Maternal Health Care Utilization Research Articles

Effect of Socioeconomic Factors on the Choice of Health care Institutions for Delivery Care

During the past two decades, Pakistan witnessed a significant progress in maternal health outcomes. However, there exist persistent urban-rural and socio-economic inequalities in access and utilization of maternal healthcare services across the country. The overall objective of this research was to identify the significant socio-economic factors determining the choice of healthcare institutions for delivery care. This was a cross-sectional study conducted in Rajan Pur, a predominantly rural district in Punjab province. Using a multi-stage random sampling technique, 368 mothers who had childbirths from 1st October to 31st December 2020 in different healthcare institutions were interviewed. Data for the study was collected through a validated study instrument used by earlier studies on maternal healthcare utilization. The results of logistic regression analysis showed that use of public healthcare facilities for delivery care increases with increasing maternal education, monthly household income, and distance to healthcare facilities. The findings and recommendations drawn from the research would provide some insights to health policymakers and planners in developing an integrated and viable maternal healthcare program in Pakistan.

Maternal exposure to intimate partner violence and uptake of maternal healthcare services in Ethiopia: Evidence from a national survey.

BackgroundWomen exposed to Intimate Partner Violence (IPV) often do not utilize maternal health care optimally both because of stigma and other social problems. The current study aims to explore an association between maternal healthcare seeking and violence exposure among Ethiopian women and to assess if educational attainment and wealth status moderate this association.MethodsThe analyses included 2836 (weighted) currently married women with one live birth. We focus on the five years preceding the 2016 Ethiopian Demographic and Health Survey (EDHS) who participate, in the domestic violence sub-study. Exposure was determined by maternal reports of physical, emotional, sexual IPV or any form of IPV. The utilization of antenatal care (ANC) and place of delivery were used as proxy outcome variables for uptake of skilled maternal healthcare utilization. Women’s education attainment and wealth status were selected as potential moderators, as they can enable women with psychological and financial resources to counteract impact of IPV. Multilevel logistic regression analyses were used to explore the association between spousal IPV and maternal health outcomes. Moderation effects by education and wealth status were tested, and the data stratified. Using statistical software Stata MP 16.1, the restricted maximum likelihood method, we obtained the model estimates.ResultsAbout 27.5% of the women who reported exposure to any form of IPV had a health facility delivery. While 23.4% and 22.4% visited four or more antenatal care services among mothers exposed to emotional IPV and sexual IPV, respectively. After adjusting for potential confounding factors, only the association between maternal exposure to emotional IPV and adequate use of ANC was statistically significant (OR = 0.73, (95% CI:0.56–0.95)). But we found no significant association between IPV and utilization of health facility delivery. Some moderation effects of education and wealth in the association between IPV and maternal healthcare service utilization outcome were found.ConclusionExposure to emotional IPV was associated with poor uptake of maternal health care service utilization for married Ethiopian women. While developing interventions to improve women’s maternal healthcare service use, it is crucial to consider the effects of socio-economic variables that moderate the association especially with the intersection of IPV.

Skilled maternal healthcare and good essential newborn care practice in rural Bangladesh: A cross-sectional study.

Background and AimsEssential newborn care (ENC) practices play an important role in reducing the risk of infant mortality and morbidity. Therefore, more studies are needed on ENC practices. Skilled maternal healthcare can be a good strategy to increase the practice. Learn about the independent and joint effects of skilled maternal healthcare during pregnancy and childbirth on newborn care practices.MethodsThe study used a cross‐sectional data obtained from Bangladesh Multiple Indicator Cluster Survey, 2019. To investigate the association between maternal healthcare utilization and good ENC practice (cord care, delayed bathing, and immediate breast‐feeding), χ 2 test and t‐test in bivariate and binary logistic regression analysis, respectively have been performed after taking into account complex survey design.ResultsOnly about 24% (95% confidence interval [CI]: 22.95%–25.89%) women given birth at home in rural Bangladesh followed good newborn care practice. The results obtained from adjusted regression analysis showed that a woman was 24%, 49%, and 75% more likely of having good ENC practice if she received four or more skilled checkups during antenatal period only (adjusted odds ratios [AOR]: 1.24, 95% CI: 0.97, 1.60), received assistance from SBA during delivery only (AOR: 1.49, 95% CI 1.12, 1.97) and received skilled healthcare in both pregnancy and delivery (AOR: 1.75, 95% CI 1.13, 2.71), respectively compared to a woman who did not get an opportunity to receive skilled healthcare during pregnancy and delivery. Among the selected confounders, maternal age at birth, birth order, education of household heads and religion showed a significant association with good ENC practice.ConclusionThe study revealed that proper maternal healthcare during pregnancy and childbirth from skilled health personnel can improve the rate of ENC practices. For this, more training programs should be started, especially at the community level, and health promotion activities are needed to create awareness about efficient maternal healthcare practices.

