Decision-making for birth location among women in Pakistan: evidence from national survey

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association of maternal, obstetric, fetal, and neonatal mortality outcomes with Lady Health Worker coverage from a cross-sectional survey of >10,000 households in Gilgit-Baltistan, Pakistan

Pakistan has among the highest rates of maternal, perinatal, and neonatal mortality globally. Many of these deaths are potentially preventable with low-cost, scalable interventions delivered through community-based health worker programs to the most remote communities. We conducted a cross-sectional survey of 10,264 households during the baseline phase of a cluster randomized controlled trial (cRCT) in Gilgit-Baltistan, Pakistan from June-August 2021. The survey was conducted through a stratified, two-stage sampling design with the objective of estimating the neonatal mortality rate (NMR) within the study catchment area, and informing implementation of the cRCT. Study outcomes were self-reported and included neonatal death, stillbirth, health facility delivery, maternal death, postpartum hemorrhage (PPH), and Lady Health Worker (LHW) coverage. Summary statistics (proportions and rates) were weighted according to the sampling design, and mixed-effects Poisson regression was conducted to explore the relationship between LHW coverage and maternal/newborn outcomes. We identified 7,600 women who gave birth in the past five years, among whom 13% reported experiencing PPH. The maternal mortality ratio was 225 maternal deaths per 100,000 live births (95% confidence interval [CI] 137-369). Among 12,376 total births, the stillbirth rate was 41.4 per 1,000 births (95% CI 36.8-46.7) and the perinatal mortality rate was 53.0 per 1,000 births (95% CI 47.6-59.0). Among 11,863 live births, NMR was 16.2 per 1,000 live births (95% CI 13.6-19.3) and 65% were delivered at a health facility. LHW home visits were associated with declines in PPH (risk ratio [RR] 0.89 per each additional visit, 95% CI 0.83-0.96) and late neonatal mortality (RR 0.80, 95% CI 0.67-0.97). Intracluster correlation coefficients were also estimated to inform the planning of future trials. The high rates of maternal, perinatal, and neonatal death in Gilgit-Baltistan continue to fall behind targets of the 2030 Sustainable Development Goals.

Why do women still give birth at home; perceptions of Pakistani women and decision-makers from marginalized communities

In low- and middle-income countries (LMICs), maternal and newborn mortality is high due to the high prevalence of home births. Understanding the reasons behind this behavior is essential for improving maternal and newborn outcomes. Therefore, a qualitative exploratory study was conducted in a peri-urban community in Karachi, Pakistan to understand the perceptions of pregnant women who delivered at home despite receiving antenatal care and the perceptions of their decision-makers regarding this behavior. In-depth interviews were conducted with 15 randomly sampled women who chose to deliver at home after receiving antenatal care at a health facility, as well as 15 family members who were purposively identified as decision-makers by the women themselves. Thematic analysis was performed to explore the perceptions, myths, and cultural beliefs about homebirths as well as women's decision-making power related to childbirth. The three main themes identified showed that traditional beliefs and practices, poverty and gender inequality, and poor healthcare systems significantly influence the preference for childbirth. Traditional beliefs and practices, including religious and cultural beliefs, played a role in perceiving childbirth as a natural process best managed at home. The presence of traditional birth attendants who provide personalized care and emotional support further reinforced this preference. Gender inequalities, including limited access to mobile phones and women's caregiving roles, were identified as barriers to seeking formal healthcare at the time of delivery. Additionally, poor experiences with the formal healthcare system, such as the poor attitude of formal healthcare workers and fear of medical interventions, also contributed to the decision to deliver at home. The study highlighted the complex interplay between traditional/religious beliefs, gender inequalities, and healthcare experiences in shaping the decision to deliver at home despite receiving ANC services in marginalized settings. Addressing these factors is necessary for promoting facility-based delivery and improving maternal and neonatal outcomes in LMICs.

