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Medicaid Family Planning Expansions: The Effect of State Plan Amendments on Postpartum Contraceptive Use.
Journal of Women's Health. 2018 Nov 28;OBJECTIVE: To determine the effect of state Medicaid family planning (FP) programs transitioning from a Section 1115 waiver to a State Plan Amendment (SPA) on reproductive health outcomes. MATERIALS AND METHODS: Data were from the Pregnancy Risk Assessment Monitoring System on 75,082 women who had a live birth between 2007 and 2013 and were living in one of nine states. We performed a difference-in-differences analysis to quantify the effect of the transition on postpartum contraceptive (PPC) use and unintended births (UBs). RESULTS: Over 80% of the sample reported using PPC; half reported an UB. The odds of PPC use among women who were living in a study state and gave birth after the transition were 1.14 times that of women who were living in a comparison state and/or gave birth before the transition (95% confidence interval: 1.04-1.24). CONCLUSIONS: Findings suggest that women living in states that transitioned from a waiver to SPA experienced an increased likelihood of PPC compared with those living in comparison states.
When things fall apart: local responses to the reintroduction of user-fees for maternal health services in rural Malawi.
Reproductive Health Matters. 2018 Nov 2; 1-11.Despite the strong global focus on improving maternal health during past decades, there is still a long way to go to ensure equitable access to services and quality of care for women and girls around the world. To understand widely acknowledged inequities and policy-to-practice gaps in maternal health, we must critically analyse the workings of power in policy and health systems. This paper analyses power dynamics at play in the implementation of maternal health policies in rural Malawi, a country with one of the world's highest burdens of maternal mortality. Specifically, we analyse Malawi's recent experience with the temporary reintroduction of user-fees for maternity services as a response to the suspension of donor funding, a shift in political leadership and priorities, and unstable service contracts between the government and its implementing partner, the Christian Health Association of Malawi. Based on ethnographic research conducted in 2015/16, the article describes the perceptions and experiences of policy implementation among various local actors (health workers, village heads and women). The way in which maternity services "fall apart" and are "fixed" is the result of dynamic interactions between policy and webs of accountability. Policies meet with a cascade of dynamic responses, which ultimately result in the exclusion of the most vulnerable rural women from maternity care services, against the aims of global and national safe motherhood policies.
Washington, D.C., Population Council, The Evidence Project, 2018 Mar. 8 p. (Case Study)Women of reproductive age in Cambodia, and many other developing countries, comprise a large part of factories’ workforce. Integrating family planning and reproductive health information and services into factories can improve workers’ health and help countries achieve FP2020 commitments. This case study looks at the process of how the Cambodian Ministry of Labor and Vocational Training launched, as formal policy, a set of workplace health infirmary guidelines for enterprises. What made this policy process unique for Cambodia – and what can be replicated by health advocates elsewhere – is that a group of organizations typically focused on public health policy successfully engaged on labor policy with a labor ministry. This case study describes the policy process, which was underpinned by the strategic use of evidence in decision-making and has been hailed by government, donors, civil society and industry as a success. The learnings presented in this case study should be useful to health advocates, labor advocates, and program designers.
Mapping evidence on decision-making on contraceptive use among adolescents: a scoping review protocol.
Systematic Reviews. 2018 Nov 20; 7(1):201.BACKGROUND: Contraceptive use among adolescents remains consistently low globally. Numerous studies have been done investigating factors that contribute to low contraceptive prevalence rates in this special population. It is particularly vital to understand decision-making processes that adolescents undergo when deciding whether or not to use contraceptives. Therefore, this scoping review seeks to map available evidence on decision-making processes in contraceptive use among adolescents. METHODS: We will conduct a scoping review to explore, describe and map literature on the adolescent decision-making regarding contraceptive use. The primary search will include peer-reviewed and review articles. Databases, including PubMed, MEDLINE with Full Text via EBSCOhost, PsychINFO via EBSCOhost, CINAHL with Full Text via EBSCOhost, Google Scholar, Science Direct and Scopus, will be searched for articles that meet the eligibility criteria. Keyword searches will be used, and for articles included after title screening, abstract and full articles will be screened by two independent reviewers with a third as a decider on any disputes. Content analysis will be used to present the narrative account of the reviews. DISCUSSION: Understanding how adolescents make decisions about whether or not to use contraception is essential for improving contraceptive prevalence rates in this special population. It is envisioned that the results from this review will highlight key evidence on how adolescent make decisions regarding contraceptive use as well as gaps and opportunities for future research. It will also be important in enhancing and re-focusing adolescent sexual and reproductive health policies and programmes.
