Predictors of home births among rural women in Ghana: analysis of data from the 2014 Ghana Demographic and Health Survey

Factors Associated with Use of Traditional Birth Attendants for Child Delivery: A Cross-Sectional Study

Background

Even though the use of skilled birth attendants at birth reduces the risk of maternal mortality and associated complications, some pregnant women prefer to use either traditional birth attendants (TBAs) or deliver at home. Although the use of assisted delivery was reduced between 2014 and 2016 in North Tongu, the rate of TBA use among pregnant women in the district was increasing. There is, therefore, the need to establish the reason for this increase in TBA use. We conducted a study to assess factors that influence the use of TBAs in the North Tongu district.

Methods

A retrospective cross-sectional facility-based survey was conducted among 449 women who delivered within the past 12 months and were accessing postnatal care services in the North Tongu district. A simple random sampling method was used to select women who attend child welfare clinics. Bivariate and multivariate analyses were conducted to determine the factors that were significantly associated with use of TBAs. All statistical analyses were done at a 95% confidence level with statistical significance at p ≤ 0.05.

Results

The mean age of the respondents was 27.0 years ± 6.2 SD. The prevalence of use of TBA during childbirth among women was 26.5%. Factors that significantly influenced use of TBAs during childbirth were age, religion, educational status, and parity. Other significant factors included several antenatal care visits and the attitude of health workers toward pregnant women.

Conclusion

Use of TBA services at birth in the study district remains relatively high. Women who use antenatal and postnatal care services should be educated on the importance of skilled delivery. There is also a need to equip TBAs and reposition them as link agents to facilitate referrals of pregnant women to health facilities where there is a need for additional birth attendants.

Women in low- and middle-income countries receive antenatal care at health institutions, yet not delivered there: a multilevel analysis of 2016-2021 DHS data

BACKGROUND

The institutional delivery dropout (IDD) is a major problem that disproportionately affects low- and middle-income countries (LMICs). It is associated with increased risks of adverse birth outcomes among pregnant women. Hence, this study assessed the pooled estimate and determinants of IDD after antenatal care (ANC) visit among women in LMICs.

METHOD

The Demographic and Health Survey (DHS) data from 29 LMICs were used for this study. Data analysis was performed with STATA version 14. The forest plot was used to estimate the pooled prevalence of IDD. Multilevel binary logistic regression was fitted to identify determinants of IDD. The statistical significance level between the outcome and independent variables was determined through the adjusted odds ratio (AOR) with 95% CI and p-value less than 0.05.

RESULT

The pooled prevalence of IDD after ANC booking among reproductive age women in LMICs was 22.25% (95%CI: 18.25, 26.25). Additionally, the prevalence of IDD was highest (29.83%) among women from the South and Central Europe and the Caribbean countries and lowest (13.72%) in Central/Western Asia and the Oceania. In the multilevel analysis; no education (AOR = 2.92; 95% CI: 2.72, 3.13), poorest wealth index (AOR = 3.46; 95% CI: 3.28, 3.66), inadequate ANC visits (AOR = 1.73; 95% CI: 1.39, 1.77), no media exposure (AOR = 1.27; 95% CI: 1.23, 1.30), rural (AOR = 1.50; 95% CI: 1.43, 1.54), distance a big problem (AOR = 1.28; 95% CI: 1.25, 1.31), and women located in the South/Eastern Europe and Caribbean region 6.67 (AOR = 6.67; 95% CI: 6.20, 7.20), women lived in low-income countries 7.05 (AOR = 7.05; 95% CI: 6.57, 7.56), and women from lower middle-income countries 5.34 (AOR = 5.57; 95% CI: 4.93, 5.78), had increased odds of IDD after ANC among women in LMICs. However, women who had ever born one child (AOR = 0.29; 95% CI: 0.28, 0.31), and women from Central and Western Asia and the Oceania (AOR = 0.78; 95%CI: 0.74, 0.82) had decreased odds of IDD.

CONCLUSION

The IDD was high among women in LMICs and significantly increased among women with no education, from poorest household, had inadequate ANC visit, no media exposure, rural, distance a big problem. Hence, interventions to reduce IDD should focus on addressing the gaps related to maternal education, access to media, and number of ANC visits among women in LMICs.

Trend and determinants of home delivery in Gambia, evidence from 2013 and 2020 Gambia Demographic and Health Survey: A multivariate decomposition analysis

BACKGROUND

Home delivery is defined as is an even of pregnant women getting giving birth in a woman her home or other homes without an unskilled health professional assistance. It is continuing as public health problem since its responsible for death of women and newborn. In Gambia there is a high maternal mortality rate, which may be related to home delivery. Therefore, this study aimed to assess the trend of home delivery and identify predictors using Gambia Demographic and Health Survey (GDHS) 2013 and 2019-2020 data sets.

