Care Coverage Research Articles

SOCIAL PROTECTION AND A RESILIENT FUTURE FOR SUB-SAHARAN AFRICA

Countries in Africa have the lowest coverage of social protection and adequate health care despite having an enormous need for such programmes and policies (ILO, 2019). The availability of social protection services is mostly limited to workers and their families in the formal sector. Nonetheless, 85.8% of employment is informal, leaving communities, often concentrated in rural areas, vulnerable to economic and political shocks and other crises (Beri, 2018). Extending social protection to workers in the informal economy is one shared priority among many African nations (ILO, 2017). Societal benefits of social protection schemes and social welfare are well documented and range from supporting and promoting human development (e.g. healthcare and education) to building political stability and social peace. Developing effective social assistance schemes, building states’ and institutional capacity, prioritizing fragile states, and integrating shock-responsive features to climate change and the increase of migrant workers can help ensure that any individual or household in need of social protection has access to it (ILO, 2017). Promoting and enforcing a rights-based approach to social protection brings the African continent several steps closer to reaching its full potential.

Predictors of Infant Mortality Rate in India

This study is an attempt to see the status of infant mortality rate (IMR) in rural and urban India. Study also finds the impact of gross domestic product (GDP), fund released by State government for health care and vaccination coverage on IMR. Secondary data has been collected from www.data.gov.ac.in . Normality of the data has been checked with Skewness, Kurtosis and Box Plots. Further analysis is done through independent sample t test, regression and correlation analysis. The results show that vaccination has significant impact on IMR in rural and urban India while GDP and government funding are unable to contribute to reducing the IMR in India. Further the IMR in rural area is significantly higher than the urban area. Therefore, only increasing the per capita income and becoming richer will not suffices for mortality rate reduction. Further health care facility, education and empowerment are also required. Fund released for the health care purpose should also be disbursed in such a way so that advantages can be given to infant child.

Health system description and assessment: a review of systematic tools for analyses

Abstract Introduction Comparing health systems allows policymakers to benchmark against other countries, and improve processes and performance. A template to guide authors on how to present systems' features and performance in a meaningful manner is the basis for understanding and assessing a country's health system. This study presents an overview of approaches for standardized descriptions and analyses of health systems. Methods We conceptualized four criteria to define a “template” for our analysis. It must have (1) a framework, (2) a list of indicators, (3) instructions for authors on how to write an informative document, and (4) should cover health systems design and performance. Based on these criteria we searched the academic and grey literature, and the web for templates. Results We found 29 tools that can be used as templates to describe and assess health systems. While ten tools are comprehensive, 19 tools focus on specific topics such as primary care, universal coverage, and quality of care. Another 21 tools focused on health system performance assessment but cannot serve as templates, as we define it. Most tools were developed by big organizations such as WHO, OECD and USAID. Discussion New models of governance and accountability are leading to increased interest in health system performance. A good template is key to write documents with an organized, coherent and meaningful description and assessment of a health system while allowing for cross-country comparison. We found ten tools that may serve as models of comprehensive templates, while most tools focus on specific topics or on performance assessment only. Conclusions This study provides a first-ever overview of templates that analyze health systems features and performance. Future studies could explore successful examples to consolidate a template that may potentially improve analysis and comparison of health systems in order to support policymaking. Key messages We found ten comprehensive tools for describing and assessing health systems. Our overview may help to improve existing templates by learning from experiences of different organizations.

Identification of optimal thalassemia screening strategies for migrant populations in Thailand using a qualitative approach

