Are women deciding against home births in low and middle income countries?

BackgroundAlthough there is evidence to tracking progress towards facility births within the UN Millennium Development Goals framework, we do not know whether women are deciding against home birth over their reproductive lives. Using Demographic and Health Surveys (DHS) data from 44 countries, this study aims to investigate the patterns and shifts in childbirth locations and to determine whether these shifts are in favour of home or health settings.Methods and FindingsThe analyses considered 108,777 women who had at least two births in the five years preceding the most recent DHS over the period 2000–2010. The vast majority of women opted for the same place of childbirth for their successive births. However, about 14% did switch their place and not all these decisions favoured health facility over home setting. In 24 of the 44 countries analysed, a higher proportion of women switched from a health facility to home. Multilevel regression analyses show significantly higher odds of switching from home to a facility for high parity women, those with frequent antenatal visits and more wealth. However, in countries with high infant mortality rates, low parity women had an increased probability of switching from home to a health facility.ConclusionsThere is clear evidence that women do change their childbirth locations over successive births in low and middle income countries. After two decades of efforts to improve maternal health, it might be expected that a higher proportion of women will be deciding against home births in favour of facility births. The results from this analysis show that is not the case

Operationalizing safe operating space for regional social-ecological systems

This study makes a first attempt to operationalize the safe operating space concept at a regional scale by considering the complex dynamics (e.g. non-linearity, feedbacks, and interactions) within a systems dynamic model (SD). We employ the model to explore eight ‘what if’ scenarios based on well-known challenges (e.g. climate change) and current policy debates (e.g. subsidy withdrawal). The findings show that the social-ecological system in the Bangladesh delta may move beyond a safe operating space when a withdrawal of a 50% subsidy for agriculture is combined with the effects of a 2 oC temperature increase and sea level rise. Further reductions in upstream river discharge in the Ganges would push the system towards a dangerous zone once a 3.5 oC temperature increase was reached. The social- ecological system in Bangladesh delta may be operated within a safe space by: 1) managing feedback (e.g. by reducing production costs) and the slow biophysical variables (e.g. temperature, rainfall) to increase the long-term resilience, 2) negotiating for transboundary water resources , and 3) revising global policies (e.g. withdrawal of subsidy) that negatively impact at regional scales. This study demonstrates how the concepts of tipping points, limits to adaptations, and boundaries for sustainable development may be defined in real world social-ecological systems

Unravelling the interrelationships between ecosystem services and human wellbeing in the Bangladesh delta

Coupled social and ecological systems need to be understood from a dynamic perspective in order to operationalise complexity concepts, such as tipping points, for sustainable ecosystem management. In this study, we strive to achieve this type of conceptual understanding through the analysis of the relationships (e.g. strength, nonlinearity) between the trends of ecosystem services (ES) and human wellbeing (HWB) between 1960 and 2010 in the south-west Bangladesh delta using generalized additive and logistic regression models. We use sequential principal components analysis to investigate the connectedness within the social–ecological system as a measure of resilience. We also use published literature to help develop a system dynamic framework in order to investigate how ES and HWB are interlinked. Overall, our results support previous work, which depicts that material wellbeing (basic materials for a good life) having a strong relationship with provisioning services, which in turn, show a weak relationship with the quality of life (security and health). Moreover, our analysis confirms the ‘Environmentalist’s Paradox’ that HWB has increased despite the deterioration in ES. However, our results suggest that provisioning services are not the only important reason for the increases in observed HWB, as these have also been substantially influenced by technology and capital investment (aid and subsidy). In addition, worsening trends in regulation services and in ‘slow’ variables such as climate suggest that the resilience of the overall social-ecological system is decreasing. Such changes may have severe consequences if they continue, for example, if temperatures exceed the upper physiological limits of key provisioning services (e.g. rice, fish) in the Bangladesh delta. These indicators all suggest that although in terms of HWB the deltaic social–ecological system may be successfully adapting to environmental change, it may also be close to transgressing critical ecological boundaries in the near future

Examining intersectoral integration for malaria control programmes in an urban and a rural district in Ghana: a multinomial multilevel analysis

Background: Intersectoral integration is acknowledged to be essential for improving provision of health care and outcomes, yet it remains one of the main primary health care strategic challenges. Although this is well articulated in the literature, the factors that explain differentials in levels of intersectoral integration have not been systematically studied, particularly in low and middle-income countries. In this study, we examine the levels and determinants of intersectoral integration amongst institutions engaged in malaria control programmes in an urban (Kumasi Metropolitan) district and a rural (Ahafo Ano South) district in Ghana. Methods: Interviews were conducted with representatives of 32 institutions engaged in promoting malaria prevention and control. The averaging technique proposed by Brown et al. and a two-level multinomial multilevel ordinal logistic regression were used to examine the levels of integration and the factors that explain the differentials. Results: The results show high disparity in levels of integration amongst institutions in the two districts. Integration was higher in the rural district compared to the urban district. The multivariate analysis revealed that the district effect explained 25% of the variations in integration. The type of institution, level of focus on malaria and source of funding are important predictors of intersectoral integration. Conclusion: Although not causal, integrated malaria control programmes could be important for improving malaria-related health outcomes in less developed regions as evident from the rapid decline in malaria fatality rates observed in the Ahafo Ano South district. Harmonisation of programmes should be encouraged amongst institutions and the public and private sectors should be motivated to work in partnership

