Suchergebnisse

On the 25 March 2017, leaders of the EU27 and European Union (EU) institutions ratified the Rome Declaration. They committed to invite citizens to discuss Europe's future and to provide recommendations that would facilitate their decision-makers in shaping their national positions on Europe. In response, citizens' dialogues on the future of Europe were instituted across the Union to facilitate public participation in shaping Europe. This paper explores Ireland's set of dialogues which took place during 2018. Although event organisers in Ireland applied a relatively atypical and more systematic and participatory approach to their dialogues, evidence suggests that Irelands' dialogues were reminiscent of a public relations exercise which showcased the country's commitment to incorporating citizens into the debate on Europe while avoiding a deliberative design which could have strengthened the quality of public discourse and the quality of public recommendations. Due to an absence of elite political will for a deliberative process, as well as structural weaknesses in design, participants' recommendations lacked any clear and prescriptive direction which could shape Ireland's national position on the future of Europe in any constructive or meaningful way.

On the 2nd of March 2012 the intergovernmental Fiscal Stability Treaty was signed by 25 European Union (EU) member-states with the exception of the United Kingdom and the Czech Republic. The treaty was part of a broader set of planned measures taken by EU member-states to protect the Euro in the wake of the 2007 Eurozone crisis. The treaty aimed to reduce national debt in EU member-states by averting fiscal imbalances. Due to the poor condition of the Irish economy, the treaty was a chance for Ireland to regain international market confidence, economic stability and growth. As an economically small EU member-state, Ireland's position to bargain for concessions was tenuous due to the weakness of its economy and its consequences for the rest of the EU. However, Ireland managed to achieve a considerable degree of influence throughout the Fiscal Stability Treaty negotiations by drawing upon opportunity structures as negotiation leverage. In achieving influence in the Fiscal Stability Treaty negotiations by drawing upon credible opportunity structures, Ireland proved that small EU member-states can and do achieve influence in intergovernmental treaty negotiations, regardless of their economic size. This study challenges traditional understandings regarding the strength of the small EU member-state in intergovernmental treaty negotiations. As the Union Method becomes ever more embraced by EU member-states, we are urged to think differently about how treaties are agreed between EU member-states. We are also urged to question what this may tell us about intergovernmental treaty making and the influence of small EU member-states in intergovernmental treaty making processes, both at the present time and in the future. This thesis provides a basis for such exploration.

Section 1. Current status of newborn infants and perinatal health in South Asia. ch. 1. Current state of the health of newborn infants in developing countries / Anthony Costello and Dharma Manandhar -- ch. 2. Recent trends in perinatal health in South Asia -- Section 2. Social, economic and cultural aspects of motherhood in South Asia. ch. 3. Social and developmental issues affecting the perinatal health of mothers and their infants / Hilary Standing and Anthony Costello -- ch. 4. Epidemiological trends in nutritional status of children and women in India / Harshpal Sachdev -- ch. 5. Women's work and maternal-child health: anthropological views on intervention / Catherine Panter-Brick -- ch. 6. Perinatal mortality in Nepal: implications for behaviour modification / Shyam Thapa -- ch. 7. Traditional and cultural aspects of neonatal care in developing countries / Shashi N.Vani -- Section 3. Cost-effective essential newborn care in poor communities: the evidence-base. ch. 8. Effective interventions in pregnancy to improve foetal growth / Amali Lokugamage and Charles H. Rodeck -- ch. 9. Hypothermia: epidemiology and prevention / Ragnar Tunell -- ch. 10. New methods for monitoring neonatal hypothermia and cold stress / Anthony Costello -- ch. 11. Birth asphyxia in developing countries: epidemiology, sequelae and prevention / Matthew Ellis -- ch. 12. Effective resuscitation / Siddarth Ramji -- ch. 13. Effective interventions to reduce neonatal mortality and morbidity from perinatal infection / Zulfiqar Ahmed Bhutta -- ch. 14. The importance of breastfeeding and strategies to sustain high breastfeeding rates / M. Q-K. Talukder -- ch. 15. Neonatal hypoglycaemia / Anthony Costello and Deb Pal -- ch. 16. Neonatal hyperbilirubinaemia in developing countries / Therese Hesketh -- ch. 17. Low birth weight newborns - the risks in infancy and beyond / Dipak K. Guha -- ch. 18. Does health education improve newborn care? / Alison Bolam, Dominique Tillen and Anthony Costello -- ch. 19. Community based strategies to improve newborn and infant care practices / Fehmida Jalil -- Section 4. Improving health service delivery. ch. 20. Special care of newborn at the district hospital / Dharma Manandhar -- ch. 21. Current controversies and recommendations for the care of high risk newborn infants / Meharban Singh -- ch. 22. Audit - a tool to improve the quality of perinatal care / Sophie Mancey-Jones -- ch. 23. Trained traditional birth attendants and essential newborn care in South Asia / Marta J. Levitt-Dayal -- ch. 24. TBA training: cost-effective? / Carole Presern -- ch. 25. What to do about referral and transfers of high risk mothers and newborns? / Daljit Singh -- ch. 26. Making perinatal services more user-friendly / Susan F. Murray -- ch. 27. How to improve information, education and communication for better newborn care -- Section 5. Challenges for future policy implementation and research. ch. 28. Challenges for future policy implementation and research / Anthony Costello and Sophie Mancey-Jones.

