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.

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.

The influence of Jaminan Kesehatan Nasional (JKN) on the cost of delivery services in Indonesia.

The maternal mortality rate in Indonesia is still high, at 305 per 100,000 live births. Several studies indicated maternal financial burden as one of the dimensions of access that influence a pregnant woman's ability to receive adequate, high-quality medical care. This study aims to identify the association between the use of Indonesia's national health insurance (JKN) and out-of-pocket (OOP) expenditures in accessing delivery services, using data from the Indonesian Family Life Survey 5. In addition, this study also investigated the relationship of JKN and the potential reduction of catastrophic delivery expenditures (CDEs) for delivery services. The results show that JKN was associated with reduced OOP expenditures for delivery as well as reduced risk of incurring CDE. However, some OOP expenditure for cost of delivery services still exists among mothers who used JKN during delivery, potentially due to factors such as medicine stock availability and inpatient care shortages.

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.

Understanding factors influencing home delivery in the context of user-fee abolition in Northern Ghana: Evidence from 2014 DHS.

User-fee exemption for skilled delivery services has been implemented in Ghana since 2003 as a way to address financial barriers to access. However, many women still deliver at home. Based on data from the 2014 Ghana Demographic and Health Survey, we estimated the prevalence of home delivery and determined the factors contributing to homebirths among a total of 622 women in the Northern region in the context of the user-fee exemption policy in Ghana. Binary and multivariate logistic regression analyses were employed. Results suggest home delivery prevalence of 59% (365/622). Traditional birth attendants attended majority of home deliveries (93.4%). After adjusting for potential confounders, making less than four antenatal care visits (aOR = 2.42; CI = 1.91-6.45; p = 0.001), being a practitioner of traditional African religion (aOR = 16.40; CI = 3.10-25.40; p = 0.000), being a Muslim (aOR 2.10; CI = 1.46-5.30; p = 0.042), not having a health insurance (aOR = 1.85; CI = 1.773-4.72; p = 0.016), living in a male-headed household (aOR = 2.07; CI = 1.02-4.53; p < 0.01), and being unexposed to media (aOR = 3.10; CI = 1.12-5.38; p = 0.021) significantly predicted home delivery. Our results suggest that unless interventions are implemented to address other health system factors like insurance coverage, and socio-cultural and religious beliefs that hinder uptake of skilled care, the full benefits of user-fee exemption may not be realized in Ghana.

Normal delivery and cesarean section: cost per brazilian regions, 2015.

OBJECTIVE: To describe the number of funds made by the Brazilian National Health System to normal delivery and cesarean procedures, according to the Brazilian regions in 2015, and estimate the cost cutting if the recommendation concerning the prevalence of cesarean deliveries by the World Health Organization (10 to 15%) were respected. METHODS: Secondary analysis of data from the Hospital Information System of the Brazilian National Health System. The variables considered were the type of delivery (cesarean section and normal), geographic region of admission, length of stay and amount paid for admission in 2015. RESULTS: In the year 2015, there were 984,307 admissions to perform labor in the five Brazilian regions, of which 36.2% were cesarean section. The Northeast and Southeast regions were the two regions that had the highest number of normal deliveries and cesarean sections. The overall average hospital stay for delivery was 3.2 days. About R$ 650 million (US$ 208,5 million) were paid, 45% of the total in cesarean deliveries. If the maximum prevalence proposed by the World Health Organization (WHO) were considered, there would be a potential reduction in spending in the order of R$ 57.7 million (US$ 18,5 million). CONCLUSIONS: Cesarean sections are above the parameter recommended by the WHO in all Brazilian regions. The Northeast and Southeast had the highest total number of normal and cesarean deliveries and thus the greatest potential reduction in estimated costs (69.6% of all considered reduction).

