The impact of funding models on the integration of Ontario midwives: a qualitative study.

BACKGROUND: Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers. METHODS: Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis. RESULTS: We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs. CONCLUSIONS: Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.

Factors influencing the free maternal health care policy under the national health insurance scheme's provision for skilled delivery services in Ghana: a narrative literature review.

BACKGROUND: Skilled Birth Attendance (SBA) is important in achieving the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1. Ghana has made steady progress in SBA, yet, unsupervised deliveries still occur. The introduction of the Free Maternal Health Care Policy under the National Health Insurance Scheme (FMHCP under the NHIS) has improved the uptake of SBA but with some implementation challenges. This narrative review sought to explore the factors influencing the FMHCP under the NHIS provision for skilled delivery services in Ghana. METHODS: Electronic searches were conducted of databases including PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 2003 and 2021 on factors influencing FMHCP/NHIS provision for skilled delivery services in Ghana. Keywords used in the literature search were in various combinations for the different databases. The articles were screened to determine the inclusion and exclusion criteria and quality was assessed using a published critical appraisal checklist. A total of 516 articles were retrieved for initial screening based on their titles, of which 61 of them, were further screened by reading their abstracts and full text. Of this number, 22 peer-reviewed and 4 grey articles were selected for the final review based on their relevance. RESULTS: The study revealed that the FMHCP under the NHIS does not cover the full costs associated with skilled delivery and low socioeconomic status of households affects SBA. Also, funding and sustainability, hinders the quality-of-service delivery offered by the policy. CONCLUSION: For Ghana to achieve the SDGs above and further improve SBA, the cost associated with skilled delivery should be fully covered by the NHIS. Also, the government and the key stakeholders involved in the policy implementation, must put in place measures that will enhance the operation and the financial sustainability of the policy.

Reducing maternal and child mortality in rural Ghana.

The lack of health infrastructure in developing countries to provide women with modern obstetric care and universal access to maternal and child health services has largely contributed to the existing high maternal and infant deaths. Access to basic obstetric care for pregnant women and their unborn babies is a key to reducing maternal and infants´ deaths, especially at the community-level. This calls for the strengthening of primary health care systems in all developing countries, including Ghana. Financial access and utilization of maternal and child health care services need action at the community-level across rural Ghana to avoid preventable deaths. Financial access and usage of maternal and child health services in rural Ghana is poor. Lack of financial access is a strong barrier to the use of maternal and child health services, particularly in rural Ghana. The sustainability of the national health insurance scheme is vital in ensuring full access to care in remote communities.

Access barriers to maternal healthcare services in selected hard-to-reach areas of Zambia: a mixed methods design.

INTRODUCTION: poor access to maternal health services is a one of the major contributing factors to maternal deaths in low-resource settings, and understanding access barriers to maternal services is an important step for targeting interventions aimed at promoting institutional delivery and improving maternal health. This study explored access barriers to maternal and antenatal services in Kaputa and Ngabwe; two of Zambia´s rural and hard-to-reach districts. METHODS: a concurrent mixed methods approach was therefore, undertaken to exploring three access dimensions, namely availability, affordability and acceptability, in the two districts. Structured interviews were conducted among 190 eligible women in both districts, while key informant interviews, in-depth interviews and focus group discussions were conducted for the qualitative component. RESULTS: the study found that respondents were happy with facilities´ opening and closing times in both districts. By comparison, however, women in Ngabwe spent significantly more time traveling to facilities than those in Kaputa, with bad roads and transport challenges cited as factors affecting service use. The requirement to have a traditional birth attendant (TBA) accompany a woman when going to deliver from the facility, and paying these TBAs, was a notable access barrier. Generally, services seemed to be more acceptable in Kaputa than in Ngabwe, though both districts complained about long queues, being delivered by male health workers and having delivery rooms next to male wards. CONCLUSION: based on the indicators of access used in this study, maternal health services seemed to be more accessible in Kaputa compared to Ngabwe.

Cost-effectiveness of public caseload midwifery compared to standard care in an Australian setting: a pragmatic analysis to inform service delivery.

