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This study assesses the impact of a voucher project that targeted vulnerable and poor pregnant women in Uganda. Highly subsidised vouchers gave access to a package of safe delivery services consisting of four antenatal visits, safe delivery, one postnatal visit, the treatment and management of selected pregnancy-related medical conditions and complications, and emergency transport. Vouchers were sold during the project's operational period from 2016 to 2019. This study covers 8 out of 25 project-benefiting districts in Uganda and a total of 1,881 pregnancies, including both beneficiary and non-beneficiary mothers. Using a matching design, the results show a positive effect on the survival of new-born babies. The difference in the survival rate between the control group and the treatment group is 5.4% points, indicating that the voucher project reduced infant mortality by more than 65 per cent. [ABSTRACT FROM AUTHOR]

It has been well documented in the literature that breastfeeding has many benefits for mothers and their infants. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first 6 months of life and continued breastfeeding until the age of 1 or longer as desired by the mother and infant; however, many mothers face barriers to achieving this goal. More specifically, we noticed that at our Rainbow Center for Women and Children (the Center), few mothers were able to achieve exclusive or sustained breastfeeding. This study aimed to determine stakeholder views at the Center regarding barriers to breastfeeding in an underserved patient population and to develop a Breastfeeding Intervention Bundle from these responses to improve breastfeeding rates. We then surveyed participants including mothers, providers, and staff about support and comfort with knowledge gained over the period of the Intervention. While our study was unable to document a clear or sustained improvement in participant support or comfort related to breastfeeding over a 6-month period, we furthered our knowledge about barriers to breastfeeding and concluded that interventions to improve breastfeeding rates will likely need to be initiated at the systems level, not only at the individual patient and provider level, and with joint support from all stakeholders. [ABSTRACT FROM AUTHOR]

Lack of access to birth facilities and maternity care providers has contributed to rising US maternal mortality and morbidity rates, especially among women in rural areas. Evidence supports the increased use of midwives as a potential solution for access-to-care issues. This observational survey was conducted to identify the practice environment for Certified Nurse-Midwives® in Colorado for the purpose of informing future workforce expansion. Study results indicate that midwives provide services aligned with the midwifery model of care and have mostly autonomous practice in hospitals where midwifery practices are already established. However, there is limited use of midwives, as fewer than half of Colorado's 69 birthing hospitals have midwifery practices, and financial constraint created by low Medicaid reimbursement could be a limiting factor in establishing new midwifery practices. Policy recommendations based on survey results include (a) support for midwifery education and workforce development, (b) removal of hospital-level restrictions for privileges of midwives, and (c) consideration for public payment models that promote expansion of midwifery practices. [ABSTRACT FROM AUTHOR]

Introduction: Despite the emphasis on more systematic and high-quality health care services in the maternal period, a high maternal mortality rate in developing countries is still reported. North Korea, one of the closed countries in the world, is no exception. This study aimed to explore the maternal health experiences in North Korea. Methodology: Qualitative content analysis suggested by Graneheim and Lundman was used to analyze the data of 10 female North Korean defectors. Results: Three categories were derived: pregnancy without self-determination rights, a huge gap between the policies on maternal protection and the reality, and discriminatory childbirth and postpartum care. The theme was "perilous existence of maternal health." Discussion: We highlighted the need for awareness of maternity protection led by health care professionals such as nurses to guarantee Universal Health Coverage as a human right for North Korean women. [ABSTRACT FROM AUTHOR]

