Utilisation, equity and determinants of full antenatal care in India: analysis from the National Family Health Survey 4

Multilevel modelling of factors associated with eight or more antenatal care contacts in low and middle-income countries: findings from national representative data

Background

Antenatal care (ANC) is the care provided by skilled healthcare professionals to pregnant women in order to ensure the best health conditions for both mother and baby. Antenatal care provides a platform for important healthcare functions including risk identification, prevention and management of pregnancy-related diseases. Inadequate ANC utilization is a global problem especially for low and middle-income countries. The 2016 WHO ANC model with a minimum of eight ANC visits was aimed to provide pregnant women with person specific care at every contact. However, there are limited studies that investigate the associated factors of inadequate ANC after the endorsement of the WHO 2016 guideline. Therefore, to enrich the evidence in the low and middle-income countries (LMICs), this study aimed to determine the pooled prevalence and associated with eight or more ANC contacts during pregnancy.

Methods

This study used data from 20 LMICs that have a recent Demographic and Health Survey. About 43 720 women aged 15-49 years who had live births within the year prior to the surveys were included. To identify associated factors of 8 or more ANC contacts, we used multilevel binary logistic regression, and four models were constructed. The results have been presented as odds ratios with 95% CIs, and P values less than 0.05 were considered significant factors for greater than or equal to 8 ANC contacts.

Results

In LMICs, the pooled utilization of 8 or more ANC contact was 18.11% (95% CI: 12.64, 23.58), and it ranged from 0.27% in Rwanda to 76.62% in Jordan. In the final multilevel logistic regression model, women with higher education [adjusted odds ratio (AOR)=3.83, 95% CI: 3.32, 4.41], husbands with higher education (AOR=1.98, 95% CI: 1.72, 2.28), women who have access to media (AOR=1.32, 95% CI: 1.19, 1.45), women with decision-making autonomy (AOR=1.52, 95% CI: 1.39, 1.66), women aged 35-49 years (AOR=1.70, 95% CI: 1.5, 1.91), women from communities with high media access (AOR=1.38, 95% CI: 1.23, 1.53), and husbands residing in communities with high literacy (AOR=1.76, 95% CI: 1.55, 1.98) were associated with higher odds of greater than or equal to 8 ANC contacts. Conversely, women with a birth order of greater than or equal to 6 (AOR=0.65, 95% CI: 0.56, 0.76), women who perceive the distance to a health facility as a significant problem (AOR=0.90, 95% CI: 0.83, 0.96), those with unwanted pregnancies (AOR=0.85, 95% CI: 0.78, 0.93), delayed initiation of ANC (AOR=0.26, 95% CI: 0.23, 0.3), women from households with the richest wealth index (AOR=0.45, 95% CI: 0.40, 0.52), and rural residents (AOR=0.47, 95% CI: 0.43, 0.51) were associated with lower odds of ≥8 ANC contacts.

Conclusion and recommendations

In compliance with the WHO guideline, the number of ANC contacts is low in LMICs. Individual-level, household-level, and community-level variables were associated with greater than or equal to 8 ANC contacts. Therefore, implementation strategies should focus on the identified factors in order to achieve the new WHO recommendation of greater than or equal to 8 ANC contacts.

Magnitude, disparity, and predictors of poor-quality antenatal care service: A systematic review and meta-analysis

Background

Antenatal care is directed toward ensuring healthy pregnancy outcomes. Quality antenatal care increases the likelihood of receiving an effective intervention to maintain maternal, fetal, and neonatal well-being, while poor quality is linked to poor pregnancy outcomes. However, owing to the complex nature of quality, researchers have followed several approaches to systematically measure it. The evidence from these variable approaches appears inconsistence and poses challenges to programmers and policymakers. Hence, it is imperative to obtain a pooled estimate of the quality of antenatal care. Therefore, considering the scarcity of evidence on the quality of antenatal care, this study aimed to review, synthesize, and bring pooled estimates of accessible evidence.

Objective

This study aimed to estimate the pooled magnitude and predictors of quality of antenatal care services and compare regional disparity.

Method

We conducted a comprehensive systematic three-step approach search of published and unpublished sources from 2002 to 2022. The methodological quality of eligible studies was checked using Joanna Briggs Institute critical appraisal tool for cross-sectional studies. Meta-analysis was carried out using STATA version 16. Statistical heterogeneity was assessed using Cochran's Q test. In the presence of moderate heterogeneity (I2 more than 50%), sensitivity and subgroup analyses were conducted and presented in a forest plot. Effect size was reported using standardized mean difference and its 95% confidence interval. Funnel plots and Egger's regression test were used to measure publication bias at the 5% significance level. A trim-and-fill analysis was conducted to adjust for publication bias. Pooled estimates were computed using random-effects models and weighted using the inverse variance method in the presence of high heterogeneity among studies. A 95% CI and 5% significance level were considered to declare significance variables.

Results

The global pooled poor-quality antenatal care was 64.28% (95% CI: 59.58%-68.98%) (I2 = 99.97%, p = 0.001). The identified pooled predictors of good-quality antenatal care service were: number of antenatal care visits (fourth and above antenatal care visit) (Adjusted odds ratio (AOR) = 2.6, 95% CI: 1.37-3.84), family wealth index (AOR = 2.72, 95% CI: 1.89-3.55), maternal education attainment (AOR = 3.03, 95% CI: 2.24-3.82), residence (urban dwellers) (AOR = 4.06, 95% CI: 0.95-7.17), and confidentiality antenatal care (AOR = 2.23, 95% CI: -0.36 to -4.82).

Conclusions

The study found regional and country-level disparities in the quality of antenatal care services for pregnant women, where poor-quality antenatal care services were provided for more than two-thirds to three-fourths of antenatal care attendants. Therefore, policymakers and health planners should put a great deal of emphasis on addressing the quality of antenatal care services.

Socioeconomic and geographic inequalities in antenatal and postnatal care components in India, 2016-2021

Despite the well-known importance of high-quality care before and after delivery, not every mother and newborn in India receive appropriate antenatal and postnatal care (ANC/PNC). Using India's National Family Health Surveys (2015-2016 and 2019-2021), we quantified the socioeconomic and geographic inequalities in the utilization of ANC/PNC among women aged 15-49 years and their newborns (N = 161,225 in 2016; N = 150,611 in 2021). For each of the eighteen ANC/PNC components, we assessed absolute and relative inequalities by household wealth (poorest vs. richest), maternal education (no education vs. higher than secondary), and type of place of residence (rural vs. urban) and evaluated state-level heterogeneity. In 2021, the national prevalence of ANC/PNC components ranged from 19.8% for 8 + ANC visits to 91.6% for maternal weight measurement. Absolute inequalities were greatest for ultrasound test (33.3%-points by wealth, 30.3%-points by education) and 8 + ANC visits (13.2%-points by residence). Relative inequalities were greatest for 8 + ANC visits (1.8 ~ 4.4 times). All inequalities declined over time. State-specific estimates were overall consistent with national results. Socioeconomic and geographic inequalities in ANC/PNC varied significantly across components and by states. To optimize maternal and newborn health in India, future interventions should aim to achieve universal coverage of all ANC/PNC components.

Utilization and determinants of adequate quality antenatal care services in India: evidence from the National Family Health Survey (NFHS-5) (2019-21)

BACKGROUND

Pregnancy-related complications and insufficiencies in antenatal care services are leading causes of maternal and infant morbidity and mortality in low-resource settings. However, there has been an undue focus on achieving a minimum number of Antenatal Care (ANC) visits without adequate focus on the factors affecting ANC service utilization. This secondary data analysis from the fifth round of the National Family Health Survey (NFHS-5, 2019-21) was conducted to estimate the coverage of adequate quality ANC service and its determinants in India.

METHODS

The study sample included 176,877 women aged 15-49 years who had experienced a pregnancy in the last 5 years. The primary outcome variable was the utilization of ANC services by women during their last pregnancy assessed by the frequency of ANC visits and the quality of ANC services. Quality of ANC service utilisation was categorised as adequate quality, inadequate quality and ≥ 4 ANC visits and, inadequate quality and < 4 ANC visits. We performed multinomial logistic regression and reported relative risk ratio (RRR) along with 95% confidence intervals. We adjusted for sampling weight, clustering, and stratification in the sampling design.

RESULTS

The median (IQR) number of ANC visits attended by a woman during her previous pregnancy was 4 (IQR 3-7). A majority (59.25%) of the women reported availing of ≥ 4 antenatal care (ANC) visits during their previous pregnancy while 6.12% of women reported availing no ANC visits in their last pregnancy. Women aged ≥ 30 years were significantly less likely (aRRR 0.73 95% CI 0.66, 0.80) to receive ANC services of inadequate quality, and < 4 ANC visits. Additionally, any exposure to mass media (aRRR 0.69 95% CI 0.66, 0.73), and having health insurance (aRRR 0.71 95% CI 0.68, 0.75) decreased their risk of receiving inadequate quality ANC services and < 4 ANC visits. Women belonging to the richest wealth quintile (aRRR 0.52 95% CI 0.47,0.58) and those with an intended pregnancy (aRRR 0.62 95% CI 0.58 ,0.66) were at significantly lower risk of utilizing inadequate quality ANC services and < 4 ANC visits.

CONCLUSION

Although nearly 3 in 5 women in India utilized a minimum mandated ≥ 4 ANC visits during their last pregnancy, only one in five of those received adequate quality of ANC services indicating suboptimal content. However, only one in five women utilized the WHO-mandated ≥ 8 ANC visits for a positive pregnancy experience. Furthermore, 14.3% of the women received ANC services of inadequate quality despite attending ≥ 4 ANC visits in their previous pregnancy. Our study emphasized the importance of the quality of ANC services utilised irrespective of number of ANC visits availed. Efforts should be undertaken to enhance the utilization of antenatal care (ANC) services by implementing media initiatives that aim to raise awareness, particularly among women belonging to disadvantaged population groups.

