Assessing the utilization of maternal and child health care among married adolescent women: evidence from India

This study explores the prevalence and factors associated with the utilization of maternal and child health care services among married adolescent women in India using the third round of the National Family Health Survey (2005-06). The findings suggest that the utilization of maternal and child health care services among adolescent women is far from satisfactory in India. A little over 10% of adolescent women utilized antenatal care, about 50% utilized safe delivery services and about 41% of the children of adolescent women received full immunization. Large differences by urban-rural residence, educational attainment, religion, economic status and region were evident. Both gross effect and fixed effect binary logit models yielded statistically significant socioeconomic and demographic factors. Women's education, wealth quintile and region are the most important determinants for the utilization of maternal and child health care services. Health care programmes should focus more on educating adolescents, providing financial support, creating awareness and counselling households with married adolescent women. Moreover, there should be substantial financial assistance for the provision of delivery and child care for married women below the age of 19 years.     

Determinants of maternity care services utilization among married adolescents in rural India

Background

Coupled with the largest number of maternal deaths, adolescent pregnancy in India has received paramount importance due to early age at marriage and low contraceptive use. The factors associated with the utilization of maternal healthcare services among married adolescents in rural India are poorly discussed.

Methodology/Principal Findings

Using the data from third wave of National Family Health Survey (2005–06), available in public domain for the use by researchers, this paper examines the factors associated with the utilization of maternal healthcare services among married adolescent women (aged 15–19 years) in rural India. Three components of maternal healthcare service utilization were measured: full antenatal care, safe delivery, and postnatal care within 42 days of delivery for the women who gave births in the last five years preceding the survey. Considering the framework on causes of maternal mortality proposed by Thaddeus and Maine (1994), selected socioeconomic, demographic, and cultural factors influencing outcome events were included as the predictor variables. Bi-variate analyses including chi-square test to determine the difference in proportion, and logistic regression to understand the net effect of predictor variables on selected outcomes were applied. Findings indicate the significant differences in the use of selected maternal healthcare utilization by educational attainment, economic status and region of residence. Muslim women, and women belonged to Scheduled Castes, Scheduled Tribes, and Other Backward Classes are less likely to avail safe delivery services. Additionally, adolescent women from the southern region utilizing the highest maternal healthcare services than the other regions.

Conclusions

The present study documents several socioeconomic and cultural factors affecting the utilization of maternal healthcare services among rural adolescent women in India. The ongoing healthcare programs should start targeting household with married adolescent women belonging to poor and specific sub-groups of the population in rural areas to address the unmet need for maternal healthcare service utilization.     

An assessment of the effect of user fee policy reform on facility-based deliveries in rural Zambia

Background

Improving maternal health outcomes by reducing barriers to accessing maternal health services is a key goal for most developing countries. This paper analyses the effect of user fee removal, which was announced for rural areas of Zambia in April 2006, on the use of public health facilities for childbirth.

Methods

Data from the 2007 Zambia Demographic and Health Survey, including birth histories for the five years preceding the survey, is linked to administrative data and geo-referenced health facility census data. We exploit a difference-in-differences design, due to a differential change in user fees at the district level; fees were removed in 54 rural districts, but not in the 18 remaining urban districts. We use multilevel modelling to estimate the effect of this policy change, based on 4018 births from May 2002 to September 2007, covering a period before and after the policy announcement in April 2006.

Results

The difference-in-difference estimates point to statistically insignificant changes in the proportion of women giving birth at home and in public facilities, but significant changes are found for deliveries in private (faith-based) facilities. Thus, the abolition of delivery fees is found to have some effect on where Zambian mothers choose to have their children born.

Conclusion

The removal of user fees has not overcome barriers to the utilisation of delivery services at public facilities. User fee removal may also yield unintended consequences deterring the utilisation of delivery services. Therefore, abolishing user fees, alone, may not be sufficient to affect changes in utilisation; instead, other efforts, such as improving service quality, may have a greater impact.

     

Assessing the Impact of Family Planning Advice on Unmet Need and Contraceptive Use among Currently Married Women in Uttar Pradesh,India

Background

Counseling/advice is one of the key interventions to promote family planning (FP) in developing countries, including India. It helps to improve the quality of care and reduce maternal deaths. This paper investigates the continuity of maternal health (MH) service utilization from antenatal care to post-natal care and the impact this service utilization has on contraceptive use and on meeting the demand for family planning among currently married women in rural Uttar Pradesh, India.

