Autonomy dimensions and care seeking for delivery in Zambia; the prevailing importance of cluster-level measurement.

It is widely held that decisions whether or when to attend health facilities for childbirth are not only influenced by risk awareness and household wealth, but also by factors such as autonomy or a woman's ability to act upon her own preferences. How autonomy should be constructed and measured - namely, as an individual or cluster-level variable - has been less examined. We drew on household survey data from Zambia to study the effect of several autonomy dimensions (financial, relationship, freedom of movement, health care seeking and violence) on place of delivery for 3200 births across 203 rural clusters (villages). In multilevel logistic regression, two autonomy dimensions (relationship and health care seeking) were strongly associated with facility delivery when measured at the cluster level (OR 1.27 and 1.57, respectively), though not at the individual level. This suggests that power relations and gender norms at the community level may override an individual woman's autonomy, and cluster-level measurement may prove critical to understanding the interplay between autonomy and care seeking in this and similar contexts

Facilitators and barriers to the implementation of a Mobile Health Wallet for pregnancy-related health care: A qualitative study of stakeholders’ perceptions in Madagascar

Financial barriers are a major obstacle to accessing maternal health care services in low-resource settings. In Madagascar, less than half of live births are attended by skilled health staff. Although mobile money-based savings and payment systems are often used to pay for a variety of services, including health care, data on the implications of a dedicated mobile money wallet restricted to health-related spending during pregnancy–a mobile health wallet (MHW)–are not well understood. In cooperation with the Madagascan Ministry of Health, this study aims to elicit the perceptions, experiences, and recommendations of key stakeholders in relation to a MHW amid a pilot study in 31 state-funded health care facilities. We conducted a two-stage qualitative study using semi-structured in-depth interviews with stakeholders (N = 21) representing the following groups: community representatives, health care providers, health officials and representatives from phone provider companies. Interviews were conducted in Atsimondrano and Renivohitra districts, between November and December of 2017. Data was coded thematically using inductive and deductive approaches, and found to align with a social ecological model. Key facilitators for successful implementation of the MHW, include (i) close collaboration with existing communal structures and (ii) creation of an incentive scheme to reward pregnant women to save. Key barriers to the application of the MHW in the study zone include (i) disruption of informal benefits for health care providers related to the current cash-based payment system, (ii) low mobile phone ownership, (iii) illiteracy among the target population, and (iv) failure of the MHW to overcome essential access barriers towards institutional health care services such as fear of unpredictable expenses. The MHW was perceived as a potential solution to reduce disparities in access to maternal health care. To ensure success of the MHW, direct demand-side and provider-side financial incentives merit consideration

The “hot potato” topic: challenges and facilitators to promoting respectful maternal care within a broader health intervention in Tanzania

In recent years, mistreatment during childbirth has captured the public health and maternal health consciousness as not only an affront to women’s rights but also a formidable deterrent to the uptake of facility-based childbirth - and thus to reductions in maternal mortality. The challenge ahead is to determine what can be done to address this public health problem. A modest but growing body of research has demonstrated that interventions to foster Respectful Maternity Care (RMC) can enact change, albeit in the relatively controlled context of a trial or study. Herein we describe our experiences in weaving elements of RMC across tiers of an existing maternal and newborn health program. As a commentary, this document does not outline program results, but instead highlights challenges and facilitators to promoting RMC within a large-scale, multi-district health platform. We conclude with lessons learned during the process and urge that others share their program learning experiences in an effort to strengthen the knowledge base on what works and what does not work in terms of addressing this complex, context-sensitive issue

Healthcare seeking for diarrhoea, malaria and pneumonia among children in four poor rural districts in Sierra Leone in the context of free health care: results of a cross-sectional survey

