Socioeconomic and geographic variations in antenatal care coverage in Angola: further analysis of the 2015 demographic and health survey

Wealth disparities in maternal health service utilization among women of reproductive age in Ethiopia: findings from the mini-EDHS 2019

BACKGROUND

Ethiopia has made strides in reducing maternal mortality, but significant discrepancies in maternal health service utilization exist across socioeconomic levels. According to studies, women from higher-income households are far more likely to use essential services such as antenatal care, delivery care, and postnatal care than poorer women. This wealth disparity is a primary contributor to persistently high maternal mortality, particularly among poor populations. The study's goal was to assess wealth disparities in maternal health service uptake and identify contributing factors.

METHODS AND MATERIALS

We used the Ethiopian Mini Demographic Health Survey (EMDHS), conducted in 2019 on women aged 15-49 living in selected census areas, with a weighted sample size of 3,909. The Erreygers Concentration Index (ECI) was used to measure wealth inequalities in maternal health care, and the ECI decomposition was used to identify factors contributing to inequality in maternal health services.

RESULTS

Maternal health service utilization was pro-rich among women in Ethiopia. The prevalence of antenatal care service (ANC), delivery, and postnatal care (PNC) service utilization showed a pro-rich distribution among Ethiopian women, with ECI = 0.115 (95% CI: 0.091-0.137), ECI = 0.223 (95% CI: 0.191-0.276), and ECI = 0.121 (95% CI: 0.041-0.200), respectively. The ECI indices were decomposed to examine the contributing factors to disparities in maternal service utilization in Ethiopia. Mother's current age, household family size, region, birth order, and parity were contributors to maternal health service utilization.

CONCLUSION

The ANC service, delivery service and PNC service utilization showed a pro-rich distribution among Ethiopian women. Mother's current age, household family size, region, birth order, and parity are important contributors of maternal health service inequality. To improve access and usage among low-income women, policymakers can develop programs including increasing the number of free or subsidized services and providing transportation.

Trends and inequalities in antenatal care coverage in Benin (2006-2017): an application of World Health Organization's Health Equity Assessment Toolkit

INTRODUCTION

Between 2006 and 2017, antenatal care (ANC) coverage in Benin declined, potentially exacerbating inequalities and substantiating the need for health inequality monitoring. This study examines inequalities in ANC attendance in Benin, disaggregated by women's age, educational level, economic status, place of residence, region of residence, and the extent to which they have changed over time.

METHODS

Three rounds of the Benin Demographic and Health Surveys (2006, 2011-12, and 2017-18) were analyzed to examine inequalities in ANC coverage. An exploratory descriptive approach was adopted for the analysis. Simple [difference (D) and ratio (R)] and complex [population attributable risk (PAR) and population attributable fraction (PAF)] measures of inequalities were computed using the World Health Organization's Health Equity Assessment Toolkit (WHO's HEAT) online platform. The measures were computed separately for each of the three surveys, and their estimates were compared.

RESULTS

The findings revealed an 8.4% decline in at least four ANC visits between 2006 and 2017-18. The decline occurred irrespective of age, educational status, economic status, place of residence, and region. Region-related inequalities were the largest and increased slightly between 2006 (D = 54.6; R = 2.6; PAF = 47.8, PAR = 29.0) and 2017-18 (D = 55.8; R = 3.1; PAF = 57.2, PAR = 29.8). Education (2006: D = 31.3, R = 1.6, PAF = 40.5, PAR = 24.5; 2017-18: D = 25.2, R = 1.6, PAF = 34.9, PAR = 18.1) and rural-urban (2006: D = 16.8, R = 1.3, PAF = 17.8, PAR = 10.8; 2017-18: D = 11.2, R = 1.2, PAF = 13.1, PAR = 6.8) inequalities reduced while economic status inequalities did not improve (2006: D = 48, R = 2.2, PAF = 44.5, PAR = 26.9; 2017-18: D = 43.9, R = 2.4, PAF = 45.0, PAR = 23.4). Age inequalities were very minimal.

CONCLUSION

ANC inequalities remain deeply ingrained in Benin. Addressing their varying levels requires comprehensive strategies that encompass both supply-and demand-side interventions, focusing on reaching uneducated women in the poorest households and those residing in rural areas and Atacora.

Multilevel Count Regression Analysis of Factors Associated with the Desired Number of Antenatal Care Service Visits in Ethiopia

BACKGROUND

Visiting the desired number of antenatal care services improve the success of maternal health programs in terms of mother and child health. The study aimed to identify the factors associated with differences in the number of antenatal care service visits across and within regions of Ethiopia by using the 2019 Ethiopian Mini Demographic Health Survey (EMDHS).

METHODS

A total of 3979 women who were pregnant or gave birth within 5 years preceding the survey from the 2019 Ethiopian Mini Demographic Health Survey were included in the analysis. A multi-level Hurdle negative binomial regression model was selected to consider the hierarchical nature of the data in determining the factors associated with the barriers to the desired number of antenatal care service visits.

RESULTS

About one-fourth (26.2%) of mothers did not visit any antenatal care, and only 137 (3.4%) women visited the service eight times and above. The random intercept with the fixed coefficient of multilevel Hurdle negative binomial model results has shown that women in the age group between 25 and 34 (AOR = 1.057), in the age group between 35 and 49 (AOR = 1.108), protestant religion follower women (AOR = 0.918), Muslim women (AOR = 0.945), other religion follower women (AOR = 0.768), mothers in primary educational level (AOR = 1.123), secondary and higher education level (AOR = 1.228), rich mothers (AOR = 1.134), and mothers living in rural (AOR = 0.789) were statistically associated with regional variation regarding the frequency of ANC service visits.

CONCLUSIONS

The majority of pregnant women did not visit antenatal care services according to the findings of this study. This study's results revealed that the predictor variables such as mother's age, education level, religion, place of residence, marital status, and wealth index were significant, and the findings revealed that there were regional differences in ANC visits in Ethiopia. Women's economic and educational interventions should be a top priority.

