Disparities in pregnancy-related deaths: spatial and Bayesian network analyses of maternal mortality ratio in 54 African countries

Level of completion of maternity continuum of care among ever-married women: An analysis of Somalia's health and demographic survey 2020

INTRODUCTION

Somalia is continuing to recover from three decades of underdevelopment, political instability, civil unrest, and protracted humanitarian crises. However, Somalia has one of the lowest maternal health indicators in the world. For instance, the maternal mortality ratio is 621 per 100,000 live births. Extra efforts are needed to improve maternal health. In this study, we aim to investigate the level of completion and coverage along the maternity continuum of care in Somalia.

METHOD

The study used data from the Somalia Health and Demographic Survey 2020. We restricted our analysis to ever-married women who had a live birth in the five years preceding the survey (n = 2432). Completion of the continuum of maternity care was the outcome variable for this study. It was constructed into a binary variable with complete coded as one and incomplete coded as 0. We categorized it into three models: ANC4+ as the first model, ANC4+ & SBA as the second model, and ANC4+ & SBA & PNC as the third model.

RESULTS

More than half of the women (53.1%) had their most recent births at ≤19 years old. Of all the mothers (n = 2432), only 235 (9.7%) had at least four or more of the recommended antenatal care (ANC4+), and 68 (2.8%) of them utilized skilled birth attendants. Only 14 (0.6%) women received all three maternal healthcare services (ANC4+, SBA, and PNC within 48 hours). About 78.1% of the mothers did not attend any of the three CoC services.

CONCLUSION

Maternal health care utilization decreases as they progress from ANC4+ to PNC utilization. The government and partners should design and implement strategies to improve maternal healthcare utilization specific to rural and nomads, less educated, not working, low income, and have less power in decision-making.

Educational inequalities and decomposition of the urban-rural disparities in maternal health care utilization in Ethiopia: further analysis of 2019 intermediate Ethiopian demography and health survey

INTRODUCTION

The utilization of maternal health services is vital to prevent maternal and child health problems. However, there is limited evidence as to why rural women have lower utilization and educational inequality in maternal health services utilization in Ethiopia. Identifying the causes is the first step to achieving maternal and child health initiatives.

OBJECTIVE

The objective of this study was to decompose the urban-rural disparities and educational inequalities in maternal health care utilization in Ethiopia.

METHODS

The study used the 2019 Ethiopian Demography Health Survey. Blinder-Oaxaca decomposition and multivariate decomposition analyses were done on a weighted 3,926.7 women to see the urban-rural differences in maternal health service utilization by using Stata 17.0. For the educational inequality of maternal health service utilization, concentration curve and concentration index were used by using conindex. P value < 0.005 was used to declare association.

RESULT

84.89% of urban and 70.75% of rural residents use antenatal care and 73% of urban and 44% rural use institutional delivery. There was no urban-rural difference in postnatal care utilization. There was educational inequality in antenatal care (CIx 0.0926; p < 0.001), delivery care (CIx 0.2137; p < 0.001 and postnatal care (CIx 0.1272; p < 0.001) utilization in Ethiopia. 83.3% of antenatal care urban-rural difference was explained by women's characteristics difference. Secondary (16.51%) and higher (23.01%) educational level difference of urban and rural women widening antenatal care utilization. Living regions (-1.33%) difference of urban and rural women mitigated antenatal care utilization. About 76.07% of the urban-rural difference in institutional delivery was explained by differences in the characteristics of women. Attending primary (3.76%), secondary (11.83%), and higher (8.44%) education, antenatal care (15.81%) difference of urban and rural women were widening institutional delivery utilization.

CONCLUSION

The urban-rural disparity in antenatal care and delivery care utilization is significant in the country. There were educational inequalities in maternal health service utilization. Attending, Secondary, higher, educational levels widening antenatal care and institutional delivery care utilization. Living regions mitigated antenatal care utilization. Antenatal care utilization widening institutional delivery utilization. Special attention is needed for rural women to improve maternal health service utilization through health extension workers and the women's developmental army.

