Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis

Antenatal care as a means of increasing birth in the health facility and reducing maternal mortality: a systematic review

BACKGROUND

Although there is a general agreement on the importance of antenatal care to improve the maternal and perinatal health, little is known about its importance to improve health facility delivery in developing countries. The objective of this study was to assess the association of antenatal care with birth in health facility.

METHODS

A systematic review with meta-analysis of Mantel-Haenszel odds ratios was conducted by including seventeen small scale studies that compared antenatal care and health facility delivery between 2003 and 2013. Additionally, national survey data of African countries which included antenatal care, health facility delivery and maternal mortality in their report were included. Data were accessed via a computer based search from MEDLINE, African Journals Online, HINARI and Google Scholar databases.

RESULTS

The regression analysis of antenatal care with health facility delivery revealed a positive correlation. The pooled analysis also demonstrated that woman attending antenatal care had more than 7 times increased chance of delivering in a health facility. The comparative descriptive analysis, however, demonstrated a big gap between the proportion of antenatal care and health facility delivery by the same individuals (27%-95% vs 4%-45%). Antenatal care and health facility delivery had negative correlation with maternal mortality.

CONCLUSION

The present regression and meta-analysis has identified the relative advantage of having antenatal care to give birth in health facilities. However, the majority of women who had antenatal care did not show up to a health facility for delivery. Therefore, future research needs to give emphasis to identifying barriers to health facility delivery despite having antenatal care follow up.

A meta-analysis of socio-demographic factors predicting birth in health facility

BACKGROUND

The low proportion of health facility delivery in developing countries is one of the main challenges in achieving the Millennium Development Goal of a global reduction of maternal deaths by 75% by 2015. There are several primary studies which identified socio-demographic and other predictors of birth in health facility. However, there are no efforts to synthesis the findings of these studies. The objective of this meta-analysis was to determine the strength of the association of birth in the health facility with selected sociodemographic factors.

METHODS

A meta-analysis of Mantel-Haenszel odds ratios was conducted by including 24 articles which were reported between 2000 and 2013 from developing countries. A computer-based search was done from MEDLINE, African Journals Online, Google Scholar and HINARI databases. Included studies did compare the women's' health facility delivery in relation to their selected socio-demographic characteristics.

RESULTS

The pooled analysis demonstrated association of health facility delivery with living in urban areas (OR = 9.8), secondary and above educational level of the parents (OR = 5.0), middle to high wealth status (OR = 2.3) and first time pregnancy (OR = 2.8). The risk of delivering outside the health facility was not significantly associated with maternal age (teenage vs 20 years and above) and marital status. The distance of pregnant women's residence from the health facility was found to have an inverse relation to the proportion of health facility delivery.

CONCLUSION

Although the present meta-analysis identified several variables which were associated with an increase in health facility delivery, the most important predictor of birth in the health facility amenable to intervention is educational status of the parents to be. Therefore, formal and informal education to women and family members on the importance of health facility delivery needs to be strengthened. Improving the wealth status of the population across the world may not be achieved soon, but should be in the long-term strategy to increase the birth rate in the health facility.

Determinants of Utilization of Health Extension Workers in the Context of Scale-Up of Integrated Community Case Management of Childhood Illnesses in Ethiopia

Ethiopia has invested significant resources in integrated community case management (iCCM) of childhood illness. In Oromia Region, iCCM scale-up was phased in, allowing for comparisons between districts providing iCCM and routine services. We assessed the determinants of utilization of health extension workers (HEWs) delivering iCCM services at rural health posts by caregivers of sick, under-five children in a cross-sectional survey. We found low utilization of HEWs with only 9.3% of caregivers of a child sick with diarrhea, fever, and/or pneumonia in the previous 2 weeks taking their child to HEWs in both iCCM and routine areas. There was a higher likelihood of utilization of HEWs in iCCM areas (OR: 1.44; 95% CI: 0.97–2.12; P = 0.07), but this effect disappeared after accounting for confounders. In iCCM areas, maternal education, illness type, and distance were associated with utilization. Perceptions of illness severity and service quality were the primary reasons given for not utilizing the health post. Our findings suggest that though iCCM is reaching some vulnerable populations, there remain significant barriers to use of HEWs delivering iCCM services. Efforts for demand generation and minimization of remaining barriers are urgently needed for the sustained success of the iCCM strategy in Ethiopia.

