Prevalence and risk factors for non-use of antenatal care visits: analysis of the 2010 South Sudan household survey

Predictors and number of antenatal care visits among reproductive age women in Sub-Saharan Africa further analysis of recent demographic and health survey from 2017-2023: Zero-inflated negative binomial regression

BACKGROUND

Antenatal care (ANC) is an important component of maternal and child health care. To reduce perinatal mortality and improve women's experience of care, the World Health Organization (WHO) recommends pregnant women should attend at least eight ANC visits. However, in Sub-Saharan Africa (SSA), the mean number of ANC visits among reproductive-age women using Demographic and Health Surveys (DHS) data following the new WHO recommendation is so far limited. Therefore, the study aimed to determine the mean number of ANC visits and its predictors among reproductive-age women in SSA.

METHOD

Community-based cross-sectional study was conducted among 188,880 weighted reproductive-age women in SSA using a recent round of DHS data from 2017-2023. Zero-inflated negative binomial regression (ZINB) was conducted and statistical significance was declared at p-value <0.05 and adjusted incidence rate ratio(AIRR) for count model part and adjusted odds ratio for logit model inflated part of ZINBR with 95% confidence interval (CI) were reported.

RESULT

The mean number of ANC visits among reproductive-age women in SSA was 4.08 with 95%CI [4.07, 4.09]. Among reproductive-age women who gave birth in the last five years before the survey, 7.3% had eight or more ANC visits during pregnancy. Age of women, maternal and husband educational status, types of pregnancy, birth order, household size, number of under-five children, and wealth index were associated with the numbers of ANC visits among reproductive-age women in Sub-Saharan.

CONCLUSION

The mean number of ANC visits among reproductive-age women in SSA is too lower than the new WHO recommendation of ANC visits for a positive pregnancy experience. This study also highlights that the proportion of at least eight ANC visits is low and there are still disparities in the mean of ANC visits across different regions of SSA. The increasing maternal age, higher maternal and husband educational status, wanted pregnancy, the number of household members, the number of under-five children, and higher wealth index increase the number of ANC visits. Unwanted pregnancy, no more fertility desire, and rural residences were contributed for zero ANC visits in SSA. Therefore, efforts should be geared towards improving maternal and husband's educational status. We strongly recommend that the governments of SSA countries should empower women economically and educationally to achieve the goals of ANC as recommended by the WHO.

Determinants of Utilization of Antenatal Care Services Among Women of Childbearing Age in Jigawa State, Nigeria

Introduction

Antenatal care (ANC) services play a crucial role in safeguarding the health of pregnant women during their reproductive years. This study aimed to evaluate the primary factors influencing the utilization of ANC among women of childbearing age in Isari town, Jigawa State.

Methods

We conducted a cross-sectional study among 400 mothers of childbearing age, selecting them using a simple random sampling method. Data were collected using interviewer-administered questionnaires. The statistical analyses performed were descriptive analysis, Pearson's chi-square test, and binary logistic regression analysis.

Results

The majority of respondents (92.5%) indicated awareness of ANC, with a significant proportion expressing the necessity of ANC services (85.7%). 57.8% of the respondents indicated attending ANC services at least four times during pregnancy. Furthermore, the number of visits has a significant relationship with age (P < 0.001), educational level (P = 0.003), occupation (P = 0.043), mother's knowledge of pregnancy danger signs (P = 0.001), and husband's support for ANC (P < 0.001).

Conclusion

Enhancing ANC utilization will necessitate focusing on women residing in rural areas and those with limited educational attainment.

The practice of polygyny on the utilisation of reproductive health services among married women in Ghana

While the practice of polygyny is common in Ghana, little is known about its impact on the use of reproductive health services. The aim of this study was to assess the relationship between polygynous marriage and the utilisation of skilled antenatal care (ANC), assisted skilled birth, and modern contraceptive services among married women in Ghana. Secondary data from the 2017 Ghana Maternal Health Survey were used for this study. The study included a weighted sample of 9,098 married women aged 15-49 years. We used multivariable logistic regression models to assess the association between polygyny and each outcome variables. Sensitivity analysis was conducted to assess the dose-response relationship between polygyny and each outcome variable. The prevalence of eight or more ANC contacts, assisted skilled births, and use of modern contraception were 47.0%, 81.4%, and 25.4%, respectively. The prevalence of women in polygynous marriages was 15.3%. Compared to monogynous marriage, polygynous marriage was associated with 19% lower odds of having eight plus ANC contacts (adjusted odds ratio [aOR] 0.81, 95% CI: 0.69, 0.96), 25% lower odds of having assisted skilled birth (aOR 0.75, 95% CI: 0.63, 0.89), and 19% lower odds of modern contraceptive utilisation (aOR 0.81, 95% CI: 0.66, 0.99). Interventions on reproductive health may need to prioritise women in polygynous marriages in order to improve the utilisation of skilled ANC, assisted skilled birth, and modern contraceptive services.

An investigation of factors affecting the utilization of antenatal care services among women in post-natal wards in two Namibian hospitals in the Khomas region

Background

Antenatal care (ANC) services are the care provided by skilled healthcare professionals to pregnant women to ensure the best health for both mother and baby during pregnancy and after delivery. In Namibia, utilization of antenatal care services has been reported to be dropping from 97% in 2013 to 91% in 2016.

Objectives

The objectives of this study were to investigate the factors affecting the utilization of ANC services.

Methods

A quantitative approach and a cross-sectional analytical design were used to carry out the study. The study population was all mothers who delivered and were admitted to the postnatal ward of Intermediate Hospital Katutura and Windhoek Central Hospital during the time of the study. Data were collected from 320 participants using self-administered structured questionnaires. The data were analyzed using the Statistical Package for Social Science (SPSS) Version 25 software.

Results

Participants were aged between 16 and 42 years with a mean age of 27 years. The results show that 229 (71.6%) utilized ANC while 91(28.4%) did not utilize ANC services. Factors such as the negative attitude of health care workers, long distance to and from health facilities, lack of transport money to travel to and from the health facilities, lack of knowledge regarding antenatal care, attitude towards pregnancy, and others, were found as hindrances to the utilization of antenatal care services. Participants also indicated motivators for ANC utilization such as preventing complications, knowing their HIV status, getting health education, knowing the estimated date of delivery, and identifying and treatment of medical conditions. The study reveals the higher knowledge of participants on ANC utilization, most participants have the right to make decisions and had positive attitudes toward the quality of ANC services. The level of attitude toward pregnancy was associated with the utilization of antenatal care services with an odd ratio OR=2.132; and P=0.014.

Conclusions

The study identified factors that affect utilization of ANC services such as age, marital status, mother's education, partner's formal education, negative attitude toward health providers, long distance to and from ANC health care facilities, fear of HIV test and results, Covid-19 regulations, inability to determine the pregnancy at the earlier stages and financial constraints Based on this study findings, it is recommended that the utilization of ANC might be improved through effective community mobilization and outreach maternity services to educate and improve awareness on the importance of ANC.

Antenatal Care Dropout and Associated Factors in Ethiopia: A Systematic Review and Meta-Analysis

Background

The prevalence and determinants of antenatal care (ANC) dropout in Ethiopia were studied. However, the results were inconsistent and showed considerable variation. Hence, this meta-analysis aimed at estimating the overall prevalence of ANC dropout and its predictors in Ethiopia.

