Practices and determinants of delivery by skilled birth attendants in Bangladesh

Reproductive health care seeking behavior in Bangladesh: A systematic literature review

BACKGROUND

Maternal health, in terms of pregnancy and childbirth, is an important aspect of women's reproductive health and remains a public health concern in underdeveloped countries of the world. Reproductive health care seeking behavior (RHSB), in both men and women in society, is influenced by a variety of social and environmental factors that needs to be summarized.

OBJECTIVES

This review aims to enhance understanding and perception of services in relation to RHSBs in several domains such as antenatal care (ANC), delivery care, postnatal care (PNC), and family planning (FP) services, for married women of reproductive age in Bangladesh.

SEARCH STRATEGY

In major databases, for example, Medline, Ovid, PubMed, Web of Science, ProQuest and Google Scholar following keywords, timeline set as 2010 up to December 30, 2022.

SELECTION CRITERIA

Articles that included discussion on married women of reproductive age, and their type of care seeking behavior for reproductive health.

DATA COLLECTION AND ANALYSIS

A systematic literature search was carried out and expected outcome was health care seeking behavior in the aspects of ANC, delivery care, PNC, and FP services. A data extraction form and quality appraisal form were used for data on RHSB of married women of the reproductive age group in Bangladesh and associated factors.

MAIN RESULTS

A total of 245 articles were retrieved from databases; stepwise screening was done and finally 23 full-text articles were included for analysis. Descriptive statistics were used based on the included articles for narrative synthesis. In the selected articles, 17 (73.91%) were cross-sectional studies and more than half discussed both urban and rural women. Ante- and postnatal visits have proven to have positively influenced overall RHSB, as seen in Bangladesh. Grass root level workers play a major role in upgrading RHSB in women. Many factors limit rural access to mother and child health services including distance of the health facility and cost of the health service.

CONCLUSIONS

In particular, education level, women's autonomy in family decision making and distance from health service can be considered as factors influencing RHSBs in Bangladesh. Exposure to mass media and TV watching are likely to positively impact RHSB patterns for women in Bangladesh.

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.

Natural disasters, livelihood, and healthcare challenges of the people of a riverine island in Bangladesh: A mixed-method exploration

BACKGROUND

Bangladesh's islands, because of their geographical location, frequently encounter crises like floods and river erosion, which pose significant threats to the residents' well-being and livelihoods. To delve into the effects of these disasters on livelihood and healthcare challenges, a mixed-method study was undertaken in a riverine-island near a major river of Bangladesh.

METHODOLOGY

Between February 15th and February 28th, 2023, a cross-sectional study was conducted on an island in Bangladesh. The quantitative method involved conducting a survey of 442 households, with a total of 2921 participants. Additionally, 10 in-depth interviews and 10 key-informant interviews were conducted using semi-structured guidelines. Qualitative interviews were audio-recorded, transcribed verbatim, and analyzed using a thematic analysis. Triangulation was employed in this study through the integration of qualitative and quantitative analysis, resulting in the presentation of findings that offer an in-depth comprehension of the phenomenon being investigated.

RESULTS

River erosions and floods are common and recurring natural disasters that significantly impact the lives of the riverine island inhabitants. These disasters often disrupted their livelihoods, forced many residents to endure substandard living conditions or relocated during flood events. The island faced a low diagnostic prevalence of chronic diseases (e.g., 5.1% of adults were hypertension and 2.5% are diabetes) because of the absence of diagnostic facilities and a shortage of certified doctors. A significant number of chronic illness people in the community turned to alternative medicine sources (39.3%) such as homeopathy, Kabiraj, and Ayurvedic medicine, especially it gets increased during periods of natural disasters. Moreover, reproductive aged women revealed that 79.4% of them gave birth at home, with 6.0% of these home deliveries resulting in miscarriage or infant death. The destruction of crops, unstable job opportunities, an inadequate educational system, and a deficient healthcare delivery system exacerbated the hardships faced by the population affected by these disasters.

CONCLUSION

The failure to seek treatment for chronic diseases and undiagnosed diseases is a significant health issue among the aging adults on the island. Island residents face the challenge of establishing effective prevention strategies for the well-being of older adults especially at the period of natural disasters. It is crucial for the government and non-governmental organizations (NGOs) to collaborate to prevent the negative effects of floods and river erosions. This should include efforts to enhance the quality of education, healthcare services, job opportunities, and financial assistance for rebuilding homes.

Southern Ethiopian skilled birth attendant variations and maternal mortality: A multilevel study of a population-based cross-sectional household survey

Studies examining skilled birth attendants (SBA) use and its correlation with maternal mortality at lower administrative levels are scarce. This study assessed the coverage and variations of SBA, the physical accessibility of health facilities for SBA, and the association of SBA with maternal mortality. A cross-sectional study using a population-based household survey was conducted in six Sidama National Regional State, southern Ethiopia districts, from July 2019 to May 2020. Women who had given birth in the past two years before the study were included. Stata 15 and ArcGIS 10.4.1 were used for data analysis. A multilevel logistic regression analysis was conducted to assess the effect of the sampling units and identify factors independently associated with SBA. The association between SBA and maternal mortality was examined using maternal mortality household survey data. A total of 3191 women who had given birth in the past two years and resided in 8880 households sampled for the associated maternal mortality household survey were interviewed. The coverage of SBA was 46.7%, with high variations in the districts. Thirty percent of SBA use was accounted for by the differences among the districts. One-third of the women travel more than two hours on foot to access the nearest hospital. Districts with low coverage of SBA and located far away from the regional referral centre had high maternal mortality. Education of the mother, occupation of the husband, pregnancy-related complications, use of antenatal care, parity, and distance to the nearest hospital and health centre were associated with the use of SBA. The coverage of SBA in the Sidama Region was low, with high variations in the districts. Low SBA use was associated with high maternal mortality. Due attention should be given to districts with low coverage of SBA and those located far away from the referral centre. Access to hospitals has to improve. All women should be encouraged to get antenatal care services.

Disparities in the maternal healthcare continuum among Bangladeshi women: evidence from nationally representative surveys

INTRODUCTION

Utilisation of maternal healthcare is low, and it consistently decreases across antenatal to postnatal period in Bangladesh. However, there is paucity of knowledge in Bangladesh to understand gaps and associated factors in seeking continuum of maternal healthcare along the pathway. Therefore, we aimed to assess the trend in socioeconomic and demographic factors and wealth inequity in maternal CoC using the Bangladesh Multiple Indicator Cluster Survey (MICS).

METHODS

We performed a secondary analysis on nationally representative data from the last two MICS survey, carried out in 2012-13 and 2019. The study included women of reproductive age (15-49 years) with a live birth within two years preceding the survey. Total of 7,950 and 9,183 respondents were identified from these two surveys, respectively. We used multivariable logistic regression and concentration index to examine the covariates and inequity, respectively, in the utilisation of CoC.

RESULTS

Utilisation of ≥4 antenatal care, skilled delivery, and postnatal care for both mother and newborn increased from 13 percent in 2012-13 to 25 percent in 2019 survey. Moreover, wealth inequity persists favouring the rich in utilisation of CoC in Bangladesh. Women belonging to wealthier quintile, urban areas, and non-Muslim families, with higher education, a household head with higher education, media use, and fewer children were most likely to avail complete CoC in both the surveys.

CONCLUSION

Overall utilisation of maternal CoC increased between 2012 and 13 and 2019, however, women in Bangladesh still lack the CoC with persistent wealth inequality. Integrated provision of ANC, delivery by SBA, and PNC should be introduced, comprising both private and public health facilities, and targeting women in poor and rural communities. Efforts should also focus on women's education, autonomy, fertility rate, and exposure to media.

Two level logistic regression analysis of factors influencing skilled birth attendant during delivery among Bangladeshi mothers: A nationally representative sample

BACKGROUND

In order to minimize the maternal and child mortality rate, the presence of skilled birth attendants (SBA) during delivery is essential. By 2022, 4th health, population and nutrition sector programme in Bangladesh aims to increase the percentage of deliveries performed by SBA to 65 percent. The objective of the present study was to determine the rate and associated factors of usage SBA among Bangladeshi mothers during their delivery.

