Place, Time and Experience: Barriers to Universalization Of Institutional Child Delivery in Rural Mozambique

How applicable is geospatial analysis in maternal and neonatal health in sub-Saharan Africa? A systematic review

Background

Sub-Saharan Africa (SSA) has the world's highest maternal and neonatal morbidity and mortality and has shown the slowest progress in reducing them. In addition, there is substantial inequality in terms of maternal and neonatal morbidity and mortality in the region. Geospatial studies can help prioritize scarce resources by pinpointing priority areas for implementation. This systematic review was conducted to explore the application of geospatial analysis to maternal and neonatal morbidity and mortality in SSA.

Methods

A systematic search of PubMed, SCOPUS, EMBASE, and Web of Science databases was performed. All observational and qualitative studies that reported on maternal or neonatal health outcomes were included if they used a spatial analysis technique and were conducted in a SSA country. After removing duplicates, two reviewers independently reviewed each study's abstract and full text for inclusion. Furthermore, the quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Finally, due to the heterogeneity of studies, narrative synthesis was used to summarize the main findings, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was strictly followed to report the review results. A total of 56 studies were included in the review.

Results

We found that geospatial analysis was used to identify inequalities in maternal and neonatal morbidity, mortality, and health care utilization and to identify gaps in the availability and geographic accessibility of maternal health facilities. In addition, we identified a few studies that used geospatial analysis for modelling intervention areas. We also detected challenges and shortcomings, such as unrealistic assumptions used by geospatial models and a shortage of reliable, up-to-date, small-scale georeferenced data.

Conclusions

The use of geospatial analysis for maternal and neonatal health in SSA is still limited, and more detailed spatial data are required to exploit the potential of geospatial technologies fully.

Determinants of facility-based childbirth among adolescents and young women in Guinea: A secondary analysis of the 2018 Demographic and Health Survey

INTRODUCTION

Maternal mortality remains very high in Sub-Saharan African countries and the risk is higher among adolescent girls. Maternal mortality occurs in these settings mainly around the time of childbirth and the first 24 hours after birth. Therefore, skilled attendance in an enabling environment is essential to reduce the occurrence of adverse outcomes for both women and their children. This study aims to analyze the determinants of facility childbirth among adolescents and young women in Guinea.

METHODS

We used the Guinea Demographic and Health Survey (DHS) conducted in 2018. All females who were adolescents (15-19) or young women (20-24 years) at the time of their most recent live birth in the five years before the survey were included. We examined the use of health facilities for childbirth and its determinants selected through the Andersen health-seeking model using descriptive analysis and multilevel multivariable logistic regression. All descriptive and analytical estimated were produced by adjusting for the survey sampling using the svy option, including adjustment for clustering, stratification and unequal probability of selection and non-response (individual sample weights). The subpopulation option was also used to account for the variance of estimations.

RESULTS

Overall, 58% of adolescents and 57% of young women gave birth in a health facility. Young women were more likely to have used private sector facilities compared to adolescents (p<0.001). Factors significantly associated with a facility birth in multivariable regression included: secondary or higher educational level (aOR = 1.86; 95%CI:1.24-2.78) compared to no formal education; receipt of 1-3 antenatal visits (aOR = 9.33; 95%CI: 5.07-17.16) and 4+ visits (aOR = 16.67; 95%CI: 8.82-31.48) compared to none; living in urban (aOR = 2.50; 95%CI: 1.57-3,98) compared to rural areas. Women from poorest households had lower odds of facility-based childbirth. There was substantial variation in the likelihood of birth in a health facility by region, with highest odds in N'Zérékoré and lowest in Labé.

CONCLUSION

The percentage of births in health facilities among adolescents and young women in Guinea was 58%. This remains suboptimal regarding the challenges associated maternal mortality and morbidity issues in Guinea. Socio-economic characteristics, region of residence and antenatal care use were the main determinants of its use. Efforts to improve maternal health among this group should target care discontinuation between antenatal care and childbirth (primarily by removing financial barriers) and increasing the demand for facility-based childbirth services in communities, while paying attention to the quality and respectful nature of healthcare services provided there.

