Utilisation of skilled birth attendants over time in Nigeria and Malawi

Prevalence and determinants of skilled birth attendance among young women aged 15-24 years in Northern Nigeria: evidence from multiple indicator cluster survey 2011 to 2021

BACKGROUND

Childbirth among adolescents and young mothers has been linked to various complications, including perinatal mortality, preterm births, low birth weight, and infections, which collectively contribute to the high burden of neonatal and maternal mortality. Despite some progress, the prevalence of skilled birth attendance, proven to improve maternal and newborn health outcomes, remains consistently low in Northern Nigeria. This study assessed the prevalence and determinants of Skilled Birth Attendance (SBA) among young women ages 15-24 years in Northern Nigeria.

METHODS

This pooled cross-sectional study included 6,461 young women aged 15-24 years from 2011, 2016 and 2021 multiple indicator cluster surveys in Nigeria. We used a binary logistic regression model to assess the factors associated with skilled birth attendance at 95% confidence intervals (CIs) with computed adjusted odds ratios (aORs).

RESULTS

The prevalence of skilled birth attendance among young women in Northern Nigeria increased from 25.6% in 2011 to 33.1% in 2021. Women who were atleast 18 years of age at first marriage had 2.48 higher odds of SBA (aOR 2.48, 95% CI = 1.54-4.00) compared those less than 18 years of age at first marriage after controlling for confounders. Young women from rich household wealth quintile were more likely to utilize SBA (aOR 1.84, 95% CI = 1.11-3.14) compared to young women from poor household wealth quintile. In terms of education, those women who had secondary (aOR = 2.52, 95% CI = 1.77-3.56) and higher education (aOR = 10.01, 95% CI = 2.21-49.31) had higher odds of SBA compared to those with no education. Individual women with media exposure had 59% higher likelihood (aOR = 1.59, 95% CI = 1.16-2.19), women who attended 4 or more antenatal care visits during their last pregnancy demonstrated 2.28 times higher odds (aOR = 2.28, 95% CI = 1.67-3.09), while those who reported no intention for their last pregnancy were 37% less likely (aOR = 0.63, 95% CI = 0.42-0.96) to utilize SBA.

CONCLUSION

A slight increase in the prevalence of skilled birth attendance was observed over the 10-year period. For a significant boost in skilled birth attendance among young women in Northern Nigeria, particular attention needs to be paid to girls' child education, delay in marriage, economic empowerment of young women, and strategic ways of leveraging trained community health workers (CHIPs) to bring reproductive healthcare close to young women living in rural areas.

The effect of health facility births on newborn mortality in Malawi

We examine the effect of health facility delivery on newborn mortality in Malawi using data from a survey of mothers in the Chimutu district, Malawi. The study exploits labour contraction time as an instrumental variable to overcome endogeneity of health facility delivery. The results show that health facility delivery does not reduce 7-day and 28-day mortality rates. In a low-income country like Malawi where the healthcare quality is severely compromised, we conclude that encouraging health facility delivery may not guarantee positive health outcomes for newborn births.

Spatial variation of skilled birth attendance and associated factors among reproductive age women in Ethiopia, 2019; a spatial and multilevel analysis

Background

The majority of maternal deaths were associated with a lack of access to skilled birth attendance. Because childbirth accounts for most maternal deaths, skilled birth attendance is crucial for reducing maternal mortality. The use of skilled birth attendance in Ethiopia is low, and it is crucial to identify factors that determine the use of skilled birth attendance. Hence, this study aimed to assess the spatial distribution, wealth-related inequality, and determinants for skilled birth attendance in Ethiopia.

Methods

Secondary data analysis was done with a total weighted sample of 5,251 reproductive-aged women using the 2019 mini EDHS. The concentration index and graph were used to assess wealth-related inequalities. Spatial analysis was done to identify the spatial distribution and multilevel logistic regression analysis was used to identify predictors of skilled birth attendance in Ethiopia. Analysis was done using STATA version 14, ArcGIS, and SaTscan software.

Results

The prevalence of skilled birth attendance was 50.04% (95% CI: 48.69%, 51.40%) in Ethiopia. Old age, being married, being educated, having television and radio, having ANC visits, being multiparous, having large household sizes, having a rich wealth index, living in rural residence, and living in a high level of community poverty and women's education were significant predictors of skilled birth attendance. Skilled birth attendance was disproportionately concentrated in rich households [C = 0.482; 95% CI: 0.436, 0.528]. High prevalence of unskilled birth attendance was found in Somalia, SNNP, Afar, and southern parts of the Amhara regions. Primary clusters of unskilled birth attendance Somalia and some parts of Oromia region of Ethiopia.

