Do women's empowerment and socioeconomic status predict the adequacy of antenatal care? A cross-sectional study in five South Asian countries

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.

Prevalence of intimate partner violence among Indian women and their determinants: a cross-sectional study from national family health survey - 5

INTRODUCTION

Intimate partner violence (IPV) can be described as a violation of human rights that results from gender inequality. It has arisen as a contemporary issue in societies from both developing and industrialized countries and an impediment to long-term development. This study evaluates the prevalence of IPV and its variants among the empowerment status of women and identify the associated sociodemographic parameters, linked to IPV.

METHODS

This study is based on data from the National Family Health Survey (NFHS) of India, 2019-21 a nationwide survey that provides scientific data on health and family welfare. Prevalence of IPV were estimated among variouss social and demographic strata. Pearson chi-square test was used to estimate the strength of association between each possible covariate and IPV. Significantly associated covariates (from univariate logistic regression) were further analyzed through separate bivariate logistic models for each of the components of IPV, viz-a-viz sexual, emotional, physical and severe violence of the partners.

RESULTS

The prevalence of IPV among empowered women was found to be 26.21%. Among those who had experienced IPV, two-thirds (60%) were faced the physical violence. When compared to highly empowered women, less empowered women were 74% more likely to face emotional abuse. Alcohol consumption by a partner was established to be attributing immensely for any kind of violence, including sexual violence [AOR: 3.28 (2.83-3.81)].

CONCLUSIONS

Our research found that less empowered women experience all forms of IPV compared to more empowered women. More efforts should to taken by government and other stakeholders to promote women empowerment by improving education, autonomy and decision-making ability.

Social Determinants of Health and Risk of Stillbirth in the United States

OBJECTIVE

Our aim was to evaluate the impact of social determinants of health (SDoH) risk factors on stillbirth among pregnancy-related hospitalizations in the United States.

STUDY DESIGN

We conducted a cross-sectional analysis of delivery-related hospital discharges using annualized data (2016-2017) from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. The International Classification of Diseases, 10th Revision ICD-10-CM codes were used to select women with singleton stillbirth. Z-codes were utilized to identify SDoH risk factors and their subtypes. The association between SDoH risk factors and stillbirth was assessed using survey logistic regression models.

RESULTS

We analyzed 8,148,646 hospitalizations, out of which 91,140 were related to stillbirth hospitalizations, yielding a stillbirth incidence of 1.1%. An increased incidence was observed for non-Hispanic (NH) Blacks (1.7%) when compared with NH Whites (1.0%). The incidence of stillbirth was greater in hospitalizations associated with SDoH risk factors compared with those without risk factors [2.0% vs. 1.1% (p <0.001)]. Among patients with SDoH risk factors, the rate of stillbirth was highest in those designated as NH other (3.0%). Mothers that presented with SDoH risk factors had a 60% greater risk of stillbirth compared with those without (odds ratio [OR] = 1.61 [95% confidence interval (CI) = 1.33-1.95], p < 0.001). The SDoH issues that showed the most significant risk for stillbirth were: occupational risk (OR = 7.05 [95% CI: 3.54-9.58], p < 0.001), upbringing (OR = 1.87 [95% CI: 1.23-2.82], p < 0.001), and primary support group and family (OR = 5.45 [95% 3.84-7.76], p < 0.001).

CONCLUSION

We found pregnancies bearing SDoH risk factors to be associated with a 60% elevated risk for stillbirth. Future studies should target a variety of risk reduction strategies aimed at modifiable SDoH risk factors that can be widely implemented at both the population health level as well as in the direct clinical setting.

KEY POINTS

· Health disparities exist in stillbirth rates, especially among NH Black women.. · Social determinants of health risk factors increase the risk of stillbirth.. · There is a need for further study on the impact of specific SDoH risk factors on stillbirth risk..

Does women's empowerment and socio-economic status predict adequacy of antenatal care in sub-Saharan Africa?

BACKGROUND

Quality and adequate antenatal care (ANC) are key strategies necessary to achieve Sustainable Development Goal 3.1. However, in sub-Saharan Africa (SSA), there is a paucity of evidence on the role women's empowerment and socio-economic status play in ANC attendance. This study aimed to examine whether women's empowerment and socio-economic status predict the adequacy of ANC in SSA.

METHODS

Data from the recent Demographic and Health Surveys (DHSs) of 10 countries in SSA were used for the study. We included countries with a survey dataset compiled between 2018 and 2020. We included 57 265 women with complete observations on variables of interest in the study. Frequencies and percentages were used to summarize the results of the coverage of adequate ANC services across the 10 countries. A multivariable binary multilevel regression analysis was employed to examine the association between women's empowerment and socio-economic status indicators and the adequacy of ANC. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were used to present the findings of the regression analysis.

