Factors associated with the use of maternity services in Enugu, southeastern Nigeria

Factors Influencing Progressive Utilization of Palliative Care Services among Cancer Patients in Kenya: The Case of Nairobi Hospice

The rising cases of non-communicable diseases, specifically cancer, have led to the integration of palliative care in their management. However, only 10% of cancer patients have access to palliative care. Healthcare utilization is an important step in disease management as it aids individuals in accessing opportunities for the prevention and treatment of diseases. The study applied the binary probit model to estimate the progressive utilization of palliative care services by cancer patients. The aim of the study was to determine factors influencing the progressive utilization of palliative care by cancer patients. A cross-sectional data survey was conducted for 169 cancer patients seeking palliative care at the Nairobi Hospice in 2013. For each patient, the predisposing, enabling, and need (PEN) factors were analyzed as key criteria for applying progressive utilization of palliative care at the Nairobi Hospice as compared to those residing in other counties in the study. Descriptive statistics showed that 27% of patients studied resided in Nairobi County, where 61% were female, 62% were married, 35% had primary education, 44% were self-employed, and 59% had medical insurance. Probit regression and marginal effects showed that employment and religion were significant in determining the progressive utilization of palliative care. Employment status and religion are consequently the main factors that both governments and health-focused non-governmental organizations need to consider increasing the probability of progressively utilizing palliative care to improve the quality of life of cancer patients.

Prevalence and predictors of elective and emergency caesarean delivery among reproductive-aged women in Bangladesh: evidence from demographic and health survey, 2017-18

Background

Over the years, an increasing trend of unnecessary caesarean section (c-section) deliveries has raised concerns in Bangladesh. So far, many studies have reported the risk factors of c-section delivery in Bangladesh. However, most of these studies did not estimate the predictors of the two c-section procedures (i.e., emergency and elective) separately based on the timing of the c-section decision. This study solely brings forward the role of socio-demographic and economic factors that may be associated differently with emergency and elective c-section deliveries.

Methods

Data for the study were drawn from the 2017–18 Bangladesh Demographic and Health Survey with 5,299 women aged 15–49 years who gave birth at a health facility during three years preceding the survey. Descriptive statistics along with bivariate analysis were used to fulfill the study objectives. Further, multivariable logistic regression analysis was conducted on binary outcome variables of elective/emergency c-section deliveries.

Results

Approximately one-third of women in the reproductive-age group opted for delivery through c-section. Out of them, 18.7% of women had elective c-sections, and 14.1% had emergency c-sections. Women who had mass media exposure were 32% more likely to deliver through elective c-sections than women who had no exposure [AOR: 1.32; CI: 1.02–1.72]. Women with higher education had a 56% lower likelihood of delivering through emergency c-section than women with no educational status [AOR: 0.44; CI: 0.24–0.83]. Children from the third or higher birth order were significantly more likely to be delivered through elective c-sections than those from the first birth order [AOR: 2.67; CI: 1.75–4.05]. In contrast, children with higher birth order had fewer chances of emergency c-section than children with first birth order [AOR: 0.29; CI: 0.18 -0.45]. Both elective and emergency c-section deliveries were significantly higher among private health facilities.

Conclusion

Although c-section delivery has emerged as a life-saving intervention, the overuse of such practice has created lucrative risks for the mother and unborn child. Proper sensitization of mothers and families can enhance the knowledge of the unsafe nature of unnecessary c-section deliveries. Authorizations in case of over-use of elective and emergency c-sections should be observed to minimize the unnecessary c-sections and related complications and to increase normal institutional deliveries in Bangladesh.

Assessment of Prenatal Care Providers’ Competencies From the Perspective of Pregnant Women: An Iranian Study

Background: Pregnant women have expectations from their providers; sometimes their expectations are somewhat different from the current situation. Objective: to assess of competencies of prenatal care providers according to the views of pregnant women in Iran. Method: This is a descriptive-analytical study. Sampling were 300 pregnant women. A researcher-made questionnaire with appropriate validity and reliability was used. These competencies were divided into 4 dimensions of professional skills, communication skills, individual characteristics of prenatal care providers, and the characteristics of pregnancy and childbirth centers. Results: The percentage of the expected status of professional skills’ score of prenatal care providers (97.17) did not significantly differ from the current status (96.07). Nevertheless, there was a significant difference between the percentages of scores of expected (95.61) and the current statuses (90.89) of communication skills. The percentage of expected status (94.74) and the current status (84.17) scores of individual characteristics of prenatal care providers. The percentages of the expected status scores (95.24) and the status quo (89.61) of characteristics of pregnancy and childbirth centers were a significant difference. Conclusion: It is needed to upgrade some competencies of prenatal care providers. So, providers should focus their efforts on strengthening the expected skills of their pregnant women.

Worlds apart: a socio-material exploration of mHealth in rural areas of developing countries

Purpose

The implementation of mobile health (mHealth) in developing countries seems to be stuck in a pattern of successive pilot studies that struggle for mainstream implementation. This study addresses the research question: what existing health-related structures, properties and practices are presented by rural areas of developing countries that might inhibit the implementation of mHealth initiatives?

Design/methodology/approach

This study was conducted using a socio-material approach, based on an exploratory case study in West Africa. Interviews and participant observation were used to gather data. A thematic analysis identified important social and material agencies, practices and imbrications which may limit the effectiveness of mHealth apps in the region.

Findings

Findings show that, while urban healthcare is highly structured, best practice-led, rural healthcare relies on peer-based knowledge sharing, and community support. This has implications for the enacted materiality of mobile technologies. While urban actors see mHealth as a tool for automation and the enforcement of responsible healthcare best practice, rural actors see mHealth as a tool for greater interconnectivity and independent, decentralised care.

Research limitations/implications

This study has two significant limitations. First, the study focussed on a region where technology-enabled guideline-driven treatment is the main mHealth concern. Second, consistent with the exploratory nature of this study, the qualitative methodology and the single-case design, the study makes no claim to statistical generalisability.

Originality/value

To the authors' knowledge, this is the first study to adopt a socio-material view that considers existing structures and practices that may influence the widespread adoption and assimilation of a new mHealth app. This helps identify contextual challenges that are limiting the potential of mHealth to improve outcomes in rural areas of developing countries.

Unnecessary Cesarean Section Delivery Causes Risk to Both Mother and Baby: A Commentary on Pregnancy Complications and Women’s Health

In Bangladesh, 3.6 million babies are born each year. But the country is now facing a quickly rising rate of cesarean section (C-section) utilization. Here about 50% of total deliveries are institutional. Among them, two-thirds are in private care facilities, where the rate of C-sections is very high (83%). The present C-section rate is 2.5 times higher than in the previous decades. In Bangladesh, many physicians from private facilities are recommending C-section regardless of the mother’s physical condition and the position of the fetus. Therefore, mothers are more likely to choose C-section delivery who receive antenatal care from a private facility. Moreover, several socio-economic and demographic factors might be responsible for these increased C-section deliveries. Also, many private hospitals prefer C-section delivery due to their profit-making tendency. The unnecessary C-section delivery causes risk to both mother and baby Also, the high prevalence of C-section in Bangladesh is putting women’s health at risk. Therefore, the government healthcare authorities should ensure proper utilization of C-section facilities and encourage people for normal births at any health facility. Also, they can develop a national guideline for the use of C-sections and normal delivery depending on the physical condition of the mother and fetus.

Individual and Community-Level Determinants of Institutional Delivery Services among Women in Bangladesh: A Cross-Sectional Study

BACKGROUND

Improving maternal mortality attracts considerable interest with the critical invention through institutional delivery services (IDS) in reducing maternal death during delivery and ensuring safe childbirth. The influence of both individual and community-level factors is essential to using IDS. Problem Statement. Maternal death may occur at any time, but delivery without designated healthcare is by far the most dangerous time for both woman and her baby. Therefore, to combat the global burden of maternal mortality, it is necessary to ensure IDS worldwide.

OBJECTIVES

This study explores the current knowledge of individual and community-level covariates and examines their extent of influence on the utilization of IDS in Bangladesh.

METHODS

Utilizing Bangladesh Demographic and Health Survey (BDHS) data, this study has used two-level random intercept binary logistic regression, together with the average annual rate of increase (AARI) in the utilization of IDS and related variables.

RESULTS

This study found appreciable changes in seeking IDS, increases from 3.4% in 2007 to 51.9% in 2017, and half of the total deliveries (51%) took place in healthcare. About 26% of the total variation in the utilization of IDS is owing to differences across communities. Further, covariates including communities with higher educated women, higher utilization of ANC and access to media and at individual level, religion, maternal and parental education, wealth index, and mother-level factors (i.e., age at birth, BMI, occupation, ANC visit, birth order, own health care decision, pregnancy intention, and exposure to media) showed significant association with the utilization of IDS.

CONCLUSION

This study observed the association between individual and community-level factors and IDS uptake. Thus, any future strategies must address individual level and community-level challenges and undertake a multisectoral approach to enhance the uptake of IDS.

