133 research outputs found
Social determinants of maternal health: a scoping review of factors influencing maternal mortality and maternal health service use in India
Background: Maternal health remains a major public health problem in India, with
large inter- and intra-state inequities in maternal health service use and maternal
deaths. The Commission on Social Determinants of Health provides a framework to
identify structural and intermediary factors of health inequities, including maternal
health, and understand their mechanism of influence, which might be important in
addressing maternal health inequities in India. Our review aims to map and
summarize the evidence on social determinants influencing maternal health in India
and understand their mechanisms of influence by using a maternal health-specific
social determinants framework.
Methods: A scoping review was conducted of peer-reviewed journal articles in two
databases (PubMed and Science Direct) on quantitative and qualitative studies
conducted in India after 2000. We also searched for articles in a search engine
(Google Scholar). Forty-one studies that met the study objectives were included: 25
identified through databases and search engines and 16 through reference check.
Results: Economic status, caste/ethnicity, education, gender, religion, and culture
were the most important structural factors of maternal health service use and
maternal mortality in India. Place of residence, maternal age at childbirth, parity and
women’s exposure to mass media, and maternal health messages were the major
intermediary factors. The structural factors influenced the intermediary factors (either
independently or in association with other factors) that contributed to the use of
maternal health service or caused maternal deaths. The health system emerged as a
crucial and independent intermediary factor of influence on maternal health in India.
Issues of power were observed in broader social contexts and in the relationships of
health workers which led to differential access to maternal healthcare for women
from different socioeconomic groups. Conclusion: The model integrates existing information from quantitative and
qualitative studies and provides a more comprehensive picture of structural and
intermediary factors of maternal health service use and maternal mortality in India
and their mechanisms of influence. Given the limitations of this study, we indicate
the areas for further research pertaining to the framework and maternal health
How do accountability problems lead to maternal health inequities? A review of qualitative literature from Indian public sector
Background: There are several studies from different
geographical settings and levels on maternal health, but none
analyzes how accountability problems may contribute to the
maternal health outcomes. This study aimed to analyze how
accountability problems in public health system lead to maternal
deaths and inequities in India. Methods: A conceptual framework
was developed bringing together accountability process (in terms
of standard setting, performance assessment, accountability (or
answerability, and enforceability) -an ongoing cyclical feedback
process at different levels of health system) and determinants
of maternal health to analyze the influence of the process on
the determinant leading to maternal health outcomes. A scoping
review of qualitative and mixed-methods studies from public
health sector in India was conducted. A narrative and
interpretive synthesis approach was applied to analyze data.
Results: An overarching influence of health system-related
factors over non-health system-related factors leading to
maternal deaths and inequities was observed. A potential link
among such factors was identified with gaps in accountability
functions at all levels of health system pertaining to policy
gaps or conflicting/discriminatory policies and political
commitment. A large number of gaps were also observed concerning
performance or implementation of existing standards. Inherent to
these issues was potentially a lack of proper monitoring and
accountability functions. A critical role of power was observed
influencing the accountability functions. Conclusion: The
narrative and interpretive synthesis approach allowed to
integrate and reframe the relevant comparable information from
the limited empirical studies to identify the hot spots of
systemic flaws from an accountability perspective. The framework
highlighted problems in health system beyond health service
delivery to wider areas such as policy or politics justifying
their relevance and importance in such analysis. A crucial
message from the study pertains to a need to move away from the
traditional concept of viewing accountability as a blame-game
approach and a concern of limited frontline health workers
towards a constructive and systemic approach
Opening the 'implementation black-box' of the user fee exemption policy for caesarean section in Benin: A realist evaluation
To improve access to maternal health services, Benin introduced in 2009 a user fee exemption policy for caesarean sections. Similar to other low- and middle-income countries, its implementation showed mixed results. Our study aimed at understanding why and in which circumstances the implementation of this policy in hospitals succeeded or failed. We adopted the realist evaluation approach and tested the initial programme theory through a multiple embedded case study design. We selected two hospitals with contrastive outcomes. We used data from 52 semi-structured interviews, a patient exit survey, a costing study of caesarean section and an analysis of financial flows. In the analysis, we used the intervention-context-actor-mechanism-outcome configuration heuristic. We identified two main causal pathways. First, in the state-owned hospital, which has a public-oriented but administrative management system, and where citizens demand accountability through various channels, the implementation process was effective. In the non-state-owned hospital, managers were guided by organizational financial interests more than by the inherent social value of the policy, there was a perceived lack of enforcement and the implementation was poor
