Integrated management of neonatal and childhood illness strategy in Zimbabwe: An evaluation

More than five million children under the age of five die each year worldwide, primarily from preventable and treatable causes. In response, the World Health Organization’s Integrated Management of Childhood Illnesses (IMNCI) strategy has been adopted in more than 95 low- and middle-income countries, 41 of them from Africa. Despite IMNCI’s widespread implementation, evidence on its impact on child mortality and institutional deliveries is limited. This study examined the effect of IMNCI strategy in the context of Zimbabwe, where neonatal and infant mortality rates are among the highest in the world. We used binary logistic regression to analyze cross-sectional data from the 2015 Zimbabwe Demographic and Health Survey. Zimbabwe implemented the IMNCI strategy in 2012. Our empirical strategy involved comparing neonatal and infant mortality and institutional deliveries within the same geographic area before and after IMNCI implementation in a nationally representative sample of children born between 2010 and 2015. Exposure to IMNCI was significantly associated with a reduction in neonatal mortality (adjusted odds ratio (95% CI): 0.70 (0.50, 0.98)) and infant mortality (adjusted odds ratio (95% CI): 0.69 (0.54, 0.91)). The strategy also helped increase institutional deliveries significantly (adjusted odds ratio (95% CI): 1.95 (1.67, 2.28)). Further analyses revealed that these associations were concentrated among educated women and in rural areas.The IMNCI strategy in Zimbabwe seems to be successful in delivering its intended goals. Future programmatic and policy efforts should target women with low education and those residing in urban areas. Furthermore, sustaining the positive impact and achieving the child health-related Sustainable Development Goals will require continued political will in raising domestic financial investments to ensure the sustainability of maternal and child health programs.

An analysis of preferences and practices related to the mode of delivery in Agra district of Uttar Pradesh

Background: Preferences and actual practices in regard to delivery of pregnant women have wide variations. This study is an attempt to explore some of the socio-demographic factors responsible for preferences and practices in regard to mode of delivery among institutional deliveries in Agra district.Methods: This community based descriptive observational study was conducted among 300 eligible women of Agra district who were selected through multistage random sampling. Both bivariate and multivariate analysis was done and appropriate statistical tests were used.Results: The study found that out of 300 subjects; 272 had institutional deliveries among which 265 (97.43%) had a preference for vaginal delivery (VD) while only 7 (2.57%) had a preference for caesarean section (CS) but in actuality, 223 (81.99%) were delivered through vaginal mode while 49 (18.01%) had CS. On multiple logistic regression analysis, mode of delivery in previous pregnancy was found to have a significant association with the preference of a woman in regard to her mode of delivery with odds ratio of 9.88 (95% CI 1.46-66.80) and p=0.019.Conclusions: Preferences in regard to mode of delivery of a woman was only associated with her mode of delivery in previous pregnancy but her actual practice was also significantly associated with her place of delivery in addition to her mode of delivery in previous pregnancy.

Rates and indications of caesarean section deliveries in Bhutan 2015–2019: a national review

Background Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan. Methods This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015–2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital. Results For the period 2015–2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were ‘past caesarean section’ (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%). Conclusion Bhutan’s caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan’s efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections.

Decentralized facility financing versus performance-based payments in primary health care: a large-scale randomized controlled trial in Nigeria

Background Health system financing presents a challenge in many developing countries. We assessed two reform packages, performance-based financing (PBF) and direct facility financing (DFF), against each other and business-as-usual for maternal and child healthcare (MCH) provision in Nigeria. Methods We sampled 571 facilities (269 in PBF; 302 in DFF) in 52 districts randomly assigned to PBF or DFF, and 215 facilities in 25 observable-matched control districts. PBF facilities received $2 ($1 for operating grants plus $1 for bonuses) for every $1 received by DFF facilities (operating grants alone). Both received autonomy, supervision, and enhanced community engagement, isolating the impact of additional performance-linked facility and health worker payments. Facilities and households with recent pregnancies in facility catchments were surveyed at baseline (2014) and endline (2017). Outcomes were Penta3 immunization, institutional deliveries, modern contraceptive prevalence rate (mCPR), four-plus antenatal care (ANC) visits, insecticide-treated mosquito net (ITN) use by under-fives, and directly observed quality of care (QOC). We estimated difference-in-differences with state fixed effects and clustered standard errors. Results PBF increased institutional deliveries by 10% points over DFF and 7% over business-as-usual (p<0.01). PBF and DFF were more effective than business-as-usual for Penta3 (p<0.05 and p<0.01, respectively); PBF also for mCPR (p<0.05). Twenty-one of 26 QOC indicators improved in both PBF and DFF relative to business-as-usual (p<0.05). However, except for deliveries, PBF was as or less effective than DFF: Penta3 immunization and ITN use were each 6% less than DFF (p<0.1 for both) and QOC gains were also comparable. Utilization gains come from the middle of the rural wealth distribution (p<0.05). Conclusions Our findings show that both PBF and DFF represent significant improvements over business-as-usual for service provision and quality of care. However, except for institutional delivery, PBF and DFF do not differ from each other despite PBF disbursing $2 for every dollar disbursed by DFF. These findings highlight the importance of direct facility financing and decentralization in improving PHC and suggest potential complementarities between the two approaches in strengthening MCH service delivery. Trial registration ClinicalTrials.gov NCT03890653; May 8, 2017. Retrospectively registered.

