Abstract
BackgroundIn low- and middle-income countries, the proportion of pregnant women who use health facilities for delivery remains low. Although delivering in a health facility with skilled health providers can make the critical difference between survival and death for both mother and child, in 2016, more than 25% of pregnant women did not deliver in a health facility in Uganda. This study examines the association of contextual factors measured at the community-level with use of facility-based delivery in Uganda, after controlling for household and individual-level factors.MethodsPooled household level data of 3310 observations of women who gave birth in the last five years is linked to community level data from the Uganda National Panel Survey (UNPS). A multilevel model that adequately accounted for the clustered nature of the data and the binary outcome of whether or not the woman delivered in a health facility was estimated.ResultsThe study findings show a positive association at the county level between place of delivery, education and access to health services, and a negative association between place of delivery and poverty. Individuals living in communities with a high level of education amongst the household heads were 1.67 times (95% Confidence Interval: 1.07–2.61) more likely to have had a facility-based delivery compared to women living in communities where household heads did not have high levels of education. Women who lived in counties with a short travel time (less than 33 min) were 1.66 times (95% CI: 1.11–2.48) more likely to have had a facility-based delivery compared to women who lived in counties with longer travel time to any health facility. Women living in poor counties were only 0.64 times (95% CI: 0.42–0.97) as likely to have delivered in a health facility compared to pregnant women from communities with more affluent individuals.ConclusionsThe findings on household head’s education, community economic status and travel time to a health facility are useful for defining the attributes for targeting and developing relevant nation-wide community-level health promotion campaigns. However, limited evidence was found in broad support of the role of community level factors.
Highlights
In low- and middle-income countries, the proportion of pregnant women who use health facilities for delivery remains low
In a study in northern Uganda that examined the factors underlying the antenatal care versus facility delivery gap, the results showed that primary barriers to subsequent delivery at a health facility after an antenatal visit included fear of maltreatment by health workers, socio-cultural and gender issues, lack of spousal support, challenges related to transportation and poverty [32]
The study findings revealed that individuals living in communities with a high level of education amongst the household heads were 1.67 times more likely to have had a facility-based delivery compared to women living in communities where household heads did not have high levels of education
Summary
In low- and middle-income countries, the proportion of pregnant women who use health facilities for delivery remains low. In 2015 alone, an estimated 303,000 women died worldwide during and after pregnancy and childbirth [1] Almost all of these women live in low- and middle- income countries. In Uganda, 5700 pregnant women died in 2015 and an estimated 34,151 children were still born [1, 2] Most of these deaths could have been prevented. This is because these deaths arise from pregnancy related complications such as unsafe abortions, high blood pressure during pregnancy, and delivery complications that may be adequately managed in a health facility by a skilled provider [3]
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