Why Pakistani Women Do Not Use Intrauterine Contraceptive Devices: A Systematic Review of Barriers and Misconceptions

This review explores barriers limiting the adoption of Intrauterine Contraceptive Devices (IUCDs) in Pakistan, focusing exclusively on local articles. As Pakistan's high population calls for widespread contraception, we aim to pinpoint obstacles hindering IUCD utilization, irrespective of parity. We conducted a comprehensive search of PubMed, Google Scholar, PakMedinet, and Wiley Online Library for English-language primary studies published between 2000 and 2022, reporting on IUCD utilization in Pakistan. Our analysis reveals multiple barriers impeding IUCD use in Pakistan. These encompass patriarchal social norms, male dominance, low education, socioeconomic status, and unemployment. Post-insertion health concerns, inadequate counseling, government commitment, and awareness were also identified barriers. Provider confidence, client trust, women's autonomy, social constraints, and limited male partner involvement hindered IUCD adoption. A desire for larger families and male offspring, vague religious beliefs, fear, and misconceptions further restricted usage. Accessibility and high service costs also posed challenges. This review highlights prevailing impediments to IUCD adoption in Pakistan, encompassing knowledge gaps, motivation deficits, resistance from husbands and in-laws, cultural and religious beliefs, limited access, and communication barriers. To promote IUCDs as a modern contraceptive method, it is essential to raise awareness among both men and women. Active involvement of religious leaders and community stakeholders is crucial in addressing these social factors hindering IUCD utilization.

Determinants of institutional delivery service utilization in Nepal

BACKGROUND

Maternal mortality continues to be a pressing concern in global health, presenting an enduring and unmet challenge for healthcare systems worldwide. Utilization of institutional delivery services has been established as a proven intervention to mitigate life-threatening risks for both mothers and newborns. Exploring the determinants of institutional delivery is crucial to improve and enhance maternal and newborn safety. This study aimed to assess the contextual and individual factors associated with institutional delivery in Nepal.

METHODS

This study utilized that data form Nepal Multiple Indicator Survey 2019, which included a sample of 1,932 women who had given birth within the two years prior to the survey. A multilevel logistic regression analysis was performed to determine the significant external environment, contextual and individual predictors of institutional delivery.

RESULTS

The women from Madhesh province [Adjusted Odds Ratio (aOR): 0.32, 95% Confidence Interval (CI): 0.17-0.61], as compared to Bagmati province, women from rural areas (aOR: 0.55, 95% CI: 0.39-0.78) as compared to urban areas, and women from a relatively less-advantaged ethnic groups (aOR: 0.52, 95% CI: 0.35-0.76) as compared to the relatively advantaged ethnic groups were less likely to deliver in health institutions. Similarly, women from the poorest (aOR: 0.09, 95% CI: 0.04-0.22) and second wealth groups (aOR: 0.29, 95% CI: 0.13-0.64) were less likely to attend institute for delivery compared to women from the richest household. Women with formal education (aOR: 1.65, 95% CI: 1.16-2.35) were more likely to deliver in an institution over uneducated women. Moreover, the uptake of institutional delivery increased by 59% (aOR: 1.59, 95% CI: 1.43-1.75) for each additional ANC visit.

CONCLUSION

The findings highlight the importance of stepping up efforts to achieve universal health care from the standpoint of long-term government investment, focusing particularly on illiterate women in rural areas, poorer households, and socially disadvantaged groups. Expanding the benefits of maternal benefit schemes targeting the women from the poorest households in the communities is recommended.

Predictors and disparities in neonatal and under 5 mortality in rural Pakistan: cross sectional analysis

Background

Adopted in 2015, the sustainable development goals (SDGs) have set specific targets (SDG 3.2) for countries to reduce their neonatal mortality rate (NMR) to below 12 deaths per 1000 live births and under 5 mortality rate (U5MR) to below 25 deaths per 1000 live births by 2030. For Pakistan to achieve these targets, there is a need to measure these rates and understand the predictors of child mortality at sub-national level. Launched in 2016, the Umeed-e-Nau (UeN) or New Hope project is based on scaling up proven and effective Maternal and Newborn Child Health (MNCH) interventions in 8 of the highest burden districts of the country, using existing public sector platforms in Pakistan at both the community and facility level. The primary aim of the project is to reduce perinatal mortality in these districts by 20% from baseline.

