Exploring the association between FGM/C and fistula: A review of the evidence

Female genital mutilation/cutting (FGM/C) and fistula are both conditions that have a range of health, socioeconomic, and lifestyle causes and consequences for women globally. There have been sparse empirical and conceptual efforts to look at how these two conditions manifest and relate to one another. This rigorous review of the literature aims to fill this research gap by assessing the state of evidence on the association of FGM/C and fistula and conceptually mapping this association within broader social, political, and health-systems contexts. Based on the findings, the authors of this report have developed a conceptual mapping framework to situate the evidence of an association between FGM/C and fistula, including high-income countries and low- and middle-income countries where migrants or underserved populations lack access to proper pregnancy and delivery care. The authors recommend that researchers, as well as policy and program implementers, think through and utilize the framework in their work in order to consider the intersectional influences on both conditions

Evaluation of the impact of the voucher program for improving maternal health behavior and status in Bangladesh

Vouchers, a demand-side financing (DSF) instrument for health-care services, were introduced in Bangladesh in 2006. The DSF program grants vouchers to pregnant women to receive free antenatal, delivery, and postpartum care services as well as free medicine, and financial assistance is provided for transportation. Deliveries with skilled service providers are financially incentivized and providers are reimbursed for their services from a special fund. After piloting DSF initially in 21 subdistricts (upazilas), the government expanded it to another 12 upazilas in 2007 (the second phase), and in its third phase in 2010 the program was expanded to another 11 upazilas. To measure DSF’s effect on improved access, quality, and reduced inequity for reproductive health services, during the third phase of the program the Population Council conducted a comprehensive evaluation with both baseline and endline surveys in 11 DSF upazilas and compared their outcomes with those from upazilas served by similar facilities not included in the DSF program. This final report contains key facility and policy program recommendations

Distance travelled and cost of transport for use of facility-based maternity services in rural Bangladesh: A cross-sectional survey

Background: Although maternal mortality in Bangladesh has decreased significantly, underutilisation of facilities for maternal health care continues to be a persistent challenge. Women often have to travel long distances and face transportation costs to deliver at a health facility. To reduce financial barriers, the Ministry of Health and Family Welfare introduced a demand-side financing programme that gives incentives to expectant mothers. We assessed the role of distance and transportation cost in the use of antenatal care, delivery, complication management, and postnatal care from a health facility. Methods: We did this cross-sectional survey in 22 subdistricts in Bangladesh. From each subdistrict, three of nine unions and three villages from each union were selected through probability proportional to size in 2010. Mothers who had given birth in the preceding year were interviewed about distance from residence to a health facility, transportation cost, and mode of transport. Findings: 3300 women were interviewed. 1742 (53%) women received antenatal care, 647 (20%) received delivery care, and 343 (10%) received postnatal care at a health-care facility. On average, women travelled 6 km for antenatal check-ups (range 0–70 km) and postnatal check-ups (range 0–45 km) and 8 km for management of complications (range 0–50 km) or delivery (0–70 km). Most women used a non-motorised rickshaw or van to reach a health facility. On average, women spent Taka 100 (US$1·4, range 0-32·14) on transportation for antenatal care, Taka 432 ($6·17, range 0-100) for delivery, and Taka 132 ($1·89, range 0-35·71) for a postnatal check-up. For each additional kilometre, the cost increased by Taka 9 ($0·13) for antenatal care, Taka 31 ($0·44) for delivery, and Taka 8 ($0·11) for postnatal care. Interpretation: Use of maternal health-care services at a health-care facility was low in rural Bangladesh. At present, the demand-side financing programme gives a flat payment of Taka 100 ($1·4) for transportation cost for each visit. This payment is insufficient. Programme managers should review the transportation allowance

Improving access to delivery care and reducing the equity gap through voucher program in Bangladesh: Evidence from difference-in-differences analysis

