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Welfare Reform has caused a dramatic change in the lives and health of single mothers living in poverty. This qualitative study explored the health and socioeconomic lives of 22 community-dwelling women in poverty in the years after they were terminated from the current work-based welfare program intended to move women from welfare to work and independence. The instruments were a semistructured interview guide, the HANES General Well-Being Schedule, and a demographic data form. Data were analyzed using multistage narrative analysis and descriptive statistics. These primary source data showed participants had multiple barriers that precede or follow poverty. Their voices of how they survive are a rich source of data to assist providers and policy makers in devising evidence-based solutions for reducing poverty in America., (© The Author(s) 2016.)

Background: Continued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities., Methods: Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated., Results: The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages., Conclusions: Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program.

Background: Targeted interventions to improve maternal and child health is suggested as a feasible and sometimes even necessary strategy to reduce inequity. The objective of this systematic review was to gather the evidence of the effectiveness of targeted interventions to improve equity in MDG 4 and 5 outcomes., Methods and Findings: We identified primary studies in all languages by searching nine health and social databases, including grey literature and dissertations. Studies evaluating the effect of an intervention tailored to address a structural determinant of inequity in maternal and child health were included. Thus general interventions targeting disadvantaged populations were excluded. Outcome measures were limited to indicators proposed for Millennium Development Goals 4 and 5. We identified 18 articles, whereof 15 evaluated various incentive programs, two evaluated a targeted policy intervention, and only one study evaluated an intervention addressing a cultural custom. Meta-analyses of the effectiveness of incentives programs showed a pooled effect size of RR 1.66 (95% CI 1.43-1.93) for antenatal care attendance (four studies with 2,476 participants) and RR 2.37 (95% CI 1.38-4.07) for health facility delivery (five studies with 25,625 participants). Meta-analyses were not performed for any of the other outcomes due to scarcity of studies., Conclusions: The targeted interventions aiming to improve maternal and child health are mainly limited to addressing economic disparities through various incentive schemes like conditional cash transfers and voucher schemes. This is a feasible strategy to reduce inequity based on income. More innovative action-oriented research is needed to speed up progress in maternal and child survival among the most disadvantaged populations through interventions targeting the underlying structural determinants of inequity.

Background: Caesarean section rates are increasing in Mexico and Latin America. This study evaluates the impact of a large-scale, conditional cash transfer programme in Mexico on caesarean section rates. The programme provides cash transfers to participating low income, rural households in Mexico conditional on accepting health care and nutrition supplements., Methods: The primary analyses uses retrospective reports from 979 women in poor rural communities participating in an effectiveness study and randomly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states. Using multivariate and instrumental variable analyses, we estimate the impact of the programme on caesarean sections and predict the adjusted mean rates by clinical setting. Programme participation is measured by beneficiary status, programme months and cash transfers., Results: More than two-thirds of poor rural women delivered in a health facility. Beneficiary status is associated with a 5.1 percentage point increase in caesarean rates; this impact increases to 7.5 percentage points for beneficiaries enrolled in the programme for >or=6 months before delivery. Beneficiaries had significantly higher caesarean delivery rates in social security facilities (24.0 compared with 5.6% among non-beneficiaries) and in other government facilities (19.3 compared with 9.5%)., Conclusion: The Oportunidades conditional cash transfer programme is associated with higher caesarean section rates in social security and government health facilities. This effect appears to be driven by the increases in disposable income from the cash transfer. These findings are relevant to other countries implementing conditional cash transfer programmes and health care requirements.

Poor women have elevated stress but also face deficits in their social networks to provide help. Consequently, they may substitute their minor children as a support source in place of more traditional ties. Support substitution and compensation theory suggest this form of substitution may not lead to compensatory benefits. We hypothesized that low-income mothers experiencing high levels of acute and network stress would be more likely to rely on their minor children, and this reliance on minor children would be related to worse health outcomes through its impact on minor children's well-being. In an interview-based community study of 116 low-income mothers from Northeast Ohio, USA we found that acute stress (but not network stress) was related to greater reliance on minor children for support and the impact on minor children's well-being mediated the link with low-income mothers' worse health outcomes. These results suggest that the reason for and type of social network substitution may determine whether compensatory benefits are realized.

Pregnancy outcomes in the United States are generally worse than those in most developed countries. Contributing to these adverse outcomes are the relatively high levels of poverty in the United States, a characteristic that is associated with decreased utilization of appropriate prenatal care and delivery services as well as having an increased number of other risk factors. Poor women tend to be more obese, to have more medical conditions, such as hypertension and diabetes, to be more likely to be stressed or depressed, and to smoke cigarettes and use illicit drugs. We present some of the potential mechanisms that explain the association between these characteristics and adverse pregnancy outcomes--focusing on preterm birth.

