Geospatial analysis of antenatal care utilization and skilled birth attendance in Zimbabwe

BackgroundInequalities in access to and utilization of skilled birth attendants (SBA) present a substantial challenge in low- and middle-income countries, hindering progress towards achieving universal health coverage in maternal health. Countries should regularly monitor inequality in access to SBA at both national and subnational levels. Therefore, this study aimed to measure socioeconomic inequalities and the contributing factors to the utilization of SBA among postpartum women in Ethiopia.MethodWe used secondary data from the second cohort’s 6-week postpartum survey in combination with the baseline data of the Performance Monitoring for Action Ethiopia longitudinal study, conducted between November 2021 and October 2022. The study employed a multistage stratified cluster sampling technique to select 1,966 postpartum women. Socioeconomic inequality in the utilization of SBA was measured using the Erreygers Normalized Concentration Index (ECI) and visualized by a concentration curve. A concentration index decomposition analysis was conducted to identify the factors that contribute to the socioeconomic related health inequality in the utilization of SBA.ResultUtilization of SBA was 61.6% (95% CI: 59.0–64.0) in Ethiopia. The concentration curve in the utilization of SBA lay below the line of equality, and the ECI was 0.5308, with a standard error of 0.0398 and a p value < 0.001, demonstrating that the utilization of SBA was disproportionally concentrated among women belonging to the highest socioeconomic status. The concentration index decomposition analysis showed that household wealth index (40.3%), educational level (16.5%), place of residence (16.5%), antenatal care visits (15.7%), administrative regions (5.3%), and use of maternal waiting homes (2.9%) were the contributing factors to the socioeconomic inequality in the utilization of SBA in Ethiopia.ConclusionWe found a strong pro-rich socioeconomic related health inequality in the utilization of SBA in Ethiopia. Therefore, the government and responsible stakeholders need to implement targeted interventions such as improving health literacy, improving the coverage of antenatal care four visits, promoting the utilization of maternal waiting homes, and establishing financial support mechanisms for economically disadvantaged women to reduce the observed socioeconomic related health inequality in utilizing SBA.

BackgroundSkilled birth attendants (SBAs) provide important interventions that improve maternal and neonatal health and reduce maternal and neonatal mortality. However, utilization and coverage of services by SBAs remain poor, especially in rural and remote areas of Nepal. This study examined the characteristics associated with utilization of SBA services in mid- and far-western Nepal.MethodsThis cross-sectional study examined three rural and remote districts of mid- and far-western Nepal (i.e., Kanchanpur, Dailekh and Bajhang), representing three ecological zones (southern plains [Tarai], hill and mountain, respectively) with low utilization of services by SBAs. Enumerators assisted a total of 2,481 women. All respondents had delivered a baby within the past 12 months. We used bivariate and multivariate analyses to assess the association between antenatal and delivery care visits and the women’s background characteristics.ResultsFifty-seven percent of study participants had completed at least four antenatal care visits and 48% delivered their babies with the assistance of SBAs. Knowing the danger signs of pregnancy and delivery (e.g., premature labor, prolonged labor, breech delivery, postpartum hemorrhage, severe headache) associated positively with four or more antenatal care visits (OR = 1.71; 95% CI: 1.41-2.07). Living less than 30 min from a health facility associated positively with increased use of both antenatal care (OR = 1.44; 95% CI: 1.18-1.77) and delivery services (OR = 1.25; CI: 1.03-1.52). Four or more antenatal care visits was a determining factor for the utilization of SBAs.ConclusionsLess than half of the women in our study delivered babies with the aid of SBAs, indicating a need to increase utilization of such services in rural and remote areas of Nepal. Distance from health facilities and inadequate transportation pose major barriers to the utilization of SBAs. Providing women with transportation funds before they go to a facility for delivery and managing transportation options will increase service utilization. Moreover, SBA utilization associates positively with women’s knowledge of pregnancy danger signs, wealth quintile, and completed antenatal care visits. Nepal’s health system must develop strategies that generate demand for SBAs and also reduce financial, geographic and cultural barriers to such services.