Justification of Wife Beating and Utilization of Antenatal and Delivery Care in Bangladesh

We examined the association between women's justification of wife beating and their utilization of professional antenatal and delivery care in Bangladesh. We used data which describes a nationally representative sample of currently married women aged 15 to 49 years (n = 3,449). Services from medically trained providers were considered professional antenatal care (ANC) and delivery services. Women's attitudes toward wife beating in five circumstances (if a woman goes out without telling her husband, neglects children, argues with her husband, refuses to have sexual intercourse with her husband, and burns food) were used to describe the justification of wife beating. Chi-square tests and multilevel logistic regression analyses were performed; 74% of the women would not justify wife beating, 65% attended ≥1 ANC visits, 25% attended ≥4 ANC visits, and 44% utilized professional delivery care. Women who would not justify wife beating were more likely to utilize ≥1 ANC visits (adjusted odds ratio [AOR]: 1.89; 95% confidence interval [CI]: [1.26, 2.81]), ≥4 ANC visits (AOR: 1.14; 95% CI: [0.76, 1.71]), and professional delivery care (AOR: 1.93; 95% CI: [1.31, 2.85]). Older age, women's and husband's higher education, lower parity, urban residence (except for ≥1 ANC visits), and higher socioeconomic statuses including divisional differences were significant confounders for increased utilization of both professional ANC and delivery care. In addition, older age at marriage and current unemployment were also associated with increased utilization of delivery care services. This association between women's justification of wife beating and their utilization of professional antenatal and delivery care services has potential implications for maternal and child health policy in Bangladesh where intimate partner violence is commonplace, and societal norms teach women to obey their husbands and accept submissive roles. Public policy should aim to create awareness among women about the negative impact of justifying wife beating, and accepting intimate partner violence on their own and children's health.

Bayesian Analysis of Trends in Utilization of Maternal Healthcare Services in Pakistan during 2006-2018

OBJECTIVES

This study is aimed at investigating the time trends and disparities in access to maternal healthcare in Pakistan using Bayesian models. Study Design. A longitudinal study from 2006 to 2018.

METHODS

The detailed analysis is based on the data from Pakistan Demographic and Health Survey (PDHS) conducted during 2006-2018. We have proposed Bayesian logistic regression models (BLRM) to investigate the trends of maternal healthcare in the country. Based on different goodness-of-fit criteria, the performance of proposed models has also been compared with repeatedly used classical logistic regression models (CLRM).

RESULTS

The results from the analysis suggested that BLRM perform better than CLRM. The access to antenatal healthcare increased from 61% to 86% during years 2006-18. The utilization of medication also improved from 44% in 2006 to 60% in 2018. Despite the improvements from 2006 to 2018, every three out of ten women were not protected against neonatal tetanus, neither delivered in the health facility place nor availed with the skilled health provider at the time of delivery during 2018. Similarly, two-fifth mothers did not received any skilled postnatal checkup within two days after delivery. Additionally, the likelihood of MHS provided to mothers is in favor of mothers with lower ages, lower birth orders, urban residences, higher education, higher wealth quintiles, and residents of Sindh and Punjab.

CONCLUSIONS

The gaps in utilization of MHS in different socioeconomic groups of the society have not decreased significantly during 2006-2018. Any future maternal health initiative in the country should focus to reduce the observed disparities among different socioeconomic sectors of the society.

Health facility delivery among women of reproductive age in Nigeria: Does age at first birth matter?

BACKGROUND

High maternal mortality ratio in sub-Saharan Africa (SSA) has been linked to inadequate medical care for pregnant women due to limited health facility delivery utilization. Thus, this study, examined the association between age at first childbirth and health facility delivery among women of reproductive age in Nigeria.

METHODS

The study used the most recent secondary dataset from Nigeria's Demographic and Health Survey (NDHS) conducted in 2018. Only women aged15-49 were considered for the study (N = 34,193). Bi-variate and multivariable logistic regression models were used to examine the association between age at first birth and place of delivery. The results were presented as crude odds ratios and adjusted odds ratios (aOR) with corresponding 95% confidence intervals (CIs). Statistical significance was set at p<0.05.

RESULTS

The results showed that the prevalence of health facility deliveries was 41% in Nigeria. Women who had their first birth below age 20 [aOR = 0.82; 95%(CI = 0.74-0.90)] were less likely to give birth at health facilities compared to those who had their first birth at age 20 and above.

CONCLUSION

Our findings suggest the need to design interventions that will encourage women of reproductive age in Nigeria who are younger than 20 years to give birth in health facilities to avoid the risks of maternal complications associated with home delivery. Such interventions should include male involvement in antenatal care visits and the education of both partners and young women on the importance of health facility delivery.

Factors associated with health facility utilization during childbirth among 15 to 49-year-old women in Uganda: evidence from the Uganda demographic health survey 2016

BACKGROUND

Almost all maternal deaths and related morbidities occur in low-income countries. Childbirth supervised by a skilled provider in a health facility is a key intervention to prevent maternal and perinatal morbidity and mortality. Our study aimed to establish the factors associated with health facility utilization during childbirth in Uganda.

METHODS

We used the Uganda Demographic and Health Survey 2016 data of 10,152 women aged 15 to 49 years. The study focused on their most recent live birth in 5 years preceding the survey. We applied multistage stratified sampling to select study participants and we conducted multivariable logistic regression to establish the factors associated with health facility utilization during childbirth, using SPSS (version 25).

RESULTS

The proportion of women who gave birth at a health facility was 76.6% (7780/10,152: (95% confidence interval, CI, 75.8-77.5). The odds of women aged 15-19 years giving birth at health facilities were twice as those of women aged 40 to 49 years (adjusted odds ratio, AOR = 2.29; 95% CI: 1.71-3.07). Residing in urban areas and attending antenatal care (ANC) were associated with health facility use. The odds of women in the northern region of Uganda using health facilities were three times of those of women in the central region (AOR = 3.13; 95% CI: 2.15-4.56). Women with tertiary education (AOR = 4.96; 95% CI: 2.71-9.11) and those in the richest wealth quintile (AOR = 4.55; 95% CI: 3.27-6.32) had higher odds of using a health facility during child birth as compared to those with no education and those in the poorest wealth quintile, respectively. Muslims, Baganda, women exposed to mass media and having no problem with distance to health facility had higher odds of utilizing health facilities during childbirth as compared to Catholic, non Baganda, women not exposed to mass media and those having challenges with distance to access healthcare.

CONCLUSION

Health facility utilization during childbirth was high and it was associated with decreasing age, increasing level of education and wealth index, urban residence, Northern region of Uganda, ANC attendance, exposure to mass media, tribe, religion and distance to the nearby health facility. We recommend that interventions to promote health facility childbirths in Uganda target the poor, less educated, and older women especially those residing in rural areas with less exposure to mass media.

Prevalence, progress, and social inequalities of home deliveries in Ghana from 2006 to 2018: insights from the multiple indicator cluster surveys

Background

Delivery in unsafe and unsupervised conditions is common in developing countries including Ghana. Over the years, the Government of Ghana has attempted to improve maternal and child healthcare services including the reduction of home deliveries through programs such as fee waiver for delivery in 2003, abolishment of delivery care cost in 2005, and the introduction of the National Health Insurance Scheme in 2005. Though these efforts have yielded some results, home delivery is still an issue of great concern in Ghana. Therefore, the aim of the present study was to identify the risk factors that are consistently associated with home deliveries in Ghana between 2006 and 2017–18.

Methods

The study relied on datasets from three waves (2006, 2011, and 2017–18) of the Ghana Multiple Indicator Cluster surveys (GMICS). Summary statistics were used to describe the sample. The survey design of the GMICS was accounted for using the ‘svyset’ command in STATA-14 before the association tests. Robust Poisson regression was used to estimate the relationship between sociodemographic factors and home deliveries in Ghana in both bivariate and multivariable models.

Results

The proportion of women who give birth at home during the period under consideration has decreased. The proportion of home deliveries has reduced from 50.56% in 2006 to 21.37% in 2017–18. In the multivariable model, women who had less than eight antenatal care visits, as well as those who dwelt in households with decreasing wealth, rural areas of residence, were consistently at risk of delivering in the home throughout the three data waves. Residing in the Upper East region was associated with a lower likelihood of delivering at home.

Conclusion

Policies should target the at-risk-women to achieve complete reduction in home deliveries. Access to facility-based deliveries should be expanded to ensure that the expansion measures are pro-poor, pro-rural, and pro-uneducated. Innovative measures such as mobile antenatal care programs should be organized in every community in the population segments that were consistently choosing home deliveries over facility-based deliveries.

Caesarian section (CS) delivery in Bangladesh: A nationally representative cross-sectional study

A growing trend in the caesarian section (CS) for delivery is a threat to child health as well as maternal health. This study was conducted to identify the potential socioeconomic and demographic factors associated with CS delivery in Bangladesh. Data obtained from the Bangladesh Demographic and Health Survey (BDHS) 2014 has been used for this study. The prevalence of CS delivery among Bangladeshi mothers was 24% (Urban: 36.9%, Rural: 17.9%). A two-level logistic regression showed that mothers having delivery in the private sector or private hospital (adjusted odds ratio [AOR] = 38.70, 95% confidence interval [CI] = 29.58 to 50.62), mother’s age 25–35 years (AOR = 1.73, 95% CI = 1.26 to 2.37), wealth index average (AOR = 1.61, 95% CI = 1.15 to 2.27) and rich (AOR = 1.80, 95% CI = 1.29 to 2.51), antenatal visit 1–2 (AOR = 2.31, 95% CI = 1.47 to 3.64) and ≥ 3 (AOR = 3.68, 95% CI = 2.35 to 5.76), overweight mothers (AOR = 1.44, 95% CI = 1.09 to 1.90), multiple births (AOR = 3.87, 95% CI = 1.15 to 12.58), husband’s occupation professional/technical/managerial (AOR = 1.68, 95% CI = 1.15 to 2.47) were significantly more prone to CS delivery. Also, place of residence, number of family members, birth order, child’s size during birth, and divisions of Bangladesh, were potentially associated with CS delivery. The current epidemiological findings and evidence suggest adopting and implementing some urgent clinical practices and strict guidelines in the healthcare system to avoid unnecessary CS delivery in Bangladesh.