Normal delivery and cesarean section: cost per brazilian regions, 2015

SUMMARY OBJECTIVE: To describe the number of funds made by the Brazilian National Health System to normal delivery and cesarean procedures, according to the Brazilian regions in 2015, and estimate the cost cutting if the recommendation concerning the prevalence of cesarean deliveries by the World Health Organization (10 to 15%) were respected. METHODS: Secondary analysis of data from the Hospital Information System of the Brazilian National Health System. The variables considered were the type of delivery (cesarean section and normal), geographic region of admission, length of stay and amount paid for admission in 2015. RESULTS: In the year 2015, there were 984,307 admissions to perform labor in the five Brazilian regions, of which 36.2% were cesarean section. The Northeast and Southeast regions were the two regions that had the highest number of normal deliveries and cesarean sections. The overall average hospital stay for delivery was 3.2 days. About R$ 650 million (US$ 208,5 million) were paid, 45% of the total in cesarean deliveries. If the maximum prevalence proposed by the World Health Organization (WHO) were considered, there would be a potential reduction in spending in the order of R$ 57.7 million (US$ 18,5 million). CONCLUSIONS: Cesarean sections are above the parameter recommended by the WHO in all Brazilian regions. The Northeast and Southeast had the highest total number of normal and cesarean deliveries and thus the greatest potential reduction in estimated costs (69.6% of all considered reduction).

RESUMO OBJETIVO: Descrever o montante de recursos pagos pelo Sistema Único de Saúde por procedimentos de parto normal e cesárea, segundo as regiões brasileiras, em 2015, estimando a redução de gastos caso a recomendação da Organização Mundial da Saúde quanto à prevalência de partos cesáreas (10% a 15%) fosse seguida. MÉTODOS: Emprego de dados secundários presentes no Sistema de Informações Hospitalares do Sistema Único de Saúde. As variáveis consideradas foram: tipo de parto (cesárea e normal), região geográfica de ocorrência, tempo de permanência hospitalar e valor da Autorização de Internação Hospitalar paga, em 2015. RESULTADOS: No ano de 2015 ocorreram 984.307 internações para realização de parto nas cinco regiões brasileiras, sendo 36,2% de partos por cesárea. Nordeste e Sudeste foram as duas regiões que se destacaram, com os maiores números de partos normais e cesáreas. A média geral em dias de internação para parto nas cinco regiões foi de 3,2 dias. Foram pagos aproximadamente R$ 650 milhões (US$ 208,5 milhões), 45% desse total em partos cesáreas. Caso o parâmetro máximo proposto pela Organização Mundial da Saúde fosse considerado, haveria uma redução potencial de gastos na ordem de R$ 57,7 milhões (US$ 18,5 milhões). CONCLUSÕES: Os partos cesáreas estão acima do parâmetro recomendado em todas as regiões brasileiras. As regiões Nordeste e Sudeste se destacaram por representar potencialmente a maior redução na estimativa de gastos (69,6% de toda a redução considerada).

Decision-making for birth location among women in Pakistan: evidence from national survey.

BACKGROUND: Pakistan ranks 149th in the maternal mortality ratio (MMR) and has failed to keep pace with other countries in the region, except Afghanistan, with respect to health indicators. Home deliveries are linked to a higher risk of maternal death; therefore, discouraging home deliveries is imperative to improve maternal health. This study provides a holistic view and analyses factors affecting home birth decisions within the context of maternal socio-demographic characteristics in Pakistan. METHODS: The study exploits the latest data from the Pakistan Demographic and Health Survey (2012-2013), which includes a nationally representative sample of 13,558 women aged 15-49 years. However, the sample was reduced to 6977 women who had given birth in the 5 years preceding the survey. Statistical techniques, including bi-variate and multivariate logistic regression, were used to analyse the data. The dependent variable was dichotomous and coded as 0 for home deliveries and 1 for deliveries at a health facility. The dependent variable was constructed based on information regarding the most recent birth in the 5 years preceding the survey. RESULTS: The study reveals that giving birth at home is highly prevalent among mothers in Pakistan (Baluchistan, 74%; Khyber-Pakhtunkhwa, 53%; Gilgit Baltistan, 46%; Punjab, 45% and Sindh, 34%) because of their difficulty obtaining permission to visit a health facility, financial barriers, the distance to health facilities and transportation. Substantial variation is observed when geo-demographic characteristics are considered. Higher home childbirth rates have been recorded in rural areas compared with those in urban areas (OR 1.32; p ≤ 0.000). The likelihood of home birth is highest (OR 2.67; p = 0.000) among women in Baluchistan province and lowest (OR 0.48; p = 0.000) among mothers in Punjab province. After controlling for all odds ratios and demographic characteristics, the parents' education levels remain a significant factor (p = 0.000) that affects women's decisions to deliver at home rather than at a health facility. CONCLUSION: The study findings provide a better understanding of why women prefer to give birth at home. These results can help policymakers to introduce appropriate interventions to increase the number of deliveries at health facilities. These findings are expected to reduce maternal and neonatal mortality in Pakistan.

