Utilization of maternal health services is associated with improved maternal and neonatal health outcomes. Considering global and national interests in the Millennium Development Goal and Nigeria's high level of maternal mortality, understanding the factors affecting maternal health use is crucial. Studies on the use of maternal care services have largely overlooked community and other contextual factors. This study examined the determinants of maternal services utilization in Nigeria, with a focus on individual, household, community and state-level factors. Data from the 2005 National HIV/AIDS and Reproductive Health Survey - an interviewer-administered nationally representative survey - were analyzed to identify individual, household and community factors that were significantly associated with utilization of maternal care services among 2148 women who had a baby during the five years preceding the survey. In view of the nested nature of the data, we used multilevel analytic methods and assessed state-level random effects. Approximately three-fifths (60.3%) of the mothers used antenatal services at least once during their most recent pregnancy, while 43.5% had skilled attendants at delivery and 41.2% received postnatal care. There are commonalities and differences in the predictors of the three indicators of maternal health service utilization. Education is the only individual-level variable that is consistently a significant predictor of service utilization, while socio-economic level is a consistent significant predictor at the household level. At the community level, urban residence and community media saturation are consistently strong predictors. In contrast, some factors are significant in predicting one or more of the indicators of use but not for all. These inconsistent predictors include some individual level variables (the woman's age at the birth of the last child, ethnicity, the notion of ideal family size, and approval of family planning), a community-level variable (prevalence of the small family norm in the community), and a state-level variable (ratio of PHC to the population). Factors influencing maternal health services utilization operate at various levels - individual, household, community and state. Depending on the indicator of maternal health services, the relevant determinants vary. Effective interventions to promote maternal health service utilization should target the underlying individual, household, community and policy-level factors. The interventions should reflect the relative roles of the various underlying factors.

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Determinants of use of maternal health services in Nigeria - looking beyond individual and household factors

Two decades after the Safe Motherhood campaign's 1987 launch in India, half a million women continue to die from pregnancy-related causes every year. Key health-care interventions can largely prevent these deaths, but their use is limited in developing countries, and is reported to vary between population groups. We reviewed the use of maternal health-care interventions in developing countries to assess the extent, strength and implications of evidence for variations according to women's place of residence and socioeconomic status. Studies with data on use of a skilled health worker at delivery, antenatal care in the first trimester of pregnancy and medical settings for delivery were assessed. We identified 30 eligible studies, 12 of which were of high or moderate quality, from 23 countries. Results of these studies showed wide variation in use of maternal health care. Methodological factors (e.g. inaccurate identification of population in need or range of potential confounders controlled for) played a part in this variation. Differences were also caused by factors related to health-care users (e.g. age, education, medical insurance, clinical risk factors) or to supply of health care (e.g. clinic availability, distance to facility), or by an interaction between such factors (e.g. perceived quality of care). Variation was usually framed by contextual issues relating to funding and organization of health care or social and cultural issues. These findings emphasize the need to investigate and assess context-specific causes of varying use of maternal health care, if safe motherhood is to become a reality in developing countries. Bulletin of the World Health Organization 2007;85:812-819.

https://scielosp.org/pdf/bwho/2007.v85n10/812-819/en

A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context

In the event of a smallpox bioterrorist attack in a large U.S. city, the interim response policy is to isolate symptomatic cases, trace and vaccinate their contacts, quarantine febrile contacts, but vaccinate more broadly if the outbreak cannot be contained by these measures. We embed this traced vaccination policy in a smallpox disease transmission model to estimate the number of cases and deaths that would result from an attack in a large urban area. Comparing the results to mass vaccination from the moment an attack is recognized, we find that mass vaccination results in both far fewer deaths and much faster epidemic eradication over a wide range of disease and intervention policy parameters, including those believed most likely, and that mass vaccination similarly outperforms the existing policy of starting with traced vaccination and switching to mass vaccination only if required.