Methods

We report overall neonatal and post neonatal mortality rates for the two years preceding the UeN baseline household survey. Rates were calculated using the synthetic cohort probability method and predictors of neonatal and post neonatal mortality examined using Cox regression. To investigate spatial variations in the mortality rates, we calculated Moran's I at the district level using predicted probabilities of mortality. Finally, we create district level maps of predicted under 5 child mortality using a stochastic partial differentiation approach.

Findings

A total of 26,258 children contributed to the analysis of mortality with 838 deaths in the neonatal period and 2236 under-5 deaths during the observation period from March 1, 2015 to March 17, 2017. Overall, we estimated the NMR to be 29.2 per 1000 live births (95% CI: 26.9-31.4) and the U5MR to be 86.1 per 1000 live births (95% CI: 85.5-86.8). We found evidence of within-district geospatial clustering of under 5 mortality (P < 0.0001) and that social factors (poverty, illiteracy, multiparity), poor coverage of community health workers and distance from health facilities were strongly associated with child mortality.

Interpretation

Important factors associated with neonatal and post-neonatal mortality in our study population included maternal education, parity, household size and gender. Additionally, antenatal care coverage (at least 4 visits) was specifically associated with neonatal mortality only, whereas, LHW coverage and distance to health facility were strongly associated with post-neonatal mortality. These findings emphasise the need for comprehensive, multisectoral strategies to be implemented for future maternal and child health programs and outreach services in rural areas.

Funding

The study was funded by an unrestricted grant from the Bill & Melinda Gates Foundation to the Aga Khan University (Grant OPP 1148892).

Socioeconomic inequalities in utilizing facility delivery in Bangladesh: A decomposition analysis using nationwide 2017-2018 demographic and health survey data

BACKGROUND

In many low- and middle-income countries (LMICs), including Bangladesh, socioeconomic inequalities in access to maternity care remain a substantial public health concern. Due to the paucity of research, we attempted to determine the factors affecting the facility delivery, quantify wealth-related inequality, and identify potential components that could explain the inequality.

METHODS

We used the latest Bangladesh Demographic and Health Survey (BDHS 2017-18) data in this study. We utilized logistic regression to investigate the associated factors of facility delivery. The concentration curves (CC), concentration index (CIX) and decomposition of CIX techniques were used to analyze the inequality in-facility delivery.

RESULTS

Women living in the urban areas, age at first birth after (18-24 years ≥25 years), being overweight/obese, having secondary and higher-level education of the women and their husband, seeking four or more ANC, coming from more affluent households, and women with high enlightenment were significant determinants of facility delivery. The concentration curve was below the line of equality, and the relative concentration index (CIX) was 0.205 (p <0.001), indicating that women from wealthy groups were disproportionately more prevalent to facility delivery. The decomposition analysis reveals that wealth status of women (57.40%), age at first birth (10.24%), husband's education (8.96%), husband's occupation (7.35%), education of women (7.13%), women's enlightenment (6.15%), residence (8.64%) and ANC visit (6.84%) are the most major contributors to the inequalities in utilizing facility delivery.

CONCLUSION

The study demonstrates a clear disparity in the use of facility delivery among Bangladeshi women; hence, immediate action is required to lower the inequalities, with a special emphasis on the contributing factors.