Utilization of skilled birth attendance during home delivery of pregnant women is proven to reduce complications during and after childbirth. Though the utilization of skilled birth attendance (SBA) during home delivery has increased significantly in recent times, the rate of utilizing skilled birth attendance is still low in several regions across India. The objective of this study is to analyze the prevalence and to identify the determinants of the utilization of skilled birth attendance during home delivery of pregnant women in India. To conduct this study, data and information from the Indian Demographic and Health Survey 2015-16 have been utilized. The sample size for this study is a weighted sample of 41,171 women. The sample consisted of women who had given a live birth in the three years preceding the survey. For women with more than one child, only the first live birth was considered. The binary logistic regression model and the log-binary logistic regression analysis have been applied as the adjusted odds ratios (AORs) with 95% confidence intervals for identifying the determinants of home-based skilled birth attendance during delivery. That allows us to select the most appropriate model for our study objective by ensuring that the determinants of skilled birth attendance for home delivery are accurately assessed based on the characteristics of the data. The analyses show that only 18.8% of women had utilized skilled birth attendance during delivery. Women residing in urban areas are more likely to utilize skilled birth attendance during home delivery (AOR: 1.14; 95% CI: 1.08-1.20). Women having higher education levels are associated with increased use of SBA during home delivery (AOR: 1.15; 95% CI: 1.04-1.28). Exposure to media is associated with increased utilization of SBA (AOR: 1.17; 95% CI: 1.11-1.23). Overweight women are also more likely to avail the SBA during home delivery (AOR: 1.11; 95% CI: 1.03-1.19). Women belonging to affluent households have higher odds of utilizing skilled birth attendance (AOR: 1.41; 95% CI: 1.33-1.49). Having 3+ tetanus injections is associated with the utilization of SBA (AOR: 1.56; 95% CI: 1.43-1.69). Women having 4+ antenatal care visits were more likely to utilize SBA (AOR: 1.81; 95% CI: 1.71-1.92). Women belonging to the Hindu religion were 1.12 times more likely to utilize SBA (AOR: 1.12; 95% CI: 1.07-1.18). Women with 1 to 3 birth orders were 1.40 times more likely to utilize skilled birth attendance during home delivery (AOR: 1.40; 95% CI: 1.30-1.51). The percentage of women utilizing skilled birth attendance during home delivery is still very low which is a matter of serious concern. Several factors have been found to be associated with the utilization of SBA during home delivery in India. As skilled birth attendance has significant positive health outcomes for pregnant women and newborns, efforts to increase the rate of SBA utilization during home delivery should be undertaken.

BackgroundEthiopia has high maternal mortality ratio and poor access to maternal health services. Attendance of at least four antenatal care (ANC) visits and delivery by a skilled birth attendant (SBA) are important in preventing maternal deaths. Understanding the reasons behind the poor use of these services is important in designing strategies to address the problem. This study aimed to determine the coverage of at least four ANC visits and delivery by a SBA and to identify determinants of utilisation of these services in three districts in South West Shoa Zone, Ethiopia.MethodsA cross-sectional survey of 500 women aged 15–49 years with a delivery in two years prior to the survey was conducted in Wolisso, Wonchi and Goro districts in February 2013. Data were collected using an interviewer administered questionnaire. Logistic regression models were used to explore determinants of ANC attendance and SBA at delivery.ResultsCoverage of at least four ANC visits and SBA at delivery were 45.5 and 28.6 %, respectively. Most institutional deliveries (69 %) occurred at the single hospital that serves the study districts. Attendance of at least four ANC visits was positively associated with wealth status, knowledge of the recommended number of ANC visits, and attitude towards maternal health care, but was negatively associated with woman’s age. SBA at delivery was negatively associated with parity and time to the health facility, but was positively associated with urban residence, wealth, knowledge of the recommended number of ANC visits, perceived good quality of maternal health services, experience of a pregnancy/delivery related problem, involvement of the partner/family in decision making on delivery place, and birth preparedness.ConclusionsRaising awareness about the minimum recommended number of ANC visits, tackling geographical inaccessibility, improving the quality of care, encouraging pregnant women to have a birth and complication readiness plan and community mobilisation targeting women, husbands, and families for their involvement in maternal health care have the potential to increase use of maternal health services in this setting. Furthermore, supporting health centres to increase uptake of institutional delivery services may rapidly increase coverage of delivery by SBA and reduce inequity.Electronic supplementary materialThe online version of this article (doi:10.1186/s12978-015-0067-y) contains supplementary material, which is available to authorized users.

