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

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

Exploring association between place of delivery and newborn care with early-neonatal mortality in Bangladesh.

OBJECTIVE: Bangladesh achieved the fourth Millennium Development Goal well ahead of schedule, with a significant reduction in under-5 mortality between 1990 and 2015. However, the reduction in neonatal mortality has been stagnant in recent years. The purpose of this study is to explore the association between place of delivery and newborn care with early neonatal mortality (ENNM), which represents more than 80% of total neonatal mortality in Bangladesh. METHODS: In this study, 2014 Bangladesh Demographic and Health Survey data were used to assess early neonatal survival in children born in the three years preceding the survey. The roles of place of the delivery and newborn care in ENNM were examined using multivariable logistic regression models adjusted for clustering and relevant socio-economic, pregnancy, and newborn characteristics. RESULTS: Between 2012 and 2014, there were 4,624 deliveries in 17,863 sampled households, 39% of which were delivered at health facilities. The estimated early neonatal mortality rate during this period was 15 deaths per 1,000 live births. We found that newborns who had received at least 3 components of essential newborn care (ENC) were 56% less likely to die during the first seven days of their lives compared to their counterparts who received 0-2 components of ENC (aOR: 0.44; 95% CI: 0.24-0.81). In addition, newborns who had received any postnatal care (PNC) were 68% less likely to die in the early neonatal period than those who had not received any PNC (aOR: 0.32; 95% CI: 0.16-0.64). Facility delivery was not significantly associated with the risk of early newborn death in any of the models. CONCLUSION: Our study findings highlight the importance of newborn and postnatal care in preventing early neonatal deaths. Further, findings suggest that increasing the proportion of women who give birth in a healthcare facility is not sufficient to reduce ENNM by itself; to realize the theoretical potential of facility delivery to avert neonatal deaths, we must also ensure quality of care during delivery, guarantee all components of ENC, and provide high-quality early PNC. Therefore, sustained efforts to expand access to high-quality ENC and PNC are needed in health facilities, particularly in facilities serving low-income populations.

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

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

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

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

Women's Perspectives on Contraceptive-Induced Amenorrhea in Burkina Faso and Uganda.

CONTEXT: Women's concerns about contraceptive-induced menstrual changes can lead to method discontinuation and nonuse, contributing to unmet need for contraception. Research on women's perceptions of amenorrhea related to longer acting methods and in low-income countries is limited. METHODS: Data were from nationally representative household surveys and focus group discussions with women of reproductive age conducted in Burkina Faso and Uganda in 2016-2017. Bivariate cross-tabulations and multivariate logistic regression analyses were used to examine sociodemographic and reproductive characteristics associated with women's attitudes about contraceptive-induced amenorrhea (n=2,673 for Burkina Faso and 2,281 for Uganda); menstrual health determinants were also examined for Burkina Faso. Qualitative data from focus group discussions were analyzed to understand reasons behind women's attitudes and how they influence contraceptive decision making. RESULTS: Sixty-five percent of women in Burkina Faso and 40% in Uganda reported they would choose a method that caused amenorrhea during use. In Burkina Faso, the predicted probability of accepting amenorrhea was higher for women aged 15-19 (compared with older women), living in rural areas, married and cohabiting (compared with never married), currently using a contraceptive method (compared with never users) and from Mossi households (compared with Gourmantché); menstrual health practices were not associated with amenorrhea acceptability. In Uganda, the least wealthy women had the highest predicted probability of accepting amenorrhea (51%). Qualitative analysis revealed a variety of reasons for women's attitudes about amenorrhea and differences by country, but the relationship between these attitudes and contraceptive decision making was similar across countries. CONCLUSIONS: Addressing misconceptions about contraception and menstruation may result in more informed method decision making.