Professional competition amidst intractable maternal mortality: Midwifery in rural Pakistan during the COVID-19 pandemic

Low-income countries with intransigent maternal mortality rates often follow WHO guidelines that prioritize access to skilled, or professionalized, prenatal and birthing care. Yet the impact of these initiatives in areas still suffering high maternal mortality is opaque. Despite heavy and long investments, the professionalization of midwifery in Pakistan is incomplete, and declines in maternal mortality have plateaued. Traditional midwives have lost status, but they continue to see clients and have influence in their rural communities. We conducted a rapid ethnography among traditional midwives (Dais) and trained Lady Health Workers (LHWs) in two communities of Attock, Pakistan from May to July of 2020. Our findings underscore the importance of long-term presence and trust to maternal care, especially in conditions of resource scarcity or fear (e.g., fear of COVID). We provide evidence of overt disparagement of Dais by LHWs; (2) illustration of the conflicts between gender norms and biomedical priorities of hospitalized births; and (3) exacerbated fear of hospitals during COVID, which served to highlight the advantages of Dai care. Professionalization programs for midwifery must include structures and training to ensure collaborative communications across the country's midwives. Failure to respect the rational decisions of traditional midwives and their patients in circumstances of scarcity, high stress, and isolation only ignores the material and cultural conditions of these vulnerable communities.

Effect of Socioeconomic Factors on the Choice of Health care Institutions for Delivery Care

During the past two decades, Pakistan witnessed a significant progress in maternal health outcomes. However, there exist persistent urban-rural and socio-economic inequalities in access and utilization of maternal healthcare services across the country. The overall objective of this research was to identify the significant socio-economic factors determining the choice of healthcare institutions for delivery care. This was a cross-sectional study conducted in Rajan Pur, a predominantly rural district in Punjab province. Using a multi-stage random sampling technique, 368 mothers who had childbirths from 1st October to 31st December 2020 in different healthcare institutions were interviewed. Data for the study was collected through a validated study instrument used by earlier studies on maternal healthcare utilization. The results of logistic regression analysis showed that use of public healthcare facilities for delivery care increases with increasing maternal education, monthly household income, and distance to healthcare facilities. The findings and recommendations drawn from the research would provide some insights to health policymakers and planners in developing an integrated and viable maternal healthcare program in Pakistan.

Respectful Maternity Care in South Asia: What Does the Evidence Say? Experiences of Care and Neglect, Associated Vulnerabilities and Social Complexities

Background

Respectful maternity care encompasses the right to continuity of care and dignified support for women during the reproductive period, enabling informed choice. However, the evidence is limited in the context of South Asia region where maternal, perinatal and newborn mortality is still a critical challenge to health systems. Evidence is required to better understand the context of respectful maternity care to inform directions for appropriate policy and practice.

Objective

The objective of this scoping review was to explore facilitators and barriers of respectful maternity care practice in South Asia.

Design

CINAHL, EMBASE, PubMed, Medline, SCOPUS and Cochrane databases were used to identify related studies. Data were systematically synthesized and analysed thematically.

Findings

There was considerable heterogeneity in the 61 included studies from seven South Asian countries, with most of the research conducted in Nepal and India. While the experience of abuse and neglect was common, 10 critical themes emerged related to neglected choices and compromised quality of care (particularly where there were health inequities) in the context of institutional care experiences; and the imperative for improved investment in training and significant policy and legislative change to enforce equitable and respectful maternity care practice.

Conclusions and Implications for Practice

Evidence about respectful maternity care in South Asia indicates that women accessing professional and facility-based services experienced high levels of disrespect, abuse and maltreatment. Women from vulnerable, socially disadvantaged and economically poor backgrounds were more likely to experience higher level abuse and receive poor quality of care. There is an urgent need for a well-resourced, sustained commitment to mandate and support the provision of respectful and equitable maternity care practice in South Asia.

Factors associated with home delivery in rural Sindh, Pakistan: results from the global network birth registry

BACKGROUND

According to global estimates for 2017, nearly 295,000 maternal deaths occurred worldwide. Thus, approximately 810 women die every day due to pregnancy-related complications. This burden of maternal deaths in LMICs is primarily due to poor healthcare service utilization, as indicated by relatively low rates of institutional deliveries and skilled-birth attendance (SBA). We conducted this study with an aim to assess the factors associated with home delivery and its subsequent effect on the pregnancy outcome in rural Sindh, Pakistan.

