Predictors of Health Care Seeking Behavior During Pregnancy, Delivery, and the Postnatal Period in Rural Tanzania

Are populations of postpartum women differentially served by community health worker programs: an observational cohort study from Zanzibar, Tanzania

BACKGROUND

Although community health worker (CHW) programs focus on improving access to healthcare, some individuals may not receive the intended quality or quantity of an intervention. The objective of this research was to examine if certain populations of pregnant women differentially experience the implementation of a community health worker-led maternal health intervention in Zanzibar.

METHODS

We included pregnant women enrolled in the Safer Deliveries (Uzazi Salama) program, which operated in 10 of 11 districts in Zanzibar, Tanzania between January 1, 2017, and June 19, 2019 (N = 33,914). The outcomes of interest were receipt of the entire postpartum intervention (three CHW visits) and time to first postpartum CHW visit (days). Visits by CHWs were done at the women's home, however, a telehealth option existed for women who were unable to be reached in-person. We conducted statistical tests to investigate the bivariate associations between our outcomes and each demographic and health characteristic. We used multivariate logistic regression to estimate the relationships between covariates and the outcomes and multivariate linear regression to estimate the association between covariates and the average time until first postpartum visit.

RESULTS

Higher parity (OR = 0.85; P = 0.014; 95%CI: 0.75-0.97), unknown or unreported HIV status (OR = 0.64; p < 0.001; 95%CI: 0.53-0.78), and receipt of phone consultations (OR = 0.77; p < 0.001; 95%CI: 0.69-0.87) were associated with a lower odds of receiving all postpartum visits. Similarly, women with an unknown or unreported HIV status (estimated mean difference of 1.81 days; p < 0.001; 95%CI: 1.03-2.59) and those who received a phone consultation (estimated mean difference of 0.83 days; p < 0.001; 95%CI: 0.43-1.23), on average, experienced delays to first visit. In addition, current delivery at a referral hospital was associated with lower odds of receiving a postpartum visit and longer time to first visit compared to delivery at home, cottage hospital, PHCU + , or district hospital. Women from all other districts received their first visit earlier than women from Kaskazini B. There were no differences in the odds of receiving the entire postpartum intervention by sociodemographic variables, including age, education, and poverty assessment indicators.

CONCLUSION

The results indicate no differences in intervention contact across wealth and education levels, suggesting that the program is effectively reaching women regardless of SES. However, women with other characteristics (e.g., higher parity, unknown or unreported HIV status) had lower odds of receiving the complete intervention. Overall, this work generates knowledge on existing disparities in intervention coverage and enables future programs to develop approaches to achieve equity in health care utilization and outcomes.

Factors associated with maternal health services utilization in Pakistan: Evidence from Pakistan maternal mortality survey, 2019

BACKGROUND

This study investigates the factors associated with maternal health services utilization in Pakistan using two outcome indicators, ideal antenatal care (IANC), defined as the pregnant woman receiving all the essential services included in standard antenatal care, and skilled birth attendance (SBA).

METHODS

This study used the Pakistan Maternal Mortality Survey 2019 data. The study utilized binary logistic regression models to investigate the adjusted association between the outcome variables, separately for IANC and SBA, and the independent variables, education, wealth, parity, and residence.

RESULTS

Wealth showed a positive association with utilization of IANC (adjusted odds ratio [AOR] = 11.48, 95% CI = 7.76, 16.99) and SBA (AOR = 4.37, 95% CI = 3.30,5. 80). Maternal age was associated only with IANC for women aged 35 or more years (AOR = 1.31, 95% CI = 1.06, 1.62). Increased likelihood of utilization of IANC and SBA services was also observed for women with formal education. Women who had 3-5 previous live births had higher odds of using IANC and SBA than women who had 1-2 or more than five previous live births. Urban residency was not correlated with either IANC or SBA.

CONCLUSION

When compared to the wealthy and educated quintile, women in the lower wealth quintile and those without any formal education were less likely to utilize ANC and SBA services. A comprehensive and multipronged approach from the health and education sectors is needed to improve maternal health in Pakistan.

