The cost effective provision of quality care for chronic diseases is a major challenge for health care systems. We describe a project to improve the care of patients with the highly prevalent disorders of diabetes and hypertension, conducted in one of the major cities of the United Arab Emirates.The project, using the principles of quality assurance cycles, was conducted in 4 stages.The assessment stage consisted of a community survey and an audit of the health care system, with particular emphasis on chronic disease care. The information gleaned from this stage provided feedback to the staff of participating health centers. In the second stage, deficiencies in health care were identified and interventions were developed for improvements, including topics for continuing professional development.In the third stage, these strategies were piloted in a single health centre for one year and the outcomes evaluated. In the still ongoing fourth stage, the project was rolled out to all the health centers in the area, with continuing evaluation. The intervention consisted of changes to establish a structured care model based on the predicted needs of this group of patients utilizing dedicated chronic disease clinics inside the existing primary health care system. These clinics incorporated decision-making tools, including evidence-based guidelines, patient education and ongoing professional education.The intervention was successfully implemented in all the health centers. The health care quality indicators that showed the greatest improvement were the documentation of patient history ; improvement in recording physical signs (e.g. body mass index (BMI)); and an improvement in the requesting of appropriate investigations, such as HbA1c and microalbuminurea. There was also improvement in those parameters reflecting outcomes of care, which included HbA1c, blood pressure and lipid profiles. Indicators related to lifestyle changes, such as smoking cessation and BMI, failed to improve.Chronic disease care is a joint commitment by health care providers and patients. This combined approach proved successful in most areas of the project, but the area of patient self management requires further improvement. Chronic diseases constitute a major global health burden. In the United Arab Emirates one in four people has diabetes, and disorders such as hypertension, asthma, and dyslipidemia are highly prevalent even in early adulthood ,2. The qIt is well recognized that tight control of hypertension, glycemia and cholesterol are all effective methods of reducing morbidity and mortality -5. In adIn recent years the role of Primary Health Care has been emphasized as the most cost-effective form of care utilizing standardized pharmacologic regimens that involve a limited number of widely used and relatively nontoxic agents . StandarTo improve the quality of care, its structure, process, and outcome must all be targeted . It is tIn Al Ain, in 2003, a primary health care project to improve the quality of care provided to patients with diabetes and hypertension was initiated. Its three main objectives were to optimize resource utilization, to improve the management and outcome of care for patients with diabetes and hypertension based on evidence based guidelines, and to improve Health Care Professionals' knowledge and adherence to up-to-date evidence based clinical practice guidelines and thereby improves patients' quality of life and satisfaction.Al Ain is the fourth largest city in the United Arab Emirates with a population of around 400,000 people, of which a quarter are United Arab Emirates (UAE) nationals and the rest expatriates. Since the early 1980s Al Ain primary health care department has operated eleven centrally managed health care centers within the city as well as eight smaller rural centers that serve the periphery of Al Ain. These centers provide highly accessible services to UAE nationals without the need for appointments. As they are free to Nationals and also are connected to the two main hospitals in the city by a good referral system, they are generally preferred to private clinics, especially for chronic conditions. Services at these centres are provided from 8 am to 11 pm during regular week days by staff working in two shifts; with some centers also providing weekend services. These health centers cater for routine ambulatory care and emergency services as well as vaccination, antenatal care and the primary care of chronic disease.With a single body providing all primary care, Al Ain's primary health care indicators for many areas, such as vaccination are good (coverage 97%). Nevertheless, rapid population growth puts pressure on service provision and concerns were raised with regards to the cost-effectiveness of the long opening hours and poor control of patient flow in the current walk-in system. Health care staff complain of insufficient time per patient during peak hours, especially for those needing more focused care such as diabetics, asthmatics, hypertensives or antenatal patients. To improve this situation a special program was initiated in all 10 urban health care centers - the subject of this study.Most Health Care Professionals working in these centers are non UAE nationals who have been working in their center for more than 5 years. Few have postgraduate degrees in family medicine or any other medical specialty.Table  shows anStage I: Included baseline studies on: i) patient flow system in the centers, ii) care of diabetes and hypertension (in 2004) and iii) a community based study carried out in parallel by the same team as ii) with the objective of assessing the prevalence of cardiovascular risk factors in the Al-Ain population. These were generally perceived to be high, but exact data was lacking despite the clear need for this information. Results from this community survey, which was conducted in 2004-2005, also in Al-Ain, have been published elsewhere ,16.The flow study (audit) was done in 2003 in all centers. The audit form included information on patient demographics, date/time of attendance, waiting time, reason for and duration of consultation and details of investigations, prescribing, referral and follow-up. After piloting this form all centers were informed about the findings of the audit and given enough time to become familiar with the form. The number of audit days required per center depended on the size of the center and the services provided.Centers that provided on-call services at weekends were also required to include a weekend. On audit days each patient utilising any service was allocated a form that was completed by all designated staff members including clerk, nurse, and the General Practitioner. Forms were then collated for data entry and analysis. In total 4947 patients were included in the audit. For logistical reasons the flow audit was only repeated after the intervention in the center where the intervention was piloted.Plan, Do, Study, Act methodology; where the Plan of the intervention was developed locally by each center's management and implemented by a local team in order to instill a sense of ownership of the project. An overall coordinator (LMB) facilitated the coordination and the running of the project.The baseline diabetes and hypertension care audit was conducted in 2004 in all centers. It was repeated annually in all intervention centers during the intervention. Stage II: Basically this stage followed the Do the intervention evolved from communicating the baseline audit results prior to inaugurating changes in settings or resources. In addition a one day workshop for health professionals, on cardiovascular risk factors was conducted at the end of 2004 highlighting assessment and management of risk by means of the Framingham risk score.In In 2005 an intervention was designed on the basis of the responses from the participating Heath Care Professionals (HCP) to the findings of the audit, including the various educational activities following the audit. The major component of this intervention was the establishment of dedicated clinics for chronic conditions, each being tailored to the local situation where chronic patients had been seen in acute care clinics and had received insufficient attention. Other components of the intervention are shown in Table The additional intervention consisted of facilitating system change, developing decision making aids, educational activities, and a self-management program. The facilitators had well defined roles and were rotating periodically to review the system of implementation depending on the perceived needs or requests of individual health centers. One facilitator (HA&TA) in charge of health education visited the health centers on a fortnightly basis to monitor patient flow and educate the nurses on various aspects of care including the measurement of waist circumference and the calculation of BMI. She also helped the nurses with patient education on such topics as dietetics and foot care. All patients were provided with "self management cards" which they were encouraged to take to each consultation. Another facilitator (SZ) monitored the overall system including the booking of patients and appointment attendance rates. The medical record facilitator (SZ&FA) reviewed the charts for the forms and the chronic diseases register, and conducted the patient satisfaction surveys.Decision making support tools were provided including color coded forms . These included reminders of care guidelines. The Clinical Practice Guidelines were reviewed and adapted by a local multidisciplinary guidelines group comprising general practitioners, family physicians, nurses and pharmacists, from the centers. Guidelines were modified from ATP III  for dyslICSI and NICE  for DiabIn addition, workshops for nurses and many CME sessions for doctors were devoted to Diabetes, Hypertension, dyslipidemias, and the assessment and management of cardiovascular risk.In order to address the problems with time allotment, daily appointment based clinics were instigated in all larger centers to manage patients with diabetes and hypertension.They were staffed by dedicated nurse and doctor.In the medium sized centers, with lower patient flow, patients were seen in-between other patients, but with appointments distributed throughout the days of the week for better time management. A telephone visit reminder system was introduced in order to decrease the non-attendance rate.Over the same period access was improved to both drugs and laboratory investigations.Centers without their own laboratory were provided with phlebotomist services to obviate the need for referring patients to the central laboratory. Finally, self management was promoted by means of hand held booklets that included all relevant patient data, space for communication with hospital based specialists, as well as self-management measures agreed upon between doctor and patient. Diabetes patients were issued free blood glucose monitoring devices for home monitoring.Stage III: After the success of the intervention