Women's decision-making autonomy and utilisation of maternal healthcare services: results from the Bangladesh Demographic and Health Survey

Women's healthcare autonomy and the utilization of maternal healthcare services in Afghanistan

OBJECTIVES

The objective of this study was to investigate the relationship between women's healthcare autonomy and the utilization of maternal healthcare services (MHS), including antenatal care services, the services of health professionals at the birth of a child, and facility-based delivery.

STUDY DESIGN

This was a cross-sectional study.

METHODS

This study utilized data from the 2015 Afghanistan Demographic and Health Survey (AFDHS 2015), which included women aged 15-49 years who had given live birth within the five years before the survey. Multilevel logistic regression was used to estimate the adjusted odd ratios (AOR) for each outcome variable.

RESULTS

Among respondents, 16.49% made at least four ANC visits, 52.57% of childbirth were assisted by a skilled birth attendant (SBA), and 45.60% of children were born in health facilities. Women with high healthcare autonomy, compared to medium and low, were more likely to use ANC (AOR 1.45; 95% CI = 1.26-1.67), SBA (AOR 1.15; 95% CI 1.02-1.29), and FBD (AOR 1.12; 95% CI 1.04-1.20). The association between women's healthcare autonomy and the use of maternal healthcare services (MHS) was positively and significantly moderated by household wealth and women's access to media.

CONCLUSION

Women's higher healthcare autonomy was significantly and positively associated with MHS in Afghanistan. Policy and programs that encourage women's empowerment and awareness of the importance of MHS utilization should be initiated.

Exposure to family planning messages on social media and its association with maternal healthcare services in Mauritania

BACKGROUND

Mauritania, a lower-middle-income country in Northwest Africa, has one of the highest maternal and infant mortality rates worldwide and struggles to ensure optimal use of maternal healthcare services. Raising health awareness through family planning messages can promote maternal healthcare use, potentially reducing preventable maternal and child mortalities. The objective of the study was to assess the potential impact of exposure to family planning messages through social media on the utilization of maternal healthcare services among Mauritanian women.

METHODS

Data from the 2019-20 Mauritania Demographic and Health Survey (MDHS) on 7,640 women were analyzed. Multiple logistic regression models were applied to examine the associations between exposure to family planning messages through social media and maternal healthcare services, specifically the timing and adequacy of ANC visits, and facility-based childbirth. Adjusted odds ratios with 95% confidence intervals (CI) were estimated.

RESULTS

The percentage of timely initiation and adequate use of ANC among the participants were 65.6% and 45.1%, respectively. Approximately 75.0% of the women reported giving birth to their last child at a healthcare facility. Exposure to family planning messages on social media was significantly associated with increased odds of receiving adequate antenatal care visits (OR = 1.38, 95% CI = 1.12,1.71) and giving birth in a health facility (OR = 1.83, 95% CI = 1.09,3.08), Other factors such as age, health insurance, wealth, and desired timing of the last child were also found to be important predictors of maternal healthcare.

CONCLUSION

The findings suggest that exposure to family planning messages on social media is strongly associated with adequate antenatal care and health facility-based childbirth, but not with early timing of antenatal care. Comprehensive maternal healthcare policies should consider the role of social media in promoting family planning messages.

Determinants of dropout from the maternal continuum of care in Ethiopia, multilevel analysis of the 2016 demographic and health survey

Over the past two decades (2000-2020), Ethiopia achieved significant reductions in maternal and neonatal mortality, with a 72% and 44%, respectively. However, low maternal health service utilization and dropout from the maternal continuum of care remain major health system challenges. This study aimed to investigate individual and community-level determinants of dropout from the maternal continuum of care. We used the recent, 2016 Ethiopian Demographic and Health Survey (EDHS) data. In the maternal continuum of care pathway, i) less than four antenatal care (ANC) attendance, ii) subsequent dropout from skilled birth attendance (SBA) after 4 or more ANC, and iii) dropout from postnatal care (PNC) after attendance of facility delivery were the outcomes for dropout. A Multilevel logistic regression analysis of individual and community level factors (e.g., place of residence, geographical regions) were included in the model. The variation in the outcomes were presented by odds ratio (OR), 95% confidence interval and intra-cluster correlation coefficient (ICC). In the maternal continuum of care pathway higher dropouts were observed from SBA to PNC (85%) and from 4+ ANC to SBA (43.4%). Poorest wealth quantile (AOR = 2.31, 95% [CI = 1.69,3.16]), having no health insurance coverage (AOR = 1.44, 95% [CI = 1.01,2.06]), and high community poverty (AOR = 1.28, 95% [CI = 1.01,1.63]) were associated with having < 4 ANC attendance. Perceived distance from health facility as a big problem (AOR = 1.45, [95% = CI, 1.12,1.88), lower community media exposure (AOR = 1.6, 95% [CI = 1.14,2.23]) and rural residency (AOR = 3.03, 95% [CI = 1.75,5.26]) increased the odds of dropout from SBA after 4+ ANC visits. The dropout from the maternal continuum of care was higher in Ethiopia and postnatal care were the most affected maternal care. Oromia and Somali regions were associated with dropouts from all levels of care. Policy strategies should prioritize geopolitical regions with higher dropout levels. In addition to improving access and quality of institutional health services, designing an alternative strategy for targeted outreach for ANC visits and postnatal checkups is recommended.

Influence of women's decision-making autonomy and partner support on adherence to the 8 antenatal care contact model in Eastern Uganda: A multicenter cross-sectional study

OBJECTIVE

Maternal and child health outcomes remain a challenge in Uganda. Antenatal care (ANC) is effective in mitigating pregnancy and childbirth risks. Women's decision-making autonomy and partner support are crucial for adherence to ANC contacts and better pregnancy outcomes. We assessed the impact of women's decision-making autonomy and partner support on adherence to the 8 + ANC contact schedule among post-partum mothers in Eastern Uganda.

METHODS

A multicenter cross-sectional study was conducted in four tertiary health facilities in Eastern Uganda, utilizing quantitative techniques to collect data from 1077 postnatal mothers. Eligible participants were those who had given birth within the previous 48 h and had documentation of ANC contacts from their pregnancy. Data was collected using structured questionnaires and analyzed using multivariable logistic regression to assess factors associated with adherence to the WHO-recommended 8 + ANC contacts.

RESULTS

Most women were aged 20-34 years (792; 73.5 %). Only 253 (23.5 %) women adhered to the 8 + ANC contacts. A significant proportion lacked decision-making autonomy (839; 77.9 %), and over half reported partner support (550; 51.2 %). Decision-making autonomy and partner support were significantly associated with adherence to the 8 + ANC contacts (aOR: 1.6, 95 % CI: 1.2 - 2.2, p = 0.005) and (aOR: 1.9, 95 % CI: 1.4 - 2.7, p < 0.001), respectively. Women with at least five children had lower adherence to the 8 + ANC contacts (aOR=0.4, 95 % CI: 0.2 - 0.7, p = 0.002).

CONCLUSION

Empowering women and engaging their partners can improve maternal health service utilization and increase ANC contact adherence, leading to better maternal and neonatal health outcomes.

Joint decision on contraceptive use and determinant factors among married women of reproductive ages (15-49) in Ethiopia: a multilevel analysis using Ethiopian Demographic and Health Survey; 2016 data

BACKGROUND

Contraceptive usage in Ethiopia is significantly influenced by the decision-maker at the household level. Joint decision-making involving both women and their husbands/partners is considered ideal for improving contraceptive uptake among women and for managing health outcomes related to contraceptive side effects. However, there is a lack of substantial evidence regarding the prevalence and impact of joint decision-making on contraceptive use in Ethiopia. Therefore, the current study aimed to assess the magnitude of joint decision-making on contraceptive use and its determinant factors among married, contraceptive-using, reproductive-age women in Ethiopia.

METHODS

This study was conducted based on the Ethiopian Demographic and Health Survey (EDHS) 2016 data. A total weighted sample of 3,669 married, contraceptive-using, reproductive-age women were included in the study. Multilevel logistic regression was employed due to the hierarchical nature of the data. Variables with a p-value of ≤ 0.2 in the bivariate multilevel analysis were included in the multivariable multilevel analysis. The adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to determine the direction and strength of associations. Variables with a p-value of < 0.05 in the multivariable multilevel analysis were considered statistically significant for joint decision-making on contraceptive use.

RESULTS

The prevalence of joint decision-making on contraceptive use in Ethiopia was 78.81% [95% CI: 71.35-74.23%]. Several factors were found to be statistically significant in relation to joint decision-making on contraceptive use: Women educational level primary, secondary, and higher (Adjusted odds' ratio (AOR = 1.5; CI 1.2-1.9), (AOR = 1.9; CI 1.3-2.9), and (AOR = 2.1; CI 1.2-3.5) respectively, protestant in religion (AOR = 1.7; CI 1.7-2.5), wealth status rich (AOR = 1.4; CI 1.1-1.9), media exposure (AOR = 1.4; CI 1.1-1.9), and community poverty high (AOR = 0.6; CI 0.6-0.9).

CONCLUSIONS

In Ethiopia, the majority of contraceptive users are married, reproductive-age women, and their decision to use contraceptives is typically made jointly with their husbands or partners. Factors positively associated with joint decision-making on contraceptive use include women's educational level (primary, secondary, and higher), being Protestant, having a higher wealth status, and media exposure. Conversely, women living in communities with high poverty levels are less likely to make joint decisions about contraceptive use. Health care providers, health care programmers and policy makers should be focused on these determinant factors to enhance joint decision-making in women's contraceptive use in Ethiopia.

Key barriers to the provision and utilization of maternal health services in low-and lower-middle-income countries; a scoping review

BACKGROUND

The preservation and promotion of maternal health (MH) emerge as vital global health objectives. Despite the considerable emphasis on MH, there are still serious challenges to equitable access to MH services in many countries. This review aimed to determine key barriers to the provision and utilization of MH services in low- and lower-middle-income countries (LLMICs).

METHODS

In this scoping review, we comprehensively searched four online databases from January 2000 to September 2022. In this study, the approach proposed by Arksey and O'Malley was used to perform the review. Consequently, 117 studies were selected for final analysis. To determine eligibility, three criteria of scoping reviews (population, concept, and context) were assessed alongside the fulfillment of the STROBE and CASP checklist criteria. To synthesize and analyze the extracted data we used the qualitative content analysis method.

RESULTS

The main challenges in the utilization of MH services in LLMICs are explained under four main themes including, knowledge barriers, barriers related to beliefs, attitudes and preferences, access barriers, and barriers related to family structure and power. Furthermore, the main barriers to the provision of MH services in these countries have been categorized into three main themes including, resource, equipment, and capital constraints, human resource barriers, and process defects in the provision of services.

CONCLUSIONS

The evidence from this study suggests that many of the barriers to the provision and utilization of MH services in LLMICs are interrelated. Therefore, in the first step, it is necessary to prioritize these factors by determining their relative importance according to the specific conditions of each country. Consequently, comprehensive policies should be developed using system modeling approaches.

The level of utilization and associated factors of WHO recommended antenatal care visits in South Asian countries

Background

Antenatal care can play an important role in reducing the death of both mothers and children. This study was designed to find out the determinants of world health organization recommended antenatal care visits in six South Asian countries to achieve the targets for Sustainable Development Goal.

Methods

This study used recent demographic and health survey data from six South Asian countries such as Afghanistan (2015), Bangladesh (2017-18), India (2015-16), Maldives (2016-17), Nepal (2016), and Pakistan (2047-18). Descriptive statistics were calculated for the distribution and prevalence of antenatal care visits. Bivariate and multivariable logistic regressions were used to investigate the influencing factors of antenatal care visits.

