The Mixed Nature of Incentives for Community Health Workers: Lessons from a Qualitative Study in Two Districts in India

Incentives play an important role in motivating community health workers (CHWs). In India, accredited social health activists (ASHAs) are female CHWs who provide a range of services, including those specific to reproductive, maternal, neonatal, child, and adolescent health. 

Qualitative interviews were conducted with 49 ASHAs and one of their family members (husband, mother-in-law, sister-in-law, or son) from Gurdaspur and Mewat districts to explore the role of family, community, and health system in supporting ASHAs in their work. Thematic analysis revealed that incentives were both empowering and a source of distress for ASHAs and their families. Earning income and contributing to the household’s financial wellbeing inspired a sense of financial independence and self-confidence for ASHAs, especially with respect to relations with their husbands and parents-in-law. 

In spite of the empowering effects of the incentives, they were a cause of distress. Low incentive rates relative to the level of effort required to complete ASHA responsibilities, compounded by irregular and incomplete payment, put pressure on families. ASHAs dedicated much of their time and own resources to perform their duties, drawing them away from their household responsibilities. Communication around incentives from supervisors may have led ASHAs to prioritize and promote those services that yielded higher incentives, as opposed to focusing on the most appropriate services for the client. ASHAs and their families maintained hope that their positions would eventually bring in a regular salary, which contributed to retention of ASHAs. 

Incentives, therefore, are both motivating and inspiring as well as a cause dissatisfaction among ASHAs and their families. Recommendations include revising the incentive scheme to be responsive to the time and effort required to complete tasks and the out-of-pocket costs incurred while working as an ASHA; improve communication to ASHAs on incentives and responsibilities; and ensure timely and complete payment of incentives to ASHAs. 

The findings from this study contribute to the existing literature on incentivized CHW programs and help throw added light on the role incentives play in family dynamics which affects performance of CHW.

Full article at:   http://goo.gl/wyuobV

By:  Enisha Sarin,^1,* Sarah Smith Lunsford,² Ankur Sooden,¹ Sanjay Rai,¹ and Nigel Livesley¹

¹University Research Co., LLC, New Delhi, India

²EnCompass LLC, Bethesda, MD, USA

Edited by: Chikaikeo Ogbonna, University of Jos, Nigeria

Reviewed by: Luret Albert Lar, University of Jos, Nigeria; Emmanuel Nwabueze Aguwa, University of Nigeria Nsukka, Nigeria; Afolaranmi Olumide Tolulope, University of Jos, Nigeria

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The Relationship Between Contraceptive Use & Maternal & Infant Health Outcomes in Tajikistan

OBJECTIVE:

There has been no evaluation of the association between contraceptive use and maternal and child health (MCH) in Tajikistan, though the government has made concerted efforts to improve accessibility to family planning methods. The aim of this study is to understand the relationship between current contraceptive utilization and specific MCH outcomes in Tajikistan.

STUDY DESIGN:

Using data from the 2012 Tajikistan Demographic and Health Survey, a total weighted sample of 6716 women aged 15 to 49 years who had at least one child at the time of interview was analyzed. Logistic regression analyses were performed to assess the relationship between current contraceptive utilization and birth spacing, birth limiting and infant mortality.

RESULTS:

Modern contraceptive use was low among women studied (27.1%). Modern contraceptive users were more likely to present with a longer birth interval [adjusted odds ratio (aOR) = 2.4, 95% confidence interval (CI) = 2.0-2.8] than traditional or nonusers. Women who used modern contraceptives were half as likely to limit births to three or fewer children compared to traditional or nonusers (aOR = 0.5, 95% CI = 0.4-0.6). Among women whose most recent live birth resulted in death, modern contraceptive use was not associated with lower levels of infant mortality.

CONCLUSION:

Efforts made by the Tajik government to increase utilization of family planning have had mixed effects on overall uptake and the MCH outcomes analyzed in this study. These findings can help to inform the government's policy on family planning.

IMPLICATIONS:

Contraceptive utilization has not yet translated into beneficial MCH outcomes. Policy makers in Tajikistan might consider placing more emphasis on family planning education, while maximizing accessibility of contraceptive methods.

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By:  Merali S1.

• 1Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, USA. 
• Contraception. 2016 Mar;93(3):216-21. doi: 10.1016/j.contraception.2015.11.009. Epub 2015 Nov 24.

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"I Used to Be an Ordinary Mom": The Maternal Identity of Mothers of Women Abused by an Intimate Partner

Mothers of children who suffer various problems tend to discuss their experience as a crisis in their maternal identity, regardless of whether the children are young or adults. However, the maternal identity of mothers who are aware that their adult daughters are being abused has not yet been explored. 

This study aims to examine the construction of the maternal identity by Israeli women whose grown daughters have been subjected to intimate partner violence (IPV), in the light of cultural representations of motherhood and domestic violence (DV). Thematic discourse analysis of in-depth interviews with 11 mothers identified discursive strategies that they used to negotiate a troubled maternal identity following their daughters' IPV experience. The mothers asserted a positive maternal identity by referring to common discourses about DV and motherhood, in a bid to bolster their "good mother" identity, to reframe motherhood, and to assign responsibility for the abuse to the abuser, to their daughters, or to the patriarchal social structure. 

The implications of these findings for motherhood and maternal identity theories and for professionals working in the field of DV are discussed.

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By:  Gueta K, Peled E, Sander-Almoznino N.