Contexto: Las preocupaciones de las mujeres acerca de los cambios menstruales inducidos por los anticonceptivos pueden conducir a la interrupción y el abandono del método, lo cual contribuye a la necesidad insatisfecha de anticoncepción. La investigación sobre la percepción de la amenorrea por parte de las mujeres sobre los métodos de acción más prolongada y en los países de bajos ingresos es limitada. Métodos: Los datos provienen de encuestas representativas de hogares a nivel nacional y discusiones de grupos focales con mujeres en edad reproductiva realizadas en Burkina Faso y Uganda entre 2016 y 2017. Se utilizaron tabulaciones cruzadas bivariadas y análisis de regresión logística multivariada para examinar las características sociodemográficas y reproductivas asociadas con las actitudes de las mujeres con respecto a la amenorrea inducida por anticonceptivos (n = 2,673 para Burkina Faso y 2,281 para Uganda); también se examinaron los determinantes de la salud menstrual en Burkina Faso. Se analizaron datos cualitativos de discusiones de los grupos focales para comprender las razones que determinan las actitudes de las mujeres y cómo influyen en la toma de decisiones sobre anticonceptivos. Resultados: El 65% de las mujeres en Burkina Faso y el 40% en Uganda informaron que elegirían un método que les causara amenorrea durante su uso. En Burkina Faso, la probabilidad predicha de aceptar la amenorrea fue mayor para las mujeres de 15 a 19 años (en comparación con las mujeres mayores), que vivían en zonas rurales, que estaban casadas y cohabitaban (en comparación con las que nunca se habían casado), que actualmente usaban un método anticonceptivo (en comparación con las mujeres que nunca lo habían usado) y de hogares Mossi (en comparación con Gourmantché). Las prácticas de salud menstrual no se asociaron con la aceptabilidad de la amenorrea. En Uganda, las mujeres menos ricas tuvieron la probabilidad más alta de aceptar amenorrea (51%). El análisis cualitativo reveló una variedad de razones con respecto a las actitudes de las mujeres sobre la amenorrea y las diferencias por país, pero la relación entre estas actitudes y la toma de decisiones sobre anticonceptivos fue similar en todos los países. Conclusiones: El abordaje de los conceptos erróneos sobre la anticoncepción y la menstruación podría resultar en una toma de decisiones más informada sobre los métodos anticonceptivos.

Contexte: Les inquiétudes des femmes à l'égard des changements menstruels induits par la contraception peuvent conduire à l'arrêt ou à la non-utilisation de la méthode et contribuer ainsi au besoin non satisfait de contraception. La recherche sur les perceptions des femmes de l'aménorrhée liée aux méthodes à durée d'action prolongée et dans les pays à revenu faible est limitée. Méthodes: Les données sont extraites d'enquêtes de ménage nationalement représentatives et de discussions de groupe avec des femmes en âge de procréer, menées au Burkina Faso et en Ouganda en 2016-2017. Les caractéristiques sociodémographiques et reproductives associées aux attitudes des femmes concernant l'aménorrhée induite par la contraception (n=2 673 pour le Burkina Faso et 2 281 pour l'Ouganda) ont été examinées en tableaux croisés bivariés et par analyses de régression logistique multivariée. Les déterminants de la santé menstruelle ont aussi été examinés pour le Burkina Faso. L'analyse des données qualitatives obtenues des discussions de groupe a permis de cerner les raisons à la base des attitudes des femmes et leur influence sur les décisions contraceptives prises. Résultats: Soixante-cinq pour cent des femmes burkinabè et 40% de leurs homologues ougandaises ont déclaré qu'elles choisiraient une méthode dont la pratique causerait l'aménorrhée. Au Burkina Faso, la probabilité prédite d'acceptation de l'aménorrhée s'est avérée supérieure pour les femmes âgées de 15 à 19 ans (par rapport à leurs aînées), vivant en milieu rural, mariées ou en union (par rapport à celles qui n'avaient jamais été mariées), pratiquant actuellement la contraception (par rapport à celles qui ne l'avaient jamais pratiquée) et d'origine Mossi (par rapport à Gourmantché). Les pratiques de santé menstruelle n'étaient pas associées à l'acceptabilité de l'aménorrhée. En Ouganda, les femmes les moins riches sont associées à la plus haute probabilité prédite d'acceptation de l'aménorrhée (51%). L'analyse qualitative a révélé diverses raisons à la base des attitudes des femmes à l'égard de l'aménorrhée ainsi que certaines différences suivant le pays, mais la relation entre ces attitudes et la décision contraceptive s'est avérée similaire dans les deux pays. Conclusions: La résolution des idées fausses concernant la contraception et la menstruation pourrait conduire à une prise de décision mieux éclairée dans le choix des méthodes.

