Competition between Public and Private Maternity Care Providers in France: Evidence on Market Segmentation.

The purpose of this paper is to investigate the potential for segmentation in hospital markets, using the French case where private for-profit providers play an important role having nearly 25% of market shares, and where prices are regulated, leading to quality competition. Using a stylized economic model of hospital competition, we investigate the potential for displacement between vertically differentiated public and private providers, focusing on maternity units where user choice is central. Building over the model, we test the following three hypotheses. First, the number of public maternity units is likely to be much larger in less populated departments than in more populated ones. Second, as the number of public maternity units decreases, the profitability constraint should allow more private players into the market. Third, private units are closer substitutes to other private units than to public units. Building an exhaustive and nationwide data set on the activity of maternity services linked to detailed data at a hospital level, we use an event study framework, which exploits two sources of variation: (1) The variation over time in the number of maternity units and (2) the variation in users' choices. We find support for our hypotheses, indicating that segmentation is at work in these markets with asymmetrical effects between public and private sectors that need to be accounted for when deciding on public market entry or exit.

The golden hour in Finnish birthing units - An ethnographic study.

OBJECTIVE: To explore midwives' and parents' perceptions and actions as well as the culture surrounding the first hour after the birth of a baby - the golden hour. DESIGN: Short-term ethnographic study, which included observations, informal interviews and focus group interviews. Thematic network analysis was used to analyse the data. SETTING: Two birthing hospitals in Finland. PARTICIPANTS: The first hour following 16 births was observed and informal interviews of attending midwives (n = 10) and parents (n = 3 couples and n = 6 mothers) were conducted to supplement the observations. The 16 cases included both primiparous (n = 8) and multiparous (n = 8) women, as well as vaginal (n = 12) and elective caesarean births (n = 4). Furthermore, two focus group interviews with midwives (n = 9) were conducted to deepen the understanding. FINDINGS: The over-arching theme Unchallenged hospital 'rules' comprised the two main themes of Safety-driven support by midwives and Silent voices of the parents. The hospital guidelines and practices guided the first hour, unchallenged by parents and midwives. Based on the guidelines, all the babies were given skin-to-skin contact early but not immediately. Midwives strictly followed the guidelines and performed many activities with the mothers during the first hour. Embedded power was present: midwives were in control but tended to listen to the parents. Although the mothers displayed a strong need to be close to their babies, their voices were silent in the units. The parents' compliance with midwives and parents' intense focus on the baby strengthened the midwives' embedded power. KEY CONCLUSION: Care culture in birthing units was 'rule-based' and the guidelines and practices sometimes inhibited uninterrupted skin-to-skin contact without questioning. The golden hour was mainly controlled by the maternity care staff. IMPLICATIONS FOR PRACTICE: Re-evaluation of hospital guidelines should enable more woman- and family-centred care. The golden hour is unique to families, and unnecessary separation and interventions should be avoided.

Do Hospitals with a Higher Level of Maternal Care Designation Have Better Maternal Outcomes?

BACKGROUND: A recent document by the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine introduced the concept of uniform levels of maternal care (LMCs). OBJECTIVE: We assessed LMC across hospitals and measured their association with maternal morbidity, focusing on women with high-risk conditions. STUDY DESIGN: We collected data from hospitals from May to November 2015 and linked survey responses to Statewide Inpatient Databases (SID) hospital discharge data in a retrospective cross-sectional study of 247,383 births admitted to 236 hospitals. Generalized logistic regression models were used to examine the associations between hospitals' LMC and the risk of severe maternal morbidity. Stratified analyses were conducted among women with high-risk conditions. RESULTS: High-risk pregnancies were more likely to be managed in hospitals with higher LMC (p < 0.001). Women with cardiac conditions had lower odds of maternal morbidity when delivered in level I compared with level IV units (adjusted odds ratio: 0.29; 95% confidence interval: 0.08-0.99; p = 0.049). There were no other significant associations between the LMC and severe maternal morbidity. CONCLUSION: A higher proportion of high-risk pregnancies were managed within level IV units, although there was no overall evidence that these births had superior outcomes. Further prospective evaluation of LMC designation with patient outcomes is necessary to determine the impact of regionalization on maternal outcomes.