METHODS

Data for this study were taken from The Global Network's Maternal Newborn Health Registry (MNHR), which is a prospective, population-based observational cohort study. Registry data for 2018-2019 for District Thatta, Pakistan was retrieved for the analysis. Multivariable logistic regression models were used to determine the effect of each independent variable on the place of delivery by including all predictors and covariates. Results of the regression analyses are presented with crude odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs).

RESULTS

A total of 4649 women were included in the study, of these, 1286 (27.7%) women had delivered at home. Of those who delivered at home, a larger proportion was illiterate (90%), had a BMI of less than 18.5 kg/m² (26.0%), had parity of 3 or more (48.1%), and had a history of pregnancy loss as compared to women who had institutional delivery. In addition, two-thirds of women (63.4%) who had delivered at home had less than 4 ANC visits, whereas 15.6% did not receive any ANC. On multivariable logistic regression we found that home delivery was significantly associated with being illiterate (aOR = 1.60; [95% CI: 1.34, 2.04]), having high parity (aOR = 1.91; [95% CI: 1.58, 2.32]), and no ANC visit (aOR = 14.8; [95% CI: 10.2, 21.5]).

CONCLUSIONS

More than a quarter of our study sample women delivered at home. These women were illiterate, multiparous, and did not receive antenatal care during pregnancy. It is essential to conduct extensive educational interventions for the women and their family members regarding the potential benefits of delivering in a safe and skilled environment. Moreover, the provision of comprehensive and quality antenatal care should be ensured as it improves the mothers' health-seeking behavior and helps them make informed decisions about their health and well-being.

Predictors of wealth-related inequality in institutional delivery: a decomposition analysis using Nepal multiple Indicator cluster survey (MICS) 2019

BACKGROUND

Inequality in maternal healthcare use is a major concern for low-and middle-income countries (LMICs). Maternal health indicators at the national level have markedly improved in the last couple of decades in Nepal. However, the progress is not uniform across different population sub-groups. This study aims to identify the determinants of institutional delivery, measure wealth-related inequality, and examine the key components that explain the inequality.

METHODS

Most recent nationally representative Multiple Indicator Cluster Survey (MICS) 2019 was used to extract data about married women (15-49 years) with a live birth within two years preceding the survey. Logistic regression models were employed to assess the association of independent variables with the institutional delivery. The concentration curve (CC) and concentration index (CIX) were used to analyze the inequality in institutional delivery. Wealth index scores were used as a socio-economic variable to rank households. Decomposition was performed to identify the determinants that explain socio-economic inequality.

RESULTS

The socio-economic status of households to which women belong was a significant predictor of institutional delivery, along with age, parity, four or more ANC visits, education status of women, area of residence, sex of household head, religious belief, and province. The concentration curve was below the line of equality and the relative concentration index (CIX) was 0.097 (p < 0.001), meaning the institutional delivery was disproportionately higher among women from wealthy groups. The decomposition analysis showed the following variables as the most significant contributor to the inequality: wealth status of women (53.20%), education of women (17.02%), residence (8.64%) and ANC visit (6.84%).

CONCLUSIONS

To reduce the existing socio-economic inequality in institutional delivery, health policies and strategies should focus more on poorest and poor quintiles of the population. The strategies should also focus on raising the education level of women especially from the rural and relatively backward province (Province 2). Increasing antenatal care (ANC) coverage through outreach campaigns is likely to increase facility-based delivery and decrease inequality. Monitoring of healthcare indicators at different sub-population levels (for example wealth, residence, province) is key to ensure equitable improvement in health status and achieve universal health coverage (UHC).

Barriers to seeking post-abortion care in Paktika Province, Afghanistan: a qualitative study of clients and community members

Background

Unsafe abortion is a leading cause of maternal mortality. In Afghanistan, which has experienced decades of armed conflict and where abortion is highly restricted, maternal mortality is high at 638 maternal deaths per 100,000 live births. Post-abortion care (PAC) is a lifesaving package of interventions to reduce morbidity and mortality related to induced or spontaneous abortion, but is rarely provided and often of poor quality, particularly in humanitarian settings. In July 2018, we conducted a study to identify the factors that influence access to and use of PAC services at Sharana Provincial Hospital.

