Contextual influences on the use of health facilities for childbirth in Africa

Survival among children under-five in India: a parametric multilevel survival approach

BACKGROUND

Many studies have been conducted on under-five mortality in India and most of them focused on the associations between individual-level factors and under-five mortality risks. On the contrary, only a scarce number of literatures talked about contextual level effect on under-five mortality. Hence, it is very important to have thorough study of under-five mortality at various levels. This can be done by applying multilevel analysis, a method that assesses both fixed and random effects in a single model. The multilevel analysis allows extracting the influence of individual and community characteristics on under-five mortality. Hence, this study would contribute substantially in understanding the under-five mortality from a different perspective.

METHOD

The study used data from the Demographic and Health Survey (DHS) acquired in India, i.e., the fourth round of National Family and Health Survey (2015-16). It is a nationally representative repeated cross-sectional data. Multilevel Parametric Survival Model (MPSM) was employed to assess the influence of contextual correlates on the outcome. The assumption behind this study is that 'individuals' (i.e., level-1) are nested within 'districts' (i.e., level-2), and districts are enclosed within 'states' (i.e., level-3). This suggests that people have varying health conditions, residing in dissimilar communities with different characteristics.

RESULTS

Highest under-five mortality i.e., 3.85% are happening among those women whose birth interval is less than two years. In case of parity, around 4% under-five mortality is among women with Third and above order parity. Further, findings from the full model is that ICC values of 1.17 and 0.65% are the correlation of the likelihood of having under-five mortality risk among people residing in the state and district communities, respectively. Besides, the risk of dying was increased alarmingly in the first year of life and slowly to aged 3 years and then it remains steady.

CONCLUSION

This study has revealed that both aspects viz. individual and contextual effect of the community are necessary to address the importance variations in under-five mortality in India. In order to ensure substantial reduction in under-five mortality, findings of the study support some policy initiatives that involves the need to think beyond individual level effects and considering contextual characteristics.

Integrating the rights-based and capability approaches in the analysis of maternal healthcare utilization in sub-Saharan Africa: A multilevel modelling study

The rights-based and capability approaches received increased attention relative to maternal health in the aftermath of the 2015 Millennium Development Goals (MDGs). This may be in view of the sub-optimal progress gained in reducing maternal and child mortality, especially in developing countries. Despite the combined potential of these approaches, there are limited empirical studies testing their viability in aiding our understanding of maternal healthcare utilization in developing countries. This is what this study sought to accomplish. We combined several datasets, including the Demographic Health Surveys (DHS), World Development Indicators, the World Governance Indicators and Freedom House. Bayesian multilevel logistic regression models were applied on three indicators of maternal healthcare utilization (antenatal care visits, institutional delivery, and postnatal check-ups) in relation to selected variables representing right-based and capability approaches. After controlling for relevant individual and community-level factors, the results show that living in countries with high freedom status (POR = 1.19) and higher female secondary school enrolments (POR = 1.54) increases the odds of adequate antenatal care. Residence in countries with high freedom status (POR = 1.33) and higher voice and accountability (POR = 1.72) has a positive influence on institutional delivery. Similar results are reported for postnatal care where country freedom status (POR = 1.89), voice and accountability (POR = 1.25) and female school enrolment (POR = 1.41) are significant predictors. The results imply that the rights-based and capability approaches have the potential to enhance maternal healthcare utilization in sub-Saharan Africa. Therefore, policy strategies emphasizing on freedoms, accountability, and individual capability functionings should be encouraged in the pursuit of partly achieving Sustainable Development Goals (SDG) number 3.

Increasing health facility childbirth in Ghana: the role of network and community norms

BACKGROUND

Reducing pregnancy-related deaths in Sub-Saharan Africa through increases in health facility births may be achieved by promoting community norms and network norms favoring health facility births. However, the process of how both norms shift attitudes and actions towards facility delivery is little studied. We examined the association of network and community norms with facility birth, following a quality improvement intervention to improve facility births in Ghana.

METHODS

A 2015 mixed methods evaluation of a Maternal and Newborn Health Referral (MNHR) project in Ghana included a cross-sectional survey of women (N = 508), aged 15-49 years; in-depth interviews (IDIs) with mothers (n = 40), husbands (n = 20) and healthcare improvement collaborative leaders (n = 8); and focus group discussions (FGDs) with mothers-in-law (n = 4) and collaborative members (n = 7). Multivariable logistic regression was used to examine the association of network and community norms with facility birth. Thematic analysis of the qualitative data was conducted to explain this relationship.

RESULTS

The network norm of perceived family approval of facility delivery (AOR: 5.54, CI: 1.65-18.57) and the community norm of perceived number of women in the community that deliver in a facility (AOR: 3.00, CI: 1.66-5.43) were independently associated with facility delivery. In qualitative IDIs and FGDs both norms were also collectively perceived as influencing facility delivery. However, network norms were more influential in women's utilization of facility-based pregnancy-related care. Healthcare improvement collaboratives were important in swaying both network and community norms toward facility-based delivery by offering pregnancy-related health information, antenatal care, and support for facility delivery.

CONCLUSION

Quality improvement initiatives impact both community and network norms. To be most impactful in advancing facility-based pregnancy-related care, these initiatives should focus on highlighting the shifting trend toward facility delivery in rural communicates and promoting support for facility delivery among women's personal networks.

Knowledge, Implementation, and Gaps of Gender-Based Violence Management Guidelines among Health Care Workers

(1) Background: Gender-based violence (GBV) is widespread globally and has a myriad of adverse effects but is vastly under-reported. Health care workers are among the first responders in GBV. The objective of this study was to assess the knowledge of health workers with regard to GBV and related management guidelines and implementation. (2) Methods: The study employed a descriptive, sequential mix-method study, beginning with the quantitative part, followed by the qualitative component. Qualitative analysis was conducted using a content framework approach. (3) Results: More than two-thirds (71.79%) of health workers were found to be generally knowledgeable about gender-based violence; however, only 36.9% had good knowledge about gender-based violence management guidelines for gender-based violence and the mean value for all the items was less than 3 which indicates poor knowledge of the management guideline. Additionally, only 36.8% found the gender-based violence management guidelines useful and practical in clinical care for gender-based violence cases. (4) Conclusions: The finding of this study revealed that knowledge of gender-based violence management guideline was not adequate among health workers and rarely used during management of GBV cases. This calls for continuous training and specific refresher courses, including on-site practical sessions, professionals' mentorship, and supervision.

Trends and patterns of inequalities in using facility delivery among reproductive-age women in Bangladesh: a decomposition analysis of 2007-2017 Demographic and Health Survey data

OBJECTIVES

The prime objectives of the study were to measure the prevalence of facility delivery, assess socioeconomic inequalities and determine potential associated factors in the use of facility delivery in Bangladesh.DesignCross-sectional.

SETTING

The study involved investigation of nationally representative secondary data from the Bangladesh Demographic and Health Survey between 2007 and 2017-2018.

PARTICIPANTS

The participants of this study were 30 940 (weighted) Bangladeshi women between the ages of 15 and 49.

METHODS

Decomposition analysis and multivariable logistic regression were both used to analyse data to achieve the study objectives.

RESULTS

The prevalence of using facility delivery in Bangladesh has increased from 14.48% in 2007 to 49.26% in 2017-2018. The concentration index for facility delivery utilisation was 0.308 with respect to household wealth status (p<0.001), indicating that use of facility delivery was more concentrated among the rich group of people. Decomposition analysis also indicated that wealth quintiles (18.31%), mothers' education (8.78%), place of residence (7.75%), birth order (5.56%), partners' education (4.30%) and antenatal care (ANC) seeking (8.51%) were the major contributors to the prorich socioeconomic inequalities in the use of facility delivery. This study found that women from urban areas, were overweight, had any level of education, from wealthier families, had ANC, and whose partners had any level of education and involved in business were more likely to have facility births compared with their respective counterparts.

CONCLUSIONS

This study found a prorich inequality in the use of facility delivery in Bangladesh. The socioeconomic disparities in facility delivery must be addressed if facility delivery usage is to increase in Bangladesh.

Factors associated with the choice of delivery place: A cross-sectional study in rural areas of Indonesia

Background

Developing countries, including Indonesia, commonly face maternal mortality as a public health concern, which needs special attention. Using maternal delivery services in health facilities may reduce maternal mortality. However, little is known about the general use of delivery services in health facilities in rural areas, Indonesia.

Objective

This study aimed to analyze determinants in choosing delivery places in rural areas of Indonesia.

Methods

A cross-sectional quantitative design with secondary data from the 2014 Indonesian Family Life Survey (IFLS) was used in this study. There were 2,389 mothers aged 15-49 years in rural areas were included. Data were analyzed using a logistic regression test.

Results

It was found that 67% of mothers gave birth in health facilities. Tertiary and secondary education levels, residence in Java and Bali regions, economic status, insurance ownership, and job status were significantly related to the choice of delivery place in health facilities. Tertiary education was the most dominant factor correlated with the use of delivery services in health facilities (p < 0.001; PR = 4.55; 95% CI = 3.751-5.542).