Determinants of institutional delivery among young married women in Nepal: Evidence from the Nepal Demographic and Health Survey, 2011
OBJECTIVES: To identify the determinants of institutional
delivery among young married women in Nepal. DESIGN: Nepal
Demographic and Health Survey (NDHS) data sets 2011 were
analysed. Bivariate and multivariate logistic regression
analyses were performed using a subset of 1662 ever-married
young women (aged 15-24 years). OUTCOME MEASURE: Place of
delivery. RESULTS: The rate of institutional delivery among
young married women was 46%, which is higher than the national
average (35%) among all women of reproductive age. Young women
who had more than four antenatal care (ANC) visits were three
times more likely to deliver in a health institution compared
with women who had no antenatal care visit (OR: 3.05; 95% CI:
2.40 to 3.87). The probability of delivering in an institution
was 69% higher among young urban women than among young women
who lived in rural areas. Young women who had secondary or above
secondary level education were 1.63 times more likely to choose
institutional delivery than young women who had no formal
education (OR: 1.626; 95% CI: 1.171 to 2.258). Lower use of a
health institution for delivery was also observed among poor
young women. Results showed that wealthy young women were 2.12
times more likely to deliver their child in an institution
compared with poor young women (OR: 2.107; 95% CI: 1.53 to
2.898). Other factors such as the age of the young woman,
religion, ethnicity, and ecological zone were also associated
with institutional delivery. CONCLUSIONS: Maternal health
programs should be designed to encourage young women to receive
adequate ANC (at least four visits). Moreover, health programs
should target poor, less educated, rural, young women who live
in mountain regions, are of Janajati ethnicity and have at least
one child as such women are less likely to choose institutional
delivery in Nepal
Existing models of maternal death surveillance systems : protocol for a scoping review
Background: Maternal mortality measurement remains a critical challenge, particularly in low and middle income countries (LMICs) where little or no data are available and maternal mortality and morbidity are often the highest in the world. Despite the progress made in data collection, underreporting and translating the results into action are two major challenges that maternal death surveillance systems (MDSSs) face in LMICs.
Objective: This paper presents a protocol for a scoping review aimed at synthesizing the existing models of MDSSs and factors that influence their completeness and usefulness.
Methods: The methodology for scoping reviews from the Joanna Briggs Institute was used as a guide for developing this protocol. A comprehensive literature search will be conducted across relevant electronic databases. We will include all articles that describe MDSSs or assess their completeness or usefulness. At least two reviewers will independently screen all articles, and discrepancies will be resolved through discussion. The same process will be used to extract data from studies fulfilling the eligibility criteria. Data analysis will involve quantitative and qualitative methods.
Results: Currently, the abstracts screening is under way and the first results are expected to be publicly available by mid-2017. The synthesis of the reviewed materials will be presented in tabular form completed by a narrative description. The results will be classified in main conceptual categories that will be obtained during the results extraction.
Conclusions: We anticipate that the results will provide a broad overview of MDSSs and describe factors related to their completeness and usefulness. The results will allow us to identify research gaps concerning the barriers and facilitating factors facing MDSSs. Results will be disseminated through publication in a peer-reviewed journal and conferences as well as domestic and international agencies in charge of implementing MDSS
Effects of a refugee-assistance programme on host population in Guinea as measured by obstetric interventions.
BACKGROUND: Since 1990, 500000 people have fled from Liberia and Sierra Leone to Guinea, west Africa, where the government allowed them to settle freely, and provided medical assistance. We assessed whether the host population gained better access to hospital care during 1988-96. METHODS: In Guéckédou prefecture, we used data on major obstetric interventions performed in the district hospital between January, 1988, and August, 1996, and estimated the expected number of births to calculate the rate of major obstetric interventions for the host population. We calculated rates for 1988-90, 1991-93, and 1994-96 for three rural areas with different numbers of refugees. FINDINGS: Rates of major obstetric interventions for the host population increased from 0.03% (95% CI 0-0.09) to 1.06% (0.74-1.38) in the area with high numbers of refugees, from 0.34% (0.22-0.45) to 0.92% (0.74-1.11) in the area with medium numbers, and from 0.07% (0-0.17) to 0.27% (0.08-0.46) in the area with low numbers. The rate ratio over time was 4.35 (2.64-7.15), 1.70 (1.40-2.07), and 1.94 (0.97-3.87) for these areas, respectively. The rates of major obstetric interventions increased significantly more in the area with high numbers of refugees than in the other two areas. INTERPRETATION: In areas with high numbers of refugees, the refugee-assistance programme improved the health system and transport infrastructure. The presence of refugees also led to economic changes and a "refugee-induced demand". The non-directive refugee policy in Guinea made such changes possible and may be a cost-effective alternative to camps
What Influences Adolescent Girls' Decision-Making Regarding Contraceptive Methods Use and Childbearing? A Qualitative Exploratory Study in Rangpur District, Bangladesh
BACKGROUND: Bangladesh has the highest rate of adolescent
pregnancy in South Asia. Child marriage is one of the leading
causes of pregnancies among adolescent girls. Although the
country's contraceptive prevalence rate is quite satisfactory,
only 52% of married adolescent girls use contraceptive methods.
