Time trends in facility-based and private-sector childbirth care: analysis of Demographic and Health Surveys from 25 sub-Saharan African countries from 2000 to 2016.

BACKGROUND: Africa, and sub-Saharan Africa in particular, remains one of the regions with modest improvements to maternal and newborn survival and morbidity. Good quality intrapartum and early postpartum care in a health facility as well as delivery under the supervision of trained personnel is associated with improved maternal and newborn health outcomes and decreased mortality. We describe and contrast recent time trends in the scale and socio-economic inequalities in facility-based and private facility-based childbirth in sub-Saharan Africa. METHODS: We used Demographic and Health Surveys in two time periods (2000-2007 and 2008-2016) to analyse levels and time trends in facility-based and private facility-based deliveries for all live births in the five-year survey recall period to women aged 15-49. Household wealth quintiles were used for equity analysis. Absolute numbers of births by facility sector were calculated applying UN Population Division crude birth rates to the total country population. RESULTS: The percentage of all live births occurring in health facilities varied across countries (5%-85%) in 2000-2007. In 2008-2016, this ranged from 22% to 92%. The lowest percentage of all births occurring in private facilities in 2000-2007 period was in Ethiopia (0.3%) and the highest in the Democratic Republic of Congo at 20.5%. By 2008-2016, this ranged from 0.6% in Niger to 22.3% in Gabon. Overall, the growth in the absolute numbers of births in facilities outpaced the growth in the percentage of births in facilities. The largest increases in absolute numbers of births occurred in public sector facilities in all countries. Overall, the percentage of births occurring in facilities was significantly lower for poorest compared to wealthiest women. As the percentage of facility births increased in all countries over time, the extent of wealth-based differences had reduced between the two time periods in most countries (median risk ratio in 2008-2016 was 2.02). The majority of countries saw a narrowing in both the absolute and relative difference in facility-based deliveries between poorest and wealthiest. CONCLUSIONS: The growth in facility-based deliveries, which was largely driven by the public sector, calls for increased investments in effective interventions to improve service delivery and quality of life for the mother and newborn. The goal of universal health coverage to provide better quality services can be achieved by deploying interventions that are holistic in managing and regulating the private sector to enhance performance of the health care system in its entirety rather than interventions that only target service delivery in one sector

Maternal and child health interventions in Nigeria: a systematic review of published studies from 1990 to 2014

BACKGROUND: Poor maternal and child health indicators have been reported in Nigeria since the 1990s. Many interventions have been instituted to reverse the trend and ensure that Nigeria is on track to achieve the Millennium Development Goals. This systematic review aims at describing and indirectly measuring the effect of the Maternal, Newborn, and Child Health (MNCH) interventions implemented in Nigeria from 1990 to 2014. METHODS: PubMed and ISI Web of Knowledge were searched from 1990 to April 2014 whereas POPLINE® was searched until 16 February 2015 to identify reports of interventions targeting Maternal, Newborn, and Child Health in Nigeria. Narrative and graphical synthesis was done by integrating the results of extracted studies with trends of maternal mortality ratio (MMR) and under five mortality (U5MR) derived from a joint point regression analysis using Nigeria Demographic and Health Survey data (1990-2013). This was supplemented by document analysis of policies, guidelines and strategies of the Federal Ministry of Health developed for Nigeria during the same period. RESULTS: We identified 66 eligible studies from 2,662 studies. Three interventions were deployed nationwide and the remainder at the regional level. Multiple study designs were employed in the enrolled studies: pre- and post-intervention or quasi-experimental (n = 40; 61%); clinical trials (n = 6;9%); cohort study or longitudinal evaluation (n = 3;5%); process/output/outcome evaluation (n = 17;26%). The national MMR shows a consistent reduction (Annual Percentage Change (APC) = -3.10%, 95% CI: -5.20 to -1.00 %) with marked decrease in the slope observed in the period with a cluster of published studies (2004-2014). Fifteen intervention studies specifically targeting under-five children were published during the 24 years of observation. A statistically insignificant downward trend in the U5MR was observed (APC = -1.25%, 95% CI: -4.70 to 2.40%) coinciding with publication of most of the studies and development of MNCH policies. CONCLUSIONS: The development of MNCH policies, implementation and publication of interventions corresponds with the downward trend of maternal and child mortality in Nigeria. This systematic review has also shown that more MNCH intervention research and publications of findings is required to generate local and relevant evidence