High Incidence of Neonatal Danger Signs and Its Implications for Postnatal Care in Ghana: A Cross-Sectional Study

Background

Reducing neonatal mortality is a major public health priority in sub-Saharan Africa. Numerous studies have examined the determinants of neonatal mortality, but few have explored neonatal danger signs which potentially cause morbidity. This study assessed danger signs observed in neonates at birth, determined the correlations of multiple danger signs and complications between neonates and their mothers, and identified factors associated with neonatal danger signs.

Methods

A cross-sectional study was conducted in three sites across Ghana between July and September in 2013. Using two-stage random sampling, we recruited 1,500 pairs of neonates and their mothers who had given birth within the preceding two years. We collected data on their socio-demographic characteristics, utilization of maternal and neonatal health services, and experiences with neonatal danger signs and maternal complications. We calculated the correlations of multiple danger signs and complications between neonates and their mothers, and performed multiple logistic regression analysis to identify factors associated with neonatal danger signs.

Results

More than 25% of the neonates were born with danger signs. At-birth danger signs in neonates were correlated with maternal delivery complications (r = 0.20, p < 0.001), and neonatal complications within the first six weeks of life (r = 0.19, p < 0.001). However, only 29.1% of neonates with danger signs received postnatal care in the first two days, and 52.4% at two weeks of life. In addition to maternal complications during delivery, maternal age less than 20 years, maternal education level lower than secondary school, and fewer than four antenatal care visits significantly predicted neonatal danger signs.

Conclusions

Over a quarter of neonates are born with danger signs. Maternal factors can be used to predict neonatal health condition at birth. Management of maternal health and close medical attention to high-risk neonates are crucial to reduce neonatal morbidity in Ghana.

Do antenatal care visits always contribute to facility-based delivery in Tanzania? A study of repeated cross-sectional data

There is a known high disparity in access to perinatal care services between urban and rural areas in Tanzania. This study analysed repeated cross-sectional (RCS) data from Tanzania to explore the relationship between antenatal care (ANC) visits, facility-based delivery and the reasons for home births in women who had made ANC visits. We used data from RCS Demographic and Health Surveys spanning 20 years and a cluster sample of 30 830 women from ∼52 districts of Tanzania. The relationship between the number of ANC visits (up to four) and facility delivery in the latest pregnancy was explored. Regional changes in facility delivery and related variables over time in urban and rural areas were analysed using linear mixed models. To explore the disconnect between ANC visits and facility deliveries, reasons for home delivery were analysed. In the analytic model with other regional-level covariates, a higher proportion of ANC (>2–4 visits) and exposure to media related to an increased facility delivery rate in urban areas. For rural women, there was no significant relationship between the number of visits and facility delivery rate. According to the fifth wave result (2009–10), the most frequent reason for home delivery was ‘physical distance to facility’, and a significantly higher proportion of rural women reported that they were ‘not allowed to deliver in facility’. The disconnect between ANC visits and facility delivery in rural areas may be attributable to physical, cultural or familial barriers, and quality of care in health facilities. This suggests that improving access to ANC may not be enough to motivate facility-based delivery, especially in rural areas.

Individual and facility-level determinants of iron and folic acid receipt and adequate consumption among pregnant women in rural Bihar, India

Background

In Bihar, India, high maternal anemia prevalence and low iron and folic acid supplement (IFA) receipt and consumption have continued over time despite universal IFA distribution and counseling during pregnancy.

Purpose

To examine individual and facility-level determinants of IFA receipt and consumption among pregnant women in rural Bihar, India.

Methods

Using District Level Household Survey (2007–08) data, multilevel modeling was conducted to examine the determinants of two outcomes: IFA receipt (any IFA receipt vs. none) and IFA consumption (≥90 days vs. <90 days). Individual-level and facility-level factors were included. Factor analysis was utilized to construct antenatal care (ANC) quality and health sub-center (HSC) capacity variables.