RESULTS

The average prevalence of adequate ANC in SSA was 10.4%. This ranged from 0.2% in Rwanda to 24.5% in Liberia. Women with medium (aOR 1.24 [CI 1.10 to 1.40]) and high (aOR 1.24 [CI 1.07 to 1.43]) decision-making power had higher odds of adequate ANC compared to those with low decision-making power. Women with higher levels of education (aOR 1.63 [CI 1.36 to 1.95]) as well as partners with higher education levels (aOR 1.34 [CI 1.14 to 1.56]) had the highest odds of adequate ANC compared to those with no formal education. Additionally, those working (aOR 1.35 [95% CI 1.23 to 1.49]) and those in the richest wealth category (aOR 2.29 [CI 1.90 to 2.76]) had higher odds of adequate ANC compared to those who are not working and those in the poorest wealth category. Those with high justification of violence against women (aOR 0.84 [CI 0.73 to 0.97]) had lower odds of adequate ANC compared to those with low justification of violence against women.

CONCLUSIONS

Adequacy of ANC was low across all 10 countries we included in this study. It is evident from the study that women's empowerment and socio-economic status significantly predicted the adequacy of ANC. As such, promoting women's empowerment programs without intensive improvements in women's socio-economic status would yield ineffective results. However, when women's empowerment programs are combined with active improvements in socio-economic status, then women will be encouraged to seek adequate ANC.

Maternal Pregnancy Intention and Antenatal Care Seeking Behaviors in Bangladesh: Evidence From Bangladesh Demographic and Health Survey, 2018

Objective: This study aimed to examine the association between pregnancy intention and antenatal care (ANC)-seeking behaviors among women in Bangladesh. Methods: ANC-related data of 5,012 women, from the 2018 Bangladesh Demographic and Health Survey (BDHS), who had a live birth within 3 years preceding the survey were analyzed in the study. Multivariate logistic regression models were used to assess the association of pregnancy intention with ANC utilization. Results: Approximately one-fifth (20.9%) of the women had unintended pregnancy. Among all the women, 40.4% received their first ANC visit within the first three months of pregnancies, 47% had at least four ANC visits, 26.1% received all the components of ANC services, and 22.2% received an adequate dosage of supplementary iron-folic acid tablets/syrup. Women with unintended pregnancy were less likely to receive their first ANC visit within the first 3 months, four or more ANC visits, and all ANC services than those with intended pregnancy. Conclusion: Unintended pregnancy was inversely associated with the proper utilization of ANC among women in Bangladesh. Appropriate measures to reduce unintended pregnancy might foster the utilization of optimum antenatal care.

Comparison of inequality in utilization of postnatal care services between Bangladesh and Pakistan: Evidence from the Demographic and Health Survey 2017-2018

BACKGROUND

Inequality in postnatal care (PNC) has remained a challenge in many low- and middle-income countries, like Bangladesh and Pakistan. The study examines within-country and between-country inequality in utilizing PNC services for Bangladesh and Pakistan.

METHODS

The study used the latest Demographic and Health Survey (DHS, 2017-2018) datasets of Bangladesh and Pakistan for women aged 15-49 years who had given at least one live birth in the three years preceding the survey. As outcome variables, three PNC service indicators were considered: PNC check of women, PNC check of newborns, and adequate PNC content of newborns. Concentration curves and equiplots were constructed to visually demonstrate inequality in PNC services. For ordered equity strata with more than two categories, the relative concentration index (RCI), absolute concentration index (ACI), and slope index of inequality (SII) were calculated to measure inequalities in the utilization of PNC services. For two categories equity strata, rate ratio (RR) and rate difference (RD) were calculated.

RESULTS

In Bangladesh, the level of inequality was high and almost the same for the PNC check of women and newborns based on women's education (PNC women- RCI: 0.404, ACI: 0.403, SII: 0.624; and PNC newborn- RCI: 0.402, ACI: 0.402, SII: 0.622), wealth (PNC women- RCI: 0.448, ACI: 0.448, SII: 0.643; and PNC newborn- 0.441, ACI: 0.441, SII: 0.633), and number of ANC visits (PNC women- RCI: 0.329, ACI: 0.329, SII: 0.595; and PNC newborn- RCI: 0.329, ACI: 0.329, SII: 0.594). In Pakistan, the level of inequality was higher for the PNC check of women among all PNC services based on women's education (ACI: 0.388 and SII: 0.676) and wealth (ACI: 0.397 and SII: 0.598). For Bangladesh and Pakistan, RR values (2.114 and 3.873, respectively) indicated greater media exposure-related inequality in adequate PNC content of newborns. Inequality in facility delivery was highest for PNC checks of women and newborns in Bangladesh (PNC women- RD: 0.905, PNC newborn- RD: 0.900) and Pakistan (PNC women- RD: 0.726, PNC newborn-RD: 0.743).

CONCLUSION

Inequality was higher in Bangladesh than in Pakistan for PNC checks of women and newborns based on wealth, media exposure, and mode of delivery. For adequate PNC content of newborns, inequality was greater in Pakistan than in Bangladesh. Country-specific customized policies would better minimize the gap between the privileged and underprivileged groups and reduce inequality.

Comparison of inequality in utilization of maternal healthcare services between Bangladesh and Pakistan: evidence from the demographic health survey 2017-2018

BACKGROUND

Inequality in maternal health has remained a challenge in many low-income countries, like Bangladesh and Pakistan. The study examines within-country and between-country inequality in utilization of maternal healthcare services for Bangladesh and Pakistan.

