COVID-19 worries, concerns and mitigation behaviours: A snapshot of Nepal during the first wave.

OBJECTIVES: To understand COVID-19 worries and how they influence COVID-19 mitigation behaviours, especially in communities prior to case surges, in Nepal. METHODS: Data related to COVID-19 impacts on life disruptions were collected from households in the Chitwan Valley Family Study, a 25-year community panel study, during February-April 2021. COVID-19 worry was measured by the extent of respondent concern for themselves or household members getting COVID-19 in the prior 2 weeks. 11 items examined COVID-19 mitigation behaviours. Logistic regression models assessed associations between socio-demographic characteristics and COVID-19 worry and then the influence of worry on any mitigation behaviour and behaviour type adjusting for age, education, sex, ethnicity and COVID-19 exposure, accounting for neighbourhood clustering. RESULTS: Of 2,678 households with a responding adult, ages 18-88, 394 (14.7%) reported moderate-to-extreme COVID-19 worry and 1,214 (45.3%) engaged in three or more mitigation behaviours. Prevalence of mitigation behaviours was higher among those with COVID-19 worry (e.g. avoided crowds: 62.7% versus 40.5% in those with minimal worry). Respondents self-reporting COVID-19 had higher odds of worry (adjusted odds ratio [aOR]: 2.73, 95% confidence interval [CI]: 1.13, 6.57). Odds of any mitigation behaviour were higher among those with COVID-19 worry compared to those with minimal worry (aOR: 6.19, 95% CI = 1.88, 20.35). CONCLUSIONS: COVID-19 mitigation behaviours were more common in people with COVID-19 worry. To address current and potential future waves of the pandemic, public health efforts should include informational campaigns about mitigation behaviours particularly for those unconcerned with COVID-19 risks.

Drought and migration: An analysis of the effects of drought on temporary labor and return migration from a migrant-sending area in Nepal.

Although the relationship between drought - a dimension of climate change - and migration has been explored in a number of settings, prior research has largely focused on out-migration and has not considered climate factors at the migrant destination. However, drought may impact not only out-migration, but also return migration, particularly in settings where temporary labor migration and agricultural reliance are common. Thus, considering drought conditions at origin and destinations is necessary to specify the effects of climate on migrant-sending populations. Using detailed data from the Chitwan Valley Family Study, a household panel study in a migrant-sending area in Nepal, we analyze the effect of drought at the neighborhood level on individual-level out-migration and drought at the origin district on return migration among adults from 2011 to 2017, assessing these associations among males and females separately. In mixed-effect discrete-time regressions, we find that neighborhood drought is positively associated with out-migration and return migration, both internally and internationally among males. Among females, drought is positively associated with internal out-migration and return migration, but not international migrations. We did not find an association between drought at the origin and return migration independent of drought status at the destination. Taken together, these findings contribute to our understanding of the complexity of the impacts of precipitation anomalies on population movement over time.

Relationship between symptoms, barriers to care and healthcare utilisation among children under five in rural Mali.

OBJECTIVES: To identify social and structural barriers to timely utilisation of qualified providers among children under five years in a high-mortality setting, rural Mali and to analyse how utilisation varies by symptom manifestation. METHODS: Using baseline household survey data from a cluster-randomised trial, we assessed symptom patterns and healthcare trajectories of 5117 children whose mothers reported fever, diarrhoea, bloody stools, cough and/or fast breathing in the preceding two weeks. We examine associations between socio-demographic factors, symptoms and utilisation outcomes in mixed-effect logistic regressions. RESULTS: Almost half of recently ill children reported multiple symptoms (46.2%). Over half (55.9%) received any treatment, while less than one-quarter (21.7%) received care from a doctor, nurse, midwife, trained community health worker or pharmacist within 24 h of symptom onset. Distance to primary health facility, household wealth and maternal education were consistently associated with better utilisation outcomes. While children with potentially more severe symptoms such as fever and cough with fast breathing or diarrhoea with bloody stools were more likely to receive any care, they were no more likely than children with fever to receive timely care with a qualified provider. CONCLUSIONS: Even distances as short as 2-5 km significantly reduced children's likelihood of utilising healthcare relative to those within 2 km of a facility. While children with symptoms indicative of pneumonia and malaria were more likely to receive any care, suggesting mothers and caregivers recognised potentially severe illness, multiple barriers to care contributed to delays and low utilisation of qualified providers, illustrating the need for improved consideration of barriers.