Implementation of Fee-Free Maternal Health-Care Policy in Ghana: Perspectives of Users of Antenatal and Delivery Care Services From Public Health-Care Facilities in Accra.
International Quarterly of Community Health Education. 2018 Jul; 38(4):259-267.In 2008, the government of Ghana implemented a national user fee maternal care exemption policy through the National Health Insurance Scheme to improve financial access to maternal health services and reduce maternal as well as perinatal deaths. Although evidence shows that there has been some success with this initiative, there are still issues relating to cost of care to beneficiaries of the initiative. A qualitative study, comprising 12 focus group discussions and 6 interviews, was conducted with 90 women in six selected urban neighborhoods in Accra, Ghana, to examine users' perspectives regarding the implementation of this policy initiative. Findings showed that direct cost of delivery care services was entirely free, but costs related to antenatal care services and indirect costs related to delivery care still limit the use of hospital-based midwifery and obstetric care. There was also misunderstanding about the initiative due to misinformation created by the government through the media.We recommend that issues related to both direct and indirect costs of antenatal and delivery care provided in public health-care facilities must be addressed to eliminate some of the lingering barriers relating to cost hindering the smooth operation and sustainability of the maternal care fee exemption policy.
Geneva, Switzerland, World Health Organization [WHO], 2018. 116 p.The guideline uses state-of-the-art evidence to identify effective policy options to strengthen community health worker (CHW) programme performance through their proper integration in health systems and communities. The development of this guideline followed the standardized WHO approach. This entailed a critical analysis of the available evidence, including 16 systematic reviews of the evidence, a stakeholder perception survey to assess feasibility and acceptability of the policy options under consideration, and the deliberations of a Guideline Development Group which comprised representation from policy makers and planners from Member States, experts, labour unions, professional associations and CHWs. Critical to the success of these efforts will be ensuring appropriate labour conditions and opportunities for professional development, as well as creating a health ecosystem in which workers at different levels collaborate to meet health needs. Adapted to context, the guideline is a tool that supports optimizing health policies and systems to achieve significant gains to meet the ambition of universal access to primary health care services.
International Journal of Community Medicine and Public Health. 2018 Sep; 5(9):3860-3864.Background: The field of medicine has changed over the years owing to the constant scientific advances and research. From a time when spontaneous vaginal delivery used to be the norm, to now, where the rates of Caesarean deliveries seemed to be increasing, obstetric care has evolved considerable. Several healthcare initiatives and schemes have been framed for the betterment of the female reproductive health in recent times. It is important to understand both medical as well socio-cultural factors that have caused this increase in the caesarean births. This study was conducted keeping in mind this trend and to find out the level of awareness regarding patterns of deliveries that factors into this trend. Methods: Cross – sectional study was done in women residing in an urban slum of Ahmedabad in February 2014. 68 consenting female were randomly selected for the study from the slum of „Madi no Kuvo . Results: Majority of females (69%) were from age group 20-30 years. With a total number of 123 deliveries counted within the 68 female interviewed 67% were normal vaginal deliveries. 63% of surveyed women had deliveries at government hospital as civil hospital is nearby localities surveyed and cost incurrence was there in about half of deliveries while 27 % deliveries occurred at private hospitals. Conclusions: Majority of women would prefer to have normal delivery whenever it is possible. Majority of people were unaware about different government schemes to help females during pregnancy.
The implementation of the free maternal health policy in rural Northern Ghana: synthesised results and lessons learnt.
BMC Research Notes. 2018 May 29; 11(1):341.OBJECTIVE: A free maternal health policy was implemented under Ghana's National Health Insurance Scheme to promote the use of maternal health services. Under the policy, women are entitled to free services throughout pregnancy and at childbirth. A mixed methods study involving women, providers and insurance managers was carried out in the Kassena-Nankana municipality of Ghana. It explored the affordability, availability, acceptability and quality of services. In this manuscript, we present synthesised results categorised as facilitators and barriers to access as well as lessons learnt (implications). RESULTS: Reasonable waiting times, cleanliness of facilities as well as good interpersonal relationships with providers were the facilitators to access. Barriers included out of pocket payments, lack of, or inadequate supply of drugs and commodities, equipment, water, electricity and emergency transport. Four lessons (implications) were identified. Firstly, out of pocket payments persisted. Secondly, the health system was not strengthened before implementing the free maternal health policy. Thirdly, lower level facilities were poorly resourced. Finally, the lack of essential inputs and infrastructure affected quality of care and therefore, access to care. It is suggested that the Government of Ghana, the Health Insurance Scheme and other stakeholders improve the provision of resources to facilities.