Conclusion

Half of the women in Ethiopia did not utilize skilled birth attendants with significant spatial clustering. Age, marital status, educational status, ANC Visit, having television and radio, parity, household size, wealth index, residence, community level poverty, and community level of women's education were significant predictors of skilled birth attendance. Skilled birth attendance was unevenly concentrated in rich households. The regions of Somalia, SNNP, Afar, and southern Amhara were identified as having a high prevalence of using unskilled birth attendance. Public health interventions should target those women at high risk of using unskilled birth attendants.

A scoping review of the residual barriers to skilled birth attendance in Ghana: A conceptual framework and a fish bone analysis

The achievement of the Sustainable Development Goals (SDGs) targets 3.1, 3.2 and 3.3.1 is strongly dependent on the effective utilization of skilled birth services. Despite advancements made in Skilled Birth Attendance (SBA) in Ghana, there are still instances of unassisted childbirths taking place. The aim of this study was to explore the residual barriers of SBA such as community- and health system-related factors affecting SBA in Ghana and to identify strategies for addressing them. An electronic search was done using PubMed, Popline, Science direct, BioMed Central, Scopus and Google scholar for peer reviewed articles as well as grey articles from other relevant sources, published between 200 and 2022 on community- and health system related factors influencing SBA in Ghana. Out of the 89 articles retrieved for full screening, a total of 52 peer-reviewed articles and 1 grey article were selected for the final review. The study revealed that cultural practices (community factors), low quality of service delivery due to the inappropriate behaviors, lack of competency of skilled birth attendants (SBAs) as well as the inefficient distribution of SBAs contribute to ineffective uptake of SBA (health system factors). Also, indirect costs are associated with the utilization of skilled delivery care even with the existence of 'free' delivery care policy under the national health insurance (policy factor). For Ghana to achieve the SDGs above and improve SBA, it is essential to enhance the quality of skilled delivery care by addressing the attitude and competencies of skilled birth professionals, while plans are put in place to expand and develop the Community-based Health Planning and Services (CHPS) strategy to help address the access barriers to SBA. More so, the 'free' delivery care policy should absorb all the costs associated with skilled delivery for pregnant women as it is intended for.

Factors Associated with Late Antenatal Initiation among Women in Malawi

Background Early initiation of antenatal care (ANC) is critical in identifying and mitigating adverse pregnancy-related complications. However, globally, a high percentage of women initiate ANC only at a late stage of their pregnancy. In view of this, the main objective of the study is to establish the prevalence and factors associated with late ANC initiation among women in Malawi. Methods The study was based on the 2015-16 Malawi Demographic and Health Survey (MDHS). The study population consisted of 13,251 women of reproductive age who had given birth during the five years preceding the survey. The data was analyzed using the chi-square test and multivariate logistic regression. Results The prevalence of late ANC initiation in Malawi was 75.6%. The logistic regression modelling revealed increased odds of late ANC initiation attendance among women residing in the Northern Region (AOR: 1.172; 95% CI: 1.021-1.345) and the Central Region (AOR: 1.178; 95% CI: 1.074-1.291), women residing in urban areas (AOR: 1.273; 95% CI: 1.108-1.463), women with no education (AOR: 1.814; 95% CI: 1.13-1.47) or with primary education (AOR: 1.697; 95% CI: 1.13-1.47), women with less than four ANC visits (AOR: 4.155; 95% CI: 4.002-4.814), unmarried women (AOR: 1.478; 95% CI: 1.111-1.985) and those whose last birth was not by caesarean section (AOR: 1.377; 95% CI: 1.179-1.607). Reduced odds of late ANC initiation among women were observed among women in the 20-24 age group (AOR: 0.634; 95% CI: 0.456-0.881), those in the 25-29 age group (AOR: 0.645; 95% CI: 0.476-0.874) and those aged 30-34 years (AOR: 0.634; 95% CI: 0.456-0.881). Conclusions The study found that ANC initiation in Malawi is often delayed, with most first visits occurring after the first trimester. Late ANC initiation is associated with region, place of residence, marital status, and the women's age. These are significant factors to be considered when designing new or reviewing ANC policies and strategies aimed at increasing ANC utilization and encouraging early initiation of ANC. Earlier ANC initiation among Malawian women can contribute positively towards improving maternal and child health in Malawi. Therefore, government policies and interventions should target women with no or little education, those living in poor families and other modifiable risk factors, such as young unmarried women.

