Ghana is identified among the developing countries with high maternal mortality ratio in Africa. This study unpacked the Demographic and Health Survey data by examining the maternal health indicators at the district level using GIS methods. Understanding the geographic patterns of antenatal care, place of delivery, and skilled birth attendants at the small scale will help to formulate and plan for location-specific health interventions that can improve maternal health care behavior among Ghanaian women. Districts with high rates and low rates were identified. Place of residence, Gini-Coefficient, wealth status, internet access, and religious affiliation were used to explore the underlying factors associated with the observed patterns. Economic inequality was positively associated with increased use of maternal health care services. The ongoing free maternal health policy serves as a cushion effect for the economic inequality among the districts in the Northern areas. Home delivery is common among the rural districts and is more prominent mostly in the western part of Northern Region and southwest of Upper West. Educating women about the free maternal health policy remains the most viable strategy for positive maternal health outcomes and in reducing MMR in Ghana.

Research objectives: This study examined research, media, and public opinion related to maternal health in order to understand some of the social and structural factors that influence the passage of comprehensive maternal health policies in the United States. This study also examined the messaging of race and racism in media and health communication. Research objectives were: 1.) To summarize the perinatal care experiences of Black birthing people through a scoping review of the literature, 2.) To explore media depictions of maternal mortality in terms of the groups, causes, and solutions discussed in coverage, and 3.) To test the effects of two different approaches to communicating maternal health on public beliefs about the causes of racial health disparities and public support for structural policies. Methods: The review of the literature followed a scoping review protocol and developed tailored search strings to retrieve relevant articles in three databases. The review protocol included developing selection criteria, screening articles retrieved from three databases, charting the data, and identifying themes across articles using an ecological health model as a conceptual guide. For the second paper – a content analysis of news media coverage of maternal mortality – relevant news articles were retrieved using NexisUni, an online database of newspaper articles. A codebook was developed deductively using previous research and grey literature on maternal health, and articles were subsequently coded for the presence or absence of codes that assessed how articles framed causes, solutions, and social groups in their coverage of maternal mortality in the United States. The third paper tested the effects of articles that communicated the maternal health issues faced by Black birthing people using a web-based survey experiment. Participants in this study were recruited using Qualtrics’ panel services, and were randomly assigned to read either a narrative or nonnarrative article communicating the relationship between race and adverse maternal health outcomes. Participants were then asked to respond to the questions that assessed their agreement with structural causes for racial health disparities and their support for policies to improve maternal health. Findings: The scoping review found that Black birthing people described factors at the interpersonal, organizational, community, and policy level in their accounts of their perinatal care experiences. This included their interactions with their providers, the dominant models of care in healthcare settings, institutional representation, and the limitations of care covered through existing Medicaid policies. The content analysis of media found that newspaper coverage of maternal health reflected the factors described in research. Media predominantly focused on structural causes and solutions for maternal health (e.g., access to services and care, social determinants of health, structural racism) and described racial disparities in maternal mortality. The final study built on the findings of the media analysis by testing the effects of news articles that described the role of social and structural factors on the maternal health outcomes of Black birthing people. Data from the experiment showed that participants who read a narrative article about the issue had greater support for structural policies than participants who read a nonnarrative article. The difference in agreement with structural causes for racial health disparities between participants in the narrative and nonnarrative groups was not statistically significant. Additionally, data showed significant differences in treatment effects and policy support across groups distinguished by race and gender.

