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Agency: European Commission | Branch: FP7 | Program: CP-FP-SICA | Phase: HEALTH-2009-4.3.2-1 | Award Amount: 3.63M | Year: 2010

Objectives: The research aims to improve the delivery of reproductive health (RH) services in Tanzania and Niger by generating new evidence about effective ways to strengthen the provision, uptake, equity and effectiveness of adolescent reproductive health (ARH) programmes. Background: Poor adolescent reproductive health (ARH) continues to be a major cause of morbidity and worsening poverty for the poorest people in sub-Saharan Africa. The effectiveness of ARH programmes implemented within the health and education sectors is seriously hampered by adverse prevailing cultural norms and practices within those sectors and the wider community, and by poor programme integration. Methods: The proposed research will promote equitable reproductive health (RH) service provision and improve its uptake and effectiveness by : (i) conducting a situation analysis of current community and implementer experiences of existing ARH programmes in Tanzania and Niger, identifying priority areas of weakness in RH service provision and opportunities for strengthened service uptake and integration; (ii) addressing identified weaknesses and opportunities by developing an innovative package of interventions in 4 areas: (1) workplace ARH strategy in health units; (2) RH support to teachers in schools; (3) integrated school and community guardian support to pupils; (4) enhanced community referral to health services. We will evaluate the processes and impact of the interventions through a series of rigorous process evaluation studies, which will generate new knowledge, about intervention development, and indicators of intervention processes and effect. The overall impact of the interventions will be evaluated in a population-based cluster randomised trial. Involvement as project partners of the government ministries directly responsible for ARH policy in both Niger and Tanzania, will ensure the policy-relevance of this research, and its continued impact beyond the life of this project.


Oct. 25, 2016 -- Dr. Mary T. Bassett, Commissioner of the New York City Department of Health and Mental Hygiene, was awarded the Frank A. Calderone Prize by the Columbia University Mailman School of Public Health at a ceremony held this morning at the Paley Center for Media in Midtown. The Calderone Prize, the most prestigious award in public health, is awarded every two years to an individual who has made a transformational contribution in the field, with selection by an international committee of public health leaders. "Commissioner Bassett has been focused on health equity at every stage of an exceptional public health career," said Dean Linda P. Fried, who presented the Calderone Award to Dr. Bassett. "Her recognition of the role of race as a driver of health disparities, her record of publication on excess disease burden among people of color, and her ability to synthesize years of experience in the developing world with her role in New York City elevate her to the pantheon of prior Calderone winners." "It is an honor to be selected as the 12th Calderone Prize recipient and join some of the finest women and men who have made public health a passion and mission in this country and beyond," said Commissioner Bassett. "I loved being a doctor who saw individual patients, but I knew that I could effect change on a much larger scale if I entered the public health field to tackle racism and other structural factors that lead to poor health outcomes." At the award ceremony, Health Commissioner Bassett delivered an original lecture entitled, "Public Health Meets the Problem of the Color Line," where she underscored the importance of explicitly naming racism in advancing health equity work. In her more than 30 years of experience in government, hospitals, and non-profits, Health Commissioner Bassett has made a significant impact on public health both locally and around the world. As an activist and a scholar, Bassett bridged the divide between academic and applied public health, on disease prevention at Harlem Hospital and at the Department of Community Medicine at the University of Zimbabwe, and in support of health equity with the Rockefeller Foundation in South Africa. At the African Health Initiative and the domestic Child Abuse Prevention Program at the Doris Duke Charitable Foundation, she worked to strengthen health systems in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. As Deputy Commissioner of Health Promotion and Disease Prevention at the Department of Health and Mental Hygiene, Bassett spearheaded campaigns to ban smoking in public places, eliminate trans fats in restaurants and require chain restaurants to post calorie information -- initiatives that have become global models, adopted widely in cities in other countries. Commissioner Bassett has worked to address obesity and diabetes and cardiovascular disease, which threaten the health of the most vulnerable in the city. Responding to the Black Lives Matter movement, she wrote in a 2015 New England Journal of Medicine article that health professionals must do more to end racial disparities and discrimination. Born and raised in New York City, Health Commissioner Bassett earned her bachelor's degree in History and Science from Harvard University, master's degree in Public Health from University of Washington in Seattle, and her medical degree from Columbia College of Physicians and Surgeons. The Calderone Prize is named for Frank A. Calderone, who had a distinguished career in public health, leading him from the New York City Department of Health and Mental Hygiene to important posts at the World Health Organization. Instrumental in shaping the WHO's policies and structure, he also raised support for its continued operation. In 1986, the Calderone family established this prize to mark Frank Calderone's lifelong commitment and recognize exceptional public health leaders. The Calderone Prize has been previously awarded to Peter Piot, MD, former Executive Director, UNAIDS, and Under Secretary-General, United Nations; Mary Robinson, MA, former UN High Commissioner for Human Rights and former President of Ireland; and Nafis Sadik, MD, Special Advisor to the Secretary-General of the UN and former Executive Director, United Nations Population Fund, among other public health luminaries. Founded in 1922, Columbia University's Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Mailman School is the third largest recipient of NIH grants among schools of public health. Its over 450 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change & health, and public health preparedness. It is a leader in public health education with over 1,300 graduate students from more than 40 nations pursuing a variety of master's and doctoral degree programs. The Mailman School is also home to numerous world-renowned research centers including ICAP (formerly the International Center for AIDS Care and Treatment Programs) and the Center for Infection and Immunity. For more information, please visit http://www. .


