The effects of maternal-child health service utilization on subsequent contraceptive use in Morocco.

There are a number of reasons for anticipating that contact by women in developing country settings with modern maternal-child health (MCH) services will lead to increased use of family planning services. Indeed, the expectation of such a relationship underlies the integrated service delivery strategy that has been adopted on a more or less global basis. However, the available empirical evidence in support of this proposition is inconclusive. This study re-examines this issue in Morocco. Household survey data and data on the supply environment for health and family planning services gathered in 1992 are analysed in the study. A full-information maximum likelihood estimator is used to control for the possible endogeneity of health care and contraceptive choices. The findings indicate a substantial and apparently causal relationship between the intensity of MCH service use and subsequent contraceptive use. Policy simulations indicate that sizeable increases in contraceptive prevalence might be realized by increasing the coverage and intensity of use of MCH services.     

Access to health: women's status and utilization of maternal health services in Nepal

With the objective of reducing maternal and neonatal mortality, the Safe Motherhood Program was implemented in Nepal in 1997. It was launched as a priority programme during the ninth five-year plan period, 1997-2002, with the aim of increasing women's access to health care and raising their status. This paper examines the association of access to health services and women's status with utilization of prenatal, delivery, and postnatal care during the plan period. The 1996 Nepal Family Health Survey and the 2001 Nepal Demographic and Health Survey data were pooled and the likelihood of women's using maternal health care was examined in 2001 in comparison with 1996. Multiple logistic regression analysis indicates that the utilization of maternal health services increased over the period. Programme interventions such as outreach worker's visits, radio programmes on maternal health, maternal health information disseminated through various mass media sources and raising women's status through education were able to explain the observed change in utilization. Health worker visits and educational status of women showed a large association, but radio programmes and other mass media information were only partially successful in increasing use of maternal health services. Socioeconomic and demographic variables such as household economic status, number of living children and place of residence showed stronger association with use of maternal health services then did intervention programmes.     

Birth defects in India: Hidden truth,need for urgent attention

Birth defects (structural, functional and metabolic disorder present from birth, may be diagnosed later) rising up as an important cause of infant mortality even in developing countries where infant mortality has been reduced to much extent. Seventy percent of birth defects are preventable through the application of various cost effective community genetic services.Indian people are living in the midst of risk factors for birth defects, e.g., universality of marriage, high fertility, large number of unplanned pregnancies, poor coverage of antenatal care, poor maternal nutritional status, high consanguineous marriages rate, and high carrier rate for hemoglobinopathies. India being the second most populous country with a large number infant born annually with birth defects should focus its attention on strategies for control of birth defects. Many population based strategies such as iodization, double fortification of salt, flour fortification with multivitamins, folic acid supplementation, periconceptional care, carrier screening and prenatal screening are some of proven strategies for control of birth defects. Strategies such as iodization of salt in spite of being initiated for a long time in the past do have a very little impact on its consumption (only 50% were using iodized salt). Community genetic services for control of birth defects can be easily flourished and integrated with primary health care in India because of its well established infrastructure and personnel in the field of maternal and child health care. As there is wide variation for infant mortality rate (IMR) in different states in India, so there is a need of deferential approach to implement community genetic services in states those had already achieved national goal of IMR. On the other hand, states those have not achieved the national goal on IMR priority should be given to management of other causes of infant mortality.     

绿色基础设施的洪水调节服务供需测度研究进展

绿色基础设施(green infrastructure, GI)可提供高效且可获取的洪水调节服务,其供需测度是提升服务水平的基础与前提,可为城市土地利用与绿色基础设施规划提供决策依据。以GI洪水调节服务供需为研究对象,梳理GI洪水调节服务供需的概念内涵、主体构成和尺度关系。回顾了GI洪水调节服务供需测度方法,包括土地利用测度法、生态系统测度法和洪水调蓄模型法等供应水平测度方法,以及风险评估法、洪水淹没模型法和经济损失法等需求水平测度方法。基于生态系统服务的供需关系,构建了GI洪水调节服务供需分析框架,通过供需数量均衡和空间匹配将供需关系分为四种情景,对应服务动态平衡、调整服务供需水平和服务流动机制3种调控手段。从服务测度重点、动态变化分析、供需阈值效能、服务流动机制等四个方面提出了未来研究方向,以期对绿色基础设施规划研究和生态系统服务管理与决策研究有所启示。     