METHODS

This study utilized secondary data that was collected by Bangladesh Demographic and Health Survey (BDHS) 2017-18. The usage of SBA was measured by a question to respondent, who assisted during your delivery? It was classified into two classes; (i) skilled birth attendant (qualified doctors, nurses, midwives, or paramedics; family welfare visitors, community skilled birth attendants, and sub-assistant community medical officers) (code 1), and (ii) unskilled birth attendant (untrained traditional birth attendants, trained traditional birth attendants, relatives, friends, or others) (code 0). Two logistic regression model was used to determine the associated factors of SBA after removing the cluster effect of the outcome variable.

RESULTS

This study found 53.2% mothers were delivered by SBA in Bangladesh, among them 56.33% and 42.24% mothers were delivered by nurse/midwife/paramedic and doctor respectively. The two level logistic model demonstrated that geographical location (division), type of residence, religion, wealth index, mothers' body mass index, mothers' education level, mothers' occupation, total ever born children, mothers' age at first birth (year), number of ANC visits, husbands' education level and husbands' occupation were significant (p<0.01) predictors of SBA. Mothers' education and wealth index were the most important contributory factors for SBA in Bangladesh.

CONCLUSIONS

This study revealed that still 46.8% mothers are delivered by unskilled birth attendant, this might be treated of Bangladesh Government to achieve SDGs indicator 3.1.2 by 2030. Counseling could be integrated during ANC to increase awareness, and should ensure for every Bangladeshi mothers visit ANC service during their pregnancy at least 4 times.

Individual and community-level determinants of skilled birth attendant delivery in Ethiopia; multilevel analysis

INTRODUCTION

Skilled birth attendant (SBA) delivery is defined as assisting birth by a trained healthcare provider, which is vital for the health of mothers and newborns. Improving maternal health is one of the world health organization's (WHO) key priorities and skilled birth attendant delivery is one of the four pillars of the initiative for safe motherhood to reduce maternal mortality. Therefore, this study aimed to assess the individual and community-level factors associated with SBA delivery in Ethiopia.

METHOD

A secondary data analysis was conducted using the 2019 Mini Ethiopian demographic and health survey. A total of 5,527 (weighted) live births were included in the analysis. A multi-level logistic regression model was fitted using Stata 14.0 to identify individual and community-level factors associated with SBA delivery. Finally, AOR with 95% CI and random effects were reported.

RESULT

In this study after fitting a multilevel model, women with poor (AOR = 0.44 95%CI 0.32-0.61) and middle wealth index (AOR = 0.64;95% CI 0.46-0.87), multipara (AOR = 0.39;95% CI 0.28-0.55) and grand multipara (AOR = 0.46;95% CI 0.29-0.72), women from rural areas (AOR = 0.34;95% CI 0.16-0.72) and high community poverty level (AOR = 0.40;95% CI 0.21-0.76) had decreased odds of having SBA delivery. Whereas those who initiated Antenatal care (ANC) visits in the first trimester (AOR = 2.65; 95% CI 1.52-4.65) and second trimester (AOR = 1.87:95%CI 1.09-3.20) had increased odds of having SBA delivery in Ethiopia.

CONCLUSION

In this study socioeconomic factors like wealth index, parity, the timing of ANC visits, place of residency, and community poverty level were significantly associated with SBA delivery. Therefore, it is better to increase timely ANC initiation particularly for women with low levels of income to improve skilled birth attendant delivery.

Maternal healthcare utilization in rural Bangladesh: A comparative analysis between high and low disaster-prone areas

This study examined the disparity in antenatal care (ANC) visits and institutional delivery between high-disaster-prone (HDP) and low-disaster-prone (LDP) areas, defined based on multi-hazards, in Bangladesh and assessed the influencing factors using Andersen's behavioral model. In this study, cross-sectional data of 345 mothers, who had live birth the year preceding the survey, were used from the second-round multipurpose survey of a longitudinal research project conducted in May-June 2011. Hierarchical multinomial logistic and binary logistic models were respectively used to assess the determinants of ANC contacts and choice of childbirth place. We found very low utilization of 4+ ANC visits in both HDP (20%) and LDP (15%) areas. The difference is also not significant. The strong influencing factors of receiving 4+ ANC were mother's education, household size, income, and proximity to health facility. The level of institutional delivery was also low (21%), and no significant difference between HDP (15.2%) and LDP (25.7%) was found. However, in the case of institutional delivery, significant (p-value ≤ .01) difference was found in C-section between HDP (42%) and LDP (79%). A significant (p-value ≤ .05) difference was also found in the attendance of graduate doctors/gynecologists between HDP (58%) and LDP (88%). Mothers of HDP areas were 52 percent less likely to choose institutional delivery compared to those of LDP areas. Moreover, there was 30 percent less likelihood of choosing institutional delivery with an increase in distance to the nearest health facility. Specific demand-side (e.g., awareness raising, expanding maternal voucher scheme, covering more mothers under maternal allowance, and facilitating more income-generating activities especially off-farm ones) and supply-side interventions (e.g., providing training to local traditional birth attendants, and deployment of boat-based medical teams in coastal and char areas) need to be undertaken to increase institutional delivery, especially in HDP areas. However, the ultimate solution depends on adopting long-term measures to prepare facilities ready by filling the vacant posts and reducing absenteeism. Public-private partnerships modality can also be introduced especially in the HDP areas. Policy attention is needed to introduce such interventions.

Is there a link between the autonomy of women and maternal healthcare utilization in Nigeria? A cross-sectional survey

BACKGROUND

Despite legislation and intervention programmes, the rates of maternal and child mortality in Nigeria remain high. Sustainable development goals on mother and child mortality would be a mirage if this continues. The study investigated the autonomy of women (women's decision-making autonomy) and the use of maternal health-care services in Nigeria.

METHODS

Secondary data obtained from the Nigeria Demographic and Health Survey, 2018 were used in this investigation. Women who indicated they gave birth in the five-year before the surveys were considered in the study. The association between autonomy of women and maternal health-care utilization was studied using binary logistic regression models.

RESULTS

In total, about one-fifth of the women (19.6%) indicated they had at least eight ANC visits for their most recent birth. Overall, 40.5% of the women gave birth in a health institution, and 20.1% went for postnatal checkups. The use of health-care services was significantly related to the autonomy of women. Women's and husbands/partners' educational levels, residency and ethnicity were socio-demographic characteristics that influenced women's healthcare service consumption.

CONCLUSIONS

For most recent childbirth, most women did not utilise the health-care services in Nigeria. To enhance the autonomy of women and, as a result, maternal health-care services use in Nigeria, effective interventions, policies, and programmes are required.

Process Evaluation of Facility Delivery Services in Northwest Ethiopia: In the Case of Public Health Centers

Background

Even if giving birth at health facility is vital for both the mothers and their newborns, the coverage of institutional delivery in Ethiopia is very low (50%). In that regard, several studies have shown the possible factors of low delivery service uptake from the patients' side, but evidences on delivery services at the health centers are meagre. This study aimed to evaluate the process of delivery services in public health centers of northwest Ethiopia.

Methods

A case study evaluation design with an embedded mixed-method was used to evaluate institutional delivery in public health centers of Gondar city. Dimensions from the access (availability, accommodation, and acceptability) and implementation fidelity (compliance) frameworks were used. A total of 363 mothers, 32 document reviews, 32 direct observations, and 17 key informants were included. The qualitative data were transcribed, translated, coded, and analysed using a thematic analysis approach. The overall process of institutional delivery services was measured based on pre-determined judgmental criteria.

Results

The overall facility delivery process was 75.1%, judged by availability (78.5%), compliance (70.6%), accommodation (68.8%), and acceptability (80.2%) of services. Essential medicines in some of the health centers were stockout, insufficient delivery rooms and inadequate training of health workers on obstetric and newborn care were observed. Using partograph and examining vulval-perineal region for possible laceration during intrapartum period were less practiced. Residence (AOR: 0.13, 95% CI: 0.06-0.30), ANC 1 to 3 visits (AOR: 2.65, 95% CI: 1.05-6.74) and ANC4⁺ (AOR: 5.57, 95% CI: 2.09, 14.84) were factors affected acceptability of delivery services.

Conclusion

Major constraints were in the accommodation of delivery services which needs a holistic effort from all stakeholders. Therefore, implementors with other stakeholders shall improve delivery rooms, facilitate training, and provide parenteral drugs as part of the obstetric and newborn care to improve the facility delivery services in Ethiopia.

