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

Exploring the factors behind socioeconomic inequalities in Antenatal Care (ANC) utilization across five South Asian natiaons: A decomposition approach

Maternal and child mortality rates remain a significant concern in South Asian countries, primarily due to limited access to maternal care services and socioeconomic disparities. While previous studies have examined the factors influencing the utilization of antenatal care (ANC) services in individual countries, there is a lack of comparative analysis across South Asian nations. This study aims to investigate the factors affecting ANC utilization among women aged 15-49 in Bangladesh, India, Nepal, Maldives, and Pakistan using the latest Demographic and Health Survey data. The study utilized a total weighted sample size of 262,531 women. Simple bivariate statistics and binary logistic regression were employed to identify potential factors influencing ANC utilization. Decomposition analysis and concentration curve (Lorenz curve) were used to assess inequality in ANC service utilization. The prevalence of ANC utilization varied across the countries, with Maldives having the highest (96.83%) and Bangladesh the lowest (47.01%). Women's and husbands' education, household wealth status, BMI, and urban residence were found to significantly influence maternal healthcare services utilization. Higher education levels, affluent wealth quintiles, and urban living were identified as significant contributors to socioeconomic disparities in accessing ANC services. This study highlights the crucial role of socioeconomic factors in the utilization of maternal healthcare services in South Asian countries. Governments should focus on improving healthcare infrastructure, addressing cultural barriers, and promoting education to address these disparities. Identifying context-specific causes of maternal healthcare utilization is essential to inform targeted interventions and policies aimed at improving access to ANC services and reducing maternal mortality rates.

Multilevel analysis of determinants in postnatal care utilisation among mother-newborn pairs in India, 2019-21

Background

Postnatal care (PNC) utilisation within 24 hours of delivery is a critical component of health care services for mothers and newborns. While substantial geographic variations in various health outcomes have been documented in India, there remains a lack of understanding regarding PNC utilisation and underlying factors accounting for these geographic variations. In this study, we aimed to partition and explain the variation in PNC utilisation across multiple geographic levels in India.

Methods

Using India's 5th National Family Health Survey (2019-21), we conducted four-level logistic regression analyses to partition the total geographic variation in PNC utilisation by state, district, and cluster levels, and to quantify how much of theses variations are explained by a set of 12 demographic, socioeconomic, and pregnancy-related factors. We also conducted analyses stratified by selected states/union territories.

Results

Among 149 622 mother-newborn pairs, 82.29% of mothers and 84.92% of newborns were reported to have received PNC within 24 hours of delivery. In the null model, more than half (56.64%) of the total geographic variation in mother's PNC utilisation was attributed to clusters, followed by 26.06% to states/union territories, and 17.30% to districts. Almost 30% of the between-state variation in mother's PNC utilisation was explained by the demographic, socioeconomic, and pregnancy-related factors (i.e. state level variance reduced from 0.486 (95% confidence interval (CI) = 0.238, 0.735) to 0.320 (95% CI = 0.152, 0.488)). We observed consistent results for newborn's PNC utilisation. State-specific analyses showed substantial geographic variation attributed to clusters across all selected states/union territories.

Conclusions

Our findings highlight the consistently large cluster variation in PNC utilisation that remains unexplained by compositional effects. Future studies should explore contextual drivers of cluster variation in PNC utilisation to inform and design interventions aimed to improve maternal and child health.

Factors affecting pregnancy registration in India: does the pregnancy intention matter?

BACKGROUND

Pregnancy registration is one of the most critical components of women's reproductive health because it is the gateway to entering the continuum of care services such as antenatal care, institutional delivery, and postnatal care. There is a lack of studies exploring the relationship between pregnancy intention and pregnancy registration, especially in the Indian context.

METHOD

This study used the National Family Health Survey-5 (2019-21) data to explore the relationship between birth intention and failure of pregnancy registration. The bivariate and multivariate (binary logistic regression) analysis was carried out.

RESULTS

Adjusting the effects of socio-demographic and economic characteristics, compared with women with an intended pregnancy, the odds of failure of pregnancy registration were significantly high among women with a mistimed pregnancy (OR = 1.60, 95% CI = 1.47-1.73) and unwanted pregnancy (OR = 1.38, 95% CI = 1.26-1.52). The study found pregnancy intention as a significant predictor of pregnancy registration.

