Determinants of use of maternal health services in Nigeria--looking beyond individual and household factors

Equity in maternal health care service utilization: a systematic review for developing countries

OBJECTIVES

The objective was to explore progress of equity in the utilization of maternal health care services in developing countries since maternal care is a crucial factor in reducing maternal mortality, which is targeted by the Millennium Development Goal 5.

METHODS

A systematic review of quantitative studies was done. PubMed Central, Web of Science, and Science Direct databases were searched for peer-reviewed and English-language articles published between 2005 and 2015.

RESULTS

Thirty-six articles were included in the review. The results reveal the lack of equity in the utilization of maternal health care in developing countries. Thirty-three out of 36 studies found evidence supporting severe inequities while three studies found evidence of equity or at least improvement in terms of equity.

CONCLUSIONS

Most of the literature devoted to utilization of maternal health care generally provides information on the level of maternal care used and ignore the equity problem. Research in this area should focus not only on the level of maternal care used but also on the most disadvantaged segments of the population in terms of utilization of maternal care in order to reach the set targets.

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.

'The government cannot do it all alone': realist analysis of the minutes of community health committee meetings in Nigeria

Since the mid-1980s, the national health policy in Nigeria has sought to inspire community engagement in primary health care by bringing communities into partnership with service providers through community health committees. Using a realist approach to understand how and under what circumstances the committees function, we explored 581 meeting minutes from 129 committees across four states in Nigeria (Lagos, Benue, Nasarawa and Kaduna). We found that community health committees provide opportunities for improving the demand and supply of health care in their community. Committees demonstrate five modes of functioning: through meetings (as ‘village square’), reaching out within their community (as ‘community connectors’), lobbying governments for support (as ‘government botherers’), inducing and augmenting government support (as ‘back-up government’) and taking control of health care in their community (as ‘general overseers’). In performing these functions, community health committees operate within and through the existing social, cultural and religious structures of their community, thereby providing an opportunity for the health facility with which they are linked to be responsive to the needs and values of the community. But due to power asymmetries, committees have limited capacity to influence health facilities for improved performance, and governments for improved health service provision. This is perhaps because national guidelines are not clear on their accountability functions; they are not aware of the minimum standards of services to expect; and they have a limited sense of legitimacy in their relations with sub-national governments because they are established as the consequence of a national policy. Committees therefore tend to promote collective action for self-support more than collective action for demanding accountability. To function optimally, community health committees require national government or non-government organization mentoring and support; they need to be enshrined in law to bolster their sense of legitimacy; and they also require financial support to subsidise their operation costs especially in geographically large communities.

The relationship of women's status and empowerment with skilled birth attendant use in Senegal and Tanzania

BACKGROUND

Maternal mortality remains unacceptably high in sub-Saharan Africa with 179,000 deaths occurring each year, accounting for 2-thirds of maternal deaths worldwide. Progress in reducing maternal deaths and increasing Skilled Birth Attendant (SBA) use at childbirth has stagnated in Africa. Although several studies demonstrate the important influences of women's status and empowerment on SBA use, this evidence is limited, particularly in Africa. Furthermore, few studies empirically test the operationalization of women's empowerment and incorporate multidimensional measures to represent the potentially disparate influence of women's status and empowerment on SBA use across settings.

METHODS

This study examined the relationship of women's status and empowerment with SBA use in two African countries--Senegal and Tanzania--using the 2010 Demographic and Health Surveys (weighted births n = 10,688 in SN; 6748 in TZ). Factor analysis was first conducted to identify the structure and multiple dimensions of empowerment. Then, a multivariate regression analysis was conducted to examine associations between these empowerment dimensions and SBA use.

RESULTS

Overall, women's status and empowerment were positively related to SBA use. Some sociodemographic characteristics showed similar effects across countries (e.g., age, wealth, residence, marital relationship, parity); however, women's status and empowerment influence SBA use differently by setting. Namely, women's education directly and positively influenced SBA use in Tanzania, but not in Senegal. Further, each of the dimensions of empowerment influenced SBA use in disparate ways. In Tanzania women's higher household decision-making power and employment were related to SBA use, while in Senegal more progressive perceptions of gender norms and older age at first marriage were related to SBA use.

CONCLUSIONS

This study provides evidence of the disparate influences of women's status and empowerment on SBA use across settings. Results indicate that efforts to increase SBA use and to reduce maternal mortality through the improvement of women's status and empowerment should focus both on improving girls' education and delaying marriage, as well as transforming gender norms and decision-making power. However, given the multi-dimensional and contextual nature of women's status and empowerment, it is critical to identify key drivers to increase SBA use in a given setting for contextually tailored policy and programming.

Health care services and maternal education in South Africa

Aims: The aim of the study is to investigate the influence of maternal education on the utilization of maternal health care services in selected areas of the Eastern Cape. Moreover, the study’s aim also is to examine the reasons for non-use as well as determinants and levels of maternal health care utilization. Methods: From the 422 participants sampled, 345 fully completed questionnaires were returned and included in the analysis. The study used multilevel analyses. The dependent variables included antenatal care, delivery care, and postnatal care within 2 months after birth. The independent variables were socioeconomic and demographic factors selected based on literature on the subject. Results: Use of antenatal and delivery care services was high in the study areas, but postnatal check-ups were reported below 50%. The majority of the women (50%) reported that the ambulance arrived too late, and, as such, they did not use health facilities when giving birth. Women with four or more children use antenatal and delivery care less than women with one child, while women with four or more children use postnatal care more than women with just one child. Conclusions: This study will be immense useful for the policy-makers, public health research managers and concerned health care decision-makers.

EXPLAINING THE GAP IN ANTENATAL CARE SERVICE UTILIZATION BETWEEN YOUNGER AND OLDER MOTHERS IN GHANA

Over two-thirds of pregnant women (69%) have at least one antenatal care (ANC) coverage contact in sub-Saharan Africa. However, to achieve the full life-saving potential that ANC promises for women and babies, a nuanced understanding of age-specific gaps in utilization of ANC services is required. Using the 2008 Ghana Demographic and Health Survey of 1456 individuals, this study examined the disparities in the use of ANC services between younger and older mothers by applying four counterfactual decomposition techniques. The results show that cross-group differences in the explanatory variables largely account for the differentials in ANC service utilization between younger and older mothers. Birth order (parity) accounts for the largest share of the contribution to the overall explained gap in ANC utilization between the younger and older mothers, suggesting that ANC differentials between the two groups are probably due to biosocial factors. To a lesser extent, wealth status of the two groups also contributes to the overall explained gap in ANC service utilization. The policy implications of these findings are that in order to bridge the ANC service utilization gap between the two groups, policymakers must systematically address gaps in cross-group differences in the explanatory variables in order to increase the utilization of ANC to attain the minimum recommendation of four visits as per World Health Organization guidelines.

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.

State of the Nigerian child - neglect of child and adolescent mental health: a review

BACKGROUND

As most child health initiatives in Nigeria lack a child and adolescent mental health (CAMH) strategy, CAMH issues have remained obscure to the country's policy-makers. The lack of current and representative epidemiological data on the mental health of Nigerian children continues to be a barrier to advocacy for CAMH policy initiatives. In view of the importance of CAMH to national development, there must be a continued search for ways of bringing the state of CAMH in Nigeria to the attention of policy-makers.

OBJECTIVES

To use information from UNICEF's State of the World's Children as proxy data to speculate on the state of child mental health in Nigeria.

METHODS

With a view to discussing its CAMH implications, social and health indicators in the Nigerian child were extracted from UNICEF's 2012 edition.

RESULTS

Most of the social and health indicators assessed reflect significant mental health risks. Up to 65% of households live on less than US$1·25 per day, child malnutrition is evident in up to 40% of children, and the primary and secondary school net enrolment ratios are only 63% and 25%, respectively. In addition, the rate of attendance for antenatal care was 45%, and only 39% of deliveries were supervised by skilled birth attendants. Child labour and under-age marriage is very common. A literature review demonstrates that children living in these circumstances are at significant risk of mental health problems.

CONCLUSION

Current data on the state of Nigerian children contain indices that can serve as proxy information for the state of CAMH in the country. Policy-makers need to invest more in pre-emptive child health initiatives as a way of preserving the physical and mental health of children.