Inequity in uptake of maternal health care services in developing countries: a systematic review and meta-analysis

Background

Maternal health service uptake remains an important predictor of maternal outcomes including maternal mortality. This systematic review and meta-analysis aimed to summarize the available evidence on the uptake of maternal health care services in developing countries and to assess the impact of place of residence, education status, and wealth index on the uptake of these services.

Methods

We examined the databases MEDLINE, Web of Science, Global Index Medicus, and Scopus until June 14, 2022. Cross-sectional studies done between 2015 and 2022 were considered. Mothers of reproductive age and all states of health were included in the study. Independently, two authors determined the eligibility of studies, extracted data, evaluated the risk of bias, and ranked the evidence's degree of certainty. To combine the data, we performed a random-effects meta-analysis. The PROSPERO registration ID is CRD42022304094.

Results

We included 51 studies. Mothers living in urban areas were three times more likely to receive antenatal care (OR 2.95; 95% CI 2.23 to 3.89; 15 studies; 340,390 participants) than rural mothers. Compared with no education, those with primary education were twice as likely to utilize antenatal care (OR 2.36; 95% CI 1.80 to 3.09; 9 studies; 154,398 participants) and those with secondary and higher education were six and fourteen times more likely to utilize antenatal care, respectively. Mothers in the second wealth index were twice as likely as mothers in the lowest wealth index to utilize antenatal care (OR 1.62; 95% CI 1.36 to 1.91; 10 studies; 224,530 participants) and antenatal care utilization increased further among mothers in the higher wealth index. We observed similar relative inequalities in skilled delivery care and postnatal care utilization based on the pace of residence, education, and wealth index.

Conclusion

In developing countries, the problem of inequity in utilizing maternal health care services persists and needs considerable attention.

Socio-economic status and pregnancy complications and their impact on antenatal care services provided at home and Upazila health complex

The stage of pregnancy is crucial for women of reproductive age and their families. However, in low- and middle-income countries like Bangladesh, antenatal and postnatal care are not widely practiced due to various socio-economic factors, such as low education levels, income, age, pregnancy knowledge, and limited healthcare facilities. The objective of this study was to examine the factors associated with antenatal care in two locations in Bangladesh based on the data collected from the Bangladesh Demographic and Health Survey (BDHS) 2017-2018. We explored different variables as explanatory variables related to ANC service. The results showed that most of the respondents were from rural areas, with 77.02% receiving antenatal care at home. Women with secondary education were more likely to receive care at home than those without education. The Chi-square test indicated a positive correlation between antenatal care at home with several variables, whereas, in the case of Upazila health complexes, only three variables showed a positive association. Logistic regression analysis further showed some specific variables such as geographical division, religion, iron intake during pregnancy, and reporting pregnancy complications had a significant impact on ANC at home. In contrast, covariates such as residence, division, and wealth index were significant for antenatal care at Upazila health complexes. The division was a significant covariate in both cases. Interestingly, we observed that mothers who had been informed about the signs of pregnancy complications were 92% more likely to receive antenatal care at home than those who had not experienced pregnancy complications. Conversely, the results revealed that mothers who were unaware of pregnancy complications were 32% more likely to receive antenatal care at home than those who had been informed about complications. This suggests that when women are educated about pregnancy complications, they are more likely to receive more antenatal care. However, Bangladesh's situation is quite different due to a lack of proper education and knowledge of antenatal care services.

Antenatal care service utilization disparities between urban and rural communities in Ethiopia: A negative binomial Poisson regression of 2019 Ethiopian Demography Health Survey

BACKGROUND

Although there have been consistent improvements in maternal mortality, it remains high in developing countries due to unequal access to healthcare services during pregnancy and childbirth. Thus, this study aimed to further analyze the variations in the number of antenatal care utilizations and associated factors among pregnant women in urban and rural Ethiopia.

METHODS

A total of 3962 pregnant women were included in the analysis of 2019 Ethiopian Demographic and Health Survey data. A negative binomial Poisson regression statistical model was used to analyze the data using STATA version 14.0. An incident rate ratio with a 95% confidence interval was used to show the significantly associated variables.

RESULTS

Of the 3962 (weighted 3916.67) pregnant women, about 155 (15.21%) lived in urban and 848 (29.29%) rural residences and did not use antenatal care services in 2019. Women age group 20-24 (IRR = 1.30, 95%CI:1.05-1.61), 25-29 (IRR = 1.56, 95%CI:1.27-1.92), 30-34 (IRR = 1.65, 95%CI:1.33-2.05), and 35-39 years old (IRR = 1.55, 95%CI:1.18-2.03), attending primary, secondary, and higher education (IRR = 1.18, 95%CI:1.07-1.30), (IRR = 1.26, 95%CI:1.13-1.42) and (IRR = 1.25, 95%CI:1.11-1.41) respectively, reside in middle household wealth (IRR = 1.31, 95%CI:1.13-1.52), richer (IRR = 1.45, 95%CI:1.26-1.66) and richest (IRR = 1.68, 95%CI:1.46-1.93) increases the number of antenatal care utilization among urban residences. While attending primary (IRR = 1.34, 95%CI:1.24-1.45), secondary (IRR = 1.54, 95%CI:1.34-1.76) and higher education (IRR = 1.58, 95%CI:1.28-1.95), following Protestant (IRR = 0.76, 95%CI:0.69-0.83), Muslim (IRR = 0.79, 95%CI:0.73-0.85) and Others (IRR = 0.56, 95%CI:0.43-0.71) religions, reside in poorer, middle, richer, and richest household wealth (IRR = 1.51, 95%CI:1.37-1.67), (IRR = 1.66, 95%CI:1.50-1.83), (IRR = 1.71, 95%CI:1.55-1.91) and (IRR = 1.89, 95%CI:1.72-2.09) respectively, being married and widowed/separated (IRR = 1.85, 95%CI:1.19-2.86), and (IRR = 1.95, 95%CI:1.24-3.07) respectively were significantly associated with the number of antenatal care utilization among rural residences.

