Characteristics of antenatal care attenders in a rural population in Tamil Nadu, South India: a community-based cross-sectional study

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.

Long-term trend in socioeconomic inequalities and geographic variation in the utilization of antenatal care service in India between 1998 and 2015

OBJECTIVE

To investigate the temporal trend of socioeconomic and rural-urban disparities and geographical variation in the utilization of antenatal care (ANC) services in India before and throughout the Millennium Development Goals era.

DATA SOURCES/STUDY SETTING

For this temporal analysis, secondary data from the Indian National Family Health Surveys between 1998 and 2015 (Waves 2, 3, and 4) were used.

STUDY DESIGN

We analyzed the trend in inequality for at least one and four ANC visits to a health care professional (ANC1+ and ANC4+, respectively) by education, wealth, and residence type. Multilevel logistic regression models were used to assess the temporal trend and the relative contribution of communities and states to the overall variation in ANC1+ and ANC4+.

DATA COLLECTION/EXTRACTION METHODS

Data on utilization of ANC services for the last birth of women aged 15-49 years during the three or five years preceding the survey (depending on the survey year) were used.

PRINCIPAL FINDINGS

Educational and wealth inequality in ANC1+ and ANC4+ worsened between 1998 and 2005 and improved between 2005 and 2015 (for ANC4+, OR [95% CI] = 0.22 [0.19-0.25] in Wave 2; OR [95% CI] = 0.19 [0.17-0.22] in Wave 3; and OR [95% CI] = 0.38 [0.36-0.40] in Wave 4 for the poorest). Rural-urban inequality showed a consistent decline (for ANC4+, OR [95% CI] = 0.59 [0.54-0.64] in Wave 2; OR [95% CI] = 0.63 [0.59-0.68] in Wave 3; and OR [95% CI] = 0.82 [0.79-0.85] in Wave 4 for rural area). The relative contribution of the community to the total geographic variation in the utilization of ANC services increased more than four times during the study period.

CONCLUSIONS

The use of ANC services remains disproportionately lower among women with low socioeconomic status. Efforts to directly target these women are necessary to tackle inequality in ANC utilization in India.

Understanding Barriers and Facilitators of Maternal Health Care Utilization in Central Myanmar

The study objective was to examine barriers and facilitators of maternal health services utilization in Myanmar with the highest maternal mortality ratio in Southeast Asia. Data for 258 mothers with children under five were extracted from a community health survey administered between 2016 and 2017 in Mandalay, the largest city in central Myanmar, and analyzed for associations between determinants of maternal health care choices and related outcomes. The study showed that late antenatal care was underutilized (41.7%), and antenatal care attendance was significantly associated with geographical setting, household income, education, and access to transportation (p ≤ 0.05). Less than one-third of women gave birth at home and 18.5% of them did so without the assistance of traditional birth attendants. Household education level was a significant predictor for home delivery (p < 0.01). Utilization of postnatal care services was irregular (47.9%-70.9%) and strongly associated with women's places of delivery (p < 0.01). Efforts geared towards improving maternal health outcomes should focus on supporting traditional birth attendants in their role of facilitating high-quality care and helping women reach traditional health facilities, as well as on maternal health literacy based on culturally appropriate communication.

Effects of Empowerment and Media Use by Women of Childbearing Age on Maternal Health Care Utilization in Developing Countries of Southeast Asia

Despite its importance to maternal health, women’s empowerment in developing countries has yet to be adequately addressed. We investigated the effects of women’s empowerment and media use on maternal antenatal care in Southeast Asian countries. The data originate from the Demographic and Health Surveys conducted in Southeast Asia between 2011 and 2014 (n = 35,905). We conducted Poisson regression and meta-analyses to examine communication inequalities in the media use for the relationships between women’s empowerment and maternal health. Women who had decision-making authority for their own health care (incidence rate ratio [IRR] = 1.03, 95% CI = 1.01–1.05), household purchases (IRR = 1.02, 95% CI = 1.00–1.04), and visiting family or relatives (IRR = 1.05, 95% CI = 1.03–1.07) were more likely to receive health care than were study participants whose partners had the decision-making authority. When we added use of each type of media into the model, the women who read a newspaper daily (IRR = 1.10, 95% CI = 1.03–1.20), listened to the radio at least once a week (IRR = 1.02, 95% CI = 1.01–1.03), and watched television daily (IRR = 1.61, 95% CI = 1.55–1.67) were more likely to receive health care than those who did not use media at all. This study revealed that women’s empowerment and their use of media were related to better maternal health care.