BackgroundThalassemia is a common inherited hemoglobin disorder in Southeast Asia. Severe thalassemia can lead to significant morbidity for patients and economic strain for under-resourced health systems. Thailand’s thalassemia prevention and control program has successfully utilized prenatal screening and diagnosis to reduce the incidence of severe thalassemia in Thai populations, but migrant populations are excluded despite having high thalassemia prevalence. We sought to identify key barriers to and facilitators of thalassemia screening and to develop tailored recommendations for providing migrants with access to thalassemia prevention and control.MethodsWe conducted 28 in-depth interviews and 4 focus group discussions (FGDs) in Chonburi, Thailand with Myanmar and Cambodian migrants, Thai healthcare providers, Thai parents of children affected by thalassemia, and migrant agents.ResultsParticipant narratives revealed that migrants’ lack of knowledge about the prevalence, manifestations, severity, and inherited nature of thalassemia led to misconceptions, fear, or indifference toward thalassemia and screening. Negative perceptions of pregnancy termination were based in religious beliefs but compounded by other sociocultural factors, presenting a key obstacle to migrant uptake of prenatal screening. Additionally, structural barriers included legal status, competing work demands, lack of health insurance, and language barriers. Participants recommended delivering public thalassemia education in migrants’ native languages, implementing carrier screening, and offering thalassemia screening in convenient settings.ConclusionsAn effective thalassemia prevention and control program should offer migrants targeted thalassemia education and outreach, universal coverage for thalassemia screening and prenatal care, and options for carrier screening, providing a comprehensive strategy for reducing the incidence of severe thalassemia in Thailand and establishing an inclusive model for regional thalassemia prevention and control.

Assessment of Referral Patterns of Adult Patients to a Sickle Cell Disease Specialty Clinic within a Statewide Sickle Cell Network

Background: Sickle cell disease (SCD) is the most common inherited blood disorder in the United States (U.S.). Despite advances in the treatment for children with SCD, care for affected adults has not significantly improved and is often inaccessible. Difficulties with access to care for adults with SCD in the US is multifactorial and includes paucity of trained, specialized physicians, limited physical access to specialty centers, lack of health insurance/health care coverage, and lack of SCD-education by other medical providers. To address these issues, we have established a state-wide sickle cell disease network to improve access to care for affect adults in South Carolina. This network, (SC)2, Sickle Cell-South Carolina is working to enhance access to care and to examine ongoing barriers to care for adults with SCD. The “hub” of (SC)2 is located at the Medical University of South Carolina (MUSC); specific outside hospitals have been identified as “spokes” within the state to form the network. Clinics are either established or being established at each spoke and additional education is being given through tele-mentoring. Current knowledge of referral patterns for patients with SCD is limited. Information on the mechanism of referral and the coordination of the referral process will ultimately help to eliminate obstacles to appropriate and timely patient referrals and help develop patient engagement.Methods: This is retrospective review of patients >18 years of age referred as “new patients” to the Lifespan Comprehensive Sickle Cell Center at MUSC from October 2015-July 2017. Patients were identified through a chart review of the (SC)2 database including referral notes, telephone calls, and initial patient visits. Data collected included the age of the individual, location (within the state) in which the individual resides, presence or absence of SCD, SCD phenotype, referral source, hematologic care within the prior two years, and the consistency of follow-up after the initial visit to the Sickle Cell Center.Results: During this period, 130 new adult patients were referred to the Lifespan Sickle Cell Center at MUSC. Patients referred for care ranged in age from 18-67 (median 34.5 years) of age and 33% (34/104) were male. To be included in the results, these individuals could not have been seen be the Lifespan Sickle Cell Center within the prior three years so that patients transitioned within the center were not included. Of those patients referred during this period, 85% percent (110/130) were successfully seen at the Lifespan Sickle Cell Center for (at least) an initial visit. However, 40% of these individuals missed their first new patient visit at the Sickle Cell Center and required additional outreach in order to complete that first visit. Of those patients successfully seen for a new patient visit, 95% were confirmed to have SCD (6 individuals were diagnosed with sickle cell trait or did not have a hemoglobinopathy). Only 1/3 of the patients referred to the Sickle Cell Center had seen a hematologist in the last 2 years. The majority of the remaining affected patients had not seen a hematologist since they were children or had never seen a hematologist in their lifetime. Referral sources included primary care physicians, subspecialists, (SC)2 affiliated hospitals (spokes), non-affiliated emergency departments, community based organizations and also included family members and peers. Most of the new referrals were from outside of the Tricounty (local) area (75%) and region did not affect the likelihood of successfully establishing care.Conclusion: The development of a statewide network (SC)2 is an effective initial strategy to facilitate referrals to a SCD center for adults with SCD. Physician-mediated engagement and outreach was key for introducing the (SC)2 network to the state and enabling referrals. When patients missed their initial new visit appointments, aggressive follow-up and trouble-shooting was key to ensuring a successful visit. Additional examination of patient-specific barriers at each phase of the referral process will be key to understanding discrepancies in follow-up rates and obstacles in the referral process. The process through which patients are referred to the center and arrive for their first visit are determinants in their future medical care. Enhanced implementation of this referral process is key to the success of the (SC)2 network. DisclosuresKanter:GBT: Research Funding; American Society of Hematology (Sickle Cell Disease Guideline Panel): Membership on an entity's Board of Directors or advisory committees; MUSC: Other: The site PI for sponsored research conducted at MUSC who receives funds from: Novartis, bluebird bio, GBT, Sancillo, Apopharma, Pfizer; Pfizer: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; NHLBI (sickle cell disease research advisory committee): Membership on an entity's Board of Directors or advisory committees, Research Funding; Apopharma: Research Funding; AstraZeneca: Membership on an entity's Board of Directors or advisory committees; Bluebird Bio: Membership on an entity's Board of Directors or advisory committees, Research Funding; Sancillo: Research Funding.