Technological developments and approaches to improving service quality

In summary, major paradigm shifts in the health care industry are altering the way technology is maintained and supported. Service organizations are now responsible for maintaining a broader base of technology within the health care delivery network and must to this on an extremely rapid, efficient, and productive basis. A number of new technologies are coming on-line, which can allow a health care technology service organization to experience significant improvements in profitability, efficiency, and productivity. To realize maximum benefit from these technologies, service organizations may find themselves re-engineering their service processes. The author believes that this is a requirement for many service organizations, regardless of whether new technology is implemented. The traditional approaches to service delivery are ineffective in managing the new structural realities and service requirements of today's health care environment. New strategies and tactics are required for ensuring that these requirements are met. These approaches will no doubt improve the overall quality, productivity, and efficiency of service and are based on best practices utilized by leading OEMs and ISOs in the medical electronics and other high technology service industry such as information technology and telecommunications, where the service organization is responsible for supporting a broad array of the technology over a large geography with a densely populated installed base, not unlike the typical health care delivery service environment. Once operational improvements are made, a service organization can take advantage of the productivity and efficiency gains brought on by new technology. Organizations interested in doing so are urged to thoroughly research the current state-of-the-art and best practices, because there are numerous systems currently available off-the-shelf. The author believes that new technology will be a basic requirement for competing in the health care technology service marketplace, because it can significantly affect the profitability of service organizations. This technology will help level the playing field between ISOs, OEMs, and biomedical personnel. As our research suggests, efficiently operating biomedical personnel can achieve a significantly higher utilization and profitability than efficiently operating OEMs, due to the advantages of lower overhead and operating cost structure. In general, the process to improve service productivity and efficiency involves a review of current service operations and understanding of the customer environment perceptions as well as understanding of key service factors parameters. From there, service organizations should identify the current state-of-the-art service and infrastructure systems and technology. Based on this assessment, a service organization can evaluate best practices and identify new strategies and tactics for improving service delivery. Through better service management control and education of users on the improvement in service, which the new processes and technologies provide, the service organization can realize real, quantifiable improvements in service quality, productivity, and profitability.     

Determinants of use of maternal-child health services in rural Ghana

This study uses data from the Ghana Demographic and Health Survey (GDHS) of 1993 to examine factors determining the use of maternal-child health (MCH) services in rural Ghana. The MCH services under study are: (1) use of a doctor for prenatal care; (2) soliciting four or more antenatal check-ups; (3) place of delivery; (4) participation in family planning. Bivariate and multivariate techniques are employed in the analyses. The analyses reveal that the use of MCH services tends to be shaped mostly by level of education, religious background and region of residence, and partially by ethnicity and occupation. The implications of these results are discussed.     

全科医学人才培养与继续教育形式的探讨

在分析全科医学人才培养现状的基础上,提出了开展全科医学人才培养和继续教育的必要性。探讨提高全科医师社区服务技能的办法,分析当前落实新医改工作中出现的矛盾和存在的关键问题,并提出在社区卫生服务工作中,要采取最好的学习方式和选择适合基层服务的内容来培养全科医学合格人才。     

Why it's time for a national health program in the United States.

The United States lacks a coherent national health program. Current programs leave major gaps in coverage and recently have become more restrictive. Influential policies that have failed to correct crucial problems of the health-care system include competitive strategies, corporate intervention, and public-sector cutbacks with bureaucratic expansion. A national health program that combines elements of national health insurance and a national health service is a policy that would help solve current health-care problems. Previous proposals for national health insurance contained weaknesses that would need correction under a national program. Based on the experiences of other economically advanced countries, a national health program could provide universal entitlement to health care while controlling costs and improving the health-care system through structural reorganization. Current proposals for a national health program contain several basic principles dealing with the scope of services, copayments, financing, cost controls, physician and professional associations, personnel and distribution, prevention, and participation in policy making. Support for a national health program is growing rapidly. Such a program would help protect all people who live in this country from unnecessary illness, suffering, and early death.     