Identifying Continuous Quality Improvement Priorities in Maternal, Infant, and Early Childhood Home Visiting.

OBJECTIVE: The purpose of this article was to describe a methodology to identify continuous quality improvement (CQI) priorities for one state's Maternal, Infant, and Early Childhood Home Visiting program from among the 40 required constructs associated with 6 program benchmarks. The authors discuss how the methodology provided consensus on system CQI quality measure priorities and describe variation among the 3 service delivery models used within the state. DESIGN: Q-sort methodology was used by home visiting (HV) service delivery providers (home visitors) to prioritize HV quality measures for the overall state HV system as well as their service delivery model. RESULTS: There was general consensus overall and among the service delivery models on CQI quality measure priorities, although some variation was observed. Measures associated with Maternal, Infant, and Early Childhood Home Visiting benchmark 1, Improved Maternal and Newborn Health, and benchmark 3, Improvement in School Readiness and Achievement, were the highest ranked. CONCLUSIONS: The Q-sort exercise allowed home visitors an opportunity to examine priorities within their service delivery model as well as for the overall First Teacher HV system. Participants engaged in meaningful discussions regarding how and why they selected specific quality measures and developed a greater awareness and understanding of a systems approach to HV within the state. The Q-sort methodology presented in this article can easily be replicated by other states to identify CQI priorities at the local and state levels and can be used effectively in states that use a single HV service delivery model or those that implement multiple evidence-based models for HV service delivery.

Mix of Maternity Care Providers in Canada.

OBJECTIVE: To identify the factors influencing women's choice of maternity care providers in Canada. METHOD: Using the Maternity Experience Survey and a multinomial logit model, this paper examined the influence of various socio-economic and demographic factors on the mix of maternity care providers, while controlling for maternal risk profiles. Additionally, provinces were interacted with maternal age to assess the extent to which regional variations in mix of maternity care providers is influenced by pregnant women's needs. RESULTS: Besides maternal risk factors, province of prenatal care and the place of residence were found to be statistically significant determinants of choice of maternity care providers. Analysis involving interaction terms indicated wide regional variations in the mix of providers by maternal age. CONCLUSIONS: The results suggest a wide provincial variation in the mix of maternity care providers. New provincial government initiatives are needed to enhance the supply and capacity of care providers.

Taxonomy for complexity theory in the context of maternity care.

BACKGROUND: The linear focus of 'normal science' is unable to adequately take account of the complex interactions that direct health care systems. There is a turn towards complexity theory as a more appropriate framework for understanding system behaviour. However, a comprehensive taxonomy for complexity theory in the context of health care is lacking. OBJECTIVE: This paper aims to build a taxonomy based on the key complexity theory components that have been used in publications on complexity theory and health care, and to explore their explanatory power for health care system behaviour, specifically for maternity care. METHOD: A search strategy was devised in PubMed and 31 papers were identified as relevant for the taxonomy. FINDINGS: The final taxonomy for complexity theory included and defined 11 components. The use of waterbirth and the impact of the Term Breech trial showed that each of the components of our taxonomy has utility in helping to understand how these techniques became widely adopted. It is not just the components themselves that characterise a complex system but also the dynamics between them.

Distance to emergency obstetric services and early neonatal mortality in Ethiopia.

