Wealth-based inequality in the continuum of maternal health service utilisation in 16 sub-Saharan African countries.

BACKGROUND: Persistent inequalities in coverage of maternal health services in sub-Saharan Africa (SSA), a region home to two-thirds of global maternal deaths in 2017, poses a challenge for countries to achieve the Sustainable Development Goal (SDG) targets. This study assesses wealth-based inequalities in coverage of maternal continuum of care in 16 SSA countries with the objective of informing targeted policies to ensure maternal health equity in the region. METHODS: We conducted a secondary analysis of Demographic and Health Survey (DHS) data from 16 SSA countries (Angola, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Liberia, Malawi, Mali, Nigeria, Sierra Leone, South Africa, Tanzania, Uganda, and Zambia). A total of 133,709 women aged 15-49 years who reported a live birth in the five years preceding the survey were included. We defined and measured completion of maternal continuum of care as having had at least one antenatal care (ANC) visit, birth in a health facility, and postnatal care (PNC) by a skilled provider within two days of birth. We used concentration index analysis to measure wealth-based inequality in maternal continuum of care and conducted decomposition analysis to estimate the contributions of sociodemographic and obstetric factors to the observed inequality. RESULTS: The percentage of women who had 1) at least one ANC visit was lowest in Ethiopia (62.3%) and highest in Burundi (99.2%), 2) birth in a health facility was less than 50% in Ethiopia and Nigeria, and 3) PNC within two days was less than 50% in eight countries (Angola, Burundi, Ethiopia, Gambia, Guinea, Malawi, Nigeria, and Tanzania). Completion of maternal continuum of care was highest in South Africa (81.4%) and below 50% in nine of the 16 countries (Angola, Burundi, Ethiopia, Guinea, Malawi, Mali, Nigeria, Tanzania, and Uganda), the lowest being in Ethiopia (12.5%). There was pro-rich wealth-based inequality in maternal continuum of care in all 16 countries, the lowest in South Africa and Liberia (concentration index = 0.04) and the highest in Nigeria (concentration index = 0.34). Our decomposition analysis showed that in 15 of the 16 countries, wealth index was the largest contributor to inequality in primary maternal continuum of care. In Malawi, geographical region was the largest contributor. CONCLUSIONS: Addressing the coverage gap in maternal continuum of care in SSA using multidimensional and people-centred approaches remains a key strategy needed to realise the SDG3. The pro-rich wealth-based inequalities observed show that bespoke pro-poor or population-wide approaches are needed.

Assessing the quality of care for children attending health facilities: a systematic review of assessment tools.

INTRODUCTION: Assessing quality of healthcare is integral in determining progress towards equitable health outcomes worldwide. Using the WHO 'Standards for improving quality of care for children and young adolescents in health facilities' as a reference standard, we aimed to evaluate existing tools that assess quality of care for children. METHODS: We undertook a systematic literature review of publications/reports between 2008 and 2020 that reported use of quality of care assessment tools for children (<15 years) in health facilities. Identified tools were reviewed against the 40 quality statements and 510 quality measures from the WHO Standards to determine the extent each tool was consistent with the WHO Standards. The protocol was registered in PROSPERO ID: CRD42020175652. RESULTS: Nine assessment tools met inclusion criteria. Two hospital care tools developed by WHO-Europe and WHO-South-East Asia Offices had the most consistency with the WHO Standards, assessing 291 (57·1%) and 208 (40·8%) of the 510 quality measures, respectively. Remaining tools included between 33 (6·5%) and 206 (40·4%) of the 510 quality measures. The WHO-Europe tool was the only tool to assess all 40 quality statements. The most common quality measures absent were related to experience of care, particularly provision of educational, emotional and psychosocial support to children and families, and fulfilment of children's rights during care. CONCLUSION: Quality of care assessment tools for children in health facilities are missing some key elements highlighted by the WHO Standards. The WHO Standards are, however, extensive and applying all the quality measures in every setting may not be feasible. A consensus of key indicators to monitor the WHO Standards is required. Existing tools could be modified to include priority indicators to strengthen progress reporting towards delivering quality health services for children. In doing so, a balance between comprehensiveness and practical utility is needed. PROSPERO REGISTRATION NUMBER: CRD42020175652.

Monitoring caesarean births using the Robson ten group classification system: A cross-sectional survey of private for-profit facilities in urban Bangladesh.

