Improving reproductive health services: Is integration with primary healthcare better than vertical programmes?

Background
Dehumanization of childbirth is one major factor deterring pregnant women from seeking facility based delivery contributing to stagnating indicators of MDG 4 and 5 including skilled birth attendance (SBA) rates.
Methods
A qualitative study was conducted in Kenya across 5 districts through 60 case narratives with women who had delivered in the last one year at a health facility or at home. This study sought to explore the determinants of place of delivery and explore the effect of dehumanized child birth experiences on utilization of SBA.
Results
The key determinants of place of delivery was perceptions of respectful care accorded, availability of money to finance health care, fear of HIV testing and socio-cultural beliefs associated with childbirth. Dehumanized childbirth was associated with use of unskilled birth attendance mainly untrained traditional birth attendants. TBAs were often sought as alternatives for provision of delivery services because they have cheaper negotiable prices; they are polite and respectful, did not detain mothers, and offered more friendly services.
Dehumanized treatment during child birth is a deterrent to SBA and service improvements addressing this aspect of care are likely to have a positive impact on health seeking behavior through encouraging utilization of SBA.

Poor maternal health remains a major reproductive health concern in developing countries, despite perceptible strides being made to reduce maternal morbidity and mortality. India has implemented the reproductive and child health (RCH) programmes after the ICPD (1994) at Cairo, which reiterated the need for health care services to enable women to go safely through pregnancy and child birth using Indian National Family and Health Survey-3 (2005-06). Results found that health complications by women vary hugely by region, ranging from 57% in East to 28% in South. Odds ratios indicate health complications is four times higher in the East compared to South (p<0.01). Women in rural areas reported more complications than those in urban areas (p<0.05). Uneducated and poorer women reported more complications compared to educated and richer women, with odds ratios of 20% higher. Women receiving ANC services also indicate lower health complications compared to women not availing ANC services (p<0.01). Analysis clearly signifies the impact of socio-economic, cultural and demographic factors on maternal health, particularly across the regions. Specific regional maternal health programmes that account for the diverse socio-cultural and demographic characteristics are essential to mitigate the regional disparity.

Quality education and sexual and reproductive health services are key to reducing the vulnerability of HIV and STI especially among young people. While the former enhances the knowledge capacity to develop the ‘power within’ to facilitate safer sex practices and reduce misconceptions and stigma, the latter provides hope via access to treatment. While external support is critical, local partnerships and development of innovative structures and arrangements are imperative. In Cape Coast, the Planned Parenthood Association of Ghana and the University of Cape Coast have partnered in this direction. Using various methodologies such as action-based teaching, peer education and mobile clinic, students’ knowledge about and access to HIV and STIs services have improved. These have contributed to students’ willingness to know their HIV status and seek treatment directly or through a referral system. The sustainability of such a partnership is essential.

The aim of this paper is to study the demand for long-acting and permanent contraceptive methods (LAPCMs), and its determinants among Kurdish women in Mahabad city, Iran. Data are taken from Mahabad Fertility Survey (MFS) conducted on a sample of over 700 households in April 2012. The results show that the demand for LAPCMs was 71.3 percent at the time of survey, although only 27.7 percent of women used these methods. Thus, the number of unintended pregnancies is likely to increase in the future if this gap does not reduce. The multivariate analysis shows significant impacts on the dependent variable of the number of children ever born, the perceived contraceptive costs, and childbearing intentions. Moreover, women at the end of reproductive ages and those with higher education are more likely to desire LAPCMs. The paper concludes that despite a growing use of contraceptive methods in recent decades, the need to develop reproductive health services, and promote the quality of family planning services remains an inevitable necessity.

Obstetric fistula is a demoralizing pregnancy related disability mostly observed in the developing countries. District Level Household and Facility Survey (DLHS-III) states that India is such a country where the prevalence of fistula is 1.5 percent. Much of the studies done on fistula are clinical based studies. Literature on the socio-economic and demographic factors associated with fistula in Indian context is scanty. Current study is an attempt to identify the prevalence and discrepancy of obstetric fistula among Indian women. This study uses data from the DLHS-III, 2007-08. Bi-variate and multivariate analysis will be employed in the study. The preliminary findings reveal that the woman with a disadvantaged socio-economic background is most likely to be adversely affected by the incidence of fistula.
(Key Words: Obstetric Fistula, public health, India)

