Maternal Health-seeking Behavior Research Articles

Impact of community-based surveillance and monitoring on maternal and neonatal health-seeking and utilization behaviors of women living in urban slums

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Rural-urban disparities in maternal immunization knowledge and childhood health-seeking behavior in Nigeria: A mixed method study

Immunization and appropriate health-seeking behavior are effective strategies to reduce child deaths. To compare maternal knowledge about immunization, use of growth chart and childhood health-seeking behavior in rural and urban areas. A cross-sectional comparative study done in Lagos, Nigeria. Questionnaire survey and focus group discussions were done. 300 respondents were selected by multi-stage sampling while discussants were purposively selected. Awareness of immunization was high but knowledge of vaccine preventable diseases (VPDs) was poor in both areas. Urban women utilized preventive services more; growth monitoring (p<0.001) and immunization (p<0.001) while higher proportions of rural women utilized nutritional counseling (p=0.005) and treatment of illness (p<0.001). Growth chart utilization was better in the urban areas (p<0.001). Increasing maternal education increased use of growth chart in both areas. Both groups of women use multiple treatment sources for children (more in urban), determined by cost, time, perceived severity of illness and type of ailment (urban) and peculiarity of illness (rural). There is a preference for orthodox care in the rural area. Knowledge of VPDs was poor and multiple treatment sources were common among rural and urban women. Education is vital to improve immunization knowledge and health-seeking behavior in both areas.

Understanding the psychosocial and environmental factors and barriers affecting utilization of maternal healthcare services in Kalomo, Zambia: a qualitative study

This qualitative study aimed to identify psychosocial and environmental factors contributing to low utilization of maternal healthcare services in Kalomo, Zambia. Twelve focus group discussions (n = 141) and 35 in-depth interviews were conducted in six health centre catchment areas. Focus group discussions comprised women of reproductive age (15-45 years), who gave birth within the last year; in-depth interviews comprised traditional leaders, mothers, fathers, community health workers and nurse-midwives. Perspectives on maternal health complications, health-seeking behaviour and barriers to utilization of maternal healthcare were explored. Most women showed insight into maternal health complications. Nevertheless, they started antenatal care visits late and did not complete the recommended schedule. Moreover, most women gave birth at home and did not use postnatal care. The main reasons for the low utilization were the low perceived quality of maternal healthcare services in clinics (negative attitude), negative opinion of important referents (subjective norms), physical and economic barriers such as long distances, high transport and indirect costs including money for baby clothes and other requirements. To improve, our findings suggest need for an integrated intervention to mitigate these barriers. Our findings also suggest need for further research to measure the elicited beliefs and determine their relevance and changeability.

Birthing choices among the Sabiny of Uganda

The paper examines maternal health-seeking behaviour among the Sabiny people of Eastern Uganda in relation to health policy ideals. It is based on a study of maternal health conducted between 2011 and 2012. Data were collected using in-depth interviews with mothers, focus group discussions with mothers and fathers and key informant interviews. The paper addresses what factors influence choice of place of delivery among the Sabiny. Findings reveal that the majority of Sabiny women opt for homebirths, with around one quarter delivering at health facilities. Some women would prefer to deliver at a health facility but do not manage to do so. Sabiny cultural beliefs and practices are a key factor influencing choice of place of birth. Comprehension of and accommodation to Sabiny concerns in available maternal health services is limited, highlighting the need to develop cultural competence among health workers and methods of accommodating (health-promoting) local practices. This should be accompanied by improved patient care and a narrowing of the gap between health workers and Sabiny communities by promoting outreach and community-based health interventions. The paper highlights how the implementation of policy might be tailored to specific local contexts.

Maternal Health-Seeking Behavior: The Role of Financing and Organization of Health Services in Ghana

This paper examines how organization and financing of maternal health services influence health-seeking behavior in Bosomtwe district, Ghana. It contributes in furthering the discussions on maternal health-seeking behavior and health outcomes from a health system perspective in sub-Saharan Africa. From a health system standpoint, the paper first presents the resources, organization and financing of maternal health service in Ghana, and later uses case study examples to explain how Ghana's health system has shaped maternal health-seeking behavior of women in the district. The paper employs a qualitative case study technique to build a complex and holistic picture, and report detailed views of the women in their natural setting. A purposeful sampling technique is applied to select 16 women in the district for this study. Through face-to-face interviews and group discussions with the selected women, comprehensive and in-depth information on health- seeking behavior and health outcomes are elicited for the analysis. The study highlights that characteristics embedded in decentralization and provision of free maternal health care influence health-seeking behavior. Particularly, the use of antenatal care has increased after the delivery exemption policy in Ghana. Interestingly, the study also reveals certain social structures, which influence women's attitude towards their decisions and choices of health facilities.

