Inequity in the face of success: understanding geographic and wealth-based equity in success of facility-based delivery for under-5 mortality reduction in six countries.

BACKGROUND: Between 2000-2015, many low- and middle-income countries (LMICs) implemented evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M). Even among LMICs successful in reducing U5M, this drop was unequal subnationally, with varying success in EBI implementation. Building on mixed methods multi-case studies of six LMICs (Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal) leading in U5M reduction, we describe geographic and wealth-based equity in facility-based delivery (FBD), a critical EBI to reduce neonatal mortality which requires a trusted and functional health system, and compare the implementation strategies and contextual factors which influenced success or challenges within and across the countries. METHODS: To obtain equity gaps in FBD coverage and changes in absolute geographic and wealth-based equity between 2000-2015, we calculated the difference between the highest and lowest FBD coverage across subnational regions and in the FBD coverage between the richest and poorest wealth quintiles. We extracted and compared contextual factors and implementation strategies associated with reduced or remaining inequities from the country case studies. RESULTS: The absolute geographic and wealth-based equity gaps decreased in three countries, with greatest drops in Rwanda - decreasing from 50 to 5% across subnational regions and from 43 to 13% across wealth quintiles. The largest increases were seen in Bangladesh - from 10 to 32% across geography - and in Ethiopia - from 22 to 58% across wealth quintiles. Facilitators to reducing equity gaps across the six countries included leadership commitment and culture of data use; in some countries, community or maternal and child health insurance was also an important factor (Rwanda and Peru). Barriers across all the countries included geography, while country-specific barriers included low female empowerment subnationally (Bangladesh) and cultural beliefs (Ethiopia). Successful strategies included building on community health worker (CHW) programs, with country-specific adaptation of pre-existing CHW programs (Rwanda, Ethiopia, and Senegal) and cultural adaptation of delivery protocols (Peru). Reducing delivery costs was successful in Senegal, and partially successful in Nepal and Ethiopia. CONCLUSION: Variable success in reducing inequity in FBD coverage among countries successful in reducing U5M underscores the importance of measuring not just coverage but also equity. Learning from FBD interventions shows the need to prioritize equity in access and uptake of EBIs for the poor and in remote areas by adapting the strategies to local context.

Women's healthcare autonomy and the utilization of maternal healthcare services in Afghanistan.

OBJECTIVES: The objective of this study was to investigate the relationship between women's healthcare autonomy and the utilization of maternal healthcare services (MHS), including antenatal care services, the services of health professionals at the birth of a child, and facility-based delivery. STUDY DESIGN: This was a cross-sectional study. METHODS: This study utilized data from the 2015 Afghanistan Demographic and Health Survey (AFDHS 2015), which included women aged 15-49 years who had given live birth within the five years before the survey. Multilevel logistic regression was used to estimate the adjusted odd ratios (AOR) for each outcome variable. RESULTS: Among respondents, 16.49% made at least four ANC visits, 52.57% of childbirth were assisted by a skilled birth attendant (SBA), and 45.60% of children were born in health facilities. Women with high healthcare autonomy, compared to medium and low, were more likely to use ANC (AOR 1.45; 95% CI = 1.26-1.67), SBA (AOR 1.15; 95% CI 1.02-1.29), and FBD (AOR 1.12; 95% CI 1.04-1.20). The association between women's healthcare autonomy and the use of maternal healthcare services (MHS) was positively and significantly moderated by household wealth and women's access to media. CONCLUSION: Women's higher healthcare autonomy was significantly and positively associated with MHS in Afghanistan. Policy and programs that encourage women's empowerment and awareness of the importance of MHS utilization should be initiated.

Determinants of Choice of Facility-Based Delivery among Mothers in Kwara State, Nigeria.

BACKGROUND: Nigeria has the highest number of maternal deaths in the world, which is a major public health problem. One of the major contributory factors is high prevalence of unskilled birth attendance from low facility delivery. However, the reasons for and against facility delivery are complex and not fully understood. OBJECTIVE: The objective of this study was to identify the facilitators and barriers to facility based deliveries (FBD) among mothers in Kwara state, Nigeria. METHODS: The study was carried out among 495 mothers that delivered in the five years prior to the study in three selected communities from the three senatorial districts of Kwara state using mixed methods. The study design consisted of a cross-sectional study with mixed data collection involving qualitative and quantitative methods. Multistage sampling technique was employed. Primary outcome measures were place of delivery, reasons for and against FBD. RESULTS: Of the 495 respondents that had their last delivery during the study period, 410 respondents delivered in the hospital (83%). Common reasons for hospital delivery were ease and convenience (87.1%), safe delivery (73.6%) and faith in healthcare providers (22.4%). The common barriers to FBD included high cost of hospital delivery (85.9%), sudden birth (58.8%) and distance (18.8%). Other important barriers were availability of cheaper alternatives (traditional birth attendants and community health extension workers practising at home), unavailability of community health insurance and lack of family support. Parity, level of education of respondents and husband had significant influence on choice of delivery (p<0.05). CONCLUSION: These findings provided a good insight into the reasons for and against facility delivery among Kwara women, which can assist policy makers and program interventions that can improve facility deliveries and ultimately improve skilled birth attendance, reduce maternal and newborn morbidity and mortality.