Who is left behind on the road to universal facility delivery? A cross-sectional multilevel analysis in rural Tanzania

OBJECTIVES

To examine factors associated with home delivery among women in Pwani Region, Tanzania, which has experienced a rapid rise in facility delivery coverage.

METHODS

Cross-sectional data from a population-based survey of women residing in rural areas of Pwani Region were linked to health facility locations. We fitted multilevel logistic models to examine individual and community factors associated with home delivery.

RESULTS

A total of 752 (27.95%) of the 2691 women who completed the survey delivered their last child at home. Women were less likely to deliver at home if they had any primary education [odds ratio (OR) 0.62; 95% confidence interval (CI): 0.50, 0.79], were primiparous (OR: 0.52; 95% CI: 0.37, 0.73), had more exposure to media (OR: 0.80; 95% CI: 0.66, 0.96) or had received more (OR: 0.78; 95% CI: 0.63, 0.96) or better quality antenatal care (ANC) services (OR: 0.48; 95% CI: 0.34, 0.67). Increased wealth was strongly associated with lower odds of home delivery (OR: 0.27; 95% CI: 0.18, 0.39), as was living in a village that grew cash crops (OR: 0.56; 95% CI: 0.35, 0.88). Farther distance to hospital, but not to lower level facilities, was associated with higher likelihood of home delivery (OR 2.49; 95% CI: 1.60, 3.88).

CONCLUSIONS

Poverty, multiparity, weak ANC and distance to hospital were associated with persistence of home delivery in a region with high coverage of facility delivery. A pro-poor path to universal coverage of safe delivery requires a greater focus on quality of care and more intensive outreach to poor and multiparous women.

Trends in delivery with no one present in Nigeria between 2003 and 2013

PURPOSE

Skilled attendance at birth is a proven intervention to improve maternal and newborn health outcomes. Unfortunately, in Nigeria there are many women who give birth alone, with no one present (NOP). The purpose of this study was to document trends in women delivering with NOP between 2003 and 2013, and to identify the characteristics of women who are engaging in this risky practice.

METHODS

We utilized pooled data sets from the 2003, 2008, and 2013 Nigerian Demographic and Health Surveys. Married women, who had given birth in the 5 years before each survey were included, resulting in a sample size of 38,949 women. We used logistic regression to assess the unadjusted and adjusted odds of a woman delivering with NOP over time, by socio-demographic characteristics.

RESULTS

Prevalence of delivery with NOP in Nigeria declined by 30% between 2003 and 2013. The largest declines occurred in Sokoto State, where the number of women giving birth with NOP declined by almost 100% between 2003 and 2013. In the North West of the country, however, there was a 27% increase in the number of women giving birth alone over this time period. Older, poorer, less educated, higher parity, Muslim women residing in the Northern regions were significantly more likely to give birth with NOP. Women, who were involved in decisions surrounding their own health, and who had accessed antenatal care were significantly less likely to give birth with NOP.

CONCLUSION

Although there have been improvements in Nigeria's Maternal Mortality Ratio since 1990, recent estimates suggest a stagnation in this trend. One reason for this protracted decline may be lack of access to skilled delivery care. The 2013 national prevalence of Nigerian women giving birth with NOP was 14%, equivalent to over 1 million births in 2013. Nigeria must implement interventions to ensure every woman's timely access to, and use of skilled care to reduce preventable maternal mortality and morbidity.

Factors influencing the use of maternal healthcare services and childhood immunization in Swaziland

BACKGROUND

Maternal and child healthcare services are very important for the health outcomes of the mother and that of the child and in ensuring that both maternal and child deaths are prevented. Studying these services is necessary in developing countries where infrastructure (which is meant to deal with these health services) is minimal or lacking. The objective of the study is to examine the factors that influence the use of maternal healthcare services and childhood immunization in Swaziland.

METHODS

Our study used secondary data from the Swaziland Demographic and Health Survey 2006-07. This is an explorative and descriptive study which used pre-selected variables to study factors influencing the use of maternal and child healthcare services in Swaziland. We ran three different types of analyses: univariate, bivariate and multivariate. For the multivariate analysis, a logistic regression was run to investigate the relationship between the dependent and independent variables.

FINDINGS

The study findings showed a high use rate of antenatal care (97.3%) and delivery care (74.0%) and a low rate of postnatal care use (20.5%). The uptake of childhood immunization is also high in the country, averaging more than 80.0%. Certain factors which were found to be influencing the use of maternal healthcare and childhood immunization include: woman's age, parity, media exposure, maternal education, wealth quintile, and residence. The findings also revealed that these factors affect the use of maternal and child health services differently.

CONCLUSION

It is important to study factors related to maternal and child health uptake to inform relevant stakeholders about possible areas of improvement. Programs to educate families about the importance of maternal and child healthcare services should be implemented. In addition, interventions should focus on: (a) age differentials in use of maternal and child health services, (b) women with higher parities, (c) women in rural areas, and (d) women from the poor quintile. We recommend that possible future studies could use the qualitative approach to study issues associated with the low use of postnatal services.

Levels and determinants of continuum of care for maternal and newborn health in Cambodia-evidence from a population-based survey

Background

Continuum of care throughout pregnancy, birth, and after delivery has become a key program strategy for improving the health of mothers and newborns. Successful program implementation to improve the continuum of care relies on a better understanding of where the gaps are in seeking care along the pathway and what factors contribute to the gaps.

Methods

Using data from the 2010 Cambodia Demographic and Health Survey, we examine the levels of service use along the continuum of care. Three sequential regression models are fitted to identify factor(s) that affect women from getting skilled birth attendance (SBA) after receiving antenatal care (ANC), and from getting postnatal care (PNC) after having both ANC and SBA.

Results

Three of every five Cambodian women received all three types of maternal care—antenatal care, skilled birth attendance at birth and postnatal care -for their most recent birth, however with substantial regional variation ranging from 14% to 96%. The results highlight that mother’s age, educational attainment, urban residence, household wealth, lower birth order are associated with women’s use of antenatal care and their continuation to using skilled birth attendant. Health insurance coverage also increases use of antenatal care but not skilled birth attendant. Having four antenatal care visits and receiving better quality of antenatal care affected women’s subsequent use of skilled birth attendant. The odds of having skilled birth attendant increases by 30 to 50% for women who received blood pressure measurement, urine sample taken, and blood sample taken as part of antenatal services. Household wealth status, urine sample taken, and delivery at a health facility were the only three factors significantly associated with the continuation from having skilled birth attendant to receiving postnatal care.

Conclusions

Cambodia has made remarkable progress in extending the reach of maternal health care in most areas of the country. Future program efforts should focus on the Northeast part of the country where the lowest level of service use was found. Poor women suffered from lower access to continued care and extending the health insurance coverage might be one way to help them out. Quality of antenatal care is connected to women’s use of skilled birth attendant and postnatal care and should be given more focus.

Determinants of suboptimal breastfeeding practices in Nigeria: evidence from the 2008 demographic and health survey

BACKGROUND

In Nigeria, suboptimal breastfeeding practices are contributing to the burden of childhood diseases and mortality. This study identified the determinants of key suboptimal breastfeeding practices among children 0-23 months in Nigeria.

METHOD

Data on 10,225 children under-24 months were obtained from the 2008 Nigeria Demographic and Health Survey (NDHS). Socio-economic, health service and individual factors associated with key breastfeeding indicators (early initiation of breastfeeding, exclusive breastfeeding, predominant breastfeeding and bottle feeding) were investigated using multiple logistic regression analyses.

RESULTS

Among infants 0-5 months of age, 14% [95% confidence Interval (CI): 13%, 15%] were exclusively breastfed and 48% [95% CI: 46, 50%] were predominantly breastfed. Among children aged 0-23 months, 38% [95% CI 36, 39%] were breastfed within the first hour of birth, and 15% [95% CI: 14, 17%] were bottle-fed. Early initiation of breastfeeding was associated with higher maternal education, frequent antenatal care (ANC) visits and birth interval but deliveries at a health facility with caesarean section was associated with delayed initiation of breastfeeding. Educated mothers, older mothers and mothers from wealthier households exclusively breastfeed their babies. The risk for bottle feeding was higher among educated mothers and fathers, and women from wealthier households including mothers who made frequent ANC visits.

