Impact of free maternal health care policy on maternal health care utilization and perinatal mortality in Ghana: protocol design for historical cohort study.

BACKGROUND: Ghana introduced what has come to be known as the 'Free' Maternal Health Care Policy (FMHCP) in 2008 via the free registration of pregnant women to the National Health Insurance Scheme to access healthcare free of charge. The policy targeted every pregnant woman in Ghana with a full benefits package covering comprehensive maternal healthcare. PURPOSE: This study seeks to measure the contribution of the FMHCP to maternal healthcare utilization; antenatal care uptake, and facility delivery and determine the utilization impact on stillbirth, perinatal, and neonatal deaths using quasi-experimental methods. The study will also contextualize the findings against funding constraints and operational bottlenecks surrounding the policy operations in the Upper East Region of Ghana. METHODS: This study adopts a mixed-method design to estimate the treatment effect using variables generated from historical data of Ghana and Kenya Demographic and Health Survey data sets of 2008/2014, as treatment and comparison groups respectively. As DHS uses complex design, weighting will be applied to the data sets to cater for clustering and stratification at all stages of the analysis by setting the data in STATA and prefix Stata commands with 'svy'. Thus, the policy impact will be determined using quasi-experimental designs; propensity score matching, and difference-in-differences methods. Prevalence, mean difference, and test of association between outcome and exposure variables will be achieved using the Rao Scot Chi-square. Confounding variables will be adjusted for using Poisson and multiple logistics regression models. Statistical results will be reported in proportions, regression coefficient, and risk ratios. This study then employs intrinsic-case study technique to explore the current operations of the 'free' policy in Ghana, using qualitative methods to obtain primary data from the Upper East Region of Ghana for an in-depth analysis. DISCUSSION: The study discussions will show the contributions of the 'free' policy towards maternal healthcare utilization and its performance towards stillbirth, perinatal and neonatal healthcare outcomes. The discussions will also centre on policy designs and implementation in resource constraints settings showing how SDG3 can be achievement or otherwise. Effectiveness of policy proxy and gains in the context of social health insurance within a broader concept of population health and economic burden will also be conferred. PROTOCOL APPROVAL: This study protocol is registered for implementation by the Ghana Health Service Ethical Review Committee, number: GHS-ERC 002/04/19.

Challenges and implementation of the German maternity protection act for female medical students in macroscopic anatomical education.

Background: Recent decades have seen controversial discussions on the validity of dissection courses in medical education, with alternative programs tested for various reasons. On April 1, 2015 the classification of formaldehyde as a hazardous substance was upgraded by the EU, leding to some universities precluding the participation of pregnant and breastfeeding students in dissection course. However, the revision to the Maternity Protection Act, implemented in Germany on January 1, 2018, now protects student mothers from being disadvantaged in their studies as a consequence of their pregnancy or breastfeeding. Therefore, universities must offer alternatives to dissection courses using formaldehyde to these female students. Project description: As an alternative to regular dissection courses, which use the abovementioned chemical, the Centre for Anatomy at Charité has opted for developing dedicated courses for student mothers. These new courses use plastinated prosection material instead of formalin-treated cadavers of body donors. As the core of the anatomical education takes place during the third and fourth semester in the current curriculum of human medicine at Charité the alternative courses are limited to those two semesters. Additionally, alternative exams at the end of both semesters had to be developed. The alternative courses were designed to offer pregnant and breastfeeding students a study program as close as possible to the one in which their peers learn human anatomy. Results: For the new courses, plastinates had to be produced and further specimens are still needed. Additionally required sets of bones, models and radiological images were readily available at the Centre for Anatomy. The planning and conceptualization of the courses took half a year of intense preparation. The courses for the third and fourth semester were first running during summer semester 2017. There is a clear demand for courses among pregnant and breastfeeding students. At least 5 student participants per course were registered, corresponding to every fortieth female student in their semester cohorts. The highest number of student participants was 13 in one course so far. The performances of the participants in the anatomical examinations were matching that of students attending the regular courses. Discussion: The alternative macroscopic anatomy courses enable the implementation of the revised Maternity Protection Act. The targeted student group is highly satisfied with the offered alternative courses. Considering the number of participants and their examination performance so far, the Centre for Anatomy regards the efforts involved in planning and implementing the courses as justified. The courses allow pregnant and breastfeeding students to address the same anatomical themes at the same time as their fellow students. However, due to restricted flexibility of plastinates and because students cannot prepare specific anatomical structures independently the scope of topographic learning is limited. That being said, well-produced plastinates can display anatomical structures which often cannot be dissected in regular courses. The alternative macroscopic anatomy courses using plastinates constitute suitable alternatives to the regular dissection courses with formalin-treated cadavers for pregnant and breastfeeding students.