Household factors and under-five mortality in Bankass, Mali: results from a cross-sectional survey.

BACKGROUND: Rural parts of Mali carry a disproportionate burden of the country's high under-five mortality rate. A range of household factors are associated with poor under-five health in resource-limited settings. However, it is unknown which most influence the under-five mortality rate in rural Mali. We aimed to describe household factors associated with under-five mortality in Bankass, a remote region in central Mali. METHODS: We analysed baseline household survey data from a trial being conducted in Bankass. The survey was administered to households between December 2016 and January 2017. Under-five deaths in the five years prior to baseline were documented along with detailed information on household factors and women's birth histories. Factors associated with under-five mortality were analysed using Cox regression. RESULTS: Our study population comprised of 17,408 under-five children from 8322 households. In the five years prior to baseline, the under-five mortality rate was 152.6 per 1000 live births (158.8 and 146.0 per 1000 live births for males and females, respectively). Living a greater distance from a primary health center was associated with a higher probability of under-five mortality for both males (adjusted hazard ratio [aHR] 1.53 for ≥10 km versus < 2 km, 95% confidence interval [CI] 1.25-1.88) and females (aHR 1.59 for ≥10 km versus < 2 km, 95% CI 1.27-1.99). Under-five male mortality was additionally associated with lower household wealth quintile (aHR 1.47 for poorest versus wealthiest, 95%CI 1.21-1.78), lower reading ability among women of reproductive age in the household (aHR 1.73 for cannot read versus can read, 95%CI 1.04-2.86), and living in a household with access to electricity (aHR 1.16 for access versus no access, 95%CI 1.00-1.34). CONCLUSIONS: U5 mortality is very high in Bankass and is associated with living a greater distance from healthcare and several other household factors that may be amenable to intervention or facilitate program targeting.

Women's empowerment, intrahousehold influences, and health system design on modern contraceptive use in rural Mali: a multilevel analysis of cross-sectional survey data.

BACKGROUND: Persistent challenges in meeting reproductive health and family planning goals underscore the value in determining what factors can be leveraged to facilitate modern contraceptive use, especially in poor access settings. In Mali, where only 15% of reproductive-aged women use modern contraception, understanding how women's realities and health system design influence contraceptive use helps to inform strategies to achieve the nation's target of 30% by 2023. METHODS: Using household survey data from the baseline round of a cluster-randomized trial, including precise geolocation data from all households and public sector primary health facilities, we used a multilevel model to assess influences at the individual, household, community, and health system levels on women's modern contraceptive use. In a three-level, mixed-effects logistic regression, we included measures of women's decision-making and mobility, as well as socio-economic sources of empowerment (education, paid labor), intrahousehold influences in the form of a co-residing user, and structural factors related to the health system, including distance to facility. RESULTS: Less than 5% of the 14,032 women of reproductive age in our study used a modern method of contraception at the time of the survey. Women who played any role in decision-making, who had any formal education and participated in any paid labor, were more likely to use modern contraception. Women had three times the odds of using modern contraception if they lived in a household with another woman, typically a co-wife, who also used a modern method. Compared to women closest to a primary health center, those who lived between 2 and 5 km were half as likely to use modern contraception, and those between 5 and 10 were a third as likely. CONCLUSIONS: Despite chronically poor service availability across our entire study area, some women-even pairings of women in single households-transcended barriers to use modern contraception. When planning and implementing strategies to expand access to contraception, policymakers and practitioners should consider women's empowerment, social networks, and health system design. Accessible and effective health systems should reconsider the conventional approach to community-based service delivery, including distance as a barrier only beyond 5 km.