[Cost-effectiveness analysis of spontaneous vaginal delivery and elective cesarean for normal risk pregnant women in the Brazilian Unified National Health System]. / Análise de custo-efetividade do parto vaginal espontâneo e da cesariana eletiva para gestantes de risco habitual no Sistema Único de Saúde.

The purpose of this study was to conduct a cost-effectiveness analysis of spontaneous vaginal delivery and elective cesarean (with no clinical indication) for normal risk pregnant women, from the perspective of the Brazilian Unified National Health System. An analytical decision model was developed and included the choice of delivery mode and clinical consequences for mothers and newborns, from admission for delivery to hospital discharge. The reference population consisted of normal risk pregnant women with singleton, at-term gestations in cephalic position, subdivided into primiparas and multiparas with prior uterine scar. Cost data were obtained from three public maternity hospitals (two in Rio de Janeiro, one in Belo Horizonte, Minas Gerais State, Brazil). Direct costs were identified with human resources, hospital inputs, and capital and administrative costs. Effectiveness measures were identified, based on the scientific literature. The study showed that vaginal delivery was more efficient for primiparas, at lower cost (BRL 1,709.58; USD 518.05) than cesarean (BRL 2,245.86; USD 680.56) and greater effectiveness for three of the four target outcomes. For multiparas with prior uterine scar, repeat cesarean was cost-effective for the outcomes averted maternal morbidity, averted uterine rupture, averted neonatal ICU, and averted neonatal death, but the result was not supported by probabilistic sensitivity analysis. For maternal death as the outcome, there was no difference in effectiveness, and labor showed the lowest cost. This study can contribute to the management of perinatal care, expanding measures that encourage adequate delivery according to the population's characteristics.

O objetivo deste estudo foi realizar uma análise de custo-efetividade do parto vaginal espontâneo comparado à cesariana eletiva, sem indicação clínica, para gestantes de risco habitual, sob a perspectiva do Sistema Único de Saúde. Um modelo de decisão analítico foi desenvolvido e incluiu a escolha do tipo de parto e consequências clínicas para mãe e recém-nascido, da internação para o parto até a alta hospitalar. A população de referência foi gestantes de risco habitual, feto único, cefálico, a termo, subdivididas em primíparas e multíparas com uma cicatriz uterina prévia. Os dados de custos foram obtidos de três maternidades públicas, duas situadas no Rio de Janeiro e uma em Belo Horizonte, Minas Gerais, Brasil. Foram identificados custos diretos com recursos humanos, insumos hospitalares, custos de capital e administrativos. As medidas de efetividade foram identificadas com base na literatura científica. O estudo evidenciou que o parto vaginal é mais eficiente para gestantes primíparas, com menor custo (R$ 1.709,58) que a cesariana (R$ 2.245,86) e melhor efetividade para três dos quatro desfechos avaliados. Para multíparas, com uma cicatriz uterina prévia, a cesariana de repetição foi custo-efetiva para os desfechos morbidade materna evitada, ruptura uterina evitada, internação em UTI neonatal evitada e óbito neonatal evitado, mas o resultado não foi suportado pela análise de sensibilidade probabilística. Para o desfecho óbito materno não houve diferença de efetividade e o trabalho de parto se mostrou com o menor custo. Este estudo pode contribuir para a gestão da atenção perinatal, ampliando medidas que estimulem o parto adequado de acordo com as características da população.

