Towards achievement of Sustainable Development Goal 3: multilevel analyses of demographic and health survey data on health insurance coverage and maternal healthcare utilisation in sub-Saharan Africa.

BACKGROUND: Improving maternal health and achieving universal health coverage (UHC) are important expectations in the global Sustainable Development Goals (SDGs) agenda. While health insurance has been shown as effective in the utilisation of maternal healthcare, there is a paucity of literature on this relationship in sub-Saharan Africa (SSA). We examined the relationship between health insurance coverage and maternal healthcare utilisation using demographic and health survey data. METHODS: This was a cross-sectional study of 195 651 women aged 15-49 y from 28 countries in SSA. We adopted bivariable and multivariable analyses comprising χ2 test and multilevel binary logistic regression in analysing the data. RESULTS: The prevalence of maternal healthcare utilisation was 58, 70.6 and 40.7% for antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC), respectively. The prevalence of health insurance coverage was 6.4%. Women covered by health insurance were more likely to utilise ANC (adjusted OR [aOR]=1.48, 95% CI 1.41 to 1.54), SBA (aOR=1.37, 95% CI 1.30 to 1.45) and PNC (aOR=1.42, 95% CI 1.37 to 1.48). CONCLUSION: Health insurance coverage was an important predictor of maternal healthcare utilisation in our study. To accelerate progress towards the achievement of SDG 3 targets related to the reduction of maternal mortality and achievement of UHC, countries should adopt interventions to increase maternal insurance coverage, which may lead to higher maternal healthcare access and utilisation during pregnancy.

Prevalence and determinants of maternal healthcare utilisation among young women in sub-Saharan Africa: cross-sectional analyses of demographic and health survey data.

BACKGROUND: Maternal health constitutes high priority agenda for governments across the world. Despite efforts by various governments in sub-Saharan Africa (SSA), the sub-region still records very high maternal mortality cases. Meanwhile, adequate utilization of maternal healthcare (antenatal care [ANC], skilled birth attendance [SBA], and Postnatal care [PNC]) plays a vital role in achieving improved maternal health outcomes. We examined the prevalence and determinants of maternal healthcare utilization among young women in 28 sub-Saharan African countries using data from demographic and health surveys. METHODS: This was a cross-sectional study of 43,786 young women aged 15-24 years from the most recent demographic and health surveys of 28 sub-Saharan African countries. We adopted a multilevel logistic regression analysis in examining the determinats of ANC, SBA, and PNC respectively. The results are presented as adjusted Odds Ratios (aOR) for the logistic regression analysis. Statistical significance was set at p < 0.05. RESULTS: The prevalence of maternal healthcare utilisation among young women in SSA was 55.2%, 78.8%, and 40% for ANC, SBA, and PNC respectively with inter-country variations. The probability of utilising maternal healthcare increased with wealth status. Young women who were in the richest wealth quintile were, for instance, 2.03, 5.80, and 1.24 times respectively more likely to utilise ANC (95% CI = 1.80-2.29), SBA (95% CI = 4.67-7.20), and PNC (95% CI = 1.08-1.43) than young women in the poorest wealth quintile. Young women who indicated having a barrier to healthcare utilisation were, however, less likely to utilise maternal healthcare (ANC: aOR = 0.83, 95% CI = 0.78-0.88; SBA: aOR = 0.82, 95% CI = 0.75-0.88; PNC: aOR = 0.88, 95% CI = 0.83-0.94). CONCLUSION: While SBA utilisation was high, we found ANC and PNC utilisation to be quite low among young women in SSA with inter-country variations. To accelerate progress towards the attainment of the Sustainable Development Goal (SDG) targets on reducing maternal mortality and achieving universal health coverage, our study recommends the adoption of interventions which have proven effective in some countries, by countries which recorded low maternal healthcare utilisation. The interventions include the implementation of free delivery services, training and integration of TBAs into orthodox maternal healthcare, improved accessibility of facilities, and consistent public health education. These interventions could particularly focus on young women in the lowest wealth quintile, those who experience barriers to maternal healthcare utilisation, uneducated women, and young women from rural areas.

Individual and contextual factors associated with maternal healthcare utilisation in Mali: a cross-sectional study using Demographic and Health Survey data.