Determinants of cervical cancer screening among women living with HIV in Zimbabwe

In sub-Saharan Africa (SSA), cervical cancer (CC) is the second leading cause of cancer-related deaths, with human immunodeficiency virus (HIV) seropositive women being particularly vulnerable. Despite the benefits of early CC screening in reducing HIV-related CC deaths, CC screening uptake remains limited, with wide disparities in access across SSA. As part of a larger study, this paper examines the determinants of CC screening among HIV-seropositive women of reproductive age (15-49 years) in Zimbabwe. Using the 2015 Zimbabwe Demographic and Health Survey, we conducted multilevel analyses of CC screening among 1490 HIV-seropositive women, nested in 400 clusters. Our findings revealed that, even though 74% of HIV-seropositive women knew about CC, only 17.6% of them reported ever screening for it. Women who held misconceptions about HIV (OR = 0.47, p = 0.01) were less likely to screen for CC compared to those with accurate knowledge about HIV and CC. HIV-seropositive women with secondary or higher education were more likely to screen (OR = 1.39, p = 0.04) for CC compared to those with a primary or lower level of education. Age was positively associated with screening for CC. Furthermore, locational factors, including province and rural-urban residence, were associated with CC screening. Based on these findings, we call for integrated care and management of HIV and non-communicable diseases in Southern Africa, specifically, Zimbabwe due to the legacy of HIV in the region.

"Don't use herbs in labor!": Plants, pharmaceuticals, and the unmaking of traditional birth attendants in Ghana, 1970-2000

This article considers efforts in the West African country of Ghana to improve maternal care through a network of trained "Traditional Birth Attendants," or TBAs in the late twentieth century. It reconsiders the rise and fall of TBAs through the lens of increasing global access to essential medicines like oxytocin and misoprostol which reduced confidence in herbal medications for pregnancy complications. Interviews with policy makers and birth attendants reflecting on their involvement in TBA programs from the 1970s as well as analysis of archival documents and training manuals shows how pharmaceuticals rose in prominence at the same time birth attendants maintained medicinal plant knowledge. Over time, Ghanaian policymakers encouraged TBAs to avoid using herbs while caring for women during pregnancy. By the early 2000s, government went so far as to ban TBAs, and urged everyone to deliver with a skilled birth attendant (SBA) such as a nurse midwife or obstetrician more conversant in biomedical interventions including pharmaceuticals. This retrospective account of TBAs across several decades suggests that once Ghanaian officials had strengthened access to standardized pharmaceuticals, they lost confidence in traditional birth attendants and the herbal remedies they cultivated. Access to pharmaceuticals shaped the difference between skilled and- "unskilled" or "traditional"-birth attendants.

Factors Associated with Deworming Medication Utilization among Pregnant Women in Benin: Evidence from the Demographic and Health Survey

Deworming medication utilization is a useful strategy to reduce the burden of anemia among pregnant women. Yet, we know very little about the prevalence and correlates of deworming medication utilization among pregnant women in sub-Saharan Africa, including Benin. To address this void in the literature, we used the 2017–2018 Benin Demographic and Health Survey and applied logistic regression analysis to explore the demographic, socioeconomic, and healthcare factors associated with deworming medication utilization in Benin. We found that deworming medication coverage was 65% at the national level. We observed that women aged 35–49 years were less likely to use deworming medication compared to those aged 15–24 years (OR = 0.79, p < 0.01). Compared to Christian women, Muslim women (OR = 0.70, p < 0.01) and women of other religions (OR = 0.51, p < 0.01) were also less likely to use deworming medication. Moreover, women with lower levels of education and household wealth, as well as unemployed women, were less likely to use deworming medication in comparison to their educated, richer, and employed counterparts. Women who visited ANC fewer than eight times were also less likely to use deworming medication compared to their counterparts who did so eight times or more (OR = 0.65, p < 0.001). Based on these findings, we discussed several implications for policymakers.