Assessment of Essential Newborn Care Practices in the Squatter Settlements of Islamabad Capital Territory in Pakistan

Background: While Pakistan has shown progress in reducing child mortality, significant challenges exist in reducing neonatal mortality rate. WHO recommends a package of “essential newborn care” practices based on effective coverage to improve newborn survival. Aim: To assess the coverage of Essential Newborn Care (ENC) as defined by WHO guidelines, in the squatter settlements of Islamabad Capital Territory (ICT). Methods: This cross-sectional survey gathered community-based data on newborn care practices from 416 eligible mothers within randomly selected squatter settlements of ICT. Three composite outcomes (safe cord care, optimal thermal care and good neonatal feeding) were generated by combining individual practices from a list of WHO recommended ENC practices. ENC was considered when all practices within each domain of safe cord care, ideal thermal care and good neonatal feeding were fulfilled. Results: Only 2.9% of newborns received all components of WHO recommended ENC. Seventeen percent newborns received safe cord care, 40.4% received optimal thermal care and 28.8% followed WHO recommended neonatal feeding practice. Various cultural and societal misconceptions were reported which translate into harmful practices for newborn care. Conclusion: The study highlighted an extremely low coverage level of effective essential newborn care. Pakistan needs to address issues of quality care for newborns through policy and programs which focus on Maternal, Newborn, and Child Health (MNCH) continuum of care. It needs a concerted effort at the grass root level, especially training front line workers to educate mothers on various cultural and societal misconceptions that translate into harmful practices for newborns.

Inclusion of oral health teams in primary health care promotes early diagnosis of oral and oropharyngeal cancers: a nationwide study

BackgroundOral and oropharyngeal cancers are considered important public health problems worldwide. This study aims to analyze the association between late diagnosis of oral and oropharyngeal cancers in Brazil and the contextual indicators of socioeconomic variables and coverage of Primary Health Care (PHC), and to assess the temporal trend of late diagnosis.MethodsIn this cross-sectional observational study, secondary data were evaluated with a time series analysis. All Brazilian cities that reported at least one case of oral and oropharyngeal cancers each year in the period between 2000 and 2013 were included; and the staging was analyzed by calculating the ratio risk for late diagnosis for each municipality. The association between staging and socioeconomic variables and offer of PHC was calculated using multiple linear regression. The time trend of the risk ratio for late-stage diagnosis was calculated using the Prais–Winsten method.ResultsOne hundred and sixty Brazilian municipalities had at least one annual case of oral and oropharyngeal cancers notified to the INCA hospital system between 2000 and 2013. The adjusted model showed that the higher the Gini value (greater social inequality) and the lower the HDI value (less human development) was, the higher was the number of tumors diagnosed at a late stage, considering the size of the tumor. A greater risk for late diagnosis was identified, as early as at the stage of lymph node involvement, when there was a higher level of social inequality and lower level of coverage by Oral Health Teams (OHT) in PHC. The greater the social inequality, the greater was the risk of late diagnosis, as early as in the stage of metastasis.ConclusionsWe concluded that, during the evaluated period, there was an increase in the number of cases diagnosed at the most advanced stage. Furthermore, there was association between higher levels of social inequality and an increase in the proportion of late diagnosis of oral and oropharyngeal cancers. In addition, the inclusion of Oral Health Teams in Primary Health Care promoted the early diagnosis of these types of cancers.

