Effects of the physical accessibility of maternal health services on their use in rural Haiti

An analysis of data from the 2000 Demographic and Health Survey shows that little use is made of antenatal and delivery-care services in rural Haiti. After adjusting for individual-level factors, poor road conditions significantly reduce the likelihood of timely receipt of antenatal care and of four or more antenatal care visits, while the availability of a health centre within 5 kilometres significantly increases the odds of each outcome. The odds of being attended at delivery by trained medical personnel and of institutional delivery are significantly reduced by mountainous terrain and distance from the nearest hospital, and are increased if a health worker providing antenatal care is present in the neighbourhood. Neighbourhood poverty reduces the likelihood of safe delivery care. The findings suggest that improving the use made of maternal healthcare services would require, among other things, improvement of the availability of services and road conditions, and the reduction of poverty.     

Fertility intentions and maternal health behaviour during and after pregnancy

This study examines associations between fertility intentions and maternal health behaviours during and after pregnancy among a nationally representative sample of 3,442 women from India. Two waves of data (2005, 2012) from the India Human Development Survey were analyzed to investigate the influence of unwanted births on women’s use of antenatal care, timely postnatal care, and the delivery setting using binary and ordered logistic regression, partial proportional odds models, and propensity score weighting. Fifty-eight per cent of sample births were unwanted. Regression results show that, net of maternal and household characteristics, women with unwanted births were less likely to obtain any antenatal care and had fewer antenatal tests performed. Unwantedness was also associated with a lower likelihood of delivering in an institutional setting and of obtaining timely postnatal care. The relationships between unwantedness and antenatal care, postnatal care, and delivery setting were robust to models accounting for propensity weighting.     

Organized Violence and Institutional Child Delivery: Micro-Level Evidence From Sub-Saharan Africa, 1989–2014

The conditions under which a mother gives birth greatly affect the health risk of both the mother and the child. This article addresses how local exposure to organized violence affects whether women give birth in a health facility. We combine geocoded data on violent events from the Uppsala Conflict Data Program with georeferenced survey data on the use of maternal health care services from the Demographic and Health Surveys. Our sample covers 569,201 births by 390,574 mothers in 31 countries in sub-Saharan Africa. We use a mother fixed-effects analysis to estimate the effect of recent organized violence events within a radius of 50 km of the home of each mother on the likelihood that her child is born in a health facility. The results indicate that geographical and temporal proximity to organized violence significantly reduces the likelihood of institutional births. Although the level of maternal health care overall is lower in rural areas, the negative effect of violence appears to be stronger in urban areas. The study further underscores the importance of household and individual resilience, indicating that the effect of organized violence on institutional child delivery is greater among poor and less-educated mothers.     

Measuring Change Over Time in Socio-economic Deprivation and Health in an Urban Context: The Case Study of Genoa

Poverty and disability are interrelated, but data that can disentangle to what extent one causes the other and vice versa is not available. However, data from Vietnam allows us to examine this interrelationship in a way not done previously. Using small area estimation techniques, we uncover three findings not yet found in the literature. First, disability prevalence rates vary significantly within a country even at the district level. Second, the poverty gap between people with and without disabilities also varies at the district level. And most importantly, the size of that gap lessens based on district characteristics that can be affected by policy. Districts with better health care and infrastructure, such as road and health services, show less of a link between disability and poverty, supporting the hypothesis that improvements in infrastructure and rehabilitation service can lessen the impact of disability on families with disabled members.     

Factors affecting rural women's utilisation of continuum of care services in remote or isolated villages or Pakistan – A mixed-methods study