Results

71,862 women aged 15 to 49 years were included in this study, and 46.64% (95% Confidence Interval = 45.59 - 47.69%) had world health organization recommended antenatal care visits. In the pooled data, urban women (AOR ([Adjusted Odds Ratio]=1.48; 95% CI [Confidence Interval]=1.33-1.66), richest family (AOR=1.48; 95% CI=1.25-1.76), women's higher education (AOR=3.76; 95% CI=3.33-4.25), women's partner/husband's higher education (AOR=1.69; 95% CI=1.50-1.92), 35-49 years (AOR=1.25, 95% CI=1.11-1.42), women's age at first birth >25 years (AOR=1.51, 95% CI=1.36-1.68) and fully media exposure (AOR=2.11; 95% CI=1.74-2.56) were significantly positively associated with WHO recommended antenatal care visits. Whereas, working women (AOR=0.82; 95% CI=0.76-0.88), healthcare decision maker by their husband/others (AOR=0.71, 95% CI=0.60-0.84), ≥7 children (AOR=0.59; 95% CI=0.50-0.69), and ≥7 family members (AOR=0.82; 95% CI=0.73-0.93) had significant negative effect on antenatal care visits. In country specific analysis, overall, media exposure, secondary and above education of women, ≥25 of years age at first birth, and <4 living children were the key factors of antenatal care visits.

Conclusions

This study reveals an overall scenario of the WHO-recommended antenatal care visit in South Asian countries, and significant factors related to ANC that we can concentrate onto improve accessibility to healthcare services and promote education and media exposure, especially for rural and less educated women, to increase the prevalence of WHO-recommended antenatal visits in South Asian countries In addition, evidence from this study can be used to assist the policymakers in planning and taking proper steps to increase WHO-recommended antenatal care visits by focusing on the related factors in South Asian countries.

Social capital and health beliefs: Exploring the effect of bridging and bonding social capital on health locus of control among women in Dhaka

This cross-sectional study examined if social capital affects women's health attributions. The study used the Internet Social Capital Scale (ISCS) and Multidimensional Health Locus of Control (MHLC) Scale to measure Social Capital and Health Locus of Control. A predefined 38-item questionnaire was used to survey 485 purposively selected women. A bidirectional reciprocal structural equation model was used to measure the covariance between Social Capital and Health Locus of Control. We hypothesized that women with strong social capital, particularly those rich in bridging ties, would exhibit a greater sense of agency and empowerment over their health, attributing their health outcomes less to internal factors like fate and more to external influences like powerful others and broader social support. However, we found that when women have higher social capital, their external health locus of control increases. Bridging and bonding social capital lower women's internal health control, but bridging social capital leads to higher attributes to powerful others. Likewise, we expected women with more social capital would exhibit a lower perception of uncontrollability over their health, but is not the case. The findings underscore the necessity for women to have more social capital.

Explaining changes in educational disparities in competent maternal health care services in urban and rural areas in Ethiopia

Introduction

Aggregate statistics of maternal health care services have improved in Ethiopia. Nevertheless, the country has one of the lowest Universal Health Coverage (UHC) service coverage indices, with slight improvement between 2000 and 2019. There are disparity studies that focus on a single dimension of inequality. However, studies that combine multiple dimensions of inequality simultaneously may have important policy implications for closing inequalities. In this study, we investigated education inequalities in the receipt of maternal health care services in rural and urban areas separately, and we examined whether these inequalities decreased, increased, or remained unchanged.

Methods

The data for the study came from the 2011 and 2016 Ethiopia Demographic and Health Surveys. Using women's education as a dimension of inequality, we separately analyzed inequalities in maternal health care services in urban and rural settings. Inequalities were measured through the Erreygers concentration index, second differences, and Relative Index of Inequality (RII). Whether inequalities changed over time was analyzed by relative and absolute measures. An Oaxaca-type decomposition approach was applied to explain changes in absolute disparities over time.

Results

There were glaring educational disparities in maternal health care services in urban and rural areas, where the services were more concentrated among women with better schooling. The disparities were more severe in urban than in rural areas. In urban areas, skilled birth service was the most unequal in both periods. Disparities in rural places were roughly similar for all services except that in 2011, postnatal care was the least unequal, and in 2016, skilled birth was the most unequal services. Trend analyses revealed that disparities significantly dropped in urban by absolute and relative measures. Conversely, in rural regions, the disparities grew by the concentration index measure for most services. The RII and second differences presented conflicting results regarding whether the gaps were increasing, shrinking, or remaining the same.

Conclusion

Substantial disparities in maternal health care services remained and even increased, as in rural areas. Different and targeted strategies are needed for urban and rural places to close the observed educational inequalities in these areas.

Predictors of maternal health services uptake in West African region: a multilevel multinomial regression analysis of demographic health survey reports

BACKGROUND

Pursuant to studies, receiving the three key maternal health services (Antenatal Care, Skilled Delivery Service, and Postnatal Care) in a continuum could prevent 71% of global maternal deaths. Despite the Western African region being known for its high maternal death and poor access to maternal health services, there is a dearth of studies that delve into the spectrum of maternal health services uptake. Hence, this study aimed to assess the level and predictors of partial and adequate utilization of health services in a single analytical model using the most recent Demographic and Health Survey (DHS) data (2013-2021).

METHODS

This study was based on the appended women's (IR) file of twelve West African countries. STATA software version 16 was used to analyze a weighted sample of 89,504 women aged 15-49 years. A composite index of maternal health service utilization has been created by combining three key health services and categorizing them into 'no', 'partial', or 'adequate' use. A multilevel multivariable multinomial logistic regression analysis was carried out to examine the effects of each predictor on the level of service utilization. The degree of association was reported using the adjusted relative risk ratio (aRRR) with a corresponding 95% confidence interval, and statistical significance was declared at p < 0.05.

RESULTS

66.4% (95% CI: 64.9, 67.7) and 23.8% (95% CI: 23.3, 24.2) of women used maternal health services partially and adequately, respectively. Togo has the highest proportion of women getting adequate health care in the region, at 56.7%, while Nigeria has the lowest proportion, at 11%. Maternal education, residence, wealth index, parity, media exposure (to radio and television), enrolment in health insurance schemes, attitude towards wife beating, and autonomy in decision-making were identified as significant predictors of partial and adequate maternal health service uptake.

CONCLUSION

The uptake of adequate maternal health services in the region was found to be low. Stakeholders should plan for and implement interventions that increase women's autonomy. Program planners and healthcare providers should give due emphasis to those women with no formal education and from low-income families. The government and the private sectors need to collaborate to improve media access and increase public enrolment in health insurance schemes.

A Comparative Analysis of Maternal Nutrition Decision-Making Autonomy During Pregnancy-An Application of the Food Choice Process Model in Burkina Faso and Madagascar

BACKGROUND

Adequate nutrition has been cited as one of the most critical components for optimal health outcomes during pregnancy. Women in Burkina Faso and Madagascar experience high rates of undernutrition due to lack of knowledge, finances, cultural norms, and autonomy. Therefore, this study aimed (1) to describe typical maternal diets during pregnancy in Burkina Faso and Madagascar, (2) to understand the multilevel factors that influence women's nutrition decision-making, and (3) to explore the extent to which women have nutrition decision-making autonomy during pregnancy.

METHODS

This study was conducted between October 2020 and February 2021 in Burkina Faso and Madagascar. Semi-structured interviews, focus group interviews, and free lists were conducted among women of reproductive age and pregnant and lactating women. Textual data from interviews were recorded and translated verbatim from local languages into French. The Food Choice Process Model guided textual content analysis using Dedoose software. Free list data were analyzed using cultural domain analysis approaches.

RESULTS

In Burkina Faso and Madagascar, women primarily consumed staple foods such as rice and tô during pregnancy. Participants cited eating fruits and vegetables when available, while the animal source foods were rarely consumed. Across both contexts, nutrition during pregnancy was influenced by factors that impact food choices, such as social factors, resources, ideals, and personal factors. While women and men in Madagascar had more shared decision-making on critical domains such as finances, men were the primary decision-makers in most areas of inquiry (eg, finances) in Burkina Faso.

CONCLUSIONS

The lack of adequate diverse diet consumed during pregnancy is primarily due to important factors including social factors and resources. Understanding the ability for women to consume optimal diets during pregnancy is needed to target behavioral change in maternal nutrition programming.

Prevalence, trends, and factors associated with maternal autonomy regarding healthcare, finances, and mobility in Bangladesh: Analysis of Demographic and Health Surveys 1999-2018

Maternal autonomy is associated with improved healthcare utilization/outcomes for mothers and babies in low- and middle-income countries. We investigated the trends in the prevalence and factors associated with maternal autonomy in Bangladesh. This cross-sectional study analyzed the Bangladesh Demographic and Health Survey for 1999-00, 2004, 2007, 2011, 2014, and 2017-18. Maternal autonomy was defined as at least one decision-making ability regarding healthcare, large household purchases, and freedom of mobility. We included 15-49-year-old mothers with at least one live-birth in the past three years. We compared the samples based on the presence of autonomy and reported the trends in prevalence (95% confidence intervals (CIs)) across the survey years. Lastly, we performed multilevel logistic regression to report prevalence odds ratios (PORs) for the associated factors. Variables investigated as potential factors included maternal age, number of children, maternal education, paternal education, current work, religion, mass media exposure, wealth quintile, place and division of residence, and survey years. The prevalence of 'any' maternal autonomy was 72.0% (95% CI: 70.5-73.5) in 1999-00 and increased to 83.8% (95% CI: 82.7-84.9) in 2017-18. In adjusted analysis, mothers with older age, higher education, work outside the home, and mass media exposure had higher odds of autonomy than their counterparts (POR > 1, p < 0.05). For instance, compared to mothers without any formal education, the odds of autonomy were significantly (p < 0.001) higher among mothers with primary (adjusted POR: 1.2, 95% CI: 1.1-1.4), secondary (adjusted POR: 1.4, 95% CI: 1.2-1.6), and college/above (adjusted POR: 1.9, 95% CI: 1.6-2.2) education. While the level of maternal autonomy has increased, a substantial proportion still do not have autonomy. Expanding educational and earning opportunities may increase maternal autonomy. Further research should investigate other ways to improve it as well.

Compliance towards WHO recommendations on antenatal care for a positive pregnancy experience: Timeliness and adequacy of antenatal care visit in Sub-Saharan African countries: Evidence from the most recent standard Demographic Health Survey data

BACKGROUND

Timely and adequate antenatal care (ANC) visits are known to reduce maternal mortality by 20%. Despite the World Health Organization updating its recommendations from four to eight antenatal care contacts, data reporting in the SSA region focused primarily on four visits, and evidence on the timing and adequacy of ANC based on the current recommendation was limited. Hence, this study aimed at assessing the level of timely and adequate ANC visits and their determinants in the 18 Sub-Saharan African countries with the most recent DHS report (2016-2021).

METHODS

The data for this study were pooled from the most recent standardized Demographic and Health Survey data of sub-Saharan African countries from 2016-2021. A total of 171,183 (with a weighted frequency of 171,488) women were included and analyzed by using STATA version 16. To account for data clustering, a multivariable multilevel mixed-effect logistic regression analysis was run to determine the effects of each predictor on the receipt of timely and adequate ANC. Adjusted odds ratio with its corresponding 95% confidence interval was used to declare the statistical significance of the independent variables.