The Ethical Conundrums of “Precision Psychiatry”

The Ethical Conundrums of “Precision Psychiatry”

Primary health care and social isolation against COVID-19 in Northeastern Brazil: Ecological time-series study.

Brazil is witnessing a massive increase of corona virus disease (COVID-19). Its peculiar primary health care (PHC) system faces a burden due to the contagion occurring in the community environment. Then, the aim is to estimate the effect of the coverage of primary health care and social isolation on the evolution of confirmed cases and deaths by COVID-19, controlling sociodemographic, economic and health system aspects. A time series design was designed with data on diagnosed cases of COVID-19 and their deaths as outcomes in the capital cities of the Northeast region of Brazil. Independent variables such as PHC coverage, hospital beds, social isolation, demographic density, Gini index and other indicators were analyzed. A Autoregressive Generalized Linear Model method was applied for model the relationship. We identified an exponential growth of cases (y = 0.00250.71x; p-value<0,001). However, there is a high variability in the occurrence of outcomes. PHC coverage≥75% (χ2 = 9.27; p-value = 0.01) and social isolation rate (χ2 = 365.99; p-value<0.001) proved to be mitigating factors for the spread of COVID-19 and its deaths. Capitals with hospital beds ≥ 3.2 per thousand inhabitants had fewer deaths (χ2 = 9.02; p-value = 0.003), but this was influenced by PHC coverage (χ2 = 30,87; p-value<0.001). PHC mitigates the occurrence of Covid-19 and its deaths in a region of social vulnerability in Brazil together with social isolation. However, it is not known until when the system will withstand the overload in view of the low adhesion to social isolation, the lack of support and appropriate direction from the government to its population.

RHCC intervention: strengthening the delivery and coverage of sexual and reproductive health care during floods in Bangladesh

Purpose The quality and availability of sexual and reproductive health care are key determinants to reducing maternal mortalities and morbidities in disaster settings; yet, these services are often lacking in developing countries. Reducing maternal mortality and morbidity is currently the main targets of the UN’s Sustainable Development Goal (SDG) 3. The purpose of this study was to develop an intervention package called RHCC (Reproductive Health Kit 8; Capacity building; Community awareness), and to implement and evaluate it in three primary health-care (PHC) facilities in Belkuchi, Bangladesh, in order to improve the quality and availability of post-abortion care (PAC) during the 2017 floods. Design/methodology/approach This research used both quantitative and qualitative methods to develop, implement and assess the RHCC in three flood-prone PHC facilities in Belkuchi. Findings The RHCC was implemented during the floods of 2017. The findings pre- and post-intervention suggest it led to an increase in skilled management among health workers, an increase in the quality of care for clients and the availability of PAC at three PHC facilities during floods. Originality/value Due to its geographic location, Bangladesh is exposed to recurrent floods and cyclones. Evidence-based integrated intervention packages, such as the RHCC, can improve the quality and availability of reproductive health care during disasters at PHC level and, in doing so, can promote the UN’s agenda on “disaster resilient health system” to achieve the SDG 3, and the WHO’s campaign on universal health coverage.

Exploring willingness to pay for health insurance and preferences for a benefits package from the perspective of women from low-income households of Karachi, Pakistan

