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Background: A free obstetric care policy (FOCP) has been implemented in Morocco in 2008 in order to further decrease maternal mortality., Methods: Through in-depth interviews we explored the perceptions of health professionals in public Moroccan hospitals with regard to fee exemption policies. We tried to understand what drives health professionals to ignore, modify or apply a health policy as formulated., Results: Respondents express significant influences of such policies on their work environment (higher workload and scarcity of resources) and on the patient/provider relationship, both of which may cause a negative effect on health workers' motivation. A mix of motivational determinants incites health workers in their turn to influence policy implementation., Conclusion: Understanding the motivational determinants of health workers may optimize policy implementation at the point of service delivery., (© 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Welfare Reform has caused a dramatic change in the lives and health of single mothers living in poverty. This qualitative study explored the health and socioeconomic lives of 22 community-dwelling women in poverty in the years after they were terminated from the current work-based welfare program intended to move women from welfare to work and independence. The instruments were a semistructured interview guide, the HANES General Well-Being Schedule, and a demographic data form. Data were analyzed using multistage narrative analysis and descriptive statistics. These primary source data showed participants had multiple barriers that precede or follow poverty. Their voices of how they survive are a rich source of data to assist providers and policy makers in devising evidence-based solutions for reducing poverty in America., (© The Author(s) 2016.)

Background: The face of international aid for health and development is changing. Private donors such as foundations and corporations are playing an increasingly important role, working in international development as direct operators or in partnerships with governments. This study compares maternal health programs of new development actors to traditional governmental donors. It aims to investigate what maternal health programs large governmental donors, foundations and corporate donors are conducting, and how and why they differ., Methods: A total of 263 projects were identified and analyzed. We focus on nine categories of maternal health programs: family planning services, focus on specific diseases, focus on capacity building, use of information and communication technology (ICT), support of research initiatives, cooperation with local non-state or state partners and cooperation with non-local non-state or state partners. Data analysis was carried out using Generalized Linear Mixed-Effects Models (GLMER)., Results: Maternal health policies of public and private donors differ with regard to strategic approaches, as can be seen in their diverging positions regarding disease focus, family planning services, capacity building, and partner choice. Bilateral donors can be characterized as focusing on family planning services, specific diseases and capacity-building while disregarding research and ICT. Bilateral donors cooperate with local public authorities and with governments and NGOs from other developed countries. In contrast, corporations focus their donor activities on specific diseases, capacity-building and ICT while disregarding family planning services and research. Corporations cooperate with local and in particular with non-local non-state actors. Foundations can be characterized as focusing on family planning services and research, while disregarding specific diseases, capacity-building and ICT. Foundations cooperate less than other donors; but when they do, they cooperate in particular with non-state actors, local as well as non-local., Conclusions: These findings should help developing coordination mechanisms that embrace the differences and similarities of the different types of donors. As donor groups specialize in different contexts, NGOs and governments working on development and health aid may target donors groups that have specialized in certain issues.

Background: The priorities of research funding bodies govern the research agenda, which has important implications for the provision of evidence to inform policy. This study examines the research funding landscape for maternal health interventions in low- and middle-income countries (LMICs)., Methods: This review draws on a database of 2340 academic papers collected through a large-scale systematic mapping of research on maternal health interventions in LMICs published from 2000-2012. The names of funders acknowledged on each paper were extracted and categorised into groups. It was noted whether support took a specific form, such as staff fellowships or drugs. Variations between funder types across regions and topics of research were assessed., Results: Funding sources were only reported in 1572 (67%) of articles reviewed. A high number of different funders (685) were acknowledged, but only a few dominated funding of published research. Bilateral funders, national research agencies and private foundations were most prominent, while private companies were most commonly acknowledged for support 'in kind'. The intervention topics and geographic regions of research funded by the various funder types had much in common, with HIV being the most common topic and sub-Saharan Africa being the most common region for all types of funder. Publication outputs rose substantially for several funder types over the period, with the largest increase among bilateral funders., Conclusions: A considerable number of organisations provide funding for maternal health research, but a handful account for most funding acknowledgements. Broadly speaking, these organisations address similar topics and regions. This suggests little coordination between funding agencies, risking duplication and neglect of some areas of maternal health research, and limiting the ability of organisations to develop the specialised skills required for systematically addressing a research topic. Greater transparency in reporting of funding is required, as the role of funders in the research process is often unclear.

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a proven, cost-effective investment in strengthening families. As part of the United States Department of Agriculture's (USDA) 15 federal nutrition assistance programs for the past 40 years, WIC has grown to be the nation's leading public health nutrition program. WIC serves as an important first access point to health care and social service systems for many limited resource families, serving approximately half the births in the nation as well as locally. By providing nutrition education, breastfeeding promotion and foods in addition to referrals, WIC plays a crucial role in promoting lifetime health for women, infants and children. WIC helps achieve national public health goals such as reducing premature births and infant mortality, increasing breastfeeding, and reducing maternal and childhood overweight. Though individuals and families can self-refer into WIC, physicians and allied health professionals have the opportunity and are encouraged to promote awareness of WIC and refer families in their care.

A complete account of the US child care subsidy system requires an understanding of its implications for both parental and child well-being. Although the effects of child care subsidies on maternal employment and child development have been recently studied, many other dimensions of family well-being have received little attention. This paper attempts to fill this gap by examining the impact of child care subsidy receipt on maternal health and the quality of child-parent interactions. The empirical analyses use data from three nationally representative surveys, providing access to numerous measures of family well-being. In addition, we attempt to handle the possibility of non-random selection into subsidy receipt by using several identification strategies both within and across the surveys. Our results consistently indicate that child care subsidies are associated with worse maternal health and poorer interactions between parents and their children. In particular, subsidized mothers report lower levels of overall health and are more likely to show symptoms consistent with anxiety, depression, and parenting stress. Such mothers also reveal more psychological and physical aggression toward their children and are more likely to utilize spanking as a disciplinary tool. Together, these findings suggest that work-based public policies aimed at economically disadvantaged mothers may ultimately undermine family well-being., (Copyright © 2013 John Wiley & Sons, Ltd.)