Methods

A comprehensive search of published studies was done using different international databases such as such as PubMed, DOJA, Embase, Cochrane Library, Google Scholar, and the institutional repository of Ethiopian universities were used to search for relevant studies. Data were extracted using Microsoft Excel spreadsheet, and exported to STATA v17 for analysis. A random effect model was used to estimate the overall national prevalence of ANC dropout. Fixed effects model were used to compute the pooled adjusted odd ratios (AOR) with the corresponding 95% confidence intervals (CIs). I2 test was used to assess heterogeneity of the included studies. Egger's tests was used to check for the presence of publication bias.

Results

A total of 7 studies were included in this systematic review and meta-analysis with 11,839 study participants. The overall pooled prevalence of ANC in Ethiopia was found to be 41.37% (95% CI =35.04, 47.70). Distance from the health care facility (AOR = 2.93, 95% CI = 2.75, 3.11), pregnancy complication signs (AOR = 2.97, 95% CI = 2.77, 3.16), place of residence (AOR =  1.79, 95% CI = 1.31, 2.26), educational level (AOR = 1.79, 95%CI = 1.37, 2.21), and age group (30-49) (AOR = 0.61, 95% CI = 0.45, 0.78) were significantly associated with ANC dropout.

Conclusion

Based on this review and meta-analysis, 41% of Ethiopian women dropped out of ANC visits before the minimum recommended visit (4 times). Hence, to reduce the number of ANC dropouts, it is important to counsel and educate women during their first prenatal care. Issues of urban–rural disparities and noted hotspot areas for ANC dropout should be given further attention.

Factors Influencing the Antenatal Care Attendance of Pregnant Women During the First COVID-19 Wave Lockdown in Thailand

Background

The coronavirus disease 2019 (COVID-19) outbreak impacted healthcare service management worldwide. Thailand had limited healthcare resources. During the pandemic, several medical supplies were in high demand and expensive. The Thai government needed to declare a lockdown to reduce the unnecessary use of medical supplies. Antenatal care (ANC) services have adapted to the outbreak situation. However, information about the potential impact of COVID-19 lockdown on pregnant women and the reduction of disease exposure risk in this population remains unclear. Thus, this study aimed to assess the percentage of ANC attendance and factors affecting the scheduled ANC attendance of pregnant women during the first COVID-19 wave lockdown in Thailand.

Methods

This retrospective cross-sectional study included Thai women who were pregnant between 1 March and 31 May 2020. An online survey was conducted among pregnant women who had first ever ANC attendance before 1 March 2020. A total of 266 completed responses were returned and analysed. Statistically, the sample size was representative of the population. The predictors of scheduled ANC attendance during the lockdown were identified through logistic regression analysis.

Results

Overall, 223 (83.8%) pregnant women had scheduled ANC attendance during the lockdown. The predictive factors of ANC attendance were non-relocation (adjusted odds ratio [AOR] = 2.91, 95% confidence interval [CI]: 1.009-8.381) and access to health services (AOR = 2.234, 95% CI: 1.125-4.436).

Conclusion

During the lockdown, ANC attendance slightly declined, and the extended duration of each ANC or reduced face-to-face interactions with healthcare professionals. For pregnant women with non-relocation, healthcare providers must provide opportunities to contact them directly if they had doubts. The limited number of pregnant women who access health services allowed the clinic to be less crowded and therefore easy to ANC attendance.

Timely Attendance of the First Antenatal Care among Pregnant Women Aged 15–49 Living with HIV in Juba, South Sudan

Timely attendance of the first antenatal care (ANC) is the period in which pregnant women visit ANC less than four months of pregnancy. There is a paucity of data on timely first ANC attendance and its associated factors among pregnant women living with human immunodeficiency virus (HIV) in Juba. The aim of this study was to investigate timely attendance of the first ANC visit among pregnant women living with HIV. Institutional cross-sectional study was conducted in three public health facilities in Juba by convenience sampling from January 2019 to December 2019. Pearson’s chi-squared test was conducted for bivariate analysis and variables with probability values ( $p$ values) less than 5% were considered as statistically significant for multivariable analyses using Fisher’s exact test. At the multivariate level, binary logistic regression analysis was conducted. Out of the 192 participants studied, 27 (14.1%) had timely first ANC attendance as recommended and 165 (85.9%) attended first ANC at four months and above. Distances (adjusted risk ratio [aOR], 7.14; 95% confidence interval [CI], 1.40–36.68), ANC card (aOR, 3.48; 95% CI, 1.17–10.40), waiting time ([aOR], 0.04; 95% CI, 0.01–0.75), and prevention of mother-to-child transmission (PMTCT) services (aOR, 0.12; 95% CI, 0.03–0.56) were the factors associated with timely first ANC attendance. Health education interventions targeting pregnant women attending ANC at health facilities should focus on increasing knowledge and awareness of the importance of timely first ANC attendance.

Why don't illiterate women in rural, Northern Tanzania, access maternal healthcare?

Background

In 2017, roughly 540 women in Sub-Saharan Africa died every day from preventable causes related to pregnancy and childbirth. To stem this public-health crisis, the WHO recommends a standard continuity of maternal healthcare, yet most women do not receive this care. Surveys suggest that illiteracy limits the uptake of the recommended care, yet little is understood about why this is so. This gap in understanding why healthcare is not sought by illiterate women compromises the ability of public health experts and healthcare providers to provide culturally relevant policy and practice. This study consequently explores the lived experiences related to care-seeking by illiterate women of reproductive age in rural Tanzania to determine why they may not access maternal healthcare services.

Methods

An exploratory, qualitative study was conducted in four communities encompassing eight focus group discussions with 81 illiterate women, 13 in-depth interviews with illiterate women and seven key-informant interviews with members of these communities who have first-hand experience with the decisions made by women concerning maternal care. Interviews were conducted in the informant’s native language. The interviews were coded, then triangulated.

Results

Two themes emerged from the analysis: 1) a communication gap arising from a) the women’s inability to read public-health documents provided by health facilities, and b) healthcare providers speaking a language, Swahili, that these women do not understand, and 2) a dependency by these women on family and neighbors to negotiate these barriers. Notably, these women understood of the potential benefits of maternal healthcare.

Conclusions

These women knew they should receive maternal healthcare but could neither read the public-health messaging provided by the clinics nor understand the language of the healthcare providers. More health needs of this group could be met by developing a protocol for healthcare providers to determine who is illiterate, providing translation services for those unable to speak Swahili, and graphic public health messaging that does not require literacy. A failure to address the needs of this at-risk group will likely mean that they will continue to experience barriers to obtaining maternal care with detrimental health outcomes for both mothers and newborns.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03906-2.

Country compliance with WHO-recommended antenatal care guidelines: equity analysis of the 2015-2016 Demography and Health Survey in Myanmar

Introduction

Early access to adequate antenatal care (ANC) from skilled providers is crucial for detecting and preventing obstetric complications of pregnancy. We aimed to assess factors associated with the utilisation of the new WHO ANC guidelines including the recommended number, on time initiation and adequate components of ANC contacts in Myanmar.