OBJECTIVE: We examined the national prevalence as well as the individual and contextual factors associated with maternal healthcare utilisation in Mali. SETTING: The study was conducted in Mali. PARTICIPANTS: We analysed data on 6335 women aged 15-49 years from Mali's 2018 Demographic and Health Survey. OUTCOME VARIABLE: Maternal healthcare utilisation comprising antenatal care (ANC) attendant, skilled birth attendant (SBA), and postnatal care (PNC) attendant, was our outcome variable. RESULTS: Prevalence of maternal healthcare utilisation was 45.6% for ANC4+, 74.7% for SBA and 25.5% for PNC. At the individual level, ANC4 + and SBA utilisation increased with increasing maternal age, level of formal education and wealth status. Higher odds of ANC4 + was found among women who are cohabiting (adjusted OR (aOR)=2.25, 95% CI 1.16 to 4.37) and delivered by caesarean section (aOR=2.53, 95% CI 1.72 to 3.73), while women who considered getting money for treatment (aOR=0.72, 95% CI 0.60 to 0.88) and distance to health facility (aOR=0.73, 95% CI 0.59 to 0.90) as a big problem had lower odds. Odds to use PNC was higher for those who were working (aOR=1.22, 95% CI 1.01 to 1.48) and those covered by health insurance (aOR=1.87, 95% CI 1.36 to 2.57). Lower odds of SBA use were associated with having two (aOR=0.48, 95% CI 0.33 to 0.71), three (aOR=0.37, 95% CI 0.24 to 0.58), and four or more (aOR=0.38, 95% CI 0.24 to 0.59) children, and residing in a rural area (aOR=0.35, 95% CI 0.17 to 1.69). Listening to the radio and watching TV were associated with increased maternal healthcare utilisation. CONCLUSION: The government should increase availability, affordability and accessibility to healthcare facilities by investing in health infrastructure and workforce to achieve Sustainable Development Goal 3.4 of reducing maternal morality to less than 70 deaths per 100 000 live births by 2030. It is important to ascertain empirically why PNC levels are astonishingly lower relative to ANC and SBA.

Legal and Ethical Considerations during Maternal Death Surveillance and Response.

Maternal death surveillance and response (MDSR) is a promising strategy, to identify record and track key drivers of maternal deaths. Despite its potential in reducing maternal mortality, ethical and legal challenges need to be properly ascertained and acted upon, to guarantee its acceptability, sustainability, and effectiveness. This paper proposes a legal and ethical framework to guide practitioners and researchers through the MDSR process. Three (03) categories of both legal and ethical issues are discussed: namely the issues related to data, people and use of findings. Most challenges of the MDSR strategy have ethical and legal underappraisal origins, the most outstanding being the low maternal death notification rates. Efforts should be made for respondents to properly understand the rationale for the process, and how the data obtained will be put into use. Dispelling fears of possible litigation remains fundamental in obtaining quality data. Health care providers involved in the process need to understand their ethical and legal responsibilities, as well as privileges (legal protection). It is hoped that this framework will offer a structure to guide professionals in improving MDSR implementation and research.

Eliminating the high abortion related complications and deaths in Cameroon: the restrictive legal atmosphere on abortions is no acceptable excuse.

BACKGROUND: The abortion law in Cameroon is highly restrictive. The law permits induced abortions only when the woman's life is at risk, to preserve her physical and mental health, and on grounds of rape or incest. Unsafe abortions remain rampant with however rare reported cases of persecution, even when these abortions are proven to have been carried out illegally. DISCUSSION: Available public health interventions are cheap and feasible (Misoprostol and Manual Vacuum Aspiration in post abortion care, modern contraception, post-abortion counseling), and must be implemented to reduce unacceptably high maternal mortality rates in the country which still stand at as high as 596/100.000. Changes in the legal status of abortions might take a long time to come by. Albeit, advocacy efforts must be reinforced to render the law more liberal to permit women to seek safe abortion services. The frequency of abortions, generally clandestine, in this restrictive legal atmosphere has adverse economic, health and social justice implications. CONCLUSION: We argue that a non-optimal or restrictive legal atmosphere is not an acceptable excuse to justify these high maternal deaths resulting from unsafe abortions, especially in Cameroon where unsafe abortions remain rampant. Implementing currently available, cheap and effective evidence based practice guidelines are possible in the country. Expansion and use of Manual Vacuum Aspiration kits in health care facilities, post-abortion misoprostol and carefully considering the content of post abortion counseling packages deserve keen attention. More large scale qualitative and quantitative studies nationwide to identify and act on context specific barriers to contraception use and abortion related stigma are urgently needed.

Use of criterion-based clinical audit to improve the quality of obstetric care: A systematic review.

Although there is evidence that audit and feedback can improve health outcomes, little is known about the effect of audit on the quality of care from client's perspective. The aim of the current review was to explore the use of criterion-based audit to improve quality of obstetric care from both the midwives/doctors' and women/mothers' perspectives. Electronic searches of Cochrane Library, MEDLINE, and EMBASE were conducted. Randomized controlled trials (RCTs) and before-and-after studies that assessed the effect of criterion-based audit on health outcomes or women/mothers' perception of obstetric care were set as selection criteria. Data were extracted, analyzed using Revman 4.2 software, and results expressed as weighted mean differences for continuous data, and odds ratios for dichotomous data. Nineteen studies (one RCT and 18 before-and-after studies) involving 32,972 participants met our inclusion criteria. None of these studies assessed the effect of audit on quality from the women/mothers' perspective and none of the studies compared the effectiveness of different types of feedback. Ninety-five percentage (18/19) of studies showed significant improvement in at least one standard measured. Criterion-based audit has been used in obstetrics to improve quality from one dimension, namely the midwives/doctors' perspective. Midwives/doctors should consider the use of audit to improve quality of care from the mothers' view. There is need for well-designed RCTs to assess the effectiveness of different types of feedback in criterion-based audit.