CONTEXTE: Le Nigeria compte le plus grand nombre de décès maternels au monde, ce qui constitue un problème majeur de santé publique. L'un des principaux facteurs contributifs est la forte prévalence de l'assistance à l'accouchement non qualifiée due à un accouchement dans des établissements de faible qualité. Cependant, les raisons pour et contre la prestation en établissement sont complexes et ne sont pas entièrement comprises. OBJECTIF: L'objectif de cette étude était d'identifier les facilitateurs et les obstacles aux accouchements en établissement (FBD) chez les mères de l'État de Kwara, au Nigeria. METHODES: L'étude a été menée auprès de 495 mères qui ont accouché au cours des cinq dernières années précédant l'étude dans trois communautés sélectionnées des trois districts sénatoriaux de l'État de Kwara en utilisant des méthodes mixtes. La conception de l'étude consistait en un entretien avec des informateurs clés et une étude transversale avec une collecte de données mixte impliquant des méthodes qualitatives et quantitatives. La technique d'échantillonnage à plusieurs degrés a été employée. Les principaux critères de jugement étaient le lieu d'accouchement, les raisons pour et contre le FBD. RESULTATS: Parmi les 495 répondantes qui ont eu leur dernier accouchement au cours de la période d'étude, 410 répondantes ont accouché à l'hôpital (83 %). Les raisons courantes de l'accouchement à l'hôpital étaient la facilité et la commodité (87,1 %), la sécurité de l'accouchement (73,6 %) et la confiance dans les prestataires de soins de santé (22,4 %). Les obstacles courants à la FBD comprenaient le coût élevé de l'accouchement à l'hôpital (85,9 %), l'accouchement soudain (58,8 %) et la distance (18,8 %). D'autres obstacles importants étaient la disponibilité d'alternatives moins chères (accoucheuses traditionnelles et agents de vulgarisation de la santé communautaire exerçant à domicile), l'absence d'assurance maladie communautaire et le manque de soutien familial. La parité, le niveau d'éducation des répondants et le mari ont une influence significative sur le choix de l'accouchement (p<0,05). CONCLUSION: Ces résultats ont fourni un bon aperçu des raisons pour et contre l'accouchement en établissement chez les femmes Kwara, ce qui peut aider les décideurs politiques et les interventions de programme qui peuvent améliorer les accouchements en établissement et, en fin de compte, améliorer l'assistance qualifiée à l'accouchement, réduire la morbidité et la mortalité maternelles et néonatales. Mots clés: Prestation en établissement; Facilitateurs; Barrières; État de Kwara; Nigeria.

Effect of four or more antenatal care visits on facility delivery and early postnatal care services utilization in Uganda: a propensity score matched analysis.

INTRODUCTION: Maternal mortality remains a global public health issue, more predominantly in developing countries, and is associated with poor maternal health services utilization. Antenatal care (ANC) visits are positively associated with facility delivery and postnatal care (PNC) utilization. However, ANC in itself may not lead to such association but due to differences that exist among users (women). The purpose of this study, therefore, is to examine the effect of four or more ANC visits on facility delivery and early PNC and also the effect of facility-based delivery on early PNC using Propensity Score Matched Analysis (PSMA). METHODS: The present study utilized the 2016 Uganda Demographic and Health Survey (UDHS) dataset. Women aged 15 - 49 years who had given birth three years preceding the survey were considered for this study. Propensity score-matched analysis was used to analyze the effect of four or more ANC visits on facility delivery and early PNC and also the effect of facility-based delivery on early PNC. RESULTS: The results revealed a significant and positive effect of four or more ANC visits on facility delivery [ATT (Average Treatment Effect of the Treated) = 0.118, 95% CI: 0.063 - 0.173] and early PNC [ATT = 0.099, 95% CI: 0.076 - 0.121]. It also found a positive and significant effect of facility-based delivery on early PNC [ATT = 0.518, 95% CI: 0.489 - 0.547]. CONCLUSION: Policies geared towards the provision of four or more ANC visits are an effective intervention towards improved facility-based delivery and early PNC utilisation in Uganda.

Economic Evaluation of User-Fee Exemption Policies for Maternal Healthcare in Burkina Faso: Evidence From a Cost-Effectiveness Analysis.