OBJECTIVES: To assess the effect of distance to emergency obstetric and newborn care (EmONC) services on early neonatal mortality in rural Ethiopia and examine whether proximity to services contributes to socio-economic inequalities in early neonatal mortality. METHODS: We linked data from the 2011 Ethiopian Demographic and Health Survey with facility data from the 2008 Ethiopian National EmONC Needs Assessment based on geographical coordinates collected in both surveys. Health facilities were classified based on the performance of nine EmONC signal functions (e.g. neonatal resuscitation, Caesarean section). We used multivariable logistic regression to assess the relationship between distance to services and early neonatal mortality. A decomposition approach was used to quantify the relative contributions of distance to EmONC services and other determinants to overall and socio-economic inequality in early neonatal mortality. RESULTS: In general, closer proximity to EmONC services and higher level of care were associated with lower early neonatal mortality. Living more than 80 km from the nearest comprehensive EmONC facility able to perform all nine signal functions compared to living within 10 km was associated with an increase of 14.4 early neonatal deaths per 1000 live births (95% CI: 0.1, 28.7). Closer proximity to a substandard EmONC facility compared with no facility was not associated with lower early neonatal mortality. Distance to EmONC services was an important determinant of early neonatal mortality, although it did not make a significant contribution to explaining socio-economic inequality. CONCLUSIONS: Our results suggest that recent initiatives by the Ethiopian government to improve geographical access to EmONC services have the potential to reduce early neonatal mortality but may not affect inequalities.

Births: final data for 2008.

OBJECTIVES: This report presents 2008 data on U.S. births according to a wide variety of characteristics. Data are presented for maternal demographic characteristics including age, live-birth order, race and Hispanic origin, marital status, attendant at birth, method of delivery, and infant characteristics (period of gestation, birthweight, and multiple births). Birth and fertility rates by age, live-birth order, race and Hispanic origin, and marital status also are presented. Selected data by mother's state of residence are shown, as well as data on age of father. Trends in fertility patterns and maternal and infant characteristics are described and interpreted. METHODS: Descriptive tabulations of data reported on the birth certificates of the 4.25 million births that occurred in 2008 are presented. Denominators for population-based rates are postcensal estimates derived from the U.S. 2000 census. RESULTS: A total of 4,247,694 births were registered in the United States in 2008, 2 percent less than in 2007. The general fertility rate declined 1 percent to 68.6 per 1,000. The teenage birth rate declined 2 percent to 41.5 per 1,000. Birth rates for women aged 20 to 39 years were down 1-3 percent, whereas the birth rate for women aged 40-44 rose to the highest level reported in more than 40 years. The total fertility rate declined 2 percent to 2,084.5 per 1,000 women. All measures of unmarried childbearing reached record levels-40.6 percent of births were to unmarried women in 2008. The cesarean delivery rate rose again to 32.3 percent. The preterm birth rate declined for the second consecutive year to 12.3 percent; the low birthweight rate was down very slightly. The twin birth rate increased 1 percent to 32.6 per 1,000; the triplet and higher-order multiple birth rate was stable.

[Consultation in a baby clinic of the PMI (mother and infant welfare service): a survey in a French department]. / Consultation du nourrisson en PMI: enquête auprès des usagers et des professionnels d'un département français.

A dual survey carried out amongst the users and the professionals of PMI showed that proximity, the range of advice available, the exchanges on parenthood, and the assessment of the child's physical and mental progress and of his/her development are the key elements that parents are looking for. It is also noted that the majority of these parents deliberately consult these services. The objectives when consulting vary, going from a model based on the body and physical abilities, found especially in lower and disadvantaged groups, to one emphasising the child's psychological aspect and potential, which is the prerogative of the middle and higher classes. Indeed, although the PMI is particularly aimed at families in difficulties, all the social classes are now represented among the users. The primary role of prevention of PMI means that few parents go there specifically for the treatment of a medical disease. The majority of families maintain a parallel follow-up with another medical professional, usually a general practitioner with whom the PMI has very little contact. Given the decrease in the current medical demography and the governmental directives aimed at improving care in the prenatal period, the prospect of a closer working relationship between these two parties involved in infant welfare would seem to be a way of the future.

Measures of strength for maternal health programs in 55 developing countries: the MNPI study.