Determinants of institutional delivery in Sub-Saharan Africa: findings from Demographic and Health Survey (2013-2017) from nine countries

Introduction

Institutional delivery is a major concern for a country’s long-term growth. Rapid population development, analphabetism, big families, and a wider range of urban-rural health facilities have had a negative impact on institutional services in Sub-Saharan Africa (SSA) countries. The aim of this study was to look into the factors that influence women’s decision to use an institutional delivery service in SSA.

Methods

The most recent Demographic and Health Survey (DHS), which was conducted in nine countries (Senegal, Ethiopia, Malawi, Rwanda, Tanzania, Zambia, Namibia, Ghana, the Democratic Republic of Congo) was used. The service’s distribution outcome (home delivery or institutional delivery) was used as an outcome predictor. Logistic regression models were used to determine the combination of delivery chances and different covariates.

Results

The odds ratio of the experience of institutional delivery for women living in rural areas vs urban area was 0.44 (95% confidence interval (CI) 0.41–0.48). Primary educated women were 1.98 (95% CI 1.85–2.12) times more likely to deliver in health institutes than non-educated women, and secondary and higher educated women were 3.17 (95% CI 2.88–3.50) times more likely to deliver in health centers with facilities. Women aged 35–49 years were 1.17 (95% CI 1.05–1.29) times more likely than women aged under 24 years to give birth in health centers. The number of ANC visits: women who visited four or more times were 2.98 (95% CI 2.77–3.22) times, while women who visited three or less times were twice (OR = 2.03; 95% CI 1.88–2.18) more likely to deliver in health institutes. Distance from home to health facility were 1.18 (95% CI 1.11–1.25) times; media exposure had 1.28 (95% CI 1.20–1.36) times more likely than non-media-exposed women to delivery in health institutions.

Conclusions

Women over 24, primary education at least, urban residents, fewer children, never married (living alone), higher number of prenatal care visits, higher economic level, have a possibility of mass-media exposure and live with educated husbands are more likely to provide health care in institutions. Additionally, the distance from home to a health facility is not observed widely as a problem in the preference of place of child delivery. Therefore, due attention needs to be given to address the challenges related to narrowing the gap of urban-rural health facilities, educational level of women improvement, increasing the number of health facilities, and create awareness on the advantage of visiting and giving birth in health facilities.

Pooled prevalence and associated factors of health facility delivery in East Africa: Mixed-effect logistic regression analysis

Background

Many mothers still give birth outside a health facility in Sub-Saharan Africa particularly in East African countries. Though there are studies on the prevalence and associated factors of health facility delivery, as to our search of literature there is limited evidence on the pooled prevalence and associated factors of health facility delivery in East Africa. This study aims to examine the pooled prevalence and associated factors of health facility delivery in East Africa based on evidence from Demographic and Health Surveys.

Methods

A secondary data analysis was conducted based on the most recent Demographic and Health Surveys (DHSs) conducted in the 12 East African countries. A total weighted sample of 141,483 reproductive-age women who gave birth within five years preceding the survey was included. All analyses presented in this paper were weighted for the sampling probabilities and non-response using sampling weight (V005), primary sampling unit (V023), and strata (V021). The analysis was done using STATA version 14 statistical software, and the pooled prevalence of health facility delivery with a 95% Confidence Interval (CI) was presented using a forest plot. For associated factors, the Generalized Linear Mixed Model (GLMM) was fitted to consider the hierarchical nature of the DHS data. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), and Likelihood Ratio (LR)-test were done to assess the presence of a significant clustering effect. Besides, deviance (-2LLR) was used for model comparison since the models were nested models. Variables with a p-value of less than 0.2 in the bivariable mixed-effect binary logistic regression analysis were considered for the multivariable analysis. In the multivariable mixed-effect analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the strength and significance of the association between the independent variable and health facility delivery.

Results

The proportion of health facility delivery in East Africa was 87.49% [95% CI: 87.34%, 87.64%], ranged from 29% in Ethiopia to 97% in Mozambique. In the Mixed-effect logistic regression model; country, urban residence [AOR = 2.08, 95% CI: 1.96, 2.17], primary women education [AOR = 1.61, 95% CI: 1.55, 1.67], secondary education and higher [AOR = 2.96, 95% CI: 2.79, 3.13], primary husband education [AOR = 1.19, 95% CI: 1.14, 1.24], secondary husband education [AOR = 1.38, 95% CI: 1.31, 1.45], being in union [AOR = 1.23, 95% CI: 1.18, 1.27], having occupation [AOR = 1.11, 95% CI: 1.07, 1.15], being rich [AOR = 1.36, 95% CI: 1.30, 1.41], and middle [AOR = 2.14, 95% CI: 2.04, 2.23], health care access problem [AOR = 0.76, 95% CI: 0.74, 0.79], having ANC visit [AOR = 1.54, 95% CI: 1.49, 1.59], parity [AOR = 0.56, 95% CI: 0.55, 0.61], multiple gestation [AOR = 1.83, 95% CI: 1.67, 2.01] and wanted pregnancy [AOR = 1.19, 95% CI: 1.13, 1.25] were significantly associated with health facility delivery.

Conclusion

This study showed that the proportion of health facility delivery in East African countries is low. Thus, improved access and utilization of antenatal care can be an effective strategy to increase health facility deliveries. Moreover, encouraging women through education is recommended to increase health facility delivery service utilization.

Trends and predictors of the use of unskilled birth attendants among Ethiopian mothers from 2000 to 2016

INTRODUCTION

Previous studies have shown that home delivery assisted by unskilled individuals contributes to maternal and neonatal deaths in developing countries. It also increases the risks of long-term maternal morbidities such as uterine prolapse, pelvic inflammatory disease, fistula, incontinence and infertility. This study aimed to determine the trends and predictors of the use of unskilled birth attendants among Ethiopian mothers from 2000 to 2016.

METHODS

This study USED used the Ethiopia Demographic and Health Survey data for the years 2000 (n = 10,873), 2005 (n = 9,861), 2011 (n = 11,654) and 2016 (n = 10,641) to estimate the trends in the use of unskilled birth attendants. Multinomial logistic regression models with adjustment for clustering and sampling weights were used to investigate the association between the independent and outcome outcome variables.

RESULTS

The analysis revealed that while births attended by Traditional Birth Attendants (TBAs) increased from 28% in 2000 to 42% in 2016, home deliveries decreased slightly from 94% to 73%. Rural residence is associated with increased odds of using unskilled birth attendants. High and middle household wealth, educational status of the women and their partners (>primary), four or more antenatal care (ANC) visits, having any form of employment and mass media engagement were significantly associated with decreased odds of unskilled birth attendant utilization during child birth in Ethiopia.

CONCLUSIONS

The results of this analysis show that the proportion of Ethiopian women giving birth without a skilled attendant is high. Interventions aiming to improve skilled attendance during childbirth should focus on the individual, community and need factors of Anderson's behavioural model.

Breaking Barriers to Healthcare Access: A Multilevel Analysis of Individual- and Community-Level Factors Affecting Women's Access to Healthcare Services in Benin

Background: In low-income countries such as Benin, most people have poor access to healthcare services. There is scarcity of evidence about barriers to accessing healthcare services in Benin. Therefore, we examined the magnitude of the problem of access to healthcare services and its associated factors. Methods: We utilized data from the 2017–2018 Benin Demographic and Health Survey (n = 15,928). We examined the associations between the demographic and socioeconomic characteristics of women using multilevel logistic regression. The outcome variable for the study was problem of access to healthcare service. Adjusted odds ratios (AORs) with 95% confidence intervals (95% CI) were estimated. Results: Overall, 60.4% of surveyed women had problems in accessing healthcare services. Partner’s education (AOR = 0.70; 95% CI; 0.55–0.89), economic status (AOR = 0.59; 95% CI; 0.47–0.73), marital status (AOR = 0.44; 95% CI; 0.39–0.51), and parity (AOR = 1.85; 95% CI; 1.45–2.35) were significant individual-level factors associated with problem of access to healthcare. Region (AOR = 5.24; 95% CI; 3.18–8.64) and community literacy level (AOR = 0.69; 95% CI; 0.51–0.94) were the main community-level risk factors. Conclusions: Enhancing husband education through adult education programs, economic empowerment of women, enhancing national education coverage, and providing priority for unmarried and multipara women need to be considered. Additionally, there is the need to ensure equity-based access to healthcare services across regions.

Assessing the contextual effect of community in the utilization of postnatal care services in Ghana

BACKGROUND

Inequalities in the use of postnatal care services (PNC) in Ghana have been linked to poor maternal and neonatal health outcomes. This has ignited a genuine concern that PNC interventions with a focus on influencing solely individual-level risk factors do not achieve the desired results. This study aimed to examine the community-level effect on the utilization of postnatal care services. Specifically, the research explored clusters of non-utilization of PNC services as well as the effect of community-level factors on the utilization of PNC services, with the aim of informing equity-oriented policies and initiatives.

METHODS

The 2014 Ghana Demographic and Health Survey GDHS dataset was used in this study. Two statistical methods were used to analyze the data; spatial scan statistics were used to identify hotspots of non-use of PNC services and second two-level mixed logistic regression modeling was used to determine community-level factors associated with PNC services usage.