Methods

In-depth interviews (IDIs) were conducted with ten women who had received PAC services at Sharana Hospital, and eight focus group discussions (FGDs) were conducted with 40 married women and 40 married men aged 18–45 from four villages surrounding Sharana Hospital.

Results

PAC clients and community participants discussed similar barriers to seeking PAC, including cost, distance to the health facility, the need for male accompaniment to seek care, perceived and actual quality of care, stigma and shame. Despite the mentioned stigma around abortion, community members expressed willingness to help women to receive PAC.

Conclusions

Our results suggest that while some barriers are not unique to PAC, others, especially those related to stigma around abortion, may be specific to PAC. It is important for the Ministry of Public Health and its partners to prioritize addressing these barriers to ensure that women have access to this critical life-saving care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01529-5.

We Won't Go There: Barriers to Accessing Maternal and Newborn Care in District Thatta, Pakistan

Accessibility and utilization of healthcare plays a significant role in preventing complications during pregnancy, labor, and the early postnatal period. However, multiple barriers can prevent women from accessing services. The aim of this study was to explore the multifaceted barriers that inhibit women from seeking maternal and newborn health care in Thatta, Sindh, Pakistan. This study employed an interpretive research design using a purposive sampling approach. Pre-tested, semi-structured interview guides were used for data collection. The data were collected through eight focus group discussions with men and women, and six in-depth interviews with lady health workers and analyzed through thematic analysis. The study identified individual, sociocultural, and structural-level barriers that inhibit women from seeking maternal and newborn care. Individual barriers included mistrust towards public health facilities and inadequate symptom recognition. The three identified sociocultural barriers were aversion to biomedical interventions, gendered imbalances in decision making, and women’s restricted mobility. The structural barriers included ineffective referral systems and prohibitively expensive transportation services. Increasing the coverage of healthcare service without addressing the multifaceted barriers that influence service utilization will not reduce the burden of maternal and neonatal mortality. As this study reveals, care seeking is influenced by a diverse array of barriers that are individual, sociocultural, and structural in nature. A combination of capacity development, health awareness, and structural interventions can address many if not all of these barriers.

Public health insurance and birth outcomes: evidence from Punjab, Pakistan

Public health insurance targeted towards low-income households has gained traction in many developing countries. However, there is limited evidence as to the effectiveness of these programs in countries where institutional constraints may limit participation by the eligible population. This paper evaluates a recent health insurance initiative introduced in Pakistan and discusses whether eligibility for the programme improves maternal health seeking behaviour. The Prime Minister National Health Program provides free insurance coverage to low-income families. The programme is in the early phases of implementation and has, since 2016, only been rolled out in a few eligible districts within the country. This allows for a comparison of eligible households in districts where the programme has been introduced to those that are eligible to receive insurance at a future date. Using repeated cross-sectional data from multiple rounds of representative household survey, a difference-in-difference model has been estimated. Results show that at least for a specific beneficiary group (i.e. pregnant women), there has been a positive increase in utilization of hospital services. Furthermore, we provide evidence using mother fixed effects that the programme increased the likelihood of a child's birth being documented. Since possession of a birth certificate can secure civic rights for a child, this is an unintended but positive outcome of the programme.

Factors influencing place of delivery: Evidence from three south-Asian countries

BACKGROUND

High maternal mortality is still a significant public health challenge in many countries of the South-Asian region. The majority of maternal deaths occur due to pregnancy and delivery-related complications, which can mostly be prevented by safe facility delivery. Due to the paucity of existing evidence, our study aimed to examine the factors associated with place of delivery, including women's preferences for such in three selected South-Asian countries.

METHODS

We extracted data from the most recent demographic and health surveys (DHS) conducted in Bangladesh (2014), Nepal (2016), and Pakistan (2017-18) and analyzed to identify the association between the outcome variable and socio-demographic characteristics. A total of 16,429 women from Bangladesh (4278; mean age 24.57 years), Nepal (3962; mean age 26.35 years), and Pakistan (8189; mean age 29.57 years) were included in this study. Following descriptive analyses, bivariate and multivariate logistic regressions were conducted.