Exploring spatial variations in level and predictors of unskilled birth attendant delivery in Bangladesh using spatial analysis techniques: Findings from nationally representative survey data

Background

Bangladesh has failed to meet the United Nations goal for reducing maternal mortality in the last decade. The high prevalence of unskilled birth attendant (UBA) delivery (47%) has resulted in negative consequences for the health of mothers and newborn babies in the country. Spatial variations in UBA delivery and its predictors are yet to be explored in Bangladesh, which could be very helpful in formulating cost-effective policies for reducing that. This study examines the spatial variations in UBA delivery and its predictors in Bangladesh.

Methods

This study analyzed the characteristics of 672 clusters extracted from the 2017/18 Bangladesh Demographic and Health Survey, and healthcare facility data from the 2017 Bangladesh Health Facility Survey. These data were analyzed using descriptive and spatial analyses (hot spot analysis, Ordinary Least Squares Regression, and Geographically Weighted Regression) techniques.

Results

Statistically significant hot spots of UBA delivery were concentrated in parts of the Mymensingh, Sylhet, Barishal, and Rangpur regions, while Khulna was the safest region. Predictive strengths of the statistically significant predictors of spatial variation in UBA delivery were observed to vary considerably across the regions. Poorest household wealth status and less than four antenatal care contacts emerged as strong predictors of UBA delivery in all the aforementioned hot spot-stricken regions, except Barisal. Additionally, primiparity and all secondary education or higher were strong predictors of lower UBA delivery rates in Mymensingh and Sylhet, while poorer household wealth status was also a strong predictor of UBA delivery in Sylhet. Multiparity was an additional strong predictor of UBA delivery in Rangpur. In Barisal, only poorer household wealth status exerted a strong positive influence on UBA delivery.

Conclusions

The remarkable spatial variations in UBA delivery and its predictors’ strengths indicate that geographically-targeted interventions could be a cost-effective method for reducing the UBA delivery prevalence in Bangladesh, thereby improve maternal and child health.

Prevalence of and factors associated with early initiation of breastfeeding in Bangladesh: a multilevel modelling

BACKGROUND

Early initiation breastfeeding (EIBF) is a sign of good health for both the mother and the newborn baby. The objective of this study was to estimate the prevalence of EIBF among mothers in Bangladesh and to identify its associated factors.

METHODS

The study used the most recent Bangladesh Demographic and Health Survey 2017-2018 data. A total of 4776 (weighted) respondents were included in the final analysis. The association between the outcome and the independent variables was determined using multilevel (mixed effects) logistic regression analysis.

RESULTS

The overall weighted prevalence of EIBF among Bangladeshi mothers was 61.19% (confidence interval [CI] 59.80 to 62.56). The study shows that non-poor wealth status (adjusted odds ratio [AOR] 0.81 [95% CI 0.68 to 0.95]), institutional delivery (AOR 0.77 [95% CI 0.61 to 0.96]) and caesarean delivery (AOR 0.31 [95% CI 0.26 to 0.38]) were associated with the lower odds of EIBF. Mother's secondary education (AOR 1.34 [95% CI 1.01 to 1.83]), at least four antenatal care visits (AOR 1.36 [95% CI 1.04 to 1.53]), normal birthweight (AOR 1.42 [95% CI 1.09 to 1.85]) and placed on mother's chest and bare skin after birth (AOR 1.33 [95% CI 1.11 to 1.60]) were associated with higher odds of EIBF.

CONCLUSION

In order to enhance EIBF in Bangladesh, health professionals should emphasise skin-to-skin contact after delivery.

Health care services use, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh: A difference-in-differences analysis of Bangladesh Demographic and Health Survey data, 2000 to 2016

BACKGROUND

Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality.

METHODS AND FINDINGS

We used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = -4.8, 10.7], 6.5 (95% CI = -0.6, 13.6), and 5.8 (95% CI = -1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = -1.3, 2.6), 0.8 (95% CI = -1.7, 3.4), and 1.3 (95% CI = -2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas.

CONCLUSIONS

In this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes.

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.

Rural-Urban Determinants of Receiving Skilled Birth Attendants among Women in Bangladesh: Evidence from National Survey 2017-18

BACKGROUND

SBAs (skilled birth attendants) play a crucial role in reducing maternal mortality. The proportion of maternal healthcare in Bangladesh that receives quality care at birth has increased; the reasons for this are unknown. The purpose of this study is to see if there has been a change in the use of specific maternal healthcare indicators in urban and rural areas, as well as significant risk factors.

MATERIALS AND METHODS

The data set was extracted from a nationally representative survey based on a cross-sectional study, the Bangladesh Health and Demographic Survey (BDHS) 2017-18. The frequency distribution reveals the general state of SBAs. To identify the association, we performed the chi-square test. Finally, multiple logistic regression was used to analyse the factors associated with SBAs and determine the degree of SBAs disparity between urban and rural areas.

RESULTS

In Bangladesh, 53% of women received SBAs during childbirth, with urban and rural areas receiving 68.1 and 52.2 percent, respectively. Women with secondary (AOR: 1.79, CI: 1.05-3.08) and higher (AOR: 4.18, CI: 2.09-8.50) education were more likely to receive SBAs than women in urban areas who were illiterate. Husband's education, women's working status, wealth index, children's birth order, and number of ANC visit are significant factors in receiving SBSs in both urban and rural areas. Higher educated husbands are 1.83 times (AOR = 1.83, CI: 1.04-3.25, p = 0.037) and 1.82 times (AOR = 1.82, CI: 1.29-2.59, p = 0.001) more likely to attend skilled births than uneducated husbands in both urban and rural areas. Respondents from the richest families are more likely to attend skilled births than those from the poorest families in both urban and rural areas.

CONCLUSION

During delivery, significant risk factors are substantially related to SBAs. More attention must be given to rural and illiterate populations, who are less likely to obtain these services, to minimize maternal and neonatal mortality. Special programs could be developed to raise awareness and facilitate the poor in receiving the basic necessities of maternal care.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

Introduction

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

Materials and methods

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

Results

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

Conclusion

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

Utilization, Predictors and Gaps in the Continuum of Care for Maternal and Newborn Health in Ghana

BACKGROUND

Continuum-of-care (CoC) throughout pregnancy, childbirth and the postnatal period is essential for the health and survival of mothers and their babies. This study assesses the utilization, predictors, and gaps in the continuum of maternal and newborn health (MNH) services in Eastern Ghana.

METHODS

A retrospective cross-sectional survey was conducted to assess utilization of MNH services and their determinants in the East Akim Municipality of Ghana. Three hundred and ten (310) mothers aged 15-49 years were sampled from 4 communities (3 rural; 1 urban) in the municipality using stratified sampling methodology. Logistic regression models were fitted to determine the likelihood of utilizing skilled birth attendance (SBA) and postnatal care (PNC) after antenatal care (ANC).

RESULTS

Sixty-six percent (66%) of mothers surveyed received the full complement of MNH services (ANC, SBA, PNC) for their most-recent birth. While 98% of mothers made at least one ANC visit with 83.5% receiving the World Health Organization-recommended 4+ visits, only 74% accessed SBA indicating a 24% attrition in the CoC from ANC to SBA, and an 8% attrition from SBA to PNC. About 86% of mothers accessed PNC within 42 days postpartum. Distance to health facility, urban residence, and exposure to media information were strong predictors of the full complement of MNH continuum-of-care utilization.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

The study found a remarkable utilization of MNH services in East Akim with significant attrition along the continuum-of-care. Efforts to enhance utilization of the MNH continuum-of-care should focus on increasing access to SBA in particular, through equitable distribution of MNH services in hard-to-reach areas and innovative communication approaches for reducing attrition at each level of the continuum-of-care. Evidence from this study can inform strategies for achieving universal access and utilization of the MNH continuum-of-care towards global goals and improved health outcomes in Ghana and other countries.

Effect of unintended pregnancy on skilled antenatal care uptake in Bangladesh: analysis of national survey data

Background

Around 48% of all pregnancies in low- and middle-income countries are unintended. Unintended pregnancy may contribute to lower use of antenatal care (ANC); however, current research in the area is largely inconclusive due to the methodological approaches applied.