This paper provides new empirical evidence on the impact of parental health shocks on investments in children's education using detailed longitudinal data from Bosnia and Herzegovina. Our study controls for individual unobserved heterogeneity by using child fixed effects, and it accounts for potential misreporting of self-reported health by employing several, more precise, health indicators. Results show that co-living children of ill mothers, but not of ill fathers, are significantly less likely to be enrolled in education at ages 15-24. Moreover, there is some evidence that mother's negative health shocks are likely to raise the employment probability of children due to the need to cover higher health expenditures., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Stress, depression, and anxiety affect 15 to 25% of pregnant women. However, fewer than 20% of prenatal care providers assess and treat mental health problems and fewer than 20% of pregnant women seek mental healthcare. For those who seek treatment, the lack of health system integration and existing barriers frequently prevent treatment access. Without treatment, poor prenatal mental health can persist for years and impact future maternal, child, and family well-being., Methods/design: The purpose of this randomized controlled trial is to evaluate the effectiveness of an integrated process of online psychosocial assessment, referral, and cognitive behavior therapy (CBT) for pregnant women compared to usual prenatal care (no formal screening or specialized care). The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6 to 8 weeks postrandomization. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. Pregnant women are eligible if they: 1) are <28 weeks gestation; 2) speak/read English; 3) are willing to complete email questionnaires; 4) have no, low, or moderate psychosocial risk on screening at recruitment; and 5) are eligible for CBT. A sample of 816 women will be recruited from large, urban primary care clinics and allocation is by computer-generated randomization. Women in the intervention group will complete an online psychosocial assessment, and those with mild or moderate depression, anxiety, or stress symptoms then complete six interactive cognitive behavior therapy modules. All women will complete email questionnaires at 6 to 8 weeks postrandomization and at 3, 6, and 12 months postpartum. Clinic-based providers and researchers conducting chart abstraction and analysis are blinded. Qualitative interviews with 8 to 10 healthcare providers and 15 to 30 intervention group women will provide data on feasibility and acceptability of the intervention. Results of this trial will determine the feasibility and effectiveness of an integrated approach to prenatal mental healthcare and the use of highly accessible computer-based psychosocial assessment and CBT on maternal, infant, and family-based outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT01901796.

Beginning with the demise of the socialist state system in 1990, Mongolia embarked on a process of neoliberal economic reform, initiating what is known among the Mongols as 'the Age of the Market'. The socialist health system has been replaced by a series of reforms initiated and substantiated by foreign donor organisations. This paper critically examines Mongolia's health system and discusses the extent to which this 'system', despite its provision of universal, accessible and essential primary health care services, is unable to accommodate the health needs of poor urban in-migrants and nomadic herders in remote provinces. With a particular focus on recurrent natural winter disasters (dzud) and an escalating rural to urban migration, the paper argues that the issues of access to health services and health system strengthening must be understood in relation to factors external to the health system. Ethnographic research highlights that despite a growing economy, considerable external aid and an established primary health care model, weak rural politics, environmental challenges and economic constraints create escalating health vulnerability among the poorest in Mongolia.

Performance-based incentives (PBIs) aim to counteract weak providers' performance in health systems of many developing countries by providing rewards that are directly linked to better health outcomes for mothers and their newborns. Translating funding into better health requires many actions by a large number of people. The actions span from community to the national level. While different forms of PBIs are being implemented in a number of countries to improve health outcomes, there has not been a systematic review of the evidence of their impact on the health of mothers and newborns. This paper analyzes and synthesizes the available evidence from published studies on the impact of supply-side PBIs on the quantity and quality of health services for mothers and newborns. This paper reviews evidence from published and grey literature that spans PBI for public-sector facilities, PBI in social insurance reforms, and PBI in NGO contracting. Some initiatives focus on safe deliveries, and others reward a broader package of results that include deliveries. The Evidence Review Team that focused on supply-side incentives for the US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives, reviewed published research reports and papers and added studies from additional grey literature that were deemed relevant. After collecting and reviewing 17 documents, nine studies were included in this review, three of which used before-after designs; four included comparison or control groups; one applied econometric methods to a five-year time series; and one reported results from a large-scale impact evaluation with randomly-assigned intervention and control facilities. The available evidence suggests that incentives that reward providers for institutional deliveries result in an increase in the number of institutional deliveries. There is some evidence that the content of antenatal care can improve with PBI. We found no direct evidence on the impact of PBI on neonatal health services or on mortality of mothers and newborns, although intention of the study was not to document impact on mortality. A number of studies describe approaches to rewarding quality as well as increases in the quantities of services provided, although how quality is defined and monitored is not always clear. Because incentives exist in all health systems, considering how to align the incentives of the many health workers and their supervisors so that they focus efforts on achieving health goals for mothers and newborns is critical if the health system is to perform more effectively and efficiently. A wide range of PBI models is being developed and tested, and there is still much to learn about what works best. Future studies should include a larger focus on rewarding quality and measuring its impact. Finally, more qualitative research to better understand PBI implementation and how various incentive models function in different settings is needed to help practitioners refine and improve their programmes.

It is increasingly clear that Millennium Development Goal 4 and 5 will not be achieved in many low- and middle-income countries with the weakest gains among the poor. Recognizing that there are large inequalities in reproductive health outcomes, the post-2015 agenda on universal health coverage will likely generate strategies that target resources where maternal and newborn deaths are the highest. In 2012, the United States Agency for International Development convened an Evidence Summit to review the knowledge and gaps on the utilization of financial incentives to enhance the quality and uptake of maternal healthcare. The goal was to provide donors and governments of the low- and middle-income countries with evidence-informed recommendations on practice, policy, and strategies regarding the use of financial incentives, including vouchers, to enhance the demand and supply of maternal health services. The findings in this paper are intended to guide governments interested in maternal health voucher programmes with recommendations for sustainable implementation and impact. The Evidence Summit undertook a systematic review of five financing strategies. This paper presents the methods and findings for vouchers, building on a taxonomy to catalogue knowledge about voucher programme design and functionality. More than 120 characteristics under five major categories were identified: programme principles (objectives and financing); governance and management; benefits package and beneficiary targeting; providers (contracting and service pricing); and implementation arrangements (marketing, claims processing, and monitoring and evaluation). Among the 28 identified maternal health voucher programmes, common characteristics included: a stated objective to increase the use of services among the means-tested poor; contracted-out programme management; contracting either exclusively private facilities or a mix of public and private providers; prioritizing community-based distribution of vouchers; and tracking individual claims for performance purposes. Maternal voucher programmes differed on whether contracted providers were given training on clinical or administrative issues; whether some form of service verification was undertaken at facility or community-level; and the relative size of programme management costs in the overall programme budget. Evidence suggests voucher programmes can serve populations with national-level impact. Reaching scale depends on whether the voucher programme can: (i) keep management costs low, (ii) induce a large demand-side response among the bottom two quintiles, and (iii) achieve a quality of care that translates a greater number of facility-based deliveries into a reduction in maternal morbidity and mortality.