Understanding healthcare provider absenteeism in Kenya: a qualitative analysis.

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

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

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

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

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

Evaluating the impact of social support services on tuberculosis treatment default in Ukraine.

Ukraine is among the top 20 highest drug-resistant tuberculosis burden countries in the world. Driving the high drug-resistant tuberculosis rates is an unchecked treatment default rate. This evaluation measures the effect of social support provided to tuberculosis patients at risk of defaulting on treatment during outpatient treatment. Five tuberculosis patient cohorts, served in three oblasts from 2011 and 2012, were constructed from medical records to compare risk factors for default, receipt of social services, and treatment outcome. Regression analyses were used to identify risk factors predictive of treatment default and to estimate the impact of the social support program on treatment default, controlling for risk, disease status, and demographics. In 2012, tuberculosis patients receiving social support in Ukraine reduced their probability of defaulting on continuation treatment by 10 percentage points compared to high-risk patients who did not receive social support in 2012 or 2011. Treatment success rates for the high-risk patients receiving social support were comparable to the low-risk cohorts and significantly improved over the high-risk comparison cohorts. Further research is recommended to quantify the costs and benefits for scaling-up social support services, evaluate social support program fidelity, identify which populations respond best to select services, and what barriers might still exist to achieve better adherence. With that information, tailoring programs to most effectively reach and serve clients in a patient-centered approach may reap substantial rewards for Ukraine.

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

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

Women's television watching and reproductive health behavior in Bangladesh.

Bangladesh has made significant social, economic, and health progress in recent decades, yet many reproductive health indicators remain weak. Access to television (TV) is increasing rapidly and provides a potential mechanism for influencing health behavior. We present a conceptual framework for the influence of different types of TV exposure on individual's aspirations and health behavior through the mechanisms of observational learning and ideational change. We analyze data from two large national surveys conducted in 2010 and 2011 to examine the association between women's TV watching and five reproductive health behaviors controlling for the effects of observed confounders. We find that TV watchers are significantly more likely to desire fewer children, are more likely to use contraceptives, and are less likely to have a birth in the two years before the survey. They are more likely to seek at least four antenatal care visits and to utilize a skilled birth attendant. Consequently, continued increase in the reach of TV and associated growth in TV viewing is potentially an important driver of health behaviors in the country.

The Mayer Hashi Large-Scale Program to Increase Use of Long-Acting Reversible Contraceptives and Permanent Methods in Bangladesh: Explaining the Disappointing Results. An Outcome and Process Evaluation.