Lags in the provision of obstetric services to indigenous women and their implications for universal access to health care in Mexico

Through quantitative and qualitative methods, in this article the authors describe the perspectives of indigenous women who received antenatal and childbirth medical care within a care model that incorporates a non-governmental organisation (NGO), Partners in Health. They discuss whether the NGO model better resolves the care-seeking process, including access to health care, compared with a standard model of care in government-subsidised health care units (setting of health services networks). Universal health coverage advocates access for the most disadvantaged and vulnerable populations as a priority. However, the issue of access includes problems related to the effect of certain structural social determinants that limit different aspects of the obstetric care process. The findings of this study show the need to modify the structure of organisational values in order to place users at the centre of medical care and ensure respect for their rights. The participation of agents outside the public system, such as NGOs, can be of great value for moving in this direction. Women’s participation is also necessary for learning how they are being cared for and the extent to which they are satisfied with obstetric services. This research experience can be used for other countries with similar conditions.

When it rains, it pours: detecting seasonal patterns in utilization of maternal healthcare in Mozambique using routine data

BACKGROUND

Climatic conditions and seasonal trends can affect population health, but typically, we consider the effect of climate on the epidemiology of communicable diseases. However, climate can also have an effect on access to care, particularly in remote rural areas of low- and middle-income countries. In this study, we investigate associations between the rainy season and the utilization of maternal health services in Mozambique.

METHODS

We examined patterns in the number of women receiving antenatal care (ANC) and delivering at a health facility for 2012-2019, using data from Mozambique's Health Management Information Systems. We investigated the association between seasonality (rainfall) and maternal health service utilization (ANC and institutional delivery) at national and provincial level. We fit a negative binomial regression model for institutional delivery and used it to estimate the yearly reduction in institutional deliveries due to the rainy season, with other factors held constant. We used the Lives Saved Tool (LiST) to model increases in mortality due to this estimated decrease in institutional delivery associated with the rainy season.

RESULTS

In our national analysis, the rate of ANC visits was 1% lower during the rainy season, adjusting for year and province (IRR = 0.99, 95% CI: 0.96-1.03). The rate of institutional deliveries was 6% lower during the rainy season than the dry season, after adjusting for time and province (IRR = 0.94, 95% CI: 0.92-0.96). In provincial analyses, all provinces except for Maputo-Cidade, Maputo-Province, Nampula, and Niassa showed a statistically significantly lower rate of institutional deliveries in the rainy season. None were statistically significantly lower for ANC. We estimate that, due to reductions in institutional delivery attributable only to the rainy season, there were 74 additional maternal deaths and 726 additional deaths of children under the age of 1 month in 2021, that would not have died if the mothers had instead delivered at a facility.

CONCLUSION

Fewer women deliver at a health facility during the rainy season in Mozambique than during the dry season. Barriers to receiving care during pregnancy and childbirth must be addressed using a multisectoral approach, considering the impact of geographical inequities.

Spatial clustering and determinants of home birth after at least one antenatal care visit in Ethiopia: Ethiopian demographic and health survey 2016 perspective

BACKGROUND

All pregnancies are at risk and have to be attended by skilled professionals. In Ethiopia however nearly half (45.7%) of the women were giving birth at home after antenatal care (ANC) visits in which skilled professionals were not available. Therefore, the aim of this study was to assess spatial clustering and the determinant factors of home delivery after antenatal care visits in Ethiopia.

METHODS

A case control study was conducted on 2110 mothers who gave birth at home after ANC (cases), and 2510 mothers who gave birth at health institutions after attending ANC (controls), based on EDHS 2016 data. As per the recommendations of the DHS program, we weighed the data before analysis. ArcGIS 10.3 was used to show spatial pattern and SaTScan™ 9.4 to identify significant clusters. Stata 14 was used for data cleaning, weighing, and the analysis of the determinant factors. Bi variable and multi variable multilevel mixed effect logistic regression was fitted. Finally, the Log-likelihood ratio (LLR) and Relative risk with p-value of spatial scan statistics and AOR with 95% CI for significant determinant factors were reported.