RéSUMé: CONTEXTE: Au Mali, où seulement 15% des femmes en âge de procréer utilisent les contraceptifs modernes, la compréhension des réalités des femmes et de la conception du système de santé aident à éclairer les stratégies pour atteindre l'objectif national de 30% d'ici 2023. MéTHODES: En utilisant les données d'enquête de base d'un essai randomisé en grappes, avec la géolocalisation précise de tous les ménages et centres de santé publiques, nous avons utilisé un modèle à plusieurs niveaux pour évaluer l'influence de l'individu, du ménage, de la communauté et du système de santé sur l'utilisation de la contraception moderne. Nous avons utilisé la régression logistique à effets mixtes pour mesurer l'autonomisation et ses sources socio-économiques (éducation, travail rémunéré), les influences intra-ménages sous forme d'une utilisatrice co-résidante et les facteurs structurels liés au système de santé. RéSULTATS: Moins de 5% des 14 032 femmes en âge de procréer utilisaient la contraception moderne au moment de l'enquête. Les femmes jouant un rôle dans la prise de décision, celles ayant une éducation formelle, un travail rémunéré, étaient plus susceptibles d'utiliser les contraceptifs modernes. Les femmes avaient trois fois plus de chances de faire la contraception moderne si elles vivaient dans un ménage avec une autre femme, généralement une coépouse, qui utilisait une méthode moderne. Comparées aux femmes les plus proches d'un centre de santé, celles qui vivaient entre 2 and 5 kilomètres étaient deux fois moins susceptibles d'utiliser un contraceptif moderne et celles entre 5 and 10 étaient plus susceptibles dans un tiers des cas. CONCLUSIONS: Malgré une faible disponibilité des services dans toute la zone d'étude, certaines femmes­même celles en cohabitation­ont pu surmonter les barrières à l'utilisation des contraceptifs modernes. Lors de la planification et de la mise en œuvre de stratégies pour élargir l'accès à la contraception, les décideurs et les praticiens devraient tenir compte de l'autonomisation des femmes, des réseaux sociaux, et de la conception du système de santé. Les systèmes de santé accessibles et efficaces devraient reconsidérer l'approche conventionnelle de la prestation de services communautaires, en prenant en compte la distance même à moins de 5 kilomètres.

The list experiment: An approach to measuring stigmatized behaviours related to sex-selective abortion.

Vietnam reports one of the highest levels of abortion globally and an increasingly skewed sex ratio at birth. Abortion and related stigmatized behaviours are notoriously difficult to measure, yet understanding women's ability and willingness to engage in sex selection is of interest to demographers and policymakers alike. We piloted the list experiment, an indirect questioning method, to estimate the prevalence of prenatal sex determination and sex-selective abortion. Respondents reported the total number of items they had engaged in from a list, reducing non-response and incentives to under-report. Among 900 women sampled at two hospitals in Hanoi, we estimated a high prevalence of prenatal sex determination. We found a low prevalence of sex-selective abortion, but higher prevalence among specific parity and children's sex composition subgroups. Responses to knowledge and attitudinal questions underscored women's perceived stigma around sex-selective abortion, suggesting the list experiment is a potentially useful tool for studying son preference.

Referral patterns, delays, and equity in access to advanced paediatric emergency care in Vietnam.

BACKGROUND: Quality emergency care is a critical component of a well-functioning health system. However, severely ill children often face barriers to timely, appropriate care in less-developed health systems. Such barriers disproportionately affect poorer children, and may be particularly acute when children seek advanced emergency care. We examine predictors of increased acuity and patient outcomes at a tertiary paediatric emergency department to identify barriers to advanced emergency care among children. METHODS: We analysed a sample of 557 children admitted to a paediatric referral hospital in Hanoi, Vietnam. We examined associations between socio-demographic and facility characteristics, referrals and transfers, and patient outcomes. We used generalized ordered logistic regression to examine predictors of increased acuity on arrival. RESULTS: Most children accessing advanced emergency care were under two years of age (68.4%). Pneumonia was the most prevalent diagnosis (23.7%). Children referred from lower-level facilities experienced higher acuity on arrival (p = .000), were more likely to be admitted to an ICU (p = .000), and were more likely to die during hospitalization (p = .009). The poorest children [OR = 4.98, (1.82-13.61)], and children entering care at provincial hospitals [OR = 3.66, (2.39-5.63)] and other lower-level facilities [OR = 3.24, (1.78-5.88)] had significantly higher odds of increased acuity on arrival. CONCLUSIONS: The poorest children, who were more likely to enter care at lower-level facilities, were especially disadvantaged. While delays in entry to care were not predictive of acuity, children referred to tertiary care from lower-level facilities experienced worse outcomes. Improvements in triage, stabilization, and referral linkages at all levels should reduce within-system delays, increasing timely access to advanced emergency care for all children.