OBJECTIVES: The reduction and removal of user fees for essential care services have recently become a key instrument to advance universal health coverage in sub-Saharan Africa, but no evidence exists on its cost-effectiveness. We aimed to address this gap by estimating the cost-effectiveness of 2 user-fee exemption interventions in Burkina Faso between 2007 and 2015: the national 80% user-fee reduction policy for delivery care services and the user-fee removal pilot (ie, the complete [100%] user-fee removal for delivery care) in the Sahel region. METHODS: We built a single decision tree to evaluate the cost-effectiveness of the 2 study interventions and the baseline. The decision tree was populated with an own impact evaluation and the best available epidemiological evidence. RESULTS: Relative to the baseline, both the national 80% user-fee reduction policy and the user-fee removal pilot are highly cost-effective, with incremental cost-effectiveness ratios of $210.22 and $252.51 per disability-adjusted life-year averted, respectively. Relative to the national 80% user-fee reduction policy, the user-fee removal pilot entails an incremental cost-effectiveness ratio of $309.74 per disability-adjusted life-year averted. CONCLUSIONS: Our study suggests that it is worthwhile for Burkina Faso to move from an 80% reduction to the complete removal of user fees for delivery care. Local analyses should be done to identify whether it is worthwhile to implement user-fee exemptions in other sub-Saharan African countries.

Institutional delivery service utilization and associated factors in Ethiopia: a systematic review and META-analysis.

BACKGROUND: There is wide variation in the utilization of institutional delivery service in Ethiopia. Various socioeconomic and cultural factors affect the decision where to give birth. Although there has been a growing interest in the assessment of institutional delivery service utilization and its predictors, nationally representative evidence is scarce. This study was aimed to estimate the pooled national prevalence of institutional delivery service utilization and associated factors in Ethiopia. METHODS: Studies were accessed through PubMed, Cochrane library, Web of Science, and Google Scholar. The funnel plot and Egger's regression test were used to see publication bias, and I-squared statistic was applied to check heterogeneity of studies. A weighted Dersimonian laired random effect model was applied to estimate the pooled national prevalence and the effect size of institutional delivery service utilization and associated factors. RESULT: Twenty four studies were included in this review. The pooled prevalence of institutional delivery service utilization was 31% (95% Confidence interval (CI): 30, 31.2%; I2 = 0.00%). Attitude towards institutional delivery (Adjusted Odd Ratio (AOR) = 2.83; 95% CI 1.35,5.92) in 3 studies, maternal age at first pregnancy (AOR = 3.59; 95% CI 2.27,5.69) in 4 studies, residence setting (AOR = 3.84; 95% CI 1.31, 11.25) in 7 studies, educational status (AOR = 2.91;95% 1.88,4.52) in 5 studies, availability of information source (AOR = 1.80;95% CI 1.16,2.78) in 6 studies, ANC follow-up (AOR = 2.57 95% CI 1.46,4.54) in 13 studies, frequency of ANC follow up (AOR = 4.04;95% CI 1.21,13.46) in 4 studies, knowledge on danger signs during pregnancy and benefits of institutional delivery (AOR = 3.04;95% CI 1.76,5.24) in 11 studies and place of birth of the elder child (AOR = 8.44;95% CI 5.75,12.39) in 4 studies were the significant predictors of institutional delivery service utilization. CONCLUSION: This review found that there are several modifiable factors such as empowering women through education; promoting antenatal care to prevent home delivery; increasing awareness of women through mass media and making services more accessible would likely increase utilization of institutional delivery.

Community-level factors associated with the use of facility-based delivery assistance in Uganda: a multilevel analysis.

BACKGROUND: In low- and middle-income countries, the proportion of pregnant women who use health facilities for delivery remains low. Although delivering in a health facility with skilled health providers can make the critical difference between survival and death for both mother and child, in 2016, more than 25% of pregnant women did not deliver in a health facility in Uganda. This study examines the association of contextual factors measured at the community-level with use of facility-based delivery in Uganda, after controlling for household and individual-level factors. METHODS: Pooled household level data of 3310 observations of women who gave birth in the last five years is linked to community level data from the Uganda National Panel Survey (UNPS). A multilevel model that adequately accounted for the clustered nature of the data and the binary outcome of whether or not the woman delivered in a health facility was estimated. RESULTS: The study findings show a positive association at the county level between place of delivery, education and access to health services, and a negative association between place of delivery and poverty. Individuals living in communities with a high level of education amongst the household heads were 1.67 times (95% Confidence Interval: 1.07-2.61) more likely to have had a facility-based delivery compared to women living in communities where household heads did not have high levels of education. Women who lived in counties with a short travel time (less than 33 min) were 1.66 times (95% CI: 1.11-2.48) more likely to have had a facility-based delivery compared to women who lived in counties with longer travel time to any health facility. Women living in poor counties were only 0.64 times (95% CI: 0.42-0.97) as likely to have delivered in a health facility compared to pregnant women from communities with more affluent individuals. CONCLUSIONS: The findings on household head's education, community economic status and travel time to a health facility are useful for defining the attributes for targeting and developing relevant nation-wide community-level health promotion campaigns. However, limited evidence was found in broad support of the role of community level factors.