IntroductionAn effective continuum of care for pregnancy and childbirth connects women and girls with essential reproductive and maternity care services. This study aimed to estimate the continuum of care utilisation rate of women who lived in remote and isolated regions of Pakistan and explored factors that influence women's utilisation of reproductive and maternity care services.MethodsA mixed-methods study was conducted in five rural villages of Sindh, Pakistan. A cross-sectional survey with 669 women who gave birth between July 2010 and September 2014 investigated women's maternity-care service utilisation during pregnancy, childbirth, and in the postpartum period. In-depth interviews with 15 women explored their maternity-care experiences with health providers.ResultsOnly 6.4% of 669 women participants reported to have completed the continuum of care for their last pregnancy. Skilled birth attendants, including health professionals, were used by 56.1% for antenatal care, 40.8% for both antenatal and childbirth, 22.3% for antenatal, childbirth and postnatal, and only 6.4% reported using all pregnancy-related and postpartum services. Limited knowledge about affordable health services, poor health literacy, and access to health services was associated with women's fragmented utilisation of maternity care. A lack of respectful maternity-care was also identified as a major barrier to women's utilisation of primary health care facilities, especially for childbirth.ConclusionThe existing primary health structure in Pakistan provides a good foundation to deliver continuity of care services; however, health services utilisation for reproductive and maternity care remains suboptimal in women who live in geographically remote regions of Pakistan.     

The perceptions and practices of Thai health professionals providing maternity care for migrant Burmese women: An ethnographic study

BackgroundAcross the globe, many women including economic and humanitarian migrants receive inadequate antenatal care. Understanding the difficulties that migrant women encounter when accessing maternity care, including the approach of health professionals, is necessary because inadequate care is associated with increasing rates of morbidity and mortality. There are very few studies of migrant women’s access to and experience of maternity services when they have migrated from a low- to a middle-income country.AimTo examine the perceptions and practices of Thai health professionals providing maternity care for migrant Burmese women, and to describe women’s experiences of their encounters with health professionals providing maternity care in Ranong Province in southern Thailand.MethodsEthnography informed the study design. Individual interviews were conducted with 13 healthcare professionals and 10 Burmese women before and after birth. Observations of interactions (130 h) between health care providers and Burmese women were also conducted. Data were analysed using thematic analysis.FindingsThe healthcare professionals’ practices differed between the antenatal clinics and the postnatal ward. Numerous barriers to accessing culturally appropriate antenatal care were evident. In contrast, the care provided in the postnatal ward was woman and family centered and culturally sensitive. One overarching theme, “The system is in control’ was identified, and comprised three sub-themes (1) ‘Being processed’ (2) ‘Insensitivity to cultural practices’ and, (3) ‘The space to care’.Discussion and conclusionsThe health system and healthcare professionals controlled the way antenatal care was provided to Burmese migrant women. This bureaucratic and culturally insensitive approach to antenatal care impacted on some women’s decision to engage in antenatal care. Conversely, the more positive examples of woman-centered care evident after birth in the postnatal ward, can inform service delivery.     

The Effect of Antenatal Care on Professional Assistance at Delivery in Rural India

Delivering births in a medical institution or at home with professional medical assistance has been shown to promote safe motherhood and child survival. Yet three-quarters of births in rural India continue to take place at home, most of them without the assistance of any trained health worker. This study examines the role of antenatal care (ANC) in promoting professional assistance at delivery, using data from India’s 1992–93 and 1998–99 National Family Health Surveys (NFHS-1 and NFHS-2). We estimate the effect of number of antenatal care visits (0, 1–2, 3+) on professional assistance at delivery (no assistance, professional assistance at home, delivery in a medical institution), using multinomial logistic regression, controlling for demographic, geographic, and socioeconomic factors, pregnancy complications, and two measures of access to health facilities. The results indicate that, after controlling for other variables (including ANC), pregnancy complications and access to health facilities do not have much effect on assistance at delivery. By contrast, ANC has a large effect, even after all other variables are controlled. The effect of ANC on professional assistance at delivery is larger in South India than in North India, and predicted percentages receiving professional assistance are higher in South India than in North India. A policy implication is that increased antenatal care coverage can be an effective means of increasing professional assistance at delivery, especially delivery in a medical institution.

Prenatal and delivery care and childhood immunization in guatemala: Do family and community matter?*

In this paper we investigate family choices about pregnancy-related care and the use of childhood immunization. Estimates obtained from a multilevel logistic model indicate that use of formal (or “modern ”) health services differs substantially by ethnicity, by social and economic factors, and by availability of health services. The results also show that family and community membership are very important determinants of the use of health care, even in the presence of controls for a large number of observed characteristics of individuals, families, and communities.     