Results

Overall, 37% of women received any IFA during their last pregnancy. Of those, 24% consumed IFA for 90 or more days. Women were more likely to receive any IFA when they received additional ANC services and counseling, and attended ANC earlier and more frequently. Significant interactions were found between ANC quality factors (odds ratio (OR): 0.37, 95% confidence interval (CI): 0.25, 0.56) and between ANC services and ANC timing and frequency (OR: 0.68, 95% CI: 0.56, 0.82). No HSC factors were significantly associated with IFA receipt. Women were more likely to consume IFA for ≥90 days if they attended at least 4 ANC check-ups and received more ANC services. IFA supply at the HSC (OR: 1.37, 95% CI: 1.04, 1.82) was also significantly associated with IFA consumption.

Conclusions

Our findings indicate that individual and ANC factors (timing, frequency, and quality) play a key role in facilitating IFA receipt and consumption. Although HSC capacity factors were not found to influence our outcomes, significant variation at the facility level indicates unmeasured factors that could be important to address in future interventions.

Social inequalities in the utilization of maternal care in Bangladesh: Have they widened or narrowed in recent years?

Background

Notwithstanding the significant progress in reducing maternal mortality in recent years, social inequalities in the utilization of maternal care continue to be a challenge in Bangladesh. In this study, we aim to provide a comprehensive analysis of trends in social inequalities in utilization of antenatal care (ANC), facility based delivery (FBD), and skilled birth attendance (SBA) in Bangladesh between 1995 and 2010.

Methods

Data were extracted from the five latest rounds of Bangladesh Demographic Health Surveys (BDHS). The Theil index (T) and between-group variance (BGV) were used to calculate relative and absolute disparities in the utilization of three measures (ANC, FBD, and SBA) of maternal care across six administrative regions. The relative and slope indices of inequality (RII and SII, respectively) were also used to calculate wealth- and education-based inequality in the utilization of maternal care.

Results

The results of the T-index suggest that relative inequality in SBA has declined by 0.2% per year. Nevertheless, the estimated BGV demonstrated that absolute inequalities in all three measures of maternal care have increased across administrative divisions. For all three measures of maternal care, the RII and SII indicated consistent socioeconomic inequalities favouring wealthier and more educated women. The adjusted RII suggested that wealth- and education-related inequalities for ANC declined by 9% and 6%, respectively, per year during the study period. The adjusted SII, however, showed that wealth- and education-related inequalities for FBD increased by 0.6% per year.

Conclusions

Although socially disadvantaged mothers increased their utilization of care relative to mothers of higher socioeconomic status, the absolute gap in utilization of care between socioeconomic groups has increased over time. Our findings indicate that wealthier and more educated women, as well as those living in urban areas, are the major users of ANC, FBD and SBA in Bangladesh. Thus, priority focus should be given to implementing and evaluating interventions that benefit women who are poorer, less educated and live in rural areas.

The effect of birth preparedness and complication readiness on skilled care use: a prospective follow-up study in Southwest Ethiopia

Abstracts

Predictors of health care use by adults 50 years and over in a rural South African setting

Background

South Africa’s epidemiological transition is characterised by an increasing burden of chronic communicable and non-communicable diseases. However, little is known about predictors of health care use (HCU) for the prevention and control of chronic diseases among older adults.

Objective

To describe reported health problems and determine predictors of HCU by adults aged 50+ living in a rural sub-district of South Africa.

Design

A cross-sectional study to measure HCU was conducted in 2010 in the Agincourt sub-district of Mpumalanga Province, an area underpinned by a robust health and demographic surveillance system. HCU, socio-demographic variables, reception of social grants, and type of medical aid were measured, and compared between responders who used health care services with those who did not. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables.