Provision of quality antenatal care (QANC) services and delivery care by skilled health professionals can effectively reduce and manage complications throughout pregnancy and childbirth, leading to better maternal and neonatal health outcomes. The WHO recently updated its recommendation to at least eight antenatal care (ANC) visits. However, little is known about how QANC services and completion of eight or more ANC visits interact with skilled delivery care utilization. This study utilized data from Bangladesh Demographic and Health Survey 2017-18, including 4,457 pregnant women aged 15-49 years who had given birth three years preceding the survey. Descriptive statistics were employed to analyze the study population's characteristics and the proportion of skilled birth attendance (SBA) and facility delivery (FD) in Bangladesh. Multilevel mixed-effects logistic regression analyses were used to determine the strength of association of QANC services and completion of eight or more ANC visits with skilled delivery care utilization. Only one in five women received good QANC services, and one in eight completed eight or more ANC visits. The overall proportions of SBA and FD were 56.74% [95% CI: 55.27-58.20] and 53.85% [52.37-55.32] respectively. Women with eight or more ANC visits had significantly higher odds of utilizing SBA (OR: 2.11 [1.60-2.77]) and FD (OR: 2.19 [1.68-2.85]) compared to those with only 1-3 ANC visits. Likewise, good QANC services were associated with higher odds of SBA (OR: 1.72 [1.38-2.15]) and FD (OR: 1.56 [1.26-1.93]). This study highlights the significant positive association of QANC services and adherence to the WHO-recommended eight or more ANC visits with increased skilled delivery care utilization in Bangladesh. Strengthening policies and programs to enhance the quality and frequency of ANC services can promote skilled delivery care, ensuring safe motherhood and childbirth.

IntroductionSkilled birth attendants play an important role in reducing maternal mortality. Although Ethiopia has shown a remarkable reduction in maternal mortality, maternal health service utilization, such as skilled birth attendance, remains low. Thus, this study aims to assess the urban-rural disparity in skilled birth attendance in Ethiopia using the 2019 Ethiopian mini demographic health survey.Methods and materialsThe study was based on data obtained from demographic and health surveys in Ethiopia. A total weighted sample of 5,527 women who gave birth within 5 years preceding the survey was included. The result of descriptive statistics was reported using the frequency, percentages, graphs, and tables. A multivariate decomposition analysis was used to identify factors contributing to the disparity of skilled birth attendance across residence. Statistical significance was defined at a 95% confidence interval with a p-value of less than 0.05.ResultSkilled birth attendance utilization among women in Ethiopia was 49.8% (95% CI: 48.5–51.1). The disparity in skilled birth attendance coverage between urban and rural areas was significantly high (Urban coverage was 72.1% and rural coverage was 42.5%). Endowment coefficients (women’s characteristics) explained 88% of the urban-rural disparity in the magnitude of skilled birth attendance. Women with secondary and above educational status, four or more antenatal care visits, households with televisions and radio, women in the richest wealth index and women with five or more parity were the determinants that explained the urban-rural disparity in skilled birth attendance.Conclusion and recommendationsThere was a significant disparity in skilled birth attendance utilization between urban and rural areas. Factors like maternal education, wealth status, antenatal care visits, and media access explained the disparity. To attain equitable progress towards universal coverage of SBA, special efforts and resources should be targeted towards rural women. Initiatives aimed at enhancing access to health services and health care consultations for the rural community are also recommended.

BackgroundThe use of maternal health care is limited in India despite several programmatic efforts for its improvement since the late 1980's. The use of maternal health care is typically patterned on socioeconomic and cultural contours. However, there is no clear perspective about how socioeconomic differences over time have contributed towards the use of maternal health care in India.Methodology/Principal FindingsUsing data from three rounds of National Family Health Survey (NFHS) conducted during 1992–2006, we analyse the trends and patterns in utilization of prenatal care (PNC) in first trimester with four or more antenatal care visits and skilled birth attendance (SBA) among poor and nonpoor mothers, disaggregated by area of residence in India and three contrasting provinces, namely, Uttar Pradesh, Maharashtra and Tamil Nadu. In addition, we investigate the relative contribution of public and private health facilities in meeting the demand for SBA, especially among poor mothers. We also examine the role of salient socioeconomic, demographic and cultural factors in influencing aforementioned outcomes. Bivariate analyses, concentration curve and concentration index, logistic regression and multinomial logistic regression models are used to understand the trends, patterns and predictors of the two outcome variables. Results indicate sluggish progress in utilization of PNC and SBA in India and selected provinces during 1992–2006. Enormous inequalities in utilization of PNC and SBA were observed largely to the disadvantage of the poor. Multivariate analysis suggests growing inequalities in utilization of the two outcomes across different economic groups.ConclusionsThe use of PNC and SBA remains disproportionately lower among poor mothers in India irrespective of area of residence and province. Despite several governmental efforts to increase access and coverage of delivery services to poor, it is clear that the poor (a) do not use SBA and (b) even if they had SBA, they were more likely to use the private providers.

