Women's status within the household as a determinant of maternal health care use in Nigeria

Inequality gaps in modern contraceptive use and associated factors among women of reproductive age in Nigeria between 2003 and 2018

BACKGROUND

Inequalities in modern contraceptive use among women in low-income countries remain a major public health challenge. Eliminating or reducing the inequalities in modern contraceptive use among women could accelerate the achievement of Sustainable Development Goals, Targets 3.7 & 5.6. Thus, this study examined the inequality gaps in modern contraceptive use and associated factors among women of reproductive age in Nigeria between 2003 and 2018.

METHODS

This study employed the World Health Organisation's Health Equity Assessment Toolkit to analyse the 2003 and 2018 Nigeria Demographic Health Surveys. Modern contraceptive use was aggregated using five equity stratifiers: age, economic status, educational level, place, and region of residence among women of reproductive aged 15 to 49, with a sample size of 5,336 and 29,090 for 2003 and 2018, respectively. Inequality was measured in this study using difference (D), ratio (R), population-attributable risk (PAR), and a population-attributable fraction (PAF).

RESULTS

The study shows an increase in modern contraceptive use among women of reproductive age in Nigeria from 8.25% in 2003 to 12.01% in 2018, with the use being more prominent among women of reproductive age 20-49 and those in the richest economic quintile. In both surveys, women with primary education showed the most upward increase in modern contraceptive use. Women residing in the urban areas also show an upward use of modern contraceptives use. The study further highlights inequality gaps, with age being a substantial factor, while economic status and sub-national regions showed mild to marginal inequality gaps. Finally, the educational level of women of reproductive age in Nigeria significantly shows inequality in modern contraceptive use, with a PAF of 129.11 in 2003 and 65.39 in 2018.

CONCLUSION

The inequality gap in modern contraceptive use among women of reproductive age in Nigeria between 2003 and 2018 reported in this study includes age, education, wealth quintile, residence, and region-related inequalities. The study highlights the need for policies and programmes that target the groups with low use of modern contraceptives to promote equity in family planning services.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"When a man drinks alcohol it's cool but when a woman drinks she is a hoe": A qualitative exploration of alcohol, gender, stigma, and sexual assault in Moshi, Tanzania

Alcohol's ever-increasing global use poses a distinct threat to human well-being, with intake and associated burdens rising especially quickly in low- and middle-income countries like Tanzania. Prior research has shown alcohol use and related consequences differ by gender in Moshi, Tanzania, with important implications for both clinical care and future alcohol-reduction interventions. This study builds upon this knowledge by providing a deeper understanding of how gender differences affect alcohol-related stigma and sexual assault among Emergency Department (ED) and Reproductive Health Center (RHC) patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi. In-depth interviews were conducted among ED and RHC KCMC patients (n = 19) selected for participation via purposive sampling. A mix of inductive and deductive coding schemes was used to identify themes and subthemes. All data were analyzed through a grounded theory approach. Gender roles that linked men with financial responsibilities and women with child caretaking led to different expectations on alcohol intake, with alcohol use encouraged for men but vilified for women. Women who drank, for example, were deemed poor mothers and undesirable spouses. Patients likewise emphasized that both alcohol-related stigma and sexual violence disproportionately impacted women, the latter fueled through alcohol use, with serious and lasting acts of discrimination and isolation from community members seen among women alcohol users but not for men. Women alcohol users in Moshi are subject to severe social consequences, facing disproportionate stigma and sexual violence as compared to men. Alcohol-related treatment for women should be mindful of the disproportionate burdens present in this context while treatment for men should be cognizant of the social pressures to drink. Strategies to address and/or mitigate these factors should be incorporated in subsequent care and interventions.

A multilevel analysis of social determinants of skilled birth attendant utilisation among married and cohabiting women of Madagascar

BACKGROUND

Maternal mortality ratio (MMR) in Madagascar is 392 deaths per 100 000 live births, and this is a major public health concern. One of the strategies for reducing MMR and achieving target 3.1 of the Sustainable Development Goals (i.e. reducing the global MMR below 70 per 100 000 live births) is the utilisation of skilled birth attendants (SBAs). This analysis examined the prevalence and social determinants of SBA utilisation among married and cohabiting women of Madagascar.

METHODS

Data from the 2021 Madagascar Demographic and Health Surveys was analysed on a weighted sample of 6997 married and cohabiting women. A multilevel regression was carried out to determine the social determinants of utilising SBAs. The results are presented as odds ratios (ORs) associated with 95% confidence intervals (CIs) and a p-value <0.05 to determine the significant associations.

RESULTS

The prevalence of SBAs among married and cohabiting women of Madagascar was 64.4% (95% CI 0.62 to 0.68). In model 3 of the multilevel regression, women 35-39 y of age (adjusted OR [aOR] 1.86 [95% CI 1.30 to 2.60]), women with secondary/higher education (aOR 1.67 [95% CI 1.32 to 2.10]), women whose partners had secondary/higher education (aOR 1.58 [95% CI 1.25 to 1.99]), cohabiting women (aOR 1.33 [95% CI 1.07 to 1.65]), women who had four or more antenatal care visits (aOR  2.05 [95% CI 1.79 to 2.35]), female household head (aOR 1.44 [95% CI 1.06 to 1.95]), Muslims (aOR 1.58 [95% CI 0.71 to 3.53]), those of the richest wealth index (aOR 4.32 [95% CI 2.93 to 6.36]) and women who lived in communities with high literacy levels (aOR 2.17 [95% CI 1.57 to 3.00]) had higher odds of utilisation of SBA.

CONCLUSION

This current analysis revealed low SBA utilisation among married and cohabiting women in Madagascar. The analysis points to the fact that understaffing and inaccessibility of health facilities remain major contributors to the low utilisation of SBAs. The findings call on the government and stakeholders in Madagascar to consider implementing programs that will empower women and focus on disadvantaged groups. These programs could include providing free maternal healthcare services to all pregnant women and intensifying health education programs that target women and their partners with no formal education.

Women empowerment domains and unmet need for contraception among married and cohabiting fecund women in Sub-Saharan Africa: A multilevel analysis based on gender role framework

BACKGROUND

Low women empowerment, is a known contributing factor to unmet needs for contraception by limiting access to health services through negative cultural beliefs and practices. However, little is known about the association between unmet needs and domains of women empowerment in Sub-Saharan African (SSA) countries. Hence, this study aimed at assessing the influence of women empowerment domains on the unmet need for contraception in the region using the most recent Demographic and Health Survey (DHS) data (2016-2021).

METHODS

The data for the study was derived from the appended women's (IR) file of eighteen SSA countries. A weighted sample of 128,939 married women was analyzed by STATA version 16. The Harvard Institute's Gender Roles Framework, which comprised of influencer, resource, and decision-making domains was employed to identify and categorize the covariates across three levels. The effects of each predictor on the unmet need for spacing and limiting were examined using a multivariable multilevel mixed-effect multinomial logistic regression analysis. Adjusted relative risk ratio (aRRR) with its corresponding 95% confidence interval was used to declare the statistical significance of the independent variables.

RESULTS

The pooled prevalence of unmet needs for contraception was 26.36% (95% CI: 24.83-30.40) in the region, with unmet needs for spacing and limiting being 16.74% (95% CI: 16.55, 17.02) and 9.62% (95% CI: 9.45, 12.78), respectively. Among variables in the influencer domain, educational level, family size of more than five, parity, number of children, attitude towards wife beating, and media exposure were substantially linked with an unmet need for spacing and limiting. Being in the poorest wealth quintile and enrollment in health insurance schemes, on the other hand, were the two variables in the resource domain that had a significant influence on unmet needs. The overall decision-making capacity of women was found to be the sole significant predictor of unmet needs among the covariates in the decision-making domain.

CONCLUSION

Unmet needs for contraception in SSA countries were found to be high. Reproductive health program planners and contraceptive service providers should place due emphasis on women who lack formal education, are from low-income families, and have large family sizes. Governments should collaborate with insurance providers to increase health insurance coverage alongside incorporating family planning within the service package to minimize out-of-pocket costs. NGOs, government bodies, and program planners should collaborate across sectors to pool resources, advocate for policies, share best practices, and coordinate initiatives to maximize the capacity of women's decision-making autonomy.