International Journal of Health Governance. 2018; 23(3):226-232.Purpose: The purpose of this paper is to describe the challenges faced by health professionals in meeting Millennium Goal 5 and reducing maternal mortality in Uganda. Design/methodology/approach: Uganda is a low income land locked country with some major challenges around maternal health. There are many comprehensive and visionary plans produced by the Ugandan Government, however, there is a disconnect between policy and practice and there are many barriers to be addressed in order to reduce maternal mortality in Uganda. Findings: Despite making considerable progress in reducing maternal mortality, Millenium Development Goal (MDG) 5 was not achieved and every day 300 children and 20 mothers die in Uganda. Major barriers include lack of resources, both human and equipment, disparities in access to care, lack of clinical skills and knowledge and financial constraints. The Millennium goals are now behind us and focus has shifted to the sustainable development goals (SDGs). The Ugandan Government must focus on using these goals as part of developing the maternal and child health strategy by prioritising the human resource and health financial issues and continuing to work towards reducing maternal and perinatal mortality. Originality/value: This paper gives a succinct review of the progress of Uganda towards meeting the Millennium Goal 5 and makes key recommendations for addressing SDG 3. © 2018, Emerald Publishing Limited.
Strengthening maternal and child health in China: Lessons from transforming policy proposals into action.
Bioscience Trends. 2018 May 13; 12(2):211-214.China has made impressive achievements in improving maternal and child health (MCH) over the past few decades. This paper uses a policy lens to examine reasons for these achievements as well as barriers to further success. We found that strong governmental commitment and leadership, effective coordination, proactive participation of different stakeholders, and the provision of adequate resources were associated with China's success in improving MCH outcomes. Other low- and middle-income countries can learn valuable lessons from China's experience. These lessons include i) prioritizing MCH on the national development agenda, ii) keeping national ownership over health development cooperation, and iii) establishing effective monitoring, evaluation and accountability mechanisms for MCH programs.
Health and sustainable development; strengthening peri-operative care in low income countries to improve maternal and neonatal outcomes.
Reproductive Health. 2018 Oct 5; 15(1):168.BACKGROUND: Uganda is far from meeting the sustainable development goals on maternal and neonatal mortality with a maternal mortality ratio of 383/100,000 live births, and 33% of the women gave birth by 18 years. The neonatal mortality ratio was 29/1000 live births and 96 stillbirths occur every day due to placental abruption, and/or eclampsia - preeclampsia and other unkown causes. These deaths could be reduced with access to timely safe surgery and safe anaesthesia if the Comprehensive Emergency Obstetric and Newborn Care services (CEmONC), and appropriate intensive care post operatively were implemented. A 2013 multi-national survey by Epiu et al. showed that, the Safe Surgical Checklist was not available for use at main referral hospitals in East Africa. We, therefore, set out to further assess 64 government and private hospitals in Uganda for the availability and usage of the WHO Checklists, and investigate the post-operative care of paturients; to advocate for CEmONC implementation in similarly burdened low income countries. METHODS: The cross-sectional survey was conducted at 64 government and private hospitals in Uganda using preset questionnaires. RESULTS: We surveyed 41% of all hospitals in Uganda: 100% of the government regional referral hospitals, 16% of government district hospitals and 33% of all private hospitals. Only 22/64 (34.38%: 95% CI = 23.56-47.09) used the WHO Safe Surgical Checklist. Additionally, only 6% of the government hospitals and 14% not-for profit hospitals had access to Intensive Care Unit (ICU) services for postoperative care compared to 57% of the private hospitals. CONCLUSIONS: There is urgent need to make WHO checklists available and operationalized. Strengthening peri-operative care in obstetrics would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood working towards Universal Health Care.
The community is just a small circle: citizen participation in the free maternal and child healthcare programme of Enugu State, Nigeria.
