Suchergebnisse

The introduction of cost-sharing strategies such as user-fees for health care in developing countries has received increasing attention due to declining government expenditure on health and reduced donor funding. Many governments of developing countries face the dilemma of introducing fees for family planning services while maintaining contraceptive prevalence rates. This study conducted 16 focus group discussions with poor communities in urban and rural areas of Malawi, to identify their views on the affordability of contraception and the perceived effects of user fees on their contraceptive use. The results show that amongst poor communities the long term health benefits of contraception are considered to be greater than a marginal increase in the cost of methods. An increase in the cost of temporary methods was seen as bearable, while financing permanent methods was seen as more problematic. The introduction of user-fees for family planning at government facilities would need to be accompanied by an increase in the quality of services provided to be acceptable. Those most likely to be affected by user fees are rural residents, for whom targeted assistance may be required to maintain contraceptive use. The introduction of user-fees with a subsidized treatment option was the most feasible strategy. However, the difficulties in determining eligibility for the subsidies are a critical issue. Results highlighted that the application of broader eligibility criteria are needed to account for social and non-monetary indicators of poverty in conjunction with economic indicators.

Background The practice of Female Genital Mutilation (FGM) is common in several African countries and some parts of Asia. This practice is not only a violation of human rights, but also puts women at risk of adverse health outcomes. This paper analysed the trends in the prevalence of FGM in Burkina Faso and investigated factors that are associated with this practice following the enactment of an FGM law in 1996. Methods The study used the Burkina Faso Demographic and Health Survey (DHS) data sets from women aged 15 to 49 years undertaken in 1999, 2003 and 2010. Chi square tests were carried out to investigate whether there has been a change in the levels of FGM in Burkina Faso between 1999 and 2010 and multilevel logistic regression analysis were employed to identify factors that were significantly associated with undergoing FGM. Results The levels of FGM in Burkina Faso declined significantly from 83.6% in 1999 to 76.1% in 2010. The percentage of women circumcised between the ages of 0 to 5 years increased from 34.2% in 1999 to 69% in 2010. Significantly more women in 2010 than in 1999 were of the opinion that FGM should stop (90.6% versus 75.1%, respectively). In 2010, the odds of getting circumcised were lowest amongst women that were born in the period 1990 to 1995 (immediately before the FGM law was enacted) compared to women born in the period 1960-1965 [OR 0.16 (0.13,0.20)]. There was significant variation of FGM across communities. Other factors that were significantly associated with being circumcised were education level, religion, ethnicity, urban residence and age at marriage. Conclusions Although the prevalence of FGM has declined in Burkina Faso, the levels are still high. In order to tackle the practice of FGM in Burkina Faso, the government of Burkina Faso and its development partners need to encourage girls' participation in education and target its sensitization campaigns against FGM towards Muslim women, women residing in rural areas and women of Mossi ethnic background.

SummaryThe 1988 Malawi Traditional and Modern Methods of Child Spacing Survey data are used to identify determinants of infant mortality in Malawi. The logistic binomial analysis shows that socioeconomic factors are significant even during the neonatal period while the length of the preceding birth interval is significant in the post-neonatal period only. There is a strong familial correlation of mortality risks during both the neonatal and post-neonatal periods but the effect of geographical area of residence is stronger in the post-neonatal period.

SummaryAfter a decade of fertility decline, Ghana's fertility and the level of unmet need for contraception stalled in mid-transition in the late 1990s. Although the literature acknowledges this, the geographical patterns in unmet need have not been adequately documented. Spatial analysis of unmet need can reveal differences in usage and provision of contraceptive commodities, thereby pointing to geographical areas where contraceptive programmes should be strengthened. This study examines the geographical variation of the risk of mistimed and unwanted pregnancies between rural communities and also between urban communities of the three ecological zones of Ghana. The study also investigates if geographical differences in the risks of mistimed and unwanted pregnancies changed during the period when unmet need stalled at the national level. A multilevel regression model was applied to pooled data from the 1998 and 2003 Ghana Demographic and Health Surveys to examine the determinants of the risk of unintended pregnancies, while controlling for clustering of outcomes within communities. The results show that between the two surveys, there was no significant change in the levels of risk of mistimed and unwanted pregnancy. However, geographical heterogeneity in the risk of mistimed and unwanted pregnancy was observed, after controlling for relevant predictors. This showed concentration of mistimed pregnancies in some rural communities relative to others, and variation in the risk of unwanted pregnancies between urban communities. The results give a clear indication that bridging the inequality gap in contraceptive use requires programmes that are area-specific.

This paper examines the association of the sociodemographic characteristics of women and the unobserved hospital factors with maternal mortality in Kenya using multilevel logistic regression. The data analysed comprise hospital records for 58,151 obstetric admissions in sixteen public hospitals, consisting of 182 maternal deaths. The results show that the probability of maternal mortality depends on both observed factors that are associated with a particular woman and unobserved factors peculiar to the admitting hospital. The individual characteristics observed to have a significant association with maternal mortality include maternal age, antenatal clinic attendance and educational attainment. The hospital variation is observed to be stronger for women with least favourable sociodemographic characteristics. For example, the risk of maternal death at high-risk hospitals for women aged 35 years and above, who had low levels of education, and did not attend antenatal care is about 280 deaths per 1000 admissions. The risk for similar women at low-risk hospitals is about 4 deaths per 1000. To complement results from the analysis of individual patient records, the paper includes findings from hospital staff reports regarding the maternal mortality situation at the hospitals.

Studies addressing factors associated with adverse birth outcomes have almost exclusively been based on hospital statistics. This is a serious limitation in developing countries where the majority of births do not occur within health facilities. This paper examines factors associated with premature deliveries, small baby's size at birth and Caesarean section deliveries in Kenya based on the 1993 Kenya Demographic and Health Survey data. Due to the hierarchical nature of the data, the analysis uses multilevel logistic regression models to take into account the family and community effects. The results show that the odds of unfavourable birth outcomes are significantly higher for first births than for higher order births. Furthermore, antenatal care (measured by frequency of antenatal care visits and tetanus toxoid injection) is observed to have a negative association with the incidence of premature births. For the baby's size at birth, maternal nutritional status is observed to be a predominant factor. Short maternal stature is confirmed as a significant risk factor for Caesarean section deliveries. The observed higher odds of Caesarean section deliveries among women from households of high socioeconomic status are attributed to the expected association between socioeconomic status and the use of appropriate maternal health care services. The odds of unfavourable birth outcomes vary significantly between women. In addition, the odds of Caesarean section deliveries vary between districts, after taking into account the individual-level characteristics of the woman.

SummaryIntermediary determinants are the most immediate mechanisms through which socioeconomic position shapes health inequities. This study examines the effect of community socioeconomic context on different indicators representing intermediary determinants of child health. In the context of Colombia, a developing country with a clear economic expansion, but one of the most unequal countries in the world, two categories of intermediary determinants, namely behavioural and psychosocial factors and the health system, are analysed. Using data from the 2010 Colombian Demographic and Health Survey (DHS), the results suggest that whilst the community context can exert a greater influence on factors linked directly to health, in the case of psychosocial factors and parent's behaviours, the family context can be more important. In addition, the results from multilevel analysis indicate that a significant percentage of the variability in the overall index of intermediary determinants of child health is explained by the community context, even after controlling for individual, family and community characteristics. These findings underline the importance of distinguishing between community and family intervention programmes in order to reduce place-based health inequities in Colombia.

The association between perception of risk of HIV infection and sexual behaviour remains poorly understood, although perception of risk is considered to be the first stage towards behavioural change from risk-taking
to safer behaviour. Using data from the 1998 Kenya Demographic and Health Survey, logistic regression models were fitted to examine the direction and the strength of the association between perceived risk of HIV/AIDS and risky sexual behaviour in the last 12 months before the survey. The findings indicate a strong positive association between perceived risk of HIV/AIDS and risky sexual behaviour for both women and men. Controlling for sociodemographic, sexual exposure and knowledge factors such as age, marital status, education, work status, residence, ethnicity, source of AIDS information, specific knowledge of AIDS, and condom use to avoid AIDS did not change the direction of the association, but altered its strength slightly. Young and unmarried women and men were more likely than older and married ones to report risky sexual behaviour. Ethnicity was significantly associated with risky sexual behaviour, suggesting a need to identify the contextual and social factors that influence behaviour among Kenyan people.

AbstractEach year, 295,000 women die during and just after pregnancy, and 2.4 million babies die in the first month of their lives. In 2019, 2,160,000 neonatal deaths and 275,000 maternal deaths occurred in low-income and lower-middle-income countries alone, translating to a welfare loss equivalent to $426 billion and $36 billion for neonatal and maternal deaths, respectively. The total loss was $462 billion or almost 6 % of these countries' combined GDP. In the sustainable development goals pledge, the world promised to reduce maternal deaths to 0.07 % and neonatal mortality to below 1.2 %, saving about 200,000 women and 1.2 million children from dying annually. However, on the current trajectory, maternal mortality is expected to decline to only 0.16 % and neonatal deaths to only 1.5 % by 2030. This article analyses the most cost-effective way to reduce maternal and neonatal deaths – Increase coverage of basic emergency obstetric and newborn care from 68 to 90 % combined with increased family planning services in 55 low-income and lower-middle-income countries which account for around 90 % of the burden of maternal and neonatal mortality globally. The proposed package will require $3.2 billion per year more investment and will deliver benefits worth $278 billion per year in avoided deaths and higher economic growth. It will also yield a demographic dividend benefit equivalent to $25 billion annually. For every $1 invested, the social and economic benefits are estimated to be $87. The benefit-cost ratio is 87.

This paper explores the pathways of the determinants of unfavourable birth outcomes, such as premature birth, the size of the baby at birth, and Caesarean section deliveries, in Kenya using graphical log-linear chain models. The results show that a number of factors that do not have direct associations with unfavourable birth outcomes contribute to these outcomes indirectly through intermediate factors. Marital status, the desirability of a pregnancy, the use of family planning and access to health facilities have no direct associations with poor birth outcomes, such as premature births and the small size of the baby at birth, but are linked to these outcomes through antenatal care. Antenatal care is identified as a central link between various sociodemographic or reproductive factors and birth outcomes.

This paper is in closed access until 17th June 2020. ; © 2019 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Background Nutritional interventions to prevent stunting of infants and young children are most often applied in rural areas in low-and middle-income countries (LMIC). Few interventions are focused on urban slums. The literature needs a systematic assessment, as infants and children living in slums are at high risk of stunting. Urban slums are complex environments in terms of biological, social, and political variables and the outcomes of nutritional interventions need to be assessed in relation to these variables. For the purposes of this review, we followed the UN-Habitat 2004 definitions for low-income informal settlements or slums as lacking one or more indicators of basic services or infrastructure. Objectives To assess the impact of nutritional interventions to reduce stunting in infants and children under five years old in urban slums from LMIC and the effect of nutritional interventions on other nutritional (wasting and underweight) and non-nutritional outcomes (socioeconomic, health and developmental) in addition to stunting. Search methods The review used a sensitive search strategy of electronic databases, bibliographies of articles, conference proceedings, websites, grey literature, and contact with experts and authors published from 1990. We searched 32 databases, in English and non-English languages (MEDLINE, CENTRAL, Web of Science, Ovid MEDLINE, etc). We performed the initial literature search from November 2015 to January 2016, and conducted top up searches in March 2017 and in August 2018. Selection criteria Research designs included randomised (including cluster-randomised) trials, quasi-randomised trials, non-randomised controlled trials, controlled before-and-after studies, pre-and postintervention, interrupted time series (ITS), and historically controlled studies among infants and children from LMIC, from birth to 59 months, living in urban slums. The interventions included were nutrition-specific or maternal education. The primary outcomes were length or height expressed in cm or length-for-age (LFA)/height-for-age (HFA) z-scores, and birth weight in grams or presence/absence of low birth weight (LBW). Data collection and analysis We screened and then retrieved titles and abstracts as full text if potentially eligible for inclusion. Working independently, one review author screened all titles and abstracts and extracted data on the selected population, intervention, comparison, and outcome parameters and two other authors assessed half each. We calculated mean selection difference (MD) and 95% confidence intervals (CI). We performed intervention-level meta-analyses to estimate pooled measures of effect, or narrative synthesis when meta-analyses were not possible. We used P less than 0.05 to assess statistical significance and intervention outcomes were also considered for their biological/ health importance. Where effect sizes were small and statistically insignificant, we concluded there was 'unclear effect'. Main results The systematic review included 15 studies, of which 14 were randomised controlled trials (RCTs). The interventions took place in recognised slums or poor urban or periurban areas. The study locations were mainly Bangladesh, India, and Peru. The participants included 9261 infants and children and 3664 pregnant women. There were no dietary intervention studies. All the studies identified were nutrient supplementation and educational interventions. The interventions included zinc supplementation in pregnant women (three studies), micronutrient or macronutrient supplementation in children (eight studies), nutrition education for pregnant women (two studies), and nutrition systems strengthening targeting children (two studies) intervention. Six interventions were adapted to the urban context and seven targeted household, community, or 'service delivery' via systems strengthening. The primary review outcomes were available from seven studies for LFA/HFA, four for LBW, and nine for length. The studies had overall high risk of bias for 11 studies and only four RCTs had moderate risk of bias. Overall, the evidence was complex to report, with a wide range of outcome measures reported. Consequently, only eight study findings were reported in meta-analyses and seven in a narrative form. The certainty of evidence was very low to moderate overall. None of the studies reported differential impacts of interventions relevant to equity issues. Zinc supplementation of pregnant women on LBW or length (versus supplementation without zinc or placebo) (three RCTs) There was no evidence of an effect on LBW (MD-36.13 g, 95% CI-83.61 to 11.35), with moderate-certainty evidence, or no evidence of an effect or unclear effect on length with low-to moderate-certainty evidence. Micronutrient or macronutrient supplementation in children (versus no intervention or placebo) (eight RCTs) There was no evidence of an effect or unclear effect of nutrient supplementation of children on HFA for studies in the meta-analysis with low-certainty evidence (MD-0.02, 95% CI-0.06 to 0.02), and inconclusive effect on length for studies reported in a narrative form with very low-to moderate-certainty evidence. Nutrition education for pregnant women (versus standard care or no intervention) (two RCTs) There was a positive impact on LBW of education interventions in pregnant women, with low-certainty evidence (MD 478.44g, 95% CI 423.55 to 533.32). Nutrition systems strengthening interventions targeting children (compared with no intervention, standard care) (one RCT and one controlled before-and-after study) There were inconclusive results on HFA, with very low-to low-certainty evidence, and a positive influence on length at 18 months, with low-certainty evidence. Authors' conclusions All the nutritional interventions reviewed had the potential to decrease stunting, based on evidence from outside of slum contexts; however, there was no evidence of an effect of the interventions included in this review (very low-to moderate-certainty evidence). Challenges linked to urban slum programming (high mobility, lack of social services, and high loss of follow-up) should be taken into account when nutrition-specific interventions are proposed to address LBW and stunting in such environments. More evidence is needed of the effects of multi-sectorial interventions, combining nutrition-specific and sensitive methods and programmes, as well as the effects of 'up-stream' practices and policies of governmental, non-governmental organisations, and the business sector on nutrition-related outcomes such as stunting.

BACKGROUND: Nutritional interventions to prevent stunting of infants and young children are most often applied in rural areas in low‐ and middle‐income countries (LMIC). Few interventions are focused on urban slums. The literature needs a systematic assessment, as infants and children living in slums are at high risk of stunting. Urban slums are complex environments in terms of biological, social, and political variables and the outcomes of nutritional interventions need to be assessed in relation to these variables. For the purposes of this review, we followed the UN‐Habitat 2004 definitions for low‐income informal settlements or slums as lacking one or more indicators of basic services or infrastructure. OBJECTIVES: To assess the impact of nutritional interventions to reduce stunting in infants and children under five years old in urban slums from LMIC and the effect of nutritional interventions on other nutritional (wasting and underweight) and non‐nutritional outcomes (socioeconomic, health and developmental) in addition to stunting. SEARCH METHODS: The review used a sensitive search strategy of electronic databases, bibliographies of articles, conference proceedings, websites, grey literature, and contact with experts and authors published from 1990. We searched 32 databases, in English and non‐English languages (MEDLINE, CENTRAL, Web of Science, Ovid MEDLINE, etc). We performed the initial literature search from November 2015 to January 2016, and conducted top up searches in March 2017 and in August 2018. SELECTION CRITERIA: Research designs included randomised (including cluster‐randomised) trials, quasi‐randomised trials, non‐randomised controlled trials, controlled before‐and‐after studies, pre‐ and postintervention, interrupted time series (ITS), and historically controlled studies among infants and children from LMIC, from birth to 59 months, living in urban slums. The interventions included were nutrition‐specific or maternal education. The primary outcomes were length or height expressed in cm or ...