Antimalarial stocking decisions among medicine retailers in Ghana: implications for quality management and control of malaria

Global health efforts such as malarial control require efficient pharmaceutical supply chains to ensure effective delivery of quality-assured medicines to those who need them. However, very little is currently known about decision-making processes within antimalarial supply chains and potential vulnerabilities to substandard and falsified medicines. Addressing this gap, we report on a study that investigated decision-making around the stocking of antimalarial products among private-sector medicine retailers in Ghana. Licensed retail pharmacies and over-the-counter (OTC) medicine retail outlets were sampled across six regions of Ghana using a two-stage stratified sampling procedure, with antimalarial medicines categorised as ‘expensive,’ ‘mid-range,’ and ‘cheaper,’ relative to other products in the shop. Retailers were asked about their motivations for choosing to stock particular products over others. The reasons were grouped into three categories: financial, reputation/experience and professional recommendation. Reputation/experience (76%, 95% CI 72.0% to 80.7%) were the drivers of antimalarial stocking decisions, followed by financial reasons (53.2%, 95% CI 48.1% to 58.3%) and recommendation by certified health professionals (24.7%, 95% CI 20.3% to 29.1%). Financial considerations were particularly influential in stocking decisions of cheaper medicines. Moreover, pharmacies and OTCs without a qualified pharmacist were significantly more likely to indicate financial reasons as a motivation for stocking decisions. No significant differences in stocking decisions were found by geographical location (zone and urban/rural) or outlet (pharmacy/OTC). These findings have implications for the management of antimalarial quality across supply chains in Ghana, with potentially important consequences for malaria control, particularly in lower-income areas where people rely on low-cost medication

Examining intersectoral integration for malaria control programmes in an urban and a rural district in Ghana: a multinomial multilevel analysis

Background: Intersectoral integration is acknowledged to be essential for improving provision of health care and outcomes, yet it remains one of the main primary health care strategic challenges. Although this is well articulated in the literature, the factors that explain differentials in levels of intersectoral integration have not been systematically studied, particularly in low and middle-income countries. In this study, we examine the levels and determinants of intersectoral integration amongst institutions engaged in malaria control programmes in an urban (Kumasi Metropolitan) district and a rural (Ahafo Ano South) district in Ghana. Methods: Interviews were conducted with representatives of 32 institutions engaged in promoting malaria prevention and control. The averaging technique proposed by Brown et al. and a two-level multinomial multilevel ordinal logistic regression were used to examine the levels of integration and the factors that explain the differentials. Results: The results show high disparity in levels of integration amongst institutions in the two districts. Integration was higher in the rural district compared to the urban district. The multivariate analysis revealed that the district effect explained 25% of the variations in integration. The type of institution, level of focus on malaria and source of funding are important predictors of intersectoral integration. Conclusion: Although not causal, integrated malaria control programmes could be important for improving malaria-related health outcomes in less developed regions as evident from the rapid decline in malaria fatality rates observed in the Ahafo Ano South district. Harmonisation of programmes should be encouraged amongst institutions and the public and private sectors should be motivated to work in partnershi

Collective influence of household and community capitals on agricultural employment as a measure of rural poverty in the Mahanadi Delta, India

The main determinants of agricultural employment are related to households’ access to private assets and the influence of inherited social–economic stratification and power relationships. However, despite the recommendations of rural studies which have shown the importance of multilevel approaches to rural poverty, very few studies have explored quantitatively the effects of common-pool resources and household livelihood capitals on agricultural employment. Understanding the influence of access to both common-pool resources and private assets on rural livelihoods can enrich our understanding of the drivers of rural poverty in agrarian societies, which is central to achieving sustainable development pathways. Based on a participatory assessment conducted in rural communities in India, this paper differentiates two levels of livelihood capitals (household capitals and community capitals) and quantifies them using national census data and remotely sensed satellite sensor data. We characterise the effects of these two levels of livelihood capitals on precarious agricultural employment by using multilevel logistic regression. Our study brings a new perspective on livelihood studies and rural economics by demonstrating that common-pool resources and private assets do not have the same effect on agricultural livelihoods. It identifies that a lack of access to human, financial and social capitals at the household level increases the levels of precarious agricultural employment, such as daily-wage agricultural labour. Households located in communities with greater access to collective natural capital are less likely to be agricultural labourers. The statistical models also show that proximity to rural centres and access to financial infrastructures increase the likelihood of being a landless agricultural labourer. These findings suggest that investment in rural infrastructure might increase livelihood vulnerability, if not accompanied by an improvement in the provisioning of complementary rural services, such as access to rural finance, and by the implementation of agricultural tenancy laws to protect smallholders’ productive assets

Integrative Analysis Applying the Delta Dynamic Integrated Emulator Model in South-West Coastal Bangladesh

A flexible meta-model, the Delta Dynamic Integrated Emulator Model (ΔDIEM), is developed to capture the socio-biophysical system of coastal Bangladesh as simply and efficiently as possible. Operating at the local scale, calculations occur efficiently using a variety of methods, including linear statistical emulators, which capture the behaviour of more complex models, internal process-based models and statistical associations. All components are tightly coupled, tested and validated, and their behaviour is explored with sensitivity tests. Using input data, the integrated model approximates the spatial and temporal change in ecosystem services and a number of livelihood, well-being, poverty and health indicators of archetypal households. Through the use of climate, socio-economic and governance scenarios plausible trajectories and futures of coastal Bangladesh can be explored