Malawi has one of the highest maternal mortality ratio (MMR) in sub-Saharan Africa (SSA). Despite investments in family planning and emergency obstetric care (EmOC), Malawi’s Millennium Development Goal (MDG) target of reducing maternal deaths to 155 deaths per 100,000 live births was not met by the end of 2015. Between 2010 and 2015, Malawi was only able to reduce the MMR from 675 to 439 per 100,000 live births. Inadequate utilisation of perinatal services is the contributing factor to the MMR target not being achieved. One approach for improving the utilisation of perinatal services is to invest in community health workers (CHWs). CHWs can be trained to: identify women of child bearing age (WCBA) who need perinatal services; provide community education; encourage timely referral of clients to the nearest health facility; and undertake community follow up for WCBA who are pregnant and/or have recently given birth. We evaluated changes in utilisation of antenatal care (ANC), facility based births, and postnatal care (PNC) after CHW deployment to conduct monthly home visits to WCBA for pregnancy identification and escorting women to ANC, labour and facility birth and PNC clinics in Neno district, Malawi. The CHW programme was implemented in two catchment areas from March 2015 to June 2016. Methodology: We employed a retrospective quasi-experimental study design to evaluate the impact of CHWs on changes in the utilisation of ANC, facility based births, and PNC in Neno district, Malawi between March 2014 and June 2016 (pre-intervention period: March 2014 to February 2015, and post-intervention period: March 2015 to June 2016). Monthly outcomes were compared between a combined CHW intervention area and its synthetic control area using the synthetic control method. The synthetic control area (or synthetic counterfactual of the CHW) 14 was the control area that was created from multiple available control sites where the CHW programme was not implemented to allow the comparison of outcomes between the sites where CHWs were implemented and the sites where CHWs was not implemented. Two hundred and eleven CHWs (128 existing CHWs plus 83 new CHWs from the community) were trained in maternal health and deployed to cover an estimated 5,132 WCBA living in a catchment area of about 20,530 people. The primary focus of the CHWs was to conduct monthly household visits to identify pregnant women, and then escort pregnant women to their initial and subsequent ANC appointments, facility births, and to PNC check-ups. As part of package of care, community mobilisation and improvements in services to achieve a minimum package of services at the local health centres were also added. Using the synthetic control method, as developed by Abadie and Gardeazabal (2003) and Abadie, Diamond and Hainmueller (2010) and a Bayesian approach of synthetic control developed by Brodersen (2015), a synthetic counterfactual of the CHW intervention was created based on six available public control facilities. The synthetic counterfactual trend was created to have similar pre-intervention characteristics as the CHW intervention trend. The impact of the CHW intervention was the difference between the CHW intervention site and its synthetic counterfactual Results: CHWs in the intervention areas visited an average of 3,147 (range 3,036 – 3,218) of WCBA monthly, covering 61.0% of WCBA. During these visit 3.6% (97 women per month) of WCBA were suspected to be pregnant every month. Of those women suspected to be pregnant, 67.8% (66 women per month) were escorted to health facilities immediately every month. CHWs 15 visited an average of 254 pregnant women enrolled in ANC and 64 women in postpartum period monthly. ANC and facility births utilisation in the CHW intervention site increased in comparison to the control site. Firstly, the number of new pregnant women enrolled in ANC per month increased by 18.0 % (95% Credible Interval (CrI) 8.0%, 28.0%), from 83 to 98 per pregnant women. Secondly, the proportion of women starting ANC in first trimester increased by 200.0% (95% CrI 162.0%, 234.0%), from 9.5% to 29.0% per month. Thirdly, the number of women attending four or more ANC visits increased by 37.0% (95% CrI 31.0%, 43.0%), from to 28.0% to 39.0%. Lastly, the number of facility births increases by 20% (CrI 13.0%, 28.0%), from 85 women to 102 per month. However, there was no net difference on PNC visits between the CHW intervention site and its counterfactual unit (-37.0%, 95% CrI -224.0%, 170.0%). Conclusions: CHW intervention significantly increased the utilisation of ANC and facility based births in Neno, Malawi. However, CHWs had no net difference on PNC utilisation.

Thesis (M.P.H.)--University of Michigan, 1945.

Thesis (M.P.H.)--University of Michigan, 1945.

