Female education and maternal health care utilization: evidence from Uganda

Caesarean section delivery and its associated factors in Ghana: A multilevel analysis

BACKGROUND

Even if the ideal rate for caesarean section (CS) is considered 10-15%, worldwide CS rates have been steadily increasing, without significant additional benefit to women's health. Its overuse was associated with maternal and fetal complications. Therefore, this study aimed to determine the rate of CS delivery and associated factors among women delivered in health facilities in Ghana.

METHODS

A cross-sectional study was conducted using the 2022 DHS datasets from Ghana. A total of 5231 weighted samples were included. STATA.16 was used for analysis. A multilevel logistic regression was applied. An adjusted odds ratio with a 95% CI and a p-value <  0.05 was used to declare significantly associated factors.

RESULT

The prevalence of CS in Ghana was 20.29% [95% CI = 19.23-21.41%]. Age 25-34 [AOR = 1.32, CI: 1.04, 1.68] and 35 + [AOR = 1.57, CI: 1.16, 2.11], primary [AOR = 1.58, CI: 1.21, 2.07], secondary [AOR = 1.36, CI: 1.07, 1.73], and higher [AOR = 2.24, CI: 1.58, 3.17] education, richer [AOR = 1.45, CI: 1.06, 1.99] and richest [AOR = 2.35, CI: 1.63, 3.39] wealth index, employment [AOR = 0.77, CI: 0.64, 0.92], primiparous [AOR = 1.33, CI: 1.07, 1.67], giving first birth after the age of 35 [AOR = 4.58, CI: 1.88, 11.19], multiple pregnancy [AOR = 5.53, CI: 4.02, 7.62], large birth size [AOR = 1.25, CI: 1.06, 1.48], 4-6 kg birth weight [AOR = 2.13, CI: 1.55, 2.92], as well as residing in Volta [AOR = 1.98, 95% CI: 1.22, 3.22] and Bono East [AOR = 2.02, 95% CI: 1.28, 3.19] regions were significant factors associated with CS delivery in Ghana.

CONCLUSION

The rate of CS was higher than previous studies in Ghana and the WHO recommended level, making it a public health concern. Age, education, wealth, employment, parity, age at first birth, pregnancy type, birth size, birth weight, and region were significantly associated with CS. Therefore, strategies aimed at examining guidelines for proper indications and uses of CS may lead to an improvement CS rate.

Exploring urban-rural inequalities of maternal healthcare utilization in Bangladesh

Background

Bangladesh has made significant progress across various sectors, including healthcare. However, noticeable disparities persist in the healthcare sector, particularly in maternal healthcare between urban and rural areas. Despite substantial advancements in maternal healthcare services (MHCS), such as Antenatal care (ANC), Facility-Based Delivery (FBD), and Skilled Birth Attendants (SBA), utilization depends on various socioeconomic factors. This study aims to assess the impact of different factors and describe the urban-rural inequalities in maternal healthcare service utilization.

Methods & study design

This study's analysis is based on data extracted from the 2017-18 Bangladesh Demographic and Health Survey (BDHS), following STROBE guidelines. Descriptive statistics provide an overview of the factors, and multiple logistic regression analysis identifies important factors in MHCS. Additionally, the Wagstaff decomposition method measures the concentration index, elasticity, contribution, and percentage contributions of different factors.

Results

According to -BDHS 2017-18, this study found a 51.84 % utilization of ANC visits. Women with "Higher Education" had odds ratios of 3.04, 3.05, and 3.12 for ANC, FBD, and SBA, respectively, compared to the "No Education" group. Similarly, women with partners having "Higher Education" exhibited odds ratios of 3.04, 3.05, and 3.12 for ANC, FBD, and SBA, respectively. Rich families had odds ratios of 1.91, 2.42, and 2.5 compared to the "poor" group for ANC, FBD, and SBA, respectively. Mother's education contributed 28.62 %, 30.3 %, and 30.47 % for ANC, FBD, and SBA, respectively. The household wealth index contributed 26.16 %, 38.49 %, and 40.3 % for ANC, FBD, and SBA, respectively of the urban-rural difference.

Conclusion

Maternal healthcare services utilization shows a significant disparity, with rural areas reporting much lower rates compared to urban areas. To achieve the Sustainable Development Goal (SDG), this study's findings can help policymakers ensure equitable access to quality care for all women, irrespective of their socioeconomic background or geographical location.

Visible and invisible cultural patterns influencing women's use of maternal health services among Igala women in Nigeria: a focused ethnographic study

BACKGROUND

Explicit and implicit cultural patterns are critical cultural norms, beliefs, and practices that determine women's health-seeking behaviour. These cultural patterns could limit women's use of maternal health services, resulting in maternal health complications. The study aims to provide an in-depth understanding of explicit and implicit cultural patterns, their meanings and how they influence women's use of maternal health services among Igala women in Nigeria.

METHODS

Roper and Shapira's (2000) focused ethnography was employed with 43 women aged 18-43 years recruited using the purposive and snowballing technique. The study was conducted with 21 women for one-on-one interviews and two focus group discussions with six women in the rural area and seven women in the urban area. In addition, participant observation of nine women from the third trimester to birth was conducted, yielding 189 h of observation in two primary healthcare facilities in rural and urban areas. Data analysis was conducted using Roper and Shapira's (2000) method.

RESULT

Three themes were generated using the PEN3 cultural model: perceptions, enabler, and nurturers. Subthemes generated under the theme of perception were, Belief in witchcraft, Pregnancy announces itself, I cannot tell people I am in labour, and Unspoken acquiescence to the culture. Under the theme of nurturer, Home birth was found to limit access to maternal health services. The theme of enabler yielded subthemes such as You are not woman enough; I want my placenta and Rising matriarchs.