El objetivo de este estudio fue realizar un análisis de costo-efectividad del parto vaginal espontáneo, comparado con la cesárea electiva, sin indicación clínica, para gestantes de riesgo habitual, bajo la perspectiva del Sistema Único de Salud. Un modelo de decisión analítico se desarrolló e incluyó la elección del tipo de parto y consecuencias clínicas para la madre y recién nacido, desde el internamiento para el parto hasta el alta hospitalaria. La población de referencia fueron gestantes de riesgo habitual, feto único, cefálico, a término, subdivididas en primíparas y multíparas, con una cicatriz uterina previa. Los datos de costos se obtuvieron de tres maternidades públicas, dos situadas en Río de Janeiro y una en Belo Horizonte, Minas Gerais, Brasil. Se identificaron costos directos con recursos humanos, insumos hospitalarios, costos de capital y administrativos. Las medidas de efectividad se identificaron en base a la literatura científica. El estudio evidenció que el parto vaginal es más eficiente para gestantes primíparas, con un menor costo (BRL 1.709,58) que la cesárea (BRL 2.245,86) y mejor efectividad para tres de los cuatro desenlaces evaluados. Para multíparas, con una cicatriz uterina previa, la cesárea de repetición fue costo-efectiva para los desenlaces de morbilidad materna evitada, rotura uterina evitada, internamiento en UTI neonatal evitado y óbito neonatal evitado, pero el resultado no fue apoyado por el análisis de sensibilidad probabilístico. Para el desenlace óbito materno no hubo diferencia de efectividad y el trabajo de parto se mostró con el menor coste. Este estudio puede contribuir a la gestión de la atención perinatal, ampliando medidas que estimulen el parto apropiado, de acuerdo con las características de la población.

Absolute income is a better predictor of coverage by skilled birth attendance than relative wealth quintiles in a multicountry analysis: comparison of 100 low- and middle-income countries.

BACKGROUND: Having high-quality data available by 2020, disaggregated by income, is one of the Sustainable Development Goals (SGD). We explored how well coverage with skilled birth attendance (SBA) is predicted by asset-based wealth quintiles and by absolute income. METHODS: We used data from 293 national surveys conducted in 100 low and middle-income countries (LMICs) from 1991 to 2014. Data on household income were computed using national income levels and income inequality data available from the World Bank and the Standardized World Income Inequality Database. Multivariate regression was used to explore the predictive capacity of absolute income compared to the traditional measure of quintiles of wealth index. RESULTS: The mean SBA coverage was 68.9% (SD: 24.2), compared to 64.7% (SD: 26.6) for institutional delivery coverage. Median daily family income in the same period was US$ 6.4 (IQR: 3.5-14.0). In cross-country analyses, log absolute income predicts 51.5% of the variability in SBA coverage compared to 22.0% predicted by the wealth index. For within-country analysis, use of absolute income improved the understanding of the gap in SBA coverage among the richest and poorest families. Information on income allowed identification of countries - such as Burkina Faso, Cambodia, Egypt, Nepal and Rwanda - which were well above what would be expected solely from changes in income. CONCLUSION: Absolute income is a better predictor of SBA and institutional delivery coverage than the relative measure of quintiles of wealth index and may help identify countries where increased coverage is likely due to interventions other than increased income.

Análise de custo-efetividade do parto vaginal espontâneo e da cesariana eletiva para gestantes de risco habitual no Sistema Único de Saúde / Cost-effectiveness analysis of spontaneous vaginal delivery and elective cesarean for normal risk pregnant women in the Brazilian Unified National Health System / Análisis de costo-efectividad del parto vaginal espontáneo y la cesárea electiva para gestantes de riesgo habitual en el Sistema Único de Salud