BACKGROUND: Decision-makers need quantifiable data on costs and outcomes to determine the optimal mix of antenatal models of care to offer. This study aimed to examine the cost utility of a publicly funded Midwifery Group Practice (MGP) caseload model of care compared to other models of care and demonstrate the feasibility of conducting such an analysis to inform service decision-making. OBJECTIVE: To provide a methodological framework to determine the value of public midwifery in different settings. METHODS: Incremental costs and incremental utility (health gains measured in quality-adjusted life years (QALYs)) of public MGP caseload were compared to other models of care currently offered at a large tertiary hospital in Australia. Patient Reported Outcomes Measurement Information System Global Short Form scores were converted into utility values by mapping to the EuroQol 5 dimensions and then converting to QALYs. Costs were assessed from a health system funder's point of view. RESULTS: There were 85 women in the public MGP caseload care group and 72 received other models of care. Unadjusted total mean cost for mothers' and babies' health service use from study entry to 12 months post-partum was $27 618 for MGP caseload care and $33 608 for other models of care. After adjusting for clinical and demographic differences between groups, total costs were 22% higher (cost ratio: 1.218, P = 0.04) for other models of maternity care. When considering costs to all funders, public MGP caseload care cost $5208 less than other models of care. There was no significant difference in QALY between the two groups (difference: 0.010, 95% CI: -0.038, 0.018). CONCLUSION: Public MGP caseload care costs 22% less than other models of care, after accounting for differences in baseline characteristics between groups. There were no significant differences in QALYs. Public MGP caseload care produced comparable health outcomes, with some indication that outcomes may be better for lower cost per woman.

Addressing the huge poor-rich gap of inequalities in accessing safe childbirth care: A first step to achieving universal maternal health coverage in Tanzania.

INTRODUCTION: Despite skilled attendance during childbirth has been linked with the reduction of maternal deaths, equality in accessing this safe childbirth care is highly needed to achieving universal maternal health coverage. However, little information is available regarding the extent of inequalities in accessing safe childbirth care in Tanzania. This study was performed to assess the current extent, trend, and potential contributors of poor-rich inequalities in accessing safe childbirth care among women in Tanzania. METHODS: This study used data from 2004, 2010, and 2016 Tanzania Demographic Health Surveys. The two maternal health services 1) institutional delivery and 2) skilled birth attendance was used to measures access to safe childbirth care. The inequalities were assessed by using concentration curves and concentration indices. The decomposition analysis was computed to identify the potential contributors to the inequalities in accessing safe childbirth care. RESULTS: A total of 8725, 8176, and 10052 women between 15 and 49 years old from 2004, 2010, and 2016 surveys respectively were included in the study. There is an average gap (>50%) between the poorest and richest in accessing safe childbirth care during the study period. The concentration curves were below the line of inequality which means women from rich households have higher access to the institutional delivery and skilled birth attendance inequalities in accessing institutional delivery and skilled birth attendance. These were also, confirmed with their respective positive concentration indices. The decomposition analysis was able to unveil that household's wealth status, place of residence, and maternal education as the major contributors to the persistent inequalities in accessing safe childbirth care. CONCLUSION: The calls for an integrated policy approach which includes fiscal policies, social protection, labor market, and employment policies need to improve education and wealth status for women from poor households. This might be the first step toward achieving universal maternal health coverage.

Perspectives of policymakers and health providers on barriers and facilitators to skilled pregnancy care: findings from a qualitative study in rural Nigeria.

BACKGROUND: The uptake of skilled pregnancy care in rural areas of Nigeria remains a challenge amid the various strategies aimed at improving access to skilled care. The low use of skilled health care during pregnancy, childbirth and postpartum indicates that Nigerian women are paying a heavy price as seen in the country's very high maternal mortality rates. The perceptions of key stakeholders on the use of skilled care will provide a broad understanding of factors that need to be addressed to increase women's access to skilled pregnancy care. The objective of this study was therefore, to explore the perspectives of policymakers and health workers, two major stakeholders in the health system, on facilitators and barriers to women's use of skilled pregnancy care in rural Edo State, Nigeria. METHODS: This paper draws on qualitative data collected in Edo State through key informant interviews with 13 key stakeholders (policy makers and healthcare providers) from a range of institutions. Data was analyzed using an iterative process of inductive and deductive approaches. RESULTS: Stakeholders identified barriers to pregnant women's use of skilled pregnancy care and they include; financial constraints, women's lack of decision-making power, ignorance, poor understanding of health, competitive services offered by traditional birth attendants, previous negative experience with skilled healthcare, shortage of health workforce, and poor financing and governance of the health system. Study participants suggested health insurance schemes, community support for skilled pregnancy care, favourable financial and governance policies, as necessary to facilitate women's use of skilled pregnancy care. CONCLUSIONS: This study adds to the literature, a rich description of views from policymakers and health providers on the deterrents and enablers to skilled pregnancy care. The views and recommendations of policymakers and health workers have highlighted the importance of multi-level factors in initiatives to improve pregnant women's health behaviour. Therefore, initiatives seeking to improve pregnant women's use of skilled pregnancy care should ensure that important factors at each distinct level of the social and physical environment are identified and addressed.