Methods

We examined data from 2943 mothers aged 15–49 years whose most recent birth occurred in the last 5 years prior to the 2015–2016 Myanmar Demographic and Health Survey. Factors associated with utilisation of the new WHO recommended ANC were explored using multinomial logistic regression and multivariate models. We used marginal standardisation methods to estimate the predicted probabilities of the factors significantly associated with the three measures of ANC.

Results

Approximately 18% of mothers met the new WHO recommended number of eight ANC contacts. About 58% of the mothers received adequate ANC components, and 47% initiated ANC within the first trimester of pregnancy. The predicted model shows that Myanmar could achieve 70% coverage of adequate components of ANC if all women were living in urban areas. Similarly, if ANC was through private health facilities, 63% would achieve adequate components of ANC. Pregnant women from urban areas (adjusted risk ratio (aRR): 4.86, 95% CI 2.44 to 9.68) were more than four times more likely to have adequate ANC components compared with women from rural areas. Pregnant women in the highest wealth quintile were three times more likely to receive eight or more ANC contacts (aRR: 3.20, 95% CI 1.61 to 6.36) relative to mothers from the lowest wealth quintile. On time initiation of the first ANC contact was fourfold for mothers aged 30–39 years relative to adolescent mothers (aRR: 4.07, 95% CI 1.53 to 10.84).

Conclusion

The 2016 WHO ANC target is not yet being met by the majority of women in Myanmar. Our results highlight the need to address health access inequity for women who are from lower socioeconomic groups, or are younger, and those living in rural areas.

Factors influencing early postnatal care utilisation among women: Evidence from the 2014 Ghana Demographic and Health Survey

INTRODUCTION

Early postnatal care (EPNC) utilisation is crucial for averting maternal deaths as recommended by the World Health Organisation. About 30% of women do not obtain EPNC in Ghana and no national level study have investigated the determinants of EPNC. Therefore, this study aimed at assessing factors associated with EPNC uptake among women aged 15-49 in Ghana.

MATERIALS AND METHODS

The study utilised data from the women's file of the 2014 Ghana Demographic and Health Survey (GDHS) and sampled 1,678 women aged 15-49 who had complete data on EPNC. Descriptive computation of EPNC was done. Since EPNC (which is the main outcome variable for the study) was dichotomous, the binary logistic regression was used to determine factors influencing utilisation of EPNC at 95% two-tailed confidence interval. The results were presented as adjusted odds ratio (AOR). Stata version 14.0 was used for all the analyses.

RESULTS

Descriptively, the results indicated that 31% of women aged 15-49 sought EPNC. At the inferential level, women aged 40-44 were more likely to seek EPNC compared to those aged 15-19 [AOR = 3.66, CI = 1.25-10.67]. Islam women had higher odds of EPNC as compared with Christians [AOR = 1.70, CI = 1.23-2.35]. Comparatively, women of Mande ethnic group had higher propensity to seek EPNC than the Akan [AOR = 3.22, CI = 1.20-8.69]. Residents of the Greater Accra region were over 11 times probable to utilise EPNC compared with the residents of Western region.

CONCLUSION

The key determinants of EPNC were age, religion, ethnicity, marital status and region. Therefore, the Health Promotion and Education Unit and Reproductive and Child Health Department of the Ghana Health Service need to scale up EPNC sensitisation programmes and should target women aged 15-19, Christians and other category of women with less likelihood of EPNC in order to offset the disparities.

Effects of a Home-Based Intervention on HIV Prevention Health Behaviors in Pregnant/Postpartum Kenyan Women: Estimating Moderating Effects of Depressive Symptoms

We estimated effects of maternal depressive symptoms, utilizing the Patient Health Questionnaire-8 (PHQ-8), on women's HIV prevention behaviors in Migori County, Kenya. Pregnant women ≥ 18 years old, with gestational age of < 37 weeks, were randomized into standard care or three home visits (2 during pregnancy, 1 postpartum) promoting couple HIV testing and counseling (CHTC) and HIV prevention. Of 105 female participants, 37 (35.24%) reported depressive symptoms and 50 (47.62%) were HIV-positive. Three Poisson regressions with robust variance (univariable, multivariable, and multivariable with depressive symptoms/study arm interaction) were modeled for three outcomes: CHTC, infant HIV testing, health-seeking postpartum. In multivariable analysis with interaction, a moderating trend for the interaction between depressive symptoms and individual health-seeking was observed (p-value = 0.067). Women scoring ≤ 9 (n = 68) on the PHQ-8 and participating in home visits were 1.76 times more likely to participate in individual health-seeking compared to participants in standard care (ARR 1.76, 95% CI 1.17-2.66).

Magnitudes of post-abortion family planning utilization and associated factors among women who seek abortion service in Bahir Dar Town health facilities, Northwest Ethiopia, facility-based cross-sectional study

INTRODUCTION

Globally an estimated 55.9 million abortions occur each year. The majority of abortions occur due to unintended pregnancies, which is a result of the non-use of family planning methods. World health organization recommends all clients to utilize modern contraceptive methods after any abortion procedure. However, post-abortion family planning utilization is still low in Ethiopia including the study area. Therefore, this study was expected to determine the utilization of post-abortion family planning and associated factors in Bahir Dar city health facilities in Northwest Ethiopia.

METHOD

Institution based cross-sectional study was conducted among 408 women from March 1 to April 30, 2019. Data were collected through face-to-face interview using a structured and pre-tested questionnaire. Systematic random sampling was used to select the study participants. Data were cleaned, coded, and entered into epi data and exported to SPSS for further analysis. Both bivariable and multivariable logistic regression were employed. Those variables that had a p-value of less than 0.2 during the bivariate analysis were retained for the multivariable analysis. P-value and confidence interval were used to measure the level of significance on multi-variable analysis and those variables whose P-value, less than 0.05 was considered as statistically significant.

RESULTS

The finding of this study showed that the magnitude of post-abortion family planning (PAFP) utilization was 61% with 95% CI (55, 65). Secondary education level(AOR, 4.58; 95% CI (1.96, 10.69)), certificate and above education level (AOR, 3.06; 95% CI (1.32, 7.08)), Manual Vacuum Aspiration(MVA) (AOR, 7.05; 95% CI (2.94, 16.90)), both medication and Manual Vacuum Aspiration (AOR, 5.34; 95% CI (2.56, 11.13)) and received Post Abortion Family Planning (PAFP) counseling (AOR, 5.99; 95% CI (3.23, 11.18)) were significantly associated with PAFP utilization.

CONCLUSION

Post-abortion family planning utilization in Bahir Dar health facilities was low compared with the national figure. Secondary and above educational level, respondents who were managed by Manual Vacuum Aspiration (MVA), both Manual Vacuum Aspiration (MVA) and medication and receiving Post Abortion Family Planning (PAFP) counseling were predictors of post-abortion family planning service utilization.