Maternal healthcare utilization in rural Bangladesh: A comparative analysis between high and low disaster-prone areas

This study examined the disparity in antenatal care (ANC) visits and institutional delivery between high-disaster-prone (HDP) and low-disaster-prone (LDP) areas, defined based on multi-hazards, in Bangladesh and assessed the influencing factors using Andersen's behavioral model. In this study, cross-sectional data of 345 mothers, who had live birth the year preceding the survey, were used from the second-round multipurpose survey of a longitudinal research project conducted in May-June 2011. Hierarchical multinomial logistic and binary logistic models were respectively used to assess the determinants of ANC contacts and choice of childbirth place. We found very low utilization of 4+ ANC visits in both HDP (20%) and LDP (15%) areas. The difference is also not significant. The strong influencing factors of receiving 4+ ANC were mother's education, household size, income, and proximity to health facility. The level of institutional delivery was also low (21%), and no significant difference between HDP (15.2%) and LDP (25.7%) was found. However, in the case of institutional delivery, significant (p-value ≤ .01) difference was found in C-section between HDP (42%) and LDP (79%). A significant (p-value ≤ .05) difference was also found in the attendance of graduate doctors/gynecologists between HDP (58%) and LDP (88%). Mothers of HDP areas were 52 percent less likely to choose institutional delivery compared to those of LDP areas. Moreover, there was 30 percent less likelihood of choosing institutional delivery with an increase in distance to the nearest health facility. Specific demand-side (e.g., awareness raising, expanding maternal voucher scheme, covering more mothers under maternal allowance, and facilitating more income-generating activities especially off-farm ones) and supply-side interventions (e.g., providing training to local traditional birth attendants, and deployment of boat-based medical teams in coastal and char areas) need to be undertaken to increase institutional delivery, especially in HDP areas. However, the ultimate solution depends on adopting long-term measures to prepare facilities ready by filling the vacant posts and reducing absenteeism. Public-private partnerships modality can also be introduced especially in the HDP areas. Policy attention is needed to introduce such interventions.

Completion of the continuum of maternity care and associated factors among women who gave birth in the last 6 months in Chelia district, West Shoa zone, Ethiopia: A community-based cross-sectional study

Background

The continuum of maternity care is a continuity of care that a woman receives during pregnancy, childbirth, and the postpartum period from skilled providers in a comprehensive and integrated manner. Despite existing evidence regarding maternal healthcare services discretely, the continuum of maternity care and its associated factors are not well-known in Ethiopia.

Objective

This study assessed the completion of the maternity continuum of care and associated factors among women who gave birth 6 months prior to the study in the Chelia district.

Methods

A community-based cross-sectional study with a stratified random sampling technique was conducted among 428 mothers at 10 randomly selected kebeles. Pretested and structured questionnaires were used to collect data. Bi-variable and multivariable logistic regression analyzes were performed to identify associated factors. Adjusted odds ratio with its 95% confidence interval was used to determine the degree of association, and statistical significance was declared at a p-value of <0.05.

Results

In this study, 92 (21.5%) mothers completed the continuum of maternity care. Secondary and above education of mothers (AOR = 4.20, 95% CI:1.26-13.97), ≤30 min spent on walking by foot (AOR = 4.00, 95% CI: 1.67-9.58), using an ambulance to reach health facility (AOR = 3.68, 95% CI: 1.23-11.06), para ≥5 mothers (AOR = 0.21, 95% CI: 0.05-0.90), planned pregnancy (AOR = 3.29, 95% CI: 1.02-10.57), attending pregnant women's conference (AOR = 13.96, 95% CI: 6.22-31.30), early antenatal care booking (AOR = 3.30, 95% CI: 1.54-7.05), accompanied by partners (AOR = 3.64, 95% CI: 1.76-7.53), and informed to return for postnatal care (AOR = 3.57, 95% CI: 1.47-8.70) were the factors identified.

Conclusion

In this study, completion of the maternity continuum of care was low. Therefore, appropriate strategic interventions that retain women in the continuum of maternity care by targeting those factors were recommended to increase the uptake of the continuum of maternity care.

Evaluation of a comprehensive maternal newborn health intervention in rural Tanzania: single-arm pre-post coverage survey results

Background

In Tanzania, maternal and newborn deaths can be prevented via quality facility-based antenatal care (ANC), delivery, and postnatal care (PNC). Scalable, integrated, and comprehensive interventions addressing demand and service-side care-seeking barriers are needed.

Objective

Assess coverage survey indicators before and after a comprehensive maternal newborn health (MNH) intervention in Misungwi District, Tanzania.

