Implementation of Fee-Free Maternal Health-Care Policy in Ghana: Perspectives of Users of Antenatal and Delivery Care Services From Public Health-Care Facilities in Accra.

In 2008, the government of Ghana implemented a national user fee maternal care exemption policy through the National Health Insurance Scheme to improve financial access to maternal health services and reduce maternal as well as perinatal deaths. Although evidence shows that there has been some success with this initiative, there are still issues relating to cost of care to beneficiaries of the initiative. A qualitative study, comprising 12 focus group discussions and 6 interviews, was conducted with 90 women in six selected urban neighborhoods in Accra, Ghana, to examine users' perspectives regarding the implementation of this policy initiative. Findings showed that direct cost of delivery care services was entirely free, but costs related to antenatal care services and indirect costs related to delivery care still limit the use of hospital-based midwifery and obstetric care. There was also misunderstanding about the initiative due to misinformation created by the government through the media.We recommend that issues related to both direct and indirect costs of antenatal and delivery care provided in public health-care facilities must be addressed to eliminate some of the lingering barriers relating to cost hindering the smooth operation and sustainability of the maternal care fee exemption policy.

The association of drinking water quality and sewage disposal with Helicobacter pylori incidence in infants: the potential role of water-borne transmission.

The mode of transmission of Helicobacter pylori, a bacterium causing gastric cancer and peptic ulcer disease, is unknown although waterborne transmission is a likely pathway. This study investigated the hypothesis that access to treated water and a sanitary sewerage system reduces the H. pylori incidence rate, using data from 472 participants in a cohort study that followed children in Juarez, Mexico, and El Paso, Texas, from April 1998, with caretaker interviews and the urea breath test for detecting H. pylori infection at target intervals of six months from birth through 24 months of age. The unadjusted hazard ratio comparing bottled/vending machine water to a municipal water supply was 0.71 (95% confidence interval (CI): 0.50, 1.01) and comparing a municipal sewer connection to a septic tank or cesspool, 0.85 (95% CI: 0.60, 1.20). After adjustment for maternal education and country, the hazard ratios decreased slightly to 0.70 (95% confidence interval: 0.49, 1.00) and 0.77 (95% confidence interval: 0.50, 1.21), respectively. These results provide moderate support for potential waterborne transmission of H. pylori.

Predictors of early postpartum vitamin use among women of Mexican origin: implications for healthcare provider recommendations.

OBJECTIVE: High parity and short birth intervals among Hispanic women may deplete their folic-acid levels and place them at risk for neural tube defects (NTDs). The purposes of this study were to evaluate factors associated with multivitamin supplementation rates during the early (one to six weeks) postpartum period among Mexican-origin women and present their implications in preventing NTDs in subsequent pregnancies. DESIGN: A cross-sectional study was conducted among Hispanic mothers attending women, infant, and children (WIC) clinics in El Paso, Texas. Information was ascertained via interview on regular multivitamin use, and independent variables including sociodemographic characteristics, multivitamin knowledge, obstetric and health history, and birth control and infant feeding methods. RESULTS: Only 66% of 329 mothers took postpartum multivitamins. Multivitamin consumption declined by 29% for each postpartum week (P=.0003). Adjusted odds ratios indicated positive associations between multivitamin supplementation and prenatal care exclusively in the United States (P=.007), breastfeeding (P=.071), preconceptional (P=.005) and prenatal multivitamin use (P=.0002), and multivitamin recommendation from a healthcare provider (P < or = .0001). The majority of 247 women with multivitamin counsel (59%) were told to finish prenatal vitamins or to continue use while breastfeeding. Smokers were less likely to take multivitamins than nonsmokers (P=.007). CONCLUSIONS: A provider recommendation highly motivates early postpartum women to consume multivitamins. Since most women have more than one child, this period likely represents an interpregnancy interval and is an opportune time to educate and encourage women to take multivitamins. This simple and inexpensive measure could prevent birth defects in future pregnancies.

Alcohol use and abuse by adolescents: the impact of living in a border community.

PURPOSE: To determine the rates of alcohol consumption and alcohol-related risk behaviors among a sample of high school students living on the U.S.-Mexico border, as well as to investigate factors associated with alcohol use among this population. METHODS: A self-administered anonymous questionnaire was administered to students in grades 9-12 during Fall and Spring semesters of 2001 (n = 1366; 639 males and 722 females) in 16 high schools in a community along the U.S.-Mexico border. The questionnaire addressed demographic factors, alcohol consumption, and alcohol-related behaviors. Surveys were completed by Chi-square tests for homogeneity of the odds ratio and logistic regression models were used to identify factors significantly associated with the outcome variables. RESULTS: Rates of binge drinking (45%), drinking and driving (19%), and riding with a driver who had been drinking (46%) were higher for our study population when compared with state and national rates. Students who consumed alcohol were more likely to report alcohol-related problems and lower academic grades. Drinking while in Mexico was significantly associated with binge drinking (OR = 6.44), drinking and driving (OR = 5.39), and riding with a driver who has been drinking (OR = 3.12). CONCLUSIONS: The high rates of alcohol risk behaviors among students living on the U.S.-Mexico border underscore the need to develop and implement culturally appropriate prevention programs that address alcohol consumption in Mexico, particularly in terms of students driving back home.