BackgroundAchieving universal health coverage (UHC) and reduction in out of pocket (OOP) expenditures on health, is a critical target of the Sustainable Development Goals (SDG). In low-middle income countries, micro-health insurance (MHI) schemes have emerged as a useful financing tool for laying grounds for Universal Health Coverage. The aim of this study was to provide evidence for designing a feasible health insurance scheme targeted at urban poor, by exploring preferences for an insurance benefits package and co-payments among women from low-income households in Karachi, Pakistan.MethodsThis was a descriptive cross-sectional study, conducted using household surveys between July–August 2015. A total of 167 female beneficiaries of Benazir Income Support Programme (BISP), a large-scale cash transfer scheme targeted at low-income households, were recruited in Karachi through a mix of convenience and snowball sampling. Hypothetical insurance benefits packages for a prospective health insurance scheme were formulated to capture respondents’ preferences for health insurance benefits package and co-payments. All data was analyzed using Stata (version 13).ResultsRespondents reporting expenditure on OPD and hospitalization in the last 2 weeks were 93.4 and 11.9% respectively. The highest median expenditure was incurred on medicines. Out of the proposed benefits package, a majority (53%) of the study participants opted for the comprehensive benefits package that provided coverage for emergency care, hospitalization, OPD consultation, diagnostic tests and transportation. For the co-payment plan, 38.9% participants preferred no co-payments that is 100% insurance coverage of medicines followed by hospitalization (25.9%). Nearly half of the respondents (49.4%) chose outpatient consultation for 50% co-payment. A majority of the participants (65.3%) agreed to 100% co-payment for the transportation cost.ConclusionHealth insurance schemes can be introduced in urban areas, against collection of micro-payments, to prevent low-income households from facing financial catastrophe. A comprehensive benefits package covering emergency care, hospitalization, OPD consultation, diagnostic tests and transportation, is the most preferred among low-income beneficiaries.

DELINEATINGACCESS TO SPECIALTY HEALTHCARE IN ZIMBABWE A CROSS-SECTIONAL STUDY TO INFORMEVIDENCE-BASED PUBLIC HEALTH POLICY AND PRACTICE

The study investigated the determinants of access and utilization of specialty healthcare services in the case of public referral hospitals in Zimbabwe using the period post-independence in 1980s to 2018. This becomes an exciting period for the study as it presents the rise and fall of Zimbabwe’s healthcare system. Although there are many specialists offering specialty healthcare, the study limited its focus on specialty care physicians operating at public health facilities. The study objectives were to identify the socio-economic and health behavioural determinants that could influence access to and utilization of specialty healthcare amongst different groupings in Zimbabwe. The study specifically examined the influence of household income, insurance, health information/ education, distance to the nearest health centre, waiting time and dual practice as a variable of interest on access to specialty care. The study utilized cross-sectional household data collected through a survey from April to October 2019. Out of the 40 selected districts from a cluster of 63 existing administrative health districts, 1000 households were randomly selected using one stage cluster sampling (probability sampling design). The study used the Logistic regression model to identify the determinants of access to and utilisation of specialty healthcare based on 653 households that had reported sickness of a member within the last twelve months before the survey. The study tested the hypotheses that dual practice does not affect the supply capacity at public hospitals hence does not reduce access and utilisation of specialty healthcare household income does not increase the demand for specialized healthcare services and that the distance to the nearest health facility does not reduce the probability of seeking of specialty healthcare services. The Logistic regression results revealed that distance to the nearest health care facility, household income, health insurance coverage, presence of dual practice and waiting time all had a significant statistical relationship with access and utilization (demand) for specialty healthcare at public health institutions. However, the study found out that health information had negative effect though an insignificant variable. Distance to the nearest health facility and waiting time was found to negatively affect access (demand) to specialty healthcare whereas household income, dual practice and insurance coverage were found to positively influence access and utilization of specialty healthcare at public health institutions. The study established that, as there is an increase in income and insurance coverage, access and utilization of specialty care also increased. More households in Zimbabwe (71%) are not medically insured. The study found that the provision of specialty healthcare services is too centralized thereby patients are compelled to travel long distancesto metropolitan facilities where specialty health services are more concentrated. The study further established that dual practice affects the supply capacity in public hospitals. The constraining arrangement of management and teaching services at main teaching hospitals affects the supply of specialty services. Households tend to wait longer to consult specialists at public hospitals due to poorly regulated dual practice that induces long waiting times. Given the study findings, the study recommends health policy planners to adopt a balanced centralized and decentralized modelon access to specialty care, differentiating higher and lower tier specialty care facilities to address the geographic accessibility and availability dimensions and revisiting management of training and structuring of specialty teaching services. Other major recommendations of the study include the review of supply-side policies used to enhance access to specialty healthcare services. The policies may target at implementing a public sector ‘National Health Insurance Fund’, driven by the government of Zimbabwe offering realistic, acceptable and affordable premiums for vulnerable groups and expanding the scope of participation in developing the policy regulating dual practice. The study also recommends the creation of Special Economic Zones (SEZ) for Specialty health riding on the existing Government framework on SEZs. The adoption of Strategic Specialty care Partnerships (SSCPs) can enhance access and institutional capacities in dealing with the expensive response to Non Communicable Diseases, which are the main drivers for households to seek specialty care. Zimbabwe through its national health authority needs to ‘Reframe the Health Agenda’ on specialty care thus initiate a national health action plan that will continue to drive to evidence-based health policy and practice.