The World Health Organization (WHO) states that no region in the world is justified in having a caesarean section rate greater than 10-15 percent, calculated as the number of caesarean deliveries over the total number of live births. There is however, an international increase in the rate of caesarean section deliveries and this is a concern to midwives. The increase is evident in South Africa as well. Currently the rate of caesarean section deliveries in the private sector can be as high as 70 percent per total number of live births per year. As a result, the public often perceives giving birth surgically in South Africa as ‘normal’ and ‘safer’ than vaginal delivery, even for low-risk pregnancies. The lack of involvement of midwives in the care of pregnant women in the private sector is indicated as one of the reasons related to the high caesarean section delivery rates. This motivated the researcher to undertake a study to explore and describe the perceptions of private sector midwives and obstetricians regarding the feasibility of collaboration in maternity care. A literature review to support the study identified research done previously regarding collaborative maternity care. The study followed a qualitative, exploratory, descriptive, contextual design. The research population included midwives and obstetricians in the private sector in the Eastern Cape. Non-probability, purposive sampling was used. The researcher conducted semi-structured one-to-one interviews to collect information rich data. The researcher ensured that the study was conducted in an ethical manner by adhering to ethical principles such as autonomy, non-maleficence, beneficence and justice. The interviews were transcribed and Creswell’s’ data analysis spiral was used as a guide for the data analysis. Themes and sub-themes were identified and grouped together to form new categories. An independent coder assisted with the coding process. Data analysis results revealed the following results Participants perceived a collaborative working relationship as being beneficial to maternity care. Participants identified that there might be critical impediments that need to be faced in order to realize collaborative maternity care. The researcher ensured the validity of the study by conforming to Lincoln and Guba’s model of trustworthiness, which consists of the following four criteria namely credibility, transferability, dependability and conformability. The information obtained from this study assisted in developing guidelines to facilitate the implementation of collaborative maternity care between midwives and obstetricians in private practice in South Africa. The objective of the study was thus met.

The Government of Malawi has entered into agreements with Christian health association of Malawi (CHAM) health care facilities in order to exempt their catchment populations from paying user fees. These agreements are called service level agreements (SLAs). Government in turn reimburses the CHAM health care facilities for the health services that they provide. The agreements started in 2006 with 28 out of 166 CHAM health care facilities and increased to 68 in 2010. The aim of the exemption policy is to guarantee universal access to a basic package of health care services. Although the agreements were designed to cover every health service in the basic health care package, only maternal and neonatal health services are included due to limited resources. The main objective of this thesis was to evaluate the impact of the health care financing change on health care utilisation and health. The specific objectives were as follows: first, to examine whether health care facility visits for maternal health care changed due to user fee exemption; second, to evaluate whether user fee exemption affected the choice of the health care provider where women living in the catchment areas of CHAM health care facilities with user fee exemption sought maternal health care; third, to analyse the effect of user fee exemption on birth weight and; fourth, to explore and apply novel methods in the evaluation of user fee exemption. The gradual uptake of service level agreements by CHAM health care facilities provided a natural experiment with treated and control health care facilities. An additional control group comprised of other demographic groups apart from pregnant women and neonates at CHAM health care facilities with service level agreements. In household survey data, individuals were assigned to treatment and control groups based on their proximity to either a CHAM health care facility with SLA or a CHAM health care facility without SLA. This proffered the unique opportunity to estimate the effect of a single treatment on multiple outcomes. The difference-in-differences (DiD) approach was used to obtain causal effects of user fee exemption. It was implemented in the context of fixed effects, switching regression and multinomial logit models across different chapters. Health care facility level panel data for utmost 146 health care facilities for a maximum of 8 years, 2003-2010, were used. The data were obtained from the Malawi health management xiii information system (HMIS). Linked survey data were also used. Malawi demographic and survey data for 2004 and 2010 were linked to health care facility data and then merged. Analyses that utilised health care facility data showed that user fee exemption had led to increases in first antenatal care visits in the first trimester, first antenatal care visits in any trimester, average antenatal care visits and deliveries at CHAM health care facilities with SLAs. Results from survey data showed that the probability of using a CHAM health care facility with user fee exemption for antenatal care increased, the probability of using home antenatal care declined and the probability of not using antenatal care also declined due to user fee exemption. The probability of delivering at a CHAM health care facility with SLA also increased while the probability of delivering at home declined. User fee exemption did not affect the choice of where to go for postpartum care. Results of the effect of user fee exemption on birth weight were not reported because of potential endogeneity bias arising from lack of instrumental variables for antenatal care. The key policy messages from this thesis are that the user fee exemption policy is an important intervention for increasing the utilisation of maternal health care and needs to be extended to as many CHAM health care facilities as necessary. User fee exemption is not enough, however. Other factors such as education of the woman and her husband/partner, wealth status and cultural factors are also important. This thesis has contributed to the body of knowledge in the following ways. First, it has generated evidence on the impact of user fee exemption on maternal health care utilisation and birth weight in Malawi. Second, with respect to maternal health care utilisation, the thesis has looked at variables that capture the whole maternal health care process from early pregnancy to postpartum care and in a policy relevant way. Third, the thesis has evaluated the effect of user fee exemption on a variable that have not been looked at before, first antenatal care visits in the first trimester. Fourth, the thesis has examined the effect of a single treatment on multiple outcomes in a methodologically unique way. Treatment effects, which were the changes in the probabilities of using different alternatives summed up to zero, thus showing where any increase in the probability of using the outcome of interest came from. Fifth, this thesis is first to use disequilibrium theory of demand and supply in health economics. Application of this theory entailed using switching regression models with unknown sample separation, a seldom used estimation method in health economics. This was an important contribution to the methods xiv of analysing aggregate health care utilisation. Sixth, the STATA program that was written for the estimation of the disequilibrium models was itself a very important contribution to the methods for estimating aggregate supply and demand.