The inequality of maternal health care in urban sub-Saharan Africa in the 1990s

Numerous studies document the disadvantage in child health of the urban poor in African cities. This study uses Demographic and Health Survey data from 23 countries in sub-Saharan Africa to examine whether the urban poor experience comparable disadvantages in maternal health care. The results show that, although on average the urban poor receive better antenatal and delivery care than rural residents, the care of the urban poor is worse than that of the urban non-poor. This suggests that the urban bias in the allocation of health services in Africa does not benefit the urban poor as much as the non-poor. Multilevel analyses reveal significant variations in maternal health in urban areas across countries of sub-Saharan Africa. The dis-advantage of the urban poor is more pronounced in countries where maternal health care is relatively good. In these countries the urban poor tend to be even worse off than rural residents, suggesting that the urban poor have benefited least from improvements in maternal health care.     

The Impact of the AIDS Pandemic on Health Services in Africa: Evidence from Demographic and Health Surveys

We document the impact of the AIDS crisis on non-AIDS-related health services in 14 sub-Saharan African countries. Using multiple waves of Demographic and Health Surveys (DHS) for each country, we examine antenatal care, birth deliveries, and rates of immunization for children born between 1988 and 2005. We find deterioration in nearly all these dimensions of health care over this period. The most recent DHS survey for each country collected data on HIV prevalence, which allows us to examine the association between HIV burden and health care. We find that erosion of health services is the largest in regions that have developed the highest rates of HIV. Regions of countries that have light AIDS burdens have witnessed small or no declines in health care, using the measures noted above, while those regions shouldering the heaviest burdens have seen the largest erosion in non-HIV-related health services for pregnant women and children. Using semiparametric techniques, we can date the beginning of the divergence in the use of antenatal care and in children’s immunizations between high- and low-HIV regions to the mid-1990s.     

Household and Contextual Indicators of Poverty in Tunisia: A Multilevel Analysis

Using micro data from the 2010 National Survey on Households’ Budget, Consumption and Standard of Living, this study aims to investigate main factors contributing to poverty distribution, one of the most severe socioeconomic problems in Tunisia. To this end, we use a multilevel Logit model and a multilevel mixed linear model to simultaneously analyze the micro-level (household) and macro-level (governorate) factors that might affect the household poverty status. Household size, household composition, occupation, education levels, the gender of the household head and the number of earner by household variables were assessed at the micro-level. Unemployment rate, poverty rate, industrial and agriculture parts and the migration are included to control the effect of contextual effects. Our findings showed that the likelihood of household being poor is positively and significantly related to household size, more children and lower education level. Extreme poverty is more likely to occur in rural than urban areas. Macro-level analyses indicated that greater neighbourhood unemployment rate was associated with higher odds of poverty, while greater industrial agglomeration and migration balance were associated with reduced odds of poverty.     

Gender and Multidimensional Poverty in South Africa: Applying the Global Multidimensional Poverty Index (MPI)

Recent work has shown that the gender gap in income poverty has widened in post-apartheid South Africa even though overall poverty levels have declined. One of the main criticisms of money-metric studies of gendered poverty differences is that income is only one dimension of poverty and that other measures of welfare may better reflect the relative well-being of women and female-headed households. This article presents a multidimensional approach to measuring the gender poverty gap in post-apartheid South Africa. Using data from the 2008 wave of the South African National Income Dynamic Study, the internationally comparable multidimensional poverty index (the MPI) is used to estimate gender differences in a number of different achievements. The findings suggest that the multidimensional gender poverty gap is similar to the poverty gap measured by the conventional money-metric approach at several national poverty lines. However, the MPI poverty differential between female- and male-headed households is slightly narrower than the income poverty gap between these two household types. In order to explore these findings further, the paper decomposes the components of multidimensional poverty by gender and for both female- and male-headed households. The paper concludes by considering how greater investments in health care delivery and in basic services, particularly in rural areas, may yield progress towards gender equality.     