CONCLUSIONS

Results suggest strengthening the interaction of grassroots-level health workers with women, especially those with possibly lower healthcare autonomy and unintended pregnancy. Higher and earlier pregnancy registration will enhance maternal healthcare utilization and reduce adverse health consequences to mothers and children, thus ensuring better maternal and child health.

A Review of the National Family Health Survey Data in Addressing India’s Maternal Health Situation

Objective: This study aims to understand the trend of research conducted on issues of maternal health in India considering data provided in five rounds of National Family Health Survey (NFHS).

Methods: Systematic review of literature has been conducted using multi-stage search and review process adapted from Page et al.’s (2021) PRISMA. Initially 14,570 studies were identified and only 134 articles meeting selection criterion were considered in this study.

Results: Approximately 32% studies have focused on regional and state variation of maternal health status; while 27% dealt with utilization of maternal healthcare services; and 19% the socio-economic determinants of maternal health. While few studies have discussed the place of delivery, antenatal care and post-natal care visits, only five studies focus on issues related to women’s autonomy, including their health-seeking behaviour, knowledge, attitude and practices related to maternal health.

Conclusion: Non-communicable diseases and its role in maternal health still remains an unexplored domain of research on maternal health in India. Moreover, there exists geographical skewness in the number of studies conducted, focusing especially on few provinces while none on few others.

Child Marriage and Problems Accessing Healthcare in Adulthood: Evidence from India

The association between child marriage and the access to or utilization of maternal and antenatal healthcare has been widely studied. However, little is known about child brides' access to healthcare for illnesses later in life. Using data on 496,283 married women aged 18 to 49 years from the India National Family and Health Survey 2015-2016, we developed an 11-point composite score (ranging from 0 to 10) outlining the extent of problems accessing healthcare, as follows: (i) no/little problem (score 0 to 2), (ii) some problems (score 3 to 6), and (iii) big problems (score 7 to 10). The differences between child brides and their peers married as adults were assessed by the relative risk ratios obtained from multinomial logistic regressions. The adjusted risk of having "some problems" and "big problems" accessing healthcare relative to "no/little problem" for child brides was found to be 1.22 (95% CI: 1.20-1.25) and 1.26 (95% CI: 1.22-1.29) times that of those married as adults, respectively. These findings highlight the disproportionate barriers to healthcare access faced by women married as children compared to women married as adults and the need for further research to inform policies regarding effective public health interventions to improve healthcare access.

Uptake of postnatal care and its determinants in Ethiopia: a positive deviance approach

BACKGROUND

Postnatal care (PNC) services are an essential intervention for improving maternal and child health. In Ethiopia, PNC service has been poorly implemented, despite the governments and partners' attempt to improve maternal and child health service utilization. Moreover, many literatures identified that women with no education are significantly underutilized the PNC services. Thus, this study aimed to assess the PNC service uptake among women at high risk for underutilization of PNC services and to identify the individual and community level determinants of PNC services uptake in Ethiopia using the positive deviance approach.

METHODS

Data from the Ethiopia Demographic and Health Survey 2016 were used. A total of 2417 deviant women (women with no education) were identified through a two-stage stratified sampling technique and included in this analysis. A multilevel mixed-effect binary logistic regression analysis was computed to identify the individual and community-level determinants of PNC services uptake among deviant women. In the final model, a p-value of less than 0.05 and adjusted odds ratio (AOR) with 95% confidence interval (CI) were used to declare statistically significant determinants of PNC services uptake.

RESULTS

In this analysis, the uptake of PNC service among deviant women was 5.8% [95% CI: 4.9-6.8]. Working in the agriculture (AOR = 2.15, 95% CI: 1.13-3.52), being Orthodox religion follower (AOR = 2.56, 95% CI: 1.42-4.57), living in the highest wealth quantile (AOR = 2.22, 95% CI: 1.25-3.91) were the individual level determinants, whereas residing in the city administration (AOR: 3.17, 95% CI: 1.15-8.71), and living closer to health facility (AOR: 1.57, 95% CI: 1.03-2.39) were the community level determinants.

CONCLUSION

The study highlighted a better PNC service uptake among deviant women who are working in the agriculture, follows orthodox religion, lives in highest household wealth status, resides in city administration, and living closer to the health facility. The positive deviance approach provides evidences for health policy makers and program implementers to improve health behavior in specific target population, and ultimately to bring better maternal and child health outcomes, despite acknowledged adverse risk profile. Such strategy and knowledge could facilitate targeted efforts aimed at achieving national goals of maternal and newborn mortality reduction in the country.