RESULTS

This study found non-use of PNC services to be especially concentrated among communities in the Northern region of Ghana. Also, the analyses revealed that community poverty level, as well as community secondary or higher education level, were significantly associated with the utilization of PNC services, independent of individual-level factors. In fact, this study identified that a woman dwelling in a community with a higher concentration of poor women is less likely to utilize of PNC services than those living in communities with a lower concentration of poor women (Adjusted odds ratio (AOR) = 0.60, 95%CI: 0.44-0.81). Finally, 24.0% of the heterogeneity in PNC services utilization was attributable to unobserved community variability.

CONCLUSION

The findings of this study indicate that community-level factors have an influence on women's health-seeking behavior. Community-level factors should be taken into consideration for planning and resource allocation purposes to reduce maternal health inequities. Also, high-risk communities of non-use of obstetric services were identified in this study which highlights the need to formulate community-specific strategies that can substantially shift post-natal use in a direction leading to universal coverage.

Determinants of maternal health service utilisation among pregnant teenagers in Delta State, Nigeria

INTRODUCTION

the prevailing high maternal mortality and morbidity rate among pregnant adolescents in Nigeria underscores all efforts said to have been made to tackle maternal deaths among this population. Not much research has been done to ascertain the reasons associated with the poor utilisation of Maternal Health Services (MHS) by pregnant teenagers. This study, therefore, explored the extent and determinants of MHS utilisation among pregnant teenagers in Delta State.

METHODS

this study made use of a mixed cross-sectional study design. Multi-stage sampling technique was adopted in selecting eight communities while snowballing was used in identifying pregnant teenagers. A structured interviewer-administered questionnaire was used for the data collection from 212 pregnant teenagers and an interview guide was further used to interview 16 pregnant teenagers randomly selected from the communities. Descriptive and inferential data analyses were done using SPSS version 22. Hypotheses were tested using Chi-square test at P≤0.05 level of significance.

RESULTS

seventy per cent of the participants stated that they utilised MHS by visiting an antenatal care centre (ANC) centre at least once during their pregnancy but only 28.3% had ANC attendance that was appropriate with their gestational age. A grand mean ± SD of 3.4714 showed that there is a high level of perception of stigmatisation among pregnant teenagers. Also, married teenagers [86%] were found to utilise MHS more than their single counterparts [67.1%]. A statistically significant association (Chi-square) was found between utilisation of MHS and maternal education [P=0.024], utilisation of MHS and availability/accessibility of MHS facilities [P=0.002], utilisation of MHS and cost of MHS [P=0.001] and utilisation of MHS and coercion/violence from partner [P=0.000].

CONCLUSION

the level of utilisation of MHS by pregnant teenagers is low with main determinants of use being stigmatisation of pregnant teenagers, availability of health personnel, accessibility to MHS facilities, permission from significant others and cost of MHS.

Beyond adequate: Factors associated with quality of antenatal care in western Tanzania

OBJECTIVE

To determine quality of antenatal care (ANC). Most literature focuses on ANC attendance and services. Less is known about quality of care (QoC).

METHOD

Data were analyzed from the 2016 Kigoma Reproductive Health Survey, a population-based survey of reproductive-aged women. Women with singleton term live births were included and principal component analysis (PCA) was used to create an ANC quality index using linear combinations of weights of the first principal component. Nineteen variables were selected for the index. The index was then used to assign a QoC score for each woman and linear regression used to identify factors associated with receiving higher QoC.

RESULTS

A total of 3178 women received some ANC. Variables that explained the most variance in the QoC index included: gave urine (0.35); gave blood (0.34); and blood pressure measured (0.30). In multivariable linear regression, factors associated with higher QoC included: ANC at a hospital (versus dispensary); older age; higher level of education; working outside the home; higher socioeconomic status; and having lower parity.

CONCLUSION

Using PCA methods, several basic components of ANC including maternal physical assessment were identified as important indicators of quality. This approach provides an affordable and effective means of evaluating ANC programs.

Determinants of newborn care utilization in Pakistan: Findings from the Demographic and Health Surveys

Background: Information on determinants of postnatal care is essential for maternal health services, and this information is scarce in Pakistan. This study aimed to determine the factors of newborn postnatal care utilization from the Pakistan Demographic and Health Surveys (PDHS) conducted from 2006–2018.

Methods: We analyzed data from three rounds of cross-sectional, nationally representative PDHS 2006–07, 2012–13, and 2017–18. Multivariable logistic regression models were applied to explore factors associated with utilization of newborn postnatal care within two months.

Results: This study included 5724 women from the 2006–07 PDHS, 7461 from the 2012–13 survey, and 8287 from the 2017–18 survey. The proportion of women receiving newborn postnatal care within the first two months of delivery increased from 13% in 2006–07 to 43% in 2012–13 but dropped to 27% in 2017–18. Respondent’s occupation and prenatal care utilization of maternal health services were common factors that significantly influenced newborn postnatal care utilization within two months. The utilization of postnatal care was greater among women having educated husbands and where the first child was a male in PDHS 2007 round. Higher wealth index and educated respondent had higher postnatal care utilization odds in DHS 2012 and DHS 2018. However, the odds of using postnatal care decreased with the number of household members and total number of children ever born in DHS 2012 and 2018 rounds.

Conclusions: There was a general increase in the proportion of women who utilized postnatal care for their newborns during 2006–2013 but a decrease in 2018. The decreased utilization in 2018 warrants further investigation. Improving women’s economic status, education, employment, and antenatal care attendance and reducing parity may increase newborn postnatal care utilization.

Impact of socio-demographic variables on antenatal services in eastern Uttar Pradesh, India

We investigated the impact of socio-demographic variables on antenatal care (ANC) utilization and the low birth weight of a child. Data were collected from 300 pregnant females. Only 22.5% of females received full antenatal care (≥4 visits). Our results showed that female's age at marriage and education plays a significant role in improving ANC. We observed an overall decrease in the utilization of services provided during each antenatal visit. ANC visits from the first trimester decrease the risk of having a baby with low birth weight. Awareness programs and educating families about pregnancy care are recommended to improve ANC utilization.

Analysis of distribution, capacity and utilization of public health facilities in Borno, North-Eastern Nigeria

Introduction

This study aimed to analyze the spatial distribution and capacities of public health facilities and assess utilization of the facilities in Biu area of Borno State, Nigeria.

Methods

A descriptive survey of health facilities and households were conducted by stratifying the area into 11 electoral wards. Data collection instruments include a hand-held GPS (Garmin 76CSx) and 2 sets of structured questionnaires (facility and household). The hand-held GPS was used in taking the coordinates of each health facility in the area. Twenty-five facility-based and 400 household-based questionnaires were administered.

Results

It was identified that 138 public health personnel serve the area’s population of 240,838. Medical professionals (doctors/nurses/midwives) to patient ratio is 1:2973, about 7 times less than the minimum WHO recommendation of 2.5 medical personal per 1000 population. Uneven distribution of facilities exists, which impact on utilisation. For instance, a ward (Mandaragrau) with a population of 18,732 have 5 facilities (4 dispensaries and 1 primary health care) in comparison to a ward (Miringa) with a population of 21,343 with only one Dispensary. Income level and distance were significant socio-economic factors affecting service utilisation (p < 0.001). Area’s households Gini index was 26.7, most of which (49.7%) survive on less than USD2/day and majority (33.6%) spend an average cost of treatment of ₦2,750 (approx. $8) per clinic visit.

Conclusion

It was concluded that insufficiency and inequity in distribution of healthcare services exist in Borno State. It is thus recommended that future policies be directed toward improving healthcare in under-served areas.

Trends and factors associated with the utilisation of antenatal care services during the Millennium Development Goals era in Tanzania

Background

A detailed understanding of trends, as well as what act as enablers and/or barriers to the utilisation of antenatal care (ANC) among Tanzanian women, is essential to policymakers and health practitioners to guide maternal health efforts. We investigated the trends and factors associated with ANC service use during the Millennium Development Goals (MDG) era in Tanzania between 1999 and 2016.

Methods

The study used the Tanzania Demographic and Health Survey (TDHS) data for the years 1999 (n = 2095), 2004–2005 (n = 5576), 2010 (n = 6903) and 2015–2016 (n = 5392). Multivariate multinomial logistic regression models were used to investigate the association between predisposing, enabling, need and community-level factors and frequency of ANC (1–3 and ≥ 4) visits in Tanzania.

Results

The proportion of women who made one to three ANC visits improved significantly from 26.4% in 1999 to 47.0% in 2016. The percentage of women who make four or more ANC visits declined from 71.1% in 1999 to 51.0% in 2016. Higher maternal education, belonging to wealthier households, being informally employed and listening to the radio were associated with four or more ANC visits. Women who did not desire pregnancy had a lower likelihood to attend four or more ANC visits. Women who had primary or higher education, those who resided in wealthier households and those who were informally employed were more likely to make between one and three ANC visits.

Conclusion

The study showed that there was an improvement in the proportion of Tanzanian women who made one to three ANC visits, but it also indicated a concurrent decrease in the prevalence of four or more ANC visits. Improving uptake of ANC among Tanzanian women is achievable if national health policies and programmes also focus on key amenable maternal factors of education, household wealth and employment.

Patterns of access to reproductive health services in Ghana and Nigeria: results of a cluster analysis

BACKGROUND

Inequalities in access to health care result in systematic health differences between social groups. Interventions to improve health do not always consider these inequalities. To examine access to reproductive health care services in Ghana and Nigeria, the patterns of use of family planning and maternal care by women in these countries are explored.

