The increases in met need and decreases in case fatality suggest that project interventions improved the quality and use of EmOC, a critical component for saving women's lives.

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Despite decades of policies and programs aimed at improving reproductive health worldwide, high maternal morbidity and mortality persist in many resource-poor settings, particularly in Sub-Saharan Africa. [1][2][3] The predominant approach to mitigating this problem has been to target the knowledge, attitudes and practices of women of reproductive age and to strengthen health service provision. Although educating and designing services for women is undoubtedly important, this focus assumes that women have control over their maternal health care decisions. Evidence from diverse settings, however, indicates that women often have only partial, if any, autonomy over their reproductive and sexual health. [4][5][6][7][8] Not only do husbands have a significant influence on the behavior and actions of their wife, 7,9,10 but other household members, especially mothers-in-law, also exert control over younger women. 5,[11][12][13] Maternal morbidity and mortality are largely preventable through the provision of antenatal care, institutional delivery and timely postnatal care. 8,[14][15][16][17] 7,12,23 in some settings, substantial gaps in coverage remain even after adjustment for the availability of services. Accordingly, researchers and program planners have begun to appreciate the complexity of contextual influences on maternal health practices, and have adopted an approach that recognizes that individual attitudes and behaviors are products of their social and cultural environments. 24,25 Still, most studies have focused exclusively on women as the target population, and have aimed to understand and influence barriers and facilitators from their perspective. This narrow focus is incongruent with a sociocultural context in which women hold low status and are subject to the preferences and beliefs of their husband and elder relatives. 26-28Interpersonal power, however, has proven difficult to measure, such that power dynamics within a household and how they influence decisions on maternal health are not fully understood. 6,[29][30][31] To address this gap, we explored the link between household power dynamics and the maternal health behaviors of married women in rural Mali. Specifically, this article examines the relative influence of the preferences and beliefs of women, their hus- METHODS Data and SettingData for this analysis were drawn from the Projet Espoir Baseline Survey (PEBS), which was conducted between June and July 2011 in Bandiagara and Bankass, two rural districts of central Mali's Mopti region. This article contributes to the project's larger goal of identifying and addressing underlying social determinants of poor maternal health in rural Mali. Ethical approval was obtained from the institutional review boards at Emory University and the Malian Ministry of Health. The Mopti region is predominantly rural and agricultural, and has the lowest levels of education in the country. 51Although men and women in the region have roughly equal educational profiles overall, among younger cohorts, educational attainm...

Using samples of reproductive aged men and women from rural Ethiopia and Kenya, this study examines the associations between two scales measuring balances of power and equitable attitudes within relationships and modern contraceptive use. The scales are developed from the Sexual and Reproductive Power Scale (SRPS) and Gender Equitable Male (GEM) scale, which were originally developed to measure relationship power (SRPS) among women and gender equitable attitudes (GEM) among men. With the exception of Ethiopian women, a higher score on the balance of power scale was associated with significantly higher odds of reporting modern contraceptive use. For men and women in both countries, a higher score on the equitable attitudes scale was associated with significantly higher odds of reporting modern contraceptive use. However, only the highest categories of the scales are associated with contraceptive use, suggesting a threshold effect in the relationships between power, equity and contraceptive use. The results presented here demonstrate how elements of the GEM and SRPS scales can be used to create scales measuring balances of power and equitable attitudes within relationships that are associated with self-reporting of modern contraceptive use in two resource-poor settings. However, further work with larger sample sizes is needed to confirm these findings, and to examine the extent to which these scales can be applied to other social and cultural contexts.

BackgroundStronger health systems, with an emphasis on community-based primary health care, are required to help accelerate the pace of ending preventable maternal and child deaths as well as contribute to the achievement of the Sustainable Development Goals (SDGs). The success of the SDGs will require unprecedented coordination across sectors, including partnerships between public, private, and non-governmental organizations (NGOs). To date, little attention has been paid to the distinct ways in which NGOs (both international and local) can partner with existing national government health systems to institutionalize community health strategies.DiscussionIn this paper, we propose a new conceptual framework that depicts three primary pathways through which NGOs can contribute to the institutionalization of community-focused maternal, newborn, and child health (MNCH) strategies to strengthen health systems at the district, national or global level. To illustrate the practical application of these three pathways, we present six illustrative cases from multiple NGOs and discuss the primary drivers of institutional change. In the first pathway, “learning for leverage,” NGOs demonstrate the effectiveness of new innovations that can stimulate changes in the health system through adaptation of research into policy and practice. In the second pathway, “thought leadership,” NGOs disseminate lessons learned to public and private partners through training, information sharing and collaborative learning. In the third pathway, “joint venturing,” NGOs work in partnership with the government health system to demonstrate the efficacy of a project and use their collective voice to help guide decision-makers. In addition to these pathways, we present six key drivers that are critical for successful institutionalization: strategic responsiveness to national health priorities, partnership with policymakers and other stakeholders, community ownership and involvement, monitoring and use of data, diversification of financial resources, and longevity of efforts.ConclusionWith additional research, we propose that this framework can contribute to program planning and policy making of donors, governments, and the NGO community in the institutionalization of community health strategies.