Nove A.,Evidence for Action | Matthews Z.,University of Southampton | Neal S.,University of Southampton | Camacho A.V.,United Nations Population Fund
The Lancet Global Health | Year: 2014

Background: Adolescents are often noted to have an increased risk of death during pregnancy or childbirth compared with older women, but the existing evidence is inconsistent and in many cases contradictory. We aimed to quantify the risk of maternal death in adolescents by estimating maternal mortality ratios for women aged 15-19 years by country, region, and worldwide, and to compare these ratios with those for women in other 5-year age groups. Methods: We used data from 144 countries and territories (65 with vital registration data and 79 with nationally representative survey data) to calculate the proportion of maternal deaths among deaths of females of reproductive age (PMDF) for each 5-year age group from 15-19 to 45-49 years. We adjusted these estimates to take into account under-reporting of maternal deaths, and deaths during pregnancy from non-maternal causes. We then applied the adjusted PMDFs to the most reliable age-specific estimates of deaths and livebirths to derive age-specific maternal mortality ratios. Findings: The aggregated data show a J-shaped curve for the age distribution of maternal mortality, with a slightly increased risk of mortality in adolescents compared with women aged 20-24 years (maternal mortality ratio 260 [uncertainty 100-410] vs 190 [120-260] maternal deaths per 100000 livebirths for all 144 countries combined), and the highest risk in women older than 30 years. Analysis for individual countries showed substantial heterogeneity; some showed a clear J-shaped curve, whereas in others adolescents had a slightly lower maternal mortality ratio than women in their early 20s. No obvious groupings were apparent in terms of economic development, demographic characteristics, or geographical region for countries with these different age patterns. Interpretation: Our findings suggest that the excess mortality risk to adolescent mothers might be less than previously believed, and in most countries the adolescent maternal mortality ratio is low compared with women older than 30 years. However, these findings should not divert focus away from efforts to reduce adolescent pregnancy, which are central to the promotion of women's educational, social, and economic development. Funding: WHO, UN Population Fund. © 2014 World Health Organization.