Maternal Tetanus Toxoid Vaccination in Benin: Evidence from the Demographic and Health Survey

Tetanus toxoid vaccination is critical for improving maternal and child health. Yet, the prevalence and correlates of maternal tetanus toxoid vaccination coverage remain largely underexplored in Benin where infant and child mortality rates are high. Using the 2017−18 Benin Demographic and Health Survey, we apply logistic regression analysis to address this void in the literature. We find that overall maternal vaccination coverage is 69%. A range of demographic, health care, and socioeconomic factors are associated with maternal tetanus toxoid vaccination coverage. Women aged 20−34 (OR = 0.84, p < 0.05) and 35−49 (OR = 0.63, p < 0.01) are less likely to receive tetanus toxoid vaccination in comparison to those aged 15−19. Health care factors are also significantly associated with maternal tetanus toxoid vaccination, indicating that women who deliver at home (OR = 0.20, p < 0.001) and visit antenatal care fewer than eight times (OR = 0.62, p < 0.001) are less likely to receive tetanus toxoid vaccination than their counterparts who deliver in a health facility and visit antenatal care eight times or more. We also find that women with secondary (OR = 0.54, p < 0.05), primary (OR = 0.47, p < 0.01), and no education (OR = 0.47, p < 0.01) are less likely to receive tetanus toxoid vaccination compared to their counterparts with higher education. Based on these findings, we discuss several implications for policymakers.

Factors impacting antenatal care utilization: a systematic review of 37 fragile and conflict-affected situations

BACKGROUND

It is estimated that over 930 million people live in fragile and conflict-affected situations (FCAS) worldwide. These regions, characterized by violence, civil unrest, and war, are often governed by corrupt administrations who are unwilling to provide their citizens with basic human rights. Individuals living in FCAS face health inequities; however, women are disproportionally affected and face additional barriers to accessing sexual and reproductive services, including antenatal care (ANC). This systematic review aims to identify the factors that impact ANC usage in the 37 countries or regions classified as FCAS in 2020 by The World Bank.

METHODS

Using the PRISMA guidelines, a systematic search of five databases (SCOPUS, Web of Science, PubMed, EMBASE, and CINAHL) was conducted. Results were limited to human studies, written in English, and published between January 2002 and January 2022. Studies that identified factors affecting utilization of ANC or maternal health services were included for review and critically appraised using the National Institute of Health's Quality Assessment Tools. Findings were summarized using a narrative synthesis approach.

RESULTS

The database search yielded 26,527 studies. After title, abstract and full-text review, and exclusion of duplicate articles, 121 studies remained. Twenty-eight of the 37 FCAS were represented in the included studies. The studies highlighted that women in FCAS' are still not meeting the World Health Organization's 2002 recommendation of four ANC visits during pregnancy, a recommendation which has since been increased to eight visits. The most cited factors impacting ANC were socioeconomic status, education, and poor quality of ANC. Despite all studies being conducted in conflict-affected regions, only nine studies explicitly identified conflict as a direct barrier to accessing ANC.

CONCLUSION

This review demonstrated that there is a paucity in the literature examining the direct and indirect impacts of conflict on ANC utilization. Specifically, research should be conducted in the nine FCAS that are not currently represented in the literature. To mitigate the barriers that prevent utilization of maternal health services identified in this review, policy makers, women utilizing ANC, and global organizations should attempt to collaborate to enact policy change at the local level.

Individual and contextual factors associated with maternal healthcare utilisation in Mali: a cross-sectional study using Demographic and Health Survey data

OBJECTIVE

We examined the national prevalence as well as the individual and contextual factors associated with maternal healthcare utilisation in Mali.

SETTING

The study was conducted in Mali.

PARTICIPANTS

We analysed data on 6335 women aged 15-49 years from Mali's 2018 Demographic and Health Survey.

OUTCOME VARIABLE

Maternal healthcare utilisation comprising antenatal care (ANC) attendant, skilled birth attendant (SBA), and postnatal care (PNC) attendant, was our outcome variable.

RESULTS

Prevalence of maternal healthcare utilisation was 45.6% for ANC4+, 74.7% for SBA and 25.5% for PNC. At the individual level, ANC4 + and SBA utilisation increased with increasing maternal age, level of formal education and wealth status. Higher odds of ANC4 + was found among women who are cohabiting (adjusted OR (aOR)=2.25, 95% CI 1.16 to 4.37) and delivered by caesarean section (aOR=2.53, 95% CI 1.72 to 3.73), while women who considered getting money for treatment (aOR=0.72, 95% CI 0.60 to 0.88) and distance to health facility (aOR=0.73, 95% CI 0.59 to 0.90) as a big problem had lower odds. Odds to use PNC was higher for those who were working (aOR=1.22, 95% CI 1.01 to 1.48) and those covered by health insurance (aOR=1.87, 95% CI 1.36 to 2.57). Lower odds of SBA use were associated with having two (aOR=0.48, 95% CI 0.33 to 0.71), three (aOR=0.37, 95% CI 0.24 to 0.58), and four or more (aOR=0.38, 95% CI 0.24 to 0.59) children, and residing in a rural area (aOR=0.35, 95% CI 0.17 to 1.69). Listening to the radio and watching TV were associated with increased maternal healthcare utilisation.

