Are community health workers effective in retaining women in the maternity care continuum? Evidence from India

Objectives Despite the recognised importance of adopting a continuum of care perspective in addressing the care of mothers and newborns, evidence on specific interventions to enhance engagement of women along the maternity care continuum has been limited. We use the example of the Accredited Social Health Activist (ASHA) programme in India, to understand the role of community health workers in retaining women in the maternity care continuum. Methods Using the Indian Human Development Survey data from 2011 to 2012, we assess the association between individual and cluster-level exposure to ASHA and four key components along the continuum of care—at least one antenatal care (ANC) visit, four or more ANC visits, presence of a skilled birth attendance (SBA) at the time of birth and postnatal care for the mother or child within 48 hours of birth, for 13 705 women with a live birth since 2005. To understand which of these services experience maximum dropout along the continuum, we use a linear probability model to calculate the weighted percentages of using each service. We assess the association between exposure to ASHA and number of services utilised using a multinomial logistic regression model adjusted for a range of confounding variables and survey weights. Results Our study indicates that exposure to the ASHA is associated with an increased probability of women receiving at least one ANC and SBA. In terms of numbers of services, exposure to ASHA accounts for a 12% (95% CI: 9.1 to 15.1) increase in women receiving at least some of the services, and an 8.8% (95% CI: −10.2 to −7.4) decrease in women receiving no services. However, exposure to ASHA does not increase the likelihood of women utilising all the services along the continuum. Conclusions While ASHA is effective in supporting women to initiate and continue care along the continuum, it does not significantly affec

The impact of India’s accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study

Background: In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services. Methods: We used data from Indian Human Development Surveys done in 2004–2005 and in 2011–2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-indifference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility. Results: Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8–22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI − 1.6–11.1), 26% increase in SBA (95% CI 20–31.1), and 28% increase (95% CI 22.4–32.8) in facility births. Conclusions: Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting servic

Indonesian couple’s pregnancy ambivalence and contraceptive use

CONTEXT: Recognizing pregnancy ambivalence is important for family planning policy and programming efforts. Most studies on pregnancy ambivalence are based on data from women; using partner’s perceived pregnancy intentions whenever partners are considered. This study examines couple’s pregnancy ambivalence and the association with contraceptive use in Indonesia. METHOD: Matched couple data from the 2002-2003 Indonesia Demographic and Health Survey are used to examine contraceptive use, fertility desires, and responses to whether a pregnancy in the next few weeks would be a big problem, small problem or no problem. Inconsistent fertility desires and responses to the problem question are used to define ambivalence. Response patterns and concordance between partners is evaluated. Multivariate logistic regression analyses are used to assess whether couple’s pregnancy ambivalence is associated with contraceptive use. RESULTS: 71% of husbands and 54% of wives report that a pregnancy in the next few weeks would be “no problem.” Couple’s concordance on the problem question is 63% (kappa statistic = 0.26) among contraceptive users and 61% (0.24) among non-users. In the multivariate analysis, couples who were discordant on the problem question were 24% less likely to use contraception than were couples in which both partners agreed a pregnancy would be a big or small problem. Results were not statistically significant at p≥0.05 in a model with a disaggregated variable on couple’s discordance that identified which partner was ambivalent; this might be related to small cell sizes. Contraceptive use was also less likely for couples with discordant fertility desires. CONCLUSION: Husbands and wives influence each other’s fertility attitudes and family planning use. To improve effective contraceptive use and/or continuation, couple’s pregnancy attitudes should be taken into account at the time of screening and method selection

Contraceptive practices, preferences and barriers among abortion clients in North Carolina.

Objectives: Abortion clinics provide an ideal setting for women to receive contraceptive care because the women served may not have other contacts with the health system and are at risk for unintended pregnancies. The objective of this study was to understand practices, preferences, and barriers to use of contraception for women obtaining abortions at clinics in North Carolina. Methods: We conducted a cross-sectional survey of abortion clients and facilities at 10 abortion clinics in North Carolina. We collected data on contraceptive availability at each clinic. We collected individual responses on women’s experiences obtaining contraception before the current pregnancy and their intentions for future use of contraception. Results: From October 2015 to February 2016, 376 client surveys were completed at 9 clinics, and 10 clinic surveys were completed. Almost one-third of women (29%) reported that they had wanted to use contraception in the last year but were unable. Approximately three-fourths of respondents (76%) stated that they intend to use contraception after this pregnancy. Approximately one-fifth of women stated that would like to use long-acting reversible contraception (LARC) after this abortion. Only the clinics that accepted insurance for abortion and other services provided LARC at the time of the abortion (40%). Conclusions: This study provides a unique, statewide view into the contraceptive barriers for women seeking abortion in North Carolina. Addressing the relatively high demand for LARC after abortion could help significantly reduce unintended pregnancy and recourse to abortion in North Carolina

The impact of an alcohol harm reduction intervention on interpersonal violence and engagement in sex work among female sex workers in Mombasa, Kenya: Results from a randomized controlled trial

To evaluate whether an alcohol harm reduction intervention was associated with reduced interpersonal violence or engagement in sex work among female sex workers (FSWs) in Mombasa, Kenya

Accuracy of Standard Measures of Family Planning Service Quality: Findings from the Simulated Client Method

Despite widespread endorsement within the field of international family planning regarding the importance of quality of care as a reproductive right, the field has yet to develop validated data collection instruments to accurately assess quality in terms of its public health importance. This study, conducted among 19 higher volume public and private facilities in Kisumu, Kenya, used the simulated client method to test the validity of three standard data collection instruments included in large-scale facility surveys: provider interviews, client interviews, and observation of client-provider interactions. Results found low specificity and positive predictive values in each of the three instruments for a number of quality indicators, suggesting that quality of care may be overestimated by traditional methods. Revised approaches to measuring family planning service quality may be needed to ensure accurate assessment of programs and to better inform quality improvement interventions