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Background Despite the progress in the Millennium Development Goals (MDGs) 4 and 5, inequity in the utilization of maternal, newborn and child health (MNCH) care services still remain high in sub-Saharan Africa (SSA). The continuum of care for MNCH that recognizes a tight inter-relationship between maternal, newborn and child health at different time periods and location is key towards reducing inequity in health. In this study, we explored the distributions in the utilization MNCH services in 12 SSA countries and further investigated the associations in the continuum of care for MNCH. Methods Using Demographic and Health Surveys data of 12 countries in SSA, structural equation modeling approach was employed to analyze the complex relationships in continuum of care for MNCH model. The Full Information Maximum Likelihood estimation procedure which account for the Missing at Random (MAR) and Missing Completely at Random (MCAR) assumptions was adopted in LISREL 8.80. The distribution of MNCH care utilization was presented before the estimated association in the continuum of care for MNCH model. Results Some countries have a consistently low (Mali, Nigeria, DR Congo and Rwanda) or high (Namibia, Senegal, Gambia and Liberia) utilization in at least two levels of MNCH care. The path relationships in the continuum of care for MNCH from ‘adequate antenatal care’ to ‘adequate delivery care’ (0.32) and to ‘adequate child’s immunization’ (0.36); from ‘adequate delivery care’ to ‘adequate postnatal care’ (0.78) and to ‘adequate child’s immunization’ (0.15) were positively associated and statistically significant at p  < 0.001. Only the path relationship from ‘adequate postnatal care’ to ‘adequate child’s immunization’ (−0.02) was negatively associated and significant at p  < 0.001. Conclusions In conclusion, utilization of each level of MNCH care is related to the next level of care, that is – antenatal care is associated with delivery care which is then associated with postnatal and subsequently with child’s immunization program. At the national level, identification of communities which are greatly contributing to overall disparity in health and a well laid out follow-up mechanism from pregnancy through to child’s immunization program could serve towards improving maternal and infant health outcomes and equity.

Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed. We assessed the effect of performance-based payment of health-care providers (payment for performance; P4P) on use and quality of child and maternal care services in health-care facilities in Rwanda. 166 facilities were randomly assigned at the district level either to begin P4P funding between June, 2006, and October, 2006 (intervention group; n=80), or to continue with the traditional input-based funding until 23 months after study baseline (control group; n=86). Randomisation was done by coin toss. We surveyed facilities and 2158 households at baseline and after 23 months. The main outcome measures were prenatal care visits and institutional deliveries, quality of prenatal care, and child preventive care visits and immunisation. We isolated the incentive effect from the resource effect by increasing comparison facilities' input-based budgets by the average P4P payments made to the treatment facilities. We estimated a multivariate regression specification of the difference-in-difference model in which an individual's outcome is regressed against a dummy variable, indicating whether the facility received P4P that year, a facility-fixed effect, a year indicator, and a series of individual and household characteristics. Our model estimated that facilities in the intervention group had a 23% increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger (56%) and aged between 24 months and 59 months (132%). No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules. We also estimate an increase of 0·157 standard deviations (95% CI 0·026–0·289) in prenatal quality as measured by compliance with Rwandan prenatal care clinical practice guidelines. The P4P scheme in Rwanda had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider. P4P financial performance incentives can improve both the use and quality of maternal and child health services, and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health. World Bank's Bank-Netherlands Partnership Program and Spanish Impact Evaluation Fund, the British Economic and Social Research Council, Government of Rwanda, and Global Development Network.