Adverse obstetric and neonatal outcomes of adolescent pregnancies in Africa: a scoping review

BackgroundAdolescent pregnancy is a public health issue with well-defined causes and health risks with social and economic implications. Aim of this review was to examine adverse pregnancy outcomes and risk factors associated with adolescent pregnancy in Africa.MethodPubMed Central, Science Direct and JSTOR were the main databases for the literature review. Other online sources and experts were consulted for relevant studies. In all, 11,574 records were identified and 122 were considered as full-text studies for evaluation after thorough screening and removal of duplicates. Finally, 53 studies were included in this review for thematic synthesis.ResultsThe 53 studies sampled 263,580 pregnant women, including 46,202 adolescents (< 20 years) and 217,378 adults (> 20 years). Adolescent pregnancy was associated with higher risks of adverse pregnancy outcomes. Factors of poor pregnancy outcomes included low socioeconomic and educational status, poor utilization of antenatal care, risky lifestyles such as alcohol consumption, and unattractive health care factors. Maternal health care utilization was identified as an important factor to improve pregnancy outcomes among adolescents in Africa.ConclusionTo prevent adolescent pregnancy, stakeholders need to help lower socioeconomic inequalities, poor utilization of antenatal care, alcohol consumption, and improve adolescents’ health care and their educational status. Issues such as child marriage, abortion, poor health care infrastructure and non-adolescent friendly health facilities need to be addressed.

Factors affecting the utilization of maternal and child health care services in North Gujarat

The present study intended to examine the factors affecting the utilization of maternal health care services in the north Gujarat region of India. The study used Data collected from various hospitals of different districts of North Gujarat. Both bivariate and multivariate techniques have been applied for data analysis. Logistic regression techniques and concentration curve and index have been used. Findings of the study indicate that there were wider socio-economic differential exits in the utilization of MCH services (full ANC, Safe delivery and post-natal care) in all the district under study. The result shows that the farther population from healthcare centre is less likely to utilize maternal and child health care services. The economic inequality in accessing the all three components of maternal health care utilization was higher in the urban area. As the educational level, wealth index, employment, atonomy and exposure to mass media of women increases the utilization of these services increases significantly.

Female education and maternal health care utilization: evidence from Uganda

BackgroundMaternal health care is among the key indicators of population health and economic development. Therefore, the study attempted to explore female education and maternal healthcare utilization in Uganda. The study identified the causal effect of introduction of free education by exploiting the age as an instrument at the second stage model (BMC Health Serv Res. 2015. https://doi.org/10.1186/s12913-015-0943-8; Matern Child Health J. 2009;14:988–98). This instrument provided an exogenous source of variation in the years of schooling and allowed to implement a regression discontinuity design which accounted for heterogeneity in the cohort overtime.MethodsThe study used the Ordinary Least Squares (OLS) to help predict years of schooling that were used in the second stage model in the Two Stage Least Squares (2SLS). The study further used the Regression Discontinuity Design (RDD) model with a running variable of birth years to observe its effect on education. To control for heterogeneity in regions in the second stage model, a fixed effects model was used.ResultsFemale education indeed had a positive impact on maternal health care utilization. It was further found out that age also influences maternal health care utilization.ConclusionsTherefore, as an effort to improve professional maternal health care utilisation, there is need to focus on education beyond primary level. Uganda Government should also ensure that there is an improvement in community infrastructure and security across all regions and locations.