Promoting gender equity in a home visits programme: a qualitative study in Northern Nigeria

BACKGROUND

Gender inequities remain critical determinants influencing maternal health. Harmful gender norms and gender-based violence adversely affect maternal health. Gendered division of labour, lack of access to and control of resources, and limited women's decision-making autonomy impede women's access to maternal healthcare services. We undertook a cluster randomized controlled trial of universal home visits to pregnant women and their spouses in one local government area in Bauchi State, North-Eastern Nigeria. The trial demonstrated a significant improvement in maternal and child health outcomes and male knowledge, attitudes and behaviours. This paper qualitatively evaluates gender equity in the home visits programme.

METHODS

The research team explored participants' views about gender equity in the home visits programme. We conducted nine key informant interviews with policymakers and 14 gender and age-stratified focus group discussions with men and women from visited households, with women and men home visitors and supervisors, and with men and women community leaders. Analysis used an adapted conceptual framework exploring gender equity in mainstream health. A deductive thematic analysis of interviews and focus group reports looked for patterns and meanings.

RESULTS

All respondents considered the home visits programme to have a positive impact on gender equity, as they perceived gender equity. Visited women and men and home visitors reported increased male support for household chores, with men doing heavy work traditionally pre-assigned to women. Men increased their support for women's maternal health by paying for healthcare and providing nutritious food. Households and community members confirmed that women no longer needed their spouses' permission to use health services for their own healthcare. Households and home visitors reported an improvement in spousal communication. They perceived a significant reduction in domestic violence, which they attributed to the changing attitudes of both women and men due to the home visits. All stakeholder groups stressed the importance of engaging male spouses in the home visits programme.

CONCLUSION

The home visits programme, as implemented, contributed to gender equity.

Measuring spatial inequalities in maternal and child mortalities in Pakistan: evidence from geographically weighted regression

BACKGROUND

In developing countries, the death probability of a child and mother is more significant than in developed countries; these inequalities in health outcomes are unfair. The present study encompasses a spatial analysis of maternal and child mortalities in Pakistan. The study aims to estimate the District Mortality Index (DMI), measure the inequality ratio and slope, and ascertain the spatial impact of numerous factors on DMI scores across Pakistani districts.

METHOD

This study used micro-level household datasets from multiple indicator cluster surveys (MICS) to estimate the DMI. To find out how different the DMI scores were, the inequality ratio and slope were used. This study further utilized spatial autocorrelation tests to determine the magnitude and location of the spatial dependence of the clusters with high and low mortality rates. The Geographically Weighted Regression (GWR) model was also applied to examine the spatial impact of socioeconomic, environmental, health, and housing attributes on DMI.

RESULTS

The inequality ratio for DMI showed that the upper decile districts are 16 times more prone to mortalities than districts in the lower decile, and the districts of Baluchistan depicted extreme spatial heterogeneity in terms of DMI. The findings of the Local Indicator of Spatial Association (LISA) and Moran's test confirmed spatial homogeneity in all mortalities among the districts in Pakistan. The H-H clusters of maternal mortality and DMI were in Baluchistan, and the H-H clusters of child mortality were seen in Punjab. The results of GWR showed that the wealth index quintile has a significant spatial impact on DMI; however, improved sanitation, handwashing practices, and antenatal care adversely influenced DMI scores.

CONCLUSION

The findings reveal a significant disparity in DMI and spatial relationships among all mortalities in Pakistan's districts. Additionally, socioeconomic, environmental, health, and housing variables have an impact on DMI. Notably, spatial proximity among individuals who are at risk of death occurs in areas with elevated mortality rates. Policymakers may mitigate these mortalities by focusing on vulnerable zones and implementing measures such as raising public awareness, enhancing healthcare services, and improving access to clean drinking water and sanitation facilities.

Multilevel Count Regression Analysis of Factors Associated with the Desired Number of Antenatal Care Service Visits in Ethiopia

BACKGROUND

Visiting the desired number of antenatal care services improve the success of maternal health programs in terms of mother and child health. The study aimed to identify the factors associated with differences in the number of antenatal care service visits across and within regions of Ethiopia by using the 2019 Ethiopian Mini Demographic Health Survey (EMDHS).

METHODS

A total of 3979 women who were pregnant or gave birth within 5 years preceding the survey from the 2019 Ethiopian Mini Demographic Health Survey were included in the analysis. A multi-level Hurdle negative binomial regression model was selected to consider the hierarchical nature of the data in determining the factors associated with the barriers to the desired number of antenatal care service visits.

