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Background: Most existing research on rural–urban health inequalities focuses on disparities in service access and health outcomes based on region. This paper examines rural–urban disparities in maternal healthcare utilization and delivery modes based on household registration (hukou) status to understand the role of state institutions in producing healthcare disparities in China. Methods: Utilizing administrative data from the Public Maternal Health Insurance scheme, we analyzed 54,733 live births in City A (2015–2019) and 25,849 live births in City B (2018–2019) in Guangdong Province in China. We constructed regression models using hukou status (rural versus urban) as the explanatory variable. Results: While there is no statistically significant difference in rural and urban mothers' probability of obtaining the minimum recommended number of prenatal care checkups in City A (OR = 0.990 [0.950, 1.032]), mothers with rural hukou status have a lower probability of obtaining the minimum recommended number of visits in City B than their counterparts with urban hukou (OR = 0.781 [0.740, 0.825]). The probability of delivering in tertiary hospital is lower among mothers with rural hukou than among those with urban hukou in both cities (City A: OR = 0.734 [0.701, 0.769]; City B: OR = 0.336 [0.319, 0.354]). Mothers with rural hukou are more likely to have a Cesarean section than those with urban hukou in both cities (City A: OR = 1.065 [1.027, 1.104]; City B: OR = 1.127 [1.069, 1.189]). Compared with mothers with urban hukou, mothers with rural hukou incurred 4 % (95 % CI [-0.046, -0.033]) and 9.4 % (95 % CI [-0.120, -0.068]) less in total medical costs for those who delivered via Cesarean section and 7.8 % (95 % CI [-0.085, -0.071]) and 19.9 % (95 % CI [-0.221, -0.177]) less for those who delivered via natural delivery in City A and City B, respectively. Conclusions: Rural hukou status is associated with younger age, no difference or lower probability of having a minimum number of prenatal checkups, higher likelihood of delivering in nontertiary hospitals, increased Cesarean delivery rates, and lower medical cost for delivery in these two Chinese cities. Evaluating how hukou status influences maternal healthcare in Chinese cities is important for devising targeted public policies to promote more equitable maternal health services. [ABSTRACT FROM AUTHOR]

Background: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania.Methods: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios.Results: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes.Conclusions: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system.Trial Registration: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009. [ABSTRACT FROM AUTHOR]

Background: The evaluation of payment for performance (P4P) programmes has focused mainly on understanding contributions to health service coverage, without unpacking causal mechanisms. The overall aim of the paper is to test the causal pathways through which P4P schemes may (or may not) influence maternal care outcomes.Methods: We used data from an evaluation of a P4P programme in Tanzania. Data were collected from a sample of 3000 women who delivered in the 12 months prior to interview and 200 health workers at 150 health facilities from seven intervention and four comparison districts in Tanzania in January 2012 and in February 2013. We applied causal mediation analysis using a linear structural equation model to identify direct and indirect effects of P4P on institutional delivery rates and on the uptake of two doses of an antimalarial drug during pregnancy. We first ran a series of linear difference-in-difference regression models to test the effect of P4P on potential mediators, which we then included in a linear difference-in-difference model evaluating the impact of P4P on the outcome. We tested the robustness of our results to unmeasured confounding using semi-parametric methods.Results: P4P reduced the probability of women paying for delivery care (-4.5 percentage points) which mediates the total effect of P4P on institutional deliveries (by 48%) and on deliveries in a public health facility (by 78%). P4P reduced the stock-out rate for some essential drugs, specifically oxytocin (-36 percentage points), which mediated the total effect of P4P on institutional deliveries (by 22%) and deliveries in a public health facility (by 30%). P4P increased kindness at delivery (5 percentage points), which mediated the effect of P4P on institutional deliveries (by 48%) and on deliveries in a public health facility (by 49%). P4P increased the likelihood of supervision visits taking place within the last 90 days (18 percentage points), which mediated 15% of the total P4P effect on the uptake of two antimalarial doses during antenatal care (IPT2). Kindness during deliveries and the probability of paying out of pocket for delivery care were the mediators most robust to unmeasured confounding.Conclusions: The effect of P4P on institutional deliveries is mediated by financing and human resources factors, while uptake of antimalarials in pregnancy is mediated by governance factors. Further research is required to explore additional and more complex causal pathways. [ABSTRACT FROM AUTHOR]

