Skilled Birth Attendant Coverage Research Articles

Skilled birth attendant utilization trends, determinant and inequality gaps in Ethiopia

BackgroundGlobally over half a million women die every year from potentially preventable and treatable pregnancy and childbirth complications; of which 99% occur in low-and middle-income countries (LMICs). The utilization of skilled birth attendants can timely identify treatable birth complications and save lives. However, utilization of services remained low in LMICs. This study aimed to examine the trends in the utilization of skilled birth attendants and the inequality gaps in Ethiopia using data from the Demographic and Health Surveys.MethodsWe used data from five rounds of Ethiopian Demographic and Health Surveys conducted in the period 2000–2019. Respondents were women in the reproductive age group who had a live birth within five years preceding the surveys. We used the concentration curve and concentration index to identify the inequalities using the World Health Organization recommended Health Equity Analysis Toolkit software. We did a logistic regression analysis to examine factors associated with skilled birth attendant utilization using STATA version 14.0.ResultThe skilled birth attendant coverage trend showed an increment from 5.7% in 2005 to 49.8% in 2019. The inequality gaps within the wealth, residence and education categories also showed a reduction over time. The odds of utilizing SBA were higher among those having primary, secondary, and above education status [AOR = 1.61 95%CI (1.33, 1.95)], being in the upper wealth quintile [AOR = 3.46 95%CI (1.8, 4.31)] and living in urban areas [AOR = 3.53 95%CI (1.88, 6.64)].ConclusionThe skilled birth attendant coverage trend showed a steady increase from 2005 to 2019 but if we continue with the current pace, it will be difficult to achieve the national target. The inequality gaps in household wealth status and residency area remain high. Efforts like strengthening the health system and engaging multisectoral agents need to be given priority to further reach the poorest and those living in rural areas to achieve national and international targets.

Health awareness and skilled birth attendance: An assessment of sustainable development goal 3.1 in south and south-east Asia

BackgroundThe United Nation's Sustainable Development Goal 3.1 aims to reduce maternal mortality worldwide to 70 per 100,000 live births by 2030, which requires greater skilled birth attendant (SBA) coverage and increased health awareness. By evaluating relevant sociodemographic factors, this study aimed to identify different groups of women who lack health awareness and access to SBA services in eight selected low-and-middle-income countries (LMICs) of South and South-East Asia (SSEA), namely, Afghanistan, India, Indonesia, Myanmar, Nepal, Pakistan, Philippines, and Timor-Leste. MethodsNationally representative Demographic and Health Surveys (DHS) on women aged 15–49 years were analysed with a pooled sample of 95,521. Complex survey-adjusted logistic regression models were fitted to assess sociodemographic factors, SBA coverage, and health awareness. ResultsWomen with higher health awareness were 44.4% (95% CI:1.32–1.58, p<0.001) more likely to access SBAs compared to the rest. Women and/or their partners with no or primary-level education, who were poorer, became young mothers (≤20 years), not involved in decision-making, or hardly exposed to media were less likely to seek SBAs and have higher health awareness. Women in rural areas with more children were also less likely to use SBAs. Timor-Leste, Afghanistan, Myanmar, and Nepal underperformed on SBA coverage amongst the selected LMICs of the SSEA region. ConclusionHealth education and mass-media-driven awareness could be an interventional avenue for LMICs to increase SBA coverage. Future studies comparing health policies within the SSEA region are required to identify reasons behind some nations’ underperformance, while others are on track to achieve SDG 3.1.

