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Background Childcare needs are an understudied social determinant of health. The effect of childcare needs on access to healthcare must be understood to inform health system interventions and policy reform. This study sought to characterize childcare needs, access to childcare, and prior experience with navigating childcare needs in healthcare settings among women in a safety-net population. Methods We conducted a cross-sectional study of patient-reported survey data collected in-person between April and October 2019. Surveys were administered in waiting rooms of ambulatory services in a large, urban safety-net health system in Dallas, Texas. Survey respondents were derived from a random convenience sample of women waiting for outpatient appointments. Participants were screened for having children under the age of 13 and/or childcare responsibilities for inclusion in the sample. Outcomes of interest included self-reported delayed or missed care, reasons for delayed or missed care, perceived difficulty in accessing childcare, prior methods for managing childcare during healthcare appointments, and prior experience with childcare centers. Results Among the 336 respondents (96.7% response rate), 121 (36.0%) reported delaying or missing a mean 3.7 appointments/year. Among women with delayed or missed care, 54.5% reported childcare barriers as the primary reason for deferral of care, greater than transportation (33%) or insurance (25%) barriers. Respondents rated childcare access as more difficult than healthcare access. Delayed or missed care due to childcare was more common among White (68.8%) and Black (55.0%) women compared to Hispanic women (34.3%). Common methods of navigating childcare needs during scheduled appointments included bringing children to appointments (69.1%) and re-scheduling or missing the scheduled appointment (43.0%). 40.6% of patients reported leaving an appointment before completion due to childcare needs. Conclusions Childcare needs are a leading barrier to healthcare among women accessing care in safety-net settings. Unmet childcare needs result in deferral of care, which may impact health outcomes. Childcare access is perceived as more challenging than healthcare access itself. Health system and policy interventions are needed to address childcare as a social determinant of health.

Background The utilisation of Reproductive, Maternal, Newborn and Child Health (RMNCH) services remains lower among the Scheduled Tribes (ST) in India than among the rest of the country’s population. The tribal population’s poorest and least-educated households are further denied access to RMNCH care due to the intersection of their social status, wealth, and education levels. The study analyses the wealth- and education-related inequalities in the utilisation of RMNCH services within the ST population in Odisha and Jharkhand. Methodology We have constructed two summary measures, namely, the Co-coverage indicator and a modified Composite Coverage Index (CC), to determine wealth- and education-related inequalities in the utilisation of RMNCH indicators within the ST population in Odisha and Jharkhand. The absolute and relative inequalities with respect to wealth and education within the ST population are estimated by employing the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII). Results The results of the study highlight that access to RMNCH services is easier for women who are better educated and belong to wealthier households. The SII and RII values in the co-coverage indicator and modified CCI exhibit an increase in wealth-related inequalities in Odisha between NFHS-4 (2015-16) and NFHS-5 (2019-21) whereas in Jharkhand, the wealth- and education-related absolute and relative inequalities present a reduction between 2016 and 2021. Among the indicators, utilisation of vaccination was high, while the uptake of Antenatal Care Centre Visits and Vitamin A supplementation should be improved. Interpretation The study results underscore the urgent need of targeted policies and interventions to address the inequalities in accessing RMNCH services among ST communities. A multi-dimensional approach that considers the socioeconomic, cultural and geographical factors affecting healthcare should be adopted while formulating health policies to reduce inequalities in access to healthcare.