in the pilot center the intervention was expanded to all other city centers. One of the elements learned in the pilot phase and implemented in all centers was how to spread all recommended care over several visits and how to use this to adjust medication. Nurses were involved in ensuring that required investigations were performed prior to the consultationStage IV: Maintenance and intervention review. Since the initial intervention an annual audit of diabetes and hypertension care has been conducted in all centers.Changes in standards of care were tracked by chart audits.The first audit in July 2004 perused 672 files, then after the implementation of the project in the pilot center in 2005 164 files were audited. The audit checklist included information on the process and outcome of care as per guideline recommendations, such as treatments prescribed, documentation of family history, smoking and physical activity, recording of blood pressure, BMI and waist circumference in physical examination and investigations ordered - ECG, Creatinine, HbA1C, lipid profile, and TSH. The auditing was conducted by specially selected nurses temporarily made available by participating health centers.In 2007 information was extracted from 1402 files. For all patients measures were recorded both before (2006) and after (2007) the intervention. This was repeated in 2008 (715 files). In 2008 three centers were not audited for organizational reasons, and the pilot center was neither audited in 2006 nor in 2008. In order to determine the effect of the intervention the 2008 audit included the same patients audited in 2007, as well as a sample of new patients for comparison. The number of records audited was determined by the size of the center. For large centers a total of around 100, and for medium size centers 60-80 patients was targeted. The attendances for large, medium and small centers are 250-300, 150-200 and 100-150 patients per day respectively.The chronic disease clinics attracted around 3000 patients per month in the ten centers. Data are not available to determine how many diabetic or hypertensive patients are registered at each center. Although registers are available and each patient has a unique "disease specific identifier" (e.g DM91) in these registers, we still found deficiencies and duplications in the registers. In order to avoid problem with sampling from these imperfect registries, a sample was extracted instead from the appointment books of patients attending in the three month period prior to the audit.Satisfaction of patients about the project was sought through annual interviews. Staff satisfaction was monitored by a constant feedback from the health care professionals to the implementation team. Comments on feasibility and problems associated with the project were elicited during face-to-face interviews by facilitators during regular (more than once weekly) visits to the centres.To compare indicators before and after implementation, standard paired and independent sample t-tests were used where appropriate. SPSS (v 15) was used for all comparisons.In the patient flow analysis, an obvious mismatch of demands and supply of services was detected . DespitIn the parallel prevalence study  a prevalOutcome: With the structured care intervention piloted in 2005-2006 measures of quality of care were constantly improving. This started with a correction in the management of patient flows. This was improved by moving patients with identified specialized needs of care such as antenatal care, well baby care, and chronic diseases to special, appointments based, clinics Figure . Thus, aIn the ongoing post-intervention audits indicators of process and outcome of care showed significant improvements Tables, , 6 and 7Also, the recording of BMI improved substantially from 2.2% in 2004 to 95.1% in 2007. Most likely only apparently obese patients had their BMI recorded in 2004 as around 70% of them had BMIs above 30 kg/m2.Adherence to Clinical Practice Guidelines adopted by the project, Table  regardinWith regards to outcome, neither smoking cessation nor BMI were much affected by the intervention. Smoking dropped from 16.4% in 2004 to around 13% in subsequent years while obesity was consistently prevalent in approximately 50% of patients  is neither 'frequently nor easily obtained' , this arOphthalmology referrals improved from 5.5% in 2004 to 50.8% in 2007, but decreased to 31.3% in 2008. This decrease may be due to doctors' loss of adherence to recommended care or due to patients' reluctance to accept long hospital waiting times. Better coordination of care with local hospitals in important areas, such as ophthalmology and nephrology, clearly needs improvement.Unfortunately, our interventions were less successful in redressing life-style related risk factors, such as obesity, physical inactivity and smoking. These domains may need more time and resources, with perhaps a different type of intervention . A deficThe increase in diagnoses of diabetes and hypertension in recent years could be due to various factors, such as a change in cut-off values, intensified screening, as well as a true increase in prevalence. Strategies used in this project, with an organized system of regular follow-up and the use of dedicated clinics  significCollaboration with health care staff working in the centers is key to success. While some aspects of the intervention may be experienced as stressful, we found that many were particularly content with the dedicated clinics, but a full analysis of their experiences remains to be done. Other important elements of this project were chart reminders and educational meetings which were shown to be effective, but only in combination with other strategies ,36 sinceOur findings also have relevance for other Gulf countries as many resemble the UAE in their high cardiovascular risk profile as well as their health care system. In addition, our approach may be extended to the management of other chronic conditions. Yet each intervention may need to be piloted separately, as a major limitation of our study was its confinement to a single city in one country, and with a single project management throughout, makings it difficult to generalize to other places and circumstances.Nevertheless, a major lesson to be learnt from this experience is the value of a single centrally coordinated primary health care system in this city, which facilitated the project and made it a relatively cost effective intervention. This is more obvious if we compare this project to a similar project implemented in the United States targeting the care of chronic diseases on the basis of payment for performance . FinanciSustainability of the improvements is a major concern. Inevitably, changes in the organization that affect the program occur. Early in 2008 three centers were moved to another managing body and in July 2008 the other centers of the department of Primary Health Care were brought under new administration. "Old" projects such as our intervention were allocated a low priority. Also we lost one of the facilitators. In spite of these two factors, decreased administrative endorsement and loss of the facilitator, the program was successfully maintained by the centers' staff. Yet, Tables We believe that because the project was initiated internally with no external intervention  gave a sense of ownership among centers, probably facilitating sustainability.However, for further improvements, e.g. for diabetics with hypertension, managing nephropathy, self-management of life-style factors, shared care with the hospital, optimizing dyslipidemia management etc., and additional components still to be developed, should be added to the project.The limitation of this study is mainly its descriptive nature and that it compares after to before the intervention rather than being a factorial randomised controlled study. This makes it difficult to attribute the success of the project to specific components and reduces its external validity.We believe that awareness of the problem of diabetes and hypertension in our community, and the clear need to have special organized care for this group of patients in the health care system, may have facilitated the uptake and sustainability of the project. But awareness is not sufficient, since without the other project components - specifically the dedicated personnel and clinics - the intervention would not have been maintained.The authors declare that they have no competing interests.LMB: Coordinated the project and wrote MS, AIS: Member in project working group,TAA: Member in project working group, LAM: Member in project working group, MHK: Member in project working group, TAA: Project Facilitator and Member in project working group, NJDN: Statistical advice and contributed to MS writing, AMA: Member in project working group, NMA: Member in project working group, SMZ: Project Facilitator and Member in project working group, TMJ: Member in project working group, AME: Member in project working group, ADR: Member in project working group, AIA: Member in project working group, FAN: Member in project working group, HOA: Project Facilitator and Member in project working group, MKN: Member in project working group, RA: Member in project working group, YOZ: Member in project working group, AOO: Project Facilitator and Member in project working group. All Authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/47/prepub


