Did Equity of Reproductive and Maternal Health Service Coverage Increase during the MDG Era? An Analysis of Trends and Determinants across 74 Low- and Middle-Income Countries

Introduction

Despite widespread gains toward the 5^th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. As countries enter the post-MDG era and strive toward UHC, it will be important to monitor the extent to which countries are achieving equity of RH and MH service coverage. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country’s progress, or lack thereof, toward more equitable RH and MH service coverage.

Methods

We used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014. We examined trends in both relative and absolute equity, and measured relative equity using a concentration index of coverage data grouped by wealth quintile. Through multivariate analysis we examined the relative importance of policy factors, such as political commitment to health, governance, and the level of prepayment, in determining countries’ progress toward greater equity in RH and MH service coverage.

Results

Relative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity.

Conclusion

Equity in RH and MH service coverage has improved but varies considerably across countries and over time. Even among the subset of countries that are close to achieving the MDGs, progress made on equity varies considerably across countries. Enduring disparities in access and outcomes underpin mounting support for targeted reforms within the broader context of universal health coverage (UHC).     

Inequalities in Global Trade: A Cross-Country Comparison of Trade Network Position,Economic Wealth,Pollution and Mortality

In this paper we investigate how structural patterns of international trade give rise to emissions inequalities across countries, and how such inequality in turn impact countries’ mortality rates. We employ Multi-regional Input-Output analysis to distinguish between sulfur-dioxide (SO2) emissions produced within a country’s boarders (production-based emissions) and emissions triggered by consumption in other countries (consumption-based emissions). We use social network analysis to capture countries’ level of integration within the global trade network. We then apply the Prais-Winsten panel estimation technique to a panel data set across 172 countries over 20 years (1990–2010) to estimate the relationships between countries’ level of integration and SO2 emissions, and the impact of trade integration and SO2 emission on mortality rates. Our findings suggest a positive, (log-) linear relationship between a country’s level of integration and both kinds of emissions. In addition, although more integrated countries are mainly responsible for both forms of emissions, our findings indicate that they also tend to experience lower mortality rates. Our approach offers a unique combination of social network analysis with multiregional input-output analysis, which better operationalizes intuitive concepts about global trade and trade structure.     

Paternal Factors and Inequity Associated with Access to Maternal Health Care Service Utilization in Nepal: A Community Based Cross-Sectional Study

Background

The threat of maternal mortality can be reduced by increasing use of maternal health services. Maternal death and access to maternal health care services are inequitable in low and middle income countries.The aim of this study is to assess associated paternal factors and degree of inequity in access to maternal health care service utilization.

Methods

Analysis illustrates on a cross-sectional household survey that followed multistage-cluster sampling. Concentration curve and indices were calculated. Binary logistic regression analysis was executed to account paternal factors associated with the utilization of maternal health services. Path model with structural equation modeling (SEM) examined the predictors of antenatal care (ANC) and institutional delivery.

Results

The finding of this study revealed that 39.9% and 45.5% of the respondents’ wives made ANC visits and utilized institutional delivery services respectively. Men with graduate and higher level of education were more likely (AOR: 5.91, 95% CI; 4.02, 8.70) to have ANC of their wives than men with no education or primary level of education. Men with higher household income (Q5) were more likely (1.99, 95% CI; 1.39, 2.86) to have ANC for their wives. Similarly, higher household income (Q5) also determined (2.74, 95% CI; 1.81, 4.15) for institutional delivery of their wives. Concentration curve and indices also favored rich than the poor. SEM revealed that ANC visit was directly associated to institutional delivery.

Conclusions

Paternal factors like age, household wealth, number of children, ethnicity, education, knowledge of danger sign during pregnancy, and husband’s decision making for seeking maternal and child health care are crucial factors associated to maternal health service utilization. Higher ANC coverage predicts higher utilization of the institutional delivery. Wealthier population is more concentrated to maternal health services. The inequities between the poor and the rich are necessary to be addressed through effective policy and programs.     

