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      Using multi-country household surveys to understand who provides reproductive and maternal health services in low- and middle-income countries: a critical appraisal of the Demographic and Health Surveys

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          Abstract

          Objective

          The Demographic and Health Surveys (DHS) are a vital data resource for cross-country comparative analyses. This study is part of a set of analyses assessing the types of providers being used for reproductive and maternal health care across 57 countries. Here, we examine some of the challenges encountered using DHS data for this purpose, present the provider classification we used, and provide recommendations to enable more detailed and accurate cross-country comparisons of healthcare provision.

          Methods

          We used the most recent DHS surveys between 2000 and 2012; 57 countries had data on family planning and delivery care providers and 47 countries had data on antenatal care. Every possible response option across the 57 countries was listed and categorised. We then developed a classification to group provider response options according to two key dimensions: clinical nature and profit motive.

          Results

          We classified the different types of maternal and reproductive healthcare providers, and the individuals providing care. Documented challenges encountered during this process were limitations inherent in household survey data based on respondents’ self-report; conflation of response options in the questionnaire or at the data processing stage; category errors of the place vs. professional for delivery; inability to determine whether care received at home is from the public or private sector; a large number of negligible response options; inconsistencies in coding and analysis of data sets; and the use of inconsistent headings.

          Conclusions

          To improve clarity, we recommend addressing issues such as conflation of response options, data on public vs. private provider, inconsistent coding and obtaining metadata. More systematic and standardised collection of data would aid international comparisons of progress towards improved financial protection, and allow us to better characterise the incentives and commercial nature of different providers.

          Objectif

          Les enquêtes démographiques et de santé (EDS) sont une ressource vitale de données pour des analyses comparatives entre les pays. Cet article fait partie d'une série d'analyses évaluant les types de prestataires utilisés pour les soins de santé reproductive et maternelle dans 57 pays. Ici, nous examinons certains des défis rencontrés, en utilisant les données EDS à cette fin, présentons la classification que nous avons utilisée pour les prestataires et fournissons des recommandations pour permettre des comparaisons plus détaillées et précises entre les pays sur la prestation des soins de santé.

          Méthodes

          Nous avons utilisé les plus récents relevés EDS entre 2000 et 2012; 57 pays avaient des données sur la planification familiale et les prestataires de soins d'accouchement et 47 pays avaient des données sur les soins prénatals. Chaque option de réponse possible dans les 57 pays a été répertoriée et classée. Nous avons ensuite développé une classification pour grouper les options de réponses des prestataires selon deux dimensions clés: la nature clinique et la recherche du profit.

          Résultats

          Nous avons classé les différents types de prestataires de soins de santé maternelle et reproductive, et les personnes qui fournissent des soins. Les défis documentées rencontrées durant ce processus étaient les limitations inhérentes aux données de l'enquête sur les ménages sur la base de l'auto-report des répondants, l'amalgame d'options de réponse dans le questionnaire ou à l’étape de traitement des données, les erreurs de catégories du lieu par rapport à la profession pour l'accouchement, l'incapacité à déterminer si les soins reçus à domicile étaient du secteur public ou privé, un grand nombre d'options de réponse négligeables, des incohérences dans le codage et l'analyse des ensembles de données, et l'utilisation de rubriques incompatibles.

          Conclusions

          Pour améliorer la clarté, nous recommandons de tacler les problèmes tels que l'amalgame d'options de réponses, les données sur les prestataires du public par rapport à ceux du privé, l'incohérence dans le codage et l'obtention de métadonnées. Plus de collecte systématique et standardisée des données aiderait les comparaisons internationales des progrès vers une meilleure protection financière et nous permettra de mieux caractériser les incitations et la nature commerciale des différents prestataires.

          Objetivo

          Las Encuestas Demográficas y de Salud (EDS) son una fuente de datos vitales para el análisis comparativo entre países. Este artículo es parte de un grupo de análisis que evalúan los tipos de proveedores de atención a la salud reproductiva y materna que están siendo utilizados en 57 países. Examinamos algunos de los retos encontrados al utilizar datos de EDS con este propósito, presentamos la clasificación de proveedores que hemos usado, y proveemos recomendaciones para permitir una comparación más detallada y más precisa de la prestación de servicios sanitarios en diferentes países.

          Métodos

          Hemos utilizado datos de las EDS más recientes, entre el 2000 y 2012; 57 países tenían datos sobre planeación familiar y proveedores de servicios durante el parto y 47 países tenían datos sobre cuidados prenatales. Cada opción posible de respuesta en los 57 países fue listada y categorizada. Después se desarrolló una clasificación para agrupar las opciones de respuesta según proveedor, siguiendo dos dimensiones clave: naturaleza clínica y afán de lucro.