Women who smoke during pregnancy are more likely to be referred to an obstetrician during pregnancy and birth: results from a cohort study

BackgroundWomen who smoke during pregnancy make less use of prenatal care; the relation of smoking behavior with the use of other forms of maternal healthcare is unknown. The objective of this study is to investigate the association between women’s smoking behavior and their use of healthcare during pregnancy, birth and six weeks postpartum.MethodsWe analyzed data from the Dutch Midwifery Case Registration System (VeCaS), period 2012–2019. We included women with a known smoking status, singleton pregnancies, and who had their first appointment before 24 weeks of gestation with the primary care midwife. We compared three groups: non-smokers, early stoppers (stopped smoking in the first trimester), and late- or non-stoppers (stopped smoking after the first trimester or continued smoking). Descriptive statistics were used to report maternal healthcare utilization (during pregnancy, birth and six weeks postpartum), statistical differences between the groups were calculated with Kruskal–Wallis tests. Multivariable logistic regression was conducted to assess the association between smoking behavior and referrals to primary, secondary or tertiary care.ResultsWe included 41 088 pregnant women. The groups differed significantly on maternal healthcare utilization. The late- or non-stoppers initiated prenatal care later and had less face-to-face consultations with primary care midwives during pregnancy. Compared to the non-smokers, the early- and late- or non-stoppers were statistically signficiantly more likely to be referred to the obstetrician during pregnancy and birth. Postpartum, the early- and late- or non-stoppers were statistically signficantly less likely to be referred to the obstetrician compared to the non-smokers.ConclusionsAlthough the early- and late- or non-stoppers initiated prenatal care later than the non-smokers, they did receive adequate prenatal care (according to the recommendations). The results suggest that not smoking during pregnancy may decrease the likelihood of referral to secondary or tertiary care. The large population of smokers being referred during pregnancy underlines the important role of the collaboration between healthcare professionals in primary and secondary or tertiary care. They need to be more aware of the importance of smoking as a medical and as a non-medical risk factor.

Girl child marriage and its association with maternal healthcare services utilization in sub-Saharan Africa

BackgroundPrevious studies on child marriage have revealed its association with adverse health behaviors and outcomes, such as increased fertility, reduced modern family planning, less safe delivery, mental health disorders, suicidal attempt, and ideation, poor socio-economic status, morbidity, and mortality of children under- five. In this study, we investigate the association between child marriage and the utilization of maternal healthcare services in sub-Saharan Africa.MethodsWe utilized data from 29 sub-Saharan African countries’ Demographic and Health Surveys conducted between 2010 and 2018. A total of 36,215 childbearing young women between the ages of 20-24 years constituted our sample size. A multilevel binary logistic regression analysis was carried out to examine the association between child marriage and the utilization of maternal healthcare services, and the results were presented as crude and adjusted odds ratios at 95% confidence interval.ResultsYoung women who experienced child marriage were less likely to have ≥4 antenatal care visits during pregnancy [cOR = 0.60, CI = 0.57-0.63] compared to those who did not experience child marriage, and this was persistent after controlling for individual and community-level factors [aOR = 0.88, CI = 0.84-0.93]. Young women who experienced child marriage were less likely to use skilled birth attendance during delivery [cOR = 0.45, CI = 0.43-0.48] compared to those who did not experience child marriage, and this was persistent after controlling for individual and community-level factors [aOR = 0.87, CI = 0.82-0.93]. Young women who experienced child marriage were less likely to use postnatal care services [cOR = 0.79, CI = 0.75-0.82] compared to those who did not experience child marriage, but this was insignificant after controlling for individual and community-level factors.ConclusionOur study found child marriage to be a major contributor to the low use of maternal healthcare services, including antenatal care visit and the use of skilled birth attendance during child delivery. Hence, there is a need to develop an intervention to address child marriage in sub-Saharan Africa and strengthen existing ones. In addition, framework that considers child marriage as a key determinant of maternal healthcare utilization must be developed as part of policies in sub-Saharan African countries to enable universal achievement of low maternal mortality ratio by 2030 as a target of the Sustainable Development Goals.