METHODS

We used population-level data from the Ghana and Nigeria Demographic Health Surveys of 2014 and 2013 respectively. We applied a two-step cluster analysis followed by multinomial logistic regression analysis.

RESULTS

The initial two-step cluster analyses related to family planning identified three clusters of women in Ghana and Nigeria: women with high, medium and poor access to family planning services. The subsequent two-step cluster analyses related to maternal care identified five distinct clusters: higher, high, medium, low and poor access to maternal health services in Ghana and Nigeria. Multinomial logistic regression showed that compared to women with secondary/higher education, women without education have higher odds of poor access to family planning services in Nigeria (OR = 2.54, 95% CI: 1.90-3.39) and in Ghana (OR = 1.257, 95% CI: 0.77-2.03). Compared to white-collar workers, women who are not working have increased odds of poor access to maternal health services in Nigeria (OR = 1.579, 95% CI: 1.081-2.307, p ≤ 0.01). This association is not observed for Ghana. Household wealth is strongly associated with access to family planning services and maternal health care services in Nigeria. Not having insurance in Ghana is associated with low access to family planning services, while this is not the case in Nigeria. In both countries, the absence of insurance is associated with poor access to maternal health services.

CONCLUSIONS

These differences confirm the importance of a focused context-specific approach towards reproductive health services, particularly to reduce inequality in access resulting from socio-economic status. Interventions should be focused on the categorization of services and population groups into priority classes based on needs assessment. In this way, they can help expand coverage of quality services bottom up to improve access among these vulnerable groups.

Trends, Differentials, and Social Determinants of Maternal Health Care Services Utilization in Rural India: An Analysis from Pooled Data

Background:

Millennium development goal 5 aimed at reduction of maternal deaths by three-quarters from 1990 to 2015: a target India commendably achieved, but this milestone remains overshadowed by inequalities in utilization of health services that are driven by determinants both at community and at individual level.

Materials and Methods:

We studied the utilization trends using descriptive statistics and analyzed the relative contribution of various socioeconomic predictors on the use of maternal health care services in rural India using binary logistic regression analysis on pooled data from three rounds of National Family Health Survey. Outcome variables included four or more antenatal care visits, skilled birth attendance, and postnatal care.

Results:

Although utilization of maternal health care services showed an upward trend from 1998–1999 to 2015–2016, factors such as illiteracy, female age ≥40 years, having five and more children, belonging to scheduled tribes, rural residence, and not possessing a health card were associated with significantly low utilization of maternal health care services. However, partner's education, good economic status, women's autonomy, and infrastructure at village level were associated with better odds of availing these services.

Conclusions:

The study generates evidence on the role of various socioeconomic determinants in maternal health care utilization and identifies gaps that must be strategically addressed to reach sustainable developmental goal maternal mortality target of 70 deaths per 100,000 live births by 2030. It reemphasizes the need for ensuring convergence among different stakeholders while structuring maternal health policies so that health reforms can be accomplished effectively at all levels of health care.

Women's economic empowerment, participation in decision-making and exposure to violence as risk indicators for early childhood caries

Objectives

In view of the association between early childhood caries (ECC])and maternal social risk factors, this study tried to determine if there were associations between indicators of processes, outputs and outcomes of women’s empowerment, and the prevalence of ECC.

Methods

In this ecological study, indicators measuring the explanatory variables - economic empowerment, decision-making and violence against women - were selected from the Integrated Results and Resources Framework of the UN-Women Strategic Plan 2018–2021 and WHO database. Indicators measuring the outcome variables - the prevalence of ECC for children aged 0 to 2 years, and 3 to 5 years - were extracted from a published literature. The general linear models used to determine the association between the outcome and explanatory variables were adjusted for economic level of countries. Regression estimates (B), 95% confidence intervals and partial eta squared (η²) were calculated.

Results

Countries with more females living under 50% of median income had higher prevalence of ECC for 3 to 5-year olds (B = 1.82, 95% CI = 0.12, 3.52). Countries with higher percentage of women participating in their own health care decisions had higher prevalence of ECC for 0 to 2-year-olds (B = 0.85, 95% CI = 0.03, 1.67). Countries with higher percentage of women participating in decisions related to visiting family, relatives and friends had higher prevalence of ECC for 3 to 5-year-olds (B = 0.67, 95% CI = 0.03, 1.32). None of the indicators for violence against women was significantly associated with the prevalence of ECC.

Conclusion

Empowerment of women is a welcome social development that may have some negative impact on children’s oral health. Changes in policies and norms are needed to protect children’s oral health while empowering women.

Return for prenatal care and childbirth services among Nigerian women using primary health care facilities

Aim

The study assessed the return for prenatal care and childbirth services among Nigerian women using primary health care facilities.

Design

A descriptive cross-sectional approach was employed for the study.

Methods

A total of 730 participants randomly recruited systematically from 21 purposively selected primary health care facilities in Ibadan, Nigeria were studied. A questionnaire and a checklist were used for data collection. The collection of data spanned three months (April to June, 2014). The data were analysed descriptively and inferentially while the results were presented in frequency tables.

Results

The women's mean age was 28 ± 5.3 years. Out of the 730 women studied, 92.6% received prenatal care. The mean difference between the number of prenatal care registration and the number of childbirths was 76.5. Poor environmental hygiene of facilities, statistically significant cost of services and non-availability of 24-hr service were implicated for dissatisfaction with care received by the women and consequent poor return rate for childbirth.

Understanding mistreatment during institutional delivery in Northeast Nigeria: a mixed-method study

BACKGROUND

Improving quality of care including the clinical aspects and the experience of care has been advocated for improved coverage and better childbirth outcomes.

OBJECTIVE

This study aimed to explore the quality of care relating to the prevalence and manifestations of mistreatment during institutional birth in Gombe State, northeast Nigeria, an area of low institutional delivery coverage.

METHODS

The frequency of dimensions of mistreatment experienced by women delivering in 10 health facilities of Gombe State were quantitatively captured during exit interviews with 342 women in July-August 2017. Manifestations of mistreatment were qualitatively explored through in-depth interviews and focus groups with 63 women living in communities with high and low coverage of institutional deliveries.

RESULTS

The quantitative data showed that at least one dimension of mistreatment was reported by 66% (95% confidence interval (CI) 45-82%) of women exiting a health facility after delivery. Mistreatment related to health system conditions and constraints were reported in 50% (95% CI 31-70%) of deliveries. In the qualitative data women expressed frustration at being urged to deliver at the health facility only to be physically or verbally mistreated, blamed for poor birth outcomes, discriminated against because of their background, left to deliver without assistance or with inadequate support, travelling long distances to the facility only to find staff unavailable, or being charged unjustified amount of money for delivery.

CONCLUSIONS

Mistreatment during institutional delivery in Gombe State is highly prevalent and predominantly relates to mistreatment arising from both health system constraints as well as health worker behaviours, limiting efforts to increase coverage of institutional delivery. To address mistreatment during institutional births, strategies that emphasise a broader health systems approach, tackle multiple causes, integrate a detailed understanding of the local context and have buy-in from grassroots-level stakeholders are recommended.

Quality of care during childbirth at public health facilities in Bangladesh: a cross-sectional study using WHO/UNICEF 'Every Mother Every Newborn (EMEN)' standards

Background

This manuscript presents findings from a baseline assessment of health facilities in Bangladesh prior to the implementation of the ‘Every Mother Every Newborn Quality Improvement’ initiative.

Methodology

A cross-sectional survey was conducted between June and August 2016 in 15 government health facilities. Structural readiness was assessed by observing the physical environment, the availability of essential drugs and equipment, and the functionality of the referral system. Structured interviews were conducted with care providers and facility managers on human resource availability and training in the maternal and newborn care. Observation of births, reviews of patient records and exit interviews with women who were discharged from the selected health facilities were used to assess the provision and experience of care.

Results

Only six (40%) facilities assessed had designated maternity wards and 11 had newborn care corners. There were stock-outs of emergency drugs including magnesium sulfate and oxytocin in nearly all facilities. Two-thirds of the positions for medical officers was vacant in district hospitals and half of the positions for nurses was vacant in subdistrict facilities. Only 60 (45%) healthcare providers interviewed received training on newborn complication management. No health facility used partograph for labour monitoring. Blood pressure was not measured in half (48%) and urine protein in 99% of pregnant women. Only 27% of babies were placed skin to skin with their mothers. Most mothers (97%) said that they were satisfied with the care received, however, only 46% intended on returning to the same facility for future deliveries.

Conclusions

Systematic implementation of quality standards to mitigate these gaps in service readiness, provision and experience of care is the next step to accelerate the country’s progress in reducing the maternal and neonatal deaths.

Accuracy of patient perceptions of maternity facility quality and the choice of providers in Nairobi, Kenya: a cohort study

OBJECTIVES

This study aimed to assess the accuracy of pregnant women's perceptions of maternity facility quality and the association between perception accuracy and the quality of facility chosen for delivery.

DESIGN

A cohort study.

SETTING

Nairobi, Kenya.

PARTICIPANTS

180 women, surveyed during pregnancy and 2 to 4 weeks after delivery.

PRIMARY OUTCOME MEASURES

Women were surveyed during pregnancy regarding their perceptions of the quality of all facilities they were considering during delivery and then, after delivery, about their ultimate facility choice. Perceptions of quality were based on perceived ability to handle emergencies and complications. Delivery facilities were assigned a quality index score based on a direct assessment of performance of emergency 'signal functions', skilled provider availability, medical equipment and drug stocks. 'Accurate perceptions' was a binary variable equal to one if a woman's ranking of facilities based on her quality perception equalled the index ranking. Ordinary least squares and logistic regressions were used to analyse associations between accurate perceptions and quality of the facility chosen for delivery.