This thesis comprises three chapters on topics in development economics. The first chapter studies access to maternal healthcare in markets with vertically differentiated public and private providers. The second chapter studies the efficacy of induction stoves in reducing indoor air pollution in rural households when faced with erratic power supply. Finally, the third chapter studies the role of financial incentives in correcting disparities in sex ratios. All three chapters study the context of India but are representative of important development issues in low-income countries. The first chapter titled "Equilibrium Effects of Subsidizing Public Services" studies one of India's largest welfare schemes Janani Suraksha Yojana (JSY) that incentivized pregnant women in India to access institutional maternal care at public hospitals. We argue that governments can make complementary investments to improve welfare gains from large scale policies. JSY did not improve health outcomes despite a substantial increase in the take-up of institutional care. We document three equilibrium responses that explain this policy failure. First, JSY led to a mismatch of risk across health facilities -- high-risk mothers sorted out of highest quality care at private facilities. Second, in line with the literature, public sector quality deteriorated as a result of congestion. This resulted in lower quality care for both marginal as well as infra-marginal patients at public hospitals. We show that only mothers with high socio-economic status adapted to the worsening quality of care at public hospitals by sorting into more expensive private hospitals. Third, despite increased competition, private hospitals maintained high prices, crowding out riskier and poorer mothers. We do not find evidence that private hospitals improved healthcare quality to justify higher prices. The second chapter titled "Electric Stoves as a Solution for Household Air Pollution" is an interdisciplinary field-based research study that studies the role of reliable electricity in inducing rural Indian households to switch away from dirty cooking fuels towards a clean cooking technology, induction cookstoves, thereby reducing the exposure to high levels of indoor air pollution. We collected minute-by-minute data on electricity availability, electric induction stove use, and kitchen and outdoor particulate pollution in a sample of rural Indian households for one year. Using within household-month variation generated by unpredictable outages, we estimate the effects of electricity availability and electric induction stove use on kitchen PM2.5 concentration at each hour of the day. Electricity availability reduces kitchen PM2.5 by up to 50 ??/?3, which is between 10 and 20 percent of peak concentrations during cooking hours. Induction stove use instrumented by electricity availability reduces PM2.5 in kitchens by 200-450 ??/?3 during cooking hours. The final chapter titled "Can Large-Scale Conditional Cash Transfers Resolve the Fertility-Sex Ratio Trade-off? Evidence from India" studies a large-scale conditional cash transfer (CCT) scheme Ladli Laxmi Yojana that offered cash incentives to households upon the birth of girl children. The policy also offered substantial incentive for investing in girls' education. In my evaluation of the Ladli Laxmi Yojana in Madhya Pradesh, India. I find that financial incentives aimed at the girl child increased average fertility by about 0.15 children per household (on baseline average of 0.93 children) children per household and improved sex-ratio by 3%. This points to the well known fertility-sex ratio trade-off. Moreover, these effects are quite opposite to a similar CCT scheme in Haryana (Anukriti, 2018) suggesting context dependence of such policies.

This dissertation is motivated by the study of economic development and inequality within and across nations. Spanning topics in labor and public economics, this collection of papers speaks to two overarching themes: (i) how the distribution of power affects economic outcomes, and (ii) how governments can mobilize resources and spend them effectively. In Chapter 1, I study how the allocation of ownership and control rights within firms affect responses to economic shocks. To shed light on this issue, I study the heterogeneous effects of a pro-competitive reform on cooperative manufacturing firms and their non-cooperative counterparts in India. The reform removed firm-size restrictions on the production of “reserved” items, increasing competition for incumbents in “de-reserved” product markets. Using a difference-in-differences approach, I find that supplier cooperatives (SCs), owned and controlled by producer-members who supply material inputs, are resilient to the shock in terms of total revenue and move away from the production of de-reserved items. SCs increase their share of