The influence of pregnancy classes on the use of maternal health services in Indonesia.

BACKGROUND: Indonesia has developed the pregnancy class program for mothers in an effort to reduce the high maternal mortality rate. This study aims to understand the influence of pregnancy classes on mothers' use of maternal and neonatal health services, which are known to improve pregnancy and delivery outcomes. METHODS: This study used data on members of households in communities in Indonesia, based on the 2016 National Health Indicators Survey (Sirkesnas), which covered 34 provinces and 264 districts/cities. The analysis focused on a sample of women ages 10-54 years who had ever been married and had given birth in the previous 3 years. The study analyzed three behaviors as outcome variables: whether a mother had adequate antenatal care, used a skilled birth attendant, and had a facility-based delivery. Logistic and multinomial logistic regression analysis was used to explore those relationships. RESULTS: 29% of mothers utilized adequate antenatal care (a minimum of five antenatal care components and at least four antenatal care visits), 77% of mothers used skilled birth attendants for delivering their baby, and 76% of mothers used a health facility to give birth. Only 7% of mothers participated in the complete pregnancy class program. Mothers who completed participation in the pregnancy class program had 2.2 times higher odds of receiving adequate antenatal care [OR = 2.19; 95% CI: 1.62 to 2.97; P < 0.001]. Those who completed participation in the class had 2.7 times higher odds of using skilled birth attendants for delivery [OR = 2.69; 95% CI: 1.52 to 4.76; P < 0.001] and 2.8 times higher odds of giving birth in a health facility compared to a non-health facility [OR = 2.77; 95% CI: 1.56 to 4.91; P < 0.001]. CONCLUSIONS: Participation in pregnancy classes was positively associated with utilization of adequate antenatal care, skilled birth attendants, and delivery at health facility. Since participation in pregnancy classes in positively associated with maternal healthcare utilization, policy efforts should focus on improving implementation of the KIH program at the local level.

Prevalence and Factors Associated with Institutional-based Delivery in The Gambia: Further Analysis of Population-based Cross- Sectional Data.

Institutional-based delivery could be the major strategy to avoid most maternal deaths occurring from preventable obstetric complications. The study examines the prevalence and factors associated with institutional-based delivery in The Gambia. The secondary data, from The Gambia Multiple Indicator Cluster Survey (MICS) - 2018 for 3,791 women aged 15-49 years who had given birth, were extracted for the analysis. Chi-square analysis and multivariable logistic regression model were used to determine factors associated with institutional-based delivery with statistical significance set at p < 0.05. About three-quarters (78.1%) of Gambian women had institutional-based delivery. The study identified that women from richer (AOR= 2.38; 95%CI: 1.49, 3.79) and richest households (4.14; 95%CI: 2.06, 8.33) were more likely to have institutional-based delivery when compared with women from poorest households. Furthermore, women with secondary or higher education (AOR= 1.66; 95%CI: 1.28, 2.16) were more likely to have institutional-based delivery, when compared with women without formal education. Conversely, rural dwellers (AOR= 0.63; 95%CI: 0.47, 0.84), women with high parity and advanced age had significant reduction in the odds of institutional-based delivery in The Gambia. There is a need for concerted efforts to improve skilled birth attendance among women of low socioeconomic status, those living in hard-to-reach communities and the multiparous women in The Gambia.

Maternal health care service utilization in post-war Liberia: analysis of nationally representative cross-sectional household surveys.

BACKGROUND: Post-war Liberia has a fast-growing population and an alarming maternal mortality ratio (MMR). To provide a better understanding about healthcare system recovery in post-war country, we explored the changes in maternal healthcare services utilization between 2007 and 2016. METHODS: We used 2007 and 2013 Liberia Demographic and Health Survey (LDHS) and the 2016 Malaria Indicator Survey (MIS) in this study. The outcomes of interest were: place of delivery and antenatal care visits. Univariate analysis was conducted using percentages and means (standard deviations) and multiple binary multivariable logistic models were used to examine the factors associated with the outcome variables. RESULTS: Between 2007 and 2016, the percentage of adequate ANC visits increased from 71.20 to 79.8%, and that of facility-based delivery increased from 40.90 to 74.60%. The odds of attending at least four ANC visits and formal institutional delivery were low among women residing in rural area, but high among women with higher education, used electronic media, and lived in high wealth index households. Additionally, attending ANC at least four times increased the odds of facility-based delivery by almost threefold. CONCLUSION: The findings suggest that key maternal healthcare utilization indicators have improved substantially, especially facility-based delivery. However, a large proportion of women remain deprived of these life-saving health services in the post-war era. Greater healthcare efforts are needed to improve the quality and coverage of maternal healthcare in order to enhance maternal survival in Liberia.