Women's Empowerment as a Mitigating Factor for Improved Antenatal Care Quality despite Impact of 2014 Ebola Outbreak in Guinea

Improving maternal outcomes and reducing pregnancy morbidity and mortality are critical public health goals. The provision of quality antenatal care (ANC) is one method of doing so. Increasing women’s empowerment is associated with positive women’s health outcomes, including the adequate timing and amount of ANC use. However, little is known about the relationship between women’s empowerment and quality ANC care. Despite a history of political instability, low women’s equality and poor maternal health, the Republic of Guinea has committed to improving the status of women and access to health. However, the 2014 Ebola outbreak may have had a negative impact on achieving these goals. This study sought to examine factors in the relationship between women’s empowerment and the receipt of quality ANC (indicated by the number of health components) within the context of the Ebola outbreak. This study conducted multiple logistic regressions examining associations between covariates and the number of ANC components received using data from the 2012 and 2018 Guinea Demographic Health Surveys. Several aspects of women’s empowerment (healthcare decision-making, literacy/access to magazines, monogamous relationship status, contraceptive use, socio-economic status/employment) were significantly linked with the receipt of a greater number of ANC components, highlighting the importance of women’s empowerment in accessing quality maternity care.

Determinants of antenatal care dropout among mothers who gave birth in the last six months in BAHIR Dar ZURIA WOREDA community; mixed designs

Background

Antenatal care is the care provides for a pregnant mother to improve the health of the mother and her baby. But in the World including Ethiopia still, mothers do not receive the required number of antenatal care visits. Therefore, the main aim of this study was to identify determinants of Antenatal care visit dropout in Bahir Dar Zuria Woreda North West Ethiopia.

Methods

The study was community-based unmatched case-control study that employed both quantitative and qualitative data. For the quantitative part, 134 cases and 266 controls (total 400) women who gave births in the last six months prior to the study in Bahir Dar Zuria Woreda were enrolled. Data were collected through face to face interviews from March 1 to 30, 2018 using a structured questionnaire. Bivariate and multivariate analysis was used. 95% confidence interval and P-value was used to measure the level of significance. For the qualitative part, six FGDs were conducted and open code software was used for the analysis of the data. The finding was narrated by triangulating with the quantitative findings.

Result

Being far distance (AOR 7.26; 95% CI 4.23, 23.01), not having a companion (AOR 3.49; 95% CI; 2.39, 8.44), lack of knowledge (AOR 2.57; 95% CI; 1.25, 5.28), poor wealth index (AOR; 3.36, 95% CI 1.71, 6.62) and not developing a danger sign (AOR 2.18; 95% CI 2.28, 7.64) were predictors of ANC dropout. In addition to this, in the qualitative finding, the socio-culture of the community, attitudes, experience, and perception of the existing services and service provisions were also determinants of ANC drop out.

Conclusion

Socio-cultural, economic, accessibility, and individual factors were determinants of ANC visit drop out. In addition, the behavior of the professional, the mother understands of the existing services, and their perception about ANC influenced ANC dropout.

Risk factors for women's non-utilization of decentralized primary health care facilities for postnatal care in rural western Ethiopia

Objective:

Evidence suggests postnatal care contributes to reductions in maternal mortality. In Ethiopia, the proportion of women who do not utilize postnatal care after birth is high and the frequency of postnatal checks falls short of the four visits recommended by World Health Organization. This study examined risk factors associated with non-utilization of decentralized local health facilities, namely, health posts, health centers, and a primary hospital, for postnatal care services in Gida Ayana Woreda in rural western Ethiopia.

Methods:

In this study, 454 mothers were examined for the following risk factors: kebele (the smallest administrative unit in Ethiopia) in which decentralized health care facilities were located, postnatal woman’s age, antenatal care service visit, experience of postnatal complications, knowledge of postnatal complications, knowledge of the recommended number of postnatal care visits, knowledge of the availability/provision of postnatal care, and health extension workers’ home visits. Bivariate and multivariable logistic regression analyses were applied to identify predictors of non-utilization of decentralized local facilities for postnatal care services.

Results:

Over half (55.7%) of the women did not utilize postnatal care within 42 days of delivery, and only 10.0% utilized the care considered appropriate according to World Health Organization guidelines. After adjusting for various potential confounding factors, we found the following risks to be strongly associated with non-utilization of decentralized health care facilities for postnatal care services: some outer rural administrative decentralization entities such as Angar, Lalistu, and Ejere kebeles; age 35 years or older (adjusted odds ratio = 3.4, 95% confidence interval: 1.4–8.3), not receiving antenatal care during this pregnancy (adjusted odds ratio = 2.0, 95% confidence interval: 1.1–3.7), no experience of any postnatal complications (adjusted odds ratio = 3.3, 95% confidence interval: 1.7–6.4), and no knowledge of at least one postnatal complication (adjusted odds ratio = 2.0, 95% confidence interval: 1.2–3.3). Risk factors highly but less strongly associated with women’s non-utilization of postnatal care services were no knowledge of the standard number of postnatal care visits recommended, no knowledge about the availability/provision of services at a local health facility, and no home visit from health extension worker by day 3 post-delivery.

Conclusion:

The risk factors for women’s non-utilization of decentralized health care facilities for postnatal care identified in this study need to be considered in interventions for enhancing the utilization of the service and reducing maternal and newborn deaths in rural western Ethiopia. Strengthening of postnatal care services, especially in the more remote kebeles, should include upgrading of the referral system and expansion of counseling of women by health extension workers.

Is development aid to strengthen health systems during protracted conflict a useful investment? The case of South Sudan, 2011-2015

Introduction

Is achievement of Sustainable Development Goal (SDG) 16 (building peaceful societies) a precondition for achieving SDG 3 (health and well-being in all societies, including conflict-affected countries)? Do health system investments in conflict-affected countries waste resources or benefit the public’s health? To answer these questions, we examine the maternal, newborn, child and reproductive health (MNCRH) service provision during protracted conflicts and economic shocks in the Republic of South Sudan between 2011 (at independence) and 2015.

Methods

We conducted two national cross-sectional probability surveys in 10 states (2011) and nine states (2015). Trained state-level health workers collected data from households randomly selected using probability proportional to size sampling of villages in each county. County data were weighted by their population sizes to measure state and national MNCRH services coverage. A two-sample, two-sided Z-test of proportions tested for changes in national health service coverage between 2011 (n=11 800) and 2015 (n=10 792).

Results

Twenty-two of 27 national indicator estimates (81.5%) of MNCRH service coverage improved significantly. Examples: malaria prophylaxis in pregnancy increased by 8.6% (p<0.001) to 33.1% (397/1199 mothers, 95% CI ±2.9%), institutional deliveries by 10.5% (p<0.001) to 20% (230/1199 mothers, ±2.6%) and measles vaccination coverage in children aged 12–23 months by 11.2% (p<0.001) to 49.7% (529/1064 children, ±2.3%). The largest increase (17.7%, p<0.001) occurred for mothers treating diarrhoea in children aged 0–59 months with oral rehydration salts to 51.4% (635/1235 children, ±2.9%). Antenatal and postnatal care, and contraceptive prevalence did not change significantly. Child vitamin A supplementation decreased. Despite significant increases, coverage remained low (median of all indicators = 31.3%, SD = 19.7). Coverage varied considerably by state (mean SD for all indicators and states=11.1%).

Conclusion

Health system strengthening is not a uniform process and not necessarily deterred by conflict. Despite the conflict, health system investments were not wasted; health service coverage increased.