Factors determining antenatal care utilization among mothers of deceased perinates in Ethiopia

Introduction

Receiving adequate antenatal care (ANC) had an integral role in improving maternal and child health outcomes. However, several factors influence the utilization of ANC from the individual level up to the community level factors. Thus, this study aims to investigate factors that determine ANC service utilization among mothers of deceased perinate using the proper count regression model.

Method

Secondary data analysis was performed on perinatal death surveillance data. A total of 3,814 mothers of deceased perinates were included in this study. Hurdle Poisson regression with a random intercept at both count-and zero-part (MHPR.ERE) model was selected as a best-fitted model. The result of the model was presented in two ways, the first part of the count segment of the model was presented using the incidence rate ratio (IRR), while the zero parts of the model utilized the adjusted odds ratio (AOR).

Result

This study revealed that 33.0% of mothers of deceased perinates had four ANC visits. Being in advanced maternal age [IRR = 1.03; 95CI: (1.01-1.09)], attending primary level education [IRR = 1.08; 95 CI: (1.02-1.15)], having an advanced education (secondary and above) [IRR = 1.14; 95 CI: (1.07-1.21)] and being resident of a city administration [IRR = 1.17; 95 CI: (1.05-1.31)] were associated with a significantly higher frequency of ANC visits. On the other hand, women with secondary and above education [AOR = 0.37; 95CI: (0.26-0.53)] and women who live in urban areas [AOR = 0.42; 95 CI: (0.33-0.54)] were less likely to have unbooked ANC visit, while women who resided in pastoralist regions [AOR = 2.63; 95 CI: (1.02-6.81)] were more likely to have no ANC visit.

Conclusion

The uptake of ANC service among mothers having a deceased perinate was determined by both individual (maternal age and educational status) and community (residence and type of region) level factors. Thus, a concerted effort is needed to improve community awareness through various means of communication by targeting younger women. Furthermore, efforts should be intensified to narrow down inequalities observed in ANC service provision due to the residence of the mothers by availing necessary personnel and improving the accessibility of service in rural areas.

Tobacco exposure among antenatal women in India: Challenges in tobacco screening & cessation counselling

Links between tobacco use and poor pregnancy outcomes are well established. Despite various tobacco control measures taken by the government, nearly 5-8 per cent of pregnant women consume tobacco in India. Antenatal check-ups are an opportunity to assess and assist women in quitting tobacco during pregnancy. This review highlights the challenges faced in identifying pregnant tobacco users and providing cessation counselling to them in a formal healthcare setup in the Indian context. For this narrative review, open access databases like PubMed and Google Scholar were searched, using the following search terms: challenges, quitting tobacco use, smokeless tobacco, pregnancy and India. Original articles published between 2010 and July 2022 were included in the English language with available free full text. Out of the thirty articles found to be eligible, seven were included in the review. Official websites of the National Health Mission and National Tobacco Control Programme were also searched to retrieve available data on health education and training material for healthcare workers: medical officers, Auxiliary Nurse and Midwives (ANMs), Accredited Social Health Activists (ASHAs) and list of tobacco cessation centres. This review identified the factors such as myths surrounding tobacco use, lack of targeted screening, inadequate training of healthcare workers and inaccessibility of cessation services, which are posing as challenges in controlling tobacco use in this vulnerable section of the population. Specific strategies to address these issues at the micro, meso and macro levels can prove to be vital in controlling tobacco use in pregnant women. This review also identified the vital role of gynaecologists and healthcare workers such as ANMs and ASHA in identifying and providing brief tobacco cessation counselling to pregnant users.

Assessment of utilisation of government programmes and services by pregnant women in India

BACKGROUND

Since the implementation of various maternal health programs, Maternal Mortality Ratio (MMR) has significantly declined in India through improvements in maternal health services. However, inequality persists at the regional and socio-economic levels. In light of this, the present study aims to assess the existing regional disparities in utilising various government initiatives for safe motherhood in India.

METHODS

National-level datasets such as National Family and Health Surveys (NFHS-3 (2005-06); NFHS-4 (2015-16) and NFHS-5(2019-21); Health Management Information System (HMIS), 2019-20; Sample Registrar System (SRS), 2001-2018) were used in the study. In addition, composite Index and inequality measures (Range, Ratio, and Gini) were calculated to examine inequality. At the same time, the Pearson correlation was used to investigate the correlation between various components of maternal health services and Maternal Mortality Rate (MMR).

RESULTS

The composite index score (0.65) reflects that India is still far behind the targets of the utilisation of maternal health care services. Within the utilisation of services, the Gini coefficient reveals that the least inequality was recorded in skilled birth assistance deliveries (0.03) and institutional deliveries (0.04). In contrast, the highest inequality was recorded in receiving Iron and Folic Acid (IFA) Tablets for 100 days (0.19) and four Antenatal Care (ANC) visits (0.13) among selected states. Based on the composite score for maternal health utilisation, Kerala, Tamil Nadu, Andhra Pradesh, Odisha, and Delhi were amongst the best performers, whereas Bihar, Jharkhand, Uttar Pradesh, and Assam were amongst the worst performers.

CONCLUSION

This indicates that the government's single-minded focus on enhancing institutional deliveries and skilled health-assisted deliveries has detracted from other essential interventions related to maternal health. Therefore, the states with the utilisation of maternal services need to initiate immediate action to increase the ANC and Post-natal Care (PNC utilisation with more attention towards better implementation of existing ANC programmes by the government.

Effectiveness of mHealth Interventions for Monitoring Antenatal Care among Pregnant Women in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Antenatal care (ANC) is essential in maternal and child health since it provides care to pregnant women from conception through to labour in order to ensure a safe pregnancy and childbirth. In recent years, mobile health (mHealth) interventions have emerged as a promising solution to improve maternal and child health outcomes in low- and middle-income countries (LMICs). The present study aimed to conduct a systematic review and meta-analysis of trials to evaluate the effectiveness of mHealth interventions to monitor prenatal care among pregnant women in LMICs. A systematic literature review was conducted using the databases CINHAL, Embase, MEDLINE, and PsycINFO on the effectiveness of mHealth interventions in monitoring the antenatal care of pregnant women. The study selection, data extraction of the included articles, and quality appraisal were assessed. Our study included six studies considering 7886 participants. All articles were from low- and middle-income countries (LMICs). Antenatal mothers who used a mobile health intervention were more likely (RR = 1.66, 95%CI = 1.07-2.58, I2 = 98%) to attend ANC check-ups when compared with the women who did not use any mobile health applications or did not receive any short message services. mHealth technologies are being utilised more and more to increase care accessibility and improve maternal and fetal health. Policymakers should prioritise the integration of mHealth interventions into maternal healthcare services in LMICs, ensuring that they are cost-effective, accessible, and sustainable and that healthcare workers are trained to deliver these interventions effectively.

Factors affecting pregnancy registration in India: does the pregnancy intention matter?

BACKGROUND

Pregnancy registration is one of the most critical components of women's reproductive health because it is the gateway to entering the continuum of care services such as antenatal care, institutional delivery, and postnatal care. There is a lack of studies exploring the relationship between pregnancy intention and pregnancy registration, especially in the Indian context.

METHOD

This study used the National Family Health Survey-5 (2019-21) data to explore the relationship between birth intention and failure of pregnancy registration. The bivariate and multivariate (binary logistic regression) analysis was carried out.

RESULTS

Adjusting the effects of socio-demographic and economic characteristics, compared with women with an intended pregnancy, the odds of failure of pregnancy registration were significantly high among women with a mistimed pregnancy (OR = 1.60, 95% CI = 1.47-1.73) and unwanted pregnancy (OR = 1.38, 95% CI = 1.26-1.52). The study found pregnancy intention as a significant predictor of pregnancy registration.

CONCLUSIONS

Results suggest strengthening the interaction of grassroots-level health workers with women, especially those with possibly lower healthcare autonomy and unintended pregnancy. Higher and earlier pregnancy registration will enhance maternal healthcare utilization and reduce adverse health consequences to mothers and children, thus ensuring better maternal and child health.

How much do we follow birth preparedness? A community-based snapshot study from rural Delhi, India

Introduction

Maternal healthcare remains a challenging public health problem in low and middle-income countries like India. The comprehension and services regarding practices related to birth preparedness and its complications in rural areas of India remain poor and underused. In view of this, we conducted this study to explore the preparedness of the pregnant women in the community residing in rural settlements of Delhi.

Methods

This cross-sectional community-based study was carried out in 165 currently pregnant women selected through proportionate sampling from rural Delhi. A semi-structured questionnaire adapted from Birth Preparedness and Complication Readiness (BPCR) tool kit was used. Binary and multivariate regression analysis was applied to identify the predictors of BPCR.

Results

In our study, BPCR index was found to be 25.78%. Only 17.6% pregnant women were well prepared. Multigravida, literacy, and higher socioeconomic status were found significant predictors for well preparedness for child birth and complication readiness in bivariate analysis. In multivariate logistic regression, multigravida and literacy were found to be predictors for well preparedness.

Conclusion

The skill and knowledge level of the mother-in-laws and other women along with husband in the family needs to be improved in context of pregnancy and child birth. Frontline health workers can assist the to-be mothers and their family members in informed decision-making for better feto-maternal outcomes.

Regional with urban-rural variation in low birth weight and its determinants of Indian children: findings from National Family Health Survey 5 data

BACKGROUND

Low birth weight is a key indicator for child health, especially a concern in low-middle-income countries. However, health and medically-related reforms are being actively implemented in some middle-income countries like India. Identifying low birth weight (LBW) babies with their determinants across the whole country is essential to formulate regional and area-specific interventions. The objective of this study was to find out the burden and determinants of LBW on the regional and residential (rural-urban) divisions of India.

METHODS

The present study was based on the NFHS-5 dataset (2019-21), a nationally representative survey in India. A total of 209,223 births were included in this study. A newborn weighing less than 2500 g was considered as LBW. According to the objectives, we used frequency distribution, chi-square test and binary logistic regression analysis for analysing the data.