An integrated and comprehensive hospital/community based health programme is presented, aimed at reducing maternal and child mortality and morbidity. It is run as part of a general programme of health care at a rural hospital situated in northern Tanzania. The purpose was through using research and statistics from the programme area, to illustrate how a hospital-based programme with a vision of integrated healthcare may have contributed to the lower figures on mortality found in the area. Such an approach may be of interest to policy makers, in relation to the global strategy that is now developed in order to meet the MDGs 4 and 5.The hospital provides reproductive and child health services, PMTCT-plus, comprehensive emergency obstetric care, ambulance, radio and transport services, paediatric care, an HIV/AIDS programme, and a generalised healthcare service to a population of approximately 500 000.We describe these services and their potential contribution to the reduction of the maternal and neonatal mortality ratios in the study area. Several studies from this area have showed a lower maternal mortality and neonatal mortality ratio compared to other studies from Tanzania and the national estimates. Many donor-funded programmes focusing on maternal and child health are vertical in their framework. However, the hospital, being the dominant supplier of health services in its catchment area, has maintained a horizontal approach through a comprehensive care programme. The total cost of the comprehensive hospital programme described is 3.2 million USD per year, corresponding to 6.4 USD per capita.Considering the relatively low cost of a comprehensive hospital programme including outreach services and the lower mortality ratios found in the catchment area of the hospital, we argue that donor funds should be used for supporting horizontal programmes aimed at comprehensive healthcare services. Through a strengthening of the collaboration between government and voluntary agency facilities, with clinical, preventive and managerial capabilities of the health facilities, the programmes will have a more sustainable impact and will achieve greater progress in the reduction of maternal and neonatal mortality, as opposed to vertical and segregated programmes that currently are commonly adopted for averting maternal and child deaths. Thus, we conclude that horizontal and comprehensive services of the type described in this article should be considered as a prerequisite for sustainable health care delivery at all policy and decision-making levels of the local, national and international health care delivery pyramid. Mortality and morbidity linked to pregnancy and childbirth have been drastically reduced in most high-income countries. Maternal mortality is one of the indicators showing the greatest disparity between high- and lower-income countries, with the proportion of maternal deaths in women of reproductive age being 0.7% in established market economies as opposed to 29.1% in Sub-Saharan Africa ..29].Concerning the issue of skilled birth attendance, Olsen et al.  found 57The hospital has an extensive reproductive and child health service which covers large parts of the catchment area. Through this RCHS programme, women are advised to come to the hospital for delivery. Deliveries have been free of charge, but extra expenses such as operative procedures and medical treatment have not been free. However, the extra costs have been strongly subsidised by the hospital during the whole time scope of the programme, in order to make them affordable. The ambulance service has given first priority to delivering women on a 24-hour basis. From 2008, after having received grants from the Royal Norwegian Embassy for an MDG 4 and 5 programme, all ambulance services for delivering women and all costs related to delivery, including extra expenses, are free, in order to mobilise use of skilled attendance at birth in accordance with the aims of the MDGs 4 and 5. In addition, HLH has a nursing and midwifery school at diploma level. We believe these factors encouraging women to come for skilled attendance at birth may contribute to the lower perinatal, neonatal and maternal death rates found at HLH and in the HLH catchment area.No patient needs to pay before service is given. The costs are calculated at discharge, and at that point in time personal financial constraints are taken into consideration.There are no official figures on the use of traditional birth attendants (TBA) for the catchment area. The RCHS coordinator at the hospital has contact with the TBAs regularly in order to improve collaboration and referral to the hospital when complications arise. Previously, training of TBAs was a national policy, and HLH participated in this training. This has been abandoned as an international strategy, and thus also as a national strategy. Using the figures from Olsen et al.'s  study ofIn 2006 there were 19 maternal deaths at the hospital. Of these, two were direct while 17 were indirect . From anOne unique feature of the emergency obstetric programme in this area is the ambulance service. The hospital has two 4-wheel drive vehicles, and in the 1990s approximately 200 kilometres of all-season feeder roads were built out to the villages. Each village has a contract with the hospital to maintain the roads, using the local community. The hospital will supply the machinery needed, while the villages supply the man power. If a village does not repair the roads, it will not receive ambulance or mother-and-child health services. Thus, the village leaders are under pressure from the community to maintain the roads. Each village also has a 24-hour solar-cell run Very High Frequency (VHF) radio placed in the homes of trusted families, with the hospital radio being in the reception where staff is available to respond on a 24-hour basis. Maternal cases are given first priority. In spite of heavy rains and at times nearly impassable roads, the ambulances are almost continuously on the road.The programme follows national guidelines using the "Focused Antenatal Care" package recommended by the World Health Organization as standard, as well as the standard vaccination and assessment guidelines for children . The womA total of 28113 mothers and 83007 children were registered in 2006 from all 28 HLH-run RCHS clinics in the catchment area  and treatment for opportunistic infections. A follow-up system involving the RCHS, the PMTCT registry, the maternity ward, the care and treatment centre (CTC) for HIV/AIDS and the community home-based care counsellors (CHBCs) has recently been introduced in order to increase the uptake and adherence of both pregnant and lactating mothers to the HAART programme. In 2007, in the maternity ward, the hospital introduced provider-initiated counselling and testing with the opt-out strategy to all delivering mothers, in order to include more HIV positive mothers in the PMTCT programme.The child is tested for HIV at 6, 12 and 18 months. The women and children are monitored with hospital and home visits by both the staff at the CTC and allocated CHBCs throughout pregnancy, lactation and until 18 months after delivery. Mothers are counselled on infant feeding options. Exclusive breastfeeding is encouraged more than replacement feeding, and mothers are provided with free food and milk aid according to their needs. In order to succeed with abrupt cessation of breastfeeding, the CTC and CHBC staffs follow up the mother closely around the date set for cessation. Social, nutritional and milk support is offered in order to ensure a safe transition. Those living close to the hospital receive milk from the HLH dairy cows, and those living further away are given financial support in order to ensure milk for the baby.The mothers are given HAART until certain weaning has taken place, and should the staff be in doubt this is extended until 18 months after delivery when the child is tested the final time. Should the mother need HAART further for her own sake, its provision is continued.In 2005, in the catchment area, 12 749 women were tested in the PMTCT/RCHS clinic sites. Of these, 52 women were found to be HIV positive, and 26 (50%) of these were enrolled in the HAART programme . In 2006During the last two years of programme implementation the HIV services have been integrated from a vertical programme into normal hospital activities, largely through the RCHS, maternity and medical departments. This involves assigning the personnel regular working hours and salaries instead of using an allowance system. The allowance system paid per service rendered or per day of outreach or other type of work was more expensive than a system of regulated salaries. Furthermore, transport and activity costs and routines are planned in conjunction with the rest of the services provided. More importantly, the integration secures unified planning and reporting using the same internal control system. It also ensures a coordinated use, remuneration, motivation and training of staff, a unified organisational culture and improved interaction and synergies between departments and within the management structure. Currently PMTCT, VCT, RCHS and CTC services are coordinated with regards to all these aspects of quality and management issues.The total programme costs for the hospital, including all preventive and clinical care services and training, amount to approximately 3.2 million United States Dollars (USD) per year. Only 15–20 percent of the hospital income comes from patient fees, which are heavily subsidised at the outset. Approximately 6–7% of the budget is financed by grants from the Tanzanian government, and the remaining funds are covered by donors  and gifts. One of the main contributors to poor patients being able to use the hospital is the fact that no payment is required for any service until discharge. This includes clinical as well as ambulance services, thus ensuring rapid help for the patients. If the patient has problems paying at discharge, the social worker at the hospital contacts village leaders in the patient's home village requesting information on the patient's economic situation. If they confirm the patient's situation, the debt is written off as exempted debt. In this manner, no matter what their income, all patients receive medical care. The exempted debt varies from year to year  according to harvest and rain conditions.Education is an important aspect of improvement of maternal and perinatal health . In the In a recent study published on risk factors for maternal death from the HLH catchment area, 70% of both women and men in the study had between 1–7 years of formal education . In thisThe HLH has always recognised how important education is for the survival of the mothers and their babies. Thus, from the early 1960's until the present time, the hospital has contributed substantially to building of primary and secondary schools in the whole wider catchment area. A secondary upgrading school functioned for approximately 10 years in the 1990's in order to assist staff and students to pass the national form four exams. Further, since 1983 the hospital has had a nursing and midwifery school, first at certificate level, and since upgraded into diploma level, producing 20 new nurse-midwives per year. HLH is currently planning to build a vocational training school for the area. Apart from formal education, HLH has since the early 1970's had an extensive RCHS work, with an outreach programme covering remote rural villages in a range up to 100 kilometres from the hospital. Every session has an hour's education on health related issues for the women attending, as described earlier. From 2003, 74 villages are reached by the HIV preventive work, where one offers VCT and educational sessions on HIV, sexually transmitted diseases (STDs) and general pregnancy, delivery and health related issues.This article describes a comprehensive programme of integrated preventive and clinical care services related to maternal and child health outcomes in a low-income, rural setting. We wished to use all available research and statistical reports to illustrate the HLH programme and its focus on maternal and neo/perinatal health over several decades in relation to the current focus on MDG 4 and 5. Further, our intent was to illustrate how the HLH programme has had a vision of integrated healthcare that may have contributed to the lower figures on mortality found in this area. We think that this integrated approach may be of interest to policy makers, in that HLH has done in practice over many decades what is now being set forward as an acknowledged global strategy in order to meet the