News Article | November 6, 2016
Site: www.theguardian.com

Dalia was 16 and living in a refugee camp in Lebanon when she was married. She agreed to marry a man she had only met once before because she knew her family, who had fled their home in Homs, Syria, could not survive financially unless she did so. Now 18 with a young daughter, she regrets the decision – although, as with many girls in the same position, it wasn’t really hers to make. “I am one of five sisters and my father is a labourer,” she says. “He couldn’t afford to provide for us all, so when my husband’s family came to propose, I had to accept because I felt it was better for my family.” Her husband is 27. Dalia’s education was interrupted when they had to leave Homs. She says: “I was in the 11th grade, expecting to go to university in two years. If it was to happen again, I wouldn’t get married at 16. I won’t let this happen to my daughter.” Child marriage is far from unusual. According to new research from Save the Children, one girl under 15 is married every seven seconds. But it’s a problem felt more acutely by refugees: 6% of Syrian girls in Lebanon aged 12–17 are married, according to UNHCR data. Child marriage among Syrians is not new, but the five-year war has accelerated the practice. “Our members working in the region tell us that child marriage is becoming an ever-growing problem, particularly among girls in refugee communities in Jordan, Lebanon, Iraq and Egypt,” says Lakshmi Sundaram, executive director at the charity Girls not Brides. “For most families, marrying off daughters is a last resort and a desperate response to extreme circumstances,” Sundaram adds. “Faced with an increasingly unstable and impoverished situation, many parents believe that marriage is the only way they can ensure that their daughters are safe. However, they do not necessarily realise the violence that girls face within the context of marriage.” The cycle of violence in which girls find themselves caught up, according to UNFPA, is horrifying. NGO workers say that many young girls think getting married sounds better to being stuck in a refugee camp tent with their family members – where, at best they will have little privacy and at worst they suffer abuse. This can come from other residents or their own family members. But once faced with the reality of what it means to be a wife – no school, no playing, staying at home, and having to have sex and bear children – they find their young bodies and minds are not ready to cope. Zada, 18, first met her husband when he came to propose. She was 16 and living in a refugee camp in Erbil, in Iraqi Kurdistan, and he was 23. Zada told the Guardian via an interpreter: “I thought that my life with him would be so beautiful, as when we were engaged he was so kind to me and he showed me love. But after marriage I discovered that everything he told me was a lie. He was having sex with other girls, he raped me many times, when he was not at home his brother would sexually harass me and when I told my husband, he did not believe me – instead he hit me. During the four months that I was married he always hit me.” Now Zada lives with her family and can’t go outside because her husband – from whom she is now separated – has threatened her. “I can’t leave the house, I can’t work and the only thing that I want is to go back to school and am not allowed because I am under threat,” she says. United Nations Population Fund (UNFPA) case workers say that, because of the trauma, Zada has twice tried to kill herself. Nour, 18, from al-Qamishli in Syria, is also living in a refugee camp in Erbil. Two months into their marriage, Nour’s husband began to shout at her, hit her and even bite her. She had willingly entered into the marriage, thinking she would be happy. Now separated from her husband, Nour has a baby daughter by him who was taken away from her as her parents believe she is incapable of caring for a young child. She wants a divorce, but is not allowed one. She wants an education, but is not getting one. “My family tells me that it’s shameful to be divorced,” she says. “Also they said that every man at the beginning is like that but with time he will be good and treat you well.” Both Zada and Nour are supported by the UNFPA, which is working with the Kurdistan regional government to break the misconception that a marriage secures a girl’s future. The idea is to make sure girls can make informed choices on marriage – with opportunities for economic, social and psychological development before marriage. “We also invest in empowering the girls to say no to child marriage,” says Ramanathan Balakrishnan, UNFPA representative. “Often, girls do marry due to lack of alternative life options when they are in the camp.” But refugee girls are not the only ones affected. Plan International found that early marriage changes the culture in host countries such as Jordan and Lebanon. “The pressure to get married for, say, Jordanian adolescent girls, increases because of the Syrian refugees,” says Nagore Moran-Llovet, Plan International UK’s gender in emergencies programme officer. “In Jordan, men from rich Arab countries come and take their pick of the girls in refugee camps. It’s believed that Syrian girls are the most beautiful ones and these men come over and see the refugee girls they like best.” In effect, she says, the girls are made to compete with each other. “The girls tell me the men do it just to have fun. After a few months the men just leave them and the girls can’t come back to live with their families because of the shame attached, so they go into prostitution or transactional sex to survive.” The girls picked by these wealthy visitors can be as young as 10 years old, Moran-Llovet says. “It is one of the most depressing situations I have ever seen.” Apart from raising awareness, Plan International provide safe spaces where they help the girls continue with education. “We help the girls to go to school and provide sessions for the parents.” Save the Children runs awareness-raising sessions to reach Syrian girls who have married early or are at risk of doing so. “The sessions tackle the harmful impact of early marriage on girls, be that physical, psychological or social,” says Sandy Maroun from Save the Children in Lebanon, adding that married women are encouraged to share their experiences with potential child brides to persuade them to delay until they reach a reasonable age. “Children should be allowed to be children, not wives.” All the girls’ names in this piece have been changed. Join our community of development professionals and humanitarians. Follow @GuardianGDP on Twitter. Join the conversation with the hashtag #SheMatters.