METHODS

The study used the latest Demographic Health Surveys (DHS, 2017-2018) datasets of Bangladesh and Pakistan for women aged 15-49 years who had given at least one live birth in three years preceding the survey. Equity strata were identified from the literature and conformed by binary logistic regressions. For ordered equity strata with more than two categories, the relative concentration index (RCI), absolute concentration index (ACI) and the slope index of inequality (SII) were calculated to measure inequalities in the utilization of four maternal healthcare services. For two-categories equity strata, rate ratio (RR), and rate difference (RD) were calculated. Concentration curves and equiplots were constructed to visually demonstrate inequality in maternal healthcare services.

RESULTS

In Bangladesh, there was greater inequality in skilled birth attendance (SBA) based on wealth (RCI: 0.424, ACI: 0.423, and SII: 0.612), women's education (RCI: 0.380, ACI: 0.379 and SII: 0.591), husband's education (RCI: 0.375, ACI: 0.373 and SII: 0.554) and birth order (RCI: - 0.242, ACI: - 0.241, and SII: -0.393). According to RCI, ACI, and SII, there was inequality in Pakistan for at least four ANC visits by the skilled provider based on wealth (RCI: 0.516, ACI: 0.516 and SII: 0.738), women's education (RCI: 0.470, ACI: 0.470 and SII: 0.757), and husband's education (RCI: 0.380, ACI: 0.379 and SII: 0.572). For Bangladesh, the RR (1.422) and RD (0.201) imply more significant urban-rural inequality in SBA. In Pakistan, urban-rural inequality was greater for at least four ANC visits by the skilled provider (RR: 1.650 and RD 0.279).

CONCLUSION

Inequality in maternal healthcare is greater among the underprivileged group in Pakistan than in Bangladesh. In Bangladesh, the SBA is the most inequitable maternal healthcare, while for Pakistan it is at least four ANC visits by the skilled provider. Customized policies based on country context would be more effective in bridging the gap between the privileged and underprivileged groups.

Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence

BACKGROUND

High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services.

METHODS

We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke's thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output).

RESULTS

Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services.

CONCLUSION

Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches.

Socioeconomic correlates of Adequate Maternal Care in Bangladesh: Analysis of the Bangladesh Demographic and Health Survey 2017-18

INTRODUCTION

In recent times, Bangladesh has made significant improvements in various health outcomes, but not so much in maternal death. The current flat trend in reducing maternal mortality in Bangladesh has been mainly due to the lower coverage of maternal health care. To improve the coverage, it is essential to find biosocial factors related to adequate maternal health care. Therefore, this study is aimed at finding out the socioeconomic correlates of adequate maternal health care in Bangladesh.

METHODS

The study used data from the Bangladeshi demographic and health survey 2017-18. The total unweighted sample of 4012 women who reported pregnancy before three years of the survey was analyzed. A composite binary indicator of adequate maternal care has been constructed using the variables-access to maternal care service, four antenatal care visits, at least one visit with qualified providers, and institutional delivery. A binary logistic regression model was employed to find out the socioeconomic correlate of adequate maternal care.

RESULTS

Only 24.4% percent of sample women received adequate maternal care. The result of the logistic regression model shows that urban, Khulna, Rajshahi, and Rangpur were associated with an increase in the odds of having adequate maternal care. High education and health care decisions taken by the partner or husband were also associated with an increased odd of adequate maternal care. Islam and lower wealth status were associated with a lower probability of adequate maternal care.

CONCLUSIONS

Policymakers and health administration should pay attention to the variation in the utilization of maternal health care across residence, region, religion, education, and wealth status to ensure safe motherhood.

Women's empowerment and fertility preferences of married women: analysis of demographic and health survey’2016 in Timor-Leste

A recently independent state, Timor-Leste, is progressing towards socioeconomic development, prioritizing women empowerment while its increased fertility rate (4.1) could hinder the growth due to an uncontrolled population. Currently, limited evidence shows that indicators of women's empowerment are associated with fertility preferences and rates. The objective of this study was to assess the association between women empowerment and fertility preferences of married women aged 15 to 49 years in Timor-Leste using nationally representative survey data. The study was conducted using the data of the latest Timor-Leste Demographic and Health Survey 2016. The study included 4040 rural residents and 1810 urban residents of Timor-Leste. Multinomial logistic regression has been performed to assess the strength of association between the exposures indicating women's empowerment and outcome (fertility preference). After adjusting the selected covariates, the findings showed that exposures that indicate women empowerment in DHS, namely, the employment status of women, house and land ownership, ownership of the mobile phone, and independent bank account status, contraceptive use, and the attitude of women towards negotiating sexual relations are significantly associated with fertility preferences. The study shows higher the level of education, the less likely were the women to want more children, and unemployed women were with a higher number of children. Our study also found that the attitude of violence of spouses significantly influenced women's reproductive choice. However, employment had no significant correlation with decision-making opportunities and contraceptive selection due to a lack of substantial data. Also, no meaningful data was available regarding decision-making and fertility preferences. Our findings suggest that women's empowerment governs decision-making in fertility preferences, causing a decline in the fertility rate.