"When a man drinks alcohol it's cool but when a woman drinks she is a hoe": A Qualitative Exploration of Alcohol, Gender, Stigma, and Sexual Assault in Moshi, Tanzania

Background

Alcohol's ever-increasing global use poses a distinct threat to human well-being, with intake and associated burdens rising especially quickly in low- and middle-income countries like Tanzania. Prior research has shown alcohol use and related consequences differ by gender in Moshi, Tanzania, with important implications for both clinical care and future alcohol-reduction interventions. This study builds upon this knowledge by providing a deeper understanding of how gender differences affect alcohol-related stigma and sexual assault among Emergency Department (ED) and Reproductive Health Center (RHC) patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi.

Methods

In-depth interviews (IDIs) were conducted among ED and RHC KCMC patients (n = 19) selected for participation via purposive sampling. A mix of inductive and deductive coding schemes was used to identify themes and subthemes. All data were analyzed through a grounded theory approach.

Results

Gender roles that linked men with financial responsibilities and women with child caretaking led to different expectations on alcohol intake, with alcohol use normalized for men but vilified for women. Women who drank, for example, were deemed poor mothers and undesirable spouses. Patients likewise emphasized that both alcohol-related stigma and sexual violence disproportionately impacted women, the latter fueled through alcohol use, with serious and lasting acts of discrimination and isolation from community members seen among women alcohol users but not for men.

Conclusion

Women alcohol users in Moshi are subject to severe social consequences, facing disproportionate stigma and sexual violence as compared to men. Alcohol-related treatment for women should be mindful of the disproportionate burdens present in this context and incorporate strategies to address and/or mitigate these harms in subsequent care and interventions.

Postnatal Care Utilization Coverage and its Associated Factors Among Mothers in South Gondar Zone, Northwest Ethiopia: A Cross-Sectional Study

Background

Postnatal care (PNC) is critical for both the mother and the infant to treat delivery complications and provide the mother with important information on caring for herself and her baby. However, only 17% of women and 13% of newborns in Ethiopia received a postnatal checkup within the first two days of birth. This figure is significantly lower than the least developed countries. This study aimed to assess the coverage and associated factors of PNC service utilization in South Gondar Zone, Northwest Ethiopia.

Method

A community-based cross-sectional study was conducted from September 2020 to May 2021. The data were gathered using an interviewer-administered structured questionnaire. A total of 434 women who gave birth within 2 years of the study were included in the analysis. Bivariable and multivariable logistic regression model was used to identify factors associated with PNC service utilization.

Result

The prevalence of women who used PNC services was 36.4%. The study showed that antenatal care visit, husbands who have a secondary education, women with a secondary education, daily laborer women, husbands working for the government or non-profit sector, delivered in a health institution, nearby hospitals, travel by car to the nearest health facility were positively associated with PNC utilization. While, not having a cell phone, rural women and not having road access to a health facility, have not been receiving counseling were negatively associated with PNC utilization.

Conclusion

The coverage of PNC service utilization in the study area was extremely low. Therefore, government and health care departments should pay special attention to uneducated women, women in rural areas, and women who are unemployed, are not exposed to mass media, and do not have access to transportation to improve PNC service utilization. Furthermore, programs educating mothers on the benefits of antenatal checkups and safer places of childbirth should be considered to increase PNC service utilization.

The Moderating Role of Maternal Education and Employment on Child Health in Pakistan

BACKGROUND

Pakistan has challenges in fulfilling its universal responsibilities of providing better health facilities to everyone. The Sustainable Development Goals (SDGs) aim to reduce maternal and infant mortality rates. Despite declines in mother and child death, the total mortality ratio has marginally increased. However, neonatal death has not decreased significantly. Family planning is important for controlling population growth and improving child as well as maternal health. Pakistan's government has unceasingly tried to enhance the provision of contraceptive facilities, but still, an unmet need for family planning (UMNFP) exists in our country. Women are said to have UMNFP if they want to limit or space childbearing, but they are not using contraception methods for any reason. The study aimed to explore the effect of the UMNFP and to investigate the moderating role of a mother's education and employment status on a child's health.

METHODS

We analyzed the data of 2,244 women in this study. To investigate the study objectives, we utilized the secondary dataset of the Pakistan Demographic and Health Survey (PDHS) 2017-18 (publicly available on the website of the National Institute of Population Studies) and applied binary logistic regression using SPSS 24.

RESULTS

Results suggest a positive effect of a woman's age (25 to 39 years), maternal education (higher), father's education (higher), family's wealth status (richest), mass media exposure, and adequate birth spacing (at least for 33 months) on a child's health. On the other hand, there is an indirect association between maternal employment, unmet need for family planning, and a child's health. The moderating role of maternal education and employment on the relationship between household wealth status and a child's health is positive.

CONCLUSIONS

We conclude that the strong predictors of child health are UMNFP, maternal education, and employment. The link between the met need for family planning and the child's health is positive. The moderating effect of maternal education and household wealth status on a child's health is progressive. Similarly, the interaction effect of a mother's employment and household wealth status on a child's health is positive. Finally, we concluded that the link between the health of the child and household wealth status is much more diverse and positive when the mother is highly educated and currently employed.

National and subnational variations in gender relations and the utilization of maternal healthcare services in Nigeria

Introduction

poor maternal health outcomes remain a major public health issue in Nigeria. These have been shown to be affected by the low level of utilization of maternal healthcare services. This study investigates the levels of gender relations (GR) among Nigerian women and how these influence their utilization of maternal healthcare services. The relations are conceptualized as feminine (FGR), masculine (MGR) and egalitarian.

Methods

data on household decision-making, antenatal care (ANC) visits, health facility delivery, and associated sociodemographic variables, were extracted from the 2018 Nigeria Demographic and Health Survey for 29,992 parous women aged 15-49 for a cross-sectional study. Associations were investigated using Chi-Square and regression analyses.

Results

women with FGR constituted 5.7% of the population at the national level, while subnational variations ranged from 1.8% in the North-East to 12.8% in the South-South regions. The prevalence rates of the recommended minimum ANC visits (RMANC) and health facility delivery were 42.1% and 30.0% at the national level and were lowest in the northern regions. At both the unadjusted and adjusted levels, FGR was not significantly associated with RMANC and health facility delivery at the national level and in all the regions except the South-West. MGR was however significantly associated with increased odds of RMANC (OR: 2.235, CI: 2.043-2.444) and health facility delivery (OR: 2.571, CI: 2.369-2.791) at national level. Significant subnational variations in the association between gender relations and the utilization of maternal healthcare services were also recorded.

Conclusion

sub-national variations in GR and their varying impacts on the utilization of maternal healthcare services in Nigeria suggest that gender-related policies to improve maternal health outcomes should be location-specific, rather than general. As FGR did not affect maternal healthcare services utilization, educating men on the benefits of supporting their wives to scale-up utilization is recommended.

Women's decision-making capacity and its association with comprehensive knowledge of HIV/AIDS in 23 sub-Saharan African countries

BACKGROUND

Globally, Human Immunodeficiency Virus (HIV) that causes Acquired Immunodeficiency Syndrome (AIDS) remains a public health problem with a higher burden in sub-Saharan African countries. Though the coverage is low in sub-Saharan Africa (SSA), comprehensive knowledge about HIV is vital for preventing and controlling the transmission of the virus. Women's decision-making power is significantly linked with the knowledge and use of healthcare services. However, there is no available evidence on women's decision-making capacity and comprehensive knowledge of HIV. Therefore, this study investigated the association between women's decision-making capacity within households and comprehensive knowledge of HIV/AIDS in SSA.

METHODS

We derived data from the 2010 to 2020 Demographic and Health Surveys of 23 sub-Saharan African countries for the analysis. Using Stata version 14, both bivariate logistic regression and multivariate multilevel logistic regression analyses were used to examine the association between women's decision-making capacity and comprehensive knowledge of HIV/AIDS at p ≤ 0.05. Results were reported using adjusted odds ratios (aOR) with their respective 95% confidence interval (CI).