BACKGROUND: Globally, Caesarean section (CS) rates are mounting and currently exceed the safe upper limit of 15%. Monitoring CS rates using clinical indications and obstetric sub-group analysis could confirm that women in need have been served. In Bangladesh, the reported CS rate was 31% in 2016, and almost twice that rate in urban settings. Delivering in the private healthcare sector was a strong determinant. This study uses Robson Ten Group Classification System (TGCS) to report CS rates in urban Bangladesh. The clinical causes and determining factors for CS births have also been examined. METHODS: This record linkage cross-sectional survey was undertaken in 34 urban for-profit private hospitals having CS facilities during the period June to August 2015. Data were supplied by inpatient case records and operation theatre registers. Descriptive analyses were performed to calculate the relative size of each group; the group-specific CS rate, and group contribution to total CS and overall CS rate. CS indications were grouped into eleven categories using ICD 10 codes. Binary logistic regression was performed to explore the determinants of CS. RESULTS: Out of 1307 births, delivery by CS occurred in 1077 (82%). Three obstetric groups contributed the most to overall CS rate: previous CS (24%), preterm (23%) and term elective groups (22%). The major clinical indications for CS were previous CS (35%), prolonged and obstructed labor (15%), fetal distress (11%) and amniotic fluid disorder (11%). Multiple gestation, non-cephalic presentation, previous bad obstetric history were positive predictors while oxytocin used for labour induction and increased parity were negative predictors of CS. CONCLUSIONS: As the first ever study in urban private for-profit health facilities in Bangladesh, this study usefully identifies the burden of CS and where to intervene. Engagement of multiple stakeholders including the private sector is crucial in planning effective strategies for safe reduction of CS.

Perceptions of appropriate treatment among the informal allopathic providers: insights from a qualitative study in two peri-urban areas in Bangladesh.

BACKGROUND: How the informal providers deliver health services are not well understood in Bangladesh. However, their practices are often considered inappropriate and unsafe. This study attempted to fill-in this knowledge gap by exploring their perceptions about diagnosis and appropriate treatment, as well as identifying existing barriers to provide appropriate treatment. METHODS: This exploratory study was conducted in two peri-urban areas of metropolitan Dhaka. Study participants were selected purposively, and an interview guideline was used to collect in-depth data from thirteen providers. Content analysis was applied through data immersion and themes identification, including coding and sub-coding, as well as data display matrix creation to draw conclusion. RESULTS: The providers relied mainly on the history and presenting symptoms for diagnosis. Information and guidelines provided by the pharmaceutical representatives were important aids in their diagnosis and treatment decision making. Lack of training, diagnostic tools and medicine, along with consumer demands for certain medicine i.e. antibiotics, were cited as barriers to deliver appropriate care. Effective and supportive supervision, training, patient education, and availability of diagnostics and guidelines in Bangla were considered necessary in overcoming these barriers. CONCLUSION: Informal providers lack the knowledge and skills for delivering appropriate treatment and care. As they provide health services for substantial proportion of the population, it's crucial that policy makers become cognizant of the fact and take measures to remedy them. This is even more urgent if government's goal to reach universal health coverage by 2030 is to be achieved.

Trends and inequities in use of maternal health care services in Indonesia, 1986-2012.

PURPOSE: Overall health status indicators have improved significantly over the past three decades in Indonesia. However, the country's maternal mortality ratio remains high with a stark inequality by region. Fewer studies have explored access inequity in maternal health care service over time using multiple inequality markers. In this study, we analyzed Indonesian Demographic and Health Survey (DHS) data to explore trends and inequities in use of any antenatal care (ANC), four or more ANC (ANC4+), institutional birth, and cesarean section (c-section) birth in Indonesia during 1986-2012 to inform policy for future strategies ending preventable maternal deaths. METHODS: Indonesian DHS data from 1991, 1994, 1997, 2002/3, 2007, and 2012 surveys were downloaded, merged, and analyzed. Inequity was measured in terms of variation in use by asset quintile, parental education, urban-rural location, religion, and region. Trends in use inequities were assessed plotting changes in rich:poor ratio, rich:poor difference, and concentration indices over period based on asset quintiles. Sociodemographic determinants for service use were explored using multivariable logistic regression analysis. FINDINGS: Between 1986 and 2012, institutional birth rate increased from 22% to 73% and c-section rate from 2% to 16%. Private sector was increasingly contributing in maternal health. There were significant access inequities by asset quintile, parental education, area of residence, and geographical region. The richest women were 5.45 times (95% CI: 4.75-6.25) more likely to give birth in a health facility and 2.83 times (95% CI: 2.23-3.60) more likely to give birth by c-section than their poorest counterparts. Urban women were 3 times more likely to use institutional birth and 1.45 times more likely to give birth by c-section than rural women. Use of all services was higher in Java and Bali than in other regions. Access inequity was narrowing over time for use of ANC and institutional birth but not for c-section birth. CONCLUSION: Ongoing pro-poor health-financing strategies should be strengthened with introduction of innovative ways to monitor access, equity, and quality of care in maternal health.