RESULTS

Assessed technical quality was modest, with an average index score of 0.65. 44% of women had accurate perceptions of quality ranking. Accurate perceptions were associated with a 0.069 higher delivery facility quality score (p=0.039; 95% CI: 0.004 to 0.135) and with a 14.5% point higher probability of delivering in a facility in the top quartile of the quality index (p=0.015; 95% CI: 0.029 to 0.260).

CONCLUSIONS

Patient misperceptions of technical quality were associated with use of lower quality facilities. Larger studies could determine whether improving patient information about relative facility quality can encourage use of higher quality care.

Regional variations in the use of postnatal care in Nigeria: a spatial analysis

Maternal health outcomes vary considerably in Nigeria, with maternal mortality ratio ranging from 165 per 100,000 live births in the South-west to 1549 per 100,000 live births in the North-east. One important maternal health indicator is an adequate use of postnatal care (PNC); however, the evidence is sparse on its spatial distribution across regions in Nigeria. This paper thus examined the spatial distribution of uptake of postnatal care in Nigeria using data from the 2013 Nigeria Demographic and Health Survey, with a sample of 12,127 women aged 15-49 years. The Bayesian-structured additive regression of the logit model was used to examine the spatial relationships. The results revealed a north-south divide in the use of postnatal care, with higher PNC uptake established in the latter. Interestingly, results showed significant intra-region residual spatial variations with higher PNC use in Yobe and Bauchi in North-east Nigeria compared to other states within the region. The findings indicate the need for policymakers to develop state- and region-specific health policy and intervention programs to address the inequity in postnatal care coverage and usage across regions in Nigeria.

The social determinants of health facility delivery in Ghana

Background

Many women still deliver outside a health facility in Ghana, often under unhygienic conditions and without skilled birth attendants. This study aims to examine the social determinants influencing the use of health facility delivery among reproductive-aged women in Ghana.

Methods

Nationally representative data from the 2014 Ghana Demographic and Health Survey was used to fit univariable and multivariable logistic regression models to estimate the influence of the social determinants on health facility delivery. Andresen’s health care utilization model was used as the conceptual framework guiding this study..

Results

Only 72% of deliveries take place at a health facility in Ghana. The results of the adjusted model indicate that place of residence, financial status, education, religion, parity and perceived need were significantly associated with health facility delivery. First, urban women had a higher likelihood of health facility delivery than rural women (Adjusted Odds ratio [AOR] =2.21; 95% Confidence interval [CI] = 1.53–3.19). Second, middle-class and rich women were 1.57 (95%CI = 1.18–2.08) times and 6.91 (95%CI = 4.12–11.59) times, respectively more likely to deliver at health facility compared to the poor. Third, women with either at least secondary education (AOR = 2.04; 95%CI = 1.57–2.64) or primary education (AOR = 1.39, 95%CI = 1.02–1.92) were more likely to deliver at health facility than women with no education. In terms of parity, first time mothers were 1.58 (95% CI = 1.18–2.12) times more likely to deliver at health facility than those who had given birth three or more times before. Finally, regarding perceived need, women who were aware of pregnancy complications were 1.32 (95%CI = 1.02–1.70) times more likely to use health facility delivery than those who were not informed about pregnancy complications.

Conclusions

First, in spite of Ghana’s free maternal health services policy, poorer women were much less likely to have a health facility delivery, which points to the need to understand the indirect costs and other financial barriers preventing women from delivering at a health facility. Second, many of the identified variables influence the demand and not just the supply for health care services, and highlight the importance of the social determinants of health and investments in interventions that extend beyond improving physical access.

Women’s health: a benefit of education in Australia

Purpose

The purpose of this paper is to examine the relationship between education and health amongst Australian women.

Design/methodology/approach

This study uses the Household, Income and Labour Dynamics in Australia data set. Spouse’s education is employed as an instrument to solve the potential endogeneity of educational attainment.

Findings

The results indicate that an additional year of schooling can lead to an increase in self-reported health, physical health, mental health and a reduced likelihood of having long-term health conditions. Women who are not in the labour force are likely to enjoy higher benefits of education compared to their employed counterparts. The findings also suggest that the relationship between education and health can be explained by the extent of positive health behaviours and social capital as mediators.

Research limitations/implications

The conclusion from the results might be different in the case of men, reducing the generalisability of the results. Several objective health variables should be used to provide further aspects of health on which education has an impact.

Practical implications

As the positive effect of education on women’s health is empirically found, investment in women’s education should be seriously considered and reevaluated.

Originality/value

This paper focuses on Australian women which not only reduces the heterogeneity between genders but also adds to the rare number of studies on this topic in Australia. This paper also employs a formal mediation analysis to examine what are the mechanisms explaining the relationship between education and health.

Factors influencing the decision to choose a birth center by pregnant women in Gombe state Nigeria

Purpose

Gombe state in northeast Nigeria records a high prevalence of home deliveries with very low facility deliveries despite the efforts of government and international non-governmental organizations in supporting maternal health services. The purpose of this paper is to assess the factors influencing the decision to choose a birth center by pregnant women in Gombe, Nigeria.

Design/methodology/approach

The design was a cross-sectional study of women from a baseline survey conducted in August 2016 in Gombe state, Nigeria. Data on women groups’ utilization of maternal services with a focus on antenatal care, delivery and postnatal care were collected using a structured questionnaire used for household survey conducted in the state. Data for 157 pregnant women from the sample of 750 women (15–49 years) were selected for the purpose of this analysis. Descriptive statistics, bivariate and multivariate analyses were used to determine the factors associated with choice of birth center.

Findings

Religion (AOR=12.117, 95% CI 1.774–82.741), paid work (AOR=3.633, 95% CI 1.243–10.615) and identification and knowledge of pregnancy complications (AOR=4.281, 95% CI 1.054–17.387) were the factors found to be significantly associated with choice of birth center by pregnant women. Age, education, closeness to a facility and decision by husband or woman were not found to be statistically significant.

Originality/value

The significance of disseminating knowledge about pregnancy complications, role of religious leaders and encouraging savings from women earnings need attention of the government to improve facility-based delivery.

Frequent Antenatal Care Visits Increase Institutional Delivery at Dabat Health and Demographic Surveillance System Site, Northwest Ethiopia

Background

Early diagnosis of pregnancy, professional follow-up, and skilled delivery service are the main interventions that reduce maternal morbidity and mortality. Generating local based evidence could support targeted and effective intervention placed by a government. Therefore, determining the prevalence of skilled institutional delivery and its associated factors is of supreme importance.

Methods

A community based cross-sectional study was conducted among pregnant women at Dabat Health and Demographic Surveillance System (DHDSS) site from 2014 to 2015. A total of 1290 pregnant women were included in the study. Data were extracted from what was collected as part of the ongoing DHDSS. Variables were extracted from the Household Registration System (HRS2 version 2.1) database and exported to STATA version 14.1 for analysis. Binary logistic regression was used to identify the factors associated with skilled institutional delivery. Statistical test was considered significant at P value < 0.05.

Results

The proportion of skilled institutional delivery was 31.0% (95% CI: 28.5, 33.6). Frequent Antenatal care (ANC) visits (Adjusted Odds Ratio (AOR): 2.94; 95% CI: 1.75, 4.94)), living in urban setting (AOR: 9.54; 95% CI: 5.99, 15.17), and ability to read and write (AOR: 1.81; 95% CI: 1.18, 2.75) were factors associated with increased delivery in the health institutions. On the other hand, giving more number of births (AOR: 0.39; 95% CI: 0.22, 0.66) decreased health institution delivery by 61%.

Conclusion

Higher rate of skilled institutional delivery has been observed at the surveillance site as compared with the previous national estimates. Giving less number of births, frequent ANC visits, being in urban residence, and ability to read and write increased the likelihood of health institution delivery. Strengthening interventions that could influence the identified factors could improve mothers' choice to skilled institutional delivery.

Examining trends in inequality in the use of reproductive health care services in Ghana and Nigeria

BACKGROUND

Equitable use of reproductive health care services is of critical importance since it may affect women's and children's health. Policies to reduce inequality in access to reproductive health care services are often general and frequently benefit the richer population. This is known as the inverse equity situation. We analyzed the magnitude and trends in wealth-related inequalities in the use of family planning, antenatal and delivery care services in Ghana and Nigeria. We also investigate horizontal inequalities in the determinants of reproductive health care service use over the years.

METHODS

We use data from Ghana's (2003, 2008 and 2014) and Nigeria's (2003, 2008 and 2013) Demographic and Health Surveys. We use concentration curves and concentration indices to measure the magnitude of socioeconomic-related inequalities and horizontal inequality in the use of reproductive health care services.

RESULTS

Exposure to family planning information via mass media, antenatal care at private facilities are more often used by women in wealthier households. Health worker's assistance during pregnancy outside a facility, antenatal care at government facilities, childbirth at home are more prevalent among women in poor households in both Ghana and Nigeria. Caesarean section is unequally spread to the disadvantage of women in poorer households in Ghana and Nigeria. In Nigeria, women in wealthier households have considerably more unmet needs for family planning than in Ghana. Country inequality was persistent over time and women in poorer households in Nigeria experienced changes that are more inequitable over the years.

