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Do experiences and perceptions about quality of care differ among social groups in Nepal? A study of maternal healthcare experiences of women with and without disabilities, and Dalit and non-Dalit women

DEVKOTA, Hridaya Raj
MURRAY, Emily
CLARKE, Andrew
GROCE, Nora
December 2017

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Background
Suboptimal quality of care and disparities in services by healthcare providers are often reported in Nepal. Experience and perceptions about quality of care may differ according to women’s socio-cultural background, individual characteristics, their exposure and expectations. This study aimed to compare perceptions of the quality of maternal healthcare services between two groups that are consistently considered vulnerable, women with disabilities from both the non-Dalit population and Dalit population and their peers without disabilities from both non-Dalit and Dalit communities.

Methods
A cross-sectional survey was conducted among 343 total women that included women with disabilities, Dalits and non-Dalits. Women were recruited for interview, who were aged 15–49 years, had been pregnant within the last five years and who had used maternal care services in one of the public health facilities of Rupandehi district. A 20-item, Likert-type scale with four sub-scales or dimensions: ‘Health Facility’, ‘Healthcare Delivery’, ‘Inter-personal’ and ‘Access to Care’ was used to measure women’s perceptions of quality of care. Chi-square test and t test were used to compare groups and to assess differences in perceptions; and linear regression was applied to assess confounding effects of socio-demographic factors. The mean score was compared for each item and separately for each dimension.

PLoS ONE 12(12): e0188554
https://doi.org/10.1371/journal.pone.0188554

Healthcare provider's attitude towards disability and experience of women with disabilities in the use of maternal healthcare service in rural Nepal

DEVKOTA, Hridaya Raj
KETT, Maria
GROCE, Nora
MURRAY, Emily
June 2017

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BACKGROUND:
Women with disabilities are less likely to receive maternal healthcare services compared to women without disabilities. While few studies have reviewed healthcare experience of women with disabilities, no studies have been conducted to understand provider's attitude towards disability in Nepal, yet the attitude and behaviour of healthcare providers may have a significant influence on aspects of care and the use of service by women with disabilities. This study examines healthcare provider's attitudes towards disability and explores the experience of women with disabilities in maternal healthcare service utilization during pregnancy and childbirth.

METHOD:
The study used mixed method approach. An attitude survey was conducted among 396 healthcare providers currently working in public health facilities in Rupandehi district of Nepal. For additional insight, eighteen in-depth interviews with women with disabilities who used maternal healthcare services in a healthcare facility within the study district in their last pregnancy were undertaken. The Attitude Towards Disabled Persons (ATDP) scale score was used to measure the attitudes of healthcare providers. For quantitative data, univariate and multivariate analysis using ANOVA was used to understand the association between outcome and independent variables and qualitative analysis generated and described themes.

Reproductive Health, 2017

UNICEF’S STRATEGY FOR HEALTH (2016-2030)

UNICEF
December 2015

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UNICEF envisions a world where no child dies from a preventable cause, and all children reach their full potential in health and well-being. To this end, UNICEF’s 2016-2030 Strategy for Health aims to:

 

- End preventable maternal, newborn, and child deaths

- Promote the health and development of all children

 

With the first goal, UNICEF commits to maintaining focus on the critical unmet needs related to maternal, newborn and under-5 survival. With the second, UNICEF highlights the importance of also looking beyond survival and addressing the health and development needs of older children and adolescents.

 

The Strategy emphasises the importance of prioritising the needs of the most deprived children and promotes multi-sectoral approaches to enhance child development and address underlying causes and determinants of poor health outcomes. It aims to shift UNICEF from vertical disease programmes to strengthening health systems and building resilience, including calling for better integration of humanitarian and development efforts by encouraging risk-informed programming in all contexts.

UNICEF’S STRATEGY FOR HEALTH (2016-2030) (full version)

UNICEF
2015

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For the five year period 2016-2020, UNICEF’s Strategy for Health sets two overarching goals: 1. End preventable maternal, newborn and child deaths 2. Promote the health and development of all children. To achieve these goals, the Strategy considers the health needs of the child at all life stages. It highlights the need for intensified efforts to address growing inequities in health outcomes, including a particular focus on addressing gender-specific needs and barriers that may determine whether boys and girls are able to reach their full potential in health and well-being. Working together with global and local partners, UNICEF will promote three approaches to contribute to these goals: addressing inequities in health outcomes; strengthening health systems including emergency preparedness, response and resilience; and promoting integrated, multisectoral policies and programmes. The three approaches described underpin a "menu of actions” from which country offices can select, based on their situation analysis, country programme focus, and context. 