CONCLUSION

Socio-economic and health service factors were associated with suboptimal breastfeeding practices in Nigeria. To improve the current breastfeeding practices, breastfeeding initiatives should target all mothers - particularly low SES mothers - including, national and sub-national health policies that ensure improved access to maternal health services, and improvements to baby friendly hospital and community initiatives for mothers.

Determinants of trends in breast-feeding indicators in Nigeria, 1999-2013

OBJECTIVE

The present study aimed to examine the trends and differentials in key breast-feeding indicators in Nigeria for the period 1999-2013.

DESIGN

Longitudinal study of trends (1999-2013) in optimal feeding practices using a series of population-based Nigerian Demographic and Health Surveys. Trends in socio-economic, health service and individual characteristics associated with key breast-feeding indicators were examined using multilevel regression analyses.

SETTING

Nigeria.

SUBJECTS

Children (n 88 152) aged under 24 months (n 8199 in 1999; n 7620 in 2003; n 33 385 in 2008; n 38 948 in 2013).

RESULTS

Among educated mothers, there was an increase in prevalence of exclusive breast-feeding (26% in 1999 to 30% in 2013) and predominant breast-feeding (27% in 1999 to 39% in 2013) compared with mothers with no schooling. A similar increasing trend was evident for mothers from wealthier households and mothers who had a higher frequency of health service access compared with mothers from poorer households and women who reported no health service access, respectively. Mothers with no schooling predominantly breast-fed, but the odds for bottle-feeding were higher among educated mothers and women from wealthier households. The odds for early initiation of breast-feeding were lower for mothers who reported no health service contacts and mothers of lower socio-economic status.

CONCLUSIONS

Significant increasing trends in key breast-feeding indicators were evident among mothers with higher socio-economic status and mothers who had more health service access in Nigeria. Broader national and sub-national policies that underpin nursing mothers in work environments and a comprehensive community-based approach are proposed to improve feeding practices in Nigeria.

Perceived barriers to utilizing maternal and neonatal health services in contracted-out versus government-managed health facilities in the rural districts of Pakistan

BACKGROUND

A number of developing countries have contracted out public health facilities to the Non-Government Organizations (NGOs) in order to improve service utilization. However, there is a paucity of in-depth qualitative information on barriers to access services as a result of contracting from service users' perspective. The objective of this study was to explore perceived barriers to utilizing Maternal and Neonatal Health (MNH) services, in health facilities contracted out by government to NGO for service provision versus in those which are managed by government (non-contracted).

METHODS

A community-based qualitative exploratory study was conducted between April to September 2012 at two contracted-out and four matched non-contracted primary healthcare facilities in Thatta and Chitral, rural districts of Pakistan. Using semi-structured guide, the data were collected through thirty-six Focus Group Discussions (FGDs) conducted with mothers and their spouses in the catchment areas of selected facilities. Thematic analysis was performed using NVivo version 10.0 in which themes and sub-themes emerged.

RESULTS

Key barriers reported in contracted sites included physical distance, user charges and familial influences. Whereas, poor functionality of health centres was the main barrier for non-contracted sites with other issues being comparatively less salient. Decision-making patterns for participants of both catchments were largely similar. Spouses and mother-in-laws particularly influenced the decision to utilize health facilities.

CONCLUSION

Contracting out of health facility reduces supply side barriers to MNH services for the community served but distance, user charges and low awareness remain significant barriers. Contracting needs to be accompanied by measures for transportation in remote settings, oversight on user fee charges by contractor, and strong community-based behavior change strategies.

EFFECT OF INDIVIDUAL AND COMMUNITY FACTORS ON MATERNAL HEALTH CARE SERVICE USE IN INDIA: A MULTILEVEL APPROACH

This study aimed to assess empirically the influence of individual and community (neighbourhood) factors on the use of maternal health care services in India through three outcomes: utilization of full antenatal care (ANC) services, safe delivery and utilization of postnatal care services. Data were from the third round of the National Family Health Survey (2005-06). The study sample constituted ever-married women aged 15-49 from 29 Indian states. Multilevel logistic regression analysis was performed for the three outcomes of interest accounting for individual- and community-level factors associated with the use of maternal health care services. A substantial amount of variation was observed at the community level. About 45%, 51% and 62% of the total variance in the use of full ANC, safe delivery and postnatal care, respectively, could be attributed to differences across the community. There was significant variation in the use of maternal health care services at the individual level, with socioeconomic status and mother's education being the most prominent factors associated with the use of maternal health care services. At the community level, urban residence and poverty concentration were found to be significantly associated with maternal health care service use. The results suggest that an increased focus on community-level interventions could lead to an increase in the utilization of maternal health care services in India.

How decentralisation influences the retention of primary health care workers in rural Nigeria

BACKGROUND

In Nigeria, the shortage of health workers is worst at the primary health care (PHC) level, especially in rural communities. And the responsibility for PHC - usually the only form of formal health service available in rural communities - is shared among the three tiers of government (federal, state, and local governments). In addition, the responsibility for community engagement in PHC is delegated to community health committees.

OBJECTIVE

This study examines how the decentralisation of health system governance influences retention of health workers in rural communities in Nigeria from the perspective of health managers, health workers, and people living in rural communities.

DESIGN

The study adopted a qualitative approach, and data were collected using semi-structured in-depth interviews and focus group discussions. The multi-stakeholder data were analysed for themes related to health system decentralisation.

RESULTS

The results showed that decentralisation influences the retention of rural health workers in two ways: 1) The salary of PHC workers is often delayed and irregular as a result of delays in transfer of funds from the national to sub-national governments and because one tier of government can blame failure on another tier of government. Further, the primary responsibility for PHC is often left to the weakest tier of government (local governments). And the result is that rural PHC workers are attracted to working at levels of care where salaries are higher and more regular - in secondary care (run by state governments) and tertiary care (run by the federal government), which are also usually in urban areas. 2) Through community health committees, rural communities influence the retention of health workers by working to increase the uptake of PHC services. Community efforts to retain health workers also include providing social, financial, and accommodation support to health workers. To encourage health workers to stay, communities also take the initiative to co-finance and co-manage PHC services in order to ensure that PHC facilities are functional.

CONCLUSIONS

In Nigeria and other low- and middle-income countries with decentralised health systems, intervention to increase the retention of health workers in rural communities should seek to reform and strengthen governance mechanisms, using both top-down and bottom-up strategies to improve the remuneration and support for health workers in rural communities.

REGIONAL VARIATIONS IN INFANT AND CHILD MORTALITY IN NIGERIA: A MULTILEVEL ANALYSIS

There are substantial regional disparities in under-five mortality in Nigeria, and evidence suggests that both individual- and community-level characteristics have an influence on health outcomes. Using 2008 Nigeria Demographic and Health Survey data, this study (1) examines the effects of individual- and community-level characteristics on infant/child mortality in Nigeria and (2) determines the extent to which characteristics at these levels influence regional variations in infant/child mortality in the country. Multilevel Cox proportional hazard analysis was performed on a nationally representative sample of 28,647 children nested within 18,028 mothers of reproductive age, who were also nested within 886 communities. The results indicate that community-level variables (such as region, place of residence, community infrastructure, community hospital delivery and community poverty level) and individual-level factors (including child's sex, birth order, birth interval, maternal education, maternal age and wealth index) are important determinants of infant/child mortality in Nigeria. For instance, the results show a lower risk of death in infancy for children of mothers residing in communities with a high proportion of hospital delivery (HR: 0.70, p < 0.05) and for children whose mothers had secondary or higher education (HR: 0.84, p < 0.05). Although community factors appear to influence the association between individual-level factors and death during infancy and childhood, the findings consistently indicate that community-level characteristics are more important in explaining regional variations in child mortality, while individual-level factors are more important for regional variations in infant mortality. The results of this study underscore the need to look beyond the influence of individual-level factors in addressing regional variations in infant and child mortality in Nigeria.