RESULTS

The pooled results show that comprehensive HIV/AIDS knowledge among married women in the studied countries was 35.5%, from 18.3% in Chad to 77.1% in Rwanda. Regarding sub-regional distribution, comprehensive knowledge of HIV/AIDS in Southern Africa was 73.2%, followed by East Africa (52.4%), West Africa (43.6%), and Central Africa (35.5%). The study showed higher odds of comprehensive knowledge of HIV/AIDS among married women who had decision making power (yes-aOR = 1.20, 95% CI; 1.16-1.25) compared to those who had no decision-making power. Age, women and partner's level of education, place of residence, exposure to media, HIV testing status, community socio-economic status, parity, religion, and distance to health facilities also had significant association with comprehensive HIV/AIDS knowledge.

CONCLUSIONS

Comprehensive knowledge of HIV/AIDS in SSA is low but varies per country. Married women with decision-making capacity were more likely to have comprehensive knowledge of HIV compared to those with no decision-making capacity. Therefore, comprehensive knowledge of HIV/AIDS can be increased through enhancing women's decision-making capacities, strengthening employment opportunities, socioeconomic capacities and creating awareness through media. Moreover, improving access to health care facilities working closely with religious leaders, can be considered to increase coverage of comprehensive knowledge of HIV among married women in SSA.

Tuition-free secondary education and women's attitudes toward intimate partner violence: Evidence from Sub-Saharan Africa

Intimate partner violence against women (IPVAW) is devastatingly common around the world. It rose further during the pandemic, increasing the urgency of finding interventions to prevent IPVAW and supporting women's ability to exit violent situations. Interventions that prevent violence and eliminate views among perpetrators that violence is acceptable should be top priority. It is also critical to study women's attitudes toward IPVAW as these shape women's responses to the abuse and their exit options. Moreover, research shows that these attitudes have a direct impact on women's health outcomes. We examine the effect of tuition-free secondary education on women's attitudes toward IPVAW across 29 Sub-Saharan African countries using data from the Demographic and Health Surveys conducted between 2000 and 2019. Using the difference-in-difference-in-differences strategy, we estimate the change in women's attitudes toward IPVAW in countries that implement tuition-free secondary policy compared with countries with tuition-free primary alone and those without any tuition-free policy during the study period. We find that while tuition-free primary education policy alone did not reduce the probability of IPVAW being perceived as justified, tuition-free secondary reduced it significantly. The probability that IPVAW was perceived as justified under at least one circumstance declined by 5.3 percentage points more on average in countries that adopted tuition-free policy up to the secondary level relative to those that adopted only up to the primary level. Tuition-free secondary affects four of the five circumstances under which IPVAW was perceived as justified — if she goes out without telling the husband, argues with him, neglects children or refuses sex. We observed no declines for when she burns food, suggesting different factors affecting this outcome. Our findings underscore the importance of making a stronger commitment toward policies that make secondary education more accessible to not only benefit education outcomes but also advance population health.

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Intimate Partner Violence against women (IPVAW) is on the rise globally.

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We examine tuition-free education policy's effect on women's attitudes toward IPVAW.

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Our study exploits variation in the timing of policy rollout in Sub-Saharan Africa.

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Tuition-free primary policy alone did not affect women's attitudes toward IPVAW.

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Tuition-free secondary reduced the probability of IPVAW being perceived as justified.

Predictors of Child's Health in Pakistan and the Moderating Role of Birth Spacing

There is a consensus that better health should be viewed both as a means and an end to achieve development. The level of development should be judged by the health status of the population and the fair distribution of health services across the people. Many determinants affect a child’s health. This study aimed to explore a child’s health predictors and the moderating role of birth spacing on the association between mother’s health care services utilization (MHCSU) and a child’s health. In this study, we used the dataset of Pakistan Demographic and Health Survey 2017-18 to explore the predictors of child health and the moderating role of birth spacing through binary logistic regression, using SPSS version 20. The results showed an association of mother’s age (35 to 49 years), her education (at least secondary), health care services (more accessible), father’s education (at least secondary), their wealth status (high), and exposure to mass media to improved child health. However, the effect of a mother’s employment status (employed) on her child’s health is significant and negative. The coefficient of moderation term indicated that the moderating role of birth spacing on the association between MHCSU and a child’s health is positive. We conclude that birth spacing is a strong predictor for improving a child’s health. The association between MHCSU and child’s health is more distinct and positive when the birth spacing is at least 33 months.

Women Empowerment and Skilled Birth Attendants among Women in Rural Ghana

Background

A critical public health issue is maternal mortality. Around 810 women die per day from pregnancy and childbirth, with approximately 99 percent of these deaths recorded in low-and middle-income countries (LMICs). In sub-Saharan Africa (SSA), more than half of these mortalities are registered. The situation is remarkably similar in Ghana, with maternal mortality standing at 319 deaths per 100,000 live births in 2015.

Methods

Using data from 2014 Demographic and Health Surveys, the study examined the association between women empowerment and skilled birth attendance among women in rural Ghana.

Results

Women with medium decision-making (OR = 0.75, CI = 0.61, 0.93), low knowledge level (OR = 0.55, CI = 0.40, 0.76), high acceptance of wife beating (OR = 0.68, CI = 0.51, 0.90), with less than 4 ANC visits (OR = 0.25, CI = 0.19, 0.32), whose partner had higher education (OR = 1.96, CI = 1.05, 3.64), and who had a big problem with the distance getting to the health facility (OR = 0.63, CI = 0.50, 0.78) had a significant association with skilled birth attendants. Decision-making power, women's knowledge level, acceptance of wife beating, antenatal care visit, partner's education, getting medical help for self, and distance to health facility were seen to have a significant association with skilled birth attendants among women in Ghana.

Conclusion

Efforts to increase the current SBA should concentrate on the empowerment of women, male involvement in maternal health problems, women's education, and participation in the ANC. There is a need to review current policies, strategies, and services to improve maternal health conditions.

TRAINING NEEDS ASSESSMENT OF STAKEHOLDERS IN THE HEALTH INSURANCE INDUSTRY IN SOUTHWEST REGION OF NIGERIA: IMPLICATIONS FOR UNIVERSAL HEALTH COVERAGE

BACKGROUND

The coverage of the social health insurance scheme in Nigeria has been low. The scheme may benefit from personnel training which has been shown to improve organisational performance.

OBJECTIVE

This study, therefore, aimed to assess the training needs of personnel in the health insurance industry in Southwest Nigeria.

METHODS

This was a cross-sectional survey conducted among personnel of the health insurance industry in Southwest of Nigeria. The survey tool adapted was the Hennessy-Hicks Training Needs Analysis Questionnaire. The tool has been psychometrically tested for validity and reliability. Originally, the tool has 30 items with an allowance for modification without compromising its psychometric properties. The 30 items were grouped into six superordinate categories; management/supervisory, administration, clinical/service delivery assessment, communication/ teamwork, facility financial audit/assessment, and facility infrastructure assessments. Respondents rated each item along two seven-point scales. In the first scale, respondents rated how important (importance rating) the item is to their job while in the second scale, respondents self-rated their current performance level of the item (performance rating). A training need index was generated by subtracting performance rating from the importance rating for each of the six superordinate categories.

RESULTS

Training needs for each of the six subcategories ranked by the magnitude of the derived training need index (from highest to lowest) were; clinical/service delivery, facility infrastructure, facility financial audit, management/supervisory skills, communication, and teamwork, and administration.

CONCLUSION

Training need was demonstrated in all six subcategories. Emphasis on the relevant training need of personnel in the health insurance industry in Nigeria is important to improve efficiency and performance.

Empirical analysis of socio-economic determinants of maternal health services utilisation in Burundi

BACKGROUND

Timely and appropriate health care during pregnancy and childbirth are the pillars of better maternal health outcomes. However, factors such as poverty and low education levels, long distances to a health facility, and high costs of health services may present barriers to timely access and utilisation of maternal health services. Despite antenatal care (ANC), delivery and postnatal care being free at the point of use in Burundi, utilisation of these services remains low: between 2011 and 2017, only 49% of pregnant women attended at least four ANC visits. This study explores the socio-economic determinants that affect utilisation of maternal health services in Burundi.

METHODS

We use data from the 2016-2017 Burundi Demographic and Health Survey (DHS) collected from 8941 women who reported a live birth in the five years that preceded the survey. We use multivariate regression analysis to explore which individual-, household-, and community-level factors determine the likelihood that women will seek ANC services from a trained health professional, the number of ANC visits they make, and the choice of assisted childbirth.