Partial vaccination and associated factors among children aged 12–23 months in eastern Ethiopia

BackgroundVaccine prevents about 2–3 million deaths from vaccine-preventable diseases each year. However, immunization coverage in Ethiopia is lower than the herd immunity level required to prevent the spread of all vaccine-preventable diseases. Thus, this study aimed to assess the partial immunization and associated factors among 12–23-month-old children in Eastern Ethiopia.MethodA community-based cross-sectional study design was carried out among 874 randomly selected mothers/caregivers of children aged 12–23 months. A structured questionnaire was adapted and data were collected through face-to-face interviews and review of vaccination cards. Data were coded and analyzed using the Stata version 14 software. A binary logistic regression model was utilized to identify the determinant factors. The predictor of partial immunization was presented by an adjusted odds ratio with a 95% confidence interval. A p-value of < 0.05 was used to establish statistical significance.ResultThe prevalence of partial immunization was 31.4% (95% CI: 28–35). The dropout rate between the first and third pentavalent vaccine was 17%. Being female child [AOR = 0.73, 95% CI: 0.52–0.95], 18–20 month child [AOR = 1.6, 95% CI: 1.1- 2.4], the child born to mothers who heard about vaccination [AOR = 3.9, 95%CI: 1.92- 8.01], a child born to mother who did not receive immunization counselling [AOR = 1.65, 95%CI: 1.15–2.36], and child whose mother walk 15–30 min, 31–60 min, and > 60 min to reach nearby health facilities [AOR = 1.94, 95% CI: 1.1–3.45], [AOR = 4.5, 95% CI: 2.47–8.15], and [AOR = 3.45, 95% CI: 1.59- 7.48] respectively were factors significantly associated with partial vaccination.ConclusionsThe prevalence of partial immunization is high compared to other studies. As a result, to decrease the proportion of defaulters and to increase immunization coverage, maternal health care utilization like antenatal care follow-up and mother knowledge about the importance of the vaccine need to be sought cautiously.

From fees to free: User fee removal, maternal health care utilization and child health in Zambia

Despite recent progress, about 295,000 women in the World still die each year from pregnancy-related causes, and about 4.1 million children die before reaching the age of one. 99% of these deaths occur in developing countries. In 2006 the Zambian government removed user fees in public and mission health facilities in 54 out of 72 districts, and then extended this policy to rural parts of unaffected districts in 2007. I exploit the staggered implementation of the policy to assess its impact on maternal health care utilization and child health outcomes. Using a difference-in-differences estimation strategy, I find a 43% increase in the probability to give birth in a medical facility following the removal and a 36% increase in the probability of being assisted by a skilled birth attendant during childbirth. These positive effects decrease with household’s distance from the nearest health facility. In terms of child health, chronic malnutrition decreased by 8% and the abolition of user fees reduced newborn mortality risk only for those living close to a health facility providing essential emergency obstetric care and child health services. Access improved but returns to formal health services remained rather limited, highlighting the importance of addressing supply-side constraints to generate substantial gains in population health.

Towards achievement of Sustainable Development Goal 3: multilevel analyses of demographic and health survey data on health insurance coverage and maternal healthcare utilisation in sub-Saharan Africa.

Improving maternal health and achieving universal health coverage (UHC) are important expectations in the global Sustainable Development Goals (SDGs) agenda. While health insurance has been shown as effective in the utilisation of maternal healthcare, there is a paucity of literature on this relationship in sub-Saharan Africa (SSA). We examined the relationship between health insurance coverage and maternal healthcare utilisation using demographic and health survey data. This was a cross-sectional study of 195 651 women aged 15-49 y from 28 countries in SSA. We adopted bivariable and multivariable analyses comprising χ2 test and multilevel binary logistic regression in analysing the data. The prevalence of maternal healthcare utilisation was 58, 70.6 and 40.7% for antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC), respectively. The prevalence of health insurance coverage was 6.4%. Women covered by health insurance were more likely to utilise ANC (adjusted OR [aOR]=1.48, 95% CI 1.41 to 1.54), SBA (aOR=1.37, 95% CI 1.30 to 1.45) and PNC (aOR=1.42, 95% CI 1.37 to 1.48). Health insurance coverage was an important predictor of maternal healthcare utilisation in our study. To accelerate progress towards the achievement of SDG 3 targets related to the reduction of maternal mortality and achievement of UHC, countries should adopt interventions to increase maternal insurance coverage, which may lead to higher maternal healthcare access and utilisation during pregnancy.