Methods

A prospective, single-arm, pre- (2016) and post-(2019) coverage survey (ClinicalTrials.gov #NCT02506413) was used to assess key maternal and newborn health (MNH) outcomes. The Mama na Mtoto intervention included district activities (planning, leadership training, supportive supervision), health facility activities (training, equipment, infrastructure upgrades), and plus community health worker mobilization. Implementation change strategies, a process model, and a motivational framework incorporated best practices from a similar Ugandan intervention. Cluster sampling randomized hamlets then used ‘wedge sampling’ protocol as an alternative to full household enumeration. Key outcomes included: four or more ANC visits (ANC4+); skilled birth attendant (SBA); PNC for mother within 48 hours (PNC-woman); health facility delivery (HFD); and PNC for newborn within 48 hours (PNC-baby). Trained interviewers administered the ‘Real Accountability: Data Analysis for Results Coverage Survey to women 15–49 years old. Descriptive statistics incorporated design effect; the Lives Saved Tool estimated deaths averted based on ANC4+/HFD.

Results

Between baseline (n = 2,431) and endline (n = 2,070), surveys revealed significant absolute percentage increases for ANC4+ (+11.6, 95% CI [5.4, 17.7], p < 0.001), SBA (+16.6, 95% CI [11.1, 22.0], p < 0.001), PNC-woman (+9.2, 95% CI [3.2, 15.2], p = 0.002), and HFD (+17.2%, 95% CI [11.3, 23.1], p < 0.001). A PNC-baby increase (+6.1%, 95% CI [−0.5, 12.8], p = 0.07) was not statistically significant. An estimated 121 neonatal and 20 maternal lives were saved between 2016 and 2019.

Conclusions

Full-district scale-up of a comprehensive MNH package embedded government health system was successfully implemented over a short time and associated with significant maternal care-seeking improvements and potential for lives saved.

Home based postpartum care and determinants in Ethiopia: A multilevel analysis

INTRODUCTION

Neonatal mortality remains a persisting public health challenge in Ethiopia. Timely intervention to neonatal morbidity and early neonatal care visit could reduce the burden of mortality. Studies related to home based postnatal care is limited in Ethiopia. Therefore, this study aimed to assess home based postnatal care visits and determinants in Ethiopia.

METHODS

A secondary data analysis using 2016 EDHS data was conducted among 7590 women who had live births two years preceding the survey. A multilevel mixed-effect logistic regression analysis model was used and those variables with a P-value ≤ of 0.05 in multivariable analysis were considered as predictors. Results: Home based postpartum care by health care providers was 6.3% and 67.9% of women gave birth at home. Women perceived that distance is not big problem [AOR = 1.37; 95% CI: 1.06, 1.68], richer wealth index [AOR = 1.69; 95% CI: 1.15, 2.48], attending antenatal care visit [AOR = 2.17; 95% CI:1.57, 2.99], giving birth in health institution [AOR = 2.07; 95% CI:1.53, 2.80], giving birth by cesarean section [AOR = 3.41; 95% CI: 2.33, 4.99], and having awareness about neonatal danger sign [AOR = 3.68; 95% CI: 2.90,4.70] were factors associated with home based postpartum care.

CONCLUSION

Home based care by health care providers was low. Therefore, measures should be taken in increasing the number of nearby health care facility, strengthen the continuum of care on antenatal care follow-up, institutional delivery and improve mother's knowledge about neonatal danger sign.

Prevalence and determinants of maternal healthcare utilisation among young women in sub-Saharan Africa: cross-sectional analyses of demographic and health survey data

BACKGROUND

Maternal health constitutes high priority agenda for governments across the world. Despite efforts by various governments in sub-Saharan Africa (SSA), the sub-region still records very high maternal mortality cases. Meanwhile, adequate utilization of maternal healthcare (antenatal care [ANC], skilled birth attendance [SBA], and Postnatal care [PNC]) plays a vital role in achieving improved maternal health outcomes. We examined the prevalence and determinants of maternal healthcare utilization among young women in 28 sub-Saharan African countries using data from demographic and health surveys.

METHODS

This was a cross-sectional study of 43,786 young women aged 15-24 years from the most recent demographic and health surveys of 28 sub-Saharan African countries. We adopted a multilevel logistic regression analysis in examining the determinats of ANC, SBA, and PNC respectively. The results are presented as adjusted Odds Ratios (aOR) for the logistic regression analysis. Statistical significance was set at p < 0.05.