The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries.

BACKGROUND: The United States (US) spends more on health care than any other high-resource country. Despite this, their maternal and newborn outcomes are worse than all other countries with similar levels of economic development. Our purpose was to describe maternal and newborn outcomes and organization of care in four high-resource countries (Australia, Canada, the Netherlands, and United Kingdom) with consistently better outcomes and lower health care costs, and to identify opportunities for emulation and improvement in the United States. METHOD: We examined resources that described health care organization and financing, provider types, birth settings, national, clinical guidelines, health care policies, surveillance data, and information for consumers. We conducted interviews with country stakeholders representing the disciplines of obstetrics, midwifery, pediatrics, neonatology, epidemiology, sociology, political science, public health, and health services. The results of the analysis were compared and contrasted with the US maternity system. RESULTS: The four countries had lower rates of maternal mortality, low birthweight, and newborn and infant death than the United States. Five commonalities were identified as follows: (1) affordable/ accessible health care, (2) a maternity workforce that emphasized midwifery care and interprofessional collaboration, (3) respectful care and maternal autonomy, (4) evidence-based guidelines on place of birth, and (5) national data collections systems. CONCLUSIONS: The findings reveal marked differences in the other countries compared to the United States. It is critical to consider the evidence for improved maternal and newborn outcomes with different models of care and to examine US cultural and structural failures that are leading to unacceptable and substandard maternal and infant outcomes.

Trading patients' choice in providers for quality of maternity care? A discrete choice experiment amongst pregnant women.

BACKGROUND: The introduction of bundled payment for maternity care, aimed at improving the quality of maternity care, may affect pregnant women's choice in providers of maternity care. This paper describes a Dutch study which examined pregnant women's preferences when choosing a maternity care provider. The study focused on factors that enhance the quality of maternity care versus (restricted) provider choice. METHODS: A discrete choice experiment was conducted amongst 611 pregnant women living in the Netherlands using an online questionnaire. The data were analysed with Latent Class Analyses. The outcome measure consisted of stated preferences in the discrete choice experiment. Included factors were: information exchange by care providers through electronic medical records, information provided by midwife, information provided by friends, freedom to choose maternity care provider and travel distance. RESULTS: Four different preference structures were found. In two of those structures, respondents found aspects of the maternity care related to quality of care more important than being able to choose a provider (provider choice). In the two other preference structures, respondents found provider choice more important than aspects related to quality of maternity care. CONCLUSIONS: In a country with presumed high-quality maternity care like the Netherlands, about half of pregnant women prefer being able to choose their maternity care provider over organisational factors that might imply better quality of care. A comparable amount of women find quality-related aspects most important when choosing a maternity care provider and are willing to accept limitations in their choice of provider. These insights are relevant for policy makers in order to be able to design a bundled payment model which justify the preferences of all pregnant women.

Midwife-led care and obstetrician-led care for low-risk pregnancies: A cost comparison.

OBJECTIVE: Low-risk pregnant women cared for by midwives have similar birth outcomes to women cared for by physicians, although experiencing fewer medical procedures. However, limited research has assessed cost implications in the United States. Using national data, we assessed costs and resource use of midwife-led care vs obstetrician-led care for low-risk pregnancies using a decision-analytic approach. METHODS: We developed a decision-analytic model of costs (health plan payments to clinicians) and use of medical procedures during childbirth (epidural analgesia, labor induction, cesarean birth, episiotomy) and outcomes of care (birth at preterm gestation) that may differ with midwife-led vs obstetrician-led care. Model parameters for obstetric procedures were generated using Listening to Mothers III data, a national survey of women who gave birth in US hospitals in 2011-2012 and other published estimates. Cost estimates came from published or publicly available information on health insurance claims payments. RESULTS: The costs of childbirth for low-risk women with midwife-led care were, on average, $2262 less than births to low-risk women cared for by obstetricians. These cost differences derive from lower rates of preterm birth and episiotomy among women with midwife-led care, compared with obstetrician-led care. Across the population of US women with low-risk births each year (approximately 2.6 million), the model predicted substantially fewer preterm births (167 259 vs 219 427 for midwife-led vs obstetrician-led care) and fewer episiotomies (170 504 vs 415 686, for midwife-led vs obstetrician-led care). CONCLUSIONS: A shift from obstetrician-led care to midwife-led care for low-risk pregnancies could be cost saving.