Maternal and child health in Seychelles.

Services aimed at improving the health of infants, children and mothers have developed over the years since the initiation of the Seychelles Child Development Study. This paper describes the policies, procedures and facilities and how they have impacted on service provision. The utilisation of antenatal, perinatal and child health services, both in the hospital and community settings, are described. The successes and challenges are illustrated by describing fertility, abortion, teenage pregnancy and infant mortality. This overview of maternal and child services provides a perspective on an important aspect of health care development and the context in which the SCDS is conducted.

The differential effect of the free maternity services policy in Kenya.

BACKGROUND: The Government of Kenya introduced the free maternity services (FMS) policy to enable mothers deliver at a health facility and thus improve maternal health indicators. AIM: The aim of this study was to determine if there was a differential effect of the policy by region (sub-county) and by facility type (hospitals vs. primary healthcare facilities [PHCFs]). SETTING: The study was conducted in Nyamira County in western Kenya. METHODS: This was an interrupted time series study where 42 data sets (24 pre- and 18 post-intervention) were collected for each observation. Monthly data were abstracted from the District Health Information System-2, verified, keyed into and analysed by using IBM-Statistical Package for the Social Sciences (SPSS-17). RESULTS: The relative effect of the policy on facility deliveries in the county was an increase of 22.5%, significant up to the 12th month (p < 0.05). The effect of the policy on deliveries by region was highest in Nyamira North and Masaba North (p < 0.001 up to the 18th month). The effect was larger (46.5% vs. 18.3%) and lasted longer (18 months vs. 6 months) in the hospitals than in the PHCFs. The increase in hospital deliveries was most significant in Nyamira North (61%; p < 0.001). There was a medium-term effect on hospital deliveries in Borabu (up to 9 months) and an effect that started in the sixth month in Manga. The relative effect of the policy on facility deliveries in PHCFs was only significant in Nyamira North and Masaba North (p < 0.001). CONCLUSION: The effect of the FMS policy was varied by region (sub-county) and by facility type.

Using medico-legal claims for quality improvement in maternity care: application and revision of an NHSLA coding taxonomy.

OBJECTIVE: To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement. DESIGN: Qualitative descriptive study. SETTING: Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia. POPULATION: All obstetric claims and incident notifications occurring within the date range were included for analysis. METHODS: De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified. MAIN OUTCOME MEASURES: Rate of claims and notifications, relative frequency of issues, a revised taxonomy. RESULTS: A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented. CONCLUSIONS: Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement. TWEETABLE ABSTRACT: New taxonomy to target health improvement from maternity claims based on NHSLA Ten Years of Maternity Claims.

Temporalities of emergency: Migrant pregnancy and healthcare networks in Southern European borderlands.

In Greece, Italy, and Spain, austerity policies combined with the structural density of migration flows have had concrete social and material manifestations in the delivery of public health care. Through our ethnographic case studies in Lampedusa and southeastern Sicily, Melilla, and Athens, we examine the maternity care offered to migrant patients in the midst and the aftermath of the so-called "migration crisis" in state and non-state structures. Research was conducted in Athens and southeastern Sicily from August 2016 to August 2017; in Melilla from August 2016 to October 2016 and in January 2017; and in Lampedusa from August 2016 to January 2017. Data collected consist in semi-structured interviews and long-term ethnographic observations. The article explores whether and how the understanding or the labeling of the maternity care of migrants as an emergency within a context of professed crisis generates new norms of care within health-care delivery. Our findings suggest a) the adoption of solutions or practices that in the past might have been considered urgent, ad hoc, or creative; b) their normalization, deeply connected to the wider social landscape of these European peripheries and c) the institutionalization of humanitarianism in the context of these practices. Our research points out temporalities of emergency against the background of a professed migration crisis. In the context of austerity-driven underfunding, temporary solutions become entrenched, producing a lasting emergency. Yet, we argue that "emergency" can, at some point, generate practices of resistance that undermine, subtly yet significantly, its own normalization.

Gendered norms of responsibility: reflections on accountability politics in maternal health care in Malawi.