The List Experiment for Measuring Abortion: What We Know and What We Need.

Measuring abortion incidence and prevalence is often difficult because of under-reporting and other biases, complicated research designs, and other issues. Recently, family planning researchers have introduced a new method called the list experiment, adopted from political science and economics, to measure abortion. Three completed studies and at least four studies currently underway use this method to measure abortion in several countries. We discuss the lessons learned from completed studies, when the list experiment may and may not be appropriate, and open questions regarding the use of the list experiment for abortion research. This method has the potential to improve measures of abortion prevalence and incidence, which could translate to better-informed interventions to increase abortion access and reduce unmet need for family planning. Future research should further clarify the advantages and limitations of the list experiment for measuring abortion.

Women's empowerment and experiences of mistreatment during childbirth in facilities in Lucknow, India: results from a cross-sectional study.

BACKGROUND: Recent evidence has found widespread reports of women experiencing abuse, neglect, discrimination, and poor interpersonal care during childbirth around the globe. Empowerment may be a protective mechanism for women against facility mistreatment during childbirth. The majority of previous research on mistreatment during childbirth has been qualitative in nature. METHODS: In this analysis, we use quantitative data from 392 women who recently gave birth in a facility in the slums of Lucknow, India, to explore whether measures of women's empowerment are associated with their experiences of mistreatment at their last childbirth. We use the Gender Equitable Men (GEM) scale to measure women's views of gender equality. RESULTS: We find that women who had more equitable views about the role of women were less likely to report experiencing mistreatment during childbirth. These findings suggest that dimensions of women's empowerment related to social norms about women's value and role are associated with experiences of mistreatment during childbirth. CONCLUSIONS: This expands our understanding of empowerment and women's health, and also suggests that the GEM scale can be used to measure certain domains of empowerment from a women's perspective in this setting.

The role of drug vendors in improving basic health-care services in Nigeria.

OBJECTIVE: To characterize patent and proprietary medicine vendors and shops in Nigeria and to assess their ability to help improve access to high-quality, primary health-care services. METHODS: In 2013 and 2014, a census of patent and proprietary medicine shops in 16 states of Nigeria was carried out to determine: (i) the size and coverage of the sector; (ii) the basic characteristics of shops and their staff; and (iii) the range of products stocked for priority health services, particularly for malaria, diarrhoea and family planning. The influence of the medical training of people in charge of the shops on the health-care products stocked and registration with official bodies was assessed by regression analysis. FINDINGS: The number of shops per 100,000 population was higher in southern than in northern states, but the average percentage of people in charge with medical training across local government areas was higher in northern states: 52.6% versus 29.7% in southern states. Shops headed by a person with medical training were significantly more likely to stock artemisinin-based combination therapy, oral rehydration salts, zinc, injectable contraceptives and intrauterine contraceptive devices. However, these shops were less likely to be registered with the National Association of Patent and Proprietary Medicine Dealers and more likely to be registered with the regulatory body, the Pharmacist Council of Nigeria. CONCLUSION: Many patent and proprietary medicine vendors in Nigeria were medically trained. With additional training and oversight, they could help improve access to basic health-care services. Specifically, vendors with medical training could participate in task-shifting interventions.

Women's status and experiences of mistreatment during childbirth in Uttar Pradesh: a mixed methods study using cultural health capital theory.

