Accelerating and improving survey implementation with mobile technology: Lessons from PMA2020 implementation in Lagos, Nigeria

Large-scale nationally representative surveys have traditionally been implemented using paper surveys, necessitating secondary steps of data entry and management after data collection. Errors occurring during data collection or entry may not be rapidly identified. The Performance Monitoring and Accountability (PMA2020) project implementation in Lagos, Nigeria demonstrates four advantages to integrating mobile technology into survey implementation. First is the rapidity of data collection; data collection lasted six weeks from mapping/listing to final collection – and, since completed surveys are uploaded to a cloud-based server, identification of errors can occur in near real-time. Second, time-stamping and GPS marking allow for improved quality assurance. Third, the inclusion of GPS coordinates creates new opportunities to analyze relationships of distance with use of health services. Fourth, PMA2014/Lagos utilized a 10% resample of households to validate data collection allowing for rapid identification of questionable data and quality control

Mortality risks in children aged 5–14 years in low-income and middle-income countries: a systematic empirical analysis

Background Health priorities since the UN Millennium Declaration have focused strongly on children younger than 5 years. The health of older children (age 5–9 years) and younger adolescents (age 10–14 years) has been neglected until recently, especially in low-income and middle-income countries, and mortality measures for these age groups have often been derived from overly fl exible models. We report global and regional empirical mortality estimates for children aged 5–14 years in low-income and middle-income countries, and compare them with ones from existing models. Methods For this empirical analysis, we obtained birth-history data from surveys done over a 25-year period from 1986 by the Demographic and Health Surveys programme for 84 World Bank low-income and middle-income countries, and data about household deaths in China from their 1990 and 2010 censuses. We used these data to calculate mortality risks for children aged 5–14 years, and compare these risks to corresponding estimates of mortality in children younger than 5 years in the same countries. We used regression analysis to model these associations, generate estimates of the risks, and derive estimates of the numbers of deaths for 1990 and 2010 by applying those risks to population estimates from the UN World Population Prospects (WPP) 2012 Revision. We then compared the numbers of deaths with those given by the UN WPP itself and by the Institute for Health Metrics and Evaluation’s Global Burden of Disease (GBD) 2010 study. Findings The mean risk of a child dying at age 5–14 years in low-income and middle-income countries is about 19% of the risk of dying between birth and age 5 years (12% at age 5–9 plus 7% at age 10–14). According to our estimates, the total number of deaths at ages 5–14 years in low-income and middle-income regions fell from about 2·4 million (95% CI 1·9–2·7) in 1990 to about 1·5 million (1·2–1·8) in 2010. From our estimates we concluded there to have been 200 000 (16%) more deaths at ages 5–14 than in the UN report; however, our estimates exceeded GBD estimates by more than 700 000 (87%). The average annual rate of decline in mortality at age 5–9 years (about 3%) slightly exceeded that for ages 0–4 years (2·8%), but progress has been slower for age 10–14 years (about 2%). Interpretation Our analysis suggests that mortality risks nowadays in the age range 5–14 years in low-income and middle-income countries are rather higher (relative to mortality in children younger than 5 years) than would be expected on the basis of historical evidence. Our fi ndings broadly lend support for the UN WPP mortality estimates, but are almost double those underpinning GBD 2010. Global policy emphasis on reduction of mortality in children younger than 5 years should be broadened to include older children and adolescents

UNDER-5 MORTALITY ESTIMATION IN HUMANITARIAN EMERGENCIES: A COMPARISON OF ESTIMATION METHODOLOGIES USING MICROSIMULATION

Complex humanitarian emergencies are characterized by increases in mortality, mass migration, and collapse of infrastructure. Demographic estimation on under-5 mortality in these settings is generally conducted using household surveys. Indirect methods of estimation, collected using summary birth histories, have clear advantages over complete birth histories, as they are faster and require less training to implement. It is unclear, however, how well the analytic techniques developed for summary birth histories perform when mortality patterns fluctuate. Using the Socsim simulation program, one baseline and four emergency scenarios were developed and each was simulated 100 times. Two methods of indirect estimation for child mortality - the Brass methodology and the IHME methodology - and the direct method of under-5 mortality estimation were applied to assess how quickly each method was able to detect rapid changes in mortality, how well the method was able to estimate the underlying level of mortality, and for how long after the crisis period ended the method was affected by the increase in mortality. In general, none of the indirect methods performed well. The Brass method, though able to detect abrupt changes in mortality is inadequate because of its reliance on a reference period. The IHME methods, though able to estimate mortality for the survey year, were generally not able to accurately estimate the level of mortality change in situations with extreme changes. In situations of fluctuating mortality, all indirect methods smoothed fluctuations, eliminating the ability to estimate excess deaths due to conflict. Although more time-consuming, if under-5 mortality is of primary interest, complete birth histories and direct estimation should be used

