Autonomy and maternal health-seeking among slum populations of Mumbai

Data from a retrospective survey of autonomy and maternal care seeking in the eastern slums of Mumbai shows that women who have recently delivered have high levels of autonomy. Components of autonomy such as freedom of movement, ability to visit natal kin and access to resources were identified using a latent class analysis of survey responses. Despite high proportions of autonomous women, substantial minorities remain in low autonomy categories. Uptake of maternal services was found to be constrained for those women with low levels of empowerment. Regression analysis suggests that autonomy is as important as education and gravida for maternal health-seeking

Impact of estimation techniques on regression analysis: an application to survey data on child nutritional status in five African countries

This paper illustrates the impact of ignoring survey design and hierarchical structure of survey data when fitting regression models. Data on child nutritional status from Ghana, Malawi, Tanzania, Zambia, and Zimbabwe are analysed using four techniques: ordinary least squares; weighted regression using standard statistical software; regression using specialist software that accounts for the survey design; and multilevel modelling. The impact of ignoring survey design on logistic and linear regression models is examined. The results show bias in estimates averaging between five and 17 per cent in linear models and between five and 22 per cent in logistic regression models. The standard errors are also under-estimated by up to 49 per cent in some countries. Socio-economic variables and service utilisation variables are poorly estimated when the survey design is ignored

Does early childbearing and a sterilization-focused family planning programme in India fuel population growth?

Recent stagnation in the reduction of infant mortality in India can arguably be attributed to early child bearing practices and the lack of progress in lengthening birth intervals. Meanwhile, family planning efforts have been particularly successful in the southern states such as Andhra Pradesh, although family limitation is almost exclusively by means of sterilisation at increasingly younger ages. This paper examines the population impact of the unprecedented convergence of early childbearing trajectories in India and quantifies the potential implications stemming from the neglect of strategies that encourage delaying and spacing of births. The effects of adopting a ‘later, longer and fewer’ family planning strategy are compared with the continuation of fertility concentrated in the younger age groups. Results from the cohort component population projections suggest that a policy encouraging later marriage and birth spacing would achieve a future total population which is about 52 million less in 2050 than if the current early fertility trajectory is continued.census, family planning, fertility, India, National Family Health Surveys, population policies, population projections, Sample Registration Systems, sterilisation

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

Financial accessibility and user fee reforms for maternal- health care in five sub-Saharan countries: a quasi-experimental analysis

Objectives: Evidence on whether removing fees benefits the poorest is patchy and weak. The aim of this paper is to measure the impact of user fee reforms on the probability of giving birth in an institution or receiving a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population. Setting: Women’s experience of user fees in five African countries. Primary and secondary outcome measures: Using quasi experimental regression analysis we tested the impact of user fee reforms on facilities’ births and CS differentiated by wealth, education and residence in Burkina Faso and Ghana. Mapping of the literature followed by key informant interviews are used to verify details of reform implementation and to confirm and support our countries' choice. Participants: We analysed data from consecutive surveys in five countries: two case countries that experienced reforms (Ghana and Burkina Faso) in contrast to three that did not experience reforms (Zambia, Cameroon, Nigeria). Results: User fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest) and non-educated women and those in rural areas benefitted the most from the reforms. User fees reforms have had a higher impact in Burkina Faso compared to Ghana. Conclusions: Findings show a clear positive impact on access when user fees are removed but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform. Speed and quality of implementation might be the key reason behind the differences between the two case countries. This calls for more research into the impact of reforms on quality of care

Mapping for Maternal and Newborn Health: The Distributions of Women of Childbearing Age, Pregnancies and Births.