Methods

Responses from 4493 women extracted from the 2014 Bangladesh Demographic and Health Survey (BDHS) were used to assess the association between unintended pregnancy and subsequent uptake of at least one and at least four skilled ANC visits. For this, Bayesian multilevel logistic regression models with informative priors (representing a range of values within which the researcher is certain the true effect of the parameters included lies) were used, adjusting for other factors that affect ANC uptake. Informative priors were selected from the BDHS data collected in 2004, 2007, and 2011.

Results

Around 64% of women in Bangladesh who had at least one pregnancy within 3 years prior to the survey (that ended in a live birth) received ANC at least once, and of these around 32% used ANC at least four times. Mistimed (aOR, 0.73, 95% Cred I, 0.66–0.81) and unwanted (aOR, 0.69, 95% Cred I, 0.64–0.75) pregnancy were associated with reduced odds of attending the recommended minimum of four skilled ANC visits compared with wanted pregnancy. These likelihoods were even lower for at least one skilled ANC visit among women with a mistimed (aOR, 0.59, 95% Cred I, 0.53–0.65) or an unwanted pregnancy (aOR, 0.67, 95% Cred I, 0.61–0.74) than women with a wanted pregnancy.

Conclusions

In Bangladesh, more than one-quarter of women who report an unintended pregnancy at conception and do not terminate the pregnancy are at high risk of not using ANC. It is important for policies to include women with unintended pregnancy in mainstream healthcare services. This will increase the use of ANC and reduce associated adverse consequences.

Does unintended pregnancy have an impact on skilled delivery care use in Bangladesh? A nationally representative cross-sectional study using Demography and Health Survey data

Skilled delivery care has been targeted in the Sustainable Development Goals to reduce preventable maternal and newborn deaths, which mostly occur because of birthing complications. Birthing complications are more frequent in women with unintended than intended pregnancies, and around 43% of total pregnancies in low- and middle-income countries are unintended. This study quantified the impact of unintended pregnancy on skilled birth attendance and delivery in health care facilities in Bangladesh. Data from 4493 women participating in the cross-sectional 2014 Bangladesh Demographic and Health Survey were analysed. Multilevel logistic regression models were used to assess the association of unintended pregnancy with skilled birth attendance and delivery in a health care facility through skilled providers while adjusting for individual-, household- and community-level factors identified using a directed acyclic graph. Around 26% of women reported that their last pregnancy (occurring within the previous 3 years) that ended with a live birth was unintended at conception. Only 42% reported having a skilled birth attendant present at their last birth and 38% gave birth in a health care facility. Significant differences were found across pregnancy intention. Lower odds of skilled birth attendance (OR, 0.70, 95% CI, 0.52-0.93) and delivery in a health care facility through skilled providers (OR, 0.65, 95% CI, 0.48-0.89) were found among women who had an unwanted pregnancy relative to women who had a wanted pregnancy. However, a mistimed pregnancy was not found to be associated with skilled birth attendance or delivery in health care facility through skilled providers. Increased availability of health care facilities at the community level is required in Bangladesh to ensure skilled delivery care for women with an unwanted pregnancy. Policies are also required to integrate women with an unwanted pregnancy into mainstream health care services through earlier detection and increased awareness in order to reduce the adverse maternal and fetal outcomes associated with lack of quality birthing care.

Intentions to use maternity waiting homes and associated factors in Northwest Ethiopia

Background

Maternity Waiting Homes (MWHs) are residential facilities located within hospitals or health centers to accommodate women in their final weeks of pregnancy to bridge the geographical gap in obstetric care. Little is known, however, about women’s intentions to use MWHs. Thus, this study aimed to assess pregnant women’s intentions to use MWHs and associated factors in East Bellesa district, northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted among 525 pregnant women in East Bellesa district from March to May 2018. Study participants were selected using systematic random sampling. Binary logistic regression was used for analysis. Adjusted Odds Ratio (aOR) with 95% Confidence Interval (CI), and p-value < 0.05 were used to identify factors associated with intentions to use MWHs.

Results

In the study area, 326/499 (65.3%) pregnant women had the intention to use MWHs. Pregnant women who had good knowledge about maternal healthcare and obstetric complications (aOR 6.40; 95% CI 3.6–11.5), positive subjective norms related to women’s perceptions of social pressure (aOR 5.14; 95% CI 2.9–9.2), positive perceived behavioral control of women on the extent to which women feel confident (aOR 4.74; 95% CI 2.7–8.4), rich wealth status (aOR 4.21; 95% CI 2.1–8.4), women who decided by themselves to use maternal services (aOR 2.74; 95% CI 1.2–6.2), attended antenatal care (aOR 2.24; 95% CI 1.2–4.1) and favorable attitudes towards women’s overall evaluation of MWHs (aOR 1.86; 95% CI 1.0–3.4) had higher odds of intentions to use MWHs.

Conclusion

Two thirds (65.3%) of pregnant women had intentions to use MWHs. Factors such as women’s knowledge, subjective norms related to women’s perceptions of social pressure, perceived behavioral control of women on the extent to which women feel confident to utilize, and wealth status, decision-making power, attending antenatal care and attitude towards women’s overall evaluation of MWHs were significantly associated with the intention to use MWHs. Therefore, improving women’s awareness by providing continuous health education during antenatal care visits, devising strategies to improve women’s wealth status, and strengthening decision-making power may enhance their intention to use MWHs.

The effects of household's climate-related displacement on delivery and postnatal care service utilization in rural Bangladesh

Exposure to extreme climate events causes population displacement and adversely affects the health of mothers and children in multiple ways. This paper investigates the effects of displacement on whether a child is delivered at a health center, as opposed to at home, and on postnatal care service utilization in Bangladesh. Using cross-sectional survey data from 599 mothers who gave birth in the three years prior to the date of interview, including 278 from households which had previously been displaced and 231 from households which had not been displaced, we use multivariate logistic regression to identify the factors associated with maternal healthcare service utilization. The results show that displaced households' mothers are only about a quarter as likely to deliver at a health center as mothers from non-displaced households. The use of health center-based delivery decreases as the numbers of past displacements increases. Higher number of previous children, lower use of antenatal care during pregnancy, lower household income, and lack of access to radio/television also significantly reduce a mother's likelihood of delivery at a health center. Displaced mothers are also substantially less likely to use postnatal care services for their neonates, especially those supplied by trained providers. Use of health facilities for delivery, use of antenatal care services, and previous number of children are other important predictors of postnatal care service utilization for neonates. In light of these findings, relocation of local health facilities with basic and emergency care provisions to areas in which the displaced have resettled, reinforcement of Family Planning services, and extension of coverage of the Maternity Allowance benefits in the displacement-prone mainland riverine areas are recommended policy responses.

Filling the human resource gap through public-private partnership: Can private, community-based skilled birth attendants improve maternal health service utilization and health outcomes in a remote region of Bangladesh?

Background

In Sunamganj there are fewer than four skilled providers per 10,000 population and just 27% of births are assisted by a skilled attendant. We evaluate a private community skilled birth attendant (P-CSBA) model, developed through the GSK-CARE Frontline Health Worker Programme, designed to address this gap and report on changes in service utilization and health outcomes from baseline to three years post-baseline.

Methods

This analysis presents the results of a pre-post cross sectional design. A baseline survey (n = 1800) was conducted using a multistage cluster sampling approach. Three years post-baseline a second cross-sectional survey (n = 1755) was conducted across the same project area. To describe demographic characteristics of the study participants descriptive statistical techniques were used as appropriate. Logistic and multiple logistic regression, controlling for a comprehensive set of covariates, were used to assess odds ratios for key maternal health behaviors and outcomes.

Results

Birth planning and the use of key maternal health services improved from baseline to follow-up. There was a dramatic increase in the proportion of respondents reporting skilled attendance at birth (aOR: 2.18, p = .001). Women also reported significantly fewer complications during the prenatal (aOR: .30, p<.001), labor and delivery (aOR: 0.41, p<.0001) and postnatal periods (aOR: 0.32, p<.0001).

Conclusion

Private-sector approaches, when coupled with robust efforts to strengthen and collaborate with the public sector, can work successfully to deliver services in underserved communities. The success of this model lends credence to the growing appreciation that reaching our development targets will require governments to work in partnership with private sector actors and highlights the potential of private-public partnerships as we drive towards universal health coverage.