Missed opportunities for family planning counselling among postpartum women in eleven counties in Kenya

Background: Mothers may access medical facilities for their babies and miss opportunities to access family planning (FP) services. This study was undertaken to describe missed opportunities for FP among women within the extended (0–11months) postpartum period from counties participating in Performance Monitoring and Accountability 2020 (PMA2020) surveys. Design and setting: This study analysed cross-sectional household survey data from 11 counties in Kenya between 2014 and 2018. PMA2020 uses questions extracted from the Demographic and Health survey (DHS) and DHS defnitions were used. Multivariable logistic regression was used for inferential statistics with p-value of \u3c0.05 considered to be signifcant. Participants: Women aged 15-49 years from the households visited. Primary outcome measure: Missed opportunity for family planning/contraceptives (FP/C) counselling. Results: Of the 34,832 women aged 15-49 years interviewed, 10.9% (3803) and 10.8% (3746) were in the period 0–11months and 12–23months postpartum respectively, of whom, 38.8 and 39.6% respectively had their previous pregnancy unintended. Overall, 50.4% of women 0-23months postpartum had missed opportunities for FP/C counselling. Among women who had contact with health care at the facility, 39.2% of women 0-11months and 44.7% of women 12-23months had missed opportunities for FP/C counselling. Less than half of the women 0-11months postpartum (46.5%) and 64.5% of women 12 – 23months postpartum were using highly efcacious methods. About 27 and 18% of the women 0-11months and 12 – 23months postpartum respectively had unmet need for FP/C. Multivariable analysis showed that being low parity and being from the low wealth quintile signifcantly increased the odds of missed opportunities for FP/C counselling among women in the extended postpartum period, p\u3c0.05. Conclusions: A large proportion of women have missed opportunities for FP/C counselling within 2 years postpartum. Programs should address these missed opportunities

Monitoring Change in Child Mortality through Household Surveys

Background: Most low- and middle-income countries lack fully functional civil registration systems. Measures of under-five mortality are typically derived from periodic household surveys collecting detailed information from women on births and child deaths. However, such surveys are expensive and are not appropriate for monitoring short-term changes in child mortality. We explored and tested the validity of two new analysis methods for less-expensive summary histories of births and child deaths for such monitoring in five African countries. Methods and Findings: The first method we explored uses individual-level survey data on births and child deaths to impute full birth histories from an earlier survey onto summary histories from a more recent survey. The second method uses cohort changes between two surveys in the average number of children born and the number of children dead by single year of age to estimate under-five mortality for the inter-survey period. The first method produces acceptable annual estimates of under-five mortality for two out of six applications to available data sets; the second method produced an acceptable estimate in only one of five applications, though none of the applications used ideal data sets. Conclusions: The methods we tested were not able to produce consistently good quality estimates of annual under-five mortality from summary birth history data. The key problem we identified was not with the methods themselves, but with the underlying quality of the summary birth histories. If summary birth histories are to be included in general household surveys, considerable emphasis must be placed on quality control

Progress and inequities in maternal mortality in Afghanistan (RAMOS-II): a retrospective observational study