Although the number of direct Ebola-related deaths from the 2013 to 2016 West African Ebola outbreak has been quantified, the number of indirect deaths, resulting from decreased utilization of routine health services, remains unknown. Such information is a key ingredient of health system resilience, essential for adequate allocation of resources to both ‘crisis response activities’ and ‘core functions’. Taking stock of indirect deaths may also help the concept of health system resilience achieve political traction over the traditional approach of disease-specific surveillance. This study responds to these imperatives by quantifying the extent of the drop in utilization of essential reproductive, maternal and neonatal health services in Sierra Leone during the Ebola outbreak by using interrupted time-series regression to analyse Health Management Information System (HMIS) data. Using the Lives Saved Tool, we then model the implication of this decrease in utilization in terms of excess maternal and neonatal deaths, as well as stillbirths. We find that antenatal care coverage suffered from the largest decrease in coverage as a result of the Ebola epidemic, with an estimated 22 percentage point (p.p.) decrease in population coverage compared with the most conservative counterfactual scenario. Use of family planning, facility delivery and post-natal care services also decreased but to a lesser extent (-6, -8 and -13 p.p. respectively). This decrease in utilization of life-saving health services translates to 3600 additional maternal, neonatal and stillbirth deaths in the year 2014–15 under the most conservative scenario. In other words, we estimate that the indirect mortality effects of a crisis in the context of a health system lacking resilience may be as important as the direct mortality effects of the crisis itself.

Background: This paper explores the multilevel factors associated with maternal health utilization in India's most populous state, Uttar Pradesh. 3 key utilization practices: registration of pregnancy, receipt of antenatal care, and delivery at home are examined for district and individual level predictors. The data is based on 5666 household surveys conducted as part of a baseline evaluation of the Uttar Pradesh Technical Support Unit (UPTSU.) program. Objectives: This intervention aims to assist the Government of Uttar Pradesh in increasing the efficiency, effectiveness, and equity of service delivery across a continuum of reproductive, maternal, new-born, child, and adolescent health (RMNCH+A) outcomes. Methods: The paper employs multilevel models that control for individuals being nested within districts in order to understand the predictors of maternal health care utilization. Results: The study identifies several individual-level predictors of health care utilization, including: literacy of the woman, the husband's schooling, age at marriage, and socio-economic factors. Key predictors of pregnancy registration include husband's schooling (OR 1.49, 95% CI 1.26-1.76), having a bank account (OR 1.36, 95% CI 1.11-1.68), and owning a house (OR 2.28, 95% CI 1.85-2.80). Factors affecting antenatal care include the woman's literacy (OR 1.49, 95% CI 1.28-1.73), the respondent having had a job in the last year (OR 1.39, 95% CI 1.10-1.77), and owning a house (OR 2.83, 95% CI 2.27-3.53). Home delivery tends to be associated with woman's literacy (OR 0.62, 95% CI 0.54-0.72) and marriage age of 15 and younger (OR 1.48, 95% CI 1.26-1.73). Conclusions: Interventions having equity considerations need to disrupt existing patterns of the health gradient. Successful implementation of such interventions, necessitate understanding the mechanisms that can disrupt the unequal utilization patterns and target domains of disadvantage. Knowledge of key predictors of utilization can aid in the implementation of such complex interventions.