Abstract PS1-05: Trends in breast-conserving surgery in Mexico after the implementation of a public health insurance system

Abstract Introduction Although temporal trends in breast conserving surgery (BCS) have been described for developed countries like the United States (US), there is a lack of information regarding the uptake of breast conservation in developing regions of the world. In developing countries, the implementation of breast conservation might be hindered by the availability of radiation therapy, lack of training among surgeons, or concerns regarding compliance with follow-up care and surveillance. In 2006, the Mexican government created Seguro Popular, which provided coverage for breast cancer care for all Mexican women, thus potentially mitigating the difficulties with obtaining care after BCS and improving access to multidisciplinary care. We undertook an overview of ten years of breast cancer surgery at our Mexican cancer center following the implementation of Seguro Popular, and explored changes in surgical technique over time. Methods A retrospective cohort analysis was conducted using the National Cancer Institute of Mexico (INCAN) database from 2006 to 2016. All patients with a diagnosis of breast cancer seen during that period were included. Patients who received surgery for breast cancer where then grouped together based on the type of surgery (mastectomy versus BCS). The effect of the year of diagnosis and of clinical stage at the time of presentation was evaluated. Logistic regression was used to model temporal trends in use of BCS over mastectomy for three 3-year periods (2006-2009, 2010-2012, and 2013-2016). Results The patient cohort consisted of 5289 women from the INCAN database, of which 4519 received some form of local surgical treatment. Sixty-one percent (n = 2764) had locally advanced disease (stages IIB-IIIC) at the time of presentation, and a quarter (n = 1156) had ≥60 days between diagnosis and receipt of surgical treatment. Eighty percent of the patients in the entire cohort (n = 3611) were treated with mastectomy, while 20% (n = 908) received BCS. For the 2006-2009 period, out of 1596 total surgeries, 9.9% were BCS (n = 158). The proportion of BCS increased for each of the other two studied periods, being 18.5% for the 2010-2012 period (n = 276/1490), and 33.1% for the 2013-2016 period (n = 474/1433) (p&amp;lt;0.01 for trend). While the increase in BCS was significant for all stages, it was most pronounced for women with early-stage disease (Stages I-IIA), going from 17% in 2006-2009 to 52% in 2013-2016 (p&amp;lt;0.01), than in those with locally-advanced disease (6.5 to 18%, p&amp;lt;0.01). Conclusions In the ten years after the start of the Seguro Popular public insurance program, the proportion of BCS at a Mexican cancer center increased significantly, particularly for women with early-stage disease. The rates seen at INCAN for the period between 2013-2106 resemble those reported by the US National Cancer Database, in which approximately 61% of women with stage I-II breast cancer and 20% of women with stage III disease receive BCS. Potential reasons for the increase in the uptake of BCS include improved access to adjuvant radiation therapy, improved access to systemic treatment, and higher adherence to follow-up care after the start of Seguro Popular, as well as improvements in surgical training. In addition, changes in BCS may also be related to improvements in the implementation of multidisciplinary teams over time, which may lead to a more homogeneous and comprehensive care. Our results show that improving access to care for patients living in developing countries positively impacts the uptake of BCS for women with breast cancer. Citation Format: Enrique Bargalló-Rocha, Nancy Reynoso-Noveron, Jaime Corona, Nereida Esparza-Arias, María Teresa Ramírez-Ugalde, Caros Daniel Robles-Vidal, Robin Shaw-Dulin, Armen Stankov, Rafael Vazquez-Romo, Patricia Villarreal-Colin, Sergio Aguilar-Villanueva, Jaime Hidalgo-Bahena, Milagros Perez-Quintanilla, Fernando U Lara-Medina, Juan Alejandro Torres, Enrique Soto-Perez-de-Celis, Paula Cabrera-Galeana, Alejandro Mohar, Abelardo Meneses-García. Trends in breast-conserving surgery in Mexico after the implementation of a public health insurance system [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-05.