CONCLUSION

The government should increase availability, affordability and accessibility to healthcare facilities by investing in health infrastructure and workforce to achieve Sustainable Development Goal 3.4 of reducing maternal morality to less than 70 deaths per 100 000 live births by 2030. It is important to ascertain empirically why PNC levels are astonishingly lower relative to ANC and SBA.

Knowledge of pregnancy complications and utilization of antenatal care services in Rwanda

BACKGROUND

While Rwanda's progress towards achieving the maternal health care targets of the Sustainable Development Goals is impressive, evidence of women's limited utilization of antenatal care (ANC) services in the context of an improved health care system provides an opportunity for exploring other essential but less highlighted factors that may shape ANC service utilization. In this study, we examined the association between women's knowledge of pregnancy complications and the utilization of maternal health services.

METHODS

We employed logistic regression analysis using the 2015 Rwanda Demographic and Health Survey data. Our analytical sample consisted of women (n = 5883) in their reproductive ages (15-49 years). Three maternal health care indicators, namely, timing of first ANC visit, number of ANC visits, and place of delivery, were explored. We controlled for the effects of socioeconomic and demographic characteristics, including marital status, place of residence and age.

RESULTS

The results show that women with no knowledge of pregnancy complications were less likely to utilize ANC services within the first trimester (odds ratio [OR] = 0.76, p < 0.01), achieve the WHO recommended minimum of eight visits (OR = 0.66, p < 0.01), and deliver at a health facility (OR = 0.77, p < 0.10).

CONCLUSION

Given these findings, we recommend restructuring existing maternal health care programs to include rigorous maternal health education.

What prevents pregnant women from adhering to the continuum of maternal care? Evidence on interrelated mechanisms from a cohort study in Kenya

OBJECTIVES

To examine the determinants of the continuum of maternal care from an integrated perspective, focusing on how key components of an adequate journey are interrelated.

DESIGN

A facility-based prospective cohort study.

SETTING

25 health facilities across three counties of Kenya: Nairobi, Kisumu and Kakamega.

PARTICIPANTS

A total of 5 879 low-income pregnant women aged 13-49 years.

OUTCOME MEASURES

Ordinary least squares, Poisson and logistic regression models were employed, to predict three key determinants of the continuum of maternal care: (i) the week of enrolment at the clinic for antenatal care (ANC), (ii) the total number of ANC visits and (iii) utilisation of skilled birth attendance (SBA). The interrelationship between the three outcome variables was assessed with structural equation modeling.

RESULTS

Each week of delayed enrolment in ANC reduced the number of ANC visits by 3% (incidence rate ratio=0.967, 95% CI 0.965 to 0.969). A higher number of ANC visits increased the relative probability of using SBA (odds ratio=1.28, 95% CI 1.22 to 1.34). The direct association between late enrolment and SBA was positive (odds ratio=1.033, 95% CI 1.02 to 1.04). Predisposing factors (age, household head's education), enabling factors (wealth, shorter distance, rural area) and need factors (risk level of pregnancy, multigravida) were positively associated with adherence to ANC.

CONCLUSION

The results point towards a domino-effect and underscore the importance of enhancing the full continuum of maternal care. A larger number of ANC visits increases SBA, while early initiation of the care journey increases the number of ANC visits, thereby indirectly supporting SBA as well. These beneficial pathways counteract the direct link between enrolment and SBA, which is partly driven by pregnant teenagers who both enrol late and are at heightened risk of complications, stressing the need for specific attention to this vulnerable population.

Socioeconomic inequalities in access and use of skilled birth attendants during childbirth in Ghana: a decomposition analysis

Background

Equitable access to skilled birth attendance during delivery is vital for reducing global maternal deaths to 70 deaths per 100, 000 to achieve the Sustainable Development Goals (SDGs) by 2030. Although several initiatives have been implemented to reduce maternal mortality in Ghana, inequalities in access to skilled birth attendance during delivery still exist among women of different socioeconomic groups. This study assesses the socioeconomic inequalities in access and use of skilled birth attendants during delivery in Ghana.