Background The risk of maternal death in Afghanistan is among the highest in the world; however, the risks within the country are poorly understood. Subnational maternal mortality estimates are needed along with a broader understanding of determinants to guide future maternal health programmes. Here we aimed to study maternal mortality risk and causes, care-seeking patterns, and costs within the country. Methods We did a household survey (RAMOS-II) in the urban area of Kabul city and the rural area of Ragh, Badakshan. Questionnaires were administered to senior female household members and data were collected by a team of female interviewers with secondary school education. Information was collected about all deaths, livebirths, stillbirths, health-care access and costs, household income, and assets. Births were documented using a pregnancy history. We investigated all deaths in women of reproductive age (12–49 years) since January, 2008, using verbal autopsy. Community members; service providers; and district, provincial, and national officials in each district were interviewed to elicit perceptions of changes in maternal mortality risk and health service provision, along with programme and policy documentation of maternal care coverage. Findings Data were collected between March 2, 2011, and Oct 16, 2011, from 130 688 participants: 63 329 in Kabul and 67 359 in Ragh. The maternal mortality ratio in Ragh was quadruple that in Kabul (713 per 100 000 livebirths, 95% CI 553–873 in Ragh vs 166, 63–270 in Kabul). We recorded similar patterns for all other maternal death indicators, including the maternal mortality rate (1·7 per 1000 women of reproductive age, 95% CI 1·3–2·1 in Ragh vs 0·2, 0·1–0·3 in Kabul). Infant mortality also differed significantly between the two areas (115·5 per 1000 livebirths, 95% CI 108·6–122·3 in Ragh vs 24·8, 20·5–29·0 in Kabul). In Kabul, 5594 (82%) of 6789 women reported a skilled attendant during recent deliveries compared with 381 (3%) of 11 366 women in Ragh. An estimated 85% of women in Kabul and 47% in Ragh incurred delivery costs (mean US$66·20, IQR$61·30 in Kabul and $9·89,$11·87 in Ragh). Maternal complications were the third leading cause of death in women of reproductive age in Kabul, and the leading cause in Ragh, and were mainly due to hypertensive diseases of pregnancy. The maternal mortality rate decreased significantly between 2002 and 2011 in both Kabul (by 71%) and Ragh (by 84%), plus all other maternal mortality indicators in Ragh. Interpretation Remarkable maternal and other mortality reductions have occurred in Afghanistan, but the disparity between urban and rural sites is alarming, with all maternal mortality indicators significantly higher in Ragh than in Kabul. Customised service delivery is needed to ensure parity for different geographic and security settings

The relationship between household sanitation and women’s experience of menstrual hygiene: Findings from a cross-sectional survey in Kaduna State, Nigeria

Global efforts to improve sanitation have emphasized the needs of women and girls. Managing menstruation is one such need, yet there is scarce research capturing current practices. This study investigated the relationships between household sanitation and women’s experience of menstrual management. Secondary analyses were undertaken on data from 1994 women and girls collected through the Performance Monitoring and Accountability 2020 survey in Kaduna, Nigeria. In multivariable models, women had higher odds of using the main household sanitation facility for menstrual management when they had access to a basic (OR = 1.76 95%CI 1.26–2.46) or limited (OR = 1.63 95%CI 1.08–2.48) sanitation facility, compared to an unimproved facility. Women with no household sanitation facility had higher odds of using their sleeping area (OR = 3.56 95%CI 2.50–5.06) or having no facility for menstrual management (OR = 9.86 95%CI 5.76–16.87) than women with an unimproved sanitation facility. Menstrual management locations were associated with ratings of their characteristics. Safely managed or basic sanitation facilities were not rated more favorably than unimproved facilities in privacy (OR = 1.02 95%CI 0.70–1.48), safety (OR = 1.45 95%CI 0.98–2.15), access to a lock (OR = 0.93 95%CI 0.62–1.37), or soap and water (OR = 1.04 95%CI 0.70–1.56). Women using their sleeping area had more favorable perceptions of their environment. Findings suggest household sanitation influences women’s choices for menstrual management, but that existing indicators for improvement are not sensitive to menstrual needs.SCOPU

UNDER-5 MORTALITY ESTIMATION IN HUMANITARIAN EMERGENCIES: A COMPARISON OF ESTIMATION METHODOLOGIES USING MICROSIMULATION

Complex humanitarian emergencies are characterized by increases in mortality, mass migration, and collapse of infrastructure. Demographic estimation on under-5 mortality in these settings is generally conducted using household surveys. Indirect methods of estimation, collected using summary birth histories, have clear advantages over complete birth histories, as they are faster and require less training to implement. It is unclear, however, how well the analytic techniques developed for summary birth histories perform when mortality patterns fluctuate. Using the Socsim simulation program, one baseline and four emergency scenarios were developed and each was simulated 100 times. Two methods of indirect estimation for child mortality - the Brass methodology and the IHME methodology - and the direct method of under-5 mortality estimation were applied to assess how quickly each method was able to detect rapid changes in mortality, how well the method was able to estimate the underlying level of mortality, and for how long after the crisis period ended the method was affected by the increase in mortality. In general, none of the indirect methods performed well. The Brass method, though able to detect abrupt changes in mortality is inadequate because of its reliance on a reference period. The IHME methods, though able to estimate mortality for the survey year, were generally not able to accurately estimate the level of mortality change in situations with extreme changes. In situations of fluctuating mortality, all indirect methods smoothed fluctuations, eliminating the ability to estimate excess deaths due to conflict. Although more time-consuming, if under-5 mortality is of primary interest, complete birth histories and direct estimation should be used