MDG 4 and 5 goals.These outcomes are particularly related to the trust of the population. The estimates from the programme area show low levels of maternal and neonatal mortality compared to those from national figures provided by national estimates from Tanzania and other studies figures  2-10,2525-27.Furthermore, table As described in the programme setting section, the HLH has an extensive collaboration with the regional and district health authorities and the other government and voluntary agency run health facilities in the catchment area., especially on the outreach programmes mentioned earlier. A greater understanding of the needs and level of care of each facility has been reached. This extensive collaboration, in the authors' view, may contribute to the positive developments seen in this area in relation to maternal and perinatal health.Although the HLH is represented in the DHMTs, it has been difficult to gain equitable access to the ten percent of the Basket fund due to several reasons. In addition to the fact that district authorities have interpreted the policies such that voluntary agencies have only received the ten per cent of the funds remaining as "unallocated" in the guidelines, the fund covers all government and voluntary agency facilities in the district, thus allocating funds regardless of the extent of services rendered. Thus, a small dispensary may be allocated the same as the hospital, which covers a much broader range of services. In addition, the HLH catchment area covers three districts, with services such as RCHS, VCT, IEC, PMTCT, ITN, IPT, and EPI, including patients from a wider area. In addition, patients from all these districts come to the hospital for curative services. The HLH only receives basket funding from the Mbulu District (in terms of funds), where it is located geographically, and Hanang District , even though the health and government authorities acknowledge and politically appreciate the hospital and outreach services covering all the 7 neighbouring districts.The hospital is, as all the other health facilities in the area, also affected by the potential weaknesses of the system on the national level. Funding from the Ministry of Health through the established funding mechanisms (bed and staff grants) and allocation of trained staff is very low. Further, there is a constant shortage of testing kits and drugs for HIV, tuberculosis, sexually transmitted diseases, the diseases to be tested and treated in the focused antenatal care, IPT, ITN and vaccine programmes. All RCHS and PMTCT related services are free of charge following national pricing guidelines. The hospital is required to cover these shortages of drugs and equipment through its own funding mechanisms, thus providing these free services to the population through funds generated elsewhere.There are some important characteristics and challenges common to the provision of comprehensive services. The services need to attain a minimum level of quality. In a previously published article it has been discussed and shown that it is important to focus on critical levels of quality rather than on quantity of services . Given tHistorically, there have been some dichotomies which have contributed to unintended conflicts of interest. Donor and government agencies, as well as national governments, have at times ended up setting maternal health against child health, short-term vertical programmes against long-term commitments with integrated programmes, community care against clinical care  and goveBy ensuring a continuum of care, and integrating preventive and clinical care services with the general health services, we believe trust will develop between the communities and the healthcare services. The issue of trust may be illustrated by the influx of women from outside the catchment area into the antenatal clinics (ANC) supervised by HLH, giving an ANC attendance of 128% in 1996  or the equivalent, and can therefore not be used as a measure against the recommended USD 50 per DALY for approval of an intervention, it could usefully be compared with larger healthcare costs where countries such as Tanzania have made available USD 7 of government expenditure on health per capita . We woulIn this programme, the focus has been on guaranteeing a long-term commitment to both maternal and perinatal/neonatal care through well-functioning comprehensive general care with emergency obstetric care services provided at a hospital, with a close collaboration with all lower level health facilities (both government and other voluntary agencies (VAs)) in the area, while at the same time ensuring well organised preventive services within both antenatal care and PMTCT-plus. We believe that a holistic approach is necessary to establish a sense of trust in the population. The programme is in a rural area of Tanzania, where the majority of the population is poor. This type of setting is common to many areas of Africa. We think that this approach would be feasible in many settings similar to this area. However, this holistic approach needs the commitment of governments and donors to facilitate the long-term strategic planning involved. The importance of this comprehensive approach needs to be emphasised at both the planning and the funding levels. Although intuitively correct for both patient and provider, it is not always easy to convince planners and funding agencies. It is a greater challenge to fund and secure a comprehensive health programme such as that described here than to fund and implement a simpler vertical programme with a limited scope and time-span. However, the tendency to simplify and focus is not conducive to securing the trust and commitment to the programme from the beneficiaries . FurtherA final challenge worth discussing is the need for a global and national acceptance for the concepts related to integrated and comprehensive healthcare services in the quest to reduce maternal and child mortality and morbidity. Reich and colleagues discuss how donors have focused on disease-specific programmes and performance measures, leading to a fragmented array of uncoordinated programmes. These programmes have depended on a functioning health system as a foundation on which to build their programmes, often without supporting the underlying health systems. Thus, these programmes have at times not fully dealt with the broader system failures. These failures may lie behind the inadequate progress of many countries on key targets such as MDGs 4, 5 and 6 .Although there is an increased focus on the effect of fragmented services on health systems, there is still insufficient emphasis on the need to provide comprehensive services at a minimum quality level to populations in low-income countries. Unless this becomes the main objective of global and national policies, as it is in most high- and middle-income countries, there is little reason to believe that a sustained reduction of maternal and child mortality can be achieved. There are many important value questions relevant to this concept, of which the basic right to health services is an important one. Mothers are sensitive to these values, and may not be persuaded into a sustained use of pregnancy and delivery services if their wider needs for healthcare are not also met.In summary, we have reported from a wide-ranging, comprehensive and integrated intervention programme aimed at providing for as many as possible of the most pressing healthcare needs and demands of a predominantly poor population in a rural setting in a low-income country. We believe the relatively low rates of maternal, perinatal and neonatal deaths in the area may be attributed to long-term access to comprehensive health services. Further, we believe a close collaboration between government and voluntary agency facilities, especially in outreach programmes aimed at maternal and perinatal health, is essential in order to cover rural areas with adequate services.Such a programme increases trust and legitimacy, and thus also improves the effects of the maternal and child health interventions. We have learned some lessons from our setting. On a national and international level, the solution from our point of view could be to coordinate donor and national funding, training, implementation and monitoring issues to support comprehensive care through all health facilities in rural and semi-rural areas, rather than creating a division between government and voluntary agency facilities. The priority setting mechanisms must be based on the values of the beneficiaries to secure trust, with an integrated approach. This means ensuring that the facilities and care providers have a unified internal control system , quality assurance procedures, remuneration and human resource policies that contribute to a productive and motivating organisational culture across all facilities. This should be considered as a prerequisite for sustainable health care delivery and coordination must be done at all levels of the local, national and international health care pyramid. The programme described may hopefully provide helpful insight to public health experts and policy makers.AIDS: Acquired Immuno Deficiency Syndrome; AMO: Assistant Medical Officer; ANC: Antenatal Clinic; BEmOC: Basic Emergency Obstetric Care; CEmOC: Comprehensive Emergency Obstetric Care; CHBC: Community Home Based Care Counsellor; CO: Clinical Officer; CSSC: Christian Social Services Commission; CTC: Care and Treatment Centre; DALY: Disability Adjusted Life Year; DHMT: District Health Management Team; DHS: Demographic Health Survey; EmOC: Emergency Obstetric Care; EPI: Expanded Programme of Immunization; HAART: Highly Active Antiretroviral Therapy; HIV: Human Immunodeficiency Virus; HLH: Haydom Lutheran Hospital; ICD-10: International Classification of Diseases, version 10; IPT: Intermittent Presumptive Treatment; ITN: Insecticide Treated Nets; MDG: Millennium Development Goals; MMR: Maternal Mortality Ratio; MO: Medical Officer; NMR: Neonatal Mortality Ratio; PMR: Perinatal Mortality Ratio; PMTCT: Prevention of Mother to Child Transmission (used in relation to HIV); RCHS: Reproductive and Child Health Services; STD: Sexually Transmitted Disease; TBA: Traditional Birth Attendant; USD: United States Dollars; VA: Voluntary Agency; VCT: Voluntary Counselling and Testing; VHF: Very High Frequency (pertaining to radio systems); WHO: World Health Organization.The authors declare that they have no competing interests.BE-O took the initiative to write the article, participated in the discussion on the concept and approach of the manuscript, the analysis of the available data, and the writing of the manuscript. ØEO participated in the initiative to write the article, the discussion on the concept and approach of the manuscript, the analysis of the available data, and the writing of the manuscript. GK participated in the initiative to write the article, the discussion on the concept and approach of the manuscript, and the writing of the manuscript. All authors read and approved the final manuscript.


