A concrete and useful way to create an action plan for improving the quality of maternity care in... more A concrete and useful way to create an action plan for improving the quality of maternity care in the United States is to start with a view of the desired result, a common definition and a shared vision for a high-quality, high-value maternity care system. In this paper, we present a long-term vision for the future of maternity care in the United States. We present overarching values and principles and specific attributes of a high-performing maternity care system. We put forth the ''2020 Vision for a High-Quality, High-Value Maternity Care System'' to serve as a positive starting place for a fruitful collaborative process to develop specific action steps for broad-based maternity care system improvement.
Background Midwives' authorization to deliver the seven basic emergency obstetric and newborn car... more Background Midwives' authorization to deliver the seven basic emergency obstetric and newborn care (BEmONC) functions is a core policy indicator in global monitoring frameworks, yet little evidence supports whether such data are captured accurately, or whether authorization demonstrates convergence with midwives' skills and actual provision of services. In this study, we aimed to validate the data reported in global monitoring frameworks (criterion validity) and to determine whether a measure of authorization is a valid indicator for BEmONC availability (construct validity). Methods We conducted a validation study in Argentina, Ghana, and India. To assess accuracy of the reported data on midwives' authorization to provide BEmONC services, we reviewed national regulatory documents and compared with reported country-specific data in Countdown to 2030 and the World Health Organization Maternal, Newborn, Child and Adolescent Health Policy Survey. To assess whether authorization demonstrates convergent validity with midwives' skills, training, and performance of BEmONC signal functions, we surveyed 1257 midwives/midwifery professionals and assessed variance.
Background There is a global shortage of midwives, whose services are essential to meet the healt... more Background There is a global shortage of midwives, whose services are essential to meet the healthcare needs of pregnant women and newborns. Evidence suggests that if enough midwives, trained and regulated to global standards, were deployed worldwide, maternal, and perinatal mortality would decline significantly. Health workforce planning estimates the number of midwives needed to achieve population coverage of midwifery interventions. However, to provide a valid measure of midwifery care coverage, an indicator must consider not only the raw number of midwives, but also their scope and competency. The tasks midwives are authorized to deliver and their competency to perform essential skills and behaviors provide crucial information for understanding the availability of safe, high-quality midwifery services. Without reliable estimates for an adequate midwifery workforce, progress toward ending preventable maternal and perinatal mortality will continue to be uneven. The International Labor Organization (ILO) and the International Confederation of Midwives (ICM) suggest standards for midwifery scope of practice and competencies. This paper compares national midwifery regulations, scope, and competencies in three countries to the ILO and ICM standards to validate measures of midwife density. We also assess midwives' self-reported skills/behaviors from the ICM competencies and their acquisition.
Background Global mechanisms have been established to monitor and facilitate state accountability... more Background Global mechanisms have been established to monitor and facilitate state accountability regarding the legal status of abortion. However, there is little evidence describing whether these mechanisms capture accurate data. Moreover, it is uncertain whether the "legal status of abortion" is a valid proxy measure for access to safe abortion, pursuant to the global goals of reducing preventable maternal mortality and advancing reproductive rights. Therefore, this study sought to assess the accuracy of reported monitoring data, and to determine whether evidence supports the consistent application of domestic law by health care professionals such that legality of abortion functions as a valid indicator of access. Methods and findings We conducted a validation study using three countries as illustrative case examples: Argentina, Ghana, and India. We compared data reported by two global monitoring mechanisms (Countdown to 2030 and the Global Abortion Policies Database) against domestic source documents collected through in-depth policy review. We then surveyed health care professionals authorized to perform abortions about their knowledge of abortion law in their countries and their personal attitudes and practices regarding provision of legal abortion. We compared professionals' responses to the domestic legal frameworks described in the
Abstract
Background
The concept of universal health coverage (UHC) encompasses both access to ess... more Abstract Background The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization’s Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, “Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?”, captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries.
Methods and findings We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15–49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures.