income spent on materials relative to similarly sized non-cooperatives in the same industry and location, with some evidence of downward adjustments in labor spending. These cooperatives are able to withstand competitive pressure from entrants while broadly catering to the interests of their membership. On the other hand, worker cooperatives (WCs), owned and controlled by worker-members employed at the firm, face a sharp decline in revenue due to de-reservation, unlike their non-cooperative counterparts. A potential channel behind these results is that WCs are less likely to respond by picking up items that are not directly affected by the reform. Spending on labor does not fall as much as revenue for WCs, which is in line with the immediate interests of membership, but adjustments to labor inputs vary sigificantly across employment categories. In the following chapter, my co-author, Utkarsh Kumar, and I study the equilibrium effects of subsidizing public services in the presence of vertically differentiated public and private suppliers. We evaluate one of India’s largest welfare schemes, Janani Suraksha Yojana (JSY), which subsidized childbirth at public health institutions. JSY did not improve health outcomes despite a substantial increase in take-up of institutional care. We document three equilibrium responses that explain this policy failure. First, JSY led to a mismatch in patient risk across health facilities. High-risk mothers sorted out of the highest-quality care at private facilities and into lower-quality public facilities. Second, in response to congestion and deterioration of care at public hospitals, only mothers with high socio-economic status sorted out of congested public facilities into more expensive private facilities. Third, private hospitals increased prices without improvements in healthcare quality in a specific subset of states, further crowding out high-risk and poor mothers. These findings point to the need for complementary public policies in addition to JSY. In Chapter 3, I, along with my co-authors, Alexander Klemm and Li Liu, explore the increasingly prominent position of services in international trade and their potential to facilitate tax-driven reporting and reallocation of economic activity. Given their potential in countering this form of base erosion, withholding taxes (WHTs) on payments for services have featured extensively in ongoing reforms of the international tax architecture. The rationale behind WHTs is to preserve some taxation rights in the source country given their straightforward application, which is particularly important for low-income countries in the absence of more effective rules. We build a simple model of reporting decisions when firms have economic activities in one country and affiliates in others. We then test the predictions of this model using newly compiled data on treaty and non-treaty rates for 120+ countries over 2009-2021. Our findings indicate that while there is no significant relationship between WHTs and services trade in general, these taxes do have a strong negative impact on services imports from known low-tax jurisdictions, when base erosion is a particular concern.

Background. Mothers of children with Autism Spectrum Disorder (ASD) report high levels of stress, depression, and poor well-being, with little sense of social support due to the high demands of their child’s care. The Incredible Years® for Autism and Language Delays (IY-ASLD) program offers a unique model in that there is a dual focus on both child and parent outcomes. However, there is a dearth of literature on whether IY-ASLD can improve parental mental health outcomes. While there is some evidence to suggest that in-vivo therapist-to-parent supportive statements reduce parental resistance to treatment, there remains a gap in the literature regarding whether these behaviors directly impact parental mental health outcomes. Therefore, the present study investigated the degree to which exposure to the IY-ASLD telehealth curriculum (total minutes in attendance across sessions) along with in-vivo therapist-parent group verbal support was related to parental mental health outcomes and parental verbal approval statements of the child at post-treatment after controlling for baseline mental health and verbal approval. Methods. Participants were seventeen mother-child dyads, with children ages 2-years-8-months to 5-years-old recruited from a preschool utilizing an Applied Behavior Analysis (ABA) approach to schooling. All or virtually all children referred to this school by their school district are at-risk for or have been diagnosed with ASD. All of the children had an IEP or IFSP with mandated speech services, 71% of the children met criteria for ASD (N = 12) on the Childhood Autism Rating Scale- 2-SF, and 2/3 of the sample had adaptive behavior composites below a standard score