Midwives' perspectives on (dis)respectful intrapartum care during facility-based delivery in sub-Saharan Africa: a qualitative systematic review and meta-synthesis.

BACKGROUND: In the past decade, the negative impact of disrespectful maternity care on women's utilisation and experiences of facility-based delivery has been well documented. Less is known about midwives' perspectives on these labour ward dynamics. Yet efforts to provide care that satisfies women's psycho-socio-cultural needs rest on midwives' capacity and willingness to provide it. We performed a systematic review of the emerging literature documenting midwives' perspectives to explore the broader drivers of (dis)respectful care during facility-based delivery in the sub-Saharan African context. METHODS: Seven databases (CINAHL, PsychINFO, PsychArticles, Embase, Global Health, Maternity and Infant Care and PubMed) were systematically searched from 1990 to May 2018. Primary qualitative studies with a substantial focus on the interpersonal aspects of care were eligible if they captured midwives' voices and perspectives. Study quality was independently assessed by two reviewers and PRISMA guidelines were followed. The results and findings from each study were synthesised using an existing conceptual framework of the drivers of disrespectful care. RESULTS: Eleven papers from six countries were included and six main themes were identified. 'Power and control' and 'Maintaining midwives' status' reflected midwives' focus on the micro-level interactions of the mother-midwife dyad. Meso-level drivers of disrespectful care were: the constraints of the 'Work environment and resources'; concerns about 'Midwives' position in the health systems hierarchy'; and the impact of 'Midwives' conceptualisations of respectful maternity care'. An emerging theme outlined the 'Impact on midwives' of (dis)respectful care. CONCLUSION: We used a theoretically informed conceptual framework to move beyond the micro-level and interrogate the social, cultural and historical factors that underpin (dis)respectful care. Controlling women was a key theme, echoing women's experiences, but midwives paid less attention to the social inequalities that distress women. The synthesis highlighted midwives' low status in the health system hierarchy, while organisational cultures of blame and a lack of consideration for them as professionals effectively constitute disrespect and abuse of these health workers. Broader, interdisciplinary perspectives on the wider drivers of midwives' disrespectful attitudes and behaviours are crucial if efforts to improve the maternity care environment - for women and midwives - are to succeed.

Qualitative evidence syntheses: Assessing the relative contributions of multi-context and single-context reviews.

AIMS: To examine the strengths and weaknesses of multi-context (international) qualitative evidence syntheses in comparison with single-context (typically single-country) reviews. We compare a multi-country synthesis with single-context syntheses on facility-based delivery in Nigeria and Kenya. DESIGN: Discussion paper. BACKGROUND: Qualitative evidence increasingly contributes to decision-making. International organizations commission multi-context reviews of qualitative evidence to gain a comprehensive picture of similarities and differences across comparable (e.g., low- and middle-income) countries. Such syntheses privilege breadth over contextual detail, risking inappropriate interpretation and application of review findings. Decision-makers value single-context syntheses that account for the contexts of their populations and health services. We explore how findings from multi- and single-context syntheses contribute against a conceptual framework (adequacy, coherence, methodological limitations and relevance) that underpins the GRADE Confidence in Evidence of Reviews of Qualitative Evidence approach. DATA SOURCES: Included studies and findings from a multi-context qualitative evidence synthesis (2001-2013) and two single-context syntheses (Nigeria, 2006-2017; and Kenya, 2002-2016; subsequently updated and revised). FINDINGS: Single-context reviews contribute cultural, ethnic and religious nuances and specific health system factors (e.g., use of a voucher system). Multi-context reviews contribute to universal health concerns and to generic health system concerns (e.g., access and availability). IMPLICATIONS FOR NURSING: Nurse decision-makers require relevant, timely and context-sensitive evidence to inform clinical and managerial decision-making. This discussion paper informs future commissioning and use of multi- and single-context qualitative evidence syntheses. CONCLUSION: Multi- and single-context syntheses fulfil complementary functions. Single-context syntheses add nuances not identifiable in the remit and timescales of a multi-context review. Impact This study offers a unique comparison between multi-context and single country (Nigeria and Kenya) qualitative syntheses exploring facility-based birth. Clear strengths and weaknesses were identified to inform commissioning and application of future syntheses. Characteristics can inform the commissioning of single- and multi-context nursing-oriented reviews across the world.