Conclusions Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.
Background Sustainable Development Goal (SDG) Indicator 5.6.2 is the "Number of countries with la... more Background Sustainable Development Goal (SDG) Indicator 5.6.2 is the "Number of countries with laws and regulations that guarantee full and equal access to women and men aged 15 years and older to sexual and reproductive health care, information, and education." This indicator plays a key role in tracking global progress toward achieving gender equity and empowerment, ensuring its validity is essential. Significant challenges related to the indicator's calculation have been noted, which have important implications for the indicator's validity in measuring progress towards meeting the SDG target. Recommendations have been made to revise the scoring of the indicator. This study examines the indicator's validity by proposing a revision to the indicator's calculation that addresses these global concerns and comparing the resulting values. Methods and findings This is an observational, validation study which used secondary data from the 2022 United Nations Population Fund's Sexual and Reproductive Health and Rights Country Profiles from 75 countries. To address global recommendations, we proposed making 2 changes to the indicator's calculation. First, we re-expressed all barriers and enablers to take positive values. Second, we used a weighted additive approach to calculate the total score, rather than the mean of the 13 individual component scores, which assigns equal weight to the
Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of e... more Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the
Background Understanding causes and contributors to maternal mortality is critical from a quality... more Background Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility-versus district-level data. Methods and findings We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of
Background Integrating measures of respectful care is an important priority in family planning pr... more Background Integrating measures of respectful care is an important priority in family planning programs, aligned with maternal health efforts. Ensuring women can make autonomous reproductive health decisions is an important indicator of respectful care. While scales have been developed and validated in family planning for dimensions of person-centered care, none focus specifically on decision-making autonomy. The Mothers Autonomy in Decision-Making (MADM) scale measures autonomy in decision-making during maternity care. We adapted the MADM scale to measure autonomy surrounding a woman's decision to use a contraceptive method within the context of contraceptive counselling. This study presents a psychometric validation of the Family Planning Autonomous Decision-Making (FP-ADM) scale using data from Argentina, Ghana, and India. Methods and findings We used cross-sectional data from women in four subnational areas in Argentina (n = 890), Ghana (n = 1,114), and India (n = 1,130). In each area, 20 primary sampling units (PSUs) were randomly selected based on probability proportional to size. Households were randomly selected in Ghana and India. In Argentina, all facilities providing reproductive and
In 2015, the World Health Organization (WHO) released global targets and strategies for reducing ... more In 2015, the World Health Organization (WHO) released global targets and strategies for reducing maternal mortality in the Sustainable Development Goal (SDG) period developed through broad stakeholder consultations. The targets and strategies identified in the "Strategies toward Ending Preventable Maternal Mortality (EPMM)" report are grounded in a systemic and human rights approach to maternal health and aim to address the broad spectrum of key social, political, economic, and health system determinants of maternal health and survival, as exemplified by 11 Key Themes. These upstream determinants of maternal survival are not well represented in maternal health measurement efforts, which tend to focus on service delivery. Thus, work was undertaken to develop a core set of maternal health indicators that could drive progress toward achieving the recommendations laid out in the EPMM Strategies that identified a menu of 25 indicators and 7 standard stratifiers related to the legal and policy environment, accountability mechanisms, inequities in access and quality, and empowerment of women, girls, families, and communities. Measurement experts have called for more research to ensure that indicators for monitoring maternal health, including its upstream determinants, are valid, which is critical if such measures are to be effective for driving and tracking progress toward ending preventable maternal deaths. This paper describes nine research reports emanating from seven discrete research studies to validate ten indicators in India, Ghana and Argentina that are compiled in a PLOS Collection with the aim of illustrating the breadth of the validation work, extracting some unifying themes and common findings, and discussing the implications for policy and practice they suggest.