Reviews find a likely adverse effect of air pollution on perinatal outcomes, but variation of findings hinders the ability to incorporate the research into policy. The International Collaboration on Air Pollution and Pregnancy Outcomes (ICAPPO) was formed to better understand relationships between air pollution and adverse birth outcomes through standardized parallel analyses in datasets from different countries. A planning group with 10 members from 6 countries was formed to coordinate the project. Collaboration participants have datasets with air pollution values and birth outcomes. Eighteen research groups with data for approximately 20 locations in Asia, Australia, Europe, North America, and South America are participating, with most participating in an initial pilot study. Datasets generally cover the 1990s. Number of births is generally in the hundreds of thousands, but ranges from around 1,000 to about one million. Almost all participants have some measure of particulate matter, and most have ozone, nitrogen dioxide, sulfur dioxide and carbon monoxide. Strong enthusiasm for participating and a geographically-diverse range of participants should lead to understanding uncertainties about the role of air pollution in perinatal outcomes and provide decision-makers with better tools to account for pregnancy outcomes in air pollution policies. TheseTwo international workshops of experts in air pollution and pregnancy outcomes were held in 2007, in Munich, Germany and Mexico City, Mexico, in which the strengths and limitations of the existing literature were discussed. Although identifying the limitations most likely to play a role in the existing literature is a complex task, the workshops identified confounding and exposure misclassification as points of particular concern . One of A focused research effort is critical in reproductive health as outdoor air pollution is an increasingly important global health hazard, with growing industry and vehicle use in many parts of the world and with potential impacts on vulnerable populations, such as the developing fetus. Thus, there is a growing focus on the reproductive implications of air pollution in many areas of the world, as demonstrated by the European Environment and Health Strategy development of the Children’s Environment and Health Action Plan for Europe (CEHAPE) . FurtherThe International Collaboration on Air Pollution and Pregnancy Outcomes (ICAPPO), was formed, based on a recommendation from the Mexico City workshop , to deveA third international workshop was held in 2008 in Pasadena, USA, to propose a way forward for ICAPPO. This workshop included planning for a collaborative pilot study and discussing epidemiologic methods, particularly those that can be applied in different settings, for collaborative analyses. A fourth workshop was held in 2009 in Dublin, Ireland to hone the study’s aims and discuss future directions.This paper describes the formation of the ICAPPO, identifies and lists its aims, and reviews the participating study locations, including study design, exposure metrics, and available outcome and covariate information.2.2.1.The ICAPPO was established to coordinate an international effort toward understanding how much differences in methodology contribute to variation in study findings. Most ICAPPO participants are researchers in the field of air pollution and pregnancy outcomes who already have datasets that link maternal exposure to air pollution with pregnancy outcomes; many of these participants have published previous papers on this topic, which comprise the major papers in the field. Other ICAPPO participants do not have an existing data source available but have expressed an interest in participating. While many ICAPPO participants are those actively involved in the research goals of this project, other researchers have provided significant contributions to the overall aims of the ICAPPO through their insights during the workshops. Currently, participation is an open process and there are no dataset criteria to participate. We identified possible participants based on publications in the peer-reviewed literature and recommendations from other researchers.The primary aim of ICAPPO is data re-analysis, so participants are asked to reanalyze or recalculate data in certain ways, we are not asking for new data collection or new variables. Participation in the ICAPPO does not in any way hinder researchers’ ability to conduct other studies with their datasets.prhe@obgyn.ucsf.edu.As part of the collaboration, we have facilitated collecting information about the eligible datasets, primarily through review and posting on a wiki hosted as part of ICAPPO. This information has been and will be used to guide protocols for re-analysis which can take advantage of the common features and distinctions of the existing data. Participants all have access to the wiki, and other researchers who are interested in the topic can also have access by emailing 2.2.The first step for the ICAPPO was to collect information on the data attributes from each of the study locations with respect to the availability of variables, timeframe, study location, and other factors. Participants were asked to provide the following information: location, available air pollutants, study period, number of births included in the study (or number of study subjects), and covariates available . Mostly these datasets have been used for previously published studies, are currently being used for ongoing studies, or both. Datasets have typically been constructed from some type of air pollution exposure metric linked to data available from routinely collected administrative records (birth certificates), birth record datasets constructed for a specific study, or to data from a pregnancy or birth cohort study. Because each dataset’s construction was tied to a variety of independent research questions unrelated to ICAPPO, there is variability in how the datasets have been or are being developed and the specifics of each study’s design. For example, many studies have used air pollution monitors to assess maternal exposures, while some studies use other methods, such as land-use regression or other modeling techniques.2.3.To evaluate whether different exposure metrics, and/or approaches used to define exposure to air pollutants, influence the relationship between air pollution and pregnancy outcomes.To identify how the consideration of covariates affects the relationship between air pollution and pregnancy outcomes. In particular, we will focus on previously identified covariates that may influence the relationship between air pollution and pregnancy outcomes; we will consider covariates measured at the individual level  and at the area level. Area-level covariates will include both socio-demographic indicators  and physical indicators including temperature, season, and co-pollutants.To investigate methods for considering critical periods of susceptibility during pregnancy ; often exposures during these periods are correlated and decisions about which time periods to study and how to consider possible correlation may affect inferences.To identify whether season of exposure influences any observed relationships between air pollution and pregnancy outcomes.To investigate the effects of exposure to co-pollutants on the strength of the relationship between pregnancy outcomes and individual pollutants.ICAPPO participants are working together to prioritize the research questions for the analytical protocols. Research questions were identified through previous workshops (Munich and Mexico City) and were honed at workshops in Pasadena, California USA, and Dublin, Ireland. The primary areas of focus include:Although a small group of researchers from ICAPPO will develop methodological approaches for each focus area, all participants will have input into the methods. Due to the inherent differences among the datasets—for example, not all datasets have data for all pollutants or covariates of interest—not all datasets can be involved in every focus area of the project. Each location will carry out analyses for their own dataset.Results from these new analyses will be evaluated for variations, and potential reasons for the variations, in the associations between outdoor air pollution and pregnancy outcomes. Results will be evaluated across the study locations using graphical and statistical techniques for understanding variability in the findings. Our overall goal is to be able to combine the results from the parallel projects to examine factors that affect differences among the study locations and, if appropriate, to develop combined estimates of association, through meta-analysis techniques.2.4.An initial first step in the collaboration was to conduct a pilot study. The aims of the pilot study are to test the dynamics of ICAPPO, the practicalities of conducting parallel analyses across multiple sites, and the feasibility of conducting a pooled analysis. The pilot study, currently in progress, investigates the effects of exposure to PM10 during pregnancy on low birth weight  in term live births (37–42 weeks of gestation). Since an objective of the pilot study was to maximize the number of participating research groups, we chose PM10 as it was the air pollutant most often analyzed, and one birth outcome, low birth weight in term births, as this was most easily accessible by most researchers and comparable across study locations. Socioeconomic status is included as a potential confounder. A protocol for the pilot study was developed by a sub-team of ICAPPO with input from all participants, and then distributed to all participants. Parallel analyses for the pilot study have been or are being conducted by researchers in a number of different centers located across the globe. After the pilot study is completed, the results will then inform the structure of ICAPPO and the next stage in the analytical protocol.3.Currently, the ICAPPO has information from over 20 separate research groups in North America, Europe, Australia, Latin America and Asia. 10 data and 15 have PM2.5 data), and most of the study locations have measurements for other common pollutants, including ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide. To estimate exposures, some study locations use measurements from the nearest air pollution