Health policy mapping and system gaps impeding the implementation of reproductive, maternal, neonatal, child, and adolescent health programs in South Sudan: a scoping review

BACKGROUND

Pregnant women, neonates, children, and adolescents are at higher risk of dying in fragile and conflict-affected settings. Strengthening the healthcare system is a key strategy for the implementation of effective policies and ultimately the improvement of health outcomes. South Sudan is a fragile country that faces challenges in implementing its reproductive, maternal, neonatal, child, and adolescent health (RMNCAH) policies. In this paper, we map the key RMNCAH policies and describe the current status of the WHO health system building blocks that impede the implementation of RMNCAH policies in South Sudan.

METHODS

We conducted a scoping review (39 documents) and individual interviews (n = 8) with staff from the national Ministry of Health (MoH) and implementing partners. We organized a workshop to discuss and validate the findings with the MoH and implementing partner staff. We synthesized and analyzed the data according to the WHO health system building blocks.

RESULTS

The significant number of policies and healthcare strategic plans focused on pregnant women, neonates, children, and adolescents evidence the political will of the MoH to improve the health of members of these categories of the population. The gap in the implementation of policies is mainly due to the weaknesses identified in different health system building blocks. A critical shortage of human resources across the blocks and levels of the health system, a lack of medicines and supplies, and low national funding are the main identified bottlenecks. The upstream factors explaining these bottlenecks are the 2012 suspension of oil production, ongoing conflict, weak governance, a lack of accountability, and a low human resource capacity. The combined effects of all these factors have led to poor-quality provision and thus a low use of RMNCAH services.

CONCLUSION

The implementation of RMNCAH policies should be accomplished through innovative and challenging approaches to building the capacities of the MoH, establishing governance and accountability mechanisms, and increasing the health budget of the national government.

Determinants to late antenatal clinic start among pregnant women: the case of Saint Elizabeth General Hospital, Shisong, Cameroon

Introduction

To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at all levels of the health system. The World Health Organisation (WHO) cites distance to health facility and inadequate health institutions as factors that prevent women from receiving or seeking care during pregnancy and childbirth. Specifically, we intended to determine factors associated with late start of late Antenatal Care (ANC) among pregnant women in the Saint Elizabeth General Hospital Shisong (SEGHS), Cameroon.

Methods

This was a cross sectional study carried out from the 24^th October to 24^th November 2016. A total of 602 pregnant women were recruited from ANC units of SEGHS and its satellite institutions. The outcome variable was gestational age at start of ANC (estimated by counting from last menstrual period to day of first ANC consultation) while the independent variables were individual, community and institutional factors. Data was analyzed using Epi info version 7. Chi square test was used to appreciate the influence of different variables on risk of late ANC initiation (> 14 weeks of pregnancy). The level of significance was set out at (p: < 0.05).

Results

Out of the 602 pregnant women included in our study, 75% initiated ANC late (after 14 weeks of pregnancy). Factors associated with late ANC start were; age (p = 0.001), level of education (p = 0.002), marital status (p = 0.016), religion (p = 0.034), parity (p = 0.001), having a source of income (p=0.001), cost of services (p = 0.010), distance to health facility (p = 0.021) and dissatisfaction with previous ANC services (p = 0.014).

Conclusion

Cameroon is one of the countries with a high maternal mortality ratio. WHO estimated it to be 529 per 100000 live births in 2017. Prompt and adequate ANC services can improve on maternal and child outcomes of pregnancy. The results of this study suggest tackling issues related to cost of ANC services and improving geographical (distance) barrier to accessing ANC services (in addition to addressing other identified measures) may lead to an increase in pregnant women starting ANC early and thus potentially improve pregnancy outcomes.

Using Andersen's behavioral model of health care utilization in a decentralized program to examine the use of antenatal care in rural western Ethiopia

Background

In Ethiopia, most women do not make the minimum number of antenatal care (ANC) visits recommended by WHO. This study modeled predisposing, enabling, need, and external environmental factors in the utilization of decentralized health facilities for ANC services in rural western Ethiopian communities.

Methods

A community-based, cross-sectional study was conducted in Gida Ayana Woreda (District) among 454 women. Data were collected through structured questionnaires. Multinomial logistic regression was used to model the association between the explanatory variables and the use of recommended and fewer than recommended visits for ANC with reference to the base model, no ANC visits.

Results

Only 15.2% of women made the recommended minimum number of ANC visits. Women with fewer than 2 children (AOR 10.7; 95% CI 3.0–8.4) were 10.7 times more likely received ANC service as recommended. Women with a delivery of 2 or more (AOR 9.7; 95% CI 3.7–5.2) home visits by health extension workers (HEWS) were 9.7 times more likely receiving minimum ANC services. Involvement in gainful activities had 4 times higher log odds of seeking recommended ANC (AOR 4.0; 95% CI 1.4–11.7). Women who experienced high fever were more likely to obtain the recommended ANC services (AOR 7.1; 95% CI 2.9–7.5). Residents of Ayana Kebele decentralization entity were 60% more likely to make the recommended number of visits to ANC (AOR 24.6; 95% CI 4.8–15.2).

Conclusions

Number of children, home visits, gainful activities, monthly income, high fever, and decentralized administrative kebele were strongly linked with recommended ANC schedule. The need for a program intervention aimed at meeting WHO recommendations for ANC visits include economizing birth size and spacing; improving home attendance by HEWs, knowledge of pregnancy complications and benefits of minimum ANC visits, local socio-economic development measures targeting poor women/households; further decentralization of health system improving proximity to ANC in rural western Ethiopia.

Factors associated with antenatal care visits in Afghanistan: secondary analysis of Afghanistan Demographic and Health Survey 2015

Afghanistan is one of the countries with the poorest maternal mortality ratio in the world. Inadequate utilization of antenatal care (ANC) services increases the risk of maternal mortality. This study aimed to identify the factors associated with ANC visits in Afghanistan. The dataset of the Afghanistan Demographic and Health Survey (AfDHS) 2015 were used for taking the socio-demographic factors, cultural factors, and the number of ANC visits. The subjects of this study were 18,790 women who had at least one live birth in the last five years, and 10,554 women (56.2%) had availed of at least one ANC visit. Most women were 20-29 years old (53.3%), poor (41.7%), had 2–4 children (43.9%), lived in rural areas (76.1%), and had no education (85.0%) or no job (86.7%). Most women answered that husbands made a decision about their healthcare and that getting permission from their husbands was a major challenge. Multivariate analysis showed that age, ethnicity, area of residence, parity, women’s education, husband’s education, literacy, having a job, wealth, the decision maker for healthcare, and difficulty in getting permission from the husband were significantly correlated with availing of the ANC visits. This study showed that not only the socio-demographic factors but also the cultural factors were associated with ANC visits. The Afghanistan government should improve the education programs at schools and healthcare facilities, for both men and women. To augment women’s propensity to take a decision, the programs for women’s empowerment need to be supported and extended across the country.

Polygamy and birth outcomes among Bedouin women of the Negev: The contribution of social determinants and pregnancy complications

Polygamy has been associated with adverse health outcomes. We examined the association between polygamy and adverse birth outcomes (composite score of preterm birth, low birth weight, small for gestational age, Apgar score < 7) using survey data linked to retrospective medical data of 9,872 cohort Bedouin women who bore live singletons in a large medical center in Southern Israel between 2008 and 2014. Women in polygamous marriages (18%) were more likely to have adverse birth outcomes after considering different factors (AOR = 1.28, 95% CI = 1.09-1.51), indicating that polygamy is an independent risk factor for birth outcomes that should be considered in research and clinical practice.