A community-based assessment of correlates of facility delivery among HIV-infected women in western Kenya

BACKGROUND

Childbirth at health facilities is an important strategy to reduce maternal morbidity and mortality, improve fetal outcomes, and reduce mother-to-child transmission of HIV. Although access to antenatal care in Kenya is high (>90%), less than half of births occur at health facilities. This analysis aims to assess correlates of facility delivery among recently pregnant HIV-infected women participating in a community-based survey, and to determine whether these correlates were unique when compared to HIV-uninfected women from the same region.

METHODS

Women residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention Health and Demographic Surveillance System, and who had delivered an infant in the previous year were visited at home in 2011. Consenting mothers answered a questionnaire assessing demographics, place of delivery, utilization of prevention of mother-to-child HIV transmission (PMTCT) services, and stigma indicators. Known HIV-positive women were purposively oversampled. Chi-square tests of proportions and multivariate logistic regression, stratified by HIV status, were performed to assess correlates of facility delivery.

RESULTS

Overall, 101 (46.8%) HIV-infected and 127 (39.9%) HIV-uninfected women delivered at health facilities. Among HIV-infected women, cost (42.8%), distance (18.8%) and fear of harsh treatment (15.2%) were primary disincentives for facility delivery; 2.9% noted fear of HIV testing was a disincentive. HIV-infected women who delivered at facilities had higher education (p = 0.04) and socioeconomic status (p < 0.005), initiated antenatal care (ANC) earlier (4.9 vs. 5.4 months, p = 0.016), were more likely to know partner's HIV status (p = 0.016), report satisfaction with delivery care (p = 0.001) and use antiretrovirals (87.1% vs. 77.4%, p = 0.063) compared to those with non-facility delivery. Stigma indicators were not associated with delivery location. Similar cofactors of facility delivery were noted among uninfected women.

CONCLUSIONS

Utilization of facility delivery remains low in Kenya and poses a challenge to elimination of infant HIV and reduction of peripartum mortality. Cost, distance, and harsh treatment were cited as barriers and these need to be addressed programmatically. HIV-infected women with lower socioeconomic status and those who present late to ANC should be prioritized for interventions to increase facility delivery. Partner involvement may increase use of maternity services and could be enhanced by couples counseling.

Uptake and predictors of contraceptive use in Afghan women

Background

Afghanistan has one of the world’s highest fertility rates and, related to this, an infant mortality rate far higher than its South Asian neighbors. Contraception enhances family spacing, improves women’s safety in child birth and, as a result, reduces infant and child mortality. Until recently, there has been a paucity of information on the comparative rates of contraceptive practices in the country and socioeconomic correlates of uptake. We aimed to elucidate the factors influencing the use of contraception in Afghanistan using recent, robust national data.

Methods

Using Afghanistan Mortality Survey (AMS) 2010 data, the distribution of Contraceptive Prevalence Rate (CPR) and correlates of contraceptive use among currently married women aged 15–49 years were explored. We initially summarised descriptive data on 25,743 married women and then derived predictors of the use of any form of contraception using a multiple logistic regression model.

Results

The prevalence of self-reported current use of any contraceptive method was 21.8% (95% CI: 20.4-23.4) at the national level though there was a wide variation in practice between provinces. Herat province in the West region had a highest contraceptive prevalence rate of 49.4% while Paktika in the Southeast region had the lowest CPR of 2%. Multiple logistic regression analysis showed that a family size of greater than 6 living children strongly predicted contraceptive use (AOR 7.4 (95% CI:6.1-9.0)). Other independent predictors included: secondary or high level of education (AOR 2.1 (95% CI: 1.8-2.5)) and being in the wealthiest stratum (OR 2.1 (95% CI 1.5-3.0)). Rural residence predicted a lower use of contraception (AOR, 0.72; 95% CI: 0.56-0.92).

Conclusion

Contraceptive uptake rate was low overall with wide inter provincial variation. Strengthening female education, targeting married women in rural area and women with no education may enhance the effectiveness of National Family planning program in Afghanistan.

Application of mobile technology for improving expanded program on immunization among highland minority and stateless populations in northern Thailand border

BACKGROUND

Studies of undervaccinated children of minority/stateless populations have highlighted significant barriers at individual, community, and state levels. These include geography-related difficulties, poverty, and social norms/beliefs.

OBJECTIVE

The objective of this study was to assess project outcomes regarding immunization coverage, as well as maternal attitudes and practices toward immunization.

METHODS

The "StatelessVac" project was conducted in Thailand-Myanmar-Laos border areas using cell phone-based mechanisms to increase immunization coverage by incorporating phone-to-phone information sharing for both identification and prevention. With limitation of the study among vulnerable populations in low-resource settings, the pre/post assessments without comparison group were conducted. Immunization coverage was collected from routine monthly reports while behavior-change outcomes were from repeat surveys.

RESULTS

This study revealed potential benefits of the initiative for case identification; immunization coverage showed an improved trend. Prevention strategies were successfully integrated into the routine health care workflows of immunization activities at point-of-care. A behavior-change-communication package contributes significantly in raising both concern and awareness in relation to child care.

CONCLUSIONS

The mobile technology has proven to be an effective mechanism in improving a children's immunization program among these hard-to-reach populations. Part of the intervention has now been revised for use at health centers across the country.

Prevention of mother-to-child transmission of the Human Immunodeficiency Virus: investigating the uptake and utilization of maternal and child health services in Tiko health district, Cameroon

Introduction

Despite evidence that interventions to prevent mother-to-child transmission (PMTCT) of HIV are effective in ensuring a healthy child and keeping mothers alive, there are many challenges to achieving successful interventions in Cameroon. The study was conducted to investigate factors that affect access to and utilization of maternal and child health (MCH) and PMTCT services among women in Tiko health district in Cameroon.

Methods

We conducted a cross-sectional, descriptive study on women of reproductive age who had experienced a pregnancy using a self-administered, structured questionnaire, in health facilities offering PMTCT services and in communities within the district.

Results

Four hundred and thirteen women were interviewed. The majority, 98.4%, of them attended antenatal care (ANC) during their most recent pregnancy. Of these women, 87.4% of them made at least four ANC visits. HIV testing during the first visit among the ANC attendees was 85.5%. Approximately, 92.1% of women who tested for HIV received their results on the same day. All participants reported to have given birth in a health facility during their most recent pregnancy. No education (Odds Ratio [OR] 0.11; 95% CI 0.01-0.83) and acquisition of primary education (OR 0.25; 95% CI 0.06-0.88) was associated with better male partner involvement in PMTCT.

Conclusion

The uptake of MCH/PMTCT services was high in this study. Further exploration of these levels is warranted so that this model of care and engagement can be replicated in other parts of the country where uptake is low.

Factors Associated with Men’s Awareness of Danger Signs of Obstetric Complications and Its Effect on Men’s Involvement in Birth Preparedness Practice in Southern Ethiopia, 2014

Background. Compared to average maternal mortality ratio of 8 per 100,000 live births in industrialized countries, Ethiopia has an estimated maternal mortality ratio of 676 per 100,000 live births. Maternal deaths can be prevented partially through increasing awareness of danger signs of obstetric complications and involving husbands (male) in birth preparedness practice.Methods. Community based cross-sectional study was done. All adult males with a wife or partner who lives in the selected kebeles were our study population. Data was collected by pretested and structured questionnaires and two-stage cluster sampling procedure was used in order to collect study samples. Data was cleaned and entered into Epi Info 7 and exported to SPSS (IBM-21) for further analysis. Ordinary and hierarchical logistic regression model were used and AOR with 95% CI were used to show factors and the effect of men’s awareness of danger sign on men’s involvement in birth preparedness practice.Results. Total numbers of men interviewed were 836 making a response rate of 98.9%. 42% of men had awareness of danger sign and 9.4% (95% CI: (7.42, 11.4) of men were involved in birth preparedness practice. Respondents who live in the rural area [(AOR: 8.41; (95% CI: (4.99, 14.2)], governments employee [(AOR: 3.75; (95% CI: (1.38, 10.2)], those who belong to the highest wealth quintile [(AOR: 3.09; (95% CI: (1.51, 6.34)], and husbands whose wives gave birth in the hospital [(AOR: 2.09; (95% CI: (1.29, 3.37)], health center [(AOR: 1.99; (95% CI: (1.21, 3.28)], and health post [(AOR: 2.2; (95% CI: 2.16 (1.06, 404)] were positively associated and those who had no role in the health development army [(AOR: 0.43; (95% CI: (0.26, 0.72)] were negatively associated with men’s awareness of danger signs of obstetric complications.Conclusion. The prevalence of men awareness of danger sign was low and male involvement in birth preparedness practice was very low. Since there is a low level of awareness (17.1%) particularly in the urban area and men act as gatekeepers to women’s health, the respective organization needs to review urban health extension program and give due emphasis to husband education in order that they are able to recognize danger signs of obstetric complications in a way to increase their involvement in birth preparedness practice.