RESULTS

Overall, the prevalence of facility-based delivery was 40%, 62%, and 69% in Bangladesh, Nepal, and Pakistan, respectively. Inequity in utilizing facility-based delivery was observed for women in the highest wealth quintile. Participants from Urban areas, educated, middle and upper household economic status, and with high antenatal care (ANC) visits were significantly associated with facility-based delivery in all three countries. Interestingly, watching TV was also found as a strong determinant for facility-based delivery in Bangladesh (aOR = 1.31, 95% CI:1.09-1.56, P = 0.003), Nepal (aOR = 1.42, 95% CI:1.20-1.67, P<0.001) and Pakistan (aOR = 1.17, 95% CI: 1.03-1.32, P = 0.013). Higher education of husband was a significant predictor for facility delivery in Bangladesh (aOR = 1.73, 95% CI:1.27-2.35, P = 0.001) and Pakistan (aOR = 1.19, 95% CI: 0.99-1.43, P = 0.065); husband's occupation was also a significant factor in Bangladesh (aOR = 1.30, 95% CI:1.04-1.61, P = 0.020) and Nepal (aOR = 1.26, 95% CI:1.01-1.58, P = 0.041).

CONCLUSION

Our findings suggest that the educational status of both women and their husbands, household economic situation, and the number of ANC visits influenced the place of delivery. There is an urgent need to promote facility delivery by building more birthing facilities, training and deployment of skilled birth attendants in rural and hard-to-reach areas, ensuring compulsory female education for all women, encouraging more ANC visits, and providing financial incentives for facility deliveries. There is a need to promote facility delivery by encouraging health facility visits through utilizing social networks and continuing mass media campaigns. Ensuring adequate Government funding for free maternal and newborn health care and local community involvement is crucial for reducing maternal and neonatal mortality and achieving sustainable development goals in this region.

Effect of an integrated neonatal care kit on cause-specific neonatal mortality in rural Pakistan

Background

In 2018, Pakistan had the world’s highest neonatal mortality rate. Within Pakistan, most neonatal deaths occur in rural areas where access to health facilities is limited, and robust vital registration systems are lacking. To improve newborn survival, there is a need to better understand the causes of neonatal death in high burden settings and engage caregivers in the promotion of newborn health.

Objective

To describe the causes of neonatal death in a rural area in Pakistan and to estimate the effect of an integrated neonatal care kit (iNCK) on cause-specific neonatal mortality.

Methods

We analyzed data from a community-based, cluster-randomized controlled trial of 5286 neonates in Rahim Yar Khan (RYK), Punjab, Pakistan between April 2014 and August 2015. In intervention clusters, Lady Health Workers (LHW) delivered the iNCK and education on its use to pregnant women while control clusters received the local standard of care. The iNCK included interventions to prevent and identify signs of infection, identify low birthweight (LBW), and identify and manage hypothermia. Verbal autopsies were attempted for all deaths. The primary outcome was cause-specific neonatal mortality.

Results

Verbal autopsies were conducted for 84 (57%) of the 147 reported neonatal deaths. The leading causes of death were infection (44%), intrapartum-related complications (26%) and prematurity/LBW (20%). There were no significant differences in neonatal mortality due to prematurity/LBW (RR 0.43; 95% CI 0.15–1.24), infection (RR 1.10; 95% CI 0.58–2.10) or intrapartum-related complications (RR 1.04; 95% CI 0.0.45–2.41) among neonates who died in the intervention arm compared to those who died in the control arm.

Conclusion

The major causes of neonatal deaths in RYK, Pakistan mirror the global landscape of neonatal deaths. The iNCK did not significantly reduce any cause-specific neonatal mortality.

Women's decision-making autonomy and utilization of antenatal, natal and post-natal healthcare services: Insights from Tajikistan's national surveys

BACKGROUND

The purpose of this article is to investigate the link between women's autonomy and their utilization of antenatal, natal and post-natal healthcare services in Tajikistan. Previous studies focused only on a single dimension of such services, for instance, utilization of antenatal care. By contrast, we explore antenatal, natal and post-natal healthcare services utilization using the number of indicator for each of the dimensions.