While research has assessed the impact of health insurance on health care utilization, few studies have focused on the effects of health insurance on use of maternal health care. Analyzing nationally representative data from the Demographic and Health Surveys (DHS), this study estimates the impact of health insurance status on the use of maternal health services in three countries with relatively high levels of health insurance coverage—Ghana, Indonesia and Rwanda. The analysis uses propensity score matching to adjust for selection bias in health insurance uptake and to assess the effect of health insurance on four measurements of maternal health care utilization: making at least one antenatal care visit; making four or more antenatal care visits; initiating antenatal care within the first trimester and giving birth in a health facility. Although health insurance schemes in these three countries are mostly designed to focus on the poor, coverage has been highly skewed toward the rich, especially in Ghana and Rwanda. Indonesia shows less variation in coverage by wealth status. The analysis found significant positive effects of health insurance coverage on at least two of the four measures of maternal health care utilization in each of the three countries. Indonesia stands out for the most systematic effect of health insurance across all four measures. The positive impact of health insurance appears more consistent on use of facilitybased delivery than use of antenatal care. The analysis suggests that broadening health insurance to include income-sensitive premiums or exemptions for the poor and low or no copayments can increase use of maternal health care. Bien que la recherche ait évalué l’impact de l’assurance maladie sur l’utilisation des soins de santé, peu d’études se sont focalisées sur les effets de l’assurance maladie sur le recours aux soins de santé maternelle. Grâce à l’analyse des données nationales représentatives provenant d’Enquêtes sur la Démographie et la Santé (DHS) cette étude évalue l’impact du régime dl’assurance maladie sur l’utilisation des services de santé maternelle dans trois pays présentant un niveau relativement élevé de couverture d’assurance maladie – le Ghana, l’Indonésie et le Rwanda. L’analyse fait appel à l’appariement des cœfficients de propension pour tenir compte d’un choix manquant d’impartialité dansl’adoption de l’assurance maladie, et pour mesurer l’impact de l’assurance maladie sur quatre évaluations d’utilisation des soins de santé maternelle: effectuer au moins une visite prénatale; effectuer quatre (ou plus) visites prénatales; commencer les soins prénataux au cours du premier trimestre de la grossesse, et accoucher dans un établissement de santé. Bien que les régimes d’assurance maladie dans ces trois pays soient surtout conçus pour se concentrer sur les pauvres, la protection a été fortement orientée vers les riches, en particulier au Ghana et au Rwanda Dans le cas de l’Indonésie, on note moins de différences entre la protection et la situation économique. L’analyse a pu révéler les effets positifs considérables de l’assurance maladie sur au moins deux des quatre mesures d”utilisation des soins de santé maternelle dans chacun des trois pays. L’Indonésie est le pays où l’effet de l’assurance maladie sur l’ensemble des quatre mesures est le plus systématique. L’impact positif de l’assurance maladie semble plus important dans le le recours à l’accouchement en maternité, que dans le recours aux soins prénataux. L’analyse suggère qu’un’élargissement de l’assurance maladie visant à inclure des primes accordées aux faibles revenus ou des exonérations pour les populations pauvres, à faible revenu ou sans quote-part, peut renforcer le recours aux des soins de santé maternelle. 虽然有研究评估了医疗保险对医疗利用率的影响, 但很少有研 究探讨医保对孕产妇医疗使用的作用。 本研究分析国家人口 和卫生调查 （DHS） 中的国家代表性数据, 评估医疗保险在三 个医保覆盖率较高的国家 （加纳、印度尼西亚和卢旺达） 中 对孕产妇医疗服务使用的影响。 本研究采用倾向得分匹配校 正医保使用的选择偏倚, 评估医保对孕产妇医疗使用四个测量 值的影响：至少接受一次产前保健； 接受四次或四次以上产 前保健； 孕前期开始产前保健； 院内分娩。尽管这三个国家 的医保大多是为贫困人口设计, 保险覆盖率却极大地向富人倾 斜, 尤其是在加纳和卢旺达。印度尼西亚不同富裕程度之间的 医保覆盖率差异较小。 本研究发现, 在这三个国家, 医保覆盖 对至少两项孕产妇医疗服务使用测量值有积极作用。较为突 出的是印度尼西亚, 医保覆盖对所有四个测量值均有影响。 与 产前保健相比, 医保覆盖对院内分娩的积极影响更为一致。 本 研究提示, 扩大医疗保险, 根据收入调整保费或免除贫困人群 费用, 降低或取消共同支付费用, 可以增加孕产妇医疗的使 用。 Mientras la investigación ha evaluado el impacto del seguroa de salud sobre la utilización del cuidado de la salud, pocos estudios se han centrado sobre los efectos del seguro de salud sobre el uso del cuidado de la salud materna. Analizando los datos nacionales representativos de las Encuestas Demográficas y de Salud (EDS), este estudio estima el impacto del estatus de seguro de salud en el uso de servicios de salud materna en tres países con niveles relativamente altos de cobertura del seguro de salud — Ghana, Indonesia y Ruanda. El análisis usa el pareamiento por puntaje de propensión para ajustar el sesgo de selección en la absorción del seguro de salud y para evaluar el efecto del seguro de salud en cuatro mediciones de la utilización del cuidado de la salud materna: realización de al menos una visita de cuidado prenatal; realización de cuatro o más visitas de cuidado prenatal; iniciación del