Evaluation of progress toward universal health coverage in Myanmar: A national and subnational analysis

BackgroundUniversal health coverage (UHC) encompasses 2 main components: access to essential healthcare services and protection from financial hardship when using healthcare. This study examines Myanmar’s efforts to achieve UHC on a national and subnational level. It is a primer of studying the concept of UHC on a subnational level, and it also establishes a baseline for assessing future progress toward reaching UHC in Myanmar.Methods and findingsThe study uses the Demographic and Health Survey (2015) and the Myanmar Living Conditions Survey (MLCS; 2017) and adapts a previously developed UHC index to provide insights into the main barriers preventing the country’s progress toward UHC. We find a negative correlation between the UHC index and the state/region poverty levels. The equity of access analysis reveals significant pro-rich inequity in access to all essential healthcare services. Socioeconomic status and limited availability of healthcare infrastructure are the main driving forces behind the unequal access to interventions that are crucial to achieving UHC by 2030. Finally, financial risk protection analysis shows that the poor are less likely to use healthcare services, and, once they do, they are at a greater risk of suffering financial catastrophe. Limitations of this study revolve around its correlational, rather than causal, nature.ConclusionsWe suggest a 2-pronged approach to help Myanmar achieve UHC: Government and state authorities should reduce the financial burden of seeking healthcare, and, coupled with this, significant investment in and expansion of health infrastructure and the health workforce should be made, particularly in the poorer and more remote states.

Zlatko Nikoloski and colleagues provide analytical insight into Myanmar’s efforts to achieve universal health coverage on a national and sub-national level.     

Stagnant Neonatal Mortality and Persistent Health Inequality in Middle-Income Countries: A Case Study of the Philippines

Background

The probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country’s socioeconomic-related child health inequality.

Methodology

Using data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality.

Findings

Despite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery.

Conclusion

The Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality – that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system – to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health.     

Assessing Coverage,Equity and Quality Gaps in Maternal and Neonatal Care in Sub-Saharan Africa: An Integrated Approach

BackgroundGaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries.MethodsData were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization’s maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care.ResultsAll the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level.ConclusionOur findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.     

Factors Contributing to Maternal and Child Mortality Reductions in 146 Low- and Middle-Income Countries between 1990 and 2010

Introduction

From 1990–2010, worldwide child mortality declined by 43%, and maternal mortality declined by 40%. This paper compares two sources of progress: improvements in societal coverage of health determinants versus improvements in the impact of health determinants as a result of technical change.

Methods

This paper decomposes the progress made by 146 low- and middle-income countries (LMICs) in lowering childhood and maternal mortality into one component due to better health determinants like literacy, income, and health coverage and a second component due to changes in the impact of these health determinants. Health determinants were selected from eight distinct health-impacting sectors. Health determinants were selected from eight distinct health-impacting sectors. Regression models are used to estimate impact size in 1990 and again in 2010. Changes in the levels of health determinants were measured using secondary data.

Findings

The model shows that respectively 100% and 89% of the reductions in maternal and child mortality since 1990 were due to improvements in nationwide coverage of health determinants. The relative share of overall improvement attributable to any single determinant varies by country and by model specification. However, in aggregate, approximately 50% of the mortality reductions were due to improvements in the health sector, and the other 50% of the mortality reductions were due to gains outside the health sector.

Conclusions

Overall, countries improved maternal and child health (MCH) from 1990 to 2010 mainly through improvements in the societal coverage of a broad array of health system, social, economic and environmental determinants of child health. These findings vindicate efforts by the global community to obtain such improvements, and align with the post-2015 development agenda that builds on the lessons from the MDGs and highlights the importance of promoting health and sustainable development in a more integrated manner across sectors.     

Assessment on the Knowledge and Reported Practices of Women on Maternal and Child Health in Rural Sierra Leone: A Cross-Sectional Survey

Background

Globally, Sierra Leone is ranked among the countries with the worst maternal and child health indicators. The mortality of women and children is significantly higher compared with other developing countries. The death of women and children can be prevented by simple cost-effective community-based interventions. The aim of this present study was to learn the knowledge levels of women on maternal and child health, and treatment-seeking and preventive behaviours in rural Sierra Leone and provide appropriate suggestions for policy makers. Moreover, the study also aimed to evaluate the effect of a husband’s involvement on health knowledge and practices of women in rural Sierra Leone.