RESULTS

The prevalence of maternal healthcare utilisation among young women in SSA was 55.2%, 78.8%, and 40% for ANC, SBA, and PNC respectively with inter-country variations. The probability of utilising maternal healthcare increased with wealth status. Young women who were in the richest wealth quintile were, for instance, 2.03, 5.80, and 1.24 times respectively more likely to utilise ANC (95% CI = 1.80-2.29), SBA (95% CI = 4.67-7.20), and PNC (95% CI = 1.08-1.43) than young women in the poorest wealth quintile. Young women who indicated having a barrier to healthcare utilisation were, however, less likely to utilise maternal healthcare (ANC: aOR = 0.83, 95% CI = 0.78-0.88; SBA: aOR = 0.82, 95% CI = 0.75-0.88; PNC: aOR = 0.88, 95% CI = 0.83-0.94).

CONCLUSION

While SBA utilisation was high, we found ANC and PNC utilisation to be quite low among young women in SSA with inter-country variations. To accelerate progress towards the attainment of the Sustainable Development Goal (SDG) targets on reducing maternal mortality and achieving universal health coverage, our study recommends the adoption of interventions which have proven effective in some countries, by countries which recorded low maternal healthcare utilisation. The interventions include the implementation of free delivery services, training and integration of TBAs into orthodox maternal healthcare, improved accessibility of facilities, and consistent public health education. These interventions could particularly focus on young women in the lowest wealth quintile, those who experience barriers to maternal healthcare utilisation, uneducated women, and young women from rural areas.

Primary Health Care during the COVID-19 pandemic in Fortaleza, Brazil: associated factors and pattern of use by mothers and children up to 18 months of age

ABSTRACT Objective: To analyze the delay or failure to seek primary health care by the mother-child dyads during the COVID-19 pandemic, a practice that has a high potential to increase maternal and child morbidity and mortality. Methods: Data from three survey rounds of the Iracema-COVID cohort study, collected 6, 12, and 18 months after birth, showed the patterns of postpartum attendance to primary health care consultation of the mother-child dyad. Crude and adjusted multinomial logistic regressions with robust variance were used to assess factors associated with nonattendance. Results: Among the 314 cohort mothers, 25% did not attend any primary health care consultation during the 18-months postpartum, while 30% of the mothers did all three. Regarding the child, 75% had regular primary health care consultations in all three survey rounds, while 4% did not attend any in their first 18 months of life. By the end of the first COVID-19 wave, the proportion of mother and child who attended the consultations had fallen by 23 and 18%, respectively. The main factors associated with nonattendance were mothers aged below 25 years, and mothers with more than one child. Conclusion: An important delay or nonattendance to primary health care consultation by the mother-child dyad was observed during the COVID-19 pandemic. Such practice, with a high potential to increase maternal and child morbidity and mortality, was particularly frequent among younger mothers and those with more than one child.

Mother's care-seeking behavior for neonatal danger signs from qualified providers in rural Bangladesh: A generalized structural equation modeling and mediation analysis

BACKGROUND

Neonatal deaths contribute to nearly half (47%) of under-five mortality globally and 67% in Bangladesh. Despite high neonatal mortality, care-seeking from qualified providers for newborn danger signs remains low. Identification of direct and indirect factors and their pathways affecting care-seeking will help to design a well-targeted intervention. This study assessed the direct, indirect, and total effect of the predictive factors on neonatal care-seeking in Bangladesh.

MATERIALS AND METHODS

This was a cross-sectional baseline household survey conducted in 14 districts of Bangladesh in 2019 with 17,251 recently delivered women (RDW) with a live birth outcome in the preceding 15 months. We used a two-stage stratified cluster sampling process to select the samples from 14 districts. We investigated the inter-relationship of maternal background characteristics, maternal health utilizations, child/neonate factors, health service delivery-related factors and newborn danger sign knowledge with newborn care-seeking practices and estimated the direct, indirect, and total effects using Generalized Structural Equation Modeling (GSEM) and mediation analysis. p-value = 0.05 was considered statistically significant. The result of the mediation analysis was reported in Log Odds (LOD). The positive LOD (LOD > 0) implies a positive association.