Conclusion

Education is the key factor associated with the choice of delivery place. Therefore, it is suggested that the government and healthcare workers, especially nurses and midwives, improve mothers' education and provide strategies to increase knowledge in choosing delivery services to enhance their health outcomes.

Gender norms and women’s empowerment as barriers to facility birth: A population-based cross-sectional study in 26 Nigerian states using the World Values Survey

Background

Central and western Africa struggle with the world’s lowest regional proportion of facility birth at 57%. The aim of the current study was to compare beliefs related to maternal health care services, science/technology, gender norms, and empowerment in states with high vs. low proportions of facility birth in Nigeria.

Methods

Face-to-face interviews were performed as part of a nationally representative survey in Nigeria using a new module to measure values and beliefs related to gender and sexual and reproductive health and rights collected as part the 2018 World Values Survey. We compared beliefs related to maternal health care services, science/technology, gender norms, and empowerment between Nigerian states with facility birth proportions > 50% vs. < 25% as presented in the 2018 Nigerian Demographic Health Survey report. Pearson’s chi-squared test, the independent t-test, and univariable and multivariable logistic and linear regression were used for analyses. Results were also stratified by gender.

Results

Among the 1,273 participants interviewed, 653 resided in states with high and 360 resided in states with low proportions of facility birth. There were no significant differences between the groups in perceived safety of facility birth (96% vs. 94%) and confidence in antenatal care (91% vs 94%). However, in states with low proportions of facility birth, participants had higher confidence in traditional birth attendants (61% vs. 39%, adjusted odds ratio [aOR] 2.1, [1.5–2.8]), men were more often perceived as the ones deciding whether a woman should give birth at a clinic (56% vs. 29%, aOR 2.4 [1.8–3.3]), and participants experienced less freedom over their own lives (56% vs. 72%, aOR 0.56 [0.41–0.76]). Most differences in responses between men and women were not statistically significant.

Conclusions

In order to increase facility births in Nigeria and other similar contexts, transforming gender norms and increasing women’s empowerment is key.

Spatial Distribution and Associated Factors of Institutional Delivery among Reproductive-Age Women in Ethiopia: The Case of Ethiopia Demographic and Health Survey

Background

Maternal mortality is unacceptably high. About 295,000 women died during and following pregnancy and childbirth in 2017. The vast majority of these deaths (94%) occurred in low-resource settings, and most could have been prevented.

Methods

This research is based on a cross-sectional study using 2016 EDHS data. The analysis included 7,590 women who had given birth in the five years prior to the survey. Clusters with high and low hot spots with institutional delivery were found using SatScan spatial statistical analysis. A multilevel multivariable mixed-effect logistic regression was utilized to discover characteristics associated with institutional delivery.

Result

In this study, 33.25% of women who gave birth in the last 5 years preceding the survey delivered their babies at health institutions. The finding also indicated that the spatial distribution of institutional delivery was nonrandom in the country. Variables achieving statically significant association with utilization of institutional delivery were as follows: at the individual level, richness (AOR = 2.18, 95%CI: 1.39-3.41), higher education (AOR = 3.89, 95%CI: 1.51-10.01), a number of antenatal care visits of four and above (AOR = 6.57, 95%CI: 4.83-8.94), and parity of more than two children (AOR = 0.48, 95%CI: 0.34-0.68); at the community level, higher education (AOR = 1.70, 95%CI: 1.22-2.36) and urban residence (AOR = 5.30, 95%CI: 3.10-9.06) were variables that had achieved statically significant association for utilization of institutional delivery.

Conclusions

This study identified a spatial cluster of institutional delivery with the Somali and Afar region having low utilization rates and Addis Ababa and Tigray regions having the highest utilization rates. The significant individual factors associated with institution delivery were woman antenatal care visits, household wealth index, maternal education, and parity, and the significant community ones were region, place of residence, and educational status. Therefore, to maximize health facility delivery in Ethiopia, the predictors of institutional delivery identified in this study should be given more attention by governmental and nongovernmental stakeholders.

Delivery Services Utilization Based on Urban Rural Status in Indonesia

INTRODUCTION: Maternal mortality has been listed in the Sustainable Development Goals’ priority. Hence, use of delivery services from health facilities is essential to improve maternal and child health. AIM: This study aimed to analyze the trends and determinants of delivery service utilization between urban and rural areas in Indonesia. METHODS: This quantitative study uses a cross-sectional design. The secondary data source came from the Indonesian Health Demographic Survey (IDHS) in 2007-2017. As many as 29,985 married women of childbearing age (15-49 years old) were selected as samples. The data analysis was done using the chi-square test then binary logistic regression test. RESULTS: Trends in the utilization of health facility delivery services increased in Indonesia. Age, residential area, education level, occupational status, antenatal visits and knowledge of danger signs during pregnancy, and economic status were associated with the utilization of health facility delivery services both in the rural and urban areas. Women who finished college had 4.55 times chances of using health facility delivery services  CONCLUSION: Demographic characteristics, antenatal visits, and knowledge of danger signs during pregnancy are associated with use of health facility delivery service sin rural and urban areas. The government needs to consider these factors in reducing inequal use of health facility delivery services between urban and rural areas.

Understanding factors associated with attending secondary school in Tanzania using household survey data

BACKGROUND

Sustainable Development Goal (SDG) 4 aims to ensure inclusive and equitable access for all by 2030, leaving no one behind. One indicator selected to measure progress towards achievement is the participation rate of youth in education (SDG 4.3.1). Here we aim to understand drivers of school attendance using one country in East Africa as an example.

METHODS

Nationally representative household survey data (2015-16 Tanzania Demographic and Health Survey) were used to explore individual, household and contextual factors associated with secondary school attendance in Tanzania. These included, age, head of household's levels of education, gender, household wealth index and total number of children under five. Contextual factors such as average pupil to qualified teacher ratio and geographic access to school were also tested at cluster level. A two-level random intercept logistic regression model was used in exploring association of these factors with attendance in a multi-level framework.

RESULTS

Age of household head, educational attainments of either of the head of the household or parent, child characteristics such as gender, were important predictors of secondary school attendance. Being in a richer household and with fewer siblings of lower age (under the age of 5) were associated with increased odds of attendance (OR = 0.91, CI 95%: 0.86; 0.96). Contextual factors were less likely to be associated with secondary school attendance.

CONCLUSIONS

Individual and household level factors are likely to impact secondary school attendance rates more compared to contextual factors, suggesting an increased focus of interventions at these levels is needed. Future studies should explore the impact of interventions targeting these levels. Policies should ideally promote gender equality in accessing secondary school as well as support those families where the dependency ratio is high. Strategies to reduce poverty will also increase the likelihood of attending school.

Factors Associated With Home Births in Benin and Mali: Evidence From the Recent Demographic and Health Surveys

Introduction

Identifying and understanding the factors associated with homebirths can contribute to improving maternal and child health and achieving the Sustainable Development Goals (SDGs). This study aimed to perform a comparative analysis of the factors associated with homebirths in Benin and Mali.

Method

This study is based on the most recent data from the Demographic Health Surveys conducted in Mali and Benin in 2018. The dependent variable was homebirth, and the explanatory variables were the individual characteristics of the woman, the distance to the health center, the place of residence, the number of prenatal consultations had, the frequency of media exposure, and the use of the Internet. The primary survey unit (PSU) was considered in the analysis to measure the effect of context on the choice of the place of delivery. Further, descriptive statistics and multilevel logistic regression analysis were used in the study.

Results

Educational level was associated with homebirth in Benin and Mali; Women with either no education or primary education are more likely to give birth at home. Women who didn't live close to a health facility were more likely to give birth at home than those who didn't face this problem in both countries. Not making visits for antenatal care (ANC) increases the odds of having a homebirth by 31.3 times (CI = 24.10-40.70) in Benin and 12.91 times (CI = 10.21-16.33) in Mali. Similarly, women who went on 1-2 ANC visits were more likely to give birth at home compared with women who made five or more ANC visits in both countries. The number of children per woman was also a significant factor in both countries. Women who often or regularly paid attention to the media messages were less likely to give birth at home compared with those who did not follow relevant media inputs (aOR = 0.42 [CI = 0.26-0.67] in Benin and aOR = 0.65 [CI = 0.50-0.85] in Mali).

Conclusion

Increasing the demand and uptake of women's health services by improving the availability and quality of services and establishing community health centers could help reduce the incidence of homebirths that can be risky and, thus, combat maternal and infant mortality.

Factors associated with unmet need for family planning in sub-Saharan Africa: A multilevel multinomial logistic regression analysis

Background

More than one out of every ten married women in the world, and one out of every five women in Africa, have unmet family planning needs. Despite this, studies concerning sub-Saharan Africa as well as the community-level factors that may influence the unmet need for family planning are scarce.

Objective

To assess factors associated with unmet need for family planning in sub-Saharan Africa.

Methods

This study used the nineteen demographic and health surveys (DHS) conducted between 2015 and 2020 in sub-Saharan Africa. A total weighted sample of 175, 820 women of reproductive age who were married during the survey was used for this study. To assess the factors associated with unmet need for family planning, I have employed a multilevel multinomial logistic regression model. After selecting variables using the bivariable analysis, a multivariable model was fitted. Finally, an adjusted relative risk ratio with its 95% Confidence Interval was reported and variables with a p-value less than 0.05 were declared to be significant predictors of unmet need for family planning.