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.

Determinants of late initiation for antenatal care follow up: the case of northern Ethiopian pregnant women

OBJECTIVE

Early antenatal care follow-up is the main strategy of preventing pregnancy related adverse outcomes; in which World Health Organization recommends first antenatal care visit should be offered within the first trimester. However, Low utilization and late booking is the predominant problem in most developing countries including Ethiopia. This study aimed to determine the prevalence of late initiation for antenatal care follow-up and associated factors among pregnant women. Institutional based cross-sectional study was conducted among 423 pregnant mothers using systematic sampling technique. Multivariable logistic regression analysis was performed at the level of significance of p-value ≤ 0.05.

RESULTS

The findings showed 59.4% of pregnant women started their first visit after first trimester. Having age ≥ 25 years (AOR = 1.62, CI 1.1, 2.49), recognition of pregnancy by missed period (AOR = 2.54 CI 1.63, 3.96), pregnant mother who were not advised to start antenatal-care (AOR = 3.36, CI 1.74, 6.5) and primary educational level (AOR = 2.22, CI 1.16, 4.25) were found to be significantly associated with late initiation for antenatal care. The prevalence of late antenatal care follow-up is high. Multidisciplinary approaches to keep empowering women through education are recommended for early initiation of antenatal care.

Prevalence and factors associated with underutilization of antenatal care services in Nigeria: A comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey

INTRODUCTION

Antenatal care (ANC) is a major public health intervention aimed at ensuring safe pregnancy outcomes. In Nigeria, the recommended minimum of four times ANC attendance is underutilized. This study investigates the prevalence and factors associated with underutilization of ANC services with a focus on the differences between rural and urban residences in Nigeria.

METHODS

We analyzed the 2013 Nigeria Demographic and Health Survey dataset with adjustment for the sampling weight and the cluster design of the survey. The prevalence of underutilization of ANC was assessed using frequency tabulation while associated factors were examined using Chi-Square test and multivariable logistic regression analysis.

RESULTS

The prevalence of underutilization of ANC was 46.5% in Nigeria, 61.1% in rural residence and 22.4% in urban residence. The North-West region had the highest prevalence of ANC underuse in Nigeria at 69.3%, 76.6% and 44.8% for the overall, rural and urban residences respectively. Factors associated with greater odds of ANC underuse in rural residence were maternal non-working status, birth interval < 24 months, single birth type, not listening to radio at all, lack of companionship to health facility and not getting money for health services. In urban residence, mothers professing Islam, those who did not read newspaper at all, and those who lacked health insurance, had greater odds of ANC underuse. In both rural and urban residence, maternal and husband's education level, region of residence, wealth index, maternal age, frequency of watching television, distance to- and permission to visit health facility were significantly associated with ANC underuse.

CONCLUSIONS

Rural-urban differences exist in the use of ANC services, and to varying degrees, factors associated with underuse of ANC in Nigeria. Interventions aimed at addressing factors identified in this study may help to improve the utilization of ANC services both in rural and urban Nigeria. Such interventions need to focus more on reducing socioeconomic, geographic and regional disparities in access to ANC in Nigeria.

Too afraid to go: fears of dignity violations as reasons for non-use of maternal health services in South Sudan

BACKGROUND

South Sudan has one of the worst health and maternal health situations in the world. Across South Sudan, while maternal health services at the primary care level are not well developed, even where they exist, many women do not use them. Developing location specific understanding of what hinders women from using services is key to developing and implementing locally appropriate public health interventions.

METHODS

A qualitative study was conducted to gain insight into what hinders women from using maternal health services. Focus group discussions (5) and interviews (44) were conducted with purposefully selected community members and health personnel. A thematic analysis was done to identify key themes.

RESULTS

While accessibility, affordability, and perceptions (need and quality of care) related barriers to the use of maternal health services exist and are important, women's decisions to use services are also shaped by a variety of social fears. Societal interactions entailed in the process of going to a health facility, interactions with other people, particularly other women on the facility premises, and the care encounters with health workers, are moments where women are afraid of experiencing dignity violations. Women's decisions to step out of their homes to seek maternal health care are the results of a complex trade-off they make or are willing to make between potential threats to their dignity in the various social spaces they need to traverse in the process of seeking care, their views on ownership of and responsibility for the unborn, and the benefits they ascribe to the care available to them.

CONCLUSIONS

Geographical accessibility, affordability, and perceptions related barriers to the use of maternal health services in South Sudan remain; they need to be addressed. Explicit attention also needs to be paid to address social accessibility related barriers; among others, to identify, address and allay the various social fears and fears of dignity violations that may hold women back from using services. Health services should work towards transforming health facilities into social spaces where all women's and citizen's dignity is protected and upheld.

Stakeholders' perspectives on facilitators of and barriers to the utilisation of and access to maternal health services in Eritrea: a qualitative study

BACKGROUND

Wars affect maternal health services by destroying health systems. Eritrea experienced two wars with neighbouring Ethiopia. Despite this, the maternal mortality ratio (MMR) in Eritrea fell by 69% from 1590 per 100,000 live births in 1990 to 501 in 2015. This study aimed to examine facilitators of and barriers to the utilisation of and access to maternal health services in Eritrea.

METHODS

Using in-depth interviews and field observations for data collection, this qualitative study was conducted in five healthcare facilities in Asmara, the capital of Eritrea, in February and March 2016. The participants were: women (n = 40), husbands (n = 5), healthcare providers (n = 10), and decision makers (n = 5).

RESULTS

There were two perceived facilitators of utilisation of and access to maternal health services: health education (related to the WHO health service delivery building blocks) and improvement in gender equality driven by the role played by Eritrean women as combatants during the War of Independence (1961-1991). The only perceived barrier was poor quality of care due to lack of ultrasound machines, short clinic opening hours, and shortage of healthcare workers (related to the WHO health workforce building block).

CONCLUSION

This study assessed women and their husbands/partners' perceptions and the possible effects of contemporary Eritrean culture and the history of war on the utilisation of and access to maternal health services in the country. As well, we examined healthcare providers' and decision makers' perspectives. The two key facilitators of women's utilisation of and access to maternal health services were health education and women's empowerment driven by their role as combatants during the War of Independence. One main barrier was poor quality of care due to lack of ultrasound machines, short clinic opening hours, and a shortage of healthcare workers. As only a limited number of qualitative studies have been published about maternal health services in war-affected sub-Saharan African countries, our findings regarding health education and women's empowerment could be considered in other war-affected countries similar to Eritrea. Nevertheless, further research is needed to investigate our findings - particularly regarding female empowerment driven by women's role in combat in relation to their maternal health.

"The system here isn't on patients' side"- perspectives of women and men on the barriers to accessing and utilizing maternal healthcare services in South Sudan

Background

In fragile and war-affected setting such as South Sudan, a combination of physical environmental, socioeconomic factors and healthcare’s characteristic contributes to higher rates of home delivery attended by unskilled attendants. This study aims to understand the community members’ experience, perceptions and the barriers in relation to accessing and utilizing maternal healthcare services in South Sudan.