Results

Seventy-five percent of the eligible adults aged 50+ responded to the survey. Average age of the targeted 7,870 older adults was 66 years (95% CI: 65.3, 65.8), and there were more women than men (70% vs. 30%, p<0.001). All 5,795 responders reported health problems, of which 96% used health care, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% – e.g. hypertension), acute conditions (27% – e.g. flu and fever), other conditions (26% – e.g. musculoskeletal pain), chronic communicable diseases (3% – e.g. HIV and TB), and injuries (3%). In multivariate logistic regression, responders with chronic communicable disease (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable disease (OR=2.85, 95% CI: 1.96, 4.14) had significantly higher odds of using health care compared with those with acute conditions. Responders with six or more years of education had a two-fold increased odds of using health care (OR=2.49, 95% CI: 1.27, 4.86) compared with those with no formal education.

Conclusion

Chronic communicable and non-communicable diseases were the most prevalent and main predictors of HCU in this population, suggesting prioritisation of public health care services for chronic diseases among older people in this rural setting.

Utilization of institutional delivery service at Wukro and Butajera districts in the Northern and South Central Ethiopia

BACKGROUND

Ethiopia has one of the highest maternal mortality in the world. Institutional delivery is the key intervention in reducing maternal mortality and complications. However, the uptake of the service has remained low and the factors which contribute to this low uptake appear to vary widely. Our study aims to determine the magnitude and identify factors affecting delivery at health institution in two districts in Ethiopia.

METHODS

A community based cross sectional household survey was conducted from January to February 2012 in 12 randomly selected villages of Wukro and Butajera districts in the northern and south central parts of Ethiopia, respectively. Data were collected using a pretested questionnaire from 4949 women who delivered in the two years preceding the survey.

RESULTS

One in four women delivered the index child at a health facility. Among women who delivered at health facility, 16.1% deliveries were in government hospitals and 7.8% were in health centers. The factors that significantly affected institutional delivery in this study were district in which the women lived (AOR: 2.21, 95% CI: 1.28, 3.82), women age at interview (AOR: 1.96, 95% CI: 1.05, 3.62), women's education (AOR: 3.53, 95% CI: 1.22, 10.20), wealth status (AOR: 16.82, 95% CI: 7.96, 35.54), women's occupation (AOR: 1.50, 95% CI: 1.01, 2.24), antenatal care (4+) use (AOR: 1.77, 95% CI: 1.42, 2.20), and number of pregnancies (AOR: 0.25, 95% CI: 0.18,0.35). We found that women who were autonomous in decision making about place of delivery were less likely to deliver in health facility (AOR: 0.38, 95% CI: 0.23,0.63).

CONCLUSIONS

Institutional delivery is still low in the Ethiopia. The most important factors that determine use of institutional delivery appear to be women education and household economic status.Women's autonomy in decision making on place of delivery did not improve health facility delivery in our study population.Actions targeting the disadvantaged, improving quality of services and service availability in the area are likely to significantly increase institutional delivery.

Determinants of institutional delivery among childbearing age women in Western Ethiopia, 2013: unmatched case control study

Background

Place of delivery is a crucial factor which affects the health and wellbeing of the mother and newborn. Institutional delivery helps the women to access skilled assistance, drugs, equipment, and referral transport. Even though 34% of pregnant women received at least one antenatal care from a skilled provider in Ethiopia by 2013, institutional delivery was 10%. The main objective of the study was to assess determinants of institutional delivery in Western Ethiopia.

Methods

Retrospective unmatched case control study design was used to assess determinants of institutional delivery in Western Ethiopia from September to October 2013. A total of 320 respondents from six districts of East Wollega zone, West Ethiopia were included. Data were collected using pretested and structured questionnaires. Data were entered and cleaned by Epi-info then exported and analyzed using SPSS software. Statistical significance was determined through a 95% confidence level.

Results

Education [Adjusted Odds Ratio (AOR) (95% Confidence Interval (CI)) = 2.754(1.510–8.911)], family size [AOR (95% CI) = .454(.209–.984)], residence [AOR (95% CI) = 3.822 (1.766–8.272)] were important predictors of place of delivery. Four or more antenatal care [(ANC) (AOR (95% CI) = 2.914(1.105–7.682)], birth order [(AOR (95% CI) = .136(.054–.344), age at last delivery [(AOR (95% CI) = 9.995(2.101–47.556)], birth preparedness [AOR (95% CI) = 6.957(2.422–19.987)], duration of labour [AOR (95% CI) = 3.541(1.732–7.239)] were significantly associated with institutional delivery. Moreover service related factors such as distance from health institutions [AOR (95% CI) = .665(.173–.954)], respondents’ awareness of skill of health care professionals [AOR (95% CI) = 2.454 (1.663–6.255)], mode of transportations [AOR (95% CI) = .258(.122–.549)] were significantly associated with institutional delivery.