CONCLUSION

Implicit and explicit cultural patterns significantly influence women's use of maternal health services. Given the complexity of culture and its influence on women's use of maternal health services, multifaceted strategies tailored to the cultural needs of communities are needed to enhance the realization of Sustainable Development Goal #3:1 in Nigeria.

Inequalities in utilization of maternal health services in Ethiopia: evidence from the PMA Ethiopia longitudinal survey

Background

Previous studies documented the existence of substantial inequalities in the utilization of maternal health services across different population subgroups in Ethiopia. Regularly monitoring the state of inequality could enhance efforts to address health inequality in the utilization of maternal health services. Therefore, this study aimed to measure the level of inequalities in the utilization of maternal health services in Ethiopia.

Method

The study used data from the Performance Monitoring for Action Ethiopia (PMA Ethiopia) dataset. Longitudinal data was collected from a weighted sample of 1966 postpartum women using multistage stratified cluster sampling techniques between November 2021 to October 2022. We assessed inequality in maternal health services using three indicators: antenatal care four (ANC), skilled birth attendants (SBA), and postnatal care (PNC). Age, economic status, education level, place of residence, and subnational regions were used as dimensions for measuring inequality. The analysis was conducted using Health Equity Assessment Toolkit Plus (HEAT Plus) software. We computed the summary measure of health inequality: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF).

Result

The simple summary measures of inequality difference (D) reported a high level of inequality in the utilization of maternal health services in ANC four, SBA, and PNC across economic, education, residence, and subnational regions. The difference (D) in maternal health service utilization between advantaged and disadvantaged population groups exceeded 20 percentage points in all four dimensions of inequality for the three maternal health indicators. Similarly, the complex summary measures of inequality (PAR and PAF) also showed high levels of inequality in the utilization of ANC four, SBA, and PNC across all four dimensions of inequality. However, there was no age-related inequality in the use of maternal health services.

Conclusion

A high level of socioeconomic and geographic area related inequality was observed in the utilization of ANC four, SBA, and PNC services in Ethiopia. Women from socioeconomically disadvantaged subgroups and women from disadvantaged geographic areas significantly lagged behind in the utilization of maternal health services. Therefore, implementing targeted interventions for the most disadvantaged groups can help to reduce inequality in accessing maternal health services.

Hotspot areas of tetanus-unprotected births and its associated factors in Ethiopia: Spatial analysis of EDHS data

Neonatal tetanus persists as a public health problem in many developing countries including Ethiopia. Maternal tetanus toxoid vaccination is a cornerstone to prevent neonatal tetanus. However, its prevalence is low in Ethiopia, and little has been devoted to its spatial epidemiology and associated factors. Hence, this study aimed to explore the spatial pattern and factors affecting tetanus-unprotected births in Ethiopia. A further analysis of the 2016 Ethiopia Demographic and Health Survey data was conducted, and a weighted sample of 7590 women was used for analysis. Spatial analysis was done using ArcGIS and SaTScan software. A binary logistic regression model was fitted to identify factors and variables with a p-value <.05 were considered as statistically significant. About 54.13% (95% CI: 53.01, 55.25) of births were not protected against neonatal tetanus, and spatial clustering of tetanus unprotected births was observed (Moran's I = 0.144, p-value = .028). The primary and secondary SaTScan clusters were detected in Northeastern Tigray, Eastern Amhara, and almost the entire Afar (RR = 1.34 & LLR = 66.5, p < .01), and in the Somali region, and the western border of Gambela (RR = 1.44 & LLR = 31.3, p < .01), respectively. Tetanus unprotected births were higher among women without formal education (AOR = 1.63; 95% CI: 1.29, 2.04), came from poor households (AOR = 1.27; 95% CI: 1.12, 1.45), who had no ANC contact (AOR = 6.97; 95% CI: 6.21, 7.88), and who were not exposed to the media (AOR = 1.26; 95% CI: 1.09, 1.47). Hence, tetanus-unprotected birth hotspots require priority interventions, and it is good if the targeted interventions consider the identified factors.

Socioeconomic and geographical inequalities in polio immunisation coverage among two-year-olds in Sierra Leone, 2008-2019

BACKGROUND

Polio, a debeilitating and potentially life-threatening disease, continues to pose a risk to young children globally. While vaccination offers a powerful shield, its reach is not always equal. This study explores socioeconomic and geographical inequalities in polio immunisation coverage among two-year-olds in Sierra Leone between 2008 and 2019.

METHODS

The study utilised data from the Sierra Leone Demographic Health Survey rounds conducted in 2008, 2013, and 2019 to examine polio immunization coverage among two-year-olds. The World Health Organisation Health Equity Assessment Toolkit software calculated various inequality measures, including simple difference, ratio, population-attributable risk, and population-attributable fraction. An inequality assessment was conducted for six stratifiers: maternal age, maternal economic status, maternal level of education, place of residence, sex of the child, and sub-national region.

RESULTS

Polio immunization coverage among two-year-olds in Sierra Leone increased from 48.7% in 2008 to 77.1% in 2013, then declined to 61.2% in 2019. No significant inequalities were observed based on maternal age, child's sex or maternal educational level. Coverage was higher among children of mothers from the poorest households, and in rural areas. However, the main inequality identified was subnational inequality.

CONCLUSION

The initial increase in coverage followed by a decline underscores the need for sustained efforts to maintain and improve immunization rates, particularly in the Western, Northwestern, and Northern provinces, where significant subnational inequalities exist. The absence of disparities related to maternal age, child sex, and education suggests that traditional demographic factors may not be the primary barriers to immunization; instead, geographic and socioeconomic contexts play a more pivotal role. This indicates that targeted interventions should focus on improving access to vaccination services in underserved areas, potentially through community outreach and mobile vaccination units. Additionally, the better coverage among children of poorer mothers and those in rural areas highlights the importance of understanding local dynamics and leveraging community strengths to enhance immunization uptake.