The impact of a nursing triage line on the use of emergency department services in a military hospital.

The purpose of this study was to evaluate the impact of nursing telephone triage on the appropriateness of emergency department (ED) use among 563 patients at a military hospital by comparing 286 ED patients referred by the Tel-a-Nurse Line (TAN) with 277 non-TAN-referred patients from October 2000 to November 2000. When controlling for confounding factors, TAN-referred patients had less appropriate ED use than non-TAN-referred patients, although this was not statistically significant (odds ratio = 0.87, p = 0.452). After excluding TAN patients with a primary clinic disposition but who were directed to the ED because no clinic appointments were available, TAN-referred patients had more appropriate referrals than non-TAN patients, although this was also not significant (odds ratio = 1.19, p = 0.401). TAN patients directed to the ED because of clinic appointment unavailability contributed significantly to inappropriate ED use with 62% having low acuity. This finding underscores the need to evaluate clinic availability for the TAN line and possibly for all patients as well.

Effectiveness of an intensive, school-based intervention for teen mothers.

PURPOSE: This study evaluated the effectiveness of a secondary teen pregnancy prevention intervention that includes school-based social work services coordinated with comprehensive health care for teen mothers and their children. METHODS: A prospective cohort study compared subsequent births to teen mothers followed for at least 24 months or until age 20 years (whichever was longer) compared with matched subjects from state data. Analyses were based on intent to treat and included chi(2), survival, and cost-benefit analysis. RESULTS: Subjects included 63 girls (97% eligible, 99% African-American, mean age 16 years). A propensity-matched comparison group (n = 252) did not differ from subjects. Participation in program components was good: (1) group meetings: 76%; (2) case management: 95%; (3) coordinated medical care: 63%. The majority of subjects used contraception (93%), with greater use of medroxyprogesterone associated with participation in coordinated medical care (80% vs. 50%, p = .0145). Subsequent births were more common in the comparison group (33%) than among subjects (17%) (p = .001), and survival curves were significantly different (p = .007) (hazard ratio = 2.5). There was a trend toward fewer births with increased participation in medical care (p = .08) and case management (p = .08) but not with group meetings. Cost savings were calculated as $19,097 per birth avoided or $5,055 per month. CONCLUSIONS: The intervention was effective in reducing subsequent births to teens; however selection bias of school enrollment cannot be excluded by this study. The cost savings of delayed births outweigh the expenses of this intensive model.

A multivitamin supplementation and education intervention as an effective means of increasing multivitamin use among postpartum women of Mexican origin.

Postpartum Hispanic women in the USA are at elevated risk for neural tube defects in subsequent pregnancies from the combined effects of ethnicity, folate depletion from the prior pregnancy and lactation, and high parity rates with short inter-birth intervals. This study evaluated an education programme and distribution of a 3-month starter package of multivitamins among Hispanic women attending nutrition clinics for low-income women in El Paso, Texas. At 1-6 weeks postpartum, 329 subjects were selected to receive education only, multivitamins only, education and multivitamins, or no intervention. Multivariable regression obtained odds ratios (OR) and 95% confidence intervals [CI] to measure the association between intervention status and self-reported multivitamin use at least four times per week at 6 and 12 months postpartum, while controlling for potential confounding variables. Multivitamin distribution was related to consumption at both 6 months (OR = 3.5 [95% CI 1.1, 11.2]) and 12 months (OR = 6.5 [95% CI 1.5, 28.3]). Multivitamins plus education was most effective in increasing multivitamin use at both periods: 6 months (OR = 4.0 [95% CI 1.53, 11.7]) and 12 months (OR = 6.4 [95% CI 1.7, 24.2]). At enrolment, 66% of women regularly took vitamins, and approximately 35% took them at both 6 and 12 months postpartum. The education intervention alone was not associated with multivitamin use at either 6 months (OR = 0.79 [95% CI 0.3, 2.4]) or 12 months (OR = 3.1 [95% CI 0.8, 12.1]). Multivitamin use declines precipitously during postpartum at the time Hispanic women may be susceptible to a subsequent pregnancy. This study provides evidence that multivitamin starter packs sustain multivitamin usage up to 1 year postpartum for a specific high-risk group, but the effect of educational intervention alone should be further studied.