Financial barriers can affect timely access to maternal health services. Health insurance can influence the use and quality of these services and potentially improve maternal and neonatal health outcomes. We conducted a systematic review of the evidence on health insurance and its effects on the use and provision of maternal health services and on maternal and neonatal health outcomes in middle- and low-income countries. Studies were identified through a literature search in key databases and consultation with experts in healthcare financing and maternal health. Twenty-nine articles met the review criteria of focusing on health insurance and its effect on the use or quality of maternal health services, or maternal and neonatal health outcomes. Sixteen studies assessed demand-side effects of insurance, eight focused on supply-side effects, and the remainder addressed both. Geographically, the studies provided evidence from sub-Saharan Africa (n = 11), Asia (n = 9), Latin America (n = 8), and Turkey. The studies included examples from national or social insurance schemes (n = 7), government-run public health insurance schemes (n = 4), community-based health insurance schemes (n = 11), and private insurance (n = 3). Half of the studies used econometric analyses while the remaining provided descriptive statistics or qualitative results. There is relatively consistent evidence that health insurance is positively correlated with the use of maternal health services. Only four studies used methods that can establish this causal relationship. Six studies presented suggestive evidence of over-provision of caesarean sections in response to providers' payment incentives through health insurance. Few studies focused on the relationship between health insurance and the quality of maternal health services or maternal and neonatal health outcomes. The available evidence on the quality and health outcomes is inconclusive, given the differences in measurement, contradictory findings, and statistical limitations. Consistent with economic theories, the studies identified a positive relationship between health insurance and the use of maternal health services. However, more rigorous causal methods are needed to identify the extent to which the use of these services increases among the insured. Better measurement of quality and the use of cross-country analyses would solidify the evidence on the impact of insurance on the quality of maternal health services and maternal and neonatal health outcomes.

Recognizing the need for evidence to inform US Government and governments of the low- and middle-income countries on efficient, effective maternal health policies, strategies, and programmes, the US Government convened the Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives in April 2012 in Washington, DC, USA. This paper summarizes the background and methods for the acquisition and evaluation of the evidence used for achieving the goals of the Summit. The goal of the Summit was to obtain multidisciplinary expert review of literature to inform both US Government and governments of the low- and middle-income countries on evidence-informed practice, policies, and strategies for financial incentives. Several steps were undertaken to define the tasks for the Summit and identify the appropriate evidence for review. The process began by identifying focal questions intended to inform governments of the low-and middle-income countries and the US Government about the efficacy of supply- and demand-side financial incentives for enhanced provision and use of quality maternal health services. Experts were selected representing the research and programme communities, academia, relevant non-governmental organizations, and government agencies and were assembled into Evidence Review Teams. This was followed by a systematic process to gather relevant peer-reviewed literature that would inform the focal questions. Members of the Evidence Review Teams were invited to add relevant papers not identified in the initial literature review to complete the bibliography. The Evidence Review Teams were asked to comply with a specific evaluation framework for recommendations on practice and policy based on both expert opinion and the quality of the data. Details of the search processes and methods used for screening and quality reviews are described.

User fee removal has been put forward as an approach to increasing priority health service utilization, reducing impoverishment, and ultimately reducing maternal and neonatal mortality. However, user fees are a source of facility revenue in many low-income countries, often used for purchasing drugs and supplies and paying incentives to health workers. This paper reviews evidence on the effects of user fee exemptions on maternal health service utilization, service provision, and outcomes, including both supply-side and demand-side effects. We reviewed 19 peer-reviewed research articles addressing user fee exemptions and maternal health services or outcomes published since 1990. Studies were identified through a USAID-commissioned call for evidence, key word search, and screening process. Teams of reviewers assigned criteria-based quality scores to each paper and prepared structured narrative reviews. The grade of the evidence was found to be relatively weak, mainly from short-term, non-controlled studies. The introduction of user fee exemptions appears to have resulted in increased rates of facility-based deliveries and caesarean sections in some contexts. Impacts on maternal and neonatal mortality have not been conclusively demonstrated; exemptions for delivery care may contribute to modest reductions in institutional maternal mortality but the evidence is very weak. User fee exemptions were found to have negative, neutral, or inconclusive effects on availability of inputs, provider motivation, and quality of services. The extent to which user fee revenue lost by facilities is replaced can directly affect service provision and may have unintended consequences for provider motivation. Few studies have looked at the equity effects of fee removal, despite clear evidence that fees disproportionately burden the poor. This review highlights potential and documented benefits (increased use of maternity services) as well as risks (decreased provider motivation and quality) of user fee exemption policies for maternal health services. Governments should link user fee exemption policies with the replacement of lost revenue for facilities as well as broader health system improvements, including facility upgrades, ensured supply of needed inputs, and improved human resources for health. Removing user fees may increase uptake but will not reduce mortality proportionally if the quality of facility-based care is poor. More rigorous evaluations of both demand- and supply-side effects of mature fee exemption programmes are needed.

