Measuring client satisfaction and the quality of family planning services: A comparative analysis of public and private health facilities in Tanzania, Kenya and Ghana

Public and private family planning providers face different incentive structures, which may affect overall quality and ultimately the acceptability of family planning for their intended clients. This analysis seeks to quantify differences in the quality of family planning (FP) services at public and private providers in three representative sub-Saharan African countries (Tanzania, Kenya and Ghana), to assess how these quality differentials impact upon FP clients' satisfaction, and to suggest how quality improvements can improve contraceptive continuation rates.\ud Indices of technical, structural and process measures of quality are constructed from Service Provision Assessments (SPAs) conducted in Tanzania (2006), Kenya (2004) and Ghana (2002) using direct observation of facility attributes and client-provider interactions. Marginal effects from multivariate regressions controlling for client characteristics and the multi-stage cluster sample design assess the relative importance of different measures of structural and process quality at public and private facilities on client satisfaction. Private health facilities appear to be of higher (interpersonal) process quality than public facilities but not necessarily higher technical quality in the three countries, though these differentials are considerably larger at lower level facilities (clinics, health centers, dispensaries) than at hospitals. Family planning client satisfaction, however, appears considerably higher at private facilities - both hospitals and clinics - most likely attributable to both process and structural factors such as shorter waiting times and fewer stockouts of methods and supplies. Because the public sector represents the major source of family planning services in developing countries, governments and Ministries of Health should continue to implement and to encourage incentives, perhaps performance-based, to improve quality at public sector health facilities, as well as to strengthen regulatory and monitoring structures to ensure quality at both public and private facilities. In the meantime, private providers appear to be fulfilling an important gap in the provision of FP services in these countries

Household headship and child death: Evidence from Nepal

<p>Abstract</p> <p>Background</p> <p>Nepal has seen substantial improvements in its reproductive health outcomes, but infant and child mortality are still high. This study attempts to examine the prevalence and factors influencing the experience of child death of mothers who have given birth during a five-year period. More specifically, this paper aims to investigate whether household headship has an impact on child death in Nepal.</p> <p>Methods</p> <p>This paper reports on data drawn from the Nepal Demographic and Health Survey (NDHS 2006), a nationally representative sample survey. The analysis is confined to women who had given birth during the five years preceding the survey (n = 4066). The association between experience of child death of mother and the explanatory variables was assessed via bivariate analysis using a chi-square test. The variables were also examined using multivariate analysis (binary logistic regression) to assess the net effect of household headship on child death after controlling for the other variables.</p> <p>Results</p> <p>Out of all the mothers who had given birth during a five-years period, 3,229 (79.4%) were from male-headed households; the remaining 837 (20.6%) were from female-headed households. A significantly higher proportion of mothers from male-headed households (6.5%) than female-headed households (4.5%) had experienced the death of a child over the five years preceding the survey. Several socio-demographic, economic, and cultural variables were significant predicators for death of a child. For instance, women who had given birth to three or more children and who were Hindu were more likely to experience a child's death than were their counterparts. On the other hand, women who were literate, who had ever used family planning methods, who had visited a health facility, who utilized antenatal care for the last pregnancy, and who were from female-headed households were less likely to see a child die than were women in their comparison group. Notably, keeping all other control variables constant in the logistic model, women from female-headed households were 31 percent less likely to experience the death of a child (odds ratio = 0.69) than were women from male-headed households.</p> <p>Conclusion</p> <p>The death of children is not uncommon in Nepal. No single factor can account for the high child mortality in the country; many factors contribute to the problem. After controlling for other variables, this study found that, among many other factors, household headship was a strong predictor. Programs seeking to help remedy this problem should focus on the issues identified here regarding women's autonomy, such as reducing the number of children born, increasing women's literacy status, increasing the use of family planning, increasing the use of antenatal care, and increasing female household headship so that child mortality will decrease and the overall well-being of the family can be maintained and enhance.</p

Demographic, socio-economic, and cultural factors affecting fertility differentials in Nepal