Factors associated with the upsurge in the use of delivery care services in Sierra Leone

OBJECTIVES

Most African countries have poor maternal and reproductive health outcomes. This is due, in part, to many factors such as accessibility issues, which hinder women in developing countries from using life-saving maternal and reproductive health services. Therefore, this study considered two main objectives: (i) to examine prevalence of delivery care services in Sierra Leone; and (ii) to identify sociodemographic factors associated with the use of the aforementioned health services.

STUDY DESIGN

A secondary analysis was undertaken using data from the Sierra Leone Demographic and Health Surveys.

METHODS

Bivariate and multivariate analyses were used to study the prevalence and factors associated with the use of delivery care services in Sierra Leone.

RESULTS

The findings show a general increase in the use of delivery care services between 2008 and 2013, although the use of these services remains quite low. The multivariate analysis shows that maternal age, marital status, socio-economic status, the number of living children, decision-making power, media exposure, skilled antenatal care, and geographic location are crucial factors in the use of delivery care services.

CONCLUSIONS

Use of delivery care services remains low in Sierra Leone. It is possible that the introduction of the Free Healthcare Initiative played a vital role in increasing the use of these services. Further policy debates are needed to ensure universal coverage.

Health workforce perspectives of barriers inhibiting the provision of quality care in Nepal and Somalia - A qualitative study

OBJECTIVE

In this paper settings from Nepal and Somalia are used to focus on the perspectives of healthcare providers within two fragile health systems. The objective of this study was to describe barriers inhibiting quality healthcare in Nepal and Somalia from a health workforce perspective.

METHODS

Data were collected through 19 semi-structured interviews with healthcare providers working in healthcare facilities. Ten interviews were conducted in Nepal and nine in Somalia.

RESULTS

Various structural barriers inhibiting the availability, accessibility, and acceptability of the quality care were similar in both countries. Barriers inhibiting the availability of quality care were linked to healthcare providers being overburdened with multiple concurrent jobs. Barriers inhibiting the accessibility to quality healthcare included long distances and the uncertain availability of transportation, and barriers to acceptability of quality healthcare was inhibited by a lack of respect from healthcare providers, characterised by neglect, verbal abuse, and lack of competence.

CONCLUSIONS

Inequality, poverty, traditional and cultural practices plus the heavy burden placed on healthcare providers are described as the underlying causes of the poor provision of quality care and the consequential shortcomings that emerge from it. In order to improve this situation adequate planning and policies that support the deployment and retention of the healthcare providers and its equitable distribution is required. Another important aspect is provision of training to equip healthcare providers with the ability to provide respectful quality care in order for the population to enjoy good standard of healthcare services.

Predisposing, enabling and need factors associated with skilled delivery care utilization among reproductive-aged women in Kersa district, eastern Ethiopia

Background

Skilled delivery care utilization in Ethiopia is still very low compared with the goal set by the global community for countries with the highest maternal mortality. As a result, the country is overburdened with high maternal morbidity and mortality. We aimed to explore the predisposing, enabling, and need factors associated with skilled delivery care utilization among reproductive-aged women in Kersa district, eastern Ethiopia.

Methods

A community-based cross-sectional study was conducted with a total of 1294 women. The participants were selected using systematic sampling techniques. An interviewer-administered structured questionnaire aided by an electronic survey tool was used to collect data. Univariate analyses were conducted to describe the study sample. Bivariate and multivariate logistic regression analyses were carried out to elicit the association of predisposing, enabling, and need factors associated with skilled delivery care utilization. Separate multivariate models were fitted for primiparous and multiparous women categories. Odds ratios with 95% confidence intervals were used to assess statistical significance.

Results

More than a quarter (30.8%) of the women surveyed used skilled delivery care for their most recent birth. Significant predisposing factors were as follows: presence of educated family member; receiving education on maternal health; previous use of skilled delivery care; and best friend’s use of maternal care. Place of residence was the enabling factor that predicted skilled delivery care use. Antenatal care attendance and pregnancy intention were significant need factors associated with skilled delivery care utilization.

Conclusion

The findings of the study highlight the need for a concerted effort to establish community-based peer education programs; improve access to family planning services (to reduce unintended pregnancies); increase antenatal care uptake; and facilitate access to skilled delivery care in rural areas.

Utilization of skilled birth attendant at birth and associated factors among women who gave birth in the last 24 months preceding the survey in Gura Dhamole Woreda, Bale zone, southeast Ethiopia

BACKGROUND

Maternal morbidity and mortality continued to be major issues in many countries. Globally a total of 10.7 million women have died between 1990 and 2015 due to maternal causes where sub-Saharan Africa alone accounts for 66% of maternal death. Since most maternal deaths are avoidable; skilled attendance during pregnancy, childbirth, and the postpartum is among the most critical interventions for improving maternal and neonatal survival. The study aimed to assess the magnitude and associated factors of utilization of skilled birth attendant at birth among women who gave birth in the last 24 months preceding the study in Gura Dhamole Woreda, Bale Zone Southeast Ethiopia, 2017.

METHODS

Community based cross-sectional study was implemented from March 25 to April 24, 2017 in Gura Dhamole Woreda on total of 402 study subjects who were selected by Multi-stage sampling technique. The data were collected using pre-tested structured questionnaire and data was coded, entered, cleaned and analyzed using Statistical Package for Social Service (SPSS) Version 20. Odds ratio with 95% Confidence Interval (CI) was used to assess associations the dependent and independent variables. Logistic regression model was employed to identify independent predictors and variables were declared statistically significant at P value < 0.05.

RESULT

In this study only 29.2% of women were assisted by Skilled Birth Attendance (SBA) during their child birth. Place of residence, mother education, travel time, joint decision on the place of delivery, ANC visit frequency, birth preparedness and complication readiness status, knowledge on obstetric danger signs after delivery and knowledge of presence of maternity waiting homes were significantly associated with SBA utilization.

CONCLUSION

Skilled birth attendant utilization in the study area was low. Strategies that improve attendance of antenatal care utilization and attention to birth preparedness and complication readiness and counseling on danger signs are recommended.

Predicting skilled delivery service use in Ethiopia: dual application of logistic regression and machine learning algorithms

Background

Skilled assistance during childbirth is essential to reduce maternal deaths. However, in Ethiopia, which is among the six countries contributing to more than half of the global maternal deaths, the coverage of births attended by skilled health personnel remains very low. The aim of this study was to identify determinants and develop a predictive model for skilled delivery service use in Ethiopia by applying logistic regression and machine-learning techniques.

Methods

Data from the 2016 Ethiopian Demographic and Health Survey (EDHS) was used for this study. Statistical Package for Social Sciences (SPSS) and Waikato Environment for Knowledge Analysis (WEKA) tools were used for logistic regression and model building respectively. Classification algorithms namely J48, Naïve Bayes, Support Vector Machine (SVM), and Artificial Neural Network (ANN) were used for model development. The validation of the predictive models was assessed using accuracy, sensitivity, specificity, and area under Receiver Operating Characteristics (ROC) curve.

Results

Only 27.7% women received skilled delivery assistance in Ethiopia. First antenatal care (ANC) [AOR = 1.83, 95% CI (1.24–2.69)], birth order [AOR = 0.22, 95% CI (0.11–0.46)], television ownership [AOR = 6.83, 95% CI (2.52–18.52)], contraceptive use [AOR = 1.92, 95% CI (1.26–2.97)], cost needed for healthcare [AOR = 2.17, 95% CI (1.47–3.21)], age at first birth [AOR = 1.96, 95% CI (1.31–2.94)], and age at first sex [AOR = 2.72, 95% CI (1.55–4.76)] were determinants for utilizing skilled delivery services during the childbirth. Predictive models were developed and the J48 model had superior predictive accuracy (98%), sensitivity (96%), specificity (99%) and, the area under ROC (98%).

Conclusions

First ANC and contraceptive uses were among the determinants of utilization of skilled delivery services. A predictive model was developed to forecast the likelihood of a pregnant woman seeking skilled delivery assistance; therefore, the predictive model can help to decide targeted interventions for a pregnant woman to ensure skilled assistance at childbirth. The model developed through the J48 algorithm has better predictive accuracy. Web-based application can be build based on results of this study.