RESULTS

The receipt of timely and adequate antenatal care visits was 41.2% (95% CI: 40.9, 41.4) and 10.4% (95% CI: 9.9, 10.2), respectively. Wontedness of pregnancy [AOR = 1.18; 95% CI: 1.13, 1.24], being 1st birth order [AOR = 1.48; 95% CI: 1.41, 2.54], having a mobile phone [AOR = 1.49; 95% CI: 1.26, 2.32], and enrolled in Health insurance schemes [AOR = 2.03; 95% CI: 1.95, 2.42] were significantly associated with early initiation of ANC. Living in a lower community poverty level[AOR = 2.23; 95% CI: 1.90,2.66], being in the richest wealth quintile [AOR = 1.49; 95% CI: 1.36, 1.62], higher educational level [AOR = 3.63; 95% CI: 3.33, 3.96], the timing of ANC visit [AOR = 4.26; 95% CI: 4.08, 4.44], being autonomous in decision making [AOR = 2.29; 95% CI: 1.83, 2.54] and having a mobile phone [AOR = 1.89; 95% CI: 1.76, 2.52] were identified as significant predictors of adequate ANC uptake.

CONCLUSION

The findings revealed a low coverage of timely and adequate ANC visits in SSA countries. Governments and healthcare managers in sub-Saharan African countries should leverage their efforts to prioritize and implement activities and interventions that increase women's autonomy, and economic capability, to improve their health-seeking behavior during pregnancy. More commitment is needed from governments to increase mobile phone distribution across countries, and then work on integrating mHealth into their health system. Finally, efforts should be made to increase the coverage of health insurance schemes enrolment for the citizens.

Psychosocial dimensions of access and their association with contraceptive use and intention to use

BACKGROUND

Several studies suggest that psychosocial accessibility appears to be the key remaining hurdle to contraceptive use when issues of geographic and financial accessibility have been resolved. To date, the literature has considered various dimensions of psychosocial accessibility, which are not well measured by the two main sources of contraceptive data (DHS and PMA2020). In a previous paper, we have designed a framework that outlines four subdimensions of cognitive and psychosocial access and their theoretical relationship to contraceptive use and intention to use. This paper aims to study the associations between the four dimensions of access to contraception with the contraceptive use and intention to use. It also aims to explore the mediation effect of these four dimensions of access in the relationships between classical individual characteristics and contraceptive use and intention to use.

METHODS

The data we used came from the 6th round of the PMA2020 survey in Burkina Faso in 2018-19. This survey included 2,763 households (98.4% response rate) and 3329 women (97.7% response rate). In addition to PMA's core questions, this survey collected data on psychosocial accessibility. Each group of questions was added to address one dimension. We use a multilevel generalized structural equation and mediation modeling to test the associations between psychosocial accessibility and contraceptive use while controlling for some individual and contextual characteristics.

RESULTS

Approval, contraceptive knowledge, and agency were associated with contraceptive use, while fears of side effects were not. Approval and agency explain part of the effects of education and parity on contraceptive use. Exposure to family planning messages had a positive impact on women's contraceptive agency.

CONCLUSION

FP messages can help enhance women's contraceptive agency, and then, contraceptive use, regardless of age and parity. The analysis highlights the mediator effects of contraceptive approval and agency on the association between parity and education with contraceptive use.

Towards a positive postnatal experience in Sub-Saharan African countries: the receipt of adequate services during the immediate postpartum period: a multilevel analysis

Background

Existing studies in the Sub-Saharan African (SSA) region have focused mainly on the frequency of postnatal visits, with little emphasis on the adequacy of care provided during visits. Hence, this study aimed to investigate the magnitude of receiving an adequate number of World Health Organization-recommended contents of care during the immediate postpartum visit, and its predictors in SSA countries.

Methods

The appended women file of the most recent (2016-2021) standardized Demographic and Health Survey report of eighteen Sub-Saharan African countries with a weighted sample of 56,673 women was used for the study. The influence of each predictor on the uptake of adequate postnatal care has been examined using multilevel mixed-effects logistic regression. Significant predictors were reported using the adjusted odds ratio (aOR) with their respective 95% confidence intervals (95% CI).

Results

The pooled prevalence of adequate postnatal care service uptake was found to be 42.94% (95% CI: 34.14, 49.13). Living in the southern sub-region (aOR = 3.08 95% CI: 2.50, 3.80), institutional delivery (aOR = 3.15; 95% CI: 2.90, 3.43), early initiation of ANC (aOR = 1.74; 95% CI: 1.45, 2.09), quality of antenatal care (aOR = 1.59; 95% CI: 1.42, 1.78), Caesarean delivery (aOR = 1.59; 95% CI: 1.42, 1.78), autonomy in decision-making (aOR = 1.30; 95% CI: 1.11, 1.39), high acceptance toward wife beating attitude (aOR = 0.83; 95% CI: 0.73, 0.94), and reading newspapers (aOR = 1.37; 95% CI: 1.21, 1.56) were identified as predictors of receiving adequate postnatal services during the immediate postpartum period.

Conclusion

The findings revealed low coverage of adequate postnatal care service uptake in the region. The Federal Ministry of Health and healthcare managers in each country should coordinate their efforts to develop interventions that promote women's empowerment to enhance their autonomy in decision-making and to reduce attitudes towards wife beating. Healthcare providers ought to strive to provide skilled delivery services and early initiation of antenatal care.

User Fee Exemption Policy Significantly Improved Adherence to Maternal Health Service Utilization in Bahir Dar City, Northwest Ethiopia: A Comparative Cross-Sectional Study

Background

Increasing free and skilled delivery is a top priority in the global effort to reduce maternal and newborn mortality. Reducing user-fees through exemption policy has contributed to universal health coverage. However, there is scant evidence regarding the effect of exempted maternal services on adherence to utilization in Ethiopia. Thus, this study aimed to assess the effect of fee exemption policy on adherence to maternal health service utilization and its predictors.

Methods

A community-based comparative cross-sectional study was conducted in Bahir Dar City. A two-stage multistage sampling was employed; 497 women participated. Data were collected by face-to-face interview; entered and cleaned using Epi-Data 3.1. SPSS version 25 was used for further analysis. Bivariable and multivariable logistic regression models were computed to assess the association between explanatory and outcome variables. An adjusted odds ratio with a 95% confidence interval was used to interpret the degree of association. The effect of fee exemption policy on adherence to maternal health service utilization was measured by propensity score matching.

Results

The overall adherence to maternal service utilization was 54.2%. Factors associated with adherence to maternal health service utilization were pregnancy complications [AOR: 4.1, 95% CI (2.32, 7.28)], secondary and above education [AOR: 4.6, 95% CI (1.38, 15.08)], early ANC1 booking [AOR: 3.1, 95% CI (1.83, 5.16)], autonomous women [AOR: 2.1, 95% CI (1.02, 4.39)], user fee exemption [AOR: 2.3, 95% CI (1.20, 4.47)] and high parity [AOR: 0.39, 95% CI (0.2, 0.75)]. User fee exemption induced a 22.7% increment in adherence to maternal service utilization (ATET=0.227, t=2.13).

Conclusion

User fee exemption policy significantly improved adherence to maternal health service utilization. Promoting a fee exemption policy through third-party financing can enhance maternal health service utilization adherence in hard-to-reach settings of Ethiopia by targeting mothers with higher pregnancies, no complications, no autonomy, and less education.

"Can't live willingly": A thematic synthesis of qualitative evidence exploring how early marriage and early pregnancy affect experiences of pregnancy in South Asia

In South Asia, early marriage has been associated with a range of adverse outcomes during pregnancy and infancy. This may partly be explained by early marriage leading to a younger maternal age, however it remains unclear which other factors are involved. This review aimed to synthesise the qualitative evidence on experiences of pregnancy following early marriage or early pregnancy in South Asia, to inform our understanding of the mechanisms between early marriage and adverse pregnancy outcomes. We searched MEDLINE, EMBASE, Scopus, Global Index Medicus, CINAHL, PsycINFO, Web of Science, and grey literature on 29/11/2022 to identify papers on experiences of pregnancy among those who married or became pregnant early in South Asia (PROSPERO registration number: CRD42022304336, funded by an MRC doctoral training grant). Seventy-nine papers from six countries were included after screening. We appraised study quality using an adapted version of the Critical Appraisal Skills Programme tool for qualitative research. Reporting of reflexivity and theoretical underpinnings was poor. We synthesised findings thematically, presenting themes alongside illustrative quotes. We categorised poor pregnancy experiences into: care-seeking challenges, mental health difficulties, and poor nutritional status. We identified eight inter-connected themes: restrictive social hierarchies within households, earning social position, disrupted education, social isolation, increased likelihood of and vulnerability to abuse, shaming of pregnant women, normalisation of risk among younger women, and burdensome workloads. Socioeconomic position and caste/ethnic group also intersected with early marriage to shape experiences during pregnancy. While we found differences between regions, the heterogeneity of the included studies limits our ability to draw conclusions across regions. Pregnancy experiences are largely determined by social hierarchies and the quality of relationships within and outside of the household. These factors limit the potential for individual factors, such as education and empowerment, to improve experiences of pregnancy for girls married early.

Women's empowerment and uptake of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy: results from a cross-sectional baseline survey in the Lake endemic region, Kenya

BACKGROUND

Malaria in pregnancy remains a major public health problem in endemic areas of the sub-Saharan African (SSA) region. However, there is limited understanding of the association between women's empowerment and the uptake of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy (IPTp-SP) in Kenya. This study examines the association between women's empowerment indicators (decision-making power, control of assets, education, and employment status) and the uptake of three or more doses of IPTp-SP in the Lake endemic region of Kenya.

METHODS

The analysis utilized a dataset from a cross-sectional baseline survey of 3129 women aged 15-49 years in Kisumu and Migori Counties who had a live birth within the last 2 years preceding the study. Data were collected between June to August 2021. A descriptive analysis was conducted to show the distribution of respondents by key background characteristics, and bivariate and multivariate logistic regression to examine statistically significant associations between women's empowerment measures and the uptake of 3+ doses of IPTp-SP.

RESULTS

Among the 3129 women surveyed, 1978 (65.7%) received 3+ doses of IPTp-SP during their most recent pregnancy. Controlling for individual characteristics and the number of ANC visits, the odds of taking 3+ doses of IPTp-SP increased among women who had high decision-making autonomy (AOR = 2.33; CI = 1.81-3.01; P < 0.001); and tertiary level of educational attainment (AOR = 1.51; CI = 1.10-2.06). However, the association between control of assets and uptake of IPTp-SP was positive but not statistically significant.

CONCLUSION

Women's decision-making autonomy and educational attainment were positively associated with the uptake of IPTp-SP. As a result, maternal health interventions should focus on less empowered women, specifically those with less decision-making autonomy and no/low formal education, as they are less likely to achieve optimal uptake of IPTp-SP during pregnancy.

Socio-economic and agricultural factors associated with stunting of under 5-year children: findings from surveys in mountains, dry zone and delta regions of rural Myanmar (2016-2017)

OBJECTIVE

The study's objective was to investigate multiple underlying social, economic and agricultural determinants of stunting among under-five children in three distinct ecological areas in rural Myanmar.

DESIGN

Repeated cross-sectional surveys in three states of Myanmar.

SETTING

Rural households in Chin (mountainous), Magway (plains) and Ayeyarwady (delta).

PARTICIPANTS

From two purposively selected adjacent townships in each state, we randomly selected twenty villages and, in each village, thirty households with under-five children. Households in the first survey in 2016 were revisited in late 2017 to capture seasonal variations.

RESULTS

Stunting increased from 40·4 % to 42·0 %, with the highest stunting prevalence in Chin state (62·4%). Univariate Poisson regression showed factors contributing to child stunting varied across the regions. Adjusted Poisson regression models showed that child's age and short maternal stature (aRR = 1·14 for Chin, aRR = 1·89 for Magway and aRR = 1·86 for Ayeyarwady) were consistently associated with child stunting across three areas. For Chin, village-level indicators such as crop consumption (aRR = 1·18), crop diversity (aRR = 0·82) and land ownership (aRR = 0·89) were significantly associated with stunting. In Magway, the number of household members (aRR = 1·92), wealth status (aRR = 0·46), food security status (aRR = 1·14), land ownership (aRR = 0·85) and in Ayeyarwady, women's decision-making (aRR = 0·67) and indicators related to hygiene (aRR = 1·13) and sanitation (aRR = 1·45) were associated with stunting.