Methods and Findings

The study assesses the impact of FP advice on unmet need and contraceptive use by adopting the propensity score matching method. It uses data from the District Level Household Survey (DLHS) (2007–08) that covered 76,147 currently married women (CMW) in the age group 15–44 years in Uttar Pradesh. Results show that the utilization of MH services [Antenatal care (ANC), institutional delivery, Postnatal care (PNC)] and FP advice during ANC and PNC has led to increase in current use of contraception by 3.7% (p<.01), 7.3% (p<.01) and 6.8% (p<.01), respectively. However, a greater utilization of these services has not translated into a reduction of unmet need for contraception at a similar manner.

Conclusion

MH service utilization including FP advice is more effective in increasing current use of spacing methods as compared to limiting methods. Findings support the need for “effective FP advice” interventions to reduce unintended births and unmet need. However, women from Scheduled Caste/Scheduled Tribe communities are less likely to receive MH services. Thus, efforts are required to ensure that currently married women across socio-economic backgrounds have equal opportunity to receive MH services and information on contraceptive use to meet the demand for family planning methods.     

Effect of Paying for Performance on Utilisation,Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study

Background

Despite widespread implementation across Africa, there is limited evidence of the effect of payment for performance (P4P) schemes in low income countries on the coverage of quality services and affordability, consistent with universal health coverage objectives. We examined the effect of a government P4P scheme on utilisation, quality, and user costs of health services in Tanzania.

Methods

We evaluated the effects of a P4P scheme on utilisation of all maternal and child immunization services targeted by the scheme, and non-targeted general outpatient service use. We also evaluated effects on patient satisfaction with care and clinical content of antenatal care, and user costs. The evaluation was done in 150 facilities across all 7 intervention districts and 4 comparison districts with two rounds of data collection over 13-months in January 2012 and February 2013. We sampled 3000 households of women who had delivered in the 12 months prior to interview; 1500 patients attending health facilities for targeted and non-targeted services at each round of data collection. Difference-in-difference regression analysis was employed.

Findings

We estimated a significant positive effect on two out of eight targeted indicators. There was an 8.2% (95% CI: 3.6% to 12.8%) increase in coverage of institutional deliveries among women in the intervention area, and a 10.3% (95% CI: 4.4% to 16.1%) increase in the provision of anti-malarials during pregnancy. Use of non-targeted services reduced at dispensaries by 57.5 visits per month among children under five (95% CI: -110.2 to -4.9) and by 90.8 visits per month for those aged over five (95% CI: -156.5 to -25.2). There was no evidence of an effect of P4P on patient experience of care for targeted services. There was a 0.05 (95% CI: 0.01 to 0.10) increase in the patient satisfaction score for non-targeted services. P4P was associated with a 5.0% reduction in those paying out of pocket for deliveries (95% CI: -9.3% to -0.7%) but there was no evidence of an effect on the average amount paid.

Conclusion

This study adds to the very limited evidence on the effects of P4P at scale and highlights the potential risks of such schemes in relation to non-targeted service use. Further consideration of the design of P4P schemes is required to enhance progress towards universal health coverage, and close monitoring of effects on non-targeted services and user costs should be encouraged.     

Equality in Maternal and Newborn Health: Modelling Geographic Disparities in Utilisation of Care in Five East African Countries

BackgroundGeographic accessibility to health facilities represents a fundamental barrier to utilisation of maternal and newborn health (MNH) services, driving historically hidden spatial pockets of localized inequalities. Here, we examine utilisation of MNH care as an emergent property of accessibility, highlighting high-resolution spatial heterogeneity and sub-national inequalities in receiving care before, during, and after delivery throughout five East African countries.MethodsWe calculated a geographic inaccessibility score to the nearest health facility at 300 x 300 m using a dataset of 9,314 facilities throughout Burundi, Kenya, Rwanda, Tanzania and Uganda. Using Demographic and Health Surveys data, we utilised hierarchical mixed effects logistic regression to examine the odds of: 1) skilled birth attendance, 2) receiving 4+ antenatal care visits at time of delivery, and 3) receiving a postnatal health check-up within 48 hours of delivery. We applied model results onto the accessibility surface to visualise the probabilities of obtaining MNH care at both high-resolution and sub-national levels after adjusting for live births in 2015.ResultsAcross all outcomes, decreasing wealth and education levels were associated with lower odds of obtaining MNH care. Increasing geographic inaccessibility scores were associated with the strongest effect in lowering odds of obtaining care observed across outcomes, with the widest disparities observed among skilled birth attendance. Specifically, for each increase in the inaccessibility score to the nearest health facility, the odds of having skilled birth attendance at delivery was reduced by over 75% (0.24; CI: 0.19–0.3), while the odds of receiving antenatal care decreased by nearly 25% (0.74; CI: 0.61–0.89) and 40% for obtaining postnatal care (0.58; CI: 0.45–0.75).ConclusionsOverall, these results suggest decreasing accessibility to the nearest health facility significantly deterred utilisation of all maternal health care services. These results demonstrate how spatial approaches can inform policy efforts and promote evidence-based decision-making, and are particularly pertinent as the world shifts into the Sustainable Goals Development era, where sub-national applications will become increasingly useful in identifying and reducing persistent inequalities.     