Trends of maternal health service coverage in the Democratic Republic of the Congo: a pooled cross-sectional study of MICS 2010 to 2018

BackgroundMaternal health services are essential for reducing maternal and newborn mortality. However, maternal health service status in the Democratic Republic of the Congo (DRC) remains poorly understood. This study aims to explore the trends of antenatal care (ANC) and skilled birth attendance coverage in the past decade in the DRC.Methods The 13,361 participants were from two rounds of Multiple Indicators Cluster Survey (MICS) conducted by the National Institute of Statistics of the Ministry of Planning of the DRC, in collaboration with the United Nations Children’s Fund (UNICEF), in 2010 and 2017-2018. A regression-based method was adopted to calculate adjusted coverage of ANC and skilled birth attendance. Subgroup analysis based on different socioeconomic status (SES) was conducted to explore the impact of domestic conflicts.ResultsFrom 2010 to 2018, the overall weighted ANC coverage in the DRC declined from 87.3 % (95 % CI 86.1–88.0 %) to 82.4 % (95 % CI 81.1–84.0 %), while the overall weighted skilled birth attendance coverage increased from 74.2 % (95 % CI 72.5–76.0 %) to 85.2 % (95 % CI 84.1–86.0 %). Adjusted ANC coverage and adjusted skilled birth attendant coverage both declined in Kasai Oriental, but increased in Nord Kivu and Sud Kivu. In Kasai Occidental, ANC coverage declined, but skilled birth coverage increased. In the Kasai region, the largest decline in adjusted coverage of ANC was found among the poorest women. However, in the Kivu region, both the adjusted coverage of ANC and skilled birth attendance increased among the poorest women.ConclusionsDue to ongoing conflicts, there has been a systemic deterioration of maternal healthcare coverage in some regions of the DRC, particularly among people with low SES. However, in other regions, maternal healthcare services were not severely disrupted possibly due to substantial international health assistance.

Maternal health care service utilization among young married women in India, 1992\u20132016: trends and determinants

BackgroundMaternal deaths among young women (15–24 years) shares 38% of total maternal mortality in India. Utilizing maternal health care services can reduce a substantial proportion of maternal mortality. However, there is a paucity of studies focusing on young women in this context. This paper, therefore, aimed to examine the trends and determinants of full antenatal care (ANC) and skilled birth attendance (SBA) utilization among young married women in India.MethodsThe study analysed data from the four rounds of National Family Health Surveys conducted in India during the years 1992–93, 1998–99, 2005–06 and 2015–16. Young married women aged 15–24 years with at least one live birth in the 3 years preceding the survey were considered for analysis in each survey round. We used descriptive statistics to assess the prevalence and trends in full ANC and SBA use. Pooled multivariate logistic regression was conducted to identify the demographic and socioeconomic determinants of the selected maternity care services. The significance level for all analyses was set at p ≤ 0.05.ResultsThe use of full ANC among young mothers increased from 27 to 46% in India, and from 9 to 28% in EAG (Empowered Action Group) states during 1992–2016. SBA utilization was 88 and 83% during 2015–16 by showing an increment of 20 and 50% since 1992 in India and EAG states, respectively. Findings from multivariate analysis revealed a significant difference in the use of selected maternal health care services by maternal age, residence, education, birth order and wealth quintile. Additionally, Muslim women, women belonging to scheduled caste (SC)/ scheduled tribe (ST) social group, and women unexposed to mass media were less likely to utilize both the maternal health care services. Concerning the time effect, the odds of the utilization of full ANC and SBA among young women was found to increase over time.ConclusionsIn India coverage of full ANC among young mothers remained unacceptably low, with a wide and persistent gap in utilization between EAG and non-EAG states since 1992. Targeted health policies should be designed to address low coverage of ANC and SBA among underprivileged young mothers and increased efforts should be made to ensure effective implementation of ongoing programs, especially in EAG states.