No description available.

INTRODUCTION: Maternity services are a priority for all health care services but in most cases there have been serious challenges experienced through service performance. The National District Hospital (NDH)‟s key performance indicator is bed occupancy rate which showed an underutilization of this facility. The maternity services statistics, especially did not give a clear picture of the performance of the unit. Various studies have been conducted to identify management challenges in maternity units of district hospitals, but no formal study has been done to systematically document this problem at the National District Hospital (NDH), although there has been anecdotal evidence of problems in the performance of the unit. It was therefore important to investigate the functioning of the maternity unit of the NDH and identify problems that hinder it from functioning effectively. AIM: To evaluate the performance of maternity services in the maternity unit at the National District Hospital. METHODOLOGY: A cross sectional study design was used comprising of a retrospective record review. The setting of this study was the maternity unit at National District Hospital. Data was collected on various variables that are relevant to the performance of maternity services. ANALYSIS: The data collected was analyzed and revealed that the factors contributing to the poor performance of the maternity services were:  Poor record keeping, such as incomplete recording of partograms.  Non adherence to guidelines and protocols, such as poor management related to HIV and AIDS care and poor management of patients in the advanced labor phase.  Failure to make informed decision due to information mismanagement.  Poor supervision in the unit. No adherence to objectives of peer review meetings. RECOMMENDATION: The recommendations based on the findings are: - Establish patient centered maternity services - Train and retraining of health care providers in the maternity unit - Review existing strategies to improve quality of care in the maternity unit - Improve information management and functioning of the Maternal Morbidity Review meetings CONCLUSION: The recommendations given can be used to improve maternity services within district hospitals as well as provincial and national maternity services.

A research report submitted to the Faculty of Health Science, in partial fulfillment of the requirement for the award of a Master’s Degree in Nursing Sciences by the Witwatersrand University of Johannesburg, South Africa. / This study, entitled “Knowledge of and challenges of health workers managing maternity patients at PHC facilities of Yobe State, Nigeria,” had the following objectives:  To describe the socio-demographic characteristics of the health workers in the Primary health care (PHC) facilities in the state.  To determine the level of knowledge of the health workers regarding the management of maternity patients in Primary health care facilities in Yobe State.  To determine the challenges experienced by the health workers in the Primary health care facilities in the state. The study was primarily aimed at exploring the health workers level of knowledge, skills and competencies in the management of maternity patients and their contributions towards the control and reduction of maternal mortality in the state. METHODS: A cross sectional survey study in PHC clinics of six selected local government areas of the state, namely Gujba, Geidam, Fune, Fika, Nguru and Jakusko local government areas. A total of 221 health workers (n=221) were interviewed using structured questionnaires, whilst 46 facility managers (n=46) were given self-administered questionnaires while on duty, and data were collected concurrently from clinic records. The data were cleaned, entered in to Epi info statistical software, imported and analysed using STATA. Descriptive and inferential statistics were used to interpret the outcomes of the analysis. RESULTS: More than half of the respondents were female (65.61%) with an average age of 33 years (SD± 8.1). Categories of the health workers who participated in the study were SCHEW, JCHEW, SSCE, TBAS, EHA/EHO and others who were not trained in any form as health workers, but were found running the affairs of maternity patients. More than 80% of the clinics did not have functional ambulances and there was gross inadequacy of basic services in most of the clinics; only 14 out of 46 clinics had portable water supply and electricity. There was a large seasonal turnout of patients in the clinics but poor patronage by maternity clients. The health workers in the maternity unit were found to be deficient in the knowledge, skills and competencies to manage maternity patients. Protocols were not followed (68.78%), some significant information about ante-natal care was not given to v clients and maternity clients were not adequately informed of some of the danger signs of pregnancy. There was a poor standard of institutional deliveries and the majority of the Health Workers had no training on EOC or conducting a clean and safe delivery. CONCLUSION: Examining the background of the current health workers in the primary health care facilities, the attainment of MDG 5 by 2015 will not be a reality, unless urgent measures are put in place, including large recruitment and motivation midwives, and deployment of these midwives to the rural health clinics. There is a need for the existing health workers to be supported by government and enrolled in short course training in Colleges of Midwifery to acquire the much needed skills and competencies for the care of maternity patients.