Legal but limited? Abortion service availability and readiness assessment in Nepal

The government of Nepal revised its law in 2002 to allow women to terminate a pregnancy up to 12 weeks gestation for any indication on request, and up to 18 weeks if certain conditions are met. We evaluated the readiness of facilities in Nepal to provide three abortion services, manual vacuum aspiration (MVA), medication abortion (MA) and post-abortion care (PAC), using the service availability and readiness assessment (SARA) framework. The framework consists broadly of three domains; service availability, general service readiness and service readiness specific to individual services (i.e. service-specific readiness). We applied the framework to data from the Nepal Health Facility Survey 2015, a nationally representative survey of 992 health facilities. Overall, we find that access to safe abortion remains limited in Nepal. Of the facilities that reported offering delivery services and were thus eligible to provide safe abortion services, 44.5, 36.0 and 25.6% had provided any MVA, MA or PAC services, respectively, in the 3 months prior to the survey, and \u3c 2% were ‘ready’ to provide any abortion service based on our application of the SARA criteria for service-specific readiness. Among only the facilities that reported providing an abortion service in the 3 months prior to the survey, 3.2% of facilities that provided MVA, 1.5% of facilities that provided MA and 1.1% of the facilities that provided PAC had all the components of care required. Although the private sector conducted approximately half of all abortion services provided in the 3 months prior to the survey, no private sector facilities had all the abortion service-specific readiness components. Results suggest that accessing safe abortion services remains a significant challenge for Nepalese women, despite a set of permissive laws

Mortality risks in children aged 5–14 years in low-income and middle-income countries: a systematic empirical analysis

Background: Health priorities since the UN Millennium Declaration have focused strongly on children younger than 5 years. The health of older children (age 5–9 years) and younger adolescents (age 10–14 years) has been neglected until recently, especially in low-income and middle-income countries, and mortality measures for these age groups have often been derived from overly flexible models. We report global and regional empirical mortality estimates for children aged 5–14 years in low-income and middle-income countries, and compare them with ones from existing models. Methods: For this empirical analysis, we obtained birth-history data from surveys done over a 25-year period from 1986 by the Demographic and Health Surveys programme for 84 World Bank low-income and middle-income countries, and data about household deaths in China from their 1990 and 2010 censuses. We used these data to calculate mortality risks for children aged 5–14 years, and compare these risks to corresponding estimates of mortality in children younger than 5 years in the same countries. We used regression analysis to model these associations, generate estimates of the risks, and derive estimates of the numbers of deaths for 1990 and 2010 by applying those risks to population estimates from the UN World Population Prospects (WPP) 2012 Revision. We then compared the numbers of deaths with those given by the UN WPP itself and by the Institute for Health Metrics and Evaluation's Global Burden of Disease (GBD) 2010 study. Findings: The mean risk of a child dying at age 5–14 years in low-income and middle-income countries is about 19% of the risk of dying between birth and age 5 years (12% at age 5–9 plus 7% at age 10–14). According to our estimates, the total number of deaths at ages 5–14 years in low-income and middle-income regions fell from about 2·4 million (95% CI 1·9–2·7) in 1990 to about 1·5 million (1·2–1·8) in 2010. From our estimates we concluded there to have been 200 000 (16%) more deaths at ages 5–14 than in the UN report; however, our estimates exceeded GBD estimates by more than 700 000 (87%). The average annual rate of decline in mortality at age 5–9 years (about 3%) slightly exceeded that for ages 0–4 years (2·8%), but progress has been slower for age 10–14 years (about 2%). Interpretation: Our analysis suggests that mortality risks nowadays in the age range 5–14 years in low-income and middle-income countries are rather higher (relative to mortality in children younger than 5 years) than would be expected on the basis of historical evidence. Our findings broadly lend support for the UN WPP mortality estimates, but are almost double those underpinning GBD 2010. Global policy emphasis on reduction of mortality in children younger than 5 years should be broadened to include older children and adolescents. Funding: The Lancet Commission on Investing in Health and the Bill & Melinda Gates Foundation