https://www.pnas.org/content/pnas/99/16/10935.full.pdf

Emergency response to a smallpox attack: The case for mass vaccination

background Many sex partners of persons with gonorrhea or chlamydial infections are not treated, which leads to frequent reinfections and further transmission. methods We randomly assigned women and heterosexual men with gonorrhea or chlamydial infection to have their partners receive expedited treatment or standard referral. Patients in the expedited-treatment group were offered medication to give to their sex partners, or if they preferred, study staff members contacted partners and provided them with medication without a clinical examination. Patients assigned to standard partner referral were advised to refer their partners for treatment and were offered assistance notifying partners. The primary outcome was persistent or recurrent gonorrhea or chlamydial infection in patients 3 to 19 weeks after treatment. results Persistent or recurrent gonorrhea or chlamydial infection occurred in 121 of 931 patients (13 percent) assigned to standard partner referral and 92 of 929 (10 percent) assigned to expedited treatment of sexual partners (relative risk, 0.76; 95 percent confidence interval, 0.59 to 0.98). Expedited treatment was more effective than standard referral of partners in reducing persistent or recurrent infection among patients with gonorrhea (3 percent vs. 11 percent, P=0.01) than in those with chlamydial infection (11 percent vs. 13 percent, P=0.17) (P=0.05 for the comparison of treatment effects) and remained independently associated with a reduced risk of persistent or recurrent infection after adjustment for other predictors of infection at follow-up (relative risk, 0.75; 95 percent confidence interval, 0.57 to 0.97). Patients assigned to expedited treatment of sexual partners were significantly more likely than those assigned to standard referral of partners to report that all of their partners were treated and significantly less likely to report having sex with an untreated partner. conclusions Expedited treatment of sex partners reduces the rates of persistent or recurrent gonorrhea or chlamydial infection.

Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection.

Contact tracing, followed by treatment or isolation, is a key control measure in the battle against infectious diseases. It is an extreme form of locally targeted control, and as such has the potential to be highly efficient when dealing with low numbers of cases. For this reason it is frequently used to combat sexually transmitted diseases and new invading pathogens. Accurate modelling of contact tracing requires explicit information about the disease-transmission pathways from each individual, and hence the network of contacts. Here, pairwise-approximation methods and full stochastic simulations are used to investigate the utility of contact tracing. A simple relationship is found between the efficiency of contact tracing necessary for eradication and the basic reproductive ratio of the disease. This holds for a wide variety of realistic situations including heterogeneous networks containing core-groups or super-spreaders, and asymptomatic individuals. Clustering (transitivity) within the transmission network is found to destroy the relationship, requiring lower efficiency than predicted.

/pdf/contact-tracing-and-disease-control-1aq39prr6m.pdf

Contact tracing and disease control

Partner notification in the United States: an evidence-based review.

Background and Objectives:Although partner notification has been a long-standing intervention and prevention strategy for sexually transmitted diseases (STD), variations in partner notification practices across sites have never been documented.Goals of the Study:To describe provider-assisted partner

Partner notification in the real world: a four site time-allocation study.

Objective: To identify determinants of time spent on partner notification clients in four STD programmes in the United States. Methods:
 11 disease intervention specialists (DIS) in each of three urban sites (n=33) and seven DIS in one rural site recorded their activities and clients for 14 working days. The total amount of time for partner notification activities was computed for each client. Data were analysed using random effects regression. Results:
Across sites, 429 of 2506 (37.4%) recorded hours were spent on partner notification (PN) activities with 1148 clients. Client type, STD diagnosis, outcome, demographic characteristics, mileage, and study site explained 33.7% of the variance in the total time spent on partner notification clients. Clients who took significantly more time than the reference case included those who were both contacts and original patients, HIV/AIDS clients, non-primary and secondary (P&S) syphilis clients, STD clients who were infected and treated, and clients for whom travel was necessary. Demographic characteristics of both client and worker were not associated with the time spent on partner notification. Conclusions:
 These data document the labour intensive nature of partner notification, especially for HIV and non-P&S syphilis clients. STD programmes that have a higher number of these clients are probably dedicating more resources to partner notification. More research is needed on additional predictors so that programmes can better understand and allocate staff and financial resources to partner notification activities.

https://sti.bmj.com/content/sextrans/76/5/371.full.pdf

Predictors of time spent on partner notification in four US sites.

Partner notification strategies for sexually transmitted diseases.

Data from the 1991 Belize Family Health Survey show differentials in the use of maternal and child health services between ethnic groups (Creole, Mestizo, Maya/Ketchi and Garifuna). Multivariate analysis is used to explore whether such differentials can truly be attributed to ethnicity or to other characteristics that distinguish the ethnic groups. Health services considered are: family planning, place of delivery (hospital/other), postpartum and newborn check-ups after a birth, and immunisations for children. The language usually spoken in the household is found to be important for interpreting ethnic differentials. Mayan-speaking Maya/Ketchis are significantly less likely to use family planning services or to give birth in a hospital. Spanish-speakers (Mestizos and Maya/Ketchis) are less likely to use newborn and postpartum check-ups, after controlling for other characteristics. There are no ethnic differentials for immunisations. Programmatic implications of these results are discussed.

/pdf/ethnicity-and-the-use-of-health-services-in-belize-bteo2u7xw8.pdf

Beth A. Macke

Papers

Partner notification in the United States: an evidence-based review.

Partner notification in the real world: a four site time-allocation study.

Predictors of time spent on partner notification in four US sites.

Partner notification strategies for sexually transmitted diseases.

Ethnicity and the use of health services in Belize.