"Our voices matter": a before-after assessment of the effect of a community-participatory intervention to promote uptake of maternal and child health services in Kwale, Kenya.

BACKGROUND: Community-participatory approaches are important for effective maternal and child health interventions. A community-participatory intervention (the Dialogue Model) was implemented in Kwale County, Kenya to enhance uptake of select maternal and child health services among women of reproductive age. METHODS: Community volunteers were trained to facilitate Dialogue Model sessions in community units associated with intervention health facilities in Matuga, Kwale. Selection of intervention facilities was purposive based on those that had an active community unit in existence. For each facility, uptake of family planning, antenatal care and facility-based delivery as reported in the District Health Information System (DHIS)-2 was compared pre- (October 2012 - September 2013) versus post- (January - December 2016) intervention implementation using a paired sample t-test. RESULTS: Between October 2013 and December 2015, a total of 570 Dialogue Model sessions were held in 12 community units associated with 10 intervention facilities. The median [interquartile range (IQR)] number of sessions per month per facility was 2 (1-3). Overall, these facilities reported 15, 2 and 74% increase in uptake of family planning, antenatal care and facility-based deliveries, respectively. This was statistically significant for family planning pre- (Mean (M) = 1014; Standard deviation (SD) = 381) versus post- (M = 1163; SD = 400); t (18) = - 0.603, P = 0.04) as well as facility-based deliveries pre- (M = 185; SD = 216) versus post- (M = 323; SD = 384); t (18) = - 0.698, P = 0.03). CONCLUSIONS: A structured, community-participatory intervention enhanced uptake of family planning services and facility-based deliveries in a rural Kenyan setting. This approach is useful in addressing demand-side factors by providing communities with a stake in influencing their health outcomes.

Predictors of person-centered maternity care: the role of socioeconomic status, empowerment, and facility type.

BACKGROUND: Low use of maternal health services, as well as poor quality care, contribute to the high maternal mortality in sub-Saharan Africa (SSA). In particular, poor person-centered maternity care (PCMC), which captures user experience, contributes both directly to pregnancy outcomes and indirectly through decreased demand for services. While many studies have examined disparities in use of maternal health services, few have examined disparities in quality of care, and none to our knowledge has empirically examined disparities in PCMC in SSA. The aim of this study is to examine factors associated with PCMC, particularly the role of household wealth, personal empowerment, and type of facility. METHODS: Data are from a survey conducted in western Kenya in 2016, with women aged 15 to 49 years who delivered in the 9 weeks preceding the survey (N = 877). PCMC is operationalized as a summative score based on responses to 30 items in the PCMC scale capturing dignity and respect, communication and autonomy, and supportive care. RESULTS: We find that net of other factors; wealthier, employed, literate, and married women report higher PCMC than poorer, unemployed, illiterate, and unmarried women respectively. Also, women who have experienced domestic violence report lower PCMC than those who have never experienced domestic violence. In addition, women who delivered in health centers and private facilities reported higher PCMC than those who delivered in public hospitals. The effect of employment and facility type is conditional on wealth, and is strongest for the poorest women. Poor women who are unemployed and poor women who deliver in higher-level facilities receive the lowest quality PCMC. CONCLUSIONS: The findings imply the most disadvantaged women receive the lowest quality PCMC, especially when they seek care in higher-level facilities. Interventions to reduce disparities in PCMC are essential to improve maternal outcomes among disadvantaged groups.

Post-discharge malaria chemoprevention (PMC) in Malawi: caregivers` acceptance and preferences with regard to delivery methods.

BACKGROUND: In malaria endemic countries of sub-Saharan Africa, many children develop severe anaemia due to previous and current malaria infections. After blood transfusions and antimalarial treatment at the hospital they are usually discharged without any follow-up. In the post-discharge period, these children may contract new malaria infections and develop rebound severe anaemia. A randomised placebo-controlled trial in Malawi showed 31% reduction in malaria- and anaemia-related deaths or hospital readmissions among children under 5 years of age given antimalarial drugs for 3 months post-discharge. Thus, post-discharge malaria chemoprevention (PMC) may provide substantial protection against malaria and anaemia in young children living in areas of high malaria transmission. A delivery implementation trial is currently being conducted in Malawi to determine the optimal strategy for PMC delivery. In the trial, PMC is delivered through community- or facility-based methods with or without the use of reminders via phone text message or visit from a Health Surveillance Assistant. This paper describes the acceptance of PMC among caregivers. METHODS: From October to December 2016, 30 in-depth interviews and 5 focus group discussions were conducted with caregivers of children who recently completed the last treatment course in the trial. Views on the feasibility of various delivery methods and reminder strategies were collected. The interviews were transcribed verbatim, translated to English, and coded using the software programme NVivo. RESULTS: Community-based delivery was perceived as more favourable than facility-based delivery due to easy home access to drugs and fewer financial concerns. Many caregivers reported lack of visits from Health Surveillance Assistants and preferred text message reminders sent directly to their phones rather than waiting on these visits. Positive attitudes towards active use of health cards for remembering treatment dates were especially evident. Additionally, caregivers shared positive experiences from participation in the programme and described dihydroartemisinin-piperaquine as a safe and effective antimalarial drug that improved the health and well-being of their children. CONCLUSIONS: Post-discharge malaria chemoprevention given to children under the age of 5 previously treated for severe anaemia is highly accepted among caregivers. Caregivers prefer community-based delivery with use of health cards as their primary tool of reference. TRIAL REGISTRATION: NCT02721420 (February 13, 2016).