Antenatal Care Services Utilization in Yobe State, Nigeria: Examining Predictors and Barriers

OBJECTIVE

In Nigeria, wide disparities exist between the different parts of the country, with the states in the North East zone having poor health resources. The objective of this study is to assess whether women's biological, sociocultural, and economic characteristics are associated with utilization of ante natal care services as measured by number of antenatal care (ANC) visits in Yobe State.

METHODS

This is a secondary data analysis of the 2008 Nigeria Demographic and Health Survey with records from 33,385 women between 15-49 years who had given birth between January 2003 and December 2008 in Yobe State. Bivariate Pearson's Chi square test and two stages of Multivariate regression analysis were conducted.

RESULTS

Women with at least primary level education (adjusted OR (AOR) = 2.40; CI 1.24 - 4.67), belonging to professional employment category (AOR = 12.07; CI 0.19 - 75.74) and those who had access to skilled health workers (AOR = 5.13; CI 2.50 - 10.52) are more likely to make the required number of ANC visits compared to those who are illiterates, unemployed and had no access to skilled health workers.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

This study demonstrated that educational level, family wealth income, and availability of skilled health worker were consistently associated with the number of ANC visits even after controlling for covariates. These three covariates are in tandem with the Millenium Development Goals (MDG) 1 - eradication of extreme poverty and hunger; MDG 2 - universal basic education; MDG 3 - gender equality; and MDG 4 - maternal mortality. There is the need for inter-sectoral holistic intervention approach.

Religion, Ethnicity and Contraceptive Use among Reproductive age Women in Nigeria

BACKGROUND

Religion and Ethnicity are the two most important factors that shape the behavioral pattern especially health seeking behaviors of the people of Nigeria. This study seeks to examine the mediatory effects of the linkage between ethnicity and religion with selected socio-demographic variables on the current use of contraception (CUC) among women of reproductive age in Nigeria.

METHODS

Nationally representative sample of 39,948 women of reproductive age (15-49 years) in the 2013 Nigerian Demographic and Health Survey (NDHS) was used. Chi-square was used to analyze the bivariate relationship between exposure variables and CUC. Multivariate logistic regression analysis was used to determine the odds ratio with the 95% confidence interval.

RESULTS

The prevalence of CUC was generally low for women of reproductive age in Nigeria, highest among the Yoruba women and lowest among the Hausa/Fulani/Kanuri/Seriberi (HFKS) women; highest among other Christian women and lowest for Muslim women and highest for Yoruba/other religion and lowest for women of Hausa/Fulani/Kanuri/Seriberi/Islam. The odds ratios showed that disparity across ethno-religious boundaries is significant.

CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS

Globally, and especially in sub-Saharan African countries, maternal mortality resulting from the abortion of unintended pregnancies pose a major challenge in health delivery system. In Nigeria, a cultural and religious heterogeneous society, current use of contraceptives by women of reproductive age is found not to be a matter of independent effects of ethnicity, religiosity and other socio-demographic variables but also dependent on the effects of interactions between the ethnicity and religion.

Poor linkages in maternal health care services-evidence on antenatal care and institutional delivery from a community-based longitudinal study in Tigray region, Ethiopia

Background

Progress towards attaining the maternal mortality and maternal health targets set by Millennium Development Goal 5 has been slow in most African countries. Assessing antenatal care and institutional delivery service utilization and their determinants is an important step towards improving maternal health care services.

Methods

Data were drawn from the longitudinal database of Kilite-Awlaelo Health and Demographic Surveillance System. A total of 2361 mothers who were pregnant and who gave birth between September 2009 and August 2013 were included in the analysis. Potential variables to explain antenatal care and institutional delivery service utilization were extracted, and descriptive statistics and logistic regression were used to determine the magnitude of maternal health care service utilization and associated factors, respectively.

Results

More than three-quarters, 76% [95% CI: 74.8%-78.2%] (n = 1806), of mothers had undergone at least one antenatal care visit during their previous pregnancy. However, only 27% [95% CI: 25.3%-28.9%] (n = 639) of mothers gave birth at a health institution. Older mothers, urban residents, mothers with higher education attainment, and farmer mothers were more likely to use antenatal care. Institutional delivery services were more likely to be used among older mothers, urban residents, women with secondary education, mothers who visited antenatal care, and mothers with lower parity.

Conclusions

Despite a relatively high proportion of mothers attending antenatal care services at least once, we found low levels of institutional delivery service utilization. Health service providers in Kilite-Awlaelo should be particularly vigilant regarding the additional maternal health needs of rural and less educated women with high parity.

Maternal complication prevention: evidence from a case-control study in southwest Nigeria

Background

The importance of strengthening maternal health services as a preventive intervention for morbidities and complications during pregnancy and delivery in developing countries cannot be over-emphasised, since use of prenatal health services improves maternal health outcomes.

Aim

This study investigated differences in risk factors for maternal complications in booked and unbooked pregnant women in Nigeria, and provided evidence for their prevention.

Setting

The study was carried out in a postnatal ward in a secondary health facility.

Methods

This was a case-control study involving booked and unbooked pregnant women who had delivered. Consecutive enrolment of all unbooked pregnant women (cases) was done, and one booked pregnant woman (control) was enrolled and matched for age with each of these. Both groups were interviewed using a questionnaire, whilst records of delivery were extracted from the hospital files. Findings were subjected to logistical regression at a significance level of p < 0.05.

Results

Booked women had a lower median length of labour (10 hours) compared to unbooked women (13 hours). More women in the booked control group (139; 35.1%) than in the unbooked case group (96; 23.6%) reported at least one type of morbidity during the index pregnancy (p = 0.0004). Booking status was associated with a likelihood of spontaneous vaginal delivery. Young maternal age, low education, rural residence and low socio-economic status were associated with less likelihood of using prenatal services. Young maternal age, low education and intervention in the delivery were associated with a likelihood of experiencing a complication of delivery.

Conclusion

Strengthening antenatal and secondary healthcare services as short- and medium-term measures might be cost-effective as a preventive strategy in complications of pregnancy, whilst socio-economic dimensions of health are accorded priority in the long term.

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.

Skilled delivery care service utilization in Ethiopia: analysis of rural-urban differentials based on national demographic and health survey (DHS) data

BACKGROUND

Despite the slight progress made on Antenatal Care (ANC) utilization, skilled delivery care service utilization in Ethiopia is still far-below any acceptable standards. Only 10% of women receive assistance from skilled birth attendants either at home or at health institutions, and as a result the country is recording a high maternal mortality ratio (MMR) of 676 per 100,000 live births (EDHS, 2011). Hence, this study aimed at identifying the rural-urban differentials in the predictors of skilled delivery care service utilization in Ethiopia.

METHODS

The study used the recent Ethiopian Demographic and Health Survey (EDHS 2011) data. Women who had at least one birth in the five years preceding the survey were included in this study. The data were analyzed using univariate (percentage), bivariate (chi-square) and multivariate (Bayesian logistic regression).

RESULTS

The results showed that of the total 6,641 women, only 15.6% received skilled delivery care services either at home or at health institution. Rural women were at greater disadvantage to receive the service. Only 4.5% women in rural areas received assistance from skilled birth attendants (SBAs) compared to 64.1 % of their urban counter parts. Through Bayesian logistic regression analysis, place of residence, ANC utilization, women's education, age and birth order were identified as key predictors of service utilization.

CONCLUSION

The findings highlight the need for coordinated effort from government and stakeholders to improve women's education, as well as strengthen community participation. Furthermore, the study recommended the need to scale up the quality of ANC and family planning services backed by improved and equitable access, availability and quality of skilled delivery care services.