Resumo: O objetivo deste estudo foi realizar uma análise de custo-efetividade do parto vaginal espontâneo comparado à cesariana eletiva, sem indicação clínica, para gestantes de risco habitual, sob a perspectiva do Sistema Único de Saúde. Um modelo de decisão analítico foi desenvolvido e incluiu a escolha do tipo de parto e consequências clínicas para mãe e recém-nascido, da internação para o parto até a alta hospitalar. A população de referência foi gestantes de risco habitual, feto único, cefálico, a termo, subdivididas em primíparas e multíparas com uma cicatriz uterina prévia. Os dados de custos foram obtidos de três maternidades públicas, duas situadas no Rio de Janeiro e uma em Belo Horizonte, Minas Gerais, Brasil. Foram identificados custos diretos com recursos humanos, insumos hospitalares, custos de capital e administrativos. As medidas de efetividade foram identificadas com base na literatura científica. O estudo evidenciou que o parto vaginal é mais eficiente para gestantes primíparas, com menor custo (R$ 1.709,58) que a cesariana (R$ 2.245,86) e melhor efetividade para três dos quatro desfechos avaliados. Para multíparas, com uma cicatriz uterina prévia, a cesariana de repetição foi custo-efetiva para os desfechos morbidade materna evitada, ruptura uterina evitada, internação em UTI neonatal evitada e óbito neonatal evitado, mas o resultado não foi suportado pela análise de sensibilidade probabilística. Para o desfecho óbito materno não houve diferença de efetividade e o trabalho de parto se mostrou com o menor custo. Este estudo pode contribuir para a gestão da atenção perinatal, ampliando medidas que estimulem o parto adequado de acordo com as características da população.

Abstract: The purpose of this study was to conduct a cost-effectiveness analysis of spontaneous vaginal delivery and elective cesarean (with no clinical indication) for normal risk pregnant women, from the perspective of the Brazilian Unified National Health System. An analytical decision model was developed and included the choice of delivery mode and clinical consequences for mothers and newborns, from admission for delivery to hospital discharge. The reference population consisted of normal risk pregnant women with singleton, at-term gestations in cephalic position, subdivided into primiparas and multiparas with prior uterine scar. Cost data were obtained from three public maternity hospitals (two in Rio de Janeiro, one in Belo Horizonte, Minas Gerais State, Brazil). Direct costs were identified with human resources, hospital inputs, and capital and administrative costs. Effectiveness measures were identified, based on the scientific literature. The study showed that vaginal delivery was more efficient for primiparas, at lower cost (BRL 1,709.58; USD 518.05) than cesarean (BRL 2,245.86; USD 680.56) and greater effectiveness for three of the four target outcomes. For multiparas with prior uterine scar, repeat cesarean was cost-effective for the outcomes averted maternal morbidity, averted uterine rupture, averted neonatal ICU, and averted neonatal death, but the result was not supported by probabilistic sensitivity analysis. For maternal death as the outcome, there was no difference in effectiveness, and labor showed the lowest cost. This study can contribute to the management of perinatal care, expanding measures that encourage adequate delivery according to the population's characteristics.

Resumen: El objetivo de este estudio fue realizar un análisis de costo-efectividad del parto vaginal espontáneo, comparado con la cesárea electiva, sin indicación clínica, para gestantes de riesgo habitual, bajo la perspectiva del Sistema Único de Salud. Un modelo de decisión analítico se desarrolló e incluyó la elección del tipo de parto y consecuencias clínicas para la madre y recién nacido, desde el internamiento para el parto hasta el alta hospitalaria. La población de referencia fueron gestantes de riesgo habitual, feto único, cefálico, a término, subdivididas en primíparas y multíparas, con una cicatriz uterina previa. Los datos de costos se obtuvieron de tres maternidades públicas, dos situadas en Río de Janeiro y una en Belo Horizonte, Minas Gerais, Brasil. Se identificaron costos directos con recursos humanos, insumos hospitalarios, costos de capital y administrativos. Las medidas de efectividad se identificaron en base a la literatura científica. El estudio evidenció que el parto vaginal es más eficiente para gestantes primíparas, con un menor costo (BRL 1.709,58) que la cesárea (BRL 2.245,86) y mejor efectividad para tres de los cuatro desenlaces evaluados. Para multíparas, con una cicatriz uterina previa, la cesárea de repetición fue costo-efectiva para los desenlaces de morbilidad materna evitada, rotura uterina evitada, internamiento en UTI neonatal evitado y óbito neonatal evitado, pero el resultado no fue apoyado por el análisis de sensibilidad probabilístico. Para el desenlace óbito materno no hubo diferencia de efectividad y el trabajo de parto se mostró con el menor coste. Este estudio puede contribuir a la gestión de la atención perinatal, ampliando medidas que estimulen el parto apropiado, de acuerdo con las características de la población.