BACKGROUND: Mistreatment of women in healthcare settings during childbirth has been gaining attention globally. Mistreatment during childbirth directly and indirectly affects health outcomes, patient satisfaction, and the likelihood of delivering in a facility currently or in the future. It is important that we study patients' reports of mistreatment and abuse to develop a deeper understanding of how it is perpetrated, its consequences, and to identify potential points of intervention. Patients' perception of the quality of care is dependent, not only on the content of care, but importantly, on women's expectations of care. METHODS: This study uses rich, mixed-methods data to explore women's characteristics and experiences of mistreatment during childbirth among slum-resident women in Uttar Pradesh, India. To understand the ways in which women's social and cultural factors influence their expectations of care and consequently their perceptions of respectful care, we adopt a Cultural Health Capital (CHC) framework. The quantitative sample includes 392 women, and the qualitative sample includes 26 women. RESULTS: Quantitative results suggest high levels of mistreatment (over 57 % of women reported any form of mistreatment). Qualitative findings suggest that lack of cultural health capital disadvantages patients in their patient-provider relationships, and that women use resources to improve care they receive. Participants articulated how providers set expectations and norms regarding behaviors in facilities; patients with lower social standing may not always understand standard practices and are likely to suffer poor health outcomes as a result. Of importance, however, patients also blame themselves for their own lack of knowledge. CONCLUSIONS: Lack of cultural health capital disadvantages women during delivery care in India. Providers set expectations and norms around behaviors during delivery, while women are often misinformed and may have low expectations of care.

Management of paediatric illnesses by patent and proprietary medicine vendors in Nigeria.

BACKGROUND: In Nigeria and elsewhere, informal drug sellers, or patent and proprietary medicine vendors (PPMVs), are a common source of care for children with malaria, diarrhoea, and pneumonia. However, their knowledge and stocking of recommended treatments for these common childhood illnesses are not well understood. METHODS: A census of PPMV shops was conducted in Kogi and Kwara states. A shop survey was conducted on a subset of 250 shops. Multivariate regression analysis was used to assess associations between shop worker characteristics and (1) knowledge of optimal treatments for malaria, diarrhoea, and pneumonia, and (2) stocking of essential medicines to treat these illnesses. RESULTS: From the census, 89.9% of shops stocked oral rehydration solution (ORS), while 61.1% of shops stocked artemisinin-based combination therapies and 72.2% of shops stocked amoxicillin. Stocking patterns varied by state, urban/rural location, and according to whether or not the shop was headed by someone with formal health training (e.g. having a professional health education degree). In multivariate analyses, selling drugs wholesale and participating in any training in the past year was associated with a higher likelihood of naming the correct treatment for malaria, and having formal health training was associated with stocking ORS. However, few other PPMV characteristics were predictive of correct knowledge of optimal treatments and stocking behaviour. CONCLUSION: Many PPMVs lack the knowledge and tools to properly treat common childhood illnesses. PPMV knowledge and selling of essential medicines for these illnesses should be strengthened to improve child health in Nigeria.

Care-seeking at patent and proprietary medicine vendors in Nigeria.

BACKGROUND: To achieve health development goals, policymakers are increasingly focused on improving primary care in low- and middle-income countries, and private sector drug retailers offer one channel through which basic services may be delivered. In Nigeria, patent and proprietary medicine vendors (PPMVs) serve as a main source of medications, but little is known about their clientele or how care is sought at PPMVs for common illnesses. We explore differences in care-seeking at PPMV shops based on the most commonly reported symptoms. METHODS: In Kogi and Kwara states, Nigeria, 250 PPMV shop workers and 2,359 customers purchasing drugs were surveyed, and each worker-customer interaction was observed. Multivariate regression analysis was used to assess the association of commonly reported symptoms with care-seeking behavior prior to attending the shop and while interacting with the provider at the shop. RESULTS: Most customers sought care for headache (30.5 %), fever (22.9 %), cough/cold (18.1 %), or diarrhea (8.4 %). Customers with fever were more likely to report being diagnosed by a formally trained person, to have discussed the illness with and be examined by the shop worker, and have more difficulty paying. In contrast, customers with headache symptoms were less likely to experience these outcomes and spent less money purchasing drugs. Those reporting cough or cold symptoms were less likely to have been diagnosed by a formally trained person, waited longer before visiting the PPMV shop, and were more likely to discuss the illness with the shop worker, but were less likely to be examined or to recommend the purchased drug themselves. If a sick child was brought to the shop, a discussion of the illness and an exam were more likely and more money was spent on drugs. CONCLUSIONS: Because care-seeking behaviors vary by symptoms and the sick person's age, PPMVs should be trained to treat common illnesses for which customers are unlikely to seek a formal medical consultation. Interventions aimed at improving primary care need to target the places where most people access care, and equip PPMV workers with knowledge and tools to provide basic services.