Personal and environmental predictors of the intention to use maternal healthcare services in Kalomo, Zambia

Low maternal healthcare service utilization contributes to poor maternal and new born health outcomes in rural Zambia. The purpose of this study was to identify important factors influencing women's intention to use these services in Kalomo, Zambia. An interviewer-administered questionnaire was used to collect data from 1007 women of reproductive age (15-45 years) from 13 rural health centres with the lowest service utilization rates in the district. Questions included measures of (past) healthcare seeking behaviour, psychosocial variables (attitude, perceived social norms, perceived behavioural control), logistical barriers (e.g., distance to the clinic) and sociodemographic variables (e.g., age, income and education level). Overall, our findings showed that most respondents had high intention to use healthcare services. Intention was positively associated with attitude, personal norms, behavioural control, education and income levels. Conversely, intention was negatively related to perceived social norms, age and distance. Multivariate regression analysis showed that, together, these variables accounted for 41.8% of the variance in intention, with perceived behavioural control being the strongest predictor of intention, followed by geographical distance and perceived social norms. These findings suggest that public health programmes mitigating these important factors are likely to motivate pregnant women to use maternal healthcare services.

Seeking evidence to support efforts to increase use of antenatal care: a cross-sectional study in two states of Nigeria

BACKGROUND

Antenatal care (ANC) attendance is a strong predictor of maternal outcomes. In Nigeria, government health planners at state level and below have limited access to population-based estimates of ANC coverage and factors associated with its use. A mixed methods study examined factors associated with the use of government ANC services in two states of Nigeria, and shared the findings with stakeholders.

METHODS

A quantitative household survey in Bauchi and Cross River states of Nigeria collected data from women aged 15-49 years on ANC use during their last completed pregnancy and potentially associated factors including socio-economic conditions, exposure to domestic violence and local availability of services. Bivariate and multivariate analysis examined associations with having at least four government ANC visits. We collected qualitative data from 180 focus groups of women who discussed the survey findings and recommended solutions. We shared the findings with state, Local Government Authority, and community stakeholders to support evidence-based planning.

RESULTS

40% of 7870 women in Bauchi and 46% of 7759 in Cross River had at least four government ANC visits. Women's education, urban residence, information from heath workers, help from family members, and household owning motorized transport were associated with ANC use in both states. Additional factors for women in Cross River included age above 18 years, being married or cohabiting, being less poor (having enough food during the last week), not experiencing intimate partner violence during the last year, and education of the household head. Factors for women in Bauchi were presence of government ANC services within their community and more than two previous pregnancies. Focus groups cited costly, poor quality, and inaccessible government services, and uncooperative partners as reasons for not attending ANC. Government and other stakeholders planned evidence-based interventions to increase ANC uptake.

CONCLUSION

Use of ANC services remains low in both states. The factors related to use of ANC services are consistent with those reported previously. Efforts to increase uptake of ANC should focus particularly on poor and uneducated women. Local solutions generated by discussion of the evidence with stakeholders could be more effective and sustainable than externally driven interventions.

Utilization of maternal healthcare among adolescent mothers in urban India: evidence from DLHS-3

Background. Low use of maternal healthcare services is one of the reasons why maternal mortality is still considerably high among adolescents mothers in India. To increase the utilization of these services, it is necessary to identify factors that affect service utilization. To our knowledge, no national level study in India has yet examined the issue in the context urban adolescent mothers. The present study is an attempt to fill this gap. Data and Methods. Using information from the third wave of District Level Household Survey (2007-08), we have examined factors associated with the utilization of maternal healthcare services among urban Indian married adolescent women (aged 13-19 years) who have given live/still births during last three years preceding the survey. The three outcome variables included in the analyses are 'full antenatal care (ANC)', 'safe delivery' and 'postnatal care within 42 days of delivery'. We have used Chi-square test to determine the difference in proportion and the binary logistic regression to understand the net effect of predictor variables on the utilization of maternity care. Results. About 22.9% of mothers have received full ANC, 65.1% of mothers have had at least one postnatal check-up within 42 days of pregnancy. The proportion of mother having a safe delivery, i.e., assisted by skilled personnel, is about 70.5%. Findings indicate that there is considerable amount of variation in use of maternity care by educational attainment, household wealth, religion, parity and region of residence. Receiving full antenatal care is significantly associated with mother's education, religion, caste, household wealth, parity, exposure to healthcare messages and region of residence. Mother's education, full antenatal care, parity, household wealth, religion and region of residence are also statistically significant in case of safe delivery. The use of postnatal care is associated with household wealth, woman's education, full antenatal care, safe delivery care and region of residence. Conclusion. Several socioeconomic and demographic factors affect the utilization of maternal healthcare services among urban adolescent women in India. Promoting the use of family planning, female education and higher age at marriage, targeting vulnerable groups such as poor, illiterate, high parity women, involving media and grass root level workers and collaboration between community leaders and health care system could be some important policy level interventions to address the unmet need of maternity services among urban adolescents.

"It's up to the woman's people": how social factors influence facility-based delivery in Rural Northern Ghana

To explore the impact of social factors on place of delivery in northern Ghana. We conducted 72 in-depth interviews and 18 focus group discussions in the Upper East Region of northern Ghana among women with newborns, grandmothers, household heads, compound heads, community leaders, traditional birth attendants, traditional healers, and formally trained healthcare providers. We audiotaped, transcribed, and analyzed interactions using NVivo 9.0. Social norms appear to be shifting in favor of facility delivery, and several respondents indicated that facility delivery confers prestige. Community members disagreed about whether women needed permission from their husbands, mother-in-laws, or compound heads to deliver in a facility, but all agreed that women rely upon their social networks for the economic and logistical support to get to a facility. Socioeconomic status also plays an important role alone and as a mediator of other social factors. Several "meta themes" permeate the data: (1) This region of Ghana is undergoing a pronounced transition from traditional to contemporary birth-related practices; (2) Power hierarchies within the community are extremely important factors in women's delivery experiences ("someone must give the order"); and (3) This community shares a widespread sense of responsibility for healthy birth outcomes for both mothers and their babies. Social factors influence women's delivery experiences in rural northern Ghana, and future research and programmatic efforts need to include community members such as husbands, mother-in-laws, compound heads, soothsayers, and traditional healers if they are to be maximally effective in improving women's birth outcomes.

Determinants of health facility utilization for childbirth in rural western Kenya: cross-sectional study

BACKGROUND

Skilled attendance at delivery is recognized as one of the most important factors in preventing maternal death. However, more than 50% of births in Kenya still occur in non-institutional locations supported by family members and/or traditional birth attendants (TBAs). To improve this situation, a study of the determinants of facility delivery, including individual, family and community factors, was necessary to consider effective intervention in Kenya.

METHODS

This study was conducted to identify the factors which influence the place of delivery in rural western Kenya, and to recommend ways to improve women's access to skilled attendants at delivery. A community-based cross-sectional survey was carried out from August to September 2011 in all 64 sub-locations which were covered by community health workers (CHWs). An interviewer-administered questionnaire on seventeen comprehensive variables was administered to 2,560 women who had children aged 12-24 months.

RESULTS

The response rate was 79% (n = 2,026). Of the respondents, 48% of births occurred in a health facility and 52% in a non-institutional location. The significant determinants of facility delivery examined using multivariate analysis were: maternal education level, maternal health knowledge, ANC visits, birth interval, economic status of household, number of household members, household sanitation practices and traveling time to nearest health facility.

CONCLUSIONS

The results suggest that the involvement of TBAs to promote facility delivery is still one of the most important strategies. Strengthening CHWs' performance by focusing on a limited number of topics and clear management guidance might also be an effective intervention. Stressing the importance of regular attendance at ANC (at least four times) would be effective in enhancing motivation for a facility delivery. Based on our findings, those actions to improve the facility delivery rate should focus more on pregnant women who have a low education level, poor health knowledge and short pregnancy spacing. In addition, women with low economic status, a large number of family members and a long distance to travel to a health facility should also be targeted by further interventions.

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.