of 70 on the Vineland Adaptive Behavior Scales- Third Edition Comprehensive Teacher Form (Sparrow et al., 2016). Participants were assigned to one of four treatment groups based on language level of the child and convenience of the group meeting time. Groups met for 12-weekly IY-ASLD sessions via telehealth. Data were collected at the beginning, mid-point, and end of treatment in the form of a parent questionnaire covering demographics, parental well-being (World Health Organization- Five Well-Being Index; WHO, 1998), depressive symptoms (Patient Health Questionnaire; Kroenke et al., 2001), and parenting stress (Parenting Stress Index-Fourth Edition, Short Form; Abidin, 2012). At post-treatment, parents reported satisfaction with the IY-ASLD-T program (IY-ASLD Parent Program Satisfaction Questionnaire). Data were also collected throughout treatment by recording IY-ASLD parent sessions. From the recorded parent sessions, two primary variables were developed. The first was treatment dosage, calculated as the total minutes each parent attended over the course of the 12-week intervention. The second was exposure to supportive therapist verbalizations during the first 10-minutes of each session, which was coded using the Therapy Process Code (TPC) to measure therapist supportive verbalizations during therapist-parent interaction (Chamberlain et al., 1986). Additionally, data were collected via a virtual parent-child play session (PCI) at the beginning, mid-point, and end of treatment, and later coded using the Verbal Behavior Developmental Language Coding System (VBDT) to measure parental verbal approval to child (Greer & Ross, 2008). Results. Mothers in this study had low levels of depression (PHQ-9; M = 4.59, SD = 4.69), average parenting stress (PSI-4-SF; M = 78.12, SD = 23.78), and low levels of well-being (WHO-5; M = 12.82, SD = 4.47). There were no statistically significant changes in parental depression, parental stress, or observed verbal approval from pre- to post-treatment and the effect sizes were small based on the partial eta squared and Kendall’s W values as per Cohen’s (1988, 1994) guidelines (small = .20-.49, medium = .50-.79, large > .80). However, there was a statistically significant change in caregiver well-being from baseline, mid-treatment, to post-treatment and a small effect size based on Kendall’s W (W = .31). A Friedman test indicated that caregivers demonstrated significant improvements in well-being from baseline to mid-treatment, and the improvement remained at post-treatment, χ2 (2) = 10.04, p < .01. There was no significant relationship between treatment dosage or supportive verbalizations and change in caregiver well-being. There was a significant negative correlation between treatment dosage and well-being at mid-treatment (r = -.493, p = .044), trending in the same direction at post-treatment (r = -.369, p = .146), possibly suggesting that parents with lower well-being, and therefore in greater need of support, attended IY-ASLD more frequently. An additional unexpected finding indicated that parents who were exposed to more supportive verbalizations had statistically significantly lower well-being at post-treatment. One explanation proposed by the authors is that parents who had lower well-being, and attended IY-ASLD sessions more frequently, received more supportive therapist verbalizations, possibly because they pulled for supportive verbalizations from the therapist. Results from the Incredible Years satisfaction questionnaire indicated there was high satisfaction with the program and the group leaders. High ratings of satisfaction with the group leaders and the program overall indicated that group leaders in the program may have successfully accomplished providing a “good enough” sense of support and reinforcement to parents over the course of the intervention. Therefore, it’s possible that specific therapist-to-parent supportive verbalizations were less related to improvements in parental well-being, and rather, the overall sense of support from the therapist to the parents in the group, along with support between the parents in the group, were sufficient to result in improvements in maternal well-being over the course of the intervention. Conclusions. Over the course of the IY-ASLD-T intervention, mothers demonstrated significant improvements in their overall well-being. While exposure to treatment and to supportive verbalizations from therapist to parents were not related to residualized change in well-being, these seem to be important factors in understanding the needs of parents with young children with ASD (e.g., parents with low well-being had higher attendance and received more supportive verbalizations). Taken together, the results suggest maternal well-being is an important and promising target for evidence-based behavioral parenting interventions such as IY-ASLD.

