Utilization of Maternal Health Care Among Immigrant Mothers in New York City, 2016–2018

Immigrant women represent half of New York City (NYC) births, and some immigrant groups have elevated risk for poor maternal health outcomes. Disparities in health care utilization across the maternity care spectrum may contribute to differential maternal health outcomes. Data on immigrant maternal health utilization are under-explored in the literature. We conducted a cross-sectional analysis of the population-based NYC Pregnancy Risk Assessment Monitoring System survey, using 2016–2018 data linked to birth certificate variables, to explore self-reported utilization of preconception, prenatal, and postpartum health care and potential explanatory pathways. We stratified results by maternal nativity and, for immigrants, by years living in the US; geographic region of origin; and country of origin income grouping. Among immigrant women, 43% did not visit a health care provider in the year before pregnancy, compared to 27% of US-born women (risk difference [RD] = 0.16, 95% CI [0.13, 0.20]), 64% had no dental cleaning during pregnancy compared to 49% of US-born women (RD = 0.15, 95% CI [0.11, 0.18]), and 11% lost health insurance postpartum compared to 1% of US-born women (RD = 0.10, 95% CI [0.08, 0.11]). The largest disparities were among recent arrivals to the US and immigrants from countries in Central America, South America, South Asia, and sub-Saharan Africa. Utilization differences were partially explained by insurance type, paternal nativity, maternal education, and race and ethnicity. Disparities may be reduced by collaborating with community-based organizations in immigrant communities on strategies to improve utilization and by expanding health care access and eligibility for public health insurance coverage before and after pregnancy.

Access to Facility-Based Childbirth: Women’s Experience on Enablers and Obstacles to the Utilisation of Waiting Mothers’ Shelters in Rural Zimbabwe

This article explores experiences and perceptions of women concerning the utilising a waiting mothers’ shelter at Bonda Mission Hospital in the Manicaland province of Zimbabwe. It draws on a phenomenological qualitative research design. This incorporated in-depth interviews and key informant interviews with purposively selected fifteen women who have used the waiting mothers’ shelter since 2015 and eight healthcare practitioners respectively. The paper is guided by Alfred Schutz’s (1972) social phenomenology. While the findings reveal that most women acknowledged the importance of waiting mothers’ shelters in improving access to skilled birth attendance and maternal health outcomes, there are still factors that militate the use of such innovations. Several socio-cultural and economic factors such as constrained decision making among women, mistreatment and lack of privacy in the shelters are some of the deterrent factors. The article concludes that, although waiting mothers’ shelters are facilities proven to be beneficial in rural communities, they continually face the risk of not being used. There is a need for a multi-stakeholder approach to address the barriers that deter women from utilising the waiting mothers’ shelters and improve access to facility-based delivery, access to skilled birth attendants and enhance the maternal health outcomes in rural communities in Zimbabwe.

686Evaluation of the impact of National Health Mission on maternal health outcomes

Background The National Health Mission (NHM) was launched in 2005 by the Government of India. As NHM has completed about 15 years (2005-2020), there is a need to review the impact of NHM on health measures. Methods Logic model (input-process-output-outcome-impact) was used to measure the impact of National Health Mission on maternal health outcomes in India. We studied the impact of NHM by comparing the proportion of women who had first-trimester registration, institutional delivery, postnatal check-ups before NHM (NFHS- 3 data) and after NHM (NFHS-4 data) among those who had a delivery in the last five years preceding the date of the survey after adjusting for sociodemographic factors, road density, telephone density and health worker density. Results The Health worker density increased from 32.67 to 50.29 per 10000 population in post NHM period as compared to pre NHM period. Beds per 10,000 population increased from 4.43 in 2005 to 5.96 in 2015. There was a significant increase in the proportion of first-trimester registration from 57.3% to 67.4%, in institutional delivery rate from 41.6% to 87.7% and postnatal check-ups from 42.4% to 72.3% from the year, 2005 to 2015. The Maternal mortality ratio declined from 250 to 130 per lakh childbirths between 2005 and 2015. Conclusions NHM has led to an improvement in maternal health-related outcomes in the country. Key messages The learnings from NHM can be utilized to improve further the outcomes for achieving Universal Health Coverage (UHC) by 2030.

Women’s Empowerment and Community Norms Association on Women’s Access to Health Facility Delivery in Ethiopia. A Multilevel Analysis.