Health care services use,stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh: A difference-in-differences analysis of Bangladesh Demographic and Health Survey data, 2000 to 2016

BackgroundStarting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality.Methods and findingsWe used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = −4.8, 10.7], 6.5 (95% CI = −0.6, 13.6), and 5.8 (95% CI = −1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = −1.3, 2.6), 0.8 (95% CI = −1.7, 3.4), and 1.3 (95% CI = −2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas.ConclusionsIn this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes.

Arijit Nandi and colleagues evaluate maternal health services utilization, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh.     

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.     

Parents’ education and child body weight in France: The trajectory of the gradient in the early years

This paper explores the relationship between parental education and offspring body weight in France. Using two large datasets spanning the 1991–2010 period, we examine the existence of inequalities in maternal and paternal education and reported child body weight measures, as well as their evolution across childhood. Our empirical specification is flexible and allows this evolution to be non-monotonic. Significant inequalities are observed for both parents’ education – maternal (respectively paternal) high education is associated with a 7.20 (resp. 7.10) percentage points decrease in the probability that the child is reported to be overweight or obese, on average for children of all ages. The gradient with respect to parents’ education follows an inverted U-shape across childhood, meaning that the association between parental education and child body weight widens from birth to age 8, and narrows afterward. Specifically, maternal high education is correlated with a 5.30 percentage points decrease in the probability that the child is reported to be overweight or obese at age 2, but a 9.62 percentage points decrease at age 8, and a 1.25 percentage point decrease at age 17. The figures for paternal high education are respectively 5.87, 9.11, and 4.52. This pattern seems robust, since it is found in the two datasets, when alternative variables for parental education and reported child body weight are employed, and when controls for potential confounding factors are included. The findings for the trajectory of the income gradient corroborate those of the education gradient. The results may be explained by an equalization in actual body weight across socioeconomic groups during youth, or by changes in reporting styles of height and weight.     

The effect of marriage on utilization of colorectal endoscopy exam in the United States

Purpose: This study examines the association between marriage and colorectal endoscopy exam, and whether this association varies by gender and financial benefits of marriage including improved access to health insurance and pooled family income. Methods: Representative survey data of the non-institutionalized United States population were used from the 2000, 2005, and 2008 National Health Interview Survey. Analyses targeted persons 50-85 years of age without a personal history of cancer and with complete information on all study variables (n=21,760). Multivariate logistic regression was used to model marital status differences in the probability of undergoing a colorectal endoscopy exam with interaction effects used to model variation over time by gender, health insurance, and poverty level. Results: Married persons were more likely than unmarried persons to report ever having undergone a colorectal endoscopy exam (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.12-1.29), and the difference between married and unmarried persons in the probability of undergoing a colorectal endoscopy exam remained stable over time. Married persons were more likely than unmarried persons to report having undergone a colorectal endoscopy exam within the past 10 years (OR, 1.49; 95% CI, 1.15-1.95). For each survey year, married men were significantly more likely than women and unmarried men to report having undergone a colorectal endoscopy exam. For example, in 2008, 56% of married men reported having undergone a colorectal endoscopy exam, compared to 49% of unmarried men, 52% of married women, and 50% of unmarried women. Among persons with health insurance, married persons were significantly more likely than unmarried persons to have undergone a colorectal endoscopy exam. Among persons who were poor, there was no difference by marital status in the likelihood of having undergone a colorectal endoscopy exam. However, among persons who were not poor, married persons were more likely than unmarried persons to have undergone a colorectal endoscopy exam. Conclusion: Given that colorectal endoscopy exams are a potentially life-saving procedure, persistently higher uptake of colorectal endoscopy for married persons over time may be an important health promoting benefit of marriage. Therefore, clinicians and policy makers should focus on improving the use of cancer prevention services among unmarried persons.     