Methods

We conducted in-depth one-on-one interview with 30 women and 15 men to investigate their perspectives on the barriers to access maternal and child health related services. We purposively selected women and their partners in this study.

Results

Our study revealed that inadequate quality of antenatal care services such as lack of essential medicine, supplies and tools was linked to individual’s mothers dissatisfaction with the services they received. In addition, sudden onset of labor and lack of safety and security were important reasons for home delivery in this study. Furthermore, lack of transport as a result of a combination of long distance to a facility and associated costs either restricted or delayed women reaching the health facilities.

Conclusions

Our study highlighted an urgent need for the government of South Sudan to implement security and safety measures in order to improved access to delivery service at night. Incorporating private transports to provide access to affordable and reliable transport services for pregnant and post-partum women is also important. Increasing the budget allocation for medicine and health supplies and improving management of medicine and supply chain logistics are essential.

Do health care reforms in Turkey have a significant effect in equal access to maternal and child health services in Turkey: An evidence from 20 years

This study aimed to investigate whether there was an improvement in the equitable access to maternal and child health care services by examining the effects of socioeconomic and individual factors in Turkey from 1993 to 2013 and determine the effectiveness of health care reforms implemented mainly under the Health Transformation Program since 2003 on equitable access t;o maternal and child health care services in terms of years. The study used nationally representative 5 Turkey Demographic and Health Surveys (1993, 1998, 2003, 2008, and 2013). Prenatal care utilization rate increased from 67.0% in 1993 to 96.2% in 2013 while the rate of women giving birth at health care facilities increased from 63.8% to 98.1% in 2013. Prenatal care utilization and giving birth at health care facilities were higher among women who were under health insurance coverage, first time mothers, those staying in the western region and urban areas, and those with the highest level of wealth. The findings suggest that the issue of equity in the utilization of maternal and child health care services exists in Turkey, and the latest health care reforms under HTP are not effective in diminishing the effect of wealth.

Patterns and determinants of pathways to reach comprehensive emergency obstetric and neonatal care (CEmONC) in South Sudan: qualitative diagrammatic pathway analysis

Background

Maternity referral systems have been under-documented, under-researched, and under-theorised. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. The pathways that women follow to reach Emergency Obstetric and Neonatal Care (EmONC) once a decision has been made to seek care have received relatively little attention. The aim of this research was to identify patterns and determinants of the pathways pregnant women follow from the onset of labour or complications until they reach an appropriate health facility.

Methods

This study was conducted in Renk County in South Sudan between 2010 and 2012. Data was collected using Critical Incident Technique (CIT) and stakeholder interviews. CIT systematically identified pathways to healthcare during labour, and factors associated with an event of maternal mortality or near miss through a series of in-depth interviews with witnesses or those involved. Face-to-face stakeholder interviews were conducted with 28 purposively identified key informants. Diagrammatic pathway and thematic analysis were conducted using NVIVO 10 software.

Results

Once the decision is made to seek emergency obstetric care, the pregnant woman may face a series of complex steps before she reaches an appropriate health facility. Four pathway patterns to CEmONC were identified of which three were associated with high rates of maternal death: late referral, zigzagging referral, and multiple referrals. Women who bypassed nonfunctional Basic EmONC facilities and went directly to CEmONC facilities (the fourth pathway pattern) were most likely to survive. Overall, the competencies of the providers and the functionality of the first point of service determine the pathway to further care.

Conclusions

Our findings indicate that outcomes are better where there is no facility available than when the woman accesses a non-functioning facility, and the absence of a healthcare provider is better than the presence of a non-competent provider. Visiting non-functioning or partially functioning healthcare facilities on the way to competent providers places the woman at greater risk of dying. Non-functioning facilities and non-competent providers are likely to contribute to the deaths of women.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1463-9) contains supplementary material, which is available to authorized users.

Investigating the accessibility factors that influence antenatal care services utilisation in Mangwe district, Zimbabwe

BACKGROUND

Maternal and infant mortality remains a huge public health problem in developing countries. One of the strategies to minimise the risks of both maternal and infant mortality is access to and utilisation of antenatal care (ANC) services.

AIM

This study aimed to investigate the accessibility factors that influence the use of ANC services in Mangwe district.

METHODS

A qualitative approach using explorative design was adopted to target women who have babies under 1 year of age. The study was conducted in Mangwe district, Matabeleland South province, Zimbabwe. Data were collected through semi-structured interviews and observations. Data saturation was reached after 15 women who were conveniently sampled were interviewed. Field notes were analysed thematically using Tech's steps. Lincoln and Guba's criteria ensured trustworthiness of the study findings.

RESULTS

Accessibility factors such as lack of transport, high transport costs and long distances to health care facilities, health care workers' attitudes, type and quality of services as well as delays in receiving care influence women's utilisation of ANC services in Mangwe district, Zimbabwe.

CONCLUSION

The study concluded that women were still facing problems of unavailability of nearby clinics; therefore, it was recommended that the government should avail resources for women to use.

RECOMMENDATIONS

Mangwe District Health Department should provide mobile clinics rendering ANC services in distant rural areas.

Barriers to utilisation of antenatal care services in South Sudan: a qualitative study in Rumbek North County

BACKGROUND

Access to adequate antenatal care (ANC) is critical in ensuring a good maternal health and in preventing maternal and neonatal morbidity and mortality. South Sudan has one of the world's poorest health indicators due to a fragile health system and a combination of socio-cultural, economic, and political factors. This study was conducted to identify barriers to utilisation of ANC services in Rumbek North County.

METHODS

Using a qualitative design, data were collected through 14 focus group discussions with 169 women and 45 men and 12 key informant interviews with community leaders, staff working in health facilities, and the staff of the County Health Department. Data were analysed using inductive content analysis.

RESULTS

The perceived barriers to ANC utilisation were categorised as follows: 1) Issues related to access to health facilities and lack of resources. These included long distance to health facilities, lack of means of transportation to the health facilities, floods and poor roads, and demand for payment for health care at some health facilities; 2) The influence of the socio-cultural context and conflict including heavy burden of domestic chores, the negative influence of husbands who were reluctant to allow their wives to attend ANC, and insecurity; 3) Perceptions about pregnancy including misperceptions about the benefits of ANC and low perceived risk of pregnancy-related complications; and 4) Perceptions about the quality of care and the efficacy of medical treatment.

CONCLUSIONS

This study identified a myriad of factors deeply entrenched in the society, which prevent women from utilising ANC services. It also elicits broad aspects of interconnectedness among the barriers. To ensure effectiveness, strategies to improve utilisation of ANC in the study area and in similar contexts need to take into account the barriers identified by this study.

A mixed methods assessment of barriers to maternal, newborn and child health in gogrial west, south Sudan

Background

Health conditions for mothers, newborns, and children in South Sudan are among the worst worldwide. South Sudan has the highest rate of maternal mortality in the world and despite alarming statistics, few women and children in South Sudan have access to needed healthcare, especially in rural areas. The purpose of this study was to understand the barriers to maternal, newborn and child health in Gogrial West, Warrap State, South Sudan, one of the most underdeveloped states.