RESULTS

About one-fourth (26.2%) of mothers did not visit any antenatal care, and only 137 (3.4%) women visited the service eight times and above. The random intercept with the fixed coefficient of multilevel Hurdle negative binomial model results has shown that women in the age group between 25 and 34 (AOR = 1.057), in the age group between 35 and 49 (AOR = 1.108), protestant religion follower women (AOR = 0.918), Muslim women (AOR = 0.945), other religion follower women (AOR = 0.768), mothers in primary educational level (AOR = 1.123), secondary and higher education level (AOR = 1.228), rich mothers (AOR = 1.134), and mothers living in rural (AOR = 0.789) were statistically associated with regional variation regarding the frequency of ANC service visits.

CONCLUSIONS

The majority of pregnant women did not visit antenatal care services according to the findings of this study. This study's results revealed that the predictor variables such as mother's age, education level, religion, place of residence, marital status, and wealth index were significant, and the findings revealed that there were regional differences in ANC visits in Ethiopia. Women's economic and educational interventions should be a top priority.

Development of a Digital Platform to Promote Mother and Child Health in Underserved Areas of a Lower-Middle-Income Country: Mixed Methods Formative Study

Background

Primary health care (PHC) is the backbone of universal health coverage, with community health workers (CHWs) being one of its critical pillars in lower-middle-income countries. Most CHW functions require them to be an efficient communicator, but their program development has been deficient in this area. Can IT provide some solutions? Moreover, can some IT-based CHW-delivered innovations help mothers and children in areas not covered by PHC services? We explored these questions during the development and feasibility testing of a digital application designed to improve the communication capacity of CHWs in two underserved areas of Islamabad.

Objective

This study aims to explore the perceptions, practices, and related gaps about mother and child health, and child development in an underserved area; develop and deploy a behavior change communication program to address the gaps; and assess the feasibility of the program.

Methods

We carried out a mixed methods study with three steps. First, we conducted 13 in-depth interviews and two focus group discussions with stakeholders to explore the issues faced by mothers living in these underserved areas. To address these barriers, we developed Sehat Ghar, a video-based health education application to demonstrate practices mothers and families needed to adopt. Second, we trained 10 volunteer CHWs from the same community to deliver health education using the application and assessed their pre-post knowledge and skills. Third, these CHWs visited pregnant and lactating mothers in the community with random observation of their work by a supporting supervisor.

Results

Initial exploration revealed a need for health-related knowledge among mothers and suboptimal utilization of public health care. Sehat Ghar used behavior change techniques, including knowledge transfer, enhancing mothers' self-efficacy, and improving family involvement in mother and child care. Volunteer CHWs were identified from the community, who after the training, showed a significant improvement in mean knowledge score (before: mean 8.00, SD 1.49; after: mean 11.40, SD 1.43; P<.001) about health. During supportive supervision, these CHWs were rated as excellent in their interaction with mothers and excellent or very good in using the application. The CHW and her community reported their satisfaction with the application and wanted its delivery regularly.

Conclusions

Sehat Ghar is a simple, easy-to-use digital application for CHWs and is acceptable to the community. Mothers appreciate the content and presentation and are ready to incorporate its messages into their daily practices. The real-world effectiveness of the innovation tested on 250 mother-infant pairs will be important for its proof of effectiveness. With its usefulness and adaptability, and the rapidly spreading use of mobile phones and internet technology, this cost-effective innovation can help in delivering health communications at a large scale in a minimum amount of time.

Contributing factors for reduction in maternal mortality ratio in India

Maternal mortality ratio (MMR) estimates have been studied over time for understanding its variation across the country. However, it is never sufficient without accounting for presence of variability across in terms of space, time, maternal and system level factors. The study endeavours to estimate and quantify the effect of exposures encompassing all maternal health indicators and system level indicators along with space-time effects influencing MMR in India. Using the most recent level of possible -factors of MMR, maternal health indicators from the National Family Health Survey (NFHS: 2019-21) and system level indicators from government reports a heatmap compared the relative performance of all 19 SRS states. Facet plots with a regression line was utilised for studying patterns of MMR for different states in one frame. Using Bayesian Spatio-temporal random effects, evidence for different MMR patterns and quantification of spatial risks among individual states was produced using estimates of MMR from SRS reports (2014-2020). India has witnessed a decline in MMR, and for the majority of the states, this drop is linear. Few states exhibit cyclical trend such as increasing trends for Haryana and West Bengal which was evident from the two analytical models i.e., facet plots and Bayesian spatio- temporal model. Period of major transition in MMR levels which was common to all states is identified as 2009-2013. Bihar and Assam have estimated posterior probabilities for spatial risk that are relatively greater than other SRS states and are classified as hot spots. More than the individual level factors, health system factors account for a greater reduction in MMR. For more robust findings district level reliable estimates are required. As evident from our study the two most strong health system influencers for reducing MMR in India are Institutional delivery and Skilled birth attendance.