Despite a relatively permissive abortion law, women in the Netherlands encounter difficulties in accessing abortion care. Little is known about their experiences. This study explores women's experiences with (online) abortion services and relevant health professionals' experiences delivering care, with the goal of identifying key barriers encountered by abortion-seekers in the Netherlands. An exploratory qualitative research design with a constructivist approach and an abbreviated grounded theory method was used. Interviews with 20 women who had had an abortion and 14 health professionals who provide abortion care, and 200 emails of women seeking abortion care through the non-governmental organisation Women on Web, were coded inductively and deductively (using the Candidacy Framework) thereby generating themes. Abortion-seekers faced barriers including: (i) burden of taboo, (ii) vulnerability (emotional, financial, and social), (iii) health professional evaluation and (iv) disempowerment and distress. The overarching theme was women's lack of autonomy in access to abortion care. The key barriers to abortion access in the Netherlands are the institutionalisation of taboo in abortion law and care, complex candidacy regulations, lack of permeability for certain marginalised groups, and women's inability to speak openly about abortion. To increase the permeability of abortion care, and thereby women's autonomy, legislators and policy-makers must trust women to make their own reproductive decisions and avoid actions that stigmatise abortion and hinder access to care, while actively developing systemic support for vulnerable groups. [ABSTRACT FROM AUTHOR]

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

The opioid crisis has impacted vulnerable populations, specifically pregnant and postpartum women, and infants prenatally exposed to substances, including infants with Neonatal Abstinence Syndrome. Lack of access to clinical and social services; potential stigma or discrimination; and lack of resources for provision of services, including screening and treatment, have impacted the health of these populations. In 2018, using a systems change approach, the Association of State and Territorial Health Officials (ASTHO) and the Centers for Disease Control and Prevention (CDC) convened an Opioid use disorder, Maternal outcomes, Neonatal abstinence syndrome Initiative Learning Community (OMNI LC) that included other federal agencies, national clinical and nonclinical organizations, and 12 state leadership groups. The purpose of the OMNI LC was to determine areas of focus and identify strategies and best practices for implementing systems change to improve maternal and infant outcomes associated with opioid use disorder (OUD) during the perinatal period. Activities included in-person convenings with policy goal action plan development, virtual learning sessions, intensive technical assistance (TA), and temporary field placements. The OMNI LC partnering agencies and state teams met bimonthly for the first year of the initiative. At the in-person convening, state teams identified barriers to developing and implementing systems change in activity-specific action plans within five areas of focus: financing and coverage; access to and coordination of quality services; provider training and awareness; ethical, legal, and social considerations; and data, monitoring, and evaluation. State teams also identified stakeholder partnerships as a necessary component of strategy development in all areas of focus. Four virtual learning sessions were conducted on the areas of focus identified by state teams, and ASTHO conducted three intensive TA opportunities, and five states were identified for temporary field placement. To successfully address the impact of the opioid crisis on pregnant and postpartum women and infants, states developed innovative strategies focused on increasing support, services, and resources. Moving forward, state teams will participate in two additional in-person meetings, continue to identify barriers to the work, refine and customize action plans, and set new goals, to effect broad-ranging systems change for these vulnerable populations. [ABSTRACT FROM AUTHOR]

Background: Equitable access to services that promote health and wellbeing is an important component of social justice. A community-engaged participatory qualitative study was conducted in Flint, Michigan, USA, to understand the needs of special populations (young women, perinatal women and new mothers, older women, women with disabilities, and LGBTQIA women) and elicit their ideas about solutions. Methods: In-depth interviews (n = 100) were conducted. Participants were either women living in the Flint area, human service providers in the area, or both. A team of community and academic coders analyzed the data using an a priori framework. Results: Participants identified needs of different groups of women and suggested ways to address them. Access to healthy food, reducing healthcare costs, and improving transportation, job opportunities and affordable quality housing were crosscutting themes across all groups of women. Mentoring support was said to protect vulnerable young women from the risk of human trafficking. Older women were said to gain a sense of purpose, build their social support and reduce their loneliness by engaging in mentoring younger women. Women with disabilities were reported to benefit from infrastructure accessibility and authentic inclusion in all areas of life. Providing help that considers their dignity, pride and self-worth were suggested. LGBTQIA women were reported to have housing needs due to discrimination; mostly turned down as renters and can be rejected from faith-based homeless shelters. LGBTQIA women would also benefit from increased sensitivity among healthcare providers. For all groups of women, streamlining access to social services and other resources, building social support networks and increasing awareness about existing resources were recommended. Conclusion: Efforts directed towards improving women's health and wellbeing should include perspectives and suggestions of diverse groups of women from the community. Acting on suggestions that emanate from the community's lived experiences may reduce inequalities in health and wellbeing. [ABSTRACT FROM AUTHOR]

The article focuses on the Centers for Medicare and Medicaid Innovation (CMMI) Strong Start for Mothers and Newborns program. It discusses the perceived weaknesses in perinatal care with induction of labor and cesarean birth, the project including Medicaid beneficiaries, comparison between three models Group Prenatal Care, Maternity Care Home and Birth Centers.