CONCLUSIONS

Area-specific factors were associated with stunting. Maternal short stature and child age were consistent determinants of stunting. A multi-sectoral local approach, including improvements in transport, is needed to address the intergenerational malnutrition problem.

Is women's household decision-making autonomy associated with their higher dietary diversity in Bangladesh? Evidence from nationally representative survey

In Bangladesh, a low-quality repetitive diet characterized by starchy staple foods is typical, leading to disorders associated with micronutrient deficiencies, particularly among mothers and their children. The purpose of the study was to validate the link between women's decision-making autonomy and higher dietary diversity score. Participants were ever married women aged 15-49 years old with comprehensive dietary information (n = 17,842), selected from the Bangladesh Demographic and Health Survey, 2014. The dietary diversity score (DDS) was obtained from a 24-h recall of dietary intake from nine food groups, categorized into lower DDS (DDS ≤ 4) and higher DDS (DDS ≥ 5). Descriptive analysis, bivariate and multivariate logistic regression were conducted using STATA version 15. Almost all women consumed starchy foods, flesh (83.86%), and fruits (67.30%). Using logistic regression, the odds of achieving dietary diversity score were higher among women who participated in household purchases (OR 2.40; 95% CI: 1.52-3.83; p = 0.022). Women who had higher and secondary education were 2.72 (95% CI: 1.49-3.02; p = 0.025) and 1.31 (95% CI: 0.58-2.18; p = 0.029) times more likely to achieve higher DDS than women having no education, as well as women in the richest quintile (OR 6.49; 95% CI: 4.12-8.5; p = 0.037) compared to women in the lowest quintile. This study highlighted the association of several socioeconomic conditions of ever married women and their dietary diversity score in Bangladesh. Therefore, promoting the women's education status, improving the socioeconomic conditions, and prioritizing their decisions are recommended for the attainment of higher dietary diversity score.

Married women decision making autonomy on health care utilization in high fertility sub-Saharan African countries: A multilevel analysis of recent Demographic and Health Survey

BACKGROUND

Women's decision-making autonomy has a potential impact on the scale-up of health care utilization. In high fertility countries, evidence regarding women's decision-making autonomy on their health care utilization and its associated factors is limited and inconclusive. Hence, it is important to investigate women decision-making autonomy on their health care utilization and associated factors in high fertility countries in sub-Saharan Africa.

METHODS

The data source for this study was obtained from recent Demographic and Health Surveys that were comprised of a weighted sample of 178875 reproductive age women. A multilevel mixed-effect binary logistic regression model was fitted. The odds ratios, along with the 95% confidence interval were generated to identify individual and community-level factors associated with women's autonomy in health care decision-making. A p-value less than 0.05 was declared as statistical significance.

RESULTS

In this study, 42% (95% CI: 41.7, 42.3) of women were able to exercise their reproductive autonomy. The highest (74.8%) and the lowest (19.74%) magnitude of women autonomy was found in Angola and Mali, respectively. In multilevel analysis; age of women 25-34 years, 35 and above (AOR = 1.34, 95% CI: 1.29, 1.39), and (AOR = 1.78, 95% CI: 1.75, 1.90), women's primary and secondary educational level (AOR = 1.25, 95% CI: 1.20, 1.31), and (AOR = 1.44, 95% CI: 1.32, 1.54), husband primary and secondary educational level (AOR = 1.24, 95% CI: 1.18, 1.29), and (AOR = 1.21, 95% CI: 1.15, 1.27), women who had work (AOR = 1.67, 95% CI: 1.59, 1.74) female household heads (AOR = 1.44, 95% CI: 1.37, 1.51), media exposure (AOR = 1.04, 95% CI: 1.09, 1.18), health insurance coverage (AOR = 1.26, 95% CI: 1.17, 1.36), urban residence (AOR = 1.14, 95% CI: 1.09, 1.19), community education (AOR = 2.43, 95% CI: 2.07, 2.85) and low community poverty level (AOR = 1.27, 95% CI: 1.08, 1.49) were predictor variables.

CONCLUSION AND RECOMMENDATION

Although every woman has the right to make her own health care decisions, this study showed that almost 58% of them had no role in making decisions about their health care utilization. Thus, each country Government should support women's decision making autonomy regarding their healthcare utilization through mass media and extensive behavioral education.

A multilevel Bayesian Markov Chain Monte Carlo Poisson modelling of factors associated with components of antenatal care offered to pregnant women in Nigeria

BACKGROUND

The most recent WHO guideline on antenatal care (ANC) utilization reaffirmed the necessary and compulsory care and services a pregnant woman should receive to maximize the importance and gains of ANC. While most studies focused on the time of initiation and number of ANC contacts, emphasis was rarely placed on the components of ANC offered to women. This study assessed how complete the components of ANC received by pregnant women are as a proxy for the quality of ANC services offered in Nigeria. We also assessed the clustering of the components and state-level differentials and inequalities in the components of ANC received in Nigeria.

METHODS

We used nationally representative cross-sectional data from the 2018 Nigeria Demographic Health Survey. We analysed the data of 11,867 women who had at least one ANC contact during the most recent pregnancy within five years preceding the survey. The assessed components were tetanus injection, blood pressure, urine test, blood test, iron supplement, malaria intermittent preventive treatment in pregnancy (IPTp), and told about danger signs. Others are intestinal parasite drugs (IPD)intermittent and HIV/PMTCT counsel. Descriptive statistics, bivariable and multivariable multilevel Bayesian Monte Carlo Poisson models were used.

RESULTS

In all, 94% had blood pressure measured, 91% received tetanus injection, had iron supplement-89%, blood test-87%, urine test-86%, IPTp-24%, danger signs-80%, HIV/PMTC-82% and IPD-22%. The overall prevalence of receiving all 9 components was 5% and highest in Ogun (24%) and lowest in Kebbi state (0.1%). The earlier the initiation of ANC, the higher the number of contacts, and the higher the quality of ANC received. Respondents with higher education have a 4% (adjusted incidence risk ratio (aIRR): 1.04, 95% credible interval (CrI): 1.01-1.09) higher risk of receiving more components of ANC relative to those with no education. The risk of receiving more ANC components was 5% (aIRRR: 1.05, 95% CI: 1.01-1.10) higher among pregnant women aged 40 to 49 years than those aged 15 to 19 years. Women who decide their healthcare utilization alone had a 2% higher risk of getting more components than those whose spouses are the only decision taker of healthcare use. Other significant factors were household wealth status, spouse education, ethnicity, place of ANC, and skill of ANC provider. Pregnant women who had their blood pressure measured were very likely to have blood and urine tests, tetanus injections, iron supplements, and HIV talks.

CONCLUSIONS

Only one in every 20 pregnant women received all the 9 ANC components with wide disparities and inequalities across the background characteristics and the States of residence in Nigeria. There is a need to ensure that all pregnant women receive adequate components. Stakeholders should increase supplies, train, and create awareness among ANC providers and pregnant women in particular.

COVID-19 vaccine decision-making among pregnant and lactating women in Bangladesh

Pregnant and lactating women's vaccine decision-making process is influenced by many factors. Pregnant women were at increased risk for severe disease and poor health outcomes from COVID-19 at various time points during the pandemic. COVID-19 vaccines have been found to be safe and protective during pregnancy and while breastfeeding. In this study, we sought to examine key factors that informed the decision-making process among pregnant and lactating women in Bangladesh. We conducted 24 in-depth interviews, with 12 pregnant and 12 lactating women. These women were from three communities in Bangladesh: one urban community, and two rural communities. We used a grounded theory approach to identify emerging themes and organized emerging themes using a socio-ecological model. The socio-ecological model suggests that individuals are influenced by many levels, including individual-level influences, interpersonal-level influences, health care system-level influences, and policy-level influences. We found key factors at each socio-ecological level that influenced the decision-making process of pregnant and lactating women, including perceived benefits of vaccines and vaccine safety (individual-level), the influence of husbands and peers (interpersonal-level), health care provider recommendations and vaccine eligibility (health care system-level), and vaccine mandates (policy-level). As vaccination can reduce the effect of COVID-19 disease in mothers, infants, and unborn children, targeting critical factors that inform the decision-making process is paramount for improving vaccine acceptance. We hope the results of this study will inform vaccine acceptance efforts to ensure that pregnant and lactating women take advantage of this life-saving intervention.

Determinants of Focused Antenatal Care Utilization Among Women in Simiyu Region Tanzania

Antenatal care (ANC) is a critical period for promoting the health of both mothers and babies. ANC visit is a key entry point for a pregnant woman to the health care system to receive health intervention. The new World Health Organization (WHO) guideline recommends eight ANC contacts. However, the coverage of at least four ANC visits is still low in the Simiyu region.

Objective

To assess determinants of focused ANC visits utilization among women in the Simiyu Region Tanzania.

Methodology

The study employed a cross-sectional study among women of reproductive age. Data was collected through an interviewer-administered questionnaire and analyzed using Stata version 15. Data were summarized using mean and standard deviation for continuous variables while frequency and percentage were used for categorical variables. A generalized linear model, Poisson family, with a log link was used to identify determinants of focused ANC utilization.

Results

All 785 women analyzed reported having at least one ANC visit, with 259 (34%) having four or more visits and only 40 (5.1%) having eight or more visits. Women who made a self-decision were 30% less likely to complete four and more ANC visits than their counterparts (APR = 0.70; 95%CI = 0.501-0.978). Women who visited the dispensary were 27% less likely to complete four ANC visits than those who visited health centers (APR = 0.73; 95%CI = 0.540-0.982). However, education level and planned pregnancy were both marginally significantly associated with focused ANC utilisation.

Conclusion

Generally, the majority of pregnant women in the Simiyu region do not adequately utilize four and more ANC visits. There is a need to enhance health education to women and their spouses on the importance of attending four or more visits and improving the quality of maternal health services to facilitate the utilization of ANC among women in the study area.

The burden of chronic diseases, disease-stratified exploration and gender-differentiated healthcare utilisation among patients in Bangladesh

BACKGROUND

Chronic diseases are considered one of the major causes of illness, disability, and death worldwide. Chronic illness leads to a huge health and economic burden, especially in low- and middle-income countries. This study examined disease-stratified healthcare utilisation (HCU) among Bangladesh patients with chronic diseases from a gender perspective.

METHODS

Data from the nationally representative Household Income and Expenditure Survey 2016-2017 consisting of 12,005 patients with diagnosed chronic diseases was used. Gender differentiated chronic disease stratified-analytical exploration was performed to identify the potential factors to higher or lower utilisation of healthcare services. Logistic regression with step-by-step adjustment for independent confounding factors was the method used.

RESULTS

The five most prevalent chronic diseases among patients were gastric/ulcer (Male/Female, M/F: 16.77%/16.40%), arthritis/rheumatism (M/F: 13.70%/ 13.86%), respiratory diseases/asthma/bronchitis (M/F: 12.09% / 12.55%), chronic heart disease (M/F: 8.30% / 7.41%), and blood pressure (M/F: 8.20% / 8.87%). Eighty-six percent of patients with chronic diseases utilised health care services during the previous 30 days. Although most patients received outpatient healthcare services, a substantial difference in HCU among employed male (53%) and female (8%) patients were observed. Chronic heart disease patients were more likely to utilise health care than other disease types, which held true for both genders while the magnitude of HCU was significantly higher in males (OR = 2.22; 95% CI:1.51-3.26) than their female counterparts (OR = 1.44; 1.02-2.04). A similar association was observed among patients with diabetes and respiratory diseases.