Investigation of technical quality of antenatal and perinatal services in a nationally representative sample of health facilities in Nepal

BACKGROUND

Access to routine antenatal and perinatal services is improved in the last two decades in Nepal. However, gaps remain in coverage and quality of care delivered from the health facilities. This study investigated the delivery of technical quality antenatal and perinatal services from health facilities and their associated determinants in Nepal.

METHODS

Data for this study were derived from the Nepal Health Facility Survey 2015. The World Health Organization's Service Availability and Readiness Assessment framework was adopted to assess the technical quality of antenatal and perinatal services of health facilities. Outcome variables included technical quality scores of i) 269 facilities providing antenatal services and ii) 109 facilities providing childbirth and postnatal care services (perinatal care). Technical quality scores of health facilities were estimated adapting recommended antenatal and perinatal interventions. Independent variables included locations and types of health facilities and their management functions (e.g., supervision). We conducted a linear regression analysis to identify the determinants of better technical quality of health services in health facilities. Beta coefficients were exponentiated into odds ratios (ORs) and reported with 95% confidence intervals (CIs). The significance level was set at p-value < 0.05.

RESULTS

The mean score of the technical quality of health facilities for each outcome variable (antenatal and perinatal services) was 0.55 (out of 1.00). Compared to province one, facilities of Madhesh province had 4% lower odds (adjusted OR = 0.96; 95%CI: 0.92, 0.99) of providing better quality antenatal services, while health facilities of Gandaki province had higher odds of providing better quality antenatal services (aOR = 1.05; 95% CI: 1.01, 1.10). Private facilities had higher odds (aOR = 1.13; 95% CI: 1.03, 1.23) of providing better quality perinatal services compared to public facilities.

CONCLUSIONS

Private facilities provide better quality antenatal and perinatal health services than public facilities, while health facilities of Madhesh province provide poor quality perinatal services. Health system needs to implement tailored strategies, including recruiting health workers, supervision and onsite coaching and access to necessary equipment and medicine in the facilities of Madhesh province. Health system inputs (trained human resources, equipment and supplies) are needed in the public facilities. Extending the safe delivery incentive programme to the privately managed facilities could also improve access to better quality health services in Nepal.

How to ensure full vaccination? The association of institutional delivery and timely postnatal care with childhood vaccination in a cross-sectional study in rural Bihar, India

Incomplete and absent doses in routine childhood vaccinations are of major concern. Health systems in low- and middle-income countries (LMIC), in particular, often struggle to enable full vaccination of children, which affects their immunity against communicable diseases. Data on child vaccination cards from a cross-sectional primary survey with 1,967 households were used to assess the vaccination status. The association of timely postnatal care (PNC) and the place of delivery with any-dose (at least one dose of each vaccine) and full vaccination of children between 10-20 months in Bihar, India, was investigated. Bivariate and multivariable logistic regression models were used. The vaccines included targeted tuberculosis, hepatitis B, polio, diphtheria/pertussis/tetanus (DPT) and measles. Moreover predictors for perinatal health care uptake were analysed by multivariable logistic regression. Of the 1,011 children with card verification, 47.9% were fully vaccinated. Timely PNC was positively associated with full vaccination (adjusted odds ratio (aOR) 1.48, 95% confidence interval (CI) 1.06-2.08) and with the administration of at least one dose (any-dose) of polio vaccine (aOR 3.37 95% CI 1.79-6.36), hepatitis B/pentavalent vaccine (aOR 2.11 95% CI 1.24-3.59), and DPT/pentavalent vaccine (aOR 2.29 95% CI 1.35-3.88). Additionally, delivery in a public health care facility was positively associated with at least one dose of hepatitis B/pentavalent vaccine administration (aOR 4.86 95% CI 2.97-7.95). Predictors for timely PNC were institutional delivery (public and private) (aOR 2.7 95% CI 1.96-3.72, aOR 2.38 95% CI 1.56-3.64), at least one ANC visit (aOR 1.59 95% CI 1.18-2.15), wealth quintile (Middle aOR 1.57 95% CI 1.02-2.41, Richer aOR 1.51 95% CI 1.01-2.25, Richest aOR 2.06 95% CI 1.28-3.31) and household size (aOR 0.95 95% CI 0.92-0.99). The findings indicate a correlation between childhood vaccination and timely postnatal care. Further, delivery in a public facility correlates with the administration of at least one dose of hepatitis B vaccine and thus impedes zero-dose vaccination. Increasing uptake of timely PNC, encouraging institutional delivery, and improving vaccination services before discharge of health facilities may lead to improved vaccination rates among children.