Los Angeles County's experience, write Christina Altmayer and Barbara Andrade DuBransky, shows how a universal offer of assistance can establish a foundation on which public and private agencies can plan meaningful systemic reform--and spark incentives for greater, more effective investments in services directed to vulnerable families. The county's vision for a universal, voluntary; integrated system of home visiting offered in 14 targeted communities builds on Welcome Baby, a universal home visiting program that provides as many as nine contacts to pregnant women and new parents until a child's ninth month. Piloted in one hospital in 2009, Welcome Baby is now available to new parents delivering in 14 hospitals throughout the county, reaching approximately one-third of all births in the county annually. As of June 2018, the program had reached more than 59,000 families. Welcome Baby and other related investments are part of a broader story unfolding in LA County. The authors describe an important policy shift that's moving both public and private providers toward an integrated system of universal and targeted home visiting. The county's action plan calls for significant investments in new parent support and responsiveness from multiple county-level agencies, as well as the development and expansion of multiple home visiting models to meet the needs of the county's diverse population. As the initiative continues to grow, Altmayer and Andrade DuBransky write, the county is aiming to streamline referral pathways to ensure maximum participation; fill service gaps for high-risk populations; increase access to voluntary home visiting for families at high risk for involvement in the child welfare system; create a common data collection system to improve outcome reporting; maximize the use of current resources while generating new revenue; and ensure that the home visiting system is deeply embedded in larger systems serving children and families. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the women, infants, and children (WIC) Oral Health Program in a county in Florida. Methods The non-traditional interdisciplinary program of the current study was designed to reach at-risk populations with untreated dental diseases and limited access to care; it provides oral health education, dental screenings, preventive dental services, and referrals for women, children, and families at WIC offices. We evaluated the health status of patients enrolled in the program and the services provided. Results From 2013 to 2016, the program provided dental screenings for 576 children and 180 women. Caries prevalence for 3-5 year olds was 46.0%. Only 6.6% (12/114) of pregnant women were eligible for comprehensive dental care under Medicaid (< 21 years). Further, 71.2% (47/66) of all pregnant women had unmet dental care needs. Conclusions for Practice Our results suggested that many children and women had untreated dental diseases and need preventive services and dental care. Also, many pregnant women were not covered by Medicaid. This program demonstrates that collaboration with the WIC program can improve access to oral health services for underserved populations. [ABSTRACT FROM AUTHOR]

The article offers information on the Australian Preterm Birth Alliance that was created in 2018 to safely lower the rate of early birth across Australia. Topics covered include data from 2017 which demonstrate that 8.7% of babies in Australia were preterm, the alliance's role in identifying preterm prevention strategies, and the Alliance's aim to lengthen pregnancy and optimise the timing of birth when planned birth is deemed necessary.

Ascertainment of vulnerable populations in health datasets is critical to monitoring disparities in health outcomes, enables service planning and guides the delivery of health care. There is emerging evidence that people of refugee backgrounds in Australia experience poor health outcomes and barriers to accessing services, yet a clear picture of these disparities is limited by what is routinely collected in health datasets. There are challenges to improving the accuracy of ascertainment of refugee background, with sensitivities for both consumers and providers about the way questions are asked. Initial testing of four data items in maternity and early childhood health services (maternal country of birth, year of arrival in Australia, requirement for an interpreter and women's preferred language) suggests that these are straightforward items to collect and acceptable to service administrators, care providers and to women. In addition to the four data items, a set of questions has been developed as a guide for clinicians to use in consultations. These new approaches to ascertainment of refugee background are essential for addressing the risk of poor health outcomes for those who are forced to leave their countries of origin because of persecution and violence. [ABSTRACT FROM AUTHOR]