Result

The overall prevalence of unmet need for family planning in sub-Saharan Africa was 23.70%, of which unmet need for spacing and limiting was 15.81% and 7.90% respectively. In the multivariable multilevel multinomial model, women’s age, women’s education, age at cohabitation, heard about family planning through media, parity, number of under-five children, and knowledge about modern contraceptive methods were among the individual-level factors that were associated with both the unmet need for spacing and limiting. Place of residence, community level of women illiteracy, and region were among the community-level factors that were associated with both unmet needs for spacing and limiting. Household size and visiting the health facility in the last 12 months were associated with unmet need for spacing only and husband education was associated with unmet need for limiting only.

Conclusion

Unmet need for family planning in sub-Saharan Africa was high. Both individual and community level factors were associated with both unmet need for spacing and limiting. Therefore, it is better to consider interventions at both individual and community levels.

Effect of Women's and Partners' Education on Maternal Health-care Services Utilization in Five Empowered Action Group States of India: An analysis of 13,443 Women of Reproductive Age

Background

Suboptimal utilization of maternal health-care services is a perennial problem in Empowered Action Group (EAG) states. This study examines role of women's and partners' education on usage of antenatal, postnatal care (PNC), and skilled birth attendance in these states.

Methodology

National Family Health Survey-4 (2015-2016) data for 13,443 women in reproductive age group of 15-49 years in Bihar, Madhya Pradesh (MP), Odisha, Rajasthan, and Uttar Pradesh (UP) were analyzed using logistic regression.

Results

Increasing level of education had a significant impact on utilization of antenatal services in all states, highest and lowest odds being observed with higher and primary level of partner's education, respectively. Skilled birth attendance universally showed rising trend with increasing women education, while it remained substantially low even at higher level of partner's education. For PNC, utilization increased with increasing level of maternal education. While significantly lower odds of PNC were seen with primary level of partner education in Rajasthan and UP, partner's secondary education showed positive and significant association in Bihar, Rajasthan, and UP. At higher level of partner education, positive and significant effects on PNC were observed only in Bihar, MP, and UP.

Conclusions

Universal education is vital to attain sustainable development goals at the grassroot level, which is happening relatively slowly in the EAG states.

Pooled prevalence and associated factors of health facility delivery in East Africa: Mixed-effect logistic regression analysis

Background

Many mothers still give birth outside a health facility in Sub-Saharan Africa particularly in East African countries. Though there are studies on the prevalence and associated factors of health facility delivery, as to our search of literature there is limited evidence on the pooled prevalence and associated factors of health facility delivery in East Africa. This study aims to examine the pooled prevalence and associated factors of health facility delivery in East Africa based on evidence from Demographic and Health Surveys.

Methods

A secondary data analysis was conducted based on the most recent Demographic and Health Surveys (DHSs) conducted in the 12 East African countries. A total weighted sample of 141,483 reproductive-age women who gave birth within five years preceding the survey was included. All analyses presented in this paper were weighted for the sampling probabilities and non-response using sampling weight (V005), primary sampling unit (V023), and strata (V021). The analysis was done using STATA version 14 statistical software, and the pooled prevalence of health facility delivery with a 95% Confidence Interval (CI) was presented using a forest plot. For associated factors, the Generalized Linear Mixed Model (GLMM) was fitted to consider the hierarchical nature of the DHS data. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), and Likelihood Ratio (LR)-test were done to assess the presence of a significant clustering effect. Besides, deviance (-2LLR) was used for model comparison since the models were nested models. Variables with a p-value of less than 0.2 in the bivariable mixed-effect binary logistic regression analysis were considered for the multivariable analysis. In the multivariable mixed-effect analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the strength and significance of the association between the independent variable and health facility delivery.

Results

The proportion of health facility delivery in East Africa was 87.49% [95% CI: 87.34%, 87.64%], ranged from 29% in Ethiopia to 97% in Mozambique. In the Mixed-effect logistic regression model; country, urban residence [AOR = 2.08, 95% CI: 1.96, 2.17], primary women education [AOR = 1.61, 95% CI: 1.55, 1.67], secondary education and higher [AOR = 2.96, 95% CI: 2.79, 3.13], primary husband education [AOR = 1.19, 95% CI: 1.14, 1.24], secondary husband education [AOR = 1.38, 95% CI: 1.31, 1.45], being in union [AOR = 1.23, 95% CI: 1.18, 1.27], having occupation [AOR = 1.11, 95% CI: 1.07, 1.15], being rich [AOR = 1.36, 95% CI: 1.30, 1.41], and middle [AOR = 2.14, 95% CI: 2.04, 2.23], health care access problem [AOR = 0.76, 95% CI: 0.74, 0.79], having ANC visit [AOR = 1.54, 95% CI: 1.49, 1.59], parity [AOR = 0.56, 95% CI: 0.55, 0.61], multiple gestation [AOR = 1.83, 95% CI: 1.67, 2.01] and wanted pregnancy [AOR = 1.19, 95% CI: 1.13, 1.25] were significantly associated with health facility delivery.

Conclusion

This study showed that the proportion of health facility delivery in East African countries is low. Thus, improved access and utilization of antenatal care can be an effective strategy to increase health facility deliveries. Moreover, encouraging women through education is recommended to increase health facility delivery service utilization.

Factors associated with home births in Peru 2015-2017: A cross-sectional population-based study

Background

Higher rates of maternal complications and deaths have been described in home births. However, few local studies have evaluated factors associated with home births in Peru. The study aims to determine the prevalence and factors associated with home birth in the Peruvian population.

Methods

A population-based analytical cross-sectional study was conducted using pooled data from the 2015–2017 Peruvian Demographic and Health Surveys. A logistic regression model was performed to calculate crude and adjusted odds ratios (aOR) for the association between sociodemographic and mother-related factors and home births.

Results

Seven out of every 100 births were home births. Living in a rural area (aOR = 3.10; 95% CI: 2.52–3.81), having a primary or secondary educational level, belonging to a medium or low wealth tertile, being from the rest of the Coast, Andean or Amazon regions, the second or greater number of birth order and considering the distance to the health center as problematic (aOR: 1.32; 95% CI: 1.17–1.48) were found to be associated with a higher probability of home births. Contrarily, being in the age groups of 25–34 and 35–39 years old, having a multiple pregnancy and giving birth to a medium (aOR: 0.88; 95% CI: 0.78–1.00) or large-sized newborn (aOR = 0.81; 95% CI: 0.72–0.93) were associated with a lower probability of presenting home births.

Conclusions

Sociodemographic factors are associated with home births in Peru. Further study of these factors is required to develop strategies specific to the needs of the population of childbearing age.

Exploring health care professionals' and women's perspectives on the barriers to maternal health services: a qualitative study in Eku Town of Delta State, Nigeria

Uptake of maternal health services (MHS) have been shown to improve maternal health outcomes. In Nigeria, the maternal outcomes are classified among the poorest worldwide, despite the provision of free MHS to all pregnant women by many Nigerian state governments. The work was aimed at exploring the barriers to the uptake of MHS, from the perspectives of both women and health care professionals (HCP) in Eku Town of Delta State Nigeria, in order to gain a better understanding on views of MHS, and to guide future interventions, effective programs and policy strategies. Using an interpretivist and social constructivist epistemology approach, a qualitative study using 13 in-depth interviews were conducted. Seven women and six HCPs were recruited using purposive and snowballing sampling methods. Thematic content analysis was applied to the data. Three themes emerged. (1) Perspectives to free MHS. The majority of women preferred non-skilled Traditional Birth Attendants (TBAs) over the hospital heath service, as TBAs were viewed as more caring; with orthodox practice not being socially, culturally and religiously friendly. (2) Barriers to utilization: HCPs saw the barriers to hospital MHS as misconceptions by the women; the women mentioned the negative attitude of the HCPs and deficits in the free MHS scheme. (3) Enhancing utilization: HCPs stated that improved uptake of MHS required synergy between the community, government/hospital management through awareness, cultural/religious sensitivity, and HCP/TBA training. For the women, a change of HCPs hostile attitude and provision of more conducive hospital environment was required. There are a number of supply and demand factors that influence HCPs and women's perspectives of the uptake of MHS. Interventions and policies need to address both factors with the aim of improving the access and uptake of MHS in Nigeria.

Depends Who's Asking: Interviewer Effects in Demographic and Health Surveys Abortion Data

Responses to survey questions about abortion are affected by a wide range of factors, including stigma, fear, and cultural norms. However, we know little about how interviewers might affect responses to survey questions on abortion. The aim of this study is to assess how interviewers affect the probability of women reporting abortions in nationally representative household surveys: Demographic and Health Surveys (DHS). We use cross-classified random intercepts at the level of the interviewer and the sampling cluster in a Bayesian framework to analyze the impact of interviewers on the probability of reporting abortions in 22 DHS conducted worldwide. Household surveys are the only available data we can use to study the determinants and pathways of abortion in detail and in a representative manner. Our analyses are motivated by improving our understanding of the reliability of these data. Results show an interviewer effect accounting for between 0.2% and 50% of the variance in the odds of a woman reporting ever having had an abortion, after women's demographic characteristics are controlled for. In contrast, sampling cluster effects are much lower in magnitude. Our findings suggest the need for additional effort in assessing the causes of abortion underreporting in household surveys, including interviewers' skills and characteristics. This study also has important implications for improving the collection of other sensitive demographic data (e.g., gender-based violence and sexual health). Data quality of responses to sensitive questions could be improved with more attention to interviewers-their recruitment, training, and characteristics. Future analyses will need to account for the role of interviewer to more fully understand possible data biases.

