socioeconomic status. We revisited the factors that contributed to MMR decline during 2001-2010 and examined the changes in these factors between 2010 and 2016 to explain the MMR stagnation in Bangladesh. Methods: We used data from the 2001, 2010, and 2016 Bangladesh Maternal Mortality Surveys, which sampled 566 115 households in total, to estimate the changes in the risk of dying of maternal causes associated with a pregnancy or birth between 2001-2010 and 2010-2016. We carried out Poisson regression analyses with random effects at the sub-district level to explore the relationship between the change in risk of maternal death from 2001 to 2016 and a range of demographic, socioeconomic, and health care factors. Results: Between 2001 and 2016, the proportion of high-risk pregnancies decreased, except for teenage pregnancies. Meanwhile, there were notable improvements in socioeconomic status, access to health services, and the utilisation of maternal health services. A comparison of factors affecting the risk of maternal death between 2001-2010 and 2010-2016 indicated that first pregnancies continued to offer significant protection against maternal deaths. However, subsequent pregnancies among girls under 20 years became a significant risk factor during 2010-2016, increasing the risk of maternal deaths by nearly 3-fold. Among the key maternal health services, only skilled birth attendants (SBA) were identified as a key contributor to MMR reduction during 2001-2010. However, SBA is no longer significantly associated with reducing mortality risk during 2010-2016. Conclusions: Despite continued improvements in the overall socioeconomic status and access to maternal health services in Bangladesh, the stagnation of MMR decline between 2010 and 2016 is associated with multiple teenage pregnancies and the lack of capacity in health facilities to provide quality delivery services, as SBA has been primarily driven by facility delivery. The findings provide a strong rationale for targeting at-risk mothers and strengthening reproductive health services, including family planning, to further reduce maternal mortality in Bangladesh.

Geographically linking population and facility surveys: methodological considerations.

BACKGROUND: The relationship between health services and population outcomes is an important area of public health research that requires bringing together data on outcomes and the relevant service environment. Linking independent, existing datasets geographically is potentially an efficient approach; however, it raises a number of methodological issues which have not been extensively explored. This sensitivity analysis explores the potential misclassification error introduced when a sample rather than a census of health facilities is used and when household survey clusters are geographically displaced for confidentiality. METHODS: Using the 2007 Rwanda Service Provision Assessment (RSPA) of all public health facilities and the 2007-2008 Rwanda Interim Demographic and Health Survey (RIDHS), five health facility samples and five household cluster displacements were created to simulate typical SPA samples and household cluster datasets. Facility datasets were matched with cluster datasets to create 36 paired datasets. Four geographic techniques were employed to link clusters with facilities in each paired dataset. The links between clusters and facilities were operationalized by creating health service variables from the RSPA and attaching them to linked RIDHS clusters. Comparisons between the original facility census and undisplaced clusters dataset with the multiple samples and displaced clusters datasets enabled measurement of error due to sampling and displacement. RESULTS: Facility sampling produced larger misclassification errors than cluster displacement, underestimating access to services. Distance to the nearest facility was misclassified for over 50% of the clusters when directly linked, while linking to all facilities within an administrative boundary produced the lowest misclassification error. Measuring relative service environment produced equally poor results with over half of the clusters assigned to the incorrect quintile when linked with a sample of facilities and more than one-third misclassified due to displacement. CONCLUSIONS: At low levels of geographic disaggregation, linking independent facility samples and household clusters is not recommended. Linking facility census data with population data at the cluster level is possible, but misclassification errors associated with geographic displacement of clusters will bias estimates of relationships between service environment and health outcomes. The potential need to link facility and population-based data requires consideration when designing a facility survey.

Factors associated with substance use among orphaned and non-orphaned youth in South Africa.

Substance use is increasing among youth in South Africa, and may be contributing to transmission of HIV. As parental death often leaves youth with altered emotional and physical resources, substance use may be greater among orphaned adolescents. Utilizing data from a household survey of 15-24 year old South Africans (n = 11,904), multivariable models were fitted to examine the association of factors from five domains with alcohol and drug use, and to compare substance use among orphaned versus non-orphaned youth. Results showed that factors from individual, family, and community domains were most associated with substance use. Compared with non-orphans, paternal and double orphaned males were more likely to have consumed alcohol, and paternally orphaned females had significantly greater odds of having used drugs. Findings confirm that some sub-groups of orphaned youth are at increased risk of substance use and families and communities may be influential in moderating this risky behavior.