CONCLUSION

A burden of chronic diseases was observed in Bangladesh. Patients with chronic heart disease utilised more healthcare services than patients experiencing other chronic diseases. The distribution of HCU varied by patient's gender as well as their employment status. Risk-pooling mechanisms and access to free or low-cost healthcare services among the most disadvantaged people in society might enhance reaching universal health coverage.

The Effect of Service and Satisfaction of Pregnant Women on Antenatal Visits to Midwives

The utilization of antenatal services for pregnant women can be determined based on the achievements of K1 (first contact) and K4 (4 times contact) during pregnancy with competent and authorized health workers. The World Health Organization asserts that the attitude and performance of health workers are an essential elements of service quality as it affects the understanding and satisfaction of women, partners, and families in seeking ANC, delivery, and postnatal services. The objective of this research is to examine the effect of antenatal care by midwives and the satisfaction of pregnant women on antenatal visits. The type of this research is analytic observational with a cross-sectional design, performed from March - June in Kupang City. The research subjects were 120 pregnant women with a gestational age of 36 weeks. Data collection employed questionnaires and MCH Handbook. The analysis conducted was univariate and bivariate by employing the Chi-square test with Alpha = 0.05. The results of the study on 120 pregnant women demonstrated that most of the pregnant women received good service (98.3%) and most of whom (60%) were satisfied with the services they experienced. Seventy-one people (59.2%) possessed complete visits. The Chi-square test results revealed relationship between service and satisfaction of pregnant women with antenatal visits (p = 0.652, p = 0.324). The majority of pregnant women had thorough consultations, received adequate antenatal care, and were pleased with the services they received. In addition to satisfaction, health services and programs must be performed in accordance with local culture and language in order to be accepted by the community, encompassing a decision-making culture that can influence pregnant women's visits to health facilities. Distance, education, profession, parity, and the husband's support can all have an impact on the mother's adherence to antenatal visits.

The double burden of maternal overweight and short stature and the likelihood of cesarean deliveries in South Asia: An analysis of national datasets from Bangladesh, India, Maldives, Nepal, and Pakistan

BACKGROUND

The aim was to investigate: (a) whether there is an association between the maternal double burden of overweight and short stature and the risk of cesarean delivery and (b) whether socioeconomic status (SES) acts as a moderator in the association between the maternal double burden of overweight and short stature and the risk of cesarean birth (CB).

MATERIALS AND METHODS

The data for this study were obtained from the nationally representative Demographic and Health Survey databases of five South Asian countries. The analyses were based on responses from married women between 15 and 49 years of age. The risk of CB was the primary outcome, while the maternal double burden of overweight and short stature (coexistence of overweight and short stature) was the exposure of interest.

RESULTS

Maternal double burden of overweight and short stature was significantly associated with 179% higher likelihood of undergoing CB in South Asia (SA), with 304%, 200%, 167%, 155%, and 125% higher likelihood of undergoing CB in Nepal, Pakistan, India, Maldives, and Bangladesh, respectively. Findings also demonstrated that mothers belonging to low SES groups with a double overweight and short stature burden were not uniquely disadvantaged.

CONCLUSIONS

A significant marker in SA of higher risk of CB is the maternal double burden of overweight and short stature. The negative effect of the maternal double burden of overweight and short stature extends across all economic backgrounds in relation to the risk of CB. It is not limited to poor mothers who suffer from the double burden of overweight and short stature.

Human papillomavirus (HPV) vaccination intent and its associated factors: a study of ethnically diverse married women aged 27 to 45 in Malaysia, a Southeast Asian country

INTRODUCTION

This study aimed to investigate HPV vaccination intention among adult married women aged 27 to 45 years and its associated factors, and their spouse/partner's influence on HPV vaccination decision-making.

METHODS

This is a cross-sectional, questionnaire-based study. Study participants were recruited through simple random sampling of patients attending obstetrics and gynecology outpatient clinics in a university teaching hospital. Participants were selected based on a computer-generated list of a random list of patients attending the clinic.

RESULTS

A total of 794 complete responses were received (response rate 88.2%). The mean age of the respondents was 32.2 years with a standard deviation (SD) of ±3.9 years.The vast majority (85.3%) would communicate with their spouse/partner with regard to HPV vaccination decision-making. Nearly 30% (over half were of the Malay ethnic group) perceived their spouse/partner would not consent to their HPV vaccination. Over half (54.9%) reported joint decision-making, and 9.1% (the majority of whom were Malay) reported that HPV vaccination was dependent on their spouse/partner's decision. Intention to vaccinate against HPV was high (74.5%). Factors influencing HPV vaccination intention were spouse/partner's consent to HPV vaccination (odds ratio [OR] = 4.51; 95% confidence interval [CI], 3.08-6.62), being a postgraduate student (OR = 4.55; 95% CI, 2.13-9.72 vs. unemployed/housewife), average household income MYR2000-4000 (OR = 2.09; 95%CI, 1.16-3.78 vs. below MYR2000), and an HPV-related knowledge score of 9-20 (OR = 1.60; 95% CI, 1.10-2.32 vs. score 0-8).

CONCLUSION

Findings highlight the importance of culture-centered interventions to enhance male partner's awareness and support for the HPV vaccination of married women.

Does provision of antenatal care in Southern Asia improve neonatal survival? A systematic review and meta-analysis

BACKGROUND

Southern Asia has one of the highest burdens of neonatal mortality worldwide (26/1000 live births). Ensuring that women receive antenatal care from a skilled provider may play an important role in reducing this burden.

OBJECTIVE

This study aimed to determine whether antenatal care received from a skilled provider could reduce neonatal mortality in Southern Asia by systematically reviewing existing evidence.

STUDY DESIGN

Seven databases were searched (MEDLINE, Embase, Cochrane Library, CINAHL, PubMed, PsycINFO, and International Bibliography of the Social Sciences [IBSS]). The key words included: "neonatal mortality," "antenatal care," and "Southern Asia." Nonrandomized comparative studies conducted in Southern Asia reporting on neonatal mortality in women who received antenatal care compared with those who did not were included. Two authors carried out the screening and data extraction. The Risk of Bias Assessment tool for Non-randomized Studies (RoBANS) was used to assess quality of studies. Results were reported using a random-effects model based on odds ratios with 95% confidence intervals.

RESULTS

Four studies were included in a meta-analysis of adjusted results. The pooled odds ratio was 0.46 (95% confidence interval, 0.24 to 0.86) for neonatal deaths among women having at least 1 antenatal care visit during pregnancy compared with women having none. In the final meta-analysis, 16 studies could not be included because of lack of adjustment for confounders, highlighting the need for further higher-quality studies to evaluate the true impact.

CONCLUSION

This review suggests that in Southern Asia, neonates born to women who received antenatal care have a lower risk of death in the neonatal period compared with neonates born to women who did not receive antenatal care. This should encourage health policy to strengthen antenatal care programs in Southern Asia.

Factors associated with comprehensive knowledge of antenatal care and attitude towards its uptake among women delivered at home in rural Sehala Seyemit district, northern Ethiopia: A community-based cross-sectional study

Background

Despite the current sustainable development goal period (i.e. SDG 3), the prevention of maternal and neonatal mortality is not satisfactory in Ethiopia. Keeping women knowledgeable about antenatal care and maintaining a positive attitude towards its uptake, particularly in the marginalized rural community is crucial. However, evidence regarding the knowledge and attitude of women towards antenatal care uptake is scarce. Therefore, this study aimed to assess factors affecting comprehensive knowledge of antenatal care and attitude towards its uptake among women delivered at home in rural Sehala Seyemit district, northern Ethiopia.

Methods

A community-based cross-sectional study was conducted from September 1^st to October 15^th, 2020. A multi-stage sampling technique was used to select 653 women. The data were collected using a semi-structured interview guide. Data were entered into EPI INFO 7.1.2 and analyzed by SPSS version 25. Both bivariable and multivariable logistic regression analyses were undertaken to identify factors associated with women’s knowledge of antenatal care and attitude towards its uptake. The level of significant association in the multivariable analysis was determined based on a p-value of < 0.05.

Results

Women’s knowledge of antenatal care and positive attitude towards its uptake was 56.5% and 75.2%, respectively. Older age (AOR = 7.2; 95% CI: 3.43, 15.1), media exposure (AOR = 3.69; 95% CI: 2.41, 5.65), history of abortion (AOR = 11.6; 95% CI: 3.3, 14.6), time to reach health facility (AOR = 4.58; 95% CI: 3.05, 6.88), and history of obstetric danger signs (AOR = 7.3; 95% CI: 3.92, 13.64) were factors significantly associated with knowledge of antenatal care. Furthermore, higher decision-making power (AOR = 8.3; 95% CI: 4.8, 13.83), adequate knowledge of antenatal care (AOR = 2.2; 95% CI: 1.26, 3.71), delivery attended by health extension workers (AOR = 2.3; 95% CI: 1.1, 5.1), and media exposure (AOR = 2.27; 95% CI: 1.30, 3.97) were predictors of a favorable attitude towards antenatal care utilization.

Conclusion

Although the majority of women in the present study had a favorable attitude towards antenatal care uptake, their knowledge level was inadequate. Strengthening access to transportation, mass media, involvement in household decision-making, and encouraging women to deliver at a health facility by a skilled provider may increase women’s knowledge and attitude towards antenatal care uptake, thereby improving maternal healthcare service uptake.

Rural-urban differentials in the influences of individual and geospatial preparedness on institutional childbirth: a cross-sectional study in Bangladesh

OBJECTIVE

This study aims to explore the rural-urban differentials in the influences of individual and geospatial preparedness on institutional childbirth in Bangladesh. A related aim of this paper is to derive estimates to measure geospatial preparedness for institutional births, through statistical modelling, when no data are available for measuring this areal indicator.

DESIGN, SETTINGS AND PARTICIPANTS

The paper used data from a large-scale nationally representative Bangladesh Multiple Indicator Cluster Survey 2019. The analytical sample included 9203 currently married women of reproductive age who had a live birth in the 2 years preceding the survey.

METHODS

Mixed effect logistic regression models were employed to explore the rural-urban differentials in influences of individual and geospatial preparedness on institutional childbirth. The district-level random effect estimation was done to measure geospatial preparedness. The conditional autoregressive model was used to examine the association of geospatial preparedness with areal variation in institutional births.

RESULTS

In rural settings, women who gave birth to a female newborn were 18% less likely to have facility births compared with women who gave birth to a male newborn. Also, women from households in the highest wealth quintile were twice as likely to have facility births compared with those from households in the poorest wealth quintile. In contrast, in urban areas, facility births did not vary by sex of the fetus or by households' socioeconomic status. The geospatial preparedness explained 8% and 9% of the variability in institutional births in rural and urban areas, respectively. Geospatial mapping revealed low preparedness in the hill tracts. Findings identified geospatial preparedness as a potential source of areal variation in facility births.

CONCLUSION

Findings suggest improving district-level preparedness and developing differential programme strategies for urban and rural areas to increase the national prevalence and more equitable use of institutional childbirth in Bangladesh.

Enhanced women's decision-making power after the Suchana intervention in north-eastern Bangladesh: a cluster randomised pre-post study

OBJECTIVES

Women's decision-making power is a dimension of empowerment and is crucial for better physical and psychosocial outcomes of mothers. Suchana, a large-scale development programme in Bangladesh, actively provided social interventions on behaviour change communication to empower women belonging to the poorest social segment. This paper aims to assess the impact of the Suchana intervention on various indicators related to women's decision-making power.

DESIGN, SETTING AND PARTICIPANTS

The evaluation design was a cluster randomised pre-post design with two cross-sectional surveys conducted among beneficiary women with at least one child aged <23 months from randomly selected poor or very poor beneficiary households in Sylhet division.