Background Food insecurity is a major public health challenge in many parts of the world, especially in sub-Saharan Africa. It affects the health and well-being of vulnerable populations, particularly women of reproductive age in their use of maternal health services. This study explores the impact of food insecurity on the use of maternal health services among Togolese women in the Savanes region, aged between 18 and 49 years. Methods This qualitative study was carried out using both focus group discussions (FGD) and in-depth interviews (IDI), which were conducted from March 14th to May 20th, 2022 in three different rural areas of the Savanes region in Togo. Firstly, we conducted twelve in-depth interviews with health professionals in three community health centers. In addition, we conducted three FGDs with 8 participants each in three different rural areas. For analysis, all the data collected were transcribed verbatim, and themes were coded using Nvivo14. Results Household food insecurity is perceived as a significant threat and barrier to maternal healthcare utilization. Women experiencing food insecurity are less likely to seek maternal health services, as their limited financial resources are prioritized for food rather than healthcare. In contexts of poverty where finances are already precarious, food insecurity further diverts funds that could otherwise be used for medical care. As a result food and financial insecurity intersect influencing women’s decisions on whether to access maternal health services. Additionally, the majority of participants identified the COVID-19 pandemic as a factor that seriously exacerbated household food insecurity and consequently further reduced access to maternal healthcare in the region. Enhancing women’s socio-economic empowerment and promoting food self-sufficiency were highlighted as potential solutions to improve access to maternal healthcare services while ensuring food security. Conclusions Findings from this study highlight the link between food insecurity and maternal healthcare utilization, emphasizing the need to address food insecurity at its root in programs aiming to improve maternal health. Prioritizing poverty reduction through education, income, women’s socioeconomic empowerment and food self-sufficiency is crucial. Hence, intersectorial interventions including prenatal nutrition programs are essential to improving access to maternal healthcare.

Background Sub-Saharan Africa suffers from the highest maternal mortality ratio (MMR) in the world, with 542 deaths per 100,000 live births in 2017, relative to a global ratio of 211. Reducing gender-based discrimination (GBD) and increasing the empowerment of women and girls have recently been recognized as prerequisites for improving maternal health. Previous studies have shown GBD to result in low utilization of maternal health services and poorer quality of care. However, limited research is available on the relationship between GBD and maternal mortality in Sub-Saharan Africa (SSA). Therefore, the objective of this study was to assess whether GBD is associated with maternal mortality in SSA. Methods We investigated the association between self-reported GBD and maternal mortality in an ecological study. We used data from two surveys: the Demographic and Health Surveys (DHS) and the Afrobarometer. Data refer to 78 sub-national regions, located in nine Sub-Saharan African countries (Benin, Malawi, Mali, Nigeria, Senegal, South Africa, Uganda, Zambia, and Zimbabwe). Data were analyzed using a two-level linear regression model with random intercept. The regression controlled for covariates at region- and country-level. Results The proportion of women who reported experiencing GBD varied between 0% in several regions in Benin, Mali, Senegal, South Africa, and Zimbabwe and 24·7% in Atacora, Benin. We identified a positive association between the proportion of women who reported experiencing GBD in a region in the past year and MMR (β 0.88, CI [0.65; 1.12]). A 1% increase in the proportion of women experiencing GBD resulted in an increase of the MMR by nearly two, meaning, an additional two more maternal deaths per 100,000 live births. This association was even more pronounced after adjusting for region-level covariates, but did not change with the inclusion of country-level covariates (β 1.95, CI [1.71; 2.19]). Conclusions The study’s findings show that the rate of self-reported GBD is associated with maternal mortality in a region, even after controlling for other factors that are known to influence maternal deaths. However, our model does not rule out endogeneity. Further research is needed to unravel causal pathways between GBD and maternal mortality.

Background A package of Maternal, Newborn and Child Health (MNCH) services are administered sequentially to mother–child dyads as Continuum of Care (CoC), but often each intervention is reviewed in silo in low-middle-income countries like India. Therefore, we aimed to examine the coverage of the entire package by computing composite CoC score of Indian mother–child dyads. We also aimed to estimate the effect of Indian states on CoC after adjusting for variations in socio-economic determinants; and then rank the Indian states based on their adjusted effects . Methods Women (15–49 years) with most recently-born child (in last 5 years) aged 12–23 months ( n  = 40,687) from National Family Health Survey-5 (2019–21) of India were analysed. Nineteen CoC interventions (Y/N) were added (equally-weighted) to construct a composite CoC score. Multi-level models were used to study the state effect on CoC score after adjusting for individual-level wealth, education, caste, urban/rural residence and fertility. Indian states were ranked by their CoC performance using adjusted state residuals from the model. Results Only 3% dyads received all the 19 interventions, however, 50% received 14/19. Sterile delivery kit usage (94.4%), newborn weighing (92.4%) and skilled birth attendance (89.4%) were services with higher coverage, whereas early initiation of breastfeeding (43.7%) and appropriate iron-folate consumption (56.8%) had low coverage. The state factor explained 23% CoC score. Odisha, a comparatively less-developed state, was ranked first and also other less-developed states like Madhya Pradesh and Chhattisgarh outperformed richer counterparts. But many traditionally weaker Northern and North-Eastern states continued to lag behind. Conclusion Odisha and a few other less-developed Indian states demonstrated that good CoC coverage can be achieved even with restricted resources, perhaps through strengthening of public health system. Other states should emulate and help India as a nation achieve full CoC coverage of all its mother–child dyads and attain MNCH-related sustainable development goals.