Two-facility longitudinal study on the effect of team medical education based on collaboration with WHO and development in Asia

The Global Health Workforce Network (GHWN), formerly Global Health Workforce Aliance, is a broad term which challenges the problems surrounding a severe health workforce shortage. In 2006, the World Health Organization (WHO) calculated that to attain a high coverage of skilled birth attendance, there was a minimum requirement of 2.28 physicians, nurses and midwives for every 1,000 people in a population. However, statistics prepared by WHO back over a decade ago suggested that 57 countries around the world fell below this threshold, this meant that an additional 4.3 million health workers were needed to fill the shortage. Fast forward to 2019 and there still appears to be a significant shortage. For that reason, there have been many investigations into how best to solve this problem – one that will only get worse as the global population continues to grow. One strategy that has been identified is interprofessional education (IPE), which is a pedagogical approach that aims to prepare health professions students by placing them in a collaborative team environment. The idea is relatively straightforward: improve the overall quality of healthcare by putting students from two or more professions in health and social care together, so that they can each learn from the others and cultivate collaborative practice (CP), which may also contribute to patient safety.

Determinants of antenatal care and skilled birth attendance in sub-Saharan Africa: A multilevel analysis.

To determine individual- and country-level determinants of utilization of key maternal health services in sub-Saharan Africa (SSA). We used the most recent standard demographic and health survey data from the period of 2005 to 2015 for 34 SSA countries. Predictors of key maternal health service indicators were determined using a sample of 245178 women who had at least one live birth 5years preceding the survey. We used a two-level hierarchical model, considering individual predictors at level one and country factors at level two of the hierarchy. While the skilled birth attendance (SBA) utilization rate reached 53 percent during the study period, the recommended four or more antenatal care (ANC) coverage was commonly low with less significant differences among different groups of women and countries. Being in a middle-income country increased the individual-level association between ANC and SBA (OR=2.34, 95% CI: 1.24, 4.44). Less privileged women with lower education level were less likely to receive maternal health services. This study reveals the existence of wide gaps between ANC and SBA coverage in SSA. Urgent policy attention is required to improve access, utilization, and quality of maternal health services.

Socioeconomic inequalities in access to skilled birth attendance among urban and rural women in low-income and middle-income countries

IntroductionRapid urbanisation is one of the greatest challenges for Sustainable Development Goals. We compared socioeconomic inequalities in urban and rural women’s access to skilled birth attendance (SBA) and to assess...

Is deployment of trained nurses to rural villages a remedy for the low skilled birth attendance in Ethiopia? A cluster randomized-controlled community trial

BackgroundLow coverage of Skilled Birth Attendance (SBA) is one of the major drivers of maternal mortality in many low- and middle-income countries (LMICs) including Ethiopia. We conducted a cluster-randomized controlled community trial to assess the effect of deploying trained community based nurses to rural communities on the uptake levels of SBA in Ethiopia.MethodsA three-arm, parallel groups, cluster-randomized community trial was conducted to assess the effect of deploying trained community based reproductive health nurses (CORN) on the uptake of SBA services. A total of 282 villages were randomly selected and assigned to a control arm (n = 94) or 1 of 2 treatment arms (n = 94 each). The treatment groups differed by where these new service providers were deployed, a health post (HP) or health center (HC). Baseline and end line surveys were conducted to document and measure the effects of the intervention. Program impacts on SBA coverage were calculated using difference‐in‐difference (DID) analysis.ResultsAfter nine months of intervention, the coverage of SBA services increased significantly by 81.1% (from 24.61 to 44.59) in the HP based intervention arm, and by 122.9% (from 16.41 to 36.59) in the HC arm, respectively (p <0.01). Conversely, a small and non-significant (2%) decline in SBA coverage were observed in the control arm (P >0.05). The DID estimate indicated a net increase in SBA coverage of 21.32 and 20.52 percentage points (PP) across the HP and HC based intervention arms, respectively (p < 0.001).ConclusionsDeployment of trained reproductive health nurses to rural communities in Ethiopia significantly improved utilization of SBA services. Therefore; in similar low income settings where coverage of SBA services is very low, deployment of trained community based nurses to grassroots level could potentiate rapid service uptake. Additional cost-effectiveness and validation studies at various setups are required, before scale-up of the innovation, however.Trial registrationclinicaltrails.gov NCT02501252.