Mortality in twentieth-century Malawi

This dissertation is a composite of three related papers that focus on mortality in Malawi. The first paper utilizes census data to examine changes in adult mortality between 1987 and 1998. In the second paper, I use the same data to examine a cohort of women aged 45 and older at the time of the 1987 census and follow them in 1998 to assess the influence of children ever born and school attainment on their survival. The third paper employs information on household characteristics that was gathered in the two censuses to examine household socioeconomic status and its relationship to childhood mortality in Malawi. In the first paper, I use a demographic technique to infer mortality conditions directly from census age distributions and age-specific growth rates. The results show that adult mortality has increased rapidly between 1987 and 1998 with huge declines in the estimated life expectancy between ages 15 and 45 for males, and between ages 15 and 35 for females. In the second paper, I use a statistical technique to examine the survival of women in 1987 to the 1998 census. The results show that women with few children and higher schooling are more likely to survive than women with more children and low schooling. The third paper explores the extent to which housing and household characteristics, including asset possessions, could be used as a proxy for income and, consequently, socioeconomic status of households in Malawi where direct measures of income are not usually available. The results are interesting. In 1987, child mortality is low among “rich” households and high among “poor” households. However, analysis of the 1998 data shows that child mortality is higher among “rich” households and also among middle-aged women. These results are consistent with parallel analysis from the 1992 and 2000 Demographic and Health Survey data suggesting the impact of HIV/AIDS which is taking a toll on the country as evidenced by the current high HIV prevalence. This analysis underscores the importance of information on household characteristics collected in censuses for studying the relationship between socioeconomic status and other demographic outcomes

Mortality in twentieth-century Malawi

This dissertation is a composite of three related papers that focus on mortality in Malawi. The first paper utilizes census data to examine changes in adult mortality between 1987 and 1998. In the second paper, I use the same data to examine a cohort of women aged 45 and older at the time of the 1987 census and follow them in 1998 to assess the influence of children ever born and school attainment on their survival. The third paper employs information on household characteristics that was gathered in the two censuses to examine household socioeconomic status and its relationship to childhood mortality in Malawi. In the first paper, I use a demographic technique to infer mortality conditions directly from census age distributions and age-specific growth rates. The results show that adult mortality has increased rapidly between 1987 and 1998 with huge declines in the estimated life expectancy between ages 15 and 45 for males, and between ages 15 and 35 for females. In the second paper, I use a statistical technique to examine the survival of women in 1987 to the 1998 census. The results show that women with few children and higher schooling are more likely to survive than women with more children and low schooling. The third paper explores the extent to which housing and household characteristics, including asset possessions, could be used as a proxy for income and, consequently, socioeconomic status of households in Malawi where direct measures of income are not usually available. The results are interesting. In 1987, child mortality is low among “rich” households and high among “poor” households. However, analysis of the 1998 data shows that child mortality is higher among “rich” households and also among middle-aged women. These results are consistent with parallel analysis from the 1992 and 2000 Demographic and Health Survey data suggesting the impact of HIV/AIDS which is taking a toll on the country as evidenced by the current high HIV prevalence. This analysis underscores the importance of information on household characteristics collected in censuses for studying the relationship between socioeconomic status and other demographic outcomes

Bridging the Communication Gap: Successes and Challenges of Mobile Phone Technology in a Health and Demographic Surveillance System in Northern Nigeria

Maternal and child health indicators are generally poor in Nigeria with the northern part of the country having the worst indicators than the southern part. Efforts to address maternal and health challenges in Nigeria include, among others, improvement in health and management information systems. We report on the experience of mobile phone technology in supporting the activities of a health and demographic surveillance system in northern Nigeria. Our experience calls for the need for the Nigerian Government, the mobile network companies, and the international community at large to consolidate their efforts in addressing the mobile network coverage and power supply challenges in order to create an enabling environment for socio-economic development particularly in rural and disadvantaged areas. Unless power and mobile network challenges are addressed, health interventions that rely on mobile phone technology will not have a significant impact in improving maternal and child health