METHODS

A Cross-Section survey was conducted based on GDHS 2013 and 2019-2020 among reproductive age group women. A total of 8607 women participated in this study. A bivariate decomposition model was fitted, and variables that had a p-value > 0.25 were dropped. Finally, variables that got a p-value of < 0.05 with 95% confidence interval (CI) in the multivariate decomposition analysis were considered as statistical significance variables in the overall decomposition.

RESULTS

There has been a dramatic decrement in maternal home delivery in Gambia. It was 36.18% (95% CI:34.78, 37.58) in 2013 GDHS and 14.39% (95% CI:13.31,15.47) in 2019-2020 GDHS. This reduction is real because there was a change in the characteristics effect of the population and the coefficient effect some variables in the home delivery. Changes in characteristics effect of husband education, women education, rural residents, more than three antenatal cares follow up, and no problem reaching health facilities played a significant role in the reduction of home delivery. Being urban resident and women who had occupation were variables that had a positive effect on coefficient effect change.

CONCLUSION

In this study, the home delivery rate had steeply declined in the Gambia during the study period of the two surveys. Just above nine-tenths decrement in home delivery rate resulted because there was a change in the characteristics effect of the study participants. Enhancing more citizens to attend high school and above, narrowing the gap between rural and urban in terms of accessing health facilities, and improving the availability of infrastructure should be done.

Do disempowered childbearing women give birth at home in Sierra Leone? A secondary analysis of the 2019 Sierra Leone demographic health survey

BACKGROUND

A nationwide assessment of the link between women's empowerment and homebirth has not been fully examined in Sierra Leone. Our study examined the association between women's empowerment and homebirth among childbearing women in Sierra Leone using the 2019 Sierra Leone Demographic Health Survey (2019 SLDHS) data.

METHOD

We used the individual file (IR) of the 2019 SLDHS dataset for our analysis. A total of 7377 women aged 15-49 years who gave birth in the five years preceding the survey were included. Outcome variable was "home birth of their last child among women in the five years preceding the 2019 SLDHS. Women's empowerment parameters include women's knowledge level, economic participation, decision-making ability and power to refuse the idea of intimate partner violence. We used the complex sample command on SPSS version 28 to conduct descriptive and multivariate logistic regression analyses.

RESULTS

Three in every 20 women had home childbirth (n = 1177; 15.3%). Women with low [aOR 2.04; 95% CI 1.43-2.92] and medium [aOR 1.44; 95%CI 1.05-1.97] levels of knowledge had higher odds of giving birth at home compared to those with high levels of knowledge. Women who did not have power to refuse the idea of intimate partner violence against women were more likely to had given birth at home [aOR 1.38; 95% CI1.09-1.74]. In addition, women with no [aOR 2.71; 95% CI1.34-5.46) and less than four antenatal care visits [aOR 2.08; 95% CI:1.51-2.88] and for whom distance to a health facility was a major problem [aOR 1.95; 95% CI1.49-2.56] were more likely to have had a homebirth. However, no statistically significant association was observed between a women's decision-making power and home birth [aOR 1.11; 95% CI 0.86-1.41].

CONCLUSION

Despite improvements in maternal health indicators, homebirth by unskilled birth attendants is still a public health concern in Sierra Leone. Women with low knowledge levels, who did not have power to refuse the idea of intimate partner violence against women, had less than four ANC visits and considered distance to a health facility as a major problem had higher odds of giving birth at home. Our findings reflect the need to empower women by improving their knowledge level through girl child and adult education, increasing media exposure, changing societal norms and unequal power relations that promote gender-based violence against women, and improving roads and transport infrastructure.

Antenatal and postnatal cervical precancer screening to increase coverage: experience from Battor, Ghana

Background

Cervical precancer screening in low-resource settings is largely opportunistic with low coverage. Many women in these settings, where the burden of cervical cancer is highest, only visit health institutions when pregnant or after delivery. We explored screening during antenatal and postnatal visits aimed at increasing coverage.

Methods

Pregnant women (in any trimester) attending antenatal care (ANC) and women attending postnatal care (PNC; 6-10 weeks) clinics were screened at Catholic Hospital, Battor and at outreach clinics from February to August 2022 (08/02/2022 to 02/08/2022). At the same visit, cervical specimens were obtained for high-risk human papillomavirus (hr-HPV) DNA testing (with the Sansure MA-6000 PCR platform) followed by either visual inspection with acetic acid (VIA) or mobile colposcopy with the enhanced visual assessment system.