Methods

Research was conducted through literature reviews and document reviews, and a secondary data analysis of the 2014 Ghana Demographic and Health Survey (GDHS), a nationally representative survey. A total of 1305 women aged 15–49 years, who had a live birth the year before to the survey in the presence of a skilled birth attendant were analysed using concentration indices and curves. The indices were further decomposed to identify the major socioeconomic factors contributing most to the inequalities.

Results

The results found that access to skilled birth attendants was more among women from rich households showing a pro-rich utilization. The decomposition analysis revealed that household wealth index, educational level of both mother and husband/partner, area of residence and mother’s health insurance coverage were the major contributing factors to socioeconomic inequalities in accessing skilled birth attendants during child delivery among Ghanaian women.

Conclusion

This study confirms that a mother’s socioeconomic status is vital to reducing maternal deaths. Therefore, it is worthy to focus attention on policy interventions to reduce the observed inequalities as revealed in the study.

Women empowerment and skilled birth attendance in sub-Saharan Africa: A multi-country analysis

Introduction

In 2017, the highest global maternal deaths occurred in sub-Saharan Africa (SSA). The WHO advocates that maternal deaths can be mitigated with the assistance of skilled birth attendants (SBAs) at childbirth. Women empowerment is also acknowledged as an enabling factor to women’s functionality and healthcare utilisation including use of SBAs’ services. Consequently, this study investigated the association between women empowerment and skilled birth attendance in SSA.

Materials and methods

This study involved the analysis of secondary data from the Demographic and Health Surveys of 29 countries conducted between January 1, 2010, and December 3, 2018. For this study, only women who had given birth in the five years prior to the surveys were included, which is 166,022. At 95% confidence interval, Binary Logistic Regression analyses were conducted and findings were presented as adjusted odds ratios (aORs).

Results

The overall prevalence of skilled birth attendance was 63.0%, with the lowest prevalence in Tanzania (13.8%) and highest in Rwanda (91.2%). Women who were empowered with high level of knowledge (aOR = 1.60, 95% CI = 1.51, 1.71), high decision-making power (aOR = 1.19, 95% CI = 1.15, 1.23), and low acceptance of wife beating had higher likelihood of skill birth attendance after adjusting for socio-demographic characteristics. Women from rural areas had lesser likelihood (OR = 0.53, 95% CI = 0.51–0.55) of skilled birth attendance compared to women from urban areas. Working women had a lesser likelihood of skilled birth attendance (OR = 0.91, 95% CI = 0.88–0.94) as compared to those not working. Women with secondary (OR = 2.13, 95% CI = 2.03–2.22), or higher education (OR = 4.40, 95% CI = 3.81–5.07), and women in the richest wealth status (OR = 3.50, 95% CI = 3.29–3.73) had higher likelihood of skilled birth attendance.

Conclusion

These findings accentuate that going forward, successful skilled birth attendant interventions are the ones that can prioritise the empowerment of women.

Antenatal care and skilled birth in the fragile and conflict-affected situation of Burundi

Burundi is a fragile and conflict-affected state characterized by persistent conflict and political violence. Amid this conflict, Burundi has one of the highest maternal mortality rates globally-548 per 100,000 births as of 2017, such deaths could be prevented with antenatal care (ANC). This cross-sectional study aimed to examine the association between conflict and ANC and skilled birth attendant (SBA) utilization. Logistic regression analysis was conducted using the 2016-2017 Burundi Demographic and Health Survey (n = 8581), as well as a Near Analysis Geographic Information System exploration. Results show that women in extremely high conflict regions were less likely to have four antenatal visits (odds ratio [OR] = 0.79, p < 0.05). However, they were more likely to use a SBA (OR = 2.31, p < 0.001) and to deliver in a hospital (OR = 1.69, p < 0.001). As well, gender equality, education, and watching television were correlated with an increased likelihood of utilization. In contrast, unwanted pregnancies and increased parity were correlated with decreased use. Moreover, with renewed violence erupting in 2015, uptake of care has likely further stagnated or declined. If Sustainable Development Goal 3.1's objective of reducing maternal mortality globally is to be achieved, women's access to maternal healthcare services in conflicted-affected areas such as Burundi must be improved.