OUTCOME MEASURE

Decision-making indicators included food purchases, major household purchases, food preparation, children's healthcare as well as women's own healthcare and visiting family and relatives.

RESULTS

Our findings suggest that 45% of women were able to make decisions on food purchases, 25% on major household purchases, 78% on food preparation, 59% on children's healthcare, 51% on their own healthcare and 43% on visiting family and relatives at baseline in the intervention group, whereas the results were almost the same in the control group. In contrast, at the endline survey, the respective proportions were 75%, 56%, 87%, 80%, 77% and 67% in the intervention group, which were significantly improved when compared with the control group. The prevalence of those outcome indicators were 64%, 41%, 80%, 71%, 68% and 56%, respectively, in the control group. As per multiple logistic regression analysis and structural equation modelling, the Suchana intervention had a substantial influence on the latent variable of women's decision-making power.

CONCLUSION

In terms of food purchases, major household purchases, children's healthcare, their own healthcare and visiting family and relatives, the Suchana intervention favourably influenced the decision-making power of rural women living in a vulnerable region of Bangladesh.

TRIAL REGISTRATION NUMBER

RIDIE-STUDY-ID-5d5678361809b.

Qualitative factors influencing breast and cervical cancer screening in women: A scoping review

Breast and cervical are top cancers for women globally, but few studies have summarised how gender norms influence screening uptake, given sexual connotations and physical exposure. These beliefs may play a central role in decision-making, and understanding them is crucial to improving screening rates and services. This review scopes international literature for gender-based qualitative factors influencing women’s screening uptake. A systematic search of peer-reviewed English articles in PubMed, Scopus, and CINAHL was conducted from inception until December 2019. Articles were included if they were about breast or cervical cancer screening, had mixed or qualitative methodology, and sampled women from the general population. 72 studies spanning 34 countries were analysed. Eight studies also included healthcare providers’ views. Our narrative thematic analysis summarised primary themes extracted from each study into first-level subthemes, then synthesising second-level and third-level themes: (I) gender socialisation of women, (II) gender inequality in society, and (III) lack of empowerment to women in making screening decisions. Women tended to face sociocultural/role-based constraints, were expected to prioritise family, and keep bodily exposure to their husbands. Women showed low awareness and had fewer opportunities for health education compared to men. Male relations were often gatekeepers to financial resources needed to pay for screening tests. Screening risked community norms about women’s or husbands’ perceived embarrassing sexual behaviours. These findings suggest that interventions targeting unhelpful stigmatising beliefs about women’s cancer screening must concurrently address community general norms, familial role-based beliefs, as well as at male relations who hold the purse-strings.

Sociodemographic correlates of cervix, breast and oral cancer screening among Indian women

INTRODUCTION

Cervix, breast and oral cancers account for about one-third of all cancers in India which as a group is a major contributor to all non-communicable disease-related morbidity and mortality among women. Existing evidence suggests that early diagnosis plays a pivotal role in the prevention and intervention of these cancers, and many community-based early screening and awareness programs have been in place in developed countries. Currently, there is not enough research evidence regarding the sociodemographic correlates of cervix, breast and oral cancer screening among Indian women. In the present study, we aimed to assess the self-reported percentage and sociodemographic factors associated with the use of these three types of cancer screening services among Indian women aged 15-49 years.

METHODS

Data were collected from National Family Health Survey conducted during 2015-16. Sample population was 699,686 women aged 15-49 years. Associations between self-reported cervical, breast and oral cancer screening status and the associated sociodemographic factors were analyzed using multivariable logistic regression methods.

RESULTS

The percentage of screening for cervical (21%), breast (8.95%), and oral cancers (13.45%) varied significantly across the population sub-groups. Higher age, urban residence, higher education, having employment, health insurance, use of electronic media, higher household wealth quintile, having healthcare autonomy, showed a positive effect on taking screening services. Further analyses revealed that the strength of the associations varied considerably between urban and rural residents, denoting the need for region-specific intervention strategies. Sex of household head, age, watching TV, using radio, and having health insurance were the most significant contributors to the outcome effects.

CONCLUSIONS

The present study provides important insights regarding the current scenario of seeking cancer screening services among women in India. These findings could inform policy analysis and make an avenue for further in-depth analysis for future studies. Our findings conclude that cancer prevention policies should focus on leveraging the positive effects of better socioeconomic status, employment, health insurance ownership, exposure to electronic media, and better healthcare autonomy to improve the cancer screening service uptake among Indian women.

Prevalence of Contraceptive Non-use Due to Husbands/Partners Influence Among Married Women in Ethiopia: A Multilevel Analysis Using Demographic and Health Survey 2016 Data

Background

In Ethiopia women with their husbands/partners are the decision-makers for contraceptives non-use suffered either due to the consequence of unintended pregnancy or due to the indirect impact of the secret use of contraceptives from their husbands/partners. Despite this challenge, there is a dearth of evidence about the magnitude of husbands/partners' decision-makers on contraceptives n non-used in Ethiopia.

Objective

This study was aimed to assess the magnitude of husbands'/partners decisions on contraceptive non-use and associated factors among married and non-contraceptive user reproductive-age women in Ethiopia.

Methods

The study was conducted based on Ethiopian demographic and health survey 2016 data which was a cross-sectional survey from 18 January 2016 to 27 June 2016. A total weighted sample size of 5,458 married and non-contraceptive user reproductive-age women were taken. A multilevel logistic regression model was used because of the data nature hierarchical, and variables with p ≤ 2 in the bivariable multilevel analysis were taken to multivariable multilevel analysis. Adjusted odds ratio with 95% CI was used to declare both the direction and strength of association and variables with p < 0.05 were considered statistically significant with the outcome variable.

Results

Husband decision-making power on contraceptive non-use was 10.44% [9.65–11.28%]. Husband's educational level higher (adjusted odds ratio (AOR = 2.6; CI 1.4–4.7), being Muslim, protestant, and others in religion (AOR = 2.4; CI 1.7–3.5), (AOR = 2.1; CI 1.4–3.1), (AOR = 4.5; CI 2.3–8.5), respectively, media exposure (AOR = 1.4; CI 1.0–1.8), husband wants more children (AOR = 3.7; CI 2.8–4.8), husband desire did not know (AOR = 1.4; CI 1.1–1.9), information about family planning (AOR = 0.6; CI 0.4–0.8), visited by field worker (AOR = 0.7; CI 0.5–0.9), visited health facility (AOR = 0.6; CI 0.4–0.7), and community husband education high (AOR = 1.6; CI 1.1–2.4) were statistically significant with husband decision making power on contraceptive non-use.

Conclusion

In Ethiopia 1 out of 10 married and non-pregnant women is influenced by their husband/partner's decision-making power of non-use contraceptives. Husband's educational level high, religion (Muslim, protestant, and others), media exposure, husband's desire for children (husband wants more and does not know), and community husband education were variables positively associated with the outcome variable; whereas having information about family planning, visited by field worker, and visited health facility were negatively associated husband decision making power for non-use contraceptive in Ethiopia.

Desire for Birth Companionship Among Pregnant Women Attending Antenatal Care in Debremarkos City, Northwest Ethiopia: Magnitude and Associated Factors

Background

Birth companionship is one of the components of the respectful maternity continuum of care recommended by the World Health Organization (WHO). Women's desire for birth companionship needs to be given attention during the antenatal care period to make them ready during labor and delivery. There is a dearth of study about the status of women's desire for birth companionship and associated factors.

Objective

This study aimed to assess the prevalence of desire for birth companionship and associated factors among pregnant women in Debremarkos city, northwest Ethiopia.

Methods

Institution-based cross-sectional study was conducted from February 1, 2021 to March 30, 2021 in Debremarkos city, northwest Ethiopia. A total of 423 participants were accessed by systematic random sampling. A face-to-face interviewer-administered questionnaire was employed. The data were entered into Epi data version 4.6 and transformed to SPSS version 25. Binary logistic regression analysis was done, and variables with a p-value ≤ 0.2 on bivariable analysis were taken for multivariable analysis. Adjusted odds ratio with a 95% confidence interval was used to detect the association, and a p-value of <0.05 in the multivariable analysis was used to declare statistical significance.

Results

The prevalence of desire for birth companionship was 57.45% (52.6–62.2%). Women who were the primary decision-maker for maternal health care services [adjusted odds ratio (AOR) =3.0; 95% CI 1.7–5.6], women with planned pregnancy (AOR = 2.0; 95% CI 1.0–3.9), women who have no bad obstetric history (AOR = 2.3; 95% CI 1.2–4.4), and women whose 1st antenatal care visit starts within the second trimester (AOR = 2.6; 1.6–4.4) were statistically significant with desire on birth companionship.

Conclusions

Desire of pregnant women for birth companionship was high in this study. Improving women's decision-making power, emphasis on the type of pregnancy, obstetrical history, and early initiation of antenatal care visit were the suggested areas to increase the desire of women for birth companionship.

Influence of women's decision-making autonomy on antenatal care utilisation and institutional delivery services in Nigeria: evidence from the Nigeria Demographic and Health Survey 2018

BACKGROUND

In the context of global health priority, understanding the role of power dynamics among women as an important intervention required towards achieving optimum maternal and child health outcomes is crucial. This study examined the influence of women's decision-making autonomy on antenatal care utilisation and institutional delivery services in Nigeria.

METHODS

The data for the study were derived from the 2018 Nigeria Demographic and Health Survey and comprised a weighted sample of 20,100 births in the last five years that preceded the survey among married/cohabiting childbearing women. Descriptive and analytical analyses were carried out, including frequency tables and multivariate using the binary logistic regression model.

RESULTS

The study revealed that despite a large number of women initiating antenatal care visits before 12 weeks of pregnancy (75.9%), far fewer numbers had at least eight antenatal care visits (24.2%) and delivered in a health facility (58.2%). It was established that the likelihood of having at least eight antenatal care visits was significantly increased among women who enjoyed decision-making autonomy on their healthcare (aOR: 1.24, CI: 1.02-1.51) and how their earnings are spent (aOR: 2.02, CI: 1.64-2.48). Surprisingly, women's decision-making autonomy on how their earnings are spent significantly reduced the odds of initiating antenatal care visits early (aOR: 0.75, CI: 0.63-0.89). Some socio-economic and demographic factors were observed to have a positive influence on quality antenatal care utilisation and delivery in a health facility.

CONCLUSION

In conclusion, women's decision-making autonomy on their healthcare and how their earnings are spent was significantly found to be protective factors to having eight antenatal care visits during pregnancy. Conversely, women's autonomy on how their earnings are spent significantly hindered their initiation of early antenatal care visits. There is a need for more pragmatic efforts through enlightenment and empowerment programmes of women to achieve universal access to quality maternal healthcare services in Nigeria.

Determinants of antenatal care use in nine sub-Saharan African countries: a statistical analysis of cross-sectional data from Demographic and Health Surveys

OBJECTIVE

To explore the factors associated with antenatal care (ANC) visits.

DESIGN

A secondary data analysis from cross-sectional studies was conducted.

SETTING

Sub-Saharan Africa.

PARTICIPANTS

56 002 women aged 15-49 years in Ghana (3224), Kenya (10 981), Malawi (9541), Namibia (2286), Rwanda (4416), Senegal (6552), Tanzania (5536), Uganda (7979) and Zambia (5487) were analysed.

OUTCOMES

4⁺ANC visits.