monitor, with ranges from 2 km up to 10 km, some locations use averages of measurements from multiple monitors over geopolitical units, such as counties in the United States. Other studies have metrics based on distance to traffic sources or individual exposure estimates from exposure models. A few of the study locations have additional air pollutant data, such information on hazardous air pollutants  and lead.In general, the birth years in each study location span the years of the mid 1990s to about 2005  . Most stThe available datasets primarily link pregnancy outcome data to some measurement of air pollution data. Most data on pregnancy outcomes stem from birth certificates; thus, information on the birth outcomes and related covariates is primarily based on what is available from the birth certificates in each location. Information on the key covariates available from each of the study locations is given in etc.).The availability of information on race and ethnicity varies, primarily by geographic locations; while race and ethnicity are important predictors of birth outcomes in the United States, other indices, such as immigration status or language are important factors in other countries. Many of the study locations also use one or more community level demographic or socioeconomic indicators . A few of the collaborating study locations  also have questionnaire data available in addition to birth certificate information, which can be used to evaluate the quality and analytic usefulness of the more widely available covariates . In addition, once standardized methodological approaches are applied across the datasets, our ability to compare results across locations should improve, including our ability to combine results through meta-analysis.We hypothesize that this novel collaboration combining worldwide individual research efforts into an efficient uniform design can provide sufficient important information to answer some of the critical questions in the field of air pollution and perinatal epidemiology. At a minimum, once methodologies are standardized, we will be able to identify factors that contribute to observed remaining variations among the findings from the individual study locations, many of which may be due to variations in site characteristics  and the cultural context of maternal education . While we will standardize some of these covariates across data sets, there will still remain some heterogeneity, which may contribute some bias to the interpretation.In addition, there is some variation in the type of air pollutants available for each location. All the studies have some measure of particulate matter and a reasonable coverage of common gaseous air pollutants. There should be sufficient information to carry out analyses with multiple locations; although not every location will be able to participate as each of the air pollutants are considered. Finally, there will be some challenges when evaluating questions related to geographic scope of the air pollution metrics, as those studies using air pollution monitoring data use varying geographic scales for averaging pollutant exposures. The variation in geographic resolution may be difficult to standardize among the studies, as setting up the metrics involved a number of analytical steps that may difficult to redo/alter.With ICAPPO, we take a different approach than other efforts such as the EU-funded GA2LEN and ESCAPE projects to gain insights from multiple cohorts. Within the GA2LEN study, data from individual researchers is pooled ,14. As p5.ICAPPO will provide important information about the relationship between air pollution and pregnancy outcomes and improve our ability to compare results across numerous geographic locations and studies. It should also greatly enhance our understanding of the effects of air pollution on pregnancy outcomes and motivate focused research questions in the field, such as biological mechanisms that link exposure to specific outcomes. It will also strengthen efforts in individual countries to understand and ultimately mitigate harmful effects from air pollution, by enhancing understanding of their individual place-based study results in the context of comparable results from other study locations around the world. Finally, it will create a network of researchers working across the globe on environmental and pregnancy outcomes generally, which will leverage other opportunities to evaluate how the environment can influence birth outcomes, and ultimately lead to insights that will inform activities to prevent harmful exposures and improve the health of children worldwide.


Taiwan's National Health Insurance (NHI), implemented in 1995, substantially increased the number of health care facilities that can deliver free prenatal care. Because of the increase in such facilities, it is usually assumed that women would have more choices regarding prenatal care facilities and thus experience reduction in travel cost. Nevertheless, there has been no research exploring these issues in the literature. This study compares how Taiwan's NHI program may have influenced choice of prenatal care facility and perception regarding convenience in transportation for obtaining such care for women in rural and non-rural areas in Taiwan.Based on data collected by a national survey conducted by Taiwan's National Health Research Institutes (NHRI) in 2000, we tried to compare how women chose prenatal care facility before and after Taiwan's National Health Insurance program was implemented. Basing our analysis on how women answered questionnaire items regarding "the type of major health care facility used and convenience of transportation to and from prenatal care facility," we investigated whether there were disparities in how women in rural and non-rural areas chose prenatal care facilities and felt about the transportation, and whether the NHI had different influences for the two groups of women.After NHI, women in rural areas were more likely than before to choose large hospitals for prenatal care services. For women in rural areas, the relative probability of choosing large hospitals to choosing non-hospital settings in 1998–1999 was about 6.54 times of that in 1990–1992. In contrast, no such change was found in women in non-rural areas. For a woman in a non-rural area, she was significantly more likely to perceive the transportation to and from prenatal care facilities to be very convenient between 1998 and 1999 than in the period between 1990 and 1992. No such improvement was found for women in rural areas.We concluded that women in rural areas were more likely to seek prenatal care in large hospitals, but were not more likely to perceive very convenient transportation to and from prenatal care facilities in the late 1990s than in the early 1990s. In contrast, women in non-rural areas did not have a stronger tendency to seek prenatal care in large hospitals in the late 1990s than in earlier periods. In addition, they did perceive an improvement in transportation for acquiring prenatal care in the late 1990s. More efforts should be made to reduce these disparities. Although there is some dispute over how prenatal care can improve child health, its potential in this regard is well recognized -3. It isLevel of utilization of prenatal care has been associated with age, marital status, educational level, occupation, income, higher parity, difficulties in dealing with health service organizations, and health insurance status -10. It hLiterature specifically discussing the effect of public health insurance on prenatal care utilization is quite limited. Some studies have found that it has a positive effect. Griffin et al. (1999), comparing enrollees of a Medicaid managed care program in Rhode Island and their counterparts with private insurance, concluded that the implementation of the Medicaid program resulted in significant improvement in adequacy of prenatal care utilization . Chen etResults from another study using data from the same Taiwanese cross-sectional surveys showed that Taiwanese women were more likely to receive adequate prenatal care in 1996, one year after the launch of the NHI, than in 1989 . HoweverSince it established its national health insurance program in 1995, Taiwan has stopped using its public health system of community health care centres as the major vehicle of providing free prenatal care, and began to provide it through the NHI system, which allows expectant mothers to seek prenatal care from a variety of healthcare facilities. Before 1995, Taiwan already had three major types of public insurance programs covering about 57% of the population. The Labor Insurance program, launched in 1950, covered employees such as workers of government-run enterprises, private company employees, blue-collar employees and members of professional unions who were over 15 years of age and under 60 years of age. Established in 1958, the Government Employee Insurance (GEI) program, covered officers and full-time employees of government agencies, teaching and administrative staff of government-owned schools and private schools, and retirees from these organizations. In 1988, the Farmer's Insurance program extended coverage to members of farmers' associations and individual farmers who were over 15 years old. The three programs had similar benefits packages, covering outpatient visits, hospitalisation, diagnostic tests and prescription drugs. However, only the GEI program covered dependents, and offered free prenatal care to its enrolees through health care facilities that had contracts with this public health program.While GEI was the only public health insurance program to provide prenatal care before the launch of the NHI, Taiwan's government had been promoting prenatal care long before the introduction of the NHI system through its public health system of community health care centres. Before 1980, each township had its own health station. Additionally, by recruiting physicians from non-rural areas to support services in rural public health stations, Taiwan's government had strengthened the functions of these public health stations and improved health care resources in remote areas by the mid-1990s. Taiwan's public health stations played an important role in providing health care to people in rural areas. For instance, most Taiwanese people in remote