Abstract Background The fifth Millennium Development Goal target for 90% of births in low and middle income countries to have a skilled birth attendant (SBA) by 2015 will not be met. In response to this, policy has focused on increasing SBA access. However, reducing maternal mortality also requires policies to prevent deaths among women giving birth unattended. We aimed to generate estimates of the absolute number of non-SBA births between 2011 and 2015 in South Asia and sub-Saharan Africa, given optimistic assumptions of future trends in SBA attendance. These estimates could be used by decision makers to inform the extent to which reductions in maternal mortality will depend on policies aimed specifically at those women giving birth unattended. Methods For each country within South Asia and sub-Saharan Africa we estimated recent trends in SBA attendance and used these as the basis for three increasingly optimistic projections for future changes in SBA attendance. For each country we obtained estimates for the current SBA attendance in rural and urban settings and forecasts for the number of births and changes in rural/urban population over 2011-2015. Based on these, we calculated estimates for the number of non-SBA births for 2011-2015 under a variety of scenarios. Results Conservative estimates are that there will be between 130 and 180 million non-SBA births in South Asia and sub-Saharan Africa from 2011 to 2015 (90% of these in rural areas). Currently, there are more non-SBA births per year in South Asia than sub-Saharan Africa, but our projections suggest that the regions will have approximately the same number of non-SBA births by 2015. We also present results for each of the six countries currently accounting for more than 50% of global maternal deaths. Conclusions Over the next five years, many millions of women within South Asia and sub-Saharan Africa will give birth without an SBA. Efforts to improve access to skilled attendance should be accompanied by interventions to improve the safety of non-attended deliveries.

AbstractParticipatory community-based women's group interventions have been successful in improving maternal and newborn survival. In rural Makwanpur, Nepal, exposure to these Participatory Learning and Action groups resulted in a thirty-percent reduction in neonatal mortality rate and significantly fewer maternal deaths. It is often theorised that participatory approaches are more likely to be sustained than top-down approaches, but this is rarely evaluated after the withdrawal of external support. We sought to understand how participatory learning and action (PLA) groups in Makwanpur fared after the supporting non-governmental organisation withdrew their support as well as factors affecting their sustainability. We used mixed methods, conducting a cross-sectional survey of 239 groups, thirty focus group discussions with group members and thirty key informant interviews within twelve–seventeen months after support was withdrawn. Eighty percent of groups were still active which suggests that PLA groups have a high chance of being sustained over time. Groups were more likely to be sustained if the group had local importance and members continued to acquire new knowledge. However, the participatory nature of the group and local embeddedness were not enough to sustain all groups. They also needed leadership capacity, a unifying activity such as a fund, and a strong belief in the value of their meeting to sustain. These key factors should be considered when seeking to enable sustainability of participatory interventions.

Abstract Background In many low-income countries women tend to deliver at home, and delays in receiving appropriate maternal care can be fatal. A contextual understanding of these delays is important if countries are to meet development targets for maternal health. We present qualitative research with women who delivered at home in rural Nepal, to gain a contemporary understanding of the context where we are testing the effectiveness of an intervention to increase institutional deliveries. Methods We purposively sampled women who had recently delivered at home and interviewed them to explore their reasons for home delivery. Interviews were recorded, transcribed and analysed using thematic content analysis. We used the 'delays' model discussed in the literature to frame our analysis. Results Usually a combination of factors prevented women from delivering in health institutions. Many women were aware of the benefits of institutional delivery yet their status in the home restricted their access to health facilities. Often they did not wish to bring shame on their family by going against their wishes, or through showing their body in a health institution. They often felt unable to demand the organisation of transportation because this may cause financial problems for their family. Some felt that government incentives were insufficient. Often, a lack of family support at the time of delivery meant that women delivered at home. Past bad experience, and poor quality health services, also prevented women from having an institutional delivery. Conclusions Formative research is important to develop an understanding of local context. Sociocultural issues, perceived accessibility of health services, and perceived quality of care were all important barriers preventing institutional delivery. Targeting one factor alone may not be effective in increasing institutional deliveries. Our intervention encourages communities to develop local responses to address the factors preventing institutional delivery through women's groups and improved health facility management. We will monitor perceptions of health services over time to help us understand the effectiveness of the intervention.

Models of household decision-making commonly focus on nuclear family members as primary decision-makers. If extended families shape the objectives and constraints of households, then neglecting the role of this network may lead to an incomplete understanding of health seeking behaviour. Understanding the decision-making processes behind care seeking may improve behaviour change interventions, better intervention targeting and support health-related development goals. This paper uses data from a cluster-randomized trial of a participatory learning and action cycle through women's groups (PLA), to assess the role of extended family networks as a determinant of gains in health knowledge and health practise. We estimate three models along a continuum of health seeking behaviour: one that explores access to PLA groups as a conduit of knowledge, another measuring whether women's health knowledge improves after exposure to the PLA groups, and a third exploring the determinants of their ability to act on knowledge gained. We find that, in this context, a larger network of family it is not associated with women's likelihood of attending groups or acquiring new knowledge but a larger network of husband's family is negatively associated with the ability to act on that knowledge during pregnancy and the post partum period. ; Models of household decision-making commonly focus on nuclear family members as primary decision-makers. If extended families shape the objectives and constraints of households, then neglecting the role of this network may lead to an incomplete understanding of health-seeking behaviour. Understanding the decision-making processes behind care-seeking may improve behaviour change interventions, better intervention targeting and support health-related development goals. This paper uses data from a cluster randomised trial of a participatory learning and action cycle (PLA) through women's groups, to assess the role of extended family networks as a determinant of gains in health knowledge and health practice. We estimate three models along a continuum of health-seeking behaviour: one that explores access to PLA groups as a conduit of knowledge, another measuring whether women's health knowledge improves after exposure to the PLA groups and a third exploring the determinants of their ability to act on knowledge gained. We find that, in this context, a larger network of family is not associated with women's likelihood of attending groups or acquiring new knowledge, but a larger network of husband's family is negatively associated with the ability to act on that knowledge during pregnancy and the postpartum period.

Abstract Background Maternal, perinatal and neonatal mortality rates remain high in rural areas of developing countries. Most deliveries take place at home and care-seeking behaviour is often delayed. We report on a combined quantitative and qualitative study of care seeking obstacles and practices relating to perinatal illness in rural Makwanpur district, Nepal, with particular emphasis on consultation strategies. Methods The analysis included a survey of 8798 women who reported a birth in the previous two years [of whom 3557 reported illness in their pregnancy], on 30 case studies of perinatal morbidity and mortality, and on 43 focus group discussions with mothers, other family members and health workers. Results Early pregnancy was often concealed, preparation for birth was minimal and trained attendance at birth was uncommon. Family members were favoured attendants, particularly mothers-in-law. The most common recalled maternal complications were prolonged labour, postpartum haemorrhage and retained placenta. Neonatal death, though less definable, was often associated with cessation of suckling and shortness of breath. Many home-based care practices for maternal and neonatal illness were described. Self-medication was common. There were delays in recognising and acting on danger signs, and in seeking care beyond the household, in which the cultural requirement for maternal seclusion, and the perceived expense of care, played a part. Of the 760 women who sought care at a government facility, 70% took more than 12 hours from the decision to seek help to actual consultation. Consultation was primarily with traditional healers, who were key actors in the ascription of causation. Use of the government primary health care system was limited: the most common source of allopathic care was the district hospital. Conclusions Major obstacles to seeking care were: a limited capacity to recognise danger signs; the need to watch and wait; and an overwhelming preference to treat illness within the community. Safer motherhood and newborn care programmes in rural communities, must address both community and health facility care to have an impact on morbidity and mortality. The roles of community actors such as mothers-in-law, husbands, local healers and pharmacies, and increased access to properly trained birth attendants need to be addressed if delays in reaching health facilities are to be shortened.

Background: There is scarce evidence on the impacts of food transfers, cash transfers, or women's groups on food sharing, dietary intakes, or nutrition during pregnancy, when nutritional needs are elevated. Objective: This study measured the effects of 3 pregnancy-focused nutrition interventions on intrahousehold food allocation, dietary adequacy, and maternal nutritional status in Nepal. Methods: Interventions tested in a cluster-randomized controlled trial (ISRCTN 75964374) were "Participatory Learning and Action" (PLA) monthly women's groups, PLA with transfers of 10 kg fortified flour ("Super Cereal"), and PLA plus transfers of 750 Nepalese rupees (∼US$7.5) to pregnant women. Control clusters received usual government services. Primary outcomes were Relative Dietary Energy Adequacy Ratios (RDEARs) between pregnant women and male household heads and pregnant women and their mothers-in-law. Diets were measured by repeated 24-h dietary recalls. Results: Relative to control, RDEARs between pregnant women and their mothers-in-law were 12% higher in the PLA plus food arm (log-RDEAR coefficient = 0.12; 95% CI: 0.02, 0.21; P = 0.014), but 10% lower in the PLA-only arm between pregnant women and male household heads (-0.11; 95% CI: -0.19, -0.02; P = 0.020). In all interventions, pregnant women's energy intakes did not improve, but odds of pregnant women consuming iron-folate supplements were 2.5-4.6 times higher, odds of pregnant women consuming more animal-source foods than the household head were 1.7-2.4 times higher, and midupper arm circumference was higher relative to control. Dietary diversity was 0.4 food groups higher in the PLA plus cash arm than in the control arm. Conclusions: All interventions improved maternal diets and nutritional status in pregnancy. PLA women's groups with food transfers increased equity in energy allocation, whereas PLA with cash improved dietary diversity. PLA alone improved diets, but effects were mixed. Scale-up of these interventions in marginalized populations is a policy option, but researchers should find ways to increase adherence to interventions. This trial was registered at www.controlled-trials.com as ISRCTN 75964374.

WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.