RESULTS

Overall, 55.52% (95% CI: 55.11% to 55.93%) of women made 4⁺ANC visits. The highest 4⁺ANC visits were in Ghana (85.6%) and Namibia (78.9%), and the lowest were in Senegal (45.3%) and Rwanda (44.5%). Young women 15-19 years had the lowest uptake of 4⁺ANC visits. Multivariable analysis indicated that the odds of 4⁺ANC visits were 14% lower among women from rural areas compared with those living in towns (adjusted OR (AOR) 0.86; 95% CI: 0.81 to 0.91). This difference was significant in Kenya, Malawi, Senegal and Zambia. However, in Zambia, the odds of 4⁺ANC visits were 48% higher (AOR 1.48; 95% CI: 1.2 to 1.82) among women from rural compared with urban areas. Women with higher educational level had more than twofold higher odds of 4⁺ANC visits in seven of the nine countries, and was significant in Kenya, Malawi, Rwanda and Zambia. Compared with the poorest household wealth category, odds of 4⁺ANC visits increased by 12%, 18%, 32% and 41% for every 20% variation on the wealth quantile. Women in their first-time pregnancy had higher odds of 4⁺ANC visits compared with others across all countries, and women who had access to media at least once a week had a 22% higher probability of 4⁺ANC visits than women who had no access to media (AOR 1.22, 95% CI: 1.15 to 1.29).

CONCLUSION

The number of ANC visits was considered to be inadequate with substantial variation among the studied countries. Comprehensive interventions on scaling uptake of ANC are needed among the low-performing countries. Particular attention should be given to women of low economic status and from rural areas.

Women decision-making autonomy on maternal health service and associated factors in low- and middle-income countries: Systematic review and meta-analysis

OBJECTIVE

This study was done to determine the overall estimate of decision-making autonomy on maternal health services and associated factors in low- and middle-income countries.

METHOD

PubMed, Science Direct, Google Scholar, Scopus, and the Ethiopian University online library were searched. Data were extracted using Microsoft Excel and analyzed using STATA statistical software (version 14). Publication bias was checked by forest plot, Begg's rank test, and Egger's regression test. To look for heterogeneity, I² was computed, and an overall estimated analysis was carried out. Subgroup analysis was done by country, year, and publication. Joanna Briggs Institute quality assessment tool was used to check the quality of each study. We carried out a leave-one-out sensitivity analysis.

RESULTS

Out of 1305 articles retrieved, 19 studies (with 104,871 study participants) met eligibility criteria and were included in this study. The pooled prevalence of women's decision-making autonomy on maternal health services in low- and middle-income countries was 55.15% (95% confidence interval: 44.11-66.19; I² = 98.6%, P < 0.001). Based on subgroup analysis, decision-making autonomy in maternal health services was the highest in Ethiopia at 61.36% (95% confidence interval: 50.58-72.15) and the lowest in Nigeria at 36.16% (95% confidence interval: 12.99-43.39). It was 32.16% (95% confidence interval: 32.72-39.60) and 60.18% (95% confidence interval: 47.92-72.44) before and after 2016, respectively. It was also 54.64% (95% confidence interval: 42.51-66.78) in published studies and 57.91% (95% confidence interval: 54.80-61.02) in unpublished studies. Age (adjusted odds ratio = 2.67; 95% confidence interval: (1.29-5.55), I² = 90.1%), primary level of education (adjusted odds ratio = 1.75; 95% confidence interval: (1.39-2.21), I² = 63.8%), secondary education level (adjusted odds ratio = 2.09; 95% confidence interval: (1.32-3.32), I² = 87.8%), being urban resident (adjusted odds ratio = 1.80; 95% confidence interval: (1.22-2.66), I² = 73%), and monthly income (adjusted odds ratio = 3.23; 95% confidence interval: (1.85-5.65), I² = 97%) were positively associated with decision-making autonomy on maternal health service.

CONCLUSION

Decision-making autonomy on maternal health services in low- and middle-income countries was low. Sociodemographic factors also influenced it. Educational accessibility and income generation should have been recommended, enabling women to decide for themselves.

Exploring Factors Associated with Women's Willingness to Provide Digital Fingerprints in Accessing Healthcare Services: A Cross-Sectional Study in Urban Slums of Bangladesh

Digital fingerprints are increasingly used for patient care and treatment delivery, health system monitoring and evaluation, and maintaining data integrity during health research. Yet, no evidence exists about the use of fingerprinting technologies in maternal healthcare services in urban slum contexts, globally. The present study aimed to explore the recently delivered women's willingness to give digital fingerprints to community health workers to access healthcare services in the urban slums of Bangladesh and identify the associated factors. Employing a two-stage cluster random sampling procedure, we chose 458 recently delivered women from eight randomly selected urban slums of Dhaka city, Bangladesh. Chi-square tests were performed for descriptive analyses, and binary logistic regression analyses were performed to explore the factors associated with willingness to provide fingerprints. Overall, 78% of the participants reported that they were willing to provide digital fingerprints if that eased access to healthcare services. After adjusting for potential confounders, the sex of the household head, family type, and household wealth status were significantly associated with the willingness to provide fingerprints to access healthcare services. The study highlighted the potentials of using fingerprints for making healthcare services accessible. Focus is needed for female-headed households, women from poor families, and engaging husbands and in-laws in mobile health programs.

Pregnant women's decision-making capacity and adherence to iron supplementation in sub-Saharan Africa: a multi-country analysis of 25 countries

BACKGROUND

Anaemia and related complications during pregnancy is a global problem but more prevalent in sub-Sahara Africa (SSA). Women's decision-making power has significantly been linked with maternal health service utilization but there is inadequate evidence about adherence to iron supplementation. This study therefore assessed the association between household decision-making power and iron supplementation adherence among pregnant married women in 25 sub-Saharan African countries.

METHODS

We used data from the Demographic and Health Surveys (DHS) of 25 sub-Saharan African countries conducted between 2010 and 2019. Women's decision-making power was measured by three parameters; own health care, making large household purchases and visits to her family or relatives. The association between women's decision-making power and iron supplementation adherence was assessed using logistic regressions, adjusting for confounders. The results were presented as adjusted odds ratio (AOR) with 95% confidence intervals (CIs).

RESULTS

Approximately 65.4% of pregnant married women had made decisions either alone or with husband in all three decisions making parameters (i.e., own health care, making large household purchases, visits to her family or relatives). The rate of adherence to iron medication during pregnancy was 51.7% (95% CI; 48.5-54.9%). Adherence to iron supplementation was found to be higher among pregnant married women who had decision-making power (AOR = 1.46, 95% CI; 1.16-1.83), secondary education (AOR = 1.45, 95% CI; 1.05-2.00) and antenatal care visit (AOR = 2.77, 95% CI; 2.19-3.51). Wealth quintiles and religion were significantly associated with adherence to iron supplementation.

CONCLUSIONS

Adherence to iron supplementation is high among pregnant women in SSA. Decision making power, educational status and antenatal care visit were found to be significantly associated with adherence to these supplements. These findings highlight that there is a need to design interventions that enhance women's decision-making capacities, and empowering them through education to improve the coverage of antenatal iron supplementation.

Effects of spousal migration on access to healthcare for women left behind: A cross-sectional follow-up study

BACKGROUND

Women left behind by migration represent a unique and growing population yet remain understudied as key players in the context of migration and development. Using a unique longitudinal survey of life in Bangladesh, the Matlab Health and Socioeconomic Surveys, we examined the role of spousal migration in healthcare utilization for women. The objective of this study was to assess realized access to care (do women actually get healthcare when it is needed) and consider specific macrostructural, predisposing, and resource barriers to care that are related to migration.

METHODS AND FINDINGS

In a sample of 3,187 currently married women, we estimated multivariate logistic and multinomial regression models controlling for a wide range of baseline sociodemographic factors measured as far back as 1982. Our analyses also controlled for selection effects and explored two mechanisms through which spousal migration can affect healthcare utilization for women, remittances and frequent contact with spouses. We found that women with migrant spouses were approximately half as likely to lack needed healthcare compared to women whose spouses remained in Bangladesh (predicted probability of not getting needed healthcare 11.7% vs. 21.8%, p<0.001). The improvements in access (logistic regression coefficient for lacking care for left-behind women -0.761 p<0.01) primarily occurred through a reduction in financial barriers to care for women whose spouses were abroad.

CONCLUSIONS

Wives of international migrants showed significantly better access to healthcare even when accounting for selection into a migrant family. While the overall story is one of positive migration effects on healthcare access due to reductions in financial barriers to care, results also showed an increase in family-related barriers such as not being permitted to get care by a family member or travel alone to a facility, indicating that some of the benefits of migration for women left behind may be diluted by gendered family structures.

Married women's decision-making autonomy in the household and maternal and neonatal healthcare utilization and associated factors in Debretabor, northwest Ethiopia

Background

Women’s decision-making autonomy is very crucial for the improvement of women empowerment, and maternal, neonatal, and child healthcare utilization. As time immemorial, Ethiopian culture is largely gender stratified, and the position of women is subordinate to men in various household and health-seeking decision-making matters. However, there is a dearth of empirical evidence on women’s decision-making autonomy, especially in the household and on maternal and newborn healthcare utilization. Therefore, this study assessed married women’s decision-making autonomy in the household and on maternal and neonatal healthcare utilization and associated factors in Debretabor, Northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted from October 1^st to 30^th, 2019. A two-stage sampling technique was used to select 730 married women. Data were collected using a structured, pretested, and interviewer-administered questionnaire. Data were entered into EPI INFO 7 and analyzed by SPSS version 23. Multivariable logistic regression model was fitted to identify factors associated with women’s decision-making autonomy in the household and maternal and neonatal healthcare utilization. The adjusted odds ratio with its 95% confidence interval was computed to determine the level of significance at a p-value of ≤ 0.05.

Results

A total of 730 married women were included in the analysis. Thus, three-fourths (75.1%) of women had higher decision-making autonomy on their health, neonatal health, and other socio-economic aspects. Besides, the proportion of four and above antenatal visits, delivery at a health facility, postnatal checkup, knowledge of neonatal danger signs, and appropriate health-seeking practices for sick newborns among autonomous women were 52.1%, 56.1%, 71.4%, 32%, and 80% respectively. Age greater than 35 years old (AOR = 2.08; 95% CI: 1.19, 3.62), monthly income of > 5000 ETB (AOR = 3.1; 95% CI: 1.36, 7.07), husband involvement (AOR = 2.36; 95% CI: 1.55, 3.43), and adequate knowledge of neonatal danger signs (AOR = 2.11; 95% CI: 1.4, 3.2) were factors independently associated with women’s decision-making autonomy on maternal and neonatal healthcare utilization and other socio-economic affairs.

Conclusion

Our findings show that women’s decision-making autonomy in the household and maternal and neonatal healthcare utilization was optimal. Increasing household income level, promotion of husband’s involvement starting from the prenatal period, and increasing women’s knowledge of maternal and neonatal danger signs will have a great role in the improvement of women’s decision-making autonomy.

Relationship between maternal healthcare utilisation and empowerment among women in Bangladesh: evidence from a nationally representative cross-sectional study

OBJECTIVE

To examine the relationship between women's empowerment and maternal healthcare utilisation in Bangladesh.

DESIGN

This cross-sectional study uses data from the most recent nationally representative Bangladesh Demographic and Health Survey, 2017-2018.

SETTING

Bangladesh.

PARTICIPANTS

Married women aged 15-49 years who had a live birth within the 3 years preceding the survey (n=4767).

PRIMARY AND SECONDARY OUTCOME MEASURES

Women's empowerment was measured using the recently developed and validated survey-based Women's emPowERment (SWPER) index. The index includes three domains: social independence, decision-making and attitude to violence. Outcomes included utilisation of at least one antenatal care from skilled providers (ANC1), at least four antenatal care visits (≥4 ANC), delivery assisted by a skilled birth attendant (SBA) and a postnatal visit within 2 days of delivery (PNC). Logistic regression analyses were used to assess the identified relationships.

