April Harding

Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data

Background In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home. Methodology/Principal Findings We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed “not necessary” by a household decision maker. Among the poorest women, “not necessary” was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended. Conclusions In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.

Innovations in health service delivery : the corporatization of public hospitals

The question of how best to run our hospitals has been a subject of intense interest for decades with a strong focus over the past 15 years. Hospital care is the largest expenditure category in the health systems of both industrialized and developing countries. Although hospitals play a critical role in ensuring delivery of health services, less is known about how to improve the efficiency and quality of care provided. This book, a well-documented collection of case studies, is an attempt to examine the design, implementation and impact of reforms that introduced market forces in the public hospital sector; and tries to answer three questions: a) what problems did this type of reform try to address; b) what are the core elements of their design, implementation, and evaluation; and c) is there any evidence that this type of reform is successful in addressing problems for which they were intended?. It also provides some insights about recent trends in the reform of public hospitals, with an emphasis on organizational changes such as increased management autonomy, corporatization, and privatization.

Public-Private Partnerships And Public Hospital Performance In São Paulo, Brazil

Public hospitals that are directly managed by government perform poorly in many developing countries. Approaches to improving them through internal managerial reforms have failed, and effective alternatives are much needed. Policymakers are considering reforms through public-private partnerships (PPPs)--a promising but so far unevaluated approach. We present results of a successful reform in São Paulo, Brazil. The PPP model gave facility managers latitude to manage human resources--a factor critical to success. Given the prevalence of direct management of public hospitals in developing countries, the São Paulo experience has implications for policymakers seeking to improve hospital performance.

Provider choice and cost conscious consumers contribute to Singapore’s performance

I agree that readers shouldn’t wrongly conclude that Medisave, Medishield, and Medifund by themselves account for Singapore’s excellent performance,1 but it is unhelpful to leave it at that. The existence of these medical savings accounts (and …

Reducing user fees often reduces supply of services

Thomson and colleagues’ analytical framework for understanding the impact of user fees is useful for developing countries.1 However, for developing countries with weak public delivery systems, user fees …