Antenatal care utilization in the fragile and conflict-affected context of the Democratic Republic of the Congo

Maternal mortality represents one of the widest gaps between developed and developing countries. Ninety-nine percent of maternal deaths occur in developing countries, with over half occurring in sub-Saharan Africa. This health indicator became a global priority when the United Nations' Sustainable Development Goal 3.1 set out to decrease the global maternal mortality rate to less than 70 per 100 000 births by 2030. In the Democratic Republic of the Congo (DRC), 473 of every 100 000 women who give birth die due to pregnancy-related complications. These deaths could be prevented through enhanced access and utilization of antenatal care services and skilled birth attendants. However, amid prolonged conflict, violence, and authoritarian governments, the Democratic Republic of the Congo has been classified as a fragile and conflict-affected situation and women are prone to face difficulties accessing maternal health services. This study examined the utilization of antenatal care and skilled birth attendants in the Democratic Republic of Congo using logistic regressions. Our findings show that women living in regions with extremely high levels of prolonged conflict were significantly less likely than those in regions with moderate levels of conflict to have their first antenatal care visit within the first trimester (OR = 0.29, p < 0.01), and to have four visits (OR = 0.46, p < 0.01). Overall, women in regions with extremely high levels of conflict (OR = 0.41, p < 0.01) were less likely to meet the World Health Organization's antenatal care recommendations compared to those in regions with moderate levels of conflict. The findings suggest that conflict-affected countries, such as the Democratic Republic of the Congo, require context-specific interventions if progress is to be made towards achieving Sustainable Development Goal 3.1.

Maternal health services utilisation among primigravidas in Uganda: what did the MDGs deliver?

BACKGROUND

Achieving maternal health outcomes in the SDGs requires the implementation of more targeted policies and strategies. While the MDGs may have deepened our understanding in this regard, we know little about the trends in maternal health services utilisation among primigravidas, and how age and geographical regions could have influenced these trends. In this study, we examined utilisation of antenatal and skilled delivery services among primigravidas in Uganda, a country with one of the highest maternal mortality ratios, and where early childbearing and its attendant challenges are common.

METHODS

Guided by Andersen's Behavioural Model, we fitted multivariate regression models to a pooled dataset of the 2006, 2011 and 2016 Ugandan Demographic and Health Survey (n = 3477) to understand the dynamics in Antenatal Care (ANC) and Skilled Birth Attendance (SBAs) utilisation among primigravidas. Post-estimation margins were employed to further highlight the effect of age and geographical regions.

RESULTS

The analyses show an improvement in access to maternal health services among primigravidas from 2006 to 2016. Compared to 2006, primigravidas in 2016 were 48%, 24% and 2.98 times more likely to have early ANC, four or more ANC visits, and SBAs, respectively. Altogether, a primigravida in 2016 relative to 2006 was 42% more likely to meet all three maternal health service indicators. Post-estimation margins analyses on age and geographical disparities revealed that younger primigravidas have lower probability, while primigravidas in Eastern Region, one of the most deprived in the country, have the lowest probability of accessing maternal health services. Also, the study found education, wealth, women's household decision-making power, place of residence as important determinants of ANC visits and SBAs.

CONCLUSIONS

Based on our findings, it is important to address the vulnerabilities of primigravidas, particularly younger individuals, in accessing early ANC. Uganda should scale-up decentralisation and integration of maternal health delivery in local communities as a strategy of addressing lingering geographical disparities, and ultimately improve maternal health outcomes in the SDGs period.

Factors associated with skilled attendants at birth among married adolescent girls in Nigeria: evidence from the Multiple Indicator Cluster Survey, 2016/2017

BACKGROUND

This study examines the factors associated with skilled birth attendants at delivery among married adolescent girls in Nigeria.

METHODS

The study was a secondary data analysis of the fifth round of the Multiple Indicator Cluster Survey conducted between September 2016 and January 2017. Married adolescent girls aged 15-19 y who had live births in the last 2 y preceding the survey were included in the analysis. We performed univariate and multivariate logistic regression analyses with a skilled birth attendant (doctor, nurse or midwife) at delivery as the outcome variable and sociodemographic, male partner- and maternal health-related factors as explanatory variables.

RESULTS

Of the 789 married adolescent girls, 387 (27% [95% CI=22.8-30.7]) had a skilled birth attendant at delivery. In the adjusted model, adolescent girls who were aged ≥18 y (ref: <18 y), primiparous (ref: multiparous), had antenatal care (ANC) provided by skilled healthcare providers (ref: no ANC), belonged to at least the poor and middle wealth index quintiles (ref: poorest), and resided in the south west zone (ref: north central), independently had a significantly higher likelihood of having a skilled birth attendant at delivery.

CONCLUSIONS

Interventions that will reduce pregnancy in younger adolescent girls, poverty, and increase ANC provided by skilled attendants, are likely to improve deliveries assisted by skilled birth attendants among married adolescent girls in Nigeria.