RESULTS

Half of the mothers (50.8%) reported a neonatal illness and among them, only 36.5% mothers of sick neonates sought care from qualified providers. Our mediation analysis showed that maternal health utilization factors, i.e., 4 + antenatal care visits (ANC) from a qualified provider (LOD: 0.63, 95% CI: 0.49, 0.78), facility delivery (LOD: 0.74, 95% CI: 0.30, 1.17) and postnatal care (PNC) from a qualified provider (LOD: 0.50, 95% CI: 0.21, 0.78) showed the highest total effect over other factors domains, and therefore, were the most important modifiable predictors for qualified neonatal care-seeking. Other important factors that directly and/or indirectly increased the chance of newborn care-seeking from qualified providers were household wealth (LOD: 0.86, 95% CI: 0.70, 1.02), maternal education (LOD: 0.48, 95% CI: 0.32, 0.63), distance to nearest health facility (LOD: 0.20, 95% CI: 0.10, 0.30), community health worker's (CHWs) home visits during ANC (LOD: 0.24, 95% CI: 0.13, 0.36), neonatal danger sign counseling after delivery (LOD: 0.20, 95% CI: 0.06, 0.34) and women's knowledge of neonatal danger signs (LOD: 0.37, 95% CI: 0.09, 0.64).

CONCLUSION

The inter-relationship and highest summative effect of ANC, facility delivery, and PNC on newborn care-seeking suggested the maternal care continuum altogether from ANC to facility delivery and PNC to improve care-seeking for the sick newborn. Additionally, referral training for unqualified providers, targeted intervention for poorer households, increasing CHWs home visits and neonatal danger sign counseling at the facility and community should also be considered.

Antenatal Care Practices Among Hard-to-Reach Fishing Communities on Lake Victoria: A Community-Based Cross-Sectional Survey

Background: Uganda has one of the highest maternal deaths in sub-Saharan Africa, with a mortality ratio of 336 per 100 000 live births. Early regular antenatal care (ANC) helps prevent adverse outcomes, including deaths, through prevention, identification, treatment, and/or referral of at-risk women. We explored ANC practices and associated factors among women from hard-to-reach Lake Victoria islands fishing communities in Kalangala district, Uganda. Methods: A cross-sectional survey among 486 consenting women aged 15 to 49 years, who were pregnant or had a birth or abortion in the past 6 months was conducted in 6 island fishing communities of Kalangala district, Uganda, during January to May 2018. ODK software interviewer-administered questionnaires were used to collect data on sociodemographics and ANC practices. Regression modeling using STATA version 15 was used to determine factors associated with ANC visits. Results: Women’s median (range) age was 26 (15-45) years, 63% (304/486) had up to primary level education, 45% (219/486) were housewives (stay home mums), 87% (423/486) were married. ANC visits ranged from 0 to 10, with over three-fifths of women having their first visit late after 3 months of being pregnant (63%, 198/316). Women without a history of pregnancy loss (adjusted odds ratio [AOR] = 1.8, 95% CI 1.1-3.0), those not staying with their partners (AOR = 2.5, 95% CI 1.1-6.0), and those whose partners were working in fishing-related activities (AOR = 1.8, 95% CI 1.0-3.0) were likely to have started care late. Women from communities with a public health facility and those with partners working in none fishing-related activities had the highest predicted number of visits. Conclusion: Antenatal practices among these communities are characterized by late start of care. Community-led early ANC awareness interventions are needed. Targeted health policies need to consider public ANC facilities for each island for improved antenatal outcomes and maternal health.

Association between WASH-Related Behaviors and Knowledge with Childhood Diarrhea in Tanzania

BACKGROUND

Diarrhea remains a major cause of morbidity and mortality among children in Tanzania. The purpose of this study was to explore associations between diarrheal disease and water, sanitation, and hygiene (WASH) related behaviors and determine care-seeking predictors for diarrheal disease.

METHODS

Data from 9996 female primary caregivers were collected as part of a larger integrated nutrition program. Logistic regression was used to measure associations between predictor and dependent variables and diarrheal and care-seeking outcomes.

RESULTS

Knowledge of the importance of handwashing after assisting a child who has defecated (OR 0.79, CI 0.72-0.87), before preparing food (OR 0.88, CI 0.80-0.97), and before feeding a child (OR 0.89, CI 0.81-0.99) were each associated with not having a child with diarrhea in the past two weeks. Fathers or male caregivers (OR 0.65, CI 0.48-0.89) were less likely to seek medical care for a child with diarrhea. No associations were found between WASH-related knowledge or behavior and seeking medical care for a child with diarrhea.

CONCLUSIONS

Findings indicate that knowledge of handwashing importance was significant in washing hands after assisting a child who has defecated, before preparing food, and prior to feeding a child. These findings demonstrate the value of parental involvement to lower morbidity and mortality among children.

