Objective We assess how countries in regions of the world where maternal mortality is highest - South Asia and Sub-Saharan Africa - are performing with regards to providing women with vital elements of the continuum of care. Methods Using recent Demographic and Health Survey data from nine countries including 18,036 women, descriptive and multilevel regression analyses were conducted on four key elements of the continuum of care - at least one antenatal care visit, four or more antenatal care visits, delivery with a skilled birth attendant and postnatal checks for the mother within the first 24 hours since birth. Family planning counseling within a year of birth was also included in the descriptive analyses. Results Results indicated that a major drop-out (more than 50%) occurs early on in the continuum of care between the first antenatal care visit and four or more antenatal care visits. Few women (less than 5%) who do not receive any antenatal care go on to have a skilled delivery or receive postnatal care. Women who receive some or all the elements of the continuum of care have greater autonomy and are richer and more educated than women who receive none of the elements. Conclusion Understanding where drop-out occurs and who drops out can enable countries to better target interventions. Four or more ANC visits plays a pivotal role within the continuum of care and warrants more programmatic attention. Strategies to ensure that vital services are available to all women are essential in efforts to improve maternal health.

BackgroundA primary cause of high maternal mortality in Bangladesh is lack of access to professional delivery care. Examining the role of the family, particularly the husband, during pregnancy and childbirth is important to understanding women's access to and utilization of professional maternal health services that can prevent maternal mortality. This qualitative study examines husbands' involvement during childbirth and professional delivery care utilization in a rural sub-district of Netrokona district, Bangladesh.MethodsUsing purposive sampling, ten households utilizing a skilled attendant during the birth of the youngest child were selected and matched with ten households utilizing an untrained traditional birth attendant, or dhatri. Households were selected based on a set of inclusion criteria, such as approximate household income, ethnicity, and distance to the nearest hospital. Twenty semi-structured interviews were conducted in Bangla with husbands in these households in June 2010. Interviews were transcribed, translated into English, and analyzed using NVivo 9.0.ResultsBy purposefully selecting households that differed on the type of provider utilized during delivery, common themes--high costs, poor transportation, and long distances to health facilities--were eliminated as sufficient barriers to the utilization of professional delivery care. Divergent themes, namely husbands' social support and perceived social norms, were identified as underlying factors associated with delivery care utilization. We found that husbands whose wives utilized professional delivery care provided emotional, instrumental and informational support to their wives during delivery and believed that medical intervention was necessary. By contrast, husbands whose wives utilized an untrained dhatri at home were uninvolved during delivery and believed childbirth should take place at home according to local traditions.ConclusionsThis study provides novel evidence about male involvement during childbirth in rural Bangladesh. These findings have important implications for program planners, who should pursue culturally sensitive ways to involve husbands in maternal health interventions and assess the effectiveness of education strategies targeted at husbands.

This study examines the association between maternal health service utilization and household decision-making in Bangladesh. Most studies of the predictors of reproductive health service use focus on women’s reports; however, men are often involved in these decisions as well. Recently, studies have started to explore the association between health outcomes and reports of household decision-making from both husbands and wives as matched pairs. Many studies of household decision-making emphasize the importance of the wife alone making decisions; however, some have argued that joint decision-making between husbands and wives may yield better reproductive health outcomes than women making decisions without input or agreement from their partners. Husbands’ involvement in decision-making is particularly important in Bangladesh because men often dominate household decisions related to large, health-related purchases. We use matched husband and wife reports about who makes common household decisions to predict use of antenatal and skilled delivery care, using data from the 2007 Bangladesh Demographic and Health Survey. Results from regression analyses suggest that it is important to consider whether husbands and wives give concordant responses about who makes household decisions since discordant reports about who makes these decisions are negatively associated with reproductive health care use. In addition, compared to joint decision-making, husband-only decision-making is negatively associated with antenatal care use and skilled delivery care. Finally, associations between household decision-making arrangements and health service utilization vary depending on whose report is used and the type of health service utilized.

Achieving ambitious health goals—from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of ‘health for all’—necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers—particularly the well-known WHO ‘building blocks’ framework—only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.

This study examines the association between social capital and the utilization of antenatal care, professional delivery care, and childhood immunizations using a multilevel analytic sample of 10,739 women who recently gave birth and 7,403 children between one and five years of age in 2,293 communities and 22 state-groups from the 2005 India Human Development Survey. Exploratory factor analysis was used to create and validate six social capital measures that were used in multilevel logistic regression models to examine whether each form of social capital had an independent, contextual effect on health care use. Results revealed that social capital operated at the community level in association with all three care-seeking behaviors; however, the results differed based on the type of health care utilized. Specifically, components of social capital that led to heterogeneous bridging ties were positively associated with all three types of health care use, whereas components of social capital that led to strong bonding ties were negatively associated with use of preventive care, but positively associated with professional delivery care.

BackgroundIn Ghana, the site of this study, the maternal mortality ratio and under-five mortality rate remain high indicating the need to focus on maternal and child health programming. Ghana has high use of antenatal care (95%) but sub-optimum levels of institutional delivery (about 57%). Numerous barriers to institutional delivery exist including financial, physical, cognitive, organizational, and psychological and social. This study examines the psychological and social barriers to institutional delivery, namely women’s decision-making autonomy and their perceptions about social support for institutional delivery in their community.MethodsThis study uses cross-sectional data collected for the evaluation of the Maternal and Newborn Referrals Project of Project Fives Alive in Northern and Central districts of Ghana. In 2012 and 2013, a total of 2,527 women aged 15 to 49 were surveyed at baseline and midterm (half in 2012 and half in 2013). The analysis sample of 1,606 includes all women who had a birth three years prior to the survey date and who had no missing data. To determine the relationship between institutional delivery and the two key social barriers—women’s decision-making autonomy and community perceptions of institutional delivery—we used multi-level logistic regression models, including cross-level interactions between community-level attitudes and individual-level autonomy. All analyses control for the clustered survey design by including robust standard errors in Stata 13 statistical software.ResultsThe findings show that women who are more autonomous and who perceive positive attitudes toward facility delivery (among women, men and mothers-in-law) were more likely to deliver in a facility. Moreover, the interactions between autonomy and community-level perceptions of institutional delivery among men and mothers-in-law were significant, such that the effect of decision-making autonomy is more important for women who live in communities that are less supportive of institutional delivery compared to communities that are more supportive.ConclusionsThis study builds upon prior work by using indicators that provide a more direct assessment of perceived community norms and women’s decision-making autonomy. The findings lead to programmatic recommendations that go beyond individuals and engaging the broader network of people (husbands and mothers-in-law) that influence delivery behaviors.

Research on the linkage between social capital and health has grown in recent years; however, there is a dearth of evidence from resource-poor countries. This review examines the association between social capital and physical health (including health behaviours) in the least developed countries (LDCs). Citations were searched using three databases from 1990 to 2011 using the keyword ‘social capital’ combined with the name of each of the 48 LDCs. Of the 14 studies reviewed, 12 took place in Africa and two in South Asia. All used cross-sectional study designs, including five qualitative and nine quantitative studies. The literature reviewed suggests that social capital is an important factor for improving health in resource-poor settings; however, more research is needed in order to determine the best measures for social capital and elucidate the mechanisms through which social capital affects health in the developing world. Future research on social capital and health in the developing world should focus on applying appropriate theoretical conceptualizations of social capital to the developing country context, adapting and validating instruments for measuring social capital, and examining multilevel models of social capital and health in developing countries.

BackgroundGlobally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes.Methods and findingsThis cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification.ConclusionsThe relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affec...