A case of intrauterine fetal demise with cord prolapse

A case of intrauterine fetal demise with cord prolapse, presenting to the labour room in active labour. Labour was uneventful; however, it reminds of importance of institutional deliveries, alert midwives, and importance of dedicated obstetric operation theatres and teams to prevent adverse maternal and neonatal outcome.

The long-term effects of free care on birth outcomes: Evidence from a national policy reform in Zambia

As women in many countries still fail to give birth in facilities due to financial barriers, many see the abolition of user fees as a key step on the path towards universal coverage. We exploited the staggered removal of user charges in Zambia from 2006 to estimate the effect of user fee removal over up to five years after the policy change. We used data from the birth histories of two nationally representative Demographic and Health Surveys to implement a difference-in-differences analysis and identify the causal impact of removing user charges on institutional and assisted deliveries, caesarean sections and neonatal deaths. We also used the rich survey data to explore heterogeneous effects of the policy. Removing fees had little effect in the short term but large positive effects appeared about two years after the policy change. Institutional deliveries in treated areas increased by 25 to 35%, driven entirely by a reduction in home births. However, there was no evidence that the reform changed the behaviours of women with lower education, the proportion of caesarean sections or reduced neonatal mortality. Institutional deliveries increased where care quality was high, but not where it was low. While abolishing user charges may reduce financial hardship from healthcare payments, it does not necessarily improve equitable access to care or health outcomes. Shifting away from user fees is a necessary but insufficient step towards universal health coverage, and concurrent reforms are needed to target vulnerable populations and improve quality of care.

Sequential impact of components of maternal and child health care services on the continuum of care in India

This paper examines the sequential impact of components of maternal and child health care on the continuum of care in India using data from the Indian National Family Health Surveys conducted in 2005–06 and 2015–16. Continuum of care (CoC) for maternal and child health is defined in this paper as the sequential uptake of three key maternal services (antenatal care, institutional delivery and postnatal care for the mother). Women who received all three services were classified as full CoC recipients. Characteristics odd ratios for achieving CoC were estimated by mother’s place of residence, household wealth status, mother’s education, birth order and child full vaccination. Odds ratios were computed to understand the relative impact of each preceding service utilization on the odds of subsequent service uptake. At national level, 30.5% and 55.5% of women achieved full CoC in 2005–06 and 2015–16, respectively, and the overall progress of CoC over the 10-year period was 25.5 percentage points, with significant variation across states and socioeconomic groups. Full CoC improved from 7.5% to 32.4% among the poorest women, whereas among the richest women it improved from 70.5% to 75.1%. Similarly, among uneducated women full CoC improved from 11.7% to 35.9% as against 75.1% to 80.5% among educated mothers over the same period. Furthermore, greater CoC was observed among parity one women. The conditionality between various components of CoC indicated that at national level the odds of having an institutional delivery with antenatal care were 9 times higher in the earlier period as against 4.5 times higher in the more recent period. Furthermore, women who had institutional deliveries complied more with mother’s postnatal care compared with women who did not have institutional deliveries. This again helps increase the likelihood of a child receiving full vaccination.

Effects of Direct Healthcare Financing on Strategic Health Indicators in Rural Health Facilities of Chikankata District of Zambia: 2014 –2018

Healthcare financing is the process of utilizing financial inputs necessary for health interventions. Health facilities do not routinely access the monthly government grant due to challenges in the access and utilization process. It is unclear if the lack of grant receipt affects strategic health indicators and thus access quality healthcare provision in rural Zambia. This study aimed at investigating the effect of funding access on health facility performance. The study analyzed data for 15 health facilities in Chikankata district from 2014 to 2018. Data was collected from the health management information system and analyzed against accounting records to determine if facilities performed better in antenatal care, Immunization and Institutional deliveries when they received their monthly grants. Grant receipt had a statistically significant (p=0.04) association with performance in maternal and child health indicators, measured by a mean composite score OR 1.46, 95% CI [1.03, 2.08]. The association between grant receipt and indicator performance was most significant on institutional deliveries OR 1.75, 95% [1.13, 2.73]. Grant receipt by the facilities was associated with an improvement in maternal and child health indicators. This demonstrates the need for effective healthcare financing mechanisms that consider the monthly grant in improving performance by facilities. Performance Based Financing mechanisms should however be combined with direct financing mechanisms to holistically improve primary healthcare. The implications of these findings are that as much as practical, funding disbursement modalities must ensure that all health facilities receive some funding

Janani Suraksha Yojana

Health of the mothers is of prime concern for growth of any country, and their level of empowerment can be significantly related to the place of delivery selected for birth of a child. Janani Suraksha Yojana (JSY) is an astute attempt towards safeguarding maternal health by Government of India under the flagship health programme, National Rural Health Mission, to promote institutional deliveries among the poor pregnant women. Safe deliveries at the institutions are an indicator of women empowerment and inclusive growth, which paves the way towards economic growth by securing the health and well-being of mothers in rural areas, thereby sustaining productive capacities of women. The chapter assesses the rise in proportion of institutional deliveries among JSY beneficiaries with increased awareness under JSY in Punjab, after carefully assessing the situation of maternal health prevailing in the world, India, and state of Punjab. Further, policy measures have been recommended to augment women's health and empowerment, an inclusive economic growth parameter of country's growth trajectory.