Prevalence and determinants of maternal healthcare utilisation among young women in sub-Saharan Africa: cross-sectional analyses of demographic and health survey data

BackgroundMaternal health constitutes high priority agenda for governments across the world. Despite efforts by various governments in sub-Saharan Africa (SSA), the sub-region still records very high maternal mortality cases. Meanwhile, adequate utilization of maternal healthcare (antenatal care [ANC], skilled birth attendance [SBA], and Postnatal care [PNC]) plays a vital role in achieving improved maternal health outcomes. We examined the prevalence and determinants of maternal healthcare utilization among young women in 28 sub-Saharan African countries using data from demographic and health surveys.MethodsThis was a cross-sectional study of 43,786 young women aged 15–24 years from the most recent demographic and health surveys of 28 sub-Saharan African countries. We adopted a multilevel logistic regression analysis in examining the determinats of ANC, SBA, and PNC respectively. The results are presented as adjusted Odds Ratios (aOR) for the logistic regression analysis. Statistical significance was set at p < 0.05.ResultsThe prevalence of maternal healthcare utilisation among young women in SSA was 55.2%, 78.8%, and 40% for ANC, SBA, and PNC respectively with inter-country variations. The probability of utilising maternal healthcare increased with wealth status. Young women who were in the richest wealth quintile were, for instance, 2.03, 5.80, and 1.24 times respectively more likely to utilise ANC (95% CI = 1.80–2.29), SBA (95% CI = 4.67–7.20), and PNC (95% CI = 1.08–1.43) than young women in the poorest wealth quintile. Young women who indicated having a barrier to healthcare utilisation were, however, less likely to utilise maternal healthcare (ANC: aOR = 0.83, 95% CI = 0.78–0.88; SBA: aOR = 0.82, 95% CI = 0.75–0.88; PNC: aOR = 0.88, 95% CI = 0.83–0.94).ConclusionWhile SBA utilisation was high, we found ANC and PNC utilisation to be quite low among young women in SSA with inter-country variations. To accelerate progress towards the attainment of the Sustainable Development Goal (SDG) targets on reducing maternal mortality and achieving universal health coverage, our study recommends the adoption of interventions which have proven effective in some countries, by countries which recorded low maternal healthcare utilisation. The interventions include the implementation of free delivery services, training and integration of TBAs into orthodox maternal healthcare, improved accessibility of facilities, and consistent public health education. These interventions could particularly focus on young women in the lowest wealth quintile, those who experience barriers to maternal healthcare utilisation, uneducated women, and young women from rural areas.

Facilitators and Barriers to the Utilisation of Maternal Healthcare Services in Empowered Action Group States, India

The use of adequate reproductive healthcare services is critical to mothers and newborn babies. This study aimed to examine the facilitators and barriers to maternal healthcare utilisation in the Empowered Action Group (EAG) states. Data were drawn from the fourth round of the National Family Health Survey, 2015–16 ( n = 103,984). In this study, full antenatal care (ANC), delivery assistance by the skilled birth attendant (SBA) and postnatal care (PNC) within 2 days of delivery were taken as indicators of maternity care. Overall, approximately 13% of women received full ANC, 69.4% were delivered by SBA and 57.7% had PNC within 2 days of delivery. The findings of this study reveal that urban residence, higher education, wealthier economic status, exposure to mass media and contraceptive use are the facilitators of maternal healthcare utilisation. On the contrary, low levels of education, poverty, marriage during childhood, having a large number of children, belonging to socioeconomically backward castes, having difficulties related to healthcare-seeking and unwanted pregnancies are some of the major barriers to the use of maternity care. This study suggests that policymakers and public health practitioners should design proper healthcare policies and programs to provide quality reproductive healthcare services, particularly among socio-economically vulnerable women.