National audit on maternal mortality in Guinea-Bissau, West-Africa: A retrospective observational study of 2020

Guinea-Bissau has particularly alarming indicators of maternal health, with one of the highest maternal mortality (MM) worldwide. According to UNICEF-2014, this ratio (MMR) was 900/100,000 live births, mostly due to preventable and treatable causes. In 2013, the European Union developed an Integrated Programme to reduce Maternal and Infant Mortality (EU/PIMI),** the largest project of this kind, implemented in Guinea-Bissau. This study performed a national audit of MM over 2020, with the aim to analyse its numbers, characteristics, and causes. We used data of local and regional hospitals where EU/PIMI-II was operating. These hospitals showed lower MMR than previous national figures; however, the exclusion of the main obstetrical referral hospitals, and the unknown number of community-based deliveries make it difficult to compare. Guinea-Bissau still faces enormous challenges in reducing MM. Despite the slow progresses, this study gives us hope, as EU/PIMI-IÍs interventions appeared to have a positive impact in MM reduction.

A systematic review of individual and ecological determinants of maternal mortality in the world based on the income level of countries

BACKGROUND

This systematic review was conducted to map the literature on all the existing evidence regarding individual and ecological determinants of maternal mortality in the world and to classify them based on the income level of countries. Such a systematic review had not been conducted before.

METHODS

We conducted an electronic search for primary and review articles using "Maternal Mortality" and "Determinant" as keywords or MeSH terms in their Title or Abstract, indexed in Scopus, PubMed, and Google with no time or geographical limitation and also hand searching was performed for most relevant journals. STROBE and Glasgow university critical appraisal checklists were used for quality assessment of the included studies. Data of the determinants were extracted and classified into individual or ecological categories based on income level of the countries according to World Bank classification.

RESULTS

In this review, 109 original studies and 12 review articles from 33 countries or at global level met the inclusion criteria. Most studies were published after 2013. Most literature studied determinants of low and lower-middle-income countries. The most important individual determinants in low and lower-middle-income countries were location of birth, maternal education, any delays in health services seeking, prenatal care and skilled birth attendance. Household-related determinants in low-income countries included improved water source and sanitation system, region of residence, house condition, wealth of household, and husband education. Additionally, ecological determinants including human resources, access to medical equipment and facilities, total fertility rate, health financing system, country income, poverty rate, governance, education, employment, social protection, gender inequality, and human development index were found to be important contributors in maternal mortality. A few factors were more important in higher-income countries than lower-income countries including parity, IVF births, older mothers, and type of delivery.

CONCLUSION

A comprehensive list of factors associated with maternal death was gathered through this systematic review, most of which were related to lower-income countries. It seems that the income level of the countries makes a significant difference in determinants of maternal mortality in the world.

The healthcare system and client failures contributing to maternal mortality in rural Kenya

BACKGROUND

The global maternal mortality ratio is estimated at 211/100 000 live births in 2017. In Kenya, progress on reducing maternal mortality appears to be slow and persistently higher than the global average, despite efforts by the government's provision of free maternity services in both private and public facilities in 2013. We aimed to explore and describe the experiences of midwives on maternal deaths that are associated with the healthcare system and client failures in Migori, Kenya.

METHODS

An explanatory, qualitative approach method was adopted. In-depth interviews were conducted with the purposively selected midwives working in peripartum units of the three sampled hospitals within Migori County in Kenya. The hospitals included two county referral hospitals and one private referral hospital. Saturation was reached with 37 respondents. NVivo 11 software was used for analysis. Content analysis using a qualitative approach was adopted. Accordingly, the data transcripts were synthesised, coded and organised into thematic domains.

RESULTS

Identified sub-themes: sub-optimal care, staff inadequacy, theatre delays, lack of blood and essential drugs, non-adherence to protocols, staff shortage, inadequate equipment and supplies, unavailable ICU wards, clients' ANC non-adherence.