Quality intrapartum care and associated factors in East Africa: multilevel analysis of recent demographic and health survey

Background

The time during labor and delivery is crucial for the survival of both women and their infants, as complications that occur during this period can significantly increase the risk of morbidity and mortality. In developing nations, women of reproductive age and their infants are still at risk of morbidity and death from complications associated with pregnancy and childbirth. Morbidity and death from complications of pregnancy and childbirth can be prevented through the utilization of quality care during labor and delivery. However, there is limited evidence on the magnitude and factors associated with quality intrapartum care in East Africa. Therefore, this study assessed the magnitude and associated factors of quality intrapartum care among women in East Africa.

Methods

In this study, we used the most recent Demographic and Health Survey (DHS) dataset from 2015 to 2023, covering 11 East African countries. STATA version 18 software was used for data analysis. Multi-level modeling was applied due to the hierarchical or nested structure of DHS data. Variables with a p-value of less than 0.25 in the bivariate multi-level logistic regression model were included in the multivariable multi-level logistic regression analysis. Variables with p-values less than 0.05 were considered significant factors associated with receiving quality intrapartum care.

Results

The prevalence of receiving quality intrapartum care in East Africa was 56.38% [95% confidence interval (CI): 56.03, 56.7]. Women with primary education [Adjusted Odds Ratio (AOR) = 1.39, 95% CI: 1.33, 1.46], secondary education (AOR = 1.62, 95% CI: 1.53, 1.62), and higher education (AOR = 1.46, 95% CI: 1.33, 1.60), those in the middle (AOR = 1.28, 95% CI: 1.23, 1.34) and rich (AOR = 1.36, 95% CI: 1.31, 1.43) wealth index categories, women with one (AOR = 1.17, 95% CI: 1.09, 1.25) or 2-4 (AOR = 1.22, 95% CI: 1.16, 1.28) living children, those who perceived the distance from the health facility as not a big problem (AOR = 1.28, 95% CI: 1.24, 1.33), and women living in Rwanda (AOR = 1.30, 95% CI: 1.19, 1.41) had higher odds of receiving quality intrapartum care. Residing in rural areas (AOR = 0.82, 95% CI: 0.78, 0.86), and being from Ethiopia, Kenya, Madagascar, Malawi, Mozambique, Tanzania, Uganda, Zambia, or Zimbabwe, were factors negatively associated with receiving quality intrapartum care.

Conclusion and recommendations

Nearly half of the women in East African countries did not receive quality intrapartum care. Both individual and community-level variables were significantly associated with receiving quality intrapartum care in East Africa. Improving the quality of intrapartum care requires enhancing women's education, addressing socioeconomic challenges, and increasing access to health facilities through targeted interventions.

Dignified care and associated factors among mothers who gave birth at public hospitals, in Sidama Regional State, southern Ethiopia, 2023

BACKGROUND

Dignified care is an important priority for childbearing mothers. Threats to this deteriorate the therapeutic relationship between healthcare providers and clients, which leads to a negative effect on the quality of care. However, little evidence is identified about dignified care and associated factors in the Ethiopian context. Therefore, this study aimed to assess dignified care and associated factors among mothers who gave birth at public hospitals in Sidama Regional States, southern Ethiopia, 2023.

METHOD

An institution-based cross-sectional study was conducted among 418 mothers who gave birth at public hospitals in Sidama Regional States from July 30 to August 30, 2023. A systematic random sampling technique was employed to select study participants. An interviewer-administered structured questionnaire was used, and the data was collected by Kobotool and analyzed using SPSS Version 25. Bivariable and multivariable logistic regression analyses were conducted, and the crude and adjusted odds ratios, together with their corresponding 95% confidence, were computed. A P value < 0.05 was considered a level of statistical significance in this study.

RESULTS

In this study, the overall study participants' magnitude of dignified care was found to be 44.1%. Secondary education (AOR: 3.91, 95% CI: 1.56, 9.82), spontaneous vaginal delivery (AOR: 2.68, 95% CI: 1.31, 5.46), the presence of a companion during labor and delivery (AOR: 12.35, 95% CI : 7.08, 21.53), and less than two days hospital stay (AOR: 3.26, 95% CI: 1.37, 7.75), and midwife attendance of labour and delivery (AOR = 4.47 (1.40-14.25) were significantly associated with dignified care.

CONCLUSIONS

The findings of this study showed that the dignified care of mothers who gave birth at public hospitals in Sidama Regional State was relatively low to the pooled prevalence of respectful maternity care in Ethiopia. In light of these results, it is recommended to prioritize midwife attendance during labor and delivery, promote the presence of companions, facilitate a shorter hospital stay, and enhance educational opportunities.

Investigating the role of women's education status and empowerment on accessing skilled birth attendance in Bangladesh: A structural equation modelling approach

BACKGROUND

The objective of this study was to investigate the associations between women's education and access to skilled birth attendant (SBA) services mediated by factors of women's empowerment and sociodemographic characteristics using a path analysis through a structural equation (SEM) modelling approach.

METHODS

A sample of 4946 mothers from the most recent Bangladesh Demographic and Health Survey of 2017-18 was used in the SEM analysis. Accessing SBA service at childbirth was operationalized as utilizing SBA during last childbirth. After extracting the relevant variables and cleaning the original survey data, a subsample of 4,946 women were eligible for analysis in the current study.