RESULTS

Home delivery after ANC was spatially clustered in Ethiopia (Moran's Index = 0.91, p-value< 0.01). Attending, 1-3 ANC visits (AOR = 1.41, 95%CI: 1.17-1.71), no information about birth preparedness plan (AOR = 2.21, 95%CI: 1.83-2.69), pregnancies wanted later (AOR = 1.55, 95%CI: 1.20, 2.06), not having health insurance (AOR = 2.16, 95% CI: 1.29, 3.62), Muslim (AOR = 1.57, 95% CI: 1.13, 2.19) and protestant (AOR = 1.72, 95%CI: 1.16, 2.42) religions were positively associated with home delivery; While being rich (AOR = 0.42, 95%CI: 0.32-0.54), middle wealth index (AOR = O.66, 95%CI: 0.51, 0.86), primary education (AOR = 0.45, 95%CI: 0.36-0.55), secondary education (AOR = 0.11, 95%CI: 0.07-0.16), above secondary education (AOR = 0.06, 95%CI: 0.03-0.11) were negatively associated.

CONCLUSIONS

Home delivery after ANC follow ups was spatially clustered. Socio-demographic, health service and pregnancy related factors determined the prevalence of home delivery after antenatal care visits. Strengthening women's education, ANC visit, giving more information about birth preparedness plan, and improving family wealth are vital to reduce home delivery after antenatal care visits.

Determinants of home delivery in Nepal - A disaggregated analysis of marginalised and non-marginalised women from the 2016 Nepal Demographic and Health Survey

INTRODUCTION

In Nepal, a substantial proportion of women still deliver their child at home. Disparities have been observed in utilisation of institutional delivery and skilled birth attendant services. We performed a disaggregated analysis among marginalised and non-marginalised women to identify if different factors are associated with home delivery among these groups.

MATERIALS AND METHODS

This study used data from the 2016 Nepal Demographic and Health Survey. It involves the analysis of 3,837 women who had experienced at least one live birth in the five years preceding the survey. Women were categorised as marginalised and non-marginalised based on ethnic group. Bivariate and multivariable logistic regression analysis were performed to identify factors associated with home delivery.

RESULTS

A higher proportion of marginalised women delivered at home (47%) than non-marginalised women (26%). Compared to non-marginalised women (35%), a larger proportion of marginalised women (64%) felt that it was not necessary to give birth at health facility. The multivariable analysis indicated an independent association of having no or basic education, belonging to middle, poorer and the poorest wealth quintile, residing in Province 2 and not having completed of four antenatal care visits per protocol with home delivery among both marginalised and non-marginalised women. Whereas residing in a rural area, residing in Province 7, and at a distance of >30 minutes to a health facility were factors independently associated with home delivery only among marginalised women.

CONCLUSION

We conclude that poor education, poor economic status, non-completion of four ANC visits and belonging to Province 2 particularly determined either group of women to deliver at home, whereas residing in rural areas, living far from health facility, and belonging to Province 7 determined marginalised women to deliver at home. Preventing mothers from delivering at home would thus require focusing on specific geographical areas besides considering wider socio-economic determinants.

Religion and Use of Institutional Child Delivery Services: Individual and Contextual Pathways in Mozambique

CONTEXT

Research on institutional child delivery in Sub-Saharan Africa typically focuses on availability and accessibility of health facilities. Cultural factors, including religion, that may facilitate or hinder the use of such services have not been well examined and remain poorly understood.

METHODS

The relationship between religious affiliation and delivery in a health facility was explored using data from a household survey of 1,297 women aged 18-50 and a census of 825 religious congregations, both conducted in a predominantly Christian district in Mozambique in 2008. Multilevel logistic regression analyses were conducted to predict the likelihood of recent institutional delivery according to both individual religious affiliation and the concentration of religious congregations of certain denominations in the community of residence.

RESULTS

Approximately 63% of deliveries occurred in a health facility. The odds of such deliveries were lower among women who belonged to Apostolic churches or had no religious affiliation than among members of Catholic or mainline Protestant churches, net of other factors (odds ratios, 0.5 and 0.6, respectively). In addition, regardless of a woman's religion, the odds that she had an institutional delivery increased by 9% for each additional Catholic or mainline Protestant congregation in her community of residence (1.1).