Effects of maternal birth season on birth seasonality in the Canadian population during the seventeenth and eighteenth centuries

Birth records of the French-Canadian population for the period 1621-1765 were analyzed retrospectively to examine the effect of maternal birth season on the seasonal distribution of births. Preliminary examination indicated that there was a bimodal pattern in birth seasonality: a major peak in early spring, a trough in early summer, a minor peak in autumn, and a trough around December. Because this seasonality was strongly biased at the level of the first birth by the month of marriage, which was concentrated in November, the seasonality of nonfirst births (n = 32,926) was examined in relation to the four seasons of maternal birth. Mothers born in May-July showed a flatter monthly distribution of nonfirst births at a maternal age of 28 years or more. Analysis of marriage-first birth intervals indicated that mothers who married in August-October showed a lower percentage of immediate conception (intervals of 8-10 months), whereas those mothers born in May-July had a higher percentage of immediate conception. This difference in birth seasonality shown by mothers born in May-July is similar to results from early twentieth-century Japan. Some seasonal infertility factors could have affected the embryos at the earliest stage of pregnancy, modifying a part of the seasonal variation in birth rate.     

The Effect of Urban Basic Medical Insurance on Health Service Utilisation in Shaanxi Province,China: A Comparison of Two Schemes

Background

Urban population in China is mainly covered by two medical insurance schemes: the Urban Employee Basic Medical Insurance (UEBMI) for urban employees in formal sector and the Urban Resident Basic Medical Insurance (URBMI) for the left urban residents, mainly the unemployed, the elderly and children. This paper studies the effects of UEBMI and URBMI on health services utilisation in Shaanxi Province, Western China.

Methods

Cross-sectional data from the 4^th National Health Services Survey - Shaanxi Province was studied. The propensity score matching and the coarsened exact matching methods have been used to estimate the average medical insurance effect on the insured.

Results

Compared to the uninsured, robust results suggest that UEBMI had significantly increased the outpatient health services utilisation in the last two weeks (p<0.10), whilst the significant effect on hospitalisation was evident in the CEM method (p<0.10). The effect of URBMI was limited in that although being insured was associated with higher health services utilisation, compared with the uninsured, none of the improvement was statistically significant (p>0.10). It was also found that compared with the uninsured, basic medical insurance enrollees were more likely to purchase inpatient treatments in lower levels of hospitals, consistent with the incentive of the benefit package design.

Conclusion

Basic Medical insurance schemes have shown a positive but limited effect on increasing health services utilisation in Shaanxi Province. The benefit package design of higher reimbursement rates for lower level hospitals has induced the insured to use medical services in lower level hospitals for inpatient services.     

Childhood predictors of late-life diabetes: the case of Mexico

We investigated the interplay between characteristics of early childhood circumstances and current socioeconomic conditions and health, focusing specifically on diabetes in mid and late life in Mexico. The analysis used data from the 2001 Mexican Health and Aging Study (MHAS), a large nationally representative study of Mexicans born before 1950. We analyzed the extent to which childhood conditions, such as exposure to infectious diseases, a poor socioeconomic environment, and parental education, affect the risk of diabetes in later life. Our results indicate that individuals age 50 and older who experienced serious health problems before age 10 have a higher risk of having late-life diabetes. There is a significant inverse relationship between maternal education and diabetes in late life of adult offspring. Individuals with better educated mothers have a lower risk of being diabetic after age 50. This relationship remains after controlling for other childhood and adult risk factors.     

Understanding the association between maternal education and use of health services in ghana: exploring the role of health knowledge

Summary This paper examines the role of health knowledge in the association between mothers' education and use of maternal and child health services in Ghana. The study uses data from a nationally representative sample of female respondents to the 2008 Ghana Demographic and Health Survey. Ordered probit regression models evaluate whether women's health knowledge helps to explain use of three specific maternal and child health services: antenatal care, giving birth with the supervision of a trained professional and complete child vaccination. The analyses reveal that mothers' years of formal education are strongly associated with health knowledge; health knowledge helps explain the association between maternal education and use of health services; and, net of a set of stringent demographic and socioeconomic controls, mothers' health knowledge is a key factor associated with use of health services.     