Health financing strategies that incorporate financial incentives are being applied in many low- and middle-income countries, and improving maternal and neonatal health is often a central goal. As yet, there have been few reviews of such programmes and their impact on maternal health. The US Government Evidence Summit on Enhancing Provision and use of Maternal Health Services through Financial Incentives was convened on 24-25 April 2012 to address this gap. This article, the final in a series assessing the effects of financial incentives--performance-based incentives (PBIs), insurance, user fee exemption programmes, conditional cash transfers, and vouchers--summarizes the evidence and discusses issues of context, programme design and implementation, cost-effectiveness, and sustainability. We suggest key areas to consider when designing and implementing financial incentive programmes for enhancing maternal health and highlight gaps in evidence that could benefit from additional research. Although the methodological rigor of studies varies, the evidence, overall, suggests that financial incentives can enhance demand for and improve the supply of maternal health services. Definitive evidence demonstrating a link between incentives and improved health outcomes is lacking; however, the evidence suggests that financial incentives can increase the quantity and quality of maternal health services and address health systems and financial barriers that prevent women from accessing and providers from delivering quality, lifesaving maternal healthcare.

Projection of current trends in maternal and neonatal mortality reduction shows that many countries will fall short of the UN Millennium Development Goal 4 and 5. Underutilization of maternal health services contributes to this poor progress toward reducing maternal and neonatal morbidity and mortality. Moreover, the quality of services continues to lag in many countries, with a negative effect on the health of women and their babies, including deterring women from seeking care. To enhance the use and provision of quality maternal care, countries and donors are increasingly using financial incentives. This paper introduces the JHPN Supplement, in which each paper reviews the evidence of the effectiveness of a specific financial incentive instrument with the aim of improving the use and quality of maternal healthcare and impact. The US Agency for International Development and the US National Institutes of Health convened a US Government Evidence Summit on Enhancing Provision and Use of Maternal Health Services through Financial Incentives on 24-25 April 2012 in Washington, DC. The Summit brought together leading global experts in finance, maternal health, and health systems from governments, academia, development organizations, and foundations to assess the evidence on whether financial incentives significantly and substantially increase provision, use and quality of maternal health services, and the contextual factors that impact the effectiveness of these incentives. Evidence review teams evaluated the multidisciplinary evidence of various financial mechanisms, including supply-side incentives (e.g. performance-based financing, user fees, and various insurance mechanisms) and demand-side incentives (e.g. conditional cash transfers, vouchers, user fee exemptions, and subsidies for care-seeking). At the Summit, the teams presented a synthesis of evidence and initial recommendations on practice, policy, and research for discussion. The Summit enabled structured feedback on recommendations which the teams included in their final papers appearing in this Supplement. Papers in this Supplement review the evidence for a specific financial incentive mechanism (e.g. pay for performance, conditional cash transfer) to improve the use and quality of maternal healthcare and makes recommendations for programmes and future research. While data on programmes using financial incentives for improved use and indications of the quality of maternal health services support specific conclusions and recommendations, including those for future research, data linking the use of financial incentives with improved health outcomes are minimal.

Maternal and newborn health (MNH) is a high priority for global health and is included among the Millennium Development Goals (MDGs). However, the slow decline in maternal and newborn mortality jeopardizes achievements of the targets of MDGs. According to UNICEF, 60 million women give birth outside of health facilities, and family planning needs are satisfied for only 50%. Further, skilled birth attendance and the use of antenatal care are most inequitably distributed in maternal and newborn health interventions in low- and middle-income countries. Conditional cash transfer (CCT) programmes have been shown to increase health service utilization among the poorest but little is written on the effects of such programmes on maternal and newborn health. We carried out a systematic review of studies on CCT that report maternal and newborn health outcomes, including studies from 8 countries. The CCT programmes have increased antenatal visits, skilled attendance at birth, delivery at a health facility, and tetanus toxoid vaccination for mothers and reduced the incidence of low birthweight. The programmes have not had a significant impact on fertility while the impact on maternal and newborn mortality has not been well-documented thus far. Given these positive effects, we make the case for further investment in CCT programmes for maternal and newborn health, noting gaps in knowledge and providing recommendations for better design and evaluation of such programmes. We recommend more rigorous impact evaluations that document impact pathways and take factors, such as cost-effectiveness, into account.

Context: Oportunidades is a large conditional cash transfer program in Mexico. It is important to examine whether the program has any direct effect on pregnancy experience and contraceptive use among young rural women, apart from those through education., Methods: Data from the 1992, 2006 and 2009 waves of a nationally representative, population-based survey were used to describe trends in pregnancy experience, contraceptive use and education among rural adolescent (15-19) and young adult (20-24) women in Mexico. To examine differences in pregnancy experience and current modern contraceptive use among young women, multivariable logistic regression analyses were conducted between matched 2006 samples of women with and without exposure to Oportunidades, predicted probabilities were calculated and indirect effects were estimated., Results: Over the three survey waves, the proportion of adolescent and young adult women reporting ever being pregnant stayed flat (33-36%) and contraceptive use increased steadily (from 13% in 1992 to 19% in 2009). Educational attainment rose dramatically: The proportion of women with a secondary education increased from 28% in 1992 to 46% in 2009. In multivariable analyses, exposure to Oportunidades was not associated with pregnancy experience among adolescents. Educational attainment, marital status, pregnancy experience and access to health insurance--but not exposure to Oportunidades--were positively associated with current modern contraceptive use among adolescent and young adult women., Conclusion: Through its effect on education, Oportunidades indirectly influences fertility among adolescents. It is important for Mexico to focus on strategies to increase contraceptive use among young rural nulliparous women, regardless of whether they are enrolled in Oportunidades.

Background: Continued inequities in coverage, low quality of care, and high out-of-pocket expenses for health services threaten attainment of Millennium Development Goals 4 and 5 in many sub-Saharan African countries. Existing health systems largely rely on input-based supply mechanisms that have a poor track record meeting the reproductive health needs of low-income and underserved segments of national populations. As a result, there is increased interest in and experimentation with results-based mechanisms like supply-side performance incentives to providers and demand-side vouchers that place purchasing power in the hands of low-income consumers to improve uptake of facility services and reduce the burden of out-of-pocket expenditures. This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities., Methods: Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated., Results: The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages., Conclusions: Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program.