RESULTS

Occupation, marital status, and wealth increase the likelihood that women will seek ANC services from a trained health professional. The likelihood that a woman consults a trained health professional for ANC services is 18 times and 16 times more for married women and women living in partnership, respectively. More educated women and those who currently live a union or partnership attend more ANC visits than non-educated women and women not in union. At higher birth orders, women tend to not attend ANC visits. The more ANC visits attended, and the wealthier women are; the more likely they are to have assisted childbirth. Women who complete four or more ANC visits are 14 times more likely to have an assisted childbirth.

CONCLUSIONS

In Burundi, utilisation of maternal health services is low and is mainly driven by legal union and wealth status. To improve equitable access to maternal health services for vulnerable population groups such as those with lower wealth status and unmarried women, the government should consider certain demand stimulating policy packages targeted at these groups.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The influence of social and cultural practices on maternal mortality: a qualitative study from South Punjab, Pakistan

Background

A disproportionately high rate of maternal deaths is reported in developing and underdeveloped regions of the world. Much of this is associated with social and cultural factors, which form barriers to women utilizing appropriate maternal healthcare. A huge body of research is available on maternal mortality in developing countries. Nevertheless, there is a lack of literature on the socio-cultural factors leading to maternal mortality within the context of the Three Delays Model. The current study aims to explore socio-cultural factors leading to a delay in seeking care in maternal healthcare in South Punjab, Pakistan.

Methods

We used a qualitative method and performed three types of data collection with different target groups: (1) 60 key informant interviews with gynaecologists, (2) four focus group discussions with Lady Health Workers (LHWs), and (3) ten case studies among family members of deceased mothers. The study was conducted in Dera Ghazi Khan, situated in South Punjab, Pakistan. The data was analysed with the help of thematic analysis.

Results

The study identified that delay in seeking care—and the potentially resulting maternal mortality—is more likely to occur in Pakistan due to certain social and cultural factors. Poor socioeconomic status, limited knowledge about maternal care, and financial constraints among rural people were the main barriers to seeking care. The low status of women and male domination keeps women less empowered. The preference for traditional birth attendants results in maternal deaths. In addition, early marriages and lack of family planning, which are deeply entrenched in cultural values, religion and traditions—e.g., the influence of traditional or spiritual healers—prevented young girls from obtaining maternal healthcare.

Conclusion

The prevalence of high maternal mortality is deeply alarming in Pakistan. The uphill struggle to reduce deaths among pregnant women is firmly rooted in addressing certain socio-cultural practices, which create constraints for women seeking maternal care. The focus on poverty reduction and enhancing decision-making power is essential for supporting women’s right to medical care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01151-6.

Round the world, many women are dying because of complications during pregnancy or in childbirth. These deaths are more frequent in developing and underdeveloped countries. Some reasons for this are related to social and cultural factors, which form barriers to women using appropriate maternal healthcare. Therefore, this study aims to explore socio-cultural factors leading to a delay in seeking maternal healthcare in South Punjab, Pakistan.

We interviewed a variety of people to get an overview of this topic: (1) 60 interviews were conducted with gynaecologists, (2) we performed four focus group discussions with eight to ten Lady Health Workers providing maternal healthcare, and (3) we talked with family members of mothers who had died.

The study shows that delays in seeking care are related to poor socioeconomic status, limited knowledge about maternal care, and low incomes of rural people. The low status of women and male domination keeps women less empowered. In addition, early marriages and lack of family planning due to cultural values, religion and traditions stopped young girls from getting maternal healthcare.

The number of new mothers who die is very worrying in Pakistan. One of the important tasks for reducing deaths among pregnant women is to address certain socio-cultural practices. It is very important to reduce poverty and improve decision-making power to make sure women can use their right to medical care.

Women's involvement in decision making for unmet need for contraception in Indonesia

BACKGROUND

The issue of gender inequality in reproductive health has a role in determining contraceptive use in women. Gender issues related to inequality in decision making are the primary context in family planning interventions. The purpose of this study is to assess women's participation in decision making and its relation to an unmet need.

METHODS

A cross-sectional study was conducted using IDHS data in 2017. The study involved 1516 women of childbearing age (15-49 years) with married categories in areas with the high unmet need (West Papua) and the lowest unmet need area (Bangka Belitung).

RESULTS

Married women in the Bangka Belitung region have more power in decision making than married women in West Papua. Involvement in economic matters and the decision to use contraception as the most dominant factor and participation in the household have a significant relationship with the occurrence of unmet need, as well as education, wealth, and experience in using contraception related to unmet need. While age, fertility preference, husband's desire to have children, and involvement in health and mobility were not directly related to unmet need.

CONCLUSIONS

Better participation in decision making is higher for women in the Bangka Belitung region than in Papua. Empowerment of women in terms of the economy and the use of contraception needs to be improved so that they have power in decision making.

Predictors of skilled birth attendance among married women in Cameroon: further analysis of 2018 Cameroon Demographic and Health Survey

BACKGROUND

In Cameroon, maternal deaths remain high. The high maternal deaths in the country have been attributed to the low utilization of maternal healthcare services, including skilled birth attendance. This study examined the predictors of skilled birth services utilization among married women in Cameroon.

METHODS

Data from the 2018 Cameroon Demographic and Health Survey was analyzed on 7881 married women of reproductive age (15-49 years). Both bivariate and multivariable logistic regression analyses were carried out to determine the predictors of skilled childbirth services. The results were presented with crude odds ratio (cOR) and adjusted odds ratio (aOR) and 95% confidence interval (CI).

RESULTS

The coverage of skilled birth attendance among married women of reproductive age in Cameroon was 66.2%. After adjusting for potential confounders, media exposure (aOR = 1.46, 95% CI: 1.11-1.91), higher decision making (aOR = 1.88, 95% CI: 1.36-2.59), maternal education (aOR = 2.38, 95% CI; 1.65-3.42), place of residence (aOR = 0.50, 95% CI; 0.33-0.74), religion (aOR = 0.55, 95% CI; 0.35-0.87), economic status (aOR = 5.16, 95% CI; 2.58-10.30), wife beating attitude (aOR = 1.32, 95% CI; 1.05-1.65), parity (aOR = 0.62, 95% CI; 0.41-0.93) and skilled antenatal care (aOR = 14.46, 95% CI; 10.01-20.89) were found to be significant predictors of skilled birth attendance.

CONCLUSIONS

This study demonstrates that social, economic, regional, and cultural factors can act as barriers to skilled childbirth services utilization in Cameroon. Interventions that target women empowerment, antenatal care awareness and strengthening are needed, especially among the rural poor, to reduce barriers to care seeking. Maternal healthcare services utilization interventions and policies in Cameroon need to focus on specific equity gaps that relate to socio-economic status, maternal education, and the economic empowerment of women. Such policies and interventions should also aim at reducing geographical barriers to access to maternal healthcare services, including skilled birth attendance. Due to the presence of inequities in the use of skilled birth attendance services, programs aimed at social protection and empowerment of economically disadvantaged women are necessary for the achievement of the post-2015 targets and the Sustainable Development Goals. Globally, Cameroon is one of the countries with high maternal deaths. Low utilization of maternal healthcare services, including skilled birth attendance have been found to account for the high maternal deaths in the country. This study sought to examine the factors associated with skilled childbirth services utilization among married women in Cameroon. Using data from the 2018 Cameroon Demographic and Health Survey, we found that the coverage of skilled birth attendance among married women of reproductive age in Cameroon is high. Factors such as higher decision-making power, higher maternal education, place of residence, religion, higher economic status, wife beating attitude, parity and skilled antenatal care were found to be the significant predictors of skilled birth attendance. This study has shown that socio-economic, regional and cultural factors account for the utilization of skilled childbirth services utilization in Cameroon. Interventions aimed at enhancing the utilization of skilled childbirth services in Cameroon should target women empowerment, antenatal care awareness creation and sensitization, especially among the rural poor, to reduce barriers to care seeking. Maternal healthcare services utilization interventions and policies in Cameroon need to focus on specific equity gaps that relate to socio-economic status, maternal education, and the economic empowerment of women.