<p>Abstract</p> <p>Background</p> <p>Traditionally Nepalese society favors high fertility. Children are a symbol of well-being both socially and economically. Although fertility has been decreasing in Nepal since 1981, it is still high compared to many other developing countries. This paper is an attempt to examine the demographic, socio-economic, and cultural factors for fertility differentials in Nepal.</p> <p>Methods</p> <p>This paper has used data from the Nepal Demographic and Health Survey (NDHS 2006). The analysis is confined to ever married women of reproductive age (8,644). Both bivariate and multivariate analyses have been performed to describe the fertility differentials. The bivariate analysis (one-way ANOVA) was applied to examine the association between children ever born and women's demographic, socio-economic, and cultural characteristics. Besides bivariate analysis, the net effect of each independent variable on the dependent variable after controlling for the effect of other predictors has also been measured through multivariate analysis (multiple linear regressions).</p> <p>Results</p> <p>The mean numbers of children ever born (CEB) among married Nepali women of reproductive age and among women aged 40-49 were three and five children, respectively. There are considerable differentials in the average number of children ever born according to women's demographic, socio-economic, and cultural settings. Regression analysis revealed that age at first marriage, perceived ideal number of children, place of residence, literacy status, religion, mass media exposure, use of family planning methods, household headship, and experience of child death were the most important variables that explained the variance in fertility. Women who considered a higher number of children as ideal (β = 0.03; p < 0.001), those who resided in rural areas (β = 0.02; p < 0.05), Muslim women (β = 0.07; p < 0.001), those who had ever used family planning methods (β = 0.08; p < 0.001), and those who had a child-death experience (β = 0.31; p < 0.001) were more likely to have a higher number of CEB compared to their counterparts. On the other hand, those who married at a later age (β = -0.15; p < 0.001), were literate (β = -0.05; p < 0.001), were exposed to both (radio/TV) mass media (β = -0.05; p < 0.001), were richest (β = -0.12; p < 0.001), and were from female-headed households (β = -0.02; p < 0.05) had a lower number of children ever born than their counterparts.</p> <p>Conclusion</p> <p>The average number of children ever born is high among women in Nepal. There are many contributing factors for the high fertility, among which are age at first marriage, perceived ideal number of children, literacy status, mass media exposure, wealth status, and child-death experience by mothers. All of these were strong predictors for CEB. It can be concluded that programs should aim to reduce fertility rates by focusing on these identified factors so that fertility as well as infant and maternal mortality and morbidity will be decreased and the overall well-being of the family maintained and enhanced.</p

CBS News Interview with U.S. Senator James O. Easland on Marijuana

CBS News reporter interviewing James O. Eastland on the subject of marijuana

Maternal mortality in the informal settlements of Nairobi city: what do we know?

Background: current estimates of maternal mortality ratios in Kenya are at least as high as 560 deaths per 100,000 live births. Given the pervasive poverty and lack of quality health services in slum areas, the maternal mortality situation in this setting can only be expected to be worse. With a functioning health care system, most maternal deaths are avoidable if complications are identified early. A major challenge to effective monitoring of maternal mortality in developing countries is the lack of reliable data since vital registration systems are either non-existent or under-utilized. In this paper, we estimated the burden and identified causes of maternal mortality in two slums of Nairobi City, Kenya.Methods: we used data from verbal autopsy interviews conducted on nearly all female deaths aged 15–49 years between January 2003 and December 2005 in two slum communities covered by the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). In describing the distribution of maternal deaths by cause, we examined maternal and late maternal deaths according to the ICD-10 classification. Additionally we used data from a survey of health care facilities that serve residents living in the surveillance areas for 2004–2005 to examine causes of maternal death.Results: the maternal mortality ratio for the two Nairobi slums, for the period January 2003 to December 2005, was 706 maternal deaths per 100,000 live births. The major causes of maternal death were: abortion complications, hemorrhage, sepsis, eclampsia, and ruptured uterus. Only 21% of the 29 maternal deaths delivered or aborted with assistance of a health professional. The verbal autopsy tool seems to capture more abortion related deaths compared to health care facility records. Additionally, there were 22 late maternal deaths (maternal deaths between 42 days and one year of pregnancy termination) most of which were due to HIV/AIDS and anemia.Conclusion: maternal mortality ratio is high in the slum population of Nairobi City. The Demographic Surveillance System and verbal autopsy tool may provide the much needed data on maternal mortality and its causes in developing countries. There is urgent need to address the burden of unwanted pregnancies and unsafe abortions among the urban poor. There is also need to strengthen access to HIV services alongside maternal health services since HIV/AIDS is becoming a major indirect cause of maternal death