BACKGROUND: To plan for a community case management (CCM) program after the implementation of the Free Health Care Initiative (FHCI), we assessed health care seeking for children with diarrhoea, malaria and pneumonia in 4 poor rural districts in Sierra Leone. METHODS: In July 2010 we undertook a cross-sectional household cluster survey and qualitative research. Caregivers of children under five years of age were interviewed about healthcare seeking. We evaluated the association of various factors with not seeking health care by obtaining adjusted odds ratios and 95% confidence limits using a multivariable logistic regression model. Focus groups and in-depth interviews of young mothers, fathers and older caregivers in 12 villages explored household recognition and response to child morbidity. RESULTS: The response rate was 93% (n=5951). Over 85% of children were brought for care for all conditions. However, 10.8% of those with diarrhoea, 36.5% of those with presumed pneumonia and 41.0% of those with fever did not receive recommended treatment. In the multivariable models, use of traditional treatments was significantly associated with not seeking outside care for all three conditions. Qualitative data showed that traditional treatments were used due to preferences for locally available treatments and barriers to facility care that remain even after FHCI. CONCLUSION: We found high healthcare seeking rates soon after the FHCI; however, many children do not receive recommended treatment, and some are given traditional treatment instead of seeking outside care. Facility care needs to be improved and the CCM program should target those few children still not accessing care

Effect Heterogeneity in Responding to Performance-Based Incentives: A Quasi-Experimental Comparison of Impacts on Health Service Indicators Between Hospitals and Health Centers in Malawi.

Heterogeneity of effects produced by performance-based incentives (PBIs) at different levels of care provision is not well understood. This study analyzes effect heterogeneities between different facility types resulting from a PBI program in Malawi. Identical PBIs were applied to both district hospitals and health centers to improve the performance of essential health services provision. We conducted two complementary quasi-experiments comparing all 17 interventions with 17 matched independent control facilities (each 12 health centers, five hospitals). A pre- and post-test design with difference-in-differences analysis was used to estimate effects on 14 binary quality indicators; interrupted time series analysis of monthly routine data was used to estimate effects on 11 continuous quantity indicators. Effects were estimated separately for health centers and hospitals. Most quality indicators performed high at baseline, producing ceiling effects on further measurable improvements. Significant positive effects were observed for stocks of iron supplements (hospitals) and partographs (health centers). Four quantity indicators showed similar positive trend improvements across facility types (first-trimester antenatal visits, voluntary HIV-testing of couples, iron supplementation in pregnancy, vitamin A supplementation of children); two showed no change for either type of facility (skilled birth attendance, fully immunized one-year-olds); five indicators revealed different effect patterns for health centers and hospitals. In both health centers and hospitals, the largely positive PBI effects on antenatal care included resilience against interrupted supply chains and improvements in attendance rates. Observed heterogeneity might have been influenced by the availability of specific resources or the redistribution of service use

"You should go so that others can come"; The Role of Facilities in Determining an Early Departure after Childbirth in Morogoro Region, Tanzania.

Tanzania is among ten countries that account for a majority of the world's newborn deaths. However, data on time-to-discharge after facility delivery, receipt of postpartum messaging by time to discharge and women's experiences in the time preceding discharge from a facility after childbirth are limited. Household survey of 1267 women who delivered in the preceding 2-14 months; in-depth interviews with 24 women, 12 husbands, and 5 community elders. Two-thirds of women with vaginal, uncomplicated births departed within 12 h; 90 % within 24 h, and 95 % within 48 h. Median departure times varied significantly across facilities (hospital: 23 h, health center: 10 h, dispensary: 7 h, p < 0.001). Quantitative and qualitative data highlight the importance of type of facility and facility amenities in determining time-to-discharge. In multiple logistic regression, level of facility (hospital, health center, dispensary) was the only significant predictor of early discharge (p = 0.001). However across all types of facilities a majority of women depart before 24 h ranging from hospitals (54 %) to health centers (64 %) to dispensaries (74 %). Most women who experienced a delivery complication (56 %), gave birth by caesarean section (90 %), or gave birth to a pre-term baby (70 %) stayed longer than 24 h. Reasons for early discharge include: facility practices including discharge routines and working hours and facility-based discomforts for women and those who accompany them to facilities. Provision of postpartum counseling was inadequate regardless of time to discharge and regardless of type of facility where delivery occurred. Our quantitative and qualitative findings indicate that the level of facility care and comforts existing or lacking in a facility have the greatest effect on time to discharge. This suggests that individual or interpersonal characteristics play a limited role in deciding whether a woman would stay for shorter or longer periods. Implementation of a policy of longer stay must incorporate enhanced postpartum counseling and should be sensitive to women's perceptions that it is safe and beneficial to leave hospitals soon after birth

Highly valued despite burdens: Qualitative implementation research on rapid tests for hospital-based SARS-CoV-2 screening.