RESULTS

The SEM model revealed strong evidence of direct, indirect, and mediating effects of both education and empowerment of women in accessing SBA services. Educated women have more autonomy in decision making and are less susceptible to family violence and consequently are more likely to access SBA services during childbirth (β = 0.094, p < 0.001). In addition, age at first marriage, media exposure, husband's education, healthcare accessibility, decision marking, and household wealth index mediated the relationship between education and SBA service use.

CONCLUSION

Bangladesh, a country that needs to improve several societal and health indices to achieve the Sustainable Development Goals, need to prioritize women's education to increase accessibility to maternal healthcare services. Health education and mass-media-driven awareness may be potential interventions for LMICs to increase SBA coverage.

Determinants of malaria spread among under-five children in Nigeria: results from a 2021 Nigerian malaria indicator cross-sectional survey

BACKGROUND

Malaria is a global disease burden, especially in Africa, with Nigeria having the highest prevalence of malaria, with approximately 50% affecting children. Children under five years of age are vulnerable to the risk of malaria spread. This research aimed to identify the determinants of malaria spread among children under the age of 5 in Nigeria.

METHODS

This study used national malaria indicator survey data from 2021 (2021NMIS). The NMIS was implemented by the National Malaria Elimination Programme (NMEP), and data were collected between 12 October and 4 December 2021. This study included 3678 children, and data cleaning and analysis were performed via STATA version 17 software.

RESULTS

There was a positive association between Child's age in months of 13-23 (AOR = 2.97; 95% CI = 1.62-5.45), 24-35 months (AOR = 2.64; 95% CI = 1.43-4.88),36-47 months (AOR = 2.18; 95% CI = 1.17-4.08) and months of 48-59(AOR = 2.82; 95% CI = 1.53-5.23), households headed by females (AOR = 0.71; 95% CI = 0.54-0.95),households with all children slept in mosquito nets last night (AOR = 2.43; 95% CI = 1.39-4.21), some children slept in the mosquito bed net (AOR = 2.83; 95% CI = 1.50-5.35) and households with no mosquito bed nets (AOR = 2.18; 95% CI = 1.22-3.88),mothers who agreed to have heard or seen malaria messages in the last 6 months (AOR = 1.32; 95% CI = 1.62-1.74),respondents with medium level of awareness of malaria prevention messages had (AOR = 2.35; 95% CI = 1.62-3.4), Children from North East (AOR = 0.7; 95% CI = 0.54-0.9), South-South (AOR = 0.65; 95% CI = 0.5-0.85) and South West (AOR = 0.52; 95% CI = 0.37-0.73) and malaria status of children under five years of age in Nigeria.

CONCLUSION

The government and other concerned malaria prevention organizations should emphasize maternal education programs that are vital for malaria prevention, early symptom recognition, and timely treatment, empowering families to take proactive measures. Collaboration among health, education, and community organizations is also crucial for integrated malaria control and prevention.

Reproductive Characteristics and Trends of Major Pregnancy Outcomes of Women at Different Parities - Beijing Municipality, China, 2013-2022

What is already known about this topic?

With socioeconomic development, the increase of older pregnancies and multiparas has brought risks to mothers and infants.

What is added by this report?

As parities increased, the proportion of women of advanced maternal age (AMA) and non-local domicile increased, while the proportion of women with higher education levels decreased. Women with ≥3 parities are more likely to have preterm birth (PTB) and macrosomia.

What are the implications for public health practice?

A comprehensive analysis of pregnancy traits among women at different parities offers a robust foundation for tailored strategies against adverse pregnancy outcomes.

Estimates and determinants of health facility delivery in the Birhan cohort in Ethiopia

Health facility delivery is one of the critical indicators to monitor progress towards the provision of skilled delivery care and reduction in perinatal mortality. In Ethiopia, utilization of health facilities for skilled delivery care has been increasing but varies greatly by region and among specific socio-demography groups. We aimed to measure the prevalence and determinants of health facility delivery in the Amhara region in Ethiopia. From December 2018 to November 2020, we conducted a longitudinal study from a cohort of 2801 pregnant women and described the location of delivery and the association with determinants. We interviewed a subset of women who delivered in the community and analyzed responses using the three delays model to understand reasons for not using health facility services. A multivariable poisson regression model with robust error variance was used to estimate the presence and magnitude of association between location of delivery and the determinants. Of the 2,482 pregnant women followed through to birth, 73.6% (n = 1,826) gave birth in health facilities, 24.3% (n = 604) gave birth at home and 2.1% (n = 52) delivered on the way to a health facility. Determinants associated with increased likelihood of delivery at a health facility included formal maternal education, shorter travel times to health facilities, primiparity, higher wealth index and having attended at least one ANC visit. Most common reasons mothers gave for not delivering in a health facility were delays in individual/family decision to seek care. The proportion of deliveries occurring in health facilities is increasing but falls below targets. Interventions that focus on the identified social-demographic determinants and delays are warranted.

Global maternal mortality projections by urban/rural location and education level: a simulation-based analysis

Background

Maternal mortality remains a challenge in global health, with well-known disparities across countries. However, less is known about disparities in maternal health by subgroups within countries. The aim of this study is to estimate maternal health indicators for subgroups of women within each country.

Methods

In this simulation-based analysis, we used the empirically calibrated Global Maternal Health (GMatH) microsimulation model to estimate a range of maternal health indicators by subgroup (urban/rural location and level of education) for 200 countries/territories from 1990 to 2050. Education levels were defined as low (less than primary), middle (less than secondary), and high (completed secondary or higher). The model simulates the reproductive lifecycle of each woman, accounting for individual-level factors such as family planning preferences, biological factors (e.g., anemia), and history of maternal complications, and how these factors vary by subgroup. We also estimated the impact of scaling up women's education on projected maternal health outcomes compared to clinical and health system-focused interventions.