Toward communities as systems: a sequential mixed methods study to understand factors enabling implementation of a skilled birth attendance intervention in Nampula Province, Mozambique

BackgroundSkilled birth attendance, institutional deliveries, and provision of quality, respectful care are key practices to improve maternal and neonatal health outcomes. In Mozambique, the government has prioritized improved service delivery and demand for these practices, alongside “humanization of the birth process.” An intervention implemented in Nampula province beginning in 2009 saw marked improvement in institutional delivery rates. This study uses a sequential explanatory mixed methods case study design to explore the contextual factors that may have contributed to the observed increase in institutional deliveries.MethodsA descriptive time series analysis was conducted using clinic register data from 2009 to 2014 to assess institutional delivery coverage rates in two primary health care facilities, in two districts of Nampula province. Site selection was based on facilities exhibiting an initial increase in institutional deliveries from 2009 to 2011, similarity of health system attributes, and accessibility for study participation. Using a modified Delphi technique, two expert panels—each composed of ten stakeholders familiar with maternal health implementation at facility, district, provincial, and national levels—were convened to formulate the “story” of the implementation and to identify contextual factors to use in developing semi-structured interview guides. Thirty-four key informant interviews with facility MCH nurses, facility managers, traditional birth attendants, community leaders, and beneficiaries were then conducted and analyzed using the Consolidated Framework for Implementation Research through inductive and deductive coding.ResultsThe two sites’ skilled birth attendance coverage of estimated live births reached 80 and 100%, respectively. Eight contextual and human factors were found as dominant themes. Though both sites achieved increases, implementation context differed significantly with compelling examples of both respectful and disrespectful care. In one site, facility and community actors worked together as complementary systems to sustain improved care and institutional deliveries. In the other, community actors sustained implementation and institutional deliveries largely in absence of health system counterparts.ConclusionFindings support global health recommendations for combined health system and community interventions for improved MNH outcomes including delivery of respectful care, and further suggest the capacity of communities to act as systems both in partnership to and independent of the formal health system.

Absolute income is a better predictor of coverage by skilled birth attendance than relative wealth quintiles in a multicountry analysis: comparison of 100 low- and middle-income countries

BackgroundHaving high-quality data available by 2020, disaggregated by income, is one of the Sustainable Development Goals (SGD). We explored how well coverage with skilled birth attendance (SBA) is predicted by asset-based wealth quintiles and by absolute income.MethodsWe used data from 293 national surveys conducted in 100 low and middle-income countries (LMICs) from 1991 to 2014. Data on household income were computed using national income levels and income inequality data available from the World Bank and the Standardized World Income Inequality Database. Multivariate regression was used to explore the predictive capacity of absolute income compared to the traditional measure of quintiles of wealth index.ResultsThe mean SBA coverage was 68.9% (SD: 24.2), compared to 64.7% (SD: 26.6) for institutional delivery coverage. Median daily family income in the same period was US$ 6.4 (IQR: 3.5–14.0). In cross-country analyses, log absolute income predicts 51.5% of the variability in SBA coverage compared to 22.0% predicted by the wealth index. For within-country analysis, use of absolute income improved the understanding of the gap in SBA coverage among the richest and poorest families. Information on income allowed identification of countries – such as Burkina Faso, Cambodia, Egypt, Nepal and Rwanda – which were well above what would be expected solely from changes in income.ConclusionAbsolute income is a better predictor of SBA and institutional delivery coverage than the relative measure of quintiles of wealth index and may help identify countries where increased coverage is likely due to interventions other than increased income.

Socioeconomic inequalities in skilled birth attendance and child stunting in selected low and middle income countries: Wealth quintiles or deciles?