CONCLUSION

The utilization of antenatal care is low among rural residents than among urban residents. To increase the frequency of antenatal care utilization, health extension workers and supporting actors should give special attention to pregnant women with low socioeconomic and educational levels through a safety-net lens.

Missed Opportunity of Antenatal Care Services Utilization and Associated Factors among Reproductive Age Women in Eastern Hararghe Zone, Eastern Ethiopia: Mixed Methods Study

Background

Despite the enormous advantages of early pregnancy-related problem diagnosis and therapy during prenatal care visits, not all pregnant women begin antenatal care at the proper time. Thus, this study aims to identify factors associated with missed opportunities for antenatal care service utilization among reproductive-age women in Eastern Ethiopia.

Methods

A mixed methods study design (quantitative and qualitative) was conducted in Grawa, Meta, and Haramaya woredas from September 5 to December 5, 2019. The quantitative data were analyzed using SPSS version 25. A multivariable logistic regression analysis model was used to identify the predictors. Statistical software programs based on ATLAS.ti version 8.2 was were used to conduct the thematic analysis of the qualitative data.

Results

Overall, missed opportunities for antenatal care were 15.4% of 95% (12.1, 19.1%). Factors such as maternal age being 15-24 (AOR = 6.9, 95% CI: 2.89-8.81); having a college education (AOR = 0.02, 95% CI: 0.001, 0.42), elementary (AOR = 0.05, 95% CI: 0.002, 0.98), and secondary education (AOR = 0.04, 95% CI: 0.001, 0.88); having five and more parity (AOR = 0.08, 95% CI: 0.01, 0.75); three visits (AOR = 0.10, 95% CI: 0.02, 0.71); those in the first trimester (AOR = 0.02, 95% CI: 0.001, 0.35) and the second trimester (AOR = 0.01, 95% CI: 0.001, 0.26); and get information from a health facility (AOR =0.09, 95% CI: 0.01, 0.67) and traditional birth attendance (AOR = 0.02, 95% CI: 0.001, 0.74) were factors statistically associated with outcome variables.

Conclusions

According to this report, relatively high proportions of pregnant women experienced missed opportunities in antenatal care follow-up. Factors such as maternal age, education, parity, frequency, timing, and media access were statistically significantly correlated with missed antenatal care follow-up. Therefore, all stakeholders should emphasize advocating for and enhancing the benefits of antenatal care; this in turn plays a crucial role in increasing the follow-up of clients for these crucial services. Moreover, health policy implementers need to coordinate their tracking of pregnant women who missed their antenatal care session.

The uptake of WHO-recommended birth preparedness and complication readiness messages during pregnancy and its determinants among Ethiopian women: A multilevel mixed-effect analyses of 2016 demographic health survey

Background

Birth preparedness and complication readiness (BPCR) is a package of interventions recommended by the World Health Organization to improve maternal and newborn health and it is provided and implemented through a focused antenatal care program. This study aimed at assessing the uptake of birth preparedness and complication readiness messages, and compliance with each key message, among Ethiopian women during their recent pregnancies using the 2016 demographic health survey report.

Methods

The data for this study was taken from the Ethiopian Demographic and Health Survey, which was conducted from January to June 2016 and covered all administrative regions. STATA version 16 was used to analyze a total of 4,712 (with a weighted frequency of 4,771.49) women. A multilevel mixed-effects logistic, and multilevel mixed-effect negative binomial regressions were fitted, respectively. Adjusted odds ratio (AOR) and Incidence rate ratio (IRR) with their corresponding 95% confidence interval (CI) were used to report significant determinants.

Results

More than half, 56.02% [95% CI: 54.58, 57.41] of women received at least one birth preparedness and complication readiness message. Being in the richest wealth quintiles (AOR = 2.33; 95% CI: 1.43, 3.73), having two birth/s in the last five years (AOR = 1.54; 95% CI: 1.13, 2.10), receiving four or more antenatal visits(AOR = 3.33; 95% CI: 2.49, 4.45), and reading a newspaper at least once a week (AOR = 1.27; 95% CI: 1.07, 1.65) were the individual‑level factors, whereas regions and residence(AOR = 1.54; 95% CI: 1.11, 1.96) were the community-level factors associated with the uptake of at least one BPCR message. On the other hand, receiving four or more antenatal visits (IRR = 2.78; 95% CI: 2.09, 3.71), getting permission to go to a health facility (IRR = 1.29; 95% CI: 1.028, 1.38), and not covered by health insurance schemes (IRR = 0.76; 95% CI: 0.68, 0.95) were identified as significant predictors of receiving key birth preparedness and complication readiness messages.

Conclusion

The overall uptake of the WHO-recommended birth readiness and complication readiness message and compliance with each message in Ethiopia was found to be low. Managers and healthcare providers in the health sector must work to increase the number of antenatal visits. Policymakers should prioritize the implementation of activities and interventions that increase women’s autonomy in decision-making, job opportunity, and economic capability to enhance their health-seeking behavior. The local administrative bodies should also work to enhance household enrollment in health insurance schemes.

Effectiveness of the maternal and child health handbook for improving continuum of care and other maternal and child health indicators: A cluster randomized controlled trial in Angola

Background

The maternal and child health (MCH) handbook is promoted as a tool for strengthening continuum of care. We assessed the effect of a MCH handbook intervention package on continuum of maternal and child health care and health outcomes for mother and child.

Methods

We conducted an open-label, parallel two-arm cluster randomized controlled trial in Angola. We randomly assigned municipalities in Benguela province through block randomization to a group using a package of enhanced maternity care service (which included the MCH handbook distribution and its supplementary intervention) and another using usual care (two stand-alone home-based records). We included women who were pregnant at the beginning of the trial period and attended a public health care facility for maternity care services. Neither health care providers, study participants nor data assessors were masked, but the statistician was. The primary outcome was a measure of service utilization assessed via achievement of maternal behavior-based continuum of care at three months postpartum. We conducted an intention-to-treat analysis in women with available data.