Conclusions and Recommendations

Policy makers, health service organizations, community leaders and other concerned bodies have to consider the predictors of institutional delivery like education, birth order, antenatal care utilization and residence to improve institutional delivery in the area.

Health extension program factors, frequency of household visits and being model households, improved utilization of basic health services in Ethiopia

BACKGROUND

Ethiopia has implemented a nationwide primary health program (the Health Extension Program) at the grassroots level since 2003. The aim of the program is to increase public access to basic health services, mainly by producing model households. These are households which attend at least 75% of the training given by health extension workers and implement at least 75% of the Health Extension Program packages. This study was conducted to assess the extent of the Health Extension Program utilization by the community, and to identify factors associated with it.

METHODS

A community-based cross-sectional study was conducted to assess the utilization of the health extension program. Data were collected from 1320 mothers using a structured questionnaire. Multilevel logistic regression was used to identify factors associated with the utilization of the program.

RESULT

Health extension workers conducted frequent visits to 52.7% (95% CI = 50.0 to 55.4%) of the households, and 78.5% (95% CI = 76.2 to 80.7%) mothers visited health posts. Mothers who had frequent household visits by health extension workers were 1.289 more likely to visit the health posts (AOR = 1.289, 95% CI = 1.028 to1.826) than mothers who did not get frequent visits. Mothers from model households (3 years after graduation) were 2.410 times more likely to visit health post (AOR = 2.150, 95% CI = 1.058 to 4.365) compared to mothers from non-model households. Mothers who felt that they understood the Health Extension Program packages were 1.573 times more likely to visit the health posts (AOR = 1.573, 95% CI = 1.056 to 2.343) than mothers who did not feel they understood the program packages. Mothers from higher income families were 2.867 times more likely to visit health posts (AOR = 2.867, 95% CI = 1.630 to 5.040) compared to mothers from lower income families.

CONCLUSIONS

Conducting continuous home visits of non-model households and following up the existing model households, producing more model households by giving model-family training to non-model households, and strengthening the information, education, and communication package are crucial in the implementation of the HEP to increase basic health services utilization.

Newborn care practices at home and in health facilities in 4 regions of Ethiopia

BACKGROUND

Ethiopia is one of the ten countries with the highest number of neonatal deaths globally, and only 1 in 10 women deliver with a skilled attendant. Promotion of essential newborn care practices is one strategy for improving newborn health outcomes that can be delivered in communities as well as facilities. This article describes newborn care practices reported by recently-delivered women (RDWs) in four regions of Ethiopia.

METHODS

We conducted a household survey with two-stage cluster sampling to assess newborn care practices among women who delivered a live baby in the period 1 to 7 months prior to data collection.

RESULTS

The majority of women made one antenatal care (ANC) visit to a health facility, although less than half made four or more visits and women were most likely to deliver their babies at home. About one-fifth of RDWs in this survey had contact with Health Extension Workers (HEWS) during ANC, but nurse/midwives were the most common providers, and few women had postnatal contact with any health provider. Common beneficial newborn care practices included exclusive breastfeeding (87.6%), wrapping the baby before delivery of the placenta (82.3%), and dry cord care (65.2%). Practices contrary to WHO recommendations that were reported in this population of recent mothers include bathing during the first 24 hours of life (74.7%), application of butter and other substances to the cord (19.9%), and discarding of colostrum milk (44.5%). The results suggest that there are not large differences for most essential newborn care indicators between facility and home deliveries, with the exception of delayed bathing and skin-to-skin care.

CONCLUSIONS

Improving newborn care and newborn health outcomes in Ethiopia will likely require a multifaceted approach. Given low facility delivery rates, community-based promotion of preventive newborn care practices, which has been effective in other settings, is an important strategy. For this strategy to be successful, the coverage of counseling delivered by HEWs and other community volunteers should be increased.