Antigen-based rapid diagnostic tests (RDTs) for SARS-CoV-2 have good reliability and have been repeatedly implemented as part of pandemic response policies, especially for screening in high-risk settings (e.g., hospitals and care homes) where fast recognition of an infection is essential. However, evidence from actual implementation efforts and associated experiences is lacking. We conducted a qualitative study at a large tertiary care hospital in Germany to identify step-by-step processes when implementing RDTs for the screening of incoming patients, as well as stakeholders' implementation experiences. We relied on 30 in-depth interviews with hospital staff (members of the regulatory body, department heads, staff working on the wards, staff training providers on how to perform RDTs, and providers performing RDTs as part of the screening) and patients being screened with RDTs. Despite some initial reservations, RDTs were rapidly accepted and adopted as the best available tool for accessible and reliable screening. Decentralized implementation efforts resulted in different procedures being operationalized across departments. Procedures were continuously refined based on initial experiences (e.g., infrastructural or scheduling constraints), pandemic dynamics (growing infection rates), and changing regulations (e.g., screening of all external personnel). To reduce interdepartmental tension, stakeholders recommended high-level, consistently communicated and enforced regulations. Despite challenges, RDT-based screening for all incoming patients was observed to be feasible and acceptable among implementers and patients, and merits continued consideration in the context of high infection and stagnating vaccination rates

Poverty, Partner Discord, and Divergent Accounts; A Mixed Methods Account of Births before Arrival to Health Facilities in Morogoro Region, Tanzania.

Births before arrival (BBA) to health care facilities are associated with higher rates of perinatal morbidity and mortality compared to facility deliveries or planned home births. Research on such births has been conducted in several high-income countries, but there are almost no studies from low-income settings where a majority of maternal and newborn deaths occur. Drawing on a household survey of women and in-depth interviews with women and their partners, we examined the experience of BBA in rural districts of Morogoro Region, Tanzania. Among survey respondents, 59 births (4 %) were classified as BBAs. Most of these births occurred in the presence of a family member (47 %) or traditional birth attendant (24 %). Low socioeconomic status was the strongest predictor of BBA. After controlling for wealth via matching, high parity and a low number of antenatal care (ANC) visits retained statistical significance. While these variables are useful indicators of which women are at greater risk of BBA, their predictive power is limited in a context where many women are poor, multiparous, and make multiple ANC visits. In qualitative interviews, stories of BBAs included themes of partner disagreement regarding when to depart for facilities and financial or logistical constraints that underpinned departure delays. Women described wanting to depart earlier to facilities than partners. As efforts continue to promote facility birth, we highlight the financial demands associated with facility delivery and the potential for these demands to place women at a heightened risk for BBAs

Optical modeling and polarization calibration for CMB measurements with ACTPol and Advanced ACTPol

The Atacama Cosmology Telescope Polarimeter (ACTPol) is a polarization sensitive upgrade to the Atacama Cosmology Telescope. Located at an elevation of 5190 m, ACTPol measures the Cosmic Microwave Background (CMB) temperature and polarization with arcminute-scale angular resolution. Calibration of the detector angles is a critical step in producing maps of the CMB polarization. Polarization angle offsets in the detector calibration can cause leakage in polarization from E to B modes and induce a spurious signal in the EB and TB cross correlations, which eliminates our ability to measure potential cosmological sources of EB and TB signals, such as cosmic birefringence. We present our optical modeling and measurements associated with calibrating the detector angles in ACTPol.Comment: 12 pages, 8 figures, conference proceedings submitted to Proceedings of SPIE; added reference in section 2 and merged repeated referenc