Background: Auxiliary Midwives (AMWs) are community health volunteers supporting the work of midwives, especially maternal and child health services in hard to-reach areas in Myanmar. This paper assessed the contributions of AMW to maternal and child health services, factors influencing their productivity and their willingness to serve the community.Method: The study applied quantitative cross-sectional survey using census method. Total of 1,185 AMWs belonging to three batches: trained prior to 2000, between 2000 and 2011, and in 2012, from 21 townships of 17 states and regions in Myanmar participated in the study. Multiple logit regression was used to examine the impact of age, marital status, education, domicile, recruitment pattern and 'batch of training', on AMW's confidence level in providing care, and their intention to serve the community more than 5 years.Results: All AMWs were able to provide essential maternal and child health services including antenatal care, normal delivery and post-natal care. They could identify and refer high-risk pregnancies to larger health facilities for proper management. On average, 9 deliveries, 11 antenatal and 9 postnatal cases were performed by an AMW during the six months prior to this study. AMWs had a comparative advantage for longer service in hard-to-reach villages where they lived, spoke the same dialect as the locals, understood the socio-cultural dimensions, and were well accepted by the community. Despite these contributions, 90 % of the respondents expressed receiving no adequate supervision, refresher training, replenishment of the AMW kits and transportation cost. AMWs in the elder age group are significantly more confident in taking care of the patients than those in the younger groups. Over 90 % of the respondents intended to stay more than five years in the community. The confidence in catering services appeared to have significant association with a longer period of stay in AMW jobs as evidenced by the odds ratio of 3.5, compared to those reporting unconfident.Conclusions: Comprehensive support system and national policy are needed to sustain and strengthen the contributions of AMWs, in sharing the workload of midwives, particularly in hard-to-reach areas of Myanmar. [ABSTRACT FROM AUTHOR]

Background: India has experienced a steep rise in institutional childbirth. The relative contributions of public and private sector facilities to emergency obstetric care (EmOC) has not been studied in this setting. This paper aims to study in three districts of Gujarat state, India:(a) the availability of EmOC facilities in the public and private sectors; (b) the availability and distribution of human resources for birth attendance in the two sectors; and (c) to benchmark the above against 2005 World Health Report benchmarks (WHR2005).Methods: A cross-sectional survey of obstetric care facilities reporting 30 or more births in the last three months was conducted (n = 159). Performance of EmOC signal functions and availability of human resources were assessed.Results: EmOC provision was dominated by private facilities (112/159) which were located mainly in district headquarters or small urban towns. The number of basic and comprehensive EmOC facilities was below WHR2005 benchmarks. A high number of private facilities performed C-sections but not all basic signal functions (72/159). Public facilities were the main EmOC providers in rural areas and 40/47 functioned at less than basic EmOC level. The rate of obstetricians per 1000 births was higher in the private sector.Conclusions: The private sector is the dominant EmOC provider in the state. Given the highly skewed distribution of facilities and resources in the private sector, state led partnerships with the private sector so that all women in the state receive care is important alongside strengthening the public sector. [ABSTRACT FROM AUTHOR]