News Article | November 18, 2016
Site: www.fastcompany.com

It's been 15 years since U.S. forces invaded Afghanistan. In the capital city of Kabul—the world’s fifth-fastest-growing urban population, which jumped from half a million in 2001 to over 4.6 million—the Afghan government struggles against a worsening humanitarian situation. As U.S. and NATO troops continue to withdraw, so do international aid workers. Typically, the burden of international problems such as poverty, disaster, and war are left exclusively to governments and nonprofit organizations. In recent years, a new approach has emerged. Social entrepreneurs are spearheading job growth and stability, and a burgeoning private sector seeks to stabilize the economy and break the dependency on foreign aid. They walk a fragile line. They must build networks with trusted government workers, the international business community, young students, and professionals. Many Afghan business leaders hope to attract investors who will bet on them to secure hard-won gains in human rights, especially for women. Shetab Afghanistan, which translates to "accelerator" in Persian/Dari, is a newly launched incubator and coworking space offering mentoring and acceleration services for social innovators, activists, and entrepreneurs. Founders Ajmal Paiman and Azadeh Tajdar launched their first lab to support six startups this September. This included the first female participant in Shetab’s emerging network, a country ranked to be the most oppressive in the world for girls and women. "Afghanistan has a nascent women-led startup scene, and women need more encouragement and incentives to actually consider the entrepreneurial option, particularly in the Afghan context, where formal employment opportunities for women are limited," explains Tajdar. "The more successful female entrepreneurs emerge in Afghanistan, the more society will leap forward." According to the U.N., the World Bank, and other organizations, when women have access to education, jobs, and leadership positions, communities and nations benefit. But there are significant challenges. estimates that almost nine out of 10 Afghan women face physical, sexual, or psychological violence or are forced into marriage. As in many countries, Afghan girls tend to drop out in secondary school due to cultural barriers, including early marriage practices. The United Nations Population Fund estimates that 46% of Afghan girls are married by age 18, and 15% of them are married before age 15. The country has the highest gender disparity in the world for primary education: 71 girls attend for every 100 boys. Only 21% of these girls end up completing primary school. According to experts and women across the war-torn country, little has changed for women there, despite upwards of $1.5 billion spent to empower women and girls. But could supporting women-led initiatives and startups ensure intervention programs run as intended? "Entrepreneurship also empowers, enabling a poor woman in a poor country to generate income, secure a good home, and send her children to school," states Steven Koltai, who helped lead the creation of the Global Entrepreneurship Program under former Secretary of State Hillary Clinton. "This is also the promise of microfinance, but full-blown entrepreneurship takes it to a meaningful, lasting level," he says. Koltai sees entrepreneurship as the first step up the economic ladder, "providing access to both well-being and social respect for those who are normally denied such access, including women, ethnic minorities, and those lacking friends in high places." Over the course of two years, Koltai acted as senior adviser to the Global Entrepreneurship Program and oversaw the launch of pilot projects across the Middle East. For Koltai, "There’s a straight-line connection between unemployment, and political instability and unrest." Fostering entrepreneurship is the remedy. Koltai believes that the U.S. government should be spending more money to support entrepreneurs. "I’d like to see it shift its international economic development resources—even slightly—so that more U.S. aid dollars are directed to bolstering the entrepreneurship ecosystems that are essential to nurturing startups," he says. Afghan President Ashraf Ghani expressed a similar view in his TEDGlobal talk, "How to Rebuild a Broken State." He urged the importance of global engagement in the region, but stressed, "Instead of sending $100 billion in aid, send the money to the most innovative companies." Ghani echoed this in his inaugural speech in 2014, referring to it as a "triangle of stability" whose three sides are the economy, security, and human resources. His leadership aims to stimulate the private sector by attracting foreign investors as traditional aid dries up. To date, the U.S. has spent over $850 billion in Afghanistan. Of that money, roughly $218 million went towards entrepreneurship. From 2012 to 2016, the U.S. Agency for International Development’s Assistance in Building Afghanistan by Developing Enterprise (ABADE) program created more than 260 public-private alliances with Afghan businesses. In 2015, the Social Impact Partnership Act was proposed to Congress with bipartisan support, but it has not yet passed. The uncertainty of the security transition poses problems for a country whose past decade of economic growth has relied on international aid and spending, which has been referred to as the "Kabul bubble." According to the World Bank, Afghanistan's economic growth was down sharply to 3.7% in 2013. An in-person poll by Gallup revealed that job prospects across Afghanistan have been in sharp decline since 2012. Supporting a new model of collaboration could be the key to securing a better future for Afghanistan's people. "As international NGOs are leaving, the status of women is even more fragile," says Dr. Massouda Jalal, the former minister of women’s affairs who ran for president in 2004. She created the Jalal Foundation in 2007, the first women-led initiative of its type in Afghanistan’s history. The Jalal Foundation reports that so far, 120,000 women have been trained in literacy, English, IT, leadership, and political participation. 