cuidado prenatal dentro del primer trimestre y parto en una instalación de salud. Aunque los planes de seguro de salud en estos tres países están diseñados principalmente para centrarse en los pobres, la cobertura ha sido altamente sesgada hacia los ricos, especialmente en Ghana y Ruanda. Indonesia muestra menos variación en la cobertura por la condición de riqueza. El análisis encontró efectos positivos significativos de la cobertura del seguro de salud sobre por lo menos dos de las cuatro medidas de utilización del cuidado de la salud materna en cada uno de los tres países. Indonesia se destaca por el efecto más sistemático del seguro de salud en las cuatro medidas. El impacto positivo sobre el seguro de salud aparece más consistentemente en el uso de instalaciones de salud durante el parto que en el uso del cuidado prenatal. El análisis sugiere que la ampliación del seguro de salud para incluir primas o exenciones sensibles a los ingresos para los pobres y copagos bajos o inexistentes puede aumentar el uso de la atención de la salud materna.

To assess social inequalities in the use of antenatal care (ANC), facility based delivery (FBD), and modern contraception (MC) in two contrasting groups of countries in sub-Saharan Africa divided based on their progress towards maternal mortality reduction. Six countries were included in this study. Three countries (Ethiopia, Madagascar, and Uganda) had <350 MMR in 2010 with >4.5% average annual reduction rate while another three (Cameroon, Zambia, and Zimbabwe) had >550 MMR in 2010 with only <1.5% average annual reduction rate. All of these countries had at least three rounds of Demographic and Health Surveys (DHS) before 2012. We measured rate ratios and differences, as well as relative and absolute concentration indices in order to examine within-country geographical and wealth-based inequalities in the utilization of ANC, FBD, and MC. In the countries which have made sufficient progress (i.e. Ethiopia, Madagascar, and Uganda), ANC use increased by 8.7, 9.3 and 5.7 percent, respectively, while the utilization of FBD increased by 4.7, 0.7 and 20.2 percent, respectively, over the last decade. By contrast, utilization of these services either plateaued or decreased in countries which did not make progress towards reducing maternal mortality, with the exception of Cameroon. Utilization of MC increased in all six countries but remained very low, with a high of 40.5% in Zimbabwe and low of 16.1% in Cameroon as of 2011. In general, relative measures of inequalities were found to have declined overtime in countries making progress towards reducing maternal mortality. In countries with insufficient progress towards maternal mortality reduction, these indicators remained stagnant or increased. Absolute measures for geographical and wealth-based inequalities remained high invariably in all six countries. The increasing trend in the utilization of maternal care services was found to concur with a steady decline in maternal mortality. Relative inequality declined overtime in countries which made progress towards reducing maternal mortality.

India accounts for 19% of global maternal deaths, three-quarters of which come from nine states. In 2005, India launched a conditional cash transfer (CCT) programme, Janani Suraksha Yojana (JSY), to reduce maternal mortality ratio (MMR) through promotion of institutional births. JSY is the largest CCT in the world. In the nine states with relatively lower socioeconomic levels, JSY provides a cash incentive to all women on birthing in health institution. The cash incentive is intended to reduce financial barriers to accessing institutional care for delivery. Increased institutional births are expected to reduce MMR. Thus, JSY is expected to (a) increase institutional births and (b) reduce MMR in states with high proportions of institutional births. We examine the association between (a) service uptake, i.e., institutional birth proportions and (b) health outcome, i.e., MMR. Data from Sample Registration Survey of India were analysed to describe trends in proportion of institutional births before (2005) and during (2006-2010) the implementation of the JSY. Data from Annual Health Survey (2010-2011) for all 284 districts in above- mentioned nine states were analysed to assess relationship between MMR and institutional births. Proportion of institutional births increased from a pre-programme average of 20% to 49% in 5 years (p<0.05). In bivariate analysis, proportion of institutional births had a small negative correlation with district MMR (r = -0.11).The multivariate regression model did not establish significant association between institutional birth proportions and MMR [CI: -0.10, 0.68]. Our analysis confirmed that JSY succeeded in raising institutional births significantly. However, we were unable to detect a significant association between institutional birth proportion and MMR. This indicates that high institutional birth proportions that JSY has achieved are of themselves inadequate to reduce MMR. Other factors including improved quality of care at institutions are required for intended effect.