RESULTS

About 18.24% of the babies were LBW in India, significantly higher in rural areas than in urban areas (18.58% vs 17.36%). Regionally prevalence was more frequent in western (20.63%) and central (20.16%) rural areas. Regarding maternal concerns, in the eastern and southern regions of India, mothers aged 25-34 were less likely to have LBW children than mothers aged 35-49 years. It was found that the risk of LBW was more likely among the children born out of unintended pregnancies in almost all regions except for eastern part. In rural India, women who delivered children at home were more likely to have LBW children in India (AOR = 1.19, CI: 1.12-1.28, p < 0.001) and its central, northern, and southern regions than those who gave birth in institutions. The study indicates that LBW coexists with lower maternal education levels and poor household wealth index across all regions. About 58% and 57% of cumulative effects of independent variables on LBW can be distinguished in urban and rural India, respectively.

CONCLUSIONS

Targeted-specific strategies need to be undertaken as per region and geographical variations. Then only India should be able to decline LBW as proposed by National Health Policy.

Assessing universal maternal health service coverage and their determinants in India: A multicentric cross-sectional study

Introduction

Universal maternal health coverage (UHC) envisages access to quality healthcare services by pregnant and lactating women without any financial hardship. Our present study attempts to assess the UHC for maternal health services and their determinants, including access to quality antenatal care (ANC), quality postnatal care (PNC), and child immunization among the marginalized populations of India.

Methods

It was a community-based cross-sectional study across five states of India among pregnant or lactating women. Quality ANC score was calculated using four indicators, including ANC registration month, attendance of four or more ANC visits, receiving at least one tetanus toxoid injection, and consumption of 100 iron-folic acid (IFA) tablets. Similarly, quality PNC care score was calculated using four indicators, including PNC within 48 h, breastfeeding initiation time, institutional delivery, and accessing conditional maternity benefit scheme. Logistic or generalized linear regression was used to depict associations depending on the outcome variables.

Results

A total of 12,976 pregnant women's and 18,061 lactating mothers' data were analyzed. Illiterate women, women from below the poverty line, and rural areas had low-quality ANC and PNC scores compared with their counterparts. Marginalized women had lower odds of immunization of children and lower quality PNC scores than nonmarginalized.

Conclusions

Sociodemographic factors, such as caste, education of women, area of residence, and economic status, are major determinants of quality ANC and PNC scores and immunization of children. Hence, interventionists ought to design community-based interventions that address the challenges in the uptake of health services.

Dissecting antenatal care inequalities in western Nepal: insights from a community-based cohort study

BACKGROUND

Antenatal care (ANC) ensures continuity of care in maternal and foetal health. Understanding the quality and timing of antenatal care (ANC) is important to further progress maternal health in Nepal. This study aimed to investigate the proportion of and factors associated with, key ANC services in western Nepal.

METHODS

Data from a community-based cohort study were utilized to evaluate the major ANC service outcomes: (i) three or less ANC visits (underutilization) (ii) late initiation (≥ 4 months) and (iii) suboptimal ANC (< 8 quality indicators). Mothers were recruited and interviewed within 30 days of childbirth. The outcomes and the factors associated with them were reported using frequency distribution and multiple logistic regressions, respectively.

RESULTS

Only 7.5% of 735 mothers reported not attending any ANC visits. While only a quarter (23.77%) of mothers reported under-utilizing ANC, more than half of the women (55.21%) initiated ANC visits late, and one-third (33.8%) received suboptimal ANC quality. A total of seven factors were associated with the suboptimal ANC. Mothers with lower education attainment, residing in rural areas, and those who received service at home, were more likely to attain three or less ANC visits, late initiation of ANC, and report receiving suboptimal ANC. Furthermore, mothers from poor family backgrounds appeared to initiate ANC late. Mothers from disadvantaged Madhesi communities tended to receive suboptimal ANC.

CONCLUSIONS

Despite a high ANC attendance, a significant proportion of mothers had initiated ANC late and received suboptimal care. There is a need to tailor ANC services to better support women from Madhesi ethnic community, as well as those with poor and less educated backgrounds to reduce the inequalities in maternal health care.

The Out-of-pocket Expenditures Incurred during Neonatal Hospitalization in a Public Hospital in Tamil Nadu - A Cross-Sectional Study

Background

For effective policy making, it is important to understand out of pocket costs incurred in neonatal admissions in public hospitals. This cross sectional study was conducted with an objective to estimate out of pocket expenses expended on neonates and attenders during neonatal hospitalizations in a tertiary care referral hospital.

Material and Methods

The data were collected using a pretested and semi structured questionnaire in 298 neonates during July'2022. Expenditures were reported as median values with interquartile range (IQR) and compared using the Kruskal Wallis test.

Result

On analyzing the results, there were no direct medical costs. The median cost spent on food per day, transport during the stay, non medical expenses per day, and total expenses per day were Rs. 300 (IQR 200, 500), Rs. 1000 (500, 1500), Rs. 500 (333, 896), and Rs. 1080 (800, 1533), respectively. Higher expenses were associated with preterm, low birth weight, neonatal seizures, and longer stay (P values <0.001, 0.028, <0.001, and <0.001, respectively). About 9.39% and 1% of the families were found to be catastrophic health expenditures at 10% and 25% threshold levels, respectively.

Conclusion

To conclude, all the direct medical costs were borne by the caregiver. However, some non medical and indirect costs are associated with neonatal hospitalizations in public hospitals and cash benefit schemes can offset them.

Estimating funds required for UHC within Indian States

Background

Universal Health Coverage (UHC) has been high on national and international agendas since its adoption as one of the Sustainable Development Goals (SDGs). Within India, there is a wide variation in the total amounts per capita spent by each state government (Government Health Expenditure or GHE) on healthcare. Bihar, with a GHE of 556 per capita (per annum), has the lowest state government spending, but there are many states in which governments spend more than four times that amount on a per capita basis. However, despite this, no state offers UHC to its residents. This failure to provide UHC could be because even the highest amounts spent by the state governments are too low for them to offer UHC or because the cost differences between states are very high. It is also possible, however, that a poor design of the government-owned health system and the degree of waste embedded within it could account for this. It is important to understand which of these factors is responsible because it then provides a clue as to what the best path to UHC might be in each state.

Methods

One way to do that would be to arrive at one or more broad estimates of the amounts needed to finance UHC and to compare them with actual amounts being spent by the governments in each state. Older research provides two such estimates. In this paper, using secondary data, we add to them using four additional approaches so that we can build greater confidence in the estimation of amounts needed by each state to offer UHC to its residents. We refer to these as Outside-in, Actuarial, Normative, and Inside-Out.

Findings

We find that, with the exception of the approach which assumes that the current design of the government health system is optimal and only needs added investment to offer UHC (the Inside-out approach), all the other approaches give a value of between 1302 and 2703 per capita for UHC, with 2000 per capita providing a reasonable point estimate. We also find no evidence to support the view that these estimates are likely to vary between states.

Interpretation

These results suggest that several Indian states may have an inherent ability to offer UHC with government financing alone and that a high degree of waste and inefficiency in the manner in which government funds are currently being deployed may well be behind their apparent inability to do so already. Another implication of these results is that several states may also be further away from the goal of offering UHC than an initial analysis of their GHE as a proportion of their Gross State Domestic Product (GSDP), i.e., GHE/GSDP, may suggest. Of particular concern are the states of Bihar, Jharkhand, Madhya Pradesh, and Uttar Pradesh, all of which have GHE/GSDP greater than 1%, but because their absolute levels of GHE are well below 2000, in order to reach UHC, they may need to more than triple their annual health budgets.

Funding

The Christian Medical College Vellore supported the second author (Sudheer Kumar Shukla) through a grant from the Infosys Foundation. Neither of these two entities had any role in the study design, data collection, data analysis, interpretation, writing of the manuscript, or the decision to submit it for publication.

Evolution of community health workers: the fourth stage

Introduction

Comprehensive primary care is a key component of any good health system. Designers need to incorporate the Starfield requirements of (i) a defined population, (ii) comprehensive range, (iii) continuity of services, and (iv) easy accessibility, as well as address several related issues. They also need to keep in mind that the classical British GP model, because of the severe challenges of physician availability, is all but infeasible for most developing countries. There is, therefore, an urgent need for them to find a new approach which offers comparable, possibly even superior, outcomes. The next evolutionary stage of the traditional Community health worker (CHW) model may well offer them one such approach.

Methods

We suggest that there are potentially four stages in the evolution of the CHW - the health messenger, the physician extender, the focused provider, and the comprehensive provider. In the latter two stages, the physician becomes much more of an adjunct figure, unlike in the first two, where the physician is at the center. We examine the comprehensive provider stage (stage 4) with the help of programs that have attempted to explore this stage, using Qualitative Comparative Analysis (QCA) developed by Ragin. Starting with the 4 Starfield principles, we first arrive at 17 potential characteristics that could be important. Based on a careful reading of the six programs, we then attempt to determine the characteristics that apply to each program. Using this data, we look across all the programs to ascertain which of these characteristics are important to the success of these six programs. Using a truth table, we then compare the programs which have more than 80% of the characteristics with those that have fewer than 80%, to identify characteristics that distinguish between them. Using these methods, we analyse two global programs and four Indian ones.

Results

Our analysis suggests that the global Alaskan and Iranian, and the Indian Dvara Health and Swasthya Swaraj programs incorporate more than 80% (> 14) of the 17 characteristics. Of these 17, there are 6 foundational characteristics that are present in all the six stage 4 programs discussed in this study. These include (i) close supervision of the CHW; (ii) care coordination for treatment not directly provided by the CHW; (iii) defined referral pathways to be used to guide referrals; (iv) medication management which closes the loop with patients on all the medicines that they need both immediately and on an ongoing basis (the only characteristic which needs engagement with a licensed physician); (v) proactive care: which ensures adherence to treatment plans; and (vi) cost-effectiveness in the use of scarce physician and financial resources. When comparing between programs, we find that the five essential added elements of a high-performance stage 4 program are (i) the full empanelment of a defined population; (ii) their comprehensive assessment, (iii) risk stratification so that the focus can be on the high-risk individuals, (iv) the use of carefully defined care protocols, and (v) the use of cultural wisdom both to learn from the community and to work with them to persuade them to adhere to treatment regimens.