BACKGROUND: This paper aims to provide insights into the role of traditional authorities in two maternal health programmes in Northern Malawi. Among strategies to improve maternal health, these authorities issue by-laws: local rules to increase the uptake of antenatal and delivery care. The study uses a framework of gendered institutions to critically assess the by-law content, process and effects and to understand how responsibilities and accountabilities are constructed, negotiated and reversed. METHODS: Findings are based on a qualitative study in five health centre catchment areas in Northern Malawi. Data were collected using meeting observations and document search, 36 semi-structured individual interviews and 19 focus group discussions with female maternal health service users, male community members, health workers, traditional leaders, local officials and health committee members. A gender and power sensitive thematic analysis was performed focusing on the formulation, interpretation and implementation process of the by-laws as well as its effects on women and men. RESULTS: In the study district, traditional leaders introduced three by-laws that oblige pregnant women to attend antenatal care; bring their husbands along and; and to give birth in a health centre. If women fail to comply with these rules, they risk being fined or denied access to maternal health services. The findings show that responsibilities and accountabilities are negotiated and that by-laws are not uniformly applied. Whereas local officials support the by-laws, lower level health cadres' and some community members contest them, in particular, the principles of individual responsibility and universality. CONCLUSIONS: The study adds new evidence on the understudied phenomenon of by-laws. From a gender perspective, the by-laws are problematic as they individualise the responsibility for maternal health care and discriminate against women in the definition and application of sanctions. Through the by-laws, supported by national policies and international institutions, women bear the full responsibility for failures in maternal health care, suggesting a form of 'reversed accountability' of women towards global maternal health goals. This can negatively impact on women's reproductive health rights and obstruct ambitions to achieve gender inequality and health equity. Contextualised gender and power analysis in health policymaking and programming as well as in accountability reforms could help to identify these challenges and potential unintended effects.

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

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

Litigating to ensure access to quality maternal health care for women and girls in Kenya.

Access to comprehensive reproductive health care for women and girls, including access to quality maternal health services remains a challenge in Kenya. A recent government enquiry assessing close to 500 maternal deaths that occurred in 2014 revealed gaps in the quality of maternal care, concluding that more than 90% of the women who had died had received "suboptimal" maternal care. In Kenya, the Center for Reproductive Rights (the Center) has undertaken public interest litigation among other strategies to challenge human rights violations and systematic failures within the health sector. In 2014, before the High Court of Bungoma in Western Kenya, the Center filed a case on behalf of Josephine Majani who had been neglected and abused by the staff of the Bungoma County Referral Hospital, a public health facility where she had gone to deliver in 2013. This commentary addresses the situation of maternal health care in Kenya and the actions leading to litigation that was specifically aimed at enabling access to quality maternal health care. It provides an analysis of some of the outcomes of the litigation and highlights the implications thereof on implementation of maternal health care in Kenya and beyond.

Legal and Ethical Considerations during Maternal Death Surveillance and Response.

Maternal death surveillance and response (MDSR) is a promising strategy, to identify record and track key drivers of maternal deaths. Despite its potential in reducing maternal mortality, ethical and legal challenges need to be properly ascertained and acted upon, to guarantee its acceptability, sustainability, and effectiveness. This paper proposes a legal and ethical framework to guide practitioners and researchers through the MDSR process. Three (03) categories of both legal and ethical issues are discussed: namely the issues related to data, people and use of findings. Most challenges of the MDSR strategy have ethical and legal underappraisal origins, the most outstanding being the low maternal death notification rates. Efforts should be made for respondents to properly understand the rationale for the process, and how the data obtained will be put into use. Dispelling fears of possible litigation remains fundamental in obtaining quality data. Health care providers involved in the process need to understand their ethical and legal responsibilities, as well as privileges (legal protection). It is hoped that this framework will offer a structure to guide professionals in improving MDSR implementation and research.

Obstetric fistula policy in Nigeria: a critical discourse analysis.