Background The three delays model proposes that maternal mortality is associated with delays in: 1) deciding to seek care; 2) reaching the healthcare facility; and 3) receiving care. Previously, the majority of women who died were reported to have experienced type 1 and 2 delays. With increased coverage of healthcare services, we sought to explore the relative contribution of each type of delay. Method 151 maternal deaths were identified during a 12-month reproductive age mortality survey (RAMOS) conducted in Malawi; verbal autopsy and facility-based medical record reviews were conducted to obtain details about the circumstances surrounding each death. Using the three delays framework, data were analysed for women who had; 1) died at a healthcare facility, 2) died at home but had previously accessed care and 3) died at home and had not accessed care. Results 62.2% (94/151) of maternal deaths occurred in a healthcare facility and a further 21.2% (32/151) of mothers died at home after they had accessed care at a healthcare facility. More than half of all women who died at a healthcare facility (52.1%) had experienced more than one type of delay. Type 3 delays were the most significant delay for women who died at a healthcare facility or women who died at home after they had accessed care, and was identified in 96.8% of cases. Type 2 delays were experienced by 59.6% and type 1 delays by 39.7% of all women. Long waiting hours before receiving treatment at a healthcare facility, multiple delays at the time of admission, shortage of drugs, non-availability and incompetence of skilled staff were some of the major causes of type 3 delays. Distance to a healthcare facility was the main problem resulting in type 2 delays. Conclusion The majority of women do try to reach health services when an emergency occurs, but type 3 delays present a major problem. Improving quality of care at healthcare facility level will help reduce maternal mortality.

Background Mass media is critical in disseminating public health information, improving health knowledge and changing health behaviours. However, most of the mass media public health interventions do not sufficiently engage the local people; they are externally determined. Due to this, very little is known about the effects of locally instigated mass media promotion. Therefore, the aim of this study was to examine the impact of a community driven mass media campaign called Phukusi la Moyo (tips of life) on the utilisation of maternal health care services. Methods A community-based cross-sectional study involving 3825 women of reproductive age (15–49 years) was conducted in rural Malawi to evaluate the Phukusi la Moyo (PLM) campaign. To do this, we compared the utilisation of maternal health care services between women who were exposed to the PLM campaign and those who were not. Respondents were identified using a multistage cluster sampling method. This involved systematically selecting communities (clusters), households and respondents. Associations were examined using Pearson chi square test and a multivariable logistic regression model. Results The likelihood of using contraceptives (AOR = 1.61; 95 % CI = 1.32–1.96), sleeping under mosquito bed-nets (AOR = 1.65; 95 % CI = 1.39–1.97), utilising antenatal care services (AOR = 2.62; 95 % CI = 1.45–4.73) and utilising postnatal care services (AOR = 1.59; CI = 1.29–1.95) were significantly higher among women who had exposure to the PLM campaign than those who did not. No significant association was found between health facility delivery and exposure to the PLM campaign. Conclusion Women exposed to a community driven mass media campaign in rural Malawi were more likely to utilise maternal health care services than their unexposed counterparts. Since, the use of maternal health care services reduces the risk of maternal morbidity and mortality, community-led mass media could play a significant role towards improving maternal health outcomes in low-and-middle-income countries. Therefore, we recommend the use of locally driven mass media in disseminating public health information in limited resource settings.