A research report submitted to the Discipline of Psychology, Faculty of Humanities, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Masters in Clinical Psychology Johannesburg, South Africa December 2015 / Extensive literature emphasises that good quality maternal care is crucial for infants to develop secure attachments which positively shapes their future mental health. In a developing society such as South Africa where many mothers are raising children in contexts of multiple adversities, interventions which focus on improving the quality of maternal care are vital. Home visiting programmes are an effective way to support mother-baby dyads. In South Africa, it has been found that lay women from local communities trained to work as home visitors can make a significant difference to these mother-infant relationships. Ongoing supportive supervision has been found to be particularly important for lay home visitors. The evaluation and improvement of these intervention programmes is recommended. One aspect of programme evaluation is the investigation of the programme staff experiences. Currently, there is a dearth of research focusing on the experiences and supervision of lay community health care workers, internationally as well as in South Africa. The Ububele Mother Baby Home Visiting Project, run in the Alexandra Township in Johannesburg, is one such intervention and no evaluation of this intervention from the perspective of the staff has, as yet, been conducted. It was felt that research into the experiences of the home visitors and their supervisors would be beneficial in gaining clarity regarding which aspects of the project they perceive to have been effective and those that have been challenging, as well as to assist the team in developing their intervention further. The current research aimed to gain insight into these experiences and to gain an understanding of the main concerns. The form of data included 10 semi-structured in-depth interviews with the staff of the programme: the home visitors, the supervising psychologists and the director of the project. An interpretive thematic analysis was used to interpret the results. The findings indicated that the staff’s experience included a mixture of positive and challenging experiences. The staff all agreed on their passion for the project and their belief in the effectiveness of their work in improving the bonds between mothers and babies in the community. The challenges included working in a community faced with multiple adversities, as well working in a team divided by education level, race, culture and socioeconomic class. Suggestions for the Ububele Mother Baby Home Visiting Project team are also provided.

This dissertation consists of three empirical essays broadly concerned with the determinants of human capital. The first essay estimates the causal effect of exposure to maternal psychological stress generated by the 9/11 attacks on the cohort in utero that day. The analysis finds that cohorts exposed during the first or second trimester in New York City weighed less at birth and had shorter gestation lengths. Male and female newborns were affected similarly. At age six, boys were more likely to be in special education and more likely to be in kindergarten rather than first grade, with no effect on girls. Births outside New York City were not affected. The results suggest that psychological stress is an important channel through which adverse conditions experienced by pregnant women negatively impact the early life outcomes of in utero cohorts. The second essay (joint with Katherine Baldiga) presents experimental evidence of a gender difference in the valuation of job training as an explanation for the female advantage in human capital investment that has emerged in many high income countries. In an online labor market, we find that when subjects have limited experience with an unfamiliar task, women are more willing to pay for training than men, and women estimate that the returns to training are higher than men do. We find that task performance, the return to training, self-confidence, and risk aversion cannot explain the gender gap in valuing training. We present suggestive evidence that training may be valued by women for increasing their willingness to take on a challenge. The third essay tests the prediction of several biological theories that maternal condition impacts the sex ratio at birth and causes differential investment by child's sex with data from the Dominican Republic, a developing country with relatively neutral offspring sex preferences. The analysis finds that more educated women are more likely to give birth to sons, and women in the middle of the maternal age distribution are less likely to have a male child die during infancy. These results provide evidence that maternal condition is correlated with the sex composition of children. / Economics