Cost-effectiveness of planned birth in a birth centre compared with alternative planned places of birth: results of the Dutch Birth Centre study.

OBJECTIVES: To estimate the cost-effectiveness of a planned birth in a birth centre compared with alternative planned places of birth for low-risk women. In addition, a distinction has been made between different types of locations and integration profiles of birth centres. DESIGN: Economic evaluation based on a prospective cohort study. SETTING: 21 Dutch birth centres, 46 hospital locations where midwife-led birth was possible and 110 midwifery practices where home birth was possible. PARTICIPANTS: 3455 low-risk women under the care of a community midwife at the start of labour in the Netherlands within the study period 1 July 2013 to 31 December 2013. MAIN OUTCOME MEASURES: Costs and health outcomes of birth for different planned places of birth. Healthcare costs were measured from start of labour until 7 days after birth. The health outcomes were assessed by the Optimality Index-NL2015 (OI) and a composite adverse outcomes score. RESULTS: The total adjusted mean costs for births planned in a birth centre, in a hospital and at home under the care of a community midwife were €3327, €3330 and €2998, respectively. There was no difference between the score on the OI for women who planned to give birth in a birth centre and that of women who planned to give birth in a hospital. Women who planned to give birth at home had better outcomes on the OI (higher score on the OI). CONCLUSIONS: We found no differences in costs and health outcomes for low-risk women under the care of a community midwife with a planned birth in a birth centre and in a hospital. For nulliparous and multiparous low-risk women, planned birth at home was the most cost-effective option compared with planned birth in a birth centre.

Home is best: Why women in rural Zimbabwe deliver in the community.

Maternal mortality in Zimbabwe has unprecedentedly risen over the last two and half decades although a decline has been noted recently. Many reasons have been advanced for the rising trend, including deliveries without skilled care, in places without appropriate or adequate facilities to handle complications. The recent decline has been attributed to health systems strengthening through a multi-donor pooled funding mechanism. On the other hand, the proportion of community deliveries has also been growing steadily over the years and in this study we investigate why. We used twelve (12) focus group discussions with child-bearing women and eight (8) key informant interviews (KIIs). Four (4) were traditional birth attendants and four (4) were spiritual birth attendants. A thematic approach was used to analyse the data in Ethnography software. The study shows that women prefer community deliveries due to perceived low economic, social and opportunity costs involved; pliant and flexible services offered; and diminishing quality and appeal of institutional maternity services. We conclude that rural women are very economic, logical and rational in making choices on place of delivery. Delivering in the community offers financial, social and opportunity advantages to disenfranchised women, particularly in remote rural areas. We recommend for increased awareness of the dangers of community deliveries; establishment of basic obstetric care facilities in the community and more efficient emergency referral systems. In the long-term, there should be a sustainable improvement of the public health delivery system to make it accessible, affordable and usable by the public.

A cost effectiveness analysis of midwife psycho-education for fearful pregnant women - a health system perspective for the antenatal period.