150,000 women are now active in local councils, 1,600 have tried to join local elections as candidates, 10,000 have been trained to serve as election clerks, and 80% of the women to vote in the 2014 election were women directed by one of her programs. Jalal wants the trend to continue for the upcoming 2017 election. Afghanistan’s constitution guarantees women both the right to an education and to employment, but in the political world, there is a gap between agreed-upon rights and the reality on the ground. For this reason, Jalal says she would like it to be easier for women to participate in rebuilding Afghanistan’s political system. Women were noticeably absent in the peace talks held in Qatar. Human Rights Watch has stressed that international donors will increase once female participation in peace talks is guaranteed. "For Afghan women’s rights, we want to build a culture where women can help the economy rise, and that’s why we rely on solidarity with organizations to promote women as first-class citizens who can contribute to social life," says Jalal. The Jalal Foundation is currently focused on attracting donors to promote computer literacy because the internet acts as a lifeline to the outside world. "If we can give women access to the internet and computer skills, then we’ve connected them to an ocean of information in the world," explains Jalal. Jalal Foundation is just one of a number of organizations campaigning for computer science education as a way to alleviate the oppression of women. Promote, a USAID program committed in Kabul until at least 2019, supports computer classes administered by local NGOs. Nagina Yari, a spokesperson for Afghans for Tomorrow (AFT), says Promote provides invaluable support and computer equipment for over 450 students at a high school level. In 2016, AFT provided scholarships for 110 young women to pursue university. Typically, they attend classes in the capital at Kabul University, which saw renewed enrollment after the Taliban fell in 2001. The computer science department is now 30% women. Before 2002, this number was zero. Fakhria Momtaz, Shetab’s first female participant and cofounder of a Kabul-based IT company called Momtaz Solutions, also aims to increase access to computer education. She wants to extend safe environments like the one that allowed her success in her profession. "My company is launching a center to encourage girls to stay in computer science classes," she says. "We want to show them a clear future and let them know they are stronger than the men who try to bully them out of the field." The project proposal, Momtaz Host, seeks to enhance employable skills like coding and programming for both students and professionals. The aim is to build capacity to train 100 young professionals at any given time. The center plans to include membership to the International Scientific Institutes such as Elsevier for research. Child care, another barrier to the workplace, will also be provided. An estimated $1.5 million is needed by donors to implement the project. "Many women face harsh discrimination in their first year of studying computer science at university," says Momtaz. "They are fighting against prescribed roles and drop out to do what is expected of them, like be a teacher or a doctor or other helping professions." An exact number was not provided, but estimates say that only half of the women who enroll graduate. Momtaz says that she’s personally benefited from a unique support system. Her father and grandfather both detested the cultural attitudes towards women, and her husband is the cofounder of her company. "My father loved to see women in leadership positions," she says. "He would show me pictures of [former Pakistani Prime Minister] Benazir Bhutto and inspire me to work on behalf of my community. These are difficult times, but this is my country and I am dedicated to it." "It gives us such joy because we are accelerating startups where the founders and cofounders are women," says Tajdar. "Societies that have increased the growth of established women entrepreneurs are more inclusive and have a more thriving private sector and entrepreneurship climate, which are so fundamental to building strong, peaceful, and competitive societies." For the business leaders aiming to lift Afghanistan out of the effects of over 30 years of war, renewed international support is crucial. The future of the country remains unclear now that the traditional aid model has reached a dead end, but many stakeholders have hope. As Jalal says, "We have a long way to go, but we are positive we can achieve our goal."