This qualitative study is aimed at exploring the factors that
influence adolescent girls' decision-making process in relation
to contraceptive methods use and childbearing. METHODS AND
RESULTS: We collected qualitative data from study participants
living in Rangpur district, Bangladesh. We conducted 35 in-depth
interviews with married adolescent girls, 4 key informant
interviews, and one focus group discussion with community health
workers. Adolescent girls showed very low decision-making
autonomy towards contraceptive methods use and childbearing.
Decisions were mainly made by either their husbands or
mothers-in-law. When husbands were unemployed and financially
dependent on their parents, then the mothers-in-law played most
important role for contraceptive use and childbearing decisions.
Lack of reproductive health knowledge, lack of negotiation and
communication ability with husbands and family members, and
mistrust towards contraceptive methods also appeared as
influential factors against using contraception resulting in
early childbearing among married adolescent girls. CONCLUSIONS:
Husbands and mothers-in-law of newly married adolescent girls
need to be actively involved in health interventions so that
they make more informed decisions regarding contraceptive use to
delay pregnancies until 20 years of age. Misunderstanding and
distrust regarding contraceptives can be diminished by engaging
the wider societal actors in health intervention including
neighbours, and other family members
Determinants and trends in health facility-based deliveries and caesarean sections among married adolescent girls in Bangladesh
OBJECTIVE: To identify the determinants and measure the trends
in health facility-based deliveries and caesarean sections among
married adolescent girls in Bangladesh. METHODS: In order to
measure the trends in health facility-based deliveries and
caesarean sections, Bangladesh Demographic Health Survey (BDHS)
data sets were analysed (BDHS; 1993-1994, 1996-1997, 1999-2000,
2004, 2007, 2011). The BDHS 2011 data sets were analysed to
identify the determinants of health facility-based deliveries
and caesarean sections. A total of 2813 adolescent girls (aged
10-19 years) were included for analysis. Bivariate and
multivariate analyses were performed. RESULTS: Health
facility-based deliveries have continuously increased among
adolescents in Bangladesh over the past two decades from 3% in
1993-1994 to 24.5% in 2011. Rates of population-based and
facility-based caesarean sections have increased linearly among
all age groups of women including adolescents. Although the
country's overall (population-based) caesarean section rate
among adolescents was within acceptable range (11.6%), a rate of
nearly 50% health facility level caesarean sections among
adolescent girls is alarming. Among adolescent girls, use of
antenatal care (ANC) appeared to be the most important predictor
of health facility-based delivery (OR: 4.04; 95% CI 2.73 to
5.99), whereas the wealth index appeared as the most important
predictor of caesarean sections (OR: 5.7; 95% CI 2.74 to 12.1).
CONCLUSIONS: Maternal health-related interventions should be
more targeted towards adolescent girls in order to encourage
them to access ANC and promote health facility-based delivery.
Rising trends of caesarean sections require further
investigation on indication and provider-client-related
determinants of these interventions among adolescent girls in
Bangladesh
Viability of diagnostic decision support for antenatal care in rural settings: findings from the Bliss4Midwives Intervention in Northern Ghana
Background: Antenatal screening is useful for early identification and management of high-risk pregnancies. In low-resource settings, provision of the full
complement of tests is limited and diagnostic referrals incure additional costs
for pregnant women. We assessed the viability of Bliss4Midwives (B4M) - a
point-of-care diagnostic decision support device for decentralized screening of
pre-eclampsia, gestational diabetes and anaemia during antenatal care (ANC).
Methods: The device was piloted in seven health facilities across two districts
in Northern Ghana over a ten-month period. Health workers were expected
to screen women at each ANC visit till delivery. All screening records from
the device were automatically archived digitally and later downloaded. After
removing duplicates or invalid entries, descriptive quantitative analysis was
carried out with IBM SPSS Statistics (version 23). B4M usage behavior, diagnostic and referral outcome were analyzed.
Results: Health workers conducted 1323 partial or full antenatal screening
on 940 women, resulting in decision support for 835 (88.8%) B4M beneficiaries. Diagnostic referral was eliminated for 708 (84.7%) beneficiaries, with
335 (40.1%) of these from facilities without on-site diagnostic alternatives.
Of visits with complete data, 92/559 (16.4%) women were screened in their
first trimester, 28/940 (2.9%) had 4+ B4M visits and 107/835 (12.8%) women were recommended for urgent referral to a higher-level facility on the first
visit. Follow-up screenings flagged an additional 17 women for urgent referral
with 10 cases of repeated alerts in five women. Wide variations between high
(9 months use) and low adopting (1.5 months use) facilities were observed,
with some similarities in usage trend.
Conclusions: B4M helped decentralize ANC screening and decrease unnecessary referrals. Project outcomes were influenced by implementation strategy, technical features and behavioural dispositions of users and beneficiaries
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