Intimate partner violence, contextual factors and under-5 mortality: a multilevel analysis of cross-sectional surveys from 20 Sub-Saharan African countries

BACKGROUND

Under-5 mortality remains a public health concern in low-income and middle-income countries. Africa contributes about one-fifth of the burden of global under-5 mortality; intimate partner violence (IPV) and polygyny, which are highly prevalent on the continent, have been linked to under-5 mortality at the individual level. This study examined the relationship between IPV and polygyny as contextual factors and the experience of under-5 mortality among women in Sub-Saharan Africa (SSA).

METHODS

We used data from the Demographic and Health Surveys (DHS) of 20 African countries with available data between 2010 and 2018 as of April 2020. We defined the experience of under-5 mortality as a woman's loss of at least one child before their fifth birthday. The DHS primary sampling unit was used to define contextual factors. The study involved a multilevel logistic regression analysis of 227 121 women of childbearing age (15-49).

RESULTS

A quarter (24.5%) of women have lost at least one child under 5 years old, more than two-thirds (40.1%) have experienced at least one form of IPV, and about two-thirds of women were in polygynous union. Our multilevel logistic regression showed that parity, polygynous union and experience of IPV were strongly associated with women's experience of under-5 mortality. The results showed that 39.9% and 19.2% of variances in odds of a woman losing a child before their fifth birthday are attributable to community-level and country-level factors, respectively. Contextual prevalence of IPV, polygynous union and gender equity attenuate the strength of associations observed at the individual level. The interaction between contextual prevalence of polygyny and IPV exacerbates the risk of under-5 mortality. Women in SSA countries with higher Human Development Index were less likely to experience under-5 mortality.

CONCLUSION

This study established that beyond individual-level effects, contextual prevalence of IPV and polygyny and their interactions shape women's experience of under-5 mortality in Africa. In designing policies and interventions to address under-5 mortality, contextual factors, especially those linked to culturally laden social norms and practices, must be considered to ensure effectiveness and sustainable impact.

Socio-cultural factors influencing the decision of women to seek care during pregnancy and delivery: A qualitative study in South Tongu District, Ghana

Many low-income countries still encounter high mortality rates. The use of maternal health care services is known to be a key intervention in reducing maternal death. Despite investment in the healthcare sector, in 2015 Ghana did not meet the Millennium Development Goal 5 of reducing maternal mortality (MM). The Volta Region registered the highest rate of MM, the lowest percentage of antenatal care (ANC) coverage and the lowest percentage of skilled delivery. This is a qualitative study that used focus group discussions and key-informant interviews to explore the views on pregnancy among rural communities in the Volta Region, identify the barriers in accessing ANC and skilled attendance birth and collect views on how to improve the access to maternal care services.Overall, the study argues that members of the community of the rural villages acknowledge the benefits of ANC and skilled delivery, and the potential risk related to home delivery. However, pregnant women in the Volta Region still encounter different kinds of obstacles that prevent them from seeking maternal health care. These obstacles are driven by social and economic constraints, and by the fact that women may still lack voice in the decision-making process, and by low males' participation.

Women's autonomy in healthcare decision-making and healthcare seeking behaviour for childhood illness in Ghana: Analysis of data from the 2014 Ghana Demographic and Health Survey

INTRODUCTION

The capacity of women to decide on their healthcare plays a key role in their health. In this study, we examined the association between women's healthcare decision-making capacity and their healthcare seeking behaviour for childhood illnesses in Ghana.

MATERIALS AND METHODS

We used data from the 2014 Ghana Demographic and Health Survey. A total sample of 2,900 women with children less than 5 years was used for the analysis. Data were processed and analysed using STATA version 14.0. Chi-square test of independence and binary logistic regression were carried out to generate the results. Statistical significance was pegged at 95% confidence intervals (CIs). We relied on the 'Strengthening the Reporting of Observational Studies in Epidemiology' (STROBE) statement in writing the manuscript.

RESULTS

Out of the 2,900 women, approximately 25.7% could take healthcare decisions alone and 89.7% sought healthcare for childhood illnesses. Women who decided alone on personal healthcare had 30% reduced odds of seeking healthcare for childhood illnesses compared to those who did not decide alone [AOR = 0.70, CI = 0.51-0.97]. With age, women aged 45-49 had 69% reduced odds of seeking healthcare for childhood illnesses compared to those aged 25-29 [AOR = 0.31, CI = 0.14-0.70]. Women from the Northern and Upper West regions had 72% [AOR: 0.28, CI: 0.11-0.70] and 77% [AOR: 0.23, CI: 0.09-0.58] reduced odds of seeking healthcare for childhood illnesses respectively, compared to those from the Western region.

CONCLUSION

Ghanaian women with autonomy in healthcare decision-making, those who were older and those from the Northern and Upper West regions were less likely to seek healthcare for childhood illness. To reduce childhood mortalities and morbidities in Ghana, we recommend educating women such as those who take healthcare decisions alone, older women and women from deprived regions like the Northern and Upper West regions on the need to seek healthcare for childhood illnesses.

Examining Individual- and Community-Level Factors Affecting Skilled Delivery Care among Women Who Received Adequate Antenatal Care in Ethiopia: Using Multilevel Analysis

Introduction

Maternal mortality continues to be a major public health and development challenge in Africa even after the permissible commitment of the international community. Although the use of skilled delivery care is the key intervention and is effective to lower maternal mortality rates, it is still at a lower proportion. The study is aimed at investigating the individual- and community level factors affecting the use of skilled delivery care among those women who had received adequate antenatal care.

Materials and Methods

Data were extracted from the 2016 Ethiopian Demographic and Health Survey on women aged 15-49 years and gave birth within five years prior to the survey (N = 957). Multilevel logistic regression model with two levels were fitted to assess the influence of the individual- and community-level factors on the use of skilled delivery care.

Results

Women who were exposed to media were more likely to use skilled delivery care (OR = 1.81; 95% CI: 1.20-2.74). Having six or more birth order (OR = 0.33; 95% CI: 0.16-0.69) and residing in rural areas (OR = 0.40; 95% CI: 0.21-0.79) were associated with less likelihood use of skilled delivery care. Attaining primary and secondary educational level, being older women, being from the richest household, and having a urine test during antenatal visits were significantly associated with the use of skilled delivery care. The value of intraclass correlation coefficient supported a significant community-level effect on the likelihood of using skilled delivery care.

Conclusions

Factors operating both at the individual level and community level were found significantly associated with the use of skilled delivery care in Ethiopia. A considerable variation at community level accounts for the difference in the use of skilled delivery level.

Exploring spatial variations and factors associated with skilled birth attendant delivery in Ethiopia: geographically weighted regression and multilevel analysis

BACKGROUND

Skilled birth attendant (SBA) delivery is vital for the health of mothers and newborns, as most maternal and newborn deaths occur at the time of childbirth or immediately after birth. This problem becomes worsen in Ethiopia in which only 28% of women give birth with the help of SBA. Therefore, this study aimed to explore the spatial variations of SBA delivery and its associated factors in Ethiopia.

METHODS

A secondary analysis was carried out using the 2016 Ethiopian Demographic and Health Survey. A total weighted sample of 11,023 women who had a live birth in the 5 years preceding the survey was included in the analysis. Arc-GIS software was used to explore the spatial distribution of SBA and a Bernoulli model was fitted using SaTScan software to identify significant clusters of non-SBA delivery. The Geographic Weighted Regression (GWR) was employed in modeling spatial relationships. Moreover, a multilevel binary logistic regression model was fitted to identify factors associated with SBA delivery.

RESULTS

In this study, SBA delivery had spatial variations across the country. The SaTScan spatial analysis identified the primary clusters' spatial window in southeastern Oromia and almost the entire Somalia. The GWR analysis identified different predictors of non- SBA delivery across regions of Ethiopia. In the multilevel analysis, mothers having primary and above educational status, health insurance coverage, and mothers from households with higher wealth status had higher odds of SBA delivery. Being multi and grand multiparous, perception of distance from the health facility as big problem, rural residence, women residing in communities with medium and higher poverty level, and women residing in communities with higher childcare burden had lower odds of SBA delivery.

CONCLUSION

Skilled birth attendant delivery had spatial variations across the country. Areas with non-skilled birth attendant delivery and mothers who had no formal education, not health insured, mothers from poor households and communities, Primiparous women, mothers from remote areas, and mothers from communities with higher childcare burden could get special attention in terms of allocation of resources including skilled human power, and improved access to health facilities.