BackgroundWealth quintiles derived from household asset indices are routinely used for measuring socioeconomic inequalities in the health of women and children in low and middle-income countries. We explore whether the use of wealth deciles rather than quintiles may be advantageous.MethodsWe selected 46 countries with available national surveys carried out between 2003 and 2013 and with a sample size of at least 3000 children. The outcomes were prevalence of under-five stunting and delivery by a skilled birth attendant (SBA). Differences and ratios between extreme groups for deciles (D1 and D10) and quintiles (Q1 and Q5) were calculated, as well as two summary measures: the slope index of inequality (SII) and concentration index (CIX).ResultsIn virtually all countries, stunting prevalence was highest among the poor, and there were larger differences between D1 and D10 than between Q1 and Q5. SBA coverage showed pro-rich patterns in all countries; in four countries the gap was greater than 80 pct points. With one exception, differences between extreme deciles were larger than between quintiles. Similar patterns emerged when using ratios instead of differences. The two summary measures provide very similar results for quintiles and deciles. Patterns of top or bottom inequality varied with national coverage levels.ConclusionResearchers and policymakers should consider breakdowns by wealth deciles, when sample sizes allow. Use of deciles may contribute to advocacy efforts, monitoring inequalities over time, and targeting health interventions. Summary indices of inequalities were unaffected by the use of quintiles or deciles in their calculation.

Reaching the unreached through trained and skilled birth attendants in Ethiopia: a cluster randomized controlled trial study protocol

BackgroundDespite improvements since 1990 to 2014, maternal mortality ratio (MMR) remains high in Ethiopia. One of the key drivers of maternal mortality in Ethiopia is the very low coverage of Skilled Birth attendance (SBA) in rural Ethiopia. This cluster randomized trial piloted an innovative approach of deploying trained community reproductive nurses (CORN) to hard to reach/unreachable rural Ethiopia to improve the coverage of SBA.MethodsWe used a three-arm cluster randomized trial to test the effect of deploying CORN in rural communities in South Ethiopia to improve SBA and other maternal health indicators. A total of 282 villages/clusters (94 from each arm) were randomly selected in the three districts of the zone for the study. The intervention was implemented in four consecutive phases that aimed at of provision of essential maternal, neonatal and child health (MNCH) services mainly focusing on SBA. The CORN were trained and deployed in health centres (arm 1) and in the community/health posts (arm2). A third arm (arm 3) consisting control villages without the intervention. A baseline and end line assessment was conducted to compare the difference in the proportion of SBA and other MNCH service uptake across the three arms Data was entered into computer, edited, cleaned, and analyzed using Epi-data statistical software. The presentation followed the Consolidated Standards of Reporting Trials (CONSORT) statement guidelines for cluster-randomized trials.DiscussionThis trial is designed to test the impact of an innovative and newly designed means of distribution for the national health extension program strategy with additional service package with no change to the target population. The focus is on effect of CORN in revitalizing the Health Extension Program (HEP) through improving SBA service uptake and other maternal health service uptake indicators. The study findings may guide national policy to strengthen and shape the already existing HEP that has certain limitations to improve maternal health indicators. The competency based training methodology could provide feedback for health science colleges to improve the national nursing or midwifery training curriculum.Trial registrationclinicaltrails.gov NCT02501252 dated on July 14, 2015.

Trends in Reproductive Health indicators in Ethiopia: 2000-2014

Introduction: The Millennium Development Goals include a focus on Reproductive Health (RH) indicators which are of substantial importance in low and middle income countries. However, little has been reported of the time-trend in these indicators in Ethiopia. This study aims to describe trends in RH indicators in Ethiopia from 2000-2014. Methods: This study is a time-trend analysis of RH indicators. We used 15-years of RH indicator data sourced mainly from Federal Ministry of Health and Demographic and Health Survey. Maternal mortality ratio, antenatal care coverage, skilled birth attendance coverage, postnatal care coverage, contraceptive prevalence rate and total fertility rate were selected and analysed using numerical and graphic summaries. We used coefficient of determination (R2) for the Federal Ministry of Health facility based data to examine the variation in annual progress explained by the regression model. Confidence intervals were used in the Demographic and Health Survey data to indicate the period when significant difference was observed. Trends of indicators from both data sources were also compared. Results: During the 15-years study period, antenatal care coverage increased from 29% to 98% (R2 = 95%). It increased more rapidly than skilled birth attendance which remained low at 41% in 2014. Postnatal care coverage increased from 5% to 64% (R 2 = 96%). Modern contraceptive prevalence rate among the married women improved from 6.3% (5.8%, 6.8%) to 40% (38.7%, 41.3%) within the 15-year period. Maternal mortality ratio decreased from 990 in 2000 to 420 in 2013. The total fertility rate decreased from 5.5 to 4.1 children per woman. With lowest performance in 2000, Ethiopia demonstrated better improvement compared to selected sub-Saharan African countries. Variations in the trends were observed when data from both sources were compared. Conclusions: RH service coverages have shown remarkable improvement while maternal mortality ratio, although reduced, remained high. There was a significant gap in the continuum of maternal health services.