Contraceptive knowledge and attitudes in urban Ilorin, Nigeria

In Nigeria as in other African countries, population growth negatively affects economic development, and high parity affects maternal health. Breastfeeding, a common practice traditionally, is declining in some situations. This study was carried out in Ilorin, Nigeria. A sample population of 932 households stratified to represent different socioeconomic groups was used. 913 currently married women aged 15-35, who were in their prime childbearing ages, were interviewed on their contraceptive knowledge and on their attitudes towards modern contraception. In a bivariate statistical analysis, of 8 variables examined (i.e. ownership of a television, radio, religion, and other) only the woman's education, age, and area of residence within the city have significant independent effects on contraceptive knowledge. A linear logistic regression technic was also applied. 90% of the women interviewed thought that women should be free to practise family planning. Also, 95% of all the women believed that too frequent births could endanger the health of the mother and her children. Only the women with previous contraceptive knowledge overwhelmingly (80%) thought that the best way to prevent too frequent births is by family planning. 66.5% of those without previous contraceptive knowledge before this study suggested that traditional abstinence should be used and only 28.9% suggested family planning. Adequate awareness of the availability and usefulness of family planning methods can influence attitudes of women towards contraception and may also enhance contraceptive use. Better use can be made of broadcasting media, and efforts should be made to target younger, more fecund women, since there was evidence that more knowledge of family planning existed among women 30+ years old.     

Modeling heterogeneity for count data: A study of maternal mortality in health facilities in Mozambique

Count data are very common in health services research, and very commonly the basic Poisson regression model has to be extended in several ways to accommodate several sources of heterogeneity: (i) an excess number of zeros relative to a Poisson distribution, (ii) hierarchical structures, and correlated data, (iii) remaining “unexplained” sources of overdispersion. In this paper, we propose hierarchical zero‐inflated and overdispersed models with independent, correlated, and shared random effects for both components of the mixture model. We show that all different extensions of the Poisson model can be based on the concept of mixture models, and that they can be combined to account for all different sources of heterogeneity. Expressions for the first two moments are derived and discussed. The models are applied to data on maternal deaths and related risk factors within health facilities in Mozambique. The final model shows that the maternal mortality rate mainly depends on the geographical location of the health facility, the percentage of women admitted with HIV and the percentage of referrals from the health facility.     

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.     

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.     

Childhood predictors of late‐life diabetes: The case of Mexico

Abstract

We investigated the interplay between characteristics of early childhood circumstances and current socioeconomic conditions and health, focusing specifically on diabetes in mid and late life in Mexico. The analysis used data from the 2001 Mexican Health and Aging Study (MHAS), a large nationally representative study of Mexicans born before 1950. We analyzed the extent to which childhood conditions, such as exposure to infectious diseases, a poor socioeconomic environment, and parental education, affect the risk of diabetes in later life. Our results indicate that individuals age 50 and older who experienced serious health problems before age 10 have a higher risk of having late‐life diabetes. There is a significant inverse relationship between maternal education and diabetes in late life of adult offspring. Individuals with better educated mothers have a lower risk of being diabetic after age 50. This relationship remains after controlling for other childhood and adult risk factors.     

Comprehensive Approach to Improving Maternal Health and Achieving MDG 5: Report from the Mountains of Lesotho

Background

Although it is now widely recognized that reductions in maternal mortality and improvements in women''s health cannot be achieved through simple, vertical strategies, few programs have provided successful models for how to integrate services into a comprehensive program for maternal health. We report our experience in rural Lesotho, where Partners In Health (PIH) in partnership with the Ministry of Health and Social Welfare implemented a program that provides comprehensive care of pregnant women from the community to the clinic level.

Methods

Between May and July 2009, PIH trained 100 women, many of whom were former traditional birth attendants, to serve as clinic-affiliated maternal health workers. They received performance-based incentives for accompanying pregnant women during antenatal care (ANC) visits and facility-based delivery. A nurse-midwife provided ANC and delivery care and supervised the maternal health workers. To overcome geographic barriers to delivering at the clinic, women who lived far from the clinic stayed at a maternal lying-in house prior to their expected delivery dates. We analyzed data routinely collected from delivery and ANC registers to compare service utilization before and after implementation of the program.

Results

After the establishment of the program, the average number first ANC visits increased from 20 to 31 per month. The clinic recorded 178 deliveries in the first year of the program and 216 in the second year, compared to 46 in the year preceding the program. During the first two years of the program, 49 women with complications were successfully transported to the district hospital, and no maternal deaths occurred among the women served by the program.

Conclusions

Our results demonstrate that it is possible to achieve dramatic improvements in the utilization of maternal health services and facility-based delivery by strengthening human resource capacity, implementing active follow-up in the community, and de-incentivizing home births.