RESULTS

Among participants, 83% received ANC1, 46.3% received ≥4 ANC, 51.9% reported SBA and 50.9% sought PNC. Women with high levels of social empowerment relative to those with low levels were more likely to use ANC1 (adjusted OR (AOR) 1.85; 95% CI 1.40 to 2.45), ≥4 ANC (AOR 1.55; 95% CI 1.27 to 1.90), SBA (AOR 2.12; 95% CI 1.71 to 2.62) and PNC (AOR 1.95; 95% CI 1.56 to 2.44). Compared with women with low levels of decision-making empowerment, women with high levels were more likely to use SBA (AOR 1.49; 95% CI 1.21 to 1.83) and PNC (AOR 1.47; 95% CI 1.19 to 1.81). Additionally, significant inequality was observed among women moving from low to high empowerment in all domains of the empowerment index.

CONCLUSIONS

Higher empowerment levels were positively associated with maternal healthcare utilisation in Bangladesh. Our findings suggest the need to address women's empowerment in policies aiming to expand health service utilisation.

What factors are associated with pre-pregnancy nutritional status? Baseline analysis of the KITE cohort: a prospective study in northern Ethiopia

OBJECTIVE

To assess a broad range of factors associated with pre-pregnancy nutritional status, a key step towards improving maternal and child health outcomes, in Ethiopia.

DESIGN

A baseline data analysis of a population-based prospective study.

SETTING

Kilite-Awlaelo Health and Demographic Surveillance Site, eastern zone of Tigray regional state, northern Ethiopia.

PARTICIPANTS

We used weight measurements of all 17 500 women of reproductive age living in the surveillance site between August 2017 and October 2017 as a baseline. Subsequently, 991 women who became pregnant were included consecutively at an average of 14.8 weeks (SD: 1.9 weeks) of gestation between February 2018 and September 2018. Eligible women were married, aged 18 years or older, with a pre-pregnancy weight measurement performed, and a gestational age ≤20 weeks at inclusion.

OUTCOME MEASURES

The outcome measure was pre-pregnancy nutritional status assessed by body mass index (BMI) and mid-upper arm circumference (MUAC). Undernutrition was defined as BMI of <18.5 kg/m2 and/or MUAC of <21.0 cm. BMI was calculated using weight measured before pregnancy, and MUAC was measured at inclusion. Linear and spline regressions were used to identify factors associated with pre-pregnancy nutritional status as a continuous and Poisson regression with pre-pregnancy undernutrition as a dichotomous variable.

RESULTS

The mean pre-pregnancy BMI and MUAC were 19.7 kg/m2 (SD: 2.0 kg/m2) and 22.6 cm (SD: 1.9 cm), respectively. Overall, the prevalence of pre-pregnancy undernutrition was 36.2% based on BMI and/or MUAC. Lower age, not being from a model household, lower values of women empowerment score, food insecurity, lower dietary diversity, regular fasting and low agrobiodiversity showed significant associations with lower BMI and/or MUAC.

CONCLUSION

The prevalence of pre-pregnancy undernutrition in our study population was very high. The pre-pregnancy nutritional status could be improved by advancing community awareness on dietary practice and gender equality, empowering females, raising agricultural productivity and strengthening health extension. Such changes require the coordinated efforts of concerned governmental bodies and religious leaders in the Ethiopian setting.

Women's empowerment and practice of maternal healthcare facilities in Bangladesh: a trend analysis

Purpose

This study aims to explore whether there is an association between women's empowerment and the utilization of maternal healthcare facilities.

Design/methodology/approach

This study considered four indices for measuring women's empowerment – labor force participation index (LFPI), decision-making power index (DMPI), attitude toward partner’s violence index (ATPVI) and knowledge level index (KLI) – and three healthcare facilities – number of antenatal visits, delivery with healthcare facilities and postnatal checkup after delivery. Data extracted for this study were from the Bangladesh Demographic and Health Survey 2011 and 2014. A chi-square test was used for bivariate analysis, and a three-level logistic regression model was applied for multivariate analysis.

Findings

An increment was observed in the practice of all considered healthcare facilities, and the percentage of highly empowered women in DMPI decreased from 2011 to 2014. This study found that higher empowerment of women in DMPI, KLI and ATPVI significantly (p-value < 0.05) increases the utilization of healthcare facilities. High empowerment of mothers in LFPI was found negatively associated with facility delivery and positively associated with the postnatal checkup.

Originality/value

Women's empowerment was found significantly associated with the utilization of maternal healthcare facilities. This study is seeking the attention of corresponding authority to come up with a more effective intervention program to empower women to utilize maternal healthcare facilities.

Women's empowerment and fertility decision-making in 53 low and middle resource countries: a pooled analysis of demographic and health surveys

OBJECTIVE

Women's empowerment and its association with fertility preference are vital for central-level promotional health policy strategies. This study examines the association between women's empowerment and fertility decision-making in low and middle resource countries (LMRCs).

DESIGN

This cross-sectional study uses the Demographic and Health Survey database.

SETTINGS

53 LMRCs from six different regions for the period ranging from 2006 to 2018.

PARTICIPANTS

The data of women-only aged 35 years and above is used as a unit of analysis. The final sample consists of 91 070 married women.

METHODS

We considered two outcome variables: women's perceived ideal number of children and their ability to achieve preferred fertility desire and the association with women empowerment. Women empowerment was measured by their participation in household decision-making and attitude towards wife-beating. The negative binomial regression model was used to assess women's perceived ideal number of children, and multivariable logistic regression was used to evaluate women's ability to achieve their preferred fertility desire.

RESULTS

Our study found that empowered women have a relatively low ideal number of children irrespective of the measures used to assess women empowerment. In this study, the measures were participation in household decision-making (incidence rate ratio (IRR): 0.92, 95% CI: 0.91 to 0.93) and attitude towards wife-beating (IRR: 0.96, 95% CI: 0.95 to 0.97). In the LMRCs, household decision-making and negative attitude towards wife-beating have been found associated with 1.12 and 1.08 times greater odds of having more than their ideal number of children.

CONCLUSION

Our findings suggest that women's perceived fertility desire can be achieved by enhancing their empowerment. Therefore, a modified community-based family planning programme at the national level is required, highlighting the importance of women's empowerment on reproductive healthcare as a part of the mission to assist women and couples to have only the number of children they desire.

Association Between Mass Media Use and Maternal Healthcare Service Utilisation in Malawi

Introduction

Using data from Malawi Demographic and Health Survey (2015–16), in the present study, we aimed to assess the role of exposure to family planning information through various mass media on the utilization of maternal healthcare services.

Methods

The sample population included 13,217 women aged 15–49 years with a history of at least one childbirth. Outcome measures included essential maternal healthcare services such as early and adequate use of antenatal care, skilled delivery service. Multivariate logistic regression models were used to find the association between maternal healthcare services and exposure to family planning messages by controlling for sociodemographic characteristics.

Results

Women who reported receiving family planning message through internet [odds ratio=1.48, 95% CI=1.15, 1.91], radio [odds ratio=1.15, 95% CI=1.05, 1.26], TV [odds ratio=1.53, 95% CI=1.32, 1.76] and mobile phone [odds ratio=1.23, 95% CI=1.02, 1.48] had higher odds of having timely ANC care. For using adequate number of ANC, the associations were significant for TV [odds ratio=1.41, 1.23, 1.62] and mobile phone [odds ratio=1.20, 95% CI=1.01, 1.43] only. For the use of facility delivery, a strong association was observed for poster [odds ratio=1.43, 95% CI=1.12, 1.82] and TV [odds ratio=2.99, 95% CI=1.78, 5.03]. The odds of using all three services varied noticeably between urban and rural areas, eg, receiving family planning messages through internet increased the odds of antenatal care and facility delivery services in the urban areas only, whereas that from poster was associated only for facility delivery and only in the rural areas.

Conclusion

The findings indicate a positive association on media communication regarding family planning on the uptake of maternal healthcare services.

Maternal healthcare utilsation and complete childhood vaccination in sub-Saharan Africa: a cross-sectional study of 29 nationally representative surveys

OBJECTIVE

The objective of the study was to examine the association between maternal healthcare utilisation and complete childhood vaccination in sub-Saharan Africa.

DESIGN

Our study was a cross-sectional study that used pooled data from 29 countries in sub-Saharan Africa.

PARTICIPANTS

A total of 60 964 mothers of children aged 11-23 months were included in the study.

OUTCOME VARIABLES

The main outcome variable was complete childhood vaccination. The explanatory variables were number of antenatal care (ANC) visits, assistance during delivery and postnatal care (PNC).

RESULTS

The average prevalence of complete childhood vaccination was 85.6%, ranging from 67.0% in Ethiopia to 98.5% in Namibia. Our adjusted model, children whose mothers had a maximum of three ANC visits were 56% less likely to have complete vaccination, compared with those who had at least four ANC visits (adjusted OR (aOR)=0.44, 95% CI 0.42 to 0.46). Children whose mothers were assisted by traditional birth attendant/other (aOR=0.43, 95% CI 0.41 to 0.56) had lower odds of complete vaccination. The odds of complete vaccination were lower among children whose mothers did not attend PNC clinics (aOR=0.26, 95% CI 0.24 to 0.29) as against those whose mothers attended.

CONCLUSION

The study found significant variations in complete childhood vaccination across countries in sub-Saharan Africa. Maternal healthcare utilisation (ANC visits, skilled birth delivery, PNC attendance) had significant association with complete childhood vaccination. These findings suggest that programmes, interventions and strategies aimed at improving vaccination should incorporate interventions that can enhance maternal healthcare utilisation. Such interventions can include education and sensitisation, reducing cost of maternal healthcare and encouraging male involvement in maternal healthcare service utilisation.

Exploring antenatal care utilization and intimate partner violence in Benin - are lives at stake?

Background

The republic of Benin ranks in the bottom third of countries recently assessed for ANC coverage and its Ministry of Family and National Solidarity (2009) reported close to 70% of Beninese women suffered abuse at least once in their lifetime. Utilization of antenatal care (ANC) services is key to positive health outcomes for both mother and infant. This study examined the impact of intimate partner violence (IPV) on the utilization of ANC services in Benin using both the basic 4 visit model (ANC-4) and the updated WHO recommended 8-visit model (ANC-8).

Methods

Data used for this study were collected from the nationally representative 2017–2018 Benin Demographic Health Survey (BDHS) on ever-partnered women aged 15–49 who had completed both reproductive maternal health and domestic violence modules of the survey. Descriptive statistics and multivariate logistic regression analysis were performed to determine significant factors associated with ANC utilization in Benin.

Results

Over 40% of the women (n = 3084) reported experience of IPV in their lifetime. Findings revealed that women who ever experienced IPV (OR 0.753, 95% CI: 0.628–0.901; p = 0.002) had 25% less odds of accessing the basic four ANC visits. IPV was not found to be a factor in accessing at least eight ANC visits. With increasing number of children, there was less likelihood of accessing at least four and at least eight visits. Being in the richest quintile (OR 5.490, 95% CI 3.907–7.714; p < 0.000 for ANC-4; OR, 5.781, 95% CI: 3.208–10.41; p < 0.000), making decisions on household and health care (OR 1.279, 95% CI: 1.042–1.569 for ANC-4; OR, 1.724; 95% CI: 1.170–2.540; p = 0.006 for ANC-8), and getting paid cash for work increased the chances of utilizing ANC-four (OR 1.451, 95% CI: 1.122–1.876; 0.005) but not for ANC-eight. Belonging to the Muslim faith decreased the odds of ANC utilization compared to all other religions.

Conclusion

This work revealed key areas for maternal health policy makers and service providers in Benin to appropriately plan effective policies (i.e., alleviate poverty; equitable health services access; cultural sensitivity) and necessary interventions (i.e. ANC education, IPV prevention, paid employment, alcohol cessation) to increase utilization of ANC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10884-9.