Intention to use maternal health services and associated factors among women who gave birth at home in rural Sehala Seyemit district: a community-based cross-sectional study

BACKGROUND

Low maternal healthcare service utilization contributes to poor maternal and newborn health outcomes in rural Ethiopia. 'Motivational factors influence women's intention to perform a specific health behavior, and the intention of subsequent home delivery and related risks that may contribute to women's death is less known. Therefore, this study aimed to assess the intention of maternal health service utilization among women who gave birth at home in the rural Sehala Seyemit district.

METHODS

A community-based cross-sectional study was conducted from September 1st to October 15th, 2020, among 653 women. A two-stage sampling technique was used to select the study participants. First, a semi-structured, pretested, and interviewer-administered questionnaire were used. The mean of the sum score was also used to categorize the intention as intended and not intended. Second, multivariable logistic regression analysis was computed to identify factors associated with women's intention to use maternal health services. Adjusted odds ratio (AOR) with a 95% confidence interval at a p-value of ≤ 0.05 were used to declare statistical association.

RESULTS

Of the women who gave birth at home the intention to use maternal health service was 62.3% (95% CI; 59, 66). Women's age of > 30 years (AOR = 6.04; 95%CI: 2.34, 15.60), short time to reach health facility (AOR = 2.52; 95% CI: 1.57, 4.10), media exposure (AOR = 2.10; 95% CI: 1.16, 3.65), history of obstetric danger signs (AOR = 4.60; 95% CI: 2.33, 9.10), positive subjective norms (AOR = 11.20; 95% CI; 6.77, 18.50) and last delivery assisted by traditional birth attendants (AOR = 0.15; 95% CI: 0.06, 0.33) were factors associated with women's intention to use maternal health services.

CONCLUSION

In this study, maternal health service utilization intention is still unsatisfactory compared to the national target plan. Maternal age, media exposure, obstetric danger signs, distance to a health facility, positive subjective norms, and delivery assistant at delivery were predictors of women's intention to use maternal healthcare services. Improving women's awareness of maternal healthcare services and developing strategies to increase women's access to mass media, skilled birth attendants, and transportation for rural women may enhance their intention to use maternal healthcare services.

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.

Comparative study on maternal healthcare services utilisation in selected Empowered Action Group states of India

The utilisation of maternal healthcare services is a principal indicator to measure the success of any maternal and child health programme. Suboptimal utilisation of maternal healthcare services is a vexatious problem in Empowered Action Group (EAG) states of India. This study aims to examine the currents status and socioeconomic determinants of antenatal services, skilled birth attendance and post-natal services in four infamous EAG states of India. This study used nationally representative, National Family Health Survey (NFHS, 2015-16) data for analysis. Descriptive statistics were used to depict the current status of maternal healthcare services utilisation and a discrete choice model was applied to examine the associated factors across the selected EAG states. The utilisation of maternal health services was higher in Rajasthan followed by Madhya Pradesh, Uttar Pradesh and Bihar respectively. Utilisation was consistently low among the socioeconomically disadvantaged women in all the selected EAG states. The study highlights that female education, mass media exposure, women's autonomy and economic status were significantly associated with the use of maternal healthcare services. The actualisation of our national and Sustainable Development Goals at the ground level is happening relatively slowly in the EAG states. Hence, achieving equitable distribution of resources, universal availability and access to information, counselling and reproductive services coupled with women empowerment are vital to the realisation of these goals.

Why women choose to deliver at home in India: a study of prevalence, factors, and socio-economic inequality

BACKGROUND

To promote institutional delivery, the Government of India, through the Janani Suraksha Yojana (JSY) program, gives monetary reward to all pregnant women who give birth at the government or private health center. Despite providing cash assistance, a higher number of women are still preferring delivering at home. Therefore, this study sought to determine the prevalence of home births and identifying the factors influencing women's choice of home deliveries.

METHODS

Data from the National Family Health Survey (NFHS) conducted during 2005-06 and 2015-16 were used in the study. The respondents were women 15-49 years; a sample of 36,850 and 190,898 women in 2005-06 and 2015-16 respectively were included in the study. Multivariate logistic regression was used to determine the factors influencing home delivery. Income-related inequality in home delivery was quantified by the concentration index (CI) and the concentration curve (CC), and decomposition analysis was used to examine the inequality in the prevalence of home deliveries.