Sociodemographic characteristics associated with the utilization of maternal health services in Cambodia

Background

Cambodia is a Southeast Asian country and has one the highest rates of maternal and child mortality with inadequate use of maternal healthcare services in the region. The present study aimed to analyse the progress made in terms of using maternal healthcare services since 2000.

Methods

Two rounds of Demographic and Health Surveys (DHS 2000 and DHS 2014) were used in the study. Sample population consisted 11,961 women aged between 15 and 49 years. The outcome measures were: Timing of first antenatal care (ANC) attendance, adequacy of ANC attendance, place of delivery and postnatal checkup. WHO guidelines were used to set the cut-off/define these measures. Data were analyzed in Stata version 14 using descriptive and multivariate regression analyses.

Results

Findings indicated that the overall prevalence of making the first ANC visit in the first trimester was 64.19% [95%CI = 62.22,66.11], and that of having at least four ANC visits was 43.80% [95%CI = 41.89,45.73]. Prevalence of health facility delivery was 48.76% [46.62,50.90] and that of postnatal checkup was 71.14% [95%CI = 69.21,73.01]. Between 2000 and 2014, the percentage of timely and adequate use of ANC increased by respectively 61.8 and 65.3%, while that of health facility delivery and postnatal care increased by respectively 74.5 and 43.9%. Important demographic, socioeconomic and geographic disparities were observed in the utilization of ANC, health facility delivery and postnatal care services. Urban residency, having better educational status, white collar job, access to electronic media showed positive association, whereas higher parity (having > 2 children) and unwanted pregnancy showed negative association with the use of maternal healthcare services. Having at least four ANC visits was associated with significantly increased higher odds of using health facility delivery and postnatal care.

Conclusion

There has a been a remarkable increase in the prevalence of women who are using the maternal healthcare services since 2000. The current findings provide important insights regarding the sociodemographic factors associated with the utilization of maternal health services in Cambodia that could contribute to evidence-based health policy making and designing intervention programs.

Inequalities in the access to and quality of healthcare in Mozambique: evidence from the household budget survey

OBJECTIVES

To assess the inequalities in the access to and quality of care and its related direct payments.

DESIGN

Secondary analysis of the cross-sectional Mozambican Household Budget Survey (HBS).

SETTING

Nationally-representative sample of households in Mozambique.

PARTICIPANTS

11 480 households (58 118 individuals) interviewed during HBS 2014/15.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Equity, utilization of healthcare, access to quality care and direct payments.

RESULTS

About 12.2% of women and 10.1% of men of the survey report a perceive health need. About 72.1% of women and 72.9% men use healthcare. Population in a disadvantaged position living in rural areas have less probabilities of using healthcare for equal health compared to the individuals of a wealthier position and living in urban settings. With regard to quality care, 47.7% women and 46.8% men do not report quality problems. No differences for women's wealth. Men in a disadvantaged position report less chances of accessing quality care compared to men of advantaged position. Also, women and men living in rural areas have less probabilities of accessing quality care. Finally, the majority of people who access healthcare paid 1 Mt during their visit.

CONCLUSIONS

This study tackles a fundamental policy concern for health systems of Sub-Saharan Africa and points to areas that urge action to address the existent of socioeconomic and geographical inequalities in the access to and quality of care for women and men, including the strengthening of health facilities in rural and deprived areas to ensure that access to adequate care of acceptable quality is distributed according to need.

Errors in estimated gestational ages reduce the likelihood of health facility deliveries: results from an observational cohort study in Zanzibar

Background

Most maternal health programs in low- and middle- income countries estimate gestational age to provide appropriate antenatal care at the correct times throughout the pregnancy. Although various gestational dating methods have been validated in research studies, the performance of these methods has not been evaluated on a larger scale, such as within health systems. The objective of this research was to investigate the magnitude and impact of errors in estimated delivery dates on health facility delivery among women enrolled in a maternal health program in Zanzibar.

Methods

This study included 4225 women who were enrolled in the Safer Deliveries program and delivered before May 31, 2017. The exposure of interest was error in estimated delivery date categorized as: severe overestimate, when estimated delivery date (EDD) was 36 days or more after the actual delivery date (ADD); moderate overestimate, when EDD was 15 to 35 days after ADD; accurate, when EDD was 6 days before to 14 days after ADD; and underestimate, when EDD was 7 days or more before ADD. We used Chi-squared tests to identify factors associated with errors in estimated delivery dates. We performed logistic regression to assess the impact of errors in estimated delivery dates on health facility delivery adjusting for age, district of residence, HIV status, and occurrence of past home delivery.