Background: In Gujarat, India, a state led public private partnership scheme to promote facility birth named Chiranjeevi Yojana (CY) was implemented in 2005. Institutional birth is provided free of cost at accredited private health facilities to women from socially disadvantaged groups (eligible women). CY has contributed in increasing facility birth and providing substantially subsidized (but not totally free) birth care; however, the retention of mothers in this scheme in subsequent child birth is unknown. Therefore, we conducted a study aimed to determine the effect of previous utilization of the scheme and previous out of pocket expenditure on subsequent child birth among multiparous eligible women in Gujarat.Methods: This was a retrospective cohort study of multiparous eligible women (after excluding abortions and births at public facility). A structured questionnaire was administered by trained research assistant to those with recent delivery between Jan and Jul 2013. Outcome of interest was CY utilization in subsequent child birth (Jan-Jul 2013). Explanatory variables included socio-demographic characteristics (including category of eligibility), pregnancy related characteristics in previous child birth, before Jan 2013, (including CY utilization, out of pocket expenditure) and type of child birth in subsequent birth. A poisson regression model was used to assess the association of factors with CY utilization in subsequent child birth.Results: Of 997 multiparous eligible women, 289 (29%) utilized and 708 (71%) did not utilize CY in their previous child birth. Of those who utilized CY (n = 289), 182 (63%) subsequently utilized CY and 33 (11%) gave birth at home; whereas those who did not utilize CY (n = 708) had four times higher risk (40% vs. 11%) of subsequent child birth at home. In multivariable models, previous utilization of the scheme was significantly associated with subsequent utilization (adjusted Relative Risk (aRR): 2.7; 95% CI: 2.2-3.3), however previous out of pocket expenditure was not found to be associated with retention in the CY scheme.Conclusion: Women with previous CY utilization were largely retained; therefore, steps to increase uptake of CY are expected to increase retention of mothers within CY in their subsequent child birth. To understand the reasons for subsequent child birth at home despite previous CY utilization and previous zero/minimal out of pocket expenditure, future research in the form of systematic qualitative enquiry is recommended. [ABSTRACT FROM AUTHOR]

Background: "Chiranjeevi Yojana (CY)", a state-led large-scale demand-side financing scheme (DSF) under public-private partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005. The scheme aims to provide free institutional childbirth services in accredited private health facilities to women from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility with the intention of service being free to the user. This community-based study estimates CY uptake among eligible women and explores factors associated with non-utilization of the CY program.Methods: This was a community-based cross sectional survey of eligible women who gave birth between January and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by trained research assistant to collect information on socio-demographic details, pregnancy details, details of childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the factors associated with non-utilization of the CY program.Results: Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6, 95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY program overall paid more than women who delivered in the free public facilities.Conclusion: Uptake of the CY among eligible women was low after almost a decade of implementation. Community level awareness programs are needed to increase participation among eligible women. OOP expense was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy which needs to be studied. There is also a need to ensure financial protection of women who have C-section. [ABSTRACT FROM AUTHOR]

Many risk factors associated with adverse pregnancy outcomes can be identified and modified preconceptionally. Despite a broad consensus that preconception care should be provided to all couples of reproductive age, it has not been integrated in routine healthcare. There are several barriers to its implementation, and even in the most resourceful countries, it is only provided to some select high-risk groups, rather than being an organized healthcare service provision to all. Recently, China seems to be leading the way by implementing preconception care nationwide in all rural areas. Its National Free Preconception Health Examination Project is a unique model of comprehensive preconception care. Advantages of this ambitious project are now becoming evident and benefiting the most vulnerable sections of Chinese society. This commentary provides an overview of National Free Preconception Health Examination Project and highlights the concepts that could be further developed and adapted into a model of preconception care. [ABSTRACT FROM AUTHOR]