To understand the health-seeking behaviour of adolescent women in Bangladesh with respect to the use of maternal health services. Literature review of seven electronic databases: PubMed, ISI Web of Knowledge, PsycINFO, Embase, CINAHL, POPLINE and Global Health. Studies published in English between 1990 and 2013 which describe Bangladeshi adolescent women's healthcare-seeking behaviour during pregnancy, delivery and post-partum were included. Twelve studies were included in this review. 11 used quantitative methods and one used a mixed-methods approach. All studies included married adolescent women only. Women with lower educational levels are less likely to seek skilled maternal health services than those with higher levels of education. Use of maternal health services is also less common among rural married adolescent women than women in urban areas. Being part of the richest bands of wealth, having had previous experiences of childbirth and higher women's autonomy positively influence the use of skilled maternal health services among married adolescent women in Bangladesh. Antenatal care is a key predictor of the use of skilled birth attendants for delivery and post-natal care. Maternal health-related programmes should be designed targeting rural and uneducated married adolescent women in Bangladesh. More qualitative investigations are required to broaden our understanding on maternal health-seeking behaviour of both married and unmarried adolescent women.

BackgroundPregnancy-related complications and insufficiencies in antenatal care services are leading causes of maternal and infant morbidity and mortality in low-resource settings. However, there has been an undue focus on achieving a minimum number of Antenatal Care (ANC) visits without adequate focus on the factors affecting ANC service utilization. This secondary data analysis from the fifth round of the National Family Health Survey (NFHS-5, 2019-21) was conducted to estimate the coverage of adequate quality ANC service and its determinants in India.MethodsThe study sample included 176,877 women aged 15–49 years who had experienced a pregnancy in the last 5 years. The primary outcome variable was the utilization of ANC services by women during their last pregnancy assessed by the frequency of ANC visits and the quality of ANC services. Quality of ANC service utilisation was categorised as adequate quality, inadequate quality and ≥ 4 ANC visits and, inadequate quality and < 4 ANC visits. We performed multinomial logistic regression and reported relative risk ratio (RRR) along with 95% confidence intervals. We adjusted for sampling weight, clustering, and stratification in the sampling design.ResultsThe median (IQR) number of ANC visits attended by a woman during her previous pregnancy was 4 (IQR 3–7). A majority (59.25%) of the women reported availing of ≥ 4 antenatal care (ANC) visits during their previous pregnancy while 6.12% of women reported availing no ANC visits in their last pregnancy. Women aged ≥ 30 years were significantly less likely (aRRR 0.73 95% CI 0.66, 0.80) to receive ANC services of inadequate quality, and < 4 ANC visits. Additionally, any exposure to mass media (aRRR 0.69 95% CI 0.66, 0.73), and having health insurance (aRRR 0.71 95% CI 0.68, 0.75) decreased their risk of receiving inadequate quality ANC services and < 4 ANC visits. Women belonging to the richest wealth quintile (aRRR 0.52 95% CI 0.47,0.58) and those with an intended pregnancy (aRRR 0.62 95% CI 0.58 ,0.66) were at significantly lower risk of utilizing inadequate quality ANC services and < 4 ANC visits.ConclusionAlthough nearly 3 in 5 women in India utilized a minimum mandated ≥ 4 ANC visits during their last pregnancy, only one in five of those received adequate quality of ANC services indicating suboptimal content. However, only one in five women utilized the WHO-mandated ≥ 8 ANC visits for a positive pregnancy experience. Furthermore, 14.3% of the women received ANC services of inadequate quality despite attending ≥ 4 ANC visits in their previous pregnancy. Our study emphasized the importance of the quality of ANC services utilised irrespective of number of ANC visits availed. Efforts should be undertaken to enhance the utilization of antenatal care (ANC) services by implementing media initiatives that aim to raise awareness, particularly among women belonging to disadvantaged population groups.