Operationalizing the ecosystems approach: Assessing the environmental impact of major infrastructure development

The ecosystem services approach is increasingly applied in the context of environmental resources management and impact assessment. Assessments often involve analysis of alternative scenarios for which potential changes in ecosystem services are quantified. For such assessments to be effective there is a requirement to represent changes in ecosystem services supply in a clear and informative manner. Here we compute Ecosystem Services Ratio (ESR), a simple index that quantifies the relative change in ecosystem service provision under altered conditions given the baseline, and the Modified Ecosystem Services State Index, which averages the ESR scores obtained for each ecosystem service assessed, to provide an overall measure of the change. Given that modelling approaches to quantification of ecosystem services often result in production of maps of ecosystem supply, the proposed metrics can be visualized as maps in support to decision making processes. We use these indices to investigate potential changes in the supply of seven modelled ecosystem services resulting from the introduction of a major road development – a highway with associated green infrastructure – into a predominantly agricultural landscape in the UK. We find that the planted woodland, scrubland and grassland can increase the supply of multiple ecosystem services not accounted for in previous green infrastructure studies, although the magnitude of change differs with the type of vegetation, initial conditions and timeframes of the assessment.     

Understanding users' perspectives of barriers to maternal health care use in Maharashtra, India.

This paper uses data collected using in-depth, semi-structured interviews to examine utilization of maternal health care services among two rural and urban populations of Pune and Mumbai in Maharashtra, India. The study aims to identify key social, economic and cultural factors influencing women's decisions to use maternal health care and the places used for child delivery, whilst considering the accessibility of facilities available in the local area. Socioeconomic status was not found to be a barrier to service use when women perceived the benefits of the service to outweigh the cost, and when the service was within reasonable distance of the respondent's place of residence. A large number of women perceived private services to be superior to those provided by the government, although cost often meant they were unable to use them. The provision of services did not ensure that women used them; they had to first perceive them to be beneficial to their health and that of their unborn child. Respondents identified the poor quality of services offered at government institutions to be a motivating factor for delivering at home. Thus further investigation is needed into the quality of services provided by government facilities in the area. A number of respondents who had received antenatal care went on to deliver in the home environment without a trained birth attendant. Further research is needed to establish the types of care provided during an antenatal consultation to establish the feasibility of using these visits to encourage women, particularly those with high-risk pregnancies, to be linked to a trained attendant for delivery.     

Use of maternal-child health services and contraception in Guatemala and Panama

This paper presents data from 2 recent maternal-child health (MCH) and family planning surveys in Guatemala and Panama and examines the extent to which the use of contraception is influenced by the use of MCH services as compared with the influence of an increase in parity. Fieldwork was initiated in July 1984 but not completed until April 1985. A total of 8240 women aged 15-49 years, of all marital statuses, completed interviews, representing 91% of households with eligible respondents. The findings suggest that utilization of MCH services and parity independently are associated with a woman's decision to use contraception. The study also found 2 groups that appear to be particularly in need of both MCH and family planning services: high parity women and Indians. Nonuse of MCH and family planning services may be due in part to their strong cultural beliefs. In both Guatemala and Panama, improved health care services for these 2 groups should be a priority. Contraceptive use in Panama was over twice as high as in Guatemala. However, method choice and residence-ethnicity patterns of use were similar in each country. In both countries and in all residence-ethnicity groups, female sterilization was the most prevalent method in use, followed by oral contraceptives, except for Panama rural Indians. In Panama, contraceptive use increases up to ages 30-34 and then declines, with a sharp decline for women 40-44. In Guatemala, contraceptive use is generally low for ages 15-24, then increases to a fairly constant level for ages 25-39.     