Antenatal care and skilled birth attendance in Bangladesh are influenced by female education and family affordability: BDHS 2014

OBJECTIVES

Antenatal care (ANC) during pregnancy and skilled birth attendance (SBA) during delivery are important policy concerns to reduce maternal deaths. Bangladesh is one of the developing countries which has made remarkable progress in both services during the last couple of decades by improving the SBA service rate from 16% in 2004 to 42.1% in 2014. However, this rate remains below the targeted level (50%) of the Health Population and Nutrition Sector Development Program set by the Ministry of the Health and Family Welfare of Bangladesh. This article explored the sociodemographic factors associated with the ANC and SBA service attainment. Furthermore, the possible implication of using ANC on SBA was also investigated.

STUDY DESIGN

The study followed a cross-sectional design using the Bangladesh demographic and health survey 2014, with a sample of size 4603 women with at least one live birth 3 years preceding the survey.

METHODS

Following a bivariate analysis, linear mixed-effect models were used to assess the relationship between sociodemographic factors and the outcome indicators (ANC and SBA). Finally, the association between SBA and ANC was evaluated through another mixed-effect model.

RESULTS

Wealth index, participation in household decisions, and partner's and respondent's education were significant predictors of ANC; whereas, residence, age at first birth, wealth index, working status, participation in household decisions, and partner and respondent's education were significant for SBA. Female education and household affordability were the strongest predictors for both ANC and SBA. ANC showed significant association with SBA as women accessing essential ANC during delivery seemed to be 4 times more likely (95% confidence interval: 3.05-5.93) to avail SBA services.

CONCLUSIONS

Overall, four factors were significant: residence, wealth index, education, and ANC access. Women residing in urban areas, having higher financial solvency, completing higher education, and accessing ANC by skilled personnel were more likely to receive SBA at delivery than their counterparts. Accessibility to skilled care during pregnancy leads to increased professional care during delivery. Thus, policies to encourage women and heads of families to seek skilled care during pregnancy would be beneficial to reach the maternal healthcare targets of Bangladesh.

Strengthening the community support group to improve maternal and neonatal health seeking behaviors: A cluster-randomized controlled trial in Satkhira District, Bangladesh

Background

Although achieved development goals on maternal and child health, in the era of Sustainable Development Goals (SDGs), Bangladesh still needs to promote skilled attendance at birth as well as a continuum of care for mothers and babies. How to implement effective interventions by strengthening the community health system also remains as a crucial policy issue. The objective of the proposed study is to evaluate the impact of a community-based intervention as part of a bilateral development aid project on utilization of maternal and neonatal care provided by skilled providers and qualified facilities.

Methods

A cluster randomized trial was conducted in Kalaroa Upazila of Satkhira District. Community Clinics (CCs) in the study setting were randomly allocated to either intervention or control. We recruited all eligible women covered by CC catchment areas who gave a birth during the past 12 months of data collection at the baseline and end-line surveys. In the intervention areas, three Community Support Groups (CSGs) were developed in each of the CC areas. The members of CSG were trained to identify pregnant women, educate community people on pregnancy related danger signs, and encourage them for utilization of skilled services in the community and health facilities. The primary outcomes were the utilization of services for antenatal care, delivery, postnatal care and sick newborns. Difference-in-Difference (DID) analysis was performed to identify the changes by the intervention with adjustment of cluster effects by generalized mixed effects regression models.

Result

The major indicators of the utilization of maternal and neonatal care among pregnant women with different wealth status showed significant improvement after the intervention. The impacts of the intervention were in particular significant among the women of 2^nd and 3^rd quintiles of household wealth status. The use of CCs increased after the intervention and private hospitals / clinics served as the major health providers. The study also identified increased practices of cesarean section.

Conclusion

The success of the intervention suggests a potential of the government efforts to strengthen the community support system for promotion of safe motherhood. The intervention helps to identify and remove existing and emerging barriers that lie between women and healthcare providers for safe motherhood and continuum of care.

Trial registration

UMIN Clinical Trial Registry UMIN000031789.

Factors associated with maternal utilization of health facilities for delivery in Ethiopia

Background

As a signatory of the Millennium Development Goals, Ethiopia has made significant achievements towards meeting the maternal mortality related goals since 1990. Despite that, the country is still experiencing unacceptably high maternal mortality rates, and challenges to improving the coverage and utilisation of health facility delivery services which represent a key strategy to combat maternal mortality. Currently, there is limited evidence on the factors associated with health facility delivery in Ethiopia. Therefore, the objective of this study was to identify the correlates of facility delivery among urban and rural women in Ethiopia.

Methods

This was a cross-sectional study based on data from the 2011 Ethiopian Demographic and Health Survey. Participants were 7540 women aged between 15 and 49 years with a history of at least one birth. The outcome variable was place of delivery. Data were analyzed using bivariate and multivariable regression techniques.

Results

The overall prevalence of health facility delivery was 17.1% (1447/7540). In the multivariable regression analysis, education, wealth status, frequency of antenatal care visits and mother's age at first birth were found to be significantly associated with women's choice of place of delivery. Among urban women, those who had primary and secondary/higher level education had increased odds of delivering at a health facility compared with those without formal education. Those who were from the richest households had higher odds of delivering at a health facility compared with those in the lowest class. In urban and rural areas, compared with those who had no ANC visits, those who had at least four visits also had increased odds of delivering at a health facility. In the urban areas, those who were over 18 years old at their first childbirth had significantly higher odds of choosing to deliver at a health facility.

Conclusion

Findings show that the prevalence of healthy facility delivery in Ethiopia is remarkably low. Addressing the sociodemographic and wealth inequities can help promote the utilisation of facility delivery in both urban and rural areas. Policy-makers should consider improving access to education as a strategy to meet maternal health related goals and treat education as a multipronged strategy. Providing free healthcare access could be one strategy to achieve the universal coverage of essential maternal healthcare services.

Women's attitude towards wife-beating and its relationship with reproductive healthcare seeking behavior: A countrywide population survey in Bangladesh

Background

Intimate partner violence (IPV) is a global public health problem that has substantial consequences on the physical, mental, sexual and reproductive health of women. This study examined the association between women’s attitudes towards wife-beating and their utilization of reproductive healthcare services.

Method

Two waves of Bangladesh Demographic and Health Survey data were analyzed using multivariate regression. Outcome variables were a set of reproductive healthcare services, namely contraception use, modern contraception use, antenatal visit by skilled health professionals (SHP), delivery in healthcare facilities, delivery by SHP and postnatal check up by SHP. Attitudes towards abuse were assessed by a set of five questions that asked the situation under which ‘hitting or beating’ one’s wife is justifiable.

Results

Around 32% of the participants reported that hitting or beating wife by husband was justified in certain situations. There is a gradient in the relationship between number of healthcare services accessed and number of situations justified for beating wife. Women who strongly reject the justification of wife beating were more likely than those who reject that weakly to report contraception use, antenatal care by SHP, delivery in healthcare facilities, delivery care by SHP, and postnatal care by SHP.

Conclusions

Women’s attitudes towards ‘wife beating’ have a significant association with reproductive healthcare seeking behavior. The impact of this malpractice on women’s health and consequences thereafter need to be brought in the forefront of public health campaign.

A comparison of practices, distributions and determinants of birth attendance in two divisions with highest and lowest skilled delivery attendance in Bangladesh

BACKGROUND

Delivery by skilled birth attendants (SBAs) is strongly recommended to reduce maternal and neonatal mortality. The percentage of births attended by SBAs is low in Bangladesh (42% in 2014), though this rate varies widely by divisions, with the highest 58% in Khulna and only 27% in Sylhet. Comparing and critically analyzing the practices, distributions and determinants of delivery attendance in two divisions with the highest and lowest SBA attendance could help to understand the differences and to employ the findings of the high-performing division to the low-performing division.

METHODS

The 7th Bangladesh Demographic and Health Survey (BDHS 2014) data were analyzed. After reporting the types of delivery attendants, logistic regression analyses were applied to calculate the odds ratios of determinants of deliveries attended by SBAs.