A pathway to establish a publicly funded home birth program in Australia.

BACKGROUND: Home births provide women a birth choice where they may feel more comfortable and confident in their ability to give birth. PROBLEM: Most women in Victoria do not have publicly funded access to appropriately trained health professionals if they choose to give birth at home. METHODS: This paper describes the process of setting up a publicly funded home birth service and provide details of description of the set up and governance. We also report outcomes over 9 years with respect to parity, transfer to hospital, adverse maternal and neonatal outcomes. RESULTS: Of the 191 women who were still booked into the home birth program at 36 weeks gestation, 148 (77.5%) women gave birth at home and 43 (22.5%) women were transferred into the hospital. The overall rate of vaginal birth was also high among the women in the home birth program, 185 (96.9%) with no added complications ascribed to home births. Such as severe perineal trauma [n=1] 0.6% PPH [n=4] 2.7%, Apgar score less than 7 at 5min [n=0] admissions post home birth to special care nursery [n=2] 1.35%. DISCUSSION: This unique study provides a detailed road map of setting up a home birth practice to facilitate other institutions keen to build a publicly funded home birth service. The birth outcome data was found to be consistent with other Australian studies on low risk home births. CONCLUSION: Well-designed home birth programs following best clinical practices and procedures can provide a safe birthing option for low risk women.

What are the costs of stillbirth? Capturing the direct health care and macroeconomic costs in Australia.

BACKGROUND: Reducing stillbirth rates is an international priority; however, little is known about the cost of stillbirth. This analysis sought to quantify the costs of stillbirth in Australia. METHODS: Mothers and costs were identified by linking a state-based registry of all births between 2012 and 2015 to other administrative data sets. Costs from time of birth to 2 years postbirth were included. Propensity score matching was used to account for differences between women who had a stillbirth and those that did not. Macroeconomic costs were estimated using value of lost output analysis and value of lost welfare analysis. RESULTS: Cost to government was on average $3774 more per mother who had a stillbirth compared with mothers who had a live birth. After accounting for gestation at birth, the cost of a stillbirth was 42% more than a live birth (P < .001). Costs for inpatient services, emergency department services, services covered under Medicare (such as primary and specialist care, diagnostic tests and imaging), and prescription pharmaceuticals were all significantly higher for mothers who had a stillbirth. Mothers who had a stillbirth paid on average $1479 out of pocket, which was 52% more than mothers who had a live birth after accounting for gestation at birth (P < .001). The value of lost output was estimated to be $73.8 million (95% CI: 44.0 million-103.9 million). The estimated value of lost social welfare was estimated to be $18 billion. DISCUSSION: Stillbirth has a sustained economic impact on society and families, which demonstrates the potential resource savings that could be generated from stillbirth prevention.

A cost-effectiveness analysis of maternal and neonatal health interventions in Ethiopia.

Ethiopia is one of the sub-Saharan African countries contributing to the highest number of maternal and neonatal deaths. Coverage of maternal and neonatal health (MNH) interventions has remained very low in Ethiopia. We examined the cost-effectiveness of selected MNH interventions in an Ethiopian setting. We analysed 13 case management and preventive MNH interventions. For all interventions, we used an ingredients-based approach for cost estimation. We employed a static life table model to estimate the health impact of a 20% increase in intervention coverage relative to the baseline. We used disability-adjusted life years (DALYs) as the health outcome measure while costs were expressed in 2018 US$. Analyses were based on local epidemiological, demographic and cost data when available. Our finding shows that 12 out of the 13 interventions included in our analysis were highly cost-effective. Interventions targeting newborns such as neonatal resuscitation (institutional), kangaroo mother care and management of newborn sepsis with injectable antibiotics were the most cost-effective interventions with incremental cost-effectiveness ratios of US$7, US$8 and US$17 per DALY averted, respectively. Obstetric interventions (induction of labour, active management of third stage of labour, management of pre-eclampsia/eclampsia and maternal sepsis, syphilis treatment and tetanus toxoid during pregnancy) and safe abortion cost between US$100 and US$300 per DALY averted. Calcium supplementation for pre-eclampsia and eclampsia prevention was the least cost-effective, with a cost per DALY of about US$3100. Many of the MNH interventions analysed were highly cost-effective, and this evidence can inform the ongoing essential health services package revision in Ethiopia. Our analysis also shows that calcium supplementation does not appear to be cost-effective in our setting.