To test a statistically significant change in delivery by medically trained providers following introduction of a demand-side financing voucher, a population-based quasi-experimental study was undertaken, with 3,300 mothers in 2010 and 3,334 mothers at follow-up in 2012 in government-implemented voucher program and control areas. Results found that voucher program was significantly associated with increased public health facility use (difference-in-differences (DID) 13.9) and significantly increased delivery complication management care (DID 13.2) at facility although a null effect was found in facility-based delivery increase. A subset analysis of the five well-functioning facilities showed that facility deliveries increased DID 5.3 percentage points. Quintile-based analysis of all facilities showed that facility delivery increased more than threefold in lower quintile households comparing to twofold in control sites. The program needs better targeting to the beneficiaries, ensuring available gynecologist–anesthetist pair and midwives, effective monitoring, and timely fund reimbursements to facilities

“Poverty is the big thing”: exploring financial, transportation, and opportunity costs associated with fistula management and repair in Nigeria and Uganda

Abstract Background Women living with obstetric fistula often live in poverty and in remote areas far from hospitals offering surgical repair. These women and their families face a range of costs while accessing fistula repair, some of which include: management of their condition, lost productivity and time, and transport to facilities. This study explores, through women’s, communities’, and providers’ perspectives, the financial, transport, and opportunity cost barriers and enabling factors for seeking repair services. Methods A qualitative approach was applied in Kano and Ebonyi in Nigeria and Hoima and Masaka in Uganda. Between June and December 2015, the study team conducted in-depth interviews (IDIs) with women affected by fistula (n = 52) – including those awaiting repair, living with fistula, and after repair, and their spouses and other family members (n = 17), along with health service providers involved in fistula repair and counseling (n = 38). Focus group discussions (FGDs) with male and female community stakeholders (n = 8) and post-repair clients (n = 6) were also conducted. Results Women’s experiences indicate the obstetric fistula results in a combined set of costs associated with delivery, repair, transportation, lost income, and companion expenses that are often limiting. Medical and non-medical ancillary costs such as food, medications, and water are not borne evenly among all fistula care centers or camps due to funding shortages. In Uganda, experienced transport costs indicate that women spend Ugandan Shilling (UGX) 10,000 to 90,000 (US$3.00-US$25.00) for two people for a single trip to a camp (client and her caregiver), while Nigerian women (Kano) spent Naira 250 to 2000 (US$0.80-US$6.41) for transportation. Factors that influence women’s and families’ ability to cover costs of fistula care access include education and vocational skills, community savings mechanisms, available resources in repair centers, client counseling, and subsidized care and transportation. Conclusions The concentration of women in poverty and the perceived and actual out of pocket costs associated with fistula repair speak to an inability to prioritize accessing fistula treatment over household expenditures. Findings recommend innovative approaches to financial assistance, transport, information of the available repair centers, rehabilitation, and reintegration in overcoming cost barriers

Distance, transportation cost, and mode of transport in the utilization of facility-based maternity services: Evidence from rural Bangladesh

Although the maternal mortality ratio in Bangladesh has decreased, significant underutilization of facilities continues to be a persistent challenge to policy makers. Women face long distances and significant transportation cost to deliver at health facilities. This study identifies the distance traveled to utilize facilities, associated transportation cost, and transport mode used for maternal healthcare services. A total of 3,300 mothers aged 18–49 years, who had given birth in the year before the survey, were interviewed from 22 sub-districts in 2010. Findings suggest that facility-based maternal healthcare service utilization was very poor. Only 53% of women received antenatal care, 20% used delivery care. and 10% used postnatal care from health centers. Median distance traveled for antenatal and postnatal check-ups was 2 kilometers but 4 kilometers for complication management care and delivery. Most women used non-motorized rickshaw or van to reach a health facility. On average, women spent Taka 100 (US$1.40) as transportation cost for antenatal care, Taka 432 (US$6.17) for delivery, and Taka 132 (US$1.89) for postnatal check-up. For each additional kilometer, the cost increased by Taka 9 (US$0.13) for antenatal, Taka 31 (US$0.44) for delivery, and Taka 8 (US$0.11) for postnatal care