A systematic review of randomized controlled trials of prenatal and postnatal vitamin A supplementation of HIV-infected women.

We searched the Cochrane Library, MEDLINE, EMBASE, AIDSearch, and Gateway to assess the effect of prenatal and/or postnatal vitamin A supplementation on the risk of mother-to-child transmission (MTCT) of HIV and other pregnancy outcomes. We included 5 trials totaling 7528 women (4 trials of prenatal and 1 trial of postnatal supplementation). Overall, there was no evidence of an effect of prenatal and/or postnatal vitamin A supplementation on the risk of MTCT of HIV (Relative Risk [RR] 1.06, 95% Confidence Interval [CI] 0.89-1.26). However, prenatal vitamin A supplementation significantly improved birth weight (weighted mean difference 89.78; 95% CI, 84.73-94.83), but there was no evidence of an effect on stillbirths (RR 0.99; 95% CI, 0.68-1.43), preterm births (RR 0.88; 95% CI, 0.65-1.19), death before 24 months among live births (RR 1.08; 95% CI, 0.91-1.29), and maternal death (RR 0.83; 95% CI, 0.59-1.17). The available evidence does not support vitamin A supplementation of HIV-infected pregnant and lactating women, despite improvement in birth weight.

A criterion based audit of the management of obstructed labour in Malawi.

OBJECTIVE: To assess and improve the management of obstructed labour in maternity units in Malawi. METHODS: A criterion based audit of the management of obstructed labour was conducted in 8 hospitals in three districts in Malawi. Management practices were: (a) assessed by a retrospective review of 44 cases notes, and (b) compared with local standards established, by a multidisciplinary team, based on the Malawi Ministry of Health guidelines and World Health Organisation manuals. Gaps in current practice were identified, reasons discussed, and recommendations made and implemented. A re-audit (41 case notes) was conducted 3 months later. RESULTS: There were significant improvements in the attainment of four standards: draining of urinary bladder (70.5 vs. 90.2%; P = 0.022), administration of broad spectrum antibiotics (72.7 vs. 90.2%; P = 0.039), commencement of Caesarean section within 1 hour or delivery of the foetus within 2 h of diagnosis (38.6 vs. 61.0%; P = 0.023), and maintaining an observation chart (45.5 vs. 61.0%; P < 0.001). However, there was no significant change in two standards: securing an intravenous line and hydrating the patient (95.5 vs. 97.6%; P = 0.804), and typing and cross-match of blood (77.3 vs. 63.4%; P = 0.197). There was a reduction in case fatality rate (9.1 vs. 2.4%; P = 0.361) and perinatal mortality (18.8 vs. 12.2%, P = 0.462). CONCLUSION: Criterion based audit can improve the management of obstructed labour in countries with limited resources.

Adverse perinatal outcomes of adolescent pregnancies in Cameroon.

BACKGROUND: There are geographic variations in fetal outcomes of adolescent pregnancies because of socio-economic differences between regions and countries. The aim of our study was to determine adverse fetal outcomes associated with adolescent pregnancies in Cameroon. METHODS: A cross-sectional study to compare the outcomes of 268 singleton, adolescent pregnancies with 832 controls, delivered in four referral hospitals in Yaounde (Cameroon), between November 2004 and April 2005. RESULTS: The adverse fetal outcomes related to adolescent pregnancies were low birth weight (<2,500 g) (odds ratios [OR], 1.71; confidence interval [CI], 1.15-2.50), premature babies (<37 weeks) (OR, 1.77; CI, 1.24-2.52) and early neonatal death (OR, 2.18; CI, 1.04-4.48). The rates of stillbirth and intrauterine growth retardation were not significantly higher among adolescents. Adverse maternal outcome associated with adolescent pregnancies were eclampsia (OR, 3.18; CI, 1.21-8.32), preeclampsia (OR, 1.99; CI, 1.24-3.15), perineal tear (OR, 1.45; CI, 1.06-1.99) and episiotomy (OR, 1.82; CI, 1.20-2.73). Caesarean delivery, instrumental delivery and premature rupture of membranes were not significantly associated with adolescent pregnancy. Maternal factors associated with adverse fetal outcome in adolescents were maternal age, number of prenatal visits <4, and the state of being unemployed. CONCLUSION: Adolescent pregnancies are associated with both adverse fetal and maternal outcomes in Cameroon. Improving compliance with prenatal care could significantly reduce the frequency of adverse fetal outcomes in adolescent populations in Cameroon.