BACKGROUND: Psycho-education can reduce childbirth fear and caesarean section numbers. This study determines the cost-effectiveness of a midwife-led psycho-education intervention for women fearful of birth. METHOD: One thousand four hundred ten pregnant women in south-east Queensland, Australia were screened for childbirth fear (W-DEQ A ≥ 66). Women with high scores (n = 339) were randomised to the BELIEF Study (Birth Emotions and Looking to Improve Expectant Fear) to receive psycho-education (n = 170) at 24 and 34 weeks of pregnancy or to the control group (n = 169). Women in both groups were surveyed 6 weeks postpartum with total cost for health service use during pregnancy calculated. Logistic regression models assessed the odds ratio of having vaginal birth or caesarean section in the study groups. RESULT: Of 339 women randomised, 184 (54%) women returned data at 6 weeks postpartum (Intervention Group n = 91; Control Group n = 93). Women receiving psycho-education had a higher likelihood of vaginal birth compared to controls (n = 60, 66% vs. n = 54, 58%; OR 2.34). Mean 'treatment' cost for women receiving psycho-education was AUS$72. Mean cost for health services excluding the cost of psycho-education, was less in the intervention group (AUS$1193 vs. AUS$1236), but not significant (p = 0.78). For every five women who received midwife counselling, one caesarean section was averted. The incremental healthcare cost to prevent one caesarean section using this intervention was AUS$145. CONCLUSION: Costs of delivering midwife psycho-education to women with childbirth fear during pregnancy are offset by improved vaginal birth rates and reduction in caesarean section numbers. TRIAL REGISTRATION: Australian New Zealand Controlled Trials Registry ACTRN12612000526875 , 17th May 2012 (retrospectively registered one week after enrolment of first participant).

Process value of care safety: women's willingness to pay for perinatal services.

OBJECTIVE: To evaluate the process value of care safety from the patient's view in perinatal services. DESIGN: Cross-sectional survey. SETTINGS: Fifty two sites of mandated public neonatal health checkup in 6 urban cities in West Japan. PARTICIPANTS: Mothers who attended neonatal health checkups for their babies in 2011 (n = 1316, response rate = 27.4%). MAIN OUTCOME MEASURE: Willingness to pay (WTP) for physician-attended care compared with midwife care as the process-related value of care safety. WTP was estimated using conjoint analysis based on the participants' choice over possible alternatives that were randomly assigned from among eight scenarios considering attributes such as professional attendance, amenities, painless delivery, caesarean section rate, travel time and price. RESULTS: The WTP for physician-attended care over midwife care was estimated 1283 USD. Women who had experienced complications in prior deliveries had a 1.5 times larger WTP. CONCLUSIONS: We empirically evaluated the process value for safety practice in perinatal care that was larger than a previously reported accounting-based value. Our results indicate that measurement of process value from the patient's view is informative for the evaluation of safety care, and that it is sensitive to individual risk perception for the care process.

Health facility and skilled birth deliveries among poor women with Jamkesmas health insurance in Indonesia: a mixed-methods study.

BACKGROUND: The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia's strategy to achieve the goal of UHC, large investments have been made to increase health access for the poor, resulting in the implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jamkesmas program. In the backdrop of Indonesia's aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. The objective of this study was to evaluate the association of health facility and skilled birth deliveries among poor women with and without Jamkesmas and explore perceived barriers to health insurance membership and maternal health service utilization. METHODS: We used a mixed-methods design. Utilizing data from the 2012 Indonesian Demographic and Health Survey (n = 45,607), secondary analysis using propensity score matching was performed on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). In-depth interviews (n = 51) were conducted in the provinces of Jakarta and Banten among poor women, midwives, and government representatives. Thematic framework analysis was performed on qualitative data to explore perceived barriers. RESULTS: In 2012, 63.0% of women did not have health insurance; 19.1% had Jamkesmas. Poor women with Jamkesmas were 19% (OR = 1.19 [1.03-1.37]) more likely to have HFD and 17% (OR = 1.17 [1.01-1.35]) more likely to have SBD compared to poor women without insurance. Qualitative interviews highlighted key issues, including: lack of proper documentation for health insurance registration; the preference of pregnant women to deliver in their parents' village; the use of traditional birth attendants; distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation. CONCLUSIONS: Poor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings are consistent with economic theory that health insurance coverage can reduce financial barriers to care and increase service uptake. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia.

A qualitative study of factors impacting accessing of institutional delivery care in the context of India's cash incentive program.