制度供给视角下的基本医疗体制改革之决策

基本医疗改革的财政投入模式应从单一关注医疗服务供给转向协同关注医疗服务产出，无过错医疗损害救济应纳入国家财政投入的预算体系。面对医疗损害的高发性，以救济为心的医疗侵权责任制度应向以预防中心的制度进行改革。医疗过失诉讼制度对医疗体系有着深刻的负面制约作用。基本医疗改革的决策应从更宏观的视角进行制度供给设计。     

Ethical, legal and social issues in nutrigenomics: the challenges of regulating service delivery and building health professional capacity

Nutrigenomics, the conjunction of molecular nutrition with human genomics, is among the first publicly available applications of the human genome project. Nutrigenomics raises ethical, legal and social issues particularly with respect to how the public may access nutrigenetic tests and associated nutritional and lifestyle advice. Current regulatory controversy focuses on potential harms associated with direct-to-consumer (DTC) marketing of nutrigenetic tests and especially the need to protect consumers from unreliable tests, false claims and unproven dietary supplements. Nutrigenomics does, however, offer the potential of important health benefits for some individuals. The regulation of nutrigenomic services is slowly evolving, but there is little indication of increased professional capacity to support service delivery. Primary care physicians have minimal training in nutrition and genetics, and medical geneticists are in high demand and short supply. Dietetic practitioners are experts in nutrition science and interest in nutrigenomics is growing among members of this professional group. However, as with physicians, dietetics practitioners would require considerable training to bring nutrigenomics into their practice capacity. A downside of regulatory restrictions on direct consumer access to nutrigenomics companies is that responsible businesses may be hindered in meeting emergent public demand while health care professional groups have not yet developed capacity to provide nutrigenomics services.     

The challenges of offering public second trimester abortion services in South Africa: health care providers' perspectives

Around 25% of abortions in South Africa are performed in the second trimester. This study aimed to better understand what doctors, nurses and hospital managers involved in second trimester abortion care thought about these services and how they could be improved. Nineteen in-depth interviews with abortion-related service providers and managers in the Western Cape Province, South Africa, were undertaken. Data were analysed using a thematic analysis approach. Participants expressed resistance to the dilation and evacuation (D&E) procedure, as this required more active provider involvement. Medical abortion was preferred as it required less provider involvement in the abortion process. A shortage of providers willing to perform D&E resulted in most public sector services being outsourced to private sector doctors. Respondents noted an increased demand for services and a concomitant lack of infrastructure, physical space and personnel to respond to these demands, sometimes resulting in fragmented or poor quality care. At medical induction sites, most thought introducing the combined mifepristone-misoprostol regimen would improve service capacity, although they were concerned about cost. Improving contraceptive services was also seen as a much-needed intervention to improve care and prevent abortion. Ongoing training, including values clarification, as well as emotional support and team-building for providers are needed to ensure sustainable, high-quality second trimester abortion services.     

Infant and child mortality in rural Egypt.

This research examines determinants of infant and child mortality in rural Egypt, primarily the effects of household economic status and the availability of health services. Certain features of the health service environment affect survival in the neonatal period. In early childhood, survival chances improve markedly as income increases and if the household depends almost exclusively on employment income. In infancy and in early childhood, mortality is strongly associated with region of residence and maternal demographic characteristics, and is weakly associated with parental schooling.     

Neonatal mortality and maternal health care in Nepal: searching for patterns of association

This study explores the factors associated with neonatal mortality and maternal health care in Nepal. The subjects were 4375 births reported in the 1996 Nepal Family Health Survey. Maternal and child health care was found to have a significant association with neonatal mortality, although preceding birth interval and sex of child had stronger effects. Four aspects of maternal care were found to be highly associated with region, household ownership of assets, mother's education and father's education. This indicates that accessibility, affordability and availability of maternal health care are important factors to consider in future research on neonatal mortality.     