Results

Two hundred and seventy and 107 women were screened in the antenatal and postnatal groups, respectively. The mean ages were 29.4 (SD, 5.4) in the ANC group and 28.6 (SD, 6.4) years in the PNC group. The overall hr-HPV prevalence rate was 25.5% (95% confidence interval (CI), 21.1-29.9) disaggregated as 26.7% (95% CI, 21.4-31.9) in the ANC group and 22.4% (95% CI, 14.5-30.3) in the PNC group (p = 0.3946). Overall, 58.9% of pregnant women (28.3% hr-HPV+) and 66.4% of postnatal women (22.5% hr-HPV+) only visited a health facility when pregnant or after delivery (at Child Welfare Clinics). The VIA 'positivity' rate for all screened women was 5.3% (95% CI, 3.1-7.6), disaggregated into 5.2% (95% CI, 2.5-7.8) in the ANC group and 5.7% (95% CI, 1.3-10.1) in the PNC group (p-value = 0.853).

Conclusion

A significant number of women in Ghana only visit a health facility during pregnancy or after delivery. ANC and PNC clinics would offer opportunities to increase coverage in cervical precancer screening in low-resource settings. Relying on community nurses ensures that such programs are readily integrated into routine care of women and no opportunity is missed.

Knowledge of Postbirth Warning Signs and Postpartum Education Among Women in Ghana

OBJECTIVE

To assess the relationship between postpartum education and knowledge of postbirth warning signs among women in Ghana.

DESIGN

Cross-sectional survey.

SETTING

Tamale West Hospital in Tamale Metropolitan Area, Ghana.

PARTICIPANTS

Women (N = 151) who gave birth to healthy newborns and were admitted to the postnatal ward.

METHODS

We collected data from surveys distributed in the hospital. The survey included items for sociodemographic characteristics, obstetric history, postpartum education provided, and knowledge of nine common postbirth warning signs. We used descriptive statistics and multivariate logistic regression models to analyze the data.

RESULTS

Participants reported knowing an average of 5.2 of 9 (SD = 2.84) postbirth warning signs. Severe bleeding (94.70%, n = 143), fever (82.12%, n = 124), and severe headache (72.19%, n = 109) were the postbirth warning signs most frequently identified by participants. Swelling in the leg (37.09%, n = 56) and thoughts of hurting oneself (33.11%, n = 50) were the postbirth warning signs least frequently identified by participants. Knowledge about postbirth warning signs was positively associated with reports of receiving educational handouts on the postnatal ward (adjusted OR = 4.64, 95% confidence interval [1.27, 17.04]) and reports that four or more postpartum complications were taught before hospital discharge (adjusted OR = 27.97, 95% confidence interval [7.55, 103.57]) compared to zero to three postpartum complications.

CONCLUSION

All women need comprehensive discharge education on the warning signs of complications after birth. Promoting knowledge of postbirth warning signs can decrease delays in seeking care and contribute to the reduction of maternal mortality in Ghana.

Socioeconomic and geographical inequalities in using skilled birth attendants during delivery in Bangladesh over two decades

BACKGROUND

Maternal and neonatal mortality is a major public health concern globally. Evidence supports that skilled birth attendants (SBA) can significantly reduce maternal and neonatal mortality. Despite the improvement in SBA use, Bangladesh lacks evidence of equality in SBA use across socioeconomic and geographic regions. Therefore, we aim to estimate the trends and magnitude of inequality in SBA use in Bangladesh over the last two decades.

METHODS

Data from the last 5 rounds of Bangladesh Demographic and Health Surveys (BDHS; 2017-18, 2014, 2011, 2007, and 2004) were used to measure the inequalities in the SBA use utilizing the WHO's Health Equity Assessment Toolkit (HEAT) software. Inequality was assessed by four summary measures, namely, Population Attributable Risk (PAR), Population Attributable Fraction (PAF), Difference (D), and Ratio (R) based on the four equity dimensions: wealth status, education level, place of residence, and subnational regions (divisions). Point estimates and a 95% confidence interval (CI) were reported for each measure.

RESULTS

An increasing trend in the overall prevalence of SBA use was observed (From 15.6% in 2004 to 52.9% in 2017). We found significant inequalities in SBA use in every wave of BDHS (from 2004 to 2017), with the result concentrating on the rich (in 2017, PAF: 57.1; 95% CI: 52.5-61.7), educated (in 2017, PAR: 9.9; 95% CI: 5.2-14.5),  and people from urban areas (in 2017, PAF: 28.0; 95% CI: 26.4-29.5). We also identified geographic disparities in SBA use favoring Khulna and Dhaka divisions (in 2017, PAR: 10.2; 95% CI: 5.7-14.7). Our study also observed inequality in using SBA among Bangladeshi women decreased over time.