Findings

We find large subgroup differences in maternal health outcomes, with an estimated global maternal mortality ratio (MMR) in 2022 of 292 (95% UI 250-341) for rural women and 100 (95% UI 84-116) for urban women, and 536 (95% UI 450-594), 143 (95% UI 117-174), and 85 (95% UI 67-108) for low, middle, and high education levels, respectively. Ensuring all women complete secondary school is associated with a large impact on the projected global MMR in 2030 (97 [95% UI 76-120]) compared to current trends (167 [95% UI 142-188]), with especially large improvements in countries such as Afghanistan, Chad, Madagascar, Niger, and Yemen.

Interpretation

Substantial subgroup disparities present a challenge for global maternal health and health equity. Outcomes are especially poor for rural women with low education, highlighting the need to ensure that policy interventions adequately address barriers to care in rural areas, and the importance of investing in social determinants of health, such as women's education, in addition to health system interventions to improve maternal health for all women.

Funding

John D. and Catherine T. MacArthur Foundation, 10-97002-000-INP.

Explaining changes in educational disparities in competent maternal health care services in urban and rural areas in Ethiopia

Introduction

Aggregate statistics of maternal health care services have improved in Ethiopia. Nevertheless, the country has one of the lowest Universal Health Coverage (UHC) service coverage indices, with slight improvement between 2000 and 2019. There are disparity studies that focus on a single dimension of inequality. However, studies that combine multiple dimensions of inequality simultaneously may have important policy implications for closing inequalities. In this study, we investigated education inequalities in the receipt of maternal health care services in rural and urban areas separately, and we examined whether these inequalities decreased, increased, or remained unchanged.

Methods

The data for the study came from the 2011 and 2016 Ethiopia Demographic and Health Surveys. Using women's education as a dimension of inequality, we separately analyzed inequalities in maternal health care services in urban and rural settings. Inequalities were measured through the Erreygers concentration index, second differences, and Relative Index of Inequality (RII). Whether inequalities changed over time was analyzed by relative and absolute measures. An Oaxaca-type decomposition approach was applied to explain changes in absolute disparities over time.

Results

There were glaring educational disparities in maternal health care services in urban and rural areas, where the services were more concentrated among women with better schooling. The disparities were more severe in urban than in rural areas. In urban areas, skilled birth service was the most unequal in both periods. Disparities in rural places were roughly similar for all services except that in 2011, postnatal care was the least unequal, and in 2016, skilled birth was the most unequal services. Trend analyses revealed that disparities significantly dropped in urban by absolute and relative measures. Conversely, in rural regions, the disparities grew by the concentration index measure for most services. The RII and second differences presented conflicting results regarding whether the gaps were increasing, shrinking, or remaining the same.

Conclusion

Substantial disparities in maternal health care services remained and even increased, as in rural areas. Different and targeted strategies are needed for urban and rural places to close the observed educational inequalities in these areas.

Do tuition-free lower secondary education policies matter for antenatal care among women in sub-saharan African countries?

BACKGROUND

Antenatal care (ANC) is critical to reducing maternal and infant mortality. However, sub-Saharan Africa (SSA) continues to have among the lowest levels of ANC receipt globally, with half of mothers not meeting the WHO minimum recommendation of at least four visits. Increasing ANC coverage will require not only directly reducing geographic and financial barriers to care but also addressing the social determinants of health that shape access. Among those with the greatest potential for impact is maternal education: past research has documented a relationship between higher educational attainment and antenatal healthcare access, as well as related outcomes like health literacy and autonomy in health decision-making. Yet little causal evidence exists about whether changing educational policies can improve ANC coverage. This study fills this research gap by investigating the impact of national-level policies that eliminate tuition fees for lower secondary education in SSA on the number of ANC visits.

METHODS

To estimate the effect of women's exposure to tuition-free education policies at the primary and lower secondary levels on their ANC visits, a difference-in-difference methodology was employed. This analysis leverages the variation in the timing of education policies across nine SSA countries.

RESULTS

Exposure to tuition-free primary and lower secondary education is associated with improvements in the number of ANC visits, increasing the share of women meeting the WHO recommendation of at least four ANC visits by 6-14%. Moreover, the impact of both education policies combined is greater than that of tuition-free primary education alone. However, the effects vary across individual treatment countries, suggesting the need for further investigation into country-specific dynamics.

CONCLUSIONS

The findings of this study have significant implications for policymakers and stakeholders seeking to improve ANC coverage. Removing the tuition barrier at the secondary level has shown to be a powerful strategy for advancing health outcomes and educational attainment. As governments across Africa consider eliminating tuition fees at the secondary level, this study provides valuable evidence about the impacts on reproductive health outcomes. While investing in free education requires initial investment, the long-term benefits for both human development and economic growth far outweigh the costs.

Public health spending in Sub-Saharan Africa: exploring transmission mechanisms using the latent growth curve mediation model

In response to the imperatives of universal health coverage, structural factors that may hinder the effectiveness of increased spending in sub-Saharan Africa (SSA) need attention. This study assessed the mediating role of these factors in domestic general government health expenditure (DGGHE) effects to propose solutions for improving population health outcomes (PHO). The analysis used the Latent Growth Curve Mediation Model (LGCMM) approach within the structural equation model (SEM) framework for panel data from 42 SSA countries from 2015 to 2018. The findings were that malaria and female education formed a channel through which DGGHE imparted its effects on DALY in SSA, and these effects were achieved via the specific path from the DGGHE slope to the DALY slope, via malaria and female education slopes. However, the paper found no evidence of immunization coverage mediating the relationship between DGGHE and DALY in SSA. The paper concludes that structural factors affect the effectiveness of DGGHE on PHO, implying that governments should emphasize existing programs to fight against malaria and increase immunization coverage.