Factors associated with health facility childbirth in districts of Kenya, Tanzania and Zambia: a population based survey

Background

Maternal mortality continues to be a heavy burden in low and middle income countries where half of all deliveries take place in homes without skilled attendance. The study aimed to investigate the underlying and proximate determinants of health facility childbirth in rural and urban areas of three districts in Kenya, Tanzania and Zambia.

Methods

A population-based survey was conducted in 2007 as part of the ‘REsponse to ACcountable priority setting for Trust in health systems’ (REACT) project. Stratified random cluster sampling was used and the data included information on place of delivery and factors that might influence health care seeking behaviour. A total of 1800 women who had childbirth in the previous five years were analysed. The distal and proximate conceptual framework for analysing determinants of maternal mortality was modified for studying factors associated with place of delivery. Socioeconomic position was measured by employing a construct of educational attainment and wealth index. All analyses were stratified by district and urban–rural residence.

Results

There were substantial inter-district differences in proportion of health facility childbirth. Facility childbirth was 15, 70 and 37% in the rural areas of Malindi, Mbarali and Kapiri Mposhi respectively, and 57, 75 and 77% in the urban areas of the districts respectively. However, striking socio-economic inequities were revealed regardless of district. Furthermore, there were indications that repeated exposure to ANC services and HIV related counselling and testing were positively associated with health facility deliveries. Perceived distance was negatively associated with facility childbirth in rural areas of Malindi and urban areas of Kapiri Mposhi.

Conclusion

Strong socio-economic inequities in the likelihood of facility childbirths were revealed in all the districts added to geographic inequities in two of the three districts. This strongly suggests an urgent need to strengthen services targeting disadvantaged and remote populations. The finding of a positive association between HIV counselling/testing and odds in favor of giving birth at a health facility suggests potential positive effects can be achieved by strengthening integrated approaches in maternal health service delivery.

Socio-demographic determinants of maternal health-care service utilization among rural women in anambra state, South East Nigeria

BACKGROUND

Although, antenatal care (ANC) attendance in sub Saharan Africa is high, however this does not always translate into quality ANC care service utilization.

AIM

This study therefore is aimed at exploring pattern of maternal health (MH) services utilization and the socio-demographic factors influencing it in Anambra State, South East Nigeria.

SUBJECTS AND METHODS

A total of 310 women of reproductive age with a previous history of gestation attending ANC services between September, 2007 and August, 2008 in selected Primary Health Centers in Anambra State were studied. Responses were elicited from the study participants using a pre-tested, semi-structured interviewer-administered questionnaire. Data collected were analyzed using Statistical Package for Social Sciences (SPSS) version 17 (SPSS Inc, Chicago Illinois, USA). Association between socio-demographic characteristics and pattern of utilization of ANC and delivery services was measured using χ(2)-test, Regression analysis was done to identify factors associated with utilization of MH services. P < 0.05 was assumed to be significant.

RESULTS

Use of health facility was 293 (97.0%) and 277 (92,7%) out 302 women for ANC and delivery services respectively. Most women attended their first ANC consultation during the preceding pregnancy was after the first trimester and about 31% (94/298) of them had <4 ANC visits prior to delivery. Socio-demographic factors were found to be significantly associated with places where MH care services are accessed. Parity was found to be associated with timing of ANC booking and number of ANC attendance (χ(2) = 9.49, P = 0.05). Odds of utilizing formal health facility for MH services were found to be significantly associated with increasing age (P < 0.01) and educational status of mothers (P < 0.001).

CONCLUSIONS

The study revealed high maternal service utilization and 10% fetal loss, hence the need to address the gaps of late ANC booking and low ANC visits.

Orthodox versus unorthodox care: A qualitative study on where rural women seek healthcare during pregnancy and childbirth in Southwest, Nigeria

INTRODUCTION

Utilization of orthodox health facilities for maternal health services is determined by factors operating at the individual, household, community and state level. The prevalence of small family norm is one of the identified variables operating within the community which influences the decision of where to access care (orthodox/traditional). The objective of the study was to determine the use of orthodox versus unorthodox maternity healthcare and determinants among rural women in southwest Nigeria.

METHODS

A qualitative study was done and involved three focus group discussions. A semi-structured interview guide was used to collect information from women of reproductive age group within a rural Local Government Area in Lagos state.

RESULTS

Most of the women access some form of healthcare during pregnancy, orthodox, unorthodox or both. Those who patronize both services concurrently do so to benefit from the two as each has some unique features such as herbal concoctions for traditional, ultrasound and immunization of babies for orthodox. Traditional belief exerts a strong influence on decision of where to access maternal healthcare services. Actual place of delivery is determined by individual and household factors including financial resources.

CONCLUSION

Rural women utilize one or both orthodox and unorthodox maternal health services for different reasons. Ward Development Committees should be strengthened so as to reach the communities, educate and convince women to dispel myths which limit their use of orthodox care. Training and monitoring of Traditional Birth Attendants (TBAs) are vital to eliminate harmful practices. We also recommend improved financial access to orthodox healthcare.

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 maternal health service utilization in Ethiopia: analysis of the 2011 Ethiopian Demographic and Health Survey

BACKGROUND

Antenatal Care (ANC), use of skilled delivery attendants and postnatal care (PNC) services are key maternal health services that can significantly reduce maternal mortality. Understanding the factors that affect service utilization helps to design appropriate strategies and policies towards improvement of service utilization and thereby reduce maternal mortality. The objective of this study was to identify factors that affect utilization of maternal health services in Ethiopia.

METHODS

Data were drawn from the 2011 Ethiopia Demographic and Health Survey. The dependent variables were use of ANC, skilled delivery attendants and PNC services. The independent variables were categorized as socio-cultural, perceived needs and accessibility related factors. Data analysis was done using SPSS for windows version 20.0. Bivariate and multivariate logistic regression models were used in the analysis.

RESULTS

Thirty four percent of women had ANC visits, 11.7% used skilled delivery attendants and 9.7% of women had a postnatal health checkup. Education of women, place of residence, ethnicity, parity, women's autonomy and household wealth had a significant association with the use of maternal health services. Women who completed higher education were more likely to use ANC (AOR = 3.8, 95% CI = 1.8-7.8), skilled delivery attendants (AOR = 3.4, 95% CI = 1.9-6.2) and PNC (AOR = 3.2, 95% CI = 2.0-5.2). Women from urban areas use ANC (AOR = 2.3, 95% CI = 1.9-2.9), skilled delivery attendants (AOR = 4.9, 95% CI = 3.8-6.3) and PNC services (AOR = 2.6, 95% CI = 2.0-3.4) more than women from rural areas. Women who have had ANC visits during the index pregnancy were more likely to subsequently use skilled delivery attendants (AOR = 1.3, 95% CI = 1.1-1.7) and PNC (AOR = 3.4, 95% CI = 2.8-4.1). Utilization of ANC, delivery and PNC services is more among more autonomous women than those whose spending is controlled by other people.

CONCLUSION

Maternal health service utilization in Ethiopia is very low. Socio-demographic and accessibility related factors are major determinants of service utilization. There is a high inequality in service utilization among women with differences in education, household wealth, autonomy and residence. ANC is an important entry point for subsequent use of delivery and PNC services. Strategies that aim improving maternal health service utilization should target improvement of education, economic status and empowerment of women.

Antenatal care visit attendance, intermittent preventive treatment during pregnancy (IPTp) and malaria parasitaemia at delivery

Background

The determinants and barriers for delivery and uptake of IPTp vary with different regions in sub-Saharan Africa. This study evaluated the determinants of ANC clinic attendance and IPTp-SP uptake among parturient women from Mount Cameroon Area and hypothesized that time of first ANC clinic attendance could influence uptake of IPTp-SP/dosage and consequently malaria parasite infection status at delivery.

Methods

Two cross sectional surveys were carried out at the Government Medical Centre in the Mutengene Health Area, Mt Cameroon Area from March to October 2007 and June 2008 to April 2009. Consented parturient women were consecutively enrolled in both surveys. In 2007, socio-demographic data, ANC clinic attendance, gestational age, fever history and reported use/dosage of IPTp-SP were documented using a structured questionnaire. In the second survey only IPT-SP usage/dosage was recorded. Malaria parasitaemia at delivery was determined by blood smear microscopy and placental histology.