Background: Discussions of maternity care in developing countries tend to emphasise service uptake and overlook choice of provider. Understanding how families choose among health providers is essential to addressing inequitable access to care. Our objectives were to quantify the determinants and choice of maternity care provider in Mumbai's informal urban settlements, and to explore the reasons underlying their choices.Methods: The study was conducted in informal urban communities in eastern Mumbai. We developed regression models using data from a census of married women aged 15-49 to test for associations between maternal characteristics and uptake of care and choice of provider. We then conducted seven focus group discussions and 16 in-depth interviews with purposively selected participants, and used grounded theory methods to examine the reasons for their choices.Results: Three thousand eight hundred forty-eight women who had given birth in the preceding 2 years were interviewed in the census. The odds of institutional prenatal and delivery care increased with education, economic status, and duration of residence in Mumbai, and decreased with parity. Tertiary public hospitals were the commonest site of care, but there was a preference for private hospitals with increasing socio-economic status. Women were more likely to use tertiary public hospitals for delivery if they had fewer children and were Hindu. The odds of delivery in the private sector increased with maternal education, wealth, age, recent arrival in Mumbai, and Muslim faith. Four processes were identified in choosing a health care provider: exploring the options, defining a sphere of access, negotiating autonomy, and protective reasoning. Women seeking a positive health experience and outcome adopted strategies to select the best or most suitable, accessible provider.Conclusions: In Mumbai's informal settlements, institutional maternity care is the norm, except among recent migrants. Poor perceptions of primary public health facilities often cause residents to bypass them in favour of tertiary hospitals or private sector facilities. Families follow a complex selection process, mediated by their ability to mobilise economic and social resources, and a concern for positive experiences of health care and outcomes. Health managers must ensure quality services, a functioning regulatory mechanism, and monitoring of provider behaviour. [ABSTRACT FROM AUTHOR]

In recent years, maternal and child health professionals have been seeking approaches to integrating the Life Course Perspective and social determinants of health into their work. In this article, we describe how community input, staff feedback, and evidence from the field that the connection between wealth and health should be addressed compelled the Contra Costa Family, Maternal and Child Health (FMCH) Programs Life Course Initiative to launch Building Economic Security Today (BEST). BEST utilizes innovative strategies to reduce inequities in health outcomes for low-income Contra Costa families by improving their financial security and stability. FMCH Programs' Women, Infants, and Children Program (WIC) conducted BEST financial education classes, and its Medically Vulnerable Infant Program (MVIP) instituted BEST financial assessments during public health nurse home visits. Educational and referral resources were also developed and distributed to all clients. The classes at WIC increased clients' awareness of financial issues and confidence that they could improve their financial situations. WIC clients and staff also gained knowledge about financial resources in the community. MVIP's financial assessments offered clients a new and needed perspective on their financial situations, as well as support around the financial and psychological stresses of caring for a child with special health care needs. BEST offered FMCH Programs staff opportunities to engage in non-traditional, cross-sector partnerships, and gain new knowledge and skills to address a pressing social determinant of health. We learned the value of flexible timelines, maintaining a long view for creating change, and challenging the traditional paradigm of maternal and child health. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To examine factors affecting prenatal and postpartum care for an insured, but vulnerable, population. Methods: Individual-level data on three measures of care adequacy were obtained for Massachusetts Medicaid Managed Care women who met the National Committee on Quality Assurance’s Healthcare Effectiveness Data and Information Set denominator criteria for the prenatal and postpartum care measures in 2007 (n = 1,882). We modeled individual compliance with each measure separately as a binomial logistic function with individual and neighborhood characteristics, provider type, and health plan as explanatory variables. Findings: In our sample, 85% of women initiated care in the first trimester, but only 62% met the goal of receiving more than 80% of the recommended number of prenatal visits. Just 60% had a timely postpartum care visit. Having a diagnosis of substance abuse or dependence reduced the odds of meeting all measures. Women with disabilities were less likely to attain two of the three measures of adequate care, as were women with other children in the household. Women who enrolled in Medicaid in the first trimester were more likely to receive the recommended number of prenatal visits than those who were enrolled before pregnancy. Conclusion: Given the importance of prenatal and postpartum care for maternal and child health and the recent national declining trend in timely care, initiatives to improve rates of timely and adequate care are crucial and must include components tailored toward particularly vulnerable subpopulations. [Copyright &y& Elsevier]