Cai X.,United Nations Population Fund | Wardlaw T.,United Nations Childrens Fund | Brown D.W.,United Nations Childrens Fund
International Breastfeeding Journal | Year: 2012

Background: Infant and young child feeding is critical for child health and survival. Proportion of infants 0-5 months who are fed exclusively with breast milk is a common indicator used for monitoring and evaluating infant and young child feeding in a given country and region. Despite progress made since 1990, a previous review in 2006 of global and regional trends found improvement to be modest. The current study provides an update in global and regional trends in exclusive breastfeeding from 1995 to 2010, taking advantage of the wealth of data from recent household surveys.Methods: Using the global database of infant and young child feeding maintained by the United Nations Children's Fund, the authors examined estimates from 440 household surveys in 140 countries over the period between 1995 and 2010 and calculated global and regional averages of the rate of exclusive breastfeeding among infants 0-5 months for the two time points to assess the trends.Results: Trend data suggest the prevalence of exclusive breastfeeding among infants younger than six months in developing countries increased from 33% in 1995 to 39% in 2010. The prevalence increased in almost all regions in the developing world, with the biggest improvement seen in West and Central Africa.Conclusions: In spite of the well-recognized importance of exclusive breastfeeding, the practice is not widespread in the developing world and increase on the global level is still very modest with much room for improvement. Child nutrition programmes worldwide continue to require investments and commitments to improve infant feeding practices in order to have maximum impact on children's lives. © 2012 Cai et al.; licensee BioMed Central Ltd.


Gottschalk L.B.,Family and Reproductive Health | Ortayli N.,United Nations Population Fund
Contraception | Year: 2014

Objective(s): Many adolescents in developing countries have an unmet need for contraception, which can contribute to poor reproductive health outcomes. Recent literature reviews have not adequately captured effective contraceptive services and interventions for adolescents in low- and middle-income countries (LMICs). This study aims to identify and evaluate the existing evidence base on contraceptive services and interventions for adolescents in LMICs that report an impact on contraceptive behavior outcomes. Study Design: Structured literature review of published and unpublished papers about contraceptive services and interventions for adolescents in LMICs that report an impact on contraceptive behavior outcomes. Results: We identify common elements used by programs that measured an impact on adolescent contraceptive behaviors and summarize outcomes from 15 studies that met inclusion criteria. Effective programs generally combined numerous program approaches and addressed both user and service provision issues. Overall, few rigorous studies have been conducted in LMICs that measure contraceptive behaviors. Few interventions reach the young, the out of school and other vulnerable groups of adolescents. Conclusion(s): Though the evidence base is weak, there are promising foundations for adolescent contraceptive interventions in nearly every region of the world. We offer recommendations for programmers and identify gaps in the evidence base to guide future research.


McKinnon B.,McGill University | Harper S.,McGill University | Kaufman J.S.,McGill University | Bergevin Y.,United Nations Population Fund
The Lancet Global Health | Year: 2014

Background: Neonatal mortality rates (NMRs) in countries of low and middle income have been only slowly decreasing; coverage of essential maternal and newborn health services needs to increase, particularly for disadvantaged populations. Our aim was to produce comparable estimates of changes in socioeconomic inequalities in NMR in the past two decades across these countries. Methods: We used data from Demographic and Health Surveys (DHS) for countries in which a survey was done in 2008 or later and one about 10 years previously. We measured absolute inequalities with the slope index of inequality and relative inequalities with the relative index of inequality. We used an asset-based wealth index and maternal education as measures of socioeconomic position and summarised inequality estimates for all included countries with random-effects meta-analysis. Findings: 24 low-income and middle-income countries were eligible for inclusion. In most countries, absolute and relative wealth-related and educational inequalities in NMR decreased between survey 1 and survey 2. In five countries (Cameroon, Nigeria, Malawi, Mozambique, and Uganda), the difference in NMR between the top and bottom of the wealth distribution was reduced by more than two neonatal deaths per 1000 livebirths per year. By contrast, wealth-related inequality increased by more than 1·5 neonatal deaths per 1000 livebirths per year in Ethiopia and Cambodia. Patterns of change in absolute and relative educational inequalities in NMR were similar to those of wealth-related NMR inequalities, although the size of educational inequalities tended to be slightly larger. Interpretation: Socioeconomic inequality in NMR seems to have decreased in the past two decades in most countries of low and middle income. However, a substantial survival advantage remains for babies born into wealthier households with a high educational level, which should be considered in global efforts to further reduce NMR. Funding: Canadian Institutes of Health Research. © 2014 McKinnon et al.