Inequalities in the coverage of place of delivery and skilled birth attendance: analyses of cross-sectional surveys in 80 low and middle-income countries.

BackgroundHaving a health worker with midwifery skills present at delivery is one of the key interventions to reduce maternal and newborn mortality. We sought to estimate the frequencies of (a) skilled birth attendant coverage, (b) institutional delivery, and (c) the combination of place of delivery and type of attendant, in LMICs.MethodsNational surveys (DHS and MICS) performed in 80 LMICs since 2005 were analyzed to estimate these four categories of delivery care. Results were stratified by wealth quintile based on asset indices, and by urban/rural residence. The combination of place of delivery and type of attendant were also calculated for seven world regions.ResultsThe proportion of institutional SBA deliveries was above 90 % in 25 of the 80 countries, and below 40 % in 11 countries. A strong positive correlation between SBA and institutional delivery coverage (rho: 0.97, p <0,001) was observed. Eight countries had over 10 % of home SBA deliveries, and two countries had over 10 % of institutional non-SBA deliveries. Except for South Asia, all regions had over 80 % of urban deliveries in the institutional SBA category, but in rural areas, only two regions (CEE & CIS, Middle East & North Africa) presented average coverage above 80 %. In all regions, institutional SBA deliveries were over 80 % in the richest quintile. Home SBA deliveries were more common in rural than in urban areas, and in the poorest quintiles in all regions. Facility non-SBA deliveries also tended to be more common in rural areas and among the poorest.ConclusionFour different categories of delivery assistance were identified worldwide. Pro-urban and pro-rich inequalities were observed for coverage of institutional SBA deliveries.Electronic supplementary materialThe online version of this article (doi:10.1186/s12978-016-0192-2) contains supplementary material, which is available to authorized users.

The Association Between Health Insurance Coverage and Skilled Birth Attendance in Ghana: A National Study.

Skilled birth attendance (SBA) is a key health intervention used by roughly two-thirds of women in Ghana. The National Health Insurance Scheme provided by the Government of Ghana is widely expected to improve maternal health outcomes by removing financial barriers to health services. In this paper, we examine if indeed health insurance is able to improve SBA, a key maternal outcome. We use data from the 2011 Ghana Multiple Indicator Cluster Survey implemented by the Ghana Statistical Services with support from the United Nations Children's Fund (UNICEF). We use a multivariate logistic model controlling for a number of enabling and predisposing factors and past experience with the health system to examine the effect of health insurance on skilled birth attendance. The sample is 2528 women. Our results show that women with health insurance are 47 % more likely to use SBA than women without health insurance. Results also underscore that women with repetitive contact with the health system (such as antenatal care) are more likely to have a skilled delivery (OR 3.00, p value 0.000). We also find that higher parity, rural and poor women are much less likely to use SBA. Health insurance may indeed be a useful mechanism to improve coverage of SBA, though many barriers to delivery care still exist for women. Further work to understand the effect of health insurance on other maternal outcomes is also warranted.

Progress towards Millennium Development Goals 4 & 5: strengthening human resources for maternal, newborn and child health.