Examining barriers to healthcare access and utilization of antenatal care services: evidence from demographic health surveys in sub-Saharan Africa

Background

Antenatal care utilization is one of the means for reducing the high maternal mortality rates in sub-Saharan Africa. This study examined the association between barriers to healthcare access and implementation of the 2016 WHO antenatal care services model among pregnant women seeking antenatal care in selected countries in sub-Saharan Africa.

Methods

This study considered only Demographic and Health Survey data collected in 2018 in sub-Saharan Africa. Hence, the Demographic and Health Survey data of four countries in sub-Saharan Africa (Nigeria, Mali, Guinea and Zambia) were used. A sample of 6761 from Nigeria, 1973 from Mali, 1690 from Guinea and 1570 from Zambia was considered. Antenatal care visits, categorized as < 8 visits or ≥8 visits, and time of the first antenatal care visit, categorized as ≤3 months or > 3 months (as per the WHO recommendations) were the outcome variables for this study. Both descriptive statistics and ordinal logistic regression were used to analyze the data. Crude odds ratios (cOR) and adjusted odds ratios (aOR) and p-values < 0.05 were used for the interpretation of results.

Results

With timing of antenatal care visits, getting money needed for treatment (aOR = 1.38, 95% CI = 1.03–1.92) influenced early timing of antenatal care visits in Mali whereas getting permission to visit the health facility (aOR = 1.62, 95% CI = 1.15–2.33) motivated women to have early timing of antenatal care visits in Guinea. We found that women who considered getting money needed for treatment as not a big problem in Nigeria were more likely to have the recommended number of antenatal care visits (aOR = 1.38, 95% CI= 1.11–1.73). On the contrary, in Guinea, Zambia and Mali, getting permission to visit health facilities, getting money for treatment, distance to the health facility and not wanting to go alone were not barriers to having ≥ 8 antenatal care visits.

Conclusion

Our study has emphasized the role played by barriers to healthcare access in antenatal care utilization across sub-Saharan African countries. There is the need for governmental and non-governmental organizations to ensure that policies geared towards improving the quality of antenatal care and promoting good interaction between health care seekers and health care providers are integrated within the health system.

Influence of women's empowerment indices on the utilization of skilled maternity care: evidence from rural Nigeria

There is increasing evidence that women with the ability to exercise control over their sexual and reproductive lives have greater access to prompt prevention and treatment of maternal health disorders, resulting in a concomitant reduction in maternal morbidity and mortality. This study assessed the association between indices of women's empowerment and utilization of skilled antenatal, intrapartum and postnatal maternity care in two rural Local Government Areas in Edo State, Nigeria. Data were taken from a household survey conducted in July and August 2017, and the study sample comprised 1245 ever-married women currently in a union who had given birth in the 5 years preceding the survey. A Gender Roles Framework guided the selection of independent women's empowerment variables. Using hierarchical logistic regression, the likelihood of receiving all three levels of skilled maternal health care service (antenatal, intrapartum and postnatal) by women's empowerment variables, grouped into resource, decision-making and influencer domains following the model of Anderson and Neuman, was assessed. Of the resource domain variables, respondent's education and respondent's participation in payment for their own health care positively predicted their use of all three levels of skilled maternal care, whereas their ownership of land negatively predicted this. Two decision-making domain variables were significantly associated with respondent's use of all three levels of service: those who made decisions alone about major household purchases were twice as likely to use all three levels of services than when decisions were made by their partners or others, while respondent making decisions alone about what food to cook each day was a negative predictor. Of the influencer variables, religion and a large spousal education gap were strong positive factors, whereas living in a consensual union rather than being legally married was a negative factor. Although health system factors are important, interventions geared towards changing gender norms that constrain women's empowerment are critical to achieving maternal health-related development goals in Nigeria. A composite strategy that targets all women's empowerment indices is recommended, as Nigeria strives towards achieving SDG-3.

Correlates of HIV-Positive Fathers' Involvement in Prevention of Mother-to-child Transmission Programs in Northern Nigeria

BACKGROUND

The involvement of men in prevention of mother-to-child HIV transmission (PMTCT) programs could accelerate the elimination of vertical transmission. Yet, little research has focused on HIV-positive male partners. This study determined the predictors of male partners' PMTCT knowledge and involvement in a tertiary hospital in northern Nigeria.

METHODS

A clinic-based sample of 401 HIV-positive male partners of women who delivered within 12 months prior were interviewed using structured questionnaires. PMTCT knowledge and involvement scores were computed. Adjusted odd ratios (AOR) for predictors were derived from multivariate logistic regression models.

RESULTS

The proportion of respondents with adequate PMTCT knowledge was 40.9%. Less than half (43.6%) of the respondents participated in PMTCT, with median involvement score of 2.00 (interquartile range, IQR = 0, 5.0). One quarter of respondents (25.7%, n =103) reported >1 sex partners, 10.5% consistently used condoms, and 20.7% had disclosed to all partners. Fathers' involvement in PMTCT was predicted by paternal education (AOR = 0.30; 95% Confidence Interval (CI): 0.12-0.77, no formal vs. post-secondary), HIV-positive child (AOR = 3.85; 95%CI: 1.41-10.54, yes vs. no), treatment duration (AOR = 4.17; 95%CI: 1.67-10.41, ≤1 vs. ≥10 years), disclosure to partner(s) (AOR = 1.21; 95%CI: 1.15-3.52, 'disclosed to all' vs. 'not disclosed'), condom use (AOR = 5.81; 95%CI: 3.07-11.0, always vs. never), and PMTCT knowledge (AOR = 0.62; 95%CI: 0.31-0.92, inadequate versus adequate).

CONCLUSION

The involvement of fathers in HIV PMTCT programs was low and predicted by paternal education, HIV-positive child, duration of antiretroviral treatment, disclosure to partner, consistent condom use, and level of PMTCT knowledge. Our findings will inform the development of policies to increase male partner involvement in PMTCT in Nigeria.

Maternal and Child Survival in Haor Region in Bangladesh. An Analysis of Fathers' Capabilities to Save the Future

Maternal and child survival is a major public health problem in haor areas in Bangladesh. Fathers feel responsible as expressed by their capability "to save the future". Using the Capability Framework for Child Growth, we aimed to identify what contextual factors underlie a father's real opportunities to secure a safe delivery, including social norms and beliefs. Parents from households having children less than two years old were asked to participate in two rounds of qualitative research. In total, 25 focus group discussions and eight in-depth interviews were conducted. Late admission to health facilities emerged as the overarching disabling factor for fathers' capability to save the lives of mothers and children. Poor communication about the mother's health condition between spouses and fear for caesarean birth were underlying this late admission. In addition, inadequate advice by local doctors, underdeveloped infrastructure, and seasonal extremities contributed to late admission to health care facilities. The participants indicated that mother's autonomy in haor to seek health care is a constraint. This capability analysis points towards relevant interventions. In addition to the need for an improved health infrastructure, programs to improve maternal and child survival in haor could focus on the gendered household responsibilities and poor communication between spouses.

Household Decision-Making and HIV Care Continuum Outcomes Among Women Living with HIV in Mozambique

Gender inequality has been associated with HIV infection among women. Less is known about the relationship between gender inequality and HIV care continuum outcomes. This study assessed whether household decision-making power (DMP), one component of gender inequality, was associated with linkage to HIV care, antiretroviral therapy (ART) initiation, or retention in care among women living with HIV in Mozambique. The sample included 600 women ≥18 years of age newly diagnosed with HIV in Mozambique. Data were collected between April 2013 and June 2016. DMP was assessed with three questions about participation in decisions regarding: major household decisions, routine household decisions, and visits to family. Women who did not contribute to decision making in any domain were categorized as having low DMP. HIV care information was obtained from electronic medical records. Multivariable log-Poisson regression analyses were conducted to assess the relationship between DMP and HIV care continuum outcomes. Almost half (49%) of participants reported medium DMP, followed by high (39%) and low DMP (12%). In multivariable regression analyses, when compared with respondents with medium DMP, those with low DMP had a lower likelihood of retention in care 12 months after diagnosis [adjusted risk ratio (aRR) 0.69 (95% CI 0.49-0.98)]. There was no significant relationship between low DMP and linkage to HIV care or ART initiation. High DMP was not significantly associated with HIV outcomes assessed. Women who report low DMP may face barriers to long-term engagement in HIV care. Interventions to improve retention in care among women should consider the role of household decision making and gender inequality.