METHODS

Data come from two national surveys that were conducted in 2012 and 2017. The target population is women of reproductive age (16-49) who were married or cohabitating with a partner (N = 7540). Several regression models were estimated to quantify association between women's autonomy and the utilization.

RESULTS

Lack of women's autonomy is associated with a lower probability of: (a) having had at least four antenatal check-ups during pregnancy, (b) beginning first antenatal check-up early, (c) delivering in a healthcare facility, (d) having the skilled attendance during pregnancy, (e) having a mother post-delivery check-up, and (f) having a child post-delivery check-up. The size effect of women's autonomy is stronger than that of well-developed precursors of utilization such as poverty and mothers' education.

CONCLUSION

Women autonomy should be improved to achieve higher rates of child and maternal healthcare utilization. Studies of maternal and child healthcare utilization should control explicitly for women's autonomy.

Health facility or home delivery? Factors influencing the choice of delivery place among mothers living in rural communities of Eritrea

BACKGROUND

In Eritrea, despite high antenatal care (ANC) use, utilization of health facilities for child birth is still low and with marked variations between urban and rural areas. Understanding the reasons behind the poor use of these services in a rural setting is important to design targeted strategies and address the challenge contextually. This study aimed to determine factors that influence women's choice of delivery place in selected rural communities in Eritrea.

METHODS

A cross-sectional survey of 309 women aged 15-49 years with a delivery in the last 1-2 years prior to the survey was conducted in a randomly selected villages of Hadish Adi, Serea, Genseba, Kelay Bealtat, Dirko, Mai Leham, Kudo Abour, Adi Koho, and Leayten. Data were collected using an interviewer administered questionnaire. Chi-square tests were used to explore association between variables. Using odds ratios with 95% confidence intervals with p < 0.05 taken as statically significant association, bivariate and multivariate logistic regression analysis were used to identify factors that affect the choice of delivery place.

RESULTS

Overall, 75.4% of the respondents delivered their last child at home while 24.6% delivered in health facility. Women whose husband's had no formal education were less likely [AOR = 0.02; 95% CI 0.01-0.54] to deliver in health facility. Women who had joint decision-making with husbands on delivery place [AOR = 5.42; 95% CI 1.78-16.49] and women whose husbands choose health facility delivery [AOR = 2.32; 95% CI 1.24-5.11] were more likely to have health facility delivery. Respondents who had medium wealth status [AOR = 3.78; 95% CI 1.38-10.37] have access to health facility within 2 km distance [AOR = 14.67; 95% CI 2.30-93.45] and women with traditional means of transport [AOR = 9.78; 95% CI 1.23-77.26] were also more likely to deliver in health facility. Women who read newspaper daily or infrequently had three [AOR = 3.77; 95% CI 1.12-4.04] and almost three times [AOR = 2.95; 95% CI 1.01-8.59] higher odds of delivering in health facility. Similarly, women who have knowledge about complications during delivery [AOR = 4.39; 95% CI 1.63-11.83], good perception on the quality of care they received [AOR = 9.52; 95% CI 1.91-47.50], had previous facility delivery [AOR = 2.69; 95% CI 0.94-7.68], have negative experiences of delivery outcomes in her community [AOR = 1.31; 95% CI 1.00-4.96], and women who perceive home delivery as life threatening [AOR = 1.84; 95% CI 1.46-3.38] were more likely to deliver in health facility.

CONCLUSION

To increase health facility delivery, raising women's awareness on the benefits of delivering in health facility, male involvement in the use of maternal health services, increasing women decision-making power, addressing common barriers of lack of transport, and compensations for transport expenses to alleviate the cost of transport are recommended. Efforts to shorten distance to reach health facility and health education focusing on the potential threats of delivering at home at the individual and community level can have substantial contribution to increase health facility delivery in rural communities of Eritrea.