This study was carried out as part of efforts to better understand the factors that impinge on childbirth service delivery and to develop guidelines to help improve the quality and safety of childbirth services in Ghana. The objectives were to: assess the factors that influence client-centredness; explore women’s and health professional’s views of and experiences with client-centred childbirth services; and develop guidelines to assist improve client-centred childbirth services in hospitals. The fixed mixed methods design comprising both quantitative and qualitative methods was employed. Structured questionnaire and exit interviews were used to gather data from 754 women who delivered in the hospitals. Furthermore, in-depth interviews were used to examine the experiences of women, doctors and midwives. STATA MP Version 13 was used to analyse the data by generating frequencies, chi-square and binary logistic regression results. Qualitative data analysis was analysed through data reduction, data display and generation of themes and categories. The process of developing the guidelines comprised: drafting based on the findings of the study and additional literature review, and a number of reviews by senior health professionls to build consesnsus on the content. With a response rate of 97.8%, the results indicated average performance. A number of the items examined under demographic characteristics, ante-natal, labour and postnatal care were significantly associated with the experience of excellent client-centred care. These included: number of weeks pregnant before delivery; health professional who assisted with delivery; mode of delivery; labour pain management; and length of stay after delivery. On the whole, the findings of the quantitative study were support by that of the structured interviews. Most of the themes from in-depth interviews with women were had to do with the relationship between health care provider and clients. Issues of support during childbirth; decision-making and informed choice; and continuity were raised. Themes deduced from the doctors’ and midwives’ interviews demonstrated a fair understanding of principles of client-centred care and delineated relational as well as client, health care worker and organisational factors that facilitate or limit effective implementation of client-centred care. The findings of the studies were used to develop guidelines to help improve services. It is recommended that the Ministry of Health, Ghana adopt the guidelines and provide the enabling environment for its effective implementation. / Health Studies / D. Litt. et Phil. (Health Studies)

In this thesis I explore the circumstances in which pregnant Guatemalan Mayan women in South Florida communities found themselves. A local non-profit organization, the Guatemalan Maya Center (GMC), offered assistance to pregnant Mayan women to secure biomedical prenatal care, yet many continued to underutilize these services. The decision to utilize this form of care largely depended on whether a woman received care from a traditional midwife in the community. Women receiving care from a midwife generally did not seek biomedical care until late in their pregnancies. Women unable to locate a midwife often incorporated biomedical care once they suspected pregnancy. Due to the difficulties accessing the GMC's services prior to enrollment many of these women did not obtain "timely" care. A better understanding of the ways in which Guatemalan Mayan women incorporated biomedical prenatal care into their lives is the first step towards increasing their participation in these services. / by Colleen Supanich. / Thesis (M.A.)--Florida Atlantic University, 2009. / Includes bibliography. / Electronic reproduction. Boca Raton, Fla., 2009. Mode of access: World Wide Web.

The purpose of this study was to determine factors influencing skilled delivery service utilisation in order to develop strategies to improve utilisation of skilled birth attendance service in North West Ethiopia. The objectives were to explore and describe the perceptions and experiences of the community regarding skilled utilisation of the birth attendance service; explore reasons for non-utilisation of skilled birth attendance service; asses the health system experience of provision of skilled birth attendance service; and formulate strategies to improve utilisation of skilled birth attendance service. The study employed a qualitative, descriptive, and explorative research design to address the research questions formulated by the researcher. The study used focus group discussion guide to obtain information from pregnant women and women who gave birth recently. Furthermore, the study used an interview guide to gather information from health extension workers, midwives, health centre heads, district health office technical experts and heads. It also employed and inductive thematic analysis approach to analyse the qualitative data. The study further used the Atlas ti version 7 for the data analysis. The steps followed for the analysis were data immersion, coding, displaying, reduction, and interpretation. Overall, nine themes emerged from the analysis of the data. Consequently, the researcher used the findings of the study to develop strategies to improve the utilisation of skilled birth attendance service. / Health Studies / D. Litt. et Phil. (Health Studies)

