Addressing the double burden of malnutrition in Egypt: do conditional cash transfers have a role?

Many developing countries are undergoing rapid socio-economic changes that impact on health and its social distribution. These changes can occur so rapidly that there is a resulting co-existence of diseases of affluence and diseases of poverty. Priority setting for nutritional programs has focused on the alleviation of undernutrition in low income settings. However, evidence shows that in many Low-and-Middle Income Countries the prevalence of obesity among women is increasing and can coexist with childhood stunting. This dual burden of poor nutrition contributes to worsening health inequity between the poor and the rich. Global and national policy makers are looking for novel programs to replace social protection mechanisms deemed inefficient. Conditional Cash Transfer (CCT) programs have emerged as an increasingly popular poverty alleviation strategy with some positive results. However, there is evidence they may have a negative impact if the complexity of transition settings is not taken into account. In this paper, we review the nutritional situation in Egypt and compare two CCT programs (Mexico and Colombia) in an attempt to identify features that would address both child undernutrition and adult overnutrition. We conclude with suggestions for design of an Egyptian CCT program that would help maximise benefit to its beneficiaries

Effect of maternal age on facility-based delivery: analysis of first-order births in 34 countries of sub-Saharan Africa using demographic and health survey data.

OBJECTIVES: Increasing access to skilled birth attendance, usually via childbirth in health facilities, is a key intervention to reduce maternal and perinatal mortality and morbidity. Yet, in some countries of sub-Saharan Africa, the uptake is <50%. Age and parity are determinants of facility-based delivery, but are strongly correlated in high fertility settings. This analysis assessed the independent effect of age on facility-based delivery by restricting to first-order births. It was hypothesised that older first-time mothers in this setting might have lower uptake of facility-based deliveries than women in the most common age groups for first birth. SETTING: The most recent Demographic and Health Surveys from 34 sub-Saharan African countries were used to assess women's delivery locations. PARTICIPANTS: 72 772 women having their first birth in the 5 years preceding the surveys were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: Proportions and 95% CIs of facility-based deliveries were estimated overall and by country. Multivariable logistic regression was used to calculate the odds of facility-based delivery for different maternal age groups (15-19, 20-24 and ≥25 years) for a pooled sample of all countries. RESULTS: 59.9% of women had a facility-based delivery for their first birth (95% CI 58.6 to 61.2), ranging from 19.4% in Chad to 96.6% in Rwanda. Compared with women aged 15-19 years, the adjusted odds of having a facility-based delivery for those aged 20-24 was 1.4 (95% CI 1.3 to 1.5, p<0.001) and for those aged ≥25, 1.9 (95% CI 1.6 to 2.2, p<0.001). CONCLUSIONS: Older age at first birth was independently associated with significantly higher odds of facility-based delivery. This went against the hypothesis. Further mixed-method research is needed to explore how increased age improves uptake of facility-based delivery. Promoting facility-based delivery, while ensuring quality of care, should be prioritised to improve birth outcomes in sub-Saharan Africa

Bad behaviour or “poor” behaviour?: Mechanisms underlying socio‐economic inequalities in maternal and child health‐seeking in Egypt

Background: Health-seeking behaviour is a key contributor to the widespread and unfair inequalities in health outcomes related to socio-economic position. This thesis compared the levels and determinants of maternal and child health-seeking between a national sample and the rural poor in Egypt, and examined whether existing inequalities could be explained by socio-cultural characteristics or ability to afford care. Methods: This quantitative analysis relied on two datasets: the Egypt Demographic and Health Survey from 2008 and a 2010/11 survey of households below the poverty line in rural Upper Egypt. Latent variables capturing several dimensions of socio-economic position were constructed and used in multivariable regression models to predict several dimensions of maternal (antenatal and delivery care) and child (diarrhoea and acute respiratory infection) health-seeking. Results: Latent constructs capturing socio-cultural and economic resources were identified in both datasets. Two further dimensions of socio-economic position in the Upper Egypt sample included dwelling quality and woman’s status. DHS analysis showed that sociocultural and economic capital were independently positively associated with seeking antenatal and delivery care among women, and with seeking timely and private child illness treatment. Free-of-charge public maternal care was not effectively targeted to poorest women. Poor households in Upper Egypt showed lower maternal healthseeking levels than nationally; both socio-cultural and economic resourcefulness positively predicted maternal health-seeking, dwelling quality was positively associated with private provider use, while women’s status was not associated with any dimension of maternal health-seeking behaviour. Conclusion: A better understanding of perceived and objective quality of care in both public and private sectors is required to reduce existing inequalities in the coverage of essential maternal and child health interventions. Improvement in free public care targeting is required to prevent catastrophically high expenditures for basic care among poor households