Methods

Women with at least a child of five years or below were interviewed in their households through a structured questionnaire. Characteristics of the households and of the respondents were collected and the number of correct answers given to the health knowledge and practice questions and their percentage distributions were tabulated and an overall health knowledge score was calculated.

Results

The mean score of the derived overall health-related knowledge was 61.6% (maximum of 91% and a minimum of 18%) with a standard deviation of 14.7% and a median of 63.3%. Multivariable regression analyses showed education and number of pregnancies are associated with knowledge score, with significantly improved health knowledge scores amongst those who accessed higher education. There were some inappropriate practices in hygiene and sanitation. However, vaccination coverage was high with almost 100% coverage for BCG.

Conclusions

Based on the findings of this study, women’s knowledge on maternal and child health care are inadequate in rural Sierra Leone. Health promotion activities focusing on prevention of diarrhoea, malaria and pneumonia, improvement in health-related knowledge on pregnancy, delivery, neonatal care and environmental sanitation would be invaluable.     

Health Extension Workers' and Mothers' Attitudes to Maternal Health Service Utilization and Acceptance in Adwa Woreda,Tigray Region,Ethiopia

Background

The maternal health system in Ethiopia links health posts in rural communities (kebeles) with district (woreda) health centres, and health centres with primary hospitals. At each health post two Health Extension Workers (HEWs) assist women with birth preparedness, complication readiness, and mobilize communities to facilitate timely referral to mid-level service providers. This study explored HEWs’ and mother’s attitudes to maternal health services in Adwa Woreda, Tigray Region.

Methods

In this qualitative study, we trained 16 HEWs to interview 45 women to gain a better understanding of the social context of maternal health related behaviours. Themes included barriers to health services; women’s social status and mobility; and women’s perceptions of skilled birth attendant’s care. All data were analyzed thematically.

Findings

There have been substantial efforts to improve maternal health and reduce maternal mortality in Adwa Woreda. Women identified barriers to healthcare including distance and lack of transportation due to geographical factors; the absence of many husbands due to off-woreda farming; traditional factors such as zwar (some pregnant women are afraid of meeting other pregnant women), and discouragement from mothers and mothers-in-law who delivered their children at home. Some women experienced disrespectful care at the hospital. Facilitators to skilled birth attendance included: identification of pregnant women through Women’s Development Groups (WDGs), and referral by ambulance to health facilities either before a woman’s Expected Due Date (EDD) or if labour started at home.

Conclusion

With the support of WDGs, HEWs have increased the rate of skilled birth attendance by calling ambulances to transfer women to health centres either before their EDD or when labour starts at home. These findings add to the growing body of evidence that health workers at the community level can work with women’s groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries.     

Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000–2019

BackgroundArmed conflicts have major indirect health impacts in addition to the direct harms from violence. They create enduring political instability, destabilise health systems, and foster negative socioeconomic and environmental conditions—all of which constrain efforts to reduce maternal and child mortality. The detrimental impacts of conflict on global maternal and child health are not robustly quantified. This study assesses the association between conflict and maternal and child health globally.Methods and findingsData for 181 countries (2000–2019) from the Uppsala Conflict Data Program and World Bank were analysed using panel regression models. Primary outcomes were maternal, under-5, infant, and neonatal mortality rates. Secondary outcomes were delivery by a skilled birth attendant and diphtheria, pertussis, and tetanus (DPT) and measles vaccination coverage. Models were adjusted for 10 confounders, country and year fixed effects, and conflict lagged by 1 year. Further lagged associations up to 10 years post-conflict were tested. The number of excess deaths due to conflict was estimated. Out of 3,718 country–year observations, 522 (14.0%) had minor conflicts and 148 (4.0%) had wars. In adjusted models, conflicts classified as wars were associated with an increase in maternal mortality of 36.9 maternal deaths per 100,000 live births (95% CI 1.9–72.0; 0.3 million excess deaths [95% CI 0.2 million–0.4 million] over the study period), an increase in infant mortality of 2.8 per 1,000 live births (95% CI 0.1–5.5; 2.0 million excess deaths [95% CI 1.6 million–2.5 million]), a decrease in DPT vaccination coverage of 4.9% (95% CI 1.5%–8.3%), and a decrease in measles vaccination coverage of 7.3% (95% CI 2.7%–11.8%). The long-term impacts of war were demonstrated by associated increases in maternal mortality observed for up to 7 years, in under-5 mortality for 3–5 years, in infant mortality for up to 8 years, in DPT vaccination coverage for up to 3 years, and in measles vaccination coverage for up to 2 years. No evidence of association between armed conflict and neonatal mortality or delivery by a skilled birth attendant was found. Study limitations include the ecological study design, which may mask sub-national variation in conflict intensity, and the quality of the underlying data.ConclusionsOur analysis indicates that armed conflict is associated with substantial and persistent excess maternal and child deaths globally, and with reductions in key measures that indicate reduced availability of organised healthcare. These findings highlight the importance of protecting women and children from the indirect harms of conflict, including those relating to health system deterioration and worsening socioeconomic conditions.

Mohammed Jawad and co-workers report on a global analysis of maternal and child health outcomes in situations of armed conflict.     

A Performance Analysis of Public Expenditure on Maternal Health in Mexico

We explore the relationship between public expenditure, coverage of adequate ANC (including timing, frequent and content), and the maternal mortality ratio -adjusted by coverage of adequate ANC- observed in Mexico in 2012 at the State level. Additionally, we examine the inequalities and concentration of public expenditure between populations with and without Social Security. Results suggest that in the 2003–2011 period, the public expenditure gap between women with and without Social Security decreased 74%, however, the distribution is less equitable among women without Social Security, across the States. Despite high levels of coverage on each dimension of ANC explored, coverage of adequate ANC was lower among Social Security than non-Social Security women. This variability results in differences up to 1.5 times in State-adjusted maternal mortality rate at the same level of expense and maternal mortality rate, respectively. The increase in the economic resources is only a necessary condition for achieving improved health outcomes. Providing adequate health services and achieving efficient, effective and transparent use of resources in health, are critical elements for health systems performance. The attainment of universal effective coverage of maternal health and reducing maternal mortality in Mexico, requires the adjustment of policy innovations including the rules of allocation and execution of health resources. Health policies should be designed on a more holistic view promoting a balance between accessibility, effective implementation and rigorous stewardship.     

Achievement and social mobility: Relationships among IQ score,education, and occupation in two generations

This research tests the hypothesis that change over time in women’s status leads to improvements in their children’s health. Specifically, we examine whether change in resources and empowerment in mother’s roles as biological mothers, caregivers, and providers and social contexts that promote the rights and representation of and investment in women are associated with better nutritional status and survival of young children. Analysis is based on a broad sample of countries (n = 28), with data at two or more points in time to enable examination of change. Key indicators of child health show improvement in the last 13 years in developing nations. Much of this improvement—90 percent of the increase in nutritional status and 47 percent of the reduction in mortality—is associated with improving status of women. Increased maternal education, control over reproduction, freedom from violence, access to health care, legislation and enforcement of women’s rights, greater political representation, equality in the education system, and lower maternal mortality are improving children’s health. These results imply that further advancement of women’s position in society would be beneficial.     