BACKGROUND: In 2012, Nigeria's Federal Ministry of Health published its National Strategic Framework for the Elimination of Obstetric Fistula (NSFEOF), 2011-2015. The framework has since lapsed and there is no tangible evidence that the goal of eliminating obstetric fistula was met. To further inform future policy directions on obstetric fistula in Nigeria, this paper explores how the NSFEOF conceptualized obstetric fistula and its related issues, including child marriage and early childbearing. METHODS: A critical discourse analysis of the policy was performed. We examined four policies in addition to the strategic framework: the Nigerian constitution; the Marriage Act; the Matrimonial Causes Act; and the National Reproductive Health Policy. We used the three phases of critical discourse analysis: textual analysis, analysis of discourse practice, and analysis of discursive events as instances of sociocultural practice. RESULTS: The analysis demonstrates that, despite its title, the policy document focuses on reduction rather than elimination of obstetric fistula. The overall orientation of the policy is downstream, with minimal focus on prevention. The policy language suggests victim blaming. Furthermore, the extent to which subnational stakeholders in government and civil society were engaged in decision-making process for developing this policy is ambiguous. Although the policy is ostensibly based on principles of social justice and equity, several rhetorical positions suggest that the Nigerian constitutional environment and justice systems make no real provisions to protect the reproductive rights of girls in accordance with the United Nations' "2030 Agenda for Sustainable Development." CONCLUSION: This analysis establishes that the Nigerian constitution, justice environment and the obstetric fistula policy itself do not demonstrate clear commitment to eradicating obstetric fistula. Specifically, a clear commitment to eradicating obstetric fistula would see the constitution and Marriage Act of Nigeria specify an age of consent that is consistent with the agenda to prevent obstetric fistula. Additionally, a policy to end obstetric fistulas in Nigeria must purposefully address the factors creating barrier to women's access to quality maternal healthcare services. Future policies and programs to eliminate obstetric fistulas should include perspectives of nurses, midwives, researchers and, women's interest groups.

The effect of Kenya's free maternal health care policy on the utilization of health facility delivery services and maternal and neonatal mortality in public health facilities.

BACKGROUND: Kenya abolished delivery fees in all public health facilities through a presidential directive effective on June 1, 2013 with an aim of promoting health facility delivery service utilization and reducing pregnancy-related mortality in the country. This paper aims to provide a brief overview of this policy's effect on health facility delivery service utilization and maternal mortality ratio and neonatal mortality rate in Kenyan public health facilities. METHODS: A time series analysis was conducted on health facility delivery services utilization, maternal and neonatal mortality 2 years before and after the policy intervention in 77 health facilities across 14 counties in Kenya. RESULTS: A statistically significant increase in the number of facility-based deliveries was identified with no significant changes in the ratio of maternal mortality and the rate of neonatal mortality. CONCLUSION: The findings suggest that cost is a deterrent to health facility delivery service utilization in Kenya and thus free delivery services are an important strategy to promote utilization of health facility delivery services; however, there is a need to simultaneously address other factors that contribute to pregnancy-related and neonatal deaths.

Effectiveness of respectful care policies for women using routine intrapartum services: a systematic review.

BACKGROUND: Several studies have identified how mistreatment during labour and childbirth can act as a barrier to the use of health facilities. Despite general agreement that respectful maternity care (RMC) is a fundamental human right, and an important component of quality intrapartum care that every pregnant woman should receive, the effectiveness of proposed policies remains uncertain. We performed a systematic review to assess the effectiveness of introducing RMC policies into health facilities providing intrapartum services. METHODS: We included randomized and non-randomized controlled studies evaluating the effectiveness of introducing RMC policies into health facilities. We searched PubMed, CINAHL, LILACS, AJOL, WHO RHL, and Popline, along with ongoing trials registers (ISRCT register, ICTRP register), and the White Ribbon Respectful Maternity Care Repository. Included studies were assessed for risk of bias. Certainty of evidence was assessed using GRADE criteria. FINDINGS: Five studies were included. All were undertaken in Africa (Kenya, Tanzania, Sudan, South Africa), and involved a range of components. Two were cluster RCTs, and three were before/after studies. In total, over 8000 women were included at baseline and over 7500 at the endpoints. Moderate certainty evidence suggested that RMC interventions increases women's experiences of respectful care (one cRCT, approx. 3000 participants; adjusted odds ratio (aOR) 3.44, 95% CI 2.45-4.84); two observational studies also reported positive changes. Reports of good quality care increased. Experiences of disrespectful or abusive care, and, specifically, physical abuse, were reduced. Low certainty evidence indicated fewer accounts of non-dignified care, lack of privacy, verbal abuse, neglect and abandonment with RMC interventions, but no difference in satisfaction rates. Other than low certainty evidence of reduced episiotomy rates, there were no data on the pre-specified clinical outcomes. CONCLUSION: Multi-component RMC policies appear to reduce women's overall experiences of disrespect and abuse, and some components of this experience. However, the sustainability of the demonstrated effect over time is unclear, and the elements of the programmes that have most effect have not been examined. While the tested RMC policies show promising results, there is a need for rigorous research to refine the optimum approach to deliver and achieve RMC in all settings.