Skilled birth attendance in Sierra Leone, Niger, and Mali: analysis of demographic and health surveys

Background

Skilled birth attendance (SBA) is a key strategy for averting maternal mortality ratio (MMR). The lifetime risk of maternal death is high in countries with low SBA. With the presence of a skilled birth attendant, the possibility of death owing to intrapartum-related complications or stillbirth can be reduced by 20%.

Methods

Using data from the most recent Demographic and Health Surveys, we investigated the prevalence of skilled birth attendance, variations, and associated factors. The sample was drawn from women aged 15–49 who were surveyed in these countries as part of the Demographic and Health Survey (DHS) program. With multivariate logistic regression, we explored the socio-demographic factors that predict women’s likelihood of seeking skilled birth attendance or otherwise.

Results

Less than half of the women in Niger, Sierra Leone, and Mali obtained skilled birth attendance, with the worst case occurring in Niger (32.6%). Women in rural areas have less likelihood of obtaining skilled birth attendance (OR 0.21; 95% CI 0.16–0.28), as compared to women in urban locations. Highly educated women (OR 2.50; 95% CI 0.72–8.69), those who had subscribed to health insurance (OR 1.39; 95% CI 0.88–2.20), those who obtain four or more antenatal care visits (OR 1.63; 95% CI 1.43–1.86), and women who watch television at least once a week (OR 2.33; 95% CI 1.88–2.88) are more probable to seek SBA.

Conclusion

Interventions to increase SBA rates in these countries need to be reassessed to focus on the rural-urban disparity in healthcare, female education, and ANC attendance.

Efforts to alter the trajectory of neonatal mortality in Malawi: evaluating relative effects of access to maternal care services and birth history risk factors

BACKGROUND

The neonatal mortality rate (NMR) in Malawi has remained stagnant at around 27 per 1000 live births over the last 15 years, despite an increase in the uptake of targeted health care interventions. We used the nationally representative 2015/16 Demographic Health Survey data set to evaluate the effect of two types of maternal exposures, namely, lack of access to maternal or intra-partum care services and birth history factors, on the risk of neonatal mortality.

METHODS

A causal inference approach was used to estimate a population attributable risk parameter for each exposure, adjusting for co-exposures and household, maternal and child-specific covariates. The maternal exposures evaluated were unmet family planning needs, less than 4+ antenatal care visits, lack of institutional delivery or skilled birth attendance, having prior neonatal mortality, short (8-24 months) birth interval preceding the index birth, first pregnancy, and two or more pregnancy outcomes within the preceding five years of the survey interview.

RESULTS

We included 9553 women and their most recent live birth within 3 years of the survey. The sample's overall neonatal mortality rate was 18.5 per 1000 live births. The adjusted population attributable risk for first pregnancies was 3.9/1000 (P < 0.001), while non-institutional deliveries and the shortest preceding birth interval (8-24 months) each had an attributable risk of 1.3/1000 (Ps = 0.01). Having 2 or more pregnancy outcomes within the last 5 years had an attributable risk of 3/1000 (P = 0.006). Attending less than 4 ANC visits had, a relatively large attributable risk (2.1/1,000), and it was not statistically significant at alpha level 0.05.

CONCLUSIONS

Our analysis addresses the gap in the literature on evaluating the effect of these exposures on neonatal mortality in Malawi. It also helps inform programs and current efforts such as the Every Newborn Action 2020 Plan. Increasing access to maternal care interventions has an important role to play in changing the trajectory of neonatal mortality, and women who are at an increased risk may not be receiving adequate care. Recent studies indicate an urgent need to assess gaps in service readiness and quality of care at the antenatal and obstetric care facilities.

Using GIS to detect cluster and spatial disparity in maternal health indicators: a need for social health interventions

Maternal mortality remains a serious global health concern. Although global efforts have produced some encouraging results in some World Health Organization's health regions, disparities persist within many countries. Additionally, in many developing countries, inadequate documentation of various health events including maternal mortality and morbidity, make it difficult to determine the true extent of the problem. Maternal health indicators are therefore proxies used in estimating health status in developing countries. Using geospatial and geovisualization techniques, this study examines district level disparities in two maternal health indicators in Ghana antenatal care (ANC) visits and skilled birth attendance (SBA). The results reveal districts with complete lack of access to higher health care professionals and others with underutilization of antenatal services. The findings provide important input for targeting location-specific public health and maternal health interventions.