This white paper was prepared with funding from the Asia and the Middle East bureaus of the Unite... more This white paper was prepared with funding from the Asia and the Middle East bureaus of the United States Agency for International Development, under the activity "Gender, Policy, and Measurement." The AME bureaus have enlisted the Health Policy Project (HPP) and MEASURE Evaluation to work together on this activity to ensure a range of expertise on family planning and maternal, neonatal, and child health; gender programming; policy and systems development/implementation; and strong measurement capacity. A joint workplan outlines the scope of work and contributions of each project. Using a system strengthening approach, HPP will apply gender and policy to the scale-up of best practices through a series of consultations, white papers, and technical assistance to bilateral projects. MEASURE Evaluation will design a rigorous evaluation to measure the impact of gender integration and policy implementation on scale-up, systems strengthening, and the contribution to health outcomes. The authors would like to thank all the participants of the "Expert Meeting on Policy Implementation and Gender Integration in the Scale-Up of Family Planning and Maternal Neonatal and Child Health Best Practices," held at Futures Group in Washington, DC, on December 12, 2011. Their valuable inputs helped to inform the development of this publication. Special thanks go to the following people for their useful suggestions on earlier drafts of the paper:
Journal of Midwifery & Women's Health, Nov 12, 2002
In 1996, the Centers for Disease Control and Prevention (CDC) and relevant professional organizat... more In 1996, the Centers for Disease Control and Prevention (CDC) and relevant professional organizations jointly released guidelines for prevention of early-onset neonatal group B streptococcal infections. The guidelines recommended that all obstetric providers and institutions providing intrapartum services follow one of two strategies. This year, on the basis of multistate surveillance data collected since prevention strategies were initiated, the CDC has released revised prevention recommendations. This article reviews the new guidelines and discusses clinical implications for practice in a variety of settings.
A concrete and useful way to create an action plan for improving the quality of maternity care in... more A concrete and useful way to create an action plan for improving the quality of maternity care in the United States is to start with a view of the desired result, a common definition and a shared vision for a high-quality, high-value maternity care system. In this paper, we present a long-term vision for the future of maternity care in the United States. We present overarching values and principles and specific attributes of a high-performing maternity care system. We put forth the ''2020 Vision for a High-Quality, High-Value Maternity Care System'' to serve as a positive starting place for a fruitful collaborative process to develop specific action steps for broad-based maternity care system improvement.
Background Midwives' authorization to deliver the seven basic emergency obstetric and newborn car... more Background Midwives' authorization to deliver the seven basic emergency obstetric and newborn care (BEmONC) functions is a core policy indicator in global monitoring frameworks, yet little evidence supports whether such data are captured accurately, or whether authorization demonstrates convergence with midwives' skills and actual provision of services. In this study, we aimed to validate the data reported in global monitoring frameworks (criterion validity) and to determine whether a measure of authorization is a valid indicator for BEmONC availability (construct validity). Methods We conducted a validation study in Argentina, Ghana, and India. To assess accuracy of the reported data on midwives' authorization to provide BEmONC services, we reviewed national regulatory documents and compared with reported country-specific data in Countdown to 2030 and the World Health Organization Maternal, Newborn, Child and Adolescent Health Policy Survey. To assess whether authorization demonstrates convergent validity with midwives' skills, training, and performance of BEmONC signal functions, we surveyed 1257 midwives/midwifery professionals and assessed variance.
Background There is a global shortage of midwives, whose services are essential to meet the healt... more Background There is a global shortage of midwives, whose services are essential to meet the healthcare needs of pregnant women and newborns. Evidence suggests that if enough midwives, trained and regulated to global standards, were deployed worldwide, maternal, and perinatal mortality would decline significantly. Health workforce planning estimates the number of midwives needed to achieve population coverage of midwifery interventions. However, to provide a valid measure of midwifery care coverage, an indicator must consider not only the raw number of midwives, but also their scope and competency. The tasks midwives are authorized to deliver and their competency to perform essential skills and behaviors provide crucial information for understanding the availability of safe, high-quality midwifery services. Without reliable estimates for an adequate midwifery workforce, progress toward ending preventable maternal and perinatal mortality will continue to be uneven. The International Labor Organization (ILO) and the International Confederation of Midwives (ICM) suggest standards for midwifery scope of practice and competencies. This paper compares national midwifery regulations, scope, and competencies in three countries to the ILO and ICM standards to validate measures of midwife density. We also assess midwives' self-reported skills/behaviors from the ICM competencies and their acquisition.