RESULTS

The prevalence of home deliveries has reduced from 58.5% in 2005-06 to 18.9% in 2015-16. The odds of delivering babies at home were lower among women who had full ANC in 2005-06 [AOR: 0.34; CI: 0.28-0.41] and in 2015-16 [AOR: 0.41; CI: 0.38-0.45] and were higher among women with four or higher parity in 2005-06 [AOR: 1.70; CI: 1.49-1.92] and in 2015-19 [AOR: 2.16; CI: 2.03-2.30]. Furthermore, the odds of delivering babies at home were higher among rural women and were lower among women with higher education. It was found that the value of CI increased from - 0.25 to - 0.39 from 2005-06 to 2015-16; this depicts that women delivering babies at home got more concentrated among women from lower socio-economic status.

CONCLUSION

There is a need to promote institutional deliveries, particular focus to be given to poor women, women with higher parity, uneducated women, and rural women. ANC is the most concurring contact point for mothers to get relevant information about the risks and complications they may encounter during delivery. Therefore, effort should be directed to provide full ANC. Targeted interventions are called for to bring improvements in rural areas.

Utilization of antenatal care services in a remote, tribal and hilly district of Himachal Pradesh: Challenges to access

BACKGROUND

A traditional African phrase, 'A pregnant woman has one foot in the grave' expresses the immense health risks associated with pregnancy and childbirth. Antenatal care (ANC) is considered an important determinant to alleviate mortalities and morbidities associated with maternal health.

OBJECTIVES

The study aimed to identify the utilization pattern of ANC services by pregnant women in a remote, tribal, and hilly district of Himachal Pradesh and to understand their healthcare needs during antenatal period.

METHODS

A community based descriptive, cross-sectional study was carried out in 41 far-flung villages of Lahaul and Spiti district in Himachal Pradesh, India, using a mixed-method approach of data collection. Purposive sampling was done to select 103 females who had experienced delivery in the past 2 years and were residents of Lahaul for minimum of 3 years. The participants were interviewed using a semi-structured questionnaire and the data were analysed by SPSS-20.

RESULTS

The study revealed high utilization of ANC services by indigenous women, but it was accompanied by physical, psychological, and financial hardships. The triple challenge of inadequacy of quality antenatal services, transport facilities, and unfavourable weather conditions compelled women to leave their communities in Lahaul and relocate to adjoining districts during the maternity period.

CONCLUSION

Pregnancy is still a stressful event that disrupts the link between families and communities in such underserved areas. The study recommends the establishment of programs that promote availability of quality ANC services within the rural and remote communities.

Perinatal Grief Among Poor Rural and Urban Women in Central India

PURPOSE

Given the pressures surrounding women's reproductive role in India, and persistent high rates of perinatal death, the purpose of this study is to describe and compare poor rural and urban Indian women's experiences of perinatal grief.

PARTICIPANTS AND METHODS

Two cross-sectional studies were compared on shared quantitative variables. Poor rural (N = 217) and urban, slum-dwelling (N = 149) Central Indian women with a history of stillbirth, and/or infant death were recruited with the aid of local community health workers. Trained, local, gender, and linguistically matched research assistants conducted the structured interviews. Shared quantitative variables include demographics, Social Provision Scale, Shortened Ways of Coping-Revised, Perinatal Grief Scale, social norms and autonomy.

RESULTS

While similar with respect to SES, age, number of living sons and perinatal loss experiences, these samples of poor women differed significantly across many variables, most notably women's household position, joint family living, number of live daughters, religious coping, autonomy, and degrees of perinatal grief. While perinatal grief was significantly associated with many variables bi-variably, most lost their relative influence in our stepwise multivariable modeling within site (rural/urban), with only social norms and social support remaining significant for rural (31% of variance) and wishful thinking and social norms for urban participants (38.4% of variance). In the combined sample household position, social support and social norms remained significant and explained 53.6% of the adjusted variance.

CONCLUSION

In both samples, perinatal grief was high following perinatal loss. Both groups of women with perinatal loss have increased risk of mental health sequelae. Notably, the context affected how they experienced perinatal grief, with rural women's grief being higher and more affected by their societal pressures and isolation. Such nuances are important considerations for much-needed tailored approaches to future interventions.