The differential effect of the free maternity services policy in Kenya

BACKGROUND

The Government of Kenya introduced the free maternity services (FMS) policy to enable mothers deliver at a health facility and thus improve maternal health indicators.

AIM

The aim of this study was to determine if there was a differential effect of the policy by region (sub-county) and by facility type (hospitals vs. primary healthcare facilities [PHCFs]).

SETTING

The study was conducted in Nyamira County in western Kenya.

METHODS

This was an interrupted time series study where 42 data sets (24 pre- and 18 post-intervention) were collected for each observation. Monthly data were abstracted from the District Health Information System-2, verified, keyed into and analysed by using IBM-Statistical Package for the Social Sciences (SPSS-17).

RESULTS

The relative effect of the policy on facility deliveries in the county was an increase of 22.5%, significant up to the 12th month (p < 0.05). The effect of the policy on deliveries by region was highest in Nyamira North and Masaba North (p < 0.001 up to the 18th month). The effect was larger (46.5% vs. 18.3%) and lasted longer (18 months vs. 6 months) in the hospitals than in the PHCFs. The increase in hospital deliveries was most significant in Nyamira North (61%; p < 0.001). There was a medium-term effect on hospital deliveries in Borabu (up to 9 months) and an effect that started in the sixth month in Manga. The relative effect of the policy on facility deliveries in PHCFs was only significant in Nyamira North and Masaba North (p < 0.001).

CONCLUSION

The effect of the FMS policy was varied by region (sub-county) and by facility type.

Heterogeneities in utilization of antenatal care in Uttar Pradesh, India: the need to contextualize interventions to individual contexts

BACKGROUND

This paper explores the heterogeneities in antenatal care (ANC) utilization in India's most populated state, Uttar Pradesh. Taking an intersectionality lens, multiple individual- and district-level factors are used to identify segments of any antenatal care usage in Uttar Pradesh Objective: This paper seeks to understand the multilevel contexts of ANC utilization. The planning and programming challenge is that such knowledge of contextual specificity is rarely known upfront at the initial stages of planning or implementing an intervention. Exploratory data analysis might be needed to identify such contextual specificity.

METHODS

Tree-structured regression methods are used to identify segments and interactions between factors. The results from the tree-structured regression were complemented with multilevel models that controlled for the clustering of individuals within districts.

RESULTS

Heterogeneities in utilization of any ANC were observed. The multiple segments of ANC utilization that were developed went from a low utilization of 23.7% for respondents who were not literate and did not have home ownership to a high of 82.4% for respondents who were literate and at the highest level of wealth. Key variables that helped define the segments of ANC utilization include: woman's literacy, ownership of home, wealth index, and district-level sex ratio. Based on the multilevel model of any ANC utilization, cross-level interactions also were obtained between sex ratio and ownership of home as well as between sex ratio and literacy. Increases in sex ratio increased the influence of ownership of home on any ANC, while increases in sex ratio reduced the impact of woman's literacy on receiving any ANC.

CONCLUSION

We argue that a focus on heterogeneous segments of utilization can help build knowledge of the mechanisms that underlie inequities in maternal health utilization. Such knowledge of heterogeneity needs to be incorporated in contextualizing interventions to meet a variety of recipients' needs.

Factors influencing timely initiation and completion of gestational diabetes mellitus screening and diagnosis - a qualitative study from Tamil Nadu, India

BACKGROUND

In 2007, universal screening for gestational diabetes mellitus (GDM) was introduced in Tamil Nadu, India. To identify factors hindering or facilitating timely initiation and completion of the GDM screening and diagnosis process, our study investigated how pregnant women in rural and urban Tamil Nadu access and navigate different GDM related health services.