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The Relationship between Unplanned Pregnancy & Maternal Body Mass Index 2009-2012

To analyse the relationship between unplanned pregnancy and maternal Body Mass Index (BMI). 

A prospective case-control study of planned vs. unplanned pregnancies among women who delivered an infant weighing ≥ 500 g during the four years 2009-2012 in a large maternity hospital in Ireland. Maternal weight and height were measured at the first antenatal visit before calculation of BMI. Clinical and sociodemographic details were computerised. BMI was categorised according to the World Health Organization. The epidemiological associations were examined using logistic regression, adjusted for confounding variables. 

Between 2009 and 2012, 34,377 women were included, 31.7% (n = 10,894) reported an unplanned pregnancy and 16.6% (n = 5647) were obese. The odds ratios of unplanned pregnancy were greater among obese women compared with those of normal BMI. These ratios increased with increasing BMI. The higher rate of unplanned pregnancy among obese women was associated with a lower rate of contraception usage and a higher rate of contraceptive failure. Only 37.6% (n = 2112) of obese women took preconceptional folic acid to prevent neural tube defects compared with 46.1% (n = 8176) of women with a normal BMI (p < 0.001). 

Higher rates of unplanned pregnancy among obese women compared with women with a normal BMI is associated with compromised prepregnancy care in this high-risk population. 

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By:  McKeating A1, O'Higgins A1, Turner C1, McMahon L1, Sheehan SR1, Turner MJ1.

• 1 UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital , Dublin , Ireland.

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‘What men don’t know can hurt women’s health’: A qualitative study of the barriers to and opportunities for men’s involvement in maternal healthcare in Ghana

The importance of men's involvement in facilitating women’s access to skilled maternal healthcare in patriarchal societies such as Ghana is increasingly being recognised. However, few studies have been conducted to examine men’s involvement in issues of maternal healthcare, the barriers to men’s involvement, and how best to actively involve men. The purpose of this paper is to explore the barriers to and opportunities for men’s involvement in maternal healthcare in the Upper West Region of Ghana.

Qualitative focus group discussions, in-depth interviews and key informant interviews were conducted with adult men and women aged 20–50 in a total of seven communities in two geographic districts and across urban and rural areas in the Upper West Region of Ghana. Attride-Stirling’s thematic network analysis framework was used to analyse and present the qualitative data.

Findings suggest that although many men recognise the importance of skilled care during pregnancy and childbirth, and the benefits of their involvement, most did not actively involve themselves in issues of maternal healthcare unless complications set in during pregnancy or labour. Less than a quarter of male participants had ever accompanied their wives for antenatal care or postnatal care in a health facility. Four main barriers to men’s involvement were identified: perceptions that pregnancy care is a female role while men are family providers; negative cultural beliefs such as the belief that men who accompany their wives to receive ANC services are being dominated by their wives; health services factors such as unfavourable opening hours of services, poor attitudes of healthcare providers such as maltreatment of women and their spouses and lack of space to accommodate male partners in health facilities; and the high cost associated with accompanying women to seek maternity care. Suggestions for addressing these barriers include community mobilisation programmes to promote greater male involvement, health education, effective leadership, and respectful and patient-centred care training for healthcare providers.

The findings in this paper highlight the need to address the barriers to men’s involvement, engage men and women on issues of maternal health, and improve the healthcare systems – both in terms of facilities and attitudes of health staff - so that couples who wish to be together when accessing care can truly do so.

Full article at:  http://goo.gl/Rzq3AA

By: John Kuumuori Ganle^1* and Isaac Dery²

¹Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Legon, Ghana

²Institute of African and Gender Studies, University of Cape Town, Cape Town, South Africa

  

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Can She Make It? Transportation Barriers to Accessing Maternal & Child Health Care Services in Rural Ghana

Below:  Political ecology of transport effect on maternal health care access in rural Ghana

Below:  Sustainable community transport system for health access

Lack of vehicular transport is suppressing the potential positive impact of CHPS on maternal and child health. Consistent neglect of road infrastructural development and endemic poverty in the study area makes provision of alternative transport services for health care difficult. As a result, pregnant women use risky methods such as bicycle/tricycle/motorbikes to access obstetric health care services, and some turn to traditional medicines and traditional birth attendants for maternal health care services.

These findings underscore the need for policy to address rural transport problems in order to improve maternal health. Community based transport strategy with CHPS is proposed to improve adherence to referral and access to emergency obstetric services.

Read more at:  http://ht.ly/Ra3nz HT @westernu 

Birth Location Preferences of Mothers and Fathers in Rural Ghana: Implications for Pregnancy, Labor and Birth Outcomes

Below:  Birth location preferences. Number of mothers and fathers who preferred health facility birth compared with those who preferred homebirth

Birth delivery location preferences were split for mothers (home delivery–9; facility delivery–11), and fathers (home delivery–7; facility delivery–11). We identified two patterns of preferences and birth outcomes: 1) preference for homebirth that resulted in delayed care seeking and was likely associated with several cases of stillbirths and postpartum morbidities; 2) Preference for health facility birth that resulted in early care seeking, and possibly enabled women to avoid adverse effects of birth complications.

Safe pregnancy and childbirth interventions should be tailored to the birth location preferences of mothers and fathers, and should include education on the development of birth preparedness plans to access timely delivery related care. Improving access to and the quality of care at health facilities will also be crucial to facilitating use of facility-based delivery care in rural Ghana.

Read more at:   http://ht.ly/QOF1X HT @UNCpublichealth