Are Husbands Involving in Their Spouses’ Utilization of Maternal Care Services?: A Cross-Sectional Study in Yangon,Myanmar

IntroductionHusbands can play a crucial role in pregnancy and childbirth, especially in patriarchal societies of developing countries. In Myanmar, despite the critical influence of husbands on the health of mothers and newborns, their roles in maternal health have not been well explored. Therefore, the aim of this study was to identify the factors associated with husbands’ involvement in maternal health in Myanmar. This study also examined the associations between husbands’ involvement and their spouses’ utilization of maternal care services during antenatal, delivery and postnatal periods.MethodsA community-based, cross sectional study was conducted with 426 husbands in Thingangyun Township, Yangon, Myanmar. Participants were husbands aged 18 years or older who had at least one child within two years at the time of interview. Face to face interviews were conducted using a pretested structured questionnaire. Factors associated with the characteristics of husband’s involvement as well as their spouses’ utilization of maternal care services were analyzed by multivariable logistic regression models.ResultsOf 426 husbands, 64.8% accompanied their spouses for an antenatal visit more than once while 51.6% accompanied them for a postnatal visit. Husbands were major financial supporters for both antenatal (95.8%) and postnatal care (68.5%). Overall, 69.7% were involved in decision making about the place of delivery. Regarding birth preparedness, the majority of husbands prepared for skilled birth attendance (91.1%), delivery place (83.6%), and money saving (81.7%) before their spouses gave birth. In contrast, fewer planned for a potential blood donor (15.5%) and a safe delivery kit (21.1%). In the context of maternal health, predictors of husband’s involvement were parity, educational level, type of marriage, decision making level in family, exposure to maternal health education and perception of risk during pregnancy and childbirth. Increased utilization of maternal health services was found among spouses of husbands who accompanied them to antenatal visits (AOR 5.82, 95% CI, 3.34–10.15) and those who had a well birth plan (AOR 2.42, 95% CI, 1.34–4.39 for antenatal visit and AOR 2.88, 95% CI, 1.52–5.47 for postnatal visit).ConclusionThe majority of husbands supported their spouses’ maternal care services use financially; however, they were less involved in birth preparedness and postnatal care. Exposure to maternal health education and their maternal health knowledge were main predictors of their involvement. Women were more likely to use maternal care services when their husbands company them for ANC visits and had a well-birth plan in advance.     

Regional Differences in Intervention Coverage and Health System Strength in Tanzania

Background

Assessments of subnational progress and performance coverage within countries should be an integral part of health sector reviews, using recent data from multiple sources on health system strength and coverage.

Method

As part of the midterm review of the national health sector strategic plan of Tanzania mainland, summary measures of health system strength and coverage of interventions were developed for all 21 regions, focusing on the priority indicators of the national plan. Household surveys, health facility data and administrative databases were used to compute the regional scores.

Findings

Regional Millennium Development Goal (MDG) intervention coverage, based on 19 indicators, ranged from 47% in Shinyanga in the northwest to 71% in Dar es Salaam region. Regions in the eastern half of the country have higher coverage than in the western half of mainland. The MDG coverage score is strongly positively correlated with health systems strength (r = 0.84). Controlling for socioeconomic status in a multivariate analysis has no impact on the association between the MDG coverage score and health system strength. During 1991–2010 intervention coverage improved considerably in all regions, but the absolute gap between the regions did not change during the past two decades, with a gap of 22% between the top and bottom three regions.

Interpretation

The assessment of regional progress and performance in 21 regions of mainland Tanzania showed considerable inequalities in coverage and health system strength and allowed the identification of high and low-performing regions. Using summary measures derived from administrative, health facility and survey data, a subnational picture of progress and performance can be obtained for use in regular health sector reviews.     

Access to Orphan Drugs: A Comprehensive Review of Legislations,Regulations and Policies in 35 Countries

ObjectiveTo review existing regulations and policies utilised by countries to enable patient access to orphan drugs.MethodsA review of the literature (1998 to 2014) was performed to identify relevant, peer-reviewed articles. Using content analysis, we synthesised regulations and policies for access to orphan drugs by type and by country.ResultsFifty seven articles and 35 countries were included in this review. Six broad categories of regulation and policy instruments were identified: national orphan drug policies, orphan drug designation, marketing authorization, incentives, marketing exclusivity, and pricing and reimbursement. The availability of orphan drugs depends on individual country’s legislation and regulations including national orphan drug policies, orphan drug designation, marketing authorization, marketing exclusivity and incentives such as tax credits to ensure research, development and marketing. The majority of countries (27/35) had in place orphan drug legislation. Access to orphan drugs depends on individual country’s pricing and reimbursement policies, which varied widely between countries. High prices and insufficient evidence often limit orphan drugs from meeting the traditional health technology assessment criteria, especially cost-effectiveness, which may influence access.ConclusionsOverall many countries have implemented a combination of legislations, regulations and policies for orphan drugs in the last two decades. While these may enable the availability and access to orphan drugs, there are critical differences between countries in terms of range and types of legislations, regulations and policies implemented. Importantly, China and India, two of the largest countries by population size, both lack national legislation for orphan medicines and rare diseases, which could have substantial negative impacts on their patient populations with rare diseases.     