The paper analyses the realities of maternal health seeking-behaviour among the Sabiny in relation to health policy ideals. It is based on a study of maternal health among the Sabiny, Eastern Uganda that was conducted in 2011 and 2012. Secondary quantitative data were analysed and primary data were collected using in-depth interviews with mothers; focus group discussions with mothers and fathers; key informant interviews, and observation of delivery settings (both at health facilities and home). Findings reveal that the majority of Sabiny women opt for homebirths, with around a quarter delivering at health facilities. Some women would prefer to deliver at a health facility but do not manage to do so. Sabiny culture is a determining factor in delivery setting. Comprehension and accommodation of Sabiny concerns within available maternal health services is limited, highlighting the need to develop cultural competence among health workers and methods of accommodating (health-promoting) local practices. This should be accompanied by improved patient care and a narrowing of the gap between health workers and Sabiny communities by revitalizing outreach and community-based health interventions. The paper highlights how the implementation of policy should be tailored to specific local contexts.

India has been trying to improve the maternal health care services but it is still low in Empowered Action Group (EAG) states. These states are socioeconomically and demographically backward. These facts motivate to examine variations in utilization of maternal health care services among EAG states and to know socio-economic determinants of MHC services at district levels and household levels. Study utilizes the data from District Level Household and Facility Survey (2007-08) and Census of India 2001 for analysis. Composite index, Bivariate, correlation and logit regression technique is used for the analysis of data. Result shows that Jharkhand and Orissa have the highest and lowest score in maternal health care index (MHCI) as, 0.11 and 0.72 respectively. The correlation Score (0.27) between MHCI and Socio-economic Development Index at state level is positive . More importantly the factors that influence the utilization of MHC. at district level is the electricity followed by female literacy rate and non-agricultural workforce participation among the development indicators in each EAG states. P value shows that those women who have received ANC have double chance to receive safe delivery and taking PNC within two weeks.

The purpose of this paper is to investigate the poor reproductive health system performance in Sudan as well as understand better the barriers of utilization of perinatal health services. Data used in the analysis come from two national representative surveys, Sudan Household health Survey in 2006 and 2010 and health facility survey 2008. Samples of 6173 and 6065 married women in reproductive age in 2006 and 2010 respectively and 4745 health facility are used in the analysis. Furthermore, primary qualitative comes from 8 FGDs discussion with women and village midwifes, 31 in-depth interviews with decision makers and stakeholders, health providers in 2012 used in the study.
A conceptual framework was developed to examine the impact of women’s characteristics and health system elements on material health using both qualitative and quantitative indicators. The indicators are on the individual, household, and community levels. Findings demonstrate that certain factors related to cultural and women’s status aspects as well as factors related to health system in Sudan are the most significant factors that constitute challenges in the utilization of perinatal health service among women thus affect maternal health. Some policy implications and suggestions to reform reproductive health system under limited resources are discussed.

The integration of family planning and maternal and child health services was anticipated with the rationales that the women who come to use maternal and child health services may get exposed to the counselling and promotional efforts for family planning, may overcome uncertainties and myths associated with modern contraception and the integration will be able to save time-related cost of obtaining a method. Utilizing the contraceptive history data collected in National Family Health Survey-3 (2005-06), this study tries to examine the relationship between MCH services and subsequent contraceptive use in India. Multinomial regression models and Cox proportional hazard models evaluated whether services sought during ANC and/or PNC visit predicted the contraceptive adoption. The preliminary findings suggest that women visited for ANC and/or PNC were more likely to opt for a modern contraceptive method during postpartum period.

The Connect Project in Tanzania a strategy for scaling-up a field trial to become a national program. It operationalizes and evaluates the impact of a community-health worker program aimed at reducing child mortality through community-based primary healthcare services, including case management of childhood diarrhea, pneumonia and malaria. It commenced in 2011 as a randomized controlled trial with features to study the effects of implementation on health systems strength. Faced with high unmet need for contraception in the study population, Connect has integrated family planning into its primary health care operation. This is scaling up the program in phases guided by evidence. In the current paper, findings from a formative micro-pilot and qualitative case study impart lessons learned and clarify the determinants and processes of successfully integrating family planning into the Connect service system. Evidence from operations research demonstrates the relative quality, productivity and coverage achieved by the intervention in settings where family planning has been integrated and not. An end of project multi-level impact analysis is presented that projects the impact of distance to service point on fertility in areas exposed and unexposed to Connect services, forecasting fertility impact if results are extended to scale.