Angela Baschieri

Contextual influences on the use of health facilities for childbirth in Africa.

OBJECTIVES Previous studies of maternal health-seeking behavior focused on individual- and household-level factors. We examined community-level influences on the decision to deliver a child in a health facility across 6 African countries. METHODS Demographic and Health Survey data were linked with contextual data, and multilevel models were fitted to identify the determinants of childbirth in a health facility in the 6 countries. RESULTS We found strong community-level influences on a womans decision to deliver her child in a health facility. Several pathways of influence between the community and individual were identified. CONCLUSIONS Community economic development, the climate of female autonomy, service provision, and fertility preferences all exert an influence on a womans decision to seek care during labor, but significant community variation remains unexplained.

Trends in out-of-pocket payments for health care in Kyrgyzstan, 2001–2007

Within the countries of the former Soviet Union, the Kyrgyz Republic has been a pioneer in reforming the system of health care finance. Since the introduction of its compulsory health insurance fund in 1997, the country has gradually moved from subsidizing the supply of services to subsidizing the purchase of services through the ‘single payer’ of the health insurance fund. In 2002 the government introduced a new co-payment for inpatients along with a basic benefit package. A key objective of the reforms has been to replace the burgeoning system of unofficial informal payments for health care with a transparent official co-payment, thereby reducing the financial burden of health care spending for the poor. This article investigates trends in out-of-pocket payments for health care using the results of a series of nationally representative household surveys conducted over the period 2001–2007, when the reforms were being rolled out. The analysis shows that there has been a significant improvement in financial access to health care amongst the population. The proportion paying state providers for consultations fell between 2004 and 2007. As a result of the introduction of co-payments for hospital care, fewer inpatients report making payments to medical personnel, but when they are made, payments are high, especially to surgeons and anaesthetists. However, although financial access for outpatient care has improved, the burden of health care payments amongst the poor remains significant.

Profile: The Karonga health and demographic surveillance system

The Karonga Health and Demographic Surveillance System (Karonga HDSS) in northern Malawi currently has a population of more than 35 000 individuals under continuous demographic surveillance since completion of a baseline census (2002–2004). The surveillance system collects data on vital events and migration for individuals and for households. It also provides data on cause-specific mortality obtained by verbal autopsy for all age groups, and estimates rates of disease for specific presentations via linkage to clinical facility data. The Karonga HDSS provides a structure for surveys of socio-economic status, HIV sero-prevalence and incidence, sexual behaviour, fertility intentions and a sampling frame for other studies, as well as evaluating the impact of interventions, such as antiretroviral therapy and vaccination programmes. Uniquely, it relies on a network of village informants to report vital events and household moves, and furthermore is linked to an archive of biological samples and data from population surveys and other studies dating back three decades.

Contextual Influences on Modern Contraceptive Use in Sub-Saharan Africa

OBJECTIVES We examined the role of community-level factors in explaining geographic variations in modern contraceptive use in 6 African countries. METHODS We analyzed Demographic and Health Survey and contextual data sources with multilevel modeling techniques to identify factors contributing to geographic variations in womens use of modern contraceptives. RESULTS We found significant associations between several community-level factors and reported use of modern contraceptive methods. We also identified several pathways of influence between the community and the individual. CONCLUSIONS Aspects of a communitys sociocultural and economic environment appear to influence a womans use of modern contraceptive methods.

Geographical access to care at birth in Ghana: a barrier to safe motherhood

BackgroundAppropriate facility-based care at birth is a key determinant of safe motherhood but geographical access remains poor in many high burden regions. Despite its importance, geographical access is rarely audited systematically, preventing integration in national-level maternal health system assessment and planning. In this study, we develop a uniquely detailed set of spatially-linked data and a calibrated geospatial model to undertake a national-scale audit of geographical access to maternity care at birth in Ghana, a high-burden country typical of many in sub-Saharan Africa.MethodsWe assembled detailed spatial data on the population, health facilities, and landscape features influencing journeys. These were used in a geospatial model to estimate journey-time for all women of childbearing age (WoCBA) to their nearest health facility offering differing levels of care at birth, taking into account different transport types and availability. We calibrated the model using data on actual journeys made by women seeking care.ResultsWe found that a third of women (34%) in Ghana live beyond the clinically significant two-hour threshold from facilities likely to offer emergency obstetric and neonatal care (EmONC) classed at the ‘partial’ standard or better. Nearly half (45%) live that distance or further from ‘comprehensive’ EmONC facilities, offering life-saving blood transfusion and surgery. In the most remote regions these figures rose to 63% and 81%, respectively. Poor levels of access were found in many regions that meet international targets based on facilities-per-capita ratios.ConclusionsDetailed data assembly combined with geospatial modelling can provide nation-wide audits of geographical access to care at birth to support systemic maternal health planning, human resource deployment, and strategic targeting. Current international benchmarks of maternal health care provision are inadequate for these purposes because they fail to take account of the location and accessibility of services relative to the women they serve.