Local people's views on the evidence-based skilled-maternal-care in Mfuwe, Zambia: a qualitative study.

BACKGROUND: There is growing demand for high quality evidence-based practice in the fight against negative maternal health outcomes in Sub-Saharan Africa (SSA). Zambia is one of the countries that has transposed this evidence-based approach by outlawing Traditional Birth Attendants (TBAs) and recommending exclusive skilled-care. There is division among scholars regarding the usefulness of this approach to maternal health in SSA in general. One strand of scholars praises the approach and the other criticizes it. However, there is still lack of evidence to legitimize either of the two positions in poor-settings. Thus the aim of this study is to fill this gap by investigating local people's views on the evidence-based practice in the form of skilled-maternal-care in Zambia, by using Mfuwe as a case study. METHODS: With the help of the Social Representation theory, Focus Group Discussions (FGDs) were conducted in Mfuwe, Zambia with 63 participants. FINDINGS: The study shows that the evidence-based strategy (of exclusive skilled-care) led to improved quality of care in cases where it was accessible. However, not all women had access to skilled-care; thus the act of outlawing the only alternative form of care (TBAs) seemed to have been counterproductive in the context of Mfuwe. The study therefore demonstrates that incorporating TBAs rather than obscuring them may offer an opportunity for improving their potential benefits and minimizing their limitations thereby increasing access and quality of care to women of Mfuwe. CONCLUSION: This study illustrates that while evidence-based strategies remain useful in improving maternal care, they need to be carefully appropriated in poor settings in order to increase access and quality of care.

Are health facilities well equipped to provide basic quality childbirth services under the free maternal health policy? Findings from rural Northern Ghana.

BACKGROUND: Basic inputs and infrastructure including drugs, supplies, equipment, water and electricity are required for the provision of quality care. In the era of the free maternal health policy in Ghana, it is unclear if such basic inputs are readily accessible in health facilities. The study aimed to assess the availability of basic inputs including drugs, supplies, equipment and emergency transport in health facilities. Women and health providers' views on privacy and satisfaction with quality of care were also assessed. METHODS: The study used a convergent parallel mixed methods in one rural municipality in Ghana, Kassena-Nankana. A survey among facilities (n = 14) was done. Another survey was carried out among women who gave birth in health facilities only (n = 353). A qualitative component involved focus group discussions (FGDs) with women (n = 10) and in-depth interviews (IDIs) with midwives and nurses (n = 25). Data were analysed using descriptive statistics for the quantitative study, while the qualitative data were recorded, transcribed, read and coded using themes. RESULTS: The survey showed that only two (14%) out of fourteen facilities had clean water, and five (36%) had electricity. Emergency transport for referrals was available in only one (7%) facility. Basic drugs, supplies, equipment and infrastructure especially physical space were inadequate. Rooms used for childbirth in some facilities were small and used for multiple purposes. Eighty-nine percent (n = 314) of women reported lack of privacy during childbirth and this was confirmed in the IDIs. Despite this, 77% of women (n = 272) were very satisfied or satisfied with quality of care for childbirth which was supported in the FGDs. Reasons for women's satisfaction included the availability of midwives to provide childbirth services and to have follow-up homes visits. Some midwives were seen to be patient and empathetic. Providers were not satisfied due to health system challenges. CONCLUSION: Government should dedicate more resources to the provision of essential inputs for CHPS compounds providing maternal health services. Health management committees should also endeavour to play an active role in the management of health facilities to ensure efficiency and accountability. These would improve quality service provision and usage, helping to achieve universal health coverage.

Policy makers' perspective on the provision of maternal health services via mobile health clinics in Tanzania-Findings from key informant interviews.