Socio-economic determinants of maternal health care utilization in Kailahun District, Sierra Leone, 2020

BackgroundAscertaining the key determinants of maternal healthcare service utilization and their relative importance is critical to priority setting in policy development. Sierra Leone has one of the world’s highest maternal death ratios in the context of a weak health system. The objectives of this study were to determine; the level of utilization of Antenatal Care (ANC), Skilled Delivery Attendants (SDA), Postnatal Care (PNC) services, and factors that influence the utilization of these services.MethodsWe conducted a community-based cross-sectional study involving 554 women of reproductive age (15–49 years) who had at least one delivery in the last 3 years and lived in the Kailahun District, Sierra Leone from November 2019 to October 2020. Data were analysed using analysed using bivariate, multivariate and multinomial logistic regression models.ResultsThe median age of respondents was 25 years (Q1 = 17 years, Q3 = 30 years). Eighty-nine percent (89%) had 4 or more ANC visits. Only 35.9% of women were delivered by SDA. Women residing in urban areas had over six-fold increased odds of utilizing SDA as compared to women residing in rural areas (AOR = 6.20, 95% CI = 3.61–10.63). Women whose husbands had a primary level of education had 2.38 times increased odds of utilizing SDA than women whose husbands had no education (AOR = 2.38, 95% CI = 1.30–4.35). Women that walked longer distances (30–60 min) to seek healthcare had 2.98 times increased odds of utilizing SBA than those that walked shorter distances (< 30 min) (AOR = 2.98, 95% CI = 1.67–5.33). Women who had a secondary/vocational level of education had 2.35 times increased odds of utilizing the standard PNC category as compared to those with no education (OR = 2.35, 95% CI = 1.19–4.63).ConclusionThe majority of women had 4 or more ANC visits yet the use of skilled birth attendants was low. Urban residence and education were significantly associated with the use of the standard PNC category. To improve the utilization of maternal health care services, national healthcare policies should target the advancement of education, train skilled Maternal Healthcare (MHC) attendants, rural infrastructure, and the empowerment of women.

Estimating the Impact of COVID-19 Pandemic Related Lockdown on Utilization of Maternal and Perinatal Health Services in an Urban Neighborhood in Delhi, India.

ObjectiveTo estimate utilization of maternal, perinatal healthcare services after the lockdown was implemented in response to the COVID-19 pandemic compared to the period before.MethodsThis study conducted in Dakshinpuri, an urban neighborhood in Delhi, reports data over a 13-month period which includes the period “before lockdown” i.e., October 1, 2019 to March 21, 2020 and “after lockdown” i.e., March 22 to November 5, 2020. The period “after lockdown” included the lockdown phase (March 22 to May 31, 2020) and unlock phase (June 1 to November 5, 2020). Mothers delivered during this period in the study area were interviewed using semi-structured questionnaires. In-depth interviews (IDIs) were conducted in a subsample to understand the experiences, challenges, and factors for underutilization of healthcare services.FindingsThe survey covered a total population of 21,025 in 4,762 households; 199 eligible mothers (mean age 27.4 years) were interviewed. In women who delivered after lockdown against before lockdown, adjusted odds of having >2 antenatal care visits in the third trimester was 80% lower (aOR 0.2, 95% CI 0.1–0.5); proportion of institutional deliveries was lower (93 vs. 97%); exclusive breastfeeding during first 6 months of birth (64.5 vs. 75.7%) and health worker home visitation within 6 weeks of birth (median, 1 vs. 3 visits) were substantially lower. Fear of contracting COVID-19, poor quality of services, lack of transportation and financial constraints were key issues faced by mothers in accessing health care. More than three-fourth (81%) of the mothers reported feeling down, depressed or hopeless after lockdown. The major factors for stress during lockdown was financial reasons (70%), followed by health-related concerns.ConclusionCOVID-19 pandemic-related lockdown substantially affected maternal and perinatal healthcare utilization and service delivery.