The Tanzania Connect Project: a cluster-randomized trial of the child survival impact of adding paid community health workers to an existing facility-focused health system

BackgroundTanzania has been a pioneer in establishing community-level services, yet challenges remain in sustaining these systems and ensuring adequate human resource strategies. In particular, the added value of a cadre of professional community health workers is under debate. While Tanzania has the highest density of primary health care facilities in Africa, equitable access and quality of care remain a challenge. Utilization for many services proven to reduce child and maternal mortality is unacceptably low. Tanzanian policy initiatives have sought to address these problems by proposing expansion of community-based providers, but the Ministry of Health and Social Welfare (MoHSW ) lacks evidence that this merits national implementation. The Tanzania Connect Project is a randomized cluster trial located in three rural districts with a population of roughly 360,000 ( Kilombero, Rufiji, and Ulanga).Description of interventionConnect aims to test whether introducing a community health worker into a general program of health systems strengthening and referral improvement will reduce child mortality, improve access to services, expand utilization, and alter reproductive, maternal, newborn and child health seeking behavior; thereby accelerating progress towards Millennium Development Goals 4 and 5. Connect has introduced a new cadre — Community Health Agents (CHA) — who were recruited from and work in their communities. To support the CHA, Connect developed supervisory systems, launched information and monitoring operations, and implemented logistics support for integration with existing district and village operations. In addition, Connect’s district-wide emergency referral strengthening intervention includes clinical and operational improvements.Evaluation designDesigned as a community-based cluster-randomized trial, CHA were randomly assigned to 50 of the 101 villages within the Health and Demographic Surveillance System (HDSS) in the three study districts. To garner detailed information on household characteristics, behaviors, and service exposure, a random sub-sample survey of 3,300 women of reproductive age will be conducted at the baseline and endline. The referral system intervention will use baseline, midline, and endline facility-based data to assess systemic changes. Implementation and impact research of Connect will assess whether and how the presence of the CHA at village level provides added life-saving value to the health system.DiscussionGlobal commitment to launching community-based primary health care has accelerated in recent years, with much of the implementation focused on Africa. Despite extensive investment, no program has been guided by a truly experimental study. Connect will not only address Tanzania’s need for policy and operational research, it will bridge a critical international knowledge gap concerning the added value of salaried professional community health workers in the context of a high density of fixed facilities.Trial registration: ISRCTN96819844

Individual and contextual factors associated with childhood stunting in Nigeria: a multilevel analysis.

Stunting, a form of undernutrition, is the best measure of child health inequalities as it captures multiple dimensions of children's health, development and the environment where they live. The aim of this study was to quantify the predictors of childhood stunting in Nigeria. This study used data obtained from the 2008 Nigeria Demographic and Health Survey (NDHS). A total of 28 647 children aged 0-59 months included in NDHS in 2008 were analysed in this study. We applied multilevel multivariate logistic regression analysis in which individual-level factors were at the first level and community-level factors at the second level. The percentage change in variance of the full model accounted for about 46% in odds of stunting across the communities. The present study found that the following predictors increased the odds of childhood stunting: male gender, age above 11 months, multiple birth, low birthweight, low maternal education, low maternal body mass index, poor maternal health-seeking behaviour, poor household wealth and short birth interval. The community-level predictors found to have significant association with childhood stunting were: child residing in community with high illiteracy rate and North West and North East regions of the country. In conclusion, this study revealed that both individual- and community-level factors are significant determinants of childhood stunting in Nigeria.