CONCLUSION

We observe horizontal inequalities among women who use reproductive health care. These inequalities did not reduce substantially over the years. The gains made in reducing inequality in use of reproductive health care services are short-lived and erode over time, usually before the poorest population group can benefit. To reduce inequality in reproductive health care use, interventions should not only be pro-poor oriented, but they should also be sustainable and user-centered.

Health facility or home delivery? Factors influencing the choice of delivery place among mothers living in rural communities of Eritrea

BACKGROUND

In Eritrea, despite high antenatal care (ANC) use, utilization of health facilities for child birth is still low and with marked variations between urban and rural areas. Understanding the reasons behind the poor use of these services in a rural setting is important to design targeted strategies and address the challenge contextually. This study aimed to determine factors that influence women's choice of delivery place in selected rural communities in Eritrea.

METHODS

A cross-sectional survey of 309 women aged 15-49 years with a delivery in the last 1-2 years prior to the survey was conducted in a randomly selected villages of Hadish Adi, Serea, Genseba, Kelay Bealtat, Dirko, Mai Leham, Kudo Abour, Adi Koho, and Leayten. Data were collected using an interviewer administered questionnaire. Chi-square tests were used to explore association between variables. Using odds ratios with 95% confidence intervals with p < 0.05 taken as statically significant association, bivariate and multivariate logistic regression analysis were used to identify factors that affect the choice of delivery place.

RESULTS

Overall, 75.4% of the respondents delivered their last child at home while 24.6% delivered in health facility. Women whose husband's had no formal education were less likely [AOR = 0.02; 95% CI 0.01-0.54] to deliver in health facility. Women who had joint decision-making with husbands on delivery place [AOR = 5.42; 95% CI 1.78-16.49] and women whose husbands choose health facility delivery [AOR = 2.32; 95% CI 1.24-5.11] were more likely to have health facility delivery. Respondents who had medium wealth status [AOR = 3.78; 95% CI 1.38-10.37] have access to health facility within 2 km distance [AOR = 14.67; 95% CI 2.30-93.45] and women with traditional means of transport [AOR = 9.78; 95% CI 1.23-77.26] were also more likely to deliver in health facility. Women who read newspaper daily or infrequently had three [AOR = 3.77; 95% CI 1.12-4.04] and almost three times [AOR = 2.95; 95% CI 1.01-8.59] higher odds of delivering in health facility. Similarly, women who have knowledge about complications during delivery [AOR = 4.39; 95% CI 1.63-11.83], good perception on the quality of care they received [AOR = 9.52; 95% CI 1.91-47.50], had previous facility delivery [AOR = 2.69; 95% CI 0.94-7.68], have negative experiences of delivery outcomes in her community [AOR = 1.31; 95% CI 1.00-4.96], and women who perceive home delivery as life threatening [AOR = 1.84; 95% CI 1.46-3.38] were more likely to deliver in health facility.

CONCLUSION

To increase health facility delivery, raising women's awareness on the benefits of delivering in health facility, male involvement in the use of maternal health services, increasing women decision-making power, addressing common barriers of lack of transport, and compensations for transport expenses to alleviate the cost of transport are recommended. Efforts to shorten distance to reach health facility and health education focusing on the potential threats of delivering at home at the individual and community level can have substantial contribution to increase health facility delivery in rural communities of Eritrea.

Determinants of caesarean section in Bangladesh: Cross-sectional analysis of Bangladesh Demographic and Health Survey 2014 Data

BACKGROUND

Caesarean section (CS) has been on the rise worldwide and Bangladesh is no exception. In Bangladesh, the CS rate, which includes both institutional and community-based deliveries, has increased from about 3% in 2000 to about 24% in 2014. This study examines the association of reported complications around delivery and socio-demographic, healthcare and spatial characteristics of mothers with CS, using data from the latest Bangladesh Demographic and Health Survey (BDHS).

METHODS

The study is based on data from the 2014 BDHS. BDHS is a nationally representative survey which is conducted periodically and 2014 is the latest of the BDHS conducted. Data collected from 4,627 mothers who gave birth in health care institutions in three years preceding the survey were used in this study.

RESULTS

Average age of the mothers was 24.6 years, while their average years of schooling were 3.2. Factors like mother being older, obese, residing in urban areas, first birth, maternal perception of large newborn size, husband being a professional, had higher number of antenatal care (ANC) visits, seeking ANC from private providers, and delivering in a private facility were statistically associated with higher rates of CS.

CONCLUSIONS

Bangladesh health system urgently needs policy guideline with monitoring of clinical indications of CS deliveries to avoid unnecessary CS. Strict adherence to this guideline, along with enhance knowledge on the unsafe nature of the unnecessary CS can achieve increased institutional normal delivery in future; otherwise, an emergency procedure may end up being a lucrative practice.

Factors associated with use of maternal healthcare services during the Boko Haram insurgency in North-East Nigeria

Studies have focused on both individual and community factors affecting the use of maternal healthcare services. However, studies in Nigeria have rarely examined whether the influence of individual and community factors in explaining the use of maternal healthcare has changed in the context of the Boko Haram insurgency in North-East Nigeria. This study investigates factors associated with the use of maternal healthcare services during the Boko Haram insurgency in North-East Nigeria. The study analysed data from the 2013 Nigeria Demographic and Health Survey. Results showed that some individual characteristics are no longer associated with the use of maternal healthcare services, compared to community characteristics which are. Humanitarian assistance to the region should take this into account when considering interventions to encourage better uptake of maternal healthcare services.

Education is the antidote: Individual- and community-level effects of maternal education on child immunizations in Nigeria

Nigeria is an interesting case study because it outperforms other lower middle-income countries in economic development, yet ranks among the lowest in the world in immunization coverage rates. Combining multi-level modeling with spatial data techniques, this study investigates the individual- and community-level factors that influence the likelihood that a child is fully immunized, underscoring the importance of maternal education for improving child health. Drawing on data from the Demographic and Health Surveys and the Global Administrative Areas database, the analysis pools data on children aged 12-24 months across 455 communities. The spatial analysis reveals substantial geographic gaps in immunization coverage across Nigeria, demonstrating that not everyone benefits from the purported benefits of economic growth. Results from the multi-level models indicate that women's education has a robust association with vaccinations at the individual level and at the community level, even net of a variety of other household and community characteristics. The education level of a child's own mother influences the likelihood of being immunized, but above and beyond that, living in a community in which many women are educated also influences that likelihood. This suggests that education has a protective effect on child health not only because more individual women are going to school, but also because everyone benefits from the education and empowerment of women in the community. As broad societal transformations take place, education may shape women's capacity to take advantage of better access to power and resources, resulting in a dispersion effect of expanded women's education on health.

Why not? Understanding the spatial clustering of private facility-based delivery and financial reasons for homebirths in Nigeria

Background

In Nigeria, the provision of public and private healthcare vary geographically, contributing to variations in one’s healthcare surroundings across space. Facility-based delivery (FBD) is also spatially heterogeneous. Levels of FBD and private FBD are significantly lower for women in certain south-eastern and northern regions. The potential influence of childbirth services frequented by the community on individual’s barriers to healthcare utilization is under-studied, possibly due to the lack of suitable data.

Using individual-level data, we present a novel analytical approach to examine the relationship between women’s reasons for homebirth and community-level, health-seeking surroundings. We aim to assess the extent to which cost or finance acts as a barrier for FBD across geographic areas with varying levels of private FBD in Nigeria.

Method

The most recent live births of 20,467 women were georeferenced to 889 locations in the 2013 Nigeria Demographic and Health Survey. Using these locations as the analytical unit, spatial clusters of high/low private FBD were detected with Kulldorff statistics in the SatScan software package. We then obtained the predicted percentages of women who self-reported financial reasons for homebirth from an adjusted generalized linear model for these clusters.

Results

Overall private FBD was 13.6% (95%CI = 11.9,15.5). We found ten clusters of low private FBD (average level: 0.8, 95%CI = 0.8,0.8) and seven clusters of high private FBD (average level: 37.9, 95%CI = 37.6,38.2). Clusters of low private FBD were primarily located in the north, and the Bayelsa and Cross River States. Financial barrier was associated with high private FBD at the cluster level – 10% increase in private FBD was associated with + 1.94% (95%CI = 1.69,2.18) in nonusers citing cost as a reason for homebirth.

Conclusions

In communities where private FBD is common, women who stay home for childbirth might have mild increased difficulties in gaining effective access to public care, or face an overriding preference to use private services, among other potential factors. The analytical approach presented in this study enables further research of the differentials in individuals’ reasons for service non-uptake across varying contexts of healthcare surroundings. This will help better devise context-specific strategies to improve health service utilization in resource-scarce settings.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3225-4) contains supplementary material, which is available to authorized users.

Implementation of a community-based intervention in the most rural and remote districts of Zambia: a process evaluation of safe motherhood action groups

BACKGROUND

A community-based intervention known as Safe Motherhood Action Groups (SMAGs) was implemented to increase coverage of maternal and neonatal health (MNH) services among the poorest and most remote populations in Zambia. While the outcome evaluation demonstrated statistically significant improvement in the MNH indicators, targets for key indicators were not achieved, and reasons for this shortfall were not known. This study was aimed at understanding why the targeted key indicators for MNH services were not achieved.

METHODS

A process evaluation, in accordance with the Medical Research Council (MRC) framework, was conducted in two selected rural districts of Zambia using qualitative approaches. Focus group discussions were conducted with SMAGs, volunteer community health workers, and mothers and in-depth interviews with healthcare providers. Content analysis was done.