Health workers\u2019 and hospital administrators\u2019 perspectives on mistreatment of women during facility-based childbirth: a multicenter qualitative study in Ghana

BackgroundGlobally, mistreatment of women during facility-based childbirth continues to impact negatively on the quality of maternal healthcare provision and utilization. The views of health workers are vital in achieving comprehensive understanding of mistreatment of women, and to design evidence-based interventions to prevent it. We explored the perspectives of health workers and hospital administrators on mistreatment of women during childbirth to identify opportunity for improvement in the quality of maternal care in health facilities.MethodsA qualitative study comprising in-depth interviews (IDIs) with 24 health workers and hospital administrators was conducted in two major towns (Koforidua and Nsawam) in the Eastern region of Ghana. The study was part of a formative mixed-methods project to develop an evidence-based definition, identification criteria and two tools for measuring mistreatment of women in facilities during childbirth. Data analysis was undertaken based on thematic content via the inductive analytic framework approach, using Nvivo version 12.6.0.ResultHealth workers and hospital administrators reported mixed feelings regarding the quality of care women receive. Almost all respondents were aware of mistreatment occurring during childbirth, describing physical and verbal abuse and denial of preferred birthing positions and companionship. Rationalizations for mistreatment included limited staff capacity, high workload, perceptions of women’s non-compliance and their attitudes towards staff. Health workers had mixed responses regarding the acceptability of mistreatment of women, although most argued against it. Increasing staff strength, number of health facilities, refresher training for health workers and adequate education of women about pregnancy and childbirth were suggestions to minimize such mistreatment.ConclusionHealth workers indicated that some women are mistreated during birth in the study sites and provided various rationalizations for why this occurred. There is urgent need to motivate, retrain or otherwise encourage health workers to prevent mistreatment of women and promote respectful maternity care. Further research on implementation of evidence-based interventions could help mitigate mistreatment of women in health facilities.

On Zero inflated models with applications to maternal healthcare utilization

We consider the problem of modelling count data with excess zeros and over-dispersion which are commonly encountered in various disciplines that limit the use of traditional models for count outcomes. Our research work applies the Zero-inflated Poisson and Negative Binomial models in modelling Maternal Health Care (MHC) utilization in Nigeria, employing the Andersen’s behavioural model to examine the effect of predisposing, enabling, and need factors on MHC utilization. The performance of these models are compared to the traditional Poisson and negative binomial models. The Vuong test and AIC suggests that the Zero-inflated Negative Binomial model provided the most significant improvement over traditional models for count outcomes.

Public health insurance and maternal health care utilization in India: evidence from the 2005–2012 mothers’ cohort data

BackgroundThe introduction of Janani Suraksha Yojana (JSY) in India, a conditional cash transfer program which incentivized women to deliver at institutions, resulted in a significant increase in institutional births. Another major health policy reform, which could have affected maternal and child health care (MCH) utilization, was the public health insurance scheme (RSBY) launched in 2008. However, there is a noticeable lack of studies that examine how RSBY had impacted on MCH utilization in India. We used data from a cohort of mothers whose delivery had been captured in both the 2005 and 2011/12 rounds of the Indian Human Development Survey (IHDS) to study the impact of health insurance (in particular, the public insurance scheme versus private insurance) on MCH access. We also investigated whether maternal empowerment was a significant correlate that affects MCH utilization.MethodsWe used the multilevel mixed-effects ordered logistic regression model to account for the clustered nature of our data. We derived indexes for women’s empowerment using Principal component analysis (PCA) technique applied to various indicators of women’s autonomy and socio-economic status.ResultsOur results indicated that the odds of mothers’ MCH utilization levels vary by district, community and mother over time. The effect of the public insurance scheme (RSBY) on MCH utilization was not as strong as privately available insurance. However, health insurance was only significant in models that did not control for household and mother level predictors. Our findings indicated that maternal empowerment indicators – in particular, maternal ability to go out of the house and complete chores and economic empowerment—were associated with higher utilization of MCH services. Among control variables, maternal age and education were significant correlates that increase MCH service utilization over time. Household wealth quintile was another significant factor with mothers belonging to upper quintiles more likely to access and utilize MCH services.ConclusionsChange in women’s and societal attitude towards maternal care may have played a significant role in increasing MCH utilization over the study period. There might be a need to increase the coverage of the public insurance scheme given the finding that it was less effective in increasing MCH utilization. Importantly, policies that aim to improve health services for women need to take maternal autonomy and empowerment into consideration.