CONCLUSION

To increase SBA use and to decrease inequality in all four equity dimensions, disadvantaged sub-groups should be prioritized in policies and planning for program implementation.

Inequalities in the prevalence of skilled birth attendance in Ghana between 1993 and 2014

BACKGROUND

Globally, maternal and neonatal health remains a public health priority, particularly for resource-constrained regions like sub-Saharan Africa (SSA). Skilled birth attendance (SBA) is essential in promoting maternal and neonatal health. This study investigated the inequalities in the prevalence of SBA in Ghana using data from the Ghana Demographic and Health Survey (GDHS) between 1993 and 2014.

METHODS

Data were analysed using the World Health Organization's Health Equity Assessment Toolkit software. In analysing the data, we first disaggregated SBA by four inequality stratifiers: wealth index, education, residence, and region. Second, we measured the inequality through summary measures, namely difference, population attributable risk, ratio, and population attributable fraction. A 95% confidence interval was constructed for point estimates to measure statistical significance.

RESULTS

Throughout the period, SBA was highest among women in the highest wealth quintile and those with a secondary or higher level of education. The analysis also indicated that SBA was highly concentrated among urban residents in 1993 (80.78 [95% uncertainty interval {UI} 76.20-84.66]) and persisted to 2014 (91.55 [95% UI 88.80-93.68]). In 1993, Northern region recorded the lowest prevalence of SBA in Ghana (15.69 [95% UI 11.20-21.54]) and the region consistently recorded the lowest SBA prevalence even into 2014 (38.21 [95% UI 27.44-50.27]).

CONCLUSIONS

There are significant inequalities in SBA across education, wealth, residence, and region in Ghana. To enhance SBA, there is the need for policymakers and interventionists to design and develop targeted policies and programs that are tailored to the needs of the subpopulations at risk of low SBA: women with no formal education, those within the poorest wealth quintile, rural-dwelling women and women in the Northern region. This will facilitate the uptake of SBA and ultimately translate into the realization of Sustainable Development Goals 3.1 and 3.2.

Prevalence and associated factors of home delivery in Eastern Africa: Further analysis of data from the recent Demographic and Health Survey data

Objectives:

The current study aimed to determine the magnitude of home delivery and its associated factors in East Africa using data from the Demographic and Health Survey.

Methods:

We pooled data from the Demographic and Health Survey of the 11 East African countries and included a total weighted sample of 126,107 women in the study. The generalized linear mixed model was fitted to identify factors associated with home delivery. Variables with adjusted odds ratio with a 95% confidence interval, and p value < 0.05 in the final generalized linear mixed model were reported to declare significantly associated factors with home delivery.

Result:

The weighted prevalence of home delivery was 23.68% (95% confidence interval: [23.45, 23.92]) among women in East African countries. Home delivery was highest in Ethiopia (72.5%) whereas, it was lowest in Mozambique (2.8%). In generalized linear mixed model, respondent’s age group, marital status, educational status, place of residence, living country, wealth index, media exposure, and number of children ever born were shown significant association with the home delivery in the East African countries,

Conclusion:

Home delivery varied between countries in the East African zone. Home delivery was significantly increased among women aged 20–34 years, higher number of ever born children, rural residence, never married, or formerly married participants. On the contrary, home delivery decreased with higher educational level, media exposure, and higher wealth index. Wide-range interventions to reduce home delivery should focus on addressing inequities associated with maternal education, family wealth, increased access to the media, and narrowing the gap between rural and urban areas, poor and rich families, and married and unmarried mothers.

Prevalence, progress, and social inequalities of home deliveries in Ghana from 2006 to 2018: insights from the multiple indicator cluster surveys

Background

Delivery in unsafe and unsupervised conditions is common in developing countries including Ghana. Over the years, the Government of Ghana has attempted to improve maternal and child healthcare services including the reduction of home deliveries through programs such as fee waiver for delivery in 2003, abolishment of delivery care cost in 2005, and the introduction of the National Health Insurance Scheme in 2005. Though these efforts have yielded some results, home delivery is still an issue of great concern in Ghana. Therefore, the aim of the present study was to identify the risk factors that are consistently associated with home deliveries in Ghana between 2006 and 2017–18.