Objective: To estimate the U.S. maternal health burden from current breastfeeding rates both in terms of premature death as well as economic costs., Methods: Using literature on associations between lactation and maternal health, we modeled the health outcomes and costs expected for a U.S. cohort of 15-year-old females followed to age 70 years. In 2002, this cohort included 1.88 million individuals. Using Monte Carlo simulations, we compared the outcomes expected if 90% of mothers were able to breastfeed for at least 1 year after each birth with outcomes under the current 1-year breastfeeding rate of 23%. We modeled cases of breast cancer, premenopausal ovarian cancer, hypertension, type 2 diabetes mellitus, and myocardial infarction considering direct costs, indirect costs, and cost of premature death (before age 70 years) expressed in 2011 dollars., Results: If observed associations between breastfeeding duration and maternal health are causal, we estimate that current breastfeeding rates result in 4,981 excess cases of breast cancer, 53,847 cases of hypertension, and 13,946 cases of myocardial infarction compared with a cohort of 1.88 million U.S. women who optimally breastfed. Using a 3% discount rate, suboptimal breastfeeding incurs a total of $17.4 billion in cost to society resulting from premature death (95% confidence interval [CI] $4.38-24.68 billion), $733.7 million in direct costs (95% CI $612.9-859.7 million), and $126.1 million indirect morbidity costs (95% CI $99.00-153.22 million). We found a nonsignificant difference in number of deaths before age 70 years under current breastfeeding rates (4,396 additional premature deaths, 95% CI -810-7,918)., Conclusions: Suboptimal breastfeeding may increase U.S. maternal morbidity and health care costs. Thus, investigating whether the observed associations between suboptimal breastfeeding and adverse maternal health outcomes are causal should be a research priority.

Objective: No official provisions are made for the medically uninsured under provincial public health programs in Canada. Studies have shown that uninsured pregnant women have inadequate access to prenatal and obstetrical services that favour healthy maternal and child outcomes. This qualitative study aimed to explore the perspectives of family physicians who provided care to uninsured pregnant women., Methods: Eight family physicians affiliated with two Montreal-based primary-care clinics and one tertiary care hospital between 2004 and 2007 were interviewed using a semi-structured interview guide. Data were assessed using thematic analysis., Results: Uninsured pregnant patients were characterized by physicians as socially vulnerable, with precarious immigration status that limited their access to health services. Uninsured patients were thought not to benefit from the same standard of perinatal care as their insured counterparts. Care of uninsured women was generally thought to be a professional obligation, regardless of the woman's ability to pay. Caring for this population was considered by family physicians to be challenging, engendering psychological stress, increased workload, and occasional tensions with other health care providers., Conclusion: In the present context, family physicians are left to negotiate the health care system in an attempt to provide adequate perinatal care for uninsured pregnant patients. This situation has repercussions for physicians, for patients and, ultimately, for infants. Leadership is required to ensure that all pregnant women in Canada have access to appropriate health care during the perinatal period.

Background: Targeted interventions to improve maternal and child health is suggested as a feasible and sometimes even necessary strategy to reduce inequity. The objective of this systematic review was to gather the evidence of the effectiveness of targeted interventions to improve equity in MDG 4 and 5 outcomes., Methods and Findings: We identified primary studies in all languages by searching nine health and social databases, including grey literature and dissertations. Studies evaluating the effect of an intervention tailored to address a structural determinant of inequity in maternal and child health were included. Thus general interventions targeting disadvantaged populations were excluded. Outcome measures were limited to indicators proposed for Millennium Development Goals 4 and 5. We identified 18 articles, whereof 15 evaluated various incentive programs, two evaluated a targeted policy intervention, and only one study evaluated an intervention addressing a cultural custom. Meta-analyses of the effectiveness of incentives programs showed a pooled effect size of RR 1.66 (95% CI 1.43-1.93) for antenatal care attendance (four studies with 2,476 participants) and RR 2.37 (95% CI 1.38-4.07) for health facility delivery (five studies with 25,625 participants). Meta-analyses were not performed for any of the other outcomes due to scarcity of studies., Conclusions: The targeted interventions aiming to improve maternal and child health are mainly limited to addressing economic disparities through various incentive schemes like conditional cash transfers and voucher schemes. This is a feasible strategy to reduce inequity based on income. More innovative action-oriented research is needed to speed up progress in maternal and child survival among the most disadvantaged populations through interventions targeting the underlying structural determinants of inequity.

Health insurance in the United States is a patchwork system whereby opportunities for coverage are strongly associated with life circumstances (ie, age, income, pregnancy, parental status). For pregnant women, this situation contributes to unstable coverage before, between, and after pregnancies. The Affordable Care Act has the potential to make coverage for women of reproductive age more stable and create new opportunities to intervene on conditions associated with maternal and neonatal morbidity. In this article, we discuss the health economics of the Affordable Care Act, its implications for maternal and neonatal health, specific challenges associated with implementation, and opportunities for obstetricians to leverage the Affordable Care Act to improve the care of women.

Aims and Objectives: Nigeria's maternal mortality indices are among the worst in the world. Various approaches aimed at combatting the persistently high maternal mortality rates in the past have been ineffective. The objective of this article was to evaluate the fairness and equitability of financing for maternal health in the Nigerian health system., Methods: A review of the performance of the Nigerian Health system with regards to financing for maternal healthcare and comparison with other health systems utilising internationally accepted criteria was done., Results: Household out-of -pocket payment was found to be the largest source of health care financing in the Nigerian health system contributing as much as 65.6 % of total health expenditure. This is in sharp contrast to the performance of more effective health systems like that in South Africa where health care is free for pregnant and breast feeding mothers. The result is that South Africa reports less than a tenth of total maternal mortalities reported from Nigeria annually. The current Nigeria health financing system is not equitable and appears to encourage maternal mortalities since it does not cater for the most vulnerable., Conclusion: There is an urgent need for a review of financing of maternal health in Nigeria to achieve universal access to maternal health care. An urgent overhaul of the currently under performing National Health Insurance scheme or adoption of the simpler system based on funding from taxation with universal access for health care including maternal care and services free at the point of access is suggested.

