Perceptions of Good-Quality Antenatal Care and Birthing Services among Postpartum Women in Nepal

"Can't live willingly": A thematic synthesis of qualitative evidence exploring how early marriage and early pregnancy affect experiences of pregnancy in South Asia

In South Asia, early marriage has been associated with a range of adverse outcomes during pregnancy and infancy. This may partly be explained by early marriage leading to a younger maternal age, however it remains unclear which other factors are involved. This review aimed to synthesise the qualitative evidence on experiences of pregnancy following early marriage or early pregnancy in South Asia, to inform our understanding of the mechanisms between early marriage and adverse pregnancy outcomes. We searched MEDLINE, EMBASE, Scopus, Global Index Medicus, CINAHL, PsycINFO, Web of Science, and grey literature on 29/11/2022 to identify papers on experiences of pregnancy among those who married or became pregnant early in South Asia (PROSPERO registration number: CRD42022304336, funded by an MRC doctoral training grant). Seventy-nine papers from six countries were included after screening. We appraised study quality using an adapted version of the Critical Appraisal Skills Programme tool for qualitative research. Reporting of reflexivity and theoretical underpinnings was poor. We synthesised findings thematically, presenting themes alongside illustrative quotes. We categorised poor pregnancy experiences into: care-seeking challenges, mental health difficulties, and poor nutritional status. We identified eight inter-connected themes: restrictive social hierarchies within households, earning social position, disrupted education, social isolation, increased likelihood of and vulnerability to abuse, shaming of pregnant women, normalisation of risk among younger women, and burdensome workloads. Socioeconomic position and caste/ethnic group also intersected with early marriage to shape experiences during pregnancy. While we found differences between regions, the heterogeneity of the included studies limits our ability to draw conclusions across regions. Pregnancy experiences are largely determined by social hierarchies and the quality of relationships within and outside of the household. These factors limit the potential for individual factors, such as education and empowerment, to improve experiences of pregnancy for girls married early.

Key factors associated with quality of postnatal care: a pooled analysis of 23 countries

Background

Progress in reducing maternal and neonatal mortality, particularly in low-income and middle-income countries (LMICs) and regions, is insufficient to achieve the Sustainable Developmental Goals by 2030. High-quality postnatal care (PNC) for mothers and neonates is crucial for mothers and babies, yet it remains the most neglected intervention on the continuum of maternal and child care. We aimed to estimate the associations between observable factors and high-quality maternal and neonatal PNC in pooled and country-specific analyses.

Methods

In this cross-sectional study, we used the most recent (2015-2022) Demographic and Health Surveys from 23 countries across Africa (n = 14), Southeast Asia (n = 3), Eastern Mediterranean (n = 2), Europe (n = 2), Americas (n = 1), and Western Pacific (n = 1). Women who, within the last 5 years, were aged 15-49 years at their last live birth that had delivered a singleton child were included. We identified eleven PNC behaviours recommended by the World Health Organization (WHO) to measure PNC quality, and applied thresholds to create binary outcomes for quality maternal and neonatal PNC. 15 factors were included in our analysis to assess their association with high-quality PNC for mothers and neonates in a series of single-adjusted and mutually adjusted logistic regression models, both in pooled and country-specific analysis. We also conducted two sets of subgroup analyses for place of residence and maternal age at last birth, and two sets of supplementary analyses to test the robustness of the results.

Findings

Among 172,526 women and their most recent child, 41.42% (40.93-41.91) received quality maternal PNC while 42.34% (41.86-42.83) received quality neonatal PNC. In the pooled analysis, we found that the factors showing the strongest associations with quality maternal PNC were delivery by skilled birth attendants (SBAs) (OR: 4.92; 95% CI: 4.32-5.59), four or more antenatal care (ANC) visits (OR: 1.69, 1.58-1.81), and institutional delivery (OR: 1.61; 1.46-1.78). Consistent results were found for all factors of quality newborn care (e.g., delivery by SBA: OR, 4.25; 3.75-4.81; four or more ANC visits: OR, 1.83; 1.70-1.96) except institutional delivery. The association between these leading factors and PNC quality were broadly consistent across countries. Subgroup analyses and sensitivity analyses showed generally consistent results.

