Measures of women’s access to care in maternal and child mortality surveillance systems: evidence and implementation Pubblico

Abstract

Maternal and child deaths are tragic events that continue to occur at unacceptably high rates worldwide. Two surveillance systems, the Child Health and Mortality Prevention Surveillance (CHAMPS) Network and Maternal Mortality Review Committees (MMRCs), aim to identify specific causes of death; however, they do not include measures of social determinants of population health. The purpose of this dissertation is to advance the use of theory-informed measures of a globally-relevant social determinant - women’s barriers and access to healthcare - in routine maternal and child mortality surveillance systems.

In Aim 1, we evaluated the acceptability of a social autopsy tool using key informant interviews and focus group discussions to qualitatively analyze its acceptability and explore its validity at the CHAMPS Sierra Leone site. We found the social autopsy was generally acceptable to the community since it is linked to efforts to improve children’s health. Participants referenced positive perceptions about health facilities, suggesting possible social desirability bias in responses.

In Aim 2, we estimated the effect of delays in accessing prenatal or obstetric care on neonatal mortality using a social autopsy questionnaire in a case-control study. Logistic regressions were used to estimate the effect. Analyzing 53 neonatal deaths and 140 neonatal controls, each additional barrier was mildly associated with neonatal death (OR=1.38, CI=0.92, 2.07), particularly delays that occurred at the facility (OR=19.15, CI=3.90, 94.19) and each additional barrier in women who did not report medical complications (OR =2.06, CI=1.17, 3.65).

Finally, in Aim 3, we evaluated differences between a pregnancy-related mortality ratio (operationalized as deaths per live-births) and a pregnancy-related mortality rate (operationalized as deaths per women of reproductive age) using data from MMRCs in nine U.S. states. For 322 pregnancy-related deaths, associations of county-level contraception need and other contextual exposures were similar or slightly stronger using live births as the denominator, except the estimate among black women for percent black population (RR=0.52 vs. 1.96). Additionally, the black-white disparity was stronger when using women of reproductive age as the denominator (RR=3.13 vs. 2.45).

In conclusion, measures of women’s access to reproductive care are important to include in maternal and child mortality surveillance systems. Future work should focus on optimizing these measures and linking social factors to specific causes of death.

Table of Contents

CHAPTER 1: INTRODUCTION........................... 1

DISSERTATION Aims ………...………………………18

CHAPTER 2: DATA SOURCES............................ 20

CHAMPS......................................................... 20

MMRCS. ..........................................................22

CHAPTER 3..................................................... 26

ABSTRACT...................................................... 26

INTRODUCTION.............................................. 28

METHODS....................................................... 30

RESULTS.......................................................... 35

DISCUSSION.................................................... 45

CHAPTER 4...................................................... 48

ABSTRACT....................................................... 48

INTRODUCTION.............................................. 50

METHODS....................................................... 52

RESULTS......................................................... 56

DISCUSSION................................................... 61

CHAPTER 5..................................................... 66

ABSTRACT...................................................... 66

INTRODUCTION.............................................. 68

METHODS....................................................... 70

RESULTS.......................................................... 72

DISCUSSION.................................................... 79

CHAPTER 6: DISCUSSION................................. 83

REFERENCES……………………..……………………..91     

About this Dissertation

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School	Laney Graduate School
Department	Epidemiology
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Epidemiology
Parola chiave	maternal and child health surveillance social determinants access to healthcare
Committee Chair / Thesis Advisor	Michael Kramer, Emory University
Committee Members	Amy Webb-Girard, Emory University David Goodman, Emory University Robert Breiman, Emory University Lauren Christiansen-Lindquist, Emory University

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