BACKGROUND: Bangladesh has achieved a low total fertility rate of 2.3. Two-thirds of currently married women of reproductive age (CMWRA) want to limit fertility, and many women achieve their desired fertility before age 30. The incidence of unintended pregnancy and pregnancy termination is high, however. Long-acting reversible contraceptives (LARCs), consisting of the intrauterine device and implant, and permanent methods (PM), including female sterilization and vasectomy, offer several advantages in this situation, but only 8% of CMWRA or 13% of method users use these methods. PROGRAM: The Mayer Hashi (MH) program (2009-2013) aimed to improve access to and the quality of LARC/PM services in 21 of the 64 districts in Bangladesh. It was grounded in the SEED (supply-enabling environment-demand) Programming Model. Supply improvements addressed provider knowledge and skills, system strengthening, and logistics. Creating an enabling environment involved holding workshops with local and community leaders, including religious leaders, to encourage them to help promote demand for LARCs and PMs and overcome cultural barriers. Demand promotion encompassed training of providers in counseling, distribution of behavior change communication materials in the community and in facilities, and community mobilization. METHODS: We selected 6 MH program districts and 3 nonprogram districts to evaluate the program. We used a before-after and intervention-comparison design to measure the changes in key contraceptive behavior outcomes, and we used a difference-in-differences (DID) specification with comparison to the nonprogram districts to capture the impact of the program. In addition to the outcome evaluation, we considered intermediate indicators that measured the processes through which the interventions were expected to affect the use of LARCs and PMs. RESULTS: The use of LARCs/PMs among CMWRA increased between 2010 and 2013 in both program (from 5.3% to 7.5%) and nonprogram (from 5.0% to 8.9%) districts, but the rate of change was higher in the nonprogram districts. Client-provider interaction and exposure to LARCs/PMs were lower in the program than nonprogram districts, and the MH program districts had higher vacancies of key providers than the nonprogram areas, both indications of a more difficult health system environment. CONCLUSION: The weaknesses in the health system in the MH districts apparently undermined the effectiveness of the program. More attention to system weaknesses, such as additional supportive supervision for providers, might have improved the outcome.

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

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

Quality of Care and Contraceptive Use in Urban Kenya.

CONTEXT: Family planning is highly beneficial to women's overall health, particularly in developing countries. Yet, in much of Sub-Saharan Africa, contraceptive prevalence remains low and unmet need for family planning remains high. It is hypothesized that the poor quality of family planning service provision in many low-income settings is a barrier to contraceptive use, but this hypothesis has not been rigorously tested. METHODS: Survey data from 3,990 women were used to investigate whether family planning service quality was associated with current modern contraceptive use in five cities in Kenya in 2010. In addition, audits of selected facilities and service provider interviews were conducted in 260 facilities, and exit interviews were conducted with family planning clients at 126 high-volume clinics. Individual- and facility-level data were linked according to the source of the woman's current method or other health service. Binomial regression was used to estimate adjusted prevalence ratios, and robust standard errors were used to account for clustering of observations within facilities. RESULTS: Sixty-five percent of women reported currently using a modern contraceptive method. Provider's solicitation of clients' method preferences, assistance with method selection, provision of information on side effects and good treatment of clients were positively associated with current modern contraceptive use (prevalence ratios, 1.1 each); associations were often stronger among younger and less educated women. CONCLUSION: Efforts to assist with method selection and to improve the content of contraceptive counseling and treatment of clients by providers have the potential to increase contraceptive use in urban Kenya.

Measuring Maternal Mortality: Three Case Studies Using Verbal Autopsy with Different Platforms.

BACKGROUND: Accurate measurement of maternal mortality is needed to develop a greater understanding of the scale of the problem, to increase effectiveness of program planning and targeting, and to track progress. In the absence of good quality vital statistics, interim methods are used to measure maternal mortality. The purpose of this study is to document experience with three community-based interim methods that measure maternal mortality using verbal autopsy. METHODS: This study uses a post-census mortality survey, a sample vital registration with verbal autopsy, and a large-scale household survey to summarize the measures of maternal mortality obtained from these three platforms, compares and contrasts the different methodologies employed, and evaluates strengths and weaknesses of each approach. Included is also a discussion of issues related to death identification and classification, estimating maternal mortality ratios and rates, sample sizes and periodicity of estimates, data quality, and cost. RESULTS: The sample sizes vary considerably between the three data sources and the number of maternal deaths identified through each platform was small. The proportion of deaths to women of reproductive age that are maternal deaths ranged from 8.8% to 17.3%. The maternal mortality rate was estimable using two of the platforms while obtaining an estimate of the maternal mortality ratio was only possible using one of the platforms. The percentage of maternal deaths due to direct obstetric causes ranged from 45.2% to 80.4%. CONCLUSIONS: This study documents experiences applying standard verbal autopsy methods to estimate maternal mortality and confirms that verbal autopsy is a feasible method for collecting maternal mortality data. None of these interim methods are likely to be suitable for detecting short term changes in mortality due to prohibitive sample size requirements, and thus, comprehensive and continuous civil registration systems to provide high quality vital statistics are essential in the long-term.