RESULTS

SBAs attended 225 (58.6%) and 128 (27.4%) deliveries in Khulna and Sylhet, respectively. Khulna had higher birth attendance by qualified doctors (42.5%, n = 163) than Sylhet (15.8%, n = 74). Sylhet had higher attendance by traditional attendants (60.8%, n = 285) than Khulna (33.7%, n = 129). In both regions, attendance by community skilled birth attendants (CSBAs) was very low (< 1%). Khulna had higher percentages of women with higher education level, husbands' higher education, antenatal care (ANC) visits by SBAs, and higher wealth quintiles than Sylhet. In multivariable analyses, higher education level (adjusted odds ratio (AOR): 8.4; 95% confidence interval (CI): 1.9-36.7), ANC visits (AOR: 3.6; 95% CI: 2.0-6.5), family planning workers' visit (AOR: 3.0; 95% CI: 1.6-5.4), and belonging to richer (AOR: 2.6; 95% CI: 1.4-5.1) or richest (AOR: 3.8; 95% CI: 1.9-7.6) household wealth quintiles had significant positive associations with deliveries by SBAs in Sylhet. Similarly, ANC visits (AOR: 2.5; 95% CI: 1.4-4.6) and higher wealth quintile (AOR: 4.7; 95% CI: 1.9-11.5) were positive predictors in Khulna.

CONCLUSIONS

The higher proportion of educated women and their husbands, wealth status and ANC visits were associated with higher SBA utilization in Khulna compared to Sylhet. Improvement of socioeconomic status, increasing birth attendant awareness programs, providing ANC services, and family-planning workers' visits could increase the proportion of SBA-attended deliveries in Sylhet Division. CSBA program should be re-evaluated for both divisions.

Factors associated with intended use of a maternity waiting home in Southern Ethiopia: a community-based cross-sectional study

Background

Although Ethiopia is scaling up Maternity Waiting Homes (MWHs) to reduce maternal and perinatal mortality, women’s use of MWHs varies markedly between facilities. To maximize MWH utilization, it is essential that policymakers are aware of supportive and inhibitory factors. This study had the objective to describe factors and perceived barriers associated with potential utilization of an MWH among recently delivered and pregnant women in Southern Ethiopia.

Methods

A community-based cross-sectional study was conducted between March and November 2014 among 428 recently delivered and pregnant women in the Eastern Gurage Zone, Southern Ethiopia, where an MWH was established for high-risk pregnant women to await onset of labour. The structured questionnaire contained questions regarding possible determinants and barriers. Logistic regression with 95% Confidence Intervals (CI) was used to examine association of selected variables with potential MWH use.

Results

While only thirty women (7.0%) had heard of MWHs prior to the study, 236 (55.1%), after being explained the concept, indicated that they intended to stay at such a structure in the future. The most important factors associated with intended MWH use in the bivariate analysis were a woman’s education (secondary school or higher vs. no schooling: odds ratio [OR] 6.3 [95% CI 3.46 to 11.37]), her husband’s education (secondary school or higher vs. no schooling: OR 5.4 [95% CI 3.21 to 9.06]) and envisioning relatively few barriers to MWH use (OR 0.32 [95% CI 0.25 to 0.39]). After adjusting for possible confounders, potential users had more frequently suffered complications in previous childbirths (adjusted odds ratio [aOR] 4.0 [95% CI 1.13 to 13.99]) and envisioned fewer barriers to MWH use (aOR 0.3 [95% CI 0.23 to 0.38]). Barriers to utilization included being away from the household (aOR 18.1 [95% CI 5.62 to 58.46]) and having children in the household cared for by the community during a woman’s absence (aOR 9.3 [95% CI 2.67 to 32.65]).

Conclusions

Most respondents had no knowledge about MWHs. Having had complications during past births and envisioning few barriers were factors found to be positively associated with intended MWH use. Unless community awareness of preventive maternity care increases and barriers for women to stay at MWHs are overcome, these facilities will continue to be underutilized, especially among marginalized women.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1670-z) contains supplementary material, which is available to authorized users.

Determinants of Skilled Care Utilization among Pregnant Women Residents in an Urban Community in Kwara State, Northcentral Nigeria

Background

Skilled attendant at delivery (SBA) is one of the key indicators used in assessing progress towards improved maternal health. This study aimed at identifying factors influencing SBA utilization in Ilorin, Nigeria.

Methods

This cross-sectional study was carried out using multi-stage sampling technique among 400 participants in Ilorin, Northcentral Nigeria. A pre-tested questionnaire was used for data collection, and data analysis was done using descriptive and inferential statistics.

Results

SBA supervised 73.8% births. Determinants of skilled birth attendance at delivery include higher education (AOR; 10.94, 95% CI; 3.60-33.26), having only one child (AOR; 4.33, 95% CI; 1.18-15.82), having at least 4 ANC attendance (AOR; 18.84, 95% CI; 8.95-55.82) and residing near delivery sites (AOR; 11.49, 95% CI; 2.43-55.56).

Conclusion

The proportion of births supervised by SBA needs improvement in Northcentral Nigeria. Full implementation of reproductive health policies will enhance skilled births in Nigeria.

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

OBJECTIVES

The aim of this study was to determine the association between women's decision-making power and utilisation of maternal healthcare services (MHS) among Bangladeshi women.

SETTINGS

This is a nationally representative survey that encompassed Dhaka, Rajshahi, Rangpur, Chittagong, Khulna, Barisal and Sylhet in Bangladesh. Sample households were selected by a two-stage stratification technique. First, 207 clusters in urban areas and 393 in rural areas were selected for 600 enumeration areas with proportional probability. In the second stage, on average 30 households were selected systematically from the enumeration areas. Finally, 17 989 households were selected for the survey of which 96% were interviewed successfully.

PARTICIPANTS

Cross-sectional data on 4309 non-pregnant women were collected from Bangladesh demographic and health survey 2014. Decision-making status on respondent's own healthcare, large household purchases, having a say on child's healthcare and visiting to family or relatives were included in the analysis.

RESULTS

Prevalence of at least four antenatal attendance, facility delivery and postnatal check-up were respectively 32.6% (95% CI 31.2 to 34), 40.6% (95% CI 39.13 to 42.07) and 66.3% (95% CI 64.89 to 67.71). Compared with women who could make decisions alone, women in the urban areas who had to decide on their healthcare with husband/partner had 20% (95% CI 0.794 to 1.799) higher odds of attending at least four antenatal visits and those in rural areas had 35% (95% CI 0.464 to 0.897) lower odds of attending at least four antenatal visits. Women in urban and rural areas had respectively 43% (95% CI 0.941 to 2.169) and 28% (95% CI 0.928 to 1.751) higher odds of receiving postnatal check-up when their health decisions were made jointly with their husband/partner.

CONCLUSION

Neither making decisions alone, nor deciding jointly with husband/partner was always positively associated with the utilisation of all three types of MHS. This study concludes that better spousal cooperation on household and health issues could lead to higher utilisation of MHS services.

Factors affecting deliveries attended by skilled birth attendants in Bangladesh

Background

The presence of skilled birth attendants (SBAs) is crucial in childbirth to reduce the maternal mortality ratio (MMR) and to achieve the maternal mortality target of the United Nations’ Sustainable Development Goals (SDGs). The aim of this study was to investigate the factors related to childbirths attended by SBAs in Bangladesh.

Methods

Data from the Bangladesh Demographic and Health Survey (2014 BDHS) were analyzed. Logistic regression was applied to calculate crude odds ratios (CORs), adjusted odds ratios (AORs), 95% confidence intervals (CIs), and p-values.

Results

In Bangladesh, 35.9% of deliveries were attended by SBAs, and 44.2% of those women received at least one antenatal check-up by a skilled provider. The deliveries by SBAs were less than 50% of the total deliveries in all divisions, excluding Khulna. Known pregnancy complications (AOR: 1.2; 95% CI: 1.1–1.4), higher level of education in both women (AOR: 1.7; 95% CI: 1.2–2.3) and their husbands (AOR: 1.8; 95% CI: 1.3–2.4), receiving antenatal care (ANC) by a skilled provider during the pregnancy period (AOR: 1.5; 95% CI: 1.1–2.1), and higher wealth quintiles (AOR: 3.4; 95% CI: 2.5–4.7) were all significantly associated with an increased likelihood of a delivery by SBAs (p <0.05). In contrast, women living in rural areas (AOR: 0.7; 95% CI: 0.6–0.8) and the Sylhet Division (AOR: 0.4; 95% CI: 0.3–0.5) were less likely to be delivered by SBAs.

Conclusions

To achieve the target of the Government of Bangladesh - 50% of deliveries to be attended by SBAs - it is important to increase ANC services and awareness programs in all seven divisions of Bangladesh. Special focus in rural areas is also required to meet this target. A new study should be conducted to explore the unexamined factors associated with the presence of SBAs during childbirth.