OBJECTIVES: To measure levels and types of effort for national maternal and neonatal health programs in 55 developing countries, in 2002, as a replication of a 1999 study. METHODS: Thirteen components of program effort were covered, based on 81 items in questionnaires completed by 10-25 expert respondents in each country. RESULTS: With 100% representing maximum effort, the international average was 58-60%, and the 13 component averages varied from 48 to 72%. The components included health center and district hospital capacities, services provided, proportion of the rural and urban populations with actual access to the services, together with the support functions of policy, training, education, resources, and evaluation. Scores are high for policies but low for access, resources, training, and public education. CONCLUSIONS: National programs to improve maternal health are far from satisfactory, as assessed here, with negligible improvement from 1999-2002. Efforts fall short in general, but considerably more so for some program features than others. Literal access to basic services is poor, and is especially lacking in rural areas. Regions differ much more in the access they provide to services than in other respects.

WHO indicators for evaluation of maternal health care services, applicability in least developed countries: a case study from Eritrea.

The World Health Organization has recommended a number of process indicators to monitor the effect of health care programmes on maternal mortality. This study was therefore conducted to know if the recommended process indicators are useful also in the least developed countries. In 1994, all 17 health facilities offering maternal health care in a rural province in Eritrea were visited. An assessment was made of the obstetric services provided, obstetric complications, and accessibility of health facilities. The study revealed that necessary data were available for most indicators. The indicators were helpful to follow the coverage of obstetric care and to identify problems within the health care system. However, in countries where the coverage of assisted deliveries is low with few obstetric complications seen within the health care system, the indicators cannot be used as a tool to monitor the effect of maternal health care programmes on maternal mortality.

Indicadores de población 2002 / Population indicators 2002

El documento Indicadores depoblación 2002 del Departamento de Nueva Segovia, presenta los indicadores de población por Municipio, el cumplimiento de los indicadoires de reducción de la pobreza durante el aó 2001, así como la gráficas de las tendencias de mortalidad materna en Nueva Segovia durante el período 1996 a febrero 2002, la tendencia de la mortalidad infantil durante el período 1992 a febrero 2002, la tendencia de la tasa de mortalidad neonatal precoz durante el período 1996 a febrero 2002, las principales tasa de mortalidad de la niñez por SILAIS y Hospital de Ocotal durante el 2001, los abastecimientos de insumos médicos para urgencias obstetricas y para la atención de la niñez durante el año 2001 y 2002. También presenta el monitoreo de los indicadores del 2002 de la Cobertura de Planificación familiar, Atención Prenatal, la Captación temparan de la Atención prenatal durante el año 2002

[Evaluation of a classification of newborns and maternity wards in the Loire-Atlantique department]. / Etude d'une classification des nouveau-nés et des maternités dans le département de Loire-Atlantique.

In order to assess the perinatal health policy in a French department in comparison with other policies, we performed a prospective transversal survey in the Loire-Atlantique for 5 weeks. Newborns were registered according to clinical data using the Paris pediatricians classification (classes 1 to 4) and maternity wards by number of health personnel and facilities using the American Academy of Pediatrician classification (I-III). 1316 newborns were registered. This survey showed that the health care organization in maternity wards is rational in the Loire-Atlantique for newborns in classes 1 and 4. However, care for newborns in classes 2 and 3 could be provided in maternity wards in classes II and III if available personnel and equipment is improved.