Public health interventions to improve maternal nutrition during pregnancy: a nationally representative study of iron and folic acid consumption and food supplements in India

OBJECTIVE

Despite a reduction in maternal mortality in recent years, a high rate of anaemia and other nutrient inadequacies during pregnancy pose a serious threat to mothers and their children in the Global South. Using the framework of the WHO-Commission on Social Determinants of Health, this study examines the socioeconomic, programmatic and contextual factors associated with the consumption of iron and folic acid (IFA) tablets/syrup for at least 100 d (IFA100) and receiving supplementary food (SF) by pregnant women in India.

DESIGN

We analysed a nationally representative cross-sectional survey of over 190 898 ever-married women aged 15-49 years who were interviewed as part of the National Family Health Survey (NFHS) conducted during 2015-16, who had at least one live birth preceding 5 years of the survey.

SETTING

All twenty-nine states and seven union territories of India.

PARTICIPANTS

Ever-married women aged 15-49 years.

RESULTS

Less than one-third of women were found to be consuming IFA100, and a little over half received SF during their last pregnancy. The consumption of IFA100 was likely to improve with women's education, household wealth, early and more prenatal visits, and in a community with high pregnancy registration. Higher parity, early and more prenatal visits, contact with community health workers during pregnancy, belonging to a poor household and living in an aggregated poor community and rural area positively determine whether a woman might receive SF during pregnancy.

CONCLUSIONS

Continuous monitoring and evaluation of provisioning IFA and SF in targeted groups and communities is a key to expanding the coverage and reducing the burden of undernutrition during pregnancy.

Community-level factors associated with the use of facility-based delivery assistance in Uganda: a multilevel analysis

BACKGROUND

In low- and middle-income countries, the proportion of pregnant women who use health facilities for delivery remains low. Although delivering in a health facility with skilled health providers can make the critical difference between survival and death for both mother and child, in 2016, more than 25% of pregnant women did not deliver in a health facility in Uganda. This study examines the association of contextual factors measured at the community-level with use of facility-based delivery in Uganda, after controlling for household and individual-level factors.

METHODS

Pooled household level data of 3310 observations of women who gave birth in the last five years is linked to community level data from the Uganda National Panel Survey (UNPS). A multilevel model that adequately accounted for the clustered nature of the data and the binary outcome of whether or not the woman delivered in a health facility was estimated.

RESULTS

The study findings show a positive association at the county level between place of delivery, education and access to health services, and a negative association between place of delivery and poverty. Individuals living in communities with a high level of education amongst the household heads were 1.67 times (95% Confidence Interval: 1.07-2.61) more likely to have had a facility-based delivery compared to women living in communities where household heads did not have high levels of education. Women who lived in counties with a short travel time (less than 33 min) were 1.66 times (95% CI: 1.11-2.48) more likely to have had a facility-based delivery compared to women who lived in counties with longer travel time to any health facility. Women living in poor counties were only 0.64 times (95% CI: 0.42-0.97) as likely to have delivered in a health facility compared to pregnant women from communities with more affluent individuals.

CONCLUSIONS

The findings on household head's education, community economic status and travel time to a health facility are useful for defining the attributes for targeting and developing relevant nation-wide community-level health promotion campaigns. However, limited evidence was found in broad support of the role of community level factors.

"I couldn't buy the items so I didn't go to deliver at the health facility" Home delivery among rural women in northern Ghana: A mixed-method analysis

Background

Maternal mortality remains a major challenge to health systems in low and middle-incoming countries. Some pregnant women develop potentially life-threatening complications during childbirth. Therefore, home delivery is a precursor for maternal mortality. In this study, we aimed at not only estimating the percentage of deliveries occurring at home and examining the factors associated with home delivery, but we also explored the reasons for home delivery among women in rural Ghana.

Methods

The study was conducted among mothers with delivery experience in selected communities in the Builsa South district located in the Upper East Region of Ghana. Both quantitative and qualitative data were collected using semi-structured questionnaires and Focus Group Discussion (FGD) guide respectively. A total of 456 mothers participated in this study. Regression models were used in the quantitative analysis whereas a thematic analysis approach was used to analyze the qualitative data.

Results

Of the 423 mothers in the quantitative research, 38.1% (95% CI: 33.5–42.8) delivered their index child at home. In adjusted analysis, women who were not exposed to information (AOR = 13.64, p<0.001) and women with 2 (AOR = 4.64, p = 0.014), 3 (AOR = 4.96, p = 0.025) or at least 4 living children (AOR = 9.59, p = 0.001) had higher odds of delivering at home. From the qualitative analysis, the poor attitude of nurses (midwives), lack of, and cost of transportation, cost of delivery kits, and traditional beliefs and practices were cited as reasons for home delivery.

Conclusion

Despite the government’s efforts to provide free maternal care services to women in Ghana, a significant proportion of rural women still deliver at home due to other ‘hidden costs’. Addressing poor staff attitude, transportation challenges, and negative traditional beliefs and practices through awareness creation may contribute to improving health facility delivery by rural pregnant women in Ghana.

Persistence of the inverse care law in maternal health service utilization: An examination of antenatal care and hospital delivery in Ghana

The gap in maternal health outcomes, access and utilization between the haves and have-nots continues to be a challenge globally despite improvements over the past decade. Though Ghana has experienced steady gains in maternal health access and utilization over the years, maternal outcomes, on the other hand, remain poor. In this regard, it is essential to know how various groups in the population achieved improvements and whether some women continue to be disproportionately disadvantaged. The paper performs an analysis of cross-sectional data from the 2017 Ghana maternal health survey to examine the existence of the inverse care law in maternal health services in Ghana. Using descriptive techniques and multivariate logistic regression models the study reveals a pro-rich and pro-urban gradient in the use of hospital facilities for delivery and antenatal care attendance — also, regions known for their high levels of poverty feature significantly lower rates of hospital deliveries. The paper concludes by stressing that unless policies are changed to accommodate these groups, overall gains in maternal health will continue to be incremental.

Effectiveness of upgraded maternity waiting homes and local leader training in improving institutional births among women in the Jimma zone, Ethiopia: study protocol for a cluster-randomized controlled trial

Background

Ethiopia is one of the ten countries in the world that together account for almost 60% of all maternal deaths. Recent reductions in maternal mortality have been seen, yet just 26% of women who gave birth in Ethiopia in 2016 reported doing so at a health facility. Maternity waiting homes (MWHs) have been introduced to overcome geographical and financial barriers to institutional births but there is no conclusive evidence as to their effectiveness. We aim to evaluate the effects of upgraded MWHs and local leader training in increasing institutional births in the Jimma zone of Ethiopia.

Methods

A parallel, three-arm, stratified, cluster-randomized controlled trial design is being employed to evaluate intervention effects on institutional births, which is the primary outcome. Trial arms are: (1) upgraded MWH + religious/community leader training; (2) leader training alone; and (3) standard care. Twenty-four primary health care unit catchment areas (clusters) have been randomized and 3840 women of reproductive age who had a pregnancy outcome (livebirth, stillbirth or abortion) are being randomly recruited for each survey round. Outcome assessments will be made using repeat cross-sectional surveys at baseline and 24 months postintervention. An intention to treat approach will be used and the primary outcome analysed using generalized linear mixed models with a random effect for cluster and time. A cost-effectiveness analysis will also be conducted from a societal perspective.

Discussion

This is one of the first trials to evaluate the effectiveness of upgraded MWHs and will provide much needed evidence to policy makers about aspects of functionality and the community engagement required as they scale-up this programme in Ethiopia.

Trial registration

ClinicalTrial.gov, NCT03299491. Retrospectively registered on 3 October 2017.

Associated factors and their individual contributions to caesarean delivery among married women in Bangladesh: analysis of Bangladesh demographic and health survey data

Background

Caesarean section (CS) delivery has a significant effect on maternal and neonatal health especially in a developing country like Bangladesh. The aim of the study was to determine the risk factors and their individual contribution to CS delivery among Bangladeshi married women in reproductive age.

Methods

The cross sectional secondary data was used in this study. Data was extracted from Bangladesh Demographic and Health Survey (BDHS), 2014 dataset. BDHS-2014 collected data from all over Bangladesh. Stepwise logistic regression analysis and population attributable fractions (PAF) were utilized in this study.

Results

A total number of 4422 married Bangladeshi women having at least one child (age ≤ 5 years) were considered in this study. The prevalence of CS delivery among Bangladeshi women was 23.94%. The stepwise logistic regression model showed that location (division), type of residence, education of respondent and her husband, working status, age at first birth, number of children, wealth index and baby’s birth weight were most important predictors of CS delivery among Bangladeshi mothers. PAF demonstrated that overweight or obese women had highest contribution (23.36%) among the risk factors of CS delivery, followed by age at first birth (age >  20 years) (18.97%), highest wealth quintile (17.39%), higher education (15.93%), living in urban environment (14.39%), having lower number of ever born children (1–2 children) (13.58%), living in Dhaka division (12.11%), delivering large size of child at birth (11.13%) and housewife (6.55%).

Conclusions

In the present study, we have identified the important risk factors and their individual contribution to CS delivery in Bangladesh. Consequently, these factors can be considered for reducing the rate of CS delivery in Bangladesh.

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.

Socioeconomic determinants of chronic health diseases among older Indian adults: a nationally representative cross-sectional multilevel study

OBJECTIVE

Study uses multilevel modelling to examine the effect of individual, household and contextual characteristics on chronic diseases among older Indian adults.