Not all eligible women use the available services under India's Janani Suraksha Yojana (JSY), which provides cash incentives to encourage pregnant women to use institutional care for childbirth; limited evidence exists on demand-side factors associated with low program uptake. This study explores the views of women and ASHAs (community health workers) on the use of the JSY and institutional delivery care facilities. In-depth qualitative interviews, carried out in September-November 2013, were completed in the local language by trained interviewers with 112 participants consisting of JSY users/non-users and ASHAs in Jharkhand, Madhya Pradesh and Uttar Pradesh. The interaction of impeding and enabling factors on the use of institutional care for delivery was explored. We found that ASHAs' support services (e.g., arrangement of transport, escort to and support at healthcare facilities) and awareness generation of the benefits of institutional healthcare emerged as major enabling factors. The JSY cash incentive played a lesser role as an enabling factor because of higher opportunity costs in the use of healthcare facilities versus home for childbirth. Trust in the skills of traditional birth-attendants and the notion of childbirth as a 'natural event' that requires no healthcare were the most prevalent impeding factors. The belief that a healthcare facility would be needed only in cases of birth complications was also highly prevalent. This often resulted in waiting until the last moments of childbirth to seek institutional healthcare, leading to delay/non-availability of transportation services and inability to reach a delivery facility in time. ASHAs opined that interpersonal communication for awareness generation has a greater influence on use of institutional healthcare, and complementary cash incentives further encourage use. Improving health workers' support services focused on marginalized populations along with better public healthcare facilities are likely to promote the uptake of institutional delivery care in resource-poor settings.

Association of Household Savings and Expected Future Means with Delivery Using a Skilled Birth Attendant in Ghana and Nigeria: A Cross-Sectional Analysis.

Objectives This study examined the association between household savings and related economic measures with utilization of skilled birth attendants (SBAs) at last birth among women living in peri-urban households (n = 381) in Ghana and Nigeria. Methods Data were drawn from the 2011-2014 Family Health and Wealth Study. Multivariable logistic regression models were used to estimate the odds of delivery with an SBA for individual and composite measures of household savings, expected financial means, debt, lending, and receipt of financial assistance, adjusting for demographic and reproductive characteristics. Results Seventy-three percent (73 %) of women delivered with an SBA during their last birth (89 %, Ghana; 63 %, Nigeria), and roughly one third (34 %) of households reported having any in-cash or in-kind savings. In adjusted analyses, women living in households with savings were significantly more likely to deliver with an SBA compared to women in households without any savings (aOR = 2.02, 95 % CI 1.09-3.73). There was also a consistent downward trend, although non-significant, in SBA utilization with worsening financial expectations in the coming year (somewhat vs. much better: aOR = 0.70, 95 % CI 0.40-1.22 and no change/worse vs. much better: aOR = 0.46, 95 % CI 0.12-1.83). Findings were null for measures relating to debt, lending, and financial assistance. Conclusion Coupling birth preparedness and complication readiness strategies with savings-led initiatives may improve SBA utilization in conjunction with targeting non-economic barriers to skilled care use.

From hospital to home: Australian midwives' experiences of transitioning into publicly-funded homebirth programs.

BACKGROUND: Over the past two decades, 14 publicly-funded homebirth models have been established in Australian hospitals. Midwives working in these hospitals now have the opportunity to provide homebirth care, despite many having never been exposed to homebirth before. The transition to providing homebirth care can be daunting for midwives who are accustomed to practising in the hospital environment. AIM: To explore midwives' experiences of transitioning from providing hospital to homebirth care in Australian public health systems. METHODS: A descriptive, exploratory study was undertaken. Data were collected through in-depth interviews with 13 midwives and midwifery managers who had recent experience transitioning into and working in publicly-funded homebirth programs. Thematic analysis was conducted on interview transcripts. FINDINGS: Six themes were identified. These were: skilling up for homebirth; feeling apprehensive; seeing birth in a new light; managing a shift in practice; homebirth-the same but different; and the importance of mentoring and support. DISCUSSION: Midwives providing homebirth work differently to those working in hospital settings. More experienced homebirth midwives may provide high quality care in a relaxed environment (compared to a hospital setting). Midwives acceptance of homebirth is influenced by their previous exposure to homebirth. CONCLUSION: The transition from hospital to homebirth care required midwives to work to the full scope of their practice. When well supported by colleagues and managers, midwives transitioning into publicly-funded homebirth programs can have a positive experience that allows for a greater understanding of and appreciation for normal birth.