CONCLUSIONS

Organized religion is associated with critical health outcomes in Mozambique and, potentially, in other Sub-Saharan African contexts. Policymakers should consider designing programs and interventions that promote the use of institutional delivery services among members of religious groups characterized by low use of these services and in areas where such religious groups have a strong presence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Uptake of intermittent preventive treatment and pregnancy outcomes: health facilities and community surveys in Chókwè district, southern Mozambique

Background

Malaria in pregnancy leads to serious adverse effects on the mother and the child and accounts for 75,000–200,000 infant deaths every year. Currently, the World Health Organization recommends intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine–pyrimethamine (SP) at each scheduled antenatal care (ANC) visit. This study aimed to assess IPTp-SP coverage in mothers delivering in health facilities and at the community. In addition, factors associated with low IPTp-SP uptake and malaria adverse outcomes in pregnancy were investigated.

Methods

A community and a health facility-based surveys were conducted in mothers delivering in Chókwè district, southern Mozambique. Social-demographic data, malaria prevention practices and obstetric history were recorded through self-report and antenatal records. For women delivering at health facilities, a clinical examination of mother and child was performed, and malaria infection at delivery was determined by rapid diagnostic test, microscopy, quantitative PCR and placental histology.

Results

Of 1141 participants, 46.6, 30.2, 13.5 and 9.6% reported taking ≥ 3, two, one and none SP doses, respectively. Low IPTp uptake (< 3 doses) was associated with non-institutional deliveries (AOR = 2.9, P < 0.001), first ANC visit after week 28 (AOR = 5.4, P < 0.001), low awareness of IPTp-SP (AOR = 1.6, P < 0.002) and having no or only primary education (AOR = 1.3, P = 0.041). The overall prevalence of maternal malaria (peripheral and/or placental) was 16.8% and was higher among women from rural areas compared to those from urban areas (AOR = 1.9, P < 0.001). Younger age (< 20 years; AOR = 1.6, P = 0.042) and living in rural areas (AOR = 1.9, P < 0.001) were predictors of maternal malaria at delivery. Being primigravidae (AOR = 2.2, P = 0.023) and preterm delivery (AOR = 2.6, P < 0.001) predicted low birth weight while younger age was also associated with premature delivery (AOR = 1.4, P = 0.031).

Conclusion

The coverage for two and ≥ 3 doses of IPTp-SP is moderately higher than estimates from routine health facility records in Gaza province in 2015. However, this is still far below the national target of 80% for ≥ 3 doses. Ongoing campaigns aiming to increase the use of malaria prevention strategies during pregnancy should particularly target rural populations, increasing IPTp-SP knowledge, stimulate early visits to ANC, improve access to health services and the quality of the service provided.

Electronic supplementary material

The online version of this article (10.1186/s12936-018-2255-z) contains supplementary material, which is available to authorized users.

HIV status, fertility intentions, and contraception in the era of expanded access to antiretroviral therapy: A case study of rural Mozambique

Provision of effective contraception to HIV-positive women of reproductive age is critical to effective management of HIV infection and prevention of both vertical and horizontal HIV transmission in developing countries. This exploratory retrospective study examines contraceptive use during the prolonged post-partum period in a sample of 285 HIV-positive and HIV-negative women who gave birth at four rural maternity clinics in a high HIV-prevalence region in Mozambique. Multivariate analyses show no significant variations by HIV status in contraceptive timing (mean time to first contraceptive use of 7.1 months) or prevalence (31% at time of survey) but detect a moderating effect of fertility intentions: while HIV status makes no difference for women wishing to stop childbearing, among women who want to continue having children, or are unsure about their reproductive plans, HIV-positive status is associated with higher likelihood of contraceptive use. Regardless of HIV status, virtually no condom use is reported. These results are situated within the context of a rapidly widening access to post-partum antiretroviral therapy in the study site and similar sub-Saharan settings.