DESIGN

Nationally representative cross-sectional study.

PARTICIPANTS

Data from the nationally representative, India Human Development Survey conducted in 2011-2012 was used in this study. The survey asked information related to the diagnosed chronic illnesses such as cataract, tuberculosis, hypertension, heart disease and others. The sample size of this study comprised 39 493 individuals who belonged to the age group 50 years and above.

MEASURES

Self-reported diagnosed chronic illness.

METHOD

Considering the hierarchal structure of the data multilevel logistic regression analysis was applied to attain the study objective.

RESULTS

Older adults aged 80 years and older were found with three times more chances (OR: 3.99, 95% CI 2.91 to 5.48) of suffering from a chronic ailment than 50-54 years old. Lifestyle risk factors such as alcohol and tobacco (smoked and smokeless) consumption were noted to be significantly associated with the presence of chronic illness whereas older adults who have never consumed smokeless tobacco stood 20% fewer chances (OR: 0.80, 95% CI 0.68 to 0.94) of having any chronic illness. Contextual level variables such as older adults residing in the rural areas were found with 17% fewer chances (OR: 0.83, 95% CI 0.70 to 0.97) of suffering from a chronic illness.

CONCLUSION

Even after controlling for various characteristics at the individual, household and contextual levels, significant variations in chronic illness remain unexplained at the community and state level, respectively. The findings of this study could effectively be utilised to consider more contextual variables to examine the chronic health status among the growing older population of India.

Factors associated with maternity waiting home use among women in Jimma Zone, Ethiopia: a multilevel cross-sectional analysis

OBJECTIVE

To identify individual-, household- and community-level factors associated with maternity waiting home (MWH) use in Ethiopia.

DESIGN

Cross-sectional analysis of baseline household survey data from an ongoing cluster-randomised controlled trial using multilevel analyses.

SETTING

Twenty-four rural primary care facility catchment areas in Jimma Zone, Ethiopia.

PARTICIPANTS

3784 women who had a pregnancy outcome (live birth, stillbirth, spontaneous/induced abortion) 12 months prior to September 2016.

OUTCOME MEASURE

The primary outcome was self-reported MWH use for any pregnancy; hypothesised factors associated with MWH use included woman's education, woman's occupation, household wealth, involvement in health-related decision-making, companion support, travel time to health facility and community-levels of institutional births.

RESULTS

Overall, 7% of women reported past MWH use. Housewives (OR: 1.74, 95% CI 1.20 to 2.52), women with companions for facility visits (OR: 2.15, 95% CI 1.44 to 3.23), wealthier households (fourth vs first quintile OR: 3.20, 95% CI 1.93 to 5.33) and those with no health facility nearby or living >30 min from a health facility (OR: 2.37, 95% CI 1.80 to 3.13) had significantly higher odds of MWH use. Education, decision-making autonomy and community-level institutional births were not significantly associated with MWH use.

CONCLUSIONS

Utilisation inequities exist; women with less wealth and companion support experienced more difficulties in accessing MWHs. Short duration of stay and failure to consider MWH as part of birth preparedness planning suggests local referral and promotion practices need investigation to ensure that women who would benefit the most are linked to MWH services.

Measuring and explaining changing patterns of inequality in institutional deliveries between urban and rural women in Ghana: a decomposition analysis

Background

Despite recent progress in improving access to maternal health services, the utilization of these services remains inequitable among women in developing countries, and rural women are particularly disadvantaged. This study sought to measure i) disparities in the rates of institutional births between rural and urban women in Ghana, ii) the extent to which existing disparities are due to differences in the distribution of the determinants of institutional delivery between rural and urban women, and iii) the extent to which existing disparities are due to discrimination in resource availability.

Methods

Using Demographic and Health Survey data from 2003, 2008, and 2014, this study decomposed inequalities in institutional delivery rates among urban and rural Ghanaian woman using the Oaxaca, the Blinder, and related decompositions for non-linear models. The determinants of the observed inequalities were also analyzed.

Results

Institutional delivery rates in urban areas exceeded those of rural areas by 32.4 percentage points due to differences in distribution of the determinants of institutional delivery between the two areas. The main determinants driving the observed disparities were wealth, which contributed to about 16.1% of the gap, followed by education level, and number of antenatal visits.

Conclusion

Relative to urban women, rural women have lower rates of institutional deliveries due primarily to lower levels of wealth, which results in financial barriers in accessing maternal health services. Economic empowerment of rural women is crucial in order to close the gap in institutional delivery between urban and rural women.

Time trends in facility-based and private-sector childbirth care: analysis of Demographic and Health Surveys from 25 sub-Saharan African countries from 2000 to 2016

Background

Africa, and sub-Saharan Africa in particular, remains one of the regions with modest improvements to maternal and newborn survival and morbidity. Good quality intrapartum and early postpartum care in a health facility as well as delivery under the supervision of trained personnel is associated with improved maternal and newborn health outcomes and decreased mortality. We describe and contrast recent time trends in the scale and socio-economic inequalities in facility-based and private facility-based childbirth in sub-Saharan Africa.

Methods

We used Demographic and Health Surveys in two time periods (2000-2007 and 2008-2016) to analyse levels and time trends in facility-based and private facility-based deliveries for all live births in the five-year survey recall period to women aged 15-49. Household wealth quintiles were used for equity analysis. Absolute numbers of births by facility sector were calculated applying UN Population Division crude birth rates to the total country population.

Results

The percentage of all live births occurring in health facilities varied across countries (5%-85%) in 2000-2007. In 2008-2016, this ranged from 22% to 92%. The lowest percentage of all births occurring in private facilities in 2000-2007 period was in Ethiopia (0.3%) and the highest in the Democratic Republic of Congo at 20.5%. By 2008-2016, this ranged from 0.6% in Niger to 22.3% in Gabon. Overall, the growth in the absolute numbers of births in facilities outpaced the growth in the percentage of births in facilities. The largest increases in absolute numbers of births occurred in public sector facilities in all countries. Overall, the percentage of births occurring in facilities was significantly lower for poorest compared to wealthiest women. As the percentage of facility births increased in all countries over time, the extent of wealth-based differences had reduced between the two time periods in most countries (median risk ratio in 2008-2016 was 2.02). The majority of countries saw a narrowing in both the absolute and relative difference in facility-based deliveries between poorest and wealthiest.

Conclusions

The growth in facility-based deliveries, which was largely driven by the public sector, calls for increased investments in effective interventions to improve service delivery and quality of life for the mother and newborn. The goal of universal health coverage to provide better quality services can be achieved by deploying interventions that are holistic in managing and regulating the private sector to enhance performance of the health care system in its entirety rather than interventions that only target service delivery in one sector.

Regional variations in the use of postnatal care in Nigeria: a spatial analysis

Maternal health outcomes vary considerably in Nigeria, with maternal mortality ratio ranging from 165 per 100,000 live births in the South-west to 1549 per 100,000 live births in the North-east. One important maternal health indicator is an adequate use of postnatal care (PNC); however, the evidence is sparse on its spatial distribution across regions in Nigeria. This paper thus examined the spatial distribution of uptake of postnatal care in Nigeria using data from the 2013 Nigeria Demographic and Health Survey, with a sample of 12,127 women aged 15-49 years. The Bayesian-structured additive regression of the logit model was used to examine the spatial relationships. The results revealed a north-south divide in the use of postnatal care, with higher PNC uptake established in the latter. Interestingly, results showed significant intra-region residual spatial variations with higher PNC use in Yobe and Bauchi in North-east Nigeria compared to other states within the region. The findings indicate the need for policymakers to develop state- and region-specific health policy and intervention programs to address the inequity in postnatal care coverage and usage across regions in Nigeria.

Factors influencing the use of supervised delivery services in Garu-Tempane District, Ghana

Background

There is evidence that supervised delivery has the potential to improve birth outcomes for both women and newborns. However, not all women especially in low-income settings like Ghana use supervised delivery services during childbirth. The purpose of this study was to estimate the prevalence of supervised delivery and determine factors that influence use of supervised delivery services in a local district of Ghana.

Methods

A retrospective cross-sectional survey of 322 randomly sampled postpartum women who delivered between January and December 2016 in the Garu-Tempane District was conducted. Structured questionnaires were used to collect data. Descriptive, binary and multivariate logistic regression analysis techniques were used to analyse data.

Results

Although antenatal care attendance among respondents was very high 291(90.4%), prevalence of supervised birth was only 219(68%). More than a quarter 103(32%) of the postpartum women delivered their babies at home without skilled birth attendants. After controlling for possible confounders in multivariable logistic regression analyses, factors that strongly independently predicted supervised delivery were religion (p < 0.01), distance to health facility (p < 0.05), making at least 4 antenatal care visits (p < 0.01), national health insurance scheme registration (p < 0.01), satisfaction with services received during antenatal care (p < 0.01), need partner’s approval before delivering in health facility (p < 0.01), woman’s thoughts that her religious beliefs prohibited health facility delivery(p < 0.01), and woman’s belief that there are norms in her community that did not support health facility delivery (p < 0.01).