Improving quality of care for maternal and newborn health: a pre-post evaluation of the Safe Childbirth Checklist at a hospital in Bangladesh.

BACKGROUND: Bangladesh has achieved major gains in maternal and newborn survival, facility childbirth and skilled birth attendance between 1991 and 2010, but excess maternal mortality persists. High-quality maternal health care is necessary to address this burden. Implementation of WHO Safe Childbirth Checklist (SCC), whose items address the major causes of maternal deaths, is hypothesized to improve adherence of providers to essential childbirth practices. METHOD: The SCC was adapted for the local context through expert consultation meetings, creating a total of 27 checklist items. This study was a pre-post evaluation of SCC implementation. Data were collected over 8 months at Magura District Hospital. We analysed 468 direct observations of birth (main analysis using 310 complete observations and sensitivity analysis with the additional 158 incomplete observations) from admission to discharge. The primary outcome of interest was the number of essential childbirth practices performed before compared to after SCC implementation. The change was assessed using adjusted Poisson regression models accounting for clustering by nurse-midwives. RESULT: After checklist introduction, significant improvements were observed: on average, around 70% more of these safe childbirth practices were performed in the follow-up period compared to baseline (from 11 to 19 out of 27 practices). Substantial increases were seen in communication between nurse-midwives and mothers (counselling), and in management of complications (including rational use of medicines). In multivariable models that included characteristics of the mothers and of the nurse-midwives, the rate of delivering the essential childbirth practices was 1.71 times greater in the follow-up compared to baseline (95% CI 1.61-1.81). CONCLUSION: Implementation of SCC has the potential to improve essential childbirth practice in resource-poor settings like Bangladesh. This study emphasizes the need for health system strengthening in order to achieve the full advantages of SCC implementation.

Indications and determinants of caesarean section delivery: Evidence from a population-based study in Matlab, Bangladesh.

BACKGROUND AND METHODS: Caesarean section (C-section) is a major obstetric intervention for saving lives of women and their newborns from pregnancy and childbirth related complications. Un-necessary C-sections may have adverse impact upon maternal and neonatal outcomes. In Bangladesh there is paucity of data on clinical indication of C-section at population level. We conducted a retrospective study in icddr,b Health and Demographic Surveillance System (HDSS) area of Matlab to look into the indications and determinants of C-sections. All resident women in HDSS service area who gave birth in 2013 with a known birth outcome, were included in the study. Women who underwent C-section were identified from birth and pregnancy files of HDSS and their indication for C-section were collected reviewing health facility records where the procedure took place, supplemented by face-to-face interview of mothers where data were missing. Indications of C-section were presented as frequency distribution and further divided into different groups following 3 distinct classification systems. Socio-demographic predictors were explored following statistical method of binary logistic regression. FINDINGS: During 2013, facility delivery rate was 84% and population based C-section rate was 35% of all deliveries in icddr,b service area. Of all C-sections, only 1.4% was conducted for Absolute Maternal Indications (AMIs). Major indications of C-sections included: repeat C-section (24%), foetal distress (21%), prolonged labour (16%), oligohydramnios (14%) and post-maturity (13%). More than 80% C-sections were performed in for-profit private facilities. Probability of C-section delivery increased with improved socio-economic status, higher education, lower birth order, higher age, and with more number of Antenatal Care use and presence of bad obstetric history. Eight maternal deaths occurred, of which five were delivered by C-section. CONCLUSIONS: C-section rate in this area was much higher than national average as well as global recommendations. Very few of C-sections were undertaken for AMIs. Routine monitoring of clinical indication of C-section in public and private facilities is needed to ensure rational use of the procedure.

Building social networks for maternal and newborn health in poor urban settlements: a cross-sectional study in Bangladesh.

BACKGROUND: The beneficial influence of social networks on health and wellbeing is well-established. In poor urban settlements in Bangladesh, BRAC's Manoshi programme trains community health workers (CHWs) to support women through pregnancy, delivery and postpartum periods. This paper test the hypothesis that the introduction of CHWs as weak ties into the social networks of Manoshi members mediates improvements in maternal and neonatal health (MNH) best practices by providing support, facilitating ideational change, connecting mother to resources, and strengthening or countering the influence of strong ties. METHODS: 1000 women who had given birth in the last three months were identified and interviewed as part of ongoing monitoring of 5 poor urban settlements in Dhaka, Bangladesh. A social networks questionnaire was administered which elicited women's perceived networks around pregnancy, delivery and post-partum periods. Mediation analysis was performed to test the hypothesis that penetration of Manoshi CHWs into women's perceived networks has a beneficial effect on MNH best practises. RESULTS: The presence and influence of Manoshi CHWs in women's networks significantly mediated the effect of Manoshi membership on MNH best practices. Respondents who were Manoshi members and who listed Manoshi CHWs as part of their support networks were significantly more likely to deliver with a trained birth attendant (OR 3.61; 95%CI 2.36-5.51), to use postnatal care (OR 3.09; 95%CI 1.83-5.22), and to give colostrum to their newborn (OR 7.51; 95%CI 3.51-16.05). CONCLUSION: Manoshi has succeeded in penetrating the perceived pregnancy, delivery and post-partum networks of poor urban women through the introduction of trained CHWs. Study findings demonstrate the benefits of moving beyond urban health care delivery models that concentrate on the provision of clinical services by medical providers, to an approach that nurtures the power of social networks as a means to support the poorest and most marginalized in changing behaviour and effectively accessing appropriate maternal services.