The behaviour towards malaria care—a multinomial logit approach

This paper attempts to estimate a disease specific demand function to study the determinants of utilisation of the services of a health care provider or a treatment regiment for malaria. The study adapts a multinomial logit framework to look at both facility characteristics and individual patient features on demand for malaria care in Ghana. The individual patient characteristics form a set of social indicators which can be used to discriminate or put into groups patients with respect to their choice of provider.The study confirms the popular use of self-medication as a first choice of action in treating malaria. The choice of malaria care providers is found to be influenced by facility price, travel time, waiting time for treatment, education, age, sex and quality of care measured in terms of drugs availability. We further find that as income increases, the odds are in favour of self-medication when people get malaria.     

A qualitative study of innovations implemented to improve transition of care from maternity to child and family health (CFH) services in Australia

BackgroundThe transition of care (ToC) from maternity services, particularly from midwifery care to child and family health (CFH) nursing services, is a critical time in the support of women as they transition into early parenting. However significant issues in service provision exist, particularly meeting the needs of women with social and emotional health risk factors. These include insufficient resources, poor communication and information transfer, limited interface between private and public health systems and tension around role boundaries. In response some services are implementing strategies to improve the transition of care from maternity to CFH services.AimThis paper describes a range of innovations developed to improve transition of care between maternity and child and family health services and identifies the characteristics common to all innovations.MethodsData reported were collected in phase three of a mixed methods study investigating the feasibility of implementing a national approach to child and family health services in Australia (CHoRUS study). Data were collected from 33 professionals including midwives, child and family health nurses, allied health staff and managers, at seven sites across four Australian states. Data were analysed thematically, guided by Braun and Clarke's six-step process of thematic analysis.FindingsThe range of innovations implemented included those which addressed; information sharing, the efficient use of funding and resources, development of new roles to improve co-ordination of care, the co-location of services and working together. Four of the seven sites implemented innovations that specifically targeted families with additional needs. Successful implementation was dependent on the preliminary work undertaken which required professionals and/or organisations to work collaboratively.ConclusionImproving the transition of care requires co-ordination and collaboration to ensure families are adequately supported. Collaboration between professionals and services facilitated innovative practice and was core to successful change.     

The Pervasive and Persistent Influence of Caste on Child Mortality in India

This study examines the effect of caste on child mortality and maternal health care utilization in rural India using data from the National Family Health Survey (NFHS-2) carried out during 1998–1999. Results from multilevel discrete-time hazard models indicate that, net of individual-level and community-level controls, children belonging to low castes have higher risks of death and women belonging to low castes have lower rates of antenatal and delivery care utilization than children and women belonging to upper castes. At the same time, the controls account for most of the differences within the low castes. Further analysis shows that the mortality disadvantage of low castes is more pronounced in poorer districts. These results highlight the need to target low caste members in the provision of maternal and child health services.     

Unmet mental health and substance abuse treatment needs of sexual minority elders

In a survey exploring the reliability and validity of a screening tool, we explored the substance abuse and mental health issues among 371 elders; 74 were sexual minorities. Analyses by age group indicated that elders 55-64 years had significantly more problems with substance abuse, posttraumatic stress disorder (PTSD), depression, anxiety, and suicidal thoughts compared to those 65 and older. Bisexuals reported significantly greater problems with depression, anxiety, and suicidality than either heterosexual or lesbian or gay elders. Mental health and substance abuse treatment utilization was low among all elders with problems. Implications for assessment, access to care, and group-specific services delivery are discussed.     

城乡差异、就医惯性与老年人卫生服务利用

现有对城乡老年人卫生服务利用不公平的研究多忽略了长期的城乡差异所导致的隐性的农村老年人就医惯性的存在。本研究在控制了收入、医疗保障和就医可及性等因素的条件下,发现就医惯性的存在;并运用集中指数分解法发现,卫生服务的利用存在不公平,偏向于富人,而就医惯性在两种卫生服务利用中的贡献度分别为12%和5%。这种城乡固定差异造成了农村老年人在身体健康、心理健康和自我照料能力上都显著地低于城市老年人。