METHODS

The study was carried out in two settings: an urban private diabetes centre and a rural government primary health centre. Observations of the process of screening and diagnosis at the health centres as well as semi-structured interviews with 30 pregnant women and nine health care providers were conducted. Data was analysed using qualitative content analysis.

RESULTS

There were significant differences in the process of GDM screening and diagnosis in the urban and rural settings. Several factors hindering or facilitating timely initiation and completion of the process were identified. Timely attendance required awareness, motivation and opportunity to attend. Women had to attend the health centre at the right time and sometimes at the right gestational age to initiate the test, wait to complete the test and obtain the test report in time to initiate further action. All these steps and requirements were influenced by factors within and outside the health system such as getting right information from health care providers, clinic timings, characteristics of the test, availability of transport, social network and support, and social norms and cultural practices.

CONCLUSIONS

Minimising and aligning complex stepwise processes of prenatal care and GDM screening delivery and attention to the factors influencing it are important for further improving and expanding GDM screening and related services, not only in Tamil Nadu but in other similar low and middle income settings. This study stresses the importance of guidelines and diagnostic criteria which are simple and feasible on the ground.

Predictors of delayed Antenatal Care (ANC) visits in Nigeria: secondary analysis of 2013 Nigeria Demographic and Health Survey (NDHS)

INTRODUCTION

Antenatal Care (ANC) is an important component of maternal health and covers a wide range of activities with huge potential benefits for positive pregnancy out comes. However, large proportions of women do initiate ANC early resulting in adverse consequences.

METHODS

The study utilized the nationally-representative sample of women of reproductive age interviewed during the 2013 Nigeria DHS. Analysis was restricted to 20, 467 women aged 15-49 years who had a live birth in the five-year period prior to the survey. Multinomial logistic regression was performed using Stata v13 to determine significant factors related to timing of initiation of ANC. Relative risk ratio (RRR) was used to assess the strength of association between independent and dependent variables.

RESULTS

Overall, 27%, 62% and 12% of women initiated ANC in the first, second and third trimesters respectively. In both the two model, the findings reveal that maternal education, level of media exposure, region and place of residence are the uniform predictors of initiation of ANC; having health insurance is a significant predictor of third trimester ANC initiation relative to first to first trimester only. Within the categories of household wealth, levels of participation in household decision-making and region some categories are significant predictors while others are not.

CONCLUSION

Maternal education, level of media exposure, region and place of residence are the uniform and consistent predictors of delay in ANC initiation. This suggests that girl-child education, universal health coverage and universal health insurance could be the interventions required to improve service utilization and maternal health.

Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria

INTRODUCTION

Utilization of antenatal care, institutional delivery and postnatal care services in Nigeria are poor even by african average.

METHODS

We analysed the 2013 Nigeria DHS to determine factors associated with utilization of these health MCH indicators by employing both bivariate and multivariate logistic regressions.

RESULTS

Overall, 54% of women had at least four ANC visits, 37% delivered in health facility and 29% of new born had postnatal care within two of births. Factors that consistently predict the utilization of the three MCH services are maternal and husband's level education, place of residence, wealth level and parity. Antenatal care strongly predicts both health facility delivery (OR = 2.16, 95%CI: 1.99-2.34) and postnatal care utilization (OR = 4.67, 95%CI: 3.95-5.54); while health facility delivery equally predicting postnatal care (OR = 2.84, 95%CI: 2.20-2.80).

CONCLUSION

Improving utilization of these three MCH indicators will require targeting women in the rural areas and those with low level of education as well as creating demand for health facility delivery. Improving ANC use by making it available and accessible will have a multiplier effect of improving facility delivery which will lead to improved postnatal care utilization.

Determinants of access to antenatal care and birth outcomes in Kumasi, Ghana

This study aimed to investigate factors that influence antenatal care utilization and their association with adverse pregnancy outcomes (defined as low birth weight, stillbirth, preterm delivery or small for gestational age) among pregnant women in Kumasi. A quantitative cross-sectional study was conducted of 643 women aged 19–48 years who presented for delivery at selected public hospitals and private traditional birth attendants from July–November 2011. Participants’ information and factors influencing antenatal attendance were collected using a structured questionnaire and antenatal records. Associations between these factors and adverse pregnancy outcomes were assessed using chi-square and logistic regression.