Factors influencing pregnancy care and institutional delivery in rural Mali: a secondary baseline analysis of a cluster-randomised trial.

OBJECTIVE: The vast majority of the 300 000 pregnancy-related deaths every year occur in South Asia and sub-Saharan Africa. Increased access to quality antepartum and intrapartum care can reduce pregnancy-related morbidity and mortality worldwide. We used a population-based cross-sectional cohort design to: (1) examine the sociodemographic risk factors and structural barriers associated with pregnancy care-seeking and institutional delivery, and (2) investigate the influence of residential distance to the nearest primary health facility in a rural population in Mali. METHODS: A baseline household survey of Malian women aged 15-49 years was conducted between December 2016 and January 2017, and those who delivereda baby in the 5 years preceding the survey were included. This study leverages the baseline survey data from a cluster-randomised controlled trial to conduct a secondary analysis. The outcomes were percentage of women who received any antenatal care (ANC) and institutional delivery; total number of ANC visits; four or more ANC visits; first ANC visit in the first trimester. RESULTS: Of the 8575 women in the study, two-thirds received any ANC in their last pregnancy, one in 10 had four or more ANC visits and among those that received any ANC, about one-quarter received it in the first trimester. For every kilometre increase in distance to the nearest facility, the likelihood of the outcomes reduced by 5 percentage points (0.95; 95% CI 0.91 to 0.98) for any ANC; 4 percentage points (0.96; 95% CI 0.94 to 0.98) for an additional ANC visit; 10 percentage points (0.90; 95% CI 0.86 to 0.95) for four or more ANC visits; 6 percentage points (0.94; 95% CI 0.94 to 0.98) for first ANC in the first trimester. In addition, there was a 35 percentage points (0.65; 95% CI 0.56 to 0.76) decrease in likelihood of institutional delivery if the residence was within 6.5 km to the nearest facility, beyond which there was no association with the place of delivery. We also found evidence of increase in likelihood of receiving any ANC care and its intensity increased with having some education or owning a business. CONCLUSION: The findings suggest that education, occupation and distance are important determinants of pregnancy and delivery care in a rural Malian context. TRIAL REGISTRATION NUMBER: NCT02694055.

Community case management to accelerate access to healthcare in Mali: A realist process evaluation nested within a cluster randomised trial.

The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional Community Health Workers (CHWs), and upgraded primary health centres (PHCs)-and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-five mortality halved, over three years compared to baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-five mortality, compared to the control arm. We aimed to explain these results by examining implementation, mechanisms, and context in both arms. We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers, and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine, and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust, and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs, and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.

The relationship between extended kin resources and children's healthcare utilization: An analysis of family networks.