OBJECTIVE: To explore the operational feasibility of using mobile health clinics to reach the chronically underserved population with maternal and child health (MCH) services in Tanzania. DESIGN: We conducted fifteen key informant interviews (KIIs) with policy makers and district health officials to explore issues related to mobile health clinic implementation and their perceived impact. MAIN RESULTS: Policy makers' perspective indicates that mobile health clinics have improved coverage of essential maternal and child health interventions; however, they face financial, human resource-related and logistic constraints. Reported are the increased engagement of the community and awareness of the importance of MCH services, which is believed to have a positive effect on uptake of services. Key informants (KIs)' perceptions and opinions were generally in favour of the mobile clinics, with few cautioning on their potential to provide care in a manner that promotes a continuum of care. Immunization, antenatal care, postnatal care and growth monitoring all seem to be successfully implemented in this mode of service delivery. Nevertheless, all informants perceive mobile clinics as a resource intensive yet unavoidable mode of service delivery given the current situation of having women and children residing in remote settings. CONCLUSION: While the government shows the clear motive, the need and the willingness to continue providing services in this mode, the plan to sustain them is still a puzzle. We argue that the continuing need for these services should go hand in hand with proper planning and resource mobilization to ensure that they are being implemented holistically and to promote the provision of quality services and continuity of care. Plans to evaluate their costs and effectiveness are crucial, and that will require the collection of relevant health information including outcome data to allow sound evaluations to take place.

Listening to the community: Using formative research to strengthen maternity waiting homes in Zambia.

BACKGROUND: The WHO recommends maternity waiting homes (MWH) as one intervention to improve maternal and newborn health. However, persistent structural, cultural and financial barriers in their design and implementation have resulted in mixed success in both their uptake and utilization. Guidance is needed on how to design a MWH intervention that is acceptable and sustainable. Using formative research and guided by a sustainability framework for health programs, we systematically collected data from key stakeholders and potential users in order to design a MWH intervention in Zambia that could overcome multi-dimensional barriers to accessing facility delivery, be acceptable to the community and be financially and operationally sustainable. METHODS AND FINDINGS: We used a concurrent triangulation study design and mixed methods. We used free listing to gather input from a total of 167 randomly sampled women who were pregnant or had a child under the age of two (n = 59), men with a child under the age of two (n = 53), and community elders (n = 55) living in the catchment areas of four rural health facilities in Zambia. We conducted 17 focus group discussions (n = 135) among a purposive sample of pregnant women (n = 33), mothers-in-law (n = 32), traditional birth attendants or community maternal health promoters (n = 38), and men with a child under two (n = 32). We administered 38 semi-structured interviews with key informants who were identified by free list respondents as having a stake in the condition and use of MWHs. Lastly, we projected fixed and variable recurrent costs for operating a MWH. Respondents most frequently mentioned distance, roads, transport, and the quality of MWHs and health facilities as the major problems facing pregnant women in their communities. They also cited inadequate advanced planning for delivery and the lack of access to delivery supplies and baby clothes as other problems. Respondents identified the main problems of MWHs specifically as over-crowding, poor infrastructure, lack of amenities, safety concerns, and cultural issues. To support operational sustainability, community members were willing to participate on oversight committees and contribute labor. The annual fixed recurrent cost per 10-bed MWH was estimated as USD543, though providing food and charcoal added another $3,000USD. Respondents identified water pumps, an agriculture shop, a shop for baby clothes and general goods, and grinding mills as needs in their communities that could potentially be linked with an MWH for financial sustainability. CONCLUSIONS: Findings informed the development of an intervention model for renovating existing MWH or constructing new MWH that meets community standards of safety, comfort and services offered and is aligned with government policies related to facility construction, ownership, and access to health services. The basic strategies of the new MWH model include improving community acceptability, strengthening governance and accountability, and building upon existing efforts to foster financial and operational sustainability. The proposed model addresses the problems cited by our respondents and challenges to MWHs identified by in previous studies and elicits opportunities for social enterprises that could serve the dual purpose of meeting a community need and generating revenue for the MWH.

Accountable Care Reforms Improve Women's And Children's Health In Nepal.

Over the past decade the Ministry of Health of Nepal and the nonprofit Possible have partnered to deliver primary and secondary health care via a public-private partnership. We applied an accountable care framework that we previously developed to describe the delivery of their integrated reproductive, maternal, newborn, and child health services in the Achham district in rural Nepal. In a prospective pre-post study, examining pregnancies at baseline and 541 pregnancies in follow-up over the course of eighteen months, we found an improvement in population-level indicators linked to reducing maternal and infant mortality: receipt of four antenatal care visits (83 percent to 90 percent), institutional birth rate (81 percent to 93 percent), and the prevalence of postpartum contraception (19 percent to 47 percent). The intervention cost $3.40 per capita (at the population level) and $185 total per pregnant woman who received services. This study provides new analysis and evidence on the implementation of innovative care and financing models in resource-limited settings.