Results

We randomized 10 municipalities to either the intervention (five clusters) or control (five clusters) group. Of the 11 530 women approached between June 8, 2019, and September 30, 2020, 11 006 were recruited and 9039 included in the final analysis (82%; 3774 in the intervention group and 5265 in the control group). The odds for achievement of maternal behavior-based continuum of care in the intervention group was not significantly different from that in the control group (adjusted odds ratio (aOR) = 1.18, 95% confidence interval (CI) = 0.46-2.93) at three months postpartum. However, the odds of initiating antenatal care clinic use were significantly higher in the intervention group (odds ratio (OR) = 5.16, 95% CI = 2.50-10.67). No harms associated with the intervention were reported.

Conclusions

Distribution of the MCH handbook and its supplementary interventions promoted initiation of antenatal care service use, but did not increase service utilization sufficiently enough for attainment of study defined maternal behavior-based continuum of care.

Registration

ISRCTN20510127.

Socio-economic disadvantage and quality Antenatal Care (ANC) in Sierra Leone: Evidence from Demographic and Health Survey

INTRODUCTION

Reduction of maternal mortality remains a global priority as highlighted by the third Sustainable Development Goal (SDG). This is critical in the case of Sierra Leone as the country is one of three (3) countries with the highest maternal mortality ratio globally, thus 1,120 per 100,000 live births. The approximate lifetime risk of maternal mortality in the country is 1 in 17, relative to 1 in 3,300 in high-income countries. These raise doubt about the quality of the continuum of maternal healthcare in the country, particularly antenatal care and as a result, the objective of the present study is to investigate the association between socio-economic disadvantage and quality antenatal care service utilisation as well as associated correlates in Sierra Leone.

MATERIALS AND METHODS

The study used data from the most recent Demographic and Health Survey (DHS) of Sierra Leone. Only women who had given birth in the five years preceding the survey were included, which is 6,028. Quality antenatal care was defined as receipt of recommended ANC services including uptake of recommended pregnancy drugs (e.g. Fansidar and iron supplement); injections (e.g. tetanus injection) and having some samples (e.g. blood and urine sample) and health status indicators (e.g. blood pressure) taken. An index was created from these indicators with scores ranging from 0 to 6. The scores 0 to 5 were labelled as "incomplete" and 6 was labelled as "complete" and this was used to create a dummy variable. In analysing the data, descriptive analysis was done using chi-square test as well as an inferential analysis using bivariate and multivariate models.

RESULTS

Socio-economic disadvantaged [1.46 (1.09, 1.95), place of residence [2.29 (1.43, 3.67)], frequency of listening to radio [1.58 (1.20, 2.09)], health insurance coverage [3.48 (1.40, 8.64)], getting medical help for self: permission to go [0.53(0.42, 0.69) were seen to have significant relationship with quality of ANC utilized by women during pregnancy. Also, women Mende ethnicity are more likely to utilise quality ANC compared to women from the Temne ethnicity [2.58 (1.79, 3.72)].

CONCLUSION

Policy makers could consider measures to boost patronage of quality ANC in Sierra Leone by targeting the socio-economically disadvantaged women. Targeting these sub-groups with pro- maternal and child health (MCH) interventions would help Sierra Leone achieve Goal 3 of the SDGs.

Individual and community level predictors of utilization of deworming medications among pregnant women in Ethiopia: A multilevel analysis

BACKGROUND

Deworming is one strategy for reducing the burden of anaemia in pregnant women caused by intestinal parasites and it is one of the components of prenatal treatment offered to pregnant women in Ethiopia during antenatal care visits. However, there is limited evidence on the levels of deworming utilization and its determinants in Ethiopia. Hence, this study was aimed to assess the levels of deworming utilization and its individual and community level determinants among pregnant women in Ethiopia.

METHOD

This study used a total weighted sample of 7590 reproductive-aged women who gave birth in the five years preceding the survey from the 2016 EDHS data. The data were cleaned and weighted using STATA version 16. Results were presented with tables and texts. Individual and community level determinants for deworming use among Ethiopian pregnant women were identified using a multilevel binary logistic regression model. In the multivariable multilevel analysis, those variables with p-value < 0.05 were considered to be significantly associated with utilization of deworming medication and reported with adjusted odd ratio with 95% confidence level.

RESULTS

The overall utilization of deworming among pregnant women was 5.69% (95% CI: 5.24%, 6.33) in Ethiopia. Having occupation [AOR = 1.59; 95% CI; 1.27, 1.99], wanted pregnancy [AOR = 1.51; 95% CI; [1.16, 1.95], having ANC visit [AOR = 2.72; 95% CI; 2.03,3.64], media exposure [AOR = 1.67; 95%CI; 1.30,2.15], and high community level poverty [AOR = 0.59; 95% CI; 0.40,0.87] were significantly associated with utilization of deworming among pregnant women's.

CONCLUSION

According to the findings of this study, out of twenty pregnant women, only one pregnant woman utilizes deworming medication in Ethiopia. Pregnant woman having an occupation, being exposed for media, having wanted pregnancy, having ANC visits and live with low level community poverty were more likely to use deworming medication. Therefore, intervention efforts to enhance utilization of deworming in Ethiopia requires working on enabling factors like media exposure, ANC visit and pregnancy desirability. In addition, Furthermore, increasing the community's economic capacity could support in increasing deworming medication uptake.

Spatial variation and factors associated with home delivery after ANC visit in Ethiopia; spatial and multilevel analysis

Introduction

Institutional delivery is crucial to reduce maternal and neonatal mortality as well as serious morbidities. However, in Ethiopia, home delivery (attended by an unskilled birth attendant) after antenatal care (ANC) visit is highly in practice. Therefore, this study aimed to assess the spatial variation and determinants of home delivery after antenatal care visits in Ethiopia.