"In the hospital, there will be nobody to pamper me": a qualitative assessment on barriers to facility-based delivery in post-Ebola Sierra Leone.

BACKGROUND: Sierra Leone has one of the highest maternal mortality rates in the world. Encouraging the use of skilled birth attendance in health facilities is an important step in the endeavor to increase the number of safe deliveries. However, public trust in health facilities has been greatly damaged during the Ebola epidemic outbreak in Sierra Leone in 2014/2015, and little is known about external and intrinsic barriers to facility-based delivery (FBD) in the country since the end of the Ebola epidemic. METHODS: We conducted a qualitative study on FBD in Princess Christian Maternity Hospital, Freetown, which is the national referral maternity hospital in Sierra Leone. We performed six focus group discussions with providers, pregnant women and recent mothers surrounding experiences, attitudes and behaviors regarding FBD and potential barriers. Discussions were tape recorded, transcribed and evaluated through content analysis. RESULTS: Women in our study were overall technically aware of the higher safety linked with FBD, but this often diverged from their individual desire to deliver in a supportive and trusted social and traditional environment. Close relatives and community members seemed to be highly influencial regarding birth practices. Many women associated FBD with negative staff attitudes and an undefined fear. Logistic issues regarding transportation problems or late referral from smaller health centers were identified as frequent barriers to FBD. CONCLUSIONS: More supportive staff attitudes and acceptance of an accompanying person throughout delivery could be promising approaches to increase women's confidence in FBDs. However, these approaches also imply revising health systems structures, like staff working conditions that are conducive for a friendly atmosphere, sufficient space in delivery wards allowing the women to bring a birth companion, or like the establishment of a reliable peripheral ambulance system to ensure transportation and fast referral.

The influence of quality maternity waiting homes on utilization of facilities for delivery in rural Zambia.

BACKGROUND: Residential accommodation for expectant mothers adjacent to health facilities, known as maternity waiting homes (MWH), is an intervention designed to improve access to skilled deliveries in low-income countries like Zambia where the maternal mortality ratio is estimated at 398 deaths per 100,000 live births. Our study aimed to assess the relationship between MWH quality and the likelihood of facility delivery in Kalomo and Choma Districts in Southern Province, Zambia. METHODS: We systematically assessed and inventoried the functional capacity of all existing MWH using a quantitative facility survey and photographs of the structures. We calculated a composite score and used multivariate regression to quantify MWH quality and its association with the likelihood of facility delivery using household survey data collected on delivery location in Kalomo and Choma Districts from 2011-2013. RESULTS: MWH were generally in poor condition and composite scores varied widely, with a median score of 28.0 and ranging from 12 to 66 out of a possible 75 points. Of the 17,200 total deliveries captured from 2011-2013 in 40 study catchment area facilities, a higher proportion occurred in facilities where there was either a MWH or the health facility provided space for pregnant waiting mothers compared to those with no accommodations (60.7% versus 55.9%, p <0.001). After controlling for confounders including implementation of Saving Mothers Giving Life, a large-scale maternal health systems strengthening program, among women whose catchment area facilities had an MWH, those women with MWHs in their catchment area that were rated medium or high quality had a 95% increase in the odds of facility delivery than those whose catchment area MWHs were of poor quality (OR: 1.95, 95% CI 1.76, 2.16). CONCLUSIONS: Improving both the availability and the quality of MWH represents a potentially useful strategy to increasing facility delivery in rural Zambia. TRIAL REGISTRATION: The Zambia Chlorhexidine Application Trial is registered at Clinical Trials.gov (identifier: NCT01241318).

Determinants of maternal health care services utilization in Pakistan: evidence from Pakistan demographic and health survey, 2012-13.