Socioeconomic factors differentiating maternal and child health-seeking behavior in rural Bangladesh: A cross-sectional analysis

BackgroundThere has been an increasing availability and accessibility of modern health services in rural Bangladesh over the past decades. However, previous studies on the socioeconomic differentials in the utilization of these services were based on a limited number of factors, focusing either on preventive or on curative modern health services. These studies failed to collect data from remote rural areas of the different regions to examine the socioeconomic differentials in health-seeking behavior.MethodsData from 3,498 randomly selected currently married women from three strata of households within 128 purposively chosen remote villages in three divisions of Bangladesh were collected in 2006. This study used bivariate and multivariate logistic analyses to examine both curative and preventive health-seeking behaviors in seven areas of maternal and child health care: antenatal care, postnatal care, child delivery care, mother's receipt of Vitamin A postpartum, newborn baby care, care during recent child fever/cough episodes, and maternal coverageby tetanus toxoid (TT).ResultsA principal finding was that a household's relative poverty status, as reflected by wealth quintiles, was a major determinant in health-seeking behavior. Mothers in the highest wealth quintile were significantly more likely to use modern trained providers for antenatal care, birth attendance, post natal care and child health care than those in the poorest quintile (χ2, p < 0.01). The differentials were less pronounced for other factors examined, such as education, age, and the relative decision-making power of a woman, in both bivariate and multivariate analyses.ConclusionWithin rural areas of Bangladesh, where overall poverty is greater and access to health care more difficult, wealth differentials in utilization remain pronounced. Those programs with high international visibility and dedicated funding (e.g., Immunization and Vitamin A delivery) have higher overall prevalence and a more equitable distribution of beneficiaries than the use of modern trained providers for basic essential health care services. Implications of these findings and recommendations are provided.

NON-UPTAKE OF FACILITY-BASED MATERNITY SERVICES IN AN INNER-CITY COMMUNITY IN LAGOS, NIGERIA: AN OBSERVATIONAL STUDY

Scaling-up of skilled attendants and facility-based services is necessary for improving maternal and child care in developing countries but their effectiveness is crucially influenced by the uptake of such services. This study set out to establish the pattern and uptake of maternity services and associated factors against the backdrop of rapid urbanization in Nigeria. A cross-sectional study of socio-demographic and obstetric characteristics of mothers attending the Bacille Calmette-Guérin (BCG) immunization clinics in inner-city Lagos was conducted from July 2005 to December 2007, and their association with non-hospital delivery and use of unskilled attendants was determined by multiple logistic regression analyses. Of the 6465 participants, over half (51.4%) delivered outside hospital facilities and 81.8% of this group had no skilled attendants at delivery. Non-hospital delivery or the presence of unskilled attendants at delivery was associated with teenage mothers, Muslim religion, low or middle social class and use of herbal drugs in pregnancy. Additionally, non-hospital delivery was associated with ethnicity (Yoruba tribe), lack of tertiary education or full-time employment, accommodation with shared sanitation facilities and multiparity. The results suggest that availability of and access/proximity to hospital facilities or skilled attendants is no guarantee of uptake of maternity services. Efforts aimed at improving maternal and child health in developing countries should take cognisance of the socio-demographic and cultural underpinnings of maternal health-seeking behaviour of urban mothers beyond the provision of facility-based services or strengthening of the existing health care systems.

Women’s Autonomy and Maternal Health-Seeking Behavior in Ethiopia

This paper examines the net effect of women's autonomy on their health seeking behavior in Ethiopia. We hypothesize that women with higher autonomy are more likely to seek health care during pregnancy and delivery than those with lower autonomy. The paper also examines whether the autonomy-health utilization relationship is influenced by individual (education, work status, religion) and, household (wealth and rural-urban residence) level factors, all of which are important for both autonomy and health-care utilization. Results indicate that women's autonomy remains significant even after adjusting for other individual and household variables. Besides autonomy, our results highlight other individual and household level influences on the health seeking behaviors of women in Ethiopia. Results also demonstrate the need to look beyond individual level factors when examining the health seeking behaviors of women in Ethiopia. The statistical significance of some individual-level measures, such as education means it cannot be used as proxy for women's autonomy. This calls for policy makers not only to empower women, but also provide them with better formal education.

A Multilevel Analysis of Individual and Community Effect on Chronic Childhood Malnutrition in Rural Nigeria

Protein energy malnutrition is the second most important cause of childhood morbidity and mortality in Nigeria after infections. The purpose of this article was to develop and test a model of childhood malnutrition that includes individual-level characteristics along with contextual characteristics defined at the community level. Multilevel logistic regression analysis. A total of 4007 children resident in 96 rural villages in Nigeria. Stunting: height-for-age that is less than the international reference value by >2 standard deviations (SDs). Independent of other factors, children born to underweight mothers were 1.32-times more likely to be stunted [adjusted odds ratio (aOR) 1.32; 95% confidence interval (CI) 1.07-1.64]. For each additional month of breastfeeding the odds of being stunted increased by 4% (aOR 1.04; 95% CI 1.03-1.06). Each SD increase in the household wealth index and maternal health-seeking behaviour index decreased the odds of being stunted by 16% (aOR 0.84; 95% CI 0.76-0.94) and 29% (aOR 0.71; 95% CI 0.60 -0.82), respectively. The study has provided evidence that both individual and community characteristics are important predictors of childhood malnutrition in rural Nigeria; and that scholars trying to understand variation in childhood malnutrition should pay attention to the characteristics of both children and place of residence.