Extended kin serve as key sources of financial, social, and instrumental support for young children and their families. In impoverished settings, the ability to rely on extended kin for investments, information, and/or in-kind support to access health care when needed may be particularly important in buffering children against poor health outcomes and mortality. Given data limitations, little is known about how specific social and economic characteristics of extended kin shape children's healthcare access and health outcomes. We use detailed household survey data from rural Mali, where related households co-reside in extended family compounds, a living arrangement typical across West Africa and other settings globally. We examine how specific social and economic characteristics of extended kin residing in close geographic proximity affect children's healthcare utilization in a sample of 3948 children under five years of age reporting illness in the preceding two weeks. Absolute wealth among extended family networks is associated with utilization of any healthcare and healthcare with a formally-trained provider, an indicator of health service quality (adjusted odds ratio (aOR) = 1.29, 95% CI 1.03, 1.63; aOR = 1.49, 95% CI 1.17, 1.90, respectively). Net of maternal characteristics, educational attainment and decision-making power of extended female relatives of reproductive age in the concession network are powerful predictors of any healthcare utilization (aOR = 1.69, 95% CI 1.18, 2.42; aOR = 1.59, 95% CI 1.27, 1.99, respectively). Labor force participation among extended relatives is not associated with healthcare utilization outcomes among young children, while maternal labor force participation is predictive of utilization of any care and care with a formally-trained provider (aOR = 1.41, 95% CI 1.12, 1.78; aOR = 1.36, 95% CI 1.11, 1.67, respectively). These findings underscore the importance of financial and instrumental support from extended family and illuminate the ways extended families work together to return young children to health in the face of resource constraints.

The association between timing in pregnancy of drought and excess rainfall, infant sex, and birthweight: Evidence from Nepal.

Background: Past research on the impact of climatic events, such as drought, on birth outcomes has primarily been focused in Africa, with less research in South Asia, including Nepal. Existing evidence has generally found that drought impacts birthweight and infant sex, with differences by trimester. Additionally, less research has looked at the impact of excess rain on birth outcomes or focused on the impact of rainfall extremes in the preconception period. Using data from a large demographic surveillance system in Nepal, combined with a novel measure of drought/excess rainfall, we explore the impact of these on birthweight by time in pregnancy. Methods: Using survey data from the 2016 to 2019 Chitwan Valley Study in rural Nepal combined with data from Climate Hazards InfraRed Precipitation with Station, we explored the association between excess rainfall and drought and birthweight, looking at exposure in the preconception period, and by trimester of pregnancy. We also explore the impact of excess rainfall and drought on infant sex and delivery with a skilled birth attendant. We used multilevel regressions and explored for effect modification by maternal age. Results: Drought in the first trimester is associated with lower birthweight (ß = -82.9 g; 95% confidence interval [CI] = 164.7, -1.2) and drought in the preconception period with a high likelihood of having a male (odds ratio [OR] = 1.41; 95% CI = 1.01, 2.01). Excess rainfall in the first trimester is associated with high birthweight (ß = 111.6 g; 95% CI = 20.5, 202.7) and higher odds of having a male (OR = 1.48; 95% CI = 1.02, 2.16), and in the third trimester with higher odds of low birth weight (OR = 2.50; 95% CI = 1.40, 4.45). Conclusions: Increasing rainfall extremes will likely impact birth outcomes and could have implications for sex ratios at birth.

Contraceptive use by number of living children in Ghana: Evidence from the 2017 maternal health survey.

BACKGROUND: There is a significant literature describing the link between parity and contraceptive use. However, there is limited knowledge about the disaggregation by parity of the type of contraceptives. In this study, we describe the use of contraceptives by parity among women of reproductive age in Ghana, focusing on use of highly effective methods (injection, pill, intrauterine device, implant, and sterilization). METHODS: Using the 2017 Ghana Maternal Health Survey, a nationally-representative cross-sectional household survey, we describe contraceptive method use by number of living children among sexually active women of reproductive age. We then estimated predictors of use of highly effective contraception in a multilevel logistic regression model. RESULTS: Most women in this survey are not using any method of contraception, although this varies by whether or not they have begun childbearing. Contraceptive method use varies by number of living children. Before having children, natural (periodic abstinence and withdrawal) and episodic (condoms) methods dominate. Once a woman has one living child, method preference changes to injectables and implants. Factors associated with using a highly effective method of contraception are: having >3 children, being in a relationship, having had an abortion, being younger than age 30, and having had sexual intercourse within days of answering the survey (p < .001 for all). CONCLUSION: In this analysis, the number of living children a woman has, her age, and timing of last intercourse are the most significant predictors of using a highly effective method of contraception. However, the majority of participants in this study report not using any method of contraception to avoid unwanted pregnancies. Future research that attempts to unpack the disconnect between not wanting to become pregnant and not using contraception is warranted.