Method

A secondary data analysis was conducted using the 2019 mini Ethiopian demographic and health survey. A total of 2,923 women who had ANC visits were included. Spatial analysis was done by using GIS 10.7 and SaTscan 9.6. The risk areas for home delivery from GIS and spatial scan statistics results were reported. A multi-level logistic regression model was fitted using Stata14 to identify individual and community-level factors associated with home delivery after ANC visit. Finally, AOR with 95% CI and random effects were reported.

Result

Home delivery after ANC visit was spatially clustered in Ethiopia(Moran’s index = 0.52, p-value <0.01). The primary clusters were detected in Oromia and SNNP region (LLR = 37.48, p < 0.001 and RR = 2.30) and secondary clusters were located in Benishangul Gumuz, Amhara, Tigray and Afar (LLR = 29.45, p<0.001 and RR = 1.54). Being rural resident (AOR = 2.52; 95%CI 1.09–5.78), having no formal education (AOR = 3.19;95% CI 1.11–9.16), being in the poor (AOR = 2.20;95%CI 1.51–3.22) and middle wealth index (AOR = 2.07;95% CI 1.44–2.98), having one ANC visit (AOR = 2.64; 95% CI 1.41–4.94), and living in the agrarian region (AOR = 3.63; 95%CI 1.03–12.77) had increased the odds of home delivery after ANC visit.

Conclusion and recommendation

Home delivery after ANC visit was spatially clustered in Ethiopia. Factors like maternal education, wealth index, number of ANC visits, residency and region were significantly associated with home delivery after ANC visit. Therefore, it is better to increase the number of ANC contact by giving health education, especially for women with low levels of education and better to improve the wealth status of women. A special strategy is also vital to reduce home delivery after ANC visit in those high-risk regions.

Women's decision-making power and knowledge of prevention of mother to child transmission of HIV in sub-Saharan Africa

Background

Sub-Saharan Africa (SSA) bears the highest burden of Human Immunodeficiency Virus (HIV) in the world. Even though the prevention of mother to child transmission (PMTCT) programmme is one of the strategies to control the HIV pandemic, the uptake in SSA countries is low. Women’s decision-making power has a positive influence on health seeking behavior and uptake of several maternal health services. However, its relationship with knowledge of PMTCT services is understudied in SSA. Therefore, this study aimed to examine the association between women’s decision-making power and knowledge of PMTCT in 24 countries in SSA.

Methods

Analysis of this study included data on 158,812 married women from the Demographic and Health Surveys of 24 sub-Saharan African countries conducted between 2010 and 2020. Using Stata version-14 software, bivariate and multivariable logistic regression analyses were conducted. The results were presented using adjusted odd ratios (aOR) with the corresponding 95% confidence intervals (CI).

Results

In the pooled results, 69.5% (95% CI; 66.7–72.1%) of married women in the studied countries had knowledge of PMTCT, ranging from 13.9% (95% CI; 11.9–16.2%) in Comoros to 75.4% (95% CI; 73.7–76.9%) in Zimbabwe. Higher odds of PMTCT knowledge were seen among married women who had decision-making power compared to married women who had no decision-making power. Moreover, we found higher odds of PMTCT knowledge among married women with manual occupation, those in the richest households and those with 1–2 children compared to married women who were not working, from the poorest households, and those with no children, respectively.

Conclusion

Women’s decision-making power had positive influence on PMTCT knowledge. To increase the coverage of PMTCT knowledge, policy makers and other stakeholders need to target ways to empower women through increasing women’s decision-making power. Moreover, creating employment opportunities and economic empowerment for women need to be considered, especially in countries with very low coverage of PMTCT knowledge.

Association of Higher Educational Attainment on Antenatal Care Utilization Among Pregnant Women in East Africa Using Demographic and Health Surveys (DHS) from 2010 to 2018: A Multilevel Analysis

Introduction

The use of antenatal care (ANC) plays a major role in minimizing maternal and child mortality through effective and appropriate screening, preventive, or treatment intervention. Even though almost all pregnancy-related mortalities are largely preventable through adequate use of ANC, sub-Saharan Africa (SSA), particularly East African Countries, continues to share the largest share of global maternal, and newborn mortality. Therefore, this study assesses if educational attainment is associated with optimal ANC utilization in East Africa.

Methods

A secondary data analysis was done based on Demographic and Health Surveys (DHS) from 2010 to 2018 in the 11 East African Countries. A total weighted sample of 84,660 women who gave birth in the 5 years preceding each country’s DHS survey and had ANC visits were included in this study. Data processing and analysis were performed using STATA 15 software. A multilevel mixed-effect logistic regression model was fitted to examine the association of educational attainment and ANC utilization. Variables with a p-value <0.05 were declared as significant factors associated with ANC utilization. Model comparison was done based on Akaike and Bayesian Information Criteria (AIC and BIC).

Results

The magnitude of optimal ANC utilization in East African Countries was 56.37% with 95% CI (56.03, 56.69) with the highest optimal ANC utilization in Zimbabwe (80.96%) and the lowest optimal ANC utilization in Rwanda (44.31%). Women who had higher education levels were more likely to have optimal ANC utilization, compared to those with no education (AOR = 2.34; 95 and CI; 2.11–2.59). Women who had media exposure were more likely to have optimal ANC utilization than those who have no media exposure (AOR = 1.07; 95% CI; 1.03, 1.10).

Conclusion

Antenatal care utilization was low in East African countries. Educational attainment, maternal age, wealth index, birth order, media exposure, and living countries were factors associated with ANC utilization. Efforts to improve antenatal care and other maternal health service utilization in East Africa must take into account these factors. Specifically, working on the access to mass media by women may also improve antenatal care utilization.