Global Health Action. 2018; 11(1):1421002.BACKGROUND: There is a gap in knowledge about how citizen participation impacts governance of free healthcare policies for universal health coverage in low- and middle-income countries. OBJECTIVE: This study provides evidence about how social accountability initiatives influenced revenue generation, pooling and fund management, purchasing and capacity of health facilities implementing the free maternal and child healthcare programme (FMCHP) in Enugu State, Nigeria. METHODS: The study adopted a descriptive, qualitative case-study design to explore how social accountability influenced implementation of the FMCHP at the state level and in two health districts (Isi-Uzo and Enugu Metropolis) in Enugu State. Data were collected from policymakers (n = 16), providers (n = 16) and health facility committee leaders (n = 12) through in-depth interviews. We also conducted focus-group discussions (n = 4) with 42 service users and document review. Data were analysed using thematic analysis. RESULTS: It was found that health facility committees (HFCs) have not been involved in the generation of funds, fund management and tracking of spending in FMCHP. The HFCs did not also seem to have increased transparency of benefits and payment of providers. The HFCs emerged as the dominant social accountability initiative in FMCHP but lacked power in the governance of free health services. The HFCs were constrained by weak legal framework, ineffectual FMCHP committees at the state and district levels, restricted financial information disclosure, distrustful relationships with policymakers and providers, weak patient complaint system and low use of service charter. CONCLUSION: The HFCs have not played a significant role in health financing and service provision in FMCHP. The gaps in HFCs' participation in health financing functions and service delivery need to be considered in the design and implementation of free maternal and child healthcare policies that aim to achieve universal health coverage.
Lancet. 2017 Sep 2; 390(10098):925.Add to my documents.
Lancet. HIV. 2018 Apr; 5(4):e155.Add to my documents.
Ethiopian Journal of Health Sciences. 2017 Jul; 27(4):314.Add to my documents.
Global Journal of Health Sciences. 2018; 3(1):41-56.Purpose: The study sought to determine satisfaction levels of mothers regarding maternity services accorded to them. Methods: This was a cross sectional study conducted at Kabarnet County Hospital among women attending maternal child health clinic who had a birth within three years from the time of the study. A sample size of 379 was obtained using Cochran’s formula and systematic random sampling. Ethical approval was obtained from Kenyatta National Hospital/ University of Nairobi ethical review committee. Data was collected through structured questionnaires and analyzed using SPSS version 20. Chi square tests were done to determine associations between various variables in the study. Results are presented in form of tables, charts and percentage. Findings: Majority of participants had socio demographic factors which promote skilled assisted deliveries. Staff competency was noted to be the most satisfactory factor rated at 91.1% while insufficient materials and equipment was the most unsatisfactory by 30.2% cumulatively. Significant differences on the condition of mother and baby depending on delivery assistant was noted with Chi-Square test of 38.7 and 32.4, P value 0.029 and 0.020, respectively.
Commitments to the Every Woman Every Child Global Strategy for Women's Children's and Adolescents' Health (2016-2030): Commitments in support of adolescent and young adult health and well-being, 2015-2017.
Geneva, Switzerland, The Partnership for Maternal, Newborn & Child Health, 2018. 11 p.Health and well-being of adolescents and young adults is one of the priorities of the EWEC Global Strategy which calls for accelerated action to more effectively meet their health needs. Adolescent health is central to the EWEC Global Strategy and to achieving the Sustainable Development Goals (SDGs). This deep dive compliments the 2018 report by the Partnership for Maternal, Newborn & Child Health on commitments to the EWEC Global Strategy by analyzing commitments made in support of adolescents and young adults aged 10-24 years.
Lancet. HIV. 2017 Oct; 4(10):e423.Add to my documents.
Lancet. 2017 Sep 30; 390(10102):1618-1619.Add to my documents.
Lancet. Infectious Diseases. 2017 Jun; 17(6):589-590.Add to my documents.
Namibia has a strong foundation for implementing the Treat All guidelines and reaching the UNAIDS 90-90-90 targets.
Washington, D.C., Population Council, Project SOAR, 2018 Mar. 4 p. (Results Brief; USAID Agreement No. AID-OAA-A-14-00060)This brief highlights baseline data collected as part of a larger study assessing the impact of implementing the treat-all guidelines on key treatment and health system outcomes. The baseline data provide a snapshot of ART services delivered by health facilities in northern Namibia during the year prior to the rollout of the treat all guidelines. We also examine ART service outcomes, including 12-month ART patient retention, viral load (VL) testing, and viral suppression, to determine the effects of service decentralization during the year preceding the national roll-out of Namibia’s treat all recommendations.
Washington, D.C., Palladium, Health Policy Plus, 2018 Aug. 2 p. (HP+ Policy Brief; USAID Agreement No. AID-OAA-A-15-00051)Oral pre-exposure prophylaxis (PrEP) is the use of oral antiretroviral medications by HIV-negative individuals to prevent HIV acquisition. The Mozambican Ministry of Health has been assessing the feasibility of integrating oral PrEP into its national HIV strategic plan, PEN IV, since 2017. To support this, HP+ developed a new mathematical modeling approach to estimate the impact and cost-effectiveness of three rollout scenarios that simulate provision of oral PrEP to progressively broader subpopulations in Mozambique.
She knows that she will not come back: tracing patients and new thresholds of collective surveillance in PMTCT Option B.
BMC Health Services Research. 2018 Feb 1; 18(1):76.BACKGROUND: Malawi, Uganda, and Zimbabwe have recently adopted a universal 'test-and-treat' approach to the prevention of mother-to-child transmission of HIV (Option B+). Amongst a largely asymptomatic population of women tested for HIV and immediately started on antiretroviral treatment (ART), a relatively high number are not retained in care; they are labelled 'defaulters' or 'lost-to-follow-up' patients. METHODS: We draw on data collected as part of a study looking at ART decentralization (Lablite) to reflect on the spaces created through the instrumentalization of community health workers (CHWs) for the purpose of bringing women who default from Option B+ back into care. Data were collected through semi-structured interviews with CHWs who are designated to trace Option B+ patients in Uganda, Malawi and Zimbabwe. FINDINGS: Lost to follow up women give a range of reasons for not coming back to health facilities and often implicitly choose not to be traced by providing a false address at enrolment. New strategies have sought to utilize CHWs' liminal positionality - situated between the experience of living with HIV, having established local social ties, and being a caretaker - in order to track 'defaulters'. CHWs are often deployed without adequate guidance or training to protect confidentiality and respect patients' choice. CONCLUSIONS: CHWs provide essential linkages between health services and patients; they embody the role of 'extension workers', a bridge between a novel health policy and 'non-compliant patients'. Option B+ offers a powerful narrative of the construction of a unilateral 'moral economy', which requires the full compliance of patients newly initiated on treatment.
Vaccine. 2017 Apr 25; 35(18):2288-2290.Add to my documents.
Examining the Implementation of the Free Maternity Services Policy in Kenya: A Mixed Methods Process Evaluation.
International Journal of Health Policy and Management. 2017 Nov 25; 7(7):603-613.BACKGROUND: Kenya introduced a free maternity policy in 2013 to address the cost barrier associated with accessing maternal health services. We carried out a mixed methods process evaluation of the policy to examine the extent to which the policy had been implemented according to design, and positive experiences and challenges encountered during implementation. METHODS: We conducted a mixed methods study in 3 purposely selected counties in Kenya. Data were collected through in-depth interviews (IDIs) with policy-makers at the national level, health managers at the county level, and frontline staff at the health facility level (n=60), focus group discussions (FGDs) with community representatives (n=10), facility records, and document reviews. We analysed the data using a framework approach. RESULTS: Rapid implementation led to inadequate stakeholder engagement and confusion about the policy. While the policy was meant to cover antenatal visits, deliveries, and post-natal visits, in practice the policy only covered deliveries. While the policy led to a rapid increase in facility deliveries, this was not matched by an increase in health facility capacity and hence compromised quality of care. The policy led to an improvement in the level of revenues for facilities. However, in all three counties, reimbursements were not made on time. The policy did not have a system of verifying health facility reports on utilization of services. CONCLUSION: The Kenyan Ministry of Health (MoH) should develop a formal policy on the free maternity services, and provide clear guidelines on its content and implementation arrangements, engage with and effectively communicate the policy to stakeholders, ensure timeliness of payment disbursement to healthcare facilities, and introduce a mechanism for verifying utilization reports prepared by healthcare providers. User fee removal policies such as free maternity programmes should be accompanied by supply side capacity strengthening. (c) 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.