Maternal Recognition and Health Care-seeking Behavior for Acute Respiratory Infection in Children in a Rural Ecuadorian County

To identify the factors which determine timely health care-seeking behaviors for childhood ARIs. A semi-structured questionnaire was administered to a non-random purposive sample of 91 female caregivers (age 18-57 years), and was analyzed using SPSS. In addition, six focus group discussions with female caregivers and 25 in-depth interviews with members from the health care setting were conducted. The primary obstacles reported for timely health care-seeking among survey respondents were money for medicines (n=29, 32%), transportation fares (n=19, 21%), and restrictive hours of the health centers (n=13, 14%). The median household salary reported was $100 per month. There was an overall lack of recognition of the biomedical signs and symptoms of serious lower respiratory infections independent of socioeconomic status. Based on the study findings, the following recommendations are offered: (1) public health campaigns need to better address appropriate home health care management of childhood health and illness to improve maternal health-seeking behavior for ARIs; (2) provincial health authorities need to adhere to regular hours of operation, expand clinic hours and increase staff; (3) health posts should establish better policies for disbursement of antibiotics and ensure that patients follow prescribed regimens; and (4) through partnerships with economic development organizations and the private sector, there will be increased employment opportunities.

Household and community socioeconomic and environmental determinants of child nutritional status in Cameroon.

BackgroundUndernutrition is a leading cause of child mortality in developing countries, especially in sub-Saharan Africa. We examine the household and community level socioeconomic and environmental factors associated with child nutritional status in Cameroon, and changes in the effects of these factors during the 1990s economic crisis. We further consider age-specific effects of household economic status on child nutrition.MethodsChild nutritional status was measured by weight-for-age (WAZ) and height-for-age (HAZ) z-scores. Data were from Demographic and Health Surveys conducted in 1991 and 1998. We used analysis of variance to assess the bivariate association between the explanatory factors and nutritional status. Multivariate, multilevel analyses were undertaken to estimate the net effects of both household and community factors.ResultsAverage WAZ and HAZ declined respectively from -0.70 standard deviations (SD), i.e. 0.70 SD below the reference median, to -0.83 SD (p = 0.006) and from -1.03 SD to -1.14 SD (p = 0.026) between 1991 and 1998. These declines occurred mostly among boys, children over 12 months of age, and those of low socioeconomic status. Maternal education and maternal health seeking behavior were associated with better child nutrition. Household economic status had an overall positive effect that increased during the crisis, but it had little effect in children under 6 months of age. Improved household (water, sanitation and cooking fuel) and community environment had positive effects. Children living in the driest regions of the country were consistently worst off, and those in the largest cities were best off.ConclusionBoth household and community factors have significant impact on child health in Cameroon. Understanding these relationships can facilitate design of age- and community-specific intervention programs.

Health impacts of macroeconomic crises and policies: determinants of variation in childhood malnutrition trends in Cameroon

It is generally hypothesized that macro economic shocks worsen child health by lowering household economic status and limiting access to health care, but this proposition seldom has been tested empirically. We examined the effects of economic crises and adjustment programmes during the 1990s in Cameroon on childhood malnutrition in population subgroups and evaluated the household and health system mediators of these effects. We used pooled cross-sectional data from two Demographic and Health Surveys conducted in 1991 and 1998. In multivariate analysis, we stratified data on child sex and age, maternal education, and place and region of residence. We used a linear regression model to estimate the net effects of changes in average household economic status and maternal health seeking behaviour (MHSB) on changes in the prevalence of malnutrition for each stratum, adjusting for all other variables. The prevalence of malnutrition in children younger than 3 years increased from 16 to 23% (P < 0.001) between 1991 and 1998. The increase in urban areas, from 13 to 15% (P = 0.391), mostly occurred in children of low-educated mothers. The increase in rural areas, from 19 to 25% (P < 0.001), mostly occurred in boys, children older than 6 months of age, those born to low-educated mothers, and those of low economic status. In urban areas, the advantage associated with higher maternal education was robust to all controls, and declines in economic status and MHSB were the mediators of increasing malnutrition. In rural areas, increase in malnutrition was higher in children with lower baseline economic status; decline in MHSB was a significant mediator of worsening nutritional status. The negative nutritional effects during economic crises and adjustment programmes of the 1990s in Cameroon were largest among children of low socioeconomic status. Declines in household economic status and access to health care were the mediators of increasing malnutrition.