Gap in knowledge of health benefits and risks of combined oral contraceptives among Lebanese women

BACKGROUND

Oral Contraceptive Pills (OCPs) are among the most commonly used forms of contraception, but they are associated with several health benefits and risks. This study aims to determine the gap in knowledge of the underlying health benefits and risks of OCPs among Lebanese women and to identify the factors that might influence their beliefs.

METHODS

A questionnaire was completed by 817 Lebanese women aged 18-64 years old and assessed sociodemographic details, medical information, contraceptive practices, knowledge of underlying health benefits and risks, and information needs related to OCPs.

RESULTS

Among the total participants, 41.5% of women reported using OCPs at some point in their lives yet 46.6% denied receiving information about their benefits and 48% denied receiving information about their risks. The mean total OCP knowledge score was 5.70 out of 25, the mean OCP risk knowledge score was 4.09 out of 15, and the mean OCP benefit knowledge score was 0.77 out of 6. Sociodemographic factors associated with greater total knowledge, risk knowledge and benefit knowledge included OCP usage, being a student, confidence in one's knowledge and satisfaction with one's information. Both the total and risk knowledge scores were found to be higher in women who found that receiving information related to OCPs was important. Finally, participants who lived in central governates had greater total knowledge scores, whereas those with higher levels of education and a family history of endometrial cancer demonstrated better benefit knowledge.

CONCLUSIONS

This study highlighted the poor knowledge of health benefits and risks associated with OCP use among Lebanese women and the associated sociodemographic factors that might influence their beliefs.

Effect of women's literacy status on maternal healthcare services utilisation in Ethiopia: a stratified analysis of the 2019 mini Ethiopian Demographic and Health Survey

OBJECTIVES

Maternal mortality remains unacceptably high in sub-Saharan Africa with 533 maternal deaths per 100 000 live births, accounting for 68% of all maternal deaths worldwide. Most maternal deaths could be prevented by adequate maternal health service use. The study examined the effect of literacy status on maternal health services utilisation among reproductive-age women in Ethiopia.

DESIGN

A cross-sectional study.

SETTINGS

Ethiopia.

PARTICIPANTS

A weighted sample of 3839 reproductive-age women who gave birth in the last 5 years preceding the survey and whose literacy status was measured were included in this study. The survey used a two-stage stratified cluster sampling technique.

PRIMARY AND SECONDARY OUTCOME MEASURES

This study used a dataset from the recent Ethiopia Mini Demographic and Health Surveys. We assessed the maternal health service utilisation among reproductive-age women. Multivariable logistic regression analyses were employed to assess the association between literacy status and maternal healthcare utilisation while controlling for other factors. Adjusted OR with a 95% CI was reported.

RESULTS

About 63.8% of reproductive-age women were illiterate. The prevalence of antenatal care (ANC) 1, ANC 4, skilled birth attendance and postnatal care (PNC) services utilisation was 74.9%, 43.5%, 51.9% and 32.0%, respectively. Literate women had significantly higher ANC 1, ANC 4, skilled birth attendance, and PNC services utilisation than illiterate women (p<0.001). Regional variation, wealth status, age at first birth, birth order and birth intervals were significantly associated with maternal healthcare utilisation among both literate and illiterate women. Similarly, ANC booking timing and utilisation, age of household head and religious affiliation were associated with institutional delivery and PNC utilisation.

CONCLUSION

Literate women had a significantly higher maternal healthcare services utilisation than illiterate, modified by sociodemographic and obstetric-related factors. Hence, wholehearted efforts should be directed towards educating and empowering women.

Multilevel and subnational analysis of the predictors of maternity continuum of care completion in Nigeria: a cross-sectional survey

Understanding population discrepancy in maternity continuum of care (CoC) completion, particularly in sub-Saharan Africa is significant for interventional plan to achieve optimal pregnancy outcome and child survival. This study thus investigated the magnitudes, distribution, and drivers of maternity CoC completion in Nigeria. A secondary analysis of 19,474 reproductive age (15-49 years) women with at least a birth (level 1) in 1400 communities (level 2) across 37 states covered in the 2018 cross-sectional survey. Stepwise regression initially identified important variables at 10% cutoff point. Multilevel analysis was performed to determine the likelihood and significance of individual and community factors. Intra-cluster correlation assessed the degree of clustering and deviance statistics identified the optimal model. Only 6.5% of the women completed the CoC. Completion rate is significantly different between communities "4.3% in urban and 2.2% in rural" (χ2 = 392.42, p < 0.001) and was higher in southern subnational than the north. Education (AOR = 1.61, 95% CI 1.20-2.16), wealth (AOR = 1.73, 95% CI 1.35-2.46), media exposure (AOR = 1.22, 95% CI 1.06-1.40), women deciding own health (AOR = 1.37, 95% CI 1.13-1.66), taking iron drug (AOR = 1.84, 95% CI 1.43-2.35) and at least 2 dose of tetanus-toxoid vaccine during pregnancy (AOR = 1.35, 95% CI 1.02-1.78) are associated individual factors. Rural residency (AOR = 1.84, 95% CI = 1.43-2.35), region (AOR = 1.84, 95% CI 1.43-2.35) and rural population proportion (AOR = 1.84, 95% CI 1.43-2.35) are community predictors of the CoC completion. About 63.2% of the total variation in CoC completion was explained by the community predictors. Magnitude of maternity CoC completion is generally low and below the recommended level in Nigeria. Completion rate in urban is twice rural and more likely in the southern than northern subnational. Women residence and region are harmful and beneficial community drivers respectively. Strengthening women health autonomy, sensitization, and education programs particularly in the rural north are essential to curtail the community disparity and optimize maternity CoC practice.