Hunger and Food Insecurity in Nairobi’s Slums: An Assessment Using IRT Models

Although linked to poverty as conditions reflecting inadequate access to resources to obtain food, issues such as hunger and food insecurity have seldom been recognized as important in urban settings. Overall, little is known about the prevalence and magnitude of hunger and food insecurity in most cities. Yet, in sub-Saharan Africa where the majority of urban dwellers live on less than one dollar a day, it is obvious that a large proportion of the urban population must be satisfied with just one meal a day. This paper suggests using the one- and two-parameter item response theory models to infer a reliable and valid measure of hunger and food insecurity relevant to low-income urban settings, drawing evidence from the Nairobi Urban Health and Demographic Surveillance System. The reliability and accuracy of the items are tested using both the Mokken scale analysis and the Cronbach test. The validity of the inferred household food insecurity measure is assessed by examining how it is associated with households’ economic status. Results show that food insecurity is pervasive amongst slum dwellers in Nairobi. Only one household in five is food-secure, and nearly half of all households are categorized as “food-insecure with both adult and child hunger.” Moreover, in line with what is known about household allocation of resources, evidence indicates that parents often forego food in order to prioritize their children.

Child growth in urban deprived settings: Does household poverty status matter? At which stage of child development?

This paper uses longitudinal data from two informal settlements of Nairobi, Kenya to examine patterns of child growth and how these are affected by four different dimensions of poverty at the household level namely, expenditures poverty, assets poverty, food poverty, and subjective poverty. The descriptive results show a grim picture, with the prevalence of overall stunting reaching nearly 60% in the age group 15–17 months and remaining almost constant thereafter. There is a strong association between food poverty and stunting among children aged 6–11 months (p<0.01), while assets poverty and subjective poverty have stronger relationships (p<0.01) with undernutrition at older age (24 months or older for assets poverty, and 12 months or older for subjective poverty). The effect of expenditures poverty does not reach statistical significant in any age group. These findings shed light on the degree of vulnerability of urban poor infants and children and on the influences of various aspects of poverty measures.

Formalizing informal payments: the progress of health reform in Kyrgyzstan

This paper evaluates the success of the recent ‘Single Payer Reform’ in the health sector of the Kyrgyz Republic in achieving the aim of replacing unofficial out-of-pocket payments with a transpare...

Risk reduction and perceived collective efficacy and community support among female sex workers in Tamil Nadu and Maharashtra, India: the importance of context

Background Empowering sex workers to mobilise and influence the structural context that obstructs risk reduction efforts is now seen an essential component of successful HIV prevention programmes. However, success depends on local programme environments and history. Methods The authors analysed data from the Integrated Behavioural and Biological Assessment Round I cross-sectional survey among female sex workers in Tamil Nadu and Maharashtra. The authors used propensity score matching to estimate the impact of participation in intervention activities on reduction of risk (consistent condom use) and vulnerability (perceived collective efficacy and community support). Results Background levels of risk and vulnerability as well as intervention impact varied widely across the different settings. The effect size ATT of attending meetings/trainings on consistent condom use was as high as 21% in Tamil Nadu (outside of Chennai) where overall use was lowest at 51%. Overall, levels of perceived collective efficacy were low at the time of the survey; perceived community support was high in Tamil Nadu and especially in Chennai (93%) contrasting with 33% in Mumbai. Consistent with previous research, the context of Mumbai seems least conducive to vulnerability reduction, yet self-help groups had a significant impact on consistent condom use (ATT=10%) and were significantly associated with higher collective efficacy (ATT=31%). Conclusions Significant risk reduction can be achieved by large-scale female sex worker interventions, but the impact depends on the history of programming, the complexity of the context in which sex work happens and pre-existing levels of support sex workers perceive from their peers.

Fertility Intentions and Use of Contraception among Monogamous Couples in Northern Malawi in the Context of HIV Testing: A Cross-Sectional Analysis

Context Knowledge of HIV status may influence fertility desires of married men and women. There is little knowledge about the importance of this influence among monogamously married couples and how knowledge of HIV status influences use of contraception among these couples. Methodology We carried out a cross-sectional analysis of interview data collected between October 2008 and September 2009 on men aged 15–59 years and women aged 15–49 years who formed 1766 monogamously married couples within the Karonga Prevention Study demographic surveillance study in northern Malawi. Results 5% of men and 4% of women knew that they were HIV positive at the time of interview and 81% of men and 89% of women knew that they were HIV negative. 73% of men and 83% of women who knew that they were HIV positive stated that they did not want more children, compared to 35% of men and 38% of women who knew they were HIV negative. Concordant HIV positive couples were more likely than concordant negative couples to desire to stop child bearing (odds ratio 11.5, 95%CI 4.3–30.7, after adjusting for other factors) but only slightly more likely to use contraceptives (adjusted odds ratio 1.5 (95%CI 0.8–3.3). Conclusion Knowledge of HIV positive status is associated with an increase in the reported desire to cease childbearing but there was limited evidence that this desire led to higher use of contraception. More efforts directed towards assisting HIV positive couples to access and use reproductive health services and limit HIV transmission among couples are recommended.