McKinnon B.,McGill University | Harper S.,McGill University | Kaufman J.S.,McGill University | Bergevin Y.,United Nations Population Fund
Health Policy and Planning | Year: 2015

Background Several countries in sub-Saharan Africa have recently adopted policies that remove user fees for facility-based delivery services. There is little rigorous evidence of the impact of these policies on utilization of delivery services and no evaluations have examined effects on neonatal mortality rates (NMR). In this article, we estimate the causal effect of removing user fees on the proportion of births delivered in facilities, the proportion of births delivered by Caesarean section, and NMR. Methods We used data from Demographic and Health Surveys conducted in 10 African countries between 1997 and 2012. Kenya, Ghana and Senegal adopted policies removing user fees for facility-based deliveries between 2003 and 2007, while seven other countries not changing user fee policies were used as controls. We used a difference-in-differences (DD) regression approach to control for secular trends in the outcomes that are common across countries and for time invariant differences between countries. Results According to covariate-adjusted DD models, the policy change was consistent with an increase of 3.1 facility-based deliveries per 100 live births (95% confidence interval (CI): 0.9, 5.2) and an estimated reduction of 2.9 neonatal deaths per 1000 births (95% CI:-6.8, 1.0). In relative terms, this corresponds to a 5% increase in facility deliveries and a 9% reduction in NMR. There was no evidence of an increase in Caesarean deliveries. We examined lead and lag-time effects, finding evidence that facility deliveries continued to increase following fee removal. Conclusions Our findings suggest removing user fees increased facility-based deliveries and possibly contributed to a reduction in NMR. Evidence from this evaluation may be useful to governments weighing the potential benefits of removing user fees. © 2014 Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.


Jat T.R.,United Nations Population Fund | Jat T.R.,Umeå University | Ng N.,Umeå University | San Sebastian M.,Umeå University
International Journal for Equity in Health | Year: 2011

Background: Improving maternal health is one of the eight Millennium Development Goals. It is widely accepted that the use of maternal health services helps in reducing maternal morbidity and mortality. The utilization of maternal health services is a complex phenomenon and it is influenced by several factors. Therefore, the factors at different levels affecting the use of these services need to be clearly understood. The objective of this study was to estimate the effects of individual, community and district level characteristics on the utilisation of maternal health services with special reference to antenatal care (ANC), skilled attendance at delivery and postnatal care (PNC). Methods. This study was designed as a cross sectional study. Data from 15,782 ever married women aged 15-49 years residing in Madhya Pradesh state of India who participated in the District Level Household and Facility Survey (DLHS-3) 2007-08 were used for this study. Multilevel logistic regression analysis was performed accounting for individual, community and district level factors associated with the use of maternal health care services. Type of residence at community level and ratio of primary health center to population and percent of tribal population in the district were included as district level variables in this study. Results: The results of this study showed that 61.7% of the respondents used ANC at least once during their most recent pregnancy whereas only 37.4% women received PNC within two weeks of delivery. In the last delivery, 49.8% mothers were assisted by skilled personnel. There was considerable amount of variation in the use of maternal health services at community and district levels. About 40% and 14% of the total variance in the use of ANC, 29% and 8% of the total variance in the use of skilled attendance at delivery and 28% and 8.5% of the total variance in the use of PNC was attributable to differences across communities and districts, respectively. When controlled for individual, community and district level factors, the variances in the use of skilled attendance at delivery attributed to the differences across communities and districts were reduced to 15% and 4.3% respectively. There were only marginal reductions observed in the variance at community and district level for ANC and PNC use. The household socio-economic status and mother's education were the most important factors associated with the use of ANC and skilled attendance at delivery. The community level variable was only significant for ANC and skilled attendance at delivery but not for PNC. None of the district level variables used in this study were found to be influential factors for the use of maternal health services. Conclusions: We found sufficient amount of variations at community and district of residence on each of the three indicators of the use of maternal health services. For increasing the utilisation of these services in the state, in addition to individual-level, there is a strong need to identify and focus on community and district-level interventions. © 2011 Jat et al; licensee BioMed Central Ltd.

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