The unfinished agenda and inequality gaps in antenatal care coverage in Ethiopia

BACKGROUND

Antenatal care is an essential platform to provide all the necessary health interventions during pregnancy that aim to reduce maternal and newborn morbidity and mortality. Although the antenatal care coverage has been increasing in Ethiopia in the last two decades, the country has not been able to meet its own coverage target to date. Most pregnant women who initiated antenatal care also do not complete the full recommended follow up contacts. This study investigated the trend in coverage and the inequalities related to the use of antenatal care in Ethiopia.

METHODS

This study utilized data from five rounds of Demographic and Health Surveys (DHSs) conducted in Ethiopia in the period between 2000 and 2019. The DHS respondents were women in the age group 15-49 who had a live birth within the five years preceding the surveys. The outcome of interest for this study was antenatal care utilization coverage. We used concentration curve and concentration index to identify the inequalities using the World Health Organization recommended Health Equity Analysis Toolkit software. We did a regression analysis to identify the drivers of urban-rural inequalities.

RESULT

The coverage trend for both initiating Antenatal care and completing the recommended four antenatal contacts showed a steady increase during 2000-2019. However, the coverages have not yet reached the national target and unlikely to meet targets by 2025. Although the economically better-off, urban and educated mother still have a better coverage, the inequality gaps within the wealth, residence and education categories generally showed significant reduction. Women in the lowest wealth quantile, those who were uneducated and those living in rural areas remained disadvantaged. Household economic status and maternal education was the stronger drivers of urban-rural inequalities.

CONCLUSION

The Antenatal care coverage is lagging below the country's target. Despite narrowing inequality gaps women from poor households, who are uneducated and residing in rural areas are still less likely to fully attend the recommended number of antenatal care contacts. Addressing these inequalities through a multisectoral efforts is critical to increase the chances of achieving the national antenatal care coverage targets in Ethiopia.

Decomposing socio-economic inequalities in antenatal care utilisation in 12 Southern African Development Community countries

Although many countries are making progress towards achieving the global sustainable development goals, sub-Saharan Africa (SSA) lags behind. SSA bears a relatively higher burden of maternal morbidity and mortality than other regions despite existing cost-effective interventions. This paper assesses antenatal care (ANC) service utilisation among women in the Southern African Development Community (SADC) countries, one of the four SSA regions. Specifically, it assesses socioeconomic inequality in the number of ANC visits, use of no ANC service, between one and three ANC visits and at least four ANC visits, previously recommended by the World Health Organization (WHO). Data come from the most recent Demographic and Health Surveys in twelve SADC countries. Wagstaff's normalised concentration index (CI) was used to assess socioeconomic inequalities. Factors explaining these inequalities were assessed using a standard method and similar variables contained in the DHS data. A positive CI means that the variable of interest is concentrated among wealthier women, while a negative CI signified the opposite. The paper found that wealthier women in the SADC countries are generally more likely to have more ANC visits than their poorer counterparts. Apart from Zambia, the CIs were positive for inequalities in at least 4 ANC visits and negative for between 1 and 3 ANC visits. Women from poorer backgrounds significantly report no ANC visits than wealthier women. Apart from the portion that was not explainable due to limitations in the variables included in the model, critical social determinants of health, including wealth, education and the number of children, explain socioeconomic inequalities in ANC coverage in SADC. A vital policy consideration is not to leave any woman behind. Therefore, addressing access barriers and critical social determinants of ANC inequalities, such as women's education and economic well-being, can potentially redress inequalities in ANC coverage in the SADC region.

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Wealthier women have more antenatal care (ANC) visits than their poorer counterparts.

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Women from poorer backgrounds report no ANC visits more often than wealthier women.

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Wealth and education are key drivers of socioeconomic inequalities in ANC coverage.

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Poorer women are being left behind in accessing maternal health services in Africa.

Causes of maternal mortality in Sub-Saharan Africa: A systematic review of studies published from 2015 to 2020

Background

Maternal deaths remain high in Sub-Saharan Africa (SSA) and their causes of maternal death must be analysed frequently in this region to guide interventions.

Methods

We conducted a systematic review of studies published from 2015 to 2020 that reported the causes of maternal deaths in 57 SSA countries. The objective was to identify the leading causes of maternal deaths using the international classification of disease - 10^th revision, for maternal mortality (ICD-MM). We searched PubMed, WorldCat Discovery Libraries Worldwide (including Medline, Web of Science, LISTA and CNHAL databases), and Google Scholar databases and citations, using the search words "maternal mortality", "maternal death", "pregnancy-related death", "reproductive age mortality" and "causes" as MeSH terms or keywords. The last date of search from all databases was 21 May 2021. We included original research articles published in English and excluded articles that mentioned SSA country names without study results for those countries, studies that reported death from a single cause or assigned causes of death using computer models or incompletely broke down the causes of death. We exported, de-duplicated and screened the searches electronically in EndNote version 20. We selected the final articles by reading the titles, abstracts and full texts. Two authors searched the articles and assessed the risk of bias using a tool adapted from Montoya and others. Data from the articles were extracted onto an Excel worksheet and the deaths classified into ICD-MM groups. Proportions were calculated with 95% confidence intervals and compared for deaths attributed to each cause and ICD-MM group. We compared the results with WHO and Global Burden of Disease (GDB) estimates.

Results

We identified 38 studies that reported 11 427 maternal and four incidental deaths. Twenty-one of the third-eight studies were retrospective record reviews. The leading causes of death (proportions and 95% confidence intervals (CI)) were obstetric hemorrhage: 28.8% (95% CI = 26.5%-31.2%), hypertensive disorders in pregnancy: 22.1% (95% CI = 19.9%-24.2%), non-obstetric complications: 18.8% (95% CI = 16.4%-21.2%) and pregnancy-related infections: 11.5% (95% CI = 9.8%-13.2%). The studies reported few deaths of unknown/undetermined and incidental causes.