areas thought that the local public health station was the health care facility most close to them . The pubTaiwan's NHI in 1995 substantially extended insurance coverage to all its citizens with an equal and comprehensive benefits package. By the end of 1995, it covered 97% of the population; by 1998, the coverage was over 99%. Since 1995, Taiwan's government has been providing ten free prenatal care visits to each pregnant woman in Taiwan through the NHI delivery system. Almost all hospitals and over 90% of clinics have contracts with the NHI program, and this has substantially expanded women's choice of health care facilities from which they can seek prenatal care. Because of the increase in facilities, it would seem natural that the NHI may substantially reduce the travelling costs for seeking prenatal care. Nevertheless, physician and health facility registration data in the NHI database show that the density of gynaecologists and obstetricians and that of health care facilities providing gynaecologic and the obstetric care were a lot lower in rural areas than non-rural areas, suggesting that the NHI could substantially expand women's prenatal health care choices only in non-rural areas.There has not been much research on the effect of public health insurance on utilization patterns of prenatal care. What little there is has focused on the number of prenatal care visits made and when they are made. This study compares the differences in how women in rural and non-rural areas chose prenatal care facilities before and after the implementation of the NHI. To do this, we analysed women's responses to a national survey in Taiwan. We focused on their replies to questions about "the type of major health care facility used," and "the convenience of transportation to and from prenatal care facility." We compared the difference in how they answered these questions for children born before and after the implementation of the NHI.The first indicator was chosen because it can be related to quality of care. Although many people tend to believe that health care delivered in large hospitals, which are usually better equipped, is better than that provided by clinics, some studies in Taiwan have suggested that one would be more likely to get more adequate prenatal care in a clinic than in a large hospital ,10. The Results obtained by this investigation may help set future directions of prenatal care provision in Taiwan, and may also be used by countries hoping to improve prenatal care delivery. In particular, Taiwan's case offers a unique opportunity to study the influences of national health insurance on women's choice of prenatal care facility in a situation in which they were once able to receive it free at designated public health facilities but now can seek it in any facility they want to go to as long as it has a contractual agreement with the Bureau of National Health Insurance. Other countries may also face such policy options in the future. Therefore, Taiwan's lesson can be useful to them.We wanted to know whether Taiwan's National Health Insurance influenced the aforementioned indicators differently in rural and non-rural areas. We examined what disparities existed in these indicators between women in rural and non-rural areas in various periods before and after the NHI was launched. Specifically, we selected two periods before NHI, which were the early 1990 to 1992 and 1993 to the early 1995, and two periods after NHI, which were 1996 to 1997, and 1998 to 1999.This study used second-hand data. The data were collected retrospectively from a national face-to-face interview survey conducted by Taiwan's National Health Research Institutes in the latter half of 2000. This national survey, which was for investigating child health and related health care utilization, collected data for two national representative samples – one for children born between March 1 of 1995 and February 28 of 1996 , and the other for children born between March 1 of 1996 and February 28 of 1999 . The survey was administered to the caregivers of these children. The respondents were also asked to report information for these children's siblings born on or after March 1 of 1990. Therefore, the database of this survey included records for children born between 1990 and 2000. The response rate was 76%, with over 98% of the respondents being the children's mothers. In total, the survey collected data for 7,817 children in 3,934 families.For each child, the survey data include the child's and the mother's demographic background, the socioeconomic conditions of the family, the child's location of residence, and childcare and health care utilization for the child. Regarding the choice of prenatal care facility, the mother was asked to reply the following question: "What was the name of your major health care facility for acquiring prenatal care during this pregnancy, and in which township was this facility located?" Based on information collected by this question, the interviewer subsequently recorded the type of the health care facility referring to a corresponding database constructed by Taiwan's Department of Health. The mother was further asked to evaluate her perceived convenience of transportation to and from this health care facility, by the following question: "Was it convenient for you to go to this prenatal care facility?" The corresponding responses were "very inconvenient," "somewhat inconvenient," "moderate," "convenient," and "very convenient."We extracted data from this database for our study based on the following criteria. First, we excluded records reported by caregivers other than the mothers. Second, we excluded records for children born between March 1 of 1995 and December 31 of 1995, because the mothers would be pregnant both before and after the NHI was implemented. Third, we also excluded children born in 2000, a special year in Taiwan. It was the start of the new millennium, and also the year of dragon, the preferred year for having babies for Taiwanese, especially male babies. Because this year was not a typical year in Taiwan in terms of the level of fertility as well as the obstetrical care market for years after the mid-1990s, but there were not enough children born in 2000 to form a sub-sample, we excluded cases for 2000. Fourth, we excluded children whose main caregivers in infancy were not the mothers, since we had to use information on the district where a child lived in infancy to construct a proxy variable reflecting the mother's living place during pregnancy. Fifth, we excluded children whose mothers were covered by the GEI during pregnancy, since women with the GEI were a special group with public insurance covering prenatal care in the pre-NHI period.We were left with 4,820 children after these selection processes. Within these cases, 1,575 were children from mothers who contributed one record each to these 4,820 cases, and the other 3,245 cases were children from mothers who contributed at least two records each to these 4,820 cases. This paper reports results based on data for the 1,575 children, out of a concern regarding correlation among multiple cases from a same woman. While our analytical sample did not end up being a nationally representative sample for children born in these years, it should still be appropriate for this present study, as the focus of this study is based on multivariate statistical analysis, and a rich set of explanatory variables were included in its estimation.Unfortunately, we did not have a sufficiently large sample size to compare the experiences of prenatal care utilization for a specific cohort before and after the implementation of the NHI. We could only find 168 women who gave a birth between March 1 of 1990 and February 28 of 1995 and another in the period between 1998 and 1999. This prohibited us from comparing a cohort of women's behaviours before the NHI and in the late 1990s.The characteristics for the 1,575 cases are presented in Table For each cohort of children, almost all of their mothers were married in 2000. The proportion of aboriginal or foreign-born mothers was higher for children born after 1995. The proportion of mothers who immigrated to Taiwan from Mainland China was also higher for children born after 1995. This is consistent with the fact that Taiwan has more and more children who have mothers immigrating to Taiwan from Mainland China or some countries in south-eastern Asia. Women who delivered children after 1995 tended to have more education, and those delivering children in the late 1990s tended to have lower family income. This should be related to the fact that the mothers of children born after 1995 tended to be younger than the women delivering children during the pre-NHI period.Table This study defined three types of health care facilities, and four levels of the convenience of transportation. , where X is the set of all explanatory variables and b1 is the set of coefficients corresponding to the category of visiting medical centres and regional hospitals. Similarly, the relative probability of choosing small hospitals to choosing non-hospital settings is exp(X'b2), where b2 is the set of coefficients corresponding to local hospitals. The change in the relative probability from 1990–1992 to a specific later period was measured as the ratio of the relative probability for that period to the relative probability for 1990–1992. The relative probability of choosing large hospitals to choosing non-hospital settings was measured as the ratio of the probability of choosing large hospitals to the probability of choosing non-hospital settings. It is exp, together with the values of coefficients, determine the probabilities of falling in various categories of the dependent variable. We used information with respect to coefficients, thresholds and their corresponding covariance matrices to calculate the probability of perceiving very convenient transportation, and estimated the changes in the probability from 1990–1992 to the three later periods in the 1990s ,20. The We needed to select a representative case for calculating the probabilities of choosing a specific type of setting as the type of major health facility used for prenatal care and of perceiving very convenient transportation. Referring to the sample characteristics, we chose the following characteristics for such