Women Health Right and Empowerment during Childbirth

Background: Women health right and empowerment during childbirth is an emerging important topic worldwide. Violation of women dignity, privacy, and confidentiality impact birth outcomes as consequence influencing both morbidity and mortality rate. This occurs as result to complex reasons that attributable to health services which include inadequate coverage of health care, lack of trained assistance, insufficient essential obstetric care and poor health referral system.&#x0D; &#x0D; Objective: To explore women experience during childbirth in terms of health rights and the quality of care provided and to further study women attuited and experience with midwives and their future role in obstetric care.&#x0D; &#x0D; Method: Based on informant report, a random snowballing sampling technique was carried out through using an anonymous online - based questionnaire. Participants in this study were (n=360) women. Ethical approval was obtained by the institutional review board at King Saud University (IRB No. E-18-32836).&#x0D; &#x0D; Results: The majority of women reported their childbirth experience as unfavourable. According to our findings, women encounter various kinds of obstetric violence including denial of access to a health care, restriction of analgesia, violation of privacy and failure of obtaining an informed consent which found to be high as (91.0%), (53.0%) respectively. &#x0D; &#x0D; Conclusion: Optimal maternity care can be assured through appropriate access to medical resources and health care expertise with a higher priority committed to supporting midwife-led care during childbirth.

Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study

BackgroundAn estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes.MethodsThe EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017–2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight.ResultsMissing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64–0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63–0.79), and report stillbirths (aOR 0.57, 95% CI 0.44–0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64–0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention.ConclusionsWe found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.

The impact of mental health parity laws on birth outcomes.

Prior studies have found that poor mental health during pregnancy is associated with poor birth outcomes, but little is known about the ability of mental health care access and treatment to counteract these effects. I use a difference-in-differences strategy exploiting the staggered enactment of state mental health parity laws in 25 states from 1995 to 2002 to identify the impact of mental health care access on the probability of an adverse birth outcome. These state mental health parity laws are insurance mandates requiring coverage of mental health care be equivalent to physical health care. Using birth records, I find that, among the group of mothers most likely to have private insurance, introduction of a mental health parity law in a state decreased the probability of an adverse birth outcome. Furthermore, I find that the parity laws decreased the likelihood that a pregnant woman hospitalized for delivery would receive a mental illness diagnosis.

Pregnancy intention and gestational age at first antenatal care visit in Lesotho

Background/aims With coverage of antenatal care in sub-Saharan Africa approaching a universal level, attention is now turning to maximising the life-saving potential of antenatal care. This study assessed the gestational age at which pregnant mothers make their first antenatal visit in the context of high antenatal coverage in Lesotho. Methods For the purposes of this study, secondary data from the Demographic and Health Survey of 2014 was analysed. These data were collected in 2014, via an interviewer administered questionnaire. Survival analysis was applied to the data, using Stata SE 15 to compute time ratios that estimate time to first antenatal visit in Lesotho. Results Despite near universal coverage, only 24% of mothers start antenatal care before 12 weeks of gestation, as recommended by the World Health Organization. In addition, mothers with unwanted pregnancies are most likely to delay antenatal care until later in gestation, followed by mothers with mistimed pregnancies. Education, but not wealth, correlates with the start of antenatal care. Conclusions Having achieved near universal coverage, emphasising a prompt start and adherence to recommended visits could optimise the life-saving potential of antenatal care in Lesotho.