Background Community acceptance of Traditional birth attendants (TBAs) as professional birth attendant was reported as one of the bottlenecks that has been hindering facility childbirth care service use. Hence, the World Health Organization (WHO) recommended that all childbirths needed to be attended by professional skilled attendants who at least possessed midwifery skill through the safe motherhood initiative. However, many births in developing countries have been being attended by Traditional birth attendants (TBAs) mainly due to pregnant women and community acceptance for TBAs as sole birth attendants. Therefore, measuring pregnant women’s perceived community acceptance towards TBAs assisted childbirth care and identifying factors could be imperative. This provides evidence for policy makers, health program managers and health care practitioners in their effort to escalate skilled and facility childbirth care there by improving maternal and newborn health outcome. Methods This study had used the cross-sectional baseline data from Performance and monitoring for action Ethiopia (PMA_Et) cohort one survey which enrolled and collected data from currently pregnant women and recently postpartum women. The baseline survey collected real time data on various sexual, reproductive, maternal and new born nationwide priority indicators using customized Open Data Kit Mobile application. These data were collected using standard pretested questionnaire prepared in three local languages (Amharic, Afan Oromo and Tigrigna) by well experienced resident enumerators. The final sample size was 2,186 women who were pregnant by the time of the survey and who provided response for the perceived community acceptance for TBAs assisted childbirth care question item. Frequencies were computed to describe the study participant’s characteristics. Multinomial logistics regression statistical model building process was employed to identify associated factors of perceived community acceptance for childbirths to be attended by TBAs. Results were presented in the form percentages and odds ratio with 95% Confidence Intervals. Candidate variables were selected using p -value of 0.25. Statistical significance was declared at p -value of 0.05. Results The overall proportion of perceived community acceptance for TBAs assisted childbirth care was found to be 58.63% (95%CI: 56.47%, 60.76%). Attending primary education was found to increase the likelihood of pregnant women perceived community acceptance by most people in their community for TBAs assisted childbirth care. Women having intentions to have another child were found to have higher likelihood perceived community acceptance by few people in their community for TBAs assisted childbirth care. On the contrary, religion, residing in the well to do households, residing in the Southern nations, nationalities and Peoples Region (SNNPR) and Addis Ababa had lowered pregnant women’s perceived community acceptance by most, few and some pleople in their community for TBAs assisted childbirth care. Conclusions The overall substantially greater proportion of pregnant perceived community acceptance for TBAs assisted childbirth care calls up on tremendous work to be done to avert such high level pregnant women perceived community acceptance for childbirths to be assisted by TBAs. Activities targeting in improving women economic status and empowerment; increasing women enrollment to secondary and higher education; using religious leaders and institutions to promote skilled delivery and childbirth care service use could likely aid in mitigating such huge surge of misconceptions towards childbirth care attendants. This significant perceived community acceptance substantially impact maternal and newborn health outcomes negatively which calls for awareness creation through community campaign to reverse this skewed perception. The activities and interventions need to be region specific. The finding also underscores the relevance of birth preparedness and complication readiness. The implication of the study is that the Health Minister and relevant actors need to design and implement region specific programs and strategies on women reproductive health empowerment and skilled childbirth care service use improvement. The other key implication of the finding was serving as one source of evidence to follow the WHO’s recommendation aimed at reducing maternal mortality through skilled delivery and childbirth care service provision. It also served to track the status of the new role of TBAs to serve as a liaison between the pregnant women and the modern health care system to escalate skilled childbirth care services.