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.

Utilization of Proximate Healthcare Facilities and Children's Wait Times in Senegal: An IV-Tobit Analysis

Universal health coverage (UHC) defines individuals' timely access to healthcare services without suffering any health-related financial constraints. The Senegalese government has shown commitments towards achievement of UHC as a way of improving access by the population to quality healthcare services. This is very pertinent for promoting some indicators of under-five health in Senegal. Therefore, this study analyzed the factors influencing sick children's utilization of the nearest healthcare facilities and their wait times in Senegal. The data were from the Service Provision Assessment (SPA) survey, which was conducted in 2018. The instrumental Tobit regression model was used for data analysis. The results showed that 63.50% and 86.01% of the children utilized health posts and publicly owned facilities, respectively. Also, 98.46% of the children utilized urban facilities. The nearest facilities were utilized by 74.55%, and 78.19% spent less than an hour in the facilities. The likelihood of using the nearest healthcare facilities significantly reduced (p < 0.05) with caregivers' primary education, higher education, residence in some regions (Fatick, Kaokack, Saint Louis, Sediou, and Tambacounda), and use of private/NGO not-for-profit facilities, but increased with not having visited any other providers, residence in the Kaffrie region, vomiting symptoms, use of health centers, and use of health posts. Moreover, treatment wait times significantly increased (p < 0.05) with the use of nearest facilities, residence in some regions (Diourbel, Kaokack, Matam and Saint Louis), use of private for-profit facilities, use of private not-for-profit facilities, and urban residence, but decreased with secondary education, use of health centers, use of health posts, vomiting symptoms, and showing other symptoms. It was concluded that reduction in wait times and utilization of the nearest healthcare facilities are fundamental to achieving UHC in Senegal. Therefore, more efforts should be integrated at promoting regional and sectoral equities through facilitated public and private healthcare investment.

The causal effect of educational attainment on stress urinary incontinence: a two-sample mendelian randomization study

BACKGROUND

Stress urinary incontinence (SUI) is characterized by involuntary urine leakage in response to increased abdominal pressure, such as coughing, laughing, or sneezing. It significantly affects women's quality of life and imposes a substantial disease burden. While pregnancy and childbirth have been previously identified as risk factors for SUI, educational attainment may also play a role. Therefore, this paper investigates the causal relationship between educational attainment and SUI using two-sample Mendelian randomization (TSMR) analysis, years of schooling (YOS), and college or university degree (CUD) as proxies.

METHODS

Summary statistics of YOS, CUD, and SUI were obtained from genome-wide association studies (GWAS), and TSMR analysis was applied to explore potential causal relationships between them. Causal effects were mainly estimated using the standard inverse variance weighting (IVW) method, and complementary and sensitivity analyses were also performed using multiple methods.

RESULTS

The results indicate that both YOS (OR = 0.994, 95% CI: 0.992-0.996; P = 7.764E-10) and CUD (OR = 0.987, 95% CI: 0.983-0.991; P = 1.217E-09) may have a negative causal effect on SUI.

CONCLUSIONS

Improving educational attainment may go some way towards reducing the risk of SUI. Therefore, it is important to increase efforts to improve the imbalance in educational development and safeguard women's health.

Gender inequities in women's access to maternal health care utilisation in Zambia: a qualitative analysis

BACKGROUND

The role of gender inequities in women's ability to access maternal health care has mainly been analysed from either women's or men's perspective only. In this article, we explore the role of gender inequities in maternal health care utilisation from both men's and women's perspectives.

METHODS

Thirty-six interviews were conducted with reproductive age women (n = 24), and men whose wives/partners gave birth within the last three years prior to our study in Zambia (n = 12). Our study sought to improve understanding of the normative environment in which women and men make decisions on maternal health care utilisation in Zambia.

RESULTS

We found that men and women had different expectations regarding their gender roles in maternal health care utilisation, which created inequities reinforced by societal norms and traditions. Men make most household decisions including those related to reproductive health and they often have the major say in access to maternal health services despite not having holistic maternal health information which creates challenges in maternal health care utilisation.

CONCLUSION

The study highlights the need for maternal health care utilisation decisions to be made by both men and women and that men should be fully involved in maternal health care from pregnancy until after child birth. Further, there is urgent need for concerted and sustained efforts to change traditional norms that reinforce these inequities and affect maternal health care utilisation if Zambia is to meet Sustainable Development Goal-3.1.

Women's empowerment and uptake of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy: results from a cross-sectional baseline survey in the Lake endemic region, Kenya

BACKGROUND

Malaria in pregnancy remains a major public health problem in endemic areas of the sub-Saharan African (SSA) region. However, there is limited understanding of the association between women's empowerment and the uptake of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy (IPTp-SP) in Kenya. This study examines the association between women's empowerment indicators (decision-making power, control of assets, education, and employment status) and the uptake of three or more doses of IPTp-SP in the Lake endemic region of Kenya.

METHODS

The analysis utilized a dataset from a cross-sectional baseline survey of 3129 women aged 15-49 years in Kisumu and Migori Counties who had a live birth within the last 2 years preceding the study. Data were collected between June to August 2021. A descriptive analysis was conducted to show the distribution of respondents by key background characteristics, and bivariate and multivariate logistic regression to examine statistically significant associations between women's empowerment measures and the uptake of 3+ doses of IPTp-SP.