Background Health-care facility delivery was the most critical in ensuring the provision of high-quality care and a distribution location that was ready in the case of an emergency for reproductive women. However, maternal mortality remains high in African nations, and the majority of women were still giving birth at home. This study was aimed to determine whether women's empowerment and community norms, plus other proximate factors, are related to the health facility delivery utilization of women in Ethiopia. Methods The data for this study was taken from the Performance Monitoring for Action (PMA) in Ethiopia of the 2019 cross-sectional survey. A weighted sample of 4864 women with at least one birth history, clustered within 264 clusters was used for this study. The impact of women's empowerment, cultural norms, and other proximate factors on the use of health facility deliveries among reproductive-age women across clusters in Ethiopia was studied using a two-level multilevel logistic regression. Results In Ethiopia, around 51 % of women were delivered their most recent child at the health facility. The use of a health facility delivery was more common among empowered women and those living in where the most people encourage a health facility delivery. Older women were less likely to deliver at a health facility and women from the highest wealth quantile more likely to have a facility delivery. Those women with higher education and living in an urban area were more likely to have a health facility delivery. Women’s chances of giving birth in health facilities vary significantly across the 264 clusters of Ethiopia ( σ_uo^2 =2.49,p.value<0.001). Conclusions This study emphasizes the importance of women's empowerment and cultural norms in enhancing maternal health outcomes of women in Ethiopia. It is more important than ever that the government and development agency should invest more in women's empowerment and raising community consciousness about the benefits of using health facility delivery as part of a strategic intervention to improve maternal health outcomes.

Maternal Mortality Litigation Review

Obstetrics and gynecology is considered one of the most litigious medical specialties; medical negligence and malpractice lawsuits are frequently filed to seek damages for improper medical care during childbirth. In fact, several studies have shown that a much greater percentage of maternal injury claims result in settlements or judgments as compared to other specialties. A considerable number of these claims can be linked to postpartum hemorrhage, or excessive bleeding following vaginal birth or cesarean delivery. This study aims to identify cases where postpartum hemorrhage contributed to maternal morbidity or mortality and led to a lawsuit. A review of litigation surrounding this topic was conducted using the Nexis Uni database from January 2011 to December 2020. Inclusion criteria consisted of maternal mortality cases due to postpartum hemorrhage, which discussed legal causes like medical negligence or obstetric violence. Evaluation of the litigation search results demonstrated various elements most associated with postpartum hemorrhage-related maternal injury litigation. Understanding challenges which arise most frequently in postnatal care settings will be useful in improving maternal health outcomes.

Pro-poor policies and improvements in maternal health outcomes in India

Background Since 2005, India has experienced an impressive 77% reduction in maternal mortality compared to the global average of 43%. What explains this impressive performance in terms of reduction in maternal mortality and improvement in maternal health outcomes? This paper evaluates the effect of household wealth status on maternal mortality in India, and also separates out the performance of the Empowered Action Group (EAG) states and the Southern states of India. The results are discussed in the light of various pro-poor programmes and policies designed to reduce maternal mortality and the existing supply side gaps in the healthcare system of India. Using multiple sources of data, this study aims to understand the trends in maternal mortality (1997–2017) between EAG and non EAG states in India and explore various household, economic and policy factors that may explain reduction in maternal mortality and improvement in maternal health outcomes in India. Methods This study triangulates data from different rounds of Sample Registration Systems to assess the trend in maternal mortality in India. It further analysed the National Family Health Surveys (NFHS). NFHS-4, 2015–16 has gathered information on maternal mortality and pregnancy-related deaths from 601,509 households. Using logistic regression, we estimate the association of various socio-economic variables on maternal deaths in the various states of India. Results On an average, wealth status of the households did not have a statistically significant association with maternal mortality in India. However, our disaggregate analysis reveals, the gains in terms of maternal mortality have been unevenly distributed. Although the rich-poor gap in maternal mortality has reduced in EAG states such as Bihar, Odisha, Assam, Rajasthan, the maternal mortality has remained above the national average for many of these states. The EAG states also experience supply side shortfalls in terms of availability of PHC and PHC doctors; and availability of specialist doctors. Conclusions The novel contribution of the present paper is that the association of household wealth status and place of residence with maternal mortality is statistically not significant implying financial barriers to access maternal health services have been minimised. This result, and India’s impressive performance with respect to maternal health outcomes, can be attributed to the various pro-poor policies and cash incentive schemes successfully launched in recent years. Community-level involvement with pivotal role played by community health workers has been one of the major reasons for the success of many ongoing policies. Policy makers need to prioritise the underperforming states and socio-economic groups within the states by addressing both demand-side and supply-side measures simultaneously mediated by contextual factors.