Since the 1990s developing countries as a whole have made remarkable efforts to reduce under-five mortality rate from 90 to 48 deaths per thousand live births in 2012. As a result the number of annual under-five deaths dropped by nearly 6 million during that period. Unfortunately the pace of reduction was slowest in sub-Saharan Africa making it impossible that the region will reach the target for the Millennium Development Goals (MDGs) 4 but a few countries including some of the poorest such as Ethiopia Liberia Malawi and Niger have already met the MDG 4 target or are making progress that are consistent with the target. At the same time global maternal deaths have been nearly halved since the 1990s from 380 deaths per 100000 live births to 210 in 2013. In sub-Saharan Africa and South Asia the two regions where more than 85% of all maternal deaths occur the maternal mortality ratio (MMR) dropped from 990 to 510 and from 530 to 190 respectively. Skilled birth attendance (SBA) one of the proximate determinants of maternal mortality increased only modestly during the period 1990-2012 from 40% to 53% in sub-Saharan Africa and from 33% to 51% in South Asia. As with most health indicators there are wide variations in the coverage of SBA from 20% or less in Ethiopia and Niger to more than 80% in countries including Benin Namibia and Botswana. Most maternal newborn and child deaths result from causes that can be adequately treated by a package of well-known interventions. One of the main challenges in delivering essential and life-saving interventions to avert these deaths is the shortage of a well-trained supervised and motivated health workforce. With the vast amount of evidence showing that increased availability of skilled health workers is directly linked to improved maternal newborn and child health (MNCH) outcomes health workforce development is increasingly seen as a critical component of MNCH care delivery. (Excerpt)

The effect of health-facility admission and skilled birth attendant coverage on maternal survival in India: a case-control analysis.

BackgroundResearch in areas of low skilled attendant coverage found that maternal mortality is paradoxically higher in women who seek obstetric care. We estimated the effect of health-facility admission on maternal survival, and how this effect varies with skilled attendant coverage across India.Methods/FindingsUsing unmatched population-based case-control analysis of national datasets, we compared the effect of health-facility admission at any time (antenatal, intrapartum, postpartum) on maternal deaths (cases) to women reporting pregnancies (controls). Probability of maternal death decreased with increasing skilled attendant coverage, among both women who were and were not admitted to a health-facility, however, the risk of death among women who were admitted was higher (at 50% coverage, OR = 2.32, 95% confidence interval 1.85–2.92) than among those women who were not; while at higher levels of coverage, the effect of health-facility admission was attenuated. In a secondary analysis, the probability of maternal death decreased with increasing coverage among both women admitted for delivery or delivered at home but there was no effect of admission for delivery on mortality risk (50% coverage, OR = 1.0, 0.80–1.25), suggesting that poor quality of obstetric care may have attenuated the benefits of facility-based care. Subpopulation analysis of obstetric hemorrhage cases and report of ‘excessive bleeding’ in controls showed that the probability of maternal death decreased with increasing skilled attendant coverage; but the effect of health-facility admission was attenuated (at 50% coverage, OR = 1.47, 0.95–1.79), suggesting that some of the effect in the main model can be explained by women arriving at facility with complications underway. Finally, highest risk associated with health-facility admission was clustered in women with education 8 years.ConclusionsThe effect of health-facility admission did vary by skilled attendant coverage, and this effect appears to be driven partially by reverse causality; however, inequitable access to and possibly poor quality of healthcare for primary and emergency services appears to play a role in maternal survival as well.

Maternal health insurance in Indonesia: assessment of a policy design

Background The main purposes of the Indonesian national insurance for maternal and delivery services were to: (1) increase antenatal and skilled birth attendance coverage, (2) increase neonatal and postnatal care, and postnatal family planning coverage, and (3) ensure effective and accountable health financing for MNCH. However, there has been a growing concern on the implementation of the policy. Increased accessibility does not always translate to better health services and improved equity in health. The programme has also put dismaying burden on the health system, particularly for health providers. To ensure better programme implementation that could better achieve the original purposes, Jampersal health insurance should be scrutinised from the policy analysis perspective. This study aimed to analyse the design of the Jampersal policy in Indonesia and to provide suggestions for improvement for future implementation.