Conclusion

There is need for targeted interventions, including community mobilization and health education, and male partner involvement to help generate local demand for, and uptake of, supervised delivery services. Improvement in the quality of services in health facilities, including ensuring respect and dignity for service users, would also be essential.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2295-6) contains supplementary material, which is available to authorized users.

Latent class analysis of the social determinants of health-seeking behaviour for delivery among pregnant women in Malawi

INTRODUCTION

In the era of Sustainable Development Goals, reducing maternal and neonatal mortality is a priority. With one of the highest maternal mortality ratios in the world, Malawi has a significant opportunity for improvement. One effort to improve maternal outcomes involves increasing access to high-quality health facilities for delivery. This study aimed to determine the role that quality plays in women's choice of delivery facility.

METHODS

A revealed-preference latent class analysis was performed with data from 6625 facility births among women in Malawi from 2013 to 2014. Responses were weighted for national representativeness, and model structure and class number were selected using the Bayesian information criterion.

RESULTS

Two classes of preferences exist for pregnant women in Malawi. Most of the population 65.85% (95% CI 65.847% to 65.853%) prefer closer facilities that do not charge fees. The remaining third (34.15%, 95% CI 34.147% to 34.153%) prefers central hospitals, facilities with higher basic obstetric readiness scores and locations further from home. Women in this class are more likely to be older, literate, educated and wealthier than the majority of women.

CONCLUSION

For only one-third of pregnant Malawian women, structural quality of care, as measured by basic obstetric readiness score, factored into their choice of facility for delivery. Most women instead prioritise closer care and care without fees. Interventions designed to increase access to high-quality care in Malawi will need to take education, distance, fees and facility type into account, as structural quality alone is not predictive of facility type selection in this population.

Death of preceding child and maternal healthcare services utilisation in Nigeria: investigation using lagged logit models

BACKGROUND

One of the factors responsible for high level of childhood mortality in Nigeria is poor utilization of maternal healthcare (MHC) services. Another important perspective which has been rarely explored is the influence of childhood death on MHC service utilization. In this study, we examined the relationship between death of preceding child and MHC services utilization [antenatal care (ANC), skilled attendant at birth (SAB), and postnatal care (PNC)] among Nigerian women and across the six geo-political zones of the country.

METHODOLOGY

We analyzed reproductive history dataset for 16,747 index births extracted from the 2013 Nigeria Demographic and Health Survey. The main explanatory variable was survival status of preceding child; therefore, only second or higher order births were considered. Analysis involved the use of descriptive statistics and lagged logit models fitted for each measure of MHC utilization. Association and statistical significance were expressed as adjusted odds ratio (AOR) with 95% confidence interval.

RESULTS

The use of MCH services for most recent births in the 2013 Nigeria DHS were ANC (56.0%), SAB (34.7%), and PNC (27.3%). Univariate models revealed that the death of preceding child was associated with lesser likelihood of ANC (OR = 0.64, CI 0.57-0.71), SAB (OR = 0.56, CI 0.50-0.63), and PNC (OR = 0.65, CI 0.55-0.69). Following adjustment for maternal socio-economic and bio-demographic variables, statistical significance in the relationship disappeared for the three MHC indicators: ANC (AOR = 1.00, CI 0.88-1.14), SAB (AOR = 0.97, CI 0.81-1.15), and PNC (AOR = 0.95, CI 0.83-1.11). There were no significant variations across the six geo-political regions in Nigeria. The likelihood of ANC utilization was higher when the preceding child died in Northcentral (AOR = 1.19, CI 0.84-1.70), Northeast (AOR = 1.26, CI 0.99-1.59), and South-south (AOR = 1.19, CI 0.72-1.99) regions while the reverse is the case in Southeast (AOR = 0.39, CI 0.23-0.60). For the Southeast, similar result was obtained for ANC, SAB, and PNC.

CONCLUSION

Death of a preceding child does not predict MHC services use in Nigeria especially when maternal socio-economic characteristics are controlled. Variations across the Northern and Southern regions did not attain statistical significance. Interventions are needed to reverse the pattern such that greater MHC utilization is recorded among women who have experienced child death.

A qualitative study of women's network social support and facility delivery in rural Ghana

Similar to many sub-Saharan African countries, maternal mortality in Ghana ranks among the highest (39th) globally. Prior research has demonstrated the impact of social network characteristics on health facility delivery in sub-Saharan Africa. However, in-depth examination of the function of all members in a woman's network, in providing various types of support for the woman's pregnancy and related care, is limited. We qualitatively explore how women's network social support influences facility delivery. Qualitative data came from a mixed methods evaluation of a Maternal and Newborn Health Referral project in Ghana. In 2015 we conducted in-depth interviews with mothers (n = 40) and husbands (n = 20), and 4 focus group interviews with mothers-in-law. Data were analyzed using narrative summaries and thematic coding procedures to first examine women's network composition during their pregnancy and childbirth experiences. We then compared those who had homebirths versus facility births on how network social support influenced their place of childbirth. Various network members were involved in providing women with social support. We found differences in how informational and instrumental support impacted women's place of childbirth. Network members of women who had facility delivery mobilized resources to support women's facility delivery. Among women who had homebirth but their network members advocated for them to have facility delivery, members delayed making arrangements for the women's facility delivery. Women who had homebirth, and their network members advocated homebirth, received support to give birth at home. Network support for women's pregnancy-related care affects their place of childbirth. Hence, maternal health interventions must develop strategies to prioritize informational and instrumental support for facility-based pregnancy and delivery care.

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.

Historical Legacies, Social Capital, and Women's Decision-Making Power: Religion and Child Nutrition in Mozambique

In sub-Saharan settings, parental religion may have important implications for children's health and well-being. Using survey data from rural Mozambique, we examine the relationship between women's religion and the likelihood of their children being chronically malnourished (stunted). Multivariate analyses show that children of religiously affiliated women are significantly less likely to be stunted than children of non-affiliated women. We also find a strong advantage of mainline Protestants, especially compared to members of Pentecostal-type denominations, net of other factors. We relate this advantage to two historically rooted characteristics of mainline Protestantism: its connections to the public health sector and higher levels of women's autonomy that it fosters.

Mothers' perceptions and experiences of using maternal health-care services in Rwanda

Reducing barriers to use maternal health care is one of the critical components to improving maternal health. Rwanda is among the countries that have made tremendous efforts to reduce maternal mortality. However, the current maternal mortality ratio is still high which calls for further efforts to be considered. This study used a qualitative approach to understand mothers' perceptions and experiences of using maternal health care in Rwanda. Using in-depth interviews and focus group discussions, data were collected in the Western and Eastern provinces of the country where forty-five women participated in the study from June to August 2014. This paper highlights perceptions of these participants regarding issues that contribute to suboptimal use of maternal health-care services. The geographical, financial, and social-cultural barriers that emerged in this study highlight the need to understand mothers' experiences and perceptions when using maternal health care as Rwanda and other countries strive to reduce negative maternal health outcomes.

Contribution of Nepal's Free Delivery Care Policies in Improving Utilisation of Maternal Health Services

BACKGROUND

Nepal has made remarkable improvements in maternal health outcomes. The implementation of demand and supply side strategies have often been attributed with the observed increase in utilization of maternal healthcare services. In 2005, Free Delivery Care (FDC) policy was implemented under the name of Maternity Incentive Scheme (MIS), with the intention of reducing transport costs associated with giving birth in a health facility. In 2009, MIS was expanded to include free delivery services. The new expanded programme was named "Aama" programme, and further provided a cash incentive for attending four or more antenatal visits. This article analysed the influence of FDC policies, individual and community level factors in the utilisation of four antenatal care (4 ANC) visits and institutional deliveries in Nepal.

METHODS

Demographic and health survey data from 1996, 2001, 2006 and 2011 were used and a multi-level analysis was employed to determine the effect of FDC policy intervention, individual and community level factors in utilisation of 4 ANC visits and institutional delivery services.

RESULTS

Multivariate analysis suggests that FDC policy had the largest effect in the utilisation of 4 ANC visits and institutional delivery compared to individual and community factors. After the implementation of MIS in 2005, women were three times (adjusted odds ratio [AOR]=3.020, P<.001) more likely to attend 4 ANC visits than when there was no FDC policy. After the implementation of Aama programme in 2009, the likelihood of attending 4 ANC visits increased six-folds (AOR=6.006, P<.001) compared prior to the implementation of FDC policy. Similarly, institutional deliveries increased two times after the implementation of the MIS (AOR=2.117, P<.001) than when there was no FDC policy. The institutional deliveries increased five-folds (AOR=5.116, P<.001) after the implementation of Aama compared to no FDC policy.

CONCLUSION

Results from this study suggest that MIS and Aama policies have had a strong positive influence on the utilisation of 4 ANC visits and institutional deliveries in Nepal. Nevertheless, results also show that FDC policies may not be sufficient in raising demand for maternal health services without adequately considering the individual and community level factors.

They receive antenatal care in health facilities, yet do not deliver there: predictors of health facility delivery by women in rural Ghana

BACKGROUND

Research has shown that use of antenatal services by pregnant women and delivery in health facilities with skilled birth attendants contribute to better delivery outcomes. However, a gap exists in Ghana between the use of antenatal care provided by health facilities and delivery in health facilities with skilled birth attendants by pregnant women. This study sought to identify the predictors of health facility delivery by women in a rural district in Ghana.