Accuracy of standard measures of family planning service quality: findings from the simulated client method.

In the field of international family planning, quality of care as a reproductive right is widely endorsed, yet we lack validated data-collection instruments that can accurately assess quality in terms of its public health importance. This study, conducted within 19 public and private facilities in Kisumu, Kenya, used the simulated client method to test the validity of three standard data-collection instruments used in large-scale facility surveys: provider interviews, client interviews, and observation of client-provider interactions. Results found low specificity and low positive predictive values in each of the three instruments for a number of quality indicators, suggesting that the quality of care provided may be overestimated by traditional methods of measurement. Revised approaches to measuring family planning service quality may be needed to ensure accurate assessment of programs and to better inform quality-improvement interventions.

Geographically linking population and facility surveys: methodological considerations.

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

An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women?

Maternal health services continue to favour the wealthiest in lower and middle income countries. Debate about the potential of performance-based financing (PBF) to address these disparities continues. As PBF is adopted by countries, it is critical to understand the equity effects for maternal services. The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population. In Rwanda, PBF was designed to increase health service use, which was universally low. Paired districts were randomly assigned to intervention and control for PBF implementation. Using Rwanda's Demographic Health Survey data from 2005 (pre-intervention) and 2007-8 (post-intervention), a cluster-level panel dataset of 7899 women 15-49 years of age from intervention (4477) and control districts (3422) was created. The impact of PBF on reported use of facility deliveries, antenatal care (ANC) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects. Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women. The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts (P = 0.014), while no significant effects were noted for ANC visits or modern contraceptive use. Service use increased for intervention and control populations and across all wealth quintiles from 2005 to 2007, with no evidence that PBF was a pro-poor or a pro-rich strategy. Insurance remained a positive predictor of service use. This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services, such as facility deliveries, may improve service use overall. However, if the equity gap is extreme, then a PBF programme without equity targets will do little to alleviate disparities.

Physical and sexual abuse of wives in urban Bangladesh: husbands' reports.

Using data from 8,320 husbands'self reports for the 2006 Urban Health Survey, this article examines the prevalence of physical and sexual intimate partner violence (IPV) perpetrated by husbands against their wives in Bangladesh and identifies risk markers associated with such violence. Of the men included in the sample for this study, 55 percent reported perpetrating physical IPV against their wives at some point in their married lives, 23 percent reported perpetrating physical IPV in the past year, 20 percent reported ever perpetrating sexual IPV, and 60 percent reported ever perpetrating physical or sexual IPV. Bivariate analyses revealed that men residing in slums had a greater likelihood than those residing in nonslum areas and in district municipalities of perpetrating lifetime and past-year physical IPV, and any lifetime (physical or sexual) IPV. Lifetime sexual IPV prevalence, by contrast, was highest in district municipalities (26 percent), followed by slum (20 percent) and nonslum (17 percent) areas. Net of other factors, low socioeconomic levels were associated with men's increased likelihood of perpetrating IPV. Alcohol and drug use, sexually transmitted disease infection, poor mental health, and holding attitudes supportive of wife beating were predictive of IPV perpetration. These results suggest that IPV-prevention programs targeting men should consider spousal abuse, substance use, and sexual risk behaviors as social and public health problems and should also consider the sociocultural context within which men who abuse their partners are embedded.