Challenges and Opportunities for Purchasing High-Quality Health Care: Lessons from Armenia

ABSTRACT This paper examines how purchasing decisions in Armenia may contribute to barriers in using high-quality health care, particularly for non-communicable diseases, drawing on a review of the literature and key informant interviews. The paper adapts the strategic health purchasing progress framework, to examine how characteristics of purchasing, the health system, and the political, administrative, and macro-fiscal environment may have facilitated or hindered the attainment of service delivery goals. We conclude with six lessons for reforms aimed at improving the coverage and quality of health care in Armenia. First, increasing the political priority of access to quality of health care is a pre-requisite to advancing reforms to address these issues. Second, improved purchasing governance in Armenia will require a purchaser that can make decisions without political interference, with appropriate accountability mechanisms, improvements in technical capacity, and the routine use of data systems. Third, there is a need for the regulatory framework to ensure that revisions of the benefits package contribute to reducing the disease burden and improving access to care. Fourth, regulations governing quality-related criteria for provider selection should be enforced and include considerations for process quality. Fifth, payment incentives should be revised to encourage an increase in the supply of primary health care, reduce bypassing for hospital care, and improve the quality of services. Sixth, the potential of purchasing to improve service delivery will be dependent on increased pre-paid and pooled funds and better governance of the quality of care.

Opening the black box of non-pharmacological care in systemic sclerosis: a cross-sectional online survey of Dutch health professionals

The objective is to describe the spectrum of the health professional (HP) treatment approach for systemic sclerosis (SSc) from the perspective of Dutch HPs, including alignment of treatment goals set by HPs with self-reported referral reasons, coverage of patient-reported unmet care needs, and quality of communication between HPs and rheumatologists. Dutch HPs were invited through their patients with SSc to complete an anonymous online survey. The survey covered referral reasons, treatment goals, and interventions of the last patient treated, as well as the perceived quality of communication between HPs and rheumatologists. Referral reasons and treatment targets were linked to the International Classification of Functioning, Disability and Health following the refined ICF Linking Rules. Seventy-nine HPs from 8 professions (including 58 physiotherapists, 73%) completed the survey. One hundred and thirty-three different referral reasons were reported, yielding 58 different ICF codes, with 41 (70.7%) being linked to the ICF domain “body structures and functions.” The reported interventions focused on body functions/structures (27.9%), training of daily activities (25.6%), education and advice (26.3%), and psychosocial interventions (20.2%). The quality of communication between HPs and rheumatologists was perceived as low. Our findings revealed numerous treatment options offered by Dutch HPs addressing the unmet care needs of patients with SSc. There is an overlap in the content of the various HP disciplines, and HP treatment goals are not sufficiently aligned with referrals of rheumatologists. HP treatment offer seemed inefficiently organized, possibly precluding rheumatologists from making targeted referrals. Communication between rheumatologists and HPs should be improved.

Reasons for Refusing Home-based Palliative Care: A Qualitative Study of Patients and Caregivers

Despite some insurance plans now paying for home-based palliative care, recent reports have suggested that coverage for palliative care may be insufficient to expanding patient access to home-based palliative care. Research has yet to explore palliative care barriers from the perspective of palliative care-eligible patients and their caregivers. To identify patients and caregivers’ perceived barriers to home-based palliative care and their recommendations for overcoming these barriers, we conducted a qualitative study using semi-structured individual interviews. Participants (patients, proxies, and their caregivers) who were eligible for a randomized controlled trial of home-based palliative care were interviewed via telephone. Our interview protocol elicited participants’ perspectives on home-based palliative care services; positive and negative aspects of the program explanation; and suggestions for improving messaging around home-based palliative care. Researchers used grounded theory to identify the themes within the transcripts. Two researchers independently coded the transcripts and then met to compare coding and reconciled discrepancies until 100% consensus was reached. Identified themes related to home-based palliative care referral barriers included reluctance to have home visits, timing, lack of palliative care knowledge, misconceptions of palliative care, and patients’ self-perceived health condition (not sick enough for palliative care). Themes related to recommendations for overcoming these barriers included preferring a palliative care referral from healthcare providers or from insurance company and clearer presentation of palliative care service. Findings reinforce the need for additional palliative care education among patients with serious illness and the importance of delivering the information from a trusted source.