Aims: To study pregnancy outcome in women with alcoholic liver disease (ALD)., Methods: Using the Swedish nation-wide Patient and Medical Birth Registers, we investigated risk of adverse pregnancy outcome in 720 women diagnosed with ALD before and 1720 diagnosed after birth and compared them with 24 460 population-based control births., Results: Women with ALD diagnosed before or after birth were generally of higher age and body mass index, more likely to smoke cigarettes during pregnancy and to have a low socio-economic status compared with controls. Women diagnosed with ALD before birth had an increased risk of moderately and very preterm birth, adjusted odd ratio (OR) = 1.53 (95% confidence interval (CI): 1.37-1.72 and 1.15-2.06 95%), respectively. Infants of mothers with ALD before birth were more often small-for-gestational age, adjusted OR = 1.22 (95% CI: 1.05-1.43), and were at increased risk for low Apgar scores (<7) at 5 min, adjusted OR = 1.49 (95% CI: 1.15-1.92) compared with controls. Similar associations with slightly lower-risk estimates were found among women diagnosed with ALD after birth., Conclusions: ALD is associated with adverse-birth outcomes, highlighting the importance of screening women for alcohol dependence in antenatal care.

Background: There is a pressing need to include cost data in the Lives Saved Tool (LiST). This paper proposes a method that combines data from both the WHO CHOosing Interventions that are Cost-Effective (CHOICE) database and the OneHealth Tool (OHT) to develop unit costs for delivering child and maternal health services, both alone and bundled., Methods: First, a translog cost function is estimated to calculate factor shares of personnel, consumables, other direct (variable or recurrent costs excluding personnel and consumables) and indirect (capital or investment) costs. Primary source facility level data from Kenya, Namibia, South Africa, Uganda, Zambia and Zimbabwe are utilized, with separate analyses for hospitals and health centres. Second, the resulting other-direct and indirect factor shares are applied to country unit costs from the WHO CHOICE unit cost database to calculate those portions of unit cost. Third, the remainder of the costs is calculated using default data from the OHT. Fourth, we calculate the effect of bundling services by assuming that a LiST intervention visit takes an average of 20 minutes when delivered alone but only incremental time in addition to the basic visit when delivered in a bundle., Results: Personnel costs account for the greatest share of costs for both hospitals and health centres at 50% and 38%, respectively. The percentages differ between hospitals and health centres for consumables (21% versus 17%), other direct (7.5% versus 6.75%), and indirect (22% versus 23%) costs. Combining the other-direct and indirect factor shares with the WHO CHOICE database and the other costs from OHT provides a comprehensive cost estimate of LiST interventions. Finally, the cost of six recommended antenatal care (ANC) interventions is $69.76 when delivered alone, but $61.18 when delivered as a bundle, a savings of $8.58 (12.2%)., Conclusions: This paper proposes a method for estimating a comprehensive cost of providing child and maternal health interventions by combining labor, consumables and drug costs from OHT with indirect and other-direct proportional costs from WHO CHOICE. In addition, we demonstrate the potential cost savings that can be achieved from bundling the delivery of essential antenatal care interventions rather than delivering the same interventions alone.

Background: High maternal mortality in India is a serious public health challenge. Demand side financing interventions have emerged as a strategy to promote access to emergency obstetric care. Two such state run programs, Janani Suraksha Yojana (JSY)and Chiranjeevi Yojana (CY), were designed and implemented to reduce financial access barriers that preclude women from obtaining emergency obstetric care. JSY, a conditional cash transfer, awards money directly to a woman who delivers in a public health facility. This will be studied in Madhya Pradesh province. CY, a voucher based program, empanels private obstetricians in Gujarat province, who are reimbursed by the government to perform deliveries of socioeconomically disadvantaged women. The programs have been in operation for the last seven years., Methods/designs: The study outlined in this protocol will assess and compare the influence of the two programs on various aspects of maternal health care including trends in program uptake, institutional delivery rates, maternal and neonatal outcomes, quality of care, experiences of service providers and users, and cost effectiveness. The study will collect primary data using a combination of qualitative and quantitative methods, including facility level questionnaires, observations, a population based survey, in-depth interviews, and focus group discussions. Primary data will be collected in three districts of each province. The research will take place at three levels: the state health departments, obstetric facilities in the districts and among recently delivered mothers in the community., Discussion: The protocol is a comprehensive assessment of the performance and impact of the programs and an economic analysis. It will fill existing evidence gaps in the scientific literature including access and quality to services, utilization, coverage and impact. The implementation of the protocol will also generate evidence to facilitate decision making among policy makers and program managers who currently work with or are planning similar programs in different contexts.

We compare the experiences of women from three studies who were in different stages of participation in the U.S. welfare program, Temporary Assistance for Needy Families (TANF). The setting for the studies was a large Midwest urban county, targeted chain referral sampling was used, and the combined sample of the three studies was 106 women. The instruments were a semistructured interview guide, the HANES General Well-Being Schedule and a demographic data form. Quantitative data are augmented with qualitative interview data. The findings suggest barriers to self-sustaining employment include health challenges, limited education, socio-economic marginalization, and the welfare policy itself. Nurses are well positioned to advocate for women in poverty and mitigate the health challenges they face. The findings add to the limited evidence base on which the TANF policy is based and can be used to modify the policy to increase the success of the women who participate in it.

We use panel data on household consumption combined with information taken from the medical records of women who gave birth in health facilities to explore the economic consequences of maternal ill health, in the context of a rural population in Bangladesh. The findings suggest that there is a large reduction in household resources associated with maternal illness, driven almost entirely by spending on health care. In spite of this loss of resources, we find that households are able to fully insure consumption against maternal ill health, although confidence intervals are unable to rule out a small effect. Households in our study area are shown to have good access to informal credit (whether it be from local money lenders or family relatives), and this appears critical in helping to smooth consumption in response to these health shocks, at least in the short term., (Copyright © 2011 John Wiley & Sons, Ltd.)

Objective: The incidence of idiopathic precocious puberty (IPP) might have an increasing trend. But the causes and risk factors of IPP are unknown. The objective of our study is to evaluate the effects of growth environments and two environmental endocrine disruptors (EDCs), zearalenone (ZEA), and 1,1-dichloro-2,2,bisethylene (p,p'-DDE), on patients with IPP., Design: Case-control study., Methods: The study consisted of 78 IPP patients at diagnosis and 100 control children matched for age and sex. A questionnaire was designed to collect data on growth environments, and serum ZEA and p,p'-DDE were tested in all subjects. We analyzed data on growth environments, two EDCs, and biological interaction between growth environments and EDCs., Results: In growth environments, small for gestational age, maternal physical disease during pregnancy, early maternal menarche, early puberty of same-degree relatives, and father's absence in 4- to 6-year olds were risk factors for children with IPP (P<0.05). Serum ZEA concentration, ZEA, and p,p'-DDE-positive rates in the IPP group were significantly higher than those in the control group (P<0.05). There was a biological interaction between growth environments and ZEA (relative excess risk due to interaction =34.562, attributable proportion due to interaction =0.745, synergy index =4.193)., Conclusions: Results suggest possible effects of growth environments and two EDCs on the development of IPP. In addition, growth environments and ZEA have biological interaction that might increase the risk of developing IPP.