A Systematic Review of Individual and Contextual Factors Affecting ART Initiation,Adherence, and Retention for HIV-Infected Pregnant and Postpartum Women

Background

Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women.

Methods

Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories.

Results

Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman’s awareness and control (e.g., commitment to child’s health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes.

Conclusions

To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.     

Countdown to 2015: Tracking Maternal and Child Health Intervention Targets Using Lot Quality Assurance Sampling in Bauchi State Nigeria

Background

Improving maternal and child health remains a top priority in Nigeria’s Bauchi State in the northeastern region where the maternal mortality ratio (MMR) and infant mortality rate (IMR) are as high as 1540 per 100,000 live births and 78 per 1,000 live births respectively. In this study, we used the framework of the continuum of maternal and child care to evaluate the impact of interventions in Bauchi State focused on improved maternal and child health, and to ascertain progress towards the achievement of Millennium Development Goals (MDGs) 4 and 5.

Methods

At baseline (2012) and then at follow-up (2013), we randomly sampled 340 households from 19 random locations in each of the 20 Local Government Areas (LGA) of Bauchi State in Northern Nigeria, using the Lot Quality Assurance Sampling (LQAS) technique. Women residents in the households were interviewed about their own health and that of their children. Estimated LGA coverage of maternal and child health indicators were aggregated across the State. These values were then compared to the national figures, and the differences from 2012 to 2014 were calculated.

Results

For several of the indicators, a modest improvement from baseline was found. However, the indicators in the continuum of care neither reached the national average nor attained the 90% globally recommended coverage level. The majority of the LGA surveyed were classifiable as high priority, thus requiring intensified efforts and programmatic scale up.

Conclusions

Intensive scale-up of programs and interventions is needed in Bauchi State, Northern Nigeria, to accelerate, consolidate and sustain the modest but significant achievements in the continuum of care, if MDGs 4 and 5 are to be achieved by the end of 2015. The intentional focus of LGAs as the unit of intervention ought to be considered a condition precedent for future investments. Priority should be given to the re-allocating resources to program areas and regions where coverage has been low. Finally, systematic considerations need to be given to the design of strategies that address the demand for health services.     

Analysis of the Maternal and Child Health Care Status in Suizhou City,Hubei Province,China, from 2005 to 2011

Background

Improving the health and well-being of women and children has long been a common goal throughout the world. From 2005 to 2011, Suizhou City had an annual average of 22,405 pregnant and parturient women (1.04% of the population) and 98,811 children under 5 years old (4.57% of the population). Understanding the status of maternal and child health care in Suizhou City during such period can provide the local health administrative department valid scientific bases upon which to construct effective policies.

Methods

Various types of annual reports on maternal and child health care were collected and analyzed retrospectively.

Results

Mortality rates for infants and children under 5 years showed a declining trend, while the rates of newborn home visiting, maternal health service coverage, and children health systematic management increased annually in Suizhou City from 2005 to 2011. The incidence of birth defect increased from 2.42‰ in 2005 to 3.89‰ in 2011. The maternal mortality ratio (MMR) fluctuated from 8.39/100,000 to 28.77/100,000, which was much lower than the national MMR (30.0/100,000 in 2010). The rates of hospitalized delivery and births attended by trained health personnel for pregnant women increased to more than 90% in the past five years.

Conclusions

The improvements in maternal and child health care work in Suizhou City are worthy of recognition. Thus, the government should continue to increase funding in these areas to promote the complete enhancement of the maternal and child health care system.     