Maternal mortality in northern Nigeria is among the highest in the world. To understand better the pathways through which the socio-demographic environment affects awareness of obstetric danger signs (i.e., potential problems associated with pregnancy), preparations for delivery, and skilled birth attendance, we conducted a survey of 5,083 women with recent pregnancies in three northern Nigerian states. Only 25% attended antenatal care (ANC), and 91% of all births took place at home. Less than one-third knew three or more danger signs of pregnancy or labor and delivery. Higher socioeconomic status was associated with knowledge of danger signs, but not with knowledge of life-threatening, critical danger signs. Antenatal care visits did not increase knowledge of critical danger signs, but they were associated with skilled birth attendance. Knowledge of critical pregnancy danger signs also was associated with skilled birth attendance. Improving the quality and coverage of ANC will ensure greater awareness of the critical danger signs. Future research is needed to identify creative and innovative ways to strengthen strategies for educating pregnant women about danger signs and in facilitating uptake of delivery services.

The Continuum of Care (CoC; defined as accessing the recommended healthcare services during pregnancy and the early postpartum period) is low in lower-middle-income countries (LMICs). This may be a major contributor to the high rates of pregnancy-related complications and deaths in LMICs, particularly among women who had an unintended pregnancy. With a lack of research on the subject in Bangladesh, we aimed to examine the effect of unintended pregnancy on CoC. Data from 4,493 mother-newborn dyads who participated in the cross-sectional 2014 Bangladesh Demographic and Health Survey were analysed. Women's level of CoC was generated from responses to questions on the use and non-use of three recommended services during the course of pregnancy: four or more antenatal care (ANC) visits, skilled birth attendance (SBA) during delivery, and at least one postnatal care (PNC) visit within 24 hours of giving birth. Global recommendations of service use were used to classify CoC as high (used each of the recommended services), moderate (used at least two of the three recommended services), and low/none (no PNC, no SBA, and ≤3 ANC visits). Women's pregnancy intention at the time of conception of their last pregnancy (ending with a live birth) was the major exposure variable, classified as wanted, mistimed, and unwanted. Unadjusted and adjusted (with individual-, household-, and community-level factors) multilevel multinomial logistic regression models were used to assess the association between unintended pregnancy and level of CoC. In Bangladesh, the highest level of CoC occurred in only 12% of pregnancies that ended with live births. This figure was reduced to 5.6% if the pregnancy was unwanted at conception. The antenatal period saw the greatest drop in CoC, with 65.13% of women receiving at least one ANC visit and 26.32% having four or more ANC visits. Following the adjustment of confounders, an unwanted pregnancy was found to be associated with 39% and 62% reduced odds of women receiving moderate and high levels of CoC, respectively, than those with a wanted pregnancy. Having a mistimed pregnancy was found to be associated with a 31% reduction in odds of women achieving a high CoC than women with a wanted pregnancy. Almost nine in ten women did not achieve CoC in their last pregnancy, which was even higher when the pregnancy was unintended. Given that the ANC period has been identified as a critical time for intervention for these women, it is necessary for policies to scale up current maternal healthcare services that provide in-home maternal healthcare services and to monitor the continuity of ANC, with a particular focus on women who have an unintended pregnancy. Integration of maternal healthcare services with family planning services is also required to ensure CoC.