The aim of this study was to determine the association between maternal utilisation of health-care services and socio-demographic factors among reproductive-age women in Pakistan. We used the sample of ever-married reproductive-age women (n = 7446) from the Pakistan Demographic and Health Survey (PDHS), 2012-13. We measured maternal utilisation of health-care services by using three dependent variables: number of antenatal care (ANC) visits, delivery assistance by a skilled health provider, and delivery in a health-care facility. Around 36.6% of women had made four or more ANC visits, 59% had received assistance from skilled health providers during delivery, and 55.3% had given birth in a health-care facility. On multivariable logistic regression, all three variables were positively associated with education and wealth, and negatively associated with birth order and women's autonomy. Policymakers and health planners may use our findings to develop efficient strategies, particularly for uneducated women and those with poor economic status, to improve the utilisation of maternal health-care services in Pakistan.

Assessing delivery practices of mothers over time and over space in Uganda, 2003-2012.

BACKGROUND: It is well known that safe delivery in a health facility reduces the risks of maternal and infant mortality resulting from perinatal complications. What is less understood are the factors associated with safe delivery practices. We investigate factors influencing health facility delivery practices while adjusting for multiple other factors simultaneously, spatial heterogeneity, and trends over time. METHODS: We fitted a logistic regression model to Lot Quality Assurance Sampling (LQAS) data from Uganda in a framework that considered individual-level covariates, geographical features, and variations over five time points. We accounted for all two-covariate interactions and all three-covariate interactions for which two of the covariates already had a significant interaction, were able to quantify uncertainty in outputs using computationally intensive cluster bootstrap methods, and displayed outputs using a geographical information system. Finally, we investigated what information could be predicted about districts at future time-points, before the next LQAS survey is carried out. To do this, we applied the model to project a confidence interval for the district level coverage of health facility delivery at future time points, by using the lower and upper end values of known demographics to construct a confidence range for the prediction and define priority groups. RESULTS: We show that ease of access, maternal age and education are strongly associated with delivery in a health facility; after accounting for this, there remains a significant trend towards greater uptake over time. We use this model together with known demographics to formulate a nascent early warning system that identifies candidate districts expected to have low prevalence of facility-based delivery in the immediate future. CONCLUSIONS: Our results support the hypothesis that increased development, particularly related to education and access to health facilities, will act to increase facility-based deliveries, a factor associated with reducing perinatal associated mortality. We provide a statistical method for using inexpensive and routinely collected monitoring and evaluation data to answer complex epidemiology and public health questions in a resource-poor setting. We produced a model based on this data that explained the spatial distribution of facility-based delivery in Uganda. Finally, we used this model to make a prediction about the future priority of districts that was validated by monitoring and evaluation data collected in the next year.

Out-of-pocket expenditures for childbirth in the context of the Janani Suraksha Yojana (JSY) cash transfer program to promote facility births: who pays and how much? Studies from Madhya Pradesh, India.

BACKGROUND: High out-of-pocket expenditures (OOPE) make delivery care difficult to access for a large proportion of India's population. Given that home deliveries increase the risk of maternal mortality, in 2005 the Indian Government implemented the Janani Suraksha Yojana (JSY) program to incentivize poor women to deliver in public health facilities by providing a cash transfer upon discharge. We study the OOPE among JSY beneficiaries and women who deliver at home, and predictors of OOPE in two districts of Madhya Pradesh. METHODS: September 2013 to April 2015 a cross-sectional community-based survey was performed. All recently delivered women were interviewed to elicit delivery costs, socio-demographic characteristics and delivery related information. RESULTS: Most women (n = 1995, 84 %) delivered in JSY public health facility, the remaining 16 % (n = 386) delivered at home. Women who delivered under JSY program had a higher median, IQR OOPE ($8, 3-18) compared to home ($6, 2-13). Among JSY beneficiaries, poorest women had twice net gain ($20) versus wealthiest ($10) post cash transfer. Informal payments (64 %) and food/baby items (77 %) were the two most common sources of OOPE. OOPE made among JSY beneficiaries was pro-poor: poorer women made proportionally less expenditures compared to wealthier women. In an adjusted model, delivering in a JSY public facility increased odds of incurring expenditures (OR: 1.58, 95 % CI: 1.11-2.25) but at the same time to a 16 % (95 % CI: 0.73-0.96) decrease in the amount paid compared to home deliveries. CONCLUSIONS: OOPE is prevalent among JSY beneficiaries as well in home deliveries. In JSY, OOPE varies by income quintile: wealthier quintiles pay more OOPE. However the cash incentive is adequate enough to provide a net gain for all quintiles. OOPE was largely due to indirect costs and not direct medical payments. The program seems to be effective in providing financial protection for the most vulnerable groups.