Effects of proactive vs fixed community health care delivery on child health and access to care: a cluster randomised trial secondary endpoint analysis.

Background: Professional community health workers (CHWs) can help achieve universal health coverage, although evidence gaps remain on how to optimise CHW service delivery. We conducted an unblinded, parallel, cluster randomised trial in rural Mali to determine whether proactive CHW delivery reduced mortality and improved access to health care among children under five years, compared to passive delivery. Here we report the secondary access endpoints. Methods: Beginning from 26-28 February 2017, 137 village-clusters were offered care by CHWs embedded in communities who were trained, paid, supervised, and integrated into a reinforced public-sector health system that did not charge user fees. Clusters were randomised (stratified on primary health centre catchment and distance) to care during CHWs during door-to-door home visits (intervention) or based at a fixed village site (control). We measured outcomes at baseline, 12-, 24-, and 36-month time points with surveys administered to all resident women aged 15-49 years. We used logistic regression with cluster-level random effects to estimate intention-to-treat and per-protocol effects over time on prompt (24-hour) treatment within the health sector. Results: Follow-up surveys between February 2018 and April 2020 generated 20 105 child-year observations. Across arms, prompt health sector treatment more than doubled compared to baseline. At 12 months, children in intervention clusters had 22% higher odds of receiving prompt health sector treatment than those in control (cluster-specific adjusted odds ratio (aOR) = 1.22; 95% confidence interval (CI) = 1.06, 1.41, P = 0.005), or 4.7 percentage points higher (adjusted risk difference (aRD) = 0.047; 95% CI = 0.014, 0.080). We found no evidence of an effect at 24 or 36 months. Conclusions: CHW-led health system redesign likely drove the 2-fold increase in rapid child access to care. In this context, proactive home visits further improved early access during the first year but waned afterwards. Registration: ClinicalTrials.gov NCT02694055.

Effect of community health worker home visits on antenatal care and institutional delivery: an analysis of secondary outcomes from a cluster randomised trial in Mali.

INTRODUCTION: Though community health workers (CHWs) have improved access to antenatal care (ANC) and institutional delivery in different settings, it is unclear what package and delivery strategy maximises impact. METHODS: This study reports a secondary aim of the Proactive Community Case Management cluster randomised trial, conducted between December 2016 and April 2020 in Mali. It evaluated whether proactive home visits can improve ANC access at a population level compared with passive site-based care. 137 unique village clusters, covering the entire study area, were stratified by health catchment area and distance to the nearest primary health centre. Within each stratum, clusters were randomly assigned to intervention or control arm. CHWs in intervention clusters proactively visited all homes to provide care. In the control clusters, CHWs provided the same services at their fixed community health post to care-seeking patients. Pregnant women 15-49 years old were enrolled in a series of community-based and facility-based visits. We analysed individual-level annual survey data from baseline and 24-month and 36-month follow-up for the secondary outcomes of ANC and institutional delivery, complemented with CHW monitoring data during the trial period. We compared outcomes between: (1) the intervention and control arms, and (2) the intervention period and baseline. RESULTS: With 2576 and 2536 pregnancies from 66 and 65 clusters in the intervention and control arms, respectively, the estimated risk ratios for receiving any ANC was 1.05 (95% CI 1.02 to 1.07), four or more ANC visits was 1.25 (95% CI 1.08 to 1.43) and ANC initiated in the first trimester was 1.11 (95% CI 1.02 to 1.19), relative to the controls; no differences in institutional delivery were found. However, both arms achieved large improvements in institutional delivery, compared with baseline. Monitoring data show that 19% and 2% of registered pregnancies received at least eight ANC contacts in the intervention and control arms, respectively. Six clusters, three from each arm had to be dropped in the last 2 years of the trial. CONCLUSIONS: Proactive home visits increased ANC and the number of antenatal contacts at the clinic and community levels. ANC and institutional delivery can be increased when provided without fees from professional CHWs in upgraded primary care clinics. TRIAL REGISTRATION NUMBER: NCT02694055.