METHODS

This was a cross-sectional study conducted in June 2016. Women who delivered in the past 6 months preceding the study were interviewed. Data on socio-demographic characteristics, use of antenatal care, place of delivery and reasons for home delivery were collected from study participants. Chi-square test and multiple logistic regression analysis were used to assess an association between women's socio-demographic and obstetric characteristics and place of delivery at 95% confidence interval.

RESULTS

The study found that 98.8% of women received antenatal care services at least once during their recent pregnancy, and 67.9% attended antenatal care at least four times before delivery. However, 61.9% of the women delivered in a health facility with a skilled attendant. The frequently mentioned reason for home delivery was "unaware of onset of labour and delivery". The odds for delivery at a health facility were reduced among women with four living children [(AOR = 0.07, CI = 0.15-0.36, p = 0.001)], with no exposure to delivery care information [(AOR = 0.06, CI = 0.01-0.34, p = 0.002), who started their first ANC visit from the second trimester of pregnancy[(AOR = 0.003, CI = 0.01-0.15, p < 0.001)] and increased among women who made at least four ANC visits before delivery [(AOR = 17.53, CI = 6.89-44.61, p < 0.001)].

CONCLUSION

Findings from this study revealed a low rate of delivery at health facilities although visits to antenatal care sessions were high, an indication that there was the need to intensify health education on early initiation of antenatal care, signs of labour and delivery, and importance of health facility delivery.

Postnatal Care Utilization and Associated Factors among Married Women in Benchi-Maji Zone, Southwest Ethiopia: A Community Based Cross-Sectional Study

BACKGROUND

In Ethiopia, maternal health service utilization is very low, especially postnatal care (PNC). The percentage of mothers who receive care within two days of childbirth has shown little progress, from 2.4% in 2000 to 13% in 2014. However, it is very far below the expected level as compared to other sub-Saharan regions. Therefore, the aim of this study was to assess PNC services utilization and its associated factors among married women in Benchi-Maji Zone, Southwest Ethiopia.

METHOD

A cross-sectional study was conducted from June 15 to August 15, 2015. A total of 801 married women was sampled from randomly selected districts in the zone. Semi-structured questionnaire was used to collect, data and informed consent was obtained from participants. The collected data were entered into the computer using Epi-data version 3.0, and then exported to SPSS Windows version 20.0 for analysis. Logistic regression was used to identify important predictors of PNC utilization.

RESULT

Out of 765 participants, 392(51.24%) of married women who attended PNC in this study. Out of them, more than two-third 305(77.8%) attended mainly to immunize their baby. The vast majority, 251(86.3%), of respondents mentioned lack of information as a main reason for not following PNC, and of them, the majority mentioned that they were appointed to come after 45 days for Family Planning(FP). In comparison with house wives, farmer women were less likely (AOR 0.3, 95 % CI 0.2-0.7) to attend for PNC. Awareness of problems during postnatal period showed the strongest association in which those who knew the problems were about nine times (AOR 8.7 95 % CI 5.6-13.4) more likely to attend PNC. Similarly, married women who followed antenatal care (ANC) were more likely (AOR 2.2 95 % CI 1.1-4.6) to attend PNC in comparison with those who did not attend ANC at all.

CONCLUSION

Residence, ANC follow-up, maternal occupation, awareness about problems of postnatal period had effects on use of PNC. In light of this study, providing deep counselling about PNC at the time of ANC visit and discharge after delivery is strongly recommended. Furthermore, targeting more of rural married women may increase PNC utilization.

Effect of maternal age on facility-based delivery: analysis of first-order births in 34 countries of sub-Saharan Africa using demographic and health survey data

OBJECTIVES

Increasing access to skilled birth attendance, usually via childbirth in health facilities, is a key intervention to reduce maternal and perinatal mortality and morbidity. Yet, in some countries of sub-Saharan Africa, the uptake is <50%. Age and parity are determinants of facility-based delivery, but are strongly correlated in high fertility settings. This analysis assessed the independent effect of age on facility-based delivery by restricting to first-order births. It was hypothesised that older first-time mothers in this setting might have lower uptake of facility-based deliveries than women in the most common age groups for first birth.

SETTING

The most recent Demographic and Health Surveys from 34 sub-Saharan African countries were used to assess women's delivery locations.

PARTICIPANTS

72 772 women having their first birth in the 5 years preceding the surveys were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportions and 95% CIs of facility-based deliveries were estimated overall and by country. Multivariable logistic regression was used to calculate the odds of facility-based delivery for different maternal age groups (15-19, 20-24 and ≥25 years) for a pooled sample of all countries.

RESULTS

59.9% of women had a facility-based delivery for their first birth (95% CI 58.6 to 61.2), ranging from 19.4% in Chad to 96.6% in Rwanda. Compared with women aged 15-19 years, the adjusted odds of having a facility-based delivery for those aged 20-24 was 1.4 (95% CI 1.3 to 1.5, p<0.001) and for those aged ≥25, 1.9 (95% CI 1.6 to 2.2, p<0.001).

CONCLUSIONS

Older age at first birth was independently associated with significantly higher odds of facility-based delivery. This went against the hypothesis. Further mixed-method research is needed to explore how increased age improves uptake of facility-based delivery. Promoting facility-based delivery, while ensuring quality of care, should be prioritised to improve birth outcomes in sub-Saharan Africa.

The influence of the social and cultural environment on maternal mortality in Nigeria: Evidence from the 2013 demographic and health survey

Introduction

Reducing maternal mortality remains a priority for global health. One in five maternal deaths, globally, are from Nigeria.

Objective

This study aimed to assess the sociocultural correlates of maternal mortality in Nigeria.

Methods

We conducted a retrospective analysis of nationally representative data from the 2013 Nigeria Demographic and Health Survey. The analysis was based on responses from the core women’s questionnaire. Maternal mortality was categorized as ‘yes’ for any death while pregnant, during delivery or two months after delivery (as reported by the sibling), and ‘no’ for deaths of other or unknown causes. Multilevel logistic regression analysis was conducted to test for association between maternal mortality and predictor variables of sociocultural status (educational attainment, community women’s education, region, type of residence, religion, and women’s empowerment).

Results

Region, Religion, and the level of community women’s education were independently associated with maternal mortality. Women in the North West were more than twice as likely to report maternal mortality (OR: 2.14; 95% CI: 1.42–3.23) compared to those in the North Central region. Muslim women were 52% more likely to report maternal deaths (OR: 1.52; 95% CI: 1.10–2.11) compared to Christian women. Respondents living in communities where a significant proportion of women have at least secondary schooling were 33% less likely to report that their sisters died of pregnancy-related causes (OR: 0.67; 95% CI: 0.48–0.95).

Conclusion

Efforts to reduce maternal mortality should implement tailored programs that address barriers to health-seeking behavior influenced by cultural beliefs and attitudes, and low educational attainment. Strategies to improve women’s agency should be at the core of these programs; they are essential for reducing maternal mortality and achieving sustainable development goals towards gender equality. Future studies should develop empirically evaluated measures which assess, and further investigate the association between women’s empowerment and maternal health status and outcomes.

Women's social networks and use of facility delivery services for uncomplicated births in North West Ethiopia: a community-based case-control study

BACKGROUND

High maternal mortality has remained an unmet public health challenge in the developing world. Maternal mortality in Ethiopia is among the highest in the world. Since most maternal deaths occur during labor, delivery, and the immediate postpartum period, facility delivery with skilled birth attendants is recommended to reduce maternal mortality. Nonetheless, the majority of women in Ethiopia give birth at home. Individual attributes and availability and accessibility of services deter service utilization. The role of social networks that may facilitate or constrain service use is not well studied.

METHODS

Community-based case-control study was conducted between February and March 2014 in Jabi Tehinan District, North West Ethiopia. Retrospective data were collected from 134 women who had uncomplicated births at health facilities and 140 women who had uncomplicated births at home within a year preceding the survey. Interviews were held with eight women who had uncomplicated births at health facilities and 11 who had uncomplicated births at home. The quantitative data were entered and analyzed using SPSS for Windows versions 16.0 and hierarchical logistic regression model was used for analysis. The qualitative data were transcribed verbatim and data were used to substantiate the quantitative data.

RESULTS

The results indicated that social network variables were significantly associated with the use of health facilities for delivery. Taking social networks into account improved the explanation of facility use for delivery services over women's individual attributes. Women embedded within homogeneous network members (Adjusted OR 2.53; 95% CI: 1.26-5.06) and embedded within high SBA endorsement networks (Adjusted OR 7.97; 95% CI: 4.07-12.16) were more likely to deliver at health facilities than their counterparts. Women living in urban areas (Adjusted OR 3.32; 95% CI: 1.37-8.05) and had better knowledge of obstetric complications (Adjusted OR 3.01; 95% CI: 1.46-6.18) were more likely to deliver at health facilities.

CONCLUSION

Social networks facilitate SBA utilization by serving as a reference for the behavior to deliver at health facilities. These findings inform health professionals and other stakeholders regarding the importance of considering women's social networks in designing intervention to increase the proportion of women who deliver at health facilities.