Nineteen percent of the women experienced an adverse pregnancy outcome. For 49% of the women, cost influenced their antenatal attendance. Cost was associated with increased likelihood of a woman experiencing an adverse outcome (adjusted OR = 2.15; 95% CI = 1.16–3.99; p = 0.016). Also, women with >5 births had an increased likelihood of an adverse outcome compared with women with single deliveries (adjusted OR = 3.77; 95% CI = 1.50–9.53; p = 0.005). The prevalence of adverse outcomes was lower than previously reported (44.6 versus 19%). Cost and distance were associated with adverse outcomes after adjusting for confounders. Cost and distance could be minimized through a wider application of the Ghana National Health Insurance Scheme.

Social inequality and antenatal care: impact of economic welfare on pregnancy monitoring in Senegal

AIM

To explore the links between antenatal care (ANC) non-attendance and economic welfare. METHOD AND SUBJECT: This was a cross-sectional, descriptive and analytical study of women aged 15 to 49 years living in Senegal in 2005. Data were from the Demography and Health Survey using a two-stage random sampling procedure. Participants were classed by quintile using an economic well-being score based on housing characteristics and ownership of sustainable goods. The quality of ANC was determined from the number of visits, the qualification of the person delivering care, and content (counseling, weight, height and blood pressure measurements). Logistic regression was used for data analysis.

RESULTS

A total of 6927 women were surveyed. Mean age was 28.15 years (±2.6); 20.3% were primiparous; 61.2% resided in rural areas; 70.0% had received no education. Each of the first four economic quintiles included about 20% (19.2% to 21.5%) of the participants while 16.9% were in the fifth (richest) quintile. A total of 457 women (6.6%) did not undergo any ANC visit. ANC non-attendance increased with parity, decreased with education level and was higher in rural areas than in urban areas, OR=7.2 (95% CI [5.1-10.1]). It decreased with increasing economic well-being: OR=0.6 [0.47-0.75] 2nd quintile vs. 1st, OR=0.02 [0.01-0.05] 5th quintile vs. 1st, p<0.05 overall.

CONCLUSION

Economic welfare plays a major role in determining use of ANC. The only way to solve health problems is to reduce inequalities. The solution to this problem is beyond the scope of health but concerns an overall economic program involving the entire community, including policy-makers.

On the socio-economic determinants of antenatal care utilization in Azerbaijan: evidence and policy implications for reforms

Azerbaijan is a country with one of the highest child mortality rates in the regions of Eastern Europe and the former Soviet Union. Drawing on the nationally representative Demographic and Health Survey, this study examines the utilization of antenatal care in Azerbaijan to identify the socio-economic determinants of the usage, and its frequency, timing and quality. Consequently, binomial logit, two ordered logit and negative binomial regression models are specified to estimate the effect of various socio-economic characteristics on the likelihood of utilization. Place of living is an important determinant of antenatal healthcare utilization in Azerbaijan. It is important in determining the likelihood of utilization, its timing and quality of care received, whereas it is not significant in the model predicting the frequency of antenatal utilization. Women's education is also significant in three models out of four. Education is important in explaining the frequency and timing of utilization as well as the quality of services received, but it is not significant in predicting the likelihood of utilization. Wealth gradient is another important determinant of antenatal care utilization in Azerbaijan inasmuch as it is significant in explaining the likelihood of prenatal care utilization and its frequency. In addition, two variables, birth order and desirability of the last child or current pregnancy, are significant only in explaining the likelihood of utilization. Therefore, we confirm the findings of previous studies, which reported that the utilization of prenatal health care is a multistage process in which decisions are sequential. Although the same set of factors may affect decision-making at all stages, the effect of these factors is different at different stages. Implications for reforms in the healthcare sector to improve antenatal care utilization in Azerbaijan are provided and discussed.