Interpretation

Our study demonstrated that institutional delivery and frequent ANC visits had the strongest positive associations with quality PNC for both mothers and neonates. Our findings highlight that improvements to the quality of maternal and neonatal PNC in the LMICs we assessed are urgently needed to achieve ambitious maternal, newborn, and child health goals.

Funding

China National Natural Science Foundation.

Where, why and who delivers our babies? Examining the perspectives of women on utilization of antenatal and delivery services in a developing country

BACKGROUND

The differences in maternal mortality between developed and developing countries is due to differences in use of antenatal and delivery services. The study was designed to determine the views of women on utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria.

METHODS

Community based descriptive exploratory study design was employed. Qualitative data was collected through use of pre-tested focus group discussion (FGD) guide. Eight FGDs were conducted among women who were pregnant and others who have delivered babies one year prior to the study. Four FGDs each were conducted in urban and rural communities. QDA Miner Lite v2.0.6 was used in the analysis of the data.

RESULTS

Most of the participants in urban and rural areas prefer the man and woman deciding on where to receive antenatal and deliver care. All the participants in urban and rural communities wish for the support of their husbands when pregnant. Perceived quality of care is the major reason the women choose a facility for antenatal and delivery services. Others reasons included cost of services and proximity to a facility. Participants in rural communities were of the opinion that traditional birth attendants deliver unique services including helping women to achieve conception. For participants in urban, traditional birth attendants are very friendly and perhaps on divine assignment. These reasons explain why women still patronize their services. The major criticism of services of traditional birth attendants is their inability to manage complications associated with pregnancy and delivery. The major reasons why women delivery at home included poverty and cultural beliefs.

CONCLUSIONS

All efforts should be made to reduce the huge maternal death burden in Nigeria. This may necessitate the involvement of men and by extension communities in antenatal and delivery matters. There is need to train health workers in orthodox health facilities on delivery of quality healthcare. Public enlightenment on importance of health facility delivery will be of essence. Encouraging women to deliver in health facilities should be prioritized. This may entail the provision of free or subsidized delivery services. The deficiencies of primary health centers especially in rural communities should be addressed.

Associations of antenatal care visit with utilization of institutional delivery care services in Afghanistan: intersections of education, wealth, and household decision-making autonomy

Background

The importance of antenatal care (ANC) visits in safe motherhood and childbirth is well-documented. However, less is known how social determinants of health interact with ANC visits in shaping the uptake of professional delivery care services in low-income countries. This study examines the associations of ANC visits with institutional delivery care utilization outcomes in Afghanistan. Further, we assess the extent to which ANC visits intersect with education, wealth, and household decision-making autonomy in predicting two outcomes of delivery care utilization- delivery at a health facility and delivery assisted by a skilled birth attendant.

Methods

We used data from the Afghanistan Demographic and Health Survey (AfDHS) 2015. The analytic sample included 15,590 women of reproductive age (15–49). We assessed the associations using logistic regression models, estimated the predicted probability of delivery care outcomes using statistical interactions, and presented estimates in margins plot.

Results

Multivariable adjusted analyses suggest that women who had 4 or more ANC visits were 5.7 times (95% CI = 4.78, 7.11; P < 0.05) more likely to use delivery care at a health facility and 6.5 times (95% CI = 5.23, 8.03; P < 0.05) more likely to have a delivery assisted by a skilled birth attendant compared to women who had no ANC visit. Estimates from models with statistical interactions of ANC visits with education, wealth, and decision-making autonomy suggest that women with higher social status were more advantageous in utilizing institutional delivery care services compared to women with lower levels of social status.

Conclusion

Our findings suggest that the associations of ANC visits with institutional delivery care services are stronger among women with higher social status. The results have implications for promoting safe motherhood and childbirth through improving women’s social status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04588-0.