Results

In our data, 28% of the estimated delivery dates were a severe overestimate, 23% moderate overestimate, 41% accurate, and 8% underestimate. Compared to women with an accurate delivery date, women with a moderate or severe overestimate were significantly less likely to deliver in a health facility (OR = 0.71, 95% CI: [0.59, 0.86]; OR = 0.74, 95% CI: [0.61, 0.91]). When adjusting for multiple confounders, women with moderate overestimates were significantly less likely to deliver in a health facility (AOR = 0.76, 95% CI: [0.61, 0.93]); the result moved slightly towards null for women with severe overestimates (AOR = 0.84, 95% CI: [0.69, 1.03]).

Conclusions

The overestimation of women’s EDDs reduces the likelihood of health facility delivery. To address this, maternal health programs should improve estimation of EDD or attempt to curb the effect of these errors within their programs.

Determinants of primary healthcare seeking behaviours for children during the first 18 months of life in Benin

Background

Primary healthcare is a key element of management of childhood illness in Africa. The objectives were to identify primary care seeking determinants among infants and young children up to 18 mo in a birth cohort from Benin.

Methods

From 2007 to 2009 in Benin, a birth cohort was followed until the age of 18 mo in three health centres. Multilevel Poisson regression models were fitted to identify the factors related to the monthly number of consultations. Maternal and newborn characteristics and infant general health parameters were considered.

Results

A total of 566 children were followed. On average, 0.46 consultations per month per child were recorded. The number of consultations was significantly lower after the first 6 mo of life (p<0.001). A distance >1000 m was associated with fewer consultations (p=0.01). Primiparity was significantly associated with higher care seeking (relative risk 1.17 [95% CI 1.05 to 1.30], p<0.01). No child characteristics at birth were significantly associated with the number of consultations (all p>0.16).

Conclusions

Development of health structures and improvement of access remain important goals for strengthening of the primary care health system. Studying factors of care seeking behaviour, like parity, can help to identify women more prone to seek care for their child during the first year of life.

Health care seeking behaviour during pregnancy, delivery and the postnatal period in Bangladesh: Assessing the compliance with WHO recommendations

BACKGROUND

The World Health Organization (WHO) recommends four antenatal care (ANC) visits, delivery in a health facility and three postnatal care (PNC) visits for women to optimize the maternal health outcomes.

OBJECTIVES

To examine the level and determinants of maternal health care seeking behaviour during pregnancy, delivery and the postnatal period, and assess the compliance with the WHO recommended levels of care in Bangladesh.

DESIGN/SETTING

The study is based on secondary analysis of the data obtained from the 2014 Bangladesh Demographic and Health Survey (BDHS). The 2014 BDHS was a cross-sectional survey of a nationally representative sample of 17,863 ever-married women aged 15-49 years. The sample was selected following a two-stage stratified cluster sampling design.

PARTICIPANTS

The dataset from a subsample of 4.627 ever-married women who had delivered their last birth within three years before the survey were included in the analysis to meet the objectives of the study.

ANALYSIS

Descriptive statistics and multinomial logistic regression model were used for data analysis.

FINDINGS

It has been observed that only 31% mothers had recommended four or more ANC visits, 37% births were delivered at health facilities, and 65% mothers received at least one PNC visit. Only 18.0% mothers received the WHO recommended optimal level of four or more ANC visits, births in a health facility and at least one PNC visit. Mothers aged less than 20 years, living in rural area, having no education and media exposure, multiparous, poor wealth status, husband with no education and husband's employment status appeared as significant predictors of optimal level maternal health care after adjusting for other factors. Mothers living in Sylhet, Chittagong and Barisal regions were less likely to receive the optimum level health care.

KEY CONCLUSION

Utilization of maternal health care during pregnancy, delivery and the postnatal period among Bangladeshi women does not reflect the complete compliance with the WHO recommendations. Further studies are needed to identify the reasons for underutilization of optimum level maternal care practice in Bangladesh.

IMPLICATION FOR PRACTICE

The findings underscore the need for targeted intervention for those groups of mothers who were identified as having lowest level of maternal care across the continuum of care.