Predictors of maternal and newborn health service utilization across the continuum of care in Ethiopia: A multilevel analysis.

The continuum of care for maternal and newborn health is a systematic approach for delivery of an integrated effective package of life-saving interventions throughout pregnancy, childbirth, and postpartum as well as across levels of service delivery to women and newborns. Nonetheless, in low-income countries, coverage of these interventions across the life cycle continuum is low. This study examined the predictors of utilization of maternal and newborn health care services along the continuum of care in Ethiopia. This was a cross-sectional population-based study. We measured maternal and newborn health care utilization practices among women who had live births in the last 12 months preceding the survey in Amhara, Oromia, SNNP, and Tigray regions of Ethiopia. We fitted multilevel random-effects logistic regression models to examine the predictors of the continuum of care accounting for the survey design, and individual, and contextual characteristics of the respondents. Our analysis revealed that only one-fifth of women utilized maternal and newborn health services across the antepartum, intrapartum, and postpartum continuum; most women discontinued at the postpartum stage. Continued use of services varied significantly across wealth, model family, prenatal stay at maternity waiting homes, antenatal care in the first trimester, complete antenatal care service, and the administrative region at all antepartum, intrapartum, and postpartum stages. Moreover, family conversation during pregnancy [AOR: 2.12; 95% CI: 1.56-2.88], delivery by cesarean [AOR: 2.70; 95% CI: 1.82-4.02] and birth notified to health extension workers [AOR: 1.95; 95% CI: 1.56-2.43] were found to be predictors of the continuum of care at the postpartum stage. In Ethiopia, despite good access to antepartum care, compliance with continuity of care across the pathway decreased with significant inequitable distributions, the poorest segment of the population being at most disadvantage. The main modifiable program factors connected to the continued uptake of maternal health services include family conversation, pregnant women conference, complete antenatal care, antenatal care in the first trimester, and birth notification.

Comparative study of the effect of National Health Insurance Scheme on use of delivery and antenatal care services between rural and urban women in Ghana

BackgroundDespite the focus of the National Health Insurance Scheme (NHIS) to bridge healthcare utilisation gap among women in Ghana, recent evidence indicates that most maternal deaths still occur from rural Ghana. The objective of this study was to examine the rural-urban differences in the effects of NHIS enrolment on delivery care utilisation (place of delivery and assistance at delivery) and antenatal care services among Ghanaian women.MethodsA nationally representative sample of 4169 women from the 2014 Ghana Demographic and Health Survey was used. Out of this sample, 2880 women are enrolled in the NHIS with 1229 and 1651 being urban and rural dwellers, respectively. Multivariate logistic and negative binomial models were fitted as the main estimation techniques. In addition, the Propensity Score Matching technique was used to verify rural-urban differences.ResultsAt the national level, enrolment in NHIS was observed to increase delivery care utilisation and the number of ANC visits in Ghana. However, rural-urban differences in effects were pronounced: whereas rural women who are enrolled in the NHIS were more likely to utilise delivery care [delivery in a health facility (OR = 1.870; CI = 1.533–2.281) and assisted delivery by a medical professional (OR = 1.994; CI = 1.631–2.438)], and have a higher number of ANC visits (IRR = 1.158; CI = 1.110–1.208) than their counterparts who are not enrolled, urban women who are enrolled in the NHIS on the other hand, recorded statistically insignificant results compared to their counterparts not enrolled. The PSM results corroborated the rural-urban differences in effects.ConclusionThe rural-urban differences in delivery and antenatal care utilisation are in favour of rural women enrolled in the NHIS. Given that poverty is endemic in rural Ghana, this positions the NHIS as a potential social equaliser in maternal health care utilisation especially in the context of developing countries by increasing access to delivery care services and the number of ANC visits.