The health and survival of women and their new-born babies in low income countries has been a key priority in public health since the 1990s. However, basic planning data, such as numbers of pregnancies and births, remain difficult to obtain and information is also lacking on geographic access to key services, such as facilities with skilled health workers. For maternal and newborn health and survival, planning for safer births and healthier newborns could be improved by more accurate estimations of the distributions of women of childbearing age. Moreover, subnational estimates of projected future numbers of pregnancies are needed for more effective strategies on human resources and infrastructure, while there is a need to link information on pregnancies to better information on health facilities in districts and regions so that coverage of services can be assessed. This paper outlines demographic mapping methods based on freely available data for the production of high resolution datasets depicting estimates of numbers of people, women of childbearing age, live births and pregnancies, and distribution of comprehensive EmONC facilities in four large high burden countries: Afghanistan, Bangladesh, Ethiopia and Tanzania. Satellite derived maps of settlements and land cover were constructed and used to redistribute areal census counts to produce detailed maps of the distributions of women of childbearing age. Household survey data, UN statistics and other sources on growth rates, age specific fertility rates, live births, stillbirths and abortions were then integrated to convert the population distribution datasets to gridded estimates of births and pregnancies.These estimates, which can be produced for current, past or future years based on standard demographic projections, can provide the basis for strategic intelligence, planning services, and provide denominators for subnational indicators to track progress. The datasets produced are part of national midwifery workforce assessments conducted in collaboration with the respective Ministries of Health and the United Nations Population Fund (UNFPA) to identify disparities between population needs, health infrastructure and workforce supply. The datasets are available to the respective Ministries as part of the UNFPA programme to inform midwifery workforce planning and also publicly available through the WorldPop population mapping project

The Impact of an Electrical Mini-grid on the Development of a Rural Community in Kenya

Electrical mini-grids can provide electrification to rural communities far from the national network. However the benefits of such schemes are disputed. We observed changes in two matched trading-centres in Makueni County, Kenya, neither of which were initially electrified. During the study a solar photovoltaic mini-grid scheme (13.5 kWp) was constructed in one of the trading-centres. After electrification there were relative increases in the number of businesses and business income. Comparing the households in the areas around the trading centres, perceived wealth increased more around the electrified trading centre. Qualitative interviews indicated improvements in service provision by the local school and health centre. The cooperative set up to run the mini-grid was free to set its own kWh tariff and chose to reduce it to a level that covers operating costs and would recover 70% of the initial investment interest-free. However, the tariff finally agreed is higher than the national grid tariff, which would be difficult to achieve if the mini-grid was not owned by and run for the benefit of the local community. Overall, we found that the mini-grid had a positive effect over background development, recovered some of its cost and charged a higher tariff than the national rate

Identification of new DNA i-motif binding ligands through a fluorescent intercalator displacement assay

i-Motifs are quadruplex DNA structures formed from sequences rich in cytosine and held together by intercalated, hemi-protonated cytosine–cytosine base pairs. These sequences are prevalent in gene promoter regions and may play a role in gene transcription. Targeting these structures with ligands could provide a novel way to target genetic disease but there are very few ligands which have been shown to interact with i-motif DNA. Fluorescent intercalator displacement (FID) assays are a simple way to screen ligands against DNA secondary structures. Here we characterise how thiazole orange interacts with i-motif DNA and assess its ability for use in a FID assay. Additionally, we report FID-based ligand screening using thiazole orange against the i-motif forming sequence from the human telomere to reveal new i-motif binding compounds which have the potential for further development

Accountability for quality of care : monitoring all aspects of quality across a framework adapted for action

Quality of care is essential to maternal and newborn survival. The multidimensional nature of quality of care means that frameworks are useful for capturing it. The present paper proposes an adaptation to a widely used quality of care framework for maternity services. The framework subdivides quality into two inter-related dimensions—provision and experience of care—but suggests adaptations to reflect changes in the concept of quality over the past 15 years. The application of the updated framework is presented in a case study, which uses it to measure and inform quality improvements in northern Nigeria across the reproductive, maternal, newborn, and child health continuum of care. Data from 231 sampled basic and comprehensive emergency obstetric and newborn care (BEmONC and CEmONC) facilities in six northern Nigerian states showed that only 35%–47% of facilities met minimum quality standards in infrastructure. Standards for human resources performed better with 49%–73% reaching minimum standards. A framework like this could form the basis for a certification scheme. Certification offers a practical and concrete opportunity to drive quality standards up and reward good performance. It also offers a mechanism to strengthen accountability.PostprintPeer reviewe

Examining the “Urban Advantage” in Maternal Health Care in Developing Countries

Andrew Channon and colleagues outline the complexities of urban advantage in maternal health where the urban poor often have worse access to health care than women in rural areas