Objectives: To examine pre-pregnancy Medicaid coverage and initiation of prenatal care among women likely eligible for Medicaid coverage regardless of pregnancy., Methods: The Pregnancy Risk Assessment Monitoring System (PRAMS) was used to identify very low-income women with Medicaid payment for delivery. We then compared prenatal care initiation among women with (Non-GAP) and without (Medicaid GAP) pre-pregnancy Medicaid coverage., Results: Rates of first trimester prenatal care were 47.3% for women in the Medicaid GAP, 70.0% for women who were not. The adjusted odds ratio for being in the Medicaid GAP and delayed prenatal care was 2.7 (95% CI 1.2, 6.2), although this varied by race/ethnicity and education. The relationship was strongest among White and Hispanic women with less than a high school education: OR=13.8, (95% CI 3.0, 62.7) and OR=19.0 (95% CI 2.4, 149.2), respectively., Conclusions: Pre-pregnancy Medicaid coverage appears to be associated with early initiation of prenatal care. Almost a decade after welfare reform, it is essential to preserve the Medicaid expansions for pregnant women, foster Medicaid family planning waivers, and promote access to primary care and early prenatal care, particularly for very low-income women.

In this paper, we take a broad perspective on maternal health and place it in its wider context. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and women's empowerment. We also consider outcomes beyond mortality, in particular, near-misses and long-term sequelae, and the implications of the close association between the mother, the fetus, and the child. We make links to a range of global survival initiatives, particularly neonatal health, HIV, and malaria, and to reproductive health. Finally, after examining the political and financial context, we call for action. The need for strategic vision, financial resources, human resources, and information are discussed.

Despite the strong interest of international health agencies, worldwide maternal mortality has not declined substantially over the past 10 years. Postpartum hemorrhage (PPH) is the most common cause of maternal death across the world, responsible for more than 25% of deaths annually. Although effective tools for prevention and treatment of PPH are available, most are not feasible or practical for use in the developing world where many births still occur at home with untrained birth attendants. Application of many available clinical solutions in rural areas would necessitate substantial changes in government infrastructure and in local culture and customs surrounding pregnancy and childbirth. Before treatment can be administered, prompt and accurate diagnosis must be made, which requires training and appropriate blood measurement tools. After diagnosis, appropriate interventions that can be applied in remote settings are needed. Many uterotonics known to be effective in reducing PPH in tertiary care settings may not be useful in community settings because they require refrigeration and/or skilled administration. Moreover, rapid transfer to a higher level of care must be available, a challenge in many settings because of distance and lack of transportation. In light of these barriers, low-technological replacements for treatments commonly applied in the developed-world must be utilized. Community education, improvements to emergency care systems, training for birth attendants, misoprostol, and Uniject have shown promise as potential solutions. In the short term, it is expedient to capitalize on practical opportunities that utilize the existing strengths and resources in each community or region in order to implement appropriate solutions to save the lives of women during childbirth.

Background: Breastfeeding can ameliorate some of the complex health issues faced by low-income families. Women who breastfeed and their infants have lower health care costs compared with those who formula feed. Increasing the duration of breastfeeding is recognized as a national priority, particularly for low-income women. This community-based randomized clinical trial involving low-income mothers compared usual care with an intervention comprising hospital and home visits, and telephone support by a community health nurse/peer counselor team for 6 months after delivery., Methods: Forty-one women were recruited after delivery of a full-term singleton infant and randomly assigned to intervention or usual care groups., Results: Women receiving the community health intervention breastfed longer than the women receiving usual care. The infants in the intervention group had fewer sick visits and reported use of fewer medications than infants in the usual care group. The intervention cost ($301/mother) was partially offset by cost savings on formula and health care., Conclusions: Community health nurse and peer counselor support can increase breastfeeding duration in low-income women, and has the potential to reduce total costs including the cost of support.

Some 5.9 million American mothers caring for young or school-aged children lack health insurance. Although nearly nine in ten uninsured mothers are members of working families, most lack access to affordable coverage through their job or a spouse's job. Most are ineligible for publicly subsidized coverage unless their incomes are far below the poverty line. The millions of uninsured mothers are at high risk of going without needed preventive and primary care. If they become seriously ill, their families can face the prospect of a financial crisis. The nation has made significant progress in extending health care coverage to children in low-income families through Medicaid and the State Children's Health Insurance Program (SCHIP), but no comparable effort has been made to insure the mothers of these children. A few states have started to address the problem by transforming their SCHIPs into family-based programs that also cover low-income parents. Bipartisan legislation under consideration, known as FamilyCare, would encourage this trend by providing more federal funding to states that could be used to extend health insurance to the parents of children already covered by publicly funded programs.

It is estimated that 1600 women die world-wide each day as a result of problems during pregnancy or childbirth. A large proportion of these deaths is preventable. This article examines the economic case for investing in safe motherhood interventions, and reviews key evidence of the cost effectiveness of safe motherhood interventions. According to one study, antenatal and maternal services comprise two of the six most cost effective sets of health interventions in low-income countries. However, little detailed evidence exists regarding the relative cost effectiveness of antenatal care, post-abortion care and essential obstetric care. Despite this there is clear evidence that interventions such as substituting manual vacuum aspiration for dilatation and curettage can result in significant savings both for health facilities and patients. The paper estimates first that 26% of maternal deaths are avoidable through antenatal/community-based interventions, costing around 30% of the WHO Mother Baby Package; and secondly that access to quality essential obstetric care can prevent a further 48% of maternal deaths, consuming 24% of total Mother Baby Package costs. Further work on the cost effectiveness of safe motherhood interventions would provide useful information for policy makers concerned with reducing maternal mortality in the most efficient manner possible.