Avaliaçäo de serviços de saúde: um desenho epidemiológico / Health services evaluation: an epidemiologic approach

Inicialmente, a partir da revisäo da literatura sobre avaliaçäo de serviços de saúde e epidemiologia da saúde materno-infantil, justificamos a importância de avaliar os serviços de saúde, públicos e privados, utilizados pela populaçäo materno-infantil, enquanto impacto das açöes de saúde (resultados), a partir de indicadores do processo de assistência à saúde, guardadas as devidas dimensöes próprias da epidemiologia de modo a incorporar o conceito de risco/proteçäo ("marcador"). Em decorrência, fornecer subsídios para o planejamento em saúde a fim de contribuir para a consolidaçäo de Sistema Unico de Saúde, conforme consta dos nossos objetivos. A metodologia usada é o estudo tipo coorte junto à populaçäo materno-infantil do Jardim Campos Elíseos, periferia do município de Campinas, caracterizada conforme a situaçäo social (condiçöes de vida, condiçöes de moradia e condiçöes de saneamento), nutricional (antropometria, alimentaçäo e amamentaçäo) e assistencial (demanda de saúde, processo de assistência, impacto das açöes de saúde e participaçäo popular no sistema de saúde) no que se refere aos equipamentos de saúde, conforme o tipo de serviço utilizado. Encontrou-se diferença significativa, entre as populaçöes dos diferentes serviços, quanto às variáveis sociais para renda, anos de estudo materno e localizaçäo damoradia, quanto às variáveis sociais para renda, anos de estudo materno e localizaçäo damoradia, quanto às variáveis nutricionais para estado nutricional pré-gestacional, ganho de peso na gestaçäo e consumo de frutas para as gestantes e idade de introduçäo de frutas para as crianças. Quanto aos indicadores de processo, observou-se diferença para idade na primeira consulta de pré-natal e puericultura, tempo de espera, número de serviços de saúde utilizados pela criança e satisgaçäo com o atendimento, negativamente para o serviço público. No que se refere aos indicadores de impacto, encontrou-se diferença para tipo de parto e tipo de alojamento ao nascer, negativamente para o serviço privado. Sugere-se a adoçäo destes indicadores na monitorizaçäo da avaliaçäo de serviços de saúde, buscando a melhoria do atendimento público e o direito à saúde de alta qualidade para todos os cidadäos

Which maternity unit? Who makes the choice?

To investigate the factors determining the choice of maternity unit in an outer London district where half of all births occur outside the district, a self-administered questionnaire was distributed by community midwives at postnatal home visits. The main outcome measures were: (1) proportion of mothers able to deliver in unit of first choice; (2) proportion of mothers making a personal choice rather than taking advice from their GP; (3) reasons for not choosing district unit, by parity. It was found that 28/166 (17 per cent) of mothers were unable to deliver in their first choice of unit, and 3/166 (2 per cent) were unable to obtain their second choice. Of the women who did obtain their first choice, 84/136 (62 per cent) had made a personal decision rather than being advised or told by their GP; 58 of these 84 personal deciders went outside the district, but for 36/58 (62 per cent) this was either because the other unit was nearer their home or because they had delivered there before. It is concluded that, although GPs are theoretically free to refer to any maternity unit, a sizeable minority of women are unable to realize their own choices. GPs seem to regulate flows by advising women without strong personal views to attend the local unit. Differences in the quality of care as perceived either by women or their GPs do not seem particularly important in determining choices. The introduction of an internal market in maternity care seems unlikely to result in improved quality of care.

Social classification and maternity practices in Aurangabad, India.

A population of 3870 individuals constituting 823 families residing in five different localities of Aurangabad city was surveyed by house to house visits. The objectives of the study were to assess the validity of social classification by residence in certain localities. The variable used in the study was maternity practices. Family members and children under five years of age were recorded. Mothers of children were asked occupation of the head of the family and delivery details pertaining to these children. Social class was decided by residence in particular localities of the city, classified according to easily ascertainable characteristics of housing. Validity of such classification was judged by comparing it with classification by well known variable like occupation. The findings indicate that the system provides an inexpensive and rapid method of social classification. A total of 661 deliveries were recorded. A total of 67.62% deliveries were conducted in Government or Private Institutions. The remaining deliveries were home deliveries conducted by untrained personnel. Indigenous dais (traditional birth attendants) conducted 20.27% and senior female relatives 10.89% of the total deliveries. The findings, thus, stress the need of identifying and training dais in urban areas.