CONCLUSION

In conclusion, the study notes that the healthcare system and client failures are contributing to maternal mortality in the study setting. The major failures are across the pregnancy continuum starting from antenatal care, and intrapartum to post-natal care. This can illustrate that some pregnant mothers are getting sub-optimal care reducing their survival chances. To reduce maternal mortality in Migori County, the key highlighted healthcare system and client failures should be addressed through a multidisciplinary approach mechanism.

Continuum of care for maternal, newborn, and child health in 17 sub-Saharan African countries

BACKGROUND

Given the intricate relationship between mothers and their children with the continuum of care, it is quintessential for their healthcare and interventions to be enhanced through a continuum of care approach. We examined the factors associated with the continuum of care for maternal, newborn, and child health in sub-Saharan Africa.

METHODS

Data for the study were pooled from the Demographic and Health Surveys of 17 countries in sub-Saharan Africa. We extracted the data from the women's files in all 17 countries. We included 15,359 married and cohabiting women with the most recent children aged 12-23 months at the time of the survey in the study. Multivariable multilevel logistic regression analysis was performed to examine the factors associated with continuum of care. Results were presented as adjusted odds ratios (aORs) with their 95% confidence interval.

RESULTS

Women whose partners had secondary or higher level of education [aOR = 1.52; 95%CI = 1.07, 2.16], those with health insurance [aOR = 1.64; 95%CI = 1.18, 2.30], those who decide alone on their healthcare [aOR = 1.38; 95%CI = 1.01, 1.89], those with joint healthcare decision [aOR = 1.33; 95%CI = 1.02, 1.74], those exposed to radio [aOR = 1.38; 95%CI = 1.06, 1.79], those who started antenatal care early [aOR = 1.88; 95%CI = 1.50, 2.36] and those in southern Africa [aOR = 7.02; 95%CI = 3.23, 15.27] had higher odds of completing the continuum of care.

CONCLUSION

We found that only 3.4% of women across the 17 sub-Saharan African countries included in this study completed all of the 11 maternal, newborn, and child health care interventions along the continuum of care. The factors that are associated with the maternal, newborn, and child health continuum of care include women's autonomy in decision-making, partners' level of education, health insurance coverage, early initiation of antenatal care, exposure to radio, and residing in Southern Africa. Problem with the distance to the facility lowered women's odds of completing the continuum of care. Governments and departments of health services across sub-Saharan African countries must leverage the radio to disseminate critical messages about the need to complete the continuum of care. Much commitment must be made toward advancing the autonomy of women. Health insurance coverage would have to be extended to reach all women to facilitate the completion of the continuum of care.

Individual, health facility and wider health system factors contributing to maternal deaths in Africa: A scoping review

The number of women dying during pregnancy and after childbirth remains unacceptably high, with African countries showing the slowest decline. The leading causes of maternal deaths in Africa are preventable direct obstetric causes such as haemorrhage, infection, hypertension, unsafe abortion, and obstructed labour. There is an information gap on factors contributing to maternal deaths in Africa. Our objective was to identify these contributing factors and assess the frequency of their reporting in published literature. We followed the Arksey and O'Malley methodological framework for scoping reviews. We searched six electronic bibliographic databases: MEDLINE, SCOPUS, African Index Medicus, African Journals Online (AJOL), French humanities and social sciences databases, and Web of Science. We included articles published between 1987 and 2021 without language restriction. Our conceptual framework was informed by a combination of the socio-ecological model, the three delays conceptual framework for analysing the determinants of maternal mortality and the signal functions of emergency obstetric care. We included 104 articles from 27 African countries. The most frequently reported contributory factors by level were: (1) Individual-level: Delay in deciding to seek help and in recognition of danger signs (37.5% of articles), (2) Health facility-level: Suboptimal service delivery relating to triage, monitoring, and referral (80.8% of articles) and (3) Wider health system-level: Transport to and between health facilities (84.6% of articles). Our findings indicate that health facility-level factors were the most frequently reported contributing factors to maternal deaths in Africa. There is a lack of data from some African countries, especially those countries with armed conflict currently or in the recent past. Information gaps exist in the following areas: Statistical significance of each contributing factor and whether contributing factors alone adequately explain the variations in maternal mortality ratios (MMR) seen between countries and at sub-national levels.