Maternal and new-born care practices among disabled women, and their attendance in community groups in rural Makwanpur, Nepal

LEONARD CHESHIRE DISABILITY AND INCLUSIVE DEVELOPMENT CENTRE
2013

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This paper presents qualitative and quantitative research that describes the type and severity of disability of married women in the study area, describes their participation in community groups and analyses associations between maternal and new-born care behaviours and disability. Health workers and field researchers were also interviewed about their experience with disabled women in rural Makwanpur
Cross-cutting Disability Research Programme, Background Paper: 01

Taking critical services to the home : scaling-up home-based maternal and postnatal care, including family planning, through community midwifery in Kenya

MWANGI, Annie
WARREN, Charlotte
2008

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This publication is the report of a project to scale-up a community-based model, in Kenya, that enabled women to give birth safely at home or be referred to a hospital when attended by a self-employed skilled midwife living in the community. The findings of the project were that community midwifery contributed to increasing the proportion of women assisted by skilled attendants during birth in the four districts in which the scheme was trialed, amounting to just under half of all skilled attended births in the districts. Although the skilled birth attendant rate in these districts was well below the national average of 42 percent, there was a steady increase in the proportion of attended deliveries since CMs were introduced in 2005. The districts also reported an increase in postnatal assessments in the first 48 hours and increase in immunization coverage

State of the world’s children 2008 : child survival

United Nations Children's Fund (UNICEF)
2008

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This publication provides a wide-ranging assessment of the current state of child survival and primary health care for mothers, newborns and children. It examines lessons learned in child health during the past few decades and outlines the most important emerging precepts and strategies for reducing deaths among children under age five and for providing a continuum of care for mothers, newborns and children

A report card on maternal mortality

UNITED NATIONS CHILDREN'S FUND (UNICEF)
2008

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‘Progress for Children’ is a series that monitors progress towards the Millennium Development Goals. This edition focuses on maternal health and, in particular, maternal mortality. It considers general progress and then examines particular regions. The report card acknowledges progress in improving maternal health, but argues that it is not sufficient to meet the MDG target of reducing maternal mortality by three quarters between 1990 and 2015

Repositioning postnatal care in a high HIV environment : Swaziland

WARREN, Charlotte
et al
2008

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This report arose from recognition of the need to provide better care and follow up of mothers and infants in the postnatal period in order to improve maternal and neonatal outcomes in Swaziland. The objectives of the study were to determine if changes to the guidelines on postnatal care would result in improvements to provision of of maternal and newborn care in the postnatal period, increase utilization of postnatal care services among all postpartum (PP) women, and improve the care and follow up of HIV-positive postpartum women and their infants. The study confirmed that the introduction of an improved postnatal package with revised timing and content provided key components of maternal, newborn, and HIV care, and increased the utilization of services among postpartum women and their infants. An assessment of the quality of care during client-provider interactions for all postpartum women demonstrated a fourfold increase in the proportion that included all aspects of care: maternal and newborn health, counseling for HIV, family planning, and improved provider-client relationships

Integrated management of pregnancy and childbirth : WHO recommended interventions for improving maternal and newborn health

WORLD HEALTH ORGANIZATION (WHO), DEPARTMENT OF MAKING PREGNANCY SAFER
2007

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This paper contains five tables listing recommendations to improve maternal and newborn health and survival, through health services, family and community. Table 1. Care in pregnancy, childbirth and postpartum period for mother and newborn infant; Table 2. Place of care, providers, interventions and commodities; Table 3. Home care, family, community and workplace support for the woman during pregnancy and childbirth and for the newborn infant; Table 4. Care for the woman before and between pregancies; Table 5. Pregnant women not wanting child

Obstetric care in poor settings

MILLS, Samuel
et al
2007

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This report explores why maternal mortality continues to be so high in developing countries, and why emergency obstetric services are little utilized, through research carried out in poor areas in Ghana (Kassena-Nankana district), India (Uttar Pradesh state), and Kenya (Nairobi slums)

Continuum of care for HIV-positive women accessing programs to prevent parent-to-child transmission : findings from India

MAHENDRA, Vaishali S
et al
2007

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This is the report of a diagnostic study in 2005 to provide an evidence base to strengthen the national Indian prevention of parent-to-child transmission (PPTCT) initiative. The key research questions were: What are the treatment, care, and support needs of HIV-positive women and what services do the women utilize to meet their needs? What are the different ways (clinic-based, community-based, etc) to link HIV-positive women and their families with treatment and care services? The study indicated that linkages between PPTCT and HIV care services, as well as PPTCT and reproductive health services, were limited