Assessing the coverage of full antenatal care among adolescent mothers from scheduled tribe and scheduled caste communities in India

BACKGROUND

The persistently high rates of maternal mortality and morbidity among historically marginalised social groups, such as adolescent Scheduled Castes (SCs) and Scheduled Tribes (STs) in India, can be attributed, in part, to the low utilisation of full antenatal healthcare services. Despite efforts by the Indian government, full antenatal care (ANC) usage remains low among this population. To address this issue, it is crucial to determine the factors that influence the utilisation of ANC services among adolescent SC/ST mothers. However, to date, no national-level comprehensive study in India has specifically examined this issue for this population. Our study aims to address this research gap and contribute to the understanding of how to improve the utilisation of ANC services among adolescent SC/ST mothers in India.

DATA AND METHODS

Data from the fourth round of the National Family Health Survey 2015-16 (NFHS-4) was used. The outcome variable was full antenatal care (ANC). A pregnant mother was considered to have 'full ANC' only when she had at least four ANC visits, at least two tetanus toxoid (TT) injections, and consumed 100 or more iron-folic acid (IFA) tablets/syrup during her pregnancy. Bivariate analysis was used to examine the disparity in the coverage of full ANC. In addition, binary logistic regression was used to understand the net effect of predictor variables on the coverage of full ANC.

RESULTS

The utilisation of full antenatal care (ANC) among adolescent SC/ST mothers was inadequate, with only 18% receiving full ANC. Although 83% of Indian adolescent SC/ST mothers received two or more TT injections, the utilisation of the other two vital components of full ANC was low, with only 46% making four or more ANC visits and 28% consuming the recommended number of IFA tablets or equivalent amount of IFA syrup. There were statistically significant differences in the utilisation of full ANC based on the background characteristics of the participants. The statistical analysis showed that there was a significant association between the receipt of full ANC and factors such as religion (OR = 0.143, CI = 0.044-0.459), household wealth (OR = 5.505, CI = 1.804-16.800), interaction with frontline health workers (OR = 1.821, CI = 1.241-2.670), and region of residence in the Southern region (OR = 3.575, CI = 1.917-6.664).

CONCLUSION

In conclusion, the study highlights the low utilisation of full antenatal care services among Indian adolescent SC/ST mothers, with only a minority receiving the recommended number of ANC visits and consuming the required amount of IFA tablets/syrup. Addressing social determinants of health and recognising the role of frontline workers can be crucial in improving full ANC coverage among this vulnerable population. Furthermore, targeted interventions tailored to the unique needs of different subgroups of adolescent SC/ST mothers are necessary to achieve optimal maternal and child health outcomes.

Impact of COVID-19 on utilization of maternal and child health services in India: Health management information system data analysis

Background/Objectives

Studies globally have documented the impact of COVID 19 on maternal and newborn health services. This study assesses the impact of COVID-19 on essential maternal and child health (MCH) services in India based on the national Health Management Information System (HMIS).

Methods

Present retrospective study used secondary data analysis upon the routinely collected data accessed from Health Management Information System. Microdata on maternal and newborn indicators was extracted for all states between April and June during 2019, 2020 and 2021. Relative change for each indicator were taken into consideration for the year 2020 and 2021; with respect to the outcomes in 2019.

Results

Compared to 2019, antenatal care registrations saw a decline in all states for both periods in 2020 and 2021 except for Sikkim, Telangana, Maharashtra and Andhra Pradesh. Similarly, the relative changes in 2019 pertaining to the proportion of pregnant women provided with emergency obstetric care for pregnancy complications registered a decline in all states except for Himachal Pradesh, Telangana and Arunachal Pradesh. There was a decreasing trend noted in institutional deliveries in 2020 and 2021 among all major states. However, an increasing trend was seen in the number of immunization sessions held among all major states.

Conclusion

The study demonstrates a disruption in service delivery during the lockdown period in the first wave and the peak of the second wave. Further qualitative studies need to be undertaken to generate evidence for maintaining continuum of care during a pandemic situation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Spatiotemporal distribution and bivariate binary analysis of antenatal and delivery care utilizations in Ethiopia: EDHS 2000-2016

BACKGROUND

Antenatal care (ANC) is a maternal health care service given by skilled health professionals to pregnant women. Women may give birth at home or in health institutions. Home delivery care (DC) increases the likelihood of mortality of the mother and the newborn. Globally, each year nearly 303,000 maternal deaths occurred from complications of pregnancy and childbirth. Ethiopia alone accounted for 13,000 deaths, which disproportionately affects women living in different places of the country. Thus, this study aimed to assess the spatiotemporal patterns and associated factors of antenatal and delivery care utilization in Ethiopia.

METHOD

This study used the 2000 to 2016 EDHS (Ethiopian and Demographic Health Survey) data as a source. A total weighted sample of 30,762 women (7966 in 2000, 7297 in 2005, 7908 in 2011, and 7591 in 2016) was used. The separate and bivariate logistic regression analyses with and without the spatial effect were modeled using SAS version 9.4 and ArcGIS version 10.8.

RESULTS

The spatial distribution of ANC and DC was non-random in Ethiopia. The overall odds ratio of ANC and DC was 2.09. In 2016, 31.8% and 33.2% of women had ANC and DC respectively. The estimated odds of following ANC among mothers from middle and rich households were 1.346 and 1.679 times the estimated odds of following ANC among mothers from poor households respectively. Women who had attained higher education were 1.56 and 2.03 times more likely to have ANC and DC respectively compared to women who had no formal education.

CONCLUSIONS

Despite the government's report that women now have better access to maternal health care, a sizable proportion of women continue to give birth at home without going to the advised antenatal care appointment. Women and husbands with low education, having non-working partners, religion, regions of dwelling, residing in rural, lower birth order, low birth interval, unable to access mass media, low wealth status, and earlier EDHS survey years were significant predictors that hinder antenatal and delivery care utilization simultaneously in Ethiopia. Whereas the spatial variable significantly affects antenatal care and being unable to access mobile phones lead to low utilization of delivery care. We recommend that policymakers, planners, and researchers consider these variables and the spatiotemporal distribution of ANC and DC to reduce maternal mortality in Ethiopia. Besides, it is recommended that further studies use the latest EDHS survey data.

Differential impact of maternal education on under-five mortality in rural and urban India

Under-five mortality rate (U5MR) differs by rural-urban place of residence and mother's education; however, the rural-urban gap in U5MR by mother's educational attainment is unclear in the existing literature. Using five rounds of the national family health surveys (NFHS I-V) conducted between 1992-93 and 2019-21 in India, this study estimated the main and interaction effects of rural-urban and maternal education on U5MR. The mixed effect Cox proportional hazard (MECPH) model was used to predict the risk of under-five mortality (U5M). The finding shows that unadjusted U5MR remained 50 per cent higher in rural areas than in urban areas across the surveys. Whereas, after controlling for demographic, socioeconomic, and maternal health care predictors of U5M, the MECPH regression results indicated that urban children had a higher risk of death than their rural counterparts in NFHS I-III. However, there are no significant rural-urban differences in the last two surveys (NFHS IV -V). In addition, increasing maternal education levels were associated with lower U5M in all surveys. Though, in recent years, primary education has had no significant effect. The U5M risk was additionally lower for urban children than rural children whose mothers had secondary and higher education by NFHS-III; however, this additional urban advantage was no longer significant in recent surveys. The higher impact of secondary education on U5MR in urban areas in the past may be attributed to poor socio-economic, healthcare conditions in rural areas. Overall, maternal education, particularly secondary education, remained a protective factor for U5M in both rural and urban areas, even after controlling for predictors. Therefore, there is a need to increase the focus on secondary education for girls for a further decline in U5M.

Pooled prevalence and determinants of antenatal care visits in countries with high maternal mortality: A multi-country analysis

Background

Complications during pregnancy and childbirth are the leading causes of maternal and child deaths and disabilities, particularly in low- and middle-income countries. Timely and frequent antenatal care prevents these burdens by promoting existing disease treatments, vaccination, iron supplementation, and HIV counseling and testing during pregnancy. Many factors could contribute to optimal ANC utilization remaining below targets in countries with high maternal mortality. This study aimed to assess the prevalence and determinants of optimal ANC utilization by using nationally representative surveys of countries with high maternal mortality.

Methods

Secondary data analysis was done using recent Demographic and Health Surveys (DHS) data of 27 countries with high maternal mortality. The multilevel binary logistic regression model was fitted to identify significantly associated factors. Variables were extracted from the individual record (IR) files of from each of the 27 countries. Adjusted odds ratios (AOR) with a 95% confidence interval (CI) and p-value of ≤0.05 in the multivariable model were used to declare significant factors associated with optimal ANC utilization.

Result

The pooled prevalence of optimal ANC utilization in countries with high maternal mortality was 55.66% (95% CI: 47.48-63.85). Several determinants at the individual and community level were significantly associated with optimal ANC utilization. Mothers aged 25-34 years, mothers aged 35-49 years, mothers who had formal education, working mothers, women who are married, had media access, households of middle-wealth quintile, richest household, history of pregnancy termination, female household head, and high community education were positively associated with optimal ANC visits in countries with high maternal mortality, whereas being rural residents, unwanted pregnancy, having birth order 2-5, and birth order >5 were negatively associated.

Conclusion and recommendations

Optimal ANC utilization in countries with high maternal mortality was relatively low. Both individual-level factors and community-level factors were significantly associated with ANC utilization. Policymakers, stakeholders, and health professionals should give special attention and intervene by targeting rural residents, uneducated mothers, economically poor women, and other significant factors this study revealed.

Factors associated with inadequate receipt of components and non-use of antenatal care services in India: a regional analysis

BACKGROUND

Failure to use antenatal care (ANC) and inadequate receipt of components of ANC pose a significant risk for the pregnant woman and the baby. This study aimed to examine a regional analysis of factors associated with receiving no ANC and inadequate receipt of components of ANC services among Indian women.

METHOD

Information from 173,970 women of reproductive age 15-49 years from the 2019-21 India National Family Health Survey (NFSH-5) was analysed. Logistic regression analyses that adjusted for cluster and survey weights were conducted to assess the socio-demographic and other factors associated with receiving non-use of ANC and inadequate receipt of components of ANC, respectively, in the six regions and 28 states, and 8 union territories in India.