The goals of this study are to estimate federal maternal and child health (MCH) expenditures and identify their sources. This analysis is intended to provide a broad view of MCH funding appropriations and a basis for discussion of whether funds could be better utilized for the benefit of the population served. Data on federal maternal and child health expenditures for fiscal year (FY) 2006 were derived from examining federal legislation, department/agency budgets, and various web-based program documents posted by federal agencies. Based on selected criteria, we identified programs targeting children under 21 or pregnant/parenting women within the United States. The funding levels of agency programs for maternal and child health activities were determined and the programs briefly summarized. The identifiable funding for maternal and child health programs in FY 2006 approached $57.5 billion dollars. Funding sources for maternal and child health were concentrated within the U.S. Department of Health and Human Services, but spread across several different agencies within the department and in the Departments of Defense, Education, Agriculture, Housing and Urban Development, and the Environmental Protection Agency. Multiple agencies and offices often funded related activities, without evidence of a common underlying strategy. Federal maternal and child health funding mechanisms may lead to a fragmentation in maternal and child health activities. The funding and service delivery apparatus would benefit from an integrative MCH infrastructure approach to pediatric research, service delivery, and data collection/access that incorporates life-course and social/environmental determinants perspectives.

Background: India launched a national conditional cash transfer program, Janani Suraksha Yojana (JSY), aimed at reducing maternal mortality by promoting institutional delivery in 2005. It provides a cash incentive to women who give birth in public health facilities. This paper studies the extent of program uptake, reasons for participation/non participation, factors associated with non uptake of the program, and the role played by a program volunteer, accredited social health activist (ASHA), among mothers in Ujjain district in Madhya Pradesh, India., Methods: A cross-sectional study was conducted from January to May 2011 among women giving birth in 30 villages in Ujjain district. A semi-structured questionnaire was administered to 418 women who delivered in 2009. Socio-demographic and pregnancy related characteristics, role of the ASHA during delivery, receipt of the incentive, and reasons for place of delivery were collected. Multinomial regression analysis was used to identify predictors for the outcome variables; program delivery, private facility delivery, or a home delivery., Results: The majority of deliveries (318/418; 76%) took place within the JSY program; 81% of all mothers below poverty line delivered in the program. Ninety percent of the women had prior knowledge of the program. Most program mothers reported receiving the cash incentive within two weeks of delivery. The ASHA's influence on the mother's decision on where to deliver appeared limited. Women who were uneducated, multiparious or lacked prior knowledge of the JSY program were significantly more likely to deliver at home., Conclusion: In this study, a large proportion of women delivered under the program. Most mothers reporting timely receipt of the cash transfer. Nevertheless, there is still a subset of mothers delivering at home, who do not or cannot access emergency obstetric care under the program and remain at risk of maternal death.

Background: Coverage of maternal and newborn health (MNH) interventions is often influenced by important determinants and decision makers are often concerned with equity issues. The net-benefit framework developed and applied alongside clinical trials and in pharmacoeconomics offers the potential for exploring how cost-effectiveness of MNH interventions varies at the margin by important covariates as well as for handling uncertainties around the ICER estimate., Aim: We applied the net-benefit framework to analyze cost-effectiveness of the Skilled Care Initiative and assessed relative advantages over a standard computation of incremental cost effectiveness ratios., Methods: Household and facility surveys were carried out from January to July 2006 in Ouargaye district (where the Skilled Care Initiative was implemented) and Diapaga (comparison site) district in Burkina Faso. Pregnancy-related and perinatal mortality were retrospectively assessed and data were collected on place of delivery, education, asset ownership, place, and distance to health facilities, costs borne by households for institutional delivery, and cost of standard provision of maternal care. Descriptive and regression analyses were performed., Results: There was a 30% increase in institutional births in the intervention district compared to 10% increase in comparison district, and a significant reduction of perinatal mortality rates (OR 0.75, CI 0.70-0.80) in intervention district. The incremental cost for achieving one additional institutional delivery in Ouargaye district compared to Diapaga district was estimated to be 170 international dollars and varied significantly by covariates. However, the joint probability distribution (net-benefit framework) of the effectiveness measure (institutional delivery), the cost data and covariates indicated distance to health facilities as the single most important determinant of the cost-effectiveness analysis with implications for policy making., Conclusion: The net-benefit framework, the application of which requires household-level effects and cost data, has proven more insightful (than traditional ICER) in presenting and interpreting cost-effectiveness results of the Skilled Care Initiative.

Background: The global impact of maternal ill health on economic productivity is estimated to be over 15 billion USD per year. Global data on productivity cost associated with maternal ill health are limited to estimations based on secondary data. Purpose of our study was to determine the productivity cost due to maternal ill health during pregnancy in Sri Lanka., Methods and Findings: We studied 466 pregnant women, aged 24 to 36 weeks, residing in Anuradhapura, Sri Lanka. A two stage cluster sampling procedure was used in a cross sectional design and all pregnant women were interviewed at clinic centers, using the culturally adapted Immpact tool kit for productivity cost assessment. Of the 466 pregnant women studied, 421 (90.3%) reported at least one ill health condition during the pregnancy period, and 353 (83.8%) of them had conditions affecting their daily life. Total incapacitation requiring another person to carry out all their routine activities was reported by 122 (26.1%) of the women. In this study sample, during the last episode of ill health, total number of days lost due to absenteeism was 3,356 (32.9% of total loss) and the days lost due to presenteeism was 6,832.8 (67.1% of the total loss). Of the 353 women with ill health conditions affecting their daily life, 280 (60%) had coping strategies to recover loss of productivity. Of the coping strategies used to recover productivity loss during maternal ill health, 76.8% (n = 215) was an intra-household adaptation, and 22.8% (n = 64) was through social networks. Loss of productivity was 28.9 days per episode of maternal ill health. The mean productivity cost due to last episode of ill health in this sample was Rs.8,444.26 (95% CI-Rs.6888.74-Rs.9999.78)., Conclusions: Maternal ill health has a major impact on household productivity and economy. The major impact is due to, generally ignored minor ailments during pregnancy.