Multilevel Factors Associated With Pregnancy-Related Health Behaviors in Indonesia: Evidence From the 2007, 2012, and 2017 Indonesian Demographic Health Surveys

This study attempted to examine individual- and community-level factors that contribute to pregnancy-related health behaviors among Indonesian women. This study used representative nationwide survey samples from the Indonesian Demographic Health Survey in the years 2007 (N = 15 193), 2012 (N = 14 431), and 2017 (N = 14 797). Generalized linear mixed models were constructed in the multivariate analyses. We found that women’s educational level, household wealth index, insurance status, access to health facilities, geographic location, general health condition, and pregnancy intentions were significantly associated with different outcome behaviors. Regarding community-level influences, women who lived in communities with a high proportion of educated women and high household wealth were more likely to have skilled birth attendance during childbirth compared with their counterparts in 2007. The similar pattern of results was also found in 2012 and 2017. The findings of this study suggest that future policies should focus on both individual- and community-level factors to improve women’s pregnancy-related behaviors.

Gender inequity as a barrier to women's access to skilled pregnancy care in rural Nigeria: a qualitative study

BACKGROUND

Maternal mortality has been an issue of global importance, with continued efforts by the international development community towards its reduction. The provision of high quality maternal healthcare has been identified as a key strategy in preventing maternal mortality. Gendered intrahousehold power structures, gendered dynamics of resource allocation and women's limited ability in decision-making can have a huge impact on maternal health-seeking behaviour and overall health status. Using a gender lens, this study explores the root causes of women's limited access to and utilisation of maternal healthcare services in rural areas of Edo State, Nigeria.

METHODS

This qualitative study involved the analysis of data collected from gender- and age-desegregated focus group discussions (FDGs) in 20 communities in Etsako East and Esan South East local government areas of Edo State, Nigeria. Focus group participants comprised women between the ages of 15-45 y who have been pregnant within the last 5 y and their male spouses and partners of varying ages. A total of 20 FGDs were conducted. Coded transcripts were reviewed and analysed using the gender framework as an analytical guide.

RESULTS

Most responses indicated that women did not entirely have the power to make decisions regarding when to seek care during pregnancy. Women's experiences of access to quality care showed intersecting areas of gender and social economic status (SES) and how they impact on access to health. Many of the responses suggested high levels of economic marginalisation among women with women being financially dependent on their spouses and partners for pregnancy healthcare-related costs. Furthermore, a man's financial status determined the type of care his spouse or partner sought. Women identified a high workload as an issue during pregnancy and a barrier to accessing maternal healthcare services. The role of men within households was generally perceived as that of financial providers, therefore a husband's support was commonly constructed to solely mean financial support.

CONCLUSION

This paper brings attention to the role of gender and SES in producing and sustaining limitations to women's access to quality care. Interventions geared towards supporting women's financial independence is an important step towards improving their access to skilled healthcare, more so are interventions that improve women's decision-making capacities.

Factors associated with the upsurge in the use of delivery care services in Sierra Leone

OBJECTIVES

Most African countries have poor maternal and reproductive health outcomes. This is due, in part, to many factors such as accessibility issues, which hinder women in developing countries from using life-saving maternal and reproductive health services. Therefore, this study considered two main objectives: (i) to examine prevalence of delivery care services in Sierra Leone; and (ii) to identify sociodemographic factors associated with the use of the aforementioned health services.

STUDY DESIGN

A secondary analysis was undertaken using data from the Sierra Leone Demographic and Health Surveys.

METHODS

Bivariate and multivariate analyses were used to study the prevalence and factors associated with the use of delivery care services in Sierra Leone.

RESULTS

The findings show a general increase in the use of delivery care services between 2008 and 2013, although the use of these services remains quite low. The multivariate analysis shows that maternal age, marital status, socio-economic status, the number of living children, decision-making power, media exposure, skilled antenatal care, and geographic location are crucial factors in the use of delivery care services.

CONCLUSIONS

Use of delivery care services remains low in Sierra Leone. It is possible that the introduction of the Free Healthcare Initiative played a vital role in increasing the use of these services. Further policy debates are needed to ensure universal coverage.

A qualitative study of community elders' perceptions about the underutilization of formal maternal care and maternal death in rural Nigeria

BACKGROUND

Underutilization of formal maternal care services and accredited health attendants is a major contributor to the high maternal mortality rates in rural communities in Nigeria. Perceptions of a poor quality of care and inaccessible services in health facilities strongly influence the low use of formal maternal care services. There is therefore a need to understand local perceptions about maternal health services utilization and maternal death. This study thereby aims to explore perceptions and beliefs about the underutilization of formal care and causes of maternal death, as well as to identify potential solutions to improve use and reduce maternal mortality in rural Nigeria.

METHODS

Data were collected through 9 community conversations, which were conducted with 158 community elders in 9 rural communities in Edo State, Nigeria. Data from transcripts were analyzed through inductive thematic analysis using NVivo 12 software.

RESULTS

Perceived reasons for the underutilization of formal maternal care included poor qualities of care, physical inaccessibility, financial inaccessibility, and lack of community knowledge. Perceived reasons for maternal death were related to medical causes, maternal healthcare services deficiencies, uptake of native maternal care, and poor community awareness and negligence. Elders identified increased access to adequate maternal care, health promotion and education, community support, and supernatural assistance from a deity as solutions for increasing use of formal maternal care and reducing maternal mortality rates.

CONCLUSION

Study results revealed that multifaceted approaches that consider community contexts, challenges, and needs are required to develop acceptable, effective and long-lasting positive changes. Interventions aiming to increase use of formal care services and curb maternal mortality rates must target improvements to the technical and interpersonal qualities of care, ease of access, community awareness and knowledge, and allow community members to actively engage in implementation phases.

Home childbirth among young mothers aged 15-24 years in Nigeria: a national population-based cross-sectional study

OBJECTIVE

To estimate the prevalence and identify factors associated with home childbirth (delivery) among young mothers aged 15-24 years in Nigeria.

DESIGN

A secondary analysis of cross-sectional data from the 2013 Nigeria Demographic and Health Survey (NDHS).

SETTING

Nigeria.

PARTICIPANTS

A total of 7543 young mothers aged 15-24 years.

OUTCOME MEASURE

Place of delivery.

RESULTS

The prevalence of home delivery among young mothers aged 15-24 years was 69.5% (95% CI 67.1% to 71.8%) in Nigeria-78.9% (95%CI 76.3% to 81.2%) in rural and 43.9% (95%CI 38.5% to 49.5%, p<0.001) in urban Nigeria. Using the Andersen's behavioural model, increased odds of home delivery were associated with the two environmental factors: rural residence (adjusted OR, AOR: 1.39, 95% CI 1.06 to 1.85) and regions of residence (North-East: AOR: 1.97, 95% CI 1.14 to 3.34; North-West: AOR: 2.94, 95% CI 1.80 to 4.83; and South-South: AOR: 3.81, 95% CI 2.38 to 6.06). Three of the enabling factors (lack of health insurance: AOR: 2.34, 95% CI 1.16 to 4.71; difficulty with distance to healthcare facilities: AOR: 1.48, 95% CI 1.15 to 1.88; and <4 times antenatal attendance: AOR: 3.80, 95% CI 3.00 to 4.85) similarly increased the odds of home delivery. Lastly, six predisposing factors-lack of maternal and husband's education, poor wealth index, Islamic religion, high parity and low frequency of listening to radio-were associated with increased odds of home delivery.

CONCLUSIONS

Young mothers aged 15-24 years had a higher prevalence of home delivery than the national average for all women of reproductive age in Nigeria. Priority attention is required for young mothers in poor households, rural areas, North-East, North-West and South-South regions. Faith-based interventions, a youth-oriented antenatal care package, education of girls and access to health insurance coverage are recommended to speed up the reduction of home delivery among young mothers in Nigeria.