RESULTS

We found that SMAGs implemented much of the intervention as was intended, particularly in the area of women's education and referral to health facilities for skilled MNH services. The SMAGs went beyond their prescribed roles to assist women with household chores and personal problems and used their own resources to enhance the success of the intervention. Deficiencies in the intervention were reported and included poor ongoing support, inadequate supplies and lack of effective transportation such as bicycles needed for the SMAGs to facilitate their work. Factors external to the intervention, such as inadequacy of health services and skilled healthcare providers in facilities where SMAGs referred mothers and poor geographical access, may have led SMAGs to engage in the unintended role of conducting deliveries, thus compromising the outcome of the intervention.

CONCLUSION

We found evidence suggesting that although SMAGs continue to play pivotal roles in contribution towards accelerated coverage of MNH services among hard-to-reach populations, they are unable to meet some of the critical sets of MNH service-targeted indicators. The complexities of the implementation mechanisms coupled with the presence of setting specific socio-cultural and geographical contextual factors could partially explain this failure. This suggests a need for innovating existing implementation strategies so as to help SMAGs and any other community health system champions to effectively respond to MNH needs of most-at-risk women and promote universal health coverage targeting hard-to-reach groups.

Women's experiences of mistreatment during childbirth: A comparative view of home- and facility-based births in Pakistan

INTRODUCTION

Respectful and dignified healthcare is a fundamental right for every woman. However, many women seeking childbirth services, especially those in low-income countries such as Pakistan, are mistreated by their birth attendants. The aim of this epidemiological study was to estimate the prevalence of mistreatment and types of mistreatment among women giving birth in facility- and home-based settings in Pakistan in order to address the lack of empirical evidence on this topic. The study also examined the association between demographics (socio-demographic, reproductive history and empowerment status) and mistreatment, both in general and according to birth setting (whether home- or facility-based).

MATERIAL AND METHODS

In phase one, we identified 24 mistreatment indicators through an extensive literature review. We then pre-tested these indicators and classified them into seven behavioural types. During phase two, the survey was conducted (April-May 2013) in 14 districts across Pakistan. A total of 1,334 women who had given birth at home or in a healthcare facility over the past 12 months were interviewed. Linear regression analysis was employed for the full data set, and for facility- and home-based births separately, using Stata version 14.1.

RESULTS

There were no significant differences in manifestations of mistreatment between facility- and home-based childbirths. Approximately 97% of women reported experiencing at least one disrespectful and abusive behaviour. Experiences of mistreatment by type were as follows: non-consented care (81%); right to information (72%); non-confidential care (69%); verbal abuse (35%); abandonment of care (32%); discriminatory care (15%); and physical abuse (15%). In overall analysis, experience of mistreatment was lower among women who were unemployed (β = -1.17, 95% CI -1.81, -0.53); and higher among less empowered women (β = 0.11, 95% CI 0.06, 0.16); and those assisted by a traditional birth attendant as opposed to a general physician (β = 0.94, 95% CI 0.13, 1.75). Sub-group analyses for home-based births identified the same significant associations with mistreatment, with ethnicity included. In facility-based births, there was a significant relationship between women's employment and empowerment status and mistreatment. Women with prior education on birth preparedness were less likely to experience mistreatment compared to those who had received no previous birth preparedness education.

CONCLUSION

In order to promote care that is woman-centred and provided in a respectful and culturally appropriate manner, service providers should be cognisant of the current situation and ensure provision of quality antenatal care. At the community level, women should seek antenatal care for improved birth preparedness, while at the interpersonal level strategies should be devised to leverage women's ability to participate in key household decisions.

Patient and provider determinants for receipt of three dimensions of respectful maternity care in Kigoma Region, Tanzania-April-July, 2016

BACKGROUND

Lack of respectful maternity care (RMC) is increasingly recognized as a human rights issue and a key deterrent to women seeking facility-based deliveries. Ensuring facility-based RMC is essential for improving maternal and neonatal health, especially in sub-Saharan African countries where mortality and non-skilled delivery care remain high. Few studies have attempted to quantitatively identify patient and delivery factors associated with RMC, and none has modeled the influence of provider characteristics on RMC. This study aims to help fill these gaps through collection and analysis of interviews linked between clients and providers, allowing for description of both patient and provider characteristics and their association with receipt of RMC.

METHODS

We conducted cross-sectional surveys across 61 facilities in Kigoma Region, Tanzania, from April to July 2016. Measures of RMC were developed using 21-items in a Principal Components Analysis (PCA). We conducted multilevel, mixed effects generalized linear regression analyses on matched data from 249 providers and 935 post-delivery clients. The outcomes of interest included three dimensions of RMC-Friendliness/Comfort/Attention; Information/Consent; and Non-abuse/Kindness-developed from the first three components of PCA. Significance level was set at p < 0.05.

RESULTS

Significant client-level determinants for perceived Friendliness/Comfort/Attention RMC included age (30-39 versus 15-19 years: Coefficient [Coef] 0.63; 40-49 versus 15-19 years: Coef 0.79) and self-reported complications (reported complications versus did not: Coef - 0.41). Significant provider-level determinants included perception of fair pay (Perceives fair pay versus unfair pay: Coef 0.46), cadre (Nurses/midwives versus Clinicians: Coef - 0.46), and number of deliveries in the last month (11-20 versus < 11 deliveries: Coef - 0.35). Significant client-level determinants for Information/Consent RMC included labor companionship (Companion versus none: Coef 0.37) and religiosity (Attends services at least weekly versus less often: Coef - 0.31). Significant provider-level determinants included perception of fair pay (Perceives fair pay versus unfair: Coef 0.37), weekly work hours (Coef 0.01), and age (30-39 versus 20-29 years: Coef - 0.34; 40-49 versus 20-29 years: Coef - 0.58). Significant provider-level determinants for Non-abuse/Kindness RMC included the predictors of age (age 50+ versus 20-29 years: Coef 0.34) and access to electronic mentoring (Access to two mentoring types versus none: Coef 0.37).

CONCLUSIONS

These findings illustrate the value of including both client and provider information in the analysis of RMC. Strategies that address provider-level determinants of RMC (such as equitable pay, work environment, access to mentoring platforms) may improve RMC and subsequently address uptake of facility delivery.

Age-specific factors related to institutional delivery in Nigeria: Insights from the 2011 Multiple Indicator Cluster Survey

With 814 maternal deaths per 100,000 live births, maternal mortality remains a significant public health problem in Nigeria. We examined associations between maternal age and institutional delivery among 9,485 women, using data from the 2011 Nigeria Multiple Indicator Cluster Survey. We used multiple logistic regression to identify enabling factors and barriers to institutional delivery. Older maternal age was positively associated with institutional delivery. In age-stratified, adjusted analyses, secondary/higher education and living in wealthy households were consistently associated with increased odds of institutional delivery among the youngest (15-19 years) and the oldest (40-49 years) women. Higher parity was associated with significantly reduced odds of institutional delivery among women <40 years, but was not associated among women aged 40-49 years. Among women of 40-49 years, attending at least four antenatal care (ANC) visits was associated with increased odds of institutional delivery; among women of ages 15-19 years, the association was not significant. Similarly, having a skilled ANC provider was not significantly associated with institutional delivery among women aged 15-19 and 40-49 years. These findings suggest that women at the highest risk for maternal death may face barriers to institutional delivery services. Focused policies and programs are needed to address women's reproductive health vulnerabilities.

Knowledge, perception, access and utilisation of HIV counselling and testing among pregnant women in rural communities of Osogbo town, Nigeria

OBJECTIVE

To assess knowledge, perception, access and utilisation of HIV counselling and testing among pregnant women from rural communities in Nigeria.

DESIGN

Descriptive cross-sectional survey.

SETTING

Primary health care facilities in rural communities of Osogbo, Osun State, Nigeria.

PARTICIPANTS

Three-hundred pregnant women attending antenatal clinics in primary health care facilities.

MAIN OUTCOME MEASURES

Knowledge of HIV counselling and testing, perception of HIV counselling and testing, utilisation of HIV counselling and testing and barriers associated with HIV counselling and testing utilisation.

RESULTS

Findings showed that 59.0% had good knowledge, while 56.7% had good perception. Majority (88.4%) of the 77.7% of respondents who reported the availability of HIV counselling and testing services said it was free and 61.3% of the respondents had HIV counselling and testing done before. Majority (78.3%) had one-on-one counselling, while a little above half (55.4%) gave consent for testing. However, less than half (36.3%) of the respondents were willing to have HIV counselling and testing done in the present pregnancy. There is significant association between the level of perception and utilisation of HIV counselling and testing. A significant association is also found between knowledge of HIV counselling and testing and utilisation. Key barriers found to be associated with utilisation of HIV counselling and testing include 'fear of how to cope with being positive' and 'absence of HIV counselling and testing centre'.

CONCLUSION

Many women selected from rural communities demonstrated good knowledge and perception of HIV counselling and testing. The majority of them also had access to HIV counselling and testing and used it. However, some still have misconception about mother-to-child transmission of HIV.

Geographical differentials in uptake of antenatal care services in Nigeria

Uptake of antenatal care (ANC) is poor in Nigeria; however, there are geographical variations. We investigated the relationship between place of residence, region and ANC utilization in Nigeria. Using data of the most recent demographic and health survey, the geographic predictors of ANC were modeled. Women in the rural areas were 79% less likely to have the recommended four ANC visits. The odds of a woman in southern Nigeria having four ANC visit are 4.347 times the odds of a woman in northern Nigeria having the recommended ANC visit. We recommend increased coverage of maternal health services.