Monitoring Intervention Coverage in the Context of Universal Health Coverage

Monitoring universal health coverage (UHC) focuses on information on health intervention coverage and financial protection. This paper addresses monitoring intervention coverage, related to the full spectrum of UHC, including health promotion and disease prevention, treatment, rehabilitation, and palliation. A comprehensive core set of indicators most relevant to the country situation should be monitored on a regular basis as part of health progress and systems performance assessment for all countries. UHC monitoring should be embedded in a broad results framework for the country health system, but focus on indicators related to the coverage of interventions that most directly reflect the results of UHC investments and strategies in each country. A set of tracer coverage indicators can be selected, divided into two groups—promotion/prevention, and treatment/care—as illustrated in this paper. Disaggregation of the indicators by the main equity stratifiers is critical to monitor progress in all population groups. Targets need to be set in accordance with baselines, historical rate of progress, and measurement considerations. Critical measurement gaps also exist, especially for treatment indicators, covering issues such as mental health, injuries, chronic conditions, surgical interventions, rehabilitation, and palliation. Consequently, further research and proxy indicators need to be used in the interim. Ideally, indicators should include a quality of intervention dimension. For some interventions, use of a single indicator is feasible, such as management of hypertension; but in many areas additional indicators are needed to capture quality of service provision. The monitoring of UHC has significant implications for health information systems. Major data gaps will need to be filled. At a minimum, countries will need to administer regular household health surveys with biological and clinical data collection. Countries will also need to improve the production of reliable, comprehensive, and timely health facility data. Please see later in the article for the Editors'' Summary

Summary Points

• Monitoring universal health coverage (UHC) should be integral to overall tracking of health progress and performance, which requires regular assessment of health system inputs (finances, health workforce, and medicines), outputs (service provision), coverage of interventions, and health impacts, as well as the social determinants of health.
• Within this overall context, we propose that UHC monitoring focus on financial protection and intervention coverage indicators, with a strong equity focus. This paper focuses on intervention coverage.
• Progress towards UHC should be tracked using tracer intervention coverage indicators selected on the basis of objective considerations and designed to keep the numbers of indicators small and manageable while covering a range of health interventions to capture the essence of the UHC goal.
• Since UHC is about progressive realization and countries differ in epidemiology, health systems, socioeconomic development, and people''s expectations, the indicator sets will not be the same everywhere.
• Coverage indicators should cover promotion and prevention, as well as treatment, rehabilitation, and palliation. While there are several suitable indicators for the first two, there are major gaps for coverage indicators of treatment, as population need for treatment is difficult to measure.
• A small set of well-established international intervention tracer coverage indicators can be identified for monitoring UHC. Where no good indicators are currently available, proxy indicators and equity analysis of service utilization can provide some insights.
• Special attention needs to be paid to quality of services, either through the tracer indicator itself (referred to as effective coverage) or through additional indicators on quality of services or health impact of the intervention.
• Targets should be set in accordance with baseline, historical rate of progress, and measurement considerations.
• The main data sources of intervention coverage indicators are household surveys and health facility reports. Investments in both are needed to improve the ability of countries to monitor progress towards UHC.
• It is essential to find effective ways of communicating progress towards UHC in ways that are meaningful to the general public and that capture the attention of policy makers.

This paper is part of the PLOS Universal Health Coverage Collection.

     

Inequalities in Maternal Health Care Utilization in Sub-Saharan African Countries: A Multiyear and Multi-Country Analysis

To assess social inequalities in the use of antenatal care (ANC), facility based delivery (FBD), and modern contraception (MC) in two contrasting groups of countries in sub-Saharan Africa divided based on their progress towards maternal mortality reduction. Six countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three (Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average annual reduction rate. All of these countries had at least three rounds of Demographic and Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as relative and absolute concentration indices in order to examine within-country geographical and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use increased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by 4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators remained stagnant or increased. Absolute measures for geographical and wealth-based inequalities remained high invariably in all six countries. The increasing trend in the utilization of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in countries which made progress towards reducing maternal mortality.