Multilevel Factors Associated With Pregnancy-Related Health Behaviors in Indonesia: Evidence From the 2007, 2012, and 2017 Indonesian Demographic Health Surveys

Indonesia has one of the highest maternal mortality rates among Southeast Asia countries. Mothers' pregnancy-related behaviors were proven to be the major determinants of maternal mortality. This study attempted to measure individual- and community-level factors that contribute to pregnancy-related health behaviors among Indonesian women. This study used representative nationwide survey samples among women aged 15 to 49 years from the Indonesian Demographic Health Survey in the years 2007 (N = 15 314), 2012 (N = 15 197), and 2017 (N = 15 300). Generalized linear mixed models were constructed to simultaneously analyze relationships of pregnancy-related health behaviors with other individual- and community-level explanatory factors. We found that women's educational level, household wealth index, insurance status, access to health facilities, geographic location, general health condition, pregnancy intentions, and community-level socioeconomic status were significantly associated with different outcome behaviors. The findings of this study suggest that future policies should focus on both individual- and community-level factors to improve women's pregnancy-related behaviors.

Why rural women do not use primary health centres for pregnancy care: evidence from a qualitative study in Nigeria

BACKGROUND

While Primary Health Care has been designed to provide universal access to skilled pregnancy care for the prevention of maternal deaths in Nigeria, available evidence suggests that pregnant women in rural communities often do not use Primary Health Care Centres for skilled care. The objective of this study was to investigate the reasons why women do not use PHC for skilled pregnancy care in rural Nigeria.

METHODS

Qualitative data were obtained from twenty focus group discussions conducted with women and men in marital union to elicit their perceptions about utilisation of maternal and child health care services in PHC centres. Groups were constituted along the focus of sex and age. The group discussions were tape-recorded, transcribed verbatim and analyzed thematically.

RESULTS

The four broad categories of reasons for non-use identified in the study were: 1) accessibility factors - poor roads, difficulty with transportation, long distances, and facility not always open; 2) perceptions relating to poor quality of care, including inadequate drugs and consumables, abusive care by health providers, providers not in sufficient numbers and not always available in the facilities, long waiting times, and inappropriate referrals; 3) high costs of services, which include the inability to pay for services even when costs are not excessive, and the introduction of informal payments by staff; and 4) Other comprising partner support and misinterpretation of signs of pregnancy complications.

CONCLUSION

Addressing these factors through adequate budgetary provisions, programs to reduce out-of-pocket expenses for maternal health, adequate staffing and training, innovative methods of transportation and male involvement are critical in efforts to improve rural women's access to skilled pregnancy care in primary health care centres in the country.

Timing between age at first sexual intercourse and age at first use of contraception among adolescents and young adults in Niger: What role do education and place of residence play?

Background: Low contraceptive use among women in Niger is one of main causes of early childbearing and unwanted pregnancies, which affect maternal and child health. Education and place of residence have been cited as factors affecting modern contraceptive use. Methods: We investigated the separate and joint effects of the place of residence and education on the time to modern contraceptive uptake among women aged 15-24 in Niger. The study used data from the second round of the 2016 Niger Performance Monitoring and Accountability 2020 (PMA2020) project. Survival analysis was applied for 830 women. Results: Nelson-Aalen curves show that urban women had higher hazards of (and shorter delays in) modern contraceptive uptake as compared to their rural counterparts. Also, the higher the level of education, the higher the hazards of (and the shorter the delays in) modern contraceptive uptake. Findings from the multivariate (survival) analysis confirms these figures and provides the net effect of the place of residence on modern contraceptive uptake. Whether living in urban or rural areas of Niger, what matters more is the level of education. Conclusions: Family planning programmes concerning adolescent and young women should focus more on women with no education and those that are illiterate.

Assessing the link between endorsing attitudes justifying partner abuse and reproductive health care utilization among women in Lao PDR

Objective: Evidence from developing countries on the association between women's endorsement of attitudes justifying partner abuse and their use of reproductive health services is suggestive but inconclusive. This study uses a nationally representative dataset from Lao PDR to provide strong evidence for the relationship between women's endorsement of attitudes justifying partner abuse and use of reproductive health services. Methods: This study used data from the 2011-2012 Lao Social Indicator survey (LSIS). The analyses were performed on the responses of 4227 women. The exposure of interest in this study was endorsement of attitudes justifying partner abuse. Antenatal care (ANC) visits divided according to amount and quality, delivery care by type and place, and utilization of postnatal care (PNC) for mothers and newborn infants were used as representative outcome variables of reproductive health service utilization. Results: Approximately seven out of ten respondents (67.9%) believed that partner abuse was justified. Women who endorsed these attitudes were significantly less likely to receive any ANC, to seek institutional delivery, and to use trained medical personnel for delivery assistance. Endorsing attitudes were associated with reduced probability of receiving PNC services for mothers and newborn infants, reduced frequency of ANC visits, and receiving a fewer number of ANC components. Other sociodemographic factors likely to affect the increased utilization of several of the indicators of reproductive health care were living in the central region, belonging to the high bands of wealth, having higher level of education, being a young adult (20-34 years) or older (35-49 years), residing in urban areas, and being sexually empowered. Conclusions: In addition to a broad range of sociodemographic factors, our findings suggested that women's endorsement of attitudes justifying partner abuse should be treated as an important psychosocial determinant of reproductive health care service utilization in Lao PDR.

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.

Gender norms and modern contraceptive use in urban Nigeria: a multilevel longitudinal study

Background

Evidence suggests that gender equality positively influences family planning. However, the evidence from urban Africa is sparse. This study aimed to examine the association between changes in gender norms and modern contraceptive use over time among women in urban Nigeria.

Methods

Data were collected in 2010/2011 from 16,118 women aged 15–49 living in six cities in Nigeria (Abuja, Benin, Ibadan, Ilorin, Kaduna, and Zaria) and again in 2014 from 10,672 of the same women (34% attrition rate). The analytical sample included 9933 women living in 480 neighborhoods. A four-category outcome variable measured their change in modern contraceptive use within the study period. The exposure variables measured the changes in the level of gender-equitable attitudes towards: a) wife beating; b) household decision-making; c) couples’ family planning decisions; and d) family planning self-efficacy. Multilevel multinomial logistic regression models estimated the associations between the exposure variables at the individual and neighborhood levels and modern contraceptive use controlling for the women’s age, education, marital status, religion, parity, household wealth, and city of residence.

Results

The proportion of women who reported current use of modern contraceptive methods increased from 21 to 32% during the four-year study period. At both surveys, 58% of the women did not report using modern contraceptives while 11% reported using modern contraceptives; 21% did not use in 2010/2011 but started using by 2014 while 10% used in 2010/2011 but discontinued use by 2014. A positive change in the gender-equitable attitudes towards household decision-making, couples’ family planning decisions, and family planning self-efficacy at the individual and neighborhood levels were associated with increased relative probability of modern contraceptive use (adoption and continued use) and decreased relative probability of modern contraceptive discontinuation by 2014. No such associations were found between the individual and neighborhood attitudes towards wife beating and modern contraceptive use. Accounting for the individual and neighborhood gender-equitable attitudes and controlling for the women’s demographic characteristics accounted for 55–61% of the variation between neighborhoods in the change in modern contraceptive use during the study period.

Conclusion

Interventions that promote gender equality have the potential to increase modern contraceptive use in Nigerian cities.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0664-3) contains supplementary material, which is available to authorized users.

Education is the antidote: Individual- and community-level effects of maternal education on child immunizations in Nigeria

Nigeria is an interesting case study because it outperforms other lower middle-income countries in economic development, yet ranks among the lowest in the world in immunization coverage rates. Combining multi-level modeling with spatial data techniques, this study investigates the individual- and community-level factors that influence the likelihood that a child is fully immunized, underscoring the importance of maternal education for improving child health. Drawing on data from the Demographic and Health Surveys and the Global Administrative Areas database, the analysis pools data on children aged 12-24 months across 455 communities. The spatial analysis reveals substantial geographic gaps in immunization coverage across Nigeria, demonstrating that not everyone benefits from the purported benefits of economic growth. Results from the multi-level models indicate that women's education has a robust association with vaccinations at the individual level and at the community level, even net of a variety of other household and community characteristics. The education level of a child's own mother influences the likelihood of being immunized, but above and beyond that, living in a community in which many women are educated also influences that likelihood. This suggests that education has a protective effect on child health not only because more individual women are going to school, but also because everyone benefits from the education and empowerment of women in the community. As broad societal transformations take place, education may shape women's capacity to take advantage of better access to power and resources, resulting in a dispersion effect of expanded women's education on health.