          Resultados

          Hemos clasificado los diferentes tipos de proveedores de cuidados sanitarios en salud materna y reproductiva, y a los individuos que ofrecían los servicios. Los retos documentados durante este proceso fueron las limitaciones inherentes a los datos en las encuestas realizadas en los hogares basados en las auto-respuestas de los encuestados; fusión de las opciones de respuesta en el cuestionario o durante la etapa de procesamiento de datos; errores de categoría sobre el lugar versus profesional que atendió el parto; incapacidad para determinar si los cuidados recibidos en el hogar eran del sector público o privado; un gran número de opciones de respuesta insignificantes; inconsistencias en la codificación y el análisis del conjunto de datos; y uso de encabezamientos inconsistentes.

          Conclusiones

          Para mejorar la claridad, recomendamos abordar cuestiones tales como la fusión de opciones de respuesta, datos sobre el proveedor público versus privado, codificación inconsistente, y la obtención de metadatos. Una recolección de datos más sistemática y estandarizada facilitaría las comparaciones internacionales del progreso hacia una protección financiera mejorada, y nos permitiría una mejor caracterización de las iniciativas y de la naturaleza comercial de los diferentes proveedores.

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          Most cited references53

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          Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data

          Background In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home. Methodology/Principal Findings We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed “not necessary” by a household decision maker. Among the poorest women, “not necessary” was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended. Conclusions In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.
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            Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries.

            Progress towards the Millennium Development Goals for maternal health has been slow, and accelerated progress in scaling up professional delivery care is needed. This paper describes poor-rich inequalities in the use of maternity care and seeks to understand these inequalities through comparisons with other types of health care. Demographic and Health Survey (DHS) data from 45 developing countries were used to describe poor-rich inequalities by wealth quintiles in maternity care (professional delivery care and antenatal care), full childhood immunization coverage and medical treatment for diarrhoea and acute respiratory infections (ARI). Poor-rich inequalities in maternity care in general, and professional delivery care in particular, are much greater than those in immunization coverage or treatment for childhood illnesses. Public-sector inequalities make up a major part of the poor-rich inequalities in professional delivery attendance. Even delivery care provided by nurses and midwives favours the rich in most countries. Although poor-rich inequalities within both rural and urban areas are large, most births without professional delivery care occur among the rural poor. Poor-rich inequalities in professional delivery care are much larger than those in the other forms of care. Reducing poor-rich inequalities in professional delivery care is essential to achieving the MDGs for maternal health. The greatest improvements in professional delivery care can be made by increasing coverage among the rural poor. Problems with availability, accessibility and affordability, as well as the nature of the services and demand factors, appear to contribute to the larger poor-rich inequalities in delivery care. A concerted effort of equity-oriented policy and research is needed to address the huge poor-rich inequalities in maternity care.
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              Skilled birth attendance-lessons learnt.

              To reduce the horrific maternal mortality figures that we have globally especially in resource poor countries, there was a global commitment to reduce maternal mortality by three-quarters by 2015 using 1990 as a baseline. To measure the achievement of this goal, two indicators: maternal mortality ratio and proportion of births attended by skilled attendance were selected. To ensure skilled attendance at birth for all women, the international community set a target of 80% by 2005, 85% by 2010 and 90% coverage by 2015. However, in 2008 only 65.7% of all women were attended to by a skilled attendant during pregnancy, childbirth and immediately postpartum globally with some countries having less than 20% coverage. With the global human resource crisis, achieving this target is challenging but possible. This paper provides a narrative review of the literature on the skilled birth attendance strategy identifying key challenges and lessons learnt.
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                Author and article information

                Journal
                Trop Med Int Health
                Trop. Med. Int. Health
                tmi
                Tropical Medicine & International Health
                BlackWell Publishing Ltd (Oxford, UK )
                1360-2276
                1365-3156
                May 2015
                05 March 2015
                : 20
                : 5
                : 589-606
                Affiliations
                [1 ]Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine London, UK
                [2 ]Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine London, UK
                Author notes
                Corresponding Author: Katharine Footman, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Email: Katharine.footman@ 123456lshtm.ac.uk
                Article
                10.1111/tmi.12471
                4409817
                25641212
                a74f29ac-cc49-4533-84d2-8dc03824f520
                © 2015 The Authors. Tropical Medicine & International Health published by John Wiley & Sons Ltd.

                This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

                History
                : 01 February 2015
                Categories
                Original Research Papers

                Medicine
                demographic and health surveys,reproductive health,maternal health,private sector,methods,healthcare providers

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