Methods

The study relied on datasets from three waves (2006, 2011, and 2017–18) of the Ghana Multiple Indicator Cluster surveys (GMICS). Summary statistics were used to describe the sample. The survey design of the GMICS was accounted for using the ‘svyset’ command in STATA-14 before the association tests. Robust Poisson regression was used to estimate the relationship between sociodemographic factors and home deliveries in Ghana in both bivariate and multivariable models.

Results

The proportion of women who give birth at home during the period under consideration has decreased. The proportion of home deliveries has reduced from 50.56% in 2006 to 21.37% in 2017–18. In the multivariable model, women who had less than eight antenatal care visits, as well as those who dwelt in households with decreasing wealth, rural areas of residence, were consistently at risk of delivering in the home throughout the three data waves. Residing in the Upper East region was associated with a lower likelihood of delivering at home.

Conclusion

Policies should target the at-risk-women to achieve complete reduction in home deliveries. Access to facility-based deliveries should be expanded to ensure that the expansion measures are pro-poor, pro-rural, and pro-uneducated. Innovative measures such as mobile antenatal care programs should be organized in every community in the population segments that were consistently choosing home deliveries over facility-based deliveries.

Multilevel geospatial analysis of factors associated with unskilled birth attendance in Ghana

Background

Globally, about 810 women die every day due to pregnancy and its related complications. Although the death of women during pregnancy or childbirth has declined from 342 deaths to 211 deaths per 100,000 live births between 2000 and 2017, maternal mortality is still higher, particularly in sub-Saharan Africa and South Asia, where 86% of all deaths occur.

Methods

A secondary analysis was carried out using the 2014 Ghana Demographic and Health Survey. A sample total of 4,290 women who had a live birth in the 5 years preceding the survey was included in the analysis. GIS software was used to explore the spatial distribution of unskilled birth attendance in Ghana. The Geographic Weighted Regression (GWR) was employed to model the spatial relationship of some predictor of unskilled birth attendance. Moreover, a multilevel binary logistic regression model was fitted to identify factors associated with unskilled birth attendance.

Results

In this study, unskilled birth attendance had spatial variations across the country. The hotspot, cluster and outlier analysis identified the concerned districts in the north-eastern part of Ghana. The GWR analysis identified different predictors of unskilled birth attendance across districts of Ghana. In the multilevel analysis, mothers with no education, no health insurance coverage, and mothers from households with lower wealth status had higher odds of unskilled birth attendance. Being multi and grand multiparous, perception of distance from the health facility as not a big problem, urban residence, women residing in communities with medium and higher poverty level had lower odds of unskilled birth attendance.

Conclusion

Unskilled birth attendance had spatial variations across the country. Areas with high levels of unskilled birth attendance had mothers who had no formal education, not health insured, mothers from poor households and communities, primiparous women, mothers from remote and border districts could get special attention in terms of allocation of resources including skilled human power, and improved access to health facilities.

What influences home delivery among women who live in urban areas? Analysis of 2014 Ghana Demographic and Health Survey data

BACKGROUND

In Ghana, home delivery among women in urban areas is relatively low compared to rural areas. However, the few women who deliver at home in urban areas still face enormous risk of infections and death, just like those in rural areas. The present study investigated the factors associated with home delivery among women who live in urban areas in Ghana.

MATERIALS AND METHODS

Data for this study was obtained from the 2014 Ghana Demographic and Health Survey. We used data of 1,441 women who gave birth in the 5 years preceding the survey and were dwelling in urban areas. By the use of Stata version 14.2, we conducted both descriptive and multivariable logistic regression analyses.

RESULTS

We found that 7.9% of women in urban areas in Ghana delivered at home. The study revealed that, compared to women who lived in the Northern region, women who lived in the Brong Ahafo region [AOR = 0.38, CI = 0.17-0.84] were less likely to deliver at home. The likelihood of home delivery was high among women in the poorest wealth quintile [AOR = 2.02, CI = 1.06-3.86], women who professed other religions [AOR = 3.45; CI = 1.53-7.81], and those who had no antenatal care visits [AOR = 7.17; 1.64-31.3]. Conversely, the likelihood of home delivery was lower among women who had attained secondary/higher education [AOR = 0.30; 0.17-0.53], compared to those with no formal education.

CONCLUSION

The study identified region of residence, wealth quintile, religion, antenatal care visits, and level of education as factors associated with home delivery among urban residents in Ghana. Therefore, health promotion programs targeted at home delivery need to focus on these factors. We also recommend that a qualitative study should be conducted to investigate the factors responsible for the differences in home delivery in terms of region, as the present study could not do so.