This study was carried out as part of efforts to better understand the factors that impinge on childbirth service delivery and to develop guidelines to help improve the quality and safety of childbirth services in Ghana. The objectives were to: assess the factors that influence client-centredness; explore women’s and health professional’s views of and experiences with client-centred childbirth services; and develop guidelines to assist improve client-centred childbirth services in hospitals. The fixed mixed methods design comprising both quantitative and qualitative methods was employed. Structured questionnaire and exit interviews were used to gather data from 754 women who delivered in the hospitals. Furthermore, in-depth interviews were used to examine the experiences of women, doctors and midwives. STATA MP Version 13 was used to analyse the data by generating frequencies, chi-square and binary logistic regression results. Qualitative data analysis was analysed through data reduction, data display and generation of themes and categories. The process of developing the guidelines comprised: drafting based on the findings of the study and additional literature review, and a number of reviews by senior health professionls to build consesnsus on the content. With a response rate of 97.8%, the results indicated average performance. A number of the items examined under demographic characteristics, ante-natal, labour and postnatal care were significantly associated with the experience of excellent client-centred care. These included: number of weeks pregnant before delivery; health professional who assisted with delivery; mode of delivery; labour pain management; and length of stay after delivery. On the whole, the findings of the quantitative study were support by that of the structured interviews. Most of the themes from in-depth interviews with women were had to do with the relationship between health care provider and clients. Issues of support during childbirth; decision-making and informed choice; and continuity were raised. Themes deduced from the doctors’ and midwives’ interviews demonstrated a fair understanding of principles of client-centred care and delineated relational as well as client, health care worker and organisational factors that facilitate or limit effective implementation of client-centred care. The findings of the studies were used to develop guidelines to help improve services. It is recommended that the Ministry of Health, Ghana adopt the guidelines and provide the enabling environment for its effective implementation. / Health Studies / D. Litt. et Phil. (Health Studies)

Text in English, with Annexures in English and Amharic / Annexure 5 and Annexure 7 "Questionnaire for qualitative study" in English and Amharic / The Ministry of Health (MOH) and its partners are determined to prevent and manage preventable causes of morbidity and mortality in mothers, neonates and children. In the last decade, special emphasis has been given to increasing the number of health facilities that provide maternal and child health services (MNCH), huge production of skilled birth attendants (SBAs), and equipping the health facilities to improve the utilisation of quality services. This study investigated the community perspectives of health service utilisation and proposes a framework for improving the utilisation of the available SBA and postnatal care (PNC). PURPOSE The purpose of this study was to develop a framework for the utilisation of skilled care for delivery and postnatal care by women of childbearing age (15-45). METHODOLOGY The study used a Sequential explanatory Mixed Methods Approach to investigate the utilisation of SBA and PNC in a district in Ethiopia. The Delphi Technique helped to solicit input from maternal health care experts on the development of a Framework for utilisation of SBA and PNC. This study utilised the Anderson Health Utilisation Model. RESULTS In the study, 79.8% of the women who delivered within 12 months prior to this study received ANC from SBA. Baby care and PNC for the mother and baby received from SBA were at 248 (71.5%), 55 (15.8%), and 131 (38%) respectively. The study further found that women who can read and write and were educated are more likely to utilise SBA and receive quality health care services. The study showed that certain factors such as disrespecting service users, abusing service users’ lack of trust on the SBA by service users, religion and superstition contribute negatively to the use of SBAs. None of the predisposing, enabling and need factors predicted the use of SBA for PNC by the mothers. Nevertheless, through the focus group discussions (FGDs) and individual interviews (IDI), it was revealed that there was a widespread knowledge and perception gaps in the community related to the importance of postnatal period and PNC. Religious sanctification also have imperative role in hampering PNC service use by the mothers. The Health care workers (HCWs) also lacked the keenness and orientation to provide the service. Babies born from families with monthly income equal to 500 or above USD were more likely to use PNC within 45 days. There was a widespread misconception in the community that Babies do not need PNC before 45 days of birth except for vaccination purpose. CONCLUSION To examine their role in health service utilisation for SBA and PNC, researches can integrate social support and social network to the Andersen’s health-service utilisation model. A framework for utilisation of SBA and PNC is proposed. The researcher recommends developing an utilisation tool kit that specifies the detail operationalisation of the framework. / Health Studies / D. Litt. et Phil. (Health Studies)