RESULTS

Across regions in India, 7% of women reported no ANC, and the prevalence of inadequate and adequate receipt of components of ANC in all six regions ranged from 67 to 89% and 8% to 24%, respectively. Of all the 36 federated entities, the prevalence of inadequate receipt of ANC components was less than two-thirds in Tamil Nadu, Puducherry, Andaman and the Nicobar Islands, Odisha, and Gujarat. Our analyses revealed that associated factors vary by region, state, and union territories. Women from poor households reported increased odds of receiving no ANC in North, East and North-eastern regions. Women who reported no schooling in South, East and Central regions were associated with increased odds of receiving no ANC. Women from poor households in Himachal Pradesh, Bihar, Uttar Pradesh, Nagaland, Manipur, Uttar Pradesh, and Madhya Pradesh states reported significantly higher odds of inadequate components ANC than women from rich households. The receipt of inadequate components of ANC was significantly higher among women who never read magazines in Delhi, Ladakh, Karnataka, Telangana, Jharkhand, Maharashtra, Uttar Pradesh, Chhattisgarh, Arunachal Pradesh, Manipur, and Mizoram states in India.

CONCLUSION

A better understanding of the factors associated with and incorporating them into the short- and long-term intervention strategies, including free financial support from the Indian government to encourage pregnant women from lower socioeconomic groups to use health services across all regions, states and union territories.

Factors associated with underutilization of antenatal care in India: Results from 2019-2021 National Family Health Survey

INTRODUCTION

Despite progress in recent years, full antenatal care utilization in India continues to be relatively low and inequitable, particularly between states and districts. In 2015-2016, for example, only 51% of women aged 15-49 in India attended antenatal care at least four times during pregnancy. Using data from the fifth iteration of India's National Family Health Survey, our study aims to explore factors related to the underutilization of antenatal care in India.

MATERIALS AND METHODS

Data from the most recent live birth in the past five years among women aged 15-49 years were included in our analysis (n = 172,702). Our outcome variable was "adequate antenatal care visits", defined as four or more antenatal visits. Utilizing Andersen's behavioral model, 14 factors were identified as possible explanatory variables. We used univariate and multivariate binary logistic regression models to analyze the association between explanatory variables and adequate visits. Associations were considered statistically significant if p<0.05.

RESULTS

Of the 172,702 women in our sample, 40.75% (95% CI: 40.31-41.18%) had an inadequate number of antenatal care visits. In multivariate analysis, women with less formal education, from poorer households and more rural areas had higher odds of inadequate visits. Regionally, women from Northeastern and Central states had higher odds of inadequate antenatal care utilization compared to those from Southern states. Caste, birth order, and pregnancy intention were also among the variables associated with utilization of antenatal care.

DISCUSSION

Despite improvements in antenatal care utilization, there is cause for concern. Notably, the percentage of Indian women receiving adequate antenatal care visits is still below the global average. Our analysis also reveals a continuity in the groups of women at highest risk for inadequate visits, which may be due to structural drivers of inequality in healthcare access. To improve maternal health and access to antenatal care services, interventions aimed at poverty alleviation, infrastructure development, and education should be pursued.

Determinants of recommended antenatal care visits among pregnant women in Ethiopia: a generalized linear mixed-effects modeling

BACKGROUND

Although antenatal care has the potential role to reduce maternal and child morbidity and mortality, utilization of a recommended number of antenatal care visits is still low in Ethiopia. Therefore, this study aimed to assess the determinants of recommended antenatal care visits in Ethiopia.

METHOD

Data from the 2019 mini-Ethiopian demographic and health survey (MEDHS) was used for this study. A total of 3916 women who gave birth 5 years preceding the MEDHS were included. A generalized linear mixed-effects (mixed-effects logistic regression) model was used to identify the determinants of recommended antenatal care service utilization. Finally, the adjusted odds ratio with a 95% confidence interval and random effects were reported.

RESULTS

In the generalized linear mixed-effects model, women with primary education (AOR = 1.55, 95%CI 1.22-2.01), secondary and above education (AOR = 5.12, 95%CI 2.80-8.16), women from the middle (AOR = 1.25, 95%CI 1.01-1.71) and rich wealth index (AOR = 1.54, 95%CI 1.12-2.25), women who were exposed to media (AOR = 1.23,95%CI 1.01-1.57) and who use contraception (AOR = 1.45 95%CI 1.25-2.03), had higher odds of recommended antenatal care service utilization.

CONCLUSION

In this study, factors like maternal educational status, media exposure, wealth index and history of contraceptive utilization were significantly associated with recommended ANC visits in Ethiopia. Therefore, encouraging women for contraceptive service utilization, consulting women to be exposed to media and improving women's wealth status will help to have recommended number of ANC visits by pregnant women in Ethiopia.

Seroprevalence of Hepatitis B Virus Among Pregnant Women in India: A Systematic Review and Meta-Analysis

Objectives

Hepatitis B virus (HBV) infection during pregnancy is associated with perinatal transmission contributing to the pool of HBV infection in the population. There is a wide variation in the reported data on the seroprevalence of HBV in pregnant patients from various parts of India. Hence, a systematic review and meta-analysis was conducted to determine the pooled seroprevalence of HBV and its associated demographic factors.

Methods

A comprehensive literature search of Medline, Scopus, and Google Scholar was conducted from January 2000 to April 2022 for studies evaluating the prevalence of HBV in pregnant patients from India.

Results

A total of 44 studies with data on 272,595 patients were included in the meta-analysis. The pooled prevalence of hepatitis B surface antigen (HBsAg) in pregnant women was 1.6% [95% confidence interval (CI), 1.4-1.8]. Among patients with HBsAg positivity, the pooled prevalence of hepatitis B e antigen was 26.0% (95%CI 17.4-34.7). There was no significant difference in the odds of HBV seroprevalence based on the age (<25 years vs. > 25 years) [odds ratio (OR) 1.07, 95%CI 0.74-1.55], parity (primipara vs. multipara) (OR 1.09, 95%CI 0.70-1.70) or area of residence (urban vs. rural) (OR 0.88, 95%CI 0.56-1.39). However, the odds of HBV seroprevalence in those with no or primary education was higher than in those with secondary level education or higher (OR 2.29, 95%CI 1.24-4.23). Prior history of risk factors was present in 13.5-22.7% of patients indicating a vertical mode of acquisition.

Conclusion

There is a low endemicity of HBV among pregnant women in India. Risk factors are seen in less than 25% of the cases, indicating vertical transmission as the predominant mode of acquisition, which can be reduced by improving vaccination coverage.

Child Survival Crisis Due to Maternal Undernourishment During the COVID Era

The coronavirus disease 2019 (COVID-19) pandemic caused a global crisis, creating the most challenging times faced by any country. The pandemic created a situation that shocked the whole world. It led to a condition of fear, and the ones to take the major hit were the vulnerable groups: children, pregnant women, and the elderly, as well as those belonging to low socio-economic groups who lost their source of daily income. It increased the pressure on already burdened healthcare and information systems and led to a situation where the well-being of even children and pregnant women could not be maintained. COVID-19 increased the risk of undernutrition in children. Though children are observed to be less affected by the virus, they are the hidden victims of the pandemic in terms of falling prey to undernutrition. Child undernutrition can also be linked to maternal malnutrition, starting from the preconception period through the postpartum period. The situation arose due to the rapid steps of mitigation taken to tackle the pandemic, leading to decreased food security, healthcare, and education. Maternal undernutrition leads to complications for the mother during childbirth and has long-term effects on both. It can lead to low birth weight (LBW) babies, postpartum complications, chronic child undernourishment, and even increased maternal and child mortality and morbidity. Because of the pandemic's disruption of immunization facilities, it appears that even preventable childhood diseases will worsen in the coming years. In these post-COVID-19 times, it has become necessary to take measures to improve the overall health status of the population, with special regard to these vulnerable groups. Proper maternal and child health should be targeted at community levels by introducing interventions that prioritize antenatal and postnatal care, nutritional education, immunization of both mother and child, and proper health and sanitation practices. The purpose of this narrative review is to create awareness about the child survival crisis that may occur in the coming years due to undernutrition and the failure of immunization.

A Review of the National Family Health Survey Data in Addressing India’s Maternal Health Situation

Objective: This study aims to understand the trend of research conducted on issues of maternal health in India considering data provided in five rounds of National Family Health Survey (NFHS).

Methods: Systematic review of literature has been conducted using multi-stage search and review process adapted from Page et al.’s (2021) PRISMA. Initially 14,570 studies were identified and only 134 articles meeting selection criterion were considered in this study.

Results: Approximately 32% studies have focused on regional and state variation of maternal health status; while 27% dealt with utilization of maternal healthcare services; and 19% the socio-economic determinants of maternal health. While few studies have discussed the place of delivery, antenatal care and post-natal care visits, only five studies focus on issues related to women’s autonomy, including their health-seeking behaviour, knowledge, attitude and practices related to maternal health.

Conclusion: Non-communicable diseases and its role in maternal health still remains an unexplored domain of research on maternal health in India. Moreover, there exists geographical skewness in the number of studies conducted, focusing especially on few provinces while none on few others.

Understanding the associations between maternal high-risk fertility behaviour and child nutrition levels in India: evidence from the National Family Health Survey 2015-2016

Anthropometric markers are the most important aspect of a child's health assessment. Using large-scale nationally representative data from the National Family Health Survey (NFHS-4), 2015-2016, this study aimed to investigate the relationship between children born to women with high-risk fertility behaviours and children's health outcomes. The sample consisted of 2,55,726 children of currently married women aged 15-49 years in India. The key explanatory variable, high-risk fertility behaviour was defined by women's age at birth (below 18 or above 34 years), birth interval (less than 24 months), and higher birth orders (four and above). The key outcome variables for assessing child health outcomes were stunting, wasting, and underweight in children aged 0-59 months. We used descriptive statistics, Pearson's chi-square test and logistic regression models to analyse the objectives. Approximately 33% of children were born with any single high-risk condition in the last 5 years in India. The bivariate analysis showed that all three components of child health, stunting, wasting, and underweight, were higher among children born to women with high-risk fertility behaviour. The findings from the multivariable analysis suggest that children born with a high risk fertility behaviour were suffering from stunting (AOR = 1.30; 95% CI 1.27-1.33) and underweight (AOR = 1.23; 95% CI 1.20-1.27). In addition, children born to women of multiple high-risk categories had higher odds of stunting (AOR = 1.53; 95% CI 1.46-1.59) and underweight (AOR = 1.38; 95% CI 1.32-1.44) as compared to children born to women with no risk. Our findings highlight an urgent need for effective legislation to prevent child marriage that would be helpful in increasing the maternal age at birth. The government should also focus on the interventions in health education and improvement of reproductive healthcare to promote optimal birth spacing.

Child Marriage and Problems Accessing Healthcare in Adulthood: Evidence from India

The association between child marriage and the access to or utilization of maternal and antenatal healthcare has been widely studied. However, little is known about child brides' access to healthcare for illnesses later in life. Using data on 496,283 married women aged 18 to 49 years from the India National Family and Health Survey 2015-2016, we developed an 11-point composite score (ranging from 0 to 10) outlining the extent of problems accessing healthcare, as follows: (i) no/little problem (score 0 to 2), (ii) some problems (score 3 to 6), and (iii) big problems (score 7 to 10). The differences between child brides and their peers married as adults were assessed by the relative risk ratios obtained from multinomial logistic regressions. The adjusted risk of having "some problems" and "big problems" accessing healthcare relative to "no/little problem" for child brides was found to be 1.22 (95% CI: 1.20-1.25) and 1.26 (95% CI: 1.22-1.29) times that of those married as adults, respectively. These findings highlight the disproportionate barriers to healthcare access faced by women married as children compared to women married as adults and the need for further research to inform policies regarding effective public health interventions to improve healthcare access.

Use of antenatal and delivery care services and their association with maternal and infant mortality in rural India

Optimum use of antenatal care (ANC) and delivery care services could reduce morbidity and mortality among prospective mothers and their children. However, the role of ANC and delivery services in prevention of both maternal and child mortality is poorly understood, primarily because of dearth of prospective cohort data. Using a ten-years population-based prospective cohort data, this study examined the use of ANC and delivery services and their association with maternal and infant mortality in rural India. Descriptive statistics were estimated, and multivariable logistic regression modelling was used to attain the study objective. Findings revealed that consumption of ≥ 100 iron-and-folic acid (IFA) tablet/equivalent syrup during pregnancy had a protective association with maternal and infant mortality. Lack of maternal blood group checks during pregnancy was associated with increased odds of the death of infants. Caesarean/forceps delivery and delivery conducted by untrained personnel were associated with increased odds of maternal mortality. Findings from this study reemphasizes on increasing coverage and consumption of IFA tablets/equivalent syrup. Improved ANC and delivery services and increased uptake of all types of ANC and delivery care services are equally important for improvement in maternal and child survival in rural India.

Prevalence of High-Risk Pregnancy Among Pregnant Women Attending Antenatal Care Camps in Primary Health Centres in Kinaye and Vantamuri and Their Sub-Centres

Introduction

Identifying pregnancy-related complications and high-risk pregnancies early on and effectively managing care for these pregnant women through a holistic approach guided by the main objectives of antenatal care (ANC) and efficient, good-quality health care through ANC services can reduce the risk of pregnancy-related complications, being favourable for both mother and child. This study was intended to identify the percentage of pregnant women in high-risk groups attending ANC clinics.

Objective

This study’s aim was to understand the prevalence of high-risk pregnancies in women attending ANC camps in Kinaye and Vantamuri villages in Belagavi, India.

Methods

A community-based cross-sectional study was carried out in a primary healthcare (PHC) setting that included all pregnant women attending antenatal camps and residing in the same areas. With a total study sample size of 200, consisting of pregnant women attending ANC camps in Kinaye and Vantamuri PHC, the data were collected using a pre-tested, pre-designed questionnaire after obtaining written informed consent from the participating pregnant women.

Results

The data were analysed using a chi-square test to uncover the relationship between socio-demographics, obstetric history, medical variables, and high-risk pregnancy. The results demonstrated that 48.5% of women attending ANC clinics were in the high-risk pregnancy group.

Conclusion

Pregnancy outcomes are greatly affected by a woman’s socio-demographic, obstetric, and medical variables. The WHO recommends a minimum of four ANC visits to safely identify and mitigate the risks and complications of high-risk pregnancy to ensure positive outcomes for both mothers and children.

Impact of antenatal care visits on childhood immunization: a propensity score-matched analysis using nationally representative survey

BACKGROUND

Evidence has suggested a relationship between antenatal care (ANC) visits and childhood immunization coverage. However, evaluating its impact using observational data suffers from the problem of selection bias. Hence, we adopted propensity score-matched (PSM) analysis for studying the impact of ANC visits on childhood immunization.

METHODS

Data regarding ANC visits and childhood immunization were collected from a nationally representative survey, National Family Health Survey-4 (NFHS-4). We performed PSM analysis with logit model using the psmatch2 command package in STATA to find the average treatment effect on the population (ATE), treated (ATT), and untreated (ATU).

RESULTS

In total, 5,430 participants were included in the analysis. Radius matching with caliper width of 0.01 was used to match the groups. The ATT values in the intervention and control groups were 0.71 and 0.47, respectively, indicating that the immunization coverage was increased by 24% because of ANC visits. The ATU values in the intervention and control groups were 0.40 and 0.65, respectively. This indicates that for the women who did not make the ANC visits, the chance of getting their children immunized would have increased by 25% if they had made four or more visits. The final ATE estimate was 0.25 among the study participants. Quality of matching was good with no significant difference in characteristics between the two groups.

CONCLUSION

Findings from our study imply that policymakers in India should focus on further improving the ANC coverage as it has a significant impact on improving childhood immunization coverage.

Determinants of very low birth weight in India: The National Family Health Survey – 4

Background

Low birth weight (LBW) is susceptible to neonatal complications, chronic medical conditions, and neurodevelopmental disabilities. We aim to describe the determinants of very low birth weight (VLBW) in India and compare it with the determinants of LBW based on the National Family Health Survey – 4 (NHFS-4)

Methods

Data from the NFHS-4 on birthweight and other socio-demographic characteristics for the youngest child born in the family during the five years preceding the survey were used. Data of 147,762 infant–mother pairs were included. Multiple logistic regression models were employed to delineate the independent predictors of VLBW (birth weight<1500 g) or LBW  (birth weight: 1500-2499 g).

Results

Of the 147,762 children included in the study, VLBW and LBW were observed in 1.2% and 15.8% of children, respectively. The odds of VLBW were higher in female children (aOR: 1.36, 95% CI: 1.15–1.60), among mothers aged 13–19 years (aOR: 1.58, 95% CI: 1.22–2.07), mothers with severe or moderate anaemia (aOR: 1.61, 95% CI: 1.34–1.94), mothers without recommended antenatal care (aOR: 1.47, 95% CI: 1.31–1.90), maternal height less than 150 cm (aOR: 1.54, 95% CI: 1.29–1.85) and among mothers with multiple pregnancy (aOR: 21.34, 95% CI: 14.70–30.96) in comparison to their corresponding counterparts. In addition to the variables associated with VLBW, educational status of mothers (no education; aOR: 1.08, 95% CI: 1.02–1.15 and primary education; aOR: 1.16, 95% CI: 1.08–1.25), caste of the children (scheduled tribe; aOR: 1.13, 95% CI: 1.03–1.24), and wealthiness of the family (poorest wealth quintiles; aOR: 1.11, 95% CI: 1.03–1.19) were associated with LBW.

Conclusions

Interventions targeting improvements in antenatal care access, maternal health, and nutritional status may reduce the number of VLBW infants. Social determinants of LBW require further detailed study to understand the high propensity of low birth-weight phenotypes in the disadvantaged communities in India.

Reducing Perinatal Mortality in India: Two-Years Results of the IRIA Fetal Radiology Samrakshan Program

Aim The aim of the study is to determine improvements in perinatal mortality at the end of the first 2 years from the initiation of the Samrakshan program of the Indian Radiological and Imaging Association.

Methods Samrakshan is a screening program of pregnant women that uses trimester-specific risk assessment protocols including maternal demographics, mean arterial pressure, and fetal Doppler studies to classify women as high risk or low risk for preterm preeclampsia (PE) and fetal growth restriction (FGR). Low dose aspirin 150 mg daily once at bedtime was started for pregnant women identified as high risk in the 11–136/7 weeks screening. The third-trimester screening focused on the staging of FGR and protocol-based management for childbirth and risk assessment for PE. Outcomes of childbirth including gestational age at delivery, development of PE, and perinatal mortality outcomes were collected.

Results Radiologists from 38 districts of 16 states of India participated in the Samrakshan program that screened 2,816 first trimester, 3,267 second trimester, and 3,272 third trimester pregnant women, respectively. At 2 years, preterm PE was identified in 2.76%, preterm births in 19.28%, abnormal Doppler study in 25.76% of third trimester pregnancies, and 75.32% of stage 1 FGR delivered at term. The neonatal mortality rate was 9.86/1,000 live births, perinatal mortality rate was 18.97/1,000 childbirths, and maternal mortality was 58/100,000 live births compared with 29.5, 36, and 113, respectively in 2016.

Conclusion Fetal Doppler integrated antenatal ultrasound studies in Samrakshan led to a significant reduction in preterm PE rates, preterm birth rates, and a significant improvement in mean birth weights. Perinatal, neonatal, and maternal mortality rates are significantly better than the targets for 2030 set by the Sustainable Development Goals-3.

Global burden of early pregnancy gestational diabetes mellitus (eGDM): A systematic review

AIMS

Gestational diabetes mellitus (GDM) diagnosed during the first trimester of pregnancy is called 'early pregnancy Gestational Diabetes Mellitus' (eGDM). The burden of eGDM has only been studied sporadically. This review aims to understand the global burden of eGDM in terms of prevalence, risk factors, pregnancy outcomes, treatment and postpartum dysglycemia.  METHODS: A review of epidemiologic studies reporting on early GDM screening as per Joanna Briggs Institute (JBI) methodology for prevalence reviews was conducted. A customized search strategy was used to search electronic databases namely, PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, MEDLINE, Ovid, ScienceDirect, and Google Scholar. Three independent reviewers reviewed studies using Covidence software. Observational studies irrespective of study design and regardless of diagnostic criteria were included. Quality of evidence was appraised, and findings were synthesized.

RESULTS

Of 58 included studies, 41 reported a prevalence of eGDM, ranging from 0.7 to 36.8%. Body mass index (BMI), previous history of GDM, family history of diabetes and multiparity were reported as eGDM risk factors. Adverse pregnancy outcomes associated with eGDM were macrosomia, caesarean delivery, induction of labour, hypertension, preterm delivery, and shoulder dystocia. The incidence of postpartum dysglycemia and the need for insulin was higher in women with eGDM. The risk of bias was moderate. Heterogeneity of studies is a limitation. Meta-analysis was not performed.

CONCLUSIONS

There is heterogeneity in the prevalence of eGDM and intrapartum and postpartum ill effects for the mother and the offspring. There is a need to develop a universal screening protocol for eGDM.

Disparities in three critical maternal health indicators amongst Muslims: Vis-a-vis the results reflected on National Health Mission

Background

The post national health mission era has been recognized for India’s accelerating improvement in maternal health care utilization. Concurrent investigations with the purview of examining inequalities in maternal care utilisation have rigorously examined across various socio-economic groups, focusing on Muslim women. The present study examined socio-economic differentials in maternal health care utilisation among Muslims and the delineated factors which are contributing for these inequalities.

Methods

Study used the data from National Family Health Survey (NFHS) conducted in 2005-06 and 2015-16. the present study applied concentration index and Wagstaff-type decomposition analysis to measure and decompose the inequality in maternal health services.

Results

This study found that utilisation of full antenatal care (full ANC), skilled attendants at birth (SBAs) and postnatal care was increased during 2005-06 to 2015-16. However, the least improvement was observed in full antenatal care whereas substantial improvement was achieved in utilising skilled attendants at birth. Further, the poor and non-poor gap in maternal health care utilisation mostly prevailed among the educated, urban resident, other backward castes among Muslims. The inequality has been declined largely in SBA utilisation compared to full ANC and PNC, especially in the southern India. Higher education, mass media exposure, higher birth order and urban residence contribute and explain most of these inequalities in maternal care among Muslim women

Conclusions

Despite the fact that free and cash benefitted health programmes, wealth, mass media exposure and education etc welfare programs benefitted a large number of citizens, it also produced most of the inequalities among Muslims in India. The results focus on the significance of wealth, education, and mass media exposure in bridging the socioeconomic gap in maternal health care utilization among Muslims.

Determinants of very low birth weight in India: The National Family Health Survey – 4

Background Low birth weight (LBW) is susceptible to neonatal complications, chronic medical conditions, and neurodevelopmental disabilities. We aim to describe the determinants of very low birth weight (VLBW) in India based on the National Family Health Survey – 4 (NHFS-4). Methods Data from the NFHS 4 on birthweight and other socio-demographic characteristics for the youngest child born in the family during the five years preceding the survey were used. Data of 147,762 infant–mother pairs were included. Multiple logistic regression models were employed to delineate the independent predictors of VLBW (birth weight<1500 g) or LBW (birth weight <2500 g). Results Of the 147,762 children included in the study, VLBW and LBW were observed in 1.2% and 15.8% of children, respectively. The odds of VLBW were higher in female children (aOR: 1.36, 95% CI: 1.15–1.60), among mothers aged 13–19 years (aOR: 1.58, 95% CI: 1.22–2.07), mothers with severe or moderate anaemia (aOR: 1.61, 95% CI: 1.34–1.94), mothers without recommended antenatal care (aOR: 1.47, 95% CI: 1.31–1.90), maternal height less than 150 cm (aOR: 1.54, 95% CI: 1.29–1.85) and among mothers with multiple pregnancy (aOR: 21.34, 95% CI: 14.70–30.96) in comparison to their corresponding counterparts. In addition to the variables associated with VLBW, educational status of mothers (no education; aOR: 1.08, 95% CI: 1.02–1.15 and primary education; aOR: 1.16, 95% CI: 1.08–1.25), caste of the children (scheduled tribe; aOR: 1.13, 95% CI: 1.03–1.24), and wealthiness of the family (poorest wealth quintiles; aOR: 1.11, 95% CI: 1.03–1.19) were associated with LBW. Conclusions Interventions targeting improvements in antenatal care access, maternal health, and nutritional status may reduce the number of VLBW infants. Social determinants of LBW require further detailed study to understand the high propensity of low birth-weight phenotypes in the disadvantaged communities in India.

Facilitating behavioral change: A comparative assessment of ASHA efficacy in rural Bihar

Community health worker (CHW) programs are essential for expanding health services to many areas of the world and improving uptake of recommended behaviors. One of these programs, called Accredited Social Health Activists (ASHA), was initiated by the government of India in 2005 and now has a workforce of about 1 million. ASHAs primarily focus on improving maternal and child health but also support other health initiatives. Evaluations of ASHA efficacy have found a range of results, from negative, to mixed, to positive. Clarity in forming a general impression of ASHA efficacy is hindered by the use of a wide range of evaluation criteria across studies, a lack of comparison to other sources of behavioral influence, and a focus on a small number of behaviors per study. We analyze survey data for 1,166 mothers from Bihar, India, to assess the influence of ASHAs and eight other health influencers on the uptake of 12 perinatal health behaviors. We find that ASHAs are highly effective at increasing the probability that women self-report having practiced biomedically-recommended behaviors. The ASHA's overall positive effect is larger than any of the nine health influencer categories in our study (covering public, private, and community sources), but their reach needs to be more widely extended to mothers who lack sufficient contact with ASHAs. We conclude that interactions between ASHAs and mothers positively impact the uptake of recommended perinatal health behaviors. ASHA training and program evaluation need to distinguish between individual-level and program-level factors in seeking ways to remove barriers that affect the reach of ASHA services.

Number of antenatal care visits and associated factors among reproductive age women in Sub-Saharan Africa using recent demographic and health survey data from 2008-2019: A multilevel negative binomial regression model

BACKGROUND

Antenatal care is one of the best strategies for maternal and neonatal mortality reduction. There is a paucity of evidence on the mean number of ANC visits and associated factors in Sub-Saharan Africa (SSA). This study aimed to investigate the mean number of ANC visits and associated factors among reproductive-age women in Sub-Saharan Africa using the Demographic and Health Survey conducted from 2008 to 2019.

METHOD

A total of 256,425 weighted numbers of women who gave birth five years before the survey were included. We used STATA version 14 for data management and analysis. A multilevel negative binomial regression model was fitted. Finally, the Adjusted Incident Rate Ratio (AIRR) with its 95% CI confidence interval was reported. Statistical significance was declared at P-value < 0.05.

RESULTS

The mean number of ANC visits among women who gave birth five years before the survey in SSA was 3.83 (95% CI = 3.82, 3.84) Individual-level factors such as being aged 36-49 years (AIRR = 1.20, 95% CI = 1.18,1.21), having secondary education &above (AIRR = 1.44, 95% CI = 1.42, 1.45), having rich wealth status (AIRR = 1.08, 95% CI = 1.07, 1.09), media exposure (AIRR = 1.10, 95% CI = 1.09,1.11), and grand multiparity (AIRR = 0.90, 95% CI = 0.89, 0.91) were significantly associated with the number of ANC visits. Furthermore, rural residence (AIRR = 0.90, 95% CI = 0.89, 0.91), Western SSA region (AIRR = 1.19, 95% CI = 1.18, 1.20) and being from a middle-income country (AIRR = 1.09, 95% CI = 1.08, 1.10) were community-level factors that had a significant association with the number of ANC visits.

CONCLUSION

The mean number of ANC visits in SSA approximates the minimum recommended number of ANC visits by the World Health Organization. Women's educational status, women's age, media exposure, parity, planned pregnancy, wealth status, residence, country's income, and region of SSA had a significant association with the frequency of ANC visits. This study suggests that addressing geographical disparities and socio-economic inequalities will help to alleviate the reduced utilization of ANC services.

Factors associated with tetanus vaccination in pregnant women living in Minas Gerais State, Brazil: A cross-sectional study

Background

Aim

Methods

Results

Conclusion

Level of completion along continuum of care for maternal, newborn and child health services and factors associated with it among women in India: a population-based cross-sectional study

Background

India, being a developing country, presents a disquiet picture of maternal and neonatal mortality and morbidity. The majority of maternal and neonatal mortality could be avoided if the continuum of care (CoC) is provided in a structured pathway from pregnancy to the postpartum period. Therefore, this article attempted to address the following research questions: What is the level of completion along CoC for MNCH services? At which stage of care do women discontinue taking services? and what are the factors affecting the continuation in receiving maternal, newborn and child health (MNCH) services among women in India?

Methods

The study utilized the data from the National Family Health Survey (NFHS-4) conducted during 2015–16 in India. The analysis was limited to 107,016 women aged 15–49 who had given a live birth in the last 5 years preceding the survey and whose children had completed 1 year. Four sequential fixed effect logit regression models were fitted to identify the predictors of completion of CoC.

Results

Nearly 39% of women in India had completed CoC for maternal and child health by receiving all four types of service (antenatal care, institutional delivery, post-natal care and full immunization of their child), with substantial regional variation ranging from 12 to 81%. The highest number of dropouts in CoC were observed at the first stage with a loss of nearly 38%. Further, education, wealth index, and health insurance coverage emerged as significant factors associated with CoC completion.

Conclusion

The major barrier in achieving CoC for maternal and child health is the low utilization of ANC services in the first stage of the continuum and hence should be addressed for increasing CoC completion rate in the country. The gaps across all the levels of CoC indicate a need for increased focus on the CoC approach in India. A strategy should be developed that will connect all the components of MNCH avoiding dropouts and the MNCH provision should be standardized to provide services to every woman and child.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04198-2.

Teenage pregnancies, practices, and utilization of RCH services by the tribal and nontribal population of West and South Tripura districts: A mixed method study

Background:

As per NFHS III, 4.5% of the teen aged women of Tripura were pregnant, 18.5% have begun childbearing, and 14% have given live births.

Objectives:

To estimate the prevalence of teenage pregnancies among tribal and nontribal population of West and South districts of Tripura, to study the social practice of care during these pregnancies, and to assess the utilization of RCH services by them.

Methods:

A community-based mixed method study was conducted from 5^th September 2014 to 4^th September 2015 among 2108 tribal and nontribal women aged 15 to ≤18 years residing in the undivided West and South districts of Tripura chosen by multistage sampling.

Result:

Among the study women, 93.5% were married, 6.3% were unmarried, and 0.2% was either divorced or widowed. Out of total, 21.35% were pregnant and 57.92% had already delivered. ASHA services were received by 59.73% and 72.13% in West and South districts and by 68.09% and 63.69% of the tribal and nontribal, respectively. JSY registration was 53.99% and 83.43% in West and South districts and 71.56% and 66.91% among tribal and nontribal, respectively. Antenatal check-up was received by 96.26% and 90.79% in West and South districts and 89.39% and 97.66% among tribal and nontribal ever pregnant women, respectively. Home deliveries were higher among tribal and they had inadequate postnatal check-up. Practice of isolated confinement following childbirth was fewer and these rooms were unclean and ill-ventilated though normal clothing was used. Qualitative component revealed that underutilization of RCH services was mainly due to poor quality of services, ignorance, and economic constraints to reach health facility.

Conclusion:

Teenage pregnancy is prevalent in Tripura and more among tribal. Ignorance of the women and poor quality of RCH services at primary health care level are responsible for its underutilization.

Mobile health technology to improve maternal health awareness in tribal populations: mobile for mothers

Mobile health (mHealth) applications have the potential to improve health awareness. This study reports a quasi-controlled intervention to augment maternal health awareness among tribal pregnant mothers through the mHealth application. Households from 2 independent villages with similar socio-demographics in tribal regions of India were selected as intervention (Village A) and control group (Village B). The control group received government mandated programs through traditional means (orally), whereas the intervention group received the same education through mHealth utilization. Postintervention, awareness about tetanus injections and consumption of iron tablets was significantly (P < .001) improved in the intervention group by 55% and 58%, respectively. Awareness about hygiene significantly (P < .001) increased by 57.1%. In addition, mothers in the intervention group who recognized vaginal bleeding, severe abdominal pain, severe blurring of vision, or convulsions as danger signs during pregnancy significantly (P < .001) increased by 18.30%, 23.2%, 20.0%, and 4.90%, respectively. Our study indicates that despite the low literacy of users, mHealth intervention can improve maternal health awareness among tribal communities.

Utilization of antenatal care services and its sociodemographic correlates in urban and rural areas in Delhi, India

INTRODUCTION

Timely and quality antenatal care (ANC) is an essential element of universal health coverage and a key determinant for the prevention of maternal mortality. Nevertheless, evidence from large-scale health surveys in developing countries highlight a lack of access and utilization of antenatal care especially among socioeconomically disadvantaged populations.

METHODS

A total of 200 women were recruited from urban and rural primary care service provision areas of a government medical college in Delhi during April 2016-2017. Women with infants were interviewed to assess the antenatal care received by them during their recently concluded pregnancy.

RESULTS

The mean (SD) age of the participants was 25.6 (3.9) years. A total of 63 (31.5%) participants were primigravida, and 137 (68.5%) were multigravida. The knowledge of ANC was significantly higher in the participants that were more educated (p<0.001) but it was similar in both the urban and rural sites. Only 107 (53%) participants reported receiving comprehensive antenatal care defined as early registration of pregnancy (within 12 weeks), at least four ANC visits, two doses of tetanus toxoid, and at least 100 days of iron/folic acid supplementation (IFAS). The participants lacking knowledge of ANC had three times higher odds of suboptimal ANC utilization during their previous pregnancy (p=0.018). Furthermore, the ANC content was adequate in terms of medical service provision but deficient in terms of educational and counseling services.

CONCLUSIONS

A high prevalence of suboptimal ANC utilization was observed despite the availability of government-funded primary care.

Contrast in utilization of maternal and child health services between Himalayan region and rest of India: Evidence from National Family Health Survey (2015-16)

Background

Maternal and child health services, like antenatal care, skilled birth attendance and postnatal care, are crucial to improve maternal and neonatal health outcomes. Numerous studies have been conducted on the distribution of utilization of maternal and child healthcare (MCH) services in India with respect to socioeconomic and demographic characteristics. But no study has analyzed the utilization of MCH services with a focus on the topography of a given region (hilly/plain). The present study analyzes the utilization of MCH services in the hilly-Himalayan region of India in comparison to the rest of the country.

Methods

Data from India’s National Family Health Survey-4 (2015–16), on 190,898 women, was utilized for analysis in the present study. The association between the utilization of MCH services and the topography of the region of residence (hilly/plain) was analyzed by calculating adjusted odds ratios (AOR) with 95% confidence interval (95%CI) and predicted probabilities using a two-level random intercept logistic regression model.

Results

It was found that the utilization of MCH services was significantly lower in the hilly regions compared to the plain regions. Women living in hilly areas (AOR: 0.42, 95%CI: 0.39–0.45) had 58% lower odds of receiving skilled birth attendance (SBA) than those living in plain areas. Similarly, the odds of receiving PNC, ANC, and full immunization were also lower in the hilly regions compared to the plain regions. The utilization of MCH services was alarmingly low in the rural-hilly regions. The odds of receiving two tetanus injections before birth were 71% lower for women in the rural-hilly areas (AOR: 0.39, 95% CI: 0.36–43) than those in the rural-plain areas. Predicted probabilities also showed that women in the hilly regions were less likely to receive MCH services compared to their counterparts in the plain regions.

Conclusion

Except for the consumption of Iron Folic Acid (IFA) and the utilization of AWC services/ICDS (Integrated Child and Development Services), all other MCH services were significantly underutilized in the hilly regions compared to the plain regions. This calls for the attention of and concentrated efforts by policy makers and stakeholders, with a special focus on the rural-hilly regions. We firmly believe that the results of the present study have important policy implications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04081-0.

Transport characteristics and predictors of mortality among neonates referred to a tertiary care centre in North India: a prospective observational study

OBJECTIVE

The paucity of specialised care in the peripheral areas of developing countries necessitates the referral of sick neonates to higher centres. Organised interhospital transport services provided by a skilled and well-equipped team can significantly improve the outcome. The present study evaluated the transport characteristics and predictors of mortality among neonates referred to a tertiary care centre in North India.

DESIGN

Prospective observational study.

SETTINGS

Tertiary care teaching hospital in North India.

PATIENTS

1013 neonates referred from peripheral health units.

MAIN OUTCOME MEASURES

Mortality among referred neonates on admission to our centre.

RESULTS

Of the 1013 enrolled neonates, 83% were transferred through national ambulance services, 13.7% through private hospital ambulances and 3.3% through personal vehicles. Major transfer indications were prematurity (35%), requirement for ventilation (32%), birth asphyxia (28%) and hyperbilirubinaemia (19%). Hypothermia (32.5%, 330 of 1013), shock (19%, 192 of 1013) and requirement for immediate cardiorespiratory support (ICRS) (10.4%, 106 of 1013) on arrival were the major complications observed during transfer. A total of 305 (30.1%, N=1013) deaths occurred. Of these, 52% (n=160) died within 24 hours of arrival. On multivariate logistic analysis, unsupervised pregnancy (<4 antenatal visits; p=0.037), antenatal complications (p<0.001), prematurity ≤30 weeks (p=0.005), shock (p=0.001), hypothermia (p<0.001), requirement for ICRS on arrival (p<0.001), birth asphyxia (p=0.004), travel time >2 hours (p=0.005) and absence of trained staff during transfer (p<0.001) were found to be significant predictors of mortality.

CONCLUSION

The present study depicts high mortality among infants referred to our centre. Adequate training of peripheral health personnel and availability of pre-referral stabilisation and dedicated interhospital transport teams for sick neonate transfers may prove valuable interventions for improved outcomes.

Magnitude and Determinants of Antenatal Care Utilization in Kandahar City, Afghanistan

Background

Women's and children's health is a crucial public health concern that epitomizes the universal platform for Sustainable Development Goals (SDGs). Appropriate and timely care during pregnancy can improve maternal and child health.

Objectives

The present study aimed at determining the magnitude and determinants of antenatal care services' utilization in Kandahar city.

Methods

A community-based cross-sectional study involving 850 women with at least one delivery in the last 2 years was carried out in Kandahar city from January to February 2021. Questionnaires to record information on sociodemographic, reproductive, and antenatal care- (ANC-) related characteristics were administered. Data were analyzed using SPSS 21.00 statistical software. We used descriptive statistics such as frequency and percentages to present the data. Determinants of antenatal care services' utilization were determined using a multivariable logistic regression model.

Results

Among all study participants, 589 (69.3%, 95% confidence interval (CI) = 66.0%-72.4%) of study participants utilized antenatal care services at least once. However, only 22% of the women were utilizing the recommended ≥4 ANC visits. Factors that remained significantly associated with antenatal care services' utilization in multivariable analysis included women's educational status (adjusted odds ratio (AOR) = 2.0, 95% CI: 1.0-4.3), pregnancy intention (AOR = 2.1, 95% CI: 1.1-3.4), and place of residence (AOR = 1.7, 95% CI: 1.1-2.6).

Conclusion

This study has found high rates (vs. the national level) of antenatal care services' utilization among women who had at least one delivery in the last 2 years. However, the rate of recommended ≥4 ANC visits was low. Factors determining antenatal care utilization such as educational status of the mother, pregnancy intention, and place of residence hold the key to address the issue of ANC services lower utilization and consequently improve maternal and fetal health.