estimation: the child was male and the first child; the mother bore the child before thirty years old, had no abnormal condition during this pregnancy, and was born before 1970, and her ethnicity was Fu-Chien; she had two children, was married, and had senior high school education and an average monthly family income less than 50,000 Taiwanese dollars when she was interviewed in 2000. Based on these characteristics, we calculated the two kinds of aforementioned probabilities for each time period, and for rural and non-rural women, separately.The probability of choosing large hospitals for women in rural areas was significantly higher between 1998 and 1999 than between 1990 and 1992 Table . AccordiRegarding the changes in the probability that women would perceive transportation to be very convenient from the period between 1990 and 1992 to the three later periods in the 1990s, only the change corresponding to 1998–1999 for women in non-rural areas was statistically significant Table . These wResults from our multivariate analysis revealed there were some other factors related to the choice of prenatal care facility (detailed results available upon request). Women with abnormal health conditions were more likely to seek prenatal health care in large hospitals. Women who bore their babies between age 30 and 34, women who were born before 1970, women with higher education and higher family income were also more likely to seek prenatal care in large hospitals.In this study of Taiwanese women's choice of prenatal care facility from the early 1990s to the late 1990s, we found that women in rural areas were more likely to go to large hospitals to obtain prenatal care in the late 1990s than in the early 1990s. Moreover, women in rural areas were less likely to perceive that transportation had improved for acquiring prenatal care in the late 1990s than their counterparts in non-rural areas. Our findings suggest that more effort is necessary to help reduce the disparities between women in rural areas and those in non-rural areas.Since the launch of NHI, recruiting physicians for certain specialties has been challenging for hospitals and medical professional groups, and recruiting for gynaecologic and obstetric departments have had particularly noticeable difficulties. The NHI payment scheme has generally been regarded as a factor associated with such a problem, as gynaecologists and obstetricians complained that the payment level for them is not as good as those for many other specialists . AnotherMoreover, business has been dropping for gynaecologists and obstetricians as Taiwan's fertility rate has been dropping since the late 1990s. The total fertility rate in 1997 was 1.77, which was about the same level in the early 1990s, but it dropped to 1.56 in 1999, and further to 1.12 in 2005 . The decRegarding the type of health care facility for obtaining prenatal care, we found that women in rural areas were more likely to seek prenatal care in large hospitals in the late 1990s than earlier in the 1990s, a finding that is consistent with results from one study which showed that a large hospital in Taiwan symbolized good quality care in the 1990s . Taiwan'If women in rural areas believe that a larger size of hospital reflects better quality of health care, and choose to leave their living districts to seek prenatal care, it appears reasonable that they would prefer large hospitals rather than smaller health care facilities. The behaviour of enduring inconvenient transportation was also consistent with the finding shown in one research which reported that time cost was a factor with a low elasticity for utilizing ambulatory care in Taiwan in the 1990s . MoreoveGiven that women in rural areas were more likely to leave their living districts to acquire prenatal care in large hospitals in the late 1990s, it makes sense that women in rural areas were less likely to perceive improved convenience in transportation in the late 1990s than women in non-rural areas. Women in non-rural areas appeared to feel more convenient transportation in the 1990s than earlier in the 1990s. Since the number of health care facilities providing gynaecologic and obstetric care did not increase in the late 1990s, a possible reason for this improvement might be because of the improvements in public transportation systems in non-rural areas. For instance, Taiwan has started developing "mass rapid transit systems" in large cities since the early 1990s. Therefore, it is reasonable that there would be an increased difference in estimation of convenience of transportation to and from prenatal care facility between women in rural areas and their counterparts living in non-rural areas in the late 1990s.One more point deserving further exploration is whether choosing large hospitals for prenatal care was worth it for women. While our data could not show whether prenatal care services in large hospitals were worse than those offered in other settings, such as clinics and public health stations, some previous studies indicated that women seeking prenatal care in clinics were more likely to obtain adequate prenatal care than those seeking such care in hospitals one year after the NHI program started ,10. Our This study, which examined disparities between rural and non-rural areas, offers new information regarding the type of major health care facility used, and women's perception of the convenience of transportation for obtaining prenatal care. It discusses in detail the links of the trend in Taiwanese women's choice of prenatal care facility with developments in Taiwan's NHI, health care market, fertility and public transportation. It thus adds important information to the field of prenatal care. Our findings should be of particular use to Taiwan and countries with similar concerns and conditions for their future reforms in the delivery of prenatal care.How to improve access to prenatal care in rural areas should be an important challenge. The literature has indicated that women who seek obstetrical care outside their local communities are more likely to have complicated deliveries, larger chances of prematurity, and more need for neonatal care for their children . PreviouThis study focused on reporting results based on data for 1,575 children in the 4,820 available cases, as previously mentioned. The reason is that we concerned correlation among multiple cases from a same woman, since the two statistical models we used, the multinomial logit model and the ordered probit model, cannot not handle this kind of correlation problem. However, for the purpose of sensitivity analysis, we have also done analysis based on the 4,820 cases (results not shown). While more coefficients were statistically significant in results from analysing the 4,820 cases, these results do not conflict with conclusions we made with regard to comparison between rural and non-rural areas according to our results from analysing the 1,575 cases.There are two main limitations for this study. The first pertains to recall bias, a problem inherent in most retrospective studies that make of surveys. Nonetheless, we believe that such recall bias in our study should not be serious. It has been shown that maternal recall of births five to seven years earlier is highly accurate, and maternal reports of prenatal events more than a decade after the birth are still reasonably accurate, especially events they directly participated in or information they have been told -31. The The second limitation is that our analysis only compared different cohorts of women giving births in the 1990s without controlling for some unobserved characteristics, such as attitudes and beliefs with regard to childbearing, prenatal care, and health care quality differences among different types of facilities. We were not able to further discuss how such characteristics that might vary among different cohorts of women might interact with the NHI influences on the prenatal care market, and subsequently result in changes in women's choice of prenatal care facilities. If we could also compare the experiences of prenatal care utilization for a specific cohort before and after the implementation of the NHI, we would be able to furnish more knowledge in this area.In conclusion, we found that the women in rural areas were more likely to seek prenatal care in large hospitals, but were not more likely to perceive very convenient transportation to and from prenatal care facilities in the late 1990s than in the early 1990s. In contrast, women in non-rural areas did not have a stronger tendency to seek prenatal care in large hospitals in the late 1990s than in earlier periods. In addition, they did perceive an improvement in transportation for acquiring prenatal care in the late 1990s. More efforts should be undertaken to reduce these disparities and improve access to prenatal care of good quality in rural areas.The author(s) declare that they have no competing interests.Likwang Chen designed the study, led the data collection and statistical analysis, and drafted the manuscript. Chi-Liang Chen participated in designing the framework of statistical analysis and preparing the manuscript. Wei-Chih Yang participated in analyzing data analysis and preparing the manuscript. All authors read and approved the final manuscript.Formulas for calculating the 95% confidence interval estimates of changes corresponding to the three later periods in the 1990sChanges in the Relative Probability of Choosing Hospitals from 1990–1992 to Later Years in the 1990sThe 95% confidence interval estimates of changes corresponding to the three later periods in the 1990s for non-rural areas were calculated as follows:For rural areas, the 95% confidence interval estimates for the three periods were respectively calculated as follows:Changes in the Probability of Perceiving Very Convenient Transportation from 1990–1992 to Later Years in the 1990sK1, K2, K3. The 95% confidence interval estimates of changes in the probability of perceiving very convenient transportation corresponding to the three later periods for non-rural areas were respectively calculated as follows:In our model, there were three thresholds: φ is the density function of the standard normal distribution.For rural areas, the three interval estimates were:The pre-publication history for this paper can be accessed here: