Horizontal inequity in the utilisation of Continuum of Maternal Health care Services (CMHS) in India: an investigation of ten years of National Rural Health Mission (NRHM)

Background Continuum of Maternal Health Care Services (CMHS) has garnered attention in recent times and reducing socio-economic disparity and geographical variations in its utilisation becomes crucial from an egalitarian perspective. In this study, we estimate inequity in the utilisation of CMHS in India between 2005 and 06 and 2015-16. Methods We used two rounds of National Family Health Survey (NFHS) - 2005-06 and 2015-16 encompassing a sample size of 34,560 and 178,857 pregnant women respectively. The magnitude of horizontal inequities (HI) in the utilisation of CMHS was captured by adopting the Erreygers Corrected Concentration indices method. Need-based standardisation was conducted to disentangle the variations in the utilisation of CMHS across different wealth quintiles and state groups. Further, a decomposition analysis was undertaken to enumerate the contribution of legitimate and illegitimate factors towards health inequity. Results The study indicates that the pro-rich inequity in the utilisation of CMHS has increased by around 2 percentage points since the implementation of National Rural Health Mission (NRHM), where illegitimate factors are dominant. Decomposition analysis reveals that the contribution of access related barriers plummeted in the considered period of time. The results also indicate that mother’s education and access to media continue to remain major contributors of pro-rich inequity in India. Considering, regional variations, it is found that the percentage of pro-rich inequity in high focus group states increased by around 3% between 2005 and 06 and 2015-16. The performance of southern states of India is commendable. Conclusions Our study concludes that there exists a pro-rich inequity in the utilisation of CMHS with marked variations across state boundaries. The pro-rich inequity in India has increased between 2005 and 06 and high focus group states suffered predominantly. Decentralisation of healthcare policies and granting greater power to the states might lead to equitable distribution of CMHS.

Acceptability and User Experiences of a Patient-Held Smart Card for Antenatal Services in Nigeria: A Qualitative Study

Background Poor maternal, newborn and child health outcomes remain a major public health challenge in Nigeria. Mobile health (mHealth) interventions such as patient-held smart cards have been proposed as effective solutions to improve maternal health outcomes. Our objectives were to assess the acceptability and experiences of pregnant women with the use of a patient-held smartcard for antenatal services in Nigeria. Methods Using focus group discussions, qualitative data were obtained from 35 pregnant women attending antenatal services in four Local Government Areas (LGAs) in Benue State, Nigeria. The audio-recorded data were transcribed and analyzed using framework analysis techniques such as the PEN-3 cultural model as a guide. Results The participants were 18-44 years of age (median age: 24 years), all were married and the majority were farmers. Most of the participants had accepted and used the smartcards for antenatal services. The most common positive perceptions about the smartcards were their ability to be used across multiple health facilities, the preference for storage of the women’s medical information on the smartcards compared to the usual paper-based system, and shorter waiting times at the clinics. Notable facilitators to using the smartcards were its provision at the “Baby showers” which were already acceptable to the women, access to free medical screenings, and ease of storage and retrieval of health records from the cards. Costs associated with health services was reported as a major barrier to using the smartcards. Support from health workers, program staff and family members, particularly spouses, encouraged the participants to use the smartcards. Conclusion These findings revealed that patient-held smart card for maternal health care services is acceptable by women utilizing antenatal services in Nigeria. Understanding perceptions, barriers, facilitators, and supportive systems that enhance the use of these smart cards may facilitate the development of lifesaving mobile health platforms that have the potential to achieve antenatal, delivery, and postnatal targets in a resource-limited setting.

Factors influencing the motivation of maternal health workers in conflict setting of Mogadishu, Somalia.

Background: Motivated health workers play an important role in delivering high-quality maternal health services, especially in low-income countries where maternal mortality rates are high, and shortages of human resource for health is prevalent. The aim of this study is to investigate the motivation of maternal health workers in three tertiary hospitals in Mogadishu Somalia. Method: To investigate health worker motivation in Somalia, we used a semi-structured questionnaire that was validated and widely used in Sub-Saharan Africa. Data were collected from 220 health workers across three tertiary hospitals in Mogadishu between February and April 2020. Health worker motivation was measured using seven constructs: general motivation, burnout, job satisfaction, intrinsic job satisfaction, organizational commitment, conscientiousness, timeliness and attendance. A multivariate regression analysis was performed to determine the predictors of health worker motivation. Results: The study found that male health workers have a higher work motivation, with a mean score of 92.75 (SD 21.31) versus 90.43 (SD 21.61) in women. A significant correlation was found between health workers motivation and being an assistant, nurse, physician, pediatric-assistant, midwife, supervisor and pharmacist. Unexpectedly, the gynecologists and midwives were the least motivated groups among the different professions, with mean scores of 83.63, (SD: 27.41) and 86.95 (SD: 21.08), respectively. Of the aforementioned seven motivation constructs, the highest mean motivation scores (from 1-5) were observed in conscientiousness and intrinsic job satisfaction. Conclusion: The results highlight the importance of targeted interventions that increase the motivation of female health workers, particularly gynecologists and midwives in Somalia. This can be done by providing non-financial incentives, in addition to encouraging their participation in the decision-making process. Further research is needed to investigate the effect of a lack of motivation among gynecologists and midwives on maternal health in Somalia.

Appearance of “Mental Hygiene” in Japan's Theory of Prenatal Care at the Beginning of the 20th Century- The Fusion of Public Hygiene and Eugenics: A Book Review

The Motherhood Protection Act (1996), which corresponds to modern family health in Japan, was enacted based on the Eugenics Protection Law (1948) for the protection of national eugenics. This leads us to the question of how maternal health and eugenics began to merge in Japan. Answer of this will elucidate the characteristics of family health in Japan and historical background. Maternal health and eugenics began to be fused in Japan in the early 20th century. In this paper, we examined Taikyō, which is the source of this fusion. This book was widely disseminated to the public. An educational book influenced the Japanese women’s movement. Taikyō argued that from the standpoint of public health, responsibility for prenatal care should be extended to the husband, family, society and the nation. It emphasized that “mental hygiene” is necessary to produce a genetically good child, and that spouse selection is important. Books on prenatal care published in the first half of the 20th century, following Taikyō’s description of prenatal care as a form of eugenics. The National Eugenic Act enacted to protect national hygiene inspired the classification of the Japanese as ​​a chosen nation. The theory of prenatal care, which was created from the combination of public hygiene and eugenics, provided a justification for the National Eugenic Act, and this still serves as the basis for the Eugenics Protection Law and Motherhood Protection Act. It provides the “scientific basis” for recognizing that “unsanitary” and “disability” are bad.

Effect of checklist based box system interventions on improving institutional delivery among reproductive age women in Northwest Ethiopia: generalized structural equation modeling

Background Previous studies have shown that there is low utilization of institutional delivery in Ethiopia, as well as various factors contributing to this low utilization. Notably, there is paucity around interventions to improve institutional delivery. Hence, this study examines the effectiveness of checklist-based box system intervention on improving institutional delivery and to investigate the association through which the intervention is linked to institutional delivery. Method The study used data from a larger trial, on the effectiveness of checklist-based box system intervention on improving maternal health service utilization. In the intervention arm, mothers received regular community-level pregnancy screening and referral, service utilization monitoring boxes, drop-out tracing mechanisms, regular communication between health centers and health posts, and person-centered health education for mothers. This study used the existing government-led maternal health program as a control arm. A total of 1062 mothers who gave birth one-year before the survey were included in the final analysis. A difference-in-difference estimator was used to test the effectiveness of the intervention. Generalized structural equation modeling was used to examine the direct and/ indirect associations between the intervention and institutional delivery. Result Among participants, 403 (79.5%) mothers from intervention and 323 (58.2%) mothers from control clusters gave birth at health facilities. The result of the study revealed a 19% increase in institutional delivery in the intervention arm (19, 95%CI: 11.4-27.3%). In this study the pathway from checklist-based box system intervention to institutional delivery was mainly direct - (AOR = 3.32, 95%CI: 2.36-4.66), however, 33% of the effect was partially mediated by attendance of antenatal care four visits (AOR = 1.39, 95%CI: 1.02-1.92). The influence of significant others (AOR = 0.25, 95%CI: 0.15-0.43) and age (AOR = 0.03, 95%CI: 0.01- 0.09) had an inverse relation with institutional delivery. Conclusion The implementation of a checklist-based box system significantly increased institutional delivery utilization, both directly and indirectly by improving antenatal care four attendance. A larger-scale implementation of the intervention was recommended, taking the continuum of care approach into account. Trial registration ClinicalTrials.gov, NCT03891030, Retrospectively registered on 26 March, 2019.