An Analysis of Factors Linked to the Decline in Maternal Mortality in Nepal

Nepal experienced a steep decline in maternal mortality between 1996 and 2006, which had again dropped by 2010. The aim of this study was to investigate any trends in factors that may be responsible for this decline. The study was based on a secondary data analysis of maternity care services and socio-demographic variables extracted from the Nepal Demographic Health Surveys (1996, 2001, 2006 and 2011). Complex sample analysis was performed to determine the trends in these variables across the four surveys. Univariate logistic regression was performed for selected maternity care service variables to calculate the average change in odds ratio for each survey. Multivariate logistic regression was performed to determine the trends in the health service uptake adjusting for socio-demographic variables. There were major demographic and socio-economic changes observed between 1996 and 2011: notably fewer women delivering at ‘high risk’ ages, decreased fertility, higher education levels and migration to urban areas. Significant trends were observed for improved uptake of all maternity care services. The largest increase was observed in health facility delivery (odds ratio = 2.21; 95% confidence interval = 1.92, 2.34) and women making four or more antenatal visits (odds ratio = 2.24; 95% confidence interval = 2.03, 2.47). After adjusting for all socio-demographic factors, the trends were still significant but disparities become more pronounced at the extremes of the socio-economic spectrum. The odds ratios for each maternity care service examined decreased slightly after adjusting for education, indicating that improved levels of education could partly explain these trends. The improved utilisation of maternity care services seems essential to the decline in maternal mortality in Nepal. These findings have implications for policy planning in terms of government resources for maternity care services and the education sector.     

The Role of a Community-Based Satellite Clinic in the Perinatal Care of Non-English-Speaking Immigrants

In the provision of health care to non-English-speaking immigrants, cultural and linguistic barriers often deter both access to and use of needed services. This is especially true of the preventive health interventions such as perinatal care and family planning that contribute significantly to reproductive health.Alternative approaches to overcoming barriers to care are being taken in an urban health department clinic serving as a satellite perinatal resource to a group of low-income Chinese-speaking immigrants. The clinic, with service linkages to San Francisco General Hospital Medical Center and the Health Department of San Francisco City and County, is an example of culturally appropriate comprehensive perinatal care. Such an institution has helped recent immigrants adapt to their new environment and learn to use health services effectively.     

Oral health and dental care facilities in Maltese residential homes

Objectives: To establish oral health care practices, including the use of dental services, in the residential homes of Malta and Gozo by assessing the knowledge of home managers and assistance of care staff regarding residents’ oral health and hygiene; and evaluating the residents’ demand for dental treatment and residential home managers response to this demand. Subjects: A total population sample of licensed residential homes (38) in Malta and Gozo was used comprising all home managers in government (seven), church (20), and privately run (11) residential homes. Method: A 19‐question questionnaire was designed, piloted and sent to the home managers requesting them to report on the dental care provision for their elderly residents. The questionnaire was distributed by post, along with a reply‐paid envelope and an explanatory letter. A response deadline of 1 month was included. Results: An 87% response rate was achieved. Whilst the majority of home managers (64%) were aware of domiciliary dental services, there was no code of care practice for oral health. Routine dental check‐ups were not organised for residents of most homes. Although home staffs were generally given information about residents’ oral health and hygiene, the majority did not assist residents with oral hygiene. Home managers identified the following barriers to the use of dental services by residents: cost, communication problems with dental staff, journey to place of treatment, waiting time at the dental clinic, access to premises/clinic, lack of information on oral health and dental service availability, no one to accompany the person to the clinic, and health problems such as mobility, poor eyesight, hearing impairment and mental health status. Conclusion: Although most home managers appreciate the importance of oral health care for their residents, the residents still face many barriers to maintaining adequate oral health care and accessing dental services.     

Nurse practitioners in primary care. VI. Assessment of their deployment with the Utilization and Financial Index.

The impact of multidisciplinary teams that incorporate nurse practitioners on total use of health services was measured with the new Utilization and Financial Index (UF-Index). The data from two studies, a randomized controlled trial and a before-and-after study, showed that, in spite of large increases in use of ambulatory services by practice populations served by family physician-nurse practitioner teams, the ultimate effect has been a substantial reduction in total use of health services. The effect was associated with major reductions in hospital care for the same populations. Such economic advantages to society proved feasible within a fee-for-service context and in settings where rigorous evidence demonstrated no concurrent deterioration in health status of patients or in quality of care.