Introduction Access to childcare is an understudied social determinant of health (SDOH). Our health system established a childcare facility for patients to address childcare barriers to healthcare. Recognizing that social risk factors often co-exist, we sought to understand intersecting social risk factors among patients with childcare needs who utilized and did not utilize the childcare facility and identify residual unmet social needs alongside childcare needs. Methods We conducted a cross-sectional analysis of patients who enrolled in the childcare facility from November 2020 to October 2022 to compare parameters of the Social Vulnerability Index (SVI) associated with the census tract extracted from electronic medical record (EMR) data among utilizers and non-utilizers of the facility. Overall SVI and segmentation into four themes of vulnerability (socioeconomic status, household characteristics, racial/ethnic minority status, and housing type/transportation) were compared across utilizers and utilizers. Number of 90th percentile indicators were also compared to assess extreme levels of vulnerability. A sample of utilizers additionally received a patient-reported social needs screening questionnaire administered at the childcare facility. Results Among 400 enrollees in the childcare facility, 70% utilized childcare services and 30% did not. Utilizers and non-utilizers were demographically similar, though utilizers were more likely to speak Spanish (34%) compared to non-utilizers (22%). Mean SVI was similar among utilizers and non-utilizers, but the mean number of 90th percentile indicators were higher for non-utilizers compared to utilizers (4.3 ± 2.7 vs 3.7 ± 2.7, p  = 0.03), primarily driven by differences in the housing type/transportation theme ( p  = 0.01). Non-utilizers had a lower rate of healthcare utilization compared to utilizers ( p  = 0.02). Among utilizers who received patient-reported screening, 84% had one unmet social need identified, of whom 62% agreed for additional assistance. Among social work referrals, 44% were linked to social workers in their medical clinics, while 56% were supported by social work integrated in the childcare facility. Conclusions This analysis of SDOH approximated by SVI showed actionable differences, potentially transportation barriers, among patients with childcare needs who utilized a health system-integrated childcare facility and patients who did not utilize services. Furthermore, residual unmet social needs among patients who utilized the facility demonstrate the multifactorial nature of social risk factors experienced by patients with childcare needs and opportunities to address intersecting social needs within an integrated intervention. Intersecting social needs require holistic examination and multifaceted interventions.

Background Reaching and vaccinating zero dose and under-immunized children requires effective strategies and quality data. Primary health care unit level interventions like hands-on training, mentoring, participatory planning and review and enhanced headcount of under two-year children were implemented in four primary health care units Afar and Somali regions. The aim of this manuscript is to describe and share the experience on the effectiveness of these interventions in reaching and vaccinating zero-dose and under immunized children through well planned headcount. Method The intended interventions were implemented in four purposely selected woredas from Afar and Somali regions. One primary health care unit was chosen from each woreda based on different criteria. Following the interventions, headcount of under two-year children was conducted in all villages of four primary health care units’ catchment with active engagement of community leaders. Modified periodic enhanced routine immunization template was used to register enumerated children. Identified zero-dose and under immunized children were referred to nearby immunization sites with referral slip for vaccination. Immunization indicators and the reason for missing immunization, descriptive analysis done using Microsoft Excel. Result Improved primary health care linkage coupled with strengthened capacity enabled primary health care units to conduct enhanced head count to identify and vaccinate unreached children. The headcount led to the identification of 390 (24%) never vaccinated and 185 (11%) under-immunized children among 1478 enumerated 6 weeks-11 months children in 21 HPs under four primary health care units. Among 1,619 enumerated 12–23 months children, 332 (21%) were zero-doses and 355 (22%) were under-immunized children. Through referral linkage to immunization service, 92% (357/390) of never vaccinated and 97% (179/185) under-immunized 6 weeks − 11 months children were subsequently vaccinated for vaccines they missed. Likewise, 94% (620/658) above one-year children were vaccinated for the measles vaccine. The reasons for failure to vaccinate for 12–23 months old children were access barriers in 70% followed by lack of knowledge (15%). Conclusion and recommendations Strengthening the primary health care unit linkage and its technical and managerial capacity accompanied by headcount through the involvement of community leaders can benefit the identification and reach of children missing vaccination and other essential health services.