Predictors of women's utilization of primary health care for skilled pregnancy care in rural Nigeria

BACKGROUND

Although Primary Health Care (PHC) was designed to provide universal access to skilled pregnancy care for the prevention of maternal deaths, very little is known of the factors that predict the use of PHC for skilled maternity care in rural parts of Nigeria - where its use is likely to have a greater positive impact on maternal health care. The objective of this study was to identify the factors that lead pregnant women to use or not use existing primary health care facilities for antenatal and delivery care.

METHODS

The study was a cross-sectional community-based study conducted in Esan South East and Etsako East LGAs of Edo State, Nigeria. A total of 1408 randomly selected women of reproductive age were interviewed in their households using a pre-tested structured questionnaire. The data were analyzed with descriptive and multivariate statistical methods.

RESULTS

The results showed antenatal care attendance rate by currently pregnant women of 62.1%, and a skilled delivery of 46.6% by recently delivered women at PHCs, while 25% of women delivered at home or with traditional birth attendants. Reasons for use and non-use of PHCs for antenatal and delivery care given by women were related to perceptions about long distances to PHCs, high costs of services and poor quality of PHC service delivery. Chi-square test of association revealed that level of education and marital status were significantly related to use of PHCs for antenatal care. The results of logistic regression for delivery care showed that women with primary (OR 3.10, CI 1.16-8.28) and secondary (OR 2.37, CI 1.19-4.71) levels education were more likely to receive delivery care in PHCs than the highly educated. Being a Muslim (OR 1.56, CI 1.00-2.42), having a partner who is employed in Estako East (OR 2.78, CI 1.04-7.44) and having more than five children in Esan South East (OR 2.00, CI 1.19-3.35) significantly increased the odds of delivery in PHCs. The likelihood of using a PHC facility was less for women who had more autonomy (OR 0.75, CI 0.57-0.99) as compared to women with higher autonomy.

CONCLUSION

We conclude that efforts devoted to addressing the limiting factors (distance, costs and quality of care) using creative and innovative approaches will increase the utilization of skilled pregnancy care in PHCs and reduce maternal mortality in rural Nigeria.

Determinants of Antenatal Healthcare Utilisation by Pregnant Women in Third Trimester in Peri-Urban Ghana

Access to quality healthcare still remains a major challenge in the efforts at reversing maternal morbidity and mortality. Despite the availability of established maternal health interventions, the health of the expectant mother and the unborn child remains poor due to low utilisation of interventions. The study examined the socioeconomic determinants of antenatal care utilisation in peri-urban Ghana using pregnant women who are in their third trimester. Two-stage sampling technique was used to sample 200 pregnant women who were in their third trimester from the District Health Information Management System software. Well-structured questionnaire was the instrument used to collect data from respondents. Descriptive statistics and inferential statistics including binary logit regression model were used to analyse the data with the help of SPSS and STATA software. The results showed varying utilisation levels of ANC. From the regression result, age, household size, and occupational status were identified as the important socioeconomic determinants of antenatal care utilisation among the respondents. The important system factors which influence antenatal care utilisation by the respondents are distance to ANC, quality of service, and service satisfaction. The study concludes that socioeconomic and health system factors are important determinants of antenatal care utilisation. Stepping up of interventions aimed at improving the socioeconomic status and addressing health system and proximity challenges could be helpful in improving antenatal care utilisation by pregnant women in Ghana.

Factors influencing Indonesian women's use of maternal health care services

Employing the 2012 Indonesia Demographic and Health Survey data, we aimed to examine factors influencing married women to use maternity services. Data of married women who had given birth in the last five years before the survey were included in the analysis (n = 14,672). Factors of education, employment, women's age at first marriage, age at first birth, spousal education difference, contraceptive use, place of residence, and woman's attitude toward wife beating were associated with the use of antenatal care, institutional delivery, and postnatal care services. The likelihood of women using those recommended maternal health care services increased along with the increased educational attainment among women and their spouses, and the older age at first birth. Higher schooling years may contribute to improving adequate maternal health care. Community awareness on maternal health issues should be promoted and include the prevention of early marriage, teenage pregnancies, and domestic violence.

Women's autonomy and maternal healthcare service utilization in Ethiopia

Background

Most previous studies on healthcare service utilization in low-income countries have not used a multilevel study design to address the importance of community-level women’s autonomy. We assessed whether women’s autonomy, measured at both individual and community levels, is associated with maternal healthcare service utilization in Ethiopia.

Methods

We analyzed data from the 2005 and 2011 Ethiopia Demographic and Health Surveys (N = 6058 and 7043, respectively) for measuring women’s decision-making power and permissive gender norms associated with wife beating. We used Spearman’s correlation and the chi-squared test for bivariate analyses and constructed generalized estimating equation logistic regression models to analyze the associations between women’s autonomy indicators and maternal healthcare service utilization with control for other socioeconomic characteristics.

Results

Our multivariate analysis showed that women living in communities with a higher percentage of opposing attitudes toward wife beating were more likely to use all three types of maternal healthcare services in 2011 (adjusted odds ratios = 1.21, 1.23, and 1.18 for four or more antenatal care visits, health facility delivery, and postnatal care visits, respectively). In 2005, the adjusted odds ratios were 1.16 and 1.17 for four or more antenatal care visits and health facility delivery, respectively. In 2011, the percentage of women in the community with high decision-making power was positively associated with the likelihood of four or more antenatal care visits (adjusted odds ratio = 1.14). The association of individual-level autonomy on maternal healthcare service utilization was less profound after we controlled for other individual-level and community-level characteristics.

Conclusions

Our study shows that women’s autonomy was positively associated with maternal healthcare service utilization in Ethiopia. We suggest addressing woman empowerment in national policies and programs would be the optimal solution.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2670-9) contains supplementary material, which is available to authorized users.

WOMEN'S EMPOWERMENT, HOUSEHOLD STATUS AND CONTRACEPTION USE IN GHANA

Gender inequality is often cited as a barrier to improving women's sexual and reproductive health outcomes, including contraceptive use, in low- and middle-income countries such as those in sub-Saharan Africa. To date there is limited, recent, evidence available regarding women's empowerment, household status and contraceptive use in Ghana. The objective of this study was to investigate whether women's empowerment and status in the household were associated with contraceptive use and unmet need for contraception using the 2014 Ghana Demographic and Health Survey. The study sample consisted of 1828 women aged 15-49. Women's empowerment was measured based on two composite indexes created by the DHS: attitudes towards intimate partner violence and decision-making. Women's status in the home was measured using indicators of work status, relationship to household head, control over monetary earnings and land ownership. Decision-making was found to be positively associated with contraceptive use and not having unmet need for contraception. Women who justified wife beating in one or more instances were less likely to use contraception, and more likely to have unmet need for contraception. Current or past employment and higher levels of male partner education were associated with contraceptive use. This study indicates that women's empowerment and household status are influential for contraceptive indicators. Future interventions aimed at improving contraceptive uptake and use should promote women's empowerment, i.e. decision-making, self-worth and education.

Payment for Health Care and Perception of the National Health Insurance Scheme in a Rural Area in Southwest Nigeria

Health insurance coverage of the informal sector is a challenge in Nigeria. This study assessed the methods of payment for health care and awareness about the National Health Insurance Scheme (NHIS) among members of selected households in a rural area in the southwest of Nigeria. Using a multistage sampling technique, a semi-structured, pretested interviewer-administered questionnaire was used to collect data from 345 households. The majority of the people still pay for health care by out-of-pocket (OOP) method. Awareness about the NHIS in Nigeria was poor, but attitude to it was encouraging; and from the responses obtained, the people implied that they were willing to enroll in the scheme if the opportunity is offered. However, lack of trust in government social policies, religious belief, and poverty were some of the factors that might impede the implementation and expansion of the NHIS in the informal sector. Stakeholders should promote socioculturally appropriate awareness program about the NHIS and its benefits. Factors that might present challenges to the scheme should be adequately addressed by the government and other stakeholders associated with prepayment schemes in Nigeria.