BackgroundThe Continuum of Care (CoC; defined as accessing the recommended healthcare services during pregnancy and the early postpartum period) is low in lower-middle-income countries (LMICs). This may be a major contributor to the high rates of pregnancy-related complications and deaths in LMICs, particularly among women who had an unintended pregnancy. With a lack of research on the subject in Bangladesh, we aimed to examine the effect of unintended pregnancy on CoC.MethodsData from 4,493 mother-newborn dyads who participated in the cross-sectional 2014 Bangladesh Demographic and Health Survey were analysed. Women’s level of CoC was generated from responses to questions on the use and non-use of three recommended services during the course of pregnancy: four or more antenatal care (ANC) visits, skilled birth attendance (SBA) during delivery, and at least one postnatal care (PNC) visit within 24 hours of giving birth. Global recommendations of service use were used to classify CoC as high (used each of the recommended services), moderate (used at least two of the three recommended services), and low/none (no PNC, no SBA, and ≤3 ANC visits). Women’s pregnancy intention at the time of conception of their last pregnancy (ending with a live birth) was the major exposure variable, classified as wanted, mistimed, and unwanted. Unadjusted and adjusted (with individual-, household-, and community-level factors) multilevel multinomial logistic regression models were used to assess the association between unintended pregnancy and level of CoC.ResultsIn Bangladesh, the highest level of CoC occurred in only 12% of pregnancies that ended with live births. This figure was reduced to 5.6% if the pregnancy was unwanted at conception. The antenatal period saw the greatest drop in CoC, with 65.13% of women receiving at least one ANC visit and 26.32% having four or more ANC visits. Following the adjustment of confounders, an unwanted pregnancy was found to be associated with 39% and 62% reduced odds of women receiving moderate and high levels of CoC, respectively, than those with a wanted pregnancy. Having a mistimed pregnancy was found to be associated with a 31% reduction in odds of women achieving a high CoC than women with a wanted pregnancy.ConclusionAlmost nine in ten women did not achieve CoC in their last pregnancy, which was even higher when the pregnancy was unintended. Given that the ANC period has been identified as a critical time for intervention for these women, it is necessary for policies to scale up current maternal healthcare services that provide in-home maternal healthcare services and to monitor the continuity of ANC, with a particular focus on women who have an unintended pregnancy. Integration of maternal healthcare services with family planning services is also required to ensure CoC.

BackgroundThe continuum of care (CoC) for maternal health, which includes ≥4 antenatal care (ANC) visits, delivery assisted by skilled birth attendants, and a postnatal care (PNC) visit within 48 hours of delivery, is a crucial health care package associated with survival and improved health outcomes for children and mothers. In addition, the CoC serves as a platform for delivering messages and counseling on child feeding practices. However, the effect of maternal use of the CoC on complementary feeding practices in Bangladesh remains unexamined.ObjectiveThis study aimed to estimate the effect of maternal use of CoC on complementary feeding practices among children aged 6 to 23 months in Bangladesh.MethodsData from 2 consecutive nationally representative surveys—the Bangladesh Demographic and Health Survey 2017-2018 and 2022—were analyzed. Observations corresponding to the CoC for maternal health and complementary feeding indicators, including (1) timely introduction of solid, semisolid, and soft food (ISSSF); (2) minimum meal frequency (MMF); (3) minimum dietary diversity (MDD); and (4) minimum acceptable diet (MAD), were merged to prepare the analyzed samples. The differences in complementary feeding practice indicators by maternal use of the CoC were observed using chi-square tests. Multivariable logistic regression models were used to observe the associations.ResultsThe analysis included 887, 4967, 4967, and 4967 mother-child pairs for the timely ISSSF, MMF, MDD, and MAD indicators, respectively. The status of complementary feeding indicators was significantly different (P<.05) by maternal use of the full CoC, ≥4 ANC visits, status of receiving PNC within 48 hours of birth, maternal educational level, husband’s educational level, maternal occupation, wealth index of families, maternal perceived problems with accessing health care, and division of residence. Mothers who received the full CoC were 29% and 32% more likely to meet the MDD (adjusted odds ratio [AOR] 1.29, 95% CI 1.10-1.51; P=.002) and MAD (AOR 1.32, 95% CI 1.13-1.55; P=.001) than those who did not receive the full CoC, respectively. Among the individual components of the CoC, mothers who received ≥4 ANC visits were 23%, 31%, and 34% more likely to meet the MMF (AOR 1.23, 95% CI 1.05-1.45; P=.01), MDD (AOR 1.31, 95% CI 1.13-1.51; P<.001), and MAD (AOR 1.34, 95% CI 1.15-1.56; P<.001) than those with fewer ANC visits, respectively. Furthermore, the effects of delivery assisted by skilled birth attendants and receiving PNC within 48 hours of delivery on complementary feeding indicators were also statistically insignificant (P≥.05).ConclusionsMaternal use of the CoC appears to be effective in improving MDD and MAD among children aged 6 to 23 months in Bangladesh. The findings highlight the pivotal role of recommended ANC visits in promoting complementary feeding practices and further suggest opportunities to amplify the impact of CoC on timely ISSSF and MMF.