Conclusions

Limitations of this review were the failure to access more data from government reports, but the study results compared well with WHO and GDB estimates. Obstetric hemorrhage, hypertensive disorders in pregnancy, non-obstetric complications, and pregnancy-related infections are the leading causes of maternal deaths in SSA. However, deaths from incidental causes are likely under-reported in this region. SSA countries must continue to invest in health information systems that collect and publishes comprehensive, quality, maternal death causes data. A publicly accessible repository of data sets and government reports for causes of maternal death will be helpful in future reviews. This review received no specific funding and was not registered.

Decomposing the urban-rural inequalities in the utilisation of maternal health care services: evidence from 27 selected countries in Sub-Saharan Africa

Background

There has been a substantial improvement in reducing maternal mortality in the Sub-Saharan African region. The vast rural-urban gap in maternal health outcomes, however, is obscured by this average achievement. This study attempts to measure the contribution of identified risk factors to describe the average rural-urban difference in the use of antenatal care, health facilities for delivery, and health professional assistance at delivery.

Method

To achieve this objective, we used descriptive analysis and Fairlie non-linear decomposition method to quantify covariates’ contribution in explaining the urban–rural difference in maternal healthcare services utilisation.

Result

The study’s finding shows much difference between urban and rural areas in the use of maternal healthcare services. Socio-economic factors such as household wealth index, exposure to media, and educational level of women and their husbands/partners contributed the most in explaining the gap between urban and rural areas in healthcare services utilisation.

Conclusions

Interventions to bridge the gap between urban and rural areas in maternal healthcare services utilisation in Sub-Saharan Africa should be centred towards socio-economic empowerment. Government can enforce targeted awareness campaigns to encourage women in rural communities in Sub-Sharan Africa to take the opportunity and use the available maternal health care services to be at par with their counterparts in urban areas.

Maternal health refers to the health of women throughout pregnancy, delivery, and the postnatal period. Each step should be a good experience that ensures mothers, and their infants realize their maximum health and well-being potential. In this study, we used individual, demographic, and socio-economic characteristics to measure the urban–rural discrepancies in maternal health care services in Sub-Saharan Africa. We used Information of 220 164 women of child-bearing age (15–49) gathered from National Demographic Health Surveys from 27 countries in the Sub-Sahara African region. We found 46.1% of women in rural areas had no education, 39.7% of the women in rural areas have husbands/partners with no education, and 60.1% of the women in rural areas are from households with poor wealth indexes. The use of maternal health care services found to be predominant in the urban areas than rural areas, and the measure of this difference can inform policymakers on the level of effort that needed to be put in place to balance the discrepancies and improve maternal health in general.

Noncompliance with the WHO's Recommended Eight Antenatal Care Visits among Pregnant Women in Sub-Saharan Africa: A Multilevel Analysis

BACKGROUND

In 2016, the World Health Organization (WHO) introduced a minimum of eight antenatal care (ANC) visits for positive pregnancy outcomes. This study examined the prevalence of noncompliance with 8+ ANCvisits and its associated factors in sub-Saharan Africa (SSA).

METHODS

We used data from the Demographic and Health Surveys of eight countries in SSA. A pooled sample of 63,266 pregnant women aged 15-49 years who had given birth to children within 5 years prior to the surveys was included in this study. To examine the factors associated with noncompliance with ANC 8+ visits, multilevel binary logistic regression analysis was conducted, and the results were reported using odds radios at 95% confidence interval (CI).

RESULTS

The pooled prevalence of noncompliance with ANC 8+ visits was 92.3% (95% CI: 91.1%-93.3%) with the highest and lowest prevalence in Zambia (98.7%, 95% CI: 98.3%-99.1%) and Libya (73.4%, 95% CI: 70.4%-76.2%), respectively. With the individual level factors, women's age (44-49 years-aOR = 0.33, 9% CI: 0.14-0.78), health insurance registration, (yes-aOR = 0.53, 95% CI: 0.29-0.98), and economic status (richest-aOR = 0.16, 95% CI: 0.05-0.49) were negatively associated with noncompliance with 8+ ANC visits, while parity (five or more children-aOR = 1.68, 95% CI: 1.12-2.52) was positively associated with noncompliance with 8+ ANC visit. With the community level factors, community level literacy was negatively associated with noncompliance with 8+ ANC visit (high-aOR = 0.56, 95% CI: 0.32-0.99).

CONCLUSION

About eight out of ten pregnant women did not comply with the WHO's recommended minimum of eight ANC visits for positive pregnancy outcomes in SSA. Empowering the economic status of women , enhancing health insurance and education coverage, and giving more attention to young pregnant women and those with more children are crucial for improving the coverage of ANC 8+ visits in the region.

Urban-rural disparities of antenatal care in South East Asia: a case study in the Philippines and Indonesia

Background

The government is obliged to guarantee equal access to antenatal care (ANC) between urban and rural areas. This study aimed to analyze urban-rural disparities in ≥4 ANC visits during pregnancy in the Philippines and Indonesia.

Methods

The study processed data from the 2017 PDHS and the 2017 IDHS. The analysis unit was women aged 15–49 years old who had given birth in the last 5 years. The weighted sample size was 7992 respondents in the Philippines and 14,568 respondents in Indonesia. Apart from ANC as the dependent variable, other variables analyzed were residence, age, husband/partner, education, parity, and wealth. Determination of urban-rural disparities using binary logistic regression.

Results

The results show that women in the urban Philippines are 0.932 times more likely than women in the rural Philippines to make ≥4 ANC visits. On the other side, women in urban Indonesia are more likely 1.255 times than women in rural Indonesia to make ≥4 ANC visits. Apart from the type of residence place (urban-rural), five other tested multivariate variables also proved significant contributions to ANC’s use in both countries, i.e., age, have a husband/partner, education, parity, and wealth status.

Conclusions

The study concluded that disparities exist between urban and rural areas utilizing ANC in the Philippines and Indonesia. Pregnant women in the rural Philippines have a better chance of making ≥4 ANC visits. Meanwhile, pregnant women in urban Indonesia have a better chance of making ≥4 ANC visits.