Financial incentives are increasingly being advocated as an effective means to influence health-related behaviours. There is, however, limited evidence on whether they work in low-income countries, particularly when implemented at scale. This paper explores the impact of a national programme in Nepal that provides cash incentives to women conditional on them giving birth in a health facility. Using propensity score matching methods, we find that the programme had a positive, albeit modest, effect on the utilisation of maternity services. Women who had heard of the SDIP before childbirth were 4.2 percentage points (17 percent) more likely to deliver with a skilled attendant. The treatment effect is positively associated with the size of the financial package offered by the programme and the quality of care in facilities. Despite the positive effect on those exposed to the SDIP, low coverage of the programme suggests that few women actually benefited in the first few years., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Approximately half of all mothers of infants born in the United States receive services through the Special Supplemental Nutrition Program for Woman, Infants and Children (WIC). Although WIC promotes breastfeeding, data suggest that, despite advances in the last 2 decades, WIC participants are less likely to initiate breastfeeding, and much less likely to continue, than non-WIC participants, including the non-WIC participants who are eligible for WIC. WIC recently revised their food packages and enhanced the monetary value of the breastfeeding packages. While these changes are an important step in supporting WIC's efforts to promote breastfeeding, other major factors, such as participants' perceptions of the value of the packages and WIC's dependency on rebates from formula companies to fund a portion of the program, may dampen WIC's breastfeeding promotion and support efforts. There is great need for additional research on these issues.

This paper exploits a unique opportunity to evaluate the impact of the quality change in the labor and delivery services brought about by the Mother and Infant Health Project in Ukraine. Employing program evaluation methods, we find that the administrative units participating in the Project have exhibited greater improvements in both maternal and infant health compared to the control ones. Among the infant health characteristics, the MIHP impact is most pronounced for infant mortality resulting from deviations in perinatal period. As for the maternal health, the MIHP is the most effective at combating anemia, blood circulation and urinary-genital system complications, and late toxicosis. The analysis suggests that the effects are due to early attendance of antenatal clinics, lower share of C-sections, and greater share of normal deliveries. Preliminary cost-effectiveness analysis shows enormous benefit per dollar spent on the project: the cost to benefit ratio is one to 97 taking into account both maternal and infant lives saved as well as cost savings due to the changes in labor and delivery practices., ((c) 2010 John Wiley & Sons, Ltd.)

Background: Caesarean section rates are increasing in Mexico and Latin America. This study evaluates the impact of a large-scale, conditional cash transfer programme in Mexico on caesarean section rates. The programme provides cash transfers to participating low income, rural households in Mexico conditional on accepting health care and nutrition supplements., Methods: The primary analyses uses retrospective reports from 979 women in poor rural communities participating in an effectiveness study and randomly assigned to incorporation into the programme in 1998 or 1999 across seven Mexican states. Using multivariate and instrumental variable analyses, we estimate the impact of the programme on caesarean sections and predict the adjusted mean rates by clinical setting. Programme participation is measured by beneficiary status, programme months and cash transfers., Results: More than two-thirds of poor rural women delivered in a health facility. Beneficiary status is associated with a 5.1 percentage point increase in caesarean rates; this impact increases to 7.5 percentage points for beneficiaries enrolled in the programme for >or=6 months before delivery. Beneficiaries had significantly higher caesarean delivery rates in social security facilities (24.0 compared with 5.6% among non-beneficiaries) and in other government facilities (19.3 compared with 9.5%)., Conclusion: The Oportunidades conditional cash transfer programme is associated with higher caesarean section rates in social security and government health facilities. This effect appears to be driven by the increases in disposable income from the cash transfer. These findings are relevant to other countries implementing conditional cash transfer programmes and health care requirements.

The majority of perinatal deaths occur in developing countries. Pragmatic reality in developing countries dictates the need for implementation of evidence-based, cost-effective interventions to improve child health outcomes. In this article we describe the implementation and evaluation of group prenatal care in Iran. Group prenatal care ideally may be suited for mothers in developing countries where lack of support, cultural and traditional practices, and low-quality health services interfere with satisfactory implementation of prenatal care. We believe that provision of prenatal care by group model improves perinatal outcomes. In developing countries such an approach is feasible and practical.

The purpose was to develop, implement and evaluate a peer-led nutrition curriculum Healthy Eating and Harambee that addresses established objectives of maternal and infant health and to shift the stage for African American women of childbearing age in Genesee County toward healthier dietary patterns using a socio-cultural and biomedical orientation. The PEN-3 model, which frames culture in the context of health promotion interventions, was integrated with the Transtheoretical Model to guide this 13-week pre-test/post-test curriculum. Materials developed included soul food plate visuals, a micronutrient availability worksheet, a fruit stand, and gardening kits. Learning activities included affirmations, stories, case-scenarios, point-of-purchase product recognition, church health teams, and community health fairs. We investigated health-promoting dietary behaviors (consumption of more fruits and vegetables (F&V), serving more F&V to their families, and moderating dietary sodium and fat intakes), and biomedical behaviors (self-monitoring blood pressure and exercising) across five stages of change. Session attendance and program satisfaction were assessed. N = 102 women participated (mean age = 27.5 years). A majority (77%) reported adopting at least one healthy eating behavior (moderating sodium, serving more F&V to their families), 23% adopted at least two such behaviors (reading food labels for sodium; using culinary herbs/spices; serving more F&V to their families), and 45% adopted both dietary (moderating sodium; eating more fruits) and biomedical behaviors. Participants and facilitators favorably evaluated the curriculum and suggested improvements. A multi-conceptual approach coupled with cultural and biomedical tailoring has potential to promote young African American women's movement to more advanced stages of change and improve self-efficacy for fruit and vegetable intake, dietary sodium moderation, and self-monitoring blood pressure and physical activity.