Maternal Health-Seeking Behavior and Associated Factors in a Rural Nigerian Community

To assess maternal health services and health-seeking behavior in a rural community (Ologbo), located in the South-south zone of Nigeria. Structured questionnaire was administered to 225 randomly selected mothers (age 15-49 years), and was analyzed using SPSS. Six focus group discussion sessions were also conducted-four for community women and two for health workers. Teenagers constituted 13.3% of the respondents. The average number of children per woman ranged from 2.5 for teenagers to 9.0 for women aged 45-49 years. Eighty percent of respondents knew at least one major medical cause of maternal mortality: the most common causes mentioned were hemorrhage (31.8%) and obstructed labor (17.3%). Private maternity center was the most preferred place for childbirth (37.3%), followed by traditional birth attendants (TBAs) (25.5%). Government facility was preferred by only 15.7%: reasons for the low preference included irregularity of staff at work (31.4%), poor quality of services (24.3%), and high costs (19.2%). Among the 81 women that delivered within a 1-year period, only 9.9% received antenatal care, 6.2% received two doses of tetanus toxoid, while 4.9% attended postnatal clinic. Private midwives and TBAs attended 49.4 and 42.0% of deliveries, respectively. Education was found to be significantly associated with choice of place for delivery (p < 0.05), but no association was found with respect to age and marital status. Only 11.4% of mothers were practicing family planning. Poor health-seeking behavior is a challenge in rural Nigeria, and interventions are needed to achieve improved maternal health status.

Contextual influences on the use of health facilities for childbirth in Africa.

Previous studies of maternal health-seeking behavior focused on individual- and household-level factors. We examined community-level influences on the decision to deliver a child in a health facility across 6 African countries. Demographic and Health Survey data were linked with contextual data, and multilevel models were fitted to identify the determinants of childbirth in a health facility in the 6 countries. We found strong community-level influences on a woman's decision to deliver her child in a health facility. Several pathways of influence between the community and individual were identified. Community economic development, the climate of female autonomy, service provision, and fertility preferences all exert an influence on a woman's decision to seek care during labor, but significant community variation remains unexplained.

Maternal health-care service use among rural-urban migrants in Mumbai, India

Previous studies of migrants’ health-seeking behaviour have demonstrated that migrants under-utilize health services in their new environment owing to problems of access, urban assimilation and the continuation of traditional rural practices (Tam, 1994; Zulkifli and others, 1994; Bender and others, 1993; Davidson, 1983; Uyanga 1983). Migrants, however, have been shown to increase their utilization of services relative to those remaining in rural areas (Tam, 1994). This study examines the maternal health-seeking behaviour of rural-urban migrants in a slum pocket of Mumbai. The objective of this study is to identify and compare the nature, prevalence and typology of maternal and child health service utilization by rural-urban migrant and non-migrant populations in Maharashtra, India. At the same time, the research aims to identify key social, cultural and economic influences on service utilization and suggest possible ways to increase the use of maternal health-care services among recent migrants to Mumbai.

Correlates of Child Mortality in Pakistan: A Hazards Model Analysis

This study investigated factors associated with child mortality in an area in Rawalpindi, one of the large cities of Pakistan. Using both demographic and anthropological methods, the research was conducted to specifically examine the process and mechanisms whereby a link is established between child mortality and its covariates. Controlling for the socioeconomic status as a determinant of child mortality, the study population was limited to a lower income stratum living in a homogeneous environment where all households had equal access to health-related and other facilities. Results of the proportional hazards model analysis on 1301 index children suggest that non-economic factors like maternal health-seeking behavior were related to high child mortality. The cultural norm of bearing a large number of children was the most significant correlate. In order of significance, this was followed by contraceptive use, current age of the mother, age at marriage, and the hygienic conditions of the household. The study provides strong evidence of familial clustering of mortality by order of the household.