Trends and inequities in use of maternal health care services in Bangladesh, 1991-2011.

BACKGROUND AND METHODS: Monitoring use-inequity is important to measure progress in efforts to address health-inequities. Using data from six Bangladesh Demographic and Health Surveys (BDHS), we examine trends, inequities and socio-demographic determinants of use of maternal health care services in Bangladesh between 1991 and 2011. FINDINGS: Access to maternal health care services has improved in the last two decades. The adjusted yearly trend was 9.0% (8.6%-9.5%) for any antenatal care (ANC), 11.9% (11.1%-12.7%) for institutional delivery, and 18.9% (17.3%-20.5%) for C-section delivery which is above the WHO recommended rate of 5-15%. Use-inequity was significant for all three indicators but is reducing over time. Between 1991-1994 and 2007-2011 the rich:poor ratio reduced from 3.65 to 1.65 for ANC and from 15.80 to 6.77 for institutional delivery. Between 1995-1998 and 2007-2011, the concentration index reduced from 0.27 (0.25-0.29) to 0.15 (0.14-0.16) for ANC, and from 0.65 (0.60-0.71) to 0.39 (0.37-0.41) for institutional delivery during that period. For use of c-section, the rich:poor ratio reduced from 18.17 to 13.39 and the concentration index from 0.66 (0.57-0.75) to 0.47 (0.45-0.49). In terms of rich:poor differences, there was equity-gain for ANC but not for facility delivery or C-section delivery. All socio-demographic variables were significant predictors of use; of them, maternal education was the most powerful. In addition, the contribution of for-profit private sector is increasingly growing in maternal health. CONCLUSION: Both access and equity are improving in maternal health. We recommend strengthening ongoing health and non-health interventions for the poor. Use-inequity should be monitored using multiple indicators which are incorporated into routine health information systems. Rising C-section rate is alarming and indication of C-sections should be monitored both in private and public sector facilities.

Structural and community-level interventions for increasing condom use to prevent the transmission of HIV and other sexually transmitted infections.

BACKGROUND: Community interventions to promote condom use are considered to be a valuable tool to reduce the transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). In particular, special emphasis has been placed on implementing such interventions through structural changes, a concept that implies public health actions that aim to improve society's health through modifications in the context wherein health-related risk behavior takes place. This strategy attempts to increase condom use and in turn lower the transmission of HIV and other STIs. OBJECTIVES: To assess the effects of structural and community-level interventions for increasing condom use in both general and high-risk populations to reduce the incidence of HIV and STI transmission by comparing alternative strategies, or by assessing the effects of a strategy compared with a control. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, from 2007, Issue 1), as well as MEDLINE, EMBASE, AEGIS and ClinicalTrials.gov, from January 1980 to April 2014. We also handsearched proceedings of international acquired immunodeficiency syndrome (AIDS) conferences, as well as major behavioral studies conferences focusing on HIV/AIDS and STIs. SELECTION CRITERIA: Randomized control trials (RCTs) featuring all of the following.1. Community interventions ('community' defined as a geographical entity, such as cities, counties, villages).2. One or more structural interventions whose objective was to promote condom use. These type of interventions can be defined as those actions improving accessibility, availability and acceptability of any given health program/technology.3. Trials that confirmed biological outcomes using laboratory testing. DATA COLLECTION AND ANALYSIS: Two authors independently screened and selected relevant studies, and conducted further risk of bias assessment. We assessed the effect of treatment by pooling trials with comparable characteristics and quantified its effect size using risk ratio. The effect of clustering at the community level was addressed through intra-cluster correlation coefficients (ICCs), and sensitivity analysis was carried out with different design effect values. MAIN RESULTS: We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high-risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.In the meta-analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV-2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV-2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes. AUTHORS' CONCLUSIONS: There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub-Saharan Africa, a region which in turn is widely diverse.