Patterns and Determinants of Care-Seeking for Antepartum and Intrapartum Complications in Rural Bangladesh: Results from a Cohort Study

BACKGROUND

The burden of maternal complications during antepartum and intrapartum periods is high and care seeking from a trained provider is low, particularly in low middle income countries of sub-Saharan Africa and South Asia. Identification of barriers to access to trained care and development of strategies to address them will contribute to improvements in maternal health. Using data from a community-based cohort of pregnant women, this study identified the prevalence of antepartum and intrapartum complications and determinants of care-seeking for these complications in rural Bangladesh.

METHODS

The study was conducted in 24,274 pregnant women between June 2011 and December 2013 in rural Sylhet district of Bangladesh. Women were interviewed during pregnancy to collect data on demographic and socioeconomic characteristics; prior miscarriages, stillbirths, live births, and neonatal deaths; as well as data on their ability to make decision to go to health center alone. They were interviewed within the first 7 days of child birth to collect data on self-reported antepartum and intrapartum complications and care seeking for those complications. Bivariate analysis was conducted to explore association between predisposing (socio-demographic), enabling (economic), perceived need, and service related factors with care-seeking for self-reported antepartum and intrapartum complications. Multivariable multinomial logistic regression was performed to examine the association of selected factors with care-seeking for self-reported antepartum and intrapartum complications adjusting for co-variates.

RESULTS

Self-reported antepartum and intrapartum complications among women were 14.8% and 20.9% respectively. Among women with any antepartum complication, 58.9% sought care and of these 46.5% received care from a trained provider. Of the women with intrapartum complications, 61.4% sought care and of them 46.5% did so from a trained provider. Care-seeking for both antepartum and intrapartum complications from a trained provider was significantly higher for women with higher household wealth status, higher literacy level of both women and their husbands, and for those living close to a health facility (<10 km). Women's decision making ability to go to health centre alone was associated with untrained care only for antepartum complications, but was associated with both trained and untrained care for intrapartum complications.

CONCLUSIONS

Nearly 40.0% of the women who experienced either an antepartum or intrapartum complications did not seek care from any provider and 11.5% -14.9% received care from untrained providers, primarily because of economic and geographic barriers to access. Development and evaluation of context specific, cost-effective, and sustainable strategies that will address these barriers to access to care for the maternal complications will enhance care seeking from trained health care providers and improve maternal health.

Institutional delivery in public and private sectors in South Asia: a comparative analysis of prospective data from four demographic surveillance sites

Background

Maternity care in South Asia is available in both public and private sectors. Using data from demographic surveillance sites in Bangladesh, Nepal and rural and urban India, we aimed to compare institutional delivery rates and public-private share.

Methods

We used records of maternity care collected in socio-economically disadvantaged communities between 2005 and 2011. Institutional delivery was summarized by four potential determinants: household asset index, maternal schooling, maternal age, and parity. We developed logistic regression models for private sector institutional delivery with these as independent covariates.

Results

The data described 52 750 deliveries. Institutional delivery proportion varied and there were differences in public-private split. In Bangladesh and urban India, the proportion of deliveries in the private sector increased with wealth, maternal education, and age. The opposite was observed in rural India and Nepal.

Conclusions

The proportion of institutional delivery increased with economic status and education. The choice of sector is more complex and provision and perceived quality of public sector services is likely to play a role. Choices for safe maternity are influenced by accessibility, quantity and perceived quality of care. Along with data linkage between private and public sectors, increased regulation should be part of the development of the pluralistic healthcare systems that characterize south Asia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1069-7) contains supplementary material, which is available to authorized users.

Factors associated with institutional delivery in Dangila district, North West Ethiopia: a cross-sectional study

INTRODUCTION

Childbirth in a health institution has been shown to be associated with lower rates of maternal and neonatal mortality. However, about 85% of mothers in Ethiopia deliver at home.

OBJECTIVE

To assess factors associated with institutional delivery service utilization among women who gave birth within one year prior to the study in Dangila district.

METHODS

A cross-sectional study was conducted from February 01-28, 2015. A total of 763 mothers were interviewed using structured questionnaire. SPSS version 20 was used for analysis. Crude and adjusted Odds ratios were computed for selected variables. A P-value less than 0.05 was considered statistical significant.

RESULTS

Only 18.3% of mothers gave birth at health facilities. Knowledge on danger signs [AOR=2.0, 95% CI: (1.1, 3.4)], plan to give birth at health institution [AOR=5.4, 95% CI: (3.0, 9.6)], having ANC follow up during pregnancy [AOR=12.9, 95% CI: (5.0, 33.3)] and time taken to get to a nearby health institution [AOR=5.1, 95% CI: (2.9, 9.1)] were associated with institutional delivery service utilization.

CONCLUSION

Institutional delivery was very low. Knowledge about danger signs, having ANC visits, and time were factors associated with institutional delivery service utilization. Thus, the findings recommend repeated re-enforcement of institutional delivery service utilization through professionals. And also, the findings recommend promotion of institutional delivery service utilization through mass media.

Ecological and socio-demographic differences in maternal care services in Nepal

Background. Nepal is set to achieve MDG-5 goals by end of 2015. However, maternal health parameters will remain way below those of developed countries. This study was conducted to assess the factors contributing to utilization of ANC and safe delivery services with the aim of furthering overall maternal health parameters in Nepal.

Material and Methods. Using survey data from the Nepal Demographic and Health Survey 2011, socio-economic and demographic factors associated with the utilization of ANC and safe delivery services among women aged 15–49 years who gave births during the last three years preceding the survey are examined. Data was segregated into three ecological zones: Mountain, Hill and Terai zones for univariate analyses. Data from all three zones was then pooled for univariate and multivariate logistic regression analyses of Antenatal Care and Safe Delivery services in Nepal.

Results and Conclusion. The analyses show that rural place of residence is at a disadvantage in receiving ANC (OR, 0.8; 95% CI [0.7–0.9]) and ensuring safe delivery (OR, 0.6; 95% CI [0.5–0.7]). Woman’s education, husband’s education and wealth quintile are significant factors in ensuring ANC and safe delivery services. Further, the analyses show that Budh/Muslim/Kirat/Christians are at a significant disadvantage in ensuring safe delivery (OR, 0.8; 95% CI [0.7–0.9]) as compared with Hindus. Though ecological zones lost their significance in receiving ANC, women in the Terai region are at a significant advantage in ensuring safe delivery (OR, 1.7; 95% CI [1.2–2.1]).

Recommendation. Segregated targets should be set for the different ecological zones for further improvement in maternal mortality rates in Nepal.

Levels and determinants of continuum of care for maternal and newborn health in Cambodia-evidence from a population-based survey

Background

Continuum of care throughout pregnancy, birth, and after delivery has become a key program strategy for improving the health of mothers and newborns. Successful program implementation to improve the continuum of care relies on a better understanding of where the gaps are in seeking care along the pathway and what factors contribute to the gaps.

Methods

Using data from the 2010 Cambodia Demographic and Health Survey, we examine the levels of service use along the continuum of care. Three sequential regression models are fitted to identify factor(s) that affect women from getting skilled birth attendance (SBA) after receiving antenatal care (ANC), and from getting postnatal care (PNC) after having both ANC and SBA.

Results

Three of every five Cambodian women received all three types of maternal care—antenatal care, skilled birth attendance at birth and postnatal care -for their most recent birth, however with substantial regional variation ranging from 14% to 96%. The results highlight that mother’s age, educational attainment, urban residence, household wealth, lower birth order are associated with women’s use of antenatal care and their continuation to using skilled birth attendant. Health insurance coverage also increases use of antenatal care but not skilled birth attendant. Having four antenatal care visits and receiving better quality of antenatal care affected women’s subsequent use of skilled birth attendant. The odds of having skilled birth attendant increases by 30 to 50% for women who received blood pressure measurement, urine sample taken, and blood sample taken as part of antenatal services. Household wealth status, urine sample taken, and delivery at a health facility were the only three factors significantly associated with the continuation from having skilled birth attendant to receiving postnatal care.

Conclusions

Cambodia has made remarkable progress in extending the reach of maternal health care in most areas of the country. Future program efforts should focus on the Northeast part of the country where the lowest level of service use was found. Poor women suffered from lower access to continued care and extending the health insurance coverage might be one way to help them out. Quality of antenatal care is connected to women’s use of skilled birth attendant and postnatal care and should be given more focus.