The effects of pregnancy intention on the use of antenatal care services: systematic review and meta-analysis

BACKGROUND

There has been considerable debate in the reproductive health literature as to whether unintended pregnancy influences use of maternal health services, particularly antenatal care. Despite the wealth of studies examining the association between pregnancy intention and antenatal care, findings remain mixed and inconclusive. The objective of this study is to systematically review and meta-analyse studies on the association between pregnancy intention and antenatal care.

METHODS

We reviewed studies reporting on pregnancy intention and antenatal care from PubMed, Popline, CINHAL and Jstor search engines by developing search strategies. Study quality was assessed for biases in selection, definition of exposure and outcome variables, confounder adjustment, and type of analyses. Adjusted odds ratios, standard errors and sample size were extracted from the included studies and meta-analyzed using STATA version 11. Heterogeneity among studies was assessed using Q test statistic. Effect-size was measured by Odds ratio. Pooled odds ratio for the effects of unintended pregnancy on the use of antenatal care services were calculated using the random effects model.

RESULTS

Our results indicate increased odds of delayed antenatal care use among women with unintended pregnancies (OR 1.42 with 95% CI, 1.27, 1.59) as compared to women with intended pregnancies. Sub-group analysis for developed (1.50 with 95% CI, 1.34, 1.68) and developing (1. 36 with 95% CI, 1.13, 1.65) countries showed significant associations. Moreover, there is an increased odds of inadequate antenatal care use among women with unintended pregnancies as compared to women with intended pregnancies (OR 1.64, 95% CI: 1.47, 1.82). Subgroup analysis for developed (OR, 1.86; 95% CI: 1.62, 2.14) and developing (OR, 1.54; 95% CI: 1.33, 1.77) countries also showed a statistically significant association. However, there were heterogeneities in the studies included in this analysis.

CONCLUSION

Unintended pregnancy is associated with late initiation and inadequate use of antenatal care services. Hence, women who report an unintended pregnancy should be targeted for antenatal care counseling and services to prevent adverse maternal and perinatal outcomes. Moreover, providing information on the importance of planning and healthy timing of pregnancies, and the means to do so, to all women of reproductive ages is essential.

Availability and components of maternity services according to providers and users perspectives in North Gondar, Northwest Ethiopia

Background

The goal of reducing maternal mortality can be achieved when women receive important service components at the time of their maternity care. This study attempted to assess the availability and the components of maternity services according to the perspectives of service users and providers.

Method

A linked facility and population-based survey was conducted over three months (January to March 2012) in North Gondar Zone. Twelve kebeles (clusters) were selected randomly from six districts to identify maternity clients cared for by skilled providers. Then 12 health centers and 3 hospitals utilized by the corresponding cluster population were selected for facility survey. Interview with facility managers/heads, providers and clients and observations were used for data collection. Data were entered using Epi Info and were exported to SPSS software for analysis.

Results

Antenatal and delivery care were available in most of the visited facilities. However, the majority of them were not fully functioning for EmOC according to their level. Signal functions including administration of anticonvulsants and assisted vaginal delivery were missing in seven and five of the 12 health centers, respectively. Only one hospital met the criteria for comprehensive emergency obstetric care (performed cesarean section). Only 24% of the providers used partograph consistently. About 538 (32.3%) and 231 (13.8%) of the women received antenatal and delivery care from skilled providers, respectively. Most of the services were at health centers by nurses/midwives. At the time of the antenatal care, women received the important components of the services (percentage of users in bracket) like blood pressure checkup (79%), urine testing (35%), tetanus immunization (45%), iron supplementation (64%), birth preparedness counseling (51%) and HIV testing (71%). During delivery, 80% had their blood pressure measured, 78% were informed on labor progress, 89% had auscultation of fetal heartbeat, 80% took drugs to prevent bleeding and 78% had counseling on early & exclusive breast-feeding.

Conclusion

Antenatal and delivery care were available in most of the visited facilities. However, important components of both the routine and emergency maternity care services were incomplete. Improving the functional capacity of health facilities for the delivery of routine maternity and EmOC services are needed.