Background Global mechanisms have been established to monitor and facilitate state accountability... more Background Global mechanisms have been established to monitor and facilitate state accountability regarding the legal status of abortion. However, there is little evidence describing whether these mechanisms capture accurate data. Moreover, it is uncertain whether the "legal status of abortion" is a valid proxy measure for access to safe abortion, pursuant to the global goals of reducing preventable maternal mortality and advancing reproductive rights. Therefore, this study sought to assess the accuracy of reported monitoring data, and to determine whether evidence supports the consistent application of domestic law by health care professionals such that legality of abortion functions as a valid indicator of access. Methods and findings We conducted a validation study using three countries as illustrative case examples: Argentina, Ghana, and India. We compared data reported by two global monitoring mechanisms (Countdown to 2030 and the Global Abortion Policies Database) against domestic source documents collected through in-depth policy review. We then surveyed health care professionals authorized to perform abortions about their knowledge of abortion law in their countries and their personal attitudes and practices regarding provision of legal abortion. We compared professionals' responses to the domestic legal frameworks described in the
Abstract
Background
The concept of universal health coverage (UHC) encompasses both access to ess... more Abstract Background The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization’s Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, “Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?”, captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries.
Methods and findings We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15–49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures.
Conclusions Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.
Background Sustainable Development Goal (SDG) Indicator 5.6.2 is the "Number of countries with la... more Background Sustainable Development Goal (SDG) Indicator 5.6.2 is the "Number of countries with laws and regulations that guarantee full and equal access to women and men aged 15 years and older to sexual and reproductive health care, information, and education." This indicator plays a key role in tracking global progress toward achieving gender equity and empowerment, ensuring its validity is essential. Significant challenges related to the indicator's calculation have been noted, which have important implications for the indicator's validity in measuring progress towards meeting the SDG target. Recommendations have been made to revise the scoring of the indicator. This study examines the indicator's validity by proposing a revision to the indicator's calculation that addresses these global concerns and comparing the resulting values. Methods and findings This is an observational, validation study which used secondary data from the 2022 United Nations Population Fund's Sexual and Reproductive Health and Rights Country Profiles from 75 countries. To address global recommendations, we proposed making 2 changes to the indicator's calculation. First, we re-expressed all barriers and enablers to take positive values. Second, we used a weighted additive approach to calculate the total score, rather than the mean of the 13 individual component scores, which assigns equal weight to the
Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of e... more Availability of emergency obstetric and newborn care (EmONC) is a strong supply side measure of essential health system capacity that is closely and causally linked to maternal mortality reduction and fundamentally to achieving universal health coverage. The World Health Organization's indicator "Availability of EmONC facilities" was prioritized as a core indicator to prevent maternal death. The indicator focuses on whether there are sufficient emergency care facilities to meet the population need, but not all facilities designated as providing EmONC function as such. This study seeks to validate "Availability of EmONC" by comparing the value of the indicator after accounting for key aspects of facility functionality and an alternative measure of geographic distribution. This study takes place in four subnational geographic areas in Argentina, Ghana, and India using a census of all birthing facilities. Performance of EmONC in the 90 days prior to data collection was assessed by examining facility records. Data were collected on facility operating hours, staffing, and availability of essential medications. Population estimates were generated using ArcGIS software using WorldPop to estimate the total population, and the number of women of reproductive age (WRA), pregnancies and births in the study areas. In addition, we estimated the population within two-hours travel time of an EmONC facility by incorporating data on terrain from Open Street Map. Using these data sources, we calculated and compared the value of the
Background Understanding causes and contributors to maternal mortality is critical from a quality... more Background Understanding causes and contributors to maternal mortality is critical from a quality improvement perspective to inform decision making and monitor progress toward ending preventable maternal mortality. The indicator "maternal death review coverage" is defined as the percentage of maternal deaths occurring in a facility that are audited. Both the numerator and denominator of this indicator are subject to misclassification errors, underreporting, and bias. This study assessed the validity of the indicator by examining both its numerator-the number and quality of death reviews-and denominator-the number of facility-based maternal deaths and comparing estimates of the indicator obtained from facility-versus district-level data. Methods and findings We collected data on the number of maternal deaths and content of death reviews from all health facilities serving as birthing sites in 12 districts in three countries: Argentina, Ghana, and India. Additional data were extracted from health management information systems on the number and dates of maternal deaths and maternal death reviews reported from health facilities to the district-level. We tabulated the percentage of facility deaths with evidence of
Background Integrating measures of respectful care is an important priority in family planning pr... more Background Integrating measures of respectful care is an important priority in family planning programs, aligned with maternal health efforts. Ensuring women can make autonomous reproductive health decisions is an important indicator of respectful care. While scales have been developed and validated in family planning for dimensions of person-centered care, none focus specifically on decision-making autonomy. The Mothers Autonomy in Decision-Making (MADM) scale measures autonomy in decision-making during maternity care. We adapted the MADM scale to measure autonomy surrounding a woman's decision to use a contraceptive method within the context of contraceptive counselling. This study presents a psychometric validation of the Family Planning Autonomous Decision-Making (FP-ADM) scale using data from Argentina, Ghana, and India. Methods and findings We used cross-sectional data from women in four subnational areas in Argentina (n = 890), Ghana (n = 1,114), and India (n = 1,130). In each area, 20 primary sampling units (PSUs) were randomly selected based on probability proportional to size. Households were randomly selected in Ghana and India. In Argentina, all facilities providing reproductive and
In 2015, the World Health Organization (WHO) released global targets and strategies for reducing ... more In 2015, the World Health Organization (WHO) released global targets and strategies for reducing maternal mortality in the Sustainable Development Goal (SDG) period developed through broad stakeholder consultations. The targets and strategies identified in the "Strategies toward Ending Preventable Maternal Mortality (EPMM)" report are grounded in a systemic and human rights approach to maternal health and aim to address the broad spectrum of key social, political, economic, and health system determinants of maternal health and survival, as exemplified by 11 Key Themes. These upstream determinants of maternal survival are not well represented in maternal health measurement efforts, which tend to focus on service delivery. Thus, work was undertaken to develop a core set of maternal health indicators that could drive progress toward achieving the recommendations laid out in the EPMM Strategies that identified a menu of 25 indicators and 7 standard stratifiers related to the legal and policy environment, accountability mechanisms, inequities in access and quality, and empowerment of women, girls, families, and communities. Measurement experts have called for more research to ensure that indicators for monitoring maternal health, including its upstream determinants, are valid, which is critical if such measures are to be effective for driving and tracking progress toward ending preventable maternal deaths. This paper describes nine research reports emanating from seven discrete research studies to validate ten indicators in India, Ghana and Argentina that are compiled in a PLOS Collection with the aim of illustrating the breadth of the validation work, extracting some unifying themes and common findings, and discussing the implications for policy and practice they suggest.
This white paper was prepared with funding from the Asia and the Middle East bureaus of the Unite... more This white paper was prepared with funding from the Asia and the Middle East bureaus of the United States Agency for International Development, under the activity "Gender, Policy, and Measurement." The AME bureaus have enlisted the Health Policy Project (HPP) and MEASURE Evaluation to work together on this activity to ensure a range of expertise on family planning and maternal, neonatal, and child health; gender programming; policy and systems development/implementation; and strong measurement capacity. A joint workplan outlines the scope of work and contributions of each project. Using a system strengthening approach, HPP will apply gender and policy to the scale-up of best practices through a series of consultations, white papers, and technical assistance to bilateral projects. MEASURE Evaluation will design a rigorous evaluation to measure the impact of gender integration and policy implementation on scale-up, systems strengthening, and the contribution to health outcomes. The authors would like to thank all the participants of the "Expert Meeting on Policy Implementation and Gender Integration in the Scale-Up of Family Planning and Maternal Neonatal and Child Health Best Practices," held at Futures Group in Washington, DC, on December 12, 2011. Their valuable inputs helped to inform the development of this publication. Special thanks go to the following people for their useful suggestions on earlier drafts of the paper:
Journal of Midwifery & Women's Health, Nov 12, 2002
In 1996, the Centers for Disease Control and Prevention (CDC) and relevant professional organizat... more In 1996, the Centers for Disease Control and Prevention (CDC) and relevant professional organizations jointly released guidelines for prevention of early-onset neonatal group B streptococcal infections. The guidelines recommended that all obstetric providers and institutions providing intrapartum services follow one of two strategies. This year, on the basis of multistate surveillance data collected since prevention strategies were initiated, the CDC has released revised prevention recommendations. This article reviews the new guidelines and discusses clinical implications for practice in a variety of settings.
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Papers by Rima Jolivet
Background
The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization’s Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, “Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?”, captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries.
Methods and findings
We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15–49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures.
Conclusions
Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.
Background
The concept of universal health coverage (UHC) encompasses both access to essential health services and freedom from financial harm. The World Health Organization’s Maternal Newborn Child and Adolescent Health (MNCAH) Policy Survey collects data on policies that have the potential to reduce maternal morbidity and mortality. The indicator, “Are the following health services provided free of charge at point-of-use in the public sector for women of reproductive age?”, captures the free provision of 13 key categories of maternal health-related services, to measure the success of UHC implementation with respect to maternal health. However, it is unknown whether it provides a valid measure of the provision of free care. Therefore, this study compared free maternal healthcare laws and policies against actual practice in three countries.
Methods and findings
We conducted a cross-sectional study in four districts/provinces in Argentina, Ghana, and India. We performed desk reviews to identify free care laws and policies at the country level and compared those with reports at the global level. We conducted exit interviews with women aged 15–49 years who used a component service or their accompanying persons, as well as with facility chief financial officers or billing administrators, to determine if women had out-of-pocket expenditures associated with accessing services. For designated free services, prevalence of expenditures at the service level for women and reports by financial officers of women ever having expenditures associated with services designated as free were computed. These three sources of data (desk review, surveys of women and administrators) were triangulated, and chi-square analysis was conducted to determine if charges were levied differentially by standard equity stratifiers. Designation of services as free matched what was reported in the MNCAH Policy Survey for Argentina and Ghana. In India, insecticide-treated bed nets and testing and treatment for syphilis were only designated as free for selected populations, differing from the WHO MNCAH Policy Survey. Among 1046, 923, and 1102 women and accompanying persons who were interviewed in Argentina, Ghana, and India, respectively, the highest prevalence of associated expenditures among women who received a component service in each setting was for cesarean section in Argentina (26%, 24/92); family planning in Ghana (78.4%, 69/88); and postnatal maternal care in India (94.4%, 85/90). The highest prevalence of women ever having out of pocket expenditures associated with accessing any free service reported by financial officers was 9.1% (2/22) in Argentina, 64.1% (93/145) in Ghana, and 29.7% (47/158) in India. Across the three countries, self-reports of out of pocket expenditures were significantly associated with district/province and educational status of women. Additionally, wealth quintile in Argentina and age in India were significantly associated with women reporting out of pocket expenditures.
Conclusions
Free care laws were largely accurately reported in the global MNCAH policy database. Notably, we found that women absorbed both direct and indirect costs and made both formal and informal payments for services designated as free. Therefore, the policy indicator does not provide a valid reflection of UHC in the three settings.