Background: Though Janani Suraksha Yojana (JSY) under National Rural Health Mission (NRHM) is successful in increasing antenatal and natal care services, little is known on the cost coverage of out-of-pocket expenditure (OOPE) on maternal care services post-NRHM period.Methods: Using data from a community-based study of 424 recently delivered women in Rajasthan, this paper examined the variation in OOPE in accessing maternal health services and the extent to which JSY incentives covered the burden of cost incurred. Descriptive statistics and logistic regression analyses are used to understand the differential and determinants of OOPE.Results: The mean OOPE for antenatal care was US$26 at public health centres and US$64 at private health centres. The OOPE (antenatal and natal) per delivery was US$32 if delivery was conducted at home, US$78 at public facility and US$154 at private facility. The OOPE varied by the type of delivery, delivery with complications and place of ANC. The OOPE in public health centre was US$44 and US$145 for normal and complicated delivery, respectively. The share of JSY was 44 % of the total cost per delivery, 77 % in case of normal delivery and 23 % for complicated delivery. Results from the log linear model suggest that economic status, educational level and pregnancy complications are significant predictors of OOPE.Conclusions: Our results suggest that JSY has increased the coverage of institutional delivery and reduced financial stress to household and families but not sufficient for complicated delivery. Provisioning of providing sonography/other test and treating complicated cases in public health centres need to be strengthened. [ABSTRACT FROM AUTHOR]

Introduction: The drive toward universal health coverage (UHC) is central to the post 2015 agenda, and is incorporated as a target in the new Sustainable Development Goals. However, it is recognised that an equity dimension needs to be included when progress to this goal is monitored. WHO have developed a monitoring framework which proposes a target of 80 % coverage for all populations regardless of income and place of residence by 2030, and this paper examines the feasibility of this target in relation to antenatal care and skilled care at delivery. Methodology: We analyse the coverage gap between the poorest and richest groups within the population for antenatal care and presence of a skilled attendant at birth for countries grouped by overall coverage of each maternal health service. Average annual rates of improvement needed for each grouping (disaggregated by wealth quintile and urban/rural residence) to reach the goal are also calculated, alongside rates of progress over the past decades for comparative purposes. Findings: Marked inequities are seen in all groups except in countries where overall coverage is high. As the monitoring framework has an absolute target countries with currently very low coverage are required to make rapid and sustained progress, in particular for the poorest and those living in rural areas. The rate of past progress will need to be accelerated markedly in most countries if the target is to be achieved, although several countries have demonstrated the rate of progress required is feasible both for the population as a whole and for the poorest. Conclusions: For countries with currently low coverage the target of 80 % essential coverage for all populations will be challenging. Lessons should be drawn from countries who have achieved rapid and equitable progress in the past. [ABSTRACT FROM AUTHOR]

Background Although antenatal care coverage in Ghana is high, there exist gaps in the continued use of maternity care, especially utilization of skilled assistance during delivery. Many pregnant women seek care from different sources aside the formal health sector. This is due to negative perceptions resulting from poor service quality experiences in health facilities. Moreover, the socio-cultural environment plays a major role for this care-seeking behavior, as this paper seeks to understand. To examine beliefs, knowledge and, perceptions about pregnancy and delivery and care-seeking behavior among pregnant women in urban Accra, Ghana. Methods A qualitative study with 6 focus group discussions and 13 in-depth interviews were conducted at Taifa-Kwabenya and Madina sub-districts, Accra. Participants included mothers who had delivered within the past 12 months, pregnant women, community members, religious and community leaders, orthodox and non-orthodox healthcare providers. Interviews and discussions were audio-taped, transcribed and coded into larger themes and categories. Results Evidence showed perceived threats, which are often given socio-cultural interpretations, increased women's anxieties, driving them to seek multiple sources of care. Crucially, careseeking behavior among pregnant women indicated sequential or concurrent use of biomedical care and other forms of care including herbalists, traditional birth attendants, and spiritual care. Use of multiple sources of care in some cases disrupted continued use of skilled provider care. Furthermore, use of multiple forms of care is encouraged by a perception that facility-based care is useful only for antenatal services and emergencies. It also highlights the belief among some participants that care from multiple sources are complementary to each other. Conclusions Socio-cultural interpretations of threats to pregnancy mediate pregnant women's use of available healthcare services. Efforts to encourage continued use of maternity care, especially skilled birth assistance at delivery, should focus on addressing generally perceived dangers to pregnancy. Also, the attractiveness of facility-based care offers important opportunities for building collaborations between orthodox and alternative care providers with the aim of increasing use of skilled obstetric care. Conventional antenatal care should be packaged to provide psychosocial support that helps women deal with pregnancy-related fear. [ABSTRACT FROM AUTHOR]