Abstract
ABSTRACT.Facility births and antenatal care (ANC) are key to improving maternal health. This study evaluates the relationship between physician and nurse/midwife densities and the use of key maternal health services in sub-Saharan Africa (SSA). We matched individual-level maternal health service indicators from Demographic and Health Surveys between 2008 and 2017, to country-level physician and nurse/midwife per-capita densities, across 35 SSA countries. We performed univariate and multivariate probit regression analyses to evaluate the association between healthcare worker (HCW) densities and facility births as our primary outcome and additional ANC services as secondary outcomes. We controlled for established maternal health predictors, including literacy, child marriage, reported problems accessing healthcare, GDP per capita, political instability, and government effectiveness scores. HCW density across SSA was low at 0.13 physicians and 0.91 nurses/midwives per 1,000 people, compared with 2010 worldwide mean densities of 1.33 and 3.07, respectively. The probability of facility birth increased by 9.8% (95% CI: 2.1–17.5%) for every additional physician per 1,000 people and 8.9% (95% CI: 7.1–9.7%) for every additional nurse/midwife per 1,000 people. HCW densities were also associated with increased likelihood of ANC by the respective provider type, and with antenatal testing for preeclampsia (urine and blood pressure checks). Other ANC services demonstrated variable relationships with HCW densities based on provider type. In 35 SSA countries, HCW density was positively associated with many key measures of maternal health service utilization including facility birth and ANC testing for preeclampsia.
Highlights
Sub-Saharan Africa (SSA) has the world’s highest maternal mortality rate, with 546 deaths related to pregnancy or childbirth for every 100,000 live births, compared with only 12 in high-income countries.[1,2,3,4] As of 2017, an estimated 295,000 women die annually because of pregnancy complications, with the majority of those deaths occurring in sub-Saharan Africa (SSA).[5]
The objective of this study is to evaluate the relationship between healthcare worker (HCW) density and rates of facility births and antenatal care (ANC) visits, diagnostic testing, and treatment across SSA
Any tetanus vaccine during pregnancy 22.15** (22.7, 21.6) 1.35* (0.5, 2.2) 233.13 (236.5, 229.8) 222.41** (227.7, 217.1) 23.14**. In this investigation of the relationship between HCW densities, facility birth and ANC services in 35 SSA countries, we found that overall HCW density is extremely low in SSA
Summary
Sub-Saharan Africa (SSA) has the world’s highest maternal mortality rate, with 546 deaths related to pregnancy or childbirth for every 100,000 live births, compared with only 12 in high-income countries.[1,2,3,4] As of 2017, an estimated 295,000 women die annually because of pregnancy complications, with the majority of those deaths occurring in SSA.[5]. The leading causes of maternal mortality in SSA are postpartum hemorrhage and pre-eclampsia/eclampsia.[8,9,10] Multiple studies demonstrate that delivery in a healthcare facility with skilled HCWs who can diagnose and treat these emergencies can significantly lower maternal and neonatal mortality.[9,10,11] access to a well-equipped facility is only one determinant of morbidity and mortality and may be insufficient to prevent maternal mortality if the quality of care before, during, and after delivery are inadequate.[12] High-quality ANC is key to decreasing maternal mortality. ANC provides an opportunity to encourage delivery in a healthcare facility, and to screen for high-risk conditions such as pre-eclampsia, anemia, and infectious diseases.[13,14] Deworming medications, iron and nutritional supplements, and tetanus vaccinations given during ANC visits decrease the risk of anemia, birth defects, low birth weight, and neonatal tetanus.[13,15]
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