The fundamental approach to improve maternal and neonatal health is increasing skilled delivery rate. Women giving birth at health institutions can prevent maternal and neonatal deaths by getting skilled birth attendance. In Ethiopia, despite a significant decrease in maternal mortality over the past decade, still a significant number of women give birth at home. Moreover, evidence from population-based longitudinal studies on skilled delivery is limited. Therefore, this study aims to investigate the magnitude, trend, and determinants of skilled delivery in Kilite-Awlaelo Health Demographic Surveillance System (KA-HDSS), Northern Ethiopia. Population-based longitudinal study design was conducted by extracting data for nine consecutive years (2009-2017) from KA-HDSS database. In order to measure the trends of skilled delivery, KA-HDSS data sets were analyzed (2009-2017). Bivariate and multivariate analyses were performed using STATA version 16. A multivariable binary logistic regression model was fitted to assess determinants of skilled delivery and odds ratio with 95% CI was used to assess presence of associations at a 0.05 level of significance. The skilled delivery rate have continuously increased among reproductive age women from 15.12% (95% CI: 13.30% - 17.09%) in 2010 to 95.85% (95% CI: 94.58% - 96.895%) in 2017. The skilled delivery rate becomes high (> = 82) in the period of 2014-2017. Education, residence, marital status, occupation and antenatal care (ANC) visits were the most important determinants for skilled delivery among reproductive age women during the period of high skilled delivery rate (2014-2017). Women urban dwellers had about 28 times (AOR = 27.66; 95% CI: 3.86-196.97) higher odds to deliver by skilled birth attendants than rural dwellers. Unmarried women who gave birth were 2.18 (AOR: 2.18; 95% CI: 1.30-3.64) times more likely to have skilled delivery service compared to those married. Likewise, women with four or more ANC visits were 3.2 times more likely to undergo skilled delivery service than those having no ANC visits (AOR: 3.16; 95% CI: 2.33-4.28). Moreover, women having at least a secondary education were 2 times more likely to have skilled delivery service compared to those women with no formal education (AOR = 2.10, 95% CI: 1.18-3.74). Regardless of the importance of health facility delivery, a significant number of women still deliver at home attended by unskilled birth attendants. There has been a substantial increase in use of health facilities for delivery among women in the reproductive age. The factors affecting skilled delivery among reproductive age women were educational level, residence, marital status, occupation and use of ANC service. Maternal health related interventions are needed to change women's attitudes towards skilled delivery. Moreover, ANC coverage should be increased to improve skilled delivery service.

Evidence has suggested that maternal use of skilled birth attendant is the most important factor to reduce maternal mortality because of more than three-fourths of maternal deaths occur during child delivery or within 24 hours after delivery due to hemorrhage, hypertension, ruptured uterus and sepsis. In Ethiopia, more than 42% of pregnant women with 4+ antenatal care (ANC) visit did not deliver by skilled birth attendant. The factors for women not using skilled birth attendant after any ANC visit is not well-studied yet. Therefore, the aim of this study was to assess effect of quality antenatal care service on maternal use of skilled birth attendant after any antenatal care visit. This study was initiated using performance monitoring for action Ethiopia longitudinal panel survey datasets. A total of 1,511 postnatal women were included in the analysis. Generalized estimating equation Poisson regression model was used to assess the effect of quality ANC service on maternal use of skilled birth attendant by accounting the clustering nature of the data using Stata vers.16 software. This study showed that about 54% of women used skilled birth attendant during the current baby delivery (rate = 53.6%, 95% UI = 51-56%). Nearly, 39% of the women received quality (more than 75th percentile) ANC service (rate = 39.05%, 95% UI = 36-42%). The highest and the lowest antenatal care service the women received, respectively, were blood pressure measure (91.9%) and syphilis test (12.4%). Women who received better quality ANC service were 20% higher more likely to use skilled birth attendant compared to women who received low quality ANC service (adjusted IRR = 1.20, 95% UI = 1.11, 1.31). Maternal use of skilled birth attendant can be improved by providing quality ANC service during subsequent ANC visits. Improving ANC service delivery may encourage or positively reinforce women's and partner's decision to use skilled birth attendant.