Evaluation of the Ethiopian Millennium Rural Initiative: Impact on Mortality and Cost-Effectiveness

Main ObjectiveFew studies have examined the long-term, impact of large-scale interventions to strengthen primary care services for women and children in rural, low-income settings. We evaluated the impact of the Ethiopian Millennium Rural Initiative (EMRI), an 18-month systems-based intervention to improve the performance of 30 primary health care units in rural areas of Ethiopia.MethodsWe assessed the impact of EMRI on maternal and child survival using The Lives Saved Tool (LiST), Demography (DemProj) and AIDS Impact Model (AIM) tools in Spectrum software, inputting monthly data on 6 indicators 1) antenatal coverage (ANC), 2) skilled birth attendance coverage (SBA), 3) post-natal coverage (PNC), 4) HIV testing during ANC, 5) measles vaccination coverage, and 6) pentavalent 3 vaccination coverages. We calculated a cost-benefit ratio of the EMRI program including lives saved during implementation and lives saved during implementation and 5 year follow-up.ResultsA total of 134 lives (all children) were estimated to have been saved due to the EMRI interventions during the 18-month intervention in 30 health centers and their catchment areas, with an estimated additional 852 lives (820 children and 2 adults) saved during the 5-year post-EMRI period. For the 18-month intervention period, EMRI cost $37,313 per life saved ($42,366 per life if evaluation costs are included). Calculated over the 18-month intervention plus 5 years post-intervention, EMRI cost $5,875 per life saved ($6,671 per life if evaluation costs are included). The cost effectiveness of EMRI improves substantially if the performance achieved during the 18 months of the EMRI intervention is sustained for 5 years. Scaling up EMRI to operate for 5 years across the 4 major regions of Ethiopia could save as many as 34,908 lives.SignificanceA systems-based approach to improving primary care in low-income settings can have transformational impact on lives saved and be cost-effective.

Equity in Maternal Health in South Africa: Analysis of Health Service Access and Health Status in a National Household Survey

BackgroundSouth Africa is increasingly focused on reducing maternal mortality. Documenting variation in access to maternal health services across one of the most inequitable nations could assist in re-direction of resources.MethodsAnalysis draws on a population-based household survey that used multistage-stratified sampling. Women, who in the past two years were pregnant (1113) or had a child (1304), completed questionnaires and HIV testing. Distribution of access to maternal health services and health status across socio-economic, education and other population groups was assessed using weighted data.FindingsPoorest women had near universal antenatal care coverage (ANC), but only 39.6% attended before 20 weeks gestation; this figure was 2.7-fold higher in the wealthiest quartile (95%CI adjusted odds ratio = 1.2–6.1). Women in rural-formal areas had lowest ANC coverage (89.7%), percentage completing four ANC visits (79.7%) and only 84.0% were offered HIV testing. Testing levels were highest among the poorest quartile (90.1% in past two years), but 10% of women above 40 or with low education had never tested. Skilled birth attendant coverage (overall 95.3%) was lowest in the poorest quartile (91.4%) and rural formal areas (85.6%). Around two thirds of the wealthiest quartile, of white and of formally-employed women had a doctor at childbirth, 11-fold higher than the poorest quartile. Overall, only 44.4% of pregnancies were planned, 31.7% of HIV-infected women and 68.1% of the wealthiest quartile. Self-reported health status also declined considerably with each drop in quartile, education level or age group.ConclusionsAside from early ANC attendance and deficiencies in care in rural-formal areas, inequalities in utilisation of services were mostly small, with some measures even highest among the poorest. Considerably larger differences were noted in maternal health status across population groups. This may reflect differences between these groups in quality of care received, HIV infection and in social determinants of health.