Factors Associated with Numbers of Antenatal Care Visits in Rural Ethiopia

INTRODUCTION

Antenatal care (ANC) is a medical care and procedure carried out for pregnant women. Data on ANC visits can help policymakers show gaps in service provision. Therefore, this study assessed the factors associated with the number of ANC visits among women in rural Ethiopia.

METHODS

We included a total of 6611 women who gave birth within 5 years preceding the survey from the 2016 Ethiopian Demographic and Health Survey. A multi-level negative binomial regression analysis was employed to consider the hierarchical nature of the data. In the multivariable analysis, variables with a p-value <0.05 were considered to be significantly associated with the number of ANC visits.

RESULTS

Overall, 27.3% (95% CI: 14.63, 15.76) of women had at least four ANC visits during pregnancy in rural Ethiopia. Among individual level factors, age group 25-29 years (adjusted incidence rate ratio (AIRR)=1.13,95% CI:1.02,1.26), household rich wealth status (AIRR=1.17, 95% CI:1.04,1.31), women's educational status (primary, AIRR=1.19,95% CI:1.08,1.32; secondary, AIRR= 1.30,95% CI:1.08,1.55; above secondary, AIRR=1.35, 95% CI:1.07,1.71), partner educational status (primary, AIRR=1.16, 95% CI:1.05,1.28; secondary, AIRR=1.22,95% CI:1.08,1.38), and autonomy to decision to their care (AIRR=1.25,95% CI:1.10,1.42) were positively associated factors whereas having a birth order of five or more (AIRR=0.80,95% CI: 0.69,0.94) was a negative associated with number of ANC visits. Among community-level variables, being in higher community level literacy (AIRR=1.35, 95% CI: 1.14, 1.59) and higher poverty level (AIRR=0.77, 95% CI: 0.64, 0.92) were significant factors with the number of ANC visits.

CONCLUSIONS AND RECOMMENDATIONS

Women's age, wealth status, women's educational status, partner educational status, autonomy to decision making in health care, and birth order were determinants of the number of ANC visits. Furthermore, poverty and literacy are also important factors at the community level. Addressing economic and educational interventions for rural women should be prioritized.

Utilization of Deworming Drugs and Its Individual and Community Level Predictors among Pregnant Married Women in Cameroon: A Multilevel Modeling

BACKGROUND

Although deworming pregnant women is one of the strategies to reduce parasites (roundworms and hookworms) causing anemia and related perinatal and maternal complications, utilization of deworming medication among pregnant women in Cameroon is suboptimal. Comprehensive assessment of individual, household (including women's autonomy), and community-level factors associated with utilization of deworming medication has not been done so far. Therefore, we investigated the individual/household and community-level factors associated with deworming among pregnant married women in Cameroon.

METHODS

Our study was limited to pregnant women because they have a greater risk due to increased chances of anemia. We used data from the 2018/19 Cameroon Demographic and Health Survey. Analysis on 5,013 pregnant married women was carried out using multilevel logistic regression. Odds ratios with a 95% confidence interval (CI) were reported.

RESULTS

Our findings showed that about 29.8% of pregnant married women received deworming medications. The individual/household level predictors of deworming medications utilization identified in this study were women's educational level, wealth quintile, and skilled antenatal care. Distance to health facility and region were identified as community-level predictors of deworming medications utilization. Higher odds of receiving deworming medication occurred among educated and wealthier pregnant married women as well as among pregnant married women who had skilled antenatal care or lived in the south region, whereas lower odds were observed among pregnant married women living in the north region.

CONCLUSION

Access to education and economic empowerment of pregnant married women in remote areas and the north region should be the primary focus of the Cameroon government to enhance deworming coverage in the country.

Factors associated with the number and timing of antenatal care visits among married women in Cameroon: evidence from the 2018 Cameroon Demographic and Health Survey

Utilization of antenatal care (ANC) services, as part of reproductive health care, presents a lifesaving chance for health promotion and the early diagnosis and treatment of illnesses throughout pregnancy. This study examines the factors associated with the number and timing of ANC visits among married women in Cameroon using data from the 2018 Cameroon Demographic and Health Survey. The outcome variables were number of ANC visits, categorized as <8 visits or ≥8 visits, and the timing of first ANC visit, categorized as ≤3 months (early) or >3 months (late) (as per the new 2016 WHO recommendations). Descriptive statistics and binary logistic regression were used to analyse the data. Crude odds ratios (cOR) and adjusted odds ratios (aOR) and p-values with significance at <0.05 were used to interpret the results. The proportions of women who had ≥8 ANC visits and first ANC visit at ≤3 months gestation were 6.3% and 35.6% respectively. Women aged 35-39 at childbirth (aOR=3.99, 95% CI=1.30-12.23), middle wealth quintile women (aOR=3.22, 95% CI=1.01-10.27), women whose husbands had secondary (aOR=7.00, 95% CI=2.26-21.71) or higher (aOR=16.93, 95% CI=4.91-58.34) education were more likely to have ≥8 ANC visits. Early timing of first ANC visit was low among women with birth order 3-4 (aOR=0.63, 95% CI=0.46-0.85). Conversely, the likelihood of having early ANC visits was high among women whose pregnancies were intended (aOR=1.32, 95% CI=1.01-1.74), the richest women (aOR=3.89, 95% CI=2.30-6.57) and women whose husbands had secondary (aOR=2.41, 95% CI=1.70-3.64) or higher (aOR=3.12, 95% CI=2.40-7.46) education. The study highlights that age at childbirth, wealth, husband's educational attainment, birth order and pregnancy intention could influence the utilization of ANC services among married women in Cameroon. Hence, to improve attendance and early initiation of ANC, interventions should be targeted at empowering women financially and removing all financial barriers associated with accessing ANC, improving ANC education among women and encouraging male involvement in ANC education.