The Landscape of Cesarean Section in Sub-Saharan Africa and South and Southeast Asia

This report seeks to assess the landscape of cesarean sections in LMICs using recent, comparable, nationally representative survey data by analyzing DHS data from 44 countries in Sub-Saharan Africa and South and Southeast Asia between 2002 and 2016

Examining trends in family planning among harder-to-reach women in Senegal 1992-2014.

Recent increases in family planning (FP) use have been reported among women of reproductive age in union (WRAU) in Senegal. However, trends have not been monitored among harder-to-reach groups (including adolescents, unmarried and rural poor women), key to understanding whether FP progress is equitable. We combined data from six Demographic and Health Surveys conducted in Senegal between 1992/93 and 2014. We examined FP trends over time among WRAU and subgroups, and trends in knowledge of FP and intention to use among women with unmet need for FP. Our results show that percent demand satisfied is lower among rural poor women and adolescents than WRAU, although higher among unmarried women. Marked recent increases have been observed in all subgroups, however fewer than 50% of women in need of FP use modern contraception in Senegal. Knowledge of FP has risen steadily among women with unmet need; however, intention to use FP has remained stable at around 40% since 2005 for all groups except unmarried women (75% of whom intend to use). Significant progress in meeting the need for FP has been achieved in Senegal, but more needs to be done particularly to improve acceptability of FP, and to strategically target interventions toward adolescents and rural poor women

Incidence of and Risk Factors for Lactational Mastitis: A Systematic Review.

BACKGROUND: Lactational mastitis is a maternal morbidity that affects the wellbeing of women and their babies, including through breastfeeding discontinuation. RESEARCH AIM: To systematically review the available global literature on the frequency of lactational mastitis, and to summarize the evidence on risk factors for lactational mastitis. We also describe gaps in the evidence and identify priority areas for future research. METHODS: We systematically searched and screened 6 databases and included 26 articles, conducted meta-analysis of disease frequency, and narratively synthesized evidence on risk factors. RESULTS: In 11 (42%) articles researchers reported a measure of disease frequency; 5 (19%) reported risk factors, and 10 (39%) included both. Overall, the quality of studies was low, related to suboptimal measurement of disease frequency, high risk of bias, reverse causality, and incomplete adjustment for confounding. Meta-analysis was based on 3 studies (pooled incidence between birth and Week 25 postpartum: 11.1 episodes per 1,000 breastfeeding weeks; 95% CI [10.2-12.0]); with high heterogeneity across contexts and highest incidence in the first four weeks postpartum. Researchers assessed 42 potential risk factors; nipple damage was the most frequently studied and strongly associated with mastitis. There was a scarcity of studies from low-resource settings. CONCLUSIONS: Lactational mastitis is a common condition, but the wide variability in incidence across contexts suggested that a substantial portion of this burden might be preventable. Provision of care to breastfeeding women at risk for or affected by mastitis is currently constrained due to a critical lack of high quality epidemiological evidence about its incidence and risk factors

Examining user fee reductions in public primary healthcare facilities in Kenya, 1997-2012: effects on the use and content of antenatal care.

BACKGROUND: In 2004, The Kenyan government removed user fees in public dispensaries and health centers and replaced them with registration charges of 10 and 20 Kenyan shillings (2004 $US 0.13 and$0.25), respectively. This was termed the 10/20 policy. We examined the effect of this policy on the coverage, timing, source, and content of antenatal care (ANC), and the equity in these outcomes. METHODS: Data from the 2003, 2008/9 and 2014 Kenya Demographic and Health Surveys were pooled to investigate women's ANC care-seeking. We conducted an interrupted time series analysis to assess the impact of the 10/20 policy on the levels of and trends in coverage for 4+ ANC contacts among all women; early ANC initiation and use of public facility-based care among 1+ ANC users; and use of public primary care facilities and receipt of good content, or quality, of ANC among users of public facilities. All analyses were conducted at the population level and separately for women with higher and lower household wealth. RESULTS: The policy had positive effects on use of 4+ ANC among both better-off and worse-off women. Among users of 1+ ANC, the 10/20 policy had positive effects on early ANC initiation at the population-level and among better-off women, but not among the worse-off. The policy was associated with reduced use of public facility-based ANC among better-off women. Among worse-off users of public facility-based ANC, the 10/20 policy was associated with reduced use of primary care facilities and increased content of ANC. CONCLUSIONS: This study highlights mixed findings on the impact of the 10/20 policy on ANC service-seeking and content of care. Given the reduced use of public facilities among the better-off and of primary care facilities among the worse-off, this research also brings into question the mechanisms through which the policy achieved any benefits and whether reducing user fees is sufficient for equitably increasing healthcare access