Methods

A randomized household quantitative study and supplemental qualitative interviews were employed in 8/9 payams in Gogrial West, Warrap, South Sudan. Interviews were conducted with randomly selected female household members (n = 860) who were pregnant or had children less than 5 years of age, and men (n = 144) with a wife having these characteristics. Non-randomized qualitative interviews (n = 72) were used to nuance and add important socio-cultural context to the quantitative data. Analysis involved the estimation of weighted population means and percentages, using 95% confidence intervals and considering p-values as significant when less than 0.05, when comparisons by age, age of marriage, wife status and wealth were to be established.

Results

Most women (90.8%) and men (96.6%) did not want contraception. Only 1.2% of women aged 15–49 had met their need for family planning. On average, pregnant women presented for antenatal care (ANC) 2.3 times and by unskilled providers. Less than half of households had a mosquito net; fewer had insecticide treated nets. Recognition of maternal, newborn and child health danger signs overall was low. Only 4.6% of women had skilled birth attendants. One quarter of children had verifiable DPT3 immunization. Five percent of men and 6% of women reported forced intercourse. Overall men and women accept beatings as a norm.

Conclusion

Barriers to care for mothers, infants and children are far more than the lack of antenatal care. Maternal, newborn and child health suffers from lack of skilled providers, resources, distance to clinics. A lack of gender equity and accepted negative social norms impedes healthy behaviors among women and children. The paucity of a peer-reviewed evidence base in the world’s newest country to address the overwhelming needs of the population suggests these data will help to align health priorities to guide programmatic strategy for key stakeholders.

Factors associated with different types of birth attendants for home deliveries: an analysis of the cross-sectional 2010 South Sudan household survey

Background

In South Sudan, birth deliveries attended by unskilled birth attendants put the mothers and their newborns at increased risk of perinatal morbidity and mortality. The aim of this study was to identify factors associated with delivery by unskilled birth attendants or by unassisted delivery.

Design

We examined data for 2,767 (weighted total) women aged 15–49 years who delivered at home 2 years prior to the South Sudan Household Health Survey 2010. Multinomial logistic regression analyses were used to identify factors associated with delivery by unskilled birth attendants or by unassisted delivery.

Results

The prevalence of delivery by unskilled birth attendants was 19% [95% confidence interval (CI) 17.0, 20.5], by skilled birth attendants (SBAs) was 45% (95% CI 42.4, 47.0), and by unassisted delivery was 36% (95% CI 34.2, 38.6). After adjusting for potential confounders, the following factors were associated with the increased odds for unassisted delivery or delivery by an unskilled birth attendant: mothers with no schooling, who did not attend antenatal care (ANC) during pregnancy, who had lower quality of ANC services, from poor households, or who had no prior knowledge about obstetric danger signs.

Conclusions

We found that non-utilization of maternal health care services, such as ANC, was significantly associated with unattended birth delivery or delivery by unskilled health providers. The increased uptake of SBAs at delivery will require easier access to ANC services, health promotion on the importance and benefits of SBAs for delivery, targeting both mothers and their families, and the training and deployment of more SBAs across the country.

Risk Factors for Non-use of Skilled Birth Attendants: Analysis of South Sudan Household Survey, 2010

Objectives South Sudan has the lowest percentage of births attended by skilled health personnel in the world. This paper aims to identify potential risk factors associated with non-use of skilled birth attendants at delivery in South Sudan. Methods Secondary data analyses of the 2010 South Sudan Household Health Survey second round were conducted with data for 3504 women aged 15-49 years who gave birth in the 2 years prior to the survey. The risk of non-use of skilled birth attendants was examined using simple and multiple logistic regression analyses. Results The prevalence rates for skilled, unskilled and no birth attendants at delivery were 41 [95 % confidence interval (CI) 38.2, 43.0], 36 [95 % CI 33.9, 38.8], and 23 % [95 % CI 20.6, 24.9] respectively. Multivariable analyses indicated that educated mothers [adjusted odds ratio (AOR) 0.70; 95 % CI 0.57, 0.86], mothers who had three and more complications during pregnancy [AOR 0.77; 95 % CI 0.65, 0.90], mothers who had at least 1-3 ANC visits [AOR 0.38; 95 % CI 0.30, 0.49] and mothers from rich households [AOR 0.52; 95 % CI 0.42, 0.65] were significantly more likely to use skilled birth attendants (SBAs) at delivery. Mothers who lived in rural areas [AOR 1.44; 95 % CI 1.06, 1.96] were less likely to deliver with SBAs. Conclusion Intensive investments to recruit and train more skilled birth attendants' on appropriate delivery care are needed, as well as building a community-based skilled birth attendants' program to reduce avoidable maternal mortality in South Sudan.

Factors that Influence Teenage Antenatal Care Utilization in John Taolo Gaetsewe (JTG) District of Northern Cape Province, South Africa: Underscoring the Need for Tackling Social Determinants of Health

BACKGROUND AND OBJECTIVES

In resource-limited settings, the uptake of antenatal care visits among women, especially teenage pregnant women, is disturbingly low. Factors that influence the uptake of ANC services among teenage women is largely understudied and poorly understood in John Taolo Gaetsewe (JTG), a predominantly rural and poor district of South Africa. The aim of this study was to determine the factors that influence uptake of ANC services among teenage mothers in JTG district.

METHODS

A cross-sectional health facility-based study utilising mixed method was conducted in all public health facilities (n=44) at JTG district. Mother-infant pairs (n=383) who brought their infants for six-week first DPT immunisation during the study period were enrolled in the study. Structured questionnaires were used to collect data on demographic, socio-economic and uptake of ANC indicators.

RESULTS

Out of 272 respondent mothers, 18.68% were adolescent mothers (13-19 years). The logistic regression analysis shows that mother's age (OR=2.11; 95%CI = 1.04 - 4.27); distance to the nearest health facility (OR=3.38; 95%CI = 1.45-7.87); and client service satisfaction (OR=8.58; 95%CI =2.10-34.95 are significantly associated with poor uptake of ANC services.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

There is a need to improve the quality of adolescent reproductive health services tailored to their health and developmental needs. Moreover, addressing the social determinants of health that affect individual's healthy life style and health seeking behavior is critical.

Effectiveness of and factors related to possession of a mother and child health handbook: an analysis using propensity score matching

BACKGROUND

Mother and Child Health handbooks (MCH handbooks) serve as useful health education tools for mothers and sources of information that allow health care professionals to understand patient status. Therefore, it is necessary to clarify the effectiveness of and identify the factors related to possession of an MCH handbook among parents in rural Western Kenya using propensity score matching (PSM).

METHODS

A community-based cross-sectional survey using a structured questionnaire was conducted in rural western Kenya from August to September, 2011. We targeted 2560 mothers with children aged 12-24 months. Both PSM and multivariate logistic analyses were used in this study.

RESULTS

Impacts of 5.9, 9.4, and 12.6 percentage points for higher health knowledge and for proper health-seeking behavior for fever and diarrhea, respectively, were statistically significant. The significant factors affecting possession of the MCH Handbook were the child's sex, the caregiver's relationship to the child, maternal age, health knowledge, birth interval, household wealth index and CHW performance accordingly.

CONCLUSIONS

An MCH handbook was an effective tool for improving both health knowledge and health-seeking behavior in Kenya. The further distribution and utilization of an MCH handbook is expected to be an effective way to improve both maternal and child health.