Background Access to family planning services among young people is crucial for reproductive health. This study explores the access and associated factors among young people in Lira City, Northern Uganda. Methods and materials A mixed-methods study was conducted in March to April 2022. Quantitative data were collected using a structured questionnaire from 553 participants aged 15–24 years. Qualitative data were obtained through in-depth interviews and focus group discussions. Data analysis included univariate, bivariate, and multivariate analyses for quantitative data, while interpretative phenomenological analysis was used for qualitative data. Results Overall, 31.7% of the respondents had a good perceived access to family planning services, with 64.6% reporting perceived availability of FP methods. Challenges included lack of privacy (57.7%), fear of mistreatment (77.2%), and decision-making difficulties (66.2%). Among females, good perceived access to FP services was less likely among urban residents (AOR: 0.22, 95% CI: 0.09–0.53), Christian respondents (AOR: 0.51, 95% CI: 0.01–0.36), Muslim respondents (AOR: 0.07, 95% CI: 0.01–0.55) and respondents with poor attitude to FP services (AOR: 0.39, 95% CI: 0.24–0.64), but more likely among respondents with a sexual a partner (AOR: 4.48, 95% CI: 2.60–7.75). Among males, good perceived access to FP services was less likely among respondents living with parents (AOR: 0.19, 95% CI: 0.05–0.67) but more likely among respondents with good knowledge of FP services (AOR: 2.28, 95% CI: 1.02–5.32). Qualitative findings showed that three themes emerged; knowledge of family planning methods, beliefs about youth contraception and, friendliness of family planning services. Conclusion The study revealed a substantial gap in perceived access to family planning services among young people in Lira City. Barriers include privacy concerns, fear of mistreatment, and decision-making difficulties. Tailored interventions addressing urban access, religious beliefs for females, and knowledge enhancement for males are essential. Positive aspects like diverse FP methods and physical accessibility provide a foundation for targeted interventions. Youth-friendly services, comprehensive sexual education, and further research are emphasized for a nuanced understanding and effective interventions in Northern Uganda.

Background Under-five mortality remains high in West Africa, where sick children are expected to first attend the primary health care before being referred to a hospital if necessary. However, little is known about how families navigate between home and higher levels of care to meet their children’s health needs, despite multiple known barriers (including social, financial, and geographical accessibility). We analysed the care pathways of children aged 0–5 years before they presented to the district hospital with a serious illness and the determinants of these care pathways in four West African countries. Methods From May to August 2022, we conducted a cross-sectional study over a one-month data collection in seven district hospitals participating in the AIRE project aimed to introduce pulse oximetry at primary health care level in Burkina Faso, Guinea, Mali, and Niger. All children aged 0–5 years, classified as severe or priority cases by clinicians at referral district hospitals were included after parental consent. Data about care pathways since the onset of their disease were collected from caregivers, and the Levesque framework was used to analyse the accessibility issues. Results A total of 861 severely ill children were included, with 33% being neonates: 20.3% in Burkina Faso, 9.2% in Guinea, 9.5% in Mali, and 61% in Niger. In Burkina Faso and Niger, most children followed the recommended care pathway and first visited a primary health centre before arriving at the hospital, with 81.1% and 73.3% of children, respectively. However, they were only 51.2% in Mali and 13.9% in Guinea. Using alternative pathways was common, particularly in Guinea, where 30.4% of children first consulted a pharmacist, and Mali, where 25.6% consulted a traditional medicine practitioner. Overall, primary care was perceived to be more geographically accessible and less expensive, but parents were much less convinced that it could improve their child's health compared to hospital care. Conclusion The recommended pathway is largely adhered to, yet parallel pathways require attention, notably in Guinea and Mali. A better understanding of healthcare-seeking behaviours can help remove barriers to care, improving the likelihood that a sick child will receive optimal care.