The role of mothers-in-law in antenatal care decision-making in Nepal: a qualitative study

Background

Antenatal care (ANC) has been recognised as a way to improve health outcomes for pregnant women and their babies. However, only 29% of pregnant women receive the recommended four antenatal visits in Nepal but reasons for such low utilisation are poorly understood. As in many countries of South Asia, mothers-in-law play a crucial role in the decisions around accessing health care facilities and providers. This paper aims to explore the mother-in-law's role in (a) her daughter-in-law's ANC uptake; and (b) the decision-making process about using ANC services in Nepal.

Methods

In-depth interviews were conducted with 30 purposively selected antenatal or postnatal mothers (half users, half non-users of ANC), 10 husbands and 10 mothers-in-law in two different (urban and rural) communities.

Results

Our findings suggest that mothers-in-law sometime have a positive influence, for example when encouraging women to seek ANC, but more often it is negative. Like many rural women of their generation, all mothers-in-law in this study were illiterate and most had not used ANC themselves. The main factors leading mothers-in-law not to support/encourage ANC check ups were expectations regarding pregnant women fulfilling their household duties, perceptions that ANC was not beneficial based largely on their own past experiences, the scarcity of resources under their control and power relations between mothers-in-law and daughters-in-law. Individual knowledge and social class of the mothers-in-law of users and non-users differed significantly, which is likely to have had an effect on their perceptions of the benefits of ANC.

Conclusion

Mothers-in-law have a strong influence on the uptake of ANC in Nepal. Understanding their role is important if we are to design and target effective community-based health promotion interventions. Health promotion and educational interventions to improve the use of ANC should target women, husbands and family members, particularly mothers-in-law where they control access to family resources.

An issue of culture: the effects of daily activities on prenatal care utilization patterns in rural South Africa

Utilization of healthcare facilities has been extensively analyzed in developed countries by researchers from a wide range of disciplines. However, there is still a need to develop a better understanding of the temporal and spatial factors that affect rural women within developing countries. An important piece of this exploration is addressing time constraints and the cultural context. After time has been spent attending to essential tasks that the entire family is dependent upon, do rural women have "disposable time" left to visit a healthcare facility? The setting for this study is the Ubombo Magisterial District, a northern rural area of KwaZulu Natal, South Africa. Environmental factors and socio-economical factors that motivate or discourage women from utilizing prenatal care are addressed using a multinomial logit model. Many of the factors documented in literature as affecting prenatal care utilization, i.e. age and parity, do not apply in this area. On the other hand, fetching water as a daily activity, which is usually not associated with prenatal care utilization, has a significant effect on utilization.

Antenatal care: provision and inequality in rural north India

The objectives of this paper are to examine factors associated with use of antenatal care in rural areas of north India, to investigate access to specific critical components of care and to study differences in the pattern of services received via health facilities versus home visits. We used the 1998-1999 Indian National Family Health Survey of ever-married women in the reproductive age group and analysed data from the states of Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh (n = 11,369). Overall, about three-fifths of rural women did not receive any antenatal check-up during their last pregnancy. Services actually received were predominantly provision of tetanus toxoid vaccination and supply of iron and folic acid tablets. Only about 13% of pregnant women had their blood pressure checked and a blood test done at least once. Women visited by health workers received fewer services compared to women who visited a health facility. Home visits were biased towards households with a better standard of living. There was significant under-utilisation of nurse/midwives in the provision of antenatal services and doctors were often the lead providers. The average number of antenatal visits reported in this study was 2.4 and most visits were in the second trimester. Higher social and economic status was associated with increased chances of receiving an antenatal check-up, and of receiving specific components including blood pressure measurement, a blood test and urine testing but not the obstetric physical examination, which was however linked to ever-use of family planning and the education of women and their husbands. Thus, pregnant women from poor and uneducated backgrounds with at least one child were the least likely to receive antenatal check-ups and services in the four large north Indian states. Basic antenatal care components are effective means to prevent a range of pregnancy complications and reduce maternal mortality. The findings indicate substantial limitations of the health services in overcoming socio-economic and cultural barriers to access.