Key steps for maternal and newborn health care in humanitarian crisis

WORLD HEALTH ORGANIZATION (WHO), DEPARTMENT OF MAKING PREGNANCY SAFER
2007

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This document has been prepared for maternal and newborn health experts as well as reproductive health experts coordinating and assisting with emergency care during the humanitarian crisis. It describes the ways to estimate the number of pregnant women and those who are about to deliver, highlights some important aspects of emergency care related to pregnancy, childbirth and newborn care, and describes the content of UN kits for such care in three different scenarios

Maternal survival : improving access to skilled care. A behavior change approach

CHANGE
February 2005

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This summary is based on the CHANGE Maternal Survival Toolkit, available online at: www.changeproject.org and on CD-ROM. It explores ways of influencing behaviours and encouraging use of health services and health professionals during childbirth and the postpartum period. A number of factors can prevent pregnant women from accessing skilled care, often putting themselves and the child at risk. They include availability of health services and high costs but also, and crucially, local culture, family and community behaviours and traditional practices. The CHANGE Project's approach and this document stress locally appropriate, behaviour-based interventions that integrate what is happening in homes, communities and health facilities. This tool is aimed at organisations and individuals working in the field of mother and child health, and willing to look at maternal and child survival issues from a behaviour change perspective

Achieving the Millennium Development Goal of improving maternal health : determinants, interventions and challenges

LULE, Elizabeth
et al
2005

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"This paper summarizes the importance of improving maternal and reproductive health, the progress made to date and lessons learned, and the major challenges confronting programs today. The paper highlights the progress that some countries, including very poor ones, have made in reducing maternal mortality, but cautions that progress in many countries remains slow. Relying on evidence from the most recent research and survey information, the paper also analyzes the key determinants and evidence on effective interventions for attaining the maternal health MDG. The paper finds that key interventions to improve maternal and reproductive health and reduce maternal mortality include the following mutually reinforcing strategies: (a) mobilizing political commitment and fostering an enabling policy environment; (b) investing in social and economic development such as female education, poverty reduction, and improvements in women’s status; (c) providing family planning services; (d) ensuring quality antenatal care, skilled attendance during childbirth, and availability of emergency obstetric services for pregnancy complications; and (e) strengthening the health system and community involvement. The paper emphasizes that carrying out interventions remains a challenge in environments where political commitment, policies, as well as institutions and health systems, are weak. The paper concludes with guiding lessons from some of the countries that have successfully improved maternal health and with a discussion of some of the difficulties of measuring maternal mortality and morbidity outcomes"

Involving men in maternity care in India

VARKEY, Leila Caleb
FRONTIERS IN REPRODUCTIVE HEALTH PROGRAM
et al
2004

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"The Men in Maternity (MiM) study investigated the feasibility, acceptability and cost of a new, more comprehensive, model of maternity care that encouraged husbands' participation in their wives' antenatal and postpartum care. The study specifically assessed the impact of the intervention on family planning in the postpartum period and STI preventitive practices among men and women. The study was conducted in collaboration with the Employees' State Insurance Corporation (ESIC), Delhi Directorate at their primary health facilities called dispensaries"

PREMA-EU : malaria and anaemia in pregnancy

PREGNANCY, MALARIA, ANAEMIA NETWORK
January 2003

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PREMA-EU is a concerted action dealing with the problem of malaria control in pregnant women. The objectives of PREMA-EU are: (i) To review, synthesise and inform on the 'state of the art' concerning malaria and anaemia in pregnancy, including burden of disease, programme strategies and research priorities; (ii) To address specific technical and operational issues that are critical for the control of malaria and anaemia in pregnancy; (iii) To promote the implementation of research findings into feasible interventions for malaria control in pregnant women; (iv) To generate information that would help RBM in formulating national and district-based policy for the control of malaria in pregnant women. The website includes PDF versions of the PREMA-EU newsletter, and other publications

Maternal mortality and poverty

MATTHEWS, Zoë
2002

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This publication identifies three components of an effective strategy to reduce maternal mortality rates: a) The existence of an extensive midwifery cadre which is well trained, autonomous, and embedded in the referral system; b) Adequate facilities for institutional deliveries, and c) An implemented strategy to support widespread access to these services. The importance of access to care and services is stressed

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