Expanding Method Choice in Africa with Long-Acting Methods: IUDs, Implants or Both?

The objective of this article is to review key components of LARC uptake in Sub-Saharan Africa with the aim of guiding policies and programs. We assess trends in access to the IUD and implant, including method knowledge and availability at facilities; examine trends in use, source of supply, discontinuation and characteristics of users; and discuss the prospects for expanding method choice by increasing the availability of LARCs in national programs and the policy implications of our results

Evaluating the impact of a maternal health voucher programme on service use before and after the introduction of free maternity services in Kenya: a quasi-experimental study.

INTRODUCTION: From 2006 to 2016, the Government of Kenya implemented a reproductive health voucher programme in select counties, providing poor women subsidised access to public and private sector care. In June 2013, the government introduced a policy calling for free maternity services to be provided in all public facilities. The concurrent implementation of these interventions presents an opportunity to provide new insights into how users adapt to a changing health financing and service provision landscape. METHODS: We used data from three cross-sectional surveys to assess changes over time in use of 4+ antenatal care visits, facility delivery, postnatal care and maternal healthcare across the continuum among a sample of predominantly poor women in six counties. We conducted a difference-in-differences analysis to estimate the impact of the voucher programme on these outcomes, and whether programme impact changed after free maternity services were introduced. RESULTS: Between the preintervention/roll-out phase and full implementation, the voucher programme was associated with a 5.5% greater absolute increase in use of facility delivery and substantial increases in use of the private sector for all services. After free maternity services were introduced, the voucher programme was associated with a 5.7% higher absolute increase in use of the recommended package of maternal health services; however, disparities in access to facility births between voucher and comparison counties declined. Increased use of private sector services by women in voucher counties accounts for their greater access to care across the continuum. CONCLUSIONS: Our findings show that the voucher programme is associated with a modest increase in women's use of the full continuum of maternal health services at the recommended timings after free maternity services were introduced. The greater use of private sector services in voucher counties also suggests that there is need to expand women's access to acceptable and affordable providers

Who, What, Where: an analysis of private sector family planning provision in 57 low- and middle-income countries.

OBJECTIVE: Family planning service delivery has been neglected; rigorous analyses of the patterns of contraceptive provision are needed to inform strategies to address this neglect. METHODS: We used 57 nationally representative Demographic and Health Surveys in low- and middle-income countries (2000-2013) in four geographic regions to estimate need for contraceptive services, and examined the sector of provision, by women's socio-economic position. We also assessed method mix and whether women were informed of side effects. RESULTS: Modern contraceptive use among women in need was lowest in sub-Saharan Africa (39%), with other regions ranging from 64% to 72%. The private sector share of the family planning market was 37-39% of users across the regions and 37% overall (median across countries: 41%). Private sector users accessed medical providers (range across regions: 30-60%, overall mean: 54% and median across countries 23%), specialised drug sellers (range across regions: 31-52%, overall mean: 36% and median across countries: 43%) and retailers (range across regions: 3-14%, overall mean: 6% and median across countries: 6%). Private retailers played a more important role in sub-Saharan Africa (14%) than in other regions (3-5%). NGOs and FBOs served a small percentage. Privileged women (richest wealth quintile, urban residents or secondary-/tertiary-level education) used private sector services more than the less privileged. Contraceptive method types with higher requirements (medical skills) for provision were less likely to be acquired from the private sector, while short-acting methods/injectables were more likely. The percentages of women informed of side effects varied by method and provider subtype, but within subtypes were higher among public than private medical providers for four of five methods assessed. CONCLUSION: Given the importance of private sector providers, we need to understand why women choose their services, what quality services the private sector provides, and how it can be improved. However, when prioritising one of the two sectors (public vs. private), it is critical to consider the potential impact on contraceptive prevalence and equity of met need