Results and discussion

In 2007, among the 287 women interviewed, 2.2%, 59.7%, and 38.1% enrolled in the first, second and third trimester respectively. About 90% of women received at least one dose SP but only 53% received the two doses in 2007 and by 2009 IPTp-two doses coverage increased to 64%. Early clinic attendance was associated (P = 0.016) with fever history while being unmarried (OR = 2.2; 95% CI: 1.3-3.8) was significantly associated with fewer clinic visits (<4visits). Women who received one SP dose (OR = 3.7; 95% CI: 2.0-6.8) were more likely not to have attended ≥ 4visits. A higher proportion (P < 0.001) of women with first visit during the third trimester received only one dose, meanwhile, those who had an early first ANC attendance were more likely (OR = 0.4; 95% CI = 0.2 - 0.7) to receive two or more doses. Microscopic parasitaemia at delivery was frequent (P = 0.007) among women who enrolled in the third trimester and had received only one SP dose than in those with two doses.

Conclusion

In the study area, late first ANC clinic enrolment and fewer clinic visits may prevent the uptake of two SP doses and education on early and regular ANC clinic visits can increase IPTp coverage.

Factors associated with place of delivery in rural Nepal

BACKGROUND

Promotion of institutional delivery is a key intervention in reducing maternal mortality and improving maternal and neonatal health. This study explored factors associated with institutional delivery in rural Nepal.

METHOD

A household survey was conducted in three rural Village Development Committees of Kavrepalanchowk district to identify the individual, household and health service factors associated with the institutional delivery. All 240 eligible mothers from the study area were interviewed during the study period. Multiple logistic regression analysis was applied to establish the factor associated with the institutional delivery, the outcome variable.

RESULTS

Antenatal care practice, adverse pregnancy outcome, ethnicity and time taken to reach the health institution were significantly associated with the institutional delivery. Utilization of an antenatal care service had the greatest effect on institutional delivery.

CONCLUSION

Universal antenatal care service utilization may be a critical intervention for increasing institutional delivery. There is a need to raise awareness in hard-to-reach areas where adverse pregnancy outcomes is not considered a serious event.

Barriers to accessing health care in Nigeria: implications for child survival

BACKGROUND

Existing studies indicate that about one in every six children dies before age five in Nigeria. While evidence suggests that improved access to adequate health care holds great potential for improved child survival, previous studies indicate that there are substantial barriers to accessing health care in Nigeria. There has not been a systematic attempt to examine the effects of barriers to health care on under-five mortality in Nigeria. This study is designed to address this knowledge gap.

DATA AND METHOD

Data came from a nationally representative sample of 18,028 women (aged 15-49) who had a total of 28,647 live births within the 5 years preceding the 2008 Nigeria Demographic and Health Survey. The risk of death in children below age five was estimated using Cox proportional hazard models and results are presented as hazards ratios (HR) with 95% confidence intervals (CI).

RESULTS

Results indicate higher under-five mortality risks for children whose mothers had cultural barriers and children whose mothers had resource-related barriers to health care (HR: 1.44, CI: 1.32-1.57, p<0.001), and those whose mothers had physical barriers (HR: 1.13, CI: 1.04-1.24, p<0.001), relative to children whose mothers reported no barriers. Barriers to health care remained an important predictor of child survival even after adjusting for the effects of possible confounders.

CONCLUSION

Findings of this study stressed the need for improved access to adequate health care in Nigeria through the elimination of barriers to access. This would enable the country to achieve a significant reduction in childhood mortality.

Ethnic differentials in under-five mortality in Nigeria

OBJECTIVE

There are huge regional disparities in under-five mortality in Nigeria. While a region within the country has as high as 222 under-five deaths per 1000 live births, the rate is as low as 89 per 1000 live births in another region. Nigeria is culturally diverse as there are more than 250 identifiable ethnic groups in the country; and various ethnic groups have different sociocultural values and practices which could influence child health outcome. Thus, the main objective of this study was to examine the ethnic differentials in under-five mortality in Nigeria.

DESIGN

The study utilized 2008 Nigeria Demographic and Health Survey (NDHS) data. We analyzed data from a nationally representative sample drawn from 33,385 women aged 15-49 that had a total of 104,808 live births within 1993-2008. In order to examine ethnic differentials in under-five mortality over a sufficiently long period of time, our analysis considered live births within 15 years preceding the 2008 NDHS. The risks of death in children below age five were estimated using Cox proportional regression analysis. Results were presented as hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

The study found substantial differentials in under-five mortality by ethnic affiliations. For instance, risks of death were significantly lower for children of the Yoruba tribes (HR: 0.39, CI: 0.37-0.42, p < 0.001), children of Igbo tribes (HR: 0.58, CI: 0.55-0.61, p < 0.001) and children of the minority ethnic groups (HR: 0.66, CI: 0.64-0.68, p < 0.001), compared to children of the Hausa/Fulani/Kanuri tribes. Besides, practices such as plural marriage, having higher-order births and too close births showed statistical significance for increased risks of under-five mortality (p < 0.05).

CONCLUSION

The findings of this study stress the need to address the ethnic norms and practices that negatively impact on child health and survival among some ethnic groups in Nigeria.

Factors associated with the use and quality of antenatal care in Nepal: a population-based study using the demographic and health survey data

BACKGROUND

Good quality antenatal care (ANC) reduces maternal and neonatal mortality and improves health outcomes, particularly in low-income countries. Quality of ANC is measured by three dimensions: number of visits, timing of initiation of care and inclusion of all recommended components of care. Although some studies report on predictors of the first two indicators, no studies on the third indicator, which measures quality of ANC received, have been conducted in Nepal. Nepal follows the World Health Organization's recommendations of initiation of ANC within the first four months of pregnancy and at least four ANC visits during the course of an uncomplicated pregnancy. This study aimed to identify factors associated with 1) attendance at four or more ANC visits and 2) receipt of good quality ANC.

METHODS

Data from Nepal Demographic and Health Survey 2011 were analysed for 4,079 mothers. Good quality ANC was defined as that which included all seven recommended components: blood pressure measurement; urine tests for detecting bacteriuria and proteinuria; blood tests for syphilis and anaemia; and provision of iron supplementation, intestinal parasite drugs, tetanus toxoid injections and health education.

RESULTS

Half the women had four or more ANC visits and 85% had at least one visit. Health education, iron supplementation, blood pressure measurement and tetanus toxoid were the more commonly received components of ANC. Older age, higher parity, and higher levels of education and household economic status of the women were predictors of both attendance at four or more visits and receipt of good quality ANC. Women who did not smoke, had a say in decision-making, whose husbands had higher levels of education and were involved in occupations other than agriculture were more likely to attend four or more visits. Other predictors of women's receipt of good quality ANC were receiving their ANC from a skilled provider, in a hospital, living in an urban area and being exposed to general media.

CONCLUSIONS

Continued efforts at improving access to quality ANC in Nepal are required. In the short term, less educated women from socioeconomically disadvantaged households require targeting. Long-term improvements require a focus on improving female education.

Spatial analysis of choice of place of delivery in Nigeria

OBJECTIVE

Access to quality healthcare during childbirth is a crucial factor for taming maternal and child mortality and morbidity. Increasing this access in developing countries depends on understanding the factors influencing maternal healthcare decision at a geographical location. This study analyzes spatial pattern in choice of place of delivery in Nigeria.

METHOD

Data analyzed came from Nigerian Demographic and Health Survey data set. The choice of place delivery was considered a multi-categorical response and a multinomial logistic regression model used to evaluate spatial variations in choosing a particular place to deliver against home delivery.

RESULTS

Results show a north-south divide in choosing health facilities against homes for delivery. The likelihood of institutional delivery was significantly lower for women residing in Bayelsa and the majority of the states in northern Nigeria. As women advance in age, they have more likelihood of having institutional deliveries. Other contributing factors that favor institutional deliveries include use of antenatal care services, urban dwelling, mass media and parity.

CONCLUSION

Usage of mass media to campaign for institutional deliveries particularly in northern Nigeria, among younger women and those of higher parity; encouraging the use of antenatal services and even distribution of health facilities making them easily accessible to rural women are important for enhancing chances of institutional deliveries. Also, state-specific policies in this regard are indispensable.