Dynamics of care and sector use between birth, contraception and sick child services

Abstract

Governments in low- and middle-income countries increasingly recognize their role as stewards of mixed health systems comprising both public and private actors, but policy often lacks a nuanced understanding of how individuals switch between these two sectors for their healthcare needs, especially for family planning (FP) and maternal, newborn and child health (MNCH). In this cross-sectional study, we used data collected by The Demographic and Health Surveys Program between 2014-2021 from eight countries (Afghanistan, India, Indonesia, Kenya, Malawi, Nigeria, Pakistan, and Uganda) to describe service and sector use among women with a recent birth, a need for FP, and a child under five years old experiencing an illness (N = 53,014). We applied multivariable logistic regressions in each country to test the associations first between sector for birth and missed opportunities for contraceptives or sick child care, and next, between sector use dynamics between birth and contraceptive use (sector fidelity, sector switching, or nonuse of services) and nonuse of sick child care. Sector at facility for birth and sector switching between services was common, but neither were generally associated with missed opportunities for care for sick children. However, private sector use at birth predicted nonuse of contraceptives in four countries, though the directionality varied. Consistently, women who did not access care at birth and contraception had significantly greater odds of missing care for sick children. Notably, in Malawi, the adjusted odds ratio of missed sick child care among those with nonuse of care for birth or contraceptives was 2.5 times that of those with sector fidelity (95% Confidence Interval: 1.43-4.22). These findings underscore the need for health system stewards to closely consider both the public and private sectors in health governance. Greater cross-sectoral cooperation and continuity of care is paramount to improving health outcomes.

Fig 1. A and B. Sector use from birth to contraception to sick child care among women with a need for all three services. Note: Other/None for birth includes those who gave birth at home or other non-facility location; for contraceptive use, this includes informal sources, traditional method use, or no use; and sick child care includes informal sources or no care. Prv = Private; Pub = Public; Phrm = Pharmacy.

Fig 2. Percentage of women with sector fidelity, sector switching, and missed opportunity for contraception and sick child care, by sectors and use of a facility for birth among women with a need for all three services.

Note: Sector fidelity refers to using the same sector for all three services, among those who gave birth in a facility, or the same sector for contraceptives and sick child care only for those who gave birth at home/other location. Other/None = includes those who gave birth at home or other non-facility location. CU = (Modern) contraceptive use; SC = Care for sick children.

Fig 3. Adjusted odds ratios and 95% confidence intervals of having no care for contraception or a sick child by place of birth among women with a need for all three services.

Note: Ref = reference.* p < 0.05 ** p < 0.01 *** p < 0.001.

Fig 4. Adjusted odds ratios and 95% confidence intervals for having missed sick child care by sector fidelity and nonuse of services for birth and contraception among women with a need for all three services.

Note: Ref = reference.* p < 0.05 ** p < 0.01 *** p < 0.001; CU = (Modern) contraceptive use.