RESULTS

Among the 3129 women surveyed, 1978 (65.7%) received 3+ doses of IPTp-SP during their most recent pregnancy. Controlling for individual characteristics and the number of ANC visits, the odds of taking 3+ doses of IPTp-SP increased among women who had high decision-making autonomy (AOR = 2.33; CI = 1.81-3.01; P < 0.001); and tertiary level of educational attainment (AOR = 1.51; CI = 1.10-2.06). However, the association between control of assets and uptake of IPTp-SP was positive but not statistically significant.

CONCLUSION

Women's decision-making autonomy and educational attainment were positively associated with the uptake of IPTp-SP. As a result, maternal health interventions should focus on less empowered women, specifically those with less decision-making autonomy and no/low formal education, as they are less likely to achieve optimal uptake of IPTp-SP during pregnancy.

How equitable is utilization of maternal health services in Uganda? Implications for achieving universal health coverage

BACKGROUND

Maternal and neonatal mortality in Uganda remain persistently high. While utilisation of maternal health services has been shown to reduce the risk of maternal death, little is known about the inequalities in utilisation of maternal health services in Uganda. This study examined the inequalities in utilisation of maternal health services between 2006 and 2016 to draw implications for achieving universal health coverage.

METHODS

We used the Uganda Demographic Health Survey 2006, 2011 and 2016 to analyse inequalities in utilisation of antenatal care (ANC4+), skilled birth attendance (SBA), postnatal care (PNC) and a package of maternal health services. Equity ratios, concentration curves, concentration indices and regression analysis were used in the estimations.

RESULTS

Inequalities in utilization of single and a package of maternal health services reduced between 2005 and 2016, but remained pro-rich. Inequalities in utilisation of package of maternal health services were greater than for a single service. Women from the richest quintile were 4 times more likely to receive a package of care compared to the poorest women, but were just 1.5 times more likely to receive ANC4 + than those in the poorest quintile. In 2006 women in urban areas were 2.6 times more likely to receive a package of all three maternal health services than their rural counterpart and they had a relative advantage of 23.4% to utilize skilled birth delivery than the poorest women. Each additional year of schooling and living in urban areas was associated with 1.2 and 1.6% point increase in utilisation of a package of care respectively. Wealth, education and living in urban areas were positively associated with utilisation of all maternal healthcare.

CONCLUSION

Declining inequalities in utilisation of maternal healthcare reflect a move towards achieving universal health coverage in Uganda. Pro-rich, education and urban-biased inequalities, imply the need for targeted interventions for the poor, less educated and rural women. Targeted voucher schemes, free distribution of birth kits for poorer and rural women, community-level mobilization to improve uptake of postnatal care, and promoting women's education and incomes are feasible interventions to improve utilisation of maternal health services and equity.

Early Postnatal Home Visit Coverage by Health Extension Workers and Associated Factors Among Postpartum Women in Gidan District, Northeast Ethiopia

Objectives: To determine the coverage and associated factors of early postnatal home visits (PNHVs) by health extension workers (HEWs) among postpartum women in Gidan district, Northeast Ethiopia.

Methods: A community-based, cross-sectional study was conducted between 30 March and 29 April 2021 in the Gidan district, Northeast Ethiopia. A multistage sampling technique was employed to select 767 postpartum women participants. Interviewer-administered questionnaires were used to collect the data. A binary logistic regression model was fitted to identify factors associated with early PNHVs by HEWs.

Results: The coverage of early postnatal home visits was 15.13% [95% confidence interval (CI): 12.75, 17.87]. Women’s education, institutional delivery, time to reach health posts, and participation in pregnant women forums were significantly associated with early PNHVs by HEWs.

Conclusion: In the current study, the coverage of early postnatal home visits by HEWs remains low in the study area. The concerned bodies should consider interventions that promote women’s education and institutional delivery, and more efforts should be made to improve community-based participation and links with HEWs.

Time to first antenatal care booking and its determinants among pregnant women in Ethiopia: survival analysis of recent evidence from EDHS 2019

BACKGROUND

Antenatal care is one of the components of the maternal and child continuum of care. Timely booking ANC during pregnancy is of utmost importance to guarantee the best possible health outcomes for women and children. Inappropriate timing of the first ANC booking is associated with poor pregnancy outcomes, including perinatal death, stillbirth, and early neonatal death. According to WHO focused ANC recommendation, every mother should start booking ANC within the first 12 weeks of gestational age. However, in developing countries, including Ethiopia, many pregnant mothers were not booking ANC at the recommended time. Thus, this study aims to assess the time to first ANC booking and its determinants in Ethiopia.

METHODS

A survival analysis was conducted to determine time to first ANC booking among 3917 weighted study subjects. The data were extracted from EDHS 2019 using STATA version 17 software. A Kaplan Meier survivor curve was computed to estimate the time of first ANC booking. A Long-rank test was used to compare the difference in survival curves. Weibull Inverse Gaussian shared frailty model was used to identify significant predictors. On multivariable analysis, variables having a p-value of ≤ 0.05 are considered statistically significant.

RESULTS

The overall median survival time was four months. The significant determinant of time to first ANC booking are residence (rural [ϕ = 1.111, 95CI: 1.060, 1.164), mother educational level (primary education [ϕ = 0.945, 95CI: 0.915, 0.977], secondary and above educational [ϕ = 0.857, 95CI: 0.819, 0.896]) and wealth index (middle [0.948 (ϕ = 0.948, 95CI: 0.911, 0.986) and rich [ϕ = 0.904, 95CI: 0.865, 0.945]) CONCLUSION: The median time for first ANC booking is 4 month, which is higher than the WHO recommended time. The timing of the first ANC booking in Ethiopia was mainly influenced by the residence of